1Working Multisectorally toImprove Maternal and Child Nutritionin IndiaThe Karnataka ComprehensiveNutrition MissionVeena S...
Some hard truths• India today, is one of the most nutrition deficient countries in the World.• More than 42% of the World’...
Indicators for Assessing Nutritional StatusDirect Indicators• Low Birth Weight (1/3 babies lbw)• Infant Mortality Rate (IM...
Stunting/ Wasting/ Under Weight• In India, 38% of children below 3 years of age are stunted,19% are wasted and 46% are und...
Nutritional status of adolescents: A matter of ConcernAs per the 21st Report of the NNMB (National Nutrition MonitoringBur...
Nutritional Status of adults:NHFS 3 again paints a gloomy picture:•36 percent of women and 34 percent of men are undernour...
MDGs and ProgressGoalNo.Goals Indicators Targets -2015SRS20115 Improve Maternal Health MaternalMortality Ratio109 2124 Red...
A Multi Causal Problem• India’s UnderNutrition is the most multi-causal in the world• It is Inter-Generational• A multi-ca...
A Multi Causal Problem9UnderNutritionPhysicalCausesSocio-Economic andHistoricCausesGovernanceRelatedCausesAttitudinal/Beha...
The Two Concentric Cycles:Inter-generational Cycle of Malnutrition & Cycle of Calorie Protein Micronutrient Deficit (CPMD)...
Fundamental causes of Malnutrition in India notyet addressed programmatically:(1)Malnutrition in India is deeply rooted in...
(2)More than 30% population of India suffers from a Calorie-Protein, Micronutrient Deficit, (CMPD) *This factor not yet ac...
Proposed Food Security Act:A laudable beginning to legalize an entitlement to FoodPresent provisions35 KG Rice or Wheat pe...
Until these two root causes aresubstantively addressed,existing scattered interventionswill have negligible impact onreduc...
(3)There is inadequate awareness and informationregarding proper nutritional practices amongstthe population, especially r...
Economics of MalnutritionProf RW Fogel: NBER Working Paper 16- Conquest of High Mortalityand Hunger in Europe and America:...
Multi-Sectoral Solutions•No single intervention can eradicate malnutrition• The package of interventions must be widely in...
What Are The Sectors and What Are Their ProgrammesProgrammes Ministries/ DepartmentsICDS Women & Child Development Ministr...
Multi-Sectoral Mega Coordination:The Inner Core and Outer CircleEducation,Social Justice,19Ministry of Information & Broad...
Essential Interventions to Combat Malnutrition –(Coalitionfor Nutrition Security in India – Prof MS Swaminathan)(A) Direct...
9. Frequent, appropriate, and active feeding for children during and after illness, including oral rehydrationwith Zinc su...
(B) Indirect Interventions –Related to issues of health, safe drinking water, hygienic sanitation and socio-cultural facto...
The Karnataka Nutrition Mission• Karnataka the 1st State in the country toannounce a Comprehensive Inter-sectoralNutrition...
The Karnataka Nutrition MissionAnnouncement by Chief Minister in 2010High Powered multi-sectoral Committee chaired by Chie...
Karnataka Comprehensive Nutrition Mission -AimsThe Karnataka Nutrition Mission (KNM) will specifically aim toeradicate the...
The Mission strategy is based on the following over-archingprinciples:• Bridge the protein-calorie-micronutrient deficit w...
Karnataka Comprehensive Nutrition Mission –Specific Objectives(a) Reduce Underweight and under-nutrition among children, l...
Karnataka Comprehensive Nutrition Mission –Addressing the Cause-Intervention DisconnectInnovative Strategy Shifts to addre...
Karnataka Comprehensive Nutrition Mission –Addressing the Cause/Intervention DisconnectInnovative Strategy Shifts to addre...
Activities Completed/ On Going In Karnataka NutritionMission – Pilot ProjectSL. No. Activity1. Selection and Appointment o...
Karnataka Comprehensive Nutrition Mission –Other InitiativesFeasibility Study sponsored by the Mission to engineer the Agr...
