A study supported by the EU bank examines how an impact investment in Senegal is contributing to improved maternal health services
By Nina Fenton and Claudio Cali
Senegal has only around 3.1 nurses and midwives per 10,000 people, which makes it one of the countries least covered with qualified maternal care in the world (162 out of 187 countries). Not surprisingly, outcomes for maternal and child health are poor.
Where public hospitals are struggling to provide quality service, private clinics have sprung up, but most charge fees that only wealthier patients can afford. The private clinics have only been able to cover about 20% of the demand.
Enter NEST, a small enterprise aiming to bridge the gap between the private and the public sectors by reaching out beyond the wealthiest segment of the population. NEST’s maternal and child health clinics in Dakar offer services at prices around 40% lower than private clinics by using a number of innovations to cut costs without compromising quality. For example, NEST minimizes the duration of hospitalization for uncomplicated deliveries and works with doctors that are willing to discount their fees for less well-off clients.
NEST received funding from I&P Afrique Entrepreneurs 1, an impact fund designed to support small and medium enterprises in which the European Investment Bank invested €7 million.
Boosting the take-up of affordable maternity services with insights from an impact study
To understand better the impact of this impact investment, the EIB supported a study on the project. Gilles Kane and Hamidou Jawara started by studying the profile of NEST’s clients. The results indicate that NEST is successfully reaching out to women from the middle class, although few of its clients are among the extreme poor.
Estimates from a survey of 90 NEST clients show that around 4% would likely fall below the national poverty line, which is the case for 17% of Dakar residents. Less wealthy women are accessing the service – 30% of respondents are estimated to live on less than $5.5 a day (a reality for 52% of residents of Dakar). Furthermore, NEST’s services are accessible to women without health insurance coverage – they account for 42%of respondents. This includes women working in the informal sector (about 27% of the economically active survey respondents).
The researchers wanted the impact study to also provide NEST with practical insights into how to further enhance the company’s impact. Together with NEST’s management, they decided to focus on how to encourage more women to use NEST’s midwife-led service. Midwife-led care is more affordable than the doctor-led options with the same quality, so increasing reliance on midwives for low-risk pregnancies and uncomplicated deliveries is an important pillar of NEST’s strategy to bring down costs of quality maternity care, allowing them to expand access to more women.
However, negative perceptions of midwife-led services have made the promotion of this package challenging. Many Senegalese women believe that midwives are only able to deliver basic care. Some of the negative perceptions are based on negative experiences with midwives, particularly those working in the public sector. Many of these midwives are often working in challenging conditions, in a difficult working environment and under time pressure. This means that they may have limited time available for consultations. Some women even report that midwives display “bad attitudes” towards patients.
NEST was interested in understanding whether an innovative information campaign could help to counteract these negative perceptions and boost the willingness of women to consider the service. Hence, in collaboration with NEST, the researchers developed and tested an information session where the benefits of midwives in maternal care are shared in the form of short stories and scenarios.
This kind of information session is commonly known as a visualization session. There is evidence that such simple intervention can be useful in motivating good behavior. In the visualization session, a presenter (e.g. skilled NEST staff) outlines issues that women could face during their pregnancies and how a midwife could provide support and advice. Participants are encouraged to think more deeply about how a qualified and highly-skilled midwife could support them.
To test whether such an innovative approach could change the demand for the midwife-led service, the researchers used a randomization approach to compare outcomes after a basic information session with outcomes after a visualization session. They selected a group of women to participate in the visualization session, and compared their willingness to consider the midwife-led service with that of another group of women, who attended just the basic information session on midwife-led care. To rule out the possibility that differences in willingness were caused by other differences between the groups, not by the way the information was delivered, the women were allocated between the two groups by random selection. This was in line with international best practice for impact evaluation. This approach was chosen to ensure that the results of the study would be a reliable guide for NEST on the benefits of the innovative approach.
The women who participated in the visualization proved more likely to be willing to consider the midwife-led service than their peers who received the same information in a more “traditional” format. NEST will now consider whether and how it can make more use of visualization techniques to promote this package.
The EU bank’s impact studies of impact investments
Impact measurement is central to the European Investment Bank’s business in developing countries. Since its inception in 1958, the European Investment Bank has invested over €1 trillion, around 10% of it outside the EU. These investments are selected and designed to generate social, economic and environmental benefits, alongside financial sustainability. The European Investment Bank tracks the development results of every investment to understand what works and how we can further enhance our impact.
The EIB has been piloting a programme of impact studies of private sector impact investments with the Global Development Network. The studies further deepen our understanding of the impacts of these projects. The programme goes beyond the results measurement the European Investment Bank does for every project by collecting data directly from the people who benefit from projects. This requires boots on the ground and an understanding of local context, so the programme has mobilised 30 talented researchers from developing countries to carry out impact studies of impact investment projects in Africa, the Caribbean and the Pacific. The results of the first wave of studies can be found here.
The research is tailored to a diverse set of impact investments. The investments made by the European Investment Bank range from direct investments in agri-business to support for innovative firms through venture capital funds and indirect lending to micro-enterprises through microfinance investment vehicles.
The researchers have been working with European Investment Bank clients to understand their business models and their development objectives. They then tailor their research to answer questions of mutual interest.
The programme is demonstrating how academically rigorous research can drive impact. Global Development Network has brought in globally renowned experts as impact advisors, who ensure that the studies are carried out with maximum rigour and using the latest methods. Their stamp of approval ensures that the results are a reliable basis for decision-making to enhance development impacts by the European Investment Bank and our clients.
This allows the European Investment Bank, amongst other things, to provide empirical evidence that the private sector can be a key engine for sustainable development.
Nina Fenton and Claudio Cali are economists at the European Investment Bank, specialising in impact finance and impact measurement.