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

Suaahara II GEOGRAPHIC FOCUS 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)

Suaahara II results framework Improved Household Nutrition and Health Behaviors Improved nutritional Increased Use of Quality Nutrition and Health status of Services by Women and Children women Improved Access to Diverse and Nutrient-Rich and Foods by Women and Children children < 2 years Accelerated Roll-Out of Multi-sector Nutrition Plan through Strengthened Local Governance Social and Behavior Change Gender Equality and Social Inclusion Emergency Preparedness and Response Plan Public Private Partnerships Monitoring Evaluation, Research for Learning

Suaahara II implementation levels and target groups Community District (3,353 wards) Households (42) National (900,000) Municipal Leaders GoN and 1.5 million pregnant GoN and Frontline workers, stakeholders and lactating women stakeholders village model farms and children <2 years Suaahara II and Suaahara II (DAG focus) Partner NGOs Health workers and FCHVs Fathers, Private sector National media Grandparents (seeds, chicken Ag/livestock brooders, agro extension workers Newly Married vets, WASH Couples Improved WASH and Nut/Food Marts) Adolescents advocacy for Security committees District media policies, Schools strategies, guidelines and Strengthened investments in service delivery Improved access to Improved family 5 nutrition systems for nutrition quality services actions on nutrition

Suaahara II implementation packages CORE package CORE PLUS package (3353 WARDS, 100%) (1504 DAG WARDS, 45%) CORE package • SBCC (Nutrition, WASH, MCH/FP) AND the following interventions • MIYCN/NACS Package • IMAM Package • Enhanced Homestead Food • Governance Production • GESI • 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

Suaahara II EHFP for 1000-day households in DAG areas Inputs for all households Garden to • Training in horticulture and poultry rearing Plate • Supplies (seasonal seeds, chicks, IEC materials) Pathway • Post training follow-up and technical support (n=98,000) • 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 Garden to • Trainings on savings & credit and business skills Plate to • Specialized Ag/ Poultry/Post harvest training Market • Strengthen Market Management Committee (MMC) Pathway • Group Registration, VMF Network Formation (n=7000) • Links to private sector opportunities

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

Suaahara II MER feedback and learning system • 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

Dietary diversity among household members, AS, 2017 (%) 100 Mean Dietary Diversity Scores: • 90 Child (6-23.9m) : 3.4 • Mothers: 4.1 80 • HH head men: 4.1 70 • Grandmothers: 4.1 60 • Adolescent girls: 4.1 47 50 37 36 35 34 40 30 20 10 0 Children 6-23.9m Mothers HH head men Gmom Adolescent (4/7FG) (N=1385) (N=3640) (N=1733) (N=1470) (N=837) 5/10FG

Dietary diversity among children 6-23.9 months, AS 2017 (%) (N=1385) 100 96 90 80 72 70 58 60 50 50 40 32 30 18 20 11 10 0 Grains Pulses Dairy Meat Eggs Vit. A rich Other (cereals and (legumes fruits/vegt. fruits/vegt. tubes) and nuts)

Dietary diversity among adult household members, AS 2017 (%) 100 88 90 86 86 85 80 76 76 74 73 70 60 50 45 44 41 40 36 36 40 35 34 31 30 29 29 29 28 27 26 30 20 10 7 6 6 10 5 5 4 4 4 2 3 2 0 Pulses Nuts and Dairy Meat Eggs Dark Vit. A rich Other Other (legumes seeds green fruits/vegt. vegt. fruits and nuts) leafy vegt. Mother (N=3640) HH head(men) (N=1733) Gmom (N=1470) Adol girl (N=837)

Commercial snack food consumption by household member, AS, 2017 (%) 100 90 80 70 57 60 46 50 38 40 31 29 25 30 24 23 18 16 20 14 10 10 8 8 8 10 3 4 3 2 0 Any of three Commercial Commercial Commercial fizzy commercial savory snacks sugary snacks or sweetened snacks snacks Child 6-59m (N=1385) Mother (N=3640) HH head(men) (N=1733) Gmom (N=1470) Adol girl (N=837)

Egg and meat consumption among children 6-23.9 months Internal monitoring checklists 2017 and 2018 (%) 100 District variation (April-June 2017 and 2018): 80 Argakhanchi (Hills): 54% to 68% Kapilbastu (Terai): 24 to 29% 60 43 40 40 39 39 38 40 34 34 32 28 18 20 11 0 N=2226 N=1385 N=2929 N=2901 N=4858 N=5624 April-June AS, 2017 July- Oct.- Jan-Mar,2018 Apr-Jun,2018 2017 Sept,2017 Dec,2017 Egg Meat

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

Program adaptations to SBC package for 1000-day HHs Interpersonal Communication (4-6 home visits) Community Mobilization (3 key life events Monthly group meetings, Quarterly food demos) Mobile technology (35 SMS) Mass Media: “ Bhanchhin Aama ” 5 SMS on dietary Weekly radio program with call in component” (33 episodes) diversity 10 episodes on dietary diversity

Data-driven ongoing program refinements to improve dietary diversity National Egg Campaign “How to” videos on poultry management • 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)

Data-driven ongoing program refinements: EHFP examples Suaahara I to II: • Change to more specific key message: from general message about importance of 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