V. Ramani
Director General
Rajmata Jijau Mother-Child Health & Nutrition Mission,
Aurangabad
1. India has among the highest percentages of children in the 0 to 6 age
group in the world who are malnourished. The fact that this prevalence of
underweight children in India is nearly double that of sub-Saharan Africa is
a matter of acute concern. National Family Health Survey (NFHS-2) data
(1998-99) show that 47% of children in India under 3 years were underweight
for their age. If the figures for Maharashtra are analysed, we see that the
percentage of underweight children under 3 fell from 54% in 1991-92 (NFHS-1)
to 50% in 1998-99 (NFHS-2). That there has been a significant reduction
between 1998-99 and 2005-06 (for which year provisional NFHS-3 data for
Maharashtra have been released) of about 11 percent in underweight children
under 3 in Maharashtra is gratifying and an indication that the war against
malnutrition can be won.
2. Malnutrition needs to be understood as reflecting both protein-calorie
undernutrition and micronutrient – iron, iodine, Vitamin A, zinc, etc. –
deficiency, which affects many aspects of children’s development. Physical
and cognitive development is impaired by malnutrition, which also increases
susceptibility to diseases. Over time, there is also an impact on educational
attainment and work productivity as also increased risk of proneness to adult
disorders. 3. Malnutrition, therefore, needs to be approached from a life-cycle
perspective. As Figure 11 shows, the vicious cycle starts with an underweight
expectant mother, often burdened with pregnancy in her teens, inadequate
spacing between successive issues, excessive work and lack of appropriate
nutrition and health care. A low birth weight baby who is exposed to poor
health, hygiene and nutrition practices develops into an underweight and
stunted adolescent. The new cycle of early marriage and pregnancy condemns
yet another generation to this vicious cycle of malnutrition. Interventions
across a number of sectors are required to address this problem. In this
paper, we look at the measures required in the health and nutrition sectors
with specific emphasis on the critical role of the anganwadi centre (AWC) and
the anganwadi worker (AWW) in bringing about permanent changes in the health
and nutrition status of populations.
Figure 1: The vicious cycle of malnutrition
4. The ICDS is now in its
fourth decade of operation. The years since its inception in 1975 have seen a
scaling up of the ICDS, which now reaches out to a large part of the country.
With the recent directives of the Supreme Court laying emphasis on universalisation of this scheme, the ICDS will, hopefully, over the next few
years, cover the entire country, including urban areas, which have hitherto
received inadequate attention. But universalisation need not necessarily
imply that every child in the 0 to 6 age group has access to the full range
of ICDS services. For one, the AWC, the basic source of service delivery at
the village level, still does not serve many hamlets at a distance from the
main village or even the entire population in a village, especially a large
one. Even the additional 12864 anganwadis recently sanctioned for Maharashtra
by the Government of India (over and above the 65000 anganwadis already in
existence in the State of Maharashtra) do not cover every human habitation,
especially in urban slums and in remote rural areas. This has the consequence
of affecting particularly disadvantaged communities, which count among them
the most vulnerable women and under-3 children. A second drawback in the
provision of services relates to the perception of the AWC as just a feeding
centre, without adequate focus on a number of other equally, if not more,
important activities of the AWC. Figure 22 brings out the range of services
that the AWW is expected to deliver to the community. What is important to
note is that the AWC today caters largely to the 3 to 6 age group, that is,
those children who are able to come to the AWC to partake of the
supplementary nutrition provided in the form of cooked meals. As such, many
of the other responsibilities of the AWW are given little importance, both in
implementation and in supervision. This impacts particularly on children in
the 0 to 3 age group, who receive little to no attention from the AWW. With
the AWW burdened with her duties in the AWC, which includes preparation of
food and feeding of children (in the 3-6 age group), there is no time for
home visits, which would enable her to effectively counsel pregnant and
nursing mothers and monitor the health and nutrition status of under-3
children and mothers. Thirdly, the lack of training of AWWs, coupled with
poor motivation, often leads to a number of activities not being undertaken
at the AWCs. Systematic growth monitoring of children and pre-school
education, as well as effective health and nutrition counseling of adolescent
girls and mothers, are the biggest casualties.
Figure 2: Components of the ICDS
5. What then are the crucial areas of
intervention where an effective, functioning anganwadi system can make a
difference in reducing malnutrition and contributing to a reduction in infant
and child mortality? It is necessary for policy-makers and the implementation
machinery to be aware of the dual role of the AWW – as a service delivery
provider and as a counselor to the mother in particular and the women in the
village in general. There is need to recognize the importance of each of the
several functions which form part of her work and to implement policy
initiatives which allow her to discharge her duties effectively.
