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MID-PROJECT EVALUATION
OF
USAID-ASSISTED INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)
IN INDIA
prepared for:
Office of Health and Nutrition
USAID/India
Contract Number PDC-1406-1-00-4065-00
prepared by:
Pragma Corporation
'5
♦
i
i
I
September, 1986
New Delhi, India
MID-PROJECT EVALUATION
OF
USAID-ASSISTED INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)
-
IN INDIA
prepared for:
Office of Health and Nutrition
USAID/India
Contract Number PDC-1406-I-00-4065-00
prepared by:
Pragma Corporation
September, 1986
New Delhi, India
L
I
DATA SUMMARY SHEET AS OF SEPTEMBER 1986
INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT (386-0476)
Office of Health and Nutrition
PURPOSE
To expand and improve ICDS to regularly reach at-risk
pregnant/nursing women and malnourished children 6-36 months
of age with Title II foods through CARE, nutrition and health
education, and selected health services. To determine
feasibility and cost of increasing birth weights of children.
ELEMENTS
(1)
(2)
(3)
(4)
SCHEDULE
Date of Original Agreement
15 Sept. 83
Original Project Assistance Completion Date
30 Sept. 89
Revised Project Assistance Completion Date
30 Sept. 90
COUNTERPART
AGENCIES
GOl/Dept. of Women and Child Development, Ministry of Human
Resource Development; Indian Council of Medical Research
U.S.
CONTRACTORS
munity Systems
John Snow Inc. (JSI), Manoff International, Community
Foundation, Montefiore Hospital Medical Center (MHMC), Centers
for Disease Control, National Institute of Allergy and
Infectious Diseases.
BUDGET
Life of Project Funding
($ OOO’s)
USAID Authorized
Cooperating Country
Other Donors
Total
PIPELINE
Functional anganwadis with managerial and technical staff
Trained workers
Nutrition and health education
Innovative activities
Low birth weight research
(6) Supplementary feeding (Title II) and food processing
plants
(7) Monitoring and evaluation
Loan
Grant
Total
7,000
10,000
17,000
9,500
0
7,000
10,000
26,500
Obligations
Accrued Expenditures
7,000
2,289
10,000
1,107
17,000
3,396
Pipeline
4,711
8,893
13,604
ACKNOWLEDGEMENTS
This final report has been prepared on the basis of findings by the
following consultants: Dr. Tina G. Sanghvi, Dr. Samir N. Chaudhury, and
Dr. Nirmala Murthy. This mid project evaluation conducted in the
USAID-assisted ICDS (Integrated Child Development Services) project
districts of Panchmahals (Gujarat) and Chandrapur (Maharashtra) could not
have been completed without the active support and participation of ICDS
officials at the central, state, district and block levels. In
particular, the team would like to thank USAID/India staff, Mary Ann
Anderson, Samaresh Sengupta and Meera Chatterjee, and John Snow Inc.’s
Judith Standley and field officers,
Dr. Aziz Popatiya and Dr. Narendra Garni for their invaluable contribution
to the design, substance and implementation of the evaluation.
i
ABBREVIATIONS
Al IMS
ANM
AWC
BDO
CARE
CDPO
CEO
CSM
DHO
DPT
FHA
FHW
FO
GOI
HPN
ICCW
ICMR
ICDS
LBW
LHV
LOP
MCH
MIS
MO
MHRD
MS
NEED
NIPCCD
ORT
UIP
All-India Institute of Medical Sciences
Auxiliary Nurse Midwife now called Female Health Worker (FHW)
Anganwadi Center
Block Development Officer
Cooperative for American Relief Everywhere
Child Development Project Officer
Chief Executive Officer, District Level
Corn Soy Milk
District Health Officer
Diptheria, Pertussis and Tetanus Immunization
Female Health Assistant formerly called Lady Health Visitor
(LHV)
Female Health Worker formerly called Auxiliary Nurse Midwife
(ANM)
Field Officer, CARE
Government of India
Health, Population, and Nutrition Office of USAID/India
Indian Council of Child Welfare
Indian Council of Medical Research
Integrated Child Development Services
Low Birth Weight
Lady Health Visitor now called Female Health Assistant (FHA)
Life of Project
Maternal 8c Child Health
Management Information System
Medical Officer, Primary Health Center, Block Level
Ministry of Human Resources Development formerly called
Ministry of Social Welfare
Mukhya Sevika or Supervisor
Nutrition and Health Education
National Institute for Public Cooperation and Child
Development
Oral Rehydration Therapy
Universal Immunization Program
PHC
PL 480
PP
RTE
Rs.
SCCW
TT
UNICEF
USAID
(
/
Primary Health Center
Public Law 480 Title II Food Assistance
Project Paper
Ready-to-eat Food
Indian Rupees ($1.00 = 13.0)
State Council of Child Welfare
Tetanus Toxoid Immunization for Pregnant Women
United Nations Children’s Fund
United States Agency for International Development or AID
MID-PROJECT EVALUATION OF USAID ASSISTED ICDS: INDIA
TABLE OF CONTENTS
1.0
Executive Summary
2
2.0
Introduction
7
3.0
Evaluation Methodology
12
4.0
Findings and Recommendations
18
4.1
4.2
4.3
Functional Anganwadis
Supplementary Feeding
Nutrition and Health Education and
Communications....
4.4 Health Services
4.5 Growth Monitoring
4.6 Management Information Systems
4.7 Staffing and Supervision
4.8 Training
4.9 Senior Staff Development
4.10 Innovative Studies...
4.11 Low Birth Weight Research
4.12 Community Participation
18
25
Project Inputs
77
5.0
5.1
5.2
5.3
5.4
f
Management and Coordination
Technical Assistance
Food
Funds
31
38
43
46
60
64
68
72
74
75
77
82
85
86
Annexes
I. ICDS Package of Services as Upgraded with USAID
Assistance
39
II. Status Report of the ICDS Projects Assisted by USAID
as on 6/30/86
92
III. Summary of Meeting Held at NIPCCD on September 11, 1 986,
to Discuss the Preliminary Findings of the Review Team... 98
IV. a.
b.
Innovative Studies
Low Birth Weight Research
V. Scope of Work
100
103
109
List of Figures
Figure
Figure
Figure
Figure
1.
3.
2.
4.
5.
6.
Map Showing Project Districts
Functional
AWC........................
Project
Activities
and Key ............
Participants
Food
Distribution
Channels
Flow Chart of NHED Component
USAID Budget
1
9
19
20
33
88
List of Tables
Table
Table
Table
Table
Table
Table
3.1
4.1
4.2
4.3
4.4
4.5
Table 4.6
Table
Table
Table
Table
Table
Table
4.7
4.8
4.9
4.10
5.1
5.2
Table
Table
Table
Table
Table
5.3
5.4
5.5
5.6
5.7
Sites Visited During Evaluation
ICDS Program Enrollment Targets
Enrollment Targets for Daily Food Distribution.
Targets for Daily Rations Distributed
Recommended Targets for Other Services
Estimated Number of Beneficiaries and
Ration Energy and Protein Requirements
for Average Rural and Tribal Anganwadis
Selected Health Staff Position in
Eleven ICDS Talukas of Panchmahals
Health Staff Position at Chandrapur District...
Anganwadis Key Indicators Format
Staffing Outputs
Participants Training Schedule
Cost Estimate for AID Assisted ICDS
Critical Performance Indicators for AID
Assisted ICDS
Technical Assistance
Food Deliveries vs. Planned
USAID Planned Grant and Loan Funds
GOI Funded Inputs LOP
USAID Inputs vs. Estimated Value of Work Done..
14
22
22
23
23
26
39
40
51
60
69
78
79
83
85
86
87
87
Figure 1.
USAID/INDIA
Integrated Child Development Services
Project Districts
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The boundaries shown do not imply any judgement on the part of the U.S.
government on the legal status of any territory or any endorsement or
acceptance of sub-boundaries.
1
Chapter 1:
EXECUTIVE SUMMARY
The USAID-assisted ICDS project with the Government of India’s (GOI)
Ministry of Human Resource Development, Department of Women and Child
Development, is being implemented in Panchmahals district (Gujarat) and
Chandrapur district (Maharashtra) since 1983. This mid-project
evaluation was conducted to document accomplishments and problems in
project implementation so that the project can be modified if necessary,
and made more effective during the remaining four years of its duration.
The project is currently reaching a rural population of 2.4 million
through a network of 3,376 anganwadis. An anganwadi is a community
center where preschool education and a food supplement are provided daily
to children under 6 years of age and pregnant and nursing women. The
USAID project proposes to test a comprehensive approach to alleviate
young child malnutrition and mortality through interventions that form a
part of the .ICDS package of services implemented nationwide by GOI.
The evaluation team visited 11 (out of 19) blocks in both districts.
Forty-seven anganwadis, 7 health centers, 7 training centers and the
project funded food processing plant at Chandrapur were evaluated.
Meetings were held at central, state and district levels.
To date, USAID has fully obligated $10.0 million in grant funds and $7.0
million in loan funds. Approximately 20% of the funds obligated account
for accrued expenditures. Budget line items on low birth weight (LBW)
research and innovative studies have not been utilized due to late GOI
clearance for research and staff constraints at USAID. Additional staff
has been recruited and negotiations are underway to begin
implementation. Expenditures on in-service training and staff salaries
have been behind schedule mainly due to delays at district, state and
central levels. The participant training plan (though accounting for a
small percentage of the budget) has been delayed due to staff not in
position at state and central levels who were intended to receive
training. Other components of USAID assistance are largely on schedule.
2
The project has gained a major impetus from the conscientious and
technically sound monitoring and management by the USAID staff in Delhi.
An unusual amount of rapport, credibility and support exists with the
counterparts at all key levels in the project. This has helped achieve
project targets in establishment of a large infrastructure of anganwadis
and has set the stage for important qualitative improvements in the next
three to four years.
■results of the evaluation show that major advances have been made in the
development of a network of anganwadi centers (AWC) (approximately one
per 700 population) most of which are staffed by trained workers, The
number of AWCs increased in number from 1,211 (612 with trained workers)
in November 1983 to 3,376 (3,160 with trained workers) in September
1986. While food supply disruptions continue in Chandrapur district, an
average of 20 to 22 days of food distribution per month is maintained in
most project areas compared to 25 days intended. Due to on-the-job
training and orientation workshops provided through USAID assistance,
regular enrollment of priority groups and growth monitoring of children
has begun to occur on a large scale. There is a better understanding
among service delivery staff of the need for strengthening nutrition and
health services for pregnant women and children below 3 years of age.
While nutrition and health education services (NEED) have not begun at
the village level yet, a systematically designed social marketing/
communications package has been developed and tested for launching in
early 1987. This activity has helped strengthen government-private
sector linkages through use of commercial advertising and market research
firms. Also, numerous monitoring and orientation activities conducted by
USAID/Delhi and JSI staff have helped identify priority coordination and
integration issues which can now be addressed more intensively.
Certain assumptions made in the project design were not valid and have
led to delays in implementation especially in the qualitative or
’software* components of the project. Firstly, according to prevailing
procedures, financial assistance by USAID to GOI for district projects
requires finance departments of state governments to internalize these
line items within their budgets. Then official directives are issued to
district level functionaries before activities can be undertaken.
Project activities that follow standard ICDS norms and have been a part
of the national program for many years such as operationalizing AWC (or
the hardware aspects) have been on schedule. Any
3
additional staff or innovative activities outside the usual ICDS pattern
(needed for qualitative improvement), require lengthy consideration by
the state finance departments before approval. In some instances, state
governments have been reluctant to add staff with additional recurrent
cost burdens beyond USAID assistance. Consensus building and a sense of
ownership of the proposed additional inputs are required by substantive
and financial departments of state governments. The entire process may
take 2-3 years. Sometimes, the very staff who could have helped in
sensitization and consensus building for the desired budget changes were
to be USAID funded. Political disturbances in Gujarat leading to
administrative stand-still for weeks at a time during 1984, 1985 and 1986
and vacant posts at state and district level in both states have also
held up operationalization of USAID funded activities. For these reasons
a number of qualitative improvements through additional staff, training,
orientation and community participation did not occur.
Secondly, a key package of health inputs to be delivered through health
departments of the state government did not materialize as expected.
Now that most of the infrastructure envisioned in the project is in
place, greater stress will have to be placed on achieving the project’s
purpose of regularly reaching most at risk pregnant and nursing women and
children under three years of age with supplementary feeding^nutrition
and health education and selected health services.
The overall conclusion of the evaluation team is that the project design
is still valid as written in the USAID Project Paper of 1983. However,
accelerated implementation of a few key activities should be undertaken
to bring about changes in the remaining project period. These activities
are as follows:
Develop specific coverage targets for districts, blocks and AWC.
Design an annual plan of operations for each district for a more
systematic and
coordinated implementation of activities including enrollment
surveys, training modules, health activities and NHED campaigns,
geared to meeting these targets. USAID should be prepared to
strengthen their district
4
monitoring teams oriented to developing a district-level model for
monitoring and technical backstopping that can be transferred to
other entities in the long term.
Social marketing, communications and nutrition and health education
can make a major impact on overall quality of services at this stage
of the project and should be the major focus of USAID staff and TA.
This component is acknowledged as being the weakest link in the
program. If it includes specific skill building activities for key
personnel, it can be replicated nationwide, it has capacity building
spin-off benefits for GOI that can be used in other sectors and is an
acknowledged sphere of AID expertise worldwide and among other donors.
The continued lack of health services inputs can seriously undermine
the achievement of the project's stated goals and subgoals. Rather
than dependence on an external mechanism, the project should devote
some of its own resources to assuring coverage of priority target
groups with key health services. ICDS staff from AWW to central
government levels need to monitor these services and make more
sustained demands on the health system.
Informal, in-service training and orientation activities aimed at
job-related skills development and motivation of workers such as the
district orientation workshop at Kadhana organized by NIPCCD and
those planned under the NEED component should take precedence over
institutional support for basic training which has failed to pay
dividends so far. Since such institutional support can have longer
term and a large multiplier effect it should continue at some minimal
level.
Given AIDrs global child survival mandate and the outstanding
potential of this project (it can successfully reach mothers and
infants with an integrated package of services and significant
qualitative improvements are likely to occur in the project during
the next few years), mechanisms for capturing the mortality effects
of this project should be carefully reviewed and strengthened.
5
The broader role that this 2 district project can play is to provide
vital insights into how the nationwide ICDS can be strengthened. Lessons
learned here are applicable elsewhere and should begin to be applied on a
larger scale. USAID can play an important role in this nationwide
qualitative strengthening of ICDS. Such an expansion should begin with
intensive exploratory work in one district of each new state to develop
state specific models. The project in the states of Gujarat and
Maharashtra should be ready to expand statewide in another 12 to 18
months, after a careful review of recurrent cost implications of the
various activities.
6
Chapter 2:
INTRODUCTION
The Integrated Child Development Services Project (No. 386-0476) is
managed by the Nutrition Division of the Office of Health and Nutrition,
USAID India and provides grant and loan assistance (DA funding) totalling
$17.0 million to the Government of India.
USAID assistance to the ICDS program began in September 1983 in
Panchmahals district of Gujarat and Chandrapur district of Maharashtra.
The project is for a period of 7 years during which technical assistance,
training, equipment, and financial assistance for other inputs are being
provided.
The Project Paper states the goals and purposes as follows:
Goal
An average decline of 25% in the 0-12 months mortality rate and an
average decline of 33% in the 13-36 months mortality rate in communities
within six years after an anganwadi is established.
To accomplish this goal, the project will have the following subgoal:
Subgoal
An average reduction of 50% in the prevalence of severe malnutrition in
children 0-36 months of age and of 35% in severe plus moderate
malnutrition in communities within four years after an anganwadi is
established.
To accomplish this subgoal, the project will have the following purposes:
7
Purposes
1.
To expand and improve the ICDS program in 19 rural and tribal blocks
by establishing approximately 4,000 anganwadis which regularly reach
most at-risk pregnant and nursing women and moderately and severely
malnourished children under 36 months of age with Title II foods
through CARE, nutrition and health education, and selected health
services.
2.
To determine the technical feasibility and cost of improving the
birth weights of children.
The main focus of this evaluation has been purpose number 1 above,
birth weight research has only recently been started.
Low
Project activities are summarized in Figure 2. In order to achieve
qualitative improvements, the USAID assisted districts are expected to
improve program management through better monitoring, supervision,
training and staffing. Coverage rates for regular supplementary feeding
of those at highest risk are expected to be around 85%. The quality of
NHED is expected to be more effective and based on careful audience
research; health services and food supplements at the AW levels are
similar to national ICDS norms but expected to be more regular and with
higher coverage rates.
8
<
IMPACT ON NUTRITIONAL
STATUS INCLUDING
MORTALITY
>
ADEQUATE
REGULAR PARTICIPATION
< BY PRIORITY TARGET
GROUPS MAINTAINED
QUALITY OF
SERVICES
on
X
ANGANWADIS
PACKAGE OF ICDS SERVICES
JRCVIDED
V
ANGANWADI WORKERS
AWC 4- HEALTH CENTERS
PHC STAFF IN
GIVEN ADEQUATE
POSITION AND IN
SUPPLIES, INCLUDING
SERVICE TRAINING AND
FOOD AND EQUIPMENT
ORIENTATION PROVIDED
* ADDITIONAL
y
AWC + STAFF
AT ALL LEVELS
* FOOD +
EQUIPMENT
DELIVERED
*
BASIC
TRAINING 8c
ORIENTATION
CONTINUOUS ENROLLMENT
OF PRIORITY TARGET
GROUPS
* HEALTH
SERVICES
*
NHED
AND GROWTH
MONITORING
»
*GOI *NIPCCD *STATE GOTTS. *USAID <ARE *UNICEF ^COMMUNITY *ICCW ^TRAINING
*AIIMS ^DISTRICT 8c BLOCK OFFICIALS
LEADERS
CENTERS
FIGURE 2.
PROJECT ACTIVITIES AND KEY PARTICIPANTS
9
The project design in 1983 was based on the cumulative results of
evaluations of supplementary feeding programs in India and abroad,
including ICDS. The main focus of the project is improvement in the
coverage of at-risk groups and better quality of services delivered,
rather than any significant deviation in the standard ICDS program
model. The project is concerned with making the present model of ICDS
more cost-effective in reaching its goals rather than finding an
alternative to the ICDS program.
