|Year : 2016 | Volume
| Issue : 2 | Page : 124-130
Evaluation of integrated Child Development Services program in Gujarat, India for the years 2012 to 2015
Rajesh K Chudasama1, Umed V Patel1, Amiruddin M Kadri2, Arohi Mitra3, Dhara Thakkar3, Jasmin Oza3
1 Associate Professor, Department of Community Medicine, PDU Medical College, Rajkot, Gujarat, India
2 Professor and Head, Department of Community Medicine, PDU Medical College, Rajkot, Gujarat, India
3 Resident, Department of Community Medicine, PDU Medical College, Rajkot, Gujarat, India
|Date of Web Publication||23-Jun-2016|
Rajesh K Chudasama
Vandana Embroidary, Mato Shree Complex, Sardar Nagar Main Road, Rajkot - 360 001, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The Integrated Child Development Services (ICDS) scheme has been operational for more than three decades in India. Objective: To evaluate the various aspects of the ICDS program in terms of inputs, process and outcome (coverage), utilization, and issues related to the ICDS program. Methods: A total of 130 Anganwadi centers (AWCs) were selected including 95 AWCs from rural areas and 35 AWCs from urban areas from April 2012 to March 2015, from 12 districts of Gujarat and the union territory of Diu. Information was collected for infrastructure, baseline characteristics of AWWs, provision, coverage and utilization of various ICDS services, and various issues related to program operation. Results: A majority of pregnant (94.7%) and lactating (74.4%) mothers, and adolescent girls (86.6%) were availing ICDS services. In 96.9% of the AWCs, a growth chart was available and 92.3% AWWs were using it accurately. A total of 14.9% children were underweight including 13.5% moderately and 1.4% severely malnourished children. Two-third (66.2%) children were covered by supplementary nutrition (SN). Only 14.6% of the AWCs reported 100% preschool education (PSE) coverage among children. More than half (55.4%) of the AWCs reported an interruption in supply during the last 6 months. Various issues were reported by AWWs related to the ICDS. Conclusion: The study has reported gaps in terms of infrastructure facility, different trainings, coverage, supply, and provision of SN, status of PSE activities in AWCs, and provision of different services to the beneficiaries.
Keywords: Evaluation, Integrated Child Development Services (ICDS), Anganwadi centers (AWCs), Anganwadi worker (AWW), Gujarat
|How to cite this article:|
Chudasama RK, Patel UV, Kadri AM, Mitra A, Thakkar D, Oza J. Evaluation of integrated Child Development Services program in Gujarat, India for the years 2012 to 2015. Indian J Public Health 2016;60:124-30
|How to cite this URL:|
Chudasama RK, Patel UV, Kadri AM, Mitra A, Thakkar D, Oza J. Evaluation of integrated Child Development Services program in Gujarat, India for the years 2012 to 2015. Indian J Public Health [serial online] 2016 [cited 2019 Dec 14];60:124-30. Available from: http://www.ijph.in/text.asp?2016/60/2/124/184544
| Introduction|| |
The Integrated Child Development Services (ICDS) program was launched on October 2, 1975 in pursuance of the National Policy for Children. The ICDS program has been operating satisfactorily for more than three decades of its establishment.  It is India's response to the challenge of providing preschool education (PSE) on the one hand and breaking the vicious cycle of malnutrition, morbidity, reduced learning capacity, and mortality on the other.  The ICDS program is a long-term development program for the community and all efforts should be continued to strengthen it in order to make it more successful. It serves the extreme underprivileged communities of backward and remote areas of the country. It delivers services right at the doorsteps of the beneficiaries to ensure their maximum participation. 
