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For maximum effectiveness, nutrition-related action must be fully integrated into the health system, health strategy and health budget of a country.

2.2 Improving nutrition through water/sanitation/hygiene

Attaining the target of MDG 7c – to halve the proportion of people without sustainable access to safe drinking water and basic sanitation – is critical to the attainment of the nutrition indicator of MDG 1. Sanitation, hygiene and water interventions primarily act to impact undernutrition by preventing diarrhoea and other enteric diseases (see Zimbabwe case study on diarrhoeal disease research in separate file). The greatest nutritional gains in this area are likely to be made by investing in sanitation and hygiene promotion. A review of data from eight countries found that improvements in sanitation were associated with increases in height ranging from 0.8 – 1.9 cm.42

Contributions to this aspect of undernutrition include:

  • Water/sanitation/hygiene policies and programmes

  • Health care (primary health care or child health) and hygiene promotion

  • Infrastructure (water treatment and delivery/distribution, sanitation, treatment of wastewater and reduction of pollution of water resources)

  • Rights to water and reducing inequalities in access to water (e.g. increase coverage of water distribution mechanisms, introduce technology that will increase access to water for poor households and reduce women’s workload);

  • Regulations to ensure water providers meet standards (equitable pricing, water quality, efficiency);

  • Monitoring and evaluation systems include nutrition-relevant indicators.

Box 3: Key indicators for nutrition benefits through water/sanitation/hygiene

(see also impact indicators given in Box 1 and more information on indicators in Annex 3)

  • Availability of soap

  • Use of improved drinking water sources

  • Distance to the nearest water point

  • Use of improved sanitation facilities

Water/sanitation programmes can improve nutrition (e.g. by prioritising areas where undernutrition and/or diarrhoeal diseases are highest), and should seek to measure the impact of interventions in terms of nutritional outcomes.

2.3 Improving nutrition through education

Chapter 1 highlights the importance of nutrition during early childhood for later educational attainment. The education sector also plays an essential role in reducing undernutrition in a sustainable, long-term and equitable manner. There is an inter-generational effect of undernutrition whereby improvements in women’s education are linked to better nutritional outcomes for their children, by improving care practices, strengthening economic prospects and delaying the first pregnancy. Survey results show a much lower prevalence of undernutrition amongst children whose mothers attended secondary school compared with those with no schooling or primary education only. For instance, the risk of child stunting is about 2.5 times lower in Burundi, half in Laos and more than 4 times lower in Niger when the mother attended secondary school compared with no schooling.43

Possible contributions to this aspect of undernutrition include:

    • Curriculum - introducing nutrition and growth; family planning, pregnancy and infant feeding and hygiene promotion into existing programmes;

    • Teacher training – on enhanced curricula;

    • Enrolment - promoting enrolment and improving attendance, especially for girls;

    • School management - incorporating health and nutrition services in schools’ calendars, such as immunisation campaigns, de-worming, family planning, ensuring adequate facilities (e.g. sanitation);

    • Community-based approaches - using children or civil society groups to promote appropriate nutrition practices at household and local levels.

School feeding programmes have been popular solutions in an attempt to improve health, growth and educational performance. However, evidence44 indicates that these programmes have a limited impact on nutrition. For this reason, the often substantial investments in school feeding under nutrition budget lines are frequently criticised for their nutrition outcomes. Moreover, food provided under these schemes is not targeted at the crucial window of opportunity for intervention i.e. from conception to two years of age.

Box 4 Key indicators for nutrition benefits through education

(see also impact indicators in Box 1 and more information on indicators in Annex 3)

    • Girls’ school attendance and academic attainment (e.g. secondary school net attendance ratio for girls, literacy rate among young women)

    • Nutrition in the curriculum

Education programmes that seek to improve long-term nutrition should address the proven benefits of policies that promote the enrolment and education of girls.

2.4 Improving nutrition through gender

Gender analysis focuses on the different roles and responsibilities of women and men and how they affect society, culture, the economy and politics. Such analyses find that women have disproportionately less access to, and control of, resources than men. Women are too often marginalised in their families and communities, suffering from a lack of access to credit, land, education, decision-making power and rights to work.

