Study on Perceptions about ICDS in Selected Districts in Rajasthan

solutio gl bal Solutions for Global Development

Innovate . Scale . Impact

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Table of Contents

Chapters Titles Page No.

Executive Summary 4

Acknowledgements 7

List of Abbreviations 8

1 Introduction 9

1.1 Background 9

1.2 Need of the Study on Perceptions about ICDS, AWC and AWWs 10

1.3 About the Project 10

1.4 Research Objectives and Scope 11

1.5 Geographical Coverage 11

1.6 Methodology 12

1.6.1 Research Design 12

1.6.2 Sampling 14

1.6.3 Data Collection Process 15

2 Perceptions about Availability, Accessibility and Quality Services of AWCs: by Frontline Health Workers, Key Influencers and Community

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2.1 Perception about Availability and Access of Services 17

2.1.1 Perception of Type of Services Available 18

2.1.2 Perception of preferred and least preferred services 21

2.1.3 Perceptions about Functioning of Anganwadi Centre, its Monitoring and Convergence with Other Departments

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2.1.4 Perception of Factors Facilitating and Obstructing Utilization of Services (Demand-side Barriers to Utilization)

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2.1.5 Perception of Community Members Availing/Not Availing the services of the AWCs

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2.2 Perception of Quality of Services Provided by AWCs 34

2.2.1 Perceptions of Quality of Services Provided by AWCs 34

2.2.2 Perception of Barriers to Provision of Quality Services (supply-side barriers)

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2.2.3 Perception on Needs to Improve Quality of Services Provided by AWCs

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3 Perception of Government Officials on Functioning of AWCs 43

3.1 Perceptions about functioning of AWCs 43

3.2 Perceptions about what is working well under the scheme 50

3.3 Perception regarding Convergence with other departments 51

3.4 Perceptions about Challenges and Needs at the State/District/ICDS Project Levels

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4 Perceptions about AWWs 57

4.1 Relationship with AWWs 57

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Chapters Titles Page No.

4.2 Value of AWWs in the community 60

5 Conclusion and Recommendations 63

5.1 Changes in Perceptions about Services Provided 63

5.2 Changes in Perception about Infrastructure and Resources 64

5.3 Build a Positive Image of AWWs 65

5.4 Improving Community perception and engagement 66

Annexure 1 Rajasthan State/District wise Children under 5 years who are stunted, wasted and underweight from NFHS 4(20015-16) (%)

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Annexure 2 List of Sample Villages in Rajasthan with respective District, ICDS Project and Sectors

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Annexure 3 Perception Matrix 71

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Executive Summary The Integrated Child Development Services (ICDS) Scheme was launched in India in 1975 to improve the nutritional and health status of pre-school children, pregnant women and nursing mothers through a package of services including supplementary nutrition, early childhood education, immunization, health check-up, referral services and nutrition & health education. The program provides an integrated approach for converging basic services through community-based Anganwadi Workers and Helpers. Today ICDS scheme is one of the world's largest and most unique programmes for early childhood development. It reaches more than 82 million children aged 0-6 years and 19 million pregnant and lactating mothers. The State of Rajasthan has more than 62,000 Anganwadi Centres (AWCs) spread across 33 districts. The State is covering more than 28 Lakh children and 9 Lakh pregnant and lactating women through its AWCs. Tata Trusts has established a partnership with the state government of Rajasthan with a commitment to demonstrate a scalable model for achieving sustainable improvement in the nutritional and health status of women of reproductive age and children. Given the mandate of Tata Trusts to demonstrate a scalable model in five districts of Rajasthan viz. Alwar, Dausa, Dholpur, Karoli and Tonk, it initiated a study to gain insights into the current perception of the ICDS program and its various stakeholders (both those implementing the program and those benefitting from it) as their perceptions impacts the growth and effectiveness of the scheme. The findings of this study are proposed to be used for designing the plan of action for rebranding of ICDS, Anganwadi Centres and Anganwadi Workers. The perception study, undertaken by Solutio Global Consulting Private Ltd, was conducted with the following objectives: (i) To understand the perception of ICDS, Anganwadi centres and Anganwadi Workers and provide recommendations for a communication or a branding model for ICDS (ii) Gain insights into why utilization of some services such as immunization is high but for other services such as complementary feeding and improved nutrition are low (iii) Analyse existing social barriers, if any, for seeking the services (iv) Provide recommendations for rebranding ICDS for image escalation and to increase community ownership of the program. The study entailed undertaking in-depth interviews with service providers viz. Anganwadi Workers (AWW), Accredited Social Health Activist (ASHA) and Auxiliary Nurse Midwife (ANM) and ICDS officials at ICDS Project, district and state level. Further it entailed conducting Focus Group Discussions with women currently availing and not availing ICDS services. Additionally observations of the functioning of AWCs and of the Village Health & Nutrition Day were undertaken. The study districts were Dausa and Dholpur. In each district two ICDS projects/ICDS Projects were covered. In each ICDS project 10 sample villages having at least 1 AWC were selected. A total of 40 AWCs were studied. The study revealed that across respondent groups, at both community and government levels, there was a marked preference for private health and education services over government services. The perception of community members that because government

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services are given ‘free of cost’ hence their quality is poor while private services by virtue of being ‘private’ provide better quality services was a predominant finding of the study. This belief was also found to have been exacerbated by the actual poor state of infrastructure and resources combined with poor quality of services, especially supplementary nutrition and pre-school education. The study team’s own observation of AWCs supported these findings. Further, it was found that Immunization and Supplementary Nutrition were the most availed services at the AWCs, even while questions were raised about the quality and variety of Supplementary Nutrition. Pre-school education, identified by AWWs as one of the key services provided by them, was perceived to be a secondary service as compared to supplementary nutrition by both, women availing services at the AWC as well as women not availing services. At the same time, it was found that among the children availing the pre-school education service, the provision of supplementary nutrition was found to be a hook for children being brought to the AWC for pre-school education. Provision of remaining services viz. growth monitoring, referral services and nutrition and health education was found to be limited. To validate the study findings, the National Family Health Survey 4 (NFHS-4) findings on the type of services availed from ICDS was referred to. As per NFHS-4, in Rajasthan 39% of children under 6 years receive services of some kind from an Anganwadi centre. The most common services that age-eligible children receive are supplementary food (32%), immunizations (31%), growth monitoring (28%) and health check-ups (26%). The service that is least likely to be accessed is early childhood care or preschool (20% of children age 3-6 years). The study revealed good convergence between ICDS and health department at the village level. The service providers like ANM, ASHA and AWW were working in close coordination while implementing the activities like routine immunization, antenatal check-ups, promotion of institutional deliveries and referral services. However convergence of Panchayat Raj Department and Education Department with ICDS was said to be poor. The study recommends that specific activities be undertaken with Panchayat members and SHG groups to seek support and build formal mechanisms of support to AWWs and AWCs. This will also help strengthen the linkage between Panchayati Raj department and the ICDS department at ground level. School teachers can also be involved as mentors in the pre-school education programme and meetings need to be conducted with school authorities at the district level to garner greater support at ground level. The study also recommends that in order to change people’s perceptions about the ICDS program and services, it is important to start with addressing the key problems with the infrastructure and service delivery. Given the poor status of infrastructure of AWCs It is of utmost importance that along with electricity, lights and fans, child friendly toilets, safe drinking water, hygienic cooking arrangements and play space for children also be provided. The study highlighted that AWWs not only require both knowledge, perspective and skills to increase their capacities as AWWs, but they also need to come across as more professional and confident service providers. Study findings showed that the general image of the AWW is that of a hardworking person but not that of a professional, skillful, knowledgeable service

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provider. Further the study recommends that along with capacity building, several concerted efforts need to be made to improve the image of the AWW and increase her visibility in the community as an efficient, hardworking, professional, skilful and supportive service provider who community members especially women, can rely on to support and advance their own as well as their children’s health and nutrition. Last, a key aspect in the findings was the lack of community engagement, support and participation as a result of negative perceptions about the ICDS and lack of established mechanisms to elicit community participation. Another critical finding was that home visits could be restructured to strategically build a more meaningful relationship of AWWs with community members, undertake structured discussions with parents on child development, good and effective parenting, health and nutrition counselling, as well as spousal communication. Home visits planned with both parents can aim to increase fathers’ role in parenting and child care as well as build capacities of women to make informed decisions around health and nutrition for themselves and their family. The study also recommends increasing visibility of the rebranded AWCs through mass media campaigns at the community level; seeking support from panchayat members and SHGs for requirements within the AWC and possibilities of partnership with ICDS; and forging stronger partnerships with government schools and the Education Department to strengthen the pre-school education service, with the aim of building an enabling environment for AWWs to function. Further, the study also recommends including community members and using existing community resources to undertake rebranding activities with the AWCs so as to increase community ownership of the service.

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Acknowledgements The research team of Solutio Global would like to acknowledge their heartfelt gratitude to the following persons for their support in various capacities during the course of the research study: Dr. Rajan Shankar from Tata Trusts for his guidance and support in the research study. We would also like to acknowledge the support and participation received from Dr. Isha Bhagwat, Tata Trusts. A special mention of Mr. Kshitij Mamgain, Tata Trusts, for his continuous support throughout the entire research and report development process. Further we would like to acknowledge Mr. Rahul Bansiwal, Jaipur, Mr. Parvat Singh Rathore, Dausa and Mr. Mohit Bajpai, Dholpur from Tata Trusts for their assistance and support for field work coordination during the data collection process. Special thanks to the ICDS officials in various capacities for their critical inputs to the research study. Finally many thanks to all the Anganwadi Workers, ASHA Workers and ANM as well as community members who generously shared their inputs, insights and experience that has added to the richness in the data.

The Team This research study has been conducted by Solutio Global Consulting Pvt. Ltd., New Delhi. The team comprised of the following members: Team Leader: Ms. Deepali Nath Project Advisor: Dr. Sudeep Singh Gadok Project Coordinator: Mr. Niharendu Jagatdeb State Coordinator: Ms. Mohona Chatterjee

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List of Abbreviations ASHA: Accredited Social Health Activist ANM: Auxiliary Nurse Midwife AWC: Anganwadi Centre AWW: Anganwadi Worker AWH: Anganwadi Helper CDPO: Child Development Project Officer DPO: District Programme Officer FGD: Focus Group Discussion ICDS: Integrated Child Development Scheme JSY: Janani Suraksha Yojana KI: Key Informant MCP: Mother-Child Protection NFHS: National Family Health Survey NHM: National Health Mission OBC: Other Backward Caste PHC: Primary Health Centre PMMVY: Pradhan Mantri Matritva Vandana Yojana PRI: Panchayati Raj Institution SC: Scheduled Caste SHG: Self Help Group ST: Schedules Tribe TFR: Take Home Ration UT: Union Territory VHND: Village Health and Nutrition Day

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Chapter 1: Introduction

1.1 Background India is home to more than 160 million children in the age group of 0-6 years. With nearly 20 per cent of the child population of the world, India is home to the largest number of children in the world. After independence there is remarkable growth in literacy and economy, but the holistic development of children remains less understood, absorbed and assimilated and more importantly underinvested. Around 40 per cent of children remain undernourished with their growth and development hindered irrevocably, over the lifetime. As per the National Family Health Survey (NFHS -4, 2015-16), 35.7 percent children below five years are underweight, 38.4 percent are stunted and 21 percent are wasted in India. In the State of Rajasthan 36.7 percent children below five years are underweight, 39.1 percent are stunted and 23 percent are wasted. The indicator “Children under 5 years who are underweight (weight-for-age)” is one of the composite indicator for child malnutrition. As per NFHS-4 data, the national average of children under 5 years who are underweight has reduced from 42.5% as reported in NFHS-3 (2005-06) to 35.7% in NFHS-4 (2015-16). In the State of Rajasthan during the same period, underweight children under 5 years has gone down from 39.9% (NFHS-3) (2005-06) to 36.7% (NFHS-4). Further in the State of Rajasthan the districts which have reported more than 50% of children under 5 years who are underweight during 2015-16 (NFHS-4) are Banswara (50.7%), Dungarpur (53.4%), Pratapgarh (54.6%), Sirohi (50.4%) and Udaipur (52.0%). Districts wise percentage of stunted, wasted and underweight children under 5 years in Rajasthan State from NFHS-4 (2015-16) is given in Annex-1: The Integrated Child Development Scheme (ICDS) launched by the Government of India in 1975, has been working continuously to break the vicious cycle of malnutrition. Since its launch, the ICDS scheme has been instrumental in improving the health and wellbeing of mothers and children under 6 by providing health and nutrition education, health services, supplementary food, and pre-school education. ICDS scheme is today one of the world's largest and most unique programmes for early childhood development. It reaches more than 82 million children aged 0-6 years and 19 million pregnant and lactating mothers. Under the ICDS scheme, six services are provided. Out of the six services two services i.e. Supplementary Nutrition and Pre School Education are directly provided by the ICDS Department, while three services i.e. Immunization, Referral Services and Health Check-ups are provided by Ministry/Department of Health and Family Welfare through NRHM & Health system. The remaining one service i.e. Nutrition and Health Education is provided by both the departments. All these services are complementary to each other and aimed towards holistic development of mothers and children.

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The six services are delivered in an integrated manner at the Anganwadi Centre (AWC) through key service providers of the programme viz. Anganwadi Worker (AWW) and Anganwadi Helper. The State of Rajasthan has more than 62000 AWCs spread over to 33 districts. The State is covering more than 28 Lakh children and 9 Lakh pregnant and lactating women through its AWCs.

1.2 Need of the Study on Perceptions about ICDS, AWC and AWWs While ICDS has contributed to combating malnutrition in women and children, to a large extent the overall performance has not been satisfactory and the scheme has a long way to go to be able to effectively tackle the issue of malnutrition. According to a World Bank report (2006), ICDS has not been able to make a significant dent in child malnutrition due to two main reasons. Firstly, the report states that the scheme prioritized food supplementation over nutrition and health education interventions. Secondly, the report highlights that the scheme has focused on children above the age of three, by which time the irreversible effects of malnutrition have already set in. Several other studies have been undertaken to evaluate and assess the effectiveness of the implementation of the ICDS scheme. These studies have outlined the positive impact of ICDS, as well as the gaps that have to be bridged to further improve the functioning of the programme. Key study areas of these researches were administration and management of ICDS, impact of ICDS, evaluation of the various components of ICDS, job performance of functionaries, etc. However there have been fewer studies conducted to gain insights into the perception of the functionaries responsible for design and implementation of the scheme in the state, the service providers and the community for whom the scheme is meant. Such a study is critical to identify the gaps that exists between planned and actual delivery and between expectation by the community and actual provision of services. A study of this nature will also help to understand and highlight discrimination as a barrier in utilization of ICDS services. All these factors are critical for the growth and expansion of the scheme and for enhancing its effectiveness. Given that Tata Trusts has the mandate to demonstrate a scalable model for achieving sustainable improvement in the nutritional and health status of women of reproductive age and children, it initiated a study to gain insights into the current perception of the ICDS program and its various stakeholders (both those implementing the program and those benefitting from it) in two states, namely, Rajasthan and Andhra Pradesh. These insights will then be used for outlining the plan of action for rebranding of ICDS, Anganwadi Centres and Anganwadi Workers. The next sections in this chapter will outline the Project Background, Study Objectives and Methodology for the Perception Study.

1.3 About the Project Tata Trusts has established partnership with the state governments of Rajasthan and Andhra Pradesh in order to demonstrate a scalable model for achieving sustainable improvement in the nutritional and health status of women of reproductive age and children. This program

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will have a special focus on the most vulnerable populations and families. Stunting and anaemia reduction will be the key outcome indicators of improved nutritional status of the population. Tata Trusts aims to implement a comprehensive nutrition program that includes nutrition-specific and nutrition-sensitive interventions, combined with household practices to improve maternal, infant and young child feeding, and utilization of ICDS and National Health Mission (NHM) services. This will result in sustained improvement in nutritional status of the population and contribute significantly to reduction in stunting. The proposed activities of the Trusts include: governance and system strengthening; supply and demand side interventions and integrated anaemia control strategy in close collaboration with NHM. As part of the system strengthening activities, rebranding of ICDS, Anganwadi centres and Anganwadi Workers is proposed to be undertaken. It is perceived that the ICDS program although delivering a fair bit of the objective, does not have a great image as a flagship effort. Key thoughts on this account are:

ICDS despite being a long standing effort does not have a very high image with its stakeholders

From the government functioning side – there hasn’t been an understanding around what the current perception of the program is.

It is presumed from initial interaction that the beneficiaries also feels that the program has not attained the set of objective it aimed at due to a plethora of reasons

Given the above, a comprehensive study was conducted to gain insights into the current perception of the ICDS program and its various stakeholders (both those implementing the program and those benefitting from it). The insights from this report is expected to be used for outlining the plan of action for rebranding of ICDS, Anganwadi centres and Anganwadi Workers.

1.4 Research Objectives and Scope The key objectives of the study were to:

Engage and understand the perception of ICDS, Anganwadi centres and Anganwadi Workers to provide recommendations for a communication or a branding model for ICDS

Gain insights into why utilization of some services such as immunization is high but for other services such as complementary feeding and improved nutrition are low

Inquire about existing social barriers, if any, for seeking the services

Provide recommendations for rebranding ICDS for image escalation and to increase community ownership of the program

1.5 Geographical Coverage The intervention districts for the project in Rajasthan are Alwar, Dausa, Dholpur, Karoli and Tonk and the intervention districts in Andhra Pradesh are: Krishna, Guntur and Nellore. From the intervention districts two districts were selected in each state for the purpose of the study. The two selected districts in Rajasthan are Dausa and Dholpur while in Andhra Pradesh

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the study districts are Krishna and Guntur. This report outlines the findings for the state of Rajasthan. The findings for Andhra Pradesh are presented in a separate report.

