Opening presentation - IFPRI-NITI workshop on "A Common Vision for Tackling Malnutrition in India: Building on Data, Evidence and Expert Opinion" - 29-30 March 2019

2. Many new and emerging streams of work in nutrition – how can we
further align them in ways that take India all the way to all nutrition-
related SDG targets?
GOAL: Nourishing India
Food
fortification
POSHAN
Abhiyaan
Agriculture -
biofortification
Anemia
Mukt
Bharat
Maternal
nutrition
program

3. The evolution of policy commitment to an issue
Yes we have a
problem
Recognize
We agree on
drivers
We agree on
solutions
Align
• Policy
instruments
• Invest in
effective
programs
Act
• Monitor
• Recalibrate
Learn
An ever-evolving scientific base on each of these areas is both an opportunity and a challenge
• Problem denial
around stunting/
linear growth
retardation
• Drivers  sanitation?
gender? Multisectoral?
• Solutions  nutrition-
specific/nutrition-
sensitive; 1000 days
• Policy instruments 
ICDS-centric; food and
feeding bias remains
strong but quality, reach,
equity all challenging
• New solution space now
– BCC, multisectoral
rhetoric and some action
• Financing adequacy
remains challenge
• Data contestation
• Recalibration of
existing policy
instruments is slower
than introducing new
ones – e.g., reforming
food supplements in
ICDS vs. Jan Andolan

4. India faces a political transition: Regardless of the outcome, insights
from a study on transitions in Central America suggests that efforts to
align and coordinate must be a key goal for our policy community
• The forces for sustaining Food Security and Nutrition Policy were Backed Up, Beneficial, Championed,
Importance, Institutionally Sound, Owned, Sensitive, Shared, Steady Resources, Strategic, Transition Effect,
and Trusted.
• The forces for not sustaining FNSP were Antagonistic Underlying Structure, Campaigning, Dysfunctional
Transition, Fractioned, Haphazard, Insensitive, Irrelevant, Misrepresentation, Neglected, Rivalry, Unsound
Institutions, and Unsteady Resources.
• The forces did not compete, but combinations of them brought about outcomes that policy actors in
charge and their collaborators could intentionally influence. The potential of forces to shape sustainability
of FSNP depended on interacting actors responding to emerging events within specific contexts. Roles
performed by civil society, governmental officials, and international cooperation were critical for policy
sustainability during transitions.
• Actors and other stakeholders can identify the predominant specific forces operating for a policy and
activate or promote the forces that enhance sustainability and deactivate or suppress the forces that inhibit
sustainability.
• Foreseeing or creating opportunities to activate (or deactivate) and promote (or suppress) forces during the
early stages of a presidential transition could help sustain policies and related practices that benefit food
and nutrition security.
Jessica L. Escobar-Alegria, Edward A.Frongillo, Christine E.Blake. 2019. Sustainability of food and nutrition
security policy during presidential transitions. Food Policy.

5. Why are we here?
Rally together
Align on challenges and actions
Think ahead
Provide
inputs to
update the
2017
National
Nutrition
Strategy

6. Scope of the challenge: India’s nutrition challenge has taken a different
shape in the last decade; despite many improvements, the new
challenge is one of variability across India
Districts
with no
data
Districts
with
10⎼20%
Districts
with 20⎼30%
Districts
with 30⎼40%
Districts
with >40%
1 29 170 202 239
Anemia among women of reproductive age, 2016
Districts
with no
data
Districts
with
0 - <20%
Districts
with
20 - <40%
Districts
with
40 - <60%
Districts
with
≥60%
0 7 122 360 151
Overweight or obesity among men, 2016
Districts
with no
data
Districts
with
0 - <10%
Districts
with
10 - <20%
Districts
with
20 - <30%
Districts
with
≥30%
0 141 288 149 62
Stunting among children < 5 years, 2016

7. Stunting: Factors related to gender, poverty and health services account for much of the
difference between high and low stunting districts. Half the difference is tied to women’s
wellbeing
Districts
with no
data
Districts
with
10⎼20%
Districts
with 20⎼30%
Districts
with 30⎼40%
Districts
with >40%
1 29 170 202 239
Stunting among children < 5 years, 2016
Source: P Menon, D Headey, P Nguyen, R. Avula. 2018. Understanding the
geographical burden of stunting in India: A regression‐decomposition analysis of
district‐level data from 2015–16. Maternal & Child Nutrition
Stunting differences between high and low stunting
districts

