Location, building, infrastructure and supplies – the gaps
There were a total of 24 AWCs that were studied for this exercise. The physical facilities available in these centers are described in this section. All AWCs except three in Idukki were working in own buildings. Two AWCs from the urban areas of Idukki were functioning in rented buildings and one from the rural area was situated within a rubber estate. Electricity was not there in this centre.
An important observation was that the social distance from the sites where the AWCs function mattered in terms of utilization of the services. The affluent parents refused to send their children to attend AWC that is located in a colony of people belonging to low socio-economic strata. Sobha (AWW from Idukki) pointing to this mentioned,
As this centre is located in the colony area (residential areas, most often inhabited by people from low socio-economic strata), parents belonging to other affluent areas do not want their children to mingle with children from the colony. They had apprehensions that the colony is not safe due to prevalent alcoholism. They do not respond properly if I call them for any purpose.
This clearly shows how the social position and social stratification plays a role in non-performance of the AWCs.
Other challenges faced include lack of proper water supply and poor state of equipments to take anthropometric measurements. Two AWCs in coastal areas of Thiruvananthapuram lacked drinking water facility. They depended on water brought in tankers by private providers. One vessel of around 10–15 liters, locally known as ‘kudam’’ is sold at a rate of ₹5/- and it was used for drinking and cooking purpose. The AWW in charge reported that she buys two ‘kudam’ on a daily basis. The tanker sometimes, especially during summer, comes only on alternate days. Water shortage along with hot weather will have serious implications on hydration of children living in this area. This is substantiated by the wrinkled and tanned skin of both adults and children as observed by the first author. The room space was reported to be inadequate as there were more children attending preschool. The water scarcity in coastal areas of Thiruvananthapuram is a matter of urgent concern. Almost all AWCs had water shortage in summer season.
Further, all AWCs had two weighing machines (one analogue/mechanical and Salters weighing scale). Periodic calibration of equipment was not done in any of the AWCs. Heights of children were reported to be measured by writing the height measures in centimeters on the wall, which is highly unreliable and the third state-wise progress report on POSHAN Abhiyaan also stated that the efficiency of weight and height measurement in Kerala is poor [2].
It is the sorry state of affairs that the things are on paper and in reality they are missing. These shortcomings would largely interfere with the functioning of an AWC which in turn would decelerate the momentum to achieve the very objectives of ICDS.
Another serious concern raised by the AWWs was the out-of-pocket expenditure to run AWCs on a daily basis and the considerable delay in reimbursing it or not reimbursing at all. The Civil Supplies Department under Government of Kerala provides food grains for supplementary nutrition for preschool children. Most often AWWs receive the money to purchase food grains apriori, however, sometimes they have to pay from their pocket. Further, they spent money on vegetables and ghee; to pay rent and electricity bills and for conducting various events on Independence Day, Republic day, etc.
Beena (AWW from rural Thiruvananthapuram) expressed,
“I buy vegetables when I come in the morning. Most often, I have to pay from my hand. With
this high price, it is very difficult to manage. It is based on attendance. So when we calculate,
we can spend only 60 paisa per day for one child. How can I buy enough vegetables with such a small amount?”
Ragini (AWW from Kasaragod) said,
I spend money for celebrations on admission day, Independence Day, Republic day, etc. from my own pocket. The normal practice is to collect money for such celebrations from the parents. But they hardly contribute. Ultimately I end up spending my personal finances.
There was a scheme called ‘Akshaya Pathra’ in which mothers were requested to give any raw vegetable to their child attending preschool. However, the scheme was a failure in all AWCs.
From the above findings, it is also clear that location of AWCs, infrastructure and equipment, improper monitoring mechanisms and inadequate funding can adversely impact the AWC service provision and thus affect the nutritional status of children as a whole.
Services – coverage of children, supplementary nutrition and management of malnutrition
Fail to attract and retain children in AWCs: mismatch of Parents’ expectations and programme objectives according to AWWs
There is huge reduction in the number of children attending preschool in the recent years. Poor follow-up of children due to the drop out from AWC for pursuing education by attending Kinder Garten system is popular in India, especially in Kerala. In addition, play schools for children below three years are also rising. As opined by the AWWs, this is mainly attributed to the divergence between services provided and parents’ expectations. Primarily parents want to provide better education for their children. However, their understanding about ‘better education’, according to AWWs, is teaching their children to read and write English from a very early stage. The working hours of AWC is another important issue emerged from the interviews. These conflicts related to programme objectives and parents’ expectations led AWWs in a helpless position to persuade parents to utilize the services from AWCs.
