I want to thank the Forum Moderator - Renata Mirulla for giving me the space to voice my views. In this discussion, I would like to focus on two aspects: a. Main issues for policy-makers to consider in the design, formulation and implementation and b. Key institutional and governance challenges.
At the outset, I would like to mention that Stein and Qaim (2007) in their study: The human and economic cost of hidden hunger, Food and Nutrition Bulletin, 28(2): 125–134, have estimated that the combined economic cost of iron-deficiency anaemia, zinc deficiency, vitamin A deficiency and iodine deficiency amounts to around 2.5 percent of GDP in the case of India (see attachment).
The two most important social protection programmes in India (at the national level) to protect and promote nutrition are: Integrated Child Development Services (ICDS) scheme and Mid Day Meal Scheme (MDMS). Apart from them, there is the Nutrition Programme for Adolescent Girls (NPAG). I will concentrate on the ICDS here.
Integrated Child Development Services (ICDS)
The programme was launched in 1975 seeking to provide an integrated package of services in a convergent manner for the holistic development of the child. It began with 33 pilot projects in different parts of the country. It is the only major national programme that addresses the health and nutrition needs of children under the age of six. It seeks to provide young children with an integrated package of services, including supplementary nutrition, health care and pre-school education. Since the needs of a young child cannot be addressed in isolation from those of his or her mother, the programme also extends to adolescent girls, pregnant women and nursing mothers. ICDS services are provided through a vast network of ICDS centres, better known as "Anganwadis".
• Lay the foundation for proper psychological development of the child
• Improve nutritional & health status of children 0-6 years
• Reduce incidence of mortality, morbidity, malnutrition and school drop-outs
• Enhance the capability of the mother and family to look after the health, nutritional and development needs of the child
• Achieve effective coordination of policy and implementation among various departments to promote child development
The Ministry for Women & Child Development launched the World Bank assisted ICDS Systems Strengthening and Nutrition Improvement Project (ISSNIP) on 9 May, 2013. The programme aims at improving child development and nutritional outcomes for children in selected districts having higher proportional of child under nutrition. For more, go to: Smt. Krishna Tirath Launches the World Bank Assisted ISSNIP, http://pib.nic.in/newsite/pmreleases.aspx?mincode=64
Many independent studies provided evidence that the ICDS was effective in combating child malnutrition and improving school enrolment. Despite all this, the Central Government was reluctant in universalising the scheme. In 2001, the Supreme Court in its landmark judgment (after a PIL was filed by People’s Union for Civil Liberties-PUCL, Rajasthan) ordered the Central government to universalise the scheme to cover all children in India. Universalisation of the ICDS took place around 2006 after the Supreme Court was compelled to chastise the Central government in several consecutive orders. Please read: Supreme Court Orders on the Right to Food, http://sccommissioners.org/CourtOrders/tool_for_action.pdf
Challenges for Integrated Child Development Services (ICDS)
If we look at the key findings of the Report of the Comptroller and Auditor General of India on Performance Audit of ICDS, CAG Report no. 22 of 2012-13, http://saiindia.gov.in/english/home/Our_Products/Audit_Report/Government_Wise/union_audit/recent_reports/union_performance/2012_2013/Civil/Report_22/Report_22.html it will help us to understand the key institutional and governance challenges to the delivery of ICDS:
• The CAG chose to audit the ICDS since India's status on key child development and health indicators did not compare well with its own targets as well as with the neighbouring and other regions. The Infant Mortality Rate (IMR) was 48 per 1000 live birth and the Child Mortality Rate (CMR) 63 per 1000 live birth in 2010 as against the targets of 30 and 31 respectively. These indicators were (IMR and CMR) for the neighbouring countries were: China (IMR: 16, CMR: 18) and Sri Lanka (IMR: 14, CMR: 17). In industrialized countries, the IMR and CMR were as low as 5 and 6 respectively.
