|Year : 2015 | Volume
| Issue : 1 | Page : 60-65
Evaluation of Anganwadi centres performance under Integrated Child Development Services (ICDS) program in Gujarat State, India during year 2012-13
Rajesh K Chudasama, Umed V Patel, Pramod B Verma, Mayur Vala, Matib Rangoonwala, Ankit Sheth, Ankit Viramgami
Department of Community Medicine, Government Medical College, Rajkot, Gujarat, India
|Date of Web Publication||19-Feb-2015|
Dr. Rajesh K Chudasama
Vandana Embroidary, Mato Shree Complex, Sardar Nagar Main Road, Rajkot - 360 001, Gujarat
Source of Support: National Institute of Public Cooperation
and Child Development, Conflict of Interest: None
Background: Even after more than 3 decades of implementation, the success of integrated child development services (ICDS) program in tackling maternal and childhood problems still remain a matter of concern. The present study was conducted to assess issues related to Anganwadi worker (AWW) and Anganwadi center (AWC) including infrastructure facilities. Materials and Methods: A total of 60 AWCs were selected including 46 AWCs from a rural area and 14 AWCs from an urban area during April 2012 to March 2013 from 12 districts of Gujarat. Five AWCs were selected from one district. Information on AWWs background characteristics, along with infrastructure and other services delivered at AWCs were observed and recorded. Results: Majority (66.7%) AWCs building were owned by state and 73.3% AWCs having pucca type of building. Almost two-third (65%) AWWs had >10 years of experience. Induction training was given to only 1 AWW (7.1%) in an urban area. Poor findings were reported for regular health checkups (30%), immunization (10.0%), referral slips availability (18.3%), and referral of sick children (8.3%). Significant number of 6 months to 3 years age group and 3 to 6 years in rural areas received services from Anganwadi. Similarly, significant number of pregnant mothers (P < 0.00), lactating mothers (P < 0.00) and adolescent girls (P < 0.00) in rural areas compared to urban areas received Anganwadi services. Nutrition and health education day was observed in 81.7% AWCs. Conclusion: The performance of AWCs and maternal and child health services delivered by AWCs still needs improvement. Coordinated steps catering to different services provided at the centers are needed to optimize the functioning of the ICDS scheme.
Keywords: Anganwadi centers, Anganwadi workers, integrated child development scheme, performance
|How to cite this article:|
Chudasama RK, Patel UV, Verma PB, Vala M, Rangoonwala M, Sheth A, Viramgami A. Evaluation of Anganwadi centres performance under Integrated Child Development Services (ICDS) program in Gujarat State, India during year 2012-13. J Mahatma Gandhi Inst Med Sci 2015;20:60-5
|How to cite this URL:|
Chudasama RK, Patel UV, Verma PB, Vala M, Rangoonwala M, Sheth A, Viramgami A. Evaluation of Anganwadi centres performance under Integrated Child Development Services (ICDS) program in Gujarat State, India during year 2012-13. J Mahatma Gandhi Inst Med Sci [serial online] 2015 [cited 2019 May 19];20:60-5. Available from: http://www.jmgims.co.in/text.asp?2015/20/1/60/151744
| Introduction|| |
Integrated child development services (ICDS) program continues to be the world's most unique early childhood development program, which is being satisfactorily operated since more than 3 decades of its existence.  Launched on 2 nd October 1975, today, ICDS scheme represents one of the world's largest and the most unique programs for early childhood development. ICDS is the foremost symbol of India's commitment to her children-India's response to the challenge of providing preschool education (PSE) on one hand and breaking the vicious cycle of malnutrition, morbidity, reduced learning capacity and mortality, on the other.  The ICDS scheme is a long term development program for community and all efforts should be continued to strengthen to make it more successful. It serves as an excellent platform for several development initiatives in India. 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 rich experience of ICDS has brought about a welcome transition from welfare orientation to a new challenging perspective of social change. It aims at enhancing survival and development of children from the vulnerable sections of the society. Being the world's largest outreach program targeting infants and children below 6 years of age, expectant and nursing mothers, ICDS has generated interest worldwide among academicians, planners, policy makers, administrators and those responsible for implementation.  The program includes a network of Anganwadi center (AWC) literally courtyard play center, provides integrated services comprising supplementary nutrition, immunization, health checkup, referral services to children below 6 years of age and expectant and nursing mothers. Nonformal PSE is imparted to children of the age group 3-6 years and health nutrition education to women in the age group 15-45 years. High priority is accorded to the needs of the most vulnerable younger children under 3 years of age in the program through capacity building of care givers to provide stimulation and quality early childhood care. 
The program is executed through dedicated cadre of female workers named Anganwadi workers (AWWs), who are chosen from the local community and given 4 months training in health, nutrition and child-care. She is in charge of an AWC and is supervised by a supervisor called Mukhyasevika. AWW is also assisted by helper who works with AWW and helps in executing routine activities at AWC.
