India's child nutrition program sees higher utilization, but fewer gains in high-burden states
Expansion and utilization of one of India's largest government-run community-based nutrition programs increased significantly between 2006 and 2016, especially among historically disadvantaged castes and tribes. But, women with low education and the poorest households are relatively more excluded from accessing program benefits. Among states too, while overall utilization has improved, high malnutrition states are relatively lagging. These are the findings of a new study, the first to offer an in-depth analysis of the utilization of the Integrated Child Development Services (ICDS)* program, conducted by researchers at the International Food Policy Research Institute (IFPRI).
The ICDS provides food, pre-school education, and primary healthcare to children under six and pregnant and lactating women. ICDS continues to be India's flagship program to tackle undernutrition, and key actions under India's new nutrition mission, the POSHAN Abhiyaan, are anchored in the program. The expanded participation between 2006 and 2016 demonstrates progress, but the researchers cautioned not all groups have benefited equally.
"Even though overall utilization has improved and reached many marginalized groups such as historically disadvantaged castes and tribes, the poor are still left behind, with lower utilization and lower expansion throughout the continuum of care," says IFPRI Research Fellow and study co-author, Kalyani Raghunathan. "These gaps are especially pronounced in the largest states of Uttar Pradesh and Bihar, which also carry the highest burden of undernutrition. While both states have shown improvements in 2016, they still fall behind national averages, suggesting that overall poor performance in high poverty states could lead to major exclusions."
"Even in better performing states exclusion of poor could be due to challenges of reaching remote areas, despite attempts to close district-wise equity gaps or local challenges of exclusion within villages due to caste- or location-based exclusion," says Raghunathan.
The study, "India's Integrated Child Development Services programme; equity and extent of coverage in 2006 and 2016", co-authored by IFPRI's Kalyani Raghunathan, Harold Alderman, Purnima Menon and Phuong Nguyen and University of Washington's Suman Chakrabarti, will be published in the April edition of the Bulletin of the World Health Organization. Using data from two rounds of the National Family Health Survey conducted in 2005-06 and in 2015-16, the researchers examine equity in program expansion and factors that determine utilization.
The study found a dramatic increase in utilization of ICDS services from 2006 to 2016 in four key areas: supplementary food (9.6 to 37.9 percent); health and nutrition education (3.2 to 21 percent); health check-up (4.5 to 28 percent); and child-specific services (10.4 to 22 percent). The frequency of monthly supplementary food for children also increased during this period by eight percentage points.
At the state level, the study highlights an increase in utilization of ICDS services between the two survey rounds. With the exception of Tamil Nadu, Chhattisgarh and Jharkhand, the coverage of food supplementation during pregnancy and lactation was less than 25 percent in most states in 2006 but increased in almost all states by 2016. The greatest expansion in ICDS services was seen in food supplementation during childhood, which reached more than 50 percent coverage in the central and southern states of Jharkhand, Madhya Pradesh, Uttaranchal, Tamil Nadu and Andhra Pradesh. [Refer to attached data note for a detailed district-wise breakdown of coverage of ICDS services, including district rankings and maps depicting areas of high and low coverage across the country.]
The study found both historically disadvantaged castes and pregnant women with low education levels were less likely to receive ICDS services than other groups.
"Given the significant implementation challenges such as state-level implementation decentralization, population size and diversity, financial constraints and community awareness, the large-scale expansion in ICDS in India is laudable. It seems India is well on its way to scale up at least some key nutrition-specific interventions using ICDS," says study co-author Harold Alderman.
The study provides important policy lessons not only for India and the states, but also for all countries that are in the process of scaling-up nutrition-specific interventions.
"Despite the positive findings of our analysis on coverage and on the closing of some equity gaps, a lot more insight is needed to further strengthen program quality. Our other studies on ICDS emphasize that key program elements like the food supplements, convergence and behavior change will need much attention to ensure that women and children across India get high quality program services," says co-author Purnima Menon, adding that special emphasis must be given to equity and program quality. "Examining the reasons for variability in program use by program clients both across and within states must underpin policy efforts to strengthen coverage, equity and quality," Menon added.