Martina Bjorkman Nyqvist

How can quality be improved in markets in developing countries, which are known to be plagued by substandard and counterfeit (“fake”, in short) products? We study the market for antimalarial drugs in Uganda, where we randomly assign entry of a retailer (non-governmental organization (NGO)) providing a superior product—an authentic drug priced below the market—and investigate how incumbent firms and consumers respond. We find that the presence of the NGO had economically important effects. Approximately one year after the new market actor entered, the share of incumbent firms selling fake drugs dropped by more than 50% in the intervention villages, with higher quality drugs sold at significantly lower prices. Household survey evidence further shows that the quality improvements were accompanied by consumers expecting fewer fake drugs sold by drug stores. The intervention increased use of the antimalarial drugs overall. The results are consistent with a simple model where the presence of a seller committed to high quality, as opposed to an average firm, strengthens reputational incentives for competing firms to improve quality in order to not be forced out of the market, leading to “good driving out bad”.

Background: Maternal and newborn mortality continue to be major challenges in Nigeria. While greater participation of men in maternal and newborn health has been associated with positive outcomes in many settings, male involvement remains low. The objective of this analysis was to investigate male involvement in maternal and newborn health in Jigawa state, northern Nigeria. Methods: This qualitative study included 40 event narratives conducted with families who had experienced a maternal or newborn complication or death, in-depth interviews with 10 husbands and four community leaders, and four focus group discussions with community health workers. The interviews focused on understanding illness recognition and care seeking as well as the role of husbands at each stage on the continuum of maternal and newborn health. Data were transcribed, translated to English, and coded and analyzed using Dedoose software and a codebook developed a priori. Results: This paper reports low levels of knowledge of obstetric and newborn complications among men and limited male involvement during pregnancy, childbirth and the post-partum period in Jigawa state. Men are key decision-makers around the location of the delivery and other decisions linked to maternal and newborn health, and they provide crucial resources including nutritious foods and transportation. However, they generally do not accompany their wives to antenatal visits, are rarely present for deliveries, and do not make decisions about complications arising during delivery and the immediate post-partum period. These gendered roles are deeply ingrained, and men are often ridiculed for stepping outside of them. Additional barriers for male involvement include minimal engagement with health programs and challenges at health facilities including a poor attitude of health providers towards men and accompanying family members. Conclusion: These findings suggest that male involvement is limited by low knowledge and barriers related to social norms and within health systems. Interventions engaging men in maternal and newborn health must take into account these obstacles while protecting women’s autonomy and avoiding reinforcement of gender inequitable roles and behaviors.

The delivery of basic health products and services remains abysmal in many parts of the world where child mortality is high. This paper shows the results from a large-scale randomized evaluation of a novel approach to health care delivery. In randomly selected villages, a sales agent was locally recruited and incentivized to conduct home visits, educate households on essential health behaviors, provide medical advice and referrals, and sell preventive and curative health products. Results after 3 years show substantial health impact: under 5-years child mortality was reduced by 27 percent at an estimated average cost of $68 per life-year saved. (JEL I12, I18, J13, O15, O18)

Maternal mortality and newborn mortality continue to be major challenges in Nigeria, with the highest levels in the northern part of the country. The objective of this study was to explore the process and sequence of symptom recognition, decision-making, and care-seeking among families experiencing maternal and neonatal illness and deaths in 24 local governmental areas in Jigawa State, Northern Nigeria. This qualitative study included 40 illness narratives (ten each for maternal deaths, perceived postpartum hemorrhage (PPH), neonatal deaths, and neonatal illness) that collected data on symptom recognition, perceptions of the causes of disease, decision-making processes, the identity of key decision-makers, and care-seeking barriers and enablers. Data were transcribed verbatim, translated to English, then coded and analyzed using Dedoose software and a codebook developed a priori based on the study’s conceptual model. Compared to maternal cases, much less care-seeking was reported for newborns, especially in cases that ended in death. Key decision-makers varied by type of case. Husbands played the lead role in maternal death and neonatal illness cases, while female relatives and traditional birth attendants were more involved in decision-making around perceived PPH, and mothers were the principal decision makers in the neonatal death cases. Demand for health services is high, but supply-side challenges including low quality of care, uncertain availability of health workers, and drug stock-outs are persistent. There is a strong belief that outcomes are controlled by God and frequent use of spiritual care sometimes contributes to delays in seeking facility-based care. These findings suggest key differences in recognition of complications, decision-making processes, and care-seeking patterns between maternal and newborn illness and death cases in Jigawa, Northern Nigeria. Interventions that provide more targeted messaging specific to case and symptom type, are inclusive of family members beyond husbands, and address gaps in quality and availability of care are urgently needed. It may also be important to address the widespread perception that adverse outcomes for mothers and newborns are controlled by fate and cannot be prevented.

Maternal mortality is extremely high in Nigeria. Accurate estimation of maternal mortality is challenging in low-income settings such as Nigeria where vital registration is incomplete. The objective of this study was to estimate the lifetime risk (LTR) of maternal death and the maternal mortality ratio (MMR) in Jigawa State, Northern Nigeria using the Sisterhood Method. Interviews with 7,069 women aged 15–49 in 96 randomly selected clusters of communities in 24 Local Government Areas (LGAs) across Jigawa state were conducted. A retrospective cohort of their sisters of reproductive age was constructed to calculate the lifetime risk of maternal mortality. Using most recent estimates of total fertility for the state, the MMR was estimated. The 7,069 respondents reported 10,957 sisters who reached reproductive age. Of the 1,026 deaths in these sisters, 300 (29.2%) occurred during pregnancy, childbirth or within 42 days after delivery. This corresponds to a LTR of 6.6% and an estimated MMR for the study areas of 1,012 maternal deaths per 100,000 live births (95% CI: 898–1,126) with a time reference of 2001. Jigawa State has an extremely high maternal mortality ratio underscoring the urgent need for health systems improvement and interventions to accelerate reductions in MMR. The trial is registered at clinicaltrials.gov ( NCT01487707 ). Initially registered on December 6, 2011.