swasth bharat preraks

SWASTH BHARATPRERAKS

Catalyzing POSHAN Abhiyaan through Innovative Young Minds: A formative study to capture key learnings

Aishwarya Joshi, M.A.Anupam Joya Sharma, M.A., M.Sc.Dr. Malavika Subramanyam, M.D., DSc.

SWASTH BHARATPRERAKSCatalyzing POSHAN Abhiyaan through Innovative Young Minds: A formative study to capture key learnings

Aishwarya Joshi, M.A.Anupam Joya Sharma, M.A., M.Sc.Dr. Malavika Subramanyam, M.D., DSc.

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List of Abbreviations .............................................................................................................................................................viiAcknowledgements .............................................................................................................................................................. ixExecutive Summary ...............................................................................................................................................................xi

INTRODUCTION 11.1. Background about Nutrition in India ................................................................................................................ 11.2. Context of the POSHAN Abhiyaan and the SBP Programme ......................................................21.3. The History and Development of the SBP Programme ....................................................................31.4. Rationale and Need for Current Study ...........................................................................................................41.5. Main Objectives of this Study ................................................................................................................................4

METHODOLOGY 72.1. Study Design for Phases I And II ..........................................................................................................................72.2. Sampling for Phases I and II: Primary and Secondary Respondents .......................................82.3. Framework Method for Qualitative Data Analysis ..................................................................................82.4. Quantitative Methods ..................................................................................................................................................92.5. Ethical Considerations ................................................................................................................................................9

THE ROLE OF THE PRERAK: PERSPECTIVES 113.1. The Roles and Responsibilities of a Prerak ............................................................................................... 113.2. Initial Perceptions of the Role of a Prerak ..................................................................................................123.3. Areas of Interest Delineated by Preraks in their Districts ...............................................................133.4. Interpretations and Suggestions .......................................................................................................................14

WORKING IN THE DISTRICT 174.1. Preraks’ Role in Rolling Out POSHAN Abhiyaan ....................................................................................174.2. Preraks’ Unique Contribution to the Districts ..........................................................................................254.3. Interpretations and Suggestions ...................................................................................................................... 32

CONTENTS

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BARRIERS FACED AND SUPPORT RECEIVED BY PRERAKS 355.1. District-specific Issues and Challenges .....................................................................................................355.2. Challenges Faced by Preraks While Working in the District ......................................................385.3. Interpretations and Suggestions ......................................................................................................................445.4. Facilitators to the Preraks’ Work .......................................................................................................................465.5. Preraks’ Relationship with the District Administration ......................................................................485.6. Interpretations and Suggestions .......................................................................................................................51

STRUCTURE OF THE SBP PROGRAMME: TRAINING, MONITORING, FEEDBACK AND SUGGESTIONS 536.1. Training Process for New Recruits ..................................................................................................................536.2. Reporting and Feedback Mechanism for Preraks ..............................................................................566.3. Interpretations and Suggestions ......................................................................................................................576.4. Respondents’ Suggestions to Improve the SBP Programme ....................................................58

EFFECT OF THE SBP PROGRAMME ON THE PRERAKS 637.1. Professional Learnings ...........................................................................................................................................637.2. Personal Learnings ....................................................................................................................................................647.3. New Perspectives Developed During the Fellowship .....................................................................65

DISCUSSION 678.1. Interpretations of Relationships Between Themes Identified in the Data ........................678.2. Our Recommendations to Develop the SBP Programme in the Future ........................... 68

Annexures ....................................................................................................................................................................................73About the Evaluators...........................................................................................................................................................85

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AAA or “Triple-A Convergence”: AWW-ANM-ASHA (in the context of inter-departmental convergence)

ANM: Auxiliary Nurse-MidwifeASHA: Accredited Social Health ActivistAWC: Anganwadi CentreAWH: Anganwadi HelperAWW: Anganwadi WorkerBBBP: Beti Bachao Beti PadhaoBCE: Behaviour Change EventsCAP: Convergence Action Plan (sometimes District-CAP or D-CAP)CAS: Common Application Software (sometimes ICDS-CAS)CDPO: Child Development Project OfficerCEO: Chief Executive OfficerCMAM: Community-based Management of Acute MalnutritionCPMU: Central Programme Management UnitCSR: Corporate Social ResponsibilityDC/BC: District Coordinator/ Block Coordinator (for POSHAN Abhiyaan)DC: District Collector DCC/BCC: District Convergence Committee/Block Convergence CommitteeDEO: Data Entry Operator (different from District Education Officer, refer to context)DEO: District Education OfficerDM: District MagistrateDMHO/DM&HO: District Medical and Health OfficerDPA/BPA: District/Block Project Assistant (for POSHAN Abhiyaan)DPO: District Project Officer (sometimes called PO)DRDA: District Rural Development AgencyDSW: Department of Social WelfareDy CEO: Deputy Chief Executive OfficerDy DEO: Deputy District Education OfficerECCE/ECE: Early Childcare and EducationHBNC: Home Based Newborn CareHBYC: Home Based Care for Young ChildrenICDS: Integrated Child Development Scheme

LIST OF ABBREVIATIONS

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IEC (material): Information Education and Communication (sometimes ICE)IFA (tablets): Iron and Folic Acid tabletsILA: Incremental Learning ApproachLS: Lady SupervisorMNREGS: Mahatma Gandhi National Rural Employment Guarantee Scheme

(under Ministry of Rural Development)MoWCD: Ministry of Women and Child DevelopmentMOU: Memorandum of UnderstandingNFHS: National Family and Health SurveyNNM: National Nutrition MissionNNRC: National Nutrition Resource CentreNRC: Nutrition Rehabilitation CentrePHC: Primary Health CentrePHN: Public Health NursePO: Programme Officer (at TINI, different from DPO/PO)POSHAN (Abhiyaan): PM’s Overarching Scheme for Holistic Nourishment PRI: Panchayati Raj InstitutionsPS: Principal SecretaryR&B: Road & Building DepartmentRBSK: Rashtriya Bal Swasthya KaryakramSAM/MAM children: Severe Acute Malnutrition/Moderate Acute MalnutritionSBP: Swasth Bharat PrerakSPMU: State Project Monitoring UnitSRG/DRG/BRG: State/District/Block Resource GroupTHR: Take Home Ration (sometimes also called pre-mix/THR pre-mix)TINI: The India Nutrition InitiativeTNCSC: Tamil Nadu Civil Supplies CorporationVHSND: Village Health Sanitation and Nutrition DayVSTF: Village Social Transformation FellowshipZSBP: Zila Swachh Bharat Prerak

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The evaluators wish to thank The Tata Trusts and The India Nutrition Initiative for making this formative study possible. We are especially grateful to Dr Rajan Sankar for his generous support and valuable insight about the Swasth Bharat Programme at every stage of the project. Our gratitude to the Indian Institute of Technology Gandhinagar for the logistical and administrative aid provided for this study. We sincerely thank the Program Officers, the State Leads, and, most importantly, the Swasth Bharat Preraks, who generously offered their time and energy to help plan district visits, schedule in-depth interviews with the district administration; in addition to consenting to be interviewed as respondents themselves. We acknowledge their efforts and thank them for the same.

We are grateful also to our respondents: the State, district, and block level officials at the Ministry of Women and Child Development, as well as other stakeholders in the POSHAN Abhiyaan implementation process in the sampled districts in the States of Assam, Bihar, Himachal Pradesh, Madhya Pradesh, Maharashtra, Rajasthan, Tamil Nadu, Telangana, Uttarakhand, and Uttar Pradesh.

Special thanks to Nilesh Thube and Ayushi Rai of IIT Gandhinagar who provided vital support as a part of the research team at various stages of the study. We also extend our gratitude to all our friends and collaborators at IIT Gandhinagar and at TINI, who have contributed to this study at various stages.

ACKNOWLEDGEMENTS

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EXECUTIVE SUMMARY

INTRODUCTION Nutrition has long been a focus for public health and welfare schemes in India. In fact, in 2015, India also adopted the 17 Sustainable Development Goals (SDGs) as delineated by the United Nations1— Goal 2 of which is to “end hunger, achieve food security and improved nutrition and promote sustainable agriculture.”2

To understand where India stands with respect to undernutrition, it is helpful to look at data from the NFHS-4 (2015-2016): of all the children surveyed under the age of five years, a total of 38.4% reported stunting, 21.0% reported wasting, and 35.8% children were underweight3. To address these issues in nutrition, the Government of India launched the POSHAN Abhiyaan in 2018, with the target of reducing levels of stunting (by 2%), undernutrition (by 2%), anemia among young children, women and adolescent girls (by 3%), and low birth weight (by 2%) per annum. Additionally, the scheme aims to reduce the prevalence of stunting to 25% by the year 20224.

Envisaged as a nutrition initiative to aid the POSHAN Abhiyaan, the Swasth Bharat Prerak Programme was designed by TINI, an arm

of The Tata Trusts, as a year-long fellowship where “young and dynamic minds” are given an opportunity to work at the district and state level, collaborating with government machinery to provide support towards the “implementation, strategy, monitoring and reporting of POSHAN Abhiyaan.”5 The Programme has been envisaged to utilise the Swasth Bharat Preraks (henceforth referred to as Preraks) to analyse and evaluate situations relating to nutritional status in various districts across the country and help improve access to nutrition and health-based services. Additionally, the Preraks are tasked with helping strengthen and catalyse the district administrative eco-system, which in turn is expected to improve the implementation of the POSHAN Abhiyaan6. As of June 2020, 310 Preraks were engaged across 27 states and six union territories in India as a part of the SBP Programme.

Since the operationalisation of the SBP Programme in 2018, no formal study has been undertaken to explore whether the goals and objectives of the fellowship are indeed being fulfilled on the ground, as envisaged by the concerned stakeholders.

1 “Sustainable Development Goals”, NITI Aayog, https://niti.gov.in/verticals/sustainable-dev-goals. Accessed 24 July 2020.

2 “2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture”, United Nations Department of Economic and Social Affairs: Sustainable Development, https://sdgs.un.org/goals/goal2. Accessed 24 July 2020.

3 India Fact Sheet: National Health and Family Survey (NFHS-4), 2015-2016, International Institute of Population Sciences Mumbai, pp 04, http://rchiips.org/nfhs/pdf/nfhs4/india.pdf. Accessed on 03 July, 2020.

4 “Cabinet approves of setting up National Nutrition Mission.” Press Information Bureau, Government of India Cabinet, Ministry of Women and Child Development, Government of India. https://icds-wcd.nic.in/nnm/NNM-Web-Contents/UPPER-MENU/AboutNNM/PIB_release_NationalNutritionMission.pdf. Accessed on 03 July, 2020.

5 Swasth Bharat Preraks—Guidelines, The Tata Trusts, pp 03.


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Quantitative data pertaining to nutritional status indicators are routinely collected and shared in the public domain under the POSHAN Abhiyaan7; likewise, some rudimentary data regarding the SBP Programme have also been collected by TINI for internal monitoring. However, a qualitative inquiry in the form of a study stands to add to the understanding of the interaction of the SBP Programme with the district administration eco-system. A formative study such as the present study can provide insights into how the SBP Programme contributes to the implementation of the POSHAN Abhiyaan.

Conducted in two phases across 20 districts across the country, the current study delineated the following objectives:

METHODOLOGYThe study uses a sequential mixed methods design that combines quantitative data analysis along with a cross-sectional case study approach. Qualitative data were first collected, followed by the collection of quantitative data concurrently with the second phase of qualitative data collection. The States and sampled districts were randomly selected from among the best performing and poor performing districts as per monitoring parameters recorded by TINI. During the first phase of the study, the research team made field visits to districts in the States of Bihar, Madhya Pradesh, Maharashtra, Rajasthan, and Uttar Pradesh, where six to ten respondents were interviewed per district. In the second phase of the study, due to the ongoing COVID-19 pandemic, the research team modified the study design to abide by government regulations. The team conducted phone interviews with Preraks and a few district-level officials from the States of Assam, Himachal Pradesh, Tamil Nadu, Telangana, and Uttarakhand. During the second phase of the study, a comprehensive quantitative survey was also circulated among 310 Preraks, which aimed at assessing the extent to which themes and issues identified through in-depth interviews resonated in the larger pool of Preraks.

SUMMARY OF FINDINGSImplementation of the SBP Programme: Role of the Preraks in their Districts

The role of the Prerak has been envisaged as that of a catalyst for the implementation of POSHAN Abhiyaan in the district. Since the administration in every State and district has its own manner of functioning, some amount of flexibility in the Prerak’s deliverables was thought to be necessary, and the deliverables for the Preraks have been designed accordingly. Instead of an

n To understand the implementation of the SBP program.

n To identify the ways the SBP program has influenced the implementation of the POSHAN Abhiyaan.

n To understand the channels of change with respect to the impact of SBP.

n To document the impact of the SBP on the Preraks.

Additionally, the following objectives were the secondary focus in Phase II of the study:

n To identify what additional contributions the Preraks have made in the area of nutrition in their districts (POSHAN-related or otherwise).

n To explore how Preraks aid the district administration during times of crises (given the present conditions).

n To understand the assessment of the POSHAN Abhiyaan by the Preraks and their suggestions to improve its reach in their respective districts.

7 POSHAN Abhiyaan, Ministry of Women and Child Development, Government of India. http://poshanabhiyaan.gov.in/#/. Accessed on 03 July, 2020.

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extensive list of specific tasks or action points, the SBP Programme provides the Preraks with components and themes within the POSHAN Abhiyaan that they must focus on during their fellowship in the district.

A majority of Preraks (86%) reported to have worked on some or all of POSHAN Abhiyaan components (training/supervision/planning for SRGs/BRGs/DRGs, dashboard monitoring, Jan Andolan activities etc.). Other tasks that a majority of Preraks reportedly undertook in their districts were informal training and mentoring of field functionaries (80%), making field visits to AWCs (78.5%), and POSHAN-related administrative and liaising work at the district headquarters (76.6%). Further, Preraks reported providing the ICDS machinery with updates about the progress of the POSHAN Abhiyaan; following up on targets and goals; helping solve emergent problems; and streamlining the overall implementation process for POSHAN by catalyzing the WCD/ICDS Department. In a few districts, Preraks also aided with technical assistance during COVID-19 relief efforts (such as helping to design and circulate ECCE materials to beneficiaries via WhatsApp groups).

Moreover, many Preraks found creative ways to work on improving the nutritional status of the residents of their districts, thus indirectly contributing to the larger goal of the POSHAN Abhiyaan even if they were not able to directly act as a catalyst in the implementation of the Abhiyaan activities.

Channels of Change: Impact of the SBP Programme on the POSHAN Abhiyaan Implementation

Preraks were perceived as a key point of contact for convergence among line departments since they were usually not hindered by bureaucratic considerations and inter-departmental equations as compared to government officials within the

traditional bureaucracy. Eighty-eight percent of the surveyed Preraks believed that they made significant contributions to the strengthening of convergence in their districts. In cases where the district administration did not prioritise POSHAN Abhiyaan, Preraks focused on indirect methods to bolster the POSHAN components (through seeking CSR involvement/focusing on other schemes like BBBP): they always tried ways to negotiate that and put at least some effort in improving the nutritional status in their districts (e.g. in Madhya Pradesh).

Convergence at the district level and troubleshooting POSHAN-related issues at ground level (by keeping an open channel of communication) were important contributions of the Preraks. Convergence is an essential part of the POSHAN Abhiyaan, and hence this is a vital contribution. At times, Preraks were also able to bring to the table new ideas that made use of existing resources and schemes, but did not strictly fall under the convergence component under POSHAN Abhiyaan. While the submission of innovation proposals were dependent on a number of other factors (funding, district priorities, other development partners), several Preraks were able to help their districts utilise the innovation funds towards bettering POSHAN implementation, further streamlining the same. With Preraks’ technical/data-related expertise and critical thinking skills, they were able to provide needs assessment to their reporting officers—highlighting bigger picture issues such as how superstitions and junk food consumption hurt the nutrition drive in the district.

Data-driven monitoring of the districts’ indicators carried out by the Prerak was considered to be one of the biggest positive impacts of the Preraks by the district administration. They also appreciated other positive impacts of the Preraks’ presence in the district, such as the clarity provided by the Preraks regarding the workings of the ICDS system; needs assessment; identifying weak

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links in the district machinery; crafting innovative solutions for such problems; and putting forward insights to bring change in the current system. In the quantitative survey, Preraks reported considerable improvement in interdepartmental convergence (at block and the district level) (~90%), behaviour change communication (90%), development of innovation proposals (~65%), and fund utilisation in their districts (~62%). In several of the districts selected, the Preraks’ impact was through intangible contributions such as acknowledging the functionaries’ efforts and increasing their motivation.

Based on our findings, we conclude that despite the absence of clear guidelines for Preraks’ responsibilities at district level, their work was mainly focused on the implementation of different components of POSHAN Abhiyaan. Some Preraks reported changing tack to “doable tasks”, which would have direct/indirect catalysing effects on the district. Thus, they seemed to have utilised the inherent flexibility of the SBP Programme, combined with their own self-motivated critical/strategic thinking capacity, to contribute to POSHAN implementation as best they could given their districts’ needs. This aligns, for the most part, with the vision for the SBP Programme. In most instances, the district administration found some use for the Preraks that helped ease the most pertinent and pressing problems of the district—even if these were at times not wholly within the ambit of the POSHAN Abhiyaan. In the absence of clear and uniform rules and responsibilities delineated for the Preraks however, these efforts could coalesce into a larger, more measurable contribution to the implementation of the POSHAN Abhiyaan across several districts of the country to a limited extent.

The Preraks’ and State Leads assessment of the POSHAN Abhiyaan and their suggestions to improve its reach in their respective districts/States, are given in Annexure (D) at the end of this report.

Areas of Concern in the Implementation of the SBP Programme

It is important to note that in order for the Programme to be successful, the Preraks must be viewed as catalysts and not fillers. As a DM in Uttar Pradesh pointed out, the WCD department in each district needs to recognise that the Preraks are meant to be support for a limited time, and not replacement for missing staff:

“The department needs to understand that someone is acting as an outside agency and outside help; that agency can’t act as a replacement for the department. The department needs to do its job. The outside support is a support and only a limited time support. You can’t piggyback on that support to run your programme. That is I suppose the biggest problem in the department. The department needs to improve on that, not the Prerak.”

While some Preraks appreciated the flexible nature of the Programme guidelines that allowed them to set goals for themselves that were tailored to their districts’ needs, most Preraks reported that arriving at the district with only a Government Order did not provide any concrete information to the district officials that they were expected to work with. Most Preraks knew what they to expect, but several district officials lacked clarity and instructions about Preraks’ role and thus assigned them tasks not related to POSHAN. Simultaneously, the Preraks’ involvement with the ICDS machinery and its functioning seemed to result, at times, in the Prerak being subsumed into the system. Such perceptions can bring imbalance to the working relationships. It is possible that once the district officers realized the reporting structure, it gave them more clarity and likely increased their comfort in working with the Prerak. A TINI core team member shared: “once the district officials realised that they have to sign and authorize the Preraks work log and payroll on

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SELECT CONTRIBUTIONS OF THE SWASTH BHARAT PRERAKS IN IMPROVING NUTRITION INDICATORS IN THEIR DISTRICTS

Planning and strategy:

n Planning and designing training sessions for AWWs on how to correctly weigh children for growth monitoring.

n Making timetables tailored specifically for the district to be followed during the POSHAN Pakhwada activities.

Monitoring:

n Monitoring dashboards for POSHAN Abhiyaan and following up with lagging districts.

n Strengthening referral services in a few districts with their active engagement in monitoring and counselling SAM children.

Convergence:

n Collaborating with Health Department officials for implementation of POSHAN activities under the CAP report: liaisoning, planning, and execution at district level.

Training and Capacity Building:

n Conducting sessions at AWCs teaching hand-wash techniques to children.

Participation in CBEs:

n Active participation in POSHAN Melas during POSHAN Maah through several campaigns on nutrition.

ICDS-CAS Rollout:

n Working with supervisors and AWWs to digital reporting is done properly on CAS, thus reducing misreporting/underreporting of nutrition levels in the district.

a monthly basis, they could begin using the Preraks accordingly to their own priority.”

Most Preraks were able to work on some if not all components of POSHAN Abhiyaan, but the lack of clear guidelines put many in a position where they could not excuse themselves away from peripheral tasks given by their reporting officers. Based on the responses gathered from Preraks and other district officials, a possible factor that

led to some diversion of Preraks’ efforts was the lack of clarity that the district officials—and in some cases, the Preraks themselves—had regarding the Preraks’ role at the district level. Most Preraks reported that it took them several months to establish a relationship of mutual trust with their district-level reporting officers. It was no doubt to be expected, since a majority of district officers likely did not have a clear idea of Prerak’s role as well as the reporting structure. District

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officials interviewed reported limited awareness about the goals and vision of the SBP Programme: there seemed to be some uncertainty regarding whether Preraks were at the disposal of the district administration with their reporting officers enjoying complete administrative control over them, or they were to be the ‘eyes and ears’ of the MoWCD at the district level. The latter seemed to be the perception in several cases—gleaned either through direct or indirect responses—which likely discouraged the district officials and field functionaries to cooperate with the Programme completely. Relationship management issues persisted—partly to do with Preraks being ‘outsiders’, partly their age/gender/inexperience, partly the lack of holistic support by SLs. However, a few Preraks used many of these factors were used to their advantage.

State Leads did report making field visits to monitor the progress of the districts under them (albeit on a case-to-case basis), as well as having regular conversations with the DMs/DPOs regarding the Preraks’ performance. Based on the responses gathered, however, this seemed to be insufficient and—in some cases—even inconsistent with the district officials’ accounts. There was a reported lack of prior communication by SLs to the district: in places with no prior Prerak being appointed, Preraks often found themselves inserted into a traditional bureaucratic setup without much support, which made it difficult for them to work in the district to their fullest capacities.

Despite the work of the Preraks on some POSHAN components, they sometimes faced active challenges in trying to fulfil their deliverables: there were instances where Preraks were used

as fillers, or for other programs/schemes, or were told not to work on some parts of the POSHAN Abhiyaan; while some states/districts did not prioritise POSHAN implementation. Challenges plaguing the ICDS staff: lack of digital/technological know-how, understaffing, lack of financial resources at district level, poor infrastructure, and issues of misreporting/underreporting8,9,10 all contribute to a weak structure within which the Prerak is placed. It is easily conceivable how such structural challenges could affect the Preraks’ ability to work efficiently. It is unlikely that the efforts of a solitary worker such as the Prerak in a system with weakened foundations would amount to truly big changes. The reduced enthusiasm for the Programme at the Centre after initially championing the Programme—due to several reasons—likely magnified the gap between expectations and delivery. One systemic challenge that is often observed in the government is frequent changes in leadership. While established programs do go on to be implemented despite such changes, a time-limited program such as the SBP Programme is especially vulnerable to such barriers. They hinder the expression of a smooth and consistent vision and effort, which tends to percolate to the district-level and manifests as ambivalence, non-cooperation, and apprehension towards the Preraks. Furthermore, it is difficult to identify outcome indicators when the vision and deliverables of a programme continue to change over time. Taking a cue from the successful ZSBP Programme, having clear goals (which are achievable in a time-limited fellowship) would help ultimately measure, in some concrete manner, the impact of the SBP Programme.

8 Debata I, P. A, S. R. A study to assess availability of basic infrastructure of anganwadi centers in a rural area. Int J Community Med Public Heal. Published online 2016. doi:10.18203/2394-6040.ijcmph20162200.

9 Sahoo J, Mahajan PB, Paul S, Bhatia V, Patra AK, Hembram DK. Operational assessment of ICDS scheme at grass root level in a rural area of Eastern India: Time to introspect. J Clin Diagnostic Res. Published online 2016. doi:10.7860/JCDR/2016/23059.9041.

10 Kumar NP. ICDS striving for holistic development insights from a field study in Uttar Pradesh. Econ Polit Wkly. Published online 2019.

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Effect of the SBP Programme on the Preraks

Among the biggest learnings reported by the surveyed Preraks were the knowledge of how government machinery worked; the development of sensitivity towards challenges faced by frontline workers; and people skills such as relationship management and communication. Each Prerak has had a different journey with the SBP program. For some Preraks, this opportunity was an attempt to understand the government’s workings and processes in the field of nutrition. Making field visits, meeting with beneficiaries and trying to find solutions to problems they faced: these were cited by Preraks as important experiences for their learning curve.

Several Preraks perceived this Programme as an important boost to their careers in the field of development and social work. Many Preraks stated that the Programme helped them acquaint themselves with government departments and administration, human resource management and program management skills; they reported honing their problem solving skills and gaining confidence during their tenure. Some Preraks also shared certain aspects of personal and professional growth that came with their experience. Preraks also reported having become more polite and patient in the face of slow-moving governmental processes.

In terms of the Programme’s effect on the Preraks, most members of the TINI core team concurred that the experience had aided the personal and professional growth of many young persons who were associated with the Programme. Many of them had reportedly developed a sensitivity regarding the processes and challenges of tackling a grave and multisectoral issue such as undernutrition.

OUR RECOMMENDATIONSSuggested Programmatic Changes:

1. The MOU signed by the MoWCD and The Tata Trusts needs to better highlight the Preraks’ deep involvement in data-driven monitoring, and explicitly state that their findings be considered seriously by the district administration after receiving feedback from the DM. Signing MoUs with States instead of Centre could help combat ownership/acceptance issues, while also making it possible to tailor the Programme to what specific states and districts actually need from Preraks. The language of the MOU with the Centre and/or the State could further clarify that any improvements the Ministries and/or State and district administration expect due to the placement of the Preraks are to be understood as contingent on the Preraks’ recommendations being implemented. Integrating VSTFs/ZSBPs/development partners into the SBP’s points of contact/ interfaces could help convert identified needs for change into actions.

2. More acceptance and ownership of the Programme by the States could be facilitated by tailoring the Programme deliverables to the individual needs of each State, based on detailed conversations that TINI has with State officials regarding what the Preraks are expected to do. The appointment of Preraks to districts could also be made contingent on the district prioritizing the POSHAN Abhiyaan implementation. In districts which do not prioritize the POSHAN Abhiyaan, a gentle easing-out of the Prerak and appointment in a different district after a few months could be an option as well.

3. Formal, regular communication/meetings at the central level between TINI and MoWCD could be helpful. An organized feedback mechanism needs to be established between

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the districts and TINI as well. A process could be established to ensure transparency in data collected through the SBP Programme and reported in collaboration with other stakeholders. Perhaps these negotiations could be channelled through third party auditors working with TINI and stakeholders such as the CPMU.

