The Registrar General of India has confirmed that India’s maternal mortality ratio was 97 in 2018-2020. From 2001 to 2003 it was 301. The infant mortality rate was 58 in 2005. In 2021 it was 27. If we have reason to be less unhappy, we still have a long way to go. However, the pace of decline accelerated after 2005.
The National Rural Health Mission (NRHM) was launched in 2005 to provide accessible and affordable health care through a public primary health care system. And to provide secondary and tertiary care services in public systems alongside private capacity to provide good quality services at efficient prices. Unfortunately, allocations for NRHM have not kept pace. But, it seems to have had a positive impact on many indicators. Healthcare facilities began to look better with untied funds, doctors, drugs and diagnostics became a reality, institutional deliveries jumped, vacancies for ANMs (auxiliary nurse midwives) and nurses began to be staffed, and the community ASHA officer began to pressure public systems to work. bringing in patients.
What explains these gains?
First, the NRHM had a clear focus on building credible public primary health care systems. Communicating with the community, human resource capacity was strong and flexible financial resources were available at all levels. Second, central, state and local government partnership with civil society, with the full involvement of frontline workers, has been a goal. Planning had to start from the bottom. Community monitoring was led by civil society. Third, the approach was pragmatic and provided for a variety of state-specific interventions. The decentralized planning process, where states developed their annual plans based on district health action plans, became the norm.
Fourth, institutional strengthening has been facilitated by working with panchayats and facility-specific Rogi Kalyan Samitis or hospital management committees. Civil society engaged in community action through the Population Foundation of India. Professionals have been mobilized to improve the processes. Over 60% of the funds were to be spent at the district level and untied grants were made available to all levels of the health facility.
Unfortunately, nutrition has not seen this kind of initiative. The Fifth National Family Health Survey 2019-21 indicates that 35.5% of children under 5 are stunted, 19.3% are wasted and 32.1% are underweight. These are unacceptable levels. The Poshan Abhiyan, although innovative, still does not meet the challenge of institutional decentralized public action.
Unfortunately, in our nutrition initiatives, we have remained siloed and fragmented. ICDS is seen as a nutrition initiative, but the institutional role of local panchayats and communities with untied financial resources still lags behind. Nutrition does not lend itself to narrow departmentalism and such broader, non-institutional partnerships are doomed to failure.
The multidimensional nature of undernutrition makes it imperative to redesign the ICDS to converge with health, education, water, sanitation and food security at all levels, under the umbrella of local government. Given the diversity of conditions, it is important to enable context and needs specific prioritization in each Anganwadi center by allowing flexibility through decentralized local action, enabled by accountable decentralized funding.
The 12 principles of reorganization for nutrition success should be: (i) Let the gram panchayat, gram sabha, livelihood mission women’s collectives and other community organizations be responsible for education, diverse health, nutrition, skills and livelihoods; (ii) committees led by the panchayat of the wider departments concerned are also needed at the level of block and district zila parishads; (iii) operationalize the village-specific planning process with decentralized financial resources; (iv) enable simultaneous interventions for all broader determinants of nutrition; (v) assess additional care providers with capacity development to provide home visits and follow-up intensity needed for nutrition outcomes; (vi) encourage the diversity of local foods, including millets, served hot; (vii) ensuring the availability of basic drugs and equipment for health care and growth monitoring in each village; (viii) intensify communication for behavior change; (ix) institutionalize monthly health days in each Anganwadi center with community connection and parental involvement; (x) create a platform for adolescent girls in every village for empowerment and livelihood diversification through skills; (xi) decentralized district plans based on village plans should be the basis of interventions to ensure that Anganwadis do not face deficits such as lack of buildings or unrelated resources; and (xii) shift to a rights-based, “leave no one behind” approach to ensure universal coverage of under-six, adolescent girls and pregnant women for all needs.
The challenge of undernutrition can be effectively addressed in a short period of time if the orientation is correct. The recently released NFHS-V highlights the unfinished agenda and slow decline of undernutrition. Nutrition as a subject does not lend itself to narrow departmentalism. It calls for a whole-of-government, whole-of-society approach. Technology can at best be a means and surveillance too must become local. Panchayats and community organizations are the best way forward. But the challenge of nutrition is also a challenge of empowering women. This requires behavioral change in favor of exclusive breastfeeding, natural foods instead of junk foods, clean water and sanitation.
We should never give up on our efforts to create a credible public health system. Let’s begin to rethink our nutrition initiative, learning from successes and failures.
The writer was in the IAS. Views are personal
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