INNOVATIONS AND IMPACTS
INDIA: Improved governance for nutrition
Over 60 million Indian underfives - 48 percent of this age group - have stunted growth. Even in Maharashtra, India’s second largest state, 46 percent of underfi ves were stunted in 2006. Maharashtra responded by launching the State Nutrition Mission, which began by improving the fl agship programmes for child health, nutrition and development (the Integrated Child Development Services and the National Rural Health Mission), particularly in the most deprived tribal districts. Key vacancies, particularly community-based workers and their supervisors, were fi lled, and the motivation and skills of these frontline workers were boosted. In its second phase (2011 onwards), the Mission is focusing on the nutrition of children under two and their mothers, in line with global evidence indicating the need to optimise the 1,000-day window of opportunity to prevent stunting in children.
In 2012, the Government of Maharashtra commissioned the fi rstever state-wide nutrition survey. It revealed that the prevalence of stunting among children under two had declined from 39 percent in 2006 to 23 percent in 2012, a decrease of 16 percentage points over six years. The decline was signifi cantly higher among Adivasi children than among non-Adivasi children. Three factors seem key to the Maharashtra Nutrition Mission’s success: (1) improving service delivery, by focusing on proven interventions for children under two and their mothers, and on the nutrition of adolescent girls; (2) delivering at scale with equity, by bringing services closer to the most vulnerable children, households and districts; and (3) coordinating and measuring nutrition results across sectors.
The Nutrition Mission has been a key policy instrument in the reduction of child stunting in Maharashtra. The main lesson learned is that a concerted effort to improve governance for nutrition has led
to a measurable reduction in child stunting, particularly among the most vulnerable children: the youngest, the poorest and the sociallyexcluded.
NEPAL: Female Community Health Volunteers
In Nepal, the prevalence of stunting in underfi ves dropped from 57 percent in 2001 to 41 percent in 2011, largely as a result of the interventions delivered by Female Community Health Volunteers (FCHVs).
Nepal created the FCHV programme to increase the outreach of health and nutrition services. Currently, there are about 53,000 Female Community Health Volunteers delivering a range of essential services to children and women. The Volunteers promote and support mothers to use the best combination of breastfeeding and complementary feeding for children under two, a service that is integrated with the twice-yearly delivery of micronutrient powders to children aged 6-23 months. They supply deworming tablets to children aged 12-59 months, and provide care and referral services for children under fi ve suffering from diarrhoea, acute respiratory infections, measles or severe acute malnutrition. Finally, they offer counselling and support to pregnant and breastfeeding women on nutrition, health and family planning.
Vitamin A deficiency is now believed to be largely under control; 80 percent of households use salt with adequate levels of iodine; the proportion of children under fi ve with symptoms of pneumonia who are taken to a health facility for treatment has increased from 18 percent in 1996 to 50 percent in 2011; and the proportion of children with diarrhoea who are taken to a health provider for treatment has increased from 14 percent in 1996 to 38 percent in 2011.
In addition, in 2012, Nepal launched the Multi-Sectoral National Nutrition Plan under the leadership of the Prime Minister. The Plan aims to address the immediate, underlying and basic causes of maternal and child under-nutrition by focusing on the nutritionspecific and nutrition-sensitive interventions that prioritize a mother’s pregnancy and her child’s fi rst two years of life.
SRI LANKA: Improved legislation, counseling and outreach
Sri Lanka has seen a significant improvement in the rate of exclusive breastfeeding in infants younger than six months, which increased from 53 percent in 2000 to 76 percent in 2007 due to policy and programme improvements.
One of the first countries to translate the International Code of Marketing of Breastmilk Substitutes into a national law, Sri Lanka has also achieved signifi cant progress in maternity protection. In 1992, paid maternity leave in government jobs was extended from six weeks to 84 working days. Private sector employees covered under the Shop and Offi ce Act are granted 84 days (including weekends and public holidays) of fully paid maternity leave for the first two children and 42 days for subsequent births.
Expanding the coverage and quality of the support provided to pregnant women and breastfeeding mothers has been central to Sri Lanka’s progress on breastfeeding. Practically the entire health workforce in the country – paediatricians, obstetricians, primary care physicians and nurses – has benefi tted from a 40-hour training course on lactation management. Mother-baby and lactation management centres have been set up in all major hospitals to support breastfeeding mothers.
Finally, the contribution of over 7,000 government-trained public health midwives cannot be overstated - they are an integral part of the team that delivers comprehensive maternal and child health care. During the
first six weeks after delivery, each mother receives four home visits by her skilled birth attendant, who provides post-partum care and supports the mother to establish and maintain exclusive breastfeeding.
Sri Lanka’s achievements in breastfeeding are the result of strong political commitment, a well-developed health system with professionals trained to support breastfeeding, a well-equipped and dedicated workforce of public-health midwives, and multiple strategies to raise awareness of the benefi ts of breastfeeding among mothers, families and communities.