POSHAN Deliberations Round-Up & Refined

Consolidation
SAMVAD (Phase II Report Year 2014)

Vikas Samvad | POSHAN

 Poshan Samvad Phase II (2014)
Deliberations Round-Up & Refined Consolidation

Background

International Food Policy Research Institute (IFPRI) has been leading a partnership initiative
titled POSHAN (Partnerships and Opportunities to Strengthen and Harmonize Actions for
Nutrition), in India. Institutions and organisations namely, Institute for Development Studies
(IDS, UK), Public Health Foundation of India (PHFI), One World South Asia, Vikas Samvad,
Coalition for Sustainable Nutrition Security in India, Save the Children, India, Public Health
Resource Network (PHRN), Vatsalya and the Centre for Equity Studies are partnering with
IFPRI in this initiative. The initiative aims to generate and disseminate evidence on efficacious
actions for nutrition and supports the use of the evidences in decision making in the realm of
Public Health Nutrition in general, and programmatic interventions on nutrition, in particular.
That the efficacious actions would occur as envisaged largely depends on the human capital,
more particularly at the field level. The Anganwadi Workers (AWWs) and the Anganwadi
Helpers (AWHs) at the village level drawing upon the support and guidance of the Sector
Supervisors under the Integrated Child Development Services (ICDS) scheme can bring about
the much cherished turnaround in the programme deliverance. However, it needs to be
acknowledged that these field functionaries (and their likes in the department of Public Health
& Family Welfare) have rather been appearing to be a distraught lot over the recent years.
More often than not, they are only told to do. Their thoughts, beliefs, feelings, experiences,
perceptions, ideas and concerns are closed behind the door of spate of instructions. The
demotivating silence and lack of ownership belittles their self-worth. The situation stunts their
personality growth, inhibits their ability to take self-initiative, blunts their sense of exploration
and wipes away a sense of confidence. These manifestations occur when communication
barriers overshadow the role clarity and credibility of their services. In addition, they adversely
affect the context, content and continuity of services, both for the provider as well as the
recipients of services. Does it call for looking at and learning from the communication theories
and models?
The sector-wide field functionaries in the domains of public health and nutrition often grapple
with the challenges pertaining to factual information and its value premises whilst performing
their designated roles. Being better informed and articulated helps them in relating the purpose
and worth of their activities with the envisaged outputs and outcomes. It is recognised that
they need to be endowed with an ongoing and incisive insight in to and urge for these premises
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in their work environment. It is believed that knowledge, its sharing and data sensitivity have a
significant potential to instil a deep sense of achievement, pride and accountability in the
functionaries. It does so by enabling them to relate the outputs of their actions to a host of
superior outcomes and impacts towards attainment of faster, joint and more effective goals of
reduction in infant, child and maternal morbidity and mortality.

Knowledge Forums Purpose and Rationale

The initiative - Knowledge Forum (Poshan Samvad), thus, aims to serve the following crucial
needs of programme functionaries:
Meet the enhanced self-worth through opportunity for open-ended and trusted
communication, and
Provide factual and value-based information.
It is hoped that the forums processes will help them to confidently tread the path of
exploration with a heightened sense of stakes and ownership. The thrust is on being open to
newer ideas and innovations, whether at work per se or being in the intra- or inter-sector
setting; and that too without being driven by the criteria of success or failure. The Knowledge
Forum seeks to use this outlook to generate and disseminate a galaxy of evidences on effective
actions for nutrition and public health. It is hoped that these evidences can and must pave the
way for enhanced programme performance in the twin realms of Public Health and Nutrition.
Dialogues with and amongst the service providers at the district and block levels and with the
Aanganwadi Workers (AWWs) at the village level indicate that they require wide-ranging
reliable information and answers to many of their queries on a host of topics pertaining to
nutrition and health issues, so that they can better perform their roles. The service providers
acknowledge that a continued dialogue would greatly enhance the quality of their services, and
would produce effective, results-based programmes.
Given the unavailability of any sort of discussion platform on which they can fall back upon, the
service providers are unable to satisfy the stream of unending questions posed by the service
recipients. Likewise, they feel vulnerable when they falter at work and do not have any sort of
support. Further, they feel the need for a backup support where they can freely share and
consult on their experiences and the challenges they have faced while implementing the
programme without feeling threatened, humiliated or apprehensive about being mocked at or
ridiculed. In addition, another objective of the Knowledge Forum is to endow the functionaries
with a heightened sense of self-worth so that they may better value the significance of their
roles.
It is contemplated that the Knowledge Forum would provide for and facilitate continuing
dialogues that can enhance the programme-wide knowledge and morale of the field-level
service providers who play vital roles in improving the status of public health and nutrition, and
would afford a newer dimension in developing their professional competence (represented by

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the tripod of Knowledge, Skills and Attitude - KSA). It is believed that a heightened sense of
confidence can be inculcated amongst these functionaries by supporting them to share latest
information and studies in the fields of nutrition and public health.

