Early Scope

India's integrated child development services scheme: challenges for scaling up

Abstract

Background

India had around 158 million children under the age of 6 and about 26 million births in 2015. In the same year, India's Integrated Child Development Services Scheme served about 82 million children under 6 years and over 19 million pregnant women and lactating mothers. These 102 million beneficiaries received services in about 1.3 million centres.

Method

This paper reviews the growth of the Scheme and considers challenges to scaling up quality with equity based on results of large-scale national or multistate studies.

Results

The Scheme is associated with decreased malnutrition and better child development. The size and diversity of the country, the policy context, funding mode and lack of community awareness and engagement have hindered scaling up access while the approach to service delivery, low institutional capacity and poor infrastructure have impeded scaling up of implementation quality.

Conclusions

This review illustrates the challenges associated with scaling-up access and implementation quality of a multicomponent, integrated early childhood programme in a large, diverse country. The future success of the Integrated Child Development Services will depend on how well it adheres to quality standards and how well it evolves to address current weaknesses.

The Integrated Child Development Services (ICDS) Scheme in India is the world's largest community-based programme to promote child health, growth and development. It has been implemented for over 40 years in a country where millions of children are at risk of failing to reach their developmental potential, and it has been credited with improving child development indicators. This paper provides an overview of the Scheme, illustrates its growth, considers challenges to scaling up implementation based on the results of large-scale evaluations and, finally, focuses on factors that have facilitated or hindered the scaling up of the Scheme.

The ICDS was started in 1975 on an experimental basis to address high infant and under-five mortality, malnutrition and poor early learning outcomes. The Scheme, which follows a life cycle approach to promote early child development, is nationwide and covers all children below 6 years but targets primarily economically disadvantaged children across the country through a process of self-selection. It offers six services related to nutrition, health, preschool and community education. Since its inception in 1975, its objectives have been to (i) improve children's nutritional and health status; (ii) ensure a sound foundation for their psychological, physical and social development; (iii) reduce incidence of mortality, morbidity, malnutrition and enhance caregivers' capabilities regarding children's health and nutritional needs; and (iv) achieve effective interdepartmental co-ordination of policy and implementation. Its services are offered through a network of Anganwadi Centres (AWCs) (the Hindi term Angan means courtyard and conveys the concept of ‘bringing services to children's doorsteps’).

The Preschool Education component of the ICDS focuses on ensuring a natural and stimulating environment for 3- to 6-year-olds, with an emphasis on promoting holistic learning and development. There is a guidebook for planning and organizing preschool education activities in AWCs, and an educational kit is provided to all centres (NIPCCD, n.d.). There are no recommendations on teacher : child ratio. The AWCs also contribute to universalization of primary education, by enhancing school readiness and freeing older children – especially girls – to attend school by offering substitute care to their younger siblings (Rao 2005; 2010).

The ICDS team comprises Anganwadi Workers (AWWs), Anganwadi Helpers, Supervisors, Child Development Project Officers and District Programme Officers. The AWW is from the local community. She is the frontline agent of social change who mobilizes community support for better care of young children, adolescent girls and women. A Medical Officer, an Auxiliary Nurse Midwife and an Accredited Social Health Activist form the Health team that works with the ICDS staff. The AWW and Helper are paid monthly honoraria that have increased over time and are often supplemented through monetary incentives by different departments of state governments in return for field-level support.

Although a federally sponsored scheme, the ICDS is organized on a project basis. This has helped decentralize the programme and reach beneficiaries directly. Centres are situated within a 30-km radius of a Project Office that oversees several sectors of the programmes. These sectors are divided into areas, each under the charge of a supervisor responsible for about 20 to 25 centres. The supervisor makes monthly supervision visits, checks the AWC functioning and records and prepares monthly reports for each centre.

