Integrating Nutrition Promotion and Rural Development in Sri Lanka

South Asia Region This project also aims to explore the pathways and quantifying their relative contributions on food security and nutrition related outcomes. It is believed that rural development programs have an impact on multiple health related behaviors and outcomes. The study focuses primarily on nutritional outcomes, but includes several others. In addition, this project aims to provide evidence on understanding the best ways to operationalize multi-sectoral approaches and innovative multi-sectoral delivery strategies. Generating this new evidence could attract more local and national level policy makers to consider health impacts when they make decisions. The output of this study will solidify the call for intersectoral collaborations and whole of government approaches to improve nutrition and health, in particular in developing countries.

The Integrating Nutrition Promotion and Rural Development (INPARD) project aims to investigate whether a multisectoral rural development programme can be utilized to deliver nutrition promotion interventions within rural Sri Lanka and whether this approach is effective in improving nutrition outcomes.

Integrating Nutrition Promotion And Rural Development (INPARD) Project
Overview 5 INPARD Connecting health and development goals is challenging, particularly in the context of a country experiencing rapid changes in socioeconomic status. In the post-conflict era, Sri Lanka has maintained a relatively high level of growth and recently graduated to the economic status of a lower-middleincome country.
Sri Lanka is currently undergoing demographic, epidemiological and social transition with rapid urbanization and development. The country is now facing the double burden of under-nutrition and over-nutrition with rapidly emerging noncommunicable diseases (NCDs). Despite improvements in many health indicators, malnutrition, anemia and other micronutrient deficiencies prevail; this indicates a need to integrate nutrition in future development policies. According to a study conducted by Katulanda et al (2009), one in four Sri Lankan adults are overweight and one in ten are obese. Their data also show that more than a quarter of adults are centrally obese (central abdominal obesity is higher waist circumference due to abdominal fat deposition).
According to the Ministry of Health (MOH), NCDs now account for 65% of all deaths in the country. These transitions have been observed in many countries as they move towards middle and high-income status. A healthy society is a key to sustainable economic development. Therefore it is important to take measures to address these nutrition and health challenges alongside the economic development.

INPARD
The World Health Organization (WHO) Country Office for Sri Lanka published a booklet on addressing noncommunicable diseases in a lower-middle-income country with a focus on Sri Lanka's approach. The above puzzle published in that publication shows key lessons learnt from a health promotion and disease prevention national programme. This INPARD study mainly focuses on three pieces of the above puzzle with reference to; addressing social determinants of health through multisectoral and stakeholder coordination, prioritizing research and evidence-based strategies and learning from demonstration projects. This focus is given for a broader health and nutrition project by integrating it with rural development.

1.2: Determinants of Nutrition
Development in various dimensions has impacts on health and nutrition. Internationally and nationally, it is recognized that some determinants of nutrition directly come under the purview of the health sector, but many of those determinants are influenced by other sectors such as education, agriculture, trade and rural development and these sectors have a considerable role to play in promoting nutrition. However, some policy makers are often unaware of the direct impact of development programmes on nutrition and therefore have not given consideration to nutrition when developing policies for other sectors.
The guide to District Nutrition Action Plan (DNAP) recommends interventions in health and non-health sectors in Sri Lanka. The action plan recognizes interventions implemented by non-health sectors such as the Ministry of Economic Development (MED), agriculture and education. There is general consensus that improvement in socioeconomic status results in better nutritional outcomes. Yet, globally, there is a lack of evidence proving the impact of development and other sectors in delivering nutritional outcomes. Furthermore, the contribution of each sector towards various dimensions of health and nutrition is poorly understood. There is, therefore, a need to study and evaluate the impact of multisectoral action on nutrition.

1.3: Funds
To proceed with the study, funds were accessed through the South Asia Food and Nutrition Security Initiative (SAFANSI) as their objectives fall in line with the aims of the INPARD study. The SAFANSI was formed to foster cross-cutting actions that will lead to measurable improvements in food and nutrition security. The objective of the SAFANSI is to increase commitment of the government and development partners towards creating more effective and integrated policies and industries towards promoting food and nutrition. Their principal aim is to promote political leadership and stewardship for food and nutrition security outcomes and to ensure nutrition outcomes central to regional and country food security and policy programmes. The SAFANSI also promotes inter-disciplinary approaches, building strong partnerships and prioritizing actions for nutrition and food security promotion.

1.5: Aims of the project
This project aims to bring health professionals and rural development practitioners together with a shared aim of integrating nutrition promotion and rural development. Even though the health sector has developed policies to recognize the role of non-health sector practitioners towards nutrition promotion, the non-health sector has not received adequate support and training as to how they can work together to achieve these nutritional goals.
The main objective of the project is to investigate whether a multisectoral rural development programme can be utilized to deliver nutrition promotion intervention within rural Sri Lanka and whether this is effective in improving nutrition outcomes. It includes identifying the pathways to promote nutrition with multiple stakeholders. It aims to explore the pathways in which development programmes have a direct impact on nutrition and health and to quantify their relative contributions on outcomes related to nutrition and food security.
In addition, this project aims to provide evidence on the best ways to operationalize multisectoral approaches and innovative multisectoral delivery strategies. Generating this new evidence could attract more local and national-level policy makers to consider health impacts when they make decisions. The output of this study will solidify the call for intersectoral collaborations and whole of government approaches to improve nutrition and health, particularly in developing countries.
The INPARD project is implemented in the Moneragala and Ampara districts of Sri Lanka. The population in these areas is ethnically, religiously, socio-economically and culturally diverse. While this diversity brings unique challenges for programme implementation, it also provides an opportunity to build new levels of evidence to inform future policies and programs.

1.4: Identifying a development project for intervention
The MED and livelihood improvement programmes have been identified as key responsible agencies to implement several non-health related interventions in Sri Lanka. The MED funds and coordinates several development projects to improve livelihoods in Sri Lanka. The Re-awakening Project (RaP) is one of the main community driven development projects in the country. INPARD has collaborated with RaP by selecting two RaP districts of Sri Lanka to implement and evaluate nutrition promotion activities. The capacity building and the interventions takes the new 'Divi Neguma' (a government programme to help five million individuals) model into consideration and they are adjusted according to the 'Divi Neguma' vision. It aims to ensure food security and to provide microfinance, physical and social infrastructure facilities in order to strengthen livelihoods and development at the community level. INPARD activities and multisectoral community-led capacity-building programmes could be adopted to scale up through the 'Divi Neguma' in the future.
The INPARD project consists of two main components: intervention and evaluation. The intervention component includes capacity building, infrastructure development and livelihood support systems towards integrating nutrition promotion and rural development. The evaluation component includes quantitative and qualitative data collection prior, during and after the intervention and is led by a team of international and local researchers. One of the strengths of this study is that it involves many partners and stakeholders that play a role in promoting nutrition and related goals.

