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. Transforming Nutrition: Ideas, Policy and Outcomes
Tackling the Immediate Drivers of
Malnutrition
(Nutrition-specific Interventions)
Day 1, Session 3
6 August 2018

2. 2
IMMEDIATE CAUSES
Breastfeeding, nutrient rich foods, and eating routine
Feeding and caregiving practices, parenting stimulation
Low burden of infectious diseases
GOAL: Optimum fetal and chid
nutrition and development
UNDERLYING CAUSES
Food security: availability, economic access and use of food
Feeding and caregiving resources (maternal, household and community level)
Access to and use of health services, a safe and hygienic environment
BASIC CAUSES
Knowledge and evidence
Politics and governance
Leadership, capacity and financial resources
Social, economic, political, and environmental context (national and global)
Nutrition-specific
interventions are to
help improve
maternal and child
diet quality and
reduce infections

3. From evidence reviews (e.g., the Lancet Series)
to global guidance
3

4. Global framework for delivering nutrition-
specific interventions
5
Bhutta et al. 2013

5. Evidence-informed nutrition interventions
in the Indian policy framework
Preconception Pregnancy
Delivery &
Postnatal
Early
childhood
•Iron and folic acid
(IFA) supplementation
•Deworming
•Fortification (Iodized
salt)
•IFA supplementation
•Calcium
supplementation
•Food
supplementation
•Counseling on
nutrition during
pregnancy
•Counseling on EIBF
•Malaria prevention
•Deworming
•Maternity benefits
•Conditional cash
transfer
•Institutional birth
•Birth conducted by
skill health personnel
•Delayed cord
clamping
•Counseling- EIBF
•Counseling on
kangaroo mother care
•IFA supplementation
•Calcium
supplementation
•Food
supplementation
•Counseling- EBF
•Counseling-
Complementary feeding
•Immunization
•Vitamin A suppl
• IFA supplementation
•ORS with zinc during
diarrhea
•Growth monitoring
•Food supplementation
•Management of SAM
•Management of MAM
•Deworming in children
•Sanitation
90% coverage  20% reduction in stunting (Bhutta et al. 2008)
* Preventive zinc supplementation in early childhood – Not in the Indian policy framework

6. 9 elements critical to scaling up (impact)
7
1. A clear vision or goal for impact
2. Matching characteristics of interventions, with (3)
3. An enabling organizational context for scaling up
4. Establishing and supporting drivers such as catalysts,
champions, ownership, incentives
5. Choosing contextually relevant pathways to scaling up
6. Building operational and strategic capacities for scaling up
7. Adequacy, flexibility, stability of financing
8. Adequate governance structures and systems
9. Mechanisms for learning and accountability
Source: Gillespie, Menon, Kennedy. Scaling up nutrition impact : What will it take and how will we get
there? Advances in Nutrition 2015

7. 2017: An unprecedented time for
accelerating nutrition actions in India
Bringing it
together
National Nutrition
Strategy, with targets
National Nutrition
Mission, with budget
Existing
landscape of
programs
State-level nutrition
commitment &
interest
New data on
nutrition
Improved nutrition
in 2022 (and looking
towards 2030)
How to turn
commitment
to impact?

8. Birthspacing-pregnancycare
AntenatalCare
Immunization
Home Based
Newborn Care
Feeding counseling: breast feeding and complementary feeding
Birth
Institutional
Deliveries
6 weeks
Facility Based
Newborn
Care
Integrated Management of Neonatal and Childhood Illnesses
Home-based Young Child Care
(Nutrition and health counseling, early
stimulation
6
months
1
year
2
years
Swachh: Safe water, hand washing, toilet use, safe disposal of feces
Supplementary nutrition: mother >>> baby
Growth monitoring; stimulation and care of the malnourished child
HEALTH*ICDS*
Not to
scale
Pregnancy
Pre-
pregna
ncy
*predominant
role
Care for severe acute malnutrition
Program packages of
Interventions for first 1000 days:
for health, nutrition and development
9
BetiBachao,betipadhao
Adolescentcare
Iron-folic acid; Vitamin A; Deworming
All
Enablers: Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), Janani Suraksha Yojana (JSY) Pradhan Mantri Maatru Vandana Yojana (PMMVY),
Janani Shishu Suraksha Yojana (JSSY), Rashtriya Bal Suraksha Karyakram (RBSK)

