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Effective Delivery of Health Products in Ghana
Last registered on April 08, 2017
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Pre-Trial

Trial Information
General Information
Title
Effective Delivery of Health Products in Ghana
RCT ID
AEARCTR-0000331
Initial registration date
May 19, 2014
Last updated
April 08, 2017 2:42 PM EDT
Location(s)
Country
Ghana
Region
Africa
Primary Investigator
Name
Pascaline Dupas
Affiliation
Stanford University
Contact Primary Investigator
Other Primary Investigator(s)
PI Name
Rebecca Dizon-Ross
PI Affiliation
J-PAL
Contact Investigator
PI Name
Jonathan Robinson
PI Affiliation
University of California, Santa Cruz
Contact Investigator
Additional Trial Information
Status
Completed
Start date
2011-05-01
End date
2014-12-31
Keywords
Governance, Health
Additional Keywords
bed nets, leakage, corruption
JEL code(s)
D73, H11, I15, I38
Secondary IDs
Abstract
The aim of this randomized controlled trial is to measure corruption in the delivery of subsidized health products in a developing country context, and to evaluate four schemes to increase pass-through of public health subsidies to their intended beneficiaries: vouchers (so that health workers do not have control over the subsidized products themselves); flat bonus pay for health workers charged with delivering the subsidies; threats of top-down audits; and, increasing the salience of the budget constraint. We measure pass-through through a rich set of data, including (1) home surveys of eligible women (registered prenatal care clients), (2) informal interviews with community members, and (3) decoy “mystery client” visits in which ineligible men attempted to obtain subsidized products from health centers. The trial involves 72 health centers from one (undisclosed) region of Ghana.
External Link(s)
J-PAL evaluation summary
Registration Citation
Citation
Dizon-Ross, Rebecca, Pascaline Dupas and Jonathan Robinson. 2017. "Effective Delivery of Health Products in Ghana." AEA RCT Registry. April 08. https://doi.org/10.1257/rct.331-3.0.
Former Citation
Dizon-Ross, Rebecca et al. 2017. "Effective Delivery of Health Products in Ghana." AEA RCT Registry. April 08. https://www.socialscienceregistry.org/trials/331/history/16139.
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Experimental Details
Interventions
Intervention(s)
Our sample consists of 72 health facilities selected for inclusion based on a census conducted of all of the public and private health facilities (over 300) in one region of Ghana, which for confidentiality purposes shall remain unnamed.
Inclusion criteria for health centers in the study were: (1) having an antenatal care clinic (ANC); (2) being rural; (3) having no other healthcare facilities within a 2 km radius, no hospitals within a 5 km radius, and not more than one other ANC within a 5 km radius (this was to keep subsidy costs manageable by limiting the potential increase in ANC attendance in response to the program); (4) having no free LLIN program currently in place (very few had); (5) having at least two stores within a 2 km radius willing to participate in a voucher scheme whereby health centers distribute vouchers redeemable at the store (only 6% of clinics were excluded by this criterion); and, (6) being accessible for net deliveries (less than 2% were inaccessible).
We asked selected health facilities to participate in a bed net distribution program called "SALI" and sponsored by the NGO JPAL. The bednet distribution program targeted pregnant seeking prenatal care. Each prenatal care registrant was eligible to one free long-lasting insecticide treated net.
We randomized the following features of the distribution program:
1. Distribution mechanism: whether the subsidized product was distributed directly through health facilities, or indirectly through a voucher scheme wherein the clinic distributes vouchers that could be redeemed at local stores (Direct vs. Voucher). We also randomized whether vouchers could be redeemed in 1 or 2 stores (1-store vs. 2-store)
2. Staff monitoring: whether the health works were told the distribution program would be monitored through audits (Audit threat vs. No Audit threat)
3. Incentives: whether, for Direct Distribution clinics only, the health worker received compensation for implementing the distribution (Compensation vs. No Compensation)
4. Stock levels: whether, for Direct clinics only, the clinic receives a high or low level of net stock (High stock vs. Low stock)

Intervention Start Date
2011-10-02
Intervention End Date
2012-04-09
Primary Outcomes
Primary Outcomes (end points)
- coverage among eligible recipients
- payment requests from eligible recipients for nets that should have been free
- incidence of leakage of nets/vouchers from the health facilities to ineligible populations
- stockouts at facilities
Primary Outcomes (explanation)
Secondary Outcomes
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Experimental Design
Experimental Design
After stratifying the 72 facilities (6 strata: size based on number of ANC visits, not registrants, and location: close to border or not, versus remote or not), they were randomized into 12 equally-sized groups:

