Impact of caregiver incentives on child health: Evidence from an experiment with Anganwadi workers in India

Size: px

Start display at page:

Download "Impact of caregiver incentives on child health: Evidence from an experiment with Anganwadi workers in India"

Gwendolyn Fowler
5 years ago
Views:

1 Impact of caregiver incentives on child health: Evidence from an experiment with Anganwadi workers in India Prakarsh Singh and William Masters Amherst College and Tufts University World Bank Workshop January 25, 2017 Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

2 Pay for performance in the public sector Performance pay in the public sector is controversial Multitasking, crowding out of intrinsic motivation, cheating Objective metrics are often missing Almost no work on impact of performance pay on health outcomes in the public sector Inability to tease out income and substitution effects Inability to have contemporaneous control groups (unionization) Inability to test for persistent and fade-out effects Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

3 Context Caloric intake low in India despite increasing incomes (Behrman and Deolalikar, 1987) Nutrients required to adequately feed a child affordable by poor families (Mendelson, 2007) Integrated Child Development Services (ICDS) set up in 1975 to address undernutrition Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

4 Context India has the largest public sector programme for child development (ICDS) targeting 87 million beneficiaries, through over 1 million government-day care centres or Anganwadis Each Anganwadi has 1 worker An Anganwadi worker takes care of children (aged 3-6) from 9am to 1pm Workers are on fixed salaries of $67 per month Child care workers feed mid-day meals and provide nutritional guidance to mothers Possible leakage, ineffi cient distribution of food and lack of communication (Gragnolati et al., 2005) Only 19 percent of the mothers reported that the workers provides nutrition counselling (Hungama Report, 2011) Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

5 Preview of the Findings We compare a performance pay bonus against a fixed bonus for ICDS child care workers (Anganwadi workers) We weigh over 4000 children in 160 government day-care centres in urban slums of Chandigarh Performance pay reduces the prevalence of weight-for-age malnutrition by about 5 percentage points in 3 months Effect is sustained in the medium term with a renewal of incentives but the differential growth rate fades away once the scheme is discontinued Fixed bonuses lead to smaller-sized effects and only in the medium-term Both treatments appear to improve worker effort and communication with mothers Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

6 Inside Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

7 Outside Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

8 Experiment Design Need to allocate Anganwadis to treatment and control groups Only Anganwadis in urban slum areas in Chandigarh selected Cannot randomize assignment of control and treatment at the level of the center Would still like to compare similar groups Geographical Blocks Clusters Anganwadis Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

9 Matching similar sets of Anganwadis Assign 84 centers in Block 1 as "Control Block" and 76 centers in Block 2 as "Treatment Block" Randomize centers from Block 2 into Performance Pay and Fixed Bonus treatments Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

10 Map of Chandigarh showing number and location of Anganwadis by treatment Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

11 Total Anganwadis under each Treatment Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

12 Performance pay treatment Cash incentive promised to each of the 38 Anganwadi workers equalled: Rs.200 n n = (# of children whose grade improved in a quarter # of children whose grade declined in a quarter) For example, if 5 children jump from moderate to normal and 1 drops from normal to moderate, she would get Rs. 200 * 4 = Rs. 800 (~$12) Monthly salary for a worker was Rs (~$60), and the bonus was paid out after three months Bonus lower bound was 0 All workers were given goal cards listing each malnourished child s minimum target weight Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

13 Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

14 Fixed bonus treatment Fixed bonus to each Anganwadi worker after 3 months equalled: Rs.200 Based on Singh and Mitra (2015) s estimate of expected change in malnutrition in the performance pay treatment Can capture part of the income effect of the performance pay treatment Proxies for the "business as usual" fixed increase in pay that is commonplace since 1975 Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

Details of the recipe book provided to all mothers Ten recipes were taken from Government s book for Anganwadi workers Easy-to-make, locally available ingredients,

15 Details of the recipe book provided to all mothers Ten recipes were taken from Government s book for Anganwadi workers Easy-to-make, locally available ingredients, nutritious The booklet contained information on the nutritive value of each recipe Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

