Targeted Interventions in Health Care: The case of PROMIN

1. Targeted Interventions in Health Care: The case of PROMIN Sebastian Galiani Mercedes Fernandez Ernesto Schargrodsky

2. State policies should expand access of the poor to social services (basic education, healthcare) • Feasible alternative: targeting resources to the poor • Benefits: Saves resources and increases efficiency. • Costs: Identification of potential beneficiaries, disincentive effects, loss of political support. • We study the targeting of PROMIN (Programa Materno Infantil y Nutrición), a program which attempts to improve infant and child health, reproductive health, and nutrition.

3. PROMIN targeting is a two-stage procedure: • In the first stage, poor localities are identified based on poverty levels. PROMIN centers are located in these areas. • In the second stage, households self-select into the program by deciding on their use of PROMIN centers • We consider first geographical targeting and then, targeting at the household level, conditional on the geographical allocationof the program.

4. PROMIN and primary health care • PROMIN seeks to improve primary medical attention in Argentina. • The first Argentine experiences in this matter date to the decade of the 1940s. • Primary health centers were created to: • treat ailments and diseases which could be tended without attending a hospital, and • foster the prevention of avoidable diseases by means of healthcare education programs.

5. A widespread view was that in Argentina, primary health centers did not take adequate account of the particular needs of the community in which they functioned. • The PROMIN intervention was designed to improve and strengthen these centers, by implementing a three-level structure for medical attention • The community • The primary health center • The local hospital

6. The program’s goal was to improve medical attention at local centers. • This did not imply building new centers. The quantity and distribution of health centers was considered to be “more than acceptable”, and the centers were thought to be appropriately located. • Instead, its aim was to improve existing constructions and properly adapt them so as to adequately provide medical services.

7. There are several targeting mechanisms. They can be classified into • Individual assessment mechanisms • Group (or geographic) targeting mechanisms • Self-targeting mechanisms • We now study PROMIN’s two-stage mechanism

8. Geographical Targeting • Is PROMIN in fact located in the poorest localities? Proportion of Localities covered by PROMIN, by UBN • PROMIN tends to be placed in localities where there are more poor people even though it may not be concentrated in the poorest localities.

9. Conditional Targeting • In the areas where it operates, are the families that use its centers the poorest ones in the population? • That is, where are the households that benefit from the program located in the local distribution of family income?

10. Conditional Targeting • We need comparable information on earnings and family structure for both the population and PROMIN beneficiaries’ households. • The information for the population is gathered from the ongoing household survey. • For PROMIN users, we conducted a survey at a random sample of centers in 3 localities where the household survey is conducted – Rosario, Mar del Plata and La Rioja.

11. Conditional Targeting • The families that use PROMIN centers are not the richest ones, and tend to be more concentrated among the bottom 5 deciles of the relevant population income distribution, with more weight in the deciles 2 to 4. • Thus, although the targeting can be judged as satisfactory, it can certainly be improved by reducing some of the leakage presently existent.

12. Self-Selection: The Role of Distance • We explore the determinants of self-selection into PROMIN. • For this purpose, we rely on a second survey conducted to a random sample of households stratified by distance to the PROMIN centers where we conducted our first survey. • For each household, we have information about the utilization of the PROMIN center for each child under 5 and any pregnant woman who is head or spouse of the head of household, or the daughter of the head or his spouse.

13. Self-Selection: The Role of Distance • We estimate a discrete choice model where the endogenous decision is the utilization of the PROMIN center. • We are interested in estimating the probability that a household with a given set of observed characteristics self-selects into a PROMIN center.

14. Table XIII: Logit model for children under 5 years old. Dependent variable: 1 if child uses PROMIN

15. Conclusions • PROMIN coverage is concentrated in the large, high density municipalities where there are more poor people, although it does not reach many of the poorest localities. • Within these localities, most of the households that use the program come from the poorest five deciles of the relevant income distribution, although there is non negligible leakage to higher income groups. • Looking at measures of structural income other than current income leads to essentially similar conclusions. • Thus, we believe that while targeting is certainly satisfactory, there is still room for improvement.

16. Conclusions • Regarding self-selection, we find that a key issue in determining PROMIN utilization is location. • Households living near the center are substantially more likely to use it than households further away. • This points to the importance of the placement of the centers within the localities selected at the first stage.