1 introduction - shodhgangashodhganga.inflibnet.ac.in/bitstream/10603/18180/9/09_chapter 1.pdf ·...

Evaluation of Integrated Program on Nutrition and Health: Estimates and Evidencefi·om !CDS

1 INTRODUCTION

Evaluation of public health programs is of special interest for policy makers due to

the large allocations of public funds for these programs. The early childhood

development programs that governments across the world administer are of special

interest due to the immediate and long term effects they have on the development of a

child. Integrated Child Development Services (!CDS) is one such universal program

in India. This study aims to estimate the impact and effects of this program on child

health and also analyze other aspects of this program.

1.1 CONTEXT

Throughout the world, governments design programs and direct huge resources to

improve health and nutrition of people. Health and nutrition play an important dual

role of being ends in themselves as critical components of basic needs as well as

being channels through which productivity and distributional goals of developing

societies may be pursued effectively. From a broad perspective, the basic economic

goals of developing countries are related to productivity growth in order to expand

consumption of goods and services and the distribution of that consumption among

different members of the society. Better nutrition may increase labour productivity

directly by making workers stronger and more productive and indirectly by increasing

productivity in the long run.

The nutrition of preschool children is of considerable interest not only because of

concern over their immediate welfare, but also because nutrition in this formative

stage of life is widely perceived to have substantial persistent impact on their physical

and mental development and on their health status as adults (Behrman and Hoddinott

2005). Children's physical and mental development shapes their later lives by

affecting their schooling success and post schooling productivity. Improving the

nutritional status of currently malnourished preschoolers may, therefore, have

important payoffs over the long tenn.

Interventions to promote early childhood environments and optimal development

are not new in the developed countries. Intensive pilot interventions are aimed at

Evaluation of Integrated Program on Nutrition and Health: Estimates and Evidence from !CDS

improving psychological conditions linked to child development in the pre-school

years. Development gains are also expected to carry over into later stages of middle

childhood, adolescence and beyond. Many studies done in the developed and

developing countries have studied the impact of these intervention programs

(Behrman et. al. 2006). Accumulated evidence reveals associations between

cognitive and psycho-social skills, nutrition and health status measured at young

ages on one hand, and later educational attainment, earnings, and employment

outcomes, on the other. Evaluations of many large scale intervention programs (such

as Head Start and PERRY Preschool Program) indicate that the programs had

positive effects on test scores, immunization rates, and earnings in young adulthood,

and lowered grade repetition (Currie and Thomas 1995; Behrman and Rosenzweig

2004; Murnane, Willett and Levy 1995). In the developing countries context,

evaluation studies have explored the relationship between preschool nutritional

status and the education of school-age children and adolescents. Malnourished

children score lower on tests of cognitive functioning, have poorer psychomotor

development and fine motor skills, have lower activity levels, interact with others

less frequently, fail to acquire skills at normal rates, have lower enrolment rates and

attain fewer grades of schooling (Alderman et. al. 2001; Alderman, Hoddinott and

Kinsey 2006; Behrman 1996; Martorell 1999; Behrman, Cheng and Todd 2004;

Glewwe, Jacoby and King 2001; Maluccio et. al. 2005). During the course of their

development young children interact with their environment and learn culturally

determined behaviours from constituents of their micro-environment which include

family's belief systems, attitudes, traditions and food likes and dislikes. It is well

known that food behaviour, nutritional status, growth and development are

influenced by each other. These factors are synergistically modulated by the socio

economic factors that include the literacy status, income and occupation of

parents/caregivers, demographic features of the home, access to quality food and

healthcare, exposure to newer information, and the resultant child care practices.

Thus, attempts directed towards improvement of the consumption of nutritious

foods by young children, requires multi-thronged interventions based on strong

formative research data that can be developed into specific behaviour change

strategies (Vazir 2003).

