Access to Nutrition in Odisha

Introduction: The Skewed Focus on Immediate Determinants of Malnutrition

Malnutrition is a universal problem, but it remains most severe in low- and middle-income countries. The global picture emphasises the continued need to prioritise commitment and multi-sectoral response to malnutrition and hunger as 150.8 million children under the age of five are stunted, 50.5 million children under the age of five are wasted and 20 million babies are born with low birth weight (Development Initiatives, 2018). Internationally, the United Nations Children’s Fund (1991) created a policy review document, strategising improved nutrition for children and women in developing countries. This framework document recognised the underlying and basic causes of malnutrition and their short- and long-term consequences.

An action-oriented approach was then evolved as part of the Lancet 2013 series, focused on nutrition-specific interventions to tackle immediate determinants of malnutrition and nutrition-sensitive interventions to address the underlying determinants. This also accounts for the role of an enabling environment to implement these interventions (Black et al., 2013). The result was a significant shift towards the international discourse on improving nutrition. While, between 2008 and 2013, attention focused on nutrition interventions in the 1,000-day window from a woman’s pregnancy to a child’s second birthday, Black et al. (2013) document the new approach of promoting the so-called lifecycle approach with a more integrated focus on adolescents, pregnant and lactating mothers, and the child. This approach advocates nutrition-sensitive programming and identifies the need to build a more robust evidence base, as this will further improve the coverage and effective delivery of nutrition-specific programmes, especially among poorer populations in need of better food security, water and sanitation, education and access to health services.

Despite the strong call for investment in nutrition-sensitive areas, the international discourse has still largely been focused on nutrition-specific interventions. This could be attributed to the lack of robust evidence on the effectiveness of nutrition-sensitive programmes on actual outcomes in specific national and local contexts. The focus of international action is thus skewed on addressing the immediate causes of malnutrition, while the underlying and basic causes, like food security, but especially access to basic services and care, are not adequately considered.

The above analysis emphasises that effective access to and delivery of nutrition programmes necessarily take place at the individual and local levels. This means that if one wants to understand how nutrition support is accessed and delivered, micro-studies based on fieldwork are required. This article therefore studies ‘access’, a key underlying determinant of undernutrition, and examines the government’s nutrition schemes for the most marginalised communities in Odisha, a tribal-dominated state of India. The study was conducted in Angul district of the state to understand how ‘access’ works in the context of two government schemes, namely the Supplementary Nutrition Programme and Mamata, a conditional cash transfer scheme for pregnant women.

Our study examined specifically the accessibility of these two schemes for Scheduled Castes (SCs) and Scheduled Tribes (STs), including Particularly Vulnerable Tribal Groups (PVTGs), the most deprived tribal groups, whose dependence on government services is known to be high. All over India, these most marginalised groups remain nutritionally worse off. The study project focused on scrutinising factors which constrain access on the demand and supply side of these schemes and also sought to provide potential solutions to overcome these bottlenecks. This research was carried out as a prelude to designing an intervention in Odisha, targeted at marginalised populations to improve their access specifically to Anganwadi Centre (AWC) services, which are delivered by government-sponsored childcare centres. These were started by the central Indian government in 1975, during the time of Prime Minister Indira Gandhi, as part of her slogan and project of Garibi Hatao (banish poverty). These services are provided as part of India’s Integrated Child Development Services (ICDS) programme to combat child hunger and malnutrition.

As these programmes are necessarily executed at local and individual level, this offers an excellent chance for focused fieldwork to examine bottlenecks of access in the evidently precarious transition from international guidance to constitutionally supported principles in national programmes, specific state initiatives and the highly diverse patterns of local service delivery within India.

Following this contextualised overview, the article first introduces the challenges faced in the state of Odisha and briefly discusses the fieldwork methodology as well as the key concept of access. Examining the key schemes, we then present the research findings and conclude with an analytical discussion and recommendations for future action.

Odisha: Progress and Challenges

Odisha, a state of 46 million people, has the third largest ST population in India (GoI, 2011). Despite challenging conditions, Odisha has made remarkable progress in improving nutrition indicators. The rate of stunting decline in the state has increased from 1.8% per annum to 2.1% per annum in the last 10 years. Menon et al. (2016) note that Odisha has performed better than rich states such as Gujarat and Madhya Pradesh in several indicators on nutrition, especially in terms of immediate determinants, according to the data they analysed for 2014–15. Notably, the state’s operational strategies included introducing eggs in the ICDS scheme, a key programme for early childhood development and nutrition.

