Integrated Child Development Services scheme is the symbol of Government of India’s commitment to the holistic develop-ment of children. Specific areas of strengths and weaknesses have been identified which require to be addressed (Table I).

(i) ICDS is a long-term development program and is not an emergency relief operation. It should be implemented as a development program for the community. This focus should not be diluted.

(ii) All efforts should be continued to strengthen the ICDS scheme to make it more successful.

Growth monitoring is a good theoretical concept. It has been tried in several projects with limited success. It is an operational strategy for the promotion of child health, which enables mothers to "visualize" growth or the lack of it in their children and to obtain specific practical and relevant guidance to ensure regular growth and health of their off-spring. This activity provides an opportunity to improve the interaction between mothers/care givers and health workers. The ultimate objective of growth monitoring is to ensure that the mothers/care givers behavior pro-motes normal growth and development of her child.

The manner in which growth monitoring is being implemented in ICDS is serving no useful purpose. Strong linkages need to be developed in growth monitoring activities for Nutrition and Health Education for behavior change.

TABLE I – Specific Areas of Strengths and Weaknesses of ICDS Scheme.

(i) ICDS program serves as an excellent platform for several development initiatives in India.

(ii) It is a holistic approach to child development involving the active participation of the family, particularly mothers.

(iii) It serves the extreme underprivileged communities of the backward and remote areas of the country.

(iv) It delivers services right at the doorsteps of the beneficiaries to ensure their maximum participation.

(v) ICDS has largest number of front line functionaries amongst all the development programs. It utilizes local women as honorary village level workers for the delivery of the package of services.

(vi) The implementation of ICDS program has made it possible for the health services to reach the most remote and difficult areas of the country.

Weaknesses

(i) Inadequate emphasis on Nutrition and Health Education (NHE) activities for behavior change

(ii) The focus and coverage of children in 0-3 years of age is inadequate.

(iii) Lack of effective co-ordination between Health and ICDS functionaries.

(iv) Irregular supply of Supplementary Food due to administrative reasons.

(v) Programmatic emphasis on Community participation is poor.

(vi) The quality of training of Anganwadi workers needs improvement.

(vii) The referral system is weak.

(viii) Home visits by AWWs are infrequent. Malnourished children who cannot come to Anganwadis due to different reasons remain largely uncovered.

(ix) There is inadequate decentralization; the same guidelines of Government of India are followed all over the country. (Representative of the Department of Women and Child Development, GOI stated that some of the recent guidelines issued are extremely flexible and State friendly).

(x) AWW has not been accorded the dignity and prestige as a voluntary worker. She is not being treated as an honorary worker.

(xi) Failure to promote effective community leadership and participation.

(xii) The role of supervisor is marginal and the CDPO s skills require improvement.

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2.2 Recommendations

(i) The frequency of weighing for each child should be reduced to every three months. The growth monitoring activity may be replaced by "Nutritional Assessment and Nutritional Counseling" (NANC) sessions. These sessions should be organized in such a manner that each child is covered every three months. The emphasis in NANC sessions should be on Nutritional and Health Counseling of mothers with objective of changing their behavior for adopting good practices in the field of nutrition and health. NANC sessions will also provide data on nutritional grades of children for their selection for the supplementary feeding program.

(ii) The existing growth chart should be simplified to a simple family held Child Card, which should include parameters on the child (including developmental milestones) and key messages related to child caring and feeding. The Departments of Family Welfare and Women and Child Development with the help of eminent scientists in the country should jointly develop and review the new card. It should be made of durable material and should be kept with the mother. Cognizance should also be given to state variations. This card should replace all the cards that currently exist, including immunization card and center based growth charts.

(iv) Growth monitoring data should not be viewed as a replacement for national nutritional surveys and surveillance, which are being conducted in a specialized manner by other institutions/agencies.

Supplementary food alone cannot elimi-nate Under nutrition in the community. Hence, supplementary food provided under ICDS program should not be viewed as an inter-vention to improve nutritional status of the children. For a meaningful impact, supple-mentary food administration should be supported with a strong component of Nutrition and Health Education (NHE) activities to change behavior of community in general and specifically of the mothers. These two activities should be further supported by strengthening of all other services in the ICDS package.

(i) Supplementary food should be viewed and used only as a magnet/ vehicle for provid-ing other services under the ICDS scheme.

(ii) Supplementary food should be essentially cereal based, palatable and of good quality. It should be suitable for use in child-ren below 1 year of age (for complementary feeding).

(iii) A randomized controlled trial should be conducted to assess whether and how the supplementary food component supports the other services provided under ICDS.

Theoretical considerations suggest that there are four problem micronutrients whose intake is likely to be low in traditional vege-tarian diets during complementary feeding in infancy. These are Iron, Zinc, Vitamin A and Iodine. Based on performance of relevant national programs and available scientific evidence in young children, particularly in relation to the magnitude of the problem, functional benefit from efficacy trials and safety issue, there may be a case for consider-ing fortification of ICDS supplementary food with Iron only.

(i) Fortification of ICDS supplementary food may be considered with iron only. The level of fortification should be decided on scientific evidence.

(ii) Policy guidelines of Ministry of Health for management of micronutrient deficiency disorders like Iron deficiency anemia, Iodine deficiency disorders, Vitamin A deficiency, etc. should also be followed in ICDS program. This would ensure that ICDS and health peripheral functionaries at the district, block and village level advocate and implement same/similar messages/ strategies for preven-tion of micronutrient malnutrition.