Initializing the Knowledge Forum

Vikas Samvad has sought to advocate the need for bringing about a forum which can serve as a
platform for frontline functionaries who are engaged in the domains of nutrition and public
health. The idea is to enable them to come together and freely share and discuss ideas,
perceptions, reflections, problems, prospects, issues, and concerns around the formidable
challenge of combating malnutrition in the state of Madhya Pradesh. The forum has been aptly
termed as Poshan Samvad in Hindi. The September 2014 Report titled, Sharing the Untold
Insights on Nutrition for Public Health: Knowledge Forums in Nutrition (Poshan Samvad) in
Madhya Pradesh published by Vikas Samvad and POSHAN elucidates this strategic action
which has been taken up in the state of Madhya Pradesh. The report identifies the broad
dimensions and options pertaining to the initiation (first phase) of the Knowledge Forum in the
state. It asserts that the forum necessarily paves the way for enabling process-centric
consultations amongst the frontline service providers and those with their related stakeholders
so that they may gain knowledgeable, articulated and shared insights into the immediate and
underlying challenges which they often confront in their work routines and role performance.
The first phase of deliberations at the Knowledge Forum had covered a total of 6 meetings
spanned over a period of one year in 2013-14. These consultations were held at Shivpuri,
Khandwa, Balaghat and Gwalior bringing together as many as 137 Anganwadi Workers, 49
Supervisors, 42 Child Development Project Officers (CDPOs) and 1 Divisional Joint Director.
Together, these functionaries came forth to render a worthy first-hand account of their ground-
level perceptions and experiences pertaining to the issue of malnutrition and its eradication.
Encouraged by the Department of Women & Child Development, Government of Madhya
Pradesh, the mechanism of Knowledge Forum has been initially instituted. It seeks to bring
together the service providers of the Integrated Child Development Services (ICDS) programme,
viz. AWWs, Supervisors, and CDPOs, as the first step towards realising a synergistic deliverance
of joint and shared performance by all stakeholders in addressing the formidable menace of
malnutrition.
Being open-ended, inclusive and process-centric are the key characteristics of Poshan Samvad
platform. Whilst it seeks and welcomes the participation of counterparts from other related
sectors, particularly those from the Department of Public Health and Family Welfare
(DoPH&FW), Government of Madhya Pradesh (GoMP), the forum has thus far been dwelling on
the programme functionaries of the ICDS. Notably, these functionaries have keenly flagged
issues pertaining to their engagement with the field functionaries of their counterpart
departments, namely, DoPH&FW, especially with the Auxiliary Nurse Midwives (ANMs),
Accredited Social Health Activists (ASHAs), Lady Health Visitors (LHVs), Male Supervisors, and
Medical Officers at these bedrock consultations.
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Accent on Process-centric Approach
The process-centric approach of the forum deliberations rests on the premise of enabling a
formative dialogue with the participating field functionaries and has been characterized by the
following attributes:
Building understanding and trust amongst the functionaries.
Articulating clear objectives that define the process as the one of mutual learning.
Participating in the forum by sharing personal views and experiences.
Developing faith in and understanding of the importance of the forum, and using it
for personal growth.
Facilitating active participation in the forum.
Contextualizing case studies.
Providing the functionaries personal space to build their confidence.
Capturing every statement that is made in the dialogue.
Documenting the process.
Using constructive and affirmative language while raising critical issues.
Towards this end, the concept of Poshan Samvadi.e., Dialogue on Nutritionwas defined
and articulated. The Knowledge Forum meetings were organized at both the district and the
divisional levels, in close coordination with and shared leadership of district- and divisional-level
officials. The purpose of the meetings was to render a platform for the frontline workers and
supervisors to share their experiences, knowledge, and concerns vis--vis the status, challenges
and potential of public health and nutrition, particularly in regard to child nutrition and
maternal health. These consultations have been followed up with certain actions by Vikas
Samvad as below:
Sharing the brief meeting report in local languages with the concerned organizations,
individuals, and Panchayati Raj institutions at the local level.
Sharing the draft report with key district officials.
Sharing the final report with state-level organizations and individuals.
Vikas Samvad has taken up the evolving experiences with the counterpart departments of ICDS
and the National Health Mission, MP so that the critical and immense value of the consultations
may be better appreciated by them. It would help towards serving the innate purpose of
advocating need for the mechanism and set off a process of inter-sector collaboration and
convergence with and amongst the sector constituents.
The programme functionaries of key departments, namely Public Health and Family Welfare,
Panchayat and Rural Development, Public Health Engineering and Food & Civil Supplies

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 constitute the major sector constituents with the Department of Women & Child Development
posited in the nodal role, across their different layers and levels. When the intended outcome
of convergence is realised, and it must, the Forum will truly be termed as an entity of and for
the frontline workers who are engaged in the domain(s) of nutrition for public health, whether
directly or indirectly and facilitate the essential interface with the community.

Phase II Deliberations of Knowledge Forum

It is clearly recognized that the Poshan Samvad has significant potential in:
supporting the interface between the community and the program management
architecture,
ensuring continued empowerment of the frontline workers; and
informing the policymaking, program design, implementation and monitoring functions at
middle and top management levels apart from promoting action research.
Therefore, the process of dialogue has been continued in year 2014-15 as part of phase II
deliberations. A total of 4 deliberations were held in the second phase of the Poshan Samvad
during the year 2014-15 which engaged with as many as 83 Anganwadi Workers, 12 ICDS
Supervisors and 28 CDPOs from the ICDS and as many as 96 keen journalists drawn from the
field of social development.