8. Anemia: Factors related to gender, poverty and health services account for
changes in anemia over time – both for women and for children
Decomposition analysis for factors contributing to change in hemoglobin among
children and pregnant women in India from 2006 to 2016
Source: Nguyen et al., 2018
Factors contributing to changes in anemia over time
• Changes in women’s anemia:
Schooling, diet, socioeconomic
status, sanitation and nutrition
interventions
• Changes in children’s anemia:
maternal schooling, SES, health
and nutrition interventions and
other factors (majority related to
maternal wellbeing)

9. The policy environment for
nutrition-specific
interventions is quite robust,
but reach of interventions
highly variable
• Coverage varies both by intervention
and by state
• Evenly high coverage for some
interventions (iodized salt, receiving any
IFA)
• Moderate and mixed coverage for most
other interventions
• Mostly low coverage for deworming,
pediatric IFA, zinc along with ORS (not
shown), counselling after weighing
• About a third of ANC is in the private
sector
State
Iodisedsalt
ReceivedIFA
Consumed100+
IFA
Deworming
Weighing
Breastfeeding
counseling
Food
supplementation
Health&nutrition
education
Food
supplementation
Health&nutrition
education
VitaminA
PediatricIFA
Deworming
Food
supplementation
Weighing
Counsellingon
childgrowth
INDIA 93.2 77.9 31.0 18.6 75.6 39.5 52.8 39.8 49.2 36.4 61.1 27.2 34.6 53.1 46.3 29.7
A & N ISLANDS 98.7 92.8 58.3 3.9 97.5 64.9 47.5 37.7 39.5 32.6 63.0 23.8 49.4 55.0 54.6 43.3
ANDHRA PRADESH 88.3 91.1 55.7 21.7 97.5 56.8 71.4 65.0 70.6 64.1 74.4 31.7 24.3 68.1 61.0 42.7
ARUNACHAL PRADESH 99.2 65.7 9.0 12.7 58.1 13.4 14.7 7.2 16.1 6.8 42.1 22.8 33.4 23.1 12.6 5.3
ASSAM 99.5 85.6 32.7 10.0 88.1 45.2 59.1 36.1 54.5 32.8 50.4 21.2 32.8 58.7 41.7 25.9
BIHAR 93.1 55.6 10.0 9.4 43.0 21.1 35.0 18.7 35.4 16.8 62.9 22.4 26.8 37.6 24.0 12.1
CHANDIGARH 99.2 90.1 46.6 16.1 94.2 49.5 43.2 22.8 37.8 21.3 50.8 12.1 19.7 50.0 42.2 30.7
CHATTISGARH 99.1 91.3 29.9 23.1 93.2 68.9 87.3 78.2 85.9 71.5 71.3 36.1 41.8 79.6 80.2 58.2
D & N HAVELI 65.3 84.0 42.9 11.7 90.3 34.2 41.3 35.5 24.0 19.5 62.9 17.9 17.3 50.1 49.2 37.7
DAMAN & DIU 97.0 73.6 44.0 20.9 80.5 15.7 18.9 17.9 13.6 15.1 65.8 26.3 23.8 23.9 23.4 13.8
