Impact evaluation : CARE - India's Title II program -- final report

480 Title II support provided through CARE to the Government of India's (GOI) Integrated Child Development Service (ICDS) Scheme, one of the largest child survival programs in the world. CARE began supporting the ICDS in 1984 and as of 1994 provided supplementary food at 141,101 anganwadi child care centers (AWCs). ICDS is a visionary program with substantial potential impact on the health and nutrition of the vulnerable poor, yet much remains to be done even though the GOI is committed to improving the ICDS and devotes considerable resources to it. The ICDS is not effectively focused enough on groups with the most dramatic opportunities for impact -- children under age 3 and pregnant/lactating women. Also, ICDS focuses more on rehabilitating severely malnourished children than on preventing growth faltering -- and yet the resources available have limited potential to rehabilitate the most malnourished children. Available data and analyses show a modest positive nutritional impact for ICDS overall and little difference in nutritional impacts between CARE and non-CARE ICDS, except in children aged 0-3, who appear less malnourished in CARE areas. Full access to the National Institute of Public Cooperation and Child Development's data base and in-depth analyses (multi-variate regression, etc.) may reveal more dramatic and positive impacts. No significant differences were found between CARE and non-CARE areas in growth monitoring and case management, but CARE has a greater differential impact (compared with non-CARE ICDS) in poorer states like Bihar and Orissa. Also, immunization coverage is higher in CARE than non-CARE ICDS areas, but is still well below national targets. Knowledge and skills of anganwadi workers in areas where CARE implements value-added programs (CARE-Plus) are far better (especially in areas with continuing health education) than in areas with food only (CARE-Regular) or non-CARE ICDS areas. Certain value-added CARE interventions -- continuing health education, acute respiratory infections, and bio-intensive gardens -- show a greater potential for enhanced health and nutritional impact than do CARE's "food only" activities. Several factors constrain the effectiveness of the ICDS program and will continue to do so over the medium- to long-term unless specific actions are taken by the GOI and its development partners (PVOs, including CARE, and donors): (1) community participation in AWC activities is low; (2) better intersectoral coordination is needed; (3) water and sanitation are universally inadequate in ICDS areas, and no priority is placed on investing in the necessary physical infrastructure or educational initiatives; (4) resources are limited, and the current lack of targeting and need-based resource allocation dilutes the impact of those limited resources; (5) CARE's resources are not focused on areas of greatest need -- GOI and CARE must work to shift resources to neediest states and phase down in more prosperous areas. Also, some states (e.g., Bihar) are experiencing distinct implementation problems. The GOI and State Governments should commit to ensuring full functioning of ICDS, with specific attention to resolving bottlenecks in transport and guaranteeing hiring and payment of workers. Numerous recommendations are addressed to CARE, USAID, and the GOI.