**Three Decades of the Integrated Child Development Services Program in India: Progress and Problems**

Niyi Awofeso1,2 and Anu Rammohan3

*1School of Population Health, University of Western Australia, 2School of Public Health and Community Medicine, University of New South Wales 3Discipline of Economics, School of Business, University of Western Australia Australia* 

#### **1. Introduction**

242 Health Management – Different Approaches and Solutions

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(2009) Interactive Effect of Stressful Life Events and the Serotonin Transporter 5- HTTLPR Genotype on Post Traumatic Stress Disorder Diagnosis in 2 Independent It is understood that life success, health and emotional wellbeing have their roots in early childhood. Investing resources to support children in their early years of life brings long-term benefits to them and to the whole community. Early childhood development outcomes are therefore important markers of the welfare of children, and can predict future health and human capital. Well conducted research studies show that Early Child Development programs benefit children, families, and communities, and are associated with; higher and timelier school enrolment, higher school completion rates, improved nutrition and health status, child morbidity and mortality, improved social and emotional behaviour, and increased earning potential and economic self-sufficiency as an adult (Reynolds et al., 2001; Young, 1996).

Over the past three decades, India has experienced high prevalence of malnutrition despite increasing agricultural production and enviable economic growth. Some analysts have attributed this to poverty, spending patterns which favour festivals and non-essential foodstuffs over staple food, and high rates of infectious and chronic diseases (Banerjee & Duflo, 2006; Radhakrishna & Ravi, 2004). India's governments have sought to address chronic malnutrition through an extensive network of food-based social safety net, price controls for staple foods, income support, food-for-work programmes and direct provision of nutritious food to children. By far the biggest nutrition supplementation programme in India is the Integrated Child Development Services (ICDS).

Early childhood care and education services were prioritised in India's 1986 National Policy on Education as a crucial input into primary education and a significant support for women wishing to work in the formal sector. An inter-ministerial survey in 1972 revealed that child care programmes in India were not having the desired impact owing to resource constraints, inadequate coverage, and a fragmented approach. Consequently, India's ICDS was established in 1975 with the following objectives; (1) lay the foundation for the physical, psychological and social development of children; (2) improve the nutritional and health status of children in the age group 0-6 years and reduce the incidence of mortality, sickness, malnutrition and school dropout; (3) enhance, through improved health care and education, the ability of mothers to look after the normal needs of their children, and; (4) achieve

Three Decades of the Integrated Child

UNESCO, 2010; WHO, 2009).

Development Services Program in India: Progress and Problems 245

from measles in 2008.; the proportion of underweight (severe and moderate) children below three years of age declined only marginally during 1998‐99 to 2005‐06, from about 47 to 46% and at this rate of decline is expected to come down to about 40% only by 2015 (UN, 2010;

The lack-lustre trends in children's nutrition in India occurred despite increased funding for the ICDS program, from \$US35m in 1990 to \$US170m in 2000, and a 2005 decision by the Indian government to accord high priority to the expansion of the ICDS program. Although major reforms in public health, and particularly in maternal and child health, are urgently required in India, it is debatable whether the management of the ICDS program is appropriate for the formidable maternal and child health challenges it was established to address. It is noteworthy that India's youth literacy rate increased from 61.9% in 1991 to 79.3% in 2008. India's 2009 MDG report (GI, 2010) projects a youth literacy rate of at least 98% by 2015. Thus,

A 2006 World Bank study of the ICDS (Lokshin et al, 2005) determined that the programme had little overall effect on nutritional outcomes, and that the only significant effect of the programme was a positive effect on boys' stunting in the data from the 1992 survey, but not in 1998. For girls, the effect was not significant. At regional levels, the only significant finding was a *negative* impact in the poor Northern states, and in the Northeastern states. There, children living in an ICDS village had a higher probability of being underweight in the 1998 survey. This chapter examines health management aspects of the operations of the ICDS program, with a focus on under-nutrition of children aged 0 – 3 years. Our central thesis is that sub-optimal health management is a major encumbrance to the realisation of the objectives of

Since malnutrition in India is mainly caused by inadequate nutrition, infectious diseases and poor sanitation, we also review public policies on food security. Public health services remain an important and cost-effective means of lowering the population's susceptibility to disease. According to Jalan and Ravallion (2003), the number of child deaths due to unsafe water is higher in India than any other country. Furthermore, World Bank estimates show that nearly a fifth of the rural Indian population does not have access to safe drinking water. It is therefore important that India's public and child health programs be complemented with community-based programmes that are specifically aimed at preventing under-nutrition and the spread of infectious diseases. India's public health and family health programs should include (at least on paper) infrastructure (water, sanitation, food storage, buildings), income generation, and provision of welfare and health safety nets. Community involvement and ownership are crucial, in contrast to the top-down delivery of health care in India (parts of which, like supplies, equipment, and trained personnel, remain necessary). Community-based, nutrition programmes have an important role in ensuring wide and timely coverage of key health services, such as immunization. Women's visits to health services, whether for curative or preventive child health care, are excellent opportunities for health workers to provide health and nutrition preventive services to women (e.g., education, counselling, and micronutrient supplements). This chapter utilises data on India's Family health surveys as well as government reports and scholarly articles to review health management facets of the ICDS,

this chapter will be focussed on health-related components of the ICDS program.

the ICDS program, especially in relation to improving children's nutrition levels.

and proposes integrated strategies for revitalising India's child health services.

