Reducing Child Malnutrition – Action Backed By Data

After many stops and starts, the National Nutrition Mission (NNM) is being launched by the Prime Minister on 8 March (International Women’s Day) at Jhunjhunu in Rajasthan. I have heard some rumblings about the NNM’s excessive focus on data monitoring and the lack of a specific programmatic focus. This is but to be expected from the Indian intelligentsia, which always looks upwards for policy and programme inspiration. In the last fifteen years, we have been snowed under with programmes designed to improve access to healthcare, employment and food. Most of these programmes have not fitted in with the lumbering public service delivery mechanisms that are a characteristic of most Indian state governments. Additionally, their implementation has been bedeviled by inadequate budgetary provisions. It is time that we move from policy obsession to action focus, as admirably enunciated by my friend Sanjeev Ahluwalia in his recent article (Junk Policy for Action). Hence, my two bits on what needs to be done in the sphere of reducing child malnutrition.

For a start, with the Fourteenth Finance Commission mandating an increased devolution of central financial resources to the states from 32% to 42%, the time has come for state governments to stop crying that they are being deprived of “mother’s milk” by the centre. Along with such budgetary provisions as accrue to them from the centre, state governments need to responsibly start making significant budget provisions for the nutrition, health and education sectors, which will contribute most to reducing the incidence of child malnutrition and mortality. States also need to take a hard look at their policies for supplementary nutrition provision to mothers and children under the Integrated Child Development Services (ICDS) programme. This area that has seen phenomenal corruption enriching contractors, politicians and bureaucrats and has drawn the ire of even the Supreme Court but has not altered politico-bureaucratic behaviour in the least, except the search for more ingenious methods to pull wool over the eyes of the Court. Schemes like the Karnataka Mathru Poorna programme, which provides a hot midday meal to pregnant and nursing mothers, need to be replicated, with close social monitoring to minimise leakages. Supplementary nutrition to children in anganwadis (and, where they are under-3, at home) needs to rely on local food preparation by mothers’ and self-help groups.

At the same time, the central government can help matters by acting as a funnel for data dissemination and technical advice. A huge volume of data relating to maternal and child health and nutrition process and outcome indicators flows into the central government data servers every month. The ICDS monthly progress report is supposed to be sent online every month by all state governments to the Ministry of Women & Child Development, Government of India (MWCD). Even if it is sent (itself a matter for investigation), no one looks at it, let alone sends analysed data back to the state government for remedial action. The Mother and Child Tracking System (MCTS) was introduced by the Ministry of Health & Family Welfare, Government of India (MOHFW) with much fanfare in 2011 to track the health and nutrition status of mothers and children from conception through delivery to the time the child reaches the age of 5 years. Not a byte of this voluminous data collected over the past seven years has been made available to, or has been used by, state government health and nutrition machineries to improve their capabilities to better serve mothers and children. If the NITI Aayog, MWCD and MOHFW work together to make all this extremely useful field-level data available to state government formations right down to the anganwadi and health sub-centre levels, they will have contributed more to reducing child malnutrition and mortality than all the central government efforts over the past forty years.

But having all the data is not enough; using it judiciously is even more crucial to successful outcomes. Since the Prime Minister is launching the NNM in Rajasthan, an example from that state will highlight what I mean. May I refer you to a report in the Hindustan Times of 27 February 2018 (Programme to address all malnutrition causes). This piece details the programme to tackle severe wasting or severe acute malnutrition (SAM) through community involvement, known in nutrition circles as Community Management of Acute Malnutrition (CMAM). The first phase of the CMAM initiative was undertaken in 2015-16 in 41 blocks in 13 districts of Rajasthan. That over 2.25 lakh under-5 children were screened and nearly 10,000 children were enrolled in the programme, of whom over 90% are reported to have recovered from SAM is good news. At the same time, this is still touching only the tip of the iceberg. These 13 districts are home to over 24.50 lakh under-5 children, of whom, if one goes by the latest National Family Health Survey (NFHS-4) figures, over 2.50 lakh children fall in the SAM category. Even if one takes just a cross-section of blocks in these 13 districts, the CMAM screening of 2015-16 ought to have uncovered a far greater number of SAM children than 10,000. Screening of entire child populations in selected areas was probably the reason for the lower number of SAM children identified, since the ICDS-health machinery would have been able to reach only a limited number of children with the resources available. Since the ICDS is supposed to record weights of all under-5 children monthly, it would have been a far more effective strategy to identify severely underweight (SUW) children (those with weights less than three standard deviations below normal) and then record the heights of these SUW children to arrive at an accurate assessment of the number of severely wasted children.

