Abstract
This paper investigates India’s nationwide health reform to understand its various channels of effect. The reform entitled socio-economically backward mothers with cash transfer if they chose to give birth at public health institutions, and simultaneously employed ASHAs as a direct link between pregnant women and the public healthcare delivery system. Using variations in mothers’ eligibility and differential implementation of ASHAs across states, birth-related outcomes are evaluated in a difference-in-difference framework. Results show that eligible mothers with both cash transfer and ASHA’s guidance outperformed those receiving only cash transfer, in institutional birth rate and timely initiation of breastfeeding. An improved outcome in the ASHA’s presence alongside the conditional cash transfer argues for the vitality of the former’s role in spreading information on the importance of health and the uptake of public healthcare.
Funding source: Suomen Kulttuurirahasto
Award Identifier / Grant number: 00190193
Funding source: Yrjö Jahnssonin Säätiö
Award Identifier / Grant number: 20197164
Acknowledgements
I thank the Editor-in-Chief, Hendrik Schmitz, and two anonymous referees for their thoughtful feedback and thorough comments in attaining the current version of the paper. I am grateful to Patricia Justino, Kaisa Kotakorpi, Jukka Pirttilä, Miri Stryjan, and Janne Tukiainen whose feedback helped improve the paper substantially. I also thank Ludovica Gazze, Ardina Hasanbasri, Mika Kortelainen, Eero Mäkynen, Henri Salokangas, Maika Schmidt, and also the participants in the Turku School of Economics research seminar (2019), the annual summer school organized by the Italian Development Economists’ Association (2019), the workshop in Public and Labour Economics at Helsinki Graduate School of Economics (2019), the Annual Congress of International Institute of Public Finance (2020), and the Nordic Conference in Development Economics (2021) for their valuable insights and comments at various stages of this work. All errors remain my own.
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Research funding: This work was supported by the Suomen Kulttuurirahasto (00190193) and Yrjö Jahnssonin Säätiö (20197164).
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Disclosure statement: I declare that there are no competing interests.
Composition of the treatment groups. Figure (a) describes the groups in the entire sample, and Figure (b) describes the groups with only the rural sample. In both cases, the eligible groups in LPS had further guidance from ASHA while the eligible groups in HPS did not. In this paper, the rural sample is used for analysis.
Raw trends in public institutional births and early breastfeeding during 2001–2004. Data used from DLHS-2 and 3. The sample consists of rural mothers with reported last birth during 2001–2004. Top panel shows institutional births and bottom panel shows early breastfeeding. The curves are fitted through points in the scatter plots by using local weighted regression with running-line least squares smoothing.
Raw trends in public institutional births and early breastfeeding during 2001–2008. Data used from DLHS-2 and 3. The sample consists of rural mothers with reported last birth during 2001–2008. Top panel shows institutional births and bottom panel shows early breastfeeding. The curves are fitted through points in the scatter plots by using local weighted regression with running-line least squares smoothing.
Definitions
Union Territories: The union territories of India come directly under the Central Government administration, whereas states of the country have decentralized governments. The union territories of India during this study period were Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, Delhi, Lakshadweep and Puducherry. According to Census of India 2011, they together covered 1.32 % of the total population of India.
Scheduled Caste, Scheduled Tribe and Other Backward Classes: Also denoted as SC/ST/OBC, these terms are recognized in the Constitution of India. These are officially designated groups of people who are most disadvantaged in socio-economic terms in India. The Constitution follows protectionary and developmental principles and affirmative action toward these groups.
Public Health Facility: A public health facility, approved by the Janani Suraksha Yojana (JSY) program, includes a public hospital, dispensary, primary health center, community health center, urban health facilities (Urban Health Center/Urban Health Post/Urban Family Welfare Center), AYUSH hospital/clinic.
ICDS: Since 1975, the Integrated Child Development Services (ICDS) scheme has been one of the flagship programs undertaken by the Government of India on early childhood care and development. The beneficiaries under this scheme are children of 0–6 years, pregnant women and lactating mothers. The offered health services are – supplementary nutrition, health check-up, referral services and immunization. Auxiliary Nurse Midwives and Anganwadi workers (Anganwadi being a rural childcare center in India) usually provide the services. Other development services include preschool and non-formal education.
