Transforming India’s Nationwide Nutrition Program: Poshan Abhiyaan

With its large young population, India has long sought to tackle the deeply entrenched challenge of undernutrition. One of the ways it has done so has been through its long-standing Integrated Child Development Services (ICDS) program, in operation since 1975.

Between 2005 and 2019, despite the magnitude and complexity of the challenge, undernutrition levels showed a consistent decline. Stunting among children under 5 years of age fell from 48% in 2005 to 35.5% in 2019, and the proportion of underweight children decreased from 42.5% to 32.1%. Even so, undernutrition levels continued to be high, with some 41 million children remaining stunted.

In 2018, therefore, the government made fundamental changes to the program. The Ministry of Women and Child Development launched the National Nutrition Mission - the Poshan Abhiyaan - placing special emphasis on the first 1,000 days of a child’s life, from conception until 2 years of age, a critical period that was largely ignored earlier.  

As before, a veritable army of 1.4 million frontline Anganwadi Workers (AWW) led the country’s war against undernutrition. They reached over 80 million beneficiaries in every village and slum across India’s 36 states and union territories.

In support of their efforts, a nationwide people’s movement was launched - a Jan Andolan – to bring the issue of nutrition to the forefront. September was designated as the National Nutrition Month (Poshan Mah) while March marked the Nutrition Fortnight (Poshan Pakhwada). In addition, the world’s largest technology platform in public health and nutrition was deployed, helping Anganwadi Workers monitor the nutritional status of women and children across the country.  

World Bank Support

Between 2018 and 2022, the World Bank supported India’s Poshan Abhiyaan nationwide with financial and technical assistance. In addition, the Bank closely tracked the pace and quality of the program’s implementation in 11 states which bore the highest burden of stunting among children and anemia among women. These focus states included Andhra Pradesh, Bihar, Chhattisgarh, Gujarat, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Rajasthan, Tamil Nadu and Uttar Pradesh.

The Poshan Abhiyaan’s Approach

India’s Poshan Abhiyaan adopted a three-pronged approach nationwide:

1.    Reaching Communities with Nutrition Messages

The Poshan Abhiyaan prepared a wide variety of communication material regarding the right nutrition and care for women, and age-appropriate feeding practices for infants and young children. These were disseminated through multiple platforms involving key stakeholders such as the Ministries of Health and Family Welfare, Drinking Water and Sanitation, School Education, Rural Development, and Panchayati Raj Institutions.

This material was used by Anganwadi Workers during home visits and community-based events to counsel pregnant women and mothers – as well as their influencers, such as husbands and mothers in law.

High visibility awareness campaigns amplified these messages through TV and radio spots in regional languages, mobile based videos, and text messages.

Monthly community events were organized, celebrating critical milestones such as ‘Godhbharai’, that marks a woman’s pregnancy, and ‘Annaprashan’, when a six-month-old child is fed solids for the first time, along with breastfeeding. Special events were also held for men, nudging them to play a more significant role in ensuring the wellbeing of their wives and children.

2. Deploying the world’s largest mobile phone-based application

The world’s largest mobile phone-based application called the Poshan Tracker was deployed, helping Anganwadi Workers prioritize home visits in the first 1,000 days of a child’s life, and record and monitor the services delivered. It also helped program officials track workers’ performance and provide support wherever necessary. The application proved transformational as this was the first time that a mobile phone-based system had replaced the 11 paper registers that frontline workers were required to maintain earlier.

3.    Building the Knowledge of Frontline Workers and Providing Incentives

Since the capacity and motivation of frontline workers was critical for the program’s success, the Poshan Abhiyaan adopted an innovative approach for the first time — the Incremental Learning Approach (ILA) – that broke down learning into smaller modules for easy assimilation. Twenty-one modules were developed in Hindi and other regional languages, explaining technical information in a simple manner, while addressing locally prevalent myths and misconceptions. One topic was taken up every month, followed by a month of practice. The face-to-face sessions were complemented by e-learning and pictorial job-aids that provided a handy reference for frontline workers.

Workers were also given performance incentives for monitoring a child’s growth and conducting priority home visits during the first 1,000 days of its life.

RESULTS FROM THE WORLD BANK’S 11 FOCUS STATES

1.    In March and April 2021, the Bank undertook a Poshan Knowledge and Behaviors telephone survey in the 11 states which bore the highest burden of stunting among children and anemia among women. The survey showed positive results, both in the delivery of services and nutrition practices:

a. The program’s core nutrition messages reached more than 80% of women.

b. Exclusive breastfeeding for the first 6 months was practiced by 81% of women covered by the program.

c. Other nutrition behaviors (consumption of iron and folic acid supplements (IFA) for at least 100 days, minimum dietary diversity in pregnancy, breastfeeding within the first hour of birth, complementary feeding initiated by 6-8 months) were practiced by 56-67% of beneficiaries.

2.  In the 11 focus states, data from the NFHS-4 (2015-16) and NFHS-5 (2019-21) was used to assess the changes in the program’s key nutrition indicators:

a.   Child Stunting and Wasting: During this four-year period, child stunting decreased significantly in the 11 focus states, from an average of 41% to 37%.  Significant reductions were seen in 7 of the 11 states.  Child wasting fell from an average of 22% to 20%, with significant reductions in 6 of the 11 states.

b.  Women's Undernutrition: In all 11 states, the proportion of undernourished women (Body Mass Index less than 18.5) fell significantly, from an average of 24.5% to 20.3%.

c.   Exclusive Breastfeeding: Exclusive breastfeeding increased from an average of 54.1% to 64.6%.

d.  Counseling: Counseling to mothers after a child was weighed increased significantly across all 11 states, rising from an average of 63.2% to 76.3%.

e.   Capacity Building: The capacity of more than 8,60,000 Anganwadi Workers (81% of the total) was built.

GOING FORWARD

Given the Program’s progress the Government of India has mainstreamed the three-pronged approach in the second phase of the program, Poshan 2.0.

Moving forward, the gains in nutrition will need to be protected while the pace of change will need to be accelerated further. This will require:

• Sustained high level political attention and commitment to the nutrition agenda,
• Continued focus on high impact interventions across the life cycle (infancy, childhood, adolescence and pregnancy), with an emphasis on improving age-appropriate complementary feeding, strengthening program management and building structures for capacity building of frontline workers at the national and state levels,
• Given the multi-dimensional nature of the challenge, households will need to be given a comprehensive package of services. This will require convergence across a range of sectors - health, education, agriculture, water and sanitation, rural development, and social protection. Tools will also need to be developed to monitor convergence.

By The World Bank’s Poshan Abhiyaan Task Team