The expected outcome of this project is the development and testing of
district-wide operational ICDS activities in 2 districts of 2 states that
could be replicated on a state-wide basis and potentially in other states
as well. Assistance is therefore not limited solely to the 2 project
districts but covers institutions and implementing units at national and
state levels also.
Components identified for special USAID assistance are listed below:
Establishment of functional anganwadis
Supplementary feeding
Communications or nutrition and health education
Growth monitoring
Management information system
Staffing (managerial and technical)
Training
Innovative studies
I
(Health services, an important part of the ICDS package^were expected to
be upgraded through USAID’s IRHP project in Panchmahals.)
The nature and magnitude of USAID assistance provided for each component
are given in Annex I
10
According to the scope of work provided to the team the II’’objective of
this evaluation was to conduct a mid-project evaluation in order to
assess the progress in achieving targets, outputs and purposes as
specified in the ICDS Project Paper dated June IQSJ”. It was not
expected to be an evaluation of the project’s impact on the target
population, but rather a review of progress in completing various
activities and an assessment of what is needed in the remaining project
period to increase the likelihood of impact.
Other evaluation activities related to this project are regular
programmatic feedback at AWC, block, district, state and central levels
through the MIS component of the project and an independent evaluation of
baseline, biannual and end-of-project impact ; it is the impact
evaluation which will estimate changes in health and nutritional status,
and knowledge, attitudes and practices of the target population.
The methodology used for this mid-project review is qualitative and
process oriented; it is described in detail in the next chapter.
11
Chapter 3:
EVALUATION METHODOLOGY
The scope of work for the evaluation can be seen in Annex V.
Qualitative techniques were the major methodology used for assessing
qualitative aspects of the project. Statistics such as on enrollment of
target groups and staff positions filled are also included.
Comparisons were made between baseline (1983) and now, USAID assisted and
non-USAID assisted, and between good anganwadi (AWC) and poor AWC to
determine what has been achieved and what remains to be done.
Work on the evaluation began in June 1986 with orientation of the team
members, review of background documents and visits to U.S.-based
consulting firms that provide the technical assistance to the program.
Field visits were conducted during July, August and September.
Indicators
The process indicators given below were used as a guide to assess each
major component.
What is the potential coverage of the network of anganwadi centers?
How many of the anganwadis are functioning (a fully equipped
anganwadi having a trained worker in position and a regular supply of
food commodities for 25 days of feeding per month)?
Is there regular feeding of priority target groups? What proportion
of severely malnourished children under 3 years and pregnant and
nursing women receive a 600 calorie supplement at least 15 days per
month?
What proportion of mothers (pregnant, nursing or having children
under 3 years) are reached with regular growth monitoring and NHED
counselling delivered through home visits and group sessions?
12
What proportion of functional anganwadi villages have the package
of ICDS health services delivered on a regular basis for priority
target groups (iron and folic acid for pregnant women. Vitamin A
for children under 6 years, prenatal checkups and referral,
immunizations for pregnant women and infants under 1, Oral
Rehydration Therapy or ORT for diarrheal disease management )?
To what extent are program management decisions based on accurate
and regular information regarding relevant indicators?
What proportion of blocks have adequate ICDS and health staff to
implement and monitor program activities?
What proportion of workers (AWW, supervisors, CDPOs, health staff)
have adequate training and skills to implement specific project
tasks assigned to them?
The indicators were based on the activities described in the USAID
project paper.
The evaluation team consisted of an MIS expert, a pediatrician with
expertise in community nutrition and training, and a public health
nutritionist. All had extensive working experience in similar projects
in India and overseas. They were accompanied by USAID staff and John
Snow Inc. field officers throughout the study.
13
Site Selection
I The total number of blocks and anganwadis in the project in each
state and numbers selected for review are shown in Table 3.1 below:
3.1. SITES VISITED DURING EVALUATION
Units
DISTRICTS
Gujarat
Maharashtra
Total
PANCHMAHALS
CHANDRAPUR
2
11
5
8
6
19
11
2278
26
1098
21
3376
47
4
3
7
BLOCKS
TOTAL IN PROJECT
NO. VISITED
ANGANWADIS
TOTAL WORKING AW
NO. VISITED
NO. OF PRIMARY HEALTH
CENTERS VISITED
TRAINING CENTERS
AWTC(ANGANWADI WORKERS)
MLTC(SUPERVISORS)
2
1
3
1
5
2
Blocks visited in Panchmahals were Santrampur, Halol, Limkheda,
Dahod and Godhra; in Chandrapur these were Warora, Mui, Gondpipri,
Sindewahi, Chimur and Bhadravati.
14
In addition, team members also visited three control anganwadis for
the purpose of comparison. These were located in Armori block in
Garhchiroli district and Brahmapuri block in Chandrapur district and
are not USAID assisted.
Criteria for site selection are given below:
Blocks were randomly selected after stratifying for rural and tribal.
To serve the purpose of estimating the level of project
implementation, over half the AWC were randomly selected for
surprise visits. To serve the purpose of recommending improvements
in project implementation, some AWC were purposely selected for
their good performance so that innovations made and experience
gained at these AWC could be considered for replication.
Primary Health Centers (PHC) and Sub-Centers (SHC) were selected on
the basis of their proximity to the AWC in the sample. Training
sites included the centers which are providing supervisory and
anganwadi level training to the two project districts.
Information gathering was done as follows:
Open-ended checklists were prepared for AWC visits and home visits.
At AWC this included observation of activities in progress; food
storage; verification of weighing, plotting and interpretation of
charts; review of registers; interviews with AWW, helpers and
supervisors. After completing each AWC visit, follow up home visits
were made to 2-3 households. At the block level, interviews and
group sessions were conducted with the CDPOs, ACDPOs, supervisors
and PHC staff. Interviews were also conducted with district, state
and central government staff.
15
Analysis:
Analysis of the information was done in the field by daily pooling
of observations by team members followed by discussion and writing
of conclusions, Statistical data were aggregated at the end of the
field work.
Considerable discussion occurred in the field with CDPOs,
supervisors, district and state level functionaries to obtain their
input regarding the progress of the project and specifically to
discuss our findings. The team felt that it was essential to obtain
the viewpoints of individuals who are highly knowledgeable and
experienced in this project, since the evaluation team had only a
limited exposure to the project and its intricacies.
Analysis and conclusions regarding the current status of the project
were based upon the following comparisons:
Comparison of actual accomplishment with the estimated schedule
of progress and targets given in the implementation plans
developed at the start of the project in 1983. These are
described in the USAID Project paper.
Comparison of USAID assisted districts, blocks and AWC with
non-USAID assisted areas.
Comparison of the status of various components at the beginning
of the project in the 2 districts as described in the USAID
baseline report (Sengupta and Anderson, February 1984), with the
present status.
Differences between AWC that received more inputs compared with
those that had not in the two project districts.
16
The
recommendations were drafted to answer the following questions:
Are the activities being implemented according to the original
schedule and in the manner originally planned as given in the
USAID Project Paper? If not, why? How can they be improved?
Have we learned anything new either about operational
difficulties in implementing certain activities or the
nutrition, health and socio-economic conditions of the target
populations that would alter the schedule or nature of project
plans for the remaining duration of the project?
In the remaining duration of the project what activities should
receive priority emphasis?
17
Chapter 4:
4.1
FINDINGS AND RECOMMENDATIONS
FUNCTIONAL ANGANWADIS
There is no more powerful mechanism in India today for reaching mothers
and children at the household level than the network of ICDS anganwadi
centers. The presence of an anganwadi with a trained worker in position
and sufficient equipment and supplies for continuous enrollment,
monitoring and food distribution is considered an important first step.
Once this infrastructure is in place at the grass roots level, the
channelling of other services and qualitative improvements become
possible.
Coverage
In Chandrapur district of Maharashtra there are at present 1,096 AWC
with trained workers in position, covering an estimated population of
811,422 (using an average AWC population of 739 per the project
Baseline Survey). Compared with the 1981 census population of
Chandrapur, estimated at 1,303,110, the network of AWC functioning in
Chandrapur district cover approximately 62% of the total population.
An additional 317 AWC have recently been sanctioned in this district
for which the GOI has requested USAID assistance.
In Panchmahals district an estimated population of 1,551,318 or 67%
out of a total district population of 2,321,689 is being covered by
the network of 2,064 anganwadis having trained AWW in position.
The uncovered population is thought to be primarily urban in nature
and therefore not within the purview of this project.
In all, the estimated current size of the population presently
covered by the USAID-assisted ICDS project is 2.4 million.
18
Anganwadi centers are sanctioned on the basis of 1:1000 rural population
and 1:700 tribal population. In this project, census data were used to
requisition a sufficient number of AWC to meet these guidelines. By the
end of the project, there are expected to be a total of 1,432 AWC in
Chandrapur and 2,729 in Panchmahals to cover all the rural and tribal
population of both districts. See Figure 3.
Target - 2729
KEY:
2,500 .
AWC with worker
AWC with trained worker
AWC with adequate food
PANCHMAHALS
2,000 .
CHANDRAPUR
1,500 .
1,500
Target -■ 1432
1,000 .
1,000 •
/
/
500
500 .
//
0 11/83
3/85
3/86
Figure 3.
2.
o I—
9/86
11/83
i
3/85
3/86
«■■
9/86
FUNCTIONAL AWC
Food Supplies
Uninterrupted food supplies sufficient for 25 days of feeding per
month are a pre-requisite for considering an AWC " functional.”
According to the project design two different food delivery systems
and products are used in the two project districts. See Figure 4
below ♦
19
CHANDRAPUR
PANCHMAHALS
CSM and Oil
CSM and oil
I u-s. |
r U-S- I
CARE
CARE
____ Y___
Bombay Port
Bombay Port
xk
Maharashtra
State Coop.
Marketing
Federation
(MSCMF)
CARE z
____ y_________
Regional Godowns
Central Processing
at Bhiwandi into
roasted, sweetened
RTE food "Sukhada n
CARE
V______
Block Storage
MSCMF
CARE
Anganwadi Centers
Anganwadi Centers
Local Processing at AWC
Final products:
Hand extruded and
fried(SEV), made into
sweetened balls (laddoos),
fritters (bhajia), pancakes
(bhakri), roasted sweet or
salty (sukhadi).
Sukhada
FIGURE 4:
FOOD DISTRIBUTION CHANNELS
20
Recommendations
1. An AWC cannot become truly functional without a system of
identification and enrollment of the priority target groups. In both
districts, the number of households surveyed and resurveyed on a
quarterly basis appeared to be well below projected levels. A systematic
and focussed community census survey one or more times a year combined
with provision for continuous enrollment of newly eligible individuals
throughout the year needs to developed and disseminated through
in-service training and supervision.
2. The definition of a functional AW should be upgraded to reflect
qualitative aspects of the program now that a basic minimum
infrastructure is in position. Perhaps another term, such as
"operational AW," can be used to distinguish these characteristics from
the current ones. The revised definition should include the following
types of criteria:
A continuous enrollment mechanism in place aimed at 100% enrollment of
pregnant and nursing women and children under 3 years of age in the
program at all times.
Monthly NEED including growth monitoring conducted with at least 85%
of the mothers of children under 3 years of age; NEED given to 85% of
pregnant and nursing women.
At least 857O of pregnant and nursing women and high risk children
under 3 years of age receive 15 days of feeding per month.
At least 85% of pregnant women and children under 3 years of age
maintain full immunization coverage, full iron 8c folic acid coverage and
twice annual Vitamin A coverage as given in the ICDS guidelines.
3. In order to operationalize the guidelines for the delivery of
services annual plans of operation for AWC to follow in each of the
districts should be developed. These plans can be geared to achieving
coverage targets in the project such as the ones listed in point number 1
above.
21
As a first step, it is recommended that a standard approach and format
for community enumeration surveys be instituted in both districts.
Accurate estimates of number of women and children to be covered, food
supplies required, and scheduling of health services will all depend on
complete and rigorously updated enrollment of eligibles.
For planning and illustration purposes, targets for ICDS enrollment and
coverage have been calculated in Tables 4-1 through 4-4. These are
average figures per AWC based on estimates derived from the population
distribution actually observed for the various beneficiary categories
during the baseline survey conducted in Panchmahals and Chandrapur.
i
Each AWC should develop its own targets of enrollment and coverage based
on community surveys. These should be updated continuously as
beneficiaries enter and exit per eligibility criteria.
Table 4-1 ICDS Program Enrollment Targets
(Average per AWC)
Panchmahals
681 (% pop.)
______
Category_______
Average Population per AWC
1. 0-3 years old
2. 3-6 years old
3a. Pregnant Women (3-9 months)
b. Nursing Women (0-6 months)
TOTAL
73
47
13
13
T4F
(11%)
( 7%)
( 2%)
(2%)
(22%)
Chandrapur
739 (% pop.)
61
45
12
12
130
(8%)
(6%)
(1.7%)
(1.7%)
Table 4-2 Enrollment Targets for Daily Food Distribution
(Average per AWC)
17
2.
3.
Category
6-36 months total per AWC
Severely Malnourished (% total)
Moderately Malnourished (% total)
37-72 months
Pregnant and Nursing Women
TOTAL
Panchmahals
_______________
677
9 (14%)
19 (32%)
47
26
FTT
Chandrapur
49
8 (16%
17 (35%
45
25
95
NOTE: If the remaining 6-36 month old children are also enrolled (because
they are all estimated to be at high risk of malnutrition based on
socioeconomic criteria), then the total enrollment for food distribution would
be 133 in Panchmahals and 114 in Chandrapur.
22
TABLE 4.3
TARGETS FOR DAILY RATIONS DISTRIBUTED
(Daily attendance assumed to be 85% of enrollments shown in Table 4.3)
/
Average No. 300 Calories Rations per AWC
Ration
Size
(Calories)
Panchmahals
Chandrapur
600
300
15
16
14
14
2. 37-72 months
300
40
38
1. Pregnant and Nursing Wonen
600
44
41
115
107
Category
1.
6-36 months
severely malnourished
moderately malnourished
i
TOTAL
f the remaining children 6-36 months of age, who are all at high risk of becoming
uialnourished are also enrolled then the number of rations targetted for daily distribution
would be 143 for Panchmahals and 127 for Chandrapur.
TABLE 4.4
RBOOMMENDED TARGETS FOR OTHER SERVICES
(AVERAGE PER AWC)
Category
Panchmahals
Chandrapur
73
61
47
45
26
24
107
13
94
12
26
24
47
45
. Growth Monitoring with NHED
Monthly (0-36 months)
Quarterly (36-72 months)
I
!
Immuni zations
DPT, Polio, BDG, measles (0-12 months)
IT (Pregnant Wonen)
Vitamin A
6 months - 72 months
Nursing women
«*. Iron and Folic Add
Pregnant and Nursing Wonen
Preschool Education
23
I
I
To meet enrollment and coverage targets, annual working schedules of all
ICDS activities should be developed for AWC, circles, blocks and
districts. Activities such as community orientations, periodic
monitoring and evaluation meetings with all key personnel, immunization
and Vitamin A campaigns, ORT campaigns, should be scheduled for the
year. Other activities need to be done on a regular (daily or weekly
basis) and would be expected to continue. The order, frequency, and
focus given to specific task-oriented, in service training and
orientation modules as well as the content and intensity of
communications efforts should be consistent with this overall annual plan
of operations. District officials such as the CEO, DDO, DHO, DPO, and
block officials, selected Mukhya Sevikas and USAID/JSI field officers
should participate in this process. Much experience has accumulated
among these district and block staff on operational issues including food
and equipment delivery systems, coordination, integration and
administrative and financial arrangements at the field level, ICDS
sponsors including USAID and state governments will need to strengthen
their district level ICDS teams presently in position to provide adequate
technical and logistical support for such an approach to produce
results. State government departments of finance and nodal (substantive)
departments will need to provide adequate support.
This type of approach could help reduce the ad hoc nature of the current
activities in the field. It should be appreciated that the ad hoc nature
of current activities was necessitated due to implementation and staffing
delays. The project managers made the correct decision to proceed with
some key training and orientation activities in the interim. The
relatively short period of time now remaining in the project (2 years
before final impact evaluation is to begin) makes it urgent that field
level operations be launched on a systematic and thorough scale.
Some of these interim activities such as training in weighing and
plotting of growth charts and innovations in MIS can serve as excellent
pilot tests for guiding the development of a more systematic plan of
operations. For example, a modular format for training and a hands-on
method of training AWW and MS (including intensive AWC level followup)
used for growth monitoring has been effective. A similar approach can be
used for other components such as how to conduct enrollment activities,
how to effectively undertake NHED with mothers in groups at the time of
weighing and in home visits, how to accomplish
24
community rapport building and participation, how to maintain and use
information records (MIS).
I
4. In Chandrapur district, additional efforts need to be made to ensure
a more regular supply of food. These may include the following:
Intensify block and AWC monitoring of food deliveries by CDPOs and
CARE field officers, so that corrective action can be taken immediately.
In the present system, AW level receipts are submitted at the end of the
month - too late for action to be taken. Establishment of block level
buffer stocks may be necessary.
Improve system of accountability by trucking contractors and secondary
distributors. Use AWW signatures as evidence of receipt.
Provide additional stocks for the rainy season along with better AW
storage facilities.
Add an inner lining to the present packaging of single layer, woven,
high density polythene bags.
5. Equipment short falls should be remedied including food distribution
measuring devices to standardize ration sizes in Panchmahals and child
weighing scales in Chimur and Rajura blocks of Chandrapur. Philips
screwdrivers and instructions for their use should be provided to all AWC
for taring the bar scales.
4.2
SUPPLEMENTARY FEEDING
According to Title II guidelines on the selection and utilization of food
commodities, there are two major functions that food inputs can perform:
as wages or an economic incentive to increase participation in
development activities including utilization of educational, health,
infrastructure building programs, and
as a source of supplementary nutrition to increase nutrient intakes
above current levels so that malnutrition is prevented.
