IFPRI Discussion Paper 01299 October 2013
The Operational Evidence Base for Delivering Direct Nutrition Interventions in India A Desk Review
Rasmi Avula Suneetha Kadiyala Kavita Singh Purnima Menon
Poverty, Health, and Nutrition Division
INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE The International Food Policy Research Institute (IFPRI), established in 1975, provides evidence-based policy solutions to sustainably end hunger and malnutrition and reduce poverty. The Institute conducts research, communicates results, optimizes partnerships, and builds capacity to ensure sustainable food production, promote healthy food systems, improve markets and trade, transform agriculture, build resilience, and strengthen institutions and governance. Gender is considered in all of the Institute’s work. IFPRI collaborates with partners around the world, including development implementers, public institutions, the private sector, and farmers’ organizations, to ensure that local, national, regional, and global food policies are based on evidence. IFPRI is a member of the CGIAR Consortium.
AUTHORS Rasmi Avula (
[email protected]) is a postdoctoral fellow in the Poverty, Health, and Nutrition Division of the International Food Policy Research Institute (IFPRI), New Delhi. Corresponding author Suneetha Kadiyala (
[email protected]) was a research fellow in the Poverty, Health, and Nutrition Division of IFPRI, New Delhi, when she wrote this work. She is currently a senior faculty member in the area of nutrition-sensitive development at the London School of Hygiene and Tropical Medicine. Kavita Singh (
[email protected]) is a senior research assistant in the Poverty, Health, and Nutrition Division of IFPRI, New Delhi. Purnima Menon (
[email protected]) is a senior research fellow in the Poverty, Health, and Nutrition Division of IFPRI, New Delhi.
Notices IFPRI Discussion Papers contain preliminary material and research results. They have been peer reviewed, but have not been subject to a formal external review via IFPRI’s Publications Review Committee. They are circulated in order to stimulate discussion and critical comment; any opinions expressed are those of the author(s) and do not necessarily reflect the policies or opinions of IFPRI. Copyright 2013 International Food Policy Research Institute. All rights reserved. Sections of this material may be reproduced for personal and not-for-profit use without the express written permission of but with acknowledgment to IFPRI. To reproduce the material contained herein for profit or commercial use requires express written permission. To obtain permission, contact the Communications Division at
[email protected].
Contents Abstract
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Acknowledgments
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Abbreviations and Acronyms
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1. Introduction
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2. Framework for Review
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3. Identifying Evidence-Based Essential Inputs and Interventions
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4. Review of National Programs
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5. Review of Published Literature and Program Models Implemented by Civil Society/Nongovernmental Organizations
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6. Summary and Discussion
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Appendix: Supplementary Tables
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References
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Tables 5.1 List of civil society/nongovernmental program models reviewed
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A.1 Essential inputs to improve infant and child nutrition
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A.2 Essential inputs to improve women’s nutrition
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A.3 Evidence-based interventions to address the essential inputs to improve nutritional status of children under age two
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A.4 Evidence-based interventions to address the essential inputs to improve nutritional status of women
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A.5 Essential inputs for nutrition included in the design of the Integrated Child Development Services and National Rural Health Mission 34 A.6 Mapping essential inputs and evidence-based interventions in the Integrated Child Development Services and National Rural Health Mission components
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A.7 Keywords used to search literature for the essential inputs
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A.8 Sample: Identifying evidence-based interventions and delivery strategies used to address essential inputs in civil society/nongovernmental program models
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A.9 Essential inputs and evidence-based interventions in civil society/nongovernmental organization program models
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Figures 1.1 Status of inputs to reduce stunting (NFHS-3, 2005–2006)
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2.1 Framework of inputs and interventions
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Boxes 3.1 Essential inputs for child nutrition
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4.1 Integrated Child Development Services Scheme package of services for improving maternal and child nutrition and health
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4.2 National Rural Health Mission services for improving maternal and child nutrition and health
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4.3 Village Health and Nutrition Days
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5.1 System-strengthening features across multiple inputs and interventions