9. Delivery platforms are central to achieving scale
Delivery platforms
• Public sector programs
• ICDS
• NHM
• Private sector providers
• Self-help groups
• Mass media
• Jan Andolan
Service providers/Events
• Anganwadi workers
• ASHAs
• ANMs
• Doctors
• Nurses
• Group facilitators
• Public service announcements
• Campaigns/Celebrations
10

10. India’s major delivery platforms: ICDS &
NHM cover all interventions
ICDS
• Food supplementation
• Counselling on pregnancy care
• Counselling on infant and young
child feeding
• Growth monitoring & referral
NHM
• Family planning
• ANC
• Micronutrient supplementation
(IFA, Calcium, Vitamin A)
• Deworming
• Immunization
• Institutional delivery
• Counselling on newborn care
• Management of SAM
• Treatment of childhood illness

11. Existing capabilities for achieving scale
Catalysts, champions, and
enabling environment
• Political intent
• Ministries
• NITI Aayog
• State departments
• District Magistrates/CEO
• Development partners
Measurement, learning, and
accountability
• Monitoring at the highest level
• Tracking indicators
• District reviews
• State reviews

12. How do you know you are reaching scale,
i.e., every woman and every child?
Data!
• Countdown to
2015/2030
• Global Nutrition Report
• National and sub-
national data
• Program monitoring
data
13

13. Data landscape within India
14
Routine Management
Information Systems
• Health Management
Information System
(HMIS)
• ICDS-Monthly Progress
Report
• ICDS-CAS dashboard
• State-specific monitoring
systems
Periodic Surveys
• National Family Health
Survey (NFHS)
• Comprehensive National
Nutrition Survey (CNNS)
• National Sample Survey
Organization (NSSO)
• Quarterly surveys in
aspirational districts
Data!

14. Coverage of nutrition-specific interventions remains
highly variable: by life-stage, by intervention, by the
delivery channel …
15
93.3
51
77.7
30.2
83
18
75.4
40.1
52.6
35.1
43.8
81
83.3
36.7
65.1
27.1
47.8
35.137.1
62.6
59.3
26.5
32.2
79.1
50.5
20.2
51.7
42.744.6
28.55
0
10
20
30
40
50
60
70
80
90
100
PREGNANCY DELIVERY & POSTNATAL EARLY CHILDHOOD
Health
ICDS
Health
ICDS
Health
ICDS

15. ….and among states and…
16
0
10
20
30
40
50
60
70
80
90
100
DemandforFPsatisfied
Iodizedsalt
≥4ANCvisits
Consumed100+IFAduring…
Neonataltetanusprotection
Dewormingduringpregnancy
Weighingduringpregnancy
Breastfeedingcounselingduring…
Supplementaryfood-pregnancy
Healthandnutritioneducation-…
Healthcheckup-pregnancy
Institutionaldelivery
Skilledbirthattendant
JSY
Postnatalcareformothers
Postnatalcareforbabies
Supplementaryfood-lactation
Healthandnutritioneducation-…
Healthcheckup-lactation
Fullimmunization
ReceivedvitaminAinthelast6…
PediatricIFA
Dewormingforchildren
Careseekingforpneumonia
ORSduringdiarrhea
Zincduringdiarrhea
Supplementaryfood-children
Healthcheckup-children
Weighing-children
Cousellingonchildgrowth
Prepregnancy Pregnancy Delivery and early postnatal Early childhood
%
Source: National Family Health Survey -4

16. Proportion of mothers receiving any ANC
…among the districts
17
Proportion of mothers receiving 4 or more ANC
Source: National Family Health Survey -4
Take a look
at your
district for
ANC
490 districts ≥75%
women received
any ANC
156 districts ≥75%
women received 4
or more ANC