1.6 Methodology 1.6.1 Research Design

The following research tasks were undertaken as part of the study: Research Task 1: Desk Research Research Task 2: Capturing perceptions of the functionaries of ICDS Research Task 3: Capturing perceptions of Anganwadi Worker Research Task 4: Capturing perceptions of Frontline Health Workers at village level Research Task 5: Capturing perceptions of Target Beneficiaries of ICDS Research Task 6: Capturing perception of Key Influencers at the Village Level Research Task 7: Observation of Anganwadi Functioning and Village Health and

Nutrition Day The following section outlines each research task. Research Task 1: Desk Research A desk research was undertaken to analyze the secondary information on the status of ICDS in the intervention states and districts. This research also examined the existing perception studies. The desk research helped define key areas towards which perceptions needed to be captured. Research Task 2: Capturing perceptions of the functionaries of ICDS With the objective of rebranding ICDS, including Anganwadi Centres, it was deemed important to gauge the perceptions of the officials involved in the implementation of the scheme, from the state to the ICDS Project level. Hence in-depth discussions were conducted with senior state level officials of Women and Child Development and functionaries of ICDS at the selected districts and the ICDS Projects. Research Task 3: Capturing perceptions of the Anganwadi Worker To capture the perceptions of the AWWs in-depth Interviews were conducted with AWWs at the village level. Anganwadi Worker is a community based frontline honorary worker of the ICDS Programme. She is also an agent of social change, mobilizing community support for better care of young children, girls and women. The perception of AWWs with regards to how the program is perceived by the community and how they are perceived by the community have provided critical inputs towards the re-branding exercise. Research Task 4: Capturing perceptions of Frontline Health Workers at Village Level ICDS envisages convergence of nutrition and health programmes. The Auxiliary Nurse Midwife (ANM) and Accredited Social Health Activist (ASHA) form a team with the ICDS

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functionaries for convergence of different services. The concept of package of nutrition and health-related services under the ICDS is based primarily on the consideration that the overall impact will be much more if different services are delivered in an integrated manner. The task expected of ASHA requires that she works in close coordination with ANM and AWW for effective delivery of services. Hence in-depth discussions were undertaken with ANMs and ASHAs for the purpose of this study. Research Task 5: Capturing perceptions of Target Beneficiaries of ICDS To capture the perceptions of target beneficiaries of ICDS, both availing and not availing the services currently, focus group discussions were conducted with mothers of children in the 0-6 age group, pregnant women and lactating mother. Research Task 6: Capturing perception of Key Influencers at the Village Level At the village level the members of the gram panchayat, school headmaster/teachers and members of Village Health and Sanitation Committee are key influencers in terms of influencing the behavior of communities with regards to utilization of various services provided by the government at the village level. Thus, in-depth discussions were conducted with these key influencers at the village level to be able to capture their perceptions with regards to the existing services provided by AWC and AWW and overall functioning of the scheme. Research Task 7: Observation of AWC and Village Health and Nutrition Day During fieldwork exercise few observations of the functioning of the AWC was organized to map the functioning of the AWC with the perceptions held with regards to the services provided by the AWC. This exercise helped to provide an understanding on the existing functional status of the Anganwadi Centres and highlight the changes that need to be made in the functioning of AWCs to implement a successful rebranding exercise. Observation & information about the "Village Health Nutrition Days" was also conducted. Village Health and Nutrition Day is organized once a month at the Anganwadi Centre. Health functionaries, ANM and ASHA visit the Anganwadi Centre on this day. A basket of services are provided on this day like immunization, micronutrient supplementation, Vitamin A & Folic Acid, deworming, registration of pregnant women, antenatal care, health check-up of sick and undernourished children etc. In addition, counselling of pregnant women and care givers is conducted ANM and AWW. The observation exercise was a full day activity and done by experienced Research Associates. The observation of the activities at AWCs and VHND was done observing the time spent on the various services provided by the AWC. Structured questionnaire with both quantitative and qualitative output was used to do this observation at both AWC and VHND.

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1.6.2 Sampling

Multistage sampling techniques were employed for selection of Districts, ICDS Projects (ICDS Projects) and Villages and the target respondents. In Rajasthan, 2 districts were selected and in each district 2 ICDS projects were selected. From each ICDS Projects 10 sample villages with AWCs were selected for the study. The procedure followed for selection of Districts, ICDS Projects and Villages is described below. Stage I: Selection of Districts For selection of districts, five key indicators from the district fact sheets of NFHS-4 (2015-16) were considered. These 5 indicators are related to the nutritional and health status of children (below 6 years) and women (15 to 49 years). These indicators are: 1: Total children age 6-23 months not receiving an adequate diet (%) 2: Children under 5 years who are stunted (height-for-age) (%) 3: Children under 5 years who are underweight (weight-for-age) (%) 4: Children age 6-59 months who are anemic (<11.0 g/dl) (%) 5: All women age 15-49 years who are anemic (%) Based on the value of the above indicators an average score of each district was calculated. Districts were then ranked based on average scoring. The district having the lowest score was ranked first and the district having highest score was ranked fifth. The first and fifth ranked districts were selected as the sample districts. Stage II: Selection of ICDS Projects In each district 2 ICDS Projects were selected. In consultation with Tata Trusts the ICDS Project which is closest to the district headquarter was selected as the first sample project and the second ICDS Project was selected which is the farthest distance from the district headquarter. Stage-III: Selection of Revenue Villages having AWC Following sampling methodology was adopted to select the Revenue Villages having AWCs.

The list of AWCs in each ICDS Project was collected from Tata Trusts. The revenue villages having one or more functional AWCs were listed for each selected ICDS Project.

To minimize error, these villages were again matched with the Census 2011 revenue village list as per their Census Code. The total number of under-6 children as per Census 2011 was recorded for each revenue village.

The list of revenue villages was sorted in ascending order based on the numbers of children under- 6 years. From the list, a total of 10 villages were selected following a systematic random sampling method.

The list of selected Revenue Villages with their corresponding Sector, ICDS Project and District is attached as Annex: A.

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1.6.3 Data Collection Process

Development of Research Instruments The issues and key enquiry areas to be covered in the study were finalized in consultation with Tata Trusts. Keeping in view the requirement of the study the following nine instruments of enquiry were used to collect the necessary information.

1) In-depth interview schedules with State level ICDS officials 2) In-depth interview schedules with District and Project level ICDS officials 3) In-depth interview schedules with AWW and Sector Supervisor 4) In-depth interview schedule with ASHA and ANM 5) In-depth interview schedule with Key Influencers 6) FGD guides with women availing ICDS services 7) FGD guides with women not availing ICDS services 8) Observation schedules for observation of Anganwadi Centres 9) Observation schedules for observation of VHND

The research instruments were designed based on our previous experience in similar qualitative study subject, review of reports/literature and objectives of the study. Pre-testing of Tools To ensure the suitability of the instruments of enquiry in actual field conditions, all the instruments were pre-tested in the field by the of quality assurance team and State Coordinators of Solutio Global along with Field Executives in different villages of Alwar district in Rajasthan. Professionals from Tata Trusts also participated in the pre-testing and monitored the entire exercise. The pre-testing of tools was conducted between 10th and 11th May 2018 in two villages, viz. Machadi and Nangalratawat in Palakhdi Gram Panchayat in Umrain ICDS Project in Alwar district. The research instruments were modified based on the findings of pre-testing. Post this, the research instruments were submitted to Tata Trusts for their comments and suggestions to make it a final version. Orientation of Professionals and Research Associates and Field Survey A 2-day orientation meeting of core team of professionals and Research Associates involved in the study was organized at New Delhi for Rajasthan. It was a residential training workshop that helped all the participants to optimally utilize the time in understanding the instruments of enquiry, methodology and survey protocols. One representative from Tata Trusts also participated in the orientation meeting.

The objectives of the workshop were as follows:

To establish a common understanding among all the professionals and Research Associates about the study, study objectives and areas of enquiry covered in the study.

To brief the participants about ICDS Programme and Tata Trusts’s initiatives in Rajasthan.

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To explain to participants the correct method of selection of participants, method of approaching and rapport building with respondents, process of seeking informed consent and method of asking questions/interviewing

To plan the field logistics and brainstorm on possible problems and the efforts to be made to solve these problems

In the month of June 2018, the fieldwork was launched simultaneously in two districts of Rajasthan. The dates of state level orientation meeting, launching of fieldwork and completion of fieldwork in respective states are presented in the following table.

Timeline

Training Date Fieldwork Start Date Fieldwork Completion Date

16-17th June, 2018 19th June, 2018 25th June, 2018

Content Analysis All the voice recordings were transcribed in English by data analysts. These transcriptions were again rechecked by the core team members. The core team members and the professional analyst under the guidance of the Project Advisor (Quality Assurance) prepared the content analysis plan. Separate content analysis plans were prepared for each research tool. Sample Coverage Following table shows the details of targeted sample size with type of respondents and sample covered in Rajasthan.

(CDPO of Mahuwa ICDS Project has recently joined. She did not agree for the in-depth interview because she is new and very less knowledge about Mahuwa Project)

Respondents Type of Interview Target Coverage

State level official In-depth 1 3

District level officials In-depth 2 2

Project level officials In-depth 4 3*

Anganwadi Workers In-depth 32 32

Supervisors In-depth 8 8

ASHA In-depth 12 12

ANM In-depth 4 4

Key Influencers In-depth 16 16

Women currently availing ICDS Services FGD 4 4

Women currently not availing ICDS Services FGD 4 4

Observation of AWCs Observation 4 4

Observation of VHND Observation 4 4

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Chapter 2: Perceptions about Availability, Accessibility and Quality Services of AWCs: by

Frontline Health Workers, Key Influencers and Community This chapter presents the expectations and perceptions of existing and potential beneficiaries of the AWCs and their key influencers viz. the sarpanch/ headmaster/ teachers, specifically focusing on availability, accessibility and quality of AWC services. It also highlights the demand and supply side barriers for use of services of the AWCs. The chapter also presents the perception of the providers of the services at the AWCs viz. the AWW as well as ASHA and the ANM, who work in conjunction with AWWs for delivery of some key services The underlying assumption in this chapter specifically and in the report, in general is that the perception of existing and potential beneficiaries directly impacts the growth and coverage of the scheme. Hence, any efforts to enhance the effectiveness and coverage of the ICDS scheme needs to give cognisance to existing and potential beneficiary perceptions and address the concerns and issues emerging from the analysis of these perceptions. Further the comparison of beneficiary perceptions with those of the service providers will help in identifying the gaps between expectation and provision of services. Analysis of the perception of the service providers will also help gain critical insights into the gap between plans and actual delivery of services as well as changes required to reduce this gap.

2.1 Perception about Availability and Access of Services Anganwadi centres are designed to provide a package of six key services, viz.

Supplementary Nutrition Pre-school non-formal education Nutrition & health education Immunization Health check-up and Referral services

The Government of India, has issued revised guidelines on nutritional and feeding norms. All States/UTs have to provide supplementary nutrition to children below six years of age (including those suffering from malnutrition) and pregnant and lactating mothers, in accordance with the guidelines which have been endorsed by the Hon’ble Supreme Court.

The provision of supplementary nutrition under ICDS Scheme prescribed for various categories of beneficiaries is as follows:

S. No. Categories Type of meal or food

1. Children (Between 6 to 36 months)

Take home ration as per Anganwadi Services (Integrated Child Development Services) guidelines in conformity with the provisions of the Act.

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S. No. Categories Type of meal or food

2. Malnourished children (Between 6 to 36 months)

The same type of take home ration as above with food supplement of 800 calories and 20-25 grams of protein.

3. Children (Between 3 to 6 years)

Morning snacks and hot cooked meal as per Anganwadi Services (Integrated Child Development Services) norms.

4. Malnourished children (Between 3 to 6 years)

Additional 300 calories of energy and 8-10 grams of protein in addition to the meal or food provided to children between three to six years.

5. Pregnant women and lactating or nursing mothers

Take home ration as per Anganwadi Services (Integrated Child Development Services) guidelines in conformity with the provisions of the Act.

During field survey it was found that in most of the Anganwadi centres only hot cooked meal was being provided to the children in the age group of 3 to 6 years. It was observed that in most of the AWCs cooked hot meal in the form of Khichidi was being provided. It was also observed that none of the Anganwadi centres provided morning snacks to the children. Take home ration (THR) was provided to pregnant women, lactating mothers and children within age group of 6 month to 3 years. THR is generally prepared by local SHG group and is a dry mixture of wheat, gram and soya bean flour, sugar and edible oil. Every week a pack of 950 grams is provided to pregnant women and lactating mothers and a pack of 750 gm is provided to children. Now the weekly distribution of THR has stopped and the monthly quota of 4 packets of THR was provided once a month. This was distributed on the VHND day. The following section explores perceptions about the extent to which the service providers make available the above services at the AWC as well as perceptions of the extent to which community members are accessing and availing these services. 2.1.1 Type of Services Available

Study findings showed that out of the six major services to be provided by AWCs, the services provided most by AWWs were first, assisting health staff in immunization and health check-up of children and mothers and organizing non-formal preschool education activities followed by the provision of supplementary nutrition. A fewer number of AWWs could identify growth monitoring, referral services and nutrition and health education as services provided which on further probing was revealed was due to the following factors:

- Weighing machines were damaged and not in use. - Some AWWs were not trained to monitor growth effectively and found it to be too

technical. - Beneficiaries availing nutrition and health education and referral services was not

high.

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- Severe malnourishment was felt to be rare and no cases of severely malnourished children or pregnant and lactating women were reported in current times.

Likewise, all ASHA and ANM workers could identify immunization as one of the services provided at the AWCs. A high percentage of ASHA and ANM workers also spoke about providing health and nutrition education services to community members. This could be linked with the fact that ASHA and ANM workers were more directly involved in providing this service as against the AWWs. It could also be linked with the finding that knowledge around malnutrition, nutrition and health especially for pregnant and lactating mothers as well as for children, was found to be more in-depth amongst ASHA and ANM as compared to AWW. Although not stated directly during discussions, it could imply that AWWs played a supportive role during health and nutrition education sessions as compared to the ASHA and ANM. This also reflects on the quality of training of AWWs as compared to ASHA and ANM workers, which will be explored in detail in the subsequent chapters. Provision of referral services by the AWCs was mentioned only by a few ASHA and ANM workers, probably because utilization of this service was poor. Further, this data might reflect the key focus or priorities given to specific services as part of the scheme. The beneficiaries identified Supplementary Nutrition and Immunization as the two main services provided by the AWCs. Pre-school education, identified by AWWs as one of the key services provided by them, was perceived to be a secondary service as compared to supplementary nutrition both by the beneficiary and non-beneficiary groups. Overall, a common feature seen across both beneficiary and non-beneficiary groups was the belief that private schools and hospitals provide better services. Upon further probing, it was found that while beneficiaries were aware about the availability of other services, immunization, supplementary nutrition and preschool education were identified as the most availed services. Apart from this few beneficiaries also identified home visits as one of the services provided by the AWCs. Beneficiaries stated that it helped that the service providers came home to provide information. Participants stated that one of the major reasons for preferring government services over private services were that services could be availed free of cost and that conditional cash transfer schemes such as the Pradhan Mantri Matritva Vandana Yojana were being provided. The National Family Health Survey (NFHS) obtains information from all the households surveyed on the type of services availed by them from ICDS and it provides state specific data on services provided by ICDS systems and utilization of services. To validate the study findings, the National Family Health Survey 4 (NFHS-4) findings on the type of services availed from ICDS was referred to. According to NFHS 4 in Rajasthan 39% of children under 6 years receive services of some kind from an Anganwadi centre. The most common services that age-eligible children receive are supplementary food (32%), immunizations (31%), growth monitoring (28%) and health check-ups (26%). The service that is least likely to be accessed is early childhood care or preschool (20% of children age 3-6 years).

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NFHS 4 also revealed that in Rajasthan among children under 6 years, slightly less than half (48%) of their mothers received any service from an Anganwadi centre during pregnancy, and almost two-fifths (38%) of their mothers received any service while breastfeeding. During the course of the study, key factors identified for availing the services of the AWCs were identified and have been outlined below: 1. Provision of Free services: As mentioned above, one of the recurrent themes across groups was the benefit that women and children, especially those belonging to poor, SC families receive from free nutrition-related services. ‘The BPL card is made through which the pregnant women can avail benefits as the treatment is free.’ (FGD with Beneficiaries, Lalsot ICDS Project, Dausa district) 'Our priority is also to save money. But when the services are not available here in the government hospital then we go outside.' (FGD with Beneficiaries, Marena ICDS Project, Dholpur district) 'In government, we get money and food if card is made, but in private, we have to give money and avail services.' (FGD with Beneficiaries, Lalsot ICDS Project, Dausa district) 'There is a lot of poverty here. So people avail the supplementary nutrition happily. Likewise immunization is a scheme by the government that is absolutely free.’ (Sarpanch, Lalsot ICDS Project, Dausa district) 2. Support for child care: While on the one hand, where women were working on the fields and were largely responsible for child care and household chores along with agricultural work, found it difficult to come to the centre themselves, on the other hand, AWWs as well as women themselves acknowledged that the AWC was a support system for them, especially when children were not old enough to attend schools.

