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Learning from implementation complexity – how might we boost both livelihoods and nutrition for the extreme poor in Bangladesh?

Avoiding soundbites on project success or failure…

By Dr Nick Nisbett, IDS research fellow and theme 3 research leader for Transform Nutrition and Ferdous Jahan, Professor of Public Administration, Dhaka University

Last week in Dhaka we were hosted generously by BRAC and ICDDR,B at a conference on the boosters and constraints to delivery of large health and nutrition programmes, where we presented the results of the project Impact Evaluation of DFID Programme to Accelerate Improved Nutrition for the Extreme Poor in Bangladesh. This was a three year, multi-methods mammoth evaluation of the nutritional impact of two of DFID’s Bangladesh programmes focusing on the extreme poor and another benefitting the urban poor. These were Economic Empowerment of the Poorest (EEP) (AKA Shiree), the Chars Livelihoods Programme (CLP) and Urban Partnerships for Poverty Reduction (UPPR).  We got a lively reaction from the audience and some tips on how we might better present our results in future, where all too often failure to find the expected, ambitious impact (in this case on child stunting) is translated into the soundbite that programme x failed, or approach y is not worth repeating.

Ferdous and Nick presenting the evaluation in Dhaka, February 2017

Ferdous and Nick presenting the evaluation in Dhaka, February 2017

This would be a sad outcome of the evaluation – ignoring the valuable lessons of these programmes and DFID’s innovative and much needed approach to try to link up the livelihoods needs of the extreme poor more holistically with specific actions designed to improve child nutrition.There is a lot riding on such models working in future, particularly in Bangladesh, where as one of us argued at the conference, most nutritional gains have not come from such holistic nutrition programming but wider improvements in aspects of people’s lives which may now start to plateau.

Supporting child outcomes in poor families more holistically…

The evaluation began in 2013 when DFID and partners recognised that the livelihoods elements of the programmes alone were not leading to nutritional improvements in the children of beneficiary households.  The food security and productive asset transfer / income creation/support elements of these programmes were likely to benefit broader household food security. But ensuring household food security and boosting income is a necessary, but not sufficient, measure to ensure improvements in the nutritional status of children.  Among other things (including sanitary, healthy environments) mothers and carers need the right support for breastfeeding and feeding in the early years so that children receive the immunity, nutrient boosting and pathogen-free benefits of breastfeeding, and are then fed sufficient, diverse diets alongside breastmilk in the critical developmental years until two.

Three to four years into the operation of these programmes, therefore, DFID added an additional component of nutritional support for mothers, children and adolescent girls.  This was to be delivered by women recruited within the community (community nutrition volunteers – or CNVs), trained to deliver a package of iron and folic acid tablets to benefit mothers and adolescent girls along with collective (e.g. courtyard meetings) and individual level (home visits) awareness raising activities. Children below two were to benefit directly from a combination of breastfeeding/feeding support to their mothers, with provision of deworming tablets and five nutrient micronutrient powders to be sprinkled on their food.

Getting ahead of our ambitions…

Ultimately this was a big ask of the three programmes, already tasked with running complex livelihoods delivery.  Ideally it would have been designed in at the beginning, rather than as a separate component, but given that this combination of support (livelihoods + nutrition) was untested, it seemed like a reasonable plan. Perhaps what was difficult though in this case was the usual donor pressures to show results within the space of two years – a theoretically possible but practically ambitious target of reducing child stunting.

We are all guilty of pushing ambitious targets on stunting, because it is a marker of chronic undernutrition – a risk factor in 45% of all child deaths and a sign of other profound deficiencies which can lead to poorer, less healthy lives. However, those who have been in the evaluation and nutrition game for some time now, including Purnima Menon, who was at the conference, have been arguing that this doesn’t necessarily mean we should be applying ambitious stunting targets to all nutrition programmes – because so many things need to happen in concert to produce both well nurtured but also all round healthy children. As Purnima’s presentation showed, even the best run programmes which focus only on child feeding practices  will not show a result on stunting and nor should they be expected to, particularly within a short evaluation time span. Asking mothers to diversify children’s diets also requires time and money to do so. Perhaps the programmes we evaluated, because of their wider and more holistic approach to livelihoods, had this opportunity, but it was untested water in this combination and at this scale.

