South Asia Agriculture and Rural Growth Discussion Note Series March 2020 7 Integration of Health and Nutrition into Livelihood Programs under DAY-NRLM Context Over the past two decades India has seen women. Low pre-pregnancy weight and low women and girls has fallen over the last significant improvements in household pregnancy weight gain are associated with decade from 55.3% in NFHS-3 to 53% incomes, agricultural productivity and low birth weight and attendant consequences. in NFHS-4. Among pregnant women child survival, although malnutrition 50.3% were found to be anemic, and among children remains high, despite Overall, the percentage of women with a considerably higher number in rural improvements over the last decade. While low BMI has fallen from 35.5% (NFHS-3) areas, amongst disadvantaged groups stunting and underweight prevalence has to 22.9% (NFHS-4). It is also seen that (particularly scheduled tribes) and women gone down, trends in corporal wasting overall, the levels of anaemia among in poorer households. show an overall increase in the last decade. The WEIGHT WOES AMONG WOMEN ANAEMIA IN WOMEN & GIRLS decrease in stunting has been from 48% to 38.4%, (1 percentage point per year). ALL INDIA ANDAMAN ANDHRA ARUNA- & NICOBAR PRADESH -CHAL ASSAM BIHAR CHANDI- -GARH CHHAT- -TIS- NCT DELHI DADRA & NAGAR DAMAN & DIU Similarly, underweight PRADESH GARH HAVELI prevalence has reduced THE DECREASE IN STUNTING by 0.68 percentage 48% to 38.4%, points from National GOA GUJARAT HARYANA HIMACHAL JAMMU& PRADESH KASHMIR JHAR- -KHAND KARNA- -TAKA KERALA LAKSHA- -DWEEP MADHYA MAHA- PRADESH -RASHTRA Family Health Survey DECREASE IN UNDERWEIGHT PREVALENCE (NFHS)-3 (2005-06) to 0.68% in 10 years NFHS-4 (2015-16). DECREASE IN WOMEN WITH MANIPUR MEGHA- MIZORAM NAGALAND ODISHA PUDU- PUNJAB RAJA- SIKKIM TAMIL TELAN- -LAYA -CHERRY -STHAN NADU -GANA LOW BMI Pregnancy and lactation 35.5% to 22.9%, have an adverse DECREASE IN LEVELS OF ANAEMIA effect on chronically 55.3% to 53% NFHS 4 NFHS 3 TRIPURA UTTAR UTTARA- WEST undernourished PRADESH -KHAND BENGAL Intervention DAY-NRLM has adopted the Dasa Sutra Lucrative and stable livelihoods are prenatal and antenatal care, Strategy1 towards an integrated FNHW necessary for access to diverse foods; at exclusive breast feeding and (Food, Nutrition, Health, WASH) approach the same time, good health and nutrition complementary feeding for holistic development of SHG members. are a condition for inclusive livelihood • Dietary diversification Through this approach, DAY-NRLM aims development. Recognizing this link, 16 • Reducing anaemia to create awareness and encourage states have initiated various activities • Menstrual hygiene – working with behavior change among rural women on targeted particularly at women and children women and adolescent girls these issues as well as mobilize the SHG who fall into the 1,000-day window of • Development of members to access related entitlements opportunity (from conception to 2 years nutri-enterprises from the concerned public health and of age) to break the cycle of malnutrition 2. WASH: line departments. Further, these FNHW in a minimum of two blocks per state. • Usage of sanitary toilets interventions are embedded in other key Some of the key interventions adopted by • Hand washing practices components of the broader program viz., DAY-NRLM are: especially at 3 critical times Institution Building, Capacity building, • Management of waste at home Financial Inclusion, Farm livelihoods, Non- 1. Health and Nutrition: • Development of sanitation-related Farm livelihoods, Gender, Social Inclusion • 1000 Days window – institutional enterprises and Convergence with PRIs. delivery, colostrum feeding, 1. Ten rules/commandments for holistic development of SHGs including the 5 related to financial intermediation (regular meetings, regular savings, regular inter-loaning, regular repayment, regular book-keeping), health including nutrition and WASH, education, PRI coordination, access to entitlements and sustainable livelihoods The integration of Food, Nutrition, Health and WASH (FNHW ) under DAY- NRLM The core of a sustainable livelihoods Foundation extended support in rolling out scaled up in these states under program is both the development of social interventions through the SHG network at the DAY-NRLM. Further, resource capital and community institutions that village level. The focus has been on rolling materials and other learning form a strong base for layering of social out of Behaviour Change Communication from the implementation of development interventions. Similarly, an (BCC) modules in SHG meetings, undertaking these initiatives have been integrated health and nutrition program acts home visits for “first 1000 days” target groups, used to facilitate state-to-state at multiple levels and is anchored in the conducting awareness drives, provision of learnings. understanding that behaviours are not just funds for