1. India has among the highest percentages of children in the 0 to 6 age group in the world who are malnourished. The fact that this prevalence of underweight children in India is nearly double that of sub-Saharan Africa is a matter of acute concern. National Family Health Survey (NFHS-2) data (1998-99) show that 47% of children in India under 3 years were underweight for their age. If the figures for Maharashtra are analysed, we see that the percentage of underweight children under 3 fell from 54% in 1991-92 (NFHS-1) to 50% in 1998-99 (NFHS-2). That there has been a significant reduction between 1998-99 and 2005-06 (for which year provisional NFHS-3 data for Maharashtra have been released) of about 11 percent in underweight children under 3 in Maharashtra is gratifying and an indication that the war against malnutrition can be won.
2. Malnutrition needs to be understood as reflecting both protein-calorie undernutrition and micronutrient – iron, iodine, Vitamin A, zinc, etc. – deficiency, which affects many aspects of children’s development. Physical and cognitive development is impaired by malnutrition, which also increases susceptibility to diseases. Over time, there is also an impact on educational attainment and work productivity as also increased risk of proneness to adult disorders.
3. Malnutrition, therefore, needs to be approached from a life-cycle perspective. The vicious cycle starts with an underweight expectant mother, often burdened with pregnancy in her teens, inadequate spacing between successive issues, excessive work and lack of appropriate nutrition and health care. A low birth weight baby who is exposed to poor health, hygiene and nutrition practices develops into an underweight and stunted adolescent. The new cycle of early marriage and pregnancy condemns yet another generation to this vicious cycle of malnutrition. Interventions across a number of sectors are required to address this problem. In this paper, we look at the measures required in the health and nutrition sectors with specific emphasis on the critical role of the anganwadi centre (AWC) and the anganwadi worker (AWW) in bringing about permanent changes in the health and nutrition status of populations
4. The ICDS is now in its fourth decade of operation. The years since its inception in 1975 have seen a scaling up of the ICDS, which now reaches out to a large part of the country. With the recent directives of the Supreme Court laying emphasis on universalisation of this scheme, the ICDS will, hopefully, over the next few years, cover the entire country, including urban areas, which have hitherto received inadequate attention. But universalisation need not necessarily imply that every child in the 0 to 6 age group has access to the full range of ICDS services. For one, the AWC, the basic source of service delivery at the village level, still does not serve many hamlets at a distance from the main village or even the entire population in a village, especially a large one. Even the additional 12864 anganwadis recently sanctioned for Maharashtra by the Government of India (over and above the 65000 anganwadis already in existence in the State of Maharashtra) do not cover every human habitation, especially in urban slums and in remote rural areas. This has the consequence of affecting particularly disadvantaged communities, which count among them the most vulnerable women and under-3 children. A second drawback in the provision of services relates to the perception of the AWC as just a feeding centre, without adequate focus on a number of other equally, if not more, important activities of the AWC. What is important to note is that the AWC today caters largely to the 3 to 6 age group, that is, those children who are able to come to the AWC to partake of the supplementary nutrition provided in the form of cooked meals. As such, many of the other responsibilities of the AWW are given little importance, both in implementation and in supervision. This impacts particularly on children in the 0 to 3 age group, who receive little to no attention from the AWW. With the AWW burdened with her duties in the AWC, which includes preparation of food and feeding of children (in the 3-6 age group), there is no time for home visits, which would enable her to effectively counsel pregnant and nursing mothers and monitor the health and nutrition status of under-3 children and mothers. Thirdly, the lack of training of AWWs, coupled with poor motivation, often leads to a number of activities not being undertaken at the AWCs. Systematic growth monitoring of children and pre-school education, as well as effective health and nutrition counseling of adolescent girls and mothers, are the biggest casualties.
5. What then are the crucial areas of intervention where an effective, functioning anganwadi system can make a difference in reducing malnutrition and contributing to a reduction in infant and child mortality? It is necessary for policy-makers and the implementation machinery to be aware of the dual role of the AWW – as a service delivery provider and as a counselor to the mother in particular and the women in the village in general. There is need to recognize the importance of each of the several functions which form part of her work and to implement policy initiatives which allow her to discharge her duties effectively.
6. Counseling: The AWW, as the only functionary available at the community level, has an important duty to discharge as a counselor for adolescent girls and newly-married women/expectant mothers (the latter category can include their partners as also mothers-in-law). This counseling would cover various aspects relating to reproductive health and nutrition, focusing especially on the following aspects: no marriages of girls below 18 years, postponing first pregnancy till 21 years, spacing of three years between successive issues, importance of adequate protein-calorie and micronutrient consumption and tackling anaemia. There is need to provide knowledge to families on how to fortify their daily diet to include items rich in energy, proteins and essential minerals and vitamins. This could, for example, include information on fortifying atta with soyabean and on including oil, dairy products, vegetables and fruits in the family’s food basket. The AWW would monitor the number of antenatal care visits of pregnant mothers and promote the concept of delivery by a skilled birth attendant. She would counsel expectant mothers (and their family members) on the importance of commencing breastfeeding immediately after birth and continuing exclusive breastfeeding for the first six months, as also moving to complementary feeding of the child (comprising solid/semi-solid food) in the seventh month. Counseling on correct feeding practices, including the need for caregivers to practice repeated feeding (four to six times a day), is equally important to check the incidence of malnutrition.
7. Breastfeeding and complementary feeding: While early and exclusive breastfeeding is itself unsatisfactory nearly all over India, undernutrition in India increases over five-fold between 6 and 23 months, that is, the period when the child moves from exclusive breastfeeding to a regular diet and when her energy requirements increase sharply. Provisional data for Maharashtra (NFHS-3) shows that just over 50% of children are breastfed within one hour of birth and exclusively breastfed for the first 6 months. Barely 48% of children in Maharashtra receive solid or semi-solid food and breast milk between 6-9 months. This is reflective of faulty feeding practices once the child has crossed 6 months. The AWW has a crucial role here in monitoring the commencement of breastfeeding within an hour after birth and its exclusive continuation for six months thereafter and the commencement of complementary feeding once the child reaches the age of six months.
