Informing humanitarians worldwide 24/7 — a service provided by UN OCHA

India

Assessment of fortification of Mid-Day Meal Programme in Dhenkanal, Odisha, 2016-2018 Evaluation Report

Attachments

Evaluation Context

Micronutrient deficiency continues to affect sizeable sections of the global population and this “hidden hunger” extracts a substantial toll in terms of morbidity, mortality, reduced economic productivity and poor quality of life from those who are affected. The major Micronutrient Deficiency (MND) driven health conditions include anaemia due to various nutrient deficiencies such as iron, vitamin B12 and folate; vitamin A deficiency diseases; and iodine deficiency disorders. India, similar to many other low and middle income nations, have a large swathe of its populace suffering from these conditions, the effect of which is often more critically felt in the deficient children of school-going age among them. Odisha, a nutritionally vulnerable state has a relatively larger burden of such deficiency related disorders afflicting its children. It is known that food fortification is a one of the most effective, equitable and cost-efficient ways to mitigate the MND problem.

The Mid-day Meal (MDM) programme of India entails nutritional support in the form of school-served lunch to the students of grade 1-8 (age group 6-14 years), attending mainly government and government-aided schools. It constitutes one of the largest nutritional supplementation programmes of the world. A pilot project conducted in the Gajapati district of Odisha state established operational model for fortified rice with iron. Learning from this success, the Department of School and Mass Education (DSME), Government of Odisha and World Food Programme (WFP) planned to demonstrate the model in Dhenkanal through multi-micronutrient fortification using two modalities- This time the multi-micronutrient fortification of MDM rice (Fortified Rice Kernel – FRK) was one strategy and use of Multi-micronutrient Powder (MNP) to fortify MDM curries was the other. Although the modality for delivery of the micronutrients was different, the micronutrient profile of both modalities (FRK and MNP) was similar in terms of the level and salt of the micronutrients which were added. Accordingly, all eligible schools in four of the eight blocks (sub-district administrative unit in the Indian administrative system) of Dhenkanal were chosen for FRK mode of fortification and the schools of the remaining four blocks of the district were to receive MNP mixed MDM.

An evaluation study was built-in the project right from the stage of conceptualization with the objectives of measuring a) changes in selected nutrition-related indicators; b) the attributability of these changes (if any) to the fortification strategies; c) the contribution of other factors to the changes (if any); and d) comparing the two strategies with regards to their costs and operational feasibility and convenience. Therefore, the evaluation exercise was designed as a pre-post study of the interventions with a counterfactual—a classical quasi-experimental study design. As a part of the evaluation baseline and endline studies were carried out by the Indian Institute of Public Health Bhubaneswar to record the characteristics of the school children and school MDM system of the Dhenkanal district. A control district – Angul—four socio-economic matched blocks of which were selected to function as the counterfactual. The control blocks were not to receive any intervention, but it was planned that the baseline and also the endline study would be administered to it to measure the same variables as those of the intervention blocks. Following the baseline study, the two interventions were rolled out in the respective schools. After 17 months of intervention in MNP and around 15 months in FRK modality the endline study was carried out which measured the same variables as was done in the baseline. Additionally, at the endline, the cost of the two intervention strategies were estimated and their operational feasibilities and conveniences were assessed. Therefore, the objective of this report is to present the results of the evaluation of the MDM fortification project of Dhenkanal.

A multistage, stratified, clustered sampling method was undertaken to draw a probability sample of 18 schools from each arm of the intervention. Similarly, 18 schools were selected from four control blocks. In the baseline phase of the evaluation, 597 students in FRK arm and 578 students from MNP arm, studying in grades 1 to 8 in the sampled schools were selected. 589 students were sampled from the control arm of the study, who did not receive any of the above interventions. The same procedure was repeated in endline phase of the evaluation. The sample size of the endline comprised 597 students from 18 schools in MNP, 574 students from 18 schools in FRK and 467 students from 14 schools in the control arm. The same schools featured in the sample in both the phases of evaluation, but not the same students. The students were chosen using a stratified (class being the stratum) random method in both the occasions from the sampled schools. In addition to repeating exactly the methods that were carried out in the baseline phase of the evaluation, the endline phase conducted costing exercise to estimate the incremental cost of the two fortification strategies. Also, the endline phase undertook qualitative study to examine the operational feasibilities of the two fortification strategies.

