Expert’s views on ‘Malnutrition’

Dr Shiela C Vir, an expert in the field of nutrition and public health nutrition has over 30 years of experience with UNICEF, the government of India and various national and international agencies on nutrition and health programmes. She has received several prestigious awards from Indian and international organisations in recognition of her contribution to this field and has authored over 75 publications in national and international journals.

The ICDS Scheme was launched in 1975 in response to the problem of child malnutrition and inadequate facilities for pre-school education. Since then, the principal beneficiaries of the ICDS scheme are children in the age group 0–6 years, pregnant and lactating women.

The main objectives of ICDS are:

  • Improve nutrition, health status of children in 0–6 years age group
  • Laying the foundation for proper psychological, physical and social development of children
  • Reduce the incidence of mortality, morbidity, malnutrition and school dropouts
  • Achieve effective co-ordination of policy and implementation to promote child development
  • Enhance the capabilities of mothers to ensure optimum growth of their children through proper nutrition and health education

This paper will address nutrition related aspects that ICDS deals with.

In the last 40 years, the MWCD expanded the number of projects from 33 and 4,891 AWCs to almost 14 lakh AWCs across the country with 7,076 ICDS projects.

Over this period, ICDS continued to focus on six core services—Health check-up, Referral services, Immunization, Supplementary nutrition, Pre-school non formal education and Nutrition and health education.

Of the six services, three of these services, namely Immunization, Health check-up and Referral services are overseen by the Ministry of Health and Family Welfare.

With reference to nutrition services, ICDS system is considered responsible for supplementary nutrition (SN) or promoting appropriate infant and child feeding practices. Since 2013, provision of SN was made a part of the National Food Security Act, 20133, but there is no evidence to date that SN has made an impact on the nutritional status.

A recent Rapid Survey of Children4, indicates eight out of 10 women in areas covered by ICDS, were aware of SN but only half the mothers availed of the SN services and only a fifth of those who availed received SN for at least 21 days in a month. Children over 3 years who attend the AWCs, compared to 7–36 months, were better impacted.

Malnutrition is persistently high in India—of children under five years, 38.4 percent are stunted, 35.7 percent underweight and 21.0 percent wasted while every second child and woman is anaemic (NFHS 4)5. Efforts to achieve the World Health Assembly (WHA) targets of nutrition by 2025 of reducing the ill-effects of undernutrition need to be intensified. In this context, it is crucial to appreciate the interrelationship between food and health care as immediate determinants of undernutrition as well as its underlying causes for rapidly improving maternal, infant, and young child nutrition (MIYCN)6. Direct nutrition actions include iron-folic acid supplements to all pregnant women, food supplements to under-nourished pregnant women, breastfeeding and complementary feeding education and vitamin A supplements in early childhood.

The poor coverage of nutrition-specific interventions, to a great extent, can be attributed to undue focus of AWCs on SN which is not evidence-based. The ICDS system is not well equipped to routinely reach pregnant women and children under three years. Universal coverage of direct nutrition actions will yield best results if the actions are focused in the first 1,000 days of life— from onset of conception up to the time a child is two years old. The “under two” period or first 1,000 days of life is considered the “window of opportunity “for preventing under-nutrition since under-nutrition rate sets in at birth and increases rapidly in the first 24 months of life7. Currently, the responsibility for these actions for under two years is under the purview of the ICDS sector while in actual practice, these actions, except the action on provision of food supplements, are a part of the health sector.

In such a situation, the rationale of continuing to make ICDS system the lead agency for reducing under-nutrition seems far from being appropriate and cost-effective.

Under the ICDS scheme, SN is expected to be universal, not selective. SN is supplied by ICDS as Take Home Ration (THR) of 500 grams or one kilogram packages of Ready to Eat (RTE) food for pregnant and lactating women and children 7–36 months. The scope of reorganising the provision of THR through the public distribution system (PDS) or cash transfer initiative using Aadhaar cards, need to be explored. ICDS offers the opportunity for accelerating coverage of nutrition- sensitive interventions as “ICDS provides the convergent interface/ platform between communities and other systems such as primary health care, education, water and sanitation among others.” (MWCD, 2012)

It is, therefore, time to consider a new ICDS programme design. Relieving ICDS from the burden of nutrition care of under two-year-olds and shifting the responsibility to health sector, seems logical.

The role of ICDS could be broadened to supplying and promoting weekly consumption of iron-folic acid tablets, promoting water-sanitation, environmental and menstrual hygiene and empowering girls and women with information on entitlements. ICDS would then substantially contribute to achieving the WHA targets of ensuring children from deprived backgrounds are healthy.