What is an Effective Nutrition Program

1
What is an Effective Nutrition Program?

• Five Important Lessons
• from 40 years of Nutrition Programs
• in India
• Meera Chatterjee
• World Bank

2
The Context

• Despite 40 years of nutrition programs
• 53 of children under 3 are still malnourished
• Chronic and seasonal hunger persist in families
  as a whole
• Women are (usually) worse off
• Further demographic progress will depend on
  nutritional improvements

3
The Five Lessons in Brief

• Reach those at greatest risk of malnutrition
• Use accumulated scientific and empirical
  knowledge to decide priority interventions
• Health care is a critical input
• Focus hardest on the soft things
• Food should be used strategically

4
Lesson 1 Reach those at greatest risk of
Malnutrition

• Why?
• Moral imperative Save lives
• Social soundness Equity
• Economic benefit Healthy bodies health minds
  good for productivity, reduce poverty
• Demographic wisdom Child survival reduces
  fertility
• Financial reason Maximize impact of resources
• Political dilemma Large numbers but least
  powerful!

5
Reach those at risk

• How?
• By Targeting
• Geographic Poorest blocks/districts and urban
  areas (slums?)
• Spatial Villages, hamlets ) These
• Social Dalits, tribal people ) interact
• Biological Adolescent girls, PL Women, Infants
  and toddlers
• Attempted but still inadequate ICDS, PDS, FFW

6
Reach those at risk

• Need to turn Inside Out! to reach spatially and
  socially most isolated people
• Problems?
• Trickle down doesnt work because of elite
  capture
• Workers dont go lack mobility or, if resident,
  skills social strictures very difficult to
  overcome need better selection and training
• Giving up the Roadside approach is politically
  most unpalatable because visibility and power
  count!
• Feasibility of obtaining and applying a whole lot
  more resources ?
• Tradeoffs between quantity and quality

7
Lesson 2 Use Knowledge to Decide Priorities

• What is the problem?
• We have a wealth of studies and data, accumulated
  and sifted knowledge of the causes of
  malnutrition and interventions needed to address
  it BUT
• We dont use it to evaluate or re/design
  activities
• We add on rather than replace old activities,
  making for cumbersome unmanageable programs
• We dont recognize adequately that times are
  changing and make the best of those changes
• gtgtgt Results in programs with high administrative
  expedience and/or low scientific validity

8
Use Knowledge

• For example, scientific knowledge tells us
• The 1-2 year-old is most at risk, requires very
  little food but needs proper feeding is at high
  risk of infection, needs protection through
  immunization and safe drinking water, needs
  simple remedies such as ORS, timely treatment of
  ARI
• The critical time to intervene to ensure adequate
  weight babies and break the LBW spell is during
  adolescent growth spurt feeding in pregnancy is
  probably too late controling infections in
  pregnancy can reduce risk of prematurity
• Depleted, anemic girls and women have highest
  risk of maternal and infant death and LBW

9
Use Knowledge

• If the goal is reducing malnutrition, the
  priority interventions must be
• Total HN care of the 0-2 year old in the home
• Prevention and treatment of anemia in females
• Ensuring Adolescent girls get food for growth
• Everything else is secondary
• Calls for a program that educates, motivates and
  supports poor families with simple inputs,
  regularly - only fortnightly/monthly

10
Use Knowledge

• The corollary of giving up whats not working is
  promoting and expanding what is working we need
  to use program data to improve program management
  and effectiveness
• The data collected must be reliable
• Timely
• Used at different levels for learning and
  capacity building

11
Lesson 3 Health care is a critical input

• What is the Problem?
• The importance of health care to the improvement
  of nutrition among young children and women (and
  all) is well proven
• BUT
• The convergence approach is not yet working
  adequately nutrition still falls through the
  cracks

12
Health care critical

• What is to be done?
• Village level workers must have proper protocols
  to ensure full range of health care provided to
  key target groups, esp. those at greatest risk of
  MN
• Health sector must make doctors and paramedics
  (esp. ANMs, MPWs) recognize the importance of
  preventing and treating malnutrition, commit to
  doing so, and equip them with the needed
  knowledge and skills to do so, incl. tools for
  screening, measuring and monitoring malnutrition
• Timeliness is critical

13
Lesson 4 Focus Hardest on the Soft Things

• Why?
• Most of the improvements we seek in nutrition can
  be achieved through
• Communication and education of families
  (particularly women) about nutrition and health
• Improving the knowledge, commitment and basic
  skills of workers
• Some community organization to provide support to
  poor families
• They are about behavioural change but BC is not
  achieved only by giving messages, it means
  demonstrating, practising and supporting them

14
Focus on the Soft Things

• What are the constraints?
• Lack of conviction that these are important
  belief in harder things e.g., food, injections,
  posters, buildings
• Need for one-on-one interaction (cf.social
  strictures)
• Lack of patience desire for quick fixes but
  these do not last, do not get handed down
• Need for community organizing skills
• Improvements have been made in training but
  hands-on, demonstrations, on-the-job, refresher
  and hand-holding remain inadequate
• Need to change all the above!

15
Focus on the Soft Things

• Also need
• Flexibility to evolve different strategies
  locally, to implement different things at
  different times not normative approaches
• Innovation at all levels
• Willingness to change program add or subtract,
  multiply and divide
• i.e., reduced bureaucratic/political pressure!

16
Lesson 5 Food must be used Strategically

• Why?
• It may not reach the most in need (program
  capture, leakages, dont come)
• It distracts workers from key tasks
• Impact on malnutrition is currently low
• Costs are high and money/effort may be better
  spent on other things

17
Use Food Strategically

• What does this entail?
• Giving paramount importance to infant and AG home
  feeding messages
• Removing food where it is not needed and is
  simply distracting the worker from the soft
  things
• Ensuring food is available where it is necessary,
  at times when it is required. This could be
  through a single channel depending on the nature
  of hunger and MN in the area/village

18
Use Food Strategically

• How?
• Use available data to produce block-wise maps and
  identify problem villages and proper choice of
  program dont need multiple programs if BC and
  health are also being done
• Ensure proper logistics to get supplies to those
  villages, plug leakages (consider easily
  identified commodity)

19
Summing Up the 5 LessonsAn Effective Nutrition
Program

• Targets those most at risk and most in need
  villages, social and biological groups
• Uses scientific knowledge and data to ensure
  valid interventions and managerial efficiency
• Ensures health services are provided when and
  where needed and are committed to address MN
• Does the hardest things best communication,
  community mobilization, training as much MN can
  be eliminated by simple changes in behavior
• Uses food strategically so that it adds but
  doesnt subtract