Knowledge Brief 7 Recommendations for Strengthening Delivery of Nutrition Services through the Platform of Community Action for Health and Nutrition in Nagaland, India Key findings from the assessment of nutrition determinants and process evaluation of early implementation of the Nagaland Health Project, suggest several recommendations for leveraging the existing project platform to enhance nutrition outcomes. These include introduction of nutrition-relevant indicators in the results-based financing design, capacity building of frontline workers and facility-based providers, and strengthening intersectoral coordination. Introduction for local services to Village Councils and sector- specific Committees. In the health sector, Village In the state of Nagaland, stunting prevalence among Health Committees were made responsible for under-five children decreased from 39 to 29 percent management of local health services, including over the decade between the National Family salary payment as well as use of small funds Health Surveys done in 2005-06 and 2015-16 and transferred by the state government. Some is lower than the national average of 38 percent. 1,300 Village Health Committees have been During the same period, under-five prevalence constituted and their level of functionality of wasting decreased marginally from 13 to 11 varies widely, with many hardly active. In 2016, percent.1 However, within the state of Nagaland, the World Bank-financed Nagaland Health there is significant variation in nutritional status Project included a US$15 million component between districts.2 For instance, stunting rates to provide technical and financial support to among under-five children range between a strengthen implementation of the communitization 19 percent in Tuensang district and 42 percent in strategy.3 The project includes training committee Kiphire district; wasting prevalence ranges between members on the importance of preventive and 2 percent in Mokokchung and 21 percent in Mon. promotive care, and on the responsibilities and functions of the committees. The project provides Further, a third of all pregnant women in Nagaland resources to committees to improve service are anaemic and about 12 percent of all women are delivery by using a results-based financing too thin. Thus, despite improvements in nutritional mechanism. At present, the project, implemented status by some measures, undernutrition in women by the Department of Health and Family Welfare, and children remains a significant challenge. does not have a substantial focus on improving Under the term “communitization,” in 2002 the state nutrition services (which are the responsibility of government of Nagaland transferred responsibility the Department of Social Welfare). July 2019  |  Page 1 Methods results-based financing design, capacity building of frontline workers and facility-based providers, and The following set of recommendations are based on strengthening intersectoral convergence for nutrition. a mixed-methods study aimed to examine drivers of nutrition outcomes in Nagaland, as well as identify Nutrition-relevant indicators existing barriers and facilitators for delivering nutrition for results-based financing services. The design also supports an assessment of At present, the project does not include any indicator early implementation of the Nagaland Health Project solely focused on nutrition services, but instead to inform possible approaches to strengthening includes composite indicators that reflect delivery of nutrition delivery through the current project design both health and nutrition services.4 New indicators and implementation strategy. The study uses a could be introduced to more explicitly tie results- combination of qualitative and quantitative methods. based payments to delivery of nutrition services. An exploratory qualitative study, including focus group discussions with community members, was followed Building capacity for the delivery by a survey of households, health committees and of nutrition services facility staff. The survey was accompanied by key informant interviews with relevant stakeholders as Given the findings on gaps in demand for and well as an assessment of project monitoring data and inadequate supply and quality of nutrition services, documents. especially counselling and growth monitoring, capacity building should be done for frontline workers (ASHAs and Anganwadi Workers) and Recommendations facility-based providers on effective delivery of nutrition services. This could include capacity Based on key findings from the assessment of building of ASHAs and Anganwadi Workers by nutrition determinants in the state and a process providing nutrition messaging tools in the form of evaluation of early implementation of the project, booklets/handbooks with contextualized content several recommendations have been developed for and visual aids for messaging at the community level leveraging the existing project platform to enhance on promotive and preventive practices. Moreover, nutrition outcomes. Recommendations include the project could provide training and mentoring to introduction of nutrition-relevant indicators in the frontline workers for regular and accurate growth At the village level Indicator on a