An evaluation of a Community-based Information Campaign on Health Demand in Mali 

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Experimental design

The program

The health product we focus on in this paper is a new prevention program called Personalized Actions Programs (PAP) implemented by the Retirement Insurance agency since 2004. An evaluation of the needs of the elderly person is performed by a caseworker mandated by the Retirement Insurance agency during a home visit. After observing the living environment and interviewing the elderly person, the caseworker recommends support and services all aimed at reducing the risk of dependency. The Retirement Insurance agency supplies nancial support for a large range of services : home help, tele-assistance, housing adaptation, bringing of meals or prevention workshops on di erent subjects.
In this study, we focus on home adaptation. This program o ers nancial sup-port for minor housing adaptations that help elderly people to perform activities independently and safety at home. It aims at limiting physical environmental bar-riers, facilitating mobility and reducing the risk of falling (Iwaksson and Isacsson, 1996). Grab bars, external handrails, stair-rails, ramps or alterations to steps are examples of the proposed adaptations. We focus on home adaptation for several reasons. First, the presence of home hazards is important in predicting falls at home, specially among the more vigorous retired people (Northridge, Nevitt, Kel-sey, and Link, 1995). Despite the e ctiveness of home adaptation measures (Hey-wood, 2001), it is still one of the less-demanded services among those o ered by the Personalized Actions Programs (PAP). 350,000 retired people bene t from a PAP each year but only 15,000 among them accept having their home adapted (around 32 demand for prevention among elderly 4%). Caseworkers face huge di culties in convincing elderly persons to adapt their homes.
To bene t from the program, persons have to contact the Retirement Insurance agency to submit an application. When accepted 4, the demand is transmitted to one of the mandated service providers. Needs are evaluated by a caseworker visiting the seniors’ place of residence. However, the senior herself takes the decision to implement the recommendations and is in charge of the practical aspects. The Retirement Insurance agency o ers a means-tested percentage of total outlays as nancial support

The randomizations

In partnership with the Retirement Insurance agency, we sent 14 yers randomly in three waves (September, October and November 2011). All individuals in the treatment groups (42,079 retired people) received a yer. Each yer corresponds to a speci c treatment aiming at increasing take-up for the program. The 14 yers provide di erent incentives to contact the Retirement Insurance agency. The phone number of the Retirement Insurance agency was clearly indicated on each yer (see yers in Appendix). Calling this number to ask for the application form is the rst step in the demand process. A description of each yer is provided in Table 2.1.
We design a rst yer which merely gives only a simple description of all the ser-vices o ered by the Retirement Insurance agency and brie y presents the prevention program. It does not contain any speci c incentive. This yer will be considered as the control in the experiment. Our basic comparisons will contrast take-up in each treatment groups with take-up in this control group.
Treatment yers all have a similar format. To the information provided by the control yer, we add only a speci c incentive message. Whereas the control yer is a simple sheet printed on both sides recto verso, treatment yers have a 4-page format (see yers in Appendix). We implement two mains categories of treatment. The rst group of treatments focuses on altering the cost of the program. The second category of yers provides information and test manipulations of the frame.

