eH m ea f o lth Community Medicine & Health Education · Community Medicine & Health Education. J Community Med Health Educ Volume 3 • Issue 1 • 1000195 ISSN: 2161-0711 JCMHE,

Volume 3 • Issue 1 • 1000195J Community Med Health EducISSN: 2161-0711 JCMHE, an open access journal

Sharma et al., J Community Med Health Educ 2013, 3:1 DOI: 10.4172/2161-0711.1000195

Research Article Open Access

Assessment of Coverage of Services among Beneficiaries Residing in Area Covered by Selected Anganwadi in Urban Project I and II of Raipur CityMini Sharma1*, Soni GP1 and Nitin Sharma2

1Department of Community Medicine, Pt. JNM Medical College, Raipur Chhattisgarh, India 2Department of Paediatric surgery, All India Institutes of Medical Sciences, Ansari nagar, New Delhi, India

AbstractIntroduction: It has been a focus of interest to expand ICDS scheme and provide adequate quality of services to

the beneficiaries. Current study is an attempt to find out the coverage deficit in services provided by Anganwadi centres to its eligible beneficiaries residing under urban project of Raipur district (I and II).

Materials and methods: Cross sectional observational study conducted at Raipur district in selected 30 Anganwadi centres (by Systemic random sampling). House to house survey was done to identify the eligible beneficiaries. Selected Anganwadi centers were visited and their infrastructure, facility and beneficiaries registers were checked beneficiaries interviewed to confirm and identify coverage gap.

Observations: 4474 (66%) beneficiaries were registered to the AWC out of 6822 in project 1 and II, 34% were thus unregistered. In growth monitoring actual coverage gap was 38%. In preschool education actual lag (i.e. service lag + coverage lag) was 47%. In supplementary nutrition actual gap was 28%. There was a service deficit of 13% in immunization services.

Conclusions: There was a gross coverage deficit on the part of the services provided by the anganwadi centres under ICDS scheme especially in the surveyed population. In a social welfare scheme a coverage gap like this is unacceptable. A thorough evaluation at the root level is required to identify the causes. Lack of supervisory activity and adequate supervision of the CDPO is required what is felt by the authors.

*Corresponding author: Dr. Mini Sharma, Department of Community Medicine, Pt. JNM Medical College, Raipur, Chhattisgarh, Room no. 232, Masjid Moth Residents Doctor Hostel, All India Institute of Medical Sciences, New Delhi-110049, India, Tel: +91 9910615499; E-mail: [email protected]

Received December 27, 2012; Accepted January 26, 2013; Published January 28, 2013

Citation: Sharma M, Soni GP, Sharma N (2013) Assessment of Coverage of Services among Beneficiaries Residing in Area Covered by Selected Anganwadi in Urban Project I and II of Raipur City. J Community Med Health Educ 3: 195. doi:10.4172/2161-0711.1000195

Copyright: © 2013 Sharma M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Keywords: Survey gap; Service gap; Actual gap; ICDS; Anganwadicentre

IntroductionChildren are the most valuable precious gift of nature and important

human resource as well. They are valuable not only because young children are the most vulnerable, but also because the foundations for cognitive, social, emotional, physical and motor development and for lifelong learning ability are laid in these crucial early years. There have to be balanced linkages between education, health and nutrition for proper development of a child. In pursuance of National Policy on Child Development, Government of India launched Integrated Child Development Services (ICDS) which has a comprehensive approach for all-round development of child up to six years of age. Because the health and nutrition needs of a child cannot be addressed in isolation from those of his/her mother, the programme also extends to adolescent girls, pregnant women and nursing mothers. ICDS is a child-focused programme rather than one targeted exclusively at children. The functional and grass route level worker of the scheme is an Anganwadi centre. Each Anganwadi is supposed to cover a population of 500-1500 persons in Rural and urban area and 300-1500 in tribal area and in Mini AWC cover a population of 150-500 persons [1].

