Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB5726 Project Name ICDS Systems Strengthening and Nutrition Improvement Program (ISSNIP) Region SOUTH ASIA Sector Health (100%) Project ID P121731 Borrower(s) GOVERNMENT OF INDIA Implementing Agency Ministry of Women and Child Development Environment Category [ ] A [] B [ X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared May 11, 2010 Estimated Date of December 2, 2010 Appraisal Authorization Estimated Date of Board March 24, 2011 Approval 1. Key development issues and rationale for Bank involvement By 2020, the people of India will be more numerous, better educated, healthier and more prosperous than at any time in our long history. - India Vision 2020, Committee Report, the Planning Commission, 2002 This vision statement captures the importance of Human Development alongside economic growth in India s national planning. The benchmarks too, along with quadrupling the per capita income by 2020, envision attaining development outcomes at par with upper-middle income countries, including a reduction of under-five malnutrition (underweight) rates from 45 to 8 percent 1. India however, has some distance to traverse in realizing this vision. It currently has one of the highest malnutrition rates in the world one-third of the children are born with low birth-weight, 43 percent of children under five are underweight (this is five times the rate in China and double the rates in Sub- Saharan Africa), 48 percent are stunted, 20 percent are wasted, 70 percent are anemic and 57 percent vitamin A deficient. WHO estimates that about 49 percent of the world s underweight children, 34 percent of the stunted children and 46 percent of the wasted children live in India. Undernourished children have higher rates of mortality, lower cognitive and school performance, are more likely to drop out of school, and are less productive later in life. Much of this undernutrition happens during pregnancy and in the first two years of life of a child, and, without appropriate interventions, the damage to brain development and future economic productivity, and to human development, is largely irreversible. While India has demonstrated impressive and sustained economic growth, progress in reducing child malnutrition has been limited despite significant investments in this area. Undernutrition has declined marginally between 1998-99 and 2005-06. For example, underweight in children under three years of age declined from 43 to 40 percent, stunting reduced from 51 to 45 percent and wasting increased from 20 to 23 percent. During the same period, undernutrition among women declined from 36 to 33 percent, but anemia levels increased from 52 to 56 percent. Evidence also shows that the fast-paced economic growth 1 The estimated average performance of selected Upper Middle Income countries has been used as a benchmark for goals achievable by 2020. For underweight in under-five children the estimated reference benchmark is 8 percent.
is leaving behind many districts/states and that inequities in income as well as in human development indices are increasing. Malnutrition is higher in rural areas, although even in urban areas a third of the children are underweight. Sixty percent of the children from the poorest quintiles are stunted. While malnutrition rates are lower in the higher income quintiles, still almost 50 percent of children in the middle income quintile are stunted. Concerns about equity are thus superimposed on questions about efficiency of resource use, India s ability to reach its human development goals, and the sustainability of economic growth and political stability. B. Sectoral and Institutional Context There is political will to address malnutrition, but it needs to translate into more concrete action: Commitment to address malnutrition is seen at the highest levels - the Prime Minister has noted the urgent need to tackle the issue in many of his addresses to the nation. The Government of India s 11th National Five-year Plan (2007-12) has laid out clear goals for improving nutrition, such as the reduction of the prevalence of underweight in children under 5 years to 20 percent, increase in the exclusive breastfeeding rates to 90 percent, reduction in the prevalence of anemia in high risk groups to 25 percent and reduction in the prevalence of iodine deficiency disorder to less than 5 percent. The financial allocations for the Integrated Child Development Services (ICDS), India s flagship nutrition program, and its geographical expansion have increased manifold over the last few years. However, increased financial allocations and geographical expansion - in the absence of reform consistent with the principles agreed by the Government of India (GoI), adequate human resources and capacity, effective nutrition stewardship and mechanisms to track progress on nutrition outcomes - are unlikely to bring about the desired change. A comprehensive nutrition policy framework exists, but the nutrition actions at-scale have largely focused on ICDS: India s nutrition policy framework is comprehensive, and includes both direct nutrition interventions (e.g., safety nets, supplemental feeding, reducing micronutrient deficiencies, food fortification), and indirect, intersectoral actions (e.g., food security, healthcare, women s status, communication, economic access). However, the programmatic response at the national level has to-date focused primarily on food security and supplemental food distribution 2 under the umbrella of India s flagship nutrition program, the Integrated Child Development