Effectiveness of nutrition/health education, … of nutrition/health education, micronutrient...

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Effectiveness of nutrition/health education,

micronutrient supplementation and lipid-milk based meals

to improve child health in India:

A comparative intervention study with cost-effectiveness analysis

to further improve the governmental feeding programme

run in rural Anganwadi Centres around Bolpur

First draft – Hohenheim University research project

Silvia Golembiewski

Dr. Veronika Scherbaum

October 2013

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Table of contents

Abbreviations .................................................................................................................................... 3 Boxes, graphs, tables and project pictures ...................................................................................... 4

1. Abstract.................................................................................................................................... 5

2. Introduction .............................................................................................................................. 6 2.1 Definition - Why improve nutrition? ........................................................................................ 6 2.2 Nutrition for whom? – Target group ....................................................................................... 7 2.3 Problem statement and background information ................................................................... 7

2.3.1 RDA and actual food habits and infant feeding practices in India .................................. 7 2.3.2 Child and maternal food and nutrition security in India ................................................... 9 2.3.3 Nutritional disorders at the research area ..................................................................... 10 2.3.4 The role of the ICDS scheme and its Anganwadi Centres to improve child health ...... 10

2.4 Rationale .............................................................................................................................. 13 2.5 Scope of the study ................................................................................................................ 14 2.6 Research objectives ............................................................................................................. 14 2.7 Hypotheses ........................................................................................................................... 15

3. Methodology .......................................................................................................................... 15 3.1 Study design overview – Baseline survey cum Intervention Study ..................................... 15 3.2 Baseline survey .................................................................................................................. 16

3.2.1 Study sites ..................................................................................................................... 17 3.2.2 Participants .................................................................................................................... 17 3.2.3 Sample size baseline survey ......................................................................................... 17 3.2.4 Statistical methods and analysis ................................................................................... 17 3.4.5 Risks and benefits .................................................................................................. 17 3.4.6 Data collection ............................................................................................................... 18

3.3 Intervention study .............................................................................................................. 18 3.3.1 Study sites ..................................................................................................................... 19 3.3.2 Participants .................................................................................................................... 19 3.3.3 Sample size intervention study ...................................................................................... 20 3.3.4 Statistical methods and analysis ................................................................................... 20 3.3.5 Risks and benefits ......................................................................................................... 21 3.3.6 Data collection ............................................................................................................... 21

3.4 Ethical considerations – informed consent .................................................................... 23 3.5 Quality assurance ................................................................................................................. 23 3.6 Data protection ..................................................................................................................... 23

4. Economic assessment of the nutrition interventions ....................................................... 23 4.1 Theoretical aspects – choice of economic analysis to be applied ....................................... 24 4.2. Cost-effectiveness-analysis – basic steps and target indicators ........................................ 24

5. Expected outcomes .............................................................................................................. 26

6. Stakeholder’s of the study ................................................................................................... 27

8. Proposed research budget ................................................................................................... 30

9. References ............................................................................................................................. 31

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Abbreviations

ARI Acute Respiratory Infection

AWC Anganwadi Centre (Indian public pre-school education and child feeding centre)

BMI Body Mass Index

BMZ Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung

BSCDB Bolpur Sriniketan Community Development Block (research area)

CINI Child in Need Institute (nearby Kolkata)

FAO Food and Agricultural Organization (of the United Nations)

GDP Gross Domestic Product

Hb Hemoglobin

HH Household

ICDS Integrated Child Development Service Programme (Indian public scheme)

INR Indian Rupees (Indian currency)

MDG Millennium Development Goal

MoWCD Ministry of Woman and Child Development (responsible for the ICDS scheme)

MUAC Mid-Upper Arm Circumference

NFHS National Family Health Survey (India)

NGO Non Governmental Organization

NREGA National Rural Employment Guarantee Act (Indian public scheme)

NSSO National Sample Survey Organization (India)

PDS Public Distribution System (Indian public scheme with subsidized cereals for the poor)

PMNCH Partnership for Maternal, Newborn and Child Health

RDA Recommended Dietary Allowance

SD Standard Deviation

SPSS Statistical Package for the Social Sciences (statistical software)

SUN Scaling Up Nutrition

UNICEF United Nations International Children Emergency Fund

USAID United States Agency for International Development

USD United States Dollar

WDR World Development Report

WFP World Food Programme (of the United Nations)

WHO World Health Organization

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Boxes, graphs, tables and project pictures

Boxes

Box 1 Scope of this Study .......................................................................................................... 5

Box 2 Need for the proposed study .......................................................................................... 13

Box 3 Investments in combating malnutrition yield benefits .................................................... 14

Box 4 Crucial questions of the study ........................................................................................ 15

Box 5 Inclusion criteria Baseline Survey .................................................................................. 17

Box 6 Sample size calculation baseline survey ....................................................................... 17

Box 7 Inclusion criteria intervention study ................................................................................ 20

Box 8 Sample size calculation intervention study .................................................................... 20

Box 9 Basic steps in economic analyses ................................................................................. 24

Box 10 Target indicators for the cost-effectiveness analysis ................................................. 26

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Graphs

Graph 1 Child malnutrition in India ............................................................................................. 5

Graph 2 Improved nutrition fosters economic growth ................................................................ 6

Graph 3 Continuum of care for mothers and children ................................................................ 7

Graph 4 Prevalence of child malnutrition and anemia in children ............................................. 9

Graph 5 Low BMI and anemia in pregnant women .................................................................. 10

Graph 6 Primary target group of this study is served food in AWCs ....................................... 11

Graph 7 Study design – Baseline survey plus randomized intervention study ........................ 16

Graph 8 Data collection baseline survey .................................................................................. 18

Graph 9 Links from the baseline to the intervention study ....................................................... 19

Graph 10 Frequency of data collection (intervention study) ................................................... 22

Graph 11 Choice of assessment tool: Cost-benefit vs. cost-effectiveness analysis............... 24

Graph 12 Basic steps in economic analysis for the proposed study ...................................... 25

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Tables

Table 1 Weekly menu provided in ICDS feeding centers ....................................................... 12

Table 2 Indicators intervention study ...................................................................................... 22

Table 3 Example how to calculate cost-effectiveness for a given indicator ........................... 26

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Project Pictures

Project picture 1 Children eat mostly plain rice, sometimes pulses and potato ......................... 8

Project picture 2 Nutritional disorders in children: Vitamin A and iron lack (anemia) ............... 10

Project picture 3 ICDS feeding centre located at the research area of Bolpur ......................... 11

Project picture 4 Weight monitoring at the AWC ...................................................................... 12

Project picture 5 Viability of the research: target group reachable ........................................... 28

Project picture 6 Viability of the research: Investigators available ........................................... 28

Project picture 7 Viability of the study: Medical doctor and health care facilities ready ........... 28

Project picture 8 Viability of the study: experience in running nutrition programmes ............... 29

Project picture 9 Viability of the research: Government recommendations will be heard ........ 29

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1. Abstract

Despite robust economic growth in the recent decades, 48% of India’s children under five

years are chronically malnourished, i.e. stunted (see Ministry of Health and Family Welfare,

2009; UNICEF). Levels of anemia are increasing with 70 percent of children under five years

being affected and India has one of the highest under-5 mortality rates outside Sub-Saharan

Africa (even Bangladesh ranks better than India). Nearly half of these deaths (43%) account

to mild and moderate malnutrition, another 11% are related to severe forms of malnutrition.

Graph 1 Child malnutrition in India

Source: Adopted from National Family Health Survey 2005-06.

Development economist Jean Drèze and Nobel Laureate Amartya Sen (2013), who are

both closely related to the study area of Bolpur, strongly argue that India’s economic suc-

cess can only persist if the downtrodden will benefit from public revenues made and get

access to proper nutrition, respectively. One way to make nutritious food available to poor

Indians is the public “Integrated Child Development Services Programme” (ICDS). Children

below 5 years as well as pregnant and lactating women receive a cooked meal on 300 days

a year through this public scheme. Yet, Indian children continue to suffer from malnutrition

during their early childhood and the American development agency USAID states that caus-

es of persistent malnutrition in India need to be better understood. Evidence on the effec-

tiveness of locally adapted rehabilitation approaches for malnourished children includ-

ing micronutrient supplementation and interventions that foster behavioral change is urgent-

ly required.

