DAY: NRLM Improving Maternal, Infant and Young...

DAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India


Deendayal Antyodaya Yojana: National Rural Livelihood Mission (DAY: NRLM)A Key Partner for Improving Maternal, Infant and Young Child Nutrition situation in India.

PART I: Deendayal Antyodaya Yojana: National Rural Livelihood Mission (DAY: NRLM): Livelihood cum Nutrition, Health, Sanitation (LNHS) Initiative - Coupling Nutrition Sensitive Interventions and Nutrition Specific Actions for Accelerating Improvement in Maternal, Infant, Young Child Nutrition (MIYCN) situation

PART II: Nutrition Situations of Women and Children in India: An Overview

A Study by Dr. Sheila C. Vir, Consultant


LIST OF ABBREVIATIONAAY Antyodaya Anna YojanaADS Area Development SocietyAHS Annual Health Survey ANC Antenatal CareASHA Accredited Social Health Activist ASY Ann Surkashana YojanaBMI Body Mass IndexCCT Conditional Cash TransferCDS Community Development SocietyCF Complementary FoodCGC Community Group CounselingCIGs Common Interest GroupsCLFs Cluster Level FederationsCMAM Community Based Management of Acute Malnutrition CORD Chinmaya Organisation for Rural DevelopmentCRP Common Resource PersonDAY:NRLM Deendayal Antyodaya Yojana: National Rural Livelihood MissionEBF Exclusive BreastfeedingEE Environmental EnteropathyE-HFP Enhanced-Homestead Food ProgramENIs Essential Nutrition InterventionsFLE Family Life EducationFPS Fair Price ShopsFSSAI Food Safety Standards Authority of IndiaGHI Global Hunger IndexGIS Geographic Information SystemGLVs Green Leafy VegetablesICDS Integrated Child Development ServicesICT Information Communication TechnologyIDA Iron deficiency anaemia IDD Iodine Deficiency DisordersIFA Iron Folic Acid IGMSY Indira Gandhi Matritva Sahyog YojanaIPC Interpersonal CounselingIQ Intelligence QuotientIYCF Infant and Young Child FeedingJLG Joint Liability GroupJSY Janani Surkhasha YojanaLBW Low Birth WeightLHNS Livelihood cum Nutrition, Health, SanitationMAM Moderate Acute MalnutritionMCPC Mother-Child Protection CardMDGs Millennium Development GoalsMDM Mid -Day MealsMNREGA Mahatma Gandhi Rural Employment Guarantee Act MIYCN Maternal, Infant, Young Child NutritionMKSP Mahila Kisan Sashaktikaran PariyojanaMM Mahila MandalsMMNS Multiple Micronutrient SupplementationMoHFW Ministry of Health and Family Welfare

LIST OF ABBREVIATION


MoTA Ministry of Tribal AffairsMUAC Mid-Upper Arm CircumferenceMoWCD Ministry of Women and ChildNDCC Nutrition cum Day Care CentresNFHS National Health and Family SurveyNFSA National Food Security Act NGOs Non-Government OrganisationsNHGs Neighbourhoods GroupsNNMB National Nutrition Monitoring BureauNRCs Nutrition Rehabilitation CentresNREGA National Rural Employment Guarantee ActNRHM National Rural Health MissionNRLM National Rural Livelihood Mission/DAY:NRLM OBC Other Backward ClassesODF Open Defecation FreeORS/HAF Oral Rehydration Solution/ Home Available Fluids PDS Public Distribution SystemPFA Prevention of Food AdulterationPHED Public Health Engineering Department PIA Project Implementing AgencyPLA Participatory Learning AssessmentPOP Poorest Of PoorPLWFGs Panchayat Level Women Farmers GroupsPRIs Panchayati Raj InstitutionsPS Parivartan SaathinRDA Recommended dietary allowancesRDI Recommended Dietary IntakeRI Routine Immunization RSOC Rapid Survey on Children SAC Social Action CommitteeSAM Severe Acute MalnutritionSC Scheduled CasteSDGs Sustainable Development GoalsSERP State Program on Elimination of Rural PovertySGA Small for Gestational AgeSHGs Self Help GroupsSRLM State Rural Livelihood MissionST Scheduled TribeTHR Take Home RationTPDS Targeted Public food Distribution systemTSP Tribal Sub PlansURTI Upper Respiratory Tract InfectionVAD Vitamin A DeficiencyVAS Vitamin A SupplementsVKY Vanbandhu Kalyan YojanaVHNSDs Village Health-Nutrition -Sanitation DaysVOs Village OrganisationsWHA World Health AssemblyWASH Water, Sanitation and HygieneWFGs Women Farmers GroupsWIFS Weekly IFA Supplements


CONTENTExecutive Summary i-x

Part IDAY: NRLM: Livelihood cum Nutrition, Health, Sanitation (LNHS) Initiative-Coupling Nutrition Sensitive Interventions and Nutrition Specific Actions for Accelerating Improvement in Maternal, Infant, Young Child Nutrition (MIYCN) Situation(DAY: NRLM-Deendayal Antyodaya Yojana: National Rural Livelihood Mission)

Page no.1. Magnitude of the problem of malnutrition, implications, determinants and evidence based actions 1-6 a. Nutrition status of women and children b. Implications of undernutrition c. Addressing undernutrition: Nutrition specific and nutrition sensitive interventions d. Current efforts to improve nutrition situation in India

2. National Rural Livelihood Mission (NRLM): An opportunity for involving institution of women for improving Maternal, Infant, Young Child Nutrition (MIYCN)

a. DAY: NRLM: Complementing poverty reduction efforts with nutrition investment b. DAY: NRLM: A suitable platform for contributing to improvement in MIYCN 6-10

3. State Level Experiences for Improving Nutrition Situation in a Community through SHGs of Women: Synthesis of Experiences and Lessons Learned 10-12

4. DAY: NRLM: A unique platform for coupling nutrition sensitive and nutrition specific interventions 12-30 a. Goal and objectives b. Nutrition program principles for the formulation of the DAY: NRLM strategy for improving MIYCN c. Livelihood cum Nutrition, Health and Sanitation (LNHS) Initiative of DAY: NRLM for accelerating rate of reduction of malnutrition in women and children d. Key components of Livelihood cum Nutrition, Health , Sanitation (LNHS) Initiative

i. Interventions to improve Food and Nutrition Security i.1 Intensify livelihood initiatives for improving access to food i.2 Improve access to entitlement to subsidised food under the National

Food Security Act (NFSA) i.3 Establish of food security credit line i.4 Ensure Diversity of diet at household level: Promote simple doable actions i.5 Organise provision of cooked meals to pregnant and nursing women

through SHG initiative in targeted geographical areas i.6 Promote production and sale of nutrition dense foods as a micro-credit investmentii. Ensure universal coverage of essential nutrition actions: Establish linkage with

ICDS, Health and WASH sectorsiii. Strengthen Behavioural Change Communication (BCC) : Influence family care

practices and creating demands for health , nutrition and social services/entitlementsiv. Address nutrition sensitive issues: Collaboration with multi-sector partners

5. Operationalization of the Livelihood cum Nutrition, Health, Sanitation (LNHS) Initiative 30-34 a. Operational Strategy: LNHS b. Major Interventions for the Development of VO Level LNHS Plan of Operation

i. Ensure food and nutrition securityii. Adopt correct family level MIYCN practices and create demands for services:

Implement actions for Behaviour Change Communication (BCC)iii. Bridge the gap in coverage with specific actions on nutrition, health and sanitation servicesiv. Address nutrition sensitive factors through multi-sector linkage

CONTENT


LIST OF TABLES No. Title Page No.1. Nutritional status by population group 22. Evidence Based Essential Nutrition Interventions 93. Monthly Themes for BCC Activities 294. Community Based Monitoring and Evaluation: Monitoring of Key Nutrition Inputs, Outputs and Outcomes 355. Composite Index for Cash Award to VOs 36

LIST OF FIGURES No. Title Page No.1. Immediate, Intermediate and Underlying Causes- Nutrition Specific and Nutrition Sensitive Interventions 42. Women Resources: Nutrition Specific and Nutrition Sensitive Interventions and MIYCN 53. Poverty and Malnutrition: A Vicious Cycle 74. Livelihood Plus Nutrition, Health, Sanitation (LNHS) Initiative 155. Current Coverage of Essential Health & Nutrition Services and the Role of DAY: NRLM in Bridging the Gap for Attaining Universal Coverage 236. Evidence Based Behavioural Change Communication Strategy Framework of Alive and Thrive 287. Community Institutions and Project Support Unit at Various Levels 32

LIST OF BOXES No. Title Page No.1. World Health Assembly (WHA): Six nutrition targets to be achieved by 2025 122. Burkina Faso Experience 173. Food security Credit Line, Bihar 184. Andhra Pradesh : Nutrition cum Day Care Centres (NDCC) 205. Nutri-mix Units Kudumbashree, SRLM program of Kerala 216. Village Health, Nutrition, Sanitation Days (VHNSDs) 247. Swabhimaan (Bihar, Chhattisgarh and Odisha) , CORD (MKSP) Himachal Pradesh and Nandurbar District (Maharashtra) Nutrition Pilot project 25

6. Indicators for Tracking Progress: LNHS Initiative 34

7. Award Incentives Linked To Progress 34-36


Part IINutrition Situations of Women and Children in India: An Overview Page no.1. Introduction 38

2. Implications of undernutrition - A silent invisible emergency 38

3. Nutrition situation in India: An overview 40-45 a. Undernutrition in children b. Prevalence rate of underweight c. Prevalence rate of stunting in under five years children d. Prevalence rate of wasting (Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM))

4. Undernutrition in children: Wide equity gap 45-49 a. Rural and urban gap b. Gender gap c. Variation with wealth index d. Caste categories and nutrition situation

5. First 1000 days of life: Trend in undernutrition with increase in age in children 0-5 years 49-50

6. Nutritional status of school aged children prior to onset of adolescents: 4 to 9 years 50-51

7. Nutritional status of adolescent girls 51-52

8. Undernutrition in women 52-53

9. Low birth weight 53-54

10. Prevalence of micronutrient deficiencies 54-57 a. Iron Deficiency Anaemia (IDA) b. Vitamin A Deficiency (VAD) c. Iodine Deficiency Disorders (IDD)

11. Dietary consumption of micronutrients 57-58 12. Overnutrition: An emerging problem 59-60

13. Determinants of malnutrition in women and children 61-72 a. Immediate determinants of undernutrition in children i. Feeding practice during pregnancy ii. Infant and young child feeding practices iii. Ill-health and undernutrition b. Underlying determinants of undernutrition i. Poverty and poor purchasing power ii. Inadequate access to diversified food iii. Poor water, sanitation and hygiene (WASH) Practices iv. Insufficient health services for women and children: v. Social status of women vi. Excess energy expenditure vii. Early marriage, adolescent pregnancy and poor height of women viii. Women’s empowerment ix. Women’s education level and undernutrition

CONTENT


14. Improving nutrition situation: Evidence based interventions for addressing key challenges 72-82 a. World Health Assembly (WHA) targets b. Nutrition specific interventions i. Package of interventions ii. Improved dietary intake in the pre-conception and adolescent stage—

building on the ongoing initiatives iii. Targeting “at risk” mothers and ensuring increased intake of nutrients

during pregnancy iv. Reaching and addressing anaemia in adolescent girls out of school and

newly- married women v. Addressing anaemia in pregnant women vi. Deworming vii. Vitamin A and Iodine viii. Calcium supplement ix. Multiple Micronutrient Supplementation (MMNS) c. Improving coverage of the specific direct nutrition interventions i. Focus and accord highest priority to reach under twos –focus on the

“Window of Opportunity” ii. Health sector involvement in the first 90 weeks of life is critical iii. Re-define the role of ICDS sector for care of under twos and strengthen the

ICDS infrastructure iv. Integrate ICDS and health services and also establish linkage with DAY: NRLM v. Build on positive attributes of the “Fixed Day Strategy” for improving

coverage of health and nutrition services vi. Effective interpersonal counseling (IPC) and social mobilisation —

use of cluster community mobiliser strategy vii. Reaching “unreached” women and out-of school adolescent girls –

developing linkage with DAY: NRLM and other sectoral programmes viii. Special measures for care of Low Birth Weight (LBW)—linking

efforts with JSSY Scheme ix. Community based management of Severely Acute Malnourished (SAM)

and Moderate Acute Malnourished (MAM) Children d. Nutrition Sensitive Interventions i. Ensuring food security – Quantity and quality of food ii. Empowering women iii. Family planning services iv. Support to employed women-Maternity leave v. Improving water , hygiene and sanitation situation vi. Encourage multiple-sector involvement to address the underlying

determinants of undernutrition

15. Special focus : Improving nutrition situation of women and children residing in 82-90 tribal areas and selected states of Bihar and Uttar Pradesh

a. Women and children in tribal areas b. Bihar state: Nutrition situation, key issues and current focus c. Uttar Pradesh state: Challenges and opportunities for improving nutrition of

women and children mission


LIST OF TABLES No. Title Page No.1. Millennium Development Goals (MDG) and Effect of Malnutrition 392. Undernutrition and Severe Undernutrition in India in Various Social Categories 493. Dietary and Nutrient Intake of Children 4-6 years and 7-9 years 504. Dietary and Nutrient Intake of Adolescent Boys and Girls in Rural India 525. Prevalence of Anaemia in Children (6-59 Months) State Wise 566. Average Consumption of Food Items and Percentage Consuming Less Than 50 Percent of the Recommended Dietary Intake of Various Food Items 587. Percentage of Households, Young Child, Adolescent Girls and Pregnant Women Consuming Less Than 50 Percent RDA of Various Nutrients 588. Association of Maternal Body Weight on Birth Weight 639. Undernutrition in Children and Protein Calorie Adequacy in Adult Women and Children 6410. Global Hunger Index (GHI): Situation in India and Other South Asia Countries 6711. Highest Risk Factors for Stunting in Young Children: India, Bangladesh and Nepal 7012. Evidence Based Essential Specific Nutrition Interventions 7413. Stunting Rates and Severity of Stunting Under Five Years of Age 82

LIST OF FIGURES No. Title Page No.1. Undernutrition Situation in Children Under Five Years in 2005-06 and 2013-14 402. Underweight Rates in Children Below 5 Years: State-Wise and All India 403. Underweight Prevalence Rate All India and State-Wise 2013-14 414. Stunting Prevalence in India Compared to Many Neighbours & Income Peers 415. Stunting and Severe Stunting Prevalence in India By State 426. Prevalence Rate of Stunting Amongst Children <5 Years in India and State-Wise 437. Comparison of Stunting Rates in Children Below 5 Years In 2005-6 and 2013-14 438. Severe Wasting Rates in India by State in 2005-06 449. Acute Malnutrition in India 4510. Underweight and Stunting Among Children (0-59 Months) in India 4611. Prevalence Rate of Stunted, Underweight and Wasted in India in Rural and Urban Region and Male and Female Children 4612. Undernutrition Prevalence Rates for All Three Indicators by Wealth Index 4713. Prevalence Rates of Stunting, Wasting, Underweight in Children <5 Years in Lowest and Highest Wealth Index 4714. Stunting, Underweight & Wasting in Children < 5 years by Caste/ Tribe 4815. Prevalence Rate of Wasting in Children Below 5 Years in 2013-14 4816. Age-wise Trend in Percentage of Children with Stunting, Underweight and Wasting 5017. Girls Aged 15-18 Years Body Mass Index Less Than 18.5 across All States and in India 5118. State Wise Prevalence of Undernourished Women (BMI < 18.5 Kg/M2) in India 5319. Prevalence Rate of Undernourished Women Based on Wealth Quintile 5320. Prevalence of Low Birth Weight (LBW) in India and South Asia 5321. Reduction in Clinical Signs of Malnutrition 5422. Prevalence of Anaemia in Different Age Groups in India 5423. Anaemia Prevalence Rate in Children, Adolescent Girls and Women in 9 High Burden States 5524. Increase in VAS Coverage: 2005-6 and 2013-14 5625. Households Using Adequate (At Least 15 ppm Iodine) Iodised Salt in India 5726. Overweight Prevalence in Indian adults (15-49 yrs): By Residence 5927. Statewise Prevalence of Overweight/Obese among Indian Adults (15-49 years) 60


28. Immediate, Intermediate and Underlying Determinants of Undernutrition 6129. Daily Dietary and Nutrient Intake of Pregnant & Non-Pregnant Women 6230. Early Child Feeding Practices in India 6431. Infant and Child Feeding (IYCF) Practices: Shift Between 2005-6 and 2013-14 6532. Undernutrition: Dietary Intake and Infection Cycle 6633. Intergeneration Cycle of Undernutrition 6934. Constraint of Women Resources: Implications on Nutrition Specific and Nutrition Influencing Interventions 7035. Level of Education of Women and Its Impact on Early Marriage, BMI, Spousal Violence and Childhood Stunting 7236. Women’s Nutrition through the Life Cycle is Crucial Determinant of Stunting in Children 7337. Gap in Universal Coverage of Specific Nutrition Interventions 7438. Undernutrition in Children below 5 years in the State of Bihar 8739. Estimated Numbers of Undernourished Under Five Years Children in Various Districts of Bihar 8840. Nutritional Status of Women in Bihar 8841. Women’s Education and Its Impact on Underweight in Children, Age of Marriage, Domestic Violence 89

References 91 - 97

iDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

EXECUTIVE SUMMARY

ii DAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in IndiaDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

EXECUTIVE SUMMARY

Breaking the Poverty-Malnutrition Cycle: Deendayal Antyodaya Yojana: National Rural Livelihood Mission, or DAY: NRLM, being implemented in Mission mode, is based on the philosophy of institutions of women driven by women. The approach of DAY: NRLM is to build, support and sustain livelihoods of poor rural women, which over a course of time are federated into Village Organisations (VOs), cluster level and higher level Federation at the district level. As per the early 2016 information, DAY: NRLM is currently operating in 411 districts with 24.62 lakh SHGs and 1.23 lakh Village Organizations. A total of 2.70 crores (27 million) households are covered. All districts and all blocks are planned to be covered by 2017. By 2020, DAY: NRLM plans universal coverage of rural households in all states and UTs of the country.

The goal of DAY: NRLM is to eliminate poverty. Efforts to achieve the goal of poverty reduction is slowed down, to a great extent, due to persistent problem of malnutrition (the term ‘malnutrition’ and ‘undernutrition’ has been used interchangeably in the document) in women and children since malnutrition reduces productivity, diminishes immunity, increases illness as well as absenteeism and adversely impacts earning capacity. Malnutrition fundamentally reduces life chances as well as has a negative impact on people’s ability to grow optimally physically and mentally. Moreover, undernutrition in early childhood also increases chances of adult onset chronic diseases such as diabetes, cardio-vascular diseases etc. with substantial decrease in work capacity, health expenditure and earnings. Poor maternal, infant, young child nutrition (MIYCN) has serious implications on health, education, productivity and economy of family, community and country.

The interrelationship of undernutrition and economic growth is evident. Malnutrition, in fact, increases the financial burden of avoidable expenditure on health care and medical treatment with serious consequence in excessive quantum of loans for medical care resulting in financial loss, monetary insecurity and eventually leading to poverty. DAY: NRLM’s efforts for reduction in absolute poverty and consistent economic growth therefore need to be actively supported and translated in improved health and nutrition situations of the marginalised populations. The value of addressing undernutrition is evident from the recent assessment that for every dollar invested in scaling up nutrition actions, $16 are realized in return. It is important to recognise that investing in nutrition is means to accelerate economic growth rather than viewing nutrition improvement merely as an outcome of economic growth.

DAY: NRLM, with its focus on economically empowering poor women, needs to be recognised to be a suitable platform for linking livelihood actions with Agriculture, horticulture, health, ICDS, water-sanitation sectors and play a key role in accelerating the rate of reduction of undernutrition in women and children and facilitate in achieving the World Health Assembly (WHA) nutrition targets by 2025 and for achieving the Sustainable Development Goals (SDG) 1 and 2, pertaining to elimination of undernutrition by 2030. Evidence from international and India experiences reveal that using women group as platforms for building on nutrition, health, and sanitation improvement activities is feasible in low resource settings. The role of DAY: NRLM in improving MIYCN situation is indisputable.

Magnitude of the Problem of Malnutrition in Women and Children: Section II of the report presents in detail the situation of malnutrition in rural India. Malnutrition or undernutrition is defined as lack of proper nutrition. It is caused by not having enough to eat, not eating enough of the right things, or being unable to utilise the food that one does eat. Malnutrition in women is common—every third women in reproductive age is undernourished and over half are anaemic. The situation is worse in tribal region and SC population- tribal (46.6 percent) and SC (41.1 percent). The prevalence of undernutrition is almost three times in the lowest wealth index compared to the highest wealth index. The impact of such poor maternal nutrition is evident with almost a third of birth weight being Low Birth Weight (LBW). Malnutrition in women sets up an intergeneration cycle of undernutrition.

With high incidence of LBW, almost a third of children are undernourished at birth itself. The prevalence rate of stunting (height for age indicating chronic undernutrition) continues to increase steadily till the age of 24 months and then stabilises. Stunting results from low birth weight or chronic malnutrition and is irreversible after two years of age. There is no cure beyond the age of two while the consequences are permanent, but indistinct and largely ‘not visible’. The effects of stunting go well beyond childhood resulting in higher chances of adult onset chronic diseases.

iiiDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

It is estimated that a 1% loss in adult height leads to 1.4% loss in economic productivity. The period of life from conception to two years of age or the first 1000 days of life i.e. from the onset of conception to 24 months of age is the “window of opportunity” for addressing undernutrition.

Four out of ten under five children in India are stunted. An estimated 45 percent of deaths of children under age 5 are linked to malnutrition. The stunting rate is higher in children living in rural region and those from families with low wealth index, scheduled caste and scheduled tribe. The prevalence rate of stunting (height for age measure), an indicator of chronic undernutrition in children, is almost double in the lowest wealth index compared to the highest wealth index –stunting 50.7 percent and 26.7 percent, respectively.

Besides stunting, sub-clinical forms of micronutrient deficiencies remain a public health problem. Prevalence of deficiencies of vitamin A and iodine has decreased significantly but sustained efforts are required to ensure measures for preventing any deterioration. Iron deficiency anaemia is a major problem across all age groups and has serious implications on health, immunity, work performance, and productivity in women and men as well as adversely impacts cognitive development and performance of school children. Every second woman in India is anaemic while 7 out of 10 young children also suffer from iron deficiency anaemia.

The following sections analyse specific aspects and recommendations for improving Maternal, Infant and Young Child Nutrition situation in India.

1. Addressing Undernutrition: Implementing Nutrition Sensitive Interventions Coupled with Essential Nutrition Specific Actions Imperative: There are many factors and behaviours that can contribute to stunting, falling in one of three categories: low birth weight, caused primarily by poor maternal health and nutrition; low intake of nutrition, caused mainly by poor infant feeding practices and low retention of nutrition, caused largely by frequent illness such as diarrhoea and poor management of childhood diseases. These determinants of malnutrition in women and children are classified under the following three categories-immediate, intermediate and underlying factors.

The immediate determinants of undernutrition in women and children are inadequate dietary intake and frequent illness. Poor diet combined with poor health care, hygiene and sanitation sets up a cycle of infection, loss of nutrients and malnutrition. The primary reason for poor dietary intake by children is often due to lack of knowledge regarding appropriate feeding and care practices including information on significance of dietary diversity. These determinants are influenced by intermediate determinants such as household food –nutrition insecurity, inappropriate maternal - child care and feeding practices including excessive physical drudgery, early marriage and conception, frequent pregnancies as well as poor access to health services and poor water, hygiene and sanitation environment. These immediate and intermediate factors are in fact influenced by underlying basic factors such as poverty, poor education, low social status, gender bias, poor decision making power as well as domestic violence.

Rapid and significant progress in reducing childhood stunting can be achieved by simultaneously addressing the intermediate and underlying socio-economic causes along with immediate causative factors. The latter include actions for promoting essential direct nutrition interventions such as appropriate infant and young child feeding practices, maternal nutrition practices, prevention & treatment of micronutrient deficiencies with special focus on anaemia and iodine deficiencies, timely and therapeutic feeding for all children with Severe Acute Malnutrition (SAM) as well as ensuring improved access to health services (routine immunisation, antenatal care).

On the other hand, the nutrition sensitive measures include interventions which impact MIYCN situation such as actions for improving women’s economic situation and education, reducing gender inequality, empowering women including preventing early marriage and conception, and enhancing access to services such as appropriate water-sanitation facilities at easy reach, maternity benefits etc. These nutrition influencing or nutrition sensitive factors need to be addressed along with nutrition specific interventions or direct essential nutrition interventions.

2. DAY: NRLM: An Appropriate Platform for Reaching with Nutrition Sensitive and Direct Essential Nutrition Interventions: The DAY: NRLM concept of “Dashasutri” includes improving health and nutrition of women as one of the ten focus areas through the Self-Help Groups (SHGs) of women network. The launch of Mahila Kisan Sashaktikaran

iv DAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in IndiaDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

Pariyojana (MKSP) where women farmers are being systematically organised for being involved in integrated farm and allied activities is evidence of efforts of DAY: NRLM is directing towards attaining food and nutrition security in the poorest of the poor families.

DAY: NRLM with its focus on elimination of poverty in fact contributes in breaking the cycle of poverty-malnutrition and complements the efforts of other government programs which address poverty as well as food and nutrition insecurity. SHGs and their federations, under the DAY: NRLM, provide a great opportunity to reach the unreached marginalised disadvantaged families who are often left out from the government schemes, services and entitlements. Moreover, these community institutions are platforms which not only empower women and contribute in breaking off disadvantageous women from the pressure of poverty but also provide an opportunity to equip them to demand their entitlements for various public services.

Using DAY: NRLM platform for mobilising SHG women members to move beyond livelihood microcredit enterprises of income generation to practising appropriate family level health, nutrition, hygiene, sanitation care practices and accessing their rights and entitlements for government schemes and services, which contribute to improving nutrition, is essential and feasible. DAY: NRLM thus offers a suitable forum for spearheading nutrition sensitive issues as well as supporting in the universal coverage of evidence based direct nutrition interventions. Anti-poverty program of DAY: NRLM therefore can be re-designed with a view to integrate livelihood activities with actions that would improve women and child nutrition within the DAY: NRLM program philosophy. The latter implies using the principles of ensuring reaching poorest of the poor and ensuring women’s participation in implementing the selected actions.

3. Livelihood cum Nutrition, Health and Sanitation (LNHS) Initiative through DAY: NRLM -The Goal and Objectives: Using the DAY: NRLM platform, a comprehensive DAY: NRLM linked “Livelihood cum Nutrition, Health and Sanitation (LNHS)” initiative is proposed with the goal to “contribute in accelerating the rate of improving women, infant, young, child nutrition (MIYCN) situation in the community and facilitate in the achievement of the World Health Assembly (WHA) targets of nutrition in India by 2025”. Towards achieving this goal, LNHS aims to achieve the following objectives by each of the Village Organisations (VOs) of SHGs. LNHS implementation is proposed in two phases – the first phase between the period 2016-2020 and the second phase between the period 2020-2025. First phase includes a) states/blocks with ‘matured’ SHGs with VOs adhering to the “Panchsutra” guidelines for at least six months and b) VOs implementing MYKSP.

• Ensure at least 90 percent of women and children of SHG members have access to not only consumption of adequate energy providing food but to diversified food from at least five food groups by pregnant women and four food groups for young children.

• Facilitate and ensure reach and coverage of at least 90 percent newly-weds, pregnant women and children 0-24 months in the community, in collaboration with health and ICDS system, with the provision of the defined essential direct nutrition and health services, including supply and consumption of Iron Folic Acid (IFA) tablets to pregnant women.

• Promote appropriate behavioural practices and ensure at least 90 percent of families are aware and at least 70 percent adopt appropriate practices pertaining to maternal and child feeding, health and water-sanitation-hygiene practices for improving maternal nutrition and preventing stunting in children aged 0-24 months.

• Ensure 90 percent VOs are aware and are mobilised to demand the entitlement for nutrition sensitive government schemes from multiple sectors dealing with improved sanitation and latrines, safe water, reduce gender discrimination, education of women, delaying age of first conception, spacing births, reducing drudgery etc.

4. The LNHS Initiative - Strategy for Improving Maternal, Infant, Young Child Nutrition: The proposed LNHS initiative is not designed as a stand-alone but a holistic approach using the untapped delivery platform of DAY: NRLM. Livelihood programs improve purchasing power and provide the scope for directing the generated resources for improving dietary diversity as well as for synergising DAY: NRLM inputs with other on-going government programs pertaining to food and agriculture, health, nutrition and sanitation interventions. Moreover, it offers the opportunity

vDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

to map, prioritise, and direct focus on the first 1000 days of life by reaching families who are considered most vulnerable to malnutrition i.e. families with children 0-24 months or pregnant women or newly-weds.

The LNHS strategy focuses on the following “doable” measures for improving nutrition situation (i) addressing food and nutrition security at household level (ii) supporting ICDS and health sectors in reaching the unreached families of under twos towards ensuring universal coverage of women and children with the defined evidence based essential specific nutrition interventions and health services (iii) promoting appropriate health, nutrition and WASH behaviour practices at family and community level and (iv) facilitating in converging at VO level selected nutrition sensitive actions such as prevention of open defecation, reduction of physical drudgery for fuel and water collection, delaying age of conception to over 18 years, addressing domestic violence etc.

5. LNHS Initiative - Package of Four Major Interventions: Based on available evidence and current experience of DAY: NRLM activities, the LNHS initiative for improving the MIYCN situations comprise four major components which are described below. The first intervention aims to improve food and nutrition security at family level. As per the LNHS strategy, each VO has the option to select suitable specific activities from the set of proposed measures a to f listed below under the first intervention pertaining to food and nutrition security. The other three interventions, presented below, are considered imperative and are recommended to be mandatory and followed by each of the VOs to impact nutrition situation. These include interventions pertaining to universal coverage of essential direct nutrition actions, behavioural change communication and convergence of sectoral interventions at VO level. The latter interventions impact nutrition situation and is referred as ”nutrition sensitive” actions.

I. Ensure food and nutrition security at family level: A range of actions are proposed below for family level food and nutrition security. VOs, based on group discussion, could select the appropriate actions from the options presented below.

a) Intensify livelihood activities for improving access to food through agriculture and its allied activities:

There is a need to increase focus on micro-credit enterprises pertaining to food production through sustainable agriculture activity, vegetable gardens, poultry keeping, goat rearing and dairy keeping. Recent reviews confirm a positive impact on dietary diversity and nutrition outcomes as a result of home production of nutrient-rich vegetables and fruits crops. The focus of MKSP initiative of DAY: NRLM is for improving agriculture intensification and horticulture activities as well as on poultry and dairy keeping. Coverage of MKSP can be expanded. However, it is critical that SHG members move beyond economic benefits through production and marketing of such food products to regular usage of such food items in family diet for enhancement of family level nutrition security. Nutrition education efforts therefore need to be built into SHG led agriculture and allied sector interventions to convince and ensure families to use a part of the agriculture, horticulture, milk or eggs produce for improving nutrition of the family members, especially in those households at the highest risk of undernutrition i.e. pregnant women, children 0-24 months and women in preconception stage.

b) Improve access to entitlement to subsidised food under the National Food Security Act (NFSA): SHG members need to be well informed for demanding their entitlements of the following components under the National Food Security Act (NFSA) i.e. subsidised cereals through the Public Distribution System (PDS), Food or Supplementary nutrition by Integrated Child Development Services (ICDS), Mid-Day meals (MDM) for children in schools in primary and middle and cash entitlements under the conditional cash transfer (CCT) scheme for pregnant mothers under the Indira Gandhi Matritva Sahyog Yojana (IGMSY) in selected districts.

c) Establish food security credit line: Experiences from some states indicate that introducing the concept of investment in food security (credit) line initiative through the SHG network ensure poorest of the poor to have access to good quality dry rations foods, such as cereal grains as well as, fats/oils and pulses. Emerging lessons are good examples of reducing the vulnerability of the poor households to market fluctuations in lean seasons and ensuring food security through the year.

vi DAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in IndiaDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

d) Promote simple doable actions for enhancing dietary diversity and retention of nutrients at household level: Micro-credit initiatives result in increasing purchasing power through non-food or food production related economic activities. The resources generated need to be systematically channelized in improving food diversity and nutrition security at family level, especially of households at high risk of nutrition i.e. households with pregnant women or young children 0-24 months or newly-weds. Using the VO forum of monthly meetings, women members need to be convinced to diversify their daily diets and not depend only on cereals. Promoting use of simple low cost traditionally acceptable food and diet practices as well as use of correct cooking practices for the retention of nutrients needs to be focus of discussion at VO meetings.

e) Organise provision of cooked meals to pregnant and nursing women through SHG initiative in targeted geographical areas: Provision of hot cooked meals to pregnant women is an initiative (referred as Nutrition cum Day Care Centre or NDCC) which has been experimented with the involvement of SHGs in selected states. Sustainability and financial management of NDCCs remains a major a challenge. However, NDCC could be considered a solution for food and nutrition security for selected geographical areas with high degree of poverty and having a poor reach of ICDS program. Further, SHG members could also consider a mechanism to provide selected food items such as eggs, milk and milk products to “at risk” families/households.

f) Promote production and sale of nutrition dense foods as a micro-credit investment: Investment of SHGs in production and marketing of “ready to eat” nutrient mixture to ICDS such as Kudumbashree State Rural Livelihoods Mission – (SRLM) program in the state of Kerala is a good example of investing in income generating activities which has the scope of investing in supporting nutrition security activities in a community. SHG groups could be supported to produce and market such nutridense “ready to eat” products for interested community members through the Fair Price Shops of the PDS network. It is important that SHG members involved in such activities are reached systematically for imparting health and nutrition education with the objective of promoting adoption of appropriate care and feeding practices for pregnant women, young children and newly- weds.

II. Ensure universal coverage of essential nutrition actions - Establish linkage with the ICDS, health, and WASH sectors: At least 90 percent coverage of each of the essential nutrition interventions (ENIs) by health and ICDS sectors is critical for reducing undernutrition rate. There is therefore a need to facilitate in attaining the goal of ensuring universal coverage of the evidence based direct nutrition interventions as well as of the preventive health services. The families not covered by health and ICDS sectors are very often the disadvantaged families belonging to poorest household, those living in remote areas and or those belonging to scheduled caste and scheduled tribe. Such families need to be identified and mobilised to attend (a) monthly village health nutrition sanitation days (VHNSDs) for receiving various maternal child health and ICDS services and (b) biannual fixed day fixed month vitamin A and deworming administration sessions. In addition, with reference to anaemia prevention, VOs need to be encouraged to use innovative strategies and play a central role not only in counselling regular consumption of IFA tablets but introduce innovative measures for ensuring timely adequate supply of IFA tablets. VOs are also proposed to play an important role in the prevention of Iodine Deficiency Disorders (IDD). Besides informing community to consume only iodised salt, VOs could play a central role to ensure village grocery/kinari shops procures and sell only iodised salt (with minimum 15 ppm) by periodically testing salt samples from village retail shops using low cost rapid salt testing kits. Additionally, VOs along with health sector could also be involved in counselling families of severe acute malnutrition (SAM) children to visit Nutrition Rehabilitation Centres (NRCs) and participate in follow up care of children who are discharged from NRCs.

III. Promote appropriate family care practices and create demand for health, nutrition and social services/ entitlements - Strengthen Behavioural Change Communication (BCC): As per the LNHS initiative, BCC strategy proposed will comprise inter-personal communication (IPC) at home level, group discussion and social mobilisation at VHNSD sessions as well as mass communication. A comprehensive BCC guideline is recommended to be developed for the LNHS initiative. BCC strategy would be developed to focus on

viiDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

promotion and adoption of appropriate family level practices pertaining to nutrition care of pregnant women, antenatal and family planning services, newborn care, infant and young child feeding, routine immunisation, use of iodised salt, promotion of daily consumption of IFA and calcium tablets by pregnant women, biannual vitamin A and deworming, hygiene and sanitation practices. In addition, BCC would also focus on increasing awareness for demanding entitlements pertaining to various government schemes such as JSY, NREGA, PDS, IGMSY, ICDS food supplements. VO forum also provides a platform for identifying barriers to various behavioural issues and appropriately address them.

As a part of the BCC strategy, fixed monthly themes on various nutrition, health, sanitation and livelihood

themes are proposed for intensive promotional activities. For successful implementation of the BCC strategy, male family members would be encouraged to be reached periodically for discussion on MIYCN issues and for seeking their cooperation at family level. Special effort is therefore proposed to reach male members of families through organisation of group counselling sessions linked to farmers’ group or seed bank group.

IV. Collaboration with multi-sector partners - Address nutrition sensitive issues: Active collaboration with sectors which impact the intermediate and underlying causes of undernutrition need to be strengthened. These include actions for improving safe drinking water, sanitation facilities, promoting school completion by girls, reducing gender discrimination in family care practices, preventing early marriage/conception as well as reducing domestic violence, physical drudgery, exposure to malaria etc. The interrelationship of poor sanitation and malnutrition is well established and as a part of LNHS, a special focus will be on developing linkage at VO and block level government representative for implementing the Swachh Bharat Abhiyaan and accelerating efforts for building of toilets with focus on attaining the goal of Open Defecation Free (ODF) villages.

LNHS strategy focuses on VO playing a central role in demand generation for such varied actions as well

as linking with concerned block level representatives of various sectors for timely response. However, to facilitate such actions at VO level, there is a need to precede such a process by undertaking active advocacy by SRLM with the concerned selected sectors at state, district and block level as well as with PRIs.

6. Operationalization of the Livelihood Cum Nutrition, Health, Sanitation (LNHS) Initiative: The LNHS initiative is proposed to be rolled out at VO level for achieving the stated objectives. The principles of participatory approach, self-reliance and women empowerment being central to prioritising the VO level actions. A ‘Parivartan Saathi’ or PS (the nomenclature “health activists” is proposed to be renamed as ‘Parivartan Saathi’ which literally means ‘Transformation friend/Pal’ ), selected by VO, is proposed to play the leading role in implementing the LNHS initiative.

