IGC Mozambique Growth Week 2015

In July 2015, The IGC Mozambique hosted a series of three workshops focused on different aspects of inclusive growth: education, health and financial inclusion. Find below the workshops’ summary report. For more detailed information on each of the workshop and related materials please click on the sessions below.

 

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Sessions

Financial inclusion workshop

IGC Mozambique hosted a workshop on evidence-based policymaking for financial development. The workshop was jointly held with the Bank of Mozambique, NOVAFRICA, NOVA School of Business and Economics , and GLM LIC.

This conference included a presentation on the research results and policy recommendations derived from the study “Determinants of Adoption of Electronic Means of Payment”, which is the result of a collaboration between the IGC and the Bank of Mozambique. The conference also featured discussions with a wide range of presenters and panellists, including Professor Dean Yang (University of Michigan and NOVAFRICA), Professor Dean Karlan (Yale University and NOVAFRICA), Dr Pedro Vicente (Nova School of Business and Economics, NOVAFRICA, and IGC), Catia Batista (Nova School of Business and Economics and NOVAFRICA), and Dr Sandra Sequeira (LSE and IGC).

Dr Esselina Macome (Bank of Mozambique) opened the workshop by emphasising the importance of the collaboration between the IGC and the Bank of Mozambique when it comes to understanding the adoption, use and impact of mobile money in Mozambique. Dr Macome outlined the development of electronic payment systems and regulation in Mozambique, which has happened alongside the expansion of the cell phone network. In the last few years, there has been an increase in financial services that can be accessed by cell phone. This has strongly contributed to financial inclusion by providing easy access to services and products for a substantial part of the adult population, especially in areas where it is difficult to access traditional financial services. In order to further continue the work on financial inclusion, collaboration with a range of actors will be crucial.

Dr Claudio Frischtak (IGC Mozambique) echoed Dr Macome’s appreciation of the successful collaboration between IGC and the Bank of Mozambique over the last 4-5 years in the area of financial inclusion. He emphasised the importance of coming together to discuss the results and to identify the way forward for ensuring that financial inclusion is effective in reducing poverty.

Ms Artemisia Gove (Bank of Mozambique) presented the results of a study on the determinants of the adoption of electronic payments in Mozambique, which was performed by the Bank of Mozambique together with NOVAFRICA, under funding from the IGC. The study focused on access to financial services for SMEs in the urban areas of Maputo and Matola, which is considered a key requirement for these companies to expand. The use of electronic payments is still limited. Out of the 1027 firms covered, only 22% used point of sales (POS) services, 4% used mobile banking, and 7% used mobile money. The main determinants for the use of POS were firm characteristics such as size, type, stability, security and access to electricity; the acceptance of electronic payments through mobile phones (mobile banking and mobile money) depends more on characteristics of the business owner, such as age, education and place of birth.

Across the various means of electronic payments, the study highlights the importance of distinguishing between access and use of financial services. Access appears not to be the main constraint to adoption, as the vast majority of the surveyed business owners (75%) have a bank account. The most frequently cited reason for not adopting electronic means of payments is a lack of knowledge about these types of services and how to access them. For example, 26.3% do not know what POS is or how it is used; for mobile banking, this figure was 35.98%.

Among those who have adopted electronic means of payment, satisfaction with the services is generally high. For example, almost half of the respondents using mobile money referred they had never had any problems with the service. However, there are also significant problems reported, including excessive bureaucracy, high fees and the quality and maintenance of networks.

To further spread the adoption of electronic means of payments, it is important to emphasise the advantages of using these services from a business perspective, and to promote and explain the correct use of the services. Ms Gove also recommended government intervention to improve coordination among all actors involved, as well as to reduce the time required by commercial banks to adhere to electronic systems (for POS).

In the discussion that followed the presentation, Dr Macome mentioned that the Bank would like to roll out this study in other cities, and may try to consult other actors about the questions they may want answered, as there was a great interest and requests for further details from a range of actors in the workshop, including mobile money operators and banks.