Box 1 Scope of this Study

This study will investigate how to meet the nutritional requirements of children aged 6-36 months as well as

of pregnant and lactating women most effectively through governmental ICDS feeding centers. A compara-

tive intervention study will show if micronutrient supplementation, lipid-milk based meals or rather nutrition

trainings are suited to boost child health in the survey area at reasonable costs (financial as well as so-

cial).

A special focus shall be laid upon children below 3 years of age as well as upon pregnant and lactating

women, as the first 1000 days from perception of a child to the completion of the second year are vital to

prevent chronic malnutrition with all its consequences - like retarded brain development, limited learning

capacity, increased morbidity and child mortality rates (see The Lancet Series 2008).

48%

70%

54%

Stunted children <5 years Anemic children <5 years Under-5 deaths related tomalnutrition

51% of India’s rural children under five years are stunted.

Daily diets miss protein, vitamins and minerals, as mothers only offer

rice, lentils and potatoes.

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A cost-effectiveness analysis will allow formulating recommendations for the Indian Government to

learn from the pilot study and scale up effective measures on a broader scale to decrease child mortality.

2. Introduction

2.1 Definition - Why improve nutrition?

Nowadays, in Germany and worldwide there is a consent that access to adequate nutrition

is a fundamental human right. The Scaling Up Nutrition (SUN) initiative, launched in 2010,

focuses on improving the nutrition of pregnant women and children under two years, as this

time (called “window of opportunity”) is considered most effective to invest in the prevention

of malnutrition (see PMNCHa 2010). SUN (2013) argues that “when children receive proper

nutrition and develop strong minds and bodies” then “the world is a safer, more resilient and

strong place”. Yet, there are other, more economic reasons to fight child malnutrition too.

The Commission on Macroeconomics and Health states that economic growth can be fos-

tered by improving nutrition and health (see PMNCHb 2013). If children are well-

nourished, they are able to follow at school and their educational attainment will be higher.

Moreover, when entering working life, those young adults will be sick less frequently. Conse-

quently, expenses on health care reduce and families are able to save some income and

invest, for instance in own small enterprises or further education. With a larger share of the

population being able to work, tax revenues increase and so does social security and stabil-

ity. Finally, economic productivity increases. Calculations show that a 10% higher life expec-

tancy leads to an additional economic growth of 0.3 - 0.4 percent annually.

Graph 2 Improved nutrition fosters economic growth

Source: Partnership for Maternal, Newborn and Child Health 2013b, p. 24 (adopted from WHO 1999).

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2.2 Nutrition for whom? – Target group

There is sufficient evidence that pregnant and lactating women as well as children below

3 years should be the primary focus group of nutrition interventions. First and foremost, the

Lancet Series (2008) pointed out that the first 1000 days from perception of a child until

completion of its second year are decisive to fight malnutrition. This critical period is now

widely known as “window of opportunity”. Second, the Copenhagen Consensus Centre,

which was founded to better understand the most efficient ways to spend development mon-

ey, stressed that nutrition of children below 5 years strongly depends on the nutritional situa-

tion of their mothers during pregnancy and lactation (see Horton et al. 2008).

This means that child malnutrition can only be overcome if women are included in nu-

trition interventions. UNICEF confirms that the poor nutritional situation of Indian children

accounts largely to the situation of women. 36% of Indian women suffer from chronic malnu-

trition and 55% have some form of anemia. As the Indian economy is rising and a new mid-

dle class is coming up, the issue of women and child malnutrition affects mainly the rural

population (see The World Bank 2005). Especially tribal communities show a high preva-

lence of undernutrition. Girls are hit harder than their male counterparts.

It is nowadays even recommended to establish a system of continuum care for mothers

and children, where adolescent women before pregnancy are also included. Yet, given

the Indian infrastructure in its public Anganwadi feeding centres, the study will focus on

pregnant and lactating women as well as infants and children under 6 years.

Graph 3 Continuum of care for mothers and children

Source: Adapted from PMNCHc 2010, p.15.

It is obvious that the nutritional requirements of adolescent and pregnant women as well as

of children under five years (with a special focus on children aged below two) need to be met

to improve their health and foster therewith economic growth and social advancement. The

following chapters will show the current nutrition security situation of women and children in

India to detect and understand the problems to be addressed by nutrition interventions.

2.3 Problem statement and background information

2.3.1 RDA and actual food habits and infant feeding practices in India

All human beings need a balanced diet to remain healthy (see National Institute of Nutrition

2009). The nutritional requirements of children are 2 to 3 times higher (per kg body weight)

than for adults as they do not only have to maintain their body functions, but also need nutri-

ents to grow. Likewise, pregnant and lactating women have a comparatively high need

of nutrients, as they need to nurture the growth of their fetus or rather their newborn baby.

The Recommended Dietary Allowance (RDA) reflects the average quantity of nutrients which

needs to be consumed by healthy persons each day. To attain the full picture, the actual nu-

tritional state and the bio-availability of different nutrients have to be considered. For exam-

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ple, cereal based diets need to contain about 20 to 30 times more iron as its actual absorp-

tion by the body is rather low in comparison to diets containing small amounts of animal

source foods (ASF).

Besides macronutrient requirements (protein, fat and carbohydrates), also a person’s micro-

nutrient needs (e.g. iron, zinc, iodine, thiamine, riboflavin, folic acid, vitamin B6 and B12) have

to be met. A 2004-05 survey of the National Sample Survey Organization (NSSO) revealed

that cereals continue to dominate Indian diets in urban as well as rural settings (see Nutri-

tion Foundation of India 2008a). Consumption of pulses, milk, fruits and vegetables are much

lower. Hence, the average Indian diet lacks essential vitamins, minerals and protein.

Several national surveys in India suggest that breastfeeding is almost universal in India

(see Nutrition Foundation of India 2008b). Yet, exclusive breastfeeding for six months and

provision of complementary semi-solid foods after 6 months are not sufficiently prac-

ticed so far. As per the third National Family Health Survey merely about half the children

under 6 months are exclusively breastfed and liquids like water and milk are introduced too

early (see Ministry of Health and Family Welfare 2009). Only about half the children aged 6-9

months receive semi-solid supplement foods (see Nutrition Foundation of India 2008b).

Thus, Indian infants lack adequate nutrition and find difficulty in covering their nutritional

needs which hampers their growth and health development.

The food consumption of pregnant and lactating women in India does not differ from the

consumption pattern of other women (see Nutrition Foundation of India 2008b).The intake of

vegetables, fruits and pulses are rather low. As pregnant women continue to do the house-

hold and other work and additionally need to nurture the growing fetus, they are finally left

without sufficient coverage of their own nutritional needs. The same is valid for lactating

women.

An own survey on the food habits of the rural families living around the survey area of Bol-

pur shows that children and women eat rice twice a day (see project pictures below) Every

second or third day they consume also pulses, sometimes mixed with green leafy vegetables

collected from the field. Red or yellow vegetables are usually prepared once or twice a week.

Egg is hardly taken, only if produced in the family (or provided in the AWC). If there are fish-

es available in the channels in the rainy season, families tend to sell them instead of con-

suming them on their own. As a consequence malnutrition and related diseases are

widespread.

Project picture 1 Children eat mostly plain rice, sometimes pulses and potato

Source: Own pictures - project area Bolpur.

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2.3.2 Child and maternal food and nutrition security in India

In 1996, the World Food Summit defined that Food Security is achieved “when all people at

all times have access to sufficient, safe, nutritious food to maintain a healthy and active life”

(WHO 2013). In India, even if food grains are available in a sufficient amount, large propor-

tions of the population lack access to the food resources available, mostly for economic

reasons (see FAO 1994). Moreover, knowledge on nutritious food and balanced diets is lim-

ited which leads to a suboptimal use of accessible nutrient sources.

The latest data available on the prevalence of stunting, wasting and underweight children is

provided by the third National Family Health Survey 2005-06 and clearly reflects the misal-

location of food resources in India and the fact that economic growth has not trickled

down to the poorest section of the society (see Ministry of Health and Family Welfare 2009).

48% of the children below 5 years are stunted (too short for their age). Another 20% are

wasted (too light for their length/height) and 43% are underweight (too light for their age).

Children in rural areas are more likely to be malnourished than children from urban settings.

