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Nutrition Operation Plan

Department of Women and Child Development

Government of Orissa

2009-13

Amit

[Type the company name]

3/26/2009

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Department of Women and Child Development, Government of Orissa

CONTENTS

LIST OF ACRONYMS.................................................................................................................... 4

EXECUTIVE SUMMARY ............................................................................................................... 6

SUMMARY MATRIX FOR NUTRITION PLAN ................................................................................ 9

CHAPTER - I .............................................................................................................................. 10

PROGRESS AND NEED FOR A COMPREHENSIVE NUTRITION OPERATIONAL PLAN .................... 10

1.1 INTRODUCTION ..............................................................................................................10

1.2 ORISSA PROFILE: DEMOGRAPHIC DATA AND TRENDS....................................................11

1.3 TRENDS IN NUTRITIONAL STATUS AND BEHAVIORS IN ORISSA ......................................13

1.4 TRENDS IN CHILD HEALTH INDICATORS..........................................................................14

1.5 ANAEMIA IN ORISSA .......................................................................................................14

1.6 VITAMIN A AND IODINE DEFICIENCY ..............................................................................15

1.7 DIARRHEA MANAGEMENT..............................................................................................15

1.8 NEED FOR NUTRITION OPERATIONAL PLAN ...................................................................16

CHAPTER – II ............................................................................................................................ 17

THE INTEGRATED CHILD DEVELOPMENT SERVICES (SCHEME) & CONVERGENCE WITH OTHER

PROGRAMS.............................................................................................................................. 17

2.1 COVERAGE ......................................................................................................................17

2.2 DWCD MIS ......................................................................................................................17

2.3 SERVICES OF ICDS............................................................................................................18

2.4 KISHORI SHAKTI YOJANA (KSY) AND NUTRITIONAL PROGRAMMEE FOR ADOLESCENT

GIRLS (NPAG) ..................................................................................................................20

2.5 INTER- SECTORAL COORDINATION WITH HEALTH & FW AND RURAL DEVELOPMENT

DEPARTMENTS ...............................................................................................................20

2.6 ICDS COVERAGE..............................................................................................................22

2.7 CONCLUSION ..................................................................................................................25

CHAPTER – III ........................................................................................................................... 26

LESSONS FROM REVIEW OF APPROACHES TO MALNUTRITION REDUCTION............................. 26

3.1 INHP: INTEGRATED NUTRITION AND HEALTH PROJECT (IMPLEMENTED IN 8 STATES IN INDIA

INCLUDING ORISSA).............................................................................................................26

3.2 ASHA SAHYOGINI: (COMMUNITY BASED VOLUNTEER IN RAJASTHAN) .......................................27

3.3 POSITIVE DEVIANCE........................................................................................................27

3.4 THAILAND EXPERIENCE...................................................................................................28

3.5 DULAR.............................................................................................................................29

3.6 ICDS IV – REFORMS IN ICDS.............................................................................................29

3.7 MANAGEMENT INFORMATION SYSTEM – MAHARASTRA..............................................30

3.8 DIFFERENT MODELS OF COMMUNITY MONITORING.....................................................30

3.9 CONCLUSION ..................................................................................................................31

CHAPTER – IV ........................................................................................................................... 32

FIELD STUDY FINDINGS ............................................................................................................ 32

4.1 METHODOLOGY..............................................................................................................32

4.2 RESULTS ..........................................................................................................................32

4.3 FINDINGS ON PERCEPTION OF BENEFICIARIES AND OTHER STAKEHOLDERS ON SERVICE

DELIVERY, SKILLS AND KEY BARRIERS..............................................................................34

4.4 REASONS FOR NON-AVAILING SERVICES ........................................................................34

4.5 SKILLS OF SERVICE PROVIDERS .......................................................................................35

4.6 OBSERVATIONS ON GAPS IN INFRASTRUCTURE .............................................................35

4.7 SUGGESTIONS FROM DISTRICT LEVEL ICDS AND HEALTH FUNCTIONARIES....................36

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4.8 BEST PRACTICES..............................................................................................................37

4.9 CONCLUSION ..................................................................................................................38

CHAPTER – V ............................................................................................................................ 39

OPERATIONAL PLAN FOR REDUCING MALNUTRITION.............................................................. 39

5.1 GOAL...............................................................................................................................39

5.2 PRINCIPLES OF OPERATIONAL PLAN ...............................................................................40

5.3 NUTRITION OPERATION PLAN ........................................................................................41

DESK REVIEW OF LITERATURE FOR THE NUTRITION STUDY ...................................................... 49

TABLES

TABLE 1 INDICATORS OF DLHS....................................................................................................................... 11

TABLE 2 REGION-WISE POVERTY RATES BY SOCIAL GROUPS FOR RURAL ORISSA (2004-05)......................................... 12

TABLE 3 ICDS COVERAGE AND UTILIZATION OF ICDS SERVICES IN ORISSA, 2005-06............................................... 22

TABLE 4 UTILIZATION OF ICDS SERVICES DURING PREGNANCY AND WHILE BREAST FEEDING BY WOMEN........................ 24

TABLE 5 COMPONENTS OF COMMUNITY MONITORING ....................................................................................... 30

TABLE 6 BENEFICIARIES AVAILING AND NOT AVAILING ANY SERVICE OF ICDS............................................................ 33

TABLE 7 PERCENTAGE OF BENEFICIARIES AVAILING SERVICES BY SOCIAL GROUP ......................................................... 33

TABLE 8 REASONS FOR NOT ABLE TO GIVE SUFFICIENT TIME IN DELIVERING ICDS SERVICES BY AWW ........................... 34

TABLE 9 NUTRITION OPERATION PLAN............................................................................................................. 42

FIGURES

FIGURE 1 - TREND IN UNDER NUTRITION IN CHILDREN IN ORISSA

FIGURE 2 - VARIABLES CORRELATED TO CHILD MALNUTRITION

FIGURE 3 - EARLY CHILDHOOD MORTALITY RATES, INDIA AND ORISSA

FIGURE 4 - IN ORISSA CHILDREN FROM ALL GROUPS HAVE HIGH ANEMIA PREVALENCE

FIGURE 5 - MICRONUTRIENT INTAKE

FIGURE 6 - PREVALENCE OF CHILDHOOD DISEASE

FIGURE 7 - NUMBER OF OPERATIONAL AWCS IN ORISSA

FIGURE 8 - HOW MANY CHILDREN IN ORISSA RECEIVE SERVICES FROM AN AWC

FIGURE 9 - COVERAGE OF FULL IMMUNIZATION, ORISSA

FIGURE 10 - CONCLUSION

FIGURE 11 - METHODOLOGY

FIGURE 12 - ICDS COVERAGE

FIGURE 13 - % OF AWC IN OWN BUILDINGS

FIGURE 14 - IF NOT OWN BUILDING % OF AWCS HOUSED IN

FIGURE 15 - CONSTRAINTS IN IMPLEMENTING ICDS SERVICES

FIGURE 16 - KEY FACTORS FOR BETTER PERFORMANCE OF AWC

MAPS

MAP 1 - % OF MODERATE AND SEVERE MALNUTRITION (GR-II, III & IV) AMONG 3-6 YEAR OF CHILDREN

MAP 2 - % OF MODERATE AND SEVERE MALNUTRITION (GR-II, III & IV) AMONG 0-3 YEAR OF CHILDREN

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LIST OF ACRONYMS

ANC Ante Natal Check-up

ANM Auxiliary Nurse-Midwife

ASHA Accredited Social Health Activist

AWC Anganwadi Centre

AWW Anganwadi Worker

BCC Behaviour Change Communication

CBO Community Based Organization

CDMO Chief District Medical Officer

CDPO Child Development Project Officer

CHC Community Health Centre

CSO Civil Society Organization

DSWO District Social Welfare Officer

DWCD Department of Women & Child Development

DFIDI Department for International Development in India

DALY Disability Adjusted Life Years

ECE Early Childhood Education

FGD Focus Group Discussion

FHND Fixed Health & Nutrition Day

FRU First Referral Unit

GoI Government of India

GoO Government of Orissa

GP Gram Panchayat

ICDS Integrated Child Development Services (Scheme)

IEC Information Education Communication

IMNCI Integrated Management of Neonatal and Childhood Illnesses

INHP Integrated Nutrition & Health Project

IMR Infant Mortality Rate

IPC Inter Personal Communication

ITDA Integrated Tribal Development Agency

IYCF Infant and Young Child Feeding

JSY Janani Suraksha Yojana

KBK Undivided Koraput Bolangir Kalahandi Districts

KSY Kishori Shakti Yojana

LRPs Local Resource Persons

LS Lady Supervisor

MIS Management Information System

MMR Maternal Mortality Rate

MOV Means of Verification

MPR Monthly Progress Report

NFHS National Family Health Survey

NGOs Non-Governmental Organizations

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NHEd Nutrition & Health Education

NPAG Nutritional Programme for Adolescent Girls

NREGS National Rural Employment Guarantee Scheme

NSSO National Sample Survey Organization

OHSP Orissa Health Sector Plan

ORS Oral Dehydration Solution

PD Positive Deviance

PHC Primary Health Centre

PPP Public Private Partnership

PRD Panchayati Raj Department

PRI Panchayati Raj Institution

PSE Pre School Education

RD Rural Development

RWSS Rural Water Supply & Sanitation

RACHANA Reproductive and Child Health, Nutrition and HIV/AIDS Program

SA Statistical Assistant

SC Scheduled Caste

SHG Self Help Group

SIHFW State Institute of Health & Family Welfare

ST Scheduled Tribe

TSC Total Sanitation Campaign

U-5 Children under 5 years

UNICEF United Nations Children's Fund

UNFPA United Nations Population Fund

VHSC Village Health and Sanitation Committee

WFP World Food Programme

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EXECUTIVE SUMMARY

The Government of Orissa is committed to bringing about improvement in the nutritional outcomes

of women and children through effective and sustainable service delivery to citizens and creating a

demand for services, especially amongst the poorest and the most difficult to reach populations. To

achieve this goal, the Department of Women and Child Development (DWCD), Government of Orissa

(GoO) has been implementing a number of innovative approaches in collaboration with other

Government Departments and development partners including local NGOs and other Civil Society

Institutions. Specifically the Integrated Child Development Services (ICDS) under DWCD implements

interventions aimed at reducing under nutrition.

The latest NHFS (2005-2006) data shows that in the last seven years, overall child nutrition status in

Orissa has improved. This is a major achievement compared to trends in many other States. The field

study carried out for the development of the nutrition plan shows that there are a number of

positive nutrition related behaviors in Orissa.

But despite progress in malnutrition reduction in the State, 41% of young children remain

underweight. It is well recognized that the multi factorial causes of under nutrition can only be

partially ameliorated by any one scheme or department. We need to link agriculture policy and

nutrition interventions with disease control, water and sanitation and anti-poverty programmes.

Malaria, Measles, Respiratory Infections, and Diarrhoea are some of the common infections to which

infants and children are especially vulnerable resulting to poor outcomes in the presence of under

nutrition and poverty. Repeated infections may also worsen their nutritional status.

In order to have a comprehensive understanding of both; the substantial progress and the remaining

challenges, DWCD decided to undertake a systematic study to develop an integrated evidence-based

nutrition operational plan. This will address the nutrition condition of the people of Orissa,

particularly those from the most vulnerable sections of the society where under nutrition is highest.

This document reports evidence from the secondary and primary data of the study; analyses

strengths and weaknesses of the current nutrition related interventions in the State; and presents

the resultant Operational Nutrition Plan. These are described in five chapters:

Chapter I: Progress and Need for a Comprehensive Nutrition Operational Plan

Chapter II: The Integrated Child Development Services (Scheme) and Convergence with

other Programs

Chapter III: Lessons from Review of Approaches to Malnutrition Reduction

Chapter IV: Field Study Findings

Chapter V: The Operational Plan for Malnutrition Reduction in Orissa (with Logical

Framework).

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A proposed budget sheet of estimated values for activities to be funded by the UK

Department for International Development (DFID), as part of their Budget Support to the

Orissa Health Sector Plan, is also attached.

The Nutrition Plan is based on five principles:

1. Targeting the most vulnerable: While there are some strategies which is applied across

the State the plan focuses interventions on 15 High Burdened Districts of Orissa. These are:

Anugul, Bhadrak, Bolangir, Gajapati, Jharsuguda, Kalahandi, Kandhamal, Keonjhar, Koraput,

Malkangiri, Nawarangpur, Nuapada, Raygada, Sambalpur and Sundergarh.

2. Flexibility: Implementation of innovative strategies so that Districts are able to take greater

responsibility and ownership of their ICDS schemes. In high burden Districts provision of

extra funds to carry out innovative strategies to ensure maximum outreach coverage.

3. Evidence and Outcome Based participatory planning: The results are expected to be

achieved, based on expanding partnerships with Community, PRIs, NGOs, Private and

Corporate participation encouraging Public Private Partnership mode.

4. Stronger Convergence: Convergence with other services especially between Health and

ICDS is integral to achieve results. Collaboration with Rural Development to mainstream

nutrition concerns into their programmes like access to safe drinking water sources,

elimination of open defecation and adoption of positive hygiene practices are critical

aspects. Considering that livelihoods are major factor for under nutrition in the 15 High

Burdened Districts, there is a need to coordinate with employment guarantee schemes of

the Rural Development Department.

5. Strong Monitoring and Results Based Framework: Results based implementation

mechanism aims at a life-cycle approach to management that integrates strategy, people,

resources, processes and measurements to improve decision-making, transparency and

accountability. The approach focuses on achieving outcomes, implementing performance

measurement and learning.