Sandra Sequeira (LSE and IGC Mozambique) then continued with a presentation on “The Role of Technology and Business Skills in Microenterprise Development: the Case of Mozambique” (ongoing study with Cátia Batista and Pedro Vicente). Over 50% of the urban poor are engaged in some form of microbusiness, and recent experience with mobile banking suggests that low-cost technologies such as cell phones could be an effective means to increase access to financial products and enhance the savings capacities of the poor, which can play a critical role in overcoming credit constraints to the growth and survival of their microbusinesses. However, experiences with such technologies have also highlighted the importance of having the business skills to effectively mobilize and apply these savings for business growth.

The study, covering 1,200 micro entrepreneurs in Maputo and Matola, seeks to answer two key research questions: 1) What is the impact of access to interest-accruing savings accounts through mobile money; and 2) What is the role of business management skills in microenterprise development and growth? Finally, the study seeks to identify the combined effects of savings products and business management skills.

The impact of three different types of intervention is tested; MKesh intervention (adoption of mobile savings account and initial incentives for utilising the service and for saving), business training intervention, and a combination of the two. Although the study is not yet concluded, the preliminary results are encouraging. The business training was well received, and increased the micro-entrepreneurs’ understanding of basic accounting. Furthermore, it reduced transfers to relatives by 14% and increased total sales by 64%. The strongest effect came from the combined treatment of mKesh adoption/use as well as business training. The impact on saving and expenditure is still unclear, and the final results may show more details on this, as well as the mechanism through which increased sales are occurring.

Dean Yang (University of Michigan) presented a study on “Smart Subsidies: How Combining Subsidies with Savings Brings Expanded Benefits to Rural Households” (joint study with Michael Carter and Rachid Laajaj).

A number of anti-poverty programmes are ‘bundled’; they consist of multiple components that are thought to complement each other, with the impact of the joint interventions being greater than the sum of impacts when offered separately. This study tries to understand the interplay of two interventions, agricultural input subsidies and formal savings, in Manica province. There were three savings treatment groups; basic savings, matched savings, as well as the control group. Within each of these groups, a subset of farmers was chosen randomly to also receive a voucher subsidising the purchase of a set of agricultural inputs.

Looking at the results, each type of treatment was successful at raising fertiliser use (although the impact was small and statistically insignificant for the basic savings treatment group alone). Similarly, all treatments increased savings, most dramatically in the treatment groups that received both the voucher as well as one of the savings interventions.

When looking at the impact of the interventions on household wellbeing (measured by daily consumption by capita), however, the results are different; in this case, the subsidies and savings programmes appear to be substitutes rather than complements, with the impact of the joint treatment being lower than the sum of the separate impacts. The results may be explained by understanding the dual role that savings can play in terms of investment and risk management.  Households receiving only a savings treatment use their savings for both purposes, while households receiving both subsidy and savings treatments seem to focus on risk management, leading to no additional impact in terms of the level of consumption.

The results also suggest that savings help households cope with negative agricultural shocks, as household consumption was more sensitive to these types of shocks when receiving the subsidy only. The consumption variance is lower in the savings treatment groups.

Pedro Vicente (NOVAFRICA, Nova University of Lisbon and IGC) presented the preliminary results of a study on “Agricultural Savings and Network Pressure: Experimental Evidence Using Mobile Money in Mozambique” (joint with Cátia Batista and Dean Yang). Savings are crucial to break the cycle of low investment and low agricultural productivity for farmers. The mobile money revolution underway in Africa seems like an opportunity to extend access to savings instruments. This study explores whether access to custom-made savings accounts offered through mobile money increases savings by farmers, and also looks at the effects on fertiliser use. Finally, the study examines whether access to a savings account can counter social pressures to share resources by shielding farmers from such pressures.