2.1: District selection
The Moneragala and Ampara districts of Sri Lanka have been chosen as sites for the INPARD project intervention. The RaP project is currently being implemented in both these districts. The Kurunegala district has been selected as a control because it has villages with similar characteristics to both Moneragala and Ampara, but it is not covered by the RaP. Consequently, it will enable us to evaluate the effect of the intervention.

2.2: Intervention
Intervention will be delivered to all 112 villages covered by the RaP project in Moneragala and Ampara districts (55 villages in Moneragala and 57 villages in Ampara). The project covers more than 120,000 people in 32,000 households in both districts.
A training programme will be developed by the INPARD project to train staff of identified sectors on how to work in collaboration to promote nutrition. Accordingly, the curriculum is being developed under three modules that includes introduction to nutrition, health promotion and intersectoral collaboration. , and civil society leaders will be invited from each village for INPARD workshops. They will play a key role in designing and delivering interventions in their setting.
Baseline survey results will be shared with the above mentioned community stakeholders. Rural development staff will organise meetings to discuss the findings relevant to their village/school and to prioritise interventions. The rural development project staff will be trained to understand the impact of their decisions on nutrition (e.g. approval of micro-finance loans for food related businesses and the impact on local dietary behaviour). Other sectors including agriculture and education will also attend this training. A multisectoral committee will discuss how each sector could contribute to address identified nutritional problems and achieve common goals. For example, schools may want to promote gardening but lack access to water or necessary gardening skills. In this example, the rural development sector could help to get water supply and agricultural officers could provide the expertise. Nutrition related technical knowledge will be provided by the local health staff and the INPARD team. INPARD staff will maintain detailed records that outline the components of each school and village's intervention. These records will include a description of the interventions' aims, the actions that were taken, who was involved and how outcomes were monitored or evaluated to measure the interventions' effectiveness.
The school-level activities will be based on the World Health Organization (WHO) Nutrition Friendly School Initiative criteria. School principals, teachers, parents and children will be supported by the rural development sector and other professionals to promote school environments that encourage healthy eating.

District
No The study will collect baseline and post-intervention surveys from a random sample of 2,000 adults, 2,000 schoolchildren (aged 12-18) and 1,000 children (under 12 years of age). Outcome measures include health behaviours (i.e. diet, physical activity, alcohol, and smoking), anthropometrics (height and weight), demographics and area-level measures related to food access (e.g. food availability, price and poverty indicators). The nutritional environment of schools (e.g. the policies, practices and environmental features that may encourage or discourage healthy eating) will be assessed using criteria set out in the WHO Nutrition Friendly Schools Initiative.
In addition, qualitative data will be collected through indepth interviews with multisectoral policy-makers and focus group discussions with teachers, community members, children, health staff, rural development staff and agriculture staff. The aim of these interviews and focus groups will be to identify barriers related to nutrition promotion and successful measures to tackle them.
• Ten villages will be selected from each stratum using probability proportional to size • Fifty villages from all three districts • Twenty households will be selected from each village • Within each household the survey will be completed by two adults and one child (<12 years) • Resulting in a total minimum sample of 2,000 adults and 1,000 children from 1,000 households • Sampling methods ensure all individuals have equal chance of selection School sample (12 -18 years of age) Cluster randomised sampling • Ten schools will be chosen from each stratum using probability proportional to size. In Rap villages where 1AB schools do not exist, 10 schools will be selected from type 1c and 2.
• A class will be selected from each school to achieve at least 30 students

3.1: Data Collection
The evaluation will include both qualitative and quantitative components. Methods used for qualitative and quantitative data collection are explained below.

3.1.1: Quantitative Data Collection
Quantitative data related to nutrition and other lifestyle risk factors will be collected at the village level and school level by trained data collectors using tools that have been developed and translated into both Sinhala and Tamil. Data from adults and children below 12 years will be collected through interviewer-administered questionnaires at the village level.
Measures from children between the ages 12 and18 will be collected at the school level through student self-completion questionnaires. Area level information on food availability, price and the nutrition-related components of schools will be collected by researchers visiting schools and shops in the villages.

3.1.2: Qualitative Data Collection
Qualitative data collection will include interviews with the stakeholders and policy makers who are involved in sectors related to promoting nutrition and nutrition related activities. The interviewees are selected from the government departmentsand non-governmental organizations (NGOs) such as District Secretariats, Divisional Secretaries (DS); central state sector stakeholders such as agriculture, health, education, water and sanitation, Samurdhi, livestock, fisheries, plantation and rural development; and nongovernmental stakeholders such as Sarvodaya who are involved in promoting nutrition and nutrition related activities in Sri Lanka. One to three key personnel were selected from each organization for the sample.
The interview guide for the first round of qualitative data collection focuses on their understanding of intersectoral collaboration and nutrition promotion, their role in nutrition promotion, current policies and practices of their organization for nutrition promotion, their mental models or accepted frameworks for collaboration, partnerships in place for nutrition promotion, and challenges and limitations. It focuses on understanding current policies and practices in intersectoral collaboration towards promoting nutrition in Sri Lanka. The second round of qualitative data collection focuses on evaluating the change in nutritional related policies and practices after the intervention, in which all the stakeholders from policy makers to grass root level officers, such as community resource persons (CRPs), will be interviewed.

3.2: Tools
Tools were developed and translated into both Sinhala and Tamil. A Sri Lankan version of the WHO STEPS tool has been revised according to the country specific requirements and validated by the Ministry of Health to collect information on diet and other behavioural risk factors and measurements such as height and weight.
A Food Frequency Questionnaire (FFQ) has been developed and validated in Sri Lanka by Ranil Jayawardena et al and will be used to collect detailed information on types of foods and quantities consumed.

3.4: Time line
The project was initiated in September 2013 and the post intervention survey will be conducted in July 2015.

Alcohol
Proportion of adults who consume alcohol STEPS (current/ever)

School
Nutrition friendliness of the school NFSI Assessment Tool (score based on WHO Nutrition-Friendly Schools Initiative criteria)

Village
Food availability and access (price and the Food availability and price presence of food items available for purchase data collected by researchers in village) Children's outcomes will be segregated by sex. Adults' outcomes will be segregated by sex and 10 year age groups.

