It is recognized that eliminating undernutrition requires actions across multiple sectors. A child must receive food with adequate energy, protein, and micronutrients while at the same time having access to safe water, good sanitation, and quality health care. However, services that need to be delivered are typically not led by the same sector, agency, or actor. The agricultural sector, for example, focuses mostly on food production. The health sector usually focuses on clinical care, rather than on care and feeding in the home.
Though it is recognized that working multisectorally is critical to ensuring that adequate food, health, and care reach children, it isn’t always clear how to do so and it is rarely easy. With an aim of garnering lessons learned that could inform India’s policymakers and program implementers, POSHAN commissioned a review of global and Indian experience in improving nutrition through multiple sectors. The new Policy Note Working Multisectorally to Improve Nutrition: Global Lessons and Current Status (Please see below the paper) in India examines best practices from other countries, including Bolivia, Colombia, Peru, Senegal, and Thailand, as well as the status of current multisectoral initiatives in India in nutrition, which include the Multisectoral Nutrition Programme to Address Maternal and Child Undernutrition, which was conceived in 2008 by the Prime Minister’s National Council on India’s Nutrition Challenges and launched in 2014. The paper features recommendations to ensure better implementation and sustainability of multisectoral approaches in India.
Last year in May 2013, POSHAN had organized a consultation on multisectoral approaches to improve maternal and child nutrition in India and had brought together key policymakers and policy advisers from a variety of ministries at the national level and from the Indian states of Odisha, Andhra Pradesh, Karnataka and Madhya Pradesh. This event highlighted lessons and experiences from other countries and from India.
Khandwa District, Madhya Pradesh, 24 September 2013
On 24th of September, 2013, Vikas Samvad, a POSHAN knowledge mobilization partner, held a network-building meeting of the Child Development Project Officers (CDPOs) and supervisors of Khandwa District Madhya Pradesh in order to gain a better understanding of any issues they face in the implementation of the Integrated Child Development Service (ICDS) programme and to discuss peer networks and knowledge sharing. Vikas Samvad organized this meeting with their partner, grassroots organisation Spandan Samaj Seva Samiti. This network-building meeting was organized as a part of the knowledge mobilization activities of the POSHAN project. 21 participants attended (CDPOs and supervisors) from the Department of Women and Child Development (DWCD), including the District Project Officer (DPO).
The meeting allowed participants to voice concerns and discuss potential solutions related to the implementation of the ICDS programme.
The participants began by highlighting the lack of convergence of programs on the ground. Participants were of the opinion that the various local departments do not communicate with one another, leading to uncoordinated responses to local health and nutrition issues in Khandwa District.
An operational challenge introduced in the discussion was related to the referral of sick children. The group discussion revealed that there is no provision for the transportation of family members, and on occasion, staff members cover these costs from their personal resources.
The group also highlighted the challenges faced by families from tribal areas as they travel to seek treatment. Typically, an Anganwadi Worker (AWW) is required to accompany severely malnourished children to the treatment facility with their respective families. However, in many cases AWWs are not fully aware of the procedures of district hospitals. This situation is even more challenging for parents from tribal communities, who are even less familiar with these types of settings. Participants reported that if visitors are mistreated at the facility, they return and recount their experiences to others in the community. In these cases, the community slowly loses faith in the established healthcare system, and is no longer receptive to the instructions of AWWs. These issues can be addressed with proper training of staff at district hospitals and Nutrition Rehabilitation Centres (NRCs).
Another concern highlighted by supervisors during the meeting was the lack of childcare services for mothers who need to stay with their severely malnourished child at the NRC. Mothers are not comfortable leaving their other children unattended at home, particularly if they are still being nursed. In such cases, despite the wide range of benefits, including treatment for malnourished children and monetary incentives, some mothers leave the NRC to attend to their other children.
Other issues, including the dispensing of expired medicines from the Arogya Kendra at AWCs, were raised during the discussion. It was said that the Auxiliary Nurse Midwife (ANM) provides general medicines to the Arogya Kendra at Anganwadi Centres (AWCs) from time to time, and those medicines are later dispensed locally by AWWs. It was reported that the medicines often expire on the shelves, and are not removed on subsequent visits by the ANM. Participants discussed the lack of clarity over whose responsibility it should be to regularly remove expired medicines and ensure that medicines nearing expiry are dispensed appropriately.
