Designing Impact Evaluations for the Nodal Anganwadi Centre Initiatives under SWASTH (Sector Wide Approach to Strengthen Health), Bihar, India

Introduction

This study, sponsored by 3iE and the Global Development Network (GDN), and led by Dr. Sumit Mazumdar at IHD, evaluates the Uddeepan Programme under Bihar’s SWASTH initiative. The programme aimed to strengthen Anganwadi Centres (AWCs), which deliver essential nutrition and health services to women and children, by introducing an additional trained worker called the Uddeepika. The project focused on improving service delivery, reducing workload constraints, and enhancing child nutrition outcomes in rural Bihar. Initially designed as an impact evaluation study, it later expanded into a large-scale research project. Covering multiple districts, the study examined how institutional strengthening and human resource augmentation influence health and nutrition indicators, while also identifying implementation challenges in resource-constrained and backward regions.

Objectives

• To conduct process evaluation of NAWCs, including infrastructure, attendance, and adherence to guidelines
• To assess knowledge and performance of cluster leaders and Anganwadi workers
• To compare outcomes between treatment and control Gram Panchayats using matched difference-in-difference methodology
• To evaluate programme impact on households, AWCs, and service delivery
• To identify short- and medium-term outcomes with long-term implications

Methodology and Coverage

The study employed a mixed-method and quasi-experimental design, combining quantitative and qualitative approaches. A matched difference-in-difference methodology was used to compare treatment Gram Panchayats (where the programme was implemented) with control Gram Panchayats. The survey covered 300 Anganwadi Centres, including 100 Nodal Anganwadi Centres, across 100 Gram Panchayats in four districts—Katihar, Supaul, Madhepura, and Kishanganj. From each AWC, 15 households were selected, resulting in a total sample of 4500 households. Data were collected through baseline and endline surveys, along with qualitative assessments of programme implementation. The study also included process evaluation focusing on attendance, infrastructure, and worker performance. This comprehensive coverage enabled a detailed assessment of both programme effectiveness and implementation challenges.

Findings

• Addition of Uddeepika helped reduce labour constraints in Anganwadi Centres
• Positive impact observed on child nutrition, particularly weight-for-age (WAZ) indicators
• Improved delivery of services like Take Home Rations and mid-day meals
• Even small improvements in worker-to-population ratio significantly enhanced outcomes
• Recruitment constraints (local hiring with higher qualifications) caused delays in implementation
• Limited reduction in human capital constraints due to hiring challenges
• Programme effectiveness affected by regional backwardness and institutional limitations
• Strengthening frontline workforce proved to be a cost-effective intervention
• Highlights importance of improving service delivery systems for maternal and child health