Impact Evaluation of the Marketing Innovation for Health Project in Bangladesh

Marketing Innovation for Health (MIH) is an integrated social marketing project funded by the United States Agency for International Development (USAID)/Bangladesh that is designed to provide comprehensive health and family planning education, products, and services in 19 priority districts of rural Bangladesh. As part of this evaluation, outcome monitoring activities tracked changes in key knowledge and health indicators between the baseline and end line surveys, and the impact evaluation assessed the effect of the MIH intervention on health knowledge and behaviour in intervention areas in relation to what was observed in comparison areas. The findings of this evaluation will serve to: (i) establish the impact of MIH interventions in rural, low-performing areas of the country, (ii) help USAID/Bangladesh design the next phase of the MIH programme, (iii) enhance learning and showcase for other donor-funded health projects what has worked in the MIH interventions, and (iv) add to the evidence base for integrated social marketing successes of health and family planning in low- and middle-income countries.

USAID/Bangladesh awarded the MIH project to Social Marketing Company (SMC), Bangladesh in July 2012 for a duration of four years. The project was carried out by SMC in collaboration with four partner non-governmental organisations (NGOs): BRAC, Concerned Women for Family Development (CWFD), Population Services and Training Centre (PSTC), and Shimantik. The goal of the project was to contribute to sustained improvements in the health status of women and children by increasing access to and demand for essential health products and services through a private-sector approach. The rationale for this approach was that increased awareness coupled with increased access to services at the doorstep would improve healthcare utilisation. Hoped-for results included: (i) Increase availability and reach through expanded commodity sales and distribution through private sector networks including NGOs at an affordable price to support family planning and other healthy practices, especially among low-income populations. Sub-results included: increased distribution and sales of reproductive health (RH) products and a secured supply of contraceptive commodities; increased distribution and sale of oral rehydration solution (ORS) and zinc, safe delivery kits, and other maternal and child health (MCH) products; increased distribution and sale of products for improving the nutritional status of children; and increased distribution and sale of new and innovative products using social marketing techniques. (ii) Improve knowledge and healthy behaviours, reduce harmful practices, and increase care-seeking practices while reaching out to new audiences (youth) through creative behaviour change communication (BCC) - with the sub-result of improved health communication activities to reach new user populations.

More specifically, demand creation or awareness-raising was done through BCC by deploying newly created and project-paid community mobilisers and through other media. Several BCC and information, education, and communication (IEC) materials were developed to improve knowledge and promote healthy behaviour in the community. These materials were used by the community mobilisation teams through interpersonal contact and group sessions like courtyard meetings. Increased access to health products and services was done through deploying newly recruited nonsalaried and entrepreneur community sales agents (CSAs) who sell their products for profit and conduct house-to-house visits. Health messages developed by SMC were disseminated in the form of a booklet used during community mobilisation activities and through an audio drama called Notun Diner Golpo. The messages covered issues on maternal, child, and adolescent health, and prevention of tuberculosis (TB). An estimated 40 million people in 19 priority districts were covered by MIH interventions.

The MIH evaluation was based on a prospective, quasi-experimental difference-in-differences design and data from representative household surveys conducted in BRAC and CPS intervention areas in 2013/2014 (baseline) and 2015/2016 (end line) in a panel of clusters. The unit of interest was married women of reproductive age (15-49), or "MWRA". The comparison group was obtained from adjacent areas to maintain similarity in individual, household, and community conditions. MEASURE Evaluation conducted both the outcome and impact evaluations in collaboration with Mitra and Associates and Bangladeshi researchers. The evaluation design permits for the examination of changes and estimation of programme impact separately for BRAC and CPS areas ("CPS" collectively refers to the MIH intervention areas of CWFD, PSTC, and Shimantik), meaning that the impacts of these two groups of implementing partners can be measured distinctly.

Table ES.1 on page 13 presents sample population means (percent) and impact estimates (percentage point) for the key MIH outcomes of interest at baseline and end line in intervention and comparison areas. Specifically, there was a significant increase in client-worker contacts and in women's knowledge and use of health products and services, as the project intended. The researchers found that all of the knowledge indicators increased over time in MIH intervention areas and that the MIH programme had strong and significant impacts on these outcomes. (An example would be % MWRA who could accurately report two specific risks/complications associated with pregnancies after age 35, which saw more than a 20 percentage point impact.) Health product and service utilisation also increased in MIH intervention areas over time, and the researchers found significant programme impacts on use of micronutrient powder (MNP) among young children, use of sanitary napkins, receipt of four or more antenatal care (ANC) visits, and use of safe delivery kits during home births. No overall MIH impact was found for facility delivery or modern contraceptive prevalence. There were differences in the performance of BRAC and CPS in some of the indicators considered, which is possibly due to organisational, policy, and fieldworker differences. For example, findings of significant positive impacts of CPS on current use of modern contraceptives and of BRAC on receiving four or more ANC visits can be partially explained by these differences.

The programmatic implications of the findings are discussed. For instance, the researchers assert that the impact of the interventions on knowledge improvement, increased use of health products, and improved behaviour is likely due to programme BCC activities and community workers selling products or provision of selected services (e.g., ANC services provided in BRAC areas) in combination with their provision of health information. The findings indicate that the addition of CSAs was associated with increased use of sanitary napkins, safe delivery kits, and MNP for children. This implies that sales of basic and essential health products at the community level (through a private-sector approach) are feasible and can reduce harmful practices and improve health. One important feature is that these sales agents also promote healthy behaviour through dissemination of health information.

Recommendations are offered. For example: Because women's knowledge on healthy timing and spacing of pregnancies (HTSP) and on reproductive, maternal, and child healthcare substantially and significantly improved following the MIH interventions, the MIH-style BCC campaign should be continued in later phases of the project.