Addressing UnderNutrition in India-Do we have an Enabling Environment• Malnutrition is invisible and silent.• Malnourished...
Posters
Posters
Nutritional Status of 6-36 Months Children ofGubbi Block (Total No. of Beneficiaries – 5004)
Nutritional Status of 6 to 36 Months Children ofGubbi Block As on July, 2012(Total No. of Beneficiaries – 5004)
Nutritional Status of 6 to 36 Months Children of GubbiBlock As on Oct, 2012(Total No. of Beneficiaries – 5004)
Nutritional Status of 6 to 36 Months Children ofGubbi Block As on Jan, 2013(Total No. of Beneficiaries – 5004)
BMI of Adolescent Girls – Gubbi Block(Total No. of Beneficiaries – 7982)
Training Program for Village NutritionVolunteers
Strengthening SHGsSHGs Strengthening Programme
Thank You42
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Working multisectorally to improve maternal and child nutrition in India: The Karnataka Comprehensive Nutrition Mission

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Working multisectorally to improve maternal and child nutrition in India: The Karnataka Comprehensive Nutrition Mission

  1. 1. 1Working Multisectorally toImprove Maternal and Child Nutritionin IndiaThe Karnataka ComprehensiveNutrition MissionVeena S RaoAdvisor, KCNM 28-5-13
  2. 2. Some hard truths• India today, is one of the most nutrition deficient countries in the World.• More than 42% of the World’s under weight children below five years live in India(UNICEF 2010).• The latest NFHS 3 and SRS Bulletins assert that some, but not enough progress hasbeen achieved in improving the country’s nutritional profile or achieving MDGgoals.• Poverty is a major, but not the only cause of macro/micro-nutrient deficiency.• The percentage of population suffering from various forms of undernutrition farexceeds the percentage below poverty line• After National Nutrition Policy 1993 and National Plan of Action, 1995 no nationalprograms or policies for eradicating undernutrition have appeared.• Today, India has no national programme with a stand alone objective ofcombating underlnutrition2
  3. 3. Indicators for Assessing Nutritional StatusDirect Indicators• Low Birth Weight (1/3 babies lbw)• Infant Mortality Rate (IMR- 47 per1000 SRS 2011)• Under 5 Mortality Rate (U5MR- 64per 1000 SRS 2011 )• Stunting/ Wasting/ Underweight• Anaemia (6mts-6 yrs 69.5%)• Immunization (42%)• Maternal Mortality Rate (MMR 212SRS 2011)• Chronic Energy Deficiency andAnaemia among adolescents andadults3Indirect Indicators Access to HygienicSanitation and ToiletFacilities (29% NFHS3) Access to Safe DrinkingWater (87.9% NFHS3) Female literacy (65.4%Census 2011) Gender equity
  4. 4. Stunting/ Wasting/ Under Weight• In India, 38% of children below 3 years of age are stunted,19% are wasted and 46% are under weight (NFHS 3 Fact Sheet2005-06).• Among children under 5 years of age:48% are stunted24% are severely stunted43% are underweight16% are severely underweight20% are wasted(NFHS 3- 2005-06, Detailed Report)4
  5. 5. Nutritional status of adolescents: A matter of ConcernAs per the 21st Report of the NNMB (National Nutrition MonitoringBureau 2003)•The percent of underweight adolescent males was 53% and offemales was 39.5%.•About 39% were stunted. Over all, the prevalence of stunting wassimilar in both the sexes (boys: 39.5% and girls: 39.1%)• The food and nutrient intake of Adolescent Girls was below RDA.More than two-thirds of them were consuming < 70% RDA forVitamin A and Riboflavin.•The Indian Adolescent Girl is the most undernourished in the world.(UNICEF, State of the World Children’s Report 2011)
  6. 6. Nutritional Status of adults:NHFS 3 again paints a gloomy picture:•36 percent of women and 34 percent of men are undernourished,with a BMI less than 18.5, indicating a high prevalence ofnutritional deficiency.•More than half of women (55 percent) and almost one-quarter ofmen (24 percent) are anaemic.
