Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study

Maximum variation sampling using a combination of purposive and random selection at different levels was applied to capture heterogeneity in service delivery contexts [24]. Three districts were purposively selected from among the 30 total districts in the state, to attain variations between districts. Existing district-level survey data [25, 26] were used to construct a set of criteria pertaining to service coverage and household factors (e.g., coverage of immunization and vitamin A supplementation, three or more antenatal care visits, and institutional delivery; access to toilet and electricity; and type of cooking fuel), and changes in these indicators between two survey rounds were examined. All districts were grouped into three categories: better performing districts (i.e., those with positive change over time), average performing districts (i.e., no change), and poorly performing districts (i.e., those with negative change). Then, in a meeting organized by the researchers to explain the study and conduct a joint process of district selection, state-level officials from the Department of Health and Family Welfare (DHFW) and the Department of Women and Child Development (DWCD) randomly drew the name of one district from each category: District 1 as better performing, District 2 as average performing, and District 3 as a poorly performing district.

In each district, we randomly selected four blocks (subdivision or town) (n = 12) and two villages from two of the blocks (n = 12) to study service delivery by three different cadres of FLWs within each village. In a village, there is usually one Anganwadi Center (AWC) with an Anganwadi Worker (AWW). The AWW is responsible for the AWC and delivers health and nutrition services and preschool education under the ICDS program; she is an honorary female worker selected from the local community. The AWW in each village, along with the Accredited Social Health Activist (ASHA) and the Auxiliary Nurse Midwife (ANM) working in the same area were interviewed in this study. The ASHA is a female health worker, selected from the community and serves the role of community mobilizer to access services and community-level care provider. The ANM is a multipurpose female health worker who provides a package of preventive and curative services largely for women and children, at a sub-center that covers a population of 3,000–5,000 for rural areas, which is approximately 6–8 villages, and through outreach services. We conducted a total of 145 semi-structured interviews with the three types of FLWs, as well as with block, district, and state-level staff of the ICDS and health departments and from other sectors (Table 1). Interview guides are shown in Additional files 1, 2, 3, and 4.

Written informed consent was obtained from the study participants prior to interview. This study was approved by the IFPRI Institutional Review Board and Odisha’s Department of Women and Child Development and Department of Health and Family Welfare in India.

Interviews were conducted in the local language (Odiya) and audio-recorded, then transcribed verbatim and translated into English. Extensive field notes were taken only for state-level interviews. We used a deductive approach to data analysis, applying pattern, theme, and content analysis for data reduction and to elucidate any similarities and differences and patterns of coordination between the ICDS and health programs for the interventions of interest [24]. A systematic process of data organization and analysis was led by the first author. The first level of analysis involved data coding using NVivo, a qualitative data software for computer-assisted data management and analysis. An a priori code list was prepared based on the study protocol and interview guides and tested using an initial set of transcripts. Then, a team of four coders (two coders were involved from the training of interviewers and data quality monitoring to summarizing the data) were trained to standardize the coding process, inter-coder reliability was tested, and the code list was reviewed and revised by the coding team and senior researchers. Bimonthly/monthly Skype calls were held to review coded data, any coding issues, and updates to the code list. Outputs of coded results using queries (on types of services, coordination mechanisms, facilitators and barriers) were generated by transcripts pooled at the district, block, and village levels. Then, second-level coding and summarizing for emergent themes and patterns were conducted. Among the various nutrition interventions that involve both the DHFW and DWCD, we present results on five intervention or service types (including combined interventions that are delivered simultaneously) to illustrate convergence in implementation: antenatal care (ANC) services, including maternal iron and folic acid (IFA) supplementation, child immunization and vitamin A supplementation, pediatric IFA supplementation, infant and young child feeding (IYCF) counseling/education, and growth monitoring and referrals for severe acute malnutrition. There were several driving questions for data analysis: To what extent do actors work together (degree of convergence), and how (mechanisms of convergence); on what do they work together (types of actions or services); and why (facilitators and barriers)? Also, are there any similarities or differences among the districts, blocks, or villages?

Respondents concurred that improving maternal and child health and nutrition across the state is a shared goal and the joint responsibility of DHFW and DWCD, in addition to other departments. Several mechanisms were in place to facilitate regular coordination and collaboration, such as monthly meetings convened by (and perceived as dominated by) Health, and biannual project meetings, held to plan for specific programs or activities and convened by Health but chaired by the Development Commissioner to facilitate horizontal collaboration. Other examples included the cross-sectoral coordination committee for NRHM’s urban health program and the frequent cross-sectoral collaboration on guidelines for specific initiatives. Within these different meetings and activities, well-positioned leadership (or champions for the initiatives or issues) was seen as a key facilitator of convergence, particularly leaders involved not just in the line departments but who transcended departmental boundaries such as the Development Commissioner and the Chief Secretary.