Services (ICDS). The ICDS has been India s primary response to the challenge of breaking the vicious cycle of malnutrition and impaired development among women and children. It aims to address both the nutrition and the early childhood care and education (ECCE) aspects through an integrated program. It was launched as a centrally sponsored scheme (CSS) in 1975 in 33 development blocks and currently covers 5,421 development blocks through over 700,000 village level anganwadi centers. The program reportedly serves 39 million children below 6 years of age and 8 million pregnant and lactating mothers. However, as explained below, ICDS has been hampered by serious internal challenges, and, in addition, alternatives and complementary initiatives to the ICDS (of which several exist and show promise) have not been adequately scaled up and supported. ICDS impact has been constrained by several programmatic challenges: Despite its manifold expansion, the nutrition impact of the ICDS has been limited, and there is an urgent need for implementation reform. Extensive assessments carried out by the GoI, analyses undertaken by the Bank, and lessons from prior Bank support to the ICDS highlight many issues that need to be addressed. GoI has committed itself to addressing the following issues: 2 Several analyses of ICDS have shown that the emphasis on the procurement, storage, distribution and cooking of food has distracted the program from a much-needed focus on nutrition and health education, and on facilitating good health-nutrition behaviors at the family level. Mitigation measures to ensure a move away from business-asusual approach are therefore proposed in the project.
a) Improving the design and targeting of nutrition programs to allow for greater innovation, learning and adaptation to suit the local context, to reorient the current focus on food supplementation to proven nutrition interventions and on the critical window of opportunity (targeting pregnant women and children below the age of two), and to improve convergence and coordination with other nutrition-related programs and departments; b) Improving supervision, monitoring and evaluation strategies to better track nutrition outcomes, including providing qualitative information to supplement quantitative data; c) Enhancing human resources capacity, including allocation of additional resources at the central, state and district levels to match the expansion of the program, improving staff skills and competencies, and developing and implementing training programs that are more knowledge transfer-oriented, as well as improving incentives and accountability structures. There is a growing recognition among stakeholders that the actions for addressing nutrition lie across many sectors and ministries and it is important to engage new platforms across multiple sectors to improve nutrition. Although a National Plan of Action for Nutrition (NPAN) that identified the roles of about 14 ministries and departments in improving nutrition was formulated in 1995, with the exception of a few initiatives such as salt iodization, the plan has yet to be operationalized in letter and spirit. Based on the discussion above, it is clear that nutrition action in India needs to focus as much on ICDS reform as on a comprehensive multisectoral response. Furthermore, given the well recognized need for policy calibration, particularly on multisectoral approaches, based on the evidence on the ground, the programmatic and institutional inertia, and the need for extensive capacity building and technical assistance at all levels, it is anticipated that reform of the sector will necessarily have to be incremental and gradual, and will entail a significant amount of learning-by-doing. Fortunately, there are several opportunities that could be leveraged in order to chart the way forward and to ensure better nutritional outcomes in the country. a) ICDS Reform: The Bank has engaged in an intensive policy dialogue with the GoI, and commissioned a wide range of analytical products related to the ICDS program in general and the Bank s support in particular. The policy dialogue has culminated in an agreement on the following five ICDS reform principles that have been enunciated by the government, which will serve as the basis for Bank support. Flexibility from central level in ICDS design A simplified, evidence and outcome-based program design Stronger convergence at the operational level Strong M& E linked to a funds disbursement strategy More intensive efforts and resources will be targeted to the high burden areas. b) A Multisectoral Response beyond ICDS: Programming platforms for nutrition interventions do exist in certain ministries, such as Health and Industry. For example, through the health system, India has implemented targeted interventions impacting on nutrition, such as iron and folic acid (IFA) supplementation during pregnancy, iron supplementation for children, Vitamin A supplementation, deworming, treatment of infections and diarrhea management. Fortification of salt is also a major program, with policy leadership from the Ministry of Health and Family Welfare and programmatic lead from the Ministry of Industry. A number of other models that show promise in terms of nutritional impact, such as those being supported by the Bank s Rural Livelihoods Projects 3, the women self-help groups, 3 This approach, which has been piloted on a large-scale in Andhra Pradesh uses a micro-finance platform to enable families to smooth out their household food consumption over the year through periods of leaner income.
