At Outlook Poshan Awards 2019, Dr Alok Kumar, IAS, Advisor - NITI Aayog, Dr Rajan Sankar, Advisor - Nutrition, TATA Trusts, Dr Purvi Mehta, Head of Asia - Agriculture, BMGF, Devjit Mittra, Vice President, Azim Premji Philanthropic Initiatives discuss how can we make nutrition a household word. The session was moderated by Ananya Awasthi, Assistant Director - Harvard India Research Centre, Harvard T. H. Chan School of Public Health.
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NewsTranscript
00:00 Potion is not the responsibility of few, it is the duty of all.
00:10 Until each and every citizen of this country feels the urge and the need to address potion,
00:15 it will be difficult to achieve the larger objectives that we have.
00:18 And for this, there is a need to disrupt the existing paradigm and make potion a household
00:23 word.
00:24 But how do we do that?
00:26 Coming up next, we discuss this in our potion roundtable.
00:29 Please welcome to the roundtable, the Vice President of Azeem Premji Philanthropic Initiative,
00:34 Mr. Devjit Mitra.
00:38 The Head of Asia Agriculture, Bill and Melinda Gates Foundation, Dr. Purvi Mehta.
00:46 The Senior Advisor Nutrition at Tata Trust, Dr. Rajan Sarkar.
00:54 And Advisor Neeti Aayog, Dr. Alok Kumar.
01:00 And could I also request to moderate this session, the Assistant Director, Harvard T.H.
01:04 Chan School of Public Health, Ananya Awasthi.
01:11 As we all know, nutrition as a program area has been around in our policy discourse for
01:16 some time now.
01:18 But the thematic focus for this current roundtable is disrupting the paradigm.
01:23 Before we jump right into that, what do we even mean by disrupting the paradigm?
01:27 A simple applied answer would be when the usual way of thinking or doing something is
01:32 replaced by a new way.
01:34 So how about we start the discussion with the first simple yet fundamental question
01:39 posed to Mr. Alok Kumar.
01:42 How is potion abhiyaan any different from our past policy efforts in nutrition?
01:48 And can you identify two or three major disruptors that you think seem to be working well?
01:54 So thank you so much.
01:56 It's an honor and privilege to be here.
02:00 So in what ways is potion abhiyaan different from other programs?
02:08 There are four basic differences to my mind.
02:11 Number one is the first and foremost is clear focus on outcomes.
02:17 So two percentage per point per annum reduction in stunting, two percentage per point reduction
02:23 in wasting, underweight, anemia.
02:26 So everything is clearly defined.
02:28 Point number one.
02:29 Point number two, for the first time we try to bring nutrition and food as separate things.
02:39 So nutrition not equal to food.
02:40 I think that is the second major important thing.
02:43 So we are trying to bring all the players together, health, WCD, water sanitation, panchayati
02:55 raj rural development, education, agriculture.
02:58 So that combined effort is the convergence of all programs and this potion mission actually
03:07 being an overarching umbrella under which we are trying to bring all together because
03:12 unless we simultaneously act on all these things we will get suboptimal results.
03:16 That is the second major change which I have seen.
03:19 The third I would say is the issue around how do you get community involvement around
03:28 this.
03:29 So the whole question of how do you build a Janandolan.
03:31 So nutrition, at least in malnutrition, is almost in your face but if you ask people
03:37 in the villages, if you ask people in the cities they would not say that that is a problem.
03:43 So first, so what are you fighting?
03:45 You are fighting something which people do not even consider a problem.
03:47 So how do you bring people into the debate, people into managing their own affairs, understanding
03:54 the problems and a large part of the behavioural change component, the demand side which was
03:59 you know largely left.
04:00 So we were very good, government is very good at supply side interventions.
04:03 So you create the best technical interventions.
04:06 But who is to consume those interventions are not really worked on.
04:12 So this is a major improvement in this.
04:15 And the fourth point I would say is really the use of technology in a sense of very,
04:21 very clear focus and trying to get data on a real time basis so that you can act in a
04:28 preventive manner rather than as a reactive manner.
04:31 So these four.
04:32 And lastly the fifth point which I think also you know is worth stressing upon is to really
04:41 focus on, so there are 1000 things that can be done but given the capacities of our frontline
04:51 workforce to deliver you have to really prioritise and their prioritisation has been done in
04:57 terms of what are those interventions which are required in the first 1000 days and really
05:02 going after them on both dimensions on ensuring that those, so I mean I was just seeing Purnima
05:10 has just supplied me a slide which says that if you look at all those interventions only
05:15 5 to 10% of the families are reaching, getting all those interventions that they should be
05:20 getting in that case.
