impact of caregiver incentives on child health: evidence from an experiment with anganwadi workers...

Impact of caregiver incentives on child health:Evidence from an experiment with

Anganwadi workers in India

Will MastersFriedman School of Nutrition & Department of Economics, Tufts University

Prakarsh SinghDepartment of Economics, Amherst College

POSHAN (IFPRI)10th November, 2016.

Can we incentivize salaried workers to target their services effectively?

• Performance pay is difficult to use and evaluate– Measurement of performance is costly, affected by noise, time lags and confounders

– Rewards may crowd out other motivations, and reduce effort on other tasks

– Rewards may drive selection into participation, targeting and level of effort

• Child nutrition is difficult to improve– Inputs (dietary intake and disease exposure) are usually not observed

– Outcomes (body size, disease state) are difficult to measure and compare

– Links between inputs and outcomes are unknown

• India’s ICDS program offers a large-scale opportunity to intervene– Over 1 million centers each serving over 30 preschool children, with salaried Anganwadi

worker providing mid-day meal, advice to mothers, some teaching

– Government aims to improve performance for both nutrition and education

– Objectives include reduced weight-for-age malnutrition, which is still widespread

– Low weight-for-age, defined as WAZ < -3 or -2 standard deviations below median of a healthy population, can be due to either inadequate diet or disease burden

Caregiver incentives and child healthmotivation | trial design | outcomes | mechanisms

Can we incentivize salaried workers to target their services effectively?

Summary of results

• Trial compares a performance pay bonus (<5% of salary) to a fixed bonus of similar size and a pure control group – Population is about 4,000 children in 160 government-run ICDS day-care centers in urban slums

of Chandigarh, India

– Primary outcome is the ICDS objective of lower weight-for-age malnutrition; we also report changes in height-for-age

– Mechanism checks measure efforts of the worker and the child’s mother, with dose-response checks around thresholds

• We find that the performance bonus reduces prevalence of weight-for-age malnutrition by about 5 percentage points over 3 months– Effect is sustained with renewal of incentives, and fades when discontinued

– Mechanism is attendance and communication with mothers of at-risk children, with improved diets at home especially for children near thresholds

• Impacts imply that small bonuses can focus caregiver attention and improve targeting of efforts such as communication with mothers


Context

Block 1 (control)

Block 2 (bonus treatments)

Block 3 (later treatments)

In urban slums of Chandigarh-- Planned city in far north India-- Capital of both Punjab and Haryana-- Income level similar to Delhi-- Population size < 2 million

Trial designed in collaboration with ICDS management-- Geographically separated blocks-- Retain 84 centers in poorer block 1 as

controls for seasonality and trends-- Split 76 centers in block 2 between

performance pay and fixed bonus-- Keep 85 centers in block 3 for later

tournament treatments (not reported here)

-- Data collected in 5 rounds at 3 monthintervals, July 2014 - July 2015, with surveys of workers, childrenand their mothers


Treatments

• Fixed bonus is Rs. 200 per worker over three months– In block 2, workers draw randomly into performance vs. fixed bonus treatments

• Performance bonus is Rs. 200 per child for status improvements – Every worker given a goal card, with baseline weight and gains needed for each child

• Bonuses calibrated based on previous ICDS experiments– Expected gains over 3 months on the order of 2 of the 30+ children enrolled

– Expected bonus after 3 months ≈ Rs. 400, relative to salary of Rs. 4000 per month

• Treatment is designed to align with government’s ICDS objectives – Status improvements can be from severe (WAZ<-3) to moderate (WAZ<-2) or to none

– Status improvements exclude any cases of overweight relative to height (WHZ>+1)

– Bonuses are net of any declines in status into moderate or severe malnutrition

– Bonuses have lower bound of zero

• Treatment is designed for potential cost-effectiveness– Every mother given a recipe book with nutrition advice, to complement worker efforts

• Both treatments are compared to block 1, to control for common shocks


Timeline of the experiment

Round Date Block 1 Block 2 Block 3

Baseline-I Jul-14Control*

(83)Control (76)

Control

(85)

Baseline-II Oct-14Control

(84)

Performance

Pay (38)

Fixed Bonus

(38)

Control

(85)

Endline-I Jan-15Control

(84)

Performance

Pay (38)

Control

(85)

Endline-II Apr-15Control

(84)

Endline-III Jul-15Control

(84)

Notes: * denotes that one center was not surveyed from Block 1 in Baseline-I as

it was closed. Numbers in parentheses show the number of centers in each arm.

Treatment dates shown are for start of treatment, with bonus payments made

at the end of Endline-I and Endline-II respectively.


