Newsletter - World Bank in India : October 2023

World Bank in India

Transforming Lives: Bihar's Unsung Heroes of Healthcare and Nutrition

“When my first child was born in 2014, he weighed just around 1.25 kgs,” recalls Ruby Devi, a homemaker in Ratni village of Jehanabad district in the eastern Indian state of Bihar. “He would fall sick often and grew up to be a slow learner.” However, everything changed after 2016 when Ruby Devi learned about the importance of proper nutrition during pregnancy, the ideal spacing between pregnancies, and how to feed her baby correctly. Her second child was born healthier at 3.5 kgs, and is now ready to start second grade, while the elder one remains in the first grade.

Ruby Devi is one of the beneficiaries of the World Bank-supported JEEViKA program, which has significantly improved awareness about nutrition among millions of women members of self-help groups across the state. This is a remarkable achievement, considering Bihar's high percentage of poor people, who face challenges in health, education, and overall standard of living.

Vinita, 29, from Muzaffarnagar, Bihar, is a “Poshan Sakhi” – nutrition friend – under the JEEViKA program. Speaking about the challenges she faced when she first joined the program in 2019, Vinita recalls, "Many women in the village would hastily retreat at the mere mention of nutrition during pregnancy or the importance of regular check-ups." Bihar, at that time, was steeped in old beliefs regarding childbirth, and old mothers argued that what worked for previous generations would suffice for today's young expectant mothers.

Today, Vinita is welcomed with open arms as she visits five to seven households daily, engaging in conversations with pregnant women and their families about proper nutrition, routine health checkups, and even suggesting meals that can be prepared using ingredients readily available in their homes. To indicate progress, she places a red dot – ‘bindi’ in the homes where she feels there is room for improvement

When my first child was born, he was under weight. He would fall sick often and was a slow learner. My Poshan Sakhi taught me about ideal spacing of pregnancy and proper nutrition during pregnancy. I followed her advice, and my second child was healthier and is growing up better.

Ruby Devi, Village Ratni, Jehanabad District, Bihar

and a green one where she is confident that her advice is being followed. Over the years, Vinita is delighted to see the once red bindis gradually turning into vibrant greens.

Poshan Sakhi - Helping Pregnant Women Adopt Healthy Practices

Bihar boasts a dedicated force of some 7,500 Poshan Sakhis, who operate within the government’s JEEViKA program for poverty alleviation. These women are selected based on their interest and knowledge about health and nutrition and receive a 7-day training by Master Resource Persons under the program. They earn about Rs 160 a day and serve as the community nutrition resource person for the gram panchayats, offering crucial guidance

to pregnant and lactating women in dispelling myths related to pregnancy. In doing so, they are jointly supporting the state in bringing down maternal mortality rates.

Bihar has made impressive strides in nutrition. Today, half of the state's young children, under 5-years of age, are eating a more diverse diet, compared to just 2 out of 10 before 2018. *According to 2018-2022 data, 6 out of 10 women of reproductive age are eating better, compared to just 2 out of 10 before. This is particularly noteworthy given Bihar's high rate of child undernutrition, where 41 percent children below 5-years of age are underweight and 69 percent anaemic. Global studies have shown how nutritional deficiencies in the first 1,000 days of life lead to slow physical development and cognitive impairment, with corresponding poor educational outcomes.

Before

2 out of 10 women

2018-2022

6 out of 10 women

2018

More women of reproductive age are eating better

Swasthya Mitra - Friends Who Guide at Hospitals

Almost 250 kilometers away in Bihar’s Bhagalpur district, 27-year-old Shalini wakes up at 4 am, readies her 7-year-old son for school, prepares food for the family, before setting off for her 6 am shift at the medical college, some 15 kilometres away, changing three auto-rickshaws on the way.

Shalini has been working as a Swasthya Mitra – health friend – at the Bhagalpur Medical College since the past 10 months guiding and assisting patients about the right doctors to meet, facilities at the hospital, and medical tests. She says, “The medical college gets about 30-40 patients each day and most of them are poor and unfamiliar with hospital procedures.

Sometimes, for example, they must undergo surgery immediately. It is my job to guide them and to connect them with the right departments.”