16 Summary statistics Table: Summary Statistics at Baseline I across treatment and control groups P Pay Fixed Bonus Control P Pay Control P Pay Fixed Bonus Panel A: Child and Household Characteristics Child's age 4.33 (0.93) 4.32 (0.94) 4.26 (0.90) 0.07 (0.05) 0.01 (0.06) Gender (Male=1; Female=0) 0.48 (0.50) 0.50 (0.50) 0.50 (0.50) 0.02 (0.01) 0.01 (0.02) Mother is SC/ST 0.64 (0.47) 0.66 (0.47) 0.59 (0.49) 0.06 (.03)* 0.01 (0.04) Mother is Hindu 0.90 (0.29) 0.92 (0.26) 0.90 (0.30) 0.01 (0.01) 0.02 (0.02) Mother's age (3.58) (3.32) (3.74) 0.18 (0.17) 0.12 (0.18) Grandmother at home 0.23 (0.42) 0.28 (0.43) 0.27 (0.45) 0.04 (0.02) 0.00 (0.03) Total children in hh 2.01 (1.30) 1.99 (1.30) 2.28 (1.39) 0.26 (0.06)*** 0.02 (0.07) Mother cannot read and write 0.27 (0.44) 0.25 (0.43) 0.39 (0.49) 0.12 (0.03) *** 0.02 (0.03) Husband cannot read and write 0.14 (0.35) 0.17 (0.38) 0.24 (0.43) 0.09 (0.02) *** 0.03 (0.03) Mother is homemaker 0.79 (0.40) 0.77 (0.41) 0.78 (0.41) 0.01 (0.04) 0.02 (0.05) Toilet communal 0.10 (0.29) 0.11 (0.31) 0.11 (0.31) 0.02 (0.03) 0.02 (0.04) Toilet without flush 0.19 (0.39) 0.15 (0.35) 0.13 (0.34) 0.06 (0.04) 0.04 (0.06) Fixed assets (out of 13) 0.52 (0.14) 0.54 (0.13) 0.47 (0.15) 0.05 (0.02) *** 0.02 (0.02) Panel B: Child Health Weight (2.02) (1.98) (1.91) 0.40 (0.12) *** 0.20 (0.15) Wfa Z score 1.50 (0.81) 1.59 (0.83) 1.65 (0.82) 0.14 (0.04) *** 0.08 (0.06) Wfa grade 0.43 (0.63) 0.49 (0.67) 0.53 (0.70) 0.11 (0.04) *** 0.06 (0.05) Wfa Malnutrition 0.36 (0.48) 0.39 (0.49) 0.41 (0.50) 0.07 (0.03) ** 0.04 (0.04) Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

17 Compliance and Attrition High compliance rates but also high attrition Attrition because attendance is low and intermittent No evidence of selective exclusion in performance pay or fixed bonus treatments Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

18 Difference-in-differences specification The effect of the treatments on weight-for-age z score of a child: othercontrols Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

19 Main results on weight, z-score and malnourished status change in Dependent Variable Weight Wfa z Wfa mal Weight Wfa z Wfa mal Weight Wfa z Wfa mal Performance Pay 0.234*** 0.108*** * 0.196*** *** * 0.219*** 0.101*** ** (0.0618) (0.0302) (0.0222) (0.0696) (0.0335) (0.0261) (0.0772) (0.0370) (0.0269) Fixed Bonus (0.0757) (0.0352) (0.0221) (0.0860) (0.0405) (0.0272) (0.0933) (0.0442) (0.0278) No controls X X X Mother and child level controls X X X X X X Worker level controls X X X Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

20 Persistent effects of the treatments change in Dependent Variable Weight Wfa z Wfa mal Performance Pay 0.231*** *** ** (0.0687) (0.0327) (0.0219) Fixed Bonus 0.196** ** (0.0776) (0.0380) (0.0241) No controls Mother and child level controls X X X Worker level controls X X X N Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

21 Fading-out effects of the treatments change in Dependent Variable Weight Wfa z Wfa mal Performance Pay (0.0904) (0.0408) (0.0235) Fixed Bonus (0.0752) (0.0357) (0.0267) No controls Mother and child level controls X X X Worker level controls X X X N Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

22 Testing for pre-trends Between Baseline-I and Baseline-II change in Dependent Variable Weight Wfa z Wfa mal Performance Pay (0.119) (0.0411) (0.0223) Fixed Bonus (0.0884) (0.0423) (0.0285) No controls Mother and child level controls X X X Worker level controls X X X N Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