Poor nutrition is a main driver of child mortality with 43% of under-five deaths relating to mild

and moderate malnutrition and another 11% to severe malnutrition.

Graph 4 Prevalence of child malnutrition and anemia in children


33% of pregnant women in India have a low Body Mass Index (BMI<18.5) and 58% are

anemic. It is estimated that 20-40% of maternal deaths account to anemia. For the children

under five an even higher proportion, namely 70%, suffers from some sort of anemia. Also

vitamin A and iodine deficiencies are widespread in India as actual intakes deviate substan-

tially from the recommended daily allowances (see Nutrition Foundation of India 2008b).

48%

20%

43%

70%

Stunted children <5 years Wasted children <5 years Underweight children <5years

Anemic children <5 years

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Graph 5 Low BMI and anemia in pregnant women


2.3.3 Nutritional disorders at the research area

Also in the study area of Bolpur nutritional deficiencies are frequently found with chil-

dren under 5 years and pregnant as well as lactating mothers. Lack of vitamin A and B, cal-

cium and iron are ubiquitous. The following pictures shall visualize the most common nutri-

tional related disorders, namely anemia and lack of Vitamin A.

Project picture 2 Nutritional disorders in children: Vitamin A and iron lack (anemia)


There are several government schemes trying to address the misallocation of available

food items. The most vital ones are the National Rural Employment Guarantee Act

(NREGA), the Public Distribution System (PDS) and the Integrated Child Development Ser-

vice Programme (ICDS). The latter is at the centre of interest in this research study and will

be described in greater detail with its salient features in the next chapter.

2.3.4 The role of the ICDS scheme and its Anganwadi Centers to improve child health

India’s “Integrated Child Development Services” Programme (ICDS) was initiated in

1975. It is one of the largest child welfare schemes in the world and aims at breaking the

vicious circle of malnutrition, morbidity, reduced learning capacity and mortality amongst

children under six years of age (see Centre for Development and Finance 2009).

33%

58%

Pregnant women withBMI<18.5

Anemic pregnantwomen

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Graph 6 Primary target group of this study are children < 3 years and pregnant and lactating women attending AWCs

Source: Own graph.

A vital component of the ICDS scheme is the provision of supplementary feeding support

to pregnant and lactating women as well as to children up to six years. 300 days a year a

cooked meal or rather a take home ration is given free of cost to children and preg-

nant/lactating women through numerous Anganwadi Centers (AWC) across the country.

Project picture 3 ICDS feeding centre located at the research area of Bolpur


Each AWC serves a population of 400 to 800 persons (see MoWCD 2009a). In the rural are-

as, typically, each village has one AWC. Yet, bigger villages may have two AWCs and small-

er villages may share one mutual AWC. At the survey area of Bolpur about 50 children and

pregnant/lactating mothers are served in each AWC. While children aged 3 to 6 years are

taught rhymes and dances in the morning at the AWC and take their food at the spot,

younger children and pregnant/lactating mothers usually take their food ration to their

homes.

In each AWC, two persons are employed to prepare and distribute the supplement meal,

which is supposed to close the caloric gap of the target group.

The weekly menu provided to the mothers and children contains mainly rice, lentils and

little vegetables as well as egg, which is the most nutritious item. Details about the food cur-

rently provided at AWCs can be seen in the following table:

pregnant &

lactating

women

children

<3 years

children

>3 to <6

years

AWC

cooked meal 300 days a year

Study’s primary target group:

pregnant women

lactating women

children <3 years

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Table 1 Weekly menu provided in ICDS feeding centers

Mildly and moderately

underweight children

Severely underweight

children

Pregnant/lactating

women

Food item 1: “KICHURI” (provided every Monday, Wednesday and Friday)

70 g rice

25g lentils

2.6g oil

vegetable/soya beans worth 0.61

INR

half egg

3g salt

100g rice

40g lentils

2.6g oil

vegetable/soya beans worth

0.52 INR

full egg

3g salt

100g rice

30g lentils

2.6g oil

vegetable/soya beans worth 0.69

INR

half egg

5g salt

Food item 2: “RICE” (provided every Tuesday, Thursday and Saturday)

70g rice

vegetable worth 0.30 INR

potato worth 0.13 INR

1.3g oil

full egg

3g salt

100g rice



8.9g oil

full egg

3g salt

100g rice



2.6g oil

full egg

3g salt

Source: Data kindly provided by the Anganwadi Worker at Phooldanga village, nearby Bolpur.

The guidelines intend to provide the following amounts per day (see MoWCD 2009a):

500 kcal and 12-15g protein worth INR 4 to all children from six to 72 months,

600 kcal and 18-20g protein worth INR. 5 to pregnant and lactating mothers.

800 kcal and 20-25g protein worth INR 6 to severely malnourished children

AWC staffs need to monitor the growth of the children and document it via weight for age

cards and are equipped with a hanging scale. Thus, the share of underweight children who

are too light in respect of their age can be easily determined in a summary analysis. Children

< 3 years have to be weighed monthly, children between 3-6 years quarterly. Yet, as per

the information given by the Phooldanga AWC worker, all children are weighted monthly and

all severely underweight children bimonthly. The documentation is kept in a separate

book.

Project picture 4 Weight monitoring at the AWC


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Moreover, the following tasks should be taken by the two AWC workers:

completion of the immunization schedule of the children under six years,

conduction of health check-ups,

referral of severe sick and malnourished children to the Primary Health Centers,

pre-school education to children between three and six years, and

awareness on nutrition and health issues.

Every first Thursday in a month, the health worker from the nearest health care centre is

supposed to visit the AWC to give needed immunizations and to provide Vitamin A injec-

tions. Common medicines, e.g. against fever, worms and vomiting, are stored in the AWC

and can be given to sick children by the AWC worker as per requirement.

It is quite obvious that AWCs do play a vital role in covering the nutritional requirements

and therefore strengthening the health of pre-school children all over India. Assuming, the

meals provided could be enriched or rather, that AWC workers would be prepared to train

mothers and aware them on healthy food items as well as proper breastfeeding and com-

plementary feeding practices, child health in India would be very much likely to boost.

2.4 Rationale

As the latest National Family Health Survey revealed, child malnutrition in India was still

alarmingly high in 2005-06. 20% of children below 5 years were wasted, 43% underweight

and even 48% stunted (see Ministry of Health and Family Welfare 2009). More recent data

on the development of child malnutrition in India is currently unavailable and urgently

required to monitor the development and take necessary action.

Box 2 Need for the proposed study

No current data on the prevalence of maternal and child malnutrition in India available

Evidence on the effectiveness of nutrition education and nutrition supplementation is needed

Nutrition trainings and micronutrient supplementation are assumed to be most effective

Cochrane analysis confirms lack of evidence from Asia, especially on nutrition education interven-

tions; blended foods are potentially as effective as lipid-milk based food to combat malnutrition

Tremendous costs are involved if child malnutrition persists

The American development agency USAID stresses that evidence on the effectiveness of

rehabilitation approaches for malnourished children in India, including micronutrient sup-

plementation and interventions that foster behavioral change, is vital for scaling up ef-

fective interventions and combating child malnutrition.

Also the Indian Supreme Court assumes nutrition supplements and nutrition trainings to

be key drivers towards decreased levels of child malnutrition. Therefore, the Indian

Government decided to promote optimal infant and young child feeding practices to achieve

behavioral change and improved caring practices in 2009 (see MoWCD 2009b). Two years

later, in 2011, the Supreme Court recommended to enrich the cooked meals provided in

AWCs by naturally occurring micro-nutrients (see Supreme Court 2011).

Just recently the Cochrane Collaboration (2013) pointed out that there is a knowledge gap

concerning nutrition interventions for malnourished children in Asia. Moreover, the

scientists stressed that there is a lack of studies which investigate the effectiveness of inter-

ventions aiming at improving the quality of home diets; this will be included in the nutri-

tion/health education intervention group of this research project.

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Interestingly, the scientists found no evidence suggesting that lipid based nutrition supple-

ments (e.g. RUTFs containing peanuts, milk powder, oil, sugar and micronutrient mix) are

superior to blended foods (which was strongly believed during the last decade). This implies

that it is worth investigating the possibilities of AWC meals to improve child growth and

health. Still, to proof the effectiveness of lipid/milk based versus cereal based nutrition inter-

ventions, a lipid/milk meal group shall be included in the comparative intervention study.

