Innovations & Good Practices In ICDS:

The West Bengal Experience

6th - 8th November, 2013NIPCCD Regional Centre

Bengaluru

Malnutrition : A Silent Emergency (0 -3 years)Malnutrition : A Silent Emergency (0 -3 years)

Micronutrient s … the hidden hungerMicronutrient s … the hidden hunger

Nutritional status of children in WB Nutritional status of children in WB

Perc

ent

Source: NFHS 3 2005-06

Malnutrition : A silent emergency (0 -3 years) .. Contd.Malnutrition : A silent emergency (0 -3 years) .. Contd.

PACKAGE OF NUTRITION INTERVENTIONS

Maternal Nutrition:

- ICDS-1000 days’ window of opportunity- Piloting of IGMSY

Adolescent Nutrition:

- WIFS & Piloting of RSEAG SABLA

Child Nutrition:- ICDS- Community based management (PD) & Facility based management & care (NRC)- Micronutrient supplementation ( VAS & IFA bundled with de-worming)

Creation of buffer stock zones at AWC levelImproving Service delivery of SN

•Heath & Nutrition Education•ECE

Improving Community

awareness & participation

Good Practices in ICDS/ State innovations

Improving Service delivery of

Supplementary Nutrition

Critical Indicators: Maternal & Child nutrition

Impact level:

Reduction in prevalence of underweight <3 yrs. & <5 yrs. children– Moderate/ <-2SD ( target: 10% point)– Severe /<-3SD (target: 50% point)

Process level: • Improve % of registered children 6-71 months who

received Supplementary Nutrition for at least 21 days a month in last 3 months ( Target: 100%)

• Improve % of registered P&L women who received Supplementary Nutrition for at least 21 days a month in last 3 months ( Target: 100%)

Strategy: Buffer Stock zone

Objectives

– Facilitate uninterrupted supply of food grains at AWCs through improved supply chain management

– Comply with feeding norm of min. 300 days a year– Influence maternal and child nutrition outcomes

positively

Implementation design

• One AWC over a cluster of 25 AWCs to be identified in each GP of the project

• The identified AWCs will stock the food grains /SNP items; and supply in case of requirement raised by other AWCs in the net

Demonstration/learning phase

• Pilot tested successfully by Burdwan district• Spread over 46 ICDS projects 9278 AWCs in the district

Jamuria (U)

Kulti (U)

Asansol (U) - I

Raniganj (U)

Durgapur (U) - I

Barddhaman (U)

SALANPURBARABONI

JAMURIA

RANIGANJ

PANDAVESWAR

ONDAL

KANKSA

FARIDPUR-DURGAPUR

AUSGRAM-II

AUSGRAM-I

GALSI-I

KETUGRAM-I KETUGRAM-II

MANGOLKOTE

KATWA- I

KATWA- II

PURBASTHALI - II

MANTESHWAR

PURBASTHALI -I

BHATAR

GALSI-IIBARDDHAMAN-I

KHANDAGHOSH

RAINA-I

BARDDHAMAN-II

MEMARI-II

MEMARI-I

KALNA-I

KALNA-II

RAINA-II

JAMALPUR

Asansol (U) - II

Durgapur (U) - II

KATWA- I

Monitoring • A user friendly monitoring tool had been in

use for tracking the status of requirement & supply

• No. of AWCs providing 21+ days of SNP increased in the district – from 95.95% in December 2011 to 99.21% in December 2012 (source: DMPR)

Expansion & way forward • Going by the success in improving feeding continuity,

the state has asked all districts to identify AWCs to act as buffer stocks for supply of SNP in respective GPs

• Currently NIC is supporting Deptt. in developing a web based solution for monitoring which would help in issuance of advisory to the projects regarding availability of stock, and therefore

» Reduce leakage within the system» Streamline indenting procedure » Reduce data transmission time» Improve food supply chain for SNP» Improve data reliability» Improve quality and coverage of ICDS SNP

Improve Community awareness & participation

Nutrition & Health Education

Critical Indicators: Child nutrition • Outcome level:

Children aged 6-9 months receiving semi solid food along with breast milk(%) : 55.9% (NFHS-3)

• Impact level: Reduction in prevalence of underweight <3 yrs. & <5 yrs.

