Reducing child undernutrition: The Maharashtra recipe

23rd February 2016
V. Ramani, who has been selected as one of the 2016 Transform Nutrition Champions, writes for Eldis on his experience of working with others in Maharashtra to tackle child undernutrition.

I was part of a small group of government officials in Maharashtra who were able to take innovative approaches to tackling child undernutrition. The very first step we took was to estimate the number of children in the moderately and severely underweight categories. When we started our work in the Aurangabad division (the Marathwada region) of Maharashtra in 2002, the decennial census figures of 2001 gave us the number of children under six years of age in each habitation in the state.

Child Development Centre

Photo: Rajmata Jijau Mother-Child Health and Nutrition Mission, Maharashtra, India

This prompted action to ensure universal child coverage through the Anganwadi system. The Anganwadi (a government sponsored child-care and mother-care center) and more specifically the Anganwadi worker (the community health worker in charge of an Anganwadi) provide services to combat child hunger and malnutrition for children under six years old. These are part of the government Integrated Child Development Services (ICDS) programme. We worked with the Anganwadi worker to make sure every child under the age of six in the village was registered and weighed once a month to determine, on the basis of the prescribed child growth charts, the present nutrition status of the child. Every child under the age of six who was severely underweight or whose growth faltered over a three month period was to be referred for medical examination to determine the reasons for his/her unsatisfactory nutrition status, so that remedial action could be initiated.

We also took a conscious decision to start big. The Marathwada initiative, which started in 2002, targeted nearly two million children under the age of six spread over eight districts of the Aurangabad division of Maharashtra. This gave us the confidence to subsequently extend the campaign, in three stages between 2005 and 2008, to the entire state of Maharashtra covering a population of about fifteen million children under the age of six. The encouraging results in the reduction of stunting and underweight in children under the age of two, shown in the Comprehensive Nutrition Survey of Maharashtra 2012, was a consequence of this broad based approach to reducing child undernutrition.

Child development centre site

Photo: Rajmata Jijau Mother-Child Health and Nutrition Mission, Maharashtra, India

We were convinced that no scaled-up initiative was possible without the fullest, enthusiastic participation of the Anganwadi workers and their immediate supervisory levels at the sub-district level. This required building up confidence, skills and capabilities in a cadre that had hitherto been largely neglected. The Mission undertook intensive training programmes throughout the state. Probably for the first time, there was no attempt to blame field workers and their supervisors for the state of affairs; instead, efforts focused on ascertaining the correct factual position and giving Anganwadi workers ample time to display their initiative in reducing child undernutrition. The results were heartwarming and reaffirmed our faith in the innate goodness, dedication and honesty of field workers and their ability to work wonders, given support and encouragement. A “star competition” to grade the performance of administrative units from the Anganwadi to the district promoted a spirit of healthy competition and saw many local initiatives being taken to reduce child undernutrition.

Convergence in the actions of the ICDS and public health programmes was one of the cornerstones of Maharashtra’s efforts. Severely underweight children required medical attention to tackle congenital ailments and other childhood illnesses, often caused by insanitary surroundings and family poverty. It was only after medical intervention that steps could be taken to improve their nutrition status. The State Nutrition Mission introduced the concept of Child Development Centres at primary level health facilities to provide inpatient care to undernourished children with health complications, where their caregivers were also imparted knowledge on how to take care of the children after their discharge from the facility. The Mission pioneered the concept of Village Child Development Centres at the Anganwadi Centres in villages, where day long child care facilities were provided along with nutritious food to children under the age of six who were not in need of hospitalisation. Counselling to mothers/caregivers on good nutrition practices was also provided. Existing programmes like the deworming and Vitamin A supplementation for children under the age of six, as well as new initiatives like the Child Development Centres were implemented enthusiastically by the public health staff.

Promoting health nutrition practices

Photo: Rajmata Jijau Mother-Child Health and Nutrition Mission, Maharashtra, India

All these measures were made possible by the continuous, unstinting support to the Mission’s initiatives by the political and administrative executive at state and local government levels. Local bodies - from the village to district levels - mobilised community participation and funded some of the costs of various programmes. Regular meetings at the state government level, chaired by the Chief Minister and the Minister for Women and Child Development, helped resolve interdepartmental issues and enforced accountability at various levels of the government. Monthly reports by the Mission on the nutrition status of children under the age of six at the district and sub-district levels highlighted the areas with the highest incidence of child undernutrition and therefore focused the attention of policymakers.

These efforts have been recognized as drivers of stunting declines in Maharashtra. Between 2006 and 2012, Maharashtra’s stunting rate among children under two years of age was reported to decline by an impressive 15 percentage points – one of the fastest rates in the world. Political and administrative commitment, focus on specific measurable outcomes, inter-departmental coordinated action and a motivated field-level bureaucracy were the essential ingredients of the package to significantly reduce child undernutrition in Maharashtra.


Tracy Zussman

Tracy has been with Eldis since 1996, having previously worked in the information sector, in both engineering and development libraries. She currently manages the day-to-day production of Eldis content with a particular interest in Ageing populations and Rising Powers in International Development.