Bihar State Nutrition Action Plan 2019-24socialwelfare.bih.nic.in/Docs/Bihar-State-Nutrition... · 2019-06-18 · NREGA - National Rural Employment Guarantee Act. NRLM - National

Bihar State

Nutrition Action Plan

2019-24

Department of Social WelfareGovernment of Bihar

Govt. of Bihar

Bihar State

Nutrition Action Plan

2019-24

Govt. of Bihar

Table of Contents

Particulars Page

Overview: The Vision of the State Nutrition plan 6

Background: Progress thus far in ensuring social Justice and development 6

Persistence of stunting and other forms of malnutrition 6

Commitment to global and national nutrition goals 7

Multi-sectoral response 7

Consonance with National and State Policies, Strategies and Legal Framework 8

Expectations of line departments 8

Governance structure for supporting and monitoring implementation 9

Long term commitment 9

Rationale for a Nutrition Workplan for the State 9

Articulation of serious commitment 9

Enable sustained focus in the long term: 10

Provide a common vision for many departments and stakeholders: 10

Meet the need for high-level governance attention: 10

Provide sufficient breadth to accommodate mid-course corrections to departmental strategies: 10

Maximize departmental ownership and accountability to results: 10

Distinctive features of this Workplan 10

Section 1: The Context of Malnutrition in Bihar 12

Status of malnutrition in Bihar 12

Status of determinants of malnutrition in Bihar 15

Immediate Determinants 15

Underlying Determinants 17

Section 2: Strategic Directions of the State Nutrition plan 19

Goals 19

Strategic Workplan principles 20

Multipronged response 20

Focus on reaching every family with what they need, simultaneously 20

Addressing diversity 21

Coordinated action in planning and monitoring 21

Long term effort 21

Priorities among multiple nutrition goals 22

Use of evidence to learn, guide strategy and measure progress 22

Bringing it all together to address determinants of malnutrition 22

Departmental Roles and Indicators 25

Section 3: Implementation and Monitoring 33

Envisaged approach to implement the State Nutrition plan 33

Ensuring that vulnerable families are benefitted concurrently by different departmental actions 33

Common set of eligibility criteria to be followed by different departments 33

Ensuring nutrition focus 34

The horizon and scope of planning by individual departments 34

Data for planning and monitoring 34

Transparency to minimize exclusion 35

Common Mechanism for maximizing awareness 35

Administrative and Monitoring Framework 36

Ward level 36

District Administration level 36

State Government level 36

Resources for Implementing the State Nutrition plan 38

ANNEXURE 1: Main forms of malnutrition, their consequences and howthey can be addressed 40

ANNEXURE 2: Data on status of malnutrition and its determinants inindividual districts of Bihar 48

ANNEXURE 3: Departmental Planning format for contributing to Workplan goals 54

ANNEXURE 4: Workplan Note on Improving Nutrition in Bihar 55

List of Abbreviations

AARR - Annual Average Rate of Reduction

ARI - Acute Respiratory Infection

AWC - Anganwadi Center

BC - Backward Class

BCC - Behavior Change Communication

BF - Breast Feeding

BKMB - Bal Kuposhan Mukt Bihar

BMI - Body Mass Index

BPL - Below Poverty Line

BSWSM - Bihar State Water & Sanitation Mission

CAB - Clinical, Anthropometric & Biochemical Survey

CDPO - Child Development Project Officer

CHHNS7 - Concurrent Household Health and Nutrition Survey (Round-7)

DPO - District Project Officer

EBC - Extremely Backward Class

FCSC - Food & Civil Supplies Corporation

GOB - Government of Bihar

GOI - Government of India

HCM - Hot Cooked Meal

HH - House Hold

HIV - Human Immunodeficiency Virus

ICDS - Integrated Child Development Services

IEC - Information Education & Communication

IFA - Iron Folic Acid

IFPRI - International Food Policy Research Institute

IGMSY - Indira Gandhi Matritva Suraksha Yojna

IIPS - Indian Institute of Population Services

IYCF - Infant & Young Child Feeding

LBW - Low Birth Weight

MAM - Moderate Acute Malnutrition

MCH - Mother & Child Health

MDM - Mid Day Meal

MVM - Manav Vikas Mission

NFHS - National Family Health Survey

NFSM - National Food Security Mission

NITI Aayog - National Institution for Transforming India

NMOOP - National Mission on Oil-seed & Oil Palm

NMSA - National Mission for Sustainable Agriculture

NRDWP - National Rural Drinking Water Programme

NREGA - National Rural Employment Guarantee Act.

NRLM - National Rural Livelihood Mission

ORS - Oral Rehydration Solution

PDS - Public Distribution System

PHED - Public Health Engineering Department

PMMVY - Pradhan Mantri Matri Vandana Yojna

POSHAN - Partnership and Opportunities to Strengthen and Harmonize Actions for Nutrition in India

RD - Rural Development

RI - Routine Immunization

RMSA - Rastriya Madhyamik Shiksha Abhiyan

RNTPC - Revised National TB Control Program

RSoC - Rapid Survey on Children

SABLA - Rajiv Gandhi Scheme for Empowerment of Adolescent Girls

SAM - Severely Acute Malnutrition

SFC - State Food Corporation

SDG - Sustainable Development Goal

SHG - Self Help Group

SNP - Supplementary Nutrition Programme

SWD - Social Welfare Department

TAG-N - Technical Advisory Group – Nutrition

TB - Tuberculosis

TFR - Total Fertility Rate

THR - Take Home Ration

WCD - Women & Child Development

WHA - World Health Assembly

WHO - World Health Organization

WIFS - Weekly Iron and Folic Acid Supplementation

Overview: The Vision of the State Nutrition Plan 2019-24

Background: Progress thus far in ensuring social Justice and development

The Bihar Government is resolved to ensure social justice with all-round progress for all its citizens. Towards this end, the state has strived to strengthen governance and make rapid progress through special initiatives and policies such as Manav Vikas Mission, Roadmap for Agriculture, Skill Development Mission, stimulus for strengthening infrastructure and industrialization and the Saat Nishchay. The Bihar Vikas Mission is engaged in guiding departments in translating these resolves into reality in mission mode, and supporting them in adopting innovative and effective implementation approaches. In focus are the most vulnerable of our people – the Mahadalits, Dalits, the extremely backward, the poor, minority communities and women – to ensure that they gain the same status and opportunities as the rest of the society, and that everyone experiences the fruits of development together.

Much progress has been made by the state in recent years, as evinced by rapid economic growth, much improved infrastructure such as roads and power, strengthened public health services, and rapid increases in girls' education, to name a few streams of development. There has been steady progress on a number of health impact parameters, including maternal and child mortality rates, which are close to national averages, as well as crude death rates and life expectancy.

Persistence of stunting and other forms of malnutrition

Hunger has been substantially conquered. However, Bihar continues to have some of the highest rates of child malnutrition in the country and globally, particularly stunting, or a failure to grow tall enough. This becomes evident in Bihar as early as the second year of life, by the end of which most children clearly fail to put on height according to standards and potential. A child normally grows rapidly from the time she is in her mother's womb to the time she is two years old, and then puts on height more slowly. When this 'window of opportunity' of the first 1000 days is missed and the child fails to put on as much height as her potential during this time, the gap becomes virtually permanent – the child grows to a stunted adult.

Worryingly, besides being an underlying cause in a significant proportion of child mortality, stunting is known to be associated with poorer cognitive development and slower learning. Together, these physical and mental handicaps affect health, survival and productivity. Undernutrition in childhood is also associated with long-term consequences on the health and well-being, paradoxically making individuals vulnerable to chronic conditions such as diabetes, cardiovascular disease and obesity. Stunting in children represents the effects of long-lasting inadequacy of diet, repeated illnesses and a range of disabling and disempowering influences that arise from social injustice and poverty, and these effects are known to last generations.

Other forms of malnutrition are also of concern. Severe wasting or thinness, also called Severe Acute Malnutrition (SAM), makes the child vulnerable to death. Anaemia affects nearly two thirds of women and children and a third of men, and is mostly due to iron deficiency, a largely preventable condition. Iodine and vitamin A deficiency are better controlled, from the use of fortified salt and vitamin A supplements. At the other extreme, childhood overweight is still rare, but could be a concern in the future.

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All forms of undernutrition share the same set of underlying structural determinants. Nutrition affects development as much as development leads to better nutrition.

Commitment to global and national nutrition goals

India has committed to achieving the Sustainable Development Goals, to which better nutrition is integral. It is also committed to achieving the World Health Assembly targets for nutrition for 2024, which include reduction in stunting by 40% and anaemia by 50%. This State Nutrition plan of Bihar, 2019-2024 affirms our commitment to achieving similar goals for the state in this time frame and outlines strategic principles and indicative actions to achieve these specific goals, on its way to eventually eliminating all forms of malnutrition.

Multi-sectoral response

Given that malnutrition is multifactorial, the response to prevent and eliminate malnutrition must be multidimensional. Families with multiple vulnerabilities need multipronged support. Therefore, the core strategic principle to achieve the best nutrition outcomes is to ensure that all necessary supportive actions reach a family burdened with multiple vulnerabilities simultaneously, and in a timely manner. The state will establish a mechanism, rooted at the ward level, for reliably identifying families that have specific vulnerabilities, and linking such families to the support services of all relevant departments.

Some services, such as ICDS or education or health, are meant to be implemented universally, and in such cases the effort will be to maximize the quality of services, while minimizing exclusions. Other programs or schemes use targeted approaches, where vulnerable sections are specifically identified as beneficiaries, or where resources permit only a phased scale up. In such cases, the attempt will be to ensure that these targeted benefits reach the most vulnerable first, and the increasingly less vulnerable later, as needed. This approach resonates with other development initiatives that are being strengthened in the state.

Consonance with National and State Policies, Strategies and Legal Framework

The National Nutrition Workplan, 1993, recognized the diversity of the nutrition problem and the need for a multi-sectoral response, and has provided broad direction to national efforts to address malnutrition in the short and the long term. The National Plan of Action on Nutrition, 1995 specified ambitious goals and laid out a wide range of Sectoral Plans of Action. Several later guidelines and strategies have mooted comprehensive responses to nutrition, both at state and national levels, including the recent National Nutrition Strategy proposed by NITI Aayog. Several national programs and schemes along with guidelines already exist that attempt to address various specific dimensions of nutrition. The Constitution of India and a number of laws govern child rights and protection, food security, food safety and standards, marketing of foods for children, affirmative actions for vulnerable sections of the population, employment guarantee, etc., which together provide a legal scaffolding and mandates to state governments to address malnutrition.

This State Nutrition plan builds on these ideas and frameworks and proposes approaches to address the problem that are appropriate for the state context and are in consonance with the substantial efforts already in place in the state to reduce inequities and ensure all-round development. It also provides the opportunity and scope for further legislation to strengthen the rights of citizens to adequate nutrition.

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Expectations of line departments

The Workplan identifies indicative sectoral actions from each department that are likely to contribute significantly to better nutrition, along with a corresponding set of broadly defined indicators of success. In many cases, departments are already implementing such actions, and the only additional effort needed is to strengthen quality and ensure inclusion, in coordination with other departments. As a first step in the implementation of the Workplan , individual departments will detail out their action plans as well as propose a set of measurable indicators through which progress may be monitored. Departments will plan together, implement individually and monitor together.

