2011 Articles

Improving the Integration of Health and Nutrition Sectors in India

Bajpai, Nirupam; Dholakia, Ravindra H.

It is a critical time for India to prioritize nutrition in its health and development agendas. While dismal nutrition indicators persist, and the country‘s levels of hunger are considered ―alarming‖ on an international index, India is expected to miss the Millennium Development Goals targeting hunger and undernutrition. Without a targeted, multi-sectoral approach to nutrition, India is still struggling to deliver evidence-based interventions during the most important windows of opportunity. At the same time, the National Rural Health Mission (NRHM) and its Accredited Social Health Activists (ASHA) are gaining ground in delivering critical, community-based health services for women, children, and families. The current period of service delivery innovation and quality improvement presents an important opportunity to better integrate nutrition into health, and to push nutrition programming reform in the country. Recognizing this critical opportunity for nutrition programming innovation and integration in India, this report will examine the following research question: How can a nutrition strategy be better integrated into health programming? In pursuing this question, the paper intends to explore mechanisms for better integration in health planning at national, state, and district levels, and strengthened operational integration between frontline health workers and their supervisory structures. It will also examine how current nutrition efforts, namely Integrated Childhood Development Services (ICDS), can be more functional and thereby be better integrated into maternal and child health services. This report draws largely upon field visits throughout the country, and a field survey conducted in Chhattisgarh, Bihar, Uttar Pradesh, and Rajasthan with anganwadi workers (AWW), Accredited Social Health Activists (ASHA), and young mothers. Our findings from the field highlight strong needs for nutrition-focused outreach to families, and more structured collaboration between health and nutrition initiatives at community, block, district, state, and national levels. With these findings, we recommend actions to be taken within policy, human resources, and operations: We argue that India requires nutrition leadership at national, state, district, and community levels. A concrete, proactive national nutrition policy is needed to unite fragmented nutrition initiatives, hold relevant departments to nutrition outcomes, and drive nutrition programming in high-focus districts. A similar push has already been initiated by the Department of Women and Child Development. We recommend that states reinforce this commitment to nutrition by creating inter-ministerial councils to emphasize political will towards state nutrition policy and planning. We strongly recommend the creation of a community advocate for nutrition, termed an Accredited Nutrition Activist in this paper, to assume outreach operations from the anganwadi centre. This role would serve as a critical point person for community-based nutrition and an intermediary between the anganwadi worker and ASHA. This role would also seek to close critical gaps in nutrition, particularly infant feeding. We advocate mechanisms for improved targeting of nutrition interventions, particularly infant feeding. Targeting the most critical beneficiaries includes focusing on the age group under 24 months (e.g. the 1000-day window of opportunity between pre-pregnancy and two years), and high-risk families through improved outreach operations. Targeting also involves innovative approaches to delivering interventions most effectively (e.g. demonstration-education for families, home-based action), and capturing beneficiaries at critical moments for nutrition counselling and support (e.g. when a child is sick, newborn feeding and care post-delivery). We reiterate calls for an overhaul of ICDS operations, particularly in anganwadi worker supervision, training and support, food supply and distribution, infrastructure, centre timings, oversight, and data management and use for action. The recommendations presented in this paper will also be piloted within the Earth Institute/MOHFW Model District project in Assam, and in due course we will be reporting back on our findings.