SAFANSI: Winners of the 2009 Development Marketplace on Nutrition

SUPPORTING LOCAL INNOVATION IN THE

FIGHT AGAINST MALNUTRITION

WINNERS OF THE 2009 DEVELOPMENT MARKETPLACE ON

NUTRITION

SUPPORTING LOCAL INNOVATION IN THE FIGHT AGAINST MALNUTRITION WINNERS OF THE 2009 SOUTH ASIA REGION DEVELOPMENT MARKETPLACE ON NUTRITION

This volume is based on materials provided by Development Marketplace grantees and an implementation support agency. It was edited by Tarra Kohli, Venkatakrishnan Ramachandran, and Melissa Williams of the World Bank.

Phoebe Folger and Lori Geurts of the World Bank reviewed the content.

Š2011 (January) The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 Telephone 202-473-1000 Internet www.worldbank.org/rural E-mail ard@worldbank.org All rights reserved.

This volume was created by staff of the International Bank for Reconstruction and Development/The World Bank based on materials from Development Marketplace grantees and an implementation support agency. The findings, interpretations, and conclusions expressed in this paper 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.

This material has been funded by UKaid from the Department for International Development; however, the views expressed do not necessarily reflect the department’s official policies.

For more information, contact: 1818 H Street, NW Washington, D.C. 20433 USA SAFANSI Program Manager: Animesh Shrivastava Telephone: +001-202-473-3652 Internet: www.worldbank.org/safansi www.worldbank.org/nutritiondm2009 Email: safansi@worldbank.org

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C ONTENTS The Development Marketplace .....................................................................................................................................5 Afghanistan: Promoting Baby Friendly Villages .............................................................................................................6 Bangladesh: Comprehensive Nutrition Care for Extremely Vulnerable Infants and Young Children ............................8 India: Community-Managed Nutrition-Cum-Day Care Centers for Tribal Communities .............................................10 India: Nutrition for Migrant Children Living on Construction Sites .............................................................................12 Sri Lanka: Three-Generation Communication for improved Infant and Young Child Nutrition ..................................14 India: Universalizing Supplementary Nutrition Under the Age of Two: a Social Business Model of NUTRIMIX Production ...................................................................................................................................................................16 Bangladesh: Community-Local Government Partnership to Combat Child Malnutrition ...........................................18 India: Coupling Diarrhea Treatment and Behavioral Change Communication to Reduce Severe Malnutrition in an Urban Slum ..................................................................................................................................................................20 Nepal: Enhanced infant and young child feeding practices linked with micronutrient sprinkles supplementation ...22 Nepal: Community-based distribution network for the Two Child Logo Ade .............................................................24 India: Community involvement in promoting neonatal & infant nutrition in tribal Vadodara ...................................26 Bangladesh: Promoting better infant and child feeding practices through performance-based payment ................28 Pakistan: A comprehensive community-based intervention to improve linear growth in children aged 6-18 months .....................................................................................................................................................................................30 India: using cell-phone technology to improve exclusive breastfeeding and reduce infant morbidity ......................32 Nepal: Nutrition through knowledge...........................................................................................................................34 India: Reducing maternal stressors to enhance birth weight and infant survival .......................................................36 Pakistan: Home based nutrition rehabilitation of severely malnourished children ....................................................38 Nepal: Action Against Malnutrition through Agriculture (AAMA) ...............................................................................40 India: Social Capital as a catapult for improving infant feeding ..................................................................................42 Bangladesh: Empowering women and adolescents to improve infant and young child nutrition..............................44 India: Addressing Iron Deficiency Anemia in Rural Rajasthan Through Iron Fortification of Flour .............................46 Photo Credits ...............................................................................................................................................................48

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T HE D EVELOPMENT M ARKETPLACE The Development Marketplace (DM) is a competitive grant program of the World Bank and partners that identifies and funds innovative, early stage development projects with high potential for developmental impact and replication. The program operates at a global, regional or country level, and uses a transparent process to support innovations that address development challenges at the community level.

The South Asia Region Development Marketplace (SAR DM) on Nutrition is a partnership between the World Bank, GTZ, Micronutrient Initiative, UNICEF, WFP, GAIN, and PepsiCo. The SAR DM was launched In February 2009 in order to engage civil society and grassroots organizations in improving infant and young child nutrition in South Asia. In August 2009, the SAR DM awarded grants up to US$40,000 each to 21 civil society organizations to implement innovative, community-based interventions to improve nutrition for pregnant women, infants and young children during the critical 'window of opportunity' - the first two years of life. The winning organizations were selected through a highly competitive process from a pool of 1000 applicants and 60 finalists. The implementation of DM grants began in the Fall of 2009 and will be completed in late Spring/early Summer 2011.

SAFANSI support to the Development Marketplace on Nutrition promotes capacity enhancement of the selected organizations to implement their programs. In addition, SAFANSI is supporting the documentation and dissemination of lessons learned and best practices from project implementation which will help fill the knowledge gap on how to improve infant and young child nutrition in the Region and inform policy and program formulation.

For more information about the South Asia Region Development Marketplace, visit: www.worldbank.org/nutritiondm2009 or contact the SAR DM team at nutritionmarketplace@worldbank.org.

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A FGHANISTAN : P ROMOTING B ABY F RIENDLY V ILLAGES The cycle of malnutrition starts with the late initiation of breastfeeding to newborns, use of pre-lacteal food (nonexclusive breastfeeding for the first six months), inappropriate complementary feeding, and lack of continuation of breastfeeding for at least two years. Disrupting the cycle of malnutrition must start with better infant care.

Promoting optimal feeding practices can considerably reduce infant and young child deaths in Afghanistan, but it requires a comprehensive approach to change the current behaviors of child feeding among families.

Reports show that only 39% of children between the ages of 6 and 9 months get proper complementary feeding with breastfeeding. Lack of proper practice among mothers to feed their infants and young children optimally is mainly due to lack of knowledge and the lack of an enabling environment. Most efforts in the past have targeted the lack of knowledge cause, but not the lack of an enabling environment. Mothers-in-law, male members of the family, and health workers heavily influence how mothers feed their children and, therefore, must be targeted to achieve success.

The Baby Friendly Village (BFV) Project, implemented by Care of Afghan Families (CAF) in four districts of Takhar Province in Afghanistan, will address both causes of improper feeding by: • • • •

Improving the knowledge and practice of 100 pregnant and lactating mothers regarding optimal feeding practices of infants and young children.

Establishing eight community support groups in the targeted villages, comprising community health workers, traditional birth attendances, local religious leaders, and traditional healers.

Raising awareness about optimal feeding practices of infants and young children among 100 fathers and their family members.

Establishing four breastfeeding counseling corners in four health facilities at the target area to provide comprehensive counseling services to needy mothers and pregnant women.

The Baby Friendly Village takes a comprehensive approach. It ensures that mothers have the required skills in optimal feeding practices, such as correct positioning of the baby during breastfeeding and preparation of nutritious dishes during the complementary feeding stage by providing counseling services in health facilities and through community support groups. Beyond that, BFV addresses the enabling environment by involving all key players—such as, mothers-in-law, husbands, other male members of the family, health workers, traditional healers, birth attendants, and local religious leaders by raising their awareness of the importance of feeding practices and involving them through support Page 6 of 48

groups in helping the mothers. The goal is to turn entire villages to baby-friendly places where all individuals have proper knowledge and skills to support a breastfeeding mother.

The project will be implemented in the rural area of Takhar Province in Northeast Afghanistan, where the only source of income is farming and poverty is widespread. The project will focus on improving the behavior of pregnant and breastfeeding mothers aged 15-49, their family members, and other stakeholders.

BFV builds on existing systems in the country.

Afghanistan has one community health worker for Only 39% of children between the ages almost every 150 families; a community health council of 6 and 9 months get proper for each health facility; and a basic health center complementary feeding with almost for each 10,000 population. In addition, there breastfeeding are women’s action groups, TBAs, and other community based groups around the country that are part of the health system. Master trainers and trainers on breastfeeding counseling already exist. Finally, BFV will communicate how the Holy Quran, as the main reference book of Muslims, supports breastfeeding and the initiative is according to the norms and values of the society. The project has the same potential of growth and expansion to the other regions and countries with similar context as Afghanistan.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S ) Care of Afghan Families (CAF) is an Afghan NGO established in 2003, with the mission of enabling families to fight against disease and its causes—poverty, lack of awareness, and injustice—by investing in health, nutrition, community development, and education. CAF’s achievements have been recognized by the leadership of the Ministry of Public Health, community leaders, and the provincial public health director. It has also received several awards from USAID, World Bank, EC, UNICEF, and other development agencies.

CAF is partnering with Social Development Association (SDA), a social association, comprising volunteers to provide awareness, training, consultancy, and advocacy about issues related to social development. SDA will provide master trainers, adapt training materials to the local context, and prepare the communication materials.

CONTACT INFORMATION Bashir Ahmad Hamid Organizational Development Director & Lead Project Manager Health & Nutrition Care of Afghan Families (CAF) H 497, Parwan-e-Do Kabul Afghanistan Email: cafkbl@gmail.com, bashirahmad.hamid@gmail.com Website: www.caf.org.af Tel. 0093 07778-223-05 or 0093 799 311 619

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Hassanullah Hedayat Administrator Social Development Association Email: admin.sda@gmail.com Tel. 0093799842289 H. 497, Street64, Dist 4 Kabul Afghanistan

B ANGLADESH : C OMPREHENSIVE N UTRITION C ARE FOR E XTREMELY V ULNERABLE I NFANTS AND Y OUNG C HILDREN Bangladesh has one of the highest levels of under nutrition in the world. Among children under the age of five: 48% are underweight, 43% are stunted, and 13% are wasted (BDHS- 2004). The Government of Bangladesh (GoB) has been implementing a national nutrition program in more than 100 Upazilas; however, many vulnerable and socially excluded groups—particularly sex workers (SWs) and people living with HIV/AIDS (PLHA)—are yet to receive services from the program. This is because the program does not cover their geographical area and because they are among the most marginalized in the country. As a result, the children of these groups suffer malnutrition more than the general population.

The children of SWs and/or PLHAs are especially vulnerable to nutritional deficiencies and their consequences; however, they are underserved by existing nutrition programs. For example, female SWs cannot breastfeed their children due to their professional demands and mothers living with HIV are sometimes discouraged from breastfeeding. The result is that children of these vulnerable populations are at particular risk for malnutrition and 1 hunger. An estimated 13,000 children in Bangladesh are prey to the commercial sex industry of the country. More than 20,000 children are born and live in the 18 registered red-light areas of Bangladesh (Asia Child Right Report, 2009).

The project, Comprehensive Nutrition Care to Extremely Vulnerable Infants and Young Children, is being implemented by HIV/AIDS and STD Alliance Bangladesh (HASAB) to promote the nutritional status of the infants and young children (up to age 10) of these extremely socially excluded families. The focus is given to the children of female SWs and PLHA. The project is working in two geographical locations: the district town Mymensingh, where more than 300 SWs live in an established brothel in the heart of city, and Nagari Union in the Kaligonj Upazila of Gazipur District.

The project will use a comprehensive approach that includes: •

• •

Training of trainers workshops for nutrition for Project Officers, Community Volunteers (CVs), and other relevant NGOs staff; Establishing two Community Nutrition Centers (CNCs) in the target areas; Supplementary feeding sessions conducted at each CNC six days each week providing food prepared by the formula of NNP and procured from community women or other service providers—severely and moderately

1

An estimated 13,000 children in Bangladesh are prey to the commercial sex industry of the country. More than 20,000 children are born and live in the 18 registered red-light areas of Bangladesh (Asia Child Right Report, 2009).

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•

• • • • • • •

malnourished children under two will be provided with food packets; Nutrition education, including breastfeeding promotion, weaning food, supplementary feeding practices, balanced diet, etc., will be held at each CNC everyday along with demonstration of available inexpensive food; Growth Monitoring and Promotion (GMP) sessions held monthly at each CNC to identify the nutrition status of target children; nd Distributing two iron tablets daily to every pregnant mother from the 2 trimester to within 42 days of delivery and 1 Vitamin-A capsule to every lactating mother within 14 days of her delivery; Weighing every newborn at their birth place within 72 hours of delivery; Establishing referral linkages to health service providers at low or no cost; Having community volunteers (CVs) visit target families regularly; Forming community vigilance teams in both areas comprising community leaders, local elites, and elected representatives to support supervision and monitoring; and Holding a series of formal and informal Advocacy and Social Mobilization Meetings in the target areas.

HASAB has been working with sex workers of Mymensingh through the Promoting Rights of the Socially Excluded People project funded by Manusher Jonno Foundation and with families affected by HIV through Continuum of Care and Support to the HIV Infected and Affected Project funded by TDH Netherlands in different parts of More than 20,000 children are born and country including Kaligonj. It will be able to draw upon its live in the 18 registered red-light areas existing rapport with the target communities to implement the project. of Bangladesh.

A B O U T TH E P R O J E C T I M PL E M E N TE R ( S ) HASAB is one of the national leading NGOs emerged as a specialized agency in HIV/AIDS & STI field with experiences of grant management and capacity building (technical, managerial and administrative) of smaller NGOs, CBOs and faith based organizations who are involved in HIV prevention and control and the care and support of people living with HIV. HASAB’s core focus is on HIV/AIDS and STI related issues which entail a wide range of integrative program that relates HIV with them as cross cutting issues. Nutrition is one of the cross cutting issue of HASAB’s programmatic mandate.

CONTACT INFORMATION Dr. Nazneen Akhter Executive Director HIV/AIDS and STD Alliance Bangladesh 1/2 Asad Avenue, Block – A, Asad Gate Dhaka 1207 Bangladesh

Email. nazneen@hasab.org, hasab@bdmail.net Web. www.hasab.org Tel. 880-2-8123021,9132644 Fax. 880-2-8122786

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I NDIA : C OMMUNITY -M ANAGED N UTRITION -C UM -D AY C ARE C ENTERS FOR T RIBAL C OMMUNITIES In rural Andhra Pradesh, India, there is great need for improved access to nutritious food for pregnant and lactating women and young children. The National Family Health Survey shows that in Andhra Pradesh, 46% of reproductive age women are below the recommended minimum body mass index of 18.5kg/m2 and 50% are anemic. Among children under 3 years old, 32.5% are underweight and 42.7% are stunted. The situation is even worse among scheduled tribes where 45.9% of children are underweight and 44.2% are stunted. These data mark the beginning of a cycle of malnutrition and poor growth, where reproductive age women have low birth weight babies who subsequently grow to be malnourished children. Often these children grow up without improved nutrition and are malnourished as they enter reproductive age, perpetuating the cycle. Discussions with women in tribal areas of AP revealed that women do not consume adequate nutritious meals at home because nutritious food is unavailable, knowledge of nutrition is lacking, and a combination of the two. In addition, gender discrimination between boys and girls begins at birth which means girls receive less food than boys.

Through this project, the Society for the Elimination of Rural Poverty (SERP) proposes to implement communitymanaged nutrition cum day care centers (NDCCs) with a nutrition behavior change campaign in tribal villages. The intervention will converge with the government’s Integrated Child Development Scheme (ICDS), which has similar aims but a different approach and that has not been able to achieve its intended outcomes.

The objective of the project is to improve the nutrition of pregnant women, lactating women, and children under five years of age in five tribal villages in Visakhapatnam District, Andhra Pradesh by improving their nutrition-seeking behavior. The selected villages are part of SERP’s larger project and are already implementing the universal interventions under the Health and Nutrition Unit of SERP.

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The NDCCs will act as a “one-stop-shop” where pregnant and lactating mothers and children can eat nutritious meals and snacks; receive health checks, vaccinations, growth monitoring and promotion; and receive behavior change messages pertaining to improved household nutrition. The project bundles the nutrition program with other government sponsored programs like ICDS and Janani Suraksha Yojana—a conditional cash transfer program—and community-managed micro credit product to make the nutritious food affordable and sustainable.

The food is consumed by pregnant and lactating mothers and children under three at the NDCCs under Among scheduled tribes in India, 45.9% of the supervision of a community resource person (CRP). children are underweight and 44.2% are The intervention combines a direct nutritional stunted. intervention with a behavior-change intervention to achieve both short-term and long-term impacts.

The project has four key innovations: •

•

• •

“Bundling” the nutrition program with other government sponsored programs like ICDS and Janani Suraksha Yojana (Rs.1000/- incentives for institutional delivery) and community-managed micro credit product to make the nutritious food affordable and sustainable “One-stop-shop” – the NDCC will double as a place where pregnant and lactating mothers and children a) come to have their food; b) receive health checks and vaccinations are provided by ANMs and medical doctors; and c) receive behavior change messages pertaining to improved household nutrition.

Food is consumed by pregnant and lactating mothers at the NDCC under the supervision of a CRP. This is to prevent the possibility of food being take home and being distributed among the household members The intervention combines a direct nutritional intervention with a behavior-change intervention so that long-term effects can be achieved.

A B OU T

THE

P R OJ E C T I M P L E M E N T E R ( S )

The Society for the Elimination of Rural Poverty (SERP) is a government agency that has been implementing a rural poverty reduction and livelihoods development project since its establishment in 2000.2 SERP’s program builds grassroots institutions of the rural poor and aggregates them at the village, sub-district, and district levels. This aggregate institutional structure provides the scale to leverage services from the public sector, private companies, and commercial banks—such as, health care, community agriculture, bank linkage, marketing centers, etc.

CONTACT INFORMATION B. Rajsekhar, Chief Executive Officer Society for Elimination of Rural Poverty (SERP) H. No. 5-10-192, Hermitage Office Complex, HUDA, Hillfort Road Hyderabad Andhra Pradesh 500004 India Email: brajsekhar@gmail.com Website: www.rd.ap.gov.in Tel. +91 04023298469 Fax: +91 04023211848

2

Ms. Lakshmi Durga Chava State Program Manager, Health and Nutrition Email: lakshmidurgac@gmail.com

The World Bank finances SERP activities through the Andhra Pradesh Rural Poverty Reduction Project (P071272)

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I NDIA : N UTRITION FOR M IGRANT C HILDREN L IVING ON C ONSTRUCTION S ITES The importance of quality early childhood care and education (ECCE) for the long-term development of children is widely acknowledged. In fact, a 2002 report by India’s National Institute of Education Planning and Administration states that a child’s ability to succeed at the primary level is heavily influenced by “what the child actually brings with him/her to [primary] school in terms not only of pre-literacy skills, but also nutritional/health status, socioeconomic background, extent of parental stimulation, and overall home environment.” Not surprisingly, it is the most marginalized children that have the least access to ECCE, while they would benefit the most from regular, quality care, and education.

Economic booms can create new marginalized populations, as has been done with the construction boom in Hyderabad in the state of Andhra Pradesh. Migrant laborers who live in camps near construction sites are a mobile and marginalized population that is not served by existing programs. This group works long hours for little pay and virtually no access to critical health, sanitation, nutrition, or education services. Often both parents migrate and are engaged in construction work, so the children are left on-site to fend for themselves; older girls are often forced to drop out of school to care for their siblings. Many, if not most, of these children suffer greatly from malnutrition, diarrhea, and other illnesses resulting from poor nutrition and poor hygiene/health.

Given the high proportion of children aged 3-6 currently attending Transit Schools, the SCOPE program by Dr. Reddy's Foundation (DRF) is expanding to ensure that children, newborn up to the age of five years have access to ECCE programs that provide integrated health, nutrition, recreation, and education services.

In order to establish an effective, low-cost model for holistic, on-site daycare facilities, DRF will start ECCE centers on 10 construction sites through the project—Improving Nutritional Health of Migrant Children Living on Construction Sites in Hyderabad, Andhra Pradesh, India. The centers, staffed by DRF-trained caregivers, will provide daily nutrition to children—seasonal fruits, biscuits, egg, milk, bread, millets, dal—and interactive training for mothers to help them make better nutrition/health decisions for their children, themselves, and their families. DRF will work on 10 construction sites, where the builder cooperation is already available, to build trust in mothers to leave their children with motivated and trained staff of the ECCE. The key objective being to use the integrative

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ECCE model to reduce malnutrition and control malnutrition related disease occurrence in these children. Other objectives are: •

To involve the mothers through building awareness about child care and feeding practices among them so as to reach to the most vulnerable age group of under three years.

• To monitor the growth of the children regularly and take corrective measures in programme implementation.

• To foster the creation of public-private partnerships between construction companies, government and civil society to attend to the educational, nutritional and health needs on children living on construction sites.

Two national acts require crèches on • To share best practices and the develop construction sites for the children of partnerships among NGOs working on ECCE issues for construction workers; however, most migrant and/or marginalized populations.

construction sites still lack ECCE facilities.

In India the Contract Labour (Regulation and Abolition) Act, 1970, and The Inter State Migrant Workmen (Regulation of Employment and Conditions of Service) Act, 1979, both require crèches on construction sites for the children of construction workers; however, most construction sites still lack ECCE facilities. Builders are generally willing to provide crèches to low-wage laborers, so long as the cost per worker is not high. The project should provide a model of high-quality, low-cost ECCE that addresses the critical nutritional and health needs of migrant children.

DRF’s ECCE program will be the first of its kind in Hyderabad. Currently no NGO is providing ECCE facilities in the city. It is also unique in that DRF’s ECCE centers will also serve as on-site resource centers for mothers, providing classes and support groups which will empower them to make long-term changes in the nutritional health of their families.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S ) Dr. Reddy's Foundation is non-profit partner of Dr. Reddy's Laboratories. DRF is pioneer in developing innovative programs in response to critical, long-term education needs of underserved populations. DRF provides access to quality pre-primary, primary and secondary education for children excluded from mainstream schooling due to social and economic marginalization.

CONTACT INFORMATION V. Mrudula Project Head - SCOPE Dr. Reddy's Foundation H.No 8-2-293/87/A MLA Colony, Rd.12, Banjara Hills Hyderabad 500034 Andhra Pradesh India

Email: kalpana@drreddysfoundation.org, mrudulav2000@yahoo.com Website: www.drreddysfoundation.org Tel. 914023554020 Fax. 914023554021

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S RI L ANKA : T HREE -G ENERATION C OMMUNICATION FOR IMPROVED I NFANT AND

Y OUNG C HILD N UTRITION

Poor nutrition of infants and young children in Sri Lanka derive mainly from inadequate complementary feeding at the age of six months. Breastfeeding practices, though not perfect, have improved with 82% of mothers exclusively breast feeding up to age 6 months (DHS 2007 Report). However complementary feeding is not started in a timely manner, is inadequate in terms of protein and dietary diversity, is of inadequate quantity, lacks palatability, and does not follow the basic principles of responsive feeding. Furthermore, feeding practices during illness is also poor. The same DHS 2007 states that, among children under five years of age, 26% are underweight, 18% are stunted, and 16% are wasted. Disaggregated data show that children under the age of two—300,000 to 500,000 children according to demographic averages—fare even worse. A 2000 report by MRI shows that anemia levels are about 30% in both groups.

This project seeks to improve complementary feeding practices and nutrition of expectant and nursing mothers through radio broadcasts. It will work through radio stations operated by three generations of women— adolescents, mothers, and grandmothers—in a creative community network to change these key nutritional behaviors. The approach draws on the power of grandmothers, who often exert considerable influence on young mothers and adolescents are the secondary target audience of the project.

