Heat, Infant Mortality and Adaptation: Evidence from …...Heat, Infant Mortality and Adaptation: Evidence from India Rakesh Banerjee and Riddhi Bhowmick Click here for the latest

Heat, Infant Mortality and Adaptation: Evidence from India

Rakesh Banerjee and Riddhi Bhowmick

Click here for the latest version.

University of Southern California

November 2016

Abstract

The predicted rise in global temperatures and more frequent extreme weather events are likelyto have a significant impact on human health. This paper asks two questions. Do higher tem-peratures during pregnancy increase infant mortality? and can public policies be effective inreducing the effects of high temperatures during pregnancy? We construct birth records, usingthe pregnancy history of mothers from the District Level Household Survey (DLHS) of India,and combine these records with daily temperature data. We show higher temperatures duringpregnancy increase infant mortality in rural areas but not in urban areas. Two plausible mecha-nisms may explain this effect a) Higher temperatures could lead to reduced agricultural output andincreased food prices. In absence of consumption smoothing this may lead to reduced fetal nutri-tion b) Higher temperatures could directly impact mothers physiologically or indirectly throughincreased disease prevalence. An employment guarantee program may help households smoothconsumption. A community health worker may help pregnant mothers in dealing with heat re-lated physiological stress. We use the phased introduction of an employment guarantee program(NREGA) and a partial introduction of a community health care worker program (ASHA) to mea-sure the effectiveness of public policies in moderating the effects of high temperatures. NREGAand ASHA are found to be effective in reducing the effects of higher temperatures during preg-nancy on infant mortality. The results indicate a significant impact on child health due to apredicted rise in global temperatures and highlight the importance of public policy as adaptationstrategies.

Keywords: Adaptation, Climate Change, Infant Mortality, Temperature

JEL Classification: Q50, Q54, Q56, Q58, I15, I18, O10

Preliminary Draft. Please do not cite or circulate without authors’ permission.

Email all correspondence to Rakesh Banerjee at [email protected] authors thank John Strauss, Jeff Nugent, Anant Nyshadham, Titus Galama, Yu-Wei Hsieh, Yilmaz Ko-cer, Jinkook Lee, Reed Walker, Tushar Bharati, Nazmul Ahsan and participants at the Western EconomicAssociation 2015 for helpful comments and suggestions. The authors also thank Panchajanya Banerjee andAniruddha Ghosh for helping us with the weather and lights data. All errors are ours.

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https://dl.dropboxusercontent.com/u/102638745/LatestTemperatureDraft.pdf

Banerjee and Bhowmick (2016) Heat, Infant Mortality and Adaptation

1 Introduction

The predicted rise in global temperatures are likely to affect human health, agricultural production and in-

come across the globe. Developing countries, which have more weather dependent production process and

have weaker health infrastructure are likely to suffer the most. Public policies in terms of better health in-

frastructure and income support in times of weather induced income shocks can play a vital role in reducing

some of the effects of global warming.

This paper explores two questions. One, do high temperatures during pregnancy increase the chance

of the newborn dying within one year of birth i.e as an infant. Two, can public policies be effective in

reducing the effects of high temperatures on infant mortality. In particular, we explore the role of a large

scale employment guarantee program and a community health care worker program in reducing the effects

of exposure to high temperatures during pregnancy on infant mortality.

We use the pregnancy history of mothers from the District Level Household Survey (DLHS) of India to

obtain birth and death records for the period of 1998-2007. We combine this data with daily level tempera-

ture data from National Oceanic and Atmospheric Administration. One key challenge is to disentangle the

effect of season of birth from the effect of temperature. Season of birth is related with several unobserved

parental characteristics and is also associated with temperature. Several studies show that season of birth

and temperature have effects on infant health and that they are related to fertility and parental characteristics

(Lam and Miron, 1996; Banegas, Rodriguez-Artalejo, Graciani and De La Cruz, 2001; Buckles and Hunger-

man, 2013; Wilde, Apouey, Jung et al., 2014). In this paper, we disentangle the effect of season of birth from

temperature by controlling for district-quarter of birth fixed effects. This corrects for any unobserved dis-

trict specific seasonal factors which can affect health and mortality of the newborn. We use number of days

temperature exceeded 90 F during pregnancy in the district of birth as measure of exposure to heat.1 Our

results show that exposure to higher temperatures in the second and third trimester and in the month of birth

increases infant mortality in rural India. In urban India, we find no such effect.

Two mechanisms may explain the observed effect. First, higher temperatures could affect agricultural

productivity and food prices. We show that high temperatures during growing season reduce agricultural

yields for a variety of major crops. In absence of consumption smoothing this may effect pre-natal nutrition

and potentially lead to poor fetal health and cause infant mortality. Second, higher temperatures could have

a direct physiological impact on the mother’s health or have an indirect effect through increased disease

prevalence. For instance, higher temperatures can increase blood pressure or can cause dehydration in

1We show robustness of our results to other values of temperature as well

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pregnant mothers. Incidence of diarrhea also increases with high temperatures. This can also contribute to

poor fetal health and may elevate the risk of the newborn dying as an infant. In this paper we explore two

public policies which may be effective in dealing with these two mechanisms.

In 2005 the government of India introduced the National Rural Employment Guarantee Act (NREGA),

which provides a guarantee of 100 days of employment to rural households at a fixed minimum wage.

Higher than usual temperatures in a year decreases agricultural yields and real wages (Burgess, Deschenes,

Donaldson and Greenstone, 2013) and rural households may not be able to completely smooth consumption

which may effect fetal health. This may be a plausible reason for increased infant mortality. In such cir-

cumstances, access to NREGA employment may help households to smooth consumption. The policy was

introduced in a phased manner — it was first implemented in 200 districts, followed by 130 districts in the

year after and the remaining districts receiving in the year after that. We use the spatial and the temporal

variation created by the phased introduction of the program to estimate the effect of NREGA in reducing

the effects of higher temperatures during pregnancy. In particular, we interact exposure to NREGA with

exposure to heat, after controlling for district-quarter of birth fixed effects, quarter of birth-year of birth

fixed effects, exposure to heat and the main effect of the program. Thus we control for endogenous program

placement by controlling for district-quarter of birth fixed effects. Also, since we are controlling for the

main program effect, we are effectively controlling for other changes which may have happened along with

the program and may have impacted infant mortality. For instance, public works from NREGA may improve

conditions of the roads. If better roads directly reduce infant mortality by improving access to the hospital

then the main program effect will control for it. The results show access to NREGA during third trimester

and the month of birth reduces the entire effect of higher temperatures during pregnancy on infant mortality.

We also explore whether access to a community health care worker program reduces the effect of heat

during pregnancy on infant mortality. Community health care workers can help in dealing with physiological

stress caused by heat or by treating mothers for any heat related illness. For instance, community health

workers can provide Oral Rehydration Solutions (ORS) to pregnant mothers suffering from diarrhea and

dehydration. The government of India introduced a community health care worker program, Accredited

Social Health Activists (ASHA), in 18 states in 2005. Health care workers make home visits to pregnant

mothers for ante-natal care, provide basic medicine to individuals suffering from diarrhea, register pregnant

mothers, accompany pregnant mothers to a health facility for delivery, promote general awareness about

health and sanitation. Since our sample of birth is from 1998 to 2007, the partial introduction of the program

in 2005 creates both a spatial and a temporal variation. We use this variation to estimate the effect of ASHA

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in reducing the effect of heat during pregnancy on infant mortality. In particular, we interact exposure to

ASHA with exposure to heat and also control for district-quarter of birth fixed effect and the main effect of

the program. The district-quarter of birth fixed effect takes care of endogenous program placement and main

effect of the program control for all the direct effects of the program on infant mortality. The results show

access to ASHA during pregnancy reduces all the effects of heat on infant mortality, particularly during the

second trimester and month of birth.

This paper primarily relates to the literature dealing with the effects of climate change on human health

and possible adaptations. Climate change is expected to increase both average temperatures and increase

the incidence of extreme temperatures (Zivin and Shrader, 2016). It is understood this may effect human

health through a variety of channels - affecting disease patterns, water and food insecurity, migration and

population growth (Costello, Abbas, Allen, Ball, Bell, Bellamy, Friel, Groce, Johnson, Kett et al., 2009).

Developing countries, whose agricultural production process are more weather dependent and have weaker

health infrastructures are more vulnerable to climate change. Children and pregnant women are particu-

larly susceptible to higher temperatures (Edwards, Saunders and Shiota, 2003). The recent literature has

documented effects of extreme temperatures on mortality, birth weight and later-life earnings (Deschenes

and Greenstone, 2011; Deschenes, Greenstone and Guryan, 2009; Isen, Rossin-Slater and Walker, 2015).

Far less is known about possible adaptation strategies, in particular for developing countries.2 Little is also

known about the role of public policies in dealing with effects of extreme temperatures. Recent studies have

documented that the spread of air-conditioning in the US had significant impacts in reducing the effects of

heat on mortality (Barreca, Clay, Deschenes, Greenstone and Shapiro, 2016). During the sample period of

1998-2007 , less than 5 percent of rural Indian households had air-conditioning. In 2012 it was less than

6 percent. More than 50 percent of the rural households did not possess an electric fan during our sample

period (See Figure 1 and Figure 2). Burgess et al. (2013) shows that expansion of bank branches in rural

India reduces the effect of high temperatures on mortality. Expansion of bank branches improves access to

credit and may help households to smooth consumption. However, commercial banks may not always find it

profitable to operate in remote and rural areas. Moreover, direct physiological impacts of high temperatures

may also increase infant mortality. Hence, it is important to explore the role of other government policies

which may moderate the effects of high temperatures. Thus, more research is required in studying other

plausible adaptation measures and particularly the role of public policies. (Deschenes, 2014).