Each VO will need to develop a micro-plan of action with PS taking the lead and supported by VO members, project block coordinators and block federation. During micro-plan development, the various entitlements and government services and schemes such as Family Planning Services, Public Distribution System, NREGA, Girls Education Schemes of state governments, Beti Bacchao Beti Padaho, Aadhaar Cards, Kisaan Beema Yojana, Jan Dhan Yojana etc. will be taken into consideration. Standardised guidelines developed by DAY: NRLM will be followed for (i) rapid “Participatory Learning Assessment” (PLA) exercise with VO members (ii) undertaking mapping of households in the VO community with pregnant women, children 0-24 months and newly-weds and identifying those not registered with ICDS or health workers (iii) Prioritising actions based on PLA and mapping exercises (iv) development of a VO level annual plan of action using the monitoring indicators described below and finalising the plan in consultation with VO members and (v) using the DAY: NRLM guidelines for BCC strategy and training. The use of health-risk funds, food security funds and other resources available to SHGs through various sectors for health and nutrition services and entitlements would also be discussed by VOs to facilitate in the planning process. VOs are also proposed to be supported by the members of the Social Action Committee (SAC) and Health Committees.

PS are proposed to coordinate with the sector mobilisers and will be the primary representative of VOs for

viii DAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in IndiaDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

putting in operation the LNHS initiative. Following the development of a VO level micro-plan, sectoral mobilisers will be selected by VO for coordinating with sector representatives for a specific sector theme, other than health and nutrition. Selection will be on the basis of requirements evident from design of the VO micro-plan and its operationalization. Not more than three-four sector mobilisers will be selected and made in-charge of specific 1-2 selected sectoral activities e.g. one sector mobiliser for agriculture/horticulture activities, another mobiliser for water-sanitation and a third mobiliser for resolving gender issues. The tasks of these mobilisers would be primarily to link the VO members, through the PS, with the concerned sectors at block and lower level for technical support and budget allocation as per the policy entitlement. These sector mobilisers are also proposed to receive an honorarium for coordinating with the concerned block officers.

An official communication issued by the state government to various departments is considered crucial to facilitate in establishing linkages of DAY: NRLM (VOs and their federations) with the concerned nutrition sensitive sectors at block level and with PRI. Advocacy on LNHS initiative with state /district/block sector representatives is essential for getting full support of the concerned nutrition influencing sectors. Advocacy package would be developed at national level for adaptation by SRLM. The advantageous position of DAY: NRLM in coupling the inputs of the nutrition specific actions with nutrition sensitive interventions through VO forum would be emphasised. Moreover, advocacy efforts would aim at breaking the myth that inputs for poverty eradication or improving food security per se is sufficient to address the problem of malnutrition.

A cluster coordinator can be made in charge of ensuring effective rolling out of the VO plan of action. The block and district coordinators along with the group of young professional at state level, appointed as a part of the State Project Unit for the SRLM, will provide technical, supervisory and implementation support to the PS, VOs and SAC members. The block coordinator is also proposed to function as block monitoring coordinator.

National and state level core trainers will be developed along with a framework plan for capacity building /training plan for rolling out LNHS initiatives for achieving the stated goal and objectives. Involvement of ICDS and health managers as trainers and frontline workers of ICDS (AWWs) and health (ASHAs) will be encouraged. The training modules developed by DAY: NRLM at the national level for implementing LNHS will be shared with SRLMs for adaptations. A wide range of communication support materials, available through other programs on essential nutrition actions, will also be used.

7. Indicators for monitoring progress - LNHS Initiative: Every six months, data can be collected on a set of selected indicators (presented in the report) pertaining to maternal - child health and nutrition (MCHN) services as well as family level livelihood and sanitation practices. The data available from the existing monitoring system of health and ICDS can be used for the MCHN indicators while data on livelihood actions can be collected through VOs.

Block coordinators in-charge of monitoring, appointed by SRLM, can compile the data obtained from the various VOs at block level while district coordinator in-charge of monitoring at district level can compile the data obtained from various blocks. “Fixed day’” approach is proposed to be used for collection of data from the various villages which form the VO. The record is proposed to be documented and shared every 6 months and progress reviewed at VO, block and district level federations of women. With the help of block project coordinators, actions can be reviewed and implemented according to the progress made. For facilitating this process, special software for compiling VO level data is proposed to be developed by DAY: NRLM.

8. Award incentives linked to composite index achievement: Cash award incentive scheme can be part of the LNHS initiative. A composite index of selected ten indicators is proposed to be used for monitoring progressive achievement by the end of 2018 and 2020. On the attainment of the targets for each of the ten selected indicators, a cash award of INR 20,000 can be given to the VO as common investment funds /revolving funds to be used by SHGs.

ixDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

x DAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in IndiaDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

1DAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

PART 1DAY: NRLM: Livelihood cum Nutrition, Health, Sanitation (LNHS) Initiative - Coupling Nutrition Sensitive Interventions and Nutrition Specific Actions for Accelerating Improvement in Maternal, Infant, Young Child Nutrition (MIYCN) Situation

2 DAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in IndiaDAY: NRLM – Improving Maternal, Infant and Young Child Nutrition Situation in India

PART 1DAY: NRLM: Livelihood cum Nutrition, Health, Sanitation (LNHS) Initiative-Coupling

Nutrition Sensitive Interventions and Nutrition Specific Actions for Accelerating Improvement in Maternal, Infant, Young Child Nutrition (MIYCN) Situation

1. Magnitude of the Problem of Malnutrition, Implications, Determinants and Evidence Based Actions

Part II presents in detail the situation of nutrition situation of women and children in India. The key issues of undernutrition are presented below in the context of the proposed nutrition strategy through DAY: NRLM.

a. Nutrition Status of Women and Children:

Four out of ten children in India are stunted. The stunting rate is higher in children living in rural region and those from families with low wealth index, scheduled caste (SC) and scheduled tribe (ST) (Table 1). As per the RSOC survey (Table 1), the prevalence rate of stunting in ST is 42.3 percent and is almost the same as of the SC population (42.4 percent). The prevalence rate of underweight and wasting in ST population is far worse than all the other three population groups (SC, other backward classes (OBC) and others). The prevalence rate of stunting and underweight is almost double in the lowest wealth index compared to the highest wealth index –stunting 50.7 percent and underweight 42.1 percent in the lowest wealth index compared to corresponding 26.7 percent and 18.6 percent in the highest wealth index. On the other hand, severe wasting does not present such a significant difference with wealth quintile –5 percent in lowest wealth index and 4.4 percent in the highest wealth index.

Table 1: Nutritional Status by Population Group

Undernutrition SC ST OBC Others

Stunted 42.3 42.3 38.9 33.9

Underweight 32.7 36.7 29.3 23.6

Wasted 15.5 18.7 14.8 13.6

Source: (RSOC 2013-14)

Undernutrition in women is common—every third women in reproductive age is undernourished. The situation is worse in tribal region and SC population- tribal (46.6 percent) and SC (41.1 percent). The prevalence of undernutrition is almost three times in the lowest wealth index compared to the highest wealth index. The impact of such poor maternal nutrition is evident on birth weight. Almost a third of children are stunted at birth or soon after birth. Recent RSOC survey (2013-14) also indicates LBW situation is worse in tribal population (21.6 percent) compared to the national average of 18.6 percent. LBW incidence shows a wide gap in the highest (15.5 percent) and lowest wealth index (21.8 percent) population.

Clinical forms of micronutrient deficiencies of B vitamins, vitamin A and iodine deficiency has reduced substantially. However, sub-clinical forms of micronutrient deficiencies are prevalent and remain a public health problem. Iron deficiency anaemia is a major problem across all age groups.

b. Implications of Undernutrition:

Maternal and child undernutrition is the underlying cause of nearly half of under- five child deaths (UNICEF, 2009, Bhutta et al, 2013). The consequences of mild and moderate undernutrition are not limited to health, physical development and survival. Undernutrition has serious implications on mental development. Undernutrition impairs brain development and cognitive abilities during the early days and can contribute to delayed enrolment, high drop-out rate as well as poor performance in school and


lower learning outcomes at a later stage. (Victora et al, 2008) This is well reflected in a multi-country study of 2007 which reports that for every 10 percent increase in prevalence of stunting (a measure of chronic undernutrition), the proportion of children reaching the final grade of school drops by almost 8 percent. (Grantham-McGregor et al, 2007) Undernutrition in fact adversely influences school concentration, learning at school, livelihood actions and productivity through the life cycle leading to intergenerational cycles of poverty and malnutrition.

Deficiencies of micronutrients such as iron, folic acid and iodine also adversely influence brain and cognitive development of young children. Vitamin A and zinc deficiency have serious impact on survival and growth of children. Anaemia in mothers results in intra-uterine growth retardation resulting in birth of low birth weight (LBW) babies who start life with the burden of undernutrition. Anaemia also contributes to high morbidity, mortality and reduces productivity. Folic acid deficiency is common in women in reproductive age and is a known to be a contributory cause of neural tube defects. Deficiency of iodine can lead to permanent brain damage in growing foetus. Iodine as well as iron deficiency results in lowering of intelligence quotient (IQ) in school children by 10-15 IQ points .Deficiency of iron adversely influences concentration in work performance and productivity in school children.

According to Global Nutrition Report 2014-15 “good nutrition is the bedrock of human well-being before birth and through infancy, good nutrition allows brain functioning to evolve without impairment and immune systems to develop more robustly in young children, good nutrition status averts death and equips the body to grow to its full potential.” (Global Nutrition Report, 2014)

Undernutrition fundamentally reduces life chances as well as adversely influences people’s ability to grow optimally physically and mentally. The adverse effects of malnutrition are not limited to children but have serious implications throughout the life cycle resulting in adversely influencing health, education, productivity and economy of the state. Since the past decade, serious implication of undernutrition which is increasingly gaining attention is the grave consequence of undernutrition in early childhood and adulthood on adult onset chronic diseases such as diabetes, cardio-vascular diseases etc. Low birth weight and its long term effect on non-communicable disease is of increased concern.

The long term consequences of chronic malnutrition are far reaching since the adverse impact is not only irreversible but intergenerational. The latter implies that a stunted young girl is likely to grow up to be a stunted adolescent girl and a stunted woman with increased chance that her children will be born undernourished with a poor start in life. Undernutrition in mother to a great extent contributes to foetal growth restriction or intrauterine growth retardation (IUGR), low birth weight and is a cause of more than a quarter of all neonatal deaths. On the other hand, improved maternal status reduces incidence of LBW, child malnutrition and mortality as well as contributes in reducing maternal mortality, improving educational outcomes and increasing productivity and growth.

Ill health and malnutrition result in increases the financial burden of avoidable expenditure on health care and medical treatment and contributes to excessive quantum of loans for medical care which contributes to financial insecurity. Moreover, ill-health also adversely impacts on productivity and reduces the scope of economic gain.

c. Addressing Undernutrition: Nutrition Specific and Nutrition Sensitive Interventions:

Malnutrition in women and children is caused due to immediate, intermediate and underlying factors (Fig 1). The Immediate cause of undernutrition in women and children are inadequate dietary intake and frequent illness while intermediate determinants are household food insecurity, inappropriate maternal and child feeding practices, poor care practices and health services and poor environment. Poor diet combined with poor health care, hygiene and sanitation sets up a cycle of infection and malnutrition which needs to be broken for improving nutrition situation of infants and children. The primary reason for poor dietary intake seems to be lack of knowledge regarding appropriate feeding practices as well as


socio-economic factors which contribute to poor dietary intake. In case of women, poor nutrition can be attributed to poor food intake in terms of quantity and quality through life cycle due to low social status and poor purchasing power, inadequate knowledge and decision making power. These factors result not only in poor intake of nutrients but in excessive physical drudgery, loss of nutrients due to infection and illness caused due to poor hygiene, water and sanitation. Additionally, other social factors such as early marriage and conception, frequent pregnancies, large families, poor nutrition care during childhood and adolescence result in an intergeneration cycle of undernutrition.

The nutrition specific interventions which address immediate and intermediate determinants comprise adoption of appropriate child feeding and maternal feeding practices, consumption of food and pharmaceutical supplements etc. There are a number of intermediate and underlying causes which are not nutrition specific but impact nutrition situation of women and children and are therefore referred as ‘nutrition sensitive’. The latter include a range of interventions which reduce poverty and purchasing power, improve household food security and diversity such as inputs in agriculture and allied sectors, improve access to water and sanitation facilities, empowerment of women and improve education, social status, and decision making power of women.

Figure 1: Immediate, Intermediate and Underlying Causes- Nutrition Specific and Nutrition Sensitive

Interventions (adaptation UNICEF,1998)


Figure 2: Women Resources: Nutrition Specific and Nutrition Sensitive Interventions and MIYCN

Source: (Vir, 2016)

Improving women’s status is essential. An analysis of current evidence indicates that constraints on women’s resources influence immediate determinants of nutrition as well as a number of underlying causes. (Vir, 2016) These resources (Fig 2) encompass not only wealth but education, gender equity, decision making power, health benefits, access to services such as mobility, maternity benefits, etc. Poor socio-economic status of women not only effect foetal growth and pregnancy outcome but also adversely impacts behavioural practices pertaining to appropriate self and child care which contribute to poor nutrition in women and stunting in children. Today, there is increasing evidence and recognition among scientific community that it will be difficult to achieve rapid and significant progress in reducing childhood stunting without simultaneously addressing the underlying socio-economic causes which adversely influence nutrition of women. (Smith & Haddad, 2015; Vir, 2016a)

Crucial: Resources Women/ Maternal

Implications: Resources Constraints

Effect: Women Life Cycle

Outcome: Poor Growth and Childhood Stunting

• Wealth/ income/ cash-in-hand

• Food security through the year

• Health

• Education/Knowledge

• Employment

• Family/ social support

• Access to facilities

- Health services

- Social protection support subsidised feeding, CCT)

- Maternity benefits

- Clean water

- Sanitation

- Safe/hygiene house

- Cooking fuel

- Time &energy saving devices

- Mobility freedom

- Mass media

Nutrition Specific Factors• Poor household food security and diversity • Sub-optimal child caregiver behaviour practices: feeding, health, hygiene• Poor nutrient intake and health care of adolescent girls & women • Inadequate protection from infection/ infestation

Nutrition Sensitive Factors• Poor decision making & purchasing power• Poor attainment of secondary education • Unhealthy living conditions with poor water-sanitation facilities• Early marriage & conception• Poor time availability• Inadequate substitute child care providers• High workload & physical expenditure• High domestic violence, psychological stress, poor mental health • Large gap in age & education level of women & her spouse

Inadequate care giving behaviours (0-24m)• Anaemia• Growth failure

Neglected adolescent care• Optimum height gain hampered• Thinness• Anaemia

Poor care: preconception/ newly-weds• Stunted adult women (<145cm)• Low BMI (<18.5 Kg/m2 • Anaemia

Inadequate pregnancy care• Weight gain <10-12kg• Anaemia • Impairment of fetal development (IUGR, preterm birth)

• Higher incidence of Low Birth Weight : Failure to catch up normal height

• Hamper optimum growth <24 months : largely irreversible

Increased incidence ofchildhood stunting


For prevention of undernutrition, the window of opportunity is the first 1000 days of life: Global data, including of India, indicates prevalence of undernutrition stunting increases steadily upto 24 months and then stabilises (Part II). This is primarliy due to the poor maternal nutrition, poor birth weight combined with poor infant and young child feeding practices in infants and young children. Moreover, the prevention of undernutrition (stunting) occuring in the first two years of life is largely irreversible. The period of life from conception to two years of age is the critical periods of life that lays the foundation for health,learning and productivity. Therefore for reducing rate of stunting, it is imperative that women enter pregnancy healthy, appropriate nutrition and health care is taken during pregnancy and in the first 24 months of life. This implies priority to be accorded to the first 1000 days of life i.e. from the onset of conception to 24 months of age.

d. Current efforts to Improve Nutrition Situation in India:

In India, program efforts to address malnutrition primarily address the proximate causes of malnutrition i.e. supplementing diet and health services. It is now well recognised that nutritional outcomes are determined by a complex interactions (Fig 1). Based on the evidence, nutrition specific interventions and nutrition sensitive interventions are considered to be crucial to be implemented simultaneously (For details see Part II).

Intensive effort is required for increasing coverage of essential specific nutrition interventions which comprise the following: promote appropriate infant and young child feeding, maternal nutrition and prevention of low birth weight, prevention & treatment of micronutrient deficiencies and timely and therapeutic feeding for all children with severe acute malnutrition (SAM) as well as ensuring improved access to health services (routine immunisation, antenatal care). These interventions are being addressed by two sectors(Figure 1): Integrated Child Development Services (ICDS), Ministry of Women and Child (MoWCD) and National Health Mission, Ministry of Health and Family Welfare (MoHFW).

These two sectors, health and ICDS, do not address the problem of women empowerment, poverty or food security and diversity at family level. The compiled data on dietary intake in rural region of 10 states indicate that overall diet consumption is poor and lacks diversity. (Part II presents details). Consumption of pulses/ legumes, oil/fat and vegetables is extremely poor in pregnant and non-pregnant rural women. Consumption of cereals is comparatively better with over 90 percent women in reproductive age group consuming over 50 percent of the dietary allowances of energy. The consumption of good quality protein and micronutrients are extremely inadequate (see Part II for details).

Food insecurity ,poor food diversity and poor consumption of micro and macronutrients at household levels of poor disadvantaged landless households who often belong to scheduled cast or scheduled tribe remains a problem. Intensification of nutrition sensitive interventions comprising measures for elimination of poverty, ensuring food security, empowerment of women, improving water-sanitation and hygiene situation, reducing drudgery in women, eliminating gender inequality, early marriage, domestic violence etc. are crucial. These nutrition sensitive interventions need to be addressed along with nutrition specific interventions being managed by health and ICDS sectors. DAY: NRLM offers a suitable platform for addressing these nutrition sensitive issues which are underlying but critical causes of undernutrition in women and children. Deendayal Antyodaya Yojana: National Rural Livelihood Mission (DAY: NRLM), a large scale development program, can be used strategically as an entry point for strengthening execution of nutrition specific measures and simultaneously mobilizing women for the implementation of nutrition sensitive interventions (Fig 1).

2. Deendayal Antyodaya Yojana: National Rural Livelihood Mission (DAY: NRLM): A Forum for Involving Institution of Women for Improving Maternal, Infant, Young Child Nutrition (MIYCN)

a. DAY: NRLM: Complementing Poverty Reduction with Nutrition Investment:

DAY: NRLM being implemented in a Mission mode, is based on the philosophy of institution of women


driven by women with the aim to “reduce poverty by enabling the poor households to access gainful self- employment and skilled wage employment opportunities, resulting in appreciable improvement in their livelihoods on a sustainable basis, through building strong grassroots institutions of the poor.” (NRLM, 2010) The approach of DAY: NRLM is to build, support and sustain livelihoods of the poor by aggregating and federating poor women who are often small and marginal farmers SCs, STs, and other marginalised and vulnerable population. DAY: NRLM promotes formation of self -help group (SHGs) of women which over a course of time are federated into Village Organisations (VOs), cluster level and higher level Federation at the district level. DAY: NRLM aims to ensure that “at least one member from each identified rural poor household, preferably a woman, is brought under the SHG network in a time bound manner.” These are therefore self- managed community institutions of participating households. (NRLM, 2010) DAY: NRLM is currently operating in 411 districts with 24.62 lakh SHGs and 1.23 lakh village organizations. (Personal communication, GoI 2016) A total of 2.70 crores (27 million) households are covered. All districts and all blocks are planned to be covered by 2017. By 2020, DAY: NRLM plans universal coverage of rural households in all states and UTs of the country.

Self Help Groups of women and their federations, under the DAY: NRLM, provide a great opportunity to reach the unreached marginalised disadvantaged families who are often left out from the government schemes and services. Moreover, these community institutions are platforms which enable participation of women in local governance, understand and demand their entitlements for public services, build linkages with health and nutrition service providers of various sectors for effective reach and service delivery. DAY: NRLM therefore provides a platform to promote behaviour change as well as serves as a unique forum to link women members in rural community to a number of sectors which in fact impact on nutrition status and are nutrition sensitive. The magnitude of reach is evident from the fact that today Bihar state has 170,000 groups reaching 2 million households with the aim of forming a million new SHGs to be formed in next 5-7 years reaching almost 10 million poor households. In the states of AP and Kerala, community institutions are well established and cover almost the entire rural region-- with 6.8 million SHG group women in rural Andhra Pradesh and about 4 million neighbourhood group (similar to SHG concept) women in Kerala.

DAY: NRLM with its focus on elimination of poverty contributes in breaking the cycle of poverty-malnutrition (Fig 3). The other programs which address poverty are Deendayal Upadhyaya Grammen Kaushaly Yojna and the Mahatma Gandhi Rural Employment Guarantee Act (MNREGA). However, the fact that undernutrition incidence is rather high in high wealth index group of India confirms that for improving MIYCN situation, it is imperative to focus on interventions that are beyond poverty reduction.

Figure 3: Poverty and Malnutrition: A Vicious Cycle

Income Poverty

Poor Purchasing Power/ Education/ Knowledge/Environment/ Mobility

MALNUTRITION

Poor sanitation

Poor nutrientintake

Direct loss of productivity

Poor physical output

Indirect loss of productivity

Poor attendance at work/ school

Loss of income/ resources

High investment in Health care

Loss of nutrients

Increase in demand for

nutrients

Poor hygiene

Lack of water

Low decision making power Poor maternal

& child care

Early marriageIncrease in

requirement of diversi�ed diet

Nutrients demand not met

Large families

Food and Nutrition

Insecurity

Frequent Infections /

Illness

High Exposure to Physical

Labour

Poor Social Status

of Women

Poor Knowledge on Maternal &

Child care/ feeding


It is well documented that economic improvement needs to be complemented with specific health-nutrition-water-sanitation inputs for reducing undernutrition in women and children. Moreover, such investments in maternal and early childhood nutrition interventions also have a large potential to reduce poverty and boost prosperity and break the cycle of poverty, ill health and undernutrition. Reducing undernutrition and economic growth are interrelated. It is estimated that for every dollar invested in scaling up nutrition actions, $16 are realized in return. (Global Nutrition Report, 2014) According to Global Nutrition Report, scaling up of nutrition specific investments in low and middle income countries can provide a return on investment of 10-13 percent. (Global Nutrition Report, 2015) The reduction in absolute poverty and consistent economic growth therefore needs to be actively supported and translated in improved health and nutrition situations of the marginalised populations.

b. DAY: NRLM: A Suitable Platform for Contributing to Improvement in MIYCN:

Health, nutrition, social and economic status of women plays a very central role in influencing maternal nutrition and nutrition of young children (Part II). SHGs and VOs, with the potential to establish linkages with Panchayati Raj Institutions (PRI) and multi-sector service providers, are in a position to address the immediate, intermediate and underlying determinants of malnutrition rooted in poverty and poor social status of women. Mobilising SHG women members to move beyond livelihood microcredit enterprises to practising appropriate family level health and nutrition care and access their rights and entitlements for government schemes and services, which contribute to improving nutrition, is essential and feasible.

DAY: NRLM philosophy of working with network of community institutions of women at village, block and district levels offers a prospect to address the following gaps in implementation of nutrition, health, water-sanitation interventions which address the immediate, intermediate and underlying determinants of undernutrition.

• Interventions through DAY: NRLM, reduces poverty and has the potential to break the cycle of poverty and malnutrition. With economic security, SHG women are empowered. For improving MIYCN situation, resources created by SHG women can be channelized appropriately for improving health and nutrition of women and children.

• DAY: NRLM targets and reaches poorest of the poor women in rural areas and therefore increases the scope of ensuring inclusion of often “unreached” disadvantaged families with livelihood activities as well as health, nutrition and sanitation services/inputs. The forum of SHG is a suitable platform for reaching the poorest women and those belonging to scheduled caste and scheduled tribe with health and nutrition services and behavioural change activities. In India, as presented earlier, these are the population groups with a much higher rate of undernutrition than the rest of the population and are often left out from programme. SHG therefore facilitates in reaching the unreached and meeting the equity gaps in terms of caste and wealth.

• Provide opportunity for introduction of microcredit enterprises of SHGs which pertain to food related agriculture and allied activities .Such activities are important measures when implemented by DAY: NRLM, supports in overcoming food and nutrition security at household level. This is critical since the two government departments in charge of improving MIYCN situation, implemented by the Ministry of Women and Child Development (MoWCD) through the ICDS or by the Ministry of Health and Family Welfare (MoHFW) through the National Health Mission (NHM), are not in-charge for addressing the problem of sustainable food and nutrition security. This gap can be bridged to a great extent by DAY: NRLM by directing micro-credit investment towards actions for increasing food production, availability and consumption at household level. Moreover, federated structure and solidarity of women member positively impacts the bargaining capacity of SHGs and VOs for various essential household items, specially food items.Economies of scale provides buffer for marketing changes.


• The coverage of essential nutrition interventions (ENIs) and health services (Table 2) is currently much below the goal of universal coverage. ENIs often do not reach women and children of the poor disadvantaged families. DAY: NRLM offers the scope to complement the efforts of the ICDS and the National Health Mission systems. Institutions of women under DAY: NRLM can bridge the gap by reaching the unreached families ‘at risk’ of undernutrition i.e. families having a pregnant women, children below 24 months or newly-weds (representing preconception stage).

• Women’s economic empowerment at individual and community level offers an opportunity to influence behaviour change and adoption of appropriate practices at family level pertaining to maternal, infant, child and family care for improved nutrition, health, hygiene and sanitation. SHG members empowered, trained and sensitised about their needs are envisaged to have confidence which is reflected in better control over resources and capacity to take household decisions for investing in family welfare, health and nutrition. Therefore, through SHGs, increased income of women can be influenced to be used wisely for the benefits of households.

• SHG offers a forum for entry point for social mobilisation and demand generation for a number of government entitlement schemes which address the underlying causes of undernutrition and are nutrition sensitive. DAY: NRLM/VOs are platforms that have the potential to inform community of their entitlements, leverage with other sectors and facilitate in operationalizing the existing policies and programs of the wide range of sectors besides health and nutrition sectors. This implies empowering SHG members with a view to create demand for their entitlements and catalyse multi-sector partnerships. SHGs thus can serve as a platform for addressing underlying issues of undernutrition and serve as a platform for convergence of inputs and services from a number of thematic sectors.

Table 2: Evidence Based Essential Nutrition Interventions

Pregnant Women Infants and Children Adolescent girls/ preconception

Proven Essential Nutrition Interventions

Antenatal care services including maternal nutrition care*

• Promote minimum weight gain 10-12Kgs#

• Iron folate supplements

• Calcium supplements

• Special supplements of fortified concentrated energy and protein to pregnant women below 45Kg

• Consumption of iodized salt*

• Provision of ICDS food supplements*

• Maternal deworming in pregnancy*

*Actions already a part of RCH or ICDS programme # Specific situational cases + being introduced

Source: The coalition for sustainable nutrition security in India, may 2014; DFID, 2010; Victora et al, 2008; Gragnolati, 2005

Feeding and care

• Promote appropriate infant and young child feeding

• Full routine immunization Biannual vitamin A supplementation and deworming*

• IFA supplementation programmes@

• Timely and quality therapeutic feeding for all children with severe acute malnutrition+

Anaemia and FLEd

• Weekly IFA*

• Biannual deworming *

• Family life education*

• Prevent early marriage and early pregnancy+


• Facilitate collective decision making against gender inequality within a community by mobilizing women for taking decisions on self and family care. Addresses the problem of gender issues such as early marriage, care of newly-weds in preconception stage, frequent pregnancies and domestic violence which negatively impacts on MIYCN situation.

• Federations of SHGs are legal entity and formal linkages with government departments as well as external stakeholders are feasible

The involvement of SHG women in livelihood activities also adversely impact MIYCN situation due to following reasons and these cannot be ignored:

• Increased involvement of women in livelihood activities may increase daily workload and reduce time available for child and family care practices. Such time pressure varies with seasonality of work.

• At times, due to mothers being busy, elder siblings especially girl child may be assigned the task of child care. Children in such situations may discontinue attending school and this in future would set up a cycle of poverty and undernutrition.

• Women’s time required for livelihood activities and for attending group meetings may reduce time as well as interest in availing of preventive health and nutrition services provided by the existing systems.

• Women very often have poor mobility and access to market facility. Despite being informed, women may not be able to influence the family food basket and largely depend on men members for food purchases.

3. State Level Experiences for Improving Nutrition Situation in a Community through SHGs of Women: Synthesis of Experiences and Lessons Learned

Prior to the launch of DAY: NRLM, there has been a movement of formation and support to Self Help Groups of women in India by a number of non-government organisations (NGOs). A number of NGOs have also used the SHG platform to address the problem of health, nutrition and WASH (Water, Sanitation and Hygiene). The international global programs built around women’s group reported from Asia are from Indonesia (Generasi Sehat dan Cerdas), Bangladesh (Shouhardo and Jibaon –o-,Jibika) and Nepal (Suaahara). Indonesia program reported positive outcome on health status of mother and children, reduction on nutritional deficiencies and increased educational achievements in poor families. Bangladesh programs reported reduction in severe underweight, reduced incidence of diarrhoea and decrease in anaemia prevalence rate. In Nepal, the outcome is reported in terms of process indicators with increase in trained volunteers, increase in open defecation free zones and increase in establishment of community gardens. (Olken et al, 2011, Tango international Inc 2009, Langworthy and Cadwell, 2009 and SUAAHARA)

In recent years, effort has been made by the State wing of DAY: NRLM (SRLM) to promote livelihood enterprises aimed at ensuring food security and improving sanitation activities through these community platforms. The launch of Mahila Kisan Sashaktikaran Pariyojana (MKSP) where women farmers are being systematically organised for integrated farm and allied activities is evidence of efforts of DAY: NRLM directed to food and nutrition security of the poorest of the poor families. An analysis of the state level SRLM experiences reveals that the following interventions are being implemented which are perceived to impact MIYCN or have the specific built in objectives to improve nutrition situation of women and children.

• Supply of hot cooked meals targeted to pregnant women is being implemented in some states (AP, Telangana, Bihar) ,managed by village organisations (VOs), with the beneficiaries (pregnant women) contributing almost a fifth of the cost of food. On the other hand, as a part of recent UP Nutrition Mission directive , SHGs are planned to be involved in a micro-credit activity of cooking and supplying hot cooked meals to ICDS beneficiaries. The latter include pregnant and lactating women and children


below 6 years who are entitled to supplementary food as a part of ICDS program. Education on influencing family level child and maternal feeding practices is almost nil .

• Production of a nutrition dense mix product as a livelihood microcredit initiative, for meeting the supply of “Ready to Eat” supplementary food for children 7-36 months who are beneficiaries the ICDS (Kerala-Kudumbashree). This has no component of improving child feeding practices of SHG members.

• Introduction of innovative measures such as “Food Credit Line”. This involves collecting information on households that are ‘cereal insecure’ and assessing total requirements at VO level to meet the cereal needs of the family. Based on the information, VOs identify suppliers, negotiate prices for bulk purchase and supply cereals at a cost lower than prevailing market price (Bihar, Maharashtra).

• Mobilisation of SHGs for availing benefits of subsidised food supplied through the Public distribution system (PDS). This is being implemented with community members being informed of their entitlement under the National Food Security Act (NFSA). In addition, some states have also introduced management of the PDS shops/Fair Price Shops by SHGs as a livelihood activity (Chhattisgarh and Bihar).

• Promotion of maternal-child care and WASH practices at family level. This is being undertaken through sensitisation of SHG members and convincing them through interpersonal and social mobilisation techniques as well as participatory approach (Bihar, Jharkhand, CORD project in HP and Nandurba District project in Maharashtra).

• Improvement in coverage of health, nutrition and WASH services, with special focus on ENIs in the first 1000 days of lives i.e. priority to families with pregnant women and children 0-24 months (Bihar and Jharkhand states).

• Introduction of livelihood programs which increases agriculture output, forest food produce or availability of vegetables and fruits such as through promotion of organic farming and low cost homestead gardening/kitchen gardening or by using rented or leased land by landless or marginalised farmers (Focus of MKSP initiatives in all states and also in the on-going SRLM activities as Joint Liability Group or JLG activity in Kerala,AP,bihar,Maharashtra).

• Provision of support for livestock/animal husbandry activities such as dairy and goat keeping, poultry and bee keeping etc. Most DAY: NRLM and all MKSP livelihood programs target women from poorest households who are often landless or are marginal farmers. These are not linked to efforts for increasing household consumption.

• Establishment of a system for implementation of various other measures which are underlying causes of undernutrition but are not viewed as nutrition sensitive or contributory causes of undernutrition. The most common interventions being implemented with sectoral support are intensive drives for building latrines and working towards ‘Open Defecation Free ‘ (ODF) villages, gender equity interventions including prevention of domestic violence and alcoholism, information on entitlements government schemes such as NREGA, JSY, IGMSY, health insurance schemes. These are addressed by sensitising and creating demands by SHGs/VOs for specific services for improving health, sanitation and social situation of community. These interventions are executed in collaboration with a number of government departments which allocate funds as well as technical support to VOs.

It is evident that with reference to nutrition improvement, the focus of SRLM initiatives has primarily been on improving income and also access to food at family level. These actions are crucial for improving food and nutrition security. However, livelihood programs pertaining to production of food items merely concentrate on production and marketing. Except for Bihar strategy and pilot project in Maharashtra, there is no input for improving consumption of food by family members of SHGs or by the population vulnerable to malnutrition comprising pregnant women, children 0-24 months and women in preconception stage/newly-weds. Only in the recent past, there is interest by states such as Bihar, Jharkhand and Maharashtra, for linking SHGs/VOs/


Federations with maternal-infant-child health-nutrition services being offered by ICDS and health sectors as well as in undertaking intensive activities for promoting appropriate health-nutrition-hygiene-sanitation behaviour practices. A few NGOs such as EKjut, Digital Green, Alive & Thrive are also partners who provide technical support in behaviour change communication (BCC) activities.

The fact that DAY: NRLM offers a unique opportunity for coupling specific nutrition interventions with measures which are nutrition sensitive and together effectively address malnutrition in the disadvantaged families need to be appreciated and accorded priority. Such an opportunity needs to be seized for designing comprehensive nutrition programs with the view that DAY: NRLM facilitates women’s involvement in multi-sector efforts for achieving WHA targets by 2025 (Box 1) and Sustainable Development Goals (SDGs) on hunger, food security, nutrition and sustainable agriculture by 2030 (Box 1).

4. DAY: NRLM: A Potential Platform for Coupling Nutrition Sensitive and Nutrition Specific Interventions for Improving MIYCN Situation

The National Rural Livelihood Mission (NRLM) is implemented through a network of SHGs of women and their federations, with especial focus on supporting women from disadvantaged poor rural families to come together for a wide variety of micro-credit livelihood enterprises. Therefore under the Mission, women are supported to be empowered with the objective to eliminate poverty as well as to be trained to be active informed members of the society. DAY: NRLM platform offers an opportunity to nurture a community centred approach that empowers women from disadvantaged households who are often not reached with economic security, knowledge, services and opportunities to effectively use resources to address their own health and nutritional needs and to take collective action to resolve community problems.

Recognising the potential of SHG platforms in accelerating malnutrition reduction efforts, poverty reduction and food security measures are proposed to be systematically linked to selected health- nutrition - sanitation initiatives. The goal, objectives and strategy for improving MIYCN situation is described below.

a. Goal and Objectives:

Goal: Through the DAY: NRLM forum of self-help groups of women and their federations, contribute in accelerating the rate of improving women, infant, young, child nutrition (MIYCN) in the community and contribute towards the achievement of the World Health Assembly (WHA) targets of nutrition in India by 2025 ( Box 1).

BOX 1

World Health Assembly (WHA): Six nutrition targets to be achieved by 2025

• 40% reduction of the global number of children younger than 5 years who are stunted

• Reduction in childhood wasting to less than 5%

• 50% reduction in anaemia in women of reproductive age

• 30% reduction of low birth weight

• An increase the rate of exclusive breastfeeding in the first 6 months to at least 50%

• No increase in childhood overweight

Sustainable development Goals (SDGs):

Target 2.1: By 2030 end hunger and assure access by all people in particular the poor and vulnerable situations, including infants, to safe nutritious and sufficient food all year around.

Target 2.2: By 2030, end all forms of malnutrition including achieving by 2025, the internationally agreed targets on stunting and wasting in children under5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.


Objectives:

The following objectives to be achieved by each of the Village Organisations (VOs) of SHGs in the first phase between 2016 -2020 and in the second phase VOs by 2025.

• Ensure at least 90 percent of women and children of SHG members have access to not only consumption of adequate energy providing food but to diversified food from at least five food groups for pregnant women and four food groups for young children.

• Facilitate and ensure reach and coverage of at least 90 percent newly-weds, pregnant women and children 0-24 months in the community, in collaboration with health and ICDS system, with the provision of the defined essential nutrition and health services, including supply and consumption of Iron Folic Acid (IFA) tablets to pregnant women.

• Promote appropriate behavioural practices and ensure at least 90 percent of families are aware and at least 70 percent adopt appropriate practices pertaining to maternal and child feeding, health and water-sanitation-hygiene practices for improving maternal nutrition and preventing stunting in children aged 0-24 months.

• Ensure 90 percent VOs are aware and are mobilised to demand the entitlement for nutrition sensitive government schemes from multiple sectors dealing with improved sanitation and latrines, safe water, reduce gender discrimination, education of women, delaying age of first conception, spacing births, reducing drudgery etc.

b. Nutrition Program Principles for the Formulation of the DAY: NRLM Strategy for Improving MIYCN:

As indicated in Fig 1 and table 2, the determinants of undernutrition and evidence based solutions indicate collective work by community as well as various sectors is required for accelerating improvement in MIYCN. The wide range of actions comprise interventions related to income generation, agriculture production and access to diversified food, adoption of appropriate maternal and child care practices as well as coverage with maternal-child health-nutrition-WASH services, women empowerment, gender equality as well as education of women. For involving women members of SHGs and their federations in appropriate care of families, especially women and children, the following facts need to be understood:

• Immediate determinant of undernutrition must be addressed. This comprises measures for increasing availability, accessibility and consumption of diversified food and prevention of infection and illness.