Public agencies at state, district and sub-district 1 levels co-ordinate the six ICDS services. At the district level, the District Magistrate oversees the convergence of services for programmes across all sectors, such as primary healthcare, education, water and sanitation and ICDS. Nationally, the Ministry of Women and Child Development (MWCD) has responsibility for implementing ICDS. The MWCD, initially a part of the Ministry of Human Resource Development, received independent status in 2006, possibly due to concerns about high levels of malnutrition in children below 5 years, and related pressure from social activists and international agencies. The MWCD, however, often gets low priority in the political hierarchy.

Growth of the ICDS

For a more nuanced understanding of the growth of ICDS, it is necessary to understand the demographic and social context in which it has gone to scale. India has undergone a significant demographic transition, and the fertility rate has decreased in the last decade. In 2011, the population was over 1.2 billion, of which 158 million were children aged 6 years and under, as compared with 163 million in 2001 (Office of the Registrar General and Census Commissioner 2011). While there are fewer children under 6 years now, more are surviving until their fifth birthdays. India has 7935 towns, 475 urban agglomerations, 640 930 villages and 22 different officially recognized languages, illustrating its immense diversity (Office of the Registrar General and Census Commissioner 2011).

There were about 26 million births in 2015 (Office of the Registrar General 2017). As shown in Table 1, in 2015, the ICDS had over 102 million beneficiaries, including 82 million children under 6 years and over 19 million pregnant women and lactating mothers receiving services through 7072 projects in over 1.3 million centres (MWCD 2016b). In terms of reach, it was estimated that the Scheme possibly covers about 50% of children under the age of 6 (Niti Aayog, Programme Evaluation Organisation 2015). While parents from middle-income and upper-income families do not send their children to the ICDS, there are still eligible children from remote areas who do not receive the ICDS. Figure 1 shows that the number of children receiving supplementary nutrition increased by about 6.75 million from 2011 to 2014. In 2015, about 46 million children under 3 years and 36 million 3- to 6-year-olds received supplementary nutrition, as compared with 14.5 and 16.9 million children, respectively, in 2002.

Table 1. Growth of the ICDS from 2002 to 2015

When the ICDS was launched in 1975, India had an Infant Mortality Rate of 140 and a fertility rate of 4.9, which had declined to 40 and 2.3, respectively, by 2013 (Office of the Registrar General and Census Commissioner 2016). The ICDS has gone through several distinct developmental phases, and several factors have contributed to its growth and restructuring in the past 40 years.

Experimental phase (1975–1979)

The ICDS was launched in 1975 after the National Policy on Children (1974) (Department of Social Welfare, Government of India 1974) raised concerns about the survival and development of young children. Inspired by the early success of the Head Start Programme (1965) in the USA, it was designed as a centrally sponsored scheme to be implemented through the States. It was piloted in 33 village-administrative blocks to reach the most vulnerable segments of society.

Consolidation of the design and strengthening institutional capacity (1980–1989)

This next phase saw the consolidation of the ICDS service delivery model and its initial expansion to new areas noting its weaknesses including inconsistent supply of supplementary nutrition and incomplete identification of severely malnourished children. An attempt was made to integrate nutrition and preschool education services at the level of the AWC (Government of India 2000). This phase also saw the strengthening of capacities in the system to deliver particularly with regard to bolstering the health infrastructure. Clearer job responsibilities of health functionaries were specified, voluntary organizations were engaged and the ICDS was strengthened at the State and District levels.

Universalization (1992–2007)

The Government of India accorded high priority to policies and programmes for child survival and development in the 1990s as reflected in the adoption of the National Nutrition Policy (1993) and the National Plan of Action for survival and development of children. The Government committed to the universalization of ICDS during the eighth Five Year Plan (1992–1997). By 2001, the programme had expanded to 4300 blocks and, by 2007, it was almost universalized. During the Universalization phase of the ICDS emphasis, for the first time, was laid on strengthening preschool education. This expansion phase also brought in the Adolescent Girls' Scheme, in consonance with the life cycle approach. The objective of this Scheme was to enhance the nutritional and health status of girls ranging in age from 11 to 18 years of, promote awareness of hygiene practices, and equip them with homemaking and child care skills. This Scheme has also evolved through the years.