25
This project is designed to provide a regular supply of supplementary
calories and nutrients to improve the nutritional status of at-risk
pregnant and nursing women and children under 6 years through a daily
food ration distributed at AWC. USAID assistance is specifically
provided to achieve high coverage of pregnant and nursing women and
malnourished 6-36 months old children with supplementary nutrition. In
1983, estimates were made for planning purposes as shown in Table 4.5.
See revised estimates based on actual figures from the baseline survey in
Tables 4.2 and 4.3 above.
Table 4.5:
Estimated Number of Beneficiaries and Ration Energy and Protein
Requirements for Average Rural and Tribal Anganwadxs
(Table 6 of Annex 7 in the PP)
Beneficiary group
Kcal
Protein
(g)
100% Coverage of
Target Group
85% Coverage of
Target Group
Rural
Tribal
Rural
Tribal
At-risk Pregnant
Women(last 4 mos)
500-600
16-24
9
6
8
6
At-risk Nursing
Women(first 6 mos)
500-600
16-24
11
8
10
7
Severely malnourished
( 36 months)
600
16-24
13
9
11
8
Moderately malnourished
( 36 months)
300
8-12
21
15
19
13
Preschool(32-72 mos)
300
8-12
40
28
34
24
Total Beneficiaries
94
66
82
58
Total Ration Units of
300 Kcal
127
89
111
79
Tribal AWC = 700 population
Rural AWC = 1000 population
26
The emphasis at the design phase of this project was on the supplementary
nutrition functions of the food component. The team found that an equal
or more important role being played by the food is its incentive effect.
This incentive role needs to be strengthened and use made of the frequent
(though not daily) presence of mothers and children through adding on
NEED and health inputs at the AWC. Also see Annex I.
Increased Enrollment and Selection for Feeding.
r
A mechanism to continuously identify and maintain high enrollments of
priority target groups for feeding is considered essential to bring
about project impact. Quarterly community surveys were designed to
accomplish this.
NOTE: Enrollment mechanisms are needed not only for information on
the food component but for every other service to be delivered under
ICDS. It has therefore been dealt with under the functional AWC and
MIS components also. See sections 4.1 and 4.6.
In both districts, rather than conducting formal enrollment surveys
every 3 months, some AWC add new eligible participants such as
new-borns and newly identified pregnancies. Some AWC use the system
of daily home visits to complete community surveys over a period of 3
months. There is little uniformity in methodology or recording
formats, making the tasks of monitoring and quality control of this
activity difficult.
There is some confusion regarding criteria for selection for
feeding. In some AWC, all pregnant and nursing women are considered
eligible, in others, some are excluded arbitrarily or because they
opted not to participate. For children, selection criteria were
reported to be weight for age grades II, III & IV or III 8c IV or red
zone (arm circumference) or red 8c yellow zone (arm circumference) , or
physical disabilities or low income families.
27
In Panchmahals, AWW have been instructed to continuously add newborns
and newly identified pregnancies. There was confusion regarding
beneficiary selection for feeding due to the different types of
criteria proposed. These are arm circumference and weight
measurement superimposed on socio economic status criteria, Within
the subject of weight measurement, the use of declining or flat
curves are confused with grades of malnutrition.
Regular Attendance
The project calls for developing an effective system of monitoring
the attendance of each individual beneficiary in the high risk
category. The objective is to encourage attendance for at least 15
days feeding out of a possible 25 days per person monthly. The
evaluation team found several malnourished children who did not
receive the food regularly in both districts.
In Chandrapur, the daily attendance registers are generally complete
but the accuracy of the information is questionable. In not even 1
AWC visited did the team observe the attendance register being
tallied with the individuals given food at the time of food
distribution. In Panchmahals in 2 out of 26 AWW visited the worker
was identifying and correctly marking individual attendance at the
time of feeding.
In general regular attendance particularly of pregnant women and
children under 2 years appears to be far below expected levels.
Reasons include: AWC not considered a place for women to convene but
rather a children’s center; women feel inhibited to consume food
there. The urgency for supplementing diets during pregnancy and of
younger children on a regular basis is not known. Logistics and time
constraints of daily walking, carrying of children and spending time
at AWC is considered a constraint .
28
In tribal villages where homesteads are scattered, this is particularly
troublesome. Most workers appear to fill in the attendance at the end of
the day after distribution is over and there are likely to be errors in
their recall of exactly who was present that day. Special activities to
encourage better attendance by priority groups such as use of incentives
to dais, AWW and helpers have not yet started. Anganwadi workers (AWW)
are aware of the need for home visits to increase participation but this
is not done systematically as a satisfactory mechanism for tracking
defaulters is not yet in place.
Given the constraints in daily on-site feeding experienced by
priority target groups, innovative approaches to increasing their
intake of the ration as well as home foods need to be explored. The
newly designed NHED component, formulating a special mothers food and
larger take home rations are some of the alternatives.
Recommendations
1.
An effective NHED component can greatly increase the effectiveness of
the food component by increasing motivation to attend regularly and
by promoting use of home foods in conjunction with distributed foods
to yield a higher cumulative level of nutrient intake, significant
enough to make a measurable impact on nutritional status.
2.
The team concluded that the incentive role of the food component may
be a highly significant one for the achievement of project goals.
However, the potential for frequent NHED sessions with mothers and
the delivery and monitoring of health services at AWC, that would
make the incentive worthwhile are yet to be realized. Project plans
for launching NHED activities early should go forward as planned.
More effective delivery of health inputs should be sought to make the
investment in food worthwhile.
29
3.
The NEED component should also emphasize increasing home food intakes
(not only the distributed food).
Since small children need frequent
feedings, which is not possible at AWC, this combined (home plus AWC)
approach may be more effective. However, a small amount of a food
consumed by infants, young children and mothers could be an important
supplement if it contains a high caloric and protein density, high
protein quality and vitamins and minerals, to complement home diets
that are typically bulky and of low nutrient density and quality.
The role of Title II food can be even more effective as an incentive
to draw women together for NHED and as a demonstration and
endorsement that the food is important for these target groups and
for maintaining child growth.
4.
The potential for improving intakes during pregnancy through special
mothers’ food should be explored on a large scale as soon as possible.
5.
With reference to the RTE plants, the packaging of Sukhada in
Chandrapur, in the newly established plant should include a plastic
liner inside the woven bags. The potential for marketing of a
commercially viable line of weaning and mothers food products should
be determined through test- marketing. This could be an important
source of recovering recurrent costs and could help boost the image
of the subsidized/free products.
Provision should be made for varying end-products so that monotony
and lower acceptability are avoided.
6.
USAID and CARE should schedule a separate review of the role of
indigenous food grain in India’s supplementary feeding programs
(including ICDS). There is a sustained track record of the country
having achieved levels of foodgrains production in excess of
effective demand; on the other hand a substantial proportion of the
population continues to consume calories far below physiological
needs. How can USAID and CARE with their decades of experience and
management expertise in food delivery systems help mobilize this
’’excess” food supply to benefit those who cannot afford to buy or
retain the food being produced?
30
4.3
NUTRITION AND HEALTH EDUCATION (NHED) AND COMMUNICATIONS
According to ICDS guidelines, the AWW and MS are key entry points in
delivering face-to-face NHED to mothers as the primary target audience
for improving nutrition and health behaviors. Other members of the
household including older siblings, grandparents and dais constitute an
important secondary audience.
USAID assistance was initially designed to establish better mechanisms
for adapting and using existing NHED materials. See Annex 1 part B on
specific activities scheduled under the USAID-assisted ICDS project.
Use of Social Marketing Techniques
The design of NHED was significantly strengthened in 1985 by the addition
of a more detailed operational plan to improve NHED which is based on the
use of ’’social marketing” techniques. This means that instead of the
NHED intervention relying largely on existing materials with pretesting
and adaptation, there would be a special effort to base the NHED
activities on the needs and perceptions of the target audience. Other
key aspects of social marketing particularly relevant to the objectives
of this project include:
Use of multiple channels of communication to reinforce messages and
reach a critical mass of target audiences.
Using a differentiated set of messages and media based on different
needs and perceptions of segments within the target audience (rather
than assuming that one approach will be effective for everyone).
In order to motivate mothers to change, create an awareness that
children are not growing well in a visible way (through growth
monitoring) and use of good growth and other culturally appreciated
outcomes as a reward or reinforcement for good behavior.
31
Implementation Schedule
The NHED component in its original form (1983) has not been implemented
mainly because of a lack of government counterparts and delayed arrival
of the long-term advisor. A more detailed operational plan was developed
by Griffiths and Lissance of Manoff International in 1985. This new plan
has been implemented successfully and almost exactly on schedule under
the direction of the JSI ^train/NHED Advisor. Field level NHED
services will be launched in the form of a campaign in early 1987. This
timing is appropriate since it will mark the launching of the qualitative
improvement phase of the project which has so far focussed on development
of infrastructure. See Figure 5 for the activities and their
implementation schedule.
Role of Private Sector
One of the unique strengths of this project has been the contracting of
private sector market research (MODE) and advertising firms (ULKA.)
directly by the government. This is not only enabling the use of
additional technical resources of high caliber but is also helping build
confidence and mutual respect for longer-term public-private sector
cooperation.
Selection of Themes or Subjects Areas
In the 1985 plan of operations for this component, the range of possible
themes that could be treated was reduced to ones dealing most directly
with feeding practices. ICDS encompasses a broad range of services and
expected target audience behaviors. In general, the selection of themes
has followed the focus of the USAID project which is increased food
intake. Ideally, the criteria for selection should also include - the
ability of a set of behaviors, subject area or theme to have the maximum
impact in terms of stated project goals, mortality and growth. It is not
clear for example, whether specific analysis of the major health and
feeding behaviors linked to flattening and declining growth was done for
this purpose. This process might have helped limit the large number of
themes and possible messages that are still being considered. For
example, has the use or rejection of colostrum been shown to be a
critical behavior? In general growth curves of Indian children parallel
international growth norms up to 4-6 months of age.
32
FIGURE 5: FLOW CHART CF IBHD SOCIAL MRRKETItC COMPONENT FOR ICDS (USAID - ASSISTED
(1985 - 1987)
-JIVIH
I.
Oct
A.j
1935
Nov
Dtc
Jan Fab March April May June July
198b
Stpl Oct
Nov
he Jan Ftb March April Kay
1987
JUAI
July Au<]
PlanAtd Tiat Allocation
July - September 12
Select Research
Mitkt Actually Coapltltd
8
Sept 12 (8 weeks)
Organiiatioe
Co
Cu
2.
Conduct Research
MODE Activity 1
].
Analyze Research
Oct 17 - March 10
isteaded to April 7
4. Select Ad Agency
March 24 * April 25
4 May 12, 11
5. Foreulate Interv.
April 1 - Nay 9
3 May 19
MODE Activity 11
10 August 4
20 April 1
(24)
Strategy
i.
Test Inverv. Strateq
May 12 - Jely 31
July 12 - 30
1. Design Message
Strategy
1
(n)
2 Aufust 19
‘
3 August 19
a.
Develop Media Plans
July - August 19
9.
Develop Prototypes
Septeeber I - 30
4
.0,
Pre-test Messages
NODE Activity III
October 7 - Noveaber 4
5
il.
Revise Messages
Novctber 4 * 18
3
.2.. Produce Materials
Movetber 8 * January 13
8
11.
Training
December I - 15
Jaa 10 - Feb 28
2
14.
lapleeent ETIort
February I * August 31
27
15.
In-process Research
MODE Activity IV
July I ~ August 15
Second Phase Deceeber
7
(V
T
-T
The set of feeding and health behaviors at the weaning age should be
given highest priority. This should include the frequent bouts of
diarrheal disease experienced, the mothers usual response to diarrhea,
reinforcement of ORT and feeding after diarrhea. The review team
strongly endorses the current emphasis on increasing food intake during
pregnancy.
Intervention Trials and Identification of Resistance Points
This step in the development of NEED has been a valuable one for the
project overall. For example it has identified two potential entry
points in one of the traditionally more difficult problems in ICDS, which
is, the low participation of pregnant women. These points are:
i,
The development of a convenience food with an image of •"mothers
’
food". If flavored with herbs and spices preferred in pregnancy, packed
in daily ration sizes, made available at an appropriate time (e.g. before
she goes to the fields for work) or given once weekly it appears likely
to be eaten by women.
Use of AWC to distribute iron and folic acid tablets considered
it
strength giving tablets" for pregnant women. This has been shown to
enhance the image of AWC and AWW as providing services for women and also
ensures a better coverage.
A spin off benefit of the focus group discusssions held for audience
research in the project area was the discovery that participatory group
discussions with nursing mothers, (preferably with infants under 6
months), is an excellent NEED forum for consensus building and motivation
regarding topics such as age at introduction of semi solid foods, ORT,
immunization and growth monitoring. However, AWW and MS need specific
training as facilitators.
34
Use of Growth Monitoring to Integrate Services
The review team is optimistic about the role of growth monitoring as a
tool for integrating health and nutrition services, for monitoring their
coverage and for facilitating behavior change. The infrastructure is
already in place for weighing, plotting, interpreting and counselling to
occur on a large scale in project sites.The qualitative improvements
possible with relatively low
cost training modules were demonstrated by the first attempts (made in
March 1986) at systematically teaching AWW and MS to weigh, plot and
interpret correctly.
One of the strengths of this project is its success so far in enrolling 2
to 3 month old infants in this activity. Firstly, this early access
greatly enhances the potential use of growth monitoring as a tool to also
monitor immunizations and ORT. Both are key services that must be in
position before the child reaches 4-5 months when the cycle of diarrhea
and malnutrition begins and when immunization coverage rates (e.g. for
second and third doses of DPT and Polio) tend to drop. Secondly, errors
in estimating ages are least during the first few months. Thirdly, the
team also found repeated instances where, in the absence of a clear
understanding of printed growth channels and grades of malnutrition, the
AWW and mothers were using the early successful growth performance of
young infants to detect a decline or flattening of the curve in the same
infant. This was clearly perceived as a crisis and trigger for action by
AWW and mothers.
Present plans to provide growth charts to mothers that can be kept at
home are essential for maximizing cost effectiveness of this activity.
Integration with other services can be achieved only if PHC and AW staff
use the charts to record immunizations and track ORT use. Other projects
have also used home based charts to track referrals and as referral
cards. PHC staff should also be able to weigh, plot, and interpret
charts.
35
Expanding the Role of Communications
The evaluation team found a visible difference in the clearer
understanding of the nutrition and health objectives of the ICDS program
in USAID assisted sites compared with non USAID sites. However, there is
a lot more work that needs to be done in clarifying what services are
available, who the priority target groups are and why, roles and
responsibilities and expected outcomes. There is a need for
communications techniques to be used for the purpose of standardizing and
reinforcing messages about the program itself and its workers. These
tools can also be useful in maintaining the motivation and knowledge of
staff in between training activities. The use of printed material (e.g.
monthly newsletters) has already been started in Gujarat. The better use
of these existing channels and other avenues needs to be explored.
Coordinating Demand and Supply
A common problem in communication activities is the finely tuned
coordination needed to ensure that when demand is created through
successful communications, the services and supplies should be in
position. This concern is particularly relevant in this project as the
evaluation team has found inconsistencies and disruptions in AWC timings,
availability of AWW and in supplies of food, iron and folic acid, Vitamin
A. The NHED campaign is scheduled for launch in early 1987, therefore
services and supplies will need urgent attention.
Recommendations
1. NHED activities should be eventually broadened to include the use of
social marketing and communication techniques for informing, motivating
and maintaining skills of ICDS program functionaries from the ministerial
to the village level. The program, its village level functionaries and
services need to be promoted along with good nutrition and health
behavior.
2. There is an immediate need for the growth monitoring counselling
component, as weighing and plotting are underway on a large scale.
However the cost factor of the proposed modules and materials should be
carefully reconsidered to assure replicability.
36
3. Given the important contributions of diarrhea and measles to
mortality and growth failure in the 2 project areas, more communications
activities related to these health problems are needed than are planned
at present. Communication activities related to immunizations during the
Universal Immunization Program (UIP) year in the 2 project districts but
especially in subsequent years (as interest at the top moves on to other
districts and immunization activity may slacken) should be coordinated
with the work of PHCs. Important lessons can be learned from CARE’s ORT
campaign in Panchmahals. A continued and expanded role for CARE in both
districts for the ORT component should be considered.
4. One of the keys to the success of social marketing approaches lies in
their emphasis on early feedback and quick response to problems after a
campaign is launched. Mechanisms need to be developed in this project
for feedback and mid-course correction through rapid assessments early
during implementation in view of the early launch date.
5. The absence of sufficient state and district level counterparts has
led to little ownership or understanding of NEED design process so far.
Special efforts and time should be devoted to filling this critical gap.
6. State clearinghouses need to be developed according to original plans
to make sure that existing materials are not excluded. Important
training texts developed at central levels or in other states need to be
translated and adapted on a continuing basis.
37
HEALTH SERVICES
It is crucial for the success of ICDS, that a well staffed health care
delivery system provide supportive services to reduce morbidity and
mortality in children under 6 years of age and post natal care for
women. The level of support available from the health sector in both the
states shows a mixed picture. Before analyzing the health care support,
one should take into consideration the remoteness of the districts, the
lack of communication facilities and unwillingness of qualified staff to
be posted in such remote areas.
The staff in place at the various health centers in both districts were
stated to be adequate per required number during interviews conducted
both at the district level as well as the block level. Tables 4.6 and
4.7 show the latest position regarding health staff at Chandrapur and
Panchmahals districts.
An analysis of the health staff position in both districts indicates that
only 54% of the medical officers were in position in Chandrapur and 67%
in Panchmahals. However, 84% of the ANMs were in position in Chandrapur
and 85% in Panchmahals, which come very close to the target of 90% filled
ANM posts recommended in the USAID Project Paper which is crucial to
assure delivery of the health services component of ICDS.
Recommendations
1. Additional resources, through the USAID ICDS project, should be set
aside for health inputs. This will be more ettective
effective than relying on a
different project (possibly also USAID) which may not be synchronized in
its schedule or be able to coordinate well with the ICDS infrastructure
in order to give the priority needed to strengthen health services in the
two districts in the next three years.
38
TABLE 4.6
SELECTED HEALTH STAFF POSITION IN ELEVEN ICDS TALUKAS OF PANCH4AHALS
NAME GF
BLOCK
1.
