Community based livelihood interventions, which focus directly on increasing income and employment, have become an increasingly important component of large-scale poverty reduction programmes. We evaluate the impact of a participatory livelihoods intervention -the Tamil Nadu Empowerment and Poverty Reduction (Pudhu Vaazhvu) Project (PVP) using propensity score matching methods. The paper explores the impact of PVP on its core goals of empowering women and the rural poor, improving their economic welfare, and facilitating public action. We find significant effects of PVP on reducing the incidence of high cost debt and diversifying livelihoods. We also find evidence of women's empowerment, and increased political participation.
Background Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. Methods We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August–October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. Results In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges. Conclusions Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.
Background Health system financing presents a challenge in many developing countries. We assessed two reform packages, performance-based financing (PBF) and direct facility financing (DFF), against each other and business-as-usual for maternal and child healthcare (MCH) provision in Nigeria. Methods We sampled 571 facilities (269 in PBF; 302 in DFF) in 52 districts randomly assigned to PBF or DFF, and 215 facilities in 25 observable-matched control districts. PBF facilities received $2 ($1 for operating grants plus $1 for bonuses) for every $1 received by DFF facilities (operating grants alone). Both received autonomy, supervision, and enhanced community engagement, isolating the impact of additional performance-linked facility and health worker payments. Facilities and households with recent pregnancies in facility catchments were surveyed at baseline (2014) and endline (2017). Outcomes were Penta3 immunization, institutional deliveries, modern contraceptive prevalence rate (mCPR), four-plus antenatal care (ANC) visits, insecticide-treated mosquito net (ITN) use by under-fives, and directly observed quality of care (QOC). We estimated difference-in-differences with state fixed effects and clustered standard errors. Results PBF increased institutional deliveries by 10% points over DFF and 7% over business-as-usual (p<0.01). PBF and DFF were more effective than business-as-usual for Penta3 (p<0.05 and p<0.01, respectively); PBF also for mCPR (p<0.05). Twenty-one of 26 QOC indicators improved in both PBF and DFF relative to business-as-usual (p<0.05). However, except for deliveries, PBF was as or less effective than DFF: Penta3 immunization and ITN use were each 6% less than DFF (p<0.1 for both) and QOC gains were also comparable. Utilization gains come from the middle of the rural wealth distribution (p<0.05). Conclusions Our findings show that both PBF and DFF represent significant improvements over business-as-usual for service provision and quality of care. However, except for institutional delivery, PBF and DFF do not differ from each other despite PBF disbursing $2 for every dollar disbursed by DFF. These findings highlight the importance of direct facility financing and decentralization in improving PHC and suggest potential complementarities between the two approaches in strengthening MCH service delivery. Trial registration ClinicalTrials.gov NCT03890653; May 8, 2017. Retrospectively registered.
Improvements in childhood nutrition increase schooling and economic returns in later life in a virtuous cycle. However, better nutrition also leads to an earlier onset of menstruation (menarche). In socio-cultural contexts where menarche adversely a↵ects educational attainments, early menarche can thus break the virtuous cycle of girls' human development. This paper focuses on one such context, India, and uses the Young Lives Longitudinal Study to show that starting menses before age twelve causes a 13% decrease in school enrollment rate. Healthier girls have higher learning outcomes at age twelve, but they also start menstruating earlier and are more likely to drop out of school, such that their initial health advantage over other girls in their cohort disappears. Further, dropout rates induced by menarche are higher if girls live in communities with a low average perception of safety among children, while dropout rates are lower in communities with higher expected wages for female-dominated professions.
Background: Nigeria piloted decentralized facility financing (DFF) and performance-based financing (PBF) programs under the Nigeria State Health Investment Project (NSHIP), funded by the World Bank. It aimed to increase the utilization and quality of MCH services. Although many low-and middle-income countries have launched or piloted DFF and/or PBF like programs and conducted impact evaluation, very few studies related DFF or PBF's impact to its cost. This study evaluates the incremental cost-effectiveness ratios (ICERs) of facilities with DFF or PBF compared to comparably funded health facilities without it.Methods: This study used a quasi-experimental research design. Local government areas (LGAs) in the three states under NSHIP were randomly assigned to the PBF group, where health facilities received payments based on their performance, and to the DFF group, where payments were not tied to performance.An additional three states served as the control group without additional funding. Reflecting the health system perspective, incremental financial costs were assessed for program implementation and verification, consumables, and donor supervision. Net effectiveness on coverage and quality were assessed through difference-in-differences calculations between baseline and endline facility and household surveys. The Lives Saved Tool and literature were used to convert statistically significant coverage changes to lives saved and quality-adjusted life years (QALYs) gained.Results: Compared to the control group the incremental costs of DFF and PBF were $45.2 million and $87.3 million in 2015 US dollars, respectively. In comparison to the control group, DFF had a major impact on Bacillus Calmette-Guérin (BCG) and diphtheria, pertussis and tetanus (DPT)], increasing their coverage by 13.4% (P<0.001) and 9.7% (P<0.05), respectively while PBF increased the rate of skilled birth attendance (SBA) by 9.1% (P<0.05), and use of modern contraceptives by 5.7% (P<0.05). Overall, the quality of care was also improved under the DFF and PBF when compared to the control group. Compared to the control group, DFF and PBF were estimated to save 756 and 1,679 lives per year respectively, with 17,878 and 39,605 QALYs gained.
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