Outcome Indicators for Adults
Interim (6month) indicators -assessed by qualitative methods Changes in nutrition related knowledge, attitudes and practices among adults and children. Changes in level of muti-sectoral collaboration for nutrition promotion 19 4. How this project may influence policies in Sri Lanka Sri Lanka has made significant improvements in health indicators, economic indicators and social development. But some nutrition related indicators have failed to show similar improvements. This void in the improvement of nutrition indicators has already come into limelight of the policymakers of Sri Lanka and many interventions have been put into place to bridge this gap in nutrition. The place for intersectoral collaboration in nutrition improvement has been widely accepted at the highest levels of authority at the government thus leading its way to formulating a national nutrition policy as well as a national nutrition council for nutrition headed by H.E the president of Sri Lanka. Despite these high-level efforts to link nutrition promotion with development, programmes continue to face several challenges at the grass-root level. Therefore, this study will be the first of its kind to analyse the structure of development projects in all sectors responsible for nutrition promotion. It aims to develop a functioning platform that will enable Sri Lanka to develop the horizontal linkages to achieve the national objective of improving nutrition indicators and wellbeing in rural areas. This study will also be one of the pioneering studies at the international arena that intends to evaluate the health impacts of economic and social development projects to provide evidence based recommendations.
Under the long term development programme introduced by the current government 'Mahinda Chinthanaya -Idiri Dekma', the government has highlighted its commitment for social development as well as infrastructure development. Thus, programmes such as 'Gama Neguma', 'Pura Neguma' etc. have been introduced to provide electricity, build small irrigation systems, develop roads and provide other necessary infrastructure. However, these programs fail to address the underline nutrition related issues which are a major component of sustainable development. Social development projects have identified the family and village community as the central focus for interventions. The Sri Lankan Government has introduced social development projects and programmes in the past such as 'Samurdhi'(a national programme introduced by the Government to alleviate poverty)and direct nutrition interventions in the form of school level midday meal programmes. However, it is impossible to address structural determinants of malnutrition through these standalone interventions.
Therefore the MED was established to interface all levels from individuals in the village to the national economy through horizontal and vertical integration. The MED looks into interfacing different sectors to facilitate collaboration and service delivery to the most disadvantaged communities.
Nutrition is commonly seen as a responsibility of the health sector. At the same time, lack of accountability and ownership to nutrition related outcomes and objectives has prevented the non-health sector from actively collaborating towards promoting nutrition. In this context, the INPARD project seeks to identify the best approaches for bringing health and nonhealth sectors together to address nutritional issues. The objectives of this study are one part of a much broader vision for the country's socioeconomic development.
The Government has launched the new Divi Neguma programme and there is a Divi Neguma Development Officer in each village. He is a non-health sector government servant who is attached to the MED. He is responsible for improving the food and nutrition security in villages and reducing the poverty. This project will provide an evidence-based working mechanism for these non-health sector officers to develop multisectoral community driven interventions to promote food and nutrition security in rural areas. The main purpose of the first workshop was to bring all the stakeholders together and to introduce the project. It also targeted on discussing the proposed interventions and the evaluation plan with the resource persons.

1.3: Summary of the workshop
The first workshop was a full-day workshop to introduce the project to high profile senior doctors and decision makers in the relevant authorities and to build a forum to discuss issues and implementation of the project. Over 35 officials participated. Discussions were based on the potential validity of the proposed INPARD intervention on the non-health programme and how such programmes could be applied to accomplish health and nutrition goals in the country.
Introducing the project Dr. Kremlin Wickramasinghe, a researcher of the British Heart Foundation Health Promotion Research Group at the University of Oxford pointed out that the aim of this study was to investigate whether a rural development programme could be utilized to deliver nutrition promotion interventions within rural Sri Lanka.
He explained why Moneragala and Ampara districts of Sri Lanka were chosen for the project study. He also explained the selection of Kurunegala District as the controller district to evaluate the effectiveness of the intervention in Moneragala and Ampara districts.
At the workshop, Dr. Nick Townsend, a researcher of the British Heart Foundation Health Promotion Research Group at the University of Oxford, introduced the study population, explained the sample size calculations and reviewed the method of analysis.
Dr. Palitha Maheepala, Director General of Health Services (MOH) emphasised that social issues should not be medicalised. He noted that it was encouraging to see this project looking at promoting wellbeing through a rural development lens.
Dr Ranil Jaywardena presented available methods to collect information on dietary patterns for children and adults. He described tools and validated Food Frequency Questionnaire (FFQ) for Sri Lanka and advantages of using such tools. Possible tools for INPARD study were considered and it was decided to use FFQ for anyone above 12 years of age and 24 hour dietary recall (parent recall) for children below 12 years. " Dr Indika Karunathialke presented the "outcome based approach" as the best option for this proposed capacity building curriculum. He presented the steps involved in needs assessment, development of outcomes, identifying competencies, getting the involvement of content experts and development of teaching learning material.
Dr. Neelamani S. Rajapaksa, Director Health Education Bureau emphasised the need to empower the community to address the determinants of health. Dr. Anoma Jayathilake highlighted the importance of organizing the INPARD training course as a multisectoral training programme. Dr. Rohan Wijekoon explained the challenges that the country is facing at present related to agriculture and measures taken by the Department of Agriculture to promote traditional crops and other agricultural activities.
The conceptual framework, funding agency and partners of the study were also disclosed to the stakeholders. Tools to collect nutrition information for the study was introduced and discussed with the forum of experts. Methods to analyze nutrition content of Sri Lankan food items were discussed in depth. Selection of villages and sampling size were introduced. Possible outcomes of training programmes such as identifying factors affecting health, nutrition related implications of community interventions, common nutrition issues of the area and planning and implementation of identified activities and building capacity to work in collaboration with the health system were highlighted in the presentations.
Workshop participants provided comments on the proposed tools for data collection: It was agreed to use the STEPs questionnaire (Sri Lankan version) developed by the MOH. The workshop also led to feedback on the training programme and interventions: It was proposed to arrange the training programme as multisectoral training by bringing all stakeholders to the same session. Curriculum will be developed according to these needs.

1.4: Outcomes:
Workshop participants provided comments on the proposed tools for data collection: It was agreed to use the STEPs questionnaire (Sri Lankan version) developed by the MOH.
The workshop also led to feedback on the training programme and interventions: It was proposed to arrange the training programme as multisectoral training by bringing all stakeholders to the same session. Curriculum will be developed according to these needs.

2.2: Purpose of the second workshop
The Second workshop was organized with the participation of stakeholder to develop training manual and guideline to strengthen the nutritional promotion component which focuses on improving nutrition and addressing underlying factors of the nutrition level among rural communities in Moneragala and Ampara districts.