2.
DAHCD
JHALOO
ND. OF
EHCS
hEDICAL OFFICER
SANCTIONED/FTLLED
%
3
9
3
9
HEALTH ASST (F)
(IHV + FHS)
SANCTIONED/FTLLED
%
SANTOAMPUR
4
12
4.
CEVGARHBARIA
3
9
HEALTH WORKER (F)
(MW + FHW)
SANCTIONED/FILLED
%
OiV
DAIS
SAhKTTlONED/FTLLED
%
SANCTIONaD/FILLED
%
6
(67)
19
16
(95)
84
69
(82)
225
225
(100)
229
5
17
15
(88)
72
59
(82)
194
196
(101)
230
6
(50)
27
15
(56)
118
104
(88)
304
304
(100)
315
7
23
22
(96)
103
87
(84)
305
296
(97)
209
54
(68)
226
217
(96)
178
(56)
3.
(JUNE 1986)
(78)
5.
LIMKHETA
3
9
6
(67)
19
16
(75)
80
6.
samuk
1
3
2
(67)
8
6
(75)
34
31
(91)
140
140
(100)
113
LUNATODA
2
4
3
(75)
11
9
(82)
52
50
(96)
237
224
(95)
178
1
3
2
(67)
3
2
(67)
8
6
(75)
25
39
(156)
64
1
3
3
(100)
7
6
(71)
34
26
(84)
135
135
(100)
196
1
3
3
(100)
7
6
(86)
34
31
(91)
137
147
(107)
118
2
6
4
(67)
17
14
(82)
81
75
(93)
240
243
(101)
262
24
70
47
(67)
158
130
(82)
697
592
(85)
2,168
to
7.
8.
9.
10.
11.
TOTAL
JAM0UGHOCA
HALOL
KALOL
GODHRA
2,166
(100)
2,092
I
N
F
O
R
M
A
T
I
O
N
N
O
T
A
V
A
I
L
A
B
L
B
lAbkE 4.I
HEALTH STAFF POSITION AT CHANDRAPOR DISTRICT - SEPTEMBER 1986
LHV
SANCTIONED/FILLED
NO. OF
PHC
CHANDRAPUR
7
14
7
12
12
32
27
202
202
159
159
MUL
8
16
10
14
13
33
33
173
173
174
174
GONDPIPRI
4
8
3
9
9
26
24
154
154
150
150
CHIMUR
5
10
7
11
11
35
29
150
150
141
141
KALOL
4
8
4
8
7
33
22
141
141
165
165
BHADRAWATI
5
10
6
10
9
33
25
146
146
151
151
SINDEWAHI
6
12
7
11
9
30
27
162
162
165
165
NAGHBHID
5
10
5
10
10
30
24
119
119
163
163
BRAHMAPUR
6
12
5
9
7
32
26
141
141
157
157
RAJURA
8
16
9
18
18
52
44
196
196
241
241
116
63
(54%)
112
105
(93%)
336
281
(84%)
1,584
1,584
1,733
1,733
TOTAL
O
MED. OFFICERS
SANCTIONED/FILLED
NAME OF THE
BLOCK
58
ANM
SANCTIONED/FILLED
CHV
SANCTIONED/FILLED
DAI
SANCTIONED/FILLED
2. Specific training and responsibilities should be assigned to PHC
staff and district health staff regarding their ICDS villages. These
could include targets based on AWW household surveys with respect to
immunizations, ORT training and referral, iron and folic acid
distribution and Vitamin A distribution. The District Development
Officer (DDO Gujarat) and Chief Executive Officer (CEO Maharashtra) could
monitor these targets at quarterly or monthly reviews.
3. Village allocations made to PHC staff (LHV and ANM) should be made
conterminous with those anganwadis assigned to the ICDS Mukhya Sevika.
In other words their circles or sectors should be made one and the same.
Joint tour programs should be developed for MO and CDPO as well as MS and
LHVs or ANMs. In one PHC, the medical officer had set aside one day per
week for ICDS activities in ICDS villages.
4. Home based growth charts for children with immunization, ORT use and
Vitamin A recording to be done by AWWs should be introduced. Mothers’
referral cards should be developed and used to record prenatal check-ups
for risk assessment, intake of iron/folic acid, and tetanus toxoid
immunization.
5. Special and immediate provisions for the cold chain, especially from
PHC to village, should be made to assure effective immunizations. Both
districts are UIP districts this year and the need is urgent.
6. The NHED activities should promote immunization in coordination with
UIP activities. The project should be prepared to pick up some slack
during the post UIP - initiation years as motivation and activity levels
may slacken.
7.
A scheduling and supply system for iron/folic acid and Vitamin A
needs to be designed to see if unusual or additional procurement is
needed, based on actual household survey data. If distribution is done
by the AWW, then estimates should be based on high rather than low
coverage. The NHED campaign should launch iron/folic acid promotion
messages only after AWC are fully stocked.
41
8. There is a large lacuna in health inputs for ICDS regarding diarrheal
disease management. Some valuable lessons from CARE’s ORT campaign in
Gujarat can be learned. Identification of grades of dehydration,
referral and PHC/SHC management of dehydration needs strengthening.
There is widespread confusion regarding use of measuring spoons and cups
(in AWW’s first aid kits), packets, and pinch and scoop method for
teaching mothers to make ORS at home.
9. PHC staff and district training teams of the health department need
to be trained in management of grade IV malnourished children. They will
need a special set of NEED materials and training on nutritional/feeding
aspects of ICDS, and nutrition rehabilitation techniques.
10.
Community orientation to ICDS should also cover private
practitioners and dais.
11. AWW training in use of first aid kits supplied for ICDS should be
given by health department staff.
42
4.5
GROWTH MONITORING
Growth monitoring is expected to play an important role in the NHED and
MIS components of the project. See sections 4.3 and 4.6 also.
In both states visited by the review team, growth monitoring was
beginning to be conducted with reasonable accuracy by AWWs. The trained
and supervised AWW were recording the weights appropriately on the growth
charts in the registers. The arrival of bar-type weighing scales at AWC
without instructions catalyzed the development and introduction of an
effective training module on growth monitoring by the JSI Training
Advisor. This has now been institutionalized in the form of training and
guidelines for use nationwide by GOI. There is a lot more training and
supervision needed before growth monitoring becomes effective.
There appear to be some problems in age assessment, In some instances it
was observed that weights were first recorded on a separate register
before entering them in the weight charts. This intervening step
prevents the mothers from receiving immediate feedback about their
child's weight gain and its implications, which the worker can only show
after plotting the weight on the chart.
It was disappointing to note that in many instances the AWW failed to
involve the mother in growth monitoring. Even when the mother was
present, AWW missed pointing out to her the section of flat curves or
inadequate weight gain over a period of time. Sometimes the AWW did not
advise the mothers regarding corrective action such as extra feeding or
other interventions such as diarrhea control with the use of ORS,
management of common illnesses, etc. The opportunity to use weight gain
or weight loss in health education, therefore, seemed to be lost on many
occasions.
It is very heartening to know that in many instances the AWW started
weighing children from two months of age onwards and thereby maintained
records for a long period, starting in early infancy. Growth monitoring
seems to have received a special impetus in the USAID assisted project
due to the in-service training support given by USAID/JSI staff.
43
Early growth monitoring as noted in both these districts is bound to have
far- reaching effects in terms of improving weaning behavior,
immunization coverage, etc. AWWs should be trained to involve the
mothers in growth monitoring and particularly to institute corrective
measures when growth falters. The review team endorses the proposed
emphasis in the NHED campaign on these critical gaps.
The weights are read correctly by the workers and in general are to be
found correctly plotted on the card or register. However, some confusion
still persists on plotting the weight correctly to the nearest 100g and
not rounding off to the nearest 500g mark, due to some faulty training in
which rounding off was recommended. Sometimes the weights recorded
previously on a register have not been found to be transferred to
charts. At some training centers workers were taught to read the grades
incorrectly.
Interpretation of the plotting differs greatly between AWWs. Some are
complacent with flat curves over months, particularly if such children
are in normal or Grade I. Interpretation may be made even more difficult
by the AWW having 3 systems for nutritional status assessment:
a)
Mid arm circumference with tricolored tape.
b)
Weight for age to arrive at Normal or grades I, II, III 8c IV.
c) Growth trajectories (relatively age independent) where the flat or
falling curve is the trigger for action, (not the cross sectional
position of the nutritional grade by weight for age).
In almost all cases the mothers are not a party to the interpretation
process, nor is action advised even when weights are consistently in
lower grades. In only a few instances, were the mothers aware that their
children were being weighed regularly at the AWCs. Both the accurate
recording and the interpretation of growth charts, particularly in
Panchmahals, has been helped considerably due to the in service training
provided by the USAID/JSI field officers who visit AWC regularly and help
in training the workers.
44
Recommendations
1. The review team is optimistic about growth monitoring’s potential for
increasing ICDS impact on mortality and growth. Its value to ICDS is
greater than simply a screening device for food distribution. It can
catalyze the integration of health inputs and change a variety of feeding
and health behaviors of mothers.
2. The NEED component is urgently needed to strengthen counselling
component of growth monitoring, to provide charts to be kept at home by
mothers and to increase participation in monthly growth monitoring
starting at an early age.
3. Efforts should be made to simplify nutritional status monitoring.
The value of arm circumference measurement in ICDS except in limited
areas where weighing is not possible in the early months of project
start-up, is questionable given that regular weighing and plotting of
weight for age has been found feasible, more accurate and sensitive to
early detection and prevention of growth failure.
4. Special efforts should be made to monitor immunizations, ORT and
Vitamin A by recording receipt of these services on growth charts to be
kept by the mothers at home as part of the NEED component. This data can
be aggregated for AWC block, district monitoring, using a small
statistical sample routine to more accurately assess coverage of children
by these services.
45
4.6 MANAGEMENT INFORMATION SYSTEMS (MIS)
The Integrated Child Development Services (ICDS) from the beginning has
paid considerable attention to the issues of monitoring and evaluation.
It has developed a standardized set of reports and registers from the
anganwadi level onwards up to the project level. Copies of the
Integrated Management Information System (IMIS) manual written in 1985
are now available in both the project districts. This manual constitutes
the official guidelines of the Ministry of Human Resources, Department of
Women and Child Development.
The IMIS consists of:
I
i)
The Health Input Monitoring System - Monthly Monitoring Reports
(MMR) under the All India Institute of Medical Sciences (AIIMS)
ii)
Supplementary Nutrition Monitoring (Form 4) under CARE
iii)
Monthly Progress Report (MPR) system under Department of Women
and Child Development
iv)
Social Input and Training Monitoring under NIPCCD.
Though the IMIS Manual was finalized only recently, the first three
reports and the supporting registers have been in use since the beginning
of the program.
Following is a summary of observations and recommendations on the
evaluation of the MIS component of the USAID assisted ICDS Project with
respect to the two project districts at the AWC, Sector (Circle), Block,
District, State and the Central levels.
46
Evaluation at the AWC Level
Anganwadi Workers have the following three major responsibilities in
relation to the information system:
i)
Quarterly community survey
ii)
Maintaining attendance and weight records
iii)
Sending monthly progress reports (MPRs), monthly monitoring reports
(health services) and monthly supplementary feeding reports (Form
4) to the CDPO.
Quarterly Community Survey
Anganwadi Workers have been asked to make quarterly surveys to
up-date the number of children and women in their areas. There were
many indications that these surveys were not being done regularly.
Some AWWs told the team that they did not make the surveys but
up-dated information as and when they learned about a vital event in
their village. This system was effective when the AWWs were
residents of the village and were working for two to three years in
the Anganwadi. Otherwise, they missed many events.
In Chandrapur district the survey coverage was about 80-85 percent of
the expected women and children. The ratio of children under 6 years
to the total rural population ranged between 10 - 22 percent when it
was expected to be 14-15 percent from the census and the USAID
Baseline Survey. In Panchmahalsdistrict the survey coverage was much
lower, between 25-60 percent. Accuracy of the survey data could not
be ascertained thoroughly.
47
Registers and Formats at the Anganwadi
In all the Anganwadis visited all the necessary registers required to
prepare the monthly progress reports were available and complete.
The formats, though not identical with the formats suggested in the
IMIS.
Manual, were essentially similar to those prescribed. Both in
Chandrapur and Panchmahals the CDPOs and district level ICDS staff
felt that these registers needed modification as they were not
conveniently designed for:
i)
follow-up of severely malnourished children;
coordination of health input with ICDS.
In both the districts the health information registers were not
filled.
Comprehension and Use of Information by the AWW
In both the districts the AWWs know how to maintain the registers.
They could plot the weight and age on the weight chart and mostly
determine the grade correctly, but they were not interpreting these
weight charts for educating the mothers, or using this information to
pay special attention to severely malnourished children.
In Chandrapur, a system of listing the grade III and IV children
separately and following their progress has just begun.
The supervisors in both the districts knew the number of
beneficiaries to be expected according to the population size and the
importance of reaching the children under 3 years of age, but did not
use that knowledge to monitor the accuracy of the survey data or
coverage of under three children, respectively.
In general, the quality of registers, their completeness and accuracy
depended on the training of AWWs and also the size of the population
she
48
had to cover. For a population of less than 600 the records were
excellent, for a population of more than 1,200 they were poor.
Education of the AWW was a factor but not always a significant one.
Educated AWWs were more likely to fabricate data than less educated
ones. Their record keeping improved if their supervisors explained
to them how to keep good records. In the two blocks in Panchmahals,
evidently a lot of such training was being imparted.
Monthly Progress Reports of the Anganwadi Worker
In Maharashtra two formats for monthly progress reports are in use one to be sent to Delhi, per the IMIS format and one for the State on
older formats. The State MPR is more elaborate and includes data on
weight and nutrition status using arm circumference data. The AWW’s
MPR is elaborate. About 80 percent of MPRs are received regularly by
the CDPO.
In Chandrapur the AWW felt a need to report 100 percent work even if
she had not done the work, Some instances we found when they had
reported arm circumference color zones of children without possessing
an arm circumference measurement tape.
Nutrition status grades were
reported in MPRs but not in the registers or on the weight cards for
the corresponding months. The correspondence between what was
recorded in the registers and what was reported in the MPRs was not
of a satisfactory level.
Also there was no uniform understanding of the terms used in the MPR.
The three terms used in the State MPR namely ’number of beneficiaries
eligible’, ’number selected’, and ’number actually received food’
were understood differently at different levels.
In Panchmahals the AWWs were not required to send the MPRs on a
proforma. They were bringing their reports on any piece of paper and
that was copied on to a register kept by the Mukhya Sevika for her
circle. AWW’s reports were not filed.
49
Use of AWW MPR by AWW
Anganwadi Workers in both the districts did not know what use they
could make of their MPRs. They did not know how to assess their
work, nor were they told by their supervisors how they fared.
In Chandrapur, the Chief Executive Officer (CEO) with the assistance
of the JSI MIS Advisor has initiated a system of monitoring which
should help in this respect. They have developed a monitoring card
which includes the major nutrition and health activities of the AWW
with a predetermined standard for the levels of activities. When the
number reported for any activity is below that standard that number
is circled, and the total number for such circles is a feedback to
the worker on her performance. This grading scheme is easy to
understand. If the AWW is told what standards are applied to her
work she can make a self assessment.
In Gujarat no such feedback exists at present, but it can be easily
instituted because the necessary data is compiled at the circle level.
At two anganwadis, the key indicator chart was seen in use. This was
introduced by USAID/JSI as an innovation in the Project. The key
indicators shown in the Table 4.8 below focus on important health and
nutrition aspect of ICDS. The purpose behind this chart is to give
greater importance to improving coverage of children under 3 and
pregnant and nursing women for health services, weighing and
feeding. However, this important concept cannot be made operational
at the anganwadi unless it is accepted at the higher level by the
district and state officers. The choice of indicators should be
consistent with the policy of emphasizing those target groups and
services. Towards this end it is suggested that key indicator charts
should be prepared for each block and district for putting up in the
CDPO’s and district health officer’s offices.
To begin with a few anganwadis could be randomly selected for this
purpose. Indicators based on their data could be taken as district
estimates. The USAID/JSI field officers can play significant role in
getting this innovation introduced.
50
Table 4.8
ANGANWADI KEY INDICATORS FORMAT
A.
1)
2)
3)
Number of pregnant women
Number of these women fed 15 days or more
Number of these women with second dose of T.T.
B.
1)
2)
Number of nursing women with children under 6 months of age
Number of these women fed 15 days or more
C.
1)
2)
3)
Number of children under 6 months of age weighed
Number of children 6-36 months of age weighed
Number of children 0-36 months of age gaining weight
D.
1)
2)
Number of children 6-36 months of age in grades II, III, IV
Number of these children fed 15 days or more
E.
1)
2)
Number of children under 12 months of age
Number of these children with third dose of DPT
F.
1)
2)
Number of children 12-36 months of age
Number of these children receiving Vitamin A during the last
six months
G.
TOTAL POPULATION
37M
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/
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iC
51
AND
>
DOCUMENTATION
J
UNIT
J
6.
Use of AWW MPR by MS
The Mukhya Sevikas were not found to be involved in the MIS.
In Chandrapur the compilation of monitoring cards and the feedback is
done by the block level statistical assistant and a copy is given to
the Mukhya Sevika for the records. She herself is not using the MPR
for selective supervision or taking corrective action.
In Panchmahals also, Mukhya Sevikas did not take interest in
monitoring of the program. The CDPOs seemed to lack confidence in
these first level supervisors - in their ability to train the AWW in
data reporting, or in taking corrective action, The Mukhya Sevika’s
knowledge and attitudes need to be improved.
Monthly Progress Reports of the CDPQ
Monthly Progress Reports were generally prepared by the accountant or
the statistical assistant at the block level. The CDPOs signed the
reports without looking at their accuracy. Sometimes, MPRs are
prepared based on the previous month’s MPR rather than on the
reported data for that month. This was obvious when some calculation
errors made in one MPR were repeated in the next month’s MPR. CDPOs
reported having received almost 100 percent reports from the AWWs
when in fact they received about 80-85 percent.