Finally, to argue in economic terms, tremendous costs are involved if malnutrition in

India should persist. The World Food Programme (WFP) has implemented in-depth cost of

hunger studies for Latin America and more recently, in 2012, also for Africa (see WFP 2007

and 2012). Both studies enumerated the costs resulting from decreased learning capacities

of children, a reduced activity of the working force and additional health costs, respectively.

These cost-benefit-analyses proofed that there is an urgent need to find effective ways of

reducing child malnutrition to boost investments and fulfill the Millennium Development Goal

(MDG) of eradicating extreme poverty and hunger.

Box 3 Investments in combating malnutrition yield benefits

Investments in combating malnutrition will finally create yields. Respectively, the WFP (2012) esti-

mates that expenses of 60 Million USD annually on vitamin A and zinc supplementation would lead to bene-

fits of 1 billion USD, which leaves a surplus of 40 million USD.

2.5 Scope of the study

This study will investigate how to meet the nutritional requirements of children aged 6-36

months as well as of pregnant and lactating women most effectively through governmental

ICDS feeding centers. A comparative intervention study will show if micronutrient supple-

mentation, lipid/milk based meals or rather nutrition trainings are suited to boost child

health in the survey area at reasonable costs (financial as well as social).

A special focus shall be laid upon children below 3 years of age as well as upon pregnant

and lactating women, as the first 1000 days from perception of a child to the completion of

the second year are vital to prevent chronic malnutrition with all its consequences - like re-

tarded brain development, limited learning capacity, increased morbidity and child mortality

rates (see The Lancet Series 2008).

A cost-effectiveness analysis will allow formulating recommendations for the Indian

Government to learn from this pilot study and scale up effective measures on a broader

scale to decrease child mortality.

2.6 Research objectives

Baseline study:

The purpose of this study is firstly to understand the current nutritional situation of wom-

en and children below 3 years living in the Bolpur. Amongst other baseline data, the preva-

lence of MUAC, stunting, wasting, underweight and anemia in children as well as the BMI

and MUAC of women shall be determined in the project area.

51% of India’s rural children under five years are stunted.

Daily diets miss protein, vitamins and minerals, as mothers only offer

rice, lentils and potatoes.

15

Comparative intervention study:

Thereafter, the research project will investigate whether the Indian Government could

foster micronutrient supplementation, lipid/milk-based meals or nutrition/health train-

ings in its ICDS feeding centers to reduce chronic malnutrition amongst children below 3

years.

Box 4 Crucial questions of the study

What is the current nutritional situation of children below 3 years?

Do nutrition/health education, lipid-milk based meals or micronutrient supplementation strengthen

child health at public feeding centers and: If yes, at what cost?

2.7 Hypotheses

(1) Mothers with better knowledge on nutrition/health issues cook improved family meals

and are less likely to have malnourished children. The nutrition education/health inter-

vention group shall verify or rather falsify this assumption.

(2) Children who cover their nutritional requirements are less likely to be malnourished.

(3) Pregnant women who cover their nutritional needs are less likely to have low birth weight

children.

(4) Children who receive lipid/milk-based foods recover more quickly from malnutrition than

those receiving blended foods in AWCs.

The nutrition supplementation groups shall proof these three latter assumptions. There shall

be three interventional subgroups, one providing a commercial supplement (e.g. “MixMe”) to

the standard diet cooked in AWCs, one providing a plant supplement (e.g. powder of dried

Moringa tree leaves) and another group shall receive lipid/milk-based meals three times a

week respectively.

3. Methodology

3.1 Study design overview

In order to obtain a comprehensive picture about the current nutritional siutation of children

below 3 years and pregnant/lactating women at Bolpur a baseline survey will be conducted.

Afterwards, a comparative intervention study will shed light on the question if intensive

nutrition/health trainings, lipid/milk based meals or micronutrient supplementation can

strengthen the growth and health development of women and children below 3 years.

Finally this research project will give an insight how the Indian Government could overcome

continuing high levels of child malnutrition around Bolpur via ICDS feedings programs.

16

Graph 7 Study design – Baseline survey plus AWC-randomized intervention study

Source: Own graph.

As can be seen in the graph above, a cluster sampling will be applied for the baseline

survey with a total coverage of n=630 households.

For the intervention study, out of the researched areas of the baseline survey, up to 5

clusters will be selected where the same or a comparative prevalence of moderate

stunting, which will serve as primary indiator of the study, is given – this is to guarantee

comparability of results on the basis of a similar stunting prevalence at the onset of the

intervention. Under these conditions, all four intervention groups can use the same control

group to achieve synergies. While the AWC-control and AWC-nutrition supplementation

groups may be in geographic nearness, the nutrition/health education intervention group has

to be located at an adequate distance to prevent dismission of training contents and the

danger of resulting biases. Each intervention group will cover at least 128 children.

The methodological approach to both, baseline and intervention study, will be described in

greater detail in the following sub-chapters.

3.2 Baseline survey

The baseline survey will assess the local food/nutrition security and vulnerability

situation. The following fields will be of primary interest:

the share of stunted, wasted and underweigtht children under 3 years

the share of women with low MUAC (in pregnancy) low BMI and MUAC (during

lactation) around Bolpur

the prevalence of anemia in women and children in the survey area

the share of newborn children wirh low birth weight

the motor development of children under 3 years of age

Research area for Baseline Survey: Bolpur Sriniketan Community Development Block (India) – n = 630 HH

Bolpur (city)

rural

area

x x x

x

stunting

= 40%

stunting

= 40%

stunting

= 40%

stunting

= 40%

Control

group

Nutrition

training

group

MixMe

group

Moringa

group

n = 128 n = 128 n = 128 n = 128

t min. = 6 months

tmax. = 24 months

rural

area

PART 1:

Baseline

Survey

PART 2:

Intervention

Study in AWCs

Primary Indicator:

stunting

stunting

= 40%

Milk-

lipid

based

meal

group

n = 128

x

x

x x

x x

x

x x x

x

x

x

x x

x

17

the caretakers knowledge on nutritious food, health and hygiene

the HH’s food intakes (diversity of diets) and weight protocol of child’s diet below 3

years (in a sub-sample)

The HH’s capacity to purchase food items from the markets (purchasing power)

the HH’s access to markets, health facilites and water/sanitation facilities

3.2.1 Study sites

The reseach area will be “Bolpur Sriniketan Community Development Block” (BSCDB), an

administrational region around Bolpur covering a total of N = 175,490 inhabitants. Clusters

comprising an equal numer of inhabitants will be defined according to locally available

statistic data. Thereafter, 15 clusters will be randomly selected to conduct the baseline

survey targeting at a cluster sample size of 42 households (HH) with children under 3 years.

A total sample size of 630 HH will be covered alltogether (see calculation sample size).

3.2.2 Participants

All households with children under 3 years and/or pregnant women are eligible. All mothers

whose children visit this AWC will be invited to participate in the survey and will be accepted

if they agree that anthropometric measurements and blood samples of their children will be

taken.

Box 5 Inclusion criteria Baseline Survey

HH with children under 3 years

HH with a pregnant or lactating woman

Informed consent that blood, weight, length etc. will be taken

3.2.3 Sample size baseline survey

The local prevalence of moderately stunted children under three years around Bolpur is es-

timated to amount to 39 percent (estimate based on own measurements). Assuming a sam-

pling error d of 0.04 and applying a confidence level of 95 percent (z = 1.96), a minimal sam-

ple size of 572 households is necessary to conduct the baseline survey.

Box 6 Sample size calculation baseline survey

n = t2 x (p x q) / d

2 = 1.96

2 x (0.39 x 0.61) / 0.042 = 3.8416 x 0.2379 / 0.0016 = 572 HH

Adding again a 10% allowance for non-response, a sample size of n = 630 HH shall be given.

3.2.4 Statistical methods and analysis

Data analysis will be done with the statistical software SPSS. This will help to determine

basic descriptive analyses such as counts and percentages. Respectively, the exact preva-

lence of moderate stunting around Bolpur can be determined and it can be tested whether

girls are more likely to be stunted than boys via cross tabulation testing.

