Report - Tracking India's Progress on Addressing Malnutrition and Enhancing the Use of Data to Improve Programs
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Tracking India’s Progress on Addressing
Malnutrition and Enhancing the Use of
Data to Improve Programs
Report
No. 12 | December 2020Written By Purnima Menon, Rasmi Avula, Esha Sarswat, Sneha Mani, Manita Jangid (IFPRI) Supreet Kaur, Anamika Singh (NITI Aayog) Alok Kumar Dubey, Suchita Gupta (previously with NITI Aayog) Divya Nair, Pulkit Agarwal, Nitya Agrawal (IDinsight) Suggested Citation Menon, P., R. Avula, E. Sarswat, S. Mani, M. Jangid, A. Singh, S. Kaur, A. K. Dubey, S. Gupta, D. Nair, P. Agarwal, and N. Agrawal. 2020. Tracking India’s Progress on Addressing Malnutrition and Enhancing the Use of Data to Improve Programs. POSHAN Report 12. New Delhi: International Food Policy Research Institute. About NITI A ayog NITI Aayog is the premier policy “think tank” of the Government of India, providing both directional and policy inputs. NITI Aayog designs strategic and long-term policies and programs for the Government of India and provides relevant technical advice to the central government and the states. About Idinsight IDinsight is a global advisory, data analytics, and research organization that helps development leaders maximize their social impact. About Datadent Data for Decisions to Expand Nutrition Transformation (DataDENT) is a four-year initiative that aims to strengthen the data value chain for nutrition globally and in several focus countries, including India. It is supported by the Bill & Melinda Gates Foundation and is implemented by IFPRI, Johns Hopkins University, and Results for Development. About Poshan at Ifpri POSHAN (Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India) is a multi-year initiative that aims to build evidence on effective actions for nutrition and to support the use of this evidence in decisionmaking. It is supported by the Bill & Melinda Gates Foundation and led by IFPRI in India. About Poshan Reports POSHAN Reports aim to provide evidence-based guidance to support policy and program actions for nutrition in India. This Report has been prepared as an output for POSHAN and DataDENT and has not been peer reviewed. Any opinions stated herein are those of the authors and do not necessarily reflect the policies or opinions of IFPRI. Copyright © 2020, International Food Policy Research Institute. All rights reserved. To obtain permission to republish, contact ifpri-copyright@cgiar.org.
Table of Contents
List of Tables...........................................................................................................................................................ii
List of Figures..........................................................................................................................................................ii
List of Abbreviations.............................................................................................................................................. iii
Executive Summary.................................................................................................................................................v
1. Introduction...................................................................................................................................................... 1
2. Mechanisms and Data Systems to Monitor Progress on Nutrition Actions and Outcomes................................... 5
3. Use of Data in the Context of India’s Nutrition Efforts........................................................................................ 8
4. A
pproach to Assessing Data Availability............................................................................................................10
5. M
onitoring Progress on Inputs..........................................................................................................................12
6. Monitoring Progress on Intervention Coverage..................................................................................................16
7. Monitoring Progress on Immediate and Underlying Determinants of Malnutrition............................................ 25
8. Data Availability on Nutrition Outcomes.......................................................................................................... 29
9. Aligning Data to Program Theory: An Illustration..............................................................................................31
10. Recommendations.......................................................................................................................................... 33
11. Conclusions.................................................................................................................................................... 35
Annex 1: Aligning Indicators along a Program Theory of Change.......................................................................... 36
Annex 2: O
rganizing Framework of Indicators for POSHAN Abhiyaan................................................................... 39
Bibliography......................................................................................................................................................... 46
iList of Tables Table 1: Summary of major population-based surveys on nutrition in India (1992–2019).......................................... 6 Table 2: Summary of key administrative data systems on nutrition in India.............................................................. 7 Table 3: Availability of input and activity indicators from administrative and other data systems.............................12 Table 4: Potential indicators and data availability on interventions during adolescence...........................................17 Table 5: Potential indicators and data availability on interventions during preconception........................................18 Table 6: Potential indicators and data availability on interventions during pregnancy..............................................19 Table 7: Potential indicators and data availability on interventions during delivery and postnatal period..................21 Table 8: Potential indicators and data availability on interventions for infants and young children ......................... 23 Table 9: Data availability on key behaviors and other immediate determinants ..................................................... 25 Table 10: Data availability on underlying determinants.......................................................................................... 27 Table 11: Data availability on nutrition outcomes ................................................................................................. 29 Table 12: Description of broad elements along a program theory..........................................................................31 Table 13: Indicator framework for iron and folic acid supplementation ................................................................. 32 Table 14: Example of interventions to address anemia during pregnancy ............................................................. 36 List of Figures Figure 1: P otential theory of change for POSHAN Abhiyaan.................................................................................... 3 Figure 2: Interventions, immediate and underlying determinants targeted by POSHAN Abhiyaan...........................11 ii