The survey figures in the MPR were not changed though the survey
figures in the AWW’s MPRs changed from month to month. Since the
population figures usually reported were the same but the beneficiary
numbers changed from month to month depending on the number of AWs
reporting, an artificial coverage variation was observed at the
project or block level. However, at present, project-wise monitoring
has not been fully operationalized at the State level or the Central
level and therefore these discrepancies are not getting corrected.
52
Data Use at the Block Level
In both the districts CDPOs were not using the anganwadi MPRs to give
feedback or to assess the anganwadi’s work.
Data Use at District Level
At the district level, the involvement in Chandrapur and Panchmahals
is very different in magnitude and quality.
In Chandrapur, because of the CEO’s personal involvement in MIS,
considerable attention is being paid to not just monitoring
performance of blocks, but also various components of ICDS. The
health activities under ICDS are reviewed by the CEO with the
district health officer and feedback is given to the PHCs also, The
system is still new and would take about a year to become fully
operational, but it has created sufficient awareness at the district
level for monitoring and taking corrective action.
In Gujarat, the district involvement is minimal. Unlike in
Maharashtra, Gujarat state has not introduced separate MPRs for the
State but is using those officially prescribed per IMIS. District
level officers play little role in the reporting and monitoring of
ICDS. The District receives one copy of the MPR sent to Delhi. It
also receives feedback from the State on the basis of the feedback
report received from Delhi. District Health Officers have been
appointed as district advisors to look after the ICDS program
implementation in one or two blocks, but their involvement was found
to be minimal. The district statistician neatly files away copies of
the MPR and the feedback without taking any action.
State Level Monitoring
The State level monitoring by the ICDS cell is dependent on the
feedback received from the centre. The written feedback from the
ICDS cell to districts generally pertained to not sending certain
data, or reports being delayed. In the quarterly meetings at the
State level perhaps more
53
I
detailed feedback is given to the districts but the team did not get
much information about this.
In Maharashtra, State level MPRs are in use. The Secretary RDD
mentioned that he wanted the state ICDS monitoring cell to develop
monitoring indicators by which he could monitor progress of his
projects in terms of impact. The evaluation’s MIS team member
developed some indicators and further work in this direction is under
way.
I
Use of Computers
1
)
I
The HCL Busybee micro computer was installed at the Rural Development
Department (RDD) Bombay in April 1986 and RDD has made some progress
in using this machine. After getting over the initial installation
problems, mostly with the hardware, the MIS staff has acquired a
working knowledge of Dbase III, mostly on their own with the help of
the manual. Their problem is what to use the computer for. Since
their backgrounds and previous technical experience are not related
to health or nutrition the MIS staff is handicapped in developing a
MIS.
In Gujarat the State level MIS Coordinator was recently appointed,
His background as a statistician in health related fields is
appropriate.
The State has placed an order for an HCL Busybee computer to be
installed in Ahmedabad. It would take another two months for the
machine to arrive, The State level officials were planning to use
the computer for the following four applications:
a)
b)
c)
d)
Circle-wise monitoring of MPRs
Weight monitoring based on a small sample of Anganwadis
Monitoring of severely malnourished children, and
Monitoring of universal immunization programme.
The State government has decided to appoint a monitoring committee to
develop monitoring indicators and feedback reports.
54
Monitoring at the central Level
ICDS from the beginning has paid considerable attention to the issues
of monitoring and evaluation. It has developed a standardized set of
reports and registers at all levels for nutrition, health and
education components. The Integrated Management Information Systems
(IMIS) Manual is now ready for implementation as a total system.
I
ICDS is also perhaps the only scheme in which block-wise monthly
progress reports (MPRs) are available at the Central level and their
return rate is over 95 percent. See Annex II.
At the Ministry level a 12 page report is produced highlighting
achievements of the scheme in: (i) recruitment and training of
personnel;
(ii) delivery of supplementary nutrition to mothers and children; and
(iii) attendance at pre-school education. At present no attempt is
made to include key health inputs. Since the data are being
processed manually, the monitoring cell is able to produce only the
statewise summaries from nearly 1,000 project MPRs received, No
further analysis of performance variations between the projects is
attempted.
HCL Busybee Microcomputer
The HCL Busybee Microcomputer provided under the USAID project to the
Department of Women and Child Development at Delhi was received in
April 1986 but was not in use at the time of the team’s visit.
Reasons given for not using the computer were that the
officer-in-charge was on leave from April to June and the training
given by HCL, the computer company was not adequate. This was
valuable time wasted which could have been used to design the input
and output formats. Though Dbase III is very easy to understand and
’’user friendly" software, it must be taught in the context of the
ICDS data for the computer. HCL, being an engineering group, was
perhaps not suitable for this task. It was obvious from the progress
made so far in using the computer that the entry for the computer was
not properly planned. As a result there is disappointment with the
machine at various quarters, especially from the top.
I
To remedy this situation, it is now suggested that the MIS Advisor
appointed by USAID should design input formats and the output
programs recommended in the Integrated Management Information System
(IMIS) documents. These should be developed separately at each
location, taking the MIS Coordinator and other members of the
monitoring team through the process of development, so that they
would develop confidence in devising new programs on their own.
This, no doubt would be a rather long, repetitive process, while the
system analyst's preference would be to develop a menu driven
package. Yet, making a menu driven package at this stage may
constrain further development of the system as it will create
dependence on the pre-determined programs.
The New IMIS
The four components of this Integrated MIS for ICDS namely, health,
supplementary nutrition (case report), Anganwadi activity progress
report (MPR), and training and social inputs monitoring reports have
been carefully designed. There is little duplication between these
reports, but these are independently being processed. Bringing some
integration among these reporting systems will greatly benefit the
program. The training and social inputs monitoring systems are just
being developed.
The most critical need seems to be integrating the health data but
there are some problems. At the All India Institute of Medical
Sciences ICDS Central Technical Committee, the health monitoring
reports are received and analysed. Compared with the MPRs, the
return rate in MMR is less than 50 percent.
None of the four PHCs
visited in Chandrapur and Panchmahals were sending these reports.
Second, the MMRs are generally sparsely filled. Except for the
immunization figures, several other items of information in this
report were either not available with PHCs or were not consistent
with the CDPO’s report.
56
Third, the MMR did not monitor the nutrition prophylaxis services
delivered through health workers such as Vitamin A and Iron/Folic
Acid. The argument against including these data was that they were
subject to misreporting. It is a valid argument but it applies also
to many other data. (Information regarding diarrhoea episodes and
ORT are included, but such data are not reliably collected.) On the
other hand by not asking for these data, one may be reducing the
importance of these nutritional supplements in the program.
Recommendations
1.
Uniformity in Reporting System: Changing over to the IMIS
registers and reporting system should pose no problem because
the existing registers are very akin to the suggested ones. It
will be necessary to print them in sufficient quantity. Some
extra registers will still be used because CDPOs who take extra
interest may want to collect more data. Some flexibility in
this area may be desirable.
2.
Improving Quality of Data: Many steps are needed to improve the
quality of data. As was done in Gujarat, regular workshops
should be organised, maybe with the help of NIPCCD, for CDPOs
and Mukhya Sevikas to ensure uniform understanding of various
terms.
I
We feel that improving quality on a sample basis will be
helpful. A possible way of doing it each month is that a small
number of anganwadis may be selected where supervisors should
prepare the monthly report after thoroughly scrutinizing the
records maintained by the worker. Through such a process one
can ensure better training to the AWW and better quality of data
on at least a sample basis.
i
Until such a system is implemented one can utilize the baseline
and follow-up evaluation surveys done by M.S. University of
Baroda to serve the purpose of developing appropriate standards
for assessing the accuracy of data collected routinely by AWWs.
57
3.
Developing Computer Based System: Presently the MIS
coordinators are expected to develop the monitoring indicators
and feedback formats. Since the coordinators do not necessarily
possess sufficient technical background in nutrition and health
they would find it difficult to proceed unless technical advice
is made available to them.
Therefore, a monitoring committee should be instituted
consisting of the project directors and a subject specialist
from within or outside the department to oversee development of
the system.
Four areas where the computer could be used profitably are:
- Analysis of MPRs and to prepare sector wise feedback,
- Indepth evaluation of sampled anganwadis,
- Monitoring of severely malnourished children, and
- Weight monitoring of a selected sample of children.
4.
Integrating Health Information with ICDS: Attempts to build an
integrated health and nutrition information system at the
anganwadi level have succeeded only in a small measure.
Specific attention and efforts are needed in this area.
However, the major health inputs in the ICDS IMIS reported
monthly refer only to immunization. The nutrition supplements
such as Vitamin A, and Iron and Folic Acid do not figure in the
MPR, nor does use of oral rehydration packets or home made
solutions. Though difficulties in getting accurate data on
these measures is known, the importance of getting those cannot
be minimized. Therefore, emphasis should be given to these
inputs and their reporting in the project area, if not in the
entire district then at least on a sample basis, MHRD at center
should request health services data along with other data
currently received.
58
5.
Use of Data: Proper use of data must begin at the state,
district and block level to improve the overall quality of data
and tempo of the program. State and district level review
seminars may be organized to improve the appreciation of the
relevance of the data, system data quality, and use of
information for program planning and control.
/
1
5
59
4.7
/
STAFFING AND SUPERVISION
The need for some additional staff and better use of existing personnel
for strengthening program management and technical guidance has been
visualized as a key component of the project. Given the large population
being covered, the comprehensiveness of the package of ICDS services to
be delivered and the multiplicity of organizational entities involved,
the achievement of proposed staffing and supervision targets is crucial
to the success of the project. Actual outputs at mid-term compared with
end of project targets are shown in Table 4.9.
Table 4.9 - Staffing Outputs
Category of Outputs
Specific Output
1. Additional Service
Workers Trained and
AWWs
Helpers
1
Quantity of Output
Total Planned
3844
3160
employed but not
trained
0
3844
3844
Employed at Anganwadis Trained dais
Actuals
a/o 9/86
2. Additional Management
& Technical Support
Staff Trained (or
oriented) and employed
At sub-block level
MSs
338
191
At the block level
Assistant CDPOs
25
11
CDPOs
19
18
Other block staff
104
99
Program Officers
2
1
Technical district staff
10
0
At District Cells
In-service workshops for
MSs, AWWs
At State Cells
MIS Coordinators
Training Coordinators
NHED Coordinators
338 MSs
3844 AWWs
0
2
2
2
2
2
0
60
I
Recommendations
AWC Level. In each district, examine the set of activities needed to
be undertaken for successful attainment of coverage targets as laid out
in the proposed annual plans of operations. Prioritize them, Critically
review AWW workload, their strengths and weaknesses. Also review
critically other human resources available such as helper, dais,
community leaders, volunteer mothers, women’s organizations etc.
Reallocate responsibilities and provide modular task-oriented, in-service
training to each entity. Use the group approach for training with joint
training of key players at the AWC level. If necessary, use innovative
studies as a possible resource for testing alternative patterns to
systematically develop a working model in each district.
2. MS/Supervisor Level. With existing MS, test out the feasibility of
assigning specific AWW, dai and helper training responsibilities together
with the use of incentives or disincentives for achieving training
targets. This may be done through use of ’’innovative studies” funds.
The DDO in Panchmahals is about to launch a scheme of selecting one AWC
per circle as an '’exemplary11 site for visits by other MS. These can also
be used as AW staff training sites and MS internship sites.
For new MS, revise selection criteria, giving precedence to her residing
in her circle headquarters, willingness to undertake and past track
record of extensive touring of villages, rather than to her academic
background. Develop a system of internship (few weeks) with selected
good MS before being assigned her regular tasks.
Develop an objective grading system of AWC performance based on coverage
achievement (see section on functional AW). Use this to schedule MS
supervisory visits more frequently to delinquent AWC and to institute a
reward system for MS to bring up their lagging AWC to acceptable
standards.
61
During group meetings with the review team, MS expressed a need for more
specific training in interpreting MIS data, community rapport building
and NEED.
3. Block Level Critically review the strengths and weaknesses of ACDPOs
and from which cadre they are being recruited. There should be a more
clear demarcation of roles and responsibilities vis-a-vis project
components and annual operational plans between CDPOs and ACDPOs.
Regular and systematic orientation/training for CDPOs and ACDPOs should
be scheduled several times a year. Focus these on use of information
(MIS) for taking quick and effective action on key activities such as
maintenance of enrollment and coverage targets, adequate food supplies at
all AWC at all times. More attention is needed on the present system of
reallocation of supervisory and AWW duties to avoid disruptions due to
long absences and leaves. There is a need to develop a system of
identifying problem circles and problem AWC for extra supervision.
l
Coordination responsibilities with PHC staff should be made a high
priority for CDPOs. The assistance of the DDO may be needed to
facilitate this coordination in Panchmahals. This should include monthly
meetings to assess progress against pre-set coverage targets for health
(immunization, iron/folic acid, Vitamin A, ORT, prenatal checkups and
referrals). Assigning overlapping circles/sectors of villages to MS and
LHVs/ANMs and scheduling their joint tours.
Explore the possibility of institutionalizing the setting aside of one
day per week by PHC staff for ICDS health inputs at each block.
Strengthen CDPO or ACDPO supervision of timely food deliveries in
Chandrapur.
62
4.
District Level Strengthen USAID monitoring teams at district level
and develop a working model that can be transferred to district cells.
Add training responsibilities to the current set of roles anticipated for
ICDS district cells. Accelerate filling of district posts, including the
possibility of increasing salary scales. Expand the use of CARE field
officers in supervision and data gathering to include non-food components
as well. The continued and increased commitment of the DDO and CEO are
vital for the success of the project. Establish a district level project
monitoring committee including health, ICDS, USAID, JSI and CARE
functionaries.
5. State Level The posts of NEED Coordinators should be filled at the
earliest. MIS and Training Coordinator’s roles should be strengthened as
described under these components respectively.
63
4.8
TRAINING
MLTCs and AWTCs in both Gujarat and Maharashtra were visited in
order to assess facilities existing at these training centers,
supply of equipment, availability of training materials, library
facilities and the number, and qualifications of instructors in the
related fields. The list of centers visited are as below. Middle
Level Training Center for Supervisor’s of Mukhya Sevika = MLTC.
Anganwadi Workers Training Center = AWTC:
Gujarat:
1.
2.
3.
4.
Maharashtra :
C.P. Trust, Ahmedabad, MLTC, AWTC
Panelav Training Center, AWTC
Bhil Sewa Mandal Training Center, Jhalod, AWTC
ICCW Training Center, Sabarmati Ashram, Ahmedabad AWTC
1. College of Social Work, Nirmala Niketan, Bombay,
MLTC
2. Panchayat Raj Training Center, Mui, AWTC
3. Sindewahi Gram Sevika AWTC
Recommendations
1.
AWW Task oriented training materials based on the roles and
responsibilities of the AWW, though clearly spelled out in GOI
guidelines, remain in practice, to be carefully developed. Keeping
in mind that preschool education also constitutes an important GOI
rationale for ICDS, resources should be devoted to gaining a better
appreciation of the AWW responsibilities through time allocation
studies. If her record keeping, community surveys for enrollment,
community motivation, NHED for mothers, weighing of children,
preschool education, distribution of food supplies, first aid and
facilitating health services activities are to be conducted
effectively, her motivation and support system need strengthening.
Specifically a more equitable division of labor with helpers who are
adequately trained is needed.
64
AWW trainees should receive proper orientation to elicit community
participation while initiating the anganwadis in their respective
villages. Subsequently, AWWs should ask the community to contribute
in cash or kind to improve the quality of food served at the AWC as
well as to provide accommodation for the AWC.
Channels of communication such as radio, print materials and
carefully selected and scheduled supervisory visits should be used
as training opportunities on a larger and more systematic basis.
2.
Training and Incentives for Dais
(Traditional Birth Attendants)
Dais are considered very vital in supporting the early recruitment
of infants into ICDS as well as the detection and enrollment of
pregnant women in the community. Dais can support the AWW in
recruiting both pregnant and lactating women and young children into
the program. The training of Dais for this innovative role in ICDS
has not taken place as proposed in the Project Paper, An incentive
scheme for dais to do ICDS enrollment work is also envisaged in the
Project Paper, but a plan needs to be worked out for activating this
component.
It is important that the Dai training and incentive program,
particularly to support the AWW in enlistment of beneficiaries be
initiated immediately as intended through the mobile in-service
workshops. Dai training for ICDS can be provided through the AWTCs
or by the ANMs at the PHC level, provided a special ICDS training
program is designed and introduced for this purpose.
The state
government should work out an incentive plan for involving Dais in
ICDS immediately.
3.
AWTC and MLTC
The instructors of AWTCs should be periodically brought in for
orientation workshops in participatory training techniques and also
task oriented training.
65
The mobile in-service training workshop envisaged in the Project
Paper should be implemented without further delay through MLTCs in
both states. This will enhance the skills of ICDS functionaries and
the quality of services in the USAID assisted districts.
The MLTCs could be used to provide continuing education and
orientation programs for district and state level officials working
in ICDS.
The MLTCs should establish closer links with NIPCCD for the academic
aspect of training related to ICDS. The State Training Coordinators
should work very closely with MLTCs in order to provide a continuous
stream of trainees in sufficient number both for job training as
well as refresher training
The cost-effectiveness of video-recorders for use by MLTCs to
improve the quality and content of training techniques and for
standardization of training modules should be explored.
The training centers involved in ICDS are mostly managed by PVOs.
Their facilities are minimal in terms of classrooms, dormitories,
library, equipment, etc. Grants should be made available to improve
these facilities.
Participatory training methods should be insisted upon and the
training should be task oriented. This can be done by conducting
workshops for re-training the trainees.
4.
Involvement of Private Voluntary Organizations (PVQ)
The use of indigenous PVOs to run model ICDS anganwadis-cum-training
sites should be explored in order to implement an action-oriented
training program in ICDS.
66
5.
Linkage Between MLTCs and ICDS Implementation
The existing training centers (MLTCs) can affect the quality of
services in an ICDS block assigned to them through their role of
philosopher, friend and guide and through field placement of
trainees. However, at present none of the training centers visited
in Gujarat and Maharashtra have been formally assigned an ICDS block
as their field practice site. Also a fair degree of rapport can be
developed between the instructors of training centers and MS, AWW
and CDPO in the assigned block through block placement of trainees.