Sri Lanka has 42 radio channels (including mainstream and rural) and 10 TV channels; however, very little air time is dedicated to food and nutrition issues. In fact, most mass media is used to detrimental effect on food related behavior—e.g., milk powder advertisements. Furthermore, health and nutrition promotion is carried out through conventional methods that do not change behavior among communities. Radio is the only communication medium that can be accessed by most of the population. It is also the most affordable and productive medium because people can go about their daily activities while listening. Rural radio is preferred over mainstream radio because air time can be dedicated to localized problem. It is also easier to train local people to run their own radio station according to their cultural context. Furthermore, Sri Lanka has experience in the use of rural radio 3 and its impact for the last 20 years.

Getting three generations of women empowered to manage and broadcast was thought of as exclusively female-run radio stations are not present in Sri Lanka especially at the rural level. However,

3

The use of ICT in Education Report, Sri Lanka part of the UNESCO Meta Survey on the use of Technology in Education

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gender equity will be addressed through featured dialogues between men and women, especially on the topic of food needs at the household level.

It is rare to have dedicated radio networks, even at the rural level, addressing the subjects of health and nutrition.

The network center (Madya Piyasa), a participating community, will centrally network the 15 Sri Lanka has 42 radio channels and 10 TV communication societies to be set up in different channels but very little air time is dedicated areas. The communication societies will be organized through the members of the National Nutrition to food and nutrition issues.

Alliance (an Alliance of 20 NGOs working towards the improvement of nutritional status of Sri Lankans). The system will run practical programs through the different communication societies and the relevant stations do live broadcasts. The unique contribution of a community initiative on health and nutrition communication will enhance the work of the national Ministry of Health in taking the messages effectively to the grassroots.

The project is based on participatory communication methodology, which is easily replicable in other areas. Well documented learning experiences from this project will enable effective replicability. Since the amount to be spent on the whole project from the envisaged budget is fairly small, this too would contribute to a low cost initiative, which is easy to replicate as the investment is fairly small.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S ) Sri Lanka Green Friends Environmental Organization was founded in 1990, in Pelmadulla, Ratnapura district and was registered as a non-government organization in 1995. Its main activities focus on biodiversity conservation and sustainable management of tropical forests in the country through advocacy, information dissemination, and by improving the livelihoods, health, and sanitation of the buffer zone population. Green Friends promotes peoples' participation and implements a significant amount of training, awareness, and extension activities in relation.

CONTACT INFORMATION Priyadarshana Saman Kumara Chairman Executive Board Sri Lanka Green Friends Environmental Organization No: 1/135, Balangoda Road, Pelmadulla Pelmadulla 70070 Sabaragamuwa Province Sri Lanka

Email: priyadharshanasamankumara@gmail.com Tel. 09404-2274852 0940718186447 Fax. 094 0452274852

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I NDIA : U NIVERSALIZING S UPPLEMENTARY N UTRITION U NDER THE A GE OF T WO : A S OCIAL B USINESS M ODEL OF NUTRIMIX P RODUCTION Child malnutrition is a major public health problem in India, with 45.9% of children under the age of two being underweight. However, the importance of nutrition security is often ignored by communities and households with telling consequences on social and economic productivity of the population leading to a loss of 3% of GDP. Supplementary nutrition for children in India is usually secured from the market and is mostly accessible to households with high purchasing power. The marginalized rural poor in general and children under two of those households in particular, are deprived of access to quality supplementary food.

Child malnutrition is attributed to high levels of infection, inadequate infant feeding, and inappropriate caring practices, and has its origin almost entirely in the first two years of life. Another contributing factor is the mothers’ lack of knowledge. Combating these will be the strategic focal point of the project, entitled Universalizing Supplementary Nutrition for Children Under the Age of Two: a Social Business Model of Nutrimix Production.

The project aims to improve the nutritional security of children under two in South 24 Parganas district of West Bengal, located in the Indo-Gangatic plain. In this district, 51.8% of the children below two years of age are malnourished, and 22.1% of these children suffer from moderate to severe anemia. Many of them also suffer from respiratory and gastro-intestinal infections, malaria, and increasingly with HIV. The specific goal of the project will be to reduce the number of malnourished children by half in its operational area at the end of 18 months.

One effective way of tackling the problem mentioned above is to make low cost, high nutrient supplementary food available to the affected population. Child In Need Institute (CINI) has developed an innovative product called Nutrimix, which is a low cost nutritious supplementary food made especially for children.

Nutrimix is a CINI innovation. It is a low cost nutritious supplementary food for children made from locally available ingredients. It has been successfully tested for its efficacy in improving the nutritional status of children in a short period through the Nutritional Rehabilitation Centre and the CINI clinic. It is easy to prepare, has a long shelf life and can be taken in solid or semisolid forms in sweet or salty variants, depending on the child's preferences. It is packed in single serve sachets of 20 gms

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each and sold for Rs 2 per sachet or Rs 5 for 3 sachets.

CINI will follow a community-based participatory approach to set up the production of Nutrimix and its distribution channels that will make it available to the affected population. It will also aim to disseminate information on better child care and feeding practices. With management Nutrimix is low cost, made from locally available support from the Indian Institute of Management, Calcutta, the project will be ingredients, has a long shelf life, can be taken in undertaken as a social business venture solid or semisolid forms, and in sweet or salty with the goal of developing a replicable varieties. Single serve sachets of 20 gms at Rs 2 social business model for enhancing early each are affordable to the poor. childhood nutritional security.

CINI has a wide network of operations in eastern India supported by a strong workforce at the grassroots level. This provides an opportunity for CINI to disseminate the idea of social business to communities. Once successfully piloted, project will scale up its operations to reach out to age groups of 3-6 years, adolescent girls, and pregnant and lactating mothers in rural communities and urban slums where it is marketed. The goal is to effectively break the inter-generational malnutrition cycle.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) CINI was established in 1974 and is committed to sustainable development and the improved health, nutrition, and education of children, adolescents, and women in need. Its commitment is reflected by its reach to about 800,000 people in rural and urban area of India.

Indian Institute of Management, Calcutta has been a premier management education institute of India since 1961. It strives to remain on the cutting edge of research, teaching and consultancy in various functional areas of management and related disciplines. IIM-C will provide management inputs to the project by providing expert services in relevant areas of the project as well as manpower.

CONTACT INFORMATION Mr. Abinash Gine Assistant Director Child Health Division CINI Nutrimix Child In Need Institute (CINI) Village: Daulatpur, P.O. Pailan, Via Joka, District: 24 Parganas (South) Daulatpur Village West Bengal 700 104 India Email: abinash@cinindia.org Website: www.cini-india.org Tel. +91 33 2497 8192 / 8206 Fax. +91 33 2497 8241

Professor Kalyan Mandal Indian Institute of Management Calcutta IIMC, Joka, DH Road, Kolkata Kolkata West Bengal 700104 India Email: ksm@iimcal.ac.in Website: www.iimcal.ac.in Tel. +913324678300 Fax. +91332678062

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B ANGLADESH : C OMMUNITY -L OCAL G OVERNMENT P ARTNERSHIP TO C OMBAT C HILD M ALNUTRITION Child malnutrition is a major public health concern for Bangladesh, and the period between conception and 24 months of age is when the prevalence of malnutrition is highest and its adverse effects on physical growth and mental development can be irreversible. Therefore, children of this age group in food insecure areas are more susceptible to malnutrition and need effective interventions. WHO reports that 48% of children under the age of five in Bangladesh are underweight compared to 39% in Nepal and 43% in India, and BDHS reported in 2007 that 30% children between 6-7 months do not receive any solid or semi-solid food, and the prevalence of severe wasting among children under the age of five is 3%.

Acute poverty and annual seasonal hunger resulting from scarce livelihood opportunities condemn the women and children of Kurigram—one of the most food insecure districts of Bangladesh—into severe hunger. Fragmented and non-functional health systems in urban areas exacerbate the already weak health and nutrition status of the poor. Community members, including mothers, lack awareness of infant and young child feeding (IYCF) practices, channels of communication and information, and most importantly, they lack opportunities to work out practical and innovative solutions with the local health system. A KPC survey of Kurigram municipality indicated that few mothers took positive steps to maintain their own health and nutrition during their pregnancy. After delivery, only 45% of mothers initiated breastfeeding within one hour of birth, only 71% of children under six months were exclusively breastfed, and only 17% children aged between 6 and 11 months received at least three complementary feedings.

Mothers also give inadequate attention to protein based nutrition.

In an effort to find workable, replicable solutions to this problem, Concern Worldwide is implementing a project to promote timely, appropriate, safe and adequate infant and young child feeding (IYCF) practices for children under two through a partnership between a municipality and a multi-stakeholder platform in three wards of Kurigram municipality.

The specific strategies of the project include strengthening the institutional capacity of the local municipality, fostering partnerships of the community stakeholders with health departments, NGOs, private sector and other government departments, promoting practical solutions at the ward level, facilitating local women’s leadership and ensuring accountability for demand driven services for the poor.

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A new form of partnership with the Municipal authority will bring in a new but mandated actor to support IYCF practices in urban areas where health systems are less functional for the extreme poor. Involvement of municipal authorities with other community stakeholders in planning, monitoring and developing schemes will ensure optimal use of the limited resources available with community, NGOs, public and private services providers.

This initiative promotes municipal leadership in engaging diverse community stakeholders and youth volunteers in IYCF promotion and better use of resources. This will bring a shift from NGO driven services for the poor by making the mandated municipal authorities accountable for demand based services for the infant and young child and their mothers. Mechanisms like mothers clubs and creation of “pot for mothers� reinforces women as the main actors to improve nutrition practices. Fathers will be engaged through awareness sessions, campaigns, actions to recognize positive practices. A combination of traditional tools and modern technologies like cell phone messages, awards, and subsidized services will be used for promoting behavior change amongst the family members and change agents.

The period between conception and 24 months is when malnutrition is highest, and its adverse effects on physical growth and mental development can be irreversible

The process expands the service and resource windows by brokering relationships with different stakeholders and encouraging them to develop innovative schemes. This fosters community learning on IYCF practices and transfer knowledge through young volunteers to improve the nutritional status of infants and young children.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) Based in Ireland, Concern Worldwide was established in 1972 and is an international, humanitarian organization dedicated to the reduction of extreme poverty in world’s poorest countries. Since 1968, through its work in emergencies, livelihoods, health, HIV&AIDS, and education, Concern has saved countless lives, and transformed lives of millions of people.

Kurigram Municipality is an autonomous body of local government mandated to improve health and sanitation, develop local infrastructure and generate revenue. They have staff and receive some grant from government.

CONTACT INFORMATION Humaira Aziz Assistant Country Director, Learning and Sharing Concern Worldwide Email: humaira.aziz@concern.net House: 15, SW(D), Road:7 Gulshan-1 Dhaka 1212 Bangladesh Website: www.concern.net Tel. +88028816923, 881 8009, 881 1469 Fax. +88028817517

Abu Bakar Siddique Mayor Kurigram Municipality Government Kurigram Municipality Kurigram 5600 Bangladesh Tel. +880581-61357 Fax. +880581-61857

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I NDIA : C OUPLING D IARRHEA T REATMENT AND B EHAVIORAL C HANGE C OMMUNICATION TO R EDUCE S EVERE M ALNUTRITION IN AN U RBAN S LUM The problem of diarrheal infection in South Asia continues to be a serious constraint on efforts to maintain and improve child nutrition particularly during the critical ‘window of opportunity’—newborns to 24 months. Every day in India, 1000 children die from diarrhea-induced dehydration. Malnutrition is associated with 61% of deaths from diarrhea-induced dehydration. Even if a mother gives birth to a child above 2.5 kilograms, breastfeeds properly, and her child is growing normally, all of this could be nullified by a single severe case of diarrhea.