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Evaluation of Integrated Program on Nutrition and Health: Estimates and Evidencefi'om !CDS

In recent years, policymakers have increasingly promoted early childhood nutrition

programs as a means to raise living standards in developing countries (Young 1995).

Proponents of such programs argue that improved diet, particularly in the crucial first

years of life, enhances intellectual development and ultimately, academic success

(Brown and Pollitt 1996). Their view is that, in addition to having direct health

benefits, early childhood nutrition programs could also be an instrument of education

policy. These findings have prompted governments and other agencies to invest

heavily in children before formal schooling begins. It has led to many targeted

childhood intervention programs. There has been evolution of comprehensive, holistic

and multilevel interventions, which employ programs, services and benefits that target

outcomes across child, parent and community domains. Several reviews and reports

provide a central source of information about the effectiveness of early childhood

interventions (Karoly et al 1998).

Interventions in early health and nutrition programs call for huge resource allocation,

at times, diverting these away from other development and growth activities. This is

especially true for the developing countries. There is a general perception that scarce

resources of a developing economy are best devoted to improving economic growth.

The argument is that improvements in child nutrition and health are likely to follow

robust income growth. Empirical studies suggest that while it is true, the trickle down

happens only at a modest rate (Haddad et. al. 2002). This calls for more direct policies

to address health concerns of children. In this context, recent studies by economists

emphasize that devoting resources to child nutrition and health, is among the most

economically justified uses of public resources (Alderman 2004). Committing

resources on children's nutrition, health and well-being brings long term economic

gains (FOCUS Report 2006). The pathways through which it works can be

categorised into three main channels: First, there are substantial productivity gains

that work directly through the physical capacity to perform tasks and indirectly

through cognitive development and schooling attainments. Second, there could be

significant saving of resources through cost reduction. These derive from lower infant

mortality and lower costs of chronic diseases and healthcare. Third, there may be

intergeneration benefits, through subsequent generations being more productive

through improved health.

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1.2 MALNUTRITION

The adverse impact of malnutrition on economic growth through the vicious circle of

poverty is well documented. Poor nutrition contributes to 1 out of 2 deaths (53%)

associated with infectious diseases among children aged under five in developing

countries.

Malnutrition is a leading contributor to infant, child and maternal mortality and

morbidity. It has been estimated to play a role in about half of all child deaths

(Horton, 1999; Pelletier et al 1995; Pelletier and Frongillo 2003) and more than half

of child deaths from major diseases such as malaria (57%), diarrhea (61 %) and

pneumonia (52%). Paediatric malnutrition is a risk factor for 16% of the global

burden of disease and 22.4% of India's burden of disease (Murray and Lopez 1997).

In tum, infections contribute to malnutrition through a variety of mechanisms,

including loss of appetite and reduced capacity to absorb nutrients (Caldor and

Jackson 2001).

Malnutrition can take many forms. Nutritional status is measured using three

anthropometric indices: height-for-age (HAZ),' weight-for-height (WHZ), and weight

for-age (W AZ). Longer-run or protein-energy malnutrition (PEM), manifested in

stunting, i.e., being short for one's age and sex relative to standards established for

healthy populations. Shorter-run PEM often is measured by wasting (low weight-for

height), underweight (low weight for one's age and sex) or a low body-mass-index).

Protein-energy malnutrition weakens immune response and aggravates the effects of

infection (Pelletier and Frongillo 2003). Malnutrition in early infancy is associated

with increased vulnerability to chronic disease in adulthood (Agarwal et al 1998,

2002; Barker et al. 2001, Lucas et al. 1999, Popkin et al. 2001 ). PEM in early

childhood is also associated with poor cognitive and motor development. The

magnitude of effect is very much dependent on the severity and duration of

malnutrition as well as its timing. There is evidence that moderate PEM of long tenn

duration has worse consequences for cognitive development than transient severe

undernutrition. Micronutrient deficiencies like iron and Vitamin A deficiencies lead to

risk factors for diseases. Sub-clinical Vitamin A deficiency (V AD) is a well known

cause of morbidity and mortality, especially among young children and pregnant

women. VAD has been shown to increase the mortality of children mainly from

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respiratory and gastrointestinal infections, and often occurring concurrently among

children with PEM, is estimated to be responsible for about one million child deaths

annually. Iodine and iron deficiencies have also been linked to the retardation of

cognitive processes in infants and young children (World Bank 2005).