All such occasions may be exploited by these service-cum-training
units to improve the quality of services provided by ICDS.
Grants-in aid to selected training centers all over the country
which will follow an agreed set of activities in ICDS will add to
the motivation of different categories of workers.
6.
Strengthening State and District Training Roles
The lack of full-time state training coordinators should be
addressed as soon as possible. District ICDS cells should be fully
staffed and training teams developed for joint orientation training
and continuing education at block level of CDPO, MS, and PHC staff
as well as circle level training and orientation of AWW, helper, Dai
and CHV.
7.
NIPCCD
Existing staff at NIPCCD had made commendable contributions to the
USAID ICDS project by organizing district level orientation
workshops and by intensively working to improve growth monitoring
training modules. However, NIPCCD can be more effective than it is
at present in its quality control functions with respect to training
at MLTCs and AWTCs. In order to do so, it is imperative that vacant
positions at NIPCCD be filled immediately, maybe on a contractual
basis which may prove more expeditious than hiring of permanent
staff. NIPCCD should also fulfil its responsibilities regarding
more frequent visits to
67
outlying training centers in order to improve the quality of
training and also to ensure that the minimum facilities are actually
present at these centers. A proper accreditation procedure should
be implemented immediately as recommended in the Project Paper.
NIPCCD has to develop closer links with the MLTCs particularly in
Gujarat where the MLTCs receive their funds from the state
government and not from NIPCCD, unlike Maharashtra. NIPCCD also
needs to play a more active role in overseeing the AWTCs in both
states. This will help ensure that academically sound training is
imparted to enable the ICDS functionaries to acquire essential
skills.
4.9
Senior Staff Development (Participant Training Plan)
According to the project design, senior management and technical staff
were scheduled to receive training in specific areas relevant to ICDS. A
needs assessment was undertaken in July 1985 and a schedule ,of 13
different types and levels of training activities were identified. The
Participant Training Plan was revised in July 1986 as shown in Table 4.10
which indicates the proposed versus actual training.
Recommendations
1.
USAID should develop a revised and more realistic participant
training plan to reflect current needs and potential. A fund for
unanticipated, ad hoc training should be added for activities geared
to problem solving as and when operational needs arise. This could
be useful, for example, in developing specific in-country training
modules on social marketing, new training methods, and MIS. There
is little understanding of the broader role of social marketing and
its application, participatory approaches to training and how
information can be used for decision-making (MIS) at various levels.
2.
Management training such as the one proposed by the National
Productivity Council (NPC) and other generic training programs
68
Table 4.10 participant training schedule g/As. ke-j'sgD
-SI.
No.
1.
O'
kD
Training Program
CDPO Management Trg.
a) Gujarat
b) Maharashtra
No. of
parti
cipants
T ra i ne r
Duration of
Training
Original
Date of
Training
Proposed
Date of
Training
13
11
National Pro
ductivity
Council
12 days
12 days
Feb. 1985
Dec. 1985
Dec. 1986
Nov. 1986
1
MSH Boston
3 v<eeks
April 1986
April 1986
10 days
10 days
March 1986
Oct. 1986
I N
Date Training
Completed
Corments and
Outstanding
Problems
Course Design
underway.
2.
Management Issues for
International Health
3.
MIS Operations Trg.
a) Gujarat
b) Maharashtra
5
5
4.
Manager's Seminar
14
Kris Oswalt
3 days
Oct. 1985
July 1986
July 30 to
Aug. 1, 1986
5.
Statistician Prog. Basic
Training Micro computer/
Software for Evaluation,
Data Analysis
6
Kris Oswalt
and local
Consultants
12 days
Oct. 1985
Aug. 1986
Aug. 4-16, 1986 Completed.
Local Consul
tant
April 1986
Completed.
MIS Coordina
tors appointed
late. Local
training found
inadequate.
Completed.
SI.
No.
O
Training Program
No. of
partici pants
T ra i ne r
Duration of
Training
Original
Date of
Training
Proposed
Date of
Training
Date Training
Completed
Comments and
Outstandi ng
Problems
6.
MSU Statistician Prog.
Basic Trg. Micro Comp./
Software for Evaluation,
Data Analysis
10
Robert Timmons
from CSF, Kris
Oswalt and local
consultants
16 days
Dec. 1985
Oct.13-30, 1986
Course design
underway
7.
NIPCCD Computer Trg.
6
Kris Oswalt and
local consul
tants
12 days
Sept. 1986
Nov.-Dec. 1986
Kris Oswalt
over extended.
Not completed
8.
AIIMS-ICDS Computer
Training
6
Kris Oswalt and 12 days
local consultant
Dec. 1986
9.
Training Technologies
NIPCCD Training
Specialist
1
University of
Pi ttsburgh
8 Meeks
April 28June 20, 1986
10.
Master Course in Trg.
Management/Tech.
7
David Kahler
3 days
11.
Trg. Technologies
and Management of Trg.
Workshop (Combined
course).
15
David Kahler
18 days
Not complted
1987 course
Nov. 1986
Aug. 1986
Nov. 1986
NIPCCD Training
Specialist not
yet appointed.
SI.
No.
Training Program
No. of
parti
cipants
Trainer
Duration of
Training
4 weeks
12.
Communication
Planning i Strategy
2
Cornell Univ.
13.
Health Education
Training
2
To be decided as
as NHED Component
material izes
Original
Date of
Training
Proposed
Date of
Training
July 13 Aug. 8, 2986
1987 course
Date Training
Completed
Comments and
Outstanding
Problems
NHED Coordinator
not yet
appointed in
Gujarat and
Maharashtra.
Need to identify
District NHED
Coordinator.
should include more of a substantive or applied focus that is
consistent with USAID’s project implementation schedule, content
focus and objectives and the proposed annual plan of operations.
Experience regarding roles and responsibilities of various staff
members such as CDPO’s, MS, DD0,and CEO and the thrust of their
future work in the project should be reviewed before such training
activities can be useful. Again, priority should be given to skills
training for achievement of specific coverage and qualitative
improvement objectives.
3.
Social marketing and communications training proposed at Cornell
University should be carefully re-assessed, now that more experience
and knowledge exists regarding ICDS-specific needs. The option of
developing a course and conducting it at an appropriate field site
in India or other Asian country using short-term TA and coordinated
by Manoff International should be considered in its place.
4.10
Innovative Studies
Annex IVA contains a recent USAID review of this component conducted
during the course of this mid-term review. This line item in the budget
has not been used so far and these activities are behind schedule. The
review team endorses the use of these funds for the design and testing of
methods for increasing the cost-effectivenes of various components in the
current project. Additional topics emerging from this mid-term review
that should be considered are listed below:
a•
Identification of who the current non-participants are in a
community especially among pregnant and nursing women and
children under 3 years. Ethnographic studies of the reasons
for their low participation. Testing of methods to increase
their participation.
b.
Testing the cost-effectiveness of AWW’s task-reallocation among
helper, Dai, ANM community leaders, AWW and MS. Activities
would include relevant training modules, incentive schemes and
72
supervision.
Two or three different models can be tested in
each district.
c.
Incentive system for Mukhya Sevikas. These could be linked to
specific skills successfully imparted to AWW and helpers (e.g.
growth monitoring, NEED, record keeping); maintenance of high
enrollment and coverage rates in her circle and her ability to
use AWC data for appropriate analysis, interpretation and
action (MIS).
d.
Development of a district level II"train-and-visit"II system for
continuous technical backstopping, in-service training,
orientation and a feedback mechanism for block, circle and AWC
level functionaries. The present USAID/JSI staff may be a
starting point for this. They will need additional support.
In the long run, the system should be complementary and
supportive of existing resources and if possible, be totally
transferable to entities such as CARE, district ICDS cells, and
training centers.
e.
Development of service-cum-training sites attached to private
voluntary organizations, MLTC’s and AWTC’s preferably those
located close to project districts. Each training center would
be allocated the budget and resources for a block or circle and
given responsibility to implement the ICDS program.
f.
Development and market testing of special weaning foods and
mothers food supplements through local retail outlets using the
new RTE food processing plants.
g-
Design and testing of protocols appropriate for ICDS for
rehabilitating III and IV grade malnourished children.
h.
Design of a cost-effective means to accurately assess mortality
impacts of ICDS. This would include strengthening the present
system for registering births and deaths in the project
73
districts in a large enough sample to be able to detect changes
in mortality.
USAID and MHRD need to develop a concept paper and implementation plan for
innovative studies as soon as possible. Entities to undertake the studies
will need to be actively sought out and encouraged. PVOs, training
centers and universities should be particularly appropriate for this
purpose.
4.11
Low Birth Weight Research
The evaluation team did not review this component of the USAID project,
recent USAID review, however, was conducted. See Annex IV.b. This has
highlighted the following issues:
A
o
Unanticipated delays in governmental approvals of the research
sites, protocols and importation of equipment has seriously
obstructed implementation of this component.
o
The collaborating scientists in the Indian and U.S.
institutions selected for the research remain eager and anxious
to begin full scale implementation. The research has a large
potential payoff in terms of understanding how to increase
child survival and optimize child development in India.
Therefore every effort should be made to operationalize this
component.
o
If full scale implementation cannot begin by early 1987, the
proposed work cannot be completed during the current life of
the project (PACD 9/30/90). The project will need another
extension or funds in this line-item will need to be
re-allocated to other activities. Activities such as social
marketing and communications and more focused health inputs
should receive high priority in this reallocation.
74
4.12
COMMUNITY PARTICIPATION
Extensive social and material support for ICDS from the community implied
in GOI guidelines and the USAID Project Paper has not been forthcoming.
The Project Paper calls for the MS and CDPO to have a catalytic role in
mobilizing this support. The team found that little motivation or
community organization skills had been systematically imparted to MS and
CDPO during basic training. It is left to the individual DCPO or MS to
do their best to promote community participation.
In Chandrapur district of Maharashtra it was observed that AWCs were
functioning in the accommodation provided by the Panchayat Samiti either
in a community building or at a local primary school. In many instances,
it was observed that ICDS feeding and pre-school activities for children
had to be adjusted to school timings. Food distribution was done very
quickly in the early morning before the school children arrived, which led
to curtailing all other activities such as pre-school education at the
AWC. In some instances food was found to be shared by school children.
Many of these irregularities or defects could have been averted if
sufficient time were devoted to village leaders and sensitize them
regarding the objectives of the ICDS program and the need for the
community to provide a proper building for the AWC. In most of the
instances, the AWCs had been established quickly without proper
orientation being provided to community leaders.
In the Project Paper, it was envisaged to conduct orientation workshops
for community leaders in order to familiarize them with ICDS. Such
workshops were to be held once a year during the first 3 years of the
USAID assistance. In both districts these workshops have not yet been
held in part due to late postings of CDPOs as well as ICDS District
Program Officers. It also took a long time to work out the financial
arrangements whereby payments will be made available at the block/distriet
level in order to conduct such workshops, since this is an activity not
usually funded in ICDS. All this led to delays in conducting these
workshops for community orientation.
75
Recommendations
1.
It is recommended that village leaders' workshops be held
immediately. Additional means of communication such as through
radio, film, print materials (some presently proposed under the NEED
component) should be considered. Celebrating one day per year as
ICDS day in each community has been found to be a useful mechanism
for maintaining community awareness.
2.
Some method of supervision of the functioning of AWCs by the
community’s leaders and according to the needs of the mothers and
children should be worked out to ensure better participation.
3.
The use of public displays of key indicators on the nutrition
situation of children in the village and their coverage with
services should be tested. For example, these could be used by MS
and CDPO at Panchayat and Mahila Mandal meetings to discuss specific
problems in ICDS. Monitoring by village leaders and women's
organizations of AWC timings, quality of pre-school activities, food
ration sizes, and coverage of priority beneficiaries may be
possible.
4.
It is also suggested that village/block level committees on ICDS be
set up. Such committees should take the responsibility of ensuring
regular activities by the AWW and helper at the center. Periodic
interruptions in food supply may also be corrected by this
committee, by providing local contributions in kind or helping with
transportation and storage.
76
CHAPTER 5:
PROJECT INPUTS
The estimated cost of the project as designed in 1983 is summarized in Table
5.1.
The main project inputs are:
o Management and Coordination
o Technical Assistance
o Food
o Funds for salaries, training, equipment and other operational
costs•
o Community Support.
5.1 MANAGEMENT AND COORDINATION
A summary list of who has primary responsibility for each major project
component follows:
Overall Management and Coordination
Supplementary Feeding
Health Services
Nutrition and Health Education
Training
Technical Assistance
Monitoring and Evaluation
Low Birth Weight Research
Innovative Studies
77
MHRD, USAID
CARE, state governments
MOHFW, state governments
State governments,
U.S. contractor
NIPCCD, ICCW, AIIMS,
training centers, U.S.
contractor, state
governments, in-service
workshop contractor
U.S. contractor
USAID, CARE, AIIMS,
home science and medical
colleges, state governments
ICMR, and various Indian
research institutes, U.S.
collaborators
MHRD, state governments
TABLE 5.1
PROJECT KLEMKKTS
AID LOAN
LC
COST ESTIMATE FOR AID ASSISTED ICDS
($ THOUSAND)
SOURCE 6F FUNDS
AID GRANT
LC
FX
AID
TOTAL
GOT
TOTAL PROJECT COSTS
LC
FX
TOTAL
1.
Staff Costs
5,006
5,006
5,006
10,012
10,012
2.
Operations
1,007
1,007
1,643
2,650
2,650
(•21)
(822)
(821)
(822)
(1.007)
(821)
(822)
(1.007)
461*
872
872
a•Petrol, Oil, Lubricant
b.Medicines
(1.007)
c«Others
3. Furniture and Equipment
(1.007)
411
411
170
1,763
1,933
317*
2,220
202
2,422
2,960
1,803
3,766
997
4,763
749
749
9*
758
758
114
114
114
114
715
334
1,049
1,049
15,000
9,573
21,611
4» Technical Assistance
170
1,763
1,933
5. Training 6 Nutrition/
Health Education
1,903
202
2,105
6« Research and Innovative
Activities
1,963
997
7. Monitoring 6 Evaluation
8. Food Processing Plants
oo
9. Contingency
576
139
TOTAL
7,000
5,038
2,962
2,962
24,573
Includes inputs expected to be provided by UNICEF under their agreement with GDI as specified in UNICEF Master
Plan uf Operations, 1981 - 83.
Does not include food inputs to be provided by CARE and state governments with an estimated value of $29 million
including Ocean transportation for the period FY 1984-1989.
TABLE 5.2
Planned Versus Actual.
CRITICAL PERFORMANCE INDICATORS FOR AID ASSISTED ICDS
Critical Performance Indicator
I
Completion Date
Date
Actual
Responsible Party
Request for proposals (RFP)
for all contracts issued
10/15/83
July '84
USAID, MHRD, NIPCCD
All project equipment ordered
and inport clearances and
waivers processed
03/01/84
In process
USAID, UNICEF, ICMR
NIAID/NIH, state
governments, ICCW
Final protocol and questionnaires
printed for prevalence of maternal
infection studies and tests of
anthropometric indicators of
fetal growth
04/30/84
Nov. 1984
ICMR, research
institutes, US
collaborators
All managerial, supervisory and
technical staff at block (ICDS
and health), district, state
M3SW, ICCW, SCCW, NIPCCD, USAID
and research institutes hired
05/01/84
August 1986
(Except
NIPCCD
Dist cell
& State cell
USAID, HiRD
NIPCCD, state
government, ICMR
ICMR, research
institutes
All contracts and agreements
signed and staff on the job
06/30/84
NIPCCD &
ICMR delayed
USAID, MHRD
ICMR, NIPCCD
Impact evaluation
designed
06/30/84
06/30/84
Heme Sciences & Medical
Colleges, USAID, MHRD
Clearinghouses for NHED
established at state
governments’ ICDS cells
07/31/84
Not done
State governments,
TA Contractor
In-Service workshops
designed and mobile
teams trained
09/30/84
Delayed
Workshop contractor,
TA contractor, NIPCCD,
USAID
Inproved MIS designed
9/30/84
In Progress
TA Contractor,
AIIMS, MHRD, USAID
CARE
79
Critical Performance Indicator
Canpletion Date
Date
Actual
All project equipment
delivered to end users
09/30/84
Done except
for LBW
UNICEF, MHRD, ICMR,
state governments
Reference laboratories
for maternal infection
studies extablisted
10/31/84
Nov *84
identified
ICMR, research
institutes, US
collaborators
Performance standards for
workers and instructors
developed
10/31/84
Not done
NIPCCD
TA Contractor
NHED materials distributed
to anganwadis by state
clear! nghouses
11/30/84
NHED Research
in process
State governments
Syllabi for training CDPO's
MSs and AWWs revised
12/31/84
Not done
NIPCCD, TA
Contractor, USAID
All villages identified,
anganwadi workers recruited
and buildings donated
03/31/85
Done for
3,200 AWCS
NHRD, state
governments
Revised syllabi and
performance standards in
use in all training centers
and ICDS blocks
06/30/85
Not done
NIPCCD,
TA Contractor
Baseline inpact
evaluation survey reports
conpleted
08/31/85
01/31/86
Hone Science &
Medical College
All managerial, supervisory
and technical staff trained
or oriented
12/15/85
40% Staff
trained by
Sept. 186
NIPCCD, Training
Centers, Training
Consultants, TA
Contractor
Prevalence of infection
studies and tests of
anthropcmetric indicators
completed
03/31/86
Not done
ICMR, research
institutes, US
collaborators
80
Responsible Party
Critical Performance Indicator
Completion Date
Date
Actual
Responsible Party
All anganwadi workers
trained
03/31/86
92% AWWs
Trained
Training centers,
oe MHRD r state
governments
Inproved MIS installed
05/15/86
In process
ME1RD, state
governemnts, TA
Contractor, Workshop
Contractor
All anganwadis operational
05/15/86
90% AWWs
operational
by 9/30/86
b-HRD, state
governments, CARE
Protocol designed for
birth veight
interventions trials
09/30/86
Not done
ICMR, research
institutes, US
collaborators
Mid-project review
conpleted
09/30/86
09/30/86
USAID
In-service workshops
held for all MSs, AWWs
and trained dais and
their instructors
05/31/87
Delayed
Workshop
Contractor
NIPCCD, state
governments
Year 2 follow-tp inpact
inpact evaluation survey
reports conpleted
08/31/87
Hone Science,
Medical Colleges
Year 4 follow-ip impact
evaluation survey reports
conpleted
08/31/89
Hone Science
Medical Colleges
Final reports or intervention
trials to improve birth weight
conpleted
09/30/89
ICMR, research
institutes, US
Collaborators
End of Project review
conpleted
09/30/89
USAID
81
The overall management and coordination provided by MHRD and USAID has been
according to plan. Individual components that have progressed least in part
due to insufficient managerial inputs include:
o Health Services
o Low Birth Weight Research
o Innovative Studies
Table 5-2 gives the planned versus actual dates of accomplishing critical
performance milestones that were initially planned. In addition to the 3
components listed above, several training activities have been delayed. But
there have been recent indications that training activities will now proceed
on schedule.
