Impact of the Gram Varta programme on health, nutrition and women’s empowerment in India Malavika Subramanyam, Indian Institute of Technology (IIT) Gandhinagar Cara Ebert, University of Göttingen Christian Bommer, University of Göttingen Lisa Bogler, University of Göttingen Abhijeet Kumar, University of Göttingen Sini Varghese, IIT Sagar Atre, IIT Sebastian Vollmer, University of Göttingen Grantee Final Report Accepted by 3ie: November 2017 Note to readers This impact evaluation has been submitted in partial fulfilment of the requirements of grant CPW.01.GV.IE issued under Bihar Policy Window. This version is being published online as it was received. A copy-edited and formatted version will be available in the 3ie Impact Evaluation Report Series in the near future. All content is the sole responsibility of the authors and does not represent the opinions of 3ie, its donors or its board of commissioners. Any errors and omissions are the sole responsibility of the authors. All affiliations of the authors listed in the title page are those that were in effect at the time the report was accepted. Any comments or queries should be directed to the corresponding author, Sebastian Vollmer at [email protected] 3ie has received funding for the Bihar Policy Window from UKaid through the Department for International Development. Suggested citation: Subramanyam, M, L, Ebert, Bommer, C, Bogler, C, Kumar, A, Varghese, S, Atre, S and Vollmer, S, 2017. Impact of the Gram Varta programme on health, nutrition and women’s empowerment in India, 3ie Grantee Final Report. New Delhi: International Initiative for Impact Evaluation (3ie) Contents Acknowledgments ................................................................................................................... i Executive Summary ............................................................................................................... ii List of figures and tables ....................................................................................................... v Abbreviations and acronyms ............................................................................................. viii 1. Introduction ........................................................................................................................ 1 2. Intervention, theory of change and research hypotheses ............................................. 5 2.1 Description of intervention .......................................................................................... 5 2.2 Theory behind PLA ...................................................................................................... 6 2.3 Theory of change (ToC) ............................................................................................... 6 2.4 Potential impact timeline ........................................................................................... 11 2.5 Research hypotheses ................................................................................................ 12 3. Context ..............................................................................................................................15 3.1 Study site .................................................................................................................... 15 3.2 Sample description and external validity ................................................................. 17 4. Timeline ............................................................................................................................ 23 5. Evaluation: Design, methods and implementation ....................................................... 24 5.1 Estimation strategy .................................................................................................... 25 5.2 Ethical clearance ........................................................................................................ 25 5.3 Sample size determination ........................................................................................ 26 ICC parameter: 0.03 0.05 0.07 .................................................................................... 27 Example 1: 1600 1800 2000 ....................................................................................... 27 Example 2: 4600 8600 72400 ..................................................................................... 27 Example 3: 600 600 600 ............................................................................................. 27 Example 4: 2800 3800 6000 ....................................................................................... 27 5.4 Quantitative sampling design ................................................................................... 27 5.5 Qualitative sampling design ...................................................................................... 30 5.6 Treatment assignment ............................................................................................... 32 5.7 Data collection ............................................................................................................ 33 5.8 Data quality control measures during generation process .................................... 37 6. Programme or policy: Design, methods and implementation ..................................... 38 6.1 Programme content ................................................................................................... 38 6.2 Implementation ........................................................................................................... 39 7. Impact analysis and results of the key evaluation questions ..................................... 43 7.1 Specification ............................................................................................................... 43 7.2 Results related to women’s self-help groups .......................................................... 48 7.3 Results related to women’s agency and empowerment ......................................... 53 7.4 Results related to HNWASH knowledge and practices .......................................... 80 7.5 Results related to pregnancy .............................................................................. 97 7.6 Results related to Anganwadi centers ................................................................... 105 7.7 Results related to health outcomes ........................................................................ 111 7.8 Results related to social cohesion ......................................................................... 126 7.9 Summary of hypotheses tests ................................................................................ 128 7.10 Cost-effectiveness analysis .................................................................................. 133 8. Discussion ...................................................................................................................... 135 8.1 Concerns regarding internal validity ...................................................................... 135 8.2 Concerns regarding external validity ..................................................................... 145 8.3 Concerns regarding implementation and uptake ............................................ 146 8.4 Concerns regarding programme design ................................................................ 150 9. Specific findings for policy and practice ..................................................................... 151 9.1 Programme and implementation ............................................................................ 151 9.2 Policy ......................................................................................................................... 153 Online appendixes ............................................................................................................. 154 References .......................................................................................................................... 155 Acknowledgments We are grateful to the residents of the villages of Madhepura who participated in this research. The project benefited greatly from the remarkable contribution of the following students of the University of Göttingen: Miriam Albe, Mark Bohnes, Daniel Geissel, Esther Heesemann, Tatjana Kulp, Jennifer Pengel, Mareike Schön, Boryana Spasova, Michaela Theilmann, Kay Tuschen, Paula van Haaren, and Ann-Charline Weber. We gratefully acknowledge the timely efforts of the following students of IIT Gandhinagar and their colleagues: Prathu Bajpai, Susanna G., Jerene George, Vikash Patel, Vaidyanathan P.R., Debapriya Ray, Promita Roy, Ambarish Singh, and Ankita Shah. We could not have completed this project without the able leadership of the Madhepura-based field team led by Abhijeet Kumar and supported by Pushkar Anand, Late Abhimanyu Das, Pratima Goswami, Budhsen Kumar, Rahul Kumar, Shivshankar Kumar, and Priyanka Kumari, many thanks to all of them! We are grateful for funding from the International Initiative for Impact Evaluation (3ie) and the support from 3ie staff, particularly Francis Rathinam. i Executive Summary The problem: HNWASH in Bihar Women’s and children’s health (WCH) and water, sanitation and hygiene remain among the key health topics that attract and require attention in India. Reducing infant and neonatal mortality, maternal morbidities, and child mortality have remained major priorities of the Government of India and the governments of Indian states such as Bihar. Bihar continues