CONTEXT AND OBJECTIVES The Integrated Child Development Services (ICDS) Programme is India’s flagship programme for the integrated development of children from prenatal to six years of age, pregnant women and nursing mothers. It represents one of the world’s largest and most unique programmes for early childhood development, adopting a multi-sectoral approach to child development, incorporating health, early education and nutrition interventions. It is implemented through a network of over one million village-level Anganwadi Centres (AWCs), staffed by Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHs). It currently reaches to around 7.28 crore children (beneficiaries of supplementary nutrition, 6 months to 6 years of age) and about 1.6 crore pregnant women and nursing mothers (March 2010).
One of the major objectives of the scheme is to improve the nutritional and health status of children in the age group of 0-6 years. This objective is sought to be achieved by providing a package of six services comprising of supplementary nutrition, early childhood education (pre-school education), nutrition and health education, immunization, health check-up and referral services to the children below six years and pregnant women and nursing mothers.
1.2 The ICDS Programme has remained in the forefront of the efforts of the Government of India (GoI) and the State Government to achieve the child nutrition related Millennium Development Goal (MDGI)1. The Government of India has committed to achieve the nutrition MDG of halving underweight rates from 54% to 27% between 1990 and 2015, and to achieving the education MDG of universal primary education (MDG2) and the Education For All goal of expanding and improving comprehensive early childhood care and education, especially for the most vulnerable and disadvantaged children. GoI is also committed to reducing infant and child mortality and improving maternal health outcomes (MDGs 4 and 5). Since malnutrition is closely linked to all of these MDGs, the interventions under the ICDS programme are expected to contribute towards achievement of each of these longer-term goals.
1.3 Despite several achievements that the ICDS scheme has witnessed during its three decades of implementation, there remain some major challenges with regard to high burden of child malnutrition in the State. The NFHS -3 (2005-06) reveals that about 44.6 percent children below five years in the State are still underweight against the national average of 43 percent (as per the WHO New Growth Standards; <-2SD). Of these, about 18.7 percent are severely malnourished (<-3SD) against the national average of 16 percent.
1.4 During the 11th Five Year Plan, the GoI has taken several measures to strengthen the implementation of ICDS Programme. The framework is restructured in such a way so as to suit the current needs which would not only hasten the Universalization of the ICDS programme with quality to reach out to all under six children in the State/Country, but also intensify decrease in child malnutrition, IMR and early child development. In order to increase the accessibility of the ICDS services to all households in the country, especially those belonging to disadvantaged and weaker sections in the community, the GoI has embarked upon massive expansion of the programme since 2006-07. In the year 2010-11, the GoG has sanctioned 1150 AWCs and 459 mini AWCs. The programme has been nearly universalized across the villages and habitations in the State. Provision was also made for sanction of AWCs on demand basis by the State. The population norms for opening up of the AWCs in rural, urban and tribal areas, as well as, the financial norms for various interventions under the scheme including that for training and capacity building of the ICDS functionaries, have been revised with effect from April 1, 2009.Honorariums of AWWs and AWHs have been revised since April 2008. In the year 2010, on the occasion of ‘Swarnim Gujarat- Celebrating 50 years of Gujarat State’, there was an additional increment in the honorarium of AWWs and AWHs since May 2010, from the State budget. Even the nutritional (calorific) norms for the supplementary food to the children below six years and pregnant women and nursing mothers have been revised. The challenge now is to harmonize the geographical expansion along with an improved implementation strategy in order to accelerate better and visible programme outcomes.
1.5 The 11th Five Year Plan has envisaged increased coverage in ICDS to ensure rapid universalization; changing the design; and planning the implementation in sufficient details that the programme objectives are not deviated by the design of implementation. Besides, all its original six services have to be delivered fully for the programme to be effective: (i) supplementary nutrition, (ii) immunization, (iii) health check-ups,
(iv) health and nutrition education, (v) referral services, and (vi) non-formal pre-school education (Planning Commission, 2008).