It has been a focus of interest of the WHO as well as government of India to expand ICDS scheme and provide adequate quality of services to the beneficiaries. The work of an anganwadi worker is a key in the implementation of this scheme and she is supposed to carry over all the survey and services efficiently. However it has repeatedly been found that there is discrepancy of the expected verses actually delivered services. If we want to decrease malnutrition, IMR, school dropout it is essential to cover every beneficiary in the respective locality of AWC.

The current study is an attempt to find out the coverage deficit and services provided by anganwadi centres to its eligible beneficiaries residing under urban project of Raipur district (Raipur I and II) the most accessible area where the work of the ICDS project is expected to be most up to date.

Aim • To estimate the eligible beneficiaries among the population

covered.

• To determine the coverage gap.

• To estimate the eligible beneficiaries among the populationcovered by selected Anganwadi centre during house to housesurvey in year 2009.

• To determine the coverage gap by comparing the data from therecords of Anganwadi centre.

Material and MethodsThis was a cross sectional observational study conducted at Raipur

district in selected 30 Anganwadi centres distributed in urban project of Raipur I and Raipur II. Eligible Beneficiaries catered by selected Anganwadi centres of ICDS project I and II in Raipur city (children less than 6 yrs of age, Pregnant women, Lactating mother (only those with children of 0- 6 month)) were included. Adolescent girls were excluded from the study because the services to them were temporarily withheld by the ICDS at the time of survey. Whereas in the women in age group

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15-45 only pregnant and lactating mothers were included because the records of the others were not available.

Sampling method

Systemic random sampling.

Sampling technique

The total number of AWC in project I and II were 111 and 190 respectively. The AWC were arranged alphabetically with their individual population written in front. For the purpose of the study systematic random sampling was chosen. In this sampling technique initially a desired number is chosen. In the present study due to the lack of resources it was decided that 15 AWC will be surveyed from each project area. Then sampling interval was calculated by using this desired number i.e. 15.

Sampling interval=Number of AWC in Project/Desired number of AWC to be visited

Project I -111/15=7 and Project II-190/15=12

Thus 7 and 12 came to be the sampling interval of project I and II respectively.

We then selected a number between 1 and the sampling interval from the random number table. This selected number came out to be 6 and 11 for Project I and II respectively. The first AWC for Project I was 6th of the list and 11th for project II and the sampling interval was added over till the desired number (15) of AWC were obtained in each Project.

During data collection total households with total population of the area of respective AWC (which was selected) were covered, house to house survey was done to find the demographic profile of the population and to identify the eligible beneficiaries among them and information was documented in predesigned pretested proforma after taking their consent. Then the selected Anganwadi centres were visited and their infrastructure, facility, beneficiaries registers were checked to verify the information about registered Beneficiaries.

Survey gap=unregistered/eligible

Service gap=registered beneficiaries not receiving/registered

Total coverage-registered beneficiaries receiving services/eligible beneficiaries

Actual coverage gap=100-total coverage

Observation and ResultsAs per the protocol door to door survey was conducted which

included a population [n=26402] of 13337 in project 1 and 13065 in project 2. The male to female ratio was 12861/13441 i.e. 0.9:1. The distribution of population in the concerned community is shown in table 1. It could be appreciated that the adolescent formed an important part of the adult urban population (39 % in both sexes). In both the project adults >75 yrs formed the least proportion. Males were highest in 10-14 yrs age group (10.99%) and females were highest between 15-19 years (10.99%) (Table 1).

From the composite population surveyed eligible beneficiaries were identified and by interview it was confirmed whether they were registered in the concerned Anganwadi centre or not, according to which the coverage gap was identified. The results were as detailed in table 2, it could be seen that 4474 (66%) were registered to the AWC out of 6822 in project 1 and II. A total of 34% were thus unregistered. Among the total, for children between 3-6 yrs, the scheme lagged by 28%, similarly for children between 6 months to 1 year, pregnant ladies and lactating mothers, the lag was 23%, 21% and 23% respectively. There was a significant survey gap in each group.

