Association for Public Policy Analysis & Management

A large body of literature has documented inequalities in health and health care in India based on religion, caste, wealth and literacy. A question of interest to policymakers is whether large scale health programs can improve health outcomes of marginalized groups or if they worsen the gap in outcomes by excluding these groups. We examine data from the evaluation of the Ananya program in Bihar, a state in India with particularly poor maternal and child health outcomes. The Ananya program funded an integrated set of grants to improve health outcomes for young children and their mothers through interventions at the household, community, health facility, and provider levels in eight districts of Bihar with a combined population of 28.3 million people.

Consistent with the literature, we find evidence of large disparities in key maternal and child health outcomes at baseline, particularly receipt of antenatal care, facility deliveries, immunizations and use of modern methods of contraception. These disparities exist across all four measures of marginalization we use based on religion, caste, wealth and literacy. We find that while the Ananya program improved some health outcomes for the population as a whole, the program had mixed impacts on equity. We find evidence of convergence in some equity gaps, such as a decrease in antenatal care disparities and a significantly higher program impact on infant nutrition outcomes such as early breastfeeding and on-time introduction of solid foods among the most marginalized women. However, the program had no impact or in some cases widened the gaps for other outcomes. For example, the Ananya program increased the gap in vaccination rates between the most and least marginalized women. These findings suggest that programs directed at the general population are unlikely to close inequality gaps by themselves, and programs may have to more explicitly target marginalized groups to improve equity in health outcomes. This paper also examines factors that are associated with worse health outcomes to inform future programming targeted at improving health inequalities for marginalized women and children.