  7. 7. MDGs and ProgressGoalNo.Goals Indicators Targets -2015SRS20115 Improve Maternal Health MaternalMortality Ratio109 2124 Reduce Infant Mortality Infant MortalityRate28 504 Reduce Child Mortality Under 5 MortalityRate42 647
  8. 8. A Multi Causal Problem• India’s UnderNutrition is the most multi-causal in the world• It is Inter-Generational• A multi-causal problem demands a multi-sectoral solution• Multi-sectoral interventions should attempt totarget all, or at least a majority of the causes8
  9. 9. A Multi Causal Problem9UnderNutritionPhysicalCausesSocio-Economic andHistoricCausesGovernanceRelatedCausesAttitudinal/BehavioralCauses•Hunger•Calorie/ProteinMicronutrientDeficit•Infection andDisease•Poverty/Low Income• Illiteracy/Lack ofSkills•GenderDiscriminationembedded in socialcustom•Lack of Informationand Awareness•Gender Discrimination•Low Status of Women•Negative Child/Mothercare practices•Early marriage of girls•Early & frequentpregnancies•Lack of Information &Awareness;Superstition•No national programmewith specific objective ofreducing malnutrition•Inadequate, health careservices for women andchildren;•Low access to safedrinking water andsanitation•Programmatic gaps•Poor coverage• No action basedNutrition Monitoring•Lack of accountablity
  10. 10. The Two Concentric Cycles:Inter-generational Cycle of Malnutrition & Cycle of Calorie Protein Micronutrient Deficit (CPMD)and PovertyANC: Antenatal CareEBF: Exclusive Breast FeedingProtein caloriemicronutrient deficitLow working capacityLow income generationPovertyLow BirthWeightStunted ChildMalnourishedGirlMalnourishedMother Inadequate growth Low weight gain Poor Diet Gender discrimination Early marriage & pregnancy• Poverty• Lack of awareness• Infections• Gender discrimination• Inadequate food &health care No feeding of colostrum Lack of EBF* for first 6 months Delayed & inadequate com food Frequent Infections & prolongeddiarrhea Gender discriminationInadequate food &health care• Inadequate foetalnutrition• Multiple pregnancies• -Gender discrimination• Poor diet and ANC **• Female illiteracy
  11. 11. Fundamental causes of Malnutrition in India notyet addressed programmatically:(1)Malnutrition in India is deeply rooted in theintergenerational cycle of low birth weight babies,underweight children, malnourished, anaemicadolescent girls and pregnant women.However, current policies and programmes do notaddress the issue inter-generationally.11
  12. 12. (2)More than 30% population of India suffers from a Calorie-Protein, Micronutrient Deficit, (CMPD) *This factor not yet acknowledged or addressed specifically inany programme, (except in general through the TPDS, whoseoutreach to the lowest percentile of poverty is poor.)Besides, TPDS even if working efficiently only provides forcereals, (and in some cases pulses and sugar,) a subsistence dietfor the poor.TPDS does not provide adequate calories, protein ormicronutrients for a healthy life.*(NNMB repeat surveys, 1988-90, 1996-97, NNMB Technical Reports No.20,21,22, 2000-03)12
  13. 13. Proposed Food Security Act:A laudable beginning to legalize an entitlement to FoodPresent provisions35 KG Rice or Wheat per family per month at Rs 2 perKGFamily constitutes average 5 members = 7 KG rice orwheat per month per person = 234 gms per day =approx 650 calories per person per day as against anRDA of average 1700 calsWould amount to prevention of starvation, but notfood or nutritional security.13
  14. 14. Until these two root causes aresubstantively addressed,existing scattered interventionswill have negligible impact onreducing malnutrition.14
  15. 15. (3)There is inadequate awareness and informationregarding proper nutritional practices amongstthe population, especially regardingchild/maternal care, even within existingpurchasing power.(Population % suffering from malnutrition/ anaemia far exceedsthe BPL%, clearly establishing that at least 10-15% of thepopulation suffer from malnutrition not because of poverty/lackof purchasing power but because of lack of awareness andinformation)Every poor person is most likely undernourished,but every udernourished person may not always bepoor15
  16. 16. Economics of MalnutritionProf RW Fogel: NBER Working Paper 16- Conquest of High Mortalityand Hunger in Europe and America:Timings and Mechanisms“The first law of thermodynamics applies as strictly to thehuman engine as to mechanical engines. Since theoverwhelming share of calories consumed by themalnourished populations is required for BMR andessential maintenance…. the typical individual in thelabour force had relatively small amounts of energy leftfor work.”