Restructuring and mission mode (2007– to date)

In 2011, the Planning Commission issued two reports that addressed design, implementation and resource gaps within the ICDS (Planning Commission 2011a, b). Taken together, these reports noted data inconsistencies, inadequate infrastructure, significant quality variations within and across states, and that the AWWs were overburdened, unskilled and underpaid. All these factors adversely affected the quality of the ICDS.

These reports may have had some bearing on the restructuring and transformation of the design of ICDS into Mission Mode and setting of specific time-bound targets. The Government of India thus approved an ambitious strengthening and restructuring of the ICDS Scheme with a budget allocation of 1.23 trillion rupees (just over USD 20 billion) during the 12th Five Year Plan (2012–2017). Some focal areas in the restructuring include giving priority to children below 3 years, strengthening Early Childhood Education, improving infrastructure and promoting flexibility and decentralization. The administration of ICDS has been strengthened at national, state and district levels. Further, planning and management have been devolved to lower levels, and monitoring processes have been enhanced. All these measures attest to the seriousness of the Government's efforts to promote early child development and make the ICDS more effective at scale.

Monitoring of the ICDS

The Central Level ICDS Monitoring Unit within the MWCD has the overall responsibility of monitoring the ICDS scheme, and reports are aggregated up from the village, to the block, and to the state levels. Reports are also received from the Ministry of Health and Family welfare on data related to ICDS such as immunization and health check-ups. The Monitoring Unit prepares quarterly reports for review, analysis and action if need be, as well as periodic progress reports. The primary emphasis of the reporting is on the input side. For example, data are collected on the number of beneficiaries of supplementary nutrition, number of beneficiaries of preschool education and number of AWCs.

Evaluation of implementation of the ICDS

Clearly, the ICDS has evolved over the past 40 years. On paper, it is an excellent and contextually relevant scheme, but implementation of the scheme had not been accorded adequate priority, perhaps due to weak institutional capacity and/or a lack of political will. Further, too much emphasis has been placed on increasing the supply of AWC and not enough on the effective utilization of services. The Government's commitment to the scheme, evidenced by an increase in budget from 81 billion rupees in 2009 to approximately 158 billion rupees (about USD 3 billion) in 2013, has again witnessed a significant decline in the current budget, further confirming low political will.

The ICDS Scheme has been evaluated in a number of large-scale and small-scale studies. Notwithstanding considerable criticism of the scheme, it has been credited with improving the health and nutritional status of children, particularly in decreasing infant and under-five mortality rates, decreasing the prevalence of malnutrition and improving children's school readiness. It should be acknowledged that factors other than the ICDS could have accounted for these improvements.

In its initial years, the ICDS had a strong research and evaluation component with the involvement of medical colleges. The number of studies evaluating the ICDS has expanded exponentially. We focus on national level studies or reports that have considered national data or data from at least three States. These include (i) the nationwide evaluation of ICDS by the National Council of Applied Economic Research (NCAER) in 1998 (NCAER 2001); (ii) the NCAER Rapid Facility Survey on ICDS Infrastructure in 2004 (NCAER 2004); (iii) the appraisal by the National Institute of Public Cooperation and Child Development (NIPCCD 2006); (iv) an Evaluation Report on ICDS by the Programme Evaluation Organisation of the Planning Commission in 2011 (Planning Commission 2011a); (v) the Rapid Survey of Children (2013–2014) (MWCD 2014); (vi) A Quick Evaluation Study of Anganwadis under ICDS (Niti Aayog, PEO 2015); and (vii) the Indian Early Childhood Education Impact Study (IECEI in press). Given the authors or sponsors of the study, we assume that the evidence presented in these reports is credible, but we note that some of them may not have been subject to rigorous peer review.

In the following section, we focus on Centres, Functioning, Training and Quality, as these factors have been considered critical to scaling up implementation of the Scheme. We also present some recent findings on the relationship between quality and school readiness.