This paper makes two key contributions. First, it provides evidence that higher temperatures during

2Adaptation is defined broadly as actions taken to reduce the adverse consequences of climate change, as well harnessany beneficial opportunities

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pregnancy have important health implications in rural India. More specifically, it increases the chance of

dying as an infant. We find average temperature of a summer month during the month of birth will increase

infant mortality by 2.1 per 1000 births. Similarly three months of average summer temperatures during

second trimester and third trimester will increase infant mortality by 2.4 and 1.7 per 1000 births. The result

is important in measuring the costs of global climate change on human health. Second, it explores two public

policy measures which can help in reducing the effect of temperatures during pregnancy. We show a public

workfare program reduces the entire effect of high temperatures during third trimester and the month of

birth. We also find a community health care worker program moderates all the effects of high temperatures

during pregnancy on infant mortality. Thus we show two public policies may serve as an effective adaptation

strategy in dealing with the health impacts of global climate change. This have not been studied before.

The paper is organized as follows, section 2 provides a literature review, section 3 provides the policy

description, section 4 discusses the data, section 5 discusses the empirical strategy, section 6 discusses the

results and section 7 concludes.

2 Literature Review

Epidemiological and medical literature have documented the association of high temperature and mortality.

Basu and Samet (2002) provides a survey of evidence of the association of high temperatures and mortality.

Most studies find a positive relation between higher temperatures and mortality. Findings also suggest that

individuals suffering from preexisting cardiovascular and respiratory diseases, elderly and infants have an

increased risk of mortality from heat. Failure of the thermoregulatory mechanism of the body is consid-

ered the main reason behind heat stress and heat stroke. Human body gains heat from environment and

metabolism. A normal body temperature is required for proper functioning of several organs. Increased heat

in the body is dissipated to maintain a normal body temperature. This process is called thermoregulation.

In response to increased temperature, blood flow to the skin increases to dissipate the heat. This leads to

increased cardiac output. An inability of the body to increase cardiac output increases the susceptibility to

heat stroke. The failure to increase cardiac output can be caused by salt and water depletion and cardiovas-

cular disease. This increased blood flow to the skin also reduces blood flow to the intestine. This may lead

to production of endotoxins. These endotoxins enter in blood circulation and cause inadequate blood flow

to organs. This may cause organ failure and death Bouchama and Knochel (2002)

Pregnant mothers are particularly susceptible to high temperatures. Evidence from epidemiological

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studies suggest that high temperatures during pregnancy leads to preterm delivery (Basu, Malig and Ostro,

2010; Dadvand, Basagana, Sartini, Figueras, Vrijheid, De Nazelle, Sunyer and Nieuwenhuijsen, 2011).

Evidence from studies on animals show higher temperatures during pregnancy causes lower birth weight,

deficient formation of muscle and reduced brain development. Exposure to higher temperatures reduces

blood flow to the uterus. This causes reduced fetal nutrient uptake (Soultanakis-Aligianni (2003)).

Some recent studies in economics have focused on the effects of extreme temperatures in utero. These

studies generally find, extreme hot temperatures during pregnancy negatively affects several birth-outcomes

like birth weight. Most of these studies also carefully control for geographic fixed effects or geography-

season specific fixed effects to control for unobservables related to both temperature and birth outcomes. For

instance, using data on 37.1 million births from United States, Deschenes et al. (2009) finds that exposure to

extreme temperature during pregnancy leads to lower birth weight. They combine their estimates with future

predictions of climate change and estimates mean birth weight will reduce by 0.22 percent for whites and

0.36 percent for blacks by end of the century. In another study, Andalon, Rodriguez-Castelan, Sanfelice,

Azevedo and Valderrama (2014) uses data from Colombian national registry and shows that heat waves

during pregnancy leads to reduced chances of being born as full term and being classified as healthy. They

also carefully control for municipality of birth fixed effects to account for geographic level unobservables

and also include month of birth fixed effects to control for seasonality. In another recent study, Molina and

Saldarriaga (2016) uses birth data from the Demographic Health Surveys (DHS) in Bolivia, Colombia and

Peru and estimates that exposure to a temperature which is one standard deviation from municipality’s long

term mean during pregnancy reduces birth weight by 20 grams. They also carefully control for municipality-

month of birth fixed effects to account for seasonality. The literature has also recently focused on long-term

effects of in utero exposure to extreme temperatures. Longer term effects on human capital accumulation

can have important consequences for economic growth. In a recent study, Isen et al. (2015) combines

administrative earnings records in United States with weather data and finds an extra day above 32C in utero

causes a 0.2 percent reduction in annual earnings. In another study in Ecuador, Carrillo, Fishman, Russ et al.

(2015) uses administrative earnings data and finds, in utero higher temperatures leads to lower earning for

women. These studies highlight the negative effects of the predicted rise in global temperatures on future

economic growth and well being.

Recent research have also documented the effects of contemporaneous exposure to extreme temper-

atures. Several studies have documented that extreme temperatures increase mortality in United States

(Deschenes and Moretti, 2009; Deschenes and Greenstone, 2011; Barreca, 2012). (Burgess et al., 2013) in-

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vestigates the effect of high temperatures on mortality in India. They carefully construct vital statistics data

from 1957-2000 and show one standard deviation increase in high temperature days increases annual mor-

tality in rural India by 7.3 percent. They find no effect of high temperatures in urban areas. They also show

that real wages and agricultural yields in rural areas decrease with high temperature days, while they find no

such effect in urban areas. They point out that inability of households to smooth consumption in response

to income shocks in rural areas are a reason for differential effects of temperature on mortality in rural and

urban areas. Sudarshan, Somanathan, Somanathan, Tewari et al. (2015); Deryugina and Hsiang (2014) have

focused on the effect of high temperatures on labour productivity and manufacturing output. They use data

from manufacturing firms in India and show that output in labour intensive production process decrease at

high temperatures by 3 percent per degree Celsius. In another study, using income data from United States

Deryugina and Hsiang (2014) shows high temperature days have negative effect on individual productivity

and economic performance. They estimate that a weekday above 30C costs an average county 20 dollars per

person. They combine their estimates with climate change projections and find warmer daily temperatures

would lower annual growth by 0.06-0.16 percentage points in the United States. Zivin and Neidell (2014)

have focused on effects of high temperatures on time allocation and substitution between labour and leisure

in United States. Individuals might reallocate their time between labour and leisure to minimize the effect of

high temperatures and this may lead to significant welfare losses for households. They find at the high end of

temperature distribution an increase in temperature reduces hours worked in industries with high exposure

to climate and also non-employed individuals reduce time allocated to outdoor leisure. These studies point

out the different effects of a predicted rise in global temperatures with effects on mortality, productivity and

employment.

However very little evidence exists about the role of public policy in adaptation. In United States, the

spread of air-conditioning has been shown to reduce the effects of heat on mortality and income (Barreca

et al., 2016; Isen et al., 2015). These papers show that the spread of residential air-conditioning in the United

States played an important role in reducing the effect of temperature on mortality and in reducing the the

effect of in utero exposure to high temperatures on income. However, the spread of air-conditioning in de-

veloping countries is very limited. Moreover, temperature fluctuations and weather shocks also have large

effect on income in developing countries, where large proportions of the work force are employed in the

agricultural sector. Moreover, in many developing access to credit, especially in times of aggregate weather

shocks is limited. Thus, individuals often cannot smooth consumption. In India Burgess et al. (2013) ex-

plores the effect of availability of credit on reducing the effect of temperature on mortality. The find that

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expansion of bank branches in rural areas reduces the effect of high temperatures on mortality. Adhvaryu,

Kala and Nyshadham (2014) explores the effect of use of LED lights on productivity in garments facto-

ries in India. They find a negative relationship between temperature and production.They then show LED

lights which emits less heat and reduces the temperature on factory floors raises productivity, particularly in

hot days. These studies explores the effectiveness several adaptation methods which are likely to become

increasingly important with the increase in global temperatures.

We contribute to the growing literature on impacts of being exposed to high temperatures in utero.

We show high temperatures in utero is likely to increase to the chances of the newborn dying as an infant.

We also explore the role of public policy in reducing the effect of high temperatures. We show that a large

scale public workfare program which provides guaranteed employment and a community health care worker

program reduces the effect of high temperatures on infant mortality.

3 Adaptation Programs

3.1 National Rural Employment Gurantee Act

The National Rural Employment Guarantee Act was passed by the Government of India in 2005. The main

purpose of the act is to provide a legal guarantee of 100 days of employment to every rural household at a

fixed minimum wage. The act stipulates the wage should be same for both males and females and at least

one third of the employment is mandated to be for females. The household is required to apply for a job card

with the local village council and is typically expected to provide manual labor on projects like road con-

struction, earthwork on irrigation canal or other maintenance work. The local village council is responsible

for processing and issuing the job card. The government is mandated to provide employment within 15 days

of application, failing which it has to provide unemployment insurance. The federal government bears all

the cost of labor and 75 percent of the material costs and state government bears the rest. A public workfare

program like NREGA has several advantages. Since those who are willing to work at the minimum wage are

only likely to apply, it will self select people into the program. Since NREGA increases labour demand , it

is also likely to increase private sector wages (Imbert and Papp, 2015). Particularly, in times of low demand

for labor, NREGA is likely to provide a guarantee of employment and hence smooth consumption (Klonner

and Oldiges, 2014). In our context, NREGA is likely to act as a coping mechanism if the effects of expo-

sure to extreme temperature on fetal health is through reduced income, arising from reduced employment

opportunities or reduced agricultural production during times of bad weather .

