Learnings from Suaahara II in Nepal Pooja Pandey Rana Deputy Chief - - PowerPoint PPT Presentation

Government of Nepal Ministry of Health

Using monitoring data to improve diets: Learnings from Suaahara II in Nepal

Pooja Pandey Rana Deputy Chief of Party of Programs, Suaahara II Helen Keller International Oct 2-4, 2018

Suaahara II overview and interventions to improve dietary diversity, particularly among vulnerable groups

GEOGRAPHIC FOCUS

Suaahara II

A 5-year (2016-2021) multi-sector nutrition project operating at scale in 42 districts to reach over 900,000 households (1.5 million women & children)

Improved Household Nutrition and Health Behaviors Improved Access to Diverse and Nutrient-Rich

Foods by Women and Children

Accelerated Roll-Out of Multi-sector Nutrition

Plan through Strengthened Local Governance Improved nutritional status of women and children < 2 years Increased Use of Quality Nutrition and Health Services by Women and Children Gender Equality and Social Inclusion Public Private Partnerships Emergency Preparedness and Response Plan Monitoring Evaluation, Research for Learning Social and Behavior Change

Suaahara II results framework

5

Improved access to quality services Improved family actions on nutrition Improved advocacy for policies, strategies, guidelines and investments in nutrition Suaahara II

National

GoN and stakeholders Strengthened service delivery systems for nutrition Ag/livestock extension workers Health workers and FCHVs Municipal Leaders WASH and Nut/Food Security committees

Community (3,353 wards)

Schools 1.5 million pregnant and lactating women and children <2 years (DAG focus)

Households (900,000)

Adolescents Newly Married Couples Fathers, Grandparents Suaahara II and Partner NGOs GoN and stakeholders

District (42)

District media Private sector (seeds, chicken brooders, agro vets, WASH Marts)

Suaahara II implementation levels and target groups

National media Frontline workers, village model farms

• SBCC (Nutrition, WASH, MCH/FP)
• MIYCN/NACS Package
• IMAM Package
• Governance
• GESI
• Enhanced Homestead Food

Production

• Intensive SBCC
• Intensive WASH
• Intensive Health
• Intensive GESI

SBCC=Social Behavior Change and Communication MIYCN=Maternal, Infant, Young Child Nutrition NACS=Nutrition Assessment and Counselling Support MCH/FP=Maternal and Child Health and Family Planning WASH=Water, Sanitation and Hygiene

CORE package AND the following interventions

CORE package

(3353 WARDS, 100%)

CORE PLUS package

(1504 DAG WARDS, 45%)

Suaahara II implementation packages

Suaahara II EHFP for 1000-day households in DAG areas Garden to Plate Pathway (n=98,000) Garden to Plate to Market Pathway (n=7000) Inputs for all households

• Training in horticulture and poultry rearing
• Supplies (seasonal seeds, chicks, IEC materials)
• Post training follow-up and technical support
• Monthly group meetings with Village Model Farmers
• Link to resources-Village Model Farms (VMF), local

brooding centers, Government services

Inputs for “profit-ready” VMF & households

• Trainings on savings & credit and business skills
• Specialized Ag/ Poultry/Post harvest training
• Strengthen Market Management Committee (MMC)
• Group Registration, VMF Network Formation
• Links to private sector opportunities

Suaahara II Monitoring, Evaluation and Research for Learning: Overview and Y1 and Y2 Key Findings

• Monitoring via district-representative monthly data collection

and ongoing feedback cycle using DHIS2 system

• Using checklists completed by field supervisors via mobile app
• Representative random sample of HHs (n~3,000), Village Model

Farmers (n=600), FCHV (1200),) and health facilities (600)

• Assess coverage of delivery platforms and adoption of key practices
• Quarterly review meetings and annual workshops to review data to

adjust workplans using district dashboards

• Use findings to improve delivery modalities at the local level by

addressing weaknesses in coverage of activities, contacts and hardest to change behaviors

• Annual survey (3,600 HHs) conducted by external team, same

season & tools each round, to assess progress, provide deeper feedback

Suaahara II MER feedback and learning system

47 36 37 34 35

10 20 30 40 50 60 70 80 90 100

Children 6-23.9m (4/7FG) (N=1385) Mothers (N=3640) HH head men (N=1733) Gmom (N=1470) Adolescent (N=837)

Dietary diversity among household members, AS, 2017 (%)

5/10FG

Mean Dietary Diversity Scores:

• Child (6-23.9m) : 3.4
• Mothers: 4.1
• HH head men: 4.1
• Grandmothers: 4.1
• Adolescent girls: 4.1

96 72 50 18 11 32 58

10 20 30 40 50 60 70 80 90 100

Grains (cereals and tubes) Pulses (legumes and nuts) Dairy Meat Eggs

• Vit. A rich

fruits/vegt. Other fruits/vegt.

Dietary diversity among children 6-23.9 months, AS 2017 (%) (N=1385)

76 4 31 29 6 45 6 86 30 76 2 28 34 5 40 5 88 35 74 4 29 27 2 44 7 85 36 73 4 29 26 3 41 10 86 36

10 20 30 40 50 60 70 80 90 100

Pulses (legumes and nuts) Nuts and seeds Dairy Meat Eggs Dark green leafy vegt.