Table 1.1: Underweight, Stunting and Wasting, by Global Region, 2000-2006

% of under-five children suffering from

Underweight* Wasting A

Stunting#

Bangladesh 48 13 43

Bhutan 19 3 40

India 43 20 48

Pakistan 38 13 37

Sri Lanka 29 14 14

Developing countries 26 11 32

Latin America and Caribbean 7 2 16

South Asia 42 18 46

Sub-Saharan Africa 28 9 38

World 25 11 31

Note:* below minus two standard deviations from median weight-for-age of rt:ference population "below minus two standard deviations from median weight-for-height of reference population #below minus two standard deviations from median height:for-age of reference population Source: UNICEF: State of World's Children 2008

Table 1.1 above reports figures for underweight, stunting and wasting across some

regions and countries. It shows that extent of undernutrition present across countries

and regions. Nearly one-third of children under-five in the world remain underweight

or stunted while almost half of them are underweight in South Asia. Despite the high

prevalence of malnutrition, majority of governments across nations have not been able

to tackle malnutrition over the past decades, even though well-tested approaches for

doing so exist (Mason et.al. 2006).

The main causes of malnutrition include insufficient intakes of calories, proteins and

micronutrients or nutrient losses from infection. Underlying these causes are

inadequacies in food security and insufficient income, knowledge, poor water and

sanitation, unhealthy hygiene behaviour, inadequate supplies of vaccines, dehydration

and inadequate medical care (Jolly 1996). The cycle of disease and dietary

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inadequacies interacting in a mutually reinforcing manner has been termed the

"malnutrition-infection complex" (Tomkins and Watson 1989). Nutrition challenges

continue throughout the life cycle with poor nutrition starting before birth (Sanghvi

and Murray 1997) and extending in girls and women into adolescence and adulthood

leading to generations of poorly nourished children. Undernutrition's most damaging

effect occurs during pregnancy and in the first two years of life, and the effects of this

early damage on health, brain development, intelligence and productivity are largely

irreversible. Therefore interventions must focus on this "window of opportunity"

(Shrimpton and others 2001).

The conceptual framework for malnutrition as adapted from UNICEF (1990) and

Engle, Menon and Haddad (1999) is presented in figure 1.1 below. The

framework recognizes three main determinants: the most immediate, the

underlying and the basic causes. The immediate determinants of child nutritional

status operate at the level of individuals. They include dietary intake (energy,

protein, fat and micronutrients) and health status. These immediate determinants

are in turn, influenced by the underlying determinants functional at the household

level. These are food security, adequate care for mothers and children and a

proper health environment, including access to health services. Food security is

achieved when a person has access to enough food to lead an active and health

life. Yet, no child can grow without nurturing and care. This concept of care for

children is mainly provided by mothers. Care is also the provision by households

and communities of time, attention and support to meet the physical, mental,

social needs of growing child and other household members (ACC/SCN 1992).

The third underlying determinant of child nutritional status, health environment

and services, rests on the availability of basic services like safe water, sanitation,

health care and environmental safety including shelter. The basic determinants

also include the potential resources available to a country or community, which

are limited by the natural environment, access to technology and the quality of

human resources.

