Written by Rashmi Sharma
Even as the Ministry of Women and Child Development undertakes ‘Poshan Maah’, a nationwide campaign for nutrition awareness this month, doubts arise about the relevance of such exercises. Is this the right approach in a country, where 35.7 per cent of children below five years are underweight (low weight for age), 38.4 per cent stunted (low height for age) and 21 per cent wasted (low weight for height)? The existing strategies of tackling malnutrition also come under question, given that between 2005-06 and 2015-16 (when the third and fourth rounds of the National Family Health Surveys were conducted), the population of underweight and stunted children fell by just 6.8 per cent and 9.6 per cent, respectively, while that of stunted actually went up by 1.2 per cent.
A recent study of five Anganwadi Centres (AWCs, the core institution providing early childhood care in rural areas) in central India reveals two fundamental problems.
The first is ineffective service delivery, thanks to poor infrastructure as well as inadequate and disempowered manpower in these centres.
An AWC is expected to function from 9 am to 4 pm, while delivering an impressive array of services: Two cooked meals to children aged 3-6 years and weekly packets of supplementary nutrition for pregnant/lactating mothers and children under 3 years; recording weight and mid-upper arm circumference for detecting moderately/severely malnourished children and providing them a third take-home meal; referring such children to Nutrition Resource Centres (NRCs) for staying and doing a follow-up on their return; ensuring vaccination, supplements and referral services for children, mothers and adolescent girls; offering pre-school education to 3-6 year olds; making house visits to pregnant women and mothers of malnourished children for health and nutrition advice; supplying sanitary napkins; addressing domestic violence etc. The AWC is managed by an Anganwadi worker (AWW), assisted by a Sahiyaka, who serves food and even fetches children from home. In our case study, the AWWs were also given other tasks, such as undertaking household surveys and ensuring Aadhaar linkage for direct benefit transfer schemes of the government.
Not surprisingly, the AWWs complained of over-work, reflected in their often being careless and inaccurate in detecting malnourished children. In one AWC, only those severely malnourished were identified, while, in another, vaccination was done under unhygienic conditions. One AWC opened late and closed early. The AWWs in two AWCs weren’t bothered about pre-school education, while a third did it sporadically. The two most sincere AWWs were keen to quit, but could not, as they needed the money. Both reported working beyond stipulated hours, with one of them even getting her husband and children to help at the centre. Clearly, the AWWs were in no position to deliver all the services expected, and coped by neglecting or not providing some.
The AWWs were also demoralised, disempowered and rebellious. They were paid a monthly “honorarium” of Rs 5,000, less than an unskilled worker’s wages, and the Sahiykas Rs 2,500. There was hardly any retirement or medical benefits. Even travel expenses weren’t reimbursed, with more than three days’ leave at a time disallowed. They often suffered punishment through arbitrary deductions from their meager salaries. One AWW was a post-graduate and worked hard, but the absence of promotional avenues or incentives to excel were demotivating factors, The AWWs had formed a union, demanding less work hours and better pay/benefits. The centres closed on the days they agitated and deductions from their honorariums followed.
The five villages in which the AWCs were located had a total of 26 such centres. Many of them were overcrowded: more than a third had 50-plus children, with the highest number at 92! Out of the 26, 23 did not have their own building. Their condition was uniformly poor and none had functioning toilets.
Simply put, a weak service delivery institution renders all plans and policies for addressing malnutrition ineffective through “implementation failure”. Our AWCs are like malfunctioning taps: no matter how much water is pumped in, even those who get to drink a little remain thirsty.
The second basic problem is of a uniform strategy applied to varying contexts.
The proportion of malnourished children in the 26 AWCs varied from 8 per cent to 48 per cent, yet they had the same kind of staff and activities. The effectiveness of their interventions was diminished due to hardly 50 per cent attendance of children, albeit for different reasons. In the AWC with the most malnourished numbers, the mothers were daily wage labourers who took their children along to work. They were also rarely available during the AWW’s home visits and unwilling to spend 14 days at the NRC, as the compensation provided for their stay was well below the wages lost from not working. Nor could these mothers afford to leave their other children behind. Such AWCs, catering to larger numbers of malnourished children, obviously need different working strategies.
In all AWCs, the weekly packets of supplementary nutrition provided to children aged below three and their mothers – the least powerful members of the family — were usually consumed by the whole households at one go. Besides, the older children and other family members, too, might be malnourished — in which case, it makes no sense to feed only the “target” population. Given the intra-family power dynamics and needs, a household-based approach to malnourishment may be necessary in certain contexts.
In one AWC near a city, many parents sent their children to private schools only to ensure better education. These children, then, missed out on the extra nourishment and health-care. Most of them had poor parents. The latter had enrolled them in private pre-schools, in the hope that they would continue there; the Right to Education Act mandates reservation of 25 per cent seats even in private schools for children from deprived groups. The neglect of pre-school education in many AWCs could be a significant reason for thin attendance, especially when parents may be more concerned about education than nutrition.
Since the first AWCs were started in 1975 as part of the Integrated Child Development Services programme, India’s per capita income has grown nearly 12 times and the country also has the world’s fourth largest number of billionaires. Yet, the problem of the underpaid, overworked and demotivated AWW continues, along with a uniform one-size-fits-all strategy to combat malnutrition. The disappointing outcomes are not surprising. More than ‘Poshan Maah’ campaigns, addressing institutional and strategy-related shortcomings are what is really required today. A hike in the honorariums for AWWs, announced by Prime Minister Narendra Modi on Tuesday, is a step in the right direction. But it’s not enough.