3 Poshan Samvad 2015 16

Poshan Samvad
Forum for Informal Dialogue with and Amongst Field

Functionaries of the Departments of Women & Child
Development and Public Health & Family Welfare
Shivpuri Balaghat Khandwa
An Endeavor of Vikas Samvad with Parhit (Shivpuri), Spandan (Khandwa) & CDC (Balaghat)
Chapter 1
Poshan Samvad: Resolving Problems through Dialogues The Decentralised Way
Poshan Samvad - Nutrition Dialogue - is a mechanism for establishing an ongoing consultation amongst the
field functionaries of the departments of Women & Child Development and Public Health & Family Welfare.
It is our endeavor that the setting of the dialogue is such that it is open and informal and enables free
consultations - free from any pressure, interference or discrimination or prejudice. The essential mandate
of the Poshan Samvad is that the participants Anganwadi Workers, Accredited Social Health Activists
(ASHAs) and the Auxiliary Nurse Midwifes (ANMs) - from both the key departments are encouraged to
freely express themselves, without any hesitation, with regard to their perceptions, thoughts and
experiences on problems, existing processes and changes required in institutional mechanisms.
The need for a forum for dialogue like that of Poshan Samvad becomes all the more relevant because it is
the ground level functionaries who have the crucial role to perform in rendering services for children under
6 years of age, pregnant women, nursing mothers and the adolescent girls. Despite the huge and significant
value of their roles, there exists no institutional mechanism that can provide for a forum for listening to
these field functionaries. Their challenges and issues with the problems encountered, thus, remain
unattended. At the same time, the policy makers and programme managers of the two departments are
deprived of their experiences pertaining to the ground situation. In a top heavy system obtaining today, the
new schemes are designed and the responsibility for implementation is thrust upon these field
functionaries, albeit, without any consultation with them. This has a bearing on their morale which
adversely affects their routine work performance, in one or the other form.
Sector Level Dialogue
A sector constitutes the bottom level ingredient of the Anganwadi Project hierarchy. In common
parlance, known as the Anganwadi Project (formally, as the Integrated Child Development Services
ICDS Scheme) under the Department of Women & Child Development, the Anganwadi is operated for
rendering services to the children under 6 years of age, pregnant women and nursing mothers. A
Community Development Block constitutes an ICDS Projects administrative unit which is further divided
in to 7 to 10 sectors. Each sector comprises about 25 Anganwadi Centres. ASHAs and ANMs of the
Department of Public Health & Family Welfare form the complementary linkage with the ICDS
counterpart the Anganwadi Workers - in the deliverance of Anganwadi services to the targeted
stakeholders.
Sector was primarily chosen as the venue for the dialogue as it entails minimum distance that is to be
traversed by the Anganwadi Workers for joining in the consultation meetings. Generally, maximum radial
distance for the Anganwadis from the sector is about 10 kms. Likewise, sector also affords greater
convenience for the ASHAs and the ANMs in attending sector meetings rather than those at the district
headquarters. With ease of access, participants routine work is also not much affected and they can
freely express themselves without any worries. The second major reason for picking up sector as the
venue is that in a sector, most of the Anganwadi Workers and the ASHAs are familiar with one another.
Process at the meetings (time duration: 2 to 3 hours)
1. A highly informal, friendly and participatory mode of consultation is followed at the sector level
Poshan Samvad meetings. It does not entail any kind of obligation, hounding or expectations.
2. The crux of the consultations lies in the focus on attribute of listening. What is of significance at the
dialogue is the accent on seeking enhanced mutual understanding amongst the field functionaries of
the two departments with regard to their perceptions and outlooks pertaining to the management
of malnutrition and building on the same.
3. Encouraging the field functionaries to express themselves.
4. Providing a forum for acknowledging the innovative practices of the participants. At the same time,
they become aware of innovations elsewhere.
5. Providing guiding resources in terms new research, information and facts for enriching the
knowledge base of the participants.
6. Sharing of problems, issues and recommendations as emerging from the meetings at the district and
state levels.
Prerequisites
Building a dialogue group of select Anganwadi Workers, ASHAs and ANMs in a sector.
Holding dialogue with them on agenda in accordance with the template for the Poshan Samvad.
Documentation of innovative practices pursued by the field functionaries.
Carefully listening to the field functionaries with regard to their perceptions on problems, thoughts and
experiences and documenting the same.
Resources (Human Resources)
Local presenter who is based at the sector.
A specialist in documentation.
A specialist to put together on-site evidences and facts with skills in audio-video and in-depth
interviews.
Resources (Material and others)
Writing pad, pen
Chart, reference material related with agenda for the meeting
Safe drinking water
Register for participants registration
Ladies toilet and convenient clean area
A hall for accommodating about 50 persons
Carpet etc.
Process
Determining agenda, programme schedule and content to be addressed in the meeting
Presenting the concept of Poshan Samvad and sharing our experiences on the dialogues held hitherto
Sharing the objective and programme content of the meeting
Conduct of meeting in a free, relaxed and non-discriminatory environment.
Encouraging and welcoming the field functionaries to share their positive experiences, innovative
activities and practices apart from soliciting their suggestions and ideas.
Identifying functionaries with excellent performance, encouraging them to engage in intensive
consultations
Documentation of case studies of such field functionaries.
Video-recording of innovative activities during the field visits to Anganwadi and health centres.
Sectors included in Poshan Samvad
The second round of meeting of the Poshan Samvad was held only in those sectors where the first round of
meeting had been gone through. The precise intent of holding two rounds of meetings had its genesis in the
realisation that it was next to impossible to garner and process all the ground level challenges faced,
experiences culled and suggestions made by the field functionaries within the precincts of just one meeting.
Secondly, it was also felt that it would not be easy for the functionaries to be able to express themselves freely
and comprehensively without gaining an insight into the purpose of the Poshan Samvad and the attendant
informal processes. Further, of course, it pays to follow-up one round of consultations with the second one so
as to refine and consolidate the intent, processes and outputs of the consultations for a lasting and productive
imprint on work performance vis--vis roles of field functionaries and the key stakeholders around them.
Consequently, going by the foregoing rationale, all sectors from one block in each of the 3 districts, namely
Khandwa, Shivpuri and Balaghat formed the domain of Poshan Samvad. The blocks and the sectors were as
follows:
District Shivpuri District Khandwa District Balaghat

Block Pohri Block Khalwa Block Baihar
S. No. Sectors S. Sectors S. Sectors
No. No.
1 Devrikhurd 1 Khalwa 1 Aamgaon
2 Bairad -1 2 Sanvli Kheda 2 Garhi -1
3 Chharch 3 Dakochi 3 Garhi - 2
4 Pohri 4 Ashapur 4 Bhanderi - 1
5 Gorwardhan 5 Khedi 5 Bhanderi - 2
6 Bhatnawar 6 Kharkala 6 Bithlee -1
7 Jhiri 7 Devlikala 7 Bithlee -2
8 Bairad-2 8 Patajan 8 Kukarra - 1
9 Roshni 9 Kukarra - 2
10 Awalya 10 Baihar
11 Gulari
12 Sendhwal
Thus, with 8 sectors in Pohri block of Shivpuri district, 12 in Khalwa block of Khandwa district and 10 sectors in
Baihar block of Balaghat district, a total of 767 Anganwadi Centres across 30 sectors drawn from 1 block each
from 3 districts formed the canvas of the focused, yet differentiated and intensive deliberations under the
Poshan Samvad intervention.
There were a total of 8 sector meetings held in Block Pohri. The Poshan Samvad at these meetings brought
together a total of 236 Anganwadi Workers, 129 ASHAs, 14 ASHA Sahyoginis, 4 ANMs (2 each at Chharch and
Jhiri) and 1 ICDS Sector Supervisor at each of the sector meetings. In addition, there were 46 other
participants.
There were a total of 12 sector meetings held in Block Khalwa. The Poshan Samvad at these meetings brought
together a total of 253 Anganwadi Workers, 16 ASHAs and 11 ICDS Sector Supervisors.
Process of Dialogue Forum Meetings