One of the six services under the ICDS is the Supplementary Nutrition Programme, a critical nutrition intervention, providing supplementary feeding to pregnant and lactating women and children in the age group of 6–35 months through Take Home Rations and to children in the age group of 36–72 months through Morning Snacks and Hot Cooked Meals. The state also provides three eggs per week as part of the Take Home Rations and five eggs as part of the Hot Cooked Meal (GoO, 2018a). In addition, the Mamata scheme is a conditional cash transfer scheme of the GoO for pregnant and lactating women to promote better caregiving and health-seeking behaviour. The scheme provides a total of ₹5,000 to each eligible beneficiary in two instalments, subject to fulfilment of certain conditionalities (GoO, 2018b). Pregnant and lactating women of 19 years of age and above, except all government/public sector undertakings (central and state) employees and their wives, are covered under the scheme for the first two live births, a norm which has been relaxed for PVTGs.

Important for achieving better access, decentralised local structures in delivery and monitoring of the ICDS scheme were promoted in Odisha. The role of women’s self-help groups (SHGs) under Mission Shakti to provide food supplements, and the introduction of Jaanch and Matru (Mothers) Committees, specific community-based monitoring platforms, in monitoring the services have been reported to play a key role in improving the ICDS services (GoI, 2015; Menon et al., 2016). Jaanch Committees, specifically tasked with monitoring different aspects of the delivery of the nutrition programmes, are formed by 5–6 community members, usually including an educated person, such as a teacher or the president or secretary of a school management committee, one retired person, one disabled person, the Mothers Committee Chairperson and one or two members of a local SHG. These interventions in Odisha were backed at highest policy level by the political and bureaucratic leadership, making the state a success story.

However, while Odisha has much to celebrate in reducing undernutrition over the last decade, one needs to recognise the persistence of malnutrition, as 34.1% of the state’s children under five continue to be stunted, 20.4% are wasted and 34.4% are underweight, as reported by the International Institute for Population Sciences (IIPS, 2017). There are marked disparities in the nutritional well-being among different populations, with SC/ST members being nutritionally worse off. This reflects the access bottlenecks that the state faces in delivering services to the tribal populations (Menon et al., 2016), especially those that reside in hard-to-reach areas. IIPS (2017) reported that the stunting levels for ST and SC children are much higher, at ~46% and ~37% respectively. The wasting levels for STs are ~28% and underweight levels are ~49%, much higher than the average for all groups taken together.

Nutrition indicators for the most deprived tribal groups, the PVTGs, are far worse, but are unfortunately not captured in the large-scale surveys (Bulliyya et al., 2002; GoI, 2018; National Advisory Council, n.d.). The PVTGs are a group of 75 tribal groups who are considered most backward and are characterised by forest-based livelihoods, low levels of literacy, pre-agriculture levels of existence, stagnant or declining populations and subsistence economy. A detailed study of health inequities among tribal communities found that among other reasons, poor access to these nutrition programmes was one major factor that results in poor nutritional status of tribal children and women (SAMA, 2018). Access is an important underlying determinant of nutrition, as evidently even the best and well-designed programmes will fail if the target population is not reached.

Methodology Details and Defining Access

The reported challenges regarding access motivated us to study access to the government’s nutrition schemes—the Supplementary Nutrition Programme and the Mamata scheme for the SC/ST communities in the Angul district of Odisha. We define access as an amalgamation of several parameters which determine whether an individual is able to use the services provided on time, while following the norms stipulated in the scheme guidelines. The access parameters include awareness of communities about the schemes and their respective details, their ability to register for the scheme services, getting the due entitlements on time, having platforms for raising grievances if and when required, and having a mechanism for grievance redressal.

The fieldwork site, Angul district in central Odisha, is surrounded by Cuttack and Dhenkanal in the east, Sambalpur and Deogarh in the west, Sundergarh and Keonjhar in the north and Kandhamal in the south (GoI, 2011). Angul, well-known for its industrial development and economic prosperity, is a fiscally well-off district, accounting for 5.7% of Odisha’s Gross State Domestic Product. Angul had one of the highest Net District Domestic Products at ₹64,014 (in 2011–12), much higher than the corresponding figure for the whole Odisha state at ₹43,463 (GoO, 2016). However, typically, the economic prosperity of the district is not equitably distributed, with marked rural–urban differentials and wide disparities between the well-being of disadvantaged sections, especially SC/ST populations and some other groups.

