A PROJECT PROPOSAL FOR AN INTEGRATED NUTRITION PROJECT IN KARNATAKA
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A PROJECT PROPOSAL FOR AN INTEGRATED NUTRITION
PROJECT IN KARNATAKA - extracted text
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A PROJECT PROPOSAL
FOR AN INTEGRATED NUTRITION
PROJECT IN KARNATAKA
Tara Gopaldas, Director, Tara Consultancy Services,
Bangalore, India.
A commissioned report for MI, India; and for the Department of Woman and
Child Development, Karnataka, June 2000
CONTENTS
(i)
6)
Executive Summary
PART ONE
Chapter One
Introduction and Rationale
Chapter Two
Overall and Specific Objectives
Chapter Three
A Situational Analysis of the Nutrition Scene in Chikmagalur. Gulbarga.
Raichur and Tumkur
Chapter Four
Karnataka’s Specific Nutrition Goals for
2000 AD.
Chapter Five
Inter-Sectoral Linkages Between:
• Women and Child Development (Nodal Dept.)
• Health and Family Welfare
• Zilla Panchayat
• Civil Supplies
• Information and Broadcasting
Chapter Six
Orientation. Training and Capacity Building
Chapter Seven
Measurement of Nutritional & Health Outcomes in the Area of Programme
Evaluation in the ICDS.
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43
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PART TWO
IMPLEMENTATION STRATEGIES
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6564
Chapter One
An Outline for the Management of the Pilot Study
Chapter Two
A Strong Awareness Campaign (Especially at the District Level)
Chapter Three
An Improved Nutrition Health Package for the Under Twos
Chapter Four
Self-Help Groups (SHGs) of Women to make Supplementary Foods for the
3-6 Years Age Group m the ICDS
Chapter Five
The Adolescent Girls.in the ICDS
Chapter Six
The Pregnant/ Lactating Woman in the ICDS
Chapter Seven
Safe Water At All the Project AWCS
Chapter Eight
Mass Deworming of .Ml ICDS Beneficiaries
Chapter Nine
Enrichment or Fornncation of Double Toned Milk with VitaminA in All the
Dairies of Karnataka
Chapter Ten
A Multinutrient Tablet Including Iron. Folic Acid. Vitamin-C And Vitamin B-12
for all Pregnant/ Lasting Women In The ICDS Of The Pilot Districts
Chapter Eleven
Enriching Ragi Atta with an Add-On of 6 Micronutirents
Chapter Twelve
(i) Drying/ Dehydration of Fruits/ Vegetables in the Glut Season.
(ii) Better Storage of Perishables at Point of Harvest
(iii) Development of a Simple Cooling Box.
Chapter Thirteen
Use of Double Fortified Salt
an
Chapter Fourteen
Deworming + Vitamin A + Iron + Iodised Salt for /Ml Schoolers
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EXECUTIVE SUMMARY
A PROJECT PROPOSAL FOR AN INTEGRATED NUTRITION PROJECT IN
KARNATAKA
1. PURPOSE AND RATIONALE :
1.1. An Integrated Nutrition Project will be undertaken in all the ICDS Projects of Chikmagalur (7),
Gulbarga (11), Raichur (5) and Tumkur (11) in the 4 Pilot Districts of the State from August 15,
2000.
O. The reason for the above Pilot Project is that the levels of Undemutrition has not come down to
the desired levels as envisioned in the State’s Plan of Action for 2000, among the beneficiary
groups of the ICDS. These were the ‘Under Twos’, the pre-schoolers, the Pregnant (P) and
Lactating (L) woman.
1.3An intergenerational life cycle approach would be adopted wherein, the ‘Under Twos’, the
preschooler (3-6 years), the adolescent girls (first time), the Pregnant and Lactating woman
would all be linked and targeted through specific nutrition (macro and micro-nutrient) and health
(preventive, deworming and reproductive health) strategies.
1.4.The Consequences of not addressing the above problem would result in:
‘Under Threes’: Growth faltering, more episodes of common illnesses especially of the gastro
intestinal tract, poor cognition/ poor physical work capacity in later life and nutritional
deficiency diseases of PEM, VAD, IDA. Riboflavin, vitamin C and zinc. The 6-12 month infant
is the most affected.
The Adolescent: Small and short stature and will probably produce a LBW baby (less than
2500g), will suffer from VAD, mild to moderate IDA, poor cognition and PWC.
The Pregnant Woman: Greatly increased IDA. great Obstetric Risk, infant is most likely to be
LBW. high neo-natal and maternal mortality.
The Lactating Woman: Breast-feeds at the cost of her own body tissues, Perhaps as
undernourished as her infant, poor care-giver, her breast milk will be deficient in vitarmnA and
iron.
2. SPECIFIC OBJECTIVES:
•
•
•
•
Immediate (March to June 2000,4 months)
Prof. Tara Gopaldas will be retained by MI to develop the above project proposal. She will
review the recent literature and prepare a detailed Situational analysis (Please refer Chapter-3)
On the basis of the Situational analysis, implementation strategies will be proposed to reduce
the undernutrition in the vulnerable groups. The emphasis will be on an improved and
appropriate food supplement for the ‘Under Threes’.
Population segments that need to be exposed to a strong Awareness Programme from State
Capital to ICDS villages, will be suggested.
Linkages with other departments at the District Level will be suggested.
U-
•
•
•
An innovative way of Training dyads of Nutrition and Health Trainers from the State Level
downwards will be suggested.
A Monitoring and Evaluation format for Delivery, Coverage, Participation and Impact with
respect to Nutrition, Health and Hygiene will be outlined (children 0-6 years)
Cost estimates will be given for each suggested Strategy to the extent possible.
Specific short term objectives (July 2000 to December 2000 - 6 months)
Fill-up all posts in the ICDS Projects of the Study Districts.
(i)
Start a strong Awareness Programme for all levels regarding the Pilot Project from
(ii)
January 2001.
Have Self-Help-Groups in-place and train them to produce a SNP for the *3-6 years'
(iii)
age group.
Orient/ Train/ Build Capacity in all implementing functionaries of the ICDS.
(iv)
Launch the Pilot as early as you can. (Hopefully by January 26th, 2001)
(v)
Specific Medium Term Objectives (January 1st, 2001 to January 2003 - 2 years)
(i)
Introduce the Interventions as shown under ‘Strategies'.
Specific Long Term Objectives (February 2003 onwards)
(i)
Expand or modify to suit the whole state of Karnataka.
In sum : The getting ready period is 10 months; the Intervention is 24 months.
3. THE PRESENT NUTRITION SITUATION IN KARNATAKA; AND IN THE 4 PILOT
PROJECT DISTRICTS
3.1 Demographic/ Socio-economic: The present population’of Karnataka is 5.5 crores in 2000.
Approximately 40% of the total population or about 2.2 crores is vulnerable. The vulnerable
segments below the Poverty Line are estimated to be 88 lakhs. The food supplement Bill
alone for ICDS beneficiaries in just the 4 districts, in the 2 years-Pilot-Project is estimated
to be about Rs.70 crores.
3.2 Burgeoning Population : Karnataka is a ‘young in age’ State like the rest of India. About 50%
are under the age of 24. Most of the female population want a terminal method of birth
limitation after 2 live births.
3.3 Reproductive Health Services: Are well above the average.
3.4 Food Security and Agriculture: Eighty percent of Karnataka’s population is engaged in
agriculture and eat off what they grow. On the face of it neither the Urban nor Rural Kamatakan
lacks in cereals. The latest National Nutnuon Monitoring Bureau (NNMB) survey shows that
per capita production of pulses are down. The Kamatakan does have a better Food Security
Picture than many other States in India. Targets for production of staple cereals in 2000, are
higher than last year. However, the poor just cannot afford to buy expensive items such as fats/
oils, flesh foods, fruits and vegetables that are the natural food source of vitamins and minerals.
Tumkur, Gulbarga and Raichur, 3 of our Pilot Projects have large milk dairies which can fortify
their double toned milk with vitaminA at the very least.
(ii?
3.5 Large Losses of Fruits/ Vegetables during the Glut Season
Much better storage and preservation methods are required at the point of harvest before the
(■)
produce leaves for the market.
Dehydration of vegetable/ fruits should be taken up by the Horticulture Department.
(ii)
A Poor Man’s Cooling box should be developed.
(iii)
3.6 Nutritional Profile of the Vulnerable Groups in Karnataka:
The infant 6 months to 12 months of age; and the child 1-3 years is in a chronic state of
(i)
starvation. This age-group, unwittingly, gets minimal amounts of home food. She/ he is
practically invisible at the AWCs. The ‘Under Threes' needs to be treated as a special
group.
The adolescent girl consumes more than her RDA in cereals. She is able to appease her raw
(ii)
hunger with respect to pulses, roots/ tubers, other vegetables, fats/oils, sugar/jaggery.
(iii) The pregnant woman gets far less than what she requires Vs her RDA in all the food groups
except for cereals.
The lactating woman : The picture of food and nutrients is even worse in the lactating
(iv)
woman.
In sum, the ‘Under Threes’, the ‘Above Threes’, and the P/L women need a food SNP
with a hefty dose of micronutrients. The adolescent needs just her micronutrients.
3.7 Undernutrition in terms of Stunted/ Underweight/ Wasted Children
Children:
Overall, 54% of the ‘Under Fours’ are underweight; 48% are stunted; and 17% are wasted.
Women (15 to 40 years of age):
42% in Gulbarga; and 50% in Tumkur districts had a BMI less than 18.5. Overall 30% were at
obstetric risk by the weight indicator (less than 38kg); and 21% by the height parameter (less
than 145 cms) Obstetric Risk (by weight) was 28% in Gulbarga and 19% in Tumkur.
3.8 Food habits. Taboos Regarding Infant Feeding:
Negative:
Abrupt weaning and virtual starvation of the infant from 6 months onwards: use of
(i)
unsafe water; poor breast hygiene, early marriage (14+years).
Slum mothers are breast feeding only upto 4 months; some stop when the infant is just 2
(ii)
months of age.
The other habits such as discarding colostrum; prelacteal feeds is no better or worse than
(iii)
the rest of India.
Positive:
In the ragi-growing regions, sprouted ragi-powder is often given to the baby as his first
(i)
weaning food. This should be capitalized on.
Excellent net-work of some -W.OOO trained dais.
They can become excellent
(ii)
communicators of EC to the parents - who trust them.
INCLUSION OF SOME GOALS OVER AND ABOVE THAT STATED IN
KARNATAKA’S GOALS FOR 2000AD.
4.1.Some more Nutrition goals that could be introduced in this Pilot Project are;
• Water is food. Ensure that safe drinking uaier is available in the Project areas.
4
C Hi'
•
•
•
•
5
•
•
•
•
6
Include 5mg zinc/ day in the vitamin-mineral pre-mixes. It is absolutely safe and improves the
growth of the child enormously. USAID-donated foods, which India has been accepting for
decades in its ICDS. fortifies its Com-Soya-Blend (CSB) with 5mg zinc/ 100g CSB.
Sometimes indirect measures such as periodic and mass community, or at least deworming of the
beneficiaries in the ICDS & MDM, improved sanitation, better personal hygiene of mother and
child can improve the nutritional status of the child.
Massive Nutrition-Education is required for all Health and Non-Health functionaries of the ICDS
and MDM. So also for the higher rungs of medical personnel.
Make Public Health Nutrition a compulsory subject in all Medical and Health Institutions of the 4
Pilot Project Districts.
A STRONG AWARENESS CAMPAIGN - ESPECIALLY AT THE DISTRICT LEVEL:
The I&B, Karnataka, and the Food & Nutrition Board, Karnataka should play a signal role in
creating Awareness about the Nutrition Situation, the consequences, and the purpose of the Pilot
Study.
All levels - Politician/ Bureaucrat to the Village Panchayats and village homes should be made
aware of the above.
Tremendous change in the mind-set of the impelementors of the National Nutrition Programmes
is urgently required.
Medical colleges need to introduce Public Health Nutrition as a compulsory subject.
INTER-SECTORAL LINKAGES:
For the purpose of this Pilot Project, the five State Depanments that have to work in close
partnership and have well understood linkages are:
The DWCD; the DH&FW;Zilla Panchayat; Civil Supplies; Information and Broadcasting.
7. ORIENTATION/ TRAINING AND CAPACITY BUILDING
• All vacant posts at the District. Block and village-levels of DWCD and DHFW. need to be filled
up before Training commences.
• NIPCCD. Karnataka will orient the Senior Level Officers at Bangalore for no cost.
• The innovation of Training dyads of Nutrition and Health Personnel to synchronize with the
major innovation and the strategy of Integrated Nutrition-Health (INHP) Days will be instituted.
• The innovation of the highest rung of Master Trainers, namely, the CDPO cum PHC doctor.dyad. training *he next tier of Supervisor cum ANMs and AWWs, CCAs. TBAs/ adolescent girls
will be instituted.
• Emphasis will be placed on ‘acting-out’ each innovative service input for the field level
implemented, namely, the Supervisor-ANM dyad and the AWWs/ CCAs/ TBAs/ adolescent
girls.
• The Budget will have to be worked out between DWCD and DHFW.
8. IMPLEMENTATION STRATEGIES/ BASELINE ASSESSMENT SURVEY/ TIME
FRAME/ TYPE AND NUMBER OF BENEFICIARIES/ COST
I.
Must be Implemented or Coordinated Strategies bv DWCD-K (8.1. to 8.5):
8.1. Programme Organisation and Management
• At the Apex Level an Advisory Committee of Ministers, namely the Minister of Woman and
Child (Chair); the Minister of Health and Family Welfare, the Minister of Panchayati Raj and
•
•
other concerned Ministers along with their Principal Secretanes and a few eminent experts in
Nutrition, Health, Food Technology will be set-up.
A Programme Management Cell (PMC) will be set-up to oversee the day-to-day Planning
Management and Implementation of the various stretegies.
Modem Methods of Management will be used.
The Budget for the PMC for two-year Pilot Study is estimated to be about 6 crores.
•
DWCD will pay.
.
.82. Awareness Campaign: (please refer point 5)
. A Baseline Assessment Survey will be carried out by a professional Market Research/
Advertising Agency located in Bangalore, and in the 4 Pilot Districts of Chikmagalur.
•
•
•
Gulbarga, Raichur and Tumkur.
lh
This is the ‘kick off strategy and a launch by AIR and TV should be in place by 26
January, 2001. Thereafter from January 2001 to January 2003.
The target audience would be the whole State of Karnataka, with emphasis on Bangalore
and the 4 Pilot districts. The Awareness Campaign will be sustained throughout the 2 years
of intervention. It is expected that the Pilot will create a demand for a similar innovative
and strengthened ICDS in all the other districts of the State.
The estimated cost is Rs3 crores, (taken at a notational value of Rs. 10/ beneficiary x 15
lakh beneficiaries x 2 years). It may be noted that media budgets depend on the frequency,
reach and the length/ duranon of the radio/ TV spots used.
8.3. For the Under Threes in the ICDS of the 4 districts:
• Innovations:
Integrated Nutrition Health Days on the 1st and 3rd Saturday of every month at every
(i)
Anganwadi in the Pilot Programme.
A well supervised ‘Take-Home-Ration’ (THR) delivery system. The adolescent girls at
(ii)
5-homes/ girl, will supervise the THR at the home level to reduce ‘Sharing’.
Community Change Agents (CCAs)
(iii)
An appropriate SNP of cereal-puise-sugar-an Amylase rich food + the entire RDA of
(iv)
vitamins and minerals. A nutnent dense yet ‘liquidy- reconstituted SNP will make the
feed go down faster.
Mass deworming (DHFW will synchronize, pay and implement)
(v)
Common medicines (ORS. anti-malarials etc.) (DHFW will synchronize, pay and
(vi)
implement)
(vii) Strengthening Mega vitamin-A from 9months to 36 months (DHFW will synchronise, pay
and implement.)
• A Baseline Assessment and Pre-Post evaluations will be conducted.
• Time Frame Jan 2001 to Jan 2003.
• Type and Number of beneficiaries: 2.30.000 ‘Under Threes .
• Cost: Rs.40 crores. (DHFW will pay approximately Rs.6.9 crores out of Rs.40 crores. This is at
Rs. 150/ beneficiary/ year x 2 years).
8.4. For the ‘Above Threes’ in the ICDS of the 4 Districts:
Implementation
(i)
[h£ ICDS .Above -j-^- in
other 3 Pilot districts
other than Gulbarga. will continue to get whatever they were getung as SNP.
- v_)
(ii)
(iii)
(iv)
•
All ‘Above 3s' in the ICDS of the 4 districts will also get such inputs as deworming 2
times a year.
They will also get mega vitmainA 2 times a year.
They will be eligible for the common medicines as the ‘Under Twos'.(DHFW as at 8.3
(v), (vi) and (vii) will synchronize, pay and implement points (ii), (iii) and (iv).
The only innovation in Gulbarga. will be that SHGs will make cooked or processed products
such as Ladoos, Ragi Muddes. Chappatis etc. An “Add On" of the micronutrients for this group
will be introduced. The cooked micronutrient enriched SNP will be served in the Anganwadi.
, If aggreable MYRADA a well known NGO in Gulbarga could be approached to manage this
enteprise. Micro-tJredit will be given to the woman at a maximum of Rs.20.000/- per enterprise.
Baseline Assessment:
Baseline Assessment and Qualitative Research Studies will be done on SHGs ability to
(i)
perform, deliver and be a sustainable enterprise.
Pre-Post Evaluations will be done.
(ii)
Time Frame:
For Chikmagalur. Raichur and Tumkur the Time Frame, with additional inputs of
(i)
deworming, mega vitaminA and common medicines will be : January T1 2001 to January
1st 2003.
For Gulbarga, as and when the SHGs are in-place and the enterprise can be
(ii)
operationalized. Hopefully from Ist January, 2001 to January ls(, 2003.
•
Number and Type of Beneficiaries:
In Gulbarga alone there would be 86137 ‘Above Threes’ (Rounded off to 1,00,000 as
(i)
always more children come in for the SNP). Also the extra food made by the SHGs can
be sold in the open market.
The number of ‘Above Threes' in all 4 districts for common additional inputs of
(ii)
deworming, common medicines, mega vitaminA would be as under:
29.517 rounded off to 30.000
86.137 rounded off to 1,00,000
42.788 rounded off to 40.000
71.450 rounded of to 70.000
2.29.892
2,40,000
Cost: Rs.17.20 crores (Cost to DHFW would be Rs.4.8 crores. The remaining amount would be
borne by DWCD).
Chikmagalur
Gulbarga
Raichur
Tumkur
83. Adolescent Girls in the ICDS of the 4 Pilot Districts:
•
Implementation Strategy/ Innovation:
Learning on the job experience, by supervising the ‘Take-Home-Ration’. Delivery
(i)
System for the ‘Under 3s’ and the P/ L women.
The Adolescents will receive dewonning and micronutrient tablet.(DHFW’s will be
(ii)
responsible for the deworming)
They
would have the potential to become an ICDS Helper or Anganwadi Worker later
(iii)
on.
Baseline Assessment and Pre-Post Evaluation will be done.
(Vi)
•
Type and Number of Beneficiaries: 46.000 Adolescent girls in the 4 districts.
•
Time Frame: January lsl, 2001 to January 1st, 2003.
•
Cost : Rs. 6 crores. (Cost of Rs. 1.38 crores for common drugs / RCH health/ Soap/ detergents/
etc. can be borne by the RCH Project of DHFW).
8.6. Pregnant/ Lactating Women:
• Implementation Strategy/ Innovation:
Take Home Rations.
(i)
INHP Days
(ii)
Mass Deworming (DHFW will synchronize, pay & implement)
(iii)
(iv)
Close Supervision by Adolescent Girls CCAs
CCAs
(v)
Common Medicines (DH&FW) (DHFW will synchronize, pay and implement).
(vi)
•
Baseline Assessment and Pre -Post Surveys will be done.
•
Time Frame: January 2001 to January 1M. 2003.
•
Type of Beneficiaries: Very nearly 1,40.000 pregnant and lactating women beneficiaries in the
ICDS Project of the 4 Study Districts.
•
Cost: Rs.23.20 crores. (Cost to DHFW will be approximately Rs.2.8 crores at Rs. 100/ woman
beneficiary/ year x 2 years)
II. Should be done in Collaboration with the concerned Pepartment/s:
8.7. Safe Water and Sanitation in all the AWCs in the 4 Pilot Districts.
• The Strategy/ Innovation:
Apart from safe and clean water (atleast for drinking purposes) water is a fundamental and
human right. It is also a vital and essential FOOD. Consequently, all the 7168 Anganwdis will
be provided with 3 taps. One clean water tap for drinking and one for washing the ICDS utensils;
and another (water need not be potable) for the toilet.
•
Baseline Assessment and Pre-Post Evaluation: Will be done.
•
Time Frame: January L 2001 to January’ 1. 2003.
•
Type of Beneficiaries: Safe water will benefit all the beneficiaries who stay at the AWC more
than 3 hrs a day, six days a week. The number of AWCs that will get the clean water + a toilet
will be 7168 in the 4 Pilot Districts.
•
Cost: A Capital cost of Rs, 10 crores - A Recurring cost of Rs.4 crores for the 2 years
intervention. Total of Rs. 14 crores. The Concerned Department, that is, Sanitation and
Sewerage will syncronize, implement and pay.
8.8. Deworming of all Vulnerable Groups of the Pilot Districts:
•
Strategy: All the vulnerable groups in zhe ICDS. namely, the ‘Under Threes’, the ‘Above
Threes’, the Pregnant and Lactating woman, and the Adolescent girl and the disadvantaged
families, about 10 lakhs in all the AWCs in the 4 districts will be dewormed 2 times/ annum.
Chappals will be sold at subsidized cost.
Baseline Assessment/ Pre-Post Evaluation: Will be done.
•
Time Frame: January 1st, 2001 to January T1 2003.
•
Number and type of Beneficiaries:
All the enrolled beneficiaries in the 7168 AWCs in the Pilot Programme and the most
disadvantaged families. The number will be approximately 10 lakh beneficiaries.
•
Cost: Rs. 4 crores for 2 years intervention.
8.9. A Multinutrient tablet including Iron. Folic Acid, Vitamin-C and Vitamin B-12 for all
Pregnant/ Lactating Women in the ICDS of the Pilot Districts
•
Strategy/ Innovation:
The IFA tablet distribution has not been very successful. VitaminC is known to be the most
powerful enhancer of Hb status. Hence, a micronutrient tablet, which would include Iron. Folic
acid. Vitamin C and Vitamin B-12 needs to be developed.
•
Pre-Post estimation of Hb status will be done.
Time Frame: Two Years.
•
•
Type and Number of Beneficiaries: All the Pregnant/ Lactating women enrolled in the ICDS.
1,40.000 + 46.000 = approximately 2 lakhs beneficiaries in all the 4 Pilot Districts.
Cost: About 1.5 crores. (DWCD will synchronize, implement and pay.
8.10. Fortification of Double Toned Milk with VitaminA in Gulbarga, Raichur and Tumkur
Districts for the Open Market.
•
Innovation/ Strategy:
The concerned dairies in the above three districts will fortify the double toned milk, at the level
of lOpg vitaminA per ml milk, at their cost, for the open market.
•
Baseline Assessment and Pre-Post Assessment will be done.
•
Time Frame: Whenever they are ready to fortify the milk.
•
Number and Type of Beneficiaries: All those families who buy double toned milk in
Gulbarga, Raichur and Tumkur will benefit.
•
Cost: About Rs. 3 crores (to be borne by the Dairies).
8.11. Enriching Ragi Atta with an Add-on of 6 Micro iNutrients in Tumkur District
•
Strategy/ Innovation:
Ragi is widely consumed in Tumkur District Ragi flour will be supplied to the 2335 AWCs in^A
Tumkur. An ‘Add-On’ Sachet of Iron, Ascorbic Acid, Riboflavin, Vitamin B-12 and Folic Acid>V/Z'/y>
which are the major micronutrient deficiencies in this district will be addressed. Each mother
will receive 6kg ragi powder/ month in 2 lots of 3 kg each. She will also receive 30 sachets of
the ‘Add-On’ of the micronutrients (also in 2 ’ots). She will be taught as to how to use the ‘AddOn’ at the last stage of making the Ragi Mudde or a Ragi kanjee. This strategy, hopefully, will
empower the Pregnant/ Lactating woman to take care of her own health.
•
Baseline Assessment and Pre Post Evaluation will be done.
•
Number and Type of Beneficiaries: 31.000 Pregnant/ Lactating ICDS beneficiaries in Tumkur
•
District.
Time Frame; The start date will depend on the speed with which the tender is processed.
•
Cost: Rs.4.19 crores. (DWCD will pay).
HI.
Strategies that should be Seriously Considered bv DWCD^ DHFW & FPL
8.12 to 8.14: Other Strategies that should be considered seriously are:
8.12. Deworming + VitaminA+Iron+Iodised Salt for All Schoolers in the 4 Pilot Districts by DHFW.
8.13. Use of Double Fortified Salt in Chikmagalur District or Reputed Brands only. By FPL
8.14. Drying Fruits/ Vegetables during their glut season by FPL
9. Approximate Total Budget Cost to DWCD/DHFW and other Departments for the 2-Year••
Pilot Project
To
Approximately Rs.90 crores.
To DWCD
DWCD
It may be noted that DWCD is already paying about Rs.70 crores for 2 years in the way of Food
Supplement alone to its ICDS beneficiaries in just these 4 Pilot Districts.
•
TO DHFW
Approximately Rs.20 crores.
•
To Sanitation and Sewage
Approximately Rs. 14 crores.
•
Approximately Rs.3 crores.
To the 3 Dairies in Gulbarga,
Raichur and Tumkur
To FPI and other Departments/ Institutions - Cannot be budgeted at the present time.
•
The Total Budget is estimated to be Rs.127 crores for the Pilot Study of 2 Years duration.
PART ONE
Chapter One
Introduction and Rationale
Chapter Two
Overall and Specific Objectives
Chapter Three
A Situational Analysis of the Nutrition Scene in
Chikmagalur, Gulbarga, Raichur and Tumkur
Chapter Four
Karnataka’s Specific Nutrition Goals for
2000 AD.
Chapter Five
Inter-Sectoral Linkages Between:
• Women and Child Development (Nodal Dept.)