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NREGA was introduced in a phased manner. The act was passed in 2005 and 200 districts got access to

the program in February 2006. In April 2007, 130 districts were added and the remaining districts got access

in 2008. The explicit goal of the phased roll out was to target the poorer districts first. It also guaranteed

each state would have atleast one district in the first phase of the program. We use this phased roll out to

identify the effects NREGA on reducing the impacts of extreme temperature on infant mortality.

3.2 Accridited Social Health Activists (ASHA)

. In 2005, the government of India introduced a community health worker program, called ASHA, with a

particular focus on 18 states in India.3 ASHA is one of the key strategies of National Rural Health Mission

(NHRM) of Government of India.4. One of the primary responsibilities of an ASHA worker is to pay

regular visits to pregnant mothers, registering pregnant mothers, accompanying them to the health facility.

They are also tasked with counselling women on needs of immunization, organize and mobilize people for

immunization camps, spread general awareness about health, sanitation and nutrition. The prescribed policy

of the Government of India requires ASHA workers to be educated, with atleast upto 8th standard, and

should belong to the age group of 25 to 40 years. They are also required to receive training in the sub center.

The ASHA worker is not a paid worker and receives small sums of money for each task performed.5.

Though an ASHA worker provides several kinds of healthcare services, some of their tasks are partic-

ularly helpful for treating heat related illness. They are trained to escort and arrange for care of a person

suffering from heat stroke. Individuals suffering from heat stroke require immediate attention. ASHA work-

ers are aware of specific services available at different health facilities. Thus they are well informed to take

the sick person to an appropriate health facility. ASHA workers carry Oral Rehydration Solution (ORS)

and other appropriate drugs to treat individuals suffering from diarrhea, nausea and vomiting. Incidence of

diarrhea often increases during episodes of high temperatures. Households in rural parts of India do not have

refrigerators. In such circumstances stored cooked food is more likely to get spoiled in extreme heat. ASHA

workers are instructed to advise households not to store cooked food. ASHA workers are also trained to

measure blood pressure. Exposure to heat often affects normal blood pressure. ASHA workers are trained

to identify such situations and danger signs during pregnancy and take appropriate action. ASHA workers

3The 18 high focus states are Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Orissa, Uttaranchal, Jharkhand, Chhat-tisgarh, Assam, Sikkim, Arunachal Pradesh, Manipur, Meghalaya, Tripura, Nagaland, Mizoram, Himachal Pradesh andJammu and Kashmir. After 2009 the program was also introduced in other parts of India.

4Though there were several other policies of NHRM apart from ASHA, Table 11 shows both high focus states andnon-high focus states had similar access to other programs except, ASHA

5For more details about the ASHA program refer to Rao (2014) and Bhowmick (2016)

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can also be effective in several other ways. For instance, they can communicate the needs of a village to

higher authorities. During episodes of high temperatures, they can request higher authorities to organize

ante-natal care camps at multiple locations such that pregnant women does not have to walk long distances.

Community health care workers and trained local midwifes have been successful in many parts of world

in providing maternal care. Government of India introduced a community health care worker program in

1977. These health care workers later came to be known as Village Health Guides. They were mostly

males whose main targets were males for family planning programs. This program was not very successful

and was later discontinued (Bhowmick (2016)). In the recent years there have been a renewed interest in

community health care workers. They are particularly important in remote rural locations where it is hard to

have trained doctors and nurses. In India the health care set up in rural India is three-tiered, with health Sub

Centers (SCs) at the primary level, followed by Primary Health Centers (PHC), Community Health Centers

(CHC) and district hospitals. Health SCs are single room facilities run by Auxiliary Nurse Midwife (ANM)

who is responsible for a population of 4, 500 individuals. The ANM worker caters to too many individuals

to provide regular home visits. ASHA workers provide the necessary bridge between the health care system

and households (Rao (2014)).

ASHA workers have been shown to be effective in improving maternal and child care. Bhowmick

(2016) finds presence of ASHA workers in villages leads to increased use of antenatal care services, espe-

cially for mothers from the backward sections of the community. In a survey in Uttar Pradesh, a state in

North India, Jain, Srivastava, Khan, Dhar, Manon, Adhish and Nandan (2008) finds that 70 percent of in-

stitutional deliveries conducted are motivated by ASHA. Rao (2014) uses the partial introduction of ASHA

and finds ASHA workers lead to an increased vaccination coverage. We also use this partial introduction

of ASHA to identify the role of ASHA in reducing the effects of extreme heat on infant mortality. In our

context, It is expected that the physiological stress created by extreme heat during pregnancy can be reduced

by better access to prenatal care, increased awareness and counseling by community health care workers.

Thus, ASHA workers can be effective in reducing the effects of extreme heat during pregnancy on infant

mortality.

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4 Data

4.1 District Level Household Survey

This paper uses data from District Level Household Survey (DLHS)-II and District Level Household Survey

(DLHS)-III. DLHS-II was conducted by International Institute of Population Sciences (IIPS), Mumbai be-

tween 2002 and 2004 across 504 Districts in India. It surveyed 620, 107 households and 507, 622 married

women across India. Similarly, DLHS-III was conducted by IIPS, Mumbai between 2007-2008 across 601

districts in India and collected data from 720, 320 households and 643, 944 ever married woman. The main

focus of the survey was reproductive health of woman, while it also collected information on general house-

hold characteristics. We combine DLHS-II and DLHS-III and use pregnancy history of married woman to

create records of born children by using their month and year of birth and if died the month and year of

death. We limit the recall period to 5 years only to limit any errors in recall.6. Unfortunately, we do not

have information on districts of birth so we proxy the location of birth of the child with the district in which

the mother is interviewed. Though we do not have data on migration in the survey, we believe district of

interview is a good proxy for district of birth as we are limiting our recall period to 5 years. In the paper,

we refer the district of birth of the child as the district where mother was interviewed. We exclude from our

analysis all union territories. 7 The survey also provides information on several mother level characteristics

which we use as control variables.

4.2 Temperature Data

This paper uses NCEP/NCAR Reanalysis 1 daily temperature data from National Oceanic and Atmospheric

Administration (NOAA). 8. The data is available as daily mean from 1948 till present over a 2.5 X 2.5

latitude longitude global grid. We match the latitude longitude of a district with the all the grids within a

distance of 250 kilometers. To calculate the daily temperature of a district, a weighted mean of temperature

of all the grids within 250 kilometers of a district is calculated, with the weights being inverse of the distance

6For DLHS-III the recall is restricted to 3-4 as the pregnancy history is only till 2004. For some districts, DLHS-II wasconducted in 2004, for them we have used a 7 year recall period to have a continuous sample from all districts from 1998

7As several new districts were created by the time DLHS-III was conducted, we map the new districts in to theircorresponding old districts. Some new districts were carved out from two or more districts, we have not included thosedistricts. We do not have information on night time lights for few districts, we have omitted those districts too. In total wehave information on 566 districts from 27 states.

8The following link provides more details http://www.esrl.noaa.gov/psd/data/gridded/data.ncep.reanalysis.surface.html

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http://www.esrl.noaa.gov/psd/data/gridded/data.ncep.reanalysis.surface.html

http://www.esrl.noaa.gov/psd/data/gridded/data.ncep.reanalysis.surface.html


from the district to the respective latitude-longitude grid. There is a large system of weather station data

available in India. However, a primary problem with using weather station data is the placement of a

weather station is not exogenous. Weather stations might be placed in less remote areas and the consequent

measurement error in extrapolating the data from these stations across space might create non-classical

measurement error in the explanatory variable, in this case temperature. Moreover, the data from the weather

stations are not consistently available over time, creating a problem of missing data. Re-analysis data uses

data from several sources and combines it with global climate models to produce consistent estimates over

time and space. One advantage of using re-analysis data is it is available uniformly over time and space.

The measurement error in that case will not be related with district level characteristics. These type of data

have been increasingly used in recent times in the economics literature. (Burgess et al. (2013))

4.3 Rainfall Data

This paper uses monthly mean rainfall data from Center for Climatic Research, University of Delaware.9

The data contains mean monthly rainfall at a 0.5X 0.5 latitude longitude grid, from 1900 to 2010. We

match the latitude longitude of a district with the all the grids within a distance of 250 kilometers. To

calculate the mean rainfall of a month in a district , a weighted mean of rainfall of all the grids within 250

kilometers of a district is calculated, with the weights being inverse of the distance from the district to the

respective latitude-longitude grid. We control for rainfall as this may be correlated with temperature and

infant mortality.