8. Immunisation and micronutrient supplementation: Provisional NFHS-3 data for Maharashtra indicates that barely 59% of children in the 12-23 month age group are fully immunized, in terms of receiving BCG and measles vaccines and three doses each of polio and DPT vaccines. Only 32% of children in the 12-35 month age group have received a six-monthly dose of Vitamin A. At the same time, 72% of children in the 6-35 month age group are anaemic. This confirms the fact that basic immunisation and micronutrient supplementation services are not reaching a significant proportion of the infant and young child population. It is here that the AWW can help in tracking the status of immunisation and micronutrient supplementation in young children. In fact, there is need to consider whether the AWC should become the depot for storage of IFA tablets/syrup, Vitamin A, deworming tablets/syrup and iodised salt, so that these can be made available to all groups in the community – adolescent girls, pregnant/nursing mothers and children in the 0-6 age group. The Government of Maharashtra has adopted a programme for giving biannual doses of deworming medicine and Vitamin A doses (every May and November) which has started in select districts and will over time be extended to the entire state. Similarly, IFA doses can be given bi-weekly to children in the 1-6 age group and adolescent girls. Making the AWC the focal point for these interventions can not only help systematize the entire procedure, it can also serve to involve the community in the implementation of these measures.
9. Growth monitoring: A major concern has been the failure to universalize the ICDS even after over thirty years of operation. The Supreme Court has ordered the establishment of AWCs in every habitation in the country and steps have been taken by the Government of India to implement this direction. Lack of universalisation not only denies access to ICDS to a large body of children, it also leads to a failure to monitor the presence of malnutrition – mild, moderate or severe – in children with the consequence that no effective steps are taken to arrest malnutrition. The excessive focus on feeding in the ICDS has tended to divert attention from growth monitoring as an important tool in child development. This is in fact one of the key interventions stressed on by the Rajmata Jijau Mother-Child Health and Nutrition Mission, set up in 2005 by the Government of Maharashtra to combat child malnutrition in the state. Monthly weighing of all children in the 0-6 age group and plotting of these weights on growth charts are the best methods of keeping track of the nutrition (as measured by weight-for-age criteria) status of children. Provision of accurate weighing scales and growth charts to AWWs facilitates this measure. Efforts have been made in this direction by the ICDS Commissionerate over the past year and it is hoped to provide every AWC with these facilities in the near future. At the same time, there is need to educate the AWW to correctly weigh the child and plot, read and interpret the growth chart intelligently. This would not only help her to identify the children in severe stages (Grades 3 & 4) of malnutrition but also to identify children whose growth shows signs of stagnation or decline over a three month period, so that all these children can be referred to the nearest medical facility for detailed examination. Growth monitoring can also be made an exercise involving the community through provision of large size (8 feet by 12 feet) community growth charts to the AWW so that she can educate the community on the weighing and gradation exercise and provoke discussion on the ways and means to reduce malnutrition.
10. Treatment of illnesses and severe malnutrition in young children: The involvement of the medical fraternity is critical in arresting severe malnutrition. Malnutrition has complex causes, which ultimately reflect in poor dietary intake and poor health outcomes. While improving dietary intake may reduce malnutrition to some extent, empirical evidence shows that the two (dietary intake and health) are intertwined and health interventions are often required to tackle severe malnutrition. Monthly medical examination of all severely malnourished children and children showing stagnation/decline in growth (as assessed by weight-for-age criteria) is essential for prescribing the correct interventions for reversing the trend of malnutrition. This also has a significant impact on reducing infant and child mortality. There is, hence, need for close interaction between the health and ICDS service delivery machinery in monitoring the status of all such children.
11. Supplementary nutrition: This has virtually become the synonym for ICDS, so much so that there is a mistaken impression in the media, lay public and even policy makers that the state is meeting the entire nutritional requirement of children in the 0-6 age group. As its name suggests, the nutrition is “supplementary”, that is, it is additional to the diet that the child is supposed to get at home. Enhanced calorie norms are prescribed for severely malnourished children and children in the Navsanjivan villages in tribal blocks of the state. However, field observations show that the prescribed food recipes in different areas are often deficient in providing the required proteins and calories. Moreover, the lack of taste suitable for young children (such as, for example, adding jaggery to the preparation) and the tendency in the AWC to require the children to take in the entire rations at one sitting are inhibiting factors in ensuring that the full nutritional benefits actually accrue. The handing over of the food preparation function to the womens’ self-help groups (SHGs) can help in improving the quality of the food, provided more imagination is exercised in devising tasty local recipes and the local community is tapped for providing additional items (like eggs, vegetables and fruits) for augmenting the nutrition at the AWCs. At the same time, take home rations for the 0-3 age group must be so devised that they appeal to that age group. The importance of repeated feeding of children through the day needs to be stressed. Above all, supplementary nutrition will fulfill its role only if it serves to educate caregivers on the components of a diet that meets all the nutrition needs of the family, particularly children and pregnant/nursing mothers.
12. Pre-school education or Early Childhood Education (ECE): Perhaps the least focused on area in the ICDS, ECE is crucial from the viewpoint of cognitive development of the child, encouraging sociability and generally promoting readiness for primary education from age 6 onwards. The AWW has been handicapped in this respect not only by the burden of other duties cast on her but also by inadequate training in how to go about ECE. Till now, the AWC has been seen primarily as a feeding centre. Hopefully, with the introduction of womens’ SHGs for preparing food, the AWW will be able to give more attention to the ECE component. However, there is need for assessing the workload of the AWW, in terms of her counseling role, the need for home visits and her other duties, in formulating an effective ECE policy, which would decide inter alia whether the AWW can effectively fulfill her ECE role or whether the ECE function needs to be transferred to another worker.