List of Abbreviations
AIDS Acquired Immune Deficiency Syndrome ICDS Integrated Child Development Services
AMB Anemia Mukt Bharat ICDS–AMPR Integrated Child Development Services—
ANC Antenatal Care AWC Monthly Progress Report
ANM Auxiliary Nurse Midwife ICDS–CAS Integrated Child Development Service–
Common Application Software
ARI Acute Respiratory Infection
IDFC Intensified Diarrhoea Control Fortnight
ARSH Adolescent, Reproductive and Sexual
Health IEC Information, Education and
Communication
ASHA Accredited Social Health Activist
IFA Iron and Folic Acid
AWC Anganwadi Centre
IFPRI International Food Policy Research Institute
AWW Anganwadi Worker
ILA Incremental Learning Approach
BCG Bacillus Calmette–Guérin
IMCI Integrated Management of Childhood
BFHI Baby-Friendly Hospital Initiative
Illnesses
BPL Below Poverty Line
IMI Intensified Mission Indradhanush
CBE Community-Based Events
IMR Infant Mortality Rate
CHC Community Health Centre
INR Indian Rupee
CNNS Comprehensive National Nutrition Survey
IYCF Infant and Young Child Feeding
DAP District Action Plan
JSSK Janani Shishu Suraksha Karyakaram
DataDENT Data for Decisions to Expand Nutrition
Transformation MAA Mother’s Absolute Affection
DH District Hospital MAM Moderate Acute Malnutrition
DHS Demographic Health Survey MDD–W Minimum Dietary Diversity–Women
DLHS District Level Health Survey MCP Mother and Child Protection
DPT Diphtheria, Pertussis and Tetanus Toxoids MDD Minimum Dietary Diversity
FP Family Planning MDM Mid Day Meal
FSSAI Food Safety and Standards Authority of MGNREGA Mahatma Gandhi National Rural
India Employment Guarantee Act
GHI Global Hunger Index MHRD Ministry of Human Resource Development
GoI Government of India MIS Management Information System
HBNC Home-Based Newborn Care MLA Member of the Legislative Assembly
HBYC Home-Based Care for Young Children MMR Maternal Mortality Ratio
HIV Human Immunodeficiency Virus MoHFW Ministry of Health and Family Welfare
HMIS Health Management Information System MP Madhya Pradesh
iiiMUAC Mid-Upper Arm Circumference SAG Scheme for Adolescent Girls
MWCD Ministry of Women and Child SAG–RRS Scheme for Adolescent Girls–Rapid
Development Reporting System
NA Not Applicable SAM Severe Acute Malnutrition
NCR National Capital Region SBA Skilled Birth Attendant
NDD National Deworming Day SBCC Social and Behavior Change
NFHS National Family Health Survey Communication
NGO Non-Governmental Organization SC Sub-Centre
NHM National Health Mission SD Standard Deviation
NIN National Institute of Nutrition SHG Self-Help Group
NIPI National Iron Plus Initiative SN Supplementary Nutrition
NPPNB due National Prophylaxis Programme against SNP Supplementary Nutrition Programme
to VAD Nutritional Blindness due to Vitamin A
SPMU State Programme Management Unit
Deficiency
SSA Sarva Shiksha Abhiyan
NRC Nutrition Rehabilitation Centre
STI Sexually Transmitted Infections
NREGS National Rural Employment Guarantee
Scheme TBD To Be Decided
NVBDC National Vector Borne Disease Control THR Take-Home Ration
Program TSC Total Sanitation Campaign
OPV Oral Polio Vaccine
TT Tetanus Toxoid
ORS Oral Rehydration Salts
UIP Universal Immunization Programme
PDS Public Distribution System
UNDP United Nations Development Programme
PHC Primary Health Centre
UNICEF United Nations Children’s Fund
PMMVY Pradhan Mantri Matru Vandana Yojana
UPHC Urban Primary Health Centre
PMO Prime Minister’s Office
VHND Village Health and Nutrition Day
PMSMA Pradhan Mantri Surakshit Matritva
VHSC Village Health and Sanitation Committee
Abhiyaan
VHSNC Village Health Sanitation and Nutrition
POSHAN Partnerships and Opportunities to
Strengthen and Harmonize Actions for Committee
Nutrition in India VHSND Village Health, Sanitation and Nutrition
PRI Panchayati Raj Institutions Day
PW Pregnant Women WCD Women and Child Development
RCH Reproductive and Child Health WHA World Health Assembly
RTF Right to Food Campaign WHO World Health Organization
RTI Reproductive Tract Infections WIFA Weekly Iron and Folic Acid
RUTF Ready-to-Use Therapeutic Food WIFS Weekly Iron and Folic Acid
Supplementation
RGSEAG Rajiv Gandhi Scheme for Empowerment of
Adolescent Girls WRA Women of Reproductive Age
ivExecutive Summary
Data systems and their usage are of great significance et al. 2013); it also has large-scale national program
in the process of tracking malnutrition and improving platforms in place (Integrated Child Development
programs. The key elements of a data system for Services and National Rural Health Mission) whose
nutrition include (1) data sources such as survey and mandate is to deliver diverse nutrition interventions
administrative data and implementation research, (Avula et al. 2013). The National Nutrition Strategy (NITI
(2) systems and processes for data use, and (3) data Aayog 2017) and POSHAN Abhiyaan (MWCD 2018)
stewardship across a data value chain. The nutrition provide an updated strategic framework for action to
data value chain includes the prioritization of indicators, improve nutritional outcomes for children, pregnant
data collection, curation, analysis, and translation to women, and lactating mothers. POSHAN Abhiyaan’s
policy and program recommendations and evidence- mission-mode approach provides an impetus to
based decisions. Finding the right fit for nutrition strengthen not only the implementation but also the
information systems is important and must include monitoring and measurement of progress. The Mission
neither too little nor too much data; finding the data explicitly notes that NITI Aayog has a mandate to lead
system that is the right fit for multiple decisionmakers is the monitoring and evaluation of POSHAN Abhiyaan.
a big challenge.
Developed together with NITI Aayog, this document WHAT TO MEASURE AND FOR WHAT
covers issues that need to be considered in the PURPOSES?
strengthening of efforts to improve the availability and 1. Programs must track progress on intervention
use of data generated through the work of POSHAN
coverage in order to know whether policy efforts
Abhiyaan,1 India’s National Nutrition Mission. The
are reaching populations throughout the key
paper provides guidance for national-, state-, and
biological periods such as the first 1,000 days.
district-level government officials and stakeholders
regarding the use of data to track progress on nutrition 2. For each intervention type, it is also useful to track
interventions, immediate and underlying determinants, progress on the most relevant immediate and
and outcomes. It examines the availability of data underlying determinants. For example, in relation
across a range of interventions in the POSHAN to nutritional counseling, it is useful to measure
Abhiyaan framework, including population-based individual dietary diversity as an immediate
surveys and administrative data systems; it then determinant and household food security as an
makes recommendations for the improvement of data underlying determinant.
availability and use.