A common phenomenon observed in maternal and child health (MCH) programs throughout South Asia is significant growth faltering in otherwise healthy children after the completion of exclusive breastfeeding.

One explanation for this is the improper treatment of naturally occurring diarrhea following the introduction of semisolid foods.

Calcutta Kids (CK) proposes to couple diarrhea treatment—systematically providing oral rehydration salts (ORS) by trained health workers—with a creative behavioral change communication (BCC) campaign designed to encourage continued complimentary feeding despite recent diarrhea, to reduce future onset of diarrhea, and to improve the nutritional status of the child. The campaign will be targeted to the mothers/caretakers of children admitted to a low-cost diarrhea treatment center based in Howrah, many of whom will become change agents in their neighborhoods.

Qualitative data from the CK catchment area suggest that ORS is often ineffective because of time constraints on the part of the mother/caretaker, and that professional diarrhea treatment, including intravenous rehydration, for children is only considered in cases of severe diarrhea, because the costs associated with available treatment are beyond the means of these households.

Calcutta Kids has set up a Diarrhea Treatment Center (DTC) in a defined urban slum area, where children can receive curative systematic oral rehydration therapy by trained community health workers (CHW) and intensive BCC counseling is provided to mothers/caretakers of these children on diarrhea prevention, timely introduction of adequate complementary feeding of children at six months, and hygiene and sanitation.

This is a replication of ICDDR-B’s successful diarrhea treatment model.

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The project aims to prevent diarrhea from precipitating malnutrition in otherwise healthy children by: • • • •

Provision of curative diarrhea treatment for at least 750 children a year under the age of two; Intensive BCC counseling aimed at the mothers/caretakers of these children; Follow up home visits by trained CHWs; and Getting at least 50% of the mothers/caretakers to act as change agents to disseminate what they learned at the DTC to neighbors and friends (minimum 5 per session).

Every day in India, 1000 children die from diarrhea-induced dehydration.

The principle underlying this project is that behavior change communication (BCC) and prevention are most effective when individuals understand, through personal experience or the experience of friends, the consequences of their behaviors and that beneficiaries embrace BCC most readily from people who have established themselves as trustworthy, e.g. those who have just provided a vital service to their family.

The project is innovated in the following ways: •

•

•

•

The replication of ICDDR-B’s successful diarrhea treatment model in a defined urban slum area, and the measurement of its effect in reducing both diarrhea prevalence and malnutrition in young children with added innovative components.

The conversion of parents – who have seen their children recover from a potentially fatal illness – into committed practitioners of improved health behaviors and into change agents disseminating information to others.

A shifted focus: primary attention to BCC relating to prevention, nutrition-related caring practices and development of change agents; and secondary attention to curative diarrhea treatment, especially conventional expensive treatment.

Assessing the sustainability of a successful diarrhea treatment model that charges clients just enough to cover CKDTC costs, while seeking multiplier benefits. If the model proves sustainable, it will be attractive to NGOs elsewhere in South Asia and in other developing countries.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) Established in November 2005, Calcutta Kids is an organization committed to the empowerment of the poorest children and expecting mothers in the underserved slums in and around Kolkata, by increasing their access to health and nutrition services, providing health information, and encouraging positive health-changing behaviors. The CK maternal and child health program (MCH) works with pregnant women and children aged 0-3. At any given time, the program is working with approximately 350 families.

CONTACT INFORMATION Noah Levinson, Director Maternal and Child Health Calcutta Kids Trust 51 Bhairab Dutta Lane Salkia, Howrah West Bengal 711106 India

Email: noah@calcuttakids.org, noah.levinson@gmail.com Web: www.calcuttakids.org Tel. 919830806313

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N EPAL : E NHANCED INFANT AND Y OUNG CHILD FEEDING PRACTICES LINKED WIT H MICRONUTRIENT SPRINKLES SUPPLEMENTATION Iron deficiency is the main cause of anemia in 80% children under the age of two. Nearly 50% of children suffer from chronic malnutrition, which drastically increases between the ages of 6 and 23 months due to poor feeding practices. Only about 60% of children aged 6–7 months are provided with complementary foods. Children are fed an average of only 1.2 meals a day, and the foods are often low-energy-density cereal porridges. High prevalence of anemia and stunting deprives children of optimum growth, cognitive and mental development resulting in irreversible intellectual capacity and productivity loss.

To address this, the Government of Nepal has decided to supplement children below two years with micronutrient powder (MNP) linked with infant and young child feeding (IYCF) community promotion package. The package includes training of health workers and community volunteers, orientation of mothers groups, mother-to-mother counseling, and demonstration of appropriate complementary foods.

While introducing MNP, mothers can be convinced to initiate complementary foods at six months, counseled on feeding frequency, making energy dense food and hygiene and trained to prepare Sabotham Lito, blended flour by mixing cereals and legumes, which drastically increases energy density and enhances protein quality.

Past training of health workers and national media campaign to increase awareness about IYCF did not produce any change since the message did not reach caregivers. To enhance IYCF community promotion, a school-based monitoring and promotion approach was pursued in selected villages. This project is an additional component of the on-going Baal Vita (multi-micronutrient powder) pilot project of the Government of Nepal in Makawanpur and Palpa districts where Health Facility model and Female Community Health Volunteer (FCHV) model are being tested respectively. The overall objective is to reduce anemia and general malnutrition in young children through improved infant and young children feeding practices by means of school based promotion and monitoring approach.

A core group of students in each school in the project area get briefed on infant/young child feeding practices, and then social mobilization activities, including household visits, identify eligible children for distribution of food, and raise awareness among mothers, are carried out. They also track mothers in their villages

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on regular basis to monitor use of Baal Vita, cross-verify its consumption by reviewing the compliance card provided to each child and report usage status to FCHVs. They also provide details of houses where compliance is poor and any problems associated with feeding so that FCHVs can follow up with mothers for further counseling and constructive encouragement to achieve project Children are fed an average of only 1.2 meals objectives.

a day, and the foods are often low-energydensity cereal porridges.

Given that school children are integral part of the community, they can easily without any logistical difficulties promote young child nutrition issues and pay a vital role in ensuring that hard to reach and most disadvantaged families receive continuous support and encouragement to adopt best feeding practices and ensure high use of MNP. The project aims to ensure that at least 90% of children under the age of two years in targeted communities are consuming 60 sachets of micronutrient MNP at the seventh, 13th, and 19th month of age. The overall objective of the project is to document the effectiveness involving school children as community advocates to will work in coordination with Female Community Health Volunteers and Community Health Workers (CHW) in promoting and reinforcing key messages on micronutrient MNP, improve IYCF and high consumption of MNP and design school children based promotion and monitoring programme for national scale up.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) Vijaya Development Resource Center (VDRC) was established in 1980 with an aim to contribute towards improving the situation of children and women. VDRC has vast experience in community based projects on nutrition and Early Childhood Development (ECD) and has initiated new innovative social mobilization approaches such as advocacy on social issues through community school and child clubs. Max Pro is supporting the Government to carry out social marketing activities. In this project they will help in training, BCC, documentation and evaluation activities.

CONTACT INFORMATION Narayan Sapkota Executive Director Vijaya Development Resource Center Ward No.8, Vijayanagar Gaindakot. Nawalparasi Nepal Email: nsapkota@vdrc.org.np, vdrc@vdrc.org.np Tel. +977-56-501172, 501100 Fax: +977-56-501401 Website:www.vdrc.org.np

Rajat Rana Managing Director Max Pro Pvt. Ltd. Swasti Sandan, Patan Dhoka Road Kathmandu Lalitpur Nepal Email: rajatrana@maxpro..com.np Website: www.maxpro.com.np Tel. 9775536681, 9775535183 Fax: 97715536682

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N EPAL : C OMMUNITY - BASED DISTRIBUTION NETWORK FOR THE

T WO C HILD L OGO A DE

Iodine Deficiency Disorder (IDD) is one of the leading causes of preventable mental retardation and has severe consequences for social and economic advancement. To address the problem of IDD, the Ministry of Health in Nepal initiated the Universal Salt Iodization (USI) Program with a goal of over 90% of households consuming adequately iodized salt (with iodine content of more than 15 ppm) and issued the “Two Child Logo” (2CL) on all Nepalese packaged salt containing adequate iodine. The last national survey conducted in 2005 found 95% of the households using salt with some iodine; however, only about 60% percent of the households were using adequately iodized salt.

The Government of Nepal set 2010 as the year to reach the Universal Salt Iodization goal. To do this, the Government, in partnership with UNICEF and Salt Trading Corporation (STC), initiated a social marketing campaign of 2CL salt targeting high population districts with low consumption. This project aims to build on existing campaigns by providing new strategies to meet campaign objectives among vulnerable populations by promoting the consumption of adequately iodized salt bearing the “Two Child Logo” (2CL) and ensuring its availability and accessibility in the project areas.

The project seeks to increase consumption of the 2CL salt among vulnerable populations, which will ensure intake of daily iodine especially by pregnant and lactating mothers and children between the ages of 6 – 24 months living in rural communities. During the course of the project, demand is expected to reach volumes that would make the trade of 2CL salt feasible for these community groups to carry on without further subsidies from STC or any external support.

The Government of Nepal is implementing (with support from UNICEF) a pilot project on distribution of multi-micronutrient powder (Baal Vita) to infants and young children aged 6-23 months in six districts of Nepal. Two distribution models are being piloted: (a) Female Community Health Volunteers (FCHVs) distribution model, and (b) Health Facilities distribution model. The project is an additional component of the on-going Baal Vita pilot project in Makawanpur and Palpa districts where Health Facility model and FCHV model are being tested respectively. The overall objective of this project is to reduce anemia and general malnutrition in young children in these two districts through improved infant and young children feeding practices by means of school based promotion and monitoring approach.

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The project aims to implement its activities in the Central Terai districts of Parsa with a high population to rapidly increase the consumption of the 2CL salt in the 20 Village Development Committees (VDCs) from an estimated 33.9% to 75% within the duration of the project. To achieve this objective, the project will carry out intensive promotion activities in 20 VDCs with the lowest availability and In 2005, 95% of households used salt with consumption of 2CL salt. In these areas, a some iodine; however, only about 60% targeted and vigorous BCC campaign will be percent of households used adequately initiated to create awareness about 2CL salt iodized salt. and its benefits. Along with awareness creation, the project aims to make 2CL salt available to at least 90% of markets in the 20 VDCs. For district-wide impact, the project will establish bulk buyers in remaining VDCs to help augment existing distribution channels which will be supported by district alliance building activities where NGOs and CBOs working in these areas will be encouraged to integrate 2CL messages in their programming.

The existing social marketing program implemented by the Government with UNICEF’s support aims to create awareness of 2CL salt in communities. However, due to the small number of bulk buyers, their initial volumes were quite nominal due to which it was difficult for STC to provide them subsidies for transport and this cost would become substantial for small volumes of orders. To overcome this problem, a number of bulk buyers would be established who would be in a position to make joint orders of feasible volumes to STC.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) MaxPro Pvt. Ltd. is a privately operated social marketing and advertising organization established in the year 2001. MaxPro started with a focus on the development of communications and marketing strategies for commercial companies and branched out into providing social marketing services to non-profit international and national institutions. The Ministry of Health and Population, Child Health Division (CHD), is the focal body in Nepal with the responsibility of implementing government policies related to child health. The CHD will help gain support of the district-based Government line agencies in implementing this program at the district level and help in the mobilization of their health service network to promote 2CL salt in the district and coordination with Salt Trading Corporation.