When the coverage of individual services was analysed the observations were again shocking. In growth monitoring services a survey gap of 21% was present i.e. 21%, who were otherwise eligible couldn’t avail the facilities because of the survey deficit. Interestingly among those who were anyways registered, there was a service gap of 21% making the actual coverage gap of 38%. Thus out of the total population 38% of those who should have actually got the services were devoid of it owing to the survey and service gap as shown in table 3.

We know that providing preschool education to children between 3-6 years is also an important work of the AWC. There was again a gross lag in this service (Table 4). There was a service lag of 19% in total. Interestingly there was a gap/lag of 36% in total among those who were registered i.e. a total of 36% of the registered beneficiaries didn’t have

Age (yrs) Project 1 Project2 Total Male Female Male Female Male Female

No. % No. % No. % No. % No. % No. % 0-4 714 11.1 708 10.2 515 7.96 641 9.7 1229 9.55 1349 9.96 5-9 309 4.8 683 9.84 384 5.94 520 7.88 693 5.38 1203 8.88 10-14 638 9.97 578 8.33 776 12 647 9.79 1414 10.99 1225 9.04 15-19 448 7.7 850 12.25 645 9.98 634 9.61 1093 8.49 1484 10.95 20-24 581 9.07 620 8.93 761 11.77 762 11.55 1342 10.43 1382 10.20 25-29 576 9.01 618 8.9 661 10.23 653 9.89 1237 9.61 1271 9.38 30-34 635 9.92 448 6.45 526 8.14 641 9.70 1161 9.02 1089 8.04 35-39 460 7.18 637 9.18 381 5.89 382 5.79 841 6.53 1019 7.52 40-44 315 4.9 441 6.3 520 8.05 372 5.64 835 6.49 813 6 45-49 469 7.32 305 4.39 364 5.64 381 5.77 833 6.47 686 5.06 50-54 304 4.75 297 4.28 123 1.90 252 3.82 427 3.32 549 4.05 55-59 310 4.84 173 2.49 253 3.92 246 3.73 563 4.37 419 3.09 60-64 181 2.82 177 2.55 251 3.89 241 3.65 432 3.35 418 3.08 65-69 168 2.09 179 2.57 125 1.94 120 1.81 293 2.27 299 2.20 70-74 176 2.75 112 1.61 120 1.86 60 0.90 296 2.30 172 1.27 >/75 115 1.79 111 1.59 57 0.89 51 0.77 172 1.34 162 1.19 Total 6399 100 6938 100 6462 100 6603 100 12861 100 13541 100

Table 1: Age and sex wise distribution of population under study [N-26402].



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the basic preschool education which they should have got in the AWC. Thus actual lag became as high as 47% which is unacceptable.

Similarly there was a survey gap of 22% and a service gap of 6% with respect to the supplementary nutrition. Thus out of the total population actually 28% were devoid of the supplementary nutrition either because they were not registered or because they felt prey of the lag in the services as shown in table 5.

There was a service deficit of 13% with respect to the immunization services (Table 6), however all those who were registered were immunized (either fully or partially), complete immunization was seen in only 20% however 80% were partially immunized. Though immunization is not the service on the part of the AWW but a proper supervision and motivation by the concerned supervisor might have helped.

Though the immunisation was 100% in registered pregnant women (either full or partial) but there was a gap of 21% in the coverage (Table 7).

DiscussionICDS Scheme represents one of the world’s largest and most unique

programmes for early childhood development. ICDS is the foremost

symbol of India’s commitment to her children – India’s response to the challenge of providing pre-school education on one hand and breaking the vicious cycle of malnutrition, morbidity, reduced learning capacity and mortality, on the other [2] Services provided by the ICDS are as shown in table 8.