3. National nutrition strategies must track progress
To improve monitoring and data use, this document on indicators on all the target outcomes but must
focuses on three questions: what types of indicators do so in meaningful timeframes.
should be used; what types of data sources can be
used; and with what frequency should progress on
WHAT ARE SOME USES OF DATA IN THE
different indicator domains be assessed.
CONTEXT OF INDIA’S NUTRITION PROGRAMS?
INDIA’S POLICY FRAMEWORK FOR NUTRITION Potential data uses at different levels (national, state,
and district) include the following:
India has a robust policy framework for nutrition
that covers most evidence-based interventions (Vir 1. Progress tracking, reporting, and assessing impact
1
The Prime Minister’s Overarching Scheme for Holistic Nutrition (POSHAN) Abhiyaan or National Nutrition Mission, is Government of India’s flagship programme to improve
nutritional outcomes for children, pregnant women and lactating mothers. Launched by the Prime Minister on the occasion of International Women’s Day on 8 March, 2018
from Jhunjhunu in Rajasthan, POSHAN Abhiyaan directs the attention of the country towards the problem of malnutrition and addresses it in a mission-mode.
v2. Strategy refinement childhood and adolescence. We focused on immediate
determinants such as maternal nutrition, infant and
3. Program refinements and course correction
young child feeding (IYCF), and child health, as well as
Each of these uses requires both the availability of a range of underlying determinants such as poverty,
data and careful choices of what data to use, in food security, sanitation and early marriage. In terms
what timeframes and for what decisions. To this of nutritional outcomes, we focused on the goals of
end, to support effective monitoring of POSHAN POSHAN Abhiyaan as well as on the nutrition-related
Abhiyaan activities and improve data use, a range of Sustainable Development Goals (SDGs) to which India
mechanisms have been set up at the national, state, has committed.
and district levels. And indeed, a number of data
Using this comprehensive list of indicators for
systems are available that can be leveraged to assess
interventions, determinants, and outcomes that is
progress on nutrition determinants and outcomes
based on the POSHAN Abhiyaan framework, we then
and to inform evidence-based decisions and actions.
examined the availability of data on these indicators
Data on intervention coverage, determinants, and
across multiple data sources, including population-
nutrition outcomes are available from population-
based household surveys and administrative data. To
based household surveys such as the National Family
assess data availability, we reviewed the questionnaires
Health Survey (IIPS 2015), the Comprehensive National
used in the National Family Health Survey (IIPS 2015),
Nutrition Survey (MoHFW, UNICEF, Population Council
the Comprehensive National Nutrition Survey (MoHFW,
2019), and surveys conducted under the Aspirational
UNICEF, Population Council 2019), and the Aspirational
Districts Programme (NITI Aayog 2018) by third-party
Districts Programme Survey (first and second rounds
organizations such as IDinsight and the Tata Trusts.
2018/2019) by IDinsight and Tata Trusts (NITI Aayog
Data on program inputs and intervention coverage,
2018). We also reviewed the currently available
and even some outcomes, are also available from
indicators in administrative data sources of the Health
administrative data systems which gather data from
Management Information Systems (MoHFW 2015),
core ministries and departments that deliver a range of
Integrated Child Development Services–Anganwadi
health and nutrition services.
Centre Monthly Progress Report (MWCD 2012), and
Given the plethora of potential data uses, data ICDS–Common Application Software (CAS) (IFPRI
sources, data visualizations and data use mechanisms 2018). We assessed whether the data sources included
that already exist in India, there is also potential for the information to create or compute a relevant
data confusion. We aimed, therefore, to develop a indicator; if information was available, we then
comprehensive framework of indicators aligned to indicated the availability of data against the potential
India’s nutrition programs and to map available data indicator.
to this framework. Our goal was to provide multiple
potential users of data in India’s nutrition eco-system WHAT DID WE FIND?
with an overview of what indicators are useful to
1. A number of data systems can be leveraged
examine, and what data is available to support effective
to monitor progress and to inform evidence-
data use. Our review also highlights gaps in data
based decisions and actions.
availability to enable data producers to close gaps.
In India, data on intervention coverage,
WHAT DID WE DO? determinants, and outcomes are available from
We first generated a comprehensive list of evidence- both population-based household surveys
based interventions, determinants, and impact and administrative data systems; these can be
indicators that align with POSHAN Abhiyaan’s program leveraged to monitor progress and to inform
framework and then identified potential indicators for evidence-based decisions and actions. Since data
each of these. POSHAN Abhiyaan’s interventions cut is available from multiple sources, comparing
across the life cycle, from preconception, pregnancy, indicators from different surveys or from survey
delivery, postnatal and newborn care, through early and administrative data is challenging. While
viinterpreting findings, it is therefore important to y Swachh Bharat Abhiyaan dashboard (Ministry
consider differences in data collection mechanisms of Jal Shakti, 2020)
across sources; these include differences in y Health management information systems
sampling, questionnaire design, frequency of (HMIS) website (MoHFW 2020)
data collection, recall periods, and referenced age
Information on program inputs is available in a
groups. While interpreting and using data from scattered manner from multiple data sources.
administrative systems, it is also important to For instance, information on nutrition-related
consider denominators, the accuracy of reporting, social and behavior change communication
and differences in reference periods for different (SBCC) activities is available from the Jan Andolan
administrative data systems. dashboard; information on the flow of finances
2. Data can and should be used for a range of for POSHAN Abhiyaan inputs is not available in a
decisions in the context of India’s nutrition consolidated manner but could be consolidated
efforts. from reported expenditures across ministries and
line departments.