The program includes a network of "Anganwadi centers" (AWCs), literally courtyard play centers, which provides integrated services comprising supplementary nutrition (SN), immunization, health check-up, and referral services to children below 6 years of age and expectant and nursing mothers. Nonformal PSE is imparted to children in the age group of 3-6 years and nutrition and health education (NHED) to women in the age group of 15-45 years. The performance of the ICDS program is to a great extent dependent on the profile of the key functionary, the Anganwadi worker (AWW) - her qualification, experience, skill, attitude, training, etc.  The job responsibilities of the AWWs are defined in the program but their responsibilities have been redefined, considering the many new policies and programs that have evolved, which ultimately affects the performance of AWWs. 
The present study was conducted to evaluate the various aspects of the ICDS program  such as infrastructure of AWCs and baseline characteristics of AWWs (inputs), provision of various services (process), coverage of various ICDS services provided (outcome), utilization of services, and issues related to program operation in different districts of the state of Gujarat and union territory of Diu.
| Materials and Methods|| |
The National Institute of Public Cooperation and Child Development (NIPCCD) under the Ministry of Women and Child Development (MWCD), Government of India is undertaking various tasks at the state level related to supervision and monitoring of the scheme with the help of selected academic institutions such as the community medicine department of medical colleges and home science colleges. From Gujarat with 25 districts, two institutions, namely, Pandit Deendayal Upadhyay (PDU) Government Medical College, Rajkot - The Community Medicine Department and Government Medical College, Vadodara - Community Medicine Department were approved by the NIPCCD. The present study was conducted by the Community Medicine Department, PDU Government Medical College, Rajkot in 12 districts of Gujarat as directed by the NIPCCD. The 12 districts included were Ahmedabad, Amreli, Bhavnagar, Gandhinagar, Jamnagar, Junagadh, Kutch, Mehsana, Patan, Porbandar, Rajkot, and Surendranagar. As suggested by the NIPCCD, the union territory of Diu was also included in the study.
The NIPCCD suggested visiting three districts in one quarter of the year and so one district had to be visited per month. As per the availability of grants, visits were paid to the selected 12 districts and also the union territory of Diu from April 2012 to March 2015. As there were no criteria given for the selection of ICDS block for supervision from the selected districts, one ICDS block was selected first by using simple random sampling (lottery method). The Child Development Project Officer (CDPO) of the respective ICDS block was then informed in advance about the nature of the visit and the number of AWCs to be visited. In the next stage, from each selected block five Anganwadi centers were randomly selected on the day of visit without prior information to the AWWs. Based on the availability of government grants provided by the NIPCCD, visits were paid to the districts in different years. A total of 60 AWCs were visited from April 2012 to March 2013, 40 AWCs from 2013 to 2014 including 5 AWCs from Diu, and 30 AWCs from 2014 to 2015. So, a total of 130 Anganwadi centers were selected including 95 AWCs from rural areas and 35 AWCs from urban areas. As no guideline was provided by the NIPCCD for selection of block in the districts to be visited, a new block was selected during the subsequent visit of the selected 12 districts. All the above 12 districts were visited from 2012 to 2013 but due to insufficient grants, 7 blocks from the 7 abovementioned districts and one block from the union territory of Diu were visited from 2013 to 2014. A total of 6 blocks were visited from 2014 to 2015 including 5 remaining districts of 2013 to 2014 and one from the previous districts. In any year, different block was selected from the same district. An attempt was made to select not more than two Anganwadi centers from each of the supervisory circles. A team of four members from the Community Medicine Department, PDU Government Medical College, Rajkot visited the selected AWCs.
The AWWs were interviewed and a review of the records was done by using a predesigned and pretested pro forma provided by the NIPCCD. Considering the usual program evaluation framework, the information was collected for:
- Inputs, i.e., infrastructure of AWCs and baseline characteristics of AWWs,
- Process, i.e., provision of various ICDS services to the beneficiaries, and
- Outcome, i.e., nutritional status of beneficiary children and coverage of services provided such as SN, PSE, and NHED. 
