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Urgent Action Needed to Overcome Persistent Malnutrition in India, says World Bank Report

In Delhi: Kiran Negi (91 11) 2461-7241
In Washington: Erik Nora (202) 458-4735

New Delhi, 11 May 2006 – India’s Integrated Child Development Services (ICDS) needs to undergo significant changes to address the current malnutrition crisis in India, according to a new World Bank report released today.

Bullet Point

Reductions in the prevalence of malnutrition over the last decade have been small – the prevalence of underweight has only fallen from 53 percent to 47 percent between 1992/93 and 1998/99

Bullet Point

Child malnutrition is a leading cause of child and adult morbidity, mortality, cognitive and motor development. Estimated to play a role in about 50 percent of all child deaths, and more than half of child deaths from malaria (57 percent), diarrhea (61 percent) and pneumonia (52 percent). Overall, child malnutrition is a risk factor for 22.4 percent of India’s total burden of disease

Bullet Point

In India, child malnutrition is mostly the result of high levels of exposure to infection and inappropriate infant and young child feeding and caring practices, and has its origins almost entirely during the first two to three years of life. However, the commonly-held assumption is that food insecurity is the primary or even sole cause of malnutrition. Consequently, the existing response to malnutrition in India has been skewed towards food-based interventions and has placed little emphasis on schemes addressing the other determinants of malnutrition

The prevalence of underweight children in India is among the highest in the world, and is nearly double that of Sub-Saharan Africa, the report says.. It also observes that malnutrition in India is a concentrated phenomenon. A relatively small number of states, districts, and villages account for a large share of the burden - 5 states and 50 percent of villages account for about 80 percent of the malnutrition cases..

The report - India’s Undernourished Children: a Call for Reform and Action - analyzes the effectiveness of the ICDS program in overcoming malnutrition, and proposes several reforms of the program.

"The need to re-examine the functioning of ICDS is an urgent one," said Meera Shekar, World Bank Senior Nutrition Specialist and co-author of the report "The prevalence of underweight among children in India is among the highest in the world, and most children suffer from at least one micronutrient deficiency."

In addition to its consequences for morbidity, mortality and cognitive development, malnutrition of this magnitude has severe long-term impact for individual educational achievement, labor productivity and for economic growth.

The report finds that the ICDS program, in general, appears to be well-designed and well-placed to address the multidimensional causes of malnutrition in India. However, there are three main "mismatches" between the program’s design and its actual implementation that prevent it from reaching its potential:

  1. There is a dominant focus on food supplementation that detracts from aspects of the program that are more crucial for improving child nutritional outcomes, such as improving mothers’ feeding and caring behavior – For example, only 40 percent of Indian mothers practice exclusive breastfeeding.
  2. Service delivery is not sufficiently focused on the youngest children (under three), who could potentially benefit most from ICDS interventions - Growth-faltering starts during pregnancy, such that approximately 30 percent of children in India are born with low birth weight, and by the age of two years most lifetime growth retardation has taken place, and is largely irreversible.
  3. States with the highest levels of malnutrition have the lowest levels of ICDS program funding and a smaller percentage of their villages covered by ICDS centers than states with less malnutrition - The five states with the highest underweight prevalence, namely Rajasthan, Uttar Pradesh, Bihar, Orissa and Madhya Pradesh, all rank in the bottom ten in terms of ICDS coverage

Urgent reforms needed to address malnutrition in India:

Bullet Point

Set clear priority for the different objectives and interventions of the ICDS program

Bullet Point

Refocus ICDS on the most important determinants of malnutrition. This means emphasizing disease control and prevention activities, education to improve domestic child-care and feeding practices, and micronutrient supplementation. Greater convergence with the health sector, and in particular the Reproductive and Child Health program, would help tremendously in this regard

Bullet Point

Increase participation of the most vulnerable groups, especially children under three and pregnant and assure that new funds and new ICDS projects are directed towards states, districts and villages with the highest prevalence of malnutrition

Bullet Point

Involve communities in the implementation and monitoring of ICDS to bring additional resources into the anganwadi centers, improve quality of service delivery and increase accountability in the system

Overcoming these mismatches will not be easy, the report says.

"Bridging the gap between the policy intentions of ICDS and its actual implementation is one of the biggest challenges in international nutrition, with large fiscal and institutional implications," said Michele Gragnolati, World Bank Senior Economist and lead author of the report. "But it can have a huge positive long-term impact on human development and economic growth in India."

To this end, the report considers a number of options that can be taken to improve the effectiveness of ICDS.

For more information on the World Bank’s support of ICDS and other nutrition-related activities, please visit

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