The news report states that the Mission Director of the National Health Mission, Rajasthan claims success for the CMAM exercise. Apart from the low numbers of SAM children reached, there is no supporting evidence to show the extent of non-relapse into SAM of the over 9000 children who are supposed to have moved out of SAM. I would be rather sceptical of a CMAM programme which does not give specific data on the same children one year after their release from the facility where they underwent treatment. The Rajasthan government now plans to expand the programme of Integrated Management of Acute Malnutrition (IMAM) to 50 blocks in 20 districts (which include the original 13 districts) of the state. IMAM is a programme developed in geographical contexts where civil strife and ethnic unrest lead to worsening of children’s nutrition status. It has to be applied cautiously in settings where child malnutrition is a chronic condition rather than an emergency situation. Rather than getting caught up in acronyms, it is desirable to focus on the fundamentals. The 20 chosen districts have an under-5 child population of over 45 lakhs, with a reasonable estimate (based on NFHS-4 data) of about 5 lakh SAM children. To avoid spreading resources (financial and manpower) too thin and to get the maximum mileage for the money spent, it would be advisable to track the weight of every child in every anganwadi in these districts and to identify the anganwadis with the maximum burden of SAM children. The heights of children falling in the SUW category could be recorded by a health functionary, who would also assess any prevalence of disease in the child requiring treatment. These SAM children could then be treated under the prescribed SAM protocols, with the highest-incidence anganwadis being taken up first, and other lesser-incidence anganwadis being taken up subsequently, depending on the financial and organisational capacity to treat the children. The condition of these children should be followed up for a year subsequently by the three As, the Auxiliary Nurse Midwife (ANM), the Accredited Social Health Activist (ASHA) and the Anganwadi Worker (AWW).

I am not discounting the importance of an integrated approach to treating child malnutrition, covering behavioural changes in families and communities and the need to focus on policy interventions in nutrition-sensitive sectors like drinking water, sanitation, hygiene and livelihoods. What I am worried about is that in the enthusiasm to do too many things, the central issue of tackling the immediate problem of SAM will be lost sight of. This is the reason why the Rajmata Jijau Mother-Child Health and Nutrition Mission of Maharashtra, the first of its kind in the country, focused on specific action areas in a sequential order, with fairly gratifying outcomes. Unless we adopt the same talisman that Gandhiji adopted, substituting the “most malnourished child” for the “poorest and weakest man”, we are unlikely to remove what has been, and continues to be, a blot on India’s development story.

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What trips street-level bureaucracy?

“There’s many a slip ‘twixt the cup and the lip.”  Nowhere is this proverb truer than in the government machinery of India that is tasked with the staggering responsibility of delivering various crucial services to the 1.3 billion inhabitants of this country.

Whether it is the police guaranteeing the security of the common citizen, the doctor attending to patients at the public health facility or the teacher imparting basic education to children in schools in remote areas, it is glaringly evident that citizens of India are being seriously short-changed in availing public services that are their inalienable right.

We in India, especially the middle class, are quick to blame the street-level bureaucracy (SLB) for faulty implementation of what we consider to be impeccably-designed policies.

Where does the truth really lie? An examination of the functioning of SLBs, covering anganwadi workers and their immediate supervisors in the Integrated Child Development Services (ICDS)*, reveals some home truths on where things are going wrong.

I. Policy vs implementation

The first unpleasant truth is that programmes as packaged in statutes and administrative regulations are not quite what the SLB implements on the ground. There are quite a few reasons for this:

Focus on a limited set of activities
While the ICDS manual prescribes several duties for the anganwadi worker, the ICDS machinery focuses only on supplementary nutrition provision to mothers and children. It excludes activities such as monitoring the growth of children, counselling of caregivers on health and nutrition, and early childhood education.

Food supply is the only concern of the officials of ICDS directorates and the departments at the state level. As a result, the anganwadi worker is considered to have done her duty if she has distributed take home rations (THR) to mothers and children aged under three, and handled cooked meals for children in the 3-6 age group.

