|Food and Nutrition Bulletin Volume 05, Number 3, 1983 (UNU, 1983, 84 pages)|
|Hunter, health, and society|
Badri N. Tandon
Department of Gastroenterology and Human Nutrition, All-India Institute of Medical Sciences,
Ansari Nagar, New Delhi, India
Indian census estimates for 1983 are 118 million pre-school children, 17 million pregnant women, and 32 million lactating mothers with 48 per cent of the population living below the poverty line. They are at high risk for malnutrition resulting from inadequate food intake and repeated episodes of infection. Infant mortality in India is estimated to be 125 per 1,000 live births, and the malnutrition-infection complex is the most important cause of this high infant and child mortality, as it is for two-thirds of the population in the world living in developing countries.
India has given a special place to children in its constitution. It has established a National Board for Children with the Prime Minister as its Chairman to monitor the progress of the programme for the care and development of children. Several programmes have been established since Independence for Indian children. A detailed review of the health and nutrition programme was undertaken by the Government of India at the beginning of 1970.
Teams comprised of planners, administrators, and technical experts reviewed the ongoing programmes by field visits and study of available records. It was decided to develop an integrated approach to provide essential health, nutrition, and education services to preschool children for their optimal development. A new experimental project, Integrated Child Development Services (ICDS), was launched on 2 October 1975 with the following objectives:
1. To improve the nutritional and health status of children in the age group 0 to 6 years.
2. To lay the foundations for proper psychological, physical, and social development of the child.
3. To reduce the incidence of mortality, morbidity, malnutrition, and school drop-out.
4. To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutritional as well as health education.
5. To achieve effective coordination of policy and implementation among the various services to promote child development.
ICDS is designed to provide services to the preschool children aged from 0 to 6 years, pregnant women in the second and third trimester, and lactating mothers for a period of six months. These include appropriate immunizations according to the national plan of the country, nutrition intervention by supplementary nutrition, vitamin A every six months, and distribution of iron and folic acid tablets, primary medical care for common ailments, health checkups, including antenatal and postnatal examinations. Preschool education for children and functional literacy for women is also included in the programme. Emphasis is on nutrition and health education to the beneficiaries.
The services are delivered at a focal point in the village called the Anganwadi, which implies a courtyard of the village. Beneficiaries assemble at the Anganwadi every day for a period of two to three hours to receive on-the-spot services. The principal functionary who delivers these services is a local village young woman educated up to eighth to tenth grade standards. In difficult, backward areas, young women with even less education may be selected from the same village to be the Anganwadi worker.
This worker receives training for a period of four months through a specially developed curriculum that is directed towards her functions in the programme. Furthermore, on-the-job training is scheduled every month by the medical officers and middle-level supervisors of the health infrastructure of the villages. She is designated as honorary worker and is not bound by the service rules of the government. She receives an honorarium of Rs.175 to Rs.200 - (US $17.50 to 20) per month. Another honorary worker helps with cleaning the space, cooking the food for the children, etc.
The Anganwadi is thus the nodal point established in a village for a population of 1,000 where preschool children, pregnant women, and lactating mothers receive health, nutrition, and education services in a coordinated way. It is linked with the village health infrastructure of the State on the one hand and the Social Welfare Department on the other. Thus, it receives support and supervision for its activities from well-established health, education, and welfare departments. in India, for all administrative and development purposes, about 100 rural villages with a total population of approximately 100,000 people are grouped together to form a block.
At the headquarters of the block, which is located in one of the villages, there is a primary health centre that has branches spread out in the villages as sub-centres. One sub-centre, on average, provides health services to a population of seven to ten villages, i.e., 7,000 to 10,000 people. The work of the sub-centre is carried out by an auxiliary nurse midwife or multipurpose workers, and maternal child health services are provided on a priority basis.
Currently, the Anganwadis of ICDS are located in each village. Thus, the sub-centres have been established at the most peripheral points to deliver effective health and nutrition services to women and children.
A new structure has been developed at the block headquarters/primary health centre for the social welfare and education components of ICDS. A graduate in sociology with special training in child development and nutrition is appointed full-time as Child Development Project Officer (CDPO). In addition three to four middle-level women supervisors with special training for their functions support the Anganwadi workers. This system provides supportive supervision and continuous help to the functioning of Anganwadis at each village.
The officers at the block level, i.e., the medical officer in charge of the primary health centre and the CDPO are linked to their respective departments of health and social welfare for interaction at the District and the State headquarters. The Ministry of Social Welfare of the Government of India at the Centre interacts with the State Social Welfare and Health Departments for proper implementation of the programme.