Under the JEEViKA program, the Swasthya Mitras are selected based on their interest in health and they must have completed at least grade 12 in school. They receive a two-day training at the All India Institute of Medical Sciences at Patna, the state’s capital city. Shalini acknowledges the steep learning curve she faced initially at the medical college. “It took time to navigate interactions with medical staff, grasp the intricacies of medical terminology, and understand hospital procedures. Today, my proudest achievement is being able to assist underprivileged individuals who journey from distant villages, laden with uncertainty and fear of being misled.”

Many of the patients coming to the medical college are poor and unfamiliar with hospital procedures. They come from distant villages, laden with uncertainty and fear of being misled. It is my job to guide them and to connect them with the right departments.

Shalini, Swasthya Mitra, District Medical College, Bhagalpur, Bihar

Forty-six-year-old Taimul Haque, an HIV patient from Purnia in Bihar, shares his experience, saying he had never visited Bhagalpur before and did not know where to go and what to expect at the hospital.

“Shalini was like a real sister to me and my family as she guided us patiently through the complicated hospital procedures and kept track of follow-up checks for us.”

Twenty-nine-year-old Rinju has a Bachelor of Business Administration degree from Haryana and works at the Sadar Hospital in Jamui district and earns a daily wage of Rs 491. Her husband is unemployed, and she remembers a time when her family of four was going through financial difficulties. “I had to ask my parents and in-laws for money. With the income I earn as a Swasthya Mitra, I can afford to send my children to school without relying on others,” she beams.

According to JEEViKA officials, a distressing trend prevailed earlier, where several expectant mothers failed to reach the Sadar Hospital for timely treatment. . Instead, they were hastily directed to private clinics, where they had to pay a premium on tests and diagnosis. “Middlemen, motivated by incentives from private clinics, used to threaten us if we tried to intervene with the patients,” says Rinju.

Efforts by the district administration and improved services in Sadar hospitals with the help of the Swasthya Sakhis have borne fruit.

Since October 2022, the Sadar Hospital at Jamui has conducted 57 c-sections and more than 600 tests, ultrasounds, and x-rays.

There are 135 Swasthya Mitras working in 35 district hospitals and 10 medical colleges throughout Bihar under the JEEViKa program.

Nourishing the Future

In a parallel endeavor to enhance nutritional outcomes among children between six months and six years of age, Bihar has embraced the Balahar collective enterprise. Supported by the Pusa Agricultural University in the state, Balahar or baby food is a nutrient-packed dry meal comprising wheat, moong daal (lentils), milk powder, sugar and ghee or clarified butter and has received quality certification from the Food Authority of India. It is packed with 370 calories per 100 gram serving and available for purchase at Rs 12 for a 50-gram pack.

Madhu, a 27-year-old mother of two, has been feeding Balahar to her two-and-a-half-year-old daughter since April and plans to continue this practice with her baby boy once he turns six months. Madhu finds that Balahar is an affordable alternative to other supplementary foods available in the market and is packed with essential nutrients necessary for

her daughter’s growth. “My little girl has gained weight and height and I will continue to use it for my second child as well.”

Two Balahar units have been operating in the state’s Samastipur district with World Bank support since December 2022, while another is scheduled to start in Bhagalpur from November 2023. Some 40 women under JEEViKA who had an interest in setting up a small-scale industry were selected and trained by Pusa University in the production, procurement, cleaning, and packaging of Balahar meals.

This multifaceted approach in Bihar showcases a collective determination to empower communities, dispel myths, improve healthcare access, and enhance nutrition, ultimately driving positive change for individuals and families. Given the program’s significant impact, JEEViKA has been recognized as a national resource organization for health and nutrition in India.

Women preparing Balahara nutrient-packed dry meal for children between 6 months to 6 years, packed with 370 calories per 100 grams and available at an affordable price.

New Projects

Kerala: Building Climate Resilience and Protecting about 5 million People from the Impacts of Floods

The World Bank has approved a $150 million loan to support the Resilient Kerala Program. This financing complements the Bank’s earlier investment of $125 million and will continue strengthening the state’s preparedness against natural disasters, climate change impacts, and disease outbreaks. This additional financing will further deepen Kerala’s resilience in the critical areas of coastal erosion and water resource management.