The second round of consultations placed an accent on the primacy of roles of Anganwadi Worker and ASHA
towards exploring measures that enables superior coordination between them in addressing ground level
challenges.
The agenda for the second round consultations largely remained identical with a pronounced emphasis on
getting the frontline workers to come out with their suggestions aimed at seeking an improvement in their
work in terms of its outputs and outcomes apart from easing the work routines.
Session Topic
First Session Significance of nutrition for the community, nutrition awareness for the community (ante
natal, post-natal condition, beliefs and practices of the community).
Second Care of the newborn, feeding colostrum to the newborn, feeding the newborn up to 6
Session months of age and food intake for children above 6 months of age and their care.
Third Session Illnesses and immunisation (which illnesses, what and when of immunisation, extent of
community participation, role of Panchayats)
Fourth Session Treatment of severely malnourished children and their care (referral, governments
protocols, roles of the department of Public Health & Family Welfare, convergence and
coordination between ICDS and Health)
It may be mentioned that since it was contemplated to be an informal process, no questions or queries were
framed in advance, albeit a template was drawn up listing certain crucial issues so that the same were not
missed out in the dialogue.
Format for the Conduct of Poshan Samvad Meeting and Elaborate Documentation
Topic What must be done?
Poshan Samvad is not intended to be a forum for bragging Keep in mind.
ones vastness of knowledge or information to the
frontline workers and service providers Showing off
knowledge. We believe that they have very wide range of
experiences and that we can build upon the same in
improving programmes and their dispensation.
Let us be entirely present amidst the participants. It is Keep in mind.
rather better to make prior arrangements for essential
services like venue for the meeting, water, tea, food,
stationery, charts, study material, camera etc. instead of
going about the same whilst the meeting is in progress. Let
there be no distractions.
It will be a team of 3 to 4 Resource Persons which will Keep in mind.
conduct the Poshan Samvad processes. One of the team
members shall be dedicated for documentation.
Our body language, words and tone of expression shows Keep in mind.
whether we are intently listening to them. We have to
ensure that we do not portray ourselves as if taking them
lightly or less important. It is also important to recognise
that everything does not need to be replied to as well.
Do pool together necessary information. How many Keep in mind and be in state of readiness.
participants were there? What was the extent of
participation from the departments of Women and Child
Development and Public Health & Family Welfare?
Registration of all participants should be ensured. It is also
useful to obtain contact information for all participants.
Discuss as to the purpose of getting together. We should Documentation of their expectations and
try to elicit the expectations that the participants have assessment (as to what is to happen in the
from the deliberations so that dialogue builds on the meeting).
same. We need to understand as to what the participants
expect or do not expect from the consultations!
What theme has been selected for the sector-centric Jot down the selected subject.
dialogue?
It will be better to arrive at the topic and framework of Documentation.
consultations based on discussion with the participants.
We update them about the Poshan Samvad hitherto and Discuss and obtain the feedback of the
articulate as to what is meant by it. Why did we start it? participants.
What have been the experiences so far? What is the
destination that we are looking for?
We must make be clear that listening to and Discussion.
understanding the frontline functionaries (Anganwadi
Workers and ASHAs) is the most significant dictum of the
Poshan Samvad. The elaborate discussion can be taken up
on some matters where felt useful.
With a view to reinforce the confidence of the Discussion.
participants, it should be mentioned to them we accord an
utmost value to the role of field functionaries in improving
the status of nutrition towards securing better health for
children and women. We should share the rationale with
them that they are the closest to the community and
hence also get to know the signs and symptoms disease
and malnutrition as soon as the same occur. After all, the
process of treatment commences only after this initial
assessment which is captured by the workers. The workers
also have the responsibility to bring about positive and
health-seeking behavioral change in the community. Thus,
we need to share our belief with the participants that their
role is central to communitys nutritional and healthy
wellbeing.
We must always bear in mind that the purpose of Poshan Keep in mind.
Samvad is to afford maximum opportunity to the field
functionaries for expressing themselves in the dialogue. Of
course, at times it may be possible that no one in the
group speaks out in the meeting. In such a case, we may
prompt them with sharing of some of our own
experiences. However, our prompts should rather be
exceptions only and not get changed in to a full-fledged
lecture-mode discourse!
It would rather be better that we avoid being principled or Keep up the effort so that the discussion
technical-centric with the participants in a top heavy remains contexualised with experiences and
mode. Instead, we should get them to come up with their practical considerations.
own experiences and stories.
We have to identify specific subjects and themes which
warrant that we provide certain informational and
technical inputs whilst they share their experiences and
stories. This ought to be need-based so as to articulate
their insight in to the concerned subject.
Where we observe that their experiences and information Keep engaged in the discussion, take hold of
are positive and progressive, we should appreciate and the right question or point and steer the
recognise the same and credit them with the impact of discussion on the same.
their work on decline in child mortality rate. They would
develop a huge sense of self-worth of their work when
they can relate it with changes in patterns of diseases and
malnutrition.
Ask them as to what gives them the maximum happiness Encouraging them to express their point or
in their work. thought.
Ask them as which aspect of their work they liked most, Encouraging them to express their point or
the one that they consider to be their best achievement. thought.
Phrase one question so as to get to know what all In the context of pregnant women and
constitute the tasks of an Anganwadi Worker. nursing mothers, children and adolescent
girls.
Amongst the host of work routines of the Anganwadi In the context of pregnant women and
Worker, find out the ones in which ASHA has a significant nursing mothers, children and adolescent
unique and complementing roles delineate the same. girls.
Phrase one question so as to get to know what all In the context of pregnant women and
constitute the tasks of an ASHA. nursing mothers, children and adolescent
girls.
Amongst the host of work routines of the ASHA, find out In the context of pregnant women and
the ones in which the Anganwadi Worker has a significant nursing mothers, children and adolescent
unique and complementing roles delineate the same. girls.
Try to find out as to beyond the village/habitation Encouraging them to express their point or
concerns, what have been their experiences in obtaining thought.
and delivering the services.
Poshan Samvad deliberations hitherto indicate that the Make use of booklets developed for Poshan
needs of the field functionaries are more pronounced with Samvad.
regard to health of the newborns, their care, diet for
younger children breast feeding and complementary
feeding, growth monitoring, getting acquainted with
different aspects of malnutrition, expansion of pre-school
non-formal education and subjects related with
pregnancy. We may dwell on these aspects for about half
a day of our deliberations.
We need to see as to how the workers undertake the Getting a feel as to the seriousness with
processes of home visit and family counselling. We should which counselling and home visits are
get to know as to how they meet up with the people. How undertaken. Getting to know as to why
do they give out the messages? Are the messages in sync Kanjars are required to undertake this work
with the needs of the community? and what are the reasons for good work, if
any being done, at some places.
Do the field functionaries know about foods, materials, We must first get to know about these food
foodgrains, leafy vegetables, fruits, tubers and their products and their uses so that meaningful
medicinal values? Do they propagate any messages or discussion can occur in the context of local
recommendations on the same to the community? aspects.
Discuss on the issue of current dispensation of Talking on options.
coordination between the Anganwadi worker and the
ASHA worker. Find out whether there are any options for
improving the same.
Ensure that all the foregoing points are extensively
incorporated in our Poshan Samvad Report. Our report
should not be tabular. It should be descriptive and
presented in order of subjects addressed. You know well
whether the report comprehensively captures all the
emerging aspects addressed in the Poshan Samvad!
Duration of the Meeting: The duration of the Poshan Samvad has been set in a manner that it clashes least
with their formal work routine. Normally, an Anganwadi starts at 9 am and ends at 1.30 pm. Accordingly, it is
more convenient to schedule the Poshan Samvad deliberations from 2 pm onwards. Accordingly, the Poshan
Samvad meetings have lasted by and large for 3 to 4 hours.
It has been mainly observed during the second round of meetings that during this period, it helps to have an
open dialogue with the workers with regard to their suggestions, challenges faced by them and other practical
considerations so that problems on mutual coordination can be effectively dealt with.
Strengthening the Knowledge Base of Frontline Functionaries
It is observed that the frontline workers of the department of Women and Child Development do not
have access to any such reading material in departmental training programmes that they can use as a
reference back up. Keeping this in view, both the Anganwadi Workers and the ASHAs have been provided
a range of reference materials during both the rounds of Poshan Samvad meetings. Guides, booklets,
reference notes and factsheets etc. pertaining to subjects including, inter alia, growth monitoring of
children, breastfeeding of new-born and children under 2 years of age, early childhood care and
development, protection of children from illnesses and infections and their treatment, community -based
initiatives in combating malnutrition comprise this reference material.
Chapter 2: About the State and the 3 Districts Covered under Poshan Samvad
Pohri Block District Shivpuri