4.4 Agricultural Yields

We use data from Directorate of Economics and Statistics, Ministry of Agriculture. This data contains

information on agricultural yields, production and area cropped for each crop and each season from 1998-

2010. This dataset provides a district level panel on agricultural output for each crop and season. We use 6

major crops which are grown in Kharif growing season. Kharif growing season is an equivalent of summer

crop. Cropping season starts from May and ends in October. We only use information on Kharif crops as

these are grown in summer and are most likely to be affected by heat. We consider six major crops grown

in Kharif season, rice, bajra, cotton, soyabean, groundnut and jowar. Thus we include both food crops and

cash crops.

9The following link provides more details http://climate.geog.udel.edu/˜climate/html_pages/README.lw.html

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http://climate.geog.udel.edu/~climate/html_pages/README.lw.html

http://climate.geog.udel.edu/~climate/html_pages/README.lw.html


5 Empirical Strategy

5.1 Main Specification

One of the key challenge in estimating the effect of high temperatures during pregnancy on infant mortality

is spatial distribution of temperature is correlated with several unobservables, like quality of available health

care, which can have an effect on maternal and child health. Moreover, high temperatures are correlated

with seasons and season and month of birth is correlated is several unobservable parental and household

characteristics. Thus to estimate the effect of temperature, seasonal and spatial unobservables have to be

accounted for.

In this paper we use a fixed effect strategy to identify the effect of in utero exposure to high temperature

on infant mortality. It estimates the following equation.

Oidyq = α+ β0 (CDD > 90F in Birth Month) +

3∑j=1

βj (CDD > 90F in Trimesterj)+

χ′idyqγ + δdq + θqy + γm + εidq

where, Oidyq indicates the mortality status of child i born in quarter q, district d. and year y . It is a

dummy variable and it takes the value thousand if the child died as an infant and zero otherwise. (CDD >

90F in Birth Month) refers to number of Cumulative Degree Days exceeding 90 degrees Fahrenheit in

the month of birth of individual i in district d in the year y and quarter q .10 (CDD > 90F in Trimesterj)

refers to Cumulative Degree Days exceeding 90 degrees Fahrenheit in Trimester j of individual i in district

d in the year y and quarter q. χidyq includes covariates like parental years of schooling, gender of the child,

mean rainfall in the each of the trimester and month of birth, night time lights of the district-year of birth

and of the year prior to birth. δdq are the district by quarter of birth dummies and θqy are quarter of birth by

year of birth dummies. γm is the month of birth dummy, εidyq is the error term.

Several studies in economics use a semi-parametric method to estimate the effects of high temperatures.

This involves constructing several 2F degree bins, and using number of days in each of these 2 degree

bins as dependent variables. The advantage of this method is it lets the effect of temperature to vary non-

linearly. In our context, since we identify the effects for each trimester, this would involve estimating

10Cumulative Degree Days> 90 F is illustrated by the following example, if, say, in district Delhi in July 2005, there aretwo days where temperature exceeded 90F. On one day it was 95F and on the other it was 100F then Cumulative DegreeDays > 90 F = (100− 90) + (95− 90) = 15

Page 13


several coefficients. In absence of very large data, this is likely to provide imprecise estimates. We avoid

this problem by estimating single coefficients for each trimester. We choose 90F as a threshold because

these studies find that temperatures above 90F increases mortality. For instance, (Burgess et al., 2013) use

10 bins of 2F. They find the effect of temperature on mortality to be significant for all temperature bins

above 88F. Barreca et al. (2016) uses 10 bins of 10F and shows the effect of high temperatures on mortality

to be significant only for temperatures above 90F. Similarly, Deschenes and Moretti (2009) uses bins of

intervals of 5F and shows high temperatures above 85F during pregnancy reduces birth weight. We also

show robustness of our results to other values of temperature cutoffs apart from 90F.

We use infant mortality instead of neo-natal mortality to avoid the problem of harvesting. A significant

part of infant mortality happens as neo-natal mortality. However, exposure to high temperatures may only

increase the mortality of sick newborns who would have otherwise died soon after one month of birth. We

avoid this problem by considering infant mortality and hence giving a long enough time since birth. We also

show our results for neo-natal mortality in Appendix A.

We only look at the effect of heat and not of cold days for three reasons. First, We compute the

distribution of number of days temperature exceeded 80F and number of days temperature was less than

30F in each month from 1948-2007. The mean number of days temperature exceeded 80F was 8.08 and the

mean number of days temperature was less than 30F was 0.24. Thus heat is far more common in India than

very cold days. Second, agricultural production is far more affected by heat than by cold days. Thus one of

the main channels through which temperature may effect fetal health is not so relevant for cold days. Third,

the physiological impact and the channels through which cold days affect fetal health is different from heat.

So the measures to prevent damage to fetal health from cold days is different from heat. For instance, an

ASHA worker advises mothers not to eat and store cooked food. Food is more likely to get spoiled in heat

than in cold temperatures.

The above regression controls for all spatial and seasonal unobservables which are constant within a

district over time. The district by quarter dummies controls for all seasonal unobservables at the district and

quarter of birth level. For example, consider the district Delhi. If it happens more unhealthy mothers give

birth during the summer quarter in Delhi and the children of unhealthy mothers are more likely to die as an

infant, then if we do not control for district-quarter of birth fixed effects, then our estimates would be upward

biased. In particular, the district-quarter of birth fixed effects controls for all seasonal unobservables which

are correlated with temperature and also affect infant mortality for Delhi. Similarly, the quarter of birth by

year of birth dummies controls for all unobservables at the quarter-year level which effect infant mortality

Page 14


and are also correlated with temperature. For example, if the summer quarter of 2005 was a particularly hot

summer and it was also hit by a swine flu epidemic across the country which affected pregnant mothers and

increased the chances of newborns dying as an infant, then if we do not control for quarter of birth-year of

birth dummies, it would misattribute the effect of swine flu epidemic on high temperatures. In the regression

we also control for rainfall, since rainfall is often correlated with temperature and it can independently effect

pregnant mothers either through effects on disease environment or indirectly through reduced agricultural

wages and production. We also control for night time lights in the district of birth for the year of birth

and the preceding year. This will help to control for broad economic changes and changes in infrastructure

like electrification. The identifying assumption is if we compare individuals born in a district-season over

different years, the event of extreme heat one faces in utero is exogenous. Thus β’s measure the effect of

having one extra Cumulative Degree Day above 90F in different stages of pregnancy on the chances of a

child dying as an infant.

5.2 Agricultural Yields

We use the following equation to estimate the effect of heat on agricultural productivity.

Ydy = α+ β(CDD > 90F During Cropping Season)dy

+γ(Mean Rainfall During Cropping Season)dy

+δd + πy + epsiliondy

In the above equation, Ydy is the log(yield) of a particular crop during Kharif season in a district d in the

year y. δd are district fixed effects and πy are the year fixed effects. The main variable of interest isCDD >

90F During Cropping Seasonwhich measures number of cumulative degree days temperature exceeded

90F during the growing season (from May to October) in district d and year y. β measures the effect of one

extra cumulative degree days greater than 90F in the growing season on log(yield).

The district fixed effect control for all unobservables which vary at the district level and is time-

invariant. For instance, districts with moderate temperatures may have better land quality. If we do not

control for district-fixed effects, the effects of temperature will be biased. The year fixed effect control for

all unobservables for a particular year. For instance it will control for a federal subsidy on fertilizers which

might effect yields. We also control for mean rainfall during the cropping season for every district and year.

Page 15


We do not need to control for season explicitly as we are only concerned about a specific season of grow-

ing. Arguably, after controlling for relevant controls, year to year temperature variation within a district is

exogenous and hence β is an unbiased estimates of high temperatures on yield.

5.3 NREGA

We use the phased introduction of NREGA, in order to estimate the effect NREGA may have on reducing

the effects of high temperatures in utero on infant mortality. Since NREGA was partially introduced in some

districts in 2006, no districts in our sample were exposed to NREGA prior to 2006. NREGA was introduced

in 200 districts in 2006, and in 2007 it was introduced in 130 districts. Thus it creates four groups of mothers

within a district-quarter a) mothers who were exposed to high temperatures during pregnancy but did not

have access to NREGA b) mothers who were not exposed to high temperatures during pregnancy and also

did not have access to NREGA c) mothers who were exposed to high temperatures during pregnancy and

had access to NREGA d) mothers who were not exposed to high temperatures during pregnancy but had

access to NREGA. We use comparison across these groups to identify the effects of NREGA in reducing

the effects of high temperatures during pregnancy on infant mortality.

In particular, we estimate the following equation to identify, if the effects of extreme heat in utero are

reduced by the availability of public works program, namely NREGA.