• Health and Family Welfare
• Zilla Panchayat
• Civil Supplies
• Information and Broadcasting
Chapter Six
Orientation, Training and Capacity Building
Chapter Seven
Measurement of Nutritional & Health
Outcomes in the Area of Programme Evaluation
in the ICDS.
CHAPTER ONE: PURPOSE AND RATIONALE FOR
THE PILOT STUDY
At a landmark meeting of the DWCD-Karnataka on 21st March, 2000, at Bangalore, Ms.Meera
CSakesena, Secretary to Government, Women and Child Development Department,
Government of Karnataka outlined the need for an Integrated Nutrition Project, as
malnutrition including micronutrient malnutrition had still not come down to the desired levels
as envisioned in the State’s Plan of Action for 2000AD. DWCD would adopt the inter. generational life cycle approach wherein the most vulnerable and linked population segments
would be the “Under Twos”, the adolescent girls, pregnant and lactating women.
The importance of inter-sectoral coordination between DWCD and all other relevant departments
was stressed by the Secretary DWCD-Karnataka. For the purpose of this Project Proposal inter
sectoral coordination between DWCD and DH&FW at all levels would have to be a pre-condition for
a successful outcome of the Pilot. The other important net-working depanments would be
Agriculture (Food Production), Civil Supplies (PDS). Education (Primary and Secondary school
levels). Food Processing Industries (Public and Private); and Information and Broadcasting (IEC)
where inter-sectoral coordination, especially at the District Level could ensure the success of this
Pilot-Project.
Mrs.Veena Rao, Jt.Secretary at DWCD, GOI succinctly brought up some imponant points as under:
• Women's groups in each of the 4 districts had to be identified, activated and empowered (to the
extent possible) to make the cereal-pulse based supplement enriched or fortified with a vitaminmineral-premix for the target groups.
• The ‘Under Twos’ were the most vulnerable and undernourished population segment and should
be treated as a special group.
• Appropriate vitamin-mineral enriched food supplements that could be added onto the cereal
pulse should be made/ devised for the adolescent girl. Likewise for the Pregnant and
Lactating women.
• The Ministry of Food Processing Industnes (FPI) had a scheme whereby capital and equipment
grants to the tune of Rs.5 lakhs could be provided to these Women s Groups or Societies. This
should be explored and utilized. FPI also had schemes to dehydrate and preserve fruits and
vegetables in their glut season. If feasible, these should be incorporated into the food
supplements.
• The widespread vitaminA deficiency in Karnataka had to be addressed and children upto sixyears of age need to be covered for vitaminA prophylaxis.
It was proposed that a Pilot Integrated Nutrition Project be undertaken in all the ICDS Projects of
Chikmagalur(7), Gulbarga (11), Raichur (5) and Tumkur (11) districts of the State from August 15,
2000. If this model is found to be promising and sustainable, it may be up-scaled to cover the whole
state of Karnataka.
THE CONSEQUENCES FOR NOT TAKING IMMEDIATE ACTION
A Situational Analysis for Karnataka in general and for the four study districts in particular has
clearly thrown up the following:
1-
The adolescent girl (15 to 18 plus years) consumes much more than she needs in the way of
local staples. Her consumption of pulses is less than adequate. But she is starved for her
vitamins and minerals (micronutrients).
• The pregnant woman also consumes what she requires of the local staple/s. Her intake of
pulses is lower than what she needs. Her need for vitamins and minerals is even more
accentuated.
• The picture for the lactating woman is similar to that of the pregnant woman.
• It is the infant/ toddler/ preshcooler (1-5 years) who is literally starved for both his macro
and micronutrients. Within this age group, the “Under Threes” in Karnataka, are in a
* precarious condition and need to be considered as a “Special Category” for urgent and
immediate food and nutritional attention.
•
The consequences of delaying or denying these vulnerable groups a fairly balanced diet now
could be extremely serious. The outcomes are:
In the Under Threes:
• Growth faltering and failure which translates into a short and skinny adolescent/ adult.
• Negative effects of repeated episodes of diarrhoea and other childhood diseases/ ailments.
• Poor cognition/ poor physical work capacity (PWC) or productivity in later life.
• Clinical or sub-clinical nutritional deficiency diseases, especially, of Protein Energy Malnutrition
(PEM) of iron. zinc. vitaminA. riboflavin, folic acid and vitaminC.
In the Adolescent:
• An undernourished adolescent will most probably be short and thin.
• She will most probably suffer from severe to moderate Iron Deficiency Anemia (IDA).
• She will have poor cognition, poor PWC and probably produce a Low Birth Weight (less than
2500g) baby when married.
The Pregnant Woman:
• IDA greatly increases the chances of maternal and neo-natal mortality.
• An underweight (<38kg) and/ or short (<145 cms) woman is definitely at Obstetric Risk. If the
mother and infant survive, the infant is almost sure to be a LBW infant.
• Poor weight gain (3-5 kg) in a pregnancy leading to LBW.
• Early pregnancy (<18 years) stunts the young woman’s own growth potential and ability to
breast-feed and nurture her infant.
The Lactating Woman:
• An undernourished lactating woman can and does breast-feed her young one: this is nature’s
bounty. But she does this at the cost of her own body tissues and nutritional status - already
perilously low.
• Maternal morbidity and fatigue make the mother a poor ‘care-giver’ to her infant.
• A vitaminA deficient lactating mother will have less of vitaminA in her milk.
• An iron-deficient lactating mother will become even more anemic; so will her infant.
Right Time for the Launch of the Said Pilot Project
• A committed political and bureaucratic will to even further improve the nutritional status of the
vulnerable groups in the State of Karnataka.
• Generous funding by the Department of Woman and Child, GO I; MI; and UNICEF etc.
2
CHAPTER TWO : OVERALL AND SPECIFIC OBJECTIVES
The overall objectives would be to improve the nutritional status of the vulnerable groups in
consonance with Karnataka’s Specific Nutrition Goals for 2000AD. However, the maximum
emphasis would be given to improving the food supplement component in the ICDS Projects of
the four Pilot districts, for the ‘Below Twos', the ‘Under Threes’, the older pre-schooler (3-6 years)
the adolescent girl, the pregnant and lactating woman.
• Specific Immediate Objectives: (March 2000 to end June 2000)
(i)
(ii)
(iii)
(iv)
(v)
(Vi)
(vii)
To review the recent, available and relevant literature on the nutrition profile of Karnataka in
general and for the four Pilot districts of Chickmagalur, Gulbarga, Raichur and Tumkur with
respect to food production, food security, food intake, food habits and taboos (with reference
to the vulnerable groups), micronutrient deficiency disorders and their prevalence rates);
ongoing nutrition and related programmes in operation; and Knowledge Attitude Practices
(KAP) among the population.
To propose implementation strategy/ ies that would reduce undemutrition in the vulnerable
groups in the ICDS projects of the four districts.
To suggest to the Government of Karnataka as to what the cost for the improved food
supplement/ ration/ beneficiary alone would be for the ‘Below One’, 1-3 years, 3-6 years,
the adolescent girl, the pregnant and lactating woman in the ICDS Projects, in consonance
with the proposed Strategies.
On the basis of (i) and (ii) to outline population segments that require a strong Awareness
Programme at State, District, ICDS Project Block and Community levels.
To outline what the linkages at the District Level should be to benefit the Pilot Project.
To suggest a Monitoring and Evaluation format based on the proposed strategies.
To workout a Cost for an improved and fortified SNP for each of the four vulnerable groups.
To give an estimate of cost for the strategy/ ies proposed.
Specific Short Term Objectives: (July 2000 to December 2000, 6 months)
Fill-up all posts in the ICDS Projects of the Study Districts.
(i)
To
set up a Programme Management Cell (PMC) to oversee the management of the project.
(ii)
Stan a strong Awareness Programme for all levels regarding the Pilot Project from
(iii)
January, 2001.
(iv)
Have Self-Help-Groups in-place and train them to produce a SNP for the ‘3-6 years’ age
group.
(v)
Orient/ Train/ Build Capacity in all implementing functionaries of the ICDS and Health
Department.
Launch the Pilot as early as you can. (Hopefully by January 26th, 2001)
(vi)
Specific Medium Term Objectives: (January 26. 2001 to January 26th 2003)
(i)
Introduce the Interventions as shown under strategies.
Specific Long Term Objectives (February 2003 onwards):
Expand or modify to suit the whole state of Karnataka.
(i)
If fairly successful and sustainable expand to other districts.
(ii)
5
CHAPTER THREE:
3.1. THE PRESENT NUTRITION SITUATION IN THE 4 PILOT
PROJECT PROGRAMME DISTRICTS: SOME BASIC
DEMOGRAPHIC AND SOCIO-ECONOMIC INDICATORS IN THE
6 PROGRAMME DISTRICTS:
.
1. Demographic Indicators:
Karnataka’s total population has been estimated to be 5.5 crores (55 million) in 2000. The most
vulnerable groups in Kamatka for nutrition-health interventions would be the Under Fours especially
the ‘Under Twos’; the primary schoolers (both boys and girls); adolescent girls (10-19 Years) and the
P & L woman. These groups alone would represent a large chunk of the base of Karnataka’s
Population Pyramid about 40% of the total population or about 2.2 crores.
Age-Group
(i)
(ii)
(iii)
(iv)
(v)
(vi)
0-4 (F & M)
5-9 (F&M)
10-14 (Female only)
15-19 (Female only)
Pregnant Woman
Lactating Woman
% of Total Population
12
14
6
5
2
4
or 40% of total population
>
or about 2.20 crores
y
If one assumes that 40% of the above 2.20 crores were below the poverty line, the target population
would still be 88 lakhs who would or should be the target population for Nutrition and Health
Interventions. If one considers that these population segments would need both their macro and
micro nutrient food supplementation day-in and day-out, even at a minimum Rs. 21 subject/
day, the food supplementation bill alone would amount to Rs.642 crores/ annum for the whole
state. The bill for the food supplement alone in all the ICDS projects of 4 pilot districts is estimated
to be about Rs.70 crores for the 2 year Pilot Programme.
2. Some Socio-Economic Indicators that could influence the Nutritional Status of the
Vulnerable Groups
In 2000 AD. it is heartening to note that 88% are involved in decisions about cooking; 49% about
their own health-care; 43% have freedom of movement (going to the market etc); 67% are permitted
to have some money to spend. In the age-group (15-24 years) more than half exercise this
autonomy.
Figure /, depicts that 52% are sterilized; another 15% do not want anymore children. Female
sterilization is the most favoured method of birth control.
Table 1, shows that Karnataka is still a ‘young-in-age’ state like almost all other states in India.
About 50% are under the age of 24. Girls gening married young (15+ years is still the norm) Female
and male illiteracy are still unacceptably high at 45% and 26% respectively.
The NHFS-2 Preliminary Report also states that 52% of the women are doing work other than house
work. The figure is 63% in Rural and 31% in Urban Areas.
Figure 2, heightens the fact that age-specific fertility peaks from 15+ to 24 years. This is the agegroup that requires maximum assistance to curb their family size, to exercise autonomy in ‘rearing
and caring' for their young-ones, and to ‘care for themselves’ as well.
The same reports NFHS-2 Preliminary Report, also indicates that RCH services are well above
average, with well over 70% receiving 2 or more doses of tetanus toxoid and IFA tablets/ syrup.
3. Food Security and Agriculture:
Eighty percent of Karnataka’s population is engaged in agriculture. Rice is grown in the coastal
areas. Next to rice are jowar and ragi. The main cash crop is sugar cane. Plantation crops are tea,
coffee, cashew, cardamom and horticulture. Cereals and pulse crops by and large dominate the
agricultural scene. NNMB has so far done 3 rounds of Food and Dietary Intake Surveys in
. Karnataka. The first round was done in 1975-79; the second repeat round in 1988-90; and the third
repeat round in 1996-1997.
There were no significant differences in average food consumption between the First and Second
rounds. However, there are some differences with respect to intake of food stuffs between Round
Two (1989-90) and the repeat Round Three (1996-97). Intake of Pulses/ Legumes is noticeably low;
milk is marginally down; and fats and oil in noticeably up.
4. Consumption of cereals (including millets), pulses, nuts and oil seeds in the Project Districts
of Karnataka
On the face of it neither the Urban nor the Rural Kamatakan is lacking in either calories or protein.
However if we look at the poorest expenditure class ( Rs 120/cu/month for the rural and Rs. 185215/cu/ month for the Urban), we see a very different picture (Table 4). The cheapest millets
namely, Jowar and Ragi are consumed with much less of rice by the Rural poor. Cereal and pulse
intake is well below RDA. The situation is much worse with respect to our vulnerable groups,
especially the ‘Under Fours’, who are in a virtual state of starvation for both their macro as well as
micronutirents. In the Urban poor the pattern is rice, jowar and much less ragi. Extremely
inadequate amounts of milk, oils, meat, fish or eggs are consumed (Table 2),
District Cereal preferences are imponant to remember when formulating RTE food supplements for
our vulnerable groups at the District or Block or Village levels. Again and again data show that the
poor just cannot afford expensive items of diet such as milk, oils, flesh foods, fruits and vegetables
which are the natural food sources of vitamins and minerals. Hence, they havi to be supplied either
through the route of medicinal supplementation and/ or through fortification/ enrichment of
those items of food that can reach the poor through the PDS. These would be fats/ oils, sugar,
cereals and flours (ragi atta for the urbanites)
Nutritional Consequences of poor Grain Storage:
Since a predominant portion of the Kamatakan’s diet comes from grains it is important to know the
nutritional consequences of poor storage and attempt to address this problem when we come to
strategies.
A major problem today with respect to cereals and pulses are poor storage conditions at the point of
harvesting. About half a century ago very low doses of irradiation of harvest crops from grains to
strawberries at the place of harvesting has saved many a crop from further loss upto the market place.
But India and Indians appear to be wary of any innovation. Lack of both time and open spaces for
storing food grains especially rice is major problem. The paddy crop is harvested at 20 - 22%
moisture levels when it should be dried and stored at 13% level. We urgently need drying or
storage structures to avoid loss of precious grains. The outcomes of poor storage (high moisture
levels) results in not only an organoleptically inferior grain, but also a high risk of mould, fungi and
5
mycotoxins. Insects thrive on wet grain, consume the most nutritious germ and excrete uric acid.
Fecal matter or body debris makes the grain far less palatable. Rats are also a menace when they get
into godowns where the grains are stored. The CFTRI came out with simple storage bins on stilts,
which prevents rodent’s atleast from getting into the primary storage containers. These are
the kind of simple innovations that we need. After 9 months of farm storage substantial losses in
the nutritive value of the grain have been reported, especially in the Protein Efficiency Ratio (PER)
or quality of Jowar which drops from 2.0 to only 0.35, chickpeas from 2.21 to 1.83 and pigeon peas
from 2.04 to 1.66. Vitamin losses after 5 months of storage were 13-25% for thiamine (Vitamin Bl),
.7-11% for riboflavin (Vitamin B2) and 7-14% for niacin. We need to go back to time-tested but
improved methods of storing paddy in a kanaja, Jhola (sorghum) in a hagevu with neem leaves or
mehandi leaves which have a charecterstic repulsive smell and which keeps the invading insects at
bay. Ragi, fortunately slippery and is not prone to insect attack. In fact a thick layer of ragi grain
is often placed on top of other grains such as Jhola or Rice as a protectant. Such simple
practices should be highlighted in the envisaged EC of this pilot-project at every level.
Pulses: The main pulse market of Karnataka is Gulbarga, one of our programme districts. Imports of
pulses come in from Maharashtra and MP. The important pulses are cowpea (karamani), black
gram, red gram kadalai. aware and tur. Green gram is grown in the fallow moisture after the paddy
crop has been harvested. Cow pea or Karamani is a hardy crop and widely used pulse among the
rural and farming households. Tur and Thuvar dal is grown as a mixed-crop with ragi in Gulbarga
and Raichur. Horsegram or kollu is popular in Bangalore. Hence, it would be quite easy to set up
small food-processing units for Self-Help-Groups to operate and market or sell back to the ICDS.
Karnataka now produces 60% or more of the State’s requirements of pulse. This is due to better
knowledge of storage, more hardy strains, higher productivity and the use of protectants.
The latest announced target for staples, pulses, oilseeds in May, 2000, is higher than last year’s
target. It is about 93 lakh tonnes for rice, maize, jowar and ragi. The remaining 7 lakh tonnes are
the target for pulses. Groundnut takes pride of place (about 12 lakh tonnes) among oil seeds.
Milk: Karnataka is again fortunate in that 14 of its districts have milk handled by dairies. The
biggest dairies are in Bangalore followed by Kolar. Tumkur. Gulbara and Raichur have milk dairies
(Table 3). Unfortunately, the per capita consumption of milk is poor (30 to 140 ml/ person per day)
in the lowest a;iu even mid-level expenditure classes. However, one way of reaching out to the
needy is to sell toned milk enriched with all the fat-soluble vitamins (A,D,E and K) at
subsidized rates. This has been done successfully by the NDDB in Gujarat and UT of Delhi.
We should try and make it the birth right of every needy child in the age-group of 1-5 years to get
atleast 250 ml (quarter litre) of such a product at Rs.2/ packet. Even poor parents will buy
provided the product is available, affordable, accessible and appropriate (enriched with
vitamins). This with two slices of bread (enriched with all the water-soluble vitamins and essential
minerals like iron and zinc) would be a far better supplementary food for children in Urban
Conglomerations. It is also more likely that the child will get his meal at home also. The fortified
milk and bread combination would be viewed as a snack and not as a meal as judged by the
experience of the free Municipal Schools in Baroda.
Oils and Fats: The intake of oils and fats is surprisingly low at 8g and 14g per person per day in the
lowest and mid-rung expenditure classes. Inspite of this low-intake, I would urge the Government of
Karnataka to either enrich the palmolein (distributed in the PDS) with red-palm-oil or with Vitamin
A palmitate. Karnatakans-man, woman and child - are most deficient in Vitamin A.
Figure 1
Fertility Preferences Among Currently
Married Women Age 15-49
Other
Want another within
2 years
13%
Want another after
2 years
12%
Sterilized
52%
Want another,
undecided when
1%
Want no more
15%
NFHS-2, Karnataka, 1999
200 '
c
0)
150 4
E
o
§
s 100 "
o
<5
Q.
€
50 -
0 ----------------------------------------------------------- -----15-19
20-24
25-29
30-34
35-39
■
•
40-44
45-49
Age
Urban
Rural i
NFHS-2, Karnataka. 1999
<7
Ta&te^L Wocncn's
Percentage of ever*mamed women invotved
househokl deasionmalung. percentage of women with freedom at movement and
percentage of women with access to money Oy background ctwactensbcs. Karnataka. 1999
Percentagenot
involved tf)
any
deosionmakmg
Percentage who
do not need
permission to:
Percentage mvotved in
decsionmaiung about:
Goto
the
market
V»Sit
fnends/
relatives
Percent*
age with
access to
money
Nianbef
of
women
26.1
344
45.1
48.6
54.8
53.5
21.4
28.3
32.7
32.7
39.6
46.6
41.6
46.6
62.3
67.1
68.7
72.0
75.8
74 4
427
777
863
721
631
534
419
50.7
41.1
52.9
37.7
41 2
30.7
79.5
60.3
1 523
2.851
46.8
43.0
39.4
33.8
60.4
726
49.3
59.0
48.4
56.3
458
57.1
41.3
54.3
33.7
44.6
63.4
80.4
1 296
254
87.3
48.1
45.6
42.6
43.9
33.7
69.9
2.097
8.0
89.3
45.7
440
40.9
36.6
31.3
59.9
2.414
6.8
11.1
89.5
84.5
52.3
52.1
48.6
50.3
45.7
47 1
41 7
45.9
J2.4
32.7
68.3
72.9
818
289
8.9
86.1
55.4
54.3
52.4
55.7
45.3
83.7
853
Religion
Hindu
Muskm
Sikh
Other
8.1
9.2
4.8
(6.0)
88.4
87J
91.3
(91.1)
49.7
42.3
60.3
(68.9)
47J
44.5
57.9
(62.9)
44.4
40.9
59.2
(56.9)
446
26.7
56.7
(57.6)
35.4
23.1
43.4
(54.7)
66.9
62.0
86.5
(83.2)
3.741
492
105
35
CastaAribe
Scheduled caste
Scheduled tube
Other backward class
Other*
Missing
8.4
7.1
7.4
8.8
(18.2)
86.9
88.6
89J
87.6
(75.8)
43.4
52.9
48.4
(38.6)
43^
43.9
49.8
46.9
(40-5)
39.5
42.7
47.2
44.2
(34.4)
38.7
46J
45.1
42.1
(38.4)
32.3
35.4
35.0
34.4
(34.4)
64.4
53.8
67.9
69.7
(54.7)
704
252
1.809
1.559
49
Tom
8.1
88.4
49.3
47_3
44.5
43.0
34.3
67.0
4.374
Background cftaractensbc
Age
15-19
20*24
25*29
30-34
35*39
40-44
45-49
Residence
Urban
Rural
Employment status
Working m family
farm/busmess
Employed by someone
else
Seil-emoioyed
Networked in last 12
months
Education
innerate
Lit. < middle school
complete
Middie school compteie
Mgh school complete
and above
Cook
ing
Own
health
care
Purchaseof
jewellery,
etc.
Staying
with
parents/
siblings
1.9
3.8
70.5
81.4
88.8
92.6
93.7
96.0
93.7
35.1
38.9
46.5
52.5
57.1
59.4
58.2
35.4
36.4
44 5
48.6
55.9
57.7
56.8
35.3
35.2
42.3
45.2
52.0
52.5
52.5
6.9
8.8
89.1
88.1
55.5
45.9
544
43.5
10.3
86.5
49.0
6.1
4.3
90.7
91.3
9.1
20.7
13.6
7.9
5.4
46.6
41.0
Note: Total includes 1 woman with missing information on employment status, who is not shown separately
() Based on 25-49 unweighted cases
'Women who do not belong to a scheduled caste, a scheduled tnbe. a an other backward class
1
Table 2 : Consumption of Cereals/ Millets/Pulses/and other food items by the poorest expenditure class (Rs.12,000/annum/
family) in 2000 in Karnataka per month
Expenditure Class
Consumption in Kg/ cu/ 30 days
Rice
Wheat
Jowar
Bajra
Ragi
Total
(Cereals)
Total
(Pulses)
Milk
(litres)
Oils
Flesh Foods
(kg)
(kg)
Rural (Rs. 125-140)
6.10
0.65
3.51
0.48
3.02
14.13
0.82
2.49
0.24
0.88
Urban (Rs. 185-215)
6.09
1.60
2.51
0.00
1.22
11.59
1.00
4.20
0.42
1.21
Source : NSS Survey - Sarvekshasna, July - September 1991.
Notes :
(i)
(ii)
(iii)
A Rural family of 6 members x Rs.140 x 12 months = Rs.10080 (below Poverty Line)
A Urban family of 6 members x Rs.215x12 months = Rs. 15480 (borderline of Poverty)
I able 3 : Milk Handled by Dairies in three Project Districts
(Lakh Litres)
Location of the Dairy
I.
Tumkur
2.
Gulbarga
3.
Raichur
Source : Statistical Outline of Karnataka J989-90)
1989-90
333
78
79
3.2. DIETARY INTKAE PATTERN NUTRITIONAL PROFILE OF THE
VULNERABLE GROUPS IN KARNATAKA
1. Introduction: The Nutrition Profile of Karnataka. 1996; The National Family Health Survey.
1999; the National Nutrition Monitoring Bureau (NNMB) Surveys of 1988-90 and 1996-97;
Dietary Guidelines for Indians-A Manual. 1998; and the Indian Council of Medical Research
(ICMR) Expert's Group Report on the Nutrient Requirements and Recommended Dietary
Allowances for Indians, 1992 (unchanged upto 2000) - have been the main reference source for
this section.
The study districts selected in the Nutrition Profile of Karnataka were Gulbarga, Uttar Kannada,
Chitradurga, Tumkur and Mysore giving a good geographic representation in the State.
Adequate representation was given to Rural, Urban and Tribal populations. The vulnerable
groups selected in the Nutrition Profile were the ‘Under Threes’, the ‘Above 3s’, the late
adolescent girls (15+ to 18+ years) and the pregnant and lactating woman. Gulbarga and Tumkur
are our Pilot districts. Though four years old, we found this report the most location specific and
useful.
2. Dietary Profile (Intake of Food Stuffs by Women and children)
Tables 4,5,6,7 and 8 set out the average intake of foodstuffs by the vulnerable groups in the Pilot
Study. Data have been presented from the 1996 (Nutrition Profile of Karnataka) and the latest
NNMB-repeat survey (1999) VS the latest ICMR-Recommended Daily Allowances. The arrows
(T,X or ok) indicate the food intake position VS the RDA.
One can see at a glance, that most of the arrows are downwards, indicating that the RDA for most
food groups in any vulnerable segment of the population - IS NOT MET. It is particularly bad
with respect to the protective groups such as green leafy vegetables (GLVs), milk, fruit, other
vegetables and fleshy foods// fish which are non-affordable by the Low or even the Middle
income groups at present day prices. These protective foods are the natural dietary sources of
vitamins, minerals and trace elements for the human being.
Women / Adolescent Girls:
It is important to note that the average intake of cereals in the adolescent girl is more than the
RDA. Pulse consumption is down in the 1999 data. Comparatively speaking, the adolescent girl
eats better than the child, and is able to appease her raw hunger (cereals, pulses, other
vegetables, roots/ tubers, fats/ oils, sugar/jaggery).
The Infant and the child (1-3 years and 4-6 years):
Table 4, depicts that it is Karnataka’s child (1-3 years of age) that is in a chronic state of
starvation for all the dietary items- macro to micro. The starvation picture was even more
magnified for the age group of 1-2 years (Table 5). This age group of (1-3 years); above all
needs to be treated as a special group. All attempts should be made to address the problem
through a strong and continued IEC for the community and parents. Also by more
effective enrolment, coverage and participation of this helpless age group.
The Dietary Guidelines for Indians (1998) strongly recommends that children in this age group
should get an additional 200ml of milk even in the breast fed children.
