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. BREAKING THE SILOS-
SYSTEMS THINKING AND
THE CASE OF NUTRITION
Arti Ahuja, Phase 3, April 2018

2. Burden of Disease Study 2017
are akin to national emergencies as these have the
potential to significantly blunt the rapid social and
economic progress to which India aspires.
The findings of the study reveal that three types of risks
Undernutrition, Air pollution,
and a group of risks
causing cardiovascular
disease and diabetes
1.What are the reports saying?

3. 3
Global Hunger Index 2017
Proportion of undernourished in
India = 14.5%
India trails North Korea,
Bangladesh in Hunger Index
India ranked 100th among 119
countries on Global Hunger Index
(GHI) 2017...

4. 4
Global Nutrition Report 2017
 Global Nutrition Report 2017: India Carries a Serious
Burden of Anemia, Obesity and Malnutrition
 Urgent need to integrate our actions on nutrition if
India hopes to meet its Sustainable Development
Goals Agenda 2030.

5. Understanding malnutrition.

6. -2
-1,75
-1,5
-1,25
-1
-0,75
-0,5
-0,25
0
0,25
0,5
0,75
1
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
Age (months)
Z-scores(WHO)
Weight for age (WAZ)
Weight for length (WHZ)
Height for age (HAZ)
Source: Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R.
Worldwide timing of growth faltering: revisiting implications for
interventions using the World Health Organization growth standards.
Pediatrics, 2010 (Feb 15 Epub ahead of print)
Worldwide timing of growth faltering, 54 countries
6

7. Fig 3. Categories of length-for-age stratified by exact month of age and site.
MAL-ED Network Investigators (2017) Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of
life: The MAL-ED longitudinal birth cohort study. PLOS Medicine 14(10): e1002408. https://doi.org/10.1371/journal.pmed.1002408
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002408

8. 8

9. Immediate causes of poor nutrition
for children
Food
• Breastfeeding
• Complementary
feeding
• Limiting non-
nutritive foods
Care
• All activities
that assure that
family food,
health and
other resources
reach the child
• Attention to the
child, care
arrangements
• Responsive
feeding
• Psychosocial
stimulation
Health
• Preventive and
curative health
care
• Assurance of a
healthy and
clean
environment
• Maternal health
and well-being

10. 3. How do we measure malnutrition?

11. Children < 5 years of age
• Stunting: child <5 years of age is too short for their age—a result of chronic undernutrition (more
than 2 standard deviations below median in a healthy population)
• Wasting: child <5 years of age has weight too low for their height—a result of acute undernutrition (more
than 2 standard deviations below median in a healthy population)
• Underweight: child <5 years of age has weight too low for their age—from either chronic or acute
undernutrition (more than 2 standard deviations below median in a healthy population)
• Overweight: child < 5 years of age has weight too high for height (more than 2 standard deviations
above median in a healthy population)
The ways malnutrition is most frequently
referred to in major reports
11

12. 12

13. 13

14. Wasting and Stunting
14
38.4% children
(<5y) in India are
stunted
21 % of children
(<5y) in India are
wasted

15. Response depends on the measure we
use
STUNTING
(CHRONIC)
NORMAL WASTING
(ACUTE)
Low height for age Low weight for height
Low MUAC

16. Trends in key global nutrition targets and
nutrition outcomes in India, 2005-06 to 2015-
16
48
19.8
55
46.4
21.5
38.4
21
53
54.9
18.6
0
10
20
30
40
50
60
70
Stunting Wasting Anemia
among
women
Exclusive
breastfeeding
Low
birthweight
2005-06 2015-16
Source: NFHS-3; NFHS-4 and RSOC for low birth weigWorld Health Assembly Nutrition Target Level

17. 4. What is the district wise prevalence?
….Stunting (among children <5 years), 2016
Source: NFHS-4.
Top 10 districts
Bottom 10 districts
Ernakulam (KL) 12.4%
Pathanamthitta (KL) 13.3%
Kollam (KL) 14.4%
Alappuzha (KL) 14.5%
Idukki (KL) 15.1%
Cuttack (OR) 15.3%
Hyderabad (TG) 15.7%
Puri (OR) 16.1%
South Garo Hills (ML) 16.8%
Kanniyakumari (TN) 17.2%
Yadgir (KA) 55.5%
Koppal (KA) 55.8%
Sitapur (UP) 56.4%
Gonda (UP) 56.9%
Sitamarhi (BR) 57.3%
Siddharthnagar (UP) 57.9%
Pashchimi Singhbhum (JH) 59.4%
Balrampur (UP) 62.8%
Shrawasti (UP) 63.5%
Bahraich (UP) 65.1%

18. …and in what kind of
households?