The community development block headquarter Pohri of district Shivpuri is located on Shivpuri-Sheopur road,
35 km east off the district headquarter. This block has 253 villages covered by 90 Gram Panchayats. As many
as 111 of the villages are tribal dominant.
The block is characterized by a host of issues. These issues include dominant share of government schemes by
the higher class people and the administrative officials being in hands-in-gloves with such elements, lack of
resources, widespread dacoit-infested menace, irregular remittances to pensioners under the social security
schemes, lack of harmony amongst the tribals, irregular functionality of fair price shops under the public
distribution system, disbursement of Mid-Day meal not according to menu and specifications, scam in
disbursements under National Rural Employment Guarantee Act, community ignorant about its entitlements
under the provisions of the National Rural Employment Guarantee Act- non-availability of basic services like
first-aid box, drinking water, rest shed, crche, muster roll and monitoring registers at the work place,
monitoring and evaluation system being not in force, corruption by government employees, migration of tribal
people in the wake of lack of work opportunities, people of lower classes not being able to make use of Right
to Information Act as the government staff ward off the applicants, rampant untouchability in villages and
caste-based disparities as the major concerns.
Likewise, there are practices wherein the tribal children are separately seated in serving mid-day meal or that
they are required bring their own bowl from their homes.
Situation of Malnutrition: The situation of malnutrition in this tribal area is rather horrible in the block. As
many as 60% children are underweight and those with acute underweight are about one-third at 32%.
Malnutrition gets rooted for the women during the adolescence stage itself and for the children, immediately
following the birth. As many as 89% adolescent girls are afflicted with anaemia 1 and 21% children suffer from
Low Birth Weight2 (LBW) in Shivpuri district.
Migration: Due to extensive lack of employment opportunities, hundreds of families migrate from their tribal
villages to places like Supad in Rajasthan, Agra in Uttar Pradesh and up to Gujarat. Children are the most
affected by the migration as they are exposed to severe heat in summer or chilling cold in winter.
Lack of Resources: Whilst the resources may not be inadequate, the problem is with lack of their access to the
community, particularly to the deprived sections. For example, the tribal people do not have any land
holdings. The land is in the control of certain influential persons. Likewise, though the block is rich in
herbaceous plants of high medicinal and nutritional value, the tribal people sell off their collections to the
traders to make living. If the deprived tribal families had the access to these resources, the level of
malnutrition would have been significantly low.
Khalwa Block District Khandwa

Khalwa block of district Khandwa is part of the eastern Nimar region. Korku community constitutes bulk of the
blocks population. Shashishekhar Gopal Devgaonkar describes in his book, The Korku Tribals at page 30 that
1
CAB
2
National Health Mission MP April-October 2015
it is believed that the term Korku is derived from two words, namely, Koru and Ku. Koru means human and
that Ku gives it the plural sense. Taken together, the two words mean Adivasi the tribal. Nimars Korku
trace their descent to a huge snake called Karakotka. They worship snake. This informs their genealogy to
snake. Hence, they are said to be nagvanshi. Though, historical references indicate that their ancestors were
part of the armies of Chouhans and Rajputs. On being chased away by the Moghul armies, they had hidden
themselves in forests. In the initial time, they wandered about before settling in the forests for their living.
English Writer, Russel and Heeralal have divided the Korku in to four sub-castes, namely, Bawadiya, Rooma,
Bondiya and Mawasi. Amongst these, Mawasi is the biggest one. The Bawadiya habitations are found in Betul,
Rooma in Amravati and that Bondiya habitations have been found to around Pachmarhi and Jeetgarh. A total
of 16 descendants have been traced for the Korku tribe. Based on this, the history records a total of 16 clans
(gotras) for them.
Devgaonkar writes in his book that a practice is followed in the Korku families that an elderly woman of the
village conducts the delivery of child. She is referred to as the wise old lady in the community. On the third
day of the child birth, a pit is dug outside the house and that the mother and the new-born are given a bath
such that the water gets collected in the pit. On the 5 th day of the child birth, the wise old lady performs the
worship of 6th Gond (a deity) and then the pit is covered with soil. On the 12 th day of the birth, the mother and
the new-born are taken to the river and given a bath there. On return, they are blessed by the Panch and
other families of the village.
Baihar Block District Balaghat

Baiga tribes are mainly found living in dense forests across Mandla, Dindori, Shahdol, Umaria, Balaghat and
Amarkantak. They are said to be the descendants of Bhumiya tribals of Chhota Nagpur. Baigas consider
themselves to be the servants of the earth and the rulers of forests. Ancestors of Baigas have been
undertaking zoom cultivation in the forests. They have primarily 5 clans (gotras). Each clan has its own
Garhi (fortification) and an emblem. Their social structure is very well organised. Their Panchayat consists of
5 officials, known as Mukaddam, Dewan, Samrath, Kotwar and Dawar. They pronounce judgements in case of
disputes in the community members. Whilst Mukaddam is the head of the village, Dawar is the priest of the
village.
The Baiga community is dependent upon the forests virtually for everything that need for their use in life.
They produce foodgrains including Kodo, Kutki, Kangni, Madiya, Sama, Ratuni, Bajra, Kaang, Silar and pulses
including Arhar, Urad, Jhunjharu, Jhurga, Barbati etc. as part of their traditional cultivation. Baigas have since
commenced growing paddy, wheat, Soybean etc. following the ban on Jhool cultivation.
Houses of Baigas are very ordinary, though they keep them neat and tidy and well-decorated. They have a
veranda or parchhi outside their house. Their traditional folk dances include Baigani, Karma, Bhilama,
Parghauni, Phaag, Jharpet, Gendi etc. Baigas more often than not use boiled or roasted food. They are very
fond of drinks made from grains like Kodo, paddy, Bajra, Kaang etc. In addition, during summers, they eat the
food cooked overnight. It is known as baasi. Their meals largely include foodgrains, both coarse and fine
ones. Their food intakes, however, are generally very low in pulses, fats, sugar or jaggery. Likewise, their
intake of milk and milk products is also relatively low. Thus, it is observed that their food has more of energy
and proteins, whilst micro nutrients, minerals and vitamins are on the lesser side. most of the Baiga children
thus are found to be underweight3.
3
http://www.omicsonline.org/open-access/nutritional-status-of-baiga-tribe-of-baihar-district-balaghat-madhya-pradesh-2155-9600.1000275.pdf
Chapter 3: Poshan Samvad Outcome -1
1. Knowledge and Behavior of the Community

Gulf between the frontline workers and the community continues to persist. Adequate community
participation and cooperation is not coming by in their work. People also have reluctance to get the children
immunized because they feel that evil eye (a curse believed to be cast by a malevolent glare, which is usually
directed towards a person who is unaware) will be cast on the children if they were exposed to public view.
Likewise, they have apprehension in getting children weighed fearing that the evil eye may make them weak.
At times, the elderly of the village become obstruction in getting the services for the beneficiary children,
women and the adolescent girls. The elderly persons have many prejudices and misconceptions with regard to
these services. Further, the frontline workers do not have any significant role in the processes of consultation,
counselling or dialogue vis--vis the ad hoc Nutrition & Health Committee of the village, its Panchayat
members or the school teacher.
Agenda for Forward Action

Issues Across Awareness and Practices Pertaining to Nutrition &
Child Care
1.1 Family Planning Social and Behavioral Change
Sahariya families in Shivpuri district are found to have many Communication in adoption of
children. With a big family, meagre income cannot help in fully modern Family Planning methods
feeding all children in the family. Addiction to intoxicants also takes towards securing reproductive
its toll on the limited economic income resources. Ultimately, it is health for women on the one
the children who have to bear the brunt. Under these hand, and limiting family size, on
circumstances, nutrition for the Sahariya families has a the other.
connotation limited to filling the tummy.
1.2 Food Security Challenges of Food Insecurity.
The Take Home Ration (THR) given by the Anganwadi also becomes Issues with efficacy of livelihood
inadequate for the pregnant women and nursing mothers. programming in addressing
They cook the THR provided for 6 days on a single day and that it is hunger and malnutrition.
finished in just one day. It is to be noted that nutrition supplement Efficacy of Public Distribution
of 125 g should be drawn and consumed daily from each packet of System.
the Take Home Ration. Displacement of tribals from
forests.
The Take Home Ration given in a packet in the form of Khichri is
cooked at home adding to it garlic, cumin seed, onion and tomato
to make a nice dish of fried pulao. The family eats it!
The THR packets should be given every day for the beneficiary
child. Every feed of the supplementary nutrition gives energy of
little more than 500 calories.
Of course, however, if there are other younger children at home, it

becomes quite difficult for the mother to feed only the
malnourished child. In such a case, she cooks and distributes the
feed amongst all children. Consequently, one packet that is good
for 6 days in a week gets exhausted in just one day.
Sahariya community does get food items from the forests. They are
dependent upon governments public distribution system or the
Child Care
market.
Communitys inclination towards poultry farming has declined

because it takes lot of time and attention in caring the birds. There
is a problem with the availability of poultry feed also.
Due to poor status of agriculture, community is forced to look for