The nutritional outcomes in the district, though relatively better than the state average, continue to be unsatisfactory, with ~32% of children under five being stunted, ~22% wasted and ~35% underweight. Moreover, ~60% of the district’s women in the reproductive age group are anaemic. Angul also has a high proportion of disadvantaged social groups, including 18.8% SC and 14.1% ST population, in addition to a localised population of PVTGs, whose nutritional well-being continues to be disproportionately worse, as they face particular challenges in accessing government’s nutrition schemes (GoI, 2018; IIPS, 2017). Angul was therefore purposely selected as the study district, as high economic growth co-exists with persistence of undernutrition, especially among the most vulnerable sections of the population.

The survey was conducted primarily using cross-sectional qualitative research methods, including focus group discussions, in-depth interviews and observation. The qualitative methods were combined with small-scale quantitative methods such as programme coverage and demographic surveys. The programme coverage survey was conducted to understand the status of receiving entitlements provisioned under the Supplementary Nutrition Programme and the Mamata scheme. Observation method was used to study the infrastructural facilities available at the AWCs, verify their records and count the number of beneficiaries and other stakeholders present at the time of visit to the AWCs. A quantitative checklist was used to collect secondary data from the AWC records.

The study focused on 12 Gram Panchayats in 4 blocks of Angul district: Pallahara, Chhendipada, Kaniha and Angul. A block is basically a group of villages put together for development projects. Purposive sampling was used for the selection of the study site and participants. A mix of six high-performing and low-performing Gram Panchayats was selected, based on the service delivery of respective ICDS sectors and AWCs, as well as their nutrition outcomes. Only those villages that had a hamlet/village tagged to it were selected in the poor-performing Gram Panchayats, as we already knew that distance plays an important role in determining access to the AWC services. For choosing the villages in high-performing Gram Panchayats, the opposite criterion was adopted, and we chose those AWCs which did not have any tagged villages.

The study covered a total of 346 respondents, involved in 45 in-depth interviews and 122 focus group discussions. The stakeholders interviewed included beneficiaries, service providers such as Anganwadi Workers (AWWs), Accredited Social Health Activists (ASHAs), who are trained female community health workers, and Auxiliary Nurse Midwives (ANMs), village-level health workers based at the government health centre and the first point of contact between the community and the government health system. Also, lady supervisors of the services, members of Jaanch and mothers community monitoring committees, ward members and village leaders (sarpanch) were interviewed. The study was conducted by the authors during February and March 2019 and detailed fieldnotes were kept, initially prepared in Odia language on a daily basis, and then subsequently translated into English. The notes were then structured under four specific heads, challenges and bottlenecks, motivation, knowledge process and roles, and relationships. Data grouped under these heads were then analysed and interpreted for presentation in this article.

Key Findings

As expected, the study revealed challenges in access to the two nutrition schemes in Angul, especially for the most deprived sections in the villages. Five clusters of factors, which were identified to restrict access to the two schemes, are summarised below.

First, lack of awareness, transparency and proactive disclosure of information about the schemes at community level hindered people’s access to the schemes. Most beneficiaries were not aware of their complete Take Home Rations entitlements, such as the number of eggs or the quantity of a local high-protein food supplement (chhatua). They mostly did not know the menu for morning snacks and hot cooked meals, conditionalities for Mamata and timings of when Mamata instalments were due. In our sample, pregnant women received only 50% of eggs under Take Home Rations in the last 6 months, and most women were not even aware that they were getting less than the stipulated 12 eggs per month. Given the low awareness levels about entitlements, most beneficiaries in our sample received only 8–10 eggs per month, instead of the 12 due to them. Similarly, growth monitoring, a service under the Supplementary Nutrition Programme, is critical for tracking the nutritional well-being of children. Unfortunately, not many beneficiaries were aware of growth monitoring, which should happen every month for children.