1.6 Despite several efforts, the level of child malnutrition remains acute in Gujarat. Every second child under five years of age is underweight in Gujarat. It is well known that malnutrition is a multi-dimensional problem and various determinants affect the nutritional status of children including food security, educational level of parents, water and sanitation, diseases, and many other socio and demographic factors. The ICDS programme follows an integrated approach for the holistic development of children below six years as well as health and nutritional needs of the pregnant women and nursing mothers. It is imperative to know how effective is the existing implementation strategy in addressing the varying needs of children and women. Hence, a detailed implementation plan at the State level would be useful to capture the programme effectiveness against the set targets or track expenditures against the physical achievements. Though ICDS is a ‘centrally sponsored scheme’ wherein the GoI provides 90 percent of the total programme cost to the States/UTs with effect from April 2009 (except the cost for supplementary nutrition, which is 50;50 between the GoI and States, and 90:10 in NE States), the basic responsibility for implementing the programme rests with the State Government. The role of State Government in monitoring the programme implementation is, therefore, very crucial. Till now, the practice followed by the GoI for releasing funds to the States/UTs under ICDS was based on the utilization certificates and monthly/quarterly progress reports.
Fig 1: CONCEPTUAL FRAMEWORK OF NUTRITION
1.7 In view of the growing concern over the programme not being able to achieve its core objectives, it has been felt that there needs to be a paradigm shift in the ICDS programme’s implementation framework / planning in order to improve and strengthen the existing implementation mechanisms. Hence, the existing annual planning process in ICDS being currently followed by the States needs re-structuring and standardization, to bring in clear focus on the programme ‘outcomes’ rather than on ‘outlays’, as was envisioned by the then Finance Minister of India during his annual budget speech on 28 February 2005.2
1.8 The Ministry of Women & Child Development has now introduced a comprehensive annual planning process through the development of an Annual Programme Implementation Plan (APIP) by each State/UT every year. The APIP will have all the details of activities with their physical and financial targets planned by the State. It is envisaged that the APIPs will help both MWCD and the State Governments to monitor the programme performance more effectively and to take mid-course corrections, if any.
1.9 The planning process is very critical to translating the vision of the Prime Minister of India, articulated in his letter to the State Chief Ministers, dated 9 January 2007. Urging that the ICDS programme be closely monitored, he stated that “proper implementation of the programme critically depends on political will, decentralized monitoring and meticulous attention to day-to-day operational issues. Otherwise, problems like irregular functioning of Anganwadi centres (AWCs), inability to provide hot, cooked food and leakage of food material meant for infants, will persist……. We are in the process of universalizing ICDS. But I am afraid, unless we take stock of the present position and remove the lacunae; universalization will mostly remain on paper and will not help our children secure a brighter future. The core objective of the ICDS Scheme in the 11th Plan should be universalization with quality.”
1.10 This document is based on the broad structure of the annual programme implementation plan provided by the GoI, and provides requisite information under various components of the programme.
The Annual Programme Implementation Plan has been prepared keeping in mind the specific objectives of the proposed annual programme implementation plan in ICDS as below:
a) to strengthen the existing programme management, planning and implementation to help accelerate programme outcomes as envisaged in the ICDS objectives;
b) to strengthen the existing monitoring of the programme implementation through tracking of expenditures against physical targets;
c) to acknowledge and capture the diversity across the State with respect to health, nutritional needs of women and children and pre-school needs of 3-6 year olds and their feasible responses;
d) to develop State specific strategies/interventions in respect of various programme components of ICDS in general and to achieve the health, nutritional and early learning outcomes through monitorable indicators; and
e) to enhance the quality of programme implementation in order to achieve ICDS universalization with quality.