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Figure 1.1: Conceptual Framework: The Causes of Malnutrition

Source: Adapted from UNICEF 1990, Smith and Haddad 2000, World Bank 2006

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Evaluation of Integrated Program on Nutrition and Health: Estimates and Evidence fi'om !CDS

The cognitive and physical consequences of under-nutrition undermine educational

attainment and labour productivity, with adverse implications for income and

economic growth. Malnutrition at any stage of childhood affects schooling and, thus,

the lifetime earnings potential of the child .Some of the pathways through which

malnutrition can affect educational outcomes include a reduced capacity to learn and

fewer total years of schooling (since caregivers may invest less in malnourished

children or schools may use child size as an indicator of school readiness) (Alderman

et. al. 2005). For example, in rural Pakistan, malnutrition has been found to decrease

the probability of ever attending school, particularly for girls (Alderman et. al. 2001).

In the Philippines, children with higher nutritional status during the preschool years

start primary school earlier, repeat fewer grades ( Glewwe et. al. 2001) and have

higher school completion rates than other children (Daniels and Adair 2004). In

Zimbabwe, stunting, via its association with a 7 month delay in school completion

and 0.7 losses in grade attainment, has been shown to reduce lifetime income by 7-

12%(Alderman and Behrman 2003).

Malnutrition leads to loss of productivity. Studies have estimated huge economic

costs on account of macro and micro-nutrient deficiencies among men and women. In

general, in low income agricultural Asian countries, the physical impainnent

associated with malnutrition is estimated tq cost more than 2-3% of GDP per annum

even without considering the long term productivity losses associated with

developmental and cognitive impairment. Iron deficiency in adults has been estimated

to decrease productivity by 5-17%, depending on the nature of the work perfonned

(Horton 1999). Other data from ten developing countries show that the median loss in

reduced work capacity associated with anaemia during adulthood is equivalent to

0.6% of GDP, while an additional 3.4% of GDP is lost due to the effects on cognitive

development attributable to anaemia during childhood (Horton and Ross 2003 ). The

impact of iodine deficiency disorders on cognitive development alone has been

associated with productivity losses approximately I 0% of GDP (Horton 1999). Of the

three channels of association discussed above, productivity gains seem to clearly

dominate the association between childhood nutrition and productivity is well

established. A 1 percent lower adult height, as a consequence of poor nutrition in

childhood is associated with a 1.4 percent loss in productivity (Hunt 2005) and 2-2.4

percent reduced earnings a an adult after controlling for competing explanations

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Evaluation of Integrated Program on Nutrition and Health: Estimates and Evidence.fi"om !CDS

(Thomas and Strauss 1997). Productivity impact also affects through cognitive

development and schooling. Poorly nourished children tend to start school later, make

slower progress through school and have lower schooling attainments. Glewwe,

Jocoby and King (2001) found that in the Philippines children with better nutritional

status started school earlier and repeated fewer grades. They also had higher school

completion rates (Daniels and Adair 2004). In Zambia, malnutrition tended to reduce

lifetime earnings by 12 percent because of effect on schooling.

Across the world, public health leaders have taken initiatives to devise program that

would address the roots of the problems of malnutrition (Nemer et. al. 2001 ). These

programs have utilized a host of approaches that include: micronutrient (Iodine, iron

and Vitamin A) supplementation; food supplementation; public health measures

(deworming, better water and sanitation, infection control etc.); multiple programs

combining growth monitoring and infant feeding and food fortification.

1.3 MALNUTRITION IN INDIA

Malnutrition contributes to about half of all the deaths among children in the

developing countries (Pellitier et al. 1994). Many researchers have documented the

presence in India of widespread child malnutrition; as measured by anthropometric

indicators such weight or height. Whether undernutrition is measured as the

prevalence of underweight, stunting or wasting, it is clear that the nutritional situation

in India is amongst the worst in the world (Table 1.1 ). India's prevalence of

underweight (43%) compares to Bangladesh (48% each), but is much higher than all

other countries within South Asia and far higher than the averages for other regions in

the world. The same is for wasting and stunting for children.