Learning what worked…

The evaluation (randomised between ‘livelihoods only’ and ‘livelihoods plus nutrition’ recipients) was therefore set up to look at impacts earlier on in the ‘impact pathway’ – e.g. in changes in the knowledge and behaviours around particularly optimal child feeding practices (e.g breastfeeding within three hours of birth, which hugely boosts immunity, avoiding feeding water before the child is six months, having a sufficient, diverse diet whilst still including breastmilk thereafter). And we wanted to explain why and how all this happened or didn’t, so a process evaluation element monitored how the programmes were implemented, whilst a qualitative community based element considered barriers, constraints and wider contexts within the communities themselves.

To cut to the chase, what we learnt at the conference was to be even more careful not to say, in future, that there were no impacts on child nutrition resulting from this type of model (to be fair that’s not what we said or exactly how the audience responded – we exaggerate!).  And ultimately, we saw that the community nutrition volunteer based model did not fail.  The programmes delivered some of the key outputs in terms of getting nutrition workers in place, and they visited most families, delivering the IFA tablets, mircronutrients and deworming tablets and some counselling.  Mothers generally had positive things to say about the workers – they trusted them and when we tested the workers’ knowledge at endline they scored reasonably highly, so they were well trained. Mothers’ knowledge about the benefit of iron in diets increased; children consumed the supplements or other iron-rich food as a result and we also saw improvements in some cases in terms of non-introduction of water or other substances before six months.

…and what didn’t…

But where things fell down were not on general programme delivery, but on the long neglected specifics of implementation– not on whether the nutrition volunteers went to households, but how often they went there, how long they spent there, how many topics they discussed, whether they were age appropriate for the situation of the mother and child (for example, too much time was spent on explaining the benefits of exclusive breastfeeding when mothers already had children too old for this).  The worker’s caseloads were too high, they were travelling too far in difficult to reach areas, spending less time with mothers than ideal and were not receiving the type of supportive supervision and monitoring which would have detected and improved these critical aspects of delivery earlier. So the types of indicators most likely to be of long term benefit to immunity or child development (ie consuming diverse and sufficient food high in micronutrients) and/or likely to actually lead to improved growth (e.g. diets including animal source-food) did not shift.  No surprise, then, that neither, ultimately, did stunting.

In the qualitative study communities mothers reported the difficulties of following prescribed practices when they were time poor, or couldn’t afford diverse diets, or time to cook separate meals for fussy children, or didn’t have the freedom to decide on child feeding practices themselves, or were equally likely to value opposing advice from e.g. mothers-in-law.

…..Nonetheless….

Despite the enormous pressure DFID are under to produce results, they have not shied from commissioning these types of evaluations which get to the heart of implementation complexity, particularly for these new types of much needed models. We’re slowly getting the evidence through that such mixed models (e.g. in a much smaller trial in Bangladesh, combining cash transfers and child feeding support) can have significant results (yes, even on stunting).  We’re still not convinced that similarly ambitious goals for stunting should be set for two year programmes experimenting at scale, even while it is still instructive to try to measure any change.  But what we have learnt is immensely valuable for future programming (and again, to their credit, DFID have taken on board all the recommendations so far). Ultimately, therefore, such knowledge leaves us better prepared for “delivering success at scale”.

The evaluation programme was led by IDS in partnership with IFPRI, BRAC Institute of Governance and Development (BIGD) and Prof. Ferdous Jahan of Dhaka University; ITAD, CNRS and was part of the MQSUN programme led by PATH. See here for the final report and here for a shorter report brief. The Delivering for Success Conference was hosted by BRAC and ICDDR,B in collaboration with the Transform Nutrition and Future Health Systems Consortia.

