Does a ban on informal health providers save lives? Evidence from Malawi

Godlonton, Susan; Okeke, Edward N.

doi:10.1016/j.jdeveco.2015.09.001

Cited by 59 publications

(51 citation statements)

References 40 publications

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“…But due to cost, logistics and time constraints, we were unable conduct a large sample study, explore the costs of community self-organisation, interview informal providers and collect cost data in this study which may have allowed for more predictive analyses of responses to transaction costs. However, evidence from legislations to ban informal providers from twentieth century Britain [57] and China [58], to contemporary Malawi [26], indicate a slow pace of shifts in preference, which is facilitated by referral linkages from informal to formal providers and “the gradual retirement of the old guard” [57]. Historical studies could investigate institutional change in countries where people have transitioned to near absolute use of formal health services.…”

Section: Discussionmentioning

confidence: 99%

“…Many pregnant women continued to use the services of traditional birth attendants albeit illegally. The ban was controversial and unpopular, it did not result in improved health outcomes, and was lifted in 2010 [26]. More commonly proposed policy responses to limit informal providers in low- and middle-income countries include government intervention to enforce existing regulation, provide training to improve their services, foster relationships between them and formal providers, and reduce demand for their services by improving access to formal providers [1].…”

Section: Introductionmentioning

confidence: 99%

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Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria

et al. 2016

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One of the consequences of ineffective governments is that they leave space for unlicensed and unregulated informal providers without formal training to deliver a large proportion of health services. Without institutions that facilitate appropriate health care transactions, patients tend to navigate health care markets from one inappropriate provider to another, receiving sub-optimal care, before they find appropriate providers; all the while incurring personal transaction costs. But the top-down interventions to address this barrier to accessing care are hampered by weak governments, as informal providers are entrenched in communities. To explore the role that communities could play in limiting informal providers, we applied the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market are greater than within a firm. In a realist analysis of qualitative data from Nigeria, we found that community health committees sometimes seek to limit informal providers in a manner that is consistent with the transaction costs theory of the firm. The committees deal not through legal sanction but by subtle influence and persuasion in a slow and faltering process of institutional change, leveraging the authority and resources available within their community, and from governments and NGOs. First, they provide information to reduce the market share controlled by informal providers, and then regulation to keep informal providers at bay while making the formal provider more competitive. When these efforts are ineffective or insufficient, committees are faced with a “make-or-buy” decision. The “make” decision involves coordination to co-produce formal health services and facilitate referrals from informal to formal providers. What sometimes results is a quasi-firm—informal and formal providers are networked in a single but loose production unit. These findings suggest that efforts to limit informal providers should seek to, among other things, augment existing community responses.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria

et al. 2016

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“…In the longer-term, we recommend that demand-side incentives be incorporated into the scheme. However, this comes with its own caveats: first, it is clear that cash incentives are not a magic bullet (Murray et al 2014); second, while there is evidence that these incentives help to stimulate demand, there is very little evidence that increased use of services translates to mortality reduction (Godlonton & Okeke 2015;Mazumdar et al 2011;Okeke & Chari 2015).…”

Section: Address Demand-side Factorsmentioning

confidence: 99%

“…Second, they underscore the need for interventions addressing both supply-and demand-side barriers simultaneously. Complementarities between the two mean that addressing one without the other may not lead to the desired outcomes (Godlonton & Okeke 2015). It is true that budget and administrative constraints necessarily limit the scope of any intervention, but they reinforce the need for a rigorous needs assessment to ensure that the right trade-offs are being made.…”

Section: Address Other Supply-side Factorsmentioning

confidence: 99%

“…Much of this literature has focused on demand-side initiatives such as conditional cash transfers (Lim et al 2010;Powell-Jackson & Hanson 2012), transportation subsidies (Ekirapa- Kiracho et al 2011), voucher schemes (Bellows, Bellows & Warren 2011;Nguyen et al 2012;Obare et al 2013), and negative incentives or penalties (Godlonton & Okeke 2015). 5 Supply-side studies are considerably less common (Kumar & Dansereau 2014).…”

Section: Introductionmentioning

confidence: 99%

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Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

Okeke¹,

Glick²,

Abubakar³

et al. 2017

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The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding, producing and synthesising high-quality evidence of what works, how, why and at what cost. We believe that better and policy-relevant evidence will make development more effective and improve people's lives. 3ie impact evaluations3ie-supported impact evaluations assess the difference a development intervention has made to social and economic outcomes. 3ie is committed to funding rigorous evaluations that include a theory-based design, use the most appropriate mix of methods to capture outcomes and are useful in complex development contexts. About this report SummaryLimited availability of skilled providers, particularly in rural areas, is thought to be an important constraint to increasing rates of use of maternal and child health services in low-and middle-income countries. There are, however, few well-identified studies of the relationship between the supply of skilled workers and outcomes. In this project, we studied the effects of a government program in Nigeria that sought to alleviate supply-side constraints by deploying skilled midwives to primary health facilities in rural communities, to provide round-the-clock access to skilled care.We evaluate the impact of the Midwives Service Scheme (MSS), a government program introduced in 2009 to increase access to skilled care in underserved rural areas in Nigeria. At rollout, the MSS deployed nearly 2,500 midwives to 652 primary health care centers across 36 states. To evaluate the impact of the program, we surveyed 7,104 women with a birth within the preceding five years in 386 communities across 12 states. The intervention group consisted of communities that participated in the initial rollout; the comparison group consisted of communities that would receive the program approximately three years later. To understand implementation challenges and contextualize the quantitative results, we carried out a nested qualitative study in three states, consisting of in-depth interviews and focus group discussions with policymakers, providers, childbearing women, and community stakeholder groups.Overall, we found that the program's effects were smaller than anticipated. The main effect was a 7.3-percentage-point increase in antenatal care use in program clinics (about 12 percent relative to baseline levels) and a 5-percentage-point increase in overall use of antenatal care (6 percent relative to baseline levels) within the first year of the program. We found suggestive but not conclusive evidence of a small increase in skilled birth attendance, but this was confined to the south, where there were fewer challenges with midwife retention. We did not find any significant improvements in postnatal visits or child immunizations. Given this, it is not surprising that we did not find any evidence of improvements in maternal and child health.Our data allow us to shed some light on why ...

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Money and my mind: Maternal cash transfers and mental health

Okeke

2021

Health Economics

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More than 300 million people, worldwide, are estimated to suffer from depression-about 4.4% of the world's population-and this number is growing (World Health Organization, 2017). Depression is a leading contributor to global disease burden and is associated with serious impairment and disability (World Health Organization, 2018). It has significant negative economic impacts that include reduced labor force participation and diminished work productivity (Moussavi et al., 2007;Kessler et al., 2009). It has been estimated that the global economy loses about $1 trillion each year in productivity due to depression and anxiety (Chisholm et al., 2016). Not surprisingly, given its economic impact, depression is now attracting increasing attention from economists (de Quidt and Haushofer, 2016;Strulik, 2019;Baranov et al., 2019).Research shows that women are twice as likely as men to suffer from depression (Piccinelli and Wilkinson, 2000). This gap opens up during adolescence and is at its widest during the childbearing years (Kessler et al., 1993). In particular, depression in the aftermath of childbirth (henceforth PPD) is one of the more common medical complications of

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Does a ban on informal health providers save lives? Evidence from Malawi

Cited by 59 publications

References 40 publications

Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria

Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria

Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

Money and my mind: Maternal cash transfers and mental health

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