Results of the fifth round of the National Family Health Survey (NFHS-5), Phase-I, revealed a mixed landscape for nutrition in India. Some pressing points of stunting and anaemia see an increase in the surveyed states. The results also mark significant progress in the uptake of services. However, it does not lay any focus on the quality of parameters of the Integrated Child Development Scheme (ICDS) through which most of the nutrition services operate. With overwhelming political will and commitment at the national and the state level of which POSHAN Mission 2.0 is a piece of remarkable evidence, a major gap continues to exist.
It is time that we focus on the skills and motivation level of the human resource machinery of the ICDS i.e., our Front-Line Workers (FLWs) which sums up to approximately 1.3 million Anganwadi Workers (AWW) across India. These AWWs are a workforce that not only contributes towards the growth of the nation by ensuring timely nutrition services but is also a network that is instrumental in running campaigns and last-mile service delivery in challenging times such as COVID-19. On one hand, digitizing their reporting and capacity building is a welcome step through POSHAN Abhiyaan, additionally, it is imperative to bring in modern methods to mentor the AWW with a focus on enhancing their service delivery skills and developing a problem resolution approach. For this, we need to lay a strong foundation of supportive supervision. In that order, the term ‘supportive supervision’ denotes a process of helping staff in a respectful and non-authoritarian way. It is a process of open, two-way communication and building a problem-solving environment. It focuses on monitoring the performance towards goals, data for decision-making, and proper follow-up and feedback mechanism.
To build the foundation of Supportive supervision, India needs to recognize certain challenges faced by the ICDS. AWWs continue to exist within the ever-changing implementation activities and strategies of ICDS. They face certain common problems of – additional duties like electoral awareness, economic surveys, and extensive reporting which competes with their time to address malnutrition. There is an absence of supportive supervision to share experiences and grievances, where officials and staff at the varying level would identify their problems, question, and discuss possible solutions, potentially on topics outside of ICDS. The process of supportive supervision can ensure quality by creating a conducive environment for all stakeholders involved, especially for the FLWs. Here is how!
First, the gap of human resource crunch and delayed hiring at the district and block level must be bridged. Pre-budget briefs (for GoI 2021-22) released by the Centre for Policy Research for ICDS have shown the vacancies of Lady Supervisors (LS) and Child Development Project Officers (CDPOs), remaining at a high of 28% in India as on till September 2020. Speeding up hiring is essential to avoid the increasing pressure on the existing staff.
Second, open and two-way communication between AWWs and their supervisors, i.e., Lady Supervisors is important to improve individual performance. This would involve the use of the right tools like – (1) supervisory checklists (2) learning materials and aids to be used by supervisors during supervision visits to AWWs, and (3) proper follow-up and feedback mechanisms. A healthy interaction by the supervisor like a coach and mentor more than the ‘reporting head’ will help in building the trust. Similarly, workers need to maintain the right attitude and assess the needs of their community to have an impact story on the field.
Third, the right capacity building of workers can help in improving their skills in terms of existing knowledge and plan interventions in the community. The training methods like participatory and practical exercises, demonstrations, and Q&A sessions should be encouraged. Technology must be further leveraged by providing WebApp and logistical support to digitize the LS and AWW checklist in a Management Information System (MIS), the data of which must be discussed at district and block level to set up the priorities for the next round of intervention as well as grievance addressal of FLWs. Further, local development partners like non-profits can be roped in to train AWWs with modern pre-school education techniques. It seems important as we focus on expanding the idea of smart anganwadis.
Fourth, the inter-departmental convergence is essential in promoting effective intervention by FLWs at ground level. Accredited Social Health Activist (ASHA), Auxiliary Nurse Midwife (ANM), and Anganwadi Worker (AWW)- Triple AAA- training should be streamlined where the collective efforts of tackling Severely Acute Malnourished (SAM) and strengthening of Village Health and Sanitation Days (VHSND) should be considered of pivotal importance, for combined ICDS and Health department.
Fifth, incorporating decent honorariums and pay is essential to boost work motivation and support quality interventions with the community.
In past, India has shown successful instances of supportive supervision, especially in ensuring quality immunization coverage and capacity building of counsellors under the Sexually Transmitted Infection (STI) control program. For instance, Jharkhand recorded its story from 9% immunization child coverage to 53% based on strengthened supportive supervision from NFHS-2 (1998-99) to NFHS-3 (2005-06). Both the case studies constituted strengthening of certain common supportive supervision parameters like – robust training, counselling services, external and internal supervision, strengthened supply chain logistics, physical verification parameters, documentation, and strong feedback mechanisms.
It is to say, if the expansion of the nutrition service coverage is a primary step, then ensuring coverage through a check of quality nutrition service delivery is indeed a necessary second step. Quality of care is core to achieving universal health coverage which amplifies the need for supportive supervision. For the nutrition sector, supportive supervision offers a methodological shift that focuses on building the capacity of FLWs which will ultimately contribute to reduced systematic and logistical implementation-based hurdles.
(Priyanka Bajaj is a Nutrition Expert and Riya Gupta is Research, Content, and Documentation Officer in Project WeCan at IPE Global Limited)
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NDTV – Dettol Banega Swasth India campaign is an extension of the five-year-old Banega Swachh India initiative helmed by Campaign Ambassador Amitabh Bachchan. It aims to spread awareness about critical health issues facing the country. In wake of the current COVID-19 pandemic, the need for WASH (Water, Sanitation and Hygiene) is reaffirmed as handwashing is one of the ways to prevent Coronavirus infection and other diseases. The campaign highlights the importance of nutrition and healthcare for women and children to prevent maternal and child mortality, fight malnutrition, stunting, wasting, anaemia and disease prevention through vaccines. Importance of programmes like Public Distribution System (PDS), Mid-day Meal Scheme, POSHAN Abhiyan and the role of Aganwadis and ASHA workers are also covered. Only a Swachh or clean India where toilets are used and open defecation free (ODF) status achieved as part of the Swachh Bharat Abhiyan launched by Prime Minister Narendra Modi in 2014, can eradicate diseases like diahorrea and become a Swasth or healthy India. The campaign will continue to cover issues like air pollution, waste management, plastic ban, manual scavenging and sanitation workers and menstrual hygiene.