Poshan Abhiyaan: Nutrition Security through Systematic and High Impact Interventions

The 5th Rashtriya Poshan Maah is being celebrated from 1st to 30th September 2022. POSHAN Abhiyaan is Government of India's flagship programme to improve nutritional outcomes for children less than 6 years of age, pregnant women and lactating mothers. POSHAN (Prime Minister's Overarching Scheme for Holistic Nutrition) Abhiyaan aims to address the challenge of malnutrition in a mission-mode. Focusing on the aims of POSHAN Abhiyaan, Mission Poshan 2.0 (Saksham Anganwadi and Poshan 2.0) has been launched as an integrated nutrition support program to strengthen nutritional content, delivery, outreach and outcomes with focus on developing practices that nurture health, wellness and immunity to disease and malnutrition.

Speaking with Sidharath Jha for Employment News, Community Health and Nutrition Expert, Dr Chandrakant Sambhaji Pandav, observed that to achieve Poshan and development outcome, it is critical to strengthen coverage, intensity and quality of evidence based high impact Health, Nutrition and WASH (Water Sanitation and Hygiene) interventions via systems and community health systems, across the continuum of care (from facility to community) during the most critical life stage (1000-day window of opportunity). Dr Chandrakant Sambhaji Pandav is former Head of Community Medicine, All India Institute of Medical Sciences (AIIMS) - popularly known as the 'Iodine Man of India' for his work in the elimination of Iodine Deficiency Disorders. He was conferred with Padma Shri in 2021.

Question: As per the NFHS-5 (2019- 21), the nutrition indicators for children under 5 years have marginally improved as compared with NFHS-4 (2015-16). Stunting has reduced from 38.4% to 35.5%, Wasting has reduced from 21.0% to 19.3% and underweight prevalence has reduced from 35.8% to 32.1%. However, the improvement has been erratic across states and across indicators. In this context, how do you evaluate the Poshan Abhiyaan?

Dr Pandav: Poshan Abhiyaan though launched in March 2018 took a year or so for states to initiate actions on several components especially ICT-RTM (Information and Communication Technology-Real Time Monitoring), ILA (Incremental Learning Approach), and SBCC (Social and Behavioral Change Communication). Further, guidance for some of the components like performance incentives and innovations was released later in 2019. So, considering this, it would be too early to evaluate Poshan Abhiyaan based on NFHS-5 data which was collected during the initial stages of implementation of Poshan Abhiyaan. Moreover, impact of nutrition interventions cannot be expected immediately, especially in a situation that was complicated by the direct and indirect effect of COVID-19, it is not fair to evaluate the efforts at this early stage. However, Poshan Abhiyaan has definitely provided the required push to the nutrition agenda in the country, with clear targets and convergent action plans in place

Question: As you pointed out, the data collected during NFHS-5 should not be taken as the benchmark for evaluating the Poshan Abhiyaan. The NFHS-6 is to be conducted in 2023-24. In the meantime, are there any statistics that may give us a peak into how the COVID-19 affected India's nutrition agenda?

