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

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

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

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

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

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

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.

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

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)

Weight Wfa z Wfa mal

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

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

Pre-trends and fade-out

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

(7) (8) (9)

Weight Wfa z Wfa mal

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)

Weight Wfa z Wfa mal

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

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%.

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

Threshold effects

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

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%.

Incentive effect All gain

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

Worker efforts

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

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)

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

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

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)

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%.

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

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

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)

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%.

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

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

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

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

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