The Nutrition Plan is expected produce results in the entire State with measurable change in 15 High

Burdened Districts for:

• Reduction of moderate and severe Malnutrition in children under two years

• Reduction in the proportion of births with birth weight less than 2.5 kg

• Reduction in nutritional anemia in women and children

The Plan sets out some key objectives to be achieved between, 2009 - 2013

The Impact Indicators are:

• Bring down malnutrition from current level of the children by 4 years

1. Underweight from 41% to 25% focusing on ST with a reduction of 3.5% every year

2. Stunting from 45% to 35% with a reduction of 2.5% every year

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3. Wasting from 20% to 10% with a reduction of 2.5 % every year

The outcome Indicators are:

• Bring down severe malnutrition from current level by 50% (17% ICDS MPR, January

2009)

• Bring down the prevalence of anemia among Children from 65% to 50% with a special focus

on ST (from 80% to 65%) and girls (67% to 50%) Women from 61% to 50%

• Improve Vitamin-A coverage from 72% to 85% (DLHS III)

• Improve adequate Iodized salt coverage by 50%

• Increase the % of children breast fed within one hour from 55% to 80 %

• Increase the % of children exclusively breastfed till 6 months of age from 51% to 70%

• Increase the timely complementary feeding from 66% to 80%

• Increase complete immunization coverage from 64% to 80%

The Plan is designed around eight strategies, detailed in the Logical Framework in Chapter V

1. Strengthened Institutional Arrangements for improved access and utilization of

ICDS services

2. Decentralized Planning identifying block priorities

3. Ensuring community participation in planning , implementation and monitoring

4. Strengthening Service Delivery for Nutrition

5. Result Based Monitoring and Evaluation

6. Early Childhood Education

7. Interdepartmental Convergence

8. Integrated Behaviour Change Communication

This Plan has emerged from six-months of evidence review, field study and many rounds of

discussion between the Department of Women and Child Development, other Departments and

nutrition and planning specialists. This is a live document for presentation and review by a high level

Nutrition Advisory Committee of the Government of Orissa, under the Chair of the Development

Commissioner. External experts and Development Partners are joint members with GoO officials.

The Plan will be revised after feedback from the Advisory Committee. The final document will

represent GoO’s Nutrition Plan 2009-2013 and will be modified during the implementation period as

a result of regular reviews.

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SUMMARY MATRIX FOR NUTRITION PLAN

STATE WIDE HIGH BURDENED DISTRICTS

NE

W I

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IVE

ST

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NG

TH

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ON

GO

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A

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IVIT

IES

Strategy – 1 - Job description of ICDS vis-a-vis health functionaries

reviewed

- Ensuring supply of improved medicine kits for AWC

(charts, weighing scales and IEC materials)

Strategy - 4 - Strengthening FHND with support of ANMs, ASHA

- Strengthening growth monitoring with support of

mother’s committee

- Improving compliance on IFA, Vitamin A and de-worming

- Guidelines for Capacity building of AWW on micronutrient

- KSY strengthened

- Home visits and supervisory visits enhanced

- Baby friendly AWCs (including Sanitation and Water)

- Maternal and child health rooms

Strategy - 5 - Strengthening M&E using web based technologies

Strategy - 6

- Improved quality of Early Child hood education

Strategy - 7 - Strengthening interdepartmental systems for convergence

Strategy - 1 - Establishment of State Project Management Unit for

convergent action in partnership with health (Nutrition,

BCC, Training, and M& E)

Strategy - 2 - Development of District nutrition plans reflecting block

priorities, identifying gaps and bottlenecks

- NGOs/CSOs involvement in preparation of District plan

- Bi-annual joint review of District plan and implementation

(RDD, Health etc.)

Strategy - 3 - Involving current SNGOs, MNGOs and FNGOs of NRHM to

focus on nutrition related indicators in the outreach areas

- VHSC/GKS monitoring

Strategy - 4 - Assessment of training of SHGs

- State resource Centre

- Training of AWW, LS, CDPO and DSWO on WHO standards

Strategy - 8 - Integrated BCC strategy

- State wide media campaign with Sanjog

- Tools for counselling and monitoring developed

Strategy -1 - District Project

Management Units

created (Nutrition, M&E

and BCC)

Strategy - 3 - Mothers committee

trained on people based

monitoring

- Social audit and

community monitoring

by GKS

Strategy - 4 - Recipes demonstration

- Integrated delivery of

feeding program

- Adolescent girls groups

formation and capacity

building

- Demonstration of

positive hygiene practices

- Sector Supervisors HQ

- Display boards in AWCs

to sensitize the

community their rights

and entitlement

- Intensive Capacity

building of Providers and

community

Strategy - 8 - Pilot integrated

communication strategy

- Social mobilization

campaigns at villages

- Use of local folk media to

communicate critical

health and nutrition

messages

- Using new avenues like

Hat Bazaar, Adolescent

Girls group, Radio

program based on local

needs for BCC

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CHAPTER - I

PROGRESS AND NEED FOR A COMPREHENSIVE NUTRITION OPERATIONAL PLAN

1.1 INTRODUCTION

The comprehensive Orissa Health Sector Plan (OHSP 2007-12) provides a unique opportunity for the

Government of Orissa to align its own, the Government of India’s (GoI) and various development

partners’ resources to complement its efforts in meeting the state’s priorities and help address the

major shortcomings in both public and private health provision. The OHSP aims to achieve equity in

health outcomes and has a key focus on access and utilization of services by vulnerable and

marginally deprived groups of the society i.e., women, schedule caste (SC), schedule tribe (ST)

populations. It aims at delivering accountable and responsive health care to reduce maternal

mortality; infant and child mortality; reduce the burden from infectious diseases; under-nutrition

and nutrition-related diseases and disorders.

The Government of Orissa is committed to bringing about improvement in the nutritional outcomes

of women and children through the effective and sustainable service delivery to citizens and creating

a demand for services, especially amongst the poorest and the most difficult to reach populations.

To achieve this goal, the Department of Women and Child Development (DWCD), GoO has been

implementing a number of innovative approaches in collaboration with other Government

departments,

developmental partners,

local NGOs and other civil

society institutions.

Specifically the

Integrated Child

Development Programme

(ICDS) under DWCD

implements interventions

aimed at reducing under

nutrition.

The latest NHFS (2005-

06) data shows that in

the last seven years,

overall child nutrition

status in Orissa has

improved (Figure-1). This

is a major achievement

compared to trends in

many other states. The

field study and the review of secondary data show that there are a number of positive nutrition

behaviors in Orissa.

Evidence of progress is further supported by recent findings from the District Level Household

Survey (DLHS) 2007-08, which shows an improvement in children breastfed within an hour and

exclusive breastfeeding for 6-months, ANC, Immunization as compared with the previous DLHS

survey 2002-04 (Table-1).

Figure: 1

49 50

30

24

4044

Stunted Underweight Wasted

NFHS-2

NFHS-3

Trend in Undernutrition in Children in Orissa

Percent

NFHS-3,Orissa, 2005*Children age under 3 years

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Table 1 Indicators of DLHS

INDICATORS DLHS - 2 DLHS - 3

Children breastfed within 1 hour 44% 64%

Exclusive breastfeeding for 6-months 21% 43%

Fully immunized 53.3 62.4

Vitamin A supplementation 52.9 71.6

Mother had full ANC 13.7 22.7

NFHS data also shows that supplementary food provided through ICDS is progressive, with food

supplementation uptake higher amongst vulnerable groups with lowest wealth quintiles than the

better off.

Despite progress in malnutrition reduction in the State, 40% of young children remain underweight

which is unacceptably high. It is also well recognized that the multifactoral causes of under nutrition

can only be partially ameliorated by any one scheme or department. We need to link agriculture

policy and nutrition interventions with disease control, water and sanitation and anti-poverty

programmes. Malaria, measles, respiratory infections and diarrhoea are some of the common

infections to which infants and children are especially vulnerable leads to poor outcomes in the

presence of under nutrition and poverty. Repeat infections may also worsen their nutritional status.

Nutrition programming should therefore be coordinated with public health and poverty reduction

programmes. Under nutrition is highly prevalent in many areas in which morbidity and mortality

from malaria are high. Research suggests malaria contributes to malnutrition in children and that

malnutrition may increase the burden of malaria, especially in pregnant women and under-five. (Am.

J. Tro. Med. 2004, August)

In order to have a comprehensive understanding of both; the substantial

progress and huge remaining challenges, DWCD decided to undertake a

systematic study to develop an integrated evidence-based practical

operational plan to address the nutrition condition of the people of Orissa,

particularly for the most vulnerable sections of the society.

This document reports evidence from the secondary and primary data of the study and the resultant

Operational Nutrition Plan.

1.2 ORISSA PROFILE: DEMOGRAPHIC DATA AND TRENDS

Orissa is one of the major states of India with 368.08 lakh population (Census 2001) accounting to

3.6 per cent of the total population of the country. The state lies in a sub-tropical geo-climatic region

with vastly varied topography. Orissa has been one of the most natural disaster-prone states of

India. Floods and droughts regularly devastate the State and cyclones are common.

Administratively Orissa has 3 revenue divisions, 30 Districts, 58 Sub-divisions, 171 tehsils and 314

community development blocks. There are 105 local bodies, 31 towns, 6,235 Gram Panchayats and

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50,972 villages. The density of population was 236 per sq. km. in 2001, which is lower than the all

India average of 313 per sq. km and ranges from a high of 666 per sq. km in Khurdha District to a low

of 81 sq. km in Kandhamal Districts. Out of the total population, 85.01 per cent live in rural areas and

depends mostly on agriculture for their livelihood.

As per the 2001 census, 22% of the state

population is scheduled tribe (ST) and 17% is

scheduled caste (SC) and together they

constitute 39% of the State population. Poverty

is overwhelmingly observed in rural Orissa and

significant disparities are seen among regional

and social groups within the state. The rural

poverty ratio is much higher in southern region

followed by northern region. The poverty rates

among Scheduled Caste (SC) and Scheduled

Tribe (ST) population in the southern and

northern region is very high (Table-2). These

regions are home to 88.56 percent of the

state’s ST population and 46.23 percent of SC

population.

Disparity across Districts is notable, especially

with regard to health and nutrition indicators for the tribal population. Since over 40 percent of land

is recoded as under forest cover, the tribal population, some of whom reside in deep forests,

dependent on forest produce for livelihoods are far from either demanding or accessing health and

nutrition services. Food insecurity and non availability of adequate food throughout the year is a

pervasive problem in these communities where poverty is a strong underlying determinant.

The undivided Districts of Koraput, Bolangir and Kalahandi, popularly known as KBK

region, have since 1992-93 been divided into eight Districts: Koraput, Malkangiri,

Nawrangpur, Rayagada, Bolangir, Sonepur, Kalahandi and Nuapada. These eight Districts

lie in the south-west Orissa and represent a fairly huge landmass of 47,646 sq. km,

comprising 30.6 percent of the state’s total area. The region constitutes nearly 20 percent

of the state’s population, and the SC and ST population accounts for 38.7 percent and 15.8

percent of the region’s population respectively.

The KBK region is one of the poorest regions in the country. It is characterized by chronic

income poverty resulting in absolute hunger, persistent drought conditions, and high

levels of food insecurity, regular distress migration, and periodic allegations of starvation

deaths. Agriculture is the mainstay of the region’s economy and kharif paddy cultivation

with very low yield is the principal means of livelihood. However, the rice economy of the

region does not provide adequate livelihood to the majority of the agriculture labor or

cultivating households.

(Human Development Report 2004, GoO, p 24)

Table 2 Region-wise poverty rates by social

groups for rural Orissa (2004-05)

Social groups

Region ST SC Others All

Coastal 67.7 32.8 19.0 27.4

Southern 82.8 67.2 44.1 72.7

Northern 72.8 64.4 33.9 59.1

Rural Orissa 75.8 49.9 23.5 46.9

Source: NSSO 61st

round 2004-05

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1.3 TRENDS IN NUTRITIONAL STATUS AND BEHAVIORS IN ORISSA

A total of 41.4 percent women aged 15-49 years were reported to have low BMI (below 18.5)

(Figure-2) in Orissa as against all India figure of 35.6 percent. The proportion of underweight

children born to thin mothers (BMI below 18.5) was 50 percent and of severely underweight

children was 18.1 % as against 35.7

and 10.5 percent children born to

normal mothers respectively (NFHS

III).

With regard to practices followed

under IYCF (Infant and Young Child

Feeding Practices) protocol, as

emerged from the NFHS-III data,

although the median duration of

any ‘breast feeding’ was more (35

months) in Orissa as compared to

India pooled (24 months), the

median duration of ’Exclusive’

breast feeding was only 2 months,

the introduction of Complimentary

feeding was delayed in large

number of children and only one

third of the children between 6 to 23 months were fed ‘3+ food groups and minimum number of

times’. The children age 6-35 months exclusively breastfed has increased from 20.7% to 42.6%.

(DLHS II and III)

It was observed that 36 percent babies under six months of age were underweight and more than a

quarter of them were stunted and wasted, even when most of them are breast fed. While

proportion of wasted children remained almost consistent till two years of age, the proportion of

stunted children doubled (52.8 percent) and underweight children increased to 41 percent during

this period. Further 24 percent of U5 children were ‘very small’ or ‘small’ at the time of birth (as per

the respondent’s observations of the NFHS III) and 63 percent of them were underweight and almost

half of them were stunted.

Declining trends in the levels of malnutrition amongst children under 3 years of age have been

observed in Orissa, in all the three standard measurements of nutrition. According to the NFHS-III

(2005-06), the proportion of underweight children below 3 years of age declined from 50.3 percent

(NFHS II 1998-99) to 39.5 percent - an almost 10 percent point decline in 7 years. Decline in stunting

was from 49.1 to 43.9 percent and in wasting from 29.7 to 23.7 percent.

According to NFHS-III, 45 percent of under-5 years of age children in the state of Orissa are stunted

and 40.7 percent are underweight. The proportions of children who are severely undernourished

(more than three standard deviation below the median of the reference population) constitute 19.6

percent according to height for age and 13.4 percent according to weight for age. Wasting is also

quite a serious problem in Orissa, affecting almost 20 percent of children below 5 years of age. No

significant difference was observed in the levels of Under-5 malnutrition of Orissa when compared

with all India pooled levels of under nutrition.

NFHS -3

Variables Correlated to Child Malnutrition

� Under 3 years – critical for setting in of

malnutrition

• Malnutrition high in the scheduled tribes

• High in poorer households - Low Wealth

Index

• Birth Order – Malnutrition high in 4th or 5th

born

• Mothers education level – Illiteracy

• Mothers BMI - below 18.5

• Defecation – open fields

• Drinking Water Sources – unprotected

including hand pumps

Figure: 2

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The above observations from the NFHS-III data clearly bring out the fact that state nutrition

intervention programs lack focus on Antenatal Care (Mothers who have full ANC has increased from

13.7% to 22.7 % only in DLHS II and III) including maternal nutrition. Essential New Born Care, IYCF

protocol and Inter Departmental Convergence are needed to facilitate timely remedial actions.

The NFHS-III also indicates that even in urban areas, more than one third of children below 5 years

(35 percent) suffer from chronic under-nutrition. The majority of scheduled tribe children are

stunted (57.2 percent) or underweight (54.4 percent).

1.4 TRENDS IN CHILD HEALTH INDICATORS

Infant Mortality Rate (IMR) in Orissa (73 per 1000 live births) has been declining rapidly but it is still

higher than the all India IMR of

57 per 1000 live births (SRS

2006). As per NFHS-III the

Under 5 Mortality was 90.6 per

1000 children (Figure-3) as

against all India figures of 82.0

per 1000 children.