  17. 17. Multi-Sectoral Solutions•No single intervention can eradicate malnutrition• The package of interventions must be widely inter-sectoral so as toaddress at least a majority of the causes• They must be simultaneous so that the benefit of one intervention isnot lost on account of the absence of another• They must cover the entire life cycle of women and children to createand immediate impact within one generation on the nutritional statusof the three critical links of malnutrition, namely, children, adolescentgirls, and women•Only then can the benefits be sustainable enough to break the inter-generational cycle, and be passed on the next generation.17
  18. 18. What Are The Sectors and What Are Their ProgrammesProgrammes Ministries/ DepartmentsICDS Women & Child Development MinistrySabla – Adolescent Girls Programme Women & Child Development MinistryImmunization Programme Health & Family Welfare MinistryMid Day Meal Programme Ministry of HRDVit A Supp Programme Health & Family Welfare MinistryNational Nutritional Anaemia ControlProgrammeHealth & Family Welfare MinistryNational Iodine Deficiency Disorder ControlProgrammeHealth & Family Welfare MinistryNational Rural Drinking Water Programme Ministry of Drinking Water & SanitationTotal Sanitation Campaign Ministry of Rural Development.These programmes address some causes of Malnutrition but not all of themand have several programmatic and coverage gaps. In the absence ofseamless and simultaneous interventions, gains accruing from existing,dispersed and often isolated interventions are lost on account of absence ofother critical interventions.
  19. 19. Multi-Sectoral Mega Coordination:The Inner Core and Outer CircleEducation,Social Justice,19Ministry of Information & BroadcastingMinistry of Women & ChildDevelopmentMinistry of Health & FamilyWelfareMinistry of FoodMinistry of AgricultureMinistry of Rural DevDepartment of Drinking Water &SanitationMinistry of HRDSTATE GOVTsMinistry ofTribalAffairsMinistry of SocialJusticeMinistry ofPanchayatiRajMinistry ofLabour
  20. 20. Essential Interventions to Combat Malnutrition –(Coalitionfor Nutrition Security in India – Prof MS Swaminathan)(A) Direct interventions –Related to the consumption and absorption of adequate protein calorie/micro-nutrient rich foodsessential to combat malnutrition, namely:1. Weighment of child within 6 hours of birth and thereafter at monthly intervals.2. Timely initiation of breastfeeding within one hour of birth, and feeding of colostrum to the infant.3. Exclusive breastfeeding during the first six months of life.4. Timely introduction of complementary foods at six months and adequate intake of the same, in terms ofquantity, quality and frequency for children between 6-24 months.5. Dietary supplements of all children between 6 months – 72 months through energy dense foods madeby SHGs from locally available food material to bridge the protein calorie gap.6. Safe handling of complementary foods and hygienic complementary feeding practices.7. Complete immunization and Vit. A supplementation.8. De-worming of all family members bi-annually.20
  21. 21. 9. Frequent, appropriate, and active feeding for children during and after illness, including oral rehydrationwith Zinc supplementation during diarrhea.10. Timely and quality therapeutic feeding and care for all children with severe and acute malnutrition.11. Dietary supplements of iron – rich, energy dense foods made from locally available food materialprepared by women SHGs for adolescent girls and women, especially during growth periods andpregnancy to fill the protein calorie gap and ensure optimal weight gain during pregnancy.12. Anaemia screening for children, adolescent girls and women.13. Weight monitoring of all adolescent girls and pregnant women.14. Prevention and management of Micro-Nutrient deficiencies, especially through IFA supplementation toprevent anaemia in adolescent girls and women.15. Making available low cost energy foods for the general population.16. Fortification of common foods.21