4. State Leads could make regular field visits as well as have regular conversations with the reporting officers. This can help streamline the linkages with the district administration. A concise set of standard indicators, and mutually agreed on with the reporting officers, could be developed at the start of the association between TINI and the district. Understanding what the district expects from the Programme and adding the same to this list could help increase the efficiency of the Preraks’ tenure. This would provide clarity to all (Preraks, district officials, State Leads) about what to expect and monitor. A set of indicators which are minimally required from all Preraks could be developed from the existing list of such indicators, but importantly, this needs to be shared with the reporting officers. Additionally, at least two district-specific indicators could be added.

5. A larger, more experienced core team at TINI, with a robust background in health and nutrition (at Centre and State levels), might be able to negotiate better with the appropriate committees at the Centre to ensure that the SBP Programme is working at its optimum. A closer look is also needed at how State Leads function, what is expected of them as a part of the TINI machinery, and how their performance is monitored by TINI. More than one State Lead could be appointed, especially in larger States, to help manage the Preraks. A formal peer-to-peer digital platform for interaction between Preraks can be established.

Suggestions Pertaining to the Responsibilities of a Prerak:

6. There is a reported mismatch between the on-paper deliverables for the Prerak and what the SBPs are told in the training: “go for the lowest hanging fruit”, as mentioned by the SBPs. This could be acknowledged to ensure the Prerak’s efforts do not look miniscule/disproportionate when compared to the current expansive job chart. It may be worthwhile even paring down the list of expectations to one/two important aspects of POSHAN, such as governance or funds utilization. Further, the roles and responsibilities of the Prerak also need to take into account the changing nature of the POSHAN Abhiyaan itself. The flexibility in the SBPs’ roles and responsibilities needs to be clearly worded, not just in terms of the content area where Preraks are expected to contribute but also in the nature of their contribution. For instance, guidelines could clarify that Preraks are expected to help with planning, prioritizing the tasks for the frontline workers to focus on, organizing district-level meetings, monitoring, supervision, and so on. The guidelines could also spell out that Preraks are expected to work closely with district-level officials and not to get involved in the day-to-day implementation of POSHAN activities at the sub-district levels. Accompanying these guidelines, a more central, formalized missive from TINI to the district administration could help to provide clarity regarding the roles and responsibility of the Preraks. Also, regular correspondence to the districts from the State as well as TINI regarding the role of the Prerak would help improve the situation. We strongly recommend that an initial meeting of the newly-appointed Prerak, at the start of their tenure, be held with the DM/DC, DPO, the state POSHAN coordinator, and the State Lead. The purpose of the meeting would be to discuss, negotiate, and decide a few clearly delineated responsibilities of the Prerak in

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that specific district, based on the district’s requirements at that point in time.

7. The responsibilities of the Prerak could include an aspect of teaching/training of district and block-level functionaries in the skills needed for the management and administration of POSHAN-related activities. Preraks should be encouraged to teach/train a few district functionaries in the use of spreadsheets, interpreting data for quick decision-making, having regular strategic meetings to discuss innovative approaches to getting the approvals needed, ideas to streamline scheduling based on the availability of different officials, and other such tasks in order to keep the POSHAN Abhiyaan implementation on track. This would likely increase the functionaries’ capabilities and ensure that a portion of the Prerak’s time is spent on having a catalytic impact. An explicit appreciation for such capacity building, accompanied by a corresponding monitoring indicator (such as “What skills did you teach this month and to whom?”) is recommended.

8. While tasks not related to POSHAN did make up significant portions of the Preraks’ work in the district—especially at the start of their tenure—it might be useful to look at such work as a part of a cohesive whole that contributed to bettering the district’s position with respect to nutrition. While Preraks cannot be expected to change district funding structures/priorities, their deliverables can be broadened to include peripheral tasks as legitimate efforts towards a multipronged tackling of undernutrition in the district by helping the district where it actually needs their aid.

9. More freedom could be given to Preraks to combat the reported lack of executive powers, as in the ZSBP programme. Some research output/value addition aspects could

also be added to Preraks’ deliverables. This could possibly also function as an outcome indicator for the Programme as a whole.

Suggestions to Improve Recruitment and Training:

10 We recommend a more rigorous Prerak selection process with an emphasis on not only familiarity with nutrition and health, but also emotional intelligence and people skills. If Preraks with no background in nutrition and health are recruited, they should be given training in these areas--along with a longer field immersion--to help them ease into their role with a better idea of on-ground realities. Alternatively, hiring Preraks with social work/health background, especially for aspirational districts, might help alleviate the perceived lack of experience among Preraks. The selection process must also assess the candidates on their approaches to conflict resolution, their attitudes towards working in a hierarchical structure, and their ability to deal with constant, unpredictable impediments in achieving goals. TINI must also emphasize these skills during the State-level training to help Preraks hone these skills, preferably also inviting the Preraks who are already posted in that State to share their experiences and advice.

11. Training given to Preraks needs to include information that acknowledges that there is a great diversity in how the ICDS operates in different states. The state-level training needs to orient the Preraks to the state-specific aspects of the ICDS. Relationship management should feature more prominently in the training/orientation. State Leads must also have protocols in place for training new recruits at the State level by providing them local and regional level inputs that would help Preraks build rapport with their reporting officers.

xx SWASTH BHARAT PRERAKS

Suggestions Regarding Feedback Mechanism and Support Provided by TINI:

12. We recommend that the contribution of Preraks be viewed bearing in mind the tasks they were asked to perform by their reporting officers. Feedback sought by the Project Officers/State Leads from the DPOs can be triangulated with inputs received from the State Leads and the Preraks themselves. The outcome indicators/evaluation mechanism can take some inputs (quantitative and/or qualitative) from district officials to ensure that the Program is looping in the district administration in a meaningful manner. State Leads should be integrated into the Prerak-DM-reporting officer structure of monitoring formally through constituting proper channels and SOPs of regular feedback loops for which they are held accountable by TINI.

13. With respect to personnel-related issues arising in the district, clear and firm guidelines from the States regarding Preraks’ role and their purpose in the district, as well as a top-down culture (consistent with traditional bureaucratic hierarchies) of involving and accepting Preraks into the MoWCD fold might help iron out many such challenges. The State Leads also need to be properly trained with skills to negotiate situations of conflict, manage human resources, and provide suggestions wherever and whenever necessary—both to the district headquarters and the Preraks.

14. We recommend setting up opportunities for Preraks to have regular formal interactions with other Preraks, where issues are discussed

in collaboration with the TINI team. Regular refresher training and Prerak review meetings can also be held to discuss learnings and sharing of skills learned to work with higher officials.

15. Increased logistical support from TINI can also reduce the financial and logistical burden that the district administration currently faces in providing the Prerak with the adequate resources. Perhaps a desktop or laptop could be provided to the Prerak by TINI, and the majority of a Prerak’s responsibilities could be restricted to the district level itself. Simple arrangements/agreements could be reached by the State Leads by visiting and speaking with the district officials before the Preraks’ arrival to their respective districts (e.g. deciding where they will sit, what resources can be provided by the district). These symbolic gestures could go a long way in helping improve the acceptance and ownership that a district displays towards a Prerak.

Lastly, we acknowledge that challenges and shortcomings pertaining to the ICDS system are outside the Preraks’ control, and do limit their ability to catalyse the district ecosystem. A larger, more holistic host of measures will be needed to address such issues; this would need more than one programme or scheme—although multiple initiatives like the SBP Programme, which focus on direct as well as indirect factors affecting POSHAN implementation, can help address these barriers to nutrition.

1SWASTH BHARAT PRERAKS

01Undernutrition is a global cause for concern in the field of healthcare. According to a 2019 study, undernutrition contributes substantially to disease burden in that “more than half of global deaths in children younger than five years of age attributable to undernutrition, the vast majority of which are in low-income and middle-income countries” (India State-Level Disease Burden Initiative Malnutrition Collaborators, pp. 855)1. A lack of adequate nutrition, especially in the formative years of life, has been linked to chronic disease and illness throughout one’s lifespan, critically affecting the quality of life. According to the United Nations, undernutrition is “both a driver and an outcome of poverty and inequality. Undernutrition can also lead to hidden hunger, wasting and stunting, which causes irreversible damage to both individuals and society”2. Addressing undernutrition in children and women is highlighted as being vital to “ensure optimal cognitive growth and development and overall health and productivity”( India State-Level Disease Burden Initiative Malnutrition Collaborators, pp. 855).

UNICEF South Asia estimated that in South Asia in particular, less than two-thirds of infants are

INTRODUCTION

exclusively breastfed, and more than half are not breastfed from within the first hour of life; further, less than half of children aged 6-23 months are fed the minimum number of meals a day3. In addition, an estimated half of adolescent girls in South Asia are “underweight, anaemic or both, and up to one in six are too thin”. UNICEF South Asia also reported that “the young age at which many girls first become pregnant, combined with their poor education, inadequate decision-making power and poor control over resources, means that many enter pregnancy with bodies unable to support healthy foetal growth”4. Thus, the challenge of eradicating undernutrition in young children, adolescent girls and pregnant and lactating women looms large before us.

1.1. BACKGROUND ABOUT NUTRITION IN INDIA

Nutrition has long been a focus for public health and welfare schemes in India. In fact, in 2015, India also adopted the 17 Sustainable Development Goals (SDGs) as delineated by the United Nations5— Goal 2 of which is to “end hunger, achieve food security and improved nutrition and

1 India State-Level Disease Burden Initiative Malnutrition Collaborators, “The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017.” Lancet Child Adolescent Health, September 2019, pp. 855-870).

2 “An End to Malnutrition”, Zero Hunger Challenge- United Nations, https://www.un.org/zerohunger/content/end-malnutrition. Accessed 24 July 2020.

3 “Nutrition”, UNICEF South Asia, https://www.unicef.org/rosa/what-we-do/nutrition. Accessed 24 July 2020.

4 “Nutrition”, UNICEF South Asia, https://www.unicef.org/rosa/what-we-do/nutrition. Accessed 24 July 2020.

5 “Sustainable Development Goals”, NITI Aayog, https://niti.gov.in/verticals/sustainable-dev-goals. Accessed 24 July 2020.

2 SWASTH BHARAT PRERAKS

promote sustainable agriculture”6. To understand where India stands with respect to undernutrition, it is helpful to look at data from the NFHS-4 (2015-2016): of all the children surveyed under the age of five years, a total of 38.4% reported stunting, 35.8% children were underweight, and 21.0% reported wasting7. A closer look at data for undernutrition across different age groups and genders makes apparent the room for improvement in the efforts towards improving the nutritional status of children as well as young adolescents, pregnant women and lactating women8. It is within this context of committing to the UN’s goals from sustainable development that initiatives such as the PM’s Overarching Scheme for Holistic Nourishment (the POSHAN Abhiyaan) as well as the Tata Swasth Bharat Prerak (SBP) Programme have been envisaged and developed.

1.2. CONTEXT OF THE POSHAN ABHIYAAN AND THE SBP PROGRAMME

POSHAN Abhiyaan is described as “India’s flagship program to improve nutritional outcomes for children, adolescents, pregnant women and lactating mothers by leveraging technology, a targeted approach and convergence”9. According to a Government of India press release in December 2017, POSHAN Abhiyaan is a step in this direction, with the targets for the scheme including reducing levels of stunting (by 2%), undernutrition (by 2%), anemia among young

children, women and adolescent girls (by 3%), and low birth weight (by 2%) per annum. Additionally, the scheme aims to bring down the rate of stunting to 25% by the year 202210.

Since there is a thrust on convergence, monitoring and achieving of targets through the use of technology under the POSHAN Abhiyaan, the MoWCD collaborated with The Tata Trusts to launch the SBP Programme with the intention of “enabl(ing) the districts with technical and management expertise, and help(ing) them in achieving the desired nutrition outcomes (elimination of anemia, malnutrition free India)”11. The Tata Trusts has been contributing to combat undernutrition in India through its holistic approach towards nutrition, reflected in its multisectoral strategies of fortification of nutrition, strengthening of existing systems, and policy and advocacy work12. As a part of system strengthening, The Tata Trusts provide support to the POSHAN Abhiyaan through one of its largest programme: the Swasth Bharat Prerak Programme. TINI, an implementing arm of The Tata Trusts, supports the implementation of this Programme in various districts across the country. TINI also coordinates to compile information on the progress of POSHAN Abhiyaan in order to report to the CPMU and MoWCD.

The Programme is designed as a year-long fellowship where “young and dynamic minds” are given an opportunity to work at the district

6 “2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture”, United Nations Department of Economic and Social Affairs: Sustainable Development, https://sdgs.un.org/goals/goal2. Accessed 24 July 2020.

7 India Fact Sheet: National Health and Family Survey (NFHS-4), 2015-2016, International Institute of Population Sciences Mumbai, pp 04, http://rchiips.org/nfhs/pdf/nfhs4/india.pdf. Accessed on 03 July, 2020.

8 Please refer to the India Fact Sheet (cited above) for a detailed break-up of data on the nutritional status of young adolescents, pregnant women and lactating women.


10 “Cabinet approves of setting up National Nutrition Mission.” Press Information Bureau, Government of India Cabinet, Ministry of Women and Child Development, Government of India. https://icds-wcd.nic.in/nnm/NNM-Web-Contents/UPPER-MENU/AboutNNM/PIB_release_NationalNutritionMission.pdf. Accessed on 03 July, 2020.


12 “Nutrition: Helping the country fight against malnutrition”, The TATA Trusts, https://www.tatatrusts.org/our-work/nutrition. Accessed 24 July 2020.


and state level, collaborating with government machinery to provide support towards the “implementation, strategy, monitoring and reporting of POSHAN Abhiyaan”13.

The Programme has been envisaged to utilise the recruited candidates, called the Swasth Bharat Preraks (henceforth referred to as Preraks) to analyse and evaluate situations relating to nutritional status in various districts across the country to help improve access to nutrition and health-based services. Additionally, Preraks are expected to help strengthen and catalyse the district administrative eco-system, which in turn is expected to improve the implementation of the POSHAN Abhiyaan14.

1.3. THE HISTORY AND DEVELOPMENT OF THE SBP PROGRAMME

The SBP Programme was launched in January 2018, following the success of the erstwhile Zila

Swachh Bharat Prerak (ZSBP) Programme which also engaged Preraks at the district level to help districts become open defecation free (ODF) under the Swachh Bharat Mission. The SBP Programme was modelled after this successful partnership between the government and The Tata Trusts, and thus a Memorandum of Understanding (MoU) was signed between MoWCD and The Tata Trusts, where the latter were brought on board as implementation partners for the POSHAN Abhiyaan.

Three hundred and ten Preraks are currently engaged across 27 states and six union territories in India15 as a part of the SBP Programme. The fellowship is operated under The India Nutrition Initiative (TINI)—a nutrition initiative of The Tata Trusts. The Tata Trusts also support National Nutrition Resource Centre (NNRC), which is a team of professionals that provide technical and operational support to the Central Programme Management Unit (CPMU) as well as the State



15 According to TINI records as of 30 June 2020.

PERSPECTIVES FROM THE TINI CORE TEAM

According to a senior TINI team member, corporate sector entities were first approached for providing managerial skills support at the district-level during the Swachh Bharat Mission, specifically for the mission to make districts Open Defecation Free (ODF). The Tata Trusts collaborated with the government on this mission by providing ZSBPs. When the POSHAN Abhiyaan was launched in 2018, MoWCD further requested The Tata Trusts for help in a similar vein at district level since it was a multisectoral program. Thus the SBP Programme was conceived. Since the inception of the Programme, the TINI core team has reportedly continued to present the CPMU with data tracking the progress of the Abhiyaan, as well as highlighting challenges faced in its implementation. The erstwhile Mission Director was cited to be of the firm belief that this Programme would help identify and overcome the challenges in the implementation of the POSHAN Abhiyaan.


Project Monitoring Units (SPMUs)16. The Preraks are employed by TINI and deputed to the MoWCD, which in turn posts them to various districts across the country. Here, they work directly under a nominated official [often the District Project Officer (DPO), WCD Department]. Tasks are allotted to the Preraks by these officials, while TINI supports and guides the Preraks as they work, and is in charge of their performance review. For this, the Preraks report to TINI on a monthly basis. The Preraks are expected to concentrate on ICDS-CAS, convergence, capacity building, and behaviour change as the main areas of intervention (refer to Chapter 3 of this report for more details). In terms of day-to-day interaction, the Preraks work alongside local government bodies (such as the WCD department, the Health department, the Education department, PRI, MNREGS etc.); ICDS field functionaries (such as CDPOs, LSs, AWWs); and the District Magistrate or District Collector17.

1.4. RATIONALE AND NEED FOR CURRENT STUDY

Since the operationalisation of the SBP Programme, no formal study has been undertaken to explore whether the goals and objectives of the fellowship are indeed being fulfilled on the ground, as envisaged by the concerned stakeholders. While there are several success stories that have been documented to showcase the Preraks’ work in the districts over the last two years, a comprehensive exploration was required to understand the specific inputs which are a part of the implementation of the SBP Programme at the district level; the concrete processes through which the Preraks make these contributions towards the POSHAN Abhiyaan; as well as the strengths and weaknesses of such a programme.

Quantitative data pertaining to nutritional status indicators are routinely collected and shared in the public domain under the POSHAN Abhiyaan18; likewise, some rudimentary data regarding the SBP Programme have also been collected by TINI for internal monitoring. However, a qualitative inquiry in the form of a study stands to add to the understanding of the interaction of the SBP Programme with the district administration eco-system. Subsequently, a formative study such as the present study can provide insights into how the SBP Programme contributes to the implementation of the POSHAN Abhiyaan.

1.5. MAIN OBJECTIVES OF THIS STUDY

The current study has attempted to address the following questions:

1. How (concrete steps and processes) is the Prerak program implemented in the districts to provide quality hand-holding support towards rolling out the POSHAN Abhiyaan components? What activities do the Preraks carry out, what interactions do they have, and what kinds of influence does this have on district administrative ecosystem concerned with the National Nutrition Mission?

2. How does the whole process play out (introduction of Preraks, the orientation of Preraks, routine work of the Preraks)? Who and what influences these and how? What plays a role in easing the process at the district level? What are the barriers and how do they impact any influence that the Prerak might have? How did the Preraks leverage the enabling factors and overcome the barriers?

16 The CPMU and the SPMUs are set up by the MoWCD to monitor and manage the POSHAN Abhiyaan.




3. In what way does the Preraks’ presence make a difference in the implementation process of POSHAN Abhiyaan at the district level? What specific tasks and strategies related to the Preraks playing the role of a supportive catalyst were effective, and why?

4. How do the district level stakeholders view the Prerak program? What changes in POSHAN Abhiyaan implementation, or in general, do the district-level stakeholders ascribe to the introduction of the Preraks? What are their views about making any changes to the design of the Prerak program?

5. What is the major effect of the SBP on the Preraks? What do the Preraks think of the whole experience? What has been the change in their worldview? Any impact on their life choices? What did they learn in their journey of implementing POSHAN Abhiyaan in their districts? Has this allowed them to fulfill their desire to give back (if they ever had such a desire)?

The intended users of this report are the stakeholders in the SBP Program (MoWCD, The Tata Trusts), other development partners, entities and trusts looking to launch similar fellowship opportunities, researchers and evaluators interested in examining partnerships in the area of nutrition, young professionals who may be interested in seeking out information about the SBP Program before applying for it, and the general public.

To be able to answer these questions, the following objectives were delineated for this formative study:

n To understand the implementation of the SBP program.

n To identify the ways the SBP program has influenced the implementation of the POSHAN Abhiyaan.

n To understand the channels of change with respect to the impact of SBP.

n To document the impact of the SBP on the Preraks.

Additionally, the following objectives were the secondary focus in Phase II of the study:

n To identify what additional contributions the Preraks have made in the area of nutrition in their districts (POSHAN-related or otherwise).

n To explore how Preraks aid the district administration during times of crises (given the present conditions).

n To understand the assessment of the POSHAN Abhiyaan by the Preraks and their suggestions to improve its reach in their respective districts.


02METHODOLOGY

2.1. STUDY DESIGN FOR PHASES I AND II

The study uses a sequential mixed methods design that combines quantitative data analysis along with a cross-sectional case study approach. Qualitative data were first collected, followed by the collection of quantitative data concurrently with the second phase of qualitative data collection. The case-study approach is suited to gaining insight into whether implementation of a particular program or intervention is in compliance with its original/planned intent1; the challenges that have been encountered during the process; the adaptations/modifications made to the original structure and the reasons for the same.

In this study, the primary focus was on in-depth interviewing, a method that aids in collection of rich, well-rounded data from the individuals involved in the process. With the help of this method, was possible to probe emergent concepts and pursue threads that cannot be pursued in survey questionnaires and quantitative data analysis. To supplement in-depth interviewing, the study also made use of an online survey circulated among Preraks to glean more information about the implementation of POSHAN Abhiyaan and the role of the SBP Programme in the same. The States and sampled districts were randomly selected from among the best performing and poor performing

PHASE IAugust 2019–February 2020

Ten districts were selected across five states: Bihar, Madhya Pradesh, Maharashtra, Rajasthan, and Uttar Pradesh.

The research team conducted in-depth, semi-structured interviews and/or focus group discussions (FGDs) with around six to ten respondents in every district.

While most interviews were conducted in person, some were conducted over telephone owing to respondents’ location/availability.

PHASE IIApril 2020 – June 2020

Ten additional districts were selected across five states for the second phase of the study: Assam, Himachal Pradesh, Tamil Nadu, Telangana, and Uttarakhand.

During this phase, a change in study design was required due to the ongoing COVID-19 pandemic. As the research team was unable to visit the districts in person, in-depth, semi-structured interviews with select respondents were conducted exclusively over telephone.

To supplement the qualitative findings from both phases, a comprehensive online survey questionnaire was circulated among all Preraks. This questionnaire was based on the qualitative interview guide, and also drew from the findings in Phase-I in order to explore certain emergent themes with a larger respondent group.

districts as per monitoring parameters recorded by TINI. The study was divided into two phases, designed as follows:

1 Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach. BMC Med Res Methodol. Published online 2011. doi:10.1186/1471-2288-11-100.


2.2. SAMPLING FOR PHASES I AND II: PRIMARY AND SECONDARY RESPONDENTS

In Phase I, primary respondents included:

n Preraks;

n State Leads and Program Officers for the SBP Programme;

n District Project Officers (DPOs) or other equivalent district officials in charge of the ICDS and POSHAN Abhiyaan implementation in the districts;

n FGDs with select CDPOs and LSs that the Preraks worked frequently with;

n POSHAN Abhiyaan functionaries at the district level: District Coordinators, Block Coordinators, and District Project Assistants.

The secondary respondents included:

n The District Collector/District Magistrate or any other high-level district officials to whom the Prerak reported (such as the Chief Executive Officers (CEOs);

n Other ICDS officials that the Preraks worked alongside (such as Extension Officers);

n DMHOs, DEOs, PRI officials and other line department officials at the district level who interacted with the Preraks regularly for convergence activities; and

n Consultants/functionaries associated with other development partners in the district who collaborated with the Preraks

In Phase II, the team faced logistical constraints and limited availability of many district-level officials and field functionaries due to the COVID-19 pandemic and related travel restrictions. Hence, the respondents selected in this phase were limited to State Leads, Preraks and one district official per district (subject to

their availability). Select members of the TINI core team were also interviewed in this phase to gain insights into macro-level workings of the SBP Programme.

The online survey questionnaire was circulated among 310 Preraks in May 2020. The responses to the questionnaire (N~247) were summarised and analysed in conjunction with the qualitative findings to better illustrate trends and common themes at the micro- and macro-levels.

2.3. FRAMEWORK METHOD FOR QUALITATIVE DATA ANALYSIS

For the analysis of the qualitative data obtained from the interviews and FGDs with respondents, the framework method of analysis was used2. Wherever consented to by the respondents, the interviews and FGDs were audio-recorded and translated transcripts of the same were produced in English. Where recording of the interviews was not possible, summaries and detailed notes were produced by the interviewers to capture the key findings from all such interactions. Field notes and the researchers’ impressions were also captured in writing to aid a better understanding of contextual factors in each district.

During the analysis, some prepared transcripts were initially open-coded by two of the members of the research team independently; these codes were then compared and grouped into thematically arranged categories of codes. An analytical framework was produced using these thematically categorised codes, which was then used to index the remaining transcripts and documents. The codes were discussed among the research team and finalized after several discussions to achieve high inter-rater reliability. Indexed data from these transcripts

2 Gale et al.: “Using the framework method for the analysis of qualitative data in multi-disciplinary health research.” BMC Medical Research Methodology 2013 13:117.


were summarised into a data matrix in a process known as charting. Finally, the written report was produced with the help of this data matrix. Wherever necessary, the team referred to individual transcripts to cite particular quotes or details from the reported data.

2.4. QUANTITATIVE METHODSBased on the findings from interviews at Phase I, a survey was administered on 313 Preraks across the country. The introductory message in the survey briefed the Preraks about the objective of the study, informed about the voluntary nature of the participation, and promised them anonymity. The primary goal of the survey was to assess the validity and generalizability of the findings from the Phase I qualitative interviews. Of the 313 Preraks approached, responses from 247 were recorded. Descriptive statistics were used to analyze the quantitative data. To further understand the results of the quantitative survey, Phase II qualitative interviews were conducted with the Preraks as well as a few district ICDS/POSHAN officials. The interpretation of the quantitative and the qualitative findings together yielded a comprehensive picture of the SBP program.

2.5. ETHICAL CONSIDERATIONSThis study was approved by the Institutional Ethics Committee (IEC), Indian Institute of Technology Gandhinagar. The researchers ensured that each respondent was informed of the background of the study and the voluntary and confidential nature of their participation. Any questions or concerns related to the study that were raised by the respondent were addressed by the researchers to the best of their knowledge and abilities. The participants were informed that they could skip any question they felt uncomfortable responding to during the interview. The participants were provided with a copy of the consent form, which also mentioned the contact details of the researchers in case of future enquiries. The participants were asked for consent to audiotape the interviews; a few did not consent, and in such instances the researchers made detailed notes to capture the participants’ responses, both during and after the interviews.

No data that revealed personal information of the respondents were shared with individuals outside the research team. The researchers have ensured that no personal information that linked certain inputs to individual respondents is made apparent in the reported findings. Some respondents preferred to share sensitive information with the researchers off the record. In such instances, the team has taken additional care to ensure that no identifiable details about the respondents were reflected in the final report.


RESULTS OF THE STUDY


033.1. THE ROLES AND

RESPONSIBILITIES OF A PRERAK

The role of the Prerak has been envisaged as that of a catalyst for the implementation of POSHAN Abhiyaan in the district1. Since the administration in every State and district has its own manner of functioning, some amount of flexibility in the Prerak’s deliverables was thought to be necessary, and the deliverables for the Preraks have been designed accordingly. Instead of an extensive list of specific tasks or action points, the SBP Programme provides the Preraks with components and themes within the POSHAN Abhiyaan that they must focus on during their fellowship in the district.

