Towards eradication of the undernourished in India, the Integrated Child Development Services Scheme was established in the early 70s. Tamil Nadu with its vision towards a developed State in our Nation is a pioneer and trail blazer in innovating and improving on its milestones. It takes visionary leadership to execute few innovations which in future becomes routine. Tamil Nadu has taken pride in its development with respect to both Health and Industrialization.
The Study to assess the Performance Outcome for Integrated Child Development ServicesScheme on Health and Nutritional Status of Children (below 6 years) in Tamil Nadu was contracted to the School of Public Health, SRM University through the Department of Evaluation and Applied Research. This study provides information regarding ICDS coverage and Health. ICDS coverage includes: various target groups of the program and if they are covered, objectives of the program and if it is met, and the various services delivered at the Anganwadi Centers (AWC). Through this study, the SPH covered comprehensive Health services including: Early Childhood Care, Ante Natal and Post Natal care, Growth Monitoring, Supplementary Nutrition, Health Services by health personnel, Referral services, Non formal Pre School Education, nutrition and health education, Supplementary nutrition under the Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA), life skills training, and vocational training to adolescent girls in 139 blocks in 9 districts, provision of Nutritious hot cooked meal for the Children in the age group of 2 to 5 years. All these were done through surveys that assessed the availability, and utility of infrastructure facilities and services of the AWC.
Towards achieving the objectives, Four surveys were designed and were carried out. The sampling for the surveys varied based on purpose and level of representativeness. Survey I, II and IV were representative at the State and Regional level, while survey III included District level data as well. To enable us to conduct survey III and IV, a prior listing survey was conducted at households in the catchment area of the AWCs. Subsequently the Child / Mother and awareness surveys were conducted at the household. Survey I, the AWC observation survey was grouped in 4 regions with 8 districts in each region and covered a sample of 1600 AWCs, while the survey II was the AWW survey and was done in the same 1600 AWCs, Survey IV it was about community awareness was done in 160 AWC areas covering 4119 sampled households. The Child nutrition survey which gave us the outcome of the ICDS program’s effectiveness was done in all 32 districts , with 1315 AWCs being covered and 44494 children were sampled.
Before the commencement of the project, the Training of Trainers was conducted followed by piloting of the questionnaires. The pilot was carried out to ascertain the components of the main study. This was done by SRM SPH, DEAR and J-PAL. Training of the teams for houselisting was carried out in 4 districts followed by training of the field team after houselisting was carried out. Quality was one critical parameter that was upheld throughout the survey. A quality control team was constituted to assure the quality of data collected. Data was collected by 20 teams, each consisting of 4 investigators and 1 supervisor. Each zone was led by a research officer. The other highlight of this survey was utilizing tablets, iball handheld mobile system was utilized and were preloaded with the survey questionnaires. The data collected was transmitted to the central server every day after the survey was complete thus ensuring data availability for daily quality assurance and quality control. To monitor data quality standards to be met was divided into 1) Center based quality checks and 2) Field Based quality checks. Center based included 1) Logical inconsistencies 2) Time taken for the interview 3) Rate of missing Data and 4) Response rate while field based included 1) Reliability Coefficient: 10% back checks 2) Accuracy and 3) Quality of data entry.
and Systems in Place
For efficient ICDS services requirements include Structure and Systems in place and this was achieved by the I, II and IV surveys. In particular the findings of survey I highlights the physical infrastructure and processes in place for the system to work seamlessly. This includes:
The proportion of Government Owned and free AWCs was around 80 per cent, while Government owned and rented was a mere 2 per cent. 15 per cent of the AWCs reported to be housed in Private rented space and close to 3 per cent reported being housed in private space for no rent. Over one-third of the AWCs served a population of 1001-1500 and close to one-fifth reported serving over 1500 population. Among the AWCs two out of three reported having terraced roofs, while another 1/5th reported having tiled roofs and 16 per cent reported having asbestos sheet. Findings also report that over 60 per cent reported having a plinth area of 300 Sq ft. Utilities for optimal functioning of AWCs include electricity and Water. Almost 2 out 3 AWCs surveyed reported having electricity. Water much needed utility in these centers, over 3 out of 4 AWCs reported having Tap Water as their primary source followed by overhead tanks and borewell. Towards having consistent water access theGoTN has installed Sintex tanks and 49 per cent per cent reported having them while 10 per cent reported having other sources for water storage and 37 per cent had no water storage facility. Close to 90 per cent of the AWCs reported having access to water throughout the year.
Having access to water throughout the year helps in another behavior which is critical to health of the Children: using of toilets. About 60 per cent of the AWCs surveyed reported having toilets, out of which 65 per cent were baby friendly and almost all of them reported having a single latrine for use. Close to 7 out 10 children were found to openly urinate and defecate, which is validated from other findings about open defecating behavior in Tamil Nadu.
