Malnutrition continues to be a significant problem for children in India. According to the third National Family Health Survey (2005-06) while there have been some improvements in the nutritional status of young children in few states still nutritional deficienceies are widespread. NFHS-3 found that 23% of children were wasted which is higher than that of 20% of NFHS-2. Almost half around 43% of all children under three are underweight and almost 70% of children in the age group of 6-59 months are anaemic.
The prevalence of anaemia is even worse than it was in NFHS-2. Anaemia in India is primarily linked to poor nutrition and this is a cause of grave concern. The prevalence rate of undernutrition in India, in the age group 0-6yrs is one of the highest in the world. Around 57 children of every 1000 children die before reaching the age of one year . These poor development indices clearly bring out the state of children under six in India and the failure of most intervention in changing the situation.
The Integrated Child Development Services (ICDS) started in 1975 is the world’s largest early child development program and the extent to which it has succeeded in attaining one of its primary objective of reducing the prevalence of child malnutrition, remains largely uncertain. The Indian Prime Minister Mr. Manmohan Singh said that the ICDS scheme had not sufficiently dented child nutrition levels in a strongly worded letter to the state chief ministers.
The fact that there has been just one percent improvement in the underweight status of children under three from the NFHS-II, which was carried out seven years earlier shows that the progress is too slow. This disturbing current scenario calls for immediate action. “On the other hand, only about 1% of the total union budget is spent on children under six years of age. ” They also receive little attention in parliament and political debates.
It is important to understand that early childhood development and care is crucial for overall development and growth of not only children but the society as whole. Therefore it is important that policymakers prioritise policies towards children under six. India’s first comprehensive policy for children was adopted in 1974 which assigned the states the responsibility of providing services to the children both before as well as after birth to ensure full physical mental and social development. With this aim the government introduced the ICDS programme in 1975.
It was started to address the problem of malnutrition among children through supplementary nutrition, growth monitoring and educating families to adopt better feeding practices during pregnancy, breast feeding, weaning and balanced nutrition in early years of development of the child (upto 6 years). It also aimed at ensuring complete immunization against diseases, de-worming, providing Vitamin A and iron supplements, facilitating referrals in case of illness through convergence with the health sector.
It further aimed at promoting holistic child development through pre-school education. A range of Anganwadi centres (AWC) were to achieve these objectives. Even thirty two years after the introduction of the ICDS programme much has not been achieved, though it is recognized that this is perhaps one of the better conceived programmes and if implemented properly can yield good results. Supreme Court orders and Rights perspective
The Supreme Court in November 2001 recognized that the right to food is justifiable, and the government is duty bound to prevent hunger and malnutrition. In a series of other judgments the court ordered the universalisation of ICDS to cover every child under the age of six and gave further directions for the strengthening of the ICDS. It called for sanctioning of 14 lakh AWCs, currently there are 7 lakh anganwadis across the country and increasing of the norm of rupee one to rupees two.
However, it is necessary to analyse the reasons for the failure of the programme at the national level. There have been examples of success of the ICDS programme but this is most of the time localized and uneven across states. The programme has been a success in Tamil Nadu and various studies have been done to understand the reasons for its success. A field survey called Focus on Children under Six (FOCUS) conducted in 2004 in six states showed how an effective ICDS programme can improve the status f undernourished children. It included a comparison between Tamil Nadu and five other states ( Chhattisgarh, Uttar Pradesh, Maharashtra, Rajasthan and Himachal Pradesh). According to economist Jean Dreze, who was associated with the FOCUS survey the success of ICDS in Tamil Nadu was due to the fact that “Women have helped to make health and nutrition political issues, and also hold the system accountable”.
Anuradha Rajivan “Tamil Nadu politics has retained the combating of hunger and malnutrition as one of its priorities, well before judicial intervention triggered responses at the Centre” adding that the State “is on the verge of establishing child rights to nutrition security,” and emphasising that malnutrition “is a problem wider than poverty. ” Bringing in the rights perspective with regard to the well-being of children has had a positive effect on policy implementation. Ms.
Rajivan calls this a `sandwich’ situation where pressure from above in the form of political will and pressure from below through wide public acceptance and expectation, with a wide network of services in between sustains these programmes . The universalisation of the ICDS needs to be implemented by the UPA government as this is also part of the commitment made by the government in the Common Minimum Programme (CMP) which stated that UPA will provide functional anganwadi in every settlement and would ensure full coverage to all children.
Funding Issues According to the report tabled by the commissioners appointed by the Supreme Court, the expenditure for running the ICDS programme is met from three broad sources . These include- 1. Funds provided by the Centre and are generally used to meet the expenses of infrastructure, salaries and honorarium of ICDS staff, training, basic medical equipment etc. 2. Allocations made by the state governments to provide supplementary nutrition to beneficiaries and 3. Funds provided under he Pradhan Mantri Gramodaya Yojna (PMGY) as additional assistance by the centre used to provide take home rations for the children in the age group of 0-3 years living below poverty line and to those in need of additional supplementary nutrition. The resources would have been adequate for the existing centres but most of the time due to delays in release of funds by the government the programme suffers. Further the funds allocated by the state governments also vary and is reflected in the functioning of the AWC . Bihar for example spends just 15 paise per day per child on cooked meal.