Similarly, under the Mamata scheme, none of the women interviewed had complete knowledge of the conditions they had to fulfil to obtain the two payment instalments under the scheme. They also did not know when their respective Mamata instalments were due for payment, making it an indefinite wait for several women. In our sample, only 48% of the eligible women had obtained the first Mamata instalment, and women receiving the second instalment included some whose instalments were due from the previous year. We also found that the payment of Mamata instalments was not contingent upon fulfilment of the scheme conditions as per the Mother Child Protection cards, which record the key maternal and child health services provided to a mother and her new-born. Beneficiaries shared that they did not have to meet all conditions to obtain the instalments. Frontline workers filled the relevant columns in the Mamata forms submitted to the block administration, without corroborating details with the beneficiaries’ Mother Child Protection cards. In our sample, 24% of beneficiaries had received the first instalment, and 93% had received the second instalment even though the scheme conditions were not completely, or only partially, fulfilled according to the Mother Child Protection card. All of this results in the objective of the scheme, better health and nutrition for mothers and children, not being fully achieved.

Lack of awareness of scheme details also proved a major factor in restricting access to complete entitlements. The frontline workers did not adhere to the scheme guidelines of displaying the scheme details at the AWCs and most did not pro-actively share this information with the community, especially in distant hamlets. Since beneficiaries did not know the details of the services they were entitled to, they did not demand their rights or raise grievances when they received less than their due. In most of the cases, they were deprived of their complete entitlement. Lack of demand also weakened the accountability of the government system to provide these due services and entitlements. Additionally, this resulted in leakages and wastage of government funds, as the money and the nutritional items did not reach the entitled beneficiaries.

Second, the distance of the tagged hamlets from the main AWC is another important factor restricting access. Tagged villages may be as far as 3–8 km from the main centre, making it tough for beneficiaries to access the Supplementary Nutrition Programme. In most cases, young children entitled to morning snacks and hot cooked meals missed out, as they could not navigate the distance on their own. We found that on average only ~17% of registered children attended the AWC on any given day. As a result, only 32.5% of the children aged 36–72 months got their morning snacks and hot cooked meals regularly, supposedly on a daily basis, in the five weeks preceding the survey. On average, children of 36–72 months received morning snacks only on 29% of the days and hot cooked meals on 54% of the days in the five weeks preceding the survey.

Regarding Mamata services, distance and difficult terrain made it arduous for pregnant women to access banks, the average distance to the bank being 14 km in our sample, and to attend Village Health and Nutrition Days, necessary for fulfilling Mamata scheme conditions. The complete conditions for the first instalments were not fulfilled in 70% of cases, while none of the women had fulfilled all conditions necessary for the second instalment.

The schemes’ services could be ensured by setting up mini-AWCs in eligible hamlets according to the scheme’s population norm. The Ministry of Women and Child Development had provided for this in small hamlets/pockets in tribal blocks in far-flung and remote areas, with the aim to make ICDS universal (National Institute of Public Cooperation and Child Development, 2014) and bringing the ICDS services closer to the communities, who at present are deprived of them. We found that a large number of hamlets were eligible for a mini-AWC but did not have one. According to the ICDS guidelines, a hamlet/village with a population of 150 persons or above is eligible to have a mini-ACW. Under existing cost norms, setting up a mini-AWC would cost the administration ~₹7.7 lakh. This includes the cost of constructing the building, providing a Pre-School Education Kit, which is a package of learning and play materials aimed at preparing the children for formal school and developing their cognitive and motor development, and the cost of an AWW, according to the existing scheme norms. About 85% of this amount is one-time cost and the remaining are recurrent costs.

Most often, hamlets inhabited by SCs or STs did not have their own AWC and were tagged to the centre in a distant main village. In our sample, almost all tagged hamlets were SC or ST hamlets. The issue is most severe in tribal areas, where long distances are compounded by difficult terrain, with streams, forests and hilly terrain, making it even more difficult to navigate the distance to the main AWC for accessing the Supplementary Nutrition or Mamata services.

Distance also restricted access to scheme information. Respondents shared that the AWW or helper hardly ever visited their hamlets to inform them about the scheme or told them when the Take Home Ration distribution or the Village Health and Nutrition Day would take place. Most often information reached these hamlets last and late. In the absence of prior information regarding the dates, time and details of scheme services, persons in tagged hamlets thus failed to avail the scheme services on time and ended up losing that month’s entitlements. This, compounded by visible forms of caste-based discrimination and skewed power dynamics, further restricted their access.

Third, and closely linked to this, caste-based power dynamics led to inequitable access. SC/ST beneficiaries shared that they were mistreated, facing verbal abuse or were made to sit separately by the AWW and helper. This made them hesitant to use the schemes. Women shared that ‘some mothers of lower castes were not allowed inside the AWW’s house and had to wait outside the gate to collect the Take Home Ration’. SC/ST communities mostly resided in the tagged hamlets, where access to ICDS services and the relevant information was poor. SC women shared that the AWW did not tell them when the Village Health and Nutrition Day is happening, thus they could not adequately access such services, critical for fulfilling the Mamata conditionalities.