• Vit. A rich

fruits/vegt. Other vegt. Other fruits

Mother (N=3640) HH head(men) (N=1733) Gmom (N=1470) Adol girl (N=837)

Dietary diversity among adult household members, AS 2017 (%)

57 38 29 3

25 16 10 3 24 14 8 8 18 10 8 2 46 31 23 4 10 20 30 40 50 60 70 80 90 100

Any of three commercial snacks Commercial savory snacks Commercial sugary snacks Commercial fizzy

• r sweetened

snacks

Child 6-59m (N=1385) Mother (N=3640) HH head(men) (N=1733) Gmom (N=1470) Adol girl (N=837)

Commercial snack food consumption by household member, AS, 2017 (%)

Egg and meat consumption among children 6-23.9 months Internal monitoring checklists 2017 and 2018 (%)

32 11 28 34 40 43 39 18 34 38 39 40 20 40 60 80 100 N=2226 N=1385 N=2929 N=2901 N=4858 N=5624 April-June 2017 AS, 2017 July- Sept,2017 Oct.- Dec,2017 Jan-Mar,2018 Apr-Jun,2018 Egg Meat

District variation (April-June 2017 and 2018): Argakhanchi (Hills): 54% to 68% Kapilbastu (Terai): 24 to 29%

Dietary diversity (4+/7 FG) among children 6-23.9 months, AS 2017 (N=1394) (%)

Equity quintiles Caste/ethnicity Agro-ecological zone

Qualitative findings on barriers to consuming a diverse diet

Barriers to consuming animal source foods (2017 formative research)

• Costs and perceived costs
• Availability/accessibility
• Poor poultry care resulting in low egg production
• Cultural/social norms regarding animal source food consumption

Barriers to consuming EGGS (2018 formative research, early findings) Mothers know the importance of eggs BUT…

• Kids don’t like eggs, easier to feed kids dairy products and meat
• Digestion issues: Egg yolk when boiled can cause kids to vomit
• Socio-cultural: Eggs considered more of a winter food than summer
• Access/availability: Costs perceived as a major barrier
• Market access a big problem in remote areas
• Religion: Adhere to strict vegetarianism

Community Mobilization (3 key life events Monthly group meetings, Quarterly food demos) Mobile technology (35 SMS) 5 SMS on dietary diversity Interpersonal Communication (4-6 home visits)

Program adaptations to SBC package for 1000-day HHs

Mass Media: “Bhanchhin Aama” Weekly radio program with call in component” (33 episodes) 10 episodes on dietary diversity

Data-driven ongoing program refinements to improve dietary diversity

• Prioritize by district: data review, targeted planning, semi-annual

revisions

• Increasing income through improved marketing knowledge and practices
• Engagement with private sector (buy back guarantee, contract farming)
• Data driven coaching and mentoring with clear follow up mechanism

e.g. post training follow ups; structured quarterly meetings; use of job aids by frontline workers)

“How to” videos on poultry management

National Egg Campaign

Suaahara I to II:

• Change to more specific key message: from general message about importance
• f four food groups (dietary diversity) to a specific message of “eat eggs/meat”
• Launch national EGG campaign: to improve egg consumption, addressing barriers

Suaahara II: Year 1 to Year 2

• Additional inputs targeted to disadvantaged HHs/VMFs (e.g. chicken coops,

strengthen vaccination services, tunnel agriculture, water harvest ponds) Suaahara II: Year 2 to Year 3

• More follow-up of VMFs for service delivery to narrow the gap in veg production

diversity between VMFs and households (7-9 vs. 1-3)

• Scale up of tailored trainings because VMF roster showed that some need

advanced trainings (e.g. specialized Ag training, marketing)

• Linkage of VMFs based on income and production levels to other existing

projects and private sectors

• District-specific plans (e.g in Rasuwa egg consumption is high, but veg diversity

low; in Sankhuwasabha egg & poultry production are high but consumption low

Data-driven ongoing program refinements: EHFP examples

Challenges of program adaptations based on data

• Developing CULTURE of data driven programming need

skills, time, resources and support

• Targeted Vs. Blanket approach tensions

– Prioritization (program behaviors, activities, messages, delivery platforms) – Different program activities by DAG/NonDAG, by agroecological, ethnicity – Different implementation roadmaps even within districts

• Adjusting workplans, budget allocation, staff changes,

staff reorientation can be stressful and time consuming

• EHFP programs, and similar agriculture/nutrition interventions,

should be carefully designed, implemented, and evaluated as magnitude of impacts varies by context, location, intensity of program participation, underlying conditions.

• EHFP is KEY BUT NOT ALL that’s needed to address dietary

diversity challenges

• Learn how to target vulnerable groups to increase equity : what

do we mean? how do we use findings for targeting in complex programs?

• MER systems must match programs in scale and complexity to

be useful; different investments needed if multiple questions (e.g. trends in program areas vs attribution)

• Building data use into programs takes careful planning and

dedicated time by all stakeholders on an ongoing basis

Summary

Government of Nepal Ministry of Health

Suaahara II is made possible by the generous support of the American people through USAID. Suaahara II would like to thank the Government

• f Nepal for their leadership.

Thank you!

For more information: Helen Keller International/Nepal