The Preraks are to design a strategy identification, documentation, and replication of best practices, to aid with preparing action plans within the four main components of the POSHAN Abhiyaan in their respective districts2. Subsequently, the Preraks are expected to choose four themes from the total of twelve POSHAN Abhiyaan themes (details on page 15 of Swasth Bharat Preraks—Guidelines). Two of these themes are fixed—Complimentary Feeding and Adolescent Girls (their education, menstrual health hygiene, anemia/IFA, age of marriage, and a healthy and balanced diet). Two other themes

may be chosen by the Prerak based on the need of the district. The Preraks must then plan behaviour change/Jan Andolan activities for the entire duration of their engagement based on these themes3. The action plans for each of the POSHAN components should be designed as follows4:

THE ROLE OF THE PRERAK: PERSPECTIVES

(i) ICDS-CAS— Preraks must aid in procuring smartphones and growth monitoring devices; configuring and register the smartphones; ensure training of the Master Trainers and field functionaries; ensure that data are punched in and that the quality of those data is satisfactory; operationalise the Dashboard; monitor the Dashboard entries made by functionaries; and provide inputs from the Dashboard in the CAP meetings.

(ii) Convergence— Preraks must ensure quarterly conduct of the Block level CAP meetings; ensure 100% attendance of master trainers and trainees at the district level CAP meetings; and facilitate implementation of decisions made at the Sate-level CAP meetings.

(iii) Capacity Building— Preraks must ensure nomination of two Master Trainers per district; plan SRGs and liaise with CPMU for the same; ensure 100% attendance and satisfactory quality of training; and coordinate for the monthly block and sector level trainings.

1 Refer to the NNRC Guidelines for details. Also see https://www.wcdsbp.org/about.php



4 Swasth Bharat Preraks—Guidelines, The Tata Trusts, pp 10-13.


In addition, Preraks are also expected to assign to themselves certain change-based targets: adoption of five Anganwadi Centres (AWCs) to help transform them into Model AWCs, action towards convergence in the district, self-capacity building, programmatic contribution (being the ‘change makers’), leadership, and identifying causes/challenges to initiate change or solutions.

3.2. INITIAL PERCEPTIONS OF THE ROLE OF A PRERAK

Some Preraks had a fair idea of the objective of the Programme, and the expectations from them as the Prerak before they joined the district. A few Preraks had prior experience in the development or social sectors, were broadly aware of what the fellowship would entail. Others acquainted themselves with the resources available on the Programme’s website; as one Prerak in Assam reported:

“I: So what were your basic expectations from this job? I mean, initially when before you joined, what were you expecting?

R: I had an idea, this is going to be work on nutrition and (that) I’ll be working at the district level. So that was kind of an idea. And I thought that (...) I will get the opportunity to work with the community. So (I knew) these basic two or three things, and I (also) browsed through their portal.”

Another Prerak working in Telangana believed that the role of a Prerak would prepare her for her long-term career goals in the field of education:

“R: ...in the long term I wanted to get into the educational field and wanted to work there. So I thought (the Programme) would be a good experience of sort, providing a basic understanding of how the grass-root level works in terms of education,”

While some Preraks were able to set down boundaries regarding their scope of work in their interactions with the district level officials, a majority of them reported a lack of clarity among the district officials (particularly the DM/DPO) regarding the Preraks’ roles and responsibilities. A Prerak in Uttar Pradesh recounted how, due to this lack of clarity, it was assumed by the district officials that he would make data entries:

“R: (…) Every district official in every department thinks that a Prerak is supposed to feed the data. But a Prerak is not supposed to do that.

I: Can you talk about that (a bit more)?

R: There was a video conference conducted before POSHAN Maah began, in which it was wrongly mentioned that the Prerak will do the data entry and he will involve the other departments as well to do the data entry. But the Prerak is not supposed to do data entry. This happened, and (since) in my district I have built rapport, I spoke to people, did the data entry for a couple of days...and I got it done from (others).”

Many district officials reported that apart from the Government Order (GO) that the Preraks brought with them by way of introduction, they had not received any prior intimation about why the Prerak was sent to the district. While a few DPOs recalled being contacted by the State Leads to inform

(iv) Behaviour Change— Preraks must select themes for Jan Andolan activities; define goals; shortlist activities and platforms (focusing on social media; influencers, community groups and community media); identify advocacy and IEC materials to be used; set monthly and quarterly timelines; and execute the activities as per the action plan.


them of the arrival of the Prerak, most district officials learnt about the Prerak’s role from the Preraks themselves. One Prerak in Maharashtra recounted how she made efforts to acquaint the district level administration with her role:

“To be honest, the first thing I did was that: I told them what my post is, I showed them the entire job chart, made a concept note for myself and stuck it around; I gave my contact card to everybody. But it just slips their mind.”

In interviews with the TINI core team, the initial vision of the Programme was reported to be that of the Preraks being deputed to the MoWCD (with TINI having no control or jurisdiction over them), and from there they would be appointed to the districts. However, as some POs confirmed, this led to the state and district administration viewing the Preraks not as catalysts for the district, but as a part of the traditional government machinery.

None of the district and sub-district officials interviewed—especially the field functionaries—were aware of the SBP’s exact scope of work and responsibilities. They also reported that they were unaware of what the program planners/developers had in mind while envisaging the position of the Prerak, and hence could not say with certainty whether or not that vision was indeed being translated on the ground. As one Prerak in Tamil Nadu stated, the initial perception in his district was that Prerak was a flexible entity that could cut across bureaucratic procedures and government hierarchy. Due to this, the functionaries perceived him as someone who could provide immediate solutions to problems, which helped them achieve their targets. Line departments also perceived the Prerak as a ‘shortcut’ to fulfil the convergence component of POSHAN Abhiyaan.

3.3. AREAS OF INTEREST DELINEATED BY PRERAKS IN THEIR DISTRICTS

Apart from the themes and components outlined by TINI, some Preraks also observed the needs and challenges faced by their districts and wished to focus on certain aspects to tackle these challenges. Some of these aspects fell within prescribed components of the SBP Programme deliverables, such as strengthening AWCs at the ground level, or helping convergence between the Health Department and the ICDS:

R: ...one aspect that I found very fascinating was that we would have the ability to get different stakeholders on the table—at least health and ICDS—and talk about this issue about nutrition or malnutrition. So this was something I was also interested in.

A Prerak in Tamil Nadu focused on procuring CSR funds for improving AWCs in their districts; he also decided to use the community radio in his district to collaborate with AWWs who would talk about different recipes that could be cooked with the help of the THR being supplied in the AWCs. A Prerak in Telangana reported that since anemia rates were high in his district, he planned to undertake a survey that would help him estimate what intervention could be introduced to the district to combat this issue. As one DPO in Uttarakhand reported, the Prerak in her district not only contributed to POSHAN Abhiyaan in the district, but was also involved in schemes that improved girls’ education (Beti Bachao Beti Padhao) and helped workers in the unorganised sector (the Pradhan Mantri Shram Yogi Maandhan Yojana). A Prerak in Madhya Pradesh shared that she was involved in catalysing and planning the implementation of many schemes operated by the MoWCD in her district:


“Now my hands are in almost all the schemes which are written by WCD like Beti Bachao Beti Padhao, Udita Yojana (menstrual hygiene scheme). Now these guys see me as an instructor, a motivator and a planner—and obviously the designing part is already there...”

Thus, while many Preraks found their areas of interest within the themes delineated in the POSHAN Abhiyaan guidelines, some Preraks also took into account the needs of their districts and focused on providing inputs to tackle the same.

3.4. INTERPRETATIONS AND SUGGESTIONS

Based on the responses from the Preraks and the district officials that they most closely work with, it was apparent that there was an obvious lack of clarity among the district administration with regard to the roles and responsibilities of the Prerak. This lack of clarity led to some Preraks being confused about their role in the district, as well as a perception among the district officials that in the absence of clear guidelines, the Preraks could be used for tasks not related to POSHAN as well. It is necessary for both the Preraks and the district officials to be on the same page about the guidelines. Our study found several instances where the mismatch in understanding of the Prerak’s responsibilities between the Prerak and district officials led to friction between the two parties.

The flexibility and room for manoeuvring that was built into the Preraks’ guidelines was a feature of the Programme that was deliberately designed in order for the Preraks to be able to act as catalysts in the district. However, this flexibility manifested as confusion or uncertainty in several instances and resulted, in some cases, in the Preraks not being able to fulfil their envisaged role of a catalyst in the district ecosystem to the fullest extent. Furthermore, the work plan and the

monitoring mechanism used with the Preraks did not take into account this flexibility either. This would be an aspect of the Programme that needs to be considered in greater depth, and the report addresses this in greater detail in the chapters that follow.

Observing all the responses we gathered, we interpret that the Preraks could have done much more if they were enabled appropriately to act as catalysts and as capacity builders. Despite the lack of such ideal conditions however, both qualitative and quantitative results suggested that most Preraks have been able to put in efforts in good faith and work for nutrition in their districts in some capacity or the other. In districts where Preraks’ efforts were diverted, many attempted to negotiate with the functionaries in their district to be able to direct at least part of their efforts towards the POSHAN Abhiyaan. Districts used their Preraks in areas where they felt the most need for the latter’s help and critical inputs. Thus most Preraks did leave a mark on the districts that they were deputed to. In districts where the POSHAN Abhiyaan was not a priority, some Preraks attempted to convince the district officials to bring their focus onto the Abhiyaan, as well.

Developing and sharing of detailed information about the scope of work of the Preraks would help to minimize the expectation-reality gaps that we observed. The flexibility in their roles and responsibilities needs to be clearly worded, not just in terms of the content area where Preraks are expected to contribute but also in the nature of their contribution. For instance, guidelines could clarify that Preraks are expected to help with planning, prioritizing the tasks for the frontline workers to focus on, organizing district-level meetings, monitoring, supervision, and so on. The guidelines could also spell out that Preraks are expected to work closely with district-level officials and not to get involved in the day-to-day implementation of POSHAN activities at the sub-


district levels. Also, regular correspondence from the State as well as TINI regarding the role of the Prerak would help improve the situation.

The roles and responsibilities of the Prerak also need to take into account the changing nature of the POSHAN Abhiyaan itself. For instance, operationalising smart phones for ICDS-CAS rollout was a one-time process, which has been carried out in many States successfully. To avoid the Preraks being co-opted for tasks related to ICDS-CAS but not within their ambit (for example, data entry), the idea that Preraks are responsible for “ICDS-CAS rollout” must also then be revised periodically and changed to suit the stage of the POSHAN Abhiyaan in the district at that time.

We recommend that a more central, formalized missive, detailing the scope of work in specific terms (content area and nature of responsibilities) be shared with the district administration. This can be accompanied by detailed structured guidelines for the Preraks that can be shared with

the officials for increased clarity. Given the hectic nature of program implementation, we strongly recommend that an initial meeting of the newly-appointed Prerak, at the start of their tenure, be held with the DM/DC, DPO, the state POSHAN coordinator, and the State Lead. The purpose of the meeting would be to discuss, negotiate, and decide upon clearly delineated responsibilities of the Prerak in that specific district, based on the district’s requirements at that point in time. These mutually agreed-on responsibilities of the Preraks could be set for a three-month period, with another meeting held after three months to revise the list as necessary. Such an arrangement would also build-in a structure of regular conversations between the district officers and the State Leads, thus helping both the partners (WCD and TINI) to be aware of the other’s priorities at the district-level. The implications of such a flexible, adaptable system in working with the structured government machinery are discussed further in the following sections.


044.1. PRERAKS’ ROLE IN ROLLING

OUT POSHAN ABHIYAAN4.1.1. SBP Deliverables, POSHAN-related

Tasks and Peripheral Work Done by Preraks

Our survey findings revealed that as mentioned in the guidelines, the Preraks spent a considerable time in activities related to Poshan Abhiyaan (Fig. 4.1).

WORKING IN THE DISTRICT

Preraks were often cited as the key contact for functionaries involved in the POSHAN Abhiyaan: they have the skills required for coordination, troubleshooting, monitoring and motivation among the district officials as well as the field functionaries. Eighty-six percent of the Preraks surveyed reported spending most of their time on some or all of the POSHAN Abhiyaan components;

FIGURE 4.1: List of activities on which least and most time was spent by the Preraks in their districts.

Working on some or all of POSHAN Abhiyaan components (SRGs/DRGs/BRGs training/

supervision/planning, dashboard monitoring etc)Admin/liaising work at district headquarters,

(feedback and follow-ups for POSHAN)

Working with other departments for convergence (CAP etc)

Working on TINI deliverables (AWC adoption etc)

Data entry related to POSHAN

NRC referrals

Working on innovation proposals

Informal training/mentoring of field workers

Making field visits to AWCs/blocks

Critical analysis of the AWC conditions (monitoring attendance/infrastructure/etc)

Working on tasks unrelated to your Job Description (JD) (making PPT presentations,

typing up letters, getting things signed)

Data entry unrelated to JD

Other unproductive tasks

POSHAN-related tasks and TINI

deliverables

Fieldwork and Work with Functionaries

Non-POSHAN related/peripheral

tasks

Percentage of Preraks reported (Most time spent)Activity


around 77% reported liaisoning at the district headquarters for feedback and follow-ups about POSHAN activities (Fig. 4.1). This was further aided by the fact that the Preraks worked with the administrative staff while also visiting the field, which strengthened their rapport across the board: as shown in Fig. 4.2, an overwhelming majority of Preraks reported high levels of interaction with the CDPOs and/or Supervisors (~96%) and DPOs (~93%) and in their district. Most Preraks stated that they made field visits to AWCs in order to understand ground level needs (~79%, as seen in Fig. 4.1); helped in planning and executing Jan Andolan activities; assisted convergence at the district level by assisting in creating D-CAPs and monitoring the implementation of the same. In states like Telangana, Preraks shared that they did not work on grievance redressal and incentivisation since those components were handled by other development partners in the district (such as the Aga Khan Foundation).

The following table (Fig. 4.2) illustrates the frequency and level of interaction of Preraks with the officials/functionaries in their districts:

ICDS-CASIn districts where Preraks had joined in the initial stages of the ICDS-CAS rollout, they reportedly aided in procurement and operationalising smartphones, registering the devices, and loading the software onto the devices for the AWWs. Some Preraks also shared that they had helped in establishing the CAS Help Desks at the block level, and were involved in troubleshooting and redressal of queries along with the DCs/DPAs/BCs in their districts. Some Preraks also reported to have trained AWWs in how to operate CAS. In the quantitative survey, round 65% of Preraks also reported making data entries related to POSHAN—of which CAS data is an important part.

Capacity BuildingPreraks also reported to assist in capacity building, mainly with regard to the ILA module delivery process, where AWWs are trained in 21 ILA modules at regular intervals, regarding issues such as growth monitoring and breastfeeding techniques.. Most Preraks shared that they were a part of the SRG, where they were trained and

FIGURE 4.2: Frequency and level of interaction of Preraks with officials and functionaries in the district

Percentage of Preraks reported (Most time spent)Activity

CDPO/Supervisor

DPO/PD

AWW/AWH

Official from other departments (convergence)

Beneficiaries

Other Development partners

ADPO/AD/APO

DM/DC

CEO/ZP


subsequently became master trainers for DRGs in their districts. They reportedly trained the DRG, and also monitored the BRGs at the block level/sector level trainings. A Prerak in Himachal Pradesh outlined the ways in which he contributed to capacity building for POSHAN Abhiyaan in his district:

“I am a member of the SRG and also the DRG. We went to Shimla, the headquarters where these trainings happen regularly...My role is not confined to DRGs; I also attend BRG trainings to see if the members I have trained in DRG are capable of delivering modules in BRGs or not. And sometimes, I visit the sectoral trainings as well, in which the Supervisors train the AWWs. Directly I don’t get involved in the training there, but I add some aspects that I think are missing...”

Some Preraks also reported helping in other capacity building trainings such as ORS week, breastfeeding week, and domestic violence awareness week. In the quantitative survey, 80% Preraks reported informally training and mentoring field functionaries, while around 85% reported high levels of interaction with AWWs and AWHs in their districts.

Jan Andolan ActivitiesDuring in-depth interviews, Preraks reportedly undertook planning, logistics, execution, and monitoring of Jan Andolan activities such as prabhat pheris, cycle rallies, POSHAN rallies, home visits, Anna Prashan Divas, VHSND, anaemia camps and community god bharai. This was corroborated by Preraks’ self-reporting in the quantitative survey (Fig. 4.3); while about 56% of the Preraks reported to participate in around four to ten of these events in a month, about 33% reported being able to attend only around zero to three events. As seen in the table below, VHSNDs, anemia camps, home visits, POSHAN melas/rallies/walks, and school-based activities were

the most conducted community-based events in several districts. A majority of the Preraks reported playing crucial role in initiating/coordinating and managing/supervising these events.

Preraks also reported being highly involved in initiating and coordinating various Jan Andolan activities; management and supervisions of the said activities; identifying and resolving challenges; and generating community awareness (Fig. 4.4).

A few Preraks shared that focusing on ‘doable and feasible’ actions as part of their tasks brought effectiveness to the SBP Programme. A DPO also in Madhya Pradesh concurred with this finding. In many districts, the Preraks engaged themselves in several of the POSHAN programs/activities, but most of the programs reportedly remained unattended by beneficiaries and functionaries alike. On the other hand, in districts where the Preraks narrowed down their focus areas to particular issues, e.g. SAM-related work (~35% of the surveyed Preraks reported focusing on NRC referrals), noticeable improvement was reportedly observed in the effectiveness of the outreach. One way that some Preraks tried to tackle such an issue was by combining (or ‘piggybacking’) their plans and ideas with programs and events that were already funded/planned by the district administration: for example, if there was a three-day training taking place which had been funded by the State, the Prerak requested the organizers to let her have half a day of this training where she could conduct sessions that she has planned for the functionaries (Supervisors/AWWs) in attendance. This helped the Preraks fulfil some of their own deliverables during the course of their fellowship.

Innovation ProposalsSeveral Preraks (around to 53% of the surveyed respondents, Fig 1) also reported designing and submitting innovation proposals to the State administration to obtain innovation funds for their


FIGURE 4.3: Jan Andolan or CBEs that Preraks participated in their districts.

FIGURE 4.4: Ranking of level of involvement in various aspects of Jan Andolan.

Perc

enta

ge o

f Pre

raks

repo

rted

Initiate/coordinate Manage/supervise existing activities

Identify challenges and resolve

Generate community awareness

least somewhat less somewhat more most

Activity

Community-based events

Home visits

VHSN day

POSHAN rally

POSHAN melas

Anaemia camp, area level federation

School-based activities

POSHAN walks

Cycle rally

POSHAN workshop/seminar

Prabhat pheri

Local leader meetings

Ensuring safe drinking water in Anganwadi centres

Nukkad natak/folk shows

Panchayat meetings

Self-help groups (SHG) meetings

Haat bazaar activities

Youth group meetings

Cooperative/federation meetings to address nutrition

Farmer club meeting

Providing water for toilets

Community radio activities

Harvest festivals

Percentage of Preraks reportedJan Andolan activities


districts1. In certain states, multiple development partners resulted in inadequate support from the State for the SBP Programme. In other states, Preraks were directed by the State to work on certain components (like grievance redressal), and innovation proposals submitted by Preraks were overlooked in favour of proposals submitted by other development partners. This reportedly affected the Preraks’ ability to introduce innovation in such districts.

ConvergenceThe Prerak was also perceived as a key point of contact for convergence among line departments since they were not usually hindered by bureaucratic considerations and inter-departmental equations as compared to government officials within the traditional bureaucracy. They were able to take the initiative and establish contact across relevant departments like Health, Education and Social Welfare; nearly 68% of the surveyed Preraks reported working closely with officials from such line departments to facilitate convergence (Fig 4.1). A DPO in Uttar Pradesh echoed this in his response by giving an example of how the Prerak in his district had helped convergence:

The main convergence that needs to happen, does happen at all the levels—district, block and the ground level. The Prerak (attends) convergence nutrition meetings that happen every month. (...) Say there are no medicines for the VHSND at the ground level: she takes care of that. It means that the issue is being noticed, the important things are being brought to your notice. When you have some non-departmental person looking after and going to these sessions—a department person would maybe ignore such things since they are working for a long time and might take them for granted. Since the Prerak gives an

outside perspective in the entire scheme, she knows that the medicines have to be there or if a medicine needs to be given to a pregnant lady, only 50 or 60 tablets are to be given. She brings that to light.”

A few Preraks also collaborated with Divisional Coordinators for other schemes and/or development partners to launch programs and schemes like VHSNDs, facilitating the process of identifying SAM children and visiting NRCs, and working closely with Gram Pradhans and CMOs on programs like the Village Social Transformation Fellowship (VSTF). A Prerak in Maharashtra shared how she worked with a coordinator for the Rajmata Jijau Mother-Child Health & Nutrition Mission:

“...There was this Aakaar (ECCE) training that was already going on, so what I thought was: let me also have a leadership workshop. I called the Divisional Coordinator and told her that let’s conduct a workshop together. So the thing was already in place, I didn’t have to get the supervisors especially for my training; I didn’t have to book a hall or have separate funds for it. It was just that theirs is a three-day training; just give us half a day where we will conduct our training.”

In other states like Rajasthan and Uttar Pradesh, development partners shared that they had a good working relationship with the Preraks. For instance, in one district of Uttar Pradesh, the convergence meetings were being conducted smoothly because of the active participation of the development partners and the coordination among the development partners, the Preraks and the district officials of all line departments. Moreover, organizing events especially during the ‘POSHAN Maah’ was reported to be seamless by a few Preraks due to the help they received from other development partners.

1 A detailed discussion is presented in the section (b) iv. of this chapter: innovations and best practices introduced by Preraks.


Our quantitative findings highlighted the Preraks’ contribution in convergence with several departments, especially with the Health and Education departments (see Fig 4.5.):

Many Preraks (around 48%, as seen in Fig. 4.5) also reported strong relationships with members of other development partners in the districts, such as the TSU and Piramal Foundation with whom they collaborated very often to strengthen POSHAN Abhiyaan. This collaborations and convergence mostly happen because of the ease of mobility that the SBP has. According to a Prerak in Tamil Nadu:

“...I’m taking up the full liaising part of ICDS with other departments, even POSHAN Abhiyaan...with Education, with Health and Family Welfare, with the DRDA. (I’m) speaking to some doctors, arranging some awareness campaigns. If some other departments also need help, they will directly call me, for example, District Medical Health (Officer) will probably need some data (for which) she will call me. They don’t consider me as POSHAN Abhiyaan staff; for them I’m just a staff member from the ICDS department...So most of the departments directly contact me for getting any work from the ICDS department. I will guide them.”

FIGURE 4.5: Department-wise contribution to convergence by Prerak

Health

Education

PRI

Water and Sanitation

Social WelfareNon-government

development partners

RLP (SHGs)

Road and Building

Percentage of Preraks reportedDepartment

A majority of the Preraks (~88%) believed that they made significant contributions to strengthening of convergence in their districts (Fig. 4.6).

FIGURE 4.6: Preraks’ responses when asked if they believed they had made significant contributions to strengthening convergence (N=243).

Yes No

11.9%

88.1%

Preraks shared that they regularly monitored dashboards and/or Google Sheets and provided data analysis to the district administration officials like the DPO/DEO and other line departments that they worked closely with. This was reported by many district administration officials as one of the biggest positive changes that the SBP program has infused into the ICDS machinery. As a Prerak in Uttarakhand recounted:

“When I found when there was no such (convergence) meeting that was being held, I went to my DM and said, “Sir, according to the guidelines all this was supposed to be done in our district and hasn’t been done till now.” He said, “Okay, go ahead, you make a plan and we’ll have a meeting.”... I moderated the meeting, I explained them why convergence is important etc. and then the DM also pitched in for a couple of minutes...that meeting was very helpful because that was the first time I met all the other officers in the district and they also got to know that there is some Swasth Bharat Prerak in the district...”


The following table (Fig. 4.7) illustrates the strengthening of specific components of convergence after the Preraks joined the district as reported by the Preraks:

as data entry, making PowerPoint presentations for the department, and typing up official letters: this resulted in them being unable to work on the deliverables of the SBP Programme. Thirty-seven percent of the surveyed Preraks reported having to make data entries that were unrelated to their job description, while 33% reported spending time doing other unproductive tasks (Fig. 4.1). For example, a Prerak in Tamil Nadu shared that he arranged food, venue, permissions, and other logistics of DRG and BRG trainings as this was expected from him in the department; he also conducted these training exercises. This Prerak was reportedly in charge of the department’s overall documentation, planning, and field visits to AWCs as well. He further discussed why doing such clerical work helped him fulfil his role as Prerak in the district:

“In my view, in a government sector, if you want to really contribute something to this particular scheme, you can’t be restricted to just one work component. It’s the clerical part (too)... because people know that you can do it in a better manner than what you are contributing to it. Most of the people are from National Institutes, so they can do it properly. So they asked me to make some presentations, do documentation, make a file, and follow up with the files. But I never restricted myself because if I’m not doing it, no one will do the work for me. My job is to get it finished as soon as possible, only then I can move on to the next task. So, in a government setup...you can’t ask some other person. In most of the cases you have to do it, the Preraks have to do it. The clerical job is part of the job for me...”

Another Prerak in Rajasthan highlighted instances where he had been required to put in extra hours to accommodate tasks that were related to POSHAN Abhiyaan but not in his ambit as a Prerak; this he attributed to a certain ‘office culture’ where people are expected to work on tasks other than their own job descriptions:

Percentage of Preraks reportedActivity

FIGURE 4.7: Components of convergence in district that were strengthened through Preraks’ contribution, self-reported.

Better planning of CAP

Better monitoring of CAP

Better AAA convergence

Better execution of CAP

More local innovations taken up by

departments together

Databases of different depts show more

sync/overlap

Tasks not related to POSHANIt was observed as well as reported that there was often an excessive reliance upon the Preraks for the daily functioning of the ICDS. More than half the Preraks surveyed (~52%) reported spending time on tasks unrelated to their job description as Preraks. A CDO in Uttar Pradesh believed that this excessive reliance was natural, due to Preraks’ competencies:

Since the Prerak is competent the department starts to rely on her. The reliance gets built over time. (...) That is purely because the person is competent and qualified; it happens everywhere. Even if there is someone competent in your own department, you tend to rely on them more as compared to other people.

