ICDS, ICDP, AND IMNCI PROGRAMMES

From Park's Textbook of Preventive and Social Medicine (SPM)

TOPIC 1: INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)

Background and History

• The ICDS scheme is currently the most important scheme in the field of child welfare in India.
• The blueprint was prepared by the Department of Social Welfare in 1975, in pursuance of the National Policy for Children.
• Started experimentally with 33 projects in 1975-76 covering 4 urban, 19 rural, and 10 tribal areas across 22 states and Union Territory of Delhi.
• Projects were sanctioned in October 1975.
• Government decided to expand to 100 areas by 1978-79. Two major evaluations in 1978 and 1982 showed positive results, leading to accelerated expansion in 1982.
• There is a strong nutrition component - supplementary nutrition, vitamin A prophylaxis, and iron and folic acid distribution.

Funding Pattern

• Prior to 2005-06: Supplementary nutrition was the responsibility of states; administrative cost by central government.
• Modified pattern: Central government gives 60% aid to states/UTs.
• North-East and Himalayan states: 90:10 (central:state) share.
• Union Territories without legislation: 100% central share.

Beneficiaries

1. Preschool children below 6 years
2. Adolescent girls 11 to 18 years
3. Pregnant and lactating mothers
4. Other women 15-45 years (nutrition and health education only)

Population Norms for Anganwadi Centres (AWC)

• 1 AWC for 400-800 population
• 2 AWCs for 800-1600 population
• 3 AWCs for 1600-2400 population
• Then 1 AWC per multiple of 800 population
• Mini-AWC: 1 for 150-400 population
• Anganwadi on demand: where a settlement has at least 40 children under 6 years but no AWC

• 1 AWC for 300-800 population
• 1 Mini-AWC for 150-300 population

Administrative Structure of ICDS Project

• Administrative unit: "community development block" in rural areas; "tribal development block" in tribal areas; group of slums in urban areas.
• Rural/urban project population: 1,00,000; Tribal project: ~35,000
• Rural project: ~100 villages; Tribal project: ~50 villages.

• Anganwadi Worker (AWW): focal point for delivery of services; multipurpose agent selected from the community; provides direct link to children and mothers; organizes non-formal education; provides health and nutrition education; assists PHC staff; maintains records.
• Child Development Project Officer (CDPO): in charge of 4 Supervisors and 100 AWWs; does field supervision.
• Supervisor (Mukhya Sevika / Mukhyasevika): responsible for 20-25 anganwadis; acts as mentor to AWWs; assists in record keeping; provides on-the-job training.
• Mahila Mandals: network built up in ICDS project areas to help anganwadi workers.

Objectives of ICDS (5 Objectives)

Package of Services (6 Services)

Note: Services of immunization, health check-up and referral are provided through public health infrastructure (sub-centres, PHC, CHC). ICDS is designed as both a preventive and development effort.

1. Supplementary Nutrition - Details

• Given to children below 6 years, nursing and expectant mothers from low income group.
• Given 300 days in a year.
• Nutritional norms:
  • Each child 6-72 months: 500 calories + 12-15 g protein (financial norm: Rs 8/child/day)
  • Severely malnourished child 6-72 months: 800 calories + 20-25 g protein (financial norm: Rs 12/child/day)
  • Each pregnant/nursing woman: 600 calories + 18-20 g protein (financial norm: Rs 9.50/beneficiary/day)
• Revised norms: State govts mandated to provide more than one meal - morning snack (milk/banana/egg/seasonal fruit/micronutrient fortified food) + hot cooked meal.
• For children below 3 years and pregnant/lactating mothers: "take home ration" provided.
• Universal scheme - Below Poverty Line not a criteria for registration.
• Children are weighed every month.
• Nutrition education for mothers of children with 1st degree malnutrition.
• Supplementary/therapeutic nutrition for 2nd and 3rd degree malnutrition.
• 4th degree malnutrition: recommended hospitalization.

2. Nutrition and Health Education

• Given to all women in age group 15-45 years, priority to nursing and expectant mothers.
• Imparted by specially organized courses in village during home visits by anganwadi workers.

3. Immunization

• Children against 9 vaccine preventable diseases.
• Expectant mothers: immunization against tetanus.

4. Health Check-up

• Includes: (a) antenatal care; (b) postnatal care of nursing mother and newborn; (c) care of children under 6 years.
• Pregnant mothers: iron and folic acid tablets + protein supplements; minimum 3 physical examinations.
• High-risk mothers referred for special care.
• Child health care (under 6 yrs) consists of:
  1. Record of weight and height at periodical intervals
  2. Watch over milestones
  3. Immunization
  4. General check-up every 3-6 months
  5. Treatment for diarrhoea, dysentery, RTI
  6. Deworming
  7. Prophylaxis against vitamin A deficiency and anaemia
  8. Referral of serious cases
  • Health records maintained; card given to mother.

5. Non-formal Pre-school Education

• Children 3-6 years get non-formal pre-school education at anganwadi.
• Objective: develop desirable attitudes, values and behaviour patterns.
• Locally produced inexpensive toys and material are used.

Schemes for Adolescent Girls under ICDS

1. Kishori Shakti Yojana: Age group 11-18 years; addresses self-development, nutrition, health status, literacy, vocational skills; implemented using ICDS infrastructure.
2. Nutrition Programme for Adolescent Girls (2009-10): Pilot in 51 identified districts; undernourished girls (body weight <30 kg in 11-15 yrs; <35 kg in 15-19 yrs); 6 kg free food grain/month.
3. SABLA (Rajiv Gandhi Scheme for Empowerment of Adolescent Girls): Age group 11-18 years.
4. IGMSY (Indira Gandhi Matritva Sahyog Yojana): Conditional cash transfer to pregnant and lactating mothers.

