How Do Community

Health Workers Contribute

to Better Nutrition?
India
About SPRING
The Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project is a five-year
USAID-funded Cooperative Agreement to strengthen global and country efforts to scale up high-impact nutrition
practices and policies and improve maternal and child nutrition outcomes. The project is managed by JSI Research
& Training Institute, Inc., with partners Helen Keller International, The Manoff Group, Save the Children, and the
International Food Policy Research Institute.

About APC
Advancing Partners & Communities (APC) is a five-year cooperative agreement funded by the U.S. Agency for
International Development under Agreement No. AID-OAA-A-12-00047, beginning. APC is implemented by JSI
Research & Training Institute, Inc., in collaboration with FHI 360. The project focuses on advancing and supporting
community programs that seek to improve the overall health of communities and achieve other health-related
impacts, especially in relationship to family planning. APC provides global leadership for community-based
programming, executes and manages small- and medium-sized sub-awards, supports procurement reform by
preparing awards for execution by USAID, and builds technical capacity of organizations to implement effective
programs.

Disclaimer
This report is made possible by the generous support of the American people through the United States Agency
for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-11-00031
(SPRING), managed by JSI Research & Training Institute, Inc. (JSI). The contents are the responsibility of JSI and do
not necessarily reflect the views of USAID or the United States Government.
Recommended Citation
SPRING and APC. 2016. How Do Community Health Workers Contribute to Better Nutrition?: India. Arlington, VA:
Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project.
SPRING
JSI Research & Training Institute, Inc.
1616 Fort Myer Drive, 16th Floor
Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
Email: [email protected]
Internet: www.spring-nutrition.org
 How to use these slides
We invite in-country stakeholders to use this information
to:
Identify which nutrition-related services
CHWs can provide, according to policies;
Prioritize and/or reassign responsibilities to
avoid overburdening CHWs;
Build a stronger foundation of policies, tools,
and systems for CHWs to conduct their work;

Plan additional support to CHWs;

Design and conduct other in-depth

assessments of community nutrition
programs;
Inform program implementers to strengthen
community health interventions.
These were developed using information collected by APC, with input from SPRING, through a desk review of existing policies
and documents related to community health systems. Due to the diversity and magnitude of community health programs in a
given country, we collected information based on country policies/strategies that comprise the key areas of a community
health system and not the realities of program implementation. Due to funding and timing, we focused on national public
sector programs, and only when possible, captured community-based private sector health programs operating at scale. We
 In India, nutrition-related health issues persist.

48%
According to most recent data,
stunting remains a major chal-
lenge in India.
%
children 57.1 of women of
under 5 48.5 51.0
47.9 reproductive age have
44.6
anemia
That means153 million
Indian women have a
critical micronutrient
1992 1997 1999 2005 2006 deficiency (2011)
Anemia also persists as a major
problem for India’s children.

%
74
only
46%
children 70.6
under 5 68.8

64.7
63.9 of infants are exclusively
breastfed for 6 months
(2005-06)
1992 1997 1999 2005 2006

Source: World Bank Databank:

We know evidence-based, cost-effective
interventions can improve nutrition
outcomes.
It is estimated that the following 10 evidence-based, nutrition-specific
interventions, if scaled to 90 percent coverage, could reduce stunting
by 20 percent and severe wasting by 60 percent.
• Management of severe • Periconceptual folic acid
acute malnutrition supplementation or
• Preventive zinc fortification
supplementation • Maternal balanced energy
• Promotion of breastfeeding protein supplementation
• Appropriate complementary • Maternal multiple
feeding micronutrient
• Management of moderate supplementation
acute malnutrition • Vitamin A supplementation
• Maternal calcium
supplementation
Source: Bhutta et al. 2013.
Studies have demonstrated the
effectiveness of community
health workers in achieving
demonstrable health benefits
directly related to the Millennium
Development Goals (MDGs),
including reducing child
malnutrition and both child
and maternal mortality.
- Perry and Zulliger, (2012)
Community health workers play a
critical role in providing these proven,
evidence-based, cost-effective interventions.

By making basic primary care available at the

community level, CHWs make it possible for women and
children to receive the services they need for better
health outcomes.

Frequently based in the communities where they are

from, community health workers (CHWs) have direct
access to the community and can link with other
nutrition-related community-based service providers.
They can provide clients with a range of services such
as medical care, information, counseling, and referral.