In West Bengal allocation of a meager amount of 80 paise per child is often quoted as the reason why required standards are not met. Jharkhand is an exception as it has not allocated a single rupee till 2004. In contrast Tamil Nadu has allocated more than Rs 150 crore for SNP against a requirement of Rs 89 crore with the allocation per beneficiary coming to Rs 1. 69 which is also the highest amount allocated by any state. This may be one of the reasons for the success of ICDS programme in Tamil Nadu . Further there has been evidence of rampant corruption in the utilization of the fund.
In Uttar Pradesh there have been evidence to show that funds are utilized and procurement of nutrition supplements have been made on paper but there is nothing to show on ground. Further, in some states ICDS centralised nutritional procurement is done at the level of chief minister and there have been instances when a little known agency located in another state is given contract for providing fortified supplements. The delivery is done at a centralized place and from there the stock is disbursed to remote districts and centres .
In Bihar of the funds released in 2003-2004 by the state government, Rs 160 lakh remained unutilised. Of the PMGY funds released in2003-2004, Rs 224 lakh remained unutilised . Quality Control The quality of the food distributed among the children is often so bad that children are not able to eat it. Most of the time there is so much delay in the distribution of supply that by the time they reach the centre they are stale and not fit to be consumed. The quality of supplementary nutrition supplied in Rajasthan was considered to be good but was very dry and not tasty.
This became a restricting factor in the consumption of the food provided. This showed that supply of fortified flour was not sufficient but supply of jaggery and other condiments was also essential in order to make the food eatable. Examples like the AWC in Bellary district of Karnataka needs to be studied and should be replicated elsewhere. Here Rice, broken wheat, pulses, jaggery and salt were supplied and vegetables and condiments were procured locally. Such meals were not only wholesome but were also liked by the children and the pregnant and lactating mothers .
There was also ambiguity regarding the quantity given to each child. While most of the time records showed children receiving double rations but this was not the ground reality. Many times the AWW (Angan Wadi Workers) and the AWHs (Angan Wadi Helpers) took cooked SNP home. Current debates are going on as to whether supply cooked meal or dry biscuits as supplementary nutrition. The government needs to design appropriate procurement procedures like introducing localised procurement of rice, wheat, dal and vegetables. Convergence
The ICDS programme comes under the purview of the Women and Child welfare department while healthcare is delivered through the health departments and they are expected to take care of pregnant women, prenatal and postnatal and children at the village level. It is envisaged that institutional coordination between the two departments would enable proper utilization of the services. But in reality there is lack of convergence between the two departments and when confronted with an issue both pass the buck to the each other.
A state secretary of the MWCD was once heard saying to a journalist in Bhopal (she had published a story on high infant mortality in Madhya Pradesh) “How come you people write like that? This is not our job, we are responsible after the baby is six months old… this is the job of ministry of health”. Here we can take lessons from the Mitanin programme of Chhattisgarh which though operationalised by the health department is a perfect example of convergence between the health sector and the ICDS programme and is perceived as increasing utilization of the healthcare services.
It operates through four key strategies: providing information on existing healthcare services; creating awareness on access to key healthcare and the ICDS services as an entitlement; facilitating the delivery of healthcare services in coordination with the ANMs, anganwadis and primary health centre; and local advocacy to ensure proper functioning and access to these services . Further, there should be greater convergence between ICDS and the NRHM for prevention and management of malnutrition. Treatment of severely malnourished child should be the responsibility of the Health department and the ICDS. Poor Remuneration for the AWW and AWH
The Key persons involved in implementing the ICDS programme are the frontline functionaries. They have a very important role to play in helping achieve the aims laid down by the policy makers which include- a society that respects women, takes care of adolescent girls, rectifies gender imbalance, ensure safe delivery of infants and help improve and maintain the nutritional status of children till they reach the age of six. AWW is further required to maintain the data of birth, death, growth of children, records for supplies of food, educational material that feeds into the statistics of the government.
However, in lieu of the amount of work done by the AWW and AWH the remuneration paid to them is very less and the kind of responsibility and accountability expected is huge. This definitely would act as a deterrent in creating committed workers. Under- recognition of child malnutrition status The most common problem is the denial on the part of the state to recognize the extent of child malnutrition. There are chances of underreporting due to denial on the part of the ICDS system to the extent of grade III and grade IV malnutrition existing in the area as this would raise questions about the working of the AWC in the area.
