75728 DIME BRIEF Evidence for combating malaria The Development Impact Evaluation Malaria With over half of the world at risk of the disease, malaria is a leading cause of Initiative is a World morbidity and mortality in much of the developing world. This is especially Bank program to striking, as the disease is both preventable and treatable. In fact, the causal link support government between the use of anti-malarial services and improved health outcomes is well agencies in adopting a established. To date, however, the evidence on which service delivery channels are culture of real time, most effective and on individual preventive and treatment behavior can be affected evidence-based is extremely limited. policy-making. The The World Bank, through its Malaria Control Booster Program, has joined an objective of the ambitious global campaign to control malaria. The Malaria Impact Evaluation initiative is not simply to Program is one of the ways the World Bank is contributing to better understand measure results, but to how innovations in service delivery, and subsidized provision of prevention and compare the treatment impact health-seeking behavior, health status, school performance, labor effectiveness and cost- productivity, and socio-economic status. Via impact evaluation, we learn how to effectiveness of enhance the delivery of key disease control and treatment services, and strengthen alternative healthcare systems to maximize the benefits of interventions on health and welfare. interventions to help Evaluation also helps us do this more cost-effectively and equitably. This note programs learn how to reviews current evidence from impact evaluation at the Bank and from other improve their sources on some important questions that face programs in malaria. performance over time. DIME works with How does free provision compare to cost sharing? 300 agencies in 72 Due to their high cost, anti-malarial treatments are subsidized to make them affordable to those that need them the most. Selecting the optimal level of countries to improve subsidization, and understanding whether free provision distort behavior are knowledge, quality of important for program design. operations and country capacity for An impact evaluation in Kenya (Cohen and Dupas 2007) shows that, contrary to impact evaluation- expectations, cost sharing does not seem to improve targeting of Insecticide based policy-making. Treated bed Nets (ITNs) toward those in greatest need, and that women who paid for their ITNs are no more likely to use them than those who receive them free of charge. In the same vein, Hoffman, Barrett and Just (2007) find no evidence that donated goods are re-sold for cash in Uganda. The authors compare households that were randomly assigned to receive either a free ITN (or cash to purchase an ITN) to households given the opportunity to purchase ITNs using their own resources. Their main findings are that very few households who received free nets go on to resell them, and that liquidity constraints, rather than undervaluation, explain the limited use of nets. Further work in Kenya (Cohen, Dupas, and Schaner 2010) is mapping out consumer Though this disease can response by randomly assigning different prices for treatment to different be prevented and households, and examining the effect of subsidy levels on health-behavior. The treated, globally it results will help target ACT subsidies more effectively. causes 243 million cases and 863 thousand deaths each year. DIME Brief – Impact Evaluation Evidence for Combating Malaria 1 Preventive treatment improves cognitive development in school age children Clarke et al. (2008) conduct a stratified, cluster- randomized, double-blind placebo controlled trial in 30 primary schools in western Kenya. Schools were stratified into three groups according to school examination performance in previous years. This enabled the authors to ensure that differences in school quality and socioeconomic environment were not driving their results. From each school-performance stratum, ten schools were randomly selected, and within each stratum schools were randomly allocated to one of six coded drug groups Does malaria prevention Assignment to the treatment groups using randomization ensured that there were no increase school performance systematic differences that would bias estimates and undermine the validity of causal findings. and labor productivity? The placebo control was necessary to ensure that Impact evaluation is starting to establish that malaria there was no placebo effect biasing the results prevention is a powerful tool to improve school upward. Also known as the Hawthorne effect, this performance and labor productivity on infected bias can result when participants exert additional populations. Understanding the economic impacts of effort, or otherwise change behavior, merely as a health investments will help further justify health result of being “observed.” expenditures. The Government of Kenya now has evidence that malaria prevention in school can improve In a randomized study in Kenya, Clarke et al. (2008) classroom concentration. This has led to the find that only a one year Intermittent Preventative allocation of more resources towards school-based Treatment (IPT) of school-children significantly malaria control and other preventive health increased their scores on attention tests and reduced interventions. by half their probability of becoming anemic (see Box). How to improve service The ongoing randomized experiment in Nigeria (Dillon et al. 2008) gave individuals access to ACTs, delivery? the first line anti-malarial drug. The study will Malaria-endemic countries are engaged in major provide a precise measure of the direct effect of efforts to distribute and deliver long-lasting malaria infection on the productivity and income of insecticidal nets (LLINs) and ACTs to their agricultural workers with and without access to populations. Effective distribution requires a good effective treatment. understanding of delivery channels, and what determines adoption and usage of LLINs and ACTs. Because prevention