Centres

The 1998 NCAER (2001) study found that most AWCs were located within accessible distances (100–200 m) from beneficiary households, and thus, the factor of distance was unlikely to affect attendance at the AWC during inclement weather. Most of the centres functioned from community buildings and, of those sampled, about 40% were in proper buildings. The NIPCCD (2006) study found that around 75% of the AWC had proper buildings, although the (NCAER 2004) suggested this figure was closer to 50–60%, and the recent study by the Niti Aayog, PEO (2015) of the Planning Commission found that about 59% had adequate space and accommodation.

Lack of toilet facilities is another problem that has been identified; more than 45% in the NCAER (2004) study and 59% in NIPCCD (2006) were reported to have no such facilities. NCAER (2004) reported that only 39% had hand pumps available for water, although the Niti Aayog, PEO (2015) study found that 86% had drinking water facilities. It should be noted that from 2011 schemes from the MWCD and the Department of Drinking Water Supply have converged to provide drinking water facilities to AWCs. This may be the reason that the Niti Aayog, PEO (2015) study found that 86% of the AWCs had drinking water facilities. Three National Family Health surveys have linked the presence of an ICDS centre to comparatively lower levels of malnutrition. Data from the most recent of these (NFHS-3) (2005–2006) (IIPS 2007) show that rural children receiving supplementary nutrition daily from birth to 2 years were 1 cm taller than their same gender rural peers but that supplementary nutrition did not have a significant effect on the height of 3- to 5-year-olds (Jain 2015).

Functioning

The functioning and participation rates were generally found to be reasonable. On an average, AWCs were reported in the 1998 NCAER (2001) study to be operating for 24 days/month, for an average of 4 h/day. NCAER (2004) also reported service provision in the centres as being frequent: 24 days/month for supplementary food, 28 days for preschool education and 13 days for nutrition and health education. From the NCAER (2004) study, the main activities identified were the provision of supplementary food (more than 90%), preschool education (90%), weighing children for growth monitoring (76%), nutrition and health education (75%) and the availability of medical kits (nearly 75%). However, only 65% provided health check-ups of children, 53% provided health check-ups for women and 50% reported providing referral services.

The NIPCCD (2006) study found a relatively high level of lack of resources. About 44% lacked preschool education kits and 37% reported non-availability of materials/aids for Nutrition and Health Education. There was also some evidence of disruptions to supplementary nutrition on an average of 46 days in a year, and an average of 36% of mothers did not report incidences of weighing of new-born children. The Niti Aayog, PEO (2015) study found that 22% of the AWCs did not have the required medications for children.

The 2013–2014 Rapid Survey of Children across the states (MWCD 2014) presented disaggregated data by wealth quartile and between States to indicate the extent of targeting and impact of the programme. Some very positive outcomes are that 43.7% of women surveyed from the lowest wealth quartile had received more than three antenatal care visits; on the other hand, full antenatal care had been utilized by only 9.5% of women in that quartile.

About half (50.6%) of the children between 12 and 23 months were found to be fully immunized, and 70% below 6 months had received exclusive breastfeeding. However, 50.7% of children are still stunted, and almost 35% did not attend any preschool programme. Overall, the beneficiaries' awareness of ICDS services was 86% but largely for the food component. That stated, as shown in Table 1, among 3- to 6-year-olds, if children received supplementary nutrition, they also received preschool education.

Training of Anganwadi Workers

The education levels and pre-service training of personnel were generally found to be satisfactory. The NCAER (2001) study reported that one out of two AWWs was found to be educated at least up to matriculation level across the country and 84% reported having received at least pre-service training. In-service training, however, remained largely neglected. AWW have to participate in a 5-day refresher Training (in-service) course once in every 2 years. Usually, the Anganwadi worker gets paid during the supervision meeting, so this is an incentive for them to attend monthly meetings. The evaluation by the Planning Commission (2011a) found that AWWs lacked appropriate skills, had heavy workloads and were poorly compensated.