13. What are the policy implications of the above? Firstly, empowerment of the field-level ICDS worker is critical to improving motivation and promoting a learning environment. Delegation of administrative and financial powers to the level of the ICDS project block and below would ensure that activities are not hampered and that the field-level worker can take decisions on matters involving the health and nutrition needs of the community. Secondly, convergence of the activities of different departments is essential for promoting health and nutrition. The example of close coordination in health and ICDS activities has been referred to earlier. But there are many other departments, the functioning of which impacts crucially on the health and nutrition environment of the community. Water supply and sanitation, livelihood and education are prime examples of the synergistic relations between the different sectors. Channeling of funds under the Tribal Sub Plan and the Special Component Plan to the health and nutrition sectors can also yield rich dividends in terms of improved health and nutrition status of the population. Thirdly, community ownership of initiatives is central to any breakthrough in reducing malnutrition. A very large part of the success of the measures detailed in the preceding paragraphs is contingent on community involvement and acceptance. What are acceptable as community norms, whether in nutrition, health, hygiene or any behavioural practices, will translate into family behaviour that promotes sound health and nutrition. In the ultimate analysis, we must recognise that malnutrition is a human problem that can be addressed by human solutions, provided the requisite social will exists to bring about enduring change for the better.
Recommended readings
1) “Food Dole or Health, Nutrition and Development Programme?” – Shanti Ghosh in special supplement of Economic & Political Weekly (EPW), 26 August 2006
2) “India’s Undernourished Children: A Call for Reform and Action” – HNP Discussion Paper, The World Bank, August 2005 3) “Infant and Young Child Feeding: An ‘Optimal’ Approach” – Arun Gupta in special supplement of EPW, 26 August 2006
4) Articles in the special supplement on the ICDS – EPW dated 26 August 2006.
5) “Universalization with Quality: Action for ICDS, A Primer” – Right to Food Campaign, March 2006 (available online at www. righttofoodindia.org)
6) “Reaching out to the child: an Integrated Approach to Child Development” – Human Development Sector, South Asia Region, The World Bank, September 2004
Sunday, February 25, 2007
mission mode for tackling malnutrition
COMBATING CHILD MALNUTRITION IN MAHARASHTRA –
THE MARATHWADA INITIATIVE AND
THE ROAD AHEAD
V. Ramani
Director General
Rajmata Jijau Mother-Child Health and Nutrition Mission
Aurangabad, Maharashtra, India
( A Mission of the Government of Maharashtra )
THE MARATHWADA INITIATIVE
The impetus for launching a concerted campaign for tackling the scourge of malnutrition in children in the 0-6 age group had its genesis in the fourteen child deaths, apparently due to malnutrition, reported from the one village of Bhadali, taluka Vaijapur, district Aurangabad during the period 2000-2001. What was unacceptable was that this took place barely seventy kilometres from a major urban centre like Aurangabad and that this occurred after more than a quarter century of implementing the Integrated Child Development Scheme (ICDS) in Maharashtra.
2. The Malnutrition Removal Campaign launched in Aurangabad Division on 14 March 2002 focused on the following important parameters:
(a) Complete (100%) survey of all children in the 0-6 age group.
(b) 100% registration of all such children.
(c) 100% weighing of all such children.
(d) On the basis of weighing, classification of all children into normal/grade 1 to 4 categories (as appropriate).
(e) Special concentration on children in Grade 3 & 4 stages of malnutrition; regular weighing, providing for health & nutrition measures for these children.
(f) Initiating measures for ensuring health and nutrition of pregnant mothers to reduce incidence of low birth weight children.
(g) Greater attention to children in the 0-3 age group given the greater incidence of malnutrition in this age group and its implications for the future development of the child.
(h) Analysis of data to bring out the relative incidence of malnutrition based on age, gender & social status (scheduled caste/tribe) etc.
3. The first & most important step was to enhance the coverage of children in the 0-6 age group in the ICDS scheme, especially in respect of the population living outside the coverage of the anganwadi area. Statistics showed that barely 60% of the child population in the 0-6 age group was recorded in the anganwadi registers. Thereafter arose the issue of timely weighing of children, especially children who were suffering from Grade 3 & 4 levels of malnutrition. A major problem here was the availability of weighing scales. The problem was solved by the provision of 7000 weighing scales to Aurangabad Division through the intervention of UNICEF. Children in grade 3 & 4 stages of malnutrition were to be weighed once a month while other children were to be weighed once every 6 months. The grade 3 & grade 4 children then formed the core target group for both the ICDS & health machinery. Special attention was given to devising schemes aimed at improving their nutrition and health status with the objective of lifting them out of the severe malnutrition stages. These included provision of supplementary nutrition, counselling of the mothers as well as regular medical check-up of the children, particularly those suffering from grade 3 and 4 malnutrition, who were to be weighed and medically examined every month.
4. The results of the initiative belied the expectations. The initial number of children in the 0-6 age group in the grade 3 & 4 stages of malnutrition in Aurangabad Division in July 2002 was 7867, as per the ICDS records. With improved survey & weighing efficiency, the number of children in grade 3 & 4 stages of malnutrition went up to 10705 in July 2002. The subsequent concentration on Grade 3 & 4 children has seen the number come down to just over 3000 in March 2004. As of April 2005, this figure has come down to below 500.
5. The reduction in the incidence of severe malnutrition (Grade 3 & Grade 4 stages) has been possible because of three factors:
(i) Training of staff at all levels on a regular basis over the past three years. The training programmes focused on all levels right from Collectors & Chief Executive Officers (CEOs) to Dy. CEOs (ICDS), District Health Officers (DHO), Medical Officers and Child Development Project Officers (CDPOs) right upto Anganwadi Supervisors and Anganwadi Workers (AWW). Workshops were also held for elected officials of Zilla Parishads & Panchayat Samitis to enlist their active cooperation & support for the campaign.