DELHI 96.4 89.7 54.5 14.8 87.4 22.2 12.1 12.3 8.9 7.8 58.8 29.5 44.4 14.5 13.4 7.4
GOA 97.7 94.2 66.3 59.3 96.4 60.9 66.7 55.7 68.5 58.4 86.2 54.5 67.7 59.9 56.3 44.8
GUJARAT 95.4 76.2 37.5 20.5 83.5 37.4 55.5 47.7 50.1 42.1 73.6 34.3 30.4 58.9 58.1 41.9
HARYANA 91.9 83.8 33.6 16.7 80.2 39.2 33.4 28.9 30.2 26.3 67.9 43.1 37.4 40.2 41.3 28.3
HIMACHAL PRADESH 99.3 93.0 49.6 11.2 86.0 29.6 78.7 44.9 68.5 38.5 65.8 20.8 45.9 77.6 53.8 29.4
JAMMU & KASHMIR 93.9 74.3 31.6 10.0 80.5 33.7 27.0 14.0 20.0 11.3 65.8 19.9 41.9 36.5 25.1 13.0
JHARKHAND 97.5 69.6 15.6 12.6 70.3 33.2 69.6 40.8 65.3 36.2 54.5 17.9 23.1 60.2 45.1 27.1
KARNATAKA 87.8 84.5 46.3 32.0 88.0 38.0 60.9 48.4 52.6 45.1 78.6 51.2 53.9 59.0 55.5 34.2
KERALA 98.3 96.5 74.6 23.3 98.7 46.0 30.2 22.9 23.3 16.2 75.6 18.3 56.1 55.4 49.7 21.1
LAKSHADWEEP 94.5 96.6 86.3 15.9 99.5 32.0 67.6 28.2 55.1 23.3 50.0 10.8 54.5 69.0 39.7 7.2
MADHYA PRADESH 92.4 82.6 23.2 18.5 72.5 41.7 69.9 54.0 65.1 48.2 60.8 26.7 31.3 65.5 60.5 37.1
MAHARASTRA 96.1 84.8 40.4 26.6 90.5 37.0 43.5 36.5 40.1 33.9 70.5 42.6 47.0 50.7 49.0 28.5
MANIPUR 99.2 83.6 40.5 2.3 86.9 11.0 26.7 2.6 22.5 1.5 33.5 5.3 10.3 32.1 3.0 0.4
MEGHALAYA 98.5 80.8 37.4 4.3 79.5 38.8 52.7 30.3 49.5 29.5 55.2 33.3 32.8 56.0 41.6 21.8
MIZORAM 98.8 83.3 55.3 5.5 84.8 37.7 68.1 40.7 63.8 38.2 69.5 26.3 61.0 71.2 63.2 24.7
NAGALAND 99.2 42.8 4.0 1.8 38.3 3.1 9.3 0.8 8.3 0.7 29.1 9.5 19.1 38.3 4.3 0.3
ORISSA 92.9 90.4 36.7 32.1 92.7 69.9 87.8 79.2 84.7 76.3 71.0 29.7 29.8 80.0 75.6 53.0
PONDICHERRY 94.1 95.3 65.5 49.0 96.5 66.5 65.0 63.5 67.3 64.5 72.1 46.9 51.2 60.9 60.7 48.9
PUNJAB 98.5 88.9 42.8 21.7 94.3 58.3 58.5 38.0 50.7 34.0 70.0 33.1 30.5 59.7 45.5 26.9
RAJASTHAN 92.6 64.6 17.5 7.2 78.8 28.2 45.5 29.2 38.0 23.4 40.9 14.7 17.1 36.1 29.4 17.5
SIKKIM 99.7 97.4 53.6 9.0 94.9 48.3 50.3 41.3 47.2 37.9 81.4 50.7 49.7 52.8 48.2 36.4
TAMIL NADU 84.3 94.0 64.4 47.0 92.8 59.4 61.4 58.3 59.9 56.6 67.1 34.5 55.2 60.9 59.1 48.7
TRIPURA 99.0 86.7 14.6 10.1 92.5 32.4 56.0 28.6 52.0 27.0 63.0 8.9 60.7 64.1 53.7 25.5
UTTAR PRADESH 93.1 62.0 13.1 8.1 45.9 22.4 34.1 16.2 29.4 13.1 40.4 13.5 18.6 32.8 24.1 11.5
UTTARANCHAL 95.3 79.7 25.0 7.3 65.5 28.6 48.4 24.1 55.3 24.8 36.2 14.6 17.9 63.5 51.8 26.1
WEST BENGAL 94.7 90.6 27.8 19.4 90.9 57.1 73.0 61.4 70.7 57.6 66.4 29.1 58.7 76.1 72.4 52.5
Source: IFPRI analysis of NFHS-4 data