• Livelihood programs of SHGs address the underlying cause of undernutrition. These inputs must be combined with nutrition, health and sanitation care and services to make a difference in quality of life of rural women and positively impact on MIYCN situation.

• For prevention of undernutrition, interventions must accord priority to families of under- two children i.e. from conception to first two years of life or the first 1000 days of life. Evidence indicates that 90 percent coverage of the selected evidence based nutrition interventions (presented in Table 2) will reduce undernutrition by almost twenty percent. Available data reveals the coverage of these interventions is much below the desired universal level (Part II). Reaching the disadvantaged households remains a challenge.

• Promotion of appropriate feeding, hygiene, sanitation practices at family level and creating demands for services need to be intensified through implementation of appropriate behavioural communication (BCC) strategy. Use of appropriate BCC techniques for influencing practices is imperative. There is a need to focus on the entire package of behavioural change communication comprising advocacy, interpersonal communication, social mobilisation and use of local data for convincing community.


• Implementation of policy on micronutrient supplements such as IFA consumption by pregnant women and women in preconception stage including creating demands for IFA supplements and support to ensure supply of supplements. Additionally, ensuring consumption of only iodised salt by community members is crucial.

• Besides the above referred nutrition specific actions, coupling of these with nutrition sensitive interventions is crucial for improving nutrition scenario in the country. There is a need to address the issue of food and non-food resources which are the underlying causes of undernutrition and are nutrition sensitive such as food production, availability and access through the year, gender equality, women’s education etc. (Fig 3).

c. DAY: NRLM Strategy for Accelerating Rate of Reduction of Malnutrition in Women and Children: Livelihood cum Nutrition, Health and Sanitation (LNHS) Initiative:

A comprehensive “Livelihood cum Nutrition, Health and Sanitation (LNHS)” initiative is proposed with SHGs and their federations being the entry point for improving maternal, infant, young child nutrition (MIYCN) situation. The primary focus is on reducing poverty through thrift and credit mechanism for income generating activities and by synergising such inputs with other on-going government programs pertaining to health, food, nutrition and sanitation interventions. LNHS is not an alternative or stand- alone approach.

The proposed Livelihood cum Nutrition, Health, Sanitation (LNHS) initiative, is a holistic approach for simultaneously addressing immediate, intermediate and underlying determinants of undernutrition in women and children (Fig 4). The strategy of LNHS focuses on the following components- introducing measures for food and nutrition security at household level, supporting universal coverage of defined essential specific nutrition and health services by supporting the health and ICDS sectors, using the SHG network for promotion of appropriate family and community behaviour practices regarding health, nutrition and WASH actions. Additionally, care at family level as well as ensuring coupling of these direct specific nutrition interventions with nutrition sensitive inputs (Fig 4).

The strategy takes into consideration SHGs, VOs and their Federations at village, block and district levels as unique platforms for reaching women members in the community who are often poor, food insecure, not informed nor reached with maternal child health-nutrition entitlements or services. The strategy also recognises and builds on SHGs strength to collectively demand inputs of a number of government schemes which are nutrition sensitive and their intensification would add substantial value in accelerating rate of reduction of undernutrition or in improving maternal, young child, infant nutrition (MIYCN) situation. The strategy therefore stresses on use of SHGs and their federations as platforms for convergence of livelihood initiatives with nutrition, health and sanitation interventions as well as with other sectoral interventions which impact nutritional status of community, especially women and children.

While formulating the program strategy, the constraints that women members of SHGs face in terms of time and mobility have been considered. These constraints are presented above in section 2. Time of meetings need to be planned by taking care of the seasonal agricultural demands and of other activities. Moreover, poor mobility of women result in SHG members even if informed being dependent on men members of the family for purchase of food. Involvement of men in counselling or group sessions therefore is crucial and cannot be ignored.

The LNHS initiative is proposed to be rolled out at each VO level for achieving the stated objectives. For rolling out the strategy, informed women members of SHGs, using a participatory approach, will be supported in making a choice from the LNHS package of interventions presented below (presented under d). The principles of participatory approach, self-reliance and women empowerment will be central to prioritising the VO level actions which will then be implemented by SHG members and their federations. Each VO will select one ‘Parivartan Saathi’ or “change agent” (the nomenclature “health activists” is


proposed to be renamed as ‘ Parivartan Saathi’ which literally means ‘Transformation friend/Pal’ ) who will play the leading role in implementing the proposed interventions and will work with members of SHG network. The honorarium to be paid to the PS will be decided by VO. VOs will also be supported by the members of the Social Action Committee (SAC) and Health Committee. The use of vulnerability reduction fund (health risk funds and food security funds) will also be explored for effective implementation of the proposed interventions. The PS and VOs will work in close coordination with the health and ICDS sectors at village and block level.

VOs will also be the forum for creating demand for nutrition sensitive interventions and reaching out to sectors beyond ICDS and health. These are described below under the components of LNHS (see section d).

Progress will be monitored using a set of monitoring indicators (section 6). An award incentive scheme will be built for progressive achievement against the set indicators (section 7). The cash ward of INR 20,000 will be given to each VO to be used by SHGs as revolving fund on attainment of the set target for all the selected ten indicators.

Figure 4: Livelihood Plus Nutrition, Health, Sanitation (LNHS) Initiative

Reaching disadvantaged families in communities

Microcredit enterprisesReduce poverty Increase women empowerment

Nutrition Sensitive Interventions

Food & Nutrition Security Measures

Promote food related livelihood activities (sustainable agriculture,horticulture, dairy, poultry)

Improve access to PDS, MDM, ICDS food supplement

Establish Food Security Credit lineOrganise provision of cooked meals (target SC/ST clusters)

Converge : Nutrition In�uencingservices/ entitlement Water, sanitationGender equity Education of girl child, raising age ofmarriage/ conceptionFamily planning services

Nutrition Sensitive InterventionsFocus on families with pregnant women/

0-24 month child/ newly wed women

Reaching the “Unreached” with Speci�c Nutrition – Health Interventions in collaboration with health, ICDS, PHED

Infant and young child feeding

Maternal nutrition

Micronutrient supplement (IFA, Vitamin A)

Health services- Routine Immunisation, antenatal care, diarrhoea management, deworming

Management of severe acute malnutrition cases (SAM)

Intensify Behaviour Change Communication (BCC)Advocacy, IPC, Social mobilizationIn�uence family level practicesCreate demand for entitlements/ servicesPromote appropriate use of resources diversify food

Community Institutions (SHGs- VOs)

Accelerate improvement in MIYCN at VO level

2016-20 (1st phase) & 2020-25 (2nd phase)

Attainment of WHA nutrition goals 2025

Contribute


d. Key Components of Livelihood cum Nutrition, Health, Sanitation (LNHS) Initiative:

Taking into consideration the DAY: NRLM focus is on poverty reduction through microcredit enterprises and the fact that it reaches poorest of the poor, the following interventions will be strengthened or introduced and built on the on-going microcredit enterprise activities under the LNHS initiative (Fig 4).

i. Interventions to Improve Food and Nutrition Security: DAY: NRLM offer a forum to improve food and nutrition security through sensitising SHGs and their federations to (a) invest in agriculture and its allied activities such as horticulture, agroforestry activities as well as animal husbandry activities (b) promote measures for ensuring supply of dry ration to targeted household (c) improve nutrition knowledge among rural households to enhance dietary diversity through wise use of resources for enriching food basket and (d) invest in feeding of pregnant women belonging to targeted poor families.

i.1 Intensify Livelihood Activities for Improving Access to Food:

Community institutions of women are the nexus between agriculture and nutrition. In India, significant land distribution inequality is well known - nearly 80% of the people have only 20% land holdings, and only 9% rural Indian women own land even though 79% contribute as agriculture workers. In India, as in other developing countries, women play a central role both in growing food and in preparing food for their families. Agriculture activities and nutrition are inter-linked. Empowering women through agriculture and with information on how to wisely use food produced by family members can have an enormous impact on nutrition of the entire family. Under the DAY: NRLM, agriculture interventions are primarily directed towards supporting landless farmers or small land holding or marginal farmers for sustainable agriculture activities.. As a part of microcredit enterprise, the SHG members collectively take a land on lease (as a part of Joint Liability Group or JLG activity) or get a patch of common property land from panchayat for agricultural activities (pertaining to food or non- food activities) with a view to generate income. Through DAY: NRLM forum, introduction of micro-credit enterprises pertaining to food production through sustainable agriculture activity, vegetable gardens, poultry keeping, goat rearing and dairy keeping could be further intensified. MKSP initiative of DAY: NRLM focuses on these activities and need to be expanded.

In some states such as Kerala, establishment of vegetable gardens, goat raising, poultry and dairy keeping is often being implemented as a “Joint Liability Group” activity under the DAY: NRLM and being scaled up under the MKSP initiative of the Mission. DAY: NRLM focuses on these food producing microcredit activities, as a stand-alone livelihood activity. Food items produced are very often not accessible to households and are utilized primarily for marketing and income generation purposes. Food security and access to food is not enough. It is important that the SHG members involved in agriculture activities are encouraged to move beyond production and marketing of food produced to enriching family food basket. There is a need to ensure that measures are also taken to intensify not only diversified food production through the season but consumption of diversified diet at family level. SHG members therefore need to be made aware on how to wisely use part of the agriculture, horticulture, milk, eggs produce for improving nutrition of the family members especially those at the highest risk of undernutrition i.e. pregnant women, children 0-24 months and women in preconception stage. On the other hand, the SHG members also need to be informed of the benefits of improved nutrition on agricultural productivity and in turn on income generation (FAO, 2013).

For influencing utilization of food produced for diversifying family diet, SHG members and families need to be counselled (section 4 below presents details). An awareness campaign on use of vegetables in daily diet is crucial. Similarly, where culturally acceptable, consumption of animal foods, especially during pregnancy, infancy and early childhood needs to be promoted. SHG members


need to be informed that foods from animals such as meat, fish, poultry, milk and eggs provide protein with all the required eight essential amino acids and a variety of essential micronutrients (zinc, iron, vitamin A, vitamins B2, B6 and B12). These are difficult to be obtained from plant foods alone or a vegetarian diet with poor milk intake. Education efforts therefore need to be built into SHG led agriculture and allied sector interventions for enhancing consumption of not only seasonal vegetables but flesh foods and eggs where culturally acceptable.

Besides counselling, the marketing strategies could also be introduced within a community by the VOs to sell eggs and green vegetables produced to those families with a pregnant woman or a child 0-24 months at a price lower than open market price. Such a strategy of targeting on a special age group is supported by positive experience of Burkina Faso experience (Box 2).

i.2 Improve Access to Entitlement to Subsidised Food under the National Food Security Act (NFSA):

SHG members need to be informed and made aware of their entitlement under the National Food Security Act (NFSA). The NFSA focuses on four components i) under the targeted PDS, provision of subsidised cereals at the rate of 5 kg per person (at the rate of INR 2/Kg for wheat and INR 3/kg for rice) to 75 percent rural and 50 percent urban population. In some of the states, the state government have further reduced the price of cereals or modified PDS food baskets to include other food items such as pulses, sugar, fortified atta and iodised salt ii) under the ICDS program, universal coverage of all pregnant and lactating women and children 6-59 months with food supplements which as per the policy are expected to provide a third of all the nutrients iii) Mid-Day meals (MDM) for children in schools in primary and middle and iv) conditional cash transfer (CCT) scheme to pregnant mothers under the Indira Gandhi Matritva Sahyog Yojana (IGMSY) scheme. IGMSY is expected to be scaled up from 50 districts to 200 districts from 2016 onwards.

BOX 2

Burkina Faso Experience

The Enhanced-Homestead Food Program (E-HFP) in Burkina Faso was introduced by Helen Keller Foundation in 2010. The program used agriculture platform and targeted women with children 3-12 months of age to ensure that the program would directly benefit children within the first 1000 days window of opportunity. The Burkina Faso program do not focus on mere nutrition education but on “modified BCC strategy to promote adoption of key nutrition practices .It also empowered women by providing education on best agriculture and nutrition practices, transferring small agriculture assets and chickens to beneficiary women, and having village model farms led by beneficiary women (rather than male farmers living in villages.” (Olney et al, 2014)

A comprehensive evaluation comprising a longitudinal cluster randomized control trial as well as two rounds of qualitative process evaluation was undertaken. It is reported to be the first such evaluation for agriculture-nutrition program. The findings revealed that as compared to children living in controlled villages, there was increased dietary diversity, reduced prevalence of undernutrition (wasting and anaemia) and diarrhoea. In case of women beneficiaries, increased intake of nutrient rich foods and reduced prevalence of thinness was observed. The intermediate impact was attributed to increase in women’s ownership of productive assets such as agriculture and small animals, increased production of nutrient rich foods by women, improvement in knowledge of child care and feeding practices, increased dietary diversity and consumption of nutrient rich foods in households, improvements in indicators of women status such as their decision regarding purchases.

The E-HFP program is evidence that “a well -designed, well- targeted and well -implemented targeted program, including a strong nutrition and health behaviour change communication strategy and women empowerment activities can have a significant and possibly; long lasting impact on nutrition and health of mothers and children during the first 1000 days.”


Using the SHG forums, all women members could be kept updated on their entitlements to government schemes so that they demand and get a better response from sectors in charge of food supply or feeding related schemes such PDS, ICDS, MDM and IGMSY. Moreover, SHG members, involved in livelihood initiatives dealing with management of the Fair Price Shops (FPS) of PDS, could also work as resource persons at VO and block level for dissemination of information. Two states, such as Bihar and Chhattisgarh, provide good examples of SHGs being involved in micro-credit enterprise of running PDS schemes or fair price shops.

i.3 Establish Food Security Credit Line:

Food security (credit) line initiative is proposed to be introduced through SHG network to ensure poorest of the poor to have access to good quality dry rations such as cereal grains as well as, fats/oils and pulses. Details of the process of Bihar Aajeevika plan is presented in the Box 3 below.

Such an approach is expected to ensure food security throughout the year and also reduce the vulnerability of the poor households to market fluctuations in lean seasons. Such an initiative would also facilitate in reducing high cost debts of poor households while coping with crisis. Further, it would help to fill in the gap of cereals available to a family through PDS against actual requirements of the poor households.

i.4 Ensure Diversity of Diet at Household Level: Promote Simple Doable Actions:

Research indicates that an increased income gives people choices but it doesn’t guarantee that the choices made would contribute to improvement in quality of diet consumed. There is adequate evidence which supports the hypothesis “that women have different preferences over household consumptions than do men”. (UNICEF, 2015). Recent research by IFAD also concludes “Women are also more likely to invest additional earnings in the health and nutritional status of the household and in children’s schooling. Agricultural income in the hands of women is also reported to be more likely to be spent on their children’s health and well-being than is income controlled by men” (UK Hunger Alliance, 2013).

Women are also the major decision makers when it comes to food preparation and child care.

BOX 3

Food security Credit Line, Bihar

Food security (credit) line initiative being experimented in Bihar and also tried out in Andhra Pradesh offer an opportunity for the poorest of the poor to have access to good quality cereal grains throughout the year and also reduce the vulnerability of the poor households to market fluctuation. The process put in place involves preparing micro-plans to estimate food requirements of each member’s household after taking into consideration their agriculture produce, entitlement and receipt of cereals from the Public Distribution System (PDS). The plans developed at SHG level is put together to VOs. Food Security committee who gets the demand scrutinised by VO on receipt of application in the format approved by the Bihar Project Implementation Unit (BPIU). The application for 3-6 months food grain requirement is shared it with State BPIU loan committee for sanction of loan. The committee appraise the request, checks the regularity of VO meetings, repayment status of VO and proper maintenance of records. The Project Implementation Unit transfers the food security fund as one time revolving funds to VOs. Following this, Food security committee of VO after a market survey and negotiation makes a bulk purchase within 7 days from the time fund is received. The VOS determines the repayment instalment and period based cash flow of SHG members. The VOs receive the cereals in packages for ease in distribution on the same day as receipt of cereals. There is no storage. Margin cost is charged bot no interest is charged to SHG members.

Nandurbar district also initiated SHG linked food and nutrition security (See Box 7 for details).


They have a large role to play in improving family food basket, child feeding practices for better nutrition. This means targeting the women has a greater positive impact on child and household poverty reduction, measured in terms of nutrition, consumption and well-being. (IFAD, 2009) It is evident that by enhancing understanding, confidence and providing support to SHG members, women can be mobilised to choose a healthy diet for family and seek care or advice outside of their homes. (Prost et al, 2013)

The effect of income on family food basket is determined, to a great extent, by what is available through own produce or purchase, as well as cost, convenience, decision making roles, and multiple other factors (Herforth & Harris, 2014; ACF International, 2013). Furthermore, choices are also influenced by culture, social conditioning and status as well as families using extra income not on food but on luxury items or nutrition sensitive inputs such as obtaining health care, clean sanitation, education, shelter, fuel and other basics necessary for a healthy, productive life. It is therefore important to combine agriculture interventions or income generating microcredit enterprise activities with dissemination of information and launch of behavioural change communication (BCC) activities which would facilitate women in making appropriate food purchases.

Micro-credit initiatives linked to increase in food production activities or other livelihood initiatives therefore need to be actively channelized in improving nutrition content of family diet, especially of pregnant women and young children. Using the VO forum monthly meetings, women can be convinced to accord high priority to diversify their daily diets and not depend only on cereals. The significance of diversifying the diet with the use of minor modifications in daily food habits could be stressed on. It is important to inform SHG members that quality of family diet is crucial for maternal health, brain and physical development of foetus and cognitive and physical development of young children. This implies for example promoting simple traditionally acceptable measures for enhancing quality of family diet e.g. use of small amount of pulses along with cereals in every meal to enhance protein quality of food consumed, regular use of sprouted pulses for increasing vitamin C content of food which facilitates iron absorption and regular use of green leafy vegetables and other vegetables and fruits for enhancing micronutrient levels in diet. The importance of using such a diversified food basket for at least two daily major meals needs to be promoted. In case of young children 7-24 months, use of a minimum of four food groups are recommended while a minimum of five food groups are considered appropriate for meeting nutrient requirements of pregnant women. A simple method to communicate with SHG members the concept of food groups and food diversity in every meal, use of the term “Tiranga food ” (Tiranga refers to three colours of the National flag, comprising white cereals, orange/yellow pulses or flesh based preparation, green leafy vegetables and other vegetables) has been found useful.

With the escalation in the cost of pulses, community could be informed how to use the traditional practices of incorporating small amounts of pulses along with cereals in every meals for escalating protein quality. Traditional cooking practices such as use of low cost measures of mixing small quantity of ground pulses or besan with cereal flour for making rotis, use of dried dal mixture such as ”baddies” with vegetables, use of sattu (cereal-pulse mixture), idli, dosas, use of peanut or chana chikkies/brittle etc. need to be emphasised. Such ‘doable’ information for diversifying diet could be made a part of the behavioural change communication (BCC) activity described below (see section 4 iii below).

For meeting the micronutrient needs through diet, use of a variety of vegetables, pulses, seasonal fruits such as amla, lemons and vitamin rich green leafy vegetables such as ,coriander and drumstick leaves are considered important. SHG members need to be informed of the significance of consuming only iodised salt in daily diet since even diversified diet cannot meet the daily requirements of iodine from food since soil is depleted of iodine.


i.5 Organise Provision of Cooked Meals to Pregnant and Nursing women through SHG Initiative in Targeted Geographical areas:

Provision of hot cooked meals to pregnant women for improving maternal nutrition and birth weight of newborns are important SHG initiative being undertaken in the states of Andhra Pradesh, Telangana and Bihar. Box 4 below presents details of Andhra Pradesh experience of Nutrition cum Day Care (NDCC), the World Bank financed AP State Program on Elimination of Rural Poverty (SERP) Project, which is being implemented in the state since 2007.

An analysis of the NDCC indicates that targeted approach of the initiative with the beneficiaries contributing partially to the cost of meals led to community ownership of the scheme and also improved acceptability and ensured regular consumption of adequate energy, good quality protein food and micronutrients by pregnant women. The impact of NDCC on reducing low birth weight (LBW) has also been documented. However, sustainability of investment and breakdown in financial management is being questioned and remains a major a challenge. Moreover, provision of hot cooked meals is also viewed as an input which runs parallel to ICDS program and not as a support to ICDS program. The scope of expanding such schemes of providing hot cooked meals therefore needs to be studied systematically prior to scaling up NDCC model in other states. However, launching of such initiatives could be considered to be limited to those selected geographical areas with high degree of poverty and with poor reach of ICDS program. Such an intervention could be targeted to SHGs having poorest of the poor households comprising scheduled caste and scheduled tribe households. Additionally, feeding contacts of NDCC must be used for systematically undertaking BCC activities on MIYCN.

BOX 4

Andhra Pradesh : Nutrition cum Day Care Centres (NDCC)

Under the State Elimination of Rural Poverty(SERP) project, NDCC was launched since it was noted that women spent 56 percent of their income on health related issues. VO was considered a common platform to converge for outreach sessions, behavioural change communication, support for health emergencies, anaemia reduction. Key elements of NDCC being balanced three meal diets (with incorporation millets, sprouted pulses) combined with growth monitoring, community gardens and income generation activities by common interest groups (CIGs). (L.D Chava, Community managed nutrition cum Day care centres, SERP, AP).

Pregnant and lactating women were involved in CIGs and earned a monthly income of INR 40-50. Beneficiaries contributed INR 10 per day towards quality diet, and from CIG INR 10 while ICDS contributed INR 5, internal lending was INR 5 and VO contribution was INR 5. Meal cost per day being INR 35/day. Every month, a complete recovery of monthly expenditure of INR 10,920 against the expenditure of INR 10,436 (Building rent INR 400, fuel=800, cook’s salary=500 and meal cost INR 8736).

In 2007, there were 200 NDCCs which increased sharply to 4200 by 2011 while the total VOs were 6336. NDCC sustainability was facilitated by revenue generation, reduction of diet cost (With use of PDS cereals, community kitchen garden and use of coarse grains). Convergence was facilitated by government directives to ICDS, Health and NREGAs for inputs. NREGA support was in leasing land and for establishing vegetable community gardens.

In 2011, coverage of NDCC members with health services was almost universal with antenatal care, routine immunisation, institutional delivery, consumption of iron-folic acid tablets (60 percent consumed at least 90 iron tablets against 80 percent having received 90 tablets).

In 2011, the CM announced support for expansion from 4200 to 36,000 NDCCs in AP and Telangana combined. Following challenges were noted for such an expansion - more investment of time required in capacitating institutions, discussions with SHGs and development of sustainable CIGs at NDCCs as well as for convincing to appreciate the power of the “demand side approaches” by the line departments for replication.


i.6 Promote Production and Sale of Nutrition Dense Foods as a Micro-Credit Investment:

Investment of SHGs in production and supply of “ready to eat” nutrient mixture has been launched successfully in some states. These are good examples of income generating activities which are linked with the state government programs for marketing the product and in turn supporting state governments in operationalizing the supplementary food component of the ICDS scheme. However, such initiatives are not linked with interventions which would improve nutritional status of the women and children in the community.

One good example of such a state-wide initiative is from Kudumbashree (SRLM program in the state of Kerala) where women members of neighbourhood groups (NHGs) are involved in production of nutrition-dense food which is supplied as ‘Take Home Ration’ (THR) to ICDS programs for children of 7-36 months (See Box 5 below).The investment in production of THR yields adequate financial benefits. SHGs are able to operate with good profit margin and income. SHG members also learn the technique to hygienically produce, packet and market such food products.

BOX 5

Nutri-mix Units Kudumbashree, SRLM program of Kerala

Kudumbashree Program, meaning ‘Prosperity of family’, was initially launched in the state of Kerala as a state-wise initiative in 1998. In Jan 2012, this State Poverty Eradication Mission was designated as the State Rural Livelihood Mission under the DAY: NRLM. The State initiative emphasis is on convergence with local government and empowerment through social, economic and gender based processes. Community groups, referred as neighbourhoods groups (NHGs) comprise 10-20 women from the same locality. Each family represented by women and five volunteers in each NHGs. NHGs act as thrift and credit groups with savings being mobilised to meet the credit needs among members. These NHGs are federated at ward level into area development society (ADS) with 7 members executive. ADS federated into Community Development Society (CDS). Today, there are 2,53,414 neighbourhood groups with 40,17,530 women members.

Economic improvement comprises microfinance and livelihood interventions which are either group enterprises or individual enterprises. The food related initiatives include agriculture farming and allied activities such as horticulture including terrace farming, with the launch of MKSP, these activities have been intensified. Today there are 2.55 lakh women coming together in more than 54,000 groups to undertake agriculture activities in 1.25 acres of land. Convergence with local governments provides technical input, sector funding support, supply support, marketing avenues etc.

Establishment of “Amrutham Nutri-mix” unit is one group enterprise activities which produces “weaning foods” for children and was started around 2006 as a group initiative. Each unit, with 5-7 members, started with a bank loan of about INR 2- 4 lakh and with each beneficiary contribution of INR 10,000 to as high as INR 25,000 in some units. In one district, there are about 15-16 units. These units function from 10am to 5pm every day except Sunday. The financial management involves capital cost of Rs 2.5 -4.0 lakhs for roasting and grinding machines and recurring cost of about Rs 1.5 lakhs per month. The latter includes purchase of food items and

In 2016, the number of NDCCs is 2650 in 13 districts of AP. (Community Managed Health and Nutrition , SERP, , Department of Rural Development, AP). It is also reported that the numbers of functioning NDCCs are in fact are reducing in numbers since ICDS is currently strengthening the food supplement program in the state and has launched the revised scheme of providing one hot cooked meal. Discussion with mothers attending NDCC also revealed rather poor knowledge about appropriate infant and young child feeding practices. Currently, the sustainability of NDCC is also being questioned. This model needs be studied with reference to financial management and for restricting it to most disadvantaged tribal, SC and ST habitations where ICDS and health functioning coverage may be poor.


rental of the building for production and storage. The composition of nutri-mix is standardised and contains the following items in one kg of mix: Wheat=450 grams, Chana dal=150 grams, groundnut=100 grams, soyabean nuggets=100 grams and sugar 200 grams. Raw food items, except wheat grain (supplied by Food Corporation of India), are purchased from local markets. The cost price of the product is INR 45-46 kg and the selling price to ICDS is INR 56 per kg. Total amount produced is between 5000-6000 kg per month. Each of NHGs have paid back the loans to the bank. Each beneficiary earns around INR 10,000 to INR 12,000 per month.

Nutri-mix are packaged in half kilo packs for supply to ICDS. Unfortunately, printing of key child feeding messages on the colourful sealed package of “Amrutham.” which would have added value in dissemination of information on appropriate infant young child feeding is missing. Monitoring of the quality of product is done by inspectors of ICDS. Each unit pays INR 250 per month per batch for monitoring and about 7 batches are produced per quarter. Transport cost has been standardised and is paid by the Nutri-mix units which is reimbursed by ICDS department. ICDS workers also confirmed that the nutri-mix was also popular in children 3-5 years (In Kerala state, 5-6 years children do not attend ICDS centres). There is also effort to enrich the product with micronutrient mixtures .Kerala experience reveals that SHG members once trained can hygienically produce, package and market such products.

Besides ICDS supply, some packets of nutri-mix are sold to hospitals and also to families in the community at a higher price of INR 60 /kg. Some of the members also fed the nutri- mix to their own children but were not aware of benefits. None of the NHG members when asked were aware of why this supply was being made primarily for younger children. Mothers with young children were not aware of the correct feeding practices. Most mothers believed breastmilk was secreted only after 3 days, children cannot eat eggs up to one year, milk should be given along with breastmilk. Semi solid food should be introduced after 6 months and child could be give ragi and banana.

Under group loan schemes, dairy and poultry keeping has also been promoted as a Joint Liability Group (JLG) activity. For example for dairy keeping, group takes a loan of about INR 5 lakhs, INR 50,000 as state SLRM subsidy and INR 5000 as per beneficiary contribution. Similarly horticulture and agriculture activity However, the women and young children were not actively using the product for their family members. These were mainly economic activities.

Kerala state despite such economic growth indicates a high rate of child undernutrition than expected – 20 % stunting, 19 % underweight and 5 % severely wasted children. It is evident from the discussion with NHG members, CDS and ICDS staff that the information on key child feeding and maternal care practices is not known nor followed. The scope of integrating inputs for influencing family level maternal and child feeding practices, with special focus on 1000 days of life (pregnant women and children 0-24 Months) remains a concern and a challenge. Awareness campaigns on appropriate child feeding practices as well as on use of diversified diet with inclusion of vegetables and flesh food in daily diet deserves attention. Discussion with NHG, ADS and CDS members confirmed the need and interest for integrating health, nutrition, sanitation interventions with livelihood initiatives, especially those micro-credit enterprises which focussed on food and nutrition security initiatives under the micro-credit enterprises.

As state level, such linkage of DAY: NRLM microcredit activity with ICDS could be institutionalised for supply of THR not only for children but for pregnant and nursing women. In addition, SHG groups could be supported to produce and market such nutridense “ready to eat” products through the PDS network not only for ICDS but for supplementing the home diet of pregnant women, children,elderly family members, school going children as well as adolescent population. Availability and consumption of such nutrient dense foods will facilitate in closing the vast gap in the recommended energy and nutrient requirements and the actual intake. Such a micro-credit activity should also be viewed as


an opportunity to educate members of SHGs on appropriate child and maternal feeding practices. Unfortunately, in Kerala, nutrition education component or BCC activities on nutrition is missing. Introduction of simple measures such as printing key messages in local language on the food package, holding discussion with SHG members and VOs on diversifying family diet for nutrition care of women and children are important and needs to be linked to microcredit activities of SHGs.

ii. Ensure Universal Coverage of Essential Nutrition Actions: Establish linkage with ICDS, Health, and WASH Sectors: As described earlier (Part II), cent percent coverage of women and children with evidence based essential nutrition interventions (ENIs) is crucial for addressing undernutrition (Table 2). An analysis of current data indicates a wide gap in actual and targeted universal coverage of these services (Fig 5).

DAY: NRLM, through the SHG groups and their Federations, could play a supportive role in bridging

the gap by reaching the unreached women and children. Trained Parivartan Saathi (PS), with the help of SHG members and frontline workers of ICDS and health, could map all families having a member who is any of the following categories - women in pre-conception stage who are often newly- wed women (defined as those women married for maximum two years and no children), pregnant women or 0-24 months child. In this context, PS needs to be trained to reach such families, including disadvantaged families of scheduled cast and scheduled tribe.

Once identified, the PS could be trained to take special care to ensure regular attendance of pregnant women and children to monthly village health nutrition sanitation days or VHNSDs (Box 6) for various maternal child health services (routine immunisation and vitamin A supplementation, antenatal care (ANC) services including weighing of pregnant women, IFA and de-worming) and ICDS services (supply of food supplements including provision of Take Home Ration or THR, counselling on child and maternal feeding, as well as assisting ICDS workers in the referral of cases of severe underweight). Through VOs and PS, community could also be informed of the dates of VHNSDs and biannual fixed months vitamin A campaigns and in mobilising all children 9 months to 5 years for six monthly administration of vitamin A supplement and deworming doses.

100

90

80

70

60

%50

40

30

20

10

0

IFA during pregnancy

Food supp. (pregnancy)

EIBF

EBF

Intro to CF

Food supp. (children)

Min. meal frequency

Min. diet diversity

ORS during diarrhea

Immunization

Vitamin A

Pediatric IFA

Deworming

Rapid Survey onChildren, 2013 - 2014

ENI-related indicators

Fig 5 : Current Coverage of Essential Health & Nutrition Services and the Gap to reach the Goal of Universal Coverage


BOX 6

Village Health, Nutrition, Sanitation Days (VHNSDs)

VHNSDs, under the NRHM, provide maternal-child health services at village level as well as disseminate information about rights and entitlements related to health, nutrition and sanitation.(http://nrhm.gov.in/images/pdf/communitisation/vhsnc/order-guidelines/vhsnc_guidelines pdf). All frontline workers of health and ICDS converge on VHNSDs and together provide an agreed package of maternal –child health and nutrition services.

Discussion on rights and entitlements of community is also recommended to be part of routine VHNSD activities (Tripathy et al, 2016). Though ASHAs enable in increasing the contact with women and children in the community, there are families who routinely do not participate on VHNSDs .Reaching and mobilising such families could be supported by SHGs and their Federations. These women SHG members and PS along with ASHAs of health sector could mobilise the most marginalised women by organising participatory group meetings at a time decided by women themselves in remote clusters or hamlets where the poorest live. This would enable ASHAs, with support of SHGs, to ensure provision of services to those women and children who need special attention and care.

For improving coverage of the specific essential nutrition services as well as maternal-child health services, the PS would be required to not only collaborate with the two primary sectors-health and ICDS frontline workers for services delivered but would also need to focus on creating demands for these services and convincing the beneficiaries and community to avail of these services. VOs could also be involved in counselling families of severe acute malnutrition (SAM) cases to visit Nutrition Rehabilitation Centres (NRCs) and follow up the care of children discharged from NRCs.The latter would require designing and implementing an effective behavioural communication strategy (details in section iii below).

With reference to maternal undernutrition and anemia, there is a need to strengthen not only counselling but also ensure regular supply of IFA tablets.DAY: NRLM offers a scope to involve women in supply of such supplements to not only targeted pregnant and lactating women beneficiaries but to all women in the reproductive age. SHGs and their federations could be sensitised to invest in measures for addressing the problem of anaemia and by resolving the problem of irregular supply of IFA tablets by the health department. Innovative strategies could be adopted by VOs for procuring and purchasing IFA tablets at a negotiated cost from open market and mobilising SHG members to purchase the IFA supply and motivate women to consume these. As indicated below on behavioural change communication (BCC), communication strategies need to be well planned and executed with emphasis on benefits of IFA consumption and not only with stress on adverse effect. The significance of regular consumption of IFA for addressing anaemia, improving productivity, and preventing serious invisible adverse effects such as damage in brain development of foetus, birth weight of newborns, physical growth and cognitive development of children in the first two years of life need special emphasis.

For prevention of Iodine Deficiency Disorders (IDD), community need to be not only informed but need to have access to iodised salt (with minimum 15 ppm). VOs therefore could play a central role to ensure village grocery/kinari shops procures and sell only iodised salt. As per the directives of the Prevention of Food Adulteration (PFA) Act (now known as the Food Safety Standards Authority of India (FSSAI), sale of non-iodised salt for edible purposes is illegal and is a punishable offence. Retail shop keepers , if not following the FSSAI standards , can be jailed for at least 6 months. VOs therefore need to be sensitized of the legal clause and of the implications of not consuming iodised salt on brain damage, lowering of IQ levels of school aged children etc.POs could be guided and supported to procure rapid salt testing kits (costs about INR 25 per kit and can test about


100 samples of salt) and test salt samples from village retail shops. Such a testing, as per the past experience will discourage procurement of non-iodized salt by retail shopkeepers. (Vir et al, 2007)and ensure availability of iodised salt to community.

iii. Strengthen Behavioural Change Communication (BCC): influence Family Care Practices and Create Demands for Health, Nutrition and Social Services/ Entitlements: A systematic review of four countries including India between 1991-2011 reveals that participatory learning and action among women’s group is a cost-effective process which contribute to about 37 percent reduction in maternal mortality and 23 percent decrease in neonatal mortality. (Wu et al, 2012) Studies from Jharkhand and Odisha have indicated that “ASHAs can successfully reduce neonatal mortality through participatory meetings with women’s groups. This is a scalable community based approach to improving neonatal survival in rural, underserved areas of India.” (Tripathy et al, 2016) The significance of participatory approach is evident.

In the past few months, nutrition projects with focus on BCC have been rolled out in selected states of SRLM–Swabhiman project being implemented in selected blocks of Bihar, Odisha and Jharkhand and another Nutrition pilot project in Nandurbar district of Maharashtra. MKSP project is also being used as a platform for BCC activities on MIYCN.A good example is an NGO (CORD) working in selected blocks of Kangra district of Himachal Pradesh .All these three projects aim at influencing behaviour practices through health and nutrition counselling sessions in groups and at family level (Details are presented in BOX 7).

BOX 7

Swabhimaan (Bihar, Chhattisgarh and Odisha), CORD (MKSP) HP, Nandurbar district (Maharashtra)

Swabhimaan Project

The project Swabhimaan (2015-18) was launched in selected blocks of one selected district in each of three states (Bihar, Chhattisgarh and Odisha) with UNICEF support. The project uses the village organisation platform to improve maternal nutrition. The innovative project was launched in Kasba and Jalalgarh blocks, Purnia district of Bihar state in collaboration with Departments of Health, PHED, Civil Supplies and social Welfare Collaborative. The rationale of the project being in poverty pockets as high as 50 percent stunting in children occurs in womb. Pre-pregnancy nutrition and nutrition in the first trimmest are crucial and impact birth weight and length. There is need to address four contributing factors—poor diet, quality, quantity, anaemia and micronutrient deficiencies, poor access to health and family planning services and poor access to water and sanitation commodities. In this context, involvement of Jeevika as accountable implementing institution with other sectors was considered critical for addressing women’s diet, family planning, WASH. The three pronged strategy comprised the following at VO level --integration of food security-quality of diet with health, WASH and family planning services, strategy focusing on demand generation, livelihood security and women empowerment. The target groups being adolescent, newly-wed, pregnant and lactating women.

