Household and Provider Behavior in the Health Sector in Africa : What Has Been Learned from Program Evaluations?

Despite a number of dramatic successes in health in the decades since independence, Africa remains behind most of the developing world in child and other health indicators, and progress in child health has slowed considerably in the last two decades. This paper examines evidence on the effectiveness of health interventions in the region, with a focus on policies designed to change the behavior of consumers (households) or health care providers. It begins with a discussion of approaches to program evaluation, with particular attention given to the benefits and limitations of randomized controlled trials (RCTs). Next, the issue of program take-up (household demand behavior) is considered, with evidence presented from RCTs and other sources on the impacts of positive pricing (and subsidies), service quality, and the role of behavioral and health externalities. Turning to the supply side, a number of policies to improve quality or coverage are discussed, including community monitoring of public health care providers, performance-based pay, and contracting with the private sector for service delivery. Also considered are the debate over, and policy options to counteract, negative supply side impacts of the free provision of health goods and services. The paper then reviews the evidence on interventions in Africa to reduce child morbidity and mortality from diarrhea illness and malaria, as well as evidence on community health programs that directly address the problem of low uptake. The final section summarizes the main findings from the literature and concludes with several observations on methodology and evaluation