Malnutrition: The Unspoken Pillars Of Systematic Challenges

Despite record food output globally, the peril of hunger is still with us. Around 45% of deaths among children <5 years of age are due to undernutrition. They occur mostly in Low and Middle-Income Countries (LMICs), including the Indian subcontinent. For India, the recent findings of the fifth National Family Health Survey (NFHS-5 from 2019-20), Phase 1, further highlights the diminutive progress made in tackling the issue of malnutrition. It brings in the good news for states like Bihar who reduced stunting (important indicator for assessing chronic malnutrition) by 5.4% and bad news for previously well-performing states like Gujarat and Maharashtra who worsened in the same category by 0.5% and 0.8% respectively (compared to NFHS-4 from 2015-16). NFHS-5 fact sheets, however, don’t include the indicators recording the performance of the Integrated Child Development Scheme (ICDS) that contributes significantly to deciding the quality of nutrition service delivery at the ground level. Overcoming systematic challenges faced by the ICDS through a careful evaluation of the existing mechanisms must be attended with severity. 

With increasing administrative pressure and targets to address malnutrition, the efforts should be a mesh of evidence and quality field intervention. This can be done by evaluating interventions based on the strategic use of data, quality human resources, supportive supervision, and right capacity building.

Further, proper incentivization of frontline workers through an established progressive promotion policy can act as a critical yardstick to boost the work motivation. It can come in a form of monthly honorariums for Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHs) or recognitional certificates by the district administration. A strong supportive supervision mechanism can help to have a healthy dialogue between Lady Supervisors (LS) and AWWs. Supervision checklists with a fixed set of Key Performance Indicators (KPIs) and imparting knowledge to workers as a coach and mentor can help further the interaction.

Technology can be a powerful tool to make informed policy decisions, improve service delivery, and solve issues related to data duplication. Incorporation of real-time monitoring by distributing Anganwadi workers with smartphones in replacement to the old system of registers is a way mapped out to address the data streamlining. However, it is difficult for workers to cope up with the technological advancements. There’s an urgent need of completing the hiring of helpdesk units at the block, district, and state level as enclosed under the administrative guidelines of POSHAN Abhiyaan. It cannot take place until the process is pro-actively pursued by all states.

One of the integral components of POSHAN Abhiyaan is convergence at national, state, district, and block. It can be a tremendous collaborative platform and a renewed opportunity for ICDS and health services to come together. For instance, the effective intervention of a field-level taskforce through AAA - Accredited Social Health Activist (ASHA), Auxiliary Nurse Midwife (ANM), and Anganwadi Worker (AWW) - is paramount to generate multifaceted awareness amongst the beneficiaries on days like Village Health, Sanitation and Nutrition days (VHSND). This includes awareness generation on issues like growth monitoring, Ante Natal Check-ups (ANCs), and counseling of pregnant and lactating women towards healthy feeding practices.

It is equally significant for convergence to take place between all schemes and domains to address malnutrition. This would not just include the direct food intake, but also underlying factors influencing nutritional outcomes – for instance, Water Sanitation and Hygiene (WASH), food security, and appropriate Social Behavioral Change Communication (SBCC). SBCC can be infused through the active involvement of gram panchayats, teachers, local religious leaders, and Self-Help Groups (SHGs). Infrastructure plays an equally important role in snowballing community participation and enrollment of beneficiaries at the AWCs. The concept of model Anganwadi can be further scaled up by the states as it reflects making AWCs an interactive physical space for learning.
In the present context, Covid-19 reiterates the importance of malnutrition as an all-time high with a definite impact on social services and affordability patterns changing. The virus has disrupted the food cycle and caused nutrition shortages such as school programs and Anganwadi cooked food services that serve the marginalized. Full impacts are yet to be realized by the mid or end of 2021. Projections made by the World Food Programme (WFP) show LMICs will face acute food insecurity with a 30% overall reduction in essential nutritional services coverage, whereas Lancet projects an additional 6.7 million will be pushed into wasting in 2020 with 57.6% of it to occur in South Asia itself.

It paves the way for public and private sector stakeholders to forge the partnerships, which would bring an impetus to our nutrition programs. Engagement of young professionals, NGOs, and development partners would provide a dynamic platform to ideate nutrition-based innovations and initiatives through localization of content as per the regional specificity. Administrative and political will to address malnutrition must be supplemented with a causative approach. The domain of malnutrition perhaps highlights the significance of right directives at all levels from Panchayat to Parliament so that a common response can be produced. The response collectively calls for shared efforts of the stakeholders whilst safeguarding the plight of field functionaries who form the fulcrum of achieving nutrition targets.

The views expressed here are personal.

(Diewakarr is a Young Professional at NITI Aayog and Riya is a Research, Content and Documentation Officer in Project WeCan at IPE Global Limited)