Pascaline Dupas

Free Distribution or Cost-Sharing? Evidence from a Randomized Malaria Prevention Experiment

It is widely believed that cost-sharing - charging a subsidized, positive price - for a health product is necessary to avoid wasting resources on those who will not use or do not need the product. We explore this argument in the context of a field experiment in Kenya, in which we randomized the price at which pregnant women could buy long lasting anti-malarial insecticide-treated nets (ITNs) at prenatal clinics. We find no evidence that cost-sharing reduces wastage on those that will not use the product: women who received free ITNs are not less likely to use them than those who paid subsidized positive prices. We also find no evidence that cost-sharing induces selection of women who need the net more: those who pay higher prices appear no sicker than the prenatal clients in the control group in terms of measured anemia (an important indicator of malaria). Cost-sharing does, however, considerably dampen demand. We find that uptake drops by 75 percent when the price of ITNs increases from 0 to

Short‐Run Subsidies and Long‐Run Adoption of New Health Products: Evidence From a Field Experiment

0.75, the price at which ITNs are currently sold to pregnant women in Kenya. We combine our estimates in a cost-effectiveness analysis of ITN prices on infant mortality that incorporates both private and social returns to ITN usage. Overall, given the large positive externality associated with widespread usage of insecticide-treated nets, our results suggest that free distribution to pregnant women is both more effective and more cost-effective than cost-sharing.

Inferring welfare maximizing treatment assignment under budget constraints

Short-run subsidies for health products are common in poor countries. How do they affect long-run adoption? A common fear among development practitioners is that one-off subsidies may negatively affect long-run adoption through reference-dependence: People might anchor around the subsidized price and be unwilling to pay more for the product later. But for experience goods, one-off subsidies could also boost long-run adoption through learning. This paper uses data from a two-stage randomized pricing experiment in Kenya to estimate the relative importance of these effects for a new, improved antimalarial bed net. Reduced form estimates show that a one-time subsidy has a positive impact on willingness to pay a year later inherit. To separately identify the learning and anchoring effects, we estimate a parsimonious experience-good model. Estimation results show a large, positive learning effect but no anchoring. We black then discuss the types of products and the contexts inherit for which these results may apply.

Getting essential health products to their end users: Subsidize, but how much?

This paper concerns the problem of allocating a binary treatment among a target population based on observed covariates. The goal is to (i) maximize the mean social welfare arising from an eventual outcome distribution, when a budget constraint limits what fraction of the population can be treated and (ii) to infer the dual value, i.e. the minimum resources needed to attain a specific level of mean welfare via efficient treatment assignment. We consider a treatment allocation procedure based on sample data from randomized treatment assignment and derive asymptotic frequentist confidence interval for the welfare generated from it. We propose choosing the conditioning covariates through cross-validation. The methodology is applied to the efficient provision of anti-malaria bed net subsidies, using data from a randomized experiment conducted in Western Kenya. We find that subsidy allocation based on wealth, presence of children and possession of bank account can lead to a rise in subsidy use by about 9% points compared to allocation based on wealth only, and by 17% points compared to a purely random allocation.

Targeting health subsidies through a nonprice mechanism: A randomized controlled trial in Kenya.

Although coverage rates and health outcomes are improving, many poor people around the world still do not benefit from essential health products. An estimated two-thirds of child deaths could be prevented with increased coverage of products such as vaccines, point-of-use water treatment, iron fortification, and insecticide-treated bednets. What limits the flow of products from the producer’s laboratory bench to the end users, and what can be done about it? Recent empirical research suggests a crucial role for heavy subsidies.

Governance and the effectiveness of public health subsidies: Evidence from Ghana, Kenya and Uganda

Delivering chlorine to those who use it In developed countries, a consumers valuation of a health product can be measured by his or her willingness to pay for it. But poorer individuals, especially those in developing countries, might want and need a product yet be unable to pay for it with money. Dupas et al. demonstrate that a nonprice voucher mechanism can be used to deliver chlorine for water treatment to people in Kenya who are too poor to pay for it, but who use it when they get it (see the Perspective by Olken). Having to redeem the vouchers screens out people who would accept the free chlorine solution but not use it. Science, this issue p. 889; see also p. 864 A voucher system allows poor people who need clean water to pay for it with time and effort. Free provision of preventive health products can markedly increase access in low-income countries. A cost concern about free provision is that some recipients may not use the product, wasting resources (overinclusion). Yet, charging a price to screen out nonusers may screen out poor people who need and would use the product (overexclusion). We report on a randomized controlled trial of a screening mechanism that combines the free provision of chlorine solution for water treatment with a small nonmonetary cost (household vouchers that need to be redeemed monthly in order). Relative to a nonvoucher free distribution program, this mechanism reduces the quantity of chlorine procured by 60 percentage points, but reduces the share of households whose stored water tests positive for chlorine residual by only one percentage point, substantially improving the trade-off between overinclusion and overexclusion.

Supply and Demand for Improved Sanitation: Results from Randomized Pricing Experiments in Rural Tanzania

Distributing subsidized health products through existing health infrastructure could substantially 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 programs 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.

Infrastructure Quality Assessment in Africa using Satellite Imagery and Deep Learning

Improving access to sanitation is a global public health priority. Sufficient consumer demand is required for sanitation coverage to expand through private provision. To measure consumer demand for hygienic latrine platform products in rural Tanzania, we conducted a randomized, voucher-based real-money sales trial with 1638 households with unimproved latrines. We also evaluated multiple supply chain options to determine the costs of supplying latrine platform products to rural households. For concrete latrine SanPlats, 60% of households were willing to pay US

Pricing and User Fees

0.48 and 10% of households were willing to pay US

Savings Constraints and Microenterprise Development: Evidence from a Field Experiment in Kenya

4.05, yet the average cost of supplying the SanPlat to households was US