Ragini (AWW from Kasaragod) pointed out that the parents consider the children’s education as a ‘status symbol’. She said,
Parents prefer their children to be in an attire which has uniform, tie and shoes, and going in school bus and schools also promise that they will make their children read and write English. Parents also prefer their children could speak in English. Hence, I started teaching children alphabets though it is not part our syllabus. Mothers verify with their children about what they have learned at Anganwadi centre back at home.
While Omana (AWW from the urban Thiruvananthapuram) had a different opinion for decreasing number of children in the Anganwadis.
The working hours of Anganwadi centre are not convenient for working parents. In my area, many women work as domestic help in the city. We generally close the centre by 3.30 pm every day and go for house visits. However, parents return after 5 PM. Most of them do not have grandparents at home to take care of the child. In such instances, we are helpless to blame parents about sending children to play school or day care centre which opens till 9 pm.
Asiya (AWW from urban areas of Idukki district) said, “It is difficult to deal with some women especially when they are a few degrees affluent and educated. They question the quality of nutrimix. Since they don’t avail our services, they respond in a discouraging manner when we call them to inform about mothers’ meeting or any other critical things.”
The records and the interactions with AWCs confirmed that the children drop out of AWCs or do not attend due to various reasons. This means that these children are out of the scheme interventions through ICDS to maintain nutritional status and stay healthy. The total number of severe underweight children from 24 AWCs in the study was five as per the records maintained in AWCs and the number of moderately nourished children was only 74 whereas the survey showed more prevalence of all forms of malnutrition.[7] The recent National Family Health Surveys also showed that the malnutrition levels of children below five years in Kerala has not been improved [3].
Supplementary nutrition – improper monitoring of take home ration (THR)
All preschool children received a sweet made of sesame seeds and jaggory, both are natural sources of iron. In urban areas of Thiruvananthapuram, where the POSHAN Abhiyaan reforms were implemented, children also received one glass of milk in the morning and boiled egg twice a week. Upma made of semolina, ghee, vegetables (mostly carrot) and black gram was given to preschool children at 3 pm every day. Menu for the lunch varied widely across and within districts. It was mainly boiled rice with one curry (which changes every day) and one ‘thoran’ (made of vegetables) or rice gruel and green gram.
Children of age six months to three years received fortified food as take home ration (THR). Children with severe nutrition deficiency will get double THR. It is prepared and supplied by Kudumbasree (Self Help Groups) units in the name ‘Amruthampodi’. Many at times, parents refuse to take THR saying their children doesn’t like to have it. By design, there is no proper monitoring mechanism to ensure the consumption of supplementary nutrition children in the age group of six to 36 months.
Blaming mothers for child’s undernutrition
It was observed that mothers were delegated with the responsibility of managing undernourished children and blamed for not following the instructions.
Ragini from Kasaragod mentioned that
It is all about how we train the children. Mothers are only to be held responsible for their children’s eating habits. At our centre, all children eat what is provided. At times, mothers are surprised to see this as they do not eat properly at home.
While discussing about the undernourished children, Jincy (a supervisor from Thiruvananthapuram) said, “There are underweight children in my area and many of them live in coastal area. The community setting in coastal area is different from the mainland. In general, mothers are very young in age, with lower educational qualifications that many did not complete even school education. It makes the Anganwadi workers try hard to educate them. Most often their efforts go in vain.”
Elsi from Idukki district said about an undernourished child. She spoke:
The child’s weight at birth was already low. Knowing that I clearly instructed the mother to bring the child once a month to collect the food and monitor the weight. But she hardly visited the centre. I reminded her during my recent house visits also. If the parents are not showing interest about their child’s health, we are helpless.
Delivering services without conviction
In case of AWWs, they themselves were not found convinced about the poor nutritional status of children. One worker from Kasaragod referring to a severely undernourished child as per the growth chart said,
The boy has a little less weight. This may be hereditary. Actually, his father is very lean. We closely observe the growth of the child. Based on my experience, after certain point of time the children will gain weight.