The study was carried out with 196 maize farmers in the province of Manica. All of them were introduced to MKesh and also got a module on fertilizer use. The two treatments were the savings treatment and the network treatment, which interacted in a 2 x 2 research design. The savings treatment offered a bonus of 20% interest on the average mobile balance held over a certain period. The network treatment offered the modules on mobile money and fertilizer use to two of the farmer´s closest friends.

The preliminary results show clear effects of access to the savings account on a number of fronts: 1) increasing mobile money adoption; 2) increasing non-frequent expenditures whilst decreasing the likelihood that individuals lend money to their closest farming friends; and 3) increasing fertiliser adoption. Finally, the data suggests that having access to a savings account counteracts social pressure to share resources.

Furthermore, the study indicates that incentivised mobile money agents are vital for both communication and adoption of mobile money; the mere existence of the service is not enough. It also suggests that more work can be done to extend access to interest-bearing accounts using mobile money platforms.

Cátia Batista (NOVAFRICA, Nova University of Lisbon) presented on “An Experimental Impact Evaluation of Introducing Mobile Money in Rural Mozambique” (joint study with Pedro Vicente). Access to financial services in rural areas of Mozambique is still very limited, and mobile money can be seen as a means of financial inclusion in these areas. The main research question in the study is the economic impact of introducing access to mobile money to people in rural areas in Southern Mozambique. The study involved a randomized field experiment, involving 102 locations, with mobile money being introduced in 51 of them using newly recruited mobile money agents and community-wide and individual dissemination.

The preliminary results show good levels of adoption of mobile money; 63% of individuals in treatment areas performed at least one mobile money transaction in the first year after the intervention. Although the number did decrease over the next two years, it did not fall dramatically. Over the period studied, there was also an evolution visible in terms of the types of transactions performed, with the proportion of transactions of airtime purchases decreasing, and an increase in transactions related to remote payments (e.g. electricity) and transfers being received. When it comes to the average number of mobile money transactions, there were no clear trends in the data, though peaks were seen which correspond to the timing of the maintenance of agent networks, highlighting the importance of a well-functioning network and customer support. Similarly, there were no obvious patterns in relation to the average value of mobile money transactions, though there seem to be peaks in the lean season, consistently with the literature on mobile money as an instrument for risk sharing.

In terms of transfers, the probability of the treatment group receiving transfers was higher. The data showed no results in terms of affecting the overall amount of savings, and aggregate consumption does not change significantly. At the same time, individuals in the treatment groups reported being less vulnerable to lack of access to water and lack of medical care, pointing to the role of mobile money in diminishing vulnerability to shocks. In light of the data, this reduced vulnerability is likely to happen through received remittances as savings are not significantly affected

Overall, challenges remain when it comes to the effective utilisation of mobile money, which requires investment in a well-functioning agent network and customer support.

The first discussant, Aurélio Matavel (mKesh), highlighted that access is still a very important element when it comes to populations living in rural areas, relating to the major challenge of establishing and servicing agent networks. Another key challenge is establishing and increasing trust in a system of electronic payments. Moving from cash to electronic means of payments is a change of paradigm, and so the process will take time, even in urban areas.

The second discussant, Dylan Lennox (M-Pesa), sees mobile money and mobile banking converging in a number of ways recently. He also emphasised that whilst competition in the market is good, collaborative competition in the area of financial inclusion is both critical and good due to the high costs involved of building agent networks and customer education. As such, collaboration across different actors and institutions is welcomed. Mr Lennox also summarised some of the key lessons from the earlier presentations, and emphasised in particular that the technology is necessary but not sufficient. Having a solid and sustainable network and infrastructure is crucial, as well as continued servicing of agents and education of both agents and customers.