PROCESSES AND TIMELINES Participatory and Micro Planning process has been adopted as the methodology for development of Annual Programme Implementation Plan in Gujarat. Participatory nature of planning process helps in assessment of actual grass root level gaps and needs as well as development of area specific strategies. This also creates a sense of ownership among the stakeholders, generates awareness and helps in the capacity building of personnel at various levels. Another important feature of planning is the use of ‘bottom-up' approach for planning. Planning is done at three levels namely Block, District and State. The entire process is continuously monitored at various levels.
The first step was to form a State level Committee, chaired by the Secretary WCD. The committee comprised of other State level officials like the Director ICDS, State Nutrition Programme Officer, State Accounts Officer and a representative from UNICEF. All the team members were actively involved in the planning process for the preparation of the PIP.
The second step was to hire an external consultant to prepare the draft of the PIP with inputs from all the key programme officials. This consultant was hired with support from UNICEF.
A State level consultation was organized, wherein the State Officials and the District Programme Officers were oriented on the process of preparation of the PIP. A copy of the Framework provided by the Government of India was also shared with them. Following this, all the necessary information of ICDS, based on the framework provided, was collected.
The first draft of the document was prepared and shared with the State level Committee on 15th March 2011. The data and other relevant information were verified by the concerned officials of ICDS.
Based on the inputs and suggestions from the key programme officials and UNICEF, and approval from the Secretary WCD, the Annual Programme Implementation Plan of ICDS for the year 2011-12 has been developed.
Planning focus for 2011-12 As per the guidelines from the Government of India, special focus has been laid on efforts to address the problem of child undernutrition and early childhood education outcomes. Emphasis has also been laid on the need for training and capacity development of staff at all levels to enhance their skills and knowledge in tackling several issues related to child undernutrition, antenatal care, referral etc.
ANNUAL PROGRAMME IMPLEMENTATION PLAN (APIP)
Gujarat is situated in the western part of the Indian sub-continent, bounded by the Arabian Sea to the west and south west and Pakistan in the North. It derives its name from the “Gurjas” who passed through Punjab and settled in some parts of western India. It has the States of Rajasthan and Madhya Pradesh towards the north east and east, Maharashtra and the Union Territories of Daman, Diu and Nagar Haveli, towards the south.
Gujarat is a progressive State and is known for its innovations and unique initiatives in governance and socio-economic development.
The state of Gujarat is characterized by sea-coastal, tribal, desert and geographically hostile terrain having sparse and scattered population at the periphery. Communities living in the remote and disadvantaged areas especially BPL population and women, are generally unable to access reliable and cost effective nutrition services. Administratively the State has been divided into 26 districts, sub-divided into 336 Blocks, having 18500 villages and 242 Towns. District Tapi has been recently created. The State has 12 Tribal districts having population of 89,96,744 accommodating 70 percent of the Tribal population (Census 2001). Approximately 18% (89,96,744) of the total population of the State is living in these Tribal districts.
Fig. 2: Map of Gujarat
SECTION 1: SITUATION AND GAP ANALYSIS
Gujarat often called as ‘The Growth Engine of India’, being one of the most industrialized States in India, has always been at the forefront of all economic activities and continues to spearhead India’s march towards the global economic superpower status. However, there is a developmental paradox in Gujarat, as social indicators including neonatal and infant mortality rates have not reduced concomitantly in the State in comparison to its economic and development growth and undernutrition in children continues to be high. Undernutrition contributes to more than one third of all deaths in children under the age of five.
a) Socio-economic and Demographic Profile (as per census 2001)
Table 1: Socio-economic and Demographic Profile of Gujarat
All weather road
All weather roads
Percent distribution of households living in pucca, semi pucca and kachcha houses
Percent distribution of households having electricity
Percent households having safe drinking water facilities
Percent households having toilet facilities
Source: Statistical Year Book – 2011 by MoSPI, GoI b) State Nutrition Policy
National Nutrition Policy (Background)
The United Nations World Summit on Children in 1990 laid down the goal of “Adequate Nutrition for all” to be achieved to improve the quality of life of all nations. Consequently, the Global Plan of Action for Nutrition was adopted in 1992.
