Presentation made at a two-day workshop "Stepping up to India’s Nutrition Challenge: The Critical Role of Policy Makers" for district administrators from India’s Aspirational Districts, on 6-7 Aug 2018, at Mussoorie.

1. #IndiaAgainstMalnutrition
Government of India
NITI Aayog

2. Annapurna, Assam
- Aged 3.5 yrs , birth weight was 2.1 kgs
- Declared stillbirth, later found alive
- Kept in ICU for 17 days
- At 6 months, diagnosed with Rickets and
under-nutrition
- Denied admission at Civil Hospital
- After 6 months, diagnosed with Cerebral Palsy
- Sent to rehabilitation centre for children with
disabilities
- Now 6.5 kgs. Still malnourished!
2

3. Fathima, Rajasthan
- 6th child in her family
- Weighed 2kgs at birth
- Development delays. Not fed food after 6 months.
- Registered in AWC BUT no field functionary has
approached her family.
- Deprived of counseling when her growth started
faltering.
- Had to be taken to the NRC by an ambulance.
- Continues to be malnourished
- Current weight of 2.2 kgs
3

4. “
▫ Are we failing our children???
4

5. Where do we Stand?
Indicator India Mexico Brazil China Russia South
Africa
Wasting 21 1.6 1.6 2.1 0.7 1.7
Stunting 38.4 13.6 6.1 6.8 12.8 22.2
5
38.40%
35.70%
44.20%
41.90%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Stunted (height-for-age) Underweight (weight-for-age)
India Aspirational Districts
NORMAL
.
WASTED
(Thin)
STUNTED
(Short)
Normal
height

6. 6
making things worse…
Child
Marriage
Low Birth
Spacing
Myths &
Beliefs
Source of Images:Google

7. “and
7
 Missing Focus on the 1st 1000 Days
 Lack of a Convergent Approach
 Limited Capacities: supply constraints
 No Coordination Among Field Functionaries
 Weak Monitoring and Supervisory Mechanism
▫ Policy & Implementation Issues

8. 8
Missing the Critical Period of
Intervention
..the first 1000 days
Children start coming to the ICDS centres
from 3 years onward

9. 9
Overemphasis on Food Based Solutions
Nutrition > Food
- Food based (nutrition-specific) solutions can only address 20% of the problem
- Investments in agriculture, WASH, social protection, education, and early
childhood development (nutrition- intensive solutions) necessary to solve the other
80%

10. Present Strategy
Recent Initiatives of the Government
10

11. 11
Enhanced allocations
to Health, Sanitation &
Nutrition
Rota Virus & Pneumococcal
Vaccine
Launch of PMMVY
Extension of HBYC & HBNC
Programme
POSHAN Abhiyaan
Anaemia Mukt Bharat Strategy
Revised Cost Norms
under SNP
Recent
Initiatives of the
Government

12. Potential Actions
on the Ground
Actions that have had an Impact
Stories of Change
12

13. 13
0
10
20
30
40
50
60
70
80
90
100
Consumed 100+
IFA during
pregnancy
Weighing during
pregnancy
Breastfeeding
counseling
during
pregnancy
Supplementary
food - pregnancy
Supplementary
food - lactation
Health and
nutrition
education-
lactation
Received vitamin
A in the last 6
months
Deworming for
children
ORS during
diarrhea
Zinc during
diarrhea
Supplementary
food - children
Weighing -
children
Pregnancy Delivery & postnatal Infancy
INDIA ASSAM BIHAR JHARKHAND MAHARASTRA ODISHA RAJASTHAN UTTAR PRADESH
At least 80%-90% Coverage of Essential Services for Health & Nutrition
Ensuring C2IQ : Coverage, Continuity, Intensity & Quality

14. 14
High Impact Interventions to be Implemented
Covering 80%-90% of Eligible Populations in a C2IQ Framework & Monitored Quarterly
Early Registration of pregnancy (preferably in the
1sttrimester)
Home visits to mothers with children between 4-24 months by
ASHA at least once every two months to promote timely and
appropriate IYCF (including complementary feeding, dietary
diversity, frequent feeding, feeding hygiene and early stimulation)
Ensure 4 ANC check-ups: Identifying HRPs and monitoring
Gestational Weight gain
Monthly VHSNDs with the provision of a comprehensive set of
interventions
Full immunization of children below 1 year Deworming (Albendazole) for children in the age group 1-19 years
in February and in August
Supply & consumption of IFA, vitamin A and calcium
supplementation as per national guidelines
Diarrhoea Management among Children (0-60 months) with ORS/
Zinc
Institutional delivery followed by early initiation (within 1
hour) of breastfeeding
Ensuring Cash & Nutrition Support to pregnant mothers; lactating
women and Children 6-24 months: PMMVY & Supplementary
Nutrition (THR) for at least 21 days in a month
Child growth monitoring SAM Children who received treatment

15. Reaching the Unreached
Snapshots
15
Frontline Workers: Our great
heroes!
They are guarding our
health frontiers… saving us
from killer diseases…
from Muripur to Mizoram to
Mangapet!
Efforts to reach out to those left out of routine immunization in flood hit areas of the North East