• The performance audit covered 2730 of the test checked Anganwadi Centres (AWCs) from 273 project offices of 67 districts from 13 states (Andhra Pradesh, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Madhya Pradesh, Meghalaya, Odisha, Rajasthan, Uttar Pradesh and West Bengal) for the period 2006-07 to 2010-11 on 3 services viz. supplementary nutrition, pre-school education and nutrition and health education under scheme. The selection of the states was made on the basis of population, funding and nutrition indicators as per the NFHS-3, 2005.
• To universalise the ICDS, Hon'ble Supreme Court had directed the Central and state Governments to operationalise 14 lakh AWCs by December, 2008. The Ministry sanctioned 13.71 lakh AWCs and could operationalise 13.17 lakh. This left a shortfall of 0.54 lakh. Similarly, out of 7075 sanctioned ICDS projects, 7005 projects were operationalised.
• 61 percent of the test-checked AWCs did not have their own buildings and 25 percent were functioning from semi-pucca/ kachcha buildings or open/ partially covered space. Separate space for cooking, storing food items and indoor and outdoor activities for children was not available in 40 to 65 percent of the test-checked AWCs.
• Poor hygiene and sanitation were noticed in the AWCs due to the absence of toilets in 52 percent of the test checked AWCs and non-availability of drinking water facility for 32 percent of the test checked AWCs.
• Functional weighing machines for babies and adults were not available in 26 and 58 percent, respectively, of the test-checked AWCs. The essential utensils required for providing supplementary nutrition to the beneficiaries were also not available in several test-checked AWCs.
• Medicine kits were not available in 33 to 49 percent of the test checked AWCs due to failure of the state governments in spending the funds released to them by the Centre.
• 53 percent of the test checked AWCs did not receive annual flexi-fund of Rs. 1000 from the state governments during the period 2009-2011.
• There were shortages of staff and key functionaries at all levels.
• The shortfall under various categories of training ranged from 19 to 58 percent of the targets fixed under the State Training Action Plan (STRAP).
• The shortfall in expenditure on Supplementary Nutrition (SN) ranged between 15 percent and 36 percent of the requirements during the period 2006-2011. The average daily expenditure per beneficiary on SN was Rs. 1.52 to Rs. 2.01 against the norm of Rs. 2.06 during 2006-09 and Rs. 3.08 to Rs. 3.64 against the norm of Rs. 4.21 during 2009-2011.
• 33 to 47 percent children were not weighed for monitoring their growth during 2006-07 to 2010-11. The data on nutritional status of children had discrepancies and were not based on WHO's growth standards.
• There was a gap of 33 to 45 percent between the number of eligible beneficiaries identified and those receiving the SN during 2006-07 to 2010-11.
• The Wheat Based Nutrition Programme suffered from lack of proper coordination among the Ministry of Women and Child Development, the Department of Food and Public Distribution and the state governments. The Ministry could allocate 78 percent of foodgrains demanded by the states. The actual take-offs by the states was merely 66 percent of total demand placed by them.
• Pre-school education (PSE) kits were not available at 41 to 51 percent of the test-checked AWCs during the period 2006-11.
• In 6 of the test checked states (Bihar, Haryana, Jharkhand, Madhya Pradesh, Uttar Pradesh and West Bengal) data on beneficiaries of PSE who joined mainstream education were not available. In 5 states (Andhra Pradesh, Chhattisgarh, Odisha, Rajasthan and Karnataka) shortfall in the number of children who actually joined the formal education during 2006-2011 ranged between 7 and 30 percent.
• Shortfall of 40 to 100 percent was noted on the expenditure against the funds released for Information, Education and Communication (IEC) in many states.
• Against the total release of Rs. 1753 crore to 13 states during 2008-09 and 15 states during 2009-2011 for meeting the expenditure on salary of ICDS functionaries, the actual expenditure was Rs. 2853 crore indicating unrealistic budgeting and consequent diversion of funds from other critical components of the scheme.