National level data of India reveals that the proportion of children who are severely

undernourished (below 3 standard deviations from median) is very high: 24 percent

are severely stunted and 16 percent are severely underweight. About 20 percent of

children under five years of age suffer from wasting, another major problem that India

faces (liPS, 2007). However, despite the gender bias that is prevalent, it does not get

reflected in malnutrition levels. Overall, girls and boys are about equally likely to be

undernourished. Also, malnutrition is generally lower for first births than for

subsequent births, and increases consistently with increasing birth order for all

measures of nutritional status. Malnutrition is substantially higher in rural areas than

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Evaluation of Integrated Program on Nutrition and Health: Estimates and Evidence.fi'om !CDS

in urban areas. Even in urban areas, however, 40 percent of children are stunted and

33 percent are underweight. Inadequate nutrition is a problem throughout India, but

malnutrition is most pronounced in Madhya Pradesh, Bihar, and Jharkhand.

Nutritional problems are also substantially higher than average in Meghalaya and (for

stunting) in Uttar Pradesh. Nutritional problems are least evident in Mizoram, Sikkim,

Manipur, and Kerala, and relatively low levels of malnutrition are also notable in Goa

and Punjab. Even in these states, however, levels of malnutrition are unacceptably

high.

Table 1.2 shows the changes in nutritional status (by residence) of children under age

three years between 1998-99 (NFHS-2) and 2005-06 (NFHS-3). The figures for

malnutrition show an overall dismal picture. The percentage of children stunted

children has increased as also the percentage for underweight children. These have

increased from 22 to 27.7 (HAZ) and 15.8 to17.6 (WAZ) between NFHS-2 and

NFHS-3. Only the weight-for-height measure shows some improvement. Also the gap

between rural and urban children seems to be widening for HAZ and WHZ. This is an

alarming situation and needs to be tackled with more concrete measures.

Table 1.2: Trends in Nutritional Status of Children

Measure of nutrition NFHS2 NFHS3

Urban Rural Total Urban Rural Total

Height-for-age (% of children below three years)

Percentage below -3 16.4 23.8 22 19.7 30.2 27.7

Percentage below -2 1 37.4 47.2 44.9 41.1 54 51

Weight-for-height(% of children below three years)

Percentage below -3 6.8 8.3 7.9 5.3 7.1 6.7

Percentage below -2 1 19 24.1 22.9 16.3 20.7 19.7

Weight-for-age(% of children below three years)

Percentage below -3 10.6 17.4 15.8 11.3 19.6 17.6

Percentage below -2 1 30.1 43.7 40.4 34.1 45.3 42.7

Number of children 6,436 20,105 26,541 5,741 18,475 24,215 Note: Each of the indices is expressed in standard deviation units (SD) from the median ()[the 2006 WHO International Reference Population. Table is based on children with valid dates ()[birth (month and year) and valid measurements of both height and weight. 1 Includes children who are below -3 standard deviations (SD) .fi'om the International Reference Population median Source: IIPS, 2007

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Evaluation of Integrated Program on Nutrition and Health: Estimates and Evidence ji-om !CDS

As mentioned above, malnutrition leads to huge productivity losses. Productivity

losses in India due to stunting, iodine and iron deficiency in India have been estimated

to be 2.95 percent of GNP (Horton 1999). In their study, Ramakrishnan et. al (1999)

provide evidence of intergenerational transmission. They show that malnourished

girls, if they grow into women with small stature, are more likely to give birth to

children with low birth weight and they also tend to have more complications during

child birth and face higher risk of child and maternal mortality. A recent study

estimates that India losses 4 percent of GDP. Alderman (2005) estimates losses due to

micronutrient deficiencies of around US$ 2.5 billion annually (Table 1.3).