This Report
This report provides a refined consolidation of the key take away messages emanating from the
entirety of Poshan Samvad consultations both from the phase I and phase II rounds of
Knowledge Forums. It further charts out priority actions in the ensuing time period of 2015-16
onwards towards securing sustained and inter-sectoral collaboration and convergence aimed at
facilitating mutual learning and enhancing joint performance in addressing the unacceptable
menace of malnutrition in the state.
The report places the key take away messages broadly in 2 dimensions. These are:
I. Enabling and sustaining the mechanism of Knowledge Forum
II. Issues and challenges in Public Health and Nutrition
It is evident that the lessons learned along these 2 dimensions are inter-related, inter-
dependent and intertwined.

I. Enabling and Sustaining the Mechanism of Knowledge Forum

Whilst phase I deliberations have laid the foundation for the need to have a Knowledge Forum
very clearly, the second phase consultations have sought to address thematic issues, concerns
and challenges thereby explicating as to how the forum can pursue a reformist agenda, both in
the short-term and the medium term. It is, however, recognised that at present, the forum
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appears to be more of a platform for the ICDS programme functionaries. Whilst this is
necessarily required to be continued as the first building block, there is a need to broaden the
participation base so that the much cherished inter-sectoral coordination and convergence is
not only sighted but also is also keenly striven for. Broadly, the following Terms of Reference of
Knowledge Forum (Poshan Samvad) emerge from the consultations that have taken place thus
far:

Purpose of the Knowledge Forum & the Concomitant Caveats

To facilitate open and free discussions amongst the participants so as to identify solutions
to issues at the local level and provide indications and leads for programmatic and policy
improvements at the state and national levels.
The caveat is that the deliberations at the Forum must not be allowed to become the
ground for witch hunting. Hence, the ground rules for process-centric deliberations need to
be laid down and the process would require to be effectively moderated to ensure that
participation is comprehensive, candid and non-threatening, thus evoking willingness and
interest amongst the participant. In addition, the process should necessarily ensure that the
field functionaries, particularly the Anganwadi Workers, do not perceive the Forum to be
adding to their work burden.
To render perceptions on a range of issues, challenges, successes and failures confronting
public health and nutrition in the community.
It is important that when there is criss-cross flow of communications amongst the
participants, sensitive moderation is done so that hierarchies and consequent reactions do
not inhibit a friendly process of dialogue and that tendencies for vilification, blame-game
and defensiveness are duly kept at bay.
To filter out and consolidate best practices and lessons learned for future adaptation and
scale up across the state and the country.
It can be a good idea to acknowledge and attribute credits. However, due diligence needs to
be observed to ensure that the attribution is even-handed and fair and that it does not
reflect an avoidable obeisance to position of authority/power.

Structure and Processes of the Forum

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It would be a formal structure at the behest of the Department of Women & Child
Development. It would essentially function at the sub-district (Community Development Block)
level and have participation from the sectoral departments. It may also have participation of
Janpad and Gram Panchayats so as to draw upon the perceptions and expectations of the
elected representatives who may echo the community thoughts, practices and feelings. It
would thus, be useful to have a mandate for the Forum so that it draws upon the support of the
nodal department at the apex level. However, in order to ensure that the Forum retains a
differentiated identity from that of a typical government review meeting where the seniors
decide what to speak to the attendees and
An Excerpt from the Report on Poshan Samvad held
defensive processes appear to prevail whilst th
at Block Pohri, District Shivpuri on 7 October 2014
the juniors are pulled up for shortfalls in the There is no formal mechanism for this consultation
meeting and the department too has not dwelt on it
numbers of targets etc., it is necessary that in separately. In fact, an interesting event occurred in
terms of its process-centric approach, the organising this meet. The CDPO instructed the
dialogue may necessarily be formal but a Supervisors on mobile phone who in turn directed the
Anganwadi Workers that the meeting shall take place
friendly one with adequate space for today itself. This message from the Supervisors did
informal expression. The Forum has to not go beyond them at the same speed because
either many villages do not have mobile connectivity
necessarily promote consultation where
and/or some Anganwadi Workers do not have mobile
participation is wide and the attendees do phones. At some places, the neighbourhoods were
feel that their say has a value and that they contacted for transmitting the message and at some
places, letters were put on to buses.
are keenly listened to.
The ICDS Supervisors too do not have any budget for
communication. This undefined process resulted in
Forums continued functionality may be the presence of only half of the Anganwadi Workers
facilitated by Vikas Samvad, a non- whilst the rest were left out. Those workers who
could make it to the meeting were also unaware
government organisation which has been
about the subject of meeting.
leading the conceptualisation of this model
and its translation into an action setting. Forums reports may be periodically vetted by the
mandated constituent departments and may form the reference feed for looking up
programme design and policy reforms. Also, it would be prudent to ensure that forums events
and documentation are necessarily incorporated and updated at the websites of the concerned
departments and agencies apart from their inclusion in departments Information, Education
and Communication (IEC) campaigns.

In order to facilitate the requisite participation of the field functionaries, the concerned
departments shall authorize the participation by way of treating the functionaries to be on duty
and also remit to them the regular travelling and daily allowance. Vikas Samvad, the convening
agency for the Forums consultative meet-ups shall coordinate with the concerned departments
to ensure that the participants are intimated well in advance and that they are aware about the
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 purpose for their participation at the deliberations. The idea is that the participants must not be
taken by surprise when they reach the consultation venue.
The concerned departments shall consider the dissemination of documentation of
consultations, primers, factsheets and booklets as are evolved from the forums processes
across the entire state in consultation with Vikas Samvad.
The Forum may also render the services of a Call Centre/Helpline whereby the field
functionaries may choose to reach out so as to secure authoritative answers to their queries.
This could be done through a toll-free number.
A perspective plan over next 10 years+ could also be drawn up for creating an online e-group,
as the field functionaries get online connectivity and become internet-savvy.