Governance structure for supporting and monitoring implementation

A distinct governance structure has been proposed, with a multi-departmental empowered body constituted by Principal Secretaries or Secretaries of relevant departments and headed by the Development Commissioner at the state level. The Department of Social Welfare will be the nodal department. The District Magistrate will oversee implementation at the district level, while the Ward Prabandhan evam Kriyanvayan Samiti will support and monitor implementation at the village level. The Bihar Vikas Mission will provide guidance and advice, and the empowered body will be assisted by a specially constituted Technical Advisory Group on Nutrition, with domain expertise. Active participation of civil society organizations and development partner agencies will be solicited.

A mechanism will be instituted to generate independent data on coverage of actions proposed by various departments, and to make data transparently available and maximize accountability.

Long term commitment

This battle against malnutrition will last long, and will require sustained governance attention to ensure success. The effort will require significant resources, but every investment in nutrition will be worthwhile for the benefits it will confer on children, women and men of the state. This Workplan

aims at a brighter nutritional future for them. This Workplan envisions a suposhit (well-

nourished) surakshit (well-protected) child that is so crucial for a samrudhh (prosperous)

Bihar.

Rationale for a Nutrition Workplan for the State

The need for a distinct Nutrition Workplan arises from reasons that are inherent to the complex nature of the problem of malnutrition and the kind of response that will be needed to minimize its influence on the people of the state:

Articulation of serious commitment: The problem of malnutrition has gained high visibility in the country, Bihar is seen as having some of the highest rates of malnutrition, particularly stunting in children. The formulation and adoption of this Workplan is an expression of the state's commitment to address the problem comprehensively with the seriousness that it deserves.

Enable sustained focus in the long term: The state has set ambitious goals for addressing malnutrition, particularly stunting in children. These goals cannot be achieved in the short term in a campaign mode. A strong Workplan framework will help sustain long term attention and focus.

Provide a common vision for many departments and stakeholders: The effort required is

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multidimensional, involving at least 6-7 departments as the main contributors, working in close coordination. An overarching Workplan framework will help provide a common vision and direction.

Meet the need for high-level governance attention: Since malnutrition occurs in the context of individual families, the core principle in addressing malnutrition is to identify specific vulnerabilities of individual families to malnutrition, and address all of these simultaneously. Without a strong institutional mechanism, this level of concerted action by different departments will be very difficult, if not impossible.

Provide sufficient breadth to accommodate mid-course corrections to departmental

strategies: A visionary Workplan framework will permit periodic assessment of strategies and action plans of individual departments with nutrition goals in mind, and enable mid-course changes to strategies and plans without deviating from the goal. This will guard against commitment only to narrow, short term actions, and will permit a sustained rational, effective and efficient response.

Maximize departmental ownership and accountability to results: A Workplan provides a broad vision within which individual departments may fashion appropriate strategies for attaining that vision by ensuring that nutrition-sensitive interventions of their departments reach the poorest. It is expect that this will enhance ownership and accountability – not just to actions but to results.

Distinctive features of this Workplan

• Drawing upon a wide evidence base, the document distils the field level implementation experience of many states, NGOs and development partners and presents a coherent vision and strategy that will address both short and long-term determinants of malnutrition. It incorporates detailed Workplan analysis by internationally renowned Nutrition Workplan researchers.

• Proposes an approach that requires the identification of vulnerability to (or risk of) malnutrition, which permits preventive measures to be prioritized. An approach of starting with identifying malnourished children is usually too late since very little can be done to reverse it completely.

• Proposes a mix of approaches that will address malnutrition in both, the short term and the long term, with equal seriousness and attention to detail.

• Provides the outline of an implementable multi-sectoral approach.

• Makes a realistic assessment of what is required, and proposes a measured, efficient response by seeking departmental support on outcomes specific to each department. It avoids making namesake promises, and leaves open the scope for individual departments to propose innovations and ideas for investments.

• Explicitly recognizes the family as the basic unit for convergent actions, proposes ways to identify vulnerabilities in individual families, and proposes a graded approach to addressing vulnerabilities, starting with the most vulnerable families first. This is in conformity with other development strategies followed by the state.

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Section 1: The Context of Malnutrition in Bihar

Malnutrition is now recognized as one of the most significant impediments to human development, certainly one of the most preventable ones. It typically begins in childhood and has serious short, medium and long-term consequences on health, survival, cognitive ability and productivity extending throughout a lifetime. The innate vulnerability of socially and economically poor sections of the community to undernutrition leads to wider inequities. Paradoxically, undernutrition in children is also recognized as a harbinger of future vulnerability to the non-communicable diseases associated with affluence – obesity, cardiovascular disease and diabetes.

This section briefly outlines the current status of different forms of malnutrition, their recent rates of decline and the status of the main determinants of malnutrition.

Status of malnutrition in Bihar

The rates of undernutrition in Bihar exceed national averages by most measures. Constituting almost 9% of the country's population, Bihar contributes significantly to the national averages. Bihar has seen a positive but limited change in undernutrition between 2006 and 2015. Stunting prevalence has declined from 56 % to 48%, wasting declined from 27% to 21% (NFHS3 to NFHS4) (Figure 1). Severe wasting, also called severe acute malnutrition (SAM) declined as well from 8.3% to 7.0% (NFHS3 to NFHS4).

Figure 1: Progress on WHA Nutrition Indicators in Bihar, 2006-2015.

Sources: NFHS-3 and NFHS-4

Progress on WHA Nutrition Indicators in Bihar, 2006-2015 (in %)

Table 1: The main forms of malnutrition: why they are important, what are the causes and what are the interventions known to be effective.

Table 1 outlines the main forms of malnutrition, and why each is important, how they are caused and what is known about how to address them to minimize health and social impact. The most familiar form of childhood undernutrition is underweight, measured as weight for age, such as in the ICDS program. Underweight results either from stunting (failure to grow tall enough) or wasting (thinness, usually from weight loss), or at times from both. Stunting and anemia, the commonest forms of undernutrition, are consequences of long lasting dietary inadequacy and disease, spanning generations, and rooted in inequities, and themselves have long lasting consequences. There are no simple measures yet of the effects of undernutrition on mental and cognitive development and learning ability, but it is recognized that such effects are potentially the most important. Childhood overweight is still uncommon in Bihar, but has been rising in other states, and could become a concern in the future. A more detailed description of the main forms of malnutrition can be found in Annexure 1.

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Causes anddeterminants

Effective Interventionsto prevent or reverse

Form ofmalnutrition

Consequences ofmalnutrition

WastingWeight that is lessthan expected for theheight or length andsex of the child (bodytoo thin)

B

AnaemiaHaemoglobin levelless than normal forage, sex andpregnancy atatus(blood too thin)

C

Low BirthWeight -Weight at birth lessthan 2500 gms

E

ChildhoodOverweightWeight more than theexpected a given ageand sex

F

OtherMicronutrientDeficiencies

D

StuntingHeight or length thatis less than theexpected for a givenage and sex (bodytoo short for age)

A

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The country is committed to meeting a set of global targets for 2024, mutually agreed upon by all nations at the World Health Assembly (WHA) in 2012, as also to the Sustainable Development Goals (SDG), to which elimination of hunger and malnutrition are integral. Bihar, with some of the highest rates of undernutrition in the country and comprising nearly 9% of India's population, needs to contribute substantially. Table 2 lays out the implications for Bihar of meeting the WHA targets for 2024. The current Annual Average Rates of Reduction (AARR) of stunting, anaemia, low birth weight and wasting are much lower than the rates required to achieve the corresponding WHA

targets by 2024 (Table 2), and much acceleration will be needed to get close.

Table 2: Current trends and required rates of reduction in MIYCN outcomes in Bihar, to achieve WHA targets for 2024.

2024 targetprevalence*

%

2024achievement% based on

current trend

CurrentAARR

%

RequiredAARR %to reach

2024 target

Prevalence %in 2015

Stunting(children < 5yrs)

Wasting(children < 5yrs)

Anaemia in womenof reproductive age

Anaemia inchildren**

Anaemia in men**

48.3

20.8

60.3

63.5

32.2

28.98

5.0

30.2

31.8

16.1

41.31

15.50

53.28

50.38

30.0

1.55

2.90

1.23

2.06

0.68

3.85

10.99

5.19

5.0

5.0

* World Health Assembly (WHA) TargetNotes: AARR- Annual average rate of reduction

We consider global targets as default national/state target. The baseline reference year for the global targets is 2012. The state baseline estimates, however, are based on NFHS-4 (2016) data as there is no survey data for 2012.

Sources: Calculations by POSHAN. The state level current AARR for all indicators except low birthweight is calculated using data from NFHS-3 (2006) and NFHS-4 (2015). For low birthweight, NFHS-3 and RSoC are used. The state level required AARR is calculated following the methodology used in WHO tracking tool for estimating country level required AARR for each indicator. http://www.who.int/nutrition/trackingtool/en/

** While separate targets have not been proposed for anaemia in children and men, they are included here in recognition of the fact that anaemia affects everyone, and must be addressed at a population level.

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Status of determinants of malnutrition in Bihar

Immediate Determinants

Common to most forms of undernutrition, two sets of determinants are considered immediate causes of undernutrition: inadequate intake of nutrients, and disease – usually infections. All underlying causes act through either reducing the adequate intake of nutrients or through causing more frequent or severe illness.

Changes in immediate determinants of nutrition in Bihar have been mixed (Figure 2), particularly among infant and young child feeding (IYCF) practices and maternal health indicators. The prevalence of low body mass index (<18.5 kg/m2) or underweight among women, declined from 44.7 % to 30.4 %. This parameter is itself a measure of women's nutrition, but also a determinant of child malnutrition. Among the indicators of adequacy of food intake are those related to complementary feeding of children 6-23 months (whether complementary feeding was started on time around the age of 6 months, whether children are being fed food of adequate diversity (at least four food groups), often enough, and according to the needs of the child), and whether breastfeeding is adequate. On some of most crucial of these indicators, Bihar currently fares poorly (for instance, less than 10% of children 6-23 months are fed adequately diverse diets). While the situation is not very different in other states, it is nevertheless one of the long-neglected determinants of stunting and anemia that must be addressed.

Figure 2: Changes in immediate determinants in nutrition in Bihar, between 2006 to 2015

Notes: ARI= Acute Respiratory Infection; Underweight women are those with Body Mass Index (BMI) <18.5kg/m2.

Adequate Diet is the minimum recommended food groups in minimum recommended frequency.

Source: NFHS-3 and NFHS-4

NFHS4, 2015

Changes in immediate determinants of nutrition in Bihar, 2006 to 2015 (in %)

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Through national and state level initiatives, several health and nutrition services are being provided to women and children. There has been improvement in the coverage of nearly all services during the last decade (Figure 3). Among the indicators of disease and services accessed to reduce disease are full immunization coverage of children (Bihar, at 61.7% is close to the national average1), incidence of diarrhea in children (at 10% two-week incidence, also close to national average1), antenatal care coverage (at 14.4% four or more antenatal check-ups, much lower than national average1), vitamin A coverage (at 62 % of children receiving vitamin A in previous six months, Bihar is slightly better than national average1).

