Abstract
OBJECTIVE:
To study the involvement and influence of local participatory governments consisting of Panchayat Raj institutions (PRIs) in implementing evidence-based interventions for eliminating maternal and child undernutrition in the state of Kerala, India.
METHODS:
In-depth interviews were carried out among stakeholders in six selected local governments using a semi-structured questionnaire. Transcribed interviews were coded and thematically analysed.
RESULTS:
PRIs facilitated nutrition interventions through additional resource mobilisation, nutrition monitoring and surveillance, acting as a more approachable point of governance, utilising general acceptance to mobilise volunteers to tackle local challenges, enabling formal and informal platforms for community participation and spaces of co-creation. Changes in the attitude of different stakeholders, timely policy backing and support, and interconnections at the local level aided the process. Gaps exist in awareness creation, dietary diversification, feeding behaviours, maternal mental health, infrastructure development, monitoring of anthropometric indicators and planning for nutrition interventions during emergencies.
CONCLUSION:
Results illustrate complex linkages PRIs have within the health system and how these linkages help in the implementation of interventions. The study explored previously identified pathways from the literature and identified additional pathways through which local participatory governance contributes to the successful implementation of nutrition interventions.
Keywords: Panchayat Raj, Kerala, local governance, child health, maternal health
Abstract
OBJECTIF :
Étudier l’implication et l’influence du système de gouvernement participatif local, composé des institutions du Panchâyat Raj (PRI), dans la mise en place d’interventions fondées sur des données scientifiques en vue d’éliminer la sous-nutrition maternelle et infantile dans l’État du Kérala, Inde.
MÉTHODES :
Des entretiens approfondis, avec questionnaire semi-structuré, ont été réalisés avec les parties prenantes de six gouvernements locaux préalablement sélectionnés. La transcription des entretiens a été codée et analysée de manière thématique.
RÉSULTATS :
Les PRI ont facilité les interventions nutritionnelles en mobilisant des ressources supplémentaires, en organisant une surveillance et un suivi nutritionnels, en agissant en tant que point de contact gouvernemental plus accessible, en misant sur l’acceptation générale afin de mobiliser les volontaires pour s’attaquer aux problèmes locaux, en mettant en place des plateformes de participation communautaire formelles et informelles et en laissant la place à la co-création. Les changements d’attitude de différentes parties prenantes, un soutien politique opportun et les liens tissés au niveau local ont contribué au processus. Certaines lacunes ont été observées, en matière d’actions de sensibilisation, de diversification alimentaire, de comportements alimentaires, de santé mentale des mères, de développement des infrastructures, de suivi des indicateurs anthropométriques et de planification des interventions nutritionnelles en période d’urgence.
CONCLUSION :
Les résultats mettent en évidence les liens complexes entre les PRI et le système de santé, et comment ces liens contribuent à la mise en place des interventions. Cette étude a analysé certains moyens, précédemment décrits dans la littérature, et en a identifié de nouveaux par lesquels les gouvernements participatifs locaux contribuent à la bonne mise en place des interventions nutritionnelles.
The Sustainable Development Goals (SDGs) are aimed at eliminating all forms of malnutrition by 2030, but despite significant improvements in economic growth and reduction in poverty, the complex issue of undernutrition remains chronic and pervasive, as indicated by an inadequate reduction in outcomes and trend reversals even in regions where better nutritional outcomes were once achieved.1 Kerala is one of the better performing states in India based on indicators of malnutrition. According to the latest National Family Health Survey (NFHS-5) data,2 in Kerala, 23.4% of the children under 5 are stunted, 15.8% experience wasting and 19.7% are underweight compared to the national averages of 35.5%, 19.3% and 32.1%, respectively. The state also experienced an overall improvement in the underlying and immediate determinants of nutrition during the 15 years covered by the NFHS-3, 4 and 5.
The local participatory governments consisting of Panchayat Raj institutions (PRIs) play a crucial role in the implementation and coordination of evidence-based nutrition interventions in the state of Kerala.3–5 (PRIs are constituted under the provision of the 73rd Constitutional Amendment which enabled states to enact legislation to devolve functions, funds and functionaries to the panchayats (elected village local bodies) to make them institutions of self-government. Kerala has devolved all the 29 subjects mentioned in the 11th Schedule of the Constitution created by the 73rd amendment to PRIs and is one of the leading states in decentralised administration in the country.