sanitation and health issues etc. driven by individual choices but also social The FNHW interventions include a (a) Food norms and values, accessible institutions, In 2016, DAY-NRLM established a Special Security Fund (FSF) aimed at facilitating available and accessible goods and Convergence Fund (SCF) to evolve collective procurement of food grains at services. Given its scope, the DAY- NRLM convergence models that are community bargain prices, to be distributed to SHG is positioned as an effective platform to centric and community led, engage with households as an interest-free or with nominal tackle the underlying causes of poor health line departments to access schemes and interest loan to be repaid over a period of including the soaring rates of malnutrition. entitlements; and evolve a more responsive three months, (b) Health Risk Fund (HRF) system. The objective of the SCF was to where SHG members have an exclusive In 2006, under the Society for Elimination of provide an impetus to convergent planning saving to meet health emergencies, (c) Food Rural Poverty (SERP), Andhra Pradesh was and to demonstrate sustained mechanisms Fortification Units, (d) Behaviour Change the first State to bring health and nutrition for mainstreaming results-based convergence Communication (BCC) and (e) Nutrition under the purview of its livelihood program. with other government programs including the Sensitive Agriculture interventions. The complementary roles played by both the Mahatma Gandhi National Rural Employment service providers of health and nutrition and Guarantee Scheme (MGNREGS), Pradhan While some interventions are implemented the SHG households,towards whom these Mantri Awas Yojana (PMAY), Swachh independently by the project, others are in services were targeted was recognized. To Bharat Mission (SBM), and National Social partnership with external agencies such demystify the concept of medical health and Assistance Programme (NSAP).This has as Bihar Technical Assistance Support integrate with social health, the program since been implemented in 9 states (Bihar, Team (BTAST) and Project Concern adopted social mobilization focusing on Chhattisgarh, Jharkhand, Karnataka, International (PCI). Additionally, to support health and nutrition, and the development Maharastra, Rajasthan, Tamil Nadu, Uttar households’ access to water, sanitation and of the local social capital. Extensive efforts Pradesh, West Bengal) at a cost of INR 64.16 hygiene services, a Sanitation, Health and were made to introduce the health and crores between April 2016 to June 2018. Nutrition (SHAN) fund in Bihar and Special nutrition agenda as part of regular SHG Convergence fund (as stimulus fund) in and federation meetings, and to influence Starting July 2016, the UNICEF Maharashtra were instituted to provide gap the adoption of positive maternal and child health practices amongst SHG households. supported “Swabhimaan” financing to households in need. In UP, a Convergence efforts to facilitate access to programme is being piloted Government Order was issued to implement entitlements from the public health system in three states namely Bihar, the FNHW interventions through partnership also contributed towards reduction of Chhattisgarh and Odisha, between UPSRLM and State Nutrition household health expenditures. focusing on integration of FNHW Mission in 2016, with clearly defined roles related interventions at SHG, VO for various line departments such as Women The model was subsequently replicated and CLF level. Based on initial and Child Development, Health and Rural in Bihar where the Bill & Melinda Gates successes, the model is also being Water Supply and Rural Development. Strategies and approaches The basic foundation of the FNHW program agriculture. Furthermore, the approach Behavior change and access to under DAY-NRLM is that health and relies on leveraging the core strength of the government nutrition services nutrition are best addressed by adopting a institutional platforms of the poor, i.e. the A comprehensive behavior change multi-sectoral approach that emphasizes SHGs and their federations to implement a communication (BCC) strategy is being the establishment of appropriate linkages multi-sectoral approach. Key elements of this implemented to increase knowledge with other key sectors like sanitation and multi-sectoral approach include the following:- and practice of recommended nutrition behaviors and improve the uptake of cooking hygiene at home/at institutions, water Dietary diversification through nutrition services with a focus on behaviors purification and storage practices by the target appropriate agricultural in the critical 1000-day period (from households, and solid waste management. interventions pregnancy to 2 years of age). Concurrently, the program is facilitating Under the guidance of the Farm Livelihoods In addition, capacity building efforts households’ access to sanitation