Figure 3: Changes in coverage of nutrition-relatedservices in Bihar, between 2006 to 2015

Source: NFHS-3 and NFHS-4. Data from Rapid Survey of Children (RSoCUNICEF, 2013-14) used for food supplementation

The Lancet Maternal and Child Nutrition Series, 2013

Changes in coverage of nutrition-specific interventions along the

continuum of care in Bihar, 2006 to 2015 (in %)

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Underlying Determinants

The roots of poor nutrition are diverse and numerous. Over the last decade, Bihar has made substantial progress on many crucial underlying determinants of nutritional status, several of them starting from very low levels.

Figure 4 A: Changes in status of underlying determinants of malnutrition in Bihar, between 2006 to 2015

Poor nutrition status cannot be addressed only by nutrition specific interventions but also requires contribution from other relevant stake holders to combat the cause2. The prohibition Workplan in place is expected to have brought down domestic violence even further, and has probably helped increased available household incomes significantly, contributing to better nutrition. Despite major progress in women's literacy and empowerment as well as sanitation, however, open defecation, secondary education for women, and access to formal banking remain low, and need to be addressed. Unmet need for contraception remains high, indicative of less than adequate reach of contraceptive services, and total fertility rate (TFR 3.4) remains higher than desirable. All of these are known to be important determinants of undernutrition in women and children and must be addressed.

Figure 4B: Changes in status of underlying determinants of malnutrition in Bihar, between 2006 to 2015

* TFR, expressed as per ten women of reproductive age

Changes in underlying determinants of malnutrition in Bihar, 2006 to 2015 (in %)

Changes in underlying determinants of malnutrition in Bihar, 2006 to 2015 (in %)

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Section 2: Strategic Directions of the State Nutrition plan

Goals

The long-term goal is to eliminate all forms of malnutrition and maximize the potential for human development in the state. To begin with, the state will focus its energies on addressing the most pressing nutritional needs of its vulnerable sections to reduce inequities and make it possible for all sections to equally participate in wide-ranging progress.

Specifically, the government commits itself to attaining or exceeding for Bihar the global targets for 2024, adopted by the World Health Assembly in 2012 and endorsed by India both at the World Health Assembly and at the SDG summit in 2015:

Table 3

2015* Target 2024

48.3%

20.8%

NA

60.3%

29.0%

4.0%

21.0%

30.2%

Stunting among children under five years old (reduction by 40%)

Wasting among children under five years old (reduction to less than 5%)

Low birth weight (reduction by 30%)

Anaemia among women in the reproductive age (reduction by 50%)

*Source NFHS-4

These goals are already being addressed through the Bal Kuposhan Mukt Bihar campaign and Manav Vikas Mission initiatives, and these efforts will be further strengthened. Other specific impact goals may be adopted in the future, as specific gaps and their solutions become more evident. This emphasis on addressing malnutrition is also expected to contribute substantially to reduction in mortality among children and mothers.

These goals will be applicable to the state as a whole, and will be applied to different regions within the state guided by evidence of differences in determinants in different regions.

Strategic Workplan principles

The roots of undernutrition arise from deep within existing social injustice and deprivation of numerous forms, and this defies simple measures and solutions; it is certainly beyond an individual's means to fight one's way out of it. Unless the governments of the day recognize their central role addressing the complexity of its causation, generations will continue to be lost to undernutrition.

Bihar, like most states in the country, bears a formidable burden of poor nutrition. The short, medium and long-term consequences of this burden on the children, women and men of the state must be mitigated. Better nutrition is one of the most sensitive indicators of development. The government is the primary enabler of development. Thus, while all sectors, public, private and civil society, must contribute to achieving goals, the Government of Bihar will take the lead.

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The strategic directions of the State Nutrition plan shall be built on the following principles:

Multipronged response

Recognizing that the roots of poor nutrition are diverse and numerous, it is imperative that the state must seek solutions that address this multidimensional problem with a multipronged approach. No single department can be expected to reduce malnutrition all on its own. Many departments are already mandated to address problems that eventually lead to undernutrition, such as reducing poverty or providing direct services to the poor. Specific actions by each of such departments that are likely to contribute to better nutrition will be identified and their implementation strengthened.

Focus on reaching every family with what they need, simultaneously

The causes of malnutrition eventually act through families. Families who are deprived in more ways are more likely to have children, women and men who are undernourished. Development programs of different departments are targeted at identifying and addressing specific gaps in the ability of families to grow and remain out of poverty; gain education; to have easy access to services that help them remain free of disease; to access a variety of foods that are necessary for healthy growth, all-round development and productivity; and to have access to information and knowledge that helps them take care of themselves better and thrive in society. Malnutrition is most likely to be addressed when all these gaps are simultaneously addressed. The key strategic direction is therefore in ensuring that every family is tracked to identify its specific vulnerabilities to falling prey to undernutrition, and to determine that all envisaged development support reaches the family synchronously, to maximize success in improving nutrition outcomes. This approach will help address specific vulnerabilities emerging from the social and economic context, such as the Mahadalits, migrants, the urban poor, the geographically inaccessible, etc.

Addressing diversity

Bihar is a diverse state, with rural, urban and some tribal populations. In examining the roles of different sectors, the varying context across and within districts in Bihar will be considered carefully because the conditions that lead to malnutrition differ by context. The 38 districts of Bihar are subject to a range of agro-ecological and economic conditions. There is a high degree of inter-district variability for some key determinants (Annexures 2 and 3), while for some there is little to none due to either high coverage or uniform challenges across all districts.

Coordinated action in planning and monitoring

The involvement of multiple departments to ensure simultaneous reach of the services and benefits from multiple programs to the same families will necessitate close coordination between departments, for both, planning and monitoring, while implementation continues to be the line management responsibility of individual departments. An administrative framework for coordinated planning and monitoring has been proposed.

Long term effort

It is also clear that undernutrition is not amenable to short term solutions, and that, while we certainly hope to see clear progress towards the goal, the complete elimination of undernutrition is unlikely to be accomplished within a generation. Recognizing that nutritional status of the people of the state is a sensitive measure of overall development, the state will invest in long term efforts to achieve this

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goal. Several kinds of efforts which will yield improvements in nutrition are already high priorities of the state government, such as the education and development of the girl child, livelihoods for women and safe water and sanitation. The state will identify and commit itself to other medium and long-term strategies as well.

Priorities among multiple nutrition goals

Undernutrition is not a single entity, ranging from stunting and wasting in infants and young children, restriction of growth before birth, deficiencies of specific micronutrients such as iron, iodine, vitamin A and zinc, and in manifest stunting and wasting among adult women and men, each with short and long-term consequences. Often, multiple forms of undernutrition coexist in individuals. At the other end of the spectrum, there are serious long-term consequences of early undernutrition, seen in adults as in increased blood pressure, blood glucose and harmful lipid levels, and overweight and obesity. There are serious consequences of these on cardiovascular health, fitness and life expectancy and out-of-pocket health spending. While every life saved is important and all of these problems must eventually be addressed, we will begin with emphasis on maternal and child undernutrition and anaemia, which are the most prevalent and most indicative of deep social inequities. Over time, strategies will be developed and added to address other problems as well, especially to prevent the rise of overweight, obesity and non-communicable diseases.

Use of evidence to learn, guide strategy and measure progress

While global evidence strongly suggests that the roots of undernutrition are numerous, it is not equally clear what combinations of pathways and actions will lead to accelerated reductions in the burden of undernutrition. It is probable that local, social and cultural factors play a role in determining success. Therefore, even as a multidimensional strategy is adopted for addressing the problem, the impact of planned and implemented actions on intermediate and final outcomes will be carefully measured and analyzed periodically, to assure that the Workplan is yielding results, and to learn how to do this better. New knowledge, generated from pilots, studies and analyses of state data or generated elsewhere in the country, will be utilized to make mid-course changes to strategy as appropriate. Such analyses will also guide resource allocations.

Bringing it all together to address determinants of malnutrition

A significant effort in Bihar's strategy to address malnutrition will be to bring it all together. The state fully recognizes and embraces the multiple causes of poor nutrition that must be addressed, and will emphasize the multiple threads that must be woven together to create a strong fabric that will support the achievement of good nutrition.

First and foremost, the state recognizes that addressing poor nutrition means addressing all critical determinants of poor nutrition at the same time, for the same people and in the same areas. The state will use all available schemes and programs to converge efficiently at the local level to ensure that all families are well-equipped to support their children to grow and thrive to meet Bihar's human potential.

Figure 5: Conceptual Framework* for Convergent Actions to Address Determinants of Undernutrition

*Adapted from UNICEF's conceptual framework

It is understood from the above that a combination of diverse actions will lead to achievement of Workplan goals (Figure 5). A combination of direct nutrition actions and broader actions through different Workplan instruments to create conditions for improved nutrition, are together expected to yield improved nutrition outcomes. The impact goals in themselves are indicative end-points of improvement in a wide range of determinant factors. Many of these determinants of undernutrition are also important indicators of development, and thus actions for reduction of malnutrition are expected to be synergistic with the wider development agenda of the state. Nutrition contributes to development, as much as it is affected by development.

Departments ProgramsDepartmentsPrograms

Women &Child

Development

ICDSIGMSY

SABLA/KSY

Immediate causes

Mid-DayMeal RMSA

Education

NFSMNMOOPNMSA;

Horticulture

Agriculture

NRDWPSwacchBharat

Abhiyaan,BSWSM

DrinkingWater andSanitation

Health andFamilyWelfare

NationalHealth

Mission

RuralDevelopment

NREGAJeevika

Maha DalitMission,BC/EBC,SC/ST,

MinorityWelfare

TSP/SCSP/15PP

HouseholdFood

Insecurity

InadequateCare

PoorAccess

to Health,drinking

waterand

sanitation

Improved nutrition outcomes for every woman and child

InadequateDietaryIntake

Disease

Inadequate Resources & Control Human, Economic and Organisational

Underlying causes

Lack of Capital:Financial,

human, social,natural physical

SocialEconomic

and PoliticalContext

Basic causes

PDSFood and

Civil Supplies

14

15

Actions Indicative Responsible Departments

Improving the dietary practices to maximize utilization of available nutrients at home for feeding children and mothers

Improving hygiene and sanitation, such as hand washing, elimination of open defecation, food hygiene

Improved nutritional quality of food available for feeding mothers and children

Reducing the incidence or impact of infectious disease among children

ICDS / Health

ICDS / Health/ PHED / Water Resources / BSWSM/ Education

ICDS / Health / Livelihood mission / Food Supplies & Consumer Welfare (PDS/ FCSC/ SFC)/ Agriculture/ Animal and Fish Resources

Health services

Some actions are expected to lead to improved nutrition outcomes in the relatively short term, such as among children of the generation that will be born in the next few years, other actions are expected to show results over much longer periods. Together, all of malnutrition can be addressed over time.

Actions that are likely to deliver impact in the short term

Actions for long term and sustainable gains

Actions Indicative Responsible Departments

Improving household incomes, reducing disparity

Improving women's education and empowerment

Improving adolescent health and nutrition

Improving access to contraception

Delaying age at marriage

Price stability of key food commodities

Addressing inequities on all fronts

Rural development / Livelihood mission

Education

Health, Social welfare

Health

Social welfare

Agriculture

Bihar Maha Dalit Vikas Mission, Minority Welfare, BC & EBC Welfare, SC & ST welfare

Current policies and initiatives of the State Government already place strong emphasis on a wide range of determinants of nutrition, symbolized by such initiatives as the Saat Nischay. The focus provided by this Work plan will enable faster progress towards nutrition goals.