The GoI adopted the National Nutrition Policy in 1993. The policy aims to identify the causes of malnutrition and formulate and launch effective sustainable inter-sectoral strategies to achieve the nutritional goals and endures nutritional security in the country. This was followed by preparation of the National Plan of Action on Nutrition, which translates the Policy statements into specific action programmes. Based on this, Nutrition Policies have been launched by different States.
Gujarat State Nutrition Policy
The Government of Gujarat is one of the few initial States in the country to develop a State Nutrition Policy. This policy formulation has been preceded by many planning exercises viz. the State Plan of Action for the Child which also incorporated a plan of action to reduce malnutrition; Inter-sectoral Plan of Action for Health and Nutrition. Simultaneously, another planning exercise was held for the preparation of the Project Proposal for external funding as well as social assessment. These planning exercises aimed to improve the ICDS services, particularly, to reduce malnutrition in women and children under two years.
Goals of Gujarat State Nutrition Policy
Reduction of malnutrition of all types including underweight and micronutrient deficiencies amongst children, adolescent girls and women in child bearing age.
To provide the conceptual framework and broad guidelines for the population with particular emphasis on pregnant and nursing women, children and adolescents (girls) through appropriate programmatic changes in existing Programmes as well as new initiatives
To improve the capacity of the communities, families and individuals to understand their own nutrition problems in terms of practical actions and address them at their own level through appropriate behaviour and action. Thus communities would be encouraged and assisted in assessing and analyzing their own nutritional problems and facilitated to take action on their own behalf.
To sensitize and involve government Departments, NGOs and academic institutions in operational issues related to malnutrition, gender dimension of malnutrition, and define their specific roles.
c) Existing mechanism for inter-sectoral convergence
The Department of Women & Child Development is collaborating with various line Departments to provide effective services to the community. The details of the inter-sectoral convergence are as below:
Department of Health
Mamta Abhiyan – It is a comprehensive package of preventive, promotive, curative and referral services under the Reproductive and Child Health Programme (RCH II) initiated in 2006. It caters through Mamta Diwas (Village Health & Nutrition Day), Mamta Mulakat (Post Natal care visit), Mamta Sandarbh (Referral Services) and Mamta Nondh (Records and Reports).
Mamta Abhiyan is a shining example of integrating the services of the Health and the Women & Child Development Departments where the grassroots level functionaries work together in harmony and provide quality services through community support.
2. Child Development Nutrition Centres
Child Development & Nutrition Centres (CDNCs) (52) have been established at the district hospitals by the Department of Health. ‘Balbhog’ is provided to the severely underweight children at the CDNCs by the ICDS. The AWWs are also involved in bringing the children to the CDNCs.
3. Integrated Management of Neonatal & Childhood Illnesses (IMNCI)
Alongwith the health functionaries, AWWs have also been trained on IMNCI for home based care of the sick children.
4. Anemia Control Program:
Government of Gujarat has adopted a multi-pronged approach to prevent and control anemia among pregnant and lactating mothers, adolescent girls and children 6-59 months. Iron Folic Acid (IFA) supplements are being provided to pregnant and lactating mothers as per the standard protocol.
From June 2009 onwards, under the RCH program, the State has introduced iron syrup for children (6-60 months) in daily regime for 100 days each year. The syrup is dispensed in 100 ml bottles (with a dropper) so designed that only 1 ml can be dispensed each time. Each ml of syrup contains 20 mg elemental iron and 100 mcg folic acid. Mamta Taruni has been launched for out of school adolescent girls.
The ICDS collaborates with Departments of Health and Food & Civil Supplies for the provision of iodized salt at the AWCs on Mamta Diwas, free of cost, to pregnant and lactating mothers. The indent of requirement is prepared by the ICDS and handed over to the Department of Food & Civil Supplies. The financial support for this is provided by the Department of Health.
