SUPPORTING LOCAL INNOVATION IN
THE FIGHT AGAINST MALNUTRITION
WINNERS OF THE 2009 DEVELOPMENT MARKETPLACE
ON NUTRITION
SUPPORTING LOCAL
INNOVATION IN THE
FIGHT AGAINST
MALNUTRITION
WINNERS OF THE 2009 SOUTH
ASIA REGION
DEVELOPMENT MARKETPLACE ON
NUTRITION
Page 2 of 48
This volume is based on materials provided by Development Marketplace
grantees and an implementation support agency. It was edited by Tarra Kohli,
Venkatakrishnan Ramachandran, and Melissa Williams of the World Bank.
Phoebe Folger and Lori Geurts of the World Bank reviewed the content.
©2011 (January) The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 Telephone 202-473-1000 Internet www.worldbank.org/rural E-mail [email protected] All rights reserved. This volume was created by staff of the International Bank for Reconstruction
and Development/The World Bank based on materials from Development
Marketplace grantees and an implementation support agency. The findings,
interpretations, and conclusions expressed in this paper do not necessarily
reflect the views of the Executive Directors of The World Bank or the
governments they represent. The World Bank does not guarantee the
accuracy of the data included in this work.
This material has been funded by UKaid from the Department for
International Development; however, the views expressed do not necessarily
reflect the department’s official policies.
For more information, contact:
1818 H Street, NW
Washington, D.C. 20433 USA
SAFANSI Program Manager: Animesh Shrivastava
Telephone: +001-202-473-3652
Internet: www.worldbank.org/safansi
www.worldbank.org/nutritiondm2009
Email: [email protected]
Page 3 of 48
CONTENTS
The Development Marketplace ..................................................................................................................................... 5
Afghanistan: Promoting Baby Friendly Villages ............................................................................................................. 6
Bangladesh: Comprehensive Nutrition Care for Extremely Vulnerable Infants and Young Children ............................ 8
India: Community-Managed Nutrition-Cum-Day Care Centers for Tribal Communities ............................................. 10
India: Nutrition for Migrant Children Living on Construction Sites ............................................................................. 12
Sri Lanka: Three-Generation Communication for improved Infant and Young Child Nutrition .................................. 14
India: Universalizing Supplementary Nutrition Under the Age of Two: a Social Business Model of NUTRIMIX
Production ................................................................................................................................................................... 16
Bangladesh: Community-Local Government Partnership to Combat Child Malnutrition ........................................... 18
India: Coupling Diarrhea Treatment and Behavioral Change Communication to Reduce Severe Malnutrition in an
Urban Slum .................................................................................................................................................................. 20
Nepal: Enhanced infant and young child feeding practices linked with micronutrient sprinkles supplementation ... 22
Nepal: Community-based distribution network for the Two Child Logo Ade ............................................................. 24
India: Community involvement in promoting neonatal & infant nutrition in tribal Vadodara ................................... 26
Bangladesh: Promoting better infant and child feeding practices through performance-based payment ................ 28
Pakistan: A comprehensive community-based intervention to improve linear growth in children aged 6-18 months
..................................................................................................................................................................................... 30
India: using cell-phone technology to improve exclusive breastfeeding and reduce infant morbidity ...................... 32
Nepal: Nutrition through knowledge........................................................................................................................... 34
India: Reducing maternal stressors to enhance birth weight and infant survival ....................................................... 36
Pakistan: Home based nutrition rehabilitation of severely malnourished children .................................................... 38
Nepal: Action Against Malnutrition through Agriculture (AAMA) ............................................................................... 40
India: Social Capital as a catapult for improving infant feeding .................................................................................. 42
Bangladesh: Empowering women and adolescents to improve infant and young child nutrition.............................. 44
India: Addressing Iron Deficiency Anemia in Rural Rajasthan Through Iron Fortification of Flour ............................. 46
Photo Credits ............................................................................................................................................................... 48
Page 5 of 48
THE DEVELOPMENT MARKETPLACE The Development Marketplace (DM) is a competitive grant program of the World Bank and partners that identifies
and funds innovative, early stage development projects with high potential for developmental impact and
replication. The program operates at a global, regional or country level, and uses a transparent process to support
innovations that address development challenges at the community level.
The South Asia Region Development Marketplace (SAR DM) on Nutrition is a partnership between the World Bank,
GTZ, Micronutrient Initiative, UNICEF, WFP, GAIN, and PepsiCo. The SAR DM was launched In February 2009 in
order to engage civil society and grassroots organizations in improving infant and young child nutrition in South
Asia. In August 2009, the SAR DM awarded grants up to US$40,000 each to 21 civil society organizations to
implement innovative, community-based interventions to improve nutrition for pregnant women, infants and
young children during the critical 'window of opportunity' - the first two years of life. The winning organizations
were selected through a highly competitive process from a pool of 1000 applicants and 60 finalists. The
implementation of DM grants began in the Fall of 2009 and will be completed in late Spring/early Summer 2011.
SAFANSI support to the Development Marketplace on Nutrition promotes capacity enhancement of the selected
organizations to implement their programs. In addition, SAFANSI is supporting the documentation and
dissemination of lessons learned and best practices from project implementation which will help fill the knowledge
gap on how to improve infant and young child nutrition in the Region and inform policy and program formulation.
For more information about the South Asia Region Development Marketplace, visit:
www.worldbank.org/nutritiondm2009 or contact the SAR DM team at [email protected].
Page 6 of 48
AFGHANISTAN: PROMOTING BABY FRIENDLY VILLAGES The cycle of malnutrition starts with the late initiation of breastfeeding to newborns, use of pre-lacteal food (non-
exclusive breastfeeding for the first six months), inappropriate complementary feeding, and lack of continuation of
breastfeeding for at least two years. Disrupting the cycle of malnutrition must start with better infant care.
Promoting optimal feeding practices can considerably reduce infant and young child deaths in Afghanistan, but it
requires a comprehensive approach to change the current behaviors of child feeding among families.
Reports show that only 39% of children between the ages of 6 and 9 months get proper complementary feeding
with breastfeeding. Lack of proper practice among mothers to feed their infants and young children optimally is
mainly due to lack of knowledge and the lack of an enabling environment. Most efforts in the past have targeted
the lack of knowledge cause, but not the lack of an enabling environment. Mothers-in-law, male members of the
family, and health workers heavily influence how mothers feed their children and, therefore, must be targeted to
achieve success.
The Baby Friendly Village (BFV) Project, implemented by Care of Afghan Families (CAF) in four districts of Takhar
Province in Afghanistan, will address both causes of improper feeding by:
• Improving the knowledge and practice of 100 pregnant and lactating mothers regarding optimal feeding
practices of infants and young children.
• Establishing eight community support groups in the targeted villages, comprising community health
workers, traditional birth attendances, local religious leaders, and traditional healers.
• Raising awareness about optimal feeding practices of infants and young children among 100 fathers and
their family members.
• Establishing four breastfeeding counseling
corners in four health facilities at the target
area to provide comprehensive counseling
services to needy mothers and pregnant
women.
The Baby Friendly Village takes a comprehensive
approach. It ensures that mothers have the
required skills in optimal feeding practices, such as
correct positioning of the baby during
breastfeeding and preparation of nutritious dishes
during the complementary feeding stage by
providing counseling services in health facilities
and through community support groups. Beyond
that, BFV addresses the enabling environment by
involving all key players—such as, mothers-in-law,
husbands, other male members of the family,
health workers, traditional healers, birth
attendants, and local religious leaders by raising
their awareness of the importance of feeding
practices and involving them through support
Page 7 of 48
groups in helping the mothers. The goal is to turn entire villages to baby-friendly places where all individuals have
proper knowledge and skills to support a breastfeeding mother.
The project will be implemented in the rural area of Takhar Province in Northeast Afghanistan, where the only
source of income is farming and poverty is widespread. The project will focus on improving the behavior of
pregnant and breastfeeding mothers aged 15-49, their family members, and other stakeholders.
BFV builds on existing systems in the country.
Afghanistan has one community health worker for
almost every 150 families; a community health council
for each health facility; and a basic health center
almost for each 10,000 population. In addition, there
are women’s action groups, TBAs, and other
community based groups around the country that are
part of the health system. Master trainers and trainers on breastfeeding counseling already exist. Finally, BFV will
communicate how the Holy Quran, as the main reference book of Muslims, supports breastfeeding and the
initiative is according to the norms and values of the society. The project has the same potential of growth and
expansion to the other regions and countries with similar context as Afghanistan.
ABOUT THE PROJECT IMPLEMENTER(S)
Care of Afghan Families (CAF) is an Afghan NGO established in 2003, with the mission of enabling families to fight
against disease and its causes—poverty, lack of awareness, and injustice—by investing in health, nutrition,
community development, and education. CAF’s achievements have been recognized by the leadership of the
Ministry of Public Health, community leaders, and the provincial public health director. It has also received several
awards from USAID, World Bank, EC, UNICEF, and other development agencies.
CAF is partnering with Social Development Association (SDA), a social association, comprising volunteers to provide
awareness, training, consultancy, and advocacy about issues related to social development. SDA will provide
master trainers, adapt training materials to the local context, and prepare the communication materials.
CONTACT INFORMATION
Bashir Ahmad Hamid Organizational Development Director & Lead Project Manager Health & Nutrition Care of Afghan Families (CAF) H 497, Parwan-e-Do Kabul Afghanistan Email: [email protected], [email protected] Website: www.caf.org.af Tel. 0093 07778-223-05 or 0093 799 311 619
Hassanullah Hedayat Administrator Social Development Association Email: [email protected] Tel. 0093799842289 H. 497, Street64, Dist 4 Kabul Afghanistan
Only 39% of children between the ages
of 6 and 9 months get proper
complementary feeding with
breastfeeding
Page 8 of 48
BANGLADESH: COMPREHENSIVE NUTRITION CARE FOR
EXTREMELY VULNERABLE INFANTS AND YOUNG CHILDREN Bangladesh has one of the highest levels of under nutrition in the world. Among children under the age of five:
48% are underweight, 43% are stunted, and 13% are wasted (BDHS- 2004). The Government of Bangladesh (GoB)
has been implementing a national nutrition program in more than 100 Upazilas; however, many vulnerable and
socially excluded groups—particularly sex workers (SWs) and people living with HIV/AIDS (PLHA)—are yet to
receive services from the program. This is because the program does not cover their geographical area and
because they are among the most marginalized in the country. As a result, the children of these groups suffer
malnutrition more than the general population.
The children of SWs and/or PLHAs are especially vulnerable to nutritional deficiencies and their consequences;
however, they are underserved by existing nutrition programs. For example, female SWs cannot breastfeed their
children due to their professional demands and mothers living with HIV are sometimes discouraged from
breastfeeding. The result is that children of these vulnerable populations are at particular risk for malnutrition and
hunger.1 An estimated 13,000 children in Bangladesh are prey to the commercial sex industry of the country. More
than 20,000 children are born and live in the 18 registered red-light areas of Bangladesh (Asia Child Right Report,
2009).
The project, Comprehensive Nutrition Care to Extremely Vulnerable Infants and Young Children, is being
implemented by HIV/AIDS and STD Alliance Bangladesh (HASAB) to promote the nutritional status of the infants
and young children (up to age 10) of these extremely socially excluded families. The focus is given to the children
of female SWs and PLHA. The project is working in two
geographical locations: the district town Mymensingh,
where more than 300 SWs live in an established
brothel in the heart of city, and Nagari Union in the
Kaligonj Upazila of Gazipur District.
The project will use a comprehensive approach that
includes:
• Training of trainers workshops for nutrition for
Project Officers, Community Volunteers (CVs),
and other relevant NGOs staff;
• Establishing two Community Nutrition Centers
(CNCs) in the target areas;
• Supplementary feeding sessions conducted at
each CNC six days each week providing food
prepared by the formula of NNP and procured
from community women or other service
providers—severely and moderately
1 An estimated 13,000 children in Bangladesh are prey to the commercial sex industry of the country. More than 20,000 children are born and live in the 18 registered red-light areas of Bangladesh (Asia Child Right Report, 2009).