16

Departmental Roles and Indicators

Table 3 lays out the primary direction of action expected from each responsible department to address specific determinants of malnutrition. The indicator groups mentioned are indicative of the specific types of outputs and outcomes which constitute such determinants. The objective is that these indicators must attain high levels of coverage to impact the state's nutrition goals.

Individual departments will make detailed action plans and set annual targets for specific determinants of malnutrition for which they are responsible, and it is expected that the coverage of actions will reach near-universal levels well before 2024, for their full effect to be felt on the impact targets by then.

While the broad directions of actions of individual departments are laid out here, there is wide scope for innovation in each sector. Departmental planning will be encouraged to look beyond current actions and perspectives to contribute more effectively to nutrition outcomes.

Table3: Departmental Actions and Indicators

Department/Program

Potential contribution toimproving nutrition

Key sectoral actions thatcan support improvements

in nutrition

Proposed monitoringindicator groups that

must reach near-universalcoverage

Social Welfare (mainly ICDS)

The health department shares a wide mandate for addressing malnutrition through direct interventions, with the department of Social Welfare.

The programs and activities of the department are expected to provide direct relief to severe and life-threatening forms of malnutrition, such as severe wasting in children (SAM) and severe anaemia is all groups, and provide holistic care to a number of health conditions that are closely linked to undernutrition.

Social and behaviour change interventions to improve maternal, infant and young child feeding practices and related hygienic practices to optimise nutrition, through frontline workers

Ensure there is one mini anganwadi per 500 families in Mahadalit areas

Provision of nutrition supplements to overcome specific dietary deficiencies

Empowerment of adolescent girls in terms of health, hygiene, vocational training in the entire state

Daily HCM for pregnant and lactating women

Optimal infant and young child feeding practices (age appropriate breastfeeding and complementary feeding, dietary diversity, dietary hygiene)

Optimal feeding practices for women and girls (including intrahousehold gender differences in access to diverse nutrients)

Access to and consumption of gap-filling macro and micronutrient supplements (calorie-protein, iron, folate, vitamin A, iodine etc as appropriate) for children, adolescents, women

Women marrying after

17

Department/Program



in nutrition



Strengthen interventions to delay age at marriage

Introduce and expand creche facilities for infants and young children

Ensure education in personal hygiene for preschool children and adolescents in all AWCs

Social and behaviour change interventions to improve maternal, infant and young child feeding practices to optimise nutrition

Universal access to maternal and child health and family planning services

Access to prevention and treatment for established nutritional deficiencies, including SAM and micronutrient deficiencies

Strengthening of deworming program to reach most vulnerable child

Ensure unbroken supplies of nutritional supplements (such as IFA, vitamin A, calcium, etc.)

Ensure appropriate

Besides directly providing health and nutrition information and services, it is expected provide technical leadership in strategy, monitoring impact, gathering evidence of effective approaches and technologies and proposing strategies for accelerating change.

The health department shares a wide mandate for addressing malnutrition through direct interventions, with the department of Social Welfare.

The programs and activities of the department are expected to provide direct relief to severe and life-threatening forms of malnutrition, such as severe wasting in children (SAM) and severe anaemia is all groups, and provide holistic care to a number of health conditions that are closely linked to undernutrition.

Besides directly providing health and nutrition information and

the age of 18 years

Mothers having access to creche facilities

AWCs having hygienic toilet and hand wash station

Optimal feeding practices among women, infants and young children.

Timely identification and successful treatment of all forms of severe malnutrition, including community based management of malnutrition

Coverage of immunization, antenatal care, deworming, vitamin A supplementation, and related MCH services

Reduction of unmet need for contraception and improved access to range of contraceptive services

Strengthened curricular training on nutrition included for nurses and doctors

TB patients under

Health

18

services, it is expected provide technical leadership in strategy, monitoring impact, gathering evidence of effective approaches and technologies and proposing strategies for accelerating change.

Education of girls is associated with improvements in their own and children's nutrition; improvements in women's educational levels over time is one of the major contributors to improvements in nutrition

Large knowledge gaps exist in nutrition and its social roots and consequences, particularly contextual to local populations and cultures

Department/Program



in nutrition



Education Stronger emphasis on curricular teaching of practical health, hygiene, nutrition and dietary principles and practices

Nutritionally adequate food for mid-day meal programs to reduce anaemia and undernutrition among school-going children

Ensuring high coverage of deworming program in schools

Ongoing and continued emphasis on interventions to enhance secondary school education for girls

Improved acceptance of IFA in school going children

Completion of secondary schooling among all young women.

School children receiving high quality meals under the MDM

School pass-outs at primary, secondary and higher secondary levels having adequate knowledge and skills in health and nutrition

All children receive micronutrient supplements under WIFS

RNTCP who are getting direct benefits

Introduction of new strategies informed by evidence

nutritional management of diseases such as TB, HIV, diarrhea etc., which are closely linked to undernutrition.

Basic nutritional assessment of all patients attending facilities, to guide therapeutic decisions

Strengthen emphasis on nutrition training of nurses and doctors

19

Department/Program



in nutrition



PHED / Water Resources / BSWSM

Agriculture

Animal and Fish Resources

Open defecation and other sanitation behaviors (disposal of child stools) are associated with childhood stunting

Improvements in sanitation over time contribute to reductions in stunting

Safe drinking water would help eliminate water borne diseases and infections

Agriculture as a source of income (increasing agriculture productivity/quality) improves women's nutrition over time

Diverse agricultural production can enhance household food diversity in poor market access areas

Cash income from agriculture, along with information, can contribute to HH diet diversity

Consumption of high nutrient value foods is price sensitive

Ensure access to toilets for each household

Increase demand for, and use of toilets; Reduce open defecation and improve safe disposal of child stools; Improve hand-washing behaviors for adults and children

Ensure safe drinking water, free of microbial contamination and free of excess fluorides, arsenic, iron and other contaminants.

Subsidized hand-wash stations at household level

Drinking water sources that are free of fecal contamination

HH with access to improved toilets

Population which does not defecate in the open

Children stools disposed safely

Hand washing practices

Households with access to piped, safe drinking water

Diversity of household diets

Stable retail prices of key commodities specially pulses, vegetables, fruits, oil, as well as dairy and animal food products etc.

Population that has regular access to all main food groups (measured as household food diversity)

Access to markets for farm produce and improved incomes

Vulnerable communities and families accessing eligible schemes

Maintaining price stability of staples and high nutrient value foods

Strengthen production diversity to ensure nutrient diversity and sustain cereal productivity.

Improve incomes from farm produce

Strengthening of IEC on local sources of nutrition

Maximize access of vulnerable communities for credit to poultry, fishery and animal husbandry schemes

Increase milk, poultry, fish and meat productivity

20

Department/Program



in nutrition



Food Supplies Consumer Welfare (PDS/FCSC/SFC)

Rural Development (NREGA, NRLM, Jeevika)

Social safety nets can improve household food security; improvements in nutrition require strong targeting and combinations with nutrition BCC

Access to work can lead to stability of incomes and increase food security/access to better diets; but hard physical labor can place biological demands on women's bodies that compromise nutritional outcomes

Women's control over assets is associated with better household food security and child nutrition outcomes

Improve diversity of food commodities under PDS to include millets, pulses etc

Ensure fortification of commodities as appropriate

Provide a special basket of nutritive food supplements (including oil, dal, millets) and soap to vulnerable families having pregnant women and children under two years old, at BPL rates

Ensure high PDS coverage, particularly to vulnerable communities

Eligible families who receive PDS benefits

Families with pregnant women and young children receiving PDS benefits

Nutritive value / range of foods supplied under PDS

Eligible families who receive NREGA benefits

Panchayats that have NREGA crèche facilities

Women engaged in hard labor for livelihood

Women who have access to credit / small savings

Women who have bank accounts in their name

SHGs that have access to health and nutrition information

Eligible families access subsidies and special schemes to boost incomes or productivity.

Ensure access to NREGA benefits to all BPL families, especially in lean work periods. Protect women's time and physical labor by allocating tasks carefully; ensure implementation of NREGA crèche facilities

Capacity building of SHGs by training and IEC material

21

Department/Program



in nutrition



Horticulture

Panchayati Raj

Urban Development

Information & Public Relations

Horticulture diversity can enhance household food

Gram panchayat is a natural point of convergence in monitoring access to services of all departments as well as gaps

Urban poverty is more strongly linked to malnutrition than rural poverty, migration to urban areas within the state is increasing, major attention needed.

Contribute to social change through improving access to information on a wide range of issues

Families that have accessed public sources of health and nutrition information, as well as those that target change in social norms

Design and execute campaigns targeted at changing social norms and behaviours

IEC on low cost local sources of nutritive foods

Ensure adaptation or design of interventions for urban areas that are nutrition sensitive, across different departments

Strengthening of waste disposal, drainage, sanitation, vector control

Urban agglomerations having adequate coverage of specific nutrition sensitive programs

Gram panchayats that engage actively in methodical tracking of coverage of all nutrition sensitive programs and inputs.

Expand scope of Anganwadi Nigrani Samiti to include all nutrition sensitive schemes

Ensure participation in planning and transparent and meticulous monitoring of programs at the village level

Leverage NREGA to promote local sapling distribution and plantation to increase production of protein rich food

Strengthening of IEC on local sources of nutrition

Explore diversification to include minerals, micro nutrients, proteins etc.

Families utilizing wider range of local horticultural products

Improved productivity and income from horticultural produce

Eligible families who receive saplings through NREGA benefits

22

Department/Program



in nutrition



Finance

Bihar MahaDalitVikas Mission

Minority Welfare

BC & EBC Welfare

SC & ST welfare

Bihar DisasterManagemet Department

Adequate financing and monitoring of expenditures will provide necessary confidence and ensure seriousness of the effort to implement Workplan

Have crucial roles in ensuring social inclusion in planning as well as execution of departmental plans. These communities have the highest vulnerability to malnutrition

To ensure the uninterrupted services related to nutrition during disaster

Adequate and timely availability and utilization of allocated funds in all sectors.

Timely and simultaneous implementation of planned actions in all sectors

Household access to credit, banking and insurance

Ensure timely fund flows to departments for all key elements

Accelerated financial inclusion of all households

Ensure adequate coverage of vulnerable sections under all plans. Sufficient enablers at village levels to ensure this.

Effective mechanisms for coordinated development of vulnerable communities

Highlight vulnerabilities and inequities and demand equal opportunity

Land reforms

Reduction in inequities in access to services and benefits, as well as in nutrition outcomes

Ensure adequate attention to Emergency Infant and Young Child Nutrition during disasters

Nutrition included in all disaster management plans

Nutrition support available during disasters

23

Section 3: Implementation and Monitoring

Building on the strategic directions set out above, the actions required to address the diverse roots of malnutrition will be executed by different departments of the government, with detailed plans including timelines and targets. As outlined, action plans should aim for achieving and sustaining near universal reach of key coverage indicators well before 2024, the year targeted for reaching the stated nutritional impact. Since the strategic approach is to ensure that individual families are simultaneously benefitted from the inputs of different departments, action planning at the operational levels of many departments will require close coordination. Both, coordinated action planning and the monitoring of implementation will be overseen at the levels of the Ward, the District Magistrate and an empowered body at the state level headed by the Development Commissioner, advised and guided by the Bihar Vikas Mission.