(i) The guidelines for import and use of GM foods as approved by Nodal Ministry of GOI should also be followed for ICDS supplementary food.

Nutritional counseling of mothers of children 0-2 years is effective in positive behavioral modification. This is irrespective of the nutritional supplementation provided. Nutritional counseling improves the know-ledge of the mothers about child feeding practices and counseling skills of providers. Home visits by AWWs are feasible. Partici-pation of NGO’s is helpful in facilitating community participation and effective ICDS implementation. Active participation of district health authorities can improve the ICDS program performance.

(i) Nutritional counseling of mothers of children 0-2 years is effective in positive behavioral modification and should be actively incorporated and emphasized in the ICDS program implementation.

Nearly half of under three children in India are moderately or severely malnourished. In the present form, supplementary feeding of severely malnourished children in the absence of complementary health services has marginal effect on the nutrition status. An integrated nutrition-health care approach with continuous monitoring of severely mal-nourished children is more beneficial for immediate management and their subsequent rehabilitation.

(i) For community-based rehabilitation of severely malnourished children, participation of health workers for management of infec-tions with other supportive interventions is critical.

There is a need to bring about change in the child caring practices in communities. The children need to be fed more. This can be achieved by counseling of mothers by AWW and ANM. The nutritional impact is age related; maximum impact is seen in 6-12 months age group. Nutritional impact can be evaluated in 5 yearly cycles. There is a need for identification and close monitoring of process indicators for evaluation of ICDS program in this context.

(i) Nutritional counseling is effective in behavioral modification and hence it should be made a key component of the nutritional services rendered by ICDS program.

(ii) Proactive efforts to encourage parti-cipation of community, community leaders, NGOs and Community Based Organizations (CBOs) will facilitate and hasten the behavioral change.

(iii) While judging the ICDS program performance, the focus should be on the process indicators rather than on the final impact (i.e., anthropometry). The decline in the prevalence of malnutrition in the community is a slow process and the reduction following nutritional interventions are in the range of 1-6% only.

The objectives of ICDS and health sector are overlapping to a great extent except for the components of supplementary feeding pro-gram and non-formal pre-school education, which are unique to ICDS. Most of the components related to health care are common to both Reproductive and Child Health program and ICDS. At present there are gaps and overlaps in the coverage of beneficiaries, i.e., children below 6 years and pregnant and lactating mothers.

For effective convergence, it is essential to outline the activities and specific areas for convergence between ICDS and health func-tionaries, which can yield maximum benefit for mother and child dyad. There is also a need to identify the key elements in this process.

Nutrition and related activities can be the primary responsibility of the ICDS function-aries. In areas that require health input such as care of pregnant and lactating women, immu-nization, management of minor ailments, management of severely malnourished children and Reproductive Tract Infections/Sexually Transmitted Diseases services, speci-fic responsibilities of the partners namely AWW and ANM need to be made clear.

Social mobilization and community participation are critical for the success of any public health program. In this pursuit, AWW can play an active role with the cooperation of ANM. The minimum essential home based records of AWW and ANM may be common.

There is a need of developing an implementation framework for convergence of activities of ICDS and health departments. This would involve revisiting the roles and responsibilities of AWW and ANM with suitable modification of their training/reorien-tation programs. The process of convergence will involve political and administrative will at the highest level. Development of coordina-tion mechanism at various administrative levels i.e., State, District, Block and Village and evolving a joint mechanism for monitoring and supervision of the program with an inbuilt provision for accountability is important.

(i) There should be harmony in the skills and knowledge of functionaries from both the Health and ICDS departments in the areas that require convergence.

(ii) Roles and responsibilities of the health and ICDS functionaries should be specified for better accountability.

(iii) Implementation framework for convergence at all levels i.e., State, District, Block and Village, should be clearly stated.

(iv) Success of convergence will require active community participation, and involve-ment of panchayats, NGOs/ Community Based Organisations (CBOs) and hence there is need for institutional mechanisms for their involvement.

(v) Political and administrative will is critical for working together of Health and ICDS functionaries. It will also involve developing coordination mechanisms at various levels and streamlining logistics and supplies in ICDS and health sector.

(vi) Academic institutions like Medical and Home Science Colleges should be assigned important functions in improving the program quality and performance.

(vii) Convergence between health and ICDS sector will be possible only if the functionaries from these two departments are given respect and recognition for their contributions and considered equal partners.

(viii) Policy guidelines of Ministry of Health for prevention and management of common childhood ailments, breastfeeding, complementary feeding, etc. should also be followed in ICDS program. This would ensure consistency in the implementation of various activities/similar messages/strategies by ICDS and health peripheral functionaries at the district, block and village level. It would avoid delivery of different messages by the peripheral functionaries.

About 67% of the infants deaths occur in the neonatal period. To bring reduction in the IMR there is need to provide care to the newborn. AWW can take care of normal neonates. Possibly she can also provide care to LBW neonates. AWW would require suppor-tive supervision and training for providing newborn care.

(i) Operational research is required in selected regions of the country before AWW can be given the responsibility of care of normal neonates and LBW newborns in the ICDS program in the country.

The workload of AWW requires to be reassessed. All types of tasks are given to AWWs, which makes it difficult for her to do the ICDS work. She is already burdened with current responsibilities.

(i) There is a need of prioritizing the work responsibilities of AWW’s keeping in view the educational status, time available, hono-rarium paid and records to be maintained.

Optimal care practices result in overall development of the child including improved nutrient intake and growth. There is need to define key care messages that should be used to improve children’s survival, growth and development in ICDS programs as part of the NHE component.