Health service in India
Despite a four-fold increase in the number of women and children receiving supplementary nutrition under the Integrated Child Development Services (ICDS) programme in the 10 years to 2016, a large proportion of the poorest have not benefited, a new study has found. Women who were uneducated or from the poorest households had lower access to the flagship programme the study found. While the poorest households had the highest utilisation of ICDS services in 2006, their share became the second lowest in 2016, the study says, suggesting that the reasons could include poor delivery, difficulty of accessing remote regions, and social divisions such as caste.
Started in 1975, ICDS, the world’s largest scheme of this kind, provides nutrition and health services to all pregnant and lactating mothers and children under six years of age. In addition to take-home food supplements and hot, cooked meals, the programme provides health and nutrition education; health check-ups; immunisation; and pre-school care services at either government-run anganwadi (childcare) centres or at home. The study, “India’s Integrated Child Development Services programme; equity and extent of coverage in 2006 and 2016”, co-authored by researchers the International Food Policy Research Institute (IFPRI).

Women with no schooling: less likely to receive ICDS

Using data from two rounds of the National Family Health Survey; conducted in 2005-06 and 2015-16, the researchers examined equity in ICDS’ expansion; and the factors that determine the utilisation of its services. Low to middle socio-economic brackets were more likely to receive food supplements; nutrition counselling, health check-up and child-specific services than both the poorest and the richest groups; the researchers found. Women with no schooling were also less likely to receive ICDS services; than those with primary and secondary education.

“Even though overall utilization has improved and reached many marginalised groups; such as historically disadvantaged castes and tribes; the poor are still left behind; with lower utilisation and lower expansion throughout the continuum of care;” said Kalyani Raghunathan. Researchers found these gaps especially pronounced in the largest states of Uttar Pradesh and Bihar; which also carry the highest burden of undernutrition. While both states have shown improvements in 2016; they still fall behind national averages; suggesting that overall poor performance in high-poverty states; could lead to major exclusions, the authors said.

Even in better-performing states, exclusion of the poor could be due to the challenges of reaching remote areas despite attempts to close district-wise and caste-based equity gaps, Raghunathan said. However, barring the richest quintile–the top 20% wealth group–the poorest quintile had the lowest share in coverage of the four services in 2016. In 2006, poorest group had reported the highest share. “Those belonging in the highest quintile may perceive ICDS as a scheme for the poor which is why they may opt out of the service,” said Purnima Menon, senior research fellow at IFPRI and co-author of the study, “It also could point out to the fact that the quality of the services would not be what they expect.”

Uttar Pradesh and Bihar have high fertility

Exclusion of the poorest could be due to difficulties with complying with programmatic conditions, the authors noted. But the most plausible explanation is poor service delivery in Uttar Pradesh and Bihar. The two states are home to almost half of the poorest quintile (20%) of the Indian population; and also have the lowest coverage of services, which adds up to the overall exclusion of the poorest quintile; said Menon. “Uttar Pradesh and Bihar have high fertility and high population so it’s likely they need more ICDS centres, and more financing to ensure full-scale delivery of all services,” she said.

When the researchers analysed the differences between different caste groups in accessing services, they found that in 2006, scheduled castes and scheduled tribes were twice as likely to receive supplementary nutrition as other groups, but in 2016 the differences were smaller. While only 34.7% of uneducated mothers received food supplements, 43.7% of those with primary education and and 43.8% of those with secondary education did. This trend was visible across services, although those with the highest category of education also had lower access.“The women with no education may intersect with the poorest quintile which is predominantly in UP and Bihar, which could explain their poor utilisation but we are yet to analyse this,” Menon said, adding that there is much to be explored in further analyses.