SUCCESS STORIES IN NUTRITION

To understand how states achieved remarkable improvements in child stunting, we examined the empirical drivers of change in stunting in children, and identified programmatic, social and political factors that contributed to changes in these drivers.

The following key research questions guided the case studies:

1. How did determinants of stunting change over time?
2. What factors contributed to stunting decline?
3. What was done in policy efforts related to the key determinants that contributed to stunting decline?
4. What drove the policy (and other) changes?

We used mixed methods to answer the research questions.

• First, we examined the data on stunting reduction and changes in known drivers of undernutrition descriptively. We then used regression-decomposition analysis to examine the contributions of changes in known determinants of stunting between 2006 and 2016.
• Second, based on the results of the decomposition analysis, we conducted a literature review and policy analysis to identify the nutrition-relevant policies and programs that were most likely associated with the drivers of change
• Third, we interviewed stakeholders in the states to understand their perceptions about the potential reasons for changes in key programs and policies.

The insights from all these research methods are interpreted together to understand what drove changes and what contributed to those changes.

1. Chhattisgarh: In Chhattisgarh, childhood stunting declined from 52.9 percent to 37.6 percent between 2006 and 2016. Improvements in three key drivers - health and nutrition services, household assets, and sanitation and hygiene explained 47 percent of the change in stunting. A shared vision for impact, political stability and capable bureaucracy, state-level innovations, supported from development partners and civil society, and community mobilization were found to contribute to improvements in programs for health, poverty, and sanitation. The study concluded that change in multiple sectors is important for stunting reduction and can be achieved in subnational contexts. Key insights from this study are summed up in a journal article in BMJ Global Health: The role of the state government, civil society and programmes across sectors in stunting reduction in Chhattisgarh, India, 2006–2016.
2. Gujarat: In Gujarat, stunting declined from 51.7 percent to 38.5 percent between 2006 & 2016. There were improvements in multiple nutrition determinants and interventions as well. It was found that the state's enabling policy environment, coupled with other catalysts, improved the coverage of interventions, which contributed to overall stunting reduction. To build on its success, Gujarat will need to focus on strengthening a district-based equity approach to close wide gaps on critical determinants and interventions. It will need to increase coverage of all interventions in the first 1000 days and invest in quality improvements. The state needs to identify ways to improve education, WASH interventions and rural development. Urgent action is also required to improve breastfeeding, complementary feeding, women’s education, age at marriage in girls, and sanitation. Key findings of the Gujarat study can be accessed HERE.
3. Odisha: In Odisha, stunting declined from 45 percent to 34.1 percent. Our analysis of stunting decline reveals that over time Odisha steadily managed to chip away at several system-level challenges to scale up, strengthen, and deliver a set of effective health and nutrition interventions. The convergence of several actors, along with several operational and financial resource pools, enabled the state to respond positively to major national policy changes and to use national fiscal commitments to health and nutrition to provide better services inside its borders. The key success factors in Odisha included high-level political support for health and nutrition programs, fiscal and policy space to operate, and useful collaborations with committed development partners. Barriers that may impede further progress include lack of sanitation, low levels of women's education, early marriage in girls, livelihood distress, and uneven progress across social groups. Key findings of the Odisha study can be accessed HERE. These findings are also a part of the following publications:

• Book chapter: 25 Years of Scaling Up: Nutrition and health interventions in Odisha, India
• Journal articles: What will it take to accelerate improvements in nutrition outcomes in Odisha? Learning from the past(Global Food Security); Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study (BMC Public Health)

4. Tamil Nadu: Between 1992 and 2016, Tamil Nadu has become a leader in reducing undernutrition and in achieving improvements in multiple domains. First, the state historically focused on improving the quality of life for its populace and overall development of the state, with a particular focus on women and children, through investments in the social sector. Second, Tamil Nadu has had a long-standing vision for child development and a recognition of the need for a multisectoral approach to fulfil it. Additionally, state-level innovations, frontline worker initiatives, influence of Tamil Nadu Integrated Nutrition Program, and focus on quality have improved the delivery of ICDS services. State-investments in health infrastructure and human resources have improved the delivery of health services. Third, partnerships with development partners provided the necessary impetus and resources for implementing the interventions. Fourth, the state took a gender focused approach and implemented state-led initiatives to improve the status and welfare of women. Finally, the state had a stable social sector implementation paradigm. Although the state leadership changed between the two major political parties in the state, social sector investments continued. Together, these factors enabled gains in maternal and child well-being and improvements in the levels of stunting among children below five years.