let me take you to an urban slum in the North Indian city of Chandigarh here
North Indian city of Chandigarh here
North Indian city of Chandigarh here water buffaloes and chickens are looking
water buffaloes and chickens are looking
water buffaloes and chickens are looking for their grain of life pools of
for their grain of life pools of
for their grain of life pools of stagnant water act as breeding ground
stagnant water act as breeding ground
stagnant water act as breeding ground for mosquitoes I cross one such open
for mosquitoes I cross one such open
for mosquitoes I cross one such open sewage and enter the residential area of
sewage and enter the residential area of
sewage and enter the residential area of the slum step into a small room this
the slum step into a small room this
the slum step into a small room this room houses 25 kids between the ages of
room houses 25 kids between the ages of
room houses 25 kids between the ages of three and six years and is staffed by a
three and six years and is staffed by a
three and six years and is staffed by a worker called the anganwadi worker this
worker called the anganwadi worker this
worker called the anganwadi worker this daycare center is called an Anganwadi
even though there are alphabet charts on
even though there are alphabet charts on walls there is no lighting the
walls there is no lighting the
walls there is no lighting the temperature is over a hundred degrees
temperature is over a hundred degrees
temperature is over a hundred degrees Fahrenheit but there are no ceiling fans
Fahrenheit but there are no ceiling fans
Fahrenheit but there are no ceiling fans I take a picture of these kids and show
I take a picture of these kids and show
I take a picture of these kids and show it to them many of them haven’t seen
it to them many of them haven’t seen
it to them many of them haven’t seen themselves on a camera before I weigh
themselves on a camera before I weigh
themselves on a camera before I weigh all these kids who are present at the
all these kids who are present at the
all these kids who are present at the centre and find that almost half of them
centre and find that almost half of them
centre and find that almost half of them are malnourished this onion body in
are malnourished this onion body in
are malnourished this onion body in Chandigarh is not unique all around the
Chandigarh is not unique all around the
Chandigarh is not unique all around the world
world
world 3 million children die every year
3 million children die every year
3 million children die every year because they are malnourished that’s
because they are malnourished that’s
because they are malnourished that’s about four times the size of Boston half
about four times the size of Boston half
about four times the size of Boston half of all child mortality happens directly
of all child mortality happens directly
of all child mortality happens directly because of undernutrition even though
because of undernutrition even though
because of undernutrition even though there has been steep declines in
there has been steep declines in
there has been steep declines in undernutrition from 1980 to 2015 the
undernutrition from 1980 to 2015 the
undernutrition from 1980 to 2015 the global malnutrition rate for instance
global malnutrition rate for instance
global malnutrition rate for instance has dropped from 40% to about 23% much
has dropped from 40% to about 23% much
has dropped from 40% to about 23% much remains to be done
remains to be done
remains to be done India is a clear outlier
India is a clear outlier
India is a clear outlier on the x-axis here you see malnutrition
on the x-axis here you see malnutrition
on the x-axis here you see malnutrition rates and on the y-axis is the per
rates and on the y-axis is the per
rates and on the y-axis is the per capita income each bubble here
capita income each bubble here
capita income each bubble here represents a country and the size of the
represents a country and the size of the
represents a country and the size of the bubble is the population as you can see
bubble is the population as you can see
bubble is the population as you can see India has higher malnutrition than
India has higher malnutrition than
India has higher malnutrition than Ethiopia Democratic Republic of Congo
Ethiopia Democratic Republic of Congo
Ethiopia Democratic Republic of Congo Liberia and even though the per capita
Liberia and even though the per capita
Liberia and even though the per capita income is the same as Ghana the
income is the same as Ghana the
income is the same as Ghana the malnutrition is three times as high what
malnutrition is three times as high what
malnutrition is three times as high what is the reason that despite being one of
is the reason that despite being one of
is the reason that despite being one of the fastest growing economies in the
the fastest growing economies in the
the fastest growing economies in the last 20 years
last 20 years
last 20 years India’s malnutrition has been declining
India’s malnutrition has been declining
India’s malnutrition has been declining only very slowly has the income not
only very slowly has the income not
only very slowly has the income not trickle down to the poor that doesn’t
trickle down to the poor that doesn’t
trickle down to the poor that doesn’t seem to be the case the poor are
seem to be the case the poor are