The Dietary Intake of the Pregnant/ Lactating Woman:
Pregnant Woman:
Whether one accepts the 1996 or 1999 figures, both show that the pregnant woman get far less in
every food category, except for the staple cereal/s. The deficits in all other categories of
foodstuffs are alarming (Table 6).
la
The Lactating Woman:
The picture is very similar for the lactating woman - only even more heightened (Table 7).
3. The Nutrient Intake Profile of the Infant, the Child, the Adolescent Girl, the Pregnant anc
Lactating Woman
The Infant (1-2 years):
(Table 8) depicts the nutrient plight of this child. On an average the calorie gap is 616 kcal; the
protein gap is 10g; the calcium gap is about 160 mg; the iron gap is 7 mg; the vitaminA gap is
180 |jg; no gap where the ^-Complex vitamins are concerned; a big gap of 5 mg in the case ol
niacin; and a huge gap of 33 mg with respect to vitaminC. The picture is similar but slightly
better for the 2-3 years old.
The Child (4-6 year):
The 1999 (NNMB) figures do show a slightly better average nutrient intake in both the 1-3 and
the 4-6 year age groups. Again whichever data set is accepted (1996 or 19991: wide nutrient
deficits persist for calcium, iron. vitaminA. niacin and vitaminC (Table 9).
The Adolescent Girl (15 to 18+years):
The only group that is overeating with respect to food energy, protein and calcium are the
adolescent girls (15 - 18* years). Glaring deficits continues for vitaminA. Although the dietary
iron intake at about 25mg VS the RDA of 30mg appears to be fairly adequate - it is well known
that veryz little will be available from a predominately cereal-based-diet (Table 9).
The Pregnant Woman:
Data were available for nutrient intake only from the NNMB Repeat Survey of 1999. We have
considered the Pregnant and Lactating Woman to be in the Moderate Worker Category. The
Pregnant Woman needs practically much more of every nutrient - both macro and micro
(Table 10).
The Lactating woman:
The picture is very similar, only worse (Table 10).
In sum, the situational analysis shows that it is unlikely that a change in the dietary pattern of
these vulnerable groups can be brought about by just IEC alone, however excellent
There is a clear need to:
> Consider the 6 months to 36 months old child as a special category. She/ he needs a huge
supplement to bridge both his macro and micro food nutrient requirements. In fact an
improved and enriched double-ration may partially solve the problem in the ICDS.
The adolescent girl needs immediate medicinal supplementation, namely a multi-vitamin
and mineral tablet Protective foods were unaffordable. The Pregnant and Lactating
Woman needs both macro and micro nutriet supplementation like the child category.
> It could well be that IDA is being caused by a large deficit of vitaminC in the diet (most
powerful enhancer of iron). Hence, a powder drink, enriched with vitaminC and as many
other vitamins/ minerals, which can be reconstituted with water to make a refreshing drink
may be tried to address the IDA problem in the adolescent girl. Pregnant and Lactating
woman.
ii
Table 4: Average intake of food stuffs by Adolescents Girls and Children and comparison with
RDA (for all 5 districts)
Age
1996
1999
No. Covered
1478
1353
Cereals
16U
152?
Pulses
12?
Leafy Veg.
(All values in grams)
16-17 Years
4-6 Years
1-3 Years
1996
1999
1108
1265
175
257ok
243>L
13?
35
19?
5?
5J,
40
Other Veg.
5?
14i
20
Roots/ Tubers
6?
16?
Oil & Fats
2?
Milk
RDA
RDA
1996
1999
75
201
270
606?
467?
440
20?
35
42ok
29?
45
10 i
50
19i
16i
100
7i
25 X
50
26?
55?
40
10
9?
28?
20
10?
54?
50
4?
15
3?
6?
25
4?
20ok
25
15?
66?
300
17?
59?
250
21?
75?
150
Sugar/ Jaggery
10?
15?
30
13?
17?
40
20ok
20ok
20
Fruit
8?
14?
10?
22?
18?
26?
Fish
1 !2^
?
3 1 ?
71 ?
51 ?
23 U
2 J
2J
1J
5
Fleshy Foods^" 2 -
5
2
RDA
Source: Nutrition Profile of Karnataka (1996): and the NNMB (1996) and the NNMB Repeat Survey
(1999). RDA. ICMR, 1992 - continuing.
Table 5: Average intake of food stuffs by the Infant and comparison with RDA
(for all 5 districts)
Age
1-2 Years
(All values in grams)
RDA
Cereals
116 i
175
Pulses
9i
35
Leafy Veg.
3X
40
Other Veg.
20
Roots/ Tubers
5X
10
Oil & Fats
1 X
15
Milk
15 X
300
Sugar/ Jaggery
7X
30
Fruit
6>L
100
Fish
2
50 I
Fleshy Foods
1
Source: Nutrition Profile of Kar*.2*'ika (1996)
RDA, ICMR, 1992
t5
Table 6 : Average intake of food stuffs during pregnancy
(All values in grams)
1999
All Karnataka (R)
Districts
Gulbarga (R)
1996
Tumkur (U)
No. Covered
45
45
Cereals
634 ?
519?
577?
475
460?
Pulses
47?
26?
37?
60
30?
Leafy- Veg.
6?
19?
13 ?
100
16?
Other Veg.
19?
10?
15 ?
40
42 ok
Roots/ Tubers
6?
22 ?
14?
50
33?
Oil & Fats
6?
8?
7?
25
12 ?
16?
20?
18?
250
65 ?
16?
21 ?
19?
30
15 ?
Fruit
14?
32 ?
23?
100
26?
Fish
0
0
0?
11
11 ?
Milk
Sugar/ Jaggery
Fleshy Foods
I
Average
RDA
128
8?
100
6?
Source: Nutrition Profile of Karnataka (1996); and the NNMB repeat survey, 1999.
//lU
Table 9 : Average Nutrient Intakes of Adolescent Girls & Children
(all 5 districts pooled) along with RDA
16-17 Years
4-6 Years
1-3 Years
Age in
years
RDA
1996
1999
75
201
RDA
1996
1999
1108
1265
1125
1098 J,
1213 X
1600
2369
21 ok
23
29 1
31ok
31
65 T
52 ok
50
239 J-
400
2954-
298 1
400
661 T
525
500
1996
1999
Number
1478
1353
Calories
700 J-
807-L
18 X
205 J-
RDA
2050
(K.Cals)
Protein
(Gms)
Calcium
ok
(Mg)
Iron
71
91
12
121
14 i
18
24 X
23 J-
30
78 1
133 1
400
1081
205 1
400
2651
249 1
6010
0.41
0.41
0.6
0.7 ok
0.7 ok
0.8
2T
11
1.1
0.6 1
0.41
0.7
1.0 ok
0.61
1.0
2T
.91
1.2
41
51
7
| 7 ok
7 ok
11
17 T
121
14
91
15 1
40
13 1
25 1
40
30
40 ok
40
(Mg)
VitaminA
(ug)
Thiamin
(Mg)
Riboflavin
(Mg)
Niacin
(Mg)
Vitamin C
(Mg)
Source : Nutrition Profile of Karnataka (1996); Repeat Survey (1999)
RDA. ICMR. 1992
17-
Table 10: Intake of Nutrients (per day) of Adult Females by
Physiological and Activity Status
Physiological
Status
Calories
Pregnant Woman
Lactating Woman
1999
RDA
1999
RDA
2137 1
2525
2396 i
2775
53 d-
65
60 i
75
409 i
1000
430 i
1000
27 J-
38
28 J-
30
291 1
600
269 i
950
1
1.3
1.4 ok
1.4
.8 J-
1.5
1.0 1
1.6
15
60
15X
18
35 X
40
36 i
80
143 X
400
168 T
150
(K.Cals)
Protein
(Gms)
Calcium
(Mg)
Iron
(Mg)
VitaminA
(ug)
Thiamin
(Mg)
Riboflavin
(Mg)
Niacin
(Mg)
Vitamin C
(Mg)
Folic Acid
(Pg)
Source : Repeat Survey - NNMB (1999)
RDA. ICMR 1992
IQ
3 3 NUTRITIONAL STATUS OF THE VULNERABLE GROUPS
(WOMEN AND CHILDREN OF 0-5 YEARS)
1. Mean Weight and Height of the Women (15-45 years of age)
Table 11 & 12 show that the women in all the districts were light and short. Women in Mysore
(Tribal) were decidedly lighter and shorter than their counterparts in the other districts. Women
(20+ years) were the tallest in Tumkur (Slums). Inspite of Uttar Kannada being the most
prosperous among the rural areas, women were the shortest here.
|
|
2. Women at Obstetric Risk by Weight and Height Indicators :
Poor height (145 cms or less) and poor weight (less than 38 kgs) are indicators of obstetric nsk.
Table 13 shows, that nearly 30% of the women surveyed were at obstetric risk by the weight
parameter. Twenty one% were at risk by the height parameter. When both parameters were
considered, the Obstetric Risk Factor ranged from 7% in Tumkur to a high 19% in Uttar
Kannada; Overall the risk was 13%. The tribal women were the lightest and demonstrated an
Obstetric Risk (by Weight) of 48%; in Gulbarga it was 28% and in Tumkur it was 19%.
3. Body Mass Index (BMI) of the women (15 to 44 years of age)
Table 14, demonstrates the poor anthropometric status of women (15-44 years) in all the five
study districts.
Body Mass Index (BMI) is an useful indicator to assess nutritional status. It is defined as weight
(kg)/ height (cm)2. Persons with a BMI of less than 18.5 are considered to be undernourished and
to be suffering from Chronic Energy Deficiency (CED). As per this criterion only 42% in
Gulbarga. 48% in Chitradurga, 40% in Uttar Kannada, 19% in Mysore, and 50% in Tumkur
could be classified as having a normal BMI.
This again points to the fact that although the adolescent girls/ women consumed more than
their RDA in food energy and protein, yet, their nutritional status was poor. A diet has to
be fairly balanced in order that fairly normal growth occurs.
Clinical Signs of Poor Nutritional Status in the Women (15-45 yeas)
Table 15, shows that clinical signs of Nutritional Anemia as judged by pallor and pale nails was
over 30% in 4 districts; it was as high as 44% in Tribal Mysore. Mottled teeth, a sure sigh of
flourosis (high fluorine content in water) was as high as 9% in Gulbarga. It appears to be a rural
problem and was 6% for the pooled data of 3 districts (R). Iodine Deficiency Disorders is
becoming an endemic problem in Karnataka and ranged from 13 to 26% in the five study
districts. Tribal Mysore was the most affected with respect to IDD.
Biochemical Indicator for Nutritional Anemia :
Tables 16 & 17 and Fig. 3 clearly sets cut the nutritional anemia or IDA scenario in 1999. Hb
values were obtained by the finger prick or heel prick and direct HemoCue method. The latest
data (2000) show that in women (15-24 years of age group), EDA is about 50%. Rural women
tend to be more anemic than their Urban counterparts.
Pregnant/ Lactating Women:
[DA has come down in the Pregnant and Lactating Women (49% and 45% respectively). It is
not very different from the prevalence figures given for women overall (42%). But the Pregnant
woman usually suffers from Moderate xsmia, while in the non-pregnant it is usually Mild.
19
Fig. 3 shows that the child 1-3 years is the more affected than the Pregnant / Lactating group
with a prevalence of 66%. The most affected group is the 1-2 year age group (78%).
In Sum:
• These disadvantaged women need a much more balanced diet. In short they need
much more vitaminA. folic acid, riboflavin and vitamin C in their diet.
• Ante-natal care has to be improved everywhere.
• The consequences of great obstetric risk to mother and child have to be emphasized
at all levels in IEC.
• Nutritional anemia is almost universal and has to be tackled on a war footing.
• Iodine Deficiency Disorder is becoming endemic inspite of iodized salt being freely
available.
Mean Weights and Heights of Children (0-5 Years) in Karnataka
1. Underweight of Children (1-5 years);
Fig 3 reproduced from the NFHS Survey (1992-’93) clearly demonstrates the plight of infants
and preschoolers in the age groups of 6> months to 47> months in Karnataka. Until 6 months of
age, the infants are totally on breast-milk. Thereafter, the mother's milk sharply diminishes
although the pattern is to breastfeed upto 2 years of age. The child is abruptly weaned onto the
home-diet almost always the cooked staple of the region. This is totally inappropriate for the
infant. Almost all families are becoming nuclear with at most a widowed father/ mother who
lives-in. The gravity of the weight deficits is setout in Table 18. To give an example an infant
boy between 1 -2 years of age should weight 13.2kg (NCHS std), whereas he weighs only about
10.5 kg. In the case of baby girl the NCHS std is 12.6kg Vs 10kg. These weight for age deficits
are totally unacceptable and need immediate attention. Karnataka households, by and large,
have an adequate amount of cereals. Why then this anomaly or enigma? Table 1 of section 3.1
and 3.2 highlights the chronic starvation levels of infants in the age group of 6-12 months.
2. Undernutrition in terms of Stunted/ Underweight or Wasted Children:
Fig.4 further accentuates the fact that overall 54% of our children are underweight, 48% are
stunted or short for their age: and 17% are wasted or emaciated. Our first priority is to try and
improve this unhappy state of affairs in our Pilot Project.
3. Height Details of Children (0-5 Years) in Karnataka:
Table 19. Our babies and pre-schoolers are not only light but also quite a bit shorter than their
privileged counterparts (NCHS) at any age. To take an example the height difference for the 1-2
years olds, is 1 Icms for boys: and 11.4cms in the case of girls. What is worse is that the deficit
widens with age.
4. Clinical Signs of Nutritional Deficiency in Children (1-5 years) in Karnataka PEM (Protein
Energy Malnutrition (Table 20)
The florid signs of PEM (Protein Energy Malnutrition), namely sparse and discoloured hair,
odema and marasmus (skin and bones) etc has virtually been eliminated. However, emaciation in
the Rural areas especially in Gulbarga (13%) has not.
Vitamin B-Complex Deficiencies:
Angular Stomatitis (Vitamin-B2 or riboflavin deficiency) is definitely a public health problem in
the Rural Karnataka preschoolers (4%) especially in Gulbarga (6%).
20
\
Vitamin A deficiency:
Night blindness (cannot see after sunset) and/or Bitot’s spots are also a Public Health Problem in
the Rural preschoolers (0.9%) Vs the WHO cut-off 0.5% to be considered so. Again Gulbarga
pre schoolers are the most affected (2%)
Iron Deficiency Anemia (IDA):
The clinical signs of IDA were high, ranging from more than 17 to 30% for pallor and a few
cases of koilnychia (concave finger nails). This was confirmed by the fact that only less than half
had Hb levels of 11g/ dl or more (WHO cut-off for children) by the Cynmethamoglobin Method
(Table 16).
Flourosis: The pooled data for the Rural pooled was 5% (again a Public Health Problem), with
U.Kannada (9%), and Gulbarga (5%) being the most affected.
Iodine Deficiency Disorders (IDD):
Our children below 5 years of age were not very affected (about 0.5%). It is the schoolers and
adults who manifested a very high prevalence of IDD (Please refer Table 21). Chikmagalur was
the most affected (41%) followed by Gulbarga (5%).
In Sum:
• Our child in Karnataka is both famished for his macro (calories and protein) as well
as his micronutrients (vitamins & minerals). He has to have both in a fairly balanced
manner, everyday of his life if he is to live let alone grow.
• One has to investigate why the LIG families give their children (1-5 years) such
minute amounts of even the cereals/ pulses, which the adults (including adolescent
girls) eat to more or less satisfy their RDA for food energy.
• All the vulnerable groups envisaged in the Pilot Project, namely, Adolescent Girl,
the Pregnant and Lactating Woman and the ‘Below Fives’ desperately need
protective foods and/ or micronutrients, which supply the vitamins/ minerals.
• The most nutritional at risk group is the 6-48 months age group. Of these the
‘Under Twos’ are a special category as they have other problems such as swallowing
reflex and less saliva to moisten and partially liquefy solid food in the mouth itself.
They need high nutrient density but liquidy foods. Hence, the addition of amy*ase is
essential.
• The micronutrient needs include vitaminA, vitamins of the B complex especially
riboflavin (B-2), bio-available iron and iodine. Also vitaminC (an enhancer of iron).
Fable 11 : Mean Heights of Women in different districts
District
Gulbarga
Chitradurga
U. Kannada
_ <L<!__
Mean Ht.
___ (l<]___
___ (H)___
Age in years
Mean Ht.
15-19
149.0
20-24
Pooled
Mysore
Tumkur
(T)
(U)
Mean Ht.
Mean Ht.
Mean Ht.
Mean Ht.
149.2
148.2
149.5
150.3
149.7
151.0
149.1
150.0
25-29
149.8
151.8
150.1
30-34
151.6
151.5
35-40
151.0
40-44
148.5
Pooled
(All 5 dists.)
149.3
No.
covered
99
_1!L_
150.4
152.1
614
150.6
150.6
150.5
151.7
736
150.8
149.5
150.8
150.5
151.7
387
150.8
150.7
148.6
150.1
148.9
151.5
152
150.1
145.1
149.8
148.5
150.4
152.9
30
149.3
Source : Nutrition Profile of Karnataka (1996). R - Rural ; T - Tribal; U - Urban
Mean
149.6
Table 12 : Mean Weights of Women in different districts
District
Age In ycurs
Gulbarga
(R)
Chitradurga
(R)
Mean Wt.
Mean Wt.
U.Kannada
(R)
Mean Wt.
Pooled
Mean Wt.
Mysore
(T)
Mean Wt.
Tumkur
(U)
Mean Wt.
No.
Mean Wt.
40.7
Pooled
(All 5 districts)
15-19
42.5
41.2
36.6
41.8
39.2
40.9
Covered
99
20-24
41.9
42.0
40.4
41.6
39.4
45.7
614
41.9
25-29
41.3
43.1
41.5
42.0
39.0
45.4
736
42.0
30-34
41.4
43.7
41.5
42.1
38.5
46.7
387
41.9
35-40
41.3
42.7
39.7
41.2
37.6
45.8
152
41.2
40-44
39.1
40.8
38.5
39.9
36.6
53.5
30
40.8
Source : Nutrition Profile of Karnataka (1996) R= Rural; T= Tribal; 11= Urban
Table 13: Percentage distribution of Adult Women (18-45 years) according to the
Obstetric Risk
District
No. Covered
Weight < = 38 kgs
Height < = 145 cms
Both
1. Gulbarga
448
28
21
13
2. Chitradurga
430
20
19
8
3. U. Kannada
428
33
28
19
Rural Pooled
1306
27
23
13
4. Mysore
414
47
24
18
5. Tumkur
400
18
15
7
2120
29
21
13
TOTAL
Source : Nutrition Profile of Karnataka (1996)
Table 14: Percentage distribution of All Adult Women (18-45 years) according to
Body Mass Index (BMI)
EMI
Gulbarga
Chitradurga
U.Kannada
Number
436
423
<=16
13
16.1 - 17.0
Mysore
Tumkur
416
409
396
14
14
28
10
15
9
16
20
10
17.1 - 18.5
29
28
29
32
20
18.6-20
23
24
22
12
18
20.1 -25.0
19
24
18
7
32
>25
1
2
2
0
10
Source : Nutrition Profile of Karnataka (1996)
7. Az
Table 15 : Percent distribution of women (15 - 45 years) according to different
Nutritional Deficiency Signs (number covered)
Gulbarga
(R)
Chitradurga
(R)
U.Kannada
(R)
Rural
Pooled
Mysore
Tribal
Tumkur
Slum
Number
448
430
428
1316
414
400
1
Pallor
31
34
34
33
43
34
2
Koilonychia
3
2
0.7
2
1
0.3
3
Teeth Mottled
Enamel
9
4
4
6
1
1
4
Thyroid
Enlargement
13
18
26
19
24
13
SI.
No.
Nutritional
Deficiency
1-5 Yrs.
I
Source : Nutrition Profile of Karnataka (1996)Table 20: Percent distribution of pre-school children
(1-5 years) according to different Nutritional Deficiency Sings (number covered)
annonq women
Percent distribution of women by degree of iron-defioency anaemia, according to background charactersbcs. Karnataka. 1999
Percentage of women with.
Background charactensoc
No
anaemia
Mild
anaemia
Moderate
anaemia
Severe
anaemia
Total
Percent
Percentage
with any
anaemia
Number
of
women
1
Age
15-24
25-34
35-49
Number of living children
0
1
2
3
52.6
59.8
59.3
100.0
100.0
100.0
100.0
100.0
446
41.5
43.4
39.9
43.2
442
669
100.0
100.0
35.8
1.439
460
2.681
100.0
100.0
100.0
100.0
47.5
406
376
31.7
2.255
100.0
42.6
3.539
41.4
36.7
.51 3)
450
(3.3)
100.0
100.0
100,0
2.4
2.2
2.4
2.2
(2.1)
100.0
100.0
100.0
100.0
100.0
466
674
231
4.1
2.3
2.4
1.8
100.0
100.0
100.0
100.0
47.3
47.4
17.2
15.9
10.9
13.7
12.9
3.0
9.8
15.4
2.9
64.2
24.6
54.0
27.7
52.5
59.4
28.7
62.4
21.7
68.3
22.1
Religion
Hindu
Muslim
Chnsoan
Other
57.4
58.6
63.3
(48.7)
26.4
27.0
30.6
(35.4)
Casta/tribe
Scheduled caste
Scheduled tnbe
Other backward dass
Other'
Missing
53.4
54.1
58.1
59.7
(50.0)
26.0
272
26.8
26.3
(35.0)
(12.9)
52.7
52.8
28.0
15.2
29.7
57.0
62.3
25.9
24.4
15.4
14.7
11.6
Employment status
Working m family famvtxjsmess
Employed by someone eise
Self-employed
Not worked in last 12 months
1,141
1.503
1.476
26.0
12.2
27.3
Education
Illiterate
Ut.. < middle school complete
Middle school complete
High school complete and above
47.4
40.2
40.7
16.4
12.5
55.4
58.5
56.6
60.1
56.8
Residence
Uman
Rural
100.0
100.0
100.0
29.3
25.4
25.8
23.1
30.1
24.3
26.8
15.5
11.5
15.5
9.1
13.8
12.4
6.2
(12.6)
18.3
16.5
1Z7
11.7
1.7
2.4
2.7
1.4
2.5
2.5
1.9
1.3
3.3
2.3
0.4
0.5
2.4
2.0
45.9
41.9
40.3
(50.0)
430
37.7
1.170
908
930
778
281
806
99
31
1 717
1.453
46
679
1.203
243
1.995
Pregnancy/breastfeeding status
Pregnant
Breastfeeding (nonpregnant)
Nonpregnant/nonbreas deeding
51.5
54.6
20.7
24.9
12.5
2.8
2.5
100.0
100.0
485
30.3
454
277
714
58.8
26.3
12.7
2.3
100.0
41.2
3.129
Total
57.6
26.6
13.5
2.3
100.0
42.4
4.120
»\ote: Haemoglobin levels are adjusted for altitude and smoking when calculating the seventy of anaemia. Total tndudes 1 woman
with messwig informatxxi on employment status, who is not shown sepaceteiy
f
() Based on 25-49 unweighted cases
'Women who do not belong to a scheduled caste, a scheduled tnbe. or an other backward dass. N FWS - 2-
^<8
I
I
I
I
I
chWron
Percent distribution of chtidren under three years of age by degree of iron-defidency anaemia, according to background
characteristics. Karnataka. 1999
Percentage of children wdh:
Background characteristic
No
anaemia
Mild
anaemia
Moderate
anaemia
Severe
anaemia
Total
percent
Percentage
with any
anaemia
Number
of
children
56.2
62.2
345
356
308
I
Age of child
< 12 months
12-23 months
24:35 months
43.8
21.9
37.8
20.8
20.2
16.4
33.7
48.7
36.8
1.7
9.2
9.0
100.0
100.0
100.0
Residence
Urban
Rural
37.6
32.6
19.8
18.9
38.0
41.1
4.6
7.5
100.0
100.0
62.4
67.4
326
685
Sex of child
Male
Female
31.8
36.7
17.0
21.5
43.0
37.0
8J
4.8
100.0
100.0
68.2
63.3
516
496
Birth order
1
2-3
4-5
6*
40.8
31.2
31.0
(22.3)
16.0
21.5
21.4
(13.4)
38.5
39.7
39.8
(57.8)
4.7
7.6
7.8
(6.5)
100.0
100.0
100.0
100.0
59.2
68.8
69.0
(77.7)
357
469
26.6
19.2
44.3
9.8
100.0
73.4
503
100.0
100.0
61.5
63.2
177
90
78.1
I
I
I
141
45
i
I
Mother's education
Illiterate
Literate. < middle school
complete
Middle school complete
High school complete
and above
38.5
3€
20.5
16.8
37.1
42.0
3.9
45.7
19.1
32.7
2.5
100.0
54.3
242
Religion
Hindu
Muslim
34.5
30.9
19.6
18.6
40.3
38.1
5.6
12.4
100.0
100.0
65.5
69.1
820
167
Castertri bo
Scheduled casta
Scheduled tribe
Other backward class
Other’
26.8
34.7
37.5
35.5
20.8
19.8
18.1
18.5
Mother's anaemia status
Not anaemic
Mildly anaemic
Moderately anaemic
Severely anaemic
39.1
31.0
25.1
(19.1)
Total
34.2
I
I
l
I
I
i
I
198
61
357
384
37.6
41.6
37.0
8.0
8.0
2.8
9.0
100.0
100.0
100.0
100.0
73.2
65.3
20.9
17.3
16.1
(23.3)
35.3
44.0
49.7
(42.5)
4.8
7.8
9J
(15.1)
100.0
100.0
100.0
100.0
60.9
69.0
74.9
(80.9)
538
310
138
19.2
40.1
6.6
100.0
65.8
1.012
62.5
64.5
26
HaemogioOin levels are adjusted for attitude when caicUating the seventy of anaemia among children. Total mcfudes 20
to 'other
and H t^ren w,th nxaa.no tnfoanaoon on the
castertribe, who are not shown separately.
