In SouthAsia, social accountability practitioners have been addressing failures in the ‘standard’ health and nutrition model. What can we learn from them? New research report Social accountability initiatives in health and nutrition: lessons from India, Pakistan and Bangladesh from Transform Nutrition and the Institute of Development Studies.
The initial focus countries include Bangladesh, India, Ethiopia and Kenya.
Our partner in Bangladesh is the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). ICDDR,B plays a lead role in Transform Nutrition's research globally and hosts one of the two joint research directors, Shams El Arifeen. ICDDR,B is also responsible for research uptake in Bangladesh. Find out about the nutrition situation in Bangladesh.
Three consortium members work together under the Transfor Nutrition banner in India. These are Public Health Foundation of India, Save the Children India and theInternational Policy Food Research Institute. PHFI is the lead organisation for Transform Nutrition in India. Find out about the nutrition situation in India.
Save the Children Ethiopia is responsible for research uptake in Ethiopia. The International Food Policy Research Institute provides the research lead role. Co-joint director of Transform Nutrition, John Hoddinott, with his extensive experience in food security in Ethiopia, is responsible for research. Find out about the nutrition situation in Ethiopia.
Find out about the nutrition situation in Kenya.
by Neha Raykar, Public Health Foundation of India
Recently, I attended a policy seminar titled ‘Transforming Food and Nutrition Landscape in Assam’ on 29th March 2017 in Guwahati, Assam. The dialogue was co-organized by the Inter-Agency Group, Assam and Coalition for Food & Nutrition Security and was attended by about 50 stakeholders comprising senior policymakers from Government of Assam and Government of India, as well as representatives from local NGOs, educational institutes, and bilateral agencies.
The purpose of the seminar [Read more...]
By Shilpa Deshpande, PhD Candidate, Institute of Development Studies, University of Sussex
Ten years before I joined the ICDS as an anganwadi worker, my cousin mother-in-law used to work here. At that time, the division of the village population between anganwadi workers was such that lower caste households were served by my mother-in-law whereas only the higher caste households were served by Lata madam, this was her rule….so… my mother-in-law’s field area was scattered across the village. Then when I joined, Lata madam said that just like my mother-in-law I should be given the lower caste communities. I refused…. I said give me any part of the village but I want half and I want it along a continuous line then only will I be able to work. This led to a fight, which continued for several days.
Meena, Anganwadi worker
Meena* is a young, field worker of the Integrated Child Development Services (ICDS) programme in Mangaon* village of Sundar* block, Aurangabad district, Maharashtra. She has been recruited by the Sundar block* administration to cater to the health, nutrition and education needs of pregnant and nursing mothers, 0-6 year old children and adolescent girls in a population of about 650 persons through a small village based centre, the anganwadi. She is one of 3 anganwadi workers in the village and joined the programme in 2010. The other two anganwadi workers were recruited in the late 80s when the ICDS programme began in the block. Meena belongs to the Scheduled Castes†, whereas Lata*, is from the dominant Maratha caste. I met Meena in 2015 as part of ethnographic fieldwork that I conducted for my PhD on understanding the governance of the ICDS programme. In the interview extract quoted, she shares that because she belongs to the Scheduled Castes, the existing anganwadi worker from the dominant caste refused to allocate higher caste households to her and insisted that she focus only on the Scheduled Caste households.
Meena’s experience is rooted in the larger Maratha-Dalit politics of the Marathwada region of the state, of which Aurangabad district is a part. Marathas have traditionally been the dominant caste in the state and more so in this region. They constitute almost 40 percent of the population, are some of the largest landholders, often holding a majority of the land and are also politically dominant. Marathas have historically occupied a majority of seats in the Zilla Parishad (district government), state legislature as well as the cabinet! Besides this, Marathas also have a historically nurtured self-image as rulers and leaders. For Waghmore (2013) the last is the most significant and the key in understanding their aggression towards the Scheduled Castes or Dalits. In Mangaon village, where Meena lives and works, and which has always had a Maratha Sarpanch (head of the village self-governance committee) there have been at least two reported incidents of Marathas attacking Dalit neighbourhoods, killing and destroying property.
Maratha dominance in the ICDS programme is reflected in that a majority of anganwadi workers in Meena’s beat‡ are Maratha even though the anganwadi worker recruitment process is designed to favour candidates from the historically marginalised groups. Political patronage, caste and kinship networks work to benefit the Marathas. Maratha anganwadi workers, whom I studied, routinely discriminated against women and children from the Scheduled Castes and Scheduled Tribes, not visiting their areas and refusing to serve them. Because of their political connections, they were also able to violate rules with impunity, often remaining absent with little or no action taken.
There is existing research on how dominant castes such as the Marathas colonise the local state to corner resources and opportunities. But Meena’s experience is significant because it emphasises that the local state, in this case the ICDS, provides a stage for the performance of caste identities – for asserting, challenging and renegotiating identities. Meena, a slight young woman, with bright eyes and an infectious smile, took on Maratha dominance in the ICDS refusing to play by the informal rules and demanding an equal footing as a programme worker. She successfully solicited community and bureaucratic support to change the decades old practice of allocating households to ICDS workers by caste.
