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NUTRITION SERVICE DELIVERY IN BIHAR
Ronald Abraham • IFPRI POSHAN Delivering for Nutrition in India
November 10, 2016
2
1. ICDS suffers from very low coverage and poor quality service
delivery
2. Low and ineffective coverage can be explained by:
o Insufficient resources
o Basic policy design gaps
o Poor implementation and pilferage
Two takeaways
Agenda
• IDinsight and study overview
• Nutrition services for mothers and infants
• Nutrition services for young children
• Discussion
Agenda
• IDinsight and study overview
• Nutrition services for mothers and infants
• Nutrition services for young children
• Discussion
5
IDinsight partners
with clients to
generate and use
rigorous evidence to
improve social
impact.
We believe that client-centered, rigorous,
and responsive evaluation is essential to
help managers maximize program
impact. Our team has collectively
coordinated over 30 randomized
evaluations in Africa and Asia, and works
on-site with client organizations to
efficiently answer important program
questions.
6
IDinsight conducted two quantitative
assessments of ICDS in 2012 and 2015
• Quantitative assessment of ICDS in 2012
o 3 districts: Gaya, Muzzafarpur, and Madhubani
o 200 anganwadis
o 550 mothers & children
o 170 shopkeepers
• Quantitative assessment of ICDS in 2015
o 4 districts: Kishanganj, Supaul, Araria and Madhubani
o 217 anganwadis
o 651 mothers & children
o 206 shopkeepers
Agenda
• IDinsight and study overview
• Nutrition services for mothers and infants
• Nutrition services for young children
• Discussion
8
“ICDS is the foremost symbol of
country’s commitment to its children
and nursing mothers”
- ICDS website
9
Take-home-ration (THR): ICDS Bihar’s
intervention for first 1000 days of a child
* First 1000 days refers to conception till age of 24 months. However, SNP targets THR up to 3-year olds.
First 1000 days
• Pregnant women
• Lactating women
• 6-month to 3-year olds*
Take-home ration
• Uncooked rice, lentils, eggs
• Quantity based on
nutritional needs of person
Evidence supports:
• Promoting “balanced energy-protein supplementation” to mothers
• Complementary feeding for 6 to 24-month children
11
There are ~ 39 lakh pregnant & lactating
mothers in Bihar
• Only 34% covered by
anganwadisResources gap
12
There are ~ 39 lakh pregnant & lactating
mothers in Bihar
• Only 34% covered by
anganwadis
• Only 54% of mothers
reported receiving THR in
previous 30 days
13
There are ~ 39 lakh pregnant & lactating
mothers in Bihar
• Only 34% covered by
anganwadis
• Only 54% of mothers
reported receiving THR in
previous 30 days
• Approximately half of the
stipulated foodstuffs was
not provided
Implementation
gaps and
pilferage
14
There are ~ 39 lakh pregnant & lactating
mothers in Bihar
• Only 34% covered by
anganwadis
• Only 54% of mothers
reported receiving THR in
previous 30 days
• Approximately half of the
stipulated foodstuffs was
not provided
• 1% women reported that
they alone consume THR
(93% said family
members consume)
Design issue
15
There are ~ 77 lakh 6-month to 3-year
olds in Bihar
• Only 42% covered by
anganwadis
• Only 58% of mothers
reported receiving THR in
previous 30 days
• Approximately half of the
stipulated foodstuffs was
not provided
• 1% mothers reported that
THR was consumed by
only the child
Agenda
• IDinsight and study overview
• Nutrition services for mothers and infants
• Nutrition services for young children
• Discussion
17
Hot cooked meals for 3-6 year olds not
likely to have impact on malnutrition
Elder children
• 3 to 6-year olds
• Malnourished and Severely
Acutely Malnourished
Hot-cooked meals
• Daily at anganwadi
• Contain adequate macro &
micronutrients
“…stunting is especially difficult to reverse after 36 months of age….
Supplementary feeding interventions beyond 36 months of age would
probably not reduce stunting.”
- Butta et al, 2008
20
There are ~ 92 lakh 3 to 6-year olds in
Bihar
• Only 35% covered by
anganwadis
• Meals served on 40% of
all stipulated days
21
There are ~ 92 lakh 3 to 6-year olds in
Bihar
• Only 35% covered by
anganwadis
• Meals served on 40% of
all stipulated days
• 92% meals had some
protein, but only 20% had
leafy vegetables
Implementation
gaps and
pilferage
22
There are ~ 92 lakh 3 to 6-year olds in
Bihar
• Only 35% covered by
anganwadis
• Meals served on 40% of
all stipulated days
• 92% meals had some
protein, but only 20% had
leafy vegetables
• 16 out of 40 students
attend when meals are
served
Agenda
• IDinsight and study overview
• Nutrition services for mothers and infants
• Nutrition services for young children
• Discussion
24
Reform is difficult
• ICDS is severely understaffed and under-resourced
• Accountability mechanisms are hard to put in place
• ICDS leadership has limited maneuverability
• Beneficiaries are not aware of their rights and entitlements
• Malnutrition is not considered a grave health issue
Supply-side
Demand-side
27
NHE: Various nutrition-specific
interventions require behavioral change
Lancet-reviewed interventions
Family planning
Delayed age of pregnancy
Birth-spacing
Early breastfeeding
Exclusive breastfeeding for 6 months
Complementary feeding after 6 months
Covered by NHE at
ICDS
29
NHE: There are ~ 39 lakh pregnant &
lactating mothers in Bihar
• 78% of mothers are in
anganwadi’s catchment
area
30
NHE: There are ~ 39 lakh pregnant &
lactating mothers in Bihar
• 78% of mothers are in
anganwadi’s catchment
area
• Only 45% reported an
AWW visiting to discuss
child care
31
NHE: There are ~ 39 lakh pregnant &
lactating mothers in Bihar
• 78% of mothers are in
anganwadi’s catchment
area
• Only 45% reported an
AWW visiting to discuss
child care
• Only 23% reported an
AWW visiting to discuss
family planning
32
NHE: Low prevalence of nutritional health
behaviors in Bihar
Metrics IDinsight
2015
AHS
2012-13
Exclusive breastfeeding 64% 31%
Initiating breastfeeding within first hour of birth 40% 37%
Knowing one should be 20 years or above before giving birth 56%
Knowing birth-spacing norm of 3 years 39%
Using antenatal clinics during pregnancy 51%
Institutional delivery 69%