However, CHWs are often expected to carry out a wide

range of interventions with limited time, resources, and
remuneration. They need appropriate academic
curricula, training programs, and support systems –
including systems for monitoring, supporting, and
mentoring. Countries like India must take this into
consideration as they scale up and expand the services
Information on the services that community
health workers provide and the systems that
support them in doing their work is often
hard to find.
To begin to fill this void, the two USAID-funded projects -
Advancing Partners and Communities (APC) and
Strengthening Partnerships , Results, and
Innovations in Nutrition Globally (SPRING) -
collaborated to conduct a desk review of existing
policies and documents related to community health
systems.

Due to the diversity and magnitude of community

health programs in a given country, we collected
information based on individual country
policies/strategies that comprise the key areas of a
community health system and not the realities of
program implementation. Due to funding and timing, we
focused on national public sector programs, and only
when possible, captured community-based private
sector health programs operating at scale.
 These are our findings:
This is what community
health workers can do in
India, according to
government policy.
See the Data Notes at the end for more on how data were collected and analyzed.
Community health service delivery in
India is guided by multiple policies.
Relevant Government Last
Policies Reviewed* Updated
National Health Mission: 2012
Framework for Implementation (assumed)
2012-2017
Guidebook for Enhancing the Not
Performance of Multipurpose available
Worker (Female)
Home-Based Newborn Care 2014
Operational Guidelines
Guidelines for Community 2013
Processes
*India is a highly decentralized country. In some states these
policies and guidelines may not be adopted at all, may be
adapted, and/or may be integrated into other documents.
India has three distinct cadres of
community health workers.
1. Auxiliary Nurse Midwives (ANM) 212,185 in country*
work out of community facilities 1:5,000 people (3,000 in hilly
primarily providing reproductive, or hard to reach areas)
maternal, newborn, and child health
(RMNCH) services.
859,331 in country*
2. Accredited Social Health Activists 1:1,000 people (rural)
(ASHA) principally work in communities 1:1,000–2,500 people (urban)
and provide a range of health services
from family planning (FP) to selected
newborn care services. 1,174,388 in
country*
3. Anganwadi Workers (AWW) or 1:1,000 people
“courtyard shelter” workers focus on
nutrition and growth monitoring
activities.
* Data on ANMs and ASHAs are from 2015; data on
AWWs are from 2012.
Community health workers in India provide
services in multiple health service
delivery areas.
Services Services
Family planning provided by not
CHWs provided by
Maternal and child health CHWs
Integrated community case
management

HIV/AIDS
How is training
Nutrition managed for CHW
cadres?
Malaria
 National training
Tuberculosis curriculum is
available
Immunization  Nutrition is
included in the
Water and sanitation training curriculum
Note: Some ANMs may be able to conduct HIV
testing and counseling, but it is not a core job
function of the CHW cadres.
Community health
workers in India
support improved
nutrition outcomes
throughout the
continuum of care.
How we present our findings on
nutrition services provided by community
health workers.
Services, listed in tables, are categorized as nutrition
assessment, counseling, or support actions.

Assessment The tables presented for each stage of

life across the continuum of care include
Activity / action to be Cadres of CHWs specific nutrition-related services
taken who conduct
this task queried as part of the Community
Health Systems Catalog Assessment.

For each stage of life, we indicate if the

service is provided by community health
Counseling workers and which cadres have the
responsibility to provide that service.

Community health workers who provide

services are identified by cadre:
Support
ASHA – Accredited Social Health Activist
ANM – Auxiliary Nurse Midwife
AWW – Anganwadi Worker
Services Service not
provided by provided by CHWs
CHWs or not clearly
specified in policy
For adolescents
Counseling
Provide information/education/counseling (IEC) ASHA /
on iron/folate for women who are not ANM / AWW
pregnant and adolescent girls

Support
Provide/administer iron/folate for women ASHA / ANM /
who are not pregnant and adolescent girls AWW
For pregnant women
Assessment
Monitor weight gain during pregnancy ANM

Measure mid-upper arm circumference --

(MUAC) screening for pregnant women
Give information on hemoglobin testing ASHA / ANM
for women who are pregnant
Test blood for hemoglobin levels ANM

Counseling
Provide IEC on nutrition/dietary practices ASHA / ANM /
during pregnancy AWW
Provide IEC on iron/folate ASHA / ANM /
AWW
Provide IEC on insecticide-treated net use ASHA / ANM

