FINAL R EPORT Midline findings from the evaluation of the Ananya program in Bihar December 12, 2014 Mathematica Policy Research: Evan Borkum Dana Rotz Anu Rangarajan Swetha Sridharan Sukhmani Sethi Mercy Manoranjini Lakshmi Ramakrishnan Public Health Foundation of India: Lalit Dandona, Rakhi Dandona, Priyanka S Kochar, G Anil Kumar, and Priyanka Singh Submitted to: Bill & Melinda Gates Foundation 3rd Fl., Left Wing Capital Court Building, Olof Palme Marag Munirka, New Delhi, India 110 067 Program Officer: Yamini Atmavilas Senior Program Officers: Katherine Hay and Usha Kiran Tarigopula Contract Number: 4993/22539 (18) Submitted by: Mathematica Policy Research P.O. Box 2393 Princeton, NJ 08543-2393 Telephone: (609) 799-3535 Facsimile: (609) 799-0005 Project Director: Anu Rangarajan Reference Number: 40195.220 This page has been left blank for double-sided copying. ANANYA MIDLINE REPORT MATHEMATICA POLICY RESEARCH ACKNOWLEDGMENTS This report would not have been possible without the support and collaboration of a broad range of individuals and organizations. At the Bill & Melinda Gates Foundation, we are indebted to our program officers, Yamini Atmavilas, Katherine Hay, and Usha Tarigopula for their guidance and support throughout. We also thank other foundation staff, including Debarshi Bhattacharya, Anand Sinha, Tanvi Jain, and Tanya Jawa, for their support and input. The contributions of our local data collection partner, Sambodhi Research and Communications, were key to the success of this effort. We would like to thank Kultar Singh, Aparna Seth, Chandan Singh, Nikhil Raj, Putul Thakur, Rahul Chatterjee, and the Sambodhi investigators for tirelessly piloting and revising multiple rounds of our survey instruments, providing a comprehensive and in-depth training to field investigators, and capably managing a complex data collection effort. Our close interactions with the Ananya partners, including CARE, BBC, WHP and, more recently, IFC and PCI, have also been critical in shaping our thinking and approach. We appreciate their willingness to engage closely with us and to provide valuable feedback throughout the process. The contributions of several Mathematica staff were integral to this effort. We would like to thank Seth Morgan, Bethany Simard, Becca Wang, and Bill Leith for their hard work on data programming tasks and their close attention to detail while working under pressing deadlines. We also thank Divya Vohra for leading the literature review, and Ramya Tallapragada and Malik Mubeen for their help with collating the references for the report. Peter Schochet provided helpful guidance on questions related to the sampling. Matt Sloan and Nancy Murray reviewed drafts of the report and provided helpful comments. Maura Butler and John Kennedy skillfully edited the report and Jennifer Baskwell assisted with formatting, uncomplainingly processing several rounds of edits to the text and graphics. Finally, we would like to thank the households who participated in this study. Their patience with us as we administered the surveys, and their willingness to share their experiences, are what finally made this study possible. iii This page has been left blank for double-sided copying. ANANYA MIDLINE REPORT MATHEMATICA POLICY RESEARCH CONTENTS EXECUTIVE SUMMARY ........................................................................................................................... XV ACRONYMS ..........................................................................................................................................XXXV I INTRODUCTION .............................................................................................................................. 1 A. The Bihar context ...................................................................................................................... 1 B. Overview of the government health system in Bihar ................................................................. 2 C. The Ananya theory of change and its grant portfolio ................................................................ 4 1. The Ananya theory of change ............................................................................................. 4 2. Ananya grant portfolio ......................................................................................................... 5 3. Program logic for IFHI and SDP interventions .................................................................... 8 D. Road map of the report ............................................................................................................... 8 II ADDITIONAL CONTEXT: LITERATURE REVIEW AND ACTIVITIES OF OTHER DEVELOPMENT PARTNERS ....................................................................................................... 11 A. Literature review ...................................................................................................................... 11 1. Interventions focusing on FLW interactions with households ........................................... 11 2. Improving facility quality and upgrading skills of facility-based health workers ................ 13 3. Improving health information through media messaging campaigns ............................... 13 4. Improving health information through women’s participatory groups ............................... 14 5. Impacts of integrated health programs ............................................................................. 15 B. Activities of other development partners in Bihar .................................................................... 15 1. Key development partners in Bihar ................................................................................... 16 2. Summary of non-Ananya interventions ............................................................................. 18 III RESEARCH QUESTIONS, STUDY DESIGN, AND DATA COLLECTION ................................... 23 A. Research questions ................................................................................................................. 23 B. Comparison group design ....................................................................................................... 23 1. Motivation for comparison group design and identification of the comparison group ................................................................................................................................. 23 2. Interpretation of estimates from comparison group design .............................................. 25 3. Subgroup impact estimates .............................................................................................. 26 C. Sample and survey approach .................................................................................................. 27 v ANANYA MIDLINE REPORT MATHEMATICA POLICY RESEARCH D. Data collection ......................................................................................................................... 29 1. Survey timing and approach ............................................................................................. 29 2. Response rates ................................................................................................................. 29 3. Sample characteristics ...................................................................................................... 30 IV EXPOSURE TO KEY PROGRAM ELEMENTS ............................................................................. 33 A. Number of FLW home visits .................................................................................................... 33 1. Home visits during pregnancy ........................................................................................... 34 2. Home visits after delivery .................................................................................................. 35 3. Home visits related to complementary feeding and family planning ................................. 36 B. FLW interactions outside of home visits .................................................................................. 37 C. Quality of FLW interactions ..................................................................................................... 39 D. Findings on FLW–beneficiary interactions from the process study ......................................... 43 1. Findings on implementation of Ananya interventions related to FLWs ............................. 44 2. Findings on FLW–beneficiary interactions ........................................................................ 44 3. Conclusion on process study findings ............................................................................... 46 E. Exposure to media ................................................................................................................... 46 F. Participation in community groups .......................................................................................... 47 V MATERNAL AND NEWBORN HEALTH ........................................................................................ 49 A. Antenatal care.......................................................................................................................... 50 B. Delivery in facilities .................................................................................................................. 53 C. Newborn care practices ........................................................................................................... 57 VI CHILD NUTRITION