CONTACT INFORMATION Rajat SJB Rana, Managing Director Social Marketing Division Max Pro Pvt. Ltd. GPO Box No. 750 Kathmandu Nepal Email: rajatrana@maxpro.com.np Website: www.maxpro.com.np Tel. +977-1- 5536681 Fax: 977-1- 5536682

Rajkumar Pokharel Chief of Nutrition Ministry of Health and Population, Child Health Division Kathmandu Nepal Email: rajkumarpokharel@gmail.com

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I NDIA : C OMMUNITY INVOLVEMENT IN PROMOTING NEONATAL

& INFANT NUTRITION IN TRIBAL V ADODARA

The National Family Health Survey estimates 22% of newborns in Gujarat are low birth weight, 47% of children below three years are underweight, and 80% of children are anemic. The infant and young child feeding indicators like early initiation of breastfeeding (27%), exclusively breastfeeding (48%), and timely complementary feeding (57%) reveal a dismal picture.

District Level Health Survey data for the rural areas of Vadodara district show that only 39% births are institutional, only 55% of children are fully immunized, and less than half of mothers receive post-partum care. Vital registration, recording, and monitoring of key nutrition-health indicators in rural areas also remains sub optimal (73%).

In most health delivery systems, the information collected by grassroots health functionaries is seldom shared with communities. Further, poor birth registration impedes correct estimation of vital indicators, which affects planning of appropriate and effective interventions. Inaccurate recording of birth weight delays the identification and management of high-risk neonates. Moreover, lack of promotion and monitoring of infant feeding practices and clean drinking water result in worsening nutritional status of children under two years. Delivery of existing health and nutrition programs and community monitoring

by Village Health and Sanitation Committees (VHSCs) needs to be strengthened to ensure optimal service delivery at the village level, especially focusing on correct vital registration and effective promotion and monitoring of nutrition-health practices and indicators.

The project by Deepak Foundation (DF) is part of a larger Safe Motherhood and Child Survival program being implemented in all villages of Vadodara district. It will implement a more intensive program to improve nutritional behavior in a subset of about 300 villages. The project objective is to improve neonatal and infant nutrition practices through inter-departmental convergence, community participation, and the use of a culturally accepted tool (a horoscope that also includes critical health information on the newborn). The project leverages the government initiatives, Nutrition Health Days (NHD) and Anemia Control Program of DF where the ASHA, Anganwadi Worker and Auxiliary Nurse Midwife conduct behavior change communication (BCC) campaigns on key health-nutrition issues. In addition to conducting home visits for BCC and supporting ANM and AWW in maintaining a beneficiary database, ASHA will also document information on time of birth, Page 26 of 48

birth weight, and time of initiating breastfeeding, needed to prepare the horoscope. The information is processed at the block level and the horoscope is distributed through outreach workers. This printed and laminated card could also help in validating vital statistics for giving birth certificates. The project beneficiaries will be newborns, children below two years of age, pregnant and nursing mothers and community members in 200 out of around 700 villages from four tribal blocks of Vadodara District Deepak Foundation will use a

culturally accepted tool—a horoscope that also includes critical health information on the newborn.

The convergence of VHSCs with water committees under Water and Sanitation Management Organization (WASMO) will raise awareness through wall paintings on nutrition-health issues, drinking water quality, and ensure distribution of fortified complementary food premix and iron supplements. Correct birth weight recording allows timely management of low birth weight babies, a common cause of high neonatal mortality and child undernutrition. Community involvement in celebrating birth of each child during the government campaigns of Nutrition Health days will ensure that government’s efforts at convergence of health and nutrition programs are effectively monitored by community members.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) DF has been implementing developmental programs in sectors of maternal and child health, livelihood promotion and pre-school education since 1982. Safe Motherhood and Child Survival is the core intervention project implemented through community participation covering all 1548 villages of Vadodara District, Gujarat in partnership with GoG, which has given constant encouragement to such public-private partnerships and supported a consortium of voluntary bodies to increase their role as ombudsman for improving health services in the State.

CONTACT INFORMATION Archana Joshi Director Deepak Foundation “Deepak Farm”, Near Harikrupa Society Vadodara Gujarat 390021 India Email: joshi@deepakfoundation.org, deepakfoundation@deepakfoundation.org www.deepakfoundation.org Tel. 91-265-2371439, 91-265-2371410 Fax: 91-265-2371679

Amarjit Singh Commissioner Health Department of Health & Family Welfare, Gujarat Block.no.5, Dr. Jivraj Mehta Bhavan, Old SachivalyaGandhinagar Gujarat 382010 India Email: cohealth@gujarat.gov.in Website: www.gujhealth.gov.in Tel. 079-23253271 Fax: 079-23256430

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B ANGLADESH : P ROMOTING BETTER INFA NT AND CHILD FEEDING PRACTICE S THROUGH PERFORMANCE - BASED PAYMENT In the slums, the rate of wasting among infants <6 months is 31% compared to only 5% among the nonslum population. Previous research has shown that suboptimal breastfeeding practices and inadequate complementary foods are associated with increased malnutrition, morbidity and mortality among infants and young children. In the urban areas, 41% of infants are put to breast within one hour of birth, 62% receive pre-lacteals, 6.6% infants are exclusively breastfed to 6-7 months, and the quality and frequency of giving complementary foods during 6-24 months are below what is recommended. It is, therefore, important that context-specific Infant and Young Child Feeding (IYCF) messages are conveyed to mothers in slum areas.

The Traditional Birth Attendants (TBA) are a significant part of the informal health care system in the urban slums as they attend almost 68% of births. The TBAs are, therefore, well-positioned to promote key infant feeding messages during the early part of infancy. In recent years, BRAC has been training the TBAs in safe motherhood issues. However, in the urban areas there have been significant dropouts as salaries offered to TBAs have not been competitive.

This SAR DM funded, â&#x20AC;&#x153;Promoting Better IYCF Practices in Urban Slums using Performance Based Paymentâ&#x20AC;? project is being implemented by ICDDR,B covering Shat Tala slum in Mohakhali, Dhaka. The project beneficiaries are mothers and other family members of children under one year age and the objectives are to increase the rates of breastfeeding initiation, increase the rates of exclusive breastfeeding, improve the quality and quantity of complementary foods, empower TBAs and local community groups to promote infant and child nutrition and lastly, create a market for nutrition education within the community and the health system. The project uses existing informal health workforce positioned to work in infant and young child feeding by providing training, referral and community linkages to community nutrition volunteers (CNVs) to raise their self-efficacy. The project also provides financial incentives for improved practices to motivate the health workforce to be innovative in their approach and strive for results.

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The project uses performance-based payment to TBAs to promote key infant and young child feeding in the slum population to improve the rates of appropriate breastfeeding and complementary feeding practices of infants and children under two years of age in Dhaka slums, disseminate context-specific IYCF messages to mothers in slum areas and use performance-based payment In urban areas, 41% of infants are put to to TBAs to promote key concepts of breast within 1 hour of birth, 62% receive IYCF in slum population.

pre-lacteals, but only 6.6% are exclusively breastfed to 6-7 months, and the quality and frequency of complementary feeding between 6 and 24 months is below recommendations.

Interested TBAs will be given training in IYCF. They will disseminate IYCF messages to mothers of infants under two years of age who will provide a list of all mothers they have reached to project staff. The TBAs will be paid remuneration for each ideal practice that the mothers on their list practiced after verification by project staff. The training, referral linkages with ICDDRB public health physician and community mobilization for IYCF that are planned as a part of the project is expected to increase the profile and social acceptability of TBAs. Their involvement in the project will be part-time allowing them to engage in other income generating activities.

Community groups and TBAs are an essential part of the informal healthcare system in both urban and rural areas of Bangladesh. Children under two years of age and their mothers will be the direct beneficiaries of this project. Improvement in feeding practice will have a positive impact on the childrenâ&#x20AC;&#x2122;s nutritional status. Training and access to referral and community network will empower TBAs and provide them with future employment opportunities. If successful as a pilot, this program could be scaled up in other areas of Bangladesh.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) ICDDR,B was founded in the 1960s and has extensive experience in conducting health research and providing evidence-based health-related services and training in collaboration with public sector and civil society partners. It partners with over 100 organizations including the Government of Bangladesh, other national governments, international institutions and national and international civil society partners.

CONTACT INFORMATION Dr. Sabrina Rasheed Assistant Scientist International Centre for Diarrheal Diseases Research, Bangladesh (ICDDR,B) GPO box 128 Dhaka 1000 Bangladesh

Email: sabrina1@icddrb.org Website: icddrb.org Tel. 88028810021 Fax: 88028826050

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P AKISTAN : A COMPREHENSIVE COMMUNITY - BASED INTERVENTION TO IMPROVE LINEAR GROWTH IN CHILDREN AGED

6-18 MONTHS

Deficiencies of iron and zinc have adverse effects on infantsâ&#x20AC;&#x2122; growth, development and immunity, and they contribute substantially towards morbidity and mortality. In Pakistan, inappropriate weaning/breastfeeding practices include: lack of exclusive breastfeeding for the recommended period of 6 months; stopping breastfeeding before two years; widespread formula feeding with substantial dilution; initiating liquids and semi-solids before six months; substantial dilution of solids for bottle feeding; and avoiding meat (rich source for zinc/iron) before 2 years of age. Most of these practices are due to lack of awareness and poverty. The former leads to selection of inappropriate foods while the latter leads to low quality of food. These result in massive nutritional deficiencies ending up in infantsâ&#x20AC;&#x2122; poor growth, development and defense mechanisms putting them at the risk of preventable infections, illnesses, morbidities, and mortality. These could be mitigated by counseling families and mothers about appropriate feeding practices and supplementation.

The Lady Health Workers (LHWs) of the National Program for Family Planning and Primary Health Care address these factors through antenatal dietary counseling and iron supplementation, promoting appropriate breastfeeding/weaning practices, and management of childhood infections. However, these strategies do not address zinc and iron deficiencies.

This project will conduct a randomized, controlled trial of counseling mothers/family members by senior women community-workers to introduce chicken liver as a complementary food for infants aged 6-18 months by enrolling 300 infants from urban slums of a cluster in Karachi, where 150 infants will receive chicken liver thrice a week and 150 will have their traditional feeding practices. The cluster will be selected from the operational areas of the Health and Nutrition Development Society (HANDS). All 300 infants would be followed for 18 months. The interventions will compare the potential benefits of incorporating chicken liver into routine infant and toddler feeding versus optimized traditional complementary feeding regimens. The use of chicken liver as a complementary food for infants is an innovative idea. Chicken liver is a rich source of zinc and iron with potential salutary impact on the linear growth of infants. Moreover, involving elderly women from the local community to counsel mothers and families of infants will be a new idea for improving the usage of chicken liver.

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The specific aim of this project is to determine the impact of intake of chicken liver as a source of zinc and iron in infants between 6-18 months of age on linear growth velocity and infectious disease morbidity in a population dependent on traditional feeding practices for complementary feeding. Established strategies for childhood nutrition focus on food fortification or the use of supplements for the amelioration of zinc and iron deficiency. The effectiveness of these programs is uncertain. Moreover, the acceptability of fortified Chicken liver is a rich source for foods in Pakistan is low as people generally fear the zinc and iron with potential safety of such fortifications, especially for infants and salutary impact on the linear children, and use of supplements is expensive. By growth of infants. comparison, little attention has been paid to foods naturally high in zinc and iron that are locally available and affordable. The current National Program for Family Planning and Primary Health Care attempts to address the poor nutritional status of infants through a variety of strategies, however, malnutrition and specifically, iron and zinc deficiencies remain prevalent in Pakistan.

Once the project is complete, results will be shared with the National Program for Family Planning and Primary Health Care and recommendations will be made for continuing the activities by LHWs so that messages given to pregnant women continue. The cost of adding chicken liver is small and is affordable for the families. Since the project will only sensitize the community through LHWs and community workers, it can be replicated in any community.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) AKU, established in 1983, is an autonomous, international institution. Its Community Health Science (CHS) Department has a niche for community-based needs assessment and research, both action and operational. CHS has taken a leadership role in the development of primary health care and health systems in the country. HANDS is a registered NGO working in health, education, poverty alleviation and infrastructure development through direct interventions. HANDS caters a population of 8,000,000 especially women and children in Sindh, including Karachi. The infants will be enrolled from the urban slums of Karachi which will be selected from one of the operational areas of HANDS. HANDS will also facilitate the implementation of the intervention through identifying the local community elderly women.

