93527 SAFANSI The South Asia Food and Nutrition Security Initiative PROMOTING POSITIVE NUTRITION BEHAVIOR IN BIHAR, INDIA This brief describes a small pilot designed to leverage the women’s self-help group platform of a World Bank- supported Livelihoods project (i.e., a non-health sector project) to: a) promote positive nutrition and health behaviors; and b) to improve, especially amongst poor and vulnerable households, the demand for and utilization of public services across many sectors to improve nutrition outcomes. The design of the pilot has been completed and implementation has recently begun. While there exists central and state government programs in almost every sector, they tend to function in their own silos and are not optimally leveraged to contribute to nutrition and health improvements. (World Bank) There are several implementation challenges that constrain the full impact of the programs, and desired services, girls’ education and gender issues. Since improvements in nutrition and health outcomes have malnutrition is a multi-sectoral problem, it requires a been elusive. Demand for services by communities, multi-sectoral solution. Furthermore, the engagement especially amongst those in greater need, is sub- of communities with a range of programs that offer optimal, either due to a lack of awareness about nutrition services (nutrition-specific or direct nutrition entitlements or due to their constraints in accessing services and nutrition-sensitive or those services that services. This, combined with the challenges on the influence nutrition outcomes) is important to improve program and provider side to reach the most needy and demand for and utilization of such services. This pilot vulnerable, leads to poor utilization of nutrition, health, is based on using a Bank-supported project platform sanitation, food security programs. Moreover, there is in a non-health and nutrition sector to leverage entry limited coordination between these different sectoral points and opportunities to improve nutrition. programs, so that services across a set of programs that offer – both nutrition-specific and nutrition-sensitive Jeevika’s Multisectoral Nutrition – services that could potentially contribute to nutritional Convergence Pilot improvements. Jeevika, which is the Bihar Rural Livelihoods Project, is implemented by the Bihar Rural Livelihoods Promotion Using a Multisectoral Approach to Address Society and the State Rural Livelihoods Mission in Malnutrition Bihar, which promotes rural livelihoods to enhance The determinants of malnutrition lie across multiple social and economic empowerment of the poorest sectors which require a multi-sectoral approach. and most marginalized women on a large scale. The immediate causes of under nutrition relate to Community groups and the project’s federations have food and nutrient intake and to health, whereas the been institutionalized to give them collective voice, underlying causes are affected by issues such as space, and resources to address their needs and lack of access to clean water and sanitation, health priorities. Jeevika is committed to improving health, October 2014 South Asia Region nutrition, and sanitation outcomes in the communities Dissemination of these messages is through where it implements its project, building on and one-to-one and one-to-many communication strengthening its existing initiatives and starting new approaches using and leveraging existing and nutrition sensitive interventions. It has developed the developing appropriate tools, materials and Jeevika Multisectoral Nutrition Convergence Pilot with resources. The community cadres support and technical support from the World Bank. The purpose work with local service providers for BCC during of this pilot is to promote behavior change related home visits, group meetings and community to maternal and child nutrition, health, hygiene and events. sanitation practices, improve food security as well as ii. Household Food and Nutrition Security. With a to facilitate interface between community institutions view to enhancing the food security of vulnerable and local service providers from government programs households, the existing Food Security Fund through a community based convergence approach to (FSF) provided through Jeevika will be expanded generate demand and utilization of services to improve to increase the availability of foods from diverse nutrition outcomes. The pilot targets the poorest and groups amongst poor, food and income insecure most vulnerable households with a special focus on households targeted by the project, including pregnant and lactating women and children below two those with pregnant women and young children. years. Pulses, oil and other food items will be added to the basic food basket of cereals and made The pilot includes the following nutrition-specific and available to the target households as required, and nutrition-sensitive interventions from across multiple at a reasonable cost in 3 to 4 tranches through sectors: the year. Kitchen gardens will be promoted i. Behavior Change Communication (BCC) on and universalized to ensure availability of fresh nutrition, health, water and sanitation. The vegetables and seasonal fruits for consumption in BCC promotes awareness on key nutrition, the daily diet of targeted households. Emphasis will health and sanitation messages and facilitates be on food availability and nutrition counseling for adoption of these behaviors through community intra-household consumption of food especially by groups and village organizations. Capacity of pregnant women and young children. In addition, community cadres and staff to understand, Jeevika Sahelis1 will facilitate participation and influence and drive change in behavior is built. contributions from mothers with young children (6 Messages specifically focus on the key behaviors to 24 months of age) to encourage them to prepare to be adopted during pregnancy and the first and feed suitable locally produced nutrient dense two years of life (the window of opportunity foods to their children below two years. to improve nutrition) and include appropriate feeding and caring practices for pregnant and lactating women, infants and young children, and 1 The JeevikaSahelis (JSs) are the nodal persons who implement the those related to health, hygiene and sanitation. activities at the village level and are supported by the VO to plan, implement and coordinate activities. Figure 1 below illustrates the multisectoral approach for improving nutrition in this pilot. MATERNAL AND CHILD NUTRITION IMMEDIATE CAUSES Interventions Breast feeding, Complementary feeding, Food/Nutrient Intake Health Status hygiene INTERMEDIATE CAUSES Interventions Health Service, Food Security, Water and Access to Maternal Nutrition, Sanitation and Women’s Empowerment and Availability of and Child Care Water, Sanitation Nutritious food Practices and Health Services UNDERLYING CAUSES Interventions Poverty Reduction, Livelihood Program, Institutions Political & Social