2.3: Summary of the second workshop
The workshop was conducted with the participation of approximately 20 experts from health, education and economic sectors with the aim to consult the stakeholders in identifying the learning outcomes and modules of the course for capacity building at the grassroot level.
Mr. Manoharan welcomed participants and explained what are the importance of the topic to the World Bank and the relevance of the topic in relation to current activities on nutrition and food security.
At the introduction, Dr. Kremlin Wickramasinghe, a researcher of the British Heart Foundation Health Promotion Research Group at the University of Oxford presented a summary of project proceedings including the proceedings of the pilot project and activities conducted at the village and school level. Accordingly, certain problems identified at the initial stages were presented to the forum.
The discussion on the training manual was led by Dr. Indika Karunathilake based on expected outcomes, content of the training manual, teaching learning methods and assessment. The need to develop training manual and guideline to build capacity of the CRPs and development officers to promote nutrition in the community with the cooperation of other sectors were presented to the forum.
During the workshop, the stakeholders and experts from different sectors were grouped into several teams and the stakeholders were encouraged to come up with suggestions and ideas after discussions and brainstorming. Limitations and challenges during the preliminary visits especially related to working in collaboration were discussed -and the teams identified ways to approach officials of each sectors at the grass root level within the existing structure without causing duplications or confusion of roles.
During discussion about expected outcomes, the groups pointed out the need for the trainer to have a basic knowledge on nutrition. They discussed the importance of having a unit to obtain correct data and directing the CRPs to the right sources for information. Giving the trainee the knowledge required to promote household food security, overcome myths, identify nutritionally vulnerable individuals in the society and identify the roles and responsibilities of different staff.
Accordingly, it was decided that the training manual should include a nutrition component to make the trainee aware of nutrition disorders / basic knowledge on nutrition relevant to the community such as awareness of the risk factors and consequences of both over-nutrition and under-nutrition. In addition, it was identified that the trainee should have awareness on affordability and local availability of food items, including knowledge about food seasonality, the effects of weather patterns on food production, climatesmart agricultural systems, food substitutes, healthy cooking methods, financial management, income management and price fluctuations.
The training includes information related to health education, such as changing health and nutrition related behaviours, common misconceptions, food safety, educating farmers on adverse use of agro-chemicals, effects on health, nonchemical practices and rules and regulations.

Workshop -03
The third workshop was organized by the project team to bring both local and international partners together to discuss and create more awareness on intersectoral collaboration on nutrition promotion and to discuss the progress of the ongoing study. Several areas related to data collection methods and findings of the ongoing qualitative study were shared with the stakeholders to create a dialogue among the experts in order to collect more feedback on the study.
Dr. Palitha Abekoon in his opening remarks emphasised the importance of bringing together all the health and non-health practitioners together to promote nutrition in Sri Lanka. He noted that despite improvements in health, there are some areas of health yet to be addressed and in that context, everyone has recognized mulisectoral action for health as one of the major pillars to promote nutrition and nutrition related practices among the community. Therefore he added bringing together a mixture of academic resource persons and correct experts to one table is crucial to find ways to sustain motivation to lead this project towards success. He highlighted the importance of a "motivated" team to complete a project successfully. Dr. Nihal Jayathilake 34 INPARD nutrition is an area in which we have not been able to achieve the expected results when compared to the improvement of the other indicators.
Sri Lanka is undergoing social, economic and demographic transition and the country is currently facing the double burden of under nutrition and over nutrition with rapidly increasing noncommunicable diseases. The WHO and other experts have identified evidence based interventions that work well to improve the nutritional status. These interventions are health related as well as non-health related. To improve the coverage and to get the expected total impact of these interventions, strengthening of advocacy, multisectoral partnerships, networking, community mobilization and behavioural change are of utmost importance.
I am well aware of the health infrastructure, organizational structure and I am personally involved in their functioning right up to the grassroot level. The MED is responsible for several development projects to improve infrastructure and livelihood in Sri Lanka. The Re-awakening Project is one of the main community driven livelihood projects under the MED.
When we consider the total organizational structure of the MED, at the national level we have our ministry. With reference to Divi Neguma Department, there is a Director General of Divi Neguma at the national level. Then for each region we have an Additional Director General of Divi Neguma covering all six regions of our country. At district level we have the government argent of the districts and each district has an Additional General to whom we have allocated lot of authority. At the electorate level we plan to appoint one officer to take in charge of the whole electorate. Then at the divisional level, we plan to have a divisional Divi Neguma officer for each division.
In addition, we have three officers under the MED serving at the GN Level -economic development officer, Divi Neguma Development Officer and Agricultural Research Officer. They are well equipped and have the knowledge and data for economic development. These MED officers are working very closely with the GN and other officers attached to the divisional secretariat. I hope this project will identify the best approaches and mechanisms as to how our teams of health and non-health sectors should work together to address nutritional issues with a broader vision for the country's socioeconomic development.
This project involves so many national and international partners such as Ministry of Finance, RaP staff of the MED, researchers from Oxford University, Australian National University, Family Health Bureau, Health Education Bureau, Nutrition Division of the Ministry of Health, Faculty of Medicine and WHO. I am glad that this project funded by the World Bank is involving all the stakeholders especially at grassroot level -which is a very important feature of this project. As the Secretary to the MED, I assure to give the fullest support to the implementation of this project successfully.

35
INPARD I am delighted that a multisectoral research team is addressing one of the key challenges that the country has been facing for many years. Despite improvements in health indicators, economic indicators and social development, some references have been made on reasons for nutritional challenges. It is observed that the progress in nutrition is somewhat set back. Even though I am not an expert in the subject, when looking at the statistics I cannot see the necessary correlation. Therefore, in the social indicators and economic indicators there is always something missing -but we cannot pinpoint as to what it is.
Infant mortality and maternal mortality is technically nonexistent in Sri Lanka and life expectancy is improved -but the malnutrition status is stubbornly residual -which means that you are stuck with a less productive population. It is dangerous because the issue is not visible. Bureaucrats probably do not understand the problem as everybody can walk, talk, read and write yet the citizens are like substandard products. Many institutions and experts introduce useless indicators nowadays. We have asked questions from the Ministry of Health (MOH) officials as to where the money should be invested to overcome this issue. Should we just invest on buildings, economic development or software building? In health, education and all sectors, we lack concerns on nutrition. I am glad that the observations are made to tackle this issue. Money is not the main problem but we are lacking the kind of planning and thinking mechanism.
When polio and malaria epidemics struck the country, we responded to it quite well and overcame the issue -but nutrition is not something that can be tackled like that. When we look at the budget every ministry is spending on nutrition but the malnourishment prevails. Sometimes teams do not like to work together. There are fully funded projects in the country, but they are not fully committed. We have complex challenges beyond funding. The Thriposha (supplementary food) programme, if properly developed, can cover the whole nation and address nutritional issues. About 1.4 million mothers require Thriposha but the supply is enough only for several hundred mothers -that is also not on regular intervals. There is difficulty in getting the Thriposha programme to work. There have been so many welfare programmes and food subsidies. There were times we financially funded individuals and then they ended up buying liquor for that money. We introduced 'Samurdhi'. Before that there was something called 'Janasavi'. There have been school level midday meal programmes -but none has so far addressed the actual underlying structural issues successfully.