II. Thematic Thrust Areas in Public Health and Nutrition and Key Take Away
Messages
The two phases of Poshan Samvad (Nutrition Dialogue) bring out a host of essential thematic
areas across the domains of public health and nutrition. Each thematic area entails a series of
key take away messages meriting a profound attention in addressing the formidable issues and
challenges facing public health and nutrition as are witnessed in the state. The thematic areas
and the relative key messages are presented
below: Eliciting Data Sensitivity of the Participants at the
A. Planning the Conduct of Knowledge Forum Knowledge Forum (Some Excerpts from the
Bhopal Forum with CDPOs)
Informed participation of field
According to the NFHS 3, in MP, 56% women in
functionaries needs to be ensured well the age-group of 15 to 49 years suffer from
in advance. It helps them to positively anaemia. This in itself is the evidence about
their frail health and alerts us against ignoring
anticipate the consultations and shed
the nutrition and health of the women.
their inhibitions and hesitations. Likewise only 15.9% infants received
Advanced planning of consultations colostrum. It shows that 84.1% infants in
Madhya Pradesh were deprived of this
would also be able to help the
protection cover of adequate nutrition and
participants to think through their health.
priorities, concerns and expectations Only 18.3% children in the age-group 6 months
to 23 months received adequate quantity of
from the ensuing consultations. three types of food groups along with mothers
The CDPOs have a key responsibility in breast milk (any 3 out of 1. milk or milk
securing the participation of the products, 2. Food grain-based meal, 3.
Vegetables rich in Vitamin A, 4. Eggs, 5. Meat
Anganwadi Workers and the ICDS or fish, 6. Legumes like gram and peas etc.).
Supervisors at the forums meet ups.

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 Complete participation of the CDPOs in the forum deliberations would help them better
understand the ground level realities so that they can pursue dynamic fine-tuning of
programme management functions.
B. Use of District Fact Sheets and other Reference Materials
Dialogue based on an informed analytics on inter-generational cycle of malnutrition and
its wide prevalence and district-specific fact sheet sets the positive tone of consultations
and helps to create keen receptivity amongst the participants. Building up and
dissemination of reference material and district-specific fact sheets on public health and
nutrition is crucial for a good run up to the Knowledge Forum.
When a fact sheet pertaining to the status of malnutrition is shared with the
participants, it provides a clear dashboard to them regarding the current situation and
its analysis thereby creating an urge to look for the immediate, underlying and basic
factors causing malnutrition and the corresponding coping actions so that the
contemplated change can be better thought through and pursued. The fact sheets
instigate and help the Anganwadi Workers to share their own perceptions on
programmatic issues which corroborate the data presented.
Sharing their experiences at the Balaghat forum, the Anganwadi Workers expressed
their view that children are adversely affected by infections like diarrhoea. They were
informed through the fact sheet that 62.1% of population in the district was deprived of
safe drinking water and that 81.1% population goes for open defecation. The data
analysis pertaining to these facts helped them to appreciate the underlying causes of
childhood illnesses.
Primers and booklets on nutrition published by Vikas Samvad in collaboration with
POSHAN have been found to be highly valuable as these resources immensely
contribute to enrich their knowledge base.

