THE problem of persistent hunger and severe malnutrition among children has been documented and highlighted for several decades. The situation was so alarming that the Government of India introduced the Integrated Child Development Programme in 1975 to achieve three inter-related objectives, namely:
* Address the problem of malnutrition among children through provision of supplementary nutrition, monitoring the growth of children and educating families (mother/primary care giver) to adopt better feeding practices – better nutrition during pregnancy, breast-feeding, weaning foods and balanced nutrition in the early years of the development of children (upto 6 years).
* Ensuring freedom from intermittent diseases and better health of children through timely and complete immunisation for vaccine-preventable diseases, regular de-worming, providing Vitamin A and iron supplements, facilitating referrals in case of illness through convergence with the health sector, and raising health awareness levels amongst the target population.
* Promoting holistic child development through pre-school education – with a focus on motor and concept development, acquiring language and social skills and preparing the child for schooling.
These objectives were to be achieved through a range of anganwadi centre (AWC) based as well as home-based services and awareness activities. The ICDS is perhaps one of the better-conceived programmes; yet on travels around the country one realises that there is a huge gap between what is expected of the programme and the ground situation. This short piece draws upon a number of qualitative research studies that I was involved in over the last three years1 as well as the reports prepared by the commissioners appointed by theSupreme Court on efforts being made to make the programme universal and available to all children in rural and urban areas.2
Twenty five years after the introduction of the ICDS programme the Supreme Court (Order dated 28 November 2001) ordered that every settlement must have a disbursement centre and that every child aged 0-6, every pregnant and nursing mother and every adolescent girl be covered under the ICDS. Four years on, the GOI and the state governments are yet to implement this order. On 29 April 2004 the Supreme Court issued another order directing the government to file (within three months) a time-bound plan for compliance. Once again the deadline passed with no concrete action or plan. Based on the report filed by the commissioners, another order was passed on 7 October 2004 noting that the Government of India has not filed its plan and that stategovernments are far from ensuring universal access to supplementary nutrition. What is even more worrying is that even the existing centres do not function effectively and that corruption, mismanagement and callousness seems to permeate the ICDS programme.
‘It is most unfortunate that instead of three months, nearly six months have expired, the Government of India has still not filed the affidavit and instead an oral application has been made by learned Additional Solicitor General for grant of further time to file an affidavit in terms of the order dated 29.4.2004. We are shocked at the attitude of the central government, which is in respect of giving nutritious food to all children though in practice it concerns those unfortunate sections of the society who can ill-afford to provide nutritious food to the children of the aforesaid age group. In absence of the affidavit, we could have straightway issued directions for the sanction of the remaining AWCs and for increase of norm of rupee one to rupees two but having regard to thetotality of the circumstances, we grant one final opportunity to the central government to file an affidavit within a period of two weeks whereafter we would consider these two aspects, namely, (i) sanction of 14 lakh AWCs; (ii) increase of norm of rupee one to rupees two.’
Why is this flagship child nutrition and development programme in such a terrible state? First, according to the report tabled by the commissioners appointed by the Supreme Court, the expenditure for running the ICDS programme is currently met from three broad sources – (a) funds provided by the Centre under ‘general ICDS; used to meet expenses on account of infrastructure, salaries and honorarium for ICDS staff, training, basic medical equipment including medicines, play school learning kits etc.; (b) allocations made by the state governments to provide supplementary nutrition to beneficiaries, and (c) funds provided under the Pradhan Mantri Gramodaya Yojna (PMGY) as additional central assistance, technically to be used to provide monthly take home rations to those children (age group 0 to 3 years) living below the poverty line and in need of additional supplementary mutrition.
The above resources are technically adequate to meet the requirements of existing centres, but the reality is that there are frequent delays in financial releases from GOI. State government allocations for supplementary nutrition varies, for example Bihar spends just 15 paise per dayper child on the cost of grain and its conversion to a cooked meal! In West Bengal the district officials (Jalpaiguri) cited a meagre budget of 80 paise per child as the reason why adequate standards could not be maintained. In Uttaranchal allocations are even less with a provision of just 67 paise per child per day. In Tamil Nadu, for instance, against an estimatedrequirement of Rs 89 crore, the state allocated more than Rs 150 crore for SNP and the allocation per beneficiary per day is also the highest atRs 1.69. Jharkhand has not allocated even a single rupee! (Fifth Report of the SC Commissioners, August 2004).