She appropriated child’s height and weight to hereditary and other factors. Contrary to this, another worker from Kasaragod district mentioned the children make-up their growth in time.
Sreekala said “Children are growing in front of us, isn’t it? After sometime they will gain weight by themselves’.
In the above scenario, the AWW might have indicated the catch-up growth in malnourished children which many studies have proven [5, 10–14]. However, high risk of stunted children to develop chronic diseases in their adulthood is also reported in the literature [15–17]. Although, the lack of conviction of AWWs is attributed by their ground level experiences, it may miss out malnourished children who need continuous monitoring and timely interventions.
Service Providers: Awareness About Nutrition, Working Conditions And Motivating Factors
Theoretical knowledge about nutrition versus actual practice: A difference in the understanding of different levels of ICDS service providers
The theoretical understanding of nutrition was found to vary among services providers reflecting their education status. It was observed that the higher-level service providers had good conceptual knowledge of nutrition, malnutrition and its causes. Whereas, AWWs seemed to by heart what they have learned in training sessions and they had difficulties to recall the terms when interviewed. Being the grassroot level workers, AWWs, in reality, are tasked to address the problem of malnutrition without even understanding the mission which is entrusted upon them. In effect, the ICDS programme serves just as an agency to distribute nutritional supplements than providing comprehensive nutritional services. It is important to take proactive training sessions to make all the stakeholders to have the understanding about nutrition; malnutrition; its causes and effects and integrate this knowledge into their day-to-day activities and goals of the ICDS mission.
Chintha (CDPO from rural Idukki) who is graduated in BSc Home Science answered,
Nutrition is the utilization of food by our body for producing energy that is required for a child’s growth and help her or him perform other functions
Sunanda (supervisor from Idukki) on causes of malnutrition said,
As I mentioned, malnutrition is directly linked to the food that we consume. No parent would let their child be hungry and they give what the child wants. What we observe in Attappadi (a place in Palakkad district of Kerala, reported to have high prevalence of child undernutrition and mortality) is the other side of the coin where the parents are too poor to feed their children. Their health is compromised even before birth as the mothers are also undernourished.
In contrast to the above, AWWs workers had a varying level of understanding about nutrition, malnutrition and its causes. They had apprehensions not to give responses which are contrary to the expected or right. For instance, Leelamma (AWW) from a rural area of Idukki reacted immediately, when asked about the term ‘nutrition’,
‘I don’t remember. I may require some time to prepare’.
On further explorations with probing, she asked, ‘Do you mean the food required for the growth of the child?’
Beena (AWW from Thiruvananthapuram said ‘nutrients are vitamins. I remember all these things from my classes, it’s been two years since I learn them. I am not able recall all those terms now’
It is clear from the above narratives that AWWs clearly lack adequate understanding about the concept of nutrition/malnutrition itself. This would have adverse impact on the identification of malnourished children in the community. However, their understanding on the causes of undernutrition reflected their ground level experiences. Many factors such as children eating less, preference for junk foods, poverty and even family harmony were emerged as reasons for poor nutrition among children.
Responding to the question how does malnutrition occur, Elsi (AWW from a rural Idukki) said,
Poverty is the main reason for malnutrition. Fathers of majority of children in my area are daily wage labourers and they hardly get work during rainy seasons.
Sobha (AWW from the same district) mentioned,
It is important to be have good relationship between both parents. One day, a child in my centre witnessed her father beating her mother. In response to that she kept herself silent and did not eat food at the centre. Later part of the day, she forgot all of that and started playing with other children. When I approached her and asked why she was silent during the morning, she replied her father slapped her mother.
Sreekala (AWW from Kasaragod) when talking about the causes of malnutrition mentioned, “-------------------. Many mothers refuse Amruthampodi as their children do not like it. But, at home they feed children with the marketed products such as ----- (says brand name) and so on. They say children do not drink milk if these are not used”.
Poor Working Conditions Leading To Poor Services
The working conditions of AWWs and higher-level key informants were not the same. The problems raised by stakeholders at various levels include maintenance of registers; additional works given; inadequate human resource and frequent transfers and meetings.