10. Solutions: Expansion of the ICDS supplementary food coverage in
the decade between 2006 and 2016: Improvements across every
state but use of ICDS is higher in poorer quintiles
Chakrabarti et al., Bulletin of WHO, 2019

11. What is the nutrition policy community
concerned about? Summary findings of an
online stakeholder survey
March 28, 2018
Survey data as of 3 p.m. IST, March 28 2018

12. Profile of Survey Participants (N=63)
Respondent Age
11
19
30
13
19
0 20 40 60 80 100
20-30 years
31-40 years
41-50 years
51-60 years
Older than 60 years
%
Gender
41
57
1 1
Male Female Other Prefer not to say
32
5
56
8
0
20
40
60
80
100
Research Civil Society Implementation
(program or
technical support)
Others
%
Primary area of work
14 10
41
11
24
0
20
40
60
80
100
Research
Institute
Government NGO University or
Academic
Organization
Others
%
Location Affiliation
43% - Delhi
37% - State
5%- District

13. Level of emphasis India should place on different malnutrition challenges: Maternal and child
undernutrition remains a higher concern but strong sense that overweight among adults needs
attention
0
10
20
30
40
50
60
70
80
90
100
Stunting Wasting Low Birth
Weight
Anemia
among
Women
Overweight
among
Children
Overweight
among Adults
Adult High
Blood
Pressure
Adult High
Blood Sugar
%
Needs Attention Top Priority
1
2
3

14. Most relevant immediate determinants of child undernutrition: Complementary feeding and
maternal undernutrition
0
10
20
30
40
50
60
70
80
90
100
Early Initiation of
Breastfeeding
Exclusive
Breastfeeding
Timely
Introduction of
Complementary
Food
Minimum
Acceptable Diet
Maternal
Undernutrition
Childhood Illness
%
Needs Attention Top Priority
1 2
3

15. Most relevant underlying determinants of undernutrition: girl’s education, early
marriage and sanitation
0
10
20
30
40
50
60
70
80
90
100
Girls Education Early Marriage Women
Economic
Participation
Women Social
Empowerment
Food Security Poverty Sanitation
%
Needs Attention Top Priority
1
2
3

16. Importance of areas of action related to food systems and agriculture for nutrition
0
10
20
30
40
50
60
70
80
90
100
Fortification of
Staple Food
Fortification of
Foods in Public
Programs
Diversifying Foods
in Public Programs
Home Gardening Large Scale
Production of
Diverse Foods
Biofortification of
Staple Foods
%
Needs Attention Top Priority
1 2

17. Interventions to improve ANC: beneficiary awareness, monitoring of
public provision and guidance to all providers are ranked highest
4.33
4.46
3.85
4.51
4.17
1
2
3
4
5
All providers (public and
private) given adequate
guidance on frequency and
components of ANC
Improve monitoring of public
provision of antenatal care
Increase private provider
compliance with ANC
guidance
Raise awareness among
beneficiaries on the
importance of early and
frequent antenatal care
Conduct implementation
research on demand and
supply-side reasons for low
coverage
AverageScore
12
3

18. 13
54
30
3
Low Medium High No response
Despite lower interest in strengthening private provider compliance, the stated likelihood of
an increase in private sector involvement in ANC in the future was very high. Current levels
of private sector ANC use are ~30%

19. Improving quality of public programs: fill positions, improve monitoring and use of data and
training
Increasing IFA consumption: raise awareness, training providers and improve procurement &
distribution
Measures to ensure quality of ANC in public sector
facilities and program platforms like VHSND
4.29
4.49
4.53
4.68
4.32
4.63
1 2 3 4 5
Assure Adequate Financing
Improve Infrastructure
Train Staff
Fill Sanctioned Staff Positions
Reassess Staffing Needs
Improve monitoring and use of data
for improvement
Average Score
Measures to increase consumption of IFA among
pregnant women
4.34
4.05
4.54
4.76
1 2 3 4 5
Improve procurement and distribution
of IFA
Improve financing processes for IFA
Train all healthcare providers on IFA
benefits and management of side-
effects
Raise awareness about IFA (benefits
and management of side-effects)
among communities
Average Score
1
2
3
1
2
3

20. Breastfeeding counseling for pregnant women: Disseminate guidance, monitoring of
provider compliance, raise awareness among private providers
Improving IFA coverage among children: Awareness raising, provider training and supply
chain
Measures to ensure that all pregnant women are
counselled on breastfeeding
4.64
4.45
4.53
3.71
1 2 3 4 5
Ensure wide-spread dissemination of
guidance
Raise awareness among private-care
providers
Monitor public provider compliance
with guidance on breastfeeding
counselling
Incentivize provision of breastfeeding
counselling
Average Score
Measures to improve IFA coverage among children
4.49
4.05
4.58
4.7
1 2 3 4 5
Improve procurement and distribution
of pediatric IFA
Improve financing processes for
pediatric IFA
Train all healthcare providers (on
benefits and side effects management)
Raise awareness of IFA (benefits and
side effects management) among
communities
Average Score
1
2
3
1
2
3

21. Growth monitoring: Beneficiary awareness, coverage and quality and equipment
Counseling after weight/GM: Provider training, provider awareness of importance,
mechanisms to increase coverage/quality
Measures to improve coverage of child weight
measurement
4.62
4.6
4.62
4.63
1 2 3 4 5
Ensure equipment is available
Ensure that providers are adequately
trained
Identify mechanisms to ensure
coverage and quality of weighing
Raise beneficiary awareness of
growth monitoring
Average Score
Measures to improve women counselling on their
child weight measurement
4.62
4.63
4.45
4.5
1 2 3 4 5
Awareness of providers about
importance of counselling after
weighing
Training of providers on growth-
related counselling
Ensure that providers have job aids
Identify mechanisms to ensure
coverage and quality of counselling
Average Score
1
2
3
1
2
3

