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Improving child nutrition and maternal health in India

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Shruti Viswanathan

Apurva Bamezai Mehjabeen Jagmag Sarthak Joshi Shweta Bahri Simon Hunt Tom Newton-Lewis 7597 BCSP

We worked with the State Government’s Social Welfare Department to introduce a maternal and child-focused social protection scheme in Bihar, India. The Bihar Child Support Programme, funded by the UK Department for International Development and Children’s Investment Fund Foundation, was a conditional cash transfer aimed at improving child nutrition outcomes across one of the country’s poorest states. Our team led on the design, implementation, and monitoring and evaluation of the pilot phase of the programme, working closely with government officials, Anganwadi Workers, and Supervisors. 9,040 beneficiaries were enrolled in the intervention blocks within Gaya district during pilot phase. The pilot concluded in November 2016.

The impact evaluation showed that the Bihar Child Support Programme had significant effects on the proportion of children who were wasted and underweight, and the proportion of mothers who were underweight and anaemic. The evaluation generates important lessons for cash transfer programming, especially the Government of India’s new Pradhan Mantri Matritva Vandana Yojana (Prime Minister’s Maternity Benefit Programme).

Under the BCSP, women were registered at the end of the first trimester of pregnancy and are eligible to receive INR 250 per month until the child is three years old. Women received the money only if they meet certain conditions, including attendance at village training days, regular child growth monitoring, and vaccination against measles.

We adopted an innovative approach to programme delivery, making use of existing infrastructure and widely used technology – mobile phones – to help ensure maximum enrolment and cost-effective operation. Under the scheme, frontline service workers (Anganwadi workers) used a specially developed mobile phone application to register beneficiaries, monitor their adherence to certain conditions, and identify gaps. Data were transmitted to a central server that generated payment lists and instructed the release of funds through direct bank transfers.

Our approach

Our mixed-methods evaluation was designed to test the impact, effectiveness, and relative cost-effectiveness of the scheme to assess its scalability as a viable and useful policy instrument, aimed at improving child nutrition through behavioural change. We used a quasi-experimental survey design to quantify child development indicators across 6,600 households, complemented by in-depth qualitative studies. As part of this evaluation, we tested a series of questions designed to help identify the potential 'pathways to impact' that the BCSP may have, including:

  • a resource effect: whether the additional household income received due to the BCSP is translated into increased expenditure on food (and more nutritious food), healthcare, and other pro-nutrition expenditures;
  • an empowerment effect: whether the fact that the cash was transferred to the woman improved her status within the household, her decision-making power, control over resources, and time use;
  • an incentive effect: whether beneficiaries changed their behaviours and seek out available services in order to receive the money; and
  • a social accountability effect: whether beneficiaries pressured service providers to improve the accessibility and quality of services to enable them to meet the conditions.

Outcomes

This multi-year project helped improve understanding around the impact of social protection measures on child nutritional and maternal health outcomes in East India. Our evaluation provided policy-relevant insights into what helps trigger positive behavioural change, and our operational assessments of the programme systems help feed into design improvements.

Over the longer-term, these insights helped support the effective and efficient scale-up of the programme, improving early childhood development outcomes for even more families across Bihar and beyond.

More broadly, findings from the pilot helped inform and strengthen existing centrally- and state-funded Conditional Cash Transfer Programmes as part of the country’s wider national social protection framework.