The consolidation of data at each level of hierarchy is the main challenge reported by all the stakeholders. Data from primary, secondary and tertiary levels needs to be tallied. Sunanda (supervisor from Idukki) mentioned,
I am supervising 33 Anganwad icentre. Maintaining the data of all these centres is the major challenge we face. Nevertheless, we have to enter the data online as per the latest guidelines. Out of four supervisors in this office, only two, including me, are equipped for the same. Hence I end up with entering the data all the day rather than doing my own work
Anganwadi workers felt maintaining registers as the herculean task for them. One worker from rural Idukki said,
We have 11 registers to be maintained on a regular basis and all comprises numbers. ---------- In normal day, we spend mornings with children in the centre. I get time to fill the registers only after lunch when the children sleep. However, I can never finish them during that time and may carry home for the purpose of completing. It is a headache!
AWWs are expected to do real time data entry through the tablets distributed to them under ICDS mission. However, it has not replaced the older system of manual maintenance of registers. In effect, they have to do double data entry, which further adds to their burden.
The ICDS supervisors have additional responsibilities as the implementing authority of activities under the Department of Social Justice, Government of Kerala, and AWWs are most often employed for different field level works under the department. It is an added burden and interfere with their nutrition-specific works. A supervisor from Kasaragod said,
We are the implementing officers of the Social Justice Department. We have to do multiple other things such as disability survey, survey for older people, visiting orphanages and elderly homes, and sending reports. Sometimes, I feel 24 hours are not sufficient for all these.
Shortage of manpower and inadequate training further compromises the working conditions of ICDS service providers. The CDPO from Idukki mentioned about the lack of staff with training in essential computer skills. She said,
There are only seven staff in this office including me, four supervisors, one clerk and peon. Supervisors have to go to respective fields. However, two of them are not going to field as they are entering the details online. Other two are not technically equipped with computers. None of them were given any training on the same. I cannot take a chance by letting them do the data entry.
The absenteeism among employees was also noted especially from Kasaragod followed by Idukki and it is mainly due to the unwillingness to work in remote areas with minimum facilities. Veena (DPO) from Kasaragod said,
There are 64 supervisors in this district, but 24 of them are on leave. Consequently, the burden falls on those who are available and ultimately their own work also gets affected.
Frequent transfers and meetings were reported by CDPOs and DPOs. Frequent transfers prevent settling down in a place so that the service providers can understand the community and need-based services could be provided. In addition to this, the frequent meetings, usually held at Thiruvananthapuram, the capital city of Kerala, also causes unstable working conditions.
Madhavi (DPO) from Idukki said,
I came to Idukki last year (2018). Prior to that, I was in Pathanamthitta for nearly two years. Frequent transfers are very troublesome especially when you are settled and have children. Here I am staying in hostel and every week I have to travel to my home. Entire family has to compromise on many things. In addition, there are multiple meetings and most of them are held at Thiruvananthapuram.
The rigid hierarchical structure with minimal flexibility poses another hurdle preventing AWWs to make decisions at the lowest level. Asiya (AWW from urban Thiruvananthapuram) said,
The Health, Sanitation and Nutrition Committee at the corporation level and the monitoring committee which includes parents meet regularly. As such, I am not allowed to make decisions about the Anganwadi functions. I always need to consult them and act accordingly.
All AWWs unanimously said that their monthly honorarium is not proportional to the work they are doing. Sobha (AWW from rural Idukki) said,
“After working for many years, our income increased marginally. Please advise me who can survive with Rs. 10000/- during this period. This amount is not even sufficient for food expenses. At my home, I am the only earner and have to support my children who are studying at school. It is very difficult to meet my ends”.
Apart from the low salary, many at times they have to pay from their pocket as mentioned elsewhere. This is a mere exploitation by not providing support and making them to pay from their pocket while they are paid meager amount as compensation as they are honorary workers and part is paid back is very painful to note.
It is evident that AWWs, compared to the higher level employees under ICDS, face lots of challenges that can affect the quality of service provided. All these were consistently reported by studies in the past [18, 19]. An alarming observation is the importance given by all stakeholders for documentation. A conscious effort is there from higher to low level to showcase that no issues in their respective areas. The non-conducive working environment eventually interferes with effective service delivery to the community, and with the very objective of the ICDS scheme.