An AWC with constructed covered area of not less than 600 sq ft was considered as having adequate indoor space.  Also, information was collected on the utilization of various services provided and issues related to program operation by interviewing the AWWs. The collected data were entered and analyzed by using Epi Info software version 3.5.1 (Centers for Disease Control and Prevention, Atlanta, Georgia, USA). 
| Result|| |
Input indicators - infrastructure and baseline characteristics
Almost two-third (63.1%) of the AWC buildings were owned by the state with 82.3% of the AWCs having a concrete (pucca) type of building [Table 1]. Three-fourth of the AWCs (74.6%) had an adequate indoor space and 64.6% had the availability of a separate toilet facility. In 96.9% of the AWCs, a growth chart was available and 92.3% of the AWWs were using it accurately.
|Table 1: Input indicators — Anganwadi centers infrastructure and baseline characteristics under integrated child development services (ICDS) program in Gujarat|
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Process indictors - various services provided and its quality
A majority of the AWCs reported that SN was fully acceptable (91.5%) [Table 2]. Hot cooked food and ready-to-eat food were given in 46.9% of the AWCs. More than two-third AWCs were using time table for PSE (70.8%). Almost three-fourth (73.8%) AWCs conducted at least one NHED meeting per quarter.
|Table 2: Process indicators — Various health services delivered under the ICDS program at Anganwadi centers (AWCs) in Gujarat|
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Outcome and impact indicators - coverage and utilization of services
Two-third (66.2%) children were covered by SN [Table 3]. A majority of pregnant (94.7%) mothers, three-fourth lactating mothers (74.4%), and 86.6% adolescent girls were availing ICDS services. One-third AWCs (33.1%) recorded the immunization of all children. Referral slips were available in 30.8% of the AWCs and referral of sick children was done from one-third (36.9%) AWCs. A total of 14.9% children were underweight including 13.5% moderately and 1.4% severely malnourished children according to the World Health Organization (WHO) growth chart.
|Table 3: Outcome and impact indicators — Coverage and utilization of various services provided under the ICDS program at Anganwadi centers in Gujarat|
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Issues related to various services
AWWs reported various issues related to ICDS services such as no separate storage facility (57.7) and high workload (31.5%). [Table 4].
|Table 4: Issues related to various services provided at Anganwadi centers in Gujarat|
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| Discussion|| |
Recognizing the need for early intervention to ensure the development of a young child's body, mind, and intellect to its maximum potential, the Government of India started the ICDS, a centrally sponsored scheme, which is a step toward responding to the child's needs in a comprehensive and holistic perspective. 
The concrete type of building (pucca) was reported in 84.2% of the AWCs in rural areas and 77.2% in urban areas; this was higher than studies from other states,  indicating more developed infrastructure in rural and urban areas in the present study. Two-third (64.6%) AWCs had the availability of a separate toilet including 65.3% in rural areas and 62.9% in urban areas, again supporting more developed infrastructure in the current study. Induction training was received by only 11.4% of the AWWs in the present study. A study has reported that performance of AWWs can be improved by proper training,  and poor performance of AWCs may be because of inadequate training.  Two-third AWWs had also received the Integrated Management of Neonatal and Childhood Illness (IMNCI) training.
The success of growth monitoring depended on the extent to which counseling support, weighing scales, growth charts, etc., were available in AWCs.  A growth chart was available in 96.9% of the AWCs and was accurately used (92.3%) by AWWs, which was higher (25-59%) than reported in other studies. , Accuracy of using a growth chart was assessed by asking AWWs to demonstrate the procedure of weighing and plotting the growth chart. A previous study had reported that AWWs were not conversant with the plotting of a growth chart even after receiving the necessary training.  The present study reported that there were 13.5% moderately underweight and 1.4% severely underweight children, lower than reported in other areas. ,, It might be possible that AWWs were underreporting the nutritional status in their routine practice, decreasing the prevalence of underweight children or the estimate of actual registration of beneficiaries might not have been available,  which is a limitation of the present study. Growth curves provide the earliest indication of growth failure; hence, AWWs must be adequately trained to plot growth curves and they be can specifically monitored on this by the supervisors and CDPOs of the project areas. 