There has been improvement

in the proportion of ‘fully

vaccinated’ children aged 12-

23 months in Orissa between

NFHS-II (44 percent) and NFHS-

III (52 percent)11 and the largest

improvement has been

observed in measles

vaccination (54 to 67 percent).

However, it is important to

note that only 50 percent of

the children are fully

immunized and in spite of the

pulse polio campaign, the proportion of children who received three doses of the polio vaccine

declined.

1.5 ANAEMIA IN ORISSA

Anemia is a major health problem in Orissa

especially among women and children. Almost

two third (65 percent) of children age 6-59

months are anemic (Figure-4), 35 percent of

them are moderate and 2 percent suffer from

severe anemia. Anemia among children age 6-35

months is slightly higher in NFHS-III as compared

to NFHS-II seven years ago. The prevalence of

Anemia amongst ever married women remained

almost unchanged over this period (63 percent

at NFHS-II vs. 62.7 percent at NFHS-III). A study

on Anemia carried out by Nutrition Foundation

1 Children 12-23m fully immunized – NFHS II: 43.1 and NFHS III: 51.8

Figure: 3

Figure: 4

In Orissa Children from All Groups Have High

Anaemia Prevalence

Percent of children with any anaemia, Orissa (65%)

• Urban (54%), Rural (67%).

• Poorest households (75%), Wealthiest

households (42%).

• Scheduled tribe (80%).

• Children whose mothers have no education

(71%), 10+ years of education (52%).

• Girls (67%), boys (64%). NFHS-3,Orissa, 2005-06

3/26/2009


15


in India says that there is higher prevalence of anemia in Orissa, Assam and Madhya Pradesh

because of lower literacy rates, lower energy and iron intake, poorer access to antenatal care, low

consumption of IFA tablets22. Mothers who consumed 100 IFA has increased from 20.8% to 37.6 only

(DLHS II and III). Early marriages and early pregnancies, low dietary intake, especially micronutrients

and minerals and ANC services registration in first trimester were very low. Anemia among

adolescent girls is quite high and it is often too late to handle during pregnancy but there is no data

to substantiate the extent of Anemia in adolescent girls.

Parasitic infections are widespread throughout the state. The nutritional and pathological

consequences of multiple infections with Plasmodium and helminthes infection may have an

additive and/or multiplicative impact on nutrition and organ pathology.

1.6 VITAMIN A AND IODINE DEFICIENCY

Disease burden associated with deficiencies in

Vitamin A and iodine are also concerns in Orissa.

Despite biannual campaigns held, only 30%

(figure -5) children in the age of 12-23 months

have received one dose of Vitamin A in the last six

months33. While coverage of vitamin A

supplementation in Orissa was, earlier recorded

very high, the recent NFHS data showed

significant decline in its coverage. Children age 9

months and above received at least one dose of

Vitamin A has improved from 52.9% to 71.6%

(DLHS II and III). Untimely and inadequate

supplies, management of biannual campaigns may

be some of the reasons for this decline. Similarly

as per NFHS -III data only about 40 percent of the

households use adequately iodized salt (>15ppm

iodine) - a marginal increase from NFHS-II (35 percent). The GoO efforts of intensively promoting

iodized salt trading through community groups and extensive IEC across the state involving more

than 200 numbers of SHGs in 30 Districts in salt trading incurring an estimated transaction of more

than 400 metric tons needs to be further intensified

coupled with advocacy campaign44.

1.7 DIARRHEA MANAGEMENT

Diarrhoea management with ORS is seen to be

extremely poor amongst households where children

suffered from diarrhea. 12% of the children have

diarrhoea in last two weeks of survey (Figure-6).

Awareness of family members around feeding

practices during diarrhoea was also very low. Only 9.4

percent households gave more liquid and 27.9 percent

gave somewhat less liquids to children suffering from

2 Nutrition Foundation of India – Anemia in Pregnancy SR 16 -2005

3 Data Source NFHS II and NFHS III

4 In July 2007, 120 SHGs were involved in 7 Districts and traded about 75 metric tones and December 2008,

about 130 SHGs in 8 Districts had successfully traded 210 metric tones. Information collected from UNICEF

based on data generated by WCD Dept.

Figure: 5

Micronutrient Intake

• Goal: Given vitamin A supplements

in last 6 months (children age 12-35

months)

Achievement: India 25% - Orissa 30%

• Goal: Universal salt iodization

Achievement: Percent of children

age 6-59 months living in households

using adequately iodized salt:

India 48% - Orissa 38%NFHS-3,Orissa, 2005-06

Figure: 6

Prevalence of childhood disease

• Percentage of children under age five with symptoms of/with

• Acute Respiratory Infection (ARI):3%

• Fever:16%

• Percentage of children under age five who had diarrhoea in the two weeks preceding the survey

• Diarrhoea:12%

NFHS-3, ORISSA, 2005-06

3/26/2009


16


diarrhoea. This was especially inadequate in young mothers, mothers with low literacy levels, rural

mothers and of the households who had low wealth index and was inappropriate for children who

were 4th or above in the birth order. Diarrhoea management amongst scheduled caste households

was poorer as compared to general and the tribal communities55.

Proportion of families with access to safe drinking water source; either from pipe water supply or

hand pump has increased from 65.3 percent in NFHS-II to 78.4 percent in NFHS-III. While the access

to safe drinking water source is high, it is observed in various studies that water contamination

happens due to incorrect water collection and storage practices and unsafe handling practices. The

low sanitation coverage is directly related to infectious diseases that cause blood loss like

hookworms. Hand washing with soap at critical times, after defecation, before food and feeding can

reduce diarrhoea attacks by about 60 percent.

1.8 NEED FOR NUTRITION OPERATIONAL PLAN

The trans- generational impact of nutrition problems, the interaction between prenatal malnutrition

and adverse birth outcomes including low birth weight, the problem of micronutrient malnutrition

and factors affecting nutrient bio-availability from indigenous foods, and interactions with parasitic

and other infections, requires interventions that are community oriented and community owned.

There is a positive trend in a number of indicators justifying evidence of a decrease of under-

nutrition among children. GoO recognizes the value of some of the important approaches

implemented in Orissa but also seeks further insights into the limitations and barriers to utilization

of services by the poor. This is key to developing and implementing a select set of evidence-based

strategies/approaches to accelerate the pace of malnutrition reduction. Although there are a

number of studies which have highlighted the key problems in delivery of nutrition and health

services, there is a need for a more systematic study to develop an integrated evidence-based

practical operational plan to address the nutrition condition of the children of Orissa, particularly for

the most vulnerable sections of the society.

The GoO, whilst recognizing important approaches implemented in the State

in the last seven years, intends to get more insights into the effectiveness of

services and barriers to utilization, especially by the poor, in order to develop

and implement a select set of evidence-based strategies/approaches. The

strategies will span programmes and departments whose services impact

directly and indirectly on nutrition and will aim to accelerate the pace of

malnutrition reduction.

5 Diarrhoea Management - NFHS 3

3/26/2009


17


CHAPTER – II

THE INTEGRATED CHILD DEVELOPMENT SERVICES (SCHEME) &

CONVERGENCE WITH OTHER PROGRAMS

The Integrated Child Development Services (ICDS) Scheme, set up under the Department of Women

and Child Development and Social Welfare, 33 years ago, provides an integrated approach for

converging basic services through community based workers and helpers.

ICDS provides a holistic approach for improved child development through delivering a package of

services comprising of supplementary nutrition, immunization, health check-ups, referral services

and health and nutrition education to children under-6 years of age, pregnant and nursing women

and pre-school education to children between 3 and 6 years of age.

2.1 COVERAGE

With one ICDS project established in 1975 – 76,

the total number of functional ICDS projects in

Orissa is 326 (314 rural and 12 urban) in 2008

including urban projects. The state has 41,697

AWCs (Figure-7) and 4819 mini AWCs now. The

ICDS guidelines envisage one rural/urban project

for 100,000 people and one tribal project for every

35,000 population.

There is also a provision of “Mini AWCs” to cover

the remote and less populated areas in tribal

blocks having a population of 150 -300 people.

Ministry WCD has approved opening of 19221

additional AWCs.

2.2 DWCD MIS

The spatial pattern in the 0-3 and 3-6 year age groups are depicted in Map 1 and Map 2. For the 0-3

year age group, 11 Districts (MAP-1), namely, Bhadrak, Gajapati, Kalahandi, Keonjhar, Koraput,

Figure: 7

MAP: 1 MAP: 2

Moderate and severe malnutrition in %

6.36 - 17.88

17.89 - 20.36 (State Average:17.88)

20.37 - 28.29

Map-1 Percentage of moderate and severe malnutrition (Gr-II,III,IV)

among 0-3 year of children

Bargarh13.01

Jharsuguda18.53

Sambalpur20.74

Debagarh11.75

Sundargarh22.68

Kendujhar20.49

Mayurbhanj15.57

Baleshw ar13.07

Bhadrak21.85

Kendrapara11.59

Jagatsinghapur6.36

Cuttack12.08

Jajapur16.06

Dhenkanal12.04

Anugul16.8

Nayagarh13.93 Khordha

10.54 Puri8.98

Ganjam15.43

Gajapati22.16

Kandhamal17.53

Baudh17.03

Sonapur14.06

Balangir18.62Nuapada

20.49

Kalahandi21.51

Rayagada23.78

Nabarangapur28.29

Koraput26.43

Malkangiri24.84

Moderate and severe malnutrition in %

4.17 - 15.76

15.77 - 18.52 (State Average;15.76)

18.52 - 26.28

Map-2 Percentage of moderate and severe malnutrition (Gr-II,III,IV)

among 3-6 year of children

Bargarh10.53

Jharsuguda17.8

Sambalpur19.95

Debagarh9.54

Sundargarh19.37

Kendujhar18.61

Mayurbhanj13.05

Baleshw ar12.03

Bhadrak18.97

Kendrapara12.23

Jagatsinghapur4.17

Cuttack10.79

Jajapur16.1

Dhenkanal9.73

Anugul13.61

Nayagarh12.64 Khordha

9.13 Puri8.44

Ganjam13.87

Gajapati20.15

Kandhamal14.64

Baudh14.4

Sonapur11.69

Balangir17.08Nuapada

10.42

Kalahandi20.83

Rayagada20.71

Nabarangapur26.28

Koraput23.79

Malkangiri21.25

3/26/2009


18


Malkanagiri, Nawarangpur, Nuapada, Rayagada, Sambalpur and Sundargarh come under the ‘high’

prevalent zone and in the 3-6 year age group (MAP-2), these 11 Districts except Nuapada Districts

fall in the ‘high prevalent’ zones. In the 0-3 year age group, 17 Districts, namely, Angul, Balasore,

Baragarh, Boudh, Cuttack, Deogarh, Dhenkanal, Ganjam, Jagatsinghpur, Jajpur, Kandhamal,

Kendrapara, Khurda, Mayurbhanj, Nayagarh, Puri & Sonepur and in the 3-6 year age group these 17

Districts except Jajpur along with Nuapada fall under the ‘low prevalent’ zone. The remaining

Districts are categorized under the ‘moderate prevalent’ zone.

96 % of ICDS projects have Child Development Project Officers and 97% AWWs are in position.

However, data shows that only 62.5% of the ICDS supervisors are in place at the sector level. This

would strongly impact upon the monitoring of the ICDS programme in the state

2.3 SERVICES OF ICDS

2.3.1 Supplementary Nutrition Programme

Malnutrition, endemic poverty, food insecurity and low household incomes have resulted in poor

nutritional status especially in the most vulnerable communities. When families suffer, children and

women suffer most due to the greater vulnerability and their higher biological need for nutritional

protection and security. This becomes more impending for pregnant and lactating women and

children in their formative years. The ICDS program addresses these concerns through its

Supplementary Nutrition Program, through the provision of nutritional support to children in the

vulnerable age group to prevent the onset of malnutrition and growth faltering in the formative

years (Figure-8). The program

does not aim to substitute

family food.

Food is provided to expectant,

nursing and children between

Six months to Six years of age

for a period of 300 days in a

year. Normally rice and lentils

are provided in the SNP

programme.

Food supplementation is also

done by World Food

Programme, a UN body

operational in Orissa since

1999. SNP is basic to WFP,

especially in the three Districts

of Koraput, Malkanagiri and Nabarangpur.6 WFP provides for INDIA MIX

7 in the three Districts. The

state Government bears only the cost of wheat and transportation from the factory point to the

AWC. In five other Districts of Rayagada, Bolangir, Sonepur, Kalahandi and Nuapada, the state

6 Information based on an interview with Programme Officer, WFP. Corn and Soya blend provided by WFP

earlier was discontinued based on allegation that the mix was genetically modified. 7 India Mix consists of 60% wheat, 20% sugar, 20% Soya, and is fortified with micronutrients like calcium,

riboflavin, potassium, sodium and nitrate. Apart from SNP, WFP also provides Food for Education, Food for

Work, High Energy Biscuits to school children in select KBK Districts and in Forestry. Maternal Health education

is also a very important. The WFP supports in the construction of 300 AWCs (KBK+). They supported the

construction of 27 in the coastal District

Figure: 8

How Many Children in Orissa Receive

Services from an AWC?

Percent of age-eligible children in areas with an AWC

NFHS-3,Orissa, 2005-06

3/26/2009


19


Government bears the entire cost of bags, fortification and quality control. The GoO pays for the

supplies, while WFP facilitates procurement and monitors the quality of the product. Mini Plants are

operating with the help of Self Help Groups in five places; Puri, Khurdha, Ganjam, Mayurbhanj and

Bolangir. However, the mini plants for production of RTE THR have become unsustainable over the

years due to power disruptions in the rural areas, poor mixing procedures and difficulty to maintain

the quality of the products.

The WCD department is supported by Vedanta Alumina to provide an additional meal to all children

in 300 plus AWCs in Kalahandi District.

2.3.2 Growth Monitoring and Growth Promotion

Growth monitoring, nutritional surveillance and analysis of nutritional status at the District level are

major activities of the ICDS. As per the norm, children below the age of 3 years are weighed once a

month and children between 3-6 years are weighed quarterly. The Fixed Health and Nutrition Days

(immunization sessions) are used as an opportunity to weigh children below 2 years of age. Weight

for age cards is also maintained for all children. This is used to detect growth faltering and stagnation

and to assess their nutritional status. A community based nutritional analysis chart has been

introduced at each AWC level to mobilize the community in promoting better child care practices.