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ABSTRACT The persistence of undernutrition in the face of India’s impressive economic growth is of enormous concern. Less than 55 percent of mothers and children receive any essential health and nutrition inputs that are critical for improving maternal and child nutrition. We conducted a desk review (1) to document the extent to which national and civil society/NGO programs in India reflect current technical recommendations for nutrition and (2) assess the operational evidence base for implementing essential interventions for nutrition in the Indian context. We reviewed the design of the two major national programs, Integrated Child Development Services (ICDS) and the National Rural Health Mission (NRHM). Subsequently, we used Google Scholar to search the published literature from 2000 to 2012 for evidence of interventions addressing the inputs to improve child nutrition. Finally, we contacted 70 program stakeholders to identify the unpublished evidence on inputs in program models implemented by civil society/nongovernment organizations. We find that, by design, the two national programs (ICDS and NRHM) together appear to incorporate all the essential inputs and use evidence-based interventions. There is an expectation by design that the frontline workers of ICDS and NRHM coordinate and collaborate to deliver the interventions. A review of 22 program models shows that a majority focused on improving breastfeeding and timely initiation of complementary feeding. However, only a few addressed the full spectrum of complementary feeding, vitamin A deficiency, pediatric anemia, and severe acute malnutrition. None addressed how to reduce intestinal parasitic burdens or prevent malaria. There is limited published literature on the effectiveness of the recommended interventions to deliver the essential inputs. There are few efficacy studies and even fewer effectiveness studies or program evaluations on delivering essential nutrition interventions in the Indian context. The most commonly used delivery strategies across multiple essential inputs were home visits that involved individual or group counseling by community health workers or by self-help groups. Mass media and community events such as marriages and fairs were used as avenues to generate support for the interventions. Some programs used community mobilization to promote the interventions. Several of these programs worked to improve coordination and convergence between ICDS and NRHM and to strengthen these existing systems through training, improved monitoring, and supervision. Overall, a large gap persists in both the published and gray literature on how to promote interventions to address the essential inputs. Much more operational evidence is needed to ensure highquality delivery of the evidence-based interventions that are already being implemented nationwide. Given the potential for the national programs to effectively deliver interventions to achieve maximum coverage and impact, and the government of India’s current interest in ICDS system strengthening, this is an opportune time to test some of the innovations using the ICDS and NRHM platforms. Keywords: undernutrition, interventions, convergence, India
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ACKNOWLEDGMENTS We gratefully acknowledge financial support from the Bill & Melinda Gates Foundation, through POSHAN (Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India), managed by the International Food Policy Research Institute. This review was made possible because of the generosity of several program implementation agencies in India who shared information and documents on their programs and thus facilitated this review. We also thank the participants of a national consultation on June 19, 2012, who provided valuable feedback on a presentation of the findings of this review.
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ABBREVIATIONS AND ACRONYMS ANM ASHA AWC AWW BCC BPM CBMCHN CDPO DEVTA eLENA ICDS IFA MSG MWCD NCCS NFHS NGO NRHM RACHNA SAM SHG TBA VHND VHW WHO
auxiliary nurse midwife accredited social health activist anganwadi center (courtyard shelter center) anganwadi worker (courtyard shelter worker) behavior change communication bar parivar mitra (friend of child’s family) Community-Based Maternal and Child Health and Nutrition program child development project officer Deworming and Enhanced Vitamin A electronic Library of Evidence for Nutrition Actions Integrated Child Development Services iron and folic acid mothers’ support group Ministry of Women and Child Development Nutrition Counseling and Childcare Session National Family Health Survey nongovernmental organization National Rural Health Mission Reproductive and Child Health, Nutrition and HIV/AIDS severe acute malnutrition self-help group traditional birth attendant Village Health and Nutrition Day village health worker World Health Organization
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1. INTRODUCTION India’s progress toward the Millennium Development Goal for reducing the under-five mortality rate is still not on track (WHO/UNICEF 2012). The persistence of undernutrition in the face of India’s impressive economic growth is of enormous concern. A comparison of National Family Health Survey data in 1998–1999 and 2005–2006 shows that across the two surveys, among children under three years of age, the proportion of children who were stunted dropped from 51 percent to 45 percent, and there was a marginal decline in the prevalence of underweight, from 42 percent to 40 percent (IIPS/Macro International 2007). The period from pregnancy to 24 months of age is a critical window of opportunity to reduce child undernutrition (Victora et al. 2010). While acknowledging the importance of both direct1 and indirect2 interventions and their enabling environment’s effect on maternal and child undernutrition, researchers have identified a set of direct interventions that are efficacious and recommended for scale-up to improve child growth during the first two years of life (Bhutta et al. 2008, 2013). In India, there is now broad agreement on the package of direct interventions targeted to the first thousand days of life, following the Lancet Series on Maternal and Child Undernutrition (Bhutta et al. 2008) and the Coalition for Sustainable Nutrition Security in India’s convening of technical expert review groups (Coalition for Sustainable Nutrition Security in India 2010). Although inputs to reduce child undernutrition must be implemented at scale to achieve rapid reductions in undernutrition, in India the coverage of several of the key inputs remains low (Figure 1.1). Furthermore, there are subnational variations in the coverage of these inputs (WHO/UNICEF 2012). To understand which interventions are promoted and how they are carried out in India, we conducted a desk review of two government-implemented national programs, examined published literature, and reviewed documents of program models implemented by civil society/nongovernmental organizations (NGOs).
1
Direct interventions address immediate causes of child nutrition (for example, appropriate child feeding practices, vitamin A supplementation, hygiene, and so on). 2 Indirect interventions address underlying causes of child nutrition (for example, agriculture, social protection, education, health systems, women’s empowerment, and so on).
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Figure 1.1 Status of inputs to reduce stunting (NFHS-3, 2005–2006)
GAP
BF Exclusive Introduction 3 expected Iron-rich Immunization Stools Vitamin A Adolescent HHDiarrhea SAM: Children Initiation BF of CF IYCF foods safely supplegirls adequately children with access (6-9 months) practices disposed mentation (15-19 years) iodized fed >= to care (