Envisaged approach to implement the State Nutrition plan

The principle is for departments to plan together, implement as line departments and review progress together. Both, interdepartmental coordination and intradepartmental implementation and monitoring effectiveness will equally determine the success of this Workplan initiative.

Ensuring that vulnerable families are benefitted concurrently by different departmental

actions

Coordinated planning will be particularly relevant for departments with schemes and interventions that are not designed to have universal coverage, such as loans for poultry or cattle or seeds/grafts or even provision of piped water or toilets, where universal coverage is expected to be achieved in a phased manner. Here, the planning principle will be a) to ensure that the most vulnerable communities and families are the first to receive benefits and entitlements, and b) to ensure that families identified as eligible for such benefits receive all due entitlements simultaneously. Departments like health, ICDS, education, which offer universal coverage are largely not concerned with targeting their benefits, but will need to pay careful attention to eliminate exclusions of vulnerable families.

Common set of eligibility criteria to be followed by different departments

The Bihar Vikas Mission will examine current eligibility criteria for schemes under different departments and provide guidelines for how different departments may adopt selection approaches that will ensure identification of vulnerable families simultaneously different departments for specific schemes. While different listings of vulnerable families are already available, such as the from the 2011 Socio Economic Caste Census or BPL, it is recognized that vulnerabilities can change with time, and a mechanism will be established to update such lists periodically. Each concerned department will accordingly issue guidelines to apply such criteria so that a common set of households in each village are identified to receive all eligible benefits from different departments simultaneously in each year. Beginning with the most vulnerable families in the first year, these benefits will be expanded as appropriate to reach progressively less vulnerable families in subsequent years.

Ensuring nutrition focus

It is important to ensure that the nutrition specific focus of actions of different departments are

24

sustained over time and does not become too diffuse. This is particularly challenging in the context of achieving nutrition outcomes, which have varied and complex causal roots. A Technical Advisory Group for Nutrition (TAG-N) constituted to advise the strategic direction of the Workplan at the state level, will provide guidance on the mix of interventions to be prioritized that are most likely to impact nutrition outcomes.

The horizon and scope of planning by individual departments

Each department is expected to plan with the perspective of a five-year horizon for achieving high coverage of its proposed interventions or positive shifts in the critical determinants of nutrition targeted by its actions. This document provides a broad and indicative set of actions that are expected of individual departments, and broadly defined indicators that will demonstrate progress in outcomes of departmental actions. Individual departments will propose a detailed plan with specific actions, either strengthening of ongoing ones or new initiatives, which they will undertake to contribute to nutrition outcomes. These plans are expected to be sensitive to contextual needs and problems, preferably building up from decentralized data and intelligence, particularly to address known pockets of exclusion, and seasonal disruptions. The availability and quality of human resource will be a critical determinant of success, and plans are expected to pay close attention to this. The proposed plans will also include sharper and measurable indicators that can be monitored through both, departmental reports of achievements against plan and independent assessments. A format that individual departments can use for planning their contributory actions to the goals of the State Nutrition plan is provided in Annexure 4.

Data for planning and monitoring

Two kinds of data will be required for planning and monitoring: a reliable list of families with their vulnerabilities mapped, and a mechanism for assessment of progress across departments and independent of departmental reports. Resources will be made available to enable the creation and maintenance of digital databases of households to maximize accuracy of eligibility information, efficiency, coordination and transparency, linking different departmental and programmatic databases. The state will also establish a mechanism, overseen by the Bihar Vikas Mission, of generating data independent departmental reports, such as through robust sample surveys, to provide credible evidence of progress towards Workplan goals. Data from such assessments along with departmental reports will be jointly reviewed periodically at district and state levels as indicated later, and corrective measures proposed from time to time. These reviews will also be opportunities to aggregate lessons learned and will help improve effectiveness of implementation. The primary focus of the reviews will be to assess whether households received the benefits of different departmental actions as planned, and whether these actions are leading to desired nutrition-related outcomes.

Transparency to minimize exclusion

Both, data from planning and monitoring will be made accessible to civil society organizations, elected representatives and the public at large to maximize transparency and accountability.

Common Mechanism for maximizing awareness

The general awareness of the public about eligibility for benefits and procedures of availing them

25

remains low, and is one of the important reasons for inadequate reach of various benefits as targeted. The Bihar Vikas Mission will commission a mechanism of raising awareness related to the expected benefits of the Workplan .

Administrative and Monitoring Framework

The vision of a malnutrition-free Bihar can only be realized through a concerted effort where responsibility is carried and owned by all departments. Given the complexity of the task, it is important to ensure oversight at critical levels by common mechanisms. A three-level administrative and monitoring mechanism will guide the progress towards achievement of Workplan objectives:

Ward level

The identification and simultaneous inclusion of all vulnerable families at the planning and implementation stages will be overseen at the ward level, using the eligibility criteria as determined by the state. The basis for planning and monitoring will be a comprehensive household database to be maintained at the ward level, designed to track eligibility for inclusion of different services and benefits, and the status of participation of each family. It is recognized that capacities will need to be strengthened at this level to enable gram panchayats to play their roles effectively. The newly constituted Ward Prabandhan evam Kriyanvayan Samiti may be given this role.

District Administration level

All development programs depend on the efficiency of the District Administration for effective implementation, and many oversight mechanisms exist that enable programmatic review and monitoring as well as interdepartmental coordination. The State Nutrition plan calls for an approach which ensures that different nutrition sensitive initiatives identified by individual departments get due implementation priority and that vulnerable families benefit simultaneously from these initiatives. This will require closely coordinated programmatic microplanning at the district level, particularly for those actions identified by each department as nutrition sensitive. A quarterly review process involving the main departments and programs concerned, chaired by the District Magistrate will drive the initiative at the district level. These reviews will be supported by data from both, departmental sources as well as data from independent assessments of various parameters related to nutrition and nutrition sensitive interventions.

State Government level

An empowered body under the chairpersonship of the Development Commissioner will oversee the implementation of the State Nutrition plan, with a mandate to direct state resources to achieve Workplan goals by 2024. The Principal Secretary or Secretary from the Department of Social Welfare will be the Member Secretary of the body, and Principal Secretaries or Secretaries of all concerned departments will constitute the empowered body (such as Empowered Body for Nutrition). The body will convene initially to set the broad parameters for planning, implementation, monitoring and coordination, and then quarterly for review and providing strategic guidance. The Bihar Vikas Mission will guide and advise the Empowered Body.

A Technical Advisory Group on Nutrition (TAG-N), will be constituted by the State Government, including eminent individuals with domain expertise and experience in nutrition science, research

26

and programming. The TAG-N will be expected to bring in the technical and analytical expertise needed to advise the Task Force on the adequacy of progress and course corrections from time to time. The Empowered Body for Nutrition may choose to invite TAG-N members to participate in reviews. Similarly, members of civil society organizations and development partners will be invited to actively participate in the reviews.

Once constituted, the Empowered Body will specify parameters and timelines for individual departments to plan and set targets and will articulate the specific roles and responsibilities of district and ward level mechanisms in monitoring implementation. It will pursue the establishment of an independent mechanism of generating data required for monitoring progress and will advocate for and requisition additional resources for implementing specific actions, as appropriate. It may also propose legislation to strengthen nutrition-related entitlements of the people of the state from time to time.

Table 6: Administrative and Monitoring Framework

Empowered Body on Nutrition

District Administration

Development Commissioner

District Magistrate

Principal Secretaries / Secretaries of relevant Departments

Nodal Department: Social Welfare (Member Secretary: PS/SWD

Secretariat: State ICDS Society)

District leads of relevant departments.

Nodal officer: DPO, ICDS

• Set broad parameters for planning, coordination and monitoring

• Quarterly review and strategic guidance

• Ensure coordinated planning

• Quarterly detailed implementation review against plans, informed by departmental and independent data

• Bihar Vikas Mission to provide advisory

• Nutrition Technical Advisory Group (TAG-N), consisting of domain experts

• Development Partners, Civil Society organizations

Local Civil Society Organizations, Development Partners

Level Chairperson Members Key Actions Support

27

WardPrabandhanevaKriyanvayanSamiti

Ward member

Ward members, VDO, LS, ANM

Nodal person: Panchayat Sevak / Vikas Mitra

• Monthly review of coverage of services from various departments at the HH level against plans, based on line lists of households

Local Civil Society Organizations

Resources for Implementing the State Nutrition plan

Most proposed sectoral actions are expected to fall under ongoing departmental activities and budgets, especially where movement of nutrition can be supported by critical sectoral actions such as improving girl's education, reducing open defecation, improving food security and reducing poverty. Where additional resources are required for additional nutrition-sensitive actions, the Empowered Body will examine departmental proposals and provide or support their approvals.

Besides core actions, departments may also propose additional work-streams of nutrition sensitive actions, not currently proposed in departmental plans, above current departmental budgets. The Empowered Body may approve these additional proposals.

The state will also embark on a nutrition-financing and fiscal space analysis exercise to estimate the costs of addressing nutrition and identify sources of financing for nutrition. Based on this analysis, and available funding, specific financial inputs will be provided to cover additional actions in support of the State Nutrition plan goals, as determined by the Empowered Body.

Ensuring that the citizens of the state are adequately nourished is the mandate of the state, and the state stands committed to invest whatever is necessary to ensure this.

Level Chairperson Members Key Actions Support

28

ANNEXURE 1:

Main forms of malnutrition, their consequences and how they can be addressed

Stunting

Stunting, or being too short for one's age, is defined as a height that is much lower than expected, more than two standard deviations below the World Health Organization (WHO) child growth standards median. It is one clearly tangible outcome among many consequences of long term damage from poor nutrition. Stunting leads to diminished cognitive and physical development, reduced productive capacity and poor health, and an increased risk of degenerative diseases such as diabetes.

Why is stunting important/what are the consequences?

What are the majorcauses of stunting?

What are effectiveinterventions to combat stunting?

Long-term effects associated with stunting include: diminished cognitive and physical development, reduced productivecapacity and poor health, and an increased risk ofdegenerative diseases such as diabetes. According to World Bank estimates,a 1% loss in adult height due to childhood stunting is associated with a 1.4% loss in economic productivity

• Infant and young child feeding practices especially suboptimal

• complementary feeding that is

• limited in quantity, quality and variety (dietary diversity)

• Repeated common infections and subclinical infections, resulting from exposure to contaminated environments and poor hygiene

• interaction of various factors like household poverty, poor maternal education, poor birth spacing, caregiver neglect, non-responsive feeding practices, inadequate child stimulation, gender inequality, neglect of the girl child and food insecurity.

• Many of these factors act across generations.

