Koraput and Angul, Odisha: Mild winter sunlight streamed through the banyan trees under which Dhana Anjaria sat cross-legged with two other pregnant women of Dumuriput village in Koraput district, 500 km west of state capital Bhubaneswar. They were listening with rapt attention to tips on nutrition for pregnant women.

Monomita Nag, 35, a community resource person (CRP), was instructing the group on the importance of dietary diversity using a booklet coloured orange, green and white. These are the colours of the tiranga (the Indian flag), but Anjaria, who knew the booklet by heart, had decoded other meanings from it. “Orange is for milk, egg, meat and pulses, white for roots, tubers and cereals, and green is for vegetables,” said Anjaria, 21, seven months pregnant with twins.

Anjaria had conceived within the first year of marriage. She could have been among half of all Indian women who are anaemic, and one-fifth who are thin. But she is neither, and also confident that her children will be born healthy.

The nutrition advice she was getting from Nag started long before her pregnancy. It began during a meeting she had with Nag as a newly-wed along with her husband. Anjaria’s mid-upper arm circumference (MUAC) -- used as a rapid assessment of her nutritional status -- measured 22cm. (An MUAC under 23 cm indicates risk of malnutrition in women.)

Anjaria followed Nag’s advice, went from eating twice a day to four times, including non-vegetarian foods, and also started resting more. She was particular about not skipping her calcium or iron folic acid tablets. Over months, her weight increased from 41 kg to 54 kg.

Nag conducts monthly meetings in the village of self-help groups on microfinance activities as a part of the Odisha Livelihood Mission, started in 2006, its an autonomous body under the panchayati raj department that implements diversified livelihoods to reduce rural poverty.

Women’s collectives have proved effective in driving nutritional outcomes earlier too -- the idea has been implemented along with economic empowerment through community conditional cash transfer programmes in Indonesia, Bangladesh and Nepal.

In India, this strategy was adopted in Kerala’s Kudumbashree programme, Andhra Pradesh’s Society for Elimination of Rural Poverty Project , in parts of Telangana and Jamkhed (Maharashtra) too. “Without health, livelihood [programmes] cannot work,” said Saroj Kumar, block project manager, OLM, Angul. “Most poor lose a lot of money in [buying] medicines. When they save this money, they can save it or use it for income generation.”

IndiaSpend visited Koraput and Angul districts to understand how it Swabhimaan is being implemented as a part of OLM and to study its impact. We found behavioural change and increased knowledge about health and nutrition among adolescents and women in villages covered by the project.

Why self-help works

A cluster-level meeting of community resource persons at the Handapa gram panchayat office in Angul district of Odisha. Self-help groups have become critical instruments of change in the state.

Self-help groups have become critical instruments of change in Odisha: It is the first state to use these to reduce poverty through the National Rural Livelihood Mission -- there are 3,85,382 such groups in the state with 4.1 million members and they reach 2.8 million households. Generally, each household has at least one woman member of a self-help group and there are 10-12 such groups in each village.

Since 2016, Nag has been working as a poshan sakhi (nutrition buddy), trained to conduct meetings and hold awareness activities to improve the nutritional status of adolescent girls and women. Nag is a part of the Swabhimaan programme — an umbrella of community-led interventions across Bihar, Chhattisgarh and Odisha.

Working in four districts across these states -- Purnea (Bihar), Bastar (Chattisgarh) Koraput, Angul (Odisha) -- the programme reaches over 356 villages and 1,25,097 households. Till now, 5824 girls and women have benefitted from the programme in 39 gram panchayats of Odisha.

Swabhimaan’s focus is on adolescent girls, newly-wed couples, pregnant women and mothers of children younger than two, groups that are most vulnerable to malnutrition. The aim is to improve nutritional intake, reduce instances of anaemia, increase the demand for health services, improve sanitation and hygiene and prevent unwanted pregnancies.

Poshan sakhis conduct monthly gatherings called maitri baithak (friendship meet) with newly- wed couples and adolescents to deal with these health and nutrition targets. They also help local women set up kitchen gardens that can help improve the family’s dietary diversity.

The benefits of the programme are measured through a randomised control trial—where the impact is measured by comparing two groups, one benefiting from the intervention and the other not covered by it, in research parlance called the “control arm”.

A midline survey conducted in 2018 in Angul and Koraput districts among 1191 adolescent girls, 614 pregnant women and 1183 mothers of children under two years, showed improvements in several areas: Increased use of sanitary napkins among adolescents, their re-enrollment in schools, improved diet -- and increased intake of iron and folic acid tablets -- among pregnant women and greater participation in community health and sanitation events.

The full impact of the work will only become visible after the endline survey in 2020.

“Most of the poverty alleviation initiatives have not been properly scrutinized enough to gauge its impact on issues of women's empowerment and nutrition,” said Babita Mahapatra, Additional CEO (Operations), State Mission Management Unit, Odisha Livelihoods Mission. This is why Swabhimaan is a fitting platform to layer women's nutrition initiatives which are being implemented, she said.

Poshan sakhis also encourage women to attend village health and nutrition days (VHND) --also known as Mamta Diwas or Mother’s Day--when they are screened for anemia and blood pressure, weighed and given calcium and iron folic acid tablets. These events are undertaken jointly by accredited social health activists (ASHA), auxiliary nurse midwives (ANM) of health department and anganwadi workers (AWW) of women and child development department.

“There is an advantage in having poshan sakhis deliver the programme -- they live in the same villages as the participants while ASHAs and ANMs are often live elsewhere,” said Meena Khora, master book-keeper--in-charge of maintaining OLM records in the gram panchayat. “This helps them in attending to the needs of the women, taking them to the PHCs etc,” she said.

Across the three states, State Livelihood Missions, in this case, OLM, anchor the programme with the departments of health, civil supplies (for public distribution system), social welfare, agriculture and public health engineering. The technical and financial support for the programme is provided by UNICEF, which is also involved in capacity building.

‘I’ll marry after I get my PhD’

“Our bodies are still growing in the teens; getting married and having children when our bodies aren’t fully grown is not good,” said Harpriya Behra, 18, (centre), secretary of the kishori samooh or adolescent girl group formed as part of the Swabhimaan scheme.

When Rima Rani Behera was 16, her parents arranged for her to marry a 26-year-old man. Three days before her wedding, Behera managed to stall the rituals by calling her cousin who brought in the police. “I had told them that I do not want to marry, I want to study but they didn’t listen,” said Behera, now with her uncle in Dumuriput and dreaming of becoming a police officer. She could not continue her education because her parents would not allow her to collect her school leaving certificate after class 10 and threatened to get her married by age 18.

In Koraput, one in every three women (34%) in the 20-24 age category is married off before age 18 -- a 13 percentage point higher incidence than Odisha’s average -- as per the National Family Health Survey (NFHS-4) data.

“Our bodies are still growing in the teens, getting married and having children when our bodies aren’t fully grown is not good,” said Harpriya Behra, 18. She is the secretary of the kishori samooh or adolescent girl group formed as a part of the Swabhimaan project to spread awareness about sanitation, health and nutrition.

The lives of young women here have changed in other ways. “We used to use cloth pads before, it was uncomfortable but we didn’t know any better,” said Sumitra Khillo, 22. Now women get pads from ASHA and ANM workers though, they complained, there are not enough to last the entire menstrual cycle. The practice of keeping women out of the house during the menstrual cycle too is changing slowly, we found.

Some entrenched beliefs have yet to change. Though most households have latrines, villagers often defecate in the open. “It is too small, I don’t like using it,” said one teenager of the toilet in her home, adding that three of her relatives also do not use the toilet.

Most of the girls in the village travel by bus to schools and colleges but have had to negotiate with their parents for the freedom. “We know why we must marry after 18,” said Behra, 18, secretary of the committee, and clearly the leader of the group. “[But] I will get married at 30, after I get my PhD.”

The poshan sakhis we spoke to pointed out that it was hard for young girls to upset their families by insisting that weddings be put off till age 18 but in most instances parents agreed. “It was common for girls to marry at 16 and 17 here,” said Nag. “But in the last few years, this is changing. Even if the girls marry 18, they want to wait till 20-21 to have children.”

