Fall Global Health Practitioner Conference 2017 Scaling Up SBC: Lessons from Nepal Jennifer Nielsen

1. SCALING UP SBC:
LESSONS FROM NEPAL
September 26, 2017 Global Health Practitioners Conference
Jennifer Nielsen, PhD, Senior Nutrition Advisor

2. • Nepal is making impressive strides in health and nutrition despite major
challenges, including the continuing earthquake recovery and moving to
a new constitution and moving to a federal structure.
• Strong government
commitment has achieved
major reductions in
stunting since 2001 but
more is needed
Additional NDHS 2016 data
• Child anemia: 53%
• WRA anemia: 41%
• WRA underweight: 17%
Indicator levels vary by
ecological zones and SES
CONTEXT

3. Evolving approach over multiple phases
Learning is continuous
• AAMA (2008 – 2011) CSP
• Suaahara I (2011 – 2016)
• Suaahara II (2016 – 2021)
• National Nutrition Policy and Strategy (2004)
• Sanitation and Hygiene Master Plan (2011)
• Nepal Health Sector Support Strategy
(2015 – 2021)
• Multi-Sector Nutrition Plan (2013 – 2017)
Government of Nepal
GUIDING GOVERNMENT POLICIES

4. • Integrated multi-sectoral strategy to improve nutrition
• Focus on 1,000 days period plus adolescence
• Implemented at scale (across 40 districts – social/geographic diversity)
• Special emphasis for disadvantaged groups
• Builds upon and strengthens government structures and platforms
• Rigorous research, plus ongoing monitoring data to inform programming
SUAAHARA II OVERVIEW
• Multichannel SBC strategy
integrated across all sectors
– Nutrition & Health/Family Planning
– Agriculture/Livestock
– WASH
– Education
– Gender & Social Equity
– Governance

5. Beneficiaries
1.1 million PLW
881,000 CU5
32,400 DAG HH
Train to plan & manage
Multisector Nutrition Plan at
District & VDC levels
40 districts
215,300 people
PROGRAM INPUTS, REACH AND SCALE
15,000 HH
Village Model Farmers
and Homestead Food
Production
Health workers
Trained in FP/RH
6,075
Frontline
workers trained in CHN
42,780

6. Climate smart
ag technology&
information
Engaging private
sector
Market linkages
and development
initiatives
Improved access
to microfinance
Empowerment of
women producers
Sales of surplus
agricultural
products
HH budgeting for
improved nutrition
and health
behaviors
Adolescent
Health &Life
Skills Programs
Emergency
Preparedness
& Response
Women’s decision-
making increased
Strengthening &
coordination with
government bodies
Improved access
to ag inputs &
extension services
WASH
FP
Health
Services
Mass Media &
Information
Technology
Strengthened
government
capacity
Gender & Social
Inclusion strategy

7. Improved Household Nutrition and Health Behaviors
Improved Access to Diverse and Nutrient-Rich
Foods byWomen and Children
Accelerated Roll-Out of Multi-sector Nutrition Plan
through Strengthened Local Governance
Improved
nutritional
status of
women
and
children
< 2 years
Increased Use of Quality Nutrition and Health
Services byWomen and Children
Gender Equality and Social Inclusion
Public Private Partnerships
Innovative Grants Program
Emergency Preparedness and Response Plan
Monitoring Evaluation, Research for Learning
SUAAHARA II RESULTS FRAMEWORK
Social and Behavior Change

8. LEARNINGS FROM AAMA AND SUAAHARA I
• Continuity in leadership to build on learnings
• Formative research conducted each phase
• Experience uncovered gaps in understanding for additional research
• Particularly disparities between knowledge and adoption
• Findings used continuously to improve intervention packages
• Target audience entire family not just 1000-day women
• Prioritized 10 key health, nutrition & WASH behaviors
• Feedback from monitoring data highlights those needing most focus
• Reinforced through all delivery platforms/communication channels
• Goal to reach each family 60 times over first 1,000 days
• Address women’s decision-making power, access to and
control over resources required to adopt key behaviors

9. LEARNINGS: MOVING FROM SBCC TO SBC
• Social and behavior change
includes not only
communication, but also
strategies to create an
enabling environment for
sustained behavior change
• These strategies include
development of supply systems,
services and infrastructure from
government and private sector,
as well as social support and
measures to transform social
norms
 This is the major challenge

10. • Apply principle of small do-able
actions to:
• Nutrition
• Food production
• WASH
• Healthy timing and spacing of
pregnancies,
• Empowerment & equity
• Increase demand for and
quality of health and nutrition
services
• Strengthen policy coordination
at all levels across food, care
and health/WASH services
dimensions
SUAAHARA SBC OBJECTIVES

11. MULTISECTOR PLATFORMS
Village model farmers
Ag extension officers
WASH committees Citizen Awareness Centers Ward Citizen Forums
Schools Health facilities
NUTRITION MESSAGING INTEGRATED ACROSS

12. SBC CONSTANT FEEDBACK LOOP
Formative
Research
Communication
Strategy
Campaign
Design
Multi-level SBCC
Implementation
Monitoring
and
evaluation
Baseline
Research
Monthly compilation of HH & coverage checklists
Annual surveys of HH, activities, progress