Quality matters

A seminal, 5-year longitudinal study of the short-term and long-term impacts of participation in and the quality of early childhood education on learning levels has been recently concluded (IECEI in press; Kaul, Bhargarh et al. 2014; Kaul, Bhargarh Chaudhary, & Sharma 2014; Kaul, Bhargarh Chaudhary, Jaswal 2015). The study included 13 686 children in 362 villages in three Indian states and identified the quality of the preschool physical setting as one of the most important predictors of school achievement at the age of 7. The study highlighted the importance of school readiness below the age of 5 as a key predictor of future achievement. Children who had participated in ECE performed significantly better on overall cognitive achievement than those who had not. Notwithstanding this, preschool education has been found to be a weak component of these programmes and children graduate with low levels of school readiness (IECEI in press).

Challenges and facilitators of scaling up

A recent meta-analysis found that integrated early childhood programmes (e.g., child-focused + parent-focused + nutrition interventions) such as the ICDS have larger effects on cognitive development than programmes that deliver single interventions (Rao et al. 2014; Rao et al. 2017). The integrated model and persisting high levels of malnutrition in India continue to provide the rationale for expansion of the ICDS.

Comprehensive reviews have made recommendations for the implementation of effective ECD programmes at scale in low-income and middle-income countries (Gillespie, Menon, & Kennedy 2015; Richter et al. 2017; Vargas-Barón 2009). All three reviews concur on the importance of contextuallyrelevant policy, the need for attention to implementation, appropriate scale-up strategies and monitoring and evaluation. They also make very similar recommendations despite their varying foci. Drawing upon the recommendations of these reviews and the large-scale studies discussed in the previous section, we discuss the critical elements that have either facilitated or hindered the scale-up of the ICDS. These include factors related to access and implementation quality.

Scaling up access

Size and diversity

The greatest challenge to scaling up the ICDS in India is the large population and diversity. The scale of resources needed to provide an effective, high quality, integrated early childhood development intervention to 100 million children is massive, and so scale-up has been slow. This is because there are not enough health and educational professionals supporting the scheme.

Substantial challenges remain with regard to ensuring equitable provision of services to all children regardless of family background. Some of the key challenges are income inequity, gender inequity, and urban-rural disparities. The ICDS is important to enhance the school readiness of children from socially disadvantaged families and the retention of girls in later education. Girls who participate in early childhood education are more likely to attend and stay in primary school.

Political will and policy

The inadequate budgetary allocations to the ICDS under the country's earlier Five Year Plans reflect a lack of political will to improve early childhood development. The ICDS did receive a larger share of the budget in the current Plan period, but currently, the allocation to the social sector has been devolved partially to the states as untied funds, and the central share for ICDS has declined. On the other hand, a positive policy environment, recognition of the importance of the early years, the promotion of children's rights and the governance structure have all supported scale up.

The role of civil society should also be acknowledged in considering factors supporting scale-up. Activism has led to government policies and programmes, such as the promulgation of The National Food Security Act (Right to Food Act) (Government of India 2013). Results of National Family Health Surveys have helped maintain a sense of urgency, and the recent enhanced capacity for implementation and evaluation has also contributed positively, with the NGO sector and International Developmental Agencies playing roles.

International commitments undertaken by the central government have also served as catalysts, particularly since one-sixth of the world's children are in India. The Indian policy framework for children has been relatively comprehensive and updated, which has been an enabling factor.

Funding mode

Another challenge to scaling up access is presumed divisions of responsibility between the central and State governments. Central sponsorship is both a challenge and a facilitator since it ensures all states implement the programme. The ICDS is seen as a central initiative, and States depend on the Central government for guidelines and have, in the past, taken less initiative to enhance the programme. For example, there are wide variations in ICDS functioning and quality across and within states (Citizens' Initiative for the Rights of Children Under Six 2006; Kaul, Bhargarh Chaudhary, Jaswal 2015; NIPCCD 2006).