39%32% 31% 28% 26%

20%

Some kind ofServices

SupplementaryNutrition

Immunizations Growth monitoring Health check-ups Early childhoodcare or preschool

Children received Anganwadi centre services (NFHS 4)

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3. Building trust- Although not a recurrent theme, it was found that building trust in the AWW and faith in services was a key factor in influencing people to avail of services. 'Some time ago when we were on a home visit, a child of a particular family was ill. We ensured timely medical treatment for him and he fully recovered within few days. This made them believe that the work done here is good and beneficial to them.' (AWW, 40 years, Rajakheda ICDS Project, Dholpur district) 4. Lack of alternative services for pre-school education and supplementary nutrition: The findings also showed that as there were no other alternatives for pre-school education and supplementary nutrition services in rural areas, people had no choice but to avail this service, especially when private services are located far away. However, this does not imply that there is absolutely no value for the services provided by the AWC. ‘Earlier there were similar centers who are working on health and education but now government has closed them. Private schools do not clear the concept of a topic. There is no private school. Hence, they send their children to AWC.’ (Headmaster, village in Rajakheda ICDS Project, Dholpur district) The above sections clearly highlight that out of the 6 services to be provided by the AWCs 3 services viz. supplementary nutrition, immunization and pre-school are being provided by the AWWS and are also being commonly availed by the community, though pre-school education to a lesser level. The provision and utilization of the remaining 3 services viz. nutrition and health education, health check-up and referral services was found to be limited. 2.1.2 Perception of preferred and least preferred services

While the above section outlines the various services being availed by the community, this section focusses on the preference of the various services available in AWCs, both most and least preferred services. Most Preferred Services The study highlighted that the preferred services of AWCs for both existing and potential beneficiaries, was immunisation, while supplementary nutrition was a close second. Similarly, AWWs, ASHAs and ANMs listed supplementary nutrition and immunization as the most preferred services of AWCs. On the contrary, awareness among key Influencers about AWC services was found to be high and most mentioned four services as most preferred, i.e. supplementary nutrition, immunization, nutrition and health education and pre-school education. This shows a gap between perceptions of key influencers about service preference as against the reality. It also highlights the need for key influencers to be more involved in ensuring that services that are supposed to be provided by the AWCs as per the mandate are in fact improved upon taking into account needs and current realities. The reasons for high preference of the 2 services viz. immunization and supplementary nutrition are outlined in the following paragraphs:

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1. Immunization: Findings showed that provision of cash incentives through conditional cash transfers have promoted immunization rates in recent times. Several evaluation studies have found that immunization rates, despite being a free government service, was very low for female children in the past due to low value for and investment in the girl child. Taking forward from this study, findings from this study showed that conditional cash transfer schemes such as the Pradhan Mantri Matritva Vandana Yojana (PMMVY) have greatly increased immunization of female children, specifically in recent times. At the same time, as later sub-sections highlight, there has also been an increase in awareness of the benefits of immunization for children among community members. 'If they have a girl child, they will get money to get the child immunized. So always when someone finds out they are pregnant they come for immunization.' (AWW, Baseri ICDS Project, Dholpur district) ‘Parents get money after delivery. However, only if they complete the immunization schedule, the pregnant women will get money after delivery. This is one reason why they ensure that they complete the full schedule. Even we get money for this.' (ASHA worker, Baseri ICDS Project, Dholpur district) ‘Earlier people would not come for immunization n. Now women receive Rs 5000/- for their delivery from the government. Female children receive monetary help from the government and families receive money to get their daughters immunized. So, immunization is done on time and people are very regular about it.' (ANM, Mahuwa ICDS Project, Dausa district) In addition, the increased push for routine immunization through concerted government efforts such as incentives for health workers and mothers for immunization, Behaviour Change Communication campaigns, door-to-door visits to counsel families on the importance of immunization and clarifying fears about side effects has resulted in a positive change in larger community perceptions w.r.t immunization. Further, knowledge regarding the benefits of immunization has also increased among community members at large. It was found that the immunization was the first service identified by community members and health workers alike that is being imparted by the AWC as well as the most popular. ‘Immunisation is popular because it is a way to prevent diseases especially polio.’ (FGD with Beneficiaries, Mahuwa ICDS Project, Dausa district) 'Immunization n is the most important for them as they are fully aware that it prevents illness. They do understand the importance of these immunization and come on their own to the centre and ask for them.' (AWW, Rajakhera ICDS Project, Dholpur district) ‘Earlier, people used to be afraid of immunizing their children. Now they have improved but earlier I had to visit their homes very frequently for immunization services. I had to call 10 times and then they would visit once. They used to fear that their child will get fever and fall sick as a result of immunization. So, I had to explain to them that yes, the child might get fever

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but you can use water cloth on their head and give medicine for fever. This would make them come for immunization.' (AWW, Rajakhera ICDS Project, Dholpur district) 2. Supplementary Nutrition: The unmet need for supplementary nutrition, especially among poor and marginalized communities was very high. This combined with the high incidence of malnutrition in these communities among pregnant women, adolescent girls as well as infants and young children, led to supplementary nutrition being identified as a preferred service as the AWCs appeared to meet the unmet nutritional needs, at least to some extent. ‘Most girls in this village are anemic. Women and girls suffer from weakness and are known to often faint and vomit. Pregnant women suffer from pain in their stomach while walking, backache while lifting heavy objects; lactating women do not have sufficient breast-milk for their children and, some women bleed while breastfeeding.’ (FGD with Beneficiaries, Mahuwa ICDS Project, Dausa district) ‘People take supplementary nutrition for its vitamin value.’ (FGD with Beneficiaries, Mahuwa ICDS Project, Dausa district) It was stated by several service providers as well as KIs that due to poverty, the utilization of supplementary nutrition was high for those who needed this ‘free service’. 'There is a lot of poverty here. So, people avail the supplementary nutrition happily.’ (Sarpanch, Lalsot ICDS Project, Dausa district) Some beneficiaries also stated that while the quality of nutrition provided was poor, the AWC could meet their need for supplementary nutrition to a certain extent and hence, they considered the service to be useful. Least Preferred Services Study findings revealed that Health and Nutrition Education, Referral Services as well as Pre-School Education were identified as the least preferred services by existing beneficiaries.

Beneficiaries also stated that Pre-School education was least preferred because of the quality of education provided although utilization of this service was found to be comparatively high as compared to other services. Discussions with AWWs revealed that the provision of supplementary nutrition was an incentive to send children for pre-school education activities, which could be the reason for high utilization but low preference for this service. Potential beneficiaries identified pre-school education and supplementary nutrition as least preferred due to poor quality of these services but it was also found that their knowledge of other services was poor. Key influencers identified only referral services as least preferred owing to the distance and lack of transport facilities to the government hospital/health centre. The following paragraphs outlines the reasons given for the various services being least preferred by the various types of respondents.

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1. Referral Services: Lack of coordination and follow up by AWWs with the PHC and hospital staff, lack of transport facilities and distance of the health centre from the village were identified as key factors for referral services as being one of the least preferred activities of the AWCs. 'The AWWs should be in touch with the PHC or hospital staff so that when she refers any person from the village, she should be able to call up the hospital and tell them that she is referring some patient so that the person gets better care.' (School teacher, Lalsot ICDS Project, Dausa district) ‘That is not of much use as we must go to the hospital that they have referred to in our own vehicle. Sometimes, it is difficult for the pregnant woman to travel a long distance. The vehicle is provided sometimes only for one way.’ (FGD with Beneficiaries, Baseri ICDS Project, Dholpur district) 'We refer people to PHC but they do not go there due to lack of transport facilities.' (ANM, Baseri ICDS Project, Dholpur district) 2. Supplementary Nutrition: In Rajasthan, the preparation of meals for the supplementary nutrition service is mainly outsourced to SHGs though in some of the AWCs the cooked hot meal is prepared at the center itself. The meal is prepared by both the Anganwadi worker and helper. In the current study, the findings showed that the quality of supplementary nutrition provided through AWC was found to be a major deterrent for utilization of this service. ‘None of the women sitting there consume the flour provided by the Anganwadi because it smells bad and it is tasteless.’ (FGD with Beneficiaries, Morena ICDS Project, Dholpur district) 'We have to force them to take the food. The food is not very tasty and there is no variety, so they are not willing to take the food.' (AWW, Morena ICDS Project, Dholpur district) 3. Pre-school education: In the current study, it was found that both existing and potential beneficiaries have negative views about the quality of pre-school education provided at the centre. They prefer the quality of services in private schools and hospitals over government education and health services. 'They have to come and request us to send our children as we are not sure of the facilities provided. We are not fully aware of their services. But in private, we send our children on our own as we know that although they take money, they will not deprive our children of the necessary education.' (FGD with Beneficiaries, Lalsot ICDS Project, Dausa district) 4. Health and Nutrition Education: While the purpose of health education is to build awareness and capacities of women to promote health seeking behaviour, findings suggested

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otherwise- that AWWs were more focused on outreach and provision of ‘tangible’ services as against education. ‘Generally, they (workers) don’t advise much but after checking weight they give the iron tablets for better health to the pregnant women.’ (FGD with Beneficiaries, Baseri ICDS Project, Dholpur district) From the above analysis pre-school services emerge as the least preferred service for both existing and potential beneficiaries though this service is somewhat being utilized due to the incentive of supplementary nutrition and lack of options to send children to private facilities. A clear preference for private facilities has emerged. The study also highlighted that supplementary nutrition will not be able to attract the non-beneficiaries as it emerged as the least preferred service for the non-beneficiaries due to its quality. The supply of supplementary nutrition by the SHG has been identified as the major cause of poor quality. Referral service has been identified as the only least preferred service by the key influencers and beneficiaries due to distance and lack of transportation facilities.

2.1.3 Perceptions about Functioning of Anganwadi Centre, its Monitoring and Convergence with Other Departments

Convergence between ICDS and Health department is critical as 3 out of the 6 services viz. Immunization, Referral Services and Health Check-ups are provided by the Health Department. The above sections have highlighted that out of these 3 services only immunisation is being utilised and in fact has emerged as a preferred service. Whereas the availability and utilisation of the other 2 services has a lot of scope for improvement. Convergence and monitoring of the activities of the AWCs has an impact on the functioning of the AWCs. In this section we explore the functioning of the AWCs, specifically with regard to two aspects, i.e. how convergence between the ICDS and Health Departments is implemented at the grassroot level and AWWs’ perceptions about supervision and monitoring of their work done by their supervisors During discussions AWWs have reported that ASHAs specifically work as key support systems for AWWs with a lesser extent of support being given by ANMs. AWWs mentioned that ASHA workers helped in mobilizing community members for ICDS activities to a large extent. ‘ASHA makes field visits and brings pregnant women to the center for registration.’ (AWW, Lalsot ICDS Project, Dausa district) ‘The Helper and Asha worker help me in visiting homes, gathering children etc.’ (AWW, Lalsot ICDS Project, Dausa district)

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‘It was also found that the AWW, ASHA and ANM were able to work together as a team to deliver ICDS services that were in convergence with the health department. ‘ANM assists me in my work and gives me important information. Both ASHA and ANM are there with me while conducting any activity with or providing any service to community members. We are constantly in touch with each other. Asha does the immunizations and she also helps me in all my work.’ (AWW, Mahuwa ICDS Project, Dausa district) Similarly, ASHAs and ANMs also reported working together smoothly with the AWWs without any report of conflict. ASHAs also reported conducting pre-school education activities together with the AWW. ‘We provide immunization along with the AWW at the AWC. We attend meetings together and, go for home visits. We also conduct registration of pregnant women and organize VHND together.’ (ASHA, Baseri ICDS Project, Dholpur district) ‘We organize the VHND together. My work is also to help the AWW to register women and children for immunization. For this we also conduct home visits to register women who have conceived and to know the number of children who need to be immunized. While making home visits we also talk about health issues and we make young mothers understand the importance of breast feeding their babies. Along with the AWW, I also do the registration of births and deaths.’ (AWW, Mahuwa ICDS Project, Dausa district) The sarpanch and school teachers were also perceived as support systems by some AWWs, with the sarpanch helping with repair of AWC buildings, providing chairs, toys and mats for the centre etc. in some cases. Teachers were reported to help AWWs with teaching skills. ‘Since we are running the AWC in the school, we come in close contact with the teachers and they give us suggestions to teach in a better manner. The sarpanch tells the villagers to avail the services of the AWC.’ (AWW, Mahuwa ICDS Project, Dausa district) ‘I require the support of the sarpanch as he is the person who is responsible for the development of the village. Earlier the AWC was at a distance of 1 km from here and as it was at a distance most children would not come to the center. So, we brought this to the notice of the sarpanch and he helped in opening the center here. Now more children are attending the AWC.’ (AWW, Mahuwa ICDS Project, Dausa district) However, in some cases, the sarpanch was also found to not be supportive which caused problems in the functioning of the AWW and the AWC. Discussions revealed that AWWs expected much greater support from the sarpanch particularly with regard to funds for maintenance and repair of infrastructure and resources at the AWC; however, often, this support was not provided.

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‘The sarpanch has to sign my attendance and only then do I get my pay. However, for some reason, he does not do it. On one occasion, I had to write an application and go to my superiors at the Gram Panchayat to get the approval.’ (AWW, Rajakhera ICDS Project, Dholpur district) ‘The space for the AWC has been given to us by the school. Our AWC was in a bad shape and would fall any day. So, we went to the sarpanch and told him about it. The Sarpanch told us to give it in writing. But till now nothing has been done about it.’ (AWW, Lalsot ICDS Project, Dausa district) ‘We did ask many times to provide toys for the children. We were denied of the same so we had to get it ourselves. We even had to purchase the clock here. He just says that you continue running the school and that the school must not shut down. He has not helped in anyway as such.’ (AWW, Baseri ICDS Project, Dholpur district) The role of the supervisor was perceived to be that of a mentor by some AWWs. AWWs reported that the supervisor informed them about new schemes and supported them to fill registers. ‘The supervisor also helps if we need her support. If any new scheme is introduced, she tells us of it.’ (AWW, Lalsot ICDS Project, Dausa district) Thus, overall, convergence appeared to be working well that led to AWWs feeling greatly supported in their work. This has led to immunization to be identified as a preferred service of the AWCs. The role of panchayats, school teachers need to be further explored to see what role they can play in smooth functioning of the AWC. With the supervisors, because it was reported that they act as mentors, their role in refresher training and capacity building of AWCs on a more regular basis needs to be further explored in order to address any pertinent gaps in knowledge and skills faced by AWWs. 2.1.4 Perception of Factors Facilitating and Obstructing Utilization of Services (Demand-side Barriers to Utilization)

This section highlights the demand-side barriers that dissuade beneficiaries from availing ICDS services. Demand-side barriers are defined as determinants of use of health care that are not dependent on service delivery or price or direct price of those services. They include distance, education, opportunity cost, and cultural and social barriers1. The following sections outline the demand-side barriers to utilization as perceived by different groups of stakeholders: 1. Lack of awareness: For AWWs, the belief that community members lack awareness and that they do not understand benefits of services emerged as a recurrent theme throughout. While in some instances health workers identified lack of basic infrastructure, facilities and resources as a key barrier, majority of the ASHA and ANM workers as well as Key Influencers

1 http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-

1095698140167/EnsorOvercomingBarriersFinal.pdf

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believed that lack of awareness and not understanding the benefits of services was the major deterrent for community members utilizing the services of the AWCs. Additionally, discussions with KIs and service providers also suggested that due to certain social beliefs and traditions, women’s and children’s health and nutrition was not valued. ‘Many villagers do not know about government schemes and some others couldn’t care less. The AWW sometimes does not let people know beforehand about camps. Most villagers are not aware about the services provided by the AWCs.’ (Sarpanch, Mahuwa ICDS Project, Dausa district) 'Villagers ask us what benefit we will get if we attend the meeting.' (AWW, Mahuwa ICDS Project, Dausa district) 2. Poor Intent and Health-Seeking Behaviour: Along with lack of awareness, the lack of intent to avail health and nutrition services was another key barrier identified by AWWs, ASHAs, ANMs and KIs. Lack of education (formal) was attributed to be the cause for this. 'As parents from SC communities are not educated, so they have to be pushed a bit to send their children to Anganwadi. Among the General community, the parents are educated and they send their children to private schools. (ASHA worker, Baseri ICDS Project, Dholpur district) Next, it was also stated that the lack of importance given to education was a key barrier. ‘Here, people don’t understand the importance of education much. Hence it becomes difficult to make them understand every now and then to send their children to school. (ASHA worker, Rajakhera ICDS Project, Dholpur district) ‘There are so many villagers who do not want to take the benefits/services provided by the AWC. Parents do not send their children and then complain that the AWC does not remain open. I don’t know why parents do not want the services but I think that the parents are irresponsible. I keep hearing from them that the AWW opens the center for only an hour. (Sarpanch, Mahuwa ICDS Project, Dausa district) 'There are some people who do not avail of the services as they are careless. There are some people who will send their children to school only if they get some money.' (School Teacher, Mahuwa ICDS Project, Dausa district) 'Their thinking is different so they can’t help much as they don’t understand the need. They don’t think of education as the primary important need for a child’ s development.' (Ward Member, Mahwa ICDS Project, Dausa district) However, discussions with beneficiaries and non-beneficiaries revealed that this was not true. On the contrary, it was revealed that if affordability was not a challenge, people preferred sending their children to private schools over government schools and Anganwadis because they felt that the quality of service in private services was much better, despite the high cost.

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This also implies that education itself was valued by community members. This preference for private over public services will be elaborated upon in detail subsequently. What is implicit in these findings is that service providers and KIs might not fully understand the value that women and their family members place on education and health and why they do so; which will be the first step for AWWs to understand why they do not value ICDS services as much or why these community members need to be convinced to avail of services. The perception of government service providers that poor and marginalized people do not value health and nutrition because of lack of education and hence, are resistant was evident in discussions. This assumption might be a gross misunderstanding of the challenges faced by women to ensure good health and nutrition for themselves and their children because of socio-cultural norms. 3. Lack of identity documents such as Aadhar card is a barrier for making the MCP card as expressed by AWWs as well as beneficiaries. 4. Resistance from older family members: Probably because of their greater community engagement, several ASHA workers could share the resistance that women face from family members in seeking health and nutrition services, especially from elders in the family such as the mother-in-law; as well as the lack of support in household chores and caregiving work. ‘Yes, sometimes there is a conflict of opinion between family members where the older generation don’t support the younger generation. They think that we are bringing unnecessary complications and sometimes are not willing to send their children to us.’ (ASHA worker, Mahuwa ICDS Project, Dausa district) 'People do not understand and follow our advice. People do not allow to take their children's weight; the mother-in-law will not allow women to take our advice.' (ASHA, Lalsot ICDS Project, Dausa district) 'Few women can't come to AWC as their husbands have gone to Chambal for bread earning.' (School Teacher, Rajakheda ICDS Project, Dholpur district) 5. Preference for private health and education services: For potential beneficiaries, it was found that their preference for private services combined with their ability to afford private services was crucial as a deterrent. At the same time, while the ICDS services on paper are not meant only for poor, marginalized groups, the belief that private services (that which you pay for) will offer better quality services was found to be predominant among potential beneficiaries and hence dissuaded them from participating in ICDS activities. Further, this belief that private schools and hospitals offer better services but that affordability is a challenge, was echoed by existing beneficiaries as well as service providers (AWWs, ASHAs and ANMs) and KIs. What role specific community norms must play in this regard was not explored in detail in this study and hence cannot be commented upon. Distance of the AWC from their homes was again a major deterrent as was found to be the case among beneficiaries as well as seen in data below.