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C. Programme Management & Governance
When a child becomes malnourished, the system does not accord much importance to
the phenomenon. It means that it is taken as a routine thing. However, if the child dies,
officials entourage of 50 vehicles shows up. Why? The forum deliberations highlight
the need for a clear policy commitment to the issue of malnutrition.
There is a continuing need to widen and sharpen scientific and social insights on
nutrition for project leads (the CDPOs) so that they may effectively deliver their roles
without any prejudice.
There is need to trace the cultural and folk roots of the tribal community instead of just
perceiving the tribal community as primitive, deprived and poor; and build their
development on the edifice of those roots.
It is recognized that programme documentation and looking up performance
management through the lens of data gap analysis is very useful for the intended
purposes. Thus, it needs to be ensured that the submission of Monthly Progress Reports
(MPRs) does not become a ritual in itself. What is needed is a thoughtful interpretation
of appraising and tracking performance. Being data sensitive and seeking to remain on
course by keeping a tab on (any) shortfalls, deviations and distortions would thus, form
a key ingredient in the renewed roles and responsibilities of the project leads, i.e., the
CDPOs.
Programmatic communication needs to be strengthened. According to the deliberations
at the Shivpuri forum, there is no well-organised mechanism for delivering the
programme related messages to the Anganwadi Workers - the cutting edge for
programme implementation. Apparently, there is a programme-wide lack of
communication system. Likewise, there is no earmarked budget for communication with
the field-level functionaries.
There is a need to look at initiatives and interventions from the perspective of skilful and
committed approaches and not just in terms of calls for higher budgetary allocations.
Programme monitoring budget needs to be reviewed and adequately provided for so
that well-planned monitoring is in place and is effectively pursued. The CDPO is given a
monthly budget of Rs. 17, 600/- for monitoring the ICDS programme in the project. He
has to bear expenses towards hiring vehicle, honorarium for the driver and cost of fuel
from this amount. Further, within this amount, s/he is called upon to log at least 2500
Km of vehicle movement. It was stated that this was not practical under any
circumstances. Under the situation, one is forced to use her/his own vehicle for the
official field work! Likewise, the ICDS Supervisors also do not have any provision for
communication and travel.
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 Campaign budgeting needs to be revisited. Field functionaries are poorly resourced for
managing campaigns like Anganwadi Chalo Abhiyan. The AWWs lamented that in order
to organise the activities over the 19-days duration of the campaign, they had to incur
expenditure ranging from Rs.600/- to Rs.1000/- whilst the government provided a paltry
sum of Rs. 100/- per Anganwadi Centre.
The Anganwadi Workers are given a total of Rs. 2000/- in a year towards meeting flexi-
fund and contingency requirements whilst they have to incur an expenditure of approx.
Rs.3600/- a year only on online data entry for Vatsalya scheme. This puts them under
financial strain to pay up for the expenditure from their own pockets as well. Flexi-funds
and contingency requirement need to be appraised and modified suitably.
The AWC have not been provided with any serving bowls to store the cooked food for
distribution. In some places, they have plates with moulded cups. However, no glasses
and spoons are available and no funds are provided. Budgeting and resourcing the
Anganwadi Centre calls for a careful attention.
A grievance was voiced by the AWW that their work is being perceived as non-
technical one. Whilst the ANM who administers the injection is considered to be
better than them, they are deemed to be unskilled despite the fact that all of their
work entails a host of skills. They felt that this discriminatory distinction is beyond
reasoning. They cited their specific technical skills and tasks including those of
comparing children with positive status of being well-nourished, identification of
malnourished children through scientific means of weighing the children and measuring
the mid-upper arm circumference using the MUAC (Mid-Upper Arm Circumference)
Tape, maintaining growth monitoring data and profiles of children to question as to how
their work could be considered a non-technical one. There is a need to take a stock of
the skills that are related with the designated tasks required to be performed by AWWs.
Periodic review, updation and appreciation of these skills can go a long way in securing
enhanced commitment from the AWWs.
Should the AWWs have the freedom to determine days menu and effect any changes in
preparing the meal in accordance with the liking of children? Participants at the Shivpuri
Forum have raised this question stating that at present the system in vogue does not
permit it. They perceive that they do not have any freedom to act on the one hand, and
do not have a forum to share their feedback, on the other. Therefore, Knowledge Forum
can also act as a bridge between ground-level functionaries and implementation of
programme design.
The Shivpuri forum flagged the concern of an AWW that there are emerging issues of
retention of children at the Anganwadi Centres in the wake of mushrooming growth of
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 nursery schools in urban and semi-urban areas within the district. There is a need to
take quick and innovative actions to address this issue as the nursery schools would
come up in rural areas as well in the coming years.
The Anganwadi Workers acknowledge that non-formal education and other services at
the Anganwadi have never been accorded a priority and thoughtful attention. They
admitted that with the programmatic attention becoming singularly focused on
nutrition/malnutrition, activities of Early Childhood Care and Development have been
relegated.
The Anganwadi Workers have called for developing policies so that children from age
group of 1 to 5 year should be compulsorily enrolled only in the Anganwadi Centres and
that they may not allowed to get admissions elsewhere. The Anganwadi should be
deemed to be equivalent to LKG (Lower Kinder Garten) and UKG (Upper Kindergarten).
The Workers raised another point of debate. They said that the child progresses from
age 6 to 14 in the school years. They asked as to where the child would go when s/he is
60 months old i.e 5 years old! They felt that the child would neither be fitting in the
criteria of Right to Education nor in that of Non-Formal Education.
Further, there is a need to look at the system of Supplementary Nutrition. It was stated
at the Shivpuri forum that at present there is an arrangement of providing Take Home
Ration (THR) for children in the age group 6 months to 3 years. It was mentioned that it
is common knowledge that when packet is opened once, its entire quantity is cooked
and one cannot save it for further helpings. Secondly, when the parents go for work,
children cannot get food timely as per their needs. This becomes a major cause of
malnutrition, the forum opined. If these children are fed twice at the Anganwadi
Centre with hot cooked meal, we can prevent them from getting malnourished, the
Forum participants concluded.
The Anganwadi Workers also emphasised on the need for comprehensive home visit.
They said that at present, their duration for home visit is one hour. Some workers felt
that the duration should be increased. Many workers observed that home visits bring
out significant improvement in bringing about behaviour change and practices. They see
tremendous value of home visits and family counselling on issues like that of promoting
colostrum feeding, initiating breastfeeding within an hour of the birth, exclusive breast
feeding till 6 months and continued breast feeding with introduction of complementary
feed from infants age 6 months to 2 years. They said that all this possible only with the
continued contact and communication with the mothers.
The Anganwadi Workers had a grievance that they are assigned other tasks in addition
to their programmatic activities. They complain that they are called upon to do a variety
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 of tasks ranging from conduct of surveys, formation of Self-Help Groups and census
operations to census of animals. Further, they are required to maintain a set of 10 to 12
registers. They were concerned that when they have to attend to all these tasks, their
basic work gets diluted. Their contacts with the children and home visits are adversely
affected. There is need to appraise the work load of the Anganwadi Workers and ensure
that their planned time for the most significant activities is not compromised.
Gram Aarogya Kendra were opened alongside the Anganwadi centre. However, not
much consultation and deliberation went in between the two departments. The ASHA
Worker does not report at the Gram Aarogya Kendra regularly and the AWW have not
been given the basic training to dispense even the general medicines. The AWWs
further mentioned that they have not been given the technical training on measuring
Blood Pressure (However, measuring the blood pressure of pregnant women is not a job
of AWW. It is the job of an ANM and AWW does not need to be trained for this
purpose). Under the circumstances, the Anganwadi Workers find it risky to dispense
medicines, in the absence of ASHA worker or ANM from the Gram Aarogya Kendras.
D. Inter-sector Coordination, Convergence and Sector Wide Approach
The CDPOs recognise that the issue and challenge of malnutrition requires the
