Can district level support enhance coverage and equity? Evidence from India’s nutrition program
Importance: India’s Integrated Child Development Services (ICDS) program is among the world’s largest nutrition and health programs that offers services to pregnant, lactating mothers, and young children. To support national investments towards universalization of ICDS interventions, between 2016 and 2020, the Indian government in collaboration with multiple partners, introduced system strengthening mechanisms at the district (subnational administrative unit) level in 64% of India’s districts.
Objectives: To examine national-level trends in coverage and equity of ICDS interventions and the role of district-level support mechanisms in improving equitable coverage.
Design, Setting, and Participants: This quasi-experimental assessment used data (N=393,097 mother-child pairs) from three rounds of nationally representative surveys in 2006, 2016, and 2020. We used inequity indices and regression models to assess changes in equity by wealth, caste, and residence. We applied difference-in-differences (DID) models to investigate changes in coverage due to district support mechanisms between 2016 and 2020.
Intervention: The district support mechanisms were introduced between 2016 and 2020 and included a combination of input features such as capacity building of frontline workers, additional human resources, financial, infrastructural, and technological support, among others.
Main Outcomes and Measures: Our primary outcomes were the receipt of thirteen ICDS services during pregnancy, lactation, and early childhood. District support mechanisms were grouped into three treatment arms for DID analyses using an intention-to-treat approach with heterogeneous treatments.
Results: ICDS utilization continued to increase from 2016 to 2020, with the most improvement observed in health and nutrition education (20-21pp). Unlike 2006-2016, there were large improvements in coverage equity between 2016-2020. DID models show, on average, that districts receiving any programmatic support had significant and faster improvements in coverage (2.2-14.7pp). Pooled effects sizes were larger, on average, for districts that received financial support in addition to human resources (8.9pp, 95% CI 7.3-10.74) compared to districts that only received human resource support (4.5pp, 95% CI 3.4-5.7).
Conclusions: India’s programmatic efforts to further strengthen the ICDS were successful in increasing coverage of ICDS program at the national-level and reducing coverage inequities that persisted earlier. Focused district support mechanisms enabled faster progress in coverage and equity.
Authors
Gune, Soyra; Alderman, Harold; Avula, Rasmi; Nguyen, Phuong; Dwivedi, Laxmikant; Kapur, Avani; Shukla, Ritwik; Pedgaonkar, Sarang; Singh, Shri Kant; Menon, Purnima; Chakrabarti, Suman
Citation
Gune, Soyra; Alderman, Harold; Avula, Rasmi; Nguyen, Phuong Hong; Dwivedi, Laxmikant; Kapur, Avani; Shukla, Ritwik; Pedgaonkar, Sarang; et al. 2025. Can district level support enhance coverage and equity? Evidence from India’s nutrition program. SSRN Preprint. Available February 7, 2025. https://doi.org/10.2139/ssrn.5109736
Keywords
Asia; Equity; Nutrition; Women; Children; Child Development
Access/Licence
Open Access
Project
National Policies and Strategies