Oidyq = α+ β0 (CDD > 90F in Birth Month) +

3∑j=1

βj (CDD > 90F in Trimesterj)+

σ0 (CDD > 90F in Birth Month) ∗ (Months till birth NREGA)idy+

3∑j=1

σj (CDD > 90F in Trimesterj ∗ (Months till T rimesterj NREGA)idy)+

π ∗ (Months till birth NREGA)idy +

3∑j=1

ηj ∗ (Months till trimesterj NREGA)idy+

χ′idyqγ + δdq + θqy + γm + εidq

where, as in the previous section Oidyq indicates the mortality status of child i born in quarter q,

district d. and year y . It is a dummy variable and it takes the value thousand if the child died as an

infant and zero otherwise. Similarly, (CDD > 90F in Birth Month) refers to number of Cumulative

Degree Days exceeding 90 degrees Fahrenheit in the month of birth of individual i in district d in the year

Page 16


y and quarter q and (CDD > 90F in Trimesterj) refers to Cumulative Degree Days exceeding 90

degrees Fahrenheit in Trimester j of individual i in district d in the year y and quarter q. In this equation,

Months till birth NREGA captures number of months NREGA is present in the district of interview,

till the time of the birth. Months till trimesterj NRGEGA captures number of months the NREGA

is present in the district of interview, till trimester j. For individuals born in 2005 and before this variables

takes the value 0. Like in the previous section, we also control for mean rainfall in birth month and each

trimester and also control for covariates like parental years of schooling, gender of the child, night time lights

of the district-year of birth and of the year prior to birth. We also control for district-quarter of birth fixed

effects and quarter-year of birth fixed effects along with month of birth. Like in the previous equation, β’s

measure the effect of having one extra Cumulative Degree Day above 90F in different stages of pregnancy

on the chances of a child dying as an infant and σ’s measure how much of that effect can be reduced by

having being exposed to one extra month in pregnancy to the NREGA program. π and η’s measures for any

direct effect that exposure to NREGA in utero may have on infant mortality.

5.4 ASHA

We use the partial introduction of ASHA to see if a community health worker program like ASHA can be

effective in reducing the effects of high temperatures during pregnancy on infant mortality. We use the fact

that ASHA was introduced from 2006 onwards in only 18 states in India. Since our sample is from 1998

to 2007, we again have four groups of mothers a) mothers who were exposed to high temperatures during

pregnancy but did not have access to ASHA workers b) mothers who were not exposed to high temperatures

during pregnancy and also did not have access to ASHA workers c) mothers who were exposed to high

temperatures during pregnancy and had access to ASHA workers d) mothers who were not exposed to high

temperatures during pregnancy but had access to ASHA workers. We use comparison across these groups

to identify the effects of ASHA in reducing the effects of high temperatures during pregnancy on infant

mortality.

Similarly, we estimate the following equation to identify, if the effects of extreme heat in utero are

Page 17


reduced by the availability of a community health care worker program, namely ASHA.

Oidyq = α+ β0 (CDD > 90F in Birth Month)

+

3∑j=1

βj (CDD > 90F in Trimesterj)

+σ0 (CDD > 90F in Birth Month) ∗ASHAidy+

3∑j=1

σj (CDD > 90F in Trimesterj ∗ASHAidy)+

+πASHAidy + χ′idyqγ + δdq + θqy + γm + εidq

where, ASHAidy= I(ASHAStates) * I(Y ear > 2005), where I(ASHAStates) indicates if the

mother is interviewed in a state where ASHA is implemented and I(Y ear > 2005) indicates if the child

is born in after 2005 ( when ASHA was implemented). As in the previous sections we control for mean

rainfall in the month of birth and each of the trimester, night time lights in the district-year of birth and in

the previous year, mother’s age and education, district-quarter of birth fixed effects, quarter-year of birth

fixed effects and month of birth fixed effects. Here β’s measure the effect of having one extra Cumulative

Degree Day above 90F in different stages of pregnancy on the chances of a child dying as an infant and

σ’s measure how much of that effect can be reduced by having being born in a state which had the ASHA

program in its year of birth. π measures for any direct effect that being born in a state which had the ASHA

program in its year of birth may have on infant mortality.

6 Results

6.1 Effect on Infant Mortality

Table 1 shows the results of the effect of high temperatures in utero on infant mortality. Panel A shows

the results for households interviewed in the rural areas and Panel B shows the results for households

interviewed in the urban areas. Column 1a is our preferred specification, which controls for district-quarter

of birth fixed effects and hence compares individuals born in the same district-quarter across different years.

This is our preferred specification because standard errors are the least amongst comparable specification.

The results show higher temperatures in utero increases the chances of a child dying as an infant, with the

second and third trimester as well as the birth month being particularly critical. To interpret the numbers,

Page 18


consider the following example — if there are 10 days in the birth month when the average temperature was

95F and for the rest of the 20 days the average temperature was less than 90F, then Cumulative Degree Days

(CDD) exceeding 90F would be 50. This would increase infant mortality by 4.1 per 1000 births. A similar

situation in the second trimester and third trimester would increase infant mortality by 1.5 and 1.1 per 1000

births.

The results show that higher temperatures in the first trimester do not have any effect on infant mortality.

Higher temperature in utero can lead to both scarring and culling of the fetus. Though we cannot explicitly

test the hypothesis, it is plausible that higher temperatures early in pregnancy leads to culling and later in

the pregnancy causes scarring, explaining why we do not observe any significant effect in first trimester.

Column 1b and 1c present the results for alternate specifications. In column 1b, instead of a district-

quarter fixed effect we add district-month fixed effects. The results are quite similar. In Column 1c, we

add state-quarter of birth specific quadratic trend — though we lose significance in some coefficients, the

direction and the magnitudes are comparable to column 1a.

Panel B presents the results for households interviewed in the urban areas. The results indicate higher

temperatures in utero do not have any effect on infant mortality. Though we cannot explicitly test, there are

several plausible reasons. Firstly, adaptation methods are perhaps better available in urban areas compared

to rural areas. For instance, electrification and air conditioning are more available in urban areas. Health

facilities to treat the illness caused by high temperatures are more readily available in urban areas. Second,

income and agricultural yields in rural areas are more susceptible to temperatures shocks than in urban areas

(Burgess et al., 2013).

6.2 Role of NREGA

Table 2 shows the effect of heat on agricultural yields. The different columns show the effect for different

crops. The results indicate that temperatures above 90F during the growing season reduces agricultural

yields for all major crops. Average monthly CDD > 90F from 1948-2014 is 25 for summer months in

India. So if there are two months during the cropping season with average heat then yield for rice will

decrease by 1.5 percent, bajra by 6 percent, cotton by 6.5 percent, soyabean by 4.5 percent, groundnut by

2 percent and jowar by 5 percent. The results here indicate high temperatures affect agricultural yield. In

absence of consumption smoothing this might effect fetal nutrition. An employment guarantee program like

NREGA can help to smooth consumption.

Table 3 shows that NREGA helps in reducing the effects of being exposed to high temperatures in

Page 19


utero on infant mortality. Since NREGA is only implemented in rural areas, we can show the results only

for rural areas. As before, column 1a is our preferred specification which controls for district-quarter of

birth fixed effect and compares individuals born in same district-quarter over different years. The results

show that the effects of being exposed to high temperatures in utero -particularly in the birth month and

third trimester-on chances of dying as an infant is reduced by having access to NREGA program while the

mother is pregnant. To interpret the numbers, compare children born when there was no NREGA during

their mother’s pregnancy with children born in the same district-quarter when there was NREGA during

their mother’s pregnancy for all 10 months including the birth month. Assume, in both cases their mothers

faced 10 days in third trimester when the average temperature was 95F and for the rest of the days it was

less than 90F. For children who did not have NREGA at all during the pregnancy, infant mortality would

increase by 1.17 per 1000 born, while those who had NREGA for all 10 months there would be no effect of

high temperatures on infant mortality. 11

Column 1b and 1c show the results in alternative specification. In Column 1b instead of district-quarter

fixed effect we add a district-month fixed effect. The results compared to column 1a are very similar. In

Column 1c we add a state-quarter of birth specific quadratic trend. We lose significance in some results,

though the directions of the results are similar compared to column 1a.

6.3 Role of ASHA

Table 4 shows results that a community health care worker program (ASHA) introduced in some select states

helps in adapting to the effects of being exposed to extreme heat in utero on infant mortality. The community

health care workers program was introduced only in rural areas, so we present the results only for rural areas.

Column 1a is our preferred specification, which compares individuals born in the same district-quarter over

different years. The results indicate ASHA workers helps in reducing the effects of high temperatures in

utero-particularly in second trimester and birth month- on infant mortality. For instance like in the previous

example if we compare mothers who faced 10 days in the second trimester when the average temperature was

95F and had ASHA during her pregnancy with a mother who did not have ASHA during her pregnancy but

faced the same temperature profile during her second trimester, in absence of ASHA infant mortality would

increase by 1.51 per 1000 births but in the presence of ASHA there will be no effect of high temperatures

in the second trimester. 12. Similarly the effects of high temperatures in the birth month and third trimester

11The NREGA coefficients in itself are insignificant, except for first trimester.12The main ASHA coefficient is insignificant.

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are also reduced by the presence of ASHA worker.

Column 1b and 1c show the results in different specifications. In column 1b we control for district-

month fixed effects instead of district-quarter fixed effect. The results are both similar in magnitude and

direction when compared to column 1a. In column 1c we add state-quarter of birth specific linear and

quadratic trend. We lose significance in some results, but the direction of the results are similar to column

1a.

6.4 Robustness Check

Table 5 and Table 6 show the robustness of the of the effects of temperature in utero with different levels

of temperature values. Table 5 shows the results with CDD 95F and CDD 92F and Table 6 shows the

results with CDD 87F and CDD 85F. If we compare the results from Table 1 with Table 5 and Table 6, the

coefficients are in same direction and have similar magnitude. For instance, if there are 10 days in the birth

month, when the average temperature was 95F and for the rest of the month it was below 85F, coefficients

from table 1 would imply infant mortality will increase by 4.1 per 1000 live births in rural areas, and panel

A (bottom panel) in table 4 would imply infant mortality would increase by 3.8 per 1000 births, panel A (top

panel) in table 5 would imply infant mortality would increase by 4.2 per 1000 live births, panel A (bottom

panel) in table 5 would imply infant mortality would increase by 4.1 per 1000 live births.