ICDS services are provided through a vast network of ICDS centres, better known as "Anganwadi". The term Anganwadi developed from the idea that a good early child care

**2. Review of health management aspects of ICDS** 

effective co-ordination of policy and implementation among various departments responsible for child development (Kaul, 1993). The ICDS is estimated to be the world's largest integrated early childhood program, with over 40,000 centres established nationwide. The program covers over 4.8 million expectant and nursing mothers and over 23 million children under the age of six. Of these children, more than half participate in early learning activities. The network consists of 3907 projects, covering nearly 70 per cent of the country's community development blocks and 260 urban slum pockets.

ICDS programs are delivered through a network of projects in slum, rural or tribal areas. Rural or urban projects cater for populations of about 100,000 people divided into 100 centres or *Anganwadis* (literally courtyards), while tribal projects cater for populations of about 35,000 people divided into 50 centres. Each centre has a trained paraprofessional or Anganwadi worker - generally a local woman proposed by the community and trained for three months in health and nutrition education, community support and participation, preschool education and record maintenance. Each project has four or five supervisors and one Child Development Officer who is responsible for the management and implementation of the entire programme in her/his jurisdiction (Lokshin et al, 2005). For children aged below 6 years, the core services offered for children are supplementary nutrition, immunisation, basic health care such as anti-helminth treatment, referral services to hospitals and health centres, non-formal pre-school education. For mothers, the core services offered are tetanus immunisation for expectant mothers, supplementary nutrition and health education (Muralialharari & Kaul, 1993). The ICDS services are delivered almost exclusively at the Anganwadi, or childcare centre. Each centre is run by an Anganwadi worker and one helper, who undergo three months of institutional training and four months of communitybased training. The cost of the ICDS program averages \$10-\$22 per child a year (Dasgupta *et al*, 2005).

As at March 2008, the ICDS comprised 6120 operational projects and 1053006 *Anganwadi* centres, which reached about 58.1 million children (and 10.23 million pregnant or lactating women) , compared with 27.5 million children enrolled in 2000 (Kapil, 2002).

Despite increasing funding of the ICDS program over the past three decades, the ICDS has so far fallen short of its stated objectives. India's sub-optimal maternal and child health and education programs are exemplified by the following trends: India slipped from Millennium Development Goals (MDG) rank 128 in 2008 to 134 in 2009; India accounts for 50% of the world's hungry; At least 46% of Indian children are undernourished; in 2006, on average 254 women died giving birth to a child for every 100,000 live births relatively modest reduction from 327 in 1990. The states of Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and Uttaranchal had the highest numbers ranging from 480 to 312. Kerala at 95, Tamil Nadu at 111 and West Bengal at 141 fared less badly; Across India 74 children died before they reached the age of five for every 1,000 live births in 2005‐06 as compared to 125 in 1990. At this rate India is likely to miss the target of reducing under-five mortality rate to 42 for 1,000 live births by 2015; About 400,000 infants die in the first 24 hours of their life and 90 per cent of deaths are due to preventable diseases like pneumonia and diarrhoea; India ranks 171 out of 175 countries in the world in public health spending; Despite 10.7% of the national budget devoted to education, only 61.9% of adult Indians aged over 15 years in 2008 (73.2% males and 56.9% females) were literate; India's measles vaccination coverage in India increased from 54% in 2000 to 70% in 2008, but this coverage is much lower than the 2008 global coverage of 83%. India achieved 23% measles mortality reduction between 2000 and 2008, but still accounts for two- thirds of the remaining global mortality

effective co-ordination of policy and implementation among various departments responsible for child development (Kaul, 1993). The ICDS is estimated to be the world's largest integrated early childhood program, with over 40,000 centres established nationwide. The program covers over 4.8 million expectant and nursing mothers and over 23 million children under the age of six. Of these children, more than half participate in early learning activities. The network consists of 3907 projects, covering nearly 70 per cent of

ICDS programs are delivered through a network of projects in slum, rural or tribal areas. Rural or urban projects cater for populations of about 100,000 people divided into 100 centres or *Anganwadis* (literally courtyards), while tribal projects cater for populations of about 35,000 people divided into 50 centres. Each centre has a trained paraprofessional or Anganwadi worker - generally a local woman proposed by the community and trained for three months in health and nutrition education, community support and participation, preschool education and record maintenance. Each project has four or five supervisors and one Child Development Officer who is responsible for the management and implementation of the entire programme in her/his jurisdiction (Lokshin et al, 2005). For children aged below 6 years, the core services offered for children are supplementary nutrition, immunisation, basic health care such as anti-helminth treatment, referral services to hospitals and health centres, non-formal pre-school education. For mothers, the core services offered are tetanus immunisation for expectant mothers, supplementary nutrition and health education (Muralialharari & Kaul, 1993). The ICDS services are delivered almost exclusively at the Anganwadi, or childcare centre. Each centre is run by an Anganwadi worker and one helper, who undergo three months of institutional training and four months of communitybased training. The cost of the ICDS program averages \$10-\$22 per child a year (Dasgupta *et* 