Data can and should be used for tracking
progress, reporting and assessing impacts, strategy 4. Data availability on intervention coverage
varies by life stage and type of intervention.
refinement, and program refinement. These
uses vary depending on whether they are at the The availability of data on the coverage of
national, state, district, or even subdistrict level. For interventions across life stages is as follows:
each of these uses, it is critical to ascertain timely 1. For adolescents, coverage data is scarce in
availability of data and effective uses of available both surveys and administrative systems.
data.
2. For preconception, limited data is available
3. Data on program inputs are primarily on the contraception, food fortification,
available from a range of dashboards and and coverage of iron and folic acid (IFA)
monitoring systems but need consolidation supplementation interventions for women of
and validation. reproductive age (that is, women between 15
and 49 years who are not currently pregnant
Input indicators refer to the resources needed to
or lactating).
support the implementation of an intervention
or program; these include financial and human 3. For pregnancy, multiple data sources are
resources, training, and infrastructure. They are available on the coverage of interventions,
primarily tracked by the administrative monitoring though the type of coverage indicators varies
systems of Integrated Child Development Services greatly across data sources. While indicators
(ICDS) and by the health department. Additional for measuring the coverage of antenatal
information on the roll-out of different elements of care (ANC) interventions exist in multiple
POSHAN Abhiyaan is available from the following data sources, there is limited information
administrative dashboards: for measuring the coverage of calcium
supplementation, malaria prevention and
y Anemia Mukt Bharat (AMB) dashboard
treatment, counseling during pregnancy, and
(MoHFW 2020) maternity benefits.
y Integrated Child Development Services–
4. For delivery and postnatal care, most surveys
Common Application Software (ICDS–CAS)
and administrative systems provide data on
y Jan Andolan dashboard (POSHAN Abhiyaan) institutional deliveries, deliveries attended by
(MWCD 2020) skilled birth attendants, and postnatal care for
y Pradhan Mantri Matru Vandana Yojana women and babies; information on kangaroo
(PMMVY) dashboard (MWCD 2020) mother care (KMC), including skin-to-skin
viicarrying of low birth weight infants) and Data availability on underlying determinants
breastfeeding counseling is not measured is better captured in survey results than in
across data systems, except in ICDS–CAS, and administrative data. Information on underlying
is limited; data is also very limited for newborn determinants such as food security, poverty, and
care interventions. gender-related determinants are available from a
5. For early childhood, most indicators for range of surveys.
measuring the coverage of interventions for
6. Data availability on nutrition outcomes.
infant and young childcare are covered to
an extent either in population-based surveys POSHAN Abhiyaan aims to have an impact on
or administrative data systems. Coverage eight nutrition-related outcomes: low birth
data on immunization and micronutrients weight, stunting, underweight, wasting, childhood
are embedded in most of the data systems; overweight, and anemia among children,
there are, however, limited options for adolescents, and women of reproductive age
tracking progress on the coverage of (WRA). In addition, India is a signatory to the
interventions related to infant and young child
nutrition-related SDGs, which include targets for
feeding counseling and the care of severely
reducing the emerging challenges of overweight
undernourished children.
and non-communicable diseases; indicators on
5. Data availability on immediate and underlying these need to be tracked as well.
determinants of malnutrition.
Outcome indicators are covered in most surveys.
To achieve the nutrition outcomes under POSHAN The National Family Health Survey (NFHS) is a
Abhiyaan, several immediate and underlying strong data system for tracking progress on all
determinants, including nutrition-related behaviors, outcome indicators, except on anemia among
need to be improved.
adolescents at different levels. Interim data
1. Research shows that child undernutrition is collection efforts (third-party surveys, etc.) could
caused by inadequacies in food, health and be useful for tracking the impact on outcomes
care for infants and young children, especially in high-burden districts or in sentinel sites which
in the first two years of life (immediate are chosen to represent specific areas of concern
determinants). Mothers’ and infants’ access to or action. Given both measurement challenges
nutrition-specific interventions can influence
and denominator challenges for outcome
these immediate determinants.
indicators in administrative data systems,
2. At the household and community level, we recommend that survey data should be
women’s status, household food security, prioritized for tracking progress on the outcomes
hygiene, and socioeconomic conditions of POSHAN Abhiyaan.
further contribute to children’s nutrition
outcomes (underlying and basic determinants). RECOMMENDATIONS
Interventions such as social safety nets,
sanitation programs, women’s empowerment, 1. Data prioritization
and agriculture programs have the potential to In order to track progress towards POSHAN
improve nutrition by addressing the underlying Abhiyaan goals and targets, a set of core indicators
and basic determinants. across the life cycle should be prioritized for
The POSHAN Abhiyaan framework recognizes monitoring the progress, diagnosis, and action in
most of these determinants explicitly and others both population-based surveys and administrative
implicitly. Data on immediate determinants are data systems; these core indicators should be
available from diverse sources, but data are reviewed at national, state, and district levels
especially limited on nutrition-related behaviors. across the existing review mechanisms.
viii2. Promote data use POSHAN Abhiyaan monitoring and strategic review
meetings at all levels (national, state, district).