facilities vertical of DAY-NRLM, the program is and coordination with the respective being made available through Government of also enabling dietary diversification at government departments ensure greater India’s Swachh Bharat Mission. the household level through promotion use and uptake of the nutrition services of homestead food production including and food security entitlements being made Behaviour change and access to kitchen gardens, backyard poultry, dairy available through the Government of government health programs and small ruminants coupled with intensive India’s ICDS and PDS. SHG members are Under DAY-NRLM, SHGs and VOs are counselling and food demonstrations for also mobilized to participate in awareness encouraged to promote and participate in improving the quality of food consumed in events like Godbharai (Indian ceremony the planning of Village Health Sanitation the household. Convergence with related during pregnancy to welcome the unborn and Nutrition Days, which is the departments, agencies and institutions are baby), Annaprashan (baby’s first feeding convergence platform for provision of health also encouraged for technical assistance ceremony), which organized at the and nutrition services, and to mobilize and implementation support. Anganwadi Centres. community members to attend. Social Action Committees (SACs) and Community Promotion of FNHW related Behavior change and access to Resource Persons (CRPs) are encouraged enterprises: government sanitation programs to work in close coordination with ASHA and Enterprises on nutritious snacks, Realizing the strong linkages with sanitation, Anganwadi workers to ensure that target processing of foods, WASH related the program is also implementing a groups can access services in a timely products are encouraged to enhance the comprehensive BCC strategy. This manner. SHG members are also given livelihoods opportunity of the members addresses the practice of open defecation information about other related entitlements as well as facilitate availability of products by women, their children and household and if required, SACs facilitate access within the community. members, hygiene practices at birth, baby to entitlements in coordination with the care, menstrual hygiene, hand washing and concerned line department. 1. Agriculture and livelihood Interventions 2. Access to entitlements/services promote sion- xten utrient-rich food Anganwadi/ICDS e /n s re ized ltu util r /u cu de i er Agr n 1. Homestead Food 1. VHSNDs se Production 2. SBM PDS div Kitchen Garden|Community 3. Midday meal Health 4. Health insurance nutri-garden|Poultry|Fisheries| Insurance in f o r m at i o n Small Ruminants/Goats | Dairy 5. DBTs/CBTs 2. Millet promotion, production and (Increase awareness of, consumption demand for, and community surveillance of (good 3. Food Security Fund quality) government an d 4. Agriculture productivity services Ve Mid-Day re te and value chain tu Meal rn development uc ar Se Health as tr y rv fr Center i ce n s ti ke Ma r Intervention activities 3. Behaviour Change Communication 4. Nutri Enterprises 1. Regular capacity building exercises 1. Sanitary Trainings | Exposure visits | napkin manufacturing Case Studies | Home visits | Counselling units 2. Thematic campaigns for promotion 2. Blood Pressure and diabetes of household behaviours: MIYCF, testing services Dietary diversification, DDS-W; DDS-IYC, 3. Bedside care services WASH behaviours 4. Medical shops/Jan Aushadhi 3. Demonstrations: cooking demonstrations, 5. Nutri snacks Rev hand wash practices 6. Dry food preserves ie w iu m 4. Community events 7. Community kitchens ed an 5. Use of IEC material: Videos, m d games, role plays 8. Take-Home-Ration en d an re su t Ma n co en rk io he o nt et mat ren lc infr r ce a astructure & info of B nic C C m a te ri al/t e c h Intervention activities Platforms and facilitators for HNS interventions integrated into livelihood program Food Intervention focus: Food Security Fund; Convergence with PDS Platform: SHG facilitators: Convergence Sakhi/VO/VO Procurement Subcommittee/PRI Health Intervention focus: Fixed NHDs; Review by VHNSCs; HRF Platform: SHG/VHND facilitators: AAAs/VO/GP Nutrition Intervention focus: Dietary diversification; IYCF-GMP; Management of SAM and MAM; Maternal and adolescent nutrition, Menstrual hygiene Platform: SHG/VO facilitators: CM/ICRP/Nutrition Counselor Convergence Sakhi & VO-Health Subcommittee and AWW & ASHA Sanitation Intervention focus: Washing hands; ISLs; Safe water supply; Menstrual hygiene products; Nutrition - WASH linkages Platform: SHG/VHNSC facilitators:VO and Sarpanch & ANM Livelihoods Intervention focus: Kitchen/community Gardens; Millet production; Nutri-mix; Nutri snacks; Ethnic cafe - millet products hubs; Sanitary napkin and sanitation Platform: VO/SHG facilitators: VO-Health Sub Committee; LH teams Given that these activities are phased and they intend to improve health