Support
Provide/administer insecticide-treated ASHA
nets
Provide/administer iron/folate ANM
For breastfeeding women
Assessment
Monitor nutritional status of women who ANM
are breastfeeding (e.g., using MUAC)

Counseling
Provide IEC on correct positioning and ASHA / ANM
attachment of the newborn during
breastfeeding
Provide IEC on managing breastfeeding ASHA / ANM
problems (breast health, perceptions of
insufficient breast milk, etc.)
Provide IEC on nutrition/dietary practices ASHA /
during lactation ANM / AWW
For newborns
Assessment
Weigh newborns ASHA / ANM /
AWW

Counseling
Provide IEC on skin-to-skin contact between ASHA / ANM
baby and mother/caregiver
Provide IEC on breastfeeding within ASHA / ANM /
1 hour of birth AWW
For children
Assessment Counseling
Scales to measure weight of ASHA / Provide IEC on Vitamin A for ASHA / ANM /
children up to 2 years of age ANM / AWW children 6–59 months of age AWW
Use length boards to measure -- Provide IEC on general ASHA / ANM /
length of children up to 2 years of micronutrient supplementation AWW
age
Provide IEC on de-worming ASHA / ANM /
Measure MUAC of children ASHA / medication AWW
ANM / AWW
Provide IEC on complementary ASHA / ANM /
Screen children for bilateral ASHA / feeding practices and continued AWW
edema ANM / AWW breastfeeding (6–23 months of
age)
Support
Provide IEC on exclusive ASHA / ANM /
Provide/administer Vitamin A ANM / AWW breastfeeding (first 6 months of AWW
supplementation for children 6–59 age)
months of age Provide IEC on introduction of ASHA / ANM /
Provide/administer micronutrient ASHA / ANM / soft, semi-solid foods at 6 months AWW
supplementation AWW of age

Provide/administer deworming ASHA / ANM / Provide IEC on continuing ASHA / ANM /

medication AWW breastfeeding for children less AWW
than 6 months of age who have
Treating moderate acute ASHA / ANM diarrhea
malnutrition for children under 2
years of age Provide IEC on increasing fluids ASHA / ANM /
and continuing solid feeding for AWW
Treat severe acute malnutrition -- children over 6 months of age
with ready-to-use therapeutic with diarrhea
foods (RUTF) or ready-to-use
supplementary foods (RUSF)
For all stages of life
Counseling
Provide IEC on handwashing with soap ASHA / ANM

Provide IEC on community-level total --

sanitation
Provide IEC on household point-of-use ASHA / ANM /
water treatment AWW
Our key takeaways
In India, three cadres of community health
workers provide 33 of the recommended
36 nutrition services discussed in this
assessment.
Adolescents Services
provided by
Pregnant women CHWs
Service not
Breastfeeding women provided by
CHWs or not
clearly
Newborns specified in
policy

Children

All stages of life

How to use this information

You can use the data we have presented here

to:
Identify which nutrition-related services
CHWs can provide, according to policies;
Prioritize and/or reassign responsibilities to
avoid overburdening CHWs;
Build a stronger foundation of policies, tools,
and systems for CHWs to conduct their work;

Plan additional support to CHWs;

Design and conduct other in-depth

assessments of community nutrition
programs;
Inform program implementers to strengthen
community health interventions.
Data Notes
This document includes rich information about This effort was undertaken
community-level nutrition policies and services in
as part of the wider
India. The data represented here are based on a
detailed analysis of survey responses and a review of Community Health Systems
select policies related to nutrition responsibilities of Catalog data collection
community health workers. effort.
The data come with their own caveats. Policies do not
always specify which particular actions CHWs are You can find more details on
allowed or expected to perform, nor do they give any the Community Health
real indication of what actions CHWs actually do
perform. Policies can be general, ambiguous, and/or
System in India and data on
contradictory. For instance, a policy might list "referral other countries at:
for antibiotics" but it doesn't specify which antibiotics. www.advancingpartners.org
/
Furthermore, India is a highly decentralized country. In
some states the policies and guidelines reviewed may resources/chsc
not be adopted at all, may be adapted, and/or may be
integrated into other documents.

