Odisha has 30 districts and 310 blocks. One of the block named Tangi is our field practice area and situated in Khordha district. The block is divided into six sectors each with a primary health centre. The current study was a cross-sectional study carried out from July 2014 to February 2015 in Bhusandapur sector, one of the most crowded sectors of Tangi with 5gram-panchayats (local self-government organization), 56 villages and an estimated population of around 57,000. As per ICDS norm, there should be one AWC for population of every 800 people or less. There were 50 AWCs for 7,400 (under six children) in Bhusandapur sector with estimated deficiency of 22 AWCs as per norms (i.e., 30% gap in infrastructure).

Out of 5gram-panchayats, we selected 3gram-panchayats using convenient sampling method. The selected gram-panchayats had 36 AWCs which constituted our sample. Data was captured using a semi-structured questionnaire and checklist for facility survey developed in the department.

Information was gathered on variables related to three domains, manpower resource, material resource and functional aspects of the AWC either through interviews of AWWs or by performing observations within the AWC.

We studied the socio-demographic profile of AWW (i.e., manpower resource). Here data was gathered on their age, educational qualification, caste, residential status in the village they worked, and years of work experience. Under material resource we collected information on the status of building, ownership aspects, accessibility to beneficiaries and provision of water, toilet, electricity, and availability of dedicated cooking space. The functional aspects of AWC were determined by analysing the gap between expected and actual enrolment of the beneficiaries (children under six, and pregnant and lactating mothers) from the registers of previous one year, by physically checking the availability of tools for promoting physical and psychological development of the beneficiary children like pre-school education kit, growth charts, weighing machines, and utensils for supplementary nutrition etc.

AWWs were also asked (qualitative inquiry) about the various components of their day to day activities; problems faced in executing their duties that could be related to infrastructure issues, logistics, human resource constraints; their perspective about different stakeholders in the program; and their suggestions for further improvement.

Data were entered and analysed in Microsoft excel (2007). The quantitative variables were summarized using median and inter-quartile range and the categorical variables were expressed in terms of numbers and percentages. The responses (qualitative data) obtained during the interview were recorded in vernacular language, translated to english and presented in the boxes in narrative form.

No ethical approval was sought specially for the study as the data was part of routine monitoring and met the criteria of operational improvement in health services in the field practice area of the Institute. Verbal informed consent was taken from all the participants before the interview and the confidentiality of the data was maintained within the department. Govt. of Odisha has given permission to the institute to take Tangi block as the field practice area. Moreover, it is a cross-sectional study and data was collected through interviews. We have taken utmost care to anonymize the data and to maintain the confidentiality.

The data was available for 36 AWCs. Findings of the study are summarized under three headings as mentioned below:

More than 80% of the AWCs had both AWW and AWH. The median age of AWWs was 33.5 years (Interquartile range 29 years, 39 years). All the AWWs had more than 8 years of schooling. In fact, 55% were either graduates or postgraduates. Most of them belonged to general caste (77.8%) and their residence was within 3 kilometres (88.9%) of the AWC. The median years of job experience was 6.5 years (Interquartile range 5 years, 15 years).

A 83.3% of AWCs were pucca houses (made of impervious walls and roof) in nature. Almost one tenth of the total studied AWCs had self-owned building and the rest were functioning in temporary arrangements made either in nearby government schools/office buildings (72.2%), in temple premises (11.1%), or rented houses (5.6%). At some places upto three AWCs operated in the same school premises. Almost 85% of the AWCs were situated within the same village. It is mandatory for every AWW to provide freshly cooked supplementary meals to the beneficiaries. However, only 16.7% AWCs had dedicated cooking space available for the same. In most other centres, cooking activities took place within the same premises that exposed children to severe indoor air pollution as seen in [Table/Fig-1]. Almost 90% of the AWCs did not have adequate provision of water, toilet and electricity [Table/Fig-2].

[Table/Fig-1]:

Smoke coming from the cooking area with children playing around in an AWC in Jhatinuagaon village, Bhusandapur, Tangi, Odisha 2014-15.

