It is not surprising that the Global Nutrition Report 20161 places India ‘off course’ for all nutrition indicators, with some progress in stunting and underweight, and none at all in anaemia among women of reproductive age and wasting of children.
India’s jinx in tackling this last unaddressed outpost in its growth and development story continues. Though a National Nutrition Mission was announced in 2014, no national programme has yet emerged, and this year’s budget speech makes no mention of it. Clearly, the subject appears to have got lodged on the backburner for the moment, and another opportunity seems to have been wasted, as this multi-turf subject continues to be stuck within the chakravyuha of stubborn turf protection, and without convergence or oversight.
However, I have great satisfaction that all the interventions of the World Bank supported Karnataka Multi-sectoral Nutrition Project being piloted by the Karnataka Comprehensive Nutrition Mission in Devadurga block in Raichur district and Chincholi block in Gulbarga district (two of the most backward blocks of Karnataka) have taken off completely and are working well.
The strategy behind2 it has several unique aspects -
i) Its interventions are multi-sectoral and intergenerational, and directly address the main root causes, viz., the intergenerational cycle of malnutrition; the calorie-protein-micronutrient deficit among children, adolescent girls and pregnant/lactating women; and the information/awareness deficit among families regarding proper nutritional practices within existing family budgets, regarding proper child, adolescent and maternal care.
ii) This is not another food programme. It begins with awareness generation and behaviour change through reasonably spaced nutrition messaging at household and community level. The food supplementation component commences only after the process of behaviour change has been triggered. Spacing of messages ensures that the beneficiaries’ receptivity is not overloaded, and field workers too can explain them more effectively to the families under their care.
iii) The most unique feature of this project is that it is being implemented not by the department of health and family welfare or women and child development, but through the department of rural development and panchayati raj, and zilla parishads, for whom multi-sectorality is an integral mandate.
iv) There is a sequencing of interventions that gradually brings about a subtle convergence and demand creation for other government programmes impacting nutritional status; for example, immunisation, sanitation, and drinking water. It is within the official responsibilities of the zilla parishad CEOs to monitor or direct any of these, which a departmental functionary cannot do.
Operational logistics are simple. A local girl is appointed as a village nutrition volunteer (VNV) for each village, and given basic training. There is a project supervisor for every 10 villages under a block project manager. The VNV’s first task is to identify infants below three years, adolescent girls between 11-18 years, and pregnant and lactating women, belonging to families below the poverty line (which we took as 40% from base of the pyramid). There are 17,005 beneficiaries in Chincholi block, and 18,001 in Devadurga block.
A nutrition card, customised for each target group, is given to each beneficiary. Common parameters for all groups are age, weight and height, education, occupation and income, source of drinking water, and sanitation. There is a monthly recording and monitoring of height and weight for children and adolescent girls, and periodic monitoring of other parameters specific to target groups. For infants, details about immunisation, exclusive breastfeeding, initiating complementary feeding, and diarrheal episodes are included. For adolescent girls and pregnant/lactating women there is monthly weight monitoring. This data is fed into a computer and monitored at field and mission level to assess impact and take corrective action. The VNV uses house visits to disseminate nutrition messages to the target groups and their families, and to counsel the beneficiaries, especially regarding prevention of child underweight, pregnancy weight gain, managing diarrheal episodes among children, improving condition of severely malnourished or wasted children, or managing any illness.
A multi-layered communication strategy has been created for triggering behaviour change. Messages are disseminated in phases to families, community, women’s self-help groups (SHGs) through different streams of media – posters and flipcharts for household counselling; radio, television and wall paintings for families and the community at large, and focus group discussions for SHGs.
The messages are simple but critical. The first phase concentrated on explaining the intergenerational cycle of malnutrition, improving family diet within existing budgets, encouraging consumption of nutritionally rich local foods such as green leafy vegetables, grains, and local fruits; the importance of exclusive breastfeeding for first six months and complementary feeding afterwards; improving low body mass index among adolescent girls and women, and preventing anaemia. The second phase of the communication strategy emphasises the importance of proper weight gain during pregnancy and prevention of low birth weight; proper health and growth of adolescent girls; encouraging consumption of IFA during pregnancy and lactation and the benefits of consuming Shakti Vita, the energy food supplied under the project.
Early results show definite improvement in nutritional indicators of the three intergenerational groups – infants under three, adolescent girls, and pregnant and lactating women3. What is significant is that this improvement in nutritional status has happened solely on account of behavioural change brought about by the communication strategy and not because of dietary supplementation from the project.
The next major intervention is bridging the calorie-protein-micronutrient deficit among the target groups. A medium scale energy food production unit with 2 tonnes production capacity per day has been set up with assistance from Global Alliance for Improved Nutrition (GAIN) in both blocks. Women from SHGs have been trained and are employed for production. Fortified energy food, branded as Shakti Vita, appropriate for the three target groups, is being prepared from local farm produce, such as wheat, green gram and defatted soya; and distributed to the beneficiaries. Energy food distribution started in October 2016 in Chincholi and in December 2016 in Devadurga. The
December data for Chincholi is being analysed, and as expected, the results appear very positive.
Convergence of existing programmes too is done in phases. To begin with, VNVs motivated and assisted families to apply to panchayats for construction of toilets in their homes. After project interventions started, 2,734 toilets have been constructed in both blocks by the end of March, and are being put to use. This will be followed by the more difficult areas of convergence, such as complete immunisation and Vitamin A administration for children.
Real-time monitoring of the beneficiaries’ nutrition indicators, particularly regarding underweight, stunting and wasting of children, body mass index of adolescent girls, pregnancy weight gain, and incidence of low birth weight babies, is stringently done at the field level by the VNVs and field supervisors, who also take corrective action, and at mission level.
The pilot projects and their early results have been appreciated by the state administration, with a general consensus that they should be replicated in the chronic malnutrition pockets of Karnataka. So with a lot of hope we are working on that, and on getting Karnataka’s malnutrition ‘On Course’.
Rao, IAS (retired), is advisor, Karnataka Nutrition Mission. The author thanks Karnataka chief secretary Subhash Khuntia, development commissioner Vijay Bhaskar, and principal secretary (rural development and panchayati raj) Dr Nagambika Devi for their support in prioritising this invisible affliction and placing it higher in the development agenda.
1.https://goo.gl/kcKEw7 (Pages 119-125)
2.Strategy Paper at https://goo.gl/fYzWKX
3.https://goo.gl/XJOFvq
(The column appears in the May 1-15, 2017 issue)