After the Swabhimaan intervention, 39 adolescents in two blocks of Pallahara and Koraput sadar rejoined schools, according to the midline survey shared by UNICEF. Also there was a decrease in the number of adolescents living in homes where open defecation was practised and an increase in the number of teens consuming iron folic acid tablets and taking their own decisions on education and expenditure.

However, there was a drop in the number of adolescents who thought they could decide who to marry and reported dietary diversity.

Also, similar trends of improvement showed up in both areas with and without intervention in many indicators. This is because Pallahara and Koraput blocks where the study was undertaken are categorised as intensive gram panchayats -- getting more focussed government attention -- where all ongoing welfare schemes are doing well, said Sourav Bhattacharjee, nutrition specialist, UNICEF, Odisha.

Source: Swabhimaan Programme, midline survey results.

Insisting on being heard

Monomita Nag demonstrates how micro-planning meetings are conducted. This involves an annual discussion spread over around 12 days across three months on issues that the women wish to prioritise.

An example from Kaliakota, a village with 1439 residents in Handapa gram panchayat of Angul district, showed why it is critical for communities to engage with health, nutrition and sanitation. For a year, the pregnant women and lactating mothers of Kaliakota did not receive any iron folic acid tablets, putting their health at risk. There had been no VHND and no antenatal check-ups either because the assigned ANM had died and not been replaced.

The community then sat together and discussed the health, nutrition and sanitation challenges facing them as part of a micro-planning exercise. This involves an annual discussion spread over around 12 days across three months on issues that the women wish to prioritise. This could be the availability of latrines, access to public distribution system or drinking water or iron folic acid tablets.

When Kaliakota’s women spoke of their problems, their CRP took their concerns to the block development officers who then assigned an ANM for the village. These meetings bring together on the same platform officials of the public distribution system, women and child development and health department to find solutions.

In another case, sanitary napkins, available at the community health centre, could not be brought to the school in Pallahara block in Angul because there was no money for it. A meeting threw up a solution -- the napkins would be transported with public distribution supplies.

Micro-planning also increases the demand and utilisation of public services, showed the midline survey. For example, mothers living in households with access to public distribution system increased in the intervention arms from 68% in 2016 to 99% in 2018; and those who received supplementary food went up from 66.7% to 96.7% in the same period.

Kitchen gardens: Nutrition at no cost

Saibalini Amanta, a poshan sakhi, collected several vegetables and fruits from Pradhan’s garden and put them on a plate to explain to Pradhan why she, seven months pregnant with her second child, needed to have an array of homegrown vegetables—moringa leaves, green papaya, lemons, chillies and cauliflower.

A fresh crop of cauliflowers was waiting to be harvested in the two-acre farm behind 22-year-old Tikina Pradhan’s home in Kishorenagar, Angul district. Saibalini Amanta, a poshan sakhi, collected several vegetables and fruits from Pradhan’s garden and put them on a plate to explain to Pradhan why she, seven months pregnant with her second child, needed to have an array of homegrown vegetables—moringa leaves, green papaya, lemons, chillies and cauliflower.

“We had everything, but we didn’t know how to have a balanced diet,” said Pradhan. She now has a varied diet of eggs, meat and green vegetables supplemented by calcium and iron supplements, as instructed by Amanta.

While Amanta already had a vegetable farm, most women in self-help groups are encouraged to grow vegetables in their own backyards to ensure food-security and dietary diversity. Given the fertile soil and availability of water, most of the households in Angul had patches of vegetables before, but they were often grown without much thought to it.

“Earlier women grew only brinjals or only cauliflowers, now they are growing all kinds of fruits and vegetables,” said Amanta. Also, most of the nutrigardens are organic without any chemical fertilisers or compost.

There was a 5.9 percentage point reduction in pregnant women worried about insufficient food in from 2016 to 2018, as per the survey. Also there were more women in 2018 than 2016 consuming a variety of foods and having at least three meals a day.

Source: Swabhimaan Programme, midline survey results.

Update: The story has been updated to include the views of Babita Mahapatra, Additional CEO (Operations), State Mission Management Unit, Odisha Livelihoods Mission.

(Yadavar is special correspondent with IndiaSpend/Healthcheck)

This report has been supported by ROSHNI-Centre of Women Collectives Led Social Action.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.