Ground Zero | How dearth of data killed a healthy diet

The tracking and monitoring of nutrition services to the poorest of the poor in India have been hampered by the lack of online data. Jagriti Chandra reports how this has affected pregnant women in a pandemic year when hunger and poverty have worsened

Afsana, whose first child is due next month, with her sister Ruqsar at Derwala village in Jhunjhunu district of Rajasthan.

Twenty-year-old Afsana’s baby is due in a month. Afsana conceived just 10 days after the nationwide lockdown was imposed to curb the spread of the novel coronavirus . Afsana and her family of nine live a hand to mouth existence and the pandemic has only worsened their woes. The expectant mother is anaemic, having survived along with her family on just chapatis and red chilli paste on most days.

Afsana’s husband, brother-in-law and father-in-law, the three breadwinners of the family, work at the local stone quarries in Derwala village in Jhunjhunu district of Rajasthan, where they live. They had no work for nearly three months, from April to June. Though work has picked up slowly since then, their daily earnings are as low as ₹150 on a good day. They survive on the wheat supply from the public distribution system. “Only if we go out in the day to work can we buy pulses, sugar and milk for our evenings. There is barely enough to last us a day,” says Mohammad Rafiq Bhati, Afsana’s brother-in-law.

Afsana has already undergone blood transfusion four times. Her eyes are listless. She has been called again to the primary healthcare centre on December 9 for a check-up. The Pradhan Mantri Surakshit Matritva Abhiyan , a scheme of the Union Health Ministry, aims to provide quality antenatal care, free of cost, to all pregnant women in the country on the ninth of every month and also a minimum package of antenatal care services to women in their second/ third trimesters of pregnancy at designated government health facilities. However, Afsana’s take-home rations as part of anganwadi services have been irregular. Of the eight months of her pregnancy, she has received 6 kg worth of monthly entitlement (1.5 kg wheat, 1.5 kg rice and 3kg pulses) only for four months. The supply of these, too, has been erratic as anganwadi workers have to wait for the stock to accumulate sufficiently before disbursing it. Though the aim of the programme is to ensure adequate nutrition for expectant mothers, this food has been used by all the members of Afsana’s impoverished and hungry family.

While Afsana, as the expectant mother of her first child, is also entitled to receive a total of ₹5,000 in multiple tranches under the Pradhan Mantri Matru Vandana Yojana , a scheme of the Ministry of Women and Child Development, she has still not got any benefits. Her sister Ruqsar Bano says no one has come to collect documents or even asked them to submit the papers at the anganwadi centre. “We have completed the paper work. We are waiting for the government to release her claim,” says Rekha Sharma, a local ASHA worker. Afsana, shy and reticent, wishes she had the money to buy vegetables and fruits.

The delivery of nutrition services to the poor in India has been brought to a halt or slowed down due to lack of online data, a problem caused by poor Internet and server issues. This has not only affected the beneficiaries, but also the anganwadi workers. It has also caused frustration among those working towards addressing India’s malnutrition, poverty and health issues. The lack of publicly available nutrition data is not only affecting India’s nutrition goals but is also pushing States into thinking of ways of setting up their own systems to tackle the problem.

In Jhunjhunu, a vague memory

An IT-based nutrition monitoring system called the Integrated Child Development Services-Common Application Software (ICDS-CAS) was inaugurated by Prime Minister Narendra Modi in Jhunjhunu on March 8, International Women’s Day, in 2018. Under this system, anganwadi workers log the details of the beneficiaries and daily activities to enable monitoring at the district, State and Central levels for improvement in the quality of delivery of services. However, in this village, ICDS-CAS is only a vague memory for most.

 

“Two years ago, we were given tablets and smartphones. But when we had Internet issues, those were taken away,” says Rekha. She and her team of one anganwadi worker and one anganwadi helper have been working overtime, about eight to 10 hours a day, conducting surveys on COVID-19 patients and ensuring social distancing at Panchayat elections, among other duties. A phone may have helped teams like hers at the block and district levels fill the gaps in programme implementation.

The ICDS-CAS was the mainstay of Poshan Abhiyaan, approved by the Union Cabinet in December 2017 at a budget outlay of ₹9,000 crore. Half of this was to be funded by the Indian government and the other half through a loan from the World Bank. Poshan Abhiyaan strives to improve nutritional outcomes for children, pregnant women and lactating mothers by reducing undernutrition, bringing down anaemia, and increasing birth weight. As the aim of Poshan Abhiyaan is to reach 10 crore beneficiaries at 14 lakh anganwadis, the government set up the ICDS-CAS to ensure swift tracking and effective implementation.