The additional financing will expand and deepen the state’s resilience to mitigate impacts of coastal erosion by building a shoreline management plan. The plan will assess the current and future shoreline changes in the state and create policies to address the risks to environmental resources, human settlements, and infrastructure along the coast.

Additional resources will now address hotspots and vulnerable coastal erosion sites where immediate attention is needed. It will also help develop an integrated river basin management plan for the Pamba river basin and support restoration of rivers and lake embankments to minimize flood damages in future.

Develop an integrated river basin management plan for the Pamba river basin.

Support restoration of embankments on rivers and lakes to reduce flood damage in future.

Integrate digital systems - satellite maps, risk maps - and sectoral data into a single platform for better planning and execution of public sector investments.

The project will help the state develop a climate budget and a roadmap to help fill gaps in the state’s open data and digital systems to reduce people’s vulnerability to natural hazards. Currently, satellite maps, risk maps and sectoral data are not integrated into a single platform, leading to gaps in planning and execution of public sector investments.

Chhattisgarh: Improving Quality of School Education Impacting about 4 Million Students

The World Bank has approved a $300 million loan to help expand and improve the quality of education in government-run schools in the state of Chhattisgarh.

Almost 86 percent of schools in the state are run by the government. While enrolment at the elementary school level is 95 percent, it is only 57.6 percent at the senior secondary level and the enrolment for boys is 10.8 percent lower than that for girls. This is due to the non-availability of science and commerce education across many senior secondary schools, a shortage of trained science and mathematics teachers, and the lack of necessary infrastructure like laboratories and facilities. Students from remote locations also face a problem with accommodation. While girls have residential school facilities under the centrally sponsored Samagra Shiksha program, there is no such scheme for boys.

The Chhattisgarh Accelerated Learning for a Knowledge Economy Operation (CHALK) aims to improve access to education across all grades and address the growing demand for science and commerce studies at the senior secondary level. For schools at remote locations, it will also provide access to residential facilities for male students and teachers.

The project will help develop and operate around 600 model composite schools – from Grades 1 to 12 –and offer science and commerce at senior secondary level. These schools will provide quality education through trained teachers, strong school leadership and management, and adequate infrastructure facilities for learning. The support will also include climate-proofing

school infrastructure using environmentally sound construction practices.

The Project will address:

Growing demand for science and commerce at senior secondary level.

Shortage of trained teachers in science and mathematics.

Shortage of laboratories & facilities in schools.

Lack of residential facilities, especially for males, in remote location schools.

The teacher training initiatives under the project will help enhance the quality of teaching-learning interactions in classrooms to improve student learning levels. More than 175,000 teachers are expected to receive in-service professional development support under the project. Teachers will be provided with access to student-specific remedial educational resources based on a system of periodic school-based learning assessments.

More than 1,75,000 teachers to receive in-service professional development support.

Assam and Tripura: Improving Healthcare and Boosting Economic Opportunities

The World Bank has approved a $252 million project in Assam to help improve access to high quality secondary healthcare services in the state.

The Assam State Secondary Healthcare Initiative for Service Delivery Transformation (ASSIST) Project will directly serve at least 1.8 million people. The project will increase access to comprehensive emergency obstetric and newborn care services and improve treatment and management of non-communicable diseases. The project will also upgrade up to 10 lower-level facilities to district hospitals in essential districts and strengthen the capacity of nurses and healthcare managers for better service delivery.

The World Bank has also approved a $140 million project for the state of Tripura to promote the socioeconomic development and improve the quality of life of 142,000 households in select tribal blocks, territories where tribal communities live and work in the state.

The Tripura Rural Economic Growth and Service Delivery Project will help upgrade more than 400 kilometers of rural roads to all-weather roads, providing farmers and communities living in hilly and forested areas with greater access to markets. Around 75,000 households will have improved livelihoods from climate-smart agriculture that will help to produce fruits and vegetables. The project will also invest in learning outcomes for secondary school students by increasing enrollments for boys and skilling up teachers.

Himachal Pradesh: Increasing Renewable Energy Penetration and Improving Services

The World Bank has approved a loan of $200 million to the Government of Himachal Pradesh to facilitate power sector reforms in the state and increase the share of renewable energy (RE) in the state’s electricity generation. This will contribute to the state’s overall aim of adding 10,000 megawatts (10 gigawatts) of additional RE capacity to make the state’s power supply greener.