6. Counseling: The AWW, as the only functionary available at the community
level, has an important duty to discharge as a counselor for adolescent girls
and newly-married women/expectant mothers (the latter category can include
their partners as also mothers-in-law). This counseling would cover various
aspects relating to reproductive health and nutrition, focusing especially on
the following aspects: no marriages of girls below 18 years, postponing first
pregnancy till 21 years, spacing of three years between successive issues,
importance of adequate protein-calorie and micronutrient consumption and
tackling anaemia. There is need to provide knowledge to families on how to
fortify their daily diet to include items rich in energy, proteins and
essential minerals and vitamins. This could, for example, include information
on fortifying atta with soyabean and on including oil, dairy products,
vegetables and fruits in the family’s food basket. The AWW would monitor the
number of antenatal care visits of pregnant mothers and promote the concept
of delivery by a skilled birth attendant. She would counsel expectant mothers
(and their family members) on the importance of commencing breastfeeding
immediately after birth and continuing exclusive breastfeeding for the first
six months, as also moving to complementary feeding of the child (comprising
solid/semi-solid food) in the seventh month. Counseling on correct feeding
practices, including the need for caregivers to practice repeated feeding
(four to six times a day), is equally important to check the incidence of
malnutrition.
Figure 3: Prevalence of undernutrition
7. Breastfeeding and complementary feeding: The importance of
correct feeding practices in the first two years of life is highlighted by
Figure 33 . While early and exclusive breastfeeding is itself unsatisfactory
nearly all over India, undernutrition in India increases over five-fold
between 6 and 23 months, that is, the period when the child moves from
exclusive breastfeeding to a regular diet and when her energy requirements
increase sharply. Provisional data for Maharashtra (NFHS-3) shows that just
over 50% of children are breastfed within one hour of birth and exclusively
breastfed for the first 6 months. Barely 48% of children in Maharashtra
receive solid or semi-solid food and breast milk between 6-9 months. This is
reflective of faulty feeding practices once the child has crossed 6 months.
The AWW has a crucial role here in monitoring the commencement of
breastfeeding within an hour after birth and its exclusive continuation for
six months thereafter and the commencement of complementary feeding once the
child reaches the age of six months.
8. Immunisation and micronutrient supplementation: Provisional NFHS-3 data
for Maharashtra indicates that barely 59% of children in the 12-23 month age
group are fully immunized, in terms of receiving BCG and measles vaccines and
three doses each of polio and DPT vaccines. Only 32% of children in the 12-35
month age group have received a six-monthly dose of Vitamin A. At the same
time, 72% of children in the 6-35 month age group are anaemic. This confirms
the fact that basic immunisation and micronutrient supplementation services
are not reaching a significant proportion of the infant and young child
population. It is here that the AWW can help in tracking the status of
immunisation and micronutrient supplementation in young children. In fact,
there is need to consider whether the AWC should become the depot for storage
of IFA tablets/syrup, Vitamin A, deworming tablets/syrup and iodised salt, so
that these can be made available to all groups in the community – adolescent
girls, pregnant/nursing mothers and children in the 0-6 age group. The
Government of Maharashtra has adopted a programme for giving biannual doses
of deworming medicine and Vitamin A doses (every May and November) which has
started in select districts and will over time be extended to the entire
state. Similarly, IFA doses can be given bi-weekly to children in the 1-6 age
group and adolescent girls. Making the AWC the focal point for these
interventions can not only help systematize the entire procedure, it can also
serve to involve the community in the implementation of these measures.
9. Growth monitoring: A major concern has been the failure to universalize
the ICDS even after over thirty years of operation. The Supreme Court has
ordered the establishment of AWCs in every habitation in the country and
steps have been taken by the Government of India to implement this direction.
Lack of universalisation not only denies access to ICDS to a large body of
children, it also leads to a failure to monitor the presence of malnutrition
– mild, moderate or severe – in children with the consequence that no
effective steps are taken to arrest malnutrition. The excessive focus on
feeding in the ICDS has tended to divert attention from growth monitoring as
an important tool in child development. This is in fact one of the key
interventions stressed on by the Rajmata Jijau Mother-Child Health and
Nutrition Mission, set up in 2005 by the Government of Maharashtra to combat
child malnutrition in the state. Monthly weighing of all children in the 0-6
age group and plotting of these weights on growth charts are the best methods
of keeping track of the nutrition (as measured by weight-for-age criteria)
status of children. Provision of accurate weighing scales and growth charts
to AWWs facilitates this measure. Efforts have been made in this direction by
the ICDS Commissionerate over the past year and it is hoped to provide every
AWC with these facilities in the near future. At the same time, there is need
to educate the AWW to correctly weigh the child and plot, read and interpret
the growth chart intelligently. This would not only help her to identify the
children in severe stages (Grades 3 & 4) of malnutrition but also to identify
children whose growth shows signs of stagnation or decline over a three month
period, so that all these children can be referred to the nearest medical
facility for detailed examination. Growth monitoring can also be made an
exercise involving the community through provision of large size (8 feet by
12 feet) community growth charts to the AWW so that she can educate the
community on the weighing and gradation exercise and provoke discussion on
the ways and means to reduce malnutrition.