3.4.5 Risks and benefits

There are no obvious risks involved for the participants. Benefits comprise the following:

Knowledge gain about the nutritional/health situation of the family (children, women)

Offer to visit the project holder’s “St-Mary’s Child and Mother Health Care Centre” at

Bolpur, where treatment is possible free of costs any time for children and mothers.

18

3.4.6 Data collection

The baseline data will be collected in 3 steps, as can be seen in the following graph:

Graph 8 Data collection baseline survey

Source: Own graph.

(1) Directly at the AWC - anthropometric data, laboratory examination

Draw blood of children and mothers to determine hemoglobin (Hb)

Take weight, length/height and MUAC of the children

Take MUAC, weight and height of women (to calculate BMI)

(2) Nearby the AWC - interviews

Overall nutritional situation (e.g. socio-economic situation, food security/diversity)

Nutrition knowledge (e.g. breastfeeding, complementary feeding, healthy food, hygiene)

(3) At home with the family – weight protocol of consumed food

The investigator will weigh the actual amounts eaten by pregnant/lactating women and

children below 3 years to understand the nutritional gap of the primary target group. This

intervention is time consuming and the investigator needs to stay one whole day in each HH.

Yet, it is a necessary action, as 24-hour-recalls are less likely to give the actual amounts

consumed (merely the items – not the real quantities – might be remembered). The sample

size will be limited to n = 30 children < 3 years and n = 30 pregnant/lactating women. The

results will help to calculate how much MixMe or Moringa has to be supplemented to cover

the RDA of iron, and other micronutrients respectively.

3.3 Intervention study

The intervention study will help to understand the role of nutrition/health education,

micronutrient supplementation and lipid-milk based meals in covering the RDA of children

below 3 years and pregnant/lactating women via the governmental ICDS feeding program in

Bolpur.

For this purpose, different groups – treatment and control - will be defined:

AWCs where mothers are trained in nutrition, hygiene and health

Data collection

at the AWC:

- Blood

- Weight

- Length/Height

- MUAC

Interview

nearby AWC:

- Nutritional situation?

- Nutrition knowledge?

Weight protocol of con-

sumed food - at home!

- Intake pregnant women?

- Intake children <3 years?

3 2 1

19

AWCs where pregnant/lactating women and children receive a micronutrient supplement

(MixMe or Moringa) along with the cooked food provided from the Government

AWCs where one meal (“RICE”) currently provided by the Indian Government in AWCs

is exchanged through a lipid-milk based meal (“HALWA”).

AWCs without treatment (control group) – pregnant/lactating women and children will

receive the food normally provided by the Government

The baseleine study will give decisive insights to otimize the design of the intervention

study. The following 3 links can be made: (1) comfirmation of the sample size, (2) curriculum

of the nutrition/health training intervention, and (3) specification of the amount of

micronutrients needed for this age group.

Graph 9 Links from the baseline to the intervention study

Source: Own graph.

Moreover, the baseline survey will give an overall understanding of the nutrition situation in

the survey area, which is currently missing due to a lack of recent data.

3.3.1 Study sites

5 clusters surveyed in the baseline study with equal prevalence of moderate stunting (e.g.

40%) will be randomly selected as study sites of the intervention study. This is to guarantee

comparable results for the interventions and control group – stunting will be defined as

primary indicator as most studies so far have been focusing on wasting and stunting is the

most spread form of malnutrition in India. Yet, the nutrition education group needs to have

the same stunting prevalence but be geographically separated to prevent spreading of teach-

ing contents and finally biased study results.

For each intervention group, AWCs need to be randomly selcted within the given cluster.

3.3.2 Participants

All children as well as pregnant and lactating women coming to the AWC to take food will

enjoy the respective treatment, i.e. micronutrient supplement (Mix-me or Moringa), lipid-milk

based meal or nutrition/health education for the mothers/pregnant women. Yet, only children

below 3 years with stunting values bigger or equal to -3SD and smaller than -1.5SD will

be considered for data evaluation. The target shall be that those moderately stunted chil-

dren gain sufficient height to cross the target value of -1.5SD, which will serve as “discharge

criterion”. In reality, the “discharged” children continue to come to the AWC and receive the

respective treatment. This will allow to see longtime effects of the treatments and to deter-

Baseline

Survey

Intervention

Study

anthropometric data

prevalence of stunting

confirmation sample

size (estimated preva-

lence stunting: 39%)

What crucial knowledge

on nutrition, hygiene,

and health is lacking?

design nutrition training

to fill up knowledge gaps

RDA – nutrient intake

=

nutritional gap

calculate amount of

micronutrient supple-

ment to be provided

20

mine the defaulter rate. Children whose age is unclear cannot be included in the data evalua-

tion, as stunting (height-for-age) will serve as primary indicator.

To be included into the data evaluation process, care takers need to agree that anthropo-

metric measurements and blood samples will be taken repeatedly.

All severely malnourished children (weight-for-height <-3SD or MUAC < 11.5 cm) will be in-

vited to the project holder’s “St. Mary’s Child and Mother Health Care Centre” at Bolpur for

intensive nutrition therapy and medical treatment as required. This service is free of cost.

Box 7 Inclusion criteria for intervention study

Children with stunting -3SD and <-1.5 SD

Consent that anthropometric data and blood will be taken repeatedly

3.3.3 Sample size intervention study

The change in prevalence of moderate stunting among children aged 6-36 months shall

serve as primary indicator for the intervention study. A reduction of 15% in moderate stunting

shall be detectable. At the outset, 39% of children are estimated to suffer from moderate

stunting (P1 = 0.39). Hence, the target level of moderate stunting is 24% (P2 = 0.24). A power

of 80% is and a significance level of 95% (Zβ =0.840 and Zα =1.645) is chosen.

Box 8 Sample size calculation intervention study

n = (Zα + Zβ)2 * ((P1*(1-P1) + P2*(1-P2))/(P2-P1)

2

= (1.645 + 0.840)2 * ((0.39*0.61) + (0.24*0.76)) / (0.24 - 0.39)

2 = 116 children

Adding a 10% allowance for non-response, a sample size of n = 128 children shall be targeted

(each for the treatment and control groups).

3.3.4 Statistical methods and analysis

Again, the statistical analysis will be done with the software SPSS. It will be determinded, if

growth, health and motor development of the children in the treatment groups differ

signifiantly from the childrens’ health and growth development as well as motor capacities in

the control group. After testing the data for normal distribution, t-tests can be applied to

analyse potential differences and recognize the effectiveness of the interventions.

To prove the posed hypotheses, one can check several points through statistical analysis:

Do children with micronutirent supplementation, children receiving lipid-milk based

meals or children with mothers under nutrition/health education recover more quickly

from stunting than control group children?

Do children with micronutirent supplementation (Mix-me or Moringa), children

receiving lipid-milk based meals or children with mothers under nutrition/health

education have higer Hb values than the control group children?

Are children with micronutirent supplementation, children receiving lipid-milk based

meals or children with mothers under nutrition/health education get sick less

frequently than the control group children?

Do children with micronutirent supplementation, children receiving lipid-milk based

meals or children with mothers under nutrition/health education have better motor

capacities than control group children?

21

Do newborn children of pregnant mothers who received supplemented (Mix-me or

Moringa) food, milk-based meals or nutrition/health education have a higher birth

weight?

Is nutrition/health education, micronutirent supplementation or the provision of lipid-

milk based meals more effective to improve child growth, health and motor

development?

Which treatment is least costly and most effective for pregnant/lactating

women and children <3 years, for instance in reducing stunting and anemia,

increasing birth weight and/or decreasing morbidity? Which interventions are

most effective and should be further strengtened and rolled out?

3.3.5 Risks and benefits

One risk in supplementing pregnant women is that problems under delivery might occur

when the head of the newborn baby becomes too big for the still slim mother with narrow

pelvis. Yet, as the pregnant women are connected to the “St. Mary’s Child and Mother Health

Care Center”, run by the project holders, antenatal checkups including sonography will allow

to recognize difficult deliveries beforehand. It is then possible to refer pregnant women with

need of a caesarean delivery to nearby nursing homes and the costs will be beard by the

project holder. Normal deliveries can be conducted free of cost at the project holder’s hospi-

tal.