SN leads to fulfillment of the deficiencies of calories, proteins, minerals, and vitamins in the existing diets, avoiding cutbacks in the family diet and taking other measures for nutritional rehabilitation of severely malnourished children and also mothers.  In the present study, SN coverage was 66.2% in children but was high (86.7%) in pregnant and lactating mothers. It indicates that the AWWs have to lay more emphasis to attract children from their community to Anganwadis by providing other services such as PSE and also by celebrating NHED days.  The take-home ration was provided from 36.2% of the AWCs, indicating interrupted supply (55.4%) from the authority at AWCs. The local authority has to give attention on this issue and provide the timely supply of take-home ration at AWCs. The state government has recommended the supply of energy dense extruded fortified blended food to children of both 6 months to 3 years (125 g/day) and 3-6 years (185 g/day) of age.  It was observed that interruption in the supply of SN also affected the image of AWWs and credibility of the activities of AWCs, and had a negative impact on community support and participation. This also impacts the delivery of other services due to poor attendance of children in AWCs.  Regular supply of SN is expected to attract the beneficiaries and make them available at AWCs for other services as well  but interruption in SN supply may affect those services at AWCs. The nonsatisfaction regarding SN has sometimes resulted in dissatisfaction among parents regarding overall ICDS services. ,
PSE improves early literacy skills, the child's ability to learn to communicate ideas and feelings, and to get along with other children.  All enrolled children were receiving PSE in only 14.6% of the AWCs. For PSE activities, 70.8% of the AWCs were using time table as prescribed by the state government. Studies have reported poor skill development of Anganwadi children as against private nursery schoolchildren, which could be attributed to a poor stimulating environment including the lack of play materials; hence, there is a need to improve the preschool environment of the Anganwadis. ,
The present study reported that 75.8% of the AWCs in rural areas and 68.6% in urban areas celebrated NHED day under the National Rural Health Mission (NRHM), which is considered as an umbrella toward maternal and child health (MCH) care in contrast to Tamil Nadu and Puducherry.  Previous studies reported that NHED were given low priority in improving the growth status of children. , The NHED was meant for effective transmission of certain basic health and nutrition messages to enhance the level of awareness of mothers about the child's needs and her capacity for care, protection, and development of the child within the family environment. 
Among the registered beneficiaries, utilization of ICDS services was high - pregnant (94.7%) and lactating (74.4%) mothers, adolescent girls (86.6%), and children of 6 months to 6 years of age (85.3%). The participation of pregnant and lactating women and adolescent girls in the ICDS program is central to tackling the problem of underweight and malnutrition in the country. 
One-third (33.1%) AWCs had records of immunization of all children while 48.5% of the AWCs did not have any such available record. Monthly health check-ups of the beneficiaries were done in 46.1% of the AWCs. In a review of AWCs by the National Council of Applied Economic Research (NCAER) in 2004, it was observed that only 64% of the centers provided health check-up for children and 53% check-up for women.  Referral slips were available in 30.8% of the AWCs and referral of sick children was reported from 36.9% of the AWCs. Emphasis should be given on good quality supervision and also sensitizing anganwadi workers about the importance of timely referral of sick children to the higher center.  AWWs reported various problems related to providing services such as the nonavailability of storage space (57.7%), interruption in the supply of SN (55.4%), workload other than ICDS (31.5%), inadequate honorarium (27.7%), and nonavailability of a separate kitchen (26.2%). Such findings were reported in a previous study from the same area and also in studies from other states. ,,
The performance of AWCs and maternal and child health services delivered by AWCs still need improvement. The study has reported gaps in terms of infrastructure facility such as separate storage and kitchen facilities, giving different trainings, coverage, supply, and provision of SN foods to the beneficiaries, status of PSE activities in AWCs, recording of immunization, regular health check-up of beneficiaries, and referral of sick children, which need to be promptly addressed.
Financial support and sponsorship
National Institute of Public Cooperation and Child Development (NIPCCD).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]