Table 1.3: Productivity Losses due to Malnutrition in India

DALY s lost due Estimated total Estimated loss of to malnutrition annual losses due adult productivity,

to malnutrition as% ofGDP* ($ billions)

PEM (stunting) 2,939,000 8.1 1.4

Vitamin A deficiency 404,000 0.4

Iodine deficiency disorder 241,000 1.5 0.3

Iron deficiency 3,672,000 6.3 1.25

Note:* GDP per capita is adjusted for purchasing power parity and in constant 199 5 internatwnal dollars Source: World Bank 2006

Given the high prevalence of malnutrition and the complex pathways through which it

can be tackled, a multifaceted approach is required to tackle the nutrition and health

of children. An integrated program addressing multiple of these issues is called for.

Large scale programs that include both nutrition and psychological components have

been implemented throughout the world and continue to increase. The following

conditions tend to maximize the impact of such programs: interventions targeted to

early life, prenatally or infancy or early childhood; targeting children in the poorest

households, with parents lacking relevant knowledge; employing several types of

intervention and more than one delivery channel; long duration and higher intensity;

and high parental interest and involvement. Experience from other countries shows

that different types of malnutrition call for varying programs and policies. For

undernutrition and malnutrition problems, which are also the major ones that India

faces, several large-scale programs have worked (in Bangladesh, Thailand,

Madagascar, Chile, Cuba and Mexico). The challenge is to apply their lessons at large

scale in more countries. Set against this background, Integrated Child Development

11


Services (ICDS) is India's primary policy response to child malnutrition, offering a

range of services and intended to target the needs of the poorest and most

malnourished, including the age groups that present a window of opportunity for

nutrition investments (DWCD, GIO).

1.4 INTEGRATED CHILD DEVELOPMENT SERVICES

The Integrated Child Development Services (ICDS) is one of the world's most unique

early childhood development programs, which is being operated for more than three

decades. The program provides package of services, comprising supplementary

nutrition, immunization, health check-up, referral services to children below six years

of age and expectant and nursing mothers. Non-formal pre-school education is

imparted to children of the age group 3-6 years and health and 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 caregivers to provide stimulation and quality care in early

childhood.

The concept of providing a package of services is based primarily on the

consideration that the overall impact would be much larger if the different services are

delivered simultaneously, as the efficiency of a particular service depends upon the

support it receives from related services.

Addressing the interrelated needs of young children, adolescent girls and women,

especially of the disadvantaged sections of the society, ICDS solicits convergence

with other services/ programs of rural development, micro-credit, and technology and

so on. There are presently 6068 ICDS projects operational in the country with

68552239 number of beneficiary children in age group 0-6 years, 14538143 number

of pregnant and lactating women beneficiaries (as on 29 February, 2008, DWCD,

GOI).

In the past, a large number of research studies have been conducted to evaluate and

assess the impact of the program on the beneficiaries. At the national level, there have

been only a few of evaluations of ICDS done by National Institute of Public

Cooperation & Child Development (NIPCCD 1992, 2006) and National Council of

Applied Economic Research (NCAER 2001). Some studies have looked at the

12

Evaluation of Integrated Program on Nutrition and Health: Estimates and Evidence_fi-om !CDS

stabilization of the program. Besides these, numerous studies at micro-level have been

done to analyze the impact on nutritional status and health and also to evaluate other

components of ICDS.

However, most of the studies have provided only piecemeal infonnation and have not

taken systematic stock of the delivery of inputs vis-a-vis output, nor have these

studies investigated the impact on target groups in a comprehensive and coordinated

fashion. The studies have not taken evaluation on a pre- and post intervention data.

Also, no longitudinal study has been conducted to estimate the long term impact of

the program. There has been little consensus on the success of the ICDS program in

tackling problems of health and nutrition in early childhood, despite it being one of

the most studied health and nutrition interventions. Among the studies there is a

paucity of impact evaluations that draw on large samples, include data on treatment

and comparison groups and move beyond bi-variate analysis to employ more vigorous

econometric techniques. Still, one can draw useful insights from these studies into the

functioning of the program and the lacunae it suffers from. In this thesis we attempt to

address some of the issues overlooked by previous studies.

