On 8th March 2018, Prime Minister Narendra Modi launched the POSHAN Abhiyaan to attack one of the most critical evils of India-malnutrition. Prime Minister’s Overarching Scheme for Holistic Nutrition (POSHAN) Abhiyan brought about a significant shift in the country’s approach in dealing with malnutrition, transitioning into mission-mode envisaging multi-dimensional attacks on the causes of the problem and related issues. A planned launch on International Women’s Day was not an empty symbolism either, but a forebear of the mission’s focus on women through guided efforts to enhance nutritional outcomes for children, pregnant women, and lactating mothers.

The POSHAN Abhiyan is extremely relevant since it prioritizes a lifestyle-based aspect of health, which often goes ignored in policy discussions on India’s healthcare and health issues. India leads the rank chart with the highest number of stunted children at 51% of the child population and 49% of the same population are wasted children. While the suffering and deprivation of India’s disadvantaged are common knowledge for even a minutely aware Indian, these numbers do come across as shocking, as they indicate that half of India’s child population suffers from malnutrition and related health outcomes. The shadows of these are permanently cast over the lives of children, who now face other repercussions like lowered educational potential and scant professional opportunities later in life. As pointed out by Banerjee and Duflo in their book ‘Poor Economics’, one of the leading harbingers of the poverty trap is a nutritional deficiency, more commonly understood as ‘hunger’. 

Talking of women, about 53.1% of them in India suffered from Anaemia (in 2015-16), with long-lasting damages made to future pregnancies and a high probability of birthing an anemic child. The lack of awareness and availability seeps into the upbringing of newborns, leading to an abysmally low prevalence of healthy breastfeeding. Only 9.6% of children below two years of age receive an adequate diet.   

POLICY AND NUTRITION

India has been running its Integrated Child Development Services (ICDS) Scheme for 45+ years now, integrating health, educational and nutritional interventions through the network of Anganwadi Centres. There also came smaller programs for the cause of enhancing nutrition in India, which later got absorbed into the larger POSHAN Abhiyan aimed at a malnutrition-free country by 2022. The PMMVY, Anganwadi Services, National Health Mission, Scheme for Adolescent Girls, Swachh Bharat Mission, Public Distribution System, and MGNREGS are some of the programs that have been dovetailed into a multi-ministerial convergence to ensure a wider reach and efficiency for the POSHAN mission.  

The NITI Aayog identifies 9 strategies or pillars for the successful rolling out of the POSHAN Abhiyan. These are- ICDS-CAS (Common Application Software), convergence, behavioral change, IEC advocacy, training and capacity building, innovations, incentives, and grievance redressal.

Source: Niti Aayog, WCD Division (2020). ‘Accelerating Progress of Nutrition in India: What will it take?’

The ICDS-CAS is an innovative web and mobile application that connects Anganwadi workers, health supervisors, and other on-ground or backend stakeholders in daily tasks, work assessment/feedback, and service tracking. As of December 2019, the ICDS-CAS has been launched in 27 States and Union Territories across India, however, the penetration of the technology is highly uneven across the States. To illustrate, in States like Assam, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan, and Telangana, the technology is available to only fewer than 35% of the Districts. A general skepticism among on-ground workers or supervising staff to use these mobile applications or the web has also been noticed, which leads to a gap in the efficient technology-based flow of information. In 7 States of India, less than 25% of supervisors used the technology and in some States like Goa, Kerala, Daman & Diu, the ICDS-CAS was not used at all. The Incremental Learning Approach (ILA) is the primary capacity building instrument where frontline workers are trained through innovative learning-by-doing methods. Nevertheless, the scope of any capacity building remains limited and uneven because of multiple delays in the roll-out and a sluggish pace of implementation in States like Assam, Karnataka, Ladakh, Arunachal Pradesh, so on and so forth.  

To deal with a multi-sectoral challenge, the POSHAN Abhiyan seeks to converge multiple government departments and levels to ensure efficiency. As effective as this sounds in theory, the approach has run into practice-based roadblocks. Under the guidelines, States, Districts, and Blocks are mandated to conduct quarterly review meetings, however, at the closer to grassroots levels of Blocks and Districts, the discussions are more often than not generic and fruitless.

On the brighter side, the mission prioritizes the behavioral aspects by unleashing strategies for Behavioural Change Communication and Community Mobilization. Several media such as door to door publicity, television, social media, radio, and posters were used to launch a Jan Andolan or people’s campaign to sensitize the population about the benefits of schemes falling under the mission. On-ground workers were trained to counsel midwives and pregnant women on the importance of nutrition. However, the behavioral campaign is at a comparatively nascent stage, with only 9 out of 11 World Bank Priority Indian states having their plans approved and States like Tamil Nadu and Karnataka yet to develop their strategy. 

NITI Aayog seems to be aware of the implementation impediments and has formulated recommendations for enhancing the effectiveness of the mission. Technology is an important focus, with a clear need identified to procure more phones and train more providers/managers to ensure that distribution is equitable across all regions and not limited to the most developed/larger ones. It is assumed that increased availability will ensure distribution to the marginalized States as well. Besides scaling up the technology and conducting regular State-based assessments, the NITI Aayog must also attack the reservations against the use of technology on the part of front line workers by introducing counseling in addition to the usual ILA training. According to NITI Aayog, ILA will also benefit from increased investments which enhance the quality of growth monitoring. 

Concerning convergence, the organization feels the need to decentralize the process in reality by allowing more ownership and flexibility in taking financial/operational decisions to the district level stakeholders. This would be a mode of incentivization to take discussions on the mission more seriously rather than conducting it just for the namesake. It also points out a need to identify gaps in effective household convergence using empirical analysis, data visualization, and sensitization processes. Furthermore, the World Bank suggests formulating a set of indicators that can guide the Convergence Action Plan meetings, bring in substance, and help track progress.

According to the data collected on the Jan Andolan for behavioral change, home visits are the most effective tool. Hence, to include remote tribal areas, difficult to reach regions and extremely underdeveloped locations, secondary media should be dropped and direct sensitization programs must be encouraged. 

The POSHAN Abhiyan is undoubtedly holistically structured. While the NITI Aayog yearly reviews the progress and successfully understands pitfalls in implementation, the latent challenge is to accept a reiterative approach. Only when the policymakers are willing to make necessary upgrades in the implementation plan and not merely report progress, will the goal seem clearer and closer.

By Malavika Ranjan, Research Associate, Policy, LQF