Page 9 of 48
malnourished children under two will be provided with food packets;
• Nutrition education, including breastfeeding promotion, weaning food, supplementary feeding practices,
balanced diet, etc., will be held at each CNC everyday along with demonstration of available inexpensive
food;
• Growth Monitoring and Promotion (GMP) sessions held monthly at each CNC to identify the nutrition status
of target children;
• Distributing two iron tablets daily to every pregnant mother from the 2nd
trimester to within 42 days of
delivery and 1 Vitamin-A capsule to every lactating mother within 14 days of her delivery;
• Weighing every newborn at their birth place within 72 hours of delivery;
• Establishing referral linkages to health service providers at low or no cost;
• Having community volunteers (CVs) visit target families regularly;
• Forming community vigilance teams in both areas comprising community leaders, local elites, and elected
representatives to support supervision and monitoring; and
• Holding a series of formal and informal Advocacy and Social Mobilization Meetings in the target areas.
HASAB has been working with sex workers of Mymensingh through the Promoting Rights of the Socially Excluded
People project funded by Manusher Jonno Foundation and with families affected by HIV through Continuum of
Care and Support to the HIV Infected and Affected
Project funded by TDH Netherlands in different parts of
country including Kaligonj. It will be able to draw upon its
existing rapport with the target communities to
implement the project.
ABOUT THE PROJECT IMPLEMENTER(S)
HASAB is one of the national leading NGOs emerged as a specialized agency in HIV/AIDS & STI field with
experiences of grant management and capacity building (technical, managerial and administrative) of smaller
NGOs, CBOs and faith based organizations who are involved in HIV prevention and control and the care and
support of people living with HIV. HASAB’s core focus is on HIV/AIDS and STI related issues which entail a wide
range of integrative program that relates HIV with them as cross cutting issues. Nutrition is one of the cross cutting
issue of HASAB’s programmatic mandate.
CONTACT INFORMATION
Dr. Nazneen Akhter Executive Director HIV/AIDS and STD Alliance Bangladesh 1/2 Asad Avenue, Block – A, Asad Gate Dhaka 1207 Bangladesh
Email. [email protected], [email protected] Web. www.hasab.org Tel. 880-2-8123021,9132644 Fax. 880-2-8122786
More than 20,000 children are born and
live in the 18 registered red-light areas
of Bangladesh.
Page 10 of 48
INDIA: COMMUNITY-MANAGED NUTRITION-CUM-DAY CARE
CENTERS FOR TRIBAL COMMUNITIES In rural Andhra Pradesh, India, there is great need for improved access to nutritious food for pregnant and
lactating women and young children. The National Family Health Survey shows that in Andhra Pradesh, 46% of
reproductive age women are below the recommended minimum body mass index of 18.5kg/m2 and 50% are
anemic. Among children under 3 years old, 32.5% are underweight and 42.7% are stunted. The situation is even
worse among scheduled tribes where 45.9% of children are underweight and 44.2% are stunted. These data mark
the beginning of a cycle of malnutrition and poor growth, where reproductive age women have low birth weight
babies who subsequently grow to be malnourished children. Often these children grow up without improved
nutrition and are malnourished as they enter reproductive age, perpetuating the cycle. Discussions with women in
tribal areas of AP revealed that women do not consume adequate nutritious meals at home because nutritious
food is unavailable, knowledge of nutrition is lacking, and a combination of the two. In addition, gender
discrimination between boys and girls begins at birth which means girls receive less food than boys.
Through this project, the Society for the Elimination of Rural Poverty (SERP) proposes to implement community-
managed nutrition cum day care centers (NDCCs) with a nutrition behavior change campaign in tribal villages. The
intervention will converge with the government’s Integrated Child Development Scheme (ICDS), which has similar
aims but a different approach and that has not been able to achieve its intended outcomes.
The objective of the project is to
improve the nutrition of pregnant
women, lactating women, and
children under five years of age in
five tribal villages in Visakhapatnam
District, Andhra Pradesh by improving
their nutrition-seeking behavior. The
selected villages are part of SERP’s
larger project and are already
implementing the universal
interventions under the Health and
Nutrition Unit of SERP.
Page 11 of 48
The NDCCs will act as a “one-stop-shop” where pregnant and lactating mothers and children can eat nutritious
meals and snacks; receive health checks, vaccinations, growth monitoring and promotion; and receive behavior
change messages pertaining to improved household nutrition. The project bundles the nutrition program with
other government sponsored programs like ICDS and Janani Suraksha Yojana—a conditional cash transfer
program—and community-managed micro credit product to make the nutritious food affordable and sustainable.
The food is consumed by pregnant and lactating
mothers and children under three at the NDCCs under
the supervision of a community resource person (CRP).
The intervention combines a direct nutritional
intervention with a behavior-change intervention to
achieve both short-term and long-term impacts.
The project has four key innovations:
• “Bundling” the nutrition program with other government sponsored programs like ICDS and Janani Suraksha
Yojana (Rs.1000/- incentives for institutional delivery) and community-managed micro credit product to
make the nutritious food affordable and sustainable
• “One-stop-shop” – the NDCC will double as a place where pregnant and lactating mothers and children a)
come to have their food; b) receive health checks and vaccinations are provided by ANMs and medical
doctors; and c) receive behavior change messages pertaining to improved household nutrition.
• Food is consumed by pregnant and lactating mothers at the NDCC under the supervision of a CRP. This is to
prevent the possibility of food being take home and being distributed among the household members
• The intervention combines a direct nutritional intervention with a behavior-change intervention so that
long-term effects can be achieved.
ABOUT THE PROJECT IMPLEMENTER(S)
The Society for the Elimination of Rural Poverty (SERP) is a government agency that has been implementing a rural
poverty reduction and livelihoods development project since its establishment in 2000.2 SERP’s program builds
grassroots institutions of the rural poor and aggregates them at the village, sub-district, and district levels. This
aggregate institutional structure provides the scale to leverage services from the public sector, private companies,
and commercial banks—such as, health care, community agriculture, bank linkage, marketing centers, etc.
CONTACT INFORMATION
B. Rajsekhar, Chief Executive Officer Society for Elimination of Rural Poverty (SERP) H. No. 5-10-192, Hermitage Office Complex, HUDA, Hillfort Road Hyderabad Andhra Pradesh 500004 India Email: [email protected] Website: www.rd.ap.gov.in Tel. +91 04023298469 Fax: +91 04023211848
Ms. Lakshmi Durga Chava State Program Manager, Health and Nutrition Email: [email protected]
2 The World Bank finances SERP activities through the Andhra Pradesh Rural Poverty Reduction Project (P071272)
Among scheduled tribes in India, 45.9% of
children are underweight and 44.2% are
stunted.
Page 12 of 48
INDIA: NUTRITION FOR M IGRANT CHILDREN LIVING ON
CONSTRUCTION SITES The importance of quality early childhood care and education (ECCE) for the long-term development of children is
widely acknowledged. In fact, a 2002 report by India’s National Institute of Education Planning and Administration
states that a child’s ability to succeed at the primary level is heavily influenced by “what the child actually brings
with him/her to [primary] school in terms not only of pre-literacy skills, but also nutritional/health status, socio-
economic background, extent of parental stimulation, and overall home environment.” Not surprisingly, it is the
most marginalized children that have the least access to ECCE, while they would benefit the most from regular,
quality care, and education.
Economic booms can create new marginalized populations, as has been done with the construction boom in
Hyderabad in the state of Andhra Pradesh. Migrant laborers who live in camps near construction sites are a mobile
and marginalized population that is not served by existing programs. This group works long hours for little pay and
virtually no access to critical health, sanitation, nutrition, or education services. Often both parents migrate and
are engaged in construction work, so the children are left on-site to fend for themselves; older girls are often
forced to drop out of school to care for their siblings. Many, if not most, of these children suffer greatly from
malnutrition, diarrhea, and other illnesses resulting from poor nutrition and poor hygiene/health.
Given the high proportion of children aged 3-6 currently attending Transit Schools, the SCOPE program by Dr.
Reddy's Foundation (DRF) is expanding to ensure
that children, newborn up to the age of five years
have access to ECCE programs that provide
integrated health, nutrition, recreation, and
education services.
In order to establish an effective, low-cost model
for holistic, on-site daycare facilities, DRF will
start ECCE centers on 10 construction sites
through the project—Improving Nutritional
Health of Migrant Children Living on Construction
Sites in Hyderabad, Andhra Pradesh, India. The
centers, staffed by DRF-trained caregivers, will
provide daily nutrition to children—seasonal
fruits, biscuits, egg, milk, bread, millets, dal—and
interactive training for mothers to help them
make better nutrition/health decisions for their
children, themselves, and their families. DRF will
work on 10 construction sites, where the builder
cooperation is already available, to build trust in
mothers to leave their children with motivated
and trained staff of the ECCE.
The key objective being to use the integrative
Page 13 of 48
ECCE model to reduce malnutrition and control malnutrition related disease occurrence in these children. Other
objectives are:
• To involve the mothers through building awareness about child care and feeding practices among them so
as to reach to the most vulnerable age group of under three years.
• To monitor the growth of the children regularly and take corrective measures in programme
implementation.
• To foster the creation of public-private partnerships between construction companies, government and civil
society to attend to the educational, nutritional and
health needs on children living on construction sites.
• To share best practices and the develop
partnerships among NGOs working on ECCE issues for
migrant and/or marginalized populations.
In India the Contract Labour (Regulation and Abolition)
Act, 1970, and The Inter State Migrant Workmen
(Regulation of Employment and Conditions of Service) Act, 1979, both require crèches on construction sites for the
children of construction workers; however, most construction sites still lack ECCE facilities. Builders are generally
willing to provide crèches to low-wage laborers, so long as the cost per worker is not high. The project should
provide a model of high-quality, low-cost ECCE that addresses the critical nutritional and health needs of migrant
children.
DRF’s ECCE program will be the first of its kind in Hyderabad. Currently no NGO is providing ECCE facilities in the
city. It is also unique in that DRF’s ECCE centers will also serve as on-site resource centers for mothers, providing
classes and support groups which will empower them to make long-term changes in the nutritional health of their
families.
ABOUT THE PROJECT IMPLEMENTER(S)
Dr. Reddy's Foundation is non-profit partner of Dr. Reddy's Laboratories. DRF is pioneer in developing innovative
programs in response to critical, long-term education needs of underserved populations. DRF provides access to
quality pre-primary, primary and secondary education for children excluded from mainstream schooling due to
social and economic marginalization.
CONTACT INFORMATION
V. Mrudula Project Head - SCOPE Dr. Reddy's Foundation H.No 8-2-293/87/A MLA Colony, Rd.12, Banjara Hills Hyderabad 500034 Andhra Pradesh India
Email: [email protected], [email protected] Website: www.drreddysfoundation.org Tel. 914023554020 Fax. 914023554021
Two national acts require crèches on
construction sites for the children of
construction workers; however, most
construction sites still lack ECCE facilities.
Page 14 of 48
SRI LANKA: THREE-GENERATION COMMUNICATION FOR
IMPROVED INFANT AND YOUNG CHILD NUTRITION Poor nutrition of infants and young children in Sri Lanka derive mainly from inadequate complementary feeding at
the age of six months. Breastfeeding practices, though not perfect, have improved with 82% of mothers exclusively
breast feeding up to age 6 months (DHS 2007 Report). However complementary feeding is not started in a timely
manner, is inadequate in terms of protein and dietary diversity, is of inadequate quantity, lacks palatability, and
does not follow the basic principles of responsive feeding. Furthermore, feeding practices during illness is also
poor. The same DHS 2007 states that, among children under five years of age, 26% are underweight, 18% are
stunted, and 16% are wasted. Disaggregated data show that children under the age of two—300,000 to 500,000
children according to demographic averages—fare even worse. A 2000 report by MRI shows that anemia levels are
about 30% in both groups.
This project seeks to improve complementary feeding practices and nutrition of expectant and nursing mothers
through radio broadcasts. It will work through radio stations operated by three generations of women—
adolescents, mothers, and grandmothers—in a creative community network to change these key nutritional
behaviors. The approach draws on the power of grandmothers, who often exert considerable influence on young
mothers and adolescents are the secondary target audience of the project.
