A World Bank report on malnutrition among India's children calls for drastic reforms in the Integrated Child Development Services.
THE Integrated Child Development Services (ICDS) scheme has never been subject to so much scrutiny since its inception in 1975 as in recent times. The latest World Bank report titled "India's Undernourished Children: A Call for Reform and Action" suggests that the scheme has not been effective in tackling child undernutrition as its "actual implementation deviates from the original design". It avers that the emphasis on supplementary feeding and pre-school education of children in the 4-6 age group has affected activities such as counselling parents on better feeding and child care practices and has led to the neglect of children of the 0-3 age group.
India has the highest incidence of underweight children in the world, nearly double that of sub-Saharan Africa.
The United Nations' Millennium Development Goals (MDG), a set of eight goals ranging from halving extreme poverty to providing universal primary education, with a target date of 2015, were adopted by countries and international institutions in 2000.
The first goal, also called the nutrition MDG as it seeks to reduce malnutrition and improve child health as an integral part of poverty reduction efforts, using the prevalence of underweight children (under five) as an indicator, is to halve the extent of underweight malnutrition. The concern of the World Bank report is, therefore, understandable given that it appears unlikely that the prevalence of malnutrition in India will fall from 54 per cent in 1990 to 27 per cent by 2015. In the 1990s, inequalities in nutritional status among demographic, socio-economic and geographic groups had widened. Since countries with similar economic growth rates as India have achieved better results, the conclusion is that economic growth alone would not be enough to reach the goals.
Malnutrition is estimated to be the cause of about half of all child deaths and associated with more than half of child deaths from diseases such as malaria (57 per cent), diarrhoea (61 per cent), pneumonia (52 per cent) and measles (45 per cent). According to National Family Health Survey data 1998-99, 47 per cent of children under three were underweight. There are of course inter-State and inter-community variations. The prevalence of underweight children is higher not only in rural areas but also among the Scheduled Castes and the Scheduled Tribes. It is also worse among girls. To add to the problem, Maharashtra, one of the more prosperous States, has joined the BIMARU States (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh) in recording high prevalence in undernutrition.
Given this situation, the report advocates the targeting of schemes and programmes that tackle undernutrition. The argument is that undernutrition is concentrated in a mere 10 per cent of the villages and districts, which account for 27-28 per cent of all underweight children. "Future efforts," recommends the report, "to combat malnutrition could be targeted to a relatively small number of districts/villages." It primarily calls for drastic reforms in the structure and functioning of the ICDS, focussing more on monitoring and evaluation instead of suggesting ways to improve the system from inside. It does not examine why India has the largest number of undernourished children in South Asia or why, particularly in the 1990s, the period of stepped-up economic growth, the decline in the levels of undernutrition was modest. Without examining the implications of involving the private sector in food distribution, the document recommends the involvement of the private sector for specific activities to combat malnutrition. While the United Progressive Alliance (UPA) government is committed to universalising and expanding the ICDS, the report appears to be sceptical about the emphasis on universalisation. According to it, the emphasis should be on strengthening the quality of implementation and monitoring in order to enhance the impact of the programme. There are three key mismatches in the ICDS, according to the report. First, the focus is on food supplementation but not enough attention is given to improving child care behaviour and educating parents on improving nutritional levels using the family food budget. Secondly, service delivery is not focussed on children under three; children from better off households participate much more than poorer ones; and the ICDS has been only partially successful in targeting girls and the lower castes.
Thirdly, the poorest States and those with the highest levels of undernutrition still have the lowest levels of programme funding and coverage by ICDS activities.
The programme, the report says, has operational challenges like inadequate worker skills, shortage of equipment, poor supervision and weak monitoring and evaluation. Community workers, that is, the anganwadi workers (AWWs) and helpers involved in the scheme are overburdened as they are expected to provide pre-school education as well as nutrition services to children under six. This, the report maintains, does not benefit the 0-3 age group, which does not get micronutrient supplements.
While the assessment of the report as far as low levels of programme funding and low coverage of the scheme in the poorest States may be correct, the onus of the success of the programme cannot be fully placed on the shoulders of the community worker. It has been the experience of AWW and helpers associated with the All India Federation of Anganwadi Workers and Helpers that it is the poorest of the poor who send their children to anganwadi centres. As the AWWs and helpers themselves are most likely to belong to the economically weaker sections, they tend to attract people from similar economic backgrounds. Secondly, the anganwadi worker is supposed to be a motivator but in the absence of any long-term incentive, there is no motivation for her to perform all the tasks that are expected of her. She is viewed as a government employee by the community and held accountable but does not enjoy any government benefit.
The World Bank report is silent on empowering the anganwadi worker but recommends further controls on her in the name of monitoring and evaluation. It recommends the involvement of communities in the implementation and monitoring of the ICDS to bring in additional resources to the anganwadi centres, improve the quality of service delivery and increase accountability in the system. The report discusses the problems of the anganwadi worker only in passing.
The ICDS revolves around the AWW and the helper. It envisages a "life-cycle" approach. This means that malnutrition has to be fought through interventions targeted at unmarried adolescent girls, pregnant women, mothers and children in the 0-6 age group. Apart from providing supplementary feed, the AWWs and helpers provide eight key services, which include immunisation, health check-ups and imparting nutrition education to adult women. Pre-school education combined with supplementary nutrition acts as an incentive for poor children to join the primary school. These are the experiences of the AWWs and helpers, but such voices are not reflected in the World Bank report.
Any proposal to improve the ICDS scheme has to take into account the needs of the AWWs. If the scheme were to be targeted in the manner of the targeted public distribution system, it is possible that it might not even reach the populations it is meant to serve. It is only in an atmosphere of universalisation of services that the probability of the needier sections gaining access to it is enhanced. In a sharply targeted programme, the ability of the "target population" to prove that it is the one that needs the scheme most would be low, and others would corner the benefits. Again, if a targeted scheme is in place, fewer AWWs and helpers will be needed to implement it. The economic implications of a targeted ICDS for the AWWs will have to be considered seriously.
Above all, their skills of imparting information on child care and nutrition can only be effective in an environment where other things are more or less equal. For instance, while dwelling on the problem of attendance at the anganwadi centres, the report quotes a study that found that of the six States surveyed it was only in Kerala that actual attendance at the centres was associated with better nutritional status. While it would be ideal for all States to be like Kerala, until such time that this happens it would be prudent to strengthen the centre and the hands of the actual implementing agency, the AWW and the helper.
Child malnutrition is intrinsically linked to adult malnutrition, rural poverty and agrarian distress. Training, skills enhancement and monitoring of the AWW can be effective only when the standards of living improve. Apart for rural poverty, there are now increasing pockets of urban poverty. It is surprising that even in Delhi there have been significant increases in rural malnutrition. Much of the "rural" population in Delhi, explains the report, consists of poor urban populations on the periphery of the city.
Neither the ICDS on its own nor the AWW and the helper can bring about radical changes in child undernutrition. The scheme and its components have at best a supplementary role in addressing the larger question of malnutrition, which itself has to be located in the context of rural poverty and food insecurity.