Stunting improvements are supported by actions that contribute to:

• improvements and expansion of maternal and child health services, particularly improved feeding and care of children under two years;

• expansion of water and sanitation systems

• Improvements in the quality and quantity of food available;

• improvements in the purchasing power of families and reduced poverty;

• improved rates of girls' education;

• improved maternal nutrition

• increased spacing between children

29

Graph 1: Distribution of height for age, z scores of U5 children (Data for 2005 Bihar)

Source: NFHS3 and WHO Standards

Wasting

Wasting is a reduction or loss of body weight in relation to height, where the child looks very thin. The World Health Organization (WHO) classifies wasting in children as severe or moderate, according to the WHO growth reference for weight-for-height. Severe wasting, also called Severe Acute Malnutrition (SAM) is one of the highest risk conditions for child mortality, and constitutes a medical emergency.


What are the majorcauses of wasting?

What are effectiveinterventions to combat wasting?

Addressing wasting is of critical importance because:

• it can lead to heightened risk of disease and death for children who lose too much of their body weight particularly from severe infections such as diarrhoea, pneumonia, malaria and measles.

Typically, a child becomes acutely wasted following a severe illness. The main underlying causes of wasting are:

• poor access to appropriate, timely and affordable health care;

• inadequate caring and feeding practices (e.g. exclusive breastfeeding or low

• Wasting can be prevented by protecting children from severe infections, and providing prompt medical care of such infections. All interventions that prevent stunting also contribute to prevention of wasting.

• Wasting is important to recognize early since it can lead to death. Wasting can be effectively reversed through a combination of medical treatment and appropriate nutritional supplements, either

30


What are the majorcauses of wasting?

What are effectiveinterventions to combat wasting?

• Evidence suggests that episodes of wasting negatively affect linear growth and, therefore, undermine child growth and development. A wasted child is likely to suffer from stunting in the long term.

quantity and quality of complementary food);

• poor food security including lack of food quantity

• lack of a sanitary environment, including access to safe water, sanitation and hygiene services.

9 Abrupt cessation of BF, such as with short pregnancy intervals or maternal death

at home alone or at home after a period of facility level care.

Graph 2: Distribution of Weight for Length / Height z scores of U5 children (Data for 2005 Bihar)

Source: NFHS3

31

Situation of Wasting in Bihar

Bihar's wasting rates have fluctuated in different assessments, with severe wasting rates ranging from around 3% to around 8%. These represent unacceptably high numbers.

2024 targetprevalence% (if global

targetapplied)

2024prevalence %

based oncurrent trend

ExpectedAARR %(to reach

2024target)

CurrentAARR %

Prevalence %in 2015*

Wasting(children < 5yrs) 20.8 5 15.50 10.09 2.90

AARR = Average Annualized Rate of Reduction. *Source: NFHS4

Anaemia

Anaemia is a condition in which the number and/or size of red blood cells, or the hemoglobin concentration in the blood, falls below an established 'normal' cut-off value, consequently impairing the capacity of the blood to transport oxygen around the body. Anaemia is an indicator of both poor nutrition and poor health.

Why is anaemiaimportant/what arethe consequences?

What are the majorcauses of anaemia?

What are effective interventionsto combat anaemia?

• Reduces individual's well-being, causes fatigue and lethargy, impairs physical capacity and work performance.

• Failure to reduce anaemia worldwide consigns millions of women to impaired health and quality of life, generations of children to impaired development and learning, and communities and nations to impaired economic productivity and development.

• The most common cause of anaemia worldwide is iron deficiency.

• Iron is deficient in most common diets consumed in India, and thus dietary deficiency of iron is almost universal.

• Others nutritional deficiencies contributing to anaemia include folate and vitamins B12, A and C., particularly among families who do not consume diet of adequate diversity, especially consumers of poorly

Public health strategies to prevent and control anaemia include improvements in dietary diversity; food fortification with iron, folic acid and other micronutrients; distribution of iron-containing supplements; and control of infections and malaria.

Examples of successful interventions to increase iron in the diet:

• Distribution of weekly folic acid along with de-worming of women of reproductive age and of preschool and school going children and adolescents

• fortification of staple foods such as flour with iron and other vitamins

32

Why is anaemiaimportant/what arethe consequences?

What are the majorcauses of anaemia?

What are effective interventionsto combat anaemia?

diverse vegetarian diets

• Hookworm infestation is one of the commonest causes of severe anaemia. Also, conditions like menstrual disorders where there is excess blood loss. Anaemia is common in severe malaria, particularly falciparum malaria.

• Most women in India become anaemic during pregnancy because they have low iron stores going into pregnancy, and there is large increase in iron requirements during pregnancy

• Children born to mothers with poor iron stores tend to become anaemic early in infancy

• Pregnant adolescents are particularly vulnerable to anaemia because they have dual iron requirements.

• Certain types of anaemia run in families, for example sickle cell anaemia and thalassaemia.

• weekly iron-folic acid supplementation for adolescent girls

• Infection control is a critical component of interventions to combat anaemia.

• Maternal anaemia is associated with mortality and morbidity in the mother and baby, including risk of miscarriages, stillbirths, prematurity and low birth weight, and an increased risk of maternal death when there is bleeding around the time of childbirth.

33

2024 targetprevalence% (if global

targetapplied)

2024prevalence %



2024target)

CurrentAARR %

Prevalence %in 2015*

Anaemia in womenof reproductive age

Anaemia inchildren

Anaemia in men

60.3

63.5

32.2

30.2

31.8

16.1

53.28

50.38

30.0

5.19

5.0

5.0

1.23

2.06

0.68

AARR = Average Annualized Rate of Reduction. The WHA target for all women of reproductive age is 50% by 2025. Separate WHA targets have not been specified for children and men. A common target of 50% reduction has been applied to all.

*Source: NFHS4

Other Micronutrient Deficiencies

Besides iron, there are other micronutrients that are critical to the body, but are not easily or consistently available in commonly consumed diets. Thus, deficiency of such micronutrients is commonly seen.

Why are micronutrientdeficiencies important?

What are the commoncauses of these deficiencies?

What are effective waysof reducing these deficiencies?

Vitamin A deficiency causes night-blindness and can lead to permanent corneal blindness when severe. Children who are deficient in this vitamin are more prone to risk of death from severe infections such a measles, malaria and diarrhoea.

Zinc deficiency is known to be a contributory factor in failure to grow normally, and in recovery from common infections like diarrhoea.

Iodine deficiency is known to cause reduced

These micronutrients are available in small amounts in many foods, but only some foods provide adequate amounts that meet human dietary requirements.

Vitamin A is most commonly available from certain animal sources of food such as animal livers (since the vitamin is stored in the liver) and egg yolk. A variety of yellow and orange fleshy vegetables and fruits (such as mango, carrots, papaya, yellow pumpkin) and certain green leafy vegetables also are rich sources but are not all

It is difficult for poor families to ensure dietary adequacy of these micronutrients, and therefore provision of micronutrient supplements or fortification of specific foods is considered a more viable option for preventing deficiencies.

Vitamin A supplements are provided to children from 9 months to 5 years. Other age groups can also be treated with such supplements when symptoms of deficiency manifest.

Iodine fortification of common salt is highly effective, and today severe iodine deficiency is rare.

Zinc is still being studied for

The Anaemia Situation in Bihar

34

Why are micronutrientdeficiencies important?

What are the commoncauses of these deficiencies?

What are effective waysof reducing these deficiencies?

consumed commonly and in sufficient quantities.

Zinc is available from red meat, poultry and sea foods, and in smaller quantities from several whole grain, beans and nuts. Since it is not stored in the body, it must be consumed regularly.

Iodine is available from almost all agricultural produce from areas where the soil has sufficient iodine. Where soils are frequently washed away, such as in hilly areas, dietary deficiency is common.

effectiveness as a routine dietary supplement. Currently, zinc supplements as tablets or liquid are recommended to be given to children along with ORS for diarrhoea, to reduce mortality and recurrence of diarrhoea.

Data is limited on micronutrient deficiencies other than anaemia; however, a national nutrition survey is currently underway with support of UNICEF and the Ministry of Health and Family Welfare. This survey will provide findings on multiple nutritional deficiencies by the end of 2018.

Low Birth Weight

Low birth weight is defined by the World Health Organization (WHO) as weight at birth less than 2500 g. Low birth weight continues to be a significant public health problem globally and is associated with a range of both short- and long-term consequences of higher mortality, poor development and higher adult onset disease. It is estimated that around 30% of all births in India are low birth weight.

Low birth weight can be either because the baby is born too early (before it has a chance of growing fully in the mother's womb) or because the baby fails to grow adequately in the mother's womb. Different causes can lead to preterm births or failure in intrauterine growth.

functioning of the thyroid glands and such deficiency during pregnancy can lead to birth of mentally retarded children. Deficiency is also related to later poor cognitive development.

Why is low birth weightimportant/what arethe consequences?

What are some of themajor causes of low

birth weight?

What are effectiveinterventions to combat

low birth weight?

There are multiple causes of failure to grow well in the uterus, including poor maternal nutrition before and during pregnancy, early pregnancy, too little spacing

Reducing the incidence of lowbirth weight requires a comprehensive strategy, which must include multiple elements: preventing and reducing early childbearing; improving pre-conceptional and

The consequences of low birth weight include high foetal and neonatal mortality, a variety of complications of preterm birth, poor cognitive

35

Why is low birth weightimportant/what arethe consequences?

What are some of themajor causes of low

birth weight?

What are effectiveinterventions to combat

low birth weight?

between pregnancies, multiple pregnancies, smoking during pregnancy, infections and high blood pressure during pregnancy – most of them preventable. The causes of preterm birth are less clearly understood, and preterm birth is more difficult to prevent.

maternal nutritional status; treating pregnancy-associated conditions such as pre-eclampsia; and providing adequate maternal care, perinatal clinical services and social support.

Situation of Low Birth weight in Bihar

2024 targetprevalence %

(if globaltarget

applied)

2024prevalence %



2024target)

CurrentAARR %

Prevalence% in

2014 (RSoC)

Low birthweight 15 12.23 6.49 2.71 7.34

AARR = Average Annualized Rate of Reduction

* This represents an approximation. The true prevalence is likely to be much higher, and the required AARR will be correspondingly higher.

Childhood Overweight

Overweight in children under 5 years of age is defined as weight-for-height >+2 standard deviations of the World Health Organization (WHO) Child Growth Standards median.

development during childhood, stunted physical growth and an increased risk of non-communicable

diseases such as diabetes and cardiovascular disease later in life

Why is childhoodoverweight important/what

are the consequences?

What are some of the majorcauses of childhood

overweight?

What are effective interventionsto combat childhood

overweight?

The fundamental cause of childhood overweight and obesity is an energy imbalance between calories consumed and calories expended. Factors include:

• shift in diet towards increased intake of energy-dense foods that

• Achieving successful behavior change during childhood through a combination of population-based measures, implemented both at the national level and as part of local school- and community-based programmes.

Children who are overweight are at a higher risk of developing serious health problems, including type 2 diabetes, high blood pressure, asthma and other respiratory problems, sleep disorders and liver disease. They may also suffer from psychological

Situation of childhood overweight in Bihar

The prevalence of childhood overweight in Bihar, according to NFHS3, is very low (0.1%), but the absence of data after that point makes it difficult to track the change in prevalence since 2006. However, data for adults clearly indicates that overweight and obesity have at least doubled in Bihar between 2005-06 and 2015-16 to levels that are well above normal population proportions. So far, hypertension and high blood sugar rates are lower than in other states for which data is available, but It is probable that going forward, these will assume much more substantial proportion.