Sri Lanka has 42 radio channels (including mainstream and rural) and 10 TV channels; however, very little air time
is dedicated to food and nutrition issues. In fact, most mass media is used to detrimental effect on food related
behavior—e.g., milk powder advertisements. Furthermore, health and nutrition promotion is carried out through
conventional methods that do not change behavior among communities. Radio is the only communication medium
that can be accessed by most of the
population. It is also the most affordable
and productive medium because people
can go about their daily activities while
listening. Rural radio is preferred over
mainstream radio because air time can be
dedicated to localized problem. It is also
easier to train local people to run their
own radio station according to their
cultural context. Furthermore, Sri Lanka
has experience in the use of rural radio
and its impact for the last 20 years.3
Getting three generations of women
empowered to manage and broadcast
was thought of as exclusively female-run
radio stations are not present in Sri Lanka
especially at the rural level. However,
3 The use of ICT in Education Report, Sri Lanka part of the UNESCO Meta Survey on the use of Technology in Education
Page 15 of 48
gender equity will be addressed through featured dialogues between men and women, especially on the topic of
food needs at the household level.
It is rare to have dedicated radio networks, even at the rural level, addressing the subjects of health and nutrition.
The network center (Madya Piyasa), a participating
community, will centrally network the 15
communication societies to be set up in different
areas. The communication societies will be organized
through the members of the National Nutrition
Alliance (an Alliance of 20 NGOs working towards the
improvement of nutritional status of Sri Lankans). The
system will run practical programs through the different communication societies and the relevant stations do live
broadcasts. The unique contribution of a community initiative on health and nutrition communication will enhance
the work of the national Ministry of Health in taking the messages effectively to the grassroots.
The project is based on participatory communication methodology, which is easily replicable in other areas. Well
documented learning experiences from this project will enable effective replicability. Since the amount to be spent
on the whole project from the envisaged budget is fairly small, this too would contribute to a low cost initiative,
which is easy to replicate as the investment is fairly small.
ABOUT THE PROJECT IMPLEMENTER(S)
Sri Lanka Green Friends Environmental Organization was founded in 1990, in Pelmadulla, Ratnapura district and
was registered as a non-government organization in 1995. Its main activities focus on biodiversity conservation
and sustainable management of tropical forests in the country through advocacy, information dissemination, and
by improving the livelihoods, health, and sanitation of the buffer zone population. Green Friends promotes
peoples' participation and implements a significant amount of training, awareness, and extension activities in
relation.
CONTACT INFORMATION
Priyadarshana Saman Kumara Chairman Executive Board Sri Lanka Green Friends Environmental Organization No: 1/135, Balangoda Road, Pelmadulla Pelmadulla 70070 Sabaragamuwa Province Sri Lanka
Email: [email protected] Tel. 09404-2274852 0940718186447 Fax. 094 0452274852
Sri Lanka has 42 radio channels and 10 TV
channels but very little air time is dedicated
to food and nutrition issues.
Page 16 of 48
INDIA: UNIVERSALIZING SUPPLEMENTARY NUTRITION
UNDER THE AGE OF TWO: A SOCIAL BUSINESS MODEL OF
NUTRIMIX PRODUCTION Child malnutrition is a major public health problem in India, with 45.9% of children under the age of two
being underweight. However, the importance of nutrition security is often ignored by communities and
households with telling consequences on social and economic productivity of the population leading to a
loss of 3% of GDP. Supplementary nutrition for children in India is usually secured from the market and is
mostly accessible to households with high purchasing power. The marginalized rural poor in general and
children under two of those households in particular, are deprived of access to quality supplementary
food.
Child malnutrition is attributed to high levels of infection, inadequate infant feeding, and inappropriate
caring practices, and has its origin almost entirely in the first two years of life. Another contributing factor
is the mothers’ lack of knowledge. Combating these will be the strategic focal point of the project, entitled
Universalizing Supplementary Nutrition for Children Under the Age of Two: a Social Business Model of
Nutrimix Production.
The project aims to improve the nutritional security of children under two in South 24 Parganas district of
West Bengal, located in the Indo-Gangatic plain. In this district, 51.8% of the children below two years of
age are malnourished, and 22.1% of these children suffer from moderate to severe anemia. Many of them
also suffer from respiratory and gastro-intestinal infections, malaria, and increasingly with HIV. The
specific goal of the project will be to reduce the number of malnourished children by half in its
operational area at the end of 18 months.
One effective way of tackling the problem mentioned above is to make low cost, high nutrient
supplementary food available to the affected population. Child In Need Institute (CINI) has developed an
innovative product called Nutrimix, which
is a low cost nutritious supplementary food
made especially for children.
Nutrimix is a CINI innovation. It is a low
cost nutritious supplementary food for
children made from locally available
ingredients. It has been successfully tested
for its efficacy in improving the nutritional
status of children in a short period through
the Nutritional Rehabilitation Centre and
the CINI clinic. It is easy to prepare, has a
long shelf life and can be taken in solid or
semisolid forms in sweet or salty variants,
depending on the child's preferences. It is
packed in single serve sachets of 20 gms
Page 17 of 48
each and sold for Rs 2 per sachet or Rs 5 for 3 sachets.
CINI will follow a community-based participatory approach to set up the production of Nutrimix and its
distribution channels that will make it available to the affected population. It will also aim to disseminate
information on better child care and
feeding practices. With management
support from the Indian Institute of
Management, Calcutta, the project will be
undertaken as a social business venture
with the goal of developing a replicable
social business model for enhancing early
childhood nutritional security.
CINI has a wide network of operations in
eastern India supported by a strong workforce at the grassroots level. This provides an opportunity for
CINI to disseminate the idea of social business to communities. Once successfully piloted, project will
scale up its operations to reach out to age groups of 3-6 years, adolescent girls, and pregnant and
lactating mothers in rural communities and urban slums where it is marketed. The goal is to effectively
break the inter-generational malnutrition cycle.
ABOUT THE PROJECT IMPLEMENTER(S)
CINI was established in 1974 and is committed to sustainable development and the improved health,
nutrition, and education of children, adolescents, and women in need. Its commitment is reflected by its
reach to about 800,000 people in rural and urban area of India.
Indian Institute of Management, Calcutta has been a premier management education institute of India
since 1961. It strives to remain on the cutting edge of research, teaching and consultancy in various
functional areas of management and related disciplines. IIM-C will provide management inputs to the
project by providing expert services in relevant areas of the project as well as manpower.
CONTACT INFORMATION
Mr. Abinash Gine Assistant Director Child Health Division CINI Nutrimix Child In Need Institute (CINI) Village: Daulatpur, P.O. Pailan, Via Joka, District: 24 Parganas (South) Daulatpur Village West Bengal 700 104 India
Email: [email protected]
Website: www.cini-india.org Tel. +91 33 2497 8192 / 8206 Fax. +91 33 2497 8241
Professor Kalyan Mandal Indian Institute of Management Calcutta IIMC, Joka, DH Road, Kolkata Kolkata West Bengal 700104 India Email: [email protected] Website: www.iimcal.ac.in Tel. +913324678300 Fax. +91332678062
Nutrimix is low cost, made from locally available
ingredients, has a long shelf life, can be taken in
solid or semisolid forms, and in sweet or salty
varieties. Single serve sachets of 20 gms at Rs 2
each are affordable to the poor.
Page 18 of 48
BANGLADESH: COMMUNITY-LOCAL GOVERNMENT
PARTNERSHIP TO COMBAT CHILD MALNUTRITION Child malnutrition is a major public health concern for Bangladesh, and the period between conception
and 24 months of age is when the prevalence of malnutrition is highest and its adverse effects on physical
growth and mental development can be irreversible. Therefore, children of this age group in food
insecure areas are more susceptible to malnutrition and need effective interventions. WHO reports that
48% of children under the age of five in Bangladesh are underweight compared to 39% in Nepal and 43%
in India, and BDHS reported in 2007 that 30% children between 6-7 months do not receive any solid or
semi-solid food, and the prevalence of severe wasting among children under the age of five is 3%.
Acute poverty and annual seasonal hunger resulting from scarce livelihood opportunities condemn the
women and children of Kurigram—one of the most food insecure districts of Bangladesh—into severe
hunger. Fragmented and non-functional health systems in urban areas exacerbate the already weak
health and nutrition status of the poor. Community members, including mothers, lack awareness of infant
and young child feeding (IYCF) practices, channels of communication and information, and most
importantly, they lack opportunities to work out practical and innovative solutions with the local health
system. A KPC survey of Kurigram municipality indicated that few mothers took positive steps to maintain
their own health and nutrition during their pregnancy. After delivery, only 45% of mothers initiated
breastfeeding within one hour of birth, only 71% of children under six months were exclusively breastfed,
and only 17% children aged between 6 and 11 months received at least three complementary feedings.
Mothers also give inadequate attention to protein based nutrition.
In an effort to find workable, replicable solutions to this problem, Concern Worldwide is implementing a
project to promote timely, appropriate, safe and adequate infant and young child feeding (IYCF) practices
for children under two through a partnership between a municipality and a multi-stakeholder platform in
three wards of Kurigram municipality.
The specific strategies of the
project include strengthening
the institutional capacity of
the local municipality,
fostering partnerships of the
community stakeholders with
health departments, NGOs,
private sector and other
government departments,
promoting practical solutions
at the ward level, facilitating
local women’s leadership and
ensuring accountability for
demand driven services for
the poor.
Page 19 of 48
A new form of partnership with the Municipal authority will bring in a new but mandated actor to support
IYCF practices in urban areas where health systems are less functional for the extreme poor. Involvement
of municipal authorities with other community stakeholders in planning, monitoring and developing
schemes will ensure optimal use of the limited resources available with community, NGOs, public and
private services providers.
This initiative promotes municipal leadership in
engaging diverse community stakeholders and
youth volunteers in IYCF promotion and better use
of resources. This will bring a shift from NGO
driven services for the poor by making the
mandated municipal authorities accountable for
demand based services for the infant and young
child and their mothers. Mechanisms like mothers clubs and creation of “pot for mothers” reinforces
women as the main actors to improve nutrition practices. Fathers will be engaged through awareness
sessions, campaigns, actions to recognize positive practices. A combination of traditional tools and
modern technologies like cell phone messages, awards, and subsidized services will be used for promoting
behavior change amongst the family members and change agents.
The process expands the service and resource windows by brokering relationships with different
stakeholders and encouraging them to develop innovative schemes. This fosters community learning on
IYCF practices and transfer knowledge through young volunteers to improve the nutritional status of
infants and young children.
ABOUT THE PROJECT IMPLEMENTER(S)
Based in Ireland, Concern Worldwide was established in 1972 and is an international, humanitarian
organization dedicated to the reduction of extreme poverty in world’s poorest countries. Since 1968,
through its work in emergencies, livelihoods, health, HIV&AIDS, and education, Concern has saved
countless lives, and transformed lives of millions of people.
Kurigram Municipality is an autonomous body of local government mandated to improve health and
sanitation, develop local infrastructure and generate revenue. They have staff and receive some grant
from government.
CONTACT INFORMATION
Humaira Aziz Assistant Country Director, Learning and Sharing Concern Worldwide Email: [email protected] House: 15, SW(D), Road:7 Gulshan-1 Dhaka 1212 Bangladesh Website: www.concern.net Tel. +88028816923, 881 8009, 881 1469 Fax. +88028817517
Abu Bakar Siddique Mayor Kurigram Municipality Government Kurigram Municipality Kurigram 5600 Bangladesh Tel. +880581-61357 Fax. +880581-61857
The period between conception and 24
months is when malnutrition is highest,
and its adverse effects on physical
growth and mental development can be
irreversible
Page 20 of 48
INDIA: COUPLING DIARRHEA TREATMENT AND
BEHAVIORAL CHANGE COMMUNICATION TO REDUCE
SEVERE MALNUTRITION IN AN URBAN SLUM The problem of diarrheal infection in South Asia continues to be a serious constraint on efforts to
maintain and improve child nutrition particularly during the critical ‘window of opportunity’—newborns
to 24 months. Every day in India, 1000 children die from diarrhea-induced dehydration. Malnutrition is
associated with 61% of deaths from diarrhea-induced dehydration. Even if a mother gives birth to a child
above 2.5 kilograms, breastfeeds properly, and her child is growing normally, all of this could be nullified
by a single severe case of diarrhea.