Conditional Cash Transfer programs, could provide lessons for multisectoral approaches. Going forward, it would be important to scale up these programs at the national and state levels. In order to maximize the impact of such initiatives, policy and programmatic actions, such as the assessment/validation of the existing national plan; political commitment and stewardship; a well-resourced (human and financial) operational plan; and effective operationalization, coordination and monitoring of these actions - possibly through a Mission mode - are urgently required at both national and state levels. It is envisaged that the scale-up process will include the private sector both for profit and non-profit - given their important role in health service provision and in food production, processing, storage, distribution and marketing. Finally, as noted above, it would be important to put in place a stewardship structure at national and state level to oversee the convergent action of various ministries and departments implementing projects/programs to improve nutrition outcomes. C. Relation to World Bank Country Assistance Strategy Halving the prevalence of underweight among children is the key indicator of progress towards MDG 1 (eradicating extreme poverty and hunger) -- a goal that India is lagging behind on, and one that impacts heavily on other MDGs (child mortality, maternal health, education & gender) and on human capital formation. Nutrition investments, if efficiently designed and implemented, have also been shown to be among the best-buys in development (Copenhagen consensus, 2004). Since malnutrition is recognized as the non-income face of poverty, the repositioning of nutrition in the Bank 4 has emphasized the need for increased and more strategic Bank investments in nutrition The India Country Strategy (2009-12) explicitly recognizes nutrition as one of the key areas within human development requiring focused and ongoing support. The project will help achieve one of the Country Strategy outcomes, namely a reformed national ICDS program, through refocusing interventions to the most important determinants of malnutrition, greater integration into the health sector, better targeting, and establishing robust support and supervisory systems. 2. Proposed objective(s) The overarching goal of the ICDS Systems Strengthening and Nutrition Improvement Project (ISSNIP) is to work with GoI and relevant stakeholders to improve the national level maternal and child nutritional outcomes. The project is proposed to be implemented as an Adaptable Program Loan (APL) in three phases, with each phase of the APL, through its specific Project Development Outcomes (PDOs) contributing to this overarching objective. Specifically, Phase I will support the national policy and institutional framework, enable effective stewardship, and strengthen systems and capacities in the context of the proposed reform of the nutrition program. Phase II will expand the reforms and systems/capacity development, support testing of alternative models, and assist in the scaling-up of proven interventions in the targeted states. Phase III will institutionalize the reforms and support the mainstreaming of the scaled-up interventions at a national level. The PDOs for Phase I of the Program are to support the GoI to strengthen: (i) the policy framework, systems and capacities of the ICDS program-- at the national level and in eight selected states 5 -- to deliver quality nutrition services to pregnant women and children under five years of age; and (ii) the policy and institutional framework and stewardship for comprehensive nutrition action beyond ICDS at the national and state levels. 4 Repositioning Nutrition as Central to Development, World Bank, 2006. 5 The States currently being considered for support include Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttarakhand, and Uttar Pradesh. This list will be confirmed during project preparation.
