Putting a Band-Aid on a corpse: Incentives for nurses in the Indian public health care system

Last registered on May 31, 2016
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Pre-Trial

Trial Information

General Information

Title
Putting a Band-Aid on a corpse: Incentives for nurses in the Indian public health care system
RCT ID
AEARCTR-0001194
Initial registration date
May 31, 2016

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
May 31, 2016, 11:10 AM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

Country
India
Region
South Asia

Primary Investigator

Name
Esther Duflo
Affiliation
MIT
Contact Primary Investigator

Other Primary Investigator(s)

PI Name
Rachel Glennerster
PI Affiliation
Executive director, Abdul Latif Jameel Poverty Action Lab
Contact Investigator
PI Name
Abhijit Vinayak Banerjee
PI Affiliation
Department of Economics, Massachusetts Institute of Technology
Contact Investigator

Additional Trial Information

Status
Completed
Start date
2002-01-01
End date
2007-12-31
Keywords
Governance, Health
Additional Keywords
nurse midwives, ANM, absenteeism, attendance incentive, public health, subcenter, primary health center, rural health care, India
JEL code(s)
Secondary IDs
Abstract
The public Indian health care system is plagued by high staff absence, low effort by providers, and limited use by potential beneficiaries who prefer private alternatives. This article reports the results of an experiment carried out with a district administration and a nongovernmental organization (NGO). The presence of government nurses in government public health facilities (subcenters and aid-posts) was recorded by the NGO, and the government took steps to punish the worst delinquents. Initially, the monitoring system was extremely effective. This shows that nurses are responsive to financial incentives. But after a few months, the local health administration appears to have undermined the scheme from the inside by letting the nurses claim an increasing number of “exempt days.” Eighteen months after its inception, the program had become completely ineffective.
External Link(s)
J-PAL Evaluation Summary

Registration Citation

Citation
Banerjee, Abhijit Vinayak, Esther Duflo and Rachel Glennerster. 2016. "Putting a Band-Aid on a corpse: Incentives for nurses in the Indian public health care system." AEA RCT Registry. May 31. https://doi.org/10.1257/rct.1194-1.0
Former Citation
Banerjee, Abhijit Vinayak, Esther Duflo and Rachel Glennerster. 2016. "Putting a Band-Aid on a corpse: Incentives for nurses in the Indian public health care system." AEA RCT Registry. May 31. https://www.socialscienceregistry.org/trials/1194/history/8514
Sponsors & Partners

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Experimental Details

Interventions

Intervention(s)
Assistant Nurse Midwives (ANM) in government healthcare subcenters (the first tier of the public healthcare infrastructure) were monitored for attendance by a time/date-stamping machine. The machine was locked into a caddy and password-protected to prevent tampering. In addition, the ANM was supposed to stamp a register secured to the wall of the subcenter three times a day: once at 9 a.m., once between 11 a.m. and 1 p.m., and once at 3 p.m. She had to both sign and stamp following a routine that ensures that only the ANM can sign. Any absence had to be recorded on the register and approved by the supervising doctor to which the nurse reports to.

Attendance was incentivized by an announcement by the Chief Medical Health Officer (CMHO) of the district which stipulated that ANMs absent for more than 50% of the time on monitored days would have their pay reduced by the number of absences recorded by Seva Mandir’s monitoring system for that month. Further, ANMs absent for more than 50% of the time on monitored days for a second month would be suspended from government service.
Intervention (Hidden)
Intervention Start Date
2006-02-01
Intervention End Date
2007-06-30

Primary Outcomes

Primary Outcomes (end points)
1) Attendance of tenured ANM on monitored days (Mondays).
2) Attendance of tenured ANM on unmonitored days
3) Attendance of contractual ANM on monitored days (three days a week).
4) Attendance of contractual ANM on unmonitored days.
Primary Outcomes (explanation)
Attendance was checked by (1) time-stamp machine data and attendance logs on the register (2) random visits by monitoring field officer.