19. Wasting (among children <5 years),
2016
Source: NFHS-4.
Top 10 districts
Bottom 10 districts
Mokokchung (NL) 1.8%
Aizawl (MZ) 2.3%
Peren (NL) 4.1%
Badgam (JK) 4.2%
Ganderbal (JK) 4.6%
Imphal West (MN) 4.7%
Kupwara (JK) 5.1%
Samba (JK) 5.2%
Anantnag (JK) 5.4%
Lunglei (MZ) 6.1%
Lalitpur (UP) 39.0%
Uttarkashi (UT) 39.4%
Nandurbar (MH) 39.8%
Purbi Singhbhum (JH) 40.6%
Dumka (JH) 41.4%
Khunti (JH) 43.0%
The Dangs (GJ) 43.0%
Gadag (KA) 43.1%
Gadchiroli (MH) 45.8%
Tehri Garhwal (UT) 46.9%

20. Emerging challenges: Nutrition-related
non-communicable diseases
13.4
18.6
7.98.8
20.7
5.8
0
10
20
30
40
50
60
70
High blood pressure Overweight/Obesity High sugar level
%
Men Women
Source: NFHS-4

21. Let us identify the immediate and
underlying factors
u

22. Optimal maternal and child
nutrition and development
Nutrition-specific
interventions
• Adolescent and
preconception nutrition
• Maternal dietary
supplementation
• Multiple micronutrient
supplementation or
fortification
• Breastfeeding and
complementary feeding
• Diet supplementation
for children
• Dietary diversification
• Feeding behaviours
and stimulation
• Treatment of severe
acute malnutrition
• Disease prevention and
management
Nutrition sensitive
interventions
• Agriculture & food
security
• Social safety nets
• Early child development
• Women’s
empowerment
• Child protection
• Education
• Water and sanitation
• Health & family
planning services
Adapted from Lancet 2013
6. What are the causes and possible interventions? [
a few of them!]
Breastfeeding,
nutrition-rich
foods
Feeding
and
caregiving
practices
Low burden
of infectious
diseases
Food
security
Feeding
and
caregiving
resources
Health
services,
safe and
hygienic
environm
ent
Basic causes

23. Immediate causes: poor infant feeding in
India, 2006-2016
Source: Progress and inequalities in infant and young child feeding practices in India between 2006-2016
Nguyen, P.H., R. Avula, D. Headey, L.M. Tran, M.T. Ruel and P. Menon. (Paper under review)
55.2
15.2
41.8
8.7
21.8
45.2
21.2
36.3
9.4
22.5
0
20
40
60
80
100
Introduction of
SSSF
Minimum dietary
diversity
Minimum meal
frequency
Minimum
acceptable diet
Consumption of
iron rich food
%
2006 2016
Add
breastfeedin
g

24. Hunger …
Women's energy/calorie consumption
2250
2500
2230
1736
1859
1786
0
500
1000
1500
2000
2500
3000
Energy
Pregnant Lactating NPNL(Mod)
RDA- Energy
(kcal/day)
Consumed
energy
(median)

25. Protein consumption
78
71
55
45
48 47
0
10
20
30
40
50
60
70
80
90
Protein
Pregnant Lactating NPNL(Mod)
RDA (g/day)
Consumed
protein (median)

26. Sanitation & undernutrition: stopping the
transmission of fecal matter is key!
26
Source: Perez et al., 2012

27. Bringing it together: Factors contributing to difference in
stunting between very high‐burden & low-burden districts,
2016
Source: Understanding the geographical burden of stunting in India: A regression‐decomposition analysis of district‐level
data from 2015–16; Authors: Purnima Menon, Derek Headey, Rasmi Avula, and Phuong Hong Nguyen

28. 7. Are these interventions a system/
part of system? What are the
interlinkages?

29. Characteristics of a system
Interrelated parts forming complex and
unified whole with a specific function
 Systems have purpose
 All parts must be present for a system to carry
out its purpose optimally
 Order in which parts are arranged affects the
performance of the system
 Systems attempt to maintain stability through
feedback.

30. Working on the system or in the
system

31. Lets get some insights into
systems thinking…..and
breaking silos!

32. Identify issue
What are the causal factors?
What are their interactions?
Draw the interrelationships
One technique to help in
systems thinking

33. Lets do some systems thinking!
 District fact sheets, and state policy papers:
1. What has worked/not worked in the
district? Causal loop- map the
components and their interactions –on
flip charts
2. What are the institutional/systemic
solutions?
3. What are the levers for change for
building convergence and breaking
silos?
 20 minutes of brainstorming…… and system

34. Problems
cannot be
solved by
the same
level of
thinking that
createdAlbert Einstein

35. 8. What are the roadblocks to
systems thinking in administration?
1. Systems are abstract[butterfly, MSP]
2. Linear thinking[field staff]
3. Position identity[govt litigation]
4. Event fixation[NH roadblock, rail
accidents]
5. Boiled frog [Delhi, “beneficiary”]
6. Experience /anecdotal evidence is right
7. Choice architecture[asha payments]
8. Predecessor bias

36. 9. How can one break silos in
administration?
1. Identify system-
2. Learn the skills- handouts
3. Build coalitions [sonam wangchuk,
ekta]
4. Build shared vision: Joint
monitoring, tours, SOPs, training,
materials [cogs]
5. Get feedback[mahindra and

37. 6. Create institutional synergy
1. Map components and
interactions
2. Identify binding constraints
3. Identify levers for action
4. Converge commitments and
actions

38. Systems thinking and us… a recap
 Visualise big picture, not schemes
“Systems thinking is a vantage point from which
you see a whole, a web of relationships, rather
than focusing only on the detail of any particular
piece. Events are seen in the larger context of a
pattern that is unfolding over time.”
 Understand the nuts and bolts, cogs and
wheels, AND their interactions [
repayments for housing loans]

39.  Think ahead….. Implications of actions
“we learn from experience but never
experience the consequences of our
decisions”
 Keep the objective in centre[ the child]
 Understand system architecture
 Build shared vision across
 Create institutions that are synergistic
 Work by design, not default

40. Insanity is continuing to do the same thing
over and over again and expecting
different results
Thank you!
Thank you for your patience!Thanks for your patience!