Summary statistics of socio-economic variables of first phase rural eligible mothers (pre- & post-reform).
| Variables | LPS | HPS | |
|---|---|---|---|
| Mean (SD) | Mean (SD) | Std. Difference | |
| Mother-specific variables | |||
| Total births by mother | 1.19 (0.38) | 1.26 (0.43) | −0.15 |
| Mother’s age at last birth | 24.83 (5.00) | 23.56 (4.32) | 0.27 |
| Max. schooling yrs. of mother | 1.07 (2.61) | 2.18 (3.53) | −0.35 |
| Hindu | 0.88 (0.32) | 0.81 (0.39) | 0.19 |
| Muslim | 0.10 (0.29) | 0.14 (0.34) | −0.12 |
| SC/ST/OBC | 0.89 (0.31) | 0.80 (0.40) | 0.24 |
| Wealth quintile | 1 (0) | 1 (0) | – |
| State-specific variables | |||
| Presence of child welfare program in village | 0.90 (0.30) | 0.95 (0.22) | −0.18 |
| Presence of public dispensary in village | 0.10 (0.29) | 0.04 (0.18) | 0.23 |
| Presence of district public hospital | 0.11 (0.31) | 0.07 (0.59) | 0.08 |
| Transportation cost to public health center | 354.88 (486.11) | 254.68 (426.60) | 0.22 |
| Costs related to giving birth at public health center1 | 1903.80 (2500.34) | 2262.42 (2995.59) | −0.13 |
| Transportation + birth-related costs | 2258.69 (2638.12) | 2517.07 (3090.55) | −0.09 |
| Observations | 32,674 | 6283 | |
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(1) Data from DLHS-2 and 3. The sample consists of rural mothers eligible from the first phase of the reform, with reported last birth during 2001–2008. (2) The variables on cost are given in Indian Rupees. (3) The last column gives the standardized difference in means. Standardized difference in mean >0.25 implies statistically significant difference between the groups (Imbens and Wooldridge 2009; Rellstab et al. 2020). (4) 1 Costs related to giving birth in public health institution usually include – out-of-pocket expenditures on medicines and supplies, lab tests, blood transfusion, food, tips, etc.
Summary statistics of socio-economic variables of all mothers in the low- and high-performing states (pre- & post reform).
| Variables | LPS | HPS | |
|---|---|---|---|
| Mean (SD) | Mean (SD) | Std. Difference | |
| Mother-specific variables | |||
| Total births by mother | 2.25 (1.89) | 1.67 (1.20) | 0.36 |
| Mother’s age at last birth | 24.87 (5.54) | 23.55 (4.62) | 0.26 |
| Max. schooling yrs. of mother | 3.19 (4.54) | 6.16 (5.08) | −0.62 |
| Hindu | 0.83 (0.38) | 0.77 (0.42) | 0.14 |
| Muslim | 0.15 (0.35) | 0.13 (0.33) | 0.06 |
| SC/ST/OBC | 0.79 (0.41) | 0.70 (0.46) | 0.22 |
| Wealth quintile | 2.49 (1.36) | 3.41 (1.30) | −0.69 |
| Rural | 0.82 (0.39) | 0.72 (0.45) | 0.23 |
| State-specific variables | |||
| Presence of child welfare program in village | 0.91 (0.30) | 0.95 (0.22) | −0.18 |
| Presence of public dispensary in village | 0.06 (0.24) | 0.06 (0.25) | −0.01 |
| Presence of district public hospital | 0.07 (0.25) | 0.05 (0.46) | 0.04 |
| Transportation cost to public health center | 361.76 (563.95) | 250.59 (418.18) | 0.22 |
| Costs related to giving birth at public health center1 | 2297.24 (2849.57) | 3432.02 (3646.91) | −0.35 |
| Transportation + birth-related costs | 2658.99 (2998.80) | 3682.60 (3701.35) | −0.30 |
| Observations | 213,147 | 113,194 | |
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(1) Data from DLHS-2 and 3. The sample consists of all mothers with reported last birth during 2001–2008. (2) The variables on cost are given in Indian Rupees. (3) The last column gives the standardized difference in means. Standardized difference in mean >0.25 implies statistically significant difference between the groups (Imbens and Wooldridge 2009; Rellstab et al. 2020). (4) 1 Costs related to giving birth in public health institution usually include – out-of-pocket expenditures on medicines and supplies, lab tests, blood transfusion, food, tips, etc.
Effects on institutional birth and early breastfeeding in LPS and HPS – considering the first phase eligible mothers only.