Secondary Outcomes

Secondary Outcomes (end points)
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
The experiment uses baseline data of nurse attendance from a 2002-2003 survey done by Banerjee, Duflo and Glennerster. That data is used to ensure there is no significant difference between treatment and control groups. According to the contract between Seva Mandir and the district, the NGO would monitor tenured ANMs on Mondays - because as per decree of the District, no meeting or field activities were to be scheduled on Monday giving the ANM no reason to be absent from the center - and the contractual ANM three days per week. Treatment subcenters received the time-stamp machine and attendance registers while control subcenters continued to operate as before.

Field officers made unannounced visits to sample subcenters to check if the center was open, whether the ANMs were present and took a date-stamped photo if the ANM was found. At the end of the month Seva Mandir consolidated the attendance data from the time stamp machine and physical registers and send it to the supervising doctor who approved any absences. Only the administration had information whether logged absences were legitimate.
Experimental Design Details
Randomization Method
Computer randomization in office.
Randomization Unit
Subcenter
Was the treatment clustered?
Yes

Experiment Characteristics

Sample size: planned number of clusters
100 Subcenters
Sample size: planned number of observations
128 ANMS (100 tenured ANMs, 28 additional ANMs)
Sample size (or number of clusters) by treatment arms
Two nurse centers (Total 28):
Treatment: 16 centers
Control: 12 centers

One-nurse center (Total 72):
Treatment: 33 centers
Control: 39 centers

Tenured ANMs (Total 100):
Treatment: 49
Control: 51

Additional ANM (Total 28):
Treatment: 16
Control: 12
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Supporting Documents and Materials
IRB

Institutional Review Boards (IRBs)

IRB Name
Vidhya Bhaban
IRB Approval Date
2006-02-01
IRB Approval Number
NA
IRB Name
MIT
IRB Approval Date
2006-02-01
IRB Approval Number
NA
Analysis Plan

Post-Trial

Post Trial Information

Study Withdrawal

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Intervention

Is the intervention completed?
Yes
Intervention Completion Date
June 30, 2007, 12:00 +00:00
Data Collection Complete
Yes
Data Collection Completion Date
December 31, 2007, 12:00 +00:00
Final Sample Size: Number of Clusters (Unit of Randomization)
100 subcenters
Was attrition correlated with treatment status?
No
Final Sample Size: Total Number of Observations
128 ANMS (100 tenured ANMs, 28 additional ANMs)
Final Sample Size (or Number of Clusters) by Treatment Arms
Two nurse centers (Total 28): Treatment: 16 centers Control: 12 centers One-nurse center (Total 72): Treatment: 33 centers Control: 39 centers Regular ANMs (Total 100): Treatment: 49 Control: 51 Additional ANM (Total 28): Treatment: 16 Control: 12
Data Publication

Data Publication

Is public data available?
Yes
Public Data URL
https://dataverse.harvard.edu/dataset.xhtml?persistentId=hdl:1902.1/RKYSWXPPAC

Program Files

Program Files
Yes
Program Files URL
https://dataverse.harvard.edu/dataset.xhtml?persistentId=hdl:1902.1/RKYSWXPPAC
Reports, Papers & Other Materials

Relevant Paper(s)

Abstract
PUTTING A BAND-AID ON A CORPSE: INCENTIVES FOR NURSES IN THE INDIAN PUBLIC HEALTH CARE SYSTEM

The public Indian health care system is plagued by high staff absence, low effort by providers, and limited use by potential beneficiaries who prefer private alternatives. This article reports the results of an experiment carried out with a district administration and a nongovernmental organization (NGO). The presence of government nurses in government public health facilities (subcenters and aid-posts) was recorded by the NGO, and the government took steps to punish the worst delinquents. Initially, the monitoring system was extremely effective. This shows that nurses are responsive to financial incentives. But after a few months, the local health administration appears to have undermined the scheme from the inside by letting the nurses claim an increasing number of “exempt days.” Eighteen months after its inception, the program had become completely ineffective.
Citation
Banerjee, Abhijit, Rachel Glennerster, and Esther Duflo. 2008. "Putting a Band-Aid on a Corpse: Incentives for Nurses in the Indian Public Health Care System." Journal of the European Economic Association 6(2-3): 487-500.
URL
https://www.povertyactionlab.org/sites/default/files/publications/139%20Putting%20a%20band-aid%20on%20a%20corpse%20author%27s%20manuscript%202008.pdf

Reports & Other Materials