3. Preliminary description The project will have three components: 1) ICDS Reform; 2) Multisectoral Nutrition Initiative; and 3) Technical Assistance and Monitoring & Evaluation. Component 1: ICDS Reform: The component will focus on policy and strategy development/strengthening (i.e. making the policy and program framework consistent with the agreed reform principles, e.g. making ICDS implementation more flexible and less centralized; focusing on implementation of proven nutrition interventions - rather than on just food supplementation - and on the nutrition window of opportunity; developing the operational guidelines and tools required to implement the new strategy, etc.); institutional strengthening and capacity building activities (e.g., strengthening monitoring and evaluation, supervision and technical assistance); and supporting innovation, pilots, and scale-up of best practices to foster new ways of doing business, build partnerships, promote convergence among nutrition platforms and engage with new platforms. Specifically, Component 1 will support interventions at three levels: i) At National level to establish the overarching nutrition policy and program framework that will guide implementation in the eight target states, and for possible adoption by other non-project states; ii) At State level in eight states to develop specific operational approaches, strengthen capacity and systems to implement the policy and program framework in the state, develop innovative pilots, scale-up best practices; and iii) At District level in selected districts 6 to build capacity and strengthen systems to implement, support, monitor the delivery of effective nutrition services and expand their utilization. Component 2: Multisectoral Nutrition Initiative: This component will support the design and development of models of multisectoral intervention, with a clear equity focus, to influence nutrition outcomes at national and state level. It is envisioned that these models be tested during Phase II, and successful models scaled up nationally in Phase III. This component will explore options at central and/or state levels for policy and program support to address critical multisectoral nutrition issues that lie beyond the mandate of ICDS, but which are crucial to influencing nutrition outcomes (e.g., food fortification with micronutrients, water and sanitation, etc.). This component will be developed during Phase I in close collaboration with the GoI (which has recognized the need for such multisectoral engagement and for an expansion of the nutrition program beyond the narrow focus on ICDS) and development partners such as DFID and others in a manner that supports the development of key nutrition-related interventions, institutional arrangements, and models required to inform the GoI s nutrition strategy, approach and allocations for India s 12th FiveYear Plan. An incremental approach to building up this component is proposed to focus initially on two to three key sectors and expand to include more sectors. Areas proposed include: defining and testing alternate institutional arrangements for an effective nutrition response, such as a state or national nutrition Mission; creating an appropriate stewardship body to convene and coordinate the actions across several ministries/departments, make decisions on cross-sectoral policy, technical and program issues, mobilize and allocate central resources, monitor performance and provide an annual report card on the progress on nutrition nationally; catalyzing the realignment of nutrition policy to invest in a range of interventions across multiple sectors that have proven to be cost-effective in improving nutritional outcomes; 6 Roughly 158 high-burden districts have been tentatively identified for support; this number will be confirmed during project preparation.
promoting periodic measurement of nutrition outcomes (anthropometry) at intervals of 2-3 years in order to effectively track improvements or lack thereof and take timely corrective action; and, setting up a Challenge Fund for states to develop and propose institutional arrangements which will be responsive to their specific context and possibly test two or three models (e.g. establishing linkages between health, education and water and sanitation using schools as a platform; enhancing the nutritional impact of existing CDD programs by building links between ICDS/health programs and the CDD platform, etc.) for their effectiveness. Component 3: Technical Assistance and M&E: This component will provide support for technical assistance for components 1 and 2. It is envisaged that the support will be in both the technical areas (e.g. validation of the policy framework, financing, supply chain management, development of new tools, identification of areas of convergence and new platforms, assessment and scaling up of successful pilots, etc.) and the managerial/fiduciary aspects (program planning and management, procurement, financial management, etc.). Explicit support is also proposed for independent third party monitoring and evaluation of the project. 4. Safeguard policies that might apply Phase I of the project would focus primarily on policy and systems strengthening, capacity building and innovations. No civil works are planned. Likewise, the project is not expected at this stage to trigger any other safeguard policies. This will be explored further with safeguards specialists during project preparation. 5. Tentative financing Source: ($m.) BORROWER/RECIPIENT 0 International Development Association (IDA) 100 Total 100 6. Contact point Contact: Ramesh Govindaraj Title: Senior Health Specialist Tel: (202) 458-8402 Fax: (202) 614-2948 Email: Rgovindaraj@worldbank.org