About 55% of 0-3 year old children in the state of Bihar are malnourished. In this article, Hena Naqvi, State Programme Officer at the Department of Social Welfare, Government of Bihar, describes an ambitious campaign launched by the government in October 2014 to reduce child malnutrition in the state to 30% by 2017.
Bihar was categorised as one of the ‘least developed’ states as per the report of the Raghuram Rajan Committee in September 2013. The Committee was responsible for evolving a composite development status of states on the basis of a multi-dimensional index. The committee’s report listed three categories of states -‘least developed’, ‘less developed’ and ‘relatively developed’. While Odisha tops the list of ‘least developed’ states, Bihar occupies the second position.
Years of multidimensional backwardness of Bihar was confirmed by the Committee. With critical indicators1 like 54.4% poverty ratio, 42.73% female literacy, 61.1 infant mortality rate (IMR), and 916 sex ratio, Bihar was bound to be a part of the list of ‘least developed states2.
Towards a malnutrition-free Bihar
An area of serious concern is the high malnutrition rate in the state. According to the consolidated revised National Rural Health Mission (NRHM) report 2012-13 for Bihar, around 80% of children below five years of age in Bihar are malnourished. The National Family Health Survey-III (NFHS-III, 2005-06) reports that 50.1% of children below three years of age in the state are stunted (low height-for-age), 32.6% are wasted (low weight-for-height) and 54.9% are underweight (low weight-for-age). The overall malnutrition rate for this age group is about 55%. The NRHM report also says that malnourishment in women in the reproductive age group (15-49 years) has worsened in Bihar (increased to 68.2% in 2012 from 60% in 1998). Hence, Bihar seems to be trapped in a vicious cycle of malnourished women and children.
Figure 1. The vicious cycle of malnutrition among women and children
To address the grave issue of malnutrition, the Department of Social Welfare, Government of Bihar has initiated a campaign called ‘Bal Kuposhan Mukta Bihar’ (BKMB). Launched on 11 October 2014 by former Chief Minister Jitan Ram Manjhi, BKMB seeks to bring down the malnutrition rate in the state, and hence address IMR and related health problems in the long run. As per the planned strategy, the programme aims to reduce child malnutrition (below 30% for 0-3 year olds) from the current status by the end of 2017.
The campaign targets pregnant women, lactating mothers and children in the 0-6 years age group (categorised into 0-3 years and 3-6 years) enrolled at 91,677 Anganwadi centres3 in 544 project areas of the Integrated Child Development Services (ICDS), but it particularly focuses on the children in the age group of 0-3 years in view of this group’s additional nutritional requirements. In total, the campaign aims to cover 1,800,000 children in the 0-3 year old age group, 3,500,000 children in the 3-6 year old age group, and 1,750,000 pregnant/ lactating women.
Designed on the pattern of the Pulse Polio Campaign, BKMB takes care of every minute aspect and all the strategic components of addressing malnutrition.
The five Cs: A multi-pronged strategy to end malnutrition
A multi-pronged strategy has been devised to achieve the ambitious goal of reducing malnutrition. It includes five ‘Cs’, namely communication for behavioural change, capacity-building, community’s access to tangibles and intangibles, community participation, and collective approach.
The five Cs are directed towards covering seven priority interventions under the campaign: colostrum feeding (within one hour of birth); exclusive breast feeding (up to six months of age; without even a single drop of water); appropriate and timely initiation of supplementary feeding from six months onwards; prevention and cure of childhood illness; use of safe drinking water (boiled and filtered); hand-washing and hygiene practices; and regular growth monitoring of children in the age group of 6-36 months.
Figure 2. Five Cs to address malnutrition in Bihar
In the short run, the communication component of the programme aims at informing, sensitising and mobilising the community towards positive health and nutrition practices. Screening of a short film on care of nutrition and hygiene of children4, movement of an awareness van branded as ‘Jagrukta Rath’, street plays, songs (in local language), print and electronic mediums, hoardings, banners, posters, booklets, stickers, mobile phone and social media (Facebook, Twitter, You Tube) have been chosen as the mediums to convey messages on reducing malnutrition. The long-term aspects include promotion of social forestry (teaching the community to cultivate nutritious fruits and vegetables under community forestry)through MNREGA (Mahatma Gandhi National Rural Employment Guarantee Act) and the Department of Agriculture, inclusion of nutrition in school and college curricula, orientation of voluntary organisations, panchayati raj institutions (PRIs) and legislators on nutrition, and establishment of a ‘nutrition museum’5. Such innovative steps have the potential of reducing malnutrition indirectly in the long-run. Thus, a combination of various mediums is used under the communication component of the campaign.