 

What factors influence community nutrition workers in performing their jobs? Preliminary findings from Bihar, India

by Aparna John, PhD candidate, Institute of Development Studies at University of Sussex

Child undernutrition rates in India are among the highest in the world (Raykar et.al, 2015). Despite the decline in undernutrition indicators such as stunting (low height for age), underweight (low weight for age) and wasting (low weight for height), India is home to 40 million stunted and 17 million wasted children. The Government of India has invested in efforts to reduce childhood undernutrition and improve maternal and child health through one of its flagship programmes — the Integrated Child Development Services (ICDS) Scheme. ICDS, the world’s largest community nutrition programme, is delivered by 1.34 million village based female workers, Anganwadi workers (AWWs).

The evidence on the ICDS suggests that it is performing sub-optimally—implementation of the interventions is often poor leading to low utilisation and low coverage (PEO, 2012). Considering AWWs are responsible for the delivery of the ICDS services, improving their performance is critical for improving the overall programme performance. However, the evidence base on what shapes AWW performance is scarce. What are the facilitators and barriers in their individual, programme, community, and organisational contexts that influence their motivation and performance? These questions are either unanswered or partly answered by studies looked at the overall ICDS implementation. This research lacuna was the key reason I chose these interesting yet unanswered questions for my doctoral study. In this blog post, I would like to present preliminary findings from the explorative qualitative study I conducted to answer these questions.

In the study, I defined performance as ‘AWWs making services accessible to the required number of beneficiaries with quality (i.e. adhering to guidelines)’ derived from the literature on Community Health Workers (CHWs) and health workers in general. I interviewed thirty AWWs from varied education backgrounds, caste status, and distance (Gram Panchayat distance from the block headquarters) from two administrative blocks of one of the southern districts of Bihar. Bihar is a state grappling with a high burden of undernutrition and demonstrating renewed efforts to improve its social welfare programmes in the last decade. As shown in Figure 1, AWWs deliver a varied set of services to different beneficiary groups. I analysed the data using the hybrid method of deductive and inductive thematic analysis.

Figure 1 Anganwadi worker in Bihar

Parth Sanyal/Save the Children

Parth Sanyal/Save the Children

  • Qualification: minimum 10th pass
  • Honorarium: Rs. 3000 per month
  • Main job responsibilities:
    • Pre-school education for forty  3-6 years
    • Supplementary nutrition
      • Daily lunch for forty 3-6years
      • Monthly dry rations to eight pregnant, eight lactating women and forty 6-36 months children
    • Counselling (individual and group)
    • Preparation for monthly Village Health and Nutrition Day to facilitate immunisation in coordination with ASHAs and Auxiliary Nurse Midwife (ANM) and growth monitoring of children and pregnant women
    • Identification and referral of Severely and Acutely Malnourished (SAM) children

Preliminary key findings from the study suggest that the following factors in the individual, programmatic, and community contexts influence an AWW’s motivation and performance:

• Individual:
Initial financial motive rooted in family reasons as the reason for continuing with the job: Whilst some AWWs actively chose to take up the job due to “moral” motives (the opportunity to positively impact their community), for many it was their families who were the driving force. Their families tended to be more focused on the “social” motive – the prestige within the community and access to social and bureaucratic networks that came with the job. Irrespective of the wider drivers leading AWWs to take up the job, there was a strong “finance” motive for workers and their families; the salary was a key source of household livelihood.

• Programmatic:
- Service preference of the beneficiary and AWW: The ICDS services can be broadly classified as product-oriented services and information-oriented services. Services that linked to products include food distribution, immunisation and pre-school. Services linked to information are individual and group counselling. AWWs perceive that beneficiaries have a clear preference for product-oriented services over information-oriented services. This product preference positively influences the attendance of these services compared to information-oriented services. Considering the pre-school attendance is influenced by food, even when the food is not available, AWWs provide the pre-school. This leads to another type of preference from the worker towards the pre-school service because of their self-identity as a teacher, as the majority of them could not be teachers and ended up being AWWs.
- Work environment factors: various work environment factors influence AWW’s motivation, job satisfaction, and performance. A summary of work environment factors and how they influence AWWs is given in Figure 1.