You can learn more about how to map health

workforce activities with the SPRING Nutrition
Workforce Mapping Toolkit, available at
spring-nutrition.org/publications/tools/nutrition-workfor
ce-mapping-toolkit
References
Bhutta, Zulfiqar A., Jai K. Das, Arjumand Rizvi, Michelle F. Gaffey, Neff Walker,
Susan Horton, Patrick Webb, Anna Lartey, Robert E. Black, The Lancet Nutrition
Interventions Review Group, the Maternal and Child Nutrition Study Group. 2013.
“Evidence-based interventions for improvement of maternal and child nutrition:
what can be done and at what cost?” Lancet 382 (9890):452-477.
doi:10.1016/S0140-6736(13)60996-4. (https://goo.gl/jrMUov)

Global Nutrition Report. “2014 Nutrition Country Profile, India.” 2014.

(https://goo.gl/MVV8s7)

World Bank DataBank. “Health Nutrition and Population Statistics.” 2016. World
Bank Group: Washington, D.C. (https://goo.gl/w1DrLr)

Perry, Roger and Rose Zulliger. 2012. “How Effective Are Community Health
Workers? An Overview of Current Evidence with Recommendations for
Strengthening Community Health Worker Programs to Accelerate Progress in
Achieving the Health-related Millennium Development Goals.” JHU: Baltimore,
MD. (https://goo.gl/3x9K91)
Additional Resources on CHWs
Community Health Systems Catalog - An innovative and interactive reference tool on country community health
systems intended for ministries of health, program managers, researchers, and donors interested in learning more
about the current state of community health systems. (https://goo.gl/N1QKYK)

Essential Package of Health Services Country Snapshot Series - A series of country profiles that analyzes the
governance dimensions of Essential Packages of Health Services (EPHS), including how government policies
contribute to the service coverage, population coverage, and financial coverage of the package (https://goo.gl/2M6FXr)

Community Health Worker (CHW) Central - An online community of practice for sharing resources and
experiences and discussing questions and ideas on CHW programs and policy. (https://goo.gl/dacnl5)

The Community Health Framework - A framework developed for government decision makers to structure
dialogues, answer questions, develop recommendations, and foster continuous learning about community health.
(https://goo.gl/VZImbm)

Global Experience of Community Health Workers for Delivery of Health Related Millennium Development
Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National H
ealth Systems
- A systematic review of CHW programs and their impact on health-related Millennium Development Goals (MDGs)
as well as eight in-depth country case studies in Sub-Saharan Africa (Ethiopia Mozambique and Uganda), South East
Asia (Bangladesh, Pakistan and Thailand) and Latin America (Brazil and Haiti). (https://goo.gl/5G0Vbc)

How Effective Are Community Health Workers?

An Overview of Current Evidence with Recommendations for Strengthening Community Health Worker Pr
ograms to Accelerate Progress in Achieving the Health-related Millennium Development Goals
- An update and supplement to the previous paper on the effectiveness of CHWs in providing a range of health
services and improving health and nutrition outcomes. (https://goo.gl/jKx2Zg)
Additional Resources from India
Improving Performance of Community-Level Health and Nutrition Functionaries: A Review of Evidence in
India
- This review of the National Rural Health Mission (NRHM) and the Integrated Child Development Scheme (ICDS) III
which highlights lack of supervision, poor worker motivation, and related issues as critical challenges. It shows that
programs often focus on training but other performance factors such as supportive supervision, clear performance
expectations and motivation and recognition are often neglected. These factors may be constraints against improving
health and nutrition programs in India. (https://goo.gl/r1kNZZ)

The Role of the Accredited Social Health Activists (ASHA) In Effective Health Care Delivery: Evidence fro
m a Study in South Orissa
- This article explores the role of ASHAs in acting as an interface between the community and the government
healthcare services, promoting and referring clients to health care delivery services. The authors identified challenges
as well as opportunities for strengthening services provided by ASHAs. (https://goo.gl/exUCDw)

Determinants of Functionality and Effectiveness of Community Health Workers: Results from Evaluation
of ASHA Program in Eight Indian States
- This paper explores several operational challenges faced by ASHAs that hinder their functions and effectiveness in
improving health services and outcomes. These include clarity of role, expected outcomes, adequacy and quality of
training and support systems. The authors conclude that for ASHAs to be effective they must serve as a healthcare
facilitator to facilitate access to care, a community level care provider for a limited range of services, and a health
activist. (https://goo.gl/77Zz8x)
 Learn more at:
www.spring-nutrition.org