In Table 7, we show the robustness of the results of Table 1 by including the temperatures of 13th

month to 24th month after birth in the regression. The results show a) the coefficients of temperatures of

13th month to 24th month is insignificant. In principle, temperatures from 13th to 24th month after birth

should have no effect on infant mortality. If the specifications of Table 1 would not have controlled for

seasonality of births, then perhaps the coefficients of temperature of 13th to 24th month after birth could

have been significant. The insignificant results shows the specifications of Table 1 adequately control for

seasonality of births. b) The results of temperature in utero is unaffected by the including the temperatures

of 13th to 24th month. This shows after controlling for relevant fixed effects, temperatures faced in different

points in time are unrelated. This indicates the temperatures are more of shocks to the mothers.

In Table 8 we show temperatures faced during pregnancy is unrelated with mother’s years of schooling

and mother’s age at the time of interview. Though we control explicitly for mother’s years of schooling

and mother’s age in all the regressions and also include district-quarter specific fixed effects to control for

any seasonality associated with parental characteristics, the results in the Table 8 assure that there are no

associations of mother’s characteristics and temperature during pregnancy. Results in column 1a indicates

Page 21


neither mother’s age at the time of interview nor mother’s years of schooling is associated with temperatures

at the time of pregnancy. Column 2a shows the same results for urban areas.

In Table 9 we test if number of live births at a district-month-year level is associated with temperatures

10 months before birth, i.e at the time of conception. If temperatures at conception alters fecundity of

mothers, then results of Table 1 could be biased estimates. In column 1a and 2a we do find some evidence

of number of live births being associated with temperatures at conception, but when we control for district-

month of birth fixed effects in columns 1b and 2b, there is no evidence of number of live births being

associated with temperature at conception. The results remain the same when we add state-quarter specific

quadratic trend.

7 Conclusion

Average global temperatures are predicted to rise. Extreme weather events are also likely to become more

frequent. This changed weather pattern is predicted to affect human health in several ways. Among other

things, global warming is expected to change disease patterns, affect agricultural production and reduce

water availability. Populations in rural parts of developing countries typically rely on weather dependent

production processes for food and for their livelihood. They are likely to be affected the most. Rural areas

in developing countries also lack reliable health infrastructure to deal with heat and other weather related

illness, making them perhaps the most vulnerable to weather changes. Aggressive mitigation efforts in terms

of reducing greenhouse gas emissions are required to prevent further global warming. However, mitigation

efforts are costly to the current population as it would involve investments in cleaner technology. It is

important to measure the different costs from predicted global warming to determine the optimal amount

of investment in mitigation efforts. Consequently, it is important to measure the costs to human health

of global climate change, especially for populations living in rural parts of developing countries. In this

context, this paper investigates the effect of high temperatures during pregnancy on infant mortality in India.

We use data from the pregnancy history of mothers from a household survey and combine it with daily

level temperature data. We explicitly disentangle the effect of season of birth from temperature and find that

higher temperatures during pregnancy increase the chance of the newborn dying within one year of birth in

rural India. We find no effect in urban India. The estimates show average temperature of a summer month

during the month of birth will increase infant mortality by 2.1 per 1000 births. Similarly, three months of

average summer temperatures during second trimester and third trimester will increase infant mortality by

Page 22


2.4 and 1.7 per 1000 births. The results of this paper points out the expected costs of the predicted rise in

global temperatures.

However, achieving a global agreement of an aggressive mitigation strategy is difficult. Hence, some

effects of global climate change are considered unavoidable. Adaptation strategies i.e actions to reduce the

adverse effects of climate change are crucial. Moreover in case of failure of agreement between countries,

individual nations need to rely on adaptation strategies. In developing countries the role of public policies

are critical. So at the same time, it is also important to explore possible policy measures which can serve

as adaptation strategies to deal with the impacts of global climate change on human health. We explore

whether a public workfare program which provides a guaranteed employment to households in rural areas

(NREGA) and a community health care worker program (ASHA) can be effective in reducing the effects

of high temperatures during pregnancy on infant mortality. A public workfare program which provides

employment guarantee can help households to smooth consumption in times of weather induced shocks

to agricultural production. A community health worker can treat pregnant mothers from weather induced

diseases and physiological stress. This paper finds access to NREGA entirely reduces the effects of high

temperatures during the third trimester and the month of birth on infant mortality. We also find exposure to

ASHA reduces all of the effects of higher temperatures during pregnancy on infant mortality. The results of

this paper points out the importance of public policy as adaptation strategies.

Page 23


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8 Tables and Figures

Figure 1: Calculated from the National Sample Survey’s (NSS) consumption survey, using the 55,61, 66 and 68 round.

Page 27


Figure 2: Calculated from the National Sample Survey’s (NSS) consumption survey, using the55,61,66 and 68 round.

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Table 1: Effect of Temperature in utero on Infant Mortality

Panel A: Rural Panel B: Urban(1a) (1b) (1c) (2a) (2b) (2c)

CDD exceeding 90F Birth Month 0.0843*** 0.0650* 0.0380 -0.00181 0.0409 0.0323(0.0141) (0.0327) (0.0322) (0.0358) (0.0646) (0.0744)

CDD exceeding 90F Trimester 1 -4.45e-05 -0.0127 -0.00803 0.00743 0.00117 0.000959(0.0147) (0.0353) (0.0318) (0.0216) (0.0419) (0.0443)

CDD exceeding 90F Trimester 2 0.0318** 0.0615*** 0.0416** -0.0176 -0.0318 -0.0220(0.0126) (0.0194) (0.0172) (0.0163) (0.0351) (0.0348)

CDD exceeding 90F Trimester 3 0.0232* 0.0687 0.0455 -0.00750 0.0396 0.0491*(0.0133) (0.0452) (0.0408) (0.0159) (0.0276) (0.0282)

Mean of Dependent Variable 54 54 54 43 43 43N 395,070 395,070 395,070 116,198 116,198 116,198p value for Joint Test 0.0312 0.0246 0.0246 0.6584 0.392 0.3501

Controls Y Y Y Y Y YDistrict-Quarter FE Y YQuarter-Year FE Y Y Y Y Y YBirth Month FE Y YDistrict-Month FE Y Y Y YState-Quarter specific Quadratic Trend Y YThe dependent variable in the regression is 1000 if the born child died as an infant and 0 otherwise. The controls in the regressions include,

mean rainfall in the district of interview in the month of birth, and in each of the three trimesters, DMSP mean night time lights in the year

of birth and the preceding year in the district of interview, DLHS survey round fixed effect, mothers age in four categories, mothers years of

schooling in categories and a dummy for religion of the household head. The sample is births from 1998 to 2007. Cumulative Degree Days

(CDD) > 90 F is illustrated by the following example, if, say, in district Delhi in July 2005, there are two days where temperature exceeded

90F. On one day it was 95F and on the other it was 100F then Cumulative Degree Days > 90 F = (100− 90) + (95− 90) = 15. All standard

errors are clustered at the state level.

Page 29


Table 2: Effect of Temperature on Yield (Kharif Season only)

(1) (2) (3)Rice Bajra Cotton

CDD >90F -.0003** -.0012*** -.0013***During Sowing and Harvesting

(.0001) (.0003) (.0003)

Mean Rainfall .0004*** .0002*** .0005***During Sowing and Harvesting

.0000 .0000 .0001N 4809 3214 2611

(4) (5) (6)Soyabean Groundnut Jowar

CDD >90F -.0009*** -.0004** -.0010***During Sowing and Harvesting

(.0003) (.0002) (.0004)

Mean Rainfall .0001*** .0004*** .0002***During Sowing and Harvesting

.0000 .0000 .0000N 2041 3615 3319

The dependent variable is log yield of each of these crops. All the regressions contain a district fixed effects and a year

fixed effects. The sample is from 1998 to 2010. The season of sowing and harvesting kharif crops is considered from May

to October. Robust Standard Errors clustered at the district level.

