For India, undernutrition has been a persistent challenge. To tackle it, the Government of India has made several policy and programmatic efforts, including the launch of the Poshan Abhiyaan, the flagship programme under the Ministry of Women and Child Development (WCD). The overarching goal of all these efforts is to improve the nutritional outcome for children, adolescents, lactating mothers and pregnant women by focusing on capacity building, improvement of service delivery, community mobilisation and participation, use of technology and interministerial and interdepartmental convergent planning and review of progress.
The quality of nutrition service delivery remains a key challenge in India, adversely affecting nutrition outcomes for women and children. To achieve the ambitious targets and to fully harness the opportunities created through the Poshan Abhiyaan, a stronger focus is needed on delivering high-impact nutrition interventions, especially in the first 1,000 days—pregnancy to age two—for children, with full coverage and quality. Government programmes are routinely monitoring coverage indicators but the focus on quality needs strengthening.
In its latest report, the Lancet Global Health Commission on High Quality Health Systems in the SDG Era estimated that in low and low middle income countries, 60 per cent of deaths are due to poor quality care and the remaining deaths result from non-utilisation of the health system. Evaluation of maternal nutrition programming in Bangladesh has highlighted the fact that improving the quality of delivery is more than twice as impactful as improving coverage.
The third progress report of the Poshan Abhiyaan emphasised the need for and importance of quality improvements in the delivery of interventions by the Integrated Child Development Scheme (ICDS), including home visits, growth monitoring and take-home ration. The report also highlighted the need for improvement in the quality of nutrition services delivered during visits for programmes related to antenatal care, home-based newborn care and home-based care for young children under the National Health Mission. Quality implies that infants, young children, and women receive effective, timely, adequate, affordable, culturally sensitive and respectful nutrition care that they need for optimal health and well-being. It encompasses both the dimensions of provision of care and experience of care.
Over the last few years, the WCD has adopted a multipronged approach to improve the quality of nutrition services under the Poshan Abhiyaan, including an incremental learning approach for capacity building of frontline workers. It has even launched a monitoring application, Poshan Tracker, to enable the real-time monitoring and tracking of all Anganwadi centres, Anganwadi workers and the beneficiaries on defined indicators. As part of the drive to improve quality, the Ministry of Health and Family Welfare has undertaken several initiatives such as labour room quality improvement initiative (LaQshya), MusQan (for quality assurance) and mothers' absolute affection (MAA) to prioritise quality improvement for nutrition interventions like early and exclusive breastfeeding, and feeding sick neonates.
A comprehensive nutrition quality programme requires responsive and accountable leadership, generating a culture of quality which is community and beneficiary-centric with clear structures and role clarity for each cadre along with mechanisms to enable the implementation of three quality management approaches like quality planning, quality assurance and quality improvement. Institutional mechanisms are required to enable continuous improvement of the quality of nutrition services across the ICDS and health systems.
First, it is crucial to make quality assurance efforts by defining the quality standards and guidelines for nutrition services delivered at community level during home visits, at community-based events and at Anganwadi centres as well as in health facilities. Care has to be measured against those standards by developing plans to fix identified gaps, conducting follow-up assessments and setting up mechanisms to recognise and make visible the achievement of standards.
To measure quality, three sets of information need to be captured: inputs in terms of training, equipment, infrastructure and commodities availability; adequate processes followed by frontline nutrition and health workers in delivering services and benefits to families; and satisfaction and knowledge level of the families on the services received. To institutionalise the quality assessment and improvement process, it is important to understand that the data, which sheds light on problems, needs to be considered as an asset rather than a liability. The objective of reviewing the data should be identification of gaps and support required for improvement rather than punitive action. Moreover, data quality can really improve significantly when data collectors see the value of the data for service delivery and improvement. Data use for programmatic improvement must become part of the DNA of our system at all levels.
Secondly, mechanisms need to be set up to embed quality improvement methods—management approaches that the team members involved in the provision, oversight and enablement of service delivery can use to solve problems at their level to improve care—into the system. They have been successful in healthcare and have shown encouraging results when utilised to improve nutrition service delivery in health facilities and promote early initiation of breastfeeding in both normal and C-section deliveries. This type of approach has the potential to transform the delivery of nutrition services in community settings as well through reviews of service quality using data, team-based discussions of the root causes of quality gaps and problem-solving processes.
Thirdly, systematic and regular measurement of the quality of service delivery—inclusive of inputs, processes and outcomes—across the ICDS and health system is the call of the hour. The system needs to build visibility on how service delivery processes are implemented in the field and how they are perceived by beneficiaries.
Lastly, it is essential to strengthen the community's role in contributing to create an enabling environment to improve the quality of nutrition services by engaging in programme design and delivery.
It is time to strengthen these efforts and develop and implement a comprehensive approach, combining both quality assurance and quality improvement for nutrition service delivery under the leadership of the government. Only that will help the country realise the vision of Suposhit Bharat and unlock the immense potential of India’s human capital.
(Dr. Sebanti Ghosh is a public health and nutrition expert, and member of several technical expert committees on maternal, newborn child health and nutrition constituted by the Ministry of Health and Family Welfare. She is also part of the World Health Organization South-East Asia Regional Office’s Technical Group on Women & Children’s Health. Ghosh is currently serving as the Senior Technical Advisor- Nutrition, South Asia, Alive & Thrive, India, FHI Solutions.)