  22. 22. (B) Indirect Interventions –Related to issues of health, safe drinking water, hygienic sanitation and socio-cultural factorssuch as early marriage and pregnancy of girls, female literacy and poverty reduction, toeradicate malnutrition on a long term, sustainable basis.1. Access to safe drinking water (treatment, storage, handling and transport), sanitation andhygiene.2. Increased female education and completion of secondary schooling for the girl child,delayed age of marriage and pregnancy.3. Increased access to basic health services by women.4. Expanded and improved nutrition education and involvement at Panchayat and communitylevel to create demand.5. Increased gender equity.6. Linking Agriculture/Horticulture and Nutrition.22
  23. 23. The Karnataka Nutrition Mission• Karnataka the 1st State in the country toannounce a Comprehensive Inter-sectoralNutrition Mission• Demonstrates Political Will & Leadership• Administrative & Programmatic Priority23
  24. 24. The Karnataka Nutrition MissionAnnouncement by Chief Minister in 2010High Powered multi-sectoral Committee chaired by ChiefSecretary set up to draw a roadmap for the Mission Strategy,and its piloting in 3 Blocks.Cabinet clearance obtained in March 2011.Mission being Piloted in 3 Blocks - Gubbi, Shikaripur andBellary RuralGrant of US$ 5 million has been received from JSDF/WB forpiloting in Chincholli and Deodurg Blocks 24
  25. 25. Karnataka Comprehensive Nutrition Mission -AimsThe Karnataka Nutrition Mission (KNM) will specifically aim toeradicate the problem of malnutrition in the State in the shortestpossible time by introducing innovative strategy changes.It will be a dedicated, stand alone programme to address the problemof malnutrition in the State in a targeted and comprehensive manner.The Programme is implemented in partnership with an NGOTarget Groups: Children between 0-3 years, with priority 0-2 yearschildren keeping in view the special significance of this period in theirprocess of development.Adolescent girls between the ages 11-18Pregnant and Lactating mothers25
  26. 26. The Mission strategy is based on the following over-archingprinciples:• Bridge the protein-calorie-micronutrient deficit which affects at least 50% of the population.• Cover the entire life-cycle of women and children so as to break the inter-generational cycle of malnutritionwithin the shortest possible time.• Formulate a tightly integrated multi-sectoral strategy to address all or majority of direct and indirect causesof malnutrition simultaneously, many of which exist in ongoing programmes.• Interventions include Direct interventions, based on adequate food and micro-nutrients, and Indirectinterventions, addressing issues of health, education, water, sanitation and socio-cultural, factors that arecritical to eradicate malnutrition on a long term, sustainable basis.• Initiate a sustained general public awareness campaign, through the multi-media and interpersonalcommunication mode to reach the general public, especially at the grass-roots, regarding proper nutritionalpractices.• Establish vigorous monitoring mechanisms at the administrative and community levels, using participatorymechanisms and cast responsibility upon the respective functionaries for achieving results. Buildaccountability through intensive monitoring of nutritional indicators in the Mission Blocks by the MissionSecretariat, Community Monitoring, and by third-party evaluations.26
  27. 27. Karnataka Comprehensive Nutrition Mission –Specific Objectives(a) Reduce Underweight and under-nutrition among children, lowbody mass index among adolescent girls and women in theproject areas in the shortest possible time, through the inter-generational, life-cycle approach.(b) Eliminate wasting of children and Grade 3 and 4 malnutritionamong children(c) Reduce the incidence of low birth babies, infant mortality, childmortality, maternal mortality, anemia and other micronutrientdeficiencies among children, adolescent girls and women; and(d) Spread information and awareness to the communities to enablebehavioral change regarding proper child care, care of the girlchild throughout her life cycle, of pregnant and nursing mothers,and proper dietary practices within existing family budgets27
