India fails its malnourished young
Village health workers report to two ministries. This hampers data-sharing and accountability
In a tiny village somewhere in northern India, three-year-old Leela is malnourished, but no one knows. Her parents, poor labourers barely making ends meet, don’t notice. The government health system hasn’t spotted the child. Across hundreds of villages, mothers and children who need attention are routinely being missed out. That is a key reason why almost 36% of children under age five are underweight and over 50% of pregnant women are anaemic, according to national health statistics.
In every village, government health and nutrition services are delivered through three women health workers. The Accredited Social Health Activist (ASHA) mobilises the community through home visits, and the anganwadi worker is responsible for nutrition needs of women and children, and early childhood education. The ASHA and the anganwadi worker independently share their information with the Auxiliary Nurse Midwife (ANM), who delivers services such as immunisation, and antenatal care, basic diagnosis, treatment and referral. These three women who have complementary health related responsibilities is an enlightened system on paper. Where they team up, they are a powerful force.
The fundamental problem is structural. The anganwadi worker reports into the Integrated Child Development Services (ICDS) system of the women and child development (WCD) ministry, the ANM into the health ministry, and the ASHA to health (with a dotted line to WCD). With two ministries controlling three women workers, there is inadequate data sharing and weak accountability.
There are problems with data collection, recording and sharing, with practices varying across states. In Rajasthan, the anganwadi worker and the ASHA do separate baseline surveys of the village population – one looks at every household, and the other only at dwellings with ‘eligible couples’ in the age group 15-49. They even use different house numbers in their records. Each of the AAA keeps voluminous registers, and their records are often unreliable. There can be different ways of collecting data. In most states, the anganwadi worker assesses malnutrition by weighing the child. In Rajasthan the ASHA does it measuring mid upper arm circumference (MUAC). Common baseline, data collection and recording are essential if the AAA workers are to zero in on cases like Leela.
Accountability for case identification fundamentally requires role clarity. ASHA’s and anganwadi worker’s responsibilities overlap. The latter maintains information on anaemia, blood pressure and other indicators which she could easily obtain from her health department counterparts. This would allow her to discharge her primary functions of nutrition and early childhood education provision more effectively. With overlapping functions, it is difficult to hold workers accountable. The accountability issue extends upward through the system, since the AAA workers have different supervisory systems, reporting into different ministries.
The first solution is better coordination, and best practices are to be found in a few states like Tamil Nadu and Kerala. Certain states, and central government, are taking good steps. In every village in Rajasthan, through the Rajsangam programme, ASHAs, ANMs and AWWs are being trained to use a common ‘AAA platform’. They together map their villages, work off a common database, and routinely share data. Poshan Abhiyan, a visionary central government programme requires that several ministries (beyond health and woman and child) take up joint activities for better nutrition.
Convergence activities are good, but ultimately, there must be a more incisive structural solution -- bring ICDS within the purview of the health ministry and create a single chain of command for health and nutrition workers and supervisors. Nutrition is ultimately a health issue. Mother and child should receive a continuum of care from conception till the child turns six. This system would also spur innovation. For instance, the Common Application Software (CAS) has been introduced by the ICDS department. It is a wonderful product, and its obvious evolution is into a ‘CAS2’—an integrated product that would link all three workers in real time. We have created such an integrated app and field tested it and seen that it makes a huge difference to workers morale as well as efficiency. The question is whether, with two ministries involved, CAS2 will happen anytime soon.
Today there is talk about convergence in activities, but little debate about structural change. Merger of ICDS with health could be painstaking, but the best solution. All stakeholders -- media, influentials, communities -must raise the issue. The well-being of thousands of Leela’s is at stake.