seem to be the case the poor are increasing in their incomes so what
increasing in their incomes so what
increasing in their incomes so what could be the reason behind high
could be the reason behind high
could be the reason behind high malnutrition in India and more or less a
malnutrition in India and more or less a
malnutrition in India and more or less a stagnant rate of undernutrition in his
stagnant rate of undernutrition in his
stagnant rate of undernutrition in his home to over a third of the world’s
home to over a third of the world’s
home to over a third of the world’s stunted children and one point to seven
stunted children and one point to seven
stunted children and one point to seven million children approximately die every
million children approximately die every
million children approximately die every year in India because of malnutrition I
year in India because of malnutrition I
year in India because of malnutrition I asked the anganwadi worker why it is
asked the anganwadi worker why it is
asked the anganwadi worker why it is that almost half the class is
that almost half the class is
that almost half the class is malnourished she blames the mother she
malnourished she blames the mother she
malnourished she blames the mother she says that the mothers lack the knowledge
says that the mothers lack the knowledge
says that the mothers lack the knowledge on what to feed the child they did they
on what to feed the child they did they
on what to feed the child they did they don’t feed the right amount of calories
don’t feed the right amount of calories
don’t feed the right amount of calories and protein now in anganwadi worker
and protein now in anganwadi worker
and protein now in anganwadi worker herself can affect the health of a child
herself can affect the health of a child
herself can affect the health of a child through two main channels she’s supposed
through two main channels she’s supposed
through two main channels she’s supposed to provide a midday meal to the kids one
to provide a midday meal to the kids one
to provide a midday meal to the kids one the porridge Bowl as you can see so
the porridge Bowl as you can see so
the porridge Bowl as you can see so she’s supposed to distribute this
she’s supposed to distribute this
she’s supposed to distribute this amongst her kids in the class and
amongst her kids in the class and
amongst her kids in the class and the other channel through which she can
the other channel through which she can
the other channel through which she can change the health of the child is by
change the health of the child is by
change the health of the child is by talking to mothers and guiding them on
talking to mothers and guiding them on
talking to mothers and guiding them on nutrition and health behavior so the
nutrition and health behavior so the
nutrition and health behavior so the worker blames the mother I go further
worker blames the mother I go further
worker blames the mother I go further into the slums and interview a mother
into the slums and interview a mother
into the slums and interview a mother and ask her why she thinks her child is
and ask her why she thinks her child is
and ask her why she thinks her child is malnourished the mother blames the state
Anganwadi is part of the integrated
Anganwadi is part of the integrated child development services which was set
child development services which was set
child development services which was set up by the government of india in 1975
up by the government of india in 1975
up by the government of india in 1975 it’s the world’s largest childcare
it’s the world’s largest childcare
it’s the world’s largest childcare program it encompasses over 1.3 million
program it encompasses over 1.3 million
program it encompasses over 1.3 million daycare centers and each Center is
daycare centers and each Center is
daycare centers and each Center is staffed by only one worker
staffed by only one worker
staffed by only one worker so there are 1.3 million workers in
so there are 1.3 million workers in
so there are 1.3 million workers in India trying to improve the health of
India trying to improve the health of
India trying to improve the health of children these workers are paid very
children these workers are paid very
children these workers are paid very meager wages their wages are about fifty
meager wages their wages are about fifty
meager wages their wages are about fifty dollars a month which is about a tenth
dollars a month which is about a tenth
dollars a month which is about a tenth of what a government assistant would
of what a government assistant would
of what a government assistant would earn in in in the same region so she
earn in in in the same region so she
earn in in in the same region so she blames a lack of worker effort the
blames a lack of worker effort the
blames a lack of worker effort the worker doesn’t teach me what I should
worker doesn’t teach me what I should
worker doesn’t teach me what I should cook the worker doesn’t show me that my
cook the worker doesn’t show me that my
cook the worker doesn’t show me that my child is undernourished the worker
child is undernourished the worker
child is undernourished the worker doesn’t show me the growth chart that
doesn’t show me the growth chart that
doesn’t show me the growth chart that she’s supposed to show and many a time
she’s supposed to show and many a time