Kasba and Jalalgarh has 108 census villages with 24 Panchayats. Of these 104 villages haveJeevika intervention with 2809 SHGs, 170 VOS and 4 Cluster Level Federations (CLFs).The expected outcome being universal coverage of five essential nutrition interventions (ENIs), new programme (for newly wed women, adolescent girls and undernourished women) as well as introducing nutri-farm options for agriculture producer groups. The organisations implementing the program comprise UNICEF for technical inputs, AIIMS-UCL for surveys and Ekjut plus LIVING Farms for capacity building. UNICEF is supporting establishment of a nutrition unit at state level, state and district consultants, block consultants, one Swabhimaan Supervisor for 5 VOs and one Poshan Sakhi per VO and one Kishore sakhi per VO. POSHAN micro-planning, community mobilization through facilitated participatory learning with support of Ekjut is planned. Envisaged interventions by Jeevika being monthly meeting by Poshan Sakhi on selected subjects, identification of nutritional risk women with MUAC less than 21 cm and special care package (weekly home counselling, Ann Daan (grain charity), supply of nutrition snack,


special inputs for newly wed by VOs, (weekly home visit for at risk women, monthly group counselling, special reproductive health camps and linkage with agriculture university. Activities by health department include besides routine maternal health services, organisation of a six monthly special women health camp. The input of PHED is to include the Project blocks in Open Defecation Free (ODF) plan of the state. ICDS department has been requested to provide double ration to Women with MUAC lower than 21 cm. The geographical phasing planned is coverage of 71 VOs in 2016, additional 70 VOs in 2017 (total 141 VOs) and cent percent 170 VOs coverage in 2017. Output indicators is planned to be monitored by Swabhimaan through specially designed Swabhimaan software. The evaluation design has been finalised in early 2016 and was followed for conducting of baseline survey.

CORD (MKSP) Project

In 2016, CORD (Chinmaya Organisation for Rural Development) based, on experience of MKSP project which commenced in 2014, is extending the initiatives in villages in a Rait block of Kangra district The project include about 500 marginal and small women farmers (selected from CORD’s facilitated Women Groups known as ‘Mahila Mandals’ (MMs)) who are being organised into 40-50 WFGs (Women Farmers Groups) and 6-7 PLWFGs (Panchayat Level Women Farmers Groups). Inclusion of poorest of poor (POP) women farmer beneficiaries based on socio-economic status and those who are marginalized is the focus. These include SC/ST/OBC, below poverty line families, and persons and families with disabilities, single women, divorced/widowed women and women headed households. These women farmer’s families are small and marginalized farmers with most of them having land holdings of less than an acre. The selection of the poorest of the poor targeted beneficiaries is being done through active participation of the communities and Mahila Mandals.

The women farmers are being supported to collectively institutionalize themselves to form an assertive forum for recognition and empowerment; not only in the field of production of agriculture and allied produce but also to enter the market as a potential, empowered entrepreneur. A total of 6-7 community resource persons or CRPs, who are selected women farmers from Panchayats (one per Panchayat for the farm activities and the other for health and nutrition activities from the local communities), are acting as mediators between PIA (Project Implementing Agency) and women farmers for better implementation of agriculture related activities. The project is directing its effort to establish a critical mass of visible empowered poor, marginal and small women farmers, who are being actively supported to focus on their own development and livelihood promotion and health and nutrition requirements.

The learning from the MKSP is being used by CORD to diversify food production to include protein and fats in poor people diet by training of women farmers on pulse and oilseeds production technology and laying pulse and oilseed demonstrations on farmers’ fields as additional inputs required to meet balanced diet needs of the poor households. Moreover, the project includes an innovative component for improving nutritional and health inputs for the vulnerable women and child populations. Families with pregnant and lactating women and those with children under the age of 2 years will be given special attention. There will be increased focus on the food and nutritional requirements of the farmer households to ensure holistic development of the farmers as well as their households.

Nandurpur District, Mahrashtra State: Nutrition pilot Project

Nandurbar District Nutrition Project, Maharashtra: The pilot project is being implemented in 27

VOs in three blocks of the district –Shahada Block (5 villages, 62 SHGs , 626 households), Dhadgaon block (10 villages,99 SHGs ,1077 households) and Akkalkuma block (10 villages, 58 SHGs,600 households). Additional 16 villages are being added making the total coverage of 41 VOs. The focus of this pilot project is to ensure food and nutrition security at household level and improve access to existing health facilities. An MoU has been signed between Maharashtra State Rural Livelihood Mission (MSRLM) or UMED and Rajmata Jijau Mother and Child Health and Nutrition Mission(RLMCHNM).TATA trust is also operating in the district with focus on identification and management of SAM cases by supplying and counselling on use of high nutrient dense paste (M&T 100grams sachets).


The project focuses on reducing IMR, MMR and low birth weight babies. The project strategy focuses on health and nutrition awareness creation through SHGs and VO meetings. The strategy is to identify a common resource person (CRP) who reach women in difficult areas for conducting group discussions and counselling sessions. These CRPs have been trained by trainers comprising master trainers (a team of UMED staff, ICDS supervisors and block medical officers) and UMED staff. Focus of program and training is on the following themes –women and health nutritious food and health of women, anaemia, health and development of adolescent girls, menstrual health, care during pregnancy, newborn care, breastfeeding, child nutrition, specific contraceptives, WASH, diarrhoea and pneumonia management. Besides counselling, health camps are organised at VO levels for assessment of haemoglobin level and treatment ofanaemic women, assessment of women’s nutrition through BMI measurement and counselling on diet, identification and referral and care of SAM children and in family planning through appropriate measures. Counselling sessions with women highlight how good health and nutrition can improve productivity, saving and break the cycle of poverty and malnutrition. Community is trained in establishment of kitchen gardens and in appropriate use of ICDS food supplement, Demonstrations are organised for effective training.

An innovative strategy for food and nutrition security entitled “ Ann Surkashana Yojana” (ASY) has been launched and have yielded positive results. A case study of an SHG in Gallottagaon , Akkalkuwa block, indicates that the SHG was formed almost three years back with support of SERP staff. The ten SHG members noted that the primary demand for loan was for household essentials such as food and soap etc. The group then launched the ASY scheme. The SHG member proved their “maturity” and good grade against Panchsutra index so that they group was in a position to be entitled to community investment fund. Each of the SHG members estimated the household requirement for food items (rice, dals, oil, spices and vegetables) and soaps for a period of three months. The group did a market search, identified the source and estimated the budget for the total purchase at a negotiated cost. The cost estimate for the first three months was estimated to be RS 44,670. The plan was submitted to VO and approved for sanction of CIF. Repayment loan was decided at one percent interest. To date, using CIF, such assessment and purchase has been made undertaken four times and the requirement for funds has decreased steadily—1st round 44,670, 2nd round 30,00, 3rd round –Rs 25,000 and 4 th round Rs 19,000. The SHG plans to go through one more round and then close the purchase with a plan to collect funds and return the total CIF amount to VO. VO would then use the CIF for another proposal from another SHG. The SHG members seemed happy with the food security achieved at household level. SHG members also got involved in various income generation activities since there was no constant stress of meeting the food needs. Today, in fact, one of the SHG members has opened a grocery shop in the village to sell the daily food items in the community and has learnt the skills of managing such a shop.

Two following BCC initiatives noted to have been effective for improving MIYCN situation are Alive &Thrive and Digital Green (Alive and Thrive, 2015, Digital Green 2015) strategies. The Alive &Thrive strategy (Fig 6) was noted to be effective in Asian countries. For example, using the strategy, child feeding practices in Bangladesh improved significantly between 2010 and 2014 – exclusive breastfeeding increased from 49 percent to 88 percent while timely introduction of complementary feeding increased from 46 to 98%, minimum dietary diversity (4 or more food groups) increased from 32 to 64% and minimum meal frequency from 42 to 75 percent. Digital Green is another strategy which uses “Pico” projector and has been used effectively for intensifying agriculture activities and is now being applied for influencing MIYCN activities. Digital Green has been designated as the national support organisation for DAY: NRLM.


Figure 6: Evidence Based Behavioural Change Communication Strategy Framework of Alive and Thrive

Participatory approach combined with core strategy of “Alive and thrive” could be operationalized through linkage with SHGs and their federations as well as ICDS, health and PHED sectors with the support of PS. For development of an effective BCC strategy, assessing local barriers to appropriate practices and using the information for planning actions, are crucial. It is therefore important that prior to planning BCC state strategy, effort is made for undertaking a state based qualitative study on maternal and child feeding and care practices. Additionally, at VO level, a rapid Participatory Learning Assessment (PLA) exercise could be undertaken with a view to reconfirm the local barriers to roll out LNHS strategy for improving the MIYCN situation. Such a PLA exercise is proposed to be undertaken by PS with the support of VOs.

Through an effective BCC strategy, DAY: NRLM can provide a forum to address a wide range of issues pertaining to improving care in the first 1000 days of life as well as creating demands not only for health, nutrition, sanitation services but for government schemes. Schemes like Swachh Bharat Mission, Jan Dhan Yojana, NREGA, Food Security Act and the Public Distribution System (PDS), Janani Surkasha Yojana (JSY) linked to institutional delivery, IGMSY or Indira Gandhi Matritva Sahyog Yojna, Jan Dhan Yojana, Insurance Scheme for Farmers, Beti Bachchao Beti Padaho, Mid-Day meal in schools can be linked. Social mobilisation activities therefore need to also focus on the wide range of government schemes and entitlements which address the underlying causes of undernutrition and are therefore known to be nutrition sensitive. Community members can be informed of the significance of these schemes on overall development of community including on MIYCN situation and their significance on overall development of community, including MIYCN. PS with the support of block coordinators, therefore can be trained to conduct discussion on such specific schemes as well as MIYCN in monthly group meetings of VOs.

Women Nutrition

Life Cycle : Critical Periods

Inadequate pregnancy care Poor child care (0-24 months) Neglected adolescent care Poor care preconception/ newlyweds

Increase in IUGR rates

Poor birth outcome Adverse e�ect on Optimum growth-largely irreversible

Reduction in material size, short stature (low heigh/BMI)

Optimum growth constrained, anaemia

Optimum weight gain hindered, anaemia

Increase in LBWs

Higher prevalence rate of stunting

Alive and Thrive statergy framework framework For scaling up Action

INTERPERSONAL COMMUNICATION& COMMUNITY MOBILIZATION

4

Improvedhealth

outcomes

1 ADVOCACY

3 MASS COMMUNICATION

STRATEGIC USE OF DATA

2

Partnerships & alliances in the health systemand other sectors for scale and sustainability

Improved knowledge

bene�tsskills and

environment

Improved breastfeeding &complementary

feeding practices

Policy Makers & legistators

Employees Studys of Multiple Sectors

Service Providers & Community Leaders

Family Mother Caregivers


Table 3: Monthly Themes for BCC Activities

Monthly Meeting of VOs Themes

January Open Defecation Free (ODF), Respiratory problems in children and health

February Jan Dhan Yojana /Preserving nutrients while cooking, seasonal vegetables and their preservations personal and environmental hygiene while cooking

March Mid-Day meals, Preparing a diversified diet for family using local resources, Feeding diversified diet to pregnant women and children 6-24 months, Importance of three types vegetables in daily diet, Importance of using a good source of protein

(dal/besan/bari or with the use of eggs, milk and flesh food) with cereals for improving protein quality

April NREGA, Use of leafy vegetables, other vegetables, potato or other root vegetables

May Swachh Bharat environmental and personal Hygiene, Washing hands after defecation, prior to cooking and prior to eating, Preventing and care during diarrhoea

June JSY, Establishing kitchen gardens

July Public Distribution System, entitlement to ICDS food Supplement and Mid -Day Meals

August IGMSY, Organising breastfeeding week

September NREGA, organising Nutrition week –using family resources for diversified diet

October Agriculture schemes, Nutrition consideration in agriculture, IDD Day

November Anaemia and Maternal care, Benefits of IFA, Preventing anaemia, IFA tablets –daily usage, government supply, investing in purchasing IFA tablets

December Beti Bachao, Beti Padhao Scheme/State Schemes to promote Girls Education/ Preventing early marriage and Conception below 18 years of age

iv. Address Nutrition Sensitive Issues: Collaboration with Multi-sector Partners: It is evident from the determinants of undernutrition that a rapid, significant and sustainable impact on improving nutritional status of women and children, to a great extent, can only be achieved through active collaboration with sectors which are normally viewed to be not related to nutrition programs. These include interventions pertaining to underlying causes of undernutrition such as reduction in poverty, increasing access to food through agriculture/agroforestry/horticulture and other allied activities, safe drinking water, improved sanitation, promoting school completion by girls, reducing gender discrimination in family care practices, preventing early marriage/conception as well as reducing domestic violence, physical drudgery, exposure to malaria etc. For addressing these nutrition sensitive issues, a number of government schemes are in operation and some of these schemes pertain to care of disadvantaged tribal and scheduled caste population. As stated above, it is evident that demands for these entitlements need to be generated by informing the SHGs and federations of their entitlements through monthly meetings. For timely response to these demands, collaboration of VOs with block level representatives of various sectors as well as PRIs is crucial.


The above referred convergence and partnerships with a number of government services and scheme is within the policy framework of DAY: NRLM. SRLM programs of Kerala and Andhra Pradesh states have demonstrated how SHGs can play a central role in creating demands for such multi-sector services and in ensuring commitments of funds and timely technical support from the various sectors. DAY: NRLM can therefore be used as a platform to address a wide range of nutrition sensitive issues and facilitate in complementing these nutrition sensitive efforts with inputs planned for universal coverage of selected nutrition specific actions (Fig 1).These inputs need to be targeted to families of under twos (appropriate infant and young child feeding, IFA tablets for pregnant women and adolescent girls, biannual vitamin A, maternal nutrition, iodised salt consumption, and care of children suffering from severe acute malnutrition).

Advocacy by SRLM with the concerned selected sectors at state, district and block level as well as with PRIs regarding the benefits of using VO forum for effective planning and delivery of various services is desirable for improving IYCN situation.

5. Operationalization of the Livelihood Cum Nutrition, Health, Sanitation (LNHS) Initiative

a. Operational Strategy-LNHS Initiative: Taking into consideration the significance of nutrition, health, sanitation, hygiene in impacting the nutrition situation of women and children, the LNHS initiative (figure 4) is proposed to be implemented not in isolation but as an integrated part of the on-going nutrition, food security, health-sanitation activities led by various sectors. The functioning of VOs is considered crucial for initiating action since only if communities are empowered to take collective decision, they can actively participate in the development and implementation of context specific solutions.

The LNHS initiative is proposed to be rolled out in two phases- first phase 2016-20 and second phase 2020-25. In the first phase, states such as Kerala, Bihar, Telangana, Maharashtra, Andhra Pradesh and Odisha where the SHG network is well established/matured, with village organisations (VOs) in place, will be covered block-wise in a phased manner and thus scaled over to cover the entire state. High priority is also proposed to be also accorded to launch the LNHS initiative in blocks where MKSP project is in operation since food and nutrition security is the central livelihood activity in such projects. In the second phase, the initiative will be expanded to other states where VOs are gradually being established. By 2020, The LHNS initiative is proposed to be scaled up in the remaining states.

The LNHS implementation plan is recommended to be prepared and driven by VOs with the support of PS (Fig 7). PS would be paid a nominal honorarium by SHG members (as already being done in Bihar, Andhra Pradesh and in pilot projects in Maharashtra). The use of health-risk funds, food security funds and other resources available to SHGs through various sectors for health and nutrition services and entitlements would also be discussed by VOs to facilitate in the planning process

Each VO can develop a micro-plan of action with PS being supported by project block coordinators and block federation members. The components considered crucial for development of micro-plan is described below under section b.

For developing the VO level plan, the following tasks can be led by PS (i) rapid “Participatory Learning Assessment” (PLA) exercise with SHG members. (ii). undertaking mapping of households in the VO community with pregnant women, children 0-24 months and newly-weds Such a data bank once prepared through mapping would be encouraged to be also shared at VOs meeting and to be updated every three months with inputs of VO members (iii) sharing the map with AWWs, ASHA or ANM and in consultation with these frontline workers identify those households not receiving services (iv) within LHNS approach (figure 4 and described below under b) Prioritising actions based on PLA and mapping exercise (v) Development of a VO level plan of action and finalising the plan in consultation with VO members.

PS would be supported by project block coordinators and block federation members in undertaking rapid


“Participatory Learning Assessment” (PLA) exercise with SHG members. The focus of PLA will be on LNHS approach components described below under b section. Based on feedback of PLA exercise, PS and VOs would be assisted by Block Federation and Block coordinators in prioritizing actions and in developing a VO level plan with defined annual targets. The proposed strategy for rolling out LNHS initiative along with the comprehensive plan developed is proposed to be discussed with women’s institutions at block federation level with a view to ensure ownership of the plan by VO.

Following development of a micro-plan, for each sectoral theme, a sector mobiliser can be selected by VO for coordinating with sector representatives for a specific theme other than health and nutrition. Mobilisers will be selected on the basis of requirements evident from design of the VO micro-plan and its operationalization. Not more than three-four sector mobilisers will be selected and made in-charge of specific 1-2 selected sectoral activities e.g. one sector mobiliser for agriculture/horticulture activities, another mobiliser for water-sanitation and a third mobiliser for resolving gender issues. The tasks of these mobilisers would be primarily to link the VO members with the concerned sector at block and lower level and organise timely technical support and the estimated budget allocation required. These sector mobilisers will also receive an honorarium for coordinating with the concerned block officers. PS will coordinate with the sector mobilisers and will be the primary representative of VOs for putting in operation the LNHS initiative.

The block and district coordinators (Fig 7) along with the group of young professional at state level, appointed as a part of the State Project Unit for of the SRLM, can provide training and capacity building inputs as well as technical, supervisory and implementation support to the PS, VOs and SAC members. Involvement of ICDS and health managers as trainers and frontline workers of ICDS (AWWs) and health (ASHAs) as trainees, who are also active member of the SHGs/VOs, will be ensured by the area coordinator or cluster coordinator towards effective rolling out of the VO plan of action (Fig 7).

A communication issued by the state government to various departments can facilitate in establishing such linkages of SHGs and their federations with the concerned nutrition sensitive sectors and PRI. This communication will also emphasise on the impact of such demands by VOs in accelerating actions by various sectors in execution of planned tasks and timely utilisation of allocated sectoral budget.

Advocacy of government functionaries and project staff will be organised at every level –from state to area coordinator level. The VOS would also be sensitised to the proposed LNHS initiative along with the rationale for making efforts to improve MIYCN situations. The rationale, the benefits, the LNHS initiative could be advocated at these levels. The significance of according highest priority to pregnant women, children 0-24 months and newly-weds also needs to be highlighted. Advocacy will also aim at breaking the myth that inputs for improving food security per se are sufficient to address the problem of malnutrition. The need to simultaneously address the immediate, intermediate and underlying causes of malnutrition will be stressed and the unique opportunity offered by VO forum to combine specific nutrition interventions with nutrition specific interventions will be highlighted. In addition, the significance of coupling the inputs of the nutrition specific actions with nutrition sensitive interventions through VO forum would be emphasised.

For undertaking systematic advocacy, an advocacy package would need to be developed at national level for adaptation by SRLM. It can be ensured that advocacy stresses on implications of malnutrition on reducing poverty, increasing productivity and income generation as well as in improving health status and education performance of children. Such advocacy may be essential to bring the various sectors and functionaries to a common understanding of the LNHS initiative. An effective advocacy will create demand and will seek inputs from district and block federations for getting the required timely inputs from departments of health, ICDS, PHED, agriculture, horticulture etc. Advocacy also can highlight the role of women members of SHGs in working in partnership with existing government programs for addressing undernutrition and for achieving the objectives at VO level. The indicators, presented in section 6 below, will be used for monitoring progress.

Tracking of progress (see section 6 below on tracking progress indicators) and reporting on progress will be the responsibility of VOs and the Block Officer of SRLM in-charge of health-nutrition-sanitation activities.


A framework for the capacity building /training plan as well as training modules and a wide range of communication support materials will be developed by DAY: NRLM at the national level and shared with SRLMs for adaptation.

b. Major Interventions For the Development of VO level LNHS Plan of Operation:

Based on the framework of LNHS initiative (Fig 4), the following major components are considered crucial to be considered for development of a VO level micro-plan.

i. Ensure Food and Nutrition Security: The interventions for achieving food and nutrition security could vary based on the plans prepared by VOs. VOs therefore would be required to discuss the various options presented above (see section iv (d) and figure 4). SHGs could be sensitised to be involved in microcredit enterprise which would result in reducing food and nutrition insecurity. The activities to be taken up by SHGs could range from investment in production of a nutritious food item for sale to community members directly or through PDS to activities such as intensifying agriculture cultivation, homestead vegetable gardens, forestry food produce, poultry keeping, dairy/goat rearing etc. In this context, rolling out of MKSP projects of DAY: NRLM (currently in operation in selected blocks of selected districts) which concentrate on such livelihood initiatives could be considered to be expanded.

Figure 7: Community Institution and Project Support Unit at Various Levels

SHGs of Women1

(10-15 women per SHG)

Community Institution of Women

Village Organisation2 (VO)(10-20 SHGs)

•Parivartan Saathi (1/VO)Mobilisers-sector themes 3

(3-4/ VO)

Block/ Mandal level Federation (President of 15-20 VOs are

members)(Deal with various thematic areas #- Sanitation, Water, Agriculture,

Health -Nutrition, Gender)

Cluster Federation 4

(40-50 VOs)

District Federation (Deals with various themes)

NRLM refers to Deendayal Antyodaya Yojana:National Rural Livelihood Mission)

1 creating solidarity, thrift and credit, implementation of income generating activities2 large thrift and credit program, encourage SHG -government sector3 VO level mobilisers (3-4)- incharge of sectors themes except health and ICDS sector4 secure linkages with banks, platforms for community processes for manufacturer/ market linkages, audit and training 5 comprises Block managers & Thematic block managers (Institutional building, �nance, skill, capacity building, livelihood, social inclusion)

Area coordinator

Block Project Coordination Unit 5

(BPCU)Deal with various sector themes

District Project Coordination Unit (DPCU)

with thematic responsibilities

Cluster coordinator

State Project Management Unit (SPMU)

Project Support Team (SRLM)

Panchayat

AWWs+ ASHAs

Health/ ICDS supervisors

BMO

District Link

CDPO + BDO/ PHED


ii. Adopt Correct Family Level MIYCN Practices and Create Demands for Services: Implement Actions for Behaviour Change Communication (BCC): As per LNHS initiative, group discussions at VO level as well as counselling at household levels would be a high priority. It is proposed evidence based “Alive and Thrive” and Digital Green strategy, described above, (Section 4 d, iii)is considered while implementing BCC strategy. Feedback from PLA exercise and data on “unreached “disadvantaged households in a village with a pregnant woman, child 0-24 months or newly-weds is recommended to be used by PS for prioritising households for conducting interpersonal counselling or group counselling and social mobilisation activities.

Household visits by PS are proposed to be targeted and restricted to those families who have a pregnant women or newly married women or children 0-24 months but are not reached by health or ICDS sectors. Home visit guidelines will need to be accordingly developed by DAY: NRLM. The guidelines will take into consideration the periods in life time most critical for counselling—preconception/newly-wed women, pregnant women in the first trimester, pregnant women in second and third trimester, infants 0-28 days, infants 1-6 months, infants 6-12 months and over 12-24 months. Counselling will be on promotion and adoption of appropriate family level practices pertaining to nutrition care of pregnant women, antenatal services, newborn care, infant and young child feeding, routine immunisation, use of iodised salt, promotion of daily consumption of IFA and calcium tablets by pregnant women, biannual vitamin A and deworming, hygiene and sanitation practices. In addition to home visits, family level and group counselling will also be undertaken to ensure families are aware of the various government schemes and entitlements such as JSY, NREGA, PDS, IGMSY, ICDS food supplements.

At group meetings, cooking demonstrations for promoting appropriate child and maternal feeding practices, using the platform of key events such as Godh Bharai (held at about 7th month of pregnancy) to, Annaprasan (held around the time child is six months old) etc. will also be institutionalised. In monthly meetings of VOs , special effort will be made to promote daily consumption of IFA tablets and use of iodised salt. Benefits of IFA tablets on reducing anaemia and its positive impact on brain damage of foetus as well as on productivity will be accorded priority. For promoting consumption of iodised salt, samples from retail village shops/kinari would also be encouraged to be routinely tested. Community will be informed brand names of the salt sample containing less than 15 ppm iodine and actively discouraged to purchase those brands from retailers. Retailers will also be informed of the results of testing iodine levels in salt. In case any salt sample is found not to have the prescribed level of iodine, retailers will be pressurised to discontinue the sale of salt of the particular batch and brand. Community members will be informed of the benefits of iodised salt and encouraged to consume only iodised salt with adequate iodine.

Group discussion and social mobilisation will focus on the proposed month- wise themes, stated above (Table 3). The theme will be the focus of discussion at monthly VOs meeting, VHNSDs as well as at the meetings of members of federations of community institutions at block and district levels. Such discussions will therefore ensure that SHG members are informed of various government schemes and entitlements.

Special effort will be made to reach male members of families through organisation of group counselling sessions such as under a forum such as farmers’ group or seed bank group. Male family members will need to be reached periodically for discussion on MIYCN issues and for seeking their cooperation at family level.

iii. Bridge the Gap in Coverage with Specific Actions on Nutrition, Health and Sanitation Services: PS, using the information on disadvantaged unreached families by ICDS or health sectors households (with newly-wed women, pregnant women, infants 0-6 months, >6 -12 months and 12-24 months), will focus on ensuring reaching these households. Following village mapping, the identified


“unreached” families will be mobilised to attend VHNSD sessions and linked to health and ICDS sectors for ANC services, immunisation and vitamin A dosage as well as for receipt of ICDS food supplements. Additionally, women will be informed of health, feeding, hygiene, sanitation care practices that must be followed for appropriate care of pregnant women, infant and young children.

As a part of improving coverage of services, special attention will be paid to improve supply and consumption of iron-folic acid tablets by pregnant women from the second trimester onwards. As per the MoHFW recent guidelines, effort will be made to ensure pregnant women are supplied with at least 180 IFA tablets for this period and counselled to consume IFA tablets one hour after meal and prior to retiring for sleep. Innovative strategy of investing and buying IFA tablets by VOs, as discussed above in section 4, will also be encouraged to be considered in case of irregularity in supply. As per the BCC strategy, PS while counselling on consumption of IFA tablets will focus not only on side effects but on benefits to the growing foetus on brain development, birth weight, prevention of future stunting and lowering of IQ and on health, energy and productivity of mothers. In addition, every newly-married woman will be encouraged to consume weekly IFA tablets. Use of a fixed day approach for promoting consumption of WIFS will be used to address the major documented constraint pertaining to ‘forgetfulness to consume” IFA tablets. (WHO, 2010; Vir & Sforza, 2011)

iv. Address Nutrition Sensitive Factors through Multi-sector Linkage: Details are presented above in the above section 4 iv. VOs, following the PLA, as stated above in the LHNS strategy section would discuss a wide range of issues of the community such as water sanitation, right age of marriage, agriculture extension and horticulture activities. VOs will also be informed and trained to discuss various entitlements and government services and schemes such as Family Planning Services, Public Distribution System, Girls Education Scheme of state governments, Aadhaar Cards, Kisaan Beema, Jan Dhan Yojana etc.

Special focus will be on developing linkage at lock level with Swachh Bharat Abhiyaan and building of toilets with focus on attaining the goal of ODF villages. The funds required for such activities could be requested from the budget that is allocated and available with the concerned sectors against the defined entilements. Positive experiences emerging from states of Kerala, Andhra Pradesh, Bihar etc. could be discussed with VOs with a view to convince them that ODF goal is doable.

6. Indicators for Tracking Progress: LNHS Initiative

Every 6 months, data will be collected on the following indicators (Table 4) through the existing system channel of health, ICDS and other sectoral programs. SRLM Block coordinator in-charge of monitoring will compile the data obtained from the various VOs at block level while district coordinator in-charge of monitoring will compile the data obtained from various blocks. Fixed day approach is proposed to be used for collection of data from the various villages which form the VO. For facilitating this process, a special software for compiling VO level data is important to be developed by DAY: NRLM.

The record is proposed to be documented and shared every 6 months and progress reviewed at block and district level federations of women level as well as discussed at VOs meetings. With the help of block project coordinators, actions will be reviewed and implemented according to the progress made.

7. Award Incentives Linked To Progress

Taking into consideration the stated objectives are to be achieved by 2020, the progress of VOS will be monitored every six months using composite index of indicators. In the first phase, VOs who achieve all the indicated targets (Table 5) by end 2018 and 2020 will be given a cash award of INR 20,000 as revolving award fund.


Table 4: Community Based Monitoring and Evaluation: Monitoring of Key Nutrition Inputs, Outputs and Outcomes

Indicator 1st Year 1st year 2nd year 2nd year Progress in Comments on first second six first 6 last six two years six monthly months months months months progress

Pregnant Women /Lactating women % of pregnant women counselled by PS or AWW/ICDS during pregnancy% of pregnant mothers attending VHNDC at least 4 times during pregnancy.% of pregnant women who conceived below 18 years of age % of pregnant women attending at least 4 ANCs % of pregnant women received at least 100 tablets % of pregnant women consuming 100 IFA tablets % of pregnant women received deworming tablets % of pregnant women weighed during pregnancy % of pregnant women delivered in institutions% of pregnant women who received JSY entitlement% of pregnant women received PDS food % of pregnant women who received ICDS food supplement % pregnant women who have a kitchen garden% of families with pregnant mothers involved in dairy /poultry keeping % pregnant women are aware of the monthly themes % of pregnant women who consumed food from minimum 5 food groups% of pregnant women who consumed pulses along with cereals in at two meals per day% of pregnant women who consumed at least 3 eggs per week% of pregnant women who consumed at least one glass of milk daily

Children 0-24 months % babies who were weighed at birth % of babies less than 2.5 kg % of babies put to breast within one hour of birth% of babies 6 months-24 months exclusively breast fed% of children 6 months-24 months not given water before 6 months% of children >12-24 months introduced to semisolid food between 6-8 months % of children >12-24 months consuming food from four food groups% of children 0-24 months being fed semi-solid food at least four times along with breast milk % of children >12-- 24 months fully immunized% of babies >12-24 months administered vitamin A in the past six months % of mothers <24 months washing hands with soap and water before feeding % of mothers <24 months suffered domestic violence % of mothers 0-24 months visited at home by PS or AWW /ASHA % of mothers 0-24 months visited at home by PS% of mothers using food from own/community vegetable gardens % of mothers feeding at least 3 eggs per child per week

VO level : Food and Nutrition Security , Water Sanitation and other details Number (% ) of PS trained in nutrition-health-sanitation issues and PLA , BCCNumber (%) of VO members attended advocacy sessions Number (%) of households aware of name of the PS Number (%) landless or marginal farmersNumber (%) household depending on special grain obtaining schemes (PDS, Cereal bank, Grain line etc. Number (%) of households involved in kitchen gardens in the VO areas Number (%) of households involved in dairy (cow/goat) keeping VO area Number (%) of households involved in poultry keeping Number of monthly campaigns organised by VOs in one year Number (%) of households aware of ‘tiranga” meal. % of salt samples from retail shop of villages with inadequate iodine% of households using a spoon ladle for drawing stored drinking water from a container% of households consuming iodized salt% households washing hands with soap and water after defecation or handling child excreta% households washing hands prior to cooking % of households using open defecation% households having a sanitary latrine% of mothers of 0-24 months who suffered domestic violence


Table 5: Composite Index of Indicators for Cash Award to VOs

Indicators Achievement by Achievement Comments December 2018 by 2020 (percent)

• Registered for pregnancy in the first trimester and attend at least 4 ANCs

• Mothers consume minimum 100 IFA tablets during pregnancy

• Mothers weighed at least thrice during pregnancy

• Institutional Delivery

• Infant with birth weight less than 2500

• Breastfeeding initiated within one hour of birth

• Infants over 7 months report being exclusively breastfed for the first six months of life

• Child at 9 months is being fed semisolid food from four food groups

• Routine immunisation

• Open Defecation in the village

Both criteria will be taken as one indicator

Measures for ensuring supply will need to be assured

This will pertain to weighing by health sector during ANC checks

This includes delivery in either government or private institution

Birth weight record will be used for information

Health record will be used

ICDS record will be used

Measles context will be used for recording information or ICDS record will be used

Health data will be used

Data of Block PHED officer will be used

75

50

50

75

20

75

50

75

75

20

90

90

90

90

15

90

90

90

90

Nil


PART IINutrition Situations of Women and Children in India: An Overview


PART II

Nutrition Situations of Women and Children in India: An Overview

1. Introduction

The term malnutrition refers to both undernutrition and overnutrition. Malnutrition includes nutritional disorders in various forms and encompasses imbalances in energy, specific macronutrients and micronutrients, and dietary patterns. Conventionally, the emphasis has been on inadequacy, but malnutrition also applies to excess and imbalanced intakes. Malnutrition in India is a public health emergency with serious health, academic and economic consequences.

Malnutrition occurs when the intake of essential macronutrients and micronutrients does not meet or exceeds the metabolic demand for those nutrients. (WHO, 2013a) The term undernutrition specifically refers to being too low weight for one’s age (underweight), too short for one’s age (stunting), dangerously thin for one’s height (wasting) and deficient in minerals and vitamins (micronutrient deficiencies).

Undernutrition slows down the progress in a country. It must be appreciated that “One underweight or one undernourished child is an individual tragedy. But multiplied by tens and millions, undernutrition becomes a global threat to societies, to economies and to generations to come.” (Venamann, 2008)

Undernutrition in children is estimated to reduce nation’s economic advancement by at least 8% due to impact on young child mortality, increasing incidence of morbidity, direct productivity losses, poor cognition, reduced schooling. (Gillespie et al, 2013) Undernutrition in women and children though common is often “not visible” and is therefore a low priority in the development agenda. Only severe acute malnutrition is visible and is a cause of concern. Unfortunately, extreme wasting, apparent in severe cases of undernutrition is often viewed by community as an effect of evil eye and not a state of extreme ill-health which is preventable.

2. Implications of Undernutrition - A Silent Invisible Emergency

There is a need to understand and appreciate that undernutrition is an underlying cause in about a third of preventable deaths in children under- fives (UNICEF, 2009). According to Lancet 2013 .maternal and child undernutrition is the underlying cause of nearly half of under- five child deaths (UNICEF, 2009, Bhutta et al, 2013). Severely undernourished child is at a much higher risk of dying - eight times at higher risk of dying than normal children. Undernutrition weakens the immune system and makes a person more susceptible to infections, including diarrhoea. A 1997 report of the National Strategies to Reduce Childhood Malnutrition states that the cost of treating malnutrition is 27 times more than investment required for its prevention. (The Coalition for Sustainable Nutrition Security in India, 2010)

In fact, the consequences of mild and moderate undernutrition are not limited to health, physical development and survival. Undernutrition has serious implications on mental development of our children. Undernutrition impairs brain development and cognitive abilities during the early days and can contribute to delayed enrolment, high drop - out rate as well as poor performance in school and lower learning outcomes at a later stage. (Victora et al, 2008) This is well reflected in a multi-country study of 2007 which reports that for every 10 percent increase in prevalence of stunting (a measure of chronic undernutrition), the proportion of children reaching the final grade of school dropped by almost 8 percent. (Grantham-McGregor et al, 2007) Undernutrition in fact adversely influences school concentration, learning at school, livelihood actions and productivity through the life cycle leading to intergenerational cycles of poverty and malnutrition.

Deficiencies of micronutrients such as iron, folic acid and iodine also adversely influence brain and cognitive development of young children. Vitamin A and zinc deficiency have serious impact on survival and growth of children. Anemia in mothers results in intra-uterine growth retardation resulting in birth of low birth weight


(LBW) babies who start life with the burden of undernutrition. In India, almost a third of babies are born LBW who often fail to catch up in growth and remain undernourished. Folic acid deficiency is common in women in reproductive age and is a known to be a contributory cause of neural tube defects. Deficiency of iodine can lead to permanent brain damage in growing foetus. Iodine deficiency results in lowering of intelligence quotient (IQ) in school children by 10-15 IQ points while deficiency of iron results in adversely influencing concentration in work and performance in school in children.

The long term consequences of chronic malnutrition are far reaching since the adverse impact is not only irreversible but intergenerational. The latter implies that a stunted young girl is likely to grow up to be a stunted adolescent girl and a stunted woman with increased chance that her children will be born undernourished with a poor start in life. Undernutrition in mother to a great extent contributes to foetal growth restriction, low birth weight and is a cause of more than a quarter of all neonatal deaths (Wu et al,2012,UNICEF,2009 ). On the other hand, improved maternal status reduces incidence of LBW, child malnutrition and mortality as well as contributes in reducing maternal mortality, improving educational outcomes and increasing productivity and growth.

Since the past decade, serious implication of undernutrition which is increasingly gaining attention is the grave consequence of undernutrition in early childhood and adulthood onset chronic diseases such as diabetes, cardio-vascular diseases etc. Low birth weight and its long term effect on non-communicable disease are of increased concern. According to Global Nutrition Report 2014-15 “good nutrition is the bedrock of human well-being before birth and through infancy, good nutrition allows brain functioning to evolve without impairment and immune systems to develop more robustly in young children, good nutrition status averts death and equips the body to grow to its full potential.” (Global Nutrition Report, 2014)

Undernutrition fundamentally reduces life chances as well as adversely influences people’s ability to grow optimally physically and mentally. The adverse effects of malnutrition are therefore not limited to children but have serious implications throughout the life cycle resulting in adversely influencing health, education, productivity and economy of the state.