The Himachal Pradesh Power Sector Development Program will help the state enhance the utilization of its existing RE resources, including hydropower, and help to diversify its RE resources further. For instance, it will add 150 megawatts of solar capacity in the state, reducing greenhouse gas emissions by more than 190,000 metric tons per year.

In Himachal’s hilly terrain where challenges in maintaining uninterrupted power supply are higher – and restoration in case of a breakdown may take longer than elsewhere – the Program will help achieve a strengthened transmission and distribution grid. It will introduce advanced technologies such as a demand response management system and seamless access to RE. This is critical during peak load periods when the state must otherwise rely on expensive fossil-fuel based

Additional 150 MW of solar capacity in the state

Reduce annual greenhouse gas emissions by more than 100,000 metric tons.

power. The introduction of automated systems will be an important step towards providing clean, reliable 24x7 power supply to citizens, reduce power outages, and minimize consumer complaints.

The Program will help strengthen environmental, social, financial management, corporate governance, and procurement capabilities of the state’s power sector utilities and agencies. In addition, it will contribute towards creating job opportunities in specialized technical and managerial fields in the sector, especially for women. HP power utilities will train around 700 female apprentices throughout the lifespan of the program, giving them hands-on exposure and training in technical roles within the power sector.

Improving Technical Education and Research Benefitting 350,000 Students Each Year

The World Bank’s Board of Executive Directors has approved a $255.5 million loan to help India improve the quality of technical education and provide more career opportunities to students. Over the next five years, the project will support around 275 governmentrun technical institutions in selected states across the country, benefitting more than 350,000 students each year.

The Multidisciplinary Education and Research Improvement in Technical Education Project will support improving student skills and employability by focusing on better research, entrepreneurship, and innovation; and improve governance in technical institutions. As part of the project, students will get access to upgraded curricula including emerging technologies in communication and climate resilience. They will also benefit from better internship and placement services, including opportunities to network with professional associations.

The project will support participating institutions to organize outreach programs providing prospective female students, parents, and guardians with more and better information on technical education program options, build sensitivity to gender issues, and address

misconceptions about women’s capabilities in the science, technology, engineering, and math (STEM) fields. Women students will also be encouraged to connect with mentors and alumni to promote completion of their course and gain early exposure to the world of work. Currently, less than 30 percent of undergraduate engineering students are women, while women from the scheduled castes and scheduled tribes face a double disadvantage.

Studies also point to the need to improve India’s research and innovation linkages with industry and society. Out of 9,581 technical education institutions, only 504 have incubated at least one startup, and 525 founded two to four startups in the past two years. The project will support research and innovation in priority sectors like climate change and sustainable energy.

The project will support around 275 government-run technical institutions in selected states across the country, benefitting more than 350,000 students each year.

Striving for Clean Air: Air Pollution and Public Health in South Asia

South Asia is home to nine of the world's 10 cities with the worst air pollution. Concentrations of fine particulate matter (PM2.5) in some of the region's most densely populated and poor areas are up to 20 times higher than 5 micrograms per cubic meter that the World Health Organization considers healthy. This pollution causes an estimated 2 million premature deaths in the region each year and results in significant economic costs.

Air pollution travels long distances in South Asia and gets trapped in large 'airsheds' that are shaped by climatology and geography.

'Striving for Clean Air' identifies six major airsheds in the region and analyzes four scenarios for reducing air pollution with varying degrees of policy implementation and cooperation among countries.

Video

Nature's Frontiers: Achieving Sustainability, Efficiency, and Prosperity with Natural Capital

Economic activity since the end of World War II has caused an unprecedented rise in living standards, but it has also caused rapid changes in earth systems. The world’s stock of resources and services provided by nature are in decline. Clean air, abundant and clean water, fertile soils, productive fisheries, dense forests, and healthy oceans are critical for healthy lives and healthy economies. Mounting pressures, however, suggest that the trend of declining natural capital may cast a long shadow into the future.