-aS
a scheduled thbe. or an other backward dass NPHS-2, Kor/xrU
^7
I
I
I
Table 20 : Percent Distribution of pre-school children (1-5 years) according to
different Nutrition Deficiency Sings (number covered)
Gulbarga
(R)
Chitradurga
(R)
U. Kannada
(R)
Rural
Pooled
Mysore
Tribal
Tumkur
Slum
Number
565
503
504
1572
524
521
0.0
02
0.2
0.1
0.2
0.2
2
Hair Sparse,
Discoloured,
Easily
pluckable
Oedema
23
12
0.8
1.5
1.1
0.0
3
Emaciation
13.3
5
8
9
7
3
4
Marasmus
3
1
0.6
1
1
0.0
5
Night Blindness
03
0.0
02
03
0.4
0.0
6
Bitot Spots
2
0.6
0.4
0.9
0.8
0.0
7
Angular
Stomatitis
6
3.0
1
4
3
1
8
Pallor
18
24
16
19
29
19
9
Koilonychia
0.9
0.6
0.8
0.8
0.6
0.2
5
1.0
9
5.0
1
0.6
0.4
0.6
1
0.6
1
0.2
SI.
No.
. 1
Nutritional
Deficiency
1 -5 years
—
10
Teeth Mottled
Enamel
—
11
Thyroid
Enlargement
Source : Nutrition Profile of Karnataka (1996)
Table 21 : Prevalence of Goitre in the Project Districts
District
Population Covered
Cases of Goitre Detected
Prevalence (%)
1. Chikmagalur
3.196
1314
41
2. Gulbarga
9.582
465
5
3. Raichur
7,765
151
4. Tumkur
17.328
388
Source :
(i)
(ii)
Baseline Survey report on goitre prevalence in Karnataka.
Directorate of Health and Family Welfare Services.
Soil deficiency of micro-nutrients is wide-spread in Karnataka, especially with respect to
iodine, zinc and iron. The Plantation districts of Chickmagalur and Kodagu standout. Other
affected districts are D.Kannada and U.Kannada which are on the coast line.
235 randomly selected villages and 169 schools in all the districts of Karnataka, were
selected for the above survey. Adults and schoolers were the subjects.
Table 22: Percentage distribution of pre-school children (1-5 years) according to
Gomez grades of Malnutrition
Normal
Mild
Moderate
Severe
Gulbarga (R)
5
27
46
20
Chitradurga (R)
6
27
52
16
U.Kannada (R)
8
39
44
9
Fooled (R)
6
31
48
15
Mysore (T)
2
24
59
15
Tumkur (U)
8
44
40
7
Districts
Source : Nutrition Profile of Karnataka (1996)
The corresponding figures for All-Kamataka in the NFHS-2 survey of 2000 were: 9% for Normal;
39% for Mild; 45% for Moderate; an 6% for Severe. There is a distinct trend of Severe Malnutrition
going down from 14% in 1975 to 6% in 2000. The Normal grade also shows an increase of 5% to
9% (most recent figure from the NNMB Survey (1999). The ‘Under Fives’ in Gulbarga (one of our
Study Districts needs special attention).
3©
Figure 3
Anaemia Among Women AndChildren
60
40
20
10
Mildly anaemic
Not anaemic
Severly
anaemic
Moderately
anaemic
Maternal and child Health Programmes in Karnataka
Fig 4: Percentage of Children Under Age Four Who Are
Under Weight by Age
Percent
70
60
50
40
30
20
10
0J
12_23
24_35
NHFS. Karnataka.,
1992-93
Age in Months
NU I
31
qn-ol
36_47
too
Percent
fig 5:
Undernutrition Among Children
Under Four Years of Age
60
50
40
fv
: J
Ogk •"./I
3020
K-<
10
, a'IIm
j£- -;r«
0?
I I
Ml
Karnataka
Urtan
■ Stunted ■ Underweight
Hural
Wasted I
Maternal and child Health Programmes in Karnataka
1. Programmes:
The major feeding programmes are the ICDS for the mother and child; and the Mid-Day(i)
Meal-Programme for the mother.
The vertical programmes are the IDD. the VAD and the IDA vertical programmes.
(ii)
The various programmes in operation are shown below.
(iii)
Implementing Agency
Programme
Target Group
Inception
1.
Special Nutrition
Programme (SNP)
Children 0-5 years:
Expectant Nursing
Mother, in Urban Slums
& Tribal areas
1970-71
2.
Mid-Day-Meals
Programme
Primary School Children
3.
Prophylaxis against
Blindness due to
vitamin'A’
Deficiency among
Children
Children 1 -5 years
4.
Prophylaxis against
Nutritional Anaemia
among mother and
children
Children 1-5 years.
Expectant Nursing
mother
5.
•Expanded
Programme of
Immunization (EPI)
Children. Expectant
mother
1978
Department of Family Welfare
6.
Integrated Child
Development
Scheme (ICDS)
Children 0-5 years.
Expectant Nursing
mother. Women age^ 1545 years
1975-76
Dept, of Women
Development.
&
Dept. of Women
Development
Child
Department of Education
1970
Department of Family Welfare
Department of Family Welfare
and
Child
* Expanded Programme of Immunization (EPI) became Universal Immunization Programme (UIP)
in 1985 when specific targets were fixed for achievement by the year 1990.
There are a three other programmes such as the National School Health Programme and the
National Diarrhoeal Diseases Control Programme, which ideally should work hand in hand
with the above programmes for synergistic results.
The Child Survival and Safe Motherhood programme, which is administered by the DH&FW. In
fact there is a lot of overlap in service delivery of health and or nutrition inputs.
(iv)
5^
3.4 FOOD HABITSAND TABOOS REGARDING INFANT FEEDING
Negative:
Virtual Starvation of the Child (6 to 48 months of age)
(i)
The greatest and most alarming negative Food Habit and Taboo is the virtual starvation of
the infant/ child from 6-48 months of age. This has been dealt with in the previous chapter.
It is particularly bad in the case of the infant (6-12 months of age)
(ii)
The habit of discarding colostrum is common to practically the whole of India. In
Karnataka it ranged from 57 to 66%. The habit of giving water and honey, herbal
concoctions, and/ or castoroil was prevalent among 70 to 90% of the mothers (Fig 6)
(iii)
Slum mothers due to economic constraints are stopping breastfeeding at 4 months. Some
do this when their infant is just 2 months old. Expensive Commercial Baby Foods are bought
but fed in highly diluted and small amounts.
Positive:
(i)
(ii)
In the ragi-growing regions- sprouted ragi powder is often given to the infant as his first
weaning food. Germination does enhance the availability of all the vitamins and minerals.
Hence, with slight modifications, this can certainly be improved with the addition of sprouted
green gram powder and fortified with necessary vitamins/ minerals.
Karnataka has a very good ‘trained-dais' net work.(approximately 40,000). These are the
women who can be given basic nutrition and health education. They enjoy the confidence of
the mothers.
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3.5 KNOWLEDGE, ATTITUDE AND PRACTICES (KAP)
1. Knowledge and Practice regarding Age of Marriage:
Adolescent girls are married much too young usually at 14+ years, when they have not
completed their own growth and development. This has been shown to have very negative
outcome for the young mother and child. This is particularly bad in Gulbarga and Raichur .
2. Practice of discarding Colostrum:
In Rural. Tribal and Slum. Karnataka, about 60% discard colostrum. The first milk is considered
unclean. This is on the advice of the elders.
3. Initiation of Breast Feeding:
Late initiation of breast-feeding of the newborn. Only about 30% in the Rural and Tribal; and
about 20% among the Slum Dwellers initiated breast feeding on the first day.
4. Pre-Lacteal Feeds:
These consisted of plain water, sugar water, herbal concoctions, castor oil or cow’s milk in 60%
or more homes. The figures in two of our Project Districts were 62% in Gulbarga and 63% in
Tumkur.
5. Reduction of Period of Exclusive Breast-Feeding by the Slum Mothers:
Fig.7 shows that about 32% of the slum mothers breast-feed their babies for only two months.
Expensive proprietary brands of Infant Formula are bought and fed to the baby in miniscule
amounts.
6. Use of Unsafe Water:
Use of Unsafe Water for making up the feeds. This is probably the worst practice. There is
scanty knowledge that water is food. If unclean water, utensil and/ or feeding bottles are used
the baby will surely have severe diarrhoea and may die.
7. Unclean breast and / or finger-nail hygiene:
Mother is unwittingly very often the cause of GIT illness in their babies. Studies have shown that
the mother’s fingernails are very often contaminated with fecal matter. The mother’s say, “where
is the water to stay clean?”
8. Abrupt Weaning and/ or late Introduction of miniscule amounts of household diet' or diluted
cows/ buffalo's milk, or kanji. In Karnataka, the 1-2 year old child gets only about 600 to 700
kcal of food energy leaving a wide gap of about 300 to 500 kcal. Since the home diet s . irtually
devoid of protective foods, the baby misses out on these essential foods as well. No major
survey has yet quantified the item/s and or amount of CF given to the baby. In short, an infant
one-year-of-age needs half what his father eats. This knowledge is totally lacking at any level
and needs to be reinforced.
9. Last but not least, we the educated, especially our medical and health fraternity need to have a
better understanding and appreciation of Public Health Nutrition, before expecting miracles
regarding KAP in the LIG and illiterate populations.
10. In Karnataka, atleast half of all the boys and girls finish upto secondary school. This population
group is a huge one-fifth of the total population or a little more than a crore of a receptive and
captive audience for practical EEC. We should capitalize on this.
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REFERENCES
1. National Nutrition Monitoring Bureau of the National Institute of Nutrition (ICMR). Survey of
1975-79. and Repeat Surveys of 1988-90 and 1996-97 (published in 1999)
2. Nutrition Trends in India. National Institute of Nutrition. ICMR. 1993.
3. Nutrition Profile - Karnataka. Centre for Youth and Development. Bangalore - 560040. 1996.
4. Nutrient Requirements and Recommended Dietary Allowances for Indians. Indian Council of
Medical Research. 1992.
5. State of Peoples Health in Karnataka. Voluntary Health Association of Karnataka. 1997.
6. State of India's Health. Voluntary Health Services of India. 1992.
7. National Family Health Survey. Population Research Centre. Institute for Social and Economic
Change, Bangalore and the International Institute for Population Sciences. Bombay. 1992-93.
8. National Family Health Survey. Institute for Social and Economic Change. Bangalore and the
International Institute for Population Sciences. Mumbai.
9. Dietary' Guidelines tor Indians - A Manual. National Institute of Nutrition. 1998.
10. Report of the Independent Commission on Health in India. 1997
CHAPTER FOUR :KARNATAKA’S SPECIFIC NUTRITION GOALS FOR
2000 AD AND ITS ACHIEVEMENTS IN THE 4 ICDS STUDY
DISTRICTS OF THE PILOT STUDY AS OF FEBRUARY, 2000
r
•
To bring down the levels of moderate and severe malnutrition to half the 1990 levels. As of
2000AD severe malnutrition in the ICDS Projects of the 4 Study districts, has been virtually
wiped out in Chikmagalur and Tumkur in the ‘Below One’ age group and in the 1-3 years age
group. It is 2% in Gulbarga and 3% in Raichur. In the 1-3 years age group the figures are again
2% for Gulbarga and 3% for Raichur, In the ‘Below Ones’ the task of moving the 23% in the
Moderate Category to the Mild in Gulbarga; or 29% in Raichur; or the 9% in the Tumkur; or 12%
in Chickmagalur will not be easy. The picture for the 1-3 year olds in similar to the figures for
Chickmagalur being 13%; for Gulbarga-30%; for Raichur 32%; and for Tumkur-14%.
•
Reduction in the incidence of Low Birth Weight (LBW) babies by 20% from the level
existing in 2000
The prevalence of LBW is 27-56% in the urban areas and 33 to 41% in the rural areas. In the
intergenerational life cycle the birth outcome depends to start with on the nutritional status and
nutriture of the schooler —> the adolescent —> the married woman -» the pregnant women —>
birth outcome. Hence, it would be best to tackle the problem starting with the Schooler
(both boy and girl from Primary upto Secondary School Level) and carry on with services/
interventions thereon. This is where great success in reducing LBW can be achieved
through an equal and willing partnership between Education and DH&FW, especially at
the district, Taluka, Block and Village Levels. School enrolment in Karnataka is high (7080%). Attendance at the Secondary school level is 55% even among the females.
Nutrition-Health Education (NHE), a meal + the health package of “deworming + iron +
VitaminA” can be easily delivered in the ‘Class Room’. Each child can become a powerful
messenger to his/ her family. This will lay a strong foundation for atleast half the school
population to become better-nourished fathers/ mothers. LBW can be wiped out in just a
few years if we can tackle the problem at its root and not wait till the horses have bolted
their stables.
If we miss the chance at the school-level we can with difficulty catch up with ihe pregnant
mothers and either enrich the ICDS food supplement with atleast iron-folic acid or deliver
iron folic acid tablets just two-times a week as soon as the woman realizes she is pregnant.
Even these strategies can considerably reduce the percentage of LBW bab:es. District-wise data
are not available on LBW and needs to be included in the Pilot Project Baseline Survey. Since
IFA tablets have not succeeded very well in India, perhaps we should change track and try
a high dose of vitamin-C in a multinutrient tablet or ‘Add-On’ of iron, folic acid and
vitamin B-12.
•
Elimination of blindness due to VitaminA Deficiency
The control, let alone elimination of blindness due to vitaminA deficiency (VAD), has not been
successful or eliminated in India or in Karnataka. The average intake of vitaminA is 403pg in
Chickmagalur; 188pg in Gulbarga; and 263pg in Raichur; and 267|ig in Tumkur VS the RDA
of 600pg. The population segment most affected in descending order are the Under 1 to 6 year
old child; the school child (where Bitot spots are >7%); and then the others. Atleast 40% of the
total population can be protected through the ICDS and the Mid-Day-Meal Programme. The
common man's diet in Karnataka is most deficient in vitaminA. All strategies to reduce the
prevalence of the clinical signs of VAD. let alone blindness, should be employed. It should be
39
made mandatory that PDS commodities such as fats/ oils, be enriched with vitaminA. It should
also be made mandatory that the double toned milk (Rs.9/ litre) be enriched with vitaminA.
vitaminD and E. Although the percapita milk be fortified. Consumption is very low among poor
families.
yet
even
this
little
bit
more
of
vitamin
A. will help reduce the eye signs, morbidity and GIT episodes to a great extent. Karnataka is
rich in horticulture. Dehydration methods to save horticulture crops and re-distribution to the
poor could be another strategy.
This Pilot Project could make a beginning by fortifying the SNP with 100% of the RDA of
each vulnerable group for as many vitamins/ minerals as possible. This has been found to
be the most cost-effective way of reducing/ eliminating VAD and other micronutrient
deficiencies in the rest of the world.
Post-partum women can be safely dosed with a mega-dose of 2 lakh units of vitaminA
(capsule or syrup) from the 4 to 40th day post-portrum. This will help enrich the breast
milk and thereon to the infant.
•
Reduction in Iron Deficiency Anemia (IDA) in Pregnant women to 30%
This has not been achieved in India nor in Karnataka in 2000 AD. There is a paucity of
information in the IDA status of the vulnerable groups in Karnataka as a whole and in the 4 Pilot
Study Districts. Using the Sahli’s method, the Nutrition Profile of Karnataka. 1996,reported that
practically all women in Gulbarga, Chitradurga, U.kannada, Mysore Tribal and Tumkur Slums
were found to be anemic with 46% being severely so; 43% moderately so and 9% mildly so.
The most recent data of the National Family Health Survey-2, using the accepted
cynmethamaglobin method has found the values to be quite improved.
Unless Karnataka takes extremely innovative and bold steps and strategies it is unlikely that the
30% IDA status in the pregnant women will be achieved. Pregnant women for some reason do
not like taking an IFA tablet every day for 100 days in their last trimester. Some of the
innovative strategies could be:
An add-on vitamin-mi neral packet to their morning ‘ganjee’ (rice or ragi gruel).
Fortification of the Atta (ragi, rice, wheat, jowar, jowla) sold through the PDS with iron,
folic acid and ascorbic acid (vitaminC).
• VitaminC medicinal supplementation tablet on ‘Add-On’ form. Mass deworming of the
subjects
• Popularising the greater use of fermented (iddli, dosai, appam) and/ or germinated cereals/
pulses.
• Try methi-pak in the North-Western region.
• We would restate that the place to start is at the Primary School level for both the boy and
girl where each district would have a huge captive and receptive audience.
• Distribute fortified foods for all the vulnerable groups in the ICDS.
•
•
Universal Consumption of iodized salt:
• IDD appears to be becoming an endemic problem inspite of note-worthy increases in the
consumption of iodized salt in Karnataka. This could be due to spurious brands of iodized salt
being sold in the market. A most recent survey (1998) conducted by Tara Consultancy
Services, in Chickmagalur (one of ±e study districts), put thyroid enlargement at 18% in the Tea
Pluckers (mostly female) 20% in the non-piuckers, and nil in children below 6 years of age. The
Karnataka Nutrition Profile (1996), put myroid enlargement in Gulbarga and Tumkur at 13%
each. Another survey (1988-91) conducted by the Directorate of Health and Family Welfare
Services, pointed to only Chickmagalur being a problem district with 41% schoolers/ adults being
clinically affected. In 1996, only 1% each in Gulbarga and Tumkur were using iodized salt.
In sum, food crops grown on soils deficient in this (Iodine) and other micronutrients (iron and zinc)
will surely affect the populations that are consuming food from these crops.
•
Encouragement of all women to breast feed their babies for the first six-months and
continue to do so with appropriate complementary foods thereafter upto the child’s second
year.
Fortunately exclusive breast-feeding till the milk dries up seems to be the norm in India and
Karnataka. However, there is a trend that only about 40% exclusively breast-feed their infants’
upto 6 months of age.
The more serious problem is the non-introduction of an appropriate and adequate
complementary food from the child’s 6th month of life. The introduction of any kind of
complementary food (amount not specified), was 8% in Gulbarga and 19% in Tumkur.
Making all hospitals and maternities “baby friendly” as defined by the Ten Steps to Successful
Breastfeeding.
The Nutrition Profile of Karnataka states that in 1996 over 60% discarded colostrum; well over 80%
gave prelacteal feeds; and only about 20-30% commenced breast-feeding on the first day. All these
poor practices should be addressed in a massive Awareness Programme not only the mother, but to
the lay public, the families, the schoolers, the adolescents, the grass-root implementers of the ICDS
and MDM Pogrammes, particularly at the District level and down wards.
A simple strategy would be to give the lactating mother 2 lakh units of vitaminA within 4 days
post-partum.
• Let the umbilical cord stop pulsating. Much more micronutrients, especially iron will flow into
the baby. Then cut and tie.
• Emphasise breast and nail hygiene.
• Emphasise cup and spoon feeding rather than bottle-feeding.
Institutional deliveries still tend to be poor at about 40% in Rural and even Urban communities.
•
Further Nutrition Goals that could be introduced in the Pilot Project
•
•
•
•
•
Water is food. Ensure that safe drinking water is available in the Project areas.
Include 5mg zinc/ day in the vitamin-mineral pre-mixes. It is absolutely safe and improves
the growth of the child enormously LSAID-donated food, which India has been accepting
for its ICDS fortifies its Corn-Soya-Btend (CSB) with 5mg zinc/ 100 g CSB.
Sometimes indirect measures such as periodic and mass community or at least deworming
(ICDS & MDM) of the vulnerable groups improved sanitation, better personal hygiene of
mother and child can improve the nutritional status of the vulnerable groups.
Massive Nutrition-Education is required for all Health and Non-Health functionaries of the
ICDS and MDM. So also for the higher rungs of medical personnel.
Make Public Health Nutrition a compulsory subject in all Medical and Health Institutions
of the 4 Pilot Project Districts. Also for the state of Karnataka.
/Fl
REFERENCES
1. The State Programme of Action for the child. Government of Karnataka. Department of Women
and Child Development. Bangalore. 1994.
2. Baseline Survey Report on Goitre Prevalence in Karnataka. Directorate of Health and Family
Welfare Services. Cross-Reference in State of People's Health in Karnataka. 1997.
. 3. Tara Gopaldas and Sunder Gujral. A Multinutrient package for Tea Plantation Workers for
Better health. Productivity and Profitability. Tara Consultancy Services. Bangalore. 1998.
4. Tara Gopaldas and Sunder Gujral. The Pre-Post Impact Evaluation of the Improved MidDay-Meal Programme. Gujarat (1994-Continuing) Tara Consultancy Services. Baroda. 1996.
5. Tara Gopaldas. An Information-Education-Communication (IEC) Project for Working Girls
(18-23 Years) on Cultural Dietary Practices to increase the Iron Content of their Every-DayDiets, Tara Consultancy Services. Bangalore. 2000.
6. Mashid Lotfi etal. Micronutrient Fortification of Foods.
Current Practices, research and
Opportunities. The Micronutrient Initiative and the International Agricultural Centre. Ottawa
1996.
CHAPTER FIVE: INTER-SECTORAL LINKAGES
For the purpose of this Pilot Project, five State Departments have been picked out for close
partnerships and linkages, especially at the District Level. These are:
• The State Department of Woman and Child (nodal department, DWCD)
• The State Department of Health and Family Welfare (DH&FW)
• Zilla Panchayat
• Civil Supplies
• Information and Broadcasting.
The Design of the ICDS and the Key Role of DWCD-Karnataka:
A close interaction and collaboration between the nodal Department of Woman and Child (DWCDK); and the Department of Health and Family Welfare (DH&FW) is essential. The Department of
woman and Child is the king-pin department in the ICDS. Its key role is to ensure inter-sectoral
coordination, especially of those departments listed above, to achieve its Nutrition Goals.
As can be seen from Section 4, Karnataka’s ICDS programme has done remarkably well in
practically eradicating severe malnutrition by 2000AD. With a strong linkage with Health, Zilla
Panchayat, Civil Supplies and Information and Broadcasting, it is sure to make a success of the ‘4District Pilot Project’. It could specifically undertake the following Actions for Success.
I
I
Health:
Some of the activities that would help this Pilot Project would be:
• DH&FW-K, can play a pivotal role in ensuring that its paramedical staff (LHVs/ ANMs) work in
close collaboration with DWCD at District, Taluka, Block and Villages levels. There should be
convergence of services of the non-health and health on the (INHP) days (Please see section
7 for details).
• Ensure that the PHCs/ SHCs are functioning in the four programme districts.
• Ensure that Public Health facilities are set-up at the Taluka Level to carry out simple estimations
of Hb, (in blood), iodine (in urine) and vitamin A (clinical) safe water (using kits) etc. One
should have continuous monitoring and evaluation.
• Ensure that the Medical and Health Staff at the District to Village Level know their NHE as far
as the ICDS goes. Give status to Nutrition and introduce it as a compulsory subject in the
medical curriculum.
Zilla Panchayat (ZP):
• Karnataka has a strong Panchyati Raj (PR) institution at District. Taluk, Block and Village
Levels. It is these institutions that should play a key role in improving the nutritional status of
the vulnerable groups, especially the ‘Under Threes’ who are scarcely visible at the Anganwadis
(AWCs)
• It should play a pivotal role in forming linkages between the various departments listed above at
District level to the Village. This where things appear to go wrong. For instance, PR could
identify and establish the Self-Help-Women’s Groups.
• If (PR) could promote and support activities such as a crusade for Nutrition in the ICDS;
food processing activities, especially weaning/ complementary foods) Nutrition-HealthPopulation education at every level especially to men and the Primary and Secondary
School Levels;
• Fortification of milk with Vitamin A and D:
•
•
•
Working closely with Information and Broadcasting to broadcast messages that are location
relevant in order to improve the nutritional status of the “Under Threes”:
Also to promote the Concept of the Intergenerational Life Cycle for Good Nutrition and that of a
“Small Family Norm”;
Ensure that there is clean and safe water in the Project Districts. Water is Food in Nutrition.
Civil Supplies:
• Ensure that the PDS runs smoothly at every level.
• Promote the concept of co-operatives or community and/ or ‘Panchayat-owned and run’ ration
shops.
• Promote the idea of fortification of fat/ oils with Vitamin A; and of the local flours/ attas with
‘add-on-mineral/ vitamin’ packages.
• Only stock good brands of iodized salt. Agitate for double-fortified salt (iodine and iron)
• Expand the PDS list to include common drugs (anti-diarrhoeals, anti-malarials, multi-vitamin
mineral tablets, ORS packet etc.)
• Sell the Complementary Food made by the ‘Under Threes' by a centrally processed factory. Do
not compromise the nutrition/ health of your precious under threes, especially your 6-24 months
age group with SHGs or with local diet.
•
•
•
Information and Broadcasting:
Multi-media, particularly the TV can be a potent influencer for good or bad in 2000 AD. Hence
Information and Broadcasting should ensure that the ‘Crusade for Nutrition' is their mission.
Broadcast the good work the ICDS had done and proposes to do in the 4 programme districts.
Take the initiative to be properly oriented to the Objectives/ Goals and Work Plan of the
particular ICDS-Pilot; and promote it strongly.
REFERENCES
1. National Plan of Action on Nutrition. Food and Nutrition Board. Department of Woman and
Child Development: Ministry of Human Resource Development, GOI, New Delhi. 1995.
CHAPTER SIX: ORIENTATION/ TRAINING AND
CAPACITY BUILDING
6.1. Karnataka is very fortunate in having the Regional National Institute of Public Cooperation
and Child DevelopmenuNIPCCD, an excellent Training Institution for senior Level Officers,
located at Bangalore. This Regional Institute continuously trains the Child Development
Project Officers (CDPOs) of the ICDS of Karnataka, Tamil Nadu, Kerala, Andhra and the
UT of Pondicherry. It charges no training fee, as it is part and parcel of NIPCCD-GOI,
New Delhi. It also holds several orientation, capacity building and training courses for State
and District level functionaries. Hence. NIPCCD-Bangalore could be identified to orient the
State and District Level Implementing officers of the Pilot Study.
6.2. NIPCCD, Bangalore is promoting the excellent concept of ‘Nutrition-Health Dyads’
which is very much in tune with the ‘INHP Days’ promoted in chapters 3 to 5 , Part
Two of this Report. It could also be identified as the Training Centre for the 34 ICDSCDPOs and 34 PHC doctors of Chikmagalur. Gulbarga, Raichur and Tumkur. These 34
CDPOs 4- 34 PHC doctors would become the Master Trainers for their Supervisors at their
respective Block Head Quarters. The Supervisors-ANM, dayads, in-tum will become the
Master Trainers for their respective flock of Anganwadi workers/ CCAs/ TBAs/ &.
Adolescent Girls.
6.3. This type of descending tier upon tier type of In-Service-Training with emphasis on the
Implementation of the various strategies suggested (pl. refer chapters 1-14 of Part Two)
has been successful in CARE-India’s Project Poshak and CARE-India’s Integrated Nutrition
Health Day Strategies (1,2). It is also a cost-effective method of Training. Please refer to
Table One. Approximately 1088 State, District. Block Level and 28472 Block to Anganwadi
Level functionaries need to be Trained in just the four Pilot Districts.
6.4.However there is a problem currently in Karnataka. Many of the posts of CDPOs,
Supervisors, Anganwadi workers and Helpers are not filled. Similarly, several District
level to the Village-level posts of Medical and Health Workers of DH&FW remain
unfilled. These posts need to be filled immediately in the four Pilot districts, if the
Training Component is to have any meaning or impact (pl. refer to Specific Short Term
Objectives listed at Chapter Two. Part One).
6.5. Training of the different categories (District Level) downwards would again depend on
which Strategies DWCD decides to implement in the Pilot Programme. The more focussed
one is on the Strategy/ ies, the better will be the Impact.
6.6. For the State Level to District Level officers, one could dwell on the Situational Analysis and
Nutritional Profile of the ‘Under Two’; the P/L woman,' the ‘Above Threes'; and the
Adolescent Girl. Then go on to the Consequences and so on. Then to the strategy/ ies. Pilot
District by Pilot District. In the case of the Block Level to the lower rungs of the ICDS, in
my experience, acting out and demonstrating each service input works better. For
instance the Flip Chart used in Project Poshak was well understood by the doctors. LHVS
and ANMs. In the case of the Tribal and Non-Tribal illiterate mothers, it was actual
‘demos’ that were comprehended. This would be true for ‘Caring Practices’ (1,2,3) or
reconstitution of a RTE food supplement for the ‘Under 2’; use of an ‘Add-On’ of “ARF +
micros”; or the use of common medicines.
6.7. The Chapters of Part One, that the four Coordinators/ Field officers and Communication
Media and Master Trainers should familarize themselves for relevant Nutrition-HealthHygiene NHE messages would be chapters 3 to 5 and chapter Seven of Part One of this
report.
6.8. There is only one Supervisor’s Training Centre at Ujjiare. Mangalore. Hence, there is no
other alternative except for the Tier-upon-Tier Training suggested at point 6.3 .
6.9.1 have tried to identify some key teaching institutions in the 4 Pilot Districts that could serve
as the key link Institution/s. This is set out in Table Two.
6.10. The Training and Information Dissemination component should also focus on :
• Need to review, evaluate and revise the ICDS, the Health, and the Medical Curriculae
and make it much more practical, do-able and grounded in field-realties.
•
Focussing on Integrated Nutrition Health Systems
• Training in building bridges with communities
• Training particularly in the absolute necessity of Nutrition and Health Services to
Converge.
• Training particularly in the importance of addressing Micro-nutrient Hunger.
6.11. The Budget for Training will be quite different from that presented for West Bengal, It
would be considerably lower as NIPCCD, Bangalore can do all the Orientation and/ or
Training for the high-level functionaries. There is only one institution to train Supervisors.
The budget estimate can only be worked out jointly by the DWCD and DHFW-Kamataka.
REFERENCES
1. Engle PL, Menon P, Haddad L. Training and Information Dissemination. Pg. 133-143; Care and
Nutrition : Concepts and Measurement, Washington D.C. International Food Policy Research
Institute, 19°7.
2. Tara Gopaldas etal. Training & Information Dissemination, Project Poshak, Pg. 131-144, Volume
Two, CARE India, 1975.
3. Tara Gopaldas & Sunder Gujral; Addressing Nutritional Gaps in Children Under Two in Rural
India, CARE-India, 1998.
CHAPTER SEVEN: MEASUREMENT OF NUTRITIONAL
AND HEALTH OUTCOMES IN THE AREA OF
PROGRAMME EVALUATION IN THE ICDS :
I.
.
INTRODUCTION :
This chapter will overview input indicators, process indicators, output indicators and the
measurements to be used for the output indicators, with reference to the Nutritional and
Health status of the 0-6 year old child only. A similar Monitoring Format can be worked out
for the Pregnant/ Lactating woman; and the Adolescent Girl.
In the ICDS, Supplementary Nutrition. Health Services; Pre-School Education and Nutrition
Health Education are the four legs of the stool. I will now discuss each of the above
components in some detail.
The Food Component is the most expensive part of the package and easily accounts for well
over 50% of the total costs/ child/ annum. It is also the ‘most valued’ component of the ICDS
package, by both the parent and the community (Gopaldas and Seshadri. (1987); Gopaldas
etal (1975); the PEG Evaluation Report (1982); Gujral and Gopaldas (1991); and Kanani and
Zararia (1996); Shah and Barua (1997).
After the Food Component, it is the Pre-School Component in the ICDS which is used most
regularly by the 3-6 year olds. It is also the most valued. It is also highly valued by the
parent and community for serving as (i) A free day-care cum free lunch Centre and (ii) The
child’s first school.
Although the Health Component (health, checkups, referral, immunization) are extremely
important for the child’s good health, the parent and community do not appear to attach much
importance or value to the Health Services given at the AWCs. The major reasons being that
the Health Staff are not readily available when they should be at the AWC (NIPCCD, 1992;
and Kanani and Zararia, 1996). Generally, health and medical services are sought, but from
a private practitioner. There is hardly any convergence of the Health and Nutrition Services
in the ICDS (Shah and Barua. 1997) and (Pillai - 1995).
When it comes to monetizing, it is not only the value the parent or community attaches to a
particular ICDS component, but also the cost of that component. The Food Component costs
Rs.300/ child/ 300 feeding days/ annum. Hence, any error in monejruig the value of this
component can land one in trouble. This will hopefully, go upto Rs.600/ child/ annum in
2000 AD in Karnataka.
There is a perennial shortage of Vitamin A. Although iron (ferrous sulphate) is both cheap
and available, there is a lot of confusion with respect to its delivery, coverage or consumption
by the child at the AWC. At the very least the child requires adequate amounts of Fe,
VitaminA and I in its diet or as a medicinal supplement. All three are required to lessen
morbidity, enhance cognitive ability and physical - work - capacity. Hence, we should
assign a high value to these ‘mighty micros’!
If there were less births, then those who are born would automatically get a better
opportunity for a healthy existence. Hence, if ICDS and FP are linked and we should
assign a high value for this.
However, it must be granted that the ICDS has resulted in better growth and development of
the child. It had also resulted in better enrolment, more retention and fewer drops - outs.
^8r
I
TABLE ONE : APPROXIMATE NUMBER OF FUNCTIONARIES TO BE ORIENTED
OR TRAINED
Name of District
Approx. No. of
State/ District
Level Officers to
be oriented
Approx. No, of
CDPO PHC Dyads
to be trained
Approx. No, of
Supervisor ANM
Dyads to be
trained
Approx. No. of
AWWs/ Helpers of
CCAS & TEAS
etc. to be trained
1. Chikmagalur
7x30 = 210
7x2= 14
7 x 10 = 70
1179 x 4 times =
4716
2. Gulbarga
11 x 30 = 330
11 x 2 = 22
11 x 10= 110
2300 x 4 times =
9200
3. Raichur
5x30= 150
5x2= 10
5 x 10 = 50
1304 x 4 times =
5216
Tumkur
11 x 30 = 330
11 x 2 = 22
11 x 10= 110
2335 x 4 times =
9340
Total
1020
68
340
28,472
Notes :
(i)
There will be no charge for the 1020 senior officials or for the 68 CDPO PHC doctor dyads
trained at NEPCCD, Bangalore.
(ii)
If the 340 CDPO PHC doctor dyads jointly train the supervisor-ANM dyads at the ICDSBlock Head Quarters, it is for DWCD and DHFW to work out this cost.
(iii)
If the Supervisor-ANM dyads jointly train the 28,472 AWW-Community Change AgentsTB As-Adolescent Girls (4 types of Trainees) at the Anganwadi, the budget again will have to
be worked out by DWCD-K.
TABLE TWO : Names of Some Teaching Institutions that could be the Link Institutions for
Continuous Support and Training in each of the Pilot Districts.
1. Chikmagalur :
2. Gulbarga:
3. Raichur:
4. Tumkur:
No teaching institution. The United Planters
Association of Southern India, could depute its
doctors to be the Link Trainers.
____
• D.R.H School of Nursing
• School of Nursing, Khaza Bhandra Nawaz
Hospital
• School of Nursing, Kreethi Education
Trust Society, Gulbarga
• School of Nursing, Raichur
» School
of
Nursing,
Siddaratha
Educational Society, Tumkur
» Shreedevi School of Nursing, Shreedevi
Educaional Society, Tumkur
I
I
i
IL
INPUT INDIATORS
1. Supplementary food to deliver 300 kcal + 8 to 12g protein/ child/ day for 300 feeding days/
annum at a low cost of Re.l/ ration (inclusive of all costs). A higher value should be given to
Ready To Eat (RTE), appropriate and fully fortified foods Vs local foods. If the food is fully
fortified with the child’s daily requirement of vitamins and minerals, we need not have vertical
programmes such as currently operating for VitaminA Deficiency (VAD) or Iron
Deficiency Anemia (IDA).
2. Monthly recording of weight-for-age of all beneficiaries. It would be useful to have length-for
age or height-for-age taken once in 3 months. Then we could calculate the Body Mass Index
(BMI) of the child (wt/ ht2).
3. Nutrition Health Education for the mother/s at the AWC or the home/s of beneficiaries.
4. Safe water at the AWC (tap, borewell).
5. Iron, folic acid supplementation. It is syrup for the ‘Under Threes’^ at 20mg elemental Fe/ day/
300 feeding days. Usually there are difficulties in procurement, delivery, coverage and
participation.
6. Mega VitaminA (2,00,000 IU) oral dose 2 times a year. Vitamin A is always in short supply.
The GOI and States should take cognizance of this fact and resolve it.
7. Use of iodized salt (30 pans per million) in the RTE or cooked food preparation.
Health
1. Immunization : Each baby should have received by one year of age : BCG, DPT (3 times); OPV
(3 times); and measles vaccine (once).
2. Health checkup by the PHC - doctor once a year/child. Rarely done!
3. Referral of sick children to PHC or District-level-hospital.
4. Timely and proper management of GIT, URI, ARI and dehydration by the ANM and AWW. This
requires adequate stocks of common medicines at the AWC. These are rarely there.
5. Regular deworming with Mebendazloe or Albendazole (200 to 400mg/ child/ twice/ year).
Stocks are rarely sufficient.
6. Health and FP education.
Hygiene:
1. Safe water at the AWC.
2. Toilet (hopefully clean and usable) at the AWC.
3. Personal hygiene e.g. child comes bathed, neatly dressed and combed. No scabies. No lice, c»;ts
nails. This is possible to check at the AWC for the 3- 6 years - olds.
4. Environmental hygiene. The AWC has a fairly clean area. No garbage. Proper storage space.
Clean cooking area. Adequate space. No open drains. Usually the opposite is true!
5. Type of flooring. A mud or kucha flooring is an open invitation to soil transmitted-helminthic
diseases.
III.
PROCESS INDICATORS:
1. Overall:
Efficiency of Delivery
(i)
Efficiency of Coverage
(ii)
Efficiency
of Participation.
(iii)
4g
2. Food :
Percentage efficiency of Delivery of the Food (RTE of donated food such as Com-Soya
(i)
Mix) from the point of Manufacture to the point of receipt in the quantity required, in good
condition, and when required (time frame) to the AWC.
Percentage efficiency of Coverage of the Registered Beneficiaries (0-1, 1-2, 2-3, 3-4, 4-5 and
(ii)
5-6 years) for the 300 feeding days. (A regular beneficiary can be defined as one who gets
the ration more than 15 days/ feeding month).
Percentage efficiency of Participation of the Registered Beneficiaries (0-1, 1-2, 2-3, 3-4, 4-5
(iii)
and 5-6 years) for the 300 feeding days.
3. NHEZ Growth Monitoring:
Percentage efficiency of Delivery of Flip Charts/ Demonstration Materials/ Weighing Scales
(i)
(in working order). Growth Charts, Registers etc. from the CDPO’s office to the AWCs on
time, in good condition and in adequate quantity.
Percentage efficiency of Coverage of Parents of the registered children (fathers should be
(ii)
involved too), for NHE, GM and Demonstrations. This should be done for the 6 age
segments of registered beneficiaries.
Percentage efficiency of Participation of the Registered Beneficiaries e.g. the Mothers and/
(iii)
or the Fathers.
4. Safe Water:
Percentage availability of safe drinking water at the AWC and the child’s home (?)
5. Health:
1. Immunization :
Percentage efficiency of delivery by health personnel. Also vaccines/ equipment etc. in
(i)
good condition (cold chain), adequate quantity and on time for immunization of the 0-1
year age group.
2. Health Checkups:
Percentage efficiency of Delivery by the Health Personnel with equipment on time to
(i)
give a health checkup to every enrolled beneficiary once a year at the AWC.
Percentage efficiency of Coverage all the enrolled beneficiaries.
(ii)
Percentage efficiency of Participation for the Health Checkups by the children
(iii)
3. Referral:
Percentage efficiency of Referring the ill child with escort to the PHC or District
(i)
Hospital.
(ii)
Percentage efficiency of Participation of taking the sick child to the hospital.
4. Management of Common Illness/ FP Demand:
Percentage efficiency of Delivery of common drugs or other materials in good condition,
(i)
on time and in adequate quantity to last for 2 months, to the AWC. The drugs like
Albendazole/ Mebendazole. ORS, Paracetamol, Chloroquine, Cotrimoxazole (Antibiotic),
Oral contraceptive pills. Condom packets. Vitamin A bottles, IFA tablets (Large and
Small) etc.
Percentage efficiency of Coverage of beneficiaries in the last 2 months.
(ii)
Percentage
efficiency of Participation of the beneficiaries in the last 2 months.
(iii)
5. Deworming Tablets: Please see above.
6. Health and FP Education:
This is not given in the ICDS but should be.
So
7. Other Related Materials:
Percentage efficiency in delivering, covering and participation for iodized salt in the
(i)
past 2 months.
Percentage efficiency in delivering cooking utensils, volumetric measures, serving
(ii)
dishes etc. on time, in good condition once a year.
I
I
I
IV.
IMPACT INDICATORS AND THEIR MEASUREMENT:
1. Nutrition Component:
Anthropometriy : Weight-for-age and length-for-age in the ‘Below Threes' once in 3
(i)
months. Weight-for-age and height-for-age in the ‘Above Threes’ once in 6 months.
Compare with IAP standards.
Dietary : Spot Check on separate days to assess how much raw ration is cooked/ child/
(ii)
day. Separately assess what is actually consumed by the 6 age segments. If ‘take-home’
the same procedure is to be used.
Clinical
: By standard methods. Pale conjunctiva (almost white) for IDA. Night
(iii)
blindness, conjunctival xerosis (wrinkled conjunctiva) and Bitot’s spots for VAD.
Biochemical : Try and do a Hemoglobin test by the Direct Cynmeth method (Oser. 1976).
(iv)
Most of our population group would have Hb value less than 11 g/ dl (WHO cut off).
Knowledge, Attitude and Practice : In child-care by Focus Group Discussions or
(v)
Participatory Research Assessment, questionnaire.
Obviously, if the impact indicators (I) to (v) above improved, and the 2 clinical signs of
IDA and VAD decreased, the subject’s Nutritional Status would improve.
2. Health Component:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
Immunization : Percentage reduction in the prevalence of cases of polio, TB, Measles,
Whooping cough among the ICDS enrolled children (0-6 years). Information can be
collected from the Registers by Surveys or by PRA>
Percentage improvement in the prevalence of healthy children (0-6 years) in the annual
health checkups. Information can be collected as stated above.
Referral: Percentage decrease in the referral of cases in the past one-year. Measurement.
Sources of information as in (1) and (2).
Management of common illness: Percentage decrease in the referral of cases in the past
one year. Measurement/ sources of information as in (1) and (2).
Deworming : Percentage decrease in the referral of cases in the past one-year.
Measurement/ sources of information as in (i) and (ii).
Health and FP Education : Percentage increase in KAP.
3. Hygiene:
Safe water : Percentage AWCs having safe water (tap, borewell). Measurement through
(i)
microbiological testing.
Toilet: Percentage AWCs having toilet and if so if it is clean. By direct observation.
(ii)
Personal hygiene: Percentage children who can be said to have a decent level of personal
(iii)
hygiene (bathed, combed, no lice in hair, no scabies, cut nails etc.). Direct observation
and recording in each of the 6 age segments, especially the ‘3-6’ category.
Environmental Hygiene : Percentage AWCs having a fairly decent level of environment
(iv)
hygiene. Percentage in a fairly clean locality, no garbage/ litter, sufficient space (indoor
and outdoors) etc. Direct observation and recording.
O
,0* / I
51
07701 V00
(V)
Kucha/ Puccka flooring: Percentage AWCs having Puccka flooring. Direct observation
and recording. There is a direct relationship between kucha flooring and intestinal
helminthic infections (10).
Evaluation Design:
Several Evaluation Designs are possible. However a Pre-Post cross-sectional Evaluation Design
is the most simple and cost effective. For instance. ICDS and non-ICDS areas can rarely be
matched for even the simplest of socio-economic parameters.
REFERENCES
1. National Evaluation of the Integrated Child Development Services:
NIPCCD, Delhi (1992). Published by NIPCCD.
2. Tara Gopaldas and Subadra Seshadri Nutrition:
Monitoring and Evaluation (1987). Published by GUP.
3. Tara Gopaldas et al:
Project Poshak, Vol One (1975). Published by CARE-India.
4. The PEG Evaluation of the ICDS (1982):
Printed by PEG, New Delhi.
5. Sunder Gujral and Tara Gopaldas
The USAID assisted ICDS Impact Evaluation Project in Panchmahals (Gujarat) and Chandrapur
(Maharashtra) (1984-1990). Printed report.
6. Kanani and Zararia:
ICDS as people view it: A Social Assessment of ICDS in Gujarat (1995). Printed report. Funded
by UNICEF. Gujarat.
7. Shah M H and Barua A:
CARE-India. ICDS Baseline Report (1997). Produced by the Foundation for Research in Health
Systems. Ahmedabad.
8. Gita Pillai:
CARE-India. Integrated Nutrition and Health Program (1995-2000).
9. Oser BL:
Hawk’s Physiological Chemistry (1976). Tata Me Graw Hill Publishing Co.. New Delhi
10. Tara Gopaldas:
Finalized Plan of Action (PGA) for Improving Nutrition Services for the ‘Below Threes’ Under
the ICDS, Rajasthan, 1992.
PART TWO
IMPLEMENTATION STRATEGIES
Chapter One
Programme Organization and Management
Chapter Two
A Strong Awareness Campaign (Especially at the
District Level)
Chapter Three
An Improved Nutrition Health Package for the Under
Twos
Chapter Four
Self-Help Groups (SHGs) of Women to make
Supplementary Foods for the 3-6 Years Age Group in the
ICDS
Chapter Five
The Adolescent Girls in the ICDS
Chapter Six
The Pregnant/ Lactating Woman in the ICDS
Chapter Seven
Safe Water At All The Project AWCS
Chapter Eight
Mass Deworming of All ICDS Beneficiaries
Chapter Nine
Enrichment or Fortification of Double Toned Milk with
VitaminA in All the Dairies of Karnataka
Chapter Ten
A Multinutrient Tablet Including Iron, Folic Acid, Vjt.
Vitamin-C and Vitamin B-12 For All Pregnant/ Lactating
Women In The ICDS of the Pilot Districts
:
Enriching Ragi Atta with an Add-On of 6 Micronutirents
Chapter Twelve :
(i) Drying/ Dehydration of Fruits/ Vegetables in the Glut
Season.
(ii) Better Storage of Perishables at Point of Harvest
(iii) Development of a Simple Cooling Box.
Chapter Thirteen :
Use of Double Fortified Salt
Chapter Fourteen :
Deworming + Vitamin A + Iron + Iodised Salt for All
Schoolers
Chapter Eleven
53
7. IMPLEMENTATION STRATEGY/ IES
Overview/ Summary:
Based on the Situational Analysis (Chapter 3, Part One), the Strategies/ Types of Interventions
would cover all avenues of nutritional status improvement in the vulnerable groups,
namely:
Chapter One:
Organization and Management
Chapter Two:
Launching a strong Awareness/ EC/ NHE campaign from August 15,
2000 regarding the Pilot Study at all levels from the State Capital
(Bangalore) to the Pilot-Study Anganwadis/ Communities. Apart from the
mothers - fathers , fathers-in-law and other caregivers will be included for
NHE (Refer Chapter 3, Part One).
Chapter Three :
It would be evident from the Situational Analysis (Sections), that the
‘Under Twos’ have to be given the maximum importance. However,
the 2-3 year old child is also very undernourished and will be included in
the special category group. They will receive exactly what the ‘Under
Twos, receive.
Chapter Four:
Self-Help-Groups of Women, who could make local recipes such as rotis,
usals, ragi muddes, laddus. dry snacks etc could be set up. The Ready-ToEat Products could be transferred to the near-by ICDS for all vulnerablegroups except for the ‘Under Threes’. The ‘add-on’ of micronutrients at
the last step of production, will be tried here. The district will be Gulbarga
only.
Chapter Five:
The Adolescent girl will receive a multi-vitamin-mineral tablet to cover
her micronutrient deficits. She will be included in the bi-annual
deworming campaign. She will also receive focussed NHE as to how to
improve her own health/ nutritional status; as also that of 5 children (6
months to 24 months) she will be responsible tor in the ‘Take-HomeRation' (THR). She will ensure that the THR reaches and is consumed in
full by the ‘Under Two'. She will be responsible for reducing the
‘Sharing Factor’.
Chapter Six:
The Pregnant and Lactating Woman will receive a fully fortified ration
to meet both her macro/ micro deficits in the THR situation. She will also
receive the biannual deworming . NHE, Caring Practices and actual
Demonstrations will form the plank of her NHE education.
Chapter Seven:
Safe water will be provided atleast at the AWCs. Attempts will be made
to also provide a toilet at all the AWCs of the 4 Pilot Districts.
Chapter Eight:
Mass deworming of all ICDS beneficiaries will be conducted on a
campaign mode.
5^
Chapter Nine:
Milk dairies will enrich their double-toned-milk (which the poor buy) with
atleast lOpg vitaminA/ ml. If vitamin D and E can be added - so much
the better. This will be done in the Urban setting only.
Chapter Ten:
Distribution of a multi-nutrient tablet including Fe. Folic acid, VitaminC
and Vitamin B-12 to the Pregnant/ Lactating women and Adolescent Girls.
Chapter Eleven:
If possible the ragi atta (widely consumed in Tumkur) will be enriched
with an ‘add on' of “iron + folic acid + vitaminC’’ for Tumkur district
only. Attempts will be made to encourage “chakki-atta” millers or
households to use the ‘add-on’.
Chapter Twelve:
Karnataka is a ‘Horticulture State’. Steps will be taken in all four districts
to dry/ dehydrate the surplus vegetables/ fruit crops in the shade (to
preserve the p-carotene and other vitamins) during the glut season and to
distribute the same through the Anganwadis to the needy communities at
subsidised rates. Also to promote better storage of perishable produce on
the field; and the development of a household cooling box.
Chapter Thirteen:
Deworming + VitaminA + Iron + Iodized Salt for All Schooler in the 4
Pilot Districts.
Chapter Fourteen: Use of Double Fortified Salt to Chikmaglur District.
5^
N
CHAPTER ONE: PROGRAMME ORGANIZATION AND
MANAGEMENT
1.1. Introduction : Thirteen types of strategies, almost all of them to control or reduce overall
under-nutrition; and ‘Micronutrient-hunger' in the ICDS and/or total populations have been
suggested (Chapter 2 to 14 of Part Two). Ideally, all the concerned State Level
Departments, namely DWCD, DH&FW, the Department of Panchayati Raj (Zilla
Panchayats), Civil Supplies, Information and Broadcasting, and the other concerned
departments such as Agriculture/ Horticulture and Food Processing Industries should be
coordinated by one Nodal Agency or Department. The Nodal Department would be
DWCD of Karnataka at the State Level. At the District Level it could be either the
District Collector or the District Level Counterpart of the Zilla Panchayat.
Coordination with the NGOs, other SHGs, and Industry is also required.
1.2. At the Apex Level an Advisory Committee of Ministers of atleast the Minister of Woman
and Child (Chair); the Minister of Health and Family Welfare; the Minister of Panchayati
Raj and the Ministers of the other concerned Departments with their Principal Secretaries,
could be formed. A few eminent experts in Nutrition, Health. Food Technology etc. could
also be included. In Year One of the Pilot Study, the Apex Level Committee should meet
atleast once a month to review Operational Plans. Progress of Implementation, and to
decide on which of the 13 strategies should form the core of the Pilot Study.
1.3.
A Programme Management Cell (PMC) could be set up, headed by a Senior Officer.
He/she will also serve as the Member Secretary of the State Level Task Force. The PMC
would function as a part of DWCD and would operate for the entire project period.
1.4. The PMC would have small sections for financial control as well as programme operations
with programme co-ordinators to coordinate activities with concerned Departments/
Agencies in the areas of Communications. Training, Pre-Post Evaluations, and Management
Information Systems for the major strategies suggested.
1.5. The PMC would produce monthly monitoring reports for distribution to the concerned
agencies and the State Level Task Force. The PMC also would prepare an annual
consolidated budget and work plan in consultation with the concerned departments, which
will provide a consolidated and uansparent resource to track programme progress and
direction.
1.6. A District Nutrition Committee headed by the DM and consisting of district-level officers of
the concerned departments would monitor the progress of implementation every month.
1.7. Insofar as possible, the program would be fully integrated into the normal operations of
implementing agencies/ departments. However, in its early implementation stages the
programme will require strengthening, initiation and coordination of activities involving a
number of departments especially that of DWCD and DHFW.