(ii) Motivation of staff at all levels was one of the prime objectives of the training programmes, apart from imparting skills in implementing & monitoring the programmes. It was apparent that the ICDS staff had to be convinced and enthused regarding the critical importance of the tasks they were carrying out. The involvement right from the top in terms of regular workshops, visits to anganwadis and the development of an interactive atmosphere for resolving day to day issues infused new life into the machinery and gave them the opportunity to take a proactive approach in solving the problems confronting them. The Star Campaign to appreciate and recognize those anganwadis, blocks and districts that were able to show no cases of severe malnutrition introduced a spirit of healthy competition and enthusiasm in the field workers.
(iii) Monitoring of results was crucial to the success of the campaign. Detailed block level reviews (going down even to the supervisory level) at the Divisional Commissioner level and regular follow up visits and reviews at the blocks level by officers from the Divisional Commissioner’s office stressed the importance of the campaign and kept it at the forefront of the district and block level machinery priorities.
6. What is of particular significance is that the entire initiative required no additional budgetary support from government nor was any additional staff asked for. The existing ICDS machinery was motivated to perform to its fullest potential and devise local workable solutions to resolve problems arising at the local level. Regular medical check-ups of children in the 0-6 age group also showed a distinct improvement after the commencement of the campaign. Most importantly, the enthusiasm of the field-level workers translated into a significant community involvement in the campaign with far-reaching implications for the success and sustainability of the campaign.
EXTENSION OF THE MARATHWADA INITIATIVE TO OTHER AREAS
7. The focus in the media in the past couple of years on deaths of children allegedly due to malnutrition in the tribal pockets in the districts of Nandurbar and Amravati highlighted the need to have in place an effective mechanism for covering all children in the 0-6 age group under ICDS and health programmes and focusing on reduction of severe malnutrition as the first goal in the ultimate war against malnutrition and child mortality. The Marathwada initiative has shown that it can be replicated elsewhere without any major budgetary support, by focusing on significant improvement of service delivery systems in the ICDS and health sectors. Such an initiative would be of particular relevance in areas that show a higher incidence of grade 3 & 4 malnutrition in the 0-6 age group, arising out of inadequate physical infrastructure as well as poor service delivery systems, particularly in the ICDS and health sectors.
ADOPTION OF MALNUTRITION REMOVAL AS A STATE MISSION & CREATION OF A UNIT FOR IMPLEMENTATION OF THE MISSION
8. Malnutrition reduction and removal requires to be placed at the centre stage of any State’s priorities. The State of Maharashtra has, therefore, treated the removal of malnutrition as a MISSION, which is to achieve quantifiable goals in a specific time frame. The Rajmata Jijau Mother-Child Health & Nutrition Mission (Mission) functions under the overall guidance and supervision of the Chief Minister, indicating the highest political sanction for this important initiative. A Mission Steering Committee under the Chairmanship of the Chief Minister with Ministers of the concerned departments like Women & Child Development, Health, Tribal Development, Rural Development, etc. would review the progress on a regular basis. A second Committee, the Mission Monitoring & Implementation Committee, under the Chairmanship of the Minister for Women & Child Development, with Ministers of all concerned departments as members, would directly oversee the implementation of the Mission objectives. The Mission Advisory Committee under the Chairmanship of the Chief Secretary with all concerned departmental Secretaries represented on the Committee would take stock of the achievement of project milestones and resolve bureaucratic bottlenecks in the effective implementation of the Mission objectives. The constitution of these three Committees is intended to send out a clear message that the goal of malnutrition removal and child mortality reduction is receiving attention at the highest levels of government and that the highest level of involvement is expected from the entire government apparatus.
9. The coordination, training and monitoring functions for successful Mission implementation require a dedicated full-time unit geared to achievement of the Mission goals. A State Mission Unit has, therefore, been established to coordinate the efforts of the various departments and provide feedback on the measures required for effective implementation of the Mission objectives. To ensure that the Unit is able to perform its role effectively and to emphasise the importance given to this Mission by the State, the composition of the Unit is as under:
i) Supertime-scale IAS officer …….……. Director-General
ii) Additional CEO rank officer ...………... Director (Training)
iii)Dy. CEO rank officer ...…..……... Director (Monitoring)
iv) DHO rank officer …………… Deputy Director (Health)
iv) CDPO rank officer …………... Assistant Director (Child Development)
vi) One accounts officer
vii) Two staff for research & monitoring
viii) Two stenographers (English & Marathi)
ix) Supporting clerical staff (2)
10. The Director General would report on a regular basis directly to the Chief Minister’s Secretariat, the Minister for Women & Child Development and the Chief Secretary, with the Department of Women & Child Development acting as the nodal department at the State level. The intention behind this is to ensure effective coordination among departments as well as quick implementation of decisions. The officers and staff comprising the Mission Unit are to be taken on deputation from the State Government or hired on contract basis. The Unit is staffed by those officers who were behind the Marathwada initiative since this would enable the Mission to commence activities immediately. The Unit has been located at Aurangabad for the following reasons:
(i) The earlier initiative was launched in this region.
(ii) Consolidation of the earlier initiative is possible; apart from establishing the feasibility of the model, it would also serve as a useful demonstration of the model, which can be studied by groups from elsewhere in the State and country.
(iii) The team, which spearheaded the earlier initiative, can be rapidly assembled with minimum cost and effort.
(iv) Coordination of the activities across the State would be possible from this central location, with regular field visits and coordination meetings at divisional and district headquarters ensuring that the tempo of activity is maintained.
The Mission Unit would function as an autonomous unit, with financial and administrative autonomy, to ensure effective functioning. The Director General would bring to the notice of the State Government the corrective measures/further policy decisions required for successful realisation of the Mission objectives.