5.2 TECHNICAL ASSISTANCE
A contract was signed with John Snow Inc. effective August 1, 1984 to run
through February 14, 1987 for a total of $1,580,000 to cover technical
assistance (TA) needs in the USAID-assisted ICDS Project. As of August 31,
1986 approximately $890,000 had been expended. Subcontractors are Manoff
International for Nutrition and Health Education (NEED) and Community Systems
Foundation (CSF) for Management Information Systems.
As stated in the contract, the chief functions are to:
provide long and short-term technical assistance in training, NEED, MIS
and other areas relevant to ICDS as identified by USAID and GOI.
arrange for non-degree short and long-term training in the U.S., in India
and in third countries for senior managerial and technical staff.
82
Level and Nature of Assistance
The level of effort in the contract and actual level provided to date are as
follows (there are still 5 months remaining in the contract):
Table 5.3
Technical Assistance
I
Training, TA & Staff Support
Boston-based Professional Staff
Contract
27.5
(in months)
Actual
17.5
Training/NHED Advisor
MIS Advisor
30
30
14
20
Field Officers/MIS Assist.
Short-term Consultants
(includes CSF & Manoff)
Clerical Staff
60
17
21
22
165
Approx, on schedule
Participant Training
48
3.5
There has been some restructuring of the contract with a larger proportion of
assistance provided through short-term consultants. The reasons for this
shift are as follows:
The high technical caliber of the short term consultants, specifically of
Indian consultants, Manoff International and CSF, their acceptability and
credibility among Indian counterparts and USAID led to an enhanced role
for them in the project. The subcontracts with Manoff International and
CSF have increased from approximately $99,000 to $291,000.
The delayed arrival of long-term advisors (in January 1985 and July 1985
instead of in August 1984) due to extenuating circumstances and the
departure of one advisor in August 1986 decreased the level of long term
TA.
83
The participant training plan has been seriously hampered because of the
unavailability of counterparts (See Section 4.9)
Recommendations
1.
There is a continued need for U.S. and Indian consultants. However, in
the Indian context, participant training may also be an effective vehicle
for improving technical exapertise. A significant restructuring of the
contract is needed for better support to the project, with a higher
proportion of short-term and Indian technical advisors. To coordinate
their work and follow up on their recommendations, long-term contract
personnel may also be needed. More sustained emphasis should be given to
participant training.
2
A new scope of work for this component should be developed at the earliest
so that the new contract can be in position when the current contract
expires in early 1987.
84
5.3 FOOD
The following table lists the planned versus actual deliveries made to USAID
assisted districts for the ICDS program.
Table 5.4
District
Panchmahals
1984
1985
1986 (April - July)
Chandrapur
1984
1985
1986 (April - July)
Food Deliveries vs. Planned
Planned (MT)
Grain
Oil
4,957
5,737
1,434
610
706
1,153
1,819
455
If OF AU1
FUNCTIONING
Actual (MT)
Grain
Oil
1,107
2,164
131
257
176
1,301
1,851
2,278
1,340
133
185
291
73
1,098
1,098
1,098
460
1,390
468
77
232
78
It can be seen from the above, during 1984 and 1985, less food was utilized in
the program than originally expected. This is due to a slower rate of
operationalizing AWC and supply disruptions. However, in the current fiscal
year utilization at the aggregate district level is according to plan.
Distribution to AWC varies by block and within blocks, especially in
Chandrapur. Inadequate food inputs at several AWC were observed by the review
team during the evaluation period.
85
5.4 FUNDS
USAID and GOI have made the proposed funding available for the first 3 years
of the project. The following tables summarize current approved levels of
funding by USAID and GOI.
Table 5.5
USAID Planned Grant Funds ($000).
LOP Planned Grant Funds ($000).
Items
Technical Assistance
Participant Training
In-Country Training
Equipment/Commodities
Other Costs
(e.g. NEED, LBW research, evaluation)
Contingency
=
LG
1,009
915
2,605
462
4,641 __________ 4,529
Total = $10,000,000
$830,000
USAID Planned
FX
3,859
320
Loan Funds
Operating Costs of Anganwadis
Management and Technical Staff
Subtotal
Contingency
Total
Total USAID Funding ($)
Grant
Loan
($000)
3,625
2,301
5,926
1,074
7,000
10,000,000
7,000,000
17,000,000
86
Table 5.6
GOI Funded Inputs LOP
Items
Training
LBW Research
Monitoring and Evaluation
Contingency_____________
Plus
Staff, Operational Costs
and Equipment
Table 5.7
Total
$ 000
195
1,756
6
571
2,528
Grand Total
7,045
9,573
USAID Inputs vs. Estimated Value of Work Done
___________ Items_____________________
% Utilization
24%
Technical Assistance (grant) 9/30/86
14%
Participant Training (grant)
In-country Training (grant)
37%
4%
Equipment/Commodities
Project Specific Inputs
(Grant NHED, LBW research, evalu. etc.)
9%
60%
(Loan AWC oper. costs, mgt. 8c tech, staff)
Total LOP ($000)
3,859
320
1,009
1,377
2,605
5,926
Accrued expenditures under the project are estimated at approximately 20% (a/o
9/30/86) of LOP funding and disbursements at approximately 10% for grant funds
and 16% for loan funds (a/o 6/30/86). See Figure 6.
Some steps are being taken to increase project disbursements and bring them in
line with utilization. Activities accounting for approximately 70% of grant
funding and all of the loan funding are now at various stages of
implementation. However, the remaining 30% grant funds are still tied up in
LBW research and innovative studies activities for which no early action seems
possible. A concept paper and implementation plan need to be developed and
approved for innovative studies as soon as possible and a mechanism for timely
disbursement of funds needs to be found.
For LBW research, USAID and GOI should begin discussions on a contingency plan
to utilize the funds elsewhere in the project should full scale implementation
be delayed beyond 1/31/87.
87
FIGURE 6
USAID Budget
20.0.
Total LOP - $17.0 m
15.0
OT
u
(C
X
c
"C
c
10.0
x
c
E
5.0
eX -
€
9/82
4/8-
88
.V
'
3/85
3/86
Annex I
ICDS Package of Services as Upgraded with USAID Assistance
A. Supplementary Food
Targets
Increased enrollment of pregnant and nursing women, and children 6-36
months from 74% to 95%
Increased and regular attendance of pregnant and nursing women, and
children 6-36 months to 85% consuming food at least 15 days per month.
Ration size equalling 300 calories and 8-10g. protein for all children,
600 calories and 16-20g. protein for severely malnourished children,
pregnant and nursing women.
Activities
Quarterly house to house surveys to recruit malnourished 0-36 months old,
children, at-risk pregnant and nursing mothers.
Registration system to monitor individual attendance and identify
defaulters
Dai incentive for regular attendance by pregnant and nursing women, AWW
and helper incentive for rehabilitation of malnourished.
Home visits focused on irregular and non-participants (pregnant and
nursing women, 6-36 months)
Selective take-home for young children, pregnant and nursing women,
mothers coupled with nutrition education.
Community’s role strengthened, Local women to contribute time and labor,
trained to conduct weighting and feeding. Village committees, donation of
room, AWW selection, monitoring, fuel, condiments and food donations.
orientation of village leaders.
89
Annex I (continued)
B
NEED/Communcations
Targets
-
Increased number of AWW-mother interpersonal sessions.
Improved quality of AWW-mother interaction to change behavior.
Increased use of growth monitoring as a teaching tool for mothers.
Community awareness regarding program services, roles of functionaries
and program objectives increased.
Activities
Selection of AWW with credibility.
Workload of AWW and re-scheduling of AWC was to allow increased mothers
availability for NEED by AWW.
Use of home visits for NEED.
AWW training in communications techniques and use of growth monitoring.
MS and CDPO training in communications techniques and use of growth
monitoring.
Supervisory duties of MS and CDPO vis-a-vis communications activities
strengthened.
Annual village leader orientation during first 3 years.
Use of multi-media to add interest and reinforce interpersonal (AWW mother and MS - mother) communication.
Expand target group to older siblings, grandparents, Dais.
Monthly evening group sessions with audio-visual media.
Use of print material as appropriate.
90
c
Health Services
Targets
Pregnant women
*
2TT
3 health checkups
★ Regular supply of Iron/Folic Acid
*
Deliveries by trained health personnel
(FHW, ANM, trained Dai)
* One check up after delivery
* 3 doses DPT
*
BCG
*
Nursing Women
0-1 years olds
*
*
*
*
*
i
1-3 year olds
*
*
•k
3-6 year olds
*
*
*
3 doses of OPV
Measles
4 health checkups per year
2 vitamin A megadoses per year
ORT for diarrhea
Booster doses for OPV and DPT
Regular health checkups
2 vitamin A megadoses per year
DT 2 doses
Vitamin A 2 megadoses per year
Health checkups
NOTE: The preschool education component in the project districts follows the
standard pattern and has not been upgraded by USAID.
91
u
Annex III
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88
Annex III
Summary of Meeting held at NIPCCD on
September 11, 1986 to discuss the
Preliminary Finds of the Review Team
The evaluation objectives, methodology, findings and recommendations were
presented by members of the review team. Mr. Subramanian, Secretary Rural
Development Department, Maharashtra State Government, chaired the meeting. In
addition to senior officials from the Central and State governments of Gujarat
and Maharashtra, USAID’s mission Director and Chief of the Health and
Nutrition Division were present. The following is a summary of the discussion
following the formal presentation.
Mr. Quaraishi: It will be useful to identify differences between AWC visited
at random and those purposely selected for good performance.
Mr. Subramanian: The review should be able to comment on ICDS in the overall
context of development. How do the findings relate to the general level of
development in different areas? What is the role of the food supplement in
deficit areas?
Mr. Fernandes:
issues:
i)
More specific recommendations are needed on the following
Supervision problems and what steps to take to increase the effectiveness
of Mukhya Sevikas.
ii) How to generate more community participation.
iii)
What specific role should Dais play and how can she be
operationalized for ICDS?
98
iv)
What was the effect of the differences in health sector activities on
ICDS in Gujarat vs. Maharashtra.
V)
What specific role can the AWW play in the delivery of health services?
Mr. Soni: The MIS component should help institutionalize use of management by
exception principles through special monitoring and follow-up of AWC and
blocks not meeting coverage targets. Grade III and IV children need more
specific health care. AWC constructed under NREP should be allocated Rs.4,000
to Rs.5,000 rather than Rs.1,500 currently allowed by GOI.
Dr.Contractor: NEED has been the weak link in the program so far which needs
to be remedied. Existing education materials should be reviewed and used as
appropriate. Regarding growth monitoring, wherever weighing scales are
available the need for the AWW to do mid-arm circumference seems redundant and
confusing. Regarding training, more emphasis is needed on frequent refresher
training of AWW.
Miss. Lalitha: There is a need for developing a systematic program to work
with the community prior to starting an ICDS program in a village.
Mr. Quraishi: As pointed out by the review team, more integration with health
inputs is needed. Specifically, MDRD should increase its monitoring of health
inputs directly. Motivational tools such as films on ICDS for PHC staff could
be used. The potential of using AWW for distribution of contraceptives needs
to be carefully re-examined; the suggestions of the review team regarding this
issue would be useful. Regarding ways of improving community participation,
perhaps celebrating one day each year as community participation day for ICDS
will be a useful and concrete activity that can be institutionalized.
The general consensus was that the increased level of monitoring provided to
the USAID assisted districts was responsible in bringing about the
improvements seen so far. Any recommendations made for qualitative
improvements should be carefully assessed in terms of replication costs.
99
Annex IV.a INNOVATIVE STUDIES
Project Proposal and Current Status
The Project also includes an allocation for innovative research and
development activities to inprove ICDS operations in general and those in
the two Project districts in particular. It was originally envisioned
that the Central Ministry of Social Welfare, (now Human Resource
Development, MHRD) and the nodal ICDS Departments at the State level
would have independent budgets reimbursable by USAID to conduct studies
which arose out of needs and problems encountered during project
inpiementation. A total of $ 1 million (Rs. 12.6 million) was set aside
for this activity over the 6 year period of the Project. Of this amount
$542,900 (Rs.6.84 million) were budgetted for FY'84, '85 and '86. To
date, no studies have been conducted under the Project and these funds
remain unutilised.
Because of the objective of relating the studies to field experience,
studies to be undertaken were not specified. However, a few topics were
identified at the inception of the Project as being potentially useful.
1.
Task analyses and time-and-motion studies of the Anganwadi Worker,
conducted in the first and fourth years of the Project. The findings of
the first study could have been useful in connection with the revision of
training syllabi, while the follow-up study would have indicated whether
training improvements had been successful. No such studies have been
conducted under the Project although we understand that similar studies
elsewhere may have been supported by the MHRD.
2. Another study suggested was on methods to increase attendance of
children under three years of age and of pregnant and nursing women, Our
field visits confirm that there is a real need for such ’operational
research’. NIPCCD is currently engaged in planning a Workshop to be held
in January 1987 on Strategies to Reach Out to Under-three's. The
Workshop will draw on the experience of other programs in the country,
culling lessons that are relevant to and implementable in ICDS. Some of
these strategies could then be tried on a pilot basis in the AID-assisted
districts.
100
3. Other suggestions given in the Project Paper for innovative
studies/research were:
incentives to Anganwadi Workers for good performance
and to parents for good child feeding behaviour,
development of a ration planning system based on
attendance and malnutrition rates
development of acceptable food supplements for
pregnant women
child-to-child nutrition and health education
regular weighing of pregnant women and mother cards
regular weighing of newborns by dais.
Future Directions
In the course of our review of field activities we have
identified some critical areas of program operation where
studies might be helpful to improve implementation.
1.
Nutrition and Health Inputs
a. A Pregnant Women’s Food Supplement, eg. matruahar. There is
currently a proposal from the M.S. University, Baroda to develop
and field test a methi flavoured product. There is a need also to
test approaches to increasing mothers participation at Anganwadis
eg. through education-demonstration.
b. The iron-folic acid tablet distribution system from central source
to beneficiary, particularly in terms of coverage and health
impact.
2.
Coverage of Target Groups
c. A take home food system for mothers and especially for
malnourished children under three years of age who may not attend
the Anganwadi. For example, one day a week could be set aside
exclusively for delivering services to pregnant and nursing women
and infants on an experimental basis.
101
374^
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I
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LIBRARY
4
.
AlVO
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d. On community perceptions of ICDS and participation, especially of
mahila mandals.
The proposal to orient village leaders should be
implemented and monitored to reveal useful approaches.
I
e. Enlisting trained dais (and offering them incentives) to assist
ICDS objectives, particularly regarding antenatal and postnatal
care and coverage of mothers by anganwadi services, as well as
newborn care, and weighing at birth.
3.
Anganwadi Workers Role
f. A task allocation study (as described in the Project Paper and
mentioned above), whose extension could be operations research of
'good1 Anganwadis, focussed on the successful AWWs' behaviour,
work performance and processes.
g. On supervision, to establish linkages between workers (AWWs, AN?4sz
MSs).
h. On the use of the Quarterly surveys to streamline and assess the
AWWs activities.
4.
Impact Assessment
i. A births and deaths registration system to improve mortality
impact assessment of ICDS.
We propose that these areas of interest be publicised by MHRD, and
proposals for specific studies be solicited from action-research oriented
institutions/individuals and screened so that in FY 87 a number of
studies can get underway. The emphasis should be on operationally
relevant studies that can be carried out quickly, say within 6 months to
1 year, so that their results can in turn be incorporated into project
design and implementation as soon as possible.
102
Annex IV.b LOW BIRTH WEIGHT RESEARCH
Recognising that low birth weight is an important contributor to high
infant mortality in India, the Project includes research to examine the
causes of low birth weight and design and implement suitable
interventions to reduce its incidence. The research will be conducted by
a number of Indian scientific institutions, coordinated by the Indian
Council of Medical Research (ICMR), with collaboration from several U.S.
based research institutes. The Institute of Medical Sciences, Banaras
Hindu University, the King Edward Memorial Hospital, Pune, the King
George’s Medical College, Lucknow, and the Trivandrum Medical College are
the four centres involved in studying the role of infection in low birth
weight, with the Christian Medical College, Vellore, as a reference
laboratory. The role of nutrition will be studied at two field centres:
the Institute of Medical Sciences, Banaras Hindu University, and the
National Institute of Nutrition at Hyderabad. The collaborating
institutions in the U.S. are the Albert Einstein College of Medicine,
New York, the Centers for Disease Control, Atlanta, the Harvard
University School of Medicine, and the National Instititute of Allergy
and Infectious Diseases (NIAID).
There have been a number of delays in getting the research underway. The
USAID ICDS Project Paper, dated June 1983, proposed that the research be
done by three different research institutions at Chandigarh, Pune and
Vellore. A protocol was also drafted for the infection studies in May
1983 but per the Project Agreement signed in September 1983, the details
of the research were to be finalized by the ICMR subject to the approval
of the Ministry of Health and Family Welfare(MOHFW). In June 1984, the
MOHFW informed ICMR that they did not concur with the sites and
institutions selected to do the research (with the exception of Pune) and
suggested that new sites and institutions be identified in states with
high, medium, and low infant mortality rates, namely Uttar Pradesh,
Maharashtra, and Kerala, respectively. In October 1984, with the help of
the U.S. collaborators, a reappraisal was done, and new sites and
institutions were identified in the states recommended by the MOHFW.