Nutrition is intricately linked to women’s biological, economic and social roles, influencing their own and their children’s nutritional status. Women are the main care providers for infants and young children, therefore ensuring women have the means and time to breastfeed and provide adequate care is essential to reducing undernutrition. As economic actors, women contribute to household food security and livelihoods (see the separate file on the Asia case study on homestead production). Gender-balanced access to opportunities and control over resources benefit the nutrition status of the entire family.

Possible contributions to this aspect of undernutrition include:-

  • Prioritising women’s nutrition in maternal and reproductive health policies;

  • Incorporating a gender dimension in agricultural policies to enhance nutrition outcomes;

  • Improving female access to education;

  • Gender-sensitive social protection policies (e.g. targeting support to pregnant and lactating women to relieve their economic burden during the later stages of pregnancy and the breastfeeding period, or providing child care support to enable women to work);

  • Legal frameworks which protect women’s rights (e.g. land inheritance rights, workplace policies supporting breastfeeding);

  • Reducing the time burden on women by improving infrastructure (such as feeder roads to markets, health facilities or water systems closer to communities) (see Laos case study on analysis in separate file).

Box 5: Key indicators of nutrition benefits through gender

(see also impact indicators given in Box 1 and more information on indicators in Annex 3)

  • Individual Dietary Diversity Score among women of childbearing age

  • Girls’ school attendance and academic attainment (e.g. secondary school net attendance ratio for girls, literacy rate among young women)

  • Adolescent fertility rate

The social position and empowerment of women is crucial to underpin nutritional success. Furthermore, recent analyses highlight the critical importance of investing in women’s nutrition to achieve lasting benefits across the generations

2.5 Improving nutrition through social protection

Social protection policies or programmes are developed in response to levels of vulnerability, risk and deprivation. Of the many social protection measures (such as legal frameworks to protect citizens’ rights or health insurance), there is increasing evidence – from Brazil, Malawi, Mexico, Nicaragua, South Africa, for instance - that social transfers can play a significant role in reducing undernutrition (see Mexico and Peru case studies below; and Brazil case study in separate file). Social transfers are non-contributory,45 publicly-funded, direct, regular and predictable resource transfers (in cash or in kind) to poor and vulnerable individuals or households. Their aim is to reduce their deficits in consumption, protect them from shocks (including economic and climatic), and, in some cases, boost their productive capacity.

Social transfer schemes can help reduce undernutrition in several ways.

First, they can be a tool to reduce inequalities and address economic income poverty at household level. This is of paramount importance as undernutrition and poverty tend to be closely interrelated. By addressing income poverty and the economic determinants of undernutrition, social transfers can have an impact on the three underlying causes: increasing access to food and dietary diversity, improving quality of care for women and children and increasing access to health care.

Second, these schemes can be a means to deliver ‘nutrition-specific’ action, such as the distribution of food supplements to pregnant/lactating women and young children.

Third, they can help establish links to other services – health in particular –needed to improve the nutritional status of women and young children. The transfer can be on condition that recipients (especially women) attend health centres, as is often the case in Latin America.

The 2008 Lancet Series on Maternal and Child Undernutrition concluded that Conditional Cash Transfers can be effective46 in helping improve nutrition (see Annex 5).

Possible contributions include:

  • Prioritising maternal and child benefits;

  • Prioritising areas or populations worst affected by undernutrition and addressing disparities;

  • Adapting the design of social transfers, e.g. exemption from labour requirements for pregnant and lactating women (see Ethiopia case study on the Productive Safety Net Programme in separate file) or by rapid disbursement of cash/vouchers in emergencies (See Niger case study – cash transfer in a context of a food crisis – Chapter 4);

  • Establishing links with other programmes and services (e.g. health) by encouraging attendance or considering setting a condition for the transfer that requires service attendance;

  • Adapting the nature of the social transfer, e.g. providing food supplements as well as cash;

  • Taking into account households’ purchasing power and the cost of a balanced diet when setting the amount of the transfer.

Mexico: The Oportunidades programme47

Mexico’s Oportunidades (formerly called PROGRESA) is an example of a multi-sector poverty alleviation programme that has had a successful impact on undernutrition. Its main objective is to develop human capital by improving education, health and nutrition for its population.

Started in 1997, the programme initially served 300 000 households in 11 rural states. By 2007, coverage reached over 5 million households from all 31 of Mexico’s states, with a total budget of 3.7 billion US$.

PROGRESA was initially financed by domestic funds but later attracted international funding.

The nutrition component of Oportunidades includes a cash transfer to women equivalent to 20 % of average monthly household expenditure. Women receive the cash payment on condition that they attend health services. The latter were reinforced by the programme and include health/nutrition education sessions. In addition, the programme provides fortified food supplements to pregnant and lactating women, children aged 6 to 23 months and children 24 – 60 months with a low weight for their age.

An evaluation conducted in 2008 examined the impact of the programme over its first 10 years. In general, the prevalence of stunting fell significantly in the seven states assessed from 1998, on average falling by ten percentage points (p.110). However, stunting persisted in all of the states, with a higher prevalence in the south of the country (36.3 %), among indigenous populations (33 %), highly marginalised and very highly marginalised (37.2 %) communities and among the poorest households (32 % vs. 14.1 % in the least poor).

The prevalence of anaemia among beneficiary children in 2007 (35.8 %) was nearly half that reported in 1999 (61.0 %), although a similar reduction was also observed among non-beneficiary children (64.7 % in 1999 and 35.2 % in 2007). However, an earlier evaluation of the programme, conducted between 1997 and 1999, showed that children who benefited from PROGRESA, compared with the control group that entered the programme one to two years later, had a lower incidence of anaemia by over 10 %.

All of the analyses demonstrate a strong association between economic well-being and the prevalence of stunting and anaemia. However, some of the most important likely direct causes of undernutrition among children - specifically inadequate breast-feeding and complementary feeding practices - continue to be a challenge. For example, over 50 % of children aged below two years were introduced very early on (at one month of age) to liquids and milks other than breast milk.

The evaluation discovered that the supplement targeting young children (6-24months) did not have the desired impact because other family members were consuming much of it instead.

Oportunidades is widely considered a successful model and it has been replicated and adapted in several Latin American countries. A key characteristic of the Conditional Cash Transfers is that they aim to address both the immediate and long-term aspects of poverty. For instance, by tackling maternal undernutrition and stunting amongst children under the age of two, they aim to break the intergenerational cycle of malnutrition.

The box below contains only indicators that have specific added value to nutrition. They are intended to complement social protection indicators essential to nutrition such as indicators of purchasing power (context-specific) and households’ ability to cover basic needs (e.g. ability to cover the cost of a balanced diet).

Box 6: Key indicators of nutrition benefits through social protection

(see also impact indicators given in Box 1 and more information on indicators in Annex 3)

  • Minimum dietary diversity (6 – 23 months)

  • Minimum acceptable diet (6 – 23 months)

  • Individual dietary diversity score (women of reproductive age)

  • Breastfeeding is continued throughout the first 12 months of life

Social transfers and social protection measures provide essential support to poor and vulnerable individuals and households. They are therefore an effective means of reaching the groups most likely to be suffering from, or at risk of, undernutrition.

2.6 Improving nutrition through food security

Food security is defined as a situation when

all people at all times have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life’48

This implies the need to consider food security beyond national and household levels and understand the situation and constraints faced by individuals.

Contributions to this aspect of undernutrition are relevant in emergency and development contexts and include:

Policies and governance:

  • Promoting comprehensive policy frameworks to tackle undernutrition and hunger;

  • Including nutrition objectives and indicators (e.g. food intake/diet quality and anthropometry) in monitoring and evaluation systems for policies, programmes and projects (See Mali case study – Applying a nutrition lens to food security projects, in separate file);

  • Including nutrition-related indicators in Food Security Information Systems and early warning systems;

  • Food policy reforms (subsidies, prices, trade, agriculture-sector investments) and pro-poor policies designed to address disparities in a sustainable manner.