Under the ICDS-CAS, anganwadi workers are provided mobile phones, and anganwadi supervisors, tablets. Anganwadi workers enter details of daily activities, including photo evidence of the opening of anganwadis; attendance of children; details of food, weight and height; etc. These are then monitored at five levels — first by the anganwadi supervisor and then at the block, district, State and Central levels. The assessments and feedback from these levels are provided to the workers. Service delivery is thus tracked and informed decisions taken based on the assessments.

Plugging gaps in Churu

Churu, a district located three hours from Jhunjhunu, paints a different picture. It is among the nine districts where the ICDS-CAS has been implemented. The use of technology and the monitoring of activities through mobile phones allow block-level supervisors to extend support to anganwadi workers and plug gaps from time to time.

Sunita is full of praise for the local anganwadi in Gajsar village in Churu. “Food was being delivered regularly. We often ask when they will open the anganwadi so that the children get hot meals and remain busy,”” she says. Before the lockdown, the Rajasthan government also attempted weekly menus which included milk, fruits, and a mixture of rice and lentil, but this was discontinued during the lockdown.

Sunita’s immediate neighbour Amina Bano, who has a six-year-old grandson Shoaib, says, “We are happy with the anganwadi as children get to learn some numbers and alphabets.”

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Here, the efficient monitoring system ensures that if there is a lag in ration supply at the anganwadis, programme supervisors at block levels are alerted and supply is restored. Smartphones distributed to anganwadi workers also help to alert them when vaccinations are due. They are also able to maintain a list of the malnourishment levels of the entire village population. The phone helps them identify children at risk of being malnourished as well as those already stunted or wasted. Those at risk of being malnourished are highlighted on the app in yellow and those already stunted/wasted are marked in red after the anganwadi workers log in the height and weight details of the children. Sanju Devi, the local anganwadi worker, shows her phone: two of the 20 children registered with the anganwadi where she works are in the red category and need special interventions.

Internet issues

However, server issues and Internet problems plague the system here, too. Also, smartphones which were given to the workers to simplify their tasks have doubled their work. Workers are now expected to note down details not only in their phones but also in registers.

In Churu, the server has been down for over two months. Since the ICDS-CAS platform is common for the whole country, this means that monitoring activities across more than 26 States where the ICDS-CAS is running have been hampered.

“For the past two months, they have been logging details in their phones as well as in registers, so there is duplication,” says Mohammed Mushtaqeem Khan, District Co-ordinator, National Nutrition Mission. “They usually use the phone to upload photos of children attending the anganwadi. Photos can’t be misused as they are uploaded directly on the app and can’t be saved in the phone’s gallery. This avoids a situation where an anganwadi worker clicks photos for the entire week on the same day. We also use the photos to do surprise checks and contact the beneficiaries and their parents to receive feedback. The technology has helped the parents become more aware too. They often use these occasions to tell us if they have been receiving less than what they are entitled to get.”

An anganwadi worker visits a household to deliver essentials and gather details about the children’s health at a village in Rajasthan’s Jhunjhunu district.

 

The collapse of the system also means that the anganwadi workers are the hardest hit. “The anganwadi workers’ incentives have been delayed at a time when the pandemic has resulted in their work increasing manifold. The system helps automatically calculate an anganwadi worker’s incentives through the activities logged in by her. But since that is not possible now, they haven’t received their incentives for the past two months. The State government is devising a new parameter to overcome this problem,” he says.

Experts say on the condition of anonymity that the server crash is a result of the government’s lack of preparedness to deal with a massive amount of data (nearly seven lakh out of 14 lakh anganwadis where the ICDS-CAS have already been implemented) and cloud storage and managing the entire architecture including hardware and software. The technology support has alternated between the National Informatics Centre and Tata Consultancy Services in the recent past, while it was earlier handled by the U.S.-based Dimagi.

Lack of data

Even before the server problem, unavailability of data from an expensive technology system set up primarily to improve service delivery caused anger among implementation partners, researchers, nutrition advocates and public health experts. This happened at a time when warnings were issued about the likelihood of an additional 10,000 under-five deaths per month globally and of 6.7 million more children suffering from wasting, a strong predictor of mortality, due to the pandemic.

“The strength of India’s future will be determined by the health and nutrition of its babies today. The government deploys significant resources and hundreds of thousands of front-line anganwadi workers across the country, who work every day, including through the pandemic, to reach some of India’s more vulnerable citizens. As an example, Poshan Abhiyaan disseminates over 10 nutrition-related messages across more than 20 platforms. But what is the reach of platforms and messages? Have pregnant and lactating women’s nutrition behaviours changed over time? How has all of this been changing during the pandemic? It is very important to track progress, understand gaps, and acknowledge and reward heroic efforts. Without live information systems like the CAS, many key decisions will be made without robust evidence,” says Divya Nair, Director, IDinsight.

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“The less said about ICDS-CAS, the better. The data have not been available, and we can’t use the software tool the way we would like. So, we use our application called Sampark, where we log the data of children, mothers as well as the status of welfare schemes such as PDS, BPL, labour cards accessible to beneficiaries...,” says a representative of the Madhya Pradesh government.