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‘People generally prefer going to private schools. The government schools are very far and it is difficult for the child to go every day. Once they are enrolled in private, they don’t have to worry about conveyance.’ (FGD with Non-Beneficiaries, Mahuwa ICDS Project, Dausa district) 'We go to private hospitals as we are treated better. We are given good care in private hospitals. Only those who are aware of the medicines and treatment prefer going to government hospitals.' (FGD with Non- Beneficiaries, Lalsot ICDS Project, Dausa district) 'People who are a little well off and are able to afford, prefer sending their children to private schools to study as they offer a better education. Also, because the AWC does not have good facilities and infrastructure.’ (ASHA worker, Lalsot ICDS Project, Dausa district) 'I think it is Private services that people prefer. In Government services the responsibilities are not allocated. Children are doing well in private schools as compared to government schools. If there is a major health problem people prefer private hospitals. If it is something not very serious, only then they go to government hospital. There are less facilities in government hospital.' (School Teacher, Mahuwa ICDS Project, Dausa district) 'It’s the mindset of the people that private school is better. In government school, there is lack of facility, but still we have 100% pass rate in 10th standard. I can say that in higher education, the guidance and facilities do matter, but not in villages for middle or higher secondary education. They mostly go to government health centers. For more serious health issues, they go to private.’ (School teacher, Mahuwa ICDS Project, Dausa district) 6. Time constraints: For both existing and potential beneficiaries, their busy work schedules combined with the distance of the AWC from their homes were deemed as major barriers to effective utilization. Further, as mentioned above, it was found that women’s daily responsibilities dissuaded them for being able to regularly access services at the ICDS and lack of support from family members only added to the problem. 'We work on the fields, so we are not aware about the centre.' (FGD with Non-Beneficiaries, Baseri ICDS Project, Dholpur district) 'If the centre is located nearby, women can go and avail services but as they are far, they don’t go much. It is also difficult for the workers to go to people's homes and provide services.' (FGD with Beneficiaries, Lalsot ICDS Project, Dausa district) 'We are not very aware of the activities taking place there as we don’t go regularly. It is very far and the children cannot go alone. The mothers must accompany them and as it is quite a distance, the mothers don’t prefer going there. If there is a centre close by, it will be easier for us to go. During the rains, as the roads are not good, we have a problem during those months

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to go to the centre. The centre should be nearby so that all of us can go and the roads should be easy and approachable.' (FGD with Non-Beneficiaries, Lalsot ICDS Project, Dausa district) 'We want the centre to be near our village so that we can go there every day and avail the services provided by the government. If the workers could get a vehicle for the home visits, then they would be able to work efficiently.' (FGD with Non-Beneficiaries, Mahuwa ICDS Project, Dausa district) 'The center is around 2 km away from our village. We don't go there regularly, only sometimes for immunization. Very rarely they(workers) come to our village for surveys and we hardly get any food supplies. As it's far, we also don't go much.' (FGD with Non-Beneficiaries, Baseri ICDS Project, Dholpur district) This implies that the support and active involvement of family members will be crucial to ensure increased utilization of services. Programmes and mobilization strategies need to consider the responsibilities and exhausting burden placed on women to ensure good health and nutrition for their children to be more effective. 7. Refusal to seek treatment for anemia: Specifically, findings suggested that malnutrition and its complexities was not understood completely in all its gravity by beneficiaries. ‘There are some pregnant women who are anemic and so we refer them to hospitals. But some of the women do not go to the hospitals. They think there is no need for them to visit hospitals and that they will get better on their own. (ASHA worker, Baseri ICDS Project, Dholpur district) 'In referral services, they don’t feel the need to visit bigger hospitals as they don’t consider children to be malnourished even if the child weighs under 2 kg' (AWW, Lalsot ICDS Project, Dausa district) 8. Fear of side effects of immunization: While the fear of side effects of immunization appeared to have reduced over time, AWWs reported that there still were some families in the areas that they worked in, where due to previous negative experiences of side effects as result of immunizations, people feared getting their children immunized. However, overall, the value of immunizations was much higher in the communities visited as against the fear of side effects. ‘Some people do not like to immunize their children as they fear that it will cause fever.' (ASHA worker, Mahuwa ICDS Project, Dausa district) 2.1.5 Perception of which Community Members Avail/Not Avail the services of the AWCs

This section explores the perceptions about community members who avail or do not avail services as well as their experiences of discrimination. Overall, findings revealed mixed perceptions, however, it must be acknowledged that this is an extremely difficult subject to explore especially in all its subtleties and complexities.

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Findings suggest that caste based discrimination is practiced in the study locations but these findings do not completely explore the extent of caste based discrimination. However, majority of AWWs, ASHAs, ANMs and KIs suggested that there was NO discrimination. Data analyzed showed that service providers perceived that people from Dalit families do not value education, that beneficiaries did not discriminate against people from Dalit families and that AWWs themselves never discriminated. 'The lower caste people do not understand the value of education and so do not send their children to school. Their children don't come to the center regularly.' (AWW, Baseri ICDS Project, Dholpur district) ‘No, there has never been any conflict among religion or community. They all sit together when we conduct meetings. We also have few people coming from general category who come to attend the meetings. (ASHA worker, Mahuwa ICDS Project, Dausa district) At the same time, findings, even though suggestive and not conclusive, suggested that there were instances of caste discrimination and service providers stated that that Dalits do not live in the same vicinity as people from other so called ‘upper’ or ‘high’ castes, and that people from ‘high’ castes do not like having food from the same place where Dalits are also present. ‘Now there is not as much discrimination as in the earlier days. When I joined in 1985, it did exist. At that time people were not educated and the general caste people would not eat the food cooked by SC/ST. Now more and more people are getting educated so there is less discrimination, although it does exist but to a lesser extent. According to me, caste plays a very important role. Although the children sit and eat together, there is still some level of discrimination in the minds of the AWWs. Some of them do not wash the utensils of the SC/ST population. I have also seen cases where if the food is cooked by SC, general caste people do not eat the food. I would like to see a change in this.’ (ANM, Mahuwa ICDS Project, Dausa district) 'Families from general category do not prefer to take the cooked food offered here. They say they can make the same at home but they do carry the packed foods.' (AWW, Rajakheda ICDS Project, Dholpur district) ‘There are no toilets or drinking water facility available at the Anganwadi center. So, the staff and children often need to carry their own water bottles. For toilet use, they are forced to go to their homes which are situated far off from the centre. There are houses nearby the centre but the people there do not give them water or allow them to use their toilets as they belong to high caste.’ (AWW, Baseri ICDS Project, Dholpur district) ‘No. All children sit together. There is absolutely no caste discrimination among the pregnant and lactating women who come to the center. We have a toilet at the centre but I bring drinking water from my house. There is a hand pump but it belongs to the SC community.’ (AWW, Lalsot ICDS Project, Dausa district)

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It was observed that most AWWs themselves belonged to the General category, even when the AWC was located in an area with high SC, ST and/or OBC population. This was in direct contrast to the selection criteria of the ICDS department in Rajasthan that provided for AWWs to be selected from that community whose population was highest in the area served by the specific Anganwadi. 'The AWW is a Brahmin but she does not discriminate. All children eat, play and study together irrespective of community. They stand in a queue for the food and there is no discrimination ‘ (ASHA worker, Mahuwa ICDS Project, Dausa district) 'Here in this panchayat, maximum people are OBCs although there are a few SC, ST and General caste families too. I don’t think general caste people go to the AWC. But most AWWs belong to the general caste.' (School Teacher, Mahuwa ICDS Project, Dausa district) Further, economic conditions and class was also a big issue, where rich people were found to be not willing to send their children to the AWC, and instead preferred private schools. 'Rich people send their children to private school however they do come to the AWC to get their children immunized.' (AWW, Baseri ICDS Project, Dholpur district) 'People from General category prefer sending their children to private schools. They want to send their children from 3 years of age to schools and make them learn from a very young age, whereas if they come here, they have to study here till 6 years and then start going to primary schools.' (AWW, Mahuwa ICDS Project, Dausa district) ‘It is mainly the upper class of society who do not send their children here as they can afford better education.' (ASHA worker, Mahuwa ICDS Project, Dausa district) Further, it was suggested that most people who avail services at the AWC are poor and those who cannot offer private services. 'Most of the people are poor and fall below the poverty line. There are many who are landless.' (Sarpanch, Last ICDS Project, Dausa district) 'The poor come so that they can feed the kid. The well off too come and take the food and give it to cattle. If I don’t give, they will argue with me.' (ASHA worker, Baseri ICDS Project, Dholpur district) These findings reveal the need for more targeted and inclusive interventions/activities designed to address structural problems of caste based discrimination in order to increase universal access to ICDS services. More research is also needed in this area to fully pan out the nature in which caste based discrimination persists not only among beneficiaries but also

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among AWWs, ASHAs and ANMs w.r.t their selection process as well as their behaviour towards beneficiaries from different castes, classes and religions.

2.2 Perception of Quality of Services Provided by AWCs Insights around the quality of services, in discussions with respondents, was explored at three levels: perceptions regarding quality, supply-side barriers to provision of services and identified needs and recommendations regarding improvement of services. 2.2.1 Perceptions of Quality of Services Provided by AWCs

Findings from the study revealed that overall there were similarities in perceptions around the quality of services provided by AWCs across frontline health service provider groups as well as existing and potential beneficiaries. The poor quality and insufficiency of, and the lack of variety in supplementary nutrition was the major challenge faced by Anganwadis which was noted by all respondent groups. Following is a more detailed analysis of perceptions around quality with each of the service.

i. Quality of Supplementary Nutrition: AWCs play a vital role in promotion of community based supplementary nutrition in India. The present section outlines the findings of the perceptions of AWWs and the community on the quality aspects of the supplementary nutrition provided through AWCs. The lack of diversity in nutrition provided emerged as a major concern as was reflected in discussions around quality. Existing beneficiaries said that whereas in schools, children were also given milk, this was not the case in Anganwadi centres. Further, women also said that their children often refused to eat the food because it did not taste good. There were also instances recorded where children fed the food provided by AWCs to cattle because they did not like how it tasted. This was shared in discussions with both existing and potential beneficiaries. Apart from this, the potential beneficiaries did not have any other insights to share about the quality of supplementary nutrition. 'There have been some changes in the working of the centre. Earlier we used to get Soya bean oil, which we do not get now. Earlier their used to be a flour made of maize which was better than the present one. We have never been provided with milk, egg or bananas.' (FGD with Existing Beneficiaries, Morena ICDS Project, Dholpur district) 'The quality of food given here is not good. Sometimes we don’t eat and feed them to cattle. ' (FGD with Existing Beneficiaries, Baseri ICDS Project, Dholpur district) 'I did send my children to the Anganwadi about 8 years ago. The children used to get a small packet of food which they didn’t consider tasty and they would feed the cattle.' (FGD with Potential Beneficiaries, Mahuwa ICDS Project, Dausa district) Pregnant women and lactating mothers are given supplementary nutrition, also called take home ration (THR), under the integrated child development services (ICDS) programme at

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Anganwadi centres. THR is a dry mixture of wheat, gram and soya bean flour, sugar and edible oil. Each 100 gram of nutritional supplement has powder of wheat (50gm), chana dal (5gm), soybean (11gm), sugar (29gm) and edible oil (5gm). The pregnant woman, lactating mothers and adolescent girls get a pack of 950 grams and the children get 750 gm of the supplement every week.

Packet of 950 gram of THR for Pregnant

women and Lactating Mothers

A Lactating Mother collecting 4 packets of

THR in Dholpur on the day of VHND

Interestingly, it was also shared that while they knew that soya bean was packed with proteins, women did not like to eat it because it did not smell good. AWWs and ASHA workers also shared that often they fall short in the quantity of food provided to them for distribution; and that if young children, came accompanied with their older siblings to the centre, the service providers did not want to refuse food to the other children. Perceptions of key influencers about supplementary nutrition in general was positive with several stating that ‘all the services provided helped the poor and needy’, but the deterioration of food quality over time was also a concern that was expressed by respondents in this group. Overall both the service providers and the beneficiaries highlighted quality issues with the supplementary nutrition being provided in the AWCs. They also felt there was a lack of diversity of the nutrition provided. At times insufficiency of quantity of food for was also highlighted.

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ii.Quality of Pre-School Education:

Across respondent groups, it was stated that the quality of pre-school education was not very good and in general, people preferred sending their children to private schools where they would be provided with uniforms and drinking water was made available. Further, it was also noted that the quality of teaching was poor. 'Only few children go for pre-school education because other than giving them khichdi, there is not much benefit- the quality of teaching is not good. So, most people send their children to private schools.' (FGD with Non-Beneficiaries, Mahuwa ICDS Project, Dausa district) ‘Some of the services are really good especially pre-school education. Some of the children coming to the AWC are really very poor. So, it is good for them. We admit children in the school only after they turn 6 years of age. So for the children below that age, AWC is a good option as they can learn something and be prepared for regular school. But at the same time there are also a lot of drawbacks.’ (School Teacher, Lalsot ICDS Project, Dausa district) Many mothers reported that private nursery school children were found to be more skilful than their Anganwadi children. Preschool education under ICDS programme should give real emphasis on child centred activities to develop creativity among children. Perceptions of the key stakeholders has also highlighted poor quality of pre-school education. In order to gauge the extent to which these perceptions are based on practices, observations of AWCs were undertaken. During these observations it was highlighted that the time spent by the AWWs on non-formal preschool education was very low and participation of children was not punctual and regular. Learning through play and outdoor activities were noticed only in very few AWCs. In all the AWCs observed it was found that the physical environment of the Anganwadi centres is not very conducive to conduct preschool education activities and lack of sufficient space for the children to sit was found to be a major problem. It is observed and reported by community leaders that the AWWs focused on formal method of learning.

iii. Quality of Other services: As supplementary nutrition and pre-school education were the

two main services that community members availed apart from immunization services, there was not substantial information gathered with regard to the quality of the other services provided at the centre as its provision and utilization was limited. Some insights with regard to quality of services were that people preferred private over government services when it came to hospitals, especially those who could afford these services. Those who could not afford private services, did face challenges with regard to quality of services on Immunization provided at the Anganwadis.

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‘People generally prefer going to private hospitals. The government hospitals are very far and it is difficult for them to go there. Additionally, private hospitals are much better as they properly take care of’ (FGD with Non-Beneficiaries, Mahuwa ICDS Project, Dausa district) Village Health and Nutrition Day (VHND) which is observed once a month at the AWC is the scheduled day for immunization. Immunization is done by the ANM supported by ASHA and AWW. During the observations of VHND it was observed that attendance with respect to immunization was very low. The other observation were that the ANM came very late and there was no publicity done in the village before the VHND day. Irregularities and lack of sincerity of frontline health functionaries affects the immunization programme in the village Overall in terms of quality of services provided clearly much work needs to be done to improve the provision of quality of services along with changing the perception on quality of services provided. Preference of private services over government services itself is a reflection of the perception of comparatively poorer quality offered by government facilities as compared to private facilities. 2.2.2 Perception of Barriers to Provision of Quality Services (supply -side barriers)

The biggest barrier to provision of quality services expressed by respondents was the lack of infrastructure and poor quality of resources available. Lack of electricity connection, drinking water facilities and no availability of toilets were huge challenges faced by the AWCs and which directly impacted the services and its quality provided by them.

Food is cooked inside class room of AWC Unused Latrine at AWC 'Irrespective of the harsh weather conditions we have to continue doing our work. There is no electricity connection, no drinking water supply, no washroom here. The centre has never been repaired.” (AWW, Morena ICDS Project, Dholpur district)

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Problems reported by AWWs with regard to infrastructure, resources and facilities were: No furniture/ seats/mats for children and women to sit on, no/less storage space for records and other materials, no electricity, lack of drinking water at the centre, maintenance of building and facilities, lack of toilets, dysfunctional weighing machines, torn books and broken toys, no boundary wall as well as lack of sufficient space to accommodate beneficiaries. During observations conducted by the study team, all of these problems mentioned above were found to be true. All four AWCs that were observed did not have electricity, fans, tube lights or sufficient cross-ventilation and one of the AWCs did not even have sufficient natural light. The only AWC that was found to have a hand pump as drinking water source was one which was located in the school premises. The others did not have any source for drinking water and AWWs had to get water from another place. Further, drinking water was stored in buckets or earthen pots that appeared visibly dirty. It was also observed that utensils used for feeding children were washed with mud. With regard to toilets, it was found that only two out of four AWCs observed had a toilet but both these toilets were not functional. Thus children in all four AWCs had to use open spaces for toilet purposes. Further, there was no garbage disposal system in any of the AWCs and garbage was observed to be thrown outside in the open. Second, the outsourcing of provision of supplementary nutrition to SHGs was attributed to the poor quality of food by KIs. ‘Nowadays, the food supply is on contract basis hence the quality had deteriorated.' (School Headmaster, Rajakhera ICDS Project, Dholpur district) Third, the poor quality of resources such as toys, educational games, books, slates etc. as well as the absence of physical space such as a playground for conducting activities with children during pre-school was a major barrier. During observation of AWCs, it was found that only two out of four AWCs had toys and books but these were broken/torn. It was also observed that while outdoor space was available outside AWCs these were not designed to be play areas and did not have a boundary wall for additional safety. Interestingly, a majority of the key influencers were of the opinion that the services provided were of good quality, but the problem lay in the mind set of community members. Several also felt that the services were good as they were helpful for the poor and needy, while also accepting that the quality had deteriorated over time. Key influencers may feel that the quality provided to the poor and needy need not be of high standards. ‘I think it(quality) is okay. There are so many villagers who do not want to take the benefits/services provided by the AWC. They do not want to complete immunizations, bring medicines and do not eat. Many of them do not send their children for the pre-school education. Parents do not send their children and then complain that the AWC does not remain open.’ (Sarpanch, Mahuwa ICDS Project, Dausa district)

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The perception that the provision of supplementary nutrition was a problem rather than a need was also stressed upon. It was stated that the provision of free food led to people misusing the service. ‘Some people send older children who are 8-10 years old to the Anganwadi for food. Meals has spoiled the education system and corruption has also increased. Meal distribution also consumes lot of time.’ (School Teacher, , Baseri ICDS Project, Dholpur district) Additionally, malpractice by AWWs was also highlighted as one of the issues affecting service quality. 'The fact is that only a few of the deserved women get the food, the rest is taken away by Anganwadi Workers to their home or their friends or relatives. Everyone know that.' (Sarpanch, Baseri ICDS Project, Dholpur district) Not receiving the food ration on time was a challenge noted by AWWs with regards to timely provision of food, resulting in problems with community members. 'We do not get food ration on time and so the children cannot be fed. Many women therefore come and fight with us when children are not fed.' (AWW, Mahuwa ICDS Project, Dausa district) Further, the distance to government health centres/hospital and lack of transport facilities was found to be a barrier that affected the utilization and quality of referral services by most beneficiaries and non-beneficiaries. ‘That is not of much use as we have to go to the hospital they have referred to, in our own vehicle. Sometimes, it is difficult for the pregnant woman to travel a long distance. The vehicle is provided sometimes only for one way.’ (FGD with Beneficiaries, Baseri ICDS Project, Dholpur district) 2.2.3 Perception on Needs to Improve Quality of Services Provided by AWCs