This is used a tool to interact with the mothers and care givers on the nutritional status of their

children. 94.3% children in the 0-3 year’s age group and between 89.4 % in the 3 to 6 years age

group have been covered under growth monitoring this year.

2.3.3 Nutrition and Health Education

A key element of the program aims to get women between 15 -45 years of age to come together

and discuss about their basic health, nutrition, child care, infant feeding practices, utilization of

health services, family planning and environmental sanitation. During the year 2007-2008 an

average number of 6.3 lakhs women per month have been covered under NHED.

2.5.1 Immunization

Immunization of pregnant women against tetanus and infants against vaccine preventable diseases

are carried out at the AWCs. These are major preventable causes of child mortality, disability,

morbidity related to malnutrition. The health functionaries carry out the immunization schedule the

AWW assists in ensuring cent percent coverage. Similarly, during the year 2007-08, 8.00 lakhs

children have been immunized against DPT; 6.79 lakhs against Polio; 6.95 lakhs against BCG and 6.77

lakhs against Measles. The coverage during the last five years shows a decreasing trend as compared

to previous years.

2.3.4 Referral Services

During the regular health checkups, immunization sessions and growth monitoring, sick and

malnourished children are referred for medical treatment. The AWWs are also trained to detect

disabilities in young children. The effectiveness of this service is dependent upon the cooperation of

the health functionaries. As per the Annual Activity Report of the Women and Child Development

Department, 6.7 lakhs beneficiaries (children, pregnant and lactating women) have been provided

referral services through AWCs. A medicine kit of Rs 600/- is provided to every AWC to treat

common ailments like cough, cold, skin infections etc.

3/26/2009


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2.3.5 Early Childhood Care Education

The ICDS programme also focuses on the pre- school education of children between 3-6 years of age

to promote pre-school preparedness for children below 6 years of age. Early childhood care aims to

support unilversalisation and quality improvement of primary education. The Early Childhood Care

Education conducts classes through non formal, play way to provide for joyful learning environment.

Pre-school education kits with toys and different kinds of educational materials are provided to

every Anganwadi Centre each year at a cost of Rs.500/- per kit. During the year 2007-08, 13.0 lakhs

children (3-6 years) have been enrolled under pre-school and the attendance was 11.3 lakhs. During

the year 6.6 lakhs children pregnant women and nursing mothers have availed the service.

2.4 KISHORI SHAKTI YOJANA (KSY) AND NUTRITIONAL PROGRAMMEE FOR ADOLESCENT

GIRLS (NPAG)

Reports and evaluations done of the ICDS services across India point out that Life cycle approaches

have shown better results regards in the reduction of malnutrition. Focusing on interventions for

adolescent girls and creating awareness on ICDS services and issues could yield sustainable and far

reaching results for reduction of malnutrition. Kishori Shakti Yojana is designed to strengthen the life

cycle approach and enhance the understanding of adolescent girls to acquaint them with different

services related to health and nutrition. As per survey report 22, 16,794 Adolescent Girls are covered

in all 326 ICDS Projects under KSY from the year 2006-07 onwards. Adolescent girls in the age group

of 11 to 18 years are being provided with iron and de-worming tablets. Undernourished Adolescent

Girls in the age group 11-19 years with body weight less than 30 kg in the age group of 11 - below 15

years and 35 kg in the age group of 15 - 19 years are covered under the scheme. Free food grains @

6 kg. Per beneficiary per month are provided to these undernourished adolescent girls. The

programme has been operationalised through the administrative set up of ICDS at the state, District,

block and Anganwadi Center level. Koraput and Kalahandi District of the State have been taken up as

pilot District s for implementation of the scheme. Under the National Programme for Adolescent

Girls 1, 37,621 undernourished adolescent girls in Koraput and Kalahandi Districts are provided free

rice @6 Kgs per beneficiary per month. The success of the intervention is dependent on effective

linkages with the Public Distribution System (PDS) and effective synergy and convergence with

health services.

2.5 INTER- SECTORAL COORDINATION WITH HEALTH & FW AND RURAL DEVELOPMENT

DEPARTMENTS

There have been many efforts in terms of programs/schemes to address issues/determinants of

malnutrition and morbidity together. The opportunity is also high in terms of maximizing these

efforts to ensure better result.

2.5.1 Verbal Autopsy

During 2006-07 this new intervention has been started as State initiative. To build a credible

database of the cause of deaths of infants and Pregnant/Lactating women in the State, ANMs and

Anganwadi workers are conducting detailed verbal enquiry into each and every case of death of

infant within one year and Pregnant/Lactating women within 42 days of deliver in their area jointly.

The report will indicate accurate information regarding cause of death, age of death, seasonal

variation, gender variation, socio-economic factors, coverage of anti-natal, post- natal services,

3/26/2009


21


immunization etc. Timely and prompt analysis of the information can lead to early and prompt

corrective action as precautionary measure for future.

2.5.2 Pustikar Dibas

As a joint venture of Health & Family Welfare Department and W&CD Department ‘Pustikar Dibas’ is

being observed at the PHCs/ CHCs on 15th of every month on fixed day basis. On this day, all

moderate and severely malnourished children and children with growth faltering are referred to the

PHC / CHC for examination, possible investigation, diagnosis and treatment of these children.

Medical Officer, PHC /CHC are placed with funds from out of Referral Transport Component of IMR

Mission to provide cash assistance for the transportation of referred children.

2.5.3 Fixed Immunization Day

To protect from several dangerous

diseases, children are immunized

during the first year of their life,

viz. B.C.G, Polio, D.P.T and

Measles. Similarly pregnant

women are protected against

Tetanus through T.T

immunization. In view of its

importance and 100% coverage of

immunization, a special fixed day,

i.e. Wednesday is being observed

as Immunization Day in our State.

This provides an opportunity to

the guardians of the children to

attend the immunization session

and ensure their children are

immunized reflected in NFHS III

(Figure-9).

The proportion children not vaccinated at all had increased more than 2 percent point from NFHS-

2 (9.4%) to NFHS-3 (11.6%).

2.5.4 Selection of ASHA

Every village has 1 ASHA for every 1000 persons. ASHA is a women nominated by WSHG members to

the Gramsabha for selection. She will work along with AWW, ANM, SHG, functionaries of other

Department under the leadership of Village Health Committee.

2.5.5 Malaria Control

AWCs have been declared as Fever treatment Depots. AWW/ASHA is handling patients with fever.

AWW are collecting Blood Slides and RDT (Rapid Diagnostic test). It is the responsibility of the Health

& Family Welfare Department to supply ACT. AWWs are trained adequately and in turn they

undertake tours the SHGs to create awareness among the village people. AWWs are supplied with

slides, lancets, Primaquine and leaflets/guidelines to create awareness.

Figure: 9

Coverage of Full Immunization, Orissa

% Fully immunized among children age 12-23 months

Urban 53%

Rural 52%

Girls 55%

Boys 49%

Scheduled tribe children 30%

With mothers having no education 35%

With mother 10+ years of education 72%

From the lowest wealth quintile 39%

From the highest wealth quintile 65%

NFHS-3, ORISSA, 2005-06

3/26/2009


22


And now more than ever is the need to study the impact of malaria control

strategies on improving the nutritional outcomes especially in women and

children U 5 when Orissa is on the threshold of adopting a major change in

the early diagnosis and effective treatment of malaria using RDT (Rapid

Diagnostic Test) and ACT (Artimisinine based Combination Therapy)

2.5.6 Oral Re-hydration Solution

ORS Packets are stored with AWW for requirement of villagers in need during diarrhoea.

2.5.7 Baby Friendly Anganwadi Toilets

Under this scheme each Anganwadi is supposed to be provided with a baby friendly toilet. Unit cost

of one such toilet is Rs.5, 000/- .Such toilet is constructed out of the Total Sanitation Campaign fund.

AWWs have been advised to construct Toilets in their own house on priority basis on security point

of view as well as to motivate others. So far, 6843 Anganwadi Toilets have been constructed

through Total Sanitation Campaign. SHGs have an important role in the implementation of TSC in

the rural areas. They have to be actively involved in bringing about awareness among rural people

for the need of rural sanitation but also ensuring the use of sanitary latrines.

2.5.8 Self Helf Group (Motivation, Installation of sanitary toilets)

Involvement of Women SHG in the Total Sanitation Campaign to promote the use of toilets has been

jointly taken up by WCD and RD departments. SHGs have been trained to motivate communities to

adopt toilet construction and correct hygiene practices. Baby friendly toilets are constructed in

AWCs. Interdepartmental convergence has been demonstrated through the successful

implementation of “Sanjog”. SHGs in select Districts have been trained to manage and operate

production centres to enable access to affordable sanitary materials.

2.6 ICDS COVERAGE

Table 3 ICDS Coverage and Utilization of ICDS Services in Orissa, 2005-06

% of 0-71m children received services from an

AWC

Background

Characteristics

% of 0-

71

months

children

covered

by an

AWC

Any

Service

Supplementary

Food

Any

Immunization

Health

Check-

ups

% of 36-

71

months

children

who went

for early

childhood

care/pre-

school at

an AWC

% of 0-

59

months

children

who

were

weighed

at an

AWC

% of 0-59

months

children

whose

mothers

received

counselling

from an AWC

after child was

weighed

SEX

Male 79.4 65.5 52.7 40.9 41.3 23.9 57.3 26.2

Female 81.5 66.1 52.4 42.4 45 32.3 54.9 33.2

RESIDENCE

3/26/2009


23


Table 3 ICDS Coverage and Utilization of ICDS Services in Orissa, 2005-06

% of 0-71m children received services from an

AWC

Background

Characteristics

% of 0-

71

months

children

covered

by an

AWC

Any

Service

Supplementary

Food

Any

Immunization

Health

Check-

ups

% of 36-

71

months

children

who went

for early

childhood

care/pre-

school at

an AWC

% of 0-

59

months

children

who

were

weighed

at an

AWC

% of 0-59

months

children

whose

mothers

received

counselling

from an AWC

after child was

weighed

Urban 20.7 41.3 26.9 14.4 26.9 14.5 37.9 18.2

Rural 90.2 66.7 53.5 42.7 43.7 28.2 56.8 29.9

EDUCATION

No Education 86.5 67.9 54.7 44.1 45.4 27.2 57.3 28

<5 years of

complete

78.7 71.6 60.8 43.5 45.7 33.3 58.9 31.3

5-9 years

complete

77.9 63.8 49.8 39.3 41.8 28.4 56.9 30.7

10 or more

years complete

65.8 54.5 40.4 34.1 32.8 20 45 33.7

CASTE/TRIBE

Scheduled

Caste

79.8 69 58.3 44.3 41.7 32.3 60.2 31

Scheduled

Tribe

83.7 69.9 62.2 43.7 51.8 27.2 61.1 27.5

Other

Backward Caste

89.9 63.8 45.6 42 40.2 24.8 55.9 30.8

Others 68.3 60.4 44.3 35.8 37.1 27.8 45.7 31.3

WEALTH INDEX

Lowest 88.3 68 58.4 42.7 47.7 26.9 60.3 27

Second 82.3 68.6 54.5 40.5 44.8 29.5 59.3 35.1

Middle 77.6 69.4 49.7 46.3 40.5 35.2 53.7 30.4

Fourth 75.4 54.9 37.9 37.6 29.4 21.9 43.4 27.9

Highest 41.2 38.5 20.2 27 26 6.5 28.1 -

Total 80.4 65.8 52.5 41.6 43.1 27.7 56.1 29.6

Source: NFHS, 2005-06

Source CTRAN – An analysis of health status of Orissa in Specific reference to health equity

The present report has also made an attempt to analyse the penetration or outreach of ICDS services

captured by NFHS in year 2005-06. It is clear that more children and women in rural areas as against

urban areas; in ST and SC communities as against OBC and other caste communities; and in lowest

wealth quintiles as against highest wealth quintiles have access to various services given by ICDS

(Table-3). However, there are still half of the children below 71 months (47.5%) are to receive

supplementary nutrition. More than 70% mothers are left out from the counselling services. About

3/26/2009


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44% children below 59 months are not weighed. The percentage of children who attends early

childhood care and pre-school education is only 27.7%.

Table 4 Utilization of ICDS Services during pregnancy and while breast feeding by women

During Pregnancy While Breastfeeding Background

Characteristics No

Services

Supplementary

Food

Health

Check-

ups

Health &

Nutrition

Education

No

Services

Supplementary

Food

Health

Check-

ups

Health &

Nutrition

Education

RESIDENCE

Urban 79.8 8.7 19.2 10.6 85.6 7.7 13.5 5.8

Rural 43.2 46 42.6 23.4 53.4 41 28.9 17.1

EDUCATION

No Education 36.8 51.7 47.9 21.9 50.7 42.7 31.5 16.7

<5 years of

complete

51.5 36.8 37.1 27.8 52.4 39.2 27.2 18.8

5-9 years

complete

47.9 41.6 37.9 24.2 55.7 40.8 26.3 18

10 or more

years complete

64.5 27.6 27.6 19.7 71.8 24.3 19.7 11.2

CASTE/TRIBE

Scheduled Caste 39.7 44.5 47.1 23.4 52.7 40.9 31.1 16

Scheduled Tribe 32.3 61.5 53.6 26.4 46.1 50.8 35.4 18

Other Backward

Caste

46.7 43.5 38.1 21.9 54.8 40.7 27.8 17.4

Others 62.2 24.2 25.9 17.7 66.9 23.6 16.9 13.4

WEALTH INDEX

Lowest 34.8 55.5 49.7 24.5 48.5 46.9 32.7 16.3

Second 44.6 43.6 39.6 26 52.5 40.5 29.2 20.1

Middle 57 31.1 32.4 22.2 55.9 33.8 25 21.9

Fourth 57.4 29.7 31.9 17.7 71.3 25.9 18.6 8.5

Highest 79.7 9.7 18.3 5.8 88.4 9.7 9.7 5.8

Total 44.5 44.6 41.8 23 54.5 39.8 28.3 16.7

Source: NFHS, 2005-06

Source – CTRAN an Analysis of health status of Orissa in specific reference to health equity.

The status of ICDS services during pregnancy and while breastfeeding by women is no way different

as compared to the status of services provided to children (Table-4). About women of 55.5% SCs and

39.5% STs have not received supplementary food during pregnancy. The percentage is even higher

during lactation period when 69.9% STs and 64.6% STs have not received the same. Similar findings

are also found with regard to the receipt of ICDS services by lowest wealth quintile groups and by

less educated persons. The case is also not different with regard to the other ICDS services received

e.g. weighing, health & nutrition education, health check-ups, etc. by women during pregnancy and

while breast feeding. In brief, the degree of outreach among the vulnerable groups requires further

3/26/2009


25


improvement in the context of the need of such services by the vulnerable while accepting the fact

that ICDS is more equitable in terms of delivery of services.