There is a need to create a strong culture of data
appreciation and data use among actors across 6. Monitoring progress on outcomes
the nutrition space. To promote awareness around
Using population-based survey data for progress
available data sources and their use, we need to
tracking ensures that all nutrition target indicators
ensure that all data users are aware of the design
are covered; efforts to improve the quality of
elements, challenges, and opportunities of each data on nutrition outcomes from administrative
type of data source; to this end, guidance on systems for program use should be supported but
different types of data sources and their use needs we discourage the use of data from administrative
to be developed. systems to track population-level progress on
3. Follow the theory of change, program and outcomes.
biological temporality
7. Data stewardship
We recommend that early progress tracking for
A primary data stewardship entity such as NITI
the nutrition mission should focus on system Aayog should work in combination with related
preparedness and readiness; in the second year, state-level entities in order to ensure coordinated
the focus should be on assessing coverage; monitoring of progress, strategy refinement, and
and only in later years should the focus turn to support in the use of data for program refinement.
assessing coverage and changes in determinants This entity must provide guidance on the use of
and outcomes that are relevant to the program data to all major committees and review platforms.
roll-out. Impacts on outcomes such as stunting
should only be explored once changes are seen in CONCLUSIONS
coverage, immediate and underlying determinants.
Tracking India’s progress on malnutrition at the
4. Tracking progress on inputs and intervention national, state and district levels using timely, relevant
coverage and high quality data is an achievable goal but it will
require key investments at different points along the
Multiple data sources for input and coverage
nutrition data value chain. Together, these investments
indicators means that a careful reconciliation of
can strengthen the strategic use of data in ways that
findings from survey data and administrative data
improve the reach and impact of India’s mission to
systems is required. Strengthening interoperability address malnutrition.
of nutrition data across data systems could also
help to resolve issues with coverage indicators
and support decisionmaking. Finally, it is also
recommended that data use cases should be
developed for survey and administrative data on
intervention coverage.
5. Monitoring progress on determinants
It is recommended that population-based survey
data be used both for progress tracking and
diagnostic exercises to decide on which immediate
and underlying determinants, including nutrition
behaviors, are major challenge areas for the region.
It is important to include implementers and sectors
that are addressing underlying determinants such
as poverty, food security, sanitation and gender in
ix1. Introduction
The key elements of a data system for nutrition include: 2. What types of data sources can be used?
(1) data sources, including survey data, administrative
3. With what frequency should progress on different
data, and implementation research; (2) systems and
indicator domains be assessed?
processes for data use; and (3) data stewardship across
a nutrition data value chain. The nutrition data value This document focuses on these questions and does
chain includes elements of prioritization of indicators, the following.
data collection, curation, analysis, translation to policy 1. To address the question of what to measure, it
and program recommendations, and evidence-based proposes a comprehensive framework of indicators
decisions. Finding the right fit for nutrition information that is based on relevant nutrition conceptual
systems is important and there should be neither much frameworks, the POSHAN Abhiyaan administrative
nor too little data; finding the right fit for a data system framework and a theory of change for POSHAN
that works for multiple decisionmakers is an even Abhiyaan.
bigger challenge.
2. To answer what data sources to use, it draws on a
Developed together with NITI Aayog—which is review of data availability for the set of indicators
primarily responsible for monitoring POSHAN Abhiyaan, and indicator domains included in the framework.
India’s National Nutrition Mission launched in early
3. To address the question of with what frequency
2018—this document lays out issues to consider in
progress on different indicator domains should
strengthening efforts to improve the availability and
be addressed, it draws on the nutrition evaluation
use of data. This “approach paper” provides guidance
literature and on the potential theory of change for
that can be used by national-, state-, and district-level
POSHAN Abhiyaan.
stakeholders on issues that should be considered
with regard to the use of data to track progress on
INDIA’S POLICY FRAMEWORK FOR NUTRITION:
nutrition interventions, immediate and underlying
FROM INPUTS TO IMPACT
determinants, and outcomes. It aims to serve POSHAN
Abhiyaan, the government’s flagship initiative, but is POSHAN Abhiyaan aims to reduce stunting, anemia,
also applicable to a range of other efforts to improve and low birth weight across high malnutrition burden
nutrition. It specifically examines the availability of data districts. It recognizes the need for convergence and
from both population-based surveys and administrative coordination such that the benefits of government
data systems in the context of POSHAN Abhiyaan’s schemes and programs reach women and children in
the first 1,000 days. The Abhiyaan aims to improve
intervention framework. In addition, it lays out issues to
service delivery and interventions using technology,
be considered in strengthening efforts to improve the
behavioral change, and convergence.
use of data in the context of POSHAN Abhiyaan, and
makes key recommendations related to improving data POSHAN Abhiyaan builds on a robust policy framework
availability and improving the use of currently available for nutrition that covers most evidence-based
data. interventions (Vir et al. 2013); it also has large-scale
national program platforms in place (Integrated
To improve nutrition monitoring and strengthen data
Child Development Services and the National Health
use, it is useful to ask and address the following
Mission) whose mandate is to deliver diverse nutrition
questions:
interventions (Avula et al. 2013). The National Nutrition
1. What types of indicators should be used, and for Strategy (NITI Aayog 2017) and POSHAN Abhiyaan
what purpose? now provide an updated strategic framework for
1action to improve nutritional outcomes for children, convergence-related actions will help to address
pregnant women, and lactating mothers. The POSHAN the underlying challenges of gender, sanitation,
Abhiyaan’s mission-mode approach provides an and poverty.
impetus to strengthen not only the implementation but
3. Finally, the theory of change assumes that
also the monitoring and measurement of progress.
changing these determinants will in turn lead to
The POSHAN Abhiyaan framework also lays out improved outcomes on POSHAN Abhiyaan targets
determinants of nutritional outcomes that are including child growth and anemia.
targeted by various interventions, schemes and
programs included in the overall framework. These ASSUMPTIONS IN THE THEORY OF CHANGE
include maternal nutrition, newborn care practices, Some key assumptions in the overall theory of change
and infant feeding, as well as care practices, and are related to:
underlying determinants, such as age at marriage and
childbearing, and sanitation. And finally, it articulates a 1. Improving capacities of frontline workers:
clear set of targeted outcomes. Through Incremental Learning Approach (ILA)
training, is it assumed that there will be an
From the perspective of developing a comprehensive improvement in the quality of public sector
framework of indicators, the conceptual framing of health and nutrition services and an enhanced
interventions leading to determinants which then lead capacity for supporting the delivery of high impact
to improved outcomes is central to what is proposed interventions such as counseling and growth
in this document. This theory of change for POSHAN monitoring.