With such wide range of implications of undernutrition on human, economic & social developments, it is considered to have adversely influenced in the attainment of millennium development goals pertaining to child survival, maternal health, education, gender equity. (Table 1)

Table 1: Millennium Development Goals (MDG) and Effect of Malnutrition**

MDG Goal Effect of Malnutrition

Goal 1

Goal 2

Goal 3

Goal 4

Goal 5

Goal 6

**Source: Gragnolati et al, 2005 (Adapted)

Eradicate extreme poverty and hunger

Achieve universal primary education

Promote gender equality and empower women

Reduce child mortality

Improves maternal health

Combat HIV / AIDS, malaria and other diseases

decreased human capital, adverse impact on cognitive and physical development

reduced school attendance, retention and performance

reduced access to food, health and care resources – female biases

increased burden of disease and death

compromised maternal health - maternal stunting and iron and iodine deficiencies

increased risk of HIV transmission, compromise antiretroviral therapy, and hasten the onset of full blown AIDS and premature deaths


3. Nutrition Situation in India: An Overview

a. Undernutrition in Children:

The 3rd National Health and Family Survey (NFHS 3) findings of 2005-6 indicate 48 per cent children are stunted, 42.5 per cent are underweight and 19.8 per cent are wasted. The last available data on nutritional status indicates prevalence rate of stunting to be 39 percent, underweight 29 percent and wasting 15 percent (Fig 1). It is estimated that the decline in the last decade is 1.0 point per year for stunting, 1.6 point per year for underweight and 0.6 point per year for wasted. (RSOC, 2013) This is much lower than the rate of 3.4 percent recommended by World Health Assembly (WHA) for achieving the 2025 global target of reducing number of stunted children by 40 percent.

b. Prevalence Rate of Underweight :

As per the NFHS-3, though the national average rate of underweight was 42.5 percent, there was a wide variation in the rate of underweight across states. According to NFHS-3 findings, the proportion of children underweight ranged from 20 per cent in Sikkim and Mizoram to 60 per cent in Madhya Pradesh. (Fig 2)

Stunting Underweight Wasting

15.120

29.4

4338.7

48

80

70

60

50

40

30

20

10

0

NFHS-3 (2005-06) RSOC (2013)

Figure 1: Undernutrition Situation in Children Under Five Years in 2005-06 and 2013-14

Figure 2: Underweight Rates in Children Below 5 Years: State-Wise and All India Source: (NFHS 3, 2005)

48 56.8

55.6 55.1

52.9 51.7

50 49.8

46.5 46.3

45.7 45

44.6 44.4

43.7 43.7 43.3

42.7 42.2

39.8 38.8 38.6 38.3

36.7 35.7 35.6

35 30.9

25.6 24.5

0 10 20 30 40 50 60

India Uttar Pradesh

Bihar Meghalaya

Chhattisgarh Gujarat

Madhya PradeshJharkhand

AssamMaharashtra

Haryana Orissa

West Bengal Uttaranchal

RajasthanKarnataka

Arunachal PradeshAndhra Pradesh

Delhi Mizoram

Nagaland Himachal Pradesh

Sikkim PunjabTripura

Manipur Jammu & Kashmir

Tamil NaduGoa

Kerela


Recent data of RSOC (Fig 3) indicates the national average rate of underweight to be 29.4 percent and indicates a wide variation. Underweight situation in under-fives is much better in 8 states with prevalence rate of underweight being below 20 percent—Manipur, Mizoram, Jammu and Kashmir, Sikkim, Punjab, Goa, Kerala and Delhi. The situation of underweight is worse of in Jharkhand, Bihar, MP, Odisha, UP, Chhattisgarh. Forty three percent of all underweight children in the country live in the high population states – UP (21 percent), Bihar (14 percent), MP (8 Percent).

c. Prevalence Rate of Stunting in Under-Five Years Children:

India is one of the eight countries where 50 per cent of the global chronic undernourished (stunted) children live. (World Bank, 2010) As evident in Fig 4, India is noted to have a much higher rate of stunting compared to some other smaller countries in South Asia and with some countries with similar or worse economic situation (Figure 4). Stunting is considered the most appropriate measure of undernutrition and is not influenced with short term interventions.

Figure 3: Underweight Prevalence Rate All India and State-Wise 2013-14 Source: RSOC, 2013-14

0

10

20

30

40

50

60

70

80

90

100

14.1

Mani

pur

Mizo

ram

Jam

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and

Kash

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Punj

ab Goa

Kera

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14.8 15.4 15.8 16 16.2 18.5 19.4 19.5 19.5 20.6 22.2 22.3 22.7 23.3 24.6 25.228.9 29.4 30 30.5 30.9 31.5 33.6 33.9 34.3 34.4 36.1 37.1

42.1

Figure 4: Stunting Prevalence in India Compared to Many Neighbours & Income Peers Source: World Bank (India Profile), 2010

Afghanistan

70

60

50

40

30

20

10

00 1000 2000

GNI per capita (US $ 2008)

Prevalence of Stunting Among Children Under

5(%)

3000 4000

Nepal Bhutan

Maldives

Sri Lanka

BangladeshCote d ivoire

PakistanVietnam

Sao Tome and Principe

India


As in the case of underweight, proportion of children suffering with stunting varies across states. As per NFHS 3 data of 2005, 18 states are reported having a stunting rate of over 40 percent and only two states-Kerala and Goa-reporting a stunting rate of less than 30 percent (Fig 5).

The NFHS 3 data also reveals highest prevalence rate of severe stunting is in the states of Uttar Pradesh, Bihar and Meghalaya with three out of under five children being severely stunted.

The recent RSOC data (Fig 6) also shows a wide variation amongst states. The two states with the highest rate of stunting continues to be UP (51 percent) and Bihar (49 percent). The other three states with high prevalence rate of stunting are Chhattisgarh, Jharkhand and Meghalaya.

The decrease in prevalence rate of stunting, as compared to NFHS 3, varies widely (Fig 7). In UP, the reduction is observed to be from 56.8 percent to 51 percent while in Bihar the reduction is from 55.6 percent to 49 percent. The three best performing states remain Kerala, Goa and Tamil Nadu with less than a quarter of under 5 year children being stunted. The decrease in the prevalence rate of stunting in the state of Tamil Nadu is rather substantial from 30.9 percent in 2005 to 23 percent in 2013 (Fig 7).

48

56.8 55.6

55.1

52.9 51.7

50

49.8

46.5

46.3

45.7

45 44.6

44.4 43.7

43.7

43.3 42.7

42.2 39.8

38.8 38.6

38.3 36.7

35.7

35.6 35

30.9

% age below - 3SD% age below - 2SD25.6

24.5

23.7

32.4

29.1 29.8

24.8

25.5 26.3

26.8

20.9

19.1

19.4 19.6

17.8 23.1

22.7 20.5

21.7 18.7

20.4 17.7

19.3 16

17.9 17.3

14.7 13.1

14.9 10.9

10.2

6.5 KeralaGoa

Tamil NaduJammu & Kashmir

ManipurTripuraPunjabSikkim

Himachal PradeshNagalandMizoram

DelhiAndhra Pradesh

Arunachal PradeshKarnatakaRajasthan

UttaranchalWest Bengal

OrissaHaryana

MaharashtraAssam

JharkhandMadhya Pradesh

GujaratChhattisgarh

MeghalayaBihar

Uttar PradeshIndia

Figure 5: Stunting and Severe Stunting Prevalence in India by State Source: NFHS-3, 2005-06

0 10 20 30 40 50 60


Kera

la

100

90

80

70

60

50

40

3019.4 21.3

23.326.9 28 28.4 29.1 29.1 30.5 31 32.7 33.2 34 34.2 34.2 34.7 35.4 35.4 36.4 36.5

38.2 38.740.6 41.5 41.6 42.9 43

47.449.4 50.4

20

10

0

Goa

Tam

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Trip

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alay

a

Biha

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sh

Indi

a

Arun

acha

l Pra

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Figure 6: Prevalence Rate of Stunting Amongst Children <5 Years in India and State-Wise Source: RSOC, 2013-14

Figure 7: Comparison of Stunting Rates in Children Below 5 Years in 2005-6 and 2013-14

Kera

la

Goa

Tam

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du

Mizo

ram

Sikk

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Mani

pur

Trip

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Punj

ab

Him

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& Ka

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Naga

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Delh

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Karn

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a

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Odish

a

Hary

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Madh

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Guja

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Chha

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Megh

alay

aBi

har

Utta

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Indi

a

Arun

acha

l Pra

desh

57 56 5553 52

50 5048 47 46 46 45 45 44 4444

50 49

43 43 42 42

47

3941

35 37 3538

3436

34

28

35

29 29

34

2831 31

33 32

2321 19

27%

43 43 4240 39 39 38 37 36 36 35

2005 - 2006 2013 - 2014

31

26 25


d. Prevalence Rate of Wasting (Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM):

Wasting or SAM is defined as the percentage of children 6-59 months whose weight for height is below minus three Z scores of the WHO Child Growth standards median. Children with mid-upper arm circumference (MUAC) of less than 115mm, with or without nutritional oedema, are also considered to suffer from SAM. SAM children in the country are nine times at higher risk of dying compared to normal children.

Moderate acute malnutrition (MAM) in children is defined as a weight-for-height between -3 and -2 Z-scores of the WHO Child Growth Standards median. MUAC of over 115 -120 mm, without oedema, is also used for measuring MAM children. As per the NFHS-3 survey report, 19.8 percent children are wasted while 6.4 percent are severely wasted. The three states with over 10 per cent SAM cases are Meghalaya, Madhya Pradesh and Jharkhand (Fig 8).

Figure 8: Severe Wasting Rates in India by State in 2005-06 Source: NFHS 3

6.4

19.9

12.6

11.8

8.9

8.6

8.3

7.3

7

6.1

5.9

5.8

5.6

5.6

5.5

5.3

5.2

5.2

5.2

5.1

5

4.5

4.4

4.1

4

3.5

3.5

3.3

2.1

2.1

19.8

30.7

35

32.3

22.2

24.6

27.1

20.4

15.4

15.3

17.6

18.7

19.5

14.1

19.3

18.8

19.5

16.5

13.3

14.8

19.1

16.9

14.8

15.9

13.7

12.2

9

9.7

9.2

9

Kerala

Tamil Nadu

Jammu & Kashmir

Manipur % age below - 2SD % age below - 3SD

Tripura

Goa

PunjabSikkim

Himachal Pradesh

Nagaland

Mizoram

Delhi

Andhra Pradesh

Arunachal PradeshKarnataka

Rajasthan

Uttaranchal

West Bengal

Orissa

Haryana

Maharashtra

Assam

JharkhandMadhya Pradesh

GujaratChhattisgarh

Meghalaya

Bihar

Uttar Pradesh

India


As per the recent RSOC survey 2013-14, prevalence rate of acute malnutrition is reported to have decreased to 5 percent (Fig 9). As per the findings, currently there are no states with severe wasting of over 10 percent while eight states have a prevalence rate of 6-7 percent i.e. above the national average. Interestingly, severe wasting is less than the national average in Bihar (4 percent) and Uttar Pradesh (3 percent).

As per the RSOC survey, children with moderate acute malnutrition (MAM) are 15.1 percent. As per the national survey, there is no difference in rural and urban prevalence rate. However, there is wide variation amongst states (Fig 9). The prevalence rate of severe wasting or acute malnutrition is highest in AP, TN, Maharashtra and Gujarat. It may be noted that the Integrated Child Development Services

(ICDS) system in the country identifies cases of severe underweight which is not a measure of SAM cases. Severe wasting is one of the indicators of severe acute malnutrition. The WHO standard recommended for identifying SAM cases is the measure of mid-upper arm circumference (MUAC). The global standard of MUAC measure of less than 11.5 cm is used by the Ministry of Health and Family welfare for identifying SAM cases and such identified SAM children are further referred for medical examination and for assessing complications, if any. It is estimated that only about 80 percent of SAM cases in India are without any medical problems and can be treated at home or at the community level without requiring any hospital or rehabilitation treatment. The data on SAM cases, using MUAC standard, is not available

4. Undernutrition in Children: Wide Equity Gap

a. Rural and Urban Gap:

As per NFHS3, the prevalence rate of undernutrition in under 5 years children in higher in rural regions compared to urban region in rural areas the rates of underweight is 42.6 per cent and stunting 50.7 per cent while in urban region 32.7 per cent are underweight and 39.6 per cent stunted (Fig 10). However, the nutritional status of urban poor (urban population not residing in slums or population covered under Municipal Corporation Facilities) is nutritionally worse off as compared to urban slums or rural India.

Figure 9: Acute Malnutrition in India Source: RSOC, 2013-2014

Kera

la

Tam

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Jam

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& Ka

shm

ir

5.1

7.1 7.18.7 8.8 9.3 9.7 10 10.1

11.812.9 13.1 13.1

14.1 14.314.315.115.315.4 15.5 15.6

17 17 17.1 17.518.3 18.6

Mani

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Punj

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a0

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15

20


b. Gender Gap:

Interestingly, as per the RSOC survey , the pattern of undernutrition (underweight, stunting or wasting) does not reveal a significant gender difference in children under 5 years in rural or urban India (Fig 11). Girls have been observed to have a nutrition advantage over boys in the first months of life which seems to be reversed overtime as girls grow older, possibly due to poor care and feeding. Interestingly, as per RSOC findings, the prevalence rare of all the three parameters of undernutrition is lower in under five female children compared to male children (Fig 11).

c. Variation with Wealth Index:

As per the NFHS-3, the rates of undernutrition in the country show a wide inequity gap between the highest and lowest wealth index group (Fig 12). Poor children are approximately three times more likely to be underweight or stunted than their wealthy counterparts. The prevalence rate of wasting is almost double in lowest wealth index under five children compared to the highest wealth index.

Figure 11: Prevalence Rate of Stunted, Underweight and Wasted in India in Rural and Urban Region and Male and Female Children Source: RSOC, 2013-2014

Figure 10: Underweight and Stunting Among Children (0-59 Months) in India Source: NFHS-3, 2005-06; UNHRC

0

10

20

30

40

50

60

Urban Poor Urban Non Poor

OverallUrban

OverallRural

All India

Underweight

47.1

54.2

26.2

33.2 32.7

39.645.6

50.7

42.548

Stunting

0

10

20

30

40

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38.7

29.4

15.1

31.6

15.1

32

24.3

15

39.5

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37.8

28.7

14.5

IndiaR ural

Stunted (Height for age below - 2 SD)

Underweight (Weight for age below - 2 SD)Wasted (weight for height below - 2 SD)

Urban

Residence and Gender

Male Female

41.6

% of Prevalence


The RSOC data also indicates a wide difference in prevalence rates of severe and moderate underweight, stunting and wasting in highest and lowest wealth index (Fig 13). The percentage prevalence rate of underweight and stunting being almost twice in the lowest wealth index compared to highest wealth index, while in the case of wasting, the difference was comparatively less. These findings also indicate that despite high wealth index, almost one in four children is stunted and one in five children is underweight. The data confirms that it is not mere poverty which is the cause of undernutrition in India.

Figure 12: Undernutrition Prevalence Rates for All Three Indicators by Wealth Index Source: NFHS-3, 2005-06

Figure 13: Prevalence Rates of Stunting, Wasting, Underweight in Children <5 Years in Lowest and Highest Wealth Index

Perc

ent

Lowest Second Middle

Stunting Underweight Wasting

Fourth Highest10

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0

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Stunted(Height for age

below - 2 SD)

% o

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Lowest Wealth Index Highest Wealth Index

Severly Stunted(Height for age

below - 3 SD)

Wasted (Weight for height

below - 2 SD)

Severly Wasted(Weight for height

below - 2 SD)

Underweight(Weight for age

below - 2 SD)

SeverlyUnderweight

(Weight for agebelow - 3 SD)

50.7

26.7 25.8

10.7

1713

5 4.4

42.1

18.616.1

5.3


d. Caste Categories and Nutrition Situation:

According to NFHS-3, an inequity in the prevalence rate of undernutrition is reported with reference to castes-rate of underweight and wasting being higher in schedule caste and tribe (Fig 14). A stunting rate of 54 % among tribal Indian children implies 6.2 million children out of 11.5 million tribal children aged under-five in India are stunted. Nine tribal dominated states of central India (Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Maharashtra, Odisha, Rajasthan and Telengana), collectively house 4.7 million of these stunted children. (UNICEF, 2015a)

As per the RSOC survey (Fig 15), the prevalence rate of stunting in ST is 42.3 percent and is almost the same as of the SC population (42.4 percent).The prevalence rate of underweight and wasting in ST population is far worse than all the other three population groups i.e. SC, OBC and others.

Figure 14: Stunting, Underweight & Wasting in Children < 5 years by Caste/ Tribe Source: NFHS-3, 2005-06; Kathuria, 2011

Figure 15: Prevalence Rate of Wasting in Children Below 5 Years in 2013-14 Source: RSOC, 2013-14

0

10

20

30

40

50

60 54 5449

41

28

21 20

Scheduled tribe

Perc

ent

Scheduled caste

OtherOther backward cast

16

55

4843

34

Stunted Wasted Underweight

42.4

32.7

15.5

42.3

36.7

18.7

38.9

29.3

14.8

33.9

23.6

13.6

0SC ST OBCO thers

10

20

30

40

50

Stunted (Height for age below - 2 SD)

Underweight (Weight for age below - 2 SD)

Wasted (weight for height below - 2 SD)

Social Category

% o

f Pr

eval

ence


Table 2 indicates that severe form of stunting, underweight and wasting has reduced since 2005-06 but remains higher with almost two in 10 being severely stunted. The prevalence rate of severe wasting has also reduced to 4.5 percent but remains comparatively higher in ST group (5.3 percent).

5. First 1000 Days of Life : Trend in Undernutrition with Increase in Age in Children 0-5 Years

An analysis of growth trend against age indicates the prevalence rate of both stunting and underweight increases rapidly in the first two years of life and reaches its peak at about two years of age. (Shrimpton et al, 2001) Such pattern of growth in the first two years of life is reported from analysis of data undertaken in the state of UP in early 2000 (Vir, 2001) and later from analysis of NFHS data (Fig 14) on nutritional status against age (NFHS 3, 2005-6). A similar pattern has been reported from other developing countries.

The age-wise data on rates of stunting in India indicates 57.8 percent children are stunted at 18-23 months compared to almost 30 percent at 6 months (NFHS-3, 2006). It is evident that the situation of stunting worsens with increase in age, from being 32.7 percent at 9-11 months and 46.9 percent at 12 -17 months followed by a sharp increase to almost 58 percent by 23 months. It is of concern to note that almost a third of children are underweight or stunted in the first 1-2 months of life itself. Such children with LBW have a poor catch up growth and have a high chance of being stunted at 24 months. Available evidence also indicates that these children fail to grow to their optimum height during adolescence which is the second and last growth spurt period of life.

Stunting or poor growth occurring during this period is largely irreversible. Stunted or underweight children also have lower immunity and have a higher chance of falling ill and thus setting up a cycle undernutrition-infection. Besides physical growth, there is an adverse impact on brain development during this period when almost over 80 percent of brain is formed. The adverse effects are life-long. Poor growth of children in the first 1000 days of life also results in female children growing up to be stunted adult women. This sets up an intergenerational cycle of undernutrition in women. Care of children 0-24 months or 1000 days is the “window of opportunity” and is the period to prevent linear growth retardation in early childhood in low and middle income countries. (Shrimpton et al. 2001)

Table 2: Undernutrition and Severe Undernutrition in India in Various Social Categories

Severe Undernutrition SC * ST * OBC * Others * India # India * (%) (%) (%) (%) (%) (%)

*RSOC, 2013-2014; #NFHS-3, 2005-06Source: NFHS-3, RSOC-2013-14

Stunted 42.4 42.3 38.9 33.9 48 38.7

Severe Stunted 19.3 19.5 17.8 14.2 23.7 17.3

Underweight 32.7 36.7 29.3 23.6 42.5 29.4

Severe underweight 10.8 13.0 9.3 7.0 15.8 9.4

Wasted 15.5 18.7 14.8 13.6 19.8 15.1

Severe wasted 4.9 5.3 4.4 4.4 6.4 4.5


6. Nutritional Status of School Aged Children Prior to Onset of Adolescents: 4 to 9 Years

Data on nutritional status of children in this age group is limited. The National Nutrition Monitoring Bureau (2012) data for 4-6 years children pooled for 10 states indicates that diet lacks diversity. The findings indicate 19.8 percent in this age group compared to a third in 1-3 years children consume less than 50 percent recommended dietary intake (RDI) of cereals. (NNMB, 2012) Similarly the intake of pulses reveal 53.6 percent consume less than 50 percent RDI of pulses compared to 65 percent in 1-3 years age group. Consumption of green leafy vegetables (GLVs) is very inadequate. Children in this age group consuming less than 50 % RDI is over 85 percent. About 81 percent children consume less than 50 percent RDI of milk and milk products (Table 3).

Nutrient intake data of children in the age group 4-6 years and 7-9 years indicate energy intake below 50 percent of recommended dietary allowances (RDA) by 14.3 percent and 14.4 percent, respectively. Intake of protein seems better than energy intake with less than 5 percent consuming less than 50 percent RDA of protein (Table 3). However, protein source is primarily from cereals and therefore protein consumed is not a good quality protein.

Poor intake of fat is evident 39.9 percent in 4-6 years and 41.1 percent in 7-9 years age group consume less than 50 percent RDA. The intake of vitamin A is rather low 80 percent in 4-6 years and 88.3 percent in 7-9 years consume less than 50% RDA of vitamin A. Rich source of dietary vitamin A are eggs, green and orange coloured vegetables and fruits and flesh foods. Similarly intake of dietary iron is poor and being from

Figure 16: Age-wise Trend in Percentage of Children with Stunting, Underweight and Wasting

4-6 years 14.3 39.9 2.6 80.0 44.6 85.6 53.6 81.8 80.1

7-9 years 14.4 41.1 4.0 88.3 46.1 NA NA NA NA

Table 3: Dietary and Nutrient Intake of Children 4-6 years and 7-9 years

Population Group Percentage consuming less than 50 % RDA of nutrients and RDI of selected food Items Children Energy Total Fat Protein Vitamin A Iron GLV Pulses Milk and Fats and Milk products oils

Source: NNMB, 2012


vegetarian food is poorly absorbed and available to the body. Percentage consuming less than 50 percent of RDA of iron being 44.6 percent in 4-6 years and 46.1 percent in 7-9 years age group. Poor intake of iron and protein and inadequate absorption of dietary iron is the primary cause of nutritional anaemia in this age group.

7. Nutritional Status of Adolescent Girls

As per the NFHS 3 survey 2005-6, a third of the adolescent girls between 11-18 years are reported to be undernourished. RSOC (2013-14) indicates a higher percentage of adolescent girls (15-18 years) i.e. 44.7 percent in the country are undernourished with body mass index (BMI) less than 18.5. Almost two –third of girls (10-18 years) were thin (BMI <18.5).

RSOC (2013) indicates a wide variation amongst states (Fig 17) — Sikkim 10.5 percent and Rajasthan 60.2 percent. Thirteen states have a higher percentage of undernourished adolescent girls than the national average which implies in these states every second girl aged 15-18 years, who will soon to be a mother, is undernourished. Bihar has a slightly higher percentage of undernourished adolescent girls (45.2 percent) than the national average while the situation in Uttar Pradesh is comparatively better (36.7 percent).

Interestingly, as per RSOC survey (Fig 17), five states with lowest prevalence rate of undernutrition in adolescent girls are Sikkim, Meghalaya, Manipur, Mizoram and Jammu and Kashmir. Of these five states, except for Meghalaya state, also have a corresponding lowest rate of underweight rates in the country. This survey finding is further supported by a recent report of a prospective study on data pooled from five low middle income countries, including India, which demonstrates a stronger association of younger maternal age with lower birth weight, preterm birth and stunting by two years of age as compared to such an association in case of women 20-24 years. (Fall et al, 2009)

Adolescence is the period of second and last growth spurt and the final height in adulthood is influenced by gain in height during this period. Optimum gain in height during adolescence in girls is adversely influenced by the onset of conception at young age. As per the NFHS 3 survey of 2005-6, 45 per cent women were reported to have been married before the legal age while in Bihar, it was as high as 69 percent. Recent data of AHS survey indicates a decline in the prevalence rate of early marriage. For example, in Bihar significant decline from 69 percent to 16.5 percent is observed. (AHS, 2012) This is possibly due to false reporting since the community is aware that the legal age for marriage in India is 18 years.

Adolescence conception as well as inadequate diet and health care hamper optimum height gain resulting in

Figure 17: Girls Aged 15-18 Years Body Mass Index Less Than 18.5 across All States and in India Source: RSOC, 2013-2014

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du

Utt

ar P

rade

sh

Punj

ab

Assa

m

Chha

ttis

garh

Jhar

khan

d

Delh

i

Indi

a

Biha

r

Mad

hya

Prad

esh

Har

yana

Arun

acha

l Pra

desh

Naga

land

Him

acha

l Pra

desh

Odis

ha

Guja

rat

Mah

aras

htra

Andh

ra P

rade

sh

Goa

Karn

atak

a

Raja

stha

n

19.721.9

24.830.5 31.8 32 34.5 34.8 35.2 36.7 38.8

40.8 43 43 43.7 44.7 45.2 45.849.3 50.3 50.9 51.6 51.8 52.6 54.2 54.8 55.9 58 60.2

70

80


adolescent girls entering adulthood with short stature, poor weight and anemia with its adverse impact on foetal growth resulting in LBW and stunting. The adverse impact of early conception on optimum growth is much worse in disadvantaged population where the velocity of adolescent growth is slower and is extended for a longer period. (Vir, 1990) Poor diet which does not meet the nutrient needs of adolescent girls is the primary cause of poor BMI.

As per the NNMB survey 2012 in rural region, the dietary intake of adolescent girls and boys is much below the recommended level (Table 4). The dietary data indicates 22.1 percent of adolescent girls and 32.1 percent boys aged 16-17 years have calories consumption less than 50 percent of RDA. Interestingly 56.7 percent boys and 37.2 percent girls consume less than 50 percent requirements of fat in the diet. Intake of protein rich foods such as pulse and milk also remains extremely deficient in both boys and girls (about 29 grams per day compared to adult recommended intake of at least 40 grams). Intake of GLVs is only between 15-18 grams against the adult requirement of 40 grams. Though both male and female adolescent have poor dietary intake, low intake of nutrients combined with early marriage and early child bearing in case of adolescent girls further worsens the situation.

8. Undernutrition in Women

Undernutrition among women in reproductive age is common. Every third women in the reproductive age is undernourished (BMI <18.5 kg/m2) with a wide variation amongst states (Fig 18). As per NFHS-3, 35.6 percent women are undernourished with BMI < 18.5. In tribal region, almost every second woman is undernourished (46.6 percent) and the prevalence rate is much higher than the national level and higher than what is reported in SC 41.1 %, OBC 35.7%, others 29.4 %.

10-12 yrs

Boys 22.6 52.6 83.6 84.6 61.6 25.1 9.2 47.8 54 75.8 85

Girls 20.0 54.4 83.4 84.1 65.7 21.2 11.5 51.6 72.4 78.9 86.6

13-15 yrs*

Boys – – – – – 33.5 14.5 57.8 70.0 71.0 83.4

Girls – – – – – 22.6 16.8 53.2 67.3 74.7 83.6

16-17 yrs*

Boys – – – – – 32.1 16.8 56.7 59.7 66.8 82.3

Girls – – – – – 22.1 18.0 37.2 60.1 71.7 84.8

Adult (>18 yrs)

Men 14.7 44.8 80 62.8 38 12.2 15.1 13.7 24.7 39.4 79.0

Women 14.1 48.8 85 56.7 45 7.7 15.1 12.1 68.3 45.1 80.7

Table 4: Dietary and Nutrient Intake of Adolescent Boys and Girls in Rural India

Girls and Boys with <50% intake of foodstuffs & nutrients as per RDI / RDA Group < 50% RDI < 50% RDA

Cereal Pulses GLVs Milk & Milk Fats & Calorie Protein Total Iron Calcium Vitamin & legumes products Oils fat

* data not available sex-wise for the refernce groupsSource: NNMB, 2012


The prevalence rate of undernourished women is almost three times in the lowest wealth index compared to the highest wealth index (Fig 19). The prevalence rate is also influenced by the level of education—rate of undernourished women decreases with increase in level of education.

9. Low Birth weight

Poor nutrition situation of women is reflected in poor birth weight of children. South Asia bears almost half of the global burden of undernutrition (Fig 20) and the country with the highest burden of LBW is India.

Sikk

im

Meg

hala

ya

Man

ipur

Miz

oram

Jam

mu

& K

ashm

ir

Trip

ura

Utt

aran

chal

Kera

la

Tam

il Na

du

Utt

ar P

rade

sh

Punj

ab

Assa

m

Chha

ttis

garh

Jhar

khan

d

Delh

i

Indi

a

Biha

r

Mad

hya

Prad

esh

Har

yana

Arun

acha

l Pra

desh

Naga

land

Him

acha

l Pra

desh

Odis

ha

Wes

t Be

ngal

Guja

rat

Mah

aras

htra

Andh

ra P

rade

sh

Goa

Karn

atak

a

Raja

stha

n

0

10

20

30

35.640

50

60

Figure 18: State Wise Prevalence of Undernourished Women (BMI < 18.5 Kg/m2) in India Source: NFHS-3, 2005-06

Figure 19: Prevalence Rate of Undernourished Women Based on Wealth Quintile Source: NFHS-3, 2005-06

0

10

20

30

40

50

Lowest Second Middle

Wealth index

Perc

enta

ge

Fourth Highest Total

35.6

18.2

28.9

38.3

46.3

51.5

Low Birth Weight in South Asia

Rest of the World 10.8

• 52% of global burden in South Asia

• One of four children born are with LBW

• Burden is high in India, Pakistan and Bangladesh

• IUGR is the main contributor of LBW in countries with LBW > 10 percent

Low birth weight in millions

India 7.5

Pakistan 1.5

Bangladesh 0.7

Figure 20: Prevalence of Low Birth Weight (LBW) in India and South Asia


According to NFHS 3 data, 21.5 percent were LBW births in the country. The situation was worse in schedule caste (23.7 percent) and in scheduled tribe (22.3 percent) population. Recent RSOC survey (2013-14) also indicates LBW situation is worse in tribal population (21.6 percent) compare to the national average of 18.6 percent. According to RSOC, the incidence of LBW is rather similar in rural (18.7 percent) and urban (18.3 percent). However, there is a very big gap in LBW incidence in the highest (15.5 percent) and lowest wealth index (21.8 percent) population. A wide variation in the incidence of LBW is noted amongst the states in the country—highest incidence rate of 23.4 percent in MP and the lowest rate of 2.2 percent in Mizoram.

10. Prevalence of Micronutrient Deficiencies

In addition to undernutrition (underweight, stunting and wasting) in women and children, deficiencies of micronutrients such as iron, vitamin A, folic acid, iodine and zinc remain a major public health problem in India. The severe form of these micronutrient deficiencies has reduced significantly but the subclinical form of these deficiencies, often referred as hidden hunger, is a public health problem of concern (Fig 21).

a. Iron Deficiency Anaemia:

As presented in Fig 22, Iron deficiency anaemia (IDA) occurs in all the age groups in both males and females

Figure 22: Prevalence of Anaemia in Different Age Groups in India Source: NNMB, 2012

Figure 21: Reduction in Clinical Signs of Malnutrition

0

1

2

Kwashiorkor and otherrelated signs

1975-79

Perc

ent

Nutritional Deficiency Signs

1.2

0.20.8

0

1.8

0.7 0.70.2

5.7 5.7

2.1

0.3

Bitot Spots Angular Stomatitis

3

4

5

6

1988-90

1996-97

2011-12

Children < 5 years Adolescent girls* Women in reproductiveage*

Pregnant Women

Perc

enta

ge

26.3

40.2

2.9

69.5

39.1

14.9

1.7

38.9

15.5

1.8

56.2

25.830.6

2.2

58.755.8

Mild anaemia (10.0 - 10.9 g/dl)

Severe anaemia (<7.0 g/dl)

Moderate anaemia (7.0 - 9.9 g/dl)

Any anaemia (<11.0 g/dl)

0

10

20

30

40

50

60

70

80


As indicated in Fig 23, recent survey findings indicate anaemia prevalence rate is in fact far worse -higher than 75 percent in all age groups and sex. (CAB, 2014)

The implications of iron deficiency and anaemia are serious across all age groups but are of special concern during pregnancy and childhood. Maternal iron deficiency anemia prior to and early pregnancy places mother at increased risk of significant decrements in foetal growth, preterm birth or low birth weight delivery (Allen, 2000; Scholl, 2005). In South Asia, most women enter pregnancy anaemic. Anemia rates in non-pregnant women is also reported to be high in most of the large South Asia countries, including India - 25 percent Afghanistan, 46 percent Bangladesh, 55 percent India, 36 percent in Nepal, 28 percent Pakistan and 16 percent in Maldives. (UNICEF, 2007; UNICEF, 2009) Anaemia situation worsens during pregnancy with higher requirements for iron. It is estimated that on an average 56 percent of pregnant women in developing countries are anaemic compared to 18 percent of pregnant women in developed countries. (Allen, 2000; Abu-Saad & Fraser, 2010)

Anaemia during pregnancy accounts for one fifth of maternal deaths and adversely affects the brain development of foetus. State-wise prevalence rates vary widely. As per NFHS 3 survey, the prevalence rates of anaemia is higher than 40, per cent in women in reproductive age group, indicating iron deficiency anaemia to be a severe public health problem, in all but five states (Punjab, Manipur, Mizoram, Goa, Kerala) where it is a moderate public health problem. Women often enter pregnancy anaemic. In case of adolescent girls, recent data indicates the prevalence rates of anaemia continue to be high (CAB, 2014).

In children, anaemia results in poor attention span, lowering of school performance. Micronutrient deficiencies also contribute to stunting. In children 6-59 months, anaemia is a serious public health problem. In case of children, anaemia rates are less than 40 per cent only in the state of Goa (Table 5).

The primary reason for high prevalence rate of anaemia is poor intake of dietary iron, low availability of iron from cereal-based diet as well as poor consumption of animal foods or haem iron due to cultural practices or cost in most South Asian countries, including India (WHO, 2011). Moreover, iron is available in Indian diet primarily from wheat and polished rice which is not biologically available.

Figure 23: Anaemia Prevalence Rate in Children, Adolescent Girls and Women in 9 High Burden States Source: CAB, 2014

Assam Bihar Chattisgarh Jharkhand MadhyaPradesh

Odisha Rajasthan UttarPradesh

Uttarakhand

Children (6-59m) Adolescent girls (10-17 yrs) Women (18-59 yrs)

0

20

40

60

80

100

78.9

89.2 90

80.7

88.1 87.2

63.8

76 76.4 78.483.1 83.5

76.3

84.8 83.7

70.878.4 77.7 77

81.4 82.686.8

92.3 91.594.4 92.9 92.9


b. Vitamin A Deficiency (VAD):

Clinical forms of VAD such as Bitot’s spot has reduced significantly with the introduction of policy on vitamin A supplements (VAS) (Fig 21). The implications of VAD on immune response and child mortality are well recognised. The recent RSOC data reveals that the VAS coverage in the country has increased substantially following the introduction of the biannual strategy for administration of VAS (Fig 24).

In pregnant women, VAD causes night blindness and may increase risk of maternal mortality. Globally, 7.8 percent pregnant women are reported to have night blindness. Data on night blindness from India is not available.

c. Iodine Deficiency Disorders:

Iodine deficiency during pregnancy can cause dysfunction of thyroid gland and may impair neurological development in foetus.

With deprivation of iodine in soil due to gradual soil erosion, there is poor content of iodine in food produced and drinking water. In fact, no state in India is free from poor iodine in the diet consumed. Daily consumption of salt fortified with iodine is therefore the public health measure to prevent deficiency of the micronutrient.

>70 % Bihar (78%), Madhya Pradesh (74.1%), Uttar Pradesh (73.9%), Haryana (72.3%), Chhattisgarh (71.2%), Andhra Pradesh (70.8%), Karnataka (70.4%), Jharkhand (70.3%)

>40- <70 % Manipur (41.1%), Mizoram (44.2%), Kerala (44.5%), Himachal Pradesh (54.7%), Arunachal Pradesh (56.9%), Delhi (57.0%), Jammu & Kashmir (58.6%), Sikkim (59.2%), West Bengal (61.0%), Uttaranchal (61.4%), Tripura (62.9%), Maharashtra (63.4%), Tamil Nadu (64.2%), Meghalaya (64.4%), Orissa (65.0%), Punjab (66.4%), Assam (69.6%), Gujarat (69.7%), Rajasthan (69.7%)

<40% Goa (38.2%)

Table 5: Prevalence of Anaemia in Children (6-59 Months) State Wise

Anaemia Prevalence State

Source: NFHS-3, 2005-06

Figure 24: Increase in VAS Coverage: 2005-6 and 2013-14

Total Rural Urban

18.2

45.2

17.7

43.8

19.7

48.3

NFHS-3 (2005-06) RSOC (2013)

0

10

20

30

40

50


Universal use of iodised salt is the policy of Government of India. As per the recent RSOC survey (Fig 25), almost 70 percent of population consumes salt with adequate level of iodine (>= 15 ppm). Increasing trend in iodised salt has resulted in a significant drop in disorders caused due to iodine deficiency. Information on subclinical deficiency is expected to be available by 2017 following completion of the on-going nation-wide micronutrient survey.

Besides these three micronutrient deficiencies, poor dietary intake of folic acid, B12 and zinc result in a number of public health problems such as neurological problems and also contributing to anaemia, lowering immune response etc. Dietary intake data reveals a poor food diversity scenario in the country.

11. Dietary Consumption of Micronutrients

The primary cause of these deficiencies is low intake of these nutrients in our daily diet. NNMB data for rural households, young children and pregnant mothers indicate intake of micronutrients is much below the recommended dietary allowances (RDA). Intake of micronutrients such as vitamin A, iron, folic acid is poor across all the members who are “at risk of nutrition” i.e. children 1-3 years, girls 13-15 years, and pregnant women. The situation is worst in case of pregnant women within the household. Over 70 per cent children 1-3 years consume less than 50 per cent RDA of vitamin A, calcium and vitamin C. Over 80 per cent population across all age groups consume less than 50 per cent RDA of vitamin A (Table 6). The situation of poor micronutrient intake in daily diet is also observed in the age group of 4-7 years and 7-9 years. In rural India, only 23.0 percent adolescent girls, 15.2 percent adult women and 9.6 percent pregnant women are reported to consume over 70 percent RDA of iron (NNMB 2012).