Social and economic measures:

  • Cash and other social transfers (including food) to increase access to food including in emergencies: see possible contributions for social protection, paragraph 2.5, see Niger case study – cash transfer in a context of a food crisis (in Chapter 4), see also Kenya case study - An integrated programme to improve diet, food security and livelihoods, (Chapter 2)

  • Income generation and improving access to financial services for the poor

  • Equitable access to labour opportunities for poor households (e.g. establishment and enforcement of legal frameworks that protect the poor in labour markets, support for alternative forms of employment)

  • Empowerment of women as key agents to improve household food security, health and nutrition outcomes

  • Agriculture – (see possible contributions for agriculture, paragraph 2.7);

  • Natural resources management – (see possible contributions for natural resources management, paragraph 2.8)

  • Market interventions – facilitating physical and/or economic access (including investments in rural infrastructure such as feeder roads)

  • Equitable access to productive assets (e.g. livestock, means of transport)

  • Improving community resilience against future shocks through asset creation and better early warning systems

  • Promoting local production of specialised products that meet quality standards

Although food security programmes can have significant nutritional benefits, they usually achieve better results, in particular for children, when combined with action addressing other determinants of child nutrition (like maternal health and care-giving practices) (see Bangladesh case study – A nutrition-oriented livelihood project in separate file). Whatever strategy is chosen, attention needs to be paid to the potential negative side effects of food security programmes on nutritional status – especially where women are targeted and yet are also expected to be the primary carers for young children. This highlights the need for a robust situation analysis and on-going monitoring to make informed decisions on interventions. Corrective measures can be incorporated to overcome obstacles, such as providing time and space for breastfeeding in public works or agricultural programmes; or distributing impregnated bed nets alongside surface irrigation schemes to prevent increased malaria.

See list of key indicators of nutrition benefits through food security and agriculture in box 7 below.

Food security programmes need to consistently measure nutritional outcomes and identify actions that work according to context.

Kenya: Diversifying diets through livestock and market based interventions

In the North Eastern Province of Kenya, increasing climatic hazards coupled with conflicts and displacement have a devastating impact on local livelihoods. Destitute herders that have lost their animals turn to casual labour or petty trading like the collection of firewood to eke out their living. These dramatic changes result in loss of direct access to animal products, lower purchasing power and thus had a serious impact on family diets.

In such context two NGOs with specific expertise and longstanding experience in the region (Vétérinaires Sans Frontières on pastoralism and markets, and Save the Children on nutrition and voucher systems) combined their efforts. A series of initial assessments into milk market, household economy, malnutrition causes and restocking initiatives led to designing an integrated programme that brought together nutrition, health, food security and rural development.

The aim was to diversify vulnerable children's diets through a voucher system while also effectively supporting the local economy. The vouchers were exchangeable for milk, meat products in local markets as well as beans.

The overall programme design built on other existing initiatives that complemented the voucher system (fodder production, regional market support, etc.) and included support to line ministries activities (Ministry of Arid Lands, Ministry of Health).

Overall the programme succeeded in:

a) Increasing direct consumption of protein-rich food amongst vulnerable households and their children through vouchers, combined nutrition education, training in child feeding and care practices;

b) Supporting the local economy by increasing the income pastoral households could generate through animal products sale, and through direct support to their production and marketing systems: training on milk management, husbandry, support to animal health services, enhanced fodder production, etc.

c) Improving the overall availability and quality of animal products in local markets which contributed, amongst others, to extend the shelf life and the hygiene conditions of safer milk products, thus improving also the economic returns of traders (including women traders).

Source: This case study is based on the Final Impact Evaluation of the Livelihood Element of ECHO Funded Reducing the Impact of Drought (RID) Programme

2.7 Improving nutrition through agriculture

In addition to its traditional focus on food and cash-crop production, agriculture holds considerable potential to help achieve broader national objectives of reducing poverty and undernutrition. By putting more focus on nutrition outcomes, agriculture will address a critical, recurring, constraint: low labour capacity and productivity due, in part, to the poor health/nutrition status of the agricultural workforce.