1.5 PRESENT STUDY: OBJECTIVES

Given the importance of the ICDS program's objectives and the size of the budget, it

is important to assess whether it is effective in its main objective of enhancing child

nutritional status. This dissertation aims to evaluate child and maternal health program

in India. Integrated Child Development Services (ICDS) program is one the world's

largest early child development program. The objectives of the study are as follows:

• We estimate program effects using child health models within the framework

of health production and demand for health inputs. Using the latest National

Family Health Survey-3 (NFHS-3) data, we study the effect of the program on

the anthropometric measures of child health status. While performing this

analysis, we also highlight the role played by related socio-economic

correlates of nutritional status, especially those related to the mother of the

child. There have been only few studies on large sample size and all-India

level that have attempted this. We use anthropometric measures as indicators

of child health and estimate effect of being in the program area.

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• Quality of ICDS has been a much talked about issue. Improvement in quality

has been the emphasis on numerous studies that evaluate the functioning and

effectiveness of ICDS. However, to our knowledge, there has been no attempt

to define and access quality in an econometric modelling framework. This

study adds a new dimension by emphasising the importance of quality of

AWC. We create an index of quality and use this index as a tool to understand

the factors affecting utilization of ICDS services. This aspect has not been

addressed adequately in the program evaluation studies of ICDS. We use a

unique data set for this analysis.

• The low rates of registration and utilization of the ICDS services is a major

concern. An in-depth analysis of data is carried on within the child health

demand framework to study factors that determine these.

• This study aims to contribute to the literature of program evaluation of social

programs that prescribe random assignment of programs and employ

comparison of mean effects to others that use analytical tools to correct for non

random assignment of programs and control for omitted variables. We use more

rigorous econometric tools to assess program effects. We use logistic and

multivariate regression models for estimation. We try to improve upon results

by the use of more econometrically robust method of propensity score matching.

• We analyse data from latest sources to understand the coverage, spread and

utilization of ICDS.

1.6 FRAMEWORK OF THESIS

In chapter 2 we discuss and review literature of the vanous strands that this

dissertation touches upon. The literature survey is divided under three broad

categories that this study incorporates: determinants of health status studies, program

evaluation studies and ICDS evaluation studies. We also look at studies undertaken to

assess program impact in other countries. The chapter also discusses the econometric

issues that need to be addressed in program evaluation. Chapter 3 presents the details

of the program, its objectives, design, functioning and -components. We also present

detailed analysis of the NFHS-3 data. The latest round of NFHS has carried a special

module of questions regarding the benefits and utilization of ICDS services by

households. This is the first time any such nation-wide survey regarding ICDS

14


services is done. In chapter 4, we present a detailed survey of tools of program

evaluation. Chapter 5 discusses the theoretical framework we use for analysis. We

also present the empirical estimations to be carried out in this chapter. This chapter

also has details of the data and the variables used in our study. The impact of the

program on child health and nutritional status are presented in chapter 6. It lays out

the objectives and hypothesis to be tested and then presents data descriptive and

estimation results. For analysis in this chapter, we use data from the latest round of

NFHS (NFHS-3 data). This is a national level data. Chapter 7 presents the quality

aspect of ICDS. We present quality in the context of explaining the low rates of

registration and attendance of the program. We use a different dataset in the analysis

of this chapter. This data was collected as a part of the routine evaluations of World

Bank financing of ICDS projects in the state of Rajasthan for 2004-2005. The unique

feature of this data is the questionnaire administered to the anganwadi worker. Also,

questions are asked to mothers regarding the services at anganwadi centre. This

enables us to assess the quality aspect of the program. The review of literature of

quality is carried in this chapter. In chapter 8, we summarize the main findings of our

study and discuss these. The chapter ends with policy implications that flow from our

analysis and areas of future research.

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