The Report presents a novel approach to address these

Engendering Access to STEM Education and Careers in South Asia

Building a skilled and diverse science, technology, engineering, and mathematics (STEM) workforce is crucial for economic development, cross-border trade, and social inclusion in South Asia. However, underrepresentation of girls and women in STEM education and careers remains a persistent issue. New ways of defining STEM occupations are required to help develop and sustain female interest in STEM education and careers. Potential strategies that governments can pursue include raising awareness and building knowledge and skills in STEM outside the formal academic environment— such as in after-school programs,

foundational challenges of sustainability. The analysis provides recommendations on how countries can better use their natural capital to achieve their economic and environmental goals. The report indicates that significant efficiency gaps exist in nearly every country. Closing these gaps can address many of the world’s pressing economic and environmental problems—economic productivity, health, food and water science fairs and competitions, and summer camps—and developing and systematically disseminating standardized resources. Inclusion and diversity must be championed by governments, the private sector, and other stakeholders who stand to benefit from more diverse workforces. Though women themselves would likely be credible champions, in South Asia they are often constrained by a range of factors. This report addresses some of those obstacles.

security, and climate change. The approach outlined in this report will entail demanding policy reforms, but the costs of inaction will be far higher.

Decarbonizing Urban Transport for Development

The path to low-carbon urban transport looks fundamentally different in developed and developing countries. While developed countries may focus on retrofitting existing fleets (e.g., through electrification), developing countries can build their transport systems with a low-carbon approach at the core, allowing for more inclusive and climate-friendly growth in the future. Most of the changes that make urban transport greener also make cities more livable.

Encouraging dense, compact, and mixed-use development (while limiting sprawl) and building effective public transport systems and safe pedestrian routes all reduce traffic and local pollution while increasing citizens’ ability to access jobs, health services and education. This report provides a framework that can help cities leverage these synergies and create transport systems that will support social and economic development outcomes while also reducing emissions.

with Smallholders: A Handbook for Firms Building Sustainable Supply Chains

Working

Rising incomes and urbanization, are driving the increased consumption of meat, dairy, and biofuels, leading to considerable increases in global production, particularly in South Asia and Sub-Saharan Africa, where smallholder farming predominates, and yields remain low.

At the same time, it will be essential to promote improved food quality, to reduce negative impacts on health, while additional initiatives must address how to reduce food losses. Climate change is bringing further stressors. These challenges also present opportunities to help smallholder farmers boost their productivity by facilitating better access to inputs, technology, knowledge, financing, and markets.

Agribusinesses are increasingly working with smallholder farmers in low- and middle-income countries to secure agricultural commodities, which help to boost rural incomes and economic growth.

Smallholders represent a growing market for farm inputs, information,

and financial services. This report shows agribusinesses how to develop more sustainable, resilient, and productive supply chains and the substantial impact of doing so on development. It compiles innovative solutions and cutting-edge ideas to meet the challenges and illustrating these points through a variety of case studies from initiatives around the world. agricultural development programs working with smallholders, as well as to academic and research institutions.

Digital-in-Health: Unlocking the Value for Everyone

The report calls for a new digital-in-health approach where digital technology and data are infused into every aspect of health systems management and health service delivery for better health outcomes. The report proposes ten recommendations across three priority areas for governments to invest in: prioritize, connect, and scale.

Tangled Seas: A Snapshot of Abandoned, Lost, or Otherwise Discarded Fishing Gear in South Asia

In recent years, marine plastic pollution has emerged as a significant global issue. Abandoned, lost, or otherwise discarded fishing gear (ALDFG), contribute significantly to plastic pollution in the ocean. There is a critical need to inform policy development and provide institutional and investment recommendations to minimize the stream of plastic waste from fishing and fishing-related activities.

Tracking Universal Health Coverage: 2023 Global Monitoring Report

This joint World Health Organization - Word Bank report presents an alarming picture of stagnating access to essential health services and increased financial hardship from out-of-pocket health payments affecting especially the poorest and most vulnerable people. Reaching the goal of UHC by 2030 requires substantial public sector investment and accelerated action by governments and development partners, building on solid evidence.

Reality Check: Lessons from 25 Policies Advancing a Low-Carbon Future

The Report identifies key policy approaches that countries are taking to decarbonize their economies. It includes 25 case studies that furnish country contexts and policy details, examine results and impacts, and outline key takeaways and lessons learned for enabling further ambition in achieving emissions reductions.