Resources Governance, Organizational Capacity & Economic Structures People Environmental Safeguards 2 iii. Institutionalize Convergence and v. Promote Gender Equality and Strengthen Coordination. The pilot will promote Women’s Empowerment. Gender cuts across coordination, collaboration and convergence all components of the pilot. It further enhances between community village organizations Jeevika’s women’s empowerment efforts and local service providers for greater mutual through enhanced awareness, understanding, accountability and support. Consultations with participation, access to resources and in decision district leadership and respective departments making. This will further contribute to improving have taken place to get their buy in to enable the capacity of women to better meet their institutionalization of coordination at village, nutrition, health and sanitation needs, as well as block and district levels. Further consultations for their family and community. with these external stakeholders allowed a shared understanding on the pilot and ways to operationalize coordination. Village Coordination Committees including local service providers such as ASHAs (accredited social health activists), auxiliary nurse midwives, Anganwadi workers, panchayat reps, school teachers, others and village organization representatives will be instituted to foster building trust, confidence and close working relationships between community and service providers. The village coordination committees will plan, implement and monitor activities related to health, nutrition and sanitation through monthly meetings, make progress and problem solve as they go along. These A community organization meeting.(World Bank) committees will be linked with similar Block and Lessons Learned District Coordination Committee to problem-solve and monitor progress. The following lessons have been learned from the iv. Sanitation Component. The pilot will generate design phase described above. As the project is awareness and demand-seeking behavior currently in the early implementation phase, lessons among the community by motivating households from implementation are not yet available. to stop open defecation (ODF) and to build • Experience has shown that it is relatively easier and use safe toilet facilities. The approach is to to include nutrition interventions within projects make safe sanitation a habit and simultaneously of other sectors projects during the design promote toilet construction. The pilot allows for stage. Getting commitment, ownership, and community mobilization rather than focusing on incorporating structures and resources(human individual households for creating demand for and financial) for nutrition actions into the project toilets. Furthermore, demand generation and results in integration of these into overall project toilet construction will go hand-in-hand. This structures and implementation arrangement, approach is different from the current practice as was experienced during the incorporation and experiences from Bihar and other states of nutrition actions into a local government that has shown that without behavior change, strengthening project under preparation. It is toilets are constructed but are not used. Personal more challenging in the case of ongoing projects hygiene and sanitation practices will be promoted such as this one, where nutrition interventions are through individual and collective action. often perceived as an add on. The project will facilitate interface of communities and program officials, including the district level • It is crucial to be pragmatic and realistic about how authorities, especially the district leadership, to much the sectoral project can take on of nutrition assure better service provision and enhanced sensitive interventions without overwhelming/ demand and utilization. overburdening the project and the team. 3 • Since nutrition is a new thematic area for sectoral to generating interest and ownership. This is projects, it is important to build perspective and especially important in a model such as this one understanding among the project team about that aims to coordinate between existing public its importance as a development priority and its programs in various sectors, rather than duplicate relevance to the project. and implement parallel services. • Issues related to ownership, assigning roles and • The core competency of the project is Rural responsibilities and commitment of time and Livelihoods, therefore there is a need for ongoing resources to nutrition interventions by the sectoral technical and capacity building support in nutrition project have to be addressed as competing to the community and the project staff. priorities and workloads can delay implementation of nutrition interventions. Looking Ahead • It is important to build on and strengthen any existing Over the last year, and thanks to coordination and initiatives within the project. For example, the Food support of SAFANSI resources, the Multisectoral Security Fund implemented by Jeevika has been Nutrition Actions in Bihar activity was designed. The strengthened in the Multisectoral pilot to allow for a Multisectoral Nutrition Convergence Pilot within the diverse basket of food such as cereals, pulses and Bihar Rural Livelihoods project (Jeevika) is a part of other food items to be included instead of cereals that effort. The model is now in the initial stages of alone to be made available to the targeted food implementation, and an impact evaluation is planned insecure and poor households. The community to be undertaken. institution of self-help groups and its federations of Village Organizations comprising poor rural women The pilot provides a unique opportunity to build the provide a unique platform and a natural entry point capacity of community institutions of poor rural women for incorporating nutrition actions based on their to improve maternal and child nutrition. It promotes felt needs. This platform further empowers women behavior change to adopt positive maternal and child and builds their awareness, understanding and health and nutrition, health, hygiene and sanitation capacity related to nutrition actions for themselves, practices, improve food security, and leverage public their families and community. services to generate demand and utilize services that will ultimately improve nutrition outcomes through • The community structures enabled by Jeevika a community based, gender sensitive approach. require further strengthening to layer nutrition Technical and implementation support will continue to actions. be provided to the pilot. Lessons learned from the full • Widely consulted communities, project staff, implementation of the pilot will need to be incorporated officials and functionaries of public programs before the effort can be scaled up. and other external stakeholders are critical Partners SA FANSI Administered by: 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. 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