This presentation by Suman Chakrabarti, IFPRI was shown at the Transform Nutrition - Evidence for Action regional meeting in Kathmandu, Nepal on 8 July 2017. This one-day event shared Transform Nutrition evidence on key issues related to nutrition policy in Nepal, Bangladesh and India, lessons on strategies for change from other contexts and discuss the relevance and applicability of the research findings to policies/programmes that aim to address nutrition in South Asia.

1. Strengthening nutrition-sensitivity of social
protection programs in India
Suman Chakrabarti with
Kalyani Raghunathan, Purnima Menon and
Harold Alderman

2. The WHA targets for nutrition –
is India on track?
Notes: Targets based on author’s estimate.
No data on child overweight in 2016 were available from the NFHS 4. Reported
figure is from a pooled sample of AHS and DLHS4 weighted by population.

3. Basic features of Right to Work and Right to
Food programs in India
Feature Right to work Right to food (NFSA)
MGNREGA TPDS MDMS
Mandated/reformed in 2005 2013 2013
Eligible population All rural households AAY, BPL and APL
families
Children aged 6-
14 in government
and government-
aided schools
Basic provisions 100 days of unskilled manual
work per household per year,
at a govt. specified minimum
wage
5 kg per person per
month of rice, wheat
and coarse cereals
available through ration
shops at 3/2/1 rupees
per kg, respectively.
A free lunch at
school providing
12 grams of
protein and 450
calories per child
per meal.
Nutrition oriented
actions/interventions
introduced
No Yes, fortification and
diversification of the
food basket
Yes, fortification,
diversification of
food provided,
deworming and
micro-nutrients

4. A framework for maximizing nutrition
sensitivity
Ruel and Alderman (2013) outline three approaches that social
protection programs can take to have a greater impact on
nutrition, i.e. be more ‘nutrition-sensitive’.
1.addressing the underlying determinants of fetal and childhood
nutrition and development
2.incorporate specific nutrition goals and actions
3.serve as delivery platforms for nutrition-specific interventions

5. Applying the framework –
Public Distribution System
1. The basic mandate: improve food security
Ensure that the scheme reaches the intended target population with low levels of leakage.
Coverage of the Targeted Public Distribution System by consumption expenditure
quintiles and years (NSS-CES)

6. Public Distribution System
1. Fulfill the basic mandate first!
2. Specific nutrition goals :
Subsidize pulses? Chakrabarti, Kishore & Roy (2016) find that impact is
positive but small on total pulses consumed.
Fortification of cereals? Raghunathan, Chakrabarti, Kishore, Scott (2017-
ongoing) find that impact on anaemia is positive in Tamil Nadu but none
in Punjab.
3. Make ration shops delivery platforms for ORS, DFS and nutrition BCC
for improved IYCF practices? – no studies found

7. Applying the framework –
The Mid-day Meal Scheme
1. The basic mandate: improve food and nutrition intake in schools and
increase attendance.
Routinely monitor and focus on nutritional content, hygiene, and
infrastructure (Shukla 2014, Planning Commission 2010, Chhabra & Rao
2014)
Coverage of the Mid-day meal scheme by gender and years (NSS-CES)

8. The Mid-day Meal Scheme
1. Fulfill the basic mandate first!
2. Specific nutrition goals :
Fortification of cereals? – Evidence suggests impact is positive on
outcomes studied (Fiedler et al. 2012, PATH 2009, Paithankar et al. 2015,
Bhagwat, Gulati, et al. 2014, Bhagwat, Sankar, et al. 2014)
Double fortified salt? – Potential for being cost-effective (Horton et al.
2011)
3. Make schools delivery platforms for deworming, IFA, and vitamin A
supplementation for children? Already in MHFW portfolio but evidence
on impact in thin (Gopaldas 2005, Bobonis et al. 2006).

9. Applying the framework –
The MGNREGA
1. The basic mandate: improve household income and protect against
adverse events.
Reduce leakage and ensure timely payments.
More research required impact on incomes, household food security,
dietary diversity and nutrition
Demand and coverage of the Mahatma Gandhi National Rural Employment
Guarantee Scheme (2011-2012) (NSS-EUS)

10. The MGNREGA
1. Fulfill the basic mandate first!
2. Specific nutrition goals :
-Construction of wells to improve access to safe drinking water.
-Construction of toilets to reduce open defecation.
-MGNREGA employees can be employed as cooks and helpers in
the MDMS, caregivers in crèches and housekeepers in primary health
centers to address labor shortfall.
3. Use MGNREGA to deliver maternity benefits (cash transfers)
A MGNREGA maternity benefit would allow women to be compensated
for lost wages from time off work, enabling exclusive breastfeeding and
discouraging pregnant women from engaging in risky manual labour.

11. A synthesis of the framework
Approach one Approach two Approach three
Address the underlying
determinants
Incorporate specific
nutrition goals and
actions
Delivery platforms for
nutrition-specific
interventions
| | |
Public distribution system _____
Openness in targeting,
administrative reform, and
technological upgrades.
Cash transfers in some
critical areas
Cereal fortification or
adding pulses
Make oral rehydration salts
(ORS), DFS, sachets for
home fortification of food
available at fair price shops
| | |
Mid-day meal scheme _____
Routinely monitor at the
state level or district level,
focus on nutritional
content, hygiene, and
infrastructure, and ensure
that delivery meets
government norms
Cereal fortification, double
fortified salt, or add
fruits/eggs
Deworming, vitamin A and
iron tablets
| | |
Mahatma Gandhi national
rural employment
guarantee scheme (act)
_____
Reduce leakage and ensure
timely payments
Construction of toilets
within the village, employ
workers in MDMS as cooks
and helpers and set up
crèches at worksites
To provide a maternity
benefit during the 1000 day
window

12. But how much will it cost?

13. Key takeaways
• Strengthening service delivery: All interventions have problems in
implementation ranging from corruption, to not adhering to quality
standards, to ensuring pro poor access.They must be addressed first.
• Innovations: The use of flagship programs as delivery platforms emerges as
a natural choice.Additions to existing platforms could include subsidizing
new food items such as fruits, pulses and fortified cereals or even
convergence between programs with specific goals.
• Systems of monitoring and evaluation need to be imbedded as routine
practices for all interventions.
• Final policy actions must be based on rigorous cost-benefit analyses of all
possible options for maximum impact and lowest cost.

14. Thank you

15. But how much will it cost?
Intervention
Estimated program cost in
2014
(per year)
Estimated
intervention/action cost for
2014
(per year)
Estimated
additional cost
as a percentage
=(3)/(1)*100
US$ million
(1)
`000 crore
INR
(2)
US$ million
(3)
`000 crore
INR
(4)
Diversification of food baskets
Pulses through TPDS 16,744 109 3200.7 20.8 19.12
Bananas through MDMS 3,906 25 213.1 1.4 5.46
Eggs through MDMS 3,906 25 778.8 5.1 19.94
Fortification
TPDS
Wheat fortification through TPDS using large
roller mills
4,722
31
13.0
0.1
0.27
Wheat fortification through TPDS using chakki
plants
4,722
31
16.2
0.1
0.34
Rice fortification through TPDS using cold
extrusion
12,022
78
586.6
3.8
4.88
MDMS
Wheat fortification through MDMS using large
roller mills
3,906
25
9.1
0.1
0.23
Rice fortification through MDMS in centralized
kitchens
3,906
25
38.4
0.2
0.98
Double Fortified Salt through MDMS 3,906 25 31.7 0.2 0.81
Anthelmintics and micronutrients
Deworming, vitamin A and iron tablets provided
through MDMS
3,906 25 44.2 0.3 1.13