Understanding Supply-Side Implementation Barriers Affecting Child Nutrition Outcomes in the Take-Home Ration Scheme: A Qualitative Study From Madhya Pradesh, India.

Background Child undernutrition persists as a critical public health challenge across India despite the extensive infrastructure of the Integrated Child Development Services (ICDS) program; child undernutrition remains persistently high, especially in Madhya Pradesh, where stunting affects 35.5% of children. The Take-Home Ration (THR) component, intended to provide supplementary nutrition to women and young children, continues to underperform due to interconnected supply-chain, governance, and community-level challenges. This study aimed to examine supply-side implementation barriers and assess the current status of THR distribution and Social and Behaviour Change Communication (SBCC) activities under ICDS in Madhya Pradesh, India, from a multi-stakeholder perspective. Methods This qualitative, multi-method study combined Net-Map supply chain analysis and semi-structured key informant interviews with 15 stakeholders spanning state, district, block, and community levels in Hoshangabad district, Madhya Pradesh, India. Thematic analysis using Braun and Clarke's framework identified systemic barriers and adaptive practices across seven organisational hierarchies. Results Network mapping revealed that the State Nutrition Committee, manufacturing divisions, and Anganwadi Centres function as non-substitutable backbone actors whose dependencies create systemic vulnerabilities. Identified constraints included multi-tiered supply chains causing cumulative delays, prolonged government payment cycles restricting manufacturer capacity, and product-community misalignment between fortification requirements and taste acceptability. Additional barriers comprised weak inter-departmental coordination, limited frontline capacity, and inadequate community engagement due to opportunity costs and digital connectivity gaps. Locally generated adaptive solutions-such as product modifications and community recipe innovations-remained institutionally disconnected from higher governance systems. Conclusion Strengthening THR implementation requires a coordinated systems approach emphasising fiscal accountability, decentralised decision-making, and context-specific, culturally grounded social and behaviour change communication. Institutionalising mechanisms that integrate frontline-derived learning into policy adaptation is essential for achieving resilient nutrition program delivery and improved outcomes.