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Study Overview

Randomized Evaluation of a Conditional Cash Transfer Program for Routine Immunizations in North West Nigeria
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IDinsight is conducting a cluster randomized controlled trial (RCT) to assess the impact of delivering cash incentives to caregivers who bring their infants for routine immunization in North West Nigeria (Katsina, Zamfara, and Jigawa states). The program is an initiative of the not-for-profit organization New Incentives and its subsidiary All Babies Are Equal. It has the goal of saving and improving lives by increasing routine vaccination coverage rates. The study’s impact estimate will be a key input into the funder, GiveWell's estimate of New Incentives’ cost effectiveness. GiveWell commissioned this study to help them decide whether to designate New Incentives as a Top Charity and/or direct funds to support its expansion. In recent years, the donor community has invested substantially in improving supply-side infrastructure for routine immunization in Nigeria (NRISP 2013), but coverage remains low. New Incentives aims to address this apparent shortfall in demand. Previous studies suggest small incentives can have a large impact on health behaviors like vaccinating children (Banerjee et al. 2010) and that this finding could apply to immunization in Nigeria (Sato 2014).
Health, Nutrition, and Population
Additional Keywords:
Conditional Cash Transfer, Cash Incentives
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Principal Investigator(s)

Name of First PI:
Alison Connor, PhD
IDinsight - Director for Health. Based in Nairobi, Kenya
Name of Second PI:
Zack Devlin-Foltz
IDinsight - Project Manager for the Evaluation and Primary corresponding investigator. Based in Dakar, Senegal

Study Sponsor

Study Sponsor Location:
United States
Funding Proposal:

Intervention Overview

New Incentives, an international non-governmental organization (NGO), is addressing the apparent shortfall in demand for immunization by offering cash incentives to caregivers for bringing their child for recommended childhood immunizations. These small cash transfers can provide some material benefit to new caregivers from poor communities. At a minimum, they help offset time and transport costs. The cash incentives are offered to caregivers who bring their child to a program clinic for routine immunizations (RI) given in the first five clinic visits in the RI schedule. New Incentives has a team of field officers responsible for disbursing incentives to caregivers. On each vaccination day, the field officers check vaccine quality and stock, and then prepare to disburse incentives. Incentives are paid in cash by a New Incentives staff member who also ensures the infant meets the age and program area residence eligibility criteria.
Theory of Change:
New Incentives anticipates that their incentive program will improve the health status of Nigerian children in a variety of ways. The primary focus of the study is the direct impact of the program on coverage rates for incentivized immunizations for eligible infants in the study area. The primary causal pathway is that cash changes the caregiver’s assessment of the benefit of vaccination by minimizing barriers and providing a larger benefit. However, the theory of change includes other pathways that increase coverage such as New Incentives’ supply side engagement, New Incentives’ marketing and outreach to community leaders, and reduced social and informational barriers to vaccination as it becomes more common. In addition, the theory of change includes secondary outcomes such as increased consumption (from cash transfers) and improvements in other health outcomes (from increased use of general health services). One secondary causal pathway warrants further mention: it is likely that New Incentives’ program indirectly increases coverage rates for vaccinations beyond those for which it directly pays incentives. New Incentives aims to incentivize initiation and adherence to the Nigeria Routine Immunization Schedule. While technically New Incentives makes cash transfers for the vaccines listed in Table 1 above; in practice they have found that infants tend to receive all vaccines scheduled for a visit once they are at the clinic. New Incentives also works with clinic staff to improve their internal procedures and address supply-side issues, such as vaccine stockouts, through existing channels. These efforts apply equally to all routine immunizations. Accordingly, New Incentives chose to pay for some of each visit's immunizations with the expectation that this will encourage all of that visit's immunizations. During piloting, they found that this simplified payment schedule is easier for beneficiaries to understand.
Multiple Treatment Arms Evaluated?

Implementing Agency

Name of Organization:
New Incentives and All Babies are Equal Initiative
Type of Organization:
NGO (International)

Program Funder

Name of Organization:
Type of Organization:
NGO (International)

Intervention Timing

Intervention or Program Started at time of Registration?
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Evaluation Method

Evaluation Method Overview

Primary (or First) Evaluation Method:
Randomized control trial
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Method Details

Details of Evaluation Approach:
The study will be structured as a two-arm cluster RCT with clinics catchment areas as clusters. One arm will serve as the control (83 clinics) and will operate as the status quo, while the other arm will receive New Incentives’ full program (84 clinics). This design will measure the causal effect of New Incentives’ program on the likelihood of an infant receiving a vaccine. The unit of treatment and randomization is the clinic catchment, while the unit of measurement for the key outcomes is the individual infant.
Outcomes (Endpoints):
The primary outcomes are: 1. The odds that a 12 to 16 month old in a community served by a program clinic received BCG 2. The odds that a 12 to 16 month old in a community served by a program clinic received at least one dose of PENTA 3. The odds that a 12 to 16 month old in a community served by a program clinic received Measles 1 Secondary outcomes are: 1. The odds that a 12 to 16 month old in a community served by a program clinic is fully immunized (loose and strict) 2. The timeliness of vaccination, particularly for Measles 1, among 12 to 16 month olds in communities served by a program clinic 3. The average number of vaccines received per 12 to 16 month old child in communities served by a program clinic 4. The percentage of 12 to 16 month olds in communities served by a program clinic that received at least one vaccination
IDinsight will use caregivers’ reports of their child’s vaccination history to measure vaccination coverage outcome variables. We will use various alternative sources, primarily administrative, to assess the accuracy of “self-reported” coverage. Administrative sources will be clinics’ registers, child health cards, and New Incentives’ internal records of cash transfers distributed to caregivers. Additionally, the BCG vaccination leaves a visible scar, for which enumerators will check, providing another opportunity to assess caregiver recall. Additional outcomes of interest include timeliness based on vaccination dates recorded on child health cards or clinic registers.
Unit of Analysis:
Individual 12 to 16 month old
New Incentives’ program will increase the percentage of children immunized with BCG, any PENTA, or Measles 1 by an average increase of at least 7-percentage points across all program clinics that share a similar profile to the clinics New Incentives will operate in at scale.
Unit of Intervention or Assignment:
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Number of Individuals in Sample:
Expect approximately 7500 in the final coverage survey (50% of the total study area population of 12 to 16-month old infants)
Size of Treatment, Control, or Comparison Subsamples:
84 clinics in treatment, 83 in control. Expected approximately 3780 infants in treatment, 3735 in control

Supplementary Files

Analysis Plan:
Pre-Analysis Plan_Final 2018_11_16.docx
Other Documents:

Outcomes Data

A survey questionnaire that asks caregivers to self-report if their infant has received injectable vaccinations. It identifies vaccinations primarily by location on the body, but also includes information on the name of the vaccine and disease it prevents. There is also a don’t know option which we will code as having not received a vaccine. In the baseline, these data sources proved to be reasonably reliable.
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Treatment Assignment Data

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Data Analysis

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Study Materials

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Registration Category

Registration Category:
Prospective, Category 1: Data for measuring impacts have not been collected

Completion Overview

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Preliminary Report:
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Data Availability

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Other Materials

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Study Stopped