Many of the interviewed Preraks echoed this sentiment, sharing that they were given work such


“When we work in an office, I’m bound to POSHAN Abhiyaan, but sometimes I have to do someone else’s work. Call it office culture or whatever; I’ve said no and yet sometimes I have stayed back in the office and worked till midnight. It was POSHAN Abhiyaan related work only, but the office timings are still 10 AM to 6 PM only.”

This could partly be due to the reported nationwide staff shortage in the ICDS program: as one district official shared, “(Preraks) are the helping hand in a handicapped system”. On the other hand, the Preraks’ technical competency and comfort with digital administration made them the favoured candidates for such tasks over the government officials who are employed to do such work. Our quantitative findings revealed that only around 35% of Preraks reportedly resisted when their reporting officers instructed them to carry out tasks outside the scope of their role as Preraks (Fig. 4.8).

work was reported to be majorly focused on the implementation of different components of POSHAN Abhiyaan. This aligns, for the most part, with the vision for the SBP Programme. Based on the responses gathered from Preraks and other district officials, a possible factor that led to some diversion of Preraks’ efforts was the lack of clarity that the district officials—and in some cases, the Preraks themselves—had regarding the Preraks’ role at the district level. District officials interviewed reported limited awareness about the goals and vision of the SBP Programme: there seemed to be some uncertainty regarding whether Preraks were at the disposal of the district administration with their reporting officers enjoying complete administrative control over them, or they were to be the ‘eyes and ears’ of the MoWCD at the district level. The latter seemed to be the perception in several cases—gleaned either through direct or indirect responses—which likely discouraged the district officials and field functionaries to cooperate with the Programme completely. Most Preraks reported that it took them several months to establish a relationship of mutual trust with their district-level reporting officers. It was no doubt to be expected, since a majority of district officers likely did not have a clear idea of Prerak’s role as well as the reporting structure.

It is possible that once the district officers realized the reporting structure (the program structure needed them to sign and authorize the Prerak’s work log and payroll), it gave them more clarity and increased their comfort in working with the Prerak. A TINI core team member shared: “once the district officials realised that they have to sign and authorize the Preraks work log and payroll on a monthly basis, they could begin using the Preraks accordingly to their own priority.” Moreover, many Preraks found creative ways to work on improving the nutritional status of the residents of their districts, thus indirectly contributing to the larger goal of the POSHAN Abhiyaan even if they were not able to directly act as a catalyst in the

FIGURE 4.8: Preraks’ responses on being asked if they do tasks outside their job description if asked by their reporting officers (N=244).

Not at all

Always

Sometimes

Most of the time

0.41%

8.61%

34.84%56.15%

Based on these findings, we conclude that despite the absence of clear guidelines for Preraks’ responsibilities at district level, their


implementation of the Abhiyaan activities. Hence, we may conclude that most Preraks were able to contribute to at least some, if not all POSHAN components in some capacity in their districts. In most instances, the district administration found some use for the Preraks that helped ease the most pertinent and pressing problems of the district—even if these were at times not wholly within the ambit of the POSHAN Abhiyaan. In the absence of clear and uniform rules and responsibilities delineated for the Preraks however, the extent to which these efforts could coalesce into a larger, more measurable contribution to the implementation of the POSHAN Abhiyaan across several districts of the country was limited.

4.1.2. Reliance of District Administration on the Preraks

The Preraks’ biggest contribution at the district level seemed to be the data-driven monitoring, follow-ups, and the feedback that they provided to the district officials and field functionaries, as reported in states such as Maharashtra and Bihar. A Prerak in Himachal Pradesh also echoed this response, describing how data driven monitoring was positively impacted by the coming of the Preraks:

“In meetings we usually didn’t have those (visual) presentations; there was a long list of data that was to be forwarded to the DC and then things were discussed one by one. But when we came in, we represented the data in the best way through which all the district officers would, understand: like, in terms of pie charts or in terms of bar graphs. And by just looking at that data, the DC could identify where the gap is, or which department is actually not performing. For example, if toilets are not being constructed and I showed them that this was the progress (in the net convergence meeting): that made a difference there. Lots of decisions were taken after that. So decision making became, you know, a bit better.”

Preraks were also perceived as reliable, trustworthy sources of information and updates by many district officials, as a Prerak in Uttarakhand revealed:

“Preraks are a credible source of instruction and coordination for instructions from the State (of Uttarakhand). See, at district level what earlier used to happen was, there was confusion as to what plan of action was, what needs to be done, how it needs to be done: no one was clear about anything. But since the Preraks (have arrived), it has transformed them into being a reliable source of information. So the district officials are pretty much convinced that Prerak is the one who can be contacted in case of any reporting, any information, any update on the POSHAN Abhiyaan. So that is one thing which I feel is very good.”

Some POs believed that the Programme’s initial vision of the Preraks being deputed to the MoWCD, with TINI having no control or jurisdiction over them had led to the State and district administration viewing the Preraks not as catalysts for the district, but as a part of the traditional government machinery.

4.2. PRERAKS’ UNIQUE CONTRIBUTION TO THE DISTRICTS

4.2.1. Inputs for General Issues and Challenges Identified

As mentioned previously, data-driven monitoring of the district’s indicators carried out by the Prerak was considered to be one of the biggest positive impacts of the Preraks by the district administration. They also appreciated other positive impacts of the Preraks’ presence in the district, such as the clarity provided by the Preraks regarding the workings of the ICDS system; needs assessment; identifying weak links in the district machinery; crafting innovative solutions for such


problems; and putting forward insights to bring change in the current system.

Many Preraks reportedly devoted their initial period in their district acquainting themselves with data about their district: assimilating information such as details of functionaries, AWCs, statistics around nutrition etc. Some Preraks also claimed to have visited the field to review POSHAN activities and ECCE during this time. This led to an improvement in the Preraks’ understanding of the district, and aided them in tailoring their contribution to suit its needs. A few Preraks, in states such as Telangana, conducted surveys among the beneficiaries to understand how AWWs were perceived in the community. In one district, a Prerak attempted to use her educational background in Pharmacy to research case studies that could help reduce anemia levels in her district.

In the quantitative survey, Preraks reported considerable improvement in fund utilisation, interdepartmental convergence (at block and the district level), development of innovation proposals, and behaviour change communication in their districts (Fig 4.9):

to be easily transferrable to the requirements in those schemes and programs. According to the Preraks, doing these non-POSHAN related tasks was important in the initial stages of their tenure to build rapport with the district administration. A Prerak in Madhya Pradesh highlighted how her efforts were diverted towards election duty and ISSNIP in the initial period of her tenure due to the administration’s perception of her as merely a technical resource person:

“For 2-3 months I didn’t get the chance to work on POSHAN; I was totally occupied with election work. There was a disconnect there because these guys saw us as technical people. And as a technical person, I was making PPTs, making IEC material for ISSNIP...So I was developing the promotional material for ISSNIP, not POSHAN Abhiyaan for approximately 2-3 months.”

The same respondent further shared that she felt compelled to acquiesce to such requests to build rapport with the DPO:

“My DPO was the Nodal Officer for ISSNIP; her whole inclination was to work on ISSNIP. She even had her whole team working on that. So the whole team was working on ISSNIP and if I was the only person who wasn’t, I would have been isolated for that. So (complying) was the necessity of the hour.”

Another Prerak in Uttarakhand highlighted the unavoidable subtle pressures of having to do non-POSHAN tasks when directed by senior officials like the DM:

“I: You mentioned (your tasks pertaining to BBBP) to be unavoidable work?

R: Yes, sometimes it is. It’s not like a trap exactly, but when you get the support from the DM or the CDO, they both are IAS officers and when they ask you to prepare a document or a report or a proposal for the BBBP event, you can’t say no to them.”

Percentage of Preraks reported(Most improvement

Areas in which improvements

perceived

Behaviour change communication

Interdepartmental convergence

Innovation proposal developed by Preraks

Fund utilization

FIGURE 4.9: Areas in which improvement was perceived by Preraks during their tenure in their districts.

Some Preraks were also utilised by district administration for other government programs like BBBP, since their skillsets were perceived


4.2.2. Inputs for POSHAN-specific Issues and Challenges Identified

In the view of district officials, Preraks were believed to have the eye of an outsider; hence they monitored activities and reports with greater detail and were, in some instances, approached by senior-level district officials for critical inputs regarding the implementation of POSHAN Abhiyaan. The Preraks’ technical skills, balanced involvement with administrative as well as field functions, convergence-related activities (such as taking constant follow-ups to ensure a smooth workflow), training skills, monitoring through field visits, and good inter-personal skills reportedly had a positive impact on the implementation process. A DM in Uttar Pradesh acknowledged how the Prerak’s ground-level reviews of the AWCs were helpful and taken into consideration by the district administration:

“There was no emphasis on education, no emphasis on training of parents, how to rear children – for parents or pregnant mothers, how to build family planning programmes into it. There has been a tremendous change (after the coming of the Prerak) which has been brought about because there has been a continuous review by her; it’s also because they have been given access to the district officials and get their point across.”

A Supervisor confirmed this by sharing the specific ways in which the Prerak took follow ups with beneficiaries:

“She checks the register for the number of children (registered), who are in red and yellow grades, why the adolescent girls are not coming to the AWCs etc. She tries to ensure that everyone comes; she questions them if they don’t come to the AWCs.”

Further, the Supervisor also shared that the Prerak followed up with individual AWWs to ensure that the turnout for trainings improved:

“Some AWWs don’t answer phones at all. So the Prerak informed them in meetings that if you don’t answer calls or come to the training, the loss is yours because training doesn’t happen repeatedly. It happens on certain dates and you’re supposed to attend all sessions. At the moment, those who don’t make it to training are called on the next day to attend the same session, but the Prerak tries to get it done in one day. Initially the percentage of AWWs who showed up was less than 60, now it’s slowly increasing, but it’s still not 100%.”

In Tamil Nadu, a Prerak helped bridging the gap in data collected by AWWs, ASHAs and ANMs (AAA) and tracked the pregnancies and census data for the district to recover missing information; this helped in streamlining convergence between the Health and ICDS departments. The Prerak also successfully obtained CSR funding for the refurbishment of 25 AWCs in the district.

A Prerak in Telangana attempted to address data inconsistencies in the Dashboard entries with the help of digital software. The Prerak also reported that through her contribution, data collection and monitoring became more streamlined and research-oriented in the State:

“...We had a meeting with the Collector where we discussed the quality of data which is gathered on ICDS-CAS, and that led to pre-verification as to how off (the mark) the data was. So we went about collecting sample data from all the projects in the district: there was a more streamlined, research-oriented way of going about things.”

In Himachal Pradesh, a Prerak reportedly trained Sarpanchs and AWWs in monitoring certain components of the Abhiyaan as well, like THR distribution:

“In January/February (2020) we did a very good exercise with the Panchayati Raj Department; the


Panchs and the Sarpanch were newly elected members then. We organized their training on the request of the District Panchayat Officer. I think those people are very important for this program...we can’t be visiting every AWC; we will go to the field for 2 days in a week and visit 3-4 AWCs. In that training, I made them aware of how they can improve this program significantly by monitoring it as well...if we are providing THR on the 1st of every month, the Panch and Sarpanch should be there to see that all the beneficiaries enrolled in the AWC are getting that ration. ...We have told them that if you see anything wrong happening, you can inform the DPO or the CDPO.”

Another Prerak shared that training in her district had improved significantly since her arrival, benefitting from her background in medicine:

“My DPO has told me that after my joining the district, the training component has improved significantly because I am also the person who is from a medical background. I can elaborate on things for the supervisors and the AWWs more efficiently, in a detailed manner.”

In Assam, a Prerak aimed to tackle the problem of undernutrition by setting up identification camps to identify malnourished children; the Prerak also conducted several activities during the POSHAN Maah and other similar programs in collaboration with the Health Department and Social Welfare Department.

It is of note that whether or not a district prioritised POSHAN was also dependent on the funds that it received from the State for the respective schemes; as a Prerak in Uttarakhand highlighted, this resulted in schemes such as the BBBP being prioritised over POSHAN Abhiyaan:

“I: Okay, so do you think your DM is prioritising the POSHAN Abhiyaan as well?

R: Not exactly, they are not prioritising. I think the issue is with the funds: the district works according to the funds given to it, and we have more funds in BBBP. The pressure upon the district administration to utilise that fund in one financial year is more for this scheme than the POSHAN Abhiyaan, therefore, they focus more on BBBP.”

Many Preraks shared their own way of gauging the effectiveness of the SBP Programme. In most cases, it did not matter how major their contributions were: in the Prerak’s eyes, each of them mattered equally. From improvement in attendance of beneficiaries (at CBEs); to reduction in number of SAM children; to strengthening convergence and conducting training sessions: every effort they made was perceived as an impact of the Programme.

4.2.3. Preraks as Motivators and Catalysts in their Districts

Preraks reported providing the ICDS machinery with updates about the progress of the POSHAN Abhiyaan; following up on targets and goals; helping solve emergent problems; and streamlining the overall implementation process for POSHAN by catalyzing the WCD/ICDS Department. A Prerak in Uttarakhand summarised her pivotal role in catalysing the entire POSHAN Abhiyaan in her district as follows:

“I think I have given a lot to my district in terms of innovation and initiatives. This is not just my introspection or my understanding, but has been said by various officers from other departments—‘before you came, we didn’t have so many events in the district. We never knew that there is a scheme called POSHAN Abhiyaan, and that we get so much funding for it’. That’s when I got to know that there was nothing in the district before I came to start the POSHAN Abhiyaan activities.”


SELECT CONTRIBUTIONS OF THE SBP IN IMPROVING THE NUTRITIONAL STATUS OF THE RESIDENTS IN THEIR DISTRICTS

Planning and strategy:

n Planning and designing training sessions for AWWs on how to correctly weigh children for growth monitoring.

n Making timetables tailored specifically for the district to be followed during the POSHAN Pakhwada activities.

Monitoring:

n Monitoring dashboards for POSHAN Abhiyaan and followed up with lagging districts.

n Strengthening referral services in a few districts with their active engagement in monitoring and counselling SAM children.

Convergence:

n Collaborating with Health Department officials for implementation of POSHAN activities under the CAP report: liaisoning, planning, and execution at district level.

Training and Capacity Building:

n Conducting sessions at AWCs teaching hand-wash techniques to children.

Participation in CBEs:

n Active participation in POSHAN Melas during POSHAN Maah through several campaigns on nutrition.

ICDS-CAS Rollout:

n Working with supervisors and AWWs to digital reporting is done properly on CAS, thus reducing misreporting/underreporting of nutrition levels in the district.

In several of the districts selected, the intangible aspect of motivation and acknowledgement of the functionaries’ efforts was an important aspect of the Preraks’ contribution to the district ecosystem. According to Supervisors in one of the sampled districts:

“We all have been working hard but never got any appreciation, which demotivated us. If you

are not appreciated for your good work then it makes no sense to work hard…but after the Prerak (joined), the atmosphere has changed…they have brought a new energy into the system.”

A Prerak in Madhya Pradesh also shared her efforts to motivate and catalyse the beneficiaries registered at her adopted AWCs, despite her own meagre resources:


“(In my adopted AWCs) I majorly focus on counselling the parents, visiting the families, meeting them. Letting them know that there are people listening to them. I can’t really help them financially; I somehow take a chocolate or two, or probably some chikki or some bananas. Sometimes, not always. I can’t help them financially, like giving them money, so I try to make them feel that there is someone listening to you. To let them know that they are not alone, that their child is not left out. The world is not that cruel to them. I know it’s not part of my job to do it but I guess this part, where you let people know that you are going to be there for them, gives them some motivation.”

In Madhya Pradesh, another Prerak recounted how she involved officials from the Health department to conduct medical camps to identify—and in some cases even expedite treatment of—SAM/MAM children in her district, where the population tended to ignore undernutrition due to lack of financial resources:

“I was actually working with the CMHO and I conducted medical camps also, several times, where children and mothers could get their iron level tests, haemoglobin tests and children could be tested for whether they have any requirement for medical attention. One such case was where we just sent the child to AIIMS Bhopal...we convinced his parents. His parents were saying ‘everything is okay, he will be fine’. People don’t care about (malnutrition) because they have a lot of other things to worry about: there is no money, no food.”

In other districts, due to the Prerak’s intervention the DPO/DM/CEO also showed greater engagement with the POSHAN Abhiyaan and the field functionaries. This has led to the functionaries believing that they are seen by their higher-ups: this was cited as a huge boost to their motivation.

Many ground level functionaries (AWWs and supervisors) felt that the presence of the Prerak—who they look up to as “much more educated, qualified, and knowledgeable”—motivated them to pursue their work with more passion. In several of the district headquarters, the technological help provided by the SBPs was considerably appreciated. In a few of such offices, the officers and other ICDS personnel shared that they learned a few technological tools/strategies from the Prerak when “the Prerak sat together with (them) in front of the computer and worked with (them)”. A supervisor from Uttar Pradesh shared how she became more confident to deliver ILA trainings with the presence of the Prerak.

“Initially I never got out to give training myself. Now, I have that confidence that even if I get stuck, she’s there to help me out. This makes me confident to give training even when the CDPOs are present. This has happened twice before because I was not in the DRG, and in the DRG the DPOs and other authorities are present. The first time I was very hesitant about giving training, but (the Prerak’s) presence helped me become confident. I gave training for the last two sessions in the BRG at the block level.”

Such skill development and motivation could be considered long-term impacts of the SBP Programme. In fact, some Preraks aimed at strengthening the existing ICDS system so that it remained streamlined long after their tenure ended; a Prerak in Uttarakhand shared her view in this regard:

“I am not a part of the system, but I am sort of external pressure saying this is how you know you are supposed to work. That’s what I am doing: advising them that this the (right) way and you have to do it (like this)...We have to ensure that everything is being done because we know that the concept of a Prerak might exist for now, but when you leave, you are strengthening them so


much so that they will remember all their roles and duties and how things have to be done for POSHAN.”

On the other hand, several Preraks also highlighted an important issue: that of being unable to fulfil their role as a catalyst due to being relegated to routine/non-POSHAN work by the district administration. While some Preraks were able to set boundaries for themselves in this regard, most of them could not do so, due to the risk of alienating their reporting officers altogether. In such cases, they were reduced to filling in for the short-staffed district administration. A Prerak in Assam described this predicament at length:

“...I don’t know whose fault it is, but there is lack of clarity on the both sides: as in, how the government has understood the role of SBPs, that’s for sure. The kind of work we often invest ourselves in our daily (routine) is (mostly) mundane activities: for instance writing a letter, writing minutes of the meetings, making PowerPoint presentations...Being bluntly honest, I will say that the role which the Prerak was supposed to play was that of a catalyst. I mean the word itself means a catalyst, the word Prerak.

But instead of being catalysts we are actually becoming fillers. Instead of being of value to the department we are actually filing the gaps of the department, the existing system. That I feel is the major drawback...The problem, according to me, is that majority of our time is being spent on such mundane activities...Instead of being a filler, I would have loved to perhaps explore the mandates of our organisation. That would have been much better.”

This experience shared by the Prerak highlights how the absence of clearly defined roles for Preraks tended to negatively impact their ability to provide critical and strategic inputs at the district level. This was also acknowledged by a DM in Uttar Pradesh, who shared how the Prerak

was burdened with tasks that were not in their ambit, and hence their ability to provide critical inputs was hampered:

“The Prerak is the one who is the initiator to get the district level meeting done, he is responsible to get the departments on board, and the departments try to do everything through the Prerak. But that is not his/her role. Their role mainly is to act as a gel and as a catalyst and be a coordinating agency in the department, to get the programme reviewed and get critical factors into the light which are feeding the development of the programme; also what can be done. I suppose the POSHAN Abhiyaan and the outside support which comes into it get so gelled together that that kind of critical review goes missing somewhere.”

In Assam, the State Lead reportedly provided guidance to the Preraks on how to achieve their goals without having to sacrifice their professional relationships with the government machinery. Other State Leads and Program Officers shared providing similar support to Preraks for relationship and/or expectation management; however, the larger problem was reported to persist.

4.2.4. Innovations/Best Practices Initiated or Facilitated by the Preraks

At times, Preraks were able to bring to the table new ideas which made use of existing resources and schemes, but did not strictly fall under the convergence component under POSHAN Abhiyaan. For example, a Prerak in Tamil Nadu shared his initiative to help SAM children in a more targeted manner through convergence between the ICDS Department and the RBSK team under the Health Department:

“There are a lot of common areas where there is a lot of scope for improvement that need not be brought under our agenda. For example, the monitoring of severely underweight children is


something that the Health Department does through their RBSK (Rashtriya Bal Swasthya Karyakram) team. The team is a bunch of doctors; for each block, this team visits all schools and AWCs in a vehicle on a rotational basis (for health checkups). They have their own cars, pharmacists, a nurse, a general practitioner, as well as an additional driver. The ICDS Department already has data on the severely underweight children in each AWC. I sort of came up with the idea this data can just be shared with the RBSK team so they can go with the line list of children who are severely underweight, and then they can counsel them in a more targeted manner. This kind of convergence doesn’t fall technically within the ambit of the District Convergence Committee or the (Convergence) action plan. These are not really mentioned the guidelines. These are just ideas, which sort of emerge when you’re working on.”

Another Prerak in Tamil Nadu took an active interest in managing a helpline for female college students, instated by the Department of Social Welfare (DSW), a sister department of the ICDS in the State. Efforts were also made by a Prerak in the State to enhance collaboration between the community radio (CR) service and the ICDS: the Prerak planned and helped execute an initiative where AWWs appeared on the CR programs to inform beneficiaries of various recipes that could be made using the premix THR that was distributed to beneficiaries at AWCs.

In Maharashtra, it was reported that Prerak-led innovation projects drive the POSHAN activities in the state: an example given by the State Lead was the pilot UHSND project being tested in select areas of Mumbai. A Prerak in one of the districts also shared that she was studying how the community led concept of ‘bal pangat’ could be scaled up and replicated in the district to increase involvement of the community in the nutrition initiative.

In states like Telangana and Andhra Pradesh, the Preraks reportedly crafted many innovation proposals: providing vitamin B12 injections to pregnant women, software application development for POSHAN Abhiyaan, distributing seed kits to households in the community, serving millet-based breakfast/drinks or inclusion of certain food groups in rations provided in AWCs to improve haemoglobin levels of pregnant women. However, respondents shared that at times the innovation funds are granted to other development partners in the State; at other times, the State Level Sanctioning Committee (SLSC) itself does not convene, hence the funds are not allotted to Preraks’ (or any other) innovation proposals.

In Uttar Pradesh, a Prerak started the practice of making home visits herself along with the AWWs in order to counsel beneficiaries about Nutrition Rehabilitation Centre (NRC) referral services, which considerably improved the uptake of that particular ICDS service component. A supervisor narrated:

“Before (the Prerak) was appointed, children did not go to the NRC, but now she goes to the children’s’ house and explains to them why it’s important; she even brings them to the NRC herself every so often. So, this change is because of her. Before this, children used to come (to the NRC), but they left very quickly, or were misinformed about the forms they had to fill or where to go in the hospital.”

Thus, given the districts’ particular needs and challenges, Preraks have been able to introduce novel initiatives and innovative practices to help improve the nutrition picture in several States.


Most Preraks were able to provide technical


assistance in CAS rollout as well as dashboard monitoring. Their data-driven inputs were appreciated by district officials—this seems to be a desired outcome based on the vision of the Preraks as young professional catalysts who made use of their managerial and technical skills.

Some Preraks reported changing tack to “doable tasks”, which would have direct/indirect catalysing effects on the district. Thus, they seemed to have utilised the inherent flexibility of the SBP Programme combined with their own self-motivated critical/strategic thinking capacity to contribute to POSHAN implementation as best they could given their districts’ needs. This comes across as a good middle ground for Preraks to operate from, given the fact that some districts were less welcoming of the Preraks than others.

While tasks not related to POSHAN did make up significant portions of the Preraks’ work in the district—especially at the start of their tenure—it might be useful to look at such work as a part of a cohesive whole that contributed to bettering the district’s position with respect to nutrition. While Preraks cannot be expected to change district funding structures/priorities, their deliverables can be broadened to include peripheral tasks as legitimate efforts towards a multipronged tackling of undernutrition in the district by helping the district where it actually needs their aid.

Preraks should be encouraged to teach/train a few district functionaries in the use of spreadsheets, interpreting data for quick decision-making, having regular strategic meetings to discuss innovating approaches to getting the approvals needed, ideas to streamline scheduling based on the availability of different officials, and other such tasks in order to keep the POSHAN Abhiyaan implementation on track. Such a change in the work ethic of the district functionaries, even if achieved while focusing on a different program, would arguably be transferable when the district implements the POSHAN Abhiyaan.

Mainly due to lack of clarity, understaffing, and the Preraks’ expertise and potential to contribute at the district level, districts relied too much on Preraks for peripheral tasks: more clear communication with MoWCD and States regarding what Preraks must be assigned might help percolate this vision down to the districts. As a DM in Uttar Pradesh stated, Preraks cannot bring change by themselves—they need a supportive and trained team of district and block level functionaries:

“The Preraks are doing very well. The only issue is that at the moment the kind of man power we have in the ICDS department needs to be trained and retrained again and their education level needs to be improved and it is a continuous process. (...) What we need essentially is to build a team along with the Prerak, and the Prerak alone will not be able to do that. The team at the district level and the team at the block level need to gel well together (with the Prerak) so that they can work properly.”

At the moment, Preraks have no executive powers to be able to act on the inputs they provide to the district and/or State administration. The MOU signed by the MoWCD and The Tata Trusts should better highlight the Preraks’ deep involvement in data-driven monitoring, and explicitly state that their findings be considered seriously by the district administration after receiving feedback from the DM. The language of the MOU with the Center and the State could further clarify that any improvements the Ministries and/or State and district administration expect due to the placement of the Preraks in the districts are to be understood as contingent on the Preraks’ recommendations being implemented. This will further help prevent Preraks from being used as mere factotums.

The Preraks’ unconventional position in the districts has helped them catalyse the district administration in many instances. Unless a clear


understanding of the overall goal of the SBP Programme is reflected in the MOUs signed at all levels (Is the Prerak to be a catalyst or a helping hand? Is the Prerak to be deputed to and managed by MoWCD or do all responsibilities lie with TINI?), and all the stakeholders are clear about the expectations--at the Centre, State, The Tata Trusts, and TINI--the Programme is unlikely to be implemented in a way that meets the expectations of all the stakeholders involved.

To tackle relationship management issues, what is needed is perhaps a more rigorous Prerak selection process with an emphasis on not only familiarity with nutrition and health, but also

emotional intelligence and people skills: this may help reduce the chance of too much friction between Preraks and the government machinery. The selection process must also assess the candidates on their approaches to conflict resolution, their attitudes towards working in a hierarchical structure, and their ability to deal with constant, unpredictable impediments in achieving goals. Following selection, TINI must also emphasize these skills during the State-level training to help Preraks hone these skills, preferably also inviting the Preraks who are already posted in that State to share their experiences and advice.