Figure 2 Influence of work environment factors on AWW performance

bihar-blog-fig-2

• Community:
- Caste dynamics between the AWW and community and discrimination towards the AWW emerged as a factor influencing the AWW motivation and performance. In the AWW context, when there are multiple caste groups in a community, and when the AWW is not able to satisfy any particular caste group due to the targeting of food and pre-school services, community dynamics explicitly negatively influence the delivery of services. In a few cases, physical violence was reported between the AWW and the community.

- Seasonal migration of low-income families (to brick kilns and back) creates changes to the fixed food distribution targets. This creates frictions between the AWW and the community and negatively influence her motivation and the delivery of food-related services.
Although factors influencing the AWW performance belong to different contexts, they are strongly interrelated. For example, this study considered ‘service preference of beneficiaries and AWWs’ as a programme factor; however, it is a good example of programmatic and community contexts interacting with each other and their dynamics influencing AWW performance (access of services). To conclude, the initial findings from the study suggests that any reform to improve the ICDS needs to be rooted in understanding of the self-identity of the AWWs and the complex configurational environment which she works.

Acknowledgement: This study was conducted as part of my doctoral work at the Institute of Development Studies funded by the Transform Nutrition doctoral fellowship. The field work for this study was was funded by POSHAN (Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India) project led by International Food Policy Research Institute (IFPRI).

What works to improve nutrition? Success stories and lessons learned from six countries

Stories of Change in Nutrition hosted a symposium at the Micronutrient Forum on Sunday 23rd October 2016.

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We were delighted to see over 50 people in the room including representatives from SUN, NGOs, research organisations and donors for our symposium at the Micronutrient Forum. This interesting and interactive session had an invited panel to present and discuss the ‘Stories of Change in Nutrition’ project which has been funded by CIFF and DFID. [Read more...]

Making malnutrition history – one story at a time

by Edwyn Shiell – Policy and Strategy Advisor, Advocacy and Communication Scaling Up Nutrition (SUN) Movement Secretariat

On Monday 12 July, I had the privilege of moderating a panel of esteemed nutrition champions at the Brighton launch of a landmark new book: Nourishing Millions – Stories of Change. It’s a major effort to bridge the gap between the technical aspects of what’s working (or not) to improve nutrition, and communicating it in simple stories that resonate. [Read more...]

US Launch of Nourishing Millions: Learning from Stories to Scale up Progress

The following post was originally posted on the Nourishing Millions website 

“Turning political commitment into implementation and into impact – that is the kind of watershed moment that we are at with regard to malnutrition in most of these countries,” said Stuart Gillespie, co-editor of Nourishing Millions: Stories of Change in Nutrition, during the US launch of the book in Washington, DC on June 29, 2016. [Read more...]

Find solutions in an Indian way: 2016 Global Nutrition Report launch in New Delhi, India

By Basanta Kumar Kar*                                                                                                                       

The Coalition for Food and Nutrition Security (CFNS) convened the 2016 Global Nutrition Report launch in on 14 June in New Delhi, India in collaboration with International Food Policy Research Institute (IFPRI). [Read more...]

India Health Report on Nutrition 2015 – how is it being used?

By Neha Raykar and Kavtia Chauhan, Public Health Foundation of India

Since the release of the India Health Report: Nutrition 2015 (IHR), the team has been engaged in disseminating the report at various platforms.  We first launched the report in Delhi at a major event that featured the Ministers of Health, and Women and Child Development of the Government of India.  This was a rare joint appearance of these two key Ministers and senior government officials to indicate broad support for an agenda to transform nutrition in India. [Read more...]

The role of the media in strengthening uptake of nutrition evidence

By Kavita Chauhan, Neha Raykar and Moutushi Majumder, Public Health Foundation of India

The Transform Nutrition project in India focuses on generating evidence and engaging with key stakeholders, including the media, to communicate research findings. The Public Health Foundation of India (PHFI), in collaboration with Vikas Samvad, a non-governmental organisation based in Bhopal, Madhya Pradesh and with support from the POSHAN Project organised a meeting on Data for Nutrition: Role of Media in Strengthening Uptake of Nutrition Evidence. The participants comprised of editors, senior health correspondents, and young journalists from various districts of Madhya Pradesh, who cover health, nutrition and social development issues. [Read more...]