Dean Karlan (Yale University and Innovations for Poverty Action) delivered a presentation entitled “Financial Inclusion: A Means to an End”. Professor Karlan emphasised the importance of remembering that financial inclusion in itself is not an end; statistics often cited do not actually tell us about the quality of the services or whether it satisfies the needs of the population. It is often difficult to know what to do or what outcomes to measure. Furthermore, many studies in the past show correlation, and not causation. To highlight this, Professor Karlan used evidence from seven RCTs in seven different countries exploring the impact of the traditional microcredit model. The model, whilst it may have other positive effects, does not effectively help with poverty alleviation. Professor Karlan emphasised the importance of two guiding principles for designing programmes: 1) evidence trumps hope and intuition; and 2) it is essential to design for humans and how they actually behave, rather than how one might think they should behave.

Some alternative microcredit programs with certain adapted loan features that are currently being implemented show encouraging signs in terms of impact, highlighting the importance of making the lending model fit better to the actual needs people have. Similarly, interventions in the areas of micro-savings and micro-insurance that incorporate features which address both transaction costs and behavioural factors are also showing encouraging results so far.

Pedro Vicente (IGC, NOVAFRICA, and Nova University of Lisbon) concluded the workshop, thanking the Bank of Mozambique for the successful collaboration and the opportunity to contribute to knowledge on the Mozambican economy. Aurora Bila (Bank of Mozambique) closed the conference, noting that the presentations generated a lot of interest across the spectrum of actors and that the Bank of Mozambique would like to continue the partnership to follow-up on already completed studies as well as undertake research in new areas of interest.

Overall, the studies presented at the workshop generated a lot of meaningful discussions on the respective roles of the various actors and stakeholders in the mobile money environment. The debate left no doubt that the perceptions on mobile money have evolved in recent years. Whereas the banking sector may at first have been hesitant about the prospect of mobile phone companies entering its traditional sphere of activities, the discussions during the workshop really recognized the complementarities between traditional banks and mobile money operators. At the same time, the banks are now also starting to develop new products resembling mobile money. As such, the relationship will surely remain a dynamic one, with complementarities across the board while competing in specific sub-areas. The IGC Mozambique has played a critical role in shaping these discussions through its 4 year research collaboration with the Bank of Mozambique. This workshop was a prime example of how the IGC can actively contribute to an effective and impactful dialogue among market players, with a view to strengthening financial inclusion in Mozambique.

Education workshop

IGC Mozambique jointly hosted with the Ministry of Education, a workshop on evidence-based policymaking in education, with a focus on the case of Conditional Cash Transfers (CCTs).

This workshop featured an opening speech by Dr Ivaldo Quincardete (National Director for Secondary Education, Ministry of Education), as well as a series of presentations by Dr Laura Poswell (Executive Director, JPAL Africa) on lessons from JPAL on successful partnerships for evidence-based policymaking, Dr Damien De Walque on a cross-country study of cash transfers and educational outcomes as well as the results from a pilot study funded by the IGC on reducing female drop-out rates in Mozambique, and a presentation by Dr Yolanda Sitoe on the preliminary evidence on constraints to skills, and job opportunities for young women, adolescent girls and marginalised youth in Mozambique. The detailed programme is included in the listed documents to the right.

Ivaldo Quincardete, the National Director of Secondary Education at the Ministry of Education of Mozambique, delivered the opening speech, emphasising the Mozambican Government’s strong belief in the right to education for all its citizens. He highlighted that the government is working to promote the continued development of education in cooperation with its partners. The gender aspect is of prime importance, which is reflected in the government´s Strategic Plan for Education striving for gender equality and a reduction in the number of female drop-outs. Dr. Quincardete mentioned existing challenges and stated that the workshop is a good example of the continued collaboration between the government and its partners to overcome such challenges and promote quality education for all Mozambicans.

Laura Poswell, the Executive Director of JPAL South Africa, presented some lessons on successful partnerships for evidence-based policymaking. She explained that there are various strategies that can be used to increase secondary school attendance, for example by addressing health issues that prevent school attendance or reducing the costs of schooling. The challenge is to identify the most effective way to do so. Randomized evaluations help as they can establish a credible comparison between the outcomes of interventions and what would have happened in the counterfactual situation without them.