Several studies reported association of improved nutritional status and immunization status of <3 years age, with ICDS services ,, and others reported no such association. , Even after more than 3 decades of implementation, the success of ICDS program in tackling maternal and childhood problems still remain a matter of concern.  According to National Family Health Survey-3, countrywide though 81.1% children under age 6 years were covered by AWCs, children who received any service from AWC were only 28.4%.  The need for revitalization of ICDS has already been recommended toward better maternal and child health (MCH) especially in rural areas.  Various studies attempted at evaluating its impact for nutritional status and child morbidity, , but the status of these AWCs and their service constraints are not assessed much. The present study was conducted to assess issues related to AWW and AWC including infrastructure facilities.
| Materials and Methods|| |
The Government of India has decided to set up a regular monitoring and supervision mechanism of ICDS scheme through National Institute of Public Cooperation and Child Development (NIPCCD) with monitoring and evaluation unit in the Ministry of Women and Child Development. The national level monitoring of ICDS scheme is being done by the central monitoring unit set up at NIPCCD. The monitoring and supervision of the ICDS scheme at secondary and primary level involves state level monitoring, district level monitoring, project level monitoring and community level monitoring. 
At the state level, various tasks relating to supervision and monitoring of the scheme is being undertaken with the help of selected academic institutions such as Community Medicine Department of Medical College, home science colleges. From Gujarat state with 25 districts, two institutions namely Community Medicine Department, Government Medical College, Vadodara and Community Medicine Department, P D U Government Medical College, Rajkot were approved by NIPCCD. The present study was conducted by Community Medicine Department, P D U Government Medical College, Rajkot in 12 districts of Gujarat as directed by NIPCCD. The 12 districts were included namely Ahmedabad, Amreli, Bhavnagar, Gandhinagar, Jamnagar, Junagadh, Kutch, Mehsana, Patan, Porbandar, Rajkot, and Surendranagar.
As per the guidelines provided by NIPCCD, from selected 12 districts, three districts are to be visited in one quarter and so one district per month. From selected district, randomly one ICDS block was selected first. In the next stage, from each selected block, five AWCs were selected randomly. So a total of 60 AWCs were selected, including 46 AWCs from a rural area and 14 AWCs from urban area during April 2012 to March 2013. An attempt was made to select not more than two AWCs from each of the supervisory circle. A team of four members from Community Medicine Department, P D U Government Medical College, Rajkot visited the selected AWCs.
Each AWC was visited on a preinformed fixed day. AWWs were interviewed using a predesigned and pretested proforma as provided by NIPCCD. Information on AWWs background characteristics was obtained. Infrastructure availability of visited AWCs were observed and recorded. All available registers at visited AWCs were reviewed and necessary information was recorded. Interview was conducted of AWWs at respective AWCs; problems faced and suggestions given by AWWs given related to their AWC was recorded. The collected data was entered and analyzed by using Epi Info software version 3.5.1 (Center for Disease Control and Prevention, Atlanta, Georgia, USA)  and appropriate statistical test (Chi-square test or Fischer's exact test) was applied.
| Results|| |
A total of 60 AWCs were visited including 46 from rural and 14 from urban areas of 12 districts [Table 1]. Majority (66.7%) building of AWCs were owned by state and 80.4% AWCs in rural areas and 50.0% in urban areas have pucca type of building. About 47% of AWCs had an adequate outdoor space and 53.3% had an adequate indoor space. Only 40% AWCs had separate storage facility. Separate toilet facility at AWCs was available in 69.6% rural and 35.7% urban areas. Majority (58.3%) AWCs were receiving water supply from tap. Forty-five AWCs (75%) started before 10 years.
|Table 1: Baseline characteristics of visited AWCs in different districts of Gujarat during year 2012-2013|
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Almost two-third (65%) AWWs had >10 years of experience [Table 2]. More than half of the AWWs received education up to 12 th standard or matriculation. Job training was received by all AWWs of urban areas compared to rural areas (82.6%). Induction training was given to only 1 AWW (7.1%) in urban area. In rural AWCs, 15.2% AWWs were residing in other village/locality. Poor findings were reported for regular health checkups (30%), immunization (10.0%), referral slips availability (18.3%), and referral of sick children (8.3%). Several problems were reported by AWWs related to AWCs as mentioned in [Table 2].
|Table 2: Characteristics of AWWs in different districts of Gujarat during year 2012-2013|
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Significant number of 6 months to 3 years age group and 3 to 6 years age group in rural areas compared to urban areas received services from Anganwadi [Table 3]. Similarly, significant number of pregnant mothers (P < 0.00), lactating mothers (P < 0.00) and adolescent girls (P < 0.00) in rural areas than in urban areas received Anganwadi services. Nutrition and health education (NHED) day was observed in 81.7% AWCs.
|Table 3: Maternal and child health services delivered by visited AWCs in Gujarat during year 2012-2013|
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Various suggestions were given by AWWs as mentioned in [Table 4]. like increase in honorarium (36.8%), regular supply of food items/material (20%), good quality of supplementary nutrition material (13.3%), availability of PSE/NHED kits (40%), timely replacement of medicine kits (23.3%), not to involve in other health programs/tasks (13.3%). Suggestions were recorded in 30 AWCs only because of change in NIPCCD proforma design.
|Table 4: Suggestion given by AWWs of visited AWCs in Gujarat during year 2012-2013|
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| Discussion|| |
This program is formulated to enhance the health, nutrition and learning opportunities of infants, young children and their mothers, especially targeted for the poor and deprived. The goals of ICDS program are reduction of infant mortality rate to <60/1000, reduction in child mortality rate to <10/1000, and reduction in maternal mortality rate by at least 50%.  The present study explains reasons for mismatch between planned design and actual implementation of ICDS program and some operational challenges preventing ICDS reaching its potential.
