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Study Overview

Title:
Randomized Evaluation of a Conditional Cash Transfer Program for Routine Immunizations in North West Nigeria
Study is 3ie funded:
No
Study ID:
RIDIE-STUDY-ID-5bfe040ac4a60
Initial Registration Date:
11/27/2018
Last Update Date:
11/29/2019
Study Status:
Ongoing
Location(s):
Nigeria
Abstract:

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).

Change History for Abstract
Changed On Previous Value
11/26/2019 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).
Registration Citation:

Connor, A. and Devlin-Foltz, Z., 2018. Randomized Evaluation of a Conditional Cash Transfer Program for Routine Immunizations in North West Nigeria. Registry for International Development for Impact Evaluations (RIDIE). Available at: 10.23846/ridie160

Categories:
Health, Nutrition, and Population
Other
Additional Keywords:
Conditional Cash Transfer, Cash Incentives
Secondary ID Number(s):

Principal Investigator(s)

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

Study Sponsor

Name:
GiveWell
Study Sponsor Location:
United States
Intervention

Intervention Overview

Intervention:

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.

Change History for Intervention
Changed On Previous Value
11/26/2019 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.

Change History for Theory of Change
Changed On Previous Value
11/26/2019 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?
No

Implementing Agency

Name of Organization:
New Incentives - All Babies Are Equal Initiative
Change History for Name of Organization
Changed On Previous Value
11/26/2019 New Incentives and All Babies are Equal Initiative
Type of Organization:
NGO (International)

Program Funder

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

Intervention Timing

Intervention or Program Started at time of Registration?
Yes
Start Date:
07/01/2018
End Date:
02/28/2020
Change History for End Date
Changed On Previous Value
11/26/2019 11/01/2019
Evaluation Method

Evaluation Method Overview

Primary (or First) Evaluation Method:
Randomized control trial
Other (not Listed) Method:
Additional Evaluation Method (If Any):
Other (not Listed) Method:

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.

Change History for Details of Evaluation Approach
Changed On Previous Value
11/26/2019

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.
11/26/2019 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 probability that a 12 to 16?month old in a community served by a study clinic received BCG
  2. The probability that a 12 to 16?month old in a community served by a study clinic received at least one dose of PENTA
  3. The probability that a 12 to 16?month old in a community served by a study clinic received Measles 1

Secondary outcomes are:

  1. The probability that a 12 to 16?month old in a community served by a study clinic is fully immunized
  2. The timeliness of vaccination among 12 to 16?month olds in communities served by a study clinic
  3. The average number of vaccines received per 12 to 16?month?old child in communities served by a study clinic
  4. The percentage of 12 to 16?month olds in communities served by a study clinic that received at least one injectable vaccine?
  5. The probability that a 12 to 16?month old in a community served by a study clinic received at least one dose of PCV?
  6. The change over time in the volume of BCG, Penta 1, Penta 2, Penta 3, and Measles vaccinations recorded in clinic administrative records
Change History for Outcomes (Endpoints)
Changed On Previous Value
11/26/2019

The primary outcomes are:

  1. The probability that a 12 to 16?month old in a community served by a study clinic received BCG
  2. The probability that a 12 to 16?month old in a community served by a study clinic received at least one dose of PENTA
  3. The probability that a 12 to 16?month old in a community served by a study clinic received Measles 1

Secondary outcomes are:

  1. The probability that a 12 to 16?month old in a community served by a study clinic is fully immunized
  2. The timeliness of vaccination among 12 to 16?month olds in communities served by a study clinic
  3. The average number of vaccines received per 12 to 16?month?old child in communities served by a study clinic
  4. The percentage of 12 to 16?month olds in communities served by a study clinic that received at least one injectable vaccine?
  5. The probability that a 12 to 16?month old in a community served by a study clinic received at least one dose of PCV?
  6. The change over time in the volume of BCG, Penta 1, Penta 2, Penta 3, and Measles vaccinations recorded in clinic administrative records
11/26/2019

The primary outcomes are:

  1. The probability that a 12 to 16?month old in a community served by a study clinic received BCG
  2. The probability that a 12 to 16?month old in a community served by a study clinic received at least one dose of PENTA
  3. The probability that a 12 to 16?month old in a community served by a study clinic received Measles 1

Secondary outcomes are:

  1. The probability that a 12 to 16?month old in a community served by a study clinic is fully immunized
  2. The timeliness of vaccination among 12 to 16?month olds in communities served by a study clinic
  3. The average number of vaccines received per 12 to 16?month?old child in communities served by a study clinic
  4. The percentage of 12 to 16?month olds in communities served by a study clinic that received at least one injectable vaccine?
  5. The probability that a 12 to 16?month old in a community served by a study clinic received at least one dose of PCV?
  6. The change over time in the volume of BCG, Penta 1, Penta 2, Penta 3, and Measles vaccinations recorded in clinic administrative records
11/26/2019

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
11/26/2019 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
Unit of Analysis:
Individual 12 to 16 month old
Hypotheses:

New Incentives’ program has meaningfully increased the percentage of children immunized with BCG, any PENTA, or Measles 1 across all program clinics.

Change History for Hypotheses
Changed On Previous Value
11/26/2019

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.
11/26/2019 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:
Clinics
Number of Clusters in Sample:
167
Number of Individuals in Sample:
Expect approximately 7500 in the final coverage survey (25% of the total study area population of 12 to 16-month old infants)
Change History for Number of Individuals in Sample
Changed On Previous Value
11/26/2019 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 2019 Update 2019_11_29_RIDIE.docx
Change History for Analysis Plan
Changed On Previous Value
11/29/2019 Pre-Analysis Plan_Final 2019 Update 2019_11_26_RIDIE.docx
11/26/2019 Pre-Analysis Plan_Final 2018_11_16.docx
Other Documents:
Change History for Other Documents
Changed On Previous Value
11/26/2019 Description:
Filename: Pre-Analysis Plan_Final 2019 Update 2019_11_26_RIDIE.docx
Data

Outcomes Data

Description:
A survey questionnaire that asks caregivers to self-report if their infant has received inject-able vaccinations. It identifies vaccinations by age and visit at which it is given, location on the body, and information on the vaccine that caregivers may have received from vaccinators. There is also a don’t know option which we will code as having not received a vaccine in primary analyses. We also collect child health cards and various administrative records stored at clinics.
Change History for Description
Changed On Previous Value
11/26/2019 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.
Data Already Collected?
No
Data Previously Used?
Data Access:
Data Obtained by the Study Researchers?
Data Approval Process:
Approval Status:

Treatment Assignment Data

Participation or Assignment Information:
Yes
Description:
Data Obtained by the Study Researchers?
Data Previously Used?
Data Access:
Data Obtained by the Study Researchers?
Data Approval Process:
Approval Status:

Data Analysis

Data Analysis Status:

Study Materials

Upload Study Materials:

Registration Category

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

Completion Overview

Intervention Completion Date:
Data Collection Completion Date:
Unit of Analysis:
Clusters in Final Sample:
Total Observations in Final Sample:
Size of Treatment, Control, or Comparison Subsamples:

Findings

Preliminary Report:
Preliminary Report URL:
Summary of Findings:
Paper:
Paper Summary:
Paper Citation:

Data Availability

Data Availability (Primary Data):
Date of Data Availability:
Data URL or Contact:
Access procedure:

Other Materials

Survey:
Survey Instrument Links or Contact:
Program Files:
Program Files Links or Contact:
External Link:
External Link Description:
Description of Changes:

Study Stopped

Date:
Reason: