93531 SAFANSI The South Asia Food and Nutrition Security Initiative IMPROVING NUTRITION IN COMMUNITIES THROUGH BEHAVIOR CHANGE: THE SUNAULA HAZAR DIN PROGRAM IN NEPAL Over the past 15 years, food insecurity and in order to improve nutritional outcomes for chronic undernutrition have declined in Nepal; children during these first 1000 days.3 however, households still remain trapped in a cycle of poverty and hunger. Twenty-five percent The project began in 2013 with two objectives: of households are “food poor”—i.e., the total (1) to introduce a results-based community value of their food consumption is insufficient mobilization approach to improve nutrition in to ensure a basic diet. Nearly half of children selected pilot areas of the SHD Project; and (2) under five years of age suffer from chronic to improve nutrition outcomes at the ward level undernutrition and its long-term consequences by sensitizing communities to the importance (about 1.6 million children out of an estimated of nutrition in the first 1000 days to build their total population of 3.5 million). Nationally, about capacity to manage their own nutrition outcomes 41 percent of children under the age of five are and to demand appropriate services from stunted, 29 percent are underweight, and 11 government. The Rapid Results Institute, an percent are wasted.1 international organization that has developed the Rapid Results Initiative (RRI), was contracted to The prevalence of chronic under-nutrition among support this pilot in four different Wards. infants under six months of age, and the fact that more than fifty percent of children are stunted by Thirty-eight percent of children under 2 years the time they reach two years of age, highlights of age in the SHD project area are chronically the importance of targeting interventions during malnourished and 33% are underweight. Sunaula Hazar Din, or the first 1,000 days, from About 518,000 children under five years the prenatal period through pregnancy and the of age suffer from acute undernutrition, first two years of life.2 or wasting, and have a heightened risk of morbidity and mortality. Severely wasted Fighting Malnutrition through Sunaula Hazar children are 5 to 20 times more likely to die Din than their well-nourished counterparts. To address the issues of food and nutrition insecurity in Nepal, the World Bank has provided Interventions focus on the risk factors that support to the Sunaula Hazar Din- Community influence nutritional outcomes during this Action for Nutrition Project (SHD) Project with critical period. These arise from a combination funding from the South Asia Food and Nutrition of individual and community level knowledge, Security Initiative (SAFANSI). Sunaula Hazar Din attitudes, and practices (KAP). They include (SHD) translates into English as the “first 1000 such practices as inadequate food intake days” and refers to the period between conception during pregnancy, smoking during pregnancy, and 24 months of age, when children are most insufficient intake and absorption of nutrients, vulnerable to malnutrition. The overall objective lack of knowledge about the nutritious value of of the SHD program is to enable Nepal to develop foods and which foods are required at specific better knowledge, attitudes and practices (KAP) October 2014 South Asia Region Figure 1 Child Malnutrition in the SHD Project Area 100 80 60 38 33 40 21 20 0 Stunting Wasting Underweight Sources: WHO/WFP/UNICEF/SCN Community-based Management of Severe Acute Malnutrition: A Joint Statement by the World Health Organization, World Food Programme, The United Nations System Standing Committee for Nutrition and the United Nations Children Fund, May 2007. Figure data come from Development Impact Evaluation (DIE), Baseline Report, Nepal Sunaula Hazar Din Community Action for Nutrition Project (SHD-CANP), June 2014, 25 times, including pregnancy and early childhood, (the district development committees and the poor sanitation practices, poor economic and village development committees). The work social access to food and poor feeding practices plan and budgets are approved by the local for children. government and released to the communities. Communities execute their plan, aiming to Community-wide supply-side factors are also achieve their goal within 100 days. At the end important - for instance the availability and of the cycle, the coach (and sometimes also cost of appropriate foods is problematic in an outside monitor) assesses whether or not many districts, and poor access to safe drinking the goal has been achieved. If the community water and poor hygiene and sanitation practices has been unsuccessful, it can apply for another affect the disease burden of communities and cycle to try to achieve the same or another goal. nutrition, particularly of young children. Cultural If the community has been successful, it can practices also perpetuate the intergenerational subsequently apply for two additional goals at problem of malnutrition. In this context, the once. SHD Community Action for Nutrition Project aims to target these risk factors to improve Figure 2 SHD implementation steps child and maternal nutrition in Nepal. Assess Implement results The SHD Approach Approve program plan The RRI process was implemented in four wards. Develop and release Select from work plan SHD communities form a “Rapid Results for and budget budget Form a menu of Nutrition Initiative” team comprising between community interventions 8 and 10 individuals. Each team is assigned a team “coach” from within the community, who helps the team select one goal from a menu of 15 Measuring Impact “focus areas.” The coaches are recruited from local NGOs and the coaches assigned to the In addition to financing work in SHD-CANP, Village Development Committees (VDCs) are SUNITA is financing an impact evaluation that from that VDC, and are trained by the RRI. The will be carried out in collaboration with the focus areas cover a variety of factors affecting Government of Nepal to draw lessons for other nutrition: health practices of pregnant mothers, programs. The evaluation will measure the food intake of children, sanitation facilities, age effectiveness of SHD-CANP and explore what of marriage, etc. The community develops a mechanisms contribute to its success. The detailed work plan to help achieve their selected impact evaluation team and the government are goal and the budget required to execute the work identifying key evaluation questions to explore, plan, which they submit to the local government which include: 2 1. What is the overall impact of SHD-CANP on to how to maintain the momentum generated outcomes such as child nutritional status, through this process. nutritional knowledge, and social cohesion? While these pilots did not see an immediate 2. To what extent does the rapid results continuum into the next cycle of 100 days, the approach improve outcomes over a more RRI initiatives will now be rolled out in a phased traditional project approach? manner in 15 districts under the project, and 3. How do the effects of SHD-CANP compare will enable individual Wards to undertake more to the effects of the cash transfer program than one 100-day plan, and thereby support as currently in use in the Karnali zone and that community to address the malnutrition for Dalits? problem. Other lessons include: 4. Does incorporation of results from the “community district malnutrition profiles” Let’s Play a Game: Measuring Trust in affect community decisions and program SHD Communities outcomes? Trust and trustworthiness were measured by The evaluation will also try to measure the a trust game played between two people from impact of social capital on the effectiveness the same communities. In the game, one of SHD (see box). SHD-CANP takes a Rapid of the players becomes a “sender” and the Results Approach where communities were other a “receiver,” but neither of them knows encouraged to select goals and formulate plans who the other player is. Both the sender and to achieve those goals. This makes social capital the receiver get 12 rupees to start, and the a critical factor that affected the outcome of sender decides how much of his 12 rupees to the project. To measure the social capital in send to the receiver. Triple the amount sent the sample, the evaluation baseline used a by the sender will be given to the receiver, combination of interview/survey and behavioral and the receiver will decide how much to games to indirectly assess and quantify trust, send back to the sender. The amount sent altruism, collective action, and social cohesion by the sender serves as a proxy for the trust in the survey. level towards community members and amount sent back by the receiver indicates Lessons Learned the trustworthiness level. It was determined The RRNI pilot in four wards (of two Village that trust and trustworthiness level is on Development Committees/municipalities) was average slightly higher in the Hill and Inner successfully completed in February 2014 and Terai than in the Terai.4 follow on funding will extend the work until 2017. The most significant lesson learned from this Coaching played a very important role in initiative was that through the Rapid Response the behavioral change process. The Rapid Approach, it is possible to achieve nutrition Results for Nutrition Initiative (RRNI) created relevant results in a short period of time (100 teams of 8-10 people, led by a coach who days). RRI process facilitated each of the four helped to prioritize and set a goal for the team. wards to select an Essential Nutrition Action— Participants required constant encouragement two selected Sanitation/Open Defecation Free and supervision monitoring, which showed status, the other two selected animal protein what an important role community leadership intake (eggs) by pregnant mothers and children played in the success of the RRI. Until the aged 6-24 months. At the close of the 100 days, project commenced, there hadn’t been each Ward had achieved their goal and discussed much engagement with the community and plans for sustaining the behavior change and constructive feedback had been limited. At tackling future challenges, including issues as the end of the project, there was much greater 3 collaboration between teams, team members, and coaches at the district level. Never make assumptions about what is important to a community. The project implementers were repeatedly surprised by the types of interventions that received high demand. For example, upon learning that exposure to indoor air pollution (smoke from cooking and cigarettes) is dangerous to pregnant women, several teams chose to act on the problem. Similarly, the implementers assumed there would be cultural resistance to using latrines for better sanitation and to eating eggs and providing better nutrition Team members and community beneficiaries meet at the local school (Rapid Results Institute) to women and pregnant women, but demand was huge. Conclusion More action is required to identify and overcome SHD-CANP made communities active participants cultural resistance. Of the issues addressed, in solving the problem of malnutrition, particularly the most difficult proved to be postponing first as it applies to the first 1000 days. The lessons marriage and the age of first pregnancy, as learned from this effort have informed the well as advocating for girls to stay in school— project’s Operational Manual and have indicated this was not a priority for communities. More that such community-driven initiatives, given research and rigorous analytical work on the right support, can yield desired results. If cultural resistance to these issues is needed. the impact evaluation shows significant impact For example, is it the opinion of the coaches or on targeted knowledge, attitudes, and behaviors the community that girls should go to school, and on selected nutrition indicators, then the or delay marriage? Do the communities see project will have provided a model for community the connection between malnutrition and early mobilization in favor of improved nutrition that marriage and child-bearing? could be replicated elsewhere. Partners SA FANSI Administered by: 1 UNICEF. 2014. State of the World’s Children. http://www.unicef.org/sowc2014/numbers/documents/english/SOWC2014_In%20Numbers_28%20Jan.pdf 2 National Planning Commission Central Bureau of Statistics, Nepal Thematic Report on FNS 2013, 6. 3 Development Impact Evaluation (DIE), Baseline Report, Nepal Sunaula Hazar Din Community Action for Nutrition Project (SHD-CANP), June 2014, 6. 4 Development Impact Evaluation (DIE), Baseline Report, Nepal Sunaula Hazar Din Community Action for Nutrition Project (SHD-CANP), June 2014, 41. This results series highlights development results, operational innovations and lessons emerging from the South Asia Food and Nutrition Security Initiative (SAFANSI) of the World Bank South Asia region. Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development / The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.