Dr. P. B Jayasundera
However, for the first time under this regime, His Excellency the President recognized the village level structure. In the villages, there are 'kanna' meetings where farmers who need water for their cultivations get together on agreed dates and times to discuss when to cultivate, how to use irrigation system, when to end the season etc. There are Maranadhara (Death and welfare) societies to give community support and funding in an event of a death. There are youth societies and village level sports clubs where youth get together and engage in various activities. Thus, series of institutions are already in existence in the villages without the involvement of any government officers. We can use those existing community organisations and values to drive towards other development goals. This is the reason why the President recognized the family and the village community as the centre of the 'Mahinda Chinthanaya', his vision for the country. Just after the war, the government was vigorously putting back together the infrastructure that was damaged during the war. In that process, they placed a significant emphasis on conflict struck nation on empowering rural development. Thus programmes such as 'Gama Neguma', 'Pura Neguma' etc came to existence.
However, we experienced that it was again about filling gaps in the villages. Some villages wanted electricity; some needed roads; some needed community centres or maternity homes; some needed small irrigation systems etc. It was also to do with filling gaps related to physical infrastructure. By 2010 after the conflict came to an end the country was getting into a good shape with reference to infrastructure. With the experience of handling village economy through 'Gama Neguma', the President felt that we needed much more of an institutional set up to interface. For that purpose the MED was formed. Thereby, the MED was established to interface from the individual level in the village, to the family, to the community, to little towns and then to the national economy and to the global economy. Our job is to see interfacing across Line Ministries as all Line Ministries have to get together. There is horizontal integration and interactions -and then we have vertical interactions. We have devolved activities by provinces and local authorities. We also have a civil society and then there are private sector organizations. The MED did not want to go to schools to carry out education programmes -but the MED recognized certain criteria of a school and accordingly built fences, name boards, toilets etc.
As pointed out by many, there is a need for change in attitude. Unless there is a change in attitude, this country's residual problem cannot be addressed. It is a very long journey to properly establish a well-integrated programme. Some people like to claim such programmes only when it is under a gazette notification. In general, if we put the word 'nutrition', it is gazetted under the MOH -then nutrition becomes a health problem. Thus, the contribution of the agriculture sector is simply forgotten. Or the Trade Ministry or the development partners go and distribute something that totally contradicts the MOH agenda. They have their own models and there is no common model to address this problem.
The president announced in a budget speech in the midway of his second term in office that his vision is not a middle income country with a $4000 per capita but his interest is to see a poverty free Sri Lanka. There was a World Bank mission that collected statistics that we have produced from 37 INPARD socioeconomics surveys. They examined under various scenarios and the conclusion was that the poverty has declined in Sri Lanka. But the remaining facets of poverty are worrying even though it seems small. Even though the population growth rate has slowed down, the population needs to be healthy. Demographically, the low growth rate of population may be a good indicator but we have to make sure what we have is a nutritionally rich population. Therefore we requested the corporate world, the private sector and development partners to dedicate their social responsibility budget on non-commercial activities.
We have World Bank and all kinds of nations helping -and every country have their bilateral arms extending ten to fifteen million dollars. If we can pool all that into one platform, we can overcome the remaining facets of poverty. We need experts like those in this forum. We need to welcome coordinated programmes and then model such programmes. In any other country, such experts from various sectors would not come together in one forum with their knowledge to do something similar to this. Sri Lanka is a country which has spent on producing best human resources with the free education, especially in medical science, capable of addressing all these issues. These challenges are nothing but we need a kind of organizational and delivery mechanism where health professionals play the main role and the experts are at the sight.
Professionals need to understand that the political management is a complex subject -the market forces work in certain areas, powerful lobbying groups work in certain areas and certain pressure groups work time to time. Politics involve managing all of these factors. In such environment, the professional view point is very crucial. I am optimistic that our health professionals will tackle malnutrition and noncommunicable diseases at the same rate that they have been freeing this nation from communicable diseases. Sri Lanka should model how we dealt with the health issues during the last phase of the war and during tsunami. We managed to handle thousands of internally displaced persons (IDPs) in one single place without any epidemic conditions by giving best medical care. Professional leadership, professional viewpoint and professional opinion making are necessary to get the perception right.
School could be used as a centre to promote nutrition but not the tuition culture. Every parent in Sri Lanka even the poorest and those from rural villages go through hardships just to send their children to school. Why can't school be the centre of promoting nutrition? We have failed to target. We need lot of thinking and research. We should fund visions not buildings.
I hope these professionals will think about these issues and come up with suggestions and solutions to address these challenges in a Sri Lankan model. That model should maintain our societal and cultural values while enjoying the benefits of economic development.
I wish you all the success and invite you to submit your suggestions to our next Budget proposal.

