The NITI Aayog (National Institution for Transforming India) launched the National Nutrition Strategy in September 2017 [6] with five specific monitorable targets to be achieved by 2022 of which the first two focus on children below six years: (i) prevent and reduce stunting in children (0-6 years) by 6% at the rate of 2% per annum and (ii) prevent and reduce under-nutrition (underweight prevalence) in children (0- 6 years) by 6% at the rate of 2% per annum [7]. In December 2017, the National Nutrition Mission (NNM) subsequently approved a multi-ministerial convergence mission to monitor, supervise and fix targets, and guide nutrition related interventions [8]. It was renamed as the POSHAN (Prime Minister’s Overarching Scheme for Holistic Nourishment) Abhiyan/ Mission (henceforth PM/PA) on 8 March 2018 [9]. The PM is guided by two policy documents, the National Nutrition Strategy and the Administrative Guidelines of the NNM across three core themes: (i) determinants of complementary feeding; (ii) convergence as the core strategy; and, (iii) IT enabled approach to monitoring.

This paper draws upon empirical evidence from our PANChSHEEEL study (that fosters collaboration between our interdisciplinary research team, local schools, frontline health workers and communities using schools and Anganwadi Centers as new innovation hubs to develop an integrated system that links health, education, engineering and environmental solutions for optimization of ICYF) in Banswara District (one of the PA districts), Rajasthan to help understand linkages between policy and practice in the PA since its inception. This mixed methods study was conducted from April 2017 to July 2019 to obtain data on Infant and Young Child Feeding (IYCF) and care practices across domains of nutrition, health, water, sanitation and hygiene (WASH) as well as education, and create a multi-dimensional intervention package through a participatory health settings approach tailored to community needs.

The study was conducted across nine villages (selected on a set of consensus criteria) of Banswara District [five in Ghatol (canal irrigated) and four in Kushalgarh (semi-arid) blocks, respectively]. Community profiling and social mapping was conducted in each village with the help of Community Researchers. Qualitative data (Phase 1) was collected using two methods – key informant interviews (49 interviews) and focus group discussions (17 FGDs), with the help of pre-tested guides in local language. Quantitative data (Phase 2) comprised of household (445 households in the nine villages with children below the age of 24 months) and maternal time use surveys (in a sub-sample of 90 households). The household survey collected data on demographic, socio-economic (under the broad domains of health, education and WASH) and IYCF indicators.

The conundrum of improvement in anthropometric indicators and decline in complementary feeding indicators in the National Family Health Survey 4 (NFHS4) makes a compelling argument for a dedicated focus on the issue of complementary feeding (CF), the first monitorable target of PA that is relatively neglected in policy, programmatic and academic discourse. IYCF practices encompass two age groups of children: 0-6 months and 6-24 months; with the latter being more critical as undernutrition sets in during this age due to lack of adequacy and diversity of foods as well as infection. Supplementary feeding interventions, infection prevention and curative measures are most effective in reducing malnutrition and promoting growth and development of a child [10].

NFHS4 data indicates a continued trend of improvement in breastfeeding practices in the first age group, but a 9.9 percentage point decline (NFHS 3: 52.6%; NFHS 4: 42.7%) in IYCF indicators [11]. Merely 9.6% children aged 6-23 months received an adequate diet including 14.3% of non-breastfeeding children and 8.7% of breastfeeding children. The declining trend is also noticeable in another indicator – children 6-8 months receiving solid or semi-solid food and breast milk.

The PA policy documents acknowledge the association of multiple factors with CF, identifying nutrition sensitive and nutrition specific factors such as access to maternal and child nutritional and health related services, drinking water, household food security, livelihood, girls’ education and interventions for vulnerable communities [12-17]. Box 1 summarizes factors that affect IYCF practices broadly classified into three levels: household, community and governance.

These factors are complexly intertwined both within and across categories; eg, one of the key emergent reasons for inadequate complementary feeding was lack of mother’s time to feed young children.

The formative phase (triangulated qualitative and quantitative data) confirmed that IYCF indicators were dismally poor across both blocks in terms of introduction of semi-solid food during the previous day, minimum dietary diversity, minimum meal frequency, minimum acceptable diet and consumption of iron-reach food. Analysis of maternal time use confirmed a crisis of care (mean time allocated to caregiving was 76.9 and 65.7 minutes in villages of Ghatol and Kushalgarh blocks, respectively) with children aged 12-24 months receiving significantly less time allocated to caregiving than those aged 0-5 months. In short our formative phase confirmed the determinants and processes summarized in Box 1, and the evidence used to design and co-create an integrated intervention package. The syncretic model was constructed through synthesis of five interlinked processes: (i) data from formative phase; (ii) discussion with community groups; (iii) collation of NGO experiences; (iv) review of national and state policies and programs; and (v) expert group advice. The output of the intervention phase consists of a series of packages with its unique set of three aims (improving breastfeeding practices from first hour of childbirth to 6 months of age; increasing minimum acceptable diet for children aged 6-24 months; and, enhancing child care practices associated with growth and development of children below 24 months), relevant facilitators and barriers, and specific components – in terms of target recipient, function, content and channel.

To its credit, the PA approach recognizes the multiple determinants affecting undernutrition in general and some of these are relevant for IYCF practices as evident from our empirical data. The chosen programs for addressing these diverse determinants have been there for long with little demonstrable effect on the indicators in the 6 months to 2 years age-band. The Integrated Child Development Services (ICDS) is a case in point; it offers little for these children except the Take Home Ration (THR); growth monitoring is a weak component and infection prevention is hardly on the agenda. The supply of THR in our study areas was regular but consumption was erratic. While most mothers did not know the correct way to cook it, some mothers also did not have time to cook separately for the children and feed them. Inadequate capacity of the frontline health functionaries, high workload, and dissatisfaction about remuneration along with shortage of managerial staff for supportive supervision resulted in their inability to respond to utilization gaps.

