Reimagining India’s Nutrition Initiative | The Indian Express
The Registrar General of India has confirmed that the Maternal Mortality Rate of India during 2018-2020 was 97. During 2001-03, it was 301. The infant mortality rate in 2005 was 58. In 2021 it was 27. While we have fewer reasons to be unhappy, we still have a long way to go. However, the pace of decline has picked up pace after 2005.
The National Rural Health Mission (NRHM) was launched in 2005 to provide accessible and affordable healthcare through a public system of primary health care. and providing secondary and tertiary care services in private capacity as well as in public systems to ensure good quality services at cost effective rates. Unfortunately, allocations for NRHM have not kept pace. But, it seems to have had a positive impact on several indicators. Untied funds made health facilities look better, doctors, medicines and diagnostics became a reality, institutional deliveries boomed, ANM (Auxiliary Nurse Midwife) and nurses vacancies filled, and community ASHA workers mobilized public systems to perform Started putting pressure on the patient from there.
What do these benefits explain?
First, the NRHM had a clear emphasis on creating a credible public system in primary health. Community connectivity, human resource capacity mattered and flexible financial resources were available at all levels. Second, there was a thrust on the involvement of central, state and local government with civil society, with full involvement of frontline workers. The plan was to start from the bottom. Community monitoring was led by civil society. Third, the approach was pragmatic and provided for a diversity of state-specific interventions. Decentralized planning processes, where states came up with their annual plans based on district health action plans, became the norm.
Fourth, institution building was facilitated by working with panchayats and facility-specific Rogi Kalyan Samitis or hospital management committees. Civil society was engaged in community action through the Population Foundation of India. Professionals were brought in to improve processes. More than 60 per cent of the funds were to be spent at the district level and untied grants were made available at each level of the health institution.
Unfortunately, Poshan has not seen such initiatives. The Fifth National Family Health Survey 2019-21 reported that 35.5 percent of children under the age of 5 are stunted, 19.3 percent are wasted, and 32.1 percent are underweight. These are unacceptable levels. The POSHAN Abhiyaan, although innovative, is still not addressing the challenge of institutionalized decentralized public action.
Unfortunately, in our initiatives to nurture, we remain fragmented and fragmented. ICDS is seen as a nutrition initiative, but the institutional role of local panchayats and communities with limited financial resources still lags behind. Nutrition does not lend itself to narrow departmentalism and such non-institutionalized broad partnerships are bound to fail.
The multidimensionality of under-nutrition makes it imperative that ICDS is redesigned to converge with health, education, water, sanitation and food security at all levels under the umbrella of local government. Given the diverse circumstances, it is important to allow flexibility for context-specific and need-based prioritization in each AWC through decentralized local action, made possible by accountable decentralized financing.
The following should be the 12 restructuring principles for the success of Poshan: (i) let the Gram Panchayat, Gram Sabha, Aajeevika Mission women’s groups and other community organizations be responsible for education, health, nutrition, skills and diversified livelihoods; (ii) There is a need for Panchayat-led committees of the concerned broad departments at the Block and District Zilla Parishad levels as well; (iii) steering village-specific planning process with decentralized financial resources; (iv) allowing simultaneous intervention for all broad determinants of nutrition; (v) assessment of additional caregivers with capacity development to ensure the intensification of monitoring and home visits needed for outcomes in nutrition; (vi) encouraging diversity of local food including millet served hot; (vii) ensuring availability of basic medicines and equipment for health care and development monitoring in each village; (viii) intensifying behavior change communication; (ix) Institutionalizing Monthly Health Day in each Anganwadi Center with community engagement and parent participation; (x) Creating a platform for adolescent girls in each village for empowerment and diversified livelihood through skills; (xi) Decentralized district plans based on village plans should be the basis of interventions to ensure that anganwadis do not suffer from deficiencies such as non-availability of buildings or lack of resources; and (xii) moving towards a “leaving no one behind”, a rights-based approach to ensure universal coverage of adolescent girls under the age of six and pregnant women for all needs.
If the thrust is right then the challenge of under-nutrition can be effectively tackled in a short span of time. The recently released NFHS-V highlights the unfinished agenda and the slow rate of decline in malnutrition. Nutrition as a subject does not lend itself to narrow departmentalism. It calls for a whole-of-government and whole-of-society approach. Technology can be a tool at most and surveillance has to be localised. Panchayats and community organizations are the best way forward. But the challenge of nutrition is also the challenge of women empowerment. It requires only breast feeding, behavioral change in favor of natural foods instead of junk food, clean water and sanitation.
We should never give up on efforts to build a reliable public health system. Let’s start reshaping our nutrition initiatives, learning from hits and misses.
The writer was in IAS. views are personal