Impact of Caregiver Incentives on Child Health: Evidence from an Experiment in India
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Will Masters
Friedman School of Nutrition & Department of Economics, Tufts University
NEUDC - November 5, 2016
Prakarsh Singh
Department of Economics, Amherst College
Funded by the Bill & Melinda Gates Foundation
Grand Challenges Exploration Program
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Caregiver incentives and child health
motivation
| trial design | outcomes | mechanisms
•
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 and allocation of effort
–
Only one earlier study of performance pay on health outcomes (Miller et al 2012
BMJ
)
–
Most studies of performance pay in health are on inputs (Basinga et al 2011
Lancet
)
•
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
–
About 1.3 million centers each serving ~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 health
motivation
| trial design | outcomes | mechanisms
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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
–
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 not reversed 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 health
motivation
| trial design | outcomes | mechanisms
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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
-- 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
control in R1-3 and later
tournament treatments
(not reported here)
-- Data collected in 5 rounds
at 3 month intervals,
July 2014 - July 2015,
with surveys of workers,
children and their mothers
Caregiver incentives and child health
motivation
|
trial design
| outcomes | mechanisms
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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
–
Formula is number of improvements minus number of declines in status
–
Every worker given a goal card, with baseline weight and gains needed for each child
–
Bonuses have lower bound of zero
–
Status improvements exclude any cases of overweight relative to height (WHZ>+1)
•
Treatments calibrated based on previous ICDS experiments
–
Expected gains over 3 months on the order of 1.5 of the 30+ children enrolled
–
All mothers in trial given a recipe book with nutrition info, to complement worker efforts
•
Treatments compared to control group, for common trends & shocks
Caregiver incentives and child health
motivation
|
trial design
| outcomes | mechanisms
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Pre-trends?
Treatment
effects over 3
and 6 months?
Fade-out?
Learning?
Caregiver incentives and child health
motivation
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trial design
| outcomes | mechanisms
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By design, bonuses were paid in better-off neighborhoods, to
obtain a lower bound; results shown will control for observables
Balance is between
PP and fixed bonus
Caregiver incentives and child health
motivation
|
trial design
| outcomes | mechanisms
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Fewer
dropouts
No weight
difference
Caregiver incentives and child health
motivation
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trial design
| outcomes | mechanisms
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Caregiver incentives and child health
motivation
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trial design
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outcomes
| mechanisms
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Treatment=>
more gain
in winter
Caregiver incentives and child health
motivation
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trial design
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outcomes
| mechanisms
Treatment=>
less loss
in summer
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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 health
motivation
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trial design
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outcomes
| mechanisms
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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 health
motivation
|
trial design
|
outcomes
| mechanisms
Parallel trends before treatment
Persistence after treatment
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“Near” and “Far” are defined around the median distance to each threshold, for groups
near the boundaries to escape moderate (z>-2) or severe (z>-3) status, or normal (z>-1)
All results control for observables on children, mothers and workers, with heteroscedasticity-
consistent standard errors clustered on centers. Wfa z is the weight-for-age z score given the
child's sex and age. *Significant at 10%, **Significant at 5%, ***Significant at 1%.
Threshold effect
Small sample
No harmful effects:
reallocation + increase
in total effort
Caregiver incentives and child health
motivation
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trial design
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outcomes
| mechanisms
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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 health
motivation
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trial design
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outcomes
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mechanisms
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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 health
motivation
|
trial design
|
outcomes
|
mechanisms
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Child’s diet at home: items consumed at least twice in past week (as reported by mother)
Caregiver incentives and child health
motivation
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trial design
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outcomes
|
mechanisms
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Caregiver incentives and child health
motivation
|
trial design
|
outcomes
|
mechanisms
C
o
n
c
l
u
s
i
o
n
s
•
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
–
In absolute terms, the additional weight gain is about 70 grams per month
–
Cost-effectiveness is roughly similar to iron + deworming (Bobonis et al 2006 in
JHR
)
–
Changes targeting weight gain also promoted linear growth
•
Mechanisms provide insight into agents’ knowledge of relative effectiveness
–
Caregivers altered frequency, content of communication with mothers
–
Mothers altered composition of children’s diets
•
Agenda for future work
–
Would tournaments improve power of incentives?