The study findings showed that to improve quality of services, changes were required in three major areas, i.e.,

Infrastructure and Resources of the AWC for Pre-School Education:

Quality, Variety and Quantity of Supplementary Nutrition and

Capacity Building / Training of AWWs.

i.Infrastructure and Resources of the AWC for Pre-School Education: Most of the AWWs shared that they would be able to do a better job at providing pre-school education services if they had the necessary infrastructure and facilities as books, toys, space for playground, drinking water etc. ‘If they could get good books and educational toys so that they learn better and quicker, they would feel encouraged to come here. We would also like to provide drinking water and toilet

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facilities. There is no electricity. If that can be improved, then lot more other services can be provided. As of now, the school don’t have anything to sit other than few mats. If we could get dome chairs and tables, the children would feel more comfortable.’ (AWW, Rajakheda ICDS Project, Dholpur district) 'I need more swings for the children to play, more toys and other good teaching aids so that the children can be taught using games and play. It would be good if children are provided with a uniform and games. If all these are provided at the center, more children will come here. There is no source of water at the center. I bring drinking water from my house. For the children, water needs to be bought from a far-off place. There are also no toilets at the centre." (AWW, Mahuwa ICDS Project, Dausa district) Service providers noted that improvement in basic infrastructure and resources would lead to an increased interest in learning and the ability to stay at the centre for longer hours without problems. ‘Basic infrastructure can be improved like the children can be given a uniform and bags. Even toilets and drinking water facilities can be improved. even to sit in classrooms they just have a mat. They can have better seating arrangements and toys to play so that the children develop an interest in learning.’ (ASHA, Rajakheda ICDS Project, Dholpur district) A good step taken by the Education Department of the Govt. of Rajasthan was to merge Anganwadi Centres with government schools for providing better facilities to students. This model of integrated Anganwadi Centres and government schools is ideal for assuring transition of children from care centres to schools as this model acquaints children with the school environment at an early age. In Rajasthan government has merged 11,000 Anganwadis with schools in the past two years. Provision of infrastructure and equipment at the AWCs followed by efforts to create awareness among community, especially gram panchayat members, govt. school teachers and village leaders to extend their contribution towards preschool education in the form of supervision of activities and solving problems of AWWs will go a long way in improving the pre-school services offered by AWCs.

ii.Quality, Variety and Quantity of Supplementary Nutrition: Beneficiaries stated that if the quantity of supplementary nutrition could be increased such that all children and pregnant women could get benefits and if they could also include a variety of food items as milk, biscuits, fruits etc, it would be nutritious as well as appealing to community members, adult and children alike. ‘The quality of food can be improved and sometimes there are more number of children and the food supplied is not sufficient. The food given here has no variety and sometimes the children don’t get sufficient quantity. If the food provided here is calculated, then all the children can be properly fed.' (FGD with Beneficiaries, Baseri ICDS Project, Dholpur district)

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‘The schools have started offering milk to students. It would be good if in the Anganwadi center also milk is supplied to the children. Also, since most of the children come from poor families, it will be a good idea to provide them with dresses. They should be provided fruits and vitamin tablets.’ (Sarpanch, Lalsot ICDS Project, Dausa district) ‘AWC provides good services however they should increase the variety in distribution of food and have more toys for education.’ (Teacher, Rajakheda ICDS Project, Dholpur district) Further, beneficiaries also stated that they saw a linkage between improvement in supplementary nutrition and increased utilization of pre-school education services. 'The children will stay here if they are given good food too and better facilities like good toys to play. Then they can show interest in studies.' (FGD with Beneficiaries, Baseri ICDS Project, Dholpur district) Key influencers stated preference for locally made food over food outsourced from other places as they felt that this would help provide freshly made, nutritious food to beneficiaries. ‘They get the food from outside, like Dholpur or somewhere else, but if it is made locally, food like, wheat gruel, it would be better. I was once checking the food provided at the centre and saw that the food was prepared centrally from somewhere else and brought in a vehicle and dispatched according to the number of children. The food should be made at the Anganwadi or at the school where it is situated. Now the food is prepared sometime in the morning at 4. o’clock and served to children at 1 o’ clock, with the risk of getting spoiled. (Sarpanch, Baseri ICDS Project, Dholpur district) In order to enhance the perception of supplementary nutrition it is essential to address the issue of variety and quantity. Further steps need to be taken to monitor the quality of food provided by the SHGs/ other local bodies along with mechanism for rectification in case of supply of poor food quality. Further it is recommended that regular reinforcement of training with on-job capacity building, supervision and follow-ups with regards to supplementary nutrition practice rather than just IEC (Information education and communication) on key supplementary nutrition messages. This would help to accelerate prevention and reduction of undernutrition in community.

iii.Capacity Building of AWWs: While the major focus of inputs on quality of services was around infrastructure, resources available at the centre and the quality of food provided, some beneficiaries as well as service providers expressed the need for having well qualified teachers to teach children and to improve the quality of teaching at the centers. Apart from these key areas of improvement, the need for AWWs to do more information dissemination and organize more health camps for women at the community level were also needs expressed in discussions by several beneficiaries.

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Discussions with AWWs revealed that while majority of AWWs had been working for 10-15 years, they had only received only one long training i.e. a one-month training at the start of their employment followed by 2-3 trainings for a duration of 1-2 days in their panchayat itself. Post this, no further refresher trainings had been conducted. Further, it was revealed that there was no formal structure of mentoring AWWs on an on-going basis except basic support (filling records, growth monitoring charts etc) provided by Lady Supervisors. Further, based on the description of trainings by AWWs, it was found that while the training provided to AWWs had focused heavily on knowledge building, there appeared to be lesser focus on skill building. With regard to knowledge, AWWs stated that they had been trained on supplementary nutrition for pregnant and lactating mothers as well as infants and children, child development, importance of immunization, ensuring balanced diets, essential nutrients and growth monitoring. With regard to skills, the only skill mentioned by AWWs that they learnt during training was teaching pre-school children using play as a method. Apart from these, no skills were mentioned as having been incorporated in their training programme. Next, AWWs also mentioned that they feel that they need more training on not only conducting pre-school education sessions better but they also need to learn about community mobilization. Further, maintaining records and growth monitoring was another aspect mentioned by AWWs that they need more training on. Some AWWs also shared that refresher trainings at regular intervals would not only help them revise topics but would also help them build their skills of working. During observation of AWCs as well as during discussions with AWWs, it was observed that AWWs had difficulty remembering and naming the services provided at the centre and often became nervous when asked to recall. Thus, a redesign of training strategy to incorporate changes in knowledge, skills as well as attitudes as training objectives would be crucial to ensure that the capabilities of AWWs are built in a more comprehensive manner. A training strategy that is more activity based and participatory in nature will also help ensure that AWWs do not rely on recall and memory to remember information but rather ‘learn by doing’. Some more critical aspects of training have been discussed in Chapter 4 in this report under Perceptions about AWWs. Keeping in mind insights from community members and service providers, next chapter will focus on perceptions of government officials at various levels (ICDS Project, District and State) to understand their perceptions of functioning of ICDS centres, what is working well, gaps and challenges as well as gain insights into their recommendations for improvements in the scheme.

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Chapter 3: Perception of Government Officials on Functioning of AWCs

Successful decentralized program planning, management and monitoring of the ICDS scheme is the responsibility of functionaries at various levels viz. at State, District, ICDS Project (Project) and Village levels. These functionaries are responsible for (i) planning (ii) designing community awareness and mobilization strategy; (iii) scheduling capacity building at village level (iv) facilitating inter-sectoral convergence and (v) ensuring regular monitoring and feedback. The perception of these functionaries regarding the functioning of the AWCs influences their priorities and decision making and hence gaining insights into these perceptions is critical. Further, their perceptions along with perceptions of other key stakeholders helps build an understanding around service-related gaps and how these can be addressed. It also highlights extent of variation or similarity in the viewpoints of the key stakeholders of the ICDS scheme and will help design strategies for convergence of viewpoints. The previous chapter outlines the perceptions of AWWs, ASHA and ANM along with community members (KIs, existing beneficiaries and potential beneficiaries). This chapter focuses on the perceptions of government officials on the functioning of ICDS and its overall implementation. The following sections outline the perceptions of functioning of AWCs with respect to infrastructure, equipment, resources and services provided and identifies factors felt to be contributing and hindering the functioning of AWCs (both demand- and supply-side). Next, the chapter explores perceptions around convergence and finally also attempts to understand the challenges and felt needs of government officials, w.r.t the scheme.

3.1 Perceptions about functioning of AWCs Before delving into perceptions, it is important to outline specific interventions undertaken in Rajasthan to further strengthen the scheme as these influence perceptions of the functionaries. Discussions with state level officials revealed that there have been several state level measures undertaken in the state, some of which have also been replicated in other states. The World Bank supported ICDS Systems Strengthening and Nutrition Improvement Project (ISSNIP) seeks to (i) strengthen the ICDS policy framework, systems and capacities, and facilitate community engagement, to ensure greater focus on children under three years of age; and (ii) strengthen convergent actions for improved nutrition outcomes. This project is being implemented in 162 high malnutrition burden districts of 8 States viz. Andhra Pradesh, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Maharashtra, Rajasthan and Uttar Pradesh covering 3.68 lakh Anganwadi Centres. One of the objectives of ISSNIP is to strengthen monitoring of ICDS services through development of ICDS-Common Application Software (ICDS-CAS)2 that involves equipping Anganwadi Workers with a Smart Phone preinstalled with ICDS-CAS and Sector Supervisors with a Tablet preinstalled with ICDS-CAS. This application also seeks to provide a mechanism for Real Time Monitoring (RTM) for nutritional outcomes. Thus, this application enables data capture, ensures assigned service delivery and prompts for interventions wherever required. This data is then available in near

2 https://icds-wcd.nic.in/nnm/NNM-Web-Contents/LEFT-MENU/ICT-RTM/Dashboard%20Manual.pdf

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real time to the supervisory staff from Sector, ICDS Project, District, State to National level through a Dashboard, for monitoring. Next, the Nand-Ghar (Adopt an AWC) Scheme is being implemented in Rajasthan as part of which private donors, NGOs and trusts can adopt an AWC and ensure funding for the adopted AWC for the next five years. The aim is to build community support and further enable revamping of the centre. The Early Childhood Education model of Rajasthan has received a lot of praise and has been scaled across India, specifically the workbooks designed for Anganwadi Centres using a child-friendly pedagogy. These workbooks are called Kilkari (3 to 4 years), Umang (4 to 5 years) and Tarang (5-6 years). The other initiative is the Sakhi Mobile application that serves as a guide for AWWs for hands-on capacity building on conducting pre-school education sessions with children. It is in this context that the following analysis of perceptions of government officials have been undertaken; to understand what are perceptions and experiences of government officials about the scheme, keeping in mind that several interesting interventions have already been undertaken to address needs and gaps within the scheme. With regards to functioning of AWCs, overall findings showed that as a result of digitization, the work of government officials at state and district levels in monitoring the functioning of centres is perceived to make their workload much easier, despite ground level challenges. Further, government officials also reported that poor infrastructure, resources, equipment was a big challenge. The need for better quality training for AWWs was also expressed. These findings are also corroborated with findings from observation of AWCs wherein it was found that in most AWCs, there was no proper storage facility for drinking water, toilets were defunct and not utilised and the AWCs had no electricity connection, fans or lights. With regards to the services of the AWCs being availed, officials at ALL levels noted that immunization and supplementary nutrition services have high uptake. On the other hand most of the government officials reported that the quality of other services i.e., Health and Nutrition Education, Health check-ups, Pre School Education and Referral Services need to be improved in order to increase the utilization. i. Infrastructure, Equipment and Resources: Officials at ALL levels identified problems with regards to the AWC infrastructure as a major challenge in the functioning of the scheme. Problems reported were to do with lack of electricity, fans, toilets etc. combined with lack of funds and support from panchayat members to fill in the gaps. Poor state of AWC infrastructure was seen to be a common challenge across different respondent groups i.e. government officials, frontline service providers or beneficiaries. ‘Lack of infrastructure facilities at the AWCs is the main issue. We need to strengthen the facilities for better utilisation of the services. We do not have sufficient funds to implement the scheme in a proper manner. A lot of work needs to be done which we are not able to do due to the lack of funds. If we have a decent budget, we can influence more people to do good

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work. The basic infrastructure facilities at the centre is not good. The budget provision for rent for the AWC is only Rs 750. For this amount, it is very difficult to get a good building to accommodate all children. At the office level, the rooms lack basic facilities like cupboards. We do not have computers without which things are difficult to do. They have no finance, no proper building and rooms, no registers to maintain the records and no good weighing scales.’ (ICDS Project level official, Dholpur district) In order to address infrastructural related challenges, the ICDS department has integrated several ICDS centres with schools across the state so that physical space, basic facilities and other resources can be shared. The plan is to seamlessly integrate pre-school education with the school education system for the children attending classes at the Anganwadi Centres. Further, state level authorities mentioned that this step has been undertaken so that school authorities can monitor the AWC, ensure utilization of existing resources and support from teachers who can act as mentors for the AWWs. Further, ICDS Project officials as well as Supervisors shared that supplies that were previously received by the AWCs, such as books, toys, weighing machines etc., were since damaged and had not been replaced despite several appeals. Supervisors also mentioned that their appeals to the panchayat members went unheard. Findings from both discussions as well as observation of AWCs showed that weighing machines were damaged, books were torn and medicines were not replenished. These findings also matched with the study team’s observation of AWCs, wherein it was found that only two out of four centres had a weighing machine and only one weighing machine was functional out of these. Toys and books were only available at two centres but were found to be in a bad state. ‘Out of 63 centres, 30 centres do not have a functional weighing machine. In addition, when children come to the centre, we give them books to read and help them in basic recognition of alphabets. Generally, the books are not given to the children to take home but are kept at the centre itself. Even then, the books are not maintained well and several are torn as children do not handle the books properly.’ (Lady Supervisor, Rajakhera ICDS Project, Dholpur district) ‘Also there are no fans in the AWCs. Of the 57 AWCs that I visit, only one AWC has a fan. So these facilities should be made available at the AWCs.’ (Lady Supervisor, Mahuwa ICDS Project, Dausa district) 'I would try to get woollen clothes for small children, because I have seen that some children don’t have sweater to fight the cold. Also, I would buy them school dress, bags, tiffin boxes, educational tools for children, stationary items and chairs for the AWC. I would also install fans and carpets for the Anganwadi Centres which will be useful when women come for meetings. I would also like to install a hand pump.’ (Lady Supervisor, Lalsot ICDS Project, Dausa district) ‘There should be toilets at the AWCs. Also drinking water facilities and electricity, salaries of AWWs and helpers should be increased, toys for children etc should be there.’ (Lady Supervisor, Baseri ICDS Project, Dholpur district)

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‘Most centres do not have weighing machines and they have to make do with the weighing machines of the ANM. Very few centres have been given electric weighing machines. But they are not able to use it because it has to be charged and there is no electricity.’ (Lady Supervisor, Mahuwa ICDS Project, Dausa district) ‘We complain at the office about the weighing machines and they keep assuring us that we will get new machines but so far they have not come.’ (Lady Supervisor, Rajakhera ICDS Project, Dholpur district) Government officials also articulated that the lack of infrastructure and resources was a contributing factor towards poor availability of certain services such as Growth Monitoring. Respondents also shared that an improvement in infrastructure and resources will also lead to increased availability as well as utilization of services. Last, State level authorities stressed on the need for having a vibrant, fully functioning AWC so that people would avail services on their own without requiring a lot of convincing. ii. Quality of Services Provided: Specifically, with regard to services, all government officials noted that the lack of variety in supplementary nutrition and pre-school education services, despite state government initiatives mentioned above, had negatively affected the functioning of the overall ICDS scheme. W.r.t Supplementary Nutrition, officials at ALL levels reported the need for more nutritious and balanced meals as well as need for variety for pregnant and lactating women as well as children. Maintaining quality of food due to decentralization was the main challenge with supplementary nutrition service as mentioned by a state level official. At the same time, it was also reported that decentralization had helped the department to do away with procurement related problems. ‘In schools, children sometimes get fruits, sometimes milk and at other times dal chawal as well. At the AWC, they get the same thing whether it is breakfast or lunch. Now, if a child between the ages of 3-6 years or younger, is given the same food daily without any change, they will obviously get bored of it. We ourselves will get bored of the same food in our own homes.’ (CDPO, Dholpur district) The outsourcing of Supplementary Nutrition to SHGs was also identified as problem by Lady Supervisors and ICDS Project Level Officials. State level authorities on the other hand, shared that due to decentralization in supplementary nutrition, the department no longer faces any challenge with procurement and supply. However, the challenge with quality was said to be prominent as a result. ‘Earlier food was supplied by the government. There are two kinds of nutrition that is given- one is Daliya and Khichdi and the other is snack items which is made available by the government. Now, the responsibility for both has been given to the SHGs. Selection of SHGs is also influenced by political connections. Hence, the outsourcing of the nutrition service to SHGs

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is one of the main reasons for corruption. I think that supplementary nutrition should be entrusted to a trust so that quality can be maintained.’ (Lady Supervisor, Mahuwa ICDS Project, Dausa district) Pre-school Education: Lady supervisors and ICDS Project officials shared that the lack of well-maintained teaching aids, toys, games, workbooks, etc combined with lack of physical space (playground, large rooms to accommodate children, functioning toilets etc) as well as facilities for a playground such as swings were major challenges. Further, Lady Supervisors felt that the harsh weather conditions in Rajasthan especially during the summer and winter months combined with lack of electricity, fans and ventilation meant that children found it difficult to sit at the centre in the heat. During the field visits for data collection, one instance of a child having fainted at the centre the previous day, was also recorded by the study team. The poor quality of pre-school education as well as lack of supplies being the cause for low preference for this service has also been reiterated in the previous chapter. ‘There are three workbooks for children in the age group of 3-4 tears, 4-5 years and 5-6 years. The workbooks were provided to the centres in 2017 March. After that there was no supply of the books. New children join the AWC every month. So the lack of books is an issue and the children have to make do with just the slates.’ (Lady Supervisor, Mahuwa ICDS Project, Dausa district) ‘There is no transport facility and the only way to keep them for long hours here would be by making education interesting and inspiring and having trained teachers. They can develop an interest in studies if they are given interesting books to read. Sometimes even the Anganwadi Workers have to be motivated to teach them. Some workers are just primary educated and it becomes difficult as we have to train them first.’ (Lady Supervisor, Baseri ICDS Project, Dholpur district) ‘Children have their food and go home. If the AWW tries to hold them back, they start crying. They have no other reason to stay at the centre.’ (Lady Supervisor, Mahuwa ICDS Project, Dausa district) 'Most parents send their children to private schools once they turn three because of the lack of facilities at the Anganwadi Centres.' (Lady Supervisor, Mahuwa ICDS Project, Dausa district) Further, it was also stated by state level officials that one cannot expect books given to children to be in good condition over a long period of time and accepted that these need to be changed periodically. Apart from this, no other supply-side barriers were mentioned for any of the other specific services. iii. Quality of Service Delivery: Supervisors and ICDS Project level officials shared that there are numerous challenges with regards to the AWWs, some of which may be due their not being very educated. Further there is lack of motivation to work and lack of professionalism