Dr. Poswell spoke about CCT programmes and their ability to break short-term liquidity constraints and help long-term savings. The aim of CCTs is to break the intergenerational cycle of poverty through encouraging investments in education and health. CCT programs have been implemented in over 30 countries and impact evaluations of these programmes have consistently generated evidence of increased school attendance. The Progresa program in Mexico was cited as an important example, not only for being one of the first large-scale CCT programs but also for having set a precedence for integrating rigorous impact evaluation into the programme design right from the outset. Without this feature, which allowed the effective communication of credible results, the expansion of the program until today would have been unlikely. The evaluations have shown that Progresa has increased school attendance, but no significant impacts have been found on learning outcomes.

The design of CCT programs has remained remarkably stable, considering that they have been implemented in many different countries over the past two decades. Recent years have seen various Randomized Control Trials (RCTs) to test the effect of changes in the timing and size of the transfers. In Colombia, for instance, it was found that reducing the monthly transfer by 30% did not result in lower attendance. Another question is whether the conditionality aspect of CCTs is essential for their effectiveness. The first study to test this was done in Malawi and showed that conditional transfers led to more significant improvements in enrolment, attendance and learning outcomes than unconditional transfers. Nevertheless, Dr. Poswell acknowledged that this is just one example and that the results of later studies on the importance of conditionality are mixed.

Damien de Walque (World Bank) presented a cross-country review on cash transfers and educational outcomes. He argued that promoting gender equality by closing the education gap in Mozambique would increase the GDP per capita growth rate by 0.3 percentage points. He pointed out that both CCTs and UCTs (Unconditional Cash Transfers) have led to improvements in enrolment and attendance. The effect sizes are larger for CCTs in comparison with UCTs, although the difference is not statistically significant. However, when looking only at CCTs with effective monitoring mechanisms and penalties for non-compliance, the effects are substantially larger than for UCTs.

A further element in this discussion is the effect of programs on the enrolment of ´marginal´ children. Dr. de Walque explained that parents are already more likely to make educational investments in high ability children, and that conditionality pushes parents to enrol the ‘marginal child’, namely girls, young children and low ability children. He went on to discuss the effects of varying the recipient of the transfer, presenting evidence that CCTs given to women tend to produce better educational outcomes, while CCTs given to fathers lead to better nutritional outcomes and increased housing investments.  Finally, there is a debate on whether it is better to provide incentives to the parents or to adolescents, given that the views of parents and children on optimal investments in human capital may not align. Although most studies have not obtained conclusive results on this matter, evidence from Brazil does show that parents attach value to the monitoring feature of CCTs, which serves to reduce information asymmetries between parent and child.

Damien de Walque (World Bank) gave a second presentation on a proposed Randomized Control Trial (RCT) to provide rigorous evidence specific to Mozambique on several unanswered questions. He started out by stating that Mozambique has traditionally suffered from low levels of human capital, and arguing that the existing body of international evidence on the positive impact of CCTs suggests that this could potentially be a beneficial road for Mozambique to follow.

The proposed RCT would seek to determine whether it is optimal to provide financial incentives to parents or to provide incentives to adolescent girls in the form of tokens that can be used to purchase a specific set of school-related items. The evidence presented from Brazil of parents attaching value to the monitoring feature of CCTs implies that simply providing information to parents on children´s school attendance could by itself raise attendance. A third treatment arm in the RCT would investigate this hypothesis by giving out certificates of exemplary attendance.

Yolanda Sitoe (DFID) presented preliminary evidence from qualitative research on the constraints to benefiting from skills and jobs opportunities facing young women, adolescent girls and marginalized youth in Mozambique. The evidence so far does not point at a systematic pattern of gender-related discrimination regarding access to vocational training or jobs. However, the responses do hint at the important role of gender roles in influencing adolescents´ occupational choices.

It was found that youth generally recognize the value of skills training, but that the main constraints faced by adolescents in accessing training opportunities are the lack of information and the lack of financial resources. Professional training institutes are mostly unknown among this group. Looking at gender-specific issues, the current range of professional training programs is largely focused on jobs that are traditionally considered as masculine. Such gender stereotypes act as a further constraint to adolescent women in accessing training opportunities.

