The Hourglass Phenomena

Nutrition is a multi-sectoral issue, and the Lancet series on maternal and child nutrition (2013) recommends a framework of action to achieve optimal foetal and child nutrition and development. The framework highlights nutrition-specific and nutrition sensitive programmes to address the immediate and underlying determinants of nutrition outcomes.

Nutrition specific programmes include adequate food and nutrient intake; feeding, caregiving and parenting practices; and low burden of infectious diseases. Nutrition-sensitive programmes include food security; adequate caregiving resources at the maternal, household and community levels; and access to health services and a safe and hygienic environment.

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In the Indian context, the most important nutrition-specific programmes are the Integrated Child Development Scheme (ICDS) and the National Health Mission (NHM). There are a large number of nutrition sensitive programmes, including the public distribution system (PDS), mid-day meals, the National Rural Livelihoods Mission (NRLM) and others.

Over the last few years, India has taken the lead in addressing malnutrition. While malnutrition among women and children has decreased over the last decade, from 48% in 2005-06 (National Family Health Survey-3) to 38% in 2015-16 (NFHS-4), the strong evidence-based policy action taken with the launch of the Poshan Abhiyaan has provided the impetus for a coordinated response across ministries and departments, in line with the Lancet framework. The Poshan Abhiyaan also provides us an opportunity to look at strengthening a systems-level approach – across health, food, social protection and community systems – to reduce malnutrition in India. The ICDS and NHM have made special efforts to ensure that preventive and promotive care services are provided for children and women, especially pregnant and lactating women.

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However, many services for nutrition – from pregnancy to the first two years of life – overlap. The NHM and ICDS are complementary and separate programmes, but there are many opportunities to streamline service delivery to address critical issues related to human resources and supply chains.

Streamlining service delivery: Gujarat has been one of the most successful states in reducing the burden of malnutrition (down 13 percentage points from 51.7% to 38.5% between 2005-06 and 2015-16, according to NFHS-3 and 4). One of the critical factors leading to Gujarat’s success was the statewide geographic synchronization of the health and ICDS programmes, which allowed for joint planning, implementation and monitoring of health and nutrition services. Close coordination between the two departments in Gujarat also led to the issuing of joint state-level directives by the health department and ICDS for observing Mamta Divas (Health and Nutrition Day) and Integrated Management of Neonatal and Child Illness (IMNCI) intervention, Mamta Abhiyan, at the village level.

The alignment across ICDS and health services also allowed frontline workers – auxiliary nurse midwives (ANMs) and accredited social health activists (ASHAs) under NHM, and anganwadi workers (AWWs) and anganwadi helpers (AWHs) under ICDS – to bundle and streamline services. Joint home visits and counselling by frontline workers can help promote and amplify the impact of nutrition messaging. Unlike many other countries, India is fortunate to have not one but three different sets of frontline workers (an anganwadi worker and an anganwadi helper from ICDS as well as one ASHA worker) for every 1,000 population. Stronger role clarity and accountability among these frontline workers for nutrition service delivery can ensure that all nutrition and health services converge at the household level for the mother-child dyad.

Addressing supply chain issues: According to The Copenhagen Consensus, one of the most cost-effective interventions for addressing micronutrient deficiencies amongst women and children is micronutrient supplementation, such as iron and folic acid (IFA) tablets during pregnancy and lactation. India’s policy guidelines recommend 180 IFA tablets during pregnancy. For these to be effective, they must be taken regularly. Disruptions in supply and lack of counselling together lead to low compliance. As frontline workers strengthen their home visits and nutrition counselling, ensuring steady and reliable supplies is important. Developing population based annual requirements, review of data under e-aushadhi and HMIS related to stock out rates, stock adequacy, coverage of micronutrient supplementation, approaches like leverage vaccine delivery mechanisms for delivering micronutrient supplements; as well as ensuring delivering the full 180-IFA tablet regimen at once instead of 30- day supplies can be effective solutions.