– Moderate/ <-2SD ( target: 10% point)– Severe /<-3SD (target: 50% point)

Strategy: Annaprashan

Objective

To improve infant and young child nutrition (initiation of age appropriate complementary feeding at 6 months)

Coverage

• Initiated in Malda - 17th amongst 19 dists. in HDI ranking ( WBHDR 2004)• Covers 26 projects, 5573 AWCs• To be intensified as part of District Integrated Nutrition intervention plan

from next year

OLD MALDAH (M)ENGLISH BAZAR (M)

GAZOLE

KALIACHAK - II

HARISCHANDRAPUR - II

CHANCHAL - II

RATUA - I

MANIKCHAK

ENGLISH BAZAR

OLD MALDAH

HABIBPUR

BAMANGOLA

HARISCHANDRAPUR - ICHANCHAL - I

RATUA - II

KALIACHAK - I

KALIACHAK - III

Activities

– Community level celebration and awareness camps

– Demonstration of age appropriate complementary food

– Initiation of Active Feeding– Counselling of mothers/ care givers– Financial support by district

Critical Indicators: Maternal Nutrition

• Outcome level:

Percentage of pregnant women who received 3 or more ANC check ups: (latest status 62.4% - NFHS-3, target : 80%)

Percentage of pregnant women who consumed IFA for 90 days or more: 24.3% (latest status -NFHS-3, target : 80%)

• Impact level: Reduction in prevalence of anemia in pregnant women

(latest status : 62.6% - NFHS3, target: 20%)

Strategy : Sadhbhakshan

Objective:

To promote maternal nutrition during pregnancy

Coverage

• Initiated in Malda - 17th amongst 19 dists. in HDI ranking ( WBHDR 2004)• Covers 26 projects, 5573 AWCs• To be intensified as part of District Integrated Nutrition intervention plan

from next year

OLD MALDAH (M)ENGLISH BAZAR (M)

GAZOLE

KALIACHAK - II

HARISCHANDRAPUR - II

CHANCHAL - II

RATUA - I

MANIKCHAK

ENGLISH BAZAR

OLD MALDAH

HABIBPUR

BAMANGOLA

HARISCHANDRAPUR - ICHANCHAL - I

RATUA - II

KALIACHAK - I

KALIACHAK - III

Activities– Community level awareness on importance of

pregnancy care through– Community level celebration– Demonstration of food basket containing samples

of all food groups– 100 IFA – IEC booklet on dos & don’ts on care during

pregnancy, (also need for institutional delivery and essential new born care)

– Counselling

Addressing Child Undernutrition through Improved Health & Nutrition Education in ICDS

The Positive Deviance Approach

Concept of Positive Deviance (PD) in Nutrition

– An important part of the nutrition gap is information gap

– People can succeed nutritionally in low-income communities

– The “positive deviants” utilize their resources effectively

• beneficial practices amongst families of similar socio-economic status living under similar conditions are shared with mothers/ care givers of moderate and severely underweight children in the age group of 6-36 months

• Emphasizes importance of behavioural change in nutrition

Goal

Reduction of undernutrition among children < 3 years

Objectives

– Identification of all undernourished children for reduction of undernutrition

– Rehabilitating them to higher nutrition status , i.e., Normal grade of nutrition

– Develop capacity of community for prevention of future incidence of malnutrition and

birth of LBW babies

Program Goal & Objectives

Implementation Phases

Phase I: Community Mobilization• Use of community level child undernutrition monitoring tools • Identification of child undernutrition prevalence and making it visible to the

community

Identification of proper nutritional status of all children Use of undernutrition monitoring tools for community

mobilization

Child Undernutrition Monitoring Tool

Social Map

COHORT Register

Mother and Child protection card

Community Growth Chart

Implementation Phases (contd.)