22. ICDS THR uptake: Ensure quality, raise awareness and strengthen supply chain
ICDS THR knowledge needs: Beneficiary perceptions, reasons for opting out and update
composition
Measures to improve THR uptake
4.41
4.46
4.42
4.72
1 2 3 4 5
Examine THR formulations and
delivery mechanisms across states
Strengthen the supply chain to
ensure availability of THR
Raise beneficiary awareness of THR
Ensure quality of THR
Average Score
Important areas of work around the ICDS THR for
women and children
4.23
4.36
4.5
1 2 3 4 5
Update THR composition guidance
Assess reasons for opting-out of ICDS
services in low coverage-high
performance states
Assess beneficiary perceptions of THR
and other ICDS and health program
services
Average Score
1
2
3
1
2
3

23. 38
41
37
39
32 30
28 28 29
25
44 44
30
39 39
34
41
44
51 52
35 34
27 28
0
10
20
30
40
50
60
70
80
90
100
Awareness
about healthy
diets
Awareness
about
unhealthy
food
Regulate
marketing of
unhealthy
food
Regulate sales
of unhealthy
food
Mandatory
labelling
norms for all
foods
Ban or reduce
junk food and
beverage in
school
Policies to
reduce prices
of healthy
foods
Last-mile
availability of
healthy foods
Opportunities
for physical
activity
Work life
balance
Early
screening for
high blood
sugar
Early
screening for
hypertension
%
Needs Attention Top Priority
Areas of action to address overweight and non communicable diseases: Price
reduction, increased availability of healthy foods, reduce HFSS in schools
1 2
3
Awareness Marketing regulations Policies/Program Exercise Screening

24. Knowledge Needs: level of
confidence on the available
evidence for understanding the
determinants of different
malnutrition outcomes
- High degree of confidence
for undernutrition
- Lower for anemia
- Lowest for overweight and
NCDs
0
10
20
30
40
50
60
70
80
90
100
Stunting Wasting Low birth
weight
Anemia Childhood
overweight
Adult
overweight
Adult NCDs
%
We know enough We need to know more

25. Knowledge Needs: level of
confidence on the available
evidence for improving the
determinants of different
malnutrition outcomes
- High degree of confidence
for breastfeeding and
complementary feeding
- Lower for maternal anemia
- Lowest for anemia, healthy
diets, physical activity
75
51
34
44
25
23
32
23
37
51
41
53 54
47
0
10
20
30
40
50
60
70
80
90
100
Breastfeeding Complementary
feeding
Maternal
undernutrition
Maternal
anemia
Healthy and
diverse diets for
all
Unhealthy
eating
Low levels of
physical activity
%
We know enough We need to know more

26. Do we know enough to deliver
these interventions at scale
with quality?
• High for breastfeeding,
growth monitoring and
screening
• Much lower for Code
monitoring, complementary
feeding and complementary
foods
• Lowest for cash transfers
and fortified staple foods
59
25
43
35
13
51
43
18
35
54
44
46
48
39
38
57
0 10 20 30 40 50 60 70 80 90 100
Breastfeeding counselling and support
Monitoring and compliance with code of marketing of
breastmilk substitutes
Complementary feeding counselling
High quality complementary foods
Cash transfers for families with young children
Growth monitoring and counselling
Screening, referral and management of severe wasting
Fortified staple foods
%
We need to know more We know enough

27. Summary of survey findings
• What aspects of the nutrition challenge should India focus on?
• SDG targets: Maternal and child undernutrition remains a higher concern but strong sense that
overweight among adults needs attention
• Other challenges: Adolescent nutrition and micronutrient deficiencies
• Determinants
• Immediate: Maternal nutrition, complementary feeding
• Underlying: Gender (education, age at marriage), sanitation
• Interventions for the first 1000 days
• Across several interventions: awareness raising, monitoring and use of data, filling positions
• Pay attention to both public and private sector provision
• Areas of action for overweight and NCDs
• Availability and prices of healthy foods
• Awareness raising and banning unhealthy foods, especially around schools
• Knowledge needs
• Adequate to act on several undernutrition areas but some determinants (e.g., maternal nutrition,
complementary feeding, etc.) need more attention