Accountability in health and nutrition in South Asia

Social and community accountability initiatives in health and nutrition have been associated with the potential for significant improvements in outcomes when applied to relevant services. A new Transform Nutrition working paper is now available Accountability in health and nutrition in South Asia – a conceptual and practical review of lessons from the global literature and from India, Pakistan and BangladeshThis  paper outlines community-specific factors, drawn from recent literature, which are likely to be of interest to researchers and practitioners in the field of health and nutrition delivery, stressing the importance of context in understanding accountability initiatives. It then brings together some of the findings of the practice review and practitioner consultation.



Pastoral Community Platforms as channels for Behavioural Change for Nutrition

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.

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, 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


• 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).

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...]

Children’s diets and access to markets in Ethiopia

Chronic undernutrition in Ethiopia is widespread and many children consume highly monotonous diets. To improve feeding practices in Ethiopia, a strong focus in nutrition programming has been placed on improving the nutrition knowledge of caregivers. In this new Transform Nutrition/ Ethiopia Strategy Support Programme working paper Children’s diets, nutrition knowledge, and access to markets , the impact of improving nutrition knowledge within households and its complementarity with market access is considered.

2016 Transform Nutrition Champions announced

After a world-wide call for nominations, Transform Nutrition are delighted to announce the 2016 Transform Nutrition Champions.

Following interviews, the stories of all 10 champions are being written up and will be available soon. We are also working with Save the Children on assessing their training needs and involving them in some of the big nutrition events taking place this year.

Our 10 champions:

  • Basanta Kumar Kar, Bangladesh/ India
  • Christine Muyama, Uganda
  • Christopher Dube, Zambia
  • Debjeet Sarangi, India
  • Frealem Shibabaw, Ethiopia
  • Manaan Mumma, Kenya
  • Neerja Chowdhury, India
  • San San Myint, Myanmar
  • V. Ramani, India
  • William Chilufya, Zambia


Transform Nutrition leaders network launched

The Transform Nutrition leaders network was launched at an event Delhi in December. The audience included Transforming Nutrition short course cohort from 2012 to 2015, nutrition researchers and nutrition champions.  The overall theme was ‘ Cross sectoral communication within nutrition and building on the strengths of networks’. [Read more...]

Made in India: Good Nutrition for all

Today sees ministers, researchers and other stakeholders come together at the launch event in Delhi of two new reports, India Health Report on Nutrition 2015 and the Global Nutrition Report 2015. Both point to India’s improved performance in reducing its high burden of malnutrition. But both reports point out that this improvement could—and should–be much more rapid. Event agenda here.

How to scale up impact on nutrition

We know a lot more about what is driving malnutrition and we know more about the type of interventions that are needed to respond. And yet, we continue to struggle with the “how” questions. A new Transform Nutrition research brief written by Stuart Gillespie is out now Scaling up impact on nutrition: what will it take? which will help guide policymakers and programme managers when designing and planning for scaling up impact on nutrition.