2. day 1 session 2 causes and systems thinking
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The document discusses India's pressing nutrition-related challenges, highlighting high rates of undernutrition, obesity, and non-communicable diseases as major risks to social and economic progress. The findings from various reports underscore the need for integrated actions on nutrition to meet Sustainable Development Goals by 2030, emphasizing the importance of understanding malnutrition's immediate and underlying causes. It also explores systems thinking as a vital approach to addressing these issues by breaking silos in administration and fostering collaborations for effective interventions.
![Optimal maternal and child
nutrition and development
Nutrition-specific
interventions
• Adolescent and
preconception nutrition
• Maternal dietary
supplementation
• Multiple micronutrient
supplementation or
fortification
• Breastfeeding and
complementary feeding
• Diet supplementation
for children
• Dietary diversification
• Feeding behaviours
and stimulation
• Treatment of severe
acute malnutrition
• Disease prevention and
management
Nutrition sensitive
interventions
• Agriculture & food
security
• Social safety nets
• Early child development
• Women’s
empowerment
• Child protection
• Education
• Water and sanitation
• Health & family
planning services
Adapted from Lancet 2013
6. What are the causes and possible interventions? [
a few of them!]
Breastfeeding,
nutrition-rich
foods
Feeding
and
caregiving
practices
Low burden
of infectious
diseases
Food
security
Feeding
and
caregiving
resources
Health
services,
safe and
hygienic
environm
ent
Basic causes](https://image.slidesharecdn.com/2-181221053042/85/2-day-1-session-2-causes-and-systems-thinking-22-320.jpg)
![8. What are the roadblocks to
systems thinking in administration?
1. Systems are abstract[butterfly, MSP]
2. Linear thinking[field staff]
3. Position identity[govt litigation]
4. Event fixation[NH roadblock, rail
accidents]
5. Boiled frog [Delhi, “beneficiary”]
6. Experience /anecdotal evidence is right
7. Choice architecture[asha payments]
8. Predecessor bias](https://image.slidesharecdn.com/2-181221053042/85/2-day-1-session-2-causes-and-systems-thinking-35-320.jpg)
![9. How can one break silos in
administration?
1. Identify system-
2. Learn the skills- handouts
3. Build coalitions [sonam wangchuk,
ekta]
4. Build shared vision: Joint
monitoring, tours, SOPs, training,
materials [cogs]
5. Get feedback[mahindra and](https://image.slidesharecdn.com/2-181221053042/85/2-day-1-session-2-causes-and-systems-thinking-36-320.jpg)
![Systems thinking and us… a recap
Visualise big picture, not schemes
“Systems thinking is a vantage point from which
you see a whole, a web of relationships, rather
than focusing only on the detail of any particular
piece. Events are seen in the larger context of a
pattern that is unfolding over time.”
Understand the nuts and bolts, cogs and
wheels, AND their interactions [
repayments for housing loans]](https://image.slidesharecdn.com/2-181221053042/85/2-day-1-session-2-causes-and-systems-thinking-38-320.jpg)
![ Think ahead….. Implications of actions
“we learn from experience but never
experience the consequences of our
decisions”
Keep the objective in centre[ the child]
Understand system architecture
Build shared vision across
Create institutions that are synergistic
Work by design, not default](https://image.slidesharecdn.com/2-181221053042/85/2-day-1-session-2-causes-and-systems-thinking-39-320.jpg)
2. day 1 session 2 causes and systems thinking
- 1. BREAKING THE SILOS- SYSTEMS THINKING AND THE CASE OF NUTRITION Arti Ahuja, Phase 3, April 2018
- 2. Burden of Disease Study 2017 are akin to national emergencies as these have the potential to significantly blunt the rapid social and economic progress to which India aspires. The findings of the study reveal that three types of risks Undernutrition, Air pollution, and a group of risks causing cardiovascular disease and diabetes 1.What are the reports saying?
- 3. 3 Global Hunger Index 2017 Proportion of undernourished in India = 14.5% India trails North Korea, Bangladesh in Hunger Index India ranked 100th among 119 countries on Global Hunger Index (GHI) 2017...
- 4. 4 Global Nutrition Report 2017 Global Nutrition Report 2017: India Carries a Serious Burden of Anemia, Obesity and Malnutrition Urgent need to integrate our actions on nutrition if India hopes to meet its Sustainable Development Goals Agenda 2030.