In this context, the present study was aimed at examining the involvement and influence of PRIs on maternal and child health, with a specific focus on nutrition interventions.
BACKGROUND
Evidence-based nutrition interventions
Over time, researchers incorporated a constellation of socio-economic, behavioural and environmental determinants into new causal models that emphasise undernutrition as a problem of development, rather than of disease.6,7 Elimination of maternal and child undernutrition therefore requires long-term interventions and investments to address problems pertaining to human development.8. However, there are evidence-based interventions that can make a clear difference in the short term if implemented at a sufficient scale.9 Interventions that affect maternal and child undernutrition and nutrition-related outcomes include the promotion of breastfeeding, promotion of complementary feeding, micronutrient interventions, general supportive strategies to improve family and community nutrition and the reduction of the disease burden.9,10
Evidence-based nutrition interventions in India
In 2013, the Partnerships and Opportunities to Strengthen and Harmonise Actions for Nutrition in India (POSHAN) compiled a list of 14 essential inputs for child nutrition in the Indian context (Table). POSHAN is a multi-year initiative funded by the Bill & Melinda Gates Foundation (Seattle, WA, USA) and led by the International Food Policy Research Institute (IFPRI; Washington DC, USA). Two large government programmes for tackling nutrition in India, the Integrated Child Development Services Scheme (ICDS) and the National Rural Health Mission (NRHM) together include interventions to address all of the 14 essential inputs for nutrition listed in the Table.
TABLE.
Essential inputs for child nutrition
| Timely initiation of breastfeeding within 1 h of birth |
| Exclusive breastfeeding during the first 6 months of life |
| Timely introduction of complementary foods at 6 months |
| Age-appropriate complementary feeding, adequate in terms of quality, quantity and frequency for children 6–24 months |
| Prevention of anaemia |
| Safe handling of complementary foods and hygienic complementary feeding practices |
| Full immunisation |
| Reducing vitamin A deficiency |
| Reducing burden of intestinal parasites |
| Prevention and treatment of diarrhoea |
| Timely and quality therapeutic feeding and care for all children with severe acute malnutrition |
| Improved food and nutrition intake for adolescent girls, particularly to prevent anaemia |
| Improved food and nutrients intake for adult women, including during pregnancy and lactation |
| Prevention and treatment of malaria |
At the national level, policy guidelines for the involvement of PRIs in the implementation of ICDS schemes are broad and categorised under “supervision”, “construction” and “maintenance” of Anganwadi Centres (child care centres through which child development programmes and interventions are implemented), selection of Anganwadi workers, supervision of the supplementary nutrition programme and monitoring.
In Kerala, a more detailed policy guideline is in place, enabling the active involvement of PRIs in scheme implementation. This includes guidelines to strengthen the supplementary nutrition programme, provide therapeutic diet for severely malnourished children, infrastructure development of Anganwadi Centres, parental and premarital counselling, development of smart Anganwadi Centres, transportation, development of special Anganwadi Centres for differently abled children, preparation of ‘nutrigarden’ to ensure the availability of vegetables, the commencement of baby gym and yoga training courses, anaemia screening camps, etc.
METHODS
Study design
Qualitative methods were used to meet the research objectives. In-depth interviews (IDIs) and key informant interviews (KIIs) guided by a semi-structured questionnaire consisting of themes that emerged from existing literature were carried out. Themes such as intersectoral cooperation for maternal and child health interventions, political accountability of elected representatives, empowerment of frontline workers, system responsiveness to felt needs and grievances, community participation, and initiatives and innovations in interventions were included. A total of 24 IDIs and 6 KIIs were carried out. IDI participants recruited using snowball sampling included Anganwadi Workers, Accredited Social Health Activists (ASHAs), ICDS Supervisors and Elected Representatives (ER) of six selected grama panchayats (panchayats at the village level): Karakulam, Alappad, Eraviperur, Vadanappally, Sholayur and Noolpuzha. One participant from each of the above-mentioned categories was interviewed. KIIs included subject experts, health department officials and Local Self-Government department officials. All interviews were conducted electronically due to COVID-19 restrictions.
