I Introduction

II Overview

1.00

0.90

0.80

0.70

0 20 40 60 80 100 120 Percentage villages with AWCs

0.00

Prevalence/Proportion

0.60

0.50

0.40

0.30

0.20

0.10

SikkimNagalandArunachalKeralaMizoramManipurGoaPunjabDelhiHaryanaJ and KAssamTamil NaduMeghalayaAPTripuraKarnatakaHPGujaratWest BengalMaharashtraRajasthanUPBiharOrissaMP

Note: Per capita net state domestic product (NSDP) is in current prices for 1998-99.

Source: Coverage calculated from NFHS II data; NSDP from Indiastat.com.

Under weight prevalence

Proportion of villages covered by ICDS

III Strategies to Enhance the Impact

Source: Underweight prevalence calculated from NFHS II; villages covered calculated from NFHS II data in Das Gupta et al 2005.

Mismatch II: Service delivery is not sufficiently focused on the youngest children (under three), who can potentially benefit the most from ICDS interventions. In addition, children from wealthier households are more likely to participate in the programme than children from poorer households. Mismatch III: The poorest states and those with the highest levels of undernutrition still have much lower levels of programme funding and coverage than other states, despite expansion of the programme into many under-served areas during the 1990s.

We now turn to examine some key dimensions of programme implementation that are central to achieving results,4 review how ICDS scores along these dimensions and present options that the Department of Women and Child Development (DWCD) could consider to realign the design and implementation of ICDS and improve the chance of maximising its impact. Particular attention is given to what can be done to fix the three mismatches identified above.

Building commitment and effectively mobilising political leadership towards supporting changes in the existing array of nutrition programmes in India is the starting point for any reform. It will require engaging several public and private stakeholders in understanding the size and characteristics of the undernutrition problem in India, the devastating human, social and economic consequences of failing to address it and the large human, social and economic benefits associated with the correct implementation of available, affordable and cost-effective nutrition interventions.

Seek Technical Consensus on the Most Effective Nutrition Strategy

Agreement among technical experts on the right strategy to combat malnutrition is a central factor in maximising the impact of a programme. While ICDS is thoughtfully conceived and welldesigned, it has not always been successful in implementing the most cost-effective nutrition interventions.

The dominant focus within the ICDS programme is on food supplementation, at the expense of other aspects of the programme that are crucial for improving child nutritional outcomes. Specifically, not enough attention is given to improving child-care behaviours and to educating parents on how to improve nutrition using the family food budget – both interventions that are highly cost-effective and part of the original design of ICDS. There is also very little attention given to micronutrient supplementation or disease prevention and control. Feeding and caring practices: Failure to exclusively breastfeed children during the first six months of life, along with delayed introduction of semi-solid foods, is an important trigger of malnutrition. In 2003, it was found that less than 40 per cent of infants in India were exclusively breastfed during the first six months [BPNI 2003], the quality of complementary foods is often poor, due to local customs and beliefs [Roy 1997] and, according to the NFHS II, only one-third of children in India were fed semi-solid foods between the ages of six and nine months.

ICDS appears to have had little success in encouraging mothers to adopt appropriate child care and feeding behaviours (including practices related to breastfeeding, weaning and diet) that have the potential to improve child growth and health outcomes. Data from Kerala, Maharashtra, Rajasthan and Uttar Pradesh yield very little evidence that these healthy behaviours are more common in villages with AWCs than without AWCs [Bredenkamp and Akin 2004].

The AWW should devote much more of her time and energy to communicating the importance of exclusive breastfeeding and, later, adding semi-solid complementary food three to four times a day in appropriate quantities thereafter [Ghosh 2004]. Also important is to show women how to use their own resources to feed their children more effectively. This approach has been used in many settings including the Republic of Korea, China and Vietnam [Whang 1981; Allen and Gillespie 2001]. Growth-monitoring: Growth monitoring activities are hampered by poor access to appropriate equipment, such as weighing scales, growth cards and wall or book charts. Often the equipment is nominally present, but not of sufficient quantity or quality. Even in AWCs with scales that are in working condition, many AWWs fail to weigh young children (under three) every month (as ICDS guidelines stipulate).