…. I started asking the people of the village if they had a problem. I said when you admit your child in the first standard and the Zilla Parishad (District Government) teacher comes do you ask them which (social) category they are from? Should we do this, should children be placed according to the (social) category of the teacher? They said no, there is no such problem, let the children learn, on the contrary your education is better than hers so let the children be with you….I got my survey area nearly 4-5 months (after joining)… I asked Madam (the Supervisor) to come and show me my area…..then I was able to start work. (Meena)
However, Meena’s challenge to caste roles did not go unanswered. Over the next several months Lata tried in different ways to appropriate her labour and resources reproducing the material and cultural basis of her social power. One day after a particularly nasty and bitter argument, Lata attacked her saying:
…. you demand half of my survey, you tell me what to do….. its gone to your head, you should never have been recruited, stop this, working by the rules…..you Chambhar, what did you think just because you move with the Marathas…. (Meena)
Meena filed a case against Lata under The Scheduled Castes and Tribes (Prevention of Atrocities) Act of 1989 – social power was countered formally by recourse to state provided legal instruments. However, Meena had to subsequently withdraw the case as Lata threatened to file a case of sexual harassment against her husband.
Meena’s experience underscores the social embeddedness of state functionaries highlighting the ways in which the state becomes an extended arena for struggles of dominance and power. These struggles in turn shape the implementation of state programmes such as the ICDS and their governance.
Waghmore, S., 2013. Civility against Caste: Dalit Politics and Citizenship in Western India. SAGE Publications India Pvt. Ltd, New Delhi.
[*] The names of persons, villages and the block have been anonymised to maintain confidentiality.
[†] Caste is a religiously sanctioned form of social stratification such that the higher castes are considered socially pure and the lower castes polluting. The Scheduled Castes are historically marginalised groups identified by the Indian Constitution for state support including affirmative action.
[‡] A beat is a set of 20-25 anganwadis under a single Supervisor.
From 2011-2017 Transform Nutrition has been strengthening the content and use of nutrition-relevant evidence, to accelerate the reduction of undernutrition.
On the 8th July 2017 in Kathmandu, Nepal, it will host a regional meeting; ‘Using evidence to inspire action in South Asia’ the day before the joint ANH Academy Week and Feed the Future Nutation innovation Lab Agriculture-Nutrition Scientific Symposium, to highlight experiential learning from South Asian countries on key drivers to improve nutrition status.
It will feature evidence on what works in nutrition-sensitive interventions, presented to policymakers from Nepal and international donors and NGOs in the South Asia region. The meeting aims to inform and equip attendees in order to address the particular challenges of tackling child undernutrition in their current contexts.
From 2011-2017 Transform Nutrition has been strengthening the content and use of nutrition-relevant evidence, to accelerate the reduction of undernutrition. On 8 June Transform Nutrition is hosting a regional meeting Using evidence to inspire action in Africa in Nairobi, Kenya.
This regional meeting will present experiential learning from other African and South Asian countries on key drivers to improve nutrition status, along with evidence on work works in nutrition-sensitive interventions, to policymakers from Kenya and international donors and NGOs in the East Africa region. It aims to inform and equip them to address the particular challenges of tackling child undernutrition in their current contexts.
New research just been published by Transform Nutrition and Vétérinaires Sans Frontières Suisse with preliminary findings of a study on Pastoral Community Platforms as Channels for Behavioural Change for Improved Nutrition (BCIN). The research was designed to explore the potential of using pastoral-community platforms for channeling maternal, infant and young-child nutrition messages to community members. We have also published some useful case studies which provide an insight into the perceptions of the participants of the study who live in the study area.
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.
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.
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.
Conference on Delivering for Success at Scale 7- 8 February 2017, BRAC Auditorium, Mohakhali, Dhaka, Bangladesh
This conference built on the longstanding partnership between BRAC, ICDDR,B and the Institute of Development Studies (IDS) to explore the role of knowledge in the conceptualisation, design, delivery and management of development programmes and policies. Bangladesh has been a lead player in the use and integration of research into development decision-making, notably in relation to health systems, nutrition, social protection, agriculture and poverty. Evidence will continue to be important in strategic development planning by the Government of Bangladesh among others.
The conference included examples of how high quality research can be embedded within programmes, showcased research findings, discussed the challenges of integrating research with programmes, highlighted successful examples and discussed future needs. The UK Department for International Development funded Transform Nutrition and Future Health Systems presented relevant research.
Read an article about the conference in the Bangladesh Financial Express ‘On health and nutrition’. We also published a blog by Rittika Brahmachari, IIHMR Pathways to scaling up interventions: reflections from delivering for success at scale
For more information contact Aazia Hossain firstname.lastname@example.org
We were delighted that one of our 2016 Transform Nutrition Champions, Basanta Kumar Kar was recently awarded an Odisha Living Legend Award for excellence in public policy. This is in recognition of his tireless work on nutrition in South Asia.
Basanta said of his award “It is very satisfying to receive this award in Odisha where I am rooted. This is the state where I experienced multiple deprivations and developed the courage and conviction to overcome these challenges. It is also where I formed my passion for helping people to make changes in their lives. I am confident that Odisha, endowed with rich human and natural resources, can move out of the clutches of a undernutrition and emerge as a talent state; a global nutrition pioneer”.
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
- 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:
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.
- 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
- 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).