Motivating factors
Security of a government job is the primary motivational factor for all service providers including AWWs even though they are honorary workers. One of the major motivating factors for the AWW is the respect they receive from the community. One AWW from Thiruvananthapuram said,
Remuneration is exceptionally less, compared to the workload. But it is better than going as sales girls and all. Many women I know who are of my age go to textiles and other shops as sales girls. They are not even permitted to sit and get less compensation than ours. I moreover get regard from all, as you know, everybody calls me ‘teacher”
All AWWs continue to do their job despite many hurdles because the time spend with the children provide them immense happiness. Anganwadi worker from Thiruvananthapuram shared,
The time spending with children is the most relaxing time for me. We will disregard all agonies in our individual life when we see their grin and play. In that way I am very satisfied.
Problems in delivering services due to poor multi-sectoral coordination
The ICDS Manual for district-level functionaries elaborates on convergence of nine different ministries and existing schemes with Anganwadi centers as the focal point [8]. It was observed that the ICDS do coordinate with Local Self Government Institutions (LSGIs), Health system and Public Distribution System (PDS) even before the reforms. The LSGIs provide the fund and the PDS distribute the food grains. This was universal across the state.
All 12 AWWs had the same story regarding the cross-sectoral convergence. There is Health, Nutrition and Sanitation Committee at each LSGI, however, no AWW or other key informants could not share more information apart from monthly meetings. Further, the supervisors, CDPOs and DPOs have such multi-sectoral meetings at their levels. As mentioned in the previous section, the documentation has been given undue importance over the service delivery due to these multiple meetings.
Members of Legislative Assembly have no link with ICDS in general. Answering a question on cross-sectoral convergence (in the Legislative Assembly), it was proved that status quo would be maintained as the government intended to engage the respective Health, Sanitation and Nutrition Committees at panchayats, municipalities and corporations at the ground level.
Panchayat president from Idukki also shared similar opinion, “Angawadi worker is a member of the Health, Nutrition and Sanitation Committee. She will contact us whenever she needs any help. We also review the reports submitted by them.
The poor cross-sectoral convergence is confirmed by the NITI Aayog progress report for states on the implementation of POSHAN Abhiyaan. Kerala was one of the states that scored low in cross-sectoral convergence [2, 20].
Low priority to nutrition - an evidence for low political will
Political will to tackle undernutrition among children in Kerala is assessed through interviews with MLAs and LSGI members and content analysis of questions and answers raised in the LA of Kerala as mentioned in the methodology. Out of 20386 questions asked during the said period, only 66 questions addressed any of these [21]. They addressed infrastructural development, funding conflicts with central government, training and welfare of AWWs, and nutritional status of children from tribal communities. It was reported that the training programmes for AWWs were temporarily stopped from 1st January 2018 as the central government fund was not released, which was ascertained from the in-depth interviews with AWWs as they have not received any training since 2017.
The answers to the questions reported that the following programmes were implemented to prevent malnutrition among children from tribal communities, 1) first 1000 days for children 2) community kitchen in Attappady for providing cooked food, 3) fortified nutritious food for children and adolescent girls, 4) millet village scheme to promote traditional farming culture of tribal population and 5) provision of food grains during rainy season and during the months of scarcity. However, no evidence was available whether these programmes achieved their objectives or not. No question was related to the nutritional status of children of fisher folk or plantation labourers who were also at increased risk of malnutrition.
Interviews with MLAs and LSGI members revealed that nutrition was not a prioritized agenda and ICDS service providers were given the responsibility of the same. An MLA from Idukki, when mentioned about the high prevalence of undernutrition among children in the district as per the National Family Health Survey-4, said,
It didn’t come to my notice. The high rates of undernutrition in Idukki could be because there are many scheduled tribe populations in this area. In addition, plantation labourers are also there. However, if there was serious issue, it would have definitely come to my notice.
Village Health, Sanitation and Nutrition Committee member from Kasaragod said,
The tribal population are more in my area. Unlike in the past, many of them have jobs and leading a good life. However, in some areas, the situation is still worse. However, many of their welfare activities are done by the Tribal Welfare Board.