Even with regular weighing, growth monitoring is effective only if accompanied by communication for behaviour change that results in the improved growth of the malnourished child. Previous studies of ICDS have noted that this does not often occur, perhaps because many AWWs are not fully competent with respect to the interpretation of growth cards/curves [Gopalan 1992] or because AWWs fail to effectively communicate the meaning of children’s growth patterns to mothers [Vasundhara and Harish 1993]. Indeed, the ICDS III baseline/ICDS II endline survey reveals a very large discrepancy between the child’s measured weight and the mother’s subjective assessment of her child’s growth status: in Kerala, for example, all mothers surveyed reported that their children are experiencing normal growth, and in Uttar Pradesh where underweight prevalence in the sample is 46 per cent, 94 per cent of women describe their children’s nutritional status as “normal” [Bredenkamp and Akin 2004]. Supplementary nutrition: Many ICDS functionaries, at all administrative levels, as well as programme beneficiaries, appear to consider the supplementary nutrition programme (i e, food distribution) to be synonymous with the full set of ICDS nutrition interventions. This is indicative of the pervasiveness of the food bias in the ICDS programme. The food bias is also reflected in the allocation of expenditure across ICDS components: the supplementary feeding programme currently accounts for about two-thirds of the total cost of the ICDS programme [Radhakrishna et al 1998]. It is also evident in the time usage of the AWW: AWWs can spend up to 40 per cent of their time on supplemental nutrition-related activities and a further 39 per cent on preschool education [NCAER 2001], which does not leave much time for other important ICDS activities such as growth-promotion, health and nutrition education, home visits, referral services and meeting with the community.

Despite the large share of resources devoted to it, the supplemental nutrition programme (SNP) performs rather poorly:

One problem is the irregularity of the food supply. In the ICDS III baseline/ICDS II endline survey, the majority of AWCs reported that they had experienced disruptions in the food supply during a preceding three-month period [Bredenkamp and Akin 2004]. Another evaluation reported that food distribution had ceased for periods longer than 90 days in 27 per cent of AWCs [NIPCCD 1992]. In the absence of localised food insecurity (such as drought or crop failure), local procurement may be a more effective means of supplying food: the supply would be more regular since it is easier to hold local providers accountable for delivery and local inhabitants have a vested interest in the well-being of the children in their community.

Another problem is leakage of the supplementary food benefit to non-targeted and non-needy beneficiaries since, in practice, there is little targeting of malnourished children for double rations of supplementary food. Food is typically distributed to all those who come to the centre [Educational Resource Unit 2004], and in cases where the AWC is located on school premises, to grade 1 children as well as preschool children so that children often receive less than the recommended 300 kcal of food. In some instances, food is also distributed to indigent

Figure 3: Inverse Relationship between the Percentage ofFigure 4: Relationship between State Underweight PrevalenceUnderweight Children and the Percentage of Children Who Areand GoI and State Public Expenditure Allocations, 1998-99ICDS Beneficiaries, by State

Underweight prevalence, 1998-99

0 10 20 30 40 50 60 70 80 90 100

0 200 400 600 800 1000 1200 1400 1600Public expenditure/child (Rs)60 50 40 30 20 10 0 Underweight prevalence

20 10 0

BiharUPRajasthanMPKeralaHaryanaMaharashtraPunjabAPWest BengalKarnatakaAssamOrissaGoaGujaratTamil NaduJ and KMehgalayaHPTripuraManipurNagalandMizoramSikkimArunachal

Percentage children who are ICDS beneficiaries, 2001-02

Source: Calculated from NFHS II, DWCD statistics and Census 2001 data.

adults and it is common practice for anganwadi helpers (AWHs), and occasionally AWWs, to take home-cooked food rations [Educational Resource Unit 2004].

In addition to the leakage in the distribution of supplementary feeding at the AWC, there is also substantial leakage in the “takehome food” component of ICDS since many children share the ICDS food with siblings or elders. In Madhya Pradesh, for example, only 32 per cent of children consume all take-home food themselves [Bredenkamp and Akin 2004].5

It is absolutely crucial that the multidimensional nature of malnutrition be recognised and reflected in ICDS implementation: food intake is only one, and most often not the main, determinant of child nutritional status. Rather than being used for supplementary feeding, some state resources could be redirected towards effecting improvements in the delivery of other ICDS services. Supplementary feeding should be used strategically, i e, as an incentive for poor and malnourished children to attend the AWC where they, and their mothers, can receive health and nutrition education interventions. Disease control and micronutrient supplementation: Recognising that child growth and health can be enhanced by improving environmental hygiene and domestic health management practices, the ICDS programme has components for de-worming and iron supplementation. These interventions need reinforcing, and can be supported by additional training for anganwadi workers in how to implement them.

