Harold Alderman

Assessing the overall benefits of programs enhancing human capital and equity: A new method with an application to school meals

Can district level support enhance coverage and equity? Evidence from India’s nutrition program

Importance: India’s Integrated Child Development Services (ICDS) program is among the world’s largest nutrition and health programs that offers services to pregnant, lactating mothers, and young children. To support national investments towards universalization of ICDS interventions, between 2016 and 2020, the Indian government in collaboration with multiple partners, introduced system strengthening mechanisms at the district (subnational administrative unit) level in 64% of India’s districts. Objectives: To examine national-level trends in coverage and equity of ICDS interventions and the role of district-level support mechanisms in improving equitable coverage. Design, Setting, and Participants: This quasi-experimental assessment used data (N=393,097 mother-child pairs) from three rounds of nationally representative surveys in 2006, 2016, and 2020. We used inequity indices and regression models to assess changes in equity by wealth, caste, and residence. We applied difference-in-differences (DID) models to investigate changes in coverage due to district support mechanisms between 2016 and 2020. Intervention: The district support mechanisms were introduced between 2016 and 2020 and included a combination of input features such as capacity building of frontline workers, additional human resources, financial, infrastructural, and technological support, among others. Main Outcomes and Measures: Our primary outcomes were the receipt of thirteen ICDS services during pregnancy, lactation, and early childhood. District support mechanisms were grouped into three treatment arms for DID analyses using an intention-to-treat approach with heterogeneous treatments. Results: ICDS utilization continued to increase from 2016 to 2020, with the most improvement observed in health and nutrition education (20-21pp). Unlike 2006-2016, there were large improvements in coverage equity between 2016-2020. DID models show, on average, that districts receiving any programmatic support had significant and faster improvements in coverage (2.2-14.7pp). Pooled effects sizes were larger, on average, for districts that received financial support in addition to human resources (8.9pp, 95% CI 7.3-10.74) compared to districts that only received human resource support (4.5pp, 95% CI 3.4-5.7). Conclusions: India’s programmatic efforts to further strengthen the ICDS were successful in increasing coverage of ICDS program at the national-level and reducing coverage inequities that persisted earlier. Focused district support mechanisms enabled faster progress in coverage and equity.

Do cash transfer programmes affect child anaemia? Results From a meta-analysis

Childhood anaemia is common and debilitating. Nutrition-specific policies are effective for addressing anaemia in many contexts but less is known about nutrition-sensitive policies such as cash transfers. We reviewed over 4000 studies and gathered 26 estimates of the effect of cash transfer programmes on childhood haemoglobin and anaemia. Overall, neither the impact of cash on haemoglobin (0.065 d/L, CI [−0.054, 0.184]) nor on anaemia prevalence (−0.092, CI [−1.227, 1.042]) were significant. While cash on its own had basically a null effect, programmes that provided cash in combination with other interventions such as behaviour change communication or nutritional supplements were more successful. The impact of social protection on haemoglobin and anaemia is surprisingly understudied compared to height, on which a previous study found well over 100 impacts of cash transfer programmes. Overall impacts of cash transfer programmes on haemoglobin and anaemia are weak: evidence is inconclusive at best. Cash transfer programmes are more successful in combination with other programmes providing education and/or nutritional supplements.