In SouthAsia, social accountability practitioners have been addressing failures in the ‘standard’ health and nutrition model. What can we learn from them? New research report Social accountability initiatives in health and nutrition: lessons from India, Pakistan and Bangladesh from Transform Nutrition and the Institute of Development Studies.
India currently has the largest number of undernourished people in the world, 212 million – only marginally below the 215 million estimated for 1990–92.
by Neha Raykar, Public Health Foundation of India
Recently, I attended a policy seminar titled ‘Transforming Food and Nutrition Landscape in Assam’ on 29th March 2017 in Guwahati, Assam. The dialogue was co-organized by the Inter-Agency Group, Assam and Coalition for Food & Nutrition Security and was attended by about 50 stakeholders comprising senior policymakers from Government of Assam and Government of India, as well as representatives from local NGOs, educational institutes, and bilateral agencies.
The purpose of the seminar [Read more...]
By Shilpa Deshpande, PhD Candidate, Institute of Development Studies, University of Sussex
Ten years before I joined the ICDS as an anganwadi worker, my cousin mother-in-law used to work here. At that time, the division of the village population between anganwadi workers was such that lower caste households were served by my mother-in-law whereas only the higher caste households were served by Lata madam, this was her rule….so… my mother-in-law’s field area was scattered across the village. Then when I joined, Lata madam said that just like my mother-in-law I should be given the lower caste communities. I refused…. I said give me any part of the village but I want half and I want it along a continuous line then only will I be able to work. This led to a fight, which continued for several days.
Meena, Anganwadi worker
Meena* is a young, field worker of the Integrated Child Development Services (ICDS) programme in Mangaon* village of Sundar* block, Aurangabad district, Maharashtra. She has been recruited by the Sundar block* administration to cater to the health, nutrition and education needs of pregnant and nursing mothers, 0-6 year old children and adolescent girls in a population of about 650 persons through a small village based centre, the anganwadi. She is one of 3 anganwadi workers in the village and joined the programme in 2010. The other two anganwadi workers were recruited in the late 80s when the ICDS programme began in the block. Meena belongs to the Scheduled Castes†, whereas Lata*, is from the dominant Maratha caste. I met Meena in 2015 as part of ethnographic fieldwork that I conducted for my PhD on understanding the governance of the ICDS programme. In the interview extract quoted, she shares that because she belongs to the Scheduled Castes, the existing anganwadi worker from the dominant caste refused to allocate higher caste households to her and insisted that she focus only on the Scheduled Caste households.
Meena’s experience is rooted in the larger Maratha-Dalit politics of the Marathwada region of the state, of which Aurangabad district is a part. Marathas have traditionally been the dominant caste in the state and more so in this region. They constitute almost 40 percent of the population, are some of the largest landholders, often holding a majority of the land and are also politically dominant. Marathas have historically occupied a majority of seats in the Zilla Parishad (district government), state legislature as well as the cabinet! Besides this, Marathas also have a historically nurtured self-image as rulers and leaders. For Waghmore (2013) the last is the most significant and the key in understanding their aggression towards the Scheduled Castes or Dalits. In Mangaon village, where Meena lives and works, and which has always had a Maratha Sarpanch (head of the village self-governance committee) there have been at least two reported incidents of Marathas attacking Dalit neighbourhoods, killing and destroying property.
Maratha dominance in the ICDS programme is reflected in that a majority of anganwadi workers in Meena’s beat‡ are Maratha even though the anganwadi worker recruitment process is designed to favour candidates from the historically marginalised groups. Political patronage, caste and kinship networks work to benefit the Marathas. Maratha anganwadi workers, whom I studied, routinely discriminated against women and children from the Scheduled Castes and Scheduled Tribes, not visiting their areas and refusing to serve them. Because of their political connections, they were also able to violate rules with impunity, often remaining absent with little or no action taken.
There is existing research on how dominant castes such as the Marathas colonise the local state to corner resources and opportunities. But Meena’s experience is significant because it emphasises that the local state, in this case the ICDS, provides a stage for the performance of caste identities – for asserting, challenging and renegotiating identities. Meena, a slight young woman, with bright eyes and an infectious smile, took on Maratha dominance in the ICDS refusing to play by the informal rules and demanding an equal footing as a programme worker. She successfully solicited community and bureaucratic support to change the decades old practice of allocating households to ICDS workers by caste.