2.7 CONCLUSION

The implementation of the ICDS services

in the state clearly indicates that the

state Government has adopted a number

of actions and services that address

malnutrition. A number of activities have

been initiated to strengthen convergence

amongst departments and

implementation of programmes at state

and District levels.

However according to NFHS III findings

(figure-10), gaps between ICDS policies

and its actual implementation have to be

addressed for better impact on

nutritional status of children. Monitoring

and evaluation activities should be strengthened through establishment of joint review mechanisms

at all levels, collection of timely, relevant, accessible, high-quality information. The information

should be adequately delivered to the highest level to influence decision making.

Figure: 10

Conclusions�Nutritional problems in Orissa is lower than

national average for the children under age 5

years but still remains a common problem among

children.

�Anaemia continues to be a major health problem

among children and women in Orissa

�An important cause of poor nutritional status is

the use of inappropriate feeding practices for

childrenNFHS-3,Orissa, 2005-06

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CHAPTER – III

LESSONS FROM REVIEW OF APPROACHES TO MALNUTRITION

REDUCTION

A review of literature indicates that all approaches used to combat malnutrition nationally and

internationally comprised a package of interventions that broadly relate to:

• Practices at institutional, community and household levels; like ensuring early initiation of

Exclusive Breast Feeding, timely initiation of appropriate complementary feeding

• Social security measures like provision of supplementary nutrition to all households,

micronutrient supplementation like vitamin A, measles immunization, iodized salt,

fortification of staple foods

• Strong behavior change and mobilization component like; counseling of mothers and care

givers on infant and young child feeding practices

• Capacity building of service providers and community groups - skill up gradation of

Anganwadi Workers and community motivators for effective counseling and behavior

change activities, ensuring access to safe drinking water, sanitation and adoption of proper

hygiene practices.

The following approaches were reviewed as part of the study and the key elements highlighted for

recommendations.

3.1 INHP: INTEGRATED NUTRITION AND HEALTH PROJECT (Implemented in 8 States in

India including Orissa)

The INHP Programme (1996 - 2009) is implemented in Eight States of India, including Orissa with the

support of CARE. The objective envisages demonstrating models of improving child health and

nutrition. The INHP package consists of I) Antenatal Care (IFA and TT), ii) Supplementary Nutrition

along with provision of oil, iii) child immunization, iv) Infant and young child feeding practices

focusing on early initiation of breast feeding, exclusive breast feeding and timely introduction of

complementary feeding.

CONCEPT AND IMPLEMENTATION PROCESS

The technical interventions focused on Essential Nutrition Action, community – based new born

care, antenatal care and primary immunization. The operational and management interventions

centered around convergent ICDS and RCH interventions, targeting the most vulnerable, supporting

universalization of ICDS, decentralized management of supplementary nutrition and emphasizing

household level contacts. Structured supervisory support, mechanisms for tracking left outs and

drop outs, planning and management of food and health supplies, promoting accountability of ICDS

and RCH programs are key determinants of the approach.

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OUTCOMES

The evaluation of Integrated Nutrition and Health Project showed significant increase in the process

indicators, especially with regard to complete immunization of children, possession of vaccination

cards and tracking by mothers, number of children who received their vaccination during the NHD,

micronutrient supplementation, and effective interpersonal contacts made with households and

increased coverage of services. It has shown reduction of malnutrition of 8% across eight states.

REPLICABILITY POTENTIAL

The Integrated Nutrition and Health Project model is implemented in more than 12000 AWCs, across

106 ICDS projects in nine tribal Districts of Orissa. Best practices of the programme like the Health

and Nutrition Day have been adopted and institutionalized in the state. Community monitoring and

change agents have the potential to be adopted in all AWCs. District level Training Teams (DTT &

BTT) and District Level Advisory Committees (DLAC) can be formulated in high burden Districts to

ensure better service delivery. The INHP tool kits like AWW home visit calendar, checklist for

supervisors, sector meeting and CDPOs can be used across the state. It is estimated that RACHANA

averted 13,356 deaths and was responsible for gain of 380,719, disability adjusted five life-years

(DALYs) It may be estimated that RACHANA cost per death averted is 47,209 rupees( US$1,098) and

its cost per DALY gained is 1656 rupees ( US $ 39). (Paper 12, A cost analysis of the RACHANA

program)

3.2 ASHA SAHYOGINI: (Community based volunteer in Rajasthan)

ASHA/Sahayogini initiative in Rajasthan as a third worker (2004-2005) in AWC is almost like the as

the INHP change agent or the Dular LRPs (Local Resource Person) and focuses on mobilizing and

counseling through IPC. The difference between ASHA/Sahayogini and change agents is that she is

formally attached to Anganwadi Centres. She is a trained worker and gets a monthly remuneration

of Rs 500 whereas change agents are primarily volunteers. She is trained on ICDS activities,

communication skills and cares during delivery, growth monitoring, child development, Birth and

Death Registration, child marriages and family planning and is expected to maintain a daily diary to

effectively track malnourished children and families. As a third worker, the Sahayogini is expected to

support the functioning of the AWW and ANM with their daily activities.

REPLICABILITY

The concept of the ASHA/Sahayogini is highly successful in Rajasthan and can be replicated in Orissa.

The ASHA can be formally paid from the ICDS and trained on nutrition related issues to act as a

support system to the AWW in the high burden Districts.

3.3 POSITIVE DEVIANCE

BACKGROUND OF THE APPROACH

The Positive Deviance approach is implemented primarily in two states including Orissa. The Positive

Deviance approach called “Ame Bi Paribu” in Orissa has been implemented in 6700 AWCs across

300 ICDS projects in 30 Districts. It began in a few centres in Mayurbhanj in 2004 with UNICEF

support and has been scaled up by the department over the last four years. WFP also supports the

Positive Deviance program in a few Districts. It is a development approach that helped the

community and its members find existing and sustainable solutions to a community problem like

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malnutrition. In addition to food it aims to address the multiplicity of causes that lead to

malnutrition-poverty, food insecurity, income fluctuations, faulty food preferences and preparation

practices, inappropriate child feeding practices, poor personal hygiene and sanitation practices, lack

of safe drinking water and their links to diseases and infestations. The focus of the programme is to

create social, behavioral and psychological adaptability to nutritional stress.

OUTCOMES

In Orissa, the Positive Deviance programme was supported by UNICEF. The evaluation of Positive

Deviance done in West Bengal brought out that there were significant improvements in methods in

child care, like breast feeding, immunization, hand-washing and community based management.

Though the Positive Deviance approach in Orissa has not been formally assessed, the reports from

the Monthly Progress Report of the WCD department shows a 4% decline in malnutrition status in

Mayurbhanj District.8

REPLICABILITY

The PD approach has been replicated in the State. However a formal evaluation needs to be carried

out to establish the results of the approach.

BUDGET UTILIZATION IN POSITIVE DEVIANCE

The budget allocated for Positive Deviance was primarily used for training purposes. An exposure

visit programme was organized for ICDS functionaries from Mayurbhanj to West Bengal in 2003-

2004. Three blocks in Mayurbhanj, Morada, Kuliana, and Suliapada initiated the Positive Deviance

approach without any external funds. A total amount of Rs 37, 00,000 was provided by UNICEF in

2006 - 2007 for state and District level trainings. 21 people were trained as state level trainers and

six people were trained from each District on Positive Deviance. In 2008, an amount of Rs 10, 30,000

has been provided for expansion of Positive Deviance through training.

3.4 THAILAND EXPERIENCE


Thailand has had the most dramatic reduction in the number of malnourished children at the rate of

3% per year. As early as 1937, Thailand started a nation wide nutrition education campaign

emphasizing on consumption of nutritionally balanced foods based on five food groups. The

Thailand Govt. emphasized use of supplementary foods for infants and compulsorily introduced

nutrition in the syllabus of medical students. During the development of different national plans,

nutrition was prioritized as key element around which political willingness was created. The

implementation of the program focused on encouraging and mobilizing rural communities to grow

and use local foods. National policies aimed at strengthening coordination between different

departments, health, nutrition, agriculture, water supply and sanitation. A nation wide IEC campaign

was launched with nutrition at the focus.

CONCEPT AND IMPLEMENTATION PROCESS

The long term strategies focused on integration of the nutrition component with Poverty Alleviation

Programs and rural development programs. Community based interventions were strengthened

through effective organization of the communities, establishment of institutions at community level

8 ICDS Data: Mayurbhanj District

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like Village Development Committees, and Mothers Committees. Community level training sessions

were organized to strengthen interventions at community level. The key lessons learnt from the

Thailand experience that a combination of long and short term strategies was imperative to bring

about significant change in nutrition status of under- five children. The need was to integrate food

and nutrition with poverty programs, link facilitators to mobilizers for family support of lagging

children and sustained support of social infrastructure through “thick and thin” pay offs.

OUTCOME

With interventions starting as early as 1940’s with focus on long and short term interventions,

Thailand has the fastest reduction rate of malnutrition in the world at 3% per year. By 1991, only one

in five is still malnourished, moderate and severe malnutrition has been virtually eliminated.

REPLICABILITY

The Thailand approach has high scalability potential because the interventions have wide range

implications and require full proof planning at the state level. It requires creation of political will for

integrated planning with line departments focusing on nutrition as a common agenda.

3.5 DULAR


Dular is an intensive community mobilization effort. It focuses on empowering families through

intensive inter personal communication, development of community based networks; create a

convergent working culture and proper monitoring systems.

CONCEPT AND IMPLEMENTATION

Dular in Bihar has a good combination of systemic strengthening through establishment of block and

District level support systems, along with community level interventions with ‘Local Resource

Persons’ (LRPs) and women volunteers who act as an interface between community and

Government delivery systems. The Local Resource Persons conduct inter-personal visits to lagging

households and support community monitoring systems. Village Contact Drives were carried out for

the identification of local resource persons. Capacity building plans, inter-sectoral partnership,

networking, effective monitoring and evaluation are key components of Dular.

REPLICABILITY

The Dular strategy has now been replicated in all the Districts of Bihar and Jharkhand. An evaluation

was carried out by Tuft University, UK and brought out that there were significant improvements in

the process indicators of nutrition. The philosophy of the Dular has the potential to be tailored to

different socio- political conditions within the state.

3.6 ICDS IV – REFORMS IN ICDS

ICDS IV supported by World Bank has been initiated in eight states of India based on experiences and

gap analysis of ICDS III implementation. The reforms process aims at restructuring institutional

arrangements at all levels. This links to strengthening of infrastructure at service delivery at AWCs

and targeting infants and children below the age of three. The key principles of the ICDS IV reforms

aim at simplifying processes and develop evidence and outcome based designs. Flexibility to design

ICDS at the state level, stronger convergence with line departments, strong monitoring and

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30


evaluation and intensive efforts targeted in high burden Districts. Though Orissa is not included in

the ICDS IV it is relevant the principles be adopted for achieving better results in the state.

3.7 MANAGEMENT INFORMATION SYSTEM – MAHARASTRA

While this cannot be called an approach in itself, the MIS system adopted in Maharastra, has been

acclaimed as one of the most effective project management systems that has helped in the

strengthening the monitoring mechanisms in the state. The system is designed for greater

accountability of functionaries at different levels, appropriate reporting and effective decision

making based on data generated. The focus is on centralized data base that is internet enabled at all

levels. The data generated at the AWC level is validated at the supervisor’s level and entered into

the system in the CDPO’s office. Along with data generated on performance of AWCs regards

malnutrition, the software is designed to provide information on AWCs, number of trained

functionaries, exception reports ( timeliness and completed data entry), and a feedback to the user

on the quality of data generated. The MIS system requires finalized formats for data collection duly

vetted by functionaries, District cells and project offices equipped with computers and internet

connection, all CDPOs allotted with user IDs and passwords and also have computers that are DVD

compatible to provide for intermittent training and IEC sessions.

REPLICABILITY

Replicability potential is high. It requires allocation of funds for infrastructure development at CDPO

level and the training of personnel on computer use. Since reporting is often seen as one of the

weakest factors in all projects, it is imperative to design simple reporting systems. Moreover, there is

evidence that reforms are better implemented if good quality data and information is available at

the level of policy makers to enable them to take quick and appropriate decisions.

3.8 DIFFERENT MODELS OF COMMUNITY MONITORING

Community monitoring is a critical aspect of decentralized planning. It aims to empower

communities with desired abilities to monitor development programs designed and implemented

with their involvement. It encourages participation and ownership, promotes transparency and

accountability amongst service providers and community facilitators, emphasizes equity and

diversity and ensures rights and dignity amongst all.

Table 5 Components of Community Monitoring

Self Monitoring Tool

and Social Map

People Based

Monitoring

Gram Sabha Social Audit

An important

participatory process

that enables

communities to monitor

practices of health and

nutrition in a user –

friendly manner, in sync

with local customs and

traditions in a cost

effective method. The

issues for monitoring

and indicators are

People based systems

focus on the involvement

of community based

organizations like the

PRIs, SHGs and aim to

minimize social exclusion

through emphasis on

representation of women,

SC/ST and minority

population. The activities

are planned and assessed

during village meetings

Revitalization of local

governance for Health

and Nutrition. It

ensures the

integration of health

and nutrition aspects

in the Gram Sabha

with executive order

and political

mandates. It

encourages people to

ask question on home

Social audits are

democratic

processes for

public

accountability &

systematic demand

of information

through

involvement of

Project

implementing

agencies, civil

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Table 5 Components of Community Monitoring

Self Monitoring Tool

and Social Map

People Based

Monitoring

Gram Sabha Social Audit

normally finalized with

the AWW and the

community enhances

coordination between

community volunteers

and AWW. Since there is

high level of

involvement by the

community, it enhances

demand for quality

services by them.

organized on a monthly

basis and look at

distribution SNP and

other health supplies and

monitor home visits. This

is line with the

requirements of the 73rd

amendment of the

constitution.

visit and nutrition

supplies thereby

prompting for better

service delivery

mechanisms. Most

importantly, it enables

people to know their

entitlements and

enhances

transparency amongst

community members.

society and

Panchayat Raj

institutions. The

process encourages

review of the

quality of work,

promotes quick

decision making

and enhances

transparency and

social capital.

3.9 CONCLUSION

To conclude, ICDS services were designed to address multidimensional causes of malnutrition.

However, findings from studies carried out by different agencies like World Bank, UNICEF, WFP9 all

point to the need to refocus ICDS services on the most important determinants of malnutrition. This

implies:

� Firstly, emphasis of the program on the disease control and prevention activities, education

to improve home based child care, feeding practices and micronutrient supplementation.