The situation in Uttar Pradesh is rather grim. While the government had made allocations and the official data on supply of supplementarynutrition reported that 100% of the AWCs received supplies, the reality (as evident in the AWC records) was that there was no supply from August 2003 to March 2004.3 Here we are faced with a situation where procurement of nutrition supplements has been made (on paper) and funds have also been utilised, but there is nothing to show on the ground.
Second, health and well-being of children is really not a priority with political parties. Resources meant for the children, be it for supplementary nutrition in the pre-school periodor the mid-day meal, are routinelysiphoned off. The grand procurement game goes on with people at all levels making money. For example, in one of the north Indian states we were informed that the ICDS nutrition procurement to the tune of Rs 400 to 600 crore is cleared at the level of the chief minister! Centralised procurementis the norm and there have beeninstances when a little known agency located in another state is contracted to provide the fortified supplements. This is supposedly delivered at one central point and it takes several weeks, if not months, to travel tothe districts, blocks and finally the centres.
There is no quality control and the food, especially the ready to eat stuff, is so bad that children cannot eat it. During one of our field visits to Sitapur district of Uttar Pradesh in 2002, we could actually purchase the nutrition supplement in local grocery stores! (Vimala Ramachandran et al 2004a). A visit made in September 2003 to Barabanki district revealed the delays in the supply of panjiree to be a regular occurrence – there were 1125 bags in storage at the block office, implying that supply meant for the month of May had not been dispatched till July 2003 (pp. 10-11, Fifth Report of the SC Commissioners,August 2004). Thankfully, the situation is not so grim in Andhra Pradesh, Karnataka, Tamil Nadu and even Rajasthan. These states have been able to ensure the food supplements reach the AWCs on time and they combine centralised with localised procurement of perishable supplements.
Third, who accesses an AWC centre is influenced by its physical location as well as the caste/community profile of its workers. The fifth report of the Commissioners notes that one of the primary reasons for poor coverage of needy groups under the scheme is the location of the AWC. Access to services by deprived communities like the SC & ST is restricted if the centre is located in upper caste predominant hamlets. Field visits also show what appears to be a glaring lack of any proper method to assess the need and requirement as a result of which many of the SC/ST hamlets have been excluded. This not only reinforces the need for implementation of the order calling for a functional anganwadi in every habitation, but also suggests that priority must be given to initially cover the SC/ST populated habitations followed by others (pp. 3-4, Fifth Report of the SC Commissioners,August 2004).
Recent studies in two district of Uttar Pradesh revealed that over 70% of anganwadi workers were from the forward castes or the OBC community. The centres were located in the main village and sometimes in the house of a forward caste worker, thereby making it out of bounds to Dalit children. During visits to the villages, we met several families living in abject poverty. Many of them reported that their children were not enrolled in the AWC and they did not avail of the supplementary nutrition provided. On exploring the reasons for non-participation, we found that daily wagers did not have the time to bring their children to the AWCs and fetch them in the afternoon. So, most took their children with them. But really, there were no surprises here. The existential reality of very poor households is well known. The exclusion of the poorest of the poor from a range of government services is well documented. The issue is one of identifying strategies to reach out to them and provide nutritional security to their children (Vimala Ramachandran et al 2004b).
Fourth, while the original intent of the ICDS programme was to address the various sub-stages (conception- 1 month, < 3 years and 3-6 years) of growth in order to ensure that negative health and nutritional outcomes do not accompany the child from one stage to the next, the way the programme manifests on the ground, it effectively concentrates only on the 3 to 6 age group. Most surveys and studies on the ICDS programme note that the ability of the programme to reach out to children under three remains a problem, even though, technically, they are enrolled in the AWC.
Nutrition supplement to this group is distributed only once a week. Given that the AWWs do not make regular home visits, their ability to monitor the growth of children in the age group is questionable. The only service made available was immunisation and occasionally, Vitamin A (through ANM) distribution. AWWs admitted that the weekly rations given to children and pregnant/lactating mothers were often consumed by the entire household in very poor families. Mothers admitted that that the AWWs asked them to give solid food to their children. However, they could notrecall the exact nutrition advice given by the workers. The reason for this could partly be because nutrition and health education is disseminatedinfrequently and casually.
On our field visits in Rajasthan and Uttar Pradesh we did not come across even a single instance where the AWW had monitored a grade 3 or 4 malnourished child and used the opportunity to demonstrate the effectiveness of supplementary feeding. Anganwadi workers find it easier to manage older children and are not motivated to provided home-based care or services. Monitoring systems currently used do not capture the range and quality of services provided tounder-3s.