wage earning employment. Even in this, wages of one person
cannot meet the needs of the entire family. This necessitates all
the adults to leave for wage work early in the morning. Thus, they
are limited with time and cannot pursue poultry like farming
properly.
1.3 Livelihood Programming Effectiveness of livelihood
The wage-earning woman in the family has to be on work well until programming for family income
the 7th month of pregnancy. The pregnant woman does not get that essentially secures food
adequate rest. security and relieves the pregnant
women from arduous work during
Women in the tribal families are required to move out for work pregnancy.
immediately after one week of delivery. They have to carry their Behavioral Change
child with them. Whilst at work, they are not able to provide the Communication in ensuring care
requisite breastfeed to the baby. during pregnancy.
Advocacy for crches at work

places in livelihood programming
and flexibility for nursing mothers
in breast feeding their children.
1.4 Healthcare During Pregnancy Behavioral Change
The pregnant women do not consume the prescribed Iron Folic Communication in care during
Acid (IFA) tablets that are given to them for free. pregnancy.
The pregnant woman does not get adequate rest.
1.5 Breast Feeding and Complementary Feeding Behavioral Change
The new-born infants do not get the colostrum feed within 1 hour Communication with regard to
of the birth because it takes time for cleanup and other processes exclusive breastfeeding for first six
after the delivery. months and introduction of
complementary feeding with
Only one out of two infants is receiving exclusive breastfeed up to continued breast feeding well in to
6 months of age. Also, beyond 6 months, only 60% of the infants and up to two years.
receive timely commencement of complementary feed, with
continued breast feed. Support for breast feeding
mothers who experience
Citing their experiences, Anganwadi Workers stated that only 50 inadequacy of breast milk.
out of 100 infants receive complete breastfeed. It is a huge
challenge for the working women to take out time to breastfeed Advocacy for crches at work
their infants or to feed them with meals. Thus, children generally places in livelihood programming
remain hungry. and flexibility for nursing mothers
One or two women in every 100 women experience lack of breast in breast feeding their children.
Child Care
milk. With a view to feed the child fully, cow or powder milk feed is Social mobilization for securing
also given. mothers continued attention in
care and feeding of children at
After the child birth, if the mothers breast milk is found to be least up to 2 years.
insufficient, different practices are followed in the community at
the local level. Forest garlic, root of euphorbia creeper (dudhia bel
ki jad) and a type twin plus (dhayee) leaf are mixed with jaggery for
creating the feed.
The working women are not able to give adequate breastfeed to

the infants. In such cases, the infants are fed cow milk. If say, there
are three children in a family and the mother is not able to produce
adequate breast milk, the liquid strain (paje) from the cooked
supplementary nutrition (dalia) received from the Anganwadi for
the other children is fed to the infant to make up for the limited
breast milk. In addition, liquid strain derived from wheat or rice is
also fed to such infants.
The infant receives the complementary diet after completing 6

months of age only when it cries out of hunger. In this situation
too, the mother first gives the breastfeed which results in loss of
appetite.
It is a practice in the Korku tribe in district Khandwa that the infant,

on attaining the age of 6 months, receives only the home food that
is generally cooked for the entire family. Only 20% children are
able to eat this food. The child does not receive the required
nutritious diet in accordance with its growth needs.
There is another misconception in the community that if the child

were fed food grain or complementary feed on completion of age
6, it will get deposited in the knees of the child and that its
stomach will get bloated causing difficulty for the child to be able
to stand or walk. Therefore, driven by this misconception, children
are given complementary feed only from the age of 8 or 9 months
onwards.
By the time the child becomes 6 months old, it is handed over to

the elder siblings or the elderly members of the family.
Consequently, the children are deprived of required nutritious feed
as the siblings or the elderly members in the family are not able to
gauge the needs of the child and/or not able to look after the child
well.
The Korku families do not have adequate nutritious food for

feeding their children. The children eat what is normally cooked in
the home for the entire family. Since all the members of the family
Child Care
have to go for work, the proper care for the children is
compromised with.
Children in the community are given market-triggered snacks like

kurkure, biscuits, chips, toast etc. This interferes with childrens
appetite resulting in the declined appropriate nutritious diet.
1.6 Gender Equity Social and community mobilization
The Korku women in Khalwa block, district Khandwa are known to in securing gender equity.
take good care of the male new-born up to 5 days from birth.
However, the level of care reduces to 3 days in case of the female
baby. After this period, the mothers take the children with them to
their place of work agricultural field or the wage work site.
1.7 Child Care during Illness Social mobilization for promotion
If a child is seen to be appearing weak in the community, its family of health seeking behavior and its
members bring over some fruits and medicines in the belief that adoption.
the child will recover and become healthy. Social mobilization for promotion
of hygiene and sanitation practices
A practice persists in the community that if a child appears to be and their adoption.
weak or sick, the family first takes the child to a traditional healer
instead of being taken to the Anganwadi Worker or to a doctor and
try to get local indigenous treatment. Only when the things go out
of hand that they rush to the hospital.
The community follows its own practice to detect whether the

child is anemic or is feeble or has deficiency of red blood cells. A
black thread is tied around the hand and waist. If the thread
becomes loosened, it is said to be indicative of deficiency in red
blood cells!
Infants are not being fed additional diet over and above breastfeed
or normal diet in case of illness, like the bouts of diarrhoea.
The community considers it fine to take measures like getting the

hair cut for the malnourished child, placing a talisman in its neck
and getting jhaad phoonk (the act of invoking or calling upon a
deity, spirit, etc., for aid, protection, inspiration, or the like) done
for the sick child.
Incidences of diarrhoea and respiratory infections are

predominantly found to occur in children.
Due to lack of hygiene and sanitation, children mainly suffer from

diarrhoea. With continued neglect, and when the diarrhoeal
episodes persist for 4 to 5 days, then the child is taken to the priest
conducting the jhaad phoonk.
Whooping cough in children is called Kukurkhansi in the

Child Care
community. Whilst the child ought to be taken to hospital for
treatment of whooping cough, the community believes that it
cures by itself in a certain period of time. They do not think that
there will be any use by going to the hospital.
1.8 Home Deliveries and Institutional Deliveries Behavioral Change
If the Janani Express does not reach in time, the delivery has to be Communication and Social
conducted at home itself. Further, in case the delivery occurs in the Mobilization for securing 100%
evening hours, the umbilical cord is left uncut overnight. The cord institutional deliveries.
is cut only in the morning and consequently, the new-born is able Advocacy for access to
to get the breastfeed only in the morning. institutional delivery.
Behavioral Change
In the event of absence of institutional delivery, the traditional Communication for good practices
birth attendant conducts the delivery at home. Consequently, the in the event of home-based
new-born is kept in old and untidy clothes instead of being delivery and child care.
provided with neat and fresh clothes. This has a potential risk for Convergence between health and
the infant to become infected. ICDS functionaries in registration
of all pregnancies.
Harassed in being asked for money by the service providers at the
Promotion of good practices in
health centers in matters of institutional deliveries, the families
ensuring access to institutional
have been reverting to home deliveries.
deliveries.
The discussions also bring out that family members are dissuading
against getting the deliveries conducted outside.
In addition, the traditional birth attendant also tries to prevent the

women from accessing the hospitals. With this resistance in place,
some information on pregnancies does not reach the Anganwadis.
A discussion held at the Roshni sector of Khalwa block, district