• Rs. 57.82 crore were diverted to activities not permitted under the ICDS in 5 of the test-checked states and Rs. 70.11 crore were parked in civil deposits/ personal ledger accounts/ bank accounts / treasury resulting in blocking of funds.
• The Central Monitoring Unit (CMU) under the ICDS failed to efficiently carry out assigned tasks, which included concurrent evaluation of the scheme, monitoring through the progress reports received from the states.
• Impact assessment of the services under the SN and the PSE based on outcome indicators, such as nutritional status of the children, was not being done.
• The follow-up action on internal monitoring and evaluation by the Ministry was inadequate and resulted in recurrence of shortcomings and lapses in the scheme implementation.
According to the article titled: Who do ICDS and PDS Exclude and What Can be Done to Change This? by Biraj Swain and M Kumaran (IDS Bulletin, Volume 43, Issue Supplement s1, pages 32–39, July 2012), the ICDS is implemented through 12.41 lakh centres known as anganwadi centres (AWCs), each located in a habitation of 400-800 population. Despite being in the final year of 11th Five Year Plan, India is 1.5 lakh short of the targeted number of AWCs meant to cover at least 1.17 crore potential beneficiaries. Despite planning universal access under ICDS, only 8.37 crore children were officially covered against the targeted 15.88 crore children aged 0-6 years.
According to the article: Elimination of Identity-based Discrimination in Food and Nutrition Programmes in India by Rajendra P Mamgain and G Dilip Diwakar (IDS Bulletin, Volume 43, Issue Supplement s1, pages 25-31, July 2012), there are 3 different types of exclusion and discrimination faced by SCs and STs in ICDS and MDMS namely—the location of infrastructure, the nature of human resources managing the scheme at the grassroots level and discriminatory practices in providing the service. Location of the infrastructure facility helps certain groups and hinders access for other social groups. The ICDS and the MDMS have been criticized for irregularities, non-adherence to guidelines and malpractices leading to leakages of benefits to non-beneficiaries and complete denial of service to some target groups.
The "Right to Food Campaign", which is quite active in suggesting the strengthening of the ICDS and MDMS under the National Food Security Bill 2013 has provided critique to the Parliamentary Standing Committee's report, which can be accessed here: Why the Parliament should reject the standing committee’s recommendations on the Food Security Bill: RTFC, http://www.im4change.org/latest-news-updates/why-the-parliament-should-reject-the-standing-committees-recommendations-on-the-food-security-bill-rtfc-19099.html
A critique on restructuring of the ICDS is available: Privatising the ICDS?-Jayati Ghosh, Frontline, 31 May, 2013, http://www.im4change.org/latest-news-updates/privatising-the-icds-jayati-ghosh-21237.html
I prepared a short note on budgetary allocations on ICDS by the Central Government.
Design, Formulation and Implementation: Monitoring Malnutrition and Hunger in India
One of the main issues for policy-makers to consider in the design, formulation and implementation of ICDS is to monitor the levels of malnutrition and hunger in India. The State of Food and Agriculture 2013: Food Systems for Better Nutrition, http://www.fao.org/docrep/018/i3300e/i3300e.pdf explains that undernutrition is the outcome of insufficient food intake and repeated infections (UNSCN, 2010). Undernutrition or underweight in adults is measured by the body mass index (BMI), with individuals with a BMI of 18.5 or less considered to be underweight. Measures of undernutrition are more widely available for children: underweight (being too thin for one’s age), wasting (being too thin for one’s height) and stunting (being too short for one’s age).
