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Community Incentives to Promote Infant and Maternal Health in Indigenous Areas in Panama (PACO: Programa de Apoyos Comunitarios)
Initial registration date
December 01, 2016
November 14, 2018 3:20 PM EST
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Inter-American Development Bank
Other Primary Investigator(s)
University of Maryland
Inter-American Development Bank
Additional Trial Information
Maternal and infant mortality in indigenous and rural areas of Panama is very high compared to the national average. This is partly due by the poor access to quality health services, that can be explained, in part, by the existence of geographical, cultural and economic barriers for the use of the services themselves.
This study aims to evaluate a project implemented by the Ministry of Health that provide incentives to increase the demand and utilization of prenatal health services in indigenous and rural areas of the country. There are two kind of schemes of incentives that will be provided on the utilization of pre-natal care services and institutional delivery at the community level. The first scheme provides incentives to pregnant women in the community and to the voluntary health promoters of the community. The second scheme of incentives provides incentives only to the pregnant women of the community. The evaluation will measure whether these schemes of incentives have an impact on the utilization of prenatal care services, institutional delivery and prevalence of maternal and infant mortality. The evaluation will measure the impact of the two schemes separately as well as the marginal impact of the incentives to the health promoters. For the evaluation purposes, the intervention will be implemented during 2019-2021 in the indigenous province of Ngabe Bugle. The evaluation will rely on an experimental design at the community level. The sample size of this experiment is 300 communities (and 3,000 observations of pregnancies). Registration Citation
Acevedo, Paloma, Sebastian Galiani and Sebastian Martinez. 2018. "Community Incentives to Promote Infant and Maternal Health in Indigenous Areas in Panama (PACO: Programa de Apoyos Comunitarios)." AEA RCT Registry. November 14.
The program consists on the delivery of cash incentives to different agents with the objective to increase the demand and use for maternal and infant health services. More specifically, the program seek to improve the number of quality prenatal controls in the first trimester, the number of quality prenatal controls, the number of institutional deliveries, the immediate care for women and infants after delivery (first 48 hours) and timely care of obstetric and neonatal emergencies.
The incentives are provided to two different agents within the communities:
1) Incentives to pregnant women to promote early controls (during the first trimester), attendance at quality quarterly prenatal controls, and attendance at institutional delivery and the first puerperal and neonatal control.
2) Incentives to the volunteer health promoters of the community to promote the early capture of pregnant women (first control within the first trimester), the performance of quality quarterly prenatal controls, and the attendance to institutional birth and care of puerperal and neonates of the first 48 hours.
The evaluation will be conducted in the indigenous province of Ngabe Bugle. The intervention in these areas will start in early 2019. The Ministry of Health of Panama, along with its partnering agency USGAF will be the implementing agencies.
Intervention Start Date
Intervention End Date
Primary Outcomes (end points)
Early detection of pregnancies (prenatal visit before the end of the first trimester), number of pre-natal visits to health facilities by pregnant women (at least one in the first trimester, one in the second trimester, and two in the third trimester), number of institutional deliveries, number of post-natal controls for the mothers and newborns (in the following 48 hours after the delivery), mortality of mothers and infants, and other indicators of health conditions during pregnancy.
Primary Outcomes (explanation)
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
The study is designed as a randomized controlled trial and will test two different schemes of community incentives: (i) the first incentive scheme consists of the combination of two incentives: direct incentives to pregnant women and incentives to health promoters; and (ii) the second incentive scheme only includes the incentive to pregnant women. By doing this, the study aims to measure the impact of the two incentive schemes separately as well as to disentangle the marginal effect of the incentive to promoters on the outcomes of interest.
The unit of assignment is the Centric Community (CC hereafter) that comprises a single community or clusters of communities that are served by the same health services providers. Based on power calculations, 300 CC will participate in the study assigning 100 CC to each of the two treatment groups and 100 to the control group (that won't receive any incentive at all). Within each community, all the houses with children under 2 years old. The main source of data for the evaluation will be household surveys, although administrative data from the health facilities are also being exploited as potential supplementary data.
Experimental Design Details
Randomization done in office by a computer
The first level of randomization is the Population Group level (PG hereafter). Each PG comprises several Centric Communities (CC). The CC of the PG assigned to treatment were randomly assigned to one of the two treatments or to the control group.
Was the treatment clustered?
Sample size: planned number of clusters
300 Centric Communities
Sample size: planned number of observations
3,000 mothers with children below 2 years old.
Sample size (or number of clusters) by treatment arms
3,000 households from 300 Centric Communities, being 100 CC assigned to one treatment (incentives to pregnant women and health promoters), 100 CC assigned to the second treatment (incentives to pregnant women), and 100 CC assigned to control (no incentives).
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
According to power calculations, we identified:
Attendance to prenatal controls: 20%
Institutional Delivery: 40%
Institutional Prenatal Control in the First Trimester: 7%
Total Number of Institutional Prenatal Controls: 7%
INSTITUTIONAL REVIEW BOARDS (IRBs)
Comite Nacional de Bioetica de la Investigacion Panama
IRB Approval Date
IRB Approval Number