What The POSHAN App Tells Us About Malnourishment In India And The Fight Against It

Watching my children grapple with issues of diet and nutritional support of grandchildren, I am reminded of the huge contrast between disinterested children whose parents hassle to force-feed them and the children without access to nutritious food or any food whatsoever.

Quite a dampening thought and I started exploring the extent of malnutrition among children.

As per National Family Health Survey (NFHS)-4 conducted during 2015-16, 38.4 per cent of children in 0-5 years age group were ‘stunted’ (low height-for-age) and 21 per cent were ‘wasted’ (low weight-for-height). NFHS-5 conducted during 2020-21 showed some improvement in these ratios to 35.5 per cent and 19.3 per cent.

Women and Child Development (WCD) Ministry recently informed that 3,323,322 children are malnourished, of which 1,776,902 are ‘severely acute malnourished’ (SAM) and 1,546,420 are ‘moderately acute malnourished’ (MAM) children as of 14 October 2021.

World Health Organisation defines SAM by very low weight-for-height or a mid-upper arm circumference less than 115 mm or by the presence of nutritional oedema. MAM is defined as moderate wasting and/or mid-upper-arm circumference (MUAC) greater or equal to 115 mm and less than 125 mm.

How has the Ministry counted these children? Have all children been counted with proper tagging of their nutritional status?

This data is based on POSHAN tracker Mobile App downloaded by Anganwadi Workers (AWWs) working in Anganwadi Centres (AWCs) to record the nutritional status of pre-school children (0-6 years), pregnant and lactating mothers and adolescent girls.

AWCs provide various services like immunisation, health check-up and referrals - and non-formal education/counselling and supplementary nutrition in the form of hot cooked meals served in situ and Take Home Rations (THR) for special needs children.

An AWC is a common delivery point for health, nutrition and educational services, so part of the expenditure is pooled by the Health Ministry, the WCD Ministry and the concerned state governments.

By the end of Dec 2019, there were 1,380,796 operational AWCs with 1,329,138 AWWs against sanctioned strength of 1,399,697 AWCs with 1,399,697 AWWs (1 AWW per AWC).

The AWCs is a network of service delivery points created under the Integrated Child Development Programme (ICDS) launched in 1975, in which the World Bank is also contributing financial support.

Earlier, monitoring and recording weight/height of children was manual, but now the data is being uploaded in a central database through the App.

Prior to 2005-06, supplementary nutrition was provided by the states, and centre covered its administrative cost. Then centre started sharing 50 per cent expenditure on nutritional component. (Changed to 90 per cent central funding for North Eastern States from 2009-10).

In Oct 2012, the scale of financial assistance (per beneficiary per day) under ICDS was raised to Rs 6 for children aged 6-72 months, Rs 7 for pregnant women and lactating mothers and Rs 9 for severely malnourished children (6-72 months).

The cost norms of Supplementary Nutrition Program were revised in October 2017, and the Anganwadi Services were rationalised with revised scope, structure and cost sharing ratio in November 2017.

Anganwadi Workers are community volunteers who are paid honorarium with some additional benefits like insurance cover. In 1975, an AWW was paid an honorarium of Rs 100 per month (Non-Matriculate) and Rs 150 per month (Matriculate). Aanganwadi Helper (AWH) was paid Rs 35 per month.

Effective 1 October 2018, central government has enhanced the honorarium of AWWs in AWCs from Rs 3,000 to Rs 4,500 per month; AWWs in mini-AWCs from Rs 2,250 to Rs 3,500 per month and of AWHs from Rs 1,500 to Rs 2,250 per month.

Government also introduced a performance-linked incentive of Rs 250 per month for AWHs. AWWs are paid performance-linked incentive of Rs 500 per month for using ICDS-CAS (Common Application Software) under POSHAN Abhiyaan. Most states/UTs are giving additional monetary incentives to these workers out of their own resources.

The expenditure on ICDS programme has ranged between Rs 18,000 crore to Rs 20,000 crore in last five years.

In March 2018, POSHAN Abhiyaan (National Nutrition Mission) was launched with the aim to bring down stunting of children in the age group of 0-6 years from 38.4 per cent to 25 per cent by March 2022 with a total budget of Rs 9,046.17 crore. (50 per cent from government source and 50 per cent from IBRD) Rs 2,700 crore has been budgeted in BE 2021-22 for this.

The programme seeks to use technology for a targeted approach and convergence strives to reduce the level of stunting, undernutrition, anaemia and low birth weight in children, as also, focus on adolescent girls, pregnant women and lactating mothers, thus holistically addressing malnutrition.

The scheme envisages providing cash incentives directly to the bank, post office account of pregnant women and lactating mothers in DBT mode during pregnancy and lactation.

In this background, it was distressing to note that in the Global Hunger Index (GHI) 2021 report released on 16 October, India slipped to the 101st rank among 116 countries. In 2019, India’s rank was 102 out of 117 countries and in 2020, it was 94 out of 107 countries.

Each year’s report is based on preceding four years’ assessment in which GHI score is computed for each country by using statistics of child mortality (33 per cent), undernourishment (33 per cent), and 16.5 per cent each of child wasting and child stunting.

India’s GHI score has diminished from a 2000 GHI score of 38.8 points considered ‘alarming’ to a 2021 GHI score of 27.5 considered ‘serious’.

If a country’s ranking changes from one year to the next, it may be in part because it is being compared to a different group of countries.

The most important parameter adversely affecting India’s ranking is child stunting. About one sixth children reportedly continue to be underweight for their age.

The data used in the GHI ranking exercise has been officially challenged by the government and hopefully more robust data will be made available for GHI-2022.

Several questions naturally come to mind.

Since AWCs are implementing multi-Ministry programmes with financial support from both the central and state government, there is no single source of information about the profile of total expenditure on AWCs. Is adequate budget provided by all the governments? Is the budget for purchase of food adequate? Is administrative expenditure of running AWCs (Honorarium etc.) increasing at the expense of food budget?

Has the system created perverse incentives to report high incidence of underweight children? Is it rural-urban issue? Are far too many healthier children out of the ‘weight-to-age’ monitoring system?

The data at https://poshantracker.in/ changes as and when fresh data gets uploaded. The data captured yesterday (16 December) at 7.40pm shows that 1,297,865 AWCs and 1,362,724 AWWs are registered on the POSHAN App; 1,706,016 children attended the AWCs, and 43,744 children were issued THR. Pregnant women, lactating mothers, children from 6-36 months and adolescent girls are entitled to THR.

As per 2011 census, there were 15.8 crore children in the 0-6 years age group. The current number is not known but it is clear that a lot of children are either not linked to any AWC or not availing its service.

How can the situation be improved? Technology is no doubt a great help. Several NGOs are helping in reaching out to needy children. Additional help can be provided through Civil Society oversight. Can AWCs be connected with local community leaders for enhanced oversight and support?

This article was originally published as a post on Subhash Pandey's Facebook page and has been reproduced here with permission.