Integrated Child Development Services – India’s flagship child nutrition programme – has recently suffered a major cut in funding. This column shows that supplementary nutrition provided under the programme positively influences long-term educational outcomes of children. The findings suggest that funding for the programme should be fully restored and efforts should be made to address its systemic inefficiencies.
We can all agree that good health, education, and gainful employment are all determinants of a meaningful life. A family’s socioeconomic status and the resources they allocate for a child’s nutrition, healthcare, education, and overall development all contribute to achieving health, education and employment. Many other factors play a role in achieving one’s full potential – they are as diverse as the nutrient composition and energy content of the child’s diet, the pupil-teacher ratio at school, and the global economic outlook .
However, much remains unclear about the relative strengths of certain factors and the timeframe of impact. It turns out that nutrition in early childhood (during the first two to three years of life) is possibly the most important determinant of adult health outcomes such as height and the likelihood of suffering from cardiovascular diseases (Victora et al. 2008, Currie and Vogl 2013, Nandi et al. 2016a). This is known as the “fetal origins” hypothesis or Barker hypothesis, named after the British epidemiologist David Barker who first proposed the theory in the 1990s (Barker 1995). Since then, numerous studies have validated the hypothesis across many countries.
Beyond health, early life nutrition could also improve future cognitive development, educational outcomes, and labour productivity, and even make children in the next generation healthier. By one estimate, 200 million children under five years of age, mainly from South Asia and sub-Saharan Africa, fail to achieve their cognitive potential due to undernutrition (Grantham-McGregor 2007).
However, it is not easy to analytically establish such relationships. There may be confounding effects from other early childhood shocks such as diseases and natural disasters on future cognitive outcomes. Also, estimating the effect of early nutrition on adult outcomes often requires following individuals over a long period of time to collect data. Naturally, such longitudinal studies tend to be very expensive and difficult to carry out. In low- and middle-income countries, this is probably why the link between nutrition and future educational outcomes has been examined only by a handful of studies in Guatemala (Maluccio 2009), Brazil (Victora et al. 2015), Tanzania (Field, Robles and Torero 2009) and Indonesia (Majid 2015).
ICDS and educational outcomes: Evidence from a regional field trial
In a recently published study, we examined the association between supplementary nutrition provided by India’s Integrated Child Development Services (ICDS) programme and long-term educational outcomes of children (Nandi et al 2016b), Launched in 1975, ICDS is the world’s largest maternal and child health programme. It provides supplementary nutrition and other services, such as preschool education, immunisation, and health checkup and referrals to more than 100 million children under the age of six years, adolescent girls, and pregnant and lactating women. Researchers have found positive effects of the programme on child nutritional status.
We used data from the Andhra Pradesh Children and Parents study (APCAPS 2003-2005). During 1987-1990, a controlled nutrition trial was conducted in 29 randomly selected villages (15 ‘intervention’ villages that received the programme and 14 ‘control’ villages that did not receive the programme) near the city of Hyderabad in Andhra Pradesh (now Telangana). In the intervention villages, pregnant women and children below the age of six years were offered a daily cooked meal (upma) for three years under the ICDS programme. The meal provided 500 kcal energy and 20-25 grams of protein to each woman and 300 kcal energy and 8-10 grams of protein to each child. Other public health components of ICDS, such as immunisation, anemia control in pregnancy were available at similar levels in intervention and control villages.
Children who were born in the study villages during the original trial and could be matched with historical records were invited to participate in the follow up survey. A total of 1,165 children of age 13-18 years – 654 in intervention villages and 511 in control villages – were interviewed during 2003-2005.
We examined the following educational outcomes of the 13-18 year old adolescents: (i) school enrolment (ii) schooling grade and (iii) academic performance (most recent test scores at school). We found that adolescents originally born in intervention villages were 7.8% more likely to be enrolled in school and completed 0.8 more schooling grades than similar children born in control villages. No significant difference was found in test scores.
ICDS and educational outcomes: Evidence from national survey data
Considering the tremendous socioeconomic differences across Indian states (and even within a state), findings from the above study are not generalisable to other contexts. In a second study (Nandi and Laxminarayan 2016), we evaluated the effect of ICDS at the national level. Using data from the National Family Health Survey (NFHS) 2005-06, we determined exposure to the programme based on the year ICDS centres were established in villages or city wards.