A common phenomenon observed in maternal and child health (MCH) programs throughout South Asia is
significant growth faltering in otherwise healthy children after the completion of exclusive breastfeeding.
One explanation for this is the improper treatment of naturally occurring diarrhea following the
introduction of semisolid foods.
Calcutta Kids (CK) proposes to couple diarrhea treatment—systematically providing oral rehydration salts
(ORS) by trained health workers—with a creative behavioral change communication (BCC) campaign
designed to encourage continued complimentary feeding despite recent diarrhea, to reduce future onset
of diarrhea, and to improve the nutritional status of the child. The campaign will be targeted to the
mothers/caretakers of children admitted to a low-cost diarrhea treatment center based in Howrah, many
of whom will become change agents in their neighborhoods.
Qualitative data from the CK catchment area suggest that ORS is often ineffective because of time
constraints on the part of the mother/caretaker, and that professional diarrhea treatment, including
intravenous rehydration, for children is only
considered in cases of severe diarrhea,
because the costs associated with available
treatment are beyond the means of these
households.
Calcutta Kids has set up a Diarrhea Treatment
Center (DTC) in a defined urban slum area,
where children can receive curative
systematic oral rehydration therapy by
trained community health workers (CHW)
and intensive BCC counseling is provided to
mothers/caretakers of these children on
diarrhea prevention, timely introduction of
adequate complementary feeding of children
at six months, and hygiene and sanitation.
This is a replication of ICDDR-B’s successful
diarrhea treatment model.
Page 21 of 48
The project aims to prevent diarrhea from precipitating malnutrition in otherwise healthy children by:
• Provision of curative diarrhea treatment for at least 750 children a year under the age of two;
• Intensive BCC counseling aimed at the mothers/caretakers of these children;
• Follow up home visits by trained CHWs; and
• Getting at least 50% of the mothers/caretakers to act as change agents to disseminate what they
learned at the DTC to neighbors and friends
(minimum 5 per session).
The principle underlying this project is that behavior
change communication (BCC) and prevention are
most effective when individuals understand, through personal experience or the experience of friends,
the consequences of their behaviors and that beneficiaries embrace BCC most readily from people who
have established themselves as trustworthy, e.g. those who have just provided a vital service to their
family.
The project is innovated in the following ways:
• The replication of ICDDR-B’s successful diarrhea treatment model in a defined urban slum area, and
the measurement of its effect in reducing both diarrhea prevalence and malnutrition in young
children with added innovative components.
• The conversion of parents – who have seen their children recover from a potentially fatal illness –
into committed practitioners of improved health behaviors and into change agents disseminating
information to others.
• A shifted focus: primary attention to BCC relating to prevention, nutrition-related caring practices
and development of change agents; and secondary attention to curative diarrhea treatment,
especially conventional expensive treatment.
• Assessing the sustainability of a successful diarrhea treatment model that charges clients just
enough to cover CKDTC costs, while seeking multiplier benefits. If the model proves sustainable, it
will be attractive to NGOs elsewhere in South Asia and in other developing countries.
ABOUT THE PROJECT IMPLEMENTER(S)
Established in November 2005, Calcutta Kids is an organization committed to the empowerment of the
poorest children and expecting mothers in the underserved slums in and around Kolkata, by increasing
their access to health and nutrition services, providing health information, and encouraging positive
health-changing behaviors. The CK maternal and child health program (MCH) works with pregnant women
and children aged 0-3. At any given time, the program is working with approximately 350 families.
CONTACT INFORMATION
Noah Levinson, Director Maternal and Child Health Calcutta Kids Trust 51 Bhairab Dutta Lane Salkia, Howrah West Bengal 711106 India
Email: [email protected], [email protected] Web: www.calcuttakids.org Tel. 919830806313
Every day in India, 1000 children die
from diarrhea-induced dehydration.
Page 22 of 48
NEPAL: ENHANCED INFANT AND YOUNG CHILD FEEDING
PRACTICES LINKED WITH MICRONUTRIENT SPRINKLES
SUPPLEMENTATION Iron deficiency is the main cause of anemia in 80% children under the age of two. Nearly 50% of children
suffer from chronic malnutrition, which drastically increases between the ages of 6 and 23 months due to
poor feeding practices. Only about 60% of children aged 6–7 months are provided with complementary
foods. Children are fed an average of only 1.2 meals a day, and the foods are often low-energy-density
cereal porridges. High prevalence of anemia and stunting deprives children of optimum growth, cognitive
and mental development resulting in irreversible intellectual capacity and productivity loss.
To address this, the Government of Nepal has decided to supplement children below two years with
micronutrient powder (MNP) linked with infant and young child feeding (IYCF) community promotion
package. The package includes training of health workers and community volunteers, orientation of
mothers groups, mother-to-mother counseling, and demonstration of appropriate complementary foods.
While introducing MNP, mothers can be convinced to initiate complementary foods at six months,
counseled on feeding frequency, making energy dense food and hygiene and trained to prepare
Sabotham Lito, blended flour by mixing cereals and legumes, which drastically increases energy density
and enhances protein quality.
Past training of health workers and national media campaign to increase awareness about IYCF did not
produce any change since the message did not reach caregivers. To enhance IYCF community promotion,
a school-based monitoring and promotion approach was pursued in selected villages. This project is an
additional component of the on-going Baal Vita (multi-micronutrient powder) pilot project of the
Government of Nepal in Makawanpur and Palpa districts where Health Facility model and Female
Community Health Volunteer (FCHV) model are being tested respectively. The overall objective is to
reduce anemia and general malnutrition in young children through improved infant and young children
feeding practices by means of school based promotion and monitoring approach.
A core group of students
in each school in the
project area get briefed
on infant/young child
feeding practices, and
then social mobilization
activities, including
household visits, identify
eligible children for
distribution of food, and
raise awareness among
mothers, are carried
out. They also track
mothers in their villages
Page 23 of 48
on regular basis to monitor use of Baal Vita, cross-verify its consumption by reviewing the compliance
card provided to each child and report usage status to FCHVs. They also provide details of houses where
compliance is poor and any problems associated with feeding so that FCHVs can follow up with mothers
for further counseling and constructive
encouragement to achieve project
objectives.
Given that school children are integral
part of the community, they can easily
without any logistical difficulties promote
young child nutrition issues and pay a
vital role in ensuring that hard to reach and most disadvantaged families receive continuous support and
encouragement to adopt best feeding practices and ensure high use of MNP. The project aims to ensure
that at least 90% of children under the age of two years in targeted communities are consuming 60
sachets of micronutrient MNP at the seventh, 13th, and 19th month of age. The overall objective of the
project is to document the effectiveness involving school children as community advocates to will work in
coordination with Female Community Health Volunteers and Community Health Workers (CHW) in
promoting and reinforcing key messages on micronutrient MNP, improve IYCF and high consumption of
MNP and design school children based promotion and monitoring programme for national scale up.
ABOUT THE PROJECT IMPLEMENTER(S)
Vijaya Development Resource Center (VDRC) was established in 1980 with an aim to contribute towards
improving the situation of children and women. VDRC has vast experience in community based projects
on nutrition and Early Childhood Development (ECD) and has initiated new innovative social mobilization
approaches such as advocacy on social issues through community school and child clubs. Max Pro is
supporting the Government to carry out social marketing activities. In this project they will help in
training, BCC, documentation and evaluation activities.
CONTACT INFORMATION
Narayan Sapkota Executive Director Vijaya Development Resource Center Ward No.8, Vijayanagar Gaindakot. Nawalparasi Nepal Email: [email protected], [email protected] Tel. +977-56-501172, 501100 Fax: +977-56-501401 Website:www.vdrc.org.np
Rajat Rana Managing Director Max Pro Pvt. Ltd. Swasti Sandan, Patan Dhoka Road Kathmandu Lalitpur Nepal Email: [email protected] Website: www.maxpro.com.np Tel. 9775536681, 9775535183 Fax: 97715536682
Children are fed an average of only 1.2 meals
a day, and the foods are often low-energy-
density cereal porridges.
Page 24 of 48
NEPAL: COMMUNITY-BASED DISTRIBUTION NETWORK FOR
THE TWO CHILD LOGO ADE Iodine Deficiency Disorder (IDD) is one of the leading causes of preventable mental retardation and has
severe consequences for social and economic advancement. To address the problem of IDD, the Ministry
of Health in Nepal initiated the Universal Salt Iodization (USI) Program with a goal of over 90% of
households consuming adequately iodized salt (with iodine content of more than 15 ppm) and issued the
“Two Child Logo” (2CL) on all Nepalese packaged salt containing adequate iodine. The last national survey
conducted in 2005 found 95% of the households using salt with some iodine; however, only about 60%
percent of the households were using adequately iodized salt.
The Government of Nepal set 2010 as the year to reach the Universal Salt Iodization goal. To do this, the
Government, in partnership with UNICEF and Salt Trading Corporation (STC), initiated a social marketing
campaign of 2CL salt targeting high population districts with low consumption. This project aims to build
on existing campaigns by providing new strategies to meet campaign objectives among vulnerable
populations by promoting the consumption of adequately iodized salt bearing the “Two Child Logo” (2CL)
and ensuring its availability and accessibility in the project areas.
The project seeks to increase consumption of the 2CL salt among vulnerable populations, which will
ensure intake of daily iodine especially by pregnant and lactating mothers and children between the ages
of 6 – 24 months living in rural communities. During the course of the project, demand is expected to
reach volumes that would make the trade of 2CL salt feasible for these community groups to carry on
without further subsidies from STC or any external support.
The Government of Nepal is implementing (with support from UNICEF) a pilot project on distribution of
multi-micronutrient powder (Baal Vita) to
infants and young children aged 6-23
months in six districts of Nepal. Two
distribution models are being piloted: (a)
Female Community Health Volunteers
(FCHVs) distribution model, and (b) Health
Facilities distribution model. The project is
an additional component of the on-going
Baal Vita pilot project in Makawanpur and
Palpa districts where Health Facility model
and FCHV model are being tested
respectively. The overall objective of this
project is to reduce anemia and general
malnutrition in young children in these
two districts through improved infant and
young children feeding practices by means
of school based promotion and monitoring
approach.
Page 25 of 48
The project aims to implement its activities in the Central Terai districts of Parsa with a high population to
rapidly increase the consumption of the 2CL salt in the 20 Village Development Committees (VDCs) from
an estimated 33.9% to 75% within the duration of the project. To achieve this objective, the project will
carry out intensive promotion activities in 20
VDCs with the lowest availability and
consumption of 2CL salt. In these areas, a
targeted and vigorous BCC campaign will be
initiated to create awareness about 2CL salt
and its benefits. Along with awareness
creation, the project aims to make 2CL salt
available to at least 90% of markets in the 20 VDCs. For district-wide impact, the project will establish bulk
buyers in remaining VDCs to help augment existing distribution channels which will be supported by
district alliance building activities where NGOs and CBOs working in these areas will be encouraged to
integrate 2CL messages in their programming.
The existing social marketing program implemented by the Government with UNICEF’s support aims to
create awareness of 2CL salt in communities. However, due to the small number of bulk buyers, their
initial volumes were quite nominal due to which it was difficult for STC to provide them subsidies for
transport and this cost would become substantial for small volumes of orders. To overcome this problem,
a number of bulk buyers would be established who would be in a position to make joint orders of feasible
volumes to STC.
ABOUT THE PROJECT IMPLEMENTER(S)
MaxPro Pvt. Ltd. is a privately operated social marketing and advertising organization established in the
year 2001. MaxPro started with a focus on the development of communications and marketing strategies
for commercial companies and branched out into providing social marketing services to non-profit
international and national institutions. The Ministry of Health and Population, Child Health Division (CHD),
is the focal body in Nepal with the responsibility of implementing government policies related to child
health. The CHD will help gain support of the district-based Government line agencies in implementing
this program at the district level and help in the mobilization of their health service network to promote
2CL salt in the district and coordination with Salt Trading Corporation.