3.2.3: World Bank Perspectives
Mr. S. Manoharan -Task Team Leader, World Bank The INPARD study intends to bring the rural development practitioners and health sector field staff together to work towards integrating nutrition promotion and rural development. The name "Suwa Neguma" was decided for this study in consultation with all stakeholders. When looking at development in various dimensions, rural development has impact on nutritional health. However there is a lack of evidence and data to demonstrate the impact of rural development on nutritional health. There is consensus that improvement in socioeconomic status results in better nutritional health outcomes -but the relative contribution of each dimension of development on nutritional health is less understood. Sri Lanka is undergoing social and economic transition and also faces nutritional issues. In that context, development projects have a huge role to play in promoting nutrition.
The health sector has developed certain policies and guidelines to recognize the non-health sector participation towards nutrition promotion. The World Bank has also recognised the importance of rural development towards nutrition promotion. However, the problem is that the nonhealth partners have not received adequate attention, training or awareness on how to work together to achieve nutritional goals.
When evaluating the rural development projects, the evaluations or assessments do not reveal information on nutritional health. Yet, as a result of the development projects, socioeconomic status of people have improved and therefore it is understood that there is some impact of development on health and nutrition. The INPARD study is trying to identify various dimensions of development on nutrition promotion within the Sri Lankan context. The evidence from this study in Sri Lanka will be shared globally.
In order to carry out the study, funds were provided from the South Asia Food and Nutrition Security Initiative (SAFANSI) Trust Fund whose objectives ideally suit the goal of the INPARD study. The Re-awakening project under the MED, which covers sixteen districts of the country, was selected for the study as it covers two third of the country and the design of the RaP suits the purpose of the INPARD study. The rural development sector is now in transition towards the Divi Neguma model. The Divi Neguma model is based on the village development organization set up where in each village, a community resource person works in collaboration with the health sector staff. This model can be used for the study as the government staff is already working in villages in both rural development sector and health sector.
This study makes an attempt to promote working in collaboration and to understand how a rural development project could promote nutrition. The team has explored the present situation and the working relationships of the stakeholders and has identified duties, responsibilities and This study intends to produce guidelines which could be used by the practitioners towards modified rural development, targeting nutrition promotion and health outcomes in the future.

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INPARD beliefs of all the stakeholders. The team has also identified current policies and practices towards nutrition and existing partnerships. The team is to now explore the opportunities, challenges and limitations for the success of future nutrition promotion in Sri Lanka. Finally this study intends to produce guidelines which will be used by all the practitioners towards modified rural development targeting nutrition promotion and nutritional outcomes.

3.2.4: INPARD Project Updates
Dr. Kremlin Wickramasinghe -Co-principal Investigator (INPARD), University of Oxford There are several determinants of nutrition. Some of these determinants lie outside the health sector. Rural development/ economic development is one example. International and local policies and action plans demonstrate how different sectors should contribute to the nutrition promotion agenda.
In Sri Lanka also, the Guide to District nutrition action plans recognises the importance of rural development, microfinance and Divi Neguma (livelihood development) programmes for nutrition promotion. Most of these policies are developed by health sector led teams and often seen as health policies. Recent research conducted by the INPARD project with multiple stakeholders shows that other sectors often do not see their accountability towards these policies and haven't seen evidence on how their activities could contribute to nutrition policies. Discussions have been based on expert opinions and logical frameworks. It is important to develop projects for nutrition promotion with the non-health sectors and build the evidence base to understand how they could make an impact on nutrition.
Previous projects, including projects conducted globally, have not had a strong evaluation arm and we still lack evidence in this area. Literature reviews have given conclusions in 2013, saying that there is not enough evidence to show the impact of non-health sector interventions on nutrition.
The INPARD project aims to work with the rural development sector in Sri Lanka and demonstrate how we can use a rural development project to support the nutrition agenda. It has a strong evaluation arm and this project will build evidence with both quantitative and qualitative data.
One of the main components of the project is capacity building at the village level for intersectoral actions to nutrition promotion. These activities will be coordinated by the rural development sector under the guidance of health colleagues. The training programme will bring professionals from different sectors together and enable them to understand how to help each other to achieve common goals.
This project is implemented by the MED and evaluated by a team of local and international researchers. This project will lead the way for a new level of evidence in Sri Lanka to understand the impact of rural development on nutrition and to demonstrate how to achieve these nutritional goals with a multisectoral approach.
Previous development projects, including many projects conducted globally, have not had a strong evaluation arm to quantify the impact on nutrition or health. We still lack evidence in this area. Most of the issues raised in Sri Lanka at the planning stage and initial phase of the project are recognized as similar issues raised globally. The necessity for intersectoral collaboration and building a mechanism and motivation for intersectoral collaboration are being identified internationally. Equally, the need to make funds available to build such mechanism is also being identified.

Dr. Kremlin Wickramasinghe
When looking at the global figures, there has been a significant improvement of health and nutrition indicators internationally. Compared to the figures of other countries, several health indicators such as the probability of dying between the ages of 15 and 60 years in Sri Lanka have shown improvements-yet not completely satisfactory.
With reference to the global hunger index, in some countries hunger is still a dominant problem. Globally 1 billion people are under nourished and 2 billion people are overweight or obese. Sri Lanka, going through demographical and social changes with rapid economic development experiences double burden of under nutrition and over nutrition and sits somewhere in the middle of the global index.
The average figures of a country does not reflect the state of nutrition of all social groups -certain groups in the society experience health and nutritional issues worse than the others.
Non-communicable diseases such as diabetes and overweight depend on socio and demographical changes and are still high in Sri Lanka which is going through economic and social transition. Economic development has a direct impact on social behaviours resulting in nutritional outcomes and the pattern is expected to change overtime.
The three recommendations to overcome nutrition issues include improving people's daily living conditions, identifying ways to distribute of power, money and resources and measuring and evaluating the value and impact of actions performed by all sectors. Power sharing is crucial for the intersectoral collaboration to be effective.
According to the International Food Policy Framework for Healthy Diets: NOURISHING Framework, responsibility of health and nutrition still lies within health and nutrition sectors but the contribution of non health sectors like economic development is not exclusively hidden. There are different activities of different sectors that are taking place globally to support the health sector achieve its goals.

Trade goals and health goals might contradict one another and advertisements might have a negative impact on nutrition goals. Some mechanisms and ownership
for nutrition goals and achievements through health and nutrition sensitive economic policies are observed as vital to achieve nutrition goals.

INPARD
Indicators seen globally depend on availability, affordability and acceptability. There may be other ways to look at integration when integrating rural development, health and education by looking at other things that operate within the system. Trade goals and health goals might contradict one another and advertisements might have a negative impact on nutrition goals. Some mechanisms and ownership for nutrition goals and achievements through health and nutrition sensitive economic policies are observed as vital to achieve nutrition goals.
The INPARD study will help generate new levels of evidence from Sri Lanka on how a multisectoral rural development program can be utilized to deliver nutrition promotion interventions within a rural community. The evidence based on Sri Lanka can be made available globally for evidence informed programmes.