PERSPECTIVES FROM THE TINI CORE TEAMThe Effect of the SBP Programme on the POSHAN Abhiyaan

According to a senior TINI team member, the Programme has contributed significantly to the implementation of POSHAN Abhiyaan, and by setting up a template for such engagements their impact could likely be increased much more, to serve as data-driven statements of how well government programs are working. Others in the core team shared that Preraks have contributed a lot to the training and rollout of POSHAN components in the districts and several States, recognising the value of having such a catalyst at the district level, continue to request the Centre for more Preraks and/or extending the SBP Programme for a longer duration.


05BARRIERS FACED AND SUPPORT RECEIVED BY PRERAKS

5.1. DISTRICT-SPECIFIC ISSUES AND CHALLENGES

5.1.1. General Issues and Challenges Identified in the Districts

Several Preraks shared that a lack of comfort with technology among field functionaries (especially AWWs) was a challenge in their districts; this led to slowing down of the data collection process through CAS as well as difficulty in working with e-ILA modules. Older AWWs often struggled to correctly operate growth monitoring machines as well, which affected the quality of data being gathered and uploaded on the Dashboard.

Other commonly reported challenges included shortage of permanent, full-time staff in the ICDS machinery: in Assam for example, it was reported that only the Preraks and State Lead were involved in the implementation of the POSHAN Abhiyaan in any considerable capacity. The lack of financial resources at the district level also hindered implementation of the POSHAN Abhiyaan. Poor mobile network coverage made data syncing difficult at AWC level, especially in remote areas. Underreporting/poor reporting of data at the district level was also listed as a challenge by some respondents. A lack of proper disbursal of funds was also reported by some Preraks as a barrier to the implementation of the POSHAN Abhiyaan.

In a few districts, Preraks found that the district administration lacked proper knowledge and

clarity about what the POSHAN Abhiyaan itself was: its objectives were not known to the district officials. These Preraks reported that they had to brief the officials regarding the same during their introduction about the Prerak’s roles and responsibilities when they first arrived in the district. Preraks also highlighted that the ICDS structure had certain inherent issues, which rendered the implementation of POSHAN Abhiyaan tougher. As a State Lead shared:

“The entire ICDS system was such a mess initially, now also it is a mess. Putting yourself in this system at the field level and then and working with different kinds of issues you realise...like, the THR distribution is in complete chaos in the State. Sometimes even the field functionaries talk about that issue in the meetings and it becomes a chaotic situation for them also.”

5.1.2. Nutrition-related Issues and Challenges Identified in the Districts

District-specific challenges to nutrition, though not commonly highlighted, were reported by a few Preraks working in the sampled districts. Respondents cited these issues as contextual to the district’s nutrition situation, and thus had to be kept in mind while designing the action plans and strategies for their beneficiaries.

A Prerak in Maharashtra shared that the biggest challenges in her district were junk food



The major barriers delineated by the core team since the operationalisation of the SBP Programme were:

i. Very few states have established SPMUs and in the absence of these Units Preraks’ contributions are hampered: further, it was observed that States which did not prioritise POSHAN Abhiyaan could not utilize the Preraks efficiently;

ii. Major implementation partners (for the POSHAN Abhiyaan) did not seem to have experience in implementing such a Programme due to which the initial vision of the Programme often faced difficulty in being translated on the ground;

iii. The ZSBP Programme—after which the SBP Programme was modelled—was a more focused, high priority program with measureable outcomes/goals, and the government showed strong acceptance of the ZSB Preraks. Unfortunately, the SBP Programme lacked these facilitating factors in its programmatic design;

iv. There was a lack of communication with the MoWCD: a brief guideline about the role of State Leads and Preraks were provided, but no discussion of detailed and specific responsibilities took place between TINI and MoWCD;

v. The position of the Mission Director at MoWCD saw a change of guard four times, each official harbouring a different perspective on SBP Programme than the others: this had a serious impact on the level of acceptance of the Programme and left a lot to be desired;

vi, The communication between The Tata Trusts and TINI about the future of the program needed to be more explicit; the possibility of an ‘abrupt closure’ of the Programme affects the environment in which the core team as well as the State Leads and Preraks work, as well the goals they can set for themselves;

vii, The TINI core team as well as the Preraks wielded very few decision making/executive powers and negotiating powers in their interaction with the government as an implementation agency which in turn affected the monitoring of the progress of the Programme as well;

viii. It was also perceived that as much as the core team wished to maintain an objective stance in such situations, it proved to be difficult due to the lack of autonomy;

ix. MoWCD reportedly expected a particular pace in implementing POSHAN Abhiyaan and deploying Preraks in the districts, but there was a mismatch in this pace among various states;

x. Uniformly capturing the learning of the Preraks was also challenging: even as Preraks were provided with a chance to share their stories, these accounts seemingly did not to fully capture their key concerns as well as successes;

xi. Dissonance in the data reported by Preraks and the CPMU was also observed by the core team: Preraks were eventually directed by the government to only to report on Jan Andolan activities and submit other data to CPMU instead which was counterproductive to the Programme;

xii. Only administrative problems in the SBP Programme were documented, leading to a lack of documentation about the POSHAN Abhiyaan itself;

xiii. Some Preraks started focusing on other tasks/themes without completing the primary deliverables of the POSHAN Abhiyaan;

xiv. Districts also started utilising Preraks in ILA module delivery and/or other tasks unrelated to POSHAN Abhiyaan—using them almost as factotums and keeping them away from their primary task of helping in convergence and data analysis/monitoring; and

xv. The TINI core team was small and faced a steep learning curve regarding the implementation of such a Programme, which reportedly did not allow for optimum stakeholder management.


consumption, superstition around certain eating/feeding practices, misinformation around issues like breastfeeding, and the lack of engagement of male members of the community in the POSHAN activities. Other factors that affect nutrition in several states were listed as: skewed child sex ratio, high IMR and MMR, early age of marriage, high numbers of cases of anemia (especially among young adolescent girls and pregnant and lactating mothers), stunting, wasting, and underweight children.

A Prerak in Telangana reported that despite data suggesting that early initiation of breastfeeding was high in the district (97-98%), she found that not many beneficiaries were aware of this aspect of nutrition when she made home visits.

In Assam, a Prerak shared that the problem of undernutrition was compounded in the State due to limitations in accurately identifying undernourished children:

“There is a problem of malnutrition in Barpeta, in some pockets...there was no (procedure) of identification. That was a problem because unless and until you identify these children, you will not be able to counsel or refer them to the NRC, or provide an adequate diet.”

5.1.3. Issues Identified Specific to POSHAN Components

A Prerak in Tamil Nadu reported that bottlenecks in convergence between line departments had been the biggest challenge in working in the district; according to him, the convergence was only formal, not substantive:

“The District Convergence Committee was happening in a symbolic manner; they called people from the departments, read out an agenda, take a photo...it was not really substantive. And so initially they were just

reading out the objectives of the POSHAN Abhiyaan, and then the DC would ask if there are any issues; they would say there were no issues, and then they would wrap up.”

The Prerak further stated that in his State, the SPMU had little knowledge about nutrition since the SPMU staff was directly recruited into the traditional state bureaucracy through public examinations. The full-time, salaried staff reportedly lacked knowledge about NFHS data as well and was not aware of how to properly collect and compile data from different districts for POSHAN Abhiyaan reports.

In Himachal Pradesh, a Prerak shared concerns regarding the lack of knowledge transfer through ILA:

“Say if I am training the DRG: everything is happening very well, because it is being closely monitored by the DPO herself since she is also the member of the DRG. But then you go down to the BRG or the sectoral level training...I think the things are not reaching to the last minds (in the chain) like the AWWs, because at the end they are the people who have been trained to deliver the things to the beneficiaries. But I think this is not percolating down well.”

Another Prerak in Himachal Pradesh also shared that the IEC material under POSHAN had not proven to be as effective as expected, for which the Prerak had proposed that an IEC impact survey be conducted.

In Assam, a Prerak reported that in the absence of ICDS-CAS in the State, Monthly Progress Reports (MPRs) were the only source of data available for the POSHAN Abhiyaan monitoring, which did not provide concrete data:

“There is a problem in Assam for data gathering so...we don’t have very concrete, very good data


as of now because CAS is not there. For (ICDS functionaries) we only have MPR. There is some help you get data from the health department.”

5.2. CHALLENGES FACED BY PRERAKS WHILE WORKING IN THE DISTRICT

The following set of graphs depicts the reports of challenges faced by the Preraks as reported in the survey (Fig 5.1).

5.2.1. Logistical Challenges

Many districts reportedly found it difficult to provide support—vehicle, cooperation, and administrative—to the Preraks despite the letter issued by the State government directing districts

to cooperate with and assist the Preraks. Several Preraks stated that they did not have resources such as a sanctioned vehicle, which made it difficult for them to move around the districts and work independently. In the graph above, it is visible that Preraks ranked the lack of vehicular support as the most severe challenge they faced while working in their districts. In such cases, Preraks strategised their commute as per the options available. The lack of a vehicle often posed additional problems of safety for female Preraks, especially if they planned on travelling to remote projects in the district—which often meant returning alone at odd/late hours. This often limited their monitoring to only a few field sites within their short distance from the district headquarters, which in turn gave rise to a general perception among field functionaries that the

Perc

enta

ge o

f Pre

raks

repo

rted

Perc

enta

ge o

f Pre

raks

repo

rted

Clerical/non-productive work

Perception of the Prerak/TINI as an “outsider”

Friction with district officials

Lack of clarity reg. Prerak’s role

Lack of resources/vehicular support

Relationship management

Side-lining of SBP deliverables in favour of state schemes

No support/coordination with other development partners

least somewhat less somewhat more most

Activity

FIGURE 5.1: Severity of challenges faced by Preraks while working in the district


Preraks do not monitor all field sites equally. To remedy this, some Preraks have taken to coordinating with development partners and other district officials to travel with them to various projects whenever possible, but this is not a permanent solution.

A few Preraks also shared that finding a seating location in the district headquarters, as well as the unavailability of a spare departmental desktop or laptop for their use had initially been minor challenges that they faced.

In states like Uttarakhand, external factors like geographical and seasonal conditions made it difficult for Preraks to travel to certain areas of the district, as reported by a State Lead:

“There are some limitations...travelling is a very important part of it. Preraks travelling within the district is a risk in mountainous areas. During rainy season, there are certain issues in travelling...I personally called Preraks and told them to avoid certain routes. In Uttarakhand, there are certain routes that are prone to landslides and during winters, there are certain routes that are completely cut off.”

As echoed by the Preraks in the Uttarakhand, such geographical challenges also affect POSHAN components, like the timely delivery of ILA modules to the AWWs.

5.2.2. Personnel-related Challenges

In districts where there was friction between the Prerak and the DPO/DWO, a lack of clarity about the Preraks’ responsibilities only compounded the incompatibility between the two. Our quantitative survey findings revealed that around 44% Preraks believed that their reporting officers had only limited clarity about the roles and responsibilities of the Preraks, while close to 20% of the Preraks reported their reporting officers had little clarity (Fig. 5.2):

FIGURE 5.2: Preraks’ perception about how clear their reporting officers in the district were regarding their roles and responsibilities (N=244).

Very clear

Most of them are clear

Not at all clear

Some guidelines are clear but some are not clear

12.7%

23.8%

19.3%44.3%

A Prerak in Madhya Pradesh echoed this issue:

“I: So after joining, did you see any difference in what you thought the programme was about and what it is actually about?

R: No, the Programme was exactly what was given in the JD, but the real gap was that the (district) system was not sure about what SBP was about to do. The Prerak’s role wasn’t clear in the system. The JDs were really clear (to us) as a Prerak, and the scenario was clear too: in line with NNM. But the work to be done in the system wasn’t clear. The disconnect there was really huge.”

Several Preraks highlighted their lack of experience in dealing with the ground level problems—especially around relationship management and expectation management while working in the districts—which was reportedly not addressed during their initial training/orientation provided by TINI.

A Prerak in Madhya Pradesh struggled with finding acceptance among Supervisors due to her initial inexperience in tactful relationship management:


“The Supervisors were not hostile, but they were surely not happy with me coming (to the district) because I was pointing out their mistakes in front of Anganwadi workers. I realized it later...whenever I go to these sector meetings to see what kind of ILA training they are giving, I monitor and I point out there itself: ‘do it like this and not like that’. Some people accept this, some don’t...But now the situation has settled down because they have accepted me.”

The dearth of proactive government officials was also cited by some Preraks as a barrier to achieving goals under the SBP Programme. Good interpersonal skills such issues could alleviate issues somewhat, but bigger issues like corruption1, misreporting of data, and behavioural biases reportedly still existed among government functionaries.

The Preraks’ age, gender and lack of authority/decision making powers were also cited as barriers to operationalising many of their ideas. Female Preraks shared that they were at times met with patronising attitudes by male officials and functionaries. A male Prerak shared that he had found it difficult to work in the ICDS machinery where majority of the staff was female. He initially faced some resistance and hesitation from the functionaries due to his gender, but over an extended period of time he was able to build a rapport with them. He further stated that the Director (ICDS) in his State also requested TINI to deploy more female Preraks. Both male and female Preraks found it difficult to extract deliverables from field functionaries who were much older than them; some field functionaries shared their initial apprehension at being spoken to firmly (at times even impatiently/harshly) by ‘young twenty-somethings’.

Furthermore, in several States, Preraks were initially perceived as ‘outsiders’ by the district functionaries (or seen as entities sent to ‘keep an eye’ on the district administration), which prohibited them from being assimilated into the district ecosystem completely. A senior administrative official in Uttar Pradesh shared their views on the reasons for such resistance:

“(The Prerak) does face challenges since she is an outsider. Any government system tries to resist change and if you try to bring out a mistake that someone has committed – supposed some CDPO has to do something and they did not/is not doing it, it’s the responsibility of the Prerak that she is closely watches them and brings it to our notice. But that is not liked by the CDPOs: they think that the Prerak is displaying their mistakes in front of the senior officers...Another issue might be that when you are hired as a consultant or a helping hand—since CDPOs are doing all the work on the ground level and if someone is asking them to work on things—they might feel that we are doing all the work and this person is only bossing us around.”

Such resistance hindered the Preraks’ ability to work as a part of the team in some instances. A Prerak in Madhya Pradesh highlighted how this perception of Preraks being outsiders exacerbated relationship management issues at the CDPO level:

“This one time, I told some CDPOs to conduct training, and they just ignored it, a ‘who are you to tell us’ sort of attitude. So, in those particular situations, it becomes very difficult to explain why your role has been assigned to that particular case, why they should be present there for training....In that sense, there is an ego issue. (...) We are external (elements) for them. When you

1 This is a delicate issue, and did not always elicit elaborate responses from respondents. Interviewers attempted to venture with care and tact while broaching such topics, especially with the district officials, to ensure that the dynamics between the Preraks and their colleagues did not suffer.


are an external resource and you are not in the government, then your orders won’t matter.”

Poor communication on the part of the district officials also reportedly exacerbated this situation all the more in some districts. It was over time, with consistent efforts, that the Preraks were seemingly able to build a rapport with the elder members of the ICDS district and block level machinery.

To overcome personnel-related barriers, some State Leads reported counselling Preraks regarding relationship management and diplomatic handling of relationships. A Prerak in Assam recounted how he had received advice from his State Lead to change his focus from district officials to project level functionaries for better rapport:

“For me, the challenge was that the DSWO in my district was known for not being ready to break the ice. I was in constant touch with my State Lead and Program Officer, and also the State officials to help with this issue. My State Lead knew what was going on; they advised (me on this matter)...I decided to change the way I work so that most of the things I did were now at the ICDS project level. So the entire work interaction channel I built was through the CDPOs because even TINI had trained us that what mattered at the end of the day were the AWCs.”

It could help to make such support and training a more permanent, in-depth component of the initial training received by the Preraks. In this regard, some Preraks suggested holding regular refresher trainings and monthly Prerak meetings to discuss learnings and developing skills with the higher officials, which would be very helpful for them.

5.2.3. Administrative Challenges

The biggest obstacle faced by Preraks, in a Prerak’s own words, was that “the State (programs and events) will always take precedence over the district and Prerak (plans and events)”. In some of the districts, the ICDS department did not primarily focus on POSHAN Abhiyaan. Therefore, given the lack of clarity of the Prerak working guidelines in the district administration, the Prerak was reportedly made to work on schemes or projects unrelated to the Prerak’s goals. Some of these schemes were prioritized by the district due to pressure from the Centre, or the fact that they had more funding available (e.g. BBBP). It would then reportedly become tough for the Preraks to divert the department’s focus to POSHAN-related tasks. The following table illustrates the work prioritisation of district officials (Fig. 5.3); we observe that planning, documentation, and capacity building are some of the most prioritised tasks in a majority of districts:


Senior TINI members shared that with change in leadership of the POSHAN Abhiyaan at the centre, the initial level of ownership or acceptance of the SBP Programme was not sustained; with Directors, Joint Secretaries and other senior official posts witnessing frequent changes of guard, it had proven challenging to maintain the initial enthusiasm and vision surrounding the SBP Program. The reduced functioning of the NNRC (after the change in Directorship) was also cited as a major challenge.


In one such district, the Prerak estimated that such peripheral tasks took up around 70% of their time. In Madhya Pradesh, a Prerak reported spending almost more than 80% of her time working for other projects unrelated to POSHAN Abhiyaan. In Tamil Nadu for example, a Prerak reported:

“For the first six months...initially when I wanted to contribute to the POSHAN Abhiyaan I wasn’t (allowed to), I got pulled up with some other departmental work, work which is other than that of POSHAN Abhiyaan. I used to be pressurised by the district officials to finish that work...(such a) situation had occurred in the initial stages (of my tenure). Post that, now I am able to manage it, how I can contribute more to the POSHAN Abhiyaan than to other departmental work.”

This was reportedly because the Prerak has “to work on the things that the department prioritises.” This appears to stem from a lack of clarity about the Prerak’s role and responsibilities, mostly among the district officials, whose cooperation is necessary for the SBP to fulfil their tasks and responsibilities. As a Prerak in Tamil Nadu stated:

“Even until now, no one in TINI knows what the job description is for the SBP program. Actually this is the drawback of the program also on one hand; and on the other hand this is (helping) the program. Since I don’t have any job description, I can work in whatever area I want to. Most of the Preraks I know take the best advantage (of this): they start involving themselves in each and every part. They independently go and speak with NGOs, get funds, and work on Anganwadi refurbishment.”

The lack of executive powers was highlighted by a few respondents. Some Preraks found this to be a hindrance, as stated by a Prerak in Himachal Pradesh:

“The main challenge is that we don’t have enough powers: being the Prerak in the district, if we see that something is not happening according to the set process, we can’t do anything about it except informing that to the DPO or the CDPO. But sometimes, they too don’t take any strict measures regarding (those violations).”

FIGURE 5.3: Preraks’ responses to how tasks are prioritised in their respective districts.

Documenting

Planning

Capacity building

Executing activities, change management

Monitoring and data-driven decision making

Needs assessment and strategizing

Administration

Stakeholder engagement and Intersectoral collaboration

Resource management

Other “non-productive” activities (clerical tasks)



While others, like a Prerak in Tamil Nadu, viewed this as an efficient way of working in the district:

“Actually, my PO plays a major role (in execution), that is quite easy for me. After planning, I’ll just put everything in front of her and she will take care of most of the execution part. When the PO is involved, all the people will work properly. 90 to 95% of the things will go according to plan, when she’s directly involved. So, I don’t control...and this is quite easy for me, it doesn’t give me much trouble. This is good for me also.”

Further, most Preraks worked from the district headquarters of the WCD Department at the Zila Parishad; visiting AWCs, NRCs, and other field venues at frequent intervals. Most Preraks highlighted that they were constantly involved in planning, training, monitoring, and executing one event after the other (e.g. POSHAN Pakhwada, CAS training and the subsequent CAS rollout). This often meant that they were not able to make sufficient field visits, or work on the deliverables and goals they set for themselves within the Programme.

Bureaucratic procedures and slow-moving official paperwork also posed additional challenges in some districts. As for working with other development/implementation partners, some Preraks reported working alongside them towards similar goals, resulting in a lack of clarity regarding each team’s roles in this case.

Surprisingly, the findings also showed that only a little over 40% of the Preraks surveyed reported having complete clarity on their own roles and responsibilities (Fig. 5.4). This was likely an outcome of a lack of more concrete and specific job description. This finding echoed the pattern observed among district officials and functionaries, and could be viewed as a crucial factor in at least a few of the other challenges that have been discussed in this chapter.

FIGURE 5.4: Preraks’ responses when asked how clear they were about their own responsibilities as Preraks as per the Programme guidelines (N=245).

Most of them are clear

Very clear

Not at all clear

Some guidelines are clear but some are not clear

Mix of proactive and reactive

Very proactive

Mostly reactive to higher officers

42.9%

14.7%

41.6%

67.5%

27.6%

4.9%

0.8%

Given the described challenges, only a little over 27% of the Preraks reported to be very proactive—as opposed to being reactive to situations—in their respective districts (Fig 5.5):

FIGUR 5.5: Preraks’ responses when asked if they spend their time in the district being proactive or reactive to situations (N=243).

A majority of the respondents reported being reactive to the behaviour or demands of their higher officials: several of the interviewed Preraks stated that their decision to do so was influenced


by their wish to have a conflict-free relationship with their reporting officers. Of the surveyed Preraks, an overwhelming majority reported building good rapport with department officials (95%) and working sincerely at the ground level (~86%) as strategies to help in this regard (Fig. 5.6). The quantitative findings also highlighted other strategies adopted by the Preraks to mitigate the challenges that they faced (Fig. 5.6).

While most of the Preraks carried out their work by actively involving themselves in the department, the work design of the ICDS machinery has its own challenges (viz. shortage of staff, technologically resource-poor, linguistic barriers), and seemingly tended to utilise the Preraks instead to work outside the ambit of their responsibilities. While the role of the Prerak is to provide hand-holding support: “making things happen” rather than “doing things themselves”—most of the Preraks tended to become a part of the government system, often working to compensate for staff shortage. This was acknowledged by the officials as well as the Preraks who were interviewed.


Bigger challenges to nutrition in the district such as high MMR, IMR, early marriage etc. become indirect contributors to undernutrition in a substantial manner. While some Preraks did attempt to tackle these issues through behaviour change events, such issues need concentrated, exclusive efforts of their own. Therefore, it is important to view the Preraks’ contribution in the larger context of such challenges which are beyond the immediate reach of POSHAN Abhiyaan, the SBP Programme, as well as their individual efforts. We recommend that the contribution of Preraks be viewed bearing in mind the tasks they were asked to perform by their reporting officers.

Among other external barriers to a Prerak’s success is the district not prioritizing the implementation of the POSHAN Abhiyaan. The Preraks lack the executive powers to make decisions which could allow them to focus on the POSHAN Abhiyaan in such a situation, thus limiting what they are able to achieve during their tenure. For

FIGUR 5.6: Strategies adopted by Preraks to work around challenges faced while working in the districts.


Building rapport with the department officials

Working sincerely at the ground level to demonstrate sincerity

Developing relationship with the senior officers (such as DM/AD etc)

Displaying “sincerity and humility” until they are kind to you

Going out of your way to help them in their work even if unrelated to yours

Not take things personally and develop a thick skin

Forcing your goals to align with their goals even if it does not fit job requirement

Be patient, do nothing, and wait for the challenge to decrease with passage of time

Discard challenging work and engage in other “easier” work


instance, a Prerak might come up with a brilliant and effective innovation design, but if the district does not prioritize POSHAN, the responsibility of the Prerak remains unfulfilled (since one major expectation is to design innovative proposals). It is laudable that several Preraks found ways to address nutrition-related problems in their districts despite such barriers. Even if these cannot be directly influenced or changed, such factors should be considered when determining a Prerak’s impact on nutrition in their district. A

longer-term strategy to address such challenges could be making the appointment of Preraks contingent on the district prioritizing the POSHAN Abhiyaan implementation. In districts which do not prioritize POSHAN Abhiyaan, a gentle easing-out of the Prerak and appointment in a different district after a few months could be an option as well. Other options could be considered if the State POSHAN Abhiyaan Coordinator is involved in helping define the Prerak’s responsibilities at the beginning of their tenure.


Lessons Learnt from the Journey of the SBP Programme

The TINI core team shared many lessons learned and suggestions to further improve the Programme in the future. A senior TINI team member recommended that the States be roped in more holistically in the implementation of the Programme, to ensure that they are more invested and that the Preraks’ role is understood better, leading to optimal utilisation of the Fellows. It was also suggested that the Mission Director (POSHAN) clearly communicate to the districts that the Preraks are their resources for improving the implementation of the POSHAN Abhiyaan, since TINI has no authority to instruct them about the same. There should be a clear explanation given to the districts as to why the Prerak has been appointed there. While members of the core team differed in their opinion about encouraging the Preraks to monitor expenditure in the districts (senior officials were in favour, while some team members were not), all of them agreed that Preraks should be primarily focusing on concrete deliverables around the six main components of the POSHAN Abhiyaan.

A holistic, long term vision of the SBP Programme was called for: some senior members reportedly broached this subject with the other stakeholders repeatedly, but as the MoU had already been signed, the stakeholders appeared to be disinterested in honing the vision of the Program itself. Further, it was highlighted that some data were needed to understand the gaps in and the strengths of the POSHAN Abhiyaan to aid the utilisation of the Preraks in the districts. Establishing specific guidelines was another recommendation: what components of POSHAN Abhiyaan are Preraks supposed to work on, how much time will they spend on the field versus the office, the nature of their contribution: will they be analysing, reporting, or liaisoning? Similar specifications were also suggested for POs; instead of merely limiting Preraks and POs to reporting, their critical and strategic inputs could also be taken. The team also shared that more executive control over the Programme was needed with TINI while negotiating with the CPMU and the States.


The biggest challenge flagged was the lack of resources (vehicle and desktop), which affected Preraks’ ability to function better in the district. From our findings it is clear that a simple letter from the Centre/State suggesting the district to provide a designated space in the office/a vehicle/a computer to the Prerak has not been successful in all cases. The primary reason for this is the existing lack of governmental resources in the districts. However, given the nature of the work assigned to a Prerak, these resources are vital. Perhaps a desktop or laptop could be provided to the Prerak by TINI, and the majority of a Prerak’s responsibilities could be restricted to the district level itself. In the event that the Preraks need to travel to blocks and projects in their districts, an agreement can be worked out with the DM’s office for a vehicle being made available to the Prerak: this can be done during the initial meeting in which the district-specific responsibilities of the Prerak are discussed and agreed upon.