Changing the cost

With the rst set of yers, we aim at nding out how demand for prevention depends on price and if price may be constituting a barrier to home adaptation. We base our analysis on a standard classical model with rational individuals. Consumer make decisions comparing costs with the bene ts deriving from the product. This model predicts that the level of demand is correlated with the expected gains relative to the price of the product. In their paper on demand for insurance against rainfall in rural India, Cole et al. (2010) nd that price has an impact on demand. Several studies on preventive health products con rm these results on the crucial role played by costs 5.
The rst set of manipulations aims at reducing monetary costs. It makes it pos-sible to measure price elasticity following a methodology close to Cohen and Dupas (2010) or Ashraf, Berry, and Shapiro (2007). A rst treatment yer provides only in-formation on the nancial support o ered by the Retirement Insurance agency. The amount of the subsidy, depending on income, is presented in the yer. A simple table indicates the percentage of subvention for each category of income. The amount va-ries from 27% for a household earning more than 2,246 euros a month to 90% for a household earning less than 1,374 euros. Two di erent scales are presented, one for persons living alone and one for couples. A concrete case is presented as an example to facilitate understanding. Despite the subsidy o ered by the Retirement Insurance agency, the price might still be considered as exceeding the expected bene ts as-sociated with the program. The second and the third yers are exactly the same as the previous one but they o er an extra subsidy of respectively 15 and 35%. A nal yer speci es that the housing adaptation is totally subsidized. For these three yers, an example presents the amount which would be paid without the subsidy and the amount with the subvention. We will compare the level of demand between groups receiving the yer without extra subsidies and groups receiving these last three yers. The main goal is to measure the sensitivity of demand to price. Finally, we test the impact of a short-run subsidy of 20% conditional on a commitment in the 15 days after receiving the yer. This yer is devoted to testing procrastination behaviors (O’Donoghue and Rabin, 1999). The assumption is that people are par-tially time inconsistent and present-biased and tend to postpone their decisions to invest in prevention. A small time-dependent discount could change the behavior of procrastinators (Du o, Kremer, and Robinson, 2009) and increase their take-up for the program.
Nonmonetary costs have also to be considered. Indeed, the demand process for home adaptation is complex and often obscure in its details (See the description of the program for more details on the di erent steps of the demand process). We test a manipulation aimed at reducing nonmonetary costs by making the application process clearer with pictograms and a well-described set of simple steps to follow.

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Providing information

This second category of treatment aims at providing information. We make the assumption that people are not perfectly informed on the risk and consequences of a fall and do not correctly perceive the bene ts of the preventive program. These treatments have two main goals. We rst test how powerful providing information is 36 demand for prevention among elderly at increasing take-up for the program. We then follow previous experiments showing that consumer behaviors are very sensitive to the framing of information (Downs, Loewenstein, and Wisdom, 2009; Urbany, 1986; Bertrand, Karlan, Mullainathan, Sha r, and Zinman, 2010). Mainly based on the growing literature in psychology, these papers point out the in uence of context on consumers choices. In a randomi-zed experiment conducted on the South African credit market, Bertrand, Karlan, Mullainathan, Sha r, and Zinman (2010) nd results inconsistent with the standard economic models and provide evidence that psychological features impact consumer decisions. We manipulate three categories of psychological features.

Table of contents :

1 Introduction generale 
1.1 Developpement de l’ore et insusance de la demande
1.2 Comprendre les determinants de la demande
1.2.1 Des biens trop co^uteux ?
1.2.2 Un manque d’information ?
1.2.3 Des individus peu rationnels ?
1.2.4 Quelques elements de reponse
1.3 Evaluer des programmes visant a augmenter la demande
1.3.1 Methode d’evaluation
1.3.2 Le r^ole de l’information
1.3.3 L’approche communautaire
1.3.4 L’espoir d’une amelioration ?
1.4 Mesurer l’eet de changements organisationnels sur la sante
1.4.1 Depreciation du capital sante
1.4.2 Des dicultes methodologiques
1.4.3 Strategie d’identication
1.4.4 Contributions
2 A eld experiment on the demand for prevention among elderly 
2.1 Introduction
2.2 Experimental design
2.2.1 The program
2.2.2 The randomizations
2.2.3 Sample selection
2.3 Results
2.3.1 Overview
2.3.2 Acting on demand
2.3.3 Changing the cost
2.3.4 Providing information
2.4 Additional Findings on the Decision-making process
2.4.1 Non-response and selection bias
2.4.2 Summary statistics
2.4.3 Decision-making process
2.5 Conclusion
3 An evaluation of a Community-based Information Campaign on Health Demand in Mali 
3.1 Introduction
3.2 Background
3.2.1 The Malian health system
3.2.2 The program
3.3 Data
3.4 Identication Strategy
3.5 Results
3.6 Conclusion
4 Organizational Change and Workers’ Health : Lessons from the 2000 Reform in the French Energy Utilities 
4.1 Introduction
4.2 Institutional background
4.3 Data and descriptive statistics
4.3.1 The GAZEL database
4.3.2 Descriptive Statistics
4.4 Empirical approach
4.4.1 Identication strategy
4.4.2 Econometric model
4.5 Results
4.5.1 Impact on working conditions
4.5.2 Impact on health
4.6 Robustness checks
4.7 Conclusion


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