| Dependent variable | Institutional birth | Early breastfeeding |
|---|---|---|
| (1) | (2) | |
| First phase eligibles | ||
| Eligible without ASHA | −0.041*** | 0.017 |
| (0.009) | (0.015) | |
| Eligible with ASHA | −0.237*** | −0.195** |
| (0.080) | (0.094) | |
| Eligible without ASHA*Post1 | 0.045*** | 0.018 |
| (0.012) | (0.018) | |
| Eligible with ASHA*Post1 | 0.082*** | 0.056*** |
| (0.011) | (0.017) | |
| Second phase eligibles | Omitted | Omitted |
| State FE | Yes | Yes |
| Birth year FE | Yes | Yes |
| Controls | Yes | Yes |
| F-test of equality between interaction coefficients of first phase eligibles | ||
| F-statistic | 6.04 | 2.66 |
| p-value | 0.014 | 0.103 |
| Baseline mean of ineligibles | 0.24 | 0.42 |
| Observations | 94,694 | 89,715 |
| R 2 | 0.103 | 0.192 |
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(1) The unit of observation is a rural mother who had her latest birth during 2001–2008. The sample omits the mothers who became eligible only from the second phase of the reform. (2) Column (1) presents the estimates for dependent variable institutional birth (binary variable: 1 if birth at JSY-affiliated public health facility, 0 otherwise). Column (2) presents estimates for dependent variable early breastfeeding (binary variable: 1 if mother started breastfeeding 1–2 h after birth, 0 otherwise). (3) Explanatory/treatment variables EligiblewithoutASHA and EligiblewithASHA denote the respective pre-reform difference in means of the first phase eligible mothers in HPS and LPS with the control group (Ineligibles). EligiblewithoutASHA*Post1 and EligiblewithASHA*Post1 denote the respective difference-in-difference effects of the reform’s treatment arms on the first phase eligible mothers in HPS and LPS. Post1 denotes the births taking place after the onset of first guideline (Apr 2005). (4) An F-test of equality between the coefficients EligiblewithoutASHA*Post1 and EligiblewithASHA*Post1 (i.e. the first phase eligibles) shows that they are significantly different from each other (at 5 % and 10 % levels for institutional birth and early breastfeeding). (5) Control variables include mother’s total live births, her maximum schooling years, her age during last birth, her religion, if her household belongs to one of the socially backward groups, her household’s wealth quintile; and village-specific health infrastructure controls like presence of any other child welfare program, distance to the nearest primary health center, community health center, to the nearest district hospital; and, time-varying net state domestic product per capita. (6) Standard errors clustered at district level are within parentheses. (7) The unadjusted R 2 values are reported here. (8) The mean of the outcome variable in the control group (Ineligibles) in the pre-reform period is reported. (9) ***, **, * imply p < 0.01, <0.05, <0.10 respectively.
Effects on institutional birth and early breastfeeding in high-performing states only – considering the first phase eligible mothers only.
| Dependent variable | Institutional birth | Early breastfeeding |
|---|---|---|
| (1) | (2) | |
| First phase eligibles | ||
| Eligible | −0.058*** | 0.009 |
| (0.009) | (0.015) | |
| Eligible*Post1 | 0.078*** | 0.017 |
| (0.012) | (0.018) | |
| Eligible*Post3 | 0.136*** | 0.010 |
| (0.019) | (0.020) | |
| Second phase eligibles | Omitted | Omitted |
| State FE | Yes | Yes |
| Birth year FE | Yes | Yes |
| Controls | Yes | Yes |
| F-test of equality between the coefficients of Eligible*Post1 & Eligible*Post3 | ||
| F-statistic | 8.34 | 0.152 |
| p-value | 0.004 | 0.697 |
| Observations | 77,123 | 73,582 |
| Baseline mean of ineligibles | 0.284 | 0.469 |
| R 2 | 0.082 | 0.115 |
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(1) The sample contains observations from rural areas in high-performing states only, omitting the mothers who became eligible only from the second phase of the reform. The unit of observation is the mother in rural HPS, who had her latest birth during 2001 – May 2011. (2) Column (1) presents the estimates for dependent variable institutional birth (binary variable: 1 if birth at JSY-affiliated public health facility, 0 otherwise). Column (2) presents estimates for dependent variable early breastfeeding (binary variable: 1 if mother started breastfeeding 1–2 h after birth, 0 otherwise). (3) Explanatory/treatment variable Eligible denotes the pre-reform difference in means of the first phase eligible mothers with the control group (Ineligibles). Eligible*Post1 denotes the difference-in-difference effect of the mother’s cash transfer only on the first phase eligible mothers. Eligible*Post3 denotes the difference-in-difference effect of the mother’s cash transfer and ASHA’s presence on the first phase eligible mothers. Post1 denotes the births taking place in Apr 2005–Mar 2009 and Post3 denotes the births taking place in Apr 2009–May 2011. (4) An F-test of equality between the coefficients Eligible*Post1 and Eligible*Post3 (i.e. the DiD effect on first phase eligibles with one package and with two packages) shows that they are significantly different from each other (below 1 %) for institutional birth but not for early breastfeeding. (5) Control variables include mother’s total live births, her maximum schooling years, her age during last birth, her religion, if her household belongs to one of the socially backward groups, her household’s wealth quintile; and village-specific health infra-structure controls like presence of any other child welfare program, distance to the nearest primary health center, community health center, to the nearest district hospital; and, time-varying net state domestic product per capita. (6) Standard errors clustered at district level are within parentheses. (7) The unadjusted R 2 values are reported here. (8) The mean of the outcome variable in the control group (Ineligibles) in the pre-reform period is reported. (9) ***, **, * imply p < 0.01, <0.05, <0.10 respectively.
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Supplementary Material
This article contains supplementary material (https://doi.org/10.1515/bejeap-2022-0220).
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