The present study reports 80.4% AWCs in rural areas and 50.0% in urban areas have pucca type of building, which was 63.6% and 81.8% in Tamil Nadu and Puducherry,  indicating more developed infrastructure in rural areas compared to urban in the present study. Findings for availability of separate toilet facility in rural (69.6%) and urban (35.7%) areas in the present study are opposite to findings of Tamil Nadu study  again indicating better infrastructure development in rural areas.
AWWs were trained for providing reproductive and child health services to the community, especially in rural areas. Majority AWWs were educated and working in their respective AWCs for long duration and had also received job training, but only 7.1% AWWs in urban areas received induction training. It has been documented that proper training improves AWWs performances,  and inadequate training of AWWs may be the reason for poor performance AWCs.  Present study reported 70% AWWs in rural areas and 50% in urban areas had >10 years of work experience as an AWW, which helps AWW to build a good rapport with their community and helps them to deliver better ICDS services.
Availability of referral slips with AWWs was poor (18.3%) and referral of sick children to higher center was very poor (8.3% including 8.7% in rural and 7.1% in urban areas). It may suggest that the AWWs still not have enough access to availability of referral slips and also referral of sick children. Emphasis should be given on good quality supervision and also by sensitizing them about the importance of timely referral of sick children to the higher center. The National Council of Applied Economic Research (NCAER) in AWCs evaluation study during 1996-2001 reported that though 84% of the functionaries had received training; it was largely pre-service in nature and in-service training remained largely neglected.  Regular refresher training courses are extremely essential as they keep the AWWs abreast with the recent trends and changes in their field. The UDISHA training program addressed the issue to a great deal  and the ICDS IV project too tries to effectively meet the training needs of the ICDS functionaries.  Evolving a package of coordinated and joint training program for various health functionaries with provision of practical field oriented training is needed. 
Present study reported that routine health checkup of enrolled beneficiaries and immunization services were inadequate in the surveyed AWCs. In a review of AWCs, by NCAER in 2004 it was observed that only 64% of the centers provided health checkup for children and 53% checkup for women.  AWWs reported various problems more in urban areas related to providing services like inadequate indoor and outdoor space especially; non availability of separate kitchen, storage and toilet facilities more in urban areas; work load other than ICDS mainly. Similar findings were also reported in other states of India. ,
It has been reported that among registered children in the age group of 6 months to 3 years, a significant number of children (84.4%) in rural AWCs were availing the services. Similarly, significant number of registered children in the age group 3-6 years (79.5%) were also availing the services from AWCs of rural areas. Significant (P < 0.00) numbers of registered pregnant (97.0%) and lactating mothers (99.0%) were availing services from AWCs of rural areas. Registered number of adolescent girls availing services from AWCs was significantly high (P < 0.00) in rural areas (90.5%) compared to urban areas (79.1%). The involvement of pregnant and lactating women and adolescent girls are central to tackling the problem of underweight and malnutrition in the country. Hence, it is essential to optimize their involvement in the scheme, formation of social networking groups and providing a comprehensive package of health services to the women and adolescent girls. 
Present study reported that 87.0% AWCs in rural areas and 64.3% in urban areas were celebrating NHED day under National Rural Health Mission, which is considered as an umbrella towards MCH care in contrast to Tamil Nadu and Puducherry. 
AWWs have suggested increase in honorarium, regular supply of food items/material, supply of good quality supplementary nutrition food, PSE/NHED kits should be made available, timely supply and replacement of medicine kits, and not to involve in other health programs/tasks. There was a shortage of PSE kits and NHED kits at the AWCs, which adversely impacted the PSE and NHED services. PSE activities have not been given much importance under the scheme as only 19% of AWW training hours have been set aside for PSE activities.  Studies have reported poor skills development of Anganwadi children as against the private nursery school children, which could be attributed to poor stimulating environment including lack of play materials; hence there is a need to improve the preschool environment of the Anganwadis. ,
| Conclusion|| |
The performance of AWCs and MCH services delivered by AWCs still needs improvement. The findings help in providing some insight into the existing situation. A holistic approach is needed to optimize the functioning of the scheme, identifying various issues concerning the scheme as a whole will help in reworking the policies related to women and child development.
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[Table 1], [Table 2], [Table 3], [Table 4]