Figure 3. Communication component: Spreading awareness among the community through street plays and ‘awareness vans’
The capacity-building component of the campaign includes training the ICDS officers and field functionaries on the themes of BKMB. Educating mothers on nutrition for reducing malnutrition at the household level is another significant aspect of this component. This is done through periodic household visits by service providers such as Anganwadi workers and ASHA (Accredited Social Health Activists)6 workers who talk to mothers on issues related to malnutrition. Design of dialogue with mothers includes tools of inter-personal communication and demonstration.
The third ‘C’ - community’s access to tangibles and intangibles –includes provision of a bowl and spoon to every registered child (registered at AWCs) in the age group of 6-36 months (to facilitate complementary supplementary feeding), two eggs per week to the beneficiary children (3-6 years age group) of pre-school education component of the Anganwadi services, water purifiers at AWCs, fuel for boiling water to every AWC, weighing machines for growth monitoring, and uniforms to the children registered at AWCs. The intangibles include information on colostrum feeding, exclusive breastfeeding up to the age of six months, supplementary feeding to children from six month onwards, balanced diet to pregnant women/ lactating mothers, hygiene/ sanitation practices, safe drinking water management and preventions and cure of childhood diseases.
Figure 4. Anna Prashan ceremonies held at community-level to promote supplementary feeding
Community participation, the fourth ‘C’ of the campaign, is undertaken through formation of ‘Anganwadi Vikas Samiti’7 with a view to ensure transparency in the services of AWCs and also to enhance community participation in the campaign. Apart from other members (elected representatives from panchayats, ASHA, teacher of a nearby government school, ANMs (Auxiliary Nurse Midwife), and Anganwadi worker from the concerned AWC), the new committee will also comprise community representatives - two mothers of children in the age group of 0-3 years, two mothers of children in the age group of 3-6 years, two pregnant women, and two lactating mothers or adolescent girls. This initiative is expected to give voice to the community voice in the decision-making system and governance of AWCs.
The fifth ‘C’ - collective approach - implies resource mobilisation from and collaboration with other government departments such as education, health, panchayati raj, information and public relations, and public health engineering. Development organisations like CARE India, UNICEF (United Nations Children’s Emergency Fund), DFID (Department for International Development, UK Government), Bihar Rural Livelihood Promotion Society, and BBC Media Action have also come forward to support the campaign. The programme’s implementation is being intensively monitored by ICDS officers at the district- and state-level.
If implemented successfully, the campaign is bound to break the vicious cycle of malnutrition and facilitate the emergence of healthy future generations.
- Sources: National Rural Livelihood Mission (NRLM), State Perspective Plan (2011-12 to 2021-22), Department of Rural Development, Government of Bihar, and Bihar Rural Livelihoods Promotion Society.
- The corresponding national figures are: 21.9% poverty ratio (Planning Commission, 2011-12), 65.56% female literacy (National Commission on Population, 2011), 47 IMR (National Commission on Population, 2010), and 943 sex ratio (Census 2011).
- An Anganwadi centre is a government-sponsored child-care and mother-care centre. The Anganwadi system is mainly managed by Anganwadi workers, who are female health workers chosen from the community and given training in health, nutrition and child-care.
- The film has been produced by the Department of Social Welfare, Government of Bihar.
- Nutrition museum’ will display models of food items that are essential for proper nutrition of lactating mothers, pregnant women and children. It will also have models on practices like exclusive breastfeeding, supplementary feeding of children after completing six months etc.
- Under the National Rural Health Mission (NRHM), every village in the country is provided with a trained female community health activist called ASHA. She is selected from the village itself and accountable to it. She is trained to work as an interface between the community and the public health system.
- Anganwadi Vikas Samiti has replaced the previously formed ‘Poshahar Vitran evam Kriyanvayan Samiti’ (Nutrition Distribution and Implementation Committee). This committee is formed wherever an AWC exists.