Moreover, HANDS will conduct the training of LHWs.

CONTACT INFORMATION Dr. Neelofar Sami Faculty Member Community Health Sciences Department Aga Khan University, Karachi, Pakistan Community Health Sciences Department stadium Road Karachi 74800 Pakistan Email: neelofar.sami@aku.edu Website: www.aku.edu Tel. 92214864828 Fax: 92214934294

Tanveer Shaikh Executive Director Health and Nutrition Development Society 140-C Block II PECHS Karachi Pakistan Email: info@hands.org.pk, www.hands.org.pk Tel. 92214532804 Fax: 92214559252

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I NDIA : USING CELL PHONE TECHNOLOGY TO IMPROVE EXCLUSIVE BREASTFEEDING AND REDUCE INFANT MORBIDITY Breastfeeding has profound health benefits for infants and mothers and has an economic advantage over all other forms of feeding. Exclusive breastfeeding (EBF) for six months prevents up to 13% of the annual 10.8 million childhood deaths worldwide. Despite WHO/UNICEF’s Baby Friendly Hospital Initiative (BFHI) in India in 1993, there have been only minimal improvements in EBF. In India, breastfeeding in the first hour of birth is at 23.5%, 75% thereafter, and declines to 16.5% at six months, largely due to inadequate counseling, support, and rampant use of infant milk substitutes. There is an urgent need to find innovative ways to promote exclusive breastfeeding to enhance the effectiveness of BFHI. This community intervention, “Evaluation of the Effectiveness of Cell Phone Technology as Communitybased Intervention to Improve Exclusive Breastfeeding and Reduce Infant Morbidity”, has the potential to change household health behavior through cell phones. In March 2008, India, the second largest mobile market in the world, had an estimated 261 million subscribers to mobile phones (a fourth of the country’s population and expected to reach half by 2010). Despite expanded coverage and affordability, cell phones have not been used for nutritional counseling. Other nutrition enhancing programs are health center based. By providing the mothers flexibility to call when she most needs help and through frequent reminders, promotion messages and ring tones for enhancing and adhering to desired health behavior, this intervention will empower women to overcome barriers of leaving home after delivery and that of transportation.

The objective is to improve rates of EBF over a control group by innovative use of cell phones to provide ongoing encouragement and counseling with a lactation counselor throughout the post partum period to six months, and on-going weekly SMSs. Women can also call for advice on breastfeeding as needed. This will demonstrate the efficacy of cell phones for lactation consultation and support for improving infant feeding indicators (timely initiation, EBF, timely complimentary feeding), understanding their barriers, reducing infant morbidity, and improving maternal satisfaction.

The intervention aims to achieve at least a 30% increase in rates of initiation of BF and EBF and of complimentary feeding at six months, and a 25% decrease in morbidities in infants 0 to 6 months in the group with

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cell phone counseling as compared to the control group. We also hope to sustain a 30% improvement in EBF rates in the post implementation phase. We will also assess its cost effectiveness to improve EBF rates and reduce infant morbidity as compared to BFHI program alone. Cell phone counseling has the potential for incorporation in national programs to improve feeding practices.

The project provides new mothers a number to call for help, frequent reminders, promotion messages, and ring tones reinforce desired health behavior, which overcome cultural and physical barriers to leaving home after delivery.

This is an innovative intervention for improving nutrition and health even in national programmatic settings. Health personnel in India have not been trained to provide support over the phone, despite it being a timely and effective tool to avert emergencies and reduce unnecessary hospital visits. This method will also promote public-private partnership and encourage corporate social responsibility. It will involve the family, which will assist in planning, implementing, and evaluating nutrition projects. This method has never been assessed for nutrition counseling for infant feeding practices and also needs evaluation of its feasibility, cost effectiveness, and sustenance.

The coverage, use, and penetration of cell phone use is increasing rapidly even in poorly accessible rural areas, making it a valuable tool to obtain timely health advice especially when a visit to health center is difficult. It can also be used for improved implementation of integrated management of neonatal and childhood illnesses of the National Rural Health Mission in India.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S ) Lata Medical Research Foundation (LMRF) was established in 2000, and is dedicated to health research and the consequent community development within the confines of the social responsibility, social cause and ethics through team work and collaborations. It is a 600-bed, well-equipped government district hospital with an annual antenatal clinic attendance of 10,000 pregnant women and 7500 annual deliveries from urban and rural communities.

CONTACT INFORMATION Dr. Archana Patel Vice President & CFO, Research Lata Medical Research Foundation(LMRF) 9/1, Vasant Nagar Nagpur Maharashtra 440022 India Email: apatel.lmrf@gmail.com; dr_apatel@yahoo.com Website: www.latamedicalresearchfoundation.org Tel. 917122249569 Fax: 917122737091

Leena Dhande Associate Professor Pediatrics Indira Gandhi Government Medical College, Nagpur Government Central Avenue Road Nagpur Maharashtra 440018 India Email: leenadhande@hotmail.com Tel. +919822467572 Fax. 917122737091

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N EPAL : N UTRITION THROUGH KNO WLEDGE According to WHO, malnutrition in Nepal is at crisis level. Nepal ranked last among 177 countries in terms of proportion of children classified as underweight (UNDP, 2004). While aggregated malnutrition indicators at national level show that nutrition status of children has improved slightly over the past years, wasting, an indicator of acute malnutrition, has increased from 10 to 13% (DHS, 2006). This high prevalence of malnutrition contributes to the high rates of disease and death in children, as well as to their slowed physical, mental growth and development (NHD, 2004). If malnutrition can be reduced, child mortality will be reduced by half. However, public awareness about this is severely lacking throughout Nepal, including the capital, where chronic malnourishment rates of over 50% in children under age five have been reported (NHDP, 2004). Though poverty is the main contributor to this situation, knowledge among mothers on feeding practices is very limited. Childrenâ&#x20AC;&#x2122;s diets are less energy dense, lack diversity, and less rich in vitamins and minerals than the diet of the household. Together with insufficient meal frequency, children in most households do not receive an adequate nutrient intake in portions they can digest. Mothers are unaware that the little food that they have access to can be prepared nutritiously.

(Terre des homes, 2005). Our project seeks to address the existing lack of awareness among parents about nutritional requirements for children.

The major objectives of this project are (a) to raise awareness among parents about infant and young child nutrition and its importance for the overall development of children, (b) to empower Nepali women to address various socio-cultural determinants of malnutrition at the household level, and (c) to engage men as key stakeholders and agents of change and advocates within families.

The project produces and broadcasts a radio program called Mamata with an objective of addressing the issues of nutrition of children under five years of age. It is a half-hour program, broadcast weekly by 31 FM stations. Produced in radio-magazine format, the program highlights issues related to nutrition as representative cases and invites experts to discuss it. Similarly, the program also includes monologues, peopleâ&#x20AC;&#x2122;s voices, and interviews in view of giving voices to the issues facing the community. Every program includes success stories of male parents who have contributed and/or played a significant role in the nutrition of their child. The radio listening groups are formed in each project district, members of which comprise both women and men.

The groups meet each week to listen to the radio messages together and discuss Page 34 of 48

the key issues with the assistance of a facilitator employed by the project. Few programs utilize targeted communications to reach out to potential and existing parents on the importance of nutrition and about existing services.

This project will utilize popular radio and focused outreach to provide parents vital information on Nepal’s nutrition policy strategy, maternal nutrition, infant and young child feeding, and importance of exclusive breastfeeding and supplementary feeding after 6 months. Messages targeting women and men on Nutrition and development needs of issues such as women rights and gender equality infants and young children are usually will prompt families, especially men, to ensure a considered a woman’s domain and healthy physical and social environment for this societal norm needs addressing. mothers and young children. This unique approach will address issues around household power relations through effective communication, as men are usually the primary decision makers.

Nutrition and development needs of infants and young children are usually considered a woman’s domain and this is a societal norm that needs addressing. Our approach will also promote discussion and dialogue around topics broadcast, leading to changes in attitudes and perceptions.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S ) As a communications for social change organization established in 2004, EAN combines the power of media with grassroots community mobilization to create customized communications strategies and outreach solutions that address the most critical challenges affecting people in the developing world such as women’s empowerment, youth life skills, livelihoods, microfinance, sustainable agriculture, human rights, and healthcare.

EAN will work with community-based partners of Plan Nepal in four districts. The partner's responsibility is to identify project groups, provide oversight for training, monitor listenership to program and outreach activities; provide feedback and reporting, facilitate monitoring and assessment activities; and integrate the radio program into their existing programs.

CONTACT INFORMATION Binita Shrestha Program Director Sagun Basnet, Program Coordinator DBI, Equal Access Nepal,Jhamsikhel, Lalitpur PO Box 118, Lalitpur, Nepal Lalitpur, Kathmandu Nepal Email: nrijal@equalaccess.org, bshrestha@equalaccess.org Website: www.equalaccess.org.np Tel. +9779851119019 Fax: +97715013561

Plan Nepal Non-Governmental Organization (NGO) Website: www.plan-international.org/where-wework/asia/nepal Tel. +97715535560 Kathmandu

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I NDIA : R EDUCING MATERNAL STR ESSORS TO ENHANCE BIRTH WEIGHT AND INFANT SURVIVAL Life begins in the motherâ&#x20AC;&#x2122;s womb. The health of the mother has a direct bearing on the growing individual. Any intervention to improve infant and child nutrition must not ignore maternal health, dietary practices, and nutritional status. Though these parameters do catch the attention of practitioners and policy planners, a vital aspect ignored is the stress factors during pregnancy that can influence pregnancy outcome. In the Indian context, these psychosocial stressors assume greater significance in light of living in joint families and the pressure to produce a male child. Recent reports highlight that India has not been very successful in dealing with the problem of Low Birth Weight (LBW) births with 22% of newborns still being LBW. Socio-cultural and psychological issues, if established as significant stressors, would necessitate a shift from health and nutrition interventions for pregnant women to a more holistic approach.

LBW contributes to high neonatal and infant mortality. Moreover, most LBW infants who survive have little chance of fully reaching their growth potential. LBW of newborns is associated with impaired immune function, poor cognitive development, and high risks of developing acute diarrhea or pneumonia and as adults, LBW children face an increased risk of chronic diseases including hypertension, diabetes mellitus, coronary heart disease and stroke. Therefore, any intervention targeted to enhance nutrition during infancy should actually begin with the well-being of the mother and the newborn.

Maternal psychosocial stressors may have an adverse impact on fetal growth, resulting in LBW births.

Intervening to develop a positive state of mind and improve self-esteem will result in improvement in nutrition practices, maternal health and improved birth weight of the newborn.

The innovation HAPPI (Healthy and Positive Pregnancy Initiative) will be designed to reduce stress during pregnancy. HAPPI is a package that would include IEC material on nutrition, health and psychosocial wellbeing during pregnancy. The intervention package will use multiple methods like theatre, role play, developing jingles, yoga, and meditation and will also incorporate traditional Indian wisdom to build up happiness quotient, a sense of well-being and optimism in the pregnant women.

The overall objective is to systematically explore maternal psychosocial stressors which may impact neonatal health and survival so as to enhance the nutrition and health status of pregnant women and intervene to develop positive state of mind and improve selfesteem.

The specific objectives include: â&#x20AC;˘ To evaluate pregnant women on sociocultural, health and

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â&#x20AC;˘ â&#x20AC;˘ â&#x20AC;˘

nutritional profile, maternal personal resources and prenatal stressors.