and nutrition. insufficient livelihood assets, poorly targeted targeted at different levels, it is important to These are based on the general understand- and low-quality entitlements, and lack of un- identify the impact pathways through which ing of the situation in SRLMs characterized by derstanding of the benefits of dietary diversity. Pathways to link Agriculture and Nutrition for Improved Diet Diversity Agriculture production Income Nutrition-sensitive Livelihood activities Outcomes Nutrition-sensitive Livelihood activities Outcomes Kitchen garden Increased availabil- Agriculture productivity and market Improved purchasing Poultry ity of diverse food access/value chain development power for secure basket, and access Handicrafts access throughout Dairy throughout the year year and improve Goat/Small ruminant Beekeeping for the household and quality of food basket at the local market Women’s Empowerment Awareness, skills, and knowledge Nutrition-sensitive Livelihood activities Outcomes Nutrition-sensitive Livelihood activities Outcomes Financial resources/decision making Intra-household BCC through Awareness, Improved Labor and time distribution and various skills, and dietary diversity, proper consumption channels knowledge complementary feeding, as well as care exclusive breastfeeding, practice sanitation Market environment Social protection / entitlements Nutrition-sensitive Livelihood activities Outcomes Nutrition-sensitive Livelihood activities Outcomes Value chain improvement by linking Access to quality, Food security Fund Access to staple farmers with markets and improv- nutrient-rich ICDS/Anganwadi foods for poor HH ing market infrastructure including and safe foods and during lean PDS processing, storage/handling and throughout year season food safety Implementation; Progress of interventions The experiences of the states like Bihar, health, nutrition and sanitation outcomes Ministry of Health and Family Maharashtra, Uttar Pradesh, Jharkhand, across its operations in states and UTs. Welfare covering the details Odisha, Chhattisgarh indicate that the of the approach, suggestive integration of FNHW interventions in SHGs To initiate the integration of interventions, and convergence and their federations may be effective in FNHW in DAY-NRLM, a joint with line departments. inculcating desired behavior changes for advisory for convergence on achieving optimal health and nutrition status key issues was issued by the MoRD has partnered with Ministry of in rural communities. Recognizing these Ministry of Rural Development Women and Child Development under successes, the DAY-NRLM has committed (MoRD), the Ministry of Women POSHAN Abhiyaan (National Nutrition to strengthening impact of its program on and Child Development and the Mission) for improving health and nutrition indicators. Under POSHAN Abhiyaan, DAY- support units for providing technical select blocks. NRLM has advised all SRLMs to organize assistance on the FNHW roll out to DAY- The initial efforts have led to the several various activities at the CLF, VO and SHG NRLM and SRLMs. To support SRLMs SRLMs integrating FNHW interventions level during POSHAN Maah and POSHAN in developing a comprehensive FNHW in their respective yearly Annual Action Pakhwada in last 2 years. MoRD has also state strategy and action plan, a pool of Plans. These AAPs detail key activities like converged with ministries similar initiatives trained National Resource Persons (NRPs) preparation of state specific operational including Jal Shakti, Intensified Mission comprising experienced professionals from strategy with clear expected outcomes, Indra Dhanush 2.0, Swachchta hi Sewa, Fit relevant fields has been developed. These orientation of state, district, block staff, India etc. NRPs are assigned to SRLMs and support activation & training of Social Action the state teams in conducting situational Committees, identification of community Further, the Ministry has developed a analysis, developing strategy documents, resource persons for taking forward FNHW partnership with Lady Irwin College, developing state level resources, imparting agenda, utilization of vulnerability reduction University of Delhi and the Bill and Melinda trainings to various stakeholders and fund for Food, Health and nutrition Gates Foundation to establish two technical demonstrating the FNHW interventions in purposes etc. Findings from Studies Conducted in Select States Food Security Fund (FSF) Implemented via more than 26,185 VOs in 534 blocks under JEEViKA - Bihar, FSFs had a profound impact on the poorest sections of society who struggle with food scarcity during lean seasons. Independent impact evaluations have shown reduced incidence of reported hunger and increased consumption of food grains for the poorest quintiles. The analysis showed a majority of the households (85%) had gone to bed after having a full meal in the past 30 days and that most households were able to procure food through different means such as food safety nets, subsistence cultivation or other means. Nutrition sensitive agriculture models In Maharashtra, Nutrition Gardens improved diet diversity with foods rich in micronutrients and showed normal levels Haemoglobin (Hb) among women and adolescent girls with the Hb tests conducted locally before and after the intervention period. It also had a ripple effects on the livelihood teams of the project to use a nutrition lens into Agriculture. 