V1 -voucher with 1 shop
V2 -voucher with 2 shops
VA1 - voucher with audits & 1 shop
VA2 - voucher with audits & 2 shops
D -direct distribution
DP -direct distribution with payment for staff
DA -direct distribution with audits
DAP -direct distribution with audits and payment
DAPL -direct distribution with audits and payment and large -stock
DPL -direct distribution with payment and large -stock
DAL -direct distribution with audits and large -stock
DL -direct distribution with large-stock
Experimental Design Details
Randomization Method
Randomization by a pre-set algorithm (done in office by a computer).
Randomization Unit
The randomization was conducted at the facility level.
Was the treatment clustered?
No
Experiment Characteristics
Sample size: planned number of clusters
72 facilities
Sample size: planned number of observations
72 facilities
Sample size (or number of clusters) by treatment arms
24 facilities sampled for indirect distribution ("voucher"), 48 facilities sampled for direct distribution
36 facilities sampled for audit treatment, 36 not sampled for audit treatment
Among 48 facilities sampled for direct distribution: 24 sampled for bonus flat pay
Among 48 facilities sampled for direct distribution: 24 sampled for large delivery
Among 24 facilities sampled for voucher: half sampled to have two shops were vouchers can be redeemed
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Supporting Documents and Materials
IRB
INSTITUTIONAL REVIEW BOARDS (IRBs)
IRB Name
MIT COUHES
IRB Approval Date
2011-01-20
IRB Approval Number
1012004251
IRB Name
IPA IRB-USA
IRB Approval Date
2011-01-20
IRB Approval Number
413.11January-002
IRB Name
UCLA IRB
IRB Approval Date
2011-02-08
IRB Approval Number
10-001848
IRB Name
Stanford
IRB Approval Date
2012-05-25
IRB Approval Number
24617
IRB Name
Ghana Health Service Ethics Review Committee
IRB Approval Date
2011-06-30
IRB Approval Number
GHS-ERC 02/5/11
Analysis Plan
Analysis Plan Documents
EDHEP Analysis Plan Final.pdf

MD5: 3cea64001d2fbe9dcafcc68d73466075

SHA1: 9be995ac2a8147c6ffa485a06ef83577299979b6

Uploaded At: May 14, 2014

Post-Trial
Post Trial Information
Study Withdrawal
Intervention
Is the intervention completed?
Yes
Intervention Completion Date
April 09, 2012, 12:00 AM +00:00
Is data collection complete?
Yes
Data Collection Completion Date
December 31, 2014, 12:00 AM +00:00
Final Sample Size: Number of Clusters (Unit of Randomization)
72 facilities
Was attrition correlated with treatment status?
No
Final Sample Size: Total Number of Observations
72 facilities
Final Sample Size (or Number of Clusters) by Treatment Arms
24 facilities sampled for indirect distribution ("voucher"), 48 facilities sampled for direct distribution 36 facilities sampled for audit treatment, 36 not sampled for audit treatment Among 48 facilities sampled for direct distribution: 24 sampled for bonus flat pay Among 48 facilities sampled for direct distribution: 24 sampled for large delivery Among 24 facilities sampled for voucher: half sampled to have two shops were vouchers can be redeemed
Data Publication
Data Publication
Is public data available?
Yes
Public Data URL
https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/P04NKK
Program Files
Program Files
No
Reports and Papers
Preliminary Reports
Relevant Papers
Abstract
Distributing subsidized health products through existing health infrastructure could sub- stantially and cost-effectively improve health in sub-Saharan Africa. There is, however, widespread concern that poor governance – in particular, limited health worker accountability – seriously undermines the effectiveness of subsidy programs. We audit targeted bednet distribution pro- grams to quantify the extent of agency problems. We find that around 80% of the eligible receive the subsidy as intended, and up to 15% of subsidies are leaked to ineligible people. Supplementing the program with simple financial or monitoring incentives for health workers does not improve performance further and is thus not cost-effective in this context.
Citation
Dizon-Ross, Rebecca, Pascaline Dupas, and Jonathan Robinson. "Governance and the Effectiveness of Public Health Subsidies: Evidence from Ghana, Kenya and Uganda." Working Paper, Janauary 2017
Url
https://www.povertyactionlab.org/sites/default/files/publications/444_Governance%26Effectiveness_PublicHealthSubsidies_Jan2017.pdf