Questionnaires were administered to the students and their parents to record information regarding their households’ socio-demographic characteristics, their MDM consumption patterns, their hygiene-related behaviours in schools, their intake pattern of iron-folate supplements and deworming medications, their knowledge of anaemia and malnutrition and how they receive health education in schools. Their physical endurance was tested by timing their 200 metres run. Blood specimens were collected from the students to measure blood haemoglobin for detection of anaemia; and serum ferritin, zinc, retinol, folate and vitamin B12 were also measured to estimate the prevalence of deficiencies of these micronutrients in the school children. Blood biomarkers were tested in the laboratories of All India Institute of Medical Sciences, Bhubaneswar. School teachers were also administered questionnaire regarding the school MDM system and regarding availability of other hygiene-related facilities in the school. The sickness absenteeism patterns of the students were enquired and estimated from the records. A checklist was used to study the relevant facilities present in the sampled schools. The costing exercise accounted for all the relevant costs incurred in the pilot project of MDM fortification that was addition to the routine MDM system. The rice miller involved in mixing FRK to routine MDM rice was interviewed in the FRK arm, so were the NGO partners facilitating the implementation of the fortification strategies and supervisors from another stakeholder of the project: World Food Programme. The operational feasibility study carried out in-depth interviews of district and block education office personnel, school teachers, school management committee members and cook cum helpers.

Key findings

Decline in prevalence of anaemia: A marked reduction in prevalence of anaemia has been observed in the treatment group in comparison to the control group. The results show increase in the mean values of Hb of 8.9%, 7.3% and 5.6% in MNP, FRK and Control arms respectively (p value of F test of ANOVA is <0.05). The difference between MNP and FRK was statistically not significant. There was no discernible gender difference as well as difference across grades in terms of the impact on anaemia of the two fortification measures.

Bio-medical status of children: Similarly marked reduction had been observed in prevalence of deficiencies of Folate (in FRK arm from 34.0% to 23.4% and in MNP from 51% to 15.3%). Folate deficiency has increased in control arm from 39.7% to 46.0%. The decline in deficiency status of Vit B12 was also discernible in two intervention arms, whereas there was remarkable decline of Vit B12 deficiency in control. Again, the decline in Ferritin deficiency, from its low prevalence in baseline was tangible in intervention arms but not in control. This further reinforces the positive effects of micronutrient fortification in reducing malnutrition in the district of Dhenkanal.
The quasi-experimental design provides us the opportunity to attribute this impact to the MDM fortification initiative primarily with possibility of contributions from other components of the school system.

Distribution of IFA and de-worming among students in schools: The proportion of students receiving Iron Folic Acid (IFA) supplementary formulations at school increased considerably in the endline phase in MNP arm (97.7% from 67% in baseline), however the percentages of receiving IFA declined quite significantly in the FRK arm (78% in endline from 91% in baseline). The receipt of deworming medications was more in the FRK arm both during baseline and endline as compared to the MNP arm.

Consumption of MDM: Approximately 90% of the students consumed MDM for all 6 days in a week in both the phases of the study. However, the endline phase witnessed a few points increase in MDM consumption for 6 days from the baseline despite the initial high bases. Only 50-60% of the parents were aware of the MDM fortification out of which ~40% reported that fortified MDM tasted better, as per their acquired information from their wards. Majority of the parents agreed that fortified MDM is beneficial and provides essential micronutrients alongside preventing malnutrition. Moreover, 40% parents felt there had been an increase in the consumption of MDM post fortification. Similarly, when inquired from children, 70% of them reported that fortified MDM tasted better and nearly 50% children recognized it to be beneficial.