We found that 15-54 year old men and 15-49 year old women who resided in a neighborhood with an ICDS centre during the first three years of life complete up to 0.65 additional years of education than other members of their household with no exposure. If we also consider partial exposure to ICDS (that is, an ICDS centre opened after the individual’s birth but before three years of age), the effect of the treatment is 0.52 extra years of education. For ICDS centres that are known to provide supplementary nutrition, individuals in the above age groups with full exposure during the first three years of life complete 1.08 additional years of education (0.93 extra years if we also consider partial exposure).
Implications for policy
These findings have tremendous significance for policy. ICDS is presently going through a tumultuous time. There are strong criticisms of inefficiency, with at least a third of the potential beneficiaries not receiving nutrition in many key states despite significant budget overruns (Comptroller and Auditor General of India, 2013). There are also persistent concerns of poor service delivery. Every so often, we see news of children falling sick from eating contaminated meals.
In 2013, a major restructuring of the programme called ICDS Mission was proposed. However, the central government’s budget for this programme was reduced by almost 50%, or Rs. 10,000 crore (US$1.5 bn approx.), from 2014–15 to 2015–16. While the cut was eventually revised to a lower amount, further cuts have been made again in the 2016-17 budget. Considering the potential benefits of the programme, funding for ICDS should probably be fully restored and a hard look taken at systemic inefficiencies. A well-planned and comprehensive restructuring (which may not necessarily be the ICDS Mission) may help the benefits reach a wider population.
- Victora, Cesar G, Linda Adair, Caroline Fall, Pedro C Hallal, Reynaldo Martorell, Linda Richter and Harshpal Singh Sachdev (2008), “Maternal and child undernutrition: consequences for adult health and human capital”, Lancet, 371, 340–57.
- Currie, Janet and Tom Vogl (2013), “Early-Life Health and Adult Circumstance in Developing Countries”, Annual Review of Economics, 5, 1–36 (2013). Available at: http://www.princeton.edu/~tvogl/currie_vogl_AR.pdf
- Nandi, A, JR Behrman, S Bhalotra, AB Deolalikar and R Laxminarayan (2016), ‘Human Capital and Productivity Benefits of Early Childhood Nutritional Interventions’, in Disease Control Priorities Third Edition, Volume 8: Child & Adolescent Development.
- Barker, DJP (1995), “Fetal origins of coronary heart disease”, BMJ (Clinical research ed.), 311, 171–4. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2550226/pdf/bmj00601-0037.pdf
- Grantham-McGregor, S et al., (2007), “Developmental potential in the first 5 years for children in developing countries”, Lancet, 369, 60–70.
- Field, Erica, Omar Robles and Maximo Torero (2009), “Iodine deficiency and schooling attainment in Tanzania”, American Economic Journal: Applied Economics, 1, 140–169. Available at: http://isites.harvard.edu/fs/docs/icb.topic1222150.files/Session%208/Field%20Iodine.pdf
- Majid, Muhammad Farhan (2015), “The persistent effects of in utero nutrition shocks over the life cycle: Evidence from Ramadan fasting”, Journal of Development Economics, 117, 48–57. Available at: http://repository.upenn.edu/cgi/viewcontent.cgi?article=1004&context=gcc_economic_returns
- Maluccio, John A, John F Hoddinott, Jere R Behrman, Reynaldo Martorell and Agnes R Quisumbing (2009), “The Impact of Nutrition during Early Childhood on Education among Guatemalan Adults”, The Economic Journal, 119, 734–763. Available at: http://repository.upenn.edu/cgi/viewcontent.cgi?article=1002&context=psc_working_papers
- Victora, CG et al. (2015), “Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil”, The Lancet Global Health, 3, e199–e205.
- Nandi, Arindam, Ashvin Ashok, Sanjay Kinra, Jere R Behrman and Ramanan Laxminarayan (2016), “Early Childhood Nutrition is Positively Associated with Adolescent Educational Outcomes: Evidence from the Andhra Pradesh Child and Parents Study (APCAPS)”, Journal of Nutrition, 146, 1–8.
- Nandi, A and R Laxminarayan (2016), ‘Can Early Childhood Nutrition Improve Adult Educational Attainment in India? Evidence from the ICDS Program’, SSRN Working Paper.
- Comptroller and Auditor General of India (2013), ‘Report of the Comptroller and Auditor General of India on Performance Audit of Integrated Child Development Services (ICDS) Scheme’, 1–141. Report No. 22 Government of India.
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