05:22 Because you may be doing some things well for instance on humanisation as Rajesh said
05:26 we had a lot of progress on humanisation.
05:29 But if you see deworming, if you see IFA tablet consumption, so if you look at the entire
05:34 package of interventions we are not able to reach every family.
05:37 The second dimension is even if we are able to reach what is the quality of the service,
05:41 so we have this aspirational district programme and where we are looking at measuring these
05:48 and asking the households what exactly is going on in these districts and we found that
05:52 a full 32% of the women who were surveyed who said they had received ANC services said
05:58 that neither their weights were taken nor their blood samples were taken nor their urine
06:02 samples were taken nor their blood pressure was measured, so I don't know what ANC did
06:07 we do with them.
06:08 So the good thing about this programme is really to focus on covering a larger number
06:14 of people trying to target the systematically excluded households and lastly to make sure
06:22 and that is less apparent now but I think it requires much more greater effort that
06:28 the services that we are giving is delivered with the quality that they are supposed to
06:32 be delivered.
06:33 So these are the five things which I thought were critical elements and this would make
06:37 a difference between the success and failure of this mission.
06:40 Thank you.
06:41 Thank you so much for giving us that overview and talking about delivery of services on
06:46 the ground and the quality of services delivered.
06:50 Have you seen any movement towards reviving the Anganwadi centres and do you see any changes
06:56 coming about in the ICDS ecosystem which will continue to be the point of delivery for most
07:02 of these services?
07:03 Yes, thank you.
07:04 I think more than one speaker very clearly said that Anganwadi centres are the centre
07:13 where everything has to happen and I think it was very well said about the concept around
07:20 Anganwadi and the services that are there are very robust and they are scientifically
07:27 very evidence based and even it was referred to as Sean mentioned that even before the
07:33 world coined all these terms of first thousand days or window of opportunity, the interventions
07:41 that are part of Anganwadi services is bang on.
07:48 We have not added a single one to what was conceived and put there in 1975.
07:55 This next point is between ICDS and the NHM together, they have all the necessary inputs
08:04 to make the health, nutrition of women and children so much better.
08:08 Third, the reach of Anganwadi is unmatched.
08:15 Nothing else can reach it.
08:16 We have 1.38 million Anganwadi centres.
08:20 So basically, but then why is the situation so bad?
08:24 There have been a lot that have been written but to just summarise, it's just two things.
08:30 One is probably it's a big implementation failure and the second one is the targeting.
08:37 I mean you are not reaching those who need to be reached and the third probably is the
08:44 community ownership or the seeking behaviour of the community.
08:50 So portion Abhiyan like what Mr. Lok Kumar elegantly said probably addresses all these
09:00 issues and I think there is so much stress on improving the capacity of the workers,
09:10 improving Anganwadi centre services, monitoring how they are delivered and at the same time
09:17 working on the demand side and creating through Janandolan, making people seek the services.
09:24 I think it's very well conceived and to your question, I have been travelling around
09:31 and seen, I have never seen so much of momentum around nutrition and Anganwadi centres, they
09:39 are the real centre of action and so there is a lot of hope and things are changing.
09:45 So can I shoot the next question to Mr. Mitra, talking about implementation and monitoring,
09:52 can you tell us a bit more about your work on social auditing and community led initiatives
09:57 of promoting accountability of Anganwadi centres?
10:00 Thank you Ananya.
10:01 In fact, just to highlight, APPA works largely in the state of Orissa as far as nutrition
10:07 work is concerned and as you said community, putting the community at centre, in fact already
10:13 the social movement has started with Poshan Aviyan and especially Janandolan is basically
10:18 kicking off that strategy and we are putting the community at the centre at the moment.
10:23 But at the same time I would say that the whole social audit programme is a prototype
10:29 and when the country is asking for how, that how we can reach out to people, this is also
10:35 providing some answer that how tools like social audit can reach to a larger audience
10:41 and how nutrition becomes a public discourse.
10:45 So I think the narrative is on that.
10:49 And this started not at a very pilot stage, this started across 240 gram panchayats across
10:55 six districts in the most remote districts of Orissa.
11:00 So there reaching out to a community and building their knowledge base was a huge challenge.
11:05 So this spread work is basically through social audit, reaching out to the people and it was
11:10 not social audit alone, it was a participatory learning which actually enhances the knowledge
11:16 base of people, especially the tribal households.
11:19 And here we are talking about a language for a discourse which is not for the audience
11:25 like us, it is an audience which has to be a palatable language.
11:30 So actually the need has come that we change our language when it comes to nutrition and
11:37 language which is often delivered at a household level rather than in other discourses.