11. A three-stage approach has been envisaged for the implementation of the malnutrition reduction programme:
(a) The first stage would, over the first year, cover the five tribal districts of Thane, Nasik, Nandurbar, Amravati & Gadchiroli.
(b) In the next stage, spread over the next two years, the ten other districts with a high percentage of tribal population would be the focus of attention.
(c) The final stage, again over a two-year period, would involve extension of the Mission to the rest of the State, especially areas like urban slums that have hitherto received lesser attention.
The Mission, therefore, envisages a five-year period for significantly reducing the level of child malnutrition and mortality in the State. It needs to be pointed out that the phases are not mutually exclusive. While implementation is going on in one phase, survey and weighing of the child population in the areas covered by the subsequent phases would be commenced along with necessary training for the concerned personnel. However, to maintain the focus, areas earmarked for a particular phase will receive the full package of measures during that phase. Obviously, there would be continuing involvement with implementation aspects in an area even after the conclusion of a phase along with ongoing evaluation to establish the sustainable nature of the changes brought about by the Mission.
12. The Mission programme involves the following aspects:
a) Assessing and improving the survey efficiency in the blocks to ensure that all children in the 0-6 age group are brought within the ambit of the programme.
b) Significantly improving the weighing efficiency in the blocks.
c) Preparation and maintenance of growth charts of the children and special monitoring of the children who are in Grade 3 and 4 stages of malnutrition, with the objective of attempting to remove altogether such malnutrition.
d) Special focus on antenatal care for expectant mothers and children in the 0-3 age group in respect of immunisation, nutrition and health care access.
e) Implementation of pilot schemes for Integrated Management of Neonatal & Childhood Illnesses (IMNCI) [the Central Government-WHO/UNICEF initiative] and Home-Based Newborn Care (HBNC) [modelled on the Gadchiroli SEARCH pattern] for impacting on infant mortality. This would require close coordination between the ICDS and health departments. Studies have revealed that the prime causes of infant and child mortality include diarrhoea, pneumonia, measles and malaria. The greater proneness of underweight children to disease requires special focus on this group. Regular follow-up visits to the homes of these children by the AWW & Auxiliary Nurse Midwife (ANM), interactions with the mother and provision of advice on good feeding practices as well as making available prompt medical treatment and supplementary nutrition would greatly help in reducing the incidence of child mortality.
f) Education of adolescent girls to reduce the incidence of child marriages, promote spacing between two issues and developing awareness on various aspects of malnutrition.
g) Seeking to evolve a social consensus on the measures, both short and long-term, required to combat malnutrition and child mortality with the ultimate aim of transferring the ownership of the programme to civil society.
COMPONENTS OF THE MISSION
13. The Mission would focus on the following four objectives:
a) Training & Motivation: A basic requirement is the need to infuse a sense of purpose in the field-level workers of different service delivery departments, especially the ICDS and health departments. There is also need to upgrade the skills and capabilities of the staff at different levels so that they are able to meet the Mission goals. Above all, it is essential to sensitise the entire machinery to the human aspects of the issue so that they look for solutions rather than treating their job as a routine exercise. Four levels of training are contemplated, at the State, district, block/PHC and village levels. The State training module would cover all State and district officers upto the level of Deputy CEOs, ICDS and DHOs and would focus on policy and coordination issues. The district training module would include all staff at the district level, officers like Project Officers, Tribal Development, CDPOs and Medical Officers and select Anganwadi Supervisors, AWWs and ANMs who could then function as Master Trainers for other staff at PHC and village level. The district training would focus on operational issues, including survey and weighing of children and inputs on monitoring the health and nutrition status of children. The block/PHC training would enable dissemination of information and sharing of experience amongst all AWWs/ANMs and aim at promoting maximum cooperation and coordination between the ANM and AWW in systematic coverage of the entire mother/child population in the village. Village-level training would draw in the community itself to internalize the goals of the Mission.
b) Coordination: The Mission cannot hope to succeed in its objectives unless there is a high degree of cooperation and coordination among the different departments involved. This coordination would need to exist right from the village to the State Government level. In particular, coordination at the implementation and supervisory levels is a must. The AWW-ANM link has already been dealt with earlier. At the block level, the CDPO and the Medical Officer would have to work in close liaison to ensure fulfillment of the common objectives. The same applies at the district level to the Dy. CEO (ICDS) and the DHO. The Collector and the Chief Executive Officer of the Zilla Parishad are key officers in ensuring the highest possible degree of coordination amongst the departments, since departments like Tribal Development, Water Supply and Public Works are also entrusted with crucial service delivery responsibilities. An important aspect of the coordination is to devise common reporting systems for the ICDS and Health departments in respect of indicators relating to mother and child health and nutrition.
c) Monitoring & Evaluation: While data is copiously gathered at field level and transmitted periodically to the levels above, very little analysis of this data aimed at corrective action is undertaken. The different reporting formats for the ICDS and Health departments are one of the major contributory factors to this situation. Consistent evaluation of block-level data, disaggregated to even lower levels, can form the basis for meaningful policy interventions. It can also help in identifying crucial gaps or deficiencies in service delivery systems in order to rectify these. The Mission would aim at developing an online reporting system that minimizes paperwork and enables two-way communication between the field machinery and the policy levels.
d) Community involvement & participation: All government efforts would be ineffectual in the absence of community involvement. Promoting healthy feeding practices like early and sustained breast-feeding and complementary nutrition as well as hygiene and ensuring complete immunisation and prompt treatment of illnesses like diarrhoea through ORT require an active community initiative. Local government representatives as well as non-government organizations (NGOs) would have to be involved in these efforts to promote community participation as well as to address issues related to changing social attitudes and beliefs.
