Supply and Demand for Maternal and Child Health Services during the Covid-19 Pandemic: Evidence from Odisha

Project Details

In March 2020, the Government of India instituted one of the most stringent Covid-19 lockdowns in the world, which marked the closure of several essential services including maternal and child health services provided under the Integrated Child Development Services (ICDS) scheme. The scheme is the government’s primary vehicle to promote early childhood development in India. ICDS workers provide preschool education and supplementary nutrition services to children aged 0–6 years from socioeconomically disadvantaged households. They also undertake home visits to monitor the health of pregnant and lactating mothers as well as children. 

As of 2021, Odisha had 73,200 operational ICDS centers (also known as anganwadis) catering to the needs of roughly 3.2 million children under the age of six, and 650,000 pregnant and lactating mothers. Researchers conducted phone surveys with ICDS workers in three districts in Odisha to understand the effects of the pandemic and subsequent lockdown measures on the supply and demand for maternal and child health services.

This descriptive study forms a part of a larger randomized evaluation that aims to uncover the impact of providing feedback on workers' own performance on the utilization of ICDS services and the rate of malnutrition among children in Odisha. Additional surveys were conducted to uncover the disruptions to ICDS services after the onset of the pandemic. Different survey rounds include:

• Pre-Covid surveys (April 2018) with the original sample of 6,003 ICDS workers in Odisha’s Baleshwar, Dhenkanal, and Ganjam districts.
• Follow-up surveys (December 2020 to April 2021) with roughly 80 percent of the original sample as well as 1,172 additional workers following the closure of ICDS centers.

Both survey rounds collected information on the provision of core ICDS services (preschool education and nutrition) and the household income, working hours, and responsibilities of ICDS workers. To understand the effects of periodic lockdown restrictions over the course of 2020, the 2021 follow-up survey asked workers to recall working conditions they experienced in February, May, August, and November 2020. Additionally, researchers also recorded details of any Covid-19-related services provided by ICDS workers. Two focus group discussions were later conducted in July 2021 with six ICDS workers—two from each district—to bolster insights from the survey. 

Research Results

India’s nationwide Covid-19 lockdown led to extended closures of anganwadi centers in Odisha even after restrictions were lifted. As per government directives in March 2020, all anganwadi centers in Odisha were shut down. While more than 75 percent of surveyed workers reported that once restrictions were lifted, workplaces had opened, and the movement of individuals and vehicles had normalized by November 2020, anganwadi centers remained closed for another three months. Even in areas with the lowest lockdown restrictions, 2 percent of workers reported the operation of anganwadi centers in November 2020.  

Preschool education was the most affected core ICDS service. 

• Reduction in the frequency and provision of preschool services: In May 2020, 36 percent fewer ICDS workers were providing preschool services compared to pre-pandemic levels. The frequency of preschool training was also lower—most workers reported conducting weekly sessions rather than the daily sessions they were conducting before the pandemic. This was partly due to the closure of the anganwadi centers, which necessitated a larger number of home visits. Areas with the strictest lockdown restrictions experienced the sharpest contraction in the number of workers providing preschool services. Although there were some improvements in August 2020, 15 percent of workers had still not returned to providing pre-school services by November 2020. 
• Reduction in demand for preschool services: Before the onset of the pandemic, 400 ICDS workers reported receiving more demand for preschool services from parents than they could provide in February 2020. However, in May 2020, this excess demand had fallen to zero and remained depressed until November 2020. Researchers posit that this might be because parents were averse to home visits from ICDS workers due to fear of contracting Covid-19 infections. Areas with the strictest restrictions witnessed the sharpest contraction in excess demand. 
• Provision of other ICDS services: The provision of take-home rations increased by thirty percent in May 2020 and remained higher than pre-pandemic levels throughout 2020. This is consistent with the government’s focus on food distribution initiatives during the pandemic to combat food insecurity faced by households, particularly by daily wage earners. There were also negligible changes in the provision of other core ICDS services such as height and weight monitoring, vaccinations, and home visits.

Rates of severe malnutrition had increased before the pandemic, but stayed constant (for girls) or declined (for boys) after March 2020. ICDS workers track the weight of child beneficiaries against growth charts to assess levels of malnutrition. Based on ICDS records from Odisha, the percentage of severely malnourished girls had doubled from 0.23 percent in April 2018 to 0.45 percent in February 2020 and remained constant throughout 2020. Severe malnutrition among boys was higher at 0.40 percent in April 2018, but exhibited a 0.06 percentage point increase by February 2020. Throughout 2020, rates of severe malnutrition for boys declined and approached their 2018 levels. 

Almost all ICDS workers reported involvement in Covid-19-related services. In May 2020, almost all ICDS workers surveyed reported being a part of Covid-19-related awareness campaigns and community surveillance activities. Roughly 60 percent of workers also reported working on government support programs, especially in areas with stricter restrictions. Over the course of 2020, workers also became increasingly involved in duties related to curbing child marriage, which had become more common following the institution of the Covid-19 lockdown. By November 2020, 65 percent of workers surveyed reported working on such activities. 

ICDS workers spent more hours working, but time spent on Covid-19-related duties reduced the time they had available to provide core ICDS services. ICDS workers reported working for 43 hours per week in May 2020 as compared to 35 hours per week in February 2020 (an increase of 23 percent), in part due to an increase in hours spent on Covid-19-related tasks. However, the increase in time spent on Covid-19 duties meant lesser time spent on ICDS activities, particularly the provision of preschool services. 

ICDS workers received regular payments throughout lockdown, but their household incomes fell by an average of 12 percent from INR 18,350 in February 2020 to INR 16,100 in May 2020. Workers’ household incomes grew gradually as the rest of the year progressed, but had not returned to pre-pandemic levels by November 2020. Workers did not receive additional compensation for any Covid-19-related duties performed. 

Fear of side effects was cited as a key reason for the non-take-up of Covid-19 vaccines. Sixty percent of workers surveyed reported that fear of side effects was the key reason for vaccine hesitancy among adults in their area.  More than 20 percent of workers also noted that those who did not get vaccinated either doubted the vaccine’s efficacy or believed that herd immunity generated from widespread vaccination among others would be sufficient to protect them. Workers also reported that vaccine hesitancy had declined during the second wave of Covid-19 infections in April 2021, with demand far outstripping supply by May 2021.