POSHAN UPDATE Dr. Suneetha Kadiyala/ Research Fellow/IFPRI/ March 5, 2013

Goal of POSHAN POSHAN’s goal is to support and strengthen policy and programme decisions and actions to accelerate reductions in maternal and child under nutrition in India, through an inclusive process of:  evidence synthesis  knowledge generation  knowledge mobilization National and State-Level Effort [Madhya Pradesh, Uttar Pradesh, A.P, Bihar, Odisha]

Partnerships are central to POSHAN  POSHAN is led by IFPRI, with — Public Health Foundation of India’s Health Communications group — Institute for Development Studies’ Knowledge Services group — Other knowledge mobilization partners — Save the Children, India — Coalition for Sustainable Nutrition Security in India — UN Solution Exchange — Right to Food Network — OneWorld South Asia — Others ( We are exploring and open to other collaborations)

POSHAN’s inception activities : ( )  Landscape of actors, policies, programs and knowledge networks in nutrition, with a focus on use of evidence  Diverse methods used: —Document review —Stakeholder interviews —Net-Map  Key findings shared at a large multistakeholder consultation on June 19 th, 2012

POSHAN’s strategic focus ( )  Core knowledge mobilization for all thematic areas (research and policy briefs, events to facilitate learning)  Mobilization of knowledge from non-POSHAN activities (abstract digests, e-consultations)  Media engagement, support to existing knowledge networks, etc.  Intersectoral convergence between health services and ICDS  Assessing multisectoral planning and action for nutrition  Strengthening evidence for improving implementation of direct interventions  Strengthening generation and use of nutrition data Key thematic areas for knowledge generation Knowledge mobilization activities

An assessment of convergence between health and ICDS to improve maternal and child nutrition in Madhya Pradesh and Odisha

There is broad agreement on direct interventions 1. Timely initiation of breastfeeding within one hour of birth 2. Exclusive breastfeeding during the first six months of life 3. Timely introduction of complementary foods at six months 4. Age appropriate complementary feeding, adequate in terms of quality, quantity, and frequency for children 6-24 months 5. Prevention of anaemia 6. Safe handling of complementary foods and hygienic complementary feeding practices 7. Full immunization 8. Reducing vitamin A deficiency 9. Reducing burden of intestinal parasite 10. Prevention /Treatment of diarrhoea 11. Timely and quality therapeutic feeding and care for all children with severe acute malnutrition 12. Improved food and nutrition intake for adolescent girls particularly to prevent anaemia 13. Improved food and nutrients intake for adult women, including during pregnancy and lactation 14. Prevention /Treatment of malaria Compiled based on recommendations from the Lancet Series on Maternal and Child Under-nutrition (2008); The Coalition for Nutrition Security in India Leadership Agenda for Action (2010); The Scaling Up Nutrition Framework (2011)

Coverage of direct interventions is low in India

Coverage of direct interventions varies by state

Some reasons for low coverage Implementation mechanisms are not able to deliver Interventions are not part of any programme platforms or guidelines Interventions are not listed in policies at all X X ? Interventions not effectively utilized by target populationnot ?

Policies do focus on direct interventionsdo  Large number of policies address major areas of public health nutrition need; substantial focus on essential actions  Most policies/guidelines are quite strongly based on scientific evidence

Interventions are included in programme guidelines - ICDS and NRHM provide for all direct interventionsare 1. Timely initiation of breastfeeding within one hour of birth 2. Exclusive breastfeeding during the first six months of life 3. Timely introduction of complementary foods at six months 4. Age appropriate complementary feeding, adequate in terms of quality, quantity, and frequency for children 6-24months 5. Prevention of anaemia 6. Safe handling of complementary foods and hygienic complementary feeding practices 7. Full immunization 8. Reducing vitamin A deficiency 9. Reducing burden of intestinal parasite* 10. Prevention /Treatment of diarrhoea 11. Timely and quality therapeutic feeding and care for all children with severe acute malnutrition 12. Improved food and nutrition intake for adolescent girls particularly to prevent anaemia** 13. Improved food and nutrients intake for adult women, including during pregnancy and lactation 14. Prevention /Treatment of malaria* * NRHM only; ** ICDS only

Operational guidelines highlight complementarities and redundancies: suggest critical role of convergence for effective service delivery TYPES OF CONVERGENCE REQUIRED TO DELIVER NUTRITION INTERVENTION Role complementarity Pediatric anemia Immunization Vitamin A supplementation Management of SAM Diarrhea Role reinforcement Promotion of breastfeeding and complementary feeding practices None Reducing burden of intestinal parasites Prevention of malaria

Research questions  How is convergence articulated by the health and nutrition sectors in policies and guidelines?  What mechanisms for convergence are operationalized at different levels within the health and nutrition sectors, for each of the essential interventions?  What is the role of intersectoral convergence in determining access [of households] and coverage of essential nutrition interventions?  Which institutional and operational factors and processes enable or hinder effective intersectoral convergent actions?

Methods: Choice of states Ongoing efforts to strengthen convergence as part of new nutrition mission Strengthening convergence across health, water and sanitation is a key goal Madhya PradeshOdisha

State District1 25 AWCs District 2District 3 Block 2Block 1Block 4 Block 3 4 households/ AWC Purposive sample Random sample Methods: Sampling District selection will be based on its representativeness to the state nutrition, health, and service delivery indicators 1.Best performance district 2.Average performance district 3.Poor performance district

Methods: Types of data collection  Document review of action plans, program operational guidelines, and checklists at state, district, and block levels.  Semi-structured interviews with state, district, and block-level officials  Observations of Village Health and Nutrition Days (VHNDs)  Surveys with the ICDS and NRHM frontline workers  Short surveys with mothers of children under-two QualitativeQuantitative

Timeline  January-March 2013: Protocol review and study planning  April-June 2013: Data collection  July-September 2013: Data processing  October-November 2013: Analysis and dissemination of early findings