Having infrastructure allows planning of the various activities of the program. Almost 80 per cent AWCs prepared their food at their centers reported having cooking gas facilities and almost all of the respondents reported having adequate space for the program. Structures in place along with the decentralization of procurement of Supplementary Nutrition and groceries have helped in securing a very high position when compared nationally however we need to improve our children’s health through better access to toilets and to encourage community participation.
To enable successful operations, just having robust infrastructure is not sufficient, but there needs to efficient systems in place to utilize the available infrastructure. Having and maintenance of documentation of activities of the AWC is one of the job responsibilities of the AWW. Towards documenting each center has to document all the activities in 11 Registers as per ICDS protocol. Findings of this enables us to understand the load on the AWW. It is worth be highlighted that in all the 1600 centers they reported missing some register. It does require mention that almost all of them (92-97 per cent) reported having updated registers and universally lack of time has been reported for poor maintenance of the registers. Another highlight being AWCs in Tirchy Zone enrolled 96 Per cent of eligible children while Dindugal zone fared very poor at on 57 per cent.
Systems in place include Logistics and Supply chain of the required supplementary nutrition and other raw materials for noon meal along with supply of cooking gas. Across the sampled centers, almost all of them (96 per cent) reported having supply delivered every month. The robustness of supply chain is well highlighted with only 7 per cent of the AWCs providing Supplementary nutrition for less than 30 days. The other highlight of the ICDS is the provision of Noon Meal, which along with Supplementary nutrition has been an attraction for mothers to bring their children to the Anganwadi. Almost all the AWCs in this survey reported providing noon meals and were following the ICDS menu and this is made possible again because of logistics and supply chain at the central headquarters because of regular supply of food and groceries across the State.
One of the flagship activities of the AWC is the periodic growth monitoring of the children (twice a month) and charting their growth which is possible only with the availability of machines, Mother / Child protection card and Growth Charts. Over 90 per cent reported having adult weighing scales and almost all centers reported having at least one type of Infant weighing machine. Although all of them reported having the weighing scales, it worth mentioning that only 77 per cent reported having growth charts at their centers. Growth monitoring also includes registering and weighing of pregnant women and almost all center reporting having ANC women registered.
To implement a project such as the ICDS, not just infrastructure is sufficient for effective and efficient implementation. The other critical component of the program is the People involved in implementation at the Village, District and the State. Having a universal recognition for its role in addressing malnutrition, the ICDS program relies heavily on "trained" AWWs and AW Helper. Part of the survey was to identify the knowledge of the AWWs about ICDS in-Toto.
Demographic details indicate that almost 93 per cent of the AWWs were in the middle and upper age groups of over 31 years - 60 years and with respect to education half of the surveyed had at least Grade 10 education.
The role of the AWW in improving the health of children is directly tied to how committed she is to improving her community and her knowledge , attitude about ICDS and its services, almost all (> 90 per cent) of them surveyed were highly knowledgeable regarding core services, menu for the week and also reported to understand the program. It is worth to note that AWWs are also exposed to other trainings which give them a comprehensive understanding of child health such as IMCNI, IYCF and life skills etc. Almost all (>90 per cent) of them universally had high level of knowledge regarding periodicity of health check ups, Vitamin A prophylaxis eligibility, time (month) of administration, deworming schedule, IFA for children, pregnant women and adolescents.
Communities' health is a priority when one is a native of that community, and in that regard it matters when AWWs are from the same community and the survey reveals that over 70 per cent reported living within 3 kms from the center.
With regards to Human Resources and trained AWWs the ICDS is functioning as well as it can when vacancies in AWW positions are taken into consideration across the State. Having robust infrastructure can only be utilized when trained staff are available to make the best use of the resources available.
As part of the Terms of Reference, listing of the population was one of the activities. Listing covered around 12 lakh population of 1315 villages across 32 districts of the State. As reported by Census 2011, the average size of a family is validated in our survey, we found it to be 3.4 and with literacy on the mid eighty per cent. Topmost services accessed as revealed by the listing found Immunization to be at the top, followed by Complementary nutrition, noon meal and Pre-School Education. Women reported using the AWCs for ANC and PNC followed by folic acid and Supplementary nutrition.
From the listing activity, over a third of male and female population was in 0-6 age group, with Hindus being the majority. Scheduled Caste was found to be significantly higher than the Tribe. Agricultural Labour was the topmost with respect to Occupation with over 50 per cent and finally majority of the listed had less than high school education.
of the Children
Among the children surveyed 30 per cent were in the 6-24 months age group while 70 was in the 25-72 month group with almost even gender distribution and almost 99 per cent of the children have been birthed at Institution as validated by all other State level surveys with regards to Institutional Deliveries. 11.5 per cent of the beneficiary children were in the 6-11 months age group , 27 per cent in the 1-2 year old group, 29 per cent in the 2-3 years old group and 32 per cent in the 3-6 year old group.