…. I started asking the people of the village if they had a problem. I said when you admit your child in the first standard and the Zilla Parishad (District Government) teacher comes do you ask them which (social) category they are from? Should we do this, should children be placed according to the (social) category of the teacher? They said no, there is no such problem, let the children learn, on the contrary your education is better than hers so let the children be with you….I got my survey area nearly 4-5 months (after joining)… I asked Madam (the Supervisor) to come and show me my area…..then I was able to start work. (Meena)
However, Meena’s challenge to caste roles did not go unanswered. Over the next several months Lata tried in different ways to appropriate her labour and resources reproducing the material and cultural basis of her social power. One day after a particularly nasty and bitter argument, Lata attacked her saying:
…. you demand half of my survey, you tell me what to do….. its gone to your head, you should never have been recruited, stop this, working by the rules…..you Chambhar, what did you think just because you move with the Marathas…. (Meena)
Meena filed a case against Lata under The Scheduled Castes and Tribes (Prevention of Atrocities) Act of 1989 – social power was countered formally by recourse to state provided legal instruments. However, Meena had to subsequently withdraw the case as Lata threatened to file a case of sexual harassment against her husband.
Meena’s experience underscores the social embeddedness of state functionaries highlighting the ways in which the state becomes an extended arena for struggles of dominance and power. These struggles in turn shape the implementation of state programmes such as the ICDS and their governance.
Waghmore, S., 2013. Civility against Caste: Dalit Politics and Citizenship in Western India. SAGE Publications India Pvt. Ltd, New Delhi.
[*] The names of persons, villages and the block have been anonymised to maintain confidentiality.
[†] Caste is a religiously sanctioned form of social stratification such that the higher castes are considered socially pure and the lower castes polluting. The Scheduled Castes are historically marginalised groups identified by the Indian Constitution for state support including affirmative action.
[‡] A beat is a set of 20-25 anganwadis under a single Supervisor.
From 2011-2017 Transform Nutrition has been strengthening the content and use of nutrition-relevant evidence, to accelerate the reduction of undernutrition.
On the 8th July 2017 in Kathmandu, Nepal, it will host a regional meeting; ‘Using evidence to inspire action in South Asia’ the day before the joint ANH Academy Week and Feed the Future Nutation innovation Lab Agriculture-Nutrition Scientific Symposium, to highlight experiential learning from South Asian countries on key drivers to improve nutrition status.
It will feature evidence on what works in nutrition-sensitive interventions, presented to policymakers from Nepal and international donors and NGOs in the South Asia region. The meeting aims to inform and equip attendees in order to address the particular challenges of tackling child undernutrition in their current contexts.
We were delighted that one of our 2016 Transform Nutrition Champions, Basanta Kumar Kar was recently awarded an Odisha Living Legend Award for excellence in public policy. This is in recognition of his tireless work on nutrition in South Asia.
Basanta said of his award “It is very satisfying to receive this award in Odisha where I am rooted. This is the state where I experienced multiple deprivations and developed the courage and conviction to overcome these challenges. It is also where I formed my passion for helping people to make changes in their lives. I am confident that Odisha, endowed with rich human and natural resources, can move out of the clutches of a undernutrition and emerge as a talent state; a global nutrition pioneer”.
by Aparna John, PhD candidate, Institute of Development Studies at University of Sussex
Child undernutrition rates in India are among the highest in the world (Raykar et.al, 2015). Despite the decline in undernutrition indicators such as stunting (low height for age), underweight (low weight for age) and wasting (low weight for height), India is home to 40 million stunted and 17 million wasted children. The Government of India has invested in efforts to reduce childhood undernutrition and improve maternal and child health through one of its flagship programmes — the Integrated Child Development Services (ICDS) Scheme. ICDS, the world’s largest community nutrition programme, is delivered by 1.34 million village based female workers, Anganwadi workers (AWWs).
The evidence on the ICDS suggests that it is performing sub-optimally—implementation of the interventions is often poor leading to low utilisation and low coverage (PEO, 2012). Considering AWWs are responsible for the delivery of the ICDS services, improving their performance is critical for improving the overall programme performance. However, the evidence base on what shapes AWW performance is scarce. What are the facilitators and barriers in their individual, programme, community, and organisational contexts that influence their motivation and performance? These questions are either unanswered or partly answered by studies looked at the overall ICDS implementation. This research lacuna was the key reason I chose these interesting yet unanswered questions for my doctoral study. In this blog post, I would like to present preliminary findings from the explorative qualitative study I conducted to answer these questions.
In the study, I defined performance as ‘AWWs making services accessible to the required number of beneficiaries with quality (i.e. adhering to guidelines)’ derived from the literature on Community Health Workers (CHWs) and health workers in general. I interviewed thirty AWWs from varied education backgrounds, caste status, and distance (Gram Panchayat distance from the block headquarters) from two administrative blocks of one of the southern districts of Bihar. Bihar is a state grappling with a high burden of undernutrition and demonstrating renewed efforts to improve its social welfare programmes in the last decade. As shown in Figure 1, AWWs deliver a varied set of services to different beneficiary groups. I analysed the data using the hybrid method of deductive and inductive thematic analysis.