Figure 25: Households Using Adequate (At Least 15 ppm Iodine) Iodised Salt in India

Total Rural Urban

51.1

67.4

41.2

61.3

71.5

79.7

NFHS-3 (2005-06) RSOC (2013)

0

10

20

30

40

50

60

70

80


Table 6: Average Consumption of Food Items and Percentage Consuming Less Than 50 Percent of the Recommended Dietary Intake (RDI) of Various Food Items

Food Items Households Children Adolescent girls Adult women Pregnant

(1-3 yrs) (10-12 yrs) sedentary women

(> 18 yrs)*

Median+ SD < 50% RDI Median+ SD < 50% RDI Median+ SD < 50% RDI Median +SD < 50% RDI Median + SD

*Intake of foodstuff as % RDI not given for pregnant women

Source: NNMB Survey, 2012

Source: NNMB Survey report, 2012

Cereal & millets 375+121 9 131+82 33 289+124 20 341+136 14.1 354+138

Pulses 31+33 43.5 15+18 65 25+26 54.4 28+32 48.8 34+39

GLVs 18+44 81.6 7+20 89.4 13+31 83.4 19+45 85 18+43

Other vegetables 46+65 54.3 13+26 68.4 34+48 55.7 49+68 48.1 47+65

Roots & tubers 63+73 42.1 21+33 47.1 50+59 39.9 70+78 37.5 60+67

Milk & milk 85+121 64.9 86+144 80.8 59+95 84.1 82+120 56.7 79+107 products

Fats & oils 15+13 39.8 6+7 87.5 11+10 65.7 15+13 45 16+13

Sugar & jaggery 13+16 69.7 10+14 77.9 10+15 91.1 13+15 57.2 13+16

Table 7: Percentage of Households, Young Child, Adolescent Girls and Pregnant Women Consuming Less Than 50 Percent RDA of Various Nutrients

Percentage consuming < 50 per cent RDA of nutrients

Nutrients Households Young child (1-3 yrs) Adolescent Girls (13-15 yrs) Pregnant women

Protein 11.2 11.7 16.8 35.7

Total Fat 13.1 56.0 53.2 19.6

Energy 7.6 28.1 22.6 13.7

Calcium 44.2 74.1 74.7 76.1

Iron 25.5 48.9 67.3 78.0

Vitamin A 80.6 81.5 83.6 83.2

Thiamine 9.8 21.9 20.1 16.1

Riboflavin 49.6 52.5 68.3 52.5

Niacin 9.7 40.7 15 13.4

Vitamin C 34.9 76.9 44.9 50.6

Dietary folate 38.5 40.3 51.5 72.0

Intake of iron is poor through the life cycle (Table 4 and 6). The situation in fact is worse since the source of dietary iron is mainly cereals which unlike iron from flesh food is poorly absorbed and not available to the body. Poor intake of vitamin C worsens the situation of bio-availability of iron resulting in high prevalence of anaemia.

As per the NNMB 2012 report from rural region of 10 states of India indicates intake of good quality protein, fat ,vitamin A, iron or folate, calcium is extremely poor (Table 7 ). This is primarily due to poor intake of green leafy vegetables and other vegetables, milk and milk products or pulses. Diet lacks diversity in diet and is cereal dominated.


12. Overnutrition: An emerging problem

The problem of overweight and obesity is increasing in India. There is therefore a dual problem of malnutrition–undernutrition and overnutrition (Fig 26). This trend has been attributed to change in dietary habits and increase in living life style.

As indicated in Fig 26, the prevalence rate of overweight is almost three times in the urban region as compared to rural areas. However, there is an increasing trend in overweight even in rural region. The problem varies across states and is highest in the states of Punjab and Kerala. In prosperous states of India, such as Punjab, Kerala and Delhi, almost a third of women are overweight (Fig 27). Today, India has the dual problem of overnutrition and undernutrition - a great public health challenge. life style.

Figure 26: Overweight Prevalence in Indian adults (15-49 yrs): By Residence Source: NFHS-3, 2005-06

Rural Urban

7.45.6

23.5

15.9

Women Men

0

5

10

15

20

25


Figure 27: Statewise Prevalence of Overweight/Obese among Indian Adults (15-49 years) Source: NFHS-3, 2005-06

WomenMen

0

India

Percent prevalence rate of overweight / obese

Punjab

Kerala

Delhi

Tamil Nadu

Goa

Haryana

Gujarat

Jammu & Kashmir

Andhra Pradesh

Sikkim

Karnataka

Maharashtra

Himachal Pradesh

Manipur

Uttaranchal

West Bengal

Mizoram

Uttar Pradesh

Rajasthan

Arunachal Pradesh

Assam

Madhya Pradesh

Tripura

Orissa

Nagaland

Chhattisgarh

Jharkhand

Meghalaya

Bihar

51 01 52 02 53 0


13. Determinants of Malnutrition in Women and Children

Malnutrition is a complex multi-determinant problem (Fig 28) with immediate, intermediate and underlying determinants. (UNICEF, 1998)

a. Immediate Determinants of Undernutrition in Children:

The immediate causes of malnutrition are diet and disease. Inadequate dietary intake and nutrient consumption is critical especially in the rapid growth period such as during foetal growth and early childhood when the demands for nutrients increases substantially.

i. Feeding Practice During Pregnancy: Dietary requirement during pregnancy increase substantially. According to FAO/WHO/UNU (2004), the additional energy requirement during pregnancy is 85 Kcals per day in the first trimester, 285 Kcals per day in the second trimester and 475 Kcals per day in the third trimester. As per the India recommendation, a normal weight woman before pregnancy requires an additional 350 kcals per day and this increases significantly to 600 Kcals per day additional requirement by a nursing women. The recommended daily energy requirements are 2350 kcals for pregnant women and 2600 kcals for nursing women. During this period of life, the requirements of micronutrients such as iron, folic acid, vitamin A, iodine increases significantly and is important for the health and growth of

Figure 28: Immediate, Intermediate and Underlying Determinants of Undernutrition

MATERNAL AND CHILD UNDERNUTRITION

CHILD UNDERNUTRITION

CAUSES

IMMEDIATE

• Inadequate dietary intake

• Disease

INTERMEDIATE• Household food insecurity• Inadequate care, feeding practices & health services• Unhealthy environment

UNDERLYING• Household access to adequate

quantity and quality of resources (land, education etc)

• Inadequate financial, human, physical & social capital

• Socio cultural, economic & political context

• DIRECT Nutrition Interventions• Infant and Young child : Feeding, hygeine & Supplementary

nutrition, micronutrient supplementation• Adolescent and maternal nutrition - Additional food, IFA• Health service - Immunization, antenatal care (ANC), diarrhoea

management

• INDIRECT Nutrition sensitive• Agriculture/horticulture (production, access & consumption)• Women’s care and development (Health, economic and social)• Improve water and sanitation

• Poverty reduction, building human nutrition manpower / institution, supportive political framework, improved governance

INTERVENTIONS


the foetus and infants and for the health of the mother. As per the National Nutrition Monitoring Bureau (NNMB) Survey undertaken in 10 states of the country, the average calorie intake of pregnant woman is 2081 kcal This implies a gap in energy intake of 270 kcal/day in pregnant woman, assuming that the women are well nourished to begin with.

Available dietary intake data reveals that in India, there is no increase in dietary intake of nutrients during pregnancy (Fig 29). Such poor dietary intake is a primary contributory cause of low birth weight and poor start in life.

Available dietary data from eight states of the country for rural region (NNMB, 2012) reveals improving dietary intake during pregnancy phase is given no special attention despite a much higher requirement for various nutrients (Fig 29). Consumption of mean energy and protein is almost identical in pregnant (1773 Calories and 49 grams protein) and adult non-pregnant women (1709 Calories and 47 grams). The percentage of calories from protein is only 11 percent against the recommended level of 25 percent. Only 61 percent of pregnant women report consuming over 70 percent of the recommended dietary allowances (RDA) of energy while only 30 percent consume over 70 percent RDA of protein. No increase in intake of iron, vitamin A and calcium is observed during pregnancy with less than 10 percent consuming >70 percent RDA of iron and calcium while only 13 percent are reported to be consuming >70 percent RDA of vitamin A. (NNMB 2012) Poor dietary intake during pregnancy and the preconception stage results in poor weight and thinness.

The primary reason for poor dietary intake seems to be lack of knowledge regarding appropriate dietary care during pregnancy since there is evidence from Northern India that intensive counselling to pregnant mothers significantly increased calorie consumption. (Garg & Kashyap, 2006) The socio-economic factors which contribute to poor dietary intake are discussed in the follow up section on the “underlying causes “of undernutrition.

Poor diet results in low weight and thinness in women. The association of weight of women on birthweight is well documented. It is estimated that 50 percent of poor growth sets in womb. In India, as indicated below (Table 8) mean birth weights of infants born to mothers below 45 kg is reported to be about 2639.6 g as compared to mean birth weight of 2779.1 g in mothers weighing 45-54 kg compared to 3009.41 g in case of mothers 55 kg and above. (Ramachandran, 1989)

Figure 29: Daily Dietary and Nutrient Intake of Pregnant & Non-Pregnant Women Source: NNMB, 2012

0

50

100

150

200

250

300

350

400

341354

Average intake of food stuff

Women

Cereal &Millets

Pulses &legumes

Nuts & Oilseeds

GLV’s

28 3419 18

87

02 04 06 08 0 100

% consumed < 50% RDA of nutrients

Pregnant Women

Dietaryfolate

Calcium

Iron

Vit A

Protein

Energy7.7

13.7

15.1

35.7

80.7

83.2

68.3

78

45.1

73.1

46.4

72


A recent prospective study from Vietnam concludes maternal prepregnancy weight to be the strongest indicator predicting infant birth size. (Young et al, 2015) Women with pre-pregnancy weight less than 43 kg or who gained < 8 kg during pregnancy are reported to be more likely to give birth to a SGA or LBW infant.

Women’s poor nutrition, both before and during pregnancy, contribute to impairment of foetal development and contributes to low birth weights (LBW) and in turn to high rates of stunting. Maternal undernutrition reduces capacity to healthy foetal growth resulting in birth of babies who are small for the gestation or low birth weight. LBW is associated with 2.5 to 3.5 fold higher odds of underweight, stunting and wasting.

Poor dietary intake is the primary contributory factor of women’s weight. Poor maternal weight has been documented to impact maternal mortality and complications during pregnancy. Besides weight, mid upper arm circumference (MUAC) measure has also been used to assess thinness. It has been reported in a Nepal study that for each one cm increase in mid upper arm circumference (MUAC) - a measure used for assessing thinness—within the first trimester the risk of mortality decreased by 24 percent. (Christian et al, 2013) Today, for identifying pregnant women at risk of undernutrition, MUAC measurement has been recommended—women with MUAC of less than 21 cm are considered to be “at risk” pregnancy with higher chances of suffering from intra-uterine growth retardation of foetus.

ii. Infant and Young Child Feeding Practices: A one year child requires almost 2-4 fold energy, protein and fat requirements per kg body weight than an average adult. If the child is not properly fed, the growth in infancy is the first point at which the immediate and intergenerational effects of a poor nutrition are evident. In the first six months of life, nutrition needs of infants are fully met if an infant is exclusively breastfed. Breastmilk is the best and complete food for the young infant 0-6 months. After completion of 6 months, breast milk is not adequate and there is a need to complement breast feed with other food –referred as complementary food (CF). The CF needs to be energy as well as nutrient dense.

Young children under two years cannot eat by themselves and they need to be fed by caregivers. Proper feeding of semi-solid to young children is of great challenge in our country where infants and young children are largely fed cereal based diets. The significance of correct time of introduction of CF, appropriate frequency of feeding semi-solid per day and of ensuring appropriate nutrient density of CF is often not known to mothers. Additionally, inadequate time available with caregivers for feeding also influences appropriate IYCF practices being followed by a family. The belief that undernutrition in young children is primarily caused by poor availability of food or hunger situation at family level is not correct. Available data on dietary intake (NNMB, 2006) indicates that in families where 80 % adults are reported to be consuming 70 per cent of the recommended energy and protein, only a third (30.1%) of 1-3 years age group consume such adequate levels of energy and protein (Table 9).

Source: Ramachandran, 1989

Table 8: Association of Maternal Body Weight on Birth Weight

Effects of maternal body weight on birth weightMother weight (Kgs) No. Mean Birth Weight (g)

< 45 128 2639.6

45-54 251 2779.1

> 55 96 3009.41

Total 475 2788.0


A mother is not aware of the significance of diversifying the food or the need to make the food energy and nutrient dense for preventing undernutrition. Simple solutions such as adding little fat or oil in the food mixture being fed to child increases calorie density of food. Additionally, daily feeding of some pulses and locally available seasonal vegetables incorporated in cereal based feed of child is important for enriching the nutrient content. Such food diversity can be further enhanced by addition of the following foods, if traditionally accepted i.e. eggs, fish, poultry flesh or milk in child’s diet. This is more feasible in situations where families have homestead garden or raise poultry or manage fish ponds.

The NFHS 3 data reveals a poor situation of IYCF in the country (Fig 30). All internationally accepted indicators (early initiation of breastfeeding, exclusive breastfeeding up to six months, timely introduction of complementary feeding) are much below the universal level.

# 70% requirements defined as energy protein adequacy Source: NNMB, 2006

Table 9: Undernutrition in Children and Protein Calorie Adequacy in Adult Women and Children

States Prevalence of Distribution (%) Distribution (%) undernutrition (%) Protein Calorie Adequacy Protein Calorie – Sedentary Adult Women# Adequacy – 1-3 year children

Andhra Pradesh 36.5 87.7 52.3

Gujarat 47.4 69.8 24.2

Karnataka 41.1 80.2 25.5

Kerala 28.8 78.6 19.4

Madhya Pradesh 60.3 77.6 33.7

Maharashtra 39.7 59.2 30.8

Orissa 44.0 93.1 24.9

Tamil Nadu 33.2 80.6 23.2

West Bengal 43.5 84.8 37.1

Pooled 41.6 80.0 30.1

Figure 30: Early Child Feeding Practices in India Source: NFHS 3, 2005-06

23.8

Breastfeeding Complementary feeding

1. Initiation of BF < 1 hr

2. Exclusive BF < 6 mo

3. Continued BF at 1 yr (12-15 mo)

4. Continued BF at 2 yr (20-23 mo)

5. Age appropriate BF (0-23 mo)

6. Timely introduction of CF (6-8 mo)

7. Minimum meal frequency (6-23 mo)

8. Minimum dietary diversity (6-23 mo)

9. Consumption of iron-rich foods (6-23 mo)

10. Minimum acceptable diet (6-23 mo)

45.5

89.4

74.8

65.2

52.9

42.9

15.8

10.3 10.0

100

50

0

Cove

rage

(%

)


Recent RSOC (2013-14) survey findings (Fig 31) indicate nearly half of the newborn (46.5 percent) are initiated to breastfeeding immediately within one hour, while there is significant improvement in exclusive breastfeeding (EBF) practices to 71.6 percent. The situation of CF continues to remain rather poor—half of children aged 6-8 months are fed CF. However frequency of feeding CF is poor in breastfed children (36 percent) and children receiving minimum dietary diversity (complementary feeding to include four or more food groups) is reported to be only 20 percent.

An analysis of child feeding practices with reference to social category reveals that the practice of initiating breastfeeding within one hour of birth is much better in ST population (54.7 percent) as compared to the SC population (43.1 percent) or OBC (42.3 percent) or others (44.8 percent). The practice of EBF is almost similar in all the social categories (between 4-67 percent). However, introduction of CF at the right age is noted to be only about 45 percent in both SC and ST class compared to 50.8 percent in OBC and 55.6 in other category. Frequency of feeding recommended number of times CF to breastfed children was low – only a third of children were fed CF using recommended frequency. The pattern of frequency of feeding was similar across all social categories (ranging from 34.7 percent to 37.8 percent).The difference in dietary diversity is noted in various social categories. The recommended use of diversity in food was found to be much lower in SC (17.9 percent) and ST (16.6 percent) compared to others (24.1 percent). Similarly the difference in percentage of breastfed children being fed with minimum food diversity differs significantly with wealth index status – being 14.2 percent in the lowest wealth index and 26.5 percent in the highest wealth index. As per the RSOC data, the overall situation of IYCF in the country is far below the level required for optimum nutrition provision in 0- 24 months of life. The data reveals that in case of scheduled tribe and scheduled caste infants, there is a need to pay special attention to complementary feeding practices and in ensuring recommended frequency of feeds and diet diversity is maintained.

Another major feeding problem is inappropriate feeding practices or withholding food during illness and making no special effort to feed during convalescence. Absence or discontinuation of breastmilk prior to 24 months further adds to the problem of undernutrition. The situation worsens with frequency of infections which results in loss of nutrients. The available national data of NFHS-3 reveals that not even 3 per cent children are fed the recommended additional amount of food during and after episode of diarrhoea.

Figure 31: Infant and Child Feeding (IYCF) Practices: Shift Between 2005-6 and 2013-14

0

10

20

30

40

50

60

70

80

24.5

44.6

49.2

64.9 63

50.5

44

36.3

Breastfeedingwithin 1 hour

ExclusiveBreastfeeding

(birth-6m)

Introduction tocomplementaryfeeding (6-8m)

Breast-fedchildren (6-23m)fed min. number

of times

NFHS - 3 (2005-06) RSOC (2013)


As indicated in Tables 4 and 6, NNMB data (NNMB, 2012) reveals that the intake of food items such as pulses, vegetables and milk in rural India remains rather low in a very high percentage of child population 1-3 years. In the daily average diet, 65 percent children consume less than 50 per cent recommended dietary intake (RDI) of pulses. Such a poor intake of pulses reduces the quality of protein consumed through cereal dominated diets. Eight out of 10 children 1-3 years consume less than 50 percent of recommended dietary intake of milk. Over 85 per cent children consume less than 50 per cent RDI of fats and oils resulting in poor energy density of food consumed by young children. Intake of green leafy vegetables (GLVs), a rich source of a number of micronutrients, is poor across all age groups.

Lack of knowledge of mother regarding appropriate breastfeeding and complementary feeding practices, poor feeding practices during and post illness, inadequate purchasing power or access to diversified food, inadequate time for feeding, poor hygiene practices adversely influences appropriate child feeding. Moreover, it is crucial to take care of diet of all lactating women and ensure that not only additional calorie intake is taken care of but there is sufficient intake of micronutrients to enhance levels of micronutrients in breastmilk.

iii. Ill-health and Undernutrition: Besides poor child feeding, the other immediate cause of undernutrition is frequent infections and worm infestations. A frequent episode of infections in early childhood as well as throughout life sets up a vicious cycle of poor appetite, ill-health, poor nutrient absorption and malnutrition (Fig 32). Frequent morbidity reduces the absorption of food.

High prevalence rate of diarrhoea and poor management of children suffering from diarrhoea are important contributory factors of undernutrition. The RSOC survey findings reveal diarrhoea prevalence rate to be 6.4 percent while the ARI prevalence is reported to have increased to 8.6 percent in 2013 compared to earlier NFHS-3 report of 5.8 percent. This implies that even in situations where food consumption is adequate and meets the nutritional requirements, infections including diarrhoea hampers absorption of nutrients or increase loss of nutrients. Infection and illness are immediate causes of undernutrition.

b. Underlying Determinants of Undernutrition:

These include factors which influence the immediate and intermediate determinants described above. The underlying determinants therefore include factors such as inadequate access to food, poverty and poor purchasing power, poor hygiene practices, poor access to safe water, in adequate sanitation facilities, poor coverage with health services such routine immunisation, prevention and management

Figure 32: Undernutrition: Dietary Intake and Infection Cycle

Weight Loss, GrowthFalterning, ImmunityLowered, Mucosal Damage

Appetite loss, Nutrient loss, Malabsorption, Altered metabolism

Disease: Higher incidence, Severity, Duration

Inadequate dietary intake

Dietary Intake Infection Cycle

Source : Mission Poshan, 2006


of diarrhoea, antenatal care and women’s nutrition and poor socio-economic and decision making power of women.

i. Poverty and Poor Purchasing Power: Poverty is the basic cause of undernutrition in children. Poverty and low income contributes to undernutrition by adversely influencing food and nutrition security, housing and living environment with increased risk of ill health, frequent infections, frequent pregnancies, large family size and undernutrition. Poor population have a low access to health and family planning services and are often involved in hard physical labour which also contributes to poor nutrition. This further contributes to direct loss in productivity from poor performance at work, loss in resources from increased health care costs of ill health as well as indirect loss in productivity from poor cognitive development and schooling. This sets up a vicious cycle of poverty and malnutrition. However, it may be noted that poverty resulting in poor purchasing power is a basic and not the sole cause of undernutrition in children.

ii. Inadequate Access to Diversified Food: Recent report of Global Hunger Index (GHI) 2015, positions India at a rank of 80 in the group of 117 countries (Table 10). India with a GHI of 29.0 is reported to be in the serious alarming category along with other south Asia countries. The GHI index combines the following four component indicators in one index—undernourished people as a percentage of population, proportion of children under five years with wasting, proportion of children under five years with stunting, and child mortality. The index captures both food supply and diversity.

The sustainable development goals (SDGs) signal a renewed commitment to end hunger and global poverty by 2030. The goal 2 states “to end hunger, achieve food security and improved nutrition, and promote sustainable agriculture”. For achieving the goal, it is critical to ensure all people, in particular the poor and people in vulnerable situations, have access to sufficient nutritious food all the year round”. (Global Nutrition Report, 2015)

The available data on the dietary intake in rural India (NNMB, 2012) reveals a poor intake of diet across households in each of the age groups (Tables 4, 6). This is reflected in poor consumption of protein and micronutrients in the various age groups. Unfortunately, no such dietary data is available for the states of Bihar and Uttar Pradesh which have the highest incidence of underweight and stunting rates.

The cause of poor availability of food is primarily due to low purchasing power, high cost of foods

Shift focus from cereal centric diet to diversified diet with improved protein quality (pulse production)** GHI: Serious 20.4 - 34.9Source IFPRI 2015

Table 10: Global Hunger Index (GHI): Situation in India and Other South Asia Countries

Global Hunger Index (GHI)** : South Asia 2015

Countries GHI Score Ranking (117 Countries)

Nepal 22.2 58

Sri Lanka 25.5 69

Bangladesh 27.3 73

India 29.0 80

Pakistan 33.9 93

Afghanistan 35.4 97


other than cereals, dependency on market price and availability, poor production of pulses and high cost, high cost of milk and milk products, fish and dairy products. There is a poor availability and poor understanding of the significance of regularly consuming seasonal and varied vegetables and fruits. There is market dependency for seasonal vegetables even in rural regions. There is lack of interest in growing seasonal vegetables as a homestead garden and using an appropriate method of storage for retention of nutrients in seasonal vegetables and for usage in dry seasons.

Lack of attention to increasing dietary intake during pregnancy or eating diversified diet through the life cycle is attributed not only to poor knowledge but to poor purchasing power, poor availability of variety of foods, inadequate effort to grow vegetables and fruits in the backyard, as well as an incorrect common cultural practices of “eating down” or “eating last” during pregnancy which is prevalent in some regions of India. These contributory factors are crucial determinants and need to be addressed.

iii. Poor Water, Sanitation and Hygiene (WASH) Practices: In the past decade, there is increased evidence regarding the nutritional consequences of sanitation. Faecal pathogens are important threat to nutritional outcomes. This is particularly strong with regard to open defecation i.e. defecating without using a toilet or latrine. India has one of the highest open defecation rates in the world—much higher than sub-Saharan Africa.

According to NFHS 3 data, 77.9 percent had no improved toilet facility while the situation in 2013-14 (RSOC, 2013-14) has improved with 59 .2 percent being in this category. In 2005, no access to drinking water is reported to be 12.1 percent while in 2013-14, the percentage households who have no access to drinking water is reported to be 9 percent. Poor sanitation practice is also common. Recent RSOC data indicates 45 percent households practice open defecation and 90 percent of poorest defecate in open. Open defecation is very high among households in central India (Orissa, Jharkhand, Bihar, Chhattisgarh, MP, Rajasthan and Uttar Pradesh). Around 80 percent households not using toilets are among SC, ST and OBC families. Interestingly, the percentage is lower in ST families (17 percent) compared to SC (25 percent) and OBC (40 percent).

Today, there is evidence of the relationship of open defecation on increase in stunting rates in young children. A strong association between reductions in density of open defecation and improvement in child height has been documented. This implies poor sanitation results in high infection exposure with high incidence of diarrhoea and parasitic infections with adverse effect on effective utilisation of dietary nutrients consumed. It is also hypothesised that “environmental enteropathy” (EE) could be the important contributory cause of undernutrition. EE is a complex disorder of the intestine – an inflammatory response to ingestion of large quantities of faecal germs. According to Spears and Haddad (2015) “EE could be an important cause of poor nutritional outcomes by reducing the ability of child’s intestine to absorb nutrients – possibly without appearing to suffer from obvious illness, such as diarrhoea.”

A recent Bangladesh study emphasizes that in addition to improving diet, appropriate hand washing with soap and water is much more important than merely reducing open defecation practice from 42 percent to one percent in the country. In India, data on hygiene practices is limited. Data from the State of Uttar Pradesh of 2004 indicates that only 34.8 per cent of the mothers interviewed had washed their hands with soap and water after defecation. The HUNGaMA report from 100 districts also indicate that hand washing with soap is rather an uncommon practice—only 11 percent mothers washed hands before a meal while 19 percent reported washing hands after a visit to the toilet. (HUNGaMA survey, 2011)

iv. Insufficient Health Services for Women and Children: Full immunisation coverage is crucial for preventing vaccine preventable diseases and breaking the infection – undernutrition cycle. As per the RSOC data, there has been a gradual increase in full immunization coverage –from 43.5 percent in 2005 (NFHS-3) to 61.0 percent in 2009 (CES, 2009) to 65.2 percent in 2013 (RSOC). It is reported that close to 7 percent children (12-23 months) are not immunized at all while 28 percent are partially immunized.


Similarly, there is poor coverage of children with diarrhoea management - roughly only half of children who had diarrhoea received oral rehydration solution/ home available fluids (ORS/HAF).

The association of antenatal care (ANC) services with stunting rates in children have been well demonstrated. (Hueston et al, 2003; Khanal et al, 2014) It is indicated that adequate ANC visits are likely to influence improvements in dietary practices, weight gain and introduction of timely interventions for preventing LBW. Studies in Bangladesh and Bhutan also report odds of stunting are much higher in cases where mothers do not receive ANC or appropriate health services at delivery by skilled health professionals. (Hong et al, 2006; Aguayo et al, 2014)

The RSOC survey (2013) findings reveal pregnant women receiving three or more ANCs has increased to 63 percent as compared to 52 percent reported by NFHS 3 (2005-6). Pregnant women delivered by skilled health provider have also increased from 47 percent in 2005 to 81 percent in 2013. The RSOC findings indicate very positive scenario of ANC with reference to about 84 percent registering pregnancy, 73 receiving MCPC (Mother-Child Protection Card) while 62 percent also having one ANC check up in the first trimester itself. However, the frequency of four or more ANC visits recommended is rather low (45 percent) and the provision of full ANC services is extremely poor - only 14 percent received full ANC and 21 received or purchased 100 or more iron folic acid (IFA) tablets.

v. Social Status of Women: As presented in below (Fig 33), undernutrition in women sets up an intergenerational cycle of undernutrition. Maternal undernutrition is estimated to account for 20% of childhood stunting. (WHO, 2014) Women’s nutrition plays a crucial role in optimising pregnancy outcome and influencing maternal, neonatal and child health outcomes. (Mason et al, 2012)

An analysis of current evidence indicates that constraints on women’s resources influence immediate determinants of nutrition as well as the other underlying causes. These resources (as shown in Fig 34) encompass not only wealth but education, decision making power, health benefits, access to services such as mobility, maternity benefits, crèches etc. (Vir, 2016) Lack of such resources and low status of women in India and other South Asia countries has been postulated to be a significant contributor to unusually high rate of undernutrition in children in South Asia. (Ramalingaswami et al, 1996) Poor socio-economic status of women not only effect foetal growth and pregnancy outcome but also adversely impacts behavioural practices pertaining to appropriate self and child care which contribute to low BMI in women and stunting in children. Today, there is increasing evidence and recognition among scientific community that it will be difficult to achieve rapid and significant progress in reducing childhood stunting without simultaneously addressing the underlying socio-economic causes which adversely influence nutrition of women. (Smith & Haddad, 2015) A recent regression analysis in India reveals that

Figure 33: Intergeneration Cycle of Undernutrition

Child Growth Failure

Short Adult Women

Low Weight and Height in Teenagers

Early PregnancyLow Birth Weight Baby

Integenerational Cycle of Undernutrition

Source : State of the World’s Children, 1998


Figure 34: Constraint of Women Resources: Implications on Nutrition Specific and Nutrition Influencing Interventions Source: Vir (2016)a

Crucial: Resources Women/ Maternal

Implications: Resources Constraints

Effect: Women Life Cycle

Outcome: Poor Growth and Childhood Stunting

• Wealth/ income/ cash-in-hand

• Food security through the year

• Health

• Education/Knowledge

• Employment

• Family/ social support

• Access to facilities

- Health services

- Social protection support subsidised feeding, CCT)

- Maternity benefits

- Clean water

- Sanitation

- Safe/hygiene house

- Cooking fuel

- Time &energy saving devices

- Mobility freedom

- Mass media

Nutrition Specific Factors• Poor household food security and diversity • Sub-optimal child caregiver behaviour practices: feeding, health, hygiene• Poor nutrient intake and health care of adolescent girls & women • Inadequate protection from infection/ infestation

Nutrition Sensitive Factors• Poor decision making & purchasing power• Poor attainment of secondary education • Unhealthy living conditions with poor water-sanitation facilities• Early marriage & conception• Poor time availability• Inadequate substitute child care providers• High workload & physical expenditure• High domestic violence, psychological stress, poor mental health • Large gap in age & education level of women & her spouse

Inadequate care giving behaviours (0-24m)• Anaemia• Growth failure

Neglected adolescent care• Optimum height gain hampered• Thinness• Anaemia

Poor care: preconception/ newly-weds• Stunted adult women (<145cm)• Low BMI (<18.5 Kg/m2 • Anaemia

Inadequate pregnancy care• Weight gain <10-12kg• Anaemia • Impairment of fetal development (IUGR, preterm birth)

• Higher incidence of Low Birth Weight : Failure to catch up normal height

• Hamper optimum growth <24 months : largely irreversible

Increased incidence ofchildhood stunting

Source: Adhikari et al, 2014; Vir et al, 2013; Heady & Hoddinott, 2013; Bhagowalia et al, 2012

Table 11: Highest Risk Factors for Stunting in Young Children: India, Bangladesh and Nepal

High Risk Factors Associated with Stunting

India Bangladesh Nepal

No education of mothers Domestic violence Maternal Height

Maternal Height Decision making power Water

Mothers with no Institutional delivery Maternal Height Open defecation

Households with low standard of living Secondary education Born in hospital

Households with no toilet facility Wealth quintile ANCs visits - or more

– – Maternal education


the five highest loading risk factors contributing to child undernutrition are related to status of mothers such as nutritional status, health care, education, domestic violence and social status as well as poor toilet facility (Adhikari et al, 2014) (Table 11). Interestingly, data from other South Asian countries also indicate that women’s height, level of education, Body Mass index (<18.5 being an indicator of being undernourished) are important determinants of stunting in children. (Bhagowalia et al, 2012; Headey et al, 2014) It is therefore evident that nutrition sensitive issues pertaining to women’s status are important determinants of undernutrition in children.

vi. Excess Energy Expenditure: Besides dietary intake, excessive energy expenditure due to heavy workload adversely influences pre-pregnancy weight, body mass index of women and gestational weight gain during pregnancy. Studies have demonstrated that in situations where energy intake is suboptimal, manual physical activity during pregnancy lowers weight gain during pregnancy with increase in incidence of SGA and lower birth weights babies. (Tafari et al, 1980; Launer et al, 1990) In rural India, high levels of daily physical activity, related to agriculture and domestic activities, has been reported to have an inverse relationship with birth weight. (Rao et al, 2003) A direct relationship between maternal physical activity and birth weight has also been reported. (Muthayya, 2009)

Working in farms or fetching water are other activities which are reported to have a significant inverse relationship to birth size even after adjusting for maternal co-founding factors. (Rao et al, 2003) Farming activities reveal a seasonal energy stress on women depending on lean or harvesting agriculture period with its impact on energy balance and impact on pregnancy outcome. Reduction in activity during harvest season, when food is in plenty, has been proposed for improving birth size of farming communities.

vii. Early Marriage, Adolescent Pregnancy and Poor Height of Women: During adolescence, up to 50 percent adult weight and 20 percent adult height is attained. (UNICEF, 2015) Besides poor nutrition intake, early marriage and early conception hampers the growth during adolescence which is the last chance of attaining growth. Early conception is an important factor influencing stunting and underweight in children. The newborns of adolescent mothers are more likely to be LBW. Moreover, stunting that would have occurred in the adolescent girls in the first 2 years of life, being largely irreversible, also interferes with optimum catch up growth in the adolescent age. Poor adult height therefore sets up a cycle of poor nutrition in preconception stage, poor foetal growth during pregnancy, LBW and undernourished children.

In India, the percentage of women with poor height (below 145cm) is reported to be 11.4 percent (NFHS-3). There is a wide variation amongst states. Three states with highest percentage of women with poor height is Meghalaya (21.6 percent), Tripura (19.2 percent) and Jharkhand (18.0 percent) while only three states (Haryana, Punjab and Jammu and Kashmir) have less than five percent of women in this category of height below 145 cm.

viii. Women’s Empowerment: An analysis of data of three developing regions (South Asia, Sub -Saharan Africa and Latin America and Caribbean) confirms women’s decision making power relative to men has a powerful effect on nutritional status of children. (Smith et al, 2003) The impact is through the following two pathways which are influenced by empowerment and a higher decision making power —firstly through improvement in self-care and prenatal care and secondly through positive influence on behavioural and child caring practices such as timely initiation of breastfeeding, complementary feeding (timely introduction, quality care), treatment of illness, immunization and quality of substitute care taking.

It has been reported that in situations where women in India have higher access to money and freedom to choose to go to market have less chances of having a stunted child as compared to women with less autonomy for such actions. (Shroff et al, 2009) Gender inequality, poor empowerment of women and poor decision making powers adversely influence socio-economic status and purchasing power, age of


marriage and conception, choice of spacing between pregnancies, level of education, experience of domestic violence which in turn impact on women’s status with serious implications on rate of childhood stunting. An association of empowerment of women with food security, dietary diversity, appropriate infant feeding practices and improved growth outcomes has been reported. (Bold et al, 2013)

Studies from developing countries have demonstrated domestic violence resulting in psychological stress is a risk factor for undernutrition. (Ackerson & Subramanian, 2008) Empowered women possibly suffer less from domestic violence and poor maternal mental health conditions. The possible factors leading to stunting is possibly through biological and behavioural pathways with adverse impact on foetal growth and pregnancy outcome as well as on self and child care behaviours.

ix. Women’s Employment: Employment status of women influences household income and influences chances of not being undernourished. (UNICEF, 2015) Owning land and having access to own agriculture products also influences risk of undernutrition. It has been documented that higher levels of autonomy gives women control over food purchasing and distribution decisions within a household. However, employment also has an adverse effect on child caring practices since mother being away on work has little time for child care. Very often children are left with the family members who are not able to provide appropriate care including feeding.

x. Women’s Education Level and Undernutrition: An analysis of NFHS-3 data indicates that the level of education beyond middle school positively impacts incidence of marriage and child bearing at young age, suffering of domestic violence, nutritional status of women (Fig 35). This association is evident in women who have ten or more years of education and is possibly a result of these women being empowered and are in a position to take decision. Moreover, these women are possibly better informed regarding appropriate child care and feeding practices, improved management of home and of the available resources as well as are better aware of their rights to services and various entitlements.

14. Improving Nutrition Situation: Evidence Based Interventions for Addressing Key Challenges

a. World Health Assembly (WHA) Targets:

Investing in maternal and childhood nutrition has both short and long term benefits which have economic and social implications such as reduced morbidity and mortality, reduced health care costs throughout life, increase in intellectual capacity, concentration capacity and educability as well as improved adult productivity. (UNICEF, 2015) Maternal nutrition is important not only for the health of the offspring for

Figure 35: Level of Education of Women and Its Impact on Early Marriage, BMI, Spousal Violence and Childhood Stunting Source: NFHS-3, 2005-06

0

10

20

30

40

50

60

70

80 76.5

18.7

40.3

46.4

57.2

64.8

19

34.9

42

48 46.2

20.1

28.732.4

40.7

14.1

23.6

16.2 16.3

27.4

No education

Perc

enta

ge (

%)

< 8 years 8-9 years 10 years and above

Mothers married by age 18 Median age of 1st brith (years)

Women who have ever experienced spousal violence Child stunting

Women with BMI below normal


Women Nutrition

Life Cycle : Critical Periods

Inadequate pregnancy care Poor child care (0-24 months) Neglected adolescent care Poor care preconception/ newlyweds

Increase in IUGR rates

Poor birth outcome Adverse e�ect on Optimum growth-largely irreversible

Reduction in material size, short stature (low heigh/BMI)

Optimum growth constrained, anaemia

Optimum weight gain hindered, anaemia

Increase in LBWs

Higher prevalence rate of stunting

Alive and Thrive statergy framework framework For scaling up Action

INTERPERSONAL COMMUNICATION& COMMUNITY MOBILIZATION

4

Improvedhealth

outcomes

1 ADVOCACY

3 MASS COMMUNICATION

STRATEGIC USE OF DATA

2

Partnerships & alliances in the health systemand other sectors for scale and sustainability

Improved knowledge

bene�tsskills and

environment

Improved breastfeeding &complementary

feeding practices

Policy Makers & legistators

Employees Studys of Multiple Sectors

Service Providers & Community Leaders

Family Mother Caregivers

well- being, productivity and progress of women. Taking these facts into consideration, World Health Assembly in agreement with member states, including India, have set the following six nutrition targets to be achieved by 2025. (WHO, 2014)

• 40% reduction of the global number of children younger than 5 years who are stunted

• Reduction in childhood wasting to less than 5%

• 50% reduction in anaemia in women of reproductive age

• 30% reduction of low birth weight

• An increase the rate of exclusive breastfeeding in the first 6 months to at least 50%

• No increase in childhood overweight

As indicated in Fig 36, it is important that life cycle approach is used for addressing the determinants which influence poor birth outcome and hamper in optimum achievement of height in the fastest growth spurt period of 0-24 months as well as adolescence. There is need to focus on pregnancy care, care of young children especially those between 0-24 months, adolescent girls and women in prepregnancy stage. Analysis of determinants and the evidence emerging from international and national experiences indicate that direct nutrition specific interventions will need to be complemented with nutrition sensitive interventions to accelerate improvement in nutrition situation through the life cycle.

b. Nutrition Specific Interventions:

i. Package of Interventions: The selected package of interventions focus directly on addressing nutrition deficits and have an impact on the prevention and treatment of undernutrition, in particular during the 1,000 days covering pregnancy and the child’s first two years. It is estimated that with at least 90 percentage coverage of the package of essential nutrition interventions, the current total of deaths in children, younger than five years, can be reduced by 15% and stunting by 20% if populations can access these ten essential nutrition interventions at 90% coverage. (WHO, 2013b)

Figure 36: Women’s Nutrition through the Life Cycle is Crucial Determinant of Stunting in Children


As per the Coalition for Food and Nutrition Security (2014), the evidence based Lancet interventions have been further modified in the context of India. These falls into the following categories: initiation of breastfeeding within one hour of birth and exclusive breastfeeding for six months, followed by continued breastfeeding till two years; introduction of complementary foods from six months onwards and provision of safe, age appropriate complementary foods; prevention & treatment of micronutrient deficiencies and maternal nutrition and prevention of low birth weight (Table 12).