Ahmad et al. [3], in their Study on utilization of ICDS services in 1-5 year children found that. Supplementary Nutrition was received by 24.30% and Non formal preschool education was received by, only 34.52%. Seema [4], in her study tried to find out the reasons for ineffective functioning of the Anganwadi centres and concluded that inadequate infra structure facility is a major constraint in the effective functioning of Anganwadi. Nayar et al. [5] revealed that Supplementary Nutrition was received by 20 to 48% of the pregnant women. They tried to analyze the cause and found that the deficient coverage by Supplementary Nutrition in the projects was due to irregular supply and non acceptance of Supplementary Nutrition. However the mean coverage for the state as a whole was 29.6 percent. Sharma and Gupta [6] in his study on impact of ICDS on health and nutritional status of children found that there was 90% coverage of children aged 0-6 years with health checkups; this level of usage may be due to the availability of medicine kits through AWWs. He concluded that ICDS provides potential for enhancing the survival of children. A study [7] showed

Table 2: Distribution of registered beneficiaries among eligible in both projects (N-6822).

Categories Eligible Beneficiaries Registered Unregistered Survey Gap %0-6 months 331 288 43 13 6 months -1 yr 463 354 109 23 1-3 yrs 1140 994 149 13 3-6 yrs 1500 1074 426 28 Pregnant women 256 203 53 21 Lactating mother 322 249 73 23 Adolescent girls 550 348 202 37 15-45 yrs 2260 964 1296 57 Total 6822 4474 2351 34

Table 3: Coverage of services for growth monitoring for children among those who were registered (N-2707).

Area Categories Growth monitoring

No of eligible’s Registered Survey gap % Receiving Service Gap% Actual Gap %

Project I and Project II

0-6 months 331 288 13 251 13 24 6 mths-1 yr 463 354 23.6 269 23.6 42

1-3 yrs 1140 991 13 862 13 24 3-6 yrs 1500 1074 28.4 773 28.4 28 Total 3434 2707 21.18 2138 21.18 38

Table 4: Coverage of services for preschool education among registered in project I and II (N-873).

Project 3-6 yrs children No of eligible children No of registered children Survey Gap% No. of children received Awc coverage Service Gap% Actual gap%

Project I 537 424 21 271 64 36 50 Project II 537 449 16 294 65.47 34.53 45 Total 1074 873 19 565 64.7 36 47

Table 5: Coverage of supplementary nutrition in both Project I and II (N- 3681).

AreaCategory of

beneficiaries

Supplementary nutrition

Project I and II

Eligible beneficiaries No of registered beneficiaries Survey gap % Those receiving Service gap% Actual Gap%

6 mths-1 yr 463 354 23.55 324 9 30 1-3 yrs 1140 991 13.08 969 2 15 3-6 yrs 1500 1074 28.4 998 7 34

Pregnant women 256 203 20.71 187 8 27 Lactating mothers 322 249 22.68 231 7 28

Total 3681 2871 22 2709 6 27



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Table 6: Immunization status among those enrolled in Project I and II [children ≤ 5 yrs] (N-2707).

Project Immunization status

Eligible Registered Service gap% Full Partial

No. % No. % Project 1 1642 1363 17% 273 20% 1090 80% Project 2 1472 1344 7% 242 18% 1102 88% Total 3114 2707 13% 515 19% 2192 81%

Table 7: Immunization status of pregnant women among those enrolled in project I and II [N-203].

Project Immunization status

Eligible Registered Service gap Full Partial Total

No No % No. % No. % No. Project I 120 96 20% 52 54% 44 46 96 Project II 136 107 21% 50 47% 57 53% 107 Total 256 203 21% 102 50.24 101 49.75 203

Table 8: Services provided by the ICDS.