With respect to personnel-related issues, clear and firm guidelines from the States regarding Preraks’ role and their purpose in the district, as well as a top-down culture (consistent with traditional bureaucratic hierarchies) of involving and accepting Preraks into the MoWCD fold might help iron out many such challenges. Other deep-seated issues such as gender/age bias among functionaries could be addressed by providing sensitivity training to ICDS staff. This could become a part of the Centre’s efforts to own the SBP Programme.

More focused training, especially at the state-level, and regular on-ground support—especially physical visits to the districts by State Leads and more uniform monitoring of the State Leads as a cadre—would boost Preraks’ ability to manage relationships. We recommend seeing up opportunities for Preraks to have regular formal interactions with other Preraks, where issues are discussed in collaboration with the TINI team. The information from such meetings could be triangulated with the reports from the

district headquarters (which at present comes from only the reporting officer) to obtain a more comprehensive picture.

A larger, more experienced core team at TINI (with a robust background in health and nutrition) might be able to negotiate better with the appropriate committees at the Centre to ensure that the SBP Programme is working at its optimum. The MOU could be designed such that TINI and GoI are viewed as equal partners, thus allowing TINI to have more executive control than it currently has.

5.4. FACILITATORS TO THE PRERAKS’ WORK

5.4.1. Personnel-related Factors (District-level Officials)

Almost 80% of the Preraks surveyed reported getting robust support from the district officials in CBEs and BCC-related activities in their respective districts (Fig. 5.7). In some States like Assam, Goa, Chhattisgarh, and Maharashtra districts have reportedly written to the State administration asking for Preraks and/or advocating an extension of the SBP Programme, which points towards a positive perception of the SBP Programme among the government machinery.

Going out of their way to support

Not much supportiveSupport only as much as they can

Not at all supportive

14.5%

18.7%

66.0%

0.8%

FIGURE 5.7: Preraks’ responses when asked the nature of support they received from district officials they worked with (N=241).


A Prerak in Tamil Nadu shared that while the Prerak’s young age may be a hindrance to obtaining the cooperation of the district officials, mentioning his salary bracket and educational qualifications helped him garner support and respect among the district officials over an extended period of time. In Assam, Preraks reported that they received a great amount of support from CDPOs, block functionaries and AWWs:

“I have better relations with LSs and AWWs, I should say. I think if you are genuinely, sincerely working on the field, then obviously you are going to have more interaction with supervisors, you will have more interaction with CDPOs and Anganwadi workers. So once you interact with them on a frequent basis, they also understand that this person is going to help us and is going to work with us. Then that sense of bonding grows, and they listen to what you say. So things become easier that way.”

5.4.2. Support Received from State Leads, Program Officers, and Others

Most Preraks surveyed—around 88%— reported that they received a healthy amount of support from the TINI team (Fig. 5.8). While there were some outliers stating they did not find adequate support in their State Leads, several Preraks mentioned that Program Officers and State Leads provided relationship management advice, helped them connect with consultants in the district, prioritised Preraks’ safety and security in the field, and were sensitive to issues arising in Preraks’ personal lives. Many Preraks shared that the TINI team and other Preraks from their state/district were members of WhatsApp or Telegram groups, which helped in quick resolution of queries and concerns, as well as fostering of a sense of community among the Preraks.

Even so, a few Preraks struggled to channel their work in their district in times of confusion/conflict, as their immediate contact with TINI (usually the State Leads) were unable to guide them in resolving such issues. As one Prerak reported:

“I don’t really particularly understand the role of a State Lead, if I’m being completely honest. How does it add value to my fellowship or to any work that I’m doing is a little alien to me…I’m unable to convey my ideas--or sometimes even get a response. I do not know what I’m supposed to expect out of the State Lead…”

Another Prerak reported:

“Even though the State Lead is available (at the state level), their efforts are not enough: they do not even visit the district office. Many Preraks resigned because of the negative approach of the government officials (and the subsequent lack of support from the State Lead).”

Some respondents felt the need for TINI to improve the feedback process between the districts and TINI, as a Prerak in Uttarakhand stated:

Going out of their way to support

Not much supportiveSupport only as much as they can

Not at all supportive

26.5%

11.2%

62.0% 0.4%

FIGURE 5.8: Preraks’ impression of the support received from TINI team in general (N=242).


“There must be a mechanism to actually hear out all ground realities and ground complications which the Prerak faces, and to divide and strategise something at the senior level where we can synergize all our efforts to achieve better outcomes of the POSHAN Abhiyaan; because the outcome for the POSHAN Abhiyaan is successful implementation. If at all we are not able to achieve/speed up/ hasten the implementation, our objective is not met. So, TINI needs to hear the ground realities and act and device the strategies as to how to improve the efficiency of this implementation program.”

5.4.3. Other Facilitating Factors

Several Preraks appreciated the virtual connection with their peers and seniors at TINI, afforded by WhatsApp groups and email correspondence. A Prerak in Telangana shared that a Telegram group had been created by TINI for Preraks nationwide as well as in the State, which helped Preraks in accessing peer-to-peer support and learning. A Prerak in Maharashtra mentioned that the prospect of updating the Prerak twitter handle for her district was also a peripheral facilitator which sustained her enthusiasm.

The Maharashtra State Lead also highlighted that since The Tata Trusts have a great amount of goodwill and a long-standing presence in the development sector in Maharashtra, the State has been very open to hosting and encouraging the SBP Programme. Such regionally specific factors also acted as facilitators in the process.

5.5. PRERAKS’ RELATIONSHIP WITH THE DISTRICT ADMINISTRATION

5.5.1. Attitudes of District Officials and Block Functionaries towards Preraks

Several Preraks reported that they enjoyed healthy cooperation from their DPOs and other colleagues (such as CDPOs and line department

officials) at the district level. Most district officials interviewed also offered a positive impression of the Preraks’ contribution to their districts. CDPOs in Uttar Pradesh, for instance, shared some ways in which the arrival of the Prerak had helped them work more efficiently:

“R1: We have a lot of work - all CDPOs do. Many times, we are unable to focus on things that need detailed attention. We get deviated. But because of the Prerak, we are able to focus on things better. If a letter comes, she forwards it to us immediately and it stays in our mind that this job too needs to be done at the earliest.

R2: The coordination wasn’t as good as it is after the appointment of the Prerak. If an activity has to be conducted, each person has different things to say about it, and she sends a video suggesting that this can be done - and by looking at the videos things get easier and get done easily by the AWWs.”

This (positive) perception however, seemed to depend partly on the interpersonal relationships that the Prerak and the district officials shared. For example, in a few districts it was observed that the reporting officers either did not share a positive relationship with the Prerak, or had different expectations from them: this resulted in dissatisfaction with the SBP’s work and/or an incomplete picture being painted regarding the Prerak’s work in the district. A Prerak in Uttarakhand talked about how DPOs often did not to highlight the work being done by Preraks, rendering their efforts invisible at the district and State level—thereby discouraging Preraks from working with as much enthusiasm:

“When it comes to my State, DPOs are quiet most of the time when it comes to Preraks: they never talk about the Preraks in the video conferences, they never mention Preraks in the official letters. So, these things seem to make us feel that we are being excluded. (...) We are working here, but are


not mentioned and our work is not recognised—neither in the district by the DPOs, nor at the State level. (...) That recognition is necessary.”

A few district functionaries were reportedly indifferent to the Preraks’ presence, or in rare cases, were openly hostile towards the Prerak. Several Preraks also discussed how their relationship with the district officials was based on a seemingly unspoken quid pro quo agreement: the officials helped the Preraks provided the Preraks returned their favours by helping them in their clerical/non-POSHAN related work.

A Prerak in Telangana reportedly enjoyed a good rapport with the POSHAN Abhiyaan team (DC, BCs, and DPA), since they were hired around the same time that the Prerak had joined the district. Additionally, it was also shared that the JPC at the State level personally directed the ICDS district officials to involve Prerak in their communication loop, after which the Prerak’s rapport with SPMU improved (the State Lead facilitated this communication). The DWO also reportedly provided streamlining suggestions and better understanding of the district demographics for the Prerak’s anemia research, indicating a largely positive relationship between the two.

The overall view of the district level stakeholders was that the SBP Programme was a good initiative which has helped with data-driven monitoring and follow-ups: both of which are perceived to be important to ensure that the programs and schemes put in place function properly, reaching all their intended beneficiaries. CDPOs in Maharashtra felt that the presence of the Prerak in their district was helpful, and opined that the SBP Programme should continue to function in the future:

“R3: We have a lot of other work to do and the speedy implementation of POSHAN Abhiyaan would not have been possible without the Prerak’s help. She

continuously followed up with the progress of policies. Her help has been essential for successful implementation of policies. It would be best if she continues to work with us as Prerak.

R1: Prerak should continue work with us. The ‘Prerak’ word itself says a lot about them: they stimulate and motivate us to complete tasks.”

Certain initiatives taken by Preraks—the POSHAN war room established by one of the Preraks interviewed, for instance—were greatly appreciated by district officials.

5.5.2. Preraks’ Relationship with Block-Level Officials and Frontline Functionaries

While some Preraks did not get a chance to work very closely with frontline workers on a regular basis, several Preraks were able to interact with LSs in person, and many encouraged AWWs to contact them on the telephone in case they had questions or concerns. Apart from regular monitoring and follow-ups with the help of data, the Preraks also acts as a point of contact for the field functionaries at the district level, who was more approachable and proactive with feedback and help than the regular ICDS cadre. They provide troubleshooting support and motivation to the frontline workers: this is greatly appreciated.

Some Preraks also address and train field functionaries personally, so as to improve their knowledge base, skill set and confidence levels. In Uttarakhand, a Prerak shared how much the functionaries looked up to her, hoping she could resolve the delays in their honorarium disbursement:

“The beneficiaries think of me as someone from the government, but the AWWs are very hopeful that I am there to do something good for them. One thing I would like to, I don’t know how much


this feedback will be beneficial to the AWWs: but they get their honorarium very late. That is one thing because of which they have high hopes in me that maybe, because she is the only lady available on-ground sometimes and who is there in the (district) office also...because no other officer goes to the ground, so frequently.”

Our quantitative findings also highlighted the positive perception of all stakeholders towards the Preraks, especially at the AWW and Block Supervisor levels (Fig. 5.9).

Through this graph, it is clear that Preraks got the impression that the block-level officials and frontline functionaries had a more positive impression of the Prerak than the higher-level officials at the district. This could be explained by the fact that majority of the work pertaining to POSHAN Abhiyaan is done in the block, sector, and AWC level. Thus, the effect of the Preraks’ streamlining efforts may have been felt the most by these functionaries, contributing to a positive impression of the Preraks.

5.5.3. Other Relationship Management Issues

While some other development partners have signed MoUs with the state governments, TINI has signed a MoU with the MoWCD at the Centre, which sometimes leads to lesser importance being given to the Preraks at the district/State level. This issue was reportedly compounded by the gap in communication between TINI and the State government in many States. A State Lead reported that other development partners in his State often approached the Prerak for tasks like conducting surveys among the beneficiaries; the Preraks however received no credit or compensation for this. In such States, the development partners also seemed to enjoy a better rapport with the State and district machinery due to a longer duration of engagement. This seemingly resulted in Preraks being left out of the loop for areas that these partners managed: such as State-level trainings, official meetings, and most recently, COVID relief efforts.

Similarly, another State Lead shared that the State administration is more inclined to entertain

FIGURE 5.9: The Preraks’ assessment of the perception of all ICDS officials and functionaries towards the Preraks.

Perc

enta

ge o

f Pre

raks

repo

rted

The district officials and senior staff at the relevant

line departments

CDPOs Supervisors AWW

neutral somewhat negative somewhat positive very negative very positive

Responses


instructions from the Centre rather than the TINI core team:

“The State team is not sure about the TINI central team: about what exactly is their plan of action. So what happens is, that State always believes that it is always the Central Ministry which actually gives them the guidelines; so whenever the set of instructions come from TINI central team, the State team does not entertain it that seriously...So anything coming from other than the WCD, they won’t entertain at all. There is some gap, but yes, that can be reduced easily...”

Whenever such matters were escalated to the State Leads, they reported contacting DMs/DPOs to tactfully demarcate the Preraks’ roles and responsibilities and deescalate such situations. However, State Leads and Project Officers were not able solve every problem brought to them since the final decision on such matters usually rested with the DPO/DM.


Several States have asked the Programme to be extended, which shows that they recognise the value that the Preraks add to the POSHAN Abhiyaan. This can be leveraged to rework the terms of engagement to ensure great clarity in Preraks’ roles, a more effective monitoring structure, and secure more negotiating power for TINI (at the Centre) and the Preraks (at the districts). High-burden districts can be prioritised for engaging Preraks to optimise resource use.

While most Preraks appreciated the support they received from the State Leads and POs, many emphasised how beneficial peer-to-peer interaction was. Thus, in addition to informal peer interaction on WhatsApp etc., TINI can introduce a more holistic digital platform where Preraks may interact with their peers and can obtain assistance

from the core team/NNRC/SPMUs as needed. We suggest a more formal, monitored platform where people are held accountable for providing timely support to Preraks as well, since support from State Leads garnered mixed reviews during the course of this study.

An organized feedback mechanism needs to be established between the districts and TINI. Several district officials reported never having been contacted by anyone from TINI ever since the Programme had been operationalised in their district. Triangulation of reviews of Preraks’ work is also necessary to obtain a week-rounded picture and avoid any personal bias from creeping in (for instance, issues officials might have with Preraks that are unrelated to the latter’s professional performance). CDPOs, Supervisors and AWWs provided an overall favourable review of the Preraks work—this should be taken into account while evaluating the Preraks.

As flagged by a few State Leads and some district officials/development partners, the MOU can be signed with States instead of Centre, thereby making it possible to tailor the Programme to what specific states and districts actually need from Preraks. This might help increase the levels of acceptance of Preraks by the government machinery, and help overcome the issue of Preraks being perceived as the ‘eyes and ears’ of the MoWCD at the Centre. However, trust will only be built over time and with positive experiences with Preraks, so this leeway should also be considered while assessing the situation.


06STRUCTURE OF THE SBP PROGRAMME:TRAINING, MONITORING, FEEDBACK AND SUGGESTIONS

The TINI core team is a small team of Program Officers (POs) and other team members who are based in the TINI headquarters in Delhi. This core team reported being in contact with the Preraks and State Leads, as well as with the government stakeholders (MoWCD) at the Centre. The POs shared that they submitted weekly and monthly reports to the CPMU (and in the initial phases of the SBP Programme, to the NNRC as well), informing them of the progress of different states in areas such as ILA, CBEs, and CAS. Apart from this, the team also resolved challenges that Preraks escalated to them. The POs also reported providing research support for innovation proposals designed by the Preraks.

Most State Leads highlighted their role as providing support and consultation to the State on implementation of POSHAN Abhiyaan, as well as the management of Preraks and their work in the districts; both these components were described as being interrelated. State Leads also reported undertaking the following tasks at the State level: they conducted field visits to various districts in the States; some coordinated department review meeting at state level for Preraks and State ICDS machinery; they attended convergence meetings at the State level. Most State Leads made field visits for ILA verification and monitoring (such as: whether the modules were suitable to be used in local language); they also provided Dashboard trainings to ICDS staff whenever necessary; they were also responsible for monitoring SRG/BRGs, Jan Andolan activities

and visits, and state level program launches (such as POSHAN Maah).

State Leads also planned convergence meetings at State level: for example, a State Lead stated that he had been entrusted with designing an economical supply chain model for THR distribution, for which he was liaisoning with the State’s Transport Department, Health Department, PRI etc. In states like Andhra Pradesh and Telangana, the State Lead also reported preparing district wise reports on the challenges faced in CAS, along with possible solutions.

6.1. TRAINING PROCESS FOR NEW RECRUITS

6.1.1. Scope of Orientation Provided by TINI

All interviewed Preraks reported having attended the three-day orientation at Delhi, where TINI organised sessions on undernutrition, how to read and use NFHS data, training in data crunching and analysis, presentation skills, team building exercises, introduction to ICDS structure and district administration hierarchies, and interaction with SBP alumni.

Most State Leads and POs stated that Preraks were provided with an orientation at the State level as well.A State Lead also summarised the process of orientation for the Preraks at the State level: according to him, each new batch of Preraks was given an orientation to acquaint them with


what can be implemented in their district; they interacted with the ICDS commissioner at the State level. They werereportedly briefed about the administration structure, of the ICDS/WCD in the state, as well as the learnings on CAS, CBE, ILA (how Preraks could be a part of the DRG/SRG). He further shared that Preraks were given a survey to carry out on the field, following which they analysed the data collected, and presented it to their peers during the State-level training. Another State Lead outlined how Preraks re made part of the SRG, so they attended ILA meetings every quarter, along with other meetings and workshops: hence, there was regular contact with State Leads and other Preraks.

Before the Preraks joined their respective districts, the State Leads reportedly also acquainted Preraks with the reporting format for TINI, and advised them to meet the DC/DPO in their districts. A Prerak in Himachal Pradesh also echoed this in his response, where he described that the Preraks had received a proper State-level training, which the Director (ICDS) himself had attended to discuss with the Preraks how they could contribute to the State’s implementation of POSHAN Abhiyaan. Preraks in Assam also reported detailed State level training. Apart from this, development partners also reportedly held regular workshops in a few districts, which some State Leads encouraged the Preraks to attend.

6.1.2. Feedback from Preraks Regarding the Orientation Provided

Overall, most Preraks found this orientation useful to understand the basics of the Programme; the quantitative survey revealed that nearly 96% of the respondents found it helpful in at least some capacity (Fig. 6.1). An outlier was a Prerak in Telangana, who pointed out that the training in Delhi mainly addressed issues in States in northern India and as such was of limited use to Preraks working in other parts of the country. Another Prerak in Tamil Nadu, who did not have a

prior background in the nutrition and/or the social and development sector, shared that he found it difficult to understand what was being addressed in the orientation and eventually brought himself up to speed by perusing various guidelines on his own time.

FIGURE 6.1: Preraks’ impression ofthe role their initial training played in helping them meet POSHAN Abhiyaan goals (N=246).

Very helpful Somewhat helpful

Not helpful at all

4.5%

49.2%46.3%

In contrast to responses from TINI officials higher up the hierarchy, some Preraks reported inadequate training at the State level, where they had expected to learn more about State- and district-specific challenges, district government hierarchies and dynamics, and other information that would better equip them to enter their districts. For example, a Prerak in Telangana reported that there had been no training at the State level, only a meeting with the Joint Principal Secretary that had been arranged by the State Lead. A Prerak in Uttarakhand stated that refresher training was needed at the State Level:

“I: So, do you think some sort of refresher training would help you deal with the (challenges)?

R: Yes. All of us, from the Uttarakhand team, all the Preraks want some sort of training or at least a conference call with the Program Officer once a week or in 15 days. That would be helpful.”


6.1.3. Suggestions Received for Improving the Training and Orientation

The findings from the quantitative survey revealed a mixed picture. While a majority (80%) of the Preraks were satisfied with the training they have received, a few raised their concerns about the trainings not being “up to the mark.” A Prerak responded to an open-ended question in the survey as follows:

“The Central Training in Delhi shared most of the components and gave us a brief about the kind of work that was expected, but looking at the diversity of the group there could’ve been a session on field work ethics and principles instead of focusing largely on government structures and the confidentiality around it. Since many Preraks are engineers and most of them do not have any direct access to actual fieldwork or any idea about the larger principles of effective fieldwork. This could have also been a session in the State training to give us a larger context of the districts that we were being deployed in.

Other suggestions from Preraks in the survey also included an emphasis on two-way communication between TINI and themselves, a longer training period, a need for interaction with former/current Preraks, and the introduction of mock exercises during training.

During the in-depth interviews, some Preraks reported that the TINI orientation lacked a session on nutrition for Preraks from a non-social sector/health background. Others opined that the training was holistic, but not helpful in practical terms for ground realities that were different in each State, as a Prerak in Uttarakhand described:

“The training sessions were holistic, but...what we were taught, not every Prerak can even perform in their district because, in the end, it is all about the way you act (while interacting with) your district administration. So it is fine that they teach you

about the basics theory, but practical (situation) is very different...how the district administration decides to make use of you...”

Similarly, a Prerak in Assam shared:

“So whatever orientation you get in the Delhi, it’s more often a briefing about what is happening, but then every state has a different way of taking the (POSHAN Abhiyaan) ahead. For Assam, it was completely different from what’s happening in the Mizoram and Meghalaya. So it took me some time to get an idea of how the program is being implemented component-wise.”

In a similar vein, a Prerak in Telangana suggested that some introduction/orientation ought to be held involving State Leads to familiarise Preraks with the region-specific administrative and government-related knowledge base, such as government hierarchy, grouping of mandals, how CAS operationalisation differs in different regions within States as well as in the north versus the south of the country. This specific knowledge should be provided by State Leads, according to the Prerak. Similarly, a Prerak in Assam also highlighted that the training in TINI did not focus on state-specific administration structures; rather, it was the State Lead who explained the same to the Preraks.In contrast, a State Lead interviewed was opposed to excessive training at the central level by TINI, since in his view the POSHAN components were State-specific and hence TINI could only provide Preraks with the guidelines. Here, we see a gap emerging where the Preraks are unable to obtain state-specific information, and there is no training given at the State Level either.

Another Prerak believed that more information should be provided in trainings on how to design BCC campaigns. It was also suggested that a structure was needed for a training session. It could be held once in a year/a certain number of new people join, at the divisional/state level.


6.2. REPORTING AND FEEDBACK MECHANISM FOR PRERAKS

6.2.1. Reporting and Feedback at the District Level

Most Preraks reported that they submitted monthly logs to TINI, which were countersigned by their DPO (or equivalent reporting officer). Most State Leads were reportedly in touch with the DPOs/DCs to ask for feedback, based on which they guided the Prerak on how to proceed with their work in the district. Preraks also presented data and findings from the Dashboard in review meetings with the District Collector and other senior district level officials: this was perceived as another measure of their work and active participation in the implementation of POSHAN Abhiyaan in the district.

6.2.2. Monitoring by and Feedback from TINI

State Leads shared that they had monthly phone calls with the Preraks in their States, where any support they need from their end was provided to the Preraks. Submissions of reports on CAPs and other deliverables such as CBEs were made by the Preraks and the State Leads using the reporting format provided by the TINI office in Delhi. A fewStates reported a buddy/mentoring system that had been established for peer-to-peer learning among Preraks: a State Lead also mentioned Preraks being made zonal leads on a rotational basis in her State. Monthly feedback was also reportedly obtained from DPOs. If necessary the State Leads met with the District Collector during their field visits (although this was quite rare according to the responses provided by district officials). A few State Leads reportedly cross-checked Preraks’ reports against State level data to ensure no data discrepancies existed before they forwarded the reports to the TINI core team.

It was of interest to note that there was a reported lack of a uniform monitoring tool which could bring substance and consistency to the Preraks’ reports. For instance, the survey revealed that more than 30% of the Preraks believed the monitoring mechanism could have been better or that they missed many important markers (Fig. 6.2). This lack of standardized monitoring and evaluation of the Preraks’ performance led to reported differences in performance and perceptions of inequality among the Preraks. As one Prerak reflected, “some Preraks work hard, some do not”. The lack of rigid monitoring of the SBPs seemed to discourage some “hardworking” Preraks as they believed that many of their peers were not making as much efforts as them as a part of the Programme. A Prerak in Madhya Pradesh summarised this predicament succinctly:

“So, there are at least a few Preraks who haven’t been to their districts, or have been to the districts for very less time: and they are now working from home or they are managing somehow. At the ground level, there are not many people who check this. This is the point where I feel the Programme Officer and the State Leads play a very important role...they should have effective checks and balances for the Preraks, and whether they are working or not. There are certain ways (to do this) without coming to the district as well: you can constantly have a word with the DPO or other officials, and the Preraks as well. (...) That was lacking initially in the Programme, at least for my Programme Officer and State Lead.”

A few Preraks provided honest feedback on their own work, which they found not to be “at par with what the Programme demands”. There were daily, weekly and monthly trackers in place to evaluate the Preraks’ progress. However, there was a perceived lack of a robust feedback mechanism in place. A Prerak in Madhya Pradesh suggested triangulating reviews of the Preraks with different


officials in the hierarchy in order to obtain an unbiased report of the Preraks’ work:

“Taking a single review from a single stakeholder will always incline the Prerak towards that official...they will go out of their way (to please them). So I suppose (TINI should be) involving more than one stakeholder in the district, who are not directly related to each other: suppose the DPO tells the CDPO to give a particular kind of review about the Prerak, the CDPO will not go against the DPO.”

FIGURE 6.2: Preraks’ impressions on TINI’s monitoring of the Preraks (N=243).


It is important to note that in order for the Programme to be successful, the Preraks must be viewed as catalysts and not fillers. As a DM in Uttar Pradesh pointed out, the WCD department in each district needs to recognise that the Preraks are meant to be support for a limited time, and not replacement for missing staff:

“The department needs to understand that someone is acting as an outside agency and outside help; that agency can’t act as a replacement for the department. The department needs to do its job. The outside support is a support and only a limited time support. You can’t piggyback on that support to run your programme. That is I suppose the biggest problem in the department. The department needs to improve on that, not the Prerak.”

More acceptance and ownership of the Programme by the States could be facilitated by tailoring the Programme deliverables to the individual needs of each State, based on detailed conversations that TINI has with State officials regarding what the Preraks are expected to do. Further, focusing the available resources more intently on the States that take an active interest in collaborating with the Programme could also improve its acceptance among States.

Many Preraks rightly pointed out that relationship management should feature more prominently in the training/orientation. State Leads must also have protocols in place for training new recruits at the State level by providing them local and regional level inputs that would help Preraks build rapport with their reporting officers.Training needs to include information that acknowledges that there is a great diversity in how the ICDS operates in different states. The state-level training needs to orient the Preraks to the state-specific aspects

Missing many crucial markers

Comprehensive

Somewhat comprehensive

Could be better

4.1%

37.0%

25.5%

33.3%

Some Preraks believed that one of the biggest barriers in the successful implementation of the SBP Programme was the perceived limited guidance that the Preraks received from TINI at the ground level, especially when the Preraks themselves found it difficult to negotiate on issues with the district administration. In some sampled districts for example, the presence of the State Leads was not appreciated by the Preraks—theyreported that the State Leads were neither incontact with the Prerak nor the district administration.


of the ICDS. This will help the Preraks work in different regions of India. Additionally, if Preraks with no background in nutrition and health are recruited, they should be given training in these areas to help them ease into their role with a better idea of on-ground realities.