14. With the State Government taking the initiative in operationalising the Mission and UNICEF, the premier multilateral agency involved with maternal and child care, supporting the Mission, both financially and in terms of technical assistance, the Mission represents a comprehensive and collaborative effort to significantly impact on child malnutrition and mortality aimed at achieving the United Nations Millennium Development Goals for the State by the year 2010 itself. The Mission’s activities comprising training activities, monitoring and coordination would also, in due course, aim to draw on funding from multilateral agencies like UNFPA and the World Bank as also bilateral agencies like the DFID and GTZ. In fact, the commitment of the State Government in making child malnutrition and mortality removal its priority mission is expected to lead to enhanced assistance from these agencies to the programmes of different departments which contribute to the removal of malnutrition. Discussions are also currently under way for creating a public-private partnership involving the government, corporate sector and community-based and non-government organisations, which would work in close liaison with the concerned communities (UNICEF & Unilever are taking the lead in this regard in association with the Government of India and the Government of Maharashtra) .
15. In the context of the focus today on the issue of child malnutrition and mortality and maternal health, the Rajmata Jijau Mother-Child Health & Nutrition Mission represents a low-cost, viable strategy for tackling these issues while ensuring that the State evolves a coordinated and integrated approach in its efforts to significantly reduce child malnutrition and mortality.
*********************************************************************
THE MARATHWADA INITIATIVE AND
THE ROAD AHEAD
V. Ramani
Director General
Rajmata Jijau Mother-Child Health and Nutrition Mission
Aurangabad, Maharashtra, India
( A Mission of the Government of Maharashtra )
THE MARATHWADA INITIATIVE
The impetus for launching a concerted campaign for tackling the scourge of malnutrition in children in the 0-6 age group had its genesis in the fourteen child deaths, apparently due to malnutrition, reported from the one village of Bhadali, taluka Vaijapur, district Aurangabad during the period 2000-2001. What was unacceptable was that this took place barely seventy kilometres from a major urban centre like Aurangabad and that this occurred after more than a quarter century of implementing the Integrated Child Development Scheme (ICDS) in Maharashtra.
2. The Malnutrition Removal Campaign launched in Aurangabad Division on 14 March 2002 focused on the following important parameters:
(a) Complete (100%) survey of all children in the 0-6 age group.
(b) 100% registration of all such children.
(c) 100% weighing of all such children.
(d) On the basis of weighing, classification of all children into normal/grade 1 to 4 categories (as appropriate).
(e) Special concentration on children in Grade 3 & 4 stages of malnutrition; regular weighing, providing for health & nutrition measures for these children.
(f) Initiating measures for ensuring health and nutrition of pregnant mothers to reduce incidence of low birth weight children.
(g) Greater attention to children in the 0-3 age group given the greater incidence of malnutrition in this age group and its implications for the future development of the child.
(h) Analysis of data to bring out the relative incidence of malnutrition based on age, gender & social status (scheduled caste/tribe) etc.
3. The first & most important step was to enhance the coverage of children in the 0-6 age group in the ICDS scheme, especially in respect of the population living outside the coverage of the anganwadi area. Statistics showed that barely 60% of the child population in the 0-6 age group was recorded in the anganwadi registers. Thereafter arose the issue of timely weighing of children, especially children who were suffering from Grade 3 & 4 levels of malnutrition. A major problem here was the availability of weighing scales. The problem was solved by the provision of 7000 weighing scales to Aurangabad Division through the intervention of UNICEF. Children in grade 3 & 4 stages of malnutrition were to be weighed once a month while other children were to be weighed once every 6 months. The grade 3 & grade 4 children then formed the core target group for both the ICDS & health machinery. Special attention was given to devising schemes aimed at improving their nutrition and health status with the objective of lifting them out of the severe malnutrition stages. These included provision of supplementary nutrition, counselling of the mothers as well as regular medical check-up of the children, particularly those suffering from grade 3 and 4 malnutrition, who were to be weighed and medically examined every month.
4. The results of the initiative belied the expectations. The initial number of children in the 0-6 age group in the grade 3 & 4 stages of malnutrition in Aurangabad Division in July 2002 was 7867, as per the ICDS records. With improved survey & weighing efficiency, the number of children in grade 3 & 4 stages of malnutrition went up to 10705 in July 2002. The subsequent concentration on Grade 3 & 4 children has seen the number come down to just over 3000 in March 2004. As of April 2005, this figure has come down to below 500.
5. The reduction in the incidence of severe malnutrition (Grade 3 & Grade 4 stages) has been possible because of three factors:
(i) Training of staff at all levels on a regular basis over the past three years. The training programmes focused on all levels right from Collectors & Chief Executive Officers (CEOs) to Dy. CEOs (ICDS), District Health Officers (DHO), Medical Officers and Child Development Project Officers (CDPOs) right upto Anganwadi Supervisors and Anganwadi Workers (AWW). Workshops were also held for elected officials of Zilla Parishads & Panchayat Samitis to enlist their active cooperation & support for the campaign.
(ii) Motivation of staff at all levels was one of the prime objectives of the training programmes, apart from imparting skills in implementing & monitoring the programmes. It was apparent that the ICDS staff had to be convinced and enthused regarding the critical importance of the tasks they were carrying out. The involvement right from the top in terms of regular workshops, visits to anganwadis and the development of an interactive atmosphere for resolving day to day issues infused new life into the machinery and gave them the opportunity to take a proactive approach in solving the problems confronting them. The Star Campaign to appreciate and recognize those anganwadis, blocks and districts that were able to show no cases of severe malnutrition introduced a spirit of healthy competition and enthusiasm in the field workers.
(iii) Monitoring of results was crucial to the success of the campaign. Detailed block level reviews (going down even to the supervisory level) at the Divisional Commissioner level and regular follow up visits and reviews at the blocks level by officers from the Divisional Commissioner’s office stressed the importance of the campaign and kept it at the forefront of the district and block level machinery priorities.
