Mapping nutrition change in Odisha: The

role of programs, policies, and politics

Rasmi Avulawith

Neha Kohli, Purnima Menon, Lawrence Haddad, Nick Nisbett, Mara Van den Bold, Elisabeth Becker

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1992-93 1998-99 2005-06 2013-14

Stunting (%)

Wasting (%)

Underweight (%)

Children with anyanemia (6-35 mo) (%)

Women (15-49yrs) withanemia (%)

Low birth weight(<2.5kgs) (%)

Changes in Odisha: IMR and undernutrition

Inter-district variation exists. Higher proportion of undernourished children tribal population

1992-1993 1998-99 2005-06 2013-14 Infant Mortality Rate

112 81 65 56

Methods

Elements of the timeline

• Nutrition outcomes • Immediate determinants • Coverage of nutrition-specific

interventions• Underlying and basic

determinants• Policies and programs

Sources

• National Family Health Surveys

• Rapid Survey on Children • National Sample Survey

Organization (NSSO) • Odisha economic surveys • Desk review of policies and

programs • Stakeholder interviews

Developed a 25 year timeline (1991-2015)

Community-level change interviews in Kalahandi

1990-1995 1995-2000 2000-2005 2005-2010 2010-2015

Improvements in most immediate

determinants

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80

1992-93 1998-99 2005-06 2013-14

Women with body massindex <18.5

+Children (<3 years)breastfed within 1 hour ofbirth (%)

Children (<6 months)exclusively breastfed (%)

Children receiving solid/semi-solid food and breast milk (%)

Children (0-59 mo) withdiarrhea in the last twoweeks (%)

Children (<5yr) with diarrheain the last 2 weeks whoreceived ORS (%)

Improvement in the coverage of many

nutrition-specific interventions

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90

100

1992-93 1998-99 2005-06 2013-14

Women received/bought iron folic acidsupplements during pregnancy (%)

Mothers who had 3+ ANC visits for last birth(%)

Mothers who had antenatal care during firsttrimester (%)

Receipt & use of ICDS supplementarynutrition during pregnancy (%)

Births in a health facility (based on last 2births in three years prior to survey) (%)

Births assisted by a health professional in lastthree years

Receipt & use of ICDS supplementarynutrition during lactation (%)

Children (12-23 mos) fully immunized (%)

Children (12-35 mos) who received vitamin A- last 6 months (%)

Receipt & use of ICDS supplementarynutrition for children (%)

Underlying determinants improved: literacy, drinking water, food security (PDS) Needs attention: poverty, sanitation, age at marriage

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Early 1990s Late 1990s Mid 2000 Late 2000 onwards

% of monthly per capita foodexpenditure in rural areas

% of people buying rice from PDS

% of households with access tosafe drinking water

% of households with access totoilet facilities

% Literacy

% Female literacy

% women (15-19 yrs) whoreceived at least secondaryeducation% of women (20-24yrs) married byage 18

Poverty headcount ratio

National guidance, state vision and innovation in place for health, nutrition & food security programs

Nutrition and Health programs Food security program

Sanitation

National guidelines

-Universalization of nutrition centers -Institutionalization of new cadre of health workers and expansion of services as a mission approach

-Expansion and reforming of the program

Exist

State vision -IMR & MMR reduction as a common goal

Innovations to improve and expand coverage through lesstargeting

Unclear

Catalysts, champions, and ownership

-Poor mortality ranking-Human Rights Commission monitoring -Political intent -Motivated bureaucracy- Development partner support

-Vigilance Committee-Political intent -Development partner support

Unclear

Other programs influencing nutrition determinants

• Gender: Early to kick off women’s empowerment programs [but note less on early marriage/pregnancy]

• Infrastructure:

– Road connectivity improved (PMGSY)

– Rural electrification

– Drinking water facilities improved but issues of contamination exist

• Agriculture: Invested in irrigation, mechanization, crop diversification

– Land access and migration remain challenges

Community-level changes mirrored program and policy evolution and innovations

Key take-aways on what helped

• Political leadership and smart politics

• Investments in social sector programs

• Investments in infrastructure

• Committed and well-trained bureaucrats who enabled program actions & innovations

• Support of committed development partners

• Availability of national policy guidance and financial support

Looking ahead

• Build on existing technical and system capacities to sustain positive story of coverage and scale in nutrition-specific

– Invest in quality improvements

• Given role of underlying determinants and limited change, identify ways to engage other government departments: education, WASH, rural development, tribal welfare

• Capitalize on high level support to social sector to raise profile of nutrition and hold sectors accountable