she’s supposed to show and many a time she is even absent so here was a problem
she is even absent so here was a problem
she is even absent so here was a problem the supply side was blaming the demand
the supply side was blaming the demand
the supply side was blaming the demand side and the demand side was blaming the
side and the demand side was blaming the
side and the demand side was blaming the supply side what could be done so we
supply side what could be done so we
supply side what could be done so we designed an experiment in the city of
designed an experiment in the city of
designed an experiment in the city of Chandigarh in 2010 and
and there were three components to this
and there were three components to this experiment the first component was a
experiment the first component was a
experiment the first component was a recipe book this was done to address the
recipe book this was done to address the
recipe book this was done to address the lack of maternal knowledge so to speak
lack of maternal knowledge so to speak
lack of maternal knowledge so to speak in the 2005-6 demographic and health
in the 2005-6 demographic and health
in the 2005-6 demographic and health survey for instance 9 out of 10 mothers
survey for instance 9 out of 10 mothers
survey for instance 9 out of 10 mothers don’t increase the fluid intake in their
don’t increase the fluid intake in their
don’t increase the fluid intake in their children when their child has diarrhea
children when their child has diarrhea
children when their child has diarrhea this is against the recommendation of
this is against the recommendation of
this is against the recommendation of the World Health Organization so we
the World Health Organization so we
the World Health Organization so we designed a recipe book in collaboration
designed a recipe book in collaboration
designed a recipe book in collaboration with the local food and nutrition board
with the local food and nutrition board
with the local food and nutrition board that contained 10 simple easy to make
that contained 10 simple easy to make
that contained 10 simple easy to make nutritious delicious calorific recipes
nutritious delicious calorific recipes
nutritious delicious calorific recipes all of them contained local ingredients
all of them contained local ingredients
all of them contained local ingredients and we said that what if we just give
and we said that what if we just give
and we said that what if we just give this to the mothers this would solve the
this to the mothers this would solve the
this to the mothers this would solve the maternal knowledge problem hopefully and
maternal knowledge problem hopefully and
maternal knowledge problem hopefully and that could improve the health of the
that could improve the health of the
that could improve the health of the kids now remember that the mother had
kids now remember that the mother had
kids now remember that the mother had blamed the state so we had to also think
blamed the state so we had to also think
blamed the state so we had to also think about ways to motivate the worker and
about ways to motivate the worker and
about ways to motivate the worker and when we had spoken with the workers
when we had spoken with the workers
when we had spoken with the workers workers were obviously they they were
workers were obviously they they were
workers were obviously they they were not satisfied with their wages they
not satisfied with their wages they
not satisfied with their wages they wanted their wages to go up for the
wanted their wages to go up for the
wanted their wages to go up for the amount of work that they were putting in
amount of work that they were putting in
amount of work that they were putting in so we thought of an incentive scheme
so we thought of an incentive scheme
so we thought of an incentive scheme wherein the worker would get a
wherein the worker would get a
wherein the worker would get a performance-based bonus and the
performance-based bonus and the
performance-based bonus and the performance would be based on the
performance would be based on the
performance would be based on the decline in malnutrition that would
decline in malnutrition that would
decline in malnutrition that would happen in her Center so she would get
happen in her Center so she would get
happen in her Center so she would get three dollars for every child that
three dollars for every child that
three dollars for every child that improved a grade of malnutrition so if a
improved a grade of malnutrition so if a
improved a grade of malnutrition so if a child went from severely malnourished to
child went from severely malnourished to
child went from severely malnourished to moderately malnourished that’s one great
moderately malnourished that’s one great
moderately malnourished that’s one great improvement or from moderate to mild
improvement or from moderate to mild
improvement or from moderate to mild that’s another great improvement so the
that’s another great improvement so the
that’s another great improvement so the worker would get three dollars for
worker would get three dollars for
worker would get three dollars for nutritional great improvements and then
nutritional great improvements and then
nutritional great improvements and then we’d also subtract from the total bonus
we’d also subtract from the total bonus