  28. 28. Karnataka Comprehensive Nutrition Mission –Addressing the Cause-Intervention DisconnectInnovative Strategy Shifts to address the Causes• Adopting the inter-generational, life cycle approach by addressing thenutritional needs of infants, children, adolescent girls and pregnant andnursing mothers.• Bridging the calorie-protein micronutrient deficit among the inter-generational target groups by providing appropriate energy densefortified supplementation for consumption.• Accelerating, integrating and tightly monitoring multi-sectoral ongoingprogrammes that have impact on malnutrition, such as Immunization andVit A Supplementation, Anemia Control, Water and Sanitation, etc.• Achieving convergence between the ongoing programmes so that theyoperate simultaneously, and• Covering Programmatic gaps through new initiatives.28
  29. 29. Karnataka Comprehensive Nutrition Mission –Addressing the Cause/Intervention DisconnectInnovative Strategy Shifts to address the Causes• Increasing programme coverage by demand creation byinvolvement of the community, NGOs, SHGs and VPs.• Launching a sustained general public awareness campaign,through the multi-media and interpersonal communicationmode to reach the general public, especially at the grass-roots,regarding proper nutritional practices within existing familybudgets and proper child and maternal care and create demandfor government programmes.• Make available low cost energy foods for the generalpopulation through Public Private Partnerships.29
  30. 30. Activities Completed/ On Going In Karnataka NutritionMission – Pilot ProjectSL. No. Activity1. Selection and Appointment of Nutrition Volunteers & Other Staff2. Purchase of Weighing Scale3. Completion of Base Line Survey4. Printing of Health & Nutrition Cards5. Creation of MIS6. Block Level Workshops7. Identification of SHGS: Gubbi Block - 767 Bellary Block -257 Shikaripura - 1568. Purchase and Installation of Machinery – Weighing Machines9. Expected Date For Trial Production of EDF Gubbi Block - May last week, 2013 Shikaripura - May last week, 201310. Expected Date For Commencing Production and Distribution of EDF – June 15,2013
  31. 31. Karnataka Comprehensive Nutrition Mission –Other InitiativesFeasibility Study sponsored by the Mission to engineer the AgricultureNutrition linkage supported by Global Alliance for Improved Nutrition,(GAIN) Study to be conducted by India Institute of Science, Center forRural Technology.Scope of Study: Though India is one of the largest fruit and vegetableproducers in the world, harvest and post harvest losses amount to about30%, on account of absence of primary processing facilities and needbased post-harvest technology.Primary processing of fruit and vegetables at village level. Zero energycooling chambers, solar dryers, which have been designed by severalrenowned Rural Technology Institutes, and Indian Institute of Science,must be introduced at rural level, for preservation of fruit and vegetables,and their consumption by the community.31
  32. 32. Addressing UnderNutrition in India-Do we have an Enabling Environment• Malnutrition is invisible and silent.• Malnourished people are not aware of their affliction. Hence, nodemand for relief• Medical profession is not oriented, as Nutrition is not a facultywithin Medical Education.• Economists have not yet focused on the national economic losscaused by malnutrition• Stronger political will to address malnutrition in a Mission Mode isrequired to follow up Finance Ministry’s Budget speech,2012. Needfor multi sectoral paradigm shift and addressing cause-interventiondisconnect32
  33. 33. Posters
  34. 34. Posters
  35. 35. Nutritional Status of 6-36 Months Children ofGubbi Block (Total No. of Beneficiaries – 5004)
  36. 36. Nutritional Status of 6 to 36 Months Children ofGubbi Block As on July, 2012(Total No. of Beneficiaries – 5004)
  37. 37. Nutritional Status of 6 to 36 Months Children of GubbiBlock As on Oct, 2012(Total No. of Beneficiaries – 5004)
  38. 38. Nutritional Status of 6 to 36 Months Children ofGubbi Block As on Jan, 2013(Total No. of Beneficiaries – 5004)
  39. 39. BMI of Adolescent Girls – Gubbi Block(Total No. of Beneficiaries – 7982)
  40. 40. Training Program for Village NutritionVolunteers
  41. 41. Strengthening SHGsSHGs Strengthening Programme
  42. 42. Thank You42

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