3.2.6: Field data collection methodology
Dr. Prasad Katulanda -Senior Lecturer, University of Colombo There needs to be a proper data collection mechanism to evaluate the effectiveness of the intervention in integrating nutrition promotion and rural development. For this purpose, pre-intervention data, post-intervention data and data for a comparison on the intervention areas and the control area need to be collected. Villages connected with the ongoing RaP under the MED in Ampara and Moneragala come under the project intervention and Kurunegala district is selected as the control area for the study.
The district level data is to be gathered through the established records from Divisional Secretariats (DS offices), NGOs and ministries while village level data will be collected based on educations, wealth etc from the RaP villages. In order to gather baseline data, household survey is being conducted targeting adults over 18 years of age and children below 12 years and the school survey is being carried out to gather data between 12 to 18 years of age children. The household survey will only include those who are residing in that particular household during the course of the study. Any secondary school students living in the household, any individuals who are diagnosed with chronic health conditions, individuals who live mostly outside the house for work or studies, individuals who are not capable of giving informed consent will be excluded in the research.
The sample size is being calculated based on nutritional variables using the proportion of adults eating five or more portions of fruits and vegetables a day as adopted in 2006 Sri Lankan national STEPwise survey -where the required sample size is 223 adults.
Ten villages have been selected for this study from each stratum -Ampara, Moneragala and Kurunegala Districts-and twenty households will be selected randomly from each village. From each household, the survey will be completed by two adults and one child below 12 years of age. Thus, the total minimum sample will amount to 2,000 adults and 1,000 children from 1,000 households.
Data will be collected from each household through an interviewer administered questionnaire. Questions for adults above 18 years old will be administered through the FFQ which has been developed depending on the food availability, price and other issues faced during the pilot programme.
The permission has also been acquired to use the Sri Lankan version of the WHO STEPwise survey for the data collection and anthropometric measurements will be also be collected for the study. Data for the children below 12 years will be gathered through a 24 hour parental dietary recall and anthropometric measurements.
In addition, there will be a qualitative study based on different types of focus groups with CRPs, village groups and other significant groups. There will be an audit of similar programmes that are ongoing in these selected areas parallel to the RaP to determine the extent of their contribution and impact on the intervention outcome. Socioeconomic status, employment and demographic information will also be assessed in the process for the study.

3.2.7: Evaluating the health impacts of the INPARD project among school-children Julianne Williams -Researcher, University of Oxford
School-based health promotion has been recognized as a cost-effective and efficient means of preventing malnutrition. However, further work is needed to understand the specific mechanisms and approaches for effective school-based approaches to promoting nutrition, particularly in low-and middle-income countries. In the past, it has been common for schools to take a didactic approach to health promotion, focusing on curricula which teach students about healthy eating. However, the WHO recognizes the complex and multifaceted nature of dietary choice and recommends that health promotion interventions in schools follow a whole school approach. Such an approach focuses not only on the teaching in the curriculum, but also includes other factors that will affect student dietary choice in schools such as school policies, supportive environments and parental involvement amongst others. Such an intervention, developed by the WHO, is the Nutrition-Friendly Schools Initiative (NFSI), which provides a framework of actions that schools should take to address the double-burden of over-and under-nutrition. INPARD aims to improve health promotion in schools through implementing the NFSI. The goal of this project is to evaluate the effects of INPARD on school environments and on the diets of school children. This project will assess if children in INPARD schools show greater improvements in dietary behaviour than those in non-INPARD schools. Additionally, it will evaluate if the NFSI guidelines that INPARD uses to develop health promotion in schools is associated with healthy student nutrition and which types of actions to promote healthy eating have the greatest impact. Finally, it will assess how much variance in dietary behaviour is explained by characteristics of the out-of-school environment.
Data will be collected at two time points from a random selection of schools, school staff and students in Ampara, Moneragala and Kurunegala. School characteristics will be assessed using two approaches. First, researchers will conduct semi-structured interviews with school principals using a tool developed in collaboration with the WHO from the NFSI. Second, characteristics of the neighbourhood surrounding schools (specifically the retail food environment) will be measured using geographical information systems. Individual-level student characteristics will be assessed using the WHO's Global School Health Survey and by measuring 43 INPARD the height and weight of at least 1,350 pupils aged 12-18 at two time-points. Longitudinal multilevel analysis will be used to analyse the impact of the INPARD intervention and school-level factors on the dietary behaviours of pupils while adjusting for the characteristics of students within the schools.
3.2.8: Barriers for nutrition promotion in Rural Sri Lanka; focus group discussions with the school principals Dr. Nick Townsend -Senior Researcher -University of Oxford The objective of the focus group discussions with the school principals was to investigate perceived barriers to healthy dietary choice among secondary school students in INPARD districts in Sri Lanka, within a Socio-Ecological framework. One of the key aims of the INPARD study is to gain insight from the community to better understand the barriers individuals facing in choosing to follow a healthy diet.
The project team conducted semi-structured focus group discussions in Moneragala and Ampara regions, two ethnically diverse districts in Sri Lanka. Twenty nine secondary school Principals from Moneragala and 26 Principals from Ampara were included in the discussions. These focus groups were conducted in Sinhala and Tamil and then were translated into English in order to analyse findings and identify and categorise main themes. The training programme is a unique, multi-disciplinary and team based training. The team should also be heterogeneous groups including CRPs, public health midwife, teachers, PHIs etc. The trainee should be able to analyse common nutrition issues of the area, their health implications and possible causes of the issues. Basic understanding of nutritional issues is important for them to refer the issues to relevant medical personnel.
The grassroot level person in this programme is the CRP who is involved in grassroot level implementations. Therefore they should be able to evaluate nutrition related implications of rural development interventions in the area. As a team they should also be able to plan and implement health promotional activities including health education at the end of the training. The participants should be able to work effectively in collaboration with health and other sectors. Skills for effective communication, leadership, team work will also be incorporated into the training programme. For sustainability, community also need to be empowered in a way that they will be able to take care of their needs in the long run in order to improve basic nutritional needs.
The training consists of 3 modules; nutrition, intersectoral collaboration and health promotion. Under the nutrition module, areas such as common nutritional issues, malnutrition, nutritional assessment, dietary supplementation, micronutrient deficiencies, breast feeding and supplementary feeding, food availability and affordability, agricultural techniques to improve nutrition, food security and food hygiene, misconceptions on nutrition, controlling the use of alcohol and tobacco and nutrition related implications of rural development interventions will be covered.
The health promotion module includes areas such as planning and implementation of health promotional activities, monitoring and evaluation of health promotional activities, basic principles of health education, communication skills and community empowerment.
Under intersectoral collaboration, skills will be developed for effective intersectoral collaboration, interpersonal communication, leadership, team work and skills to collaborate at local and institutional levels.
Accordingly, teaching and learning of the course module will be done through lectures, small group discussions, dramas or role playing, case scenarios, practical skills demonstrations (via posters, photosexamples) leaflets/ booklets and team building sessions. A qualitative study will explore the knowledge, practices, beliefs and attitudes on intersectoral collaboration for nutrition promotion among key stakeholders in Sri Lanka.
The specific objectives of the study are to identify beliefs and attitudes on promoting nutrition (especially in rural communities). It will focus on the role of intersectoral collaboration, perceived roles; current policies and practices, existing partnerships with other agencies and limitations in intersectoral collaboration for nutrition promotion.
Semi-structured interviews are conducted with executive level state and non-governmental sector stakeholders who are directly or indirectly involved in promoting nutrition. For the preliminary study 10 interviews were conducted with the executive level officers of the government ministries, funding/ International agencies, Eastern and Uva local governments and community based NGOs.
Several themes have been identified on analysing the preliminary interviews. These were based on the participants' understanding of the existing intersectoral collaboration mechanisms for nutrition promotion in Sri Lanka. A main theme that emerged was on role clarification. Many sectors have recognized the MOH as the lead and established ministry on nutrition related activities. An emerging role was identified for the MED for its capacity to implement projects at the grass root level. A major role is also seen for the Ministry of Planning. There is limited accountability on the non-health sector to deliver nutrition related outcomes and a limited recognition of their role. In relation to individuals' roles within these organizations, decisions are made at the top level with limited consultation of the ground realities whereas the grass root level follow given instructions (e.g. circulars) but contribute minimally to decision making.
In implementation and evaluation, participants recognized that duties and activities are being identified for each sector, but that few are on the nutrition-related objectives. Each sector has individual institutional objectives that limit collaboration. There is also a need for nutrition-related indicators to evaluate the contribution of other sectors, building on the existing health sector indicators. This was seen as a response Non-health sector experts felt that, if they initiate a nutrition promotion project their capacity will be questioned by nutrition experts. As a result of this attitude some opportunities are missed… Dr. Asela Olupeliyawa 46 INPARD to a lack of mechanism to evaluate collaboration. Many agreed that sufficient funds are being received to promote nutrition but that there is no consensus on what needs to be done to make an impact.
Participants also discussed communication gaps. Even though there is a good existing structure, there is a lack of knowledge on the local structure which limits the collaboration. Decision making power is also limited to the top level and the grass root level work based on activities assigned to them. Based on these, the need for an upward reporting mechanism for multisectoral action was identified.
A major determinant of effective multisectoral action was the attitude towards collaboration. The need for collaboration was readily recognised by all the sectors based on minimizing waste, and sharing knowledge and resources. However, there is a lack of commitment to achieve a common goal related to nutrition due to individual institutional objectives that limit intersectoral collaboration. Furthermore, the capacity of nonhealth sectors is constantly being questioned by experts of the health and nutrition sector.
The need for training and development was recognized as critical. Understanding the role of the health sector and other sectors and programme objectives in nutrition promotion was 47 INPARD highlighted as a training need. Participants also emphasised the importance of not duplicating the roles in the training process, but supplementing the roles to get a better outcome. While operational guidelines should promote intersectoral collaboration, the existing structure at the grass root level should be put into practice.
Based on this preliminary study our recommendations include: national multisectoral planning to promote nutrition -not only financial planning but also necessary technical input in planning; Flexibility in operational guidelines of different ministries; specifying objectives of each sector related to nutrition and making each sector accountable to deliver those objectives. We also recommend that the implementation stage is monitored, evaluated and cross-communicated to all sectors through a proper mechanism. Additionally, we encourage broader discussion on nutrition indicators and identifying indicators to measure the contribution of other sectors in promoting nutrition. Finally, we highlight the need for the health sector to genuinely support activities led by non-health sector institutions and individuals; and the need for other sectors to identify necessary interventions to promote nutrition and evaluate them appropriately.