16. 16
Intensive Efforts in UP during the IDCF Week
In the pre-monsoon season to curb Diarrhoea
- Diarrhea contributes to ~25% of under-nutrition
- Proportion of stunting attributed to 5 or more episodes of diarrhea before 2 years was 25%.
Chekley, 2008

17. 17
Celebrating the National Breastfeeding Week in Chhattisgarh
Using National Platforms/Campaigns for Outreach Purposes

18. 18
Community
Screening of
SAM Children
in Assam
- Active referral mechanism
to NRCs
- Strong community based
management mechanism
- Regular follow-ups through
women’s groups/ field
workers

19. 19
Engaging the Community to create a
Jan Andolan

20. Using VHSNDs for
Service Delivery
20
ANC Check ups during VHSNDS Jaisalmer, Rajasthan
ANC Check ups during VHSNDS Khandva, MP
Platform can be used for:
- IEC/ BCC Campaigns
- Counseling on IYCF
- Growth Monitoring
- Immunization
- Distribution of IFA, Calcium,
Vit A
- Monitoring
- Feed from the Community

21. 21
VHSNDs in Assam

22. Resolving Common Issues
through Simple Solutions
22
OUTCOMEIssue:
Inability of the Worker to organize Community Based Events due to a heterogeneous
community
Challenge:
AWW could not organize events such as Annaprashanna as the habitants belonged
to different religions and caste. For example, it was difficult to organise such events
among the Muslim community.
Action :
Field Functionaries came together and brought in the local religious leader who
played a crucial role in imparting the purpose of the CBEs especially for ensuring
appropriate growth and development of the child.

23. 23
Recognitions & Incentives
Drawing Inspiration from Dr Tapas Majumdar
• Worked for 30 years in the Hospital
• Paediatrician who wears 3 hats : Sub divisional Medical
Health Officer, also In-charge of NRC Nodal Officer SCNU
• Working on 50% capacity. (shortage of 6 Nurse Midwives). 3
lab technicians also needed.
• Single-handedly led to the creation of the NRC at the District
Hospital

24. Strengthening the
Review Mechanism
24
- Joint Monthly/ Quarterly Reviews of
Nutrition Programmes
- Checking the veracity of data which is
fed into Data Systems such as ICDS-
CAS, HMIS
- Field visits and interaction with
beneficiaries to improvise service
delivery
- Using ICDS-CAS for corrective action

25. Key Messages…
• Community Engagement in a Campaign Mode: a
contextualized SBCC focussing on determinants of nutritional
outcome
▫ Package of interventions: Ensure at least 80-90% coverage
in the C2IQ framework with 0 Stock:-outs
▫ Use VHSNDs as a platform for convergent action, service
delivery , IEC & BCC activities
▫ Enhance the capacities of frontline workers through ILA
training. Recognition & Incentives to good performers
▫ Use ICDS CAS-RTM / RCH portal for better quality data
▫ Quarterly Review of all Schemes/ Programmes related to
Nutrition
25
To summarise…
*Lancet (2013)

26. 26
Thanks!

27. 27
Fulwari
Scheme
(Chhattisgarh
)
Community run feeding & day
care centres managed by
mothers.
Enhanced
Beneficiary
Registration
for PMVVY
Chhatua
(Odisha)
SHGs involved in the
production of THR.
Integration of
Anganwadi
Centres
(Andhra
Pradesh)
Kundumbash
ree
(Kerala)
Decentralized model of procurement
& delivery of THR/ income
opportunities for women
Karnataka
State Nutrition
Mission
Using Flexi Funds to give
incentives to AWW
Community Volunteers to drive
Behavioral Change
Merging 3 AWCs into 1,
converging it into a pre-
school model

28. 28
ANC Check ups during VHSNDS in Shrawasti, UP ANC Check ups during VHSNDS Jaisalmer, Rajasthan
ANC Check ups during VHSNDS Khandva, MPANC Check ups during VHSNDS Balrampur, UP

29. Resolving Issues through Simple Solutions
Example 1
29
Issue:
AWC of the village was found to be closed upon visit.
Reason:
Closer inspection revealed that the Centre was shut because the Worker found
it difficult to open/ run the centre as it did not have a proper room/ house.
Children also refused to come due to this.
Action:
Problem was discussed with the CDPO, Statistical Assistant LS and
ultimately the Village president. He promptly agreed to resolve the problem of
Anganawadi house. He spoke to the Village Sangha (Club) & subsequently
provided a room with good condition.
OUTCOME

30. Engaging the Local
Community
30
Engage the community through:
- Community Based Events
- Poshan Melas
- Engage members of SHGs,
PRIs & VOs
- Gram Sabhas dedicated to
Health & Nutrition
Annaprasa in Kathihar, Bihar Annaprasa in Khadva, MP
Annaprasa in Sitamarhi, Bihar VHSNC Meeting in Jaisalmer, Rajasthan

31. 31
Co-Creating a Jan Andolan