Fifth, the programme is expectedto monitor the growth of children by weighing them every month and plotting their growth on a chart. The entire monitoring system is based on the growth monitoring data. How does this work? During field visits to Rajasthan and Uttar Pradesh we noted that children between 3-6 years were weighed on adult weighing machines that were not calibrated (we did not see under-3s being weighed). As a result, the growth monitoring charts (wherever maintained) were not accurate. We tried to crosscheck this information in the registers with real children. We could not tally the names of children in almost 60% of the cases.
Where the weights wererecorded there was no mention of the age of the children. We were not able to access the GM data in most of the AWCs. The lady supervisor gave us this information from her notebookor we got it from the CDPO’s office. They had aggregate numbers of children in each grade and the supervisor’s could not name the children who were recorded as being grade 3 or 4 level malnourished. Every centre in Rajasthan had two children recorded as receiving double rations – but the AWWs could not give us the name of the children. Given this scenario on the ground, the growth monitoring data that is fed in the system may well be incorrect (Vimala Ramachandran et al 2004b).
Sixth, another issue that repeatedly surfaced during group discussions and individual interactions was theadequacy of the nutrition supplement in tackling persistent hunger among children. While the quality of SNP supplied was fairly good in Rajasthan, it was not as tasty – it was dry and salty. Small children could hardly beexpected to eat more than a handful. Almost all the children spilled some, packed some in old newspapers and only ate a small portion in the presence of the AWW. The message was loud and clear. It was not enough to ensure the supply of fortified flour alone. Supplying jaggery or sugar and other condiments was essential if the SNP was to be made more palatable to children. The AWCs in Bellary district of Karnataka are an excellent example of a well-run programme. Rice, broken wheat, pulses, jaggery and salt were supplied and vegetables and condiments were procured locally. The meal served was wholesome and palatable to children and pregnant and lactating mothers.
Another area of concern was the quantity given to each child. Given the village milieu, the AWW distributed the supplements to any child who came to the centre. In two AWCs of Rajasthan, we also observed old women (who had little or no family support) and men coming to the centre for food. We did not come across any child who was officially getting double rations even though nearly all the registers recorded two to four children as being given double rations. The AWWs were at a loss trying to name the children who were identified as the recipients of double rations.
On further exploration, the lady supervisors and AWWs said that they distributed what was cooked to those who came to the centre. Most AWWs admitted that the AWHs took some cooked SNP home. In some cases, even the AWWs carried some SNP home. We were informed that they added the fortified supplement to wheat flour to make rotis (flat bread) or cooked it as porridge for the entire family. In UP too, the AWWs reported that nutrition was not distributed asper the stipulated amount, as there were often more children than those enrolled at the centres. In the AWCs located in school premises, children of class I were also fed along with pre-schoolers (Vimala Ramachandran 2004a and b).
Seventh, our field visits across five states revealed that pre-school education comprised reciting rhymes, singing songs and repeating the alphabets. Children in UP used slates (white slate with liquid chalk) and were expected to copy numbers and alphabets. The AWH was seen singing to the children in some centres. In some others, the children were seen sitting around and playing by themselves. The AWCs located in the primary schools functioned from 9 am to 1 pm in winter and 8 am to 12 pm in summer with the AWW managing 3-6 year olds along with class I students! Given the high pupil-teacher ratios in UP (in one school there were over 240 children and one teacher) the AWW were elevated to the status of a teacher and given the responsibility of class I. The situation in Karnataka and Andhra Pradesh was somewhat better withthe AWWs giving children some toys to play with and also teaching songs and games. We did not come across any pre-school education activity in Rajasthan.
What does this all this imply? What lessons can we learn from the gaping schism between what the ICDS programme is expected to deliver and what actually happens on the ground? Child development programmes of the government need an extraordinary amount of individual attention. Given the size of the problem, and the complexity of issues involved – the government has to take the lead and make sure that the persistent problem of hunger and malnutrition among children is addressed with care and sensitivity. Where there is one anganwadi, we probably need four. There is no dearth of people who are ready to work, but it is important that they get out of the typical sarkari naukri (government service) mentality. Where the parent is unable to provide the necessary food and nutrition the government service provider has to assume some surrogate responsibilities.
The anganwadi worker needs to show greater empathy and reachout to children who are in dire need of proper nutrition and health care services. They have to transform themselves into ‘professional care-givers’, working with and giving attention to fewer numbers of children. This is especially true for children in poverty situations. All this does not only mean more resources, but a lot more care and attention. Can we not involve mothers in the nutrition componentof the ICDS programme? Maybe this is asking too much of a system that is so enormous and impersonal. But there are no shortcuts – children need care, love and, above all, individualised attention.