It is alleged that the Central Government is not monitoring the state of malnutrition and hunger since the time the last National Family Health Survey-3 (NFHS-3) got published in 2005-06. For more, please read my blogpost: India’s nutrition and hunger data is too old, http://talkative-shambhu.blogspot.in/2012/10/indias-nutrition-and-hunger-data-is-too.html
The 2013 UNICEF report Improving Child Nutrition: The achievable imperative for global progress, http://www.unicef.org/publications/files/Nutrition_Report_final_lo_res_8_April.pdf informs that during 2012, the Government of Maharashtra commissioned the first-ever statewide nutrition survey (independent of the Central Government) to assess progress and identify areas for future action. Results of this Comprehensive Nutrition Survey in Maharashtra indicated that prevalence of stunting in children under 2 years of age was 23 per cent in 2012 – a decrease of 16 percentage points over a seven-year period. The other observations are:
• From 2005–2006 to 2012, the percentage of children 6 to 23 months old who were fed a required minimum number of times per day increased from 34 to 77 and the proportion of mothers who benefited from at least three antenatal visits during pregnancy increased from 75 to 90 per cent.
• The provisional results of the Maharashtra survey showed that in spite of more frequent meals, only 7 per cent of children 6–23 months old received a minimal acceptable diet in 2012.
The aforementioned CAG report on ICDS found:
• Total number of malnourished children (Grade I, II, III and IV) exceeded the 40 percent mark in 10 states/ UTs (Andhra Pradesh: 49 percent, Bihar: 82 percent, Haryana: 43 percent, Jharkhand: 40 percent, Odisha: 50 percent, Rajasthan: 43 percent, UP: 41 percent, Delhi: 50 percent, Daman and Diu: 50 percent and Lakshadweep: 40 percent), as on 31 March, 2011.
• The number of severely malnourished children (Grade III and IV) exceeded 1 percent of total weighed children in 8 states (Bihar: 26 percent, Chhattisgarh: 2 percent, Gujarat: 5 percent, Karnataka: 3 percent, Madhya Pradesh: 2 percent, Maharashtra: 3 percent, Uttarakhand: 1 percent and West Bengal: 4 percent) as on 31 March, 2011.
• There was substantial decrease in the malnourished children in 6 states between 31 March 2007 and 31 March 2011 (Gujarat: from 71 percent to 39 percent, Karnataka: from 53 to 40 percent, Maharashtra: from 45 to 23 percent, UP: from 53 to 41 percent, Uttarakhand: 46 to 25 percent and West Bengal: 53 to 37 percent.
• North-eastern states fared better in respect of the nutritional status of children, where percentage of normal children was satisfactory vis-a-vis the total weighed children as on 31 March 2011 (Arunachal Pradesh: 98 percent, Assam: 69 percent, Manipur: 86 percent, Meghalaya: 71 percent, Mizoran: 77 percent, Nagaland: 92 percent, Sikkim: 89 percent and Tripura: 63 percent).
• In 5 other states/ UTs the percentage of normal children exceeded 70 percent as of 31 March 2011, viz. MP: 72 percent, Maharashtra: 77 percent, Uttarakhand: 75 percent, A & N Islands: 82 percent and Dadra & Nagar Haveli: 75 percent.
Present debate on malnutrition
Some experts have opined that ICDS doesn’t impact nutrition since it is determined not only by food and nutrition intake but also by people’s knowledge about nutrition and hygiene, accessibility and availability of clean drinking water and sanitation etc. It has been argued that early marriage (due to social prejudice) when female body is not prepared to give birth is the main reason behind low birth weight. (Nearly 47 percent Indian girls get married before age 18). Exclusive breast feeding is not done in many cases in the first 6 months, which affects child nutrition. Poor people emulate things, which are not healthy practices. Immunization rate in India is worse than that in Bangladesh and China. [Vaccine coverage in the case of DTP3 (third dose of diphtheria and tetanus toxoid and pertussis vaccine) is 72 percent and in the case of measles is 74 percent in 2011]. ICDS should concentrate on children below 3 years instead of children between 3 years and 6 years since most of the damage due to malnutrition is done to the children below 3 years.
Economists have questioned the way height and weight for Indian children (for a particular age) are measured with reference to 2006 norms set by the WHO to arrive at malnutrition figures without taking into consideration the genetic differences.