convergent action from the wide spectrum of stakeholders (the community, the
functionaries of ICDS, health, agriculture, rural development-livelihood, public health
engineering etc.) to engage with one another in a sector-wide approach.
Malnutrition cannot be combated only through the architecture of Anganwadi Centres.
The Anganwadi Workers believe that though the Anganwadi Centre is a significant step
towards eradicating malnutrition but what is required is to look at the complete chain of
availability of food within the households, arrangements for availability of ration from
public distribution shops and employment for work. They cited other important
determinants including education and social gender disparity which have a bearing on
wide spread prevalence of womens anaemia and malnutrition.
It is recognized that some select Anganwadi Centres (mainly those which have pucca
government buildings) have been transformed into Gram Aarogya Kendras (Village
Health Centres). The underlying concept is that this transformed structure will also
render a platform to the ASHA (Accredited Social Health Activist) Worker so that she can
be present there and deliver essential services to the community. The Gram Aarogya
Kendra is equipped with Blood Pressure (BP) measuring instrument, essential medicines,
weighing scale and some basic investigation facilities. Sharing their first hand
experiences on the Gram Aarogya Kendras, the participants at the forum stated that the
centres were merely the structures and that the intended purpose with which the
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 Kendras have been established is yet to be realised. There are no organised initiatives to
bring about the deliverance of coordinated and convergent services at the centre and
that the workers are lacking in mutual coordination. The Anganwadi Workers opined
that it would have been better if the officers of Health Department and the CDPOs of
ICDS had framed a joint outline of the action plan delineating roles and functions
pertaining to health check-up, referral and treatment protocols in case of seriously ill
children. This outline would also have formed the basis for the supervisors in conducting
their regular supervision. Anganwadi Workers cited a host of cases with problems
pertaining to the new-borns (like large size of head, extremely low birth weight, tumour
in stomach, chronic jaundice, or diarrhoea) wherein the complete and timely treatment
could not be provided. They attribute this to lack of coordination and non-functionality
of clear referral processes.
An authoritative arrangement was made that the ANM would visit the Gram Aarogya
Kendra once a week and be available for diagnosis and treatment of the children for the
day. However, in view of longer elapsed time between consecutive visits and lack of
surveillance, the envisaged visits for health check-up and treatment do not occur.
Data points out that 80% adolescent girls of Shivpuri district suffer from anaemia. It
needs to be seen as to how they are being looked after. Whilst the workers questioned
about the data, they informed that when the ANM does the health check-up, the
adolescent girls are not included. They are not given the IFA tablets also. Lack of
education also comes in the way of consumption of the IFA tablets by adolescents.
Some girls do complain of giddiness. The Anganwadi Workers also said that the IFA
tablets provided in the governments programmes are not as effective as those which
are available in the open market. With all this in the backdrop, the workers
apprehended that the proportion of anaemic adolescent girls could definitely be high.
There is a need to look up the criteria for childrens admission to Nutrition
Rehabilitation Centre (NRC). We convince the community with great difficulty for
taking the child to the NRC. Once at the NRC, in the event the MUAC Tape showing even
11.4 cm, the admission is declined, the AWWs lamented. One fails to realise that it
takes months to convince a family to seek the medical attention at the NRC. Without
any attention, the child might fall into that category soon and due to this rejection, the
parents might not come back to NRC.
Despite the fact that there is an order of Department of Public Health & Family Welfare
that every admitted child would be diagnosed for TB, the required investigation is not
carried out in a scrupulous manner. Further, when asked as to what is the link between
malnutrition and TB, the workers expressed their ignorance about it. It needs to be
15
 mentioned that the workers were mentioning this notwithstanding the fact that the
prevalence of TB is maximum in the Sahariya community. And the children of this
community have the highest prevalence of malnutrition.
Generally, the ASHA Worker is present at the Gram Aarogya Kendra only on the day of
immunization. There is no proper surveillance of expiry dates of medicines. It had been
decided at the Nutrition Campaign (Suposhan Abhiyan) at the block level that the health
department will organise Health Camps at village level wherein the doctors will also
train the Anganwadi Workers on dispensing medicines and in the use of equipments.
An annual allotment of Rs. 10,000/- is made from the health department towards
Village Health, Nutrition and Sanitation Committee. However, due to lack of
coordination and low level of trust amongst the functionaries, meaningful use of
available resources is not taking place.
Foodgrains given by the ration shops to the Self Help Groups of the Sanjha Choolha
Programme for providing hot cooked food to the children of 3 to 6 years is of poor
quality and at times it is infested with insects too. At times, the grain quality improves
following the complaints.
In urban areas like Baihar, a self-help group is serving 20 Anganwadi Centres (AWCs) and
only uses one vehicle for distribution of food. Thus, the food gets spoiled by the time it
reaches the last AWCs and gets delayed also. This problem in logistics needs to be
resolved. In urban areas, the AWW complained that khichri is served on all days and it
becomes monotonous for children to eat khichri every day. This depicts that in some
areas, menu is not followed.
Although, arrangement has been made to provide for a trained ASHA Worker at the
village and community level under the National Health Mission, many Anganwadi
Workers cited issues pertaining to health of children under 3 years which have remained
unresolved due to lack of supportive and responsible health check-ups.
The Child Development Project Officer in the Balaghat forum stated that he would seek
out better coordination with the Block Medical Officer so that severely malnourished
and sick children can avail the essential treatment promptly. The CDPO said that he
would initiate a conversation with BMO on the better functioning of the Gram Aarogya
Kendra.
E. Community Engagement
Community is yet to be engaged on evidences pertaining to immediate, underlying and
root causes of malnutrition. Although, now a system of the District Annual Action Plan
has been instituted, nevertheless an accelerated beginning is yet to be made for taking
up innovations at the community level.
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 The community now take illnesses like
Alumni Meet of the Anganwadi Pass Outs
diarrhoea, cough, fever etc. with a sense of
An example was shared at a Forum about an
seriousness and does seek out medical AWW of district Datia who had organised an
treatment. However, they do not yet alumni meet of those who had at some point in
the earliest years of their life had attended the
acknowledge malnutrition as a serious same Anganwadi Centre.
problem. Some of those children are now well placed
professionally and some are working as
Superstitions persist in the community, like
officers. The AWW had felt as to why the
child malnutrition and consequent alumni meet be restricted only to colleges and
weakness being perceived by the schools. It can as well apply to Anganwadi
Centres and thus she was able to bring in the
community as ascribed to evil spirit.
support and cooperation of erstwhile children
F. Maternity and Child Rights and Entitlements from the Anganwadi Centres!
Bhopal Forum of 26 newly recruited CDPOs
stated that ignoring the nutrition and
An Excerpt from the Knowledge Forum for
the Media health of women in the milieu of their
One must acknowledge that there exists a domestic and wage- work burden
native system of food security which has kept
amounts to an assault on their human
the tribal communities going over the ages.
The system has variety which includes as rights. There is need to recognise that
many as 12 types of food grains and 70-80 pregnancy aggravates this burden, and
types of vegetables! Variety in diet alone is
has implications for womans own well-
not all about food security. It is variety in soil
use also in food production. The Baiga being and that of the new-born. It calls
community employs soil in 5 ways. For for a priority attention to the issue of
example, they practice shifting cultivation.
concomitant maternity rights and
They do Bewar cultivation on steep soil tract
whereas plough on the lesser steep land. entitlements.
They produce kodo-kutki food grains on such Despite the comparative labour being
land and sow paddy in plain areas.
more pronounced and skewed against
the women as compared to men, their
nutritional needs have been ignored. What alarms is that the tribal community too is
now in the grip of gender disparity, Chanderi Media Forum apprehended.
G. Evidence-based Best Practices for Healthy and Nutritional Well-being
There is an urgent need for securing consistent and continued observance of evidence-
based practices for healthy and nutritional well-being of women and younger children.
Many of the food items of tribal community have rich medicinal value. There is
significant potential of learning from the health practices of the tribal community, the
media forum held at Chanderi noted.