Page 30


Table 3: Effect of Temperature in utero on Infant Mortality and adaptation by NREGA

Panel A: Rural(1a) (1b) (1c)

Months NREGA Till Birth Month*CDD exceeding 90F Birth Month -0.0155 -0.0193* -0.00637(0.00926) (0.00962) (0.00811)

Months NREGA Till Trimester 1*CDD exceeding 90F Trimester 1 -0.00964* -0.00994 -0.000552(0.00508) (0.00613) (0.00492)

Months NREGA Till Trimester 2*CDD exceeding 90F Trimester 2 0.000157 0.000445 0.00339(0.00318) (0.00294) (0.00442)

Months NREGA Till Trimester 3*CDD exceeding 90F Trimester 3 -0.00758** -0.00775** -0.00437(0.00321) (0.00366) (0.00543)

CDD exceeding 90F Birth Month 0.0872*** 0.0703** 0.0396(0.0144) (0.0316) (0.0317)

CDD exceeding 90F Trimester 1 0.00128 -0.0125 -0.00950(0.0141) (0.0359) (0.0328)

CDD exceeding 90F Trimester 2 0.0295** 0.0560*** 0.0370**(0.0126) (0.0189) (0.0176)

CDD exceeding 90F Trimester 3 0.0234* 0.0693 0.0457(0.0136) (0.0447) (0.0397)

N 394,746 394,746 394,746p value for Joint Test 0.0821 0.0754 0.3417

Controls Y Y YDistrict-Quarter FE YQuarter-Year FE Y Y YBirth Month FE YDistrict-Month FE Y YState-Quarter specific Quadratic Trend YThe dependent variable in the regression is 1000 if the born child died as an infant and 0 otherwise. The controls in the regressions

include, mean rainfall in the district of interview in the month of birth, and in each of the three trimesters, DMSP mean night time

lights in the year of birth and the preceding year in the district of interview, DLHS survey round fixed effect, mothers age in four

categories, mothers years of schooling in categories and a dummy for religion of the household head. The sample is births from 1998

to 2007. Cumulative Degree Days > 90 F is illustrated by the following example, if, say, in district Delhi in July 2005, there are two

days where temperature exceeded 90F. On one day it was 95F and on the other it was 100F then Cumulative Degree Days > 90 F

= (100−90)+(95−90) = 15. Months NREGA Till Trimester i is number of months NREGA was present in the district of interview

till trimester i. All standard errors are clustered at the state level.Page 31


Table 4: Effect of Temperature in utero on Infant Mortality and adaptation by ASHA

Panel A: Rural(1a) (1b) (1c)

ASHA*CDD exceeding 90F Birth Month -0.0731* -0.0643 0.00288(0.0385) (0.0449) (0.0268)

ASHA*CDD exceeding 90F Trimester 1 -0.0694*** -0.0693** -0.0405**(0.0241) (0.0268) (0.0149)

ASHA*CDD exceeding 90F Trimester 2 -0.0455* -0.0429* -0.0239***(0.0230) (0.0228) (0.00575)

ASHA*CDD exceeding 90F Trimester 3 -0.0297 -0.0200 0.0371*(0.0270) (0.0223) (0.0194)

CDD exceeding 90F Birth Month 0.0959*** 0.0714** 0.0369(0.0177) (0.0336) (0.0338)

CDD exceeding 90F Trimester 1 0.00845 -0.00964 -0.00570(0.0157) (0.0354) (0.0313)

CDD exceeding 90F Trimester 2 0.0302** 0.0494** 0.0458**(0.0127) (0.0193) (0.0167)

CDD exceeding 90F Trimester 3 0.0195 0.0561 0.0503(0.0137) (0.0460) (0.0411)

N 395,070 395,070 395,070p value for Joint Test 0.0322 0.015 0.0009

Controls Y Y YDistrict-Quarter FE YQuarter-Year FE Y Y YBirth Month FE YDistrict-Month FE Y YState-Quarter specific Quadratic Trend YThe dependent variable in the regression is 1000 if the born child died as an infant and 0 otherwise.

The controls in the regressions include, mean rainfall in the district of interview in the month of

birth, and in each of the three trimesters, DMSP mean night time lights in the year of birth and the

preceding year in the district of interview, DLHS survey round fixed effect, mothers age in four cat-

egories, mothers years of schooling in categories and a dummy for religion of the household head.

The sample is births from 1998 to 2007. Cumulative Degree Days (CDD) > 90 F is illustrated by

the following example, if, say, in district Delhi in July 2005, there are two days where temperature

exceeded 90F. On one day it was 95F and on the other it was 100F then Cumulative Degree Days

> 90 F = (100− 90)+ (95− 90) = 15. ASHA takes the value one if a) the mother is interviewed

in a state where ASHA is implemented and b) the child is born after 2005. All standard errors are

clustered at the state level.

Page 32


Table 5: Effect of Temperature in utero on Infant Mortality (Robustness Check)


CDD exceeding 95F Birth Month 0.257*** 0.232*** 0.173*** 0.0293 0.322*** 0.296**(0.0334) (0.0476) (0.0386) (0.0842) (0.0935) (0.106)

CDD exceeding 95F Trimester 1 0.0460 0.0868 0.0696 0.0772 0.0417 0.0396(0.0511) (0.109) (0.116) (0.0556) (0.0758) (0.0844)

CDD exceeding 95F Trimester 2 0.106*** 0.104** 0.0543 -0.0234 -0.0337 -0.0200(0.0320) (0.0459) (0.0365) (0.0590) (0.0789) (0.0557)

CDD exceeding 95F Trimester 3 0.0454 0.0812 0.0353 -0.0503 0.0347 0.0313(0.0312) (0.0888) (0.0821) (0.0784) (0.0917) (0.106)

N 395,070 395,070 395,070 116,198 116,198 116,198p value for Joint Test 0.0166 0.0601 0.3651 0.4293 0.8086 0.9007


CDD exceeding 92F Birth Month 0.126*** 0.108** 0.0803** 0.00911 0.130* 0.119(0.0166) (0.0401) (0.0372) (0.0408) (0.0760) (0.0903)

CDD exceeding 92F Trimester 1 0.00449 0.000427 0.00628 0.0250 0.0159 0.0191(0.0230) (0.0550) (0.0514) (0.0295) (0.0477) (0.0521)

CDD exceeding 92F Trimester 2 0.0520*** 0.0811*** 0.0562** -0.0210 -0.0329 -0.0235(0.0179) (0.0273) (0.0218) (0.0218) (0.0428) (0.0379)

CDD exceeding 92F Trimester 3 0.0330 0.0847 0.0593 -0.0171 0.0342 0.0435(0.0198) (0.0576) (0.0544) (0.0260) (0.0404) (0.0443)


Controls Y Y Y Y Y YDistrict-Quarter FE Y YQuarter-Year FE Y Y Y Y Y YBirth Month FE Y YDistrict-Month FE Y Y Y YState-Quarter specific Quadratic Trend Y YThe dependent variable in the regression is 1000 if the born child died as an infant and 0 otherwise. The controls in the regressions include,







Page 33




CDD exceeding 87F Birth Month 0.0523*** 0.0233 0.00941 -0.000517 -0.0119 -0.0171(0.0143) (0.0268) (0.0290) (0.0138) (0.0276) (0.0590)

CDD exceeding 87F Trimester 1 -0.00243 -0.0275 -0.0229 -0.00760 -0.00455 -0.0120(0.00899) (0.0211) (0.0164) (0.0125) (0.0312) (0.0306)

CDD exceeding 87F Trimester 2 0.0154* 0.0471*** 0.0288** -0.000598 0.0354 0.00111(0.00815) (0.0127) (0.0123) (0.0111) (0.0227) (0.0313)

CDD exceeding 87F Trimester 3 0.0129 0.0419 0.0225 -0.00213 -0.00354 0.0454*(0.00822) (0.0301) (0.0275) (0.0293) (0.0508) (0.0225)



CDD exceeding 85F Birth Month 0.0405*** 0.0142 0.00491 -0.00154 -0.0215 -0.0356(0.0133) (0.0226) (0.0244) (0.0260) (0.0456) (0.0521)

CDD exceeding 85F Trimester 1 -0.00279 -0.0318* -0.0274** -0.00328 -0.0211 -0.0218(0.00732) (0.0161) (0.0114) (0.0106) (0.0219) (0.0242)

CDD exceeding 85F Trimester 2 0.00935 0.0389*** 0.0250** -0.00428 0.00951 0.0154(0.00650) (0.00978) (0.00959) (0.00992) (0.0251) (0.0256)

CDD exceeding 85F Trimester 3 0.00849 0.0266 0.0115 0.000780 0.0329* 0.0435**(0.00630) (0.0246) (0.0223) (0.00902) (0.0190) (0.0187)


Controls Y Y Y Y Y YDistrict-Quarter FE Y Y YQuarter-Year FE Y Y Y Y YBirth Month FE Y YDistrict-Month FE Y Y Y YState-Quarter specific Quadratic Trend Y YThe dependent variable in the regression is 1000 if the born child died as an infant and 0 otherwise. The controls in the regressions include,







Page 34




CDD exceeding 90F- Month13 to Month 24 0.00508 0.00880 -0.00653 0.0299 0.0299 0.0111(0.0117) (0.0108) (0.00902) (0.0350) (0.0337) (0.0312)

CDD exceeding 90F Birth Month 0.0842*** 0.0591* 0.0381 -0.00191 0.0435 0.0318(0.0140) (0.0324) (0.0324) (0.0360) (0.0632) (0.0748)

CDD exceeding 90F Trimester 1 1.41e-05 -0.0144 -0.00796 0.00815 -0.000194 0.000998(0.0147) (0.0357) (0.0319) (0.0209) (0.0390) (0.0441)

CDD exceeding 90F Trimester 2 0.0320** 0.0651*** 0.0413** -0.0161 -0.0270 -0.0217(0.0126) (0.0198) (0.0173) (0.0164) (0.0377) (0.0353)

CDD exceeding 90F Trimester 3 0.0233* 0.0701 0.0452 -0.00636 0.0400 0.0494*(0.0133) (0.0438) (0.0402) (0.0161) (0.0270) (0.0279)


Controls Y Y Y Y Y YDistrict-Quarter FE Y YQuarter-Year FE Y Y Y Y Y YBirth Month FE Y YDistrict-Month FE Y Y Y YState-Quarter specific Quadratic Trend Y YThe dependent variable in the regression is 1000 if the born child died as an infant and 0 otherwise. The controls in the regressions include, mean

rainfall in the district of interview in the month of birth, and in each of the three trimesters, DMSP mean night time lights in the year of birth and the

preceding year in the district of interview, DLHS survey round fixed effect, mothers age in four categories, mothers years of schooling in categories

and a dummy for religion of the household head. The sample is births from 1998 to 2007. Cumulative Degree Days (CDD) > 90 F is illustrated by the

following example, if, say, in district Delhi in July 2005, there are two days where temperature exceeded 90F. On one day it was 95F and on the other

it was 100F then Cumulative Degree Days > 90 F = (100− 90) + (95− 90) = 15. All standard errors are clustered at the state level.