Figure 1 Anganwadi worker in Bihar
- Qualification: minimum 10th pass
- Honorarium: Rs. 3000 per month
- Main job responsibilities:
- Pre-school education for forty 3-6 years
- Supplementary nutrition
- Daily lunch for forty 3-6years
- Monthly dry rations to eight pregnant, eight lactating women and forty 6-36 months children
- Counselling (individual and group)
- Preparation for monthly Village Health and Nutrition Day to facilitate immunisation in coordination with ASHAs and Auxiliary Nurse Midwife (ANM) and growth monitoring of children and pregnant women
- Identification and referral of Severely and Acutely Malnourished (SAM) children
Preliminary key findings from the study suggest that the following factors in the individual, programmatic, and community contexts influence an AWW’s motivation and performance:
Initial financial motive rooted in family reasons as the reason for continuing with the job: Whilst some AWWs actively chose to take up the job due to “moral” motives (the opportunity to positively impact their community), for many it was their families who were the driving force. Their families tended to be more focused on the “social” motive – the prestige within the community and access to social and bureaucratic networks that came with the job. Irrespective of the wider drivers leading AWWs to take up the job, there was a strong “finance” motive for workers and their families; the salary was a key source of household livelihood.
- Service preference of the beneficiary and AWW: The ICDS services can be broadly classified as product-oriented services and information-oriented services. Services that linked to products include food distribution, immunisation and pre-school. Services linked to information are individual and group counselling. AWWs perceive that beneficiaries have a clear preference for product-oriented services over information-oriented services. This product preference positively influences the attendance of these services compared to information-oriented services. Considering the pre-school attendance is influenced by food, even when the food is not available, AWWs provide the pre-school. This leads to another type of preference from the worker towards the pre-school service because of their self-identity as a teacher, as the majority of them could not be teachers and ended up being AWWs.
- Work environment factors: various work environment factors influence AWW’s motivation, job satisfaction, and performance. A summary of work environment factors and how they influence AWWs is given in Figure 1.
Figure 2 Influence of work environment factors on AWW performance
- Caste dynamics between the AWW and community and discrimination towards the AWW emerged as a factor influencing the AWW motivation and performance. In the AWW context, when there are multiple caste groups in a community, and when the AWW is not able to satisfy any particular caste group due to the targeting of food and pre-school services, community dynamics explicitly negatively influence the delivery of services. In a few cases, physical violence was reported between the AWW and the community.
- Seasonal migration of low-income families (to brick kilns and back) creates changes to the fixed food distribution targets. This creates frictions between the AWW and the community and negatively influence her motivation and the delivery of food-related services.
Although factors influencing the AWW performance belong to different contexts, they are strongly interrelated. For example, this study considered ‘service preference of beneficiaries and AWWs’ as a programme factor; however, it is a good example of programmatic and community contexts interacting with each other and their dynamics influencing AWW performance (access of services). To conclude, the initial findings from the study suggests that any reform to improve the ICDS needs to be rooted in understanding of the self-identity of the AWWs and the complex configurational environment which she works.
Acknowledgement: This study was conducted as part of my doctoral work at the Institute of Development Studies funded by the Transform Nutrition doctoral fellowship. The field work for this study was was funded by POSHAN (Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India) project led by International Food Policy Research Institute (IFPRI).
This Odisha country brief is a summary of findings from our Stories of Change in Nutrition study.
Despite many challenges, Odisha has demonstrated significant commitment to reducing undernutrition, has expanded nationally sponsored nutrition-specific programmes, and has launched state-led initiatives relevant to improving nutrition. How has Odisha achieved these improvements and what is holding it back from accelerating progress?
By Basanta Kumar Kar*
The Coalition for Food and Nutrition Security (CFNS) convened the 2016 Global Nutrition Report launch in on 14 June in New Delhi, India in collaboration with International Food Policy Research Institute (IFPRI). [Read more...]
By Neha Raykar and Kavtia Chauhan, Public Health Foundation of India
Since the release of the India Health Report: Nutrition 2015 (IHR), the team has been engaged in disseminating the report at various platforms. We first launched the report in Delhi at a major event that featured the Ministers of Health, and Women and Child Development of the Government of India. This was a rare joint appearance of these two key Ministers and senior government officials to indicate broad support for an agenda to transform nutrition in India. [Read more...]