 The next speaker is Caroline Ochieng, also from Stockholm Environment Institute. She will be speaking about an interesting community project in Kenya, and it's about the financial incentives to promote health. I believe it's aimed around pregnant women, and it's a rather innovative thing, and it's attracted quite a bit of attention, both in the region and amongst funders as well. Welcome Caroline. The topic of my presentation is the feasibility and potential sustainability of financial incentives for health, and in this case the focus is on pregnant women in Kenya. So I'm a researcher based at Stockholm Environment Institute here in Sweden, where we've been working mainly on household energy issues and health as well. Yeah, so a bit of a background to this project. So we have very high maternal mortality in sub-Saharan Africa, and you have, I mean we are coming to the end of the Millennium Development Goals, which called for 75% reduction in maternal mortality ratio, but there's been very slow progress in this, and you can see where you have a greater than or equal to 1,000 deaths, 100,000 live bats, it's mainly in Africa region. And I think all the presentations here brought out some of the factors you're talking of in poor water and sanitation, and the diarrheal diseases, and the use of biomass fuels in the air pollution. All those are among the main contributors to the high rates of maternal mortality that we witness. So quite a number of environmentally related factors. So focusing on Kenya is among the countries where you have highest maternal mortality rates, you're talking of 360 maternal deaths per 100,000 live bats. And when you look at the causes of these deaths, most of them can actually be prevented. And especially if women come into contact with the health care services when they are pregnant and throughout the course of pregnancy. And that entails anti-natal care clinic visits and delivering at the health facility and also post-natal checkup. And with A and C especially, the benefits can be quite substantial, not just in terms of early detection of complications, but it's also a very good avenue for bringing in other interventions, whether it's health, education, or maybe the need to use efficient cook stoves or on the need for clean water and sanitation. It provides a very good opportunity for getting into contact with women at that point to offer these extra services. But then you find very low rates of attendance for these services. So when you try to focus on the reasons of why you have this, and maybe I would like to emphasize that although this project is looking at pregnant mothers and attending clinics, but the same challenges encompass all the other issues related to water, sanitation, cook stoves and so on, there are so many underlying reasons why people do not use the technologies that work. So the science of technology development is going on, has gone on quite ahead, but there's very low knowledge on why people behave in certain ways they do. So in this case you have a proven technology that if women could attend A and C services and receive those targeted interventions at that stage, then you'd have better health. So if people use water, hand washing and so on, it's known that it works but then people don't use them. So in this context then there are issues that are directly financial costs like if women have, there's no transport to take them to the clinics or to take them to hospitals. So even if they know they need to go, then they would not go. But those are the direct ones and there's been a tendency to focus on those, but then they are also very high in direct costs associated with this. For instance, if a mother is to go and spend three days in a hospital giving birth, who cares for the remaining children at home? If they are to spend a whole day traveling to go to clinic, then who is there to go to the farm or to do all those other services? So there's high opportunity costs associated with this. That then makes one note to be able to take on that recommended behavior. So this project is looking at personal financial incentives. And from behavioral economics, it's that individuals commonly holding consistent preferences for similar outcomes occurring at different points in the future. And then you have outcomes in your future are valued more than those in the distance. So going for clinic is good for the health of my baby who will be born nine months later. I don't know what exactly the outcome would be. But then I have to miss going to the farm today. And that's more important to somebody than a lady. And if I pit like on the cookstove issues, I've worked a lot on. So use this stove. It's going to be good for your health. You are not going to develop chronic obstructive pulmonary disease later, but we are talking of 30, 20 years maybe down the line. But in the meantime, okay, it means I have to cut my wood into small pieces and so on. Or I have to purchase it. So then, and that limits people taking rather adopting this kind of interventions. So you have PFI's which have been used and have shown quite success in the developed world. So for example, given a few examples. So like weight loss programs if you go in the UK, for instance. So you lose some pounds and you are given some cash. Or there are programs that pay employees, people are given money to quit smoking. So you have under justification is that if people get sick from these complications, then you are going to spend much more treating them. But to give them this immediate reward, then they would take up such a behavior, which is positive for their health. So they do it for the money reason rather than for the health reason. Although behind it, you know that you are targeting them. So let me talk more about this project. So which was funded by the Gates Foundation for the pilot phase. So the idea is to test if using personal financial incentives can retain women in the continuum of care from early pregnancy till birth and postpartum period. So from the available evidence, women do go for these antenatal clinic visits, but they only go once. And most of the time they go very late in pregnancy. But ideally, WHO recommends they should go for four visits and then give back in the health facility and come back for postnatal follow-up. So you need six continuous visits. You miss one and it doesn't quite work the strategy as it should. So we will be using cash. The values have sort of reduced. This was what we had initially, but we've been told you can actually manage it at much lower cost so we might enroll more women. So the idea is to get 200 women who are pregnant. At the stage we enroll them, we give them a card with a cash value. And then if they honor their next appointment, they get a high amount. So the amount of money they get increases. So that the last visit, which is to bring back the baby for final checkup, then they get the maximum amount. So with this, the idea is that they would come for all their visits compared to, and then we make a comparison with the rest of the population where this incident is not possible. And the aim is to assess if the PF5 can actually influence health behavior in this regard. So I'm approaching it from a research perspective rather than a program, testing the hypothesis if it can work. And then to see if it's feasible to implement it in this setting. And if it is feasible and if it's shown to work, then later do a randomized trial or a big study to actually demonstrate if it's successful. Yeah, and if it's successful then you can have very significant outcomes. Say if it's a program scale. Because from research you see that just A in C visits can lead to up to 65% of lives saved in Africa. And giving birth in hospital can lower the deaths that occurred delivery by up to 50%. Then like I was saying if it's successful then it's also a method that can be replicated to other behavior of determinants of health. So where people struggle to internalize the benefits. So you give financial incentive but for a targeted period of time. So that then they are able to see that actually this service can benefit me. And after that then you probably do not need an incentive anymore. So then they would have known and internalized the benefits for themselves. Yeah, so this is our time plan. We are currently at the planning phase getting all approvals then to implement the pilot project which you run for 18 months period. Okay, leave that one there so we can see the website. Thank you. So any questions to Caroline Ochieng? I think all of us who have been born in the north know that our mothers received some sort of child allowance to make sure you didn't starve. But this thing about the incentives to make sure that you even get born and that the mother stays alive. That's interesting. Thanks Caroline. I just had a burning question because you know this whole thing as I'm listening to her. I'm wondering how she would see that having heard what health clubs can do. How she would operationalize this concept because I think the idea of rewarding women coming for consultations is brilliant. But how do you roll it out and how do you operationalize it? Wondering if she could see the role of a community health club in this context? I mean I think this would be a very, if you are to roll it out it would be very expensive if you are to be offering every mother some reward for each visit they make. So you can't do it with everyone. But I mean from what I've heard of the community health club it looks like it's something that maybe if you could link with the clubs then maybe you could have it out as like some lottery system or something that you are a part of the club. And then maybe if you participate maybe you have an opportunity to win and then you'll get this kind of services. Then in which case you've involved everybody or yeah so it becomes a reward for participating. And it looks like it would be an incentive also for then people to join such clubs. From what I've read in other countries they develop some of the ways they've tried these approaches. Yeah have lottery tickets so you win and then you get this rather than just giving out to everybody. So everyone still participates but then you have an equal probability of maybe winning this cash value for every visit you make. It's the motor to health insurance. When a life is worth something then you can see that countries start insuring their citizens. And I think this is a few like the beginning of it. I think through the CHCs you'd have that you could house it and of course it's an integrated part of it.