we’d also subtract from the total bonus if there were kids who declined in the
if there were kids who declined in the
if there were kids who declined in the nutritional status so for instance if
nutritional status so for instance if
nutritional status so for instance if three kids went up and one kid went down
three kids went up and one kid went down
three kids went up and one kid went down then the total payout to the worker
then the total payout to the worker
then the total payout to the worker would be six dollars 4101 children were
would be six dollars 4101 children were
would be six dollars 4101 children were weighed twice
weighed twice
weighed twice during the course of this experiment in
during the course of this experiment in
during the course of this experiment in 2010 in the city of Chandigarh that I
2010 in the city of Chandigarh that I
2010 in the city of Chandigarh that I just showed you there were three
just showed you there were three
just showed you there were three treatment arms the first treatment was
treatment arms the first treatment was
treatment arms the first treatment was the recipe cook group treatment where
the recipe cook group treatment where
the recipe cook group treatment where about 900 mothers got a recipe book in
about 900 mothers got a recipe book in
about 900 mothers got a recipe book in the incentive treatment which was the
the incentive treatment which was the
the incentive treatment which was the second treatment and the bonus treatment
second treatment and the bonus treatment
second treatment and the bonus treatment for the worker there were a thousand
for the worker there were a thousand
for the worker there were a thousand 1061 children and 38 workers in the
1061 children and 38 workers in the
1061 children and 38 workers in the combined treatment again they were close
combined treatment again they were close
combined treatment again they were close to a thousand children and the combined
to a thousand children and the combined
to a thousand children and the combined treatment the mothers got the recipe
treatment the mothers got the recipe
treatment the mothers got the recipe books and the workers got the incentives
books and the workers got the incentives
books and the workers got the incentives the intuition behind the combined
the intuition behind the combined
the intuition behind the combined treatment was that it takes two to tango
perhaps you need both the mother and the
perhaps you need both the mother and the worker to reduce undernutrition and not
worker to reduce undernutrition and not
worker to reduce undernutrition and not one or the other in economics this is
one or the other in economics this is
one or the other in economics this is called complementarity so to test for
called complementarity so to test for
called complementarity so to test for complementarity we had to test whether
complementarity we had to test whether
complementarity we had to test whether the effect of the combined treatment was
the effect of the combined treatment was
the effect of the combined treatment was greater than the sum of the effects of
greater than the sum of the effects of
greater than the sum of the effects of the recipe treatment and the incent of
the recipe treatment and the incent of
the recipe treatment and the incent of treatment and we can statistically test
treatment and we can statistically test
treatment and we can statistically test for that the fourth group was the
for that the fourth group was the
for that the fourth group was the control group where we just follow the
control group where we just follow the
control group where we just follow the kids over time and see how they grow and
kids over time and see how they grow and
kids over time and see how they grow and what we found was very insightful
what we found was very insightful
what we found was very insightful because the recipe treatment had no
because the recipe treatment had no
because the recipe treatment had no significant effect the incentive scheme
significant effect the incentive scheme
significant effect the incentive scheme alone had no effect and these were
alone had no effect and these were
alone had no effect and these were precisely estimated zero effects but the
precisely estimated zero effects but the
precisely estimated zero effects but the combined treatment actually led to a
combined treatment actually led to a
combined treatment actually led to a significant drop in malnutrition which
significant drop in malnutrition which
significant drop in malnutrition which is about four percentage points over a
is about four percentage points over a
is about four percentage points over a quarter once we discontinued the
quarter once we discontinued the
quarter once we discontinued the incentive scheme and weighed these kids
incentive scheme and weighed these kids
incentive scheme and weighed these kids a year later they had the the gains that
a year later they had the the gains that
a year later they had the the gains that they had accumulated initially those
they had accumulated initially those
they had accumulated initially those gains had
gains had
gains had assisted over a year then we delved into
assisted over a year then we delved into
assisted over a year then we delved into why this happened
why this happened
why this happened what were the mechanisms driving this
what were the mechanisms driving this