Average treatment effects

Short term effects (R2 to R3) over 3 mo.

(7) (8) (9)

Weight Wfa z Wfa mal

Performance 0.219*** 0.101*** -0.0561**

Pay (0.0772) (0.0370) (0.0269)

Fixed 0.123 0.0557 -0.0333

Bonus (0.0933) (0.0442) (0.0278)

N 3528 3522 3524

Medium-term effects (R3-R4) over 3 mo.

(7) (8) (9)


Performance 0.231*** 0.0976*** -0.0522**

Pay (0.0687) (0.0327) (0.0219)

Fixed 0.196** 0.0878** -0.0341

Bonus (0.0776) (0.0380) (0.0241)

N 2303 2301 2302

All results control for observables on children, mothers and workers, with heteroscedasticity-consistent standard errors clustered on centers. Weight is in kilograms. Wfa z is the weight-for-age z score given the child's sex and age, and Wfa mal is an indicator for malnutrition status. *Significant at 10%, **Significant at 5%, ***Significant at 1%.

Note: Results are robust to checks using Lee (2009) treatment effect bounds, or Moulton standard errors for sample size


Pre-trends and fade-out

Pre-trends (R1 to R2) over 3 mo.

(7) (8) (9)


Performance -0.0991 -0.00620 -0.0305

Pay (0.119) (0.0411) (0.0223)

Fixed 0.0971 0.0694 -0.0305

Bonus (0.0884) (0.0423) (0.0285)

N 3744 3730 3739

Fade-out after treatments (R4 to R5) over 3 mo.

(7) (8) (9)


Performance 0.0898 0.0355 -0.0338

Pay (0.0904) (0.0408) (0.0235)

Fixed 0.00967 0.00266 0.00262

Bonus (0.0752) (0.0357) (0.0267)

N 2230 2223 2224



Threshold effects

“Near” and “Far” are defined around the median distance to each threshold.


Incentive effect All gain


Worker efforts


Home

visits by

worker

Center

visits by

mother

Frequency of

worker talking

about the child

Performance -1.256 -1.141 4.410***

Pay (0.915) (1.438) (0.970)

Fixed -2.019* -1.223 5.012***

Bonus (1.092) (0.855) (1.029)

N 3275 2831 3062

All results control for observables on children, mothers and workers, with heteroscedasticity-consistent standard errors clustered on centers. *Significant at 10%, **Significant at 5%, ***Significant at 1%.

Type of mother-worker interactions in the past month (as reported by mother)



Dietary

Intake Hygiene

Growth

Chart

Harmful

Effects

Perf. 0.226*** 0.0949 0.0712 -0.0206

Pay (0.0767) (0.0832) (0.0780) (0.0866)

Fixed 0.245*** 0.0757* 0.0138 -0.0922

Bonus (0.0633) (0.0907) (0.0792) (0.0725)

N 3223 3223 3223 3223

Worker efforts

Topic of mother-worker interactions in the past month (as reported by mother)




Milk

Green

veg. Dessert Porridge

Perf. 0.0616*** -0.130*** 0.228*** 0.105*

Pay (0.0182) (0.0341) (0.0608) (0.0617)

Fixed 0.0666*** -0.148*** 0.213*** 0.293***

Bonus (0.0228) (0.0312) (0.0582) (0.0573)

N 3223 3223 3223 3223

Mothers’ response

Child’s diet at home: items consumed at least twice in past week (as reported by mother)



Other outcomes: Child height

Change in height (cm) over 3 mo.

R1 to R2 R2 to R3 R3 to R4 R4 to R5

Performance 0.381 1.077** -0.263 -0.0946

Pay (0.480) (0.502) (0.375) (0.382)

Fixed 0.571 0.988* -0.206 -0.546

Bonus (0.494) (0.511) (0.332) (0.353)

N 3721 3497 2286 2220


Conclusions

• Small bonuses to staff did improve outcomes of children in their care– Total gains and threshold effects were larger when bonuses were tied to outcomes

– Some improvement even with fixed bonuses

– Complements include goal cards to guide efforts, recipe books to help mothers respond

• Magnitude of improvement was significant– Reduced weight-for-age malnutrition prevalence by about 5 pct. points over 3 months

– Average speed of additional weight gain was about 70 grams per month

– Cost-benefit ratios are roughly similar to iron, deworming, etc.

– Weight gain and also promoted linear growth

– Implications for scale-up

• Mechanisms provide insight into agents’ knowledge of relative effectiveness

– Caregivers altered frequency, content of communication with mothers

– Mothers altered composition of children’s diets


impact of caregiver incentives on child health: evidence from an experiment with anganwadi workers...

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