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about their work. The honorarium amounts not being satisfactory and in several cases the long distance between the AWC and the AWW’s homes were considered to be major barriers that dissuaded the AWWs from performing effectively. ‘There are many centres that do not open on time. According to me, even if there are only two children who come to the centre, we still need to give them services. We should not be concerned with the number of children availing the services.’ (Lady Supervisor, Mahuwa ICDS Project, Dausa district) ‘What happens is that AWWs want the AWCs to be close to their home. They say that they wake up at 6am and have 4 children, so they are not able to reach the AWC on time. 50% AWWs have been shut down because of this. The main problem is that they do not want to work.’ (CDPO, Dholpur district) However, what was also reflected during discussions with district and ICDS Project level officials is that there was little or no acknowledgement of AWWs’ burden of household and child care responsibilities. Lady Supervisors were felt to be more connected to the realities and challenges faced by AWWs. Further, for reasons not identified, it was observed that ASHA workers appeared much more vibrant, vocal, informed and confident in comparison to the AWWs. This insight was also shared by government officials interviewed in Rajasthan. They shared that the training for AWWs need to draw from the trainings conducted for ASHA workers and incorporate the learning into their own design as well. ‘Some Anganwadi Workers are not able to deliver in this sector, mostly because they are not much educated, so that’s the reason this scheme is not doing well.’ (Lady Supervisor, Lalsot ICDS Project, Dausa district) State level officials said that the newer lot of AWWs who have been hired were better educated, are performing better and more motivated, one of the reasons being the increase in their honorarium. They also stated that the earlier criteria for selection of AWWs was that they should be from poor, vulnerable communities while the change in selection criteria in 2013 has made educational qualifications a compulsory criteria. Further, ICDS Project level officials also reported political interference and corruption in the selection process. How this affects the selection and inclusion of AWWs from poor and marginalized communities needs to be assessed and efforts to ensure their selection also needs to be made. Primarily, findings from the study showed that while Lady Supervisors and district level officials attributed barriers to lack of infrastructure and resources, training of AWWs as well as poor quality of services, ICDS Project and state level government officials perceived lack of awareness among community members to be the major challenge. The other challenge noted by ICDS Project level officials was the distance to the AWC and/or to the hospitals that dissuaded people from availing services, thus resulting in poor utilization of services. Further, it was found that as majority beneficiaries were found to be farmers, they did not have time or willingness to avail of health and nutrition services. This concern was also echoed by a state

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level official. Overall, similar findings were also recorded in discussions with service providers and community members. ‘People do not use referral services and do not attend health education meetings because most people here are farmers and do not have time.' (Lady Supervisor, Baseri ICDS Project, Dholpur district) ‘Even if we tell women that they need to get health check-ups done at the hospitals, they do not go. They think it is a waste of time. Also, maybe because the hospitals are at a distance from their homes.’ (Lady Supervisor, Rajakheda ICDS Project, Dholpur district) 'Referral services are the least preferred as they don’t want to travel long distances for medical facilities. They just take some home remedies for their illness and try to recover. Slowly the awareness is increasing as we keep briefing them about facilities provided by the hospitals which we refer.' (Lady Supervisor, Rajakhera ICDS Project, Dholpur district) Discussions with government officials as noted above showed that there appeared to be no acknowledgement that beneficiaries who are largely women in the reproductive age, lack the support or the decision-making capacity to ensure these services for themselves and their children, as has also been reiterated in the previous chapter. Further, the lack of willingness or time to come to the centre needs to be understood in the context of the decision-making capacity that women have within their families. Involvement of men and elders in the family to promote health-seeking behaviour within them as well as involving them to ensure services for women and children needs to be explored. Further, ways of reducing women’s household burden (both AWWs as well as that of women beneficiaries) needs to be weaved into the programme design and strategy as well. Government officials also stated that sometimes AWWs and helpers are discriminated upon by community members and this becomes a reason for people not willing to avail of services. It was also mentioned that caste-based discrimination is not as prevalent in current times ‘Casteism is not prevalent very much now. Earlier if an SC helper was appointed at a centre where beneficiaries belonged to other castes, it was considered to be a problem. I have myself seen that people would refuse to take anything from the helper’s hands. They used to make up excuses such as they would say that she does not give us the right thing and would also insist that the AWW should give it to them as she was also a Thakur like them. If the helper would touch anything, they would refuse to take it and not allow their children to do so as well. It is prevalent in some places not everywhere. In some villages, casteism is still very prevalent like in Baseri. In Baseri, if a Thakur goes to the Pandit’s place and has tea, the Pandit will wash the utensil and hang it upside-down and then it will go for cleansing. What is this? This is casteism.’ (CDPO, Dholpur district)

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3.2 Perceptions about what is working well under the scheme Study findings showed that similar to discussions with AWWs, ASHAs, ANMs and community members, government officials at all levels also articulated that Immunization and Supplementary Nutrition services were most utilized. Government officials reported that community members understand the benefits of immunization much more in current times and conditional cash transfer schemes such as the Pradhan Mantri Matritva Vandana Yojana have led to an increase in immunization rate, especially for female children. ‘Immunization leads to better health for both the mother and the child. There are fewer pregnancy related deaths in current times because of high rates of immunization. Nowadays we see that villagers come to the AWC voluntarily to get immunized.’ (Lady Supervisor, Lalsot ICDS Project, Dausa district) ‘Nutrition and immunization are most preferred services because our beneficiaries are of lower class and they do utilize these services. For immunization, our outreach has increased because of the Rs. 5000 incentive provided to pregnant women. The money that they get is spent on nutrition and both the mother and child are healthy after delivery.' (DPO, Dholpur district) ‘The first service that is most preferred is nutrition services where food packets are given. People try and avail that the most. Some people even fight for the food packets because it is food. Second is immunization. Our immunization service is going very well. Earlier people wouldn’t come by themselves as they wouldn’t want to leave their houses. Now they come on their own. Also, women are very eager to avail of benefits from the Pradhan Mantri Matritva Vandana Yojana because there is money in it. We do not even need to call them.' (CDPO, Dausa district) Most of the government officials as well as the sector supervisors believe that the Janani Surakshya Yojana (JSY) under the NRHM had effectively helped in promoting the institutional delivery among the poor pregnant women and increased the neo-natal services. There is provision of cash incentive to both mothers and ASHAs. The ASHA will Identify pregnant woman as beneficiary of the scheme and help the women in receiving at least three ANC check-ups including TT injection, IFA tablets. According to the sector supervisors, people have become more aware about the benefits of immunization, especially the benefits of immunization during neonatal care period. ‘People understand benefits of immunization and cash incentive: The reason is that without the MCP card, the people will not get any other benefits. For institutional delivery, the government pays a sum of Rs 1400. If they do not register for immunisation, this benefit cannot be availed. Also, people are now aware that if they need to prevent diseases, immunisation is a must.' (Lady Supervisor, Mahuwa ICDS Project, Dausa district) 'Due to regular health check-up, they do understand that immunization enables them to maintain a healthy lifestyle. Pregnant women are fully aware that immunization enable their

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children to remain healthy and that they should complete immunization as per the schedule starting from BCG to keep their children in best of health and it prevents illness.' (Lady Supervisor, Rajakhera ICDS Project, Dholpur district) Again, as articulated by community members and service providers, the unmet need for supplementary nutrition was found to be high; especially among poor households, thus, resulting in people ‘fighting over food packets’ despite poor quality and lack of variety as mentioned earlier in the previous section. It was also mentioned that the supply of supplementary nutrition could not meet the demand in several instances. ‘As they are children, they eat whatever is given to them. Sometimes, children would prefer that they be given milk and biscuits. A variety in food supply will increase their motivation to come here. The quality of food needs to be improved. Also, in some instances, there are more number of children and the food supplied is not sufficient.’ (Lady Supervisor, Baseri ICDS Project, Dholpur district) ‘Our beneficiaries are from lower classes and they try to utilize the services like food and nutrition.’ (CDPO, Dausa district) ‘People try and avail Supplementary Nutrition services the most. Some people even fight after that. Because it is food. If someone doesn’t get it they just won’t listen, they would start fights.’ (CDPO, Dholpur district)

3.3 Perception regarding Convergence with other departments Early childhood development mainly depends on psychosocial care, early learning environment, the quality of caregiver interaction, provision of nutrition, accessing health facilities, provision of safe drinking water, access to sanitation etc. Recognising the importance of wider determinants of child development, ICDS Mission adopts a convergent approach for intervention of various related departments. AWC at the village is the convergent point for child development action. Involvement of many departments including the PRIs would ensure an opportunity for convergent action. Involving AWWs, ASHAs, women’s groups, VHSNCs and PRIs is attempted to improve the availability of health outreach services, drinking water, sanitation, school linkages and related issues. This study examined the perception of district and ICDS Project level officials regarding the convergence of key stakeholders for provision of ICDS services in an integrated manner at the community level. The study revealed that most of the CDPOs felt that there was good convergence between ICDS and health department at the village level. The services providers like ANM, ASHA and AWW were working in close coordination while implementing the activities like routine immunization, antenatal check-ups, promotion of institutional deliveries and referral

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services. However the study also highlighted that the AWWs face difficultly due to over burdening of activities. However convergence of Panchayat Raj Department and Education Department with ICDS was said to be poor. One of the district level Deputy Director of ICDS indicated that the convergence of these 2 departments with ICDS in their district was absent. The government school teachers were said to be only monitoring the AWCs which were attached to their schools. They did not visit the AWCs not attached to their schools. The Deputy Director also mentioned that while the Village Health and Nutrition Day (VHNDs) is supposed to be organised jointly by ICDS, Health department and PRIs it is mainly being conducted by ANM, ASHA and AWW with no support from PRI members. During observation of VHND the study team also observed that the VHNDs are only managed by the ANM, ASHA and AWWs and no effective support from PRI members was provided.

VHND organised by ANM, ASHA and AWW at one of the AWCs in Dholpur district

Most of the Sector Supervisors opined that it was the responsibility of the Gram Panchayat to ensure safe drinking water in all Anganwadi Centres. However they indicated that most of the AWCs had no drinking water facility. With regards to convergence, state level officials felt that the ‘trio’ of AWW, ASHA and ANM was a useful resource for the community and needs to be strengthened further as a team. However district and ICDS Project level functionaries were sceptical about convergence. They felt that AWWs were engaged in other schemes a lot because the AWC is a centre-point of government services in villages. Lady Supervisors articulated that AWWs often felt burdened with the number of activities that they had to participate in, apart from ICDS services. Further, the most important and well-functioning convergence was said to be taking place between ICDS and the Health Departments. ‘AWC being the centre of implementation for many schemes, all departments give several tasks to AWWs. For e.g., when there was Yoga divas, they called us from 7am till 8:30am. Then who can go and open the centre?’ (CDPO, Dholpur district)

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‘Convergence is mainly about attending events of the other department. The main convergence is between the Health and ICDS Departments. One challenge identified was that whilst the ICDS department now functions independently from WCD, AWWs still continue to work under WCD schemes, which increases workload.’ (CDPO, Dholpur district) ‘The camp ‘Nyay Aapke Dwar’ (Justice at your doorstep) is held in which people from the head office should attend. But in our case, I am the only person who attends the camp. No one accompanies me. In other departments, there are various people who attend it. No other officials from our office cooperate and attend the camps. Also, it is not easy to take care of 57 AWCs.’ (Lady Supervisor, Mahuwa ICDS Project, Dausa district)

3.4 Perceptions about Challenges and Needs at the State/District/ICDS Project Levels Study findings showed that the most important needs in the present situation were that of more training and capacity building of AWWs, improvement in infrastructure and resources, increased honorarium for AWWs as well as filling up of vacant posts at district and ICDS Project levels in the department. The following challenges and needs were mentioned at each level: 1. Lady Supervisors: i. Need for greater support and involvement of Elected Representatives: Lady Supervisors shared that in their opinion, the panchayat needs to play a greater role in filling gaps with regards to infrastructure in Anganwadi Centres where needed. ‘They can help by providing the centre with stationary items, chairs for small children, ceiling fans and uniforms for children. It will be good. If they give bag and other things for children, it will be good.’ (Lady Supervisor, Lalsot ICDS Project, Dausa district) ii. Political Interference: Political interference and corruption were two main challenges identified that affected quality of services and selection of AWWs. ‘My biggest challenge in my work is political interference. We just have been given power superficially But in reality, we do not have any power.’ (Lady Supervisor, Mahuwa ICDS Project, Dausa district) iii. Better Infrastructure: Most of the sector Supervisors interviewed during the survey stated that that the AWCs were not satisfactory in terms of infrastructure and materials. Also many supervisors expressed that logistics like chairs, desks and playing materials for children are absent in their AWCs. Emphasis should be given to strengthen the basic infrastructure of

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AWCs to be improved along with resources and equipment for effective provision of services. This would further help the AWWs in delivering quality services to the beneficiaries. Also many supervisors gave suggestions that along with strengthening infrastructure the quality of supplementary nutrition should also be improved that in turn will attract the children to come to AWCs and stay there for longer time. ‘Firstly, it should be made compulsory in city schools that they would admit them after 5 years of age so that they can complete the pre-primary education here at the village centre. Secondly, the food that is provided here should be improved like they could get a mid-day meal which would encourage them to come here to study and have a good meal as well. All children come to school with their elder siblings and as we provide food only to children below 5 years of age, it becomes difficult to explain to the older children that they will not be given food here. Such things have to be taken care of. Also the timings of the centre are such that they don’t prefer to wake up early and come to school.’ (Lady Supervisor, Baseri ICDS Project, Dholpur district) ‘The first thing is that there should be chairs and desks for children. The food distributed should be more nutritious. There should be more toys for children to play.’ (Lady Supervisor, Baseri ICDS Project, Dholpur district) iv. Better and More Frequent Training: Lady Supervisors felt that more training for AWWs was required for conducting better pre-school education sessions and activities, more effective record keeping and use of technology, software and computers. Supervisors themselves stated the need to be more trained about computers and software that they are required to use for monitoring and supervision of AWCs and AWWs. ‘We could get some training in children’s activities so that we can train them better and learn how to imbibe good values in them and manage them better.’ (Lady Supervisor, Rajakhera ICDS Project, Dholpur district) ‘We should be given computer trainings as now everything has become online.’ (Lady Supervisor, Baseri ICDS Project, Dholpur district) ‘The new software CAS which is now installed called the common application software is not clear to them and we feel that they require more training in this.’ (Lady Supervisor, Baseri ICDS Project, Dholpur district) ‘Some AWWs are not educated enough to give the information that needs to be filled up in the registers. So we take the help of somebody else or the nearby centre to fill up the data. So, for doing records they take the help of their family members or others to do it for them. I teach them how to do it, but still they might not understand fully and I will need to take the help of some children and explain it to them. When we go to the centres, if they are residing close by, we ask their family members to come and learn. For example, they need help to make the health charts, to fill up column no. 8 etc.’ (Lady Supervisor, Lalsot ICDS Project, Dausa district)

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2. CDPO: i. CDPOs as Mentors: CDPOs felt that at the district level good leadership needs to be maintained. They felt the need to be treated as mentors by the district officers and be given moral support. ii. Increased Honorarium for AWWs was mentioned as important for the AWWs to do better work. iii. Low Budgets: ICDS Project level officials mentioned that there is allocation of fund in budgets but it was not enough to meet their needs and address gaps in infrastructure and implementation. ‘None of our complaints are solved ever. Budgets are not released on time. Budget has been allocated for computers to be purchased but we could not get it.’ (CDPO, Dholpur district) 3. District Level (DPOs): i. Vacant Posts: District level officials mentioned that often posts were not filled at various levels leading to people already working at a specific level taking on more work than they could possibly manage. Particularly, the need for more Lady Supervisors was strongly felt. ii. Capacity Building of AWWs: District level officials mentioned that capacity building of AWWs needs to be undertaken more regularly and should also be conducted at the village level to ensure better outcomes. Officials also mentioned the need for literature for AWWs so they can keep revising what they learn in trainings. Last, they also shared that more hands-on support was required from doctors, because the AWWs are not very educated. They suggested that this can be done by organizing regular meetings and village level camps- villagers can also benefit. iii. Increase in Honorarium: District level officials also opined that AWWs’ honorarium needs to be increased. iv. AWWs should be focused only on ICDS activities: District officials also shared that they felt a lot of time of AWWs was consumed in participating in activities of other departments. Hence, they shared that they felt that AWWs should be focused only on ICDS work without diversion. 4. State Level Official: i. Vacant Posts: The high number of supervisor posts that had been left vacant was considered to be a problem by State level officials and they felt that there was a need to address this deficit.

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ii. Infrastructure: The state officials stressed on the fact that poor infrastructure was the cause for poor service availability and utilization. They also highlighted the need for drinking water and sanitation facilities. State level officials said that along with allocating space to AWCs within government schools, there should be more effective strategies for integrating services of AWCs with the schools. iii. Greater Community Engagement: State level officials identified parents-teachers meeting as well as Godbharai and Annaprashan events conducted by AWCs as a great platform for interaction and felt that this needs to be strengthened further so as to deliver better outcomes and increase awareness among community members. iv. Better Coordination between various actors: State level officials also realised that several groups such as NGOs as well as Corporates were working on revamping ICDS centres and shared that efforts need to be consolidated so as to maximize impact. Some effort by the state level department had also been initiated in this direction, during the time of data collection for this study, by meeting with the different actors involved.