The major factors in sustainability of the ICDS are State funding and prioritization. The ICDS funding pattern has been designed from this perspective, with central-State ratios gradually changing towards greater State responsibility, thus providing scaffolding to States. The enhanced devolution of funds to States in the recent budget has also provided some impetus at the State level towards greater responsibility and contextualization. However, this has also allowed for more state variation in supporting ICDS, depending greatly on the state's own priorities.

Community perceptions and engagement

National evaluations suggest that the many communities still perceive AWCs to simply be feeding stations (IECEI in press; MWCD 2014). The lack of attention to implementation and monitoring (low fidelity of implementation checks), in the context of insufficient public knowledge about early childhood development, has contributed to less public demand for the ICDS. Further, the AWCs tend to be drab and do not attract parents and children.

It should be noted that alongside the ICDS, India has a proliferating private preschool education sector including in rural areas, and parents who can afford private schools will send their children to these because of perceptions about ICDS (Kaul & Sharma in press), and there are concerns that demand for the ICDS will decrease (IECEI in press). A conservative estimate is that over 30% of children in the rural areas of the country attend private preschools/schools (ASER 2014) and the percentage in urban areas may be significantly higher. Further, corruption in food procurement and distribution and in the appointment of AWWs in some States contributes to negative perceptions (Saxena & Mander 2005). Effecting an improvement in community perception is a major challenge to scaling up access and necessitates improvement in the implementation of the ICDS Scheme.

Community engagement is critical to the success to the ICDS Scheme. Pregnant and lactating mothers are part of the Scheme and are an ideal way to encourage access of infants.

Scaling up implementation quality

Mode of service

Multicomponent comprehensive, integrated models such as the ICDS are harder to implement than stand-alone interventions. The ICDS follows a single-window approach, and this adversely affects its quality. Promoting health, nutrition or early education requires domain specific expertise (Kaul & Sharma in press), but the ICDS relies on a single multipurpose worker, the AWW. She is expected not only to be the sole service provider but also to be multiskilled. It is unlikely that she will have the skills to provide all these services to a high standard (Kaul & Sharma in press). AWWs have low levels of training, high workloads and shoulder the burden of expectations of implementing the programme, leading to gaps between what is covered in training, and the realities of managing the AWCs. As Ved (2009, p. 54) noted, ‘Experience shows that models with several components, some of which require substantial behaviour change, extensive outreach, and convergence of multiple government line departments, are less amenable to scaling-up, than models with few components, delivered vertically, emphasizing technical solutions, which do not rely on collaboration between various partners, since decentralization entails reliance on local governance and capacity’.

Kaul and Sharma (in press) also discuss problems with the lack of the flexibility in the operation of the ICDS model as one approach is followed throughout the country. This approach does not accord adequate importance to contextual variations across the country.

Monitoring

Overseeing implementation of the scheme is critical to effective scaling-up of its quality. There are supervision and monitoring mechanisms at village, Block, District and State levels. But the focus of the ICDS monitoring system thus far has been monitoring of inputs and recording child growth. If the ICDS is to have impact at scale, more attention needs to be allocated to monitoring the quality of the programme and ensuring that changes are made based on the results of monitoring/inspection visits.

Institutional capacity

The capacity across the system for planning, management, implementation, monitoring and evaluation of the ICDS is low as this affects the quality of service provision. Indeed, ICDS programmes have been spending below budget allocations and created a vicious cycle of low spending, low allocations and poor human development indicators (World Bank 2004). At the same time, it should be acknowledged that the government is leveraging technology for the monitoring of the ICDS. Systematic evaluation and follow-up of the various recent nation-wide initiatives is needed, as is more rigorous research to understand better how to make the ICDS more effective. Clearly, a focus not just on input indicators but also on process and output indicators associated with the ICDS is required.