6. State Nutrition Cell
The Liaison Officer (ICDS-Health) of the State Nutrition Cell, established under NRHM, participates in monthly meetings of ICDS. This provides a platform to discuss field level problems and also facilitates on-the-spot problem-solving.
7. Synchronization between Health and ICDS programs
Unique to Gujarat is the geographical and functional synchronization between Health and ICDS Departments at the level of supervisors in the field. Initially it was implemented as a pilot exercise in Valsad district in 2007 with UNICEF support. Currently, synchronization has been scaled across the State.
All Health and ICDS supervisory sectors have now been synchronized for effective joint service delivery, training, planning and review. Detailed report is given in Annexure 1.
The ICDS is carrying out the ‘Doodh Sanjeevani Yojana’ in collaboration with the Tribal department in 10 selected Blocks of 6 Tribal districts in the State. The Districts and the selected Blocks are-
Banaskantha – Danta, Amirgarh
Tapi – Nizar
Narmada – Dediapada 1 and 2
Vadodara – Kwant
Dahod – Jhalod 1, Jhalod 2
Panchmahal – Santrampur 1 and 2
Under this scheme, double fortified milk (100 ml) is provided to each child twice a week. The budget allowance is Rs. 2.45 per beneficiary for 1 time supply of 100 ml milk. This scheme is implemented with the help of local dairies.
Total Sanitation Campaign (TSC) and Water Supply Department
TSC: The Total Sanitation Campaign (TSC) programme of GoI concentrates on providing toilets to all Households, Schools and Anganwadi Centres. Under this programme, District Rural Development Agency at the District level receives a proposal from ICDS regarding the village wise requirement of toilets. The requirement is then included in the annual implementation plan of the district.
Based on the requirement District funds allocated under TSC for AWCs are transferred to ICDS for implementation/construction of the toilets.
WASMO: Water and Sanitation Management Organization (WASMO) is a registered autonomous body under Bombay Charitable Trust Act by Government of Gujarat.
This organization primarily facilitates provision of drinking water facility in villages through “Paani Samiti” constituted under Gram Panchayat.
In this process, WASMO ensures that all public amenities and households are provided with tap connections. Anganwadi centres are also covered under this programme for making the toilets functional.
Food & Civil Supplies Department
The Department provides fortified wheat flour (130 gm per child) and fortified oil at the AWCs. The fortified wheat flour comprises of wheat, chana, defated soyabean, oil and sugar. The 130 g fortified flour provides 500 Kcal, 12-15 gm protein and 6 mg iron, besides other nutrients.
The Department also provides iodized salt at subsidized rate (Rs. 1.00 per kg) through Public Distribution System (PDS) to BPL families and those living in tribal areas.
Nutri-candy, manufactured by SWAN Pvt. Ltd., is supplied by the Food & Civil Supplies Department. The grant for this is provided by ICDS. Cottonseed Oil is supplied by the Department at Taluka level. From there, the CDPOs take charge and distribute it at the AWC level.
Gram Panchayat and Cooperatives
Kitchen Gardens have been developed in the campus of AWCs in many Districts with support from the Gram Panchayats and village level Cooperatives. A Village Health & Sanitation Committee (VHSC) has been formed at village level, wherein Anganwadi Workers (AWWs) of the ICDS department are also active members of this committee.
Rural Development Department
Sakhi Mandal: Economically weak women of our community have come together to work towards their self empowerment. For the empowerment and improvement of their economic and social status, creation of Sakhi Mandals has been undertaken since 2nd February 2007. Under this initiative, in order to promote economic self dependence and habit of saving some money for future, women members of Self Help Groups are motivated and engaged in income generation activities. The scheme is effectively implemented by the Department of Women and Child Development in convergence with the Department of Rural Development. With an aim of providing Revolving Fund grants along with loans, Government of Gujarat provides Rs. 1500 per Sakhi Mandal group as a motivation.
