Amarjeet Sinha writes: 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 at best be a means. Monitoring, too, has to become local.
The Registrar General of India has confirmed that India’s maternal mortality rate was 97 during 2018-2020. During 2001-03, it was 301. The infant mortality rate was 58 in 2005. In 2021 it was 27. While we have reasons to be less unhappy, we still have a long way to go. The pace of decline, however, has gained momentum post-2005.
The National Rural Health Mission (NRHM) was launched in 2005 to provide accessible and affordable healthcare through a public system of primary healthcare. And to provide secondary and tertiary care services in public systems alongside the private capacity to ensure good quality services at effective rates. Unfortunately, allocations for NRHM did not keep pace. But, it seems to have had a positive impact on many indicators. Health facilities started looking better with untied funds, doctors, drugs and diagnostics became a reality, institutional deliveries jumped, vacancies of ANMs (Auxiliary Nurse Midwife) and nurses started getting filled up, and the community’s ASHA worker started putting pressure on public systems to perform by getting patients there.
First, NRHM had a clear thrust on crafting credible public systems in primary health. Community connect, human resource capacity mattered and flexible financial resources were available at all levels. Second, the central, state and local government partnership with civil society, with the full involvement of frontline workers was a thrust. Planning had to begin from below. Community monitoring was civil society led. Third, the approach was pragmatic and provided for diversity of state-specific interventions. The decentralised planning process, where the states came up with their annual plans on the basis of district health action plans, became the norm.
Fourth, institution building was facilitated in work 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. Over 60 per cent of funds were to be spent at the district level and untied grants were made available to every level of the health institution.
Unfortunately, nutrition has not seen this kind of initiative. The fifth National Family Health Survey 2019-21 reports 35.5 per cent of children under 5 are stunted, 19.3 per cent are wasted, and 32.1 per cent are underweight. These are unacceptable levels. The Poshan Abhiyan, though innovative, is still not addressing the institutional decentralised public action challenge yet.
Unfortunately, in our initiatives for nutrition, we have remained compartmentalised and fragmented. The ICDS is seen as a nutrition initiative, but the institutional role of local panchayats and communities with untied financial resources is still lagging. Nutrition does not lend itself to narrow departmentalism and such non-institutional wider partnerships are destined to fail.
The multi-dimensionality of under-nutrition makes it imperative that ICDS is revamped to converge with health, education, water, sanitation, and food security at all levels, under the local government umbrella. Given the diverse conditions, it is important to allow for context-specific and need-based prioritisation at every Anganwadi centre by allowing flexibility through decentralised local action, made possible by accountable decentralised financing.
The 12 reorganisation principles for nutrition success, should be the following: (i) Let the gram panchayat, gram sabha, women’s collectives of livelihood mission and other community organisations be responsible for education, health, nutrition, skills and diversified livelihoods; (ii) panchayat-led committees of the concerned wider departments are needed at the block and district zila parishad levels as well; (iii) operationalise village-specific planning process with decentralised financial resources; (iv) allow simultaneous interventions for all wider determinants of nutrition; (v) assess for additional care givers with capacity development to ensure household visits and intensity of monitoring needed for outcomes in nutrition; (vi) encourage diversity of local food including millets, served hot; (vii) ensure availability of basic drugs and equipment for healthcare and growth monitoring in each village; (viii) intensify behavior change communication; (ix) institutionalise monthly health days at every Anganwadi centre with community connect and parental involvement; (x) create a platform for adolescent girls in every village for empowerment and for diversified livelihoods through skills; (xi) decentralised district plans based on village plans should be the basis for interventions to ensure anganwadis face no deficits like no buildings or no untied resources; and (xii) move to a “leaving no one behind”, rights-based approach to ensure universal coverage of the under six, adolescent girls and pregnant women for all needs.
The challenge of undernutrition can be tackled effectively over a short period if the thrust is correct. The recently released NFHS-V brings out the unfinished agenda and the slow rate of decline in undernutrition. 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 at best be a means and monitoring too has to become local. Panchayats and community organisations are the best way forward. But the nutrition challenge is also a women’s empowerment challenge. It requires a behaviour change in favour of exclusive breastfeeding, natural foods instead of junk food, and clean water and sanitation.
We should never give up efforts at crafting a credible public healthcare system. Let us begin re-crafting our nutrition initiative, learning from the hits and misses.
Source: The Indian Express, 5/12/22
