Understanding undernutrition and its determinants at the district level:

The POSHAN District Nutrition Profiles

Purnima Menon with Abhilasha Vaid, Shruthi Cyriac, Suman Chakrabarti, Parul Tyagi, Aparna John and Neha Kohli

IFPRI, New Delhi

April 25, 2015

POSHAN is supported by the Bill & Melinda Gates Foundation

The state of nutrition in Bihar

Source: NFHS-3 (2005-06)Current nutrition situation remains unknown

What factors cause undernutriton?

Source: Gillespie et al. 2013

The most crucial period for child nutrition is from pre-pregnancy to the second year of life

What factors have led to improvements in undernutrition over time?

Global

(Smith & Haddad, 2014)

• Women’s education

• Sanitation

• Household assets

• Food security (energy and non-energy)

Brazil

(Monteiro et al., 2010)

• Equity in all underlying determinants

• Income

• Antenatal care

• Assets

Bangladesh

(Headey et al., 2014)

• Asset accumulation

• Antenatal care

• Fertility

• Decreasing open defecation

• Agricultural growth

Photo: P. Menon, UP, 2013

What does this mean for policy and programs?

Essential nutrition-specific

interventions to improve

essential actions within home

and community:

FeedingCare

Hygiene

Supportive environments at home and in communities through linking up with key sectors that are already

ramping up programs:

Social safety nets (PDS, MNREGA)Sanitation

Family planningSecondary education

Economic growth must continue because it has the potential to put

more resources in the hands of families.

Critical question is how to put in place *at the same time* and at the same place, for the same mother-child dyad* the conditions at both the underlying and

immediate levels to reach adolescents, women and children?

DISTRICT NUTRITION PROFILES (DNP): AN ATTEMPT TO PACKAGE DATA TO SUPPORT STRONGER DECENTRALIZED ACTION

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District Nutrition Profiles (DNP)

• Draw on diverse sources of data to compile a set of indicators on the state of nutrition and its cross-sectoral determinants

• Aim to “bring people on the same page” about extent, causality and actions areas to address undernutrition• Serve as conversation –

starters

Indicator types

• Nutrition outcomes– Stunting; Underweight; Wasting; Anemia;

Underweight among women

• Determinants of undernutrition– Immediate

• IYCF practices; Immunization & supplementation; Disease burden; Adolescent & maternal health

– Underlying• Women’s status; WASH; Food security; Socio-economic

conditions

– Basic• Adult literacy rate• Access to services

AN EXAMPLE FROM GAYA, BIHARDEVELOPING DNPs

The nutrition situation

Data based on rural populationNO DATA AVAILABLE TO MAKE COMPARISONS!

^Children aged <5years; ^^Children aged <6years

Source: DLHS-2 (2002-04); NFHS-3 (2005-06); HUNGaMA (2011)

Anything on change?

Immediate determinants

22.2%18.6%

35.7%

48.3%

97.4% 98.5%

16.0%

31.0%

60.7%

10.0%

41.4%

51.8%

97.1% 99.2%

Early initiation ofbreastfeeding

Exclusivebreastfeeding

Children between6-8 mo whoreceived any

solid/semi solidfood in the last 24

hrs

Children between6-23 mo who

achieve minimumdiet diversity

Full immunizationcoverage

Children 12-35mo) who got

vitamin Asupplementation

Any anemiaamong adolescent

girls

Any anemiaamong pregnant

women

Gaya Bihar

Infant & Young Child Feeding Immunization & Supplementation

Adolescent & Maternal Health

NO DATA AVAILABLE TO MAKE COMPARISONS!

Source: DLHS-2 (2002-04); NFHS-3 (2005-06); DLHS-3 (2007-08); Census (2011)

Underlying determinants

NO DATA AVAILABLE TO MAKE COMPARISONS!!!

NO DATA AVAILABLE TO MAKE COMPARISONS!!!

Source: NFHS-3 (2005-6); DLHS-3 (2007-08); HUNGaMA (2011); Census (2011)

Basic determinants

Source: DLHS-3 (2007-08); Census (2011); NSSO (2011-12)

A vast landscape of schemes to address immediate, underlying and basic causes

Immediate

• ICDS

• NHRM

• Use of Jeevika platform to strengthen health and nutrition behavior change

Underlying

• Beti Bachao (2015); Mukhyamantri Kanya Suraksha Yojana (2007); CM’s bicycle program for girls’ education

• National Food Security Act programs – PDS, MDM, others; Agriculture programs

• NRLM; Jeevika

• Swachh Bharat Mission (2014)

Basic

• Financial inclusion programs

• Economic growth efforts

• Infrastructure investments, including housing programs

• Agriculture subsidies, price policies

Challenges in developing District Nutrition Profiles

• Multiple data sources for indicators

• Temporal issues– Data collected from different reports; data collection years vary

• Indicator definitions

– Some definitions had to be altered slightly to the data available. • Ex: Vitamin A supplementation, for instance, used data for children aged 9 to 59

months in one official report and data for children aged 12 to 23 months in another.

• Sampling differences– Some of the data sources provided only rural data and used smaller samples

• Data skills– Some data, e.g., on food security and diet diversity, require the use of unit-level

information from large, complex data sources such as National Sample Survey Organization data.

Experiences with use of District Nutrition Profiles indicates that facilitated dialogue at district-level can help build understanding of nutrition challenges,

potential solutions and immediate actions. But, it is a long process!

District-level consultation in Unnao, Uttar Pradesh

District-level consultation in Keonjhar, Odisha

Source: poshan.ifpri.info

Next steps in Bihar

• Refine indicators in the district nutrition profiles

• Develop profiles for all districts in Bihar

• Engage with Bihar nutrition technical support unit and other partners to strengthen district-level dialogue and action using nutrition profiles

Photo: P. Menon, W. Champaran, Bihar, Aug 2013