� Secondly, activities need to be better targeted towards the vulnerable age groups (children

under -2 and pregnant women).

� Thirdly, supplementary feeding needs to be targeted towards those who need it most and

growth monitoring needs to be done regularly.

� Fourthly, involving communities in the implementation and the monitoring of ICDS in order

to bring in additional resources into AWCs were issues that were considered to strengthen

the implementation of ICDS in Orissa.

9 Michele Gragnolati & Monica Das Gupta etal, Call for Reforms Introduction

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CHAPTER – IV

FIELD STUDY FINDINGS

The Evidence based nutrition plan has two aspects; desk review of studies and approaches on

malnutrition interventions and a field study in select Districts of Orissa. The field study involved

interactions with community, ICDS functionaries and of other line departments at different levels

with the following objectives;

• To assess the coverage of services of the Anganwadi Centres (AWCs)

• To understand the key barriers in utilization of services by the community

• To understand the perceptions of beneficiaries regarding the services.

Further, it identifies the gaps in infrastructure, service provision, skills of service providers and need

for capacity building of service providers. It also identifies good practices and the prevailing

convergence between various departments at different levels for effective functioning of the ICDS.

The study was conducted in five Districts of Orissa covering ten AWCs in each District. The Districts

covered in the study include Kendrapara, Keonjhar, Sambalpur, Rayagada and Kalahandi.

4.1 METHODOLOGY

The methodology used both

qualitative and quantitative data

collection tools. According to

suggestions of the Advisory Group,

two blocks in each of the Districts

were identified based on

performance and accessibility. From

each block, five AWCs were selected

as units for study (Figure-11). The

study captures views from various

service providers, stake holders, and

community through FGDs, interview

schedules and observations.

Interviews were conducted at all

levels, village, block and District.

100% enumeration of all the

households was carried out in the

catchments area of the selected AWC.

Interviews were conducted with District and block level officials of ICDS, Health and RWSS. Skill and

infrastructure observation of the AWW and the AWCs were conducted in each village.

4.2 RESULTS

i) The study indicates that overall just over 70% of the children in the age group 6 months to 3

years and 3 to 6 years avail any services of ICDS

Figure: 11

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33


ii) 76.5% pregnant mothers (PM) and

64% of lactating mothers (LM) avail

any ICDS services (Table-6).

iii) The study supports NFHS findings

that the uptake of services is higher

in tribal Districts (Table-7) as

compared to coastal Districts. The

ICDS coverage is more Orissa than

India (Figure-12).

Table 6 Beneficiaries availing and not availing any service of ICDS

Beneficiaries Pregnant mother Lactating

Mothers

Children (6

months to 3 years)

Children (3 years to 6

Years)

No’s % No’s % No’s % No’s %

Availing 202 76.5 390 64 1111 72.3 1448 71.8

Non-Availing 62 23.5 219 36 425 27.7 568 28.2

Total 264 100 609 100 1536 100 2016 100

Table 7 Percentage of beneficiaries availing services by social group

General SC ST OBC TOTAL District

Av

ailin

g

No

n-

Av

ailin

g

Av

ailin

g

No

n-

Av

ailin

g

Av

ailin

g

No

n-

Av

ailin

g

Av

ailin

g

No

n-

Av

ailin

g

Av

ailin

g

No

n-

Av

ailin

g

Kendrapada 84% 16% 81% 19% 75% 25% 83% 17% 83% 17%

Keonjhar 63% 37% 58% 42% 76% 24% 63% 37% 70% 30%

Sambalpur 88% 13% 92% 8% 85% 15% 84% 16% 87% 13%

Kalahandi 94% 6% 97% 3% 97% 3% 87% 13% 94% 6%

iv) 52% of AWCs showed 100% immunization coverage while 26% of the AWCs showed more

than 90% coverage. The main reasons cited for not being able to achieve 100%

immunization is the lack of cooperation from parents and non-availability of vaccines. (This

is from AWC reporting data)

ICDS Coverage

�72% of NFHS-3 enumeration areas (EAs) in India and 71%

in Orissa are covered by an

Anganwadi Centre.

� 62% of EAs in India and 57% in Orissa are covered by an AWC

that has existed for at least 5

years. NFHS- 3, O r i ssa, 2005- 06

Figure: 12

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4.3 FINDINGS ON PERCEPTION OF BENEFICIARIES AND OTHER STAKEHOLDERS ON

SERVICE DELIVERY, SKILLS AND KEY BARRIERS

i) Awareness about ICDS services is good. The need and importance of immunization is

realized by the beneficiaries. Poor roads and forest areas were cited as barriers to access.

22% of the AWCs studied are geographically inaccessible (beneficiaries do not live within

easy access of an AWC)

ii) The behavior, attitude and competency of AWW were appreciated by beneficiaries availing

services where as 70% of the non- availing beneficiaries complained about the competency

of the AWW, implying this was a reason for non-use of ICDS services.

iii) The study shows that social exclusion is not a major concern in service delivery. 81.6% of

the AWHs opine that all children have food together irrespective of their caste.

iv) From 20 FGDs (of availing beneficiaries excluding adolescents) only 3 groups expressed

irregularity of services. Four groups felt that immunization was regular while two groups felt

that PSE was regular.

v) The general consensus with respect to the quality of food provided is that it is poor and

there is no variety.

vi) Adolescent girls who attend clubs e.g. Balika and Kishori are better informed about issues

like health and hygiene. However, they expressed the need for vocational training for

income generation opportunities.

4.4 REASONS FOR NON-AVAILING SERVICES

i) Although awareness about ICDS and AWC is considerable, accessibility to the services by all

beneficiaries is an issue of concern. The reasons cited by non-availing beneficiaries are

geographical barriers, inadequate information about range of AWC services, incompetence

of AWW, untimely supply of vaccines, ORS and quality of food provided.

ii) AWWs expressed that they do not have regular supply of ORS and vaccines. They are

overburdened with various other duties like election duty, SHG, etc. and are hence not able

to focus solely on ICDS (Table-8).

Table 8 Reasons for not able to give sufficient time in delivering ICDS services by AWW

Issues Kendrapada Keonjhar Sambalpur Kalahandi Rayagada

1. Distance to be traveled � � � � �

2. SHG work � � � � �

3. Bank related activities � � � � �

4. Register/record maintenance � � � � �

5. Immunization services � � � � �

6. Election work � � � � �

7. Attending training � � � � �

8. Working with NGOs � � � � �

Except Kalahandi in all the other four Districts AWWs felt that due to various reasons they are not

able to give sufficient time in delivering ICDS services

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4.5 SKILLS OF SERVICE PROVIDERS

The study revealed that 42% of AWWs are educated up to standard nine. Though 96% of the AWWs

were trained, only 50% of them felt the training was useful. Most AWWs were of the opinion that

the training helped in conducting PSE. 22.2% of the ICDS supervisors were matriculates and 61.1%

were graduates. Only 89% of the supervisors have been trained.

The findings on the daily functions of the AWWs is quiet satisfactory. 94% of AWW organize PSE (Pre

School Education) daily, 72% organize spot feeding and supplementary nutrition and 66% go for

home visits. On a monthly basis 68% are involved in THR (Take Home ration) and RTE (Ready to Eat)

distribution. During house visits 96% of the AWWs counsel the mother, 78% impart health and

nutrition education, only 54% monitor the weight of the children and just 22% are involved in

detection of illness.

20% of AWWs mentioned that they had not seen severe malnutrition. Of the remaining AWWs, 80%

counsel, 95% suggest referral services and 57% give double ration.

72.9% of the AWWs had good behavior according to beneficiaries, 21.3% have poor communication

skills and 53.2% had very poor communication skills. The attitude of AWW towards marginalized

sections was mostly found satisfactory. Only 4% scored below average.

4.6 OBSERVATIONS ON GAPS IN

INFRASTRUCTURE

Lack of infrastructure in AWC with respect

to having its own building (Figure-13),

drinking water, toilet facility, storage

facility, cooking utensils, medical kits,

education material are all areas of

concern. Not even half of the AWCs have

their own building (38%). 37.5% of the

AWCs are located in primary schools

(Figure-14).

It is striking to note that:

• Only 8% AWCs have toilet facilities.

• Only 54% have functional water

facilities.

• 18% of AWCs do not have weighing

scales and 16% have defunct scales.

This means 34% AWCs do not use

scales.

• Non-availability of learning material

ranges from 36% to as high as 72%.

The findings of the study indicate the

following areas where efforts are required to accelerate and improve the available services of ICDS:

Figure: 13

Figure: 14

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• Barriers to the beneficiaries accessing services

• Capacity building of AWWs and AWHs specifically on communication and mobilization skills

and Supervisor training.

• Equipping the AWCs with supplies (medicines, weighing machines, IEC materials, water and

sanitation facilities, utensils etc)

4.7 SUGGESTIONS FROM DISTRICT

LEVEL ICDS AND HEALTH

FUNCTIONARIES

Interactions with key Health and ICDS

functionaries brought out some critical

points that confirmed the problems

identified (Figure-15) in the desk review and

also highlighted as practical difficulties they

faced during implementation of the

programme.

4.7.1 Convergence:

The scope of convergence between health and ICDS are immense in terms of joint implementation

of number of activities having common goal (Figure-16). The following are few suggestions given by

respondents:

• Joint planning, monitoring

with a ‘cautious’ involvement

of PRI

• Joint implementation

guidelines like VHSC, FHND,

untied fund, sector meeting,

home visits should be

focussed.

• Sector alignment and joint

visits are suggested to be the

most crucial one.

• Strengthening Pushtikar Divas,

FHND, Theme of the Month and Health Day.

4.7.2 Capacity Building

The major suggestions are

• Skill and capacity of AWWs needs to be upgraded keeping IMNCI, Mapedi, IYCF, and the

treatment of the minor ailments to handle the above mentioned issues independently.

• Need of improvement in the quality of training and AWTC (Anganwadi Training Centres) to

be strengthened with equipment and quality trainers.

Figure: 15

Figure: 16

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• More ongoing capacity building is required than long duration classroom trainings.

4.7.3 HR, Infrastructure, Monitoring and Supervision

The major suggestions which needs attention are

• Infrastructure is a prerequisite in the absence of which the quality of service delivery suffers.

• In places where AWC operates in schools, pre – school activities have to be wound up earlier

than the scheduled time. The major fall outs of these are that monitoring and supervision is

weak. Parents do not feel encouraged to send their little children to the AWC. Normally the

worst class room in the school is let out for the functioning of the AWC which makes it very

difficult for the AWW to retain both the interest of the parents and the child.

• Vacancy (Kendrapara, out of 52 Supervisor posts only 9 supervisors are in place) of

supervisory staff greatly impacts on joint meetings, reviews, data triangulation, reporting

and monitoring.

• Supervisory visits of District and block level officials to the village is reduced due to focus on

administrative issues like utilization of funds, check records, explain new schemes, formats

efficiently filled up etc. There is little time left in District reviews to emphasize on

malnutrition issues.

• Supervisors should be attached to Project Offices to ensure accountability.

4.7.4 Food Supplementation

There was a clear recommendation for RTE for all children since there was a possibility of

strengthening it with micronutrients. One tea spoon of oil/ butter/ ghee in supplementary feeding

per child was recommended. Traditional Chhatua and Jaggery were recommended to given in

palatable recipes as a cost effective method to combat protein energy deficiency and anemia.

4.7.5 Community Participation

The major suggestions are

• SHGs as change agents to promote positive behavior among the community members.

• Construction of baby friendly AWCs with ramps for physically challenged

• Ensuring community participation especially in remote tribal Districts where AWW is not

staying at HQs and often commute from distant villages.

• Accommodation for AWWs and LS especially in the inaccessible pockets

4.8 BEST PRACTICES

• Community based interventions like the PD Approach was successful in addressing issues on

malnutrition at the village level. The involvement of mothers, care givers, nutritional

counseling and child care sessions worked well.

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• The IMNCI training provided to AWWs was of good quality and is seen to impact positively

upon the confidence and capacity of the AWWs.

• The INHP initiative of using NGOs, with good training and orientation was considered very

important in Districts like Rayagada, Keonjhar and Kalahandi. This helped in wider coverage

and supports better reporting.

4.9 CONCLUSION

In conclusion, the key pointers from the field study and interactions with the different functionaries

brings out that re-organizing sector boundaries, strengthening service delivery through staff

placement, regular monitoring at all levels, and effective convergence between Health, ICDS, RWSS,

will help in increasing the impact of ICDS programme. There is a need to ensure a firm front line

contact and coordination through rigorous training especially on counselling skills.

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CHAPTER – V

OPERATIONAL PLAN FOR REDUCING MALNUTRITION

This chapter consists of the nutrition plan based on the recommendations emerging from the desk

review, different approaches and the field study. The Operational Plan to combat malnutrition in the

state, incorporates strategies to support convergent health and nutrition services at the grass root

level encompassing disease control and prevention activities; education to improve home based

newborn and child care; feeding practices including diet diversification and micronutrient

supplementation; and greater convergent health and nutrition actions, uninterrupted and

qualitative delivery of ICDS services with a focus on nutritionally vulnerable, poor and socially

excluded, improve departmental coordination between ICDS, Health, RWSS and Panchayati Raj that

needed to be ingrained in our priorities to accelerate the pace of reducing malnutrition and

improving child survival in the state.

The nutritional plan of Orissa is founded on the Goals of the National

Nutrition Policy as well as the 11th

Plan on Nutrition

5.1 GOAL

To achieve maximum nutritional health for all children below six years of age, especially

from the poorest and the most disadvantaged through effective inter-sectoral

coordination.

The objectives of the plan are: (2009-2013)

• Bring down malnutrition from current level of the children by 4 years

i) Underweight from 41% to 25% focusing on ST with a reduction of 3.5% every

year

ii) Stunting from 45% to 35% with a reduction of 2.5% every year

iii) Wasting from 20% to 10% with a reduction of 2.5 % every year

• Bring down severe malnutrition from current level by 50% (17% ICDS MPR, January

2009)

• Bring down the prevalence of anemia among Children from 65% to 50% with a special

focus on ST (from 80% to 65%) and girls (67% to 50%) Women from 61% to 50%

• Improve Vitamin-A coverage from 72% to 85% (DLHS III)

• Improve adequate Iodized salt coverage by 50%

• Increase the % of children breast fed within one hour from 55% to 80 %.

• Increase the % of children exclusively breastfed till 6 months of age from 51% to 70%.

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• Increase the timely complementary feeding from 66% to 80%

• Increase complete immunization coverage from 64% to 80%

The outcome of the nutrition plan will result in (specifically in high burden Districts)

• Reduction of moderate and severe Malnutrition in children under two years

• Reduction in the proportion of births with birth weight less than 2.5 kg

• Reduction in nutritional anemia in women and children

5.2 PRINCIPLES OF OPERATIONAL PLAN

Targeting: A differential implementation mechanism needs to be adapted to impact upon the critical

44% of children who suffer from under-nutrition in the state; since a blanket approach generally

excludes the vulnerable communities in effectively accessing and utilizing services. The critical

geographical areas (less populated, difficult to reach) and vulnerable communities could be mapped

so that focused and area specific actions could be taken based on the critical nutritional indicators.

This goes beyond establishment of infrastructure like Mini AWCs but stresses more on varied levels

of implementation in these areas; a package of services which would include an AWC, AWW posted,

trained and equipped, simple monitoring formats, timely supplies, joint with health functionaries

that impacts upon effective service delivery(Table-9). Keeping that in view the plan has focused on

High burden Districts of Orissa.

Flexibility: Area specific needs to be part of District plans for enhanced impact of ICDS. Innovative

strategies should be allowed so that Districts are able to take greater responsibility and ownership of

their ICDS schemes. This can be achieved through development of District plans, decentralized

planning at village levels through participatory processes, availability of funds at AWC level,

especially in high burden Districts and provision of extra funds to high burden Districts to carry out

innovative strategies to ensure maximum out reach.

Evidence and Outcome Based planning: This refers to the process through which the department

could create evidences of successes reduction of malnutrition and advocate with other less

performing AWCs for replication of the specific strategies. Towards this it is important that hard

facts on malnutrition are reported and discussed. This helps to build a culture in which people are

encouraged to tell the truth, even though it might sound startling. Evidence base also encourages

fact based decision making. Incentivising accurate reporting will encourage the AWW to treat her

centre for experimenting new ideas and learning. The results are expected to be achieved based on

expanding partnerships with community, PRIs, NGOs, private and corporate participation

encouraging PPP (Public Private Partnership) mode.

Stronger Convergence: Convergence with other services, especially between Health and ICDS is

integral to achieve maternal child health, family planning use, treatment of illness and reduction in

mortality. Water, sanitation and environment borne diseases, like diarrhoea, malaria and ARI (acute

respiratory infections) are major contributants to malnourishment especially in the remote Districts.

Collaboration with Rural Development to mainstream nutrition concerns into their programme; like

access to safe drinking water sources, elimination of open defecation, timely repair of broken hand

pumps, adoption of positive hygiene practices, especially washing hands with soap at critical times,

diarrhoea management through awareness creation are critical aspects for reducing malnutrition.

The NRGES scheme operational under the RD department also has provisions for wages for crèche

managers for children of working mothers. Reports and studies carried out in Orissa suggest that

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malnutrition has direct linkages with food insecurity in the vulnerable Districts National Rural

Employment Guarantee Scheme (NRGES), Watershed program (Water Resources Department),

WORLP, Revised Long Term Action Plan in KBK Districts provide a platform to mainstream ICDS

concerns especially in their village micro plans. Expanding and strengthening partnership to non –

traditional sectors, like Agriculture, Water and Sanitation, Education is important. It is seen that

introducing simple agricultural technologies – development of kitchen gardens (already initiated in a

number of areas in Orissa), promoting local foods for use as supplementary foods, (encourage rural

communities to use local food and introduce it into complementary feeding practices introduction of

HY (High Yielding) variety of traditional pulses and millets (protein energy deficiency being high)

could be promoted.

Strong Monitoring and Results Based Framework: Results based implementation mechanism aims

at a life-cycle approach to management that integrates strategy, people, resources, processes and

measurements to improve decision-making, transparency, and accountability. The approach focuses

on achieving outcomes, implementing performance measurement, learning and changing, and

reporting performance.

Improving the governance and service delivery provided by various departments with a citizen

interface. Institutional reforms will lead to improved access and quality of basic services for the

poor. It is proposed that we have Project Support Unit established at the state level which will act as

a strategic change management unit of the department.

Key Strategies of the Nutritional Plan are:

1. Strengthened Institutional Arrangements for improved access and

utilization of ICDS services

2. Decentralized Planning identifying block priorities

3. Ensuring community participation in planning, implementation and

monitoring

4. Strengthening Service Delivery for Nutrition

5. Result Based Monitoring and Evaluation

6. Early Childhood Education

7. Interdepartmental Convergence

8. Integrated Behavior Change Communication

5.3 NUTRITION OPERATION PLAN

Based on the analysis made in the earlier chapters and the critical areas that need focus in the

forthcoming years to bring positive impact and further the reduction in malnutrition rates in Orissa,

the results matrix has two sets of activities. One set of activities can be generally implemented

across the state and the specific package of activities that need to be carried out specifically in the

high burden Districts (Table-9). The High burden Districts are Anugul, Bhadrak, Bolangir, Gajapati,

Jharsuguda, Kalahandi, Kandhamal, Keonjhar, Koraput, Malkangiri, Nawarangpur, Nuapada,

Raygada, Sambalpur and Sundergarh including KBK Districts.

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Table 9 Nutrition Operation Plan

Strategy - 1: Institutional Arrangements Strengthened for improved access and utilization

of essential nutrition and health services

Output Indicator MOV

Independent review of plan State Plan developed and ratified

Minutes of the meeting

Stakeholders at State, District and

village level aware of plans

WCD MIS and Concurrent

Monitoring system

Output-1 State Plan and

guidelines for

implementation of

integrated nutrition and

health actions developed

reflecting lessons learnt

by addressing equity

concerns

Role of nutrition and health

functionaries defined

Government and Partners Joint

Reviews

1.1 Development of State Nutrition Plan identifying gaps and bottlenecks, focusing on malnutrition in

under 2 years

1.2 Ratification and Communication of Nutrition Plan to all stakeholders

1.3 Dissemination of Nutrition State Plan through workshops at state and District level

1.4 Establishment of State Project Management Unit for convergent action in partnership with

health (Nutrition, BCC, Training, and M&E) and District Project Management Units (Nutrition, M&E

and BCC) in 15 High Burdened Districts

1.5 Job Description of ICDS vis a vis Health functionaries (AWW, ANM, ASHA, LS, LHV)

reviewed

1. 6 Ensuring supply of improved medicine kit for AWC (charts, weighing scales and IEC materials)

Strategy - 2: Decentralized Planning in all Districts (In each District all the blocks with 5

villages each following the same guidelines like NRHM but incorporating nutrition

component)


Independent review of plan Output-1 Joint District Plans

reflecting block priorities and

addressing equity concerns

developed

District integrated Plans

developed informed by baselines

data, emphasizing high burden

malnutrition pockets in the

blocks.

WCD MIS and Concurrent

Monitoring system

2.1 Development of District Nutrition Plan reflecting block priorities; identifying gaps and

bottlenecks, focusing on malnutrition in under 2, pregnant and lactating women.

2.2 District planning unit (DPMU) strengthened to initiate activities on decentralized planning,

implementation and monitoring.

2.3 District involved NGOs/CSOs, other institutions to facilitate development and implementation of

decentralized plans in outreach areas.

2.4 State and District level biannual joint review of the District plan and implementation (RDD,

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Health etc.)

Strategy – 3: Ensuring community participation in planning, implementation & monitoring


Output-1 Community

participation in

planning,

implementation and

monitoring

established to ensure

malnourishment

tracking in children

- VHSC functional in 50% AWCs

- NGOs partner in effective service

delivery and community

empowerment

- Community monitoring introduced

and implemented (self monitoring

tools, Social Audits, jansunwai

established with support from NGOs,

PRIs, community organizations)

- Independent review of

plan

- WCD MIS and Concurrent

Monitoring system

- Government and Partners

Joint Reviews


- Monitoring system,

3.1 Selected ICDS functionaries, SHGs, PRIs and Mothers Committee trained on People Based

Monitoring

3.2 Engaging SNGOs, MNGOs and FNGOs of NRHM (currently supporting RCH) to focus on nutrition

related indicators in the outreach areas

3.3 VHSCs periodically monitors and updates information and maintain data boards on key

indicators related to nutrition and health for public information

3.4 Social audit, community monitoring introduced in (20% in each year) selected blocks villages

through GKS in the high burden Districts

Strategy - 4: Strengthening Service Delivery for Nutrition and Health (0 to 2 years , 2 years –

below 6 years, Pregnant and Lactating Mothers)


Output-1 Nutrition and Health

Education Sessions conducted

NHE sessions held and reported Independent review of

plan

4.1 Ensuring quality implementation of Fixed Health and Nutrition Days with support of ANMs, ASHA;

participation of PRIs, SHG members and NGOs with service provisioning

4.2 Formation and capacity building of Mothers committee by NGOs

4.3 Quarterly recipe demonstration sessions with mothers in sync with cultural patterns and local

food habits

4.4 Planners and guide books introduced to carry out NHE sessions developed to conduct thematic

NHE

4.5 Counselling through home visits for mothers with malnourished children using mother and child

card and home visit calendar


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Output-2

Growth

Monitoring and

Promotion

- Monthly weighment for 0 to 2 years

- Quarterly growth monitoring (2 to 6 years) and

- 100% weighing efficiency achieved

- Minimum three weighment of PM during ANC

- WCD MIS

- Concurrent monitoring

4.2.1 Strengthening growth monitoring by AWW with support of Mothers committee and SHG to

ensure 100% coverage

4.2.2 Improved weighing at birth through involvement of AWWs, mothers committee and SHG

embers.


Output-3 Effective

Micronutrient

Supplementation

along with SNP

- Micronutrient supplementation done in all

AWCs in the high burden Districts/Blocks

- Chronic energy deficiency reduced in

children

- Regular procurement

and supply of IFA, de-

worming tablets,

iodized salt etc

4.3.1 Increased coverage of Vitamin A through biannual campaigns (doubling up with De-worming)

4.3.2 Filing in supply gaps (IFA for children, adolescents, pregnant and lactating mothers, de-

worming for children)

4.3.3 Improving compliance of IFA among PM, LM, AG and children through Mothers committee and

SHG members

4.3.4 Scale up SHGs initiative for promotion of iodized salt and salt trading in high burden Districts

4.3.5 Develop and provide guidelines for capacity building of AWW on micronutrients like Vitamin A

and zinc supplementation

4.3.6 Integrate with NREGA, PDS program for ensuring availability of food at HH level in high burden

Districts


Output-4 Empowering

Adolescents Girls

Adolescent Girls groups organized and

functional

Adolescent girls

participating in FHND

4.4.1 Adolescent Girls groups formed and regular interaction sessions organized in High Burden

Districts through NGOs. With a special focus on drop out of 10th class to appear in the examination

(special program of SSWB)

4.4.2 Strengthening Kishori Shakti Yojana and provision of dietary and nutritional advice on locally

available foods

4.4.3 Training Material developed and introduced for adolescent girls education on reproductive

health


Output-5 Strengthening

Service Delivery at AWC

- Uninterrupted and consistent supply of

ORS, IFA and medicines

- Availability of thermometers, adult

weighing scales and AWW Kit updated as

- Independent

Evaluations

- Monthly MIS

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per IMNCI package

4.5.1 Minimum 10 home visits by AWW and ASHA to promote maternal health, IYCF and health care

4.5.2 Assessment of ongoing training of SHG members by MNGOs

4.5.3 AWW equipped to provide essential ANC (IFA supplementation, monitoring weight gain and

high risk detection and referral)

4.5.4 Demonstration of positive hygiene practices (hand washing), use of toilets and use of safe

drinking water, use of ORS, medicines for common ailments, temperature measurement

(provisioning of nail cutter and soap) of children and advise appropriate action

4.5.5 Cluster Supervisors visit minimum 5/7 AWCs for supportive supervision using supervisory

checklist every month


Output-6

Infrastructure

Development

- Baby friendly AWC function in independent buildings,

with water and sanitation facilities, separate cooking

area in at least 50% of the AWC

- Number of AWCs opened in tribal areas

- AWWs have space to live especially in distant villages

- Percentage of AWCs having functional water facilities

increased 50%

- Percentage of AWCs having sanitation facilities

increased by 50%

- No of AWC

having water and

toilet facility

- No of AWCs with

storage and

cooking space

- No of AWCs

functional in own

buildings

4.6.1 Baby Friendly AWCs established functional in independent buildings

4.6.2 100% AWCs have access to drinking water and sanitation facilities

4.6.3 Adequate number of AWCs opened in tribal on priority basis

4.6.3 Sector Resource Centres constructed/rented for ICDS supervisors

4.6.4 Construction of Sector Supervisor HQ to promote joint planning, monitoring and review in high

burden Districts

4.6.5 Provision of Display Boards to AWCs for sensitizing the community regarding their rights and

entitlements with regard to health and nutrition

4.6.6 Construction of maternal and child health activity rooms for ANCs


Output-7 Capacity

Building of ICDS

functionaries

- Trainings and Capacity Building Calendars

developed and implemented

- AWW and grass root functionaries

demonstrate knowledge and skills

regards IPC and mobilizing activities

- Training Modules on supportive

supervision developed and implemented

- Comprehensive Training

Calendar document

prepared

- Training Modules

developed

- Independent evaluations

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4.7. 1 Comprehensive skill development of AWW on IMNCI, ANC and IYCF

4.7.2 Training of AWW, LS, CDPO and DSWO on WHO standards and decentralized joint planning

4.7.3 Skill up gradation of AWW – IPC on counseling, life cycle approach, prioritized home visits,

FHND

4.7.4 Short training on record maintenance and pre-school activities

4.7.6 Training of SA, LS and CDPO on computing

4.7.7 Mothers committee training by NGOs

4.7.8 All LS and CDPOs are trained in supportive supervision

4.7. 9 Capacity assessment of state and District training institutes

4.7.10 Development of comprehensive training calendars and modules jointly with health

Strategy - 5: Monitoring and Evaluation


Output-1 Improved Quality

of data collected and

increased use of data for

management and decision

making

- Monthly Electronic report

generated

- Annual Performance plan

prepared

- Baseline commissioned

- Independent baseline

report


Monitoring system

- PD assessment report

5.1 CDPO equipped with Computer and internet password/ID to facilitate internet compatible data

entry and strengthen e-pragati

5.2 Develop appropriate software to check internal data consistency and auto checks

5.3 AMC for three years to support and handhold to generate and manage electronic report.

5.4 Monthly Exception reports generated and feedback on status of reports generated and shared

with blocks

5.5 Annual Performance Plans developed and reviewed to fix accountabilities at all levels.

5.6 Compilation and triangulation of Sector Level data and discussion at block level

5.7 Monthly Joint District review on common indicators on malnutrition reduction

5.8 Development of Case studies and Audio Visuals on successful projects on malnutrition reduction

5.9 Annual Assessments in selected Districts to promote evidence based programming

5.10 Independent survey in every alternative year to assess nutritional status

5.11 Assessment of current PD initiatives for replication

5.12 Independent baseline and end line for the project period

Strategy - 6 : Early Childhood Care Education


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Output-1

Improved

Quality of

ECE

- ECE conducted regularly with

high attendance of children

- Availability of joyful TLM

- Enhanced skills of AWWs to

carry out ECE

- Independent review of plan

- WCD MIS and Concurrent Monitoring system

- Government and Partners Joint Reviews

- WCD MIS and Concurrent Monitoring system,

6.1 Setting up of resource centre at District level with the help of SCERT, DIET, SSA and other

agencies to revisit curriculum based on Arunima and develop material for training at all level

6.2 Setting a District resource /core group for planning activities, for proper implementations of

activities and monitoring of the program implementation

6.3 Joyful and activity based teaching methods introduced based on teaching and learning materials

6.4 Community Based Crèche with support of Adolescent girl volunteers for migrant and daily wage

labors at work sites (NRGES and RDD) with daily wages.