Involvement of Medical Institutions in ICDS
The original plan of ICDS did not include the involvement of faculty of the medical institutions in this national programme. However, the then Cabinet Minister of Education and Social Welfare, Professor Nural Hassan, an academician in his own right, had the foresight to consider the value of participation on the part of the faculty of paediatrics and community medicine departments in this programme. He asked the All-India Institute of Medical Sciences to organize a two-day meeting of professors of paediatrics and community medicine from the medical institutions located close to the proposed 33 ICDS projects. Twenty-seven medical institutions were identified, and invitations were sent to their staffs requesting them to send one physician each from the paediatric and community medicine departments for the meeting on ICDS at the All-India Institute of Medical Sciences on February 18-19, 1976. The meeting unanimously recommended that the medical faculty should participate in this national experimental project on child development and offer the following services as consultants: evaluation, monitoring, training, and continued education.
The Department of Social Welfare of the Government of India appointed a Central Technical Committee for Health and Nutrition at the All-India Institute of Medical Sciences, and a small biostatistics unit was established at the Institute for data analysis. Members of the Central Committee included representatives from the Ministry of Health, Planning, Social Welfare, the National Institute of Public Cooperation and Child Development, and the All-India Institute of Medical Sciences. Twenty-seven ICDS consultants were appointed from different medical institutions located at a reasonable proximity to the project blocks. The consultants were reorganized on a zonal basis, and five regional convenors from among the consultants were appointed to monitor the work by mutual discussion with each consultant in a given zone.
Consultants were given an orientation course where the objectives of the ICDS, organization, its implementation, budget, accounting, and their own specific functions of evaluation, training, and monitoring were explained in detail. The forms for survey and monitoring and the training curriculum for medical officers of the ICDS block were finalized after a critical discussion by all the consultants.
The survey work is done on an annual basis, and the data are analyzed at the central biostatistics unit. Comments on the data are forwarded to the Social Welfare Department and to each consultant for appropriate action. The conclusions of the data on the flow of services and its impact are provided to this Department.
Regional coordinators monitor the implementation of ICDS through the data collected by the consultants from the block level through regional meetings that will be held by rotation at different project blocks once every two months. The deliberations at these regional meetings are forwarded to the Central Committee for information and appropriate action.
The Chairman of the Central Technical Committee meets with the regional coordinators of ICDS once every four months to review the monitoring, training, and survey work being done by the consultants. The Central Committee meets once every two months to review the progress of ICDS, particularly in the health and nutrition sector. The number of experimental projects has expanded from 33 to 100, then to 150 and 200 during 1978, 1979, and 1980.
During this four-year period from 1976 to 1980, ICDS consultants were able to provide orientation and training courses for nearly 75 to 85 per cent of the medical and paramedical functionaries. Five surveys were conducted and the results of the initial three surveys have been published. Monitoring reports are continuously reviewed and the appropriate actions taken. Overall, it appeared that this system worked quite satisfactorily. For less than 0.6 per cent of the total budget for an ICDS project, experts were able to assist a national programme for training, monitoring, and evaluation.
After a critical review, Prime Minister Ghandi decided that the programme should expand to 1,000 projects by the end of the sixth Five-Year Plan that ends in March 1985. Furthermore, she declared it a programme of national importance and included it in the 20-Point Development Programme for the country. The Central Committee has devised a new system for evaluation, monitoring, training, and continued education to cope with the expanded ICDS programme. The characteristics of the new system are:
1. The four functions mentioned above are preserved.
2. Each State will have two to three training consultants drawn from medical colleges with wide experience in ICDS. All the medical officers and district health officers (advisers) and other non-medical officials will receive orientation in ICDS at these training centres under the training consultants.
3.There will be about 40 training consultants through out the country who will also help the Anganwadi Training Centres conduct courses for the Anganwadi workers.
4. The survey will be carried out in 20 per cent of all the projects, and each State will have two to three survey consultants who will do a relatively more detailed survey on the 10 per cent of samples under the guidance of the Biostatistics Unit of the All-India Institute of Medical Sciences. They will also do a survey of severely malnourished children and perform other specific functions assigned to them. The data analysis will be done by the survey consultants for their own project and forwarded to the State coordinator as well as to the Central Committee.
5. There will be 10 research consultants who will do the research on a contract basis to provide answers for specific problems related to ICDS and to guide changes or modifications in ICDS in the future.
6. District Health Officers or persons with equivalent rank will be appointed as advisers. Their main functions will be monitoring and continuing education at the level of the project block. They will also receive continuous guidance and supervision from senior advisers.