what were the mechanisms driving this increase in weight for age and also a
increase in weight for age and also a
increase in weight for age and also a decline in the malnutrition a team of
decline in the malnutrition a team of
decline in the malnutrition a team of enumerators had not only weighed these
enumerators had not only weighed these
enumerators had not only weighed these kids but they had gone to the mothers
kids but they had gone to the mothers
kids but they had gone to the mothers and interviewed them both before the
and interviewed them both before the
and interviewed them both before the treatment and after the treatment at end
treatment and after the treatment at end
treatment and after the treatment at end line what we found was that workers had
line what we found was that workers had
line what we found was that workers had started making more home visits when
started making more home visits when
started making more home visits when they were incentivized and when they
they were incentivized and when they
they were incentivized and when they went to the homes they gave specific
went to the homes they gave specific
went to the homes they gave specific nutritional advice to the mothers when
nutritional advice to the mothers when
nutritional advice to the mothers when the mothers had recipe books so the
the mothers had recipe books so the
the mothers had recipe books so the communication was much more effective
communication was much more effective
communication was much more effective when the mothers had the recipe books at
when the mothers had the recipe books at
when the mothers had the recipe books at home and the workers when the workers
home and the workers when the workers
home and the workers when the workers were incentivized so this communication
were incentivized so this communication
were incentivized so this communication effectiveness actually drove the
effectiveness actually drove the
effectiveness actually drove the complementarity in improvement in
complementarity in improvement in
complementarity in improvement in improvement of weights in turn we also
improvement of weights in turn we also
improvement of weights in turn we also asked mothers about the diet that they
asked mothers about the diet that they
asked mothers about the diet that they were giving to their kids and we found
were giving to their kids and we found
were giving to their kids and we found that mothers improved calorie and
that mothers improved calorie and
that mothers improved calorie and protein intake in their children that
protein intake in their children that
protein intake in their children that experiment was carried out in 2010 since
experiment was carried out in 2010 since
experiment was carried out in 2010 since then
then
then I’ve carried out a similar experiment in
I’ve carried out a similar experiment in
I’ve carried out a similar experiment in Kolkata among 290 care centers and again
Kolkata among 290 care centers and again
Kolkata among 290 care centers and again in Chandigarh in 2014-15 in 165 daycare
in Chandigarh in 2014-15 in 165 daycare
in Chandigarh in 2014-15 in 165 daycare centers in both of these experiments we
centers in both of these experiments we
centers in both of these experiments we have been able to corroborate a decline
have been able to corroborate a decline
have been able to corroborate a decline in malnutrition of roughly the same
in malnutrition of roughly the same
in malnutrition of roughly the same magnitude every quarter where workers
magnitude every quarter where workers
magnitude every quarter where workers got performance-based pay and mothers
got performance-based pay and mothers
got performance-based pay and mothers got information so this has been
got information so this has been
got information so this has been replicated over and over again what
replicated over and over again what
replicated over and over again what we’ve also found is that just increasing
we’ve also found is that just increasing
we’ve also found is that just increasing the wage without conditioning it on the
the wage without conditioning it on the
the wage without conditioning it on the weight gain of the kids is not as
weight gain of the kids is not as
weight gain of the kids is not as effective so just increasing the wages
effective so just increasing the wages
effective so just increasing the wages as a fixed
as a fixed
as a fixed lump sum amount is not as effective
lump sum amount is not as effective
lump sum amount is not as effective we found that making workers compete
we found that making workers compete
we found that making workers compete against one another is not as effective
against one another is not as effective
against one another is not as effective as just giving them this piecemeal
as just giving them this piecemeal
as just giving them this piecemeal incentive you might think that after
incentive you might think that after
incentive you might think that after giving it once if you give it if you
giving it once if you give it if you
giving it once if you give it if you implement this incentive scheme again it
implement this incentive scheme again it
implement this incentive scheme again it would have no effect but a renewal of
would have no effect but a renewal of
would have no effect but a renewal of incentives also leads to a decline and
incentives also leads to a decline and