Abhiyaan and the linked interventions and programs
2. Use of technology: The assumption is that
are, therefore, used to define the full set of indicators
technology adoption by frontline workers,
and indicator domains in this approach paper.
including the use of smartphones, dashboards, and
other features of the technology, will lead to better
THEORY OF CHANGE FOR POSHAN ABHIYAAN coverage and quality of service delivery.
The theory of change for POSHAN Abhiyaan outcomes
3. Cross-sectoral convergence actions: The
is based on several assumptions that map to the
assumption is that establishing convergence
key components of POSHAN Abhiyaan: improving
committees at the state, district, and block
capacities, using technology, the convergence
levels will facilitate decentralized and convergent
of multiple programs, and behavior change
planning, implementation, and review of actions
communications. (Details on assumptions related to
at the community level; this, in turn, assumes that
specific components are given in Figure 1)
convergent planning activities can bring together the
1. It assumes that core components related to actions of different sectors to address determinants
technology, capacity building, and social and of undernutrition at the household level.
behavior change will trigger a series of changes 4. Social and behavior change communication
that will improve the availability and quality of (SBCC): It is assumed that SBCC actions, especially
nutrition interventions in the ICDS and health Jan Andolan related activities such as community-
system. It also assumes that the multisectoral based events and mass media, will lead to improved
convergence component will induce collective knowledge, motivation, and skills, and that
action in multiple sectors. households will adopt behaviors to achieve impact.
2. It assumes that putting these interventions in place 5. Linked to this, there is an overarching assumption
will address both the immediate and underlying that, especially at the district level, delivering
determinants of poor nutritional outcomes; these all these components together, will lead to an
include behaviors such as dietary practices for improvement in the reach, quality, and intensity
women and children, the use of micronutrient of high impact nutrition-specific interventions in
supplements and food supplements, and sanitation the first 1,000 days of life and other interventions
practices. It also assumes that multisectoral addressing underlying drivers.
2Figure 1: Potential theory of change for POSHAN Abhiyaan
Improved availability
Improvements in
POSHAN Abhiyaan of, and access to,
determinants of
actions POSHAN Abhiyaan
undernutrition
interventions
• Train Integrated Child • Improved public sector • Better diets during
Development Services and antental care (ANC) pregnancy
(ICDS) workers in service services and nutrition • More IFA and calcium
delivery using an interventions during pregnancy
Incremental Learning (counseling, weight gain
• Better breastfeeding
Approach (ILA) monitoring, iron and
folic acid [IFA], calcium) • More postnatal care
• Train ICDS workers in
use of technology and • Private sector ANC • Better complementary
ensure availability and feeding
• Improved ICDS services
functioning of (SNP, growth • Higher consumption of
technology monitoring, home visits) micronutrient
• Address other ICDS supplements
• Micronutrient
challenge areas, supplements for • Consumption of
including the fortified food • Better child
children at Village
Supplementry Nutrition growth
Health, Sanitation and • Improved handwashing
Program (SNP) Nutrition Days (VHSNDs) • Better
• Improved use of toilets
• Activities to strengthen hemoglobin
• More frequent and
health ICDS better community-based • Low birth
convergence events weight
(team-based incentives,
• Mass media campaigns
joint planning, etc.)
• Sanitation information
• Convergent actions -
and subsidies
sectors identify key
actions and put in the • Mahatma Gandhi
place mechanisms to National Rural
implement, review, Employment Guarantee
monitor Act (MGNREGA)
• Social and behavior
change communication
(SBCC)/Jan Andolan
activities - materials,
messages, planning and
support for
community-based
events
6. It is assumed that these will lead to improvements interventions at critical biological periods, there will
in household practices, such as dietary diversity, be improvements in nutritional outcomes.
care during pregnancy and early childhood,
and household conditions including improved ADDRESSING TEMPORALITY IN THE THEORY OF
sanitation. CHANGE
7. Finally, an ultimate assumption around the In addition to the considerations above, there are two
biological theory of change is that over major issues related to temporality that should be
time, for women and children exposed to these considered in assessing which indicators to monitor
3at what time. The first is biological and the second is 2. The level of hemoglobin, which is used to assess
programmatic. the population prevalence of anemia, can improve
in short periods of time—months rather than
From a biological perspective, each nutritional
years—because the red blood cells that carry
outcome as specified in POSHAN Abhiyaan takes a
hemoglobin are formed continuously in the body
different amount of time to respond to interventions; and have a short life cycle. If interventions to
this temporal variability in the biological response of address all major causes of low hemoglobin (iron,
different outcomes has implications for how to think B vitamins, intestinal worms, and inflammation)
about monitoring. are put into place, then the impact on anemia
outcomes can be seen within a much shorter
Below, we offer two examples:
timeframe than interventions that address
1. Child linear growth, which is used to assess outcomes such as child growth.
the prevalence of population-level stunting, is
From a programmatic perspective, systems
a process that begins in utero and continues
strengthening efforts can take time, especially to
throughout childhood. For children under the
deploy interventions at scale. Each of the core pillars of
age of five years, it is well established that peak POSHAN Abhiyaan—capacity building, technological
responsiveness to interventions occurs in the interventions, convergence planning and action, and
first 1,000 days. This means that for a woman social and behavior change interventions—takes
who entered her pregnancy in the first month of time to design, develop, deploy at scale, strengthen,
POSHAN Abhiyaan’s launch (April 2018), the full and sustain. This has implications for what should be
impact of all interventions delivered to her and her monitored at what point in the Mission. We suggest
child in the first 1,000 days should be assessed that in its first year, the Mission should focus on
only in January 2021. Furthermore, if the systems monitoring preparedness and readiness; in the second
are not fully ready to deliver all interventions in year it should be on assessing coverage; and in later
the first 1,000 days to all women and children, years the focus should be on assessing both coverage
then their full impact on child growth can only be and changes in determinants and outcomes that are
assessed in later years. Full impacts should only relevant to the program roll-out.
be assessed among children born to women who Hence, paying attention to both biological and
entered the 1,000 days period when all major programmatic issues related to temporality is central to
interventions were fully in place. the pragmatic tracking of progress.