92% 97% 98% Maintenance Women and adolescent girls after 6 months of of households of households of households of RDA in consumption from their own Nutri - Gardens grown used vegetables had regular terms of nutri gardens increased their with >5 varieties of for own consumption of 5-7 vegetables Hb levels between 1 to 3 mg vegetables consumption food groups consumption added to the initial value. • Findings from midline evaluation2 of FNHW interventions in Swabhimaan sites i.e. selected blocks in Bihar, Chhattisgarh and Odisha showed higher consumption of protein and iron-rich foods in the intervention area, as compared to control area among pregnant women. Also, higher rate of attendance in VHSND is recorded among the pregnant women who participated in the FNHW monthly meetings (maitribaithaks) as compared to those who did not participate. Attendance in maitribaithaks by mothers was found to have a significant reduction in their practice of open defecation and improved use of soap for hand washing before meals. 2. Factsheets available at http://www.roshni-cwcsa.in/ResourcesFNHWReports.aspx?flag=1, Midline evaluation study, 2018-19. • A significant impact of intervention on diet diversity score among pregnant women in both Bihar (36.1%; ES=14.9***) and Chhattisgarh (82.5%; ES=10.0**) was observed. Chhattisgarh showed significant increase in use of safe pads or sanitary pads during period by adolescent girls from baseline (36.1%) to midline (61.7%) in intervention area as compared to control area. Though in Bihar, midline results show an increase from 27.7% to 39.5% in control, the change is not as high and significant as compared to the control area. Whereas, in Odisha similar increase from baseline to endline was recorded in use of pads in intervention and control area. Key Lessons and the Way Forward Based on initial successes and learnings, States are expected to develop and Most interventions developed under FNHW DAY-NRLM is now focusing on accelerating implement scale up plans linked to their component of DAY-NRLM are universal the integration of FNHW interventions implementation experience and learnings. and can be sustained by leveraging and across SRLMs in a phased manner. The The focus of the plans will be given on first building capacity of the community. There initial focus is on developing a state strategy 1000 days, reducing anaemia, diet diversity, is a need to integrate community cadre and implementation plan, as well as the menstrual hygiene, usage of toilets, hand developed under NRLM (community development of a resource pool and reference washing practices, promoting FNHW mobilizers, convergence Sakhis) with material before initiating implementation in at enterprises including nutri-enterprises, the existing network of frontline health least 2 blocks in two selected districts within nutri-gardens. extension workers including Anganwadi the state. The strategy development will be and ASHA workers and ensure that efforts completed in consultation with representatives However, to establish linkages between are complementary. The role of women’s of all the verticals within SRLMs, relevant agriculture and FNHW in livelihoods collectives and local mobilizers is critical to government departments and development projects, concerted efforts and inter- the success of mainstreaming health and agencies to ensure optimal utilization of ministerial convergence is needed to nutrition interventions under large-scale available resources and entitlements under institutionalize processes and engender rural livelihoods programs. various schemes. sustainability within the project. About the discussion note series This note is part of the South Asia Agriculture and Rural Growth Discussion Note Series, that seeks to disseminate operational learnings and implementation experiences from World Bank financed rural, agriculture and food systems programs in South Asia. Author(s): Lakshmi Durga Chava, Padma Buggineni, P. Usha Rani Series editors: Alreena Renita Pinto, Deepti Kakkar Publication design & illustrations: Satwik Gade We are grateful for the generous support from the Ministry of Rural Development, The Bill & Melinda Gates Foundation, The Department for International Development, and various State Rural Development departments. Disclaimer: The findings, interpretations, and conclusions expressed in this note are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent.