achieving optimum nutrition and development potential · r.k. meena alka kala in recognition of...

AchievingOptimum Nutrition and

Development Potential for Every Child in Rajasthan

The Mission Mode

In collaboration with:

Department of Medical & HealthDepartment of Education

Department for Tribal Area DevelopmentDepartment for Rural Development & Panchayati Raj

Department of Information & Public RelationsDepartment for Ground Water

Department of AgricultureDepartment of Food & Civil Supplies

Salt CommissionerPublic Health Engineering Department

Home Science Departments of Universities

Department of Women and Child DevelopmentGovernment of Rajasthan

AchievingOptimum Nutrition and

Development Potential for Every Child in Rajasthan

The Mission Mode

Message from Chief Minister

Nutrition is the cornerstone that defi nes and affects health and well being. Despite

several policies and plans both at national and state levels, raising the health and

nutritional status of the tribal population remains a challenge. Social and cultural

constraints alongwith little access to health care facilities play a role in the poor

nutritional status of tribal communities which constitute nearly 13 per cent of the

total population of the state.

Malnutrition among children, high infant, child and maternal mortality rates and

a poor nutritional status undermines economic growth and perpetuates poverty.

Micronutrient defi ciencies, especially iron, iodine and vitamin A, among vulnerable

sections are closely related to the poor nutritional status of the entire tribal

community.

Through the State Nutrition Mission, we aspire to address the nutritional problems of

tribal communities, in particular children below 3 years of age, pregnant and nursing

mothers and adolescent girls, in a time-bound and result-oriented manner. In its

fi rst phase, the Mission shall focus on 13 districts of the state, fi ve of which are largely

tribal. It is hoped that the interventions visualized in this Mission would stem the

levels of morbidity and mortality among women and children and lead to a better

quality of life for the vulnerable sections targeted in this Mission.

I take great pleasure in launching this Mission and committing ourselves to the

rights of women and children. I also take this as an opportunity to rededicate our

Government’s commitment to the cause of improving the well being of the people,

especially the women and future generations.

My best wishes are with this Mission.

(Vasundhara Raje)

Vasundhara RajeChief Minister

Government of Rajasthan

The departments of Women and Child Development and Medical and Health have been

implementing various schemes and programmes at the state level, addressing the health

and nutritional needs of women and children in Rajasthan. These schemes and programmes

have to respond even more strongly to the specifi c regional variations and needs of the

state’s vast tribal population by adopting new and innovative approaches to ensure access

to quality services.

It is estimated that nearly 51 per cent of children below 5 years of age suffer from varying

degrees of malnutrition in Rajasthan. In addition, the high prevalence of anemia, vitamin

A defi ciency and iodine defi ciency disorders is crippling development efforts in invisible

ways. While food and nutrition security have come to be recognized as key to tackling the

problem of malnutrition along with community participation, the Government of Rajasthan

recognizes the increasing concern for the survival and protection of the child, and improved

health for the mother and the adolescent girl.

In pursuance of the decisions taken in late 2005 by the Economic Policy and Reform Council,

we commence this Mission by addressing the nutritional needs of critical sections of

population of 13 districts, fi ve of them predominantly tribal, of the State. Subsequently, the

Mission will be extended to include the remaining 19 districts in a phased manner.

Although the Rajasthan State Nutrition Mission is a joint initiative of the departments of

Women and Child Development and Medical and Health and has had the benefi t of the

technical support and guidance of UNICEF Rajasthan, the Mission calls for a convergence

of all concerned departments and sectors who will be actively involved in addressing the

multiplicity of causes and the multiple determinants of nutrition.

We hope that this Mission would serve as an example for achieving health and nutritional

goals through a mission mode, based on specifi c strategies and local initiatives.

Dr Digember SinghMinisterMedical and Health

(Kanak Mal Katara)

Message from Ministers

Kanak Mal KataraMinister

Women and Child Development

(Dr Digember Singh)

R.K. Meena Alka Kala

In recognition of nutrition being vital to development, the Departments of Women and

Child Development and Medical and Health jointly commit to working toward reducing

malnutrition and micronutrient defi ciencies in a mission mode. This Mission Document,

which is the outcome of the collective brainstorming of several departments and experts

facilitated by UNICEF Rajasthan to design a feasible framework for action, not only reviews

the current health and nutritional situation of children, adolescent girls and pregnant and

nursing mothers in the tribal areas of Rajasthan but also sets out the approaches and strategic

interventions to be adopted by the Mission, both multi-pronged and multi-sectoral.

The Mission that will be initiated in 13 districts of the state, fi ve of which are predominantly

tribal, aims to reduce prevalence of malnutrition among children in the 0-3 years age group,

make advances in the prevention of malnutrition, eliminate Vitamin A defi ciency, reduce

prevalence of anaemia and iodine defi ciency disorders among women, adolescent girls and

children.

Ensuring implementation and consistent monitoring along with social mobilization across

sectors and within communities is critical to the success of this mission as is the need for

strengthening partnerships between departments and sectors. UNICEF Rajasthan's support

in developing the vision and technical guidance provided has been both valuable and

critical

Eliminating hunger and malnutrition is a vision that is achievable and feasible. Rajasthan

has not only the political will but also the ability to develop plans of action to ensure their

implementation. We dedicate this Mission to the cause of maternal and child health and

pledge to leave no stone unturned in realising the objectives.

(R.K. Meena) (Alka Kala)Principal Secretary Principal Secretary

Deptt of Medical & Health Deptt of Women and Child Development

Message from Principal Secretaries

AWW : Aangan Wadi Worker

AWC : Aangan Wadi Centre

ANM : Auxiliary Nurse-Midwife

ANC : Ante Natal Check-up

ASHA : Accredited Social Health Activist

BPL : Below Poverty Line

CHC : Community Health Centre

CF : Complementary Feeding

EBF : Exclusive Breast Feeding

FRU : First Referral Unit

GDP : Gross Domestic Product

IMR : Infant Mortality Rate

IFA : Iron and Folic Acid

ICDS : Integrated Child Development

Services

IDD : Iodine Defi ciency Disorders

IYCF : Infant and Young Child Feeding

IEC : Information Education

Communication

MCHN : Maternal and Child Health and

Nutrition

MO : Medical Offi cer

NGO : Non-Governmental Organisation

NFHS : National Family Health Survey

NTFP : Non-Timber Forest Produce

NRHM : National Rural Health Mission

ORS : Oral Rehydration Salts

ORT : Oral Rehydration Therapy

PDS : Public Distribution System

PR : Panchayati Raj

PHE : Public Health Engineering

P&LM : Pregnant & Lactating Mother

PRI : Panchayati Raj Institution

PHC : Primary Health Centre

PNC : Post Natal Check-up

RCH : Reproductive and Child Health

RD : Rural Development

SSA : Sarva Shiksha Abhiyan

SHG : Self Help Group

TBA : Trained Birth Attendant

TT : Tetanus Toxoid

WCD : Women and Child Development

List of abbreviations

Contents

Undernutrition – the silent emergency 1

Rajasthan – The indigenous pointers 11

The mission mode – Responding to the emergency 19

Practising the principles 28

Starting right 34

Firm foundations 41

Caring for the care giver 58

Towards a healthy transition 66

Measuring success 71

References 79

Annexures 80

1. Micronutrients – Defi ciencies and sources

2. Health & nutritional status of Rajasthan vs its tribal districts

3. Target population (rural)

4. Global declarations and conventions recognizing the Right to Nutrition

5. Four options of low-cost latrines

1Undernutrition

The silent emergency


Undernutrition

The crisis of undernutrition is a harsh

reality, with Asia having the largest number

of malnourished children in the world. In

India, undernutrition is fast turning into an

emergency. It is estimated that one in every three malnourished children in the world lives in India1.

The current situation In India, around 46 per cent of all children

below the age of three are too small for their

age, 47 per cent are underweight and at least

16 per cent are wasted. Many of these children

are severely malnourished.2 In comparison,

Rajasthan has a higher percentage of

underweight children at 50.6 per cent while 52

per cent are too small for their age. With respect

to wasting, Rajasthan's record with 11.5 per

cent is better than the national average.

The prevalence of malnutrition varies across

states, with Madhya Pradesh recording the

highest rate (55 per cent), followed closely by

Rajasthan (51 per cent3) and Kerala among the

lowest (27 per cent).4

As a result of the ongoing interventions of the

ICDS, the percentage of underweight children

has come down (4.1 per cent) as also the

percentage of severely malnourished children

(1.7 per cent). What results also indicate is the

need for urgency and acceleration in order to

achieve improved results quickly.

2.40.0

17.9

14.813.2

20.4

27.5

12.8 13.1 13.2

0.02.3

7.15.1

1.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

UP Maharashtra Rajasthan Tamil Nadu Kerala

BLS ELS % change

Severely malnourished children

Percent of severly malnourished children

(0-36 months) (<3SD)

58.151.8 50.9

39.5

11.33

44.4 42.639.5

35.4

3.513.7 7.839.2 11.44.1

0

10

20

30

40

50

60

70

UP Maharashtra Tamil Nadu Rajasthan Kerala

BLS ELS % chang

State-wise prevalence of underweight children

Percent of underweight children (0-36 months) (<2SD)

All differences statistically signifi cant [p<0.0001]

In Rajasthan, severe and moderate malnutrition

stood at 50.6 per cent of the population (NFHS

II) against the all-India average of 47 per cent.

Between NFHS I (‘92-’93) and NFHS II (‘98-

’99), there has been an approximate 10 per

cent increase in malnutrition. Most of the

malnourished children are in the 7-36 months

age group. Approximately 80 per cent of the

1 ‘The picture in India’ UNICEF, www.unicef.org/india/nutrition2 Ibid3 NFHS II-1998-994 The picture in India’ UNICEF, www.unicef.org/india/nutrition

Chapter 1

Source: ICDS III – Evaluation 1999-2006, Presentation made at National Consultation on Child Under Nutrition and ICDS in India, May 2006

Achieving Optimum Nutrition and Development Potential for Every Child in Rajasthan : The Mission Mode2

3Undernutrition


malnourished children are in grades I and

II and 20 -30 per cent of the malnourished

children are in grades III and IV. What is

worrying is that there is an increasing trend of

growth faltering - even among children in the

normal grade.

Micronutrient defi ciencies among pregnant

and lactating women and adolescent girls

are of serious concern. Major micronutrient

defi ciencies - iron defi ciency anaemia, iodine

defi ciency diseases, and vitamin A defi ciency

- continue to affect adolescent girls and

women, which in turn affect the growth of the

foetus during their pregnancy. This means that

more children are likely to be born as low birth

weight babies, thus starting life with a severe

handicap.

The Tenth Plan states that “more than half the

women and children are anaemic; reduction

in Vitamin-A defi ciency and iodine defi ciency

disorders (IDD) is sub-optimal”.

The overall prevalence of iron defi ciency

anaemia in children between the ages of 6 and

35 months in the country is 77.7 per cent, while

for Rajasthan, it is as high as 82.3 per cent;

half of the adolescent girls and pregnant and

lactating women suffer from iron defi ciency

anaemia.

Under nutrition also contributes to the person's

inability to fi ght infection and disease. The

under nourished child is not only prone to

childhood illnesses, but once affected takes

The 1990 World Summit for Children singled out defi ciencies of three micronutrients — iron, iodine, and vitamin A — as being particularly common and of special concern for children and women in developing countries.

Malnutrition is low (10-30%) until around 6 months and peaks (50-80%) by about 18 months.

Less than 25% of 6-18 month-old children eat half of what is recommended and fall sick once in every three weeks.


Why children die?

Source: UNICEF

Under nutrition underlies more than half of

child deaths

that much more time to recover and gain from

the twin attack of infection and nutritional

defi ciency.

Causes of undernutrition and micronutrient defi cienciesUndernutrition is not caused simply by

a dissatisfi ed appetite or household food

insecurity (unavailability and inaccessibility of

food).

It is a consequence of a combination of

inadequate dietary intake and disease.

However, there are certain underlying causes

that lead to inadequate dietary intake and

infectious disease. These are insuffi cient access

to food in a household by the female members,

inadequate maternal and child care practices,

poor water and sanitation facilities and

inadequate health services.

The basic causes at societal level are the

quantity and quality of actual economic,

human and organisational resources which

are further infl uenced by political, cultural,

religious, economic and social systems,

including women’s status, and the limit to the

utilisation of potential resources.

While solutions to larger problems of

poverty and the system are long drawn,

there is no doubt that well-planned high-

impact interventions at the community

and family levels can lead to prevention of

under nutrition and in arresting the progress

of undernutrition and protecting the child

and ensuring his/her healthy growth and

development.

Maternal care, both pre-natal and post-natal,

becomes critical to ensure healthy births and

the child's right to survival. It also reduces the

risk of maternal mortality. All-round healthy

growth and development becomes the natural

corollary.

The multi-stage causal framework of

malnutrition (See next page) explains how and

why malnutrition occurs.

Impact of undernutrition and micronutrient defi cienciesUndernutrition causes direct and indirect

losses in productivity and resources. Low birth

weight, iron defi ciency anaemia and iodine

defi ciency are all known to have a profound

effect on a child’s IQ levels and ability to learn

and educational attainment. Malnourished

children also tend to be enrolled late in school

and drop out early.

• GDP losses 2-3 per cent

• Leads to a >10 per cent potential reduction

in lifetime earnings for each malnourished

individual

• Undernutrition (stunting) in early years is

linked to the following:

4.6 cm loss of height in adolescence

0.7 grades loss of schooling

7 month delay in starting school

45%

10%

20%

25%

Neonatal disorders

Pneumonia

Diarrhoea

Others

5Undernutrition


Malnutrition

Inadequate dietary intake

Disease

Insuffi cient access to food

Inadequate maternal & child care

practices

Poor water/sanitation & inadequate

health services

Quantity and quality of actual resources – human, economic & organizational –

and the way they are controlled

Potential resources: environment, technology, people

Inadequate and/or inappropriate knowledge

and discriminatoryattitudes limit household

access to actual resourcesaccess to actual resources

Political, cultural, religious,economic and social systems,including women’s status, limit

the utilization of potential resources

Conceptual framework of causes of malnutrition

Immediate causes

Outcome

Underlying causes at household/family level

Basic causes at societal level

Source: Adapted from Nutrition Strategy UNICEF

6Achieving Optimum Nutrition and Development Potential for Every Child in Rajasthan : The Mission Mode

7Undernutrition


Direct loss in productivity from poor

physical status

Indirect loss in productivity from poor cognitive

development and schooling

Loss in resources from increased health care costs

of ill health

Undernutrition

Undernutrition costs India at least $10 billion annually in terms of lost productivity, illness, and death and is seriously retarding improvements in human development and further reduction of childhood mortality.

Direct and indirect losses as a result of undernutrition

8

The information in the following boxes highlights the impact of micronutrient defi ciencies on

women, adolescent girls and children:

Micronutrient defi ciencies

IRON

Impact of defi ciency• Impairs immunity and reduces physical and

mental capacities

• In infants and young children, even in mild form, can impair intellectual development

• In pregnancy is a major cause of maternal mortality, increasing the risk of haemorrhage and sepsis during childbirth

• Infants born to anaemic mothers often suffer from low birthweight and anaemia themselves. Causes include blood loss associated with menstruation and parasitic infections such as hookworm, but an inadequate intake of iron is the main cause.

Who is affected?• Women, pregnant women

• Children under fi ve

Source: The State of the World’s Children, UNICEF 1998

VITAMIN A

Impact of defi ciency• Makes children especially vulnerable to

infection and worsens the course of many infections

• Heightens a child’s risk of dying

• Single-most important cause of blindness among children

Who is affected?• Pre-school-age children

• Women in their reproductive years


FOLATE

Impact of defi ciency• Causes birth defects in the developing foetus

during the earliest weeks of pregnancy — before most women are aware that they are pregnant

• Has been found to be associated with a high risk of pre-term delivery and low birthweight

• Also contributes to anaemia, especially in pregnant and lactating women

Who is affected?• Women in their reproductive years

• Young children


IODINE

Impact of defi ciencyImpact of defi ciencyI• Single-most important cause of preventable

brain damage and mental retardation, most of the damage occurring before birth

• Raises the risk of stillbirth and miscarriage for pregnant women

Who is affected?• People in all ages, specifi cally infants and

young children


(See Annexure 1 for more details on the four micronutrients)

9Undernutrition


Causes at the household level include intra-

household food distribution, lack of awareness

regarding correct infant and young child

feeding (IYCF) practices and poor hygiene, all of

which call for improved nutrition and child care

practices at the household level.

Why undernutrition persists in many

food-secure households

Inter-generational cycle Poor nutrition perpetuates itself across

generations. Young girls who grow poorly

become stunted women and are more likely to

give birth to low birthweight infants. If those

infants are girls, they are likely to continue the

cycle by being stunted in adulthood, and so

on, if something is not done to break the cycle.

Adolescent pregnancy heightens the risk of

low birthweight and the diffi culty of breaking

the cycle. Support is needed for good nutrition

at all these stages — infancy, childhood,

adolescence and adulthood — especially for

girls and women.

Thus, what is evident is that undernutrition

impacts the morbidity and mortality of young

children before they reach the 12-24 months

age group. It weakens them and makes them

doubly vulnerable to childhood illnesses.

Rajasthan is facing a child survival protection

and growth and development challenge. Of

every 1,000 children born in the state, 115 die

before the age of 5. Of these, 75 die in the fi rst

year and 48 in the fi rst four weeks.

Such wastage of our future generation and slow

deaths is the SILENT EMERGENCY that needs

immediate and urgent attention.

• Pregnant and nursing women eat too few calories and too little protein, or do not get enough rest.

• Mothers have too little time to take care of their young children or themselves during pregnancy because of repeated pregnancies.

• Short birth intervals and low age at marriage cause undernutrition.

• Mothers of newborns discard colostrum, the fi rst milk, which strengthens the child’s immune system.

• Mothers often feed children under age 6 months foods other than breast milk even though exclusive breastfeeding is the best source of nutrients and the best protection against many infectious and chronic diseases.

• Caregivers start introducing complementary solid foods too late.

• Caregivers feed children under age two years too little food, or foods that are not energy dense.

• Though food is available, because of inappropriate household food allocation, women and young children’s needs are not met and their diets often do not contain enough of the right micronutrients or protein.

• Caregivers do not know how to feed children during and following diarrhoea or fever.

• Caregivers’ poor hygiene contaminates food with bacteria or parasites.

Source: Repositioning nutrition as central to development, A strategy for large-scale action, The World Bank, 2006

High impact interventions that ensure timely prevention of

undernutrition and promote sound health and growth and development of the child, the adolescent and the mother in the natural life cycle process

can defi nitely produce positive results


Source: ACC/SCN, Second Report on the World Nutrition Situation: Vol. I: Global and Regional Results, ACC/SCN, Geneva, 1992

Inter-generational cycle of growth failure

Child growth failure

Low weight & height in

adolescence

Early pregnancy

Low birth-weight baby

Small adult woman

A child’s organs and tissues, blood, brain and bones are formed, and intellectual and physical potential is shaped, during the period from conception through age three.

Improving adolescent girls’ nutrition before they enter pregnancy (and delaying it), could help to reduce maternal and infant mortality, and contribute to break the vicious cycle of intergenerational undernutrition and even chronic disease.

Growth during the foetal stage depends on how well nourished a woman was before pregnancy, as well as how much weight she gains while she is pregnant. Gains in weight are essential for the development of new maternal and foetal tissues, and for maternal body maintenance and energy. Since the foetus relies entirely on the mother for nutrients, pregnant women not only need to gain weight but also must maintain an optimal intake of essential nutrients such as iron and iodine.

Breastmilk contains all the nutrients, antibodies, hormones and antioxidants an infant needs to thrive. Breastfed infants not only show better immune responses to immunizations, but their intake of breastmilk also protects the mucous membranes that line their gastrointestinal and respiratory tracts, thus shielding them against diarrhoea and upper respiratory tract infections.

0-3 years Lactating period

PregnancyAdolescence

10-19

The time to act is now. The

Nutrition Mission has to

use the critical windows of

opportunity to realise the

objectives.

The most critically vulnerable

groups are developing

fetuses, children up to the age

of three and women before

and during pregnancy and

while they are breastfeeding.

In addition, adolescence

is considered a potential

period to correct nutritional

defi ciencies and introduce

behaviour change with regard

to diet and lifestyle.

Critical windows of opportunity

11Rajasthan

The indigenous pointers


Rajasthan

The health scenario across the country is

characterised by gender imbalance, low vital

rates and an uneven health care coverage.

Ill-health has a strong correlation to social

variables, in a context where expectant mothers

and girl children are neglected, and women

as a cohort are more vulnerable to diseases

that affl ict the population in general. There

is a general consensus that the health and

nutritional status is the worst among the tribal

population owing to distinct health problems,

mainly governed by multi-dimensional factors

like their habitat, diffi cult terrain, ecologically

variable niches, illiteracy, poverty, livelihood

insecurities, isolation, superstition and

deforestation. These factors make them doubly

vulnerable to disease and undernutrition.

As per Census 2001, Scheduled Tribes account

for approximately 12.6 per cent of the

entire population of Rajasthan. The highest

concentration is noticed in Banswara and

Dungarpur districts where their proportion to

total population of the districts comes to 73.47

per cent and 65.84 per cent, respectively. Other

districts with higher proportion are Udaipur

(46.34%), Sirohi (23.39%), Sawai Madhopur

(22.47%), Bundi (20.25%), Chittorgarh (20.28%)

and Baran (21.13%).

According to the Fifth Schedule of the

Constitution of India, Banswara and Dungarpur

are declared as fully tribal districts and Udaipur,

Chittorgarh and Sirohi as partly tribal.

The prominent Scheduled Tribes are the

Bhils and the Meenas. The Bhils are mostly

concentrated in the hill-locked districts of

Udaipur, Dungarpur and Banswara while

the Meenas are settled mainly in the Jaipur,

Sawai Madhopur and Udaipur districts. Other

Scheduled Tribes are the Garasias and the

Sahariyas. The Garasias are concentrated in the

Pali and Sirohi districts while the Sahariyas are

limited to a pocket of two tehsils in the Kota

district. The most underdeveloped tribal groups

are the Sahariya and the Kathodi. Only 5 percent

of these groups is literate, and they are grossly

underemployed.

Largely due to poverty and heavy burden of

debt, tribals of these districts have failed to

Scheduled Tribes in Rajasthan

Chapter 2

1. Bhil, Bhil Garasia, Dholi Bhil, Dungri Bhil, Dungri Garasia, Mewasi Bhil, Rawal Bhil, Tadvi Bhil, Bhagalia, Bhilala, Pawra, Vasava, Vasave

2. Bhil Mina

3. Damor, Damaria

4. Dhanka, Tadvi, Tetaria, Valvi

5. Garasia (excluding Rajput Garasia)

6. Kathodi, Katkari, Dhor Kathodi, Dhor Katkari, Son Kathodi, Son Katkari

7. Kokna, Kokni, Kukna

8. Koli Dhor, Tokre koli, Kolcha, Kolgha

9. Mina

10. Naikda, Nayaka, Cholivala Nayaka, Kapadia Nayaka, Mota Nayaka, Nana Nayak

11. Patelia

12. Seharia, Sehria, Sahariya

Source: Constitution of India


optimally use the resources at their disposal

and continue to remain poor.

Several factors contribute to the tribals’

inequitable access and poor status in terms of

health care and nutrition. These include lack

of awareness and social barriers preventing

the utilisation of available health and nutrition

supplementation programme and services,

poor environmental sanitation and lack of safe

drinking water, leading to increased morbidity

from water-borne infections, environmental

conditions that favour vector borne, diseases,

lack of access to health care facilities resulting

in increased severity and/or duration of

illnesses.

The tribal population is largely faced by a

diffi cult and diverse physiography, ranging

from desert and semi-arid to hilly tribal tracts.

Frequent occurrence of droughts coupled with

these geographical barriers has translated

into poor health status for the tribes who

are confi ned to the deserts, forests and hills,

making timely treatment unattainable.

A very large majority of the tribals are engaged

in agriculture; their other economic activities

being food gathering (including hunting),

forestland cultivation, minor forest produce

collection, pastoral and handicrafts. Forests

are an important source of livelihood for the

poor in Rajasthan, and approximately 5 million

TRIBALS Poor accessibility & utilisation of health services

Diffi cult terrain and

sparsely distributed tribal population

in forests and hilly regionsregions

Locational Locational disadvantage

of sub-centres, PHCs, CHCs

Non availability of

service providers due to vacant

posts and lack of residential facilities

Non involvement of the local

traditional faith healers

Lack of suitable Lack of suitable transport facility

for quick referral of emergency cases

Services not being client

friendly in terms of timing, cultural barriers inhibiting

utilization

Inadequate mobilization

of NGOs

IEC activities not tuned to the tribal idioms, beliefs and

practices

Weak monitoring

and supervision systems

mobilization

Lack of integration

with other health programs and

other development sectors

13Rajasthan


tribal people derive seasonal incomes through

the collection, processing, transportation

and marketing of non-timber forest produce

(NTFP). Forests are traditionally a source of

subsistence and livelihoods for the tribals and

are often their only source of fuel wood and

fodder. Animal husbandry is another important

source of livelihood, specially for the poor. The

tribals are also nomadic herders of sheep and

camel.

The tribal’s right to basic resources such

as land, forest and water and their entire

environment have been seriously eroded. Not

only is the landscape changing with the large-

scale soil erosion, making it uncultivable,

water sources are also drying up as a result

of the depletion of forests. The tribals with

their lack of skills are faced with serious

livelihood issues. The tribal-dominated

districts of Udaipur, Dungarpur, Dholpur

and Chittorgarh have the largest incidence of

under-employment. Migration is one of the

mechanisms that help them cope with

poverty.

Water and sanitationWater is a crucial determinant of nutritional

status. Rajasthan is defi cient in water (surface

and ground). Ground water at many places is

unfi t for human and livestock consumption.

Water-borne diseases, especially diarrhoea and

jaundice, are among the frequently occurring

diseases among tribal children.

High concentrations of fl uoride occurring

naturally in groundwater have caused widespread

fl uorosis - a serious bone disease - among local

populations. The districts of Tonk, Sirohi and

Rajsamand are among the worst affected.

Most of the households (85 per cent) in rural

Rajasthan use no latrine and more than than


half (57 per cent) had no drainage while 32 per

cent had only kuccha drainage that leads to

widespread clogged, overfl owing and broken

drains. Lack of good drainage is another source

contributing to water-borne diseases. The

coverage of rural areas under sanitation and

hygiene education (under the Total Sanitation

Campaign) is only 14 per cent as per Census

2001.

Food patternsThe main food crops of the state are bajra,

wheat, rice and pulses. The main non-food

crops are oilseeds, pulses and vegetables and

spices.

The district-wise comparison of average food

consumption shows variations. Banswara,

Dungarpur, Chittaurgarh, Rajsmand and Alwar

are districts with inadequate nutrient intake of

50 per cent and higher, with the tribal district

of Dungarpur being inadequate in intake of

cereals, pulses, green leafy vegetables, toots

and tubers, other vegetables, milk and milk

products, fats and oils and sugar. Consumption

of pulses, green leafy vegetables, other

vegetables and sugar are the lowest in the 13

predominantly tribal districts. In a basically

vegetarian state, the low consumption of

pulses, vegetables, sugar and fruits has resulted

in low intake of energy, iron, ribofl avin and

vitamins C and A.

The lifestyles and food habits of the tribals are

different from that of their rural neighbours.

They depend on minor forest produce,

are employed in manual labour and often

do not have adequate income. Their food

consumption pattern is dependent on the

vagaries of nature and varies from extreme

deprivation (in the lean seasons) to high intakes

(in the post harvest period).

15Rajasthan


IMR Districts

<60 per 1000 live births Ganganagar, Hanumangarh, Bikaner, Jhunjhunu, Sikar

60-90 per 1000 live births Churu, Alwar, Bharatpur, Dholpur, Karauli, Sawai Madhopur, Dausa, Jaipur, Nagaur, Jodhpur, Jaisalmer, Barmer, Jalor, Sirohi, Ajmer, Bundi, Kota, Baran, Jhalawar

>90 per 1000 live births Pali, Bhilwara, Rajsamand, Udaipur, Dungarpur, Banswara, Chittorgarh, Tonk

[Source: UNICEF]

Child careInfant mortality rate, which is a parameter

of the society’s ability to provide care for the

children, is high at 94.7 for tribal populations,

while in Rajasthan as a whole too, it fi gures at

97.3. A major proportion (38 per cent) of under-

5 deaths among Scheduled Tribes takes place in

the fi rst year of birth.

The nutritional status of tribal children

in Rajasthan between the ages of 6 and

35 months indicates that 59 per cent are

underweight (Rajasthan 50.6 per cent), 60

per cent are stunted (Rajasthan 52 per cent)

and 17.6 per cent are wasted (11.7 per cent).

It is no surprise that 80.2 per cent of the tribal

children were found to be anaemic (Rajasthan

82.3 per cent). Twenty-one per cent of the

children were suffering from acute respiratory

illnesses out of which only 50 per cent were

taken to a health facility or provider. Twenty-

seven per cent were found suffering from

fever, and out of the 23 per cent suffering from

diarrhoea, nearly 40 per cent were not taken Source: NFHS II 1998-988

Infant & child mortality among STs of Rajasthan

22%

15%

38%

25%

0%

Neonatal

Post-neonatal

IMR

Child mortality

Under 5 mortality

Infant & child mortality among STs of Rajasthan

Infant mortality in districts


to any health provider or facility. Only 32.7 per

cent of the mothers were found to know about

ORS (Source: NFHS II).

All the districts that show an IMR of >90 per

1000 live births are tribal-dominated except

Pali and Bhilwara, and none of the districts

with an IMR of <60 per 1000 live births are

tribal.

In the tribal dominated districts (see table on

previous page), in the month of October 2005,

incidence of total malnutrition was found to

be 50 percent or more. The total numbers of

children suffering from severe malnutrition in

these districts were as high as 700 and 786 in

Banswara and Udaipur, respectively, and 1,074

and 1,227 in Jhalawar and Baran, respectively.

Eight out of the 13 districts recorded more than

20 deaths each, with Alwar, Chittorgarh and

Udaipur recording deaths as high as 43, 55 and

60, respectively.

Malnutrition in tribal-dominated districts

Tribal-dominated

districts

Total malnutrition* (%)

Moderate & severe

malnutrition** (%)

Total no. of children in

Grades III & IV

Total deaths in 0-5 age group

Dungarpur 59.20 22.17 20 17Banswara 64.38 33.59 700 32Udaipur 63.74 27.45 786 60Chittorgarh 61.93 24.70 517 55Sirohi 60.31 24.24 13 0Sawai Madhopur 62.12 28.00 29 11Jodhpur 50.08 19.11 155 1Baran 60.46 27.64 1227 37Rajsamand 49.24 19.40 15 30Alwar 52.91 21.76 521 43Dholpur 54.72 21.76 402 37Tonk 51.49 22.78 355 14Jhalawar 50.46 22.44 1074 24

Source: ICDS data, October 2005, DWCD, Govt of Rajasthan

17Rajasthan


Lack of care and timely treatment, especially

at the household level, and in acute cases, at

the institutional level, is a major cause of non-

recovery or delayed recovery.

Infant and young child feeding practices in

tribal Rajasthan further throws light on the

poor nutritional status of children. Only 3.7

per cent of the infants were initiated into

breastfeeding within an hour of birth and 27.2

per cent within a day. More appalling is the

fact that colostrum feeding is unpopular and

73.8 per cent of the children were initiated into

breastfeeding after squeezing the fi rst breast

milk.

Adolescent Adolescent girls face more problems than boys,

largely due to socio-cultural factors. Adolescent

girls are deprived of adequate health care,

good nutrition and opportunity for schooling.

Stunted and underweight anaemic girls with

inadequate knowledge of personal care, family

planning or child rearing practices enter into

marriage and motherhood, thus perpetuating

the problems of malnutrition and poverty on to

the coming generation.

The prevalence of iron defi ciency anaemia too

is widespread among tribal adolescent girls.

Maternal care The quality of maternal care is most evident

from the data collected regarding institutional

deliveries, pre-natal and post-natal check-

ups , IFA consumption and TT injections. In

Rajasthan, of every 1,00,000 live births, 670

maternal deaths take place. Among the tribal

population, 58.4 per cent of women in the

reproductive age were found to be anaemic.

Only 15.8 per cent had delivered at a medical

institution. Deliveries assisted by a trained

doctor or a nurse/midwife were slightly higher

at 23.9 per cent though not much. Only 35.8

per cent had received IFA and 42.1 per cent

administered with TT injections. More than half

the tribal mothers and pregnant women (57.9

per cent) had received no ante-natal check-

19

How the probability of underweight increasesfor girls in increasingly vulnerable positions

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Ris

k ca

tego

ry

Probabability of under we ight

Girl ST girl ST girl in poorest quintile ST girl in poorest quintile in rural area

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Probability of under weight

Girl ST girls in poorest quintile ST girls in poorest quintile Girl ST girls in poorest quintile ST girls in poorest quintile Girl ST girls in poorest quintile ST girls in poorest quintile

How the probability of underweight increases for

girls in increasingly vulnerable positions


This is the time to act to end child hunger and

undernutrition.

ups and only 4.7 per cent had received a post-

partum check-up within 2 months of birth.

(It is important to note that out of the 52.5 per

cent of the women who received no ante-natal

check-up, 68.6 per cent cited the reason for not

having received the same as “Not necessary”.)

While it is critical to recognise the challenges

faced in delivering services to tribal

communities, it is equally important to

understand that traditional practices and ways

of living and healing exist and these need to be

appropriately taken into account in order to

adopt sustainable solutions.

(See Annexure 1 for comparative information

on the health and nutrition status of Rajasthan

and its tribal districts.)

19The Mission Mode

Responding to the emergency


The Mission Mode

The nutritional status of the tribal population

of Rajasthan can be improved only through

the adoption of the Mission mode. This move

is initiated by the Department of Women &

Child Development, Government of Rajasthan,

and would involve the active support and

participation of other departments.

Why the ‘Mission Mode’?

because … … the malnutrition crisis in Rajasthan is fast

turning into an emergency

… the interventions need to move on a fast

track

… only well-planned and time-bound efforts

bear fruit

… focus, coordination and convergence

– essential elements of a Mission - are the

pillars of quality service delivery

Objectives of the MissionThe Nutrition Mission would aim to attain the

following by 2011:

With respect to children Reduce prevalence of under-nutrition in 0-6

year-olds

Reduce prevalence specifi cally under the age

of 3 by 60 per cent (from 51 per cent to 30

per cent)

Reduce severe undernutrition in children

below 6 years (weight for age)

Reduce severe undernutrition in children

below 3 years to less than 5 per cent

Reduce prevalence of anaemia in children

below 6 years by 50 per cent of existing level

Eliminate Vitamin A defi ciency as a public

health problem among children in 0-6 years

age group

With respect to adolescent girls Reduce prevalence of anaemia among

adolescent girls by 50 per cent of existing level

Empower adolescent girls with life skills

education

Chapter 3

Article 47 of the Constitution of India states that “the State shall regard raising the level of nutrition and standard of living of its people and improvement in

public health among its primary duties”.

India is among the 191 nations that are committed to achieving the Millennium Development Goals (MDGs), which are the world’s time-bound and quantifi ed targets for dramatically reducing extreme poverty in its many dimensions by 2015 – income poverty, hunger, disease, exclusion, lack of infrastructure and shelter – while promoting gender equality, education, health, and environmental sustainability. The eight MDGs include reduction of child mortality (Goal 5: Reduce under-fi ve mortality rate by two-thirds between 1990 and 2015) and improvement in maternal health (Goal 6: Reduce the maternal mortality ratio by three-quarters between 1990 and 2015). The importance of achieving these goals in Rajasthan gains signifi cance as the state is among the four states (the other three being Madhya Pradesh, Uttar Pradesh and Bihar) that account for more than 50 per cent of infant mortality in India.

Millennium Development Goals:

Child and Maternal Care


With respect to women (pregnant & lactating) Reduce prevalence of anaemia among

pregnant & lactating women by 50 per cent

of existing level

Eliminate Vitamin A defi ciency among this

target group through improved practices

related to dietary intake

Empower women in this target group

through information related to infant and

young child feeding and care leading to

behaviour change and adoption of optimal

care practices

At family level Virtual elimination of IDD disorders by

ensuring and sustaining universal salt

iodisation at family level

It is the right of every child to reach his/her development potential; obligatory to reach every child till the age of 6 years in the state to ensure optimal survival & development

Provide best start for every child- recognising that the early childhood years (pre-natal to 3 years) are most crucial and vulnerable for development of full potential

To ensure an integrated approach and promote effective convergence of available services, resources, human & infrastructure, in the areas of health, nutrition and education for realising better parenting, all driven in the best interest of the child

Vision and Guiding Principles

Specifi c Actions

Child nutrition Pregnant & lactating women Adolescent girls

Reduce undernutrition among the 0-6 age group with special emphasis on 0-3 year-olds

Operationalise universal screening of pregnant and lactating women; ensure ANCs and PNCs, encourage institutional deliveries

Increase intake of iron and folate to reduce anaemia levels by 25% in fi rst year, 50% in second year and 100% in third year

Sustain effi cient weighing and growth monitoring

Ensure appropriate infant feeding practices (universal colostrum feeding, exclusive breast feeding up to six months, introduction of semisolids at six months)

Dietary diversifi cation for intake of iron-rich foods

Increase immunisation coverage

Dietary diversifi cation to include vitamin A-rich, vitamin C-rich and iron-rich foods

Prevent hookworm infection

Encourage AWC- and home-based treatment of common childhood illnesses, especially diarrhea

Promote appropriate intra-family distribution of food based on requirements

Increase consciousness about underlying causes of under-nutrition, i.e. age at marriage, education, intra-household food distribution

Protect, promote and support optimal infant and young child feeding

Promote hygienic ways of cooking and sanitary practices

Life skills education for school-going and non-school-going adolescent girls

Promote sanitary and hygienic practices and use of clean drinking water at AWC and family level

Promote sanitary and hygienic practices and use of clean drinking water at school and family levels

21The Mission Mode


Time Line The Mission would comprise three phases. The

fi rst phase would begin in 2006 and cover 6

tribal districts (Dungarpur, Banswara, Udaipur,

Chittorgarh, Sirohi and Dholpur) and 7 non-

tribal districts (Jodhpur, Baran, Rajsamand,

Alwar, Sawai Madhopur, Tonk, Jhalawar).

UNICEF is already supporting 7 of the 13 Phase

1 districts through its programme Aanchal se

aangan tak. The second phase would succeed

a year later, in 2007, in which 9 districts would

be included followed by Phase 3 districts in year

2008 to cover the remaining 10 districts of the

state.

Phase 1 Beginning 2006



Reorientation to targetingSo far, there has been a tendency to target

children between 3 and 6 years as it is

associated with SNP and pre-school education.

Children below 3 years are only targeted

through mothers who happen to be registered

with the AWC. Under the Mission, there would

be a consious reorientation of targeting to

cover the under-3 children. The Mission

will, therefore, give priority to screening all

children from birth to 3 years to ascertain levels

of undernutrition and in a systematic and

planned manner target those who are most

vulnerable.

Target populationThe Mission would aim to achieve its objectives

by targeting the rural population in the critical

age groups, namely the following:

1. Children in the 0-6 years age group with

special focus on 0-3 year-olds

2. Adolescent girls (10-19 year-olds)

3. Pregnant and lactating women

Under 4 Adolescent girls Women Total

Phase 1 2272051 1686692 2980508 6939251

Phase 2 1636890 1243303 2133158 5013351

Phase 3 1923819 1549035 2562105 6034959

Total 5832760 4479030 7675771 17987561

Source: Census 2001

The Mission would target an estimated population of 17,987,561 women, girls and

children in the 0-6 age group.


Coverage1

*Districts that will receive special focus from the Govt of Rajasthan**UNICEF-supported districts that will continue to receive support from the agency

(See Annexure 3 for district-wise fi gures)

Phase 1

Dungarpur/*Dungarpur/*Dungarpur/*Dungarpur/*Dungarpur/*

Sirohi*Sirohi*Sirohi*Sirohi*Sirohi*Sirohi*

Sawai Madhopur*Sawai Madhopur*Sawai Madhopur*Sawai Madhopur*

Jodhpur** Dhaulpur**Dhaulpur**Dhaulpur**Dhaulpur**Dhaulpur**

S.No. District01. Dungarpur*02. Banswara*03. Udaipur*04. Chittorgarh*05. Sirohi*06. Sawai Madhopur*07. Jodhpur**08. Baran**09. Rajsamand**10. Alwar**11. Dhaulpur**12. Tonk**13. Jhalawar**

Dungarpur/*Dungarpur/*Dungarpur/*Dungarpur/*Dungarpur/*

Target PopulationWomen– 29,80,508Adolescent girls – 16,86,6920-4 – 2272051

1 These fi gures refer to Census 2001. They are being provided only as an estimation of the population that would need to be covered. The fi gures pertain to the rural population only. Adolescent population consists of the population in the 10-19 age group. 'Women' here refers to females in the 20-49 age group. While the Mission will target 0-6 year-olds, fi gures for 0-4 year-olds have been provided.

23The Mission Mode



Coverage1

Phase 2


Coverage1

1 These fi gures refer to Census 2001. They are being provided only as an estimation of the population that would need to be covered. The fi gures pertain to the rural population only. Adolescent population consists of the population in the 10-19 age group. 'Women' here refers to females in the 20-49 age group. While the Mission will target 0-6 year-olds, fi gures for 0-4 year-olds have been provided.

GanganagarGanganagarGanganagarGanganagar

Jaisalmer

HanumangarhHanumangarhHanumangarhHanumangarh

KarauliKarauliKarauliKarauliKarauliKarauli

BharatpurBharatpurBharatpur

S.No. District01. Nagour02. Pali03. Bhilwara04. Kota05. Barmer06. Jaisalmer07. Jalore08. Bikaner09. Ganganagar

Target PopulationWomen– 21,33,158Adolescent girls – 12,43,3030-4 – 16,36,890

S.No. District01. Hanumangarh02. Dausa03. Jaipur04. Bharatpur05. Ajmer06. Bundi07. Karauli08. Jhunjhunu09. Sikar10. Churu

Phase 3

Target PopulationWomen– 25,62,105

Adolescent girls– 15,49,0350-4– 19,23,819


Nutrition MissionInter-departmental

convergence

Women & Child

Development

Women &

DevelopmentDevelopment

Medical &health

Ground water

Nutrition Mission

water

Agriculture

Food

Civil

Supplies

Civil

Supplies

EducationEducationInformation & Public Relations

Medical &

Tribal

Area

DevelopmentDevelopment

Information Public Health

Engineering

Inter-departmental convergence in the Mission

Public Health

Salt Commissioner

Salt

Rural

Development

& Panchayati

Raj

ConvergenceThe Mission would involve

the active participation of all

concerned departments of the

Government of Rajasthan. The

determinants of malnutrition, as

we have seen in Chapter 1, include

not just food but also health, water

and sanitation, which imply that

the concerned departments need

to contribute in several ways. several ways. several

Inter-departmental convergence

would be organized in the Mission

in terms of offi cials’ roles and

responsibilities, functionaries,

infrastructure and objectives.

For this, prior agreements would

be made between departments

right from the policy level

to the grassroots in order to

operationalize the convergence on

the fi eld for interventions.

An agreement with ongoing

Missions and schemes/

programmes is necessary as

in each Mission, manpower,

infrastructure and other

resources are being put to use

towards an end. Where there

is convergence of purpose, it

proves to be more benefi cial and

constructive to cross-utilize these

resources. (See illustrations)

Tribal area programmes and

specifi c schemes and institutional

services that are already in place

must be strengthened in tribal

areas, such as public distribution

system, iodised salt distribution

and the employment guarantee

scheme.

Nutrition Mission

RCH IIRCH IITotal

Sanitation campaign

Swajaldhara

National Adolescent Girls

ProgrammeAdolescent Girls

Mid-day meal/ school

lunch

Bharat Nirman

Kishori Shakti Yojna

Nirman

PDS

EmploymentGuaranteeSchemeScheme

Iodised Salt Distribution

meal/ school Iodised Salt Distribution

Tribal Area Development

Inter-scheme convergence in Mission

National Rural Health

MissionRural Health

NutritionMission

Inter-mission convergence

25The Mission Mode


With the objective of ensuring intake of clean water and healthy sanitary practices, while the Dept of WCD would ensure that the AWC staff at the village level is engaged in the transfer of information to women and adolescent girls regarding the importance of safe drinking water and washing hands after defecation and before cooking and eating, the Dept of Medical & Health functionary Sahayogini would spread awareness about water-borne diseases and ways of management at household level and the critical time for referral. The district and block level offi cials of the Public Health Engineering and Panchayati Raj & Rural Development Depts would ensure that all wells, hand pumps, taps and toilets are repaired and maintained. Ground Water Dept would ensure that supply of water is adequate and also oversee the quality of water.

Messages: ‘Drink safe water’, ‘Wash your hands’

Example of Convergence

Sahayogini

AWW

PHEDept.

Panchayati Raj & Rural Develop-

ment Dept.

Tribal Area

Develop-ment Dept.

Ground Water Dept.

Departments that will ensure repair and maintenance of infrastructure for water supply and toilets, supply of water, awareness about clean drinking water, sanitation, hygiene and prevention of water-borne diseases

Drink safe water.

Wash your hands.

Medical & Health Dept.


Some examples of convergenceThe following example illustrates an area of

a fruitful convergence between the National

Rural Health Mission (in particular, the Janani

Suraksha Yojana) and the Nutrition Mission

in order to achieve the objective of ensuring

safe and healthy pregnancy, delivery and

motherhood.

Note: In Rajasthan, the roles of Sahayogini and ASHA (an NRHM functionary) have been merged, and the Sahayogini is expected to fulfi ll the role of the ASHA.

Ensuring safe and healthy pregnancy,

delivery and motherhood

National Rural Health Mission

Janani Suraksha Yojna Early registration

Early identifi cation of complicated cases

3 ANC & post-delivery visits

Referral and referral transport assistance to Sahayogini and pregnant woman to go to nearest health centre

24/7 delivery services at PHC level providing basic obstetric care

FRUs providing emergency obstetric care

Cash assistance to mother for enabling institutional delivery

Assistance for Caesarean Section

Compensation payment for tubectomy/laparoscopy

Nutrition Mission

Village-level Community-driven mapping of pregnant

and lactating women (weighing, updating & maintenance of records

Door-to-door micronutrient supplementation

Identifi cation of cheap, locally available nutritious foods and demonstrations of nutritive cooking on MCHN Day

Consumption of one nutritious, wholesome meal every day at AWC

Homestead production of vegetables

Support group for employed pregnant & lactating women

Breastfeeding support groups

Cluster counselling on complementary feeding

IEC activities

Fathers' groups

Mothers' groups

Community-based volunteer

teams

Sahayogini

ANM

AWW

Village Health

Committee

27The Mission Mode


Inter-departmental convergence with the

objective of ensuring food security among

adolescent girls and pregnant and lactating

women is illustrated below, wherein the active

involvement of each department is seen as

imperative towards the desired end.

Ensuring food security

Depts of Panchayati Raj & RD and Food and Civil Supplies Ensuring that each BPL family owns a

ration card

Ensuring smooth functioning of and supply at the PDS shop

Local PDS shop

Targeted PDS (10 kg food grain)

Antyodaya Anna Yojana (35 kg food grain)

Aanganwadi Centre

Supplementary Nutrition Programme

National Adolescent Girls Scheme (35 kg food grain for those weighing <35kg)weighing <35kg)

Dept. of Food & Dept. of Food & Civil SuppliesCivil Supplies

Dept. of Women and Dept. of Women and Child DevelopmentChild Development

Depts of Panchayati Raj & Rural Depts of Panchayati Raj & Rural Depts of Panchayati Raj & Rural Development, Food & Civil SuppliesDevelopment, Food & Civil SuppliesDevelopment, Food & Civil Supplies

Inter-departmental convergence to ensure food security to adolescent girls


Practising the PrinciplesKey approaches & core interventions

Central to the approaches adopted by the

Nutrition Mission is the increased and

maximum interface between the service

provider and the household/family. While the

service provider would ensure the availability

and access to resources and services, the

family would take on increased responsibility

for maternal and child care and thus support

proper utilization of the services.

In every phase of the Mission and through

each intervention, it would embody the

above illustrated principle and display

improved service delivery in all sectors and

institutions involved, increased interaction

between functionaries of all service providing

institutions and the family, improved

accessibility and a system of monitoring

wherein the community and the institutions

are involved, thus leading to transparency and

shared analysis and learning from successes as

well as failures.

Service provider Capacity building on

management of child malnutrition

Use of standard protocols Quality services

FamilyEmpowerment

Involvement of both parents for signifi cant improvement in caring practices

Institutions Political commitment Mobilisation of resources Policy implementation

(targeted PDS; NREG & food fortifi cation)

Rights-basedGender equity

Life cycle

Behaviour change communication

Community-driven, participatory Community

Ownership Local initiative Community-based monitoring Mobilisation for better targeting,

food security

I. Key approachesThe Mission attempts to base its strategies and

interventions on key principles that would pave

Chapter 4

29Practising the Principles

Key approaches & core interventions

the way for achieving several overarching goals,

such as

gender equity,

recognition of people's right to nutrition,

breaking the intergenerational cycle of

growth failure and

community ownership of essential services

and programmes.

The Mission acknowledges the ongoing

involvement and roles of institutions, families,

service providers and communities and

endeavours to synergize existing programmes

and encourage creative initiatives.

a. Rights-basedFreedom from hunger and malnutrition is

a basic human right and their alleviation is

a fundamental prerequisite for human and

national development.

National and state governments, in their

policies, are obliged to promote nutrition

actions and reduce diet-related diseases. They

should do this within the context of respecting,

protecting and fulfi lling the right to adequate

food, and should ensure that these actions are

adequately funded.

The Nutrition Mission, an initiative of the

State government recognizes this right of every

individual, even the most marginalized of all,

and endeavours to empower communities

and families to protect their nutrition, human

rights and entitlements and those of their

Constitution of Food and Nutrition Council in 1997 – On its recommendations, a proposal on National Nutrition Mission, set up under the Prime Minister, was developed with a view to address the problem of malnutrition in a Mission Modeapproach

c. Life cycleGood nutrition is needed for all stages of

life — infancy, childhood, adolescence and

adulthood — especially for girls and women.

When these malnourished children do not

eat well and fall ill frequently, they grow up

to be malnourished adolescent girls who

in turn, in their adulthood, give birth to

babies who are born with low birth weight

and are micronutrient-defi cient. In this way,

malnutrition passes from one generation to

another and becomes a vicious cycle.

children, through knowledge, skills, policies

and regulations.

(See Annexure 4 for key global declarations

and conventions that recognize the Right to

Nutrition)

b. Gender equityInequities in access to and control of assets

have severe consequences for women’s ability

to provide food, care and health and sanitation

services to themselves, their husbands, and

their children, especially their female

children.

Intra-household food distribution has been

recognized as a key cause of nutritional

gender inequity. Even though the primary

burden of the household and the primary

care-giving responsibility of the family is

the woman’s, she is placed in a position that

often fails to address her own nutritional

requirements.

This Mission endeavors to introduce

operationally effective interventions, including

gender-sensitive nutrition education and

involving men and adolescent boys, to improve

the nutrition status of adolescent girls and

pregnant women.


This Mission recognizes that in order to

reduce malnutrition, it is imperative to

control it at all stages of life, infancy,

adolescence and adulthood. It operationalizes

the pregnant women’s access to adequate

nutrition as a combination of food, health

and care so that they give birth to healthy

babies. Under nutrition in the 0-3 age group

needs to be tackled with appropriate caring,

feeding and health-seeking behaviours whereas

adolescence provides yet another window of

opportunity to correct nutritional defi ciencies

and adopt good behaviours. The Mission will

act upon these to ensure that specifi c actions

lead to specifi c results.

Rest, adequate & nutritious food, iodized salt, complete ANC and PNC, weight gain, safe delivery practices

Maternal nutrition and safe

motherhood

Care of 0-3 year-old

children

Control of anaemia in adolescents

Colostrum feeding and breastfeeding, complementary feeding , complete immunization including Vitamin A, growth monitoring & promotion, preventing growth faltering, management of severe malnutrition (hospital and community-based), safe drinking water, personal and environmental hygiene

Weekly IFA supply, parents counselling, teacher training, self- monitoring, delay age at marriage, personality development, completion of school, food practices, prevention of worms, sanitation and hygiene

The life cycle approach to nutritional security

d. Community-drivenThe Mission will adopt a community-driven,

participatory, partnership approach based

on dialogue and involvement, which would

ultimately lead to community ownership.

Collective action would ensure that the

interventions would reach the hardest to

reach. A key element of this approach is

collaboration and communication between

the community and institutional facilities,

which would lead to improved service

delivery, improved access to services and

an improvement in the services and

indicators.



Promotion of positive behaviour Promotion and sustaining of individual, community and societal behaviour change Maintenance of appropriate behaviours

Community& Family

Support

groups

Counselling &

home visits

Social mobilisation

& IEC activities

Folk theatre

Positive deviants

The approach would:

address needs identifi ed by community

build on the strengths and resources of the

community

recognise the community as unit of identity

with common interests, shared values and

Community mobilisation

Formation of community-based volunteer teams

Training of volunteer teams

Planning together

Action

Evaluating together The

community-driven,

participatory approach

Community-driven participatory approach

Effecting behaviour change

norms and a commitment to meeting shared

needs

promote local knowledge and practices and

bridge cultural gaps

e. Behaviour change communicationBehaviour change communication is an

interactive process with communities (as

integrated with an overall program) to

develop tailored messages and approaches

using a variety of communication channels

to develop positive behaviours; promote and

sustain individual, community and societal

behaviour change; and maintain appropriate

behaviours.

In this Mission, communication strategies will

address not only individual behaviour change

of the mother and the adolescent girl, but also

the beliefs of those who infl uence them at all

levels: health workers, family members, elders

and community members.


II. Core Interventions The core interventions of the Mission refl ect the objectives, need and approach of the Mission.

These are presented below:

By target group

Formation of volunteer teams and trained groups

Malnutrition Growth promotion,

monitoring and referral Targeted feeding at AWC Managing Grades III and IV

malnutrition using standard protocols at AWC

Improving weighing effi ciency

Weight recording & monitoring weight gain (Grades III/IV) every 15 days

Hospital management Community-based treatment

Referral and follow-up Compulsory registration of

all 0-6 year-olds at AWC Community arrangement of

transport for referral cases

Immunisation Immunisation brigade Fixed site-fi xed day strategy

Illnesses Home-based management

of childhood illnesses and at AWC – fathers’ and mothers’ groups

IMNCI Programme to be included in the strategy

Feeding IYCF practices Capacity Building AWW/Sahyoginis in BCC

and approaches Effective use of time

Community-based Anaemia screening and

prophylaxis Life skill education Formation of Anaemia

Sentinel Club through Kishori Shakti samoohs

School-based Weekly IFA supplementation Deworming Nutrition education Life skill education Preparation of easy-to-

understand pictorial calendar Peer group support and

monitoring Nurturing school gardens

Formation of volunteer teams and trained groups; equipping and strengthening of institutional delivery mechanisms

Health Weight monitoring Ensuring micronutrient

supplementation in MCHN sessions and in catch-up sessions

Ensuring ANCs and post-natal check-ups

Skilled birth attendants for home deliveries (where institutional delivery is not possible)

Encouraging institutional delivery by arrangement of timely transport

Strengthening of PHCs and CHCs to provide essential obstetric and neo-natal care

Promotion of Janani Suraksha Yojana

Food Identifi cation of low cost,

locally available nutritious foods and demonstrations of nutritive cooking on MCHN Day

Consumption of one nutritious meal a day at AWC

Encouraging homestead production

Consumption of iodised salt

Care Optimal practices at family

level Breastfeeding support

groups and mother-to-mother exchange of information

Cluster counselling on complementary feeding at AWC and for fathers' groups

0-6 year-olds Adolescent girls Pregnant & lactating



Establishment of cooperative grain banks

Homestead gardening

Revisiting households to ensure that each BPL family owns a ration card

Management of PDS by women's groups

Ensure optimal utilisation of employment and food security schemes

Capacity building and technical support in rain water harvesting/conservation, artifi cial recharge

Promoting use of low-cost latrines (1 for a family)

Communication and education to health workers, families and community on hand-washing, drinking water, hygienic cooking and practices

Distribution of low cost water fi lters (in areas with excess fl uoride in ground water)

Ensuring execution of all works falling under Swajaldhara and Total Sanitation Campaign

Promoting key child care behaviours through community IMNCI

Malnutrition Treatment Centres at CHCs

Improved and well planned home visits for counselling and behaviour change

Strengthening quality of organisation of MCHN days with focus on unreached

Establishing and equipping mini aanganwadi centres for far-fl ung hamlets

Ensuring safe drinking water and sanitation in schools

Life skill education for school and non-school going adolescent girls

Exploring possibilities for nutrition supplementation for out of school adolescent girls

Water & sanitationHealth Food securityEducation

By malnutrition determinant (common for all target groups)


Starting rightThe Nutrition Mission would function with

the village as the basic unit where all key

interventions would be executed. To facilitate

smooth functioning of the Mission and to

ensure timely monitoring and corrective on-

course action, a fi ve-tiered implementation

structure is proposed.

Implementation StructureThe Mission would function through a fi ve-

tiered implementation structure, with a

state-level Mission Appraisal Council headed

by the Honourable Chief Minister. This

body would comprise Ministers, Principal

Secretaries of concerned departments and

UNICEF State Representative along with

Director, DWCD. There would also be a

Mission Empowered Committee at the state-

level headed by Principal Secretary, DWCD

and be constituted by Principal Secretaries

of concerned departments, Secretary PHED,

Commissioner Tribal Area Development,

UNICEF representatives, etc.

At the divisional level, there would be a

Mission Implementation Committee only for

tribal areas headed by Commissioner, TAD,

Udaipur. At the district level, a Mission Review

Committee would be headed by the District

Collector followed by Mission Implementation

Committees at the block and village levels,

which would be chaired by the Pradhan of the

concerned Panchayat Samiti and the Gram

Sarpanch, respectively. The terms of reference

for each of these tiers are provided in the

following pages.

Chapter 5

35

TERMS OF REFERENCE Meet at least twice a year Policy planning and periodic review of

implementation of programme Provide directions and guidance to Mission

Empowered Committee, wherever necessary Provide necessary administrative and fi nancial

support Institutionalise inter-departmental cooperation

and coordination to create channels of inter-departmental communication

Comment on results of monitoring, review Mission and set benchmarks in subsequent phases

MISSION APPRAISAL COUNCILChairperson: Hon'ble Chief Minister Rajasthan

Convener: Principal Secretary, DWCDMember Secretary: Director, DWCD

Members: Hon’ble Ministers WCD, TAD, Medical & Health, Food & Civil Supplies, RD & PR,

Agriculture and Education, Chief Secretary, Addl. Chief Secretary Development, Principal Secretaries Medical & Health, SWD & TAD, RD & PR, Food &

Civil Supplies, Agriculture and Education, Secretary PHED, State Representative UNICEF, Rajasthan

MISSION EMPOWERED COMMITTEEChairperson: Principal Secretary, DWCD

Member Secretary: Director, DWCDMembers: Principal Secretaries SWD & TADFood & Civil Supply, RD & PR, Agriculture,

Medical & Health and Education, Secretary PHED, Commissioner TAD, Salt Commissioner GoI,

Representative from Home Science Department, UoR, UNICEF/CARE/WFP

3 NGOs (to be co-opted by MEC)

State Level

Implementation framework

TERMS OF REFERENCE Meet at least at quarterly intervals Ensure inter-departmental coordination and

convergence Suggest means and modes for better

implementation of programme and provide necessary direction and guidance to Mission Implementation Committees

Regularly review and monitor progress under Mission activities

Suggest innovation and new activities Submit periodic appraisal report along with

suggestions to Mission Appraisal Council Arrange to implement directions given by

Mission Appraisal Council and provide necessary administrative and fi nancial back-up for implementation of approved projects programmes

MISSION IMPLEMENTATION COMMITTEE (Only for Tribal Areas)

Chairperson: Commissioner, TAD, Udaipur Members: Director, SIERT, Udaipur

Addl.Comm./Deputy Comm., Food Department, CEOs of 5 districts Banswara, Dungarpur, Udaipur, Chittorgarh, Sirohi, Regional Joint Director, M & H

DD-PD (ICDS) 5 districts Banswara, Dungarpur, Udaipur, Chittorgarh, Sirohi, DD, Elementary EducationAddl. C.E./S.Engineer, PHED, Dean, Home Science College, Udaipur

ACF/DCF, Forest Department, Udaipur, Regional Offi cer, Agriculture Deptt.Representative, WFP, Technical Advisor, F&NB, Udaipur

Divisional Level

35Starting right


MISSION REVIEW COMMITTEE Chairperson: District Collector

Member Secretary: DD-PD (ICDS)Members: District-level Offi cers of Line

Departments, Unicef Representative, 2 NGOs

District Level

MISSION IMPLEMENTATION COMMITTEE Chairperson: Pradhan, Panchayat Samiti

concernedMember Secretary: CDPO

Members: BDO, BEO, AEN PHED, Medical Offi cer CHC, Medical Offi cer Incharge PHCs, Enforcement

Inspector, Asst. Agriculture Offi cer Local NGO

Block Level

MISSION REVIEW COMMITTEE Chairperson: Gram Sarpanch

Member Secretary: Secretary PanchayatMembers: Supervisor WCD, ANM, HM

Primary School, Patwari, AWW, Sahayogini, Manager Gram Seva Sahkari Samiti, Social worker/NGO (Depending upon availability),

Gram Sevak

Village Level

TERMS OF REFERENCE Meet once in two months

Make available requirements specifi ed by block-level committee

Analyse data collected and present fi ndings before the state-level offi cials

TERMS OF REFERENCE Meet once in a month

Ensure community participation

Collect data and analyse at block level

Oversee programme implementation in block and suggest modifi cations, if any, for better implementation

TERMS OF REFERENCE Meet once in a month

Discuss operational diffi culties and suggest remedial course of action to block-level implementation committee

Undertake sole responsibility for operationalisation of Mission at grassroots level

Identify/track benefi ciaries for various services

Make available/select various functionaries at grassroots

Regularly inspect AWCs and guide AWW/Sahayogini to improve service delivery

37Starting right

Nodal agency The Dept of Women and Child Development

would be the nodal agency that would

Dept of Medical & Health

Dept of Public Health Engineering

Dept of Tribal Area Development Dept of

Information & PR

Dept of RD &Panchayati Raj

Salt Commissioner

Dept of Food

Dept of Civil SuppliesDept of

Education

Dept of Agriculture

Dept of Ground Water

Village level

State Level

Network Network

CoordinateCoordinate

Organise Organise

IntegrateIntegrate

District

Block level

Divisional N

odal

age

ncy

DW

CD

level

level

coordinate all activities among the identifi ed

departments at the state, district, block and

village levels of the Mission.

Role of nodal agency DWCD


The launchThe Mission would be launched with a

week-long massive Information-Education-

Communication (IEC) drive in order to ensure

social mobilisation.

Each of the 13 districts will be required to

develop extensive and detailed plans for

implementation of the Mission. A task force

would be set up at the district level involving all

the stakeholders, including departments, active

NGOs, Tribal Council representatives, etc.

Micro-level Action PlansThe Mission recognises the fact that a single

formula for all districts and regions within the

state would not produce the desired change.

Micro-level action plans would be developed by

taking into account the geographical conditions

of the area in focus (hilly, desert etc) and other

area-specifi c factors that infl uence the health

and nutritional status the population. These

micro-level interventions would also need to be

esigned keeping in mind the locally available

resources and ways to maximize their use.

In terms of health and illnesses, illnesses

occurring frequently in those regions would

need to be combated by reviewing the causal

factors. Similarly, appropriate locally available

food would need to be included in the

nutritional diet rather than transporting food

products from far-off markets.

For e.g., with respect to water availability

and quality, the micro-level planning would

incorporate ways of lessening the drudgery

of fetching water from distant sources by

encouraging the revival of traditional systems

of water harvesting (repairing and recharging

of baoris, johads) and water conservation

at the domestic and community levels etc

and ensuring that the water is fi t for human

consumption.

Nutrition Awareness Week

Objectives Spreading the message of the importance of nutrition

Informing about nutritional status of tribal people

Enlisting volunteers for the community-based teams

Key messagesEnsuring healthy children is in our handsCommunities, government and civil society have to work together to ensure thisNutrition care starts before birth and with special attention for children up to 3 yearsThe malnutrition status of the tribal peoples is an emergency. Urgent community-based steps need to be taken.

Key activities Prabhat Pheri involving school children and Nehru Yuvak Kendra Youth

Promotion of local foods through Melas promoting nutritious food cooked at home using locally available items

Health camp for pregnant/nursing women, adolescent girls and children below 3 years

Awareness-raising on hygiene, hand-washing, washing of food items and utensils, clean drinking water

Film shows of the Food and Nutrition Board

Promotional drives on TV, radio, local newspapers and any other local medium of communication

The driving force The Information & Publicity Relations department

would play a key role during this IEC drive.

PRIs at all levels, NGOs, voluntary organizations, youth organizations, school children and teachers, anganwadi functionaries, health workers religious leaders, women workers, etc.

39Starting right

Formation of volunteer teamsDuring the awareness week, Gram Sabha

meetings would be held during which selection

of volunteers would take place and where

the community will actively discuss and

decide on suitable volunteers, the role and

functions of these volunteers, time allocation,

compensation, etc. When volunteers are

selected in this participatory manner, the

community too would appreciate their

efforts and there would be an affi rmation of

the self esteem of volunteers. The leader of

each volunteer team will liaise with the Chief

Executive of the Block Programme Committee.

Capacity building of volunteer teamsAn essential part of the Mission is to impart

training or build capacities of the volunteer

teams. The Mission recommends that in each

village, specifi c teams for specifi c activities are

formed. This would have to be planned and

conducted in a time-bound manner as well as

in stages. The training for all villages in a district

could be conducted in groups, covering a cluster

of villages at convenient spots where training

would be conducive. The volunteers would have

to be brought together from the cluster for about

two days at a time for capacity building.

Preparatory tasks at district and block levels

1. Creating a common understanding about the Mission

2. Orientation and information communication about Mission goals, target populations, sectoral interventions and activities, time-bound results with district- and block-level staff of concerned departments

3. Clearly defi ne roles & responsibilities and tasks related to specifi c interventions

4. Communicate clear objectives and set clear guidelines for all district and block level offi cials of the concerned departments

5. Inform about District-level Review Meetings – once a month for the fi rst six months, once in 3 months subsequently – and the village-level, block level Mission Representatives who will attend these

6. Identifi cation of focal persons within community

7. Rapid assessment of facilities and infrastructure

8. Upgrade infrastructure wherever required – AWCs, PHCs, (For e.g, AWCs to have adequate space, functional weighing machine and other facilities for all activities envisaged, repairing weighing machines )

Preparatory tasks at village level1. Identifi cation of focal persons at village level

2. Identifi cation of persons for volunteer teams

3. Formation of volunteer teams

4. Creating a common understanding among volunteer teams about the Mission, about their role, and the importance of nutrition mapping

5. Capacity building of volunteer teams, on nutrition, IYCF and care, growth monitoring, message transmission, etc


Understanding nutrition situation among children,

targeted women and adolescents

Learning to conduct participatory exercises for situation analysis of nutrition status

How and what to measure and how to documentUse of simple pictorial monitoring formats

Understanding how to monitor nutrition status through effective growth monitoring and

motivate for optimal practices

IYCF and care ; management of childhood illnesses, especially diarrhoea

Pregnancy and carePreventing anaemia among adolescents

Understanding how to assist in the organisation and

management of health days

Understanding how to plan for community actions - vegetable gardens, water protection,

managing PDS, etc

Capacity building needs for volunteer teams are

suggested below in the fl ow chart:

Understanding how to identify malnourished children and care for them (home management

& referral)

Understanding Mission goals and activities and expected results

Helping villagers help themselvesHaving undergone capacity building in

the areas mentioned in the fl ow chart

above, the community-based volunteer

teams would have acquired information

and skills regarding growth monitoring of

0-6 year-olds and weighing of pregnant

women, care of severely malnourished

children, detection and management (at

community level) of childhood illnesses,

intake and distribution of IFA (women

and adolescents, IYCF practices, healthy

sanitary practices etc.

41Firm foundations

Reducing malnutrition in 0-6 year-olds


Firm foundations

Fundamental ObjectiveTo reduce the prevalence of malnutrition

among 0-6 year-old children, with special

focus on 0-3 year-olds, of the Scheduled Tribe

community, and usher in a healthy, disease-free

childhood

Specifi c Goals1. Reduce undernutrition among the 0-6 age

group with special emphasis on 0-3 year-

olds

2. Sustain effi cient weighing and growth

monitoring

3. Increase immunisation coverage

4. Encourage AWC- and home-based treatment

of common childhood illnesses, especially

diarrhoea

5. Protect, promote and support optimal infant

and young child feeding

6. Promote sanitary and hygienic practices

and use of clean drinking water at AWC and

family level

Strategic Interventions

Malnutrition mapping of children in village 1. Growth monitoring of all children in the 0-6

age group by AWW, Sahayogini and Growth

Monitoring Volunteers through home visits

2. Maintenance of village malnutrition record (sex-wise, age-wise, grade-wise) by Growth

Monitoring Volunteer team

Related tasks:

Sharing of information with concerned

families and in health committee meetings

and decisions taken to rectify situations

Chapter 6


Tasks during home visits (focussing on 0-3 year-olds)a. Nutritional counselling to family

b. Home-based care, advice, support

c. Recording immunisation coverage, types and frequency of other illnesses, such as diarrhoea

d. Categorising the children by malnutrition grades

e. Care of pregnant and lactating women

Recording of weight of all children in 0-6 age group

Plotting of weight on growth chart by AWW, ANM, Growth Monitoring Volunteers

Determine whether or not child is suffering from any grade of malnutrition or has evidence of growth faltering

Normal weight without growth

Grade I

Grade II

Growth faltering

Grades III, IV

Identifi cation of malnourished children in village

Motivating families whose children are

faltering and/or are not in normal grade

Encouraging families whose children are

doing well to maintain positive growth

Planning for information sharing

3. Preparation and monthly updating of Child Nutrition Map of village and associating

households having children by malnutrition

grade by colour (red – grade IV, light blue

– grade III, dark blue – grade II, light green

– grade I, dark green – normal)

Outcomes of home visits are to be shared with

ANM on her monthly/immunisation visits and

if referral is critical, information is to be made

available to the ANM.

43Firm foundations


1 Management of severe malnutrition: A manual for physicians and other senior health workers, World Health Organization, Geneva, 1999

I. Management of Grades III and IVChildren falling in grades III and IV are

severely malnourished. Timely and effective

interventions combined with efforts to prevent

further growth failure are crucial for these

children. Successful management of the

severely malnourished child does not require

sophisticated facilities and equipment or highly

qualifi ed personnel. It does, however, require

that each child be treated with proper care and

affection, and that each phase of treatment be

carried out properly by appropriately trained

and dedicated health workers. When this is

done, the risk of death can be substantially

reduced and the opportunity for full recovery

greatly improved1.

1. ANM ReferralIn order to assess how the severely

malnourished child is to be taken care of,

the ANM has to determine (after assessing

symptoms) whether the child can be managed

by the family/AWC level or needs to be referred

to the PHC/CHC/FRU


Clinical assessment by ANM to be made to determine whether or not the severely malnourished child needs hospital care or community-based care

Once the assessment is made for each of

those children who are severely malnourished

- the management details will have to be

communicated to the concerned families. This

will be done by the ANM with volunteer team

and AWW. The latter will take responsibility

for ensuring follow-up action and volunteer

team will facilitate family to organise if hospital

management is necessary.

Recording of weight of all children in 0-6 age group

Plotting of weight on growth chart by AWW, ANM, Growth Monitoring Volunteers

Determine whether or not child is suffering from any grade of malnutrition or has evidence of growth faltering

Normal weight without growth

Grade I

Grade II

Growth faltering

Grades III, IV

Aangan Wadi Centre/Community

PHC/CHC/FRU

Nutritional status of child:

Grades III & IVTAKE CHILD TO

Grade assessment of children in 0-6 years age group

45Firm foundations


Phases Actions Principles

Phase 1 Initial treatment Life threatening problems identifi ed; treated in hospital or community; specifi c defi ciencies corrected; metabolic abnormalities reversed; feeding begun

Treat or prevent thypoglycemia and hypothermia;

Treat or prevent dehydration and restore electrolyte balance;

Treat incipient or developed septic shock, if present;

Start to feed the child; Treat infection; Identify and treat any other problems,

including vitamin defi ciency, severe anemia and heart failure.

Phase 2 Rehabilitation Intensive feeding given to recover most of the lost weight; emotional and physical stimulation increased; mother or carer trained to continue care at home; preparations made for discharge of the child

Encourage the child to eat as much as possible;

Re-initiate and/or encourage breastfeeding as necessary;

Stimulate emotional and physical development; and

Prepare the mother or carer to continue to look after the child after discharge.

Phase 3 Follow-up After discharge, child and family followed to prevent relapse and assure continued physical, mental and emotional development of child

Phases in Management of Severe MalnutritionManagement of the child with severe

malnutrition is divided into three phases. It is

important for all stakeholders - the family, the

AWW and the volunteer team - to understand

and assimilate this. In case the child is referred

to the hospital at the district level, the family

would be assisted by the community, the AWW,

the ANM and the volunteer team.


2 a. Hospital Management

Primary health centre/Community health centre/District hospital

DAY CARECondition: Presence of infection Child is conscious Accepting oral feed

INPATIENT CARECondition: Listless Presence of severe infection (fever,

diarrhoea, blood in stools, chest drawn in) Child is conscious Accepting oral feed

1. Supervised feeding2. Treatment of infection 1. Supervised feeding

2. Treatment of infection3. Progress monitoring

Follow-up care at AWC

2b. Management at Aangan Wadi Centre/Community-based careIn order to effect successful intervention, the

AWCs need to be equipped to manage severely

malnourished children in terms of the skills

of the functionaries and necessary equipment

and medical supplies. Once the severely

malnourished child is identifi ed, targeted

feeding would begin at the AWC coupled with

monthly prognosis on a fortnightly basis. If

the child is found to not gain weight at the rate

of at least 10 gm per kg (body weight) per day,

she/he would be referred to the PHC or CHC

or the fi rst referral unit. However, if the child

is found to make progress, feeding care at

the family level would follow which would be

supervised by the Sahayogini.

Skill building of the AWW and Sahayogini

through on-the-job training in order to carry

out this intervention effectively is extremely

important for the Mission. Supervision of the

AWW would be conducted at the block level

through the Block Programme Committee (see

Implementation Framework in Chapter 5).

3. Establishing support system for families of children referred to PHC/CHC/FRU in the

event of the primary caregiver in the family

needing to accompany the malnourished child

Counselling to the family for need to take

malnourished child to PHC/CHC/FRU

Children to be taken in groups using a

common vehicle

1 Referral Volunteer per group to accompany

the group

Management at AWW/Community-based care

47Firm foundations


Targeted feeding at the Aangan Wadi Centre – minimum 2 feeds

Fortnightly weight recording Visit by Sahayogini for supervised active feeding

at home Maintain warmth by covering the child in

multiplayer with head caps and socks or advice about kangaroo care

Put the child on antibiotics (Cotrimaxazol) for 7 days

Give one course of Mebendazol or Albendazol beyond 2 years

Increase the number of usual feeds and add ghee/oil 1 to 2 tablespoonfuls a day

Continue feeding during illness give supplementary feeding and reinforce correct feeding practice

If the child does not revisit AWC, Referral Volunteer will bring the child to the AWC

Equip AWCs for management of

severely malnourished children

Begin targeted feeding at AWC

Monitor prognosis on fortnightly basis (weight

gain @ 10 gm/kg body weight per day

If yes, continue community-based

care

If no (within 2 weeks)refer to PHC/CHC/FRU

Feeding care at home; supervision

by Sahayogini

Management at AWC/Community-based care

IMPORTANTFrequent causes of failure to

respondProblems with the treatment facility: Poor environment for malnourished children

Insuffi cient or inadequately trained staff

Inaccurate weighing machines

Food prepared or given incorrectly

Problems of individual children: Insuffi cient food given

Vitamin or mineral defi ciency

Malabsorption of nutrients

Rumination

Infections, especially diarrhoea, dysentery, otitis media, pneumonia, tuberculosis, urinary tract infection, malaria, intestinal helminthiasis and HIV/AIDS

Serious underlying disease

Source: ‘Management of Severe Malnutrition – A Manual for Physicians and Other Senior Health Workers’, World Health Organization, 1999


Normal weight without faltering

Grades I and II

Growth faltering as per established criteria

Praise mother/caregiver

Emphasise on EBF up to 6 months

Complementary feeding at 6 months & reinforce correct feeding practices through nutritional counselling

Advice to continue feeding Advice to continue feeding during illness

Advice on immunization, Advice on immunization, vitamin A supplement and IFA tablet (small)

Advice revisit or ask her Advice revisit or ask her to report early in case of illness

If child does not come for revisit, Sahayogini/AWW/Growth monitoring Volunteer to bring child to centre

Sensory stimulation

Enquire about any illness/alteration of feeding practices

Increase no. of usual feeds and add ghee/oil 1 to 2 tablespoonfuls a day

Continue feeding during illness, give supplementary feeding as per norms and reinforce correct feeding practice

Give advice on immunisation, vitamin A supplement and IFA tablets (small)



In case of children in Grade II, monitor closely for downward trend

Sensory stimulation

Enquire about any illness/alteration of feeding practices

Increase no. of usual feeds and add ghee/oil 1 to 2 tablespoonfuls a day

Continue feeding during illness, give supplementary feeding as per norms and reinforce correct feeding practice

Give advice on immunisation, vitamin A supplement and IFA tablets (small)



In case of improve-ment, continue family/community-based care

In case of no improvement, refer to

health facility

Pointer cards to be given to volunteer teams:

Each volunteer team will be given simple

instructions on cards as part of capacity

building to deal with growth monitoring results.

Supporting families

49Firm foundations


II. Registration of all births and community-based care of new-born

Register births in the village

Record birth weight

Normal > 2500 gm 2000-2500 gm < 2000 gm

Home care Community management by

preventing: hypothermia hypoglycaemia avoiding infection

Refer newborn to FRU/CHC/PHC

Action to be taken: Feeding colostrum; - Exclusive breastfeeding; - No bathing

for 7 days; - Keeping baby by the side of mother StabilizedNot

stabilized

Action to be taken: Feeding colostrum Exclusive breastfeeding No bathing for 7 days Keeping baby by the side of mother Less handling of baby

Refer to apex institution

Under the Mission, each village volunteer

team will ensure registration of births and

community-based care of the new-born. This

aspect has to be given utmost attention as one-

third of the babies that are born have low birth

weight.

Registration and care of new born


III. Compulsory registration of all 0-3 year-olds at AWC & optimal utilisation of servicesAs the newborn is followed up closely up to the

fi rst year and thereafter up to 3 years of age, it

is of utmost importance that the family avails

the services at the AWC for the child. The AWW,

therefore, has to inform and make the family

understand the method and signifi cance of the

following:

Monthly weighing and growth monitoring

Immunisation schedule

Danger signs of illness

Importance of adopting hygienic practices

IIIa. Immunisation of all children in the 0-6 age group to be undertaken by /ANM and AWW during growth monitoring visitsGrowth monitoring team and volunteer group

for immunization will communicate the

messages of timely vaccinations through the

use of songs in local dialect

The schedule for immunisation that is provided

in the Mamta card has to be followed as shown

under.

Schedule for 0-3 year-olds' immunisation

YEAR 1 YEAR 2 YEAR 3

Month 1

Month 2 BCG, DPT, Polio

Month 3 DPT

Polio

Month 4 DPT, Polio

Month 5

Month 6 DPT,

Polio,

Vitamin A

Vitamin A

Month 7

Month 8

Month 9 Vitamin A,

Measles

Month 10

Month 11

Month 12 Vitamin A Vitamin A

All mothers need to be motivated to come to

the centre for immunisation at fi xed times.

The volunteer team for growth monitoring

and immunisation needs to inform mothers

accordingly.

In families with severely malnourished or

those in rehabilitation phase have to be

immunised at home. For this, the ANM/

Sahayogini and AWW would need to plan the

home visits.

The volunteer team has to make a list of absent

children so that they too can be covered by the

ANM when the round of home visits are being

planned.

III b. Infant and Young Child Feeding The growth rate in the life of human beings

is maximum during the fi rst year of life

and infant feeding practices comprising

breastfeeding and complementary feeding

plays a major role in determining the

51Firm foundations


0-6 month-old 6-36 month-old

Colostrum feeding and exclusive breastfeeding

Preparing for timely and proper initiation of complementary foods

Proper initiation of complementary food Start with small amounts of mashed

cereal, dal, vegetables, fruits

Increase quantity, frequency and thickness of foods gradually

Understand child’s signals for hunger and respond accordingly

Sit with child and feed her/him

Infant and young child feeding

nutritional status of the child. Optimal infant

and young child feeding practices include six

months of exclusive breastfeeding, continued

breastfeeding for two years or beyond,

timely, adequate, safe and appropriate

complementary foods and feeding starting

after six months, and related support for

maternal health, nutrition and birth spacing.

III.c Celebrating a healthy, safe and well-nourished motherhood and childhood: Maternal and Child Health & Nutrition Day (MCHN Day)The Maternal and Child Health and Nutrition

Day is an activity wherein convergence

between the departments of WCD and Medical

& Health is taking place.

It is a fi xed health day held every month at

the AWC to provide antenatal, postnatal,

family planning and child health services. The

AWW, ANM and a Medical offi cer from the

PHC would be in attendance. The AWW and

Sahayogini (and other community volunteers)

would be responsible for ensuring that all

children 0-6 and children for immunization

and other health services be brought to the

AWC on that day, when ANM and MO visit

to provide immunization, and other health

care services. Services to be provided on

the Health Day (by the ANM or PHC MO)

include ANC, newborn check-up, postnatal

care, immunization of mothers and children,

IFA and Vitamin A administration, growth

monitoring, treatment for minor ailments, and

health education.

During the Nutrition Mission, the MCHN Day

would celebrate health and nutrition of the

mother and the child in the 0-6 age group.

Cultural activities, celebrating milestones of

children and other entertaining and festive

events would mark the MCHN Day.

The MCHN Day will help strengthen the

Mission objectives through the reiteration of


the importance of the health and well being of

mothers and children for society.

Frequency : 1 fi xed day of the month

Participants: All pregnant and lactating womenAll children in the 0-6 age group

Events: Bringing Mamta card for making any enquiriesHealth check up - ANC + infant/young child’s healthGrowth monitoringDemonstrations of nutritive cooking Dialogue between mothers and health & nutrition functionaries and volunteer teams on milestonesHealth and nutrition education

IV. Integrated management of childhood illnesses2

It is seen that in most cases, more than

one underlying cause contributes to the

illness of the child. While the Mission will

focus on treatment, it will also emphasise

prevention of illness through education on the

importance of immunisation, micronutrient

supplementation, and improved nutrition

- especially breastfeeding and infant feeding.

The Mission will also achieve its objective by

improving family and community practices

for the home management of illness, and

improving case management of skills of health

workers.

Detection of symptoms of illnesses, such as diarrhoea, and referral by Childhood Illnesses Volunteers who would be trained on WHO

recommendations.

2 The Integrated Management of Childhood Illness (IMCI) was fi rst developed in 1992 by UNICEF and the World Health Organization (WHO) with the aim of prevention, or early detection and treatment of the leading childhood killers.

Diseases occurring frequently among tribal children in Rajasthan

Pneumonia

Malaria

Jaundice

Diarrhoea

Source: Assessment of ICDS in tribal areas in Rajasthan, IIHMR

Training to Childhood Illnesses Volunteers on

detection of cases of common illnesses

Case treatment by health workers

Fortnightly visits to homes to detect

cases

Management and follow-up of ill children

53Firm foundations


In order to accelerate the decline in infant mortality, a special program has been launched in Rajasthan, especially focusing on newborns. This approach is called integrated management of childhood illnesses (IMNCI).

The core IMNCI intervention is integrated case management of the fi ve most important causes of childhood deaths — acute respiratory infections, diarrhoea, measles, malaria and malnutrition. In addition, it ensures that skilled providers visit all newborns at least three times within fi rst week of life. This strategy is likely to increase the survival of newborns in the state.

Integrated case management involves training of a large number of health and nutrition workers in an intensive skill-based program. These trained workers make home visits to newborns and manage sick children in their communities. These workers include the following: Medical offi cers

Auxiliary Nurse-Midwives

Angan Wadi workers

Accredited Social Health Activists

Sahayoginis

Progress so far: In Rajasthan, IMNCI is a core strategy for improving child health under RCH-II. An outlay of Rs 20 cores have been kept for upscaling IMNCI. IMNCI will be implemented in 9 districts in the fi rst phase:

1. Jhalawar, 2. Tonk, 3. Bharatpur, 4. Sawai Madhopur, 5. Dholpur, 6. Baran, 7. Kota, 8. Bundi, 9. Karauli

Kota Medical College and SMS Medical College are acting as regional resource centers. UNICEF provides technical support.

Training of master trainers: State facilitators (consisting of faculty from medical colleges and pediatricians) have been trained in a Master Training Workshop conducted at SMS Medical College and Jaykaylon Hospital. About 20 facilitators have been trained.

Training of trainers: District-level training of trainers has been conducted for the following districts: Baran

Jhalawar

Tonk

Karauli

Training for Bundi is ongoing.

Training of frontline workers: About 400 frontline workers have been trained in the districts of Jhalawar and Tonk. Training in Baran is being initiated. Trained workers have visited more than 2,000 newborns at home after training: more than 90% of births in their fi eld area. Initial results are encouraging.

Keeping illness at bay, the IMNCI way

Encouraging home-based management of childhood illnesses through night classes (by Childhood Illnesses Volunteer Team) for fathers’ groups and day classes for mothers’ groups

1. Diarrhoea Understanding causes, consequences &

symptoms

Home-based care (Application of ORT,

dosage of ORS and other management tips)

2. Malaria Use of treated malaria nets/involve in efforts

targeting breeding of mosquitoes to be taken

up as cleanliness drive

3. Jaundice Understanding causes, consequences &

symptoms


4. Pneumonia Understanding causes, consequences &

symptoms

V. Establishing community food security systems during lean season and water security systemsAccess to clean water and adequate sanitation

facilities is an essential component for the

success of any nutrition drive. Water supply,

sanitation and hygiene, given their direct

impact on infectious disease, especially

diarrhoea, are important for preventing

malnutrition. In drought-prone Rajasthan with

its scarce water resources, it becomes all the

more important to ensure water supply through

alternate means such as water harvesting and

also the quality of drinking water.

Similarly, seasonal food shortages tend to

recur on an annual basis among the tribal

Some tips for home management of childhood illnesses

Diarrhoea Breastfeed more often Give extra fl uids Give correct dosage of

ORS Continue to give normal diet If loose motions do not

stop, take child to centre

DANGER SIGNS

FeverUse cold, wet sponge on the forehead and limbs during high fever and take child to centre If loose motions do not

stop, take child to centre

centre

Acute Respiratory InfectionTake child immediately to centre if she/he is: breathing fast breathing with diffi culty not able to drink/breastfeed becoming sicker developing fever

DANGER SIGNS

DANGER SIGNS

populations, which have a serious and

damning effect on their nutritional status. In

order to avoid this, through the Mission, in

the focus areas, efforts to maintain adequate

food stock and deliver emergency food will be

promoted.

1. Nutrition Team comprising AWW and Health volunteers to undertake Assessment Drive to:a. Check access and availability of food grain

by households having Grade III & IV children

b. Assessing storage facilities at AWCs

c. Assessing cooking facilities at AWC

2. Establishment of cooperative grain banksLocal-level grain banks (1 per village) operated

by self-help groups supported by a revolving

fund; PDS to be involved; storing of grains for

the lean season

55Firm foundations


Fluoride poisoning can be prevented or minimised by using alternative water sources, by removing excessive fl uoride from drinking water, and by improving the nutritional status of populations at risk.

Source: UNICEF http://www.unicef.org/programme/wes/info/fl uor.htm, UNICEF's Position on Water Fluoridation

such tankas and transporting it to their

individual household storage tanks.

Wherever possible individual households

shall be encouraged to construct ground

water recharge dug well/kui so as to use

surplus rain water of their household for

recharge purposes.

Surplus rain water of a village shall be

impounded in an already existing nadi/

johar/local taalaab for storage. The

VWSC shall also arrange to clear any

encroachment of the catchments area of

such structures and shall be responsible for

its maintenance.

The PHED in consultation with other

concerned departments shall take up

construction of anicut, sub-surface barrier

on rivers/streams/nallas and provide

necessary recharge structures. Such

works shall be executed by the relevant

department.

4. Ensuring availability of India Mix/Rajasthan Mix during hungry seasonIndigenously produced, low-cost nutritious

food supplement (blended mix of wheat and

soya, enriched with vitamins and minerals)

5. Construction of low cost latrines These can be constructed even by the families

themselves with a little labour and fi nancial

assistance from UNICEF, Dept of PHE and the

Total Sanitation Campaign (See Annexure 5 for options provided by UNICEF).options provided by UNICEF).options provided by UNICEF

3. Water harvesting and conservationAt department level

Repairing of old pipelines, taps, hand pumps

and other sources in households, schools,

AWCs

Identifying and weeding out ineffi cient

pumping machinery

Distribution of defl uoridation fi lters

– household/community units

At community and departmental level: Rain

water harvesting & artifi cial recharge efforts

Rain water harvesting both in individual houses

and on community basis shall be taken up.

Similarly, massive action for artifi cial recharge

of the ground water aquifer on community

basis in a village shall be required.

Roof top/ground level water harvesting will

be taken up in individual households. The

benefi ciary family shall contribute towards

labour component of the work so that it

develops a sense of ownership of the assets

so created.

Community ‘tankas’ would be constructed

wherever possible so that surplus rainwater

of a village is collected and utilised during

critical period.

The local Village Water and Sanitation

Committee shall look after the up-keep of

such community assets and impose a ban

on taking out or pumping out of water from


IEC Activities The information-education-communication

component of the Mission is extremely

important and will be built into all the activities

and interventions. The objective of IEC activities

will include motivating people to adopt new

attitudes or behaviour and to improve utilisation

of existing services. IEC has to promote dialogue,

gather feedback and result in increased

understanding, thus facilitating learning to

enable the community and the family to make

rational and informed decisions. These activities

would be undertaken by several groups of

persons, departments, and functionaries. The

IEC messages need to be standardized across

departments and every contact should be

viewed as an opportunity for reinforcing these

common messages. A review of all existing IEC

material should be undertaken in order to avoid

duplication and unnecessary production of

additional materials. Some illustrative activities

are given below:

Paint the wall of the AWC in black and use it

as a blackboard to put up main information

such as number of children who are showing

healthy growth; numbers in different

grades and action taken for each month in

comparison to the previous month.

Integrating optimal behaviour/practices

related to handwashing and clean drinking

water with illness and disease into EVS as

part of school project activities

Nutrition and health education for parents

on MCHN Days

Nutrient-rich food for children

Water and sanitation

At family level Family to ensure that the child defecates in a

safe latrine or in small dug pit and excreta is covered with ash or soil to prevent odour and fl ies

Hand washing after defecation, before cooking and feeding

Safe drinking water, hygienic cooking, vessel washing

57Firm foundations


Activity Responsibility

Growth monitoring AWW, ANM, Sahayogini

Referral ANM

Drive against mosquito breeding Panchayati Raj and Medical & Health departments

Distribution of treated malaria nets Medical & Health department

Distribution of IEC material on hygiene UNICEF

Facilitation of establishment of Grain Bank and its SHG

Dept of Food & Civil Supplies along with DWCD & Home Science Colleges

Provision of IndiaMix / RajasthanMix DWCD through SHGs

Building capacities of local teams Home Science Colleges, NGOs

using creative learning methods, such as

local mythological characters

using local/vernacular and colloquial

dialect

Household level competitions on

hygiene maintenance in cooking and

feeding

Quiz and other programmes with adolescent

girls in and out of school

Implementing Responsibility & ConvergenceRelevant departments, functionaries and

volunteer teams would converge and be

responsible for the activities and in achieving

the related objectives. The following table

provides information about who will do what:

Helping HandsIt is important to build and strengthen

local level teams, build human resources

at the community level that will result

in local ownership and strengthen local

learning. The interventions related to child

malnutrition would be community-driven

and be implemented at the grassroots by the

community-based volunteer teams

Community-based volunteer teams comprising

Nehru Yuva Kendra members, Mahila Mandal

members, Kishori Balika Mandal members

1. Growth Monitoring VolunteerTeam

2. Referral Volunteer Team

3. Childhood Illnesses Volunteer Team

4. Grain Bank SHGs


Caring for the care giver

Fundamental Objective To ensure safe and healthy pregnancy and

delivery and pave the way for a healthy

motherhood

Specifi c Goals1. Operationalising universal screening of

pregnant and lactating women; ensuring

ANCs and PNCs, encouraging institutional

deliveries

2. Ensuring appropriate infant feeding

practices (universal colostrum feeding,

exclusive breast feeding up to six months,

introduction of semisolids at six months)

3. Dietary diversifi cation to include vitamin A-

rich, vitamin C-rich and iron-rich foods

4. Promoting appropriate intra-family

distribution of food based on requirements;

5. Promotion of hygienic ways of cooking and

sanitary practices

Strategic Interventions

Strategy: Community-led mapping of all pregnant & lactating women

Actions to be taken1. Identifi cation of all pregnant & lactating

women in village

i) Maintenance of ANC and PNC records

related to:

ii) Preparing easy-to-understand records

iii) Preparing map of village and associating

households having pregnant and

lactating women

iv) Identifi cation of high-risk mothers

v) Weighing and identifi cation of low-

weight mothers (those with less than

40kg body weight)

Chapter 7

Pregnant and lactating women

HealthFood

Care

Elements that infl uence the nutritional status of women

59Caring for the care giver


Strategy: Empowering women with knowledge of importance of antenatal check-ups and all elements

Strategy: Door-to-door micronutrient supplementation (IFA, Vitamin A) undertaken by Peer Group of mothers of 1-year olds and above in addition to distribution of IFA at AWCs

ANTENATAL CHECK -UPS

First check-up: Prior to Month 3Second check-up: During Month 7Third check-up: During Month 9

ANTENATAL

Visits the AWC

PregnantWoman

Home visits by AWW/ANC/

Sahayogini

Residingnear AWC

Residing farfrom AWC

Strategy: Women who reside far from the AWC will be visited by a team led by AWW/ ANM/Sahayogini

Care of pregnant woman


Fortifi cation of common food items, such as salt with iron, to increase the dietary intake of iron and improve the haemoglobin status of the entire population, including girls and women prior to pregnancy

Screening of all pregnant women for anaemia using a reliable method of haemoglobin estimation

Oral iron folate prophylactic therapy for all non-anaemic pregnant women (with haemoglobin more than 11 g/dl);

Iron folate oral medication at the maximum tolerable dose throughout pregnancy for women with haemoglobin level between 8 and 11 g/dl;

Parenteral iron therapy for women with haemoglobin level between 5 and 8 g/dl if they do not have any obstetric or systemic complication;

Hospital admission and intensive personalized care for women with haemoglobin less than 5 g/dl;

Screening and effective management of obstetric and systemic problems in all anaemic pregnant women; and

Improvement in health care delivery systems and health education to the community to promote utilization of available care

Source: Tenth Five-Year Plan Nutrition goals, Govt of India

Danger signsDanger signs

Bleeding during pregnancy/

delivery

Danger signsDanger signsSevere

anaemia with/without breathlessness

Labour pain for more than 12 hours

Danger signs

Bursting of water bag

without labor pain

Danger signsDanger signs

Convulsions or fi ts, blurring of vision, or fi ts, blurring of vision,

headache, sudden swelling of feet

or fi ts, blurring of vision, or fi ts, blurring of vision, headache, sudden

High fever during pregnancy

or within 1 month of delivery

Strategy: Recognition of high risk factors and equipping mothers/

AWWs/Sahayginis and ANMs to manage these

Educating family in understanding danger signs

Multi-pronged strategy for control of anaemia in pregnancy



If delivery conducted at home, it is to be done

only by skilled TBAs, trained dais or ANM

Community arrangement of transport in times of emergency and for deliveryImprove facilities for referral transportation

at panchayat, zilla parishad and primary

health centre levels. At sub-centres, provide

ANMs with soft loans for purchase of mopeds,

to enhance their mobility. This will increase

coverage of ante-natal and post natal

check-ups, which, in turn, and will bring

about reductions in maternal and infant

mortality.

Institutional strategies Strengthen community health centres to

provide comprehensive emergency obstetric

and neo-natal care. These may function as

clinical training centres as well.

Strengthen primary health centres to provide

essential obstetric and neo-natal care

Strengthen sub-centres to provide

a comprehensive range of services,

with delivery rooms, counselling

for contraception, supplies of free

contraceptives, ORS and basic medicines,

together with facilities for immunization

Post-natalStrategy: Ensuring post-natal check-ups and spreading awareness on spacing during the check-ups

During the post-natal check-ups, the

importance of spacing births and the methods

to do so would be conveyed to the new parents.

Easy-to-understand, pictorial IEC material on

this will be provided so that in case the father is

not present, he can appreciate and understand

the same at home.

Health

AntenatalStrategy: AWW/ANM/Sahayogini to ensure

that all pregnant women attend 3 compulsory

antenatal check-ups, which includes weighing

Ensuring safe deliveriesEnsuring safe delivery with assistance of skilled

attendants

Preparation for home delivery Clean hands

Clean surface & surroundings

Clean blade

Clean umbilical cord

Clean thread to tie the cord


Janani Suraksha Yojana (JSY) integrates cash assistance with antenatal care during pregnancy, institutional care during delivery and immediate post-partum period in a health centre by establishing a system of coordinated care by the fi eld-level health worker. The Nutrition Mission aims to converge with the scheme in its objective to ensure maternal care.

Objectives of JSY To reduce overall maternal mortality ratio and infant

mortality rate

To increase institutional deliveries in BPL families

Target group of JSYAll pregnant women belonging to the below poverty line (BPL) households and Of the age of 19 years or above

Up to two live births

Strategy of JSYLink cash assistance under JSY to institutional delivery by carrying out the following: Early registration of the benefi ciaries with the help

of the village level health workers like ASHA or an equivalent worker

Early identifi cation of complicated cases

Providing at least three antenatal care, and post delivery visits

Organizing appropriate referral and provide referral transport to the pregnant mother

Convergence with Integrated Child Development Services (ICDS) worker by way of involving Angan Wadi worker (AWW) intensively

Devising as well as ensuring transparent and timely disbursement of the cash assistance to the

mother and the incentive to the Accredited Social Health Activist (ASHA) or an equivalent worker with fund available with ANM

The strategy also involves the following: Operationalisation of 24/7 delivery services at PHC

level to provide basic obstetric care

Operationalisation of First Referral Units (FRUs) to provide the emergency obstetric care

Building partnerships through a process of recognition/accreditation with doctors, hospitals/nursing homes/clinics from the private sector specially in the rural areas to provide obstetric services to the JSY benefi ciaries.

Janani Suraksha Helpline was started in April 2006 in Dholpur district by UNICEF Rajasthan’s NGO partner Mangalam Seva Samiti (MSS) with the specifi c objective of developing a 24-hour obstetric helpline. On receiving a call, the helpline staff not only support the transportation of the woman to the health facility, but actually negotiate the health system for admission and hospital stay of the woman. The helpline is truly a community based and supported initiative. The phone number of the helpline has been popularized through wall writings, stickers and by word of mouth. The taxi drivers have been mobilized and sensitized to be ready to transport obstetric emergencies. A standardized fare chart has been prepared after consulting them to ensure there is no delay due to price negotiation. At present, 346 transport vehicles are involved in the project and 105 telephone contact points have been identifi ed which can be used to access the helpline. The Police Department has been brought on board to ensure prompt and safe movement of vehicle carrying women with obstetric emergencies.

Janani Suraksha Yojana

Safe water and sanitation Ensuring intake of clean drinking water and

maintenance of hygiene during and after

pregnancy.

FoodStrategy: Identifi cation of cheap, locally available nutritious foods and demonstrations of nutritive cooking on MCHN Day

Strategy: Consumption of nutritious, wholesome meal every day at the AWC, using locally available, followed by quizzes and songs to make it a fun event

Pregnant and lactating women of the village to

gather at the AWC daily, form groups, cook a

nutritious meal, and consume the same at

the AWC



Vitamin A – rich foodsDark green leafy vegetables like spinach, amaranth,

deep yellow fruits like papaya, mango and melon and milk and milk products, fi sh and eggs

Iron-rich foods Green leafy vegetables, wheat, ragi, jowar, pulses

Vitamin C – rich foodsamla, guava, oranges

Key messages: Hand washing and hygienic preparation of

meals and before eating

Using iodized salt in food

Identifying foods rich in iron and vitamin A

Homestead production Using degraded lands for vegetable

production

Farm wastes as well as food grains unfi t

for human consumption can be used to

feed backyard poultry in order to increase

homestead production of eggs and chicken

and also increase consumption of these at

home

Adolescents can also be involved in this and

school children

A pregnant woman should consume More food

A variety of foods like cereals and whole grains, green leafy vegetables, fruits, lentils and beans, milk and its products, and meat and eggs

Only iodised salt

FIRST FEEDSome important steps

1. Initiate child into breastfeeding within an hour2. Show mothers how to breastfeed and how

to maintain lactation even if they should be separated from their infants

3. Give newborn infants no food or drink other than breastmilk, unless medically indicated

4. Practise rooming-in – allow mothers and infants to remain together – 24 hours a day

5. Encourage breastfeeding on demand

Source: Protecting, Promoting and Supporting Breastfeeding: The special role of maternity services;A Joint WHO/UNICEF Statement (WHO, 1989) and ‘The Global Criteria for the WHO/UNICEF Baby-Friendly Hospital Initiative’ (UNICEF, 1992)

Care

Adequate rest and reduced workload

Strategy: Support group to ensure that the pregnant and lactating women do not take on arduous work

Collective effort for procuring fi rewood

– using boys in the village

Breaks during work


Infant and young child feeding

Strategy: Formation of breastfeeding & child feeding support groups

Support groups to meet once a week in order to

access information on:

1. Colostrum feeding

2. Exclusive breastfeeding for 6 months

3. Breast hygiene and dietary intake of mother

affecting breastfeeding

4. Young Child Feeding & illness management

The group will share concerns and experiences

and, thereby, help women breastfeed effectively.

The support group will meet at a unanimously

chosen venue, which could either be at the

AWC or at the home of a member.

Strategy: Cluster counselling on complementary feeding at AWC and for fathers’ groups by IYCF Volunteer Team

Counselling on timely, adequate, safe and

appropriate complementary foods and feeding

starting after six months

Strategy: Demonstration of appropriate feeding by lactating women with infants above 6 months of age, peer review and discussions

Thematic discussions : E.g. ‘Breastfeeding - the

right way’, Ensuring proper IYCF”

IEC activities Posters on breastfeeding to be displayed at

the AWC, health centre and using cultural

events/

Development of culturally appropriate

messages

MCHN Day to be used to spread messages n

the following

Important to have that extra, energy-

dense, nutritious meal during pregnancy

Connection between maternal and infant

nutrition and a clean environment and

adequate personal hygiene

MCHN Day – Quizzes on elements of ante-

natal care and prize distribution

Lactating mother’s groups to engage in

dialogue with pregnant women’s groups

(mother-to-mother support)

An easy-to-understand chart:

Antenatal Dangers signs & how to control

Labour & delivery Special care

Immediate newborn Danger signs & care

Postpartum care for new born & mother

Dangers signs & care

Adolescent girls would be encouraged to

develop this chart, using locally available

pictorials.

Another method would be to use positive

deviants within the community as role models.

This could be a woman who is adopting

optimal practices with respect to IYCF or a

family which has collectively ensured healthy

growth and development of the child below 3

years. During the capacity building sessions

for volunteer teams, they could be equipped

to identify steps in developing such role

models.

Helping Hands

Community-based teams/groupsGrowth monitoring team

Breastfeeding support group

Mother-to-mother support group

IYCF Volunteer team comprising Nehru Yuva

Kendra members, Mahila Mandal members,

Kishori Balika Mandal members.



Activity Implementing responsibility

Mapping, monitoring Growth monitoring team

IYCF practices Support groups

Facilities for referral transportation Panchayat

Repairing of taps, common wells Deptts of PHE and PR

Formation of breastfeeding support groups Women’s NGO, post-graduate Home Science students from local institutions

Door-to-door supplementation of IFA AWW, ANM, Sahayogini

Empowering fathers’ groups on CF AWW, ANM

Activities on MCHN Day Dept of Medical and Health

IEC strategy & materials Home Science departments & UNICEF

Implementing responsibility & convergence


The adolescent girl in focus

Towards a healthy transition

Fundamental ObjectiveTo promote the health and development of

adolescent girls (aged 10-19 years) by reducing

the prevalence of anaemia and making way for

a healthy adulthood

Specifi c Goals1. Increase intake of iron and folate to reduce

anaemia levels by 25% in fi rst year, 50% in

second year and 100% in the third year

2. Dietary diversifi cation for intake of iron-rich

foods

3. Prevent hookworm infection

4. Increase consciousness about underlying

causes of under-nutrition, i.e. age at

marriage, education, intra-household food

distribution

5. Life skills education for school-going and

non-school-going adolescent girls

6. Promote sanitary and hygienic practices and

use of clean drinking water at school and

family level

Adolescents gain 30 per cent of their adult weight and more than 20 per cent of their adult height between 10 and 19 years.

Anaemic: Haemoglobin level <12gm/dL; Severely anaemic: Haemoglobin level <7gm/dL

Chapter 8

67Towards a health transitionThe adolescent girl in focus

Key Strategies & Actions

Nutritional screening of all adolescent girls in village

1. Identify all adolescent girls (13-19 years) in

village, both school-going and non-school-

going

2. Screening of adolescent girls, especially

those who are undernourished or have

menstrual problems, for anaemia and

provide appropriate treatment

The two key approaches to combat anaemia

that the Mission would comprise medicinal

supplementation, i.e., intake of iron and

folic acid tablets or syrup, and dietary

diversifi cation, i.e., intake of foods that

contain vitamin A, such as dark green leafy

vegetables such as spinach, amaranth, cholai,

deep yellow fruits like mango, papaya and

melon, and milk and milk products.

SupplementationMedicinal supplementation requires supplying

the supplements to the adolescent girls. This can

be done through two channels, community and

school either on a weekly or bi-weekly basis.

Screening, counselling to combat anemia

Pregnant adolescentsAdolescents who are pregnant should receive very

high priority for screening and management of anaemia

Community-level activities – for non-school-going adolescents Sentinel Club

Step 1: Formation of Adolescent Sentinel Club – groups

of adolescent boys, each of which is in charge

Medicinal supplementationWeekly/bi-weekly

At community level At school level

School-based, health facility-based and community-based programmes should be considered together

Dietary diversifi cation (Micronutrient-dense

energy foods)

Key approaches

Medicinal supplementation

Combating anaemia

Supplementation

No

n-school going

Sc

hool-going


of an adolescent girls group, which will ensure

peer group support and monitoring

Step 2: Door-to-door distribution of IFA tablets by

Club members

Step 3: Six-monthly anaemia check-up; group with low

level of anaemia will be rewarded

Inclusion of extension of mid-day meal for out-

of-school girls in select locations

School-level activities – for school-going adolescents

Preparation of easy-to-understand, pictorial

calendar listing benefi ts of taking iron, advice

on where to fi nd them, how families can assist

with compliance; distribution of calendar

among school-going and non-school-going

adolescents

Distribution of IFA at school: The responsibility

for this task would be that of the school

authorities.

Implementing responsibility & convergence

Activity Implementing responsibility

Homestead production Deptts of Panchayati Raj, Food & Civil Supplies

Adolescent Sentinel Club Community, AWW, ANM, Sahayogini

IFA distribution and compliance Adolescent Sentinel Club

Anaemia reduction Departments of Education, Medical & Health

IFA calendar School going adolescent girls

Ensuring toilet and drinking water facilities in schools Depts. of PHE, Education

School gardens Teachers, Dept of Education, PR, WCD

Curriculum development Department of Education

Mid-day meal for non-school going adolescent girls Department of Panchayati Raj

69Towards a health transitionThe adolescent girl in focus

use one day of the week as an

opportunity to cook the vegetables

grown for a meal at the school

Bottom-up educational strategy:

Schoolchildren convey information to their

families. Therefore, families can be sensitized

through information and innovative activities

learned by their children in school.

IEC activities Health education

Promotion of delayed marriage for

girls, not earlier than age 18 and

preferably after 20 years of age

Educating families through drama

and songs about need for equity in

intra-household food distribution

Helping handsAdolescent Sentinel Club comprising village

youth.

Inclusion of life skills topic in Std VI-VII text books and training of teachers for ensuring life skills

Dietary diversifi cation At AWC level

Weighing of all adolescent girls at least four

times in a year, identify those with weight less

than 35 kg and provide food grains for the next

three months or until they weigh more than

35 kg

At school level

Nurture school gardens

Teachers and students nurture gardens at

school to:

learn about the importance of

diversifying the diet, and the

importance of fruits and vegetables

identify space and the vegetables to

be grown

learn how to grow vegetables


Complementing Nutrition Mission through ongoing Schemes/Programmes/Missions

Provisions in Nutrition Mission Scheme/programme/mission

Institutional delivery (beginning with early registration, identifi cation of complicated cases, ANCs, post-delivery visits, referral, referral transport, active participation of fi eld worker

Janani Suraksha Yojana (National Rural Health Mission)

Janani Suraksha Helpline : 24-hour emergency obstetric care telephone service for referral transport

Janani Suraksha Yojana (National Rural Health Mission)

Immunization, health check-up, referral services and nutrition & health education

Integrated Child Development Services (ICDS) scheme

Nutrition, health, and skill formation for adolescent girls Adolescent Girls’ Scheme/ Kishori Shakti Yojana (ICDS)

Monthly weighing of all adolescent girls in village and provision of grain to low-weight girls

National Adolescent Girls’ Scheme

Integrated Management of Neo and Childhood Illnesses (IMNCI) package

National Rural Health Mission, Reproductive and Child Health Programme II

Capacity building of health & nutrition workers in newborn care

IMNCI package, Reproductive and Child Health Programme II

ANC&PNC services, IFA distribution, delivery by skilled attendant, referral for institutional delivery, immunization, management of childhood illness, de-worming, nutrition and health education for mothers

Tribal component of Reproductive and Child Health Programme II

Grassroots level support for service provision and engagement & training of social workers/link volunteers/Sahayogini for maintaining link between health facility and community

Reproductive and Child Health Programme II (RCH II)

Water harvesting infrastructure Jal Chetna Rath Yatra

Establishment of grain banks Village Grain Bank Scheme, Ministry of Tribal Affairs, Govt of India

Ensure water supply Swajaldhara; Bharat Nirman

Construction of household latrines, AWC toilets, school toilets

Total Sanitation Campaign

School sanitation & hygiene education Total Sanitation Campaign

IEC on hygiene & sanitation Total Sanitation Campaign

School gardens, homestead gardens 20-Point Programme (11B), Ministry of Tribal Affairs, Govt of India

Food security interventions Annapurna Scheme, Mid-day Meal Scheme, Antyodaya Anna Yojana, Targeted Public Distribution Scheme

Drinking water in schools, toilets in schools Sarva Shiksha Abhiyan

71Measuring Success

Participatory monitoring and evaluation

Why Monitor And Evaluate?Participatory monitoring and evaluation is an

essential part of the Mission that will serve twin

purposes:

improve the effi ciency and effectiveness of

the interventions

increase community’s awareness and

understanding of the various factors that

affect their nutritional status

Through the exercise, the community will be

able to assess the progress of their activities

with respect to each target group, identify

gaps, re-examine resources, make mid-course

corrections, if required, and ascertain whether

or not certain strategies are better than others

and draw lessons thereof.

Measuring Success

Monitoring involves more than simply a one-time collection of information. It involves review, which is conducted more frequently.

Implementation

Monitoring

Evaluation

Planning

Review & adjustment

Problem identifi cation


Chapter 9

The participatory cycle


Participatory monitoring is a bottom-up

process. Intrinsic to the community-based

interventions in the Mission is lateral and

vertical feedback both from peers as well as

from the community.

These in-built mechanisms will ensure that

that responses, appraisals and reviews will take

place on a continuous basis.

How to Monitor & Evaluate?Data for monitoring the Mission will be

obtained from the following sources:

1. Family-based, home-retained Mamta Card

The Mamta Card was developed with the

objective of making families in rural areas

informed and well-versed in health and

nutrition. It also helps in accessing services and

generating demand for these.

The Mamta Card is especially useful for

illiterate women and families from rural areas

as it is easy to understand and use. It is meant

for families including a either a pregnant

woman and/or children below the age of 3

years.

The Mamta Card contains information on the

following:

a. For the pregnant woman Frequency and elements of ante-natal

check-up,

Diet and rest requirements

Danger signs to be recognised during

pregnancy and delivery

b. For the 0-3 year-old Weight monitoring

Immunisation

Feeding (breast and complementary)

Signs of childhood illnesses

c. For community Pre-school education at AWC

Spacing of births

Education and upbringing of girls

Age at marriage

Hygiene and sanitary practices

2. Display board at AWCInformation of all children enrolled in the AWC

by their malnutrition grade would be presented

on a display board outside every AWC. This

would make families and communities

conscious of the issues and facilitate dialogue

in appropriate forums.

3. Interviews with community members Data collection for monitoring would emanate

from respondents who would be members of

the community. They would include not just

the target groups members but also families,

community leaders, teachers, AWWs, ANMs,

Sahayoginis etc.

4. Visits to target householdsVisits by health workers and volunteer teams to

the homes of high risk children and pregnant

women would be a part of the review and

monitoring.

5. Independent surveys and evaluationsIn order to study, monitor and evaluate the

Mission, independent surveys and evaluation

studies would be commissioned. Rajasthan-

based credible research organisations having

experience in such work would be taken on for

the assignments.

73Measuring Success


6. National Nutrition Monitoring Bureau unitThe National Nutrition Monitoring Bureau

(NNMB) at the National Institute of Nutrition,

Hyderabad assesses the nutrition situation

in the country on a continuous basis. NNMB

measures nutrition status in 10 states. It is

suggested that a state-level NNMB unit be set

up as Rajasthan is not among the 10 states

monitored by NNMB.


7. Sentinel surveillanceA nutrition surveillance system is already in

place in seven districts where the UNICEF

programme Aanchal se aangan tak is underway. Aanchal se aangan tak is underway. Aanchal se aangan tak

Through this mechanism, quality data, which

would indicate any concerns under conditions

of stress such as severe drought, famines etc, is

continually collected. Sentinel Surveillance is

simple, sensitive, fl exible, acceptable and cost-

effective.

Essential requisites Preparation of protocols (questionnaires) to

be used during the period

Sensitisation of the administrators, training

of the functionaries

Developing a system of regular scrutiny and

compilation of the data generated

Dissemination and feedback of information

To begin with, one AWC per block in the

13 districts can be selected as the sentinel

surveillance centre.

Review and SupervisionIn addition to monitoring, half-yearly

review would take place wherein the district

coordination committee would review all

aspects of the Mission, including performance

of functionaries. Here, the volunteer teams too

would be active.

How to go about?

13 districts

District 1 District 2 District 3

Project 1 Project 2

Project 2

Project 2

Sentinel surveillance could be initiated in a selected area. The sentinel communities could be representative, both spatially and in numbers. Therefore, in each district, 2 ICDS projects may be selected in consultation with the district and state

authorities ensuring that they are not contiguous. From each project, 2 sectors can be randomly selected to serve as sentinel sectors. From each sector, 2 AWCs can be randomly selected.

75Measuring Success


This review would be a two-way process where

information will fl ow back and forth between

the fi eld staff and volunteer teams and the

management at the district level.

The review and supervision would monitor the

process and be followed immediately by post-

review action and follow-up.

Who will Monitor & Evaluate? True to its participatory character, the

monitoring & evaluation methods in the

Mission will be qualitative and quantitative and

collection of information will largely be done by

the community itself. However, monitoring and

evaluation will be a part of the institutional set-

up, right from the village level to the state level.

At the village level, the Stakeholders’ Group

and the Monitoring Committee (which would

be led by key members of the Village Health

Committee) will be actively involved. The block

level monitoring committee will be involved

in overseeing data collection and compilation

of the same for submission to the district level

monitoring committee.

State Executive Committee Task: Review results; review strategies;

defi ne fresh benchmarks

District-level monitoring unitTask: Data interpretation & identifi cation of

gaps; make presentation at state level and give feedback to block

Block-level monitoring unitTask: Data compilation; use data to support

effective actions at village level

Village-level data collection teamTask: Data collection; monitoring actions; learning

and improving practices

The monitoring mechanism


Impact indicators Process indicators Behaviour indicatorsChild malnutrition

Malnutrition statusGrowth falteringImmunisationIYCFIllnessesNutritional status of pregnant and lactating womenAdolescent anaemiaIodine defi ciency disorders

Water & sanitation

Food availability, accessibility, dietary practicesCommunity participationGender equityCapacity building

Outcomes to be monitored and evaluated

Target group – Adolescent Girls

December 2007 December 2008 December 2009

IFA supplementation Universalise IFA supplementation in phase 1 districts & sustain coverage

Universalise IFA supplementation in phase II districts & sustain coverage

Universalise IFA supplementation in phase III districts & sustain coverage

Life Skill & Nutrition Education

Coverage of girls (school going 100% and out of school girls -50% out of school) in phase 1 districts.

Coverage of girls (school going 100% and out of school girls -50% out of school) in phase II districts

Coverage of girls (school going 100% and out of school girls -50% out of school) in phase III districts

What To Monitor And Evaluate?What is to be monitored can best be decided

by the community. Essentially, the impact,

process and behaviour will be monitored and

these will be associated with the objectives

framed for the Mission. To this end, relevant

information will need to be collected, which

will be quantitative as well as qualitative. Each

District Mission Management will discuss

and defi ne the impact, process and behaviour

indicators that are to be achieved for their

district.

Some performance indicators are given below:

77Measuring Success


Target group – 0-6 year-olds; special focus- 0-3 years


Malnutrition

Weight assessment of all 0-3 year olds; referral of severely undernourished and their management; 20% reduction in malnutrition rates from present levels

Continued growth monitoring of all 0-3 year-olds; strong community-based care; 30% reduction in under-nutrition rates

No cases of severe under-nutrition; total control over growth faltering; strengthened community-based care; 40% reduction in under-nutrition rates

ImmunisationIncrease immunisation coverage to reach 70%

Increase immunisation coverage to 80%

90 % immunisation of 0-3 year-olds

Treatment of illnesses/infections

Universalise IMNCI to Phase 1 districts

Universalisation IMNCI to Phase II districts

Universalisation IMNCI to Phase III districts

Exclusive breastfeeding

Early initiation & exclusive breastfeeding improved to reach 60%

80% mothers giving colostrum within 1st hr of birth; Early initiation & exclusive breastfeeding improved to reach 80%


Timely complementary feeding

40% children provided appropriate CF and optimal IYCF & care



Target group – Pregnant & lactating women


Quality ANCs, PNCs, & safe deliveries

50 % quality ANC, obstetric (institution) & post natal coverage

70 % quality ANC obstetric (institution) & post natal coverage

90 % quality ANC obstetric (institution) & post natal coverage

Micronutrient intake IFA Iodised salt

Ensure 60% IFA consumption; Reduce anemia by 20%; HH level consumption of IS to 80%



Exclusive breastfeeding


80% mothers giving colostrum within 1st hr st hr st

of birth; Early initiation & exclusive breastfeeding improved to reach 80%



When to Monitor & Evaluate

Timeline


Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4

Data collection

Data compilation

Data interpretation

Presentation at state level

Sharing with community

79Reference

References1. Food Insecurity Atlas of Rural India, WFP and MSSRF 2001

2. NFHS II 1998-99, Rajasthan

3. Census 2001

4. National Rural Health Mission, mohfw.nic.in/nrhm.html

5. Micronutrient Profi le of Indian Population, ICMR 2004

6. ICDS III – Evaluation 1999-2006, Presentation made at National Consultation on Child Under

Nutrition and ICDS in India, May 2006

7. www.unicef.org/india/nutrition

8. The State of the World’s Children, UNICEF 1998

9. Repositioning nutrition as central to development, A strategy for large-scale action, The World

Bank, 2006

10. ACC/SCN, Second Report on the World Nutrition Situation: Vol. I: Global and Regional Results,

ACC/SCN, Geneva, 1992

11. Constitution of India

12. ICDS data, October 2005, DWCD, Govt of Rajasthan

13. Management of severe malnutrition: A manual for physicians and other senior health

workers, World Health Organization, Geneva, 1999

14. Tenth Five-Year Plan Nutrition goals, Govt of India

15. UNICEF and the Global Strategy on Infant and Young Child Feeding (GSIYCF), Understanding

the Past – Planning the Future, UNICEF Working Paper

16. Nutrition and Gender, Ruth Oniang’O and Edith Mukudi, A Foundation for Development,

Brief 7 of 12

17. Nutrition in adolescence – Issues and Challenges for the Health Sector, Issues in Adolescent

Health and Development, World Health Organization 2005

18. Sector Policy for Rural Drinking Water and Sanitation (Draft), Govt of Rajasthan, 2005

19. Guidelines for Participatory Nutrition Projects, Food and Agriculture Organization (FAO)

Corporate Document Repository

20. Rajasthan Human Development Report 2002 (HDRC, UNDP)

21. Background note and recommendations, State Secretaries’ Working Group workshop, Govt of

Rajasthan, July 2005

22. Study on existing system of distribution of nutrition, its quality acceptability of benefi ciaries

and need for alternative cost-effective system - IDS Jaipur

23. Study on effi cacy of pre-school activity in anganwari centres and its relevance in view of DPEP

at RGSJ Pathshala etc. - IIHMR

24. World Bank-assisted ICDS Project Phase III Rajasthan: Baseline Survey - IIHMR

25. World Bank-assisted ICDS Project Phase III Rajasthan: Project Implementation Plan


Annexure 1

Micronutrients –defi ciencies and sources

IODINEWhat iodine doesIodine is needed by the thyroid gland fornormal mental and physical development.Most commonly and visibly associatedwith goitre (a swelling of the neck as theenlarged thyroid works to collect iodinefrom the blood), iodine defi ciency takes agraver toll in impaired mental acuity.Persons suffering from IDD face a rangeof serious impairments including cretinism,spastic diplegia (a spastic paralysis of thelower limbs) and dwarfi sm. Less severedefi ciencies in both adults and childrencan mean the loss of 10 to 15 intelligencequotient (IQ) points, as well as impairedphysical coordination and lethargy.

Sources of iodineIodized salt is the best source of iodine.Sea fi sh and some seaweed also containiodine, although sea salt does not.

VITAMIN AWhat Vitamin A doesVitamin A, stored normally in the liver, is crucial for effective immune-system functioning, protecting the integrity of epithelial cells lining the skin, the surface of the eyes, the inside of the mouth and the alimentary and respiratory tracts. When this defence breaks down in a vitamin A defi cient child, the child is more likely to develop infections, and the severity of an infection is likely to be greater. Depending on the degree of the defi ciency, a range of abnormalities also appears in the eyes of vitamin A-defi cient children. In the mildest form, nightblindness occurs because the rods in the eye no longer produce rhodopsin, a pigment essential for seeing in the dark. In more severe forms, lesions occur on the conjunctiva and the cornea that if left untreated can cause irreversible damage, including partial or total blindness.

Sources of vitamin AVitamin A is found as retinol in breastmilk, liver, eggs, butter and whole cow’s milk. Carotene, a precursor of vitamin A that is converted to retinol in the abdominal walls, is found in green leafy vegetables,orange and yellow fruits, and red palm oil.



81Annexures

IRONWhat iron doesThe body needs iron to produce haemoglobin, the protein in red blood cells responsible for carrying oxygen. Iron is also a component of the many enzymes essential for the adequate functioning of brain, muscle and the immune-system cells. A certain amount of iron is stored in the liver, spleen and bone marrow. Irondefi ciency develops as these stores aredepleted and there is insuffi cient ironabsorption. In anaemia, the iron defi ciencyis so severe that the production ofhaemoglobin is signifi cantly reduced.The main symptoms and signs are paleness of the tongue and inside the lips,tiredness and breathlessness. Defi cienciesof folic acid, vitamin A, ascorbic acid,ribofl avin and various minerals can alsocontribute to anaemia.

SourcesIron is found in liver, lean meats, eggs,wholegrain breads and molasses.

FOLATEWhat folate doesThis B vitamin helps in the formation ofred blood cells. Folate also regulates thenerve cells at the embryonic and foetalstages of development, helping to preventserious neural tube defects (of the brain and/or spinal cord).

SourcesFolate is found in almost all foods, butthe best sources are liver, kidney, fi sh,green leafy vegetables, beans andgroundnuts.




Annexure 2

Health & nutritional profi le of Rajasthan vs STs of Rajasthan

Child Care Parameters

Rajasthan (All) Rajasthan (Scheduled Tribe)Infant and child mortalityNeo-natal mortality 58.3 58.0

Post-neonatal mortality 39.0 36.7

Infant mortality 97.3 94.71

Child mortality 53.0 66.6

Under-5 mortality 145.1 155.00

Nutritional status

Underweight (Weight for age) 50.6 59.3

Stunting (Height for age) 52.0 60.0

Wasting (Weight for height) 11.7 17.6

% with anaemia 82.3 80.2

Childhood vaccinations2

BCG 53.9 39.7

DPT DPT 1 47.8 36.8

DPT 2 40.2 29.2

DPT 3 26.1 15.7

Polio Polio 1 75.5 63.6

Polio 2 67.3 52.3

Polio 3 44.6 31.5

Measles 27.1 19.0

Vaccinations received (all) (before 12 months) (%)

17.3 10.3

Vaccinations received (none) (before 12 months) (%)

22.5 34.5

Vitamin A received at least 1 dose (12-35 months) (%)

17.6 12.9

Childhood illnesses% suffering from ARI 22.0 21.5

% with ARI taken to health facility or provider 60.6 50.0

% suffering from fever 25.8 27.7

% suffering from diarrhoea 19.8 23.1

% with diarrhoea taken to health facility or provider

58.2 59.4

83Annexures

% mothers who know about ORS packets 44.8 32.7

% who know two or more signs of medical treatment of diarrhoea

17.9 19.7

Infant and young child feeding (IYCF) practices

*Initiation of breastfeeding (within 1 hour) (%) 4.8 3.7

*Initiation of breastfeeding (within 1 day) (%) 33.6 27.2

*Initiation of breastfeeding after squeezing fi rst breast milk (%)

69.1 73.8

Maternal Care Parameters

Maternal mortality ratio 670 NA

% of ever-married women with anaemia (age 15-49) 48.5 58.4

Deliveries in a medical institution (%) 21.5 15.8

Deliveries assisted by a trained doctor or a nurse/midwife (%)

35.8 23.9

IFA tablet/syrup received (%) 39.3 35.8

Tetanus toxoid (at least 2 injections) received (%) 52.1 42.1

% receiving no ante-natal check-up 52.5 57.9

% with a postpartum check-up within 2 months of birth

6.4 4.7

Iodization of Salt

% household not using iodized salt while cooking 37.1 44.2

1 IMR for Rajasthan, as per SRS 2004, stands at 67.2 Percentage of children aged 12-23 months who received specifi c vaccinations at any time before interview (according to the vaccination card or the mother)Source: NFHS II 1998-99


Annexure 3

Target Population (Rural)Phase 1 districts

District 0-4 Adolescent girls Women

Total SC ST Total SC ST Total SC STDungarpur 155307 5380 117758 103528 3805 71322 188616 7304 123886Banswara 209447 8181 171069 141136 5345 110602 244681 10066 184640Udaipur 293212 13341 193281 217773 10747 125814 407335 20442 225954Chittorgarh 181030 25589 56665 145999 19369 36267 299761 42546 71473Sirohi 99362 19727 34379 69366 12609 18293 128609 24192 35118Sawai Madhopur

115565 24908 27381 94123 18881 24049 155403 31045 41211

Jodhpur 279926 54268 11329 199979 32881 6091 320697 54024 9512Baran 107528 19101 29361 88333 14867 21505 151230 25753 37684Rajsamand 109322 13928 18633 85128 10400 10761 164741 20037 23486Alwar 351616 67996 29970 270247 49185 23181 436135 78287 39438Dhaulpur 126312 27863 7189 76670 15617 4583 126354 26151 7484

Tonk 120888 25675 19317 96775 19263 14296 171457 33461 25267Jhalawar 122536 20712 19265 97635 14678 13076 185489 28804 23997Total 2272051 326669 735597 1686692 227647 479840 2980508 402112 849150

0-4 includes males and females; adolescent girls comprise 10-19 year-olds; women comprise 20-49 year-olds

(source: Census 2001)

Phase 2 districts


Total SC ST Total SC ST Total SC ST

Nagaur 296786 70665 736 247241 50736 589 409835 81554 935

Pali 184022 36062 15135 151097 26069 8926 256888 44830 16619

Bhilwara 197730 35186 23193 153680 24088 14204 298368 47869 31146

Kota 86361 20013 19317 76621 15852 14296 133354 28890 25267

Barmer 285579 49878 20588 174049 26713 10792 302116 46639 18484

Jaisalmer 68519 11435 4661 39123 6221 2306 69534 10580 3825

Jalore 198501 38533 21106 141753 24355 11285 233647 39353 19750

Bikaner 163011 44047 315 117026 28134 207 178968 42534 293

Ganganagar 156381 69895 536 142713 55587 411 250448 91435 690

Total 1636890 375714 105587 1243303 257755 63016 2133158 433684 1170090-4 includes males and females; adolescent girls comprise 10-19 year-olds; women comprise 20-49 year-olds

(source: Census 2001)

85Annexures

Phase 3 districts


Total SC ST Total SC ST Total SC STHanumangarh 142810 46604 608 128429 37332 463 232308 62647 835Dausa 162990 37146 48470 122386 26733 35235 201756 42857 59213Jaipur 350152 59963 45135 285373 47122 33952 456144 74252 53448Bharatpur 242536 53987 5298 168218 34107 4263 275833 57376 7409Ajmer 174383 28163 5928 132792 20978 3697 236204 37263 7381Bundi 97316 18319 23788 80424 14295 18976 140968 25268 34040Karauli 146190 38127 34695 102420 23503 26204 168644 39581 44132Jhunjhunu 182658 31768 4060 171351 28008 3870 280313 43405 5884Sikar 226554 37612 7412 206893 32062 6545 323575 47337 9843Churu 198230 53234 813 150749 34931 698 246360 56611 1048Total 1923819 404923 176207 1549035 299071 133903 2562105 486597 223233


Global declarations and conventions recognizing the Right to Nutrition

Global recognition of the Right to Nutrition

Declaration of the Rights of the Child

1924 The Declaration affi rms that “the child must be given the means needed for its normal development, both materially and spiritually” and states that “the hungry child should be fed.”

Universal Declaration of Human Rights

1948 Article 25 states that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services . . . .” This article also affi rms that “motherhood and childhood are entitled to special care and assistance.”

Declaration of the Rights of the Child

1959 The Declaration states in principle 4 that children “shall be entitled to grow and develop in health” and that children “shall have the right to adequate nutrition, housing, recreation and medical services.”

International Covenant on Economic, Social and Cultural Rights

1966 Article 11 affi rms the right of everyone to an adequate standard of living, including adequate food, and the “fundamental right of everyone to be free from hunger.” The Covenant also mandates States parties to take steps to realize this right, including measures “to improve methods of production, conservation and distribution of food.”

Declaration on the Right to Development

1986 Article 1 of the Declaration proclaims that the right to development “is an inalienable human right,” with all people entitled to participate in and enjoy economic, social, cultural and political development “in which all human rights and fundamental freedoms can be fully realized.” Article 8 calls for all States to ensure equal opportunity for all in access to health services and food.

Convention on the Rights of the Child

1989 Article 24 mandates States parties to recognize children’s right to the “highest attainable standard of health” and to take measures to implement this right. Among key steps, States are mandated to provide medical assistance and health care to all children, with an emphasis on primary health care; combat disease and malnutrition, within the framework of primary health care, through the provision of adequate nutritious foods, and safe drinking water and adequate sanitation; and provide families with information about the advantages of breastfeeding.

World Declaration and Plan of Action on the Survival, Protection

and Development of Children

1990 Reducing severe and moderate malnutrition by half of 1990 levels among under-fi ve children by the end of the century is the main nutrition goal. The 7 supporting nutrition goals are: reduction of low-weight births to less than 10 per cent of all births; reduction of iron defi ciency anaemia in women by one third of 1990 levels; virtual elimination of iodine defi ciency disorders; virtual elimination of vitamin A defi ciency; empowerment of all women to exclusively breastfeed their children for about the fi rst six months; institutionalization of growth monitoring and promotion; and dissemination of knowledge and supporting services to increase food production to ensure household food security

Annexure 4

87Annexures

Four options of low-cost latrinesAnnexure 5

achieving optimum nutrition and development potential · r.k. meena alka kala in recognition of...

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