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 We can learn as to how the tribal community in earlier times had been meeting its food
and nutrition needs straight from the natural sources and thus seek to re-establish the
linkage between community and its erstwhile food security resources, the Chanderi
forum for the media
Used own salary to get the dress made for children
commended. Every Poshan Samvad leaves its own imprint of innovative
Sharing of good practices helps. experiments. At the same time, one feels bad that despite
such innovations occurring, why they dont echo at the
A few examples were cited at
State/District/Centre level! Recently, in the month of July a
the Balaghat and Shivpuri nursery school was opened just in front of the Katra
forums. Whilst a Gram Anganwadi Centre in Pohri Project. A couple from Mumbai
have opened this school. Though this school charges fee,
Panchayat in district Balaghat
there is a facility for dress, seating arrangement and that
had adopted a malnourished snacks are given to the children. With the opening of the
child, an Anganwadi Worker in school, most of the children in the age group of 3 to 5 years
started going to this school.
district Datia had organised the
Anganwadi Worker, Hafeeza informs that with this
alumni meet of the Anganwadis development, our Anganwadi Centre was virtually deserted.
erstwhile children. Prompted She was concerned that if an inspection were held now, no
one would be ready to accept the real reason for the
with these cited examples at the absence of children. Further, the children who had remained
forum, a participant at the at the Centre were also getting attracted to the school. She
Shivpuri Forum, Hafeeza from decided to ask the children as to what attracted them to the
school. The children cited dress as the factor.
Pohri block shared her own
experience as to how she got Hafeeza said that in view of non-availability of any budget,
she decided to get dresses made for the children from her
dresses made for children at her own money. It helped us retain the children at the Centre,
Anganwadi Centre from her she affirms. Interestingly, she proudly says that the colour
of the dress matches with that of the growth charts for
own expenses so as to dissuade
boys and girls.
them from being weaned away
to a private school where the children were donning their uniforms!
The Anganwadi Workers informed that the Pre-School Non-formal Education (PSE) Kit
provided to them is very good and the children are able to learn very well with it.
During the media forum, it was suggested that training modules should be developed
for journalists so that they can better understand the tribal community and appreciate
as to how to cover subjects like agriculture, health and maternity entitlement in the
social milieu.