To reiterate the relevance of the three cross-cutting PA core intervention themes: (i) the determinants of IYCF are complex and as exemplified above, the ICDS in its present siloed form shall continue to be ill-equipped to deliver a multi-dimensional package of interventions; (ii) the IT enabled approach is essentially designed to replace the registers and streamline monitoring and there is no scope (in its present vision) to engage with indicators from other sectors (that the convergent approach seeks to address); and (iii) convergence as the core strategy is thus intended to be the game-changer.

The PM correctly recognizes that a multi-dimensional problem like undernutrition requires multi-sectoral intervention; hence the centrality of convergence as the key strategy. Besides convergence at the political level, there will be a Committee of Secretaries from various ministries at central and state levels. Committees at district and block levels will draw up Convergent Action Plans (CAP). At the community level this is envisaged through the Village Health Sanitation and Nutrition Committees (VHSNC). Recent evaluations of VHSNCs revealed low awareness among members about their role and only few specified functions for decentralized planning and action were actually undertaken [18,19]. The PA documents call for a joining of forces by converging resources, skill and knowledge and outlines elements of engagement and specific contributions of a wide range of ‘line departments’ through the CAPs which is in sync with the WHO’s call for ‘grand convergence’. In order to do so needs assessment at village/Anganwadi Center (AWC) levels across related sectors have to be conducted jointly by frontline WCD (Women and Child Development) staff and supervisors and Panchayat (local self-government) members. Each ‘line department’ shall, on the basis of these needs, prepare ‘action plans’ that will be collated as Block Convergent Action Plans (BCAPs); and upwards to district (DCAPs) and state (SCAPs) levels.

Our extensive interactions (during the preparatory phase of the current CAPs) with block and district level officials of Banswara District point to several key challenges:

In contrast, our own community workshops adopted an integrated approach to formulate a package that was grounded on the core principles of: co-designing interventions that are flexible, feasible; acceptable, adaptable, accessible; sustainable, scalable; tailored and targeted; effective; resource efficient (Co-De FASTER) [personal communication-Lakhanpaul M 2019]. Co-De FASTER captured emic views from individual, household, community, organizational and governmental levels and were able to formulate a well-rounded package of interventions (in contrast to the CAPs prepared this year) that addressed aspects of target recipients, channels, content as well as barriers and facilitators than (Box 2). Policy makers need integrated evidence and support from academia that may act as ‘policy entrepreneurs’ and the PANChSHEEEL evidence provides a glimpse of that.

Convergent planning as envisioned by the PA is a multi-sectoral governance challenge and faces several key barriers, the first of which is political, not technical: how an issue is framed and the extent to which this resonates with high-level political agenda [20]. The extent to which an actor (departments, program managers or technical leads) engages with a problem reflects a match between the nature of the problem and their own nature. There is thus a difference in levels of participation by the different actors; bringing all actors out of their ‘silos’ requires collaborative and distributive leadership that entails trust, accountability, analysis of networks, and scope of mutual learning and fostering the ability to manage conflicts; the PM documents are silent on these vital aspects of governance. For the success of such a complex mission, it is therefore important to align all the departments to these core values.

Windows of convergence open (and close) by the coupling (or de-coupling) of three streams: problems, policies and politics [21]. There is a need to focus on the relative roles of each department with respect to the commitment and motivation, funding, administration, organization and service delivery [22]. The PA is highly ambitious in aiming for a targeted reduction of key malnutrition indicators by 2022, and needs to meticulously address the emerging crisis of declines in IYCF indicators. Convergent Action Plans (CAP) is the capstone of this Abhiyan; and a lot rests on its systematic operationalization, and demonstrating a public health imagination. Effective convergence mechanisms, as visualized in the PA documents and emergent in our co-designing exercises, are crucial for breaking free of business as usual. PA recognizes the criticality of inter-departmental convergence for this multi-sectoral issue, but the implementation framework does not provide an adequate roadmap; without that CAPs are reduced to merely filling up templates with (numeric) targets. This reductionist framing of the CAPs, and the lack of well-rounded action plans, point to a lost opportunity as far as the first year of this Abhiyan is concerned. Building capacities across sectors and levels of government fast enough is an up-hill task that ought to be foregrounded in order to be able to rise to the challenge in the next planning cycle. Policy implementation is most likely when there is a ‘synthesis of plausible evidence, political vision and practical strategies’ [23]. At stake is the ambitious 2022 deadline, with little evidence in the first year that demonstrates convergence as the core strategy.

Contributors: The authors drafted the manuscript on behalf of the PANChSHEEEL Project. All project team members reviewed the manuscript and approved the final version.

Funding: Global Challenges Research Fund and funded by the MRC, AHRC, BBSRC, ESRC and NERC.

Competing Interests: None stated.

Principal Investigator: Monica Lakshanpaul, UCL Great Ormond Street Institute of Child Health.

Co-investigators: Marie Lall, Institute of Education, UCL; Priti Parikh, Civil Environmental and Geomatic Eng, UCL; Lorna Benton UCL, Great Ormond Street Institute of Child Health; Rajib Dasgupta, Jawaharlal Nehru University; Virendra Kumar Vijay, Indian Institute of Technology Delhi; Rajesh Khanna, Save the Children, India; Hanimi Reddy, Save the Children, India; Logan Manikam, UCL Great Ormond Street Institute of Child Health.

Save the Children: Sanjay Sharma, Susrita Roy, Neha Santwani, Satya Prakash Pattanaik, Priyanka Dang, Hemant Chaturvedi, Pramod Pandya, Tol Singh.

Indian Institute of Technology: Namrata Agrahari.

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