Bihar: The Paradoxes Of Innovation And Malnutrition

Bihar has one of the highest burdens of undernutrition among women and children in India.  According to the NFHS-4, in 2015-16, almost 48% of children under 5 in the state were stunted, which is the highest for India.  The survey also shows that over the decade (between 2005-06 to 2015-16) Bihar made some gains in nutrition: Stunting prevalence declined from 55.6 percent to 48.3 percent, the prevalence of wasting declined from 27.1 percent to 20.8 percent and severe wasting declined from 8.3 percent to 7 percent. The prevalence of low birth weight declined from 27.6 percent to 15 percent. The percentage of children who were breastfed within the first hour after birth increased from 4 percentage to 34.9 percentage. The proportion of infants under six months who were exclusively breastfed increased considerably from 28 percent in 2006 to 53.5 percent in 2016.  In spite of these mixed results, there are reasons to be optimistic; several innovations piloted in Bihar have been included in the government’s recently launched scheme for nutrition, POSHAN Abhiyan. 

The initial avatar for Common Application Software (CAS), job-aid for service delivery was piloted in Bihar in a few blocks.  Under POSHAN Abhiyan, CAS will now be scaled across the entire 1.3 Million Anganwadi Centre’s across India over the next few years including all 38 districts in Bihar that are covered by the scheme.  Another aspect of POSHAN Abhiyan, the capacity development of the Anganwadi Workers by their supervisors using the existing meeting platforms, through the Incremental Learning Approach (ILA) for nutrition has been developed from lessons in Bihar and it was also one of the initial states to have adopted community-based events like Annaprashan (starting kids on solid/semi-solid food after six months of age) and Godbharai (focusing on health and nutrition counselling for pregnant women).  The Bihar state JEEViKA (State Rural Livelihood Mission) has been a front leader on strengthening age-appropriate feeding practices among the most marginalized communities for children under two years of age. 

The second reason for optimism around nutrition in Bihar is that the state is taking a systems approach to nutrition: Health Systems, Community Systems and Food Systems that acting together can break the intergenerational cycle of malnutrition.  Health Systems are being strengthened with better antenatal care (during pregnancy); higher numbers of institutional deliveries; and better care of infants, for example through increased immunization coverage.  Currently these platforms are not being used well for nutrition interventions that is a missed opportunity. The improvement of these systems is good for nutrition (and other) interventions in the near future.  Most direct nutrition interventions have to be delivered through these same platforms and through the same service providers, so in the coming years, they can be used to focus on nutrition interventions like iron folic supplementation, breastfeeding as well as age-appropriate feeding. 

Under the community systems drive, the scale up of Self Help Groups (SHGs) in Bihar and their focus on promoting age-appropriate feeding practices is promising.  JEEViKA, as mentioned above, is scaling up this nutrition work across Bihar by integrating nutrition in the entire SHG movement in the state.  The focus on the Food Systems in Bihar will have a positive impact on nutrition outcomes with a greater emphasis on the agriculture-nutrition linkage and access by the most marginalized communities to a diverse basket of food. 

Bihar can also look to past success stories in public health and nutrition in the state for inspiration.  Its fight against Polio, increase in the Routine Immunization coverage levels, as well as high coverage achieved in the past for Vitamin A are a few of the success stories.  We have seen the Health and ICDS systems jointly deliver on these programs, and the same machinery can also deliver on nutrition, especially now that nutrition is a high priority both at the state and national level. 

There must be strong accountability for quality implementation and as we learnt in the cases of polio, routine immunization or vitamin-A programs in Bihar, what gets reviewed with strategic use of data specially at the district level gets implemented well at the grass root level.