The time has come to turn the ICDS programme upside down – doing away with the existing model and thinking afresh on how best we can reach out to the most vulnerable. We need to plan separately for different sub-groups of children – looking at the specific needs of home-based care and outreach services upto 3 years and a centre based approach for the 3+ group. It may be worthwhile discussing the possibility of splitting the ICDS programme into two: (a) a dedicated home-based programme to promote health and nutrition of children in the 0-3 group; health and nutrition of adolescent girls and pregnant and lactating mothers; (b) a centre-based nutrition and pre-school education programme for 3-6 years. This is essential if we are serious about reaching out to this very important segment of our population. Poor health, malnutrition and frequent bouts of illness at this stage have an irreversible impact on the overall health and well being of children.
Given the enormous diversity in the country and different administrative environments, political leadership and awareness levels among the people, the government needs to initiate a state-wise revisioning exercise to revisit the objectives of the ICDS programme – within the agreed ICD conceptual framework. This is essential to secure the commitment of the state leadership to the core objectives of the programme. This needs to be followed by stakeholders’ meetings at the state and district levels, with political leaders and other important opinion makers in the state.
A vision document that is circulated widely could help involve a larger number of people in reshaping the programme. This will also provide an opportunity to engage the political leadership in an informed debate on the importance of a child health and nutrition programme in the larger development strategy. Such a process will hopefully throw up positive stakeholders who can then be involved in a periodic social audit of the programme. It will also enable greater participation of the corporate and business community, who can be invited to contribute in cash or kind.
It is important to take on board governance issues while designing the ICDS programme as corruption has plagued the programme in many states. The government has to design appropriate procurement procedures, introducing localised procurementof rice, wheat, dal and vegetablesand move away from the ready-to-eat food supplements. DWCRA and other women’s groups could also be given a per-child budget for procuring and feeding children in the village.
While appreciating fears about misappropriation of funds, given the abysmal supply situation in several states, such a shift may not lead to greater leakages. Needless to add, the situation with respect to supplies needs to be reviewed for each stateand appropriate systems designed to suit the specific administrative and political situation in the state concerned. If the ICDS programme is meant for the poorest of the poor, then all efforts should be made to ensure that it reaches them. Appropriate checks and balances are necessary to enforce proper targeting. This is where larger civil society institutions (not just NGOs, but corporate, media, eminent people) have to be involved in monitoring targeting.
Since not all poor children have access to an ICDS centre (especially in Bihar, Jharkhand, MP, Chhattisgarh, UP and Rajasthan where most villages have only one centre), the state governments should be assisted by GOI to make ICDS a universal programme – in accordance with theSupreme Court directives. GOI has to play a more proactive and hands on role in the universalisation of the ICDS programme.
Learning from the successful polio campaign in many parts of the country, the programme should be geared to promote better and accessible nutritional practices. Public health and nutrition education has received a setback in the last 30 years. It may be worthwhile revisiting earliernutrition education and preventive health programmes. One disturbing feature is that every new programme introduced tends to diminish the validity of earlier efforts. It is rather disconcerting that basic public health and nutrition messages have beenlost in the din of family planning, and now HIV and AIDS control. Whilenot challenging the importance or validity of the new focus, simple messages (kitchen gardens, eating leafy vegetables, universal planting of common fruits like guava/berries,nutritional value of coarse grains etc.) can enable people to harvest whatever local resources they haveto improve the nutritional status of children. This aspect needs urgent attention.
Footnotes:
1. Vimala Ramachandran and team: Snakes and Ladders: Factors Influencing Successful Primary School Completion for Children in Poverty Contexts. South Asian Human Development Sector Report No. 6, World Bank, New Delhi, 2004a and Vimala Ramachandran and team: Analysis of Positive Deviance in ICDS Programmes – Rajasthan and Uttar Pradesh. World Bank, New Delhi, 2004b.
2. Supreme Court order of 28 November2001 called for one anganwadi centre (AWC) in every settlement and complete coverage of all children till they attained the age of six years, all pregnant and nursing mothers and adolescent girls. The order of 29 April 2004 reiterated the previous order and directed the government to universalise the ICDS programme, and order passed on 7 October 2004 after reviewing the reports dated 12February and 5 August 2004 submitted by the commissioners, N.C. Saxena and N.R. Sankaran.
3. Source: CPMU, DWCD, GOI, 25 November 2003, cited in Vimala Ramachandran and team: Analysis of positive deviance in ICDS programme – Rajasthan and Uttar Pradesh. World Bank, New Delhi, 2004b.