Data analysis
Interviews were recorded, translated and transcribed from Malayalam to English. A directed content analysis was carried out on the transcripts. The researchers read the transcripts and highlighted relevant text. Themes from the semi-structured questionnaire were used for identifying key concepts as initial coding categories. A priori codes based on the semi-structured questionnaire included Policies, Intersectoral cooperation, Accountability, Empowerment, Responsiveness, Participation, Landscape, Interpretations and Innovations, and Intervention Pathways. Highlighted text was coded using these a priori codes. Any text that could not be categorised under the initial coding scheme was given new codes. Such codes that emerged from the data were used for a second round of analysis. Data saturation was observed after 18 interviews. Codes were sorted into categories on the basis of their relationships and these categories were then clustered to make larger final themes. Final themes relevant to the topic under discussion are presented as subsections in the findings section.
Ethical approval
Ethical clearance was obtained from the Institutional Ethics Committee of the Health Action by People, Thiruvananthapuram, India (IEC No EC2/P1/Sep/2020/HAP). Informed consent was obtained from all participants.
RESULTS
Additional resources mobilisation
Anganwadi Workers and other frontline workers could ensure availability of nutritious food with additional help from PRIs and also ensure the consumption of the food by the children. The PRIs planned for procurement, transportation and distribution of these supplementary nutrients, whenever required. Priority was given to ensuring the uninterrupted delivery of supplementary nutrition. Additional learning aides, play materials and toys were also mobilised with the help of PRIs at times.
…it is helpful for small things also. Like arranging lunch packets while I go for house visits or to conduct a survey. We shared our difficulty once and panchayat acted. These small things can’t be solved by supervisor or the Child Development Project Officer (CDPO) alone but with panchayat we could. (Anganwadi Worker)
Facilitation of nutrition monitoring and surveillance
PRIs provided guidance in identifying village requirements and including them in development plans, helped in the coordination of nutrition monitoring activities of Anganwadi Workers, medical officers (MOs) and auxiliary nurse midwives (ANMs), and facilitated household visits and surveys. Through community interventions, they also dealt with challenges and social resistance (e.g., inhibitions about immunisation, institutional delivery and the practice of underage marriages) that may have contributed to the underlying determinants of nutrition. This included.
There is underage marriage in the panchayat. I come to know about it through mothers and I have intervened. Once I had to take help from the member, and police to visit the house and stop a marriage…I was scared to do such things in the beginning but these days I am not. (Anganwadi Worker)
Most of the times resistance to go to hospital for delivery come from the father. Sometimes they resist very strongly and I have to take help from other officials…yes, panchayat gives full support for these interventions. They try and convince the parents with me and make arrangements for transportation also. (Supervisor)
A more approachable point of governance
At the village level, PRIs are seen as a more approachable point of governance by frontline workers, volunteers and activists than line departments and higher tiers of the government. The beneficiaries felt more empowered to approach the grama panchayat representatives than other government officials.
…for example, last summer suddenly the fan stopped working at the centre. You can’t sit inside for a minute in that weather without fan. I called the panchayat office and within few hours they arranged another fan. Can any other department do that? It is because they are here, near to us we can request such things and get it done fast also. (Anganwadi Worker)
Transcending legitimacy and public credibility
The legitimacy and public credibility enjoyed by PRIs at the ground level enabled them to mobilise volunteers and other local resources needed for tackling local challenges.
We get support from organisations and from the people through panchayats. The goodwill of the panchayat is being utilised. It helps in obtaining the trust of the general population also. (Supervisor)
Formal and informal platforms for community participation
The formal platforms of community participation such as gramsabhas, the local participatory governance forums at the village level where people discuss issues related to development and prepare need-based plans for the village, and special gramsabhas, along with informal platforms (youth clubs, sports clubs, friends’ groups, neighbourhood groups, etc.) at the community level, were able to identify local needs, collect and verify information, and prioritise these. They are observed to bring transparency into the process and manage conflicts. Participation of Anganwadi Workers in gramsabhas has enabled the formulation of child-sensitive interventions in some instances. Anganwadi Workers have become an integral part of the gramsabhas and the planning process at the local level. Anganwadi Workers felt empowered to raise their professional, as well as personal requirements in the gramsabhas. PRIs opened up new venues for awareness creation through its participatory platforms.