To develop and implement an innovative intervention package to address nutritional and psychosocial well-being and reduce stress during pregnancy.

To assess the effectiveness of the intervention in terms of pregnancy outcome.

To determine associations between pregnancy outcome and sociocultural, health and nutritional profile, maternal personal resources and prenatal stressors.

Any innovation to augment infant and child nutrition would ignore the prenatal beginnings at its own peril. The project is unique as it addresses the concern of ensuring the well-being of the growing fetus by not just focusing on the obvious nutrition needs of the mother, but also the psycho-social and cultural stressors that she faces which could have a bearing on the birth outcome.

Intervening to develop a positive state of mind and improve self-esteem will result in improvement in nutrition practices, maternal health and improved birth weight.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S )

A College of the University Of Delhi, the Institute Of Home Economics, was established in 1961 and offers undergraduate degree in home science (with majors in human development, food and nutrition), microbiology, biochemistry and elementary education. It offers post graduate and Ph.D. programmes.

Experienced faculty members are actively involved in research of national and international acclaim.

Manzil offers for slum children and women, preschool education, nutrition health education and vocational training. The underprivileged youth receive opportunities for computer literacy, personality development and life skills enhancement.

CONTACT INFORMATION Dr. Seema Puri; Dr. Geeta Chopra Associate Professors Nutrition, Human Development Departments Institute Of Home Economics, University Of Delhi F4 Hauz Khas Enclave Delhi 110016 India Email: dr.seemapuri@gmail.com; drgeeta_chopra@yahoo.com Website: www. ihe-du.co.in Tel. 91-11-46018108 Fax: 91-11-26510616

Ravi Gulati Coordinator Manzil Welfare Society 13 Khan Market New Delhi Delhi 110001 India Email: mail@manzil.in, www.manzil.in Tel. 91-11-24618513 Fax: 91-11-29815857

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P AKISTAN : H OME BASED NUTRITION REHABILITATION OF SEVERELY MALNOURISHE D CHILDREN In Pakistan, 38% of all children below five years of age (estimated >3 million children) are moderate to severely underweight and 9.6% of children 6-24 months are moderate to severely malnourished. This figure is higher in rural areas due to poverty, illiteracy, and a lack of awareness of mothers regarding infant and young child feeding. Health facilities are lacking, and the ones present are located in towns and cities far from the rural population.

According to initial WHO protocols, severely malnourished children should be managed in hospitals, but given the limitations and the unfeasibility of admission of such large numbers of children for 4-6 weeks, it is imperative to look for alternate home-based strategies. Community-based WHO protocol (CMAM) suggests ready-to-use therapeutic foods to manage severe acute malnutrition, which are imported and expensive.

After consultation with nutritionists, HELP (Health Education and Literacy Program) formulated an indigenous High Density Diet (HDD), which is highly cost effective compared to the imported RUTF. HDD is an indigenous and low cost diet comprising of rice, pulses, milk powder, oil, and sugar. Appropriately packed, HDD has a shelf life of 6 months. This can replace high cost food supplements currently imported by donor agencies for use in rehabilitation of malnourished children. HELP conducted a pilot study in a peri-urban slum to determine HDD’s effect. The project was successful in all three of its objectives: 

Improve nutrition of 90% identified children using HDD;



Counsel 90% mothers and family members of target households on key messages regarding feeding of infants and young children through trained LHWs; and



Build capacity of government health facilities and their personnel in target areas in order to stabilize severely malnourished children with complications.

The innovation is that homebased directly observed therapy (DOTS) to rehabilitate severely malnourished children, using indigenous and low cost HDD for treating severe malnutrition, is an alternative to standard recommended WHO protocols.

The key project partner is the government’s National Program

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for the Family Planning and Primary Health Care that is run throughout the country and has Lady Health Workers (LHWs) throughout the country.

High Density Diet is an indigenous and low cost diet consisting of rice, pulses, milk powder, oil, and sugar.

A B O U T TH E P R O J E C T I M PL E M E N T E R ( S )

HELP is a community-based primary health care and education program working in various slum areas of Karachi and rural Sindh. Its chief focus is on the health care of women of reproductive age and children, pertaining to nutrition, immunization and reproductive health. HELPâ&#x20AC;&#x2122;s team consists of highly committed professionals.

National Programme for Family Planning and Primary Healthcare is a federal government funded project covering all four provinces. Trained community health workers provide basic preventive health care to mothers/children at their doorstep including growth monitoring of children and nutrition counseling.

CONTACT INFORMATION Prof. Dure- Samin Akram Executive Director (honorary) HELP (Health Education and Literacy Program) 1-C, 3rd commercial street, Zamzama. Phase 6, Karachi Karachi Sindh 75600 Pakistan Email: dsakram@gmail.comhelpngo@post.com Website: www.helpngo.org.pk Tel. 0092215834465 Fax: 0092215834465

National Programme for Family Planning and Primary Healthcare (est. 1992) 14-D (West) Feroze Center Blue Area, Islamabad Pakistan Email: fpiu@phc.gov.pk Website: www.phc.gov.pk/sindh.php Tel. 051-9202289 Fax: 051-9215610

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N EPAL : A CTION A GAINST M ALNUTRITION THROUGH A GRICULTURE (AAMA) Despite progress in reducing child/maternal morbidity, Nepalâ&#x20AC;&#x2122;s current infant and under-five mortality rates remains some of the highest in the Asia-Pacific region. Additionally, the progress is spread unevenly throughout the Nepal. The Nepal Demographic and Health Survey (NDHS) 2006 shows that in the Far Western Region (FWR), the infant mortality rate stands at 74% while the under-five mortality rate is 100.

Malnutrition levels remain unacceptably high. Stunting or evidence of chronic malnutrition among children under-five is 49% nationally and 52% in the FWR; wasting or evidence of recent severe undernutrition peaks at 23% in children 12-24 months and rates in the Far Western terai are among the highest. Anemia prevalence is extremely high among both women of reproductive age and young children, at over 50%.

Feeding and care practices of young children combined with poor sanitation practices are a major cause of poor nutritional status. The NDHS 2006 showed that 36% of children 6-9 months receive less than two meals a day and 64% less than three food groups. The average duration of exclusive breastfeeding was four months, short of the six month WHO recommendation, and upon introduction of complementary food only 50% of children under 12 months of age consumed fruits/vegetables. In the FWR, year-round household food security is a main obstacle to achieving optimum nutrition in young children and women.

Equally important, optimal feeding practices for improved nutrition, especially for infants, young children and their mothers are under-utilized.

The major objectives of the Action Against Malnutrition through Agriculture (AAMA) project are to improve the nutrition and health status of children under two years and pregnant and lactating women and to increase the accessibility and availability of year round micronutrient-rich foods for consumption by the target population groups. The main project strategies include (a) Essential Nutrition Actions (ENA), (b) Homestead Food Production (HFP), and (c) Behavior Change. ENA covers breastfeeding, complementary feeding, maternal nutrition, nutrition for sick child, and micronutrient deficiencies.

Similarly, HFP include Village Model Farms (VMF), home gardens and poultry. BCC include activities such counseling and negotiations skills, IEC and follow up.

By creating strong community level linkages between these sectors, households, individual mothers, and children under two will benefit through improved household food Page 40 of 48

consumption and nutritional practices. AAMA will use HKI’s proven HFP model that increases households’ year-round access to nutritious foods as a platform to deliver a package of Essential Nutrition Actions.

HKI’s HFP model is innovative: an improved, completely organic, diversified approach for increasing yearround food production, targeting women as the primary beneficiaries and establishing community capacity to sustain the program.

Creating strong community level linkages between sectors, allows households, mothers, and children under 2 benefit from improved household food consumption and nutritional practices.

HKI’s experience with the ENA framework has demonstrated positive impact on nutrition behaviors and maternal and child health. The intent is to disseminate key messages on seven fundamental topics (breastfeeding, complementary feeding, maternal nutrition and more) using advanced BCC techniques through multiple program pathways.

The AAMA approach will address food security and nutrition constraints simultaneously. It will teach sound nutritional practices, develop and disseminate messages targeting traditional beliefs, and increase year round food supply to enable such change. The program will provide marginalized/vulnerable groups with the technical inputs/supplies they need to improve food supply and overcome malnutrition and poverty together.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S ) Helen Keller International, established in 1915, is a private voluntary organization with expertise in nutrition (including breastfeeding, complementary feeding, micronutrient supplementation, food fortification, dietary diversification, nutritional surveillance, and nutrition and infectious diseases) and eye health (including cataract, trachoma, onchocerciasis control, and refractive error). The agency has programs in 23 countries.

Established in 1990, NNSWA is one of the leading development organizations in the FWR. Education, early Childhood Development, Reproductive Health, Nutrition, Trachoma Reduction, Women's Empowerment, and Advocacy constitute its core focus and expertise.

CONTACT INFORMATION David Spiro Country Director-Nepal Helen Keller International PO BOX 3752 Green Block, Ward #10 Chakupat, Patan Dhoka Kathmandu Nepal Email: dspiro@hki.org Website: www.hki.org Tel. 977-1-5547359 Fax: 977-1-5547359

Ashok Jairu Executive Director Nepali National Social Welfare Association (NNSWA) Airport Road Bhimdutta Municipality Ward-# 18, Kanchanpur Nepal Email: nnswa06@ntc.net.np Website: www.nnswa.org Tel. 977-99-522182 Phone: 977-99-523805

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I NDIA : S OCIAL C APITAL AS A CATAPULT FOR IMPROVING INFANT FEEDING Infant feeding is the most effective intervention in improving the health of children. A recent study as part of The Lancet Maternal and Child Undernutrition Series estimated that sub-optimal breastfeeding, especially non-exclusive breastfeeding in the first 6 months of life, results in 1.4 million deaths and 10% of the disease burden in children younger than five years old. Breastfed infants show better cognitive development, good weight gain and neurological development, particularly in premature and term infants.

In India, breastfeeding is practiced universally in rural as well as urban areas. However, there continue to be reasons why there is no exclusive breastfeeding for first six months, as recommended. These reasons are linked to the mother’s health and nutritional status, socio-cultural practices and also beliefs and rituals concerning “purity” and “impurity.” Only 27.8 % of the infants in Gujarat are breastfed within one hour of delivery, and exclusive breastfeeding for first six months is lower than 30%. Thus there are still gaps in the evidence-based practices due to possible lack of knowledge and strong age old practices percolated by elders in the family who defy scientific knowledge.

AKHS,I seeks to design specific interventions in improving infant feeding practices (breastfeeding, colostrums feeding and complementary feeding) working on the concept of social capital which is an integral part of rural communities. Social capital can be considered as the resource of community that is built over a period of time, through the networks of participation, group membership, shared norms, trust and most importantly a feeling of ‘belonging’.

The project seeks to improve knowledge, attitude and practices related to infant feeding by providing adolescent girls, mothers and grandmothers of infants with accurate information, thus dispelling their myths and misconceptions. The target groups for this project are pregnant and lactating women.

As grandmothers exert considerable influence in the care of the newborn and children, they form the secondary audience of the project to help promote recommended Page 42 of 48

behavior and discourage traditional practices which are harmful to the child. Adolescent girls are also form a secondary target group to sensitize future mothers as well as reinforce practices among young mothers in their communities. The project area comprises seven villages in Malia block of Junagarh district in Gujarat.

Social capital is particularly relevant to addressing the issue of infant feeding since the practices are to a large extent influenced by traditional beliefs and customs rather than medical recommendations. The The techniques of discussion and project seeks to involve the support and participation personal stories will be used since of the key influencing members in a baby’s life – the health related decision making is mother and grandmother. Unlike conventional programs addressing infant nutrition in a ‘top down’, not just information-linked, but also informational manner, this project tries to engage linked to other socio-cultural communities in combining scientific knowledge using factors. traditional communication mediums. Using the tool of social capital, the techniques of discussions and personal stories will be used since health related decision making is not just information-linked, but also linked to other socio-cultural factors. The village as a community will be encouraged to address the problem along with adolescent girls (‘future mothers), ‘present mothers’ and ‘past mothers’.