3.3: Discussions and Recommendations
Before closing the third workshop, stakeholders were invited to provide comments, ask questions or raise concerns related to the material that was covered over the course of the day. Their comments and recommendations are outlined below.
• Ensure that roles are not duplicated and everybody is clear about their roles -CRPs should not do the midwife's job and they should be clear of their job role and responsibilities. CRPs should be able to identify their duties and work in collaboration with the health sector. Any confusion of job roles should not be allowed in the process.
• Since the PHMs are currently very much over burdened with activities outside the scope of maternal and child health, in order to ensure that MCH work is not compromised it was also suggested to carefully consider additional activities that may be assigned to them.
• Distribute programme ownership among the stakeholders -Activities in terms of health and nutrition in general are seen as a responsibility of the health sector. Therefore, other stakeholders do not share health and nutritional objectives mainly because they do not feel their contribution for health achievements. Therefore, the programme should be designed in a manner in which other stakeholders can also feel responsible and share ownership of the project.
• Address the social determinants of health and nutrition -Health and nutritional status of a community largely depend on social determinants based on social and economic conditions such as distribution of income, wealth, influence and power rather than individual behavioral or genetics. Issues with reference to social determinants should be prioritized for better health and nutritional outcome.
• Identify mechanisms to sustain motivation -There had been some nutrition integration projects in the past. Even though the motivation was there they had not been able to sustain it. Identifying a mechanism to sustain motivation is very important for sustainable outcomes.
• Use the existing network at the grassroot level and improve it -At the grassroot level there is a good opportunity where Agricultural Research officer, Divi Neguma Development officer, Economic Development officer and public health midwife can be linked at the village level. Even though 'Divi Neguma' livelihood development project is still in transitional period once it is established it could be used to deliver multisectoral interventions to villages.
• Improve coordination between the stakeholders -Even though there is an existing structure the coordination between the stakeholders to achieve a common health and nutrition goal is still low. Different government officers visit the village on different days and lack the opportunity to work as a team.
• Promote a mechanism to mainstream all the forces and work in collaboration -The advice and opinions of other sectors 48 INPARD should be put together to improve nutrition outcomes. Right now, projects are being implemented by individual sectors targeting different objectives that sometimes clash. At the grass root level, the results need to be agreed upon. Results that need to be achieved in terms of livelihood, economic development, nutrition or other outcomes should be cleared and agreed upon by all the sectors rather than each sector producing outcomes that contradict each other.
• Conduct a community impact assessment at the rudimentary stage -The impact of the intervention should be evaluated at the very basic level where certain parties get together and discuss goals and implementations.
• Coordinate existing projects -There are so many livelihood and other development projects that are being implemented in rural areas in Sri Lanka. Therefore, this project should not be just another project to be added to the list but should be something that supports the existing programmes to make a better effect through their investments.
• Maintain records-Keep detailed records through all stages of the project. Identify and record case studies that may elucidate key concepts or lessons learned.
• Conduct regular review meetings -Meet regularly to review progress and discuss next steps.
• Publish reports -Share updates and findings with stakeholders through regular publications.