Benefits for the participants include the following:

Provision of micronutrients 6 days a week (for nutrition supplementation groups)

Lipid-milk based meal 3 days a week (milk meal group)

Knowledge gain on nutrition, health and hygiene (nutrition/health intervention group)

Offer to visit the project holder’s “St-Mary’s Child and Mother Health Care Centre” at

Bolpur, where treatment is possible free of costs any time for children and mothers.

The control group will get access to the most effective treatment (either MixMe supplementa-

tion, Moringa supplementation, lipid-milk based meals or nutrition/health education) after

evaluation of the study results (cross-over study design).

3.3.6 Data collection

A set of indicators will be applied to assess the growth, health and motor development of

the children in the comparative intervention study. Largely quantitative indicators will be ap-

plied with addition of one qualitative component (mother’s opinion – focus group interviews).

22

Table 2 Indicators intervention study for target children (<3yrs) and pregnant/lactating women

Indicator Applied for

(1) Anthropometric assessment:

- Stunting (length/height-for-age)

- Wasting (weight-for-length/height)

- Underweight (weight-for-age)

- MUAC (arm circumference)

- BMI before pregnancy

- Weight gain during pregnancy

- BMI after delivery

all children

all children

all children

children after 6 months and pregnant women

pregnant women

pregnant women

lactating women

(2) Health assessment:

- Anemia (Hb) via blood

- Morbidity (fever, ARI, diarrhea)

- Malnutrition diseases (teeth, skin, eyes)

all children and pregnant/lactating women

all children and pregnant/lactating women

all children

(3) Assessment of motor development:

- Motor milestones (WHO)

children under 2 years

(4) Qualitative assessment:

- Mother’s opinion about the child’s health and

nutritional situation (focus group discussions)

all mothers

In order to assess growth, health and motor development of the children under treatment in

comparison to the control group children, anthropometric data will be gathered and health as

well as motor capacity assessments will be done. Also mothers will be heard to listen how

they perceive the health and nutritional situation of their children.

The following graph shows in what intervals the data will be collected. The interventions will

start all at the same time and are planned for a duration of 2 years with an exit option

every 6 months if significant results (i.e. decrease in moderate stunting) can be shown.

Graph 10 Frequency of data collection (intervention study)

Source: Own graph.

primary indiactor Q

U

A

N

T

I

T

A

T

I

V

E

2 years

1 year

Start

Half yearly:

Blood (Hb)

Monthly:

Weight

MUAC

Morbidity

Motor milestones

Quarterly:

Length/height

Beginning/end:

Malnutrition diseases

Focus group discussion mothers

QUALI-

TATIVE

23

Moreover, compliance will be a main issue within the data collection process, as it is obvi-

ously influencing the success of all interventions. If compliance should be low in one treat-

ment group, but high in another, this might be seen in the outcomes achieved. It will be cru-

cial to understand the reasons for non-compliance and aim to motivate participants to eat the

full meal given and attend all nutrition/health trainings offered, respectively.

3.4 Ethical considerations – informed consent

Ethical approval will be obtained from relevant institutions in India before implementing the

proposed study.

Written consent (signature by thumb impression for illiterate families) will be obtained from

each HH at the day of first data assessment. Investigators will be responsible to explain

clearly to the families what is going to happen (purpose of the study, data to be collected,

examinations to be done), so they are free to decide voluntarily to take part in the survey or

not. A form will give guidelines for these explanations to the investigators.

The participants will get time to ask any question and to decide about her participation.

The investigator/research assistant and the participant have to sign the prepared Informed

Consent Form to confirm that the participant is willing to take part in the survey.

3.5 Quality assurance

Field staff can be recruited from the Visva-Bharati University at Santiniketan, Department

of Rural Development. Dr. Sujit Paul will be helpful to find suitable field staff and investiga-

tors. The main selection criteria shall be:

English and Bengali language skills (Santali preferable)

Open to learn about nutrition and health issues

Ready to continue the work for 24 months

The investigators will be trained about the research process and will learn to fulfill all

steps, especially to take anthropometric data. A pretest will be done to ensure that the inves-

tigators have understood clearly their tasks and quality of data is reliable.

3.6 Data protection

All data sets will be encoded via SPSS as to prevent that conclusions about individuals can

be drawn. In no publication any individual data will be presented.

4. Economic assessment of the nutrition interventions

Cost-benefit and cost-effectiveness analyses are nowadays recommendable as devel-

opment and public financial resources are limited and need to be invested as effectively as

possible. Already in 1996, the World Bank published a guideline for the economic analysis of

nutrition projects. In 2004 the first Copenhagen Consensus Conference took place in Den-

mark to find out what are the most effective nutrition interventions known. The initiative con-

tinues until today and also this research project shall include economic concerns.

So far, costs of nutrition interventions are often underestimated, which is not useful, as final

payoffs of nutrition interventions are incontestable since a longer time (see The World Bank

http://www.visva-bharati.ac.in/

24

1996 with reference to McGuire, 1996; WDR, 1993). Therefore, the economic analysis to be

done shall depict the real (discounted) costs involved for the proposed interventions. To at-

tain a full picture, economies of scale shall also be considered as to show the synergetic

effects of rolling out the proposed interventions on a broader scale.

An ex-post-analysis will be done applying available financial records of the respective nutri-

tion interventions and referring back to the actual welfare outputs achieved (e.g. decrease in

stunting or anemia). Eventually, this research project will show which of the implemented

interventions might be fostered and rolled out by the Indian Government.

4.1 Theoretical aspects – choice of economic analysis to be applied

There are two major methodological approaches to assess the economic viability of the pro-

posed interventions: (1) cost-benefit analysis and (2) cost-effectiveness analysis.

While cost-befit analyses present the outcome achieved by a nutrition intervention in mone-

tary units, cost-effectiveness-analyses portray welfare benefits in physical units, e.g. de-

crease in stunting (see The World Bank 1996). Even though cost-benefit-analyses are sup-

posed to be the most powerful economic tool to assess nutrition interventions, cost-

effectiveness-interventions can still give insights about the least costly way to achieve a spe-

cific objective, e.g. decreasing moderate stunting by 5%. A central advantage of cost-

effectiveness analyses compared to cost-benefit-analyses is that less data is required.

As the objective of this research project is not to tell whether at all the Indian Government

should invest in nutrition interventions, but to give insights in which intervention available

funds should be channeled, a cost-effectiveness analysis will be favored in this study.

Graph 11 Choice of assessment tool: Cost-benefit vs. cost-effectiveness analysis

Source: Own graph.

4.2. Cost-effectiveness-analysis – basic steps and target indicators

Some basic steps have to be done for every economic analysis, also the cost-effectiveness

analysis planned in this study (see The World Bank 1996). Those are:

Box 9 Basic steps in economic analyses

Estimate of the costs of each intervention option

Estimate of the effectiveness of each intervention option

Analysis of the relationship between costs and effectiveness

Source: Adopted from The World Bank 1996, p. 11.

The following graph demonstrates what this means in regard to the proposed comparative

nutrition intervention study.

Cost-benefit-analysis

Cost-effectiveness-analysis

Should the Indian Government at all invest in

more specific nutrition interventions?

In which nutrition interventions should the Indi-

an Government invest on a broader scale?

25

Graph 12 Basic steps in economic analysis for the proposed study

Source: Own graph.

Estimating costs needs to be done thoroughly, as the final recommendation for roll out of

one of the interventions under investigation will be highly dependent on the costs involved.

Besides the actual material costs (e.g. money needed to purchase MixMe supplements, ad-

ditional costs of preparing a lipid-milk based meal instead of rice etc.), social costs will be

considered, which may well be a crucial cost driver within the estimate. What time do AWC

workers and mothers have to invest to implement the proposed nutrition/health training, to

change the “rice” meal to a lipid-milk based meal or to provide the Moringa and MixMe sup-

plements to the children on a daily basis? A combination of material and social costs will lead

to the final cost estimate of each intervention. Moreover, economies of scale need to be

considered, as far as roll out options are concerned. Respectively, initial costs to produce

education materials are high, but this is only a one time investment. Afterwards paintings can

be copied and laminated for substantially lower costs. Those costs (not the initial production

costs) should be included in the calculations.

As the analysis will be done ex-post, the effectiveness will be determinable free of doubt.

How many percent did moderate stunting decrease within 2 years in the Moringa, MixMe,

lipid-milk meal and nutrition/health training group? How many percent did anemia decline?