Each centre is competing with others for resources, right? Everyone raises their demand, and try to get it passed. If something is not accepted this time, we hope it is passed the next time. Sometimes we know another canter’s demand is more urgent than ours. Since we know everyone it is not a problem. (Anganwadi Worker)
Spaces for collaboration
PRIs have created spaces of co-creation and collaboration where elected representatives, community- based organisations (CBOs), religious organisations and civil society organisations (CSOs) can come together and participate in maternal and child health interventions. These acted as interactive structures that enabled participation. A symbiotic relationship between formal (gramsabhas and special gramsabhas) and non-formal structures of community participation such as CBOs, CSOs, youth clubs and self-help groups (SHGs) was observed. Informal platforms benefitted from the legitimacy and general acceptance associated with PRIs, while PRIs had easy access to volunteers and resources.
Some will volunteer only through religious organisations because they believe it will bring them blessings, and some will contribute only through government agencies because they feel others are all ineffective or even fake. That is why we bring everyone on board. To move together towards the greater good. (Elected Representative)
Changes in attitude
Stakeholders observed a significant change in attitude of elected representatives towards ICDS activities over the study period. This is said to be partially due to the training they received and the awareness created, and partially due to an empowered demand side consisting of Anganwadi Workers and beneficiaries. Similarly, a change in attitude of medical professionals towards PRIs resulting in better cooperation and proactiveness was also observed.
The change is like day and night. The elected representatives were not really aware of our activities then. Now I think they realise Anganwadis are one of the important faces of development among people. I think they receive such awareness during the training also. (Anganwadi Worker)
People are more aware now. They will point out if an Anganwadi Centre/Anganwadi Worker is not working properly. So PRIs don’t have any other option than to respond. (Elected Representative)
Connections at the local level
It was observed that whenever the Anganwadi Workers do not perform adequately or there are complaints, the beneficiaries reach out to local governments through elected representatives at the local level. The local government sort out the issues along with the line department. Similarly, when line department supervisors are not performing properly, frontline workers reach out to the local government. PRIs are thus able to coordinate an informal grievance redressal mechanism at the local level by collecting feedback from the community from Anganwadi Workers, supervisors and CDPOs. This has resulted in the timely monitoring of the work of functionaries.
…some say it (frontline workers being accountable to PRIs and the line department simultaneously) is double reporting, but it is double monitoring. I get to know from the people if a centre (Anganwadi Centre) is not functioning properly. (Elected Representative)
Inclusiveness
The awareness and political accountability of elected representatives involved in interventions are monitored to make the implementation of interventions more inclusive, with better identification of marginalisation. Instances of proactive measures, especially by elected representatives, were taken to sensitively address additional challenges associated with marginalisation were observed.
There is tendency to victim-blame when it comes to the implementation of schemes. The Anganwadi Worker says that no matter how hard we try the parents don’t come and collect supplementary nutrients and it is because of their tribal nature. This tendency should change, it is changing slowly. When the community feel that they are being listened to, they show more interest. (Elected Representative)
Policy backing and support
According to the participants, clarifications on policy documents to the stakeholders are provided promptly, and policy support and required policy changes take place in a timely manner, which helps PRIs in implementing nutrition interventions. Policy documents are also circulated to share insights on innovative practices; these thus act as guidelines and directives. Response to letters and queries were received without much delay from the concerned departments.
The Panchayat Acts and Circulars handbook has clarifications for almost all the doubts we might encounter while getting involved in any interventions, also there are guidelines on how to use provisions of different schemes to meet requirements of ICDS activities. (Elected Representative)
Gaps in actions to achieve optimum child nutrition and development
Participants observed a lack of adequate awareness about the need for dietary diversification in mothers and children, and feeding behaviours and stimulation. They also observed inadequate monitoring of anthropometric indicators, and lack of planning for nutrition interventions in emergencies. Interventions focused on maternal mental health is observed to be absent.