A uniform monitoring tool (with outcome indicators drawn from the specific guidelines laid down) is needed to evaluate Preraks as well as State Leads. To overcome the current lack of such a tool (as highlighted by some Preraks), we suggest that feedback sought by the Project Officers/State Leads from the DPOs be triangulated with inputs received from the State Leads and the Preraks themselves.

While we have flagged the need for a uniform monitoring tool for Preraks, a closer look is also needed at how State Leads function, what is expected of them as a part of the TINI machinery, and how their performance is monitored by TINI. Our findings indicate that some State Leads are much more actively involved in providing support to the Preraks than their counterparts, and this creates an imbalance in the quality of guidance and assistance that Preraks receive from TINI. A few Preraks reported that their State Leads did not mentor them, and that they expected the Preraks to deal with relationship management issues and/or differences in perception of the Preraks’ responsibilities in the district, all on their own. (Please refer to section 3.4 for a discussion on the lack of clarity of the role of the Preraks.) Since State Leads are often the first points of contact for the Preraks, it is extremely important that State Leads’ responsibilities are clearly laid out, and their work is monitored regularly as well. This will help especially improve their accountability towards the Preraks.

Since the State Leads are the immediate contact persons for the Preraks in regard to any problem faced on the ground, the State Leads need to be

properly trained with skills to negotiate situations of conflict, manage human resource, and provide suggestions wherever and whenever necessary—both to the district headquarters and the Preraks—in favour of achieving the goals of the SBP Programme. State Leads should be integrated into the Prerak-DM-reporting officer structure of monitoring formally through constituting proper channels and SOPs of regular feedback loops for which they are held accountable by TINI.We recommend that a more formalised/standardised process be formulated regarding field visits as well as conversations with the reporting officers; this would help streamline the linkages with the district administration.

Increased logistical support from TINI can also reduce the financial and logistical burden that the district administration currently faces in providing the Prerak with the adequate resources. Simple arrangements/agreements could be reached by the State Leads by visiting and speaking with the district officials before the Preraks’ arrival to their respective districts (e.g. deciding where they will sit, what resources can be provided by the district). These symbolic gestures could go a long way in helping improve the acceptance and ownership that a district displays towards a Prerak.

6.4. RESPONDENTS’ SUGGESTIONS TO IMPROVE THE SBP PROGRAMME

6.4.1. Suggested Changes to Programme Design

The district officials suggested that the SBP Program should be continued for at least a few more years until the ICDS functionaries are able to work in a manner similar to the Preraks, having inculcated within themselves digital/technical competency and a self-driven, robust work ethic that is needed in the government functionaries to perennially catalyze the ICDS. As one of the ICDS functionaries said:


“It takes almost a year for the Prerak to get familiar with the field, the real job starts then.”

Similarly, a Prerak suggested that a longer period of induction/settling in at the district level would help Preraks understand their field better. Most of the interviewed district officials did not suggest any major changes to the SBP Program itself; a few district officials suggested that older candidates could be chosen for the position of the Prerak to help with issues of experience, hierarchy and authority: those who had prior experience in the field of nutrition, as well as certain contextual knowledge about the district itself.

In terms of improvements to the linkages between the Preraks’ position and the district administration, the officials interviewed suggested the following: it would be helpful to conduct an orientation for the district officials and field functionaries where they would be told what kind of work the Prerak can help them with, and what they can be approached for. A few Preraks also reported that the district officials and field functionaries were not aware of the exact structure and organisational flowchart of the SBP Programme: who employed the Preraks, who they reported to etc. As a Prerak in Tamil Nadu stated, initially he introduced himself simply as an official sent to the district by TINI to work on the POSHAN Abhiyaan:

“So initially when I used to attend these department meetings, I used to introduce myself as the person that has been appointed by TINI, and that I worked for the National Nutrition Mission.”

As another Prerak in Himachal Pradesh recounted:

“There were some complaints regarding—I would rather say confusion...the district officials in the beginning were actually confused about our roles,

that what our role is (in the district); we have joined with this letter, how we will proceed? And how they would have to act in terms of managing us or cooperating with us. So, I (addressed) all those queries...I would want to add that there is no one structure that how a Prerak in a district would operate.”

This suggestion was also echoed by a District Magistrate (DM) in Bihar:

“One suggestion I would give regarding the Prerak is that, if not possible at the lower level like the block or sub division, at least at the district level or the State level Tata Trust should hold a meeting with the DPO, and ICDS district level officials. They should be aware of how they can more effectively utilise the Prerak for the challenges they face...I hardly find that in the district. Maybe they just write a letter to the Department. But mostly in the district it’s the Prerak only who is representative of Tata Trust. So if Tata has a meeting with a higher official, with the help of the Department itself, I think it will be very useful.”

According to the several Preraks and district officials alike, regular follow ups and monitoring of the Prerakscan also be instituted, along with robust feedback mechanisms that can help the DM/DPO communicate with TINI regarding the SBP program. Preraks suggested that regular, in-depth guidance from the TINI team, as well as peer-to-peer learning from other Preraks could boost their motivation, dedication and leadership skills, helping them contribute more fruitfully to the SBP Program. Some Preraks also requested State Leads for a virtual peer-to-peer platform where none existed. As the following figure illustrates (Fig. 6.3), a majority of Preraks (74.4%) found it very helpful to communicate with other Preraks about the challenges they faced to aid resolving the same:


FIGURE 6.3: Preraks’ impression of how helpful communication with other Preraks is for their work (N=246).

technical aspects like MS Excel, MS PowerPoint, as well as proposal writing. He further suggested that personality mapping could also help TINI in selecting candidates most suited for the profile. According to him, candidates should have the ability to be patient and persistent during their dealings with government mechanisms. Since the demand for Preraks is consistent, and the Abhiyaan is in late phase, a State Lead suggested that research output should be the focus now: according to him, some framework would have to be developed within the program to help with this. The respondent also advocated for strengthening of State level SBP framework, with more resources and travel support given to State Leads so they can go to the field more frequently.

6.4.2. Suggested Changes to the Scope of Preraks’ Role

Several Preraks called for the deliverables and the scope of work for the Preraks to be fixed to ensure they do not get side-tracked into responsibilities not related to POSHAN. As a Prerak stated:

Some Preraks opined that candidates who are recruited should have good communication skills as well, and should be able to work in a people-oriented environment in the district administration. A State Lead suggested more careful vetting of candidates while hiring for the Prerak cadre to ensure that recruited Preraks are skilled in

Very helpful

Somewhat helpfulModerately helpful

20.7%

4.9%

74.4%


Most core team members concurred that a larger question needed to be answered as the Programme moved forward: is the SBP Programme a fellowship, one that is substantially benefitting the Fellows? Or is the Programme merely providing additional workforce to the district administration? As one team member suggested, the goals and deliverables could be selected to be ‘smarter’: moving forward, TINI could identify achievable milestones as a part of the Programme goals, since some of these factors have already been leveraged by the Preraks to their advantage in several districts. Some of the indicators of such successful work by the Preraks was delineated by the core team members as follows: improvement of around two thousand AWCs nationwide, writing and implementing innovation proposals (including budget proposals, CSR funds proposals) and this has been replicated in many districts, streamlining convergence in the district, strengthening NRCs, actively reporting SAM/MAM data and CAS data to the district administration, and suggesting improvements in systems processes and capacity building.


“I would say structure the program well, be very specific with the components which you want the Prerak to work on. These things should be very clear for the Prerak as well as for the district administration. In my experience, you should give specific components to the Prerak then see how they are working on those and this is how it will be easier for TINI to analyse their work.”

It was suggested that since technology is the Prerak’s strength, it should be used in some capacity building for POSHAN Abhiyaan.

In Telangana, a Prerak suggested that Preraks should also be asked to monitor FCR (food supply management) data, and be kept in the loop so that they could suggest innovative ideas for how to stop wastage of THR (which is reportedly used as cattle feed by beneficiaries).

A Prerak in Assam suggested that Preraks could be presented with opportunities by TINI for capacity building (photography, documentation, subject-specific knowledge, according to her); she also suggested that some inter-district visits for Preraks would help them understand how challenges were tackled in other areas of the State.

Lastly, it was suggested by an outlier respondent that the role of the Prerak could be redesigned to provide them with some control over and/or involvement in ICDS tasks to make POSHAN more effective. For instance, as suggested by one of the respondents: Preraks should be “…able to focus on all beneficiaries, not just mothers”.

6.4.3. Possible Outcome Indicators for the SBP Programme

According to the TINI core team: since the goals of the Programme have not been structured rigidly, TINI reportedly found it challenging—due to a

lack of authority with the district administration in particular—not only to implement and monitor the Program, but also to clearly demonstrate the performance and the impact of the SBP Programme on the implementation of the POSHAN Abhiyaan. A senior TINI team member suggested that taking a cue from strategies of the World Bank, certain Disbursement Linked Indicators (DLIs) could be used; however, administration in various districts were reportedly not welcoming of this idea. Other team members shared that delineating the Programme’s contribution to the implementation of POSHAN Abhiyaan has also proven difficult due to the lack of baseline data, as well as a perceived reluctance on the part of the districts to credit the Preraks for their contributions (since it might imply that the government machinery is not performing optimally). As one senior member highlighted, any change or positive trend in outcomes would take a considerable period of time in any effort as herculean as reducing undernutrition in the country.

Apart from using progress in the existing POSHAN Abhiyaan components as indicators for the success of the Programme, other outcome indicators suggested by TINI officials and Preraks were as follows: drafting of innovation proposals, use of innovation funds, convergence activities, documenting efforts of the Prerak, the use of technology, bolstering research output by publishing research papers about the SBP Programme. These were perceived to be not necessarily quantitative indicators; some respondents were open to the idea of qualitative indicators as well. According to a few POs interviewed, some nutritional indicators for the particular districts could also be taken into account while assessing the impact of the SBP Programme on the implementation of the POSHAN Abhiyaan.


PERSPECTIVES FROM THE TINI CORE TEAMWhen asked about the goals for the Programme in the times ahead, members of the core team offered the following suggestions and recommendations:

i. Clearer, more concrete deliverables should be designed for Preraks;

ii. More negotiating/executive power is needed for TINI especially in its interactions with States;

iii. The duration of the Fellowship must be decided upon and adhered to in order to avoid fatigue among Preraks who work for more than two years;

iv. Better communication within the TINI team hierarchy is required;

v. Acomponent pertaining to research or value addition should be included in the Programme to ensure that Preraks are seen as Fellows and not merely employees;

vi. The Programme can be withdrawn from self-sufficient States in order to focus resources and strategy on States that need them the most;

vii. A set of reliable outcome indicators which would inspire confidence in the donors to continue the Programme for a longer period of time; and

viii. Expanding the core team by hiring newer members who have expertise in the fields of public health and nutrition.

A senior team member summarised the suggestions in a manner that would conclude this section fittingly: in the next two years, the SBP Programmecould be steered in a different direction, where instead of the Preraks being used merely as administrative ‘foot soldiers’, the Fellows are provided the opportunity to play more of a managerial rolein the district. By focusing on streamlining convergence and on providing critical strategic inputs, the Preraks could contribute to the implementation of the POSHAN Abhiyaan in more concrete and fruitful ways.


07EFFECT OF THE SBP PROGRAMME ON THE PRERAKS

In terms of the Programme’s effect on the Preraks, most members of the TINI core team concurred that the experience has aided the personal and professional growth many young candidates who have been associated with the Programme. Many of them have reportedly developed a sensitivity regarding the processes and challenges of tackling a grave and multisectoral issue such as undernutrition. In the view of a senior team member, this helped transform them into a ‘good citizen’ and thus was a good investment—and indeed, a great achievement of the Programme. However, it was also suggested that if this transformation is to be one of the thrusts of the Programme, then it ought to be a dominant theme in the Programme, and not be perceived as a mere side-effect of the same.

Our quantitative findings revealed the areas of learnings as reported by the Preraks (Fig. 7.1):

As observed, among the biggest learnings reported by the surveyed Preraks were the knowledge of how government machinery works, development of sensitivity towards challenges faced by frontline workers, and people skills such as relationship management and communication.

7.1. PROFESSIONAL LEARNINGS Each Prerak has had a different journey with the SBP program. For some Preraks, this Fellowship was an attempt to understand the government’s workings and processes in the field of nutrition. As one Prerak described it:

FIGURE 7.1: Findings from the quantitative survey about learnings from the SBP Programme.

Percentage of Preraks reportedLearning

How social sector/government machinery worksSensitivity towards problems that government and

frontline workers have to face

People skills

A sense of fulfilling civic duty/giving back to the society

More clarity in terms of what you want to do in the future

Setting achievable goals

Prioritisation of tasks

How to innovate and solve problems creatively

Time management


“Actually my plan for the future is that I want to get into public policymaking. So, I think if I go someplace where I can bring about a change, I think these experiences from the field will help me devise policies that are much more effective for the person in the last line also...I think I will be able to do much better.”

Several Preraks perceived this Programme as an important boost to their careers in the field of development and social work. Many Preraks stated that the Programme has helped them acquaint themselves with government departments and administration, human resource management and program management skills; they had reportedly honed their problem solving skills and confidence during their tenure. Some respondents also shared with the researchers certain aspects of personal and professional growth that came with their current tenure. As a Prerak in Maharashtra reported:

“I quit my previous job because I did not feel like I was doing justice to my educational background. When I joined (the SBP Program), I wanted to work on the issue of livelihood, as I have a background in social entrepreneurship. Currently, I am working on a proposal to help women working in SHGs…it (will hopefully) happen in the future!”

Preraks also reported having become more polite and patient in the face of slow-moving governmental processes. For example, a Prerak in Telangana shared that after many years of working independently, her tenure as a Prerak had taught her to work in a traditional work setup. She subsequently became less chaotic in her style of working, learning to take constant feedback and how to work in a team:

“R: I have been in the kind of work where I work alone, where I submit my work when I am done

with my work, which was not the case with Tata’s work, which was constantly taking feedback and improving myself and improving my process of working which was one of the good things you have in a professional scenario. Personally, as much as a cliché that it is to say, teambuilding, that you have to work as a team, it was quite difficult for me to make a habit of it and delve into a team and say that we are going to do this. “

I: Do you find that reflecting even in your personal life, or do you feel that you will take this learning even in your next career choice? Do you think this will have a lasting impact on how you deal with work and people at work?

R: Definitely! Working in a government office, working with Tata, with authorities as such, having an actual boss for the first time who is directly in front of you. All of these are good enough to qualify for milestones and teach you that when you are at a job, his is how you have to interact with your boss, this is how you have to be at a workplace if you want feedback you need to have a proper mechanism in place, which you can tell them that this is what I followed, this is where I’ve stopped…which are learnings from this particular job in itself. So, all the fundamentals of how working should go about have been learnt from this proper job itself because all that I have done before this is remote work, which is widely different from this.”

7.2. PERSONAL LEARNINGS For some Preraks, being a part of this Programme has led to unexpected benefits in their personal lives. As one Prerak in Maharashtra shared:

“I have learnt so many interesting things in detail… (Because of my work as a Prerak) I could give my sister good advice and many options regarding nutrition when she was pregnant. When she had a baby, I already knew what diet the child should have, what habits were necessary (to ensure good nutrition…”.


Another Prerak shared how the experience had contributed to their personal growth:

“I think in my personal life, (the Programme) has made me more open in terms of interaction. For instance, all those self-doubts have been transformed into possibilities in terms of how you perform, how you interact. It builds a lot of confidence when you are interacting with all those top-notch bureaucrats at the district level. And when they are ready to listen to you, it is personally transforming because you feel good about yourself; you are valued...”

A Prerak in Uttar Pradesh recounted how the SBP Programme had helped him, an introvert, to develop more efficient communication skills as well as an interest in the field of health and nutrition:

“My interpersonal skills have developed; I can easily interact with anyone. Being an introvert earlier, it’s a development. How to talk to people at different levels and how to deal with the public: these things I have learnt and become better at. Health and nutrition has never been my background, but now I have developed an interest in it.”

Making field visits, meeting with beneficiaries and trying to find solutions to problems they faced: these were cited by Preraks as important experiences for their learning curve. For example, a Prerak in Maharashtra spoke of her overnight stay in one of the more remote projects of her district, where she stayed with the Lady Supervisor for a few days. She described witnessing firsthand the hardships they face in carrying out ICDS and POSHAN deliverables, which seemed to have an effect on her motivation to help ease the POSHAN implementation process in whatever way she could.

7.3. NEW PERSPECTIVES DEVELOPED DURING THE FELLOWSHIP

For a few Preraks, the Program has reportedly taught them how to work. While initially there was a time when their dedication to work was low due to their “helpless, lacking support” situation, soon after deployment their levels of dedication peaked because of their conviction to make a difference, albeit at the micro level. For example, being able to bring a small change in “one life” (that of the beneficiary) brought a huge change in how one Prerak thought about life. Every small healthy change that these Preraks could bring in the beneficiaries’ lives has enhanced their passion for work, even though they faced hurdles which were difficult or even impossible for them to eliminate.

Others, such as a Prerak in Himachal Pradesh, have come to appreciate the stress under which field functionaries work in difficult circumstances to deliver services to beneficiaries:

“Basically, any program that the government launches, the AWWs are assigned some duty. How can we expect them to perform their duties along with this other work as well? This sidelines their main work and they are used for other work, such as election duty. By talking to the grass level functions, I was made aware of the challenges that they face, too. Sometimes there are no answers that I can provide them with, because those are all administrative challenges that I don’t have much say in…”

Another Prerak described how, being enrolled in the Programme had made him think about himself differently. He shared that during the initial period of his tenure, he was not dedicated and merely “did the minimal so as to not get fired”. However, his growth occurred along with the Programme: while bringing about a change in the district and


working towards the betterment of children’s health, he became more determined and came to develop respect for his own work.

“R: When I looked upon this programme, my main perception was to generate an income for me so that I can support myself. And work in a minimalistic manner and pursue my studies. That was my perception when I looked into this programme. As I was already preparing for civil services, I knew the government schemes, programmes, initiatives, everything. So, while giving the interview, I was pretty confident that I will know what they are asking. I guess that worked in my favour, I got into the programme. After coming into the programme, for the initial few months I was sceptical about working very much. I worked enough so that I could just be at the edge.

I: To not get fired.

R: To not get fired; and the District Administration doesn’t complain directly. But not probably for the potential I had in myself. Later on, when I got the intent of the programme and the responsibilities, or the things that I could fulfil here, probably even changing a person, children’s lives over here, and then I felt really good about working in this. Because, if in a month there is change in even a single child’s life, I was very happy.”


088.1. INTERPRETATIONS OF

RELATIONSHIPS BETWEEN THEMES IDENTIFIED IN THE DATA

On the whole, in all the sampled districts we observed that the Prerak has had some impact on the district ecosystem, albeit to varying degrees depending on local factors. Their technical know-how and digital competency, familiarity and comfort with data analysis and data-driven monitoring, as well as their efforts towards buttressing the intangible aspect of motivation and encouragement amongst the field functionaries have all provided an overall boost to the POSHAN Abhiyaan implementation process. Some logistical and administrative hurdles persisted. Some of these could be addressed to some extent by reworking the guidelines and deliverables of the SBP Programme to be clearer; however, other larger, deep-rooted sociocultural and administrative factors are beyond the control of any one person—Prerak or otherwise. Challenges and shortcomings pertaining to the ICDS system are outside the Preraks’ control, and do limit their ability to catalyse the district ecosystem. A larger, more holistic host of measures will be needed to address such issues; this would need more than one programme or scheme—although multiple initiatives like the SBP Programme, which focus on direct as well as indirect factors affecting POSHAN implementation, can help address these barriers to nutrition. This should be considered when attempting to measure the impact of such a Programme.

DISCUSSION

Wherever possible, State Leads assisted the Preraks in smoothing over challenges—or at the very least, working around them. However, some concrete steps could nevertheless be taken in order to streamline the SBP Programme and provide increased support to the Preraks working on ground. The primary ones that we recommend are taking steps to ensure that the government as a stakeholder is more involved and accountable in this Programme; and, steps by TINI to negotiate for more executive control as an implementation partner, to be able to contribute actionable inputs to the POSHAN Abhiyaan. Along with this, Preraks must be provided with more in-depth, State- and district-specific knowledge and insights before they arrive at the districts: special attention needs to be given to recruits who do not have a background in health and nutrition. Relationship management being made a more integral part of the initial training might help the Preraks tackle many of the personnel-related issues they face when they eventually begin working in the field. This would require extended on-ground support from State Leads, as well as a robust, triangulated feedback mechanism between the Preraks, the district officials, and the TINI core team. Introducing an effective monitoring tool for Preraks as well as State Leads, that is uniform on core responsibilities but flexible in terms of content, would help in bringing everyone at par and also measuring the impact that Preraks have across many districts. A clearer set of guidelines and a more definitive MOU with the Centre and the States might help increase the acceptability


of the Programme and consequently the Preraks at the district level. All of these factors, when considered together, can substantially improve the implementation of the SBP Programme, making its impact on the rollout of POSHAN Abhiyaan all the more visible and measurable.

8.2. OUR RECOMMENDATIONS TO DEVELOP THE SBP PROGRAMME IN THE FUTURE

Suggested Programmatic Changes:

1. The MOU signed by the MoWCD and The Tata Trusts needs to better highlight the Preraks’ deep involvement in data-driven monitoring, and explicitly state that their findings be considered seriously by the district administration after receiving feedback from the DM. Signing MoUs with States instead of Centre could help combat ownership/acceptance issues, while also making it possible to tailor the Programme to what specific states and districts actually need from Preraks. The language of the MOU with the Centre and/or the State could further clarify that any improvements the Ministries and/or State and district administration expect due to the placement of the Preraks are to be understood as contingent on the Preraks’ recommendations being implemented. Integrating VSTFs/ZSBPs/development partners into the SBP’s points of contact/interfaces could help convert identified needs for change into actions.

2. More acceptance and ownership of the Programme by the States could be facilitated by tailoring the Programme deliverables to the individual needs of each State, based on detailed conversations that TINI has with State officials regarding what the Preraks are expected to do. The appointment of Preraks to districts could also be made contingent on

the district prioritizing the POSHAN Abhiyaan implementation. In districts which do not prioritize the POSHAN Abhiyaan, a gentle easing-out of the Prerak and appointment in a different district after a few months could be an option as well.

3. Formal, regular communication/meetings at the central level between TINI and MoWCD could be helpful. An organized feedback mechanism needs to be established between the districts and TINI as well. A process could be established to ensure transparency in data collected through the SBP Programme and reported in collaboration with other stakeholders. Perhaps these negotiations could be channelled through third party auditors working with TINI and stakeholders such as the CPMU.

4. State Leads could make regular field visits as well as have regular conversations with the reporting officers. This can help streamline the linkages with the district administration. A concise set of standard indicators, and mutually agreed on with the reporting officers, could be developed at the start of the association between TINI and the district. Understanding what the district expects from the Programme and adding the same to this list could help increase the efficiency of the Preraks’ tenure. This would provide clarity to all (Preraks, district officials, State Leads) about what to expect and monitor. A set of indicators which are minimally required from all Preraks could be developed from the existing list of such indicators, but importantly, this needs to be shared with the reporting officers. Additionally, at least two district-specific indicators could be added.

5. A larger, more experienced core team at TINI, with a robust background in health and nutrition (at Centre and State levels), might be able to negotiate better with the appropriate


committees at the Centre to ensure that the SBP Programme is working at its optimum. A closer look is also needed at how State Leads function, what is expected of them as a part of the TINI machinery, and how their performance is monitored by TINI. More than one State Lead could be appointed, especially in larger States, to help manage the Preraks. A formal peer-to-peer digital platform for interaction between Preraks can be established.

Suggestions Pertaining to the Responsibilities of a Prerak:

6. There is a reported mismatch between the on-paper deliverables for the Prerak and what the SBPs are told in the training: “go for the lowest hanging fruit”, as mentioned by the SBPs. This could be acknowledged to ensure the Prerak’s efforts do not look miniscule/ disproportionate when compared to the current expansive job chart. It may be worthwhile even paring down the list of expectations to one/two important aspects of POSHAN, such as governance or funds utilization. Further, the roles and responsibilities of the Prerak also need to take into account the changing nature of the POSHAN Abhiyaan itself. The flexibility in the SBPs’ roles and responsibilities needs to be clearly worded, not just in terms of the content area where Preraks are expected to contribute but also in the nature of their contribution. For instance, guidelines could clarify that Preraks are expected to help with planning, prioritizing the tasks for the frontline workers to focus on, organizing district-level meetings, monitoring, supervision, and so on. The guidelines could also spell out that Preraks are expected to work closely with district-level officials and not to get involved in the day-to-day implementation of POSHAN activities at the sub-district levels. Accompanying these

guidelines, a more central, formalized missive from TINI to the district administration could help to provide clarity regarding the roles and responsibility of the Preraks. Also, regular correspondence to the districts from the State as well as TINI regarding the role of the Prerak would help improve the situation. We strongly recommend that an initial meeting of the newly-appointed Prerak, at the start of their tenure, be held with the DM/DC, DPO, the state POSHAN coordinator, and the State Lead. The purpose of the meeting would be to discuss, negotiate, and decide a few clearly delineated responsibilities of the Prerak in that specific district, based on the district’s requirements at that point in time.

7. The responsibilities of the Prerak could include an aspect of teaching/training of district and block-level functionaries in the skills needed for the management and administration of POSHAN-related activities. Preraks should be encouraged to teach/train a few district functionaries in the use of spreadsheets, interpreting data for quick decision-making, having regular strategic meetings to discuss innovative approaches to getting the approvals needed, ideas to streamline scheduling based on the availability of different officials, and other such tasks in order to keep the POSHAN Abhiyaan implementation on track. This would likely increase the functionaries’ capabilities and ensure that a portion of the Prerak’s time is spent on having a catalytic impact. An explicit appreciation for such capacity building, accompanied by a corresponding monitoring indicator (such as “What skills did you teach this month and to whom?”) is recommended.

8. While tasks not related to POSHAN did make up significant portions of the Preraks’ work in the district—especially at the start of their tenure—it might be useful to look at


such work as a part of a cohesive whole that contributed to bettering the district’s position with respect to nutrition. While Preraks cannot be expected to change district funding structures/priorities, their deliverables can be broadened to include peripheral tasks as legitimate efforts towards a multipronged tackling of undernutrition in the district by helping the district where it actually needs their aid.

9. More freedom could be given to Preraks to combat the reported lack of executive powers, as in the ZSBP programme. Some research output/value addition aspects could also be added to Preraks’ deliverables. This could possibly also function as an outcome indicator for the Programme as a whole.