Profile of Children
Top three districts for child nutrition was found to be Chennai, Coimbatore and Namakkal with less than 12 per cent with moderate Malnutrition and less than 2 per cent with Severe Malnutrition. Across the State around 20 per cent of the children and male tribal children were found to be moderately under nourished. Severe Malnutrition was almost 5 per cent across the State, 3.5 and 5 per cent respectively in urban and rural children.
Weight Monitoring was reported to be the top most services utilized by both beneficiaries andnon beneficiaries in the past year. A five point differential was seen in Low Birth Weight Babies, with better numbers seen in Non Beneficiaries than Beneficiaries. It is worth noting that among Tribal beneficiaries LBW is twice as much as non- beneficiary tribes.
Poor performing districts were Dindugal, Thiruvannamalai and Villupuram with moderate malnutrition at 27, 34 and 42 per cent respectively and severe malnutrition at 10, 13 and 26 per cent respectively.
Further probing is required into the levels of moderate and severe malnutrition considering that almost all the children (> 98 per cent) were given colostrum as first feed, 82 per cent of the 6-11 month beneficiary children were consuming Saathumaavu along with Breast Milk. Also, almost 60 per cent had initiated complementary feed at six months. Some of the deficiency can be explained by the fact that only 55 per cent of beneficiary children in the 2-6 year age reported receiving supplementary feed at the AWC, also 25 per cent of beneficiary children in 6- 11 month age group have the supplementary nutrition shared with others in the family. Prevalence of Anemia was 73.4% among pre school children aged 6-59 month in Tamilnadu.
About illness, almost 50 per cent of the beneficiary children and 37 per cent of non beneficiary children reported any type of illness. It is to be highlighted that 95 per cent of the 10209 children of the 12-24 month age group reported being completely immunized. Beneficiary mothers showed better practice with regards to breast feeding during illness when compared with non beneficiary mothers and they chose the public health while the non beneficiaries preferred private clinics.
Good Hygiene and Sanitation practices which help in prevention of infection is rather poor in Tamil Nadu, although 60 per cent of the non beneficiaries and 50 per cent of beneficiaries reported having toilets, open defecation is still practiced by 40 per cent of the non beneficiaries and 50 per cent of the beneficiaries. Handwashing practices among mothers and children are consistently high.
From the findings of the survey 81 percent of the beneficiary children are regular to the AWC with almost 80 per cent reported the AWC to be less than 10 minutes by walk and almost all of them reported walking to the AWC. The beneficiaries when queried about ICDS services, almost all of them were aware that Immunization, Sathumaavu, weight monitoring and 2/3rds of them knew about AWC timings and among the beneficiaries a majority reported having the AWW visit their home , while only 57 per cent of non beneficiaries reported the same. Self report among the beneficiaries about AWC and services had 81 per cent rating them to be good while 71 per cent reported the facilities to be good. Pre School Education seems to be robust with 90 per cent of the children were able to identify body parts and shapes and over 3 out of 4 of these children also identified colors and vegetables correctly.
As part of assessing the performance of the ICDS program, it is imperative to get the opinion of the community, which is the intent of Survey IV.
characteristics of Community
As part of the study only a sample of the community was surveyed, a total of 4119 households. Findings reveal that 53 per cent of the sampled population was in the age range of 30-49 years old and 30 per cent in the age group of 50 and only 17 per cent in the 18-29 age group. In our sampled population 23 per cent reported not having any formal education and almost similar percentage of people have primary and middle/high school education. Occupation predominantly was non agriculturallabour at 48 per cent, and agricultural labourers accounted for about 20 per cent only.
Awareness about AWC among the respondents was high and 3 out 4 respondents reported having the AWC very easily accessible and within walking distance of most households.
Majority of the respondents identified the AWC with Saathumaavu, noon-meals and weight monitoring and fewer identified AWC for pre school education and nutritional education as well as adolescent girl services which could be because implementation has been in select districts, over 85 per cent were aware about the eligibility to be an AWC beneficiary.
Strategies that the ICDS is currently utilizing involve Early Childhood Care Education Days and Village Health and Nutrition Days which are conducted at the AWC. These strategies are to engage the community, however only 42 per cent of the respondents were aware of these days. Among the community who knew about the topics covered 84 per cent mentioned the importance of early childhood, 57 per cent about giving care at home, 30 per cent early stimulation. With regards to VHN days, 79 per cent respondents have attended a VHN day at the AWC. All these activities are for engagement of the community in its health and 60 per cent of the community has rated the AWC to be good and 34 per cent as Satisfactory and only 2 per cent as poor. Having these strategies to involve the community is paying off, with 20 per cent reporting contributing in one way or another.
In the big picture, the community survey highlights a few areas that we need to address. 90 per cent of the women were utilizing the AWC.