Page 35


Table 8: Prenatal Temperature and Mother’s Charachteristics


Mother Years of Schooling

CDD exceeding 90F Birth Month 3.24e-05 -0.000433 4.10e-05 -0.000357 -0.000591 -0.000482(0.000838) (0.00123) (0.00113) (0.00110) (0.00112) (0.000874)

CDD exceeding 90F Trimester 1 7.61e-05 0.000301 0.000393 0.000574 0.000786 0.000502(0.000270) (0.000373) (0.000379) (0.000373) (0.000925) (0.00100)

CDD exceeding 90F Trimester 2 -0.000323 0.000146 6.60e-06 0.000813* 0.00272*** 0.00234**(0.000334) (0.000779) (0.000709) (0.000418) (0.000635) (0.000848)

CDD exceeding 90F Trimester 3 0.000195 -0.000510 -0.000403 -9.41e-05 -0.00148 -0.00182(0.000329) (0.000469) (0.000418) (0.000506) (0.00136) (0.00141)


Mother Age (in Years)

CDD exceeding 90F Birth Month 0.000635 0.00200* 0.00167 0.000899 5.56e-05 -0.00144(0.000829) (0.00101) (0.00113) (0.000768) (0.00160) (0.00164)

CDD exceeding 90F Trimester 1 0.000815** -0.000288 -7.26e-05 1.45e-05 -0.000199 0.000183(0.000341) (0.000462) (0.000429) (0.000636) (0.000740) (0.000769)

CDD exceeding 90F Trimester 2 0.000498 0.000744 0.000469 4.75e-05 5.45e-05 -0.000142(0.000418) (0.000476) (0.000502) (0.000900) (0.000840) (0.000794)

CDD exceeding 90F Trimester 3 0.000130 0.000759 0.000377 0.000931 0.00101 9.60e-05(0.000301) (0.000561) (0.000699) (0.00103) (0.00133) (0.00131)


Controls Y Y Y Y Y YDistrict-Quarter FE Y YQuarter-Year FE Y Y Y Y Y YBirth Month FE Y YDistrict-Month FE Y Y Y YState-Quarter specific Quadratic Trend Y YThe sample for mother years of schooling includes all mothers who can read and write if interviewed in DLHS 2 and all mothers who have ever attended

school if interviewed in DLHS 3. Mother age is mother’s age at the time of interview. The controls in the regressions include, mean rainfall in the

district of interview in the month of birth, and in each of the three trimesters, DMSP mean night time lights in the year of birth and the preceding year

in the district of interview, DLHS survey round fixed effect and a dummy. The sample is births from 1998 to 2007. Cumulative Degree Days (CDD) >

90 F is illustrated by the following example, if, say, in district Delhi in July 2005, there are two days where temperature exceeded 90F. On one day it

was 95F and on the other it was 100F then Cumulative Degree Days > 90 F = (100− 90) + (95− 90) = 15. All standard errors are clustered at the

state level.Page 36


Table 9: Temperature and Number of Births


CDD exceeding 90F Birth Month 6.90e-05 -0.000739 -0.000770 0.000852 -0.00159 -0.00251(0.00261) (0.00215) (0.00169) (0.00335) (0.00629) (0.00556)

CDD exceeding 90F at Conception -0.00690** -4.04e-05 0.00196 -0.00676** -0.00338 -0.00526(0.00321) (0.00395) (0.00456) (0.00289) (0.00855) (0.00948)

CDD exceeding 90F Trimester 1 -0.00106 -0.000921 0.00170 -0.00231 -0.00150 -0.00166(0.00238) (0.00204) (0.00237) (0.00231) (0.00344) (0.00341)

CDD exceeding 90F Trimester 2 0.00307* 0.000624 0.00180 0.00378 0.000354 0.000258(0.00150) (0.00359) (0.00331) (0.00315) (0.00516) (0.00645)

CDD exceeding 90F Trimester 3 0.00657** 0.000707 0.00152 0.00596** -0.000382 -0.000893(0.00239) (0.00252) (0.00311) (0.00228) (0.00409) (0.00413)


District-Quarter FE Y YQuarter-Year FE Y Y Y Y Y YBirth Month FE Y YDistrict-Month FE Y Y Y YState-Quarter specific Quadratic Trend Y YThe dependent variable is number of births at the district-month-year level. At conception means 10 months before the month of birth, trimester 1 is 9,

8, 7 months before birth, trimester 2 is 6, 5, 4 months before birth, trimester 3 is 3, 2, 1 months before birth. All standard errors are clustered at district

level. The regressions are weighted by sum of sample weights in a district. The regression specification also controls for DLHS wave fixed effects,

rainfall in all birth trimesters and month of conception and birth as well as DMSP mean night time lights in the year of birth and the preceding year

in the district of interview. The sample is births from 1998 to 2008. Cumulative Degree Days (CDD) > 90 F is illustrated by the following example,

if, say, in district Delhi in July 2005, there are two days where temperature exceeded 90F. On one day it was 95F and on the other it was 100F then

Cumulative Degree Days > 90 F = (100− 90) + (95− 90) = 15. All standard errors are clustered at the state level.

Page 37


9 Appendix A

Table 10 presents results of the effects of textitin utero exposure to high temperatures on neonatal mortality.

The results show the effects of in utero exposure to high temperatures on neonatal mortality are similar to

the effects of high temperatures on infant mortality as presented in Table 1. For rural areas, second and third

trimester and the birth month are particularly important. High temperatures increases chances of a new born

dying within one month. The magnitudes of the effects are also similar to that of Table 1. For instance,

using the same example, if mothers faces 10 days in the birth month when the temperature was 95F and for

the rest of the month it below 90F, then neonatal mortality would increase by 2.7 per 1000 live births, which

is a 7.5 percent increase over mean. A similar situation would increase infant mortality by 4.1 per 1000 live

births, which is also a 7.6 percent increase over mean.

Page 38


Table 10: Effect of Temperature in utero on Neonatal Mortality


CDD exceeding 90F Birth Month 0.0548** 0.0717*** 0.0545*** 0.0229 0.111** 0.112**(0.0206) (0.0208) (0.0172) (0.0295) (0.0505) (0.0522)

CDD exceeding 90F Trimester 1 -0.00718 -0.0140 -0.00858 0.0303* 0.0412 0.0482(0.00783) (0.0234) (0.0235) (0.0165) (0.0374) (0.0390)

CDD exceeding 90F Trimester 2 0.0172* 0.0196 0.0157 0.0196 0.0130 0.0254(0.00934) (0.0159) (0.0142) (0.0156) (0.0303) (0.0319)

CDD exceeding 90F Trimester 3 0.0203* 0.0552*** 0.0388** 0.0231 0.0114 0.0208(0.0114) (0.0173) (0.0153) (0.0143) (0.0301) (0.0316)

Mean of Dependent Variable 36 36 36 29 29 29N 509,096 509,096 509,096 146,482 146,482 146,482p value for Joint Test 0.0193 0.0144 0.0961 0.0143 0.4746 0.2345

Controls Y Y Y Y Y YDistrict-Quarter FE Y YQuarter-Year FE Y Y Y Y Y YBirth Month FE Y YDistrict-Month FE Y Y Y YState-Quarter specific Quadratic Trend Y YThe dependent variable in the regression is 1000 if the born child died as an infant and 0 otherwise. The controls in the regressions include, mean

rainfall in the district of interview in the month of birth, and in each of the three trimesters, DMSP mean night time lights in the year of birth

and the preceding year in the district of interview, DLHS survey round fixed effect, mothers age in four categories, mothers years of schooling

in categories and a dummy for religion of the household head. The sample is births from 1998 to 2007. Cumulative Degree Days(CDD) > 90

F is illustrated by the following example, if, say, in district Delhi in July 2005, there are two days where temperature exceeded 90F. On one

day it was 95F and on the other it was 100F then Cumulative Degree Days > 90 F = (100 − 90) + (95 − 90) = 15. All standard errors are

clustered at the state level.

Page 39


Table 11: Different NRHM provisions in High and Non-Focus states (Reproduced from Rao (2014))

High-Focus Non-Focus

% of villages with an ASHA worker 74.02 33.04Average number of ASHA workers who have completed first round of training in Sub-Center area 4.6 1.66% of Sub-Centers that have received untied funds 76.26 89.14% of Sub-Centers that have fully utilized untied funds 28.92 50.13% of Sub-Centre areas that have a Village Health & Sanitation Committee 63.96 84.64% of Primary Health Centers that have received untied funds 65.34 87.2% of Primary Health Centers that have fully utilized untied funds 24.26 48.02% of Community Health Centers that have received untied funds 81.82 90.09% of Community Health Centers that have fully utilized untied funds 32.62 46.06% of District Hospitals with a Rogi Kalyan Samiti (RKS) 86.61 93.43

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