India's Primary Policy Response: The Integrated Child Development Services (ICDS) Program
Challenges and Way Forward
(Source World Bank: India's Undernourished Children: A Call for Reform and Action - August 2005)
In 2005, several factors converged to make a review of the Integrated Child Development Services (ICDS) program timely. These included the launch of the Government of India's National Health Mission and a National Nutrition Mission in fiscal year 2005-2006; the decision to target improving nutrition outcomes as part of the MDGs; the findings of the Copenhagen Consensus project which identified several nutrition interventions as some of the most high-yielding of all possible development investments; and the Government of India's pledge, in its February 2005 Budget speech, to expedite the expansion of the ICDS program.
The report aimed at providing information on the characteristics of child malnutrition across regions and over time and on the effectiveness of the ICDS program in addressing the causes and symptoms of undernutrition.
NOTE: the report is based on data from the NFHS-2 (1998-99). However, key findings and considerations are still valid for the NFHS-3.
- The reduction in the proportion of undernourished children in India over the past decade has been modest and slower than what has been achieved in other countries with comparable socioeconomic indicators.
- While aggregate levels of undernutrition are shockingly high, the picture is further exacerbated by the significant inequalities across states and socioeconomic groups
- girls, rural areas, the poorest and scheduled tribes and castes are the worst affected - and these inequalities appear to be increasing.
- Child malnutrition is mostly the result of high levels of exposure to infection and inappropriate infant and young child feeding and caring practices, and has its origins almost entirely during the first two to three years of life.
- The ICDS program, while successful in many ways, has not made a significant dent in child malnutrition. This is mostly due to the priority that the program has placed on food supplementation, targeting mostly children after the age of three when malnutrition has already set in.
- The ICDS program should be redirected towards the younger children (0-3 years) and the most vulnerable population segments in those states and districts where the prevalence of undernutrition is higher.
- The ICDS program should aim at:
- Improving mothers' feeding and caring behaviour with emphasis on infant and young child feeding and maternal nutrition during pregnancy and lactation.
- Improving household water and sanitation.
- Stregthening the referral to the health system with emphasis on prevention and control of common child diseases including acute malnutrition.
- Providing micronutrients.
- Urgent changes are needed to bridge the gap between the policy intentions of ICDS and its actual implementation.
- The demographic and socioeconomic patterns at the state level do not necessarily mirror those at the national level. Nutrition policy should acknowledge variations and address inequalities by closing the gap.
- Undernutrition is concentrated in a relatively small number of districts and villages suggesting that future efforts to combat malnutrition could be targeted to a relatively small number of districts/villages.
- Micronutrient deficiencies are widespread in India especially among preschool children and progress in reducing the prevalence has been slow.
- The key constraint on the ICDS effectiveness is that its actual implementation deviates from the original design with an increased emphasis on the provision of supplementary feeding and preschool education to children four to six years old. As a result, most children under three years do not get micronutrient supplements, and most of their parents are not reached with counselling on better feeding and child care practices using family budget.
- Children from wealthier households participate much more than poorer ones and ICDS is only partially succeeding in preferentially targeting girls and lower castes (who are at higher risk of undernutrition).
- Although program growth was greater in underserved than well-served areas during the 1990s, the poorest states and those with the highest levels of undernutrition still have the lowest levels of program funding and coverage by ICDS activities.
Program operational challenges:
- Inadequate worker skills, shortage of equipment, poor supervision and weak monitoring and evaluation.
- Community workers are overburdened, because they are expected to provide pre-school education to four to six year olds as well as nutrition services to all children under six. Because of the emphasis on food supplementation and pre-school education, most children under three years are not targeted.
- Supplementary feeding activities need to be better targeted towards those who need it most with clear criteria set for admission, quality assurance and accountability.
- Growth-monitoring activities need to be performed with greater regularity, with an emphasis on using this process to help parents understand how to improve their children's health and nutrition.
- Involving communities in the implementation and monitoring of ICDS can be used to mobilize additional resources the anganwadi centers, improve quality of service delivery and increase accountability in the system.
- Monitoring and evaluation activities need strengthening through the collection of timely, relevant, accessible, high-quality information to inform decision, improve performance quality and increase accountability.
6 March, 2016