Early lessons from Swabhimaan, a multi-sector integrated health and nutrition programme for women and girls in India

This is a summary of a Field Exchange field article that was included in issue 65. The original article was authored by Monica Shrivastav, Abhishek Saraswat, Neha Abraham, R.S. Reshmi, Sarita Anand,  Apolenarius Purty, Rika Shalima Xaxa, Jagjit Minj, Babita Mohapatra and Vani Sethi.

Monica Shrivastav is a consultant with the UNICEF supported ROSHNI-Centre of Women Collectives led Social Action, Lady Irwin College, New Delhi, India.

Dr. Abhishek Saraswat is a demographer currently affiliated with the International Institute for Population Sciences, Mumbai, India.

Neha Abraham is a Knowledge Management Consultant at ROSHNI-Centre of Women Collectives led Social Action.

Dr. R.S. Reshmi is an Assistant Professor in the Department of Migration and Urban Studies at the International Institute for Population Sciences, Mumbai.

Dr. Sarita Anand is an Associate Professor at the Department of Development Communication and Extension, Lady Irwin College.

Apolenarius Purty is State Programme Manager, Health and Nutrition, Bihar Rural Livelihoods Promotion Society (JEEViKA), Government of Bihar, Patna, India.

Rika Shalima Xaxa is State Programme Manager of the Social Inclusion and Social Development at Chhattisgarh State Rural Livelihoods Mission’ BIHAN’, under the Department of Panchayat and Rural Development, Raipur, Chhattisgarh, India

Jagjit Minj is Programme Executive of the Social Inclusion and Social Development at Chhattisgarh State Rural Livelihoods Mission’ BIHAN’, under the Department of Panchayat and Rural Development, Raipur, Chhattisgarh, India.

Dr. Babita Mahapatra is the Additional Chief Executive Officer in the Odisha Livelihoods Mission (OLM), Government of Odisha.

Dr. Vani Sethi is a Nutrition Specialist at the Nutrition Division of UNICEF India.

Background

A woman’s poor nutritional status before and during pregnancy is a major cause of foetal stunting and low birth weight. In 2016, Deendayal Antyodaya Yojana-National Rural Livelihoods Mission (DAY-NRLM), the Indian Government’s flagship poverty alleviation programme, launched Swabhimaan in partnership with UNICEF India across three states, Bihar, Chhattisgarh and Odisha. Swabhimaan is a five-year initiative that aims to improve the nutrition outcomes of women and adolescent girls.

Intervention

Swabhimaan provides a comprehensive package of 18 nutrition-specific and nutrition-sensitive interventions spanning the health, nutrition, agriculture and livelihoods sectors. These interventions are delivered through a combination of community-led and systems strengthening actions and focus on four primary target groups: adolescent girls, newly-wed women, pregnant women and mothers of children under two years of age.

For community-led actions, DAY-NRLM women’s collectives, made up of female representatives from self-help groups (SHGs) and their federations (Village Organizations (VOs) and Cluster Level Federations (CLFs) are used as the primary mode of delivery. Each federation develops an integrated nutrition microplan that identifies and prioritises nutrition and related problems among target groups, an annual plan of activities and a budget. The development of nutrition microplans is facilitated by a social action committee (SAC) for each VO. Each SAC nominates an active SHG member to be the Community Resource Person (CRP).

Following a three-day training, CRPs facilitate the development of nutrition microplans, facilitate monthly meetings for women and adolescent girls, provide home-based counselling for target groups, food demonstrations and support for the development of household nutrition gardens. The CRPs receive INR 450 (USD7) to develop an integrated nutrition microplan and a similar monthly incentive to facilitate planned activities. Community-led interventions are monitored through monthly reports submitted by CPRs.

The system strengthening interventions include:

• Quarterly training of Government Accredited Social Health Activist and Auxiliary Nurse Midwives to strengthen the delivery of fixed monthly health camps (Village Health Sanitation and Nutrition Days (VHSND)) which provide the following services: antenatal care check-ups, counselling, micronutrient supplementation, take-home rations, immunisation, weight monitoring, family planning and the identification and care of groups at nutritional risk.
• Training to strengthen Adolescent Health Days.
• Regular engagement with health service providers and fair price shop owners to improve the delivery of the service package and entitlements.
• Regular review and convergence meetings with the departments involved in service delivery.
• Activity-based reporting on system strengthening with annual review of overall programme reports by the national government. 