Shivpuri brought out that the home deliveries are conducted in the
shed where animals are housed and in some places the delivery is
done near the kitchen fireplace. Most of the deliveries are
conducted on the clay floor of the house. These responses
emerged to the query as to what did they do in case the delivery is
not an institutional one.
Workers informed in the Baihar Poshan Samvad in district Balaghat

that even in case of the institutional deliveries, the families carry
with them concealed tamarind and oil which is applied to the
childs umbilical cord!
There is a silver lining in the Khalwa block as well. The Korku

community largely seeks institutional deliveries. In the event that
the Janani Express does not arrive in time, they hire a vehicle and
take the woman for delivery to the hospital for delivery. Secondly,
the Korku community has also been utilizing the Maternity Benefit
Scheme also in availing institutional deliveries.
Child Care
1.9 Immunisation Social Mobilization for
4
After the pentavalent vaccination , children may get some fever. immunisation, including that on
Unaware about it, community members get worked up as to how a responses to the natural effects
vaccination caused fever. This apprehensive perception obstructs and adverse events.
other children in getting vaccinated. Convergence between health and
ICDS functionaries in planned and
Still, many children are not covered by immunisation. Families, complete immunisation.
particularly the elderly members take exception to immunisation. IEC campaign for covering
Problems of diarrhoea, fever are the main causes for the immunisation of children of
apprehension. migrating tribal families.
When the Mahua Tola, ASHA or the Anganwadi Worker visit the
village, they are chased away with rods. This is cited where
vaccinations have been followed by fever to the children.
Situation with regard to immunisation is rather good at certain

places. Children and women are not being left out due to the
activeness of the field workers. Although, fear persists in the
community that immunisation causes fever to the child.
Migration in the tribal community appears to be becoming a major

barrier in securing full immunisation of children.
1.10 Hygiene, Sanitation and Safe Drinking Water Behavioral Change
Practices in use of safe drinking water for the infant, observing Communication and Social
hygiene and cleanliness like washing hands before cooking food Mobilization for adoption of
and before feeding the child, washing hands after use of environmental and personal
toilet/handling faeces have not yet become part of intrinsic habits. hygienic and sanitation practices
Only 20 to 30% of women follow the practice of washing hands and safe drinking water.
before cooking food or feeding the child. Community mobilization for
securing and maintaining safe
Unsafe contaminated water, dumped waste water and filth in drinking water sources and use.
home and in surroundings, not keeping the food covered with lid
are some of the habits which cause illnesses. It is not just the
problem of open field defecation.
1.11 Referrals of Severely Acute Malnourished (SAM) children Social mobilization for promotion
to Nutrition Rehabilitation Centre (NRC) of health seeking behavior and its
Sahariya community in district Shivpuri calls ghost by the name adoption.
Masaan. They apprehend that if the child goes to Nutrition
Rehabilitation Centre (NRC), it will become a Masaan, i.e. a ghost!
This belief has a genesis in their experiences that some of the
Severely Acute Malnourished (SAM) children who had received
treatment at the NRC had died after returning to the village.
4
It is a set of five individual vaccines conjugated in one, intended to actively protect infant children from 5 potentially deadly diseases:
Haemophilus Influenza Type B (bacteria that cause meningitis, pneumonia and otitis), whooping cough, tetanus, hepatitis B and diphtheria.
Chapter 4: Poshan Samvad Outcome - 2
2. Institutional Issues and Forward Action Agenda

Systemic and Institutional Issues
2.1 Institutional Deliveries and the Primary Health Care System Social mobilization with
In the Senghwal sector of district Khandwa, institutional deliveries community for demand
are being done 45 km away in the Khalwa block. The road between generation.
the sector and the block is rugged and is full of pits. Taking the Advocacy with Janpad/Zila
pregnant women for deliveries in vehicles through these roads is Panchayat and district
very risky. Under these circumstances, the community feels it safer administration for convergent
to get the deliveries conducted at their homes only. action by the road construction
agencies.
Anganwadi Workers and ASHAs in Shivpuri informed that the Advocacy with Department of
deliveries being conducted at the hospital also could not be Public Health & Family Welfare
considered to be safe and free from infections. with regard to content and quality
of service provision.
The ANM herself asks the delivering women and their families to
Address issues of patient rights in
bring clothes from homes. If they do not have the clothes, the
terms of privacy and dignity vis--
mother has to manage with the same clothes for 3 days in the
vis behavior of health
health centre. Further, most of the health centres do not have
functionaries.
delivery tables. The delivery is conducted on the floor by spreading

a gunny bag/sack.
Further, if the ASHA has accompanied the woman for delivery,

colostrum is fed to the new-born. In case the ASHA is not around,
the doctor does not assist in feeding the new-born with colostrum.
Women also avoid going for institutional deliveries in view of harsh

behavior of nurses in the hospitals. They complain that the nurses
abuse them and that at times they thrash them too.
The health centre is not equipped with emergency services. If the

case becomes complicated, the woman is referred to a higher
facility.
The Sub Health Centres do not have adequate medicines. It should

be made mandatory for the ANMs to stay at the Centre 24*7 and
that the doctors must be available at least for 2 hours there, the
participants opined. They called for the Community Health Centres
to well-equipped with laboratories, doctors, nurses and other
facilities.
2.2 Access to Institutional Deliveries Address issues of access to health
The participants also informed that in case the Janani Express does facilities in consultation with
not reach for carrying the pregnant woman or it gets delayed, 108 Department of Public Health &
Ambulance immediately reaches, if asked for. Family Welfare.
It was brought out that the Janani Express has never come to
Atarua village in Jhiri sector of the Pohri block, district Shivpuri
though the Jhiri Community Health Centre is just 5 to 6 km from
the village.
The Janani Express Call Centre is down for the last one month in
Baihar, district Balaghat.
As an alternative, 108 service is called up but that also arrives late.

In case it arrives, it is good enough. However, if the 108 does not
arrive, one has no option but to go for home delivery. Of course, in
such cases, the umbilical cord is cut only by using a blade.
2.3 Referrals
Anganwadi Workers of Balaghat informed that referrals were being
made up to the Community Health Centres (CHCs). However, the
referral process beyond the CHCs was fraught with delays and
hurdles. They were also worried that mobilising funds for the
treatment of severely ill children was a daunting task. The role of
the service providers is limited to rendering services. Beyond it,
they rather felt discouraged.
2.4 Corruption Need to address the issue of
Majority of the Anganwadi workers from Baihar in Balaghat district corruption in DoPH&FW and
complained that the family members accompanying the pregnant DWCD from the standpoints of
women to the hospitals for delivery are asked for money (that is systemic transparency and culture
illegal, yet asked for informally in the form of tip) in lieu of every of ethics.
service in the hospital. For example, if the nurse is not paid, the
woman would not be discharged after the delivery.
Likewise, asking for money at the time of weighing the infant and
its immunisation and the money is asked even for cleaning the
room.
Whilst the pregnant woman receives the incentive amount of Rs.

1400/- for availing institutional delivery at the government, she
spends more than this amount in paying up the staff at the hospital
towards bribe.
The Anganwadi Workers also informed that a Baiga family did not
receive the service of Janani Express for being dropped back at
home, despite being entitled to it.
There is no arrangement for maintaining cleanliness in the delivery

room. The family has to bring its own cleaning person or pay for
hiring the service @Rs. 30/- per day!
The birth certificate is issued after a month or more of the date of

delivery. The family has to shell out Rs. 50/- even for obtaining this
certificate.
If one does not pay for the bribe, the bedsheet of the woman is not
changed.
One has to pay for availing the Janani Express service too.
The funds for supplementary nutrition is credited to the account of

Anganwadi Worker. However, her senior officers ask her to partake
with some of it with them. This results in lowered service affecting
the attendance of children. Moreover, when the attendance is
found short, the same officers demand a bribe of Rs. 1000/- for
overlooking the poor attendance!
Situation is similar in the health department. ASHA receives an

amount of Rs.7500/- from which materials are procured for about
Rs.2500/-. Rest of the money is siphoned off amongst the officials.
The untied money received under the ad hoc committees account

is also gobbled by the officials!
2.5 Referrals of Severely Acute Malnourished (SAM) children to
Nutrition Rehabilitation Centre (NRC)
The Workers from Khandwa pointed out the important need for
positioning a paediatrician at the Nutrition Rehabilitation Centre
(NRC) so that children suffering from illness or infection can be
better treated.
2.6 Other Issues Advocacy with the ICDS
It emerged from the Poshan Samvad meeting at Khedi sector in programme management at
Khalwa, district Khandwa that the food provided by the Self-Help district and state levels for
Group was not adequate to satiate the children. Whilst some addressing the systemic issues.
children are still asking for chapatis, the food gets exhausted.
Workers from Khandwa suggested that crche should be provided

for children of age 6 months to 3 years.
The Anganwadi Workers have to pay from their own pocket

towards buying the Monthly Progress Report (MPR) formats, for
getting the data fed in computer or for the transportation
expenses for supplementary nutrition that arrives by bus.
3. Policy and Implementation Issues and Recommendations

