ronald abraham_ session vi_nutrition services in bihar – a performance assessment of service...

NUTRITION SERVICE DELIVERY IN BIHAR

Ronald Abraham • IFPRI POSHAN Delivering for Nutrition in India

November 10, 2016

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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

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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.

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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




• Discussion

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“ICDS is the foremost symbol of

country’s commitment to its children

and nursing mothers”

- ICDS website

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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

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There are ~ 39 lakh pregnant & lactating

mothers in Bihar

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mothers in Bihar

• Only 34% covered by

anganwadisResources gap

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mothers in Bihar


anganwadis

• Only 54% of mothers

reported receiving THR in

previous 30 days

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mothers in Bihar


anganwadis



previous 30 days

• Approximately half of the

stipulated foodstuffs was

not provided

Implementation

gaps and

pilferage

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mothers in Bihar


anganwadis



previous 30 days



not provided

• 1% women reported that

they alone consume THR

(93% said family

members consume)

Design issue

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There are ~ 77 lakh 6-month to 3-year

olds in Bihar


anganwadis



previous 30 days



not provided

• 1% mothers reported that

THR was consumed by

only the child

Agenda




• Discussion

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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

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There are ~ 92 lakh 3 to 6-year olds in

Bihar

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Bihar


anganwadisResources gap

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Bihar


anganwadis

• Meals served on 40% of

all stipulated days

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Bihar


anganwadis


all stipulated days

• 92% meals had some

protein, but only 20% had

leafy vegetables

Implementation

gaps and

pilferage

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Bihar


anganwadis


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




• Discussion

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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

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Thank you

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Appendix

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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

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mothers in Bihar

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NHE: There are ~ 39 lakh pregnant &

lactating mothers in Bihar

• 78% of mothers are in

anganwadi’s catchment

area

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area

• Only 45% reported an

AWW visiting to discuss

child care

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area



child care



family planning

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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%

ronald abraham_ session vi_nutrition services in bihar – a performance assessment of service...

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