Dr. Vandana Prasad, a public health expert, Joint Convenor of the People’s Health Movement-India (Jan Swasthya Abhiyan) and a member of the Steering Committee of the Right to Food Campaign agrees. She says, “ICDS is important because it caters to the entire life cycle of pregnant women and lactating mothers, adolescent girls and children between the age of six months and six years, by making direct interventions. It also provides a platform for delivering health services. Data are critical to any programme, especially nutrition programmes. During a pandemic we need more data, not less. Data are critical as people are at a higher risk now, they are severely vulnerable. All public data need to be made public. Data must be open for evaluation so that there are no cover-ups.”

The problem of lack of access to data is also faced by State governments. Many States, including Rajasthan and Andhra Pradesh, are known to have written to the Centre raising their concerns about unavailability of data for programme implementation and review.

“The guidelines for a supplementary nutrition programme allow States to decide what food they would like to distribute, but the ICDS-CAS is a common application for the entire country which doesn’t allow us the flexibility to record and monitor data as per the specifics of our scheme. We have written to the Centre raising this issue and demanded that all data be put in the public domain so that there is transparency and accountability. If we want the data of the past two or three months, for instance, to study the impact of our interventions, we don’t have them,” says Rajasthan’s Women and Child Development Secretary, Krishna Kant Pathak.

“There are no data available. We have requested the Central government for access, but beyond their templated dashboard, nothing is available to us. We haven’t even received a response from the Centre,” says Annapurna Garu, Joint Project Co-ordinator, National Nutrition Mission.

When the scheme was designed and being implemented, it was driven by a spirit of co-ordination and co-operation, explains one of the chief architects of the Poshan Abhiyaan at the Centre, on the condition of anonymity. “We often wrote letters and communicated over the phone to address the problems expressed by the States. Data, too, were always discussed at meetings where different non-government stakeholders were present as well. It is not true that data were meant to be kept under lock and key because of privacy issues. There are enough ways to mask the identity of the beneficiaries,” he says.

Need for convergence

States demand not only the Centre’s co-operation but also harp on the need for convergence between the Ministry of Health and Family Welfare and the Women and Child Development’s ICDS through a common data portal. “There is a need for convergence. The Pregnancy, Child Tracking and Health Services Management System, for example, can give us data about a woman becoming pregnant. We can then use this to transfer their entitlements through the Pradhan Mantri Matritva Vandana Yojana, a maternity benefit scheme,” says Pathak.

Since the Centre has failed to do this, the Rajasthan government is now planning to launch an AAA app or the ‘Auxiliary Nurse Midwife, Anganwadi and ASHA’ app , to ensure that all three of them are connected through the same tool. Andhra Pradesh, too, says that a pre-existing app called NutriTask, which was put aside after the ICDS-CAS was conceived, may now be revived.

Ironically, a month before the launch of Poshan Abhiyaan, the Union Women and Child Development Ministry had written to the State Chief Secretaries to ensure a “single point of impact for all nutrition-related schemes” through the ICDS-CAS and advised them to “phase out State-/ UT-level initiatives to enable a synergised approach, avoid replication, and achieve the overall goals of the Mission.” But three years later, things seem to be moving in the opposite direction as several States are keen to develop their own software modules.

“The accountability system is enormously centralised and top-down and is focused on surveillance of anganwadi workers. This is risky during a crisis like a pandemic or a flood because it means that the local community is not taught to take ownership of nutrition services and trained to monitor service delivery. To me if you want accountability, you could have a mother’s group that can monitor whether or not an anganwadi is functioning, whether the supplies are there, whether an anganwadi worker is providing those supplies to children or not. Local mothers’ groups and panchayat committees can play not just an inspectorial role, but also a supportive role,” says Jashodhara Dasgupta, social researcher on gender, health and rights, and convener of the Feminist Policy Collective.

The ICDS-CAS harps on accountability of the person at the ground level instead of addressing other systemic issues, she says. “Anganwadi workers are treated as voluntary workers as they are considered to be part-time workers, and they live close to the houses they monitor. They are underpaid, overworked and deprived of social protection. So why are we so hooked to their accountability when there are inadequate budgets, delays in disbursal of cash benefits, lack of data, etc.? The entire system is intent on policing her,” Dasgupta says.

“There is a strong case against centralisation of data systems. The systems must be flexible and in tune with local interventions. They must also be available to the front-line workers as well as at the local level for analyses and execution of corrective measures, and not just to programme developers. After all, it is an anganwadi worker who can take corrective steps immediately. Data systems should also be built with local participation and consensus. The Centre can facilitate setting this up locally and providing a supportive role to ensure capacity building for effective use of data,” Prasad contends.