CONTACT INFORMATION
Rajat SJB Rana, Managing Director Social Marketing Division Max Pro Pvt. Ltd. GPO Box No. 750 Kathmandu Nepal Email: [email protected] Website: www.maxpro.com.np Tel. +977-1- 5536681 Fax: 977-1- 5536682
Rajkumar Pokharel Chief of Nutrition Ministry of Health and Population, Child Health Division Kathmandu Nepal Email: [email protected]
In 2005, 95% of households used salt with
some iodine; however, only about 60%
percent of households used adequately
iodized salt.
Page 26 of 48
INDIA: COMMUNITY INVOLVEMENT IN PROMOTING
NEONATAL & INFANT NUTRITION IN TRIBAL VADODARA The National Family Health Survey estimates 22% of newborns in Gujarat are low birth weight, 47% of
children below three years are underweight, and 80% of children are anemic. The infant and young child
feeding indicators like early initiation of breastfeeding (27%), exclusively breastfeeding (48%), and timely
complementary feeding (57%) reveal a dismal picture.
District Level Health Survey data for the rural areas of Vadodara district show that only 39% births are
institutional, only 55% of children are fully immunized, and less than half of mothers receive post-partum
care. Vital registration, recording, and monitoring of key nutrition-health indicators in rural areas also
remains sub optimal (73%).
In most health delivery systems, the information collected by grassroots health functionaries is seldom
shared with communities. Further, poor birth registration impedes correct estimation of vital indicators,
which affects planning of appropriate and effective interventions. Inaccurate recording of birth weight
delays the identification and management of high-risk neonates. Moreover, lack of promotion and
monitoring of infant feeding practices and clean drinking water result in worsening nutritional status of
children under two years. Delivery of existing health and nutrition programs and community monitoring
by Village Health and Sanitation Committees (VHSCs) needs to be strengthened to ensure optimal service
delivery at the village level, especially focusing on correct vital registration and effective promotion and
monitoring of nutrition-health practices and indicators.
The project by Deepak Foundation (DF) is part of a larger Safe Motherhood and Child Survival program
being implemented in all villages of Vadodara district. It will implement a more intensive program to
improve nutritional behavior in a subset of
about 300 villages. The project objective is
to improve neonatal and infant nutrition
practices through inter-departmental con-
vergence, community participation, and
the use of a culturally accepted tool (a
horoscope that also includes critical health
information on the newborn). The project
leverages the government initiatives,
Nutrition Health Days (NHD) and Anemia
Control Program of DF where the ASHA,
Anganwadi Worker and Auxiliary Nurse
Midwife conduct behavior change
communication (BCC) campaigns on key
health-nutrition issues. In addition to
conducting home visits for BCC and
supporting ANM and AWW in maintaining
a beneficiary database, ASHA will also
document information on time of birth,
Page 27 of 48
birth weight, and time of initiating breastfeeding, needed to prepare the horoscope. The information is
processed at the block level and the horoscope is distributed through outreach workers. This printed and
laminated card could also help in validating vital statistics for giving birth certificates. The project
beneficiaries will be newborns, children below two years of age, pregnant and nursing mothers and
community members in 200 out of around 700
villages from four tribal blocks of Vadodara District
The convergence of VHSCs with water committees
under Water and Sanitation Management
Organization (WASMO) will raise awareness
through wall paintings on nutrition-health issues,
drinking water quality, and ensure distribution of
fortified complementary food premix and iron supplements. Correct birth weight recording allows timely
management of low birth weight babies, a common cause of high neonatal mortality and child under-
nutrition. Community involvement in celebrating birth of each child during the government campaigns of
Nutrition Health days will ensure that government’s efforts at convergence of health and nutrition
programs are effectively monitored by community members.
ABOUT THE PROJECT IMPLEMENTER(S)
DF has been implementing developmental programs in sectors of maternal and child health, livelihood
promotion and pre-school education since 1982. Safe Motherhood and Child Survival is the core
intervention project implemented through community participation covering all 1548 villages of Vadodara
District, Gujarat in partnership with GoG, which has given constant encouragement to such public-private
partnerships and supported a consortium of voluntary bodies to increase their role as ombudsman for
improving health services in the State.
CONTACT INFORMATION
Archana Joshi Director Deepak Foundation “Deepak Farm”, Near Harikrupa Society Vadodara Gujarat 390021 India Email: [email protected], [email protected] www.deepakfoundation.org Tel. 91-265-2371439, 91-265-2371410 Fax: 91-265-2371679
Amarjit Singh Commissioner Health Department of Health & Family Welfare, Gujarat Block.no.5, Dr. Jivraj Mehta Bhavan, Old SachivalyaGandhinagar Gujarat 382010 India Email: [email protected] Website: www.gujhealth.gov.in Tel. 079-23253271 Fax: 079-23256430
Deepak Foundation will use a
culturally accepted tool—a
horoscope that also includes critical
health information on the newborn.
Page 28 of 48
BANGLADESH: PROMOTING BETTER INFANT AND CHILD
FEEDING PRACTICES THROUGH PERFORMANCE-BASED
PAYMENT In the slums, the rate of wasting among infants <6 months is 31% compared to only 5% among the non-
slum population. Previous research has shown that suboptimal breastfeeding practices and inadequate
complementary foods are associated with increased malnutrition, morbidity and mortality among infants
and young children. In the urban areas, 41% of infants are put to breast within one hour of birth, 62%
receive pre-lacteals, 6.6% infants are exclusively breastfed to 6-7 months, and the quality and frequency
of giving complementary foods during 6-24 months are below what is recommended. It is, therefore,
important that context-specific Infant and Young Child Feeding (IYCF) messages are conveyed to mothers
in slum areas.
The Traditional Birth Attendants (TBA) are a significant part of the informal health care system in the
urban slums as they attend almost 68% of births. The TBAs are, therefore, well-positioned to promote key
infant feeding messages during the early part of infancy. In recent years, BRAC has been training the TBAs
in safe motherhood issues. However, in the urban areas there have been significant dropouts as salaries
offered to TBAs have not been competitive.
This SAR DM funded, “Promoting Better IYCF
Practices in Urban Slums using Performance
Based Payment” project is being implemented by
ICDDR,B covering Shat Tala slum in Mohakhali,
Dhaka. The project beneficiaries are mothers and
other family members of children under one year
age and the objectives are to increase the rates of
breastfeeding initiation, increase the rates of
exclusive breastfeeding, improve the quality and
quantity of complementary foods, empower TBAs
and local community groups to promote infant
and child nutrition and lastly, create a market for
nutrition education within the community and the
health system. The project uses existing informal
health workforce positioned to work in infant and
young child feeding by providing training, referral
and community linkages to community nutrition
volunteers (CNVs) to raise their self-efficacy. The
project also provides financial incentives for
improved practices to motivate the health
workforce to be innovative in their approach and
strive for results.
Page 29 of 48
The project uses performance-based payment to TBAs to promote key infant and young child feeding in
the slum population to improve the rates of appropriate breastfeeding and complementary feeding
practices of infants and children under two years of age in Dhaka slums, disseminate context-specific IYCF
messages to mothers in slum areas
and use performance-based payment
to TBAs to promote key concepts of
IYCF in slum population.
Interested TBAs will be given training
in IYCF. They will disseminate IYCF
messages to mothers of infants under
two years of age who will provide a
list of all mothers they have reached
to project staff. The TBAs will be paid
remuneration for each ideal practice that the mothers on their list practiced after verification by project
staff. The training, referral linkages with ICDDRB public health physician and community mobilization for
IYCF that are planned as a part of the project is expected to increase the profile and social acceptability of
TBAs. Their involvement in the project will be part-time allowing them to engage in other income
generating activities.
Community groups and TBAs are an essential part of the informal healthcare system in both urban and
rural areas of Bangladesh. Children under two years of age and their mothers will be the direct
beneficiaries of this project. Improvement in feeding practice will have a positive impact on the children’s
nutritional status. Training and access to referral and community network will empower TBAs and provide
them with future employment opportunities. If successful as a pilot, this program could be scaled up in
other areas of Bangladesh.
ABOUT THE PROJECT IMPLEMENTER(S)
ICDDR,B was founded in the 1960s and has extensive experience in conducting health research and
providing evidence-based health-related services and training in collaboration with public sector and civil
society partners. It partners with over 100 organizations including the Government of Bangladesh, other
national governments, international institutions and national and international civil society partners.
CONTACT INFORMATION
Dr. Sabrina Rasheed Assistant Scientist International Centre for Diarrheal Diseases Research, Bangladesh (ICDDR,B) GPO box 128 Dhaka 1000 Bangladesh
Email: [email protected] Website: icddrb.org Tel. 88028810021 Fax: 88028826050
In urban areas, 41% of infants are put to
breast within 1 hour of birth, 62% receive
pre-lacteals, but only 6.6% are exclusively
breastfed to 6-7 months, and the quality
and frequency of complementary feeding
between 6 and 24 months is below
recommendations.
Page 30 of 48
PAKISTAN: A COMPREHENSIVE COMMUNITY-BASED
INTERVENTION TO IMPROVE LINEAR GROWTH IN CHILDREN
AGED 6-18 MONTHS Deficiencies of iron and zinc have adverse effects on infants’ growth, development and immunity, and
they contribute substantially towards morbidity and mortality. In Pakistan, inappropriate
weaning/breastfeeding practices include: lack of exclusive breastfeeding for the recommended period of
6 months; stopping breastfeeding before two years; widespread formula feeding with substantial dilution;
initiating liquids and semi-solids before six months; substantial dilution of solids for bottle feeding; and
avoiding meat (rich source for zinc/iron) before 2 years of age. Most of these practices are due to lack of
awareness and poverty. The former leads to selection of inappropriate foods while the latter leads to low
quality of food. These result in massive nutritional deficiencies ending up in infants’ poor growth,
development and defense mechanisms putting them at the risk of preventable infections, illnesses,
morbidities, and mortality. These could be mitigated by counseling families and mothers about
appropriate feeding practices and supplementation.
The Lady Health Workers (LHWs) of the National Program for Family Planning and Primary Health Care
address these factors through antenatal dietary counseling and iron supplementation, promoting
appropriate breastfeeding/weaning practices, and management of childhood infections. However, these
strategies do not address zinc and iron deficiencies.
This project will conduct a randomized, controlled trial of counseling mothers/family members by senior
women community-workers to introduce chicken liver as a complementary food for infants aged 6-18
months by enrolling 300 infants from urban slums of a cluster in Karachi, where 150 infants will receive
chicken liver thrice a week and 150 will have
their traditional feeding practices. The cluster will
be selected from the operational areas of the
Health and Nutrition Development Society
(HANDS). All 300 infants would be followed for
18 months. The interventions will compare the
potential benefits of incorporating chicken liver
into routine infant and toddler feeding versus
optimized traditional complementary feeding
regimens. The use of chicken liver as a
complementary food for infants is an innovative
idea. Chicken liver is a rich source of zinc and iron
with potential salutary impact on the linear
growth of infants. Moreover, involving elderly
women from the local community to counsel
mothers and families of infants will be a new idea
for improving the usage of chicken liver.
Page 31 of 48
The specific aim of this project is to determine the impact of intake of chicken liver as a source of zinc and
iron in infants between 6-18 months of age on linear growth velocity and infectious disease morbidity in a
population dependent on traditional feeding practices for complementary feeding. Established strategies
for childhood nutrition focus on food fortification or the use of supplements for the amelioration of zinc
and iron deficiency. The effectiveness of these programs
is uncertain. Moreover, the acceptability of fortified
foods in Pakistan is low as people generally fear the
safety of such fortifications, especially for infants and
children, and use of supplements is expensive. By
comparison, little attention has been paid to foods
naturally high in zinc and iron that are locally available
and affordable. The current National Program for Family Planning and Primary Health Care attempts to
address the poor nutritional status of infants through a variety of strategies, however, malnutrition and
specifically, iron and zinc deficiencies remain prevalent in Pakistan.
Once the project is complete, results will be shared with the National Program for Family Planning and
Primary Health Care and recommendations will be made for continuing the activities by LHWs so that
messages given to pregnant women continue. The cost of adding chicken liver is small and is affordable
for the families. Since the project will only sensitize the community through LHWs and community
workers, it can be replicated in any community.