Details of the Nutrition studies were also worked out at that time and a
revised protocol for Nutrition and Infection studies was jointly prepared
103
by the Indian investigators and U.S. collaborators and finalized by ICMR
and USAID in November 1984. However, formal clearance from the MOHFW and
other concerned GOI entities, which was necessary to commence the
research, was not received until September 1985. The original Project
assistance completion date of September 1989 was revised to September
1990 in early 1985 in order to accommodate the one year delay experienced
at that time. However, further delays in clearance procedures have
resulted in the low birth weight research being more than two years
behind schedule at the current time.
In view of these delays, this progress review, reflects activities over
the past one year, rather than three years, as is the case with the main
ICDS Project. The delayed start of the Low Birth Weight research was
also due in part to the complexity of the research and to the involvement
of several institutions in India and the U.S. This complexity continues
to be a contributing factor to the slow progress made by this Project
component. It is apparent that an additional extension of the life of
project by 1 1/2 - 2 years will be necessary to complete all phases of
the research as originally planned.
The Research Programme
The research consists of separate Nutrition and Infection studies, The
latter commence with measurement of the prevalence of four specific
gynecologic infections and the effects of these on birth weight. The
Nutrition studies go directly into assessing the effects of maternal
nutritional status and food supplementation in the ICDS programme on
birth weight. Both sets of studies investigate the role of
socio-economic and related factors, such as physical activity, on birth
weight. In its later phases, the Infection study envisions an
intervention trial using antibiotics against infection to increase birth
weight.
The technical feasibility and cost of improving birth weights through
anti-microbial therapy or food supplementation will be assessed in these
studies. The ultimate goal is to develop cost-effective interventions
widely useable in India to improve birth weights. It is also envisioned
that the technology developed and skills transferred would have
applications to topics of research other than low birth weight.
104
The Project Paper envisioned the following Infection study phases and
specific tasks:
Phase I - 6 months (Over)
A. Recruit laboratory and field staff, and train principals of the
Infection Study Centers and Reference Laboratories for three months in
the U.S.
Status:
Done
B. Finalize research protocols and develop and pre-test field
questionnaires and manuals.
Status:
Almost done.
C. Train research staff in questionnaire administration and clinic and
field techniques.
Status:
Done
D. Equip laboratories, standardize laboratory procedures between Indian
and U.S.-based labs, and develop the logistics of specimen handling upto
the investigating labs.
Status:
Not done.
Equipment import delayed on account of clearance
procedures.
Phase II - 18 months (Ongoing, but commencement delayed,
run through FY 87 and atleast first half of FY 88).
Estimated to
A. Conduct prevalence studies of maternal infection in hospital
settings. In this connection, test laboratory methodologies including a
cold chain for specimens, and effect quality control through exchanges of
specimens with U.S. laboratories.
Status:
Not yet begun
105
B.
Extend the hospital-based Infection study to a rural population.
Status:
Not yet begun.
Inter Phase - 6 months
(Future:
Estimated in second half of FY 88)
A. Analyse the results of Phase II, and prepare protocols for subsequent
phases.
B.
Identify appropriate institutions for Infection study intervention.
Phases III and IV - 3 years (Future: Contingent on prevalence of
infections and their association with low birth weight as determined in
Phase II. Unlikely to commence before FY 89.)
A.
Test relation between infection and low birth weight through an
antimicrobial intervention designed based on results of Phase II.
B.
Train relevant Indian personnel in the U.S.
C.
Continue quality control system, periodic progress reviews, etc.
D. Analyse intervention’s cost benefit/effectiveness and assess its
suitability for large-scale application.
The phasing of the Nutrition study is as follows:
Phase I - 1 year
(Ongoing)
A. Select experimental and control sites and ensure supplementary food
supply to test areas.
Status: Being done
B.
Finalise and pre-test protocols and instruments.
Status:
Almost done
106
c.
Recruit and train field staff.
Status:
D.
Done
Initiate field survey and recruit pregnant women into study.
Status:
In progress
Phase II - 3 years
into FY 90)
(Estimate commencement during FY 87 and continuation
A. Continue to recruit pregnant women into study, ensure prenatal
supplementation, measure birth weights and do one year infant followup.
Status:
B.
Not yet begun
Begin data analysis.
Status:
No data yet.
Phase III - 1 year
A.
(Future: estimate in FY 90)
Analyze data and write report.
Recommendations
Although staff have been recruited and trained at all the investigating
centers, research protocols, questionnaires and manuals have been
prepared, and some preliminary field work has begun, the above review
clearly shows that the research particularly in the Infection study is
considerably behind schedule. laboratory and field equipment has been
ordered in the U.S. but its import into India has been delayed on account
of GOI clearance procedures. Local procurement of other equipment is
similarly handicapped by the lack of a mechanism to advance USAID funds
to the participating centers. These procedures clearly need to be worked
out before the research can begin in earnest. The participating
investigators are eager and anxious to get the research underway.
107
The project provides for a Senior Research Officer to be hired by ICMR
specifically to manage these studies. This has not been done but in our
view remains advisable because of the procedural delays encountered thus
far.
It is clear that the antimicrobial treatment trial for maternal
infections (Phases in and IV) is unlikely to commence before January
1989. As it will take three years to complete, the Infection research
study will not be possible to finish within the current Project
assistance completion date of Septonber 1990. It will be necessary for
USAID to assess the successful completion of the Phase II Infection
prevalence studies in late FY 88. if it seems warranted to proceed with
the Phase in - iv intervention trials, the Project assistance completion
date will then have to be extended for 11/2-2 years.
108
USAID ASSISTED INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)
MID-PROJECT EVALUATION
Scope of Work
I.
OBJECTIVE
The overall objective of this scope of work is to conduct a
mid-project evaluation of the USAID assisted Integrated Child
Development Services (ICDS) Project in order to assess the progress
in achieving tne targets, outputs and purpose as specified in the
ICDS Project Paper (PP) dated June 19S3.
conducted by a team of three members.
The evaluation will be
The specific tasks to be
performed by each of the team members in order to accomplish the
overall objective of this scope of work are outlined below,
The
evaluation will be conducted in the USAID assisted districts of
Panchmahals, Gujarat, and Chandrapur, Maharashtra, with necessary
discussions with government officials at the state and central
levels.
II.
BACKGROUND READING
All lean members will be expected to read the following documents:
A.
Integrated Child Development Services Project Paper, USAID/New
Delhi, June 1983.
B.
USAID Assisted Integrated Child Development (ICDS) Project in
the districts of Panchmahals, Gujarat and Chandrapur,
Maharashtra - A Baseline Appraisal, USAID/India, February 1984
by S. Sen Gupta and M.A. Anderson.
C.
USAID Assisted ICDS Impact Evaluation Baseline Survey, M.S.
University, Barada, 1995.
109
III. TEAM LEADER: DR. TINA 6. SANGHVI
The teifi leader will have primary responsibility for coordinating
the work of the evaluation tear* members and for writing consolidated
evaluation reports and a Project Evaluation Summary (FES) in AID
specified foreat.
A.
Specific tasks include evaluation of:
1.
Performance by ICDS Project’s Technical Assistance
Contractor, John Snow Inc, (JSI) and sub-contractors, Manoff
International and Community Systems Foundation,
(CSF) of the
scope of work in their contract, and the quality of their
services.
Assessment will be made in India as well as
through one day vdsits by the team leader to the offices of
JSI, Boston, CSF, Ann Arbor ana Manoff International,
Washington, D.C. for discussions with ICDS contract staff.
2.
Achievement of PP targets for establishment of functional
anganwadis (village child care centres).
3.
Achievement of PP targets for filling managerial,
supervisory and technical posts at all levels.
4.
Achievement of Participant Training Plan, John Snow Inc.,
July 19S5.
5.
Progress in the Nutrition and Health Education LMHED)
component (Essential reference - ICDa Social Marketing
Consultancy Report by Daniel,Lissance and Marcia Griffiths entitled Project_Implement atjon_P2an, Manoff International,
July 1985.
6.
Progress toward establishing two food processing plants
(Essential reference - ICDS Food Processing Plant
Feasibility Study by J.M. Harper and 6.R. Jansen, August
1985)
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7.
Achieveaent of PP targets (or coverage o( malnourished
children 6-36 months of age, pregnant women and nursing
mothers with regular supplementary feeding.
8.
Adequacy of supervision of Anganwadi Workers (village child
care workers) by Mukhya Sevikas (middle level supervisors),
and of Mukhya Sevikas and Anganwadi Workers by Child
Development Project Officers (CDPOs - block level).
B.
Report
The team leader will write the following reports:
(1) an ICDS
mid-project evaluation report on overall progress which will
incorporate the findings of each of tna evaluation team members,
(2) a JSI contract performance report, and (3) a Project
Evaluation Summary in AID specified report,
All of these
reports will be presented to USAID in draft form by September
and in final form by September 6, 1936.
C.
Timetable and Itinerary (Tea® leader)
Activity
Date
I
July 1996
Read background documents; visit
U.S.A.
JSI, CSF, and Manoff
(5 days)
International.
I
August 4-6
New Delhi
Read project documentation;
meet with USAID, CARE, JSI, and
Ministry of Human Resource
Development/Department of Women
and Child Development officials.
August 7-13
I
Panchmahals
Visit 3 blocks, spending 2 days
District,
in each and visiting 4-6
Gujar at
anganwadis in each (Different
sample for Team leader and Team
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member 2).
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Site •
August 14
Act i.vitx
Place
Ahmedabad/
Meet government of Gujarat ICDS*
Gandhinagar
officials in the Health and
Family Welfare Department and
CARE.
August 15
Independence Day (Holiday)
Aucust 16-17
Free
August 18-23
Chandrapur
Visit 3 blocks spending 2 days
Distr ict
in each and visiting 4-6
Maharashtra
anganwadis in each (Different
sample for team leader and team
member 2).
I
Free
August 24
August 25
Meet government of Maharashtra
Bombay
ICDS officials, in the Rural
Development Department, CARE,
MODE, advertising agency,
Maharashtra State Cooperative
Marketing Federation, and
Mixi-Therm Engineers.
August 26-
New Delhi
Write report.
New Delhi
Attend mid-project review
September 1
September 2
meeting with central and state
government ICDS officials and
present report in draft.
September 3-6
New Delhi
Finalize report
and Project
Evaluation Summary and present
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to USAID.
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IV.
TEAM MEMBER 2: DR. SAMIR. CHAUDHURI
Team mender two will concentrate on evaluation of the health
services^ community participation, training and growth monitoring
components of the USAID ICOS project.
A.
Specific tasks include evaluation of:
1.
Coverage of ICDS project beneficiaries with essential health
services, i.a.
a.
Pregnant women - tetanus toxoid immunization, iron/folic
acid supplements and health check-up,
b.
Nursing waeen (first six nonths)
c.
Children (0-3 years of age) - immunization, health
health check-up,
check-up, megadose Vitamin A (1-3 years).
2.
Achievements of PP targets for basic training of Anganwadi
Workers, Mukhya Sevikas and Child Development Project
Off icers.
3.
Achievement of PP targets for orientation of village leaders
and extent of community participation and capacity building.
4.
Progress toward retraining field level, service delivery and
supervisory ICDS and health workers through Mobile
In-service Workshops.
5.
Progress toward accomplishing training improvements
envisioned in the PP, namely revised syllabi and performance
standards for all levels of workers, accreditation of
Anganwadi Mekers' Training Centres, and enhanced monitoring
by the Indian Council of Child Welfare (ICCW) and the State
Councils of Child Wefare (SCCW) of Anganwadi Training
Centres run by them.
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6.
Role and performance of the John Snow Inc. resident Training
Advisor in achievement of items 4 and 5 above.
7.
The extent and quality of growth monitoring conducted by the
Anganwadi Workers.
Report
B.
The consultant will write a report on the findings of the
evaluation of the items specified in section A and present it to
the team leader by August 29, 1986.
C.
Timetable and Itinerary (Team Member 2)
Bite
Place
July 1986
CINI,
(2 days)
West Bengal
August 4-6
New Delhi
Activity
Read background docupents
Read project documentation; meet
with USAID, JSI, NIPCCD, ICCW, and
Ministry of Human Resource
Development/Department of Women
and Child Development officials.
August 7-13
Visit 3 blocks, spending 2 days ir.
Panchmahals
District, Gujarat each and visiting 4-6 anganwadis
in each (Different sample for team
leader and team member 2).
August 14
Meet government of Gujarat
officials in the Department of
Ahmedabad/
Sandhinagar
Health and Faaily Welfare, SCCW,
and staff of other training
centres.
Independence Day (Holiday)
August 15
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Date
Activity
PJjce
Free
August 16-17
August 18-23
Chandrapur
Visit 3 blocks spending 2 days in
District,
each and visiting 4-6 anganwadis
Maharashtra
in each (Different sample for team
leader and team member 2)
Free
August 24
August 25
Meet government of Maharashtra
Bailbay
ICDS officials in the Rural
Development Department and Health
and Faaily Welfare Department,
SCCW, and staff of training
centres.
August 26-29
Write report
New Delhi
Free
August 30 September 1
September 2
Attend mid-project review meeting
New Delhi
with central and state government
ICDS officials and present report.
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VI.
TEAtt-MEMBER 3: DR. NIRMALA MURTHY
Team member three will concentrate on evaluation of the management
information system (MIS) and monitoring components of the USAID ICDS
project at the central, state, district, block, supervisoy (Mukhya
Sevika) and anganwadi levels.
An assessment will be made of the
extent to which an improved MIS system has been installed, with
reference to use of the system prescribed in the ICDS Integrated MIS
Manual prepared by the Department of Women and Child Development in
1985 and modifications to that system to insure the accurate
reporting and use of weight data on nutrition status and coverage of
supplementary feeding, health services, and nutrition and health
education, as prescribed in the USAID ICDS Project Paper (PP).
A.
Specific tasks include evaluation of:
1.
Regularity, completeness, and accuracy of quarterly
community surveys by Anganwadi Workers, including weight
data on all children under six years of age, and vital
statistics and census data for all families.
2.
Standardization of register formats at the anganwadi level,
and accuracy and completeness of such registers.
3.
Comprehension of recordkeeping and use of the information by
the Anganwadi Worker.
4.
Accuracy and completeness of Monthly Progress Reports
*
prepared by Anganwadi Workers.
5.
Use of Monthly Progress Report data by the Anganwadi Worker
to assess the performance of her anganwadi and take
corrective action.
6.
Use of Monthly Progress Report data by the Mukhya Sevika to
assess the perforoance of her anganwadis, to give feedback
to Anganwadi Workers and to take corrective action.
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7.
Use of solar calculators (provided with USAID assistance) by
Child Development Project Officers and Mukhya Sevikas for
MIS work.
8.
Accuracy and completeness of Monthly Progress Reports
prepared at the block level by the Child Development Project
Officer (CDPO).
9.
Use of AWW Monthly Progress Report data by the Child
Development Project Officer, and Assistant Child Development
Project Officer (where relevant) to assess the performance
of and give feedback to Anganwadi Workers and Mukhya Sevikas
and to take corrective action.
10. Use of CDPO Monthly Progress Report data by the District
ICDS Prograe Officer to assess the performance of various
ICDS blacks under his supervision, to give feedback to Child
Development Project Officers and to take corrective action.
11. Use of CDPO Monthly Progress Report data by the State
government’s ICDS cell to assess the performance of various
ICDS blocks in the state, to give feedback to the District
ICDS Program Officer, or CDPCs and to take corrective action.
12. Extent to which the HCL Busybee eicrocoaputer (provided with
USAID funds) is being effectively used for ICDS-MIS work by
the state government’s ICDS cell.
13. Use of CDPQ Monthly Progress Report data by the Department
of Women and Child Development, Ministry of Human Resource
Development to assess the ICDS performance of various
states, to give feedback to state governments, and to take
corrective action.
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14. Extent to which the HCL Busybee aicrocoeputer (provided with
USAID funds) is being effectively used for ICDS—MIS work by
the Department of Hoaen and Child Development's. ICDS staff
in New Delhi.
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15. Linkages established between: (1) ICDS health inputs
monitoring system under AIIMS (Monthly Monitoring Reports),
(2) ICDS supplementary nutrition monitoring system designed
by CARE, (3) the Monthly Progress Report system under the
Department of Women and Child Development and (4) social
inputs and training aonitoring system designed by NIPCCD.
16. Effectiveness of project monitoring services performed by
the district level field officers under contract with John
Snow, Inc. and regularity and usefulness of their monthly
reports..
17. Role ^nd performance of the John Snow, Inc. resident MIS
Advisor in achievement of items 1-15 above.
B.
Report
The consultant will write a report on the findings of the
evaluation of the items specified in Section A and present it to
the team leader by August 29, 1906.
C.
Pate
July 15-17
Activity
Place
New Delhi
Read background documents;
review MIS at Ministry of Human
Resource Development/Department
of Women and Child Development
and meet with USAID, JSI, CARE,
NIPCCD and AIIMS.
July 10
Chandrapur
Review MIS at district level
July 19-23
Chandrapur
Visit 2 blacks, spending 2 days
District
in each and visiting 2-3
anganwadis to review MIS.
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Date
July 24-25
Activity
Elase
Review MIS at state level in
Bombay
Rural Development Department.
Free
July 26-27
July 28
Review MIS at District level
Sodhra,
Panchmahals
July 29-
Panchffl&hals
Visit 2 blocks; spending 2 days
August 1
Distr ict
in each and visiting 2-3
anganwadis.
August 4
Aheedabad/
Review MIS at state level in
Gandhinagar
Health and Family Welfare
Department
August 5
New Delhi
Debriefing at USAID
August 26-29
New Delhi
Write report
Free
August 30 -'
September 1
September 2
New Delhi
Attend mid-project review
meeting with central and state
governments ICDS officials and
present report.
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Relationships and Responsibilities;
The Evaluation Team will work under the technical guidance and
supervision of the Chief, Nutrition Division and the Program
Specialist (Nutrition? in the Office of Health and Nutrition,
USAID/New Delhi.
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