According to the ICDS norms identified severely malnourished children are to be given double rations and should also be reffered for medical services. Since there is underreporting hence many severely malnourished children would be left out from benefiting from the programme. Another way in which malnutrition is under-recognised is that grade I and grade II represent only mild forms of malnutrition and that they are not serious. This belief is dangerous as it denies the kind of risks associated with grade I and grade II malnutrition.
Lack of focus on the vulnerable group 0- 3 years The ICDS programme more focus is given to the children aged 3-6 years due to the fact that they are more mobile and visit the AWC. While, children of the 6- 24 months are neglected as they are dependent on their caretaker for food. The ICDS programmes requires such children to stay at home and be given “take home rations” only. Shanti Ghosh’s paper ‘ICDS: Food Dole or Health, Nutrition and Development programme? ’ In this paper she stresses on the need to pay much more attention on children under the age of three. he explains that there are ample data to suggest that the onset of malnutrition is generally between six months and two years. In India the high prevalence of low birth weight babies is due to the young age of the mother, poor nutrition and repeated pregnancies. This leads to a vicious cycle of poverty and malnutrition. Further, the author points out that it is during this crucial age (6- 24 months) that the nutritional status of the child deteriorates in an irreversible way. Accessibility Accessibility to the AWC is another issue which prevents the community from improving the malnutrition status of its children.
When the anganwadi centre is situated in areas dominated by the high castes the socially disadvantaged families tend to get left out. Another limiting factor is the informal limit on the number of children to be admitted per centre and there being no affirmative action to ensure that the disadvantaged families get priority. Further, if the AWW belongs to an upper caste then social distance between service provider and the population increases and makes accessibility difficult. Families living in hamlets which are far away from the AWC also lack accessibility.
Staff Appointments For the successful implementation of any programme it is necessary that the staff designated to carry out the required responsibility should be there. This is perhaps one of the reason for the bismal performance of the ICDS in Bihar and Jharkhand. Nandini Nayak and Naresh C Saxena in the article “Implementation of ICDS in Bihar and Jharkhand” write about the vacancies in the sanctioned posts being serious problems in the ICDS. Around 85% of sanctioned post in Bihar are lying vacant and result in non operationalisation of the ICDS projects.
Similar condition exists in Jharkhan also where half of the supervisor position is lying vacant. In both Jharkhand and Bihar the staff get salaries only twice a year. Nutrition Counselling Most of the time nutrition counselling and health education is done in such a way as to blame the families for their ignorance and reluctance in the families to adopt good feeding habits and is most of the time confined to mothers coming to the AWC and thus ignoring to bring in the key decision makers in the house.
The method of delivery of message is didactic and is often stereotyped. This is it seems is used as tool to divert attention from the key issue of undernutrition which can only be tackled by achieving a required level of calorie intake which the people are unable to achieve due to extensive poverty. Conclusion India’s ICDS programme needs to undergo significant changes so as to address the current malnutrition problem in India.
Since child malnutrition is a leading cause of child and adult morbidity and mortality hence the need of the hour is to check this as soon as possible. There are various gaps in the ICDS programme which needs to be filled in order to get effective results. The lack of focus on children below three years needs to be relooked at since growth retardation starts during pregnancy itself and around 30% of children in India are born with low birth weight, and by the age of two growth retardation sets in and also becomes irreversible.
The Working Group on Children under Six called at the request of the Planning Commission to develop strategies for children under six recognized this fact talks about establishment of creches, maternity entitlements and most important the appointment of a second anganwadi worker for community based intervention for children under three, pregnant and lactating mothers. The government needs to form quality control measures inorder to maintain a certain standard of supplementary nutrition provided and further need to design appropriate procurement strategy.
A periodic social audit of the programme would help in checking much of the corruption. Further, success stories from states like Tamil Nadu should be studied and the strategies used should be replicated in other states. For the success of the programme it is necessary that it should be recognized as a right of the children which would enable pressure from above in the form of political will, and pressure from below in the form of expectation and acceptance with active community participation in the programme.
States with the highest levels of malnutrition have the lowest levels of ICDS program funding and have problems with fund disbursement and also suffer from faulty implementation stategy. This needs to be rectified soon so as to check further delays in proper functioning of the ICDS and would also help proper utilization of Funds. If the ICDS programme is meant for the poorest of the poor, then all efforts should be made to ensure that they donot get left out and the benefits reaches them.
Reference 1. Working Group on children under Six (2008): “Strategies for Children under Six”, Economic and Political Weekly, Vol 42, No. 2, pp-87-101 2. IIPS(2007): National Family Health Survey (NFHS-3), 2005-2006. 3. Lakshman, Nirmala (2006): “ICDS- The entitlement of every Indian child by”, in The Hindu, Thursday Aug 17th 2006 4. Ramchandran, Vimla (2005): “Reflections on the ICDS programme”, http://www. india-seminar. com/2005/546/546%20vimla%20ramachandran. htm.