Strategy – 7 Interdepartmental convergence


Output 1- Establish systems to

ensure interdepartmental

convergence and facilitate

joint review and monitoring at

each level (State, District,

block, sector and village)

- Joint activities carried out in

convergence with Health, RDD

and PR depts. at State, District,

Block and Village levels

- Joint Task Force set up and

functional

- No of department

aligned

- No of joint meeting held

- No of joint reviews held

- No of joint letter and

guidelines issues

7.1 Set up Task force (RDD, Health, PR and Education) for interdepartmental convergence and ensure

periodic meeting for policy formulation and review.

7.2 Up scaling of IMNCI in High Burden Districts

7.3 Up scaling Positive Deviance in High Burden Districts

7.4 Issue joint guidelines on schemes like JSY, FHND, VHSC etc

7.5 Joint Monitoring Indicators Health and ICDS agreed, implemented and reviewed at all level

7.6 Sector alignment of health ICDS for better convergence

7.7 Activity schedule for all functionaries developed for delivery of convergent health and nutrition

actions

7.8 Van Surakhya Samitees and Horticulture functionaries involved in promotion of local foods

through kitchen gardens

7.9 All referrals to be addressed by the concerned health service providers

Strategy - 8 Behavior Change Communication


Output-1 A State level communication strategy developed Concurrent

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Communication

strategies for

behavior change,

reflecting equity

concerns, developed

In all 30 Districts and especially in high burden pockets

men, women of different socio-economic groups and

functionaries at all levels understand and practice key

behaviors related to IYCF, IMNCI, ANC , hygiene

practices, use of impregnated bed nets, immunization.

Monitoring

Systems

Rapid Assessments

8.1 Assess and refine approaches to communication, focusing on sustainability, effectiveness and

outreach through a Review and Assessment of BCC material

8.2 Integrated BCC strategy for Health and Nutrition developed through OHSP for behavior change

around under nutrition, IYCF, hygiene practices, use of impregnated bed nets and immunization

8.3 Skill development training of AWWs, ANMs and ASHA on BCC

8.4 Prepare community friendly communication materials for behavior change

8.5 Pilot integrated communication strategy to reduce child malnutrition in high burden Districts

8.6 Social Mobilization Campaigns carried out at Village level through village rallies, street plays,

slogan etc

8.7 Use of specific BCC approaches through SHGs, VHSCs, NGOs, PRI members, Mothers Committee

and Adolescent girls

8.8 Intensify Inter – personal contacts through the cadre of AWWs, AWHs, ASHA through home

visits, counselling, FHNDs, Mothers Meetings, SHG meetings, Adolescent girls groups

8.9 State Wide Media Campaign – Sanjog to create wider awareness on malnutrition

8.10 Integrate with RDD, Health, ITDA (in tribal regions) NRGES, livelihood programs to have nutrition

on their IEC plan.

8.11Tools like, Home visit planner, supervisory checklist, CDPO checklist, sector meeting checklist,

BLAC and DLAC developed and printed

8.12 Celebrations of various days like ICDS Day, Nutrition Week, Breast feeding week (media

Strategy) at different levels from State till village to create awareness.

8.13 Organizing local folk media at GP levels in 500 GPs for communication of critical health and

nutrition messages in outreach areas

8.14 Use of innovative methods/forums of BCC like Hat Bazaar, adolescent groups and radio

programmes based on local needs

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DESK REVIEW OF LITERATURE FOR THE NUTRITION STUDY

SL Name of the Document Agency

1 Micronutrient Profile of Indian Population Indian Council of Medical Research,

New Delhi 2004

2 IX Asian Congress of Nutrition – Vision 2020 Nutrition Foundation of India,

Nutrition Society of India

3 Improving Child Nutrition Outcomes in India World Bank Policy Research Working

Paper – June 2005

4 India Undernourished Children – A Call for Reform and

Action

World Bank Report

5 Impact of Positive Deviance in West Bengal National Institute of Nutrition,

Hyerabad 2006

6 Effectiveness of Large Scale Nutrition Interventions

7 Anaemia in Pregnancy Nutrition Foundation of India

8 Combating Low Birth Weight and Intra Uterine Growth

Retardation

Nutrition Foundation of India

9 Vitamin A and Iron Folic Acid – A Case Study

(Programme Evaluation)

Ministry of Health and Family

welfare, GoI

10 Annual Activity Report (2006 -2007) WCD Department, GoO

11 Annual Activity Report (2006-2007) Rural Development Department, GoO

12 Evaluation of Dular – successful approach in Bihar and

Jharkhand

Tuft University, UNICEF

13 Evaluation of Positive Deviance

14 Lancet series

15 District Statistical handbook (Sambalpur , Rayagada,

Kendrapara, Keonjhar, Kalahandi)

Government of Orissa

16 Orissa : Food Insecurity and Vulnerability FAO – UN

17 Formats for Field Study

18 Analysis and Results; ICDS Report WFP

19 Benefits and Safety of Administration of Vitamin A to

Pre School Children and Pregnant & lactating Women

National Consultation, New Delhi

September 2000

20 Elimination of Micronutrient Deficiencies through

Food Fortification

National Conference, Jaipur,

February 1999

21 Compendium of Micronutrients

22 Preparedness of PRIs in Operation of Water and

Sanitation Systems

State Water and sanitation Mission,

RD Department

23 Operational Guidelines for implementation of TSC in State Water and sanitation Mission,

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50


SL Name of the Document Agency

Orissa RD Department

24 Communication Needs Assessment State Water and sanitation Mission,

RD Department

25 Study on Environmental Health Outcomes of

Improving Rural Sanitation and Hygiene

World Bank Report - State Water and

sanitation Mission, RD Department

26 Benefits and Safety of Administration of Vitamin A to

Pre School Children ad Pregnant and lactating Women

National Consultation, New Delhi

September 2000

27 Food Security Atlas of Rural Orissa WFP

State level Workshop on dissemination of StateNutrition Plan

50,000 1 50,000 50,000

Distrcit level Workshop on dissemination of StateNutrition Plan

11,300 30 339,000 339,000

Establishment of State Project Management Unitfor convergent action in partnership with health(Nutrition, BCC, Training, and M&E)

1,250,000 4 1,250,000 1,250,000 1,250,000 1,250,000 5,000,000

Establishment of District Project Management Unitsfor convergent action in partnership with health(Nutrition, BCC and M&E) in 15 High BurdenDistricts

985,000 60 14,775,000 14,775,000 14,775,000 14,775,000 59,100,000

16,414,000 16,025,000 16,025,000 16,025,000 64,489,0000 0 0 0 0

Joint District Plansreflecting block prioritiesand addressing equityconcerns developed

Development of District Nutrition Plan reflectingblock priorities; identifying gaps and bottlenecks,focusing on malnutrition in Under 2 Children,Pregnant and Lactating Women

11,300 120 339,000 339,000 339,000 339,000 1,356,000

339,000 339,000 339,000 339,000 1,356,0000 0 0 0 0

Community participation inplanning, implementationand monitoringestablished to ensuremalnourishment trackingin children

Social Audit, Community Monitoring introduced in(25% in each year) selected blocks villages throughGKS in the 15 High Burden Districts

10,000 2,000 5,000,000 5,000,000 5,000,000 5,000,000 20,000,000

5,000,000 5,000,000 5,000,000 5,000,000 20,000,0000 0 0 0 0

Nutrition and HealthEducation Sessionsconducted

Six monthly Recipe Demonstration sessions withmothers in sync with cultural patterns and localfood habits

100 215,488 2,693,600 5,387,200 5,387,200 5,387,200 18,855,200

Empowering AdolescentsGirls

Adolescent Girls groups formed and regularinteraction sessions organized (50% in each year) n15 High Burdened districts through NGOs. With a

special focus on drop out of 10th class to appear inthe examination (special program of SSWB)

2,250 53,872 30,303,000 30,303,000 30,303,000 30,303,000 121,212,000

Strategy ‐ 4: Strengthening Service Delivery for Nutrition and health (0 to 2

YEAR 4 ESTIMATED BUDGET

Strategy ‐ 1: Institutional Arrangements Strengthened for improved access and State Plan and Guidelinesfor implementation ofintegrated nutrition andhealth actions developedreflecting lessons learnt byaddressing equity concerns

Strategy ‐ 2: Decentralized Planning in all districts

Strategy ‐ 3: Ensuring community participation in planning, implementation

STATE NUTRITION PLAN (2009‐2013)Districts = 30 (15 High Burdened), ICDS Projects = 326 (160 High Burdened), ICDS Sectors = 2042 (1001 High Burdened), GPs = (1800 approximately High

Burdened) AWCs = 60918 (26936 High Burdened)

OUTPUT PLANNED ACTIVITIES DETAILS OF BUDGETCOST PER BATCH

NUMBER OF BATCH

YEAR 1 YEAR 2 YEAR 3



NUMBER OF BATCH


0 0 0 0 0Strengthening ServiceDelivery at AWC

Demonstration of positive hygiene practices (handwashing), use of toilets and use of safe drinkingwater, use of ORS, medicines for common ailments,temperature measurement (provisioning of nailcutter and soap) of children and advise appropriateaction

800 80,808 21,548,800 21,548,800 21,548,800 64,646,400

0 0 0 0 0Infrastructure Development

Provision of display board to AWC for sensitizing thecommunity regarding their rights and entitlementwith regard to health and nutrition

200 80,808 5,387,200 5,387,200 5,387,200 16,161,600

0 0 0 0 01 Day Training of DSWO, CDPO and LS on WHO standards and decentralized joint planning

5950 39 232,050 232,050

1 Day Training of AWW on WHO standards and decentralized joint planning

3800 898 1,706,200 1,706,200 3,412,400

Mothers commee training by NGOs 2250 53,872 60,606,000 60,606,000 121,212,000Capacity assessment of state and District TrainingInstitutes

1,000,000 1 1,000,000 1,000,000

35,934,850 124,938,400 62,626,200 123,232,200 346,731,6500 0 0 0 0

E‐pragati strengthening at State and District level 7,000,000 4 4,600,000 7,000,000 7,000,000 7,000,000 25,600,000

Development of Case studies and Audio Visuals onsuccessful projects on malnutrition reduction

100,000 3 100,000 100,000 100,000 300,000

Annual Assessments in select districts to promoteevidence based programming

200,000 3 200,000 200,000 200,000 600,000

Independent survey in every alternative year toassess nutritional status

2,500,000 2 2,500,000 2,500,000 5,000,000

Assessment of current PD initiatives for replication 2,000,000 1 2,000,000 2,000,000

6,600,000 9,800,000 7,300,000 9,800,000 33,500,000

Strengthening Service Delivery Systems ‐ Strengthening Service Delivery at

Strengthening Service Delivery Systems ‐ Infrastructure Development

Capacity Building of ICDS Functionaries Capacity Building of ICDSfunctionaries

Strategy ‐ 5: Monitoring and Evaluation Improved Quality of datacollected and increased useof data for managementand decision making



NUMBER OF BATCH


0 0 0 0 0Establish systems to ensureinterdepartmental convergence and facilitatejoint review andmonitoring at each level(State, District, Block,Sector and Village)

Van Surakhya Committees and Horticulturefunctionaries involved in promotion of local foodsthrough kitchen gardens (33.3% each in 1st, 2nd and 3rd year)

250 26,936 0 2,244,667 2,244,667 2,244,667 6,734,000

0 2,244,667 2,244,667 2,244,667 6,734,0000 0 0 0 0

Skill development training of AWWs, ANMs andASHA on BCC

3800 1,731 3,288,900 3,288,900 6,577,800

Prepare community friendly communicationmaterials for behaviour change

1000 26,936 13,468,000 13,468,000 26,936,000

Social Mobilization Campaigns carried out at Villagelevel through village rallies, street plays, slogan etc.(33.3% in each year)

200 26,936 1,795,733 1,795,733 1,795,733 5,387,200

State Wide Media Campaign – Sanjog to createwider awareness on malnutrition

2,500,000 1 2,500,000 2,500,000

Tools like, Home visit planner, supervisory andCDPO checklist developed and printed Rs.85 perunit

85 125,000 5,312,500 5,312,500 10,625,000

Organizing local folk media at AWC level (33.3% ineach year) in 500 GPs for communication of criticalhealth and nutrition massages in outreach areas

500 500 83,333 83,333 83,333 250,000

Use of innovative methods/forums of BCC like HaatBazaar, Adolescent Girls group, Radio prog. basedon local needs (33.3% each in 1st, 2nd and 3rd year)

500 2,000 333,333 333,333 333,333 1,000,000

0 26,781,800 18,969,300 7,524,900 53,276,00064,287,850 185,128,867 112,504,167 164,165,767 526,086,650

State Budget 8,900,000 18,937,200 13,937,200 16,437,200 58,211,600District Budget (commonfor 30)

678,000 5,651,500 339,000 5,651,500 12,320,000

District Budget (only HighBurdened)

54,709,850 160,540,167 98,227,967 142,077,067 455,555,050

GRAND TOTAL 64,287,850 185,128,867 112,504,167 164,165,767 526,086,650

Communication strategiesfor behaviour change,reflecting equity concerns,developed

GRAND TOTAL

Strategy ‐ 7: Interdepartmental Convergence

Strategy ‐ 8: Behaviour Change Communication

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