Leveraging technology solutions: India has seen many nutrition development partners collaborating, sharing information and leveraging technology solutions such as WhatsApp for social behaviour change, or web platforms for meetings and trainings.
Technology can help streamline collaboration. In times when it is difficult to reach communities physically, these digital solutions can help targeted counselling for households with a 1000 days mother-child dyad, and telemedicine solutions can be leveraged for remote medical services, reducing the burden on health facilities as well. This can be of huge value in the care
and treatment of various forms of malnutrition as well.

Technology platforms can dynamically change nutrition service delivery. Nutrition development partners in many states are coming together on the C2IQ (coverage, continuity, intensity and quality) platform, developing a common understanding of global and national guidelines and status of nutrition service delivery, and jointly creating plans to support state governments on nutrition. This platform is also leading to cross-learning among partners across states.
Beyond the health system, the community system is also critical for service delivery at the household level. Honourable Prime Minister has noted the importance of villages becoming self-reliant for their basic needs. This is an opportunity to strengthen convergence of household-level service delivery, increase accountability of health and nutrition services in villages, and better target 1,000-day mother-child dyad. The self-help groups (SHGs) set up under the National Rural Livelihood Mission (NRLM) across India provide an opportunity to reach communities in a holistic manner. While SHGs provide an empowering platform for women – often from marginalized communities – to come together and work collectively towards poverty alleviation, they also provide a valuable opportunity to provide health and nutrition messaging directly to women of the community. This can support awareness and create demand for nutrition services as part of Poshan Abhiyaan’s Jan Andolan component.

Local elected representatives (panchayat members) can act as facilitators, ensuring that nutrition-specific and nutrition- sensitive interventions are delivered at the household level for the mother-child dyad.

Diverse food groups are needed to promote health and nutritional wellbeing, which directly contribute to a strong immune system. India has been a food secure nation for many decades now, but there is a need to look at food systems through a nutrition lens to enable India to become not just food secure but nutrition secure. Greater emphasis is needed on growing inexpensive local food produce, rich in micronutrients, to meet nutritional needs and avoid future deficiencies. This would allow vulnerable communities in rural and urban areas to access the much-needed dietary diversity. The Ministry of Women and Child Development is leading the development of the Bharatiya Poshan Krishi Kosh, a repository of diverse crops across India’s agro-climatic zones, which will help in accelerating cost-effective and sustainable agriculture for better nutritional outcomes.

Another opportunity to improve diets is providing education to promote behaviour change. The government’s Eat Right India initiative has been incredibly successful in focusing behaviour change communication on healthy diets. Efforts must continue to be scaled up to reach vulnerable populations and change behaviour. Such healthy and mindful eating habits will help reduce the burden of both under as well as over-nutrition.
India has an extensive social safety net programme. Bringing a nutrition perspective to social safety programmes such as the PDS can help address dietary deficiencies that hinder progress in nutrition. Fortifying staples and expanding the PDS food basket can help provide diverse and nutritious food to those who need it most.

Just as in an hourglass all the grains of sand, no matter how dispersed they are in the top half of the glass, converge to enter the bottom half, so nutrition-specific and nutrition- sensitive interventions spread across all these different systems must converge to make the mother-child dyad well-nourished and healthy. And just as in an hourglass all the grains of sand trickling down can
settle at different places, so also a convergence across various streams can yield multiple benefits – better education, better earning capacity as an adult, and a healthier population.

The health of the mother-child dyad, which is dependent on the convergence of delivery of all critical services at the household level, will lead to healthier individuals, healthier households, communities, states and nations.

(The author is the Country Lead, Nutrition at the Bill & Melinda Gates Foundation.)

Copyright Seminar Publications. This article was published in Seminar's June 2020 edition. Seminar is a monthly journal that discusses various national and international issues. Each issue of the journal focuses on a single problem, bringing together different viewpoints, to provide in-depth insights to readers and decision makers.