incentives also leads to a decline and malnutrition of about four percentage
malnutrition of about four percentage
malnutrition of about four percentage points
points
points finally withdrawal of incentives did not
finally withdrawal of incentives did not
finally withdrawal of incentives did not crowd out intrinsic motivation of
crowd out intrinsic motivation of
crowd out intrinsic motivation of workers it did not reverse the gains
workers it did not reverse the gains
workers it did not reverse the gains that the that the children had
that the that the children had
that the that the children had accumulated when the incentives were in
accumulated when the incentives were in
accumulated when the incentives were in place and the main channel that was
place and the main channel that was
place and the main channel that was driving this was mother worker
driving this was mother worker
driving this was mother worker communication and we in a recent paper I
communication and we in a recent paper I
communication and we in a recent paper I also find that worker attendance went up
also find that worker attendance went up
also find that worker attendance went up so enumerators went in randomly and saw
so enumerators went in randomly and saw
so enumerators went in randomly and saw whether the workers were present in the
whether the workers were present in the
whether the workers were present in the classroom or not and they were more
classroom or not and they were more
classroom or not and they were more likely to be present when they were
likely to be present when they were
likely to be present when they were incentivized now different contexts will
incentivized now different contexts will
incentivized now different contexts will involve different strategies what we can
involve different strategies what we can
involve different strategies what we can do is try an experiment and sometimes
do is try an experiment and sometimes
do is try an experiment and sometimes experiments are going to be successful
experiments are going to be successful
experiments are going to be successful and when they are successful in the
and when they are successful in the
and when they are successful in the realm of early childhood nutrition the
realm of early childhood nutrition the
realm of early childhood nutrition the benefit cost ratios can be really really
benefit cost ratios can be really really
benefit cost ratios can be really really high so think about what happens when a
high so think about what happens when a
high so think about what happens when a child is no longer undernourished not
child is no longer undernourished not
child is no longer undernourished not only is that child less likely to die
only is that child less likely to die
only is that child less likely to die because of diseases such as diarrhea
because of diseases such as diarrhea
because of diseases such as diarrhea pneumonia but that child is also more
pneumonia but that child is also more
pneumonia but that child is also more likely to come to school the child is
likely to come to school the child is
likely to come to school the child is more likely to have higher grades in
more likely to have higher grades in
more likely to have higher grades in school to get more schooling to have
school to get more schooling to have
school to get more schooling to have higher labor productivity and eventually
higher labor productivity and eventually
higher labor productivity and eventually higher wages economists can back out the
higher wages economists can back out the
higher wages economists can back out the lifetime increase in wages and say
lifetime increase in wages and say
lifetime increase in wages and say that’s the benefit of not being
that’s the benefit of not being
that’s the benefit of not being undernourished the benefit cost ratio
undernourished the benefit cost ratio
undernourished the benefit cost ratio estimate of the combined treatment was
estimate of the combined treatment was
estimate of the combined treatment was close to 16 which means that if you
close to 16 which means that if you
close to 16 which means that if you spend a dollar today on implementing the
spend a dollar today on implementing the
spend a dollar today on implementing the combined treatment over a long enough
combined treatment over a long enough
combined treatment over a long enough period you are actually gonna get 16
period you are actually gonna get 16
period you are actually gonna get 16 dollars back so it’s in the interests of
dollars back so it’s in the interests of
dollars back so it’s in the interests of governments and NGOs
governments and NGOs
governments and NGOs and communities to actually implement
and communities to actually implement
and communities to actually implement policies that have high benefit cost
policies that have high benefit cost
policies that have high benefit cost ratios finally improvement in child
ratios finally improvement in child
ratios finally improvement in child health is just the first step towards
health is just the first step towards
health is just the first step towards kids realizing their potential and
kids realizing their potential and
kids realizing their potential and leading fulfilling lives thank you
leading fulfilling lives thank you
leading fulfilling lives thank you [Applause]
”
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