affects labor productivity, Results from a randomized study in Zambia households may allocate preventive resources (Friedman et al. 2008) show that a new public accordingly. Hoffman et al. (2007) indeed find that sector distribution system was successful in nets purchased by men tend to be used by the increasing access to effective pediatric malaria household’s primary income earner, whereas those treatment. In the eight districts where it was purchased by women tend to be used by household introduced, availability of pediatric anti-malarials members perceived to suffer from malaria most increased from 247 to 345 days per year. frequently. The proportion of children under five Nationwide scale-up could save 18,000 children and sleeping under a net, for example, was found to be 2,000 adults from drying of malaria by 2015 (see 20% higher when the net was purchased by a Box). woman. DIME Brief – Impact Evaluation Evidence for Combating Malaria 2 A study by Meghir et al. (2008) in Nigeria will examine innovations in malaria New distribution model service provision through community-directed interventions (CDIs); and improves availability of public-private partnerships (PPPs) with patent medicine vendors (PMVs), pediatric anti-malarial small-scale private purveyors of drugs and related goods. A series of impact evaluations of these interventions in the states of Akwa Ibom, Anambra, and An impact evaluation Gombe, will inform the scale-up of critical operational decisions for the second conducted in 2009 year of the government program. Specifically the study will examine the compares the effectiveness of two alternative models to effectiveness and cost-effectiveness of the CDI and PPP interventions, jointly address breakdowns in the and in isolation, in improving malaria prevention and case management, and public sector drug supply changes in health status, productivity, and socioeconomic outcomes. chain. Finally, an evaluation in India will consider alternate delivery mechanisms This evaluation was a through non-state channels, and will systematically vary information provided collaboration between the to households receiving mosquito nets, as well as exposure to motivation for World Bank, the Government of Zambia, and monitoring of use. Ninety-six villages and constituent households surveyed John Snow Inc., Crown at the baseline will be divided into treatment and control groups. An additional Agents, the Massachusetts 48 villages from non-selected sub-districts will serve as additional controls, Institute of Technology, and which will be less subject to any potential spillovers from treated villages. the MIT-Zaragoza Logistics Results will enable policy makers to understand which delivery approaches Program. are more effective. The more successful of the two models simply docked drug shipments at district Building on past successes to eliminate malaria storage facilities, eliminating Can multiple malaria control strategies used in combination eliminate the the need to unpack and burden of malaria? After its unique successes in controlling malaria, through a repackage shipments. combination of treatment, larval control, ITN distribution, and prompt and effective epidemic response, Eritrea has been experimenting with indoor In the districts where the residual spraying (IRS) with insecticide, to move the country towards malaria supply chain improvements were introduced, pediatric elimination. Forthcoming results from Keating et al. will measure the additive malaria drugs are now impact of IRS over existing malaria control interventions in 117 treated villages available 345 days a year. on behavioral, health, and socioeconomic outcomes. In control districts, they are only available 247 days a year. References Meghir, C. et al. 2010. “Impact Evaluation of Community-Directed Interventions and Private Sector “The difference between Approaches to Malaria Control in Seven Nigerian States.” World Bank. Concept Note. life and death can be Clarke, SE et al. 2008. “Effect of intermittent preventive treatment of malaria on health and painfully simple in rural education in schoolchildren: a cluster-randomised, double-blind, placebo-controlled trial.” Lancet areas,” said Vledder, Senior 372(9633): 127-38. Health Specialist leading the Cohen, J. & P. Dupas. 2007. “Free Distribution of Cost-Sharing? Evidence from a Randomized project. “Our work has Malaria Prevention Experiment.” Brookings Institute Global Economy & Development Working focused on identifying the Paper best way to get drugs to the Cohen, J., Dupas, P., and Schaner, S. 2010. Prices, Diagnostic and the Demand for malaria right place at the right time, Treatment: Evidence from a Randomized Trial. maximizing the Dillon, A., Friedman, K. and Serneels, P. 2008. Experimental Estimates of the Impacts of Malarial effectiveness of every Infection on Agricultural Worker Productivity. IFPRI. Concept Note. public health dollar spent in Friedman, J. et al. 2008. “Improving the Public Sector Supply Chain, Community Engagement, and the process, and delivering Affordable Access to ACTs in the Private Sector.” World Bank. Concept Note. tangible results.” Hoffmann, V. 2008. “Psychology, gender, and the intrahousehold allocation of free and purchased mosquito nets.” Job Market Paper, Cornell University. Beyond malaria control, it Hoffmann, V., C.B. Barrett, D.R. Just. 2007. “Do free goods stick to poor households? Experimental addresses a common evidence on insecticide treated bednets.” Unpublished draft, under review at World Development. bottleneck found in the Keating, Joseph et al. (forthcoming). "An evaluation of an indoor residual spray campaign for health systems of low- reducing malaria infection prevalence in an intervention suppressed low-transmission setting in income countries: the Eritrea: results from a household survey." delivery of essential drugs to the population. www.worldbank.org/dime DIME Brief – Impact Evaluation Evidence for Combating Malaria 3 For further information contact Jed Friedman jfriedman@worldbank.org, Arianna Legovini alegovini@worldbank.org or Edit Velenyi evelenyi@worldbank.org