Does Local System Strengthening Improve Nutrition Program Coverage and Child Growth: Evidence from a Large-Scale Program Initiative in India.

BACKGROUND

Acknowledging the importance of the first 1000 d of life, the Indian government is delivering nutrition-specific and -sensitive interventions targeting mothers and young children. However, implementation challenges at the district level prevent achieving coverage at scale. The government, in collaboration with multiple development partners, introduced system-strengthening models to improve the intervention delivery between 2016 and 2020 in 64% of districts.

OBJECTIVES

This study aimed to assess the effectiveness of system-strengthening models in improving coverage of interventions and child growth.

METHODS

We used data from the 2015-2016 (N = 185,101) and 2019-2021 (N = 172,426) National Family Health Surveys. We assessed the impact of system-strengthening models on coverage of interventions and child nutrition using a difference-in-differences study design. We compared districts that received additional support to those that only received usual programming. Among supported districts, 98.0% received a base package of input features consisting of human resources, community mobilization, and technological support. In addition, 76.3% received an enhanced package that included capacity building, finance, performance-based incentives, and infrastructure. Therefore, we additionally tested for potential additive effects from receiving an enhanced package of input features.

RESULTS

Coverage of nutrition-specific [range of significant (P < 0.05) coefficients: 5.8-14.5 percentage points (pp)] and nutrition-sensitive interventions (range of significant coefficients: 4.1-13.6 pp) improved at a faster rate in supported districts compared with usual programming districts between 2016 and 2020. Children in supported districts also experienced significantly faster improvements in height-for-age z-scores (0.18 SDs) relative to children in districts with usual programming. Although receiving the enhanced package on top of the base was associated with significant additive improvements in coverage of nutrition-specific interventions, no similar synergistic effect was observed for nutrition-sensitive interventions or child growth.

CONCLUSIONS

Targeted support at the district level can help to address implementation challenges and lead to improvements in coverage and nutrition.