1.8. The details of the Programme Organizational Chart, the Programme Management Cell, the
Plan of Action in Summary and the Budget for the same are attached at Annexure 1,2,3 and
4 of this chapter.
1.9. CARE-India is possibly the most skilled and experienced NGO in the Management of such
Pilot Studies. It might be a good idea for DWCD to explore the possibility of their
managing the Pilot Programme in Bangalore, Gulbarga, Raichur, Chickmagalur and
Tumkur. CARE-India has worked in Karnataka previously with the MDM programme. It
has now shifted its focus to the ICDS, where it works in 7 states, namely AP, Bihar, MP,
UP, West Bengal, Orissa and Rajashthan. It is particularly skilled in food commodities
procurement, logistical delivery, coverage of target populations by appropriate food delivery
systems such as the ‘Take-Home’ for the invisible Pregnant/ Lactating women and ‘Under
Threes’ of the ICDS. The ‘Take-Home-Ration’ (THR) and Integrated Nutrition Health
Programme (INHP) are one of CARE-India’s most successful innovations in recent
years. It has kept pace with the Computer Age and uses Management Information Systems
(MIS) extensively.
1.10. It is beyond the scope of this report to go into details of Program Management. The
Program Management Cell when in place may like to consider the following aspects of
Programme Mangement.
•
•
•
•
•
•
•
•
•
•
•
Modem management methods in ICDS programmes.
Maximal utilization of potential or existing resources
Utilization of PERT as a planning and evaluative tool
Utilization of manpower and personnel management systems
Incorporation of modem administrative procedures in training programmes for ICDS
and PHC staff
Motivation of staff to superior job performance
Utilization of efficient purchasing and procurement methods
Vital importance of efficient logistical planning in large-scale nutrition and public
health programs
Budgetary control and fiscal management
Cost-effectiveness and Linear Programing
Utilization of the Systems approach and MIS in large-scale nutrition and public health
programs
I
5^
Fig 1: Programme Organisation and Management
APEX COMMITTEE
Headed by the Cabinet Minister of
Woman and Child Development,
Principal Secretaries & Eminent Experts of
Nutrition, Health and Food Technology
PROGRAMME MANAGEMENT
CELL
Chikmagalur
Dist. Collector
(DO/Zilla
Panchayat (ZP)
Gulbarga
Dist. Collector
(DC) / Zilla
Panchavat
5&
Raichur
Tumkur
Dist. Collector
(DC)/Zilla
Panchavat (ZP)
Dist. Collector
(DC)/Zilla
Panchavat (ZP)
Fig 2: PROGRAMME MANAGEMENT CELL
DIRECTOR
PROJECT MANAGER
EXECUTIVE
SECRETARY
ACCOUNTS
OFFICER
COORDINATOR
Nutrition & h?a!th
COORDINATOR
Operational Research
Pre-Post Evaluation
I
Steno
Accountant
T'ypist
Attendant
Steno
Typist
Filed
Officer
Field
Attendant
Field
Officer
Field
Officer
Field
Officer
Field
Attendant
Attendant
Source: /Adapted from Micronutrient Malnutrition Control in West Bengal, Report of the Task Force Set-up by
the Govt, of West Bengal, Social Welfare Dept. 1998.
COORDINATOR
Environmental Sanitation &
other related strategies
Field
Officer
Field
Attendant
Field
Officer
COORDINATOR
Awareness/TrainingZ
IEC
Field
Officer
Field
Attendant
Field
Office
TABLE 1 : SUMMARY STATEMENT OF PLAN OF ACTION STRATEGIES
S.N
L__
1.
2.
3.
4.
5.
II
6.
7.
8.
9.
10.
11.
12.
____________ STRATEGIES
CONCERNED DEPARTMENT/S
Must be done Strategies by DWCD:
Awareness Campaign
For whole State/ 4 Pilot Districts
DWCD. IB (State) FN Board. DH&FW.
Agriculture. Civil Supplies. Food Processing
Industries. Education. Private and Public.
DWCD. DH&FW and District Panchayt
Under Threes in the ICDS of 4 Pilot Districts
2.30.000 Under Threes in the 4 Districts.____________
• Above Threes in the ICDS of Gulbarga
DWCD. District Panchayati and the Self-Help
(i) 86,137 ‘Above 3s’ Rounded off to 1.00.000
Groups of Women (SHGs)
beneficiaries.(ii) Total No. of ICDS ‘Above 3s' =
2.40.000 in the 4 distircts.________________________
Adolescent Girls in the ICDS of the 4 Pilot Districts
DWCD. FN Board. DH&FW and District
46.000 Adolescent Girls
__
Panchayat________________________
Pregnant/ Lactating Women in the ICDS of the 4 Pilot
DWCD. FN Board. DH&FW and District
Districts
Panchayat
1.38.778 rounded off to 1.40.000 P/L beneficiaries
Should be done in Collaboration with other
Depts.____________________
Safe Water and Sanitation in all the AWCs in the 4 Pilot DWCD. The District Panchyat. The District
Districts
level Water and Sewerage Boards
7168 AWCs in the 4 districts._____________
De worming of all Vulnerable Groups of the 4 Pilot
I DWCD. The District Panchayat and a reputed
I Private Pharma Cos.____________________
Districts (About 7 lakh beneficiaries)
Fortification of Double Toned Milk with Vitamin A in
Concerned Dairies and Suppliers of VitaminA
Gulbarga, Raichur and Tumkur for the Open Market
All those who buy double toned milk will benefit
A Multinutnent tablet including Iron. Folic Acid.
DWCD. Food Processing Industries. Private &
Vitmain-C and Vitamin B-12 for all Pregnant/ Lactating
Public. The District Panchayat
Women in the ICDS of the Pilot Districs
Fortifying Ragi Atta in Tumkur District
DWCD. Civil supplies. Food Processing
31,000 Pregnant/ Lactating women
Industnes. Private & Public. The District
Panchayat____________________________
Drying of Fruits/ Vegetables During the Glut Season for
DWCD. Agriculture/ Horticulture. The Distrit
the open market
Panchayat
Use of Double Fortified Salt in Chikmagalur District or
Reputed Brands only
DWCD and Food Processing Indus.rv
i
III.
Strategies that should be seriously considered
13.
Deworming + VitaminA+lron+Iodised Salt for All
Schoolers in the 4 Pilot Districts
i DW&FW, School Health and Education
! Department
COST
Rs. 3 crores
Rs. 40 crores
Rs. 17.20
crores
Rs. 6 crores
Rs. 23.20
crores
Rs. 14 crores
Rs. 4 crores
Rs. 3 crores
Rs. 1.5 crores
Rs. 4.19 crores
Estimate
cannot be
given
Estimate
cannot be
given
Estimate
cannot be
given
Total cost = Rs.J27 crores.
Approximate Total Budget Cost to DWCD/DHFW and other Departments for the 2-Year-Pilot
Project
•
To DWCD
Approximately Rs.90 crores.
It may be noted that DWCD is already paying about Rs.70 crores for 2 years in the way of Food Supplement
alone to its ICDS beneficiaries in just these 4 Pilot Districts.
•
•
TO DHFW
To Sanitation and Sewage
•
To the 3 Dairies in Gulbarga, Raichur and Tumkur
•
To FPI and other Departments/ Institutions - Cannot be budgeted at the present time.
-
Approximately Rs. 14 crores.
Approximately Rs.14 crores.
Approximately Rs.3 crores.
The Total Budget is estimated to be Rs4%T crores for the Pilot Study of 2 Years duration.
TABLE 2: BUDGET FOR PROGRAMME IMPLEMENTATION CELL
:l
Non-Recurring Costs
1. EQUIPMENTS________________________
i. Computer. Laser Printer & Necessary Softwares
ii. Fax________________________________
iii. Telephone________________________ '
iv. Photocopier (Digital)___________________
v. E-mail Registration & installation
5.00.000
40.000
15.000
3.50.000
4.000
2. FURNITURE & FIXTURES
5.00.000
Rs.
3. STATE LEVEL MICRONUTRIENT LABORATORY
Total Non-Rccurring Costs
50.00.000
9,09.000
7.31.80.000
Recurring Costs (Annual)
For 2 Years
For 5 Years
2.40.000
1.92.000
5.76.000
1.20.000
96.000
72.000
1.80.000 '
3.84.000 '
96.000 '
96.000 '
48.000
21.00.000 '
6.00.000
4.80.000
14.40.000
3.00.000
2.40.000
18.000
4.50.000
9.60.000
2.40.000
2.40,000
1.20,000
52.50.000
72.000
24.000
72.000
180.000
60.000
180.000
40,000
3.2*.000
100.000
820.000
2.40.000
600.000
5. MEETING EXPENDITURE
2.00.000
500.000
6. CONTINGENCY (Post, Telegram. Printing, Stationery, etc.
including contingency staff) 10% of Recurrent Cost of f 1) 4-... 4- (5)
Total Recurrent Costs
Total Recurrent Cost for Five Year=5xRs.8.459.000/Rs.4.22.95.000
Assuming an escalation of 35%
Total Recurrent Cost = 1.25 x Rs.4.22.95,000 = Rs.528,68,750/-
3,07.tXX)
769,000
33830.000
8.459.000
1, HONORARIUM TO PROJECT PERSONNEL
i. Director. Programme Implementation Cell - 1 No.
ii. Project Manager - 1 No.___________________
iii. Field Co-ordinator - 4 Nos, x Rs.3.60.000_____
iv. Accounts Officer - 1 No.__________________
iv. Executive Secretary - 1 No.________________
vi. Accountant - 1 No.______________________
vii. Computer Analyst - 3 Nos, x Rs, 1.50.000/viii. Field Assistant - 8 Nos, x Rs, 1.20.000/-______
ix. Steno-Tvpist - 2 Nos, x Rs. 1.20.000/-________
x. Field Worker - 4 Nos, x Rs.60.000/-__________
xi. Office Attendant - 2 Nos, x Rs.60.000/-_______
Sub-Total Recurrent Costs
2. OFFICE ARRANGEMENT____________________
i. Space Hire Charge (Rs.l5.000/-p.m.)______________
ii. Electricity (Rs.5.000/-p.m.)_____________________
Iii, Phone. Fax & E-mail (15.000/-p.m.)_____________ _
3. TRAVEL & TRANSPORT_____________________
i. Vehicle hire charges including P.O.L. (3xRs.20.000xl2)
ii. TA/ DA___________________________________
Sub-Total Recurrent Costs
4.
OPERATIONAL
&
MAINTENANCE
COST
MICRONUTRIENT LAB INCLUDING STAFF COST
Hence Total Cost = Non-Recurrent Cost + Recurrent Cost
= Rs.64.09.000/- + Rs.5.28.68.750/- =
OF
Rs.5.92.77,750
Rs.23720.000
Source : Adapted from Micronutrient Malnutrition Control in West Bengal, Repon of the Task Force set-up by the
Govt, of West Bengal. Social Welfare Dept. 1998.
Note : The WB budget is on the Low side. We feel that about Rs.6 crores will be required in a 2-year-Pilot
Programme.
CHAPTER TWO: A STRONG AWARENESS CAMPAJNGN
(ESPECIALLY AT THE DISTRICT LEVEL)
I
I
2.1. Introduction: The problem with Nutrition is that though everybody talks about
• Malnutrition, yet, there is insufficient knowledge about it. Nutrition is our country needs
to get the status of Health or Medicine if not IT’
The various activities that might set the stage for the launch of the Pilot Programme on 15th
August. 2000 could be as under:
I
{
'For Information and Broadcasting:
• Accord high priority to awareness generation programmes concerning Nutrition in General
and this Pilot Programme in particular.
• Allocate free time for communicating location specific Nutrition Themes/ Messages during
prime time on Siti Channel (Karnataka), Kaveri Channel (for Karnataka) and on
Doordarshan.
• Involve Subject Matter. Advertising Agencies and Communication Expens in EC
programmes.
• Use social marketing strategies for conveying nutrition and health messages.
• Create adequate software to highlight nutrition issues.
• Arrange preparation of various types of programmes on nutrition with special reference to
prevention and control of protein energy and micronutrient malnutrition.
• Regularly telecast/ broadcast these programmes for communicating the requisite messages,
• Overview the activities concerning mass-media communication on nutrition through a
screening committee.
• Undertake steps for creating nutritional awareness among the people through different units
of information and broadcasting like the State F&B Board, Publication Division, Dept, of
Advertising and Visual Publicity, Research and Reference Division, Photo Division, AIR,
Doordarshan. Press Information Bureau and Directorate of Field Publicity.
• Incorporate nutrition education programmes in Educational Programmes on AIR and in
Special Campaigns, Rural Programmes. Educational Programmes and Social Awareness
Programmes on Doordarshan.
2 J. Orientation/ Capacity Building/ IEC/ Others
• The various State Level Depanments, that is. Woman and Child, Health. Agriculture, Civil
Supplies. Food Processing Industries and Education should be oriented together.
• Involve EC Experts to evolve simple frequency and reach messages that will highlight the
plight of the 0-3 years age group. Highlight that what everyone in Karnataka needs is their
daily vitamins/ minerals. Highlight that the adults are eating too much of cereals. Highlight
that they need to eat much more of pulses. Also seasonal vegetables/ fruits, milk, fat/ oils
and flesh foods.
• Doordarshan. AIR, Field Publicity Units. ±e Press (Vernacular and English) should be
involved in a big way.
• Make a directory of media institutions in the capital/ districts that can and should help. Give
facts as to how fortification of common man’s foods can wipe out micronutrient
undemutrition for man. woman and child in a couple of years. Until then support the
strategy of a multinutrient tablet for every member of the family. Stress the dire
consequences of undemutrition for everyone, especially the ‘Under-Threes’ and the
Pregnant/ Lactating woman. Stress the fact that water is food and should be clean.
Promote consumption of fermented/ germinated foods.
G2-
Make each District a unit for accountability for all activities of the Pilot Project, starting
with Raising of Awareness Levels of Public, Private, NGOs, Funders and the Lay
Public, with respect to Nutrition and Health.
• Print booklets in the vernacular of the district/s based on the Nutrition Component of
Karnataka’s State Programme of Action for the child and disseminate information widely.
• Involve Milk Dairies, Weaning Food Units. Pharma Companies to create a corpus fund to
fund the Market and Advertising Research Component of this Pilot Project.
• Approach the IT giants of the State to evolve the software for the Awareness Campaign.
Also to form a generous corpus fund on a continuing basis, to fuel the Awareness as well
as other Activities in this Pilot Project
• Set-up a small secretariat at DWCD (nodal department) to oversee and report progress to the
Secretary DWCD and Secretary DH&FW (main actors) once in 3 months.
• Capitalise on the present political will for Good Nutrition for Woman and Child and
periodically inform the Cabinet and MLAs.
•
I
•
23. Baseline Assessment: Pre -Post Survey will be done by a reputed Market Research/
Advenising Research Organization.
2.4. Type and Number of Beneficiaries: A notational figure of 15 lakh beneficiaries has been
taken at atleast 2 members/ ICDS family into approximately 6.5 lakh ICDS families + the
ICDS Programme Implemented + others such as the District Panchayats. the District Level
Officials and the lay public.
23. Time Frame: August 15lh, 2000 and continuously till the end of the Pilot Study.
2.6. COST: The estimated cost is Rs.3 crores (taken at a notational value of Rs. 10/ beneficiary
x 15 lakh beneficiary x 2 years). It may be noted that media budgets depend on the
frequency, and the length/ duration of the radio/ TV spots used.
15 lakh beneficiaries X Rs.10/ benefician = Rs.13 crores/ annum or
Rs.3 crores for the 2 year Pilot Project.
REFERECES
1. Manoff RK. Social Marketing, New Imperative for Public Health. New York. Praeger
Publishr, 1985.
2. Manoff Group, Inc. The Weaning Project. Improving Young Children feeding practices in
Indonesia: project overview. Nutrition Directorate, Ministry of Health and the Manoff t
Group. Inc. 1991.
3. Tara Gopaldas etal. Project Poshak (Vol 2). Child Care Education Component, pgs 81-116.
1975.
4. Kanani S and Agarwal V. Reducing Anemia and Improving Growth in Ealy Adolescence Nutrition Education Alone can Make Difference. Paper presented at the lb111 IUNS,
Montreal. Cananda (1997).
5. Seshadri S etal. Non-Cognitive Barriers to Compliance with Iron Supplementation.
University Dept, of Foods and Nutrition. M.S.University. 2000.
G5
CHAPTER THREE: AN IMPROVED NUTRITION-HEALTH
PACKAGE FOR THE UNDER TWOS.
3.1. Introduction:
The Interventions/ Strategies proposed will work within the plus and minus aspects of the
ICDS as it exists now in 2000AD. Most of the proposed Interventions will ride ‘piggy-back'
on the existing system.(l-16).
*3.2. Specific Intervention and Areas of Operation:
It would be evident from the Situational Analysis (Chapter-3) that the ‘Under Twos’
have to be given the first priority and maximum importance. Therefore, a package of
services, including an appropriate nutrient dense and low-bulk complementary feed
will be offered to the mother and child through a ‘Take-Home-Package’ delivery
system operated through the ICDS anganwadis in the 4 Pilot Districts. These are
Gulbarga, Chikmagalur, Raichur and Tumkur.
3.3. Details of the Intervention:
The ‘Under Twos’ in the ICDS will receive a centrally, hygienically and fully fortified
complementary or weaning food which will deliver about 400 kcal and their
Recommended Daily Allowances (RDA) of vitamins/ minerals in a 100g ration. The
ration will also contain atleast 10% of ragi malt powder, or 10% wheat malt powder or
2% barley malt powder - the natural source of a-amylase.
3.4. The Karnataka Agro Com Industries will deliver this complementary food for the said agegroup 3 days in the week. Specifications will be worked out and open tenders will be
called for the other 3 days of the week. Parties who have had a good track record in
the production of Weaning Foods will be selected.
3^. The cost of the ration has been unrealistically low. It will be fixed at Rs.2/ child/ ration
for a 100g individually packed portion. This will ensure to some extent, more
accountability, proper ration size, less pilferage/ leakage and hygiene. This will amount to
Rs.600/ child/ annum. There are about 230,000 ‘Under Twos’ in the ICDS Pilot
Projects. These small beneficiaries should be treated as a Very Special Category and
proportionately more should be spent on the them VS the other vulnerable categories.
3.6. Another Re. 1/child will have to be set aside to give the mother of the child some concrete
inputs “To Care With”. For just 5OpZ child/ day x 300 ICDS-days, or Rs. 150/ child per
annum, the mother will receive the following for her child:
•
Some common generic drugs such as paracetamol, chloroquine (anti-malarial)
cortimoxazole (antibiotic for ARD and ORS for the Index child (about Rs.40/ annum).
• The mother and child will participate in the Mass Deworming for all vulnerable groups
in the Pilot (Rs. 10 for 2 times). DWCD may get albendazole for much lower rates from
its own Pharma Companies or from LOWCOST, Baroda. .Although Zentel (400 mg
albendazole sells at Rs.5/ tablet. I have known SmithKline Beecham to have a social
conscience. They may give Zentel at much lower rates.
• The mother will receive a one-time plastic volumetric measure to make up the child’s
feed properly (and not dilute it as the Anganwadi Worker or Care Giver usually do).
She will also receive an air-tight container to stock the 15 packets of the child’s RTE
I
f
I
i
!
I
ration (Rs.20). The Integtrated Nutrition Health Days (INHP) will be held 2 times a
month.
• Another Rs.20/ annum will be set aside for items such as carbolic soap, detergents,
washing powder etc.
• She will receive 2 ORS packets if required (About Rs. 10).
• The remaining Rs.50/ annum will go into a Corpus Fund, which will be used for
emergencies, that is, transportation to PHC/ hospitals etc. This is only for the ‘Under
Threes' age group.
i
3.7. The main plank and focus of the Nutrition-Health-Education will be on demonstration
of how the RTE is to be reconstituted, feeding demonstrations of infants 6.9,12.15 and 18
months of age. Demonstrations of what medicine are to be administered when and why.
3.8. Important behaviours to address would be child care (exclusive breastfeeding, timely
introduction of complementary food, home preparation of appropriate complementary
foods, treatment of diarrhea with breastmilk. ORS and improved sanitation/ hygiene. Selfcare prior to pregnancy, during pregnancy and lactation, and during the inter-pregnancy
period (improved diets for adolescents, more equitable gender distribution of high-quality
foods in the household, increased intake of energy and micronutrient-rich foods especially
during pregnancy and lactation, delay of first pregnancy or of marriage, and adequate birth
spacing)
3.9. Since the Delivery System has to be ‘Take-Home’, inspite of some sharing of all inputs,
this is the only system that reaches the infant/ toddler in his home. Hence, the
adolescent girl (hopefully with atleast Primary School education), will be made the Monitor
for 5 households having ‘Under Twos'. This will not only be Learning by doing experience,
but will also limit the “sharing” element. The induction of Adolescent Girls as ‘Watch
dogs' is an innovation in itself. If may or may not work. But most illiterate mothers do
respect ‘learning’ whether the giver is young or old.
3.10. The Schooler (Primary and Secondary’ Grade) makes the best NHE educator for his family.
She/ he should be brought Centre Stage to disseminate and demonstrate to the family simple
and double practices. The NHE and EC reach will be tremendous. Parents do not listen to
^i’*siders (the AWW or ANM). They do and will listen to their son or daughter.
3.11. The parents in turn have to make a commitment to feed one banana or some seasonal fruit
every day to the index child at the very7 least. They must also commit to give 200ml of milk
over and above Breast Milk.
3.12. Lastly, couples that have limited their families to 2 children - should be made much
of. In fact only the children of the most fertile age group of ‘15-24 years’ women
should be enrolled in the ICDS. Although, hard-hearted, there is not much point in
enrolling children from large families. At some point irresponsible parents have to
get the message of a “small family norm”. This will be a bold experiment in the
convergence of Population, Health and Nutrition (PHN).
3.13. Details on how to Implement the Integrated Nutrition Health Days for the Pilot
Project:
•
•
The Delivery System has to be a ‘Take-Home-Ration’ or THR (refer point 2.7).
Village Community Agents (CCA)/ have to be identified and trained in each ICDS village.
These could be the Adolescent Girls.
Q5
On a pre-set date Health (ANM), Non-Health (ICDS Supervisors), AWW and Helper
will meet at the AWC 2 times a month.
• The Community Change Agents (CCAs) will identify and round up all the eligible ‘Under
Twos’ on the specified day, date and time at the AWC. The Adolescent Girls can be
recruited as the CCAs. In a village of 1000, there would be about 45 ‘Under Twos'. Hence
the 45 Mothers with their Index Infant/ Toddler and the Containers for the THR will
assemble at the AWC. Each child will be quickly weighed and his weight plotted. The
mother will be told where her Index child stands. The mothers/ CCAs will help in
distributing the THRs for the Index child only. The Supplementary Food will be
demarcated by colour - so that wrong distributions do not take place. This will be
followed by actual reconstitution and feeding of the RTE to a volunteer mother + volunteer
• demonstration baby. Proper Volumetric Measures will be supplied to the AWC, for the
‘Under Twos’. The Index child will set 15 individual packets of THR rations, one for each
day. The mother of the Index child will get a one time plastic box to hold the 15 RTE
packets and a volumetric measure for the water.
• Other ‘Care Giving’ Messages as elegantly enunciated by Engle (16) will also form the
part of the NHE.
• On this day, date (usually the 1st and 4th Saturday of the month), the older children
will not come to the AWC and will stay at home. The Index child will be in focus.
• On the other two Saturdays, the same procedure will be repeated for the Pregnant/
Lactating women (Chapter Three and Four).
• The mother has to put down Re. 1 for a feeling of ownership; and as a token for paying for
services.
• It has worked very well in the 7 States where CARE-India works, Please see Table 3
attached.
• Other ‘Care Giving’ Messages as elegantly enunciated by Engle (16) will also form the part
•
of the NHE.
3.14. Baseline Assessment Survey:
NIPCCD or a professional agency under the guidance of an evaluation expert in this field
will conduct an independent Baseline Assessment Survey. From September 1st to
December 1st, 2000. Impressionistic data will be in by 1st January, 2000. Concurrently
the same agency will collect and collate data from the ICDS registers of the selected
ICDS Projects. (Monitorirg ^r Process for the same period of the Baseline Assessment).
Please refer Chapter Seven, for details on Monitoring and Evaluation.
3.15. Time Frame: Intervention should commence form 1st January 2001 to 2003.
3.16. Type and Number of Beneficiaries:
Total no. of ‘Under Threes’ in Chikmagalur =30,000 {rounded off to the neaest 10,000)
Total no. of ‘Under Threes’ in Gulbarga
= 90,000
Total no. of ‘Under Threes’ in Raichur
= 40,000
Total no. of ‘Under Threes’ in Tumkur
= 70,000
2,30,000
Type of Delivery System: It will be closely supervised ‘Take-Home-Ration” system.
All the ‘Under Threes’ will get their THR 7 days a week or 365 days/ year. They have to
get the other medicines. ORS, deworming etc. inputs described earlier at Rs. 100/ annum.
3.17. Cost:
i.
i
The cost of the improved SNP at Rs.2.00/ child/ day x 2.3 lakhs beneficiaries
GG
ii.
iii.
iv.
X 365 feeding days/ year = Rs. 16.79 crores/ annum x years = Rs.33.58 crores.
Other inputs such as common medicines i.e., deworming tablets, anti-maiarials and ORS
packets etc. at Rs. 100/ child/ annum = Rs.2.30 crores/ annum x 2years = 4.6 crores.
Cost of the corpus fund at Rs.50/ child/ year x 2 years x 2,30,000 children = 2.3 crores
Total of (ii) and (iii) 6.9 crores.
33.58 crores
Approximate cost to DWCD =
Approximate cost to DHFW =
6.90 cores
Total =
39.48 crores
Or rounded off
40 crores.
REFRENCES
1. Tara Gopaldas & Sunder Gujral
USAID assisted ICDS Impact Evaluation Project in Panchamahals (Gujrat) and Chandrapur
(Maharashtra); MS.University, Baroda. 1991.
2. Planning Commision Evaluation Report on the ICDS (1976-78), New Delhi, India. Planning
Evaluation Organization, New Delhi. 1982.