ICDS can also be used to facilitate children’s access to the national micronutrient supplementation programmes for iron, vitamin A and iodine. The benefits of micronutrient supplementation for child growth, health, and cognitive development are well-documented, and have been shown to be exceptionally costeffective in a number of settings [Behrman et al 2004]. However, in India, they have not yet had much impact [Vijayaraghavan 2002] and need strengthening.

ICDS policy stipulates that there should be one anganwadi centre in place per 1,000 population, with more intensive placement of one per 700 population in tribal areas, where poverty tends to be more prevalent. While this policy aims to promote an equitable distribution of centres, in reality, the ICDS programme

State funds allocated per child aged 0-6

1998 uderweight prevalence GoI funds spent per child aged 0-6

Source: Inderweight prevalence calculated from NFHS II data; funding figures from DWCD.

is rather poorly targeted. The poorest states and those states with the highest levels of undernutrition tend to have the lowest coverage by ICDS activities and the smallest government budgetary allocations per malnourished child.

Poorer states have lower levels of ICDS programme coverage than the richer states: The coverage of villages by ICDS is much more pronounced in wealthier states, as can be seen by the steep slope of the curve in Figure 1. States with lower per capita net state domestic product (NSDP) have a smaller percentage of villages covered by the ICDS programme than those with higher per capita NSDP.

The states with the worst malnutrition have the lowest levels of ICDS programme coverage: Regardless of the indicator of ICDS coverage used, whether it be (a) the percentage of villages with an anganwadi centre, (b) the number of ICDS beneficiaries or

(c) public expenditure on ICDS, access to the ICDS programme is poorest in the states with the worst nutrition indicators:

(a) Examining the percentage of villages with an anganwadi centre, it can be seen that the five states with the highest underweight prevalence, namely, Rajasthan, Uttar Pradesh, Bihar, Orissa and Madhya Pradesh, all rank in the bottom 10 in terms of ICDS coverage.

Wealthier communities are also more likely to have the ICDS programme than poorer communities. In 1998, for example, while only half of the villages from the lowest two deciles of the all-India wealth distribution had the ICDS programme in place, the programme covered about 80 per cent of the richest villages [Das Gupta et al 2005].

(b) Also, in terms of beneficiary numbers, states with a greater percentage of underweight children tend to have a smaller percentage of children enrolled in the ICDS programme (see Figure 3). Worst is Bihar where, despite an underweight prevalence of 55 per cent, only 1.5 per cent of children benefit from the ICDS programme. At the other end of the spectrum, Manipur, Mizoram, Nagaland and Sikkim exhibit an underweight prevalence that is among the lowest in India (between 20 per cent and 30 per cent), yet are among the five states with the highest percentage of ICDS beneficiaries. The clear exception to this pattern is Orissa, which has a very high underweight prevalence of 47 per cent and has managed to enrol as many as 95 per cent of children in the programme.

(c) The states where the prevalence of malnutrition is highest are also the states that are most poorly funded by GoI and state

Table: Summary of Strengths and Weaknesses of ICDS

financial allocations to ICDS. GoI per child expenditure in support of states’ ICDS programmes appears to be strongly and inversely proportional to the states’ underweight prevalence (see dark bars in Figure 4).

In addition, the (per child) amount allocated by state governments to ICDS – most of which is spent on the supplemental feeding component – is lowest in the states with the highest underweight prevalence and highest in the states with the lowest underweight prevalence (see dotted bars in Figure 4). Total public expenditure6 figures (see stacked bars in Figure 4) show that four of the states that rank in the top five for underweight prevalence (namely Bihar, Uttar Pradesh, Rajasthan and Madhya Pradesh) are also the four states that receive the least for ICDS, on a per child basis. This regressive relationship holds true at the other end of the spectrum, too, where the five largest per child allocations are made to and by the five states that have the lowest underweight prevalence.