36

36

Why is childhoodoverweight important/what

are the consequences?

What are some of the majorcauses of childhood

overweight?

What are effective interventionsto combat childhood

overweight?

are high in fat and sugars.

• A trend towards insufficient physical activity levels.

• creating an enabling environment that promotes physical activity to address sedentary lifestyle from the early stages of life.

• Reducing the marketing of sugar-sweetened beverages and poor nutrient quality foods like snacks and junk foods.

effects, such as low self-esteem, depression and social isolation. Childhood overweight and obesity also increase the risk of obesity, noncommunicable diseases (NCDs), premature death and disability in adulthood. Finally, it entails high economic costs, both in terms of the enormous financial strains it places on health-care systems and in terms of lost economic productivity.

37

AN

NE

XU

RE

2:

Dat

a on

sta

tus

of m

aln

utr

itio

n a

nd

its

det

erm

inan

ts in

ind

ivid

ual

dis

tric

ts o

f Bih

arT

able

A2.

1: T

he b

elow

tab

le r

epre

sent

s di

stri

ct w

ise

data

of

WH

A t

arge

t in

dica

tors

– s

tunt

ing,

was

ting

, lo

w b

irth

wei

ght,

ana

emia

etc

. S

ourc

e: P

OS

HA

N

Tab

le 1

: T

HE

ST

AT

E O

F N

UT

RIT

ION

IN

BIH

AR

Ch

ild

ren

st

un

ted

(<

5 yr

) (%

)

Ch

ild

ren

w

aste

d

(<5

yr)

(%)

Ch

ild

ren

u

nd

erw

eigh

t

(<5

yr)

(%)

Ch

ild

ren

w

ith

an

y an

aem

ia

(0-5

9 m

o)

(%)

Wom

en

un

der

wei

ght

(BM

I <

18.5

)

(15

-49

yr)

(%)

Ch

ild

ren

w

ith

bir

th

wei

ght

<25

00gm

s

(0-2

mo)

(%

)

Ad

ult

s w

ho

are

obes

e in

th

e d

istr

ict

(18

-59

yr)

(%)

Sl.

S

ourc

e

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4 (

2015

-2

016)

CH

HN

S7

(201

5) C

AB

(20

14)

Bih

ar

48.3

20

.8

43.9

63

.5

30.4

9.

5

0.6

1

A

rari

a

48

.4

22

.8

45

.4

61

.8

38

.3

9.

8

0.

5

2

Arw

al

50.2

30.7

54

66.8

30.8

10.8

0

3

Aur

anga

bad

48.3

24.8

47.6

53.4

30.9

12.9

0.2

4

Ban

ka

49.6

26

48.5

70.4

32

8.3

0.3

5

Beg

usar

ai

44.9

18.4

39.1

62.7

31

8

0.3

6

Bha

galp

ur

46.6

23.1

40.8

70.1

26.2

8.2

0.3

7

Bho

jpur

43.5

26

47.2

70.6

24.1

7.5

1.2

8

Bux

ar

43.9

19.6

41.2

59.8

24.7

8.5

0.5

9

Dar

bhan

ga

49

16.6

41.1

69.9

31.2

7.9

0.8

10

Eas

t C

ham

para

n

47.2

18

40.8

65.7

28.9

6.7

1

11G

aya

52.9

25.6

53.1

5936

.113

.1N

A

Tab

le 1

: T

HE

ST

AT

E O

F N

UT

RIT

ION

IN

BIH

AR

Ch

ild

ren

st

un

ted

(<

5 yr

) (%

)

Ch

ild

ren

w

aste

d

(<5

yr)

(%)

Ch

ild

ren

u

nd

erw

eigh

t

(<5

yr)

(%)

Ch

ild

ren

w

ith

an

y an

aem

ia

(0-5

9 m

o)

(%)

Wom

en

un

der

wei

ght

(BM

I <

18.5

)

(15

-49

yr)

(%)

Ch

ild

ren

w

ith

bir

th

wei

ght

<25

00gm

s

(0-2

mo)

(%

)

Ad

ult

s w

ho

are

obes

e in

th

e d

istr

ict

(18

-59

yr)

(%)

Sl.

S

ourc

e

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4 (

2015

-2

016)

CH

HN

S7

(201

5) C

AB

(20

14)

Bih

ar

48.3

20

.8

43.9

63

.5

30.4

9.

5

0.6

38

12

G

opal

ganj

35

.6

16

.5

30

.5

63

.1

25

.7

6.

4

N

A

13

Jam

ui

45.9

29.4

47.2

61.3

37.5

7.7

0.4

14

Jeha

naba

d

52.1

19.6

47.1

61.4

30.6

13.4

0.3

15

Kai

mur

53.8

21.4

48.1

63

28.6

11.4

NA

16

Kat

ihar

49.2

20.7

45.1

61.3

32.4

10

1.2

17

Kha

gar

ia

49.8

17

42.4

63.4

31.1

9.5

1.7

18

Kis

hang

anj

46.9

22.8

45.4

65.2

34.5

5.2

0.2

19

Lak

hisa

rai

50.6

20.1

47.3

66.3

27.6

8.5

0.3

20

Mad

hepu

ra

51.8

24.2

49.2

61.4

32.9

9

1.2

21

Mad

huba

ni

51.8

19.1

45.4

62.9

32

6.2

NA

22

Mun

ger

46.6

21.5

43.7

62.5

28.8

10.6

NA

23

Muz

affa

rpur

47.9

17.5

42.3

58.5

33

6.7

1.7

24N

alan

da54

.124

.350

.259

30.7

17.1

0.2

39

25N

awad

a48

.421

.445

.956

.43

3.6

9.6

0.3

26

Pat

na

43.5

28.5

43.3

51.6

24

13.7

1.1

27

Pur

nia

52.1

20.8

47

66.5

38.

8

12.4

0

28

Roh

tas

48.5

19.9

45.1

61.3

26.

9

9.3

2.3

29

Sah

arsa

43.9

24

44.4

68.4

34.

6

11.6

0

30

Sam

asti

pur

49.2

18.4

41.3

65.4

29.

7

10.2

0.3

31

Sar

an

46.1

18.1

40.4

61.9

23.

9

NA

0.4

32

She

oha

r

53

14.8

42.8

63.7

33.

1

9.3

0.5

33

Shi

khpu

ra

46.4

28.9

51.7

66

35.

6

18.6

0.5

34

Sit

mar

hi

57.3

15.8

47.7

69

33.

6

7.2

0.4

35

Siw

an

37.9

15

31.6

63.1

24.

2

5.1

0

36

Sup

aul

48.1

20.9

43.4

72.4

38.

6

6.6

NA

37

Vai

shal

i

53.7

15.1

41.3

67.4

28.

9

NA

1.2

38

Wes

t_C

ham

para

n

43.6

21.7

39.1

62.3

27

3.9

0

Tab

le 1

: T

HE

ST

AT

E O

F N

UT

RIT

ION

IN

BIH

AR

Ch

ild

ren

st

un

ted

(<

5 yr

) (%

)

Ch

ild

ren

w

aste

d

(<5

yr)

(%)

Ch

ild

ren

u

nd

erw

eigh

t

(<5

yr)

(%)

Ch

ild

ren

w

ith

an

y an

aem

ia

(0-5

9 m

o)

(%)

Wom

en

un

der

wei

ght

(BM

I <

18.5

)

(15

-49

yr)

(%)

Ch

ild

ren

w

ith

bir

th

wei

ght

<25

00gm

s

(0-2

mo)

(%

)

Ad

ult

s w

ho

are

obes

e in

th

e d

istr

ict

(18

-59

yr)

(%)

Sl.

S

ourc

e

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4

(201

5-2

016)

NF

HS

4 (

2015

-2

016)

CH

HN

S7

(201

5) C

AB

(20

14)

Bih

ar

48.3

20

.8

43.9

63

.5

30.4

9.

5

0.6

40

Tab

le A

2.2:

Dif

fere

nt s

chem

es i

n B

ihar

per

tain

ing

to H

ealt

h an

d N

utri

tion

. Sou

rce:

PO

SH

AN

1

Ara

ria

10

0

31.9

15.5

41.4

48.5

Ta

ble

2:

EV

AL

UA

TIO

N O

F H

EA

LT

H A

ND

NU

TR

ITIO

N S

CH

EM

ES

IN

BIH

AR

Ho

use

ho

lds

wit

h a

cces

s to

A

nga

nw

ad

i w

ork

er (

%)

Hou

seh

old

s w

ith

acc

ess

to a

S

ub

-Hea

lth

C

entr

e (%

)

Hou

seh

old

s th

at r

ecei

ved

fi

nan

cial

as

sist

ance

for

d

eliv

ery

and

ch

ild

care

(%

)

Hou

seh

old

s th

at

rece

ive

any

tak

e h

ome

rati

on (

%)

Hou

seh

old

s w

ith

ac

cess

to

PD

S

(%)

Sl.

Sou

rce

DL

HS

3 (

200

7-2

008

)

DL

HS

3 (

2007

-20

08)

CH

HN

S 7

(2

015)

CH

HN

S 7

(2

015)

NS

S 6

8th

rou

nd

(2

011

-201

2)

Bih

ar91

.732

.731

40.3

43.9

2

Arw

al

NA

NA

6.7

38.1

36.5

3

Au

ran

gaba

d

87

21.7

32.2

37.6

21.2

4

Ban

ka

89.6

16.7

30.7

42.6

27.8

5

Beg

usar

ai

95.8

37.5

21.9

44.7

58.2

6

Bh

agal

pur

97.6

48.8

28.9

44.1

40.6

7

Bh

ojpu

r

97.6

48.8

16.8

35.6

48.8

8

Bu

xar

88.9

33.3

18.3

32.4

30.1

9D

arb

han

ga91

.337

6.2

42.6

34.4

10E

ast_

Cha

mp

aran

87.2

29.8

10.9

42.4

41.6

11G

aya

10

025

.618

.640

19.1

41

Tab

le 2

: E

VA

LU

AT

ION

OF

HE

AL

TH

AN

D N

UT

RIT

ION

SC

HE

ME

S I

N B

IHA

R

Hou

seh

old

s w

ith

acc

ess

to

An

gan

wad

i w

ork

er (

%)

Hou

seh

old

s w

ith

acc

ess

to a

S

ub

-Hea

lth

C

entr

e (%

)

Hou

seh

old

s th

at r

ecei

ved

fi

nan

cial

as

sist

ance

for

d

eliv

ery

and

ch

ild

care

(%

)

H

ouse

hol

ds

that

re

ceiv

e an

y ta

ke

hom

e ra

tion

(%

)

Hou

seh

old

s w

ith

ac

cess

to

PD

S

(%)

Sl.

Sou

rce

DL

HS

3 (

2007

-200

8)

DL

HS

3 (

2007

-20

08)

CH

HN

S 7

(2

015)

CH

HN

S 7

(2

015)

NS

S 6

8th

rou

nd

(2

011

-201

2)

Bih

ar

91.7

32.7

31

40.

3

43.9

12G

opa

lgan

j

87.2

23.4

30

49.