As per RSOC survey report of 2013, there remains a wide gap for attaining at least 90 percent coverage (Fig 37).

The link between women’s health and nutrition and child health and nutrition is inextricable and therefore both the issues need to be addressed simultaneously. Besides focus in infant and young child feeding, there is a need to pay attention not only to maternal nutrition but to women’s nutrition. The specific actions are summarized below.

Figure 37: Gap in Universal Coverage of Specific Nutrition Interventions Source: Menon (2015) Presentation made at Coalition For Food and Nutrition Security Meeting 18th Dec 2015

Table 12: Evidence Based Essential Specific Nutrition Interventions

Source: The Coalition for Sustainable Nutrition Security in India, May 2014; DFID, 2010; Victora et al, 2008; Gragnolati, 2005

Pregnant Women Infants and Children Adolescent girls/ preconception

Proven Essential Nutrition Interventions

ANTENATAL CARE SERVICES INCLUDING maternal nutrition care*

• Promote minimum weight gain 10-12Kgs#

• Iron folate supplements

• Calcium supplements

• Special supplements of fortified concentrated energy and protein to pregnant women below 45Kg

• Consumption of iodized salt*

• Provision of ICDS food supplements*

• Maternal deworming in pregnancy*

*Actions already a part of RCH or ICDS programme # Specific situational cases + to be introduced

Feeding and care

• Promote appropriate infant and young child feeding

• Full routine immunization Biannual vitamin A supplementation and deworming*

• IFA supplementation programmes@

• Timely and quality therapeutic feeding for all children with severe acute malnutrition+

Anaemia and FLEd

• Weekly IFA*

• Biannual deworming *

• Family life education*

• Prevent early marriage and early pregnancy+

100

90

80

70

60

%50

40

30

20

10

0

IFA during pregnancy

Food supp. (pregnancy)

EIBF

EBF

Intro to CF

Food supp. (children)

Min. meal frequency

Min. diet diversity

ORS during diarrhea

Immunization

Vitamin A

Pediatric IFA

Deworming

Rapid Survey onChildren, 2013 - 2014

ENI-related indicators


ii. Improved Dietary Intake in the Pre-Conception and Adolescent Stage—Building on the Ongoing Initiatives: An effort needs to be directed to ensure women enter pregnancy healthy. Interventions for improving nutritional status in the pre-pregnancy stage are crucial to break the intergenerational cycle of malnutrition. This implies reaching the adolescents girls as well as the newly- weds to prepare them physically and mentally for self- care and care of their children in future. Women in the preconception stage should be at least 43 kilogram in weight and with adequate levels of iron and folic acid. The data presented in (Table 4, 6 and Fig 29) indicates that the dietary intake proteins and micronutrients are very poor in the adolescence phase. The intake of pulses along with cereals is low with almost a third consuming less than 50% RDA of pulses while over 80 percent consume less than 50 percent RDA of milk and milk products or green leafy vegetables. Intake of fats and oils is extremely low with almost two thirds consuming less than 50 percent RDA of fats and oils. Programme effort needs to be directed to improve quantity and quality of diet.

iii. Targeting “At Risk” Mothers and Ensuring Increased Intake of Nutrients During Pregnancy: During pregnancy, weight gain of 10-12 kilograms is important, especially in the disadvantaged population. The benefits of providing energy – protein dense food supplement and provision of multi-micronutrients have demonstrated positive results on birth weights. (Ceesay et al, 1997; Gupta et al, 2007)

Meta-analysis reports a significant reduction of 31 percent in the risk of giving birth to small for gestational age (SGA) infants when pregnant women are provided with balanced protein energy supplements. (Imdad & Bhutta, 2011) A study from Bangladesh reports that monthly education sessions, promoting consumption of local food item ‘Khichuri’ during the third trimester of pregnancy, resulted in maternal weight gain in third trimester to be 60 percent higher, mean birth weight 20 percent higher and the rate of LBW to be 94 percent lower in the intervention group compared to control. (Khurshid et al, 2014) A recent report from Southern India of a large scale innovative trial of providing one hot cooked meal per day with diversified food items at a subsidised rate to pregnant women along with nutrition education resulted in much higher increase in weight gain during pregnancy and reduction in the incidence of LBW. (Chava, 2012)

Poor diet diversity during pregnancy has been identified as an important factor which needs to be addressed for reducing prevalence rate of stunting in South Asia. (Smith & Haddad, 2015) Reports on consumption of micronutrient rich foods such as green leafy vegetables or GLVs and milk, even after adjusting for maternal co-founding factors, are reported to have a significant association with birth weight. (Rao et al, 2001)

Pune Maternal Nutrition and Foetal Growth Study (PMNS) from India reports birth size is not associated with energy or protein intake but is associated with consumption foods rich in micronutrients. Another study from Northern India reports variation in mean birth weight of babies born during different seasons of the year and has demonstrated an association of incidence of birth weight with availability of seasonal fresh fruits and vegetables and consumption of micronutrients during pregnancy. (Tamber, 2006)

Targeting of mothers having low BMI with supplement of more than 700 kcals per day is recommended. The daily food consumed should not have more than 25 percent of energy as protein. (WHO, 2014) Pre- conception and early gestational supplements are considered most important period to have positive impact on nutrition outcomes. Special effort are therefore important to ensure that pregnant mothers who are below 45 kg or BMI < 17 in the first trimester or with MUAC of less than 21 cm are provided with special energy – protein dense fortified foods with essential micronutrients. Additionally, food needs to be rich in micronutrients and therefore use of vegetables, especially green leafy vegetables needs to be promoted along with promoting daily consumption of lemons, adequate pulses and dietary fat. Improving access to green leafy vegetables (GLV), seasonal vegetables rich in iron and vitamin A and locally available seasonal fruits appears crucial for improving micronutrient intakes and improving birth size even when energy intakes are limiting during pregnancy.


iv. Reaching and Addressing Anaemia in Adolescent Girls Out of School and Newly- Married Women: The significance of women entering pregnancy with adequate iron nutrition is well recognised and a weekly IFA supplements (WIFS) for prevention of anemia in adolescent girls and women in reproductive age group is recommended. (WHO, 2009) WIFS policy is already in place in India. (NIPI, 2013) Education, Health and ICDS sectors are recommended to continue to reach adolescent girls out of school and in school with the following package of services: weekly consumption of iron-folic acid (IFA) tablets, Family Life Education (FLE) (including education on hygiene, hand washing and safe disposal of faeces) and biannual de-worming. Programme designs need to be strengthened to reach girls out of school and women prior to onset of pregnancy.

v. Addressing Anaemia in Pregnant Women: There is a need to take special care for preventing and managing anaemia. It is well established that deficiency of iron in the first trimester of pregnancy results in significant decrements in foetal growth and is generally more damaging to pregnancy outcome than iron deficiency anemia in second or third trimesters. (Abu-Saad & Fraser, 2010) Iron supplementation is documented to have a significant effect on LBW. (Balarajan et al, 2013; Khanal et al, 2014) In Nepal, mothers not consuming iron supplement during their pregnancy are reported to more likely have low birth weight babies. (Imdad & Bhutta 2012) A sixty seven percent reduction in anemia caused by iron deficiency, as well as a decrease in the occurrence of LBW and anemia in offspring has been reported. (Bhutta et al, 2013)

In India, provision of daily iron-folic acid (IFA) supplements to pregnant women is an integral part of antenatal care (ANC) services. In India, about thirds (65.1 percent) receive or buy IFA tablets compared to 44 percent in South Asia and 53 percent globally. (NFHS-3, 2005-2006; Gwatkin et al, 2007; UNICEF, 2014) Coverage and compliance of at least 90-100 IFA tablets during pregnancy is low and has marginally increased from 22.3 percent in 2005-06 to 23.6 percent in 2013-14. As per NFHS-3 data, percentage who consumes IFA tablets for at least 90 days varies widely—less than 10 percent in Nagaland, UP and Bihar and over 65 percent in Goa (68.6 percent) and Kerala (75.1 percent). Positive factors contributing to high coverage in these two states need to be studied and replicated other states.

vi. Deworming: Deworming in the second trimester of pregnancy in Nepal has been reported to lowering the rate of severe anemia and improving birth weight. (Christian et al, 2004) Deworming policy for pregnant women has also been issued by GoI (one dose of Albendazole 500 mg in the second trimester) and this needs to be effectively implemented.

vii. Vitamin A and Iodine: Vitamin A supplement massive dose to postpartum mothers is not the policy of Government of India. However, vitamin A nutritional status of post-partum mothers need to be taken care of since it is associated with vitamin A levels in breastmilk. Dietary diversification and use of vitamin A rich food along with use of adequate dietary fat is important. In case of mothers with night blindness history in the third trimester, it is important to inform the health officers who could then prescribe for vitamin A supplements dose within 4 weeks of delivery.

Iodine status of pregnant women is adequately protected by daily intake of iodized salt. Only in situations where iodized salt is not being consumed, iodine supplementation is required.

viii. Calcium Supplement: Calcium supplementation during pregnancy is known to reduce the incidence of gestational hypertension by 35 percent, preeclampsia by 55 percent and preterm birth by 24 percent. (Hofmeyr et al, 2010) The GOI policy prescribes calcium supplement in the antenatal care package. The dosage recommended is 500 mg twice a day from the second trimester.

ix. Multiple Micronutrient Supplementation (MMNS): It has been reported to reduce LBW by about 10 percent in low income countries (Fall et al, 2009). A hospital based trial from India in pregnant women enrolled at 24-32 weeks of gestation with low BMI and anemia reports positive impact of adding on MMNS to the regular IFA supplement on improving birth weight by 98 g and increasing birth length by


0.80 cm and a substantial decline in LBW as compared to the placebo group. (Gupta et al, 2007) The ANC package of GoI includes IFA supplements and not MMN supplements.

c. Improving Coverage of the Specific Direct Nutrition Interventions:

Analysis of recent data indicates that intensive and focused inputs are required for improving the coverage of direct nutrition interventions to 90 percent. There are two primary systems which deal with these interventions—the National Rural Health Mission (NRHM) and the Integrated Child Development Services (ICDS). The Government of India has policies in place which address all these interventions except the policy on community based management of severe acute malnutrition (SAM) cases and explicit package of direct nutrition interventions for women in preconception and pregnancy stage.

With a view to increase the rate of reduction of stunting from the current 2.3 percent to the WHO recommended rate of 3.4 percent, it is crucial that the following programme principles are followed:

i. Focus and Accord Highest Priority to Reach Under Twos –Focus on the “Window of Opportunity”: As described earlier, stunting and underweight prevalence continue to rise in the first two years of life (Fig 16). The damage caused during this early period is to a great extent irreversible. In order to improve nutrition, it is critical to ensure that nutrition interventions are prioritized in the period of undertwos when they are most vulnerable to effects of poor nutrition i.e. the period between conception and two years of age. This period of first 1000 days of life is also the window within which good nutrition yields maximum returns in terms of education, income, chronic diseases and other outcomes.

ii. Health Sector Involvement in the First 90 Weeks of Life is Critical: It is important to note that most of the selected direct interventions in the first 1000 days are under the jurisdiction of health sector and not the ICDS sector sand the health network is expected to reach pregnant women and infants. These interventions include direct nutrition actions such as promotion of exclusive breastfeeding, introduction and establishment of appropriate complementary feeding practices, promotion of weight gain during pregnancy, iron folic acid supplements through the life cycle, vitamin A and calcium supplements, deworming etc. Building on the on-going NRHM activities and working with a smaller defined focussed population comprising newly-wed/preconception women, pregnant women and infants would maximise benefits and contribute in effective implementation of direct selected actions for accelerating coverage to over 90 percent.

iii. Re-define the Role of ICDS Sector for Care of Under Twos and Strengthen the ICDS Infrastructure: Available evidence indicates that ICDS primarily reaches children 3-6 years and has very limited coverage of the most vulnerable groups i.e. 0-24 months and pregnant women. ICDS, however, plays an important role in undertaking biannual village surveys, undertaking weighing of children, provision of food supplements, reaching children 3-6 years, identification of newly-weds as well as converging with the health sector in the organisation of the village health-nutrition -sanitation days (VHNSDs) and in mobilising community for provision of health services such as routine immunization and ANC services. These roles of ICDS, if clearly defined, will further improve in coverage of interventions.

iv. Integrate ICDS and Health Services and Also Establish Linkage with DAY: NRLM: For effective delivery of maternal and child health nutrition services, it is well experienced and documented that functionally integrating actions of health and ICDS sectors is critical. Often, the efforts of Accredited Social Health Activist (ASHA) (frontline workers of health) and ICDS are not integrated and the package of relevant services and messages therefore are not delivered effectively. This implies defining roles of these two sectors for each of the selected direct actions and undertaking joint planning and implementation.

v. Build on Positive Attributes of the “Fixed Day Strategy” for Improving Coverage of Health and Nutrition Services: Fixing a day for execution of a specific task facilitates programme management. In this context, use of fixed day, fixed week or fixed month approach such as fixed Routine Immunization


(RI) days, fixed Village Health and Nutrition Sanitation Day (VHNSD), fixed weekly day for Iron Folic Acid (IFA) distribution to adolescent girls and fixed biannual child health and nutrition months are in operation to increase coverage. Fixed Day approach facilitates in improving supply and logistics management as well as contributes in effective mobilisation of beneficiaries for receiving services.

vi. Effective Interpersonal Counseling (IPC) and Social Mobilisation —Use of Cluster Community Mobiliser Strategy: Effective communication through IPC is an important key condition for programmes that seek to improve child care and nutrition practices at family level. IPC needs to be combined with community mobilisation to increase the acceptance of counselors by community, as well as for reinforcing child care practices being promoted. The success stories of Thailand and India programmes (Maternal Child Health-Nutrition Project in UP state and Integrated Nutrition and Health Project of CARE in 7 states), indicate that caregivers at community level need to be regularly and frequently contacted and counseled at home level for effective inter-personal counseling (IPC) and for bringing a positive change in practices pertaining to feeding, care, hygiene, disease prevention and treatment.

An analysis of a number of such initiatives in community based programs (Mitanin, Dular) launched in 1990s confirmed that community volunteers/mobilizers create not only a functional link between service delivery outlets and the communities but result in providing a sense of joint ownership of the programme / project by the community and government. (Vir, 2013; Vir et al, 2014) Based on these experiences, a ratio of one community mobilizer to 20-25 households has been reported to be most effectual personal counseling. Moreover, it is evident that such a community mobiliser- government functionary partnerships needs to be forged through broad based social mobilization strategies.

Mass communication interventions are essential to complement interpersonal counseling (IPC) as well as social mobilization and community group counseling (CGC). “Village contact drive” is a suitable proven strategy which is important for strengthening social mobilization. Additionally, use of the information communication technology (ICT) strategies such as sending timely appropriate messages using SMS is being extensively used by many states and has been found to be very effective.

vii. Reaching “Unreached” Women and Out-of School Adolescent Girls –Developing Linkage with DAY: NRLM and Other Sectoral Programmes: For improving coverage of direct nutrition interventions, it is well recognized that women from the marginalized section of society, those belonging to scheduled caste or scheduled tribe are the ones who are often missed out from programme benefits. Rashtriya Bal Swasthya Karyakram, innovations for improving adolescent, maternal and child care etc. offers an opportunity for improving delivery of health services along the continuum of care. For improving coverage of direct nutrition interventions, there is a need to develop an operational plan for linking the NRHM and ICDS activity with the National Rural Livelihood Mission (NRLM), Panchayati Raj Institutions (PRIs) and the Targeted Public food Distribution system (TPDS).

viii. Special Measures for Care of Low Birth Weight (LBW)—Linking Efforts with JSY and JSSK Schemes: Almost a third of children are undernourished at birth with LBW (below 2.5 kg). Such newborns with low birth weights would continue to remain stunted unless special effort is made to promote “catch up growth” in the first two years of life. With the launch of Janani Surkhasha Yojana or JSY in 2005 (conditional cash transfer scheme) and later in 2011 complemented this with Janani Shishu Surkhasha Karyakram JSSK scheme(aimed at mitigating the out of pocket expenses incurred by pregnant women and sick infants. The uptake of JSSK is gradually increasing), there is a significant increase in institutional delivery coverage and care of infants. As per the NFHS-3 and RSOC, the percentage of institutional births reported in 2004-5 was 38.7 percent against 78.7 percent in 2013-14. The institution delivery has also resulted in increase in improving registration of births and records of birth weight. Thus, unlike a couple of years back, an opportunity exists for identifying low birth weight newborns and following them up for promoting catch up growth with inputs such as motivating and encouraging continuation of exclusive breastfeeding up to six months despite LBW newborn possibly having poor sucking ability. Additionally,


a system needs to be established for the fortnightly monitoring of weight and counseling for promoting adequate growth.

ix. Community Based Management of Severely Acute Malnourished (SAM) and Moderate Acute Malnourished (MAM) Children: There is enough evidence to indicate that special attention must be directed to manage SAM cases who are at a very high risk of dying, if not identified and managed appropriately. It is well known that only about 20% of SAM cases possibly require institutional support while 80 percent cases with no medical complication could be managed at family or community level. With the establishment of Nutrition Rehabilitation Centres (NRCs) by the Ministry of Health and Family Welfare, medically complicated cases of SAM are taken care of. The MoHFW soon will be issuing policy guidelines for community based management (CMAM) of SAM cases and the formula for supply of energy dense food to severe cases. The management of MAM through promotion of appropriate energy dense food requires special attention.

d. Nutrition Sensitive Interventions:

Nutrition Sensitive Interventions must complement nutrition specific interventions for increasing the rate of reduction of stunting rates in children under- fives. This is well documented from countries such as Vietnam, Brazil and Thailand which rapidly reduced undernutrition by addressing simultaneously both nutrition specific and nutrition sensitive interventions. These indirect actions include measures to protect not only food security but improve diversity in food consumed, especially of the poorest and unreached households. The actions for these range from improving entitlement of community members to ICDS food supplements and subsidised food supply through TPDS to support to community to increase agriculture production and establish homestead gardens.

Besides food related interventions, the other important nutrition sensitive interventions comprise improving water and sanitation situation as well measures for empowering women that increases not only purchasing power but reduces poverty, increases cash in hand, increases decision making role of women, decreases gender bias, encourages education, family planning and discourages adolescent age marriage. It has therefore been proposed “that engaging women and implementing interventions to protect and promote their nutritional well-being , physical and mental health, social status, decision making and their overall empowerment and ability to manage their time, resources and assets is an important pathway for nutrition sensitive approaches and programs.” (Ruel et al, 2013)

i. Ensuring Food Security –Quantity and Quality of Food: For addressing the energy, protein and micronutrient gaps, there is need to ensure consumption of three food items in at least the two major meals - cereals, pulses or flesh food or egg preparation and seasonal vegetables. For enhancing energy intake, minimum recommended amount of fat or oil is required to be used. The accessibility to such food items require increase in purchasing power, knowledge on how best to use the available resources wisely to eat a meal with the required nutrients, availability and access to seasonal vegetables through the year, retention of nutrients during cooking, home level preservation and use of excess production of seasonal vegetables for use in lean or rainy seasons etc. This implies measures to eliminate poverty, enhance the purchasing power of a family as well as disseminate information and empower women to have cash in hand and take a decision on selection purchase and preservations of food items using traditional practices, establish homestead gardens, encourage poultry keeping, dairy and other livestock measures. Support to families, particularly to women, in improving agriculture output and linking nutrition consideration into agriculture is crucial.

Increase production needs to be accompanied with information and education actions for using the produce for the better nutrition of family, ensuring meeting the feeding needs of pregnant women and children below two years, enhancing skills for preservation of food for use when required and in the lean season, ensuring a desirable balance in marketing and consumption of produce. Additionally, micro-credit programmes and other poverty alleviation scheme such as National Rural Employment Guarantee


Act (NREGA) are important measures for ensuring food security and diet diversity at family level. Community needs to be informed of their entitlement. There are also experiences of establishing grain banks in community over and above the barter system of exchanging grains against seasonal vegetables and other items that exist in some tribal communities. DAY: NRLM offers an opportunity to increase resources which could be used for improving food diversity. Innovative approaches for increasing animal source food for increasing dietary quality also needs to be explored. Women groups could also be guided to identify, domesticate and cultivate traditional and locally available wildly growing vegetables which are micronutrient rich.

Besides the above measures, there are other social support programmes which are directed to meet the gaps in cereal consumption of population and nutrition gaps in diets of pregnant and lactating women and children below six years, The National Food Security Act (NFSA), 2013 address the problem of gap in energy consumption. The Act provides for coverage of up to 75% of the rural population and up to 50% of the urban population. Under the targeted public distribution system, every enrolled person is entitled to receive subsidized cereal - entitlement being 5Kg of cereal per person per month (about 150 grams/day) at the rate Rs 2 for wheat, Rs 3 for rice and Rs 1 for coarse cereals. PDS provision therefore meets almost 50 percent of the cereal requirement of adolescent girls 16-17 years (346 grams per day) and of adult non-pregnant and non-lactating women (340 grams per day). A number of states use the Public Distribution System (PDS) for supply of pulses, iodized salt, oil and other selected food items at rates lower than market rates to the public enrolled with the TPDS benefits. It may be noted, as per the Act, the existing Antyodaya Anna Yojana (AAY) households, which constitute the poorest of the poor, will continue to receive 35 kgs of food grains per household per month i.e. about 230 grams of cereal per day per person for a family of 5 members. The TPDS scheme therefore, meets the cereal needs of such families to a great extent during the lean seasons.

The Act also has a special focus on the nutritional support to women and children. This is provided through the ICDS system. Besides meal to pregnant women and lactating mothers during pregnancy and six months after the child birth, such women are entitled under the IGMSY (Indira Gandhi Matritva Sahyog Yojana) Scheme to receive maternity benefit of not less than Rs. 6,000. School children up to 14 years of age are also entitled to nutritious meals or mid -day meals (MDM) as per the prescribed nutritional standards. Under the NFSA, State Food Commissions are being established for the purpose of monitoring and review of implementation of the Act with financial assistance from the Central Government.

Taking into consideration the significance of food adequacy and diversity in the first 1000 days of life, women in the preconception stage (especially newly- weds) and adolescent girls, there is an urgent need to ensure this population “at risk” of undernutrition is accorded the highest priority for meeting the energy, protein and micronutrient gaps.

ii. Empowering Women: Nutritional impacts are more relevant when agriculture interventions target women, empower women with cash-in hand, encourage their increased control over income as well as enhance their knowledge and skills through behavior change communication.

Employment of women in formal and non-formal sector and completion of secondary education are interventions which empower women for taking decisions on family care, including food, health, hygiene and sanitation. Microcredit programmes with formation of self -help groups (SHGs) offer the opportunity to reach the most underprivileged women who are in a better position to participate in decision making process than other disadvantaged women in the community. Moreover, women who are members of such credit group can be guided for effective use of monetary resources that they generate through the micro-credit systems.

The National Rural Livelihood Mission (NRLM) approach offers an opportunity to reach the unreached women to influence them in appropriate use of resources generated by them for family care and in


improving the nutrition situation. These women, using the platform of SHGs, therefore, need to be made aware of various health and nutrition issues and services of NRHM and ICDS as well as of the social support schemes such as PDS, supplementary nutrition of ICDS, mid day schemes for school children. The women groups could be also guided to use the resources generated through livelihood programs effective for family, self and appropriate child care practices. In India, the platform of microcredit women groups has been used successfully in many states such as Andhra Pradesh, Odisha, Chhattisgarh (described in Part I of the report).

Social protection programs such as the Conditional Cash Transfer (CCT) Programme are recognized to be an extremely important approach for improving nutrition. CCT Programme of Mexico is an example of an effort to reduce poverty and food insecurity along with encouraging poor women to invest in betterment of the children. (Benderly, 2010) Significant benefits of these programmes in increasing household food security and consumption of protective/ nutrition rich foods such as meat, dairy, fruit and vegetables as well as on improved use of health services and health outcome is well documented. Results from Mexico and Nicaragua also indicate a positive impact of CCT on nutritional status of children. The CCT programme in India, the Janani Surkasha Yojna (JSY)/JSSK, has also been noted to impact on rapidly improving coverage of defined services such as ANC and institutional services as well as infant care. Improved reach of these services also indirectly influence health and nutrition care of women and children. In India, another CCT programme which has been launched in selected districts of the country is the Indira Gandhi Matriva Sahyog Yojna (IGMSY). (IGMSY, 2011) The IGMSY programme links cash transfer to feeding actions taken by the mother. IGMSY has been used as an entry point for a number of direct nutrition interventions in states such as Odisha and has proved successful.

For empowering women and for overall development of the country, measures have been taken by the government for promoting education of girls. States have launched varieties of incentive schemes. These schemes influence school enrolment and completion of school education. The use of such schemes in the remote poor regions needs to be encouraged. One of the national initiative taken by the GoI is the Beti Bachhao Beti Padaho Anandolan. (wcd.nic.in/BBBPScheme/main.htm) The mid- day meal or school feeding program has also contributed significantly in school enrolment and retention. Retention in school helps in delaying age of marriage and delaying conception.

iii. Family Planning Services: Preventing early conception below 18 years is crucial for breaking the intergeneration cycle of undernutrition in children. Social pressure of early marriage is difficult to address and the best solution is encouraging girls to complete at least school education. There is a need to delay conception to over 18 years. Family planning services for newly married couple is a policy of the Ministry of Health and Family Welfare. There is a need to systematically identify newly married women and encourage the couple to delay conception up to 20 years of age. These efforts should be combined with inputs for encouraging women to enter pregnancy healthy by ensuring intake of weekly iron-folic acid tablets, improve daily dietary intake in terms of quantity and quality to increase weight to at least 43Kg and also consume six monthly deworming tablets to improve the nutrition situation. Additionally, it is important to ensure at least two years of spacing between births and limit the family size to two children.

iv. Support to Employed Women-Maternity Leave: Women returning to work in early postnatal period adversely influence the practice of breastfeeding and overall child care practices. In India, maternity leave is limited to formal sector and varies in duration and package. There is a need for a uniform policy to encourage maternity leave of at least 6 months post -delivery.

v. Improving Water ,Hygiene and Sanitation Situation: Access to potable water, use of appropriate method for storing and drawing water needs attention to reduce the incidence of water borne diseases which play a very important role in precipitating undernutrition. Use of soap and using appropriate method of hand-washing is critical. Involvement of community in Swachh Bharat Abhiyan (swachhbharaturban.gov.in/)


through mobilization of community and various forums such as the school system, youth groups, farmers groups, self-help or micro-credit groups of women is crucial for preventing undernutrition. Besides drives for discouraging open defecation through building and using latrines, there is an urgent need to intensifying education for instilling the practice of washing of hands with soap and water by every member in the community. The significance of the correct WASH practices with health and nutrition status of children and mothers deserve special attention.

vi. Encourage Multiple-Sector Involvement to Address the Underlying Determinants of Undernutrition: For implementation of nutrition sensitive interventions, there is a need to not limit nutrition interventions to merely health and ICDS sectors. The other key priority departments which need to be involved are Rural Development Ministry and departments dealing with DAY: NRLM, water- sanitation, Panchayati Raj Institutions, Ministry of Food and Agriculture including Department of Horticulture, Ministry of Food Processing, Ministry of Consumers Affairs, Food and Public Distribution, Ministry of Tribal Affairs, Ministry of Human Resource Development and Department of Education. These line departments need to be sensitized to their contribution and roles in improving nutrition situation and seeking their commitment to give priority to the inputs/interventions that could make a difference in nutrition situation of the country. Evidence exists in Latin America (Brazil, Peru) and Asia (Bangladesh) of the results yielded with such multi-sector effort. Nepal has successfully brought together key line ministries and a multi-sector plan is being implemented in select high burden areas. (Vir, 2011)

15. Special Focus: Improving Nutrition Situation of Women and Children Residing in Tribal areas and Selected States of Bihar and Uttar Pradesh

a. Women and Children in Tribal Areas:

There are 104 million people estimated to be tribal population in India and these belong to 705 distinct schedule tribes. (National Tribal Policy, 2006) Of these, 11.5 million are children under five years of age. Tribal population – almost 85 percent live in 12 Indian states: Andhra Pradesh, Telangana (earlier a combined state of Andhra Pradesh), Assam, Chhattisgarh, Gujarat, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Rajasthan and West Bengal. Almost 90 percent live in rural areas. Tribal population reside in hills, forests and difficult to reach geographical areas with limited access to public services. The ST population is the most deprived social group with poverty rates (47 percent) similar to those found in general population 20 years ago. (Das et al, 2010) According to Census of India (Census, 2011b), only 14 percent of tribal population in rural areas have a source of drinking water within their premises (Census, 2011a) and less than half (46 %) have electricity in their households (Census, 2011b).

Analysis of 2005 data reveals every second tribal child (54%) is stunted and severe stunting is 9 percentage points higher in tribal children as compared to non-tribal population (29% vs 20%). In tribal population, 75 percent children are either mildly stunted (-1SD of median WHO standard) or moderately or severely stunted compared to 71 percent is non-tribal population. Recent data of RSOC 2013-14 indicates stunting rate in tribal population (moderate and severe) is 53 percent while in non-tribal area the prevalence rate of stunting is 45% percent. Land alienation, displacement and poor compensation,

*includes SC, ST, OBC and others Source: UNICEF, 2014

Table 13: Stunting Rates and Severity of Stunting Under Five Years of Age

Stunting Rate (%) Mild stunting Moderate stunting Severe stunting

Tribal 22 24 29

Non-tribal * 26 25 20


and rehabilitation provisions are often reported as core reasons for poverty with subsequent adverse consequences on traditional food habits, livelihood and overall living conditions. (Munshi, 2012) Gender bias is noted with reference to denial of land rights to women and polygamy in tribal regions (Munshi, 2012).

Maternal indicators (education, anaemia and irregularity in employment) are reported to be 1.2 to 1.5 times poorer in tribal families compared to non-tribal areas. Maternal undernutrition emerges as the key determinant of stunting. Interestingly, the risk of undernutrition can be tracked to early childhood. Severe stunting is nearly two fold higher for girls aged 6-23 months compared to boys indicating possibly a gender bias in child care practices in tribal region. In addition, 68% mothers are noted to be less than 20 years old, 48 percent mothers are reported to be undernourished themselves, 76 percent mothers are anaemic and birth orders range in tribal population from 1-12. (UNICEF, 2014)

The three factors reported to be the key predictors of stunting in tribal areas are the same as those in nontribal areas i.e. child’s increasing age, maternal stunting, pregnancy interval of less than two years. In tribal areas, poverty plays a very central role as reflected from the findings of RSOC where 85 percent of the tribal sample that was studied belonged to the bottom two wealth quintiles. Alcoholism, tobacco and smoking are noted to be common in tribal population even during pregnancy and are culturally accepted since it is considered to be a good measure to reduce the desire for food. Despite maternal smoking being common in the tribal population, it does not feature as one of the 10 predictors of severe stunting in tribal population as statistically observed in non-tribal population. In tribal population, as in case of non-tribal population, being the fourth or later born child or being a girl coming from poorer family, illiteracy of mothers are noted to be determinants of severe form of stunting.

The analysis of RSOC data on infant and young child feeding (IYCF) practices reveal that the traditional pattern for feeding semi-solid food or complementary feed is particularly poor. Only 16 percent children aged 6-23 months are fed the minimum recommended types of food items with correct frequency of feeding compared to 28 percent non-tribal children. The data reveals poor food diversity. Lack of information on appropriate IYCF practices, poor cooking methods to retain nutrients combined with extreme poverty adversely influences frequency of feeding as well as maintaining quality of child feeding. Dietary survey has reported milk, fruit and sugar are almost absent from tribal diets. (Mittal and Srivastava, 2006; Meshram et al, 2012) However, there are some good existing practices such as use of coarse grains and wild food plants which are traditionally part of tribal diet and needs to be encouraged. Amongst the tribals in MP (Bhil tribe), there is a good practice of providing calorie dense food (porridge comprising wheat, palm sugar, coconut, milk fat/ghee) to postpartum women. Active effort needs to be directed to identify and promote such existing good practices for nursing mothers as well as during pregnancy. Additionally, the quality of ICDS supplementary food could be improved such as by addition of egg in the menu as reported from AP, Chhattisgarh, Karnataka, Kerala and Tamil Nadu. There is also a need to explore inclusion of pulses in the PDS for families with pregnant women or under two year children. A study undertaken by WIPRO for WFP has proposed a monthly food basket for every targeted household with a pregnant woman of Antodya Anna Yojana or AAY to comprise 25- 35 kg of cereals, 5 Kg of pulses, 2 Kg of edible oil and 1.5 kg of iodized salt. The estimated range of monthly expenditure is between Rs. 346-524 per household while the subsidy requirement has been estimated to be Rs. 6964.84 crores per annum for AAY households. (WIPRO and WFP, 2014) The National Conclave on improving Nutrition of Women and Children in Tribal Areas proposes that interventions should focus on reduction of low birth weight (LBW), care of children 0-6 months for health and nutrition services including universal coverage with complete routine immunization and deworming, care of 7-36 months with attention to improve feeding of semi-solids along with continuation of breast milk. The tribal data emphasises nutrition care of female children below two years need a high priority and special attention.

Reduction in LBW incidence would require interventions such as actions directed to ensure adequate weight gain during pregnancy as well as timely and complete package of services under ANCs. Moreover,


identification and special care of mothers including provision of nutrition dense food as supplements to “at nutritional risk” women is crucial. Such food items are also required to be made available to women who are newly wed to improve their weight, iron and folic acid status prior to onset of pregnancy. Weight or MUAC criteria of less than 21 cm could be used to identify at risk women and give such special support. These women also need family planning advice for preventing first pregnancy to above 18 years and also for avoiding subsequent pregnancies at an interval of less than three years. For provision of such support, there is a need to link with various existing schemes which help in enriching the diet of women during pregnancy and lactation such as with ICDS food supplement. In some states, livelihood programs for women have been linked to production of ICDS supplementary food in cooked or dry ready to eat food form.

Women also need to be informed to of child care and child feeding practices to be followed at family level as well as of avoiding harmful traditional taboos. Community members need to be informed of their entitlement to various services and schemes. It is important that behaviour change strategy takes into consideration traditional systems of feeding, food, medicine, faith in healers, strong tradition of folk entertainment etc. Promoting indigenous food forests, improving access to livelihood, universalization of public funded crèches in tribal areas with communication channels in tribal areas being rather poor, special strategies are required for communicating with tribal population for influencing behavioral practices at family level and social mobilization. Additionally, adequate access to health, potable drinking water needs attention.

b. Vanbandhu Kalyan Yojana (VKY)

The Ministry of Tribal Affairs (MoTA), on October 28th 2014, launched Vanbandhu Kalyan Yojana. VKY aims at achieving defined outcomes in socio-economic development of tribal population. Monitoring of results will be outcome-based and people’s participation will be central strategy in VKY implementation. Malnutrition among tribals will be accorded special focus. Implementation of IFA scheme in tribal schools will be monitored. Universal coverage of pregnant mothers will be aimed at by undertaking survey of pregnant mothers in tribal areas.

Besides direct nutrition interventions, VKY will focus on evolving institutional mechanism for growing traditional coarse-grain crops (millets etc.), green leafy vegetables etc. Growing and use of drum-stick among the tribal people will be encouraged to help nutritional supplement. The practice of raising kitchen gardens in the residential schools will be promoted. Minor millets will be encouraged in school menu. Tribal households will be encouraged to take up backyard fisheries projects. Local raising of fish lings and fingerlings should be promoted with proper linkages to the market value chain. Dairy development under VKY will include a number of activities, such as organization of milk cooperatives, training of farmers, clean milk production, artificial insemination program, improved productivity of existing cows through immunization. Tribal households will be encouraged to take up kitchen gardens, backyard fisheries projects, dairy development activities through milk co-operative societies.

In addition to above measures, ensuring access and availability of safe drinking water, building of functional toilets separately for boys and girls in many schools, addressing major diseases such as malaria, sickle cell anemia, Upper Respiratory Tract Infection (URTI) are planned to be given special attention.