23 Channels Quantity of mother-worker interactions Quality of mother-worker interactions Food intake at home Worker effort at center food effort qlt qty Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

24 Threshold effects in the short-term Near Far Near Far Near Far Moderate Severe Normal (1) (2) (3) (4) (5) (6) change in Dependent Variable Wfa z Wfa z Wfa z Wfa z Wfa z Wfa z Performance Pay 0.142*** *** 0.199*** (0.0472) (0.0521) (0.121) (0.142) (0.0409) (0.0432) Fixed Bonus * ** 0.121** (0.0479) (0.0783) (0.0977) (0.165) (0.0414) (0.0512) N Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

25 Policy implications policy The performance pay treatment led to a decline in weight-for-age malnutrition by 5% points in 3 months and this effect is persistent Reduces the chance of worsening health status Demand-side behavioral change is an important component of the malnutrition puzzle This can be triggered through supply-side incentives The average weight gain per month is 70 gms as opposed to 100 gms per month in the iron and deworming treatment (Bobonis, Miguel and Sharma, 2004) Assuming a linear relationship between participation rates and change in weight, the benefit-cost ratio is comparable to that of the iron and deworming treatment Results similar to earlier controlled experiments Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

26 N Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31 Mother-worker interaction in the past month (reported by mother) back change in Dependent Variable Home visits by worker Center visits by mother Frequency of worker talking about child Performance Pay *** (0.915) (1.438) (0.970) Fixed Bonus 2.019* *** (1.092) (0.855) (1.029) No controls Mother and child level controls X X X Worker level controls X X X

27 Change in content of interaction back change in Dependent Variable Nutrition Hygiene Chart Scare Performance Pay 0.226*** (0.0767) (0.0832) (0.0780) (0.0866) Fixed Bonus 0.245*** (0.0633) (0.0907) (0.0792) (0.0725) No controls Mother and child level controls X X X X Worker level controls X X X X N Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

28 Food intake (at least twice a week) for child reported by mother back change in Dependent Variable Milk Green veg Dessert Porridge Performance Pay *** 0.130*** 0.228*** 0.105* (0.0182) (0.0341) (0.0608) (0.0617) Fixed Bonus *** 0.148*** 0.213*** 0.293*** (0.0228) (0.0312) (0.0582) (0.0573) No controls Mother and child level controls X X X X Worker level controls X X X X Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

Worker effort at center back Diffi cult to observe effort of workers directly Unannounced visits by supervisors in the intervening months Find an

29 Worker effort at center back Diffi cult to observe effort of workers directly Unannounced visits by supervisors in the intervening months Find an increase in attendance in the short term in the performance pay treatment Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

30 Policy implications back Short term (from R2 to R3) N Net Gain Improved No Change Worsened (# of obs.) Performance Pay Fixed Bonus Control Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

31 Other controls back Mother and child-level controls include age and sex of child, a dummy variables for if mother identifies herself as scheduled caste, if mother identifies herself as Hindu, if there is a grandmother at home, if mother cannot read and write, if husband cannot read and write, if mother is a homemaker, if toilet is communal, if toilet has no flush, mother s age, total children in household, household income and an index of 13 fixed assets in the household. Worker-level controls are dummy variables for if worker identifies herself as scheduled caste, if worker identifies herself as Hindu, if worker is college-educated, worker s age and dummy variables for the availability of the following resources at the center: electricity, fan, helper, chart, blackboard, drinking water and toilet. Singh & Masters (World Bank Workshop) Caregiver incentives January 25, / 31

EXIT STRATEGIES STUDY: INDIA BEATRICE LORGE ROGERS, CARISA KLEMEYER, AMEYA BRONDRE

EXIT STRATEGIES STUDY: INDIA BEATRICE LORGE ROGERS, CARISA KLEMEYER, AMEYA BRONDRE EXIT STRATEGIES STUDY: INDIA 1 BEATRICE LORGE ROGERS, CARISA KLEMEYER, AMEYA BRONDRE Overview of India Study 2 One program (CARE); one sector (health) Four states: AP, Orissa, Chhattisgarh, UP India contrasts