6. What is of particular significance is that the entire initiative required no additional budgetary support from government nor was any additional staff asked for. The existing ICDS machinery was motivated to perform to its fullest potential and devise local workable solutions to resolve problems arising at the local level. Regular medical check-ups of children in the 0-6 age group also showed a distinct improvement after the commencement of the campaign. Most importantly, the enthusiasm of the field-level workers translated into a significant community involvement in the campaign with far-reaching implications for the success and sustainability of the campaign.
EXTENSION OF THE MARATHWADA INITIATIVE TO OTHER AREAS
7. The focus in the media in the past couple of years on deaths of children allegedly due to malnutrition in the tribal pockets in the districts of Nandurbar and Amravati highlighted the need to have in place an effective mechanism for covering all children in the 0-6 age group under ICDS and health programmes and focusing on reduction of severe malnutrition as the first goal in the ultimate war against malnutrition and child mortality. The Marathwada initiative has shown that it can be replicated elsewhere without any major budgetary support, by focusing on significant improvement of service delivery systems in the ICDS and health sectors. Such an initiative would be of particular relevance in areas that show a higher incidence of grade 3 & 4 malnutrition in the 0-6 age group, arising out of inadequate physical infrastructure as well as poor service delivery systems, particularly in the ICDS and health sectors.
ADOPTION OF MALNUTRITION REMOVAL AS A STATE MISSION & CREATION OF A UNIT FOR IMPLEMENTATION OF THE MISSION
8. Malnutrition reduction and removal requires to be placed at the centre stage of any State’s priorities. The State of Maharashtra has, therefore, treated the removal of malnutrition as a MISSION, which is to achieve quantifiable goals in a specific time frame. The Rajmata Jijau Mother-Child Health & Nutrition Mission (Mission) functions under the overall guidance and supervision of the Chief Minister, indicating the highest political sanction for this important initiative. A Mission Steering Committee under the Chairmanship of the Chief Minister with Ministers of the concerned departments like Women & Child Development, Health, Tribal Development, Rural Development, etc. would review the progress on a regular basis. A second Committee, the Mission Monitoring & Implementation Committee, under the Chairmanship of the Minister for Women & Child Development, with Ministers of all concerned departments as members, would directly oversee the implementation of the Mission objectives. The Mission Advisory Committee under the Chairmanship of the Chief Secretary with all concerned departmental Secretaries represented on the Committee would take stock of the achievement of project milestones and resolve bureaucratic bottlenecks in the effective implementation of the Mission objectives. The constitution of these three Committees is intended to send out a clear message that the goal of malnutrition removal and child mortality reduction is receiving attention at the highest levels of government and that the highest level of involvement is expected from the entire government apparatus.
9. The coordination, training and monitoring functions for successful Mission implementation require a dedicated full-time unit geared to achievement of the Mission goals. A State Mission Unit has, therefore, been established to coordinate the efforts of the various departments and provide feedback on the measures required for effective implementation of the Mission objectives. To ensure that the Unit is able to perform its role effectively and to emphasise the importance given to this Mission by the State, the composition of the Unit is as under:
i) Supertime-scale IAS officer …….……. Director-General
ii) Additional CEO rank officer ...………... Director (Training)
iii)Dy. CEO rank officer ...…..……... Director (Monitoring)
iv) DHO rank officer …………… Deputy Director (Health)
iv) CDPO rank officer …………... Assistant Director (Child Development)
vi) One accounts officer
vii) Two staff for research & monitoring
viii) Two stenographers (English & Marathi)
ix) Supporting clerical staff (2)
10. The Director General would report on a regular basis directly to the Chief Minister’s Secretariat, the Minister for Women & Child Development and the Chief Secretary, with the Department of Women & Child Development acting as the nodal department at the State level. The intention behind this is to ensure effective coordination among departments as well as quick implementation of decisions. The officers and staff comprising the Mission Unit are to be taken on deputation from the State Government or hired on contract basis. The Unit is staffed by those officers who were behind the Marathwada initiative since this would enable the Mission to commence activities immediately. The Unit has been located at Aurangabad for the following reasons:
(i) The earlier initiative was launched in this region.
(ii) Consolidation of the earlier initiative is possible; apart from establishing the feasibility of the model, it would also serve as a useful demonstration of the model, which can be studied by groups from elsewhere in the State and country.
(iii) The team, which spearheaded the earlier initiative, can be rapidly assembled with minimum cost and effort.
(iv) Coordination of the activities across the State would be possible from this central location, with regular field visits and coordination meetings at divisional and district headquarters ensuring that the tempo of activity is maintained.
The Mission Unit would function as an autonomous unit, with financial and administrative autonomy, to ensure effective functioning. The Director General would bring to the notice of the State Government the corrective measures/further policy decisions required for successful realisation of the Mission objectives.
11. A three-stage approach has been envisaged for the implementation of the malnutrition reduction programme:
(a) The first stage would, over the first year, cover the five tribal districts of Thane, Nasik, Nandurbar, Amravati & Gadchiroli.
(b) In the next stage, spread over the next two years, the ten other districts with a high percentage of tribal population would be the focus of attention.
(c) The final stage, again over a two-year period, would involve extension of the Mission to the rest of the State, especially areas like urban slums that have hitherto received lesser attention.
The Mission, therefore, envisages a five-year period for significantly reducing the level of child malnutrition and mortality in the State. It needs to be pointed out that the phases are not mutually exclusive. While implementation is going on in one phase, survey and weighing of the child population in the areas covered by the subsequent phases would be commenced along with necessary training for the concerned personnel. However, to maintain the focus, areas earmarked for a particular phase will receive the full package of measures during that phase. Obviously, there would be continuing involvement with implementation aspects in an area even after the conclusion of a phase along with ongoing evaluation to establish the sustainable nature of the changes brought about by the Mission.