In tribal areas, coverage of health services such as immunization, ANC is also planned to be substantially increased. In tribal areas, Ministry of Health and Family Welfare has also constituted a national tribal health task force. For the tribal dominated high burden districts, there is provision for relaxed norms such as mobile services, incentives for infrastructures, human resources including ASHAs. Financial allocation has accordingly been enhanced for child health, Similarly, there are other initiatives launched by the Department of Health and Family welfare such as the Nav Sanjeevani scheme, launched in 1995-96 , aiming to improve health and nutrition delivery system in 15 tribal districts with high infant


mortality rate and maternal mortality ratio. In 2005, based on the experience, mission approach was used to cover the entire state. Survey in 2012 reports significant decline in stunting in tribal population –from 53 % in 2006 to 28 percent in 2012 non-government organisations (NGOs) are active in health sector services and have introduced innovations for geographic information system (GIS), planning and monitoring, transport etc.

Similarly, ICDS has approved 7076 projects and 1.4 million ICDS workers. Out of these 2,544 projects and 535,499 Anganwadi centres are in rural/tribal areas of nine states. Of the 200 high burden districts, many are tribal dominated. The need for crèches in tribal areas is considered important. Effort has been made to set up crèches in tribal areas (in six tribal districts of Maharashtra and Surguja tribal district project of Chhattisgarh).

Besides government managed programmes, NGOs and faith –based organizations have been working in tribal areas with primary focus on reaching the tribal population living in remote inaccessible areas with establishment of health and education institutions as well as creating demands for health services and improving access to services.These will help both livelihood and nutritional level.

As per the National Conclave of Jan 2015, the following challenges have been identified for improving nutrition situation of women and children in tribal areas:

i. Access to food: Poor market access and purchasing power impact on poor access to food. Loss in productive resources has worsened the situation. This includes losses in rights to forests or agriculture land coupled with low amounts received as compensations. Dependency on debts is therefore common coping strategy. Introduction of micro-credit schemes for women and organising them in self –help groups is considered crucial to address these issues. DAY: NRLM offers an opportunity and can be explored.

ii. Public distribution system (PDS): The tribal households are often not aware of their entitlements to the public distribution system (PDS). Moreover, access is constrained by poor listing of beneficiaries. The scope of using various coarse cereals in the PDS also needs to be explored.

iii. NREGA: The scheme offers the scope of improving cash in hand of women and men. It is reported that the average number days of work for tribal persons under the NREGA scheme was only 49 days during 2013-14. It has been pointed out that this is primarily due to lack of crèche facilities in tribal regions.

iv. Attitude to traditional foods: Forest produce which were edible products are not available with deforestation. Moreover, there is a tendency to consider uncultivated yet nutritious tribal food as being not proper food—in fact unfashionable by communities themselves. The attitude towards coarse cereals has also resulted in increased use of wheat and rice.

v. Agriculture and Horticulture: Indigenous seeds and methods and mixed cropping are not used to make agriculture nutrition sensitive. Planted trees are not selected keeping in mind source of fruit or food. There is dependency on rain irrigated agriculture which is of concern with climate change. Use of traditional practices of production and technologies result in depletion of natural resource base and setting up a cycle of poor production and soil depletion. Moreover, information on correct use of pesticide is also observed to be lacking and needs to be addressed for health of women and children. Incorporation of nutritious crops such as seasonal vegetables and pulses are essential for food diversity in under-twos and population in general.

vi. NGOs led Initiatives: Livelihoods have been a major concern in tribal areas. In the past, a number of NGOs have been working with tribal communities with focus on organizing formation of thrift and credit groups and linking them to livelihood options. These NGOs have introduced a number of interventions linked to thrift and credit programmes such as dairy farm activities, sericulture, farming and poultry. The innovative work of NGOs- Pradan and BAIF Development Research Foundation, in agriculture sector


is an example of beneficial and sustainable initiative in tribal areas. These include interventions such as introduction of a system of rice fortification in 12 districts of Chhattisgarh (UNICEF, 2015b) and BAIF inputs in an innovative WADI, a farming system combining “agri-hori-forestry” with required in-situ soil and water conservation works, integration of crop diversification practices, intensification of skill oriented training for good production systems and integration of animal husbandry and continuous on- field support using just 0.4 hectares of land. Mixed cropping, promotion of small plot vegetables water resource management and forward marketing linkages are other important inputs which have also been combined with other inputs for women development, drudgery reduction measures, clean drinking water and sanitation, health and nutrition improvements.

vii. Linkage with DAY: NRLM: DAY:NRLM or Aajeevika is estimated to reach over 100 million poor households in Tribal region and have organized 7-9 million SHGs and their federations at village and cluster level. (UNICEF, 2015b) There is a scope to use the DAY: NRLM forum to build on crucial nutrition activities in tribal areas. In this context, some states offer excellent examples of innovations under the State Rural Livelihood Mission (SRLM) e.g. introduction of health risk fund and food security fund in Bihar, homestead kitchen gardens in Odisha, provision of hot cooked meals for pregnant and lactating women AP and Bihar.

Ministry of Tribal Affairs (MoTA) is the nodal ministry in-charge of welfare of schedule tribes. The Ministry has the mandate to convene and coordinate inter-ministerial policy, planning, and programme coordination. The MoTA prepares state plans and tribal sub plans (TSP) in coordination with 28 sectoral ministries. (UNICEF, 2015b) .The ministry provides top up grants to state tribal departments for special projects to be taken in tribal sub-plan blocks (under special central assistance and provisions under Article 275(1) of the Constitution with very little control on implementation of the TSP).

At the National Conclave held in January 2015, it has been recommended that the districts in the tribal dominated states be undertaken on highest priority basis these have highest burden of stunted children in terms of numbers. Use of district level data (DLHS, AHS, CAB) is recommended to be used block level planning. The National Institute of Rural Development and Panchayati Raj and UNICEF signed a MoU on 17th June 2015 (UNICEF, 2015b) to create and institutionalize a curriculum for multi-sector officials. The Ministry would therefore focus on influencing coverage of not only direct nutrition interventions but also address issues which influence nutrition sensitive interventions.

c. Bihar State: Nutrition Situation, Key Issues and Current Focus:

The prevalence rate of stunting among children under five in Bihar continues, as per RSOC survey continues to be worse than the national average, 49 percent in Bihar compared to the national average of 38.7 percent. Recent NFHS 4 data also reveals 49.3 percent rural children are stunted compared to 48.3 percent at state level and a lower prevalence of 39.8 percent in urban population. This implies nearly every second child aged under five is stunted in Bihar; 6.3 million of 12.7 million children of Bihar are stunted. (RSOC, 2013) Over half of the stunted children are already severely stunted (prevalence of severe stunting is 26%); their physical and cognitive development is permanently impaired. (RSOC, 2013) Pace of reduction in stunting is slow at annual decline of less than one % point in seven years (2006 to 2013) that is only 6.6 percent points, from 56% to 49%. (RSOC, 2013). Recent NFHS 4 findings also indicate a similar situation (Fig 38).

As indicated in the figure below, seven of the 38 districts account for 30% of the total number of stunted children in Bihar (Fig 39). These include Patna, Purba, Champaran, Muzzafarpur, Samastipur, Darbhanga, Gaya and Paschim Champaran. (AHS, 2012-2013; Census 2011 and UNICEF, 2015) Undernutrition is much higher in SC and ST population compared to others. (NFHS-3) In 20 of 38 districts, severe form of stunting contributes to over 50% of the total prevalence of stunting. There are over 100,000 severely stunted children in 13 of the 38 districts. (AHS 2012-13; CAB, 2014) The prevalence rate of wasting is 13.1 percent and is lower than the national average of 15.1 percent.


NFHS 4 data reveals only 34.2 percent of rural children below 3 years were fed breastmilk within one hour of birth while children under 6 months of age with exclusive breastfeed were 54.2 percent. Only 29.5 percent introduced semi-solid food between 6-8 months.

Anaemia is prevalent across all age groups. As per NFHS-3 survey, 75 percent preschool children and over 65 per cent women in reproductive age and adolescent girls and 60 percent pregnant women are reported to be suffering from anemia. NFHS 4 data also indicates 64 percent rural children 6-59 months to be anaemic while anaemia in rural women 15-49 years and in pregnant women is reported to be 60.7 percent and 58.0 percent, respectively. Consumption of at least 1000 iron and folic acid (IFA) tablets during pregnancy was as low as 9.7 percent in the state - 9.4 percent rural and 12.3 percent urban. As per the AHS and CAB surveys, nine in 10 girls aged 10 to 17 years suffer from anaemia. (AHS, 2012-13; CAB, 2014) Almost every second girl aged 15 to 18 years, who will soon be a mother, is undernourished.

Undernourished adolescent girls are unable to catch-up before entering adulthood and motherhood. There is a sharp decline in the percentage of women married before the legal age of 18 years—from 69 percent in 2006 to 16.5 percent in 2013—among women aged 20-24 years at the time of the surveys.

In Bihar state, girls become mothers before entering full adulthood of women; 42 percent girls are already mothers by age of 18 years in 19 of the 38 districts (AHS, 2012-13). NFHS 4 also indicates 40.9 percent rural women age 20-24 years were married before age of 18 years. Women aged 15-19 years who were already mothers was noted to be 12.8 percent. This is also reflected in poor education of mothers with only 46.3 percent mothers being literate and with only 19.5 percent rural women who have completed 10 or more years of schooling.

Poor nutrition of mothers is noted across all the social categories but the situation is worst in case of scheduled caste women where almost six out of 10 women are undernourished and about 2 out of 10 are moderately or severely thin (Fig 40). The recent data of NFHS 4 of 2016 indicates the nutritional status of women has improved substantially but continues to be rather poor with 31.8 rural women aged 15-49 years with low body index compared to 22.2 percent urban and 30.8 percent in the entire state.

The number of children per family continues to be higher in Bihar. As per RSOC, 2013, nearly 5 of 10 women had three or more children in Bihar which was higher than the national average of nearly four of 10 women in 2006. Less than 4 out of 10 women in reproductive age group use family planning method. Women attending ANC services in the first trimester or attending 3 ANCs was reported to be about 61 percent. According to NFHS 4, in rural Bihar only 13.0 attend the prescribed 4 ANCS, 80.3 percent receive mother-child protection cards while the percentage of women with institutional deliveries is as high as 62.7 percent (NFHS 4, 2016).

0

10

20

30

40

50

39.8

Stunted

Perc

ent

prev

alan

ce a

mon

g <5

yr

child

ren

Wasted Underweight Severely wasted

49.3 48.3

21.3 20.8 20.8

37.5

44.6 43.9

7.9 6.9 7

Urban Rural State

Figure 38: Undernutrition in Children below 5 years in the State of Bihar, (NFHS 4)


As stated above women completing 10 years of schooling is rather low, 19.5 percent in rural compared to 44.3 percent in urban. Analysis of NFHS-3 data indicates (Fig 41) that with increase in years of education, there is positive impact on nutrition of children and women, age of marriage and conception, suffering of women from domestic violence.

The key interventions being focused in the state are on maternal and child nutrition which is being primarily being implemented by the health and ICDS sectors. There is an effort to reach the newly wed women. Effort to address the nutrition sensitive interventions such as education, family planning as

Figure 40: Nutritional Status of Women in Bihar

Figure 39: Estimated Numbers of Undernourished Under Five Years Children in Various Districts of Bihar Source: AHS, CAB (2013-14), CENSUS (2011), V. Seth, UNICEF Personal Communication 2015

100

90

80

70

60

50

40

30

20

10

0

400,000

350,000

300,000

250,000

200,000

150,000

100,000

50,000

0

Prevalence

Number

35.2

50.5

64.6

52.8

64.661.4

40.6

53.8

59.2

39.6

47.250.9

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52.155.2

48.251.4 52.1

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52.450.1

51.6

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well as improving the status of women through the micro-credit initiative under the State Livelihood Programme (Ajeevika programme) is being given special focus.

d. Uttar Pradesh State: Challenges and Opportunities for Improving Nutrition of Women and Children Mission

Uttar Pradesh, the most populous state with an estimated population of 20 crores, alone accounts for over an estimated 5 lakh child deaths, of which nearly 45% can be attributed to undernutrition of the mother and child. Uttar Pradesh, alone accounts for over an estimated 5.5 lakh child deaths, of which nearly 45 percent can be attributed to poor nutritional status of the mother and children.

As per NFHS 3, 42.4 percent of children below five years are underweight, 56.8 percent are stunted and 19.5 percent are wasted (NFHS-3, 2005-06).The findings indicate that approximately 12.6 lakh children suffer from severe acute malnutrition (weight-for-height <3SD) at any point in time. Recent data of RSOC (2013-14) indicate 50.4 percent under- fives are stunted the state has the highest prevalence rate of stunting in the country. The prevalence rate of wasting has declined to 10.0 percent. Children with severe acute malnutrition are nine times more likely to die than children who are not malnourished.

Undernutrition sets early in life and nearly one-third of the children are underweight before the age of six months, of which 12 percent are severely underweight. The undernutrition curve continues to rise with the age of child and peaks to 45 percent by two years. (NFHS-3, 2005-06) Poor maternal nutrition of women (36 percent women with low BMI) contribute to undernutrition and sets up the intergeneration cycle of low birth weight, undernutrition in children and poor adolescent nutrition.

The practice of breastfeeding and complementary feeding continues to be poor. Only 33 percent children (NFHS-3, 2005-06) are fed mothers milk within the first hour of birth. As regards exclusive breastfeeding, only 51 percent children between 0-5 months in UP were exclusively breastfed in 2005 compared to 62.2 percent reported in 2013. (NFHS-3, 2005-06; RSOC, 2013) Complementary feeding practices in the state are reported to be poor with only 46 percent children 6-9 months receive solid/semi solid foods along with breast milk. The coverage with other nutrition interventions also remains poor with 46 percent women in the adolescent reproductive age being anaemic, 36 percent families using salt

Figure 41: Women’s Education and Its Impact on Underweight in Children, Age of Marriage, Domestic Violence


that is adequately iodized and very low coverage with Vitamin A (7 percent) and Zinc, two important micronutrients for improved immunity and child survival. (NFHS-3, 2005-06)

Poor maternal nutrition and faulty infant and young child feeding practices are major factors responsible for poor birth weight and undernutrition in early infancy. According to NFHS-3 and RSOC data, 36.7 percent adolescent girls 15-18 years have low BMI. The incidence of LBW is 22.5 percent with UP state ranking third highest with regard to incidence of LBW. (RSOC, 2013) Inadequate complementary foods and feeding practices coupled with poor hygiene and sanitation conditions are important determinants of undernutrition in late infancy and early childhood. Interventions for addressing undernutrition therefore need to start early i.e. from pre-conception to first two years of life. The first 1000 days is the critical window of opportunity for the delivery of nutrition interventions. Efforts made after this period will not make much difference and children would have suffered irreversible damage affecting their adult life and that of their subsequent generations.

The Nutrition Mission of UP state has been created to provide the platform for convergence, coordination and cooperation of interventions .The setting up of the Mission reflects highest level of leadership and commitment by the state government which is very important to address the following problems:

• Interventions are not implemented at scale.

• Quality of the interventions is not of the optimal standards.

• Actual target groups in need of services are neither reached nor a demand created.

• High impact interventions which are known to make a difference are not in the implementation priority list.

The State Nutrition Mission provides the much needed platform and aims to strengthen the implementation of the on-going schemes targeting undernutrition and also for exploring opportunities and pilot innovations for community based care of undernourished children by converging with not only Health and Women and Child Department but also other sectors such as Panchayati Raj, Livelihood Programmes such as DAY: NRLM. The nutrition specific interventions fall broadly into the following categories:

• Maternal nutrition and prevention of low birth weight.

• Infant and young child feeding with early initiation (within one hour of birth) and

• Exclusive breastfeeding for the first six months followed by continued breastfeeding upto the age of at least two years.

• Safe, timely, adequate and appropriate complementary feeding from 7th month onwards

• Prevention and treatment of micronutrient deficiencies.

• Prevention and treatment of severe acute malnutrition.

• Promotion of good sanitation practices and access to clean drinking water.

• Promotion of healthy practices and appropriate use of health services.

These interventions are complemented by broader, nutrition-sensitive approaches that will have an indirect impact on nutrition status.


REFERENCES

1. Abu-Saad K. and Fraser D. (2010) Maternal Nutrition and Birth outcomes. Epidem Review 32, 5-25.

2. ACF International (2013) Sowing the Seeds of Good Nutrition: Making Agricultural Policies Deliver Better Nutrition. ACF International.

3. Ackerson L.K. and Subramanian S.V. (2008) Domestic violence and chronic malnutrition among women and children in India. Am. J. Epidemiology 167, 1188-1196.

4. Adhikari T., Vir S.C., Pandey A., et al. (2014) Undernutrition in Children under Two Years (U2) in India: An Analysis of Determinants, National Institute of Medical Statistics and Public Health Nutrition and Development Centre. Published by National Institute of Medical Statistics, New Delhi.

5. Aguayo V.M., Badgaiyan N. and Paintal K. (2014) Determinants of child stunting in the Royal Kingdom of Bhutan: an in-depth analysis of nationally representative data. Maternal Child Nutrition, DOI: 10.1111/mcn.12168.

6. AHS (2012). Annual Health Survey. Available at: www.censusindia.gov.in/.../AHSBulletins/AHS_Factsheets_2012_13.html. (Accessed on 24 April 2016).

7. Alive and Thrive (2015) Alive and Thrive: A vibrant future –maternal, infant and young child nutrition in India. Available at: www.aliveandthrive.org

8. Allen L.H. (2000) Anaemia and iron deficiency: Effects on pregnancy outcome. Am J clin Nutr 71 suppl 5, 1280s-1284Ss

9. Balarajan Y., Subramanian S. and Fawzi W.W. (2013) Maternal iron and folic acid supplement is associated with lower risk of LBW in India. J Nutr (in print).

10. Benderly B.L. (2010) Mexico’s Model Conditional Cash Transfer (CCT) Program for fighting Poverty, The World Bank, Available at: rbfhealth.org.

11. Beti Bacahao Beti Padhao (2015). Available at: wcd.nic.in/BBBPScheme/main.htm. (Accessed on 24 April 2016).

12. Bhagowalia P., Quisumbing A.R., Menon P. and Soundararajan V. (2012) What dimensions of women’s empowerment matter most for child nutrition? Evidence using nationally representative data from Bangladesh, IFPRI, Discussion paper:01192, International Food Policy Research Institute, Washigton DC.

13. Bhutta Z.A., Das J.K., Rizvi A., Gaffey M.F., Walker N., Horton S. et al. (2013) The Lancet nutrition intervention review group, and the maternal and child nutrition study group. Evidence based interventions for improvement of maternal and child nutrition: what can be done at what cost? Lancet, 40-65.

14. Bold M.V., Quisumbing A.R. & Gillespie S. (2013) Women’s empowerment and nutrition: An evidence review, IFPRI, Discussion Paper: 01294, Transform Nutrition, International Food Policy Research Institute.

15. CAB (2014) Clinical, anthropometric and Biochemical. Available at: http//www.census/ 4hh-series /cab.html.

16. Ceesay S.M., Prentice A.M., Cole T.J., Foord F., Weaver L.T., Poskitt E.M. and Whitehead R.G. (1997) Effects of birth weight and perinatal mortality of maternal dietary supplements in rural Gambia: 5 year randomized controlled trial. BMJ 315, 786-90.

17. Census of India (2011a). HH-6 ST: Scheduled tribe households by main source of drinking water and location. Office of Registrar General and Census Commissioner of India. Available at: http: //www.censusindia.gov.


in/2011census/hlo/SC_ST/st/HH2706T-0000CRC.pdf. (Accessed 7 April 2016).

18. Census of India (2011b) Scheduled Tribe (ST) Data Tables - (India & States/UTs). HH-7 ST: Scheduled tribe households by main source of lighting. Office of Registrar General and Census Commissioner of India. Available at: http://www.censusindia.gov.in/2011census/hlo/ SC_ST/st/HH3007T-0000CRCD.pdf. (Accessed 7 April 2016).

19. Chava L.D. (2012) Community managed Nutrition cum Day Centres, Society for elimination of rural poverty, Department of Rural Development, Andhra Pradesh, India.

20. Christian P., Khatry S.K., West K. (2004) Antenatal anti-helminthic treatment, birthweight, infant survival in rural Nepal. Lancet 364, 981-863.

21. Christian P., Lee S.E., Angel M.D., Adair L.S., Arifeen S.E., Ashorn P. et al. (2013) Risk of childhood undernutrition related to small for gestational age and preterm birth in low and middle income countries. J of epidemiology 1-16.

22. Coalition for Food and Nutrition Security (2014) An Action Agenda For Nutrition Security in India, October 2014 , Save the Children.

23. Coalition for Sustainable Nutrition Security In India (2010) Sustainable Nutrition security in India : A Leadership agenda For Action ,May 2010,The Vistaar Project.

24. CORD (2016) Institutionalizing and empowering small and marginal women farmers in hill agriculture through systematic investment in district Kangra, Himachal Pradesh, India, Chinmaya Organisation for Rural development, CORD Sidhbari, Kangra district, Himachal Pradesh.

25. Coverage Evaluation Survey 2009, MoHFW and UNICEF

26. Das M.B, Kapoor S, Nikitin D. (2010) A closer look at child mortality among Adivasis in India. Policy research working paper: 5231, Human Development Department, South Asia Region. New Delhi, World Bank.

27. Digital Green (2015) Digital Green Annual Report 2014-15.

28. Fall H.D., Fisher J., Osmond C., and Margetts M. (2009) Multiple micronutrient supplementation during pregnancy in low income countries: A meta-analysis of effects on birth size and length of gestation. Food and nutrition Bulletin 30, 533-546.

29. FAO/WHO/UNU (2004). Avaialble at: www2.moh.gov.my/images /gallery/rni/2-chat .pdf. (Accessed on 15 April 2016).

30. FAO (2013) Synthesis of Guiding Principles on Agriculture Programming for Nutrition, FAO, Rome.

31. Garg A. and Kashyap S. (2006) Effect of counselling on nutritional status during pregnancy. Ind J of Paed 73, 687-692.

32. Gillespie S., Haddad L., Mannar V., et al. (2013) The politics of reducing malnutrition: building commitment and Accelerating progress. Lancet 382, 552-569.

33. Global Hunger Index: Armed Conflict and the Challenge of Hunger (2015) IFPRI, Concern Worldwide, Welthungerhilfe, World peace Foundation/tufts university.

34. Global Nutrition Report (2014) Actions and Accountability to Accelerate the World’s Progress on Nutrition, IFPRI. Available at: http://jn.nutrition.org/content/early/2015/02/25/jn.114.206078. (Accessed on 24 April 2016).

35. Global Nutrition Report (2015) Actions and Accountability to advance nutrition and sustainable Development,


IFPRI. Available at: https://www.ifpri.org/publication/global-nutrition-report-2015. (Accessed on 24 April 2016).

36. Government of India, Coverage of NRLM (Personal communication).

37. Government of Uttar Pradesh and UNICEF (2004) Mobilising for Change Community Based Maternal Child Health and Nutrition (MCHN) Project, Uttar Pradesh.

38. Gragnolati M., Shekhr M., Gupta M.D. et al (2005) India’s undernourished Children: A Call for Reform and Action Washington DC, World Bank.

39. Grantham-McGregor S., Cheung Y.B., Cueto S. (2007) Child Development in Developing Countries: Development potential in the first 5 years for children in Developing Countries. Lancet 369, 66-70.

40. Gupta P., Ray M., Dua T., et al. (2007) Multi micronutrient supplementation for undernourished pregnant women and the birth size of their offspring: A double blind, randomized, placebo controlled trial. Arch Pediatr adolescence Med 161, 58-64.

41. Gwatkin D.R., Rutstein S., Jonson K., Suliman E., Wagstaff A. and Amozou A. (2007) Socioeconomic differences in health, nutrition and population, Washigton, DC, World Bank.

42. Headey D.D. and Hoddinton J. (2014) Understanding the rapid reduction of undernutrition in Nepal, 2001-2011, IFPRI Report.

43. Headey D.D., Hoddinott J., Ali D., Tesfaye R., Dereje M. (2014) The Other Asia Enigma: Explaining the rapid reduction of undernutrition in Bangladesh, IFPRI, Discussion Paper:01358, Poverty, Health and Nutrition Division, International Food Policy Research Institute.

44. Herforth, A. & Harris, J. (2014) Understanding and Applying Primary Pathways and Principles. Brief #1. Improving Nutrition through Agriculture Technical Brief Series. Arlington, VA: USAID/Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.

45. Hofmeyr GJ, Attalah N and Duley L (2010) Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. The Cochrane Database of Systematic Reviews 2010(8),:CD 001059.

46. Hong R., Banta J.E. & Betancourt J.A. (2006) Relationship between household wealth inequity and chronic child undernutrition in Bangladesh International Journal of Equity n Health 5, 15.

47. Hueston W.J., Gilbert G.E., Davis L. and Sturgill V. (2003) Delayed prenatal care and the risk of low birth weight delivery. J.Community Health 28, 199-208.

48. IFAD (2009) International Fund for Agriculture Development, Gender and Rural Microfinance: Reaching and Empowering Women, pg 6.

49. IGMSY (2011) Indira Gandhi Matritva Sahyog Yojana: A conditional Maternity Benefit scheme .Implementation Guidelines for state governments/UTs Administration, MWCD, GoI, New Delhi.

50. Imdad A. and Bhutta Z.A. (2011) Effect of balanced protein energy supplements during pregnancy on birth outcomes. BMC Public Health 11, suppl 3- s17.

51. Imdad A. and Bhutta Z.A. (2012) Routine iron-folate supplementation during pregnancy: Effect on maternal anemia and birth outcomes. Paediatric and Perinatal epidemiology 26 suppl 1, 168-177.

52. Kathuria A.K (2011) Nutrition in India, India Health Beat: Supporting evidence based policies and implementation. Vol 5,1.


53. Khanal V., Zhao Y., Sauer K. (2014) Role of antenatal care and iron supplementation during pregnancy in preventing low birth weight in Nepal: Comparison of Maternal Surveys in archives of Public Health 72, 1-10.

54. Khurshid J., Roy S.K., Mihrshahi S., et al. (2014) Short -term nutrition education reduces low birth weight and improves pregnancy outcomes among urban poor women in Bangladesh. Food and Nutrition Bulletin 35, 414-421.

55. Langworthy M. and Caldwell R. (2009) Jibon o Jibika Program: End-line Survey Report. TANGO International Inc. Available at: http://pdf.usaid.gov/pdf_docs/Pnads875.pdf. (Accessed on 28 April 2016).

56. Launer I.J., Villar J., Kestler E., de Onis M. (1990) The effect of maternal work on fetal growth and duration of pregnancy: A prospective study. Br J, Obtet Gynaecol 97, 62-70.

57. Mason J.B., Saldana L.S., Ramakrishnan U., et al. (2012) Opportunities for improving maternal nutrition and birth outcomes: Synthesis of country experiences. Food and Nutrition Bulletin 33 Supple 1, S104-S137.

58. Menon (2015) Presentation made at Coalition for Food and Nutrition Security Meeting.

59. Meshram I.I., Arlappa N., Balakrishna N., et al. (2012) Trends in the prevalence of undernutrition, nutrient and food intake and predictors of undernutrition among under five year tribal children in India. Asia Pac J Clin Nutr. 21, 568-76.

60. Mittal P.C. and Srivastava S. (2006) Diet, nutritional status and food related traditions of Oraon tribes of New Mal (West Bengal), India. Rural and Remote Health 6, 385.

61. Munshi I. (2012) Introduction- The Adivasi Question: Issues of land, forest and livelihood. Essays from Economic and Political Weekly, Orient Blackswan Private Limited: Hyderabad.

62. Muthayya S.S. (2009) Maternal nutrition and low birth weight –what is really important? IJMR 130, 600-608.

63. Nandurbar Nutrition Pilot project (2016) field Visit observations 5-6th May 2016

64. National Tribal policy - draft (2006). Available at: http://www.legalpundits.com/Content_folder/tribalpolicy.pdf. (Accessed on 15 April 2016).

65. NFHS-3 (2005-06) Indian Institute of Population Studies, Mumbai. Available at: rchiips.org/nfhs/nfhs3.shtml. (Accessed on 24 April 2016).

66. NFHS-4 (2016), National Family Health Survey 2015-16, State Fact Sheets, Ministry of Health and Family Welfare, International Institute of Population Sciences, Mumbai.

67. NHM (2013) National Health Mission , Guidelines for Village health, sanitation and nutrition Committees, Government of India. Available at: http://nrhm.gov.in/images/pdf/communitisation/vhsnc/order-guidelines/vhsnc_guidelines pdf. (Accessed on 24 April 2016).

68. NIPI (2013). Available at: http://www.nrhmhp.gov.in/sites/default/files/files/Iron%20plus%20initiative%20for%206%20months%20-5%20years.pdf. (Accessed on 24 April 2016).

69. NNMB (2006) National Nutrition Monitoring Bureau Technical report 24, National Institute of Nutrition, Hyderabad.

70. NNMB (2012) National Nutrition Monitoring Bureau, Technical Report 26, Diet and Nutritional Status of Rural population, Report of Third Repeat Survey.

71. NRLM (2010) National Rural Livelihood Mission, Framework for Implementation, Government of India.

72. Olken B.A., Onishi J., Wong S. (2011) Indonesia’s PNPM Generasi Program: final impact evaluation report.


Washington, DC: World Bank.

73. Olney D.K., Dillon A., Pedehombga A., et al. (2015) Using an agriculture platform in Burkina Faso to improve nutrition during the first 1000 days. Global Nutrition Report 2014, Panel 6.3, IFPRI.

74. Prost A., Colbourn T., Sewardet N., et al. (2013) Women’s group practising participatory learning and action to improve maternal and newborn health in low –resource settings: A systematic review and meta-analysis, Lancet 381, 1736-1746.

75. Ramachandran P. (1989) Nutrition in pregnancy in women and nutrition in India. Ed: Gopalan C., Kaur S., Special Publication No.5, Nutrition foundation of India, New Delhi.

76. Ramalingaswamy V., Jonsson U. and Rohde J. (1996) Commentary: The Asian Enigma- The Progress of Nations, New York, United States Children’s Fund.

77. Rao S., Kanade A., Margetts B.M., et al. (2003) Maternal activity in relation to birth size in rural India. The Pune Maternal Nutrition Study. Eur.J. Clin Nutr 57, 531-42.

78. Rao S., Yajnik C.S., Kanade A.N., et al. (2001) Intake of micronutrient rich foods in rural Indian mothers and size of their babies at birth. Pune Maternal nutrition Study. Journal of Nutrition 131, 1217-1224.

79. RSOC (2013) Rapid Survey on Children 2013-14. Ministry of Women and Child and UNICEF.

80. Ruel M.T., Alderman H., and the Maternal and Child Nutrition Study Group (2013) Nutrition sensitive Interventions and Programs. How can they help accelerate progress in improving maternal and child nutrition. The Lancet 382, 536–551.

81. Swabhiman (2015) Swabhiman Pariyojana, Bihar 2015-18, UNICEF, Patna.

82. Scholl T.O. (2005) Iron status during pregnancy: setting the stage for mother and infant. Am J.Clin Nutr 81 Suppl 5, 1218S-1222S.

83. Shrimpton J.R., Victora C.G., deonis M., et al. (2001) Worldwide timing of growth faltering: Implications for nutritional interventions. Paediatrics 107, 1-7.

84. Shroff M., Griffiths P., Adair L., et al. (2009) Maternal autonomy is inversely related to child stunting in Andhra Pradesh, India. Matern Child Nutr 5, 64–74.

85. Smith L.C. and Haddad L. (2015) Reducing child undernutrition: Past drivers and priorities for Post-MDG era. World Development 68, 180-204.

86. Smith L.C., Ramakrishnan U., Ndiaye A., et al. (2003) The importance of women’s status for child nutrition in developing countries, Research Project: 131, International Food Policy Research Institute.

87. Spears D. and Haddad L. (2015) The power of WASH: Why sanitation matters for nutrition. ch 3. International Food Policy Research Institute.

88. Suhaahara– Nutrition project (2016) Available at: https://www.k4health.org/toolkits/SUAAHARA-nutrition-project. (Accessed on 28 April 2016).

89. Swachh Bharat Abhiyaan (2014). Available at: swachhbharaturban.gov.in/. (Accessed on 24 April 2016).

90. Tafari N., Naeye R.I. and Gobezie A. (1980) Effects of maternal undernutrition and heavy physical work during pregnancy on birth weight. Br J Obstet Gynaecol 87, 222-6.

91. Tamber B. (2006) Seasonality and maternal factors affecting pregnancy outcome—A study, Ph D thesis, Delhi University.


92. Tango International Inc. (2009) SHOUHARDO- A title II program of USAID final evaluation report, USAID Bangladesh. Available at: http://pdf.usaid.gov/pdf_docs/Pdacp746.pdf. (Accessed on 28 April 2016).

93. The HUNGaMA Survey Report (2011) Fighting Hunger and Malnutrition, Naandi Foundation.

94. Tripathy P., Nair N., Sinha R., et al. (2016) Effect of participatory women’s groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trial. Lancet Glob Health 4: e119–28.

95. UMED (2016) Field Visit Observations May 2016, Nandurbar district, Maharashtra.

96. UNICEF (1998) The State of the World’s Children Report, UNICEF, New York.

97. UNICEF (2007) Project Report, National Micronutrient Survey 2007, Republic of Maldives, Ministry of Health and Family, Male, United Nations Children’s Fund.

98. UNICEF (2009) Tracking progress on child and maternal nutrition, United Nations Children’s Fund, New York.

99. UNICEF (2014) Nourishing India’s tribal Children: The nutrition situation of children of India’s scheduled tribes. United Nations Children´s Fund, New Delhi.

100. UNICEF (2015) Women’s Nutrition: A review of evidence and actions for UNICEF, July 2015, UNICEF, New York.

101. UNICEF (2015a) National Conclave Nourishing India’s Tribal Children, Voices of frontliners, promising practices and policy implications, Synthesis of deliberations and recommendations, 15-16 January, Bhuvaneshwar, Odisha, India.

102. UNICEF (2015b) Background Paper “Accelerating and Harmonizing Actions for Nourishing Bihar’s Children (Draft Doc 2015). United Nations Children´s Fund.

103. UK Hunger Alliance (2013) Small scale, big impact: Smallholder agriculture’s contribution to better nutrition.

104. Venamann A.M. (2008) 35th SCN Session Opening Speech by SCN chairperson, SCN News Vol 36, 4-6.

105. Victora C.G., Adair L., Fall C., et al. (2008) Maternal and Child Undernutrition: Consequences for adult health and human capital. Lancet 371, 340-57.

106. Vir S.C. (1990) Adolescent growth in girls-the Indian perspective. Indian Paediatrics 17, 1249.

107. Vir S.C. (2001) National Status of Children in Uttar Pradesh, NFI Bulletin, January.

108. Vir S.C. (2011) International success stories in reducing undernutrition: Strategic choice, policy actions, and lessons. India health Beat vol 5. The world bank and PHFI.

109. Vir S.C. (2013) Community based maternal and child health nutrition project, Uttar Pradesh: An innovative strategy focusing on “At Risk” families. Indian Journal of Community Medicine 38, 234-239.

110. Vir S.C. (2016) Maternal Nutrition: Breaking the intergeneration cycle of malnutrition: Significance, challenges and opportunities, Undernutrition and Public Policy in India: Investing in the Future. In ed: Desai S., Haddad L., Chopra D., and Throat A., Routledge Publisher, pP 153-181, South Asia Edition.

111. Vir S.C. (2016a) Improving women nutrition imperative for rapid reduction of childhood stunting: Coupling of nutrition specific and nutrition sensitive measures essential. Journal of Maternal and Child Nutrition, Special supplement May, under publication.

112. Vir S.C., Dwivedi S., Singh R and Mukherjee A. (2007) Reaching the goal of universal salt iodization (USI): Experience of Uttar Pradesh, India. Food and Nutrition Bulletin 28, 384 – 390.


113. Vir S.C., and Sforza C. (2011) Weekly Iron and Folic Acid Supplementation Programmes for Women of Reproductive Age- An Analysis of Best Programme Practices. WHO Western Pacific Region.

114. Vir S.C., Kalita A., Mondal S. and Malik R. (2014) Impact of community based mitanin programme on the undernutrition scenario in rural Chhattisgarh state, India. Food and Nutrition Bulletin, 35, 83-91.

115. WHO (2009) Weekly Iron Folic Acid Supplementation (WIFS) in women of reproductive age: Its role in promoting optimal maternal and child health, World Health Organisation.

116. WHO (2011) Prevention of iron deficiency anaemia in adolescents: Role of weekly iron and folic acid supplementation SEA-CAH -02, World Health Organisation Regional Office for South East.

117. WHO (2013a) Global Nutrition Policy Review: What does it to take to scale Up Nutrition Action. Geneva, WHO.

118. WHO (2013b) Essential nutrition actions, improving maternal, newborn, infant and young child health and nutrition. World Health Organisation.

119. WHO (2014) WHA Global Nutrition targets 2025: Stunting Policy Brief. World Health Organisation.

120. WIPRO and WFP (2014) Enhancing the Nutritional Content of the Food Basket Distributed in the Targeted Public Distribution System.

121. World bank (2010) Nutrition country profiles: Nutrition at a glance (India). Available at: http://siteresources.worldbank.org/NUTRITION/resources/281846-12719638237772/india.pdf. (Accessed on 7 April 2016).

122. Wu G., Imhoff-Kunsch B. and Girard A.W. (2012) Biological mechanism for nutritional regulation of maternal health and fetal development. Paediatric and Perinatal Epidemiology 26, Supple 1, 4-26.

123. Young F.M., Nguyen P.H., Addo O.Y., et al. (2015) The relative influence of maternal nutrition before and during pregnancy on birth outcomes in Vietnam. Hunert Department of Global Health and Doctoral Program in Nutrition and Health Sciences, Emory University Atlanta, GA 30322. (Personal Communication).

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