Lack of own building forced the AWWs to organize their day to day activities like immunization, growth monitoring, cooking meals etc. in different temporary settings. This put extra burden on them for daily transfer of items like Pre-School Education (PSE) kits, registers, utensils, etc. required for these activities between their place of residence and centre. Scarcity of water at these sites was a major problem [Table/Fig-3]. There was an earmarked budget for the construction of AWCs. However, the site for its construction was left to be determined by the AWW. The villages were mostly overcrowded; therefore, most people had illegally occupied vacant government lands over generations. This led to conflicts while identifying suitable area for construction of new AWCs in those villages and the AWWs were helpless due to local pressure. [Table/Fig-3] summarizes key statements of interviewee and observation made by the interviewers during this study under material resource section.

A 96.9% of children less than 3 years of age availed the services as compared to 76.6% of children between 3-6 years of age. Among others while all the lactating mother availed the services, only 94.8% of pregnant mothers availed the services [Table/Fig-4]. Those children who didn’t attend the AWCs, most preferred to attend private play schools. Reasons cited for this, was poor satisfaction with respect to quality of services provided to them. According to the AWCs, supplementary nutrition didn’t meet their demands and supply of only eight eggs per month was not at all acceptable [Table/Fig-5]. Utensils for cooking food weren’t available in 20% of the AWCs.

[Table/Fig-4]:

Percentage of beneficiaries availing services at AWC in Bhusandapur sector, Tangi, Odisha 2014-15.

Besides, AWWs also acted as one of the nodal persons for conditional cash transfer under Mamata scheme under reproductive child health program to pregnant and lactating mothers (scheme) [13]. Irregular disbursement of funds under the Mamata scheme often resulted into lack of faith in AWWs which inadvertently also affected their performance in ICDS largely due to non-acceptance.

Under ICDS, preschool education is one of the vital service com-ponents and requires availability of a preschool education kit. This kit consists of picture charts, fruit models, kitchen sets, hollow ball, counting frames, animal toys etc., [14]. Nearly half of the AWCs didn’t have many of these items. All the AWCs lacked simple puzzle game or stacked rings or fun dough for mental stimulation and development of the children. The available kits were old and potentially unusable.

Though, growth charts and weighing scales were universally present, most AWWs didn’t know about zero correction and proper placement of children in the sling of weighing machines. The quality of these slings was also not up to the mark. All these have been captured in narrative statements in [Table/Fig-5]. As per the ICDS scheme, every AWW has to deliver certain services like preschool education, immunization, supplementary nutrition, health education and referral support. On repeated probing about various activities, most AWWs were able to remember their role and responsibilities in each of these service domains. The very fact that it did not come out spontaneously, raises doubt about its execution on regular basis.

It was also observed that AWW had to participate in various other community based activities of the State Government like Village Health Nutrition Days (VHND), monetary disbursements under the Mamata scheme, besides attending monthly meetings with ICDS beneficiaries and updating the demographic information of the village assigned to them. They also had to maintain number of registers like family survey register, immunization register, pregnant & lactating mothers register, birth & death register and growth monitoring registers. This was a paper based record and lacked uniformity in reporting across different AWCs. There was no electronic data gathering system available at these centers [15]. All this overburdened the AWW, who was left confused most of the times while prioritizing the jobs (service delivery, documentation, health promotion, liaising with ASHA etc.,) expected of them.

Nearly 90% AWWs had undergone induction training, but only half of them ever had any refresher training within the last three years [Table/Fig-6]. The reasons cited were lack of training facilities in their localities and their inability to attend trainings 60 kilometres away from their work place in the capital city of Bhubaneswar.

Low salary, heavy work load, late disbursement of fund from gov-ernment and lack of communication with the supervisors etc., were some of the additional problems related to their job that affected their satisfaction levels.

Some of the innovative suggestions given by participants to improve performance of AWCs were provision of milk based products in the daily menu of AWCs, making uniforms mandatory for the children in all AWCs to improve the visibility of AWC and ICDS implementation in the community, introduction of skill based training for adolescent girls to boost their enrolment rates in the AWCs, and providing effective health education services at these centres.