The DPO also described some of the challenges related to budgetary provisions for AWCs. A provision of 500 INR is allotted for a Salter scale for each AWC. However, the actual price of a salter scale is over 1200 INR. There are no untied funds available to the AWC to cover the remaining balance. Furthermore, the untied funds from the gram panchayat are not utilized for any such expenses at the AWC. Within the ICDS, an annual contingency fund of 300 INR is available to each AWC. This amount is usually spent on the purchasing of water containers, soap, brooms, etc.
The meeting highlighted a number of topical issues related to maternal and child nutrition in Khandwa District. The group emphasized the importance of considering health and nutrition together, while recognizing that issues such as food security, access to clean water, sanitation, livelihoods and migration are equally important and closely related to addressing malnutrition. The participants recognized that it is essential that the different departments work in tandem on the ground to address the issue of malnutrition. In order to facilitate dialogue, the participants agreed that the development of a forum to openly discuss local issues related to convergence, including examples of successful coordination, would be beneficial.
Following this meeting, Vikas Samvad plans to support further discussions with the CDPOs and supervisors of Khandwa District.
Shivpuri District, Madhya Pradesh, 5 August 2013A knowledge mobilization meeting with district and block-level officials of the Women and Child Development Department in Shivpuri, Madhya Pradesh, has led to the recognition of the value of establishing a knowledge sharing platform to share concerns, issues and solutions among this peer group. Vikas Samvad, a POSHAN knowledge mobilization partner, organized a meeting of the Child Development Project Officers (CDPOs) in Shivpuri, Madhya Pradesh, to gain a better understanding of their activities, identify their information and knowledge needs and discuss peer networks and knowledge sharing. The meeting was attended by roughly 35 participants (CDPOs and Senior Supervisors) from the Department of Women and Child Development (WCD). The group recognized that the various national and international level studies in the field of malnutrition aren’t feeding through to the program implementers at the frontline, in part because the actors at the district, block, and village-level are too busy dealing with operational issues. ‘The very noise on the status of malnutrition at the national level hardly reaches us or concerns us as we are too busy with our own operational issues …’ said one of the Child Development Project Officer (CDPO) at the first meeting of the district level officials of the Department of Women and Child Development (WCD) at Shivpuri District of Madhya Pradesh on 5th August 2013. The participants identified many issues that they faced during implementation of the schemes and programs. These included: low education levels of the Anganwadi Workers (AWWs); lack of clarity in filling out certain sections of the Monthly Progress Report (MPR) form; restricted allocation of funds for transport for Take Home Rations (THR) and cooked meals; THR being consumed by the entire family due to food insecurity, rather than by the child alone; no training provided to the cook; and the biggest issue, lack of convergence between government schemes. Lack of convergence causes many operational difficulties. Participants shared many examples of the same resources being used for the same purpose, but under different programs, due to the lack of convergence. In addition, the participants also noted that the recruitment policies for AWW must be revised, to ensure that decisions are based on the suitability of the candidate. The persistent challenge of documentation was also raised by participants. The block-level participants noted that there were 12 registers to be filled by the AWWs and in many cases the AWW did not have adequate literacy skills, therefore training alone doesn’t help. Along with this, the format of registers and the focus of the programs appeared to keep changing. The officials noted that they found these changes difficult to adapt to, which provides some indication of the difficulties that the frontline workers like the AWWs face. Ultimately, however, the participants recognized that there will likely always be such operational constraints, and that what were needed were solutions to enable them to deliver the tasks effectively. Knowledge-sharing across the district was identified as a possible solution that was feasible to implement without major policy changes. The participants discussed their current knowledge sharing practice and mechanisms. In many cases the officials turn to their peers for advice on day-to-day operational issues, or approach senior staff. However, there is currently no systematic mechanism or platform to support access to new knowledge, provide solutions to queries and offer technical advice on how to deal with new interventions. In closing, the workshop concluded that participants were facing several similar issues and suggested that there could be a significant benefit of a forum or platform to discuss these issues and to identify solutions at the local levels as well as follow-up actions at the state and national level. It was agreed that a knowledge network of the CDPOs and other district level officials could facilitate discussion of the ground-level issues and help to mobilize knowledge across the district. The network could also be useful for sharing new research findings and updates in the field of nutrition, and possibly even to generate knowledge to reach state and national level actors. Vikas Samvad and IDS, another POSHAN knowledge mobilization partner, will now be exploring ways to take this plan forward. Shivpuri District Level Meeting in Hindi
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