These numbers will be pure evidence, totally reliable and without room to manipulate results.

The relationship of costs and effectiveness can be calculated easily, as the targets of all

interventions are the same. The following box describes the target indicators which shall be

analyzed within the cost-effectiveness study for each intervention:

What are the costs?

Material costs

Social costs (time)

? %

? %

? %

? %

? %

? %

? %

? %

? %

? %

? %

? %

? %

? %

? %

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

? €

What is the effectiveness?

e.g. decrease in stunting

e.g. decrease in anemia

e.g. proportion of newborns with

normal birth weight

What is the relationship

of costs and effectiveness?

e.g. costs per 1% less stunting

e.g. costs per 1% anemia reduction

e.g. costs per 1% more newborns

with normal birth weight

26

Box 10 Target indicators for the cost-effectiveness analysis

What are the costs to decrease stunting by 1%?

What are the costs to decrease wasting by 1%?

What are the costs to decrease undernutrition by 1%?

What are the costs to have 1% more children > 6 months with MUAC > 13.0 cm?

What are the costs to have 1% more newborn babies with normal weight?

What are the costs to decrease anemia by 1% (pregnant women and children)?

What are the costs to have 1% less cases of diarrhea?

What are the costs to have 1% less cases of fever?

What are the costs to have 1% less cases of acute respiratory infections?

What are the costs to have 1% less cases of vitamin A related eye deficiencies?

What are the costs to have 1% less cases of micronutrient related teeth deficiencies?

What are the costs to have 1% less cases of micronutrient related skin problems?

What are the costs to have 1% more children with a timely motor development?

What are the costs to have 1% more mothers who tell the health situation of their children is good?

The cost-effectiveness-analysis will be done after completion of the research project which is

planned for a duration of 2 years. The economic assessment will be carried out on a monthly

basis, displaying the discounted costs to meet a target indicator for 1 AWC. This means that

the Indian Government will know what are the monthly expenses per AWC to reduce stunting

amongst children under 6 years by 1%, if nutrition education is rolled out OR if Moringa sup-

plementation is rolled out OR if MixMe supplementation is rolled out OR if lipid-milk based

meals are introduced on 3 days a week. This exercise can be done for every indicator listed

above.

Table 3 Example how to calculate cost-effectiveness for a given indicator

Intervention 1 Intervention 2 Intervention 3 Intervention 4

Decrease in stunting after 2 years 10% 8% 8% 7%

Total costs (2 years) for 4 AWCs 20,000 € 20,000 € 10,000 € 12,000 €

Monthly costs per AWC 208 € 208 € 104 € 125 €

Money to be spent to decrease stunting by 1% in 1 AWC

20,80 € 26 € 13 € 17,80 €

Source: Own example.

In the example given above, intervention 3 would be most effective to decrease stunting and

should be recommended for scaling up (in a one indicator analysis). As several indicators will

be assessed, a weighing according to the priorities is possible to merge the single indica-

tors into an overall effectiveness indicator and give a final suggestion to the Government.

5. Expected outcomes

The research study will produce the following outcomes:

(1) Knowledge gain – some questions to be answered are:

Can the child’s nutrition/health situation be improved via training mothers?

Does child’s growth improve when children receive additional micronutrients?

Are lipid-milk based meals superior to blended foods with respect to a reduction in

stunting?

27

What are the costs involved in different interventions?

What intervention has the best effect regarding the investments made?

Can pregnant women be supplemented without causing danger during delivery (e.g.

increased maternal mortality)?

Do newborn children of supplemented women have a higher birth weight?

(2) Scientific papers – some paper to be published comprise the following:

Nutrition situation at Bolpur – maternal nutrition and child health

Impact of nutrition/health education at Indian AWCs on child growth, health and mo-

tor development - statistical findings cum cost-effectiveness analysis

Impact of MixMe supplementation at Indian AWCs on child growth, health and motor

development - statistical findings cum cost-effectiveness analysis

Impact of Moringa supplementation at Indian AWCs on child growth, health and mo-

tor development - statistical findings cum cost- effectiveness analysis

Impact of lipid-milk based meals at Indian AWCs on child growth, health and motor

development - statistical findings cum cost-effectiveness analysis

Does nutrition education, micronutrient supplementation or the provision of lipid-milk

based meals yield better results?

Are there significant differences concerning child growth, health and motor devel-

opment between children with commercial and plant micronutrient supplements?

A comprehensive cost-effectiveness analysis of all tested treatment approaches

Supplementing pregnant/lactating women – experiences from Bolpur

Effectiveness of nutrition/health training, micronutrient supplementation and milk

based meals in preventing micronutrient deficiencies and decreasing morbidity in

pre-school-children

(3) Conference participation/networking – some organizations to contact are:

Pratichi Trust (Amartya Sen’s research institute at Kolkata/Bolpur - India)

National Institute of Nutrition (India)

Copenhagen Consensus (looking for efficient ways to spend development money)

SUN Initiative (interested in mother and child health)

BMZ’s Task Force für Ernährungssicherung (nutriton in German development politics)

Conference on Hidden Hunger (Germany, University of Hohenheim)

(4) Recommendations for nutrition interventions – some actors to be advised may be:

Government officials of Bolpur Sriniketan Community Development Block, India

West Bengal Government, India

Central Government, India

Local and regional NGOs like (CINI, German Doctors,…)

6. Stakeholder’s of the study

An extensive network to implement the study does already exist. Critical success factors are

the following:

Reaching the target group – easily possible via the existing governmental AWCs, where

cooked food is given to pre-school-children and pregnant/lactating women 300 days a year.

28

Project picture 5 Viability of the research: target group reachable


Data collection - will be supported by Dr. Sujit Kumar Paul, lecturer at Visva-Bharati Univer-

sity of Santiniketan (department of Rural Development). He can provide talented students

who can be trained as interviewers and supervise the research. 3 students are already work-

ing with the project holder’s children hospital and trained to take weight, length and MUAC.

They do awareness trainings with the mothers and nutrition research with home visits. 7

more would be necessary to complete the study as proposed.

Project picture 6 Viability of the research: Investigators available


Project picture 7 Viability of the study: Medical doctor and health care facilities ready


http://www.visva-bharati.ac.in/

29

Health checkup and Hb determination – can be realized via the project holder’s “St. Mary’s

Child and Mother Health Care Centre”, located at Bolpur. Severely malnourished children

and be admitted and antenatal checkups for pregnant women can be done (all free of cost).

Dr. Med. Monika Golembiewski, a German pediatrician, has built up this hospital together

with her son and her daughter-in-law Silvia Golembiewski, who will be responsible to carry

out the proposed research. An ambulance car will be available to draw blood in the villages.

Practical experience – Monika Golembiewski has been working in the study area for the

last 19 years. Silvia joined her in 2007, when the first nutrition programmes were introduced.

This experience in running nutrition programmes with a mix of blended foods and milk-based

meals will help to organize the research project (e.g. recipe milk meal “Halwa”).

Project picture 8 Viability of the study: experience in running nutrition programmes


Recommendations to the Government – Development economist Jean Drèze, who is a

close colleague of Nobel Laureate Amartya Sen, is related to the project holders. He will be

open to support the work and may ask the Indian Government to listen the research findings.

Lately he undertook all efforts to bring the national “Food Security Bill” on the way.

Project picture 9 Viability of the research: Government recommendations will be heard


To conclude, the implementation of the proposed research project is viable and will shed light

on the crucial question of how to overcome counting high levels of child malnutrition in India.

