93532 SAFANSI The South Asia Food and Nutrition Security Initiative INTEGRATING NUTRITION PROMOTION AND RURAL DEVELOPMENT IN SRI LANKA Connecting health and development goals This project also aims to explore the pathways is challenging, particularly in the context and quantifying their relative contributions on of a country experiencing rapid changes in food security and nutrition related outcomes. It is socioeconomic status. In the post-conflict era, believed that rural development programs have Sri Lanka has maintained a relatively high level of an impact on multiple health related behaviors growth and recently graduated to the economic and outcomes. The study focuses primarily status of a lower-middle-income country. on nutritional outcomes, but includes several others. In addition, this project aims to provide Sri Lanka is currently undergoing demographic, evidence on understanding the best ways to epidemiological and social transition with rapid operationalize multi-sectoral approaches and urbanization and development. The country innovative multi-sectoral delivery strategies. is facing the double burden of under-nutrition Generating this new evidence could attract more and over-nutrition with rapidly emerging local and national level policy makers to consider non-communicable diseases (NCDs). Despite health impacts when they make decisions. The improvements in many health indicators, output of this study will solidify the call for inter- malnutrition, anemia and other micronutrient sectoral collaborations and whole of government deficiencies prevail. approaches to improve nutrition and health, in particular in developing countries. Several policies have highlighted the need for an inter-sectoral approach to promote nutrition and the importance of linking rural development and nutrition promotion. There are no previous studies or local evidence on how to integrate these two sectors and how to evaluate the impact of different development projects on nutrition. The Integrating Nutrition Promotion and Rural Development (INPARD) Project aims to implement and evaluate nutrition promotion activities through the on-going World Bank financed Community Livelihoods in Conflict Affected Areas Project—popularly known as Reawakening Project (RaP)—in two districts of Sri Lanka. Stakeholder Meeting Moneragala, August 2014 The project focuses on identifying the pathways to promote nutrition with multiple stakeholders. October 2014 South Asia Region Approach community stakeholders. Rural development staff organized meetings to discuss the findings Two districts in Sri Lanka were identified for relevant to their village/school and to prioritize the project—Ampara and Moneragala. Villages interventions. The rural development project covered by the Re-awakening Project were staff was trained to understand the impact of selected as intervention areas. A control area their decisions on nutrition (e.g. approval of was selected based on a sample of villages micro-finance loans for food related businesses in the same districts not covered by the Re- and the impact on local dietary behavior). Other awakening project, and a sample of villages sectors including agriculture and education also from the Kurunegala district. attended this training. Multisectoral committee A baseline survey was designed with both discussed how each sector could contribute qualitative and quantitative components to address identified nutritional problems to understand the exiting dietary patterns, and achieve common goals. Nutrition related nutritional status, myths, practices and technical knowledge was provided by the local behaviors related to nutrition and current state health staff and the INPARD team. Details were of collaboration between each sector towards recorded about interventions in each school promoting nutrition in the country. and village to measure their effectiveness. The training program and village/school level A random sample of 2000 adults, 2000 school- workshops are now taking place in both Ampara children (aged 12-18) and 1000 children (under and Moneragala Districts. 12 years of age) was selected from two districts where Re-Awakening was being implemented. Baseline and post intervention surveys collected Livelihood Development Community Grama Niladhari School Principal information on diet, physical activity, alcohol, Officer Resource Person (Divisional (Ministry of (Divi-Neguma (RaP) Secretariat) Education) and smoking. Anthropometric data, other Department) demographic data, and area level measures of food availability, food price, and poverty data Economic Medical Officer of Health and Agricultural Research Production Assistant were also been collected. Development Public Health Officer (Department of Midwife (MED) Agrarian Services) (MOH) In addition, qualitative data was collected, including in-depth interviews with policy-makers and focus group discussions with teachers, community An ex-post survey will be conducted in summer of members, children, and the staff of health rural 2015 to assess the impact of these interventions development and agriculture ministries to identify on nutritional outcomes. barriers for nutrition promotion and successful measures to tackle them. Summary of Findings The criteria from the World Health Organization Experts developed a training program on (WHO) Nutrition Friendly Schools Initiative was nutrition basics, health promotion, and used to assess the nutritional environment in inter-sectoral collaboration for stakeholders schools and to help schools to improve the representing various sector disciplines. nutritional status of students. Focus group discussions with school INPARD developed a training program teachers identified several barriers for representatives of identified sectors (see figure) nutrition promotion in schools. Teachers on how to collaborate to promote nutrition. These identified a number of barriers to healthy