3. National Evaluation of the ICDS.
Development, New Delhi, 1992.
National Institute of Public Co-operation and child
4. Tara Gopaldas and Sunder Gujral
Addressing Nutritional Gaps in Children Under Two in Rural India, CARE India; 1998.
5. a. Gopaldas T etal:
Project Poshak. Vol.One, and 1975, printed by CARE-India, New Delhi.
b. Gopaldas T etal:
Project Poshak. Vol. Two 1975, printed by CARE-India. New Delhi.
6. Tara Gopaldas
Fighting infant malnutritin with amylase-rich complementary foods; Nutriview 1998.
7. Gopaldas T and Deshpande S:
The Miracle of Germinated Cereal Grain Powders. Daya Publishing House. Delhi. 1992.
8. Mujoo R:
Studies on Commercial Barley Malt. Unpublished Ph.D.results, 1993.
9. Tajjuddin K.M:
Studies on Nutritional Rehabilitation with ARE. Unpublished Ph.D results, 1990.
10. Gopaldas T, John C:
Evaluation of a controlled six months feeding trial on intake by infants and toddlers fed a
high-energy, low-bulk grul, J.Trop Paediatr 1992; 38: 278-283.
11. John C. Gopaldas T;
Evaluation of the impact on growth of a controlled six-months feeding trial on children (6-24
months) fed a complementary of a high-energy, low-bulk gruel versus a high energy, high
bulk gruel in addition to their habitual home diet. J Trop Paediatr 1993; 39: 16-22.
12. Johri N:
CARE-India’s Nutrition and Health Sector Program update, 1998.
13. Johri N:
CARE-India’s INHP Results Repons. Achievements versus Plans (FY 1997 VS FY 1996)
1998.
14. Pillai G:
CARE-India's Integrated Nutrition and Health Program (1995-2000)
15. A Critical Link : Interventions for physical growth and psychological development.
review. WHO/ CHS/ CAH/ 1999.
A
16. Engle PL. The Care Initiative: assessment, analysis and action to improve care for nutrition.
New York. UNICEF. 1997.
Table 1 : A Ready-To-Reconstitute “Take-Home” ration for children below three years of
age, providing about 400 kcal energy + 12g protein for the child, as well as the complete
RDA of key micronutrients.
Item
Ragi or rice flour_____________
Green gram flour_____________
Sugar______________________
Commercial Barley Malt Powder
Total*
Infants 6-24 months
_______ (g)_______
_______60________
_______ 20________
_______ 16________
________ 4________
100
* Plus micronutrient mix: calcium (500mg), iron (20mg), zinc (5mg), retinol (500|ig), thiamin
(0.9mg), riboflavin (Img), nicotinic acid (1 Img), pyridoxine (0.9mg), ascorbic acid (40mg),
folic acid (30pg) vitamin B-12 (Ipg). (ICMR, 1992).
Manufacturer : Jeevee Foods Pvt. Ltd.. Bangalore.
Table 2: A Ready-To-Reconstitute “Take-Home” ration for children below two years of
age, providing about 380 kcal energy + 14-15g protein for the child, as well as the
complete RDA of key micronutrientss.
per 100g
Wheat/ maize/ Bajra flour______________
Malted Ragi Flour_____________________
B.G.Dhal flour_______________________
Edible Groundnut/ Edible low fat soya flour
Powdered Jaggery_____________________
Vitamin/ Mineral Premix_______________
Total
35g
5g
12g
17g
30g
lg
100g
Calcium (lgm7. iron (40mg), niacin (5mg). vitamin B-12 (O.Spg), vitamin Bl (0.6mg), vitamin
B-2 (0.8 mg), folic acid (10pg), vitamin A (1500 IU)
Manufacturer : Karnataka State Agro Com Products Ltd.
Note :
(i)
(ii)
(iii)
The differences in the levels of micronutrients added should be noted. It should
be made mandatory that all Weaning Food/ Complementary Food
Manufacturers add the micronutrients as prescribed for a 2-year-old Indian child
(ICMR, 1992).
Although there is no danger of any vitamin/ mineral being dangerous/ toxic to
the infant/ toddler, at the levels used in either Table 1 or Table 2, we feel a little
more uniformity in the micronutrient mixes used, should be insisted upon.
Manufacturers of such mixes will also find it much easier to produce one mix. It
will also be cheaper.
<53
Table 3: Improvement in Selected Nutrition Performance Indicators in
CARE-INHP Project
All States
Performance
Indicator (Results
for Q4-HI)
MP
UP
Final
1997
Baseline
1996
Final
1997
Baseline
1996
Final
1997
Baseline
1996
Final
1997
Baseline
1996
68
41
87
57
NA
11
72
22
Feeding %
within 6/8 65
35
33
29
NA
66
43
8
46
62
56
NA
49
NA
52
Supplementary
Nutrition %
6-24 months
(past 2 days)
Breast
giving
hours
AP
Complementary
Feeding % 6-10
months giving
mushy foods
(Amount not
specified)
75
Source: INHP : Integrated Nutrition Health Programme.
CHAPTER FOUR: SELF HELP GROUPS (SHGS) OF WOMEN TO
MAKE SUPPLEMENTARY FOODS FOR THE 3-6 YEARS AGE
GROUP IN THE LCDS
4.1. Introduction : The self-help-groups of women are not in place. Hence, till they are, it will
be rather premature to give a strategy for the same. Until such time, the 3-6 year old ICDS
beneficiaries in the 4 Pilot Project Districts will receive whatever they were getting to date.
The children will also be mass-dewormed twice a year. They will get vitaminA mega dose
two times a year.
In Gulbarga a well-known NGO. namely, MYRADA is operating in a big way. Please
see Annexure One of this chapter for details as to why MYRADA may be a good choice. It
may noted that MYRADA's largest number of partners are Self Help Groups (3547 out of
5744 partners). Although they have not specifically managed a Nutrition-related-project,
their organizational, training and management skills are very evident. It has had the
financial support of Ford Foundation, the Swiss Agency for Development and Cooperation
(SDC), German Agro Action, CIDA/ HIDA. It has a committed and well-trained staff. It is
hoped that they will manage the SHGs and operate this venture both for the ICDS and
the Open market. In the case of poor income and poor literacy groups, it is the lack of
Numericaffy, and the total lack of Management Skills that has brought many such ventures
to a short and sad end. (Please refer Table one which shows that several such ventures have
been tried from village to the Centrally Processed Scale (CPS). It is the CPS that has
survived.
4.2 Specific Intervention: A weekly and cyclic menu within the ration limit of 100g of cereal
pulse per beneficiary/ feeding day will be adhered to. These items as well as other items such
as sugar, jaggery, condiments and oil will have to be purchased by the SHGs on a ‘Micro
Credit System’. Provided they supply the required quantity as per weekly indent from the
ICDS centres, they will be permitted to sell the excess at a higher rate in the open
market. The SNP rate per ICDS pre-Schooler (3-6 years) would be the same R.2/
beneficiary/ feeding day. The emphasis will be on units of consumption namely, ladoos,
muddes. chappatis. iddlis with much less pilferage in this system. It will also free the AWWs
and Helpers from the daily and time consuming task of cooking the SNP.
4.3 Micro-credit will be given to the woman at a maximum of Rs.20.000/ enterprise.
4.4. ‘Add On’ of the Micronutrients:
The RDA of micronutrients for the ‘3-6 year old’ in sachets to fortify lOkgs of the the said
item, (raw ingredients) will be supplied by a reputed supplier on the open tender system.
This amount will be required per AWC on the assumption that 100 preshoolers will be fed.
Since, it is expected that about 80 ‘3-6 year old’s should be at the AWC at the feeding time.
100 ladoos. 100 big chappatis. 100 ragi muddes. 100 servings of upittu. etc will be made. The
‘Add On' will be added at the intermediate state (atta dough, iddili batter, ragi mudde; or at
the last stage for upittu. ladoo etc.) Although there will be some loss in the micronutrients,
yet, it is hoped that atleast 30-50% of the much needed RDA, will go into the child.
The expenise of MI in Small Scale Mill Fortification will be utilized.
4.5. Number and Type of Beneficiary:
The ‘3-6 years old’ in the Gulbarga ICDS = 86137
Since, many more than those who should be fed are fed in this category, we have
rounded off the figure to 1,00.000.
The total number of ‘Above threes’ in the 4 Pilot Districts are about 2-4 lakhs in
(ii)
number.
4.6. Time Frame:
January lsl, 2001 to January lsl 2003.
(i)
'll
4.7. Cost: Only for SNP (Gulbarga):
(i)
(i)
(ii)
(iii)
(iv)
One lakh ICDS preschoolers X 300 feeding days X Rs.2/ ration X 2 years = Rs. 12
crores. Only for Gulbarga.
Common medicines etc. for 4 Pilot Districts (same as for the Under Three) at Rs. 100
per child/ annum X 2 Years x 2.40 lakh beneficiaries = Rs.4.8 crores.
Baseline Assessment and Pre-Post Evaluation = Rs. 10 lakhs.
Research Studies on loss in Micros by the colleges of Home-Science = Rs.10 lakhs.
Training and Managerial Costs to Myrada = Rs. 20 lakhs.
Total = Rs. 12 crores + Rs.4.80 crores + 0.40 crores = Rs. 17.20 crores.
Table 1 : Protein enriched RTEs for infants, toddlers and pre-school children at the
community and industrial level :
REFERENCE
PRODUCT
INGREDIENTS
COMMUNITY LEVEL :
1. Pasricha et al (1973)
Ready-to-mix powder
60g cereal (wheat, bajari or
ragi) 15g pulse (roasted
bengal-gram). an oilseed and
40g sugar/jaggery.
2. Devadas et al (1974)
Weaning mix
Cereal (cholum. ragi or
maize), pulse (roasted
grrengram or bengal gram
dal) oil seed (roasted
groundnut) and jaggery.
3. Gopaldas et al (1975)
Poshak (a)
Cereal (wheat, maize, rice or
jowar), pulse (chana dal or
mung dal), an oil seed
(groundnut) and jaggery in
the proportion of 4:2:1:2
Poshak (b)
Same ingredients as Poshak
(a) but in the proportion of
60:17:14:9
4. Rau et al (1975)
Extruded RTE
85g com soya milk (CSM)
and 15g salad oil.
5. Chandrashekhara et al
(1976)
Kerala indigenous food (KIF)
Tapioca rava. soya fortified
bulgar wheat (SEE) rava and
groundnut flour.
Ready-to-consume mixture
Roasted cereal (cholam.
maize, ragi or bajra). Pulse
(roasted or sprouted
bengalgram. greengram or
foxgram), oil seed
(groundnut,
groundnut/sesame cake
flour.)
6. ICMR(1977)
ANNEXURE ONE (EXCERPTS) ON THE PROFILE OF MYRADA (1999)
MYRADA was started in 1968. In Karnataka, staff has been deputed on a long-term basis to the
Women’s Development Corporation. Belgaum Zilla Parishad and to Regional Rural Banks. MYRADA
has initiated a District strategy through a network of NGOs. and the support of Regional Rural Banks
(RRBs) and private institutions to foster Self-Help Groups and to promote Watershed Management and
technical support for off-farm livelihood sources. MYRADA has emerged as a major training resource.
On average 4700 training programmes are conducted annually, 90% for our people and the rest for NGOs.
Bankers and Government officials.
Our Partners:
The following institutions are the primary partners of MYRADA.
Self Help Groups_______________________________________
Watershed Development Associations_______________________
Apex Bodies___________________________________
Village Development Committees/ Councils___________________
School Better Committees/ Parents Teacher Assn_______________
Village Water and Sanitation Committees_____________________
Village Progressive Farmers Association______________________
Children’s Clubs________________________________________
Village Forest Committees________________________________
Village Health Committees________________________________
Others
Total
3547
129
65
84
305
112
_ 10
261
296
__ 18
917
5744
Our Staff:
In 1990 MYRADA had 699 staff. The numbers declined to 460 in March 1999. Groups are taking over many
of the functions earlier performed by MYRADA. Besides. MYRADA’s interventions have become more
strategic in recent years; this requires fewer but experienced staff. There are over 1500 volunteers trained in
health care, animal husbandry, forestry, literacy and other relevant areas who provide services in project areas,
enabling MYRADA to withdraw. 98% of MYRADA’s staff come from the rural areas; they are graduates or
post graduates. MYRADA has invested over Rs. 12 million in training staff during the past 14 years with the
suppon of the Ford Foundation. Swiss Agency for Development and Co-operation (SDC). German Agro
Action and CID A/ HIDA. MYRADA looks for and develops the following qualities in its staff: commitment,
professionalism, innovativeness and the ability to work in a participatory manner.
FIVE OUT OF TEN CRITICAL AREAS OF MYRADA
RELEVENT TO OUR PROPOSAL
1.
Identifying and fostering affinity groups : Since l°84-85 MYRADA has fostered SHGs of the rural poor.
These groups not only manage credit, they also pro/ide space for the poor to grow skills and in confidence to
make decisions regarding their lives.
2.
A focus on women and children: MYRADA adopts the SHG strategy for women’s empowerment and invest
heavily in formal and non-formal education for school going children and dropouts, with a basis towards the
girl child.
3.
District Strategy: During 1998. the District was identified as a suitable operational area. MYRADA's district
strategy (initially in three districts Gulbarga, Chitradurga and Mysore) rests on three thrusts or pillars:
(i) Provision of credit (ii) Microwatershed management (iii) Off-Farm enterprise
4.
MYRADA has not actively promoted itself as a Training Resource.
5.
OfT-Farm IGPs. MYRADA. like most NGO’s. is weak in design and marketing; it therefore linked up with
Industnes. which provide suppon in these areas, while it built up the capacity of the poor to cope with
organisational demands and quality control.
'-T5
CHAPTER FIVE: THE ADOLESCENT GIRL IN THE ICDS
5.1. Introduction : This group is not a regular beneficiary of the ICDS. The Pilot Project will
for the first time include this age group. To the extent possible school-dropouts (12-18
years of age) will be recruited. About 10 adolescents per village of 1000 population will
have to be recruited at the rate of one girl to supervise and oversee the THR of five ‘Under Twos’, the Pregnant/ Lactating woman. The girl will receive a token honorarium of Rs.200
per month. The main focus will be on her taking over as a Helper or Anganwadi Worker
later on. Capacity building by on the job-training and demonstrations, will be the key in
building up her efficiency and confidence.
. The Situational Analysis data (1999 NNMB-Repeat Survey Data) show that the adolescent
girl is actually consuming more calories than she needs. She is more or less OK for protein
and calcium too. However, like the other vulnerable groups, what she needs is more iron,
much more vitamin A. a little more of the B-complex vitamins and vitamin C (to enhance
her Hb levels). Consequently, she will receive a multi-vitamin-mineral tablet to meet her
RDA. She will also receive the bi-annual deworming along with the other vulnerable
groups of the ICDS. Since she will be a active helper in the 4 monthly THR days, she will
receive practical NHE; and also how to keep her self and her reproductive health in better
shape.
5.2. Baseline Assessment Survey ;
Since not much information is available regarding this group, a Baseline Assessment Survey
will be done from August, 2000 onwards. Impressionistic data should be in by January
2001.
5.3. Time Frame :
The Intervention should commence from 1st January 2001 to 1st January 2003.
5.4. Type and Number of Beneficiarie:
Adolescent Girl Helper/ Trainees in Chikmagalur
Adolescent Girl Helper/ Trainees in Gulbarga
Adolescent Girl Helper/ Trainees in Raichur
Adolescent Girl Helper/ Trainees in Tumkur
No.
6,000
18,000
8,000
14,000
46,000
Note: This is based on each Helper/ Trainee being in charge of 5 ‘Under Threes’. Their
mothers will also be supervised. The Trainee has to demonstrate her mettle in ensuring that
sharing is kept to the minimum in the THR situation.
5.5. Cost:
(i)
(ii)
(iii)
(iv)
Cost of a complete vitamin-mineral tablet to cover the adolescent’s micro-nutrient
deficiency at Re.l per micronutrient tablet X Rs.365 per beneficiary per annum x 2 year
intervention x 46,000 beneficiaries = Rs. 3.36 crores.
Cost of common drugs, cheap yet clean cloth in lieu of sanitary napkins, soap, detergents
etc at Rs. 150/ Trainee X 2 years 46,000 = Rs. 1.38 crores.
Cost of Nutrition-Health-Education. On-the-job-training and Capacity Building at R.100/
adolescent girl for 2 years x 46,000 = Rs.92 lakhs.
Baseline Assessment and Pre-Post Survey = A total Adhoc Grant of Rs.30 lakhs
Total cost of the Adolescent Girls Intervention would be about Rs. 6 crores.
7^
REFERENCES
1. Tara Gopaldas, An Information-Education-Communication (EEC) Project for Working Girls
(18-23 Years) on Cultural Dietary Practices to Increase the Iron Content of their Every-DayDiets, Tara Consultancy Services, Bangalore. 2000.
2. Shubhada Kanani etal. Nutritional Anemia: A Problem in Search of a Solution -— Even
Today. University Deartment of Foods and Nutrition and Baroda Citizen’s Council, 1998.
• 3. Shubhada Kanani etal. The Impact of Iron Supplementation on Appetite and Growth of
Adolescent Girls of Vadodara. University Department of Foods and Nutrition and the
Baroda Citizen’s Council, 1998.
4. WHO (1989). WHO/ UNFPA/ UNICEF Statement. The Reproductive Health of
Adolescents. Geneva, WHO, 1989.
5. ICMR. A National Collaborative Study of Identification of High Risk Families. Mothers and
Outcome of their offsprings with Particular Reference to the Problem of Maternal Nutrition.
LBW, Perintal and Infant Mortality in Rural and Urban Slum Communities. ICMR, New
Delhi, 1990.
6. Gopalan C, Motherhood in early adolescence in Combating Undernutrition. Special
Publication Series 3. New Delhi NFL 304-305.
7. Huffman SL, Baker J, Schumann J, Zehner ER. The case for promoting multiple vitamin/
mineral supplements for Women of Reproductive Age in Developing Countries.
LINKAGES PROJECT of AED. USA. 1998.
75
CHAPTER SIX: THE PREGNANT/ LACTATING WOMAN
IN THEICDS
6.1.Introduction: There would be approximately 1.4 lakhs of Pregnant and Lactating women in
the ICDS of the 4 Pilot Districts. These two categories will also be included in the ‘TakeHome-Ration' Delivery System.
6.2. Specific Supplementary Food Interventions:
The Pregnant/ Lactating woman is presently getting 140 g of the local cereal with some
pulse in the ICDS. However, what she needs to get is less of cereal, but her entire RDA of
vitamins & minerals. Hence, the ‘Take-Home-Ration' can consist of an energy bar, made
out of the local cereal. local pulse, groundnuts and the ‘Add On’ of the Pregnant/ Lactating
Woman's entire RDA. Thie Energy Bar would deliver 400kcal + 25g protein per feeding
day. However, what the Pregnant/ Lactating -ICDS beneficiaries need even more is their
large quota of vitamins and minerals. Please see Table 4 for the Pregnant/Lactating
woman (higher value has been taken) for her ‘micro + macro' requirements. The commodity
Change Agent (CCA) and/ or the ‘Watch-dog-adolescent girl’ should try and ensure that the
targeted beneficiary consumes this ICDS supplementary ration, and does not share it with
other family members.
6.3. If the woman prefers an “add on of her vitamins/ minerals" to her morning kanjee or tea
rather than an Energy Bar, this would be infinitely simpler and should be tried out. In this
case, she will also receive 3kgs of local staple + 15 sachets of the ‘micros'. Since some
‘sharing’ is bound to take place, at least one can ensure she gets her iron, vitaminC. calcium,
folic acid, vitamin B-12 and riboflavin. In short, she will get 6kgs of staple + 30 sachets per
month. The Integrated Nutrition Health Days will be held on the alternate Saturdays. As in
the case of the “Under Threes”, she will bring her containers for the ‘Take-Home-Ration’
and her one-time-box for the sachets. The AWC will be kept free for the woman only. She
will put down her Re. 1 for services rendered.
6.4. Everything else will be similar as described for the “Under Threes'.
6.5. In the case of the Pregnant/Lactating group, a woman doctor could be in attendance for
counselling and for giving specific advice on birth-control. If the woman wants a terminal
method (which is what most woman want after tneir second child) she should be helped in
this.
6.6. The Pregnant/ Lactating-INHP day can be combined with the sale or the give-away of such
medicines/ sanitary requirements specifically required for reproductive health. She would
also require common medicines such as paracetamol, anti-diarrhoeals. anti-malarials. ORS,
etc as listed for her child. She could also be given carbolic soap (to keep herself clean and for
breast hygiene), detergents, washing powder etc. Re. 150/ annum can be set aside for the
above.
6.7. The mother will also participate in the bi-annual deworming campaign.
6.8. If the woman is a lactating mother, she can receive 2.00,000 IU vitamin A post-partum dose
within from 4-40 days of delivery.
6.9. The NHE will be given to her, mostly concentrating on eating more home food, doing less
hard work, more rest, and ‘demos’. The adolescent girls and trained TBAs should also
attend.
6.10.Baseline and Pre-Post Evaluation:
The same agency that did the Karnataka Nutrition Profile, can be hired to do the above.
6.11.Time Frame : Intervention should commence from 1st January 2001 to 1st Jan 2003.
6.12. Type and Number of beneficiaries by District
Type (P/L)
Chikmagalur
Gulbarga
Raichur
Tumkur
Total
Nos.
11165
63973
32981
30959
1,38,778 or about 1.4 lakh beneficiaries.
6.13. Cost
(i)
1.4 lakhs Pregnant/Lactating women at Rs.2/ feeding X 365 days X 2 years = Rs.20.044
crores.
(ii)
1.4 lakhs Pregnant/Lactating women at Rs. 100/ woman/ annum for common medicines/
RCH health/ etc. X 2 years = Rs.2.80 crores. (This will be borne by DHFW).
(iii)
Baseline Assessment. Pre-Post Evaluation = Rs.20 lakhs.
Total cost is Rs.23.20 crores.
REFERENCES
1. Strategy for Elimination of Micronutrient Malnutrition in India. Proceedings of the
Workshops held in Jaipur. DWCD, GOI in Collaboration with MI and UNICEF, 1995.
2. Seshadri S etal. Non-Cognitive barriers to compliance with iron supplementation. University
Department of Foods and Nutrition, M.S.University, 2000.
3. Sheshadri etal. Control of Nutritional Anaemia in Pregnancy the Imapct of Decentralized
Delivery of Iron Supplements and Counselling on Coverage. Compliance and Kb Levels.
Department of Foods and Nutrition, M.S.University, 1999.
4. Improving Adolescent and Maternal Nutrition: An Overview of Benefits and Options. A
working Paper of the Programme Division of UNICEF. No. 97-002. 1997.
5. A UNICEF Nutrition Information Strategy. Improving Decesion-Making at Household,
Community and National Levels. A Working Paper. Thematic Series. No. PD-98-004.
1998.
6. Preventing Iron Deficiency in Women and Children. Background and Consensus on Key
Technical Issues and Resources for Advocacy. Planning and Implementing National
Programmes. Co-published by: International Nutrition foundation and Micronutrient
Initiative, 1998.
77
CHAPTER SEVEN: SAFE WATER AT ALL THE PROJECT AWCS:
7.1. Introduction:
Apart from safe and clean water (atleast for drinking purposes) water is a fundamental and
human right. It is also a vital and essential FOOD. Consequently, the Pilot Project in the 4
districts with a total 7168 Anganwadi Centres, will accord high priority to atleast (i) one tap
for drinking purposes; (ii) one for washing the ICDS utensils; and (iii) one (need not be potable)
but plentiful for the pour-bucket-of-water-latrine. All three sources, particularly (i & ii) will be
tested periodicaily.
7.2. Baseline Assessmnet: and Pre-Post Evaluation will be done.
7.3. Time Frame: January 1st, 2001 to January 1SI, 2003.
7.4. Type and Number of Beneficiaries:
The number of AWCs in the 4 Pilot Project districts are as under:
Chikmagalur
Gulbarga
Raichur
Tumkur
Total
=
1179 AWCs
2350 AWCs
1304 AWCs
2335 AWCs
7168 AWCs
7J. Cost:
(i)
It is difficult to assign a cost. An adhoc one time cost of Rs. 10,000 for the installation of
the 3 taps (probably from a deep bore well) + Rs.5000 for annual maintenance has been
provided.
(ii)
A cost of R.45,000 for the one time construction of a low-cost, deep pit and pour-bucket
latrine will be constructed. Rs.5000/ p.a. will be set aside as maintenance cost.
(iii)
Water safety testing kit every year + analyst at Rs.500/ annum/AWC.
(iv)
Total cost for the Project Period would be : Capital cost Rs.1,45,000
Recurring every year (average) would be : 25,000/ AWC.
Consequently the one-time cost for 7168 AWCs at Rs.1,45,000 will be Rs.10 crores.
Consequently the recurring cost for 7168 AWCs at Rs.25,000 x 7168/ annum will be
2 crores/ annum or Rs.2 crores for 2 years of Project.
A capital cost of Rs.10 crores to be made.
A recurring cost of Rs.4 crores to be made for 2 years of the Project.
REFRENCES
1. Touching Lives Across Borders. Water and Sanitation Programme for the South Asia
Region, 2000. Funders are from several developed countries of the world, UNDP & WB.
CHAPTER EIGHT: HASS DEWORMING OF ALL ICDS
BENEFICIARIES
Introduction:
Recent studies among Working Girls in peri-urban Bangalore (1), among plantation workers in
Chikmagalur District (2) and among school children for free Municipal Schools in Gujarat (3,4,)
and elsewhere(5-9) have clearly shown the high prevalence and incidence of all worms, not
only hook-worms, on negative overall nutritional status, the iron status, and vitaminA status of
the vulnerable groups in question.
8.1. Intervention:
It may be noted from chapters 2,3,4 and 5 that it is intended to cover all the
(i)
vulnerable groups in all the ICDS Projects for bi-annual deworming.
All staff in the ICDS, especially the AWWs^Helpers will also get the treatment along
(ii)
with the ICDS beneficiaries.
