India persistently faces high levels of maternal and child under-nutrition as well as anaemia, characterized by an inter-generational cycle that is compounded by multiple deprivations caused by poverty, social exclusion and deeply entrenched gender discrimination. Decreasing child mortality and improving maternal health depend on reducing malnutrition which is directly or indirectly responsible for 35 percent of deaths among children under five.

Under-nutrition in infants and children is further categorized as Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM).

  • Severe Acute Malnutrition (SAM) refers to very low weight for height (< 3z scores of the median), visible severe wasting, or the presence of nutritional oedema.
  • Moderate Acute Malnutrition (MAM) is defined as a weight-for-age between -3 and -2 z-scores below the median. It can be due to a low weight for height (wasting) or a low height-for-age (stunting) or to a combination of both. Similarly, moderate wasting refers to weight-for-height between -3 and -2 z-scores while moderate stunting refers to height-for age between -3 and -2 z-scores.

Causes of Malnutrition:

  • Malnutrition is a complex multidimensional issue. It is caused due to a number of generic factors such as poverty, inadequate food consumption (due to poor availability/access), inequitable food distribution, poor maternal nutrition, sub-optimal infant feeding and child care practices, inequity/gender imbalances, poor sanitary and environmental conditions, and restricted access to quality health care, education and social safety-net services/facilities.
  • Further, various economic, environmental, geographical, agricultural, cultural, health and governance issues complement the general factors in causing under-nutrition in children.

Nutrition/Health Interventions:

  • For eradicating malnutrition in the country, the direct targeted interventions include schemes/programmes like Integrated Child Development Services (ICDS), POSHAN Abhiyaan, National Health Mission (NHM), Mid-Day Meal Scheme and Scheme for Adolescent Girls, Pradhan Mantri Matru Vandana Yojana.
  • In addition, various indirect multi-sectoral interventions/schemes having potential to address one or the other aspect related to nutrition include Swachh Bharat Mission (Ministry of Drinking Water & Sanitation/DW&S), Public Distribution System/PDS (Ministry of Consumer Affairs, Food & Public Distribution/CAF&PD), Mahatma Gandhi National Rural Employment Guarantee Scheme/MGNREGS (Ministry of Rural Development/MoRD), Drinking Water & Toilets (Ministry of Panchayati Raj and Ministry of Urban Development via the Urban Local Bodies).

Role of Anganwadi Workers and ASHAs:

  • Anganwadi Workers and the ASHA workers are the grassroots level functionaries under the umbrella ICDS Scheme and the National Health Mission respectively.
  • Both these functionaries being closely connected with the rural and urban poor families, play a pivotal role in addressing their nutrition and health related problems/issues.

Roles and Responsibilities of Anganwadi Workers:

Under the ICDS Scheme, Anganwadi Services were launched in 1975 as a pilot project covering 33 blocks in the country; its objectives are:

  • To improve nutritional and health status of children in the age-group 0-6 years;
  • To lay the foundation for proper psychological, physical and social development of the child;
  • To reduce the incidence of mortality, morbidity, malnutrition and school dropouts;
  • To achieve effective coordination of policies and implementation strategies among the various departments for promoting child development; and
  • To enhance the capability of the mothers to look after the normal health and nutritional needs of their children through proper nutrition and health education.

Package of services under the ICDS scheme:

  1. Supplementary nutrition
  2. Pre-school non-formal education
  3. Nutrition & health education
  4. Immunization
  5. Health check-up
  6. Referral services

Out of the six, three health related services viz., immunization, health check-up and referral services are provided by NRHM & Public Health Infrastructure. This convergence is facilitated by the grassroot level functionaries i.e. AWWs (Anganwadi Services Scheme) and the ANMs/ASHA Workers (Ministry of Health & Family Welfare) through:

  • Observance of monthly Village Health and Nutrition Days (VHND) at AWCs- immunization, ANC/PNC etc.;
  • Referral of sick/malnourished children by AWWs to health facilities and the ANMs;
  • Biannual rounds of Vitamin A supplementation (in several States);
  • Use of joint Mother Child Protection (MCP) cards by ANM and AWWs;
  • Participation at the Village Health Sanitation and Nutrition Committee (VHSNC) meetings;
  • Monthly meetings by ANM and AWW at the sub-centre level; and joint training conducted by NRHM.