Emphasis on paperwork versus outcomes
The anganwadi worker is also required to complete a huge load of paperwork on the supply of food and on the nutrition status of children, to be sent to her superiors every month. If these duties are completed and reports sent to the state and central governments regularly, there is no accountability for outcomes. For example, the nutrition status of children—as revealed by their height and weight measurements, which are critical for determining and addressing stunting and wasting in children below five years—is never addressed in a systematic manner.

II. Leakage in programme implementation

The second shocking fact lies in the subversion of the supplementary nutrition programme by the contractor-politician-bureaucrat nexus. An average Indian state has around 75 lakh children aged below six. With a provision of supplementary nutrition at a rate of INR 6 per day to each child, the annual bill works out to approximately INR 1,350 crore. This huge budget lends itself to manipulation by vested interests.

A recent LANSA study documents the systematic siphoning of public money in Uttar Pradesh through this programme. While a few packets of the THR (daliya) are distributed to families, the bulk of the supplies are sold as cattle feed, giving additional illegal income to the anganwadi worker. Silence is bought through the complicity of all those who are part of the supply chain.

The situation is not much better in respect of hot, cooked meals, where the proceeds of funds received (even if irregularly) are distributed among all stakeholders, including the anganwadi worker and the ICDS supervisor, with very little reaching children in the form of improved nutrition.

III. Socio-cultural barriers

Traditional social prejudices and behavioural patterns also adversely impact the messages being understood and acted upon. Two examples come to mind. Promoting early breastfeeding within an hour of birth has been recommended for a variety of reasons. However, social practices have often militated against this, with the belief that the child must be fed specific fluids before breastfeeding is initiated.

In the area of sanitation, proper hygiene practices and the absence of open defecation are known to promote the healthy growth of children. A recent study by Diane Coffey and Dean Spears has attributed the failure in restricting open defecation in India to social and cultural forces unique to the country. These are centred around religious practices of purity and pollution and the consequent reluctance to locate toilets in proximity to the house.

While these instances reflect the demand factor impacting the efficacy of public services, there are also supply aspects that affect client response to public services.

IV. Inadequate infrastructure

Irregularly functioning Primary Health Centres, which are often closed when the citizen has spent time and money to make her way there, act as a disincentive to use public health facilities. The problem is compounded when the health provider behaves indifferently, and/or demands illegal payments. Such experiences discourage citizens from using the facility and force many to shift to private doctors, sometimes of very dubious quality.

What is being done to address this?

India’s policy mandarins are frustrated by this lack of success at translating significant budgetary allocations and governmental effort into improved outcomes in different social sectors. They are, thus, increasingly seduced by direct cash transfers to clients and privatisation of health, education and corrective services.

However, this approach still begs the question: are citizens guaranteed access to improved services? There will still be need for regulatory agencies that monitor how private agencies function, including the quality and pricing of their services. Poor governance in direct management of public service delivery systems can easily transfer to equally poor oversight of private providers.

Take the case of the Universal Basic Income (UBI), which has caught the fancy of academics and policymakers in India. Apart from the vital issue of who will be entitled to UBI, and its fiscal implications, the question of fair and equal access to services critical to human health and development is still a moot point.

Is there a solution?

The few short-lived successes in child nutrition programmes in certain states have been the result of inspiring bureaucratic leadership, backed by political commitment. Unfortunately, results show only as long as the bureaucratic champion is around.

But long-term success in reducing key indicators of malnutrition, such as stunting and wasting, require sustained efforts to put in place functional systems that can operate irrespective of personalities and governments. These include:

  1. Evidence-based, nutrition-specific and nutrition-sensitive interventions, backed by committed government budgets and active participation of different government departments and agencies.
  2. Health and nutrition protocols that are scrupulously followed, with rigorous monitoring of child nutrition outcomes to ensure accountability.
  3. Empowering local governments and frontline workers and supervisors with financial and administrative authority to deliver meaningful outcomes.

Above all, the political and bureaucratic leadership in the various states must provide a conducive and supportive environment for the effective functioning of SLBs, something that has been sorely lacking till now.

*ICDS is the largest programme in the world devoted to the care of pregnant and nursing mothers and children under 6 years of age.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here