11:44 So this is building a prototype across 240 gram panchayats in six districts of Orissa
11:52 and social audit as a tool and which is already mandated and Niti Aayog's document clearly
11:57 specifies that social audit has to be done for ICDAs and if I am correct on this, and
12:04 social audit is also mandated under National Food Security Act.
12:08 So this is talking about how, so this how is this initiative is going to be a learning
12:15 tool for the country as well.
12:17 Right.
12:18 So Dr. Purvi Mehta, I think while we keep discussing all the interventions downstream,
12:22 can you take us to a more upstream issue about India being a predominantly agricultural country,
12:30 what are the linkages between agriculture and nutrition in light of diet diversification?
12:36 Thank you Ananya.
12:37 I think we have been hearing this since the morning that India hosts some of the world's
12:44 largest number of under nutrient people.
12:47 But let us also match it with another fact which is among the malnutrient Indians, the
12:54 largest number also happen to be in rural areas and dependent on agriculture.
13:00 So the largest number of malnutrient Indians are also the farmers of India.
13:06 Right.
13:07 And so there is a huge linkage there.
13:09 But of course, you know, there are multiple factors that impact nutrition and we've been
13:13 talking about that.
13:14 So it's not just the source of food, but it is sanitation, the health, people's genetic
13:20 makeup and absorption capacity, a lot of things.
13:23 But food, of course, plays a central role and therefore agriculture has a huge linkage
13:27 and this is even more in a country like ours, as you said, 48% of our population depends
13:33 on agriculture.
13:34 That's why it is very important.
13:36 But also the huge dependence on locally grown and locally sourced food in this country is
13:44 one of the highest in the world and therefore agriculture nutrition linkages are going to
13:49 be extremely important.
13:51 Any of these reforms or the disruptive reforms and transformation, Dr. Rajesh Kumar, you
13:57 also spoke about, whether it was the Green Revolution, whether it was the White Revolution,
14:02 the PDS systems of India and so forth, have been predominantly based on two agriculture
14:08 commodities, rice and wheat.
14:11 And we have really missed out on the whole diversification because I think food security
14:17 was an extremely important part, but we have to move on to the nutrition security and that's
14:23 where agriculture can play a very, very critical role.
14:26 So, Mr. Kumar, you were talking about convergence at the policy level.
14:32 How closely does the nutrition mission, you know, how easy or difficult it is to be working
14:37 with say the Ministries of Agriculture for linking things up to say minimum support prices
14:43 for pulses vis-a-vis millet, vis-a-vis rice and wheat.
14:47 How easy or difficult is that convergence in real life?
14:50 So, government is a strange creature.
14:52 Though it's an amorphous one, but if you look at the way we work, the way we are organized
15:01 into ministries and that is inherent in that organization, that each organization has its
15:07 own agenda.
15:09 Now getting everybody together for a common agenda and a common outcome is a difficult
15:16 task because there are multiple priorities and I mean if you look at India, there are
15:24 hundreds of thousands of priorities that you could think of which India needs to do and
15:29 today.
15:31 But to my mind, I think the good thing which I have seen in this Poshan Abhiyan and the
15:37 fact that Niti Aayog in a sense is convening that as a convener we are trying to get multiple
15:44 ministries and multiple actors and not only in government, but what I find even more encouraging
15:51 is that we have seen philanthropies, we have seen civil society people, we have seen state
15:57 governments, we have seen district administrations.
16:00 So we see, never before I have seen this kind of an energy about this mission and that gives
16:10 me a lot of hope and confidence that maybe what has illuminated, it's not that we have
16:16 not made progress, as Rajesh was saying we have declined by about 0.9 percentage points
16:22 per annum in terms of our stunting rate over the last 10 years.
16:26 As I say, NFHS5 is now on the fields, we will be getting some of those results by late this
16:33 year so we will see where all this effort has led to.
16:36 But what I have seen is almost a flurry of action.
16:46 So if you look at the health ministry, I see home-based newborn care programme has been
16:51 intensified, Mission Indra Dhanush has been intensified, the vaccination programme, rotavirus
17:01 and PCV have been introduced, Anemia Bharat programme which was in the making for a long
17:08 time has been introduced, a home-based young child care programme to target 6 to 24 month
17:15 child which is the time when we see the slide at the maximum has been introduced.
17:21 So simultaneously Swachh Bharat has made a lot of difference and it is continuing and
17:29 now with the Har Ghar Jal programme we will see a lot of prevention part in terms of what
17:36 infections which lead to malnourishment.
17:39 Then on the agriculture ministry side we see a biofortification programme, a return
17:46 to the millets programme.