ABOUT THE PROJECT IMPLEMENTER(S)
AKU, established in 1983, is an autonomous, international institution. Its Community Health Science (CHS)
Department has a niche for community-based needs assessment and research, both action and
operational. CHS has taken a leadership role in the development of primary health care and health
systems in the country. HANDS is a registered NGO working in health, education, poverty alleviation and
infrastructure development through direct interventions. HANDS caters a population of 8,000,000
especially women and children in Sindh, including Karachi. The infants will be enrolled from the urban
slums of Karachi which will be selected from one of the operational areas of HANDS. HANDS will also
facilitate the implementation of the intervention through identifying the local community elderly women.
Moreover, HANDS will conduct the training of LHWs.
CONTACT INFORMATION
Dr. Neelofar Sami Faculty Member Community Health Sciences Department Aga Khan University, Karachi, Pakistan Community Health Sciences Department stadium Road Karachi 74800 Pakistan Email: [email protected] Website: www.aku.edu Tel. 92214864828 Fax: 92214934294
Tanveer Shaikh Executive Director Health and Nutrition Development Society 140-C Block II PECHS Karachi Pakistan Email: [email protected], www.hands.org.pk Tel. 92214532804 Fax: 92214559252
Chicken liver is a rich source for
zinc and iron with potential
salutary impact on the linear
growth of infants.
Page 32 of 48
INDIA: USING CELL PHONE TECHNOLOGY TO IMPROVE
EXCLUSIVE BREASTFEEDING AND REDUCE INFANT
MORBIDITY Breastfeeding has profound health benefits for infants and mothers and has an economic advantage over
all other forms of feeding. Exclusive breastfeeding (EBF) for six months prevents up to 13% of the annual
10.8 million childhood deaths worldwide. Despite WHO/UNICEF’s Baby Friendly Hospital Initiative (BFHI)
in India in 1993, there have been only minimal improvements in EBF. In India, breastfeeding in the first
hour of birth is at 23.5%, 75% thereafter, and declines to 16.5% at six months, largely due to inadequate
counseling, support, and rampant use of infant milk substitutes. There is an urgent need to find innovative
ways to promote exclusive breastfeeding to enhance the effectiveness of BFHI.
This community intervention, “Evaluation of the Effectiveness of Cell Phone Technology as Community-
based Intervention to Improve Exclusive Breastfeeding and Reduce Infant Morbidity”, has the potential to
change household health behavior through cell phones. In March 2008, India, the second largest mobile
market in the world, had an estimated 261 million subscribers to mobile phones (a fourth of the country’s
population and expected to reach half by 2010). Despite expanded coverage and affordability, cell phones
have not been used for nutritional counseling. Other nutrition enhancing programs are health center
based. By providing the mothers flexibility to call when she most needs help and through frequent
reminders, promotion messages and ring tones for enhancing and adhering to desired health behavior,
this intervention will empower women to overcome barriers of leaving home after delivery and that of
transportation.
The objective is to improve rates of EBF over
a control group by innovative use of cell
phones to provide ongoing encouragement
and counseling with a lactation counselor
throughout the post partum period to six
months, and on-going weekly SMSs. Women
can also call for advice on breastfeeding as
needed. This will demonstrate the efficacy of
cell phones for lactation consultation and
support for improving infant feeding
indicators (timely initiation, EBF, timely
complimentary feeding), understanding
their barriers, reducing infant morbidity, and
improving maternal satisfaction.
The intervention aims to achieve at least a
30% increase in rates of initiation of BF and
EBF and of complimentary feeding at six
months, and a 25% decrease in morbidities
in infants 0 to 6 months in the group with
Page 33 of 48
cell phone counseling as compared to the control group. We also hope to sustain a 30% improvement in
EBF rates in the post implementation phase. We will also assess its cost effectiveness to improve EBF
rates and reduce infant morbidity as compared to BFHI program alone. Cell phone counseling has the
potential for incorporation in national programs
to improve feeding practices.
This is an innovative intervention for improving
nutrition and health even in national
programmatic settings. Health personnel in India
have not been trained to provide support over
the phone, despite it being a timely and effective
tool to avert emergencies and reduce
unnecessary hospital visits. This method will also
promote public-private partnership and
encourage corporate social responsibility. It will
involve the family, which will assist in planning, implementing, and evaluating nutrition projects. This
method has never been assessed for nutrition counseling for infant feeding practices and also needs
evaluation of its feasibility, cost effectiveness, and sustenance.
The coverage, use, and penetration of cell phone use is increasing rapidly even in poorly accessible rural
areas, making it a valuable tool to obtain timely health advice especially when a visit to health center is
difficult. It can also be used for improved implementation of integrated management of neonatal and
childhood illnesses of the National Rural Health Mission in India.
ABOUT THE PROJECT IMPLEMENTER(S)
Lata Medical Research Foundation (LMRF) was established in 2000, and is dedicated to health research
and the consequent community development within the confines of the social responsibility, social cause
and ethics through team work and collaborations. It is a 600-bed, well-equipped government district
hospital with an annual antenatal clinic attendance of 10,000 pregnant women and 7500 annual deliveries
from urban and rural communities.
CONTACT INFORMATION
Dr. Archana Patel Vice President & CFO, Research Lata Medical Research Foundation(LMRF) 9/1, Vasant Nagar Nagpur Maharashtra 440022 India Email: [email protected]; [email protected] Website: www.latamedicalresearchfoundation.org Tel. 917122249569 Fax: 917122737091
Leena Dhande Associate Professor Pediatrics Indira Gandhi Government Medical College, Nagpur Government Central Avenue Road Nagpur Maharashtra 440018 India Email: [email protected] Tel. +919822467572 Fax. 917122737091
The project provides new mothers a
number to call for help, frequent
reminders, promotion messages, and
ring tones reinforce desired health
behavior, which overcome cultural and
physical barriers to leaving home after
delivery.
Page 34 of 48
NEPAL: NUTRITION THROUGH KNOWLEDGE According to WHO, malnutrition in Nepal is at crisis level. Nepal ranked last among 177 countries in terms
of proportion of children classified as underweight (UNDP, 2004). While aggregated malnutrition
indicators at national level show that nutrition status of children has improved slightly over the past years,
wasting, an indicator of acute malnutrition, has increased from 10 to 13% (DHS, 2006). This high
prevalence of malnutrition contributes to the high rates of disease and death in children, as well as to
their slowed physical, mental growth and development (NHD, 2004). If malnutrition can be reduced, child
mortality will be reduced by half. However, public awareness about this is severely lacking throughout
Nepal, including the capital, where chronic malnourishment rates of over 50% in children under age five
have been reported (NHDP, 2004). Though poverty is the main contributor to this situation, knowledge
among mothers on feeding practices is very limited. Children’s diets are less energy dense, lack diversity,
and less rich in vitamins and minerals than the diet of the household. Together with insufficient meal
frequency, children in most households do not receive an adequate nutrient intake in portions they can
digest. Mothers are unaware that the little food that they have access to can be prepared nutritiously.
(Terre des homes, 2005). Our project seeks to address the existing lack of awareness among parents
about nutritional requirements for children.
The major objectives of this project are (a) to raise awareness among parents about infant and young
child nutrition and its importance for the overall development of children, (b) to empower Nepali women
to address various socio-cultural determinants of malnutrition at the household level, and (c) to engage
men as key stakeholders and agents of change and advocates within families.
The project produces and broadcasts a
radio program called Mamata with an
objective of addressing the issues of
nutrition of children under five years of
age. It is a half-hour program, broadcast
weekly by 31 FM stations. Produced in
radio-magazine format, the program
highlights issues related to nutrition as
representative cases and invites experts to
discuss it. Similarly, the program also
includes monologues, people’s voices, and
interviews in view of giving voices to the
issues facing the community. Every
program includes success stories of male
parents who have contributed and/or
played a significant role in the nutrition of
their child. The radio listening groups are
formed in each project district, members
of which comprise both women and men.
The groups meet each week to listen to
the radio messages together and discuss
Page 35 of 48
the key issues with the assistance of a facilitator employed by the project. Few programs utilize targeted
communications to reach out to potential and existing parents on the importance of nutrition and about
existing services.
This project will utilize popular radio and focused outreach to provide parents vital information on Nepal’s
nutrition policy strategy, maternal nutrition, infant and young child feeding, and importance of exclusive
breastfeeding and supplementary feeding after 6
months. Messages targeting women and men on
issues such as women rights and gender equality
will prompt families, especially men, to ensure a
healthy physical and social environment for
mothers and young children. This unique
approach will address issues around household
power relations through effective communication, as men are usually the primary decision makers.
Nutrition and development needs of infants and young children are usually considered a woman’s domain
and this is a societal norm that needs addressing. Our approach will also promote discussion and dialogue
around topics broadcast, leading to changes in attitudes and perceptions.
ABOUT THE PROJECT IMPLEMENTER(S)
As a communications for social change organization established in 2004, EAN combines the power of
media with grassroots community mobilization to create customized communications strategies and
outreach solutions that address the most critical challenges affecting people in the developing world such
as women’s empowerment, youth life skills, livelihoods, microfinance, sustainable agriculture, human
rights, and healthcare.
EAN will work with community-based partners of Plan Nepal in four districts. The partner's responsibility
is to identify project groups, provide oversight for training, monitor listenership to program and outreach
activities; provide feedback and reporting, facilitate monitoring and assessment activities; and integrate
the radio program into their existing programs.
CONTACT INFORMATION
Binita Shrestha Program Director Sagun Basnet, Program Coordinator DBI, Equal Access Nepal,Jhamsikhel, Lalitpur PO Box 118, Lalitpur, Nepal Lalitpur, Kathmandu Nepal Email: [email protected], [email protected] Website: www.equalaccess.org.np Tel. +9779851119019 Fax: +97715013561
Plan Nepal Non-Governmental Organization (NGO) Website: www.plan-international.org/where-we-work/asia/nepal Tel. +97715535560 Kathmandu
Nutrition and development needs of
infants and young children are usually
considered a woman’s domain and
this societal norm needs addressing.
Page 36 of 48
INDIA: REDUCING MATERNAL STRESSORS TO ENHANCE
BIRTH WEIGHT AND INFANT SURVIVAL Life begins in the mother’s womb. The health of the mother has a direct bearing on the growing
individual. Any intervention to improve infant and child nutrition must not ignore maternal health, dietary
practices, and nutritional status. Though these parameters do catch the attention of practitioners and
policy planners, a vital aspect ignored is the stress factors during pregnancy that can influence pregnancy
outcome. In the Indian context, these psychosocial stressors assume greater significance in light of living
in joint families and the pressure to produce a male child. Recent reports highlight that India has not been
very successful in dealing with the problem of Low Birth Weight (LBW) births with 22% of newborns still
being LBW. Socio-cultural and psychological issues, if established as significant stressors, would
necessitate a shift from health and nutrition interventions for pregnant women to a more holistic
approach.
LBW contributes to high neonatal and infant mortality. Moreover, most LBW infants who survive have
little chance of fully reaching their growth potential. LBW of newborns is associated with impaired
immune function, poor cognitive development, and high risks of developing acute diarrhea or pneumonia
and as adults, LBW children face an increased risk of chronic diseases including hypertension, diabetes
mellitus, coronary heart disease and stroke. Therefore, any intervention targeted to enhance nutrition
during infancy should actually begin with the well-being of the mother and the newborn.
Maternal psychosocial stressors may have an adverse impact on fetal growth, resulting in LBW births.
Intervening to develop a positive state of mind and improve self-esteem will result in improvement in
nutrition practices, maternal health and improved birth weight of the newborn.
The innovation HAPPI (Healthy and Positive Pregnancy Initiative) will be designed to reduce stress during
pregnancy. HAPPI is a package that would include IEC material on nutrition, health and psychosocial well-
being during pregnancy. The intervention package will use multiple methods like theatre, role play,
developing jingles, yoga, and meditation and will also incorporate traditional Indian wisdom to build up
happiness quotient, a sense of well-being and optimism in the pregnant women.
The overall objective is to
systematically explore maternal
psychosocial stressors which may
impact neonatal health and survival
so as to enhance the nutrition and
health status of pregnant women
and intervene to develop positive
state of mind and improve self-
esteem.
