Impact of caregiver incentives on child health: Evidence from an - PowerPoint PPT Presentation

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, 2017 1 / 31

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, 2017 2 / 31

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, 2017 3 / 31

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, inefficient 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, 2017 4 / 31

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, 2017 5 / 31

Inside Singh & Masters (World Bank Workshop) Caregiver incentives January 25, 2017 6 / 31

Outside Singh & Masters (World Bank Workshop) Caregiver incentives January 25, 2017 7 / 31

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, 2017 8 / 31

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, 2017 9 / 31

Map of Chandigarh showing number and location of Anganwadis by treatment Singh & Masters (World Bank Workshop) Caregiver incentives January 25, 2017 10 / 31

Total Anganwadis under each Treatment Singh & Masters (World Bank Workshop) Caregiver incentives January 25, 2017 11 / 31

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. 4000 (~$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, 2017 12 / 31

Singh & Masters (World Bank Workshop) Caregiver incentives January 25, 2017 13 / 31

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, 2017 14 / 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, nutritious The booklet contained information on the nutritive value of each recipe Singh & Masters (World Bank Workshop) Caregiver incentives January 25, 2017 15 / 31

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 27.04 (3.58) 26.92 (3.32) 26.87 (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 13.67 (2.02) 13.48 (1.98) 13.27 (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, 2017 16 / 31

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, 2017 17 / 31

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, 2017 18 / 31

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*** -0.0400* 0.196*** 0.0899*** -0.0451* 0.219*** 0.101*** -0.0561** (0.0618) (0.0302) (0.0222) (0.0696) (0.0335) (0.0261) (0.0772) (0.0370) (0.0269) Fixed Bonus 0.107 0.0490 -0.0185 0.103 0.0474 -0.0238 0.123 0.0557 -0.0333 (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, 2017 19 / 31

Persistent effects of the treatments change in Dependent Variable Weight Wfa z Wfa mal Performance Pay 0.231*** 0.0976*** -0.0522** (0.0687) (0.0327) (0.0219) Fixed Bonus 0.196** 0.0878** -0.0341 (0.0776) (0.0380) (0.0241) No controls Mother and child-level controls X X X Worker-level controls X X X N 2303 2301 2302 Singh & Masters (World Bank Workshop) Caregiver incentives January 25, 2017 20 / 31

Fading-out effects of the treatments change in Dependent Variable Weight Wfa z Wfa mal Performance Pay 0.0898 0.0355 -0.0338 (0.0904) (0.0408) (0.0235) Fixed Bonus 0.00967 0.00266 0.00262 (0.0752) (0.0357) (0.0267) No controls Mother and child-level controls X X X Worker-level controls X X X N 2230 2223 2224 Singh & Masters (World Bank Workshop) Caregiver incentives January 25, 2017 21 / 31