Despite these successes, however, challenges to convergent actions remain. For example, despite the shared goal to reduce infant and maternal mortality, DHFW focuses on antenatal care services and DWCD contributes to improving maternal nutrition by providing food supplements during pregnancy, and there is little data sharing across these actions to demonstrate process towards the goal, even where common indicators exist. This has resulted in discrepancies in data presentations and limitations on the extent to which there is collaboration on program monitoring. Although policies and platforms for integrated service delivery have been developed, there is little evaluation and resource allocation to understand the performance of these strategies. There is also limited supervision and lack of accountability mechanisms for the implementation process from the state to lower levels, which leads to repercussions (such as irregular meetings and poor attendance) as discussed in following results.

At the district level, DHFW and DWCD staff clearly identified their roles and responsibilities as applying state guidelines for programs, prioritizing services or activities based on their contexts, planning, monitoring data, allocating resources, and training block-level staff. District level officials primarily coordinated across sectors through review meetings and training sessions for local staff on specific common priority actions. However, the extent and nature of coordination between DHFW and DWCD at the district level was dependent mainly on the specific intervention types and narrow outcomes of interest in common to the individual departments.

There was good coordination in implementing the immunization program in all three districts. The departments often came together to prepare annual or monthly action plans, as a district program officer (ICDS) explained: “There is an immunization plan for the entire district, which is the joint action plan of health and ICDS departments. It is prepared with coordination between both the departments… so that service is provided in a better way, coverage is expanded, coordination is maintained, and there are no missed cases.” District coordination meetings were also held for special programs such as pulse polio and vitamin A supplementation campaigns. Additionally, the departments coordinated for training about IYCF, use of maternal and child (health) protection cards, and MAMATA program guidelines. Coordination at the district level was reported to be driven by directives issued from the state.

In each district, monthly review meetings are convened by the chief administrative official, i.e., the state-appointed district collector. During these meetings, ICDS and health staff reported their activities, reviewed outcomes, and assessed any gaps. The topics discussed most often were infant and maternal mortality, immunization, VHND, diseases and other health topics usually decided by health staff. While most of the district-level respondents considered these meetings as necessary, poor participation or low attendance were identified as common problems: “Attending the coordination meetings should be regular. If [staff] regularly participate in those meetings, we will know the gaps and take steps… but they are not regular, so we face some difficulties.” (District community mobilizer, Health). However, little accountability and consequence were seen for participation in meetings. Data sharing also takes place at the district level, but a narrow set of indicators was identified across all three districts, particularly infant and maternal mortality, verbal autopsy, institutional delivery, and immunization.

Supervision was reported to be limited, and when it does take place, it focused mostly on immunization and VHNDs or addressing problems or emergency cases. Lack of time was named as the main barrier to conducting joint supervision. Only in District 2, joint supervisory visits and coordination of supervisory activities was frequently reported, as described by one district health official: “When I go to an Anganwadi centre, I always check the registers of that Anganwadi, weights of the children, food distribution… I also monitor the instruments, logistics, infant registry, and birth registry. When they [ICDS officials] visit, they look into both ICDS and health activities, and whenever I visit, I also check both activities.”

The main responsibilities at the block level included planning activities, monitoring and reporting data, and supervision. “Both departments [DHFW and DWCD] are very much associated with each other because they have the same objectives.” (Block program manager, Health). However, most block-level respondents expressed limited cooperation overall. “Each person is doing his or her responsibilities very well. There is no need of any help [from each other]. We are aware about [each other’s] programs, but we are doing our work, and they are doing theirs” (Lady supervisor, ICDS). Block-level respondents pointed to the lack of direction or guidelines for intersectoral coordination from higher levels, thus it was unclear how they were expected to work together.

Staff worked across sectors primarily for meetings and supervision. Separate ICDS and health sector meetings are held regularly and attended by respective block-level and field staff. Although staff from the other department are usually invited to participate at the sector meetings, to learn about planned activities and any outcomes and gaps, cross-sectoral participation was low and irregular. The lack of time or heavy workload, schedule conflicts, lack of physical space to conduct joint meetings, and poor communication were named as barriers. “They [health staff] do not attend ours [sector meetings], and we do not attend their meetings. Because it is a fixed date, when they do not have a meeting and have time, they attend our meeting. And when we don’t have any, we attend their meeting,” explained a child development project officer (ICDS). One public health extension officer shared, “I have the letter from ICDS, that they asked me to come on a particular date, and I made plans and sent it to the CDPO [child development project officer]…but that day there was no such meeting, so my staff returned and complained that you sent us for a meeting but there was no meeting… they make such changes without any notice. We do not know the date of their plans.” Similar to the district level, the topics discussed were limited to immunization and infant and maternal mortality, as data for these topics (e.g., tally of birth and death cases) are collected by both sectors.