Dr Pandav: COVID-19 pandemic along with its devasting waves have heightened the risk of nutritional vulnerabilities in India through disruption in services, loss of livelihood, increasing food prices and repeated episodes of economic distresses during the pandemic. NFHS-5 does not reflect the impact of the COVID19 as the majority of data was collected prior to the pandemic. Analysis of Centre for Monitoring Indian Economy (CMIE) data and other studies conducted during the pandemic period reveal large scale job loss and economic hardship caused to people, with daily wage workers, migrant labourers, women workers and small farmers more adversely affected. There were disruptions in the agricultural sector as well with a number of studies reporting supply chain issues, sharp decline in prices of non-cereal agricultural produces due to non availability of markets, in turn causing loss of income and economic hardships particularly for women and small farmers. Food security became a major challenge, with many studies reporting reduction in consumption of food due to economic hardships. Again, this was more pronounced among economically weaker sections of the society. Government initiated various measures to mitigate the crisis through allocation of additional food rations under Pradhan Mantri Garib Kalyan Anna Yojana (PMGKAY) for families covered under National Food Security Act, increased allocation for Mahatma Gandhi National Rural Employment Guarantee Act (MNREGA) and direct cash transfer to bank accounts of women under Jan Dhan Yojana. However, while these measures provided succour to a large section of the population, yet accessibility was reported to be a challenge by many vulnerable communities like migrant labourers, nomadic and denotified tribes, or by households left out from NFSA safety net due to exclusion or implementation errors. Many studies have shown changes in food consumption pattern with lower consumption of fruits, vegetables and animal proteins, particularly during the initial phase of the pandemic due to non-availability, non-affordability and misconceptions related to consumption of animal origin foods. Dietary diversity took a backseat particularly during the initial phases of the pandemic. On the other hand, there was also a growing consciousness for consuming nutritious, homemade and "immunity-boosting" food due to the different awareness campaigns from Government and nonGovernment agencies, including by civil society organizations, media and social media. Since the lockdown announced in March 2020 during the first wave of COVID-19, most frontline functionaries and health facilities were repurposed for COVID tracing and treatment. This along with the closure of schools and Anganwadi Centres led to disruption in routine health and nutrition services. However, the Government issued various guidelines for restoration and continuity of these services in containment (red), buffer (orange) and areas beyond containment and buffer (green) zones. Very little information is available of the impact of COVID pandemic on the anthropometric status of children or adults. A few small studies during this period show varied results; while some studies report loss of weight among adults, others have reported to increased BMI. However, these studies are limited by small sample size and cannot be generalized. NFHS-6 might show us the longer term impact of pandemic.

Question: A two-way link exists between malnutrition and poverty, creating a vicious cycle with each fueling the other. So, what kind of convergence in policies is happening or is needed to effectively end this vicious cycle?

Dr Pandav: The issue of malnutrition is quite complex and multifactorial having intergenerational effects. Moreover, poor socio-economic situation tend to perpetuate the problem across generations creating a vicious cycle. So, addressing such a scenario requires multisectoral engagement to address immediate as well as root causes. Convergent programming among several sectors having impact at different levels of determinants is key. Under Poshan Abhiyaan, convergent action plans is key instrument to deliver on this agenda. The programme guidance has laid significant emphasis on mapping the convergent sectors, developing stronger convergent action plans and review under the highest authority within states. This has led to some convergent action at the state and district level. However, there is still a tremendous scope to strengthen convergence among policies and programmes for addressing malnutrition and its socioeconomic impact. Convergence in true sense requires all sectors to come together to deliver all the high impact interventions to the most vulnerable families, keeping the child at the center of the business achieving continuum of care especially during first 1000 days of life.

Question: Every year, the month of September is observed as a Poshan Maah. Several activities are undertaken to spread awareness of nutrition in the community. In this context, kindly elaborate the role of Social Behavioural Change and Communication (SBCC) activities.

Dr Pandav: Malnutrition is closely linked to several behaviors at the household level like hand washing, sanitation, use of safe drinking water, infant and young child feeding practices and influence of traditional practices, practices related to intra-household food distribution, healthcare seeking behaviors, etc. Most of these behaviors are determined by deep rooted family beliefs and practices and go beyond routine delivery of services. Changing these behaviors at individual, family and community level requires concerted efforts through community mobilization and Social Behavior Change Communication (SBCC). The objective is to address myths and misunderstandings prevalent in the society by creating awareness and raising demand for accessing services. The strategy should be to adopt context specific communication approaches that would enable families to change the behavior sustainably.

Question: Under Poshan 2.0 launched in 2021, States/UTs have been advised to promote use of AYUSH systems for prevention of malnutrition and related diseases. A programme to support development of Poshan Vatikas at Anganwadi Centres to meet dietary diversity gap leveraging traditional knowledge in nutritional practices has also been taken up. How do you see this approach?