We also found that SC/ST persons remained excluded from positions of power in the ICDS service delivery structure. In our sample villages, ~65% of the population comprised of SCs/STs, but there was no SC/ST AWW, and SC/ST representation in community monitoring platforms like the Jaanch Committee was less than 30%, making it difficult for them to raise any issues faced in accessing scheme entitlements.

Fourth, the community monitoring platforms for the two schemes remain weak and ineffective, because of which scheme beneficiaries and communities are not able to raise grievances when they face any difficulty in accessing the schemes. This, in turn, restricted further demand. The Jaanch and Mothers Committees were mostly non-functional, and the capacity of members for grievance redressal was limited. They themselves were unaware of the schemes’ details and their own roles in scheme implementation. Absence of any orientation, training or capacity building on the two schemes for the Jaanch Committee and Mothers Committee members resulted in limited capacities of these members for grievance redressal. In some cases, members were not even aware that they were part of the committee, as the AWW chose them without any consultation or consent, and others lacked incentives to carry out their functions. The communities too were not informed about the formation or roles of the committees, did not know who the members were and thus could not approach them about grievances. While guidelines stipulate that the AWW should display important scheme details such as scheme entitlements, names of Mamata beneficiaries, names of committee members, among others, at the AWC, in practice this was not done. The names of committee members were displayed only in half of the AWCs visited. The community shared that they had never seen any committee member during the Take Home Ration distribution or inspecting the morning snacks and hot cooked meals. Several existing grievances pertaining to the schemes thus remained unaddressed, constraining access.

As a result, the two committees could not become an effective nodal point for grievance redressal. One important demand from the communities was for an accessible platform to raise and resolve their grievances if they faced any issues in accessing scheme services. The communities shared that they would be more confident of voicing their demand for services if they were assured of having their issues heard and resolved.

Fifth, lack of education among the beneficiaries also impacted on access. About one third of the women included in the study were illiterate, and only 43% had educational qualifications of 8th standard or higher. Discussions with AWWs and beneficiaries themselves revealed that many beneficiaries found it difficult to manoeuvre the systems for opening bank accounts, registering themselves at the AWC and arranging the required documents, which delays the process of registration. Several women did not have Aadhaar cards, had incorrect particulars on the card, or the cards were not linked to a bank account.

Conclusions

Access is an important underlying determinant of undernutrition and becomes especially significant for most marginalised communities such as the SCs/STs and PVTGs. Our study suggests that access cannot be a factor of awareness and registration of services alone. It has to move beyond this to consider and check whether the beneficiaries are actually receiving their entitlement in the right quantity and quality, and in a timely manner. The study in Angul not only raised important challenges that need to be addressed to tackle the issues around access but also gave us insights on potential solutions. Most of the following suggestions were raised by the communities who were most affected by defects in the existing arrangements.

The study thus concludes that there is a need to focus interventions on geographies that are hard-to-reach and on SC/ST populations. The state should invest in campaigns that inform beneficiaries about details of relevant schemes and services under the AWC structure, along with steps they can take if they do not receive the benefits they are entitled to. Given that the GoO is one of few to provide eggs under the Supplementary Nutrition Scheme, for example, communities need to be aware of the benefits of demanding and consuming these eggs.

Odisha is unique to the extent that it has community monitoring mechanisms such as the Jaanch and Mothers committees. The state should focus on their training, not just to build their capacity but also for them to feel empowered. It is important that these committees include SC/ST representation. At the village level, these committees could become the first point of grievance redressal for beneficiaries as they have a role in monitoring the AWC services. Training of all ICDS cadre on dealing with grievances could go a long way in improving access. Our experience suggests that a working grievance redressal model at the village level can help in utilising the district funds effectively.

Finally, the provision of mini-AWCs in hard-to-reach areas would help in the delivery of services to marginalised communities. Many beneficiaries in tagged hamlets demanded such a centre, so that their children are regularly provided with morning snacks and hot cooked meals. The Indian state has a constitutional obligation to implement such schemes and to do so efficiently. The GoO is already a role model in nutrition interventions and is ready to introduce initiatives that improve accountability and citizen participation at the Anganwadi level. Clearly, Odisha could further improve its nutrition indicators by facilitating access especially for SC/ST populations.