Poshan Abhiyan

• Launched 18th December 2017 for 3 years in all 36 states/UTs.
• Goals (targets over 3 years):
  1. Reduce stunting (0-6 yrs): by 6% (2%/year)
  2. Reduce under-nutrition (0-6 yrs): by 6% (2%/year)
  3. Reduce low birth weight: by 6% (2%/year)
  4. Reduce anaemia (15-49 yrs): by 9% (3%/year)
• Aims to reduce malnutrition through a life cycle approach.
• Ensures convergence of various programmes: Anganwadi services, PMMVY, Jan Suraksha Yojana, NHM, Swachh Bharat Mission, etc.
• Focus on first 1000 days of the child (9 months pregnancy + 6 months exclusive breastfeeding + 6 months-2 years).

ICDS Current Status

• End of 2019: ~7,075 ICDS projects and 13.77 lakh AWC/Mini-AWC functional.
• About 305.09 lakh children are pre-school education beneficiaries.
• 836.25 lakh supplementary nutrition beneficiaries (children + pregnant/lactating mothers).
• Impact: increased birth weight, reduced malnutrition, increased immunization coverage, reduced IMR and child mortality.

TOPIC 2: ICDP (Integrated Child Development Programme)

Note from Park's textbook: Park's SPM does not use "ICDP" as a separate programme acronym. The programme discussed at length is ICDS (Integrated Child Development Services). In Park's textbook, the term "ICDS Programme" and the "Child Development Project" (CDP) are the same entity:

• The administrative unit is the "community development block" also called the Child Development Project.
• The field officer is the Child Development Project Officer (CDPO).
• The "ICDS Programme" heading (page 757, block9) describes the same scheme.

TOPIC 3: INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS (IMNCI)

Origin - IMCI to IMNCI

• IMCI (Integrated Management of Childhood Illness) was originally a WHO/UNICEF strategy for integrated management of childhood illness.
• Rationale: Most sick children present with signs and symptoms of more than one condition (diarrhoea, ARI, malaria, measles, malnutrition). A single diagnosis is not possible; treatment must combine for several conditions.
• The strategy is cost effective and emphasizes prevention and promotion besides standard case management.

• ARI: 17%
• Diarrhoea: 13%
• Fever: 27%
• Under-nutrition: 43%
• Measles vaccination coverage in 12-23 months was also low.

Indian Adaptation - IMNCI

• Indian version of IMCI was renamed IMNCI - Integrated Management of Neonatal and Childhood Illness.
• IMNCI is the central pillar of child health interventions under the RCH II strategy.
• IMNCI strategy is one of the main interventions under RCH-II/NRHM.

Major Highlights of Indian Adaptation (5 Points)

Objectives and Focus

• Focuses on preventive, promotive and curative aspects.
• Objective: To implement IMNCI package at the level of:
  • Household
  • ANMs at sub-centre level
  • Medical officers, nurses and LHVs at PHC level

Components of IMNCI Strategy

• Accepted as an important strategy to scale up IMNCI by Government of India.
• Being included in curriculum of medical colleges of the country.
• Helps in providing trained IMNCI manpower in public and private sector.

• Integration of the facility-based care package with the IMNCI package.
• Empowers health personnel with skill to manage newborn and childhood illness at:
  • Community level
  • Health facility level
• Focuses on inpatient management of major causes of neonatal and childhood mortality:
  • Asphyxia
  • Sepsis
  • Low birth weight
  • Pneumonia
  • Diarrhoea
  • Malaria
  • Meningitis
  • Severe malnutrition
• Master trainers: Paediatricians from tertiary hospitals and medical colleges at state and district level.

IMNCI Integrated Case Management Process (Line of Action)

• Outpatient health facility care with referral pathways categorized by urgency.
• Color-coded treatment streams:
  • Urgent referral (most severe cases)
  • Specific treatment at facility
  • Home management

Diseases Targeted by IMNCI

1. Diarrhoea
2. Acute Respiratory Illness (ARI/Pneumonia)
3. Malaria
4. Measles
5. Malnutrition

Additionally, in the neonatal component: asphyxia, sepsis, LBW, meningitis.

IMNCI and NRC (Nutritional Rehabilitation Centres)

• NRCs: Facility-based units providing medical and nutritional care to SAM (Severe Acute Malnutrition) children under 5 years with medical complications.
• Children screened at peripheries through IMNCI are referred to health facilities/NRCs.
• NRC services include: 24-hour care, treatment of medical complications, therapeutic feeding, sensory stimulation and emotional care, counseling, follow-up.
• Close collaboration between NRC and community-based care (PHC, sub-centre, AWC) is essential.
• 1075 NRCs are functional across 17 states/UTs.

IMNCI and RBSK (Rashtriya Bal Swasthya Karyakram)

• RBSK: new initiative launched in February 2013.
• Child Health Screening and Early Intervention Services - detection and management of 4 Ds:
  1. Defects at birth
  2. Diseases in children
  3. Deficiency conditions
  4. Development delays including disabilities

QUICK REVISION TABLE

All content above is strictly from Park's Textbook of Preventive and Social Medicine - specifically Chapter on Child Health and Social Welfare Programmes (blocks 7 and 9, pages 686-688 and related). ICDP as a standalone acronym does not appear as a separate heading in Park's; the content is covered under "ICDS Programme."