Under the ICDS program, AWC represents the grass root level facility which should be manned by one AWW and one assistant i.e., AWH [6]. At national level, nearly 90% AWCs were fully staffed as per the status report on ICDS scheme 2013 [16]. Previously published reports and studies indicated that the educational status of AWWs in Odisha was reportedly higher as compared to other states in India [10,17]. This finding had also reflected in our study. This could be one of the reasons, for better awareness among AWWs about their roles and responsibilities as envisioned under ICDS, and also for maintenance of different registers in our study site, irrespective of its completeness and unlike in other places across the country [18,19].

As per the guidelines issued by Ministry of Women and Child Development, Government of India, AWWs should be selected from the local community, and the selection process should reflect representation of all the sections of the society based on the prevailing caste distribution within the community. This is necessary to improve the accessibility of children of schedule castes and other weaker sections of the society to the centers [20]. Our study site indicated a fair selection of AWWs as per these norms.

Regular refresher and specific need based-training of involved manpower is vital to maintain quality of services rendered. Therefore, Govt. of India had sanctioned 5 billion rupees especially for training during the 11^th five year plan for creation of new training centres. However, this vision doesn’t seem to have been translated into reality as per our findings and few other published studies [21,22].

Apart from performing routine duties within the ambit of ICDS, AWWs are forced to participate in other state run programs throughout the country [10,23,24]. Any deficiency in implementation of those programs would negatively impact the image of AWWs and implementation of the ICDS scheme in the bargain. Kishori Shakti Yojana and Sabala scheme focusing on adolescent girls were also planned to be implemented through ICDS infrastructure. However, the existing woes of the AWWs failed to generate any interest among the targeted beneficiaries [25].

AWWs are expected to carry out their routine activities through temporary makeshift arrangements. The scenario is not very different elsewhere in the country [10,26]. This could prove to be a demotivating factor to the workers as well as the beneficiaries [23]. Ministry of Women and Child Development recognized the importance of self-owned buildings for better service provision, in its annual report (2012-13) [11]. But, over last few years there appears to be a lack of political will as indicated by reduction (55%) in budgetary provision for the program both at the centre and state level in Odisha during the last two years [27].

In spite of existence of ICDS for many years, there is no palpable difference in terms of availability of basic facilities like electrification of centres, provision of toilets and safe water supply to the children and working staff across the country [10,23,28,29]. Use of alternate source of fuel in the form of firewood/coal adds to the health hazard of the children. Attendance in private play schools instead of AWCs in our study area reflected the dissatisfaction among parents. The reasons for this were poor quality of services, non-availability of play materials and infrastructural deficiencies. Similar results were obtained in previous studies [30,31].

A motivated, skilled and satisfied worker is essential for improving the quality of services. Lack of communication with supervisors, delay in release of salary, lack of training opportunities and non-recognition of long standing contribution breeds contempt and sense of unfairness among the AWWs which demotivates and results in sub optimal performance [10,17–19,22,24,32].

All these findings have been projected from the perspective of health systems analysis in [Table/Fig-7]. It shows how various factors interact with each other resulting into poor service delivery and negatively impact the goals of the program meant for betterment of maternal and child health. Strength of our study lies in combining different approaches of research to corroborate the findings and bring out a clearer picture into focus.

[Table/Fig-7]:

Using Health systems Framework to analyse status of ICDS implementation in Odisha, India.

In recent years, researchers have evaluated the ICDS program at different sites and suggested changes for better functioning of AWCs time to time, but the age old problems of infrastructure, logistics, lack of quality of services, lack of minimum amenities etc. are still persisting that require urgent attention of policy makers.

First of all, the study was carried out in a field practice area and is not a true reflection of the performance of the programme at the state level. Secondly, we could not assess the supply chain management, perspectives of AWW supervisors, the policy makers and implementers at state level. However, we believe that it does expose key factors that affect the effective implementation of the scheme and the felt needs of its implementers at the grass root level.

Current study found out many issues regarding manpower, functionality and infrastructure of AWCs under ICDS program. Such issues warrants strengthening of grass root level facilities based on findings of regular needs assessment, effective monitoring and supervision. Involvement of the lowest level workers in stakeholder analysis for performance improvement, adequate supply of logistic, performance based incentives etc. may be some ways that could improve functioning ICDS and can help to achieve its intended goals.