Evaluation methodology

The baseline survey was conducted between October 2016 and January 2017 and included 6,352 adolescent girls, 2,573 pregnant women and 8,755 mothers of children under two years of age. The midline survey was conducted between September 2018 and June 2019 with 3,171 adolescent girls, 1,856 pregnant women and 3,277 mothers of children under two years of age. A midline process evaluation was also undertaken using a mixed-method approach comprising a cross-sectional survey and qualitative data collection. The endline survey will be conducted in 2021.

Results

Outputs

All 336 VOs across the three states developed integrated nutrition microplans. By the end of 2019 across the intervention areas:

• VOs had screened over 77,000 adolescent girls, pregnant women, mothers and newly-wed women using mid-upper-arm circumference (MUAC)
• Nearly 15,122 individuals were identified at nutritional risk and referred for customised counselling, home visits, food demonstrations, the development of nutrition gardens and, for some, links with government social protection schemes.
• CRPs had facilitated a total of 37,079 monthly meetings for pregnant women, mothers and newly-weds with the latter provided with ‘welcome kits’ (contraceptives, iron-folic acid (IFA), sanitary pads, soap) inducted into SHGs.
• Over 1,000 adolescent groups had been formed.
• Over 5,000 backyard nutrition gardens had been developed by households with target individuals at nutritional risk through small loans provided by SHGs.

In addition, the Swabhimaan programme facilitated the revision of VHSND guidelines and integrated maternal calcium supplementation, deworming and the screening of women at nutritional risk using maternal MUAC into the guidelines. The target base was also expanded to newly-weds and adolescent girls.

Outcomes

The comparison of baseline to midline survey data revealed:

• A statistically significant improvement in dietary diversity scores in all target groups.
• The percentage of thin adolescents (body mass index (BMI) <-2SD) and mothers of children under two years of age (BMI <18.5 kg/m²) reduced by 4.7% and 3.8%, respectively.
• MUAC scores in pregnant women improved from 23.5cm to 24cm, although this improvement was not statistically significant.
• Access to maternal nutrition services also improved with a 16-17% (p<0.001) improvement in the number of pregnant women receiving antenatal care (ANC) in the first trimester and at least four ANCs in their last pregnancy.
• Significant improvement in IFA compliance all target groups, particularly adolescents, although overall compliance remains low at less than 30%.
• Modest improvements in the use of modern family planning methods by both pregnant women and mothers. At baseline, only 31.6% of the adolescent girls used sanitary pads which significantly increased to 57.3% (p<0.001).
• Access to toilets still remains low, with over half of participants not having access to a toilet.
• There was also evidence for improved household food security and improved uptake of government health, water, sanitation and hygiene and social protection services.

Limitations and challenges

CPRs reported challenges in mobilising the target groups regularly for meetings and observed gender-related issues as barriers to improving nutrition.

As in most programmes that operate in real settings, systemic challenges exist. These are related to delays in the flow of funds for government schemes on which the delivery of maternal nutrition services hinge, delays in the procurement and/or distribution of supplies and health worker strikes. Secondly, the SHG-VO-CLF platform has varying maturity and stability across and within states, with some groups well established while some are fairly new. Consequently, the pace of implementation is non-uniform. To reduce this bias, Swabhimaan has retained the originally identified collectives in the research.

Lessons learned for scale up

The lessons learned from programme implementation to date include:

• VOs and CLFs can develop microplans, manage grants and collaborate with agriculture universities/training centres to design nutrition-sensitive backyard gardens.
• CRPs can successfully mobilise women and adolescent girls and organise monthly discussions on priority nutrition issues using a participatory learning and action approach despite societal resistance and challenges in mobilisation.
• Convergence of government departments is critical to ensure that essential women’s nutrition interventions are available. This is possible through the joint planning and review of activities at block and district level quarterly convergence meetings.
• The integration of a systems strengthening activities into Swabhimaan led to improvements on the supply side.

Conclusion

Over the three years of the implementation of the Swabhimaan programme, the findings suggest that both the community-led and systems strengthening components of the programme have significant impact on increasing coverage of essential nutrition-specific and nutrition-sensitive interventions for women and girls. Swabhimaan will continue to scale up activities within the three intervention states and focus on addressing gender norms and social issues during the next phase of the programme. Results of the endline and impact evaluations are forthcoming and will provide further evidence to inform maternal and preconception nutrition policy at national and state level in support of the integration of nutrition interventions into large-scale poverty alleviation programmes delivered via women’s collectives.

For more information, please contact Dr. Vani Sethi at vsethi@unicef.org