17. 18
Proportion of mothers who received any IFA
Proportion of mothers who consumed IFA for at
least 100+ days
65% of districts
≥75% women
received any IFA
<2% of districts
≥75% women
consumed IFA for
100+ days
An example of coverage variability - IFA
Take a look
at your
district for
IFA receipt
and
consumption
of IFA
Source: National Family Health Survey -4

18. 19
Proportion of women who received food
supplements during their pregnancy
Proportion of children (6-35 mo) who received
food supplements
172 districts ≥75%
children received
food supplements
An example of coverage variability – Food
supplementation
Source: National Family Health Survey -4
144 districts - ≥75%
women who received
food supplements
during pregnancy
Take a look at
your district for
food
supplementation
coverage

19. 20
A QUICK RECAP

20. 21
Source: National Family Health Surveys- 3 and 4
Coverage inequity over time 2006-2016
Pregnancy
& delivery

21. 22
Source: National Family Health Surveys- 3 and 4
Coverage inequity over time
2006-2016
Lactation
&
Early
childhood

22. 23
Pregnancy
Coverage inequity
over time by
rural/urban
2006-2016
Source: National Family Health Surveys- 3 and 4

23. 24
Delivery &
postnatal
Coverage inequity
over time by
rural/urban
2006-2016
Source: National Family Health Surveys- 3 and 4

24. 25
Early
childhood
Coverage inequity
over time by
rural/urban
2006-2016
Source: National Family Health Surveys- 3 & 4

25. Let’s not forget the political economy
26
The story of an egg Supplementary Nutrition
Production models
• Central-production model
• Government owned
• Private corporation led
• Decentalized production
models
- SHG models
- Decentralized Production
Facility Models

26. 27
The Story of Odisha

27. 28
0
10
20
30
40
50
60
70
80
90
100
2006 2016
Percentage
ANC (4 or more)
Breastfeeding counsel
IFA receive/buy
Consume IFA 100+
Food supplementation (preg)
Institutional birth
Received cash JSY
Postnatal visit-mother (2 day)
Food supplementation (lact)
Immunization
Vitamin A supplementation
IFA supplementation
Deworming
ORS during diarrhea
Zinc during diarrhea
Food supplementation (children)
Weighing (child)
Counsel on child growth
Source: National Family Health Surveys- 3 and 4
Changes in nutrition-specific interventions in
Odisha, 2006 to 2016

28. Coverage of nutrition-specific interventions in
Odisha in 2016
29
93.3
62
90.4
36.5
89.3
31.1
92.6
70.6
88.2
75.4
83.2
86.687.6
72.7
78.6
40
83.8
75.4
77.8 78.8
64.9
27.226.2
69.968.4
17.3
80.2
71.1
75.9
53.9
0
10
20
30
40
50
60
70
80
90
100
PREGNANCY DELIVERY & POSTNATAL EARLY CHILDHOOD
Health ICDS Health
ICDS
Health ICDS

29. 30
Timeline of program & policy evolution for
nutrition-specific interventions

30. A confluence of factors and actors
contributed to the nutrition success story in
Odisha
• A common goal for IMR and MMR
• Political leadership support and smart
politics
• Committed and capable bureaucrats
• Policy space for programs
• Investments in social sector programs
• Investments in infrastructure
• National-level policy and program
changes with accompanied funding
• Fiscal space: adequate, flexible,
stable financing
• Support of development partners
Stories of Change research, available in: Menon et al., Nourishing Millions, 2016; Kohli et al., Global Food Security, 2017

31. Thinking together
• What do such stories of change look like for
other successful states?
• Is it possible to replicate the same set of
conditions in other states?
• Can the timeline for positive change be
shortened?
• How to accelerate similar changes in
underlying determinants of nutrition as well
(sanitation, early marriage, poverty, etc.)?