Services Beneficiaries (Covered all comes under area of respective AWC) Services Provided By Supplementary Nutrition Children below 6 years; pregnant and lactating mothers Anganwadi Workers (AWW) & Anganwadi Helper (AWH) Immunization* Children below 6 years; pregnant and lactating mothers ANM/MO Health Check-ups* Children below 6 years; pregnant and lactating mothers ANM/MO/AWW Referral Services Children below 6 years; pregnant and lactating mothers AWW/ANM/MO Pre-School Education Children 3-6 years AWW Nutrition & Health Education Women in age group of 15-45 Years AWW Growth monitoring Children below 6 years AWW

the high extent of undernourishment and unsatisfactory performance of ICDS. Despite a pioneering start by ICDS, Orissa faced the greatest severe and chronic under nourishment. It was also felt that there is a need to educate mothers on proper feeding practices. Provision of less than the prescribed supplementary food indicated the flawed implementation. Weighing machines and growth charts were not available, regular growth monitoring was not done. As a conclusion they felt that a lot more has to be done to improve the efficiency of the programme and ameliorate malnutrition and ill health. Ameya Balsekar et al. [8] attempted to assess the functioning of the ICDS (Anganwadi) at the grassroots level in selected villages of Kerala. They viewed ICDS from two angles:

1. The extent to which the Anganwadi contributes to child welfare in terms of nutrition status and pre-school education, and

2. The extent to which active community participation contributes to the effective functioning of the Anganwadi.

The study included ten anganwadi centres. Five Anganwadi centres were selected from each of two blocks, based on the grades given to them by the ICDS office. In the Anganwadi centres studied, it was found that the grade of an Anganwadi centre could not completely explain the nutritional status of the children enrolled. Hence as a criterion to evaluate nutritional status outcomes, the practice of grading of Anganwadi centres followed by the ICDS project had little value as an operational tool.

However, centres with higher grades tended to have higher levels of community participation, which was crucial to the effective functioning of a centre. Tandon and Sahai [9] in his study observed the management of Severely Malnourished Children by Village Worker in Integrated Child Development Services in India. Four thousand two hundred and ninety two children with severe protein calorie malnutrition were managed by village level workers at village centres. Treatment included provision of 700 to 900 calories and 15-20 g protein as supplement to the breast milk and weaning food being received at home and simple drug therapy for associated diseases 85 percent

children improved, 6.3 percent had no change, 3.6 percent deterioted, 3.0 percent died and 2.1 percent were lost to follow up. Diarrhoea, fever and apparent respiratory illness were associated illnesses contributing to the death in 42.6 percent, 38 percent and 34.9 percent of fatal cases. Prevalence of severe malnutrition and fatality were higher in younger children less than 3 years of age compared to older ones between 3-6 years of age. It was seen however that the referral services were not utilized by majority of sick children it was thus concluded that village level management of severely malnourished children by a local worker is an acceptable and effective approach and low cost. Tandon and gandhi [10] studied the impact of ICDS on immunization coverage of children aged 12-24 months and of mothers of infants in projects that had been operational for more than 5 years. Complete coverage with BCG, diphtheria-pertussis-tetanus (DPT) and poliomyelitis vaccines was recorded for 65%, 63% and 64% of children. TT coverage was 68% in pregnant mothers. Coverage was greater in urban and lower in the tribal projects. Arora et al. [11] observed in the study to assess the non formal preschool educational services provided at AWC to the children that non-formal preschool education was provided to the children at the AWC. Most of the parents were satisfied with the non formal education provided at the Anganwadi centre but few weren’t as they felt that Anganwadi worker laid more emphasis on nutrition. Current study was a serious attempt to document the deficit I of the coverage at the grass root level and the find out the possible cause.

Conclusions

It could be thus concluded that there was a gross coverage deficit on the part of the services provided by the Anganwadi centres under ICDS scheme especially in the surveyed population. This scheme is a social welfare scheme and a coverage gap like this is unacceptable. A thorough evaluation at the root level is required to identify the causes; a lack of supervisory activity and adequate supervision of the CDPO is required.



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Contribution of Authors

Dr. Mini Sharma- chief investigator, Dr GP Soni- chief guide in the project Dr Nitin Sharma- co investigator in survey.

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eH m ea f o lth Community Medicine & Health Education · Community Medicine & Health Education. J Community Med Health Educ Volume 3 • Issue 1 • 1000195 ISSN: 2161-0711 JCMHE,