- 6. -2 -1,75 -1,5 -1,25 -1 -0,75 -0,5 -0,25 0 0,25 0,5 0,75 1 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 Age (months) Z-scores(WHO) Weight for age (WAZ) Weight for length (WHZ) Height for age (HAZ) Source: Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics, 2010 (Feb 15 Epub ahead of print) Worldwide timing of growth faltering, 54 countries 6
- 7. Fig 3. Categories of length-for-age stratified by exact month of age and site. MAL-ED Network Investigators (2017) Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of life: The MAL-ED longitudinal birth cohort study. PLOS Medicine 14(10): e1002408. https://doi.org/10.1371/journal.pmed.1002408 http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002408
- 8. 8
- 9. Immediate causes of poor nutrition for children Food • Breastfeeding • Complementary feeding • Limiting non- nutritive foods Care • All activities that assure that family food, health and other resources reach the child • Attention to the child, care arrangements • Responsive feeding • Psychosocial stimulation Health • Preventive and curative health care • Assurance of a healthy and clean environment • Maternal health and well-being
- 10. 3. How do we measure malnutrition?
- 11. Children < 5 years of age • Stunting: child <5 years of age is too short for their age—a result of chronic undernutrition (more than 2 standard deviations below median in a healthy population) • Wasting: child <5 years of age has weight too low for their height—a result of acute undernutrition (more than 2 standard deviations below median in a healthy population) • Underweight: child <5 years of age has weight too low for their age—from either chronic or acute undernutrition (more than 2 standard deviations below median in a healthy population) • Overweight: child < 5 years of age has weight too high for height (more than 2 standard deviations above median in a healthy population) The ways malnutrition is most frequently referred to in major reports 11
- 12. 12
- 13. 13
- 14. Wasting and Stunting 14 38.4% children (<5y) in India are stunted 21 % of children (<5y) in India are wasted
- 15. Response depends on the measure we use STUNTING (CHRONIC) NORMAL WASTING (ACUTE) Low height for age Low weight for height Low MUAC
- 16. Trends in key global nutrition targets and nutrition outcomes in India, 2005-06 to 2015- 16 48 19.8 55 46.4 21.5 38.4 21 53 54.9 18.6 0 10 20 30 40 50 60 70 Stunting Wasting Anemia among women Exclusive breastfeeding Low birthweight 2005-06 2015-16 Source: NFHS-3; NFHS-4 and RSOC for low birth weigWorld Health Assembly Nutrition Target Level
- 17. 4. What is the district wise prevalence? ….Stunting (among children <5 years), 2016 Source: NFHS-4. Top 10 districts Bottom 10 districts Ernakulam (KL) 12.4% Pathanamthitta (KL) 13.3% Kollam (KL) 14.4% Alappuzha (KL) 14.5% Idukki (KL) 15.1% Cuttack (OR) 15.3% Hyderabad (TG) 15.7% Puri (OR) 16.1% South Garo Hills (ML) 16.8% Kanniyakumari (TN) 17.2% Yadgir (KA) 55.5% Koppal (KA) 55.8% Sitapur (UP) 56.4% Gonda (UP) 56.9% Sitamarhi (BR) 57.3% Siddharthnagar (UP) 57.9% Pashchimi Singhbhum (JH) 59.4% Balrampur (UP) 62.8% Shrawasti (UP) 63.5% Bahraich (UP) 65.1%
- 18. …and in what kind of households?