Conclusions

India's efforts with the ICDS reflect its complex social structures and an emphasis on community capacity building and access equity (Rao & Sun 2015). A number of programmatic, management and institutional reforms have been implemented (MWCD, 2016a) that will provide the ICDS the impetus to shift its focus from access to enhanced quality and equity. The ICDS Scheme is clearly critical to the health and education of a large number of India's children. It has made gains in reach every year since its inception in 1975. From the evaluations reported earlier, it appears that while AWCs are doing comparatively well with respect to the numbers of days on which services are offered and provisions like supplementary food and nutritional information, there are notable problems associated with implementation quality. As noted earlier, not all reports on evaluations of the implementation of the ICDS presented in this paper have been subject to rigorous peer review. Questions remain regarding the robustness of the research approaches and reliability of the findings from these studies.

The pre-service and in-service training of the AWW is critical to improving children's early development and learning. While the evaluations indicated a reasonable percentage have completed high school and received pre-service training, ongoing in-service training is infrequent. However, there is evidence that teacher-related factors such as process characteristics and class management are important predictors of future achievement and that it is not necessarily the presence of learning/play aids that has an impact on achievement as much as they way in which they are used (IECEI in press). Hence, there is a need to ascertain more details about the current situation and take measures to upgrade and expand the training of personnel. The registration and participation statistics reported in the evaluations seem to indicate a lack of motivation on the part of the AWW in identifying and registering the entire eligible population. Clearly, more inclusive involvement is imperative for successful implementation of the ICDS. There are gaps in the ways in which AWCs are equipped to provide school readiness in terms of physical infrastructure and opportunities for indoor and outdoor free play (IECEI in press).

To date, there is a lack of government regulations for registering and operating these preschools, although there is a National Curriculum Framework, and there are Quality Standards for Early Childhood Care and Education (MHRD 2014) There are, of course, high-quality preschool programmes run by private organizations, but it has been estimated that over 90% of private preschools are more like prep schools and use developmentally inappropriate methods (Rao & Sun 2010). Herein lies a strong argument in favour of providing high-quality resources and facilities for AWCs in order to provide this essential stimulation. Yet the evaluation studies considered earlier seem to have revealed inadequate building, toilet and water facilities and often a lack of the important stimulating resources.

The life course approach of the ICDS is supported by neuroscience and may enhance programme reach and effectiveness. Further, the recent emphasis on monitoring of fidelity of implementation of the ICDS is in keeping with views of the value of implementation research to inform the expansion of evidence-based programmes. Future monitoring, implementation and evaluation research on the ICDS should focus on how well the Scheme meets its goals of enhancing child nutritional status and school readiness and the barriers to reaching these objectives. Further, research should also focus on identifying barriers to promoting equitable access to services and evaluate the efficacy of interventions to enhance access and quality. The Government of India has recognized the importance of improving the quality of the ICDS and has launched a number of noteworthy initiatives to address many of the concerns noted in the various reviews of the scheme – including that of the need to improve government run preschool education.

The continued success of the ICDS will be determined by how well it adheres to quality standards, evolves to address current weaknesses, adheres to evolving quality standards and prepares children for life at school and beyond.

Key messages 

  • India's Integrated Child Development Services (ICDS) Scheme has been associated with decreases in infant mortality and child malnutrition.
  • Initiated in 1975, the ICDS now serves about 82 million children under 6 years, but many factors including population size, diversity of the country, the policy context, funding mode and lack of community awareness were barriers to scaling up this Scheme.
  • Challenges to implementation quality arise from the approach to service delivery, low institutional capacity and poor infrastructure.
  • The life course appr’oach of the ICDS is supported by neuroscience and may enhance programme reach and effectiveness.
  • The recent emphasis on monitoring of fidelity of implementation of the ICDS is in keeping with views of the value of implementation research to inform the expansion of evidence-based programmes.

Acknowledgements

The authors thank Anupa Ramana, Margaret Taplin and Vishnu Murthy for their assistance and Patrick Ip for comments on the manuscript.

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