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Chapter 4: Perceptions about AWWs

This chapter delves into perceptions of different respondents about the AWWs as well as AWWs own insights of people’s perceptions about her. Understanding these perceptions required the research team to investigate into the relationship of different respondents with the AWWs and value of AWWs in the community. This aspect of the study provided insights into how the behaviour, attitudes, skills and capacities of the workers themselves affects the overall image of the AWC in the community. Further, it also helped to understand the nature of relationship that AWWs share with community members and the value with which they are held in the community as well as identify areas for improvement. Understanding perceptions about AWWs will help understand gaps in service delivery and highlight what is working well and provide recommendations for changes in functioning of AWWs. For the purpose of this study, in-depth interviews were conducted with 32 AWWs across two districts in Rajasthan, i.e., Dausa and Dholpur. It was found that majority of AWWs were over the age of 35 years and had only completed primary school education (upto 5th standard) followed by a lesser number having completed high-school education (10th standard). Further, majority AWWs were found to reside in the same village as the AWCs and had over 10-15 years of experience of working as AWWs.

4.1 Relationship with AWWs Relationship of AWWs with community members (existing beneficiaries, potential beneficiaries and key influencers) was analyzed based on the following indicators:

- Knowledge of who the AWW is and where the centre is located. - Engagement with community members

It was found that while several potential beneficiaries did not know who the AWW of their area was, but they did know where the centre was located. Most potential beneficiaries stated that they had had few interactions with AWWs and were not aware of all services provided. Some potential beneficiaries stated that owing to the distance of the centre from their homes, they did not prefer going there. However, some potential beneficiaries stated that the few times that they had gone to the centre, they had found it closed and did not meet any AWW. Further, potential beneficiaries in all discussions, showed preference for private education and health services, the stated reason being that the quality of service is better in private services. This preference for private services has also been articulated in previous chapters. ‘Private schools are much better as children are taken care of. The centre is very far and we don’t get anything there. We only know that they provide immunization. We are not fully aware of the services provided there. We don’t like the supplements given there.’ (FGD with Potential Beneficiaries, Mahuwa ICDS Project, Dausa district).

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With existing beneficiaries who were currently availing services at the AWC and hence, had more regular interactions with AWWs, it was found that most beneficiaries thought that the AWW worked hard and had to face a lot of difficulties especially when they had to call women and children to the centre for availing services. In some places, it was stated that the AWW went out of her way to provide services to even those not registered at the centre. ‘She is good but she has a lot of work. She has to go from home to home to call children to attend the AWC.’ (FGD with Beneficiaries, Mahuwa ICDS Project, Dausa district) ‘AWWs work hard but due to a lot of work and pressure, sometimes are not able to do full justice.’ (FGD with Beneficiaries, Baseri ICDS Project, Dholpur district) ‘Anganwadi worker never refuses anyone who go to her, even if someone is not registered.’ (FGD with Beneficiaries, Morena ICDS Project, Dholpur district) However, in all discussions, what was striking was that most existing beneficiaries had a better relationship with ASHA workers and referred to ASHA workers more during discussions. Discussions with existing beneficiaries revealed that ASHA workers had built better rapport with them through counselling during home visits and being present with them during health visits and deliveries. Most beneficiaries reported that AWWs only came to call them to come to the centre, or to participate in campaigns; but often it was found that it was the ASHA worker who did the mobilization. Further, existing as well as potential beneficiaries expressed the need for more capacity building of AWWs thereby highlighting gaps in their existing skill sets. ‘They (AWWs) never come and inform us about the facilities provided there (AWC). We have only seen the workers when they came in our village during pulse polio campaign. They do come when a child is born to register the birth and they also get money for registration. Once we had gone to the centre but we never got to see anyone there.’ (FGD with Potential Beneficiaries, Baseri ICDS Project, Dholpur district) 'Anganwadi workers never come for home visits. In case there is a meeting, only the ASHA goes to call women for such meetings. ASHA also accompanies pregnant women for delivery of the child.' (FGD with Beneficiaries, Morena ICDS Project, Dholpur district) The higher educational qualifications of the ASHA worker could be a reason for her better capabilities and better image. Analysis showed that more ASHA workers had completed secondary school education (10th standard) as compared to AWWs. In terms of age, it was found that majority ASHAs were over the age of 35 years as seen in the case of AWWs as well. As mentioned in the previous chapter, government officials emphasized on the need for better training for AWWs because they found that AWWs seemed less competent in comparison to ASHA workers. Given the link of educational qualifications with capabilities there has been a recent change in the educational qualifications of the AWWs. Government officials, as outlined in the previous chapter, have reported that the criteria for selection of

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AWWs has recently been changed to make educational qualifications compulsory. Further, government officials also felt that the increase in honorarium has also increased motivation of AWWs. Thus, officials noted that these changes have resulted in younger, more qualified and motivated AWWs in now being appointed. On the contrary, several of the current lot of AWWS interviewed showed dissatisfaction with the honorarium received and said that (i) they felt that they felt that they were not paid enough for the volume of work that they were required to do and (ii) they were not paid for the surveys or election duties. Several AWWs expressed strong desire for their honorarium to be increased and belief that they deserved to earn more. ‘We should also get good incentives here as we have lot of work to be done here. We get salary as little as Rs.1850/- which is not enough for the kind of work we are doing here.’ (AWW, Rajakhera ICDS Project, Dholpur district) Relationship of KIs and ASHAs and ANMs with AWWs was also assessed in terms of how much support and engagement there is between one another. With regard to KIs, it was found that in some locations where KIs had a good working relationship with AWWs, they were found to be more supportive of the work of AWWs. Further, some school teachers reported helping AWWs with mobilizing community members. Male school teachers reported counselling men who were resistant on family planning. Further, in locations where the AWC was within the school premises, there was greater interaction and engagement between the school teachers and AWWs. School teachers reported that AWWs sought guidance from them in motivating and teaching young children. ‘We support them in field work – like visiting homes. If there is a meeting and we need to collect the villagers at one place we distribute the work. They are responsible for collecting the women while we take care of the men. Also, regarding family planning, we try to motivate the men. Many times, the AWW tells us that the women are ready but the men are not. In such cases we help in convincing men.’ (Male School Teacher, Lalsot ICDS Project, Dausa district) ‘I have a meeting with the AWWs on the 5th and 20th of every month. I have a good relation with them. All of them do good work. The AWWs call the children to the centers and do all the work on time. They consult me if they face any problems/challenges. If there are any problems at the AWC, the AWW brings it to my notice and I try to solve their problems. If I cannot solve the issues, I bring it to the notice of the gram panchayat headquarters.’ (Sarpanch, Lalsot ICDS Project, Dausa district) AWWs reported that the panchayat members were needed to address infrastructure related problems as well as approval for certain activities/ initiatives at the AWC, where relevant. Further, as already established in previous chapters, while the provision of immunization (which ASHA and ANM workers are responsible for) has built a positive image of the AWCs, the primary services that AWWs are currently providing, i.e. provision of supplementary nutrition and, pre-school education service does not hold much value in the community for reasons already mentioned in detail in those sections. This negative image of the services was found to also negatively impact the image of the AWW. Thus, it can be concluded that

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where there are supply related challenges, there needs to be greater community involvement and awareness in creating a larger demand for these services and hold government officials accountable. As a first step of building greater community participation, AWWs must work to improve their community presence and relationship with members as the first step. Additionally, as seen in the data above, the purpose of home visits by AWWs should add more value to the beneficiaries. For instance, AWWs should be trained on rapport building and communication skills and use home visits to not only call people to the centre or provide information about services, but also engage more deeply with beneficiaries. Further, training should help AWWs not only to become better facilitators; but also, to increase their knowledge about health and nutrition. This will help AWWs strengthen their relationship with community members while also providing valuable information to them.

4.2 Value of AWWs in the community While beneficiaries and KIs accepted that AWWs worked hard, they were not trained to teach children to and, needed to be more punctual to ensure immunization and open the centre on time. ‘The AWW comes and tells us about the children’s common ailments and cleanliness. We know her but not too well. It would be good for them to undergo training on how to run the centre, so that people can benefit. They should inform us about the immunization provided here so that we can come regularly.’ (FGD with Potential Beneficiaries, Mahuwa ICDS Project, Dausa district) KIs in general had good feedback to provide about AWWs. According to KIs, AWWs worked hard and were an important part in the community. However, this was found to not be entirely true in discussions with other community members. Similar to findings from community members, according to Lady Supervisors, AWWs were appreciated and valued when they were found to be hardworking, when they organized good events at the community level and when beneficiaries availed benefits of schemes such as the Pradhan Mantri Matritva Vandana Yojana. ‘I talk to them once a week i.e. every Monday. We talk about the services of the Anganwadi center and I ask them if they face any problems in their work. I also find out if the supply of supplementary nutrition is regular and if it is distributed properly.’ (Sarpanch, Lalsot ICDS Project, Dausa district) ‘The villagers think well of the AWC, especially when the AWW is very hardworking. With the Pradhan Mantri Matritva Vandana Yojana, some of the AWWs enrolled up to 25 people. The negative comments are much lesser now. Earlier there used to be complaints that the AWC does not open on time; that it opens at 7.30 instead of 7. But now the complaints are less.’ (Lady Supervisor, Lalsot ICDS Project, Dausa district) AWWs were also asked about their experiences of feeling valued or not feeling valued in the community. In discussions with AWWs, it was found that reasons for which they were appreciated for their work by community members were to do with their punctuality, going

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out of their way to improve infrastructure or services (when supply was poor), when they had helped women seek medical care during pregnancy related complications or their children’s illness and for providing valuable information. ‘I had put in a lot of effort towards ensuring that toilets were built at our centre. I went from house to house and talked to people regarding this and personally supervised the work, which people appreciated. In one instance, I took the initiative of bringing a child to the centre for checkup. The family members thanked me for it.’ (AWW, Mahuwa ICDS Project, Dausa district) AWWs also shared feeling a significant sense of pride and feeling valued in the community along with an increase in their own confidence over the years. However, this feeling of being a valued resource in the community not only resonated in discussions with KIs but was reflected in discussions with potential beneficiary or existing beneficiary groups. As detailed out earlier, beneficiaries appeared to value the ASHA worker much more. Being able to express their opinion and participate in decision-making processes in the community contributed to their sense of pride and self-confidence. ‘People give me more importance now. Elders of the village call me forward to participate in all village development activities, voting duty and meetings and they even ask me for my opinion. During immunization campaigns, when I go from house to house, people give me a lot of respect. I too give them information about all the services of the center.’ (AWW, Mahuwa ICDS Project, Dausa district) ‘Earlier while going for survey I used to go with a veil and would feel shy in talking to people. Now I can talk to men and older people frankly.’ (AWW, Mahuwa ICDS Project, Dausa district) At the same time, AWWs also specifically reported being harassed by men in the community. They said that men in the village often come drunk and litter around the centre, while also using bad language. Further, for reasons not known, AWWs, said that often men were responsible for spreading false rumors about them stealing government supplies that were meant for children in the community. While these cases of harassment shared were few and far in between, these suggest the need for greater involvement of men not only so that harassment is reduced but also to ensure greater involvement of men in health and nutrition of pregnant and lactating mothers and children. This is also resonated in several other studies3 that suggest the need to change gender relations within households where women are already overburdened with child care and household work along with agricultural work, need the support of their husbands and their in-laws in increasing health seeking behaviour. Studies4 have also shown the need for involvement of fathers in child development as critical in ensuring better child health outcomes.

3 https://siteresources.worldbank.org/INTPOVERTY/Resources/335642-1124115102975/1555199-1124115187705/ch5.pdf 4 https://www.savethechildren.net/article/involved-fatherhood-critical-gender-equality-and-child-development-reveals-world’s-first

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Finally, contrasting views about AWWs among different respondent groups implies that while AWWs themselves as well as KIs believe that their work is of value to the community, the people who are at the receiving end of services appeared to have mixed views about the AWW and her work. This could partly also have to do with shortage of supplies from the government due to which beneficiaries’ perceptions of AWWs was also not completely positive. Further, such contrasting views also points towards the need for more honest and open dialogue facilitated between service providers and community members so as to generate community support and involvement and also, clarify incorrect perceptions. Further, an important challenge that AWWs reported facing was in engaging with male community members. It is thus important that strategies be devised for including men strategically in specific activities not only to garner their support in ICDS work but to also garner their contribution in ensuring women and children’s health and nutrition. Overall, findings regarding the perception of AWWs suggest the need for more capacity building of AWWs not only in terms of knowledge, but also skills w.r.t. building rapport with the community, community mobilization, strengthening community participation as well as engagement and support in ICDS activities. Further, strategies for working with resistant male members in the community also need to be devised. While nobody distinctly stated negative views about the AWWs, the findings clearly indicate the need for AWWs who are more professional (punctual, trained etc.) as well as someone who can build strong relationships with community members.

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Chapter 5: Conclusion and Recommendations

The previous chapters have highlighted the gaps that exists between expectation by the community and actual provision of services by the Anganwadi centres. Comparison of perceptions across different stakeholders and with the ground realities of the functioning of the AWCs has helped identify areas that need to be addressed for the purposes of re-branding the ICDS services in the intervention areas. In rebranding ICDS efforts, identifying the objective and expected outcomes of rebranding becomes a critical aspect of building a more positive image of the ICDS. The ICDS brand is a reflection of the reputation and visibility of the AWCs. Study findings highlighted several supply and demand related barriers in the functioning of the AWCs. For the purposes of brand building these challenges need to be first addressed and then followed up with efforts to change perceptions and build the positive image of the AWCs across all key stakeholders. A crucial part of these efforts will be to redesign strategies of engagement and capacity building of AWWs and thereafter work on building a positive image of the AWWs. Overall, the study concludes that it is important to change the perception of both the government officials and community members that government services provide poor quality services because they are free and ‘meant’ for the ‘poor’; thus, services are availed by poor people who cannot afford to pay for these services. The study recommends that people’s perceptions should change so that free or subsidized government services is considered a basic right and not one that is given as an act of charity towards poor people, while also maintaining the prime focus on vulnerable and marginalized groups in service delivery. Further, greater community engagement and ownership to ensure government accountability is recommended as a critical part of rebranding of the programme. Community engagement and involvement is also deemed to be important in ensuring that the programme incorporates locally/contextually relevant elements and needs into the programme. The following sections outlines the key perceptional changes required to be made as part of the re-branding exercise. For bringing this change the key issues that need to be addressed are also outlined 5.1 Changes in Perceptions about Services Provided Recognizing the devastating impact that malnutrition can have on the health of infants and children, the ICDS was planned with the objective to improve the health and nutritional status of children between 0-6 years as well as of pregnant and lactating women through provision of supplementary nutrition, health and nutrition education, immunization, health check-ups and referral services. Further, the ICDS also aimed to contribute towards psychological, physical and social development of the child and reduce school dropout through provision of pre-school education.

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The study conducted in two districts in Rajasthan, i.e. Dausa and Dholpur found that while people appreciated and valued services that were being provided free of cost; there was also a high level of disappointment shown in the quality of services provided. Further, in several instances, the lack of alternative services viz. for pre-school education and nutrition, was found to be the reason of increasing use of Anganwadi services. In general, there was a widespread belief that private services provide better quality of care and that if someone can afford private services then they will prefer to use private services as compared to government services. Immunization was found to be the one service that people perceived to be the best service provided. Supplementary nutrition while availed by community members was considered to be of poor quality, of insufficient quantity in some cases and lacking in variety. Thus, the message that currently the ICDS programme seems to put across to people is that because services are free, they do not necessarily need to be of good quality or cater to the perceived needs and likes and dislikes of community members. In order to change these perceptions, it is important to focus on strengthening the services themselves as well as include community members’ voices in the planning process. It is equally important to address other challenges mentioned in the findings w.r.t changes in infrastructure and resources, capacity building of AWWs and intensified engagement with community members. 5.2 Changes in Perception about Infrastructure and Resources In order to change community members’ and AWWs’ perceptions about the Anganwadi centre itself, the most basic change that is required in the rebranding of ICDS in the context of Rajasthan are the AWC facilities themselves. In discussions, several AWWs mentioned that it was important that the Anganwadi be made into such a place where people will willingly come by themselves without having to be called. AWWs also suggested making the place more attractive through wall painting, charts, lights etc. Thus, it is recommended that model AWCs should be set up which need to use existing community resources and involvement of community members within a minimal budget. This model can then be proposed to the government for scaling up. It is of utmost importance that along with electricity, lights and fans, child friendly toilets, safe drinking water, hygienic cooking arrangements and play space for children also be provided. Further, advocacy efforts with the state government need to be taken up for more regular management of resources. The CAS application should be used not only to monitor whether AWCs, AWWs and LSs are functioning effectively, but also to keep a check on the supplies and resources that need to be replenished. While, infrastructure- and resource-related recommendations have already been mentioned in detail in previous chapters under findings, what is crucial here is that these model AWCs need to be low-cost, yet effective and elicit community participation. The latter, i.e., community members’ involvement in bringing about greater involvement of community members in AWC activities and with service providers, thus increasing engagement and

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ownership. Further, support from and active participation of local youth and women’s collectives can also be sought in this process. However, keeping in mind the caste dynamics in villages, the risk of building a centre that is appealing to all might result in the dominant groups accessing services more while the marginalized groups get left behind. Strategies need to be in place to ensure that the programme does not lose its focus on women and children belonging to vulnerable and marginalized families in the community. 5.3 Build a Positive Image of AWWs Findings from the study emphasize on the need for overall perspective, skill and knowledge building of AWWs. Study findings showed that the general image of the AWW is that of a hardworking person but not that of a professional, skillful, knowledgeable service provider. Community members reported that AWWs need to be more punctual, engage more meaningfully with community members and enhance their capacities on providing pre-school education. Further, it was also found that AWW trainings focus heavily on information provision and there is very little focus on skills and perspective. AWWs themselves shared that some of the tasks expected of them such as growth monitoring was too technical for them and they felt that they either need more training or help from medical doctors to undertake this work. It was also found that the capacity of AWWs to undertake pre-school education was very low in most cases. AWWs were expected to do varied kinds of activities some of which involved staying at the centre for a fixed number of hours and others involved mobilizing community members. It was also found that AWWs were not paid extra for work that they did outside of their assigned duties such as election duties. AWWs reported feeling underpaid (this perception may have reduced with the recent hike in honorarium) and did not have any growth in their work as AWWs, even those who had been working for more than 10-15 years in the programme. Their recruitment procedure and service condition needs restructuring and this will need an advocacy plan to be formulated and be undertaken with the state government. Thus, what came across about the image of the AWW in the study was that of an over-burdened, underpaid, and mostly unskilled worker who did not have enough motivation, guidance and support to undertake her work. Trust: In order to build a positive image of the AWW, it is important that AWWs come across as people who community members can trust and rely upon to take care of their children for the hours that women are away at work. Currently, the study found that the supplementary nutrition provided was the hook that made beneficiaries send their children to the centre and the value they saw in immunization. Likewise, if women were able to feel supported in their daily household chores and farm work, they would also see value in sending their children for pre-school education. This will also provide recognition to women’s burden of household and agricultural work and function as a support system for women beneficiaries and thus, of greater value to them. Building women’s and families’ faith in the AWW can not only improve people’s perceptions of the AWW but also improve people’s perceptions of the programme and services in its entirety.