4

36.2

13Ja

mui

82.6

21.7

4.4

39.

7

61.1

14Je

hanab

ad

91.3

34.8

40.5

39.

7

21.6

15K

aim

ur

83.3

12.5

7.1

34.

2

37.9

16K

atih

ar

91.1

28.9

11.1

44

63

17K

hag

aria

97.9

68.1

16.2

47

38.1

18K

ishan

ganj

91

.1

13

.3

6.

7 50.

5

64

.1

19L

akhi

sara

i

90.7

25

.6

28.4

46.

5

28.6

20M

adhe

pura

91

.7

29.2

26

.7

36.

2

64.4

21M

adhu

bani

91

.7

47.9

3.

2 27.

6

63.2

22M

unge

r

86.1

41

.7

34.2

45.

9

53.9

23M

uzaf

farp

ur

100

35

.6

9 38.

1

63

42

Tab

le 2

: E

VA

LU

AT

ION

OF

HE

AL

TH

AN

D N

UT

RIT

ION

SC

HE

ME

S I

N B

IHA

R

Ho

use

ho

lds

wit

h a

cces

s to

A

nga

nw

adi

wor

ker

(%

)

Hou

seh

old

s w

ith

acc

ess

to a

S

ub

-Hea

lth

C

entr

e (%

)

Hou

seh

old

s th

at r

ecei

ved

fi

nan

cial

as

sist

ance

for

d

eliv

ery

and

ch

ild

care

(%

)

Hou

seh

old

sth

at

rece

ive

any

tak

e h

ome

rati

on (

%)

Hou

seh

old

s w

ith

ac

cess

to

PD

S

(%)

Sl.

Sou

rce

DL

HS

3 (

200

7-2

008

)

DL

HS

3 (

2007

-20

08)

CH

HN

S 7

(2

015)

CH

HN

S 7

(2

015)

NS

S 6

8th

rou

nd

(2

011

-201

2)

Bih

ar

91.7

32.7

31

40.3

43.9

24

Nal

anda

95.3

30.2

40.4

47.9

21.7

25

Naw

ada

93.5

28.3

0

37.3

24.9

26

Pat

na

82.8

48.3

19.9

34

22.4

27

Pu

rnia

91.3

26.1

16.2

31.6

52.4

28

Roh

tas

83.7

20.9

14.3

41.1

31.9

29

Sah

arsa

91.3

45.7

4.4

29.4

52.3

30

Sam

asti

pur

73.4

5.1

5.5

46.9

47.9

31

Sar

an

NA

NA

NA

NA

NA

32

Sh

eoh

ar

100

25

4.1

33.5

72.2

33

Sh

ikh

pura

90.5

28.6

39.4

40.2

32

34

Sit

mar

hi

37.3

9.6

11.2

28.7

41.5

35S

iwan

75.2

8.9

21.8

48.9

60.1

36S

upa

ul

95.8

35.4

11.7

43.5

78.3

37V

aish

ali

NA

NA

NA

NA

NA

38W

est

Cha

mp

aran

88.9

28.9

6.2

4941

.2

43

Table A2.3: District wise break-up for dietary aspects regarding undernutrition. Source:POSHAN

Table 3: Determinants of Undernutrition –Dietary Aspects

Children breastfed within

one hour of birth (<3 year) (%)

Children exclusively

breastfed (0-6 months) (%)

Children who received any solid/semi solid

food in the last 24 hours (6-8 months) (%)

Sl.

Source

NFHS 4 (2015-2016)

NFHS 4 (2015-2016)

NFHS 4 (2015-2016)

Bihar

34.9

53.5

30.7

1

Araria

29.6

51.2

30.9

2

Arwal

39.3

43.2

44.2

3

Aurangabad

42.8

51.9

48.3

4

Banka

35

54.3

23.1

5

Begusarai

29.8

27.3

27.9

6

Bhagalpur

33.7

61.7

36.5

7

Bhojpur

28

57

33.2

8

Buxar

31.4

56.2

31.4

9

Darbhanga

22.6

61.4

34.1

10

East Champaran

40.6

51.7

42.3

11 Gaya 29 28.4 27.5

12 Gopalganj 32.7 61.4 37.5

13 Jamui 34.4 40.2 26.8

14 Jehanabad 50 35.9 43.2

15 Kaimur 40.9 34.1 23.4

16 Katihar 44.2 62.4 25.6

17 Khagaria 32.4 48.4 25

18 Kishanganj 30.1 66.8 40.9

44

19 Lakhisarai 39.2 32.7 36.8

20 Madhepura 47.3 64.4 24.8

21 Madhubani 32.6 63.2 23.8

22 Munger 35 46.4 39.2

23 Muzaffarpur 36.7 78.9 33.1

24 Nalanda 47.1 36.7 29.9

25 Nawada 42.6 32.8 45.4

26 Patna 39 35.4 32

27 Purnia 43.9 60 18.6

28 Rohtas 20.4 42.6 29.5

29 Saharsa 26 59.9 14.9

30 Samastipur 37.7 44 19.3

31 Saran 43.6 73.8 34.9

32 Sheohar 33.1 55 30.9

33 Shikhpura 40.1 41.2 45.1

34 Sitmarhi 34.4 38.4 38.5

35 Siwan 31 63.3 39.9

36 Supaul 25.3 68.3 17.6

37 Vaishali 35.1 63.4 19.1

38 WestChamparan 32.1 48.7 41.4

Children

breastfed within

one hour of birth

(<3 year) (%)

Children

exclusively

breastfed (0-6

months) (%)

Children who received

any solid/semi solid

food in the last 24

hours (6-8 months) (%)

Sl. SourceNFHS 4 (2015-

2016)

NFHS 4 (2015-

2016)NFHS 4 (2015-2016)

Bihar 34.9 53.5 30.7

45

Table A2.4: District wise data for Anaemia

Table 4: ADOLESCENT & MATERNAL HEALTH

Anaemia among

pregnant women

(15-49 year) (%)

Anaemia among

adolescent girls

(10-19 year) (%)

Prevalence of

Anaemia amongst

children under-six

(Children 0-59

months with <11

g/dl)

Sl. Source NFHS 4 (2015) DLHS 2 (2002-2004) NFHS 4 (2015)

Bihar 58.3 99.2 63.5

1 Araria 58.4 98.9 61.8

2 Arwal 57.8 98.9 66.8

3 Aurangabad 55 98.9 53.4

4 Banka 67.4 99.4 70.4

5 Begusarai 51 99.1 62.7

6 Bhagalpur 61.9 99.1 70.1

7 Bhojpur 51.9 98.5 70.6

8 Buxar 49.2 98.7 59.8

9 Darbhanga 62.3 100 69.9

10 East Champaran 52.8 100 65.7

11 Gaya 68.1 98.5 59

12 Gopalganj 51.6 99.8 63.1

13 Jamui 48 99.6 61.3

14 Jehanabad 55.1 99 61.4

15 Kaimur 64.3 99.2 63

16 Katihar 57.8 99.8 61.3

17 Khagaria 56.2 99.9 63.4

18 Kishanganj 62 98.7 65.2

46

Anaemia among pregnant women

(15-49 year) (%)

Anaemia among adolescent girls

(10-19 year) (%)

Prevalence of Anaemia amongst children under-six

(Children 0-59 months with <11

g/dl)

Sl.

Source

NFHS 4 (2015)

DLHS 2 (2002-2004)

NFHS 4 (2015)

Bihar

58.3

99.2

63.5

19

Lakhisarai

57.5

100

66.3

20

Madhepura

58.5

98.9

61.4

21

Madhubani

54

100

62.9

22

Munger

58.6

100

62.5

23

Muzaffarpur

55.7

100

58.5

24

Nalanda

51.2

99.2

59

25

Nawada

48.1

97.4

56.4

26

Patna

40.7

97.8

51.6

27

Purnia

72.2

99.8

66.5

28

Rohtas

67.2

99.1

61.3

29

Saharsa

58.2

99

68.4

30

Samastipur

56.3

100

65.4

31

Saran

50.4

NA

61.9

32

Sheohar

46

98.3

63.7

33

Shikhpura

61

99.2

66

34

Sitmarhi

68

99.7

69

35

Siwan

67

98.7

63.1

36

Supaul

63.9

99.8

72.4

37

Vaishali

64.5

NA

67.4

38

West

Champaran

64

99.9

62.3

47

AN

NE

XU

RE

3:

Dep

artm

enta

l P

lan

nin

g fo

rmat

for

con

trib

uti

ng

to p

olic

y go

als

48

Improving Nutrition in Bihar: Insights from Examining Trends in Outcomes, Determinants and Interventions between 2006 and 2016

Introduction

Indian has made considerable progress in child nutrition outcomes in the last decade. These rates of improvement, however, have been highly variable across the states, likely due to variabilities in state-leve changes in the determinants of nutrition and in the coverage of health and nutrition interventions. Although all of the states operate under a similar national policy and programmatic environment, the variability in trends in nutritional outcomes points to state-specific factors. An understanding of such factors can facilitate both state-specific learning and cross-state learning, and help to identify strategies to help India accelerate progress in nutrition. In a series of policy Notes, we examine state-specific trends in nutrition outcomes, determinants and the coverage of interventions, with the overall goal of supporting the state. This policy Note focuses on Bihar.

Bihar is a landlocked state in eastern and northern India. It is split into 9 divisions and 38 districts. It is the nation's third most populated state, and is home to 103 million people. With only 11.3 percent of its population living in cities, Bihar is one of India's least urbanized states (Government of Bihar 2017). Fifty-eight percent of Bihar's population in the country. The state has a sex ration of 916 females for 1000 males (Census of India 2011).

The purpose of this Policy Note is to examine the trends in under nutrition in Bihar and to document trends and geographic variability in the major determinants of nutrition and the coverage of key nutrition and health interventions. In doing this analysis, we aim to highlight key areas for actions to improve nutrition in Bihar.

Methods

We use summary date from the recently released National Family Health Survey-4 (NFHS-4 2015-16) fact sheets (International Institute for population sciences, 2017) and data from the NFHS-3 from 2005-6 to compare trends in outcomes, determinants and interventions over a decade (International Institute for Population Sciences 2008). We also use information from fact sheets of the Rapid Survey on Children (RSoc 2013-2014) (Ministry of Women and Child Development 2015) for indicators that are currently not available in the NFHS-4 fact sheets. We used summary data reported in the NFHS-4 district level fact sheets to examine inter-district variablility.

For outcome indicators, we examine progress on a set of global nutrition targets for maternal, infant and young child nutrition (World Health Organization 2014). These include stunting, wasting, low birth weight, exclusive breast feeding, child overweight and anemia status among women of reproductive age.

We also examined levels and changes in several immediate, underlying and basic determinants (Blacket al. 2013). for interwention coverage, we chose a set of nutrition-specific interventions across the lifecycle, including interventions affecting pregnant women, newborn babies, infants, and children.

ANNEXURE 4:Policy Note on Improving Nutrition in Bihar

Department of Social WelfareGovernment of Bihar

Govt. of Bihar

Documents

Bihar State Nutrition Action Plan 2019-24socialwelfare.bih.nic.in/Docs/Bihar-State-Nutrition... · 2019-06-18 · NREGA - National Rural Employment Guarantee Act. NRLM - National