Agriculture can improve nutrition in several ways:

  • improved diet (quantity and quality) – by increasing household consumption of own food produced and diversifying production;

  • reduced income poverty – by selling own produce or agricultural labour/employment – with a potential knock-on effect on the quality of the diet, access to health services and care;

  • empowerment of women as income-earners, decision-makers and primary child care-providers;

  • lower food prices for consumers through increased food production and availability;

  • higher national revenue, which can be used to improve state services.

Despite the above, the impact of agricultural policies and programmes on nutrition is not always clear. First, agricultural programmes are not necessarily designed with a nutrition objective in mind and hence are not assessed by that criterion. Second, even those that do have nutrition objectives tend to have mixed results. However, evidence49 shows that interventions promoting increased production of fruit and vegetables (homestead gardens in particular) and animal food products50 have considerable potential to address micronutrient deficiencies – not least because such programmes are more likely to include nutrition objectives. This evidence shows gains in production, income, household food security, dietary intake and fewer micronutrient deficiencies as a result of the interventions, especially when combined with other components - education, behaviour change and women’s empowerment. Nevertheless, the potential benefits of agricultural programmes that focus on the production of energy-rich staples are also very likely to help reduce undernutrition (such as maternal undernutrition) but the evidence simply is not there, yet. 

Possible contributions to this aspect of undernutrition include:

Policies and programmes

  • Explicitly incorporating nutrition objectives in policies and programmes;

  • Designing strong monitoring and evaluation systems and reporting on nutrition and food intake/diet quality indicators in addition to production figures and staple food availability;

  • Increasing collaboration with other sectors and joint programming (e.g. establishing links between agricultural extension and health services for activities such as communication and information systems). This is especially important in emergencies;

  • Empowering women, strengthening their roles as economic actors and creating an enabling environment for child care;

  • Prioritising areas or groups (e.g. smallholders or agricultural labourers) worst affected by undernutrition;

  • Controlling for potential negative impacts on nutrition (e.g. increase in food-borne or water-borne diseases, or in women’s workload to the detriment of child care).

Conducive natural resource management

  • Securing access to land (e.g. land use rights) and other productive resources (e.g. water) for poor or marginalised groups (e.g. ethnic minorities, emergency-affected populations, pastoralists depending on the context);

  • Adaptation to the effects of climate change (e.g. to the foreseen reduction in water availability in Sub Saharan Africa);

  • Risk mitigation and management of climatic shocks and natural hazards (e.g. droughts, floods, pests).

Conducive investments and services

  • Facilitate equitable access to financial services for smallholders, including the poor;

  • Increasing investment for the production and consumption of fruit and vegetables (micronutrient-rich plants) alongside staple crops (see Asia case study – Diversifying diets through homestead production, and Asia case study – Counting on beans for nutrition, in separate file);

  • Increasing household access to and consumption of animal products through strategic support to the livestock and fishery sectors (e.g. facilitating access to milk for households who do not own cattle, increasing livestock ownership while ensuring environmental sustainability) (see East Africa case study – The impact of fodder trees on milk production and income, in separate file);

  • Increasing the productivity of small-scale farming through good agricultural practice (e.g. improving soil fertility, control of soil erosion, water conservation);

  • Supporting storage and processing methods to reduce post-harvest losses and increase profit margins;

  • Fortifying basic foods, including bio-fortification (e.g. bio-fortification of sweet potatoes in vitamin A. See Nigeria case study - Public/Private Partnership in Fortification).

The box below contains only indicators that have specific added value to nutrition. They are intended to complement household level food security and agriculture indicators essential to nutrition, such as indicators of purchasing power (context-specific), proportion of food needs met through own production or the proportion of expenditure on food.

Box 7: Key indicators of nutrition benefits through food security and agriculture

(see also impact indicators in Box 1 and more information on indicators in Annex 3)

  • Minimum dietary diversity (6 – 23 months)

  • Individual dietary diversity score (women of reproductive age)

  • Consumption of iron-rich or iron-fortified foods (6 - 23 months)

  • Minimum acceptable diet (6 – 23 months)

  • Iodisation of salt

Agriculture can and should be an effective way to improve nutrition. The sector should therefore consistently incorporate nutrition indicators in programme design, and nutrition criteria in evaluations. Regardless of the specific entry point, nutrition training andawareness-raising is necessary for agricultural workers and decision makers to understand the links and work towards achieving them.