As at March 2008, the ICDS comprised 6120 operational projects and 1053006 *Anganwadi* centres, which reached about 58.1 million children (and 10.23 million pregnant or lactating

Despite increasing funding of the ICDS program over the past three decades, the ICDS has so far fallen short of its stated objectives. India's sub-optimal maternal and child health and education programs are exemplified by the following trends: India slipped from Millennium Development Goals (MDG) rank 128 in 2008 to 134 in 2009; India accounts for 50% of the world's hungry; At least 46% of Indian children are undernourished; in 2006, on average 254 women died giving birth to a child for every 100,000 live births relatively modest reduction from 327 in 1990. The states of Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and Uttaranchal had the highest numbers ranging from 480 to 312. Kerala at 95, Tamil Nadu at 111 and West Bengal at 141 fared less badly; Across India 74 children died before they reached the age of five for every 1,000 live births in 2005‐06 as compared to 125 in 1990. At this rate India is likely to miss the target of reducing under-five mortality rate to 42 for 1,000 live births by 2015; About 400,000 infants die in the first 24 hours of their life and 90 per cent of deaths are due to preventable diseases like pneumonia and diarrhoea; India ranks 171 out of 175 countries in the world in public health spending; Despite 10.7% of the national budget devoted to education, only 61.9% of adult Indians aged over 15 years in 2008 (73.2% males and 56.9% females) were literate; India's measles vaccination coverage in India increased from 54% in 2000 to 70% in 2008, but this coverage is much lower than the 2008 global coverage of 83%. India achieved 23% measles mortality reduction between 2000 and 2008, but still accounts for two- thirds of the remaining global mortality

women) , compared with 27.5 million children enrolled in 2000 (Kapil, 2002).

the country's community development blocks and 260 urban slum pockets.

*al*, 2005).

from measles in 2008.; the proportion of underweight (severe and moderate) children below three years of age declined only marginally during 1998‐99 to 2005‐06, from about 47 to 46% and at this rate of decline is expected to come down to about 40% only by 2015 (UN, 2010; UNESCO, 2010; WHO, 2009).

The lack-lustre trends in children's nutrition in India occurred despite increased funding for the ICDS program, from \$US35m in 1990 to \$US170m in 2000, and a 2005 decision by the Indian government to accord high priority to the expansion of the ICDS program. Although major reforms in public health, and particularly in maternal and child health, are urgently required in India, it is debatable whether the management of the ICDS program is appropriate for the formidable maternal and child health challenges it was established to address. It is noteworthy that India's youth literacy rate increased from 61.9% in 1991 to 79.3% in 2008. India's 2009 MDG report (GI, 2010) projects a youth literacy rate of at least 98% by 2015. Thus, this chapter will be focussed on health-related components of the ICDS program.

A 2006 World Bank study of the ICDS (Lokshin et al, 2005) determined that the programme had little overall effect on nutritional outcomes, and that the only significant effect of the programme was a positive effect on boys' stunting in the data from the 1992 survey, but not in 1998. For girls, the effect was not significant. At regional levels, the only significant finding was a *negative* impact in the poor Northern states, and in the Northeastern states. There, children living in an ICDS village had a higher probability of being underweight in the 1998 survey. This chapter examines health management aspects of the operations of the ICDS program, with a focus on under-nutrition of children aged 0 – 3 years. Our central thesis is that sub-optimal health management is a major encumbrance to the realisation of the objectives of the ICDS program, especially in relation to improving children's nutrition levels.

Since malnutrition in India is mainly caused by inadequate nutrition, infectious diseases and poor sanitation, we also review public policies on food security. Public health services remain an important and cost-effective means of lowering the population's susceptibility to disease. According to Jalan and Ravallion (2003), the number of child deaths due to unsafe water is higher in India than any other country. Furthermore, World Bank estimates show that nearly a fifth of the rural Indian population does not have access to safe drinking water. It is therefore important that India's public and child health programs be complemented with community-based programmes that are specifically aimed at preventing under-nutrition and the spread of infectious diseases. India's public health and family health programs should include (at least on paper) infrastructure (water, sanitation, food storage, buildings), income generation, and provision of welfare and health safety nets. Community involvement and ownership are crucial, in contrast to the top-down delivery of health care in India (parts of which, like supplies, equipment, and trained personnel, remain necessary). Community-based, nutrition programmes have an important role in ensuring wide and timely coverage of key health services, such as immunization. Women's visits to health services, whether for curative or preventive child health care, are excellent opportunities for health workers to provide health and nutrition preventive services to women (e.g., education, counselling, and micronutrient supplements). This chapter utilises data on India's Family health surveys as well as government reports and scholarly articles to review health management facets of the ICDS, and proposes integrated strategies for revitalising India's child health services.