12. The Mission programme involves the following aspects:
a) Assessing and improving the survey efficiency in the blocks to ensure that all children in the 0-6 age group are brought within the ambit of the programme.
b) Significantly improving the weighing efficiency in the blocks.
c) Preparation and maintenance of growth charts of the children and special monitoring of the children who are in Grade 3 and 4 stages of malnutrition, with the objective of attempting to remove altogether such malnutrition.
d) Special focus on antenatal care for expectant mothers and children in the 0-3 age group in respect of immunisation, nutrition and health care access.
e) Implementation of pilot schemes for Integrated Management of Neonatal & Childhood Illnesses (IMNCI) [the Central Government-WHO/UNICEF initiative] and Home-Based Newborn Care (HBNC) [modelled on the Gadchiroli SEARCH pattern] for impacting on infant mortality. This would require close coordination between the ICDS and health departments. Studies have revealed that the prime causes of infant and child mortality include diarrhoea, pneumonia, measles and malaria. The greater proneness of underweight children to disease requires special focus on this group. Regular follow-up visits to the homes of these children by the AWW & Auxiliary Nurse Midwife (ANM), interactions with the mother and provision of advice on good feeding practices as well as making available prompt medical treatment and supplementary nutrition would greatly help in reducing the incidence of child mortality.
f) Education of adolescent girls to reduce the incidence of child marriages, promote spacing between two issues and developing awareness on various aspects of malnutrition.
g) Seeking to evolve a social consensus on the measures, both short and long-term, required to combat malnutrition and child mortality with the ultimate aim of transferring the ownership of the programme to civil society.
COMPONENTS OF THE MISSION
13. The Mission would focus on the following four objectives:
a) Training & Motivation: A basic requirement is the need to infuse a sense of purpose in the field-level workers of different service delivery departments, especially the ICDS and health departments. There is also need to upgrade the skills and capabilities of the staff at different levels so that they are able to meet the Mission goals. Above all, it is essential to sensitise the entire machinery to the human aspects of the issue so that they look for solutions rather than treating their job as a routine exercise. Four levels of training are contemplated, at the State, district, block/PHC and village levels. The State training module would cover all State and district officers upto the level of Deputy CEOs, ICDS and DHOs and would focus on policy and coordination issues. The district training module would include all staff at the district level, officers like Project Officers, Tribal Development, CDPOs and Medical Officers and select Anganwadi Supervisors, AWWs and ANMs who could then function as Master Trainers for other staff at PHC and village level. The district training would focus on operational issues, including survey and weighing of children and inputs on monitoring the health and nutrition status of children. The block/PHC training would enable dissemination of information and sharing of experience amongst all AWWs/ANMs and aim at promoting maximum cooperation and coordination between the ANM and AWW in systematic coverage of the entire mother/child population in the village. Village-level training would draw in the community itself to internalize the goals of the Mission.
b) Coordination: The Mission cannot hope to succeed in its objectives unless there is a high degree of cooperation and coordination among the different departments involved. This coordination would need to exist right from the village to the State Government level. In particular, coordination at the implementation and supervisory levels is a must. The AWW-ANM link has already been dealt with earlier. At the block level, the CDPO and the Medical Officer would have to work in close liaison to ensure fulfillment of the common objectives. The same applies at the district level to the Dy. CEO (ICDS) and the DHO. The Collector and the Chief Executive Officer of the Zilla Parishad are key officers in ensuring the highest possible degree of coordination amongst the departments, since departments like Tribal Development, Water Supply and Public Works are also entrusted with crucial service delivery responsibilities. An important aspect of the coordination is to devise common reporting systems for the ICDS and Health departments in respect of indicators relating to mother and child health and nutrition.
c) Monitoring & Evaluation: While data is copiously gathered at field level and transmitted periodically to the levels above, very little analysis of this data aimed at corrective action is undertaken. The different reporting formats for the ICDS and Health departments are one of the major contributory factors to this situation. Consistent evaluation of block-level data, disaggregated to even lower levels, can form the basis for meaningful policy interventions. It can also help in identifying crucial gaps or deficiencies in service delivery systems in order to rectify these. The Mission would aim at developing an online reporting system that minimizes paperwork and enables two-way communication between the field machinery and the policy levels.
d) Community involvement & participation: All government efforts would be ineffectual in the absence of community involvement. Promoting healthy feeding practices like early and sustained breast-feeding and complementary nutrition as well as hygiene and ensuring complete immunisation and prompt treatment of illnesses like diarrhoea through ORT require an active community initiative. Local government representatives as well as non-government organizations (NGOs) would have to be involved in these efforts to promote community participation as well as to address issues related to changing social attitudes and beliefs.
14. With the State Government taking the initiative in operationalising the Mission and UNICEF, the premier multilateral agency involved with maternal and child care, supporting the Mission, both financially and in terms of technical assistance, the Mission represents a comprehensive and collaborative effort to significantly impact on child malnutrition and mortality aimed at achieving the United Nations Millennium Development Goals for the State by the year 2010 itself. The Mission’s activities comprising training activities, monitoring and coordination would also, in due course, aim to draw on funding from multilateral agencies like UNFPA and the World Bank as also bilateral agencies like the DFID and GTZ. In fact, the commitment of the State Government in making child malnutrition and mortality removal its priority mission is expected to lead to enhanced assistance from these agencies to the programmes of different departments which contribute to the removal of malnutrition. Discussions are also currently under way for creating a public-private partnership involving the government, corporate sector and community-based and non-government organisations, which would work in close liaison with the concerned communities (UNICEF & Unilever are taking the lead in this regard in association with the Government of India and the Government of Maharashtra) .
15. In the context of the focus today on the issue of child malnutrition and mortality and maternal health, the Rajmata Jijau Mother-Child Health & Nutrition Mission represents a low-cost, viable strategy for tackling these issues while ensuring that the State evolves a coordinated and integrated approach in its efforts to significantly reduce child malnutrition and mortality.
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Thursday, February 22, 2007
Hello
This is my first blog (and I'm not even sure I've got the correct nomenclature! I hope to convey my views on a wide variety of subjects through this blog. Happy reading!!
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