In the Swarnim Gujarat year, with an objective of women empowerment and improving the Human Development Index especially among the poor through self economic generation activities; formation of Mission Mangalam has been undertaken. In the fifth submit of Vibrant Gujarat 2011 ‘Gujarat Livelihood Promotion Company’ has signed a 57 Memorandum of Understanding with 32 corporate companies. On execution of these MOUs, within 3 – 5 years more than 15 lakhs women will receive employment. Statistically more than 2 lakh Sakhi Mandals are functional wherein 25 lakhs women have a saving of total Rs. 161.54 crore in banks proving success of the collective and teamwork efforts.
d) Nutrition and Health status of Women and Children in Gujarat
Gujarat is home to 51 million people3 and often called India’s growth engine. Undoubtedly, it is better positioned compared to many other States in terms of economy, infrastructure, industrialization and governance. However, the status of undernutrition remains high and staggering in the State. Government of Gujarat (GoG) has accorded highest priority to address this formidable challenge and has been undertaking notable initiatives in this regard in the recent past.
Fig 3: Nutrition Situation in Gujarat
DLHS 2, 2002-04
ccording to DLHS -2 data, 16 out of 26 districts have 45-64% children underweight and 9 of the 12 Tribal districts have 45% or more underweight children. While, the NFHS 3 data shows that 45% children under 5 years are underweight. According to the CES 2009, only half of the children are breastfed within 1 hour of birth while less than half (45%) are exclusively breastfed. A little more than half of the children (56%) 6-9 months initiate timely complementary foods. According to the NFHS 3, 80% of the children 6-35 months are anaemic while only 56% households consume iodized salt. The DLHS 3, 2008, shows that 56% of children received vitamin A supplements.
Fig 4: Reasons for Undernutrition in Gujarat
In Gujarat, the coverage for the 8 of the 10 proven interventions which can reduce undernutrition is less than 50%.
Fig 5: Status of adoption of IYCF interventions in Gujarat
The figure above shows that the adoption of the 3 most critical IYCF interventions (Breastfeeding within 1 hour or birth, Exclusive Breastfeeding for 6 months and Timely initiation of Complementary Feeding) is very poor. The State average is only 19.5%.
Fig 6: Infant Mortality in Gujarat - High & Static
> 13 lakh births annually
> 65,000 deaths among under-ones annually
> 71% infant deaths during neonatal period
Infant Mortality Rate is very high and stagnated in the recent past in Gujarat, in spite of very good economic and infrastructure growth in the State. There is a wide Rural Urban disparity. Most Infants (i.e. 71 %) die in Gujarat during neonatal period and Gujarat contributes to 5 % of neonatal deaths in India. Factors associated with neonatal deaths are (1) Mothers age-Lower the age, higher is the risk eg < 20yrs 54.2/1000 live births Vs 20-29 yrs 34.2/1000 live births (2.) Neonatal deaths directly related to birth interval (< 2 yrs birth interval NMR 57.9 /1000 live births Vs >3 yrs of birth interval it is 19.2/1000 live births (3) Poor & (4) rural population have higher neonatal deaths
Fig 7: Infant Mortality Rat Fig 8: IMR and U5MR -Disparity
Ref: SRS 2009
Infant Mortality Rate is much lower in other developed states. Infant Mortality Rate in Gujarat is higher than other developed states.
Fig 8: IMR and U5MR -Disparity
SC, ST & Others: Gujarat and India: 2005-2006
Scheduled Tribes in Gujarat have higher mortality compared to national level IMR and U5MR.
Fig 9: Coverage along the continuum of care: Scheduled Tribes Vs Others: Gujarat 2005-2006
Scheduled Tribes have poor coverage compared to others except for initiation of breast feeding.
Fig 10: Nutritional status of children below 3 years in Gujarat NFHS-3 (2005-06)