This presentation was made by Dr. Prakarsh Singh (Amherst College) in the session on ‘Taking it to the frontline: Improving frontline worker motivation, performance and convergence in health and nutrition’ at the POSHAN Conference "Delivering for Nutrition in India Learnings from Implementation Research", November 9–10, 2016, New Delhi. For more information about the conference visit our website: www.poshan.ifpri.info

1. Impact of caregiver incentives on child health:
Evidence from an experiment with
Anganwadi workers in India
Will Masters
Friedman School of Nutrition & Department of Economics, Tufts University
Prakarsh Singh
Department of Economics, Amherst College
POSHAN (IFPRI)
10th November, 2016.

2. Can we incentivize salaried workers to target
their services effectively?

3. • 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 health
motivation | trial design | outcomes | mechanisms
Can we incentivize salaried workers to target
their services effectively?

4. 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 health
motivation | trial design | outcomes | mechanisms

5. 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 month
intervals, July 2014 - July 2015,
with surveys of workers, children
and their mothers
Caregiver incentives and child health
motivation | trial design | outcomes | mechanisms

6. 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 health
motivation | trial design | outcomes | mechanisms

7. Timeline of the experiment
Round Date Block 1 Block 2 Block 3
Baseline-I Jul-14
Control*
(83)
Control (76)
Control
(85)
Baseline-II Oct-14
Control
(84)
Performance
Pay (38)
Fixed Bonus
(38)
Control
(85)
Endline-I Jan-15
Control
(84)
Performance
Pay (38)
Control
(85)
Endline-II Apr-15
Control
(84)
Endline-III Jul-15
Control
(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 health
motivation | trial design | outcomes | mechanisms

8. 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 health
motivation | trial design | outcomes | mechanisms

9. 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 health
motivation | trial design | outcomes | mechanisms

10. 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 health
motivation | trial design | outcomes | mechanisms

11. 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 health
motivation | trial design | outcomes | mechanisms

12. 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 health
motivation | trial design | outcomes | mechanisms

13. 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 health
motivation | trial design | outcomes | mechanisms

14. 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 health
motivation | trial design | outcomes | mechanisms

15. 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 health
motivation | trial design | outcomes | mechanisms