13. • Monitoring via district-representative monthly data collection
and rapid ongoing feedback cycle using DHIS2 system
• Using checklists completed by field supervisors via mobile app
• Representative random sample of HH (n~3,000), FCHV (1200), VMF (600)
and health facilities (600)
• Assess coverage on 60 contact points and adoption of 10 practices
• Monthly meetings and annual workshops to review data
• Use findings to improve SBC strategy at the local level by addressing
weaknesses in coverage of activities, contacts and hardest to change
behaviors
• Annual survey (3,600 HH) conducted by external team, same
season & tools each round, to assess progress, provide
deeper feedback
MONITORING FEEDBACK SYSTEM

14. • Monthly monitoring checklists
• Household level questions targeted to appropriate point in the life cycle
• Attendance at mothers’ group meetings
• Homestead food production practices
• FCHV activities & coverage
• Health facility services & counseling
• Community mapping census generates denominators and
identifies DAGs for better targeting
• Also allows identification of individual HH needing extra attention and
reinforcement of the particular appropriate messages
MONITORING FEEDBACK SYSTEM

15. • Scale of project facilitates local tailoring
• Staffing is substantial, with district office staff, partner
NGO teams, district and local government partners,
FCHV, community nutrition facilitators – nearly 2,000
people across the 40 districts
• Kathmandu sets minimum program standards and
guides, but teams have local autonomy for problem-
solving, creative collaborations and adapting to local
culture, challenges and needs
• Both GON and USAID recognize importance
of flexibility
• Workplans regularly updated to local realities
• Recent example: to respond to flooding emergency
Suaahara teams in affected districts trained in IMAM
• Nepal federalist structure will divide 40 districts into
>350 municipalities with local control…creating
challenges and opportunities
SUCCESS FACTORS

16. SBC APPROACHES
Communication
Strategy
Campaign
Design
• Leveraging key aspirations: family’s value of
education and child’s success in school
• Multi-channel communication to reach families with
intensive and persistent messaging on key
practices/social change
• Interpersonal communication (IPC)
• Information technologies for frontline workers
• Mother health group discussions
• Community mobilization
• Interactive radio and listener groups
• Tools to guide counseling and improve quality
(complementary feeding wheels, phone videos)
• Innovation grants and public private partnerships
to build local entrepreneurship in filling supply
barriers to adoption

17. “MOTHER KNOWS BEST” CAMPAIGN
ADAPTED TO LOCAL CONTEXT
Mothers-in-law
• Portrayed as a catalyst of change in social norms for nutrition
• Building on her central role in household decision-making
Branding umbrella
• Linked across channels (mass media, community, interpersonal)
• And issues (nutrition, WASH, health, agriculture)

18. SBC COMMUNICATIONS
Mass Media: Localized radio programs (Terai, Hills, Mountains)
• Bhanchin Aama the wise mother-in-law character - brand who also
listens to and empowers young mothers
• Serial drama to teach through stories
• Phone-in segments with main character, quizzes & contests via SMS for
audience engagement & feedback
• Chatting with my Best Friend for adolescents to promote health

19. FREQUENT (60) INTERPERSONAL CONTACTS
WITH ALL CAREGIVERS
Interpersonal
communication
Community
mobilization
Mobile
technology
- Home visits
- Health mothers group
meeting
- Radio discussion groups
- Counselling at health
contact points
- Cooking demonstrations
- Ward level interactions
- Key life event celebrations
- Community fairs
- Radio contests & awards
- Complementary food recipe
competitions
- Push messaging to
motivate and remind
- Videos & apps to guide
frontline workers
- Calls & SMS with
radio hosts

20. SUMMARY - KEY PRINCIPLES
• To close knowledge-practice gap
• Address both supply constraints through WASH
marts, outreach clinics, ag and health supply
chains, and health quality through community
scorecards and demand constraints by working
with individuals but also family & community
social norms
• Prioritize fewer behaviors and phasing
of messages
• But saturate families with the messages
appropriate to their needs (60 contacts in first
1,000 days)
• User-friendly, mobile M&E data
collection and feedback promotes data
utilization to improve SBC strategies
and targeting

21. SUMMARY - KEY PRINCIPLES
• Multiple SBCC approaches and channels appropriate to context
• Provide local teams with guidelines and QA tools but allow freedom to tailor
intervention package & SBC strategies to their context
• Specialized delivery platforms for disadvantaged groups to close gap
• Making all platforms nutrition-sensitive takes time, given Nepal’s
geographic and cultural diversity, and requires capacity building but
is the key

22. ACKNOWLEDGEMENTS
• Christopher Landry, Chief of Party, Suaahara II
• Pooja Pandey Rana, HKI/Nepal Director of Programs
• Kenda Cunningham, Senior Technical Advisor Suaahara II
• Dipak Sharma, Public-Private Partnership Manager
• Dale Davis, HKI/Nepal Country Director
• Nancy Haselow, HKI Vice President for Asia & Pacific

23. Thank you!
“The only think worse than being blind is having sight but no vision.”
-Helen Keller