specific number of behavior change campaigns that include nutrition topics: for example, at least one campaign on a nutrition topic per quarter. Indicator on organizing group counselling sessions exclusively on nutrition topics at least once a quarter at Village Health and Nutrition Days held jointly by Auxilliary Nurse Midwives, ASHAs and Anganwadi Workers. At the facility level Indicator on completeness of child growth data on the Mother-Child Protection card in order to improve growth monitoring and early identification of severe malnutrition. Indicator on availability of functional infant and adult weighing scales, infantometer and stadiometer at the Sub-centre and Anganwadi Centre to enable routine growth monitoring. Page 2  |  July 2019 measurement, identifying growth faltering using could benefit from interdepartmental coordination WHO growth charts, and ensuring completeness of at the village and block level. Similarly, orientation growth measurement on Mother-Child Protection on the project for district and block level Department cards. Similarly, capacity building efforts for facility- of Social Welfare officials may be beneficial for based providers could aim to improve nutrition securing their buy-in and active participation. Finally, counselling as part of antenatal, postnatal and a combined effort by both departments for capacity newborn care, as well as growth monitoring and building of Auxiliary Nurse Midwives, ASHAs and early identification and management of severe Anganwadi Workers, on planning, organisation, and malnutrition among children. service delivery at Village Health and Nutrition Days, as well as joint field visits for better supervision of Strengthening intersectoral and feedback to frontline workers, could contribute coordination for nutrition to improved delivery of nutrition services. Given the multifactorial nature of undernutrition and The Nagaland Health Project has adopted these the complementarities between services provided recommendations and agreed to incorporate by the Department of Health and Family Welfare them in the design and implementation of the and the Department of Social Welfare, there is a project in a phased manner. It aims to pilot test need for improved coordination. This could be the inclusion of nutrition-relevant indicators for achieved through quarterly meetings between the results-based financing in a selected sample of project team and concerned Department of Social sites, to understand better data requirements and Welfare officials at the state level to discuss, develop processes involved in monitoring and verifying and review plans and guidelines for strengthened these indicators, before scaling them to all sites. coordination at the local level. Such coordination of It has also agreed to provide combined training service delivery could be centred on: Village Health to ASHAs and Anganwadi Workers for improving and Nutrition Days, home visits, behaviour change delivery of nutrition counselling services. campaigns, data sharing, and other activities that Footnotes 1 International Institute for Population Sciences and ICF. (2018). National Family Health Survey - 4 (NFHS 4) India 2015-16: Nagaland. 2 Kohli, N., Nguyen, P., Avula, R., & Menon, P. 2017. Improving nutrition in Nagaland: Insights from examining trends in outcomes, determinants and interventions between 2006 and 2016. POSHAN Policy Note #28. New Delhi: International Food Policy Research Institute. 3 World Bank. 2016. Project Appraisal Document on a Proposed Credit in the Amount of US$48 Million to the Republic of India for a Nagaland Health Project. November 28. http://documents.worldbank.org/curated/en/719521482375675651/pdf/INDIA- NAGALAND-PAD-11302016.pdf 4 Several indicators reflect implementation of Village Health and Nutrition Days that are co-organized by health workers (under the Department of Health and Family Welfare) and Anganwadi Workers (under the Department of Social Welfare), who provide nutrition services such as growth monitoring. July 2019  |  Page 3 © 2019 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some Rights Reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of 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. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution Please cite the work as follows: “World Bank. 2019. India: Nutrition Determinants and Strategies in Nagaland, Knowledge Brief - Recommendations for Strengthening Delivery of Nutrition Services through the Platform of Community Action for Health and Nutrition in Nagaland, India. © World Bank.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Acknowledgements This work was led by Patrick Mullen and Aarushi Bhatnagar, with contributions from Young Eun Kim, Mohini Kak, Bathula Amith Nagaraj, Neesha Harnam, Avril Kaplan and Mamata Baruah, under the oversight of Rekha Menon. The World Bank team would like to thank the Directorate of Health and Family Welfare and Department of Social Welfare, Government of Nagaland, the Nagaland Health Project team, Oxford Policy Management Ltd., the Kohima Institute and all study participants for their contributions. This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies of the World Bank and its Board of Executive Directors. Page 4  |  July 2019