Putting a Band-Aid on a corpse: Incentives for nurses in the Indian public health care system
Last registered on May 31, 2016

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
Last updated
May 31, 2016 11:10 AM EDT
Location(s)
Region
Primary Investigator
Affiliation
MIT
Other Primary Investigator(s)
PI Affiliation
Department of Economics, Massachusetts Institute of Technology
PI Affiliation
Executive director, Abdul Latif Jameel Poverty Action Lab
Additional Trial Information
Status
Completed
Start date
2002-01-01
End date
2007-12-31
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)
Registration Citation
Citation
Banerjee, Abhijit, 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
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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 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)
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
Post-Trial
Post Trial Information
Study Withdrawal
Intervention
Is the intervention completed?
Yes
Intervention Completion Date
June 30, 2007, 12:00 AM +00:00
Is data collection complete?
Yes
Data Collection Completion Date
December 31, 2007, 12:00 AM +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
Reports and Papers
Preliminary Reports
Relevant Papers
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.