Dr Pandav: While involvement of AYUSH and other allied systems to adopt traditional good practices to prevent malnutrition and diseases is well intended, it is critical to systematically build the approach based on available evidence for achieving the results at scale. Poshan Vatikas could provide a good platform for addressing dietary diversity provided it is adopted by every family and the produce is used on daily basis. Building evidence on the traditional knowledge and practices to influence nutrition status is key to further strengthen this approach and to achieve significant results.

Question: One key target of Poshan 2.0 has been leveraging technology to empower the frontline worker with near real time information. In your opinion, has technological intervention made it easy for frontline workers to ensure prompt and preventive action; rather than reactive one?

Dr Pandav: Use of technology is a game changer in equipping frontline functionaries to deliver services and initiate actions that are well informed. While there are several challenges with regards to procurement, operations and maintenance of the technology solutions, it holds a significant promise of making the business easier for the frontline functionaries. It is also important to use the information on a real time basis to initiate programme actions and take corrective steps, going beyond data collection and upload mechanism. This year, the objective is to trigger Poshan Maah through Gram Panchayats as Poshan Panchayats with key focus on 'Mahila aur Swasthya' and 'Bacha aur Shiksha'. The month long events include intensive activities across the country for awareness about nutrition at the ground level through sensitization drives, outreach programmes, identification drives, camps and fairs with special focus on pregnant and lactating women, children below six years and adolescent girls, in order to realise the vision of 'Swasth Bharat'.

At the Panchayat level, awareness activities are being conducted by local functionaries under the guidance of the concerned District Panchayati Raj Officers and CDPOs (Child Development Project Officers). Poshan Panchayat Committees are working closely with field level workers (FLWs) - AWWs (Aanganwadi Workers), ASHAs (Accredited Social Health Activists), ANMs (Auxilary Nurse Midwife) - to support problem solving and enabling service delivery through Anganwadi Centres (AWCs), Village Health and Nutrition Day (VHNDs), and other relevant platforms to ensure all pregnant and lactating women, children below six years, and adolescent girls receive basic Integrated Child Development services. Awareness drives on Anganwadi Services and good health practices are also being organised. Growth measurement drives are being conducted to bring more beneficiaries under the ambit of Anganwadi Services. Growth measurement drives under 'Swasth Balak Spardha' are being conducted by States with the help of AWWs, AWHs, ASHA, district functionaries and agencies such as Lions Club, Rotary Club etc. Health camps for anemia checkups are being especially organised at AWCs for adolescent girls. Further, land will also be identified for NutriGardens or 'Poshan Vatikas' at or near Anganwadi Centres (AWCs). Special focus has been put on the importance of creating awareness about rainwater conservation among women at Anganwadi centers and on traditional foods in tribal areas for healthy mother and child. Under the State - level activities, 'Amma ki Rasoi' or Grandmother's Kitchen of traditional nutritious recipes is being organized with extensive efforts to link traditional foods with local festivals during the month. A national level toy-creation workshop is being held to promote use of indigenous and local toys for learning in Anganwadi Centres. In States/UTs, women and child development departments through Anganwadi workers and helpers and health and family welfare departments through ASHA, ANM, primary health centers, community health centers, school education and literacy department through schools, Panchayati Raj departments through panchayats and rural development through self-help groups etc. are carrying out various thematic activities and spreading the message of the importance of holistic nutrition throughout the month to ensure a healthier future for women and children. Rashtriya Poshan Maah serves as a platform to bring focus to the discourse of nutrition and good health. In the 5th Rashtriya Poshan Maah the aim is to convert 'Jan Andolan' into 'Jan Bhagidari' to fulfill the Hon'ble Prime Minister Shri Narendra Modi's vision of a 'Suposhit Bharat.'

The interviewee is a Delhibased senior journalist. He can be reached at jha.air. sidharath@gmail.com). Views expressed are personal.