3.1 With regard to beneficiaries
Access to and Efficacy of Institutional Deliveries
Service provision clauses of the Janani Express operators need to be made stringent. Negligent service
providers need to be penalized and such other measures are required to be instituted as the negligence
can cause fatality as well.
Despite being called up; Janani Express does not arrive on time. If at all it arrives, the driver stops half way
through and refuses to drop the woman at the destination point. With effect from 2015, the state
government has linked the Janani Express and the Sanjeevni 108 ambulance services with the EMRIs Call
Centre. Installing GPS on these vehicles has been made mandatory so that the vehicles can be tracked and
to determine whether there has been any misuse of the services. However, due to poor surveillance of the
scheme, the pregnant women have to bear the brunt of lack or absence of transportation services.
A village, Awalia is at a distance of 40 km from the CHC. This is the major reason for domicile deliveries in
this village. Janani Express not reaching in time is another factor in getting deprived of the institutional
deliveries.
In the Sahariya tribal families, deliveries are conducted by women belonging to basod or dalit class (known
as dai- Traditional Birth Attendants TBAs -). If the TBAs are trained in safe delivery practices and are
remitted some incentive money in learning and following safe practices, safe deliveries can also be
conducted at homes.
Khalwa: There is a shortage of doctors in government hospitals. The community is not able to access the
district hospital. Local Community Health Centre (CHC) does not have doctors. The Roshni CHC covers as
many as 52 villages.
Benefits to Beneficiaries
It is suggested that the pregnant women should be served freshly cooked meal at the Anganwadi Centre
itself. It would ensure their presence at the centre apart from facilitating their health check-up. At present,
often, pregnant womans mother-in-law or a member of her family collects the Take Home Ration from
the Centre on her behalf.
Disbursement of Rs. 1000/- towards Maternity Security Benefit scheme has been pending in Shivpuri
district for that last 6 months. Now, the Government of Madhya Pradesh says that this money will be
disbursed only to those women who have worked for 100 days under the MNREGA scheme. It is notable
that none of the pregnant women from any of the villages of Govardhan sector has worked for 100 days
under the MNREGA!
Arrangements should be made to take care of the severely malnourished children. When their care takes
place right in the presence of the community duly observing measures for diet, hygiene and infection
prevention, it will have a salutary effect on the community.
The incentive amount on admission to the NRC is also not being given. Earlier, the beneficiaries were
getting cash remittance. Now, the amount is credited in to the bank account. Beneficiaries have not
received any amount by cheque over the last one year. Workers informed that they had got 9 children
admitted to the NRC from June 2015 to September 2015. The incentive payment on this account has not
been made.
Accompanying child of age up to 4 years should also be entitled to food at the NRC.
Morning and evening snacks should be provided at the NRC. At present, food is given at 12 noon and at 5
in the evening.
Adolescent Girls
Adolescent girls in district Shivpuri have not received sanitary napkins for the last 3 years.
Two adolescent girls are selected every 6 months under the Sabla scheme. This is too less because only
these girls receive the packet of supplementary nutrition and others do not. Consequently, other
adolescent girls do not come to the Anganwadi Centre and are thus deprived of disbursement of IFA
tablets. Also, it becomes difficult to counsel them about personal hygiene and share information about the
value and significance of nutrition in diet.
An effort should be made to align the adolescent girls also with the Mangal Diwas.
Entitlements
Claims for lease on forest rights should settled promptly for the Sahariya families in district Shivpuri.
Treatment of sick children entails lot of expenditure including that on medicines. In addition, there are
other expenses too. Whilst the government provides for medical services to the poor and the deprived,
the money is not received in a timely manner. What needs to be ensured is that the holders of Deen Dayal
Antyodaya Upchar Card should be rendered completely free medical care, including the medicines. Only if
the government bears the entire cost of treatment that the people will have faith in it.
There is a clear policy of the government in providing money for the treatment of severely ill children.
However, it is interpreted differently at different levels. The process needs to be articulated so that there
is uniform clarity in the administration of the scheme.
The department of Public Health & Family Welfare needs to bring about coordination in the referral of
severely malnourished and sick children across the state, district and block level health institutions.
Corruption
Certain references were made as follows:
Money is asked from the delivering woman and her family for every service provided at the health centre.
Janani Express is expected to provide free transportation for the delivering women. However, they are
charged Rs. 100/- for being shifted to the hospital.
Nurse charges Rs. 500/-, cleaning person asks for Rs. 100/- and Rs. 100/- are required to be paid in getting
the discharge certificate from the hospital.
Further, if bank account is not there in the name of the delivering woman, a charge of Rs. 100/- has to be
paid for.
In the Sahariya tribal families, deliveries are conducted by women belonging to basod or dalit class (known
as dai- Traditional Birth Attendants TBAs -). If the beneficiary family has to shell out an amount ranging
from Rs. 900/- to Rs. 1000/- in getting the delivery conducted at the government hospital, the incentive
amount of Rs. 1400/- that is remitted to the beneficiary for availing institutional deliveries becomes
meaningless.
3.2 With regard to workers
The ICDS Workers should receive tea at least once a day during winter.
Anganwadi Workers complain that often there is dispute with the ASHA when it comes to the entitlement
of incentive amount. As many as 8 Anganwadi workers informed that whilst they took the cases for
institutional deliveries, the credit is registered in the name of ASHAs. Subsequently, the ANM shares this
money with the ASHA with the Anganwadi Worker being deprived of the remittance towards the incentive
amount that is due to her.
The Anganwadi Workers cite an order issued by the directorate that states that the Anganwadi Workers
will not bring along the delivery cases to the health institutions. The question is what about those cases
where there is no ASHA.
4. Issues Pertaining to Behavior of Service Providers