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Based on the points above, the following recommendations are proposed: Image of the AWW: The AWW should be projected as a happy, welcoming, competent, confident woman on communication materials and at the AWC. Projecting the AWW, Helper, ANM and ASHA together as a team can also help build a positive image. Perspective building trainings: Trainings on building perspective around socio-economic determinants of health, nutrition as well as child and reproductive health should be given to AWWs. Study findings showed that exposure of AWWs to cases of severe malnourishment by AWWs was limited despite Rajasthan’s reported level of malnutrition being higher than the national average. Trainings on malnutrition to build capacities of AWWs to handle cases of severe malnutrition effectively can be undertaken so that if AWWs come across any such cases in the future, they are capable enough to provide help. Further, as the primary target group of the ICDS are women and children from marginalized communities, perspective building around gender and caste norms and how these norms differentially affect beneficiaries’ access to resources and services can be undertaken to sensitize AWWs about these norms. Skill based training: Hands on skill based training on community mobilization, as well as teaching pre-school children using interesting methodology needs to be conducted from time to time. Behaviour Change Communication Training: AWWs need to be trained on Behaviour Change Communication strategies specifically around health and nutrition. Further, for their own personal growth, AWWs need to learn self-efficacy skills in order to negotiate challenges within their homes and within the community, especially when faced with resistance. Exposure visits: Exposure visits for AWWs to well-functioning private pre-schools will help them learn about how private facilities function. Advocacy: Advocacy efforts with state government be undertaken to improve the working conditions of AWWs Provision of and training on using smartphones/tablets/computers: Provision of computers/ tablets/ smartphones accompanied with training to AWWs can help aid record-maintenance and make their work simpler, although funds can prove to be a challenge. 5.4 Improving Community perception and engagement Study findings showed that while there were several gaps identified by community members in ICDS functioning, there were very few instances of community support except in instances where the sarpanch was reported to have helped with infrastructure and resources. Another important finding was that often beneficiaries who are primarily women do not have the time to visit AWCs as they are burdened with household and agricultural work, with little or no support from other family members. This might also contribute to women neglecting their

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own health, consequently leading to anemia and/or malnutrition esp. among pregnant women. Thus, it is recommended that strategies be put in place to generate community level awareness in a fun and participatory manner. Second, the study recommends building active community participation and involvement in ICDS activities. This will also help ensure that the community members can be more actively involved in monitoring ICDS activities. Third, study findings show that it is important to create a supportive environment for women beneficiaries in order to be able to access ICDS services. Keeping these challenges and broad recommendations in mind, the following specific recommendations are made: Community Mobilization Campaign: Involving a media agency to design and implement an interactive mobilization campaign in the form of celebrations will aid visibility of the rebranded AWCs. This campaign can help showcase features of the rebranded AWCs as well. Campaign strategies can include competitions, celebrations at the Anganwadi centre, street plays, etc. combined with informative sessions with medical doctors from district hospitals on the importance of health and nutrition. IEC materials will also have to be accordingly designed and response from the campaign can be used to garner more publicity in the state. Further, dialogue with community leaders and male members can be undertaken to seek their involvement in community mobilization efforts. Redesign the structure and purpose of Home Visits: The purpose of home visits for AWWs needs to be expanded so as to include detection of malnutrition among children and pregnant and lactating mothers, early detection of developmental delays, counselling on parenting, nutrition and child care for both mothers and fathers as well as community based care for those who are not able to visit the centre. Additionally, home visits should incorporate structured discussions on good parenting, child development and spousal communication in order to increase men’s involvement in child care and also increase women’s role in decision-making around health and nutrition in the family. Build access to referral services: In order to strengthen referral services and increase access, medical doctors from a nearby PHC should be present at the AWCs on certain days of the week (for instance, twice a week) as well as be part of home visits. Use existing platforms for dialogue: Gram Sabhas can be used as an effective platform for building community members’ awareness on ICDS services and sensitizing family members about health and nutrition needs of pregnant and lactating women and children. Use of Digital media: AWWs can be trained to use digital media for behaviour-change communication with community members especially during home visits and health and nutrition education sessions to enhance appeal of the service. Building an enabling environment: It is recommended that specific activities be undertaken with Panchayat members and SHG groups to seek support and build formal mechanisms of support to AWWs and AWCs. This will also help strengthen the linkage between Panchayati Raj department and the ICDS department at ground level. School teachers can also be involved as mentors in the pre-school education programme and meetings need to be

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conducted with school authorities at the district level to garner greater support at ground level. With regard to supplementary nutrition, while SHGs can be trained by nutrition counsellors to provide a balanced diet and a variety of food, yet, this should also be accompanied with advocacy with the state government to increase funds for providing supplementary nutrition. Meanwhile, SHGs should be encouraged to make use of local knowledge and nutritious, low-cost recipes to provide more variety in meals along with expert guidance. Further, monitoring of quality of supplementary nutrition by community members should also be undertaken to ensure government accountability. This will increase pressure on the government to improve quality services. To conclude, it is important for rebranding of the ICDS that there is a change in perspective about government services and an increase in the value of women and children’s health and nutrition. Community ownership and engagement along with advocacy with the state government to provide better quality services will be crucial to ensuring this change.

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Annexture-1: Rajasthan State/District wise Children under 5 years who are stunted, wasted and underweight from NFHS 4 (20015-16) (%)

Children under 5 years who are stunted (%)

Children under 5 years who are wasted (%)

Children under 5 years who are underweight (%)

Rajasthan State 39.1 23.0 36.7

Districts

Ajmer 33.5 31.6 39.6

Alwar 41.8 18.5 35.6

Banswara 50.0 30.8 50.7

Baran 40.2 28.5 41.1

Barmer 36.6 25.9 39.6

Bharatpur 47.6 14.6 30.9

Bhilwara 35.5 33.8 42.6

Bikaner 33.7 24.4 33.2

Bundi 38.4 27.7 43.4

Chittaurgarh 37.4 23.8 41.9

Churu 31.2 21.7 27.1

Dausa 33.8 15.3 28.1

Dholpur 54.3 15.8 39.8

Dungarpur 46.8 37.5 53.4

Ganganagar 29.1 20.6 29.3

Hanumangarh 35.0 20.7 23.4

Jaipur 35.7 12.8 25.2

Jaisalmer 37.4 21.9 37.4

Jalor 45.0 27.2 42.7

Jhalawar 38.1 31.8 47.2

Jhunjhunun 32.5 13.6 19.5

Jodhpur 40.3 23.8 38.6

Karauli 45.5 18.9 35.7

Kota 32.0 27.7 39.7

Nagaur 39.1 18.4 31.4

Pali 44.4 21.7 41.3

Pratapgarh 46.3 38.2 54.6

Rajsamand 38.6 28.9 38.8

SawaiMadhopur 39.4 16.4 34.4

Sikar 28.4 11.5 20.5

Sirohi 42.3 36.6 50.4

Tonk 32.0 23.6 37.3

Udaipur 47.5 29.9 52.0

(The information on the 5 projects districts viz. Alwar, Dausa, Dholpur, Karauli and Tonk are highlighted)

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Annexure- 2: List of Sample Villages in Rajasthan with respective District, ICDS Project and Sectors

Sl. No.

District Name ICDS Project Name Sector Name Village Name

1 Dholpur Baseri Sarmathura-I Maharpur

2 Dholpur Baseri Baroli Madanpur

3 Dholpur Baseri Sarmathura-II Chandpura

4 Dholpur Baseri Baroli Jakha

5 Dholpur Baseri Sarmathura-I Pabaini

6 Dholpur Baseri Baseri Sangoli

7 Dholpur Baseri Baseri Khidora

8 Dholpur Baseri Dhorr Dhaur

9 Dholpur Baseri Mahugulawali Boreli

10 Dholpur Baseri Baseri Baseri

11 Dholpur Rajakhera Marena Tor Shankra

12 Dholpur Rajakhera Mangrol Parsoda

13 Dholpur Rajakhera Barehmori Bhooda

14 Dholpur Rajakhera Machariya Samaliyapura

15 Dholpur Rajakhera Marena Farashpura

16 Dholpur Rajakhera Jatoli Bhaisakh

17 Dholpur Rajakhera Barehmori Samor

18 Dholpur Rajakhera Jatoli Luhari

19 Dholpur Rajakhera Rajakhera-II Nahila

20 Dholpur Rajakhera Marena Marena

21 Dausa Lalsot Deedwana Palri

22 Dausa Lalsot Bilona Kalan Prahladpura

23 Dausa Lalsot Kallawas Jeetpur

24 Dausa Lalsot Deedwana Aranya Kalan

25 Dausa Lalsot Kallawas Doongarpur

26 Dausa Lalsot Kallawas Gopalpura

27 Dausa Lalsot Rajoli Gol

28 Dausa Lalsot Sanwasa Chandsen

29 Dausa Lalsot Bilona Kalan Bilona Kalan

30 Dausa Lalsot Mandawari Mandawari

31 Dausa Mahuwa Mandawar Nangal Kolra

32 Dausa Mahuwa Santha Nayagaon

33 Dausa Mahuwa Mandawar Banawar

34 Dausa Mahuwa Mandawar Bandanpura

35 Dausa Mahuwa Khedla Jalalpura

36 Dausa Mahuwa Santha Palanhera

37 Dausa Mahuwa Balahedi Balaheri

38 Dausa Mahuwa Mandawar Garh Himmat Singh

39 Dausa Mahuwa Santha Santha

40 Dausa Mahuwa Mahuwa Mahuwa (CT)

Annexure 3 Perception Matrix

Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

Perception: Availability of and Access to Services

Type of Services Available

Immunization

Supplementary nutrition

Preschool education

Immunization

Supplementary nutrition

Preschool education

Home visits for health and nutrition education

Supplementary nutrition

Immunization

Health and Nutrition education

Pre-school education

Assisting health staff in immunization

Health check-up of children and mothers

Preschool education

Supplementary nutrition

Referral services

Immunization

Health and nutrition education services

Supplementary Nutrition

Referral services

Most preferred services

Immunization

Supplementary nutrition

Immunization

Supplementary nutrition

Supplementary nutrition

Immunization

Health and Nutrition education

Pre-school education

Supplementary nutrition

Immunization

Health and Nutrition education

Pre-school education

Supplementary nutrition

Immunization

Health and Nutrition education

Pre-school education

Least preferred services

Health and Nutrition Education

Referral Services

Pre-School Education

Pre-school education

Supplementary nutrition

Referral services Referral services Referral services

Growth monitoring

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Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

Perception: Quality of Services

Quality of Supplementary Nutrition

Lack of diversity in nutrition

Absence of provision of milk

Poor taste of food

Soya bean based THR did not smell good

Helpful for the poor and needy

Deterioration of food quality over time

Outsourcing of provision of supplementary nutrition to SHGs affecting quality

Provision of free food led to people misusing the service

Malpractice by AWWs: Few eligible women get the food, rest is taken by AWW

Insufficient quantity

Older children accompanying siblings also provided food leading to food shortage

Lack of diversity

Do not receive the food ration on time

Insufficient quantity

Older children accompanying siblings also provided food leading to food shortage

Lack of diversity

Lack of diverse menu leading to children being bored of eating the same food

Outsourcing of Supplementary Nutrition to SHGs has led to poor quality

Maintaining quality of food due to decentralization the main challenge

Decentralization had helped the department tackle procurement related problems.

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Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

Quality of Pre-school education

Poor quality of pre-school education

Preference for Private Schools

Poor quality of pre-school education

Preference for Private Schools

Good option for children below 6 years, not eligible for school

Services are good and meant for the poor but not valued by people

Lack of infrastructure like electricity, fans and facilities like toilets, drinking water supply etc. affects quality of service

Lack of replacement of damaged supplies like toys, books etc affects teaching quality

Lack of refresher training.

Absence of physical space such as a playground limits activities that can be conducted with children

Lack of good infrastructure and facilities like electricity, fans, toilets, drinking water etc. and broken toys, torn books.

Lack of well-maintained teaching aids, toys, games, workbooks, etc

Absence of physical space (playground, large rooms to accommodate children, functioning toilets etc) and facilities for a playground

Lack of trained teachers

Education provided is not interesting or inspiring.

Communities Availing/ Not Availing Services

Communities Availing/ Not Availing Services of AWCs

Those who can afford prefer private services

Those who can afford prefer private services

Most people availing services at AWC are poor and unable to afford private services

Most people availing services at AWC are poor and unable to afford private services

Most people availing services at AWC are poor and unable to afford private services

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Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

Convergence with Other Departments

Convergence with Other Departments

Receive a lot of support from ASHAs and also ANMs

Attending different events and activities of other departments takes up a lot of time

Three of us (ASHA, ANM and AWW) support each other in our work and conduct activities together

ASHA workers help in community mobilization for ICDS activities to a large extent

Good convergence between ICDS and health depart. at the village level

Poor convergence of Panchayati Raj Department and Education Department with ICDS. Poor support from PRI members

Government school teachers only monitoring AWCs attached to their schools. No monitoring visit to AWCs not attached to their schools was made

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Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

Supply side barriers to utilization

Supply side barriers to utilization

Poor quality of teaching

Lack of infrastructure and teaching aids

Poor quality of supplementary nutrition

Poor quality of teaching

Lack of infrastructure and teaching aids

Poor quality of supplementary nutrition

Defunct weighing machines

AWWs find ‘growth monitoring ‘too technical’

Lack of regular refresher trainings.

Absence of formal structure of mentoring AWWs on an on-going basis, excepting basic support

AWW training focused heavily on knowledge building, less focus on skill building

AWC located far from home making it difficult to reach on time to open the centre after completing household work early in the morning

#Lack of good infrastructure and facilities like electricity, fans, toilets, drinking water etc

AWWs not very educated

Low honorarium for AWW and helper

Need a vibrant, fully functioning AWC to attract people to avail services on their own

Lack of punctuality of AWWs in opening centre

Political interference and corruption in the selection process of AWWs

Poor infrastructure of AWC

ASHA workers appeared much more vibrant, vocal, informed and confident in comparison to the AWWs.

Newly hired AWWs were better educated, are performing better and more motivated, probably due to

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Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

increase in honorarium

Distance to the AWC and/or to the hospitals dissuaded people from availing services

Demand-side barriers to utilization

Demand-side barriers to utilization

Preference for private over public education and health services

Lack of identity documents for making the MCP card

Time constraints due to women’s daily responsibilities and Lack of support from and involvement of family members

Preference for private over public education and health services

Time constraints due to women’s daily responsibilities

Lack of support from and involvement of family members AWC is located too far from their homes

Community members lack awareness and that they do not understand benefits of services

Lack of intent to avail health and nutrition services

Lack of importance given to education

Preference for private over public education and health services,

Community members lack awareness and also do not understand benefits of services

Lack of importance given to education

Lack of identity documents for making the MCP card

Women do not consider children to be malnourished even if the child weighs under 2 kg Fear of side effects of immunization

Community members lack awareness and also do not understand benefits of services

Lack of importance given to education

Resistance from older family members, esp mothers-in-law

Preference for private over public education and health services

As majority beneficiaries were found to be farmers, they did not have time or willingness to avail of health and nutrition services

Women think of health check-ups to be a waste of their time

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Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

especially among families who can afford

Women believe they will get better on their own

Fear of side effects of immunization

Perception: Functioning of Anganwadi Workers

Relationship with AWWs

AWW worked hard and had to face a lot of difficulties

AWW does not refuse anyone when it comes to providing a service, even when they are not registered

Better relationship with ASHA workers

AWWs only came to call them to come to the centre, or to participate in campaigns; but often it was found that it was the

Had few interactions with AWWs and were not aware of all services provided

Some potential beneficiaries stated that owing to the distance of the centre from their homes, they did not prefer going there.

Some potential beneficiaries stated that the few times that they had gone to the

In some locations where KIs had a good working relationship with AWWs, they were found to be more supportive of the work of AWWs.

Some school teachers reported helping AWWs with mobilizing community members

Male school teachers reported counselling men who were

ASHA workers were a key support system for AWWs with lesser support being given by ANMs

ASHA workers reported working together smoothly with the AWWs without any report of conflict. ASHAs also reported conducting pre-school education activities together with the AWW.

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Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

ASHA worker who did the mobilization

centre, they had found it closed and did not meet any AWW.

resistant on family planning.

Where AWC was within the school premises, greater interaction and engagement between the school teachers was indicated

School teachers reported that AWWs sought guidance from them in motivating and teaching young children.

Value of AWWs in the community

AWWs not trained to teach children

AWW needed to be more punctual to ensure timely immunisation and opening of the centre

Many potential beneficiaries did not know AWW

AWWs worked hard and are an important part of the community

AWWs were appreciated for their punctuality, going out of their way to improve infrastructure or services (when supply was poor), helping women seek medical care during pregnancy related complications or their children’s illness and for

AWWs are appreciated and valued when they were found to be hardworking, when they organized good events at the community level and when beneficiaries availed benefits of schemes such as the Pradhan Mantri

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Respondents

Beneficiaries Community Level Functionaries/Influencers Gov. Functionaries

Existing Beneficiaries

Potential Beneficiaries

Key Influencers AWWs ASHA/ANM (Supervisors, Govt Officials at Project /District/State

providing valuable information

AWWs felt a significant sense of pride and felt valued in the community

Felt an increase in their own confidence over the years

AWWs reported feeling good that they were invited to participate in village development activities in the community by elders in their villages and their opinion was also sought during meetings

Matritva Vandana Yojana.