17:48 So what I see is that multiple ministries, the food ministry has come up with a pilot
17:54 project for rice fortification to address the micronutrient deficiency because the biofortification
18:01 part will be a little bit in a medium run perspective.
18:06 So the FSSAI has come and defined standards for fortification of wheat, wheat flour, for
18:14 rice, for oil, for milk.
18:17 So I see a lot of action on all fronts.
18:23 The state governments when I go and meet across with chief ministers, chief secretaries, all
18:27 of them seem to be asking this question as to why despite having all the conditions why
18:33 we are not able to move as quickly as we would like.
18:37 It's not that we are not moving, we are moving but the pace needs to be accelerated and I
18:41 think from the Niti Aayog perspective we see nutrition probably, under nutrition in particularly
18:48 as the single biggest challenge which is facing.
18:52 You said that the government is a strange creature and I think things are not very different
18:57 in the social sector as well, right.
18:59 We see a lot of foundations, NGOs and CSR activities operating in a very fragmented
19:05 manner with such reputed organizations as the Tata Trust.
19:10 Do you see in the social sector, you know, organizations like the Tata Trust can act
19:14 as conveners to help coordinate all this multi-sectoral action that seems to be happening?
19:22 Thank you.
19:23 I think it's naturally happening as it is today.
19:27 I'm just out of a meeting where Tata Trust, Asim Premji Philanthropy Initiative and several
19:34 other philanthropies got together to look at how do we form a coalition for nutrition
19:41 and in India as well as at global level it is happening.
19:45 Now there are many what they like to call as, you know, a collectives where people pool
19:54 in, you have common, you know, implementation framework, monitoring framework, you just
20:02 get together, plan together, go and implement on your own, come back and take stock together.
20:08 That kind of implementation frameworks and collectives are happening.
20:12 It's not only with big philanthropies of people with a lot of resources but this opens
20:18 a thing for civil society as a whole and big philanthropies are investing heavily in improving
20:26 the implementation capabilities, monitoring capabilities of civil society organizations
20:34 and community-based organizations.
20:35 So it's a lot that is happening on that space.
20:39 Dr. Mehta, can you just share one or two examples of some evidence-based interventions, you
20:46 know, that the Gates Foundation has implemented, particularly in food insecure environments?
20:56 Thank you.
20:57 I think there are a lot of evidences on how diversification in farming system has implications
21:04 on the food system, yeah, because, you know, as I said earlier, you know, what people are
21:10 growing and what people are eating is very, very connected, right.
21:14 And so I think there are two types of initiatives that is generally needed and we are investing
21:22 into as well but there are many, many organizations and especially the government of India, as
21:27 Alok Kumarji, you just said, is paying a lot of attention to.
21:32 And this is from two types of angles, right.
21:36 Number one is the staple crop.
21:39 About 60% of this country's diet, Sanjeevji, comes from two crops, rice and wheat, right.
21:46 And this is across any quantile, right.
21:50 But so the challenge comes in terms of the diversification or the non-cereal diets, which
21:57 is also not just calories but nutritious diets and how do you add it.
22:02 So there are two ways of doing that.
22:03 There are multiple ways but two major ways.
22:05 Number one is within the cereals, within the rice and wheat system, you could do, as you
22:12 said, Alokji, you know, the pre-harvest and post-harvest fortification.
22:17 That could be one.
22:19 For example, in this country, there are 137 varieties of rice which is ready to be commercialized,
22:27 right.
22:28 And we have commercialized only about eight to nine varieties in the country because we
22:33 have only commercialized the varieties which were high yielding.
22:37 We hardly saw nutrition as an important trait and therefore just looking at those varieties,
22:43 screening those varieties and looking at the nutrition trait, Kala Namak variety of UP,
22:49 for example, has an extremely high nutrition content.
22:53 But we have never commercialized it because Kala Namak was never part of those six, seven
22:58 varieties that we have always commercialized.
23:01 So looking at not just the production and productivity but also from a nutrition angle.
23:07 And the second would be in bringing in an additional crop.
23:11 For example, there are very easily available technologies which is late sowing and early
23:16 harvest varieties.
23:18 You can take one full crop in between the two and increase the nutrition.
23:22 So there are a large number of these areas where interventions and sometimes very simple
23:29 interventions can lead to really, to use your word, disruptive reforms.
23:36 Thank you.
23:38 Coming back to Jana Andolan, and this could be a closing question considering the timelines,
23:44 you work with a lot of Samakhya Saathis in Orissa, which are essentially community volunteers.