Roles and Responsibilities of Anganwadi Workers:

  • To elicit community support and participation in running the programme.
  • To weigh each child every month and plotting it on the growth card; maintain the child cards (for children below 6 years) to be examined by the visiting medical/para-medical personnel; and using the referral cards for referring mothers/children to the sub-centre/PHC etc.
  • To carry out, annually, a quick survey of all the families in their respective area of work with particular attention to the mothers and children.
  • To organise non-formal pre-school activities for children aged 3-6 years and to help in designing/making toys out of indigenous resources.
  • To organise supplementary nutrition feeding for infants/children (below 6 years) as well as pregnant women and nursing mothers via planning of menu based on locally available food/local recipes.
  • To provide health/nutrition education along with counselling on breastfeeding as well as infant/young child feeding practices to the mothers. Further, anganwadi workers being rather close to the local community can motivate the married women for adopting family planning practices/birth control measures.
  • To help and coordinate the health centre visits of pregnant women/nursing mothers for registering their child's birth and reporting the same to the village level functionary notified as Registrar of Births.
  • To conduct home visits for educating the parents, especially the mothers, for enabling them to play an effective role in their child's growth and development with particular emphasis on that of the newborn child.
  • To assist the PHC staff in effective implementation of the programme's health component viz. immunization, health checkups and ante-natal/postnatal check-ups etc.
  • To assist the ANMs in the administration of IFA tablets (for anaemia control) and vitamin A doses (for preventing VAD) to the beneficiaries.
  • To share the health-related information with the ANM.
  • To support in organizing Pulse Polio Immunization (PPI) drives.
  • To inform the ANM regarding any emergency cases like diarrhoea, cholera etc.
  • To guide ASHAs (Accredited Social Health Activists under NRHM) in the delivery of healthcare services and maintaining the records.
  • Anganwadi Workers can act as depot holders for RCH Kit/contraceptives and disposable delivery kits, though the actual responsibility lies with the ANMs or ASHAs except that for over-the counter drugs.
  • To assist in implementing Scheme for Adolescent Girls (SAG) and motivate/educate the adolescent girls, their parents and community as a whole by organizing social awareness programmes/campaigns etc. Also, to assist in implementing the Nutrition Programme for Adolescent Girls (NPAG) and maintaining the records.
  • During home visits, to identify disability among children and referring them immediately to the nearest PHC or District Disability Rehabilitation Centre.
  • To inform the Supervisors/CDPO regarding any village level developments requiring their attention and intervention, particularly for the coordinating arrangements with different departments.
  • To maintain liaison with other institutions (eg. Mahila Mandals) and to involve school teachers (women only) and primary/middle school girl students of the village, where necessary.

Roles and Responsibilities of ASHA Workers:

  • ASHA workers are expected to elicit community participation in public health programmes in the village. She is the first person to be called for any health-related needs of the deprived sections of the population, especially women and children, who find it difficult to access healthcare services. ASHAs are the community-level health activist for creating awareness on health and its social determinants as well as for mobilizing the community towards local health planning and increased utilization/accountability of the existing health services.
  • They are promoters of good health practices. In addition, they provide a minimum package of appropriate and feasible curative care or arrange for timely referrals.
  • They generate community awareness concerning the various determinants of health such as nutrition, basic sanitation & hygienic practices and healthy living/working conditions, as well as regarding the existing healthcare services and the importance of timely utilisation of health & family welfare services.
  • They counsel women on birth preparedness, importance of safe delivery, breastfeeding & complementary feeding, appropriate care of the young child, immunization, contraception and prevention of common infections including reproductive tract infections/sexually transmitted infections (RTIs/STIs).
  • They mobilise the community and facilitate their accessing health/health related services such as immunisation, antenatal/postnatal check-ups(ANC/PNC), supplementary nutrition, sanitation and other governmental services available at the anganwadi/sub-centre/primary health centres.
  • They act as depot holders for essential provisions like Oral Rehydration Solution (ORS), Iron Folic Acid tablets (IFA), chloroquine, Disposable Delivery Kits (DDK), oral contraceptive pills & condoms, etc.
  • Since ASHAs cannot function without adequate institutional support at the village level, women's committees (self-help groups/women's health committees), village health & sanitation committee (Gram Panchayat), peripheral health workers especially ANMs and Anganwadi workers, and the ASHA trainers (for periodic in-service training) provide them the needed support.
  • Recently, Home-Based-Care for Young Children (HBYC) has been initiated to extend the community-based-care by ASHA workers with particular focus on nutrition counselling, improved child rearing practices and breastfeeding promotion etc.

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Courtesy: Kurukshetra