Phase II: Nutritional Counselling and Child Care Sessions (NCCS)

• Use of PD approach to identify local resources and beneficial child care practices • Demonstration, practice and active feeding at AWC with mothers/ Care givers of

undernourished children apart from issue based counselling• Monitoring of weight gain of children till rehabilitation to Normal grade

Identification of community level child care practices through

FGD / PDI

Involvement of community in running NCCS

Practice of food hygiene and cleanliness

Active child feeding practices at community

set up

Package of services in NCCS

• 12 day learning by doing technique to adopt correct feeding, hygiene, health and psychosocial practices

• Package of services– Health check up by ANM, de-worming of children– Weighing of children to monitor weight gain – Active feeding of children– Theme based nutrition and health education for 12 days at AWCs– Use of self monitoring tool for mothers to monitor attendance & learning– Counseling of care givers on ten essential nutrition interventions– Referral of severely underweight with medical complications to health facility/

NRC

• 18 days’ of continued practice at household till child shifts to normal grade of nutrition

Self MonitoringSelf Monitoring Tool for mothersNHED Issues

Day Issues for discussion

1Colostrum feeding and Breastfeeding; Exclusive breastfeeding for

first six months

2Timely initiation of Adequate Complementary Feeding - Quantity,

quality, density and frequency

3Food and feeding hygiene, hand washing with soap, and use of

clean potable water4 feeding of child during and after illness

5 Growth monitoring and promotion

6Child immunization - Primary immunization schedule ,

immunization upto 5 years, , vitamin A and iron supplementation

7

Micronutrients - importance of Iodine and use of adequately iodized salt, testing of iodine content in household salt using MBI

kits8 Diarrhoea and ARI - care of the child 9 Worm infestation and personal hygiene

10Psycho-social development of children - milestones (with focus

on under three)

11 ANC - check up, household care, diet and rest

12PNC - check up, household care, diet and rest; care of the new

born

Monitoring

Individual: – Child wise tracking : NCCS report

Community: – Anganwadi- wise : NCCS and GMP report– Sector - wise : NCCS and GMP report– Project-wise :NCCS and GMP report– District-wise: NCCS and GMP report– State: NCCS and GMP report

Map Not to Scale

• Introduced by UNICEF in March, 2001 in collaboration with DWCD& SW as a pilot initiative for reduction of Infant & young child malnutrition

• CINI was commissioned as a facilitating agency for implementation

• Piloting was done in 2 blocks of Murshidabad – Beldanga- I and Berhampore; and in 2 blocks of South 24 parganas – Falta and Bishnupur- I

Inception: The Pilot Phase of PD

Murshidabad

South 24 parganas

Upscaling of Pilot experience

As the pilot initiative became successful, Positive Deviance was gradually introduced to Murshidabad, Purulia, Dakshin Dinajpur, South 24 Parganas from 2003 followed by phase-wise introduction in other districts

Murshidabad

Dakshin Dinajpur

Purulia

South 24 parganas

Map Not to Scale

Positive Deviance Program in West Bengal ( as of Dec, 2012)

** Total no. of ICDS projects ( pre- bifurcation number)

Implementation by Deptt. of CD, GoWB, Financial support mainly from NRHM, Deptt. of H&FW and part from UNICEF, Technical support by UNICEF

District 10Block / projects 133 **

AWC 40979Training completed 24742

AWCs running Nutritional Counselling and Child Care Sessions (NCCS)

19746

Moderate and severely undernourished children 6m–3 yrs. receiving active feeding and care giving services during NCCS

236952 (approx)

Bankura

Hooghly

BarddhamanPurulia

Birbhum

Malda

Dakshin Dinajpur

South24 ParganasHowrah

Murshidabad

Nadia

Kolkata

North24 Parganas

Darjeeling

Jalpaiguri

Cooch Behar

Uttar Dinajpur

Paschim Medