Knowledge Brief 5 Impact of a Community Result- Based Financing Strategy for Health and Nutrition in Nagaland, India This analysis of baseline and follow-up data indicates that the Nagaland Health Project has had an impact on utilization of delivery care at Community Health Centres as well as on immunization coverage. As the project matures, continued monitoring and evaluation of implementation and results, including further quantitative and qualitative data collection, will be important to confirm these initial positive results. Introduction strategy, providing funds to Health Committees if targets in their health and nutrition action plans Under the term “communitization,” in 2002 the state are met, following verification by project staff. government of Nagaland transferred responsibility Health Committees use the financial incentives at for local services to Village Councils and sector- their discretion to implement their action plans, for specific Committees. In the health sector, Village example for improving health facility infrastructure Health Committees were made responsible for and supplies, conducting community campaigns management of local health services, including for behavior change, and providing nutrition salary payment as well as use of small funds supplements to pregnant women. The project was transferred by the state government. Some 1,300 initially piloted in 30 villages across 2 districts and Village Health Committees have been constituted has been scaled up in a phased manner since 2017 and their level of functionality varies widely, with to about 450 villages in all 11 districts of the state. many hardly active. In 2016, the World Bank- financed Nagaland Health Project included a US$15 million component to provide technical and Methods financial support to strengthen implementation of the communitization strategy.1 The project aims Before the project was launched, a baseline survey was to support community participation in planning, done in 2015 to assess the delivery and utilization of delivering, monitoring, and evaluating health and health and nutrition services in Nagaland. Households nutrition services. A major focus is on enhancing and health facilities were surveyed in 110 villages knowledge and skills of Health Committees at the across 11 districts. In late 2018, as a part of a study village and facility levels, as well as engaging other on nutrition determinants and strategies in Nagaland, stakeholders including women’s groups and Village a follow-up survey was carried out in 55 out of the Councils. The project uses a result-based financing 110 villages covered by the baseline survey. July 2019  |  Page 1 To assess whether the project has had an impact on in the treated group and decreased in the control the utilization of maternal and child health services, group. In our difference-in-differences analysis, the we compared villages which received training effect of the project is not significant with regard and financial incentives as a part of the project to antenatal care. However, the effect is significant (treated) and those which received neither training for deliveries in Community Health Centres and full nor financial incentives (control). At the time of the immunization for children under 2 years old. The survey, the project had been implemented in 29 out increase in the log odds of receiving delivery care in of the 55 villages covered by the follow-up survey. a Community Health Centre in the treatment group To select a control village with a similar initial level after project intervention is higher than the control of maternal and child health service utilization as group by 5.6, while the increase in the log odds of each of the 29 treated villages, we calculated the being fully immunized is higher by 3.0. propensity score based on antenatal care visit rate, institutional delivery rate, and full immunization rate for children under 2 years of age at the Conclusion village level and applied the method of Nearest Neighbor Matching without replacement.2 The The analysis was limited by sample size and descriptive statistics provided in Table 1 show that selection constraints imposed by the baseline the socioeconomic variables are not statistically survey and the phasing of implementation, neither different between the matched control and the of which prioritized the needs of an impact treated villages before and after the introduction evaluation. Nonetheless, the data indicate that of project interventions. We used the difference-in- the project had an impact on utilization of delivery differences approach to evaluate the impact of the care at Community Health Centres as well as project by controlling for socioeconomic variables on immunization coverage, while no impact was and using village-clustered robust variance discernible for antenatal care or delivery care at estimation, assuming that the treated group would District Hospitals. At the time that this study was have followed the same trend as the control group conducted, a majority of the committees (over 70 if it had not received the intervention. percent) in the intervention group had achieved the target for and received payment against the indicator on full immunization while less than 30 Findings percent had met the target for antenatal care. These results are encouraging, suggesting that, in Figure 1 shows that the percentage of mothers this hilly state with poor connectivity, community who received antenatal care at least four times participation supported by the project has the increased with a similar slope in the control and potential to improve utilization of key health services. the treated groups after the start of the project, the The project is currently scaling-up its interventions percentage of mothers who delivered in Community to over 450 sites, with implementation planned Health Centres increased in the treated group and over a period of several years, providing more decreased in the control group, the percentage time for evaluation of its impact. Monitoring and of mothers who delivered in District Hospitals evaluation of project implementation and results, decreased in the treated group and increased in the including further quantitative and qualitative data control group, and the percentage of children under collection, will be important to confirm these initial two years old who were fully immunized increased positive results. Page 2  |  July 2019  escriptive statistics of socioeconomic variables and its comparison between villages with and Table 1: D without project interventions Change Over Baseline (2015) 2015–18 Villages Without Villages with Control- Control- Socioeconomic Variables the Project the Project Treated Treated (Control) (Treated) Mother’s age (years) 27 27 0 0 Mother has primary education 75% 65% 10% -5% Mother has secondary education 25% 21% 4% 2% Household head’s age (years) 36 39 -3 3 Household head is male 95% 94% 1% -2% Household head has primary education 74% 74% 0% 12% Household head has secondary education 34% 21% 13%* 1% Household religion is Christianity 92% 96% -4% 7% Wealth index a -0.21 -0.05 -0.16 0.46 Participation in government health service 21% 13% 8% -5% subsidy programs Note 1. Sample is restricted to children under 2 years old. The total sample size is 621 (197 in the control group and 424 in the treated). Note 2. ***: significant at 1%; **: significant at 5%; *: significant at 1%. Wealth index is derived from principal component analysis of data on housing material (finished wall, floor, and roof), assets (radio, TV, a cell phone, and refrigerator), vehicle (bicycle, motorcycle, car), land ownership, and livestock (cow, pig, chicken, and goat). Its mean is 0 and standard deviation is 1.69. Trends in antenatal care, institutional delivery in Community Health Centers and District Hospitals, FIGURE 1:  and childhood immunization before and after project implementation a. Antenatal care at least 4 times b. Delivery in Community Health Centre 30% 30% 27.7% 25% 25% 23.6% 23.5% 20% 20% 15% 15% 10% 10.3% 10% 9.8% 5% 6.0% 5% 5.2% 3.4% 0% 0% Before After Before After Not Signi cant Signi cant c. Delivery in District Hospital d. Full immunization of children under 2 years old 30% 30% 29.5% 25% 25% 22.9% 20% 20% 17.6% 18.4% 15% 15% 12.0% 15.4% 10% 10.3% 10% 9.6% 5% 5% 0% 0% Before After Before After Not Signi cant Signi cant Control Intervention Page 3 Footnotes 1 World Bank. 2016. Project Appraisal Document on a Proposed Credit in the Amount of US$48 Million to the Republic of India for a Nagaland Health Project. November 28. http://documents.worldbank.org/curated/en/719521482375675651/pdf/INDIA- NAGALAND-PAD-11302016.pdf 2 Gertler, Paul J., Sebastian Martinez, Patrick Premand, Laura B. Rawlings, and Christel M. J. Vermeersch. 2016. Impact Evaluation in Practice, Second Edition. Washington, DC: Inter-American Development Bank and World Bank. https://openknowledge. worldbank.org/handle/10986/25030 © 2019 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution Please cite the work as follows: “World Bank. 2019. India: Nutrition Determinants and Strategies in Nagaland, Knowledge Brief - Impact of a Community Result-Based Financing Strategy for Health and Nutrition in Nagaland, India. © World Bank.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Acknowledgements This work was led by Patrick Mullen and Aarushi Bhatnagar, with contributions from Young Eun Kim, Mohini Kak, Bathula Amith Nagaraj, Neesha Harnam, Avril Kaplan and Mamata Baruah, under the oversight of Rekha Menon. The World Bank team would like to thank the Directorate of Health and Family Welfare and Department of Social Welfare, Government of Nagaland, the Nagaland Health Project team, Oxford Policy Management Ltd., the Kohima Institute and all study participants for their contributions. This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies of the World Bank and its Board of Executive Directors. Page 4  |  July 2019