Recommendations for Strengthening Delivery of Nutrition Services through the Platform of Community Action for Health and Nutrition in Nagaland, India

Key findings from the assessment of nutrition determinants and process evaluation of early implementation of the Nagaland Health Project, suggest several recommendations for leveraging the existing project platform to enhance nutrition outcomes. These include introduction of nutrition-relevant indicators in the results-based financing design, capacity building of frontline workers and facility-based providers, and strengthening intersectoral coordination.


Introduction
In the state of Nagaland, stunting prevalence among under-five children decreased from 39 to 29 percent over the decade between the National Family Health Surveys done in 2005-06 and 2015-16 and is lower than the national average of 38 percent. During the same period, under-five prevalence of wasting decreased marginally from 13 to 11 percent. 1 However, within the state of Nagaland, there is significant variation in nutritional status between districts. 2 For instance, stunting rates among under-five children range between a 19 percent in Tuensang district and 42 percent in Kiphire district; wasting prevalence ranges between 2 percent in Mokokchung and 21 percent in Mon. Further, a third of all pregnant women in Nagaland are anaemic and about 12 percent of all women are too thin. Thus, despite improvements in nutritional status by some measures, undernutrition in women and children remains a significant challenge.
Under the term "communitization," in 2002 the state government of Nagaland transferred responsibility for local services to Village Councils and sectorspecific Committees. In the health sector, Village Health Committees were made responsible for management of local health services, including salary payment as well as use of small funds transferred by the state government. Some 1,300 Village Health Committees have been constituted and their level of functionality varies widely, with many hardly active. In 2016, the World Bank-financed Nagaland Health Project included a US$15 million component to provide technical and financial support to strengthen implementation of the communitization strategy. 3 The project includes training committee members on the importance of preventive and promotive care, and on the responsibilities and functions of the committees. The project provides resources to committees to improve service delivery by using a results-based financing mechanism. At present, the project, implemented by the Department of Health and Family Welfare, does not have a substantial focus on improving nutrition services (which are the responsibility of the Department of Social Welfare).

Knowledge Brief 7
Recommendations for Strengthening Delivery of Nutrition Services through the Platform of Community Action for Health and Nutrition in Nagaland, India

Methods
The following set of recommendations are based on a mixed-methods study aimed to examine drivers of nutrition outcomes in Nagaland, as well as identify existing barriers and facilitators for delivering nutrition services. The design also supports an assessment of early implementation of the Nagaland Health Project to inform possible approaches to strengthening nutrition delivery through the current project design and implementation strategy. The study uses a combination of qualitative and quantitative methods. An exploratory qualitative study, including focus group discussions with community members, was followed by a survey of households, health committees and facility staff. The survey was accompanied by key informant interviews with relevant stakeholders as well as an assessment of project monitoring data and documents.

Recommendations
Based on key findings from the assessment of nutrition determinants in the state and a process evaluation of early implementation of the project, several recommendations have been developed for leveraging the existing project platform to enhance nutrition outcomes. Recommendations include introduction of nutrition-relevant indicators in the results-based financing design, capacity building of frontline workers and facility-based providers, and strengthening intersectoral convergence for nutrition.

Nutrition-relevant indicators for results-based financing
At present, the project does not include any indicator solely focused on nutrition services, but instead includes composite indicators that reflect delivery of both health and nutrition services. 4 New indicators could be introduced to more explicitly tie resultsbased payments to delivery of nutrition services.

Building capacity for the delivery of nutrition services
Given the findings on gaps in demand for and inadequate supply and quality of nutrition services, especially counselling and growth monitoring, capacity building should be done for frontline workers (ASHAs and Anganwadi Workers) and facility-based providers on effective delivery of nutrition services. This could include capacity building of ASHAs and Anganwadi Workers by providing nutrition messaging tools in the form of booklets/handbooks with contextualized content and visual aids for messaging at the community level on promotive and preventive practices. Moreover, the project could provide training and mentoring to frontline workers for regular and accurate growth At the village level Indicator on a specific number of behavior change campaigns that include nutrition topics: for example, at least one campaign on a nutrition topic per quarter.
Indicator on organizing group counselling sessions exclusively on nutrition topics at least once a quarter at Village Health and Nutrition Days held jointly by Auxilliary Nurse Midwives, ASHAs and Anganwadi Workers.
At the facility level Indicator on completeness of child growth data on the Mother-Child Protection card in order to improve growth monitoring and early identification of severe malnutrition.
Indicator on availability of functional infant and adult weighing scales, infantometer and stadiometer at the Sub-centre and Anganwadi Centre to enable routine growth monitoring. measurement, identifying growth faltering using WHO growth charts, and ensuring completeness of growth measurement on Mother-Child Protection cards. Similarly, capacity building efforts for facilitybased providers could aim to improve nutrition counselling as part of antenatal, postnatal and newborn care, as well as growth monitoring and early identification and management of severe malnutrition among children.

Strengthening intersectoral coordination for nutrition
Given the multifactorial nature of undernutrition and the complementarities between services provided by the Department of Health and Family Welfare and the Department of Social Welfare, there is a need for improved coordination. This could be achieved through quarterly meetings between the project team and concerned Department of Social Welfare officials at the state level to discuss, develop and review plans and guidelines for strengthened coordination at the local level. Such coordination of service delivery could be centred on: Village Health and Nutrition Days, home visits, behaviour change campaigns, data sharing, and other activities that Footnotes could benefit from interdepartmental coordination at the village and block level. Similarly, orientation on the project for district and block level Department of Social Welfare officials may be beneficial for securing their buy-in and active participation. Finally, a combined effort by both departments for capacity building of Auxiliary Nurse Midwives, ASHAs and Anganwadi Workers, on planning, organisation, and service delivery at Village Health and Nutrition Days, as well as joint field visits for better supervision of and feedback to frontline workers, could contribute to improved delivery of nutrition services.
The Nagaland Health Project has adopted these recommendations and agreed to incorporate them in the design and implementation of the project in a phased manner. It aims to pilot test the inclusion of nutrition-relevant indicators for results-based financing in a selected sample of sites, to understand better data requirements and processes involved in monitoring and verifying these indicators, before scaling them to all sites. It has also agreed to provide combined training to ASHAs and Anganwadi Workers for improving delivery of nutrition counselling services.