However, there are some encouraging signs. First, the poorest states have shown the highest rate of growth of programme coverage during the 1990s [Das Gupta et al 2005]. Second, the programme is more evenly distributed within states than across states – about 60 per cent of the poorest villages in every state were covered by ICDS programmes compared with 70 per cent of wealthiest villages. Third, since poorer states find it difficult to mobilise resources for ICDS, the government of India has recently proposed to provide additional central financing to all states to cover 50 per cent of the cost of the supplementary nutrition component.7

Since most growth faltering occurs during the first two years of life, and continues to negatively affect children’s development all through their lives [ACC/SCN 2004], it is essential that children under the age of three are effectively reached with ICDS interventions. In addition, according to ICDS policy, a “special effort” should be made to reach children from lower income families or scheduled tribe and scheduled caste groups [DWCD 2003]. There is also supposed to be explicit targeting of severely malnourished children who should receive double food rations. Effectively reach children under three: Because of the type of services provided and the focus on centre-based activities, ICDS does not attract as large a share of the youngest children as it could. Consequently, monthly growth-monitoring of under-threes is not regularly performed and the supplemental feeding programme is not effectively targeted at children during the early childhood years, i e, during the optimal window for influencing growth [Allen and Gillespie 2001]. Instead, the centre tends to attract more four to six year olds, partly because of the preschool activities that are offered concurrently. Thus, interventions miss the most critical age group, and the prevalence of stunting and underweight remains very high.

A more concerted effort needs to be made to recruit young children into the programme, perhaps through reaching out to women effectively while they are still pregnant or when their children are born. Succeeding in this effort would produce a shift towards preventing malnutrition instead of just treating it, when it is often already too late to recover the growth trajectory. One possibility is to explore the use of conditional cash-transfers which have been very successful in other countries. In Mexico [Skoufias 2001], Honduras [Rawlings and Rubio 2003] and Colombia [Attanasio et al 2004], they have been used to increase the demand for healthcare among young children, educate parents about adequate caring and feeding practices and, ultimately, appear to have improved child nutritional and health status quite rapidly. Better target children of low economic status: In states included in the ICDS III baseline/ICDS II endline survey, remarkably little variation was found in children’s participation rates across wealth quintiles – not much more than a 10 per centage point difference. On the one hand, this implies that a poor economic background does not present too formidable an obstacle to ICDS attendance. On the other hand, since poorer children are more likely to be malnourished, it is desirable that ICDS attracts a larger share of lower quintile than upper quintile children. In Kerala and Madhya Pradesh, attendance is particularly regressive, with higher attendance rates in the upper quintiles [Bredenkamp and Akin 2004]. Ensure that girls and lower castes are reached: There are welcome indications of an absence of gender discrimination in the reach of ICDS. The ICDS III baseline/ICDS II endline data show that there is no statistically significant difference in the participation rates of boys and girls [Bredenkamp and Akin 2004]. Given the patterns of malnutrition in India, ICDS could even go further and preferentially target young girls for certain interventions.

It is imperative that the AWW is perceived and treated as the core input for ICDS service delivery and given the right tools and support to perform her tasks effectively. The frequent delays in payment of honoraria to AWWs are inexcusable: in Uttar Pradesh in 2000, for example, as many as 67 per cent of urban AWWs reported that they did not receive their honoraria regularly [Bredenkamp and Akin 2004].

The objectives of the Reproductive and Child Health (RCH) programme and ICDS are intertwined and, so, the promotion of linkages between the activities of the two would be mutually beneficial. Already some of these linkages are recognised in the job descriptions of the anganwadi workers and auxiliary nursemidwives (ANMs). AWWs are supposed to promote awareness of national immunisation days (NIDs) and maintain immunisation records, refer sick children to healthcare facilities and encourage mothers to seek antenatal care. In their turn, ANMs, employed by the department of health, are supposed to conduct general health check-ups of ICDS beneficiaries, give immunisations, dispense medicines and contraceptives, and provide assistance and guidance to AWWs in the discharge of their health-related duties.

Collaboration between ICDS and the health delivery system has improved in recent years, one consequence of which has been better immunisation coverage. However, the partnership between the AWW and the ANM has been less successful with respect to identifying high-risk pregnancies, providing prenatal and postnatal care, and conveying adequate health and nutritional messages to women. One reason is the absence of a designated person or body to oversee the promotion of this collaboration. Site visits reveal that AWWs seldom enquire whether mothers are registered with the ANM and receiving antenatal care, and the ICDS III baseline/ICDS II endline survey showed that, in some states, the ANM’s visits to the AWC are not very regular. Strengthening the convergence of ICDS and RCH will help to ensure the provision of a broader set of child and maternal health services, and should be a priority for the departments concerned.

With a few exceptions, ICDS remains a highly standardised intervention that follows rules and regulations set centrally. Given the heterogeneity of malnutrition patterns observed in India, state governments should be encouraged to tailor the basic model to local needs and assume responsibility for the management of the overall programme rather than focus almost exclusively on the procurement and distribution of supplementary food, i e, the only activity in the programme that they finance directly.