leaders were trained to play a key role in designing dietary choice by students, which could be and delivering interventions in their setting. found at a number of levels of influence of a Baseline survey results were then shared with socio-ecological framework (table 1). Results 2 concluded that barriers to healthy dietary structure, there is a lack of knowledge choice amongst secondary school students in on the local structure which limits the Sri Lanka are varied, and that multi-sectoral collaboration. The need for an upward programs could be used to promote healthy reporting mechanism for multi-sectoral dietary patterns amongst the students. action was identified. • Understanding the role of the health sector Table 1: Barriers to good nutrition and other sectors and program objectives Level Barrier in nutrition promotion was highlighted as a training need. Structural Educational policies Agricultural policies • Non-health sector officers felt that nutrition experts usually thought “nutrition promotion Living and Employment opportunities Working Local food production programs” should always be led by nutrition experts. Therefore they did not initiate Social and Traditions social/cultural beliefs programs, even if they had the opportunity. Community Individual Knowledge, attitudes, and practices Lessons Learned • Level of collaboration towards the project is In-depth interviews with national multi- different from one official to another. sectoral policy makers showed that: • Even though grass-root level officers from different sectors are motivated to • Many sectors have recognized the Ministry of collaborate, they need to wait for approval Health as the lead and established ministry and guidance from their higher authorities. on nutrition related activities. An emerging role was identified for Economic Development • Middle level managers were often left out Ministry for its capacity to implement projects from top level or community level discussions at the grass root level. A major role is also and they did not support village level officers seen for the Ministry of Planning. There is to promote multi-sectoral approach. limited accountability on the non-health • Different officers (agriculture, rural sector to deliver nutrition related outcomes development, primary health care) visit and a limited recognition of their role. the village on different days and they • In relation to individuals’ roles within many could not meet in the field. There needs to organizations, decisions are made at the top be advanced planning to arrange regular level with limited consultation of the ground meeting for different sectors. realities whereas the grass root level follow • Individual level attitude towards given instructions but contribute minimally collaboration also make a great impact to decision making. when implementing multi-sectoral projects. • Each sector has individual institutional • Activities overlap with organizational work objectives that limit collaboration. The need plans and it is very difficult to arrange for collaboration was readily recognized by regular multi-sectoral meetings. all the sectors based on minimizing waste, • There should always be an optional plan to and sharing knowledge and resources. implement the programmed activities in an • There is a need for nutrition-related event where the first plan fails. indicators to evaluate the contribution • Organizational structures / policies/ circulars of other sectors, building on the existing may prevent officials from participating health sector indicators. in events that are outside their job roles • Even though there is a good existing despite being useful to the community. 3 Conclusion sectoral delivery strategies. Generating this new evidence could attract more local and national- This study aims to bring health professionals and level policy makers to consider health impacts rural development practitioners together with a when they make decisions. The output of this shared aim of integrating nutrition promotion study will solidify the call for inter-sectoral and rural development. Even though the health collaborations and whole of government sector has developed policies to recognize the approaches to improve nutrition and health, in role of non-health sector practitioners towards particular in developing countries. nutrition promotion, the non-health sector has not received adequate support and training as The INPARD study is implemented in two districts to how they can work together to achieve these of Sri Lanka where there is a diverse population, nutritional goals. based on ethnicity, religion, socioeconomic status and culture in these areas. While this Therefore, it is essential to provide adequate diversity brings unique challenges for program training for multisectoral stakeholders on how implementation, it also provides an opportunity to collaborate and promote nutrition in their to build new levels of evidence to inform future own settings. Policy level changes are required policies and programs. to facilitate this process and provide recognition. The main objective of the study is to investigate whether a multisectoral rural development program can be utilized to deliver nutrition promotion intervention within rural Sri Lanka and whether this is effective in improving nutrition outcomes. It includes identifying the pathways to promote nutrition with multiple stakeholders. It aims to explore the pathways in which development programs have a direct impact on nutrition and health and to quantify their relative contributions on nutrition and food security related outcomes. In addition, this project aims to provide evidence on understanding the best ways to operationalize multi-sectoral approaches and innovative multi- Stakeholder Meeting Moneragala, August 2014 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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