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Some Quotes from the Participants at the Nutrition Forum at Pohri Block, District Shivpuri

Usha Dixit
Krishnaganj, Pohri (Urban) Project

Such nutrition dialogues are very much needed. We have participated

in such a dialogue-centric conversation for the first time. So far, we
have only been at the listening end. When such dialogues are held, we
would be able to learn about other experiments and learn newer
things. It will motivate us. Definitely, we shall endeavour to make
better efforts in our own work situations.

Amit Yadav
Child Development Project Officer, Baihar, District Balaghat.

This dialogue is very much needed though the system does not provide
for its scope anywhere. The dialogue does help us appreciate the
problems being faced by functionaries at the ground level. It also helps us
perceive the roles of coordination more clearly. One gets an insight here
as to how to best harness the available resources, provided such
consultations are held regularly so that the issues can take shape in the
future for triggering meaningful initiative.

Hafeeza Khan
Katra Anganwadi Centre, Pohri (Urban) Project

There is need for such dialogues. They give us an opportunity to inform what we
are doing and learn from others. It is good medium to help us better understand
the problems. As it is, we are distant from the ongoing national/international
debate on malnutrition. We are only required to follow the orders. We have to
scope to intervene and modify the same. We also desire that what we share at
this dialogue should be appreciated by the people in right earnest. They should
not take it as a complaint and rather act in securing solutions for the emerging
problems.

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 The Way Forward
Following key actions may be agreed upon:
Drawing upon the support of the Mission Director, National Health Mission and the Health
Commissioner, Directorate of Health Services and having the respective district Collector on
board, a meeting at the ICDS Project level may be convened by the Directorate of ICDS at
which the following may participate:
1. Child Development Project Officer
2. Block Medical Officer
3. Block Programme Manager, NHM
4. LHVs of the block
5. ICDS Supervisors of the block/project
6. 2 ANMs
7. 2 Anganwadi Workers who have participated at the Poshan Samvad earlier
8. 2 ASHAs
Vikas Samvad may present the processes and emerging outputs of the Poshan Samvad
deliberations held at the district earlier, with accent on inter-sectoral issues, challenges and
opportunities.
A discussion may be facilitated to dwell upon areas wherein the functionaries of health may
be called upon to specifically list areas of support of the counterpart (ICDS) functionaries
which helps them perform their roles efficaciously. This discussion may bring out mutual
expectations, both fulfilled and otherwise.
The consultation may then proceed to identify priority thrust areas in inter-sectoral
convergence and select specific themes for the ensuing quarter and agree to select
theme(s) for developing a Joint Action Plan.
An effort may be made to have a team of volunteers identified from the participants which
may work on developing a Joint Action Plan, formulating implementation modalities and
draw up a joint monitoring plan.
The Joint Action Plan may be finalised in 15 days time. It may be clarified that the Action
Plan, to begin with, will not be a comprehensive action plan of the project/block. The plan
would be a skeleton one, limited to a few select themes on inter-sector convergence and
would be amenable for implementation over a small time period of 3 months.
During and post the implementation of the 3-months action plan, a documentation of
experiences shall be consolidated which will feed in to developing a fuller and
comprehensive action plan. It is at this stage that the participation would also be widened
to include participation of other counterpart functionaries, particularly those from Rural
Development and Panchayats, Food & Civil supplies, School Education and Public Health
Engineering department.
Drawing upon the emerging experiences, recommendations shall be identified for having
the requisite district and state-level mandatory directives issued.
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 Annexure I
The Fact Sheet
The first edition of Fact Sheet has been brought out in August 2014.
It provides the District Nutrition Profile. The profile includes the following:
- Total district population and gender, residence (rural/urban) and vulnerable class
(SC/ST) disaggregated proportion.
- Malnutrition status of children in the district in terms of underweight, stunting
and severe acute malnutrition.
- Changes in the malnutrition status over years 2002-2010.
It flags a question about the non-availability of data on malnutrition amongst women.
When to intervene to improve child nutrition? - A graphical display of importance of early
intervention.
Identifying the immediate, underlying and basic factors of malnutrition.
Identifying the factor-specific requisite immediate measures and challenges of availability of
data.

The Causative Factors Requisite Measures Challenges of Availability of

Data

Immediate Poor rate of initiation of No data on variety of

breast feeding, exclusive food for children.
breast feeding till 6
Lack of availability of data
months age and
on immediate factors,
introduction of
where available it is
complementary feeding
limited to rural areas.
with continued breast
feeding up to 2 years. Non-standard definitions
of indicators, and at
Poor status of awareness
variance with those by
about illnesses and
the WHO.
medical treatment.
Poor access to ANC and
high rate of anaemia
amongst women,
pregnant women and
adolescent girls.

Underlying Very poor access to No data on land

hygiene and sanitation ownership by women.
facilities. Lack of data on water and
Situation of open sanitation, no data for
defecation is alarming. children.
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 The Causative Factors Requisite Measures Challenges of Availability of
Data
Food insecurity and Hand washing data
quality of food are areas available only with
of serious concern. HUNGAMA Report.

Basic Improvement in access to Data on access to services

services is required. is old.
Plateau in rise in districts
GDP.
Lack of political will to
combat malnutrition.

Contact us @
Vikas Samvad
{A Research, Capacity Building, Advocacy Support & Ground-based Resource
Organisation}
E-7/226, First Floor, Opp. Dhanvantri Complex,
Arera Colony, Shahpura,
Bhopal 462016
Madhya Pradesh, India
00 91 755 4252789
vikassamvad@gmail.com

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