The specific objectives include:
• To evaluate pregnant
women on sociocultural, health and
Page 37 of 48
nutritional profile, maternal personal resources and prenatal stressors.
• To develop and implement an innovative intervention package to address nutritional and
psychosocial well-being and reduce stress during pregnancy.
• To assess the effectiveness of the intervention in terms of pregnancy outcome.
• To determine associations between pregnancy outcome and sociocultural, health and nutritional
profile, maternal personal resources and prenatal stressors.
Any innovation to augment infant and child nutrition
would ignore the prenatal beginnings at its own
peril. The project is unique as it addresses the
concern of ensuring the well-being of the growing
fetus by not just focusing on the obvious nutrition
needs of the mother, but also the psycho-social and
cultural stressors that she faces which could have a
bearing on the birth outcome.
ABOUT THE PROJECT IMPLEMENTER(S)
A College of the University Of Delhi, the Institute Of Home Economics, was established in 1961 and offers
undergraduate degree in home science (with majors in human development, food and nutrition),
microbiology, biochemistry and elementary education. It offers post graduate and Ph.D. programmes.
Experienced faculty members are actively involved in research of national and international acclaim.
Manzil offers for slum children and women, preschool education, nutrition health education and
vocational training. The underprivileged youth receive opportunities for computer literacy, personality
development and life skills enhancement.
CONTACT INFORMATION
Dr. Seema Puri; Dr. Geeta Chopra Associate Professors Nutrition, Human Development Departments Institute Of Home Economics, University Of Delhi F4 Hauz Khas Enclave Delhi 110016 India Email: [email protected]; [email protected] Website: www. ihe-du.co.in Tel. 91-11-46018108 Fax: 91-11-26510616
Ravi Gulati Coordinator Manzil Welfare Society 13 Khan Market New Delhi Delhi 110001 India Email: [email protected], www.manzil.in Tel. 91-11-24618513 Fax: 91-11-29815857
Intervening to develop a positive state
of mind and improve self-esteem will
result in improvement in nutrition
practices, maternal health and
improved birth weight.
Page 38 of 48
PAKISTAN: HOME BASED NUTRITION REHABILITATION OF
SEVERELY MALNOURISHED CHILDREN In Pakistan, 38% of all children below five years of age (estimated >3 million children) are moderate to
severely underweight and 9.6% of children 6-24 months are moderate to severely malnourished. This
figure is higher in rural areas due to poverty, illiteracy, and a lack of awareness of mothers regarding
infant and young child feeding. Health facilities are lacking, and the ones present are located in towns and
cities far from the rural population.
According to initial WHO protocols, severely malnourished children should be managed in hospitals, but
given the limitations and the unfeasibility of admission of such large numbers of children for 4-6 weeks, it
is imperative to look for alternate home-based strategies. Community-based WHO protocol (CMAM)
suggests ready-to-use therapeutic foods to manage severe acute malnutrition, which are imported and
expensive.
After consultation with nutritionists, HELP (Health Education and Literacy Program) formulated an
indigenous High Density Diet (HDD), which is highly cost effective compared to the imported RUTF. HDD is
an indigenous and low cost diet comprising of rice, pulses, milk powder, oil, and sugar. Appropriately
packed, HDD has a shelf life of 6 months. This can replace high cost food supplements currently imported
by donor agencies for use in rehabilitation of malnourished children. HELP conducted a pilot study in a
peri-urban slum to determine HDD’s effect. The project was successful in all three of its objectives:
Improve nutrition of 90% identified children using HDD;
Counsel 90% mothers and family members of target households on key messages regarding
feeding of infants and young children through trained LHWs; and
Build capacity of
government health
facilities and their
personnel in target
areas in order to
stabilize severely
malnourished children
with complications.
The innovation is that home-
based directly observed therapy
(DOTS) to rehabilitate severely
malnourished children, using
indigenous and low cost HDD
for treating severe malnutrition,
is an alternative to standard
recommended WHO protocols.
The key project partner is the
government’s National Program
Page 39 of 48
for the Family Planning and Primary Health Care
that is run throughout the country and has Lady
Health Workers (LHWs) throughout the country.
ABOUT THE PROJECT
IMPLEMENTER(S)
HELP is a community-based primary health care and education program working in various slum areas of
Karachi and rural Sindh. Its chief focus is on the health care of women of reproductive age and children,
pertaining to nutrition, immunization and reproductive health. HELP’s team consists of highly committed
professionals.
National Programme for Family Planning and Primary Healthcare is a federal government funded project
covering all four provinces. Trained community health workers provide basic preventive health care to
mothers/children at their doorstep including growth monitoring of children and nutrition counseling.
CONTACT INFORMATION
Prof. Dure- Samin Akram Executive Director (honorary) HELP (Health Education and Literacy Program) 1-C, 3rd commercial street, Zamzama. Phase 6, Karachi Karachi Sindh 75600 Pakistan Email: [email protected]@post.com Website: www.helpngo.org.pk Tel. 0092215834465 Fax: 0092215834465
National Programme for Family Planning and Primary Healthcare (est. 1992) 14-D (West) Feroze Center Blue Area, Islamabad Pakistan Email: [email protected] Website: www.phc.gov.pk/sindh.php Tel. 051-9202289 Fax: 051-9215610
High Density Diet is an indigenous and low
cost diet consisting of rice, pulses, milk
powder, oil, and sugar.
Page 40 of 48
NEPAL: ACTION AGAINST MALNUTRITION THROUGH
AGRICULTURE (AAMA) Despite progress in reducing child/maternal morbidity, Nepal’s current infant and under-five mortality
rates remains some of the highest in the Asia-Pacific region. Additionally, the progress is spread unevenly
throughout the Nepal. The Nepal Demographic and Health Survey (NDHS) 2006 shows that in the Far
Western Region (FWR), the infant mortality rate stands at 74% while the under-five mortality rate is 100.
Malnutrition levels remain unacceptably high. Stunting or evidence of chronic malnutrition among
children under-five is 49% nationally and 52% in the FWR; wasting or evidence of recent severe
undernutrition peaks at 23% in children 12-24 months and rates in the Far Western terai are among the
highest. Anemia prevalence is extremely high among both women of reproductive age and young
children, at over 50%.
Feeding and care practices of young children combined with poor sanitation practices are a major cause
of poor nutritional status. The NDHS 2006 showed that 36% of children 6-9 months receive less than two
meals a day and 64% less than three food groups. The average duration of exclusive breastfeeding was
four months, short of the six month WHO recommendation, and upon introduction of complementary
food only 50% of children under 12 months of age consumed fruits/vegetables. In the FWR, year-round
household food security is a main obstacle to achieving optimum nutrition in young children and women.
Equally important, optimal feeding practices for improved nutrition, especially for infants, young children
and their mothers are under-utilized.
The major objectives of the Action Against Malnutrition through Agriculture (AAMA) project are to
improve the nutrition and health status of children under two years and pregnant and lactating women
and to increase the accessibility and availability of year round micronutrient-rich foods for consumption
by the target population groups. The main project strategies include (a) Essential Nutrition Actions (ENA),
(b) Homestead Food Production (HFP), and (c) Behavior Change. ENA covers breastfeeding,
complementary feeding,
maternal nutrition, nutrition
for sick child, and
micronutrient deficiencies.
Similarly, HFP include Village
Model Farms (VMF), home
gardens and poultry. BCC
include activities such
counseling and negotiations
skills, IEC and follow up.
By creating strong community
level linkages between these
sectors, households, individual
mothers, and children under
two will benefit through
improved household food
Page 41 of 48
consumption and nutritional practices. AAMA will use HKI’s proven HFP model that increases households’
year-round access to nutritious foods as a platform to deliver a package of Essential Nutrition Actions.
HKI’s HFP model is innovative: an improved, completely organic, diversified approach for increasing year-
round food production, targeting women as the primary beneficiaries and establishing community
capacity to sustain the program.
HKI’s experience with the ENA framework has
demonstrated positive impact on nutrition
behaviors and maternal and child health. The
intent is to disseminate key messages on seven
fundamental topics (breastfeeding,
complementary feeding, maternal nutrition and
more) using advanced BCC techniques through
multiple program pathways.
The AAMA approach will address food security and nutrition constraints simultaneously. It will teach
sound nutritional practices, develop and disseminate messages targeting traditional beliefs, and increase
year round food supply to enable such change. The program will provide marginalized/vulnerable groups
with the technical inputs/supplies they need to improve food supply and overcome malnutrition and
poverty together.
ABOUT THE PROJECT IMPLEMENTER(S)
Helen Keller International, established in 1915, is a private voluntary organization with expertise in
nutrition (including breastfeeding, complementary feeding, micronutrient supplementation, food
fortification, dietary diversification, nutritional surveillance, and nutrition and infectious diseases) and eye
health (including cataract, trachoma, onchocerciasis control, and refractive error). The agency has
programs in 23 countries.
Established in 1990, NNSWA is one of the leading development organizations in the FWR. Education, early
Childhood Development, Reproductive Health, Nutrition, Trachoma Reduction, Women's Empowerment,
and Advocacy constitute its core focus and expertise.
CONTACT INFORMATION
David Spiro Country Director-Nepal Helen Keller International PO BOX 3752 Green Block, Ward #10 Chakupat, Patan Dhoka Kathmandu Nepal Email: [email protected] Website: www.hki.org Tel. 977-1-5547359 Fax: 977-1-5547359
Ashok Jairu Executive Director Nepali National Social Welfare Association (NNSWA) Airport Road Bhimdutta Municipality Ward-# 18, Kanchanpur Nepal Email: [email protected] Website: www.nnswa.org Tel. 977-99-522182 Phone: 977-99-523805
Creating strong community level
linkages between sectors, allows
households, mothers, and children
under 2 benefit from improved
household food consumption and
nutritional practices.
Page 42 of 48
INDIA: SOCIAL CAPITAL AS A CATAPULT FOR IMPROVING
INFANT FEEDING Infant feeding is the most effective intervention in improving the health of children. A recent study as part
of The Lancet Maternal and Child Undernutrition Series estimated that sub-optimal breastfeeding,
especially non-exclusive breastfeeding in the first 6 months of life, results in 1.4 million deaths and 10% of
the disease burden in children younger than five years old. Breastfed infants show better cognitive
development, good weight gain and neurological development, particularly in premature and term
infants.
In India, breastfeeding is practiced universally in rural as well as urban areas. However, there continue to
be reasons why there is no exclusive breastfeeding for first six months, as recommended. These reasons
are linked to the mother’s health and nutritional status, socio-cultural practices and also beliefs and
rituals concerning “purity” and “impurity.” Only 27.8 % of the infants in Gujarat are breastfed within one
hour of delivery, and exclusive breastfeeding for first six months is lower than 30%. Thus there are still
gaps in the evidence-based practices due to possible lack of knowledge and strong age old practices
percolated by elders in the family who defy scientific knowledge.
AKHS,I seeks to design specific interventions in improving infant feeding practices (breastfeeding,
colostrums feeding and complementary feeding) working on the concept of social capital which is an
integral part of rural communities. Social capital can be considered as the resource of community that is
built over a period of time, through the networks of participation, group membership, shared norms, trust
and most importantly a feeling of ‘belonging’.
The project seeks to
improve knowledge,
attitude and practices
related to infant feeding
by providing adolescent
girls, mothers and
grandmothers of infants
with accurate information,
thus dispelling their myths
and misconceptions. The
target groups for this
project are pregnant and
lactating women. As
grandmothers exert
considerable influence in
the care of the newborn
and children, they form
the secondary audience of
the project to help
promote recommended
Page 43 of 48
behavior and discourage traditional practices which are harmful to the child. Adolescent girls are also
form a secondary target group to sensitize future mothers as well as reinforce practices among young
mothers in their communities. The project area comprises seven villages in Malia block of Junagarh
district in Gujarat.
