Partnering for a better tomorrow: the successful example of Maharashtra, India

The Power of Nutrition has been working with Unicef in the State of Maharashtra, India since 2019. I recently took the opportunity to travel to Mumbai and Nashik to meet with Unicef colleagues and an inspiring team of local partners. Whilst there, we visited locations in both urban and rural settings where nutrition programming is being delivered across health facilities, community hubs, and family homes. As we approach the end of this transformational programme to improve nutrition outcomes for women and children, it was great to see firsthand the great achievements of the programme, learn more about what has worked, and discuss sustainability and the plans for the future.

This $10m programme was designed to scale-up the Aarambh (the Hindi word for “beginning”) programme in the State of Maharashtra. Building on a previous pilot, and in partnership with the Mahatma Gandhi Institute of Medical Sciences and Wadia Hospital in Mumbai (Centre of Excellence) this programme was initially scaled up in 2 districts to provide proof of concept and generate evidence, which gave the State Government sufficient confidence to take up state-wide rollout. Despite the challenges of a global pandemic shortly after launching the programme, the Aarambh strategy was fully endorsed by the Maharashtra State Government in 2021, and has now been rolled out to 36 districts, using existing government structures and increased investment of domestic financial resources.

The partnership with the Centre of Excellence has been pivotal in providing thought leadership to the programme, as well as free at the point of care service to the most critical cases of malnutrition through its nutrition rehabilitation centre. The passion, knowledge, and care provided by the team was clearly evident, and it was fascinating hearing about their innovative work around mental health support for mothers, and work around the treatment of malnutrition in children with disabilities.

In India, the development of community health has resulted in the creation of two separate lines of support delivered by the public health department (ASHA workers) and the department for women and children (Anganwadi workers; Anganwadis are community hubs where frontline workers perform early childhood development activities as well as spread and discuss key health and nutrition messages and practices with parents), with nutrition support generally falling through the gaps between the two. At community level the programme has therefore focussed on providing nutrition training to frontline workers and creating a more coordinated approach to their ways of working using the nurturing care framework. Working closely together, these workers are now able to deliver an integrated package of support, in community hubs as well as home visits, from pre-conception through to the child’s 2^nd birthday. This includes pre- and post-natal support, growth monitoring, SAM screening, immunisation, advice on breastfeeding and complimentary feeding, dietary diversity, responsive care, and even mental health screening for mothers. This also includes an integrated digital platform for keeping the health records for each child and tracking the support provided.

Unlike in other parts of the world, many children in India are born malnourished, as opposed to being born healthy and then becoming malnourished. The evidence has shown that if a child is malnourished at 6-months then the effects of stunting are likely to be irreversible. For this reason, the programme has shifted to screening children under 6 months of age for malnutrition, as well as promoting nutritional supplements for adolescent girls and women during pregnancy to prevent them giving birth to low-birth-weight babies. Placing the emphasis on early child development has been critical to bringing services together and focussing on the needs of the mother and child. Vatsalya (the Hindi word for “affection”), a special flagship programme to improve maternal and newborn health and nutrition outcomes has now been endorsed by Public Health Department and is funded across 18 districts.

We were also lucky enough to visit a parenting fair organised by local ASHA and Anganwadi workers in the Nashik province, where the community came together to celebrate and share key health, nutrition, and early childhood development messages. These events have been a great method to engage community members, reinforce the important messages and help change behaviour in a joyous and judgement free environment. Throughout the visit, it was great to see that it was not just mothers being targeted. From the young father, as the main care giver, at the urban Anganwadi centre sharing his hopes for his daughter whilst happily entertaining her with homemade finger puppets; to the grandfather, during the home visit, proudly telling us how to hold and talk to his granddaughter in order to engage and reassure her; it was brilliant to see traditional gender roles being challenged. As the adage goes, it takes a village…

The model has been recognised as an example of best practice across India, with other States now seeking support to replicate and adapt it for their own contexts. An MoU has even been signed with the Family Health Bureau in Sri Lanka to look at developing a similar programme there. Whilst great progress has been achieved, there is still more to be done. The data tells us that there are still gaps and that impact is not consistent across all communities. We are now looking at how the programme can be further adapted to ensure that the specific needs of all communities are met. For example, further investigation has shown that in cotton growing communities impact has not been in line with other parts of the State. With the introduction of masks for women working in the fields it is thought that the harmful effects of breathing in chemicals used on the crops will be reduced, leading to a reduction in low-birth-weight births. Some of the challenges are however more significant. The Anganwadi structure is not fully implemented across urban areas. In Mumbai, it is thought coverage in slum areas is only ~10%. With a lack of space, an absence of extended family support, and the scale of urban poverty not being properly mapped, additional support and resources are going to be needed to support the State Government to come up with suitable solutions to ensure that no child is left behind.

The Power of Nutrition is proud to have been a part of getting this multisectoral programme established and scaled up, matured, and really embedded in policy making and funding decisions. This is a really exciting stage in the programme’s development, and whilst not directly involved in this next phase, The Power of Nutrition will be eagerly watching to see how it develops and championing the approach and learnings whenever and wherever we can.