(iii) All members of families in the most dis-advantaged sections of a village, where caste is
still very predominant, will receive the deworming.
All members of families (will overlap with iii) in ‘kucha’ dwellings with mud floors will
(iv)
be eligible for deworming.
The remaining populations will be encouraged to buy the deworming tablets from the
(v)
open market.
Deworming has to be done only 2 times a year, 6 months apart. It will be done in the
(vi)
campaign mode. The Panchayat and the ICDS staff will take full responsibility for the
deworming campaigns.
8.2.Number and Type of Beneficiaries:
About 10 lakhs in the ICDS (Under 3s. Above 3s, Adolescent girls, P/ L Women) plus all
AWWs + disadvantaged families in all the ICDS projects of 4 Pilot Districts.
8.3. Time Frame: Since the cost effectiveness of deworming is well established the first
campaign could be launched on 15th August. 2000. The next campaign could be planned for
February 15^2001 and so on until lsl January 2003.
8.4. Cost of Product and Cost
(i)
The approximate number of beneficiaries (ICDS) + staff + most disadvantaged families
has been taken to be about 10 lakhs.
(ii)
The cost of albendazole in bulk order should not be more than Rs.5/ tablet (400 mg).
Again the open tender system will be followed.
(iii)
Consequently the approximate cost of this essential intervention will be = 10,00.000
(target population) x Rs.5 (cost of 1 tablet) x 2 times = Rs.l crore/ annum.
(iv)
Therefore for 2 years of the Pilot Project the cost of the deworming drug will be = Rs.2
crores.
(v)
Rubber chappals will be sold at subsidizsed cost (cost of subsidy Rs.20/ subject/ year) =
.20 xlO lakhs beneficiaries = Rs.2 crore.
^9
ft
?
(vi)
The cost of evaluation (by questioning for prevalnence of worms) and by Hb status (Pre
and Post) will be included in the evaluations of the ICDS beneficiaries, namely,
the'Under Twos’, the 3-6 year olds, the adolescent girls, and the Pregnant/ Lactating
women.
The Total Cost of the Deworming + chappal intervention will be Rs. 4 crores.
REFERENCES
1. Tara Gopaldas:
An Information-Education-Communication(IEC) Project for Working Girls (18-23 years) on
Cultural Dietary Practices to Increase the Iron Content of their Every-Day-Diets. 2000.
1. Tara Gopaldas and Sunder Gujral:
A Multinutrient Package for Tea Plantation Workers for Better Health. Productivity and
profitabilty.
2. Tara Gopaldas & Sunder Gujral:
The Pre-Post Impact Evaluation of the Improved Mid-Day-Meal Programme. Gujarat (1994
-Continuing): Tara Consultancy Services. Baroda, India, 1996.
3. Nokes C and Bundy :
Compliance and absenteeism in school children implications for helmith control, Trans
Royal Soc Trop Med Hyg 87: 145-152, 1993.
4. Tara Gopaldas:
More nutrients, fwer parasites, better learning; Public Health Practice; World Health Forum
Vol 17,1996.
5. Warren KS, Bundy DAP, Anderson RM. Davis AR, Henderson DA, Jamison DT,
Prescott N and Seuft A:
Helminth infection. In: Jamison DT. Mosley WH, Measham AR. Bobadella IL 'Eds) Disease
control priorities in developing countries. Oxford University Press. Washington DC USA
pp 131-160,1993.
6. Atukorala TMS, De Silva LDR, Dechering WHJC, Dassenaike TSC, Perere RS:
Evaluation of effectiveness of iron-folate supplementation and anthelmintic therapy against
anemia in pregnancy - a study in the plantation sector of Sri Lanka. Am J Clin Nutr. 60, 286292,1994.
7. S to Ifus RJ, Chwaya HM, Tielsch JM, Schulze KI, Albonico IM, Savioli L:
Epidemiology of iron deficiency anemia in Zanzibari school children: the importance of
hookworms: Am J Clin Nutr, 65, 153-159, 1997.
8. Bundy DAP, Kan SP, Ross R:
Age related prevalence, intensity and frequency of distribution of gastrointestinal helminthic
infections in urban slum children from Kuala Lumpur. Malaysia: Trans Roy Soc Trop Med
Hyg : 82, 289-294, 1988.
CHAPTER NINE: ENRICHMENT OR FORTIFICATION OF
DOUBLE TONED MILK IN ALL THE DAIRIES OF KARNATAKA
i
9.1. Introduction/ Strategy:
The Situational Analysis has clearly shown that Karnataka as a State is most deficient in
VitaminA. On the basis of an average per capita consumption of 50ml a day with lOug of
vitamin A per ml with vitamin A palmitate will deliver 500ug vitaminA/ subject. The
dairies of Gulbarga , Tumkur and Raichur will be persuaded to do this. The three districts
have a daily production of about 500 lakh litres/ day. Even at just 100 lakh litres being the
daily production of double-toned-milk which is bought by the poor, would be the most
feasible method of delivering vitaminA to the needy populations at large. If the ICDS can
afford to give the ‘Above 3s’ atleast 50 mi of double toned milk at the AWCS, this will add
a much nerrfed 500|ig to the child’s everyday diet. Logistics may be the problem.
This will be offered through the open market and not the ICDS.
9.2. Baseline Assessment and Pre-Post Intervention Evaluation:
Evaluation of random samples of milk for the vitaminA content/ ml milk. HPLC
(i)
is very expensive but accurate. CFTRI could be approached. About Rs.6 lakhs.
A Pre-Post Evaluation could be done by CFTRI. The Market Research by a
(ii)
reputed Technical Agency.
Cost
of Evaluation is relatively expensive, but necessary , especially in a newly
(iii)
tested innovation as in the above.
93. Number and Type of Beneficiaries: All those who buy the double toned and enriched milk
in Gulbarga, Tumkur and Raichur will benefit.
i
9.4. Time Frame: whenever the dairies are ready to enrich the double-toned milk with
vitaminA. Tentatively January 1* 2000 to January lsl, 2003.
9.5. Cost:
Cost of fortification of 1000 litres = Rs.31
Cost of fortifying one lakh litres would be = Rs.3100
Cost of fortifying 100 lakh litres would be - Rs.3,10.000 (about Rs. 3 lakhs)
This is a relatively small sum, which can be absorbed by the dairies themselves. There
wjuld be a problem in acquiring the required amount of vitaminA-palmitate. The Private
Sector could donate this.
Total cost plus R & D plus Market Research and Pre-Post Assessment = Rs.3 crores.
REFERENCES
1. Kunde M K
Vehicles for Fortification of Food with vitmain A. Elimination of Micronutrient
Deficiencies through Fortification of Food. National Conference on Micronutrient
Fonification of Food. Organised by ILS I. ML MFPI and DWCD-GOI, pg. 130-138,1999.
2. Sashi Prabha
Case Study on Fortification of Milk with Vitamin A. Elimination of Micronutrient
Deficiencies through Fortification of Food. National Conference on Micronutrient
Fortification of Food. Organised by ILS I. ML MFPI and DWCD-GOI, pg. 139-143,1999.
SI
3. M.M.Chkrabarthy
Case Study on Fortification of Vanaspati with VitaminA in India. Elimination of
Micronutrient Deficiencies through Fortification of Food. National Conference on
Micronutrient fortification of Food. Organised by ILSI. MI. MFPI and DWCD-GOI. p<\
144-147,1999
4. Tara Gopaldas and Sunder Gujral:
A Multinutrient Package for Tea plantation Workers for Better Health. Productivity and
Profitability.
5. Mejia LA, Hodges RE, Arroyave G, Viteri F, Torun B:
VitaminA deficiency and anemia in Central Americal Chidren ; Am J Clin Nutr. 30, 117584, 1977.
6. Bloem MW, Wedel M, Agtamaal EJ, Speek AJ, Saowakontha S, Screurs WHP;
Vitamin A intervention : Short-term effects of a single, oral massive dose on iron
metabolism ; Amer J c\Clin Nutr, 51, 76-9. 1990.
7. Northrop Clewes CA, Paracha PI, Me Lonne UJ, Thurnham D:
Effect of improved Vitamin A status on response to iron supplementation in Pakistani infant:
Am J Clin Nutr, 64, 694-9, 1996.
^9.
CHAPTER TEN: A MULTINUTRIENT TABLET INCLUDING IRON,
FOLIC ACID, VITAMIN-CAND VITAMIN B-12 FOR ALL
PREGNANT/LACTATING WOMEN IN THE ICDS OF THE PILOT
DISTRICTS
10.1. Strategy/ Innovation:
The EA tablet distribution has not been very successful. VitammC is known to be the most
powerful enhancer of Hb status. Hence, a ^picrpnutrient tablet, which would include Iron,
Folic acid. Vitamin C and Vitamin B-12/ne^us
to be developed.
B-12^n<
10.2. Pre-Post estimation of Hb status will be done.
10.3. Time Frame: Two Years.
10.4. Type and Number of Beneficiaries: All the Pregnant/ Lactating women enrolled in the
ICDS. 1,40,000 + 46,000 = approximately 2 lakhs beneficiaries in all the 4 Pilot Districts.
1.5. Cost: About 1.5 crores. (DWCD will synchronize, implement and pay).
REFERENCES
1. Subadra Sheshadri and Budhwarkar S.:
Effect of guava fruit (Psidium gujava) consumption with the meals on Hb levels in young
anemic women : Dept, of Food and Nutrition. M.S.University, Baroda, 1998.
2. Subadara Sheshadri, shah A and Bhade S.:
Hematologic response of preschool children to ascorbic acid supplementation: J Human Nutr
Appl Nutr 39 A: 151-154,1985.
3. Tara Gopaidas:
An Information-Education-Communication (EC) Project for Working Girls (18-23 years) on
Cultural Dietary Practices to Increase the Iron Content of their Every-Day-Diets, 2000.
4. Mashid Lotfi etal.
Micronutrient Fortification of Foods. Current Practices, research and opportunities. The
Micronutrient Initiative and International Agricultural Centre, 1996.
5. Vitamin C-Fortified Drink to Calcutta Corporation schools. In Micronutrient Malnutrition
Control in West Bengal. An Integrated Programme for West Bengal, Report of the Task
Force set up by the Government of West Bengal, Social Welfare Department 1999.
4?^
CHAPTER ELE^N: ENRICHING RAGI ATTA WITH AN ADD ON
OF 6 MICRO NUTRIENTS
11.1. Introduction/ Strategy:
Ragi is widely consumed in Tumkur District. Ragi flour will be supplied to the 2335
AWCs in Tumkur. An ‘Add on' of koi^Ascorbic Acid. Riboflavin, vitamin B-12 and
Folic Acid which are the major (IDA and vitamin B comlex) micronutrient deficiencies in
the State, will be tried on an experimental basis to provide the entire RDA of the Pregnant/
Lactating woman for 7 days a week. Since the delivery system will be a ‘Take-HomeRation* (THR) as in the case of the ‘Under Threes’, the mothers will receive 200g/ day x
15 days = 3kg of ragi powder. Ragi is the cheapest millet at Rs.4/ kg orRs.24 for 6 kg of
ragi powder. The mothers will be taught how to ‘add on’ as one would , salt to taste at the
end of the cooking. It is quite possible that ‘sharing’ to the extent of 50% will take place.
Even so, the Pregnant/ Lactating woman will receive atleast half her RDA. It is now well
excepted that dosing of iron even once a week is sufficient to raise Hb levels. Ragi does
contain high levels of calcium, which is known to inhibit the absorption of iron. However,
to counter this, the packet or sachet will contain ascorbic acid, which is known to be a
known enhancer of dietary iron.
The Packets/ Sachets;
A Pregnant woman needs 38mg iron, 600pg vitaminA, 40mg ascorbic acid, 1 pg vitamin
(i)
B-12, lOOpg folic acid and 1.5mg vitamin B-2 per day.
A Lactating Woman needs 38mg of iron, 950pg vitaminA, 40mg ascorbic acid. 1.5jig
(ii)
vitamin B-12, 150|ig folic acid and 1.5|ig vitamin B-12 per day.
Any fine chemicals/ vitamins manufacturer will be able to make individual
packets of the same. Or else the local chakki grinder of ragi flour could be given larger
sachets of micronutrients/ kg of the ragi flour to be blended into the ragi flour. The price
will be set at Re 1/ RDA of the woman. This would be inclusive of a bio-degradable
sachet package.
11.2. Baseline Assessment and Pre-Post Evaluation would be done.
11.3. Number and Type of Beneficiaries: 31.000 Pregnant/ Lactating women in Tumkur
District only.
11.4. Time Frame: January 1st 2001 to January 1st 2003.
11.5. Cost:
The cost of the Micronutrient Sachet at Re. 1/ sachet x 365 days x 2 years of Project =
(i)
Rs.730/ beneficiary for the Project.
Therefore for nearly 31,000 Pregnant/ Lactating women, the cost would be 31000 x
(ii)
Rs.730 = Rs. 2.30 crores.
(iii) Cost of the Ragi Flour at Rs.24/ beneficiary x 12 months X 12 months 2 years X 31000
Pregnant/ Lactating woman = Rs. 1.79 crores.
(iv)
Pre-Post Evaluation = Rs. 10 lakhs (for IDA and VAD status Pre and Post)
Total of (I) + (ii) + (iii) + (iv) = Rs. 4.19 crores.
REFERENCES
1. Vinod Kapoor
Case Study on Fortification of Wheat Flour with Iron. Elimination of Micronutrient
Deficiencies through Fortification of Food. National Conference on Micronutrient
Fortification of Food. Organised by ILS I. MI, MFPI and DWCD-GOI, pg.71-72 ,1999.
1. Mashid Lotfi etal
Micronutrient Fortification of Foods. Current Practices, research and opportunities. The
Micronutrient Initiative and International Agriculture Centre, 1996.
(i)
(ii)
(ni)
CHAPTER TWELVE:
DRYING/ DEHYDRATION OF FRUITS/ VEGETABLES IN THE
GLUT SEASON.
BETTER STORAGE OF PERISHABLES AT POINT OF
HARVEST
DEVELOPMENT OF A SIMPLE COOUNG BOX
12.1. Introduction/Strategies:
Bangalore is a ‘Horticulture State’. Steps will be taken in all four districts to dry/
dehydrate the surplus vegetables/ fruit crops in the shade (to preserve the P-carotene and
other vitamins) during the glut season and to distribute the same through the Anganwadis
to the needy communities at subsidised rates. Also to promote better storage of perishable
produce on the field; and the development of a household cooling box.
This chapter will cover strategies for drying of fruits/ vegetables during the glut season,
strategies for better storage conditions; and lastly a simple cooling box to save food
commodities such as milk, gruels, left over cooked food for adeast 12 hours for the Low
Income Group Families.
(i)
(ii)
Strategies for fruits/ vegetables:
The simplest method would be to have sufficient space at the point of harvest to set up
simple dehydraters to dry the surplus vegetables/ fruits without extensive loss of Pcarotene and/ or vitamins. The CFTRI. Mysore could be the Technical Adviser.
Strategies for Better Storage Conditions for freshly harvested produce (fruits/
vegetables:
• Even small storage hut-like containers on stilts will be the first step in saving much ot
the perishable crop.
• The Indian Council of Agricultural Research has come-up with simple brick-lined
storage bins/ containers. More details will be sought from ICAR, who could serve as
the Technical Adviser for this poiject.
(iii)
A cooling box in lieu of a poor-man s refrigerator:
Practical and Action-Research needs to be done urgently in this area. A multi-centricstudy involving colleges of Home-Science is urgently needed.
12.2. Baseline Assessment and Pre-Post Assessment can only be done after the strategies have
been well defined.
12.3. Number and Type of Beneficiaries: Not relevant at this point of time.
12.4. Time Frame: Not relevant at this point of time.
12.5. Cost:
A costing cannot be given as a great deal of preliminary enquiries have to be made.
85
REFERENCES
1. Increasing Production and Availability of Vitamin A Rich Plant Foods. A Training Manual
for Horticulture/ Agriculture Functionaries. Prepared by the Institute of Home Economics,
Delhi University with the Department of Agriculture and Cooperation. 1997.
2. Ensuring Adequate Production and Availability of Vitamin A Rich Horticulture Crops. A
Training Aid for the Community. Prepared by the division of Horticulture: and the Institute
of Home Economics (Delhi University). 1997.
3. Increasing Production of Vitamin A Rich Horticultural Crops. A Long Term Solution to
Combat vitamin A deficiency. Prepared by the Depanment of Agriculture and Cooperation.
Ministry of Agriculture, GOI. 1996.
4. Consume Green Leafy Vegetables Daily and Improve your Vitality. Food and Nutrition
Board. Ministry of Food, GOI 1992.
5. Horticulture intervention in Purulia District. Annexure IX. In Micronutrient Malnutrition
Control in West Bengal. An Integrated Programme for West Bengal. Report of the Task
Force set up by the Government of West Bengal. Report of the Task Force set up by the
Government of West Bengal, social Welfare Depanment. 1999.
CHAPTER THIRTEEN: USE OF DOUBLE FORTIFIED SALT
13.1. Introduction & Rationale :The technology for Double-Fortified Salt is available at long
last through the excellent Research done by University of Toronto, Canada and funded by
the Micronutrient Initiative Canada. If the technology is made freely available it will wipe
out IDA and IDD in entire populations of Karnataka. It will also free the DHFW from the
vertical programmes for EDA and IDD. The National Institute of Nutrition. Hyderabad has
also had this technology available for some time. Consequently if the Food Processing
Industries, the National Institute of Nutrition, MI India, and DWCD join hands this could
become a distinct strategy for Chikmagalur District in the near future.
13.2. Chikmagalur District is a plantation district. And is dotted with several large plantations
who would like to keep their work force in good health. (1). Unfortunately Chikmagalur
district is highly endemic for IDD. Please refer to table 21, chapter 3 of part 1 for further
details on the prevalence of goitre. Chikmagalur headsihe list with the prevalence of 41%
in schoolers and adults. Generally districts which arfimills or slopes such as Chikmagalur
and Kodugu; or coastal sealine districts, such as D.Kannada and U.Kannada are effected.
A baseline survey report on goitre prevalence in Karnataka by the DHFW-K has pin
pointed the reason to be a deficiency of these vital micronutrients namely, iodine, zinc and
iron in the soil of these districts.
13.3. The Strategy :
1 kg of double fortified salts could be sold through the plantations at a heavily subsidised
(i)
rate (1) . For instance if it could be sold at Rs.4 versus R.7, which is the current market
rate for iodized salt, it would capture the entire plantation population. It should also be
made mandatory that no other types of salt or spurious brands of iodized salt be sold in
Chikmagalur District. Concurrently the pricing of double fortified salt should be such
that it is 1 rupee/ kilo lower than the cheapest types of rock salt or crystal salt sold in the
market. Possible partners in this enterprise could be Hindustan Levers and/or Tata
Chemicals.
The 7 ICDS Projects of Chikmagalur will distribute 1kg packet of double fortified salt
(ii)
per ICDS family per month - free.
(iii) All other ICDS services will continue as before.
13.4. Baseline Assessment and Prepost Evaluation :
A Pre-Post Evaluation would be done.
(i)
Continuous testing of the potency of iodine in random samples using kits should also be
(ii)
done.
13.5. Number and Type of Beneficiaries
There are 87627 ICDS beneficiaries in the 7 ICDS projects of Chikmagalur. If one
includes adolescent girls we could round off the figure to 1 lakh beneficiaries.
13.6. Time Frame:
lsl January 2001 to l sl January 2003.
13.7. Cost:
(i)
Double fortified salt is not yet available anywhere in the open market.
3T
(ii)
(iii)
Taking a notational cost of Rs. 10/kg of double fortified salt, the cost for 1 lakh
beneficiary families x 24 months would be 24 lakhs.
Thetotal cost of project + the Pre-Post Evaluation would be approximately = 50
lakns. (This cost would be borne by DWCD)
REFERENCES
1. Tara Gopaldas and Sunder Gujrai. A Multinutrient Package for Tea Plantation Workers for
Better Health. Productivity and Profitability. 1998.
2. State of Peoples Health in Karnataka. Voluntary Health Association of Karnataka. 1997.
3. Micronutrient Fortification of Foods. Current practices, research and opportunities : Lotfi
etal: The Micronutrient Initiative and the International Agriculture Centre Ottawa. Canada.
1996.
88
CHAPTER FOURTEEN: DEWORMING + VITAMIN A + IRON +
IODISED SALT FOR PRIMARY SCHOOLERS (6-15 YEARS)
14.1. Introduction and Rationale :
Schoolers are a population group that are most infected with parasitic infestations. The prevalence
of IDA, IDD and VAD is also known to be very high in this population group. Karnataka at the
present time has a total population of approximately 60 million. Approximately this would yield
a captive audience in the classroom in Karnataka of about 12 million schoolers.
14.2. Strategy/ Strategies:
In Gujarat approximately 3 million schoolers who are enrolled in the MDM programme are dosed
with albendazole (400mg) at the beginning of every school term. They are also dosed with mega
vitamin-A dose (200.000 IU). It has been mandaotry by the commissionerate of the MDM
programme that only iodised salt is used in the Mid Day Meal. Iron tablet (60 milligram elemental
iron as ferrous sulphate ) is distributed in the classroom by the teacher. This cost the MDM
commissionerate only about Rs.l 1/ child/ year. Since it is the chepest of cheap intervention which
can reach and benefit the schooler we would request DHFW to seriously consider this strategy.
The schooler is the only population segment left out of the intergenerational life cycle
described in Part one of this report. We would urge DHFW to consider synchronising
with DWCD and launch this project from January l a. 2001.
The school child can also be given nutrition-health-education in general and on the
importance of micronutrient in particular to keep him/ her physically and mentally active
and in a good state of ehalth.
14.3. Baseline Assessment and Pre-Post Evaluation :This will be done. Such an evaluation
done on approximately 6000 schoolers availing of the improved MDM programme in
Gujarat clearly showed a significant benefit in terms of improved Hb levels, decrease
clinical signs of vitamin-A deficiency and decreased prevalence of intestinal worms (1).
14.4. Time Frame: Is’ January 2001 to 1st January 2003.
14.5. Cost:
(i)
(ii)
In 1993 the above intervention cost the Government of Gujarat only about eleven rupees/
child/ year.
Assuming that only 50% of the 12 million schoolers would be in school and eligible for
this service, the cost would be as under:
6 million x Rs. 20 (at current cost) / year x 2 years = 24 crores (Will be
borne by DHFW).
REFERENCES
1. Tara Gopaldas and Sunder Gujral: The Pre-Post Impact Evaluation of the Improved MidDay-Meal Programme, Gujarat, 1996.
2. Tara Gopaldas ; Health of Schoolage Children - Bellagio Papers, 1991.
3. Tara Gopaldas and Sunder Gujrai; Educability Before Education. 1994.
4. Pollitt E. Malnutrition and infection in the classroom. UNU Food Nutr. Bull 1990- P(3) •
178-88.
5. Leslie J. Jamison DT. Health and nutrition considerations in education planning. 1.
Educational consequences of health problems among school-aae children. UNU Food Nutr
Bull 1990; 12(3): 191-203.
6. Gopalan C, Nutrition and India’s chilren. Assignment Children 1975 : 29: 51-60
7. Gopaldas T. Strategies and approaches to combat undemutrition : India's eighth five year
plan (1990-1995). Depanment of Foods and Nutritio, M.S.University, Baroda. 1989.
8. Pollitt E, Leibel RL. Greenfield D. Brielf fasting, Stress and Cognitive function. Am Clin
-Nutr 1978 : 34: 1525-33
I
AIR_____
ANM __
AWC
AWW
BMI
BMI
CCA
CEP
CFTRI
CSB
CSIR
CSSM
DHFW-K
DWCD-K
EPl______
GLVs
GO I
I&B
ICDS
ICMR
IDA
IDD
IEC
IFA
INHP_____
IT_______
KAP
LBW
LBW
LIG
MDM
MPs/ MLAs
NCHS
NGO
NGOs
NHFS
NIN
NIPCCD
NNMB
ORS
P/L_______
PDS
PEM
PHN
PWC
RDA
RTE
SHGS
SNP_______
THR
UIP_______
VAD
ZP
_________ ACRONYMS________________________________
All India Radio________________________________________
Auxiliary Nurse Midwife________________________________
Anganwadi Centre_____________________________________
Anganwadi Worker____________________________________
Body Mass Index______________________________________
Body Mass Index______________________________________
Community Change Agent_______________________________
Chronic Energy Deficiency______________________________
Council Food Technological Research Institute______________
Com Soya Blend_______________________________________
Council Of Scientific And Industrial Research_______________
Child Survival And Safe Motherhood Programme____________
Department Of Health And Family Welfare. Karnataka________
Depanment Of Woman And Child Development Of Karnataka
Expanded Programmed Of Immunization___________________
Green Leafy Vegetables_________________________________
Government Of India___________________________________
Information And Broadcasting____________________________
Integrated Child Development Services_____________________
Indian Council Of Medical Research_______________________
Iron Deficiency Disorder
_____________________________
Iodine Deficiency Disorder_______________________________
Information Education Communication_____________________
Iron-Folic-Acid________________________________________
Integrated Nutrition And Health Programme_________________
Information Technology_________________________________
Knowledge. Attitude. Practice_____________________________
Low Birth Weight______________________________________
Low Birth Rate_________________________________________
Low Income Group_____________________________________
Mid Day Meal_________________________________________
Members Of Parliament/ Legislative Assembly_______________
National Centre For Health Statistics. USA__________________
Non Government Organization____________________________
Non Government Organizations___________________________
National Health Family Survey____________________________
National Institute Of Nutrition_________ *___________________
National Institute Of Public Cooperation And Child Development
National Nutrition Monitoring Bureau______________________
Oral Rehydration Solution________________________________
Pregnant And Lactating Women___________________________
Public Distribution System_______________________________
Protein Energy Malnutrition_______________________________
Population Health Nutrition_______________________________
Physical Work Capacity__________________________________
Recommended Daily Allowances__________________________
Ready-To-Eat__________________________________________
Self-Help-Groups_______________________________________
Special Nutnuon Programme______________________________
Take-Home-Ration______________________________________
Universal Immunization Programme________________________
Vitamin A Deficiency____________________________________
Zilla Panchavat
*
KARNATAKA
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