32. Exercise
• Discuss gaps, opportunities and challenges
35

33. EXTRA MATERIAL

34. Maternal supplements of multiple micronutrients
Effect on nutrition and health
Sources: Bhutta, 2008 (1)
45
Evidence-informed interventions
• Maternal supplementation during pregnancy (1)
Challenge area:
Many countries have not adopted this guideline; there are still lingering
challenges with scaling up basic IFA supply and delivery that could affect
progress with MM supplements in pregnancy as well.
Prenatal and antenatal Neonates (0-1m) Infants (1-12m)
Multiple micronutrient
Supplementation (≥3
micronutrients)
39% reduction in
maternal anaemia
(compared with placebo
or ≤2 micronutrients)
16% reduction in
risk of LBW
22% reduction in
infant mortality

35. Maternal calcium supplementation
Effect on nutrition and health
• Reduced incidence of pre-eclampsia by 48%
• Also reduced maternal death or serious morbidity (RR 0.80,
0.65-0.97)
Evidence-informed interventions
• Supplementation during pregnancy (1)
Challenge area:
Countries are slowly experimenting with inclusion of calcium supplements.
Many challenges remain about how best to deliver the calcium (pill, powder)
and how to integrate with antenatal care. Operational studies are in
progress. Stay tuned. Source- Bhutta, 2008 (1)
46

36. Direct interventions for pregnant & women of
reproductive age
• Folic acid supplementation
• Iron and iron-folate supplementation
• Multiple micronutrient supplementation
• Calcium supplementation
• Iodisation of salt
• Balanced energy protein supplementation for
pregnant women
47
Bhutta et al. 2013

37. Direct interventions for neonates
Sources: Bhutta et al. 2013
• Delayed cord clamping
• Vitamin K
• Vitamin A
• Kangaroo mother care for promotion of
breastfeeding & preterm care
– Includes early and immediate breastfeeding
48

38. Direct interventions for infants & children -
preventive
Sources: Bhutta et al. 2013
• Breastfeeding promotion
• Complementary feeding promotion (6-24mths)
• Vitamin A supplementation (6mths-5 years)
• Iron supplementation
• Multiple micronutrients (plus iron)
• Zinc supplementation
49

39. Breastfeeding promotion settings
Source: Rollins et al. 2016
50
Settings Interventions Effect
Health systems Individual counselling or group
counselling of mothers
Baby-friendly hospital support
Exclusive breastfeeding
> 49% (95% CI 33-68)
Family & community Antenatal & postnatal support
mothers, fathers & other family
member at home (by health
worker, peer)
Exclusive breastfeeding RR
1.42 (95% CI 1.32-1.66)
Community-based
breastfeeding education
Social mobilisation
Exclusive breastfeeding
> 20% (95% CI 3-39)
Workplace Maternity leave policies Exclusive breastfeeding RR
1.52 (95% CI 1.03-2.23)
Paid-break policies for lactating
mothers
Exclusive breastfeeding
> 8.9%

40. Breastfeeding promotion settings
Source: Bhutta et al. 2013
51
Settings Interventions Effect
Food secure population Nutrition education HAZ (SMD 0.22 (95% CI 0.01-
0.43)
No effect on stunting
Food insecure
populations
Nutrition education HAZ (SMD 0.25 (95% CI 0.09-
0.42)
Stunting (RR0.68, 95% CI 0.60-
0.76)
Food provision (with or
without education)
HAZ (SMD 0.39 (95% CI 0.05-
0.73)
No significant effect on
stunting

41. Multiple micronutrient powders for children
Effect on nutrition and health
Evidence-informed interventions
• Home fortification with multiple
micronutrient powders for children (1)
Home fortification products
available in Bangladesh
Sources: Horton, 2010 (1),
52
Intervention Percentage of deaths in
children under 5 years
Percentage of DALYs in
children under 5 years
Vitamin A deficiency 6.5 5.3
Zinc deficiency 4.4 3.8
Iron deficiency 0.2 0.5
Iodine deficiency 0.03 0.6