- 19. Wasting (among children <5 years), 2016 Source: NFHS-4. Top 10 districts Bottom 10 districts Mokokchung (NL) 1.8% Aizawl (MZ) 2.3% Peren (NL) 4.1% Badgam (JK) 4.2% Ganderbal (JK) 4.6% Imphal West (MN) 4.7% Kupwara (JK) 5.1% Samba (JK) 5.2% Anantnag (JK) 5.4% Lunglei (MZ) 6.1% Lalitpur (UP) 39.0% Uttarkashi (UT) 39.4% Nandurbar (MH) 39.8% Purbi Singhbhum (JH) 40.6% Dumka (JH) 41.4% Khunti (JH) 43.0% The Dangs (GJ) 43.0% Gadag (KA) 43.1% Gadchiroli (MH) 45.8% Tehri Garhwal (UT) 46.9%
- 20. Emerging challenges: Nutrition-related non-communicable diseases 13.4 18.6 7.98.8 20.7 5.8 0 10 20 30 40 50 60 70 High blood pressure Overweight/Obesity High sugar level % Men Women Source: NFHS-4
- 21. Let us identify the immediate and underlying factors u
- 22. Optimal maternal and child nutrition and development Nutrition-specific interventions • Adolescent and preconception nutrition • Maternal dietary supplementation • Multiple micronutrient supplementation or fortification • Breastfeeding and complementary feeding • Diet supplementation for children • Dietary diversification • Feeding behaviours and stimulation • Treatment of severe acute malnutrition • Disease prevention and management Nutrition sensitive interventions • Agriculture & food security • Social safety nets • Early child development • Women’s empowerment • Child protection • Education • Water and sanitation • Health & family planning services Adapted from Lancet 2013 6. What are the causes and possible interventions? [ a few of them!] Breastfeeding, nutrition-rich foods Feeding and caregiving practices Low burden of infectious diseases Food security Feeding and caregiving resources Health services, safe and hygienic environm ent Basic causes
- 23. Immediate causes: poor infant feeding in India, 2006-2016 Source: Progress and inequalities in infant and young child feeding practices in India between 2006-2016 Nguyen, P.H., R. Avula, D. Headey, L.M. Tran, M.T. Ruel and P. Menon. (Paper under review) 55.2 15.2 41.8 8.7 21.8 45.2 21.2 36.3 9.4 22.5 0 20 40 60 80 100 Introduction of SSSF Minimum dietary diversity Minimum meal frequency Minimum acceptable diet Consumption of iron rich food % 2006 2016 Add breastfeedin g
- 24. Hunger … Women's energy/calorie consumption 2250 2500 2230 1736 1859 1786 0 500 1000 1500 2000 2500 3000 Energy Pregnant Lactating NPNL(Mod) RDA- Energy (kcal/day) Consumed energy (median)
- 25. Protein consumption 78 71 55 45 48 47 0 10 20 30 40 50 60 70 80 90 Protein Pregnant Lactating NPNL(Mod) RDA (g/day) Consumed protein (median)
- 26. Sanitation & undernutrition: stopping the transmission of fecal matter is key! 26 Source: Perez et al., 2012
- 27. Bringing it together: Factors contributing to difference in stunting between very high‐burden & low-burden districts, 2016 Source: Understanding the geographical burden of stunting in India: A regression‐decomposition analysis of district‐level data from 2015–16; Authors: Purnima Menon, Derek Headey, Rasmi Avula, and Phuong Hong Nguyen
- 28. 7. Are these interventions a system/ part of system? What are the interlinkages?
- 29. Characteristics of a system Interrelated parts forming complex and unified whole with a specific function Systems have purpose All parts must be present for a system to carry out its purpose optimally Order in which parts are arranged affects the performance of the system Systems attempt to maintain stability through feedback.
- 30. Working on the system or in the system
- 31. Lets get some insights into systems thinking…..and breaking silos!
- 32. Identify issue What are the causal factors? What are their interactions? Draw the interrelationships One technique to help in systems thinking
- 33. Lets do some systems thinking! District fact sheets, and state policy papers: 1. What has worked/not worked in the district? Causal loop- map the components and their interactions –on flip charts 2. What are the institutional/systemic solutions? 3. What are the levers for change for building convergence and breaking silos? 20 minutes of brainstorming…… and system
- 34. Problems cannot be solved by the same level of thinking that createdAlbert Einstein
- 35. 8. What are the roadblocks to systems thinking in administration? 1. Systems are abstract[butterfly, MSP] 2. Linear thinking[field staff] 3. Position identity[govt litigation] 4. Event fixation[NH roadblock, rail accidents] 5. Boiled frog [Delhi, “beneficiary”] 6. Experience /anecdotal evidence is right 7. Choice architecture[asha payments] 8. Predecessor bias
- 36. 9. How can one break silos in administration? 1. Identify system- 2. Learn the skills- handouts 3. Build coalitions [sonam wangchuk, ekta] 4. Build shared vision: Joint monitoring, tours, SOPs, training, materials [cogs] 5. Get feedback[mahindra and
- 37. 6. Create institutional synergy 1. Map components and interactions 2. Identify binding constraints 3. Identify levers for action 4. Converge commitments and actions
- 38. Systems thinking and us… a recap Visualise big picture, not schemes “Systems thinking is a vantage point from which you see a whole, a web of relationships, rather than focusing only on the detail of any particular piece. Events are seen in the larger context of a pattern that is unfolding over time.” Understand the nuts and bolts, cogs and wheels, AND their interactions [ repayments for housing loans]
- 39. Think ahead….. Implications of actions “we learn from experience but never experience the consequences of our decisions” Keep the objective in centre[ the child] Understand system architecture Build shared vision across Create institutions that are synergistic Work by design, not default
- 40. Insanity is continuing to do the same thing over and over again and expecting different results Thank you! Thank you for your patience!Thanks for your patience!