Community should engage itself in the deliverance of services like distribution of supplementary nutrition,
growth monitoring of the children, serving of hot cooked food, immunisation and counselling at the
Anganwadi Centres. This can become possible only when the service providers at the ground level
establish an identity with the community whereby they are perceived to be dedicated for its betterment
instead of just being the providers of services.
People generally leave their homes at 10 in the morning for wage earning and get back home at 7 in the
evening. Thus, home visits by the Anganwadi Workers become scarce. This becomes rarer with the
workers time getting further eroded due to departmental tasks. In addition, it is observed that there are
fewer opportunities for carrying out joint home visits by Anganwadi Worker and ASHA.
Malnutrition during pregnancy is quite common in Baihar block. The IFA tablets and Take Home ration
disbursed from the Anganwadi Centre is rather inadequate. Anganwadi Workers informed when the Rapid
Test shows the hemoglobin level below 10 g, the ANM advises the pregnant women to get the 3 drips of
Iron-Glucose. How reliable and correct is this method? If the procedure is wrong and blood is extracted
from the wrong finger from the upper layer, i.e. the plasma, low hemoglobin is bound to show. This is so
because the color of plasma is yellowish. It is known that the Iron-Glucose drip is administered to the
women when the hemoglobin level goes down to 6-8 g. At the level of 10 g hemoglobin, iron-rich diet can
make up the deficiency. Thus, Iron-Glucose drip should be given only in case of serious anaemic condition.
The programme protocol thus needs a careful attention.
Generally, the childs weight taken immediately after birth at the health centre is higher than what is
observed at the Anganwadi Centre. For example, a child may weigh 2700 g at the health centre and that
the weight at the Anganwadi Centre could be at 2500 g.
It emerged from the dialogue with both the health and ICDS ground level functionaries that doctors
themselves recommend giving Amul milk to the new-born through caesarean section in delivery. People
follow the advice. It needs a clarity.
The Anganwadi Workers in Shivpuri dialogue agreed that there is need for meetings with people of
different age-groups, that Panchayati Raj Committees and office bearers participate and that ASHAs and
the Anganwadi Workers undertake joint home visits. It is necessary that the ASHA and the Anganwadi
Workers come out of their service provision shell and identify themselves as catalysts for the community.
An example was cited about the work done by the Anganwadi Worker in Ghoom.
There is a need to give proper counselling to the families in adding local vegetables, food grains etc. to the
supplementary nutrition in feeding the children. It is suggested that the mother of the beneficiary child
should be counselled for making a tasty meal with use of locally available ingredients at the Anganwadi
Centre itself. Organising only the immunisation camps will not serve the purpose. People have to be
continually counselled and told about the benefits of immunisation and how to prevent the diseases. The
vicious cycle between illnesses and malnutrition has to be shown very vividly underlining the significant
role of immunisation in breaking this vicious cycle. Both the Anganwadi Worker and the ASHA have to play
this role together. Likewise, Panchayat, Village Committees, Womens Groups, Mothers Committee,
School Education Committee and elderly persons of the village have to be roped in this endeavor.
There have been many such instances in the sector where the Anganwadi Worker has taken up the issue of
hygiene, cleanliness, diet and nutrition at her level by either visiting childs home or has brought the child
to the Anganwadi centre so that the childs malnutrition is mitigated. If the right counsel is provided, this
can be done by the family at its home as well. Efforts need to be made for continuing with follow up of the
severely malnourished child and for providing counselling for diet and care of such children.
Not only in the village where the Community-based Nutrition Rehabilitation Centre is being run, but also in
every village, community members committee should be set up. The committee can meet once a week
and take stock of weighing of malnourished children, status of malnutrition and services provided at the
Anganwadi Centre. It should seek to find out as to which child is not coming to the Anganwadi Centre and
why and which children should be sent to the NRC etc. The idea is that the discussions should be issue-
centric aimed at securing improved decision making. At the same time, roles of Anganwadi Worker, ASHA,
ANM, Nutrition Committee, Panchayat office bearers, Mothers Committee need to be reviewed once a
week by this community members committee.
5. Recommendations on Coordination
Whilst the counselling for pregnant women about nutrition and diet intake has had its effect, aspects of
postnatal care and ensuring appropriate nutritional wellbeing need more attention, particularly in respect
of home visits and follow up actions by the frontline workers. This requires that individuals who have
prime role in institutional structure and that in the communitys traditional structures should be aligned
with the process and mechanism of counselling. These may include elderly persons in the village,
padiyaars etc.
There is a need to stress upon strengthening of the complementary role of Gram Panchayat and villages
other legal committees in addressing issues of malnutrition and child care. ANMs visit to the village is and
should not just be for the purpose of immunisation. She has a wider and significant role in counselling the
people with regard to prevention and treatment of illnesses.
Both the Anganwadi Worker and ASHA should undertake joint home visits. Presently, they undertake
separate visits.
The Anganwadi Workers find it a bit difficult in counselling the families because they are not equipped
with solid reference material in written form pertaining to malnutrition, health, immunisation, child care
etc.
In ASHAs work, ASHA Sahyogini has also an important contributory role. However, her presence on the
ground at present is thin.
With ASHAs coming in, workload of the ANM has lessened. Earlier, they had to go every home by
themselves. However, it is also an issue with regard to limiting her role without its commensurate and
needful widening which is the call of the day. The ASHAs opine that the work of the ANMs is not just
limited to immunisation. They also need to give attention to the synergistic functionality of Gram Aarogya
Kendra and the Anganwadi Centre.
It has been recommended that at least once in a month, the school teacher, Panchayat Secretary,
Sarpanch, and ANM should join the Anganwadi Worker and ASHA in making home visits.
Roles of ASHA Sahyogini and ICDS Supervisor need to be aligned and ensured.
Roles of the Village Ad Hoc Health & Nutrition Committee and Matru Sahyogini Samiti need to be
articulated and specified. In particular, their roles will be of great help in overcoming age-old superstitions
and beliefs and in generating faith of families in institutional services.
It will be good to have the presence of the elderly members of the community during growth monitoring
of children, immunisation, organising Mangal Diwas and in disbursement of Take Home Ration. It will go a
long way in removing superstitions of the community.
The members of the Ad hoc village committee should be trained so that they may effectively assist the
field functionaries in their engagement with the community.
There is need to get along well with the community and the children coming to the Anganwadi Centre so
that the intended outcomes in realising nutritional wellbeing of children are achieved.
Promotion of feeding colostrum to the new-born within one hour of birth and initiation of breastfeeding
by the Anganwadi Worker and ASHA has witnessed the involvement of ANM and hospitals nurse as well.
This networking has yielded positive outcomes.
In matters of jhaad-phoonk (the act of invoking or calling upon a deity, spirit, etc., for aid, protection,
inspiration, or the like), despite the best efforts of the Anganwadi Worker and the ASHA, people still take
the sick child first to the priest performing the jhaad-phoonk. The Anganwadi Workers and the ASHAs have
found a way out to handle the situation. They now tell the families that it is alright for them to pursue their
faith but they encourage them to necessarily take the child to the doctor as well.
Finally, children eat in a better manner when they observe the other children. Demos of proper eating
habits need to be promoted.
Case Study
Case: 1
One-year-old Akash weighed 6.900 kg in the month of August. However, his weight decreased to 6.500 kg in
September. Akashs mother, Laxmi Devi informs that at the time of birth, her son weighed 2.500 kg. The child
has not had any illness except for common cold. Still his weight is on the decline. Why? Neither Laxmi Devi has
any clue about it nor the Anganwadi Worker of the village, Govardhan.
This case brings out certain questions which pose a few queries on the work of the Anganwadi Worker and
ASHA/ANM. These are:
1. Does any service provider have the case history of Akash or not?
2. Should the health history of all children registered with the Anganwadi be part of work routine of the
service providers? This is an important question as all interventions related with health, dietary
practices and nutrition of the child are associated with it.
3. Has there been a discussion between the field functionaries of the departments of Women & Child
Development and Public Health & Family Welfare with regard to decline in the weight of Akash?
4. According to Akashs mother, his dietary intake is alright. But the Anganwadi worker does not know
as to what Akash eats and how often? Is he getting the food that meets his energy and growth needs
in terms of calories, proteins and micro-nutrients? Is it not necessary to have the information for
putting in place an appropriate nutritional initiative?
Case: 2
A girl was severely malnourished in village, Gurichha. Anganwadi Worker, Savita Tomar observed in the home
visit that the girl was not being proper cared for. She was handed a roti and was sitting outside the house.
Savita then explained to her mother that the girl suffered from severe malnutrition not because of just
teething, but more due to lack of hygiene and neglect in her care. After this, the mother started feeding food
to the girl in a neat and tidy manner. Savita followed up every day. Now, the girl has gained weight and is
recording normal grade in her weight-for-age.
Case: 3
1. Three years back, a Community-based Nutrition Rehabilitation Centre was established in village
Nohantakhurd. During its operations, children were given laddoos made of groundnut in cooperation
with and support from the community. Sudha Bhadoriya, the Anganwadi Worker states that the effort
brought out good results. This led the community to appreciate the significance of nutrition for the
children. She says that now it is no more difficult to counsel the families during the home visits.
2. In the same vein, Usha Bhadoriya, the Anganwadi Worker from Mehra village made laddoos from the
Take Home Rations Soya Barfi and served it to the children in the Anganwadi. This resulted in the
recovery of 3 severely malnourished children at home only without the need to take them to the
Nutrition Resource Centre.
Case: 4
In a village in the Bairad-2 sector in Shivpuri district, a girl child was prematurely born. She weighed 1.300 kg at
the time of her birth. Malti Sharma, the Anganwadi Worker from Echwara got her admitted to Sick New-born
Care Unit (SNCU) in Shivpuri. After return from the SNCU, she followed up scrupulously with her mother and
advised on breastfeeding and hygiene practices. The effort was continued for a period of 3 months. The
outcome is that now the childs weight is normal. In the same village, child of Pooran Prajapati was also
rehabilitated to normal grade of weight. This child too had premature birth with a birth weight of just 1.000
kg.
Case: 5
Anganwadi Worker of village Ghoom in sector Bairad-2 of district Shivpuri informed that in her village, people
were reluctant to send their children to the Anganwadi Centre. If an attempt was made to counsel them, they
would become abusive. However, with cooperation and support of educated and aware families, a number of
meetings were held. It helped in overcoming superstitions and prejudices. The children then started coming
over to the Anganwadi Centres.
Case: 6
A girl child was severely malnourished in village Bagwasa Kala Gaon in Jhiri sector of Shivpuri district. When
the Anganwadi Worker advised her parents to admit the child in the Nutrition Resource Centre, they were
reluctant. Then the Anganwadi Worker visited the child every day in her home and took care of her hygiene
and cleanliness and prepared different dishes from the Take Home Ration, like laddoo, barfi and sometimes
khichri and fed to the child. The girl completely recovered in three months, thanks to the intensive efforts of
the worker. In the same manner, Annapoorna, the Anganwadi Worker of village Parichcha took care of a
severely malnourished child at its home. She massaged the child with mustard oil. The child fully recovered in
2 months time.
Case: 7
When the parents of a severely malnourished child in village Dourani, sector Devrikhurd of district Shivpuri did
not agree to the advice of the Anganwadi Worker to admit the child to the Nutrition Resource Centre, she met
the childs mother and counselled heron need for hygiene and cleanliness and nutritious diet intake in the
proper care of the child. The mother told the Anganwadi Worker that she has only dry roti for feeding the
child in her home. The worker then suggested that salt may be sprinkled on the roti and should be dipped in
slight oil for serving to the child. She also explained about the proper manner in which the supplementary
nutrition provided from the Anganwadi Centre should be consumed. Gradually, the child recovered and now
the child is back to the normal grade in its weight-for-age.
Case: 8
In village Veshi in the same sector, families used to send children to the Anganwadi Centre without giving
them bath. After the worker counselled, for some days, the children were sent in neat and tidy condition.
However, afterwards the situation reverted to the earlier state. Upset with it, the Anganwadi Worker started
sending the children who were not neat and tidy out of the centre. Special meetings were held in the village
with regard to hygiene and sanitation. People were explained significance of cleanliness. With this, people
became aware and now the parents send the children in neat and tidy condition regularly.
In Timani village, the worker made different items from the Take Home Ration like khichri, laddoo and barfi
and served the same to the children. This showed a significant change in the form of weight gain for the
children. The Anganwadi Worker states that if the Take Home Ration is used properly, malnutrition can be
significantly reduced.
Case: 9
A child in a family of village Ganeshkheda of sector Govardhan was suffering from severely acute malnutrition.
When the childs mother was advised to take the child to the Nutrition Resource Centre, she said that she has
3 more children who cannot be left behind alone in the house. The Anganwadi Worker then came up with an
option. She took the help of another woman in the village who would look after the three children with regard
to their food and care. The mother then was able to move over to the Nutrition Resource Centre for a period
of 14 days care. The child has now recovered to the normal grade.
Case: 10
A 3-year-old severely acute malnourished child in Siyarpur village of Baihar block was observed to be suffering
from physical deformity. The child was referred from the Nutrition Resource Centre to the hospital for proper
medical treatment. First, the family brought the child to district Balaghat. Subsequently, they took the child to
Gondia and then to Nagpur. There, it was diagnosed as a case of defect in heart valve. An estimate of Rs. 1.50
lakh was given for the surgery. Childs family sold off their house and agricultural field and mobilised the
money for treatment and got the treatment done.
Case: 11
Meera Prajapati, the Anganwadi Worker of village Thakur Tola, sector Kukarra, district Balaghat informed that
a woman had given birth to a child whose birth weight was 2.500 kg. However, within 9 months of the birth,
childs weight fell to just 900 g. Despite the best efforts of counselling, parents of the child declined to take the
child to the Nutrition Resource Centre. It then came to be known that the childs mother had become
pregnant again. The family said that leave it for now. The mother is pregnant again and that another child will
be born. Finally, the Anganwadi Worker took the child on her own expenses to the Nutrition Resource Centre.
Now, the child has normal weight.
Case: 12
In village, Beshi, block Pohri, the mother-in-law of a pregnant woman, Ramvanti used to be very angry at the
pregnant woman during the morning food time. She would cajole her as to how she could have her meal when
others in the family have not had the food. When the Anganwadi Sahayika got to know about it, she informed
the Anganwadi Worker about it. The worker sent for the mother-in-law to the Anganwadi Centre and asked
her about the treatment being meted out by her to the pregnant woman. The Mother-in-law flatly denied the
charge. She said that why would she dissuade her from eating what and when she wants to. The Anganwadi
Worker then patiently counselled the Ajia Saas saying that daughter-in-law has increased need for diet due to
pregnancy and pleaded with her to be responsive to this need. She told her that if she wished to have a strong
and healthy child, the daughter-in-law must be cared for. If it is not done, the family may have to visit
hospitals again and again if the child was born weak, the worker cautioned. If she (the daughter-in-law) feels
hungry, let her have the food. The situation became normal in some time and now Ramvanti, wife of Dheeraj
is getting adequate diet in a timely manner.
Case: 13
Kusha Dixit informed that twins were born to a Namdeo about a year and a half back. The family lived behind
the Anganwadi Centre. Both the new-borns were Low Birth Weight (LBW) babies, with weight not above 1 kg.
The Anganwadi Worker informed that both the infants were kept on breastfeed up to 6 months. However, the
expected improvement in the infants was not forthcoming. After this, complementary feed comprising boiled
potato with salt, roti mashed sometimes with milk and sometimes with sugar was introduced for the children.
Kusha Dixit herself made daily follow up visits and delivered the Take Home Ration packets. The efforts of the
worker have yielded positive outcomes. Now, both the infants are showing an improvement. The girl in the
twins has progressed to medium grade and the boy has moved from the Severe Acute Malnutrition to the
border of medium grade and would soon improve further. Now, the children have also started coming to the
Anganwadi Centre every day.
Case: 14
Sadhna Tomar, the Anganwadi Worker of Beshi centre informed that Julie and Ratiram had 6 children. All of
them were malnourished. Both the parents used to leave the children in the care of their grandmother and go
for work. Sadhna spoke to the grandmother and sought to know as to why the children were not being
properly looked after. The grandmother cited her age and expressed her limitation in cooking food and
feeding the children. Sadhna Tomar then took the initiative and started getting the children to the Anganwadi
Centre. She started separately cooking hot nutritious food for the children and fed them. However, the
children came to the centre without bath and were untidy. Now Sadhna Tomar had the challenge as to how to
keep the children neat and tidy. She then sent back the children to home asking them to come to centre
having had bath. The worker knew that the food being served at the centre would attract them. And it
happened. Now, the children took daily bath and come to the centre neat and tidy.
Case: 15
Sudha Mishra, an Anganwadi Worker of Brahman Tola informed over the last five years, a tribal woman,
Phoolwati has lost her 8 children, one by one. Phoolwati had slightly bent back. Because of this, the woman
was blaming herself for the deaths of her children. Every child had died during the age of 8 to 12 months.
Sudha Mishra observed that childrens growth was not proper. When Phoolwati became pregnant for the 9 th
time, Sudha took up the responsibility and told her that she would see that this time the child survives. The
worker put in her efforts with full dedication. Regular home visits were done and Phoolwati was given IFA
tablets to eat in a regular manner. Alongside, she was encouraged to take the diet of leafy vegetables and
daal. The tribal woman delivery occurred. The child was looked after with care for the entire first year. All the
dosages of immunisation were administered on time. Complementary feed was commenced from the age 6
months onwards. She was also given glucose. Now the child is entirely health.
Case: 16
Dhanwanti Marawi, the Anganwadi Worker from Berwa Tola informed at the Aamgaon Poshan Samvad that
those children who word red or yellow strips for indicating their level of malnutrition, she counsels the
families by drawing analogy with crops. When the crop is good and healthy, it looks green. If it is yellowish, it is
indicative of poor crop. Likewise, when the crop is deadheaded, it shows severe illness.
Contact us @
Vikas Samvad
{A Research, Capacity Building, Advocacy Support & Ground-based Resource Organisation}
E-7/226, First Floor, Opp. Dhanvantri Complex,
Arera Colony, Shahpura,
Bhopal 462016
Madhya Pradesh, India
00 91 755 4252789
vikassamvad@gmail.com