In the debate that followed the presentations, some of the participants raised doubts on the feasibility of introducing Conditional Cash Transfers in Mozambique, citing sociocultural and financial sustainability concerns. Laura Poswell recognized that there are many different factors at play in explaining the school attendance of girls and that those factors also differ across countries. She cited one example where it was found that intestinal parasites leading to health problems were the binding constraint on school attendance, so that deworming pills turned out to be the most effective intervention for raising attendance rates. She therefore mentioned the need to understand the specific obstacles in each case, although stressing at the same time that CCTs have been found to improve attendance across highly diverse countries and contexts.

Damien de Walque echoed her comments, recognizing that any CCT has to be tailored to the local context and that these programs should not be seen as substitutes for civic education campaigns to convince people of the importance of schooling. Regarding the financial sustainability, the panel members stressed the importance of identifying interventions that are low-cost yet highly effective.

Ivaldo Quincardete closed the workshop, by thanking the presenters for sharing the interesting experiences of other countries. The issue of raising female school attendance is of great concern to the government, and the Ministry of Education will be looking forward to evidence specific to Mozambique and to continue the discussions on this important topic.

 

 

Health workshop

IGC Mozambique jointly hosted a workshop with the National Institute of Health on research into primary healthcare, and more specifically on how to generate evidence to support policymaking in the health sector.

This workshop included an opening speech by Eduardo Samo Gudo (Scientific Director, National Institute of Health), as well as presentations by Dr Laura Poswell (Executive Director, JPAL Africa) on lessons from JPAL on partnerships between researchers and government for evidence-based policymaking, Dr Marcos Vera Hernandez (University College London) on scientific research in the area of primary healthcare,  Dr Damien de Walque (World Bank) on community-led interventions and the improvement of primary healthcare, Dr Sergio Chicube (National Institute of Health) on the evaluation of the implementation of the esential functions of the public health service at the district level, and Dr Sandra Sequeira (LSE and IGC) on the IGC project on management interventions at the clinic level to improve antenatal care in Mozambique. The detailed programme can be found below.

Eduardo Samo Gudo (National Health Institute, Ministry of Health of Mozambique) delivered the opening speech, welcoming the opportunity to discuss economic research on the management of the health system. He stressed that most of the research carried out by the Ministry is of a clinical nature, and expressed his hope that the workshop would result in more partnerships for research on aspects of health management in Mozambique.

Laura Poswell (Executive Director, JPAL South Africa) discussed ways to improve health worker productivity and attendance, and referred to a study conducted in India aimed at improving the attendance of health workers through performance pay incentives. This study showed that the problem is not the incentives themselves, but rather the way they are implemented: incentives can work to change modes of behaviour, but the specific design of how these incentives are delivered and administrated may be the obstacle. In this case, the relationship between the nurses and the members of staff responsible for monitoring attendance served to hinder any potential impact of increased worker attendance because the monitors were reluctant to deduct nurses’ pay. In a different intervention, an alternative approach to monitoring teachers’ attendance proved very successful: to request teachers to take pictures of themselves with their students twice during the school day, using cameras with a timestamp feature. Dr. Poswell highlighted that incentive programmes can work if administered effectively but that the design is key to ensure success.

Dr. Poswell also discussed the effect of community monitoring and community participation programmes that aim to improve health worker productivity and attendance, explaining that, generally, such programmes are not very effective. In contrast, career incentives at the recruitment stage can have a positive impact on worker productivity by selecting more productive health workers, as shown by a study conducted on recruiting and motivating community health assistants in Zambia.