7. One senior adviser will be appointed for each State. He will be a very senior person with wide experience in nutrition, child development, and ICDS. His main task will be to guide the advisers to discharge their functions effectively and advise the State coordinator on proper implementation of ICDS in each State. These appointments will be on an honorary basis with contingencies and funds for travailing for the project work.
8. The data from training, survey, and monitoring will be analyzed at the first level by the individual officers, then they will be forwarded to the State coordinator. There will be a data analysis cell at the State headquarters to compile all the State data. These data will be sent to the Central Committee that will then prepare the national data report.
Regional meetings are organized for consultants, and State level meetings are organized for advisers to review and continuously monitor the progress of the work. The monthly monitoring system has evolved with a flow from Anganwadis to the apex at the State level and Centre. The training programme has been expanded with greater emphasis on continuous education of the field workers, creating awareness among administrators, voluntary organizations, and the people. A new component of research has been added through a selective group of consultants who will be able to provide answers for pressing questions raised from time to time by the Social Welfare Department, the Planning Commission, and others.
The Ministry of Social Welfare, through its apex institution known as the National Institute of Public Cooperation and Child Development, has been responsible for organizing the training of ICDS staff working as Anganwadi workers, Mukhya Sevikas, and Child Development Project Officers. further, continuing education for these functionaries is arranged through appropriate workshops and seminars. The number of training institutions and training courses has substantially increased during the phase of extension of ICDS. At present there are 200 Anganwadi worker-training institutions, 25 Mukhya Sevikas-training institutions, and 3 regional centres for training Child Development Project Officers who will be spread out in the country.
PERFORMANCE OF ICDS
Data from the expanded programme suggest a significant increase in the proportion of immunized children, vitamin A distribution, and a decrease in prevalence of severe malnutrition.
Severe malnutrition is a serious, life-threatening condition for children. Very high death rates have been reported among such children if they are left untreated for a long time or taken to the hospital in very late stages of their illness. Readily available services at Anganwadis in their own villages improved the prognosis for these children. A follow-up of more than 4,000 severely malnourished children by our consultants at the Anganwadi centres revealed an overall fatality of only 3 per cent after treatment by Anganwadi workers and a significant improvement in the nutritional status of about 46.5 per cent of the children. Diarrhoea, fever, and respiratory infections were the main diseases associated with severe malnutrition, and could be treated satisfactorily at the Anganwadi centre in the majority of cases by the workers.
There are also several research studies by individual consultants that have demonstrated a decrease in the infant mortality rate, an increase in birth weight, and improvement in nutritional and health status of pregnant women in ICDS project areas. Comparative studies in a few ICDS and non-ICDS populations have also confirmed these findings.
The achievements of ICDS can be summarized as follows:
1. A wide network of infrastructure has been established.
2. A good system of continuous education and supportive supervision of the functionaries has been developed.
3. A team approach for the delivery of essential services at the village is in operation.
4. There is unequivocal evidence of progressive improvement in the coverage and utilization of all the essential services delivered through ICDS.
5. The nutritional status of children has improved; in particular, there has been a marked decline in the prevalence rate of severe malnutrition.
6. The language and values of the academic community of medical scientists are being modified to suit the health needs of the community.
There are, however, several shortcomings in this national programme, namely:
1. It is a multisectoral programme and coordination among different
departments, e.g., health, education, and social welfare, is not yet up to the
2. Participation by the community and voluntary organizations is not as great as it should be.
3. Nutrition and health education, and even preschool and non-formal education, need more emphasis.
4. Younger children 0 to 3 years are receiving proportionately less ICDS services compared to children 4 to 6 years of age.
5. The impact of the programme on morbidity and mortality needs further evaluation.
6. It is often said that ICDS is a costly programme. However, this needs more careful cost-benefit analysis.
(a) The total cost of a primary health centre establishment where ICDS does not exist is about Rs. 350,000 to 500,000 (US $35,000 to 50,000).
(b) The ICDS health component adds Rs.130,000 (US $13,000) to the primary health centre, with a very significant improvement in the maternal-child health services.
(c) The cost of non-medical, i.e., social welfare and education input, in each rural ICDS project is about Rs.397,000 (US $39,700), which covers the management, social welfare activities, and particularly preschool education. This is lower than the cost of sporadic vertical programmes in non-ICDS blocks.
(d) The cost of supplementary nutrition is the major component, i.e., about Rs.800,000 (US $80,000) per project per year. This is the same or less than for other vertical supplementary nutrition programmes in the country.
We have also to answer two other questions when considering the cost of ICDS: What would be the cost of not having a programme like ICDS? Is there another less expensive and successful model? If there is a less costly programme that does not bring the desired results, then it is not really cheap.