10. Treatment of illnesses and severe malnutrition in young children: The
involvement of the medical fraternity is critical in arresting severe
malnutrition. Malnutrition has complex causes, which ultimately reflect in
poor dietary intake and poor health outcomes. While improving dietary intake
may reduce malnutrition to some extent, empirical evidence shows that the two
(dietary intake and health) are intertwined and health interventions are
often required to tackle severe malnutrition. Monthly medical examination of
all severely malnourished children and children showing stagnation/decline in
growth (as assessed by weight-for-age criteria) is essential for prescribing
the correct interventions for reversing the trend of malnutrition. This also
has a significant impact on reducing infant and child mortality. There is,
hence, need for close interaction between the health and ICDS service
delivery machinery in monitoring the status of all such children.
11. Supplementary nutrition: This has virtually become the synonym for ICDS,
so much so that there is a mistaken impression in the media, lay public and
even policy makers that the state is meeting the entire nutritional
requirement of children in the 0-6 age group. As its name suggests, the
nutrition is “supplementary”, that is, it is additional to the diet that the
child is supposed to get at home. Enhanced calorie norms are prescribed for
severely malnourished children and children in the Navsanjivan villages in
tribal blocks of the state. However, field observations show that the
prescribed food recipes in different areas are often deficient in providing
the required proteins and calories. Moreover, the lack of taste suitable for
young children (such as, for example, adding jaggery to the preparation) and
the tendency in the AWC to require the children to take in the entire rations
at one sitting are inhibiting factors in ensuring that the full nutritional
benefits actually accrue. The handing over of the food preparation function
to the womens’ self-help groups (SHGs) can help in improving the quality of
the food, provided more imagination is exercised in devising tasty local
recipes and the local community is tapped for providing additional items
(like eggs, vegetables and fruits) for augmenting the nutrition at the AWCs.
At the same time, take home rations for the 0-3 age group must be so devised
that they appeal to that age group. The importance of repeated feeding of
children through the day needs to be stressed. Above all, supplementary
nutrition will fulfill its role only if it serves to educate caregivers on
the components of a diet that meets all the nutrition needs of the family,
particularly children and pregnant/nursing mothers.
12. Pre-school education or Early Childhood Education (ECE): Perhaps the
least focused on area in the ICDS, ECE is crucial from the viewpoint of
cognitive development of the child, encouraging sociability and generally
promoting readiness for primary education from age 6 onwards. The AWW has
been handicapped in this respect not only by the burden of other duties cast
on her but also by inadequate training in how to go about ECE. Till now, the
AWC has been seen primarily as a feeding centre. Hopefully, with the
introduction of womens’ SHGs for preparing food, the AWW will be able to give
more attention to the ECE component. However, there is need for assessing the
workload of the AWW, in terms of her counseling role, the need for home
visits and her other duties, in formulating an effective ECE policy, which
would decide inter alia whether the AWW can effectively fulfill her ECE role
or whether the ECE function needs to be transferred to another worker.
13. What are the policy implications of the above? Firstly,
empowerment of
the field-level ICDS worker is critical to improving motivation and promoting
a learning environment. Delegation of administrative and financial powers to
the level of the ICDS project block and below would ensure that activities
are not hampered and that the field-level worker can take decisions on
matters involving the health and nutrition needs of the community. Secondly,
convergence of the activities of different departments is essential for
promoting health and nutrition. The example of close coordination in health
and ICDS activities has been referred to earlier. But there are many other
departments, the functioning of which impacts crucially on the health and
nutrition environment of the community. Water supply and sanitation,
livelihood and education are prime examples of the synergistic relations
between the different sectors. Channeling of funds under the Tribal Sub Plan
and the Special Component Plan to the health and nutrition sectors can also
yield rich dividends in terms of improved health and nutrition status of the
population. Thirdly, community ownership of initiatives is central to any
breakthrough in reducing malnutrition. A very large part of the success of
the measures detailed in the preceding paragraphs is contingent on community
involvement and acceptance. What are acceptable as community norms, whether
in nutrition, health, hygiene or any behavioural practices, will translate
into family behaviour that promotes sound health and nutrition. In the
ultimate analysis, we must recognise that malnutrition is a human problem
that can be addressed by human solutions, provided the requisite social will
exists to bring about enduring change for the better.
1 “Food Dole or Health, Nutrition and Development
Programme?” – Shanti Ghosh in special supplement of Economic & Political
Weekly (EPW), 26 August 2006
2
“India’s Undernourished Children: A Call for Reform and Action” – HNP
Discussion Paper, The World Bank, August 2005
3
“Infant and Young Child Feeding: An ‘Optimal’ Approach” – Arun Gupta in
special supplement of EPW, 26 August 2006
Suggested readings (in addition to the above)
1. Articles in the special supplement on the ICDS – EPW dated 26 August 2006.
2. “Universalization with Quality: Action for ICDS, A Primer” – Right to Food
Campaign, March 2006 (available online at www.
righttofoodindia.org)
3. “Reaching out to the child: an Integrated Approach to Child Development” –
Human Development Sector, South Asia Region, The World Bank, September 2004
04 March, 2008
Rajmata Jijau Mother-Child Health & Nutrition Mission
First Floor, "Bhaskarayan", Plot No. 7 E/1, Town Centre, CIDCO,
Aurangabad - 431 003 India
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