Child malnutrition constitutes one of India’s biggest public health challenges. A look at international child nutrition rankings can be very sobering: India (with 44% of under-6 children underweight and 48% of under-6 children stunted) is in the same league as countries with far more pressing social, economic and political problems. The recently released Rapid Survey of Children carried out by the Ministry of Women & Child Development (MWCD), Government of India and UNICEF highlights the gap between better-performing and laggard states within India. The bulk of the poor performance on under-6 child nutrition (underweight and stunting) indicators is accounted for by just seven states: Bihar, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Meghalaya and Uttar Pradesh. This is in spite of India having one of the oldest programmes (since 1975) – the Integrated Child Development Services (ICDS) – dedicated to improving maternal and child health and nutrition. The problem clearly does not lie in the intent: it lies in the inability of governments at the national and state levels to adopt a systems approach to tackling this issue. This blog argues that there are four must-dos for governments in India (all coincidentally starting with the letter D) which will hopefully contribute to significant reductions in child malnutrition. These are based on my personal experience with Maharashtra’s Rajmata Jijau Mother-Child Health & Nutrition Mission (“the Maharashtra Mission”) which I headed from 2005 to 2010 and from the heartening statistics which show that stunting and underweight in under-2 children in Maharashtra fell by 41% and 24% respectively between 2006 and 2012, attributable, at least in part, to a more focused approach of the Government of Maharashtra towards tackling child malnutrition.
Data & Disaggregation
Government systems are noticeably reluctant to use data, especially disaggregated data, to inform public policy direction and the ICDS is no exception. The MWCD receives monthly progress reports online from all state governments detailing inter alia the under-6 child underweight status (as per the WHO classification) on an ICDS project wise basis at the sub-district level. Unfortunately, this data often arrives after a considerable time-lag (when it does arrive at all) and there is no insistence on timely, accurate reporting. In any case, no use has been, or is, made of this rich source of data by governments at the national and state levels to focus attention on specific geographical areas where the incidence of child malnutrition is severe. In all development indicators, some regions in the country will lag well behind others. In child nutrition outcome indicators, too, it is observed that some regions in specific districts of the country, particularly those inhabited by tribal populations, minority communities and other socially disadvantaged groups show markedly poorer performance. There is also the issue of child coverage under the ICDS: despite the orders of the Supreme Court over ten years ago, a significant proportion of under-6 children still do not receive the full range of health and nutrition services. The decennial Census of India gives figures of children in the 0-6 age group right down to the village and urban ward level. Using these figures as the denominator for action, as the Maharashtra Mission did from 2005 onwards, enables inclusive coverage of all 0-6 children. Ensuring that each and every one of these children are regularly weighed gives comprehensive monthly data on the nutrition status of children in each habitation and enables taking of corrective nutrition and health measures in a timely manner. The availability of disaggregated data, including nutrition outcome indicators, draws the attention of policymakers to the worst affected areas and enables concentration of financial and human resources in those areas. More recently, Geographic Information System (GIS) tools like Jatak (see www.issnip.jatak.org ) have been developed to track individual child nutrition status and take steps to improve the health and nutrition status of children. Using Interactive Voice Response Systems (IVRS), data on key child nutrition indicators are received from frontline nutrition workers as voice files and converted into data at a central facility. This data has a two-way flow: it goes downwards for initiation of timely action by field workers and also enables supervision of their activities by middle-level managers. Aggregated at sub-district and district levels, it also aids timely policy interventions.
Design & Delivery
As mentioned in the preceding section, the use of the latest census data on 0-6 child population allows firming up of the numbers of children to be covered by each anganwadi or a cluster of anganwadis in a revenue village or urban ward. The starting point has to be the provision of public health and nutrition services to the child based on an assessment of her nutrition status. Growth monitoring is one area where significant systemic weaknesses can be seen in nearly all states. Maintaining monthly weight records of under-6 children and monitoring their growth progress enables the anganwadi worker to refer children at risk to medical facilities for early treatment of childhood illnesses or congenital diseases. The focus in the ICDS system thus far has been only on under-6 child underweight status. However, extensive research has shown that stunting (height-related) and wasting (weight to height related) indicators are also crucial to the healthy development of the child. Till such time as government policy sanctions length/height measurement as an indicator, the appropriate strategy, as adopted by the Maharashtra Mission, would be to record the lengths/heights of all under-6 children listed as being severely (more than three standard deviations below normal) underweight as also of under-6 children with faltering growth patterns and determine children, especially in the under-2 age category, requiring urgent health and nutrition interventions to check severe acute malnutrition (SAM), which significantly increases infant and child mortality. This requires close coordination between the ICDS and health systems at village and health centre levels. The use of a system like Jatak would give an upto date list of severely underweight children and those displaying faltering growth patterns. The anganwadi worker would provide this list to the nearest health worker/ medical facility to record the lengths/heights of these children and determine those children failing in the SAM category. Such children would be admitted to medical facilities, with continued post-treatment monitoring by field workers at home subsequently. Children in the moderate acute malnutrition category can be attended to at the anganwadis or at home by anganwadi workers.
The focus on reducing moderate and severe underweight and wasting rates in under-6 children requires revamping of delivery systems in the ICDS sector through building up motivation, skills and knowledge in anganwadi workers, supervisors and Child Development Project Officers. The negative mentality of blaming field workers for high rates of child malnutrition has to give way to an appreciation of the severe constraints they operate under, moving, as the Maharashtra Mission termed it, from “a fault-finding to a fact-finding approach”. Anganwadi workers are paid a pittance (often after a delay of many months) for the devoted services they render to the community and are handicapped by a severe shortage of infrastructure and equipment essential to the effective performance of their duties, as well as voluminous reporting requirements and absence of on-the-job training. The awareness that they are contributing to the raising of the next generation needs to be imprinted in the minds of all ICDS functionaries. It is not that monetary incentives alone motivate people: non-monetary recognition, through an appreciation of work by those higher in the hierarchy and giving publicity to achievers, can be a major inspiration to workers. At the same time, senior officer levels in the ICDS need to take on team leadership – they should be available 24*7 for solving implementation problems and making available resources to frontline workers to enable them to give of their best. A large part of the Maharashtra Mission’s efforts went into establishing an easy rapport with ICDS staff, encouraging innovative approaches at their level, appreciating their efforts and resolving their operational and organizational problems with higher levels in the ICDS Commissioner’s office.
It’s not rocket science!
The above approach combines responsive governance with the intelligent use of data in a systematic, disciplined manner, adopting a standard operating protocol, which can yield rich dividends where improving child nutrition outcomes are concerned. Of course, there are very relevant issues like the nutrition and health status of adolescent girls, effective antenatal care for expecting mothers, behavioural changes in communities and families on issues of health, nutrition, education, sanitation and gender equality, not to mention the all-important aspect of tackling poverty and low incomes. Trying to tackle all these issues is beyond the capacity of any one agency or department, let alone the government; governments, corporates, nonprofits and civil society have to come together to evolve solutions to these problems. These will take time; till then, our emphasis has to be on the child, as poignantly penned by the poet Gabriela Mistral:
“Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed. To him we cannot answer “Tomorrow”, his name is today.”