–
Would goal cards and nonmonetary rewards be sufficient?
–
Do results hold in other contexts and over time?
Caregiver incentives and child health
motivation
|
trial design
|
outcomes
|
mechanisms
This study explores the impact of caregiver incentives on child health, focusing on reducing weight-for-age malnutrition. Results show a positive effect of performance bonuses on nutrition outcomes over time, indicating the effectiveness of incentivizing salaried workers.
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Impact of caregiver incentives on child health: Evidence from an experiment with Anganwadi workers in India Prakarsh Singh Department of Economics, Amherst College Will Masters Friedman School of Nutrition & Department of Economics, Tufts University Funded by the Bill & Melinda Gates Foundation Grand Challenges Exploration Program NEUDC - November 5, 2016
Caregiver incentives and child health motivation | trial design | outcomes | mechanisms Can the state incentivize salaried workers to target their services effectively?
Caregiver incentives and child health motivation | trial design | outcomes | mechanisms Can the state 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 and allocation of effort Only one earlier study of performance pay on health outcomes (Miller et al 2012 BMJ) Most studies of performance pay in health are on inputs (Basinga et al 2011 Lancet) 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 About 1.3 million centers each serving ~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 health motivation | trial design | outcomes | mechanisms 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 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 not reversed 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 health motivation | trial design | outcomes | mechanisms Context In urban slums of Chandigarh -- Planned city in far north India -- Capital of both Punjab and Haryana -- Population size < 2 million Block 2 (bonus treatments) 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 control in R1-3 and later tournament treatments (not reported here) -- Data collected in 5 rounds at 3 month intervals, July 2014 - July 2015, with surveys of workers, children and their mothers Block 1 (control) Block 3 (later treatments)
Caregiver incentives and child health motivation | 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 Formula is number of improvements minus number of declines in status Every worker given a goal card, with baseline weight and gains needed for each child Bonuses have lower bound of zero Status improvements exclude any cases of overweight relative to height (WHZ>+1) Treatments calibrated based on previous ICDS experiments Expected gains over 3 months on the order of 1.5 of the 30+ children enrolled All mothers in trial given a recipe book with nutrition info, to complement worker efforts Treatments compared to control group, for common trends & shocks
Caregiver incentives and child health motivation | trial design | outcomes | mechanisms Timeline of the experiment Round Date Block 1 Control* (83) Control (84) Control (84) Control (84) Control (84) Block 2 Block 3 Control (85) Control (85) Control (85) Baseline-I Jul-14 Control (76) Performance Pay (38) Performance Pay (38) Fixed Bonus (38) Baseline-II Oct-14 Endline-I Jan-15 Endline-II Apr-15 Endline-III Jul-15 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 health motivation | trial design | outcomes | mechanisms Balance at baseline
Caregiver incentives and child health motivation | trial design | outcomes | mechanisms Selective attrition after treatment?