23:51 So can you tell us what was the working experience in such districts and how can they be some
23:56 sort of change agents?
23:58 In fact, these are very interesting community-led actors who played a major role in terms of
24:05 not only, I would say, not place it as, it is truly in the form of a Jana Andolan.
24:11 So in fact, I'll just go back that what exactly it meant.
24:17 In fact, one is, one of the key learnings that has come from this particular social
24:21 audit model is that we could define the role of PRIs.
24:26 So that's an interesting learning which is coming very, in fact, that is what it gives
24:32 back to the country that how PRIs can be involved in the discourse of nutrition.
24:39 And Samakhya Saathis playing that lead role in terms of feeding the PRIs.
24:44 So Samakhya Saathis are now a community-level actor who not only understands the space of
24:52 nutrition or understands nutrition, but also connects the gaps from a family to a grievance
24:59 redressal mechanism.
25:01 So somewhere that connect which Mr. Alok Kumar was mentioning in terms of from a systems
25:08 knowledge to a community knowledge and especially that bridging that discourse and also to basically
25:15 take that, take the lead from the front is something which has been led by the Samakhya
25:20 Saathis.
25:21 So the social audit process has engaged them with the family level, has also engaged them
25:29 at the facility level, has also engaged them at the panchayat level.
25:33 So palli sabhas and gram sabhas on nutrition are well facilitated when these kind of community
25:38 actors come into play and basically in the morning session we heard a lot of data, but
25:43 if the data is not speaking to its users, so data loses its significance.
25:50 So this is where the Samakhya Saathis are playing that role in terms of changing that
25:55 narration of data into actions and that is where you can see some quick results happening
26:00 and the needle is moving is that the Anganwadi centres, now 85% of the Anganwadi centres
26:06 in these 240 gram panchayats are opening on time and closing on time, which is not a small
26:12 piece of data for us.
26:15 You can see that more than 80% of the Anganwadi centres have a functional weighing machine.
26:23 When it translates to that level of actions, then it speaks, then it starts speaking volumes.
26:29 So these are the actors, leading actors who are able to understand that what problem lies
26:35 at the facility level, what problem lies at the household level and how they can do the
26:40 grievance redressal by taking it to the right forum.
26:43 So these are the connects which has made Samakhya Saathis as a lead actor there.
26:49 Can I just close with a short question to Mr. Kumar?
26:53 Considering NITI is so central to coordinating all our efforts around Jana Andolan, for everybody
26:58 present in the room, what would be the three actionable points or strategies or recommendations
27:04 that you may have as next steps for Jana Andolan?
27:08 So I think there are, number one is to try and involve the panchayat representatives.
27:17 So that is one key initiative.
27:20 The second one is we have seen and Basanta is sitting here, a lot of success in terms
27:29 of involving the SHG groups, because they are the people who can be influencer and large
27:37 parts of our research shows that the word of mouth communication is the best in terms
27:41 of when we are looking for behaviour change.
27:45 And the third element then is to look at the frontline workforce and their supportive supervisors.
27:55 Because even though they have been in charge of this program for a very long period of
28:02 time, their vision about what they need to do is very narrow and these were the old departmental
28:11 guidelines what they were thinking and they were, so getting them to think a little bit
28:16 big.
28:17 So in terms of, we are now looking at designing job aids, because we cannot translate those
28:22 complex guidelines into action on ground.
28:27 So how we can simplify their jobs through whatever aids that it would be possible.
28:32 So I think for this coming portion, Ma, these were the three main issues.
28:38 And I just also like to add that among the various priorities that we have the programs,
28:45 we are really targeting four things this time.
28:48 Point number one, can we eliminate all diarrheal deaths, because this is doable.
28:53 It's easy.
28:54 We know the solutions.
28:55 It is doable.
28:56 Second is around complementary feeding, because that is the place where we are lacking the
29:02 most.
29:03 Can we initiate the complementary feeding in times and make sure that between six and
29:06 twenty-four months that is taken care of.
29:09 The third item is looking really at anemia in a big way and can we give a significant
29:14 push to the anemia mubhaparat which is now already launched.
29:18 And lastly it is about the home-based newborn care program that is now intensified.
29:25 And it is around the whole IYCF practices.
29:30 Are we able to get this message to every household, to every child, newborn child who deserves
29:36 that care?
29:37 Are we able to reach that care to that child?
29:39 That is, these are the four key themes for at least this year.
29:43 Thank you so much.
29:45 Thank you to all the panelists for a wide and experiential learnings.
29:49 Thank you.
29:50 Thank you so much.
29:50 Thank you.
29:50 Thank you.
29:52 [Music]
29:56 (bell dings)