Marcos Vera-Hernandez (UCL) emphasised the importance of child nutrition and its impact on a child’s development, especially during the early years. He explained that the causes of malnutrition are complex and diverse, and gave examples of deeply rooted ‘unhealthy norms’ that exist in parts of Africa, such as the idea that eggs are unhealthy for children to consume. Dr. Vera-Hernandez argued that intensive communication strategies are required in order to break these norms that have been passed down from generation to generation. He explained that home visits in Malawi seem to have promising and positive effects on changing norms and practices. He compares this to an alternative strategy using women’s groups; such groups for child and maternal health issues have been seen to work well in Nepal and India. This could be a more effective way to break norms, allowing for stronger collective action. However, as Dr. Vera-Hernandez mentions, the drawback of such a strategy is that it relies on women attending the group rather than the health worker making the home visit. He suggests that a study is needed to compare both approaches and their effectiveness, and that perhaps a combined approach should be introduced.

Dr. Vera-Hernandez also discussed health insurance as a way to build effective and responsive health systems, highlighting that the percentage of the population with health insurance is increasing in many parts of the world with a big push in the international community for greater health care coverage. He compares insurance-based and zero fee health systems, explaining that in the former, money follows the patient so that the patient is empowered and can choose which health facility to go to. In a zero-fee system, on the other hand, the money follows the facility and therefore the facility does not have an incentive to work hard to increase the number of patients utilising its services. The Colombian experience with universal health insurance shows positive results, demonstrating increases in curative and preventative care visits and a fall in health expenditure.

Damien de Walque (World Bank) discussed community-led interventions and the improvement of primary healthcare. He explained that one prominent idea to improve public service provision is to enhance beneficiary involvement, empowering users of public services. He compares the impact of two alternative interventions in Uganda that shared a similar package of process-based components aimed at enhancing beneficiary involvement. This included the facilitation of meetings between the provider and the user (health facilities and community groups) with the final outcome being a joint action plan identifying issues to be addressed and how to address them. The two different interventions were a ‘participation only’ and a ‘participation and information’ intervention where in the latter, quantitative information on health facilities and staff performance was disseminated as part of the process of agreeing on a joint action plan. The results showed that the ‘participation only’ intervention yielded no significant differences in outcomes, whereas the ‘participation and information’ intervention resulted in large and long run improvements in both service provision and health outcomes. Therefore, the results suggest that unless the community has access to objective information on staff performance, community involvement is not likely to have much of an impact. Dr. de Walque explains the results by describing the role of information as allowing clients to distinguish between the lack of effort of the provider (local level) and a lack of resources assigned to the facility (higher level). He explains that it addresses information asymmetries and allows for action plans to focus on activities actionable at the local level. He finds that the percentage of local actions is much higher in the joint action plans of those facilities receiving information.

Sérgio Chicumbe (INS – Ministry of Health) presented on a pilot to evaluate the performance of the health system in Mozambique in the delivery of its core functions at the district level. The pilot was based on the Essential Public Health Functions (EPHF) framework, which defines eleven core functions of national health systems. This approach was found to be helpful for identifying the core functions that present most scope for improvements at the level of each particular district. Furthermore, it promoted much more active participation by health staff members themselves in the evaluation process than is common in regular supervision visits carried out by the Ministry of Health. This was found to stimulate self-reflection of district-level health officials on their strong points, their weak points and opportunities for improvements.

Sandra Sequeira (LSE) presented on managing primary healthcare resources, and in particular scheduling medical appointments for ante-natal care (ANC) visits in Mozambique. Dr. Sequeira explained that universal access to health care and free maternal care raises the question of how to deal with large patient flows, particularly in the context of health care worker shortages. These forces can generate long queues and waiting times that carry significant costs, both from the demand side and the supply side. The demand for health care services can be directly impacted by long waiting times. Furthermore, when health workers have to operate with large queues of patients waiting outside, the resulting pressure can lead to a deterioration of the quality of the health services provided.

Dr. Sequeira presented a research project where a simple scheduling system for maternal care visits will be introduced at the clinics in the treatment group.  The research is designed to test the impact of this low cost intervention in the management of patient flows on the quantity and quality of health care services demanded by patients and provided by health care workers.