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Poshan Samvad

Forum for Informal Dialogue with and Amongst Field

Shivpuri Balaghat Khandwa

Poshan Samvad: Resolving Problems through Dialogues The Decentralised Way

District Shivpuri District Khandwa District Balaghat

Process of Dialogue Forum Meetings

Strengthening the Knowledge Base of Frontline Functionaries

Pohri Block District Shivpuri

Khalwa Block District Khandwa

Baihar Block District Balaghat

1. Knowledge and Behavior of the Community

Agenda for Forward Action

Of course, however, if there are other younger children at home, it

Communitys inclination towards poultry farming has declined

Due to poor status of agriculture, community is forced to look for

Advocacy for crches at work

The working women are not able to give adequate breastfeed to

The infant receives the complementary diet after completing 6

It is a practice in the Korku tribe in district Khandwa that the infant,

There is another misconception in the community that if the child

By the time the child becomes 6 months old, it is handed over to

The Korku families do not have adequate nutritious food for

Children in the community are given market-triggered snacks like

The community follows its own practice to detect whether the

The community considers it fine to take measures like getting the

Incidences of diarrhoea and respiratory infections are

Due to lack of hygiene and sanitation, children mainly suffer from

Whooping cough in children is called Kukurkhansi in the

In addition, the traditional birth attendant also tries to prevent the

A discussion held at the Roshni sector of Khalwa block, district

Workers informed in the Baihar Poshan Samvad in district Balaghat

There is a silver lining in the Khalwa block as well. The Korku

Situation with regard to immunisation is rather good at certain

Migration in the tribal community appears to be becoming a major

2. Institutional Issues and Forward Action Agenda

Further, if the ASHA has accompanied the woman for delivery,

Women also avoid going for institutional deliveries in view of harsh

The health centre is not equipped with emergency services. If the

The Sub Health Centres do not have adequate medicines. It should

As an alternative, 108 service is called up but that also arrives late.

Whilst the pregnant woman receives the incentive amount of Rs.

There is no arrangement for maintaining cleanliness in the delivery

The birth certificate is issued after a month or more of the date of

The funds for supplementary nutrition is credited to the account of

Situation is similar in the health department. ASHA receives an

The untied money received under the ad hoc committees account

Workers from Khandwa suggested that crche should be provided

The Anganwadi Workers have to pay from their own pocket

3. Policy and Implementation Issues and Recommendations

4. Issues Pertaining to Behavior of Service Providers

Chapter 8: Poshan Samvad Outcome - 6

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