30

8. Proposed research budget

Total research costs 91,317 €

A) Direct research costs 43,469 €

B) Data management 2,000 €

C) Transportation in India 2,086 €

D) International transportation 5,250 €

E) Research team allowances 37,300 €

F) Communication expenses 1,212 €

A) Direct research costs 43,469 €

1 76,800 packets MixMe supplement (for 128 children on 600 days) 0.20 € (production cost)

15,360 €

2 4 sets Nutrition training posters

Santal artist draws 20 pictures for 5 € each

XEROX Copy and lamination posters: 80 pictures, 2 € each

Expert to work out curriculum, 20 days, 70 € each

International flight for this expert

--

100 €

160 €

1,400 €

750 €

2,410 €

3 400 kg Moringa powder

2 gardeners arrange Moringa production, 60 days, 140 € each

2 international flights for the expert gardeners

2 villagers produce concentrate, 24 months, 36 € each

Materials like plastic foil, mosquito net for drying, plastic packets

8,400 €

1,500 €

1,728 €

500 €

12,128 €

4 288 Meals Milk based meals “Halwa” – per year

(128 children, 3 days a week for 24 months)

3,686.40 € 7,373 €

5 5560 copies Questionnaires and monitoring charts

1 person to work out the charts, 30 days, 8 € each

3200 copies intervention study (5 per child), 2 INR each

3000 copies baseline study (5 pages per HH), 2 INR each

240 €

91 €

86 €

417 €

6 4 sets Measurements instruments

5 digital weight machines, 100 € each

25 spare batteries, 1.50 € each

10 MUAC measurements, 3 € each

20 fixed height measurements, 45 € each

5 mobile length measurements, 38 € each

500 €

37.50 €

30 €

900 €

190 €

1,658 €

7 3220 Hb tests Hb blood control (laboratory test)

3,160 tests (128 children) intervention study, 0.40 € each

660 tests (600 HH) baseline study, 0.40 € each

2 lab technicians, 120 working days, 14 € each

Petrol ambulance car, 120 days, 4 € each

Driver ambulance car, 120 days, 3,50 € each

1,280 €

264 €

1680 €

480 €

420 €

4,124 €

B) Data management 2,000 €

1 1 unit Laptop 500 € 500 €

2 1 unit SPSS software packet 920 € 920 €

3 30 months Internet access 10 € 300 €

4 9 packets Stationeries

8 research assistants, each for 25 €

200 €

280 €

31

1 research coordinator, 80 € 80 €

C) Transportation in India 2,086 €

1 8 no. Bicycles (6 assistant researchers will work nearby Bolpur) 60 € 480 €

2 2 no. Motor scooters (2 assistant researchers will work little far away) 360 € 720 €

3 608 days Fuel scooters (2 assistant researchers, 0.8 € per day) 0.80 € 487 €

4 800 tickets Bus fare (40 rainy working days per year, 8 persons, 0.5 € each) 0.5 € 400 €

D) International transportation 5,250 €

1 5 flights Research coordinator (half yearly coordination in India) 750 € 3,750 €

2 2 flights Medical doctor (check up children start and end) 750 € 1,500 €

E) Research team allowances 37,300 €

1 10 persons Assistant researchers (for 25 months, 120 € monthly) 3,000 € 30,000 €

2 1 person Research coordinator (for 5 months, 900 € monthly) 4,500 € 4,500 €

3 1 person Medical doctor (40 days for check up, 70 € daily) 2,800 € 2,800 €

F) Communication expenses 1,212 €

1 11 persons Mobile phone expenses

1 Assistant researchers, 25 months, 3 € each

1 Research coordinator 5 months, 8 € each

750 €

40 €

790 €

2 31 meetings Meeting expenses (snacks, tea)

6 baseline meetings, 12 € each

25 intervention meetings (monthly), 14 € each

72 €

350 €

422 €

9. References

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th March 2013.

Das, Kallol (2013): Evaluation Report on food habits and Hygiene. Own survey in the project area of Bolpur, West Bengal.

Drèze, Jean and Sen, Amartya (2013): An Uncertain Glory – India and its Contradictions. New Delhi: Penguin Books.

FAO through Nawani, N.P. (1994): Indian experience on household food and nutrition security. URL: http://www.fao.org/docrep/x0172e/x0172e00.htm#TopOfPage, last accessed on 2nd October 2013.

Horton, S., Alderman, H. and Rivera, J.A. (2008): Copenhagen Consensus 2008 Challenge Paper - The Challenge of Hunger and Malnutrition. URL: http://copenhagenconsensus.com/sites/default/files/CP_HungerandMalnutritionCC08vol2.pdf. Last accessed on 2

nd October 2013.

McGuire J.S. (1996): The Payoff from Improving Nutrition. (Updated). The World Bank.

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nd October 2013.

http://www.fao.org/docrep/x0172e/x0172e00.htm#TopOfPage

http://copenhagenconsensus.com/sites/default/files/CP_HungerandMalnutritionCC08vol2.pdf

http://www.measuredhs.com/pubs/pdf/OD56/OD56.pdf

32

MoWCD (2009a): Integrated Child Development Services (ICDS) Scheme. URL: http://wcd.nic.in/icds/icds.aspx. Last accessed on 5th October 2013.

MoWCD (2009b): Revised Nutritional and Feeding Norms for Supplementary Nutrition in ICDS Scheme. URL: http://www.righttofoodindia.org/data/letter_stating_revised_nutritional_and_feeding_norms_for%20_supplementary_nutrition_in_icds_scheme2008.pdf. Last accessed on 19

th March 2013.

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nd October 2013.

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nd October 2013.

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nd October

2013.

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nd October 2013.

PMNCHb (2013): Knowledge Summary: Women’s and Children’s Health – The economic Benefit of investing in Women’s and Children’s Health. URL: http://portal.pmnch.org/downloads/high/ks24-high.pdf. Last accessed on 2

nd October 2013.

PMNCHc (2010): Knowledge Summary: Enable the Continuum of Care. URL: http://portal.pmnch.org/downloads/high/Knowledge_for_Action_KS2_highres.pdf. Last accessed on 2

nd October 2013.

SUN (2013): Why nutrition? URL: http://scalingupnutrition.org/about/why-nutrition. Last accessed on 2

nd October 2013.

Supreme Court (2011): Issues in the implementation of ICDS in India. Letter to Secretary Ministry of Women and Child Development from the Commissioners to the Supreme Court in the Right to Food Case, Dr. N.C.Saxena and Harsh Mander, 7 February 2011. URL: http://www.righttofoodindia.org/data/icds/March_2012_letter_to_secretary_women_and_child_development_sc_commissioners_7_february_2012.pdf. Last accessed on 19

th March 2013.

The Cochrane Collaboration through Lazzerini, M., Rubert, L. and Pani, P. (2013): Specially formulat-ed foods for treating children with moderate acute malnutrition in low- and middle-income coun-tries (Review). The Cochrane Library 2013, Issue 6.

The Lancet Series (2008): Maternal and Child Undernutrition. URL: http://www.thelancet.com/series/maternal-and-child-undernutrition. Last accessed on 18

th March

2013.

The World Bank (1996): The Economic Analysis of Nutrition Projects - Guiding Principles and Exam-ples. URL: http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/0,,contentMDK:20186688~menuPK:495830~pagePK:148956~piPK:216618~theSitePK:282575~isCURL:Y,00.html. Last accessed on 4

th October 2013.

The World Bank (2005) through Gragnolati, M., Shekar, M., Das Gupta, M. Bredenkamp, C. and Lee, Y.-K.: India’s Undernourished Children: A Call for Reform and Action. URL: http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546-1147272668285/IndiaUndernourishedChildrenFinal.pdf. Last accessed on 5

th October 2013.

UNICEF (w.y.): Child Undernutrition in India: A Gender Issue. URL: http://www.unicef.org/india/reallives_5901.htm. Last accessed on 5

th October 2013.

USAID (w.y.): Child and Maternal Nutrition in India (Factsheet). URL: http://pdf.usaid.gov/pdf_docs/PNADM627.pdf. Last accessed on 5

th October 2013.

WDR (1993): Investing in Health. The World Bank: Washington, D.C.

WFP (2007): The Cost of Hunger Analysis of the Social and Impact of Child Undernutrition in Latin America: Central America and the Dominican Republic – Summary. URL:

http://wcd.nic.in/icds/icds.aspx

http://icmr.nic.in/final/RDA-2010.pdf

http://www.nutritionfoundationofindia.res.in/pdfs/About-and-Others/4-PAPER.pdf

http://nutritionfoundationofindia.res.in/NutritionTransition.asp

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http://portal.pmnch.org/downloads/high/ks24-high.pdf

http://portal.pmnch.org/downloads/high/Knowledge_for_Action_KS2_highres.pdf

http://scalingupnutrition.org/about/why-nutrition

http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/0,,contentMDK:20186688~menuPK:495830~pagePK:148956~piPK:216618~theSitePK:282575~isCURL:Y,00.html



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http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546-1147272668285/IndiaUndernourishedChildrenFinal.pdf

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33

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nd October 2013.

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