Participation by adolescent girls entails influencing decision making of future mothers. Close observation and involvement in the whole process of infant care will give them a greater sense of critical thinking and responsible decision making. Furthermore, recognizing the significance that older women have as health advisors and decision makers, they have been included to play a pivotal role. Seeking their participation and equipping them with correct information will help to create an enabling environment for mothers to adopt correct infant feeding practices.

Thus the project works with current, future and past mothers, seeking a holistic, sustainable lifecycle approach to addressing the issue. This is the outcome-linked innovation of the project. The process-linked innovation lies in use of existing communication channels of women to discuss and act upon a critical issue.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S ) Aga Khan Health Service (AKHS) was established in 1986 as part of Aga Khan Development is an international non-profit organization. AKHS, India focuses on promoting effective, sustainable healthcare of underserved populations, especially women and children in Gujarat.

CONTACT INFORMATION Dr. Sultan Pradhan Chairman Community Health Division Aga Khan Health Services, India Diamond Complex, 3rd floor, 39/43 Nesbit Road, Mazgaon, Mumbai Maharashtra, India 400 010 Email: akhealth@gmail.com

Dr. Sulaiman Ladhani Program Director Email: sladhani@gmail.com Tel. 912266139630 Fax: 912266139670

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B ANGLADESH : E MPOWERING WOMEN AND ADOLESCENTS TO IMPROVE INFANT AND YOUNG CHI LD NUTRITION Bangladesh has the second highest rate of child malnutrition in South Asia with 41% of children below 5 years underweight (BDHS, 20007), and it is slightly higher in Chittagong division at 43%. High malnutrition rates are largely due to suboptimal infant and young child feeding (IYCF) practices and frequent illness.

While almost all children are breastfed, delayed initiation of breastfeeding, pre-lacteal feeding, nonexclusive breastfeeding, bottle feeding and inappropriate complementary feeding (either early or late) are common and contribute to malnutrition, which peak between 6-12 months. Despite efforts by governmental and other agencies, exclusive breastfeeding rates for infants below six months has stagnated at around 40% for last 15 years. Mixed (breast and bottle) feeding is common in urban and rural areas and is generally not discouraged by health workers. Skilled support for breastfeeding is almost non-existent. Community-based IYCF promotion activities are conducted through the National Nutrition Program but cover only about 20% of the country.

The idea is to prevent malnutrition by improved quality and intensity of counseling on complementary feeding (CF) in addition to exclusive breastfeeding (EBF), promotion of culturally acceptable and affordable complementary foods and micronutrient powder for enriching diets of infants and young children 6-24 months where needed; and by involving adolescents and community members—fathers, grandfathers, influential men. Adequate knowledge and motivation levels for specific actions needed to improve CF are weak. The project has trained community women as peer counselors (PCs) who provide individual home visits from the third trimester of pregnancy until infants are one year old to improve IYCF. PCs have demonstrated impact on EBF, and will be able to use the same techniques to promote and support complementary feeding. They will encourage timely and appropriate access and utilization of health care, good sanitation and hygiene. PCs are well accepted in the community, are monitored and receive supportive supervision.

The innovations of this project include: a) PCs trained to promote complementary feeding effectively; b) cell phones for communication c) adolescent girls trained to promote IYCF, computers provided to group leaders; d) influential local community leaders are actively involved - for suggestions, support, advocacy, and “buy in;” and e) referral linkages are established with health

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facilities/organizations.

The project’s holistic community approach goes beyond the short term DM project phase for each of the following innovative ideas: •

Empowering female community-based peer counselors to support appropriate complementary feeding, and sustainable household and health-seeking behaviors – with cell phones for communication and referral between the community and health facilities; Bangladesh has the second highest • Informing and involving fathers in buying rates of child malnutrition in South diverse foods, child care, responsive feeding and Asia with 41% children below 5 years parenting, and involving influential men in the community in order to change social norms about underweight. infant nutrition for sustainability; • Empowering adolescents to understand the importance of appropriate nutrition for themselves and for young children, and be responsible for IYCN promotion in some households by, ensuring adolescents are already knowledgeable about IYCF BEFORE they become parents – and utilizing their abilities to promote IYCN; and providing computer assisted learning – CAL for adolescents – in addition to basic computer literacy - as an incentive to join the adolescent groups and promote IYCF; and • Establishment of referral linkages with health facilities and NGOs to promote and support IYCF, and provision of affordable health services tailored to urban and rural needs.

A B O U T T H E P R O J E C T I M PL E M E N TE R ( S ) A non-profit organization formed by dedicated professionals established in 2000, TAHN aims to improve the health, nutrition and well-being of communities by empowering and enabling them. TAHN supports PCS for IYCF and nutrition, trains government and non-government health workers, community volunteers, undertakes strategy development, evaluation of programs, and conducts relevant research.

Plan Bangladesh (BD) was established in 1994 and aims to ensure basic needs of children, adolescents, women and men, advocating community participation and ownership for social development, health, learning and family economic security. Plan BD has an advisory role for TAHN, focusing especially on their experiences of working both with other NGOs and with government health services providers on adolescent reproductive health, and on ensuring community participation and ownership.

CONTACT INFORMATION Dr Rukhsana Haider Chairperson Training And Assistance For Health And Nutrition House 15, Rd 128, Gulshan-1 Dhaka 1212 Bangladesh Email: rukhsana.haider@gmail.com Website: www.tahn.net Tel. +8801715034902

Edward Espey Country Director Plan Bangladesh House 14, Road 35, Gulshan-2 Dhaka 1212 Bangladesh Email: Ned.Espey@plan-international.org Website : www.plan-international.org Tel. +8802-8826209 Fax: +8802-9861599

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I NDIA : A DDRESSING I RON D EFICIENCY A NEMIA IN R URAL R AJASTHAN T HROUGH I RON F ORTIFICATION OF F LOUR Iron deficiency anemia (IDA) is one of the most common nutritional disorders, and it has a profound effect on psychological and physical development, work performance, and, as a result, on productivity. A study conducted in 2002-03 by Seva Mandir and Massachusetts Institute of Technology found 80% of women, 51% of men and 90% of children are anemic. The study showed that the principal reason for high anemia is poor dietary intake of iron. There is lack of iron rich foods in the region and efforts to improve anemia through supplemental tablets have failed due to very low intake rates in these areas. Iron supplementation of foods is an attractive alternative as it requires no additional effort on the part of the consumer, and can be done relatively cheaply in centralized locations. However, for very poor and isolated population, such as the population in the tribal district of Udaipur, centralized food fortification is not a practical solution: most households consume their own grain, and do not purchase any goods that could easily be fortified. Even households who obtain wheat or maize from the Public Distribution System obtain whole grain, which cannot be fortified. Fortification of commercialized food would thus leave marginalized households behind, which would be particularly unfortunate given that they are likely to be the most at risk for IDA. This project is designed to provide the option for iron supplementation for households who do not buy processed food (including flour), and can therefore not be targeted by centralized fortification.

The project aims at addressing anemia among the general population with special focus on pregnant women and children aged 0-24 months by increasing the intake of iron through fortified flour and by educating the mothers and pregnant women on nutrition and feeding practices.

The key innovations of the project are the decentralized delivery system and equipment for fortifying flour. The fortification equipment (a hand operated blender) designed at the local level is also very easy to handle and involves very simple technology. The program is designed to provide the option for iron supplementation for households who do not buy processed food (including flour), and can therefore not be targeted by centralized fortification. The other innovative idea of the project is to complement education with actual availability. The key implementation strategies of the project are: ď&#x201A;ˇ Mapping of village mills and meeting with villagers to select mills for fortification; ď&#x201A;ˇ Training of millers and provision of fortification equipment along with instruction manual; and Page 46 of 48



Training of village volunteers for educating and counseling pregnant women and mothers of children aged 0-24 months on nutrition during pregnancy, breastfeeding and weaning practices, and the use of fortified wheat flour.



Fortification of flour by mill owners. The millers are provided with pre blend on a fixed date every month. Considering the extra workload on account of fortification activities, the millers are paid certain amount based on their performance (higher the production of fortified flour, the higher the fee amount).



Special meetings and counseling of pregnant women and caregivers of children is another strategy involved in the project to ensure continued consumption of fortified flour.

In the past, we tried to address nutritional deficiency through awareness-raising interventions; these awareness interventions alone have been unsuccessful in achieving this goal. Thus, through the project, increased awareness about anemia through education will be coupled with the tangible fortification strategy to achieve a drop in overall anemia rates, specifically among women and children aged 0-24 months. Alongside the project, the TBAs and Bal Sakhis will focus on education on exclusive Iron supplementation is an attractive breastfeeding for children under six months to alternative that requires no additional lactating mothers. While children aged 6-12 months will get their iron requirement from effort on the part of the consumer and weaning food prepared using fortified flour; for can be done relatively cheaply in adults including pregnant and lactating women and centralized locations. children aged 12-24 months, chapattis made out of fortified flour will be a source of increased iron intake. The project design will include strategies to ensure that the families keep fortifying their flour so that the additional iron intake is there for a consistently long time.

A B O U T T H E P R O J E C T I M PL E M E N T E R ( S ) Seva Mandir was established in 1968 as a non-profit organization based in Udaipur district of Rajasthan, reaching out to over 626 villages and 56 urban slum settlements. Seva Mandir’s work entails creating social, institutional and livelihood base for a democratic and participatory approach to development that benefits and empowers the poorest sections of society.

CONTACT INFORMATION Neelima Khetan Chief Executive, Health Unit Seva Mandir Seva Mandir, Old Fatehpura Udaipur Rajasthan 313004 India Email: neelima@sevamandir.org, health@sevamandir.org Website: www.sevamandir.org Tel. 912942451041 Fax: 912942450947

Ms. Priyanka Singh Programme in Charge-Health & Education Email: priyanka.singh@sevamandir.org

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P HOTO C REDITS Front Cover: Deepak Foundation; Aga Khan Health Services, India; Helen Keller International, Inc.; Ziagul, Kakan Village Afghanistan, May 14, 2010; Helen Keller International, Inc.; Sri Lanka Green Friends Environmental Organization; Dr. Reddy's Foundation; HELP (Health Education and Literacy Program; Training And Assistance For Health And Nutrition, Bangladesh Page 6: Ziagul, Kakan Village Afghanistan, May 14, 2010 Page 8: World Bank Page 10: Society for the Elimination of Rural Poverty Page 12: Dr. Reddy's Foundation Page 14: Sri Lanka Green Friends Environmental Organization Page 16: World Bank Page 18: World Bank Page 20: World Bank Page 22: Vijaya Development Resource Center Page 24: MaxPro Pvt. Ltd. Page 26: Deepak Foundation Page 28: World Bank Page 30: Community Health Sciences Department, Aga Khan University, Karachi, Pakistan Page 32: World Bank Page 34: World Bank Page 36: Institute Of Home Economics, University Of Delhi Page 38: HELP (Health Education and Literacy Program) Page 40: Helen Keller International, Inc. Page 42: Aga Khan Health Services, India Page 44: Training and Assistance For Health And Nutrition, Bangladesh Page 46: Curt Carnemark, World Bank, 1996, India Back cover: Sri Lanka Green Friends Environmental Organization

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The World Bank 1818 H Street, NW Washington, D.C. 20433 USA Program Manager: Animesh Shrivastava Telephone: +001-202-473-3652 Internet: www.worldbank.org/safansi Email: safansi@worldbank.org