For more on the debate, please consult the following links:
The Myth of Child Malnutrition in India-Arvind Panagariya, Columbia University, September 2012 Conference, Paper 8 http://indianeconomy.columbia.edu/sites/default/files/paper_8-panagariya.pdf
When myth is reality-Stuart Gillespie, Transform Nutrition, January, 2013, http://www.transformnutrition.org/2013/01/24/when-myth-is-reality/
Is Child Malnutrition Overstated in India? A Reponse to Arvind Panagariya--By Deepankar Basu and Amit Basole, December 30, 2012 http://sanhati.com/excerpted/5950/
A nutritional crisis in India, Live Mint, 14 May, 2013, http://www.im4change.org/latest-news-updates/a-nutritional-crisis-in-india-21167.html
Is malnutrition in India a myth? -Pramit Bhattacharya, Live Mint, 16 May, 2013, http://www.im4change.org/latest-news-updates/is-malnutrition-in-india-a-myth-pramit-bhattacharya-21166.html
Arvind Panagariya, a professor of Indian economics at Columbia University interviewed by Ullekh NP, The Economic Times, 17 May, 2013, http://www.im4change.org/interviews/arvind-panagariya-a-professor-of-indian-economics-at-columbia-university-interviewed-by-ullekh-np-21165.html
Stuck record: Why Amartya Sen is wrong on food security again -R Jagannathan, Firstpost.com, 7 May, 2013, http://www.im4change.org/latest-news-updates/stuck-record-why-amartya-sen-is-wrong-on-food-security-again-r-jagannathan-21031.html
Food Security Bill: Freedom from hunger?, NDTV, 19 May, 2013 http://www.ndtv.com/video/player/we-the-people/food-security-bill-freedom-from-hunger/275900?hp
Growth vs Development: Nobel winner Amartya Sen discusses way ahead for India with NDTV, NDTV, 4 May, 2013 http://www.ndtv.com/video/player/ndtv-special-ndtv-24x7/growth-vs-development-nobel-winner-amartya-sen-discusses-way-ahead-for-india-with-ndtv/273449
Politics stalling Food Security Bill: Amartya Sen to NDTV, NDTV, 7 May, 2013
After doing a literature survey, The State of Food and Agriculture 2013-Food Systems for Better Nutrition observed:
• Household surveys from Bangladesh, Egypt, Ghana, India, Kenya, Malawi, Mexico, Mozambique and the Philippines find that dietary diversity is strongly associated with household consumption expenditure (Hoddinott and Yohannes, 2002).
• Fortifying rice served in school lunches in India led to statistically significant declines in iron-deficiency anaemia, from 30 percent to 15 percent for the treatment group, while anaemia remained essentially unchanged for the control group (Moretti et al., 2006).
• Agricultural productivity growth was associated with reductions in the prevalence of child malnutrition in most countries, including India, during the period of rapid adoption of Green Revolution technologies and up until the early 1990s. Since 1992, however, agricultural growth has not been associated with improved nutrition among children in many Indian states (Headey, 2011).
• Various explanations have been offered for the persistence of high levels of undernutrition in India. These include economic inequality, gender inequality, poor hygiene, lack of access to clean water and other factors beyond the performance of the agriculture sector. However, the phenomenon remains largely unexplained and additional research is needed (Deaton and Drèze, 2009; Headey, 2011).
• Evidence from farm input subsidy programmes in India and Malawi indicates that they can significantly boost agricultural production and farmers’ incomes, albeit at a high budgetary cost (HLPE, 2012), but the impact of such policies on nutrition has not been well studied.
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Centre for the Study of Developing Societies
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Links and resources:
Concept note on social protection and nutrition
Social Protection for Food Security HLPE Report
Improving Nutrition through multisectoral Approaches – Social Protection
Talking points on social protection and nutrition, Centre for Social Protection
Post-2015 Development Agenda - Joint Chairs and co-Leads Synthesis Report
TST Issues Brief: Food Security and Nutrition
Lancet article on maternal and child nutrition