INDIA - Working Papers

The Added Value of Local Democracy: Evidence from a Natural Experiment in India

Governments across the world have increasingly devolved powers to locally elected leaders. This paper studies the consequences of local democracy, exploiting a natural experiment in Karnataka, India. Local elections were postponed in 2020, resulting in appointed administrators taking over governance in villages whose elected leaders completed their term that year. This created quasi-random variation in the governance regime across villages. The paper brings together a rich set of administrative datasets— budgetary allocations from the universe of 6,000 villages, more than a million public works projects, local bureaucratic attendance, welfare benefits, and a primary survey of more than 11,810 households—to estimate the impacts of local democracy.

Does Food Insecurity Hinder Migration? Experimental Evidence from the Indian Public Distribution System

People may avoid migrating if they cannot insure themselves against the risk of a bad outcome. Governments can reduce the consumption risk faced by migrants by allowing them to access social protection programs in the destination. This study randomly informed around 62,000 households across 18 Indian states about a new program allowing migrants to collect their food ration across the country, together with information about practical barriers to using the program. Four months later, treated households held lower beliefs about food ration portability, and were less likely to migrate to cities. The findings indicate that food insecurity risk reduces urban migration.

From Scheme to System: Understanding the Concept and Measurement of Hospitalizations for Ambulatory-Care-Sensitive Conditions

The paper highlights the relevance of Ambulatory Care Sensitive Conditions (ACSC) analysis in the context of India's flagship health sector reforms—Ayushman Bharat—which aims to achieve universal health coverage. Monitoring and analyzing hospitalizations for ACSCs under Pradhan Mantri Jan Arogya Yojana (PM-JAY) - the world's largest health insurance scheme - will allow decision-makers to assess the magnitude of preventable hospital admissions from an economic efficiency and patient well-being perspective and enable them to make informed policy decisions on strengthening the quality of primary healthcare services.

Air Pollution Reduces Economic Activity: Evidence from India

Exposure to fine particulate pollution (PM2.5) increases mortality and morbidity and reduces human capital formation and worker productivity. Therefore, high levels of particulate pollution may adversely affect economic activity. Using a novel dataset of changes in the annual

gross domestic product of Indian districts, this paper investigates the impact of changes in the level of ambient PM2.5 on district-level gross domestic product. Using daily temperature inversions as an instrument for pollution exposure, this paper finds that higher levels of particulate pollution reduce gross domestic product.

How Did India Successfully Reform Women’s Rights? Part I: Answers from the Movement on Equal Inheritance Rights

How Did India Successfully Reform Women’s Rights? Part II : Answers from the Movement on Protection from Violence

This two-part policy brief series traces the development and reform of law in India related to three critical areas that affect women’s rights and economic opportunities: women’s property rights, domestic violence, and sexual harassment in the workplace. It explores the underlying factors and driving forces that led to reforms as well as the broad processes and extensive timelines required for change. It also highlights the remaining gaps in the rights for Indian women which often makes real gender equality elusive for many. The achievements in India, which are the result of years of concerted efforts and thought leadership by multiple governmental and nongovernmental players, private actors, and women’s rights activists, could function as a “how to” guide for other countries that may want to carry out similar reforms in the future.

(Perceptions of) Inequality, Demand for Redistribution, and Group-Specific Public Goods : A Survey Experiment in India

This paper uses data from a survey of 116,061 households in India to study people’s beliefs about inequality and demand for redistribution. The findings show that a household’s beliefs about inequality, implied by the perception of their position on income distribution, is negatively correlated with support for reducing inequality. This is relevant since there are significant differences between where individuals believe their household stands and their actual position, with the gap between perceived and actual position exceeding two deciles on average.

Over-Drilling : Local Externalities and the Social Cost of Electricity Subsidies in South India

Borewells for groundwater extraction have proliferated across India, encouraged by massive electricity subsidies. Because the discharges from borewells operating near one another are mutually reduced, farmers interact strategically with potentially many neighbors in deciding whether and when to drill. An analysis of survey data from two districts in southern India establishes both the importance of this well interference externality and its influence on drilling decisions.

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