Odisha’s progress in nutrition:

multiple drivers of change

Neha Kohli

With

Rasmi Avula, Mara van den Bold, Elisabeth Becker

Purnima Menon, Lawrence Haddad, Nick Nisbett

Focus for the Odisha study

- Odisha recognized as a high performing state on mortality reductions and nutrition

- Survey data and our own operations research on nutrition service delivery had highlighted high coverage of nutrition-specific interventions

- The focus of the Odisha study, therefore, was to understand what factors had contributed to change in outcomes and scale up of key health and nutrition interventions

Methods

Developed a 25 year timeline (1991-2015)

Elements of the timeline Sources

• Nutrition outcomes• Immediate determinants• Coverage of nutrition-specific

interventions• Underlying and basic determinants• Policies and programs

• National Family Health Surveys• Rapid Survey on Children • National Sample Survey

Organization (NSSO) • Odisha economic surveys • Desk review of policies and

programs • Stakeholder interviews

Community-level interviews in Kalahandi

1990-1995 1995-2000 2000-2005 2005-2010 2010-2015

Progress in most immediate

determinants

0

10

20

30

40

50

60

70

80

1992-93 1998-99 2005-06 2013-14

Women with body mass index<18.5

+Children (<3 years) breastfedwithin 1 hour of birth (%)

Children (<6 months)exclusively breastfed (%)

Children receiving solid/semi-solid food and breast milk (%)

Children (0-59 mo) withdiarrhea in the last two weeks(%)

Children (<5yr) with diarrheain the last 2 weeks whoreceived ORS (%)

Progress in most Nutrition- Specific

Interventions

0

10

20

30

40

50

60

70

80

90

100

1992-93 1998-99 2005-06 2013-14

Women received/bought iron folic acidsupplements during pregnancy (%)

Mothers who had 3+ ANC visits for last birth(%)

Mothers who had antenatal care during firsttrimester (%)

Receipt & use of ICDS supplementary nutritionduring pregnancy (%)

Births in a health facility (based on last 2 birthsin three years prior to survey) (%)

Births assisted by a health professional in lastthree years

Receipt & use of ICDS supplementary nutritionduring lactation (%)

Children (12-23 mos) fully immunized (%)

Children (12-35 mos) who received vitamin A -last 6 months (%)

Receipt & use of ICDS supplementary nutritionfor children (%)

Community-level changes mirrored

changes in nutrition interventionsPregnancy care

– “Not going to any hospital…….

there were no facilities then, like

there are now….. How could I go?”

“Nothing like that.....no

injection....no medicine.....nothing

was there at that time”.

– “They (pregnant women) are not

dying now”. “Anganwadi offers

everything” Place of delivery

-“Now ASHA facilitates everything....., but no one was there to help back then.... I gave birth to four children... All of them at home only”

Progress in literacy, infrastructure, food

security

Of concern: Sanitation & early marriage in

girls

0

10

20

30

40

50

60

70

80

90

100

Early 1990s Late 1990s Mid 2000 Late 2000 onwards

% of monthly per capita foodexpenditure in rural areas

% of people buying rice from PDS

% of households with access tosafe drinking water

% of households with access totoilet facilities

% Literacy

% Female literacy

% women (15-19 yrs) whoreceived at least secondaryeducation% of women (20-24yrs) marriedby age 18

Poverty headcount ratio

Vision, catalysts, implementation strategies in

place for health & nutrition

Elements Health and Nutrition

Clear vision IMR & MMR reduction

Delivering interventions through multiple platforms

Integrated Child Development Services & Health worked with a common goal

Catalysts, champions, and ownership

- Poor mortality ranking- Human Rights Commission- Political support - Motivated bureaucracy- Development Partner and Civil Society

support

Pathways for scaling up - Expansion of platforms- Frontline workers expansion- New platforms

Operational capacities, financing, enabling

policy and learning environment for health &

nutritionElements Health and Nutrition

Building strategic and operational capacities

- High caliber bureaucrats appointed- Transparency in hiring FLWs- Training of the FLWs- Development partner support

Adequate, stable, and flexible financing

- Financial restructuring- Central funding

Enabling policy environment - Chief Minister leadership- Bureaucratic stability- Supportive national policies

Measurement, learning, and accountability

- Periodic program reviews- Surveys

Other programs and factors influencing

nutrition determinants

Food security interventions have a similar story of scaling up but not sanitation

Gender: Early to kick off women’s empowerment programs [but note less on early marriage/pregnancy]

Infrastructure:

• Road connectivity improved Rural electrification but distribution problems exist

• Drinking water facilities improved but issues of contamination exist

Agriculture and livelihoods: Invested in irrigation and mechanization

• Struggles over land access and migration remain challengesCommunity-level changes mirrored some of these perceptions

Key takeaways: Enablers of change in

nutrition

• State vision and goal

• National policy guidance

• Investment in social sector

programs

• Stable and able

bureaucracy

• Political leadership and

politics

• Improvement in

infrastructure

• Support across

stakeholders

Challenges and Looking ahead

Stunting levels are still high (34%), gaps in complementary feeding and use of IFA during pregnancy. Inter-district variability across outcomes and determinants persist. Hence a need to:

• Strengthen existing system & technical capacities for further scale up of nutrition interventions• Invest in quality improvements

• Engage with other government departments to improve underlying determinants of nutrition: WASH, education, land rights

• Capitalize on high level support to social sector

Thank you!