2.8 The environment and sustainable management of natural resources

Environmental changes (e.g. urbanisation, loss of natural resources and biological diversity) affect key determinants of nutrition wellbeing. For instance, climate change with its higher frequency and severity of extreme weather events (e.g. droughts, floods) alters:

  • Access to food which is imperilled by droughts, water scarcity and floods. According to IFPRI, ‘by 2050, the decline in calorie availability will increase child malnutrition by 20 % relative to a world with no climate change’.51

  • Health status with diarrhoeal diseases is expected to increase and some infections likely to spread to new areas.

These changes will particularly affect those who are less able to adapt, threatening already strained livelihoods, deepening poverty and increasing undernutrition. It is essential that action prioritises those most affected by undernutrition: women, young children and the poorest households.

Moreover, ‘the nutritional status of populations, as a recognisable and measurable outcome, should help direct other scientific disciplines and intervention programs in identifying sustainable solutions to the environmental and economic problems facing global communities.’52

Possible contributions to this aspect of undernutrition include:

  • Restoring or enhancing natural resources (e.g. rangeland rehabilitation, re-vegetation of stream banks);

  • Securing ownership, access and management rights to land (e.g. forests, rangelands) and other productive resources for poor or marginalised groups (e.g. ethnic minorities, emergency-affected populations);

  • Pro-poor, efficient and integrated management of water resources including controlling for potential negative impacts, such as an increase in water-borne diseases;

  • Risk mitigation and management of water-related shocks (e.g. droughts, floods, extreme forms of water insecurity) through adequate infrastructure – storage and flood control, for instance;

  • Supporting adaptation to the effects of environmental changes (e.g. climate change);

  • Strengthening early warning and nutrition surveillance systems;

  • Increasing collaboration with other sectors and joint programming to increase households and communities’ resilience. This is especially important in emergencies;

  • Monitoring and evaluation systems include nutrition relevant indicators.

The box below contains only indicators that have specific added value to nutrition.

Box 8 Key indicators of nutrition benefits through environment and the sustainable management of natural resources

(see more details on indicators in Annex 3)

  • Minimum dietary diversity (6 – 23 months)

  • Minimum acceptable diet (6 – 23 months)

  • Individual dietary diversity score (women of reproductive age)

2.9 Improving nutrition through governance

Governance denotes the rules, processes and behaviour by which interests are articulated, resources are managed and power is exercised in a society and the state’s capacity and will to serve its citizens. Governance programmes tend to address public functions, public resource management and the exercise of public regulatory powers, democratic control and participation.

Regarding nutrition, the power and voice of poor people, and the state’s accountability towards them, are important aspects of the environment where nutrition improvements are being sought. Quantitative and qualitative methods are required to identify and learn whether institutional and governance arrangements can improve the capacity, responsiveness and accountability of the state and civil society to generate improved nutrition outcomes.

Poor governance is often associated with a state’s failure to meet the fundamental rights of its citizens, including nutrition (see Section 2.10). It constitutes a major impediment to development, as it limits the choice of aid modalities that donors can responsibly apply (budget support programmes are precluded in nations with poor governance indicators).

The increasingly prominent role played by the private sector in nutrition is recognised. This ranges from concerns about marketing practices linked to infant feeding through their role in transport and logistics to current debates on food processing and new products.

Contributions to this aspect of undernutrition include:

  • Information and transparency: ensuring access to nutrition information53 in public affairs; strengthening food and nutrition surveillance systems;

  • Civil society inclusion: participation of civil society in planning nutrition strategies;

  • Budget: monitoring expenditure likely to yield nutrition benefits;

  • National policies: including nutrition objectives and indicators in national strategies and policies; developing national action plans on nutrition; nutrition incorporated in national emergency plans, attention to governance, government leadership and institutional arrangements concerning nutrition strategies/plans;

  • International instruments establishing the right to adequate nutrition as a basic human right;54

  • Accountability of the state to fulfil their responsibilities and promises;

  • Improving the implementation of the International Code on Marketing of Breast-Milk Substitutes;55

  • Coordination with civil society, international and private sector organisations (e.g. assess the private partners’ comparative advantage and make it available to local actors; identify effective nutrition champions in different stakeholder groups);

  • Carrying out research and testing that new products meet European standards.