42. Mechanisms and Data Systems to
Monitor Progress on Nutrition Actions
and Outcomes
Effective monitoring needs mechanisms and data to most senior principal secretary, who is nominated
enable informed decisions. Below we have summarized by the chief secretary—is expected to facilitate
several review and monitoring mechanisms that are sectoral departments to create their action plans;
available in POSHAN Abhiyaan to track progress. this includes monitoring of interventions under
POSHAN Abhiyaan. There is no guidance in the
EXISTING NUTRITION MONITORING public domain as to what should be monitored by
MECHANISMS UNDER POSHAN ABHIYAAN the states.
To support effective monitoring of POSHAN Abhiyaan 3. District administrators are required to monitor
activities and outcomes, various institutional progress at that level through a quarterly review
mechanisms have been set up at the national, state, meeting; meetings are convened by the district
and district levels. collector, who is expected to use a set of indicators
1. A national council has been established under across the continuum of care to review the data
the vice chair of NITI Aayog, and an executive available from programs like the ICDS, the National
committee has been set up which is chaired by Health Mission (NHM), and other sectors. Data for
the secretary of the Ministry of Women and the quarterly reviews is to be provided by frontline
Child Development. Both these committees have workers, cross-checked at the block level, and
representation from all the aligned line ministries, validated by a district validation committee. Other
partners, selected states, and districts; they are mechanisms include reviews by sectoral officials,
scheduled to meet every three months and a block dashboards (ICDS–CAS), the Jan Andolan
progress report is to be submitted to the prime dashboard, the Swachh Bharat dashboards,
minister every six months. NITI Aayog, which is the and data from third-party surveys such as the
Government of India’s policy think tank, provides Aspirational Districts Programme Survey.
oversight of monitoring and evaluation activities.
A technical support unit (TSU) and a monitoring EXISTING DATA SYSTEMS TO SUPPORT DATA
and data analytics cell have been established at USE FOR NUTRITION
NITI Aayog to periodically assess progress and In India, data on intervention coverage, determinants,
impacts; also, formal partnerships with technical and nutrition outcomes is available from both
experts (Tata Trusts, Harvard University, IFPRI, population-based household surveys and administrative
IDinsight) support monitoring and data analytics. data systems.
Partnerships with district-level support partners
Population-based household surveys include
such as Tata Trusts and the Piramal Foundation
the National Family Health Survey (NFHS), the
strengthen the use of data.
Comprehensive National Nutrition Survey (CNNS), and
2. State Project Management Units (SPMUs) are surveys conducted under the Aspirational Districts
expected to function as State Nutrition Resource Programme by third-party organizations such as
Centres, monitoring activities and providing IDinsight and the Tata Trusts. Table 1 summarizes
direction for effective program implementation. some key features of these surveys, and highlights
A state convergence committee—headed by the the differences in geographic representativeness,
5temporality, frequency, and data availability. nutrition. In India, these include the data systems from
Population-based surveys need to ensure the availability ICDS and the NHM for nutrition-specific interventions,
of data on relevant indicators in order to assess the and from other systems such as the Swachh
coverage of interventions, key determinants, and levels Bharat Mission for sanitation, which can support
of outcome. This data, obtained in given timeframes improvements in underlying determinants of nutrition.
and with geographic representativeness, can be used Table 2 summarizes the key features of different
to support appropriate decisions. administrative monitoring information systems. These
administrative systems should generate data around
Administrative data systems include data from the
common administrative boundaries such as blocks,
core ministries and departments that deliver public
districts, and supervisory service areas, and should
services for health and nutrition. These also support
support effective reviews and action.
improvements in the underlying determinants of
Table 1: Summary of major population-based surveys on nutrition in India (1992–2019)
Survey name Survey rounds Geographic scope Frequency Data availability Comparability
anthropometry
group for child
and full report
representative
Level at which
Time between
Time between
survey rounds
Access to data
end of survey
Target group
the survey is
respondents
Geographic
of women
Reference
coverage
NFHS 1 All India—24 National 2 years DHS < 4 years Ever-married
(1992—1993) states and State (1995) website women age
Delhi National 13—49 years
Capital
Region (NCR)
NFHS 2 All India— 25 6 years 1 year < 3 years Ever-married
National Family (1998—1999) states (2000) women age
Health Surveys 15—49 years
(NFHS)
NFHS 3 All India— 29 7 years 1 year < 5 years All women age
(2005—2006) states (2007) 15—49 years
NFHS 4 All India—29 National > 9 years 1 year < 5 years All women age
(2015—2016) states and State (2017) 15—49 years
6 union District
territories
Comprehensive CNNS All India— 30 National NA Published NHM 0–4 years All women age
National (2017–2018) states State website 15—19 years
5–9 years
Nutrition
Survey (CNNS) 10–14 years
Round 1 27 districts District 6 months Unknown On < 5 years Pregnant
(May–Aug (IDinsight) request women,
2018) mothers of
85 districts
Aspirational children < 5
Districts (Tata Trusts) years
Programme Round 2 27 districts District 6 months Unknown On < 5 years Pregnant
(ADP) Surveys1 (Jan–Feb 2019) (IDinsight) request women,
mothers of
85 districts
children < 5
(Tata Trusts) years
Note: 1The Aspirational Districts Programme Surveys are ongoing; NHM = National Health Mission; DHS = Demographic Health Survey.