Social capital is particularly relevant to addressing the issue of infant feeding since the practices are to a
large extent influenced by traditional beliefs and
customs rather than medical recommendations. The
project seeks to involve the support and participation
of the key influencing members in a baby’s life – the
mother and grandmother. Unlike conventional
programs addressing infant nutrition in a ‘top down’,
informational manner, this project tries to engage
communities in combining scientific knowledge using
traditional communication mediums. Using the tool of
social capital, the techniques of discussions and
personal stories will be used since health related decision making is not just information-linked, but also
linked to other socio-cultural factors. The village as a community will be encouraged to address the
problem along with adolescent girls (‘future mothers), ‘present mothers’ and ‘past mothers’.
Participation by adolescent girls entails influencing decision making of future mothers. Close observation
and involvement in the whole process of infant care will give them a greater sense of critical thinking and
responsible decision making. Furthermore, recognizing the significance that older women have as health
advisors and decision makers, they have been included to play a pivotal role. Seeking their participation
and equipping them with correct information will help to create an enabling environment for mothers to
adopt correct infant feeding practices.
Thus the project works with current, future and past mothers, seeking a holistic, sustainable lifecycle
approach to addressing the issue. This is the outcome-linked innovation of the project. The process-linked
innovation lies in use of existing communication channels of women to discuss and act upon a critical
issue.
ABOUT THE PROJECT IMPLEMENTER(S)
Aga Khan Health Service (AKHS) was established in 1986 as part of Aga Khan Development is an
international non-profit organization. AKHS, India focuses on promoting effective, sustainable healthcare
of underserved populations, especially women and children in Gujarat.
CONTACT INFORMATION
Dr. Sultan Pradhan Chairman Community Health Division Aga Khan Health Services, India Diamond Complex, 3rd floor, 39/43 Nesbit Road, Mazgaon, Mumbai Maharashtra, India 400 010 Email: [email protected]
Dr. Sulaiman Ladhani Program Director Email: [email protected] Tel. 912266139630 Fax: 912266139670
The techniques of discussion and
personal stories will be used since
health related decision making is
not just information-linked, but also
linked to other socio-cultural
factors.
Page 44 of 48
BANGLADESH: EMPOWERING WOMEN AND ADOLESCENTS TO
IMPROVE INFANT AND YOUNG CHILD NUTRITION Bangladesh has the second highest rate of child malnutrition in South Asia with 41% of children below 5
years underweight (BDHS, 20007), and it is slightly higher in Chittagong division at 43%. High malnutrition
rates are largely due to suboptimal infant and young child feeding (IYCF) practices and frequent illness.
While almost all children are breastfed, delayed initiation of breastfeeding, pre-lacteal feeding, non-
exclusive breastfeeding, bottle feeding and inappropriate complementary feeding (either early or late) are
common and contribute to malnutrition, which peak between 6-12 months. Despite efforts by
governmental and other agencies, exclusive breastfeeding rates for infants below six months has
stagnated at around 40% for last 15 years. Mixed (breast and bottle) feeding is common in urban and
rural areas and is generally not discouraged by health workers. Skilled support for breastfeeding is almost
non-existent. Community-based IYCF promotion activities are conducted through the National Nutrition
Program but cover only about 20% of the country.
The idea is to prevent malnutrition by improved quality and intensity of counseling on complementary
feeding (CF) in addition to exclusive breastfeeding (EBF), promotion of culturally acceptable and
affordable complementary foods and micronutrient powder for enriching diets of infants and young
children 6-24 months where needed; and by involving adolescents and community members—fathers,
grandfathers, influential men. Adequate knowledge and motivation levels for specific actions needed to
improve CF are weak. The project has trained community women as peer counselors (PCs) who provide
individual home visits from the third trimester of pregnancy until infants are one year old to improve IYCF.
PCs have demonstrated impact on EBF, and will be able to use the same techniques to promote and
support complementary feeding. They will encourage timely and appropriate access and utilization of
health care, good sanitation and hygiene. PCs are well accepted in the community, are monitored and
receive supportive
supervision.
The innovations of this
project include: a) PCs
trained to promote
complementary feeding
effectively; b) cell phones
for communication c)
adolescent girls trained to
promote IYCF, computers
provided to group leaders;
d) influential local
community leaders are
actively involved - for
suggestions, support,
advocacy, and “buy in;” and
e) referral linkages are
established with health
Page 45 of 48
facilities/organizations.
The project’s holistic community approach goes beyond the short term DM project phase for each of the
following innovative ideas:
• Empowering female community-based peer counselors to support appropriate complementary
feeding, and sustainable household and health-seeking behaviors – with cell phones for
communication and referral between the
community and health facilities;
• Informing and involving fathers in buying
diverse foods, child care, responsive feeding and
parenting, and involving influential men in the
community in order to change social norms about
infant nutrition for sustainability;
• Empowering adolescents to understand the importance of appropriate nutrition for themselves
and for young children, and be responsible for IYCN promotion in some households by,
- ensuring adolescents are already knowledgeable about IYCF BEFORE they become parents –
and utilizing their abilities to promote IYCN; and
- providing computer assisted learning – CAL for adolescents – in addition to basic computer
literacy - as an incentive to join the adolescent groups and promote IYCF; and
• Establishment of referral linkages with health facilities and NGOs to promote and support IYCF, and
provision of affordable health services tailored to urban and rural needs.
ABOUT THE PROJECT IMPLEMENTER(S)
A non-profit organization formed by dedicated professionals established in 2000, TAHN aims to improve
the health, nutrition and well-being of communities by empowering and enabling them. TAHN supports
PCS for IYCF and nutrition, trains government and non-government health workers, community
volunteers, undertakes strategy development, evaluation of programs, and conducts relevant research.
Plan Bangladesh (BD) was established in 1994 and aims to ensure basic needs of children, adolescents,
women and men, advocating community participation and ownership for social development, health,
learning and family economic security. Plan BD has an advisory role for TAHN, focusing especially on their
experiences of working both with other NGOs and with government health services providers on
adolescent reproductive health, and on ensuring community participation and ownership.
CONTACT INFORMATION
Dr Rukhsana Haider Chairperson Training And Assistance For Health And Nutrition House 15, Rd 128, Gulshan-1 Dhaka 1212 Bangladesh Email: [email protected] Website: www.tahn.net Tel. +8801715034902
Edward Espey Country Director Plan Bangladesh House 14, Road 35, Gulshan-2 Dhaka 1212 Bangladesh Email: [email protected] Website : www.plan-international.org Tel. +8802-8826209 Fax: +8802-9861599
Bangladesh has the second highest
rates of child malnutrition in South
Asia with 41% children below 5 years
underweight.
Page 46 of 48
INDIA: ADDRESSING IRON DEFICIENCY ANEMIA IN RURAL
RAJASTHAN THROUGH IRON FORTIFICATION OF FLOUR Iron deficiency anemia (IDA) is one of the most common nutritional disorders, and it has a profound effect
on psychological and physical development, work performance, and, as a result, on productivity. A study
conducted in 2002-03 by Seva Mandir and Massachusetts Institute of Technology found 80% of women,
51% of men and 90% of children are anemic. The study showed that the principal reason for high anemia
is poor dietary intake of iron. There is lack of iron rich foods in the region and efforts to improve anemia
through supplemental tablets have failed due to very low intake rates in these areas. Iron
supplementation of foods is an attractive alternative as it requires no additional effort on the part of the
consumer, and can be done relatively cheaply in centralized locations. However, for very poor and
isolated population, such as the population in the tribal district of Udaipur, centralized food fortification is
not a practical solution: most households consume their own grain, and do not purchase any goods that
could easily be fortified. Even households who obtain wheat or maize from the Public Distribution System
obtain whole grain, which cannot be fortified. Fortification of commercialized food would thus leave
marginalized households behind, which would be particularly unfortunate given that they are likely to be
the most at risk for IDA. This project is designed to provide the option for iron supplementation for
households who do not buy processed food (including flour), and can therefore not be targeted by
centralized fortification.
The project aims at addressing anemia among the general population with special focus on pregnant
women and children aged 0-24 months by increasing the intake of iron through fortified flour and by
educating the mothers and pregnant women on nutrition and feeding practices.
The key innovations of the project are the decentralized delivery system and equipment for fortifying
flour. The fortification equipment (a hand operated blender) designed at the local level is also very easy to
handle and involves very simple
technology. The program is designed to
provide the option for iron
supplementation for households who do
not buy processed food (including flour),
and can therefore not be targeted by
centralized fortification. The other
innovative idea of the project is to
complement education with actual
availability. The key implementation
strategies of the project are:
Mapping of village mills and
meeting with villagers to select mills for
fortification;
Training of millers and provision
of fortification equipment along with
instruction manual; and
Page 47 of 48
Training of village volunteers for educating and counseling pregnant women and mothers of
children aged 0-24 months on nutrition during pregnancy, breastfeeding and weaning practices,
and the use of fortified wheat flour.
Fortification of flour by mill owners. The millers are provided with pre blend on a fixed date every
month. Considering the extra workload on account of fortification activities, the millers are paid
certain amount based on their performance (higher the production of fortified flour, the higher
the fee amount).
Special meetings and counseling of pregnant women and caregivers of children is another
strategy involved in the project to ensure continued consumption of fortified flour.
In the past, we tried to address nutritional deficiency through awareness-raising interventions; these
awareness interventions alone have been unsuccessful in achieving this goal. Thus, through the project,
increased awareness about anemia through education will be coupled with the tangible fortification
strategy to achieve a drop in overall anemia rates, specifically among women and children aged 0-24
months. Alongside the project, the TBAs and Bal
Sakhis will focus on education on exclusive
breastfeeding for children under six months to
lactating mothers. While children aged 6-12
months will get their iron requirement from
weaning food prepared using fortified flour; for
adults including pregnant and lactating women and
children aged 12-24 months, chapattis made out of
fortified flour will be a source of increased iron
intake. The project design will include strategies to ensure that the families keep fortifying their flour so
that the additional iron intake is there for a consistently long time.
ABOUT THE PROJECT IMPLEMENTER(S)
Seva Mandir was established in 1968 as a non-profit organization based in Udaipur district of Rajasthan,
reaching out to over 626 villages and 56 urban slum settlements. Seva Mandir’s work entails creating
social, institutional and livelihood base for a democratic and participatory approach to development that
benefits and empowers the poorest sections of society.
CONTACT INFORMATION
Neelima Khetan Chief Executive, Health Unit Seva Mandir Seva Mandir, Old Fatehpura Udaipur Rajasthan 313004 India Email: [email protected], [email protected] Website: www.sevamandir.org Tel. 912942451041 Fax: 912942450947
Ms. Priyanka Singh Programme in Charge-Health & Education Email: [email protected]
Iron supplementation is an attractive
alternative that requires no additional
effort on the part of the consumer and
can be done relatively cheaply in
centralized locations.
PHOTO CREDITS
Front Cover: Deepak Foundation; Aga Khan Health Services, India; Helen Keller International, Inc.; Ziagul, Kakan Village
Afghanistan, May 14, 2010; Helen Keller International, Inc.; Sri Lanka Green Friends Environmental Organization; Dr. Reddy's
Foundation; HELP (Health Education and Literacy Program; Training And Assistance For Health And Nutrition, Bangladesh
Page 6: Ziagul, Kakan Village Afghanistan, May 14, 2010
Page 8: World Bank
Page 10: Society for the Elimination of Rural Poverty
Page 12: Dr. Reddy's Foundation
Page 14: Sri Lanka Green Friends Environmental Organization
Page 16: World Bank
Page 18: World Bank
Page 20: World Bank
Page 22: Vijaya Development Resource Center
Page 24: MaxPro Pvt. Ltd.
Page 26: Deepak Foundation
Page 28: World Bank
Page 30: Community Health Sciences Department, Aga Khan University, Karachi, Pakistan
Page 32: World Bank
Page 34: World Bank
Page 36: Institute Of Home Economics, University Of Delhi
Page 38: HELP (Health Education and Literacy Program)
Page 40: Helen Keller International, Inc.
Page 42: Aga Khan Health Services, India
Page 44: Training and Assistance For Health And Nutrition, Bangladesh
Page 46: Curt Carnemark, World Bank, 1996, India
Back cover: Sri Lanka Green Friends Environmental Organization
.
The World Bank 1818 H Street, NW Washington, D.C. 20433 USA Program Manager: Animesh Shrivastava Telephone: +001-202-473-3652 Internet: www.worldbank.org/safansi
Email: [email protected]