A budget line that is specific to the financing of ICDS should be introduced in the state budgets so that planning and monitoring of investments in ICDS becomes an explicit activity of state governments.

The programme is also run in a very top-down fashion, with all the logistical and implementation inefficiencies and rigidities that such an approach entails. A programme to provide daily services to young children and pregnant women requires active participation and supervision by the community. There does appear to be some empirical association between those states (and areas) in which AWCs have been identified as being better performers and those in which community support for ICDS, in the form of financial contributions from the panchayat, have been forthcoming [Bredenkamp and Akin 2004]. However, countrywide, only about 25 per cent of states receive support from panchayat leaders, and this support has mainly been in the form of the provision of space for the AWC and the recruitment of beneficiaries [NCAER 2001].

Despite statements of intent to involve communities in the process, there is little sense of community ownership. This impression is reinforced by the fact that, in most places, the AWW is hired and paid by the government, and is not made accountable to the community in which she works. Also, equipment, food and other supplies are provided directly by the government. Given the extensive decentralisation that has been underway in India over the past decade, there is considerable scope for involving locally-elected village committees much more actively in implementing the ICDS programme.

It is generally recognised that the monitoring and evaluation activities related to ICDS need strengthening. What is crucial is an emphasis on collecting high quality information that is relevant, in the sense that the data that are collected clearly reveal something about the functioning of important aspects of the programme, and are of a manageable quantity, since large volumes of information are unlikely to be utilised to inform decisions.

In this regard, it may be helpful to revisit the guidelines and instructions issued for the monitoring and evaluation of ICDS in the past, and streamline and fine-tune them. This would cut down on the volume of superfluous information, and personhours needed to process it. The number of registers currently collected by AWWs, for example, far exceeds the existing capacity to use this information for programme management. Simultaneous with an effort that streamlines and standardises the indicators that are collected across states, the development of a standard template with which to display information would make ICDS data more immediately accessible – at more levels and to more people in the project management system.

Computerisation and electronic processing of information would aid in processing data into a form that is useable, so that a programme manager or other interested party can find out what the status of activities is at any point in time, present or past. Ideally, he or she should have easy access not only to aggregate indicators, but also to block and district level information. It is only then that data collected at the AWC level and aggregated further up the chain of implementation becomes potentially useable information that can be utilised to identify problem areas and take ameliorating action.

In general, more human resources need to be devoted to monitoring and evaluation activities. An awareness of its importance needs to be created at all levels of implementation so that, in the portions of their tasks that are allocated to monitoring and evaluation-related activities, functionaries give it the attention it deserves. This is challenging and requires a substantial mind-shift for functionaries – towards outcomes, results and performance, rather than inputs. In addition, some strengthening of community monitoring is desirable, either through existing community institutions or more informally, e g, through encouraging community members to be alert to AWC opening hours and attendance, and to demand improvements where needed.

IV The Road Ahead

To conclude, greater clarity and focus are needed if the ICDS programme is to make a substantial dent in the problem of persistent undernutrition in India. In particular, the three mismatches identified earlier need to be resolved so that a nutrition intervention is implemented that (a) provides the most effective services to address the most important determinants of malnutrition; (b) reaches younger children and the most vulnerable segments of the population; and (c) is well targeted to areas where the prevalence of undernutrition is highest.

Bridging the gap between the policy intentions of ICDS and its actual implementation is probably the single biggest challenge in international nutrition, with large fiscal and institutional implications and a huge potential long-term impact on human development and economic growth in India.

l:i

Email: mgragnolati@worldbank.org

Notes

[The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affiliated organisations or to members of its board of executive directors or the countries they represent.]

1 The term underweight is an anthropometric measure of protein-energy

undernutrition. It is used to describe children who have a weight-for-age

that is less than two standard deviations below the median value of the

NCHS/WHO reference group. The term severe underweight is used when

the measurements are less than three standard deviations below the reference

median, and mild underweight when measurements are less than one

standard deviation below the reference population. 2 This paper has been published as part of the HNP discussion paper series

under the title “India’s Undernourished Children: A Call for Reform and

Action” [Gragnolati et al 2005]. 3 This survey, henceforth referred to as the ICDS III baseline/ICDS II endline

survey 2000-02, involved the collection of data in the states of Kerala,

Maharashtra, Rajasthan and Uttar Pradesh in 2000 as part of a baseline for activities, and in Bihar, Chhattisgarh, Jharkhand and Madhya Pradesh as part of an endline evaluation in 2002.

References