(See India case study below; and Yemen Governance case study in separate file) 

India: The Dular Strategy: a grassroots programme to reduce undernutrition

The “Dular Strategy” was implemented across the Indian States of Bihar and Jharkhand from 1999 to 2005 (Dular is the Hindi word for ‘love and ‘care’). It was initiated by UNICEF in collaboration with the Indian state authorities as a nutrition programme that capitalised on grassroots community resources. The emphasis was on neighbourhood-based “local resource persons” who tracked the health status of women and of children up to three years of age. The main goal of the Dular Strategy was to empower the family and the community to make positive changes in health-related behaviour, so as to address undernutrition among women and children and reduce anaemia among adolescent girls. It was implemented in specific areas of Bihar and Jharkhand where the ICDS was working (the Government’s Integrated Child Development Service programme).

Key objectives:

  • To create a ‘working together environment’ for ICDS and health teams through innovative capacity building strategies at the district level

  • To establish State-level monitoring systems for care behaviour, malnutrition and micronutrient deficiencies

  • To prevent and reduce malnutrition and micronutrient deficiencies among children and women

  • To reduce or eliminate entrenched cultural and behaviour practices that undermined nutrition

  • To create learning opportunities for pre-school children between three and six years of age

  • To reduce nutritional anaemia for adolescent girls through micronutrient supplements

  • To monitor and improve health and nutrition-related indicators for women and children

Implementation strategies:

  • A life course approach to the care of children under three

  • Ensuring that girls and women of reproductive age had access to adequate nutrition, health care and information about child care throughout their lives, especially the period from conception to two years

  • Mobilising communities and training community members to disseminate information and encourage healthy behaviour and practices

  • Initiating a ‘Village Contact Drive’ where participatory methods and demonstrations were used to enhance awareness and behaviour change by the community

  • Introducing a new cadre of volunteers - local resource persons - to assist the health workers (AWW)

  • Counselling households on issues related to health and nutrition

  • Regular weighing of children

  • Setting up a mobile team to monitor progress and provide on-the-job guidance to village teams

  • Instituting a District Support Team to improve coordination between sectors, review overall progress and ensure effective implementation across the district

  • Setting up a taskforce at the State level to assess and develop communication/training needs

Villages were divided into Dular and non-Dular villages. Non-Dular villages received services normally provided by ICDS, including standard prenatal counselling and well-baby checkups. Dular villages received the services from ICDS plus they had a team of local villagers trained to be health workers responsible for consistent contact and follow-up. Key issues they covered included maternal nutrition, the need to feed infants colostrum, and breastfeeding.


The 2005 evaluation indicates:

® A significantly lower underweight rate in Dular villages (55.5%) compared to non-Dular villages (65.4%).

® A significantly lower rate of stunting in the Dular villages (61.8%) compared to non-Dular villages (72.0%).

® Dular villages had a significantly higher rate of colostrum feeding (84%) than the non-Dular villages (64%).

® The median age of introduction of complementary foods did not differ significantly between the two groups and remained high at eight months.

® Wasting was not found to be statistically significantly different.

® There was a widening gap between malnutrition rates in Dular villages as compared to non-Dular villages, indicating that over time the interventions became increasingly effective.

Lessons learnt:

The decentralised Local Resource Group was perhaps the strongest element of the Dular project. The monitoring was very intensive. It needed rigorous and regular monitoring not only of Local Resource Groups but also of programme activities in general. Given appropriate guidance and support, the health workers were effective in bringing about behavior change in mothers and family members.


The Dular Strategy demonstrates that intensive support and extensive use of inter-personal communication techniques played an important role in securing positive outcomes. Village health committees or local community-based groups could undertake the role that local support groups had in Dular, so that the potential for scaling-up is feasible.

Box 9 Key indicators for nutrition benefits through governance

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