Caregiver incentives and child health motivation | trial design | outcomes | mechanisms Non-parametrics Common trends and seasonality: -1 Winter Monsoon Monsoon Performance pay bonus -1.2 wfa z score -1.4 Fixed bonus -1.6 Pure control -1.8 1 2 3 4 5 Survey Round Control Cash 95% CI Absolute
Caregiver incentives and child health motivation | trial design | outcomes | mechanisms Transitions between malnutrition categories by treatment arm
Caregiver incentives and child health motivation | trial design | outcomes | mechanisms Average treatment effects Short term effects (R2 to R3) (2) Weight Wfa z Medium-term effects (R3 to R4) (4) (5) Weight Wfa z (1) (3) (6) Wfa mal Wfa mal 0.219*** (0.0772) 0.101*** (0.0370) -0.0561** (0.0269) Performance 0.231*** (0.0687) 0.0976*** (0.0327) -0.0522** (0.0219) Pay 0.123 (0.0933) 0.0557 (0.0442) -0.0333 (0.0278) Fixed Bonus 0.196** (0.0776) 0.0878** (0.0380) -0.0341 (0.0241) 3528 3522 3524 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 health motivation | trial design | outcomes | mechanisms Pre-trends and fade-out Pre-trends (R1 to R2) (2) Weight Wfa z Fade-out after treatments (R4 to R5) (4) Weight Wfa z (1) (3) (5) (6) Wfa mal Wfa mal Performance -0.0991 -0.00620 -0.0305 0.0898 (0.0904) 0.0355 (0.0408) -0.0338 (0.0235) Pay (0.119) (0.0411) (0.0223) 0.00967 (0.0752) 0.00266 (0.0357) 0.00262 (0.0267) Fixed Bonus 0.0971 (0.0884) 0.0694 (0.0423) -0.0305 (0.0285) N 3744 3730 3739 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 health motivation | trial design | outcomes | mechanisms Threshold effects Threshold effect Small sample Near and Far are defined around the median distance to each threshold, for groups near the boundaries to escape moderate (z>-2) or severe (z>-3) status, or normal (z>-1) All results control for observables on children, mothers and workers, with heteroscedasticity- consistent standard errors clustered on centers. Wfa z is the weight-for-age z score given the child's sex and age. *Significant at 10%, **Significant at 5%, ***Significant at 1%.
Caregiver incentives and child health motivation | trial design | outcomes | mechanisms Worker efforts Type of mother-worker interactions in the past month (as reported by mother) Short term effects (R2 to R3) Home visits by worker mother Medium term effects (R3 to R4) Center visits by mother Center visits by Frequency of worker talking about the child Frequency of worker talking about the child Home visits by worker Performance Pay -1.256 (0.915) -1.141 (1.438) 4.410*** (0.970) 4.434*** (0.869) -1.468 (1.229) 0.834 (1.323) Fixed Bonus -2.019* (1.092) -1.223 (0.855) 5.012*** (1.029) 4.570*** (0.929) -0.841 (1.248) 1.876 (1.354) N 3275 2831 3062 2108 1753 1997 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 health motivation | trial design | outcomes | mechanisms Worker efforts Topic of mother-worker interactions in the past month (as reported by mother) Short term effects (R2 to R3) over 3 mo. Dietary Intake Growth Chart Harmful Effects Hygiene Perf. Pay 0.226*** (0.0767) 0.0949 (0.0832) 0.0712 (0.0780) -0.0206 (0.0866) Fixed Bonus 0.245*** (0.0633) 0.0757* (0.0907) 0.0138 (0.0792) -0.0922 (0.0725) N 3223 3223 3223 3223 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 health motivation | trial design | outcomes | mechanisms Mothers response Child s diet at home: items consumed at least twice in past week (as reported by mother) Short term effects (R2 to R3) Green veg. Milk Dessert Porridge Perf. Pay 0.0616*** (0.0182) -0.130*** (0.0341) 0.228*** (0.0608) 0.105* (0.0617) Fixed Bonus 0.0666*** (0.0228) -0.148*** (0.0312) 0.213*** (0.0582) 0.293*** (0.0573) N 3223 3223 3223 3223 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 health motivation | 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 Pay 0.381 (0.480) 1.077** (0.502) -0.263 (0.375) -0.0946 (0.382) Fixed Bonus 0.571 (0.494) 0.988* (0.511) -0.206 (0.332) -0.546 (0.353) N 3721 3497 2286 2220
Caregiver incentives and child health motivation | 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 In absolute terms, the additional weight gain is about 70 grams per month Cost-effectiveness is roughly similar to iron + deworming (Bobonis et al 2006 in JHR) Changes targeting weight gain also promoted linear growth Mechanisms provide insight into agents knowledge of relative effectiveness Caregivers altered frequency, content of communication with mothers Mothers altered composition of children s diets Agenda for future work Would tournaments improve power of incentives? Would goal cards and nonmonetary rewards be sufficient? Do results hold in other contexts and over time?