Source: NFHS Rounds 1, 2, 3 and 4; CNNS 2017-18; ADP Survey by IDinsight (Rounds 1 & 2).
6Box 1: Broad issues to consider while using and interpreting data from different data sources
• Survey design elements such as sampling, questionnaire design, and questions that were used to create the
indicators, can differ for population-based surveys; this has implications for interpretation.
• Population coverage can differ across data sources. Sample surveys intend to cover the entire population
whereas monitoring information systems (MIS) data are limited to those who access government services; also,
denominators in MIS data may need to be updated, for example estimates of pregnant women in a district.
• Reference periods can also differ; survey questions, for example, often ask for different reference periods than
what is reported in MIS data.
• Administrative data entered by frontline workers may have several biases, both random and systematic, that
can lead to inaccurate reporting; also, if training and field monitoring are limited, the survey data that is
obtained can be of poor quality.
• If the indicators for intervention coverage are missing, it may mean that for some areas the data may be
unavailable from either surveys or administrative data systems.
Table 2: Summary of key administrative data systems on nutrition in India
Administrative Responsible Geographic scope Access Web
Frequency
data system ministry to data link
Geographic Level at which
coverage the data is
reported
Health Health and Family All India—29 National Monthly Public www.nrhm-
Management Welfare, National states and 6 State mis.nic.in
Information Health Mission (NHM) union territories District
Systems (HMIS)
Integrated Child Women and Child All India—29 National Monthly Government https://icds-
Development Development, ICDS states and 6 State wcd.nic.in/
Services Monitoring union territories District
Information Block
Systems (ICDS MIS)
ICDS-CAS Women & Child All India—29 National Real-time Government www.icds-
dashboard Development, ICDS states and 6 State cas.gov.in/a/
union territories District icds-cas/login/
Block
AWC
Jan Andolan Women & Child All India—29 National Real-time Public www.poshan
dashboard Development, ICDS states and 6 State abhiyaan.
union territories District gov.in/#/
Health and Family All India—29 National Quarterly Public www.anemia
Anemia Mukt Welfare, NHM states and 6 State muktbharat.
Bharat dashboard union territories District info/
dashboard/#/
Pradhan Mantri Women & Child All India—29 National Real-time Government https://
Matru Vandana Development, ICDS states and 6 State pmmvy-cas.
Yojana (PMMVY) union territories District nic.in
dashboard
Swachh Bharat Drinking water and All India—29 National Real-time Public https://
Mission dashboard sanitation states and 6 State sbm.gov.in/
union territories District sbmdashboard/
Village
Source: The web links provided in the table above.
73. Use of Data in the Context of India’s
Nutrition Efforts
In India, as noted above, nutrition information is POSHAN Abhiyaan actions and on benchmarking
accessed from multiple data sources, including surveys intervention coverage. Subsequent reports should
and routine administrative data systems. Data can and focus on the coverage of nutrition interventions
should be used for tracking progress, reporting and and related behaviors.
assessing impact, strategy refinement, and program
6. The impact of the various components of
refinement. These uses vary by levels, including
POSHAN Abhiyaan and its linked programs can be
national, state, district, and even subdistrict. For each
effectively assessed with the help of well-designed
of these uses, it is critical to ascertain timely availability
impact evaluations; impact evaluation procedures
of data and effective uses of available data. Below, we
should be planned early, but the impact
lay out key considerations for different data use cases.
assessment itself should not be done so early in
the implementation that it could underestimate
TRACKING PROGRESS, REPORTING,
impact on major outcomes such as anthropometry.
AND ASSESSING IMPACT
1. Tracking helps to establish priorities and to monitor
STRATEGY REFINEMENT
efforts aimed at achieving targets.
1. The policy community needs timely data to enable
2. Reliable data to monitor progress must be available refinement of nutrition strategies.
in timeframes necessary for reporting.
2. Strategy refinement is needed only periodically
3. To track progress, data on program inputs and on and should be undertaken by a broad range
coverage of interventions is useful in a short-term of stakeholders who have the analytic and
timeframe; data on immediate and underlying programmatic experience necessary to develop
determinants is useful in a medium-term effective strategies.
timeframe; and data on outcomes is useful in a
long-term timeframe. 3. While considering a strategy, along with assessing
which nutrition outcomes and determinants
4. Data from both administrative systems and should be focused on, data on intervention
surveys can be used to track progress in the coverage is also needed to guide refinement. In
implementation of planned activities and can help
states or districts, for example, examining the
prioritize actions in different geographies and
data on intervention coverage can provide clear
timeframes.
insights into which specific interventions should be
5. Currently, one of the primary reporting targeted.
mechanisms is the report on the progress of
4. A range of data related to nutrition outcomes, the
POSHAN Abhiyaan that is submitted to the
immediate and underlying causes of malnutrition
Prime Minister’s Office (PMO) every six months
and the reach of interventions are vital to an
by NITI Aayog. This includes tracking progress
analysis of the nature of the nutrition challenge, its
and reporting on actions that are relevant
potential determinants, target groups and to the
to the timeframe of the Mission and to the
prioritization of interventions.
progress anticipated in that time period. The
first report to the PMO focused on reporting 5. In POSHAN Abhiyaan, national strategy
the states’ readiness, while the second report development was conducted in the 2017/2018
focused on reporting the implementation of timeframe, prior to the development of the
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