According to frontline workers, infrastructure requirements are met timely through planned funds. However, certain policy documents.11 reflect state government observations on subpar infrastructure development of Anganwadis and calls for better initiatives and investments at the local level. Policy documents also report inefficiencies of welfare committees, standing committees and frontline workers in meeting infrastructure requirements; some also reported the underutilisation of available funds towards the betterment of ICDS activities and infrastructure development.
DISCUSSION
The paper set out to illustrate the ways in which PRIs facilitate the implementation of nutrition interventions at the gram panchayat level. The Figure shows the policy landscape of actors and institutions involved in the implementation of the interventions at the grassroots level that emerged as a result of policy analysis.
FIGURE.
Landscape of actors and institutions in implementation of nutrition interventions. *Anganwadis are child care centres through which child development programmes and interventions are implemented. Gram panchayats are panchayats at the village level. Sarpanch is the president of the gram panchayat. PHC = primary healthcare; PRI = Panchayat Raj Institution.
Understanding the intricacies of these pathways can be beneficial for further strengthening, adaptation, replication and institutionalisation of these pathways. As indicated in the existing literature, participatory governance improves the health system mainly by increasing system responsiveness, and improving political accountability, and community empowerment.12–14 Reflections from actors and beneficiaries at the ground level in this study further reinforce and explore the pathways and linkages within health systems, particularly those related to participatory governance. The role played by the PRIs in each intervention differs from panchayat to panchayat and is mostly designed to address challenges faced by frontline workers in implementing interventions. A uniform evaluation of PRIs based on intervention support is therefore challenging. However, the ability of PRIs to fill local gaps, identify local resources to meet additional requirements and address unique local challenges in implementing interventions were recurring themes during the study. These findings, especially those confirming the strong positive role played by the PRIs in implementing interventions, were consistent across the six gram panchayats studied and among all the participants.
The final themes from the study findings tell us that the formal platforms of participation, local decision-making process, co-creation spaces and their interactive nature promoted community empowerment. Frontline workers were able to successfully deal with some infrastructural and logistical challenges with the help of PRIs. The legitimacy and public credibility of PRIs earned over time have aided community mobilisation activities. Local political responsibility was enhanced with the assistance of an empowered community’s participation. Community participation and political accountability have resulted in better felt-need identification, transparency and identification of marginalisation. While the community provided the PRIs with volunteers, local funds, information and participation, the PRIs have made maternal and child health interventions more accessible through innovation, initiative and inclusiveness. Timely top-down interventions and policy support further facilitated the process.
CONCLUSION
PRIs have a valuable role to play in implementing nutrition interventions. Mobilisation and empowerment of the community, and participation of such an empowered community in the implementation of interventions was the most important way in which PRIs contributed to the effective implementation of nutrition interventions in Kerala. Results of the study illustrate the complex linkages PRIs have within the health system; these should be further explored and strengthened. However, when considering the larger development issue of nutrition, influence of PRIs needs to be studied not only in relation to nutrition-specific interventions, but across all the other sectors that contribute to the various basic, underlying and immediate determinants of nutrition and health. A detailed analysis of expenditure data of PRIs and ICDS to understand how PRI involvement translates into actual resource mobilisation for nutrition interventions is thus required.
ACKNOWLEDGMENTS
The authors thank HSTP (Health Systems Transformation Platform) for supporting this research and the Local Self Government Department of the Government of Kerala for granting permission to undertake the study. JRJ would like to thank the Health Governance Hub members of Public Health Foundation of India (PHFI; Gurugram, India) for their guidance during the former study
Funding Statement
The authors thank the Sir Ratan Tata Trust (Mumbai, India) which made this research possible.
Footnotes
JRJ was part of a previous study on local self-governments in Kerala conducted by PHFI insights from which has helped the current study in different aspects.
The manuscript was prepared from one of the sub-themes of the project Local Government and Health in Kerala, implemented by Health Action by People, Thiruvananthapuram, Kerala, India.
The funders had no role in data collection and analysis or preparation of the manuscript.
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