Extent of coordination or joint supervision visits and frequency of supervision varied only slightly among blocks in different districts. Despite expressing the lack of guidelines for coordination in supervision, block staff usually planned together to cover supervision for immunization and VHND. Joint supervision involving staff from both departments was more frequently reported in Districts 1 and 2, particularly for verification of maternal or infant deaths and in case of emergencies or field problems. However, lack of time or heavy workload and insufficient resources (i.e., personnel and vehicle for transport, particularly in District 3) were repeated as barriers to coordination. “There is good relationship, but due to paper work and other work, we cannot attend their meetings or supervision.” (CDPO). In various blocks, there were reports of vacant posts or insufficient staff allocation and vehicles for conducting supervision. A public health extension officer explained, “I supervise 25 ANMs in 25 sub-centers… in the block, there are 4 supervisors for 8 sectors, not enough, and 100 plus AWWs and 60 ASHAs in the villages.” Among the administrative levels, most gaps and limitations in convergence appeared at the block level.

FLW functions involved planning and implementing services and activities, maintaining data records, submitting reports, and building rapport with communities, particularly to create demand for services. All of the FLWs across the districts described working together, facilitated by their close vicinity (AWWs and ASHAs usually live within the same village) and interpersonal relationship.

With overlapping functions and activities, the three cadres of FLWs work together to deliver nearly all of the essential nutrition interventions. We present findings on FLW roles and factors influencing the provision of five specific interventions to illustrate the extent of convergence among FLWs (Table 3).

The VHND provides a common platform for FLWs to work together in delivering the ICDS and health services such as ANC, referrals, growth monitoring, and counseling. One AWW stated, “On VHND, ASHA calls all the children, ANM does checkup of the pregnant ladies, and I weigh young girls and women. We give IFA syrup to children. ANM worker checks the health of the 3 to 5 years old children”. In all three districts, coordination among FLWs varied depending on the type of services delivered. There was a clear understanding of roles and responsibilities and good coordination among the FLWs for implementing ANC, immunization and vitamin A supplementation. One ANM stated, “My duty is to check the pregnant women and advise them about their diet and give them IFA and TT [tetanous toxoid]. “If the pregnant woman does not come (to VHND) with her child, then the ASHA worker goes to call and brings her.” In parallel with these findings, exposure to the interventions usually provided during VHND, particularly ANC, immunization and vitamin A supplementation, and growth monitoring across the three districts were generally over 50% [23] (Table 3).

On the contrary, FLWs across the three districts demonstrated varying levels of understanding of their roles in providing IYCF counseling and pediatric IFA supplementation. For instance, in District 2, one ANM stated that AWW, ANM and ASHA plan together for counseling over the phone and jointly conduct home visits. In District 1, an ASHA informed that AWW accompanies her to home visits whenever she calls her, and ANM also comes along only when it is required, such as in cases of an underweight child. In District 3, one ANM stated that she plans for home visits with AWW, and another ANM said that she coordinates the action plan for home visits with ASHA and AWW. While there appears to be overall coordination to deliver the service, there is ambiguity on who leads the counseling and how it is organized. Similarly in the patterns of exposure, less than one-third of beneficiaries had been exposed to these two interventions across the three districts [23] (Table 3).

In general, there is a common understanding among the FLWs that they need each other to effectively deliver services. One AWW said, “All three of us- ANM, ASHA, and I work together. We all decide before doing anything”, and further explained, “We have good coordination; ASHA is always with us. We respect each other’s work and discussion.” However, the lack of time or heavy workload, scheduling conflicts, and poor communication were named as barriers to coordination. AWWs and ANMs perceive that VHND increased their workload. In addition, after the introduction of the cadre of ASHAs at the village level, some block-level officials observed that AWWs are less motivated to deliver services for which ASHAs are receiving incentives. For example, AWWs usually weigh the children for monthly growth monitoring, but ASHAs receive incentives specifically for referring children (based on the growth monitoring results) to the nutrition rehabilitation center; thus, AWWs become discontented by the unbalanced incentive system.