Suggestions to Improve Recruitment and Training:

10. We recommend a more rigorous Prerak selection process with an emphasis on not only familiarity with nutrition and health, but also emotional intelligence and people skills. If Preraks with no background in nutrition and health are recruited, they should be given training in these areas--along with a longer field immersion--to help them ease into their role with a better idea of on-ground realities. Alternatively, hiring Preraks with social work/health background, especially for aspirational districts, might help alleviate the perceived lack of experience among Preraks. The selection process must also assess the candidates on their approaches to conflict resolution, their attitudes towards working in a hierarchical structure, and their ability to deal with constant, unpredictable impediments in achieving goals. TINI must also emphasize these skills during the State-level training to help Preraks hone these skills, preferably also inviting the Preraks who are already posted in that State to share their experiences and advice.

11. Training given to Preraks needs to include information that acknowledges that there is a great diversity in how the ICDS operates in different states. The state-level training needs to orient the Preraks to the state-specific aspects of the ICDS. Relationship management should feature more prominently in the training/orientation. State Leads must also have protocols in place for training new recruits at the State level by providing them local and regional level inputs that would help Preraks build rapport with their reporting officers.

Suggestions Regarding Feedback Mechanism and Support Provided by TINI:

12. We recommend that the contribution of Preraks be viewed bearing in mind the tasks they were asked to perform by their reporting officers. Feedback sought by the Project Officers/State Leads from the DPOs can be triangulated with inputs received from the State Leads and the Preraks themselves. The outcome indicators/evaluation mechanism can take some inputs (quantitative and/or qualitative) from district officials to ensure that the Program is looping in the district administration in a meaningful manner. State Leads should be integrated into the Prerak-DM-reporting officer structure of monitoring formally through constituting proper channels and SOPs of regular feedback loops for which they are held accountable by TINI.

13. With respect to personnel-related issues arising in the district, clear and firm guidelines from the States regarding Preraks’ role and their purpose in the district, as well as a top-down culture (consistent with traditional bureaucratic hierarchies) of involving and accepting Preraks into the MoWCD fold might help iron out many such challenges. The State Leads also need to be properly trained with skills to negotiate situations


of conflict, manage human resources, and provide suggestions wherever and whenever necessary—both to the district headquarters and the Preraks.

14. We recommend setting up opportunities for Preraks to have regular formal interactions with other Preraks, where issues are discussed in collaboration with the TINI team. Regular refresher training and Prerak review meetings can also be held to discuss learnings and sharing of skills learned to work with higher officials.

15. Increased logistical support from TINI can also reduce the financial and logistical burden that the district administration currently faces in providing the Prerak with the adequate resources. Perhaps a desktop or laptop could be provided to the Prerak by TINI, and the majority of a Prerak’s responsibilities could be restricted to the district level itself. Simple

arrangements/agreements could be reached by the State Leads by visiting and speaking with the district officials before the Preraks’ arrival to their respective districts (e.g. deciding where they will sit, what resources can be provided by the district). These symbolic gestures could go a long way in helping improve the acceptance and ownership that a district displays towards a Prerak.

Lastly, we acknowledge that challenges and shortcomings pertaining to the ICDS system are outside the Preraks’ control, and do limit their ability to catalyse the district ecosystem. A larger, more holistic host of measures will be needed to address such issues; this would need more than one programme or scheme—although multiple initiatives like the SBP Programme, which focus on direct as well as indirect factors affecting POSHAN implementation, can help address these barriers to nutrition.


A. STATES SELECTED FOR THE STUDY: PHASE-WISE BREAK UP

NOTE: Two districts from each State were chosen to be sampled based on their performance indicators in the field of nutrition.

B. GROUP-WISE BREAK UP OF RESPONDENTS FOR IN-DEPTH INTERVIEWS/FGDs

PHASE II (N=10)

Assam

Himachal Pradesh

Tamil Nadu

Telangana

Uttarakhand

PHASE I (N=10)

Bihar

Madhya Pradesh

Maharashtra

Rajasthan

Uttar Pradesh

RESPONDENT TYPE NO. OF RESPONDENTS INTERVIEWED

Swasth Bharat Preraks 20

State Leads 10

Program Officers/TINI Core Team Members 06

DPOs/DWOs/Dy CEOs (ICDS) 09

District Collectors/District Magistrates/CEOs 05

POSHAN Abhiyaan officials at district and sub-district levels (DCs/DPAs/BCs)

07

Other district-level officials (Extension Officers, heads of line departments such as DMHOs, DEOs etc.)

05

ICDS sub-district officials and field functionaries (CDPOs/LSs/AWWs etc.)

15

Consultants/other development partners in the districts 02

ANNEXURES


Start time:

End time:

hours mins

hours mins

Name of the Prerak:

Name of the State and District:

Type of the District:

Mainly rural/urban/ tribal Aspirational district? Yes/No

Month and Year of joining as SBP:

Educational Qualification:

Total Work Experience (short work history):

Interviewer Comments (Note to reviewer: Additional field notes will be submitted by the interviewer in a separate sheet. This is just to jot down any quick points about general mood/tone, others in the room, and any other relevant information.)

C. IN-DEPTH INTERVIEW GUIDE FOR SWASTH BHARAT PRERAKS

NOTE: This is a sample guide. Similar guides were prepared for and used with other types of respondents such as TINI core team members and district officials.

(Note to reviewer: We will begin after obtaining written informed consent. A separate consent form will be used. This is just the suggested opening for the actual interview to begin.) Thank you for agreeing to talk to us! We will begin by chatting about your responsibilities as the Prerak in your district, and will then proceed to talk about your views and experiences with respect to the Swasth Bharat Prerak program in general. If any of our questions make you uncomfortable, please feel free to not answer that question. Shall we begin?

Proceed after the interviewee gives consent to be interviewed:

FORM 1:

SECTION 1: General Information, Tasks and Responsibilities, Organisational Structure, Training and Capacity of Human Resource

1. How did you hear about the program? And what did you learn about it when you were first introduced to the program?

n Where did you get to know about this opportunity?

n What were you briefed about the program when applied?

n What kind of training did you receive and how/when did you joined the district? What topics did the training cover?

n Describe your experience of the training period. What did you think? What did you like? What was puzzling? Any changes that you had first thought of? Any changes you recommend now? Did the training enable/not enable you to manage this role? What skills did you learn from the training which have helped you to conduct your work in the implementation of POSHAN Abhiyaan activities?

n What was told about your goals and ways to accomplish them?


n Did these change after you joined as Prerak?

n (Ask at an opportune moment:) What advice would you give to someone who is newly joining as a Prerak?

2. Please tell me what your roles and responsibilities are.

n How do you achieve these?

n What are the specific tasks that you need to carry out?

n How often do you have to do…..?

n Whom do you need to work with?

n How do this collaborative work help?

Probe specifically about any tasks related to:

n eeds assessment and strategizing

n Planning

n Executing activities, change management

n Documenting

n Capacity building

n Resource management

n Administration

n Stakeholder engagement and Intersectoral collaboration

n Monitoring and data-driven decision making

n Other “non-productive” activities xcvxcv (probe here about what these activities are, and how much time they spend on these).

3. How different is the work you do in the field and at the office when compared to what you thought it was when you joined?

— What were your expectations from the job before you joined as a Prerak?

— Have your expectations changed over the year(s) and how?

— Do you have an idea if the other Preraks feel the same, or is it different for them? How is it different? (Reasons. Examples.)

4. You have already shared that your main responsibilities are …… Now please tell me if there are factors that prevent you from meeting those responsibilities…...what you may consider as barriers to your work (Probe: It could be about the execution or the planning, administration etc)?

(Probes: clerical/non-productive work, friction with district officials, lack of resources/vehicular support, sidelining of SBP deliverables in favour of State schemes, perception of the Prerak/TINI as an “outsider”, lack of clarity reg. Prerak’s role)


Follow-up (about each barrier mentioned): Why do you consider ___ to be a barrier? Exactly how does it affect your work? What do

you do (strategies) in order to overcome these barriers? Summarize: Let me see if I have noted everything you said, you mentioned A, B, and C.

Anything else?

5. Among all of the work, what specific tasks as a Prerak do you think are more important to the program? Follow-up: Why did you mention these tasks, what are your reasons?

6. What are the resources you require to carry out your duties. Do you get the required resources? (If not, how do you manage? Whom do you approach?) What additional resources do you think you need for your work?

7. What are the different ways in which you receive support from higher authorities? (administrative/managerial/execution etc.)

n Probe: communication, execution, releasing orders, organizing events, on-service orientation, feedback. Any other?

n Does it sometimes differ from the way it is described in program documents? (Ask for examples.)

n Is the support received enough? Is it timely? Is it helpful?

n Is there any other kind of support that you wish you could get?

8. Are you able to complete all the activities expected as part of your job description? If not, why? How much time do you spend in responding to situations versus being proactive? Do you sometimes need to respond to unexpected events that need urgent attention? Examples? How do you respond to such situations? Do you have enough resources and support to act in such situations?

9. What is your assessment of how your presence was received by the district officials of all relevant line departments?

n Examples, details.

n Was there a change in how you were perceived initially versus now?

n What do you think led to the change?

n What strategies helped you work with different departments and officials at different levels? What did not work well?

10. Have you noticed a difference in the attitude towards and actual practices related to convergence in your district?

n Among whom? Please share examples.

n What do you think prompted this change?

11. What competencies/skills do you think are required in a person who wants to work as a Prerak?


12. (Ask if this has not already been covered:) Thinking about yourself specifically, what did you think should have been included/removed/changed in the training which would have equipped you with the skills you require for your job as a Prerak?

SECTION 2: Ease of the Abhiyaan roll-outs

13. Are there times when you and functionaries of other departments work together? Which other departments are you associated with?

n Probe specifically about departments: health, education, PRI, water and sanitation.

n If the respondent is unable to think of an example, use pointers: ask how they work with other departments for VHSNDs/immunisation camps/ECE scheme etc.

n Does working with other departments help? Why/why not? Give an example.

14. What is your role in promoting convergence in POSHAN Abhiyaan?

n What is your role in planning/organizing/leading/controlling activities in POSHAN Abhiyaan convergence?

15. What are the activities which you conduct on a monthly basis as part of convergence for POSHAN Abhiyaan and how frequently?

n E.g.: formation of block and district convergence committees, CAP meetings etc.

n How do you plan/perceive the need to initiate these activities? Were these activities implemented as planned? If not, why?

16. How much time in a day/week/month do you spend on each of these activities?

n Are there any particular aspects needing more/less time? (Productivity- the ratio of time spent on valuable/required services to time spent on non-required services)

17. How much of control do you have on the execution of activities? More or less? Why?

18. How do you decide/prioritize your activities in terms of execution?

19. How many and which community events (VHSNDs, sensitization workshops, Jan Andolan activities, etc) do you participate in on a monthly basis?

20. Where do you conduct visits/implement BC activities – AWC, panchayat, health centre, home visits, block development office etc?

21. How many behaviour change and community mobilization events were conducted in your district in the past one month/quarter? (such as anaemia camp, VHSND, POSHAN rally, panchayat meetings, nukkad nataks, school-based meetings, SHG meetings, home visits etc).

n How many tehsils/villages/hamlets could you cover in your district?

n Who participated in the events conducted?

n How many people/communities could you reach out to?


22. Please describe the various ways you participated or played a role in the behaviour change and mobilization events – Probe: Initiate/coordinate? Manage/supervise existing activities? Identify challenges and resolve? Generate community awareness? etc.

23. How do you capture/record your activities related to behaviour change and mobilization? What do you report on your work pertaining to this component of POSHAN Abhiyaan (Ask for log books, documents such as village development/action plans for nutrition if available.)

n Do you receive any feedback? How do you respond to it?

24. In all of these activities, did you receive any support from the government officials and community members? Who supported/not support you? Which members and what kind of support did you receive?

25. Describe your experience of implementing behaviour change and mobilization activities – what were the challenges identified and how did you resolve them?

n Can you give us an example of a problem which you faced, how did you resolve it?

n Which parts of behaviour change and mobilization activities worked/not worked and why?

n Can you share any best practices, role models or success stories in terms of implementing various components of POSHAN Abhiyaan which you have documented and replicated?

26. In your experience, how well did these activities work? What were the key issues identified related to nutrition in your district?

n Was there a difference as compared to what existed before you started working?

n Do you observe any change in the community’s perceptions, attitudes, and behaviours on child nutrition?

27. Describe your role in conducting capacity building activities in your district. How many trainings have you conducted at the block and sector level?

28. How did you support the formation of district and block resource groups (DRG, BRG)? Describe your role in terms of execution/coordination/management/monitoring. Could you please share a few examples?

29. How did you monitor/ensure quality of training in your district? Can you share some of the gaps that you found in training quality? How did you address them? Did you receive support from stakeholders (e.g. CDPOs)?

30. What challenges did you face and how did you overcome them? Please share examples. (Challenges in meeting prerequisites? Conducting training activities? A lack of support from stakeholders? etc.)

31. Please describe your role in supporting CAS activities in your district. How did you assist in rolling out CAS including CAS training, data collection and monitoring?


32. How many Anganwadi centers in your district are collecting data on CAS?

— What issues are being faced by AWWs in using CAS and how do you resolve them?

— Please share examples where you have supported AWCs and improved the use of CAS.

33. Any challenges faced in implementing CAS in your district? How did you overcome them?

34. Apart from these areas, are there any other tasks/projects/work that you have undertaken that is related to nutrition? This can be POSHAN-related or otherwise. What are these tasks/projects?

(Probe: Why did you choose this task/project? Who do you collaborate with for this? Does the WCD staff help you with this work? How so? How do you split your time between the POSHAN/SBP deliverables and this work? Do you think these projects have in any way affected your work on the deliverables? How? Do you think adding this task to a Prerak’s JD can help them fulfil their primary tasks better?)

35. Overall, what would you say about the implementation of POSHAN Abhiyaan in your district? How has your arrival and contribution to the Abhiyaan changed the district performance? (Probe: Do you think things could be done better on the district level? What would be your top 3 suggestions to turn this district into an ideal one with respect to POSHAN? How do you envisage the Prerak contributing to this vision?)

36. If you had to suggest 3-4 outcome indicators for the SBP program, based on which we can track its progress, what would these be?

(Probe: Ask for the logic behind each suggestion, e.g. any specific experiences they have had because of which they believe these are good outcome indicators. If needed, use additional probes regarding potential indicators: fund utilisation, interdepartmental convergence (ILA, line department convergence, BRGs/DRGs), innovation proposals developed by Preraks, behaviour change communication.

Clarify that this question is not about the position of the SBP, but the program on the whole.)

37. What has your role been in the Covid-19 related response in your district? How did your district attempt to keep the functioning of POSHAN Abhiyaan on track during the pandemic? What was your role in these steps taken? (Did you help innovate and brainstorm new ways to reach beneficiaries with THR and rations? What worked and what did not? Why? Has this crisis made you think of the role of the Prerak in the district differently? Do you think the Prerak can go above and beyond their JD in such exceptional times to aid their district when all of the ICDS machinery is pulled in for non-POSHAN related/relief work? How so? Please give examples from your own experience in the past few weeks.)


SECTION 3: Effect of the SBP program on the Preraks

38. Now please think about your experience as a Prerak, as a whole. What do you think of the whole experience? What have you personally learned from this experience?

— What initially inspired you to apply to this program. (Probe: Did it fit with her experience with the program later? Do not ask directly, but see if there is any mention of “give back to society.”)

39. Are you content with what you were able to achieve, and responsibilities assigned to you? If yes/no, why? What else would you have liked to work on?

40. Every experience in life teaches us something, whether positive or negative. Has there been any change in how you think? Please share examples.

n What are your plans for the future, what next? Is this what you had planned all along? (Probe to see if experience as a Prerak influenced any life choices they mention. Ask them to describe the event(s) that they think were landmarks/very significant in their experience as a SBP.)

41. Given a choice, would you like to continue to work as a Prerak for some more time? Why/why not? Any suggestions for modifications in the Prerak program to make it even better?

42. Are there any other questions that you think we should have asked you? Would you like to add any additional comments?

43. On a scale of 1 to 5, where 1 is the least content and 5 is the most content, kindly rate how content you are with your job as the Prerak. (Probe why that rating?)

1 2 3 4 5

Thank you for taking the time to talk to us!

D. PERSPECTIVES ON THE POSHAN ABHIYAAN: PRERAKS & STATE LEADS

Select Preraks and TINI team members were asked to share their views on how the implementation of POSHAN Abhiyaan has been progressing in their respective districts/regions. Compiled below are their observations, views and suggestions.

In Maharashtra, officials in various districts reportedly had written to the State administration asking for Preraks to be appointed to their districts. According to the Maharashtra State Lead, implementation of POSHAN Abhiyaan in Maharashtra had seen incremental improvements since its launch. Preraks analyse secondary data sources to bring analytical insights to POSHAN Abhiyaan: they monitor the situation on the field by examining CAS data, and help improve the implementation of POSHAN Abhiyaan. According to the State Lead, Preraks are the ‘eyes of the program’: he reported that “Prerak-led innovation projects drive POSHAN Abhiyaan in Maharashtra”.


In Andhra Pradesh and Telangana, POSHAN Abhiyaan implementation has taken different trajectories. It is helpful to observe both states to understand how regional differences in administration and attitudes towards the POSHAN Abhiyaan ultimately affect its implementation. POSHAN Abhiyaan (erstwhile ISSNIP) was introduced in Andhra Pradesh in 2017, while Telangana introduced the same in 2019. According to the State Lead, in Andhra Pradesh the S-CAP has been established at the State level, and the review meetings take place regularly. However, in Telangana the CAP has been delayed across levels due to the administrative issue of district diversification and difference in block/mandal classification. Both these factors reportedly affect how ICDS projects are divided and administered across Telangana. According to the State Lead, the Preraks headed the convergence efforts in Andhra Pradesh. Senior officials in the state also pushed for convergence, which helped the POSHAN Abhiyaan efforts considerably. In Telangana however, the journey of the SBP Programme has been more laborious due to administrative issues that have slowed the process down. All modules of ILA have been rolled out in Andhra Pradesh, while Telangana is still in the process of the rollout. Preraks reportedly arrange, execute, monitor, and obtain feedback for this process.

The State Lead also shared that implementation of BCEs has been successful in both Telangana and Andhra Pradesh; Preraks design these events at the district level, monitor the POSHAN Abhiyaan calendar, and modify the schedules to suit the state/district needs as required. In his view, there needs to be more of a targeted focus on message delivery during these BCEs. He further shared that Preraks in Andhra Pradesh and Telangana have been able to get around 7 innovation proposals accepted among them, with Telangana Preraks generally enjoying a higher success rate than their counterparts in Andhra Pradesh (due to other development partners having already secured the funds for innovation). In Andhra Pradesh, some of the innovations proposed by Preraks have been as follows: providing vitamin B12 injections for pregnant women, NRC related innovation, and software application development to aid POSHAN Abhiyaan. In Telangana, Preraks have proposed innovations such as distributing seed kits to households in the community and millet-based breakfast and drinks for pregnant beneficiaries to improve their haemoglobin levels. Additional barriers faced by the Preraks in Telangana were reported as follows: the absence of SLSC meetings, which approves funds for innovation proposals; and delay in procurement of smartphones, which affects the CAS rollout.

A Prerak in Telangana reported that there was strong convergence between the Health Department and the ICDS machinery at district and grass root levels in the state, which affected the implementation positively. Further, according to her the constant counselling and training of AWWs aids in strengthening their knowledge base. Bringing together medical professionals and ICDS functionaries to talk about the concepts addressed in POSHAN Abhiyaan, and the measures being taken to reduce stunting, underweight and undernutrition helps convert the medical facts and measures from merely things learnt by rote, to something tangible and understandable for the functionaries:


“The ICDS department, in general, has a lot of staff which has been working for a very long time, for about 25-30 years. And while a lot of the medical facts remain same, their meaning is lost in time...one thing that ILA, convergence and their meetings are doing, is bringing medical professionals and the supervisors into the same room. And it helps in bringing out the message as to why we are doing what we are doing: when we are saying ‘First 1000 days’, ‘early initiation of breastfeeding’, it feels as though they become rote learnt facts. The first 1000 days are reported, but why are the first 1000 days reported, why is early initiation important, what is exactly happening in that period? (POSHAN Abhiyaan) is bringing more meaning into whatever has been learnt so far in a more effective, efficient manner which wouldn’t have happened were it not for the structuring that the Abhiyaan has.”

Some Preraks were cautious about the bigger targets set by the Abhiyaan. In the view of another Prerak, the target of reducing levels of stunting (by 2%), undernutrition (by 2%), anemia among young children, women and adolescent girls (by 3%), and low birth weight (by 2%) per annum were very ambitious targets, which were difficult to achieve. He opined that reduction in these rates by 1-2% in the next three years might be a more realistic target given the situation on the ground.

In Himachal Pradesh, the State Lead shared that the implementation of POSHAN Abhiyaan has been satisfactory until now. The State and district administration were reportedly active and supportive of the Abhiyaan. The State Lead further shared that the utilisation of funds for CBEs and ILA trainings in the state was satisfactory. According to his reports, the Preraks in districts such as Una and Solan have been successful in streamlining the implementation of POSHAN Abhiyaan through problem-solving, supervision, liaisoning with field functionaries. A Prerak in Himachal Pradesh also reported that capacity building and convergence were satisfactory in her district; additionally, the district was leading in CAS performance, and had received commendations at State level. Some common challenges remained, as she shared: inadequate mobile network coverage, issues with the CAS software and other technological glitches, and the lack of comfort and know-how around digital technology among field functionaries. Additionally, district officials were reportedly unable to attend review meetings in many instances, which hindered their ability to track the progress of the district. It was suggested that better fund utilisation could address some of these barriers. Moreover, the State Lead also recommended that information/guidelines regarding POSHAN Abhiyaan should be formally and clearly disseminated to the State and districts, which would considerably ease the peripheral workload on the Preraks in many districts.

In Uttarakhand, the State Lead stated that all the targets assigned under the POSHAN Abhiyaan had been achieved in all districts (with or without appointed Preraks): the State had procured smartphones, set up State and District Convergence Committees, conducted CBEs, formulated the CAP, disbursed (innovation) funds, and completed ILA module delivery at all levels through to the AWCs. The State has now reportedly entered the phase where monitoring has begun, which can make apparent the effects of


the intervention. According to the State Lead, the implementation, execution, planning, coordination, monitoring, and reporting for POSHAN Abhiyaan has progressed smoothly in districts where Preraks have been appointed; however, reporting on fund utilisation takes longer in districts without Preraks. Further, coordination with district officials is reportedly more labour-intensive for the State Leads in such districts, as opposed to districts which have Preraks appointed to them. Therefore, the State Leads recommended that Preraks be appointed to all districts in the Uttarakhand to further streamline the implementation of POSHAN Abhiyaan. These views were echoed by another Prerak in the state, as well.

In Assam, by contrast, a Prerak shared that while CAS rollout and Jan Andolan activities have seen some efforts at the district level, the implementation of POSHAN Abhiyaan has not been satisfactory due to the barriers to establishing convergence, an important aspect of the Abhiyaan. She further added that the major challenge had been that the D-CAP was yet to be established, and thus a large portion of the convergence component remained unfulfilled. Thus, in her view, there was still much scope for improvement in the implementation of the POSHAN Abhiyaan in Assam.


Dr. MALAVIKA SUBRAMANYAM is an Assistant Professor of Social Epidemiology at the Indian Institute of Technology Gandhinagar. She has a background in Community Medicine (MD from Manipal University), community health education (MPH from the University of Northern Colorado), and social epidemiology (DSc from Harvard University). Malavika has over 20 years of community health experience and a track record of research and public health practice related to child undernutrition in India. Her papers on this topic have been published in PLoS Medicine, Lancet Global Health, PLoS ONE, and Social Science & Medicine among others. She was a PI on a two-year long mixed-method evaluation study that investigated the impact of a complex health, nutrition, water and sanitation focused intervention called Gram Varta in rural Bihar. This evaluation study, sponsored by the International Initiative for Impact Evaluation, was in collaboration with Prof Sebastian Vollmer (the Lead PI) of the University of Goettingen. It required liaising with Bihar Rural Livelihoods Program and several other governmental and non-governmental partners. As part of this study Malavika contributed to the design and supervision of baseline and endline surveys of ~4000 households and ~2000 pregnant women in 180 villages of Madhepura district, Bihar. Malavika is also a PI (with Prof William Joe of IEG) on a qualitative inquiry into the implementation of the ICDS funded by the NITI Aayog. She has supervised several mixed methods research projects including studies on menstrual health among adolescents in Maharashtra, psychological well-being of queer men in India, evaluation of a nutrition-education intervention in the slums of Ahmedabad, digital literacy among Kerala’s community health workers, and validation of the John Henryism scale in India.

ABOUT THE EVALUATORS


ANUPAM JOYA SHARMA is a doctoral student of Social Epidemiology at the Indian Institute of Technology, Gandhinagar. He is a physicist by training and a Social Epidemiologist by choice. Anupam’s recent works include the inquiry of psychosocial wellbeing and ageing of middle-aged to older queer adults in India, psychosocial effect of the COVID-19 pandemic across social groups in India, intimate partner violence in the aftermath of natural disasters in India, and effects of reservation-based discrimination in Indian institutions. His papers on these topics have been published in reputed journals such as PLoS ONE and Ageing International (Springer). Anupam also works as a Junior Research Fellow (JRF) on a project funded by the Department of Science and Technology (DST) on the impact of climate change on health and vulnerable communities in Gujarat. He is particularly experienced in conducting qualitative interviews, including on sensitive topics, in vulnerable populations such as sexual minorities, socially disadvantaged students, and older persons seeking reproductive interventions. Anupam has more than two years of experience in working on mixed-methods projects related to nutrition and health.

AISHWARYA JOSHI is a research consultant based in Hyderabad, India. She works with academic and research institutions, non-governmental organisations, and independent researchers to provide research support for academic and academic-adjacent research projects. She is an alumna of the M.A. in Society and Culture programme at IIT Gandhinagar, and holds a B.A. in Sociology from Fergusson College, Pune. Her research interests include gender, cinema, culture, and development. Her skills lie in qualitative data analysis and conversational interviewing. Over the past two years, Aishwarya has worked on projects for the University of Goettingen, the NITI Aayog, Population Council India, and the US Consulate among others, where she has conducted literature reviews, assisted in study design, created and translated research tools, conducted fieldwork, managed baseline studies, assisted in creating and delivering workshop modules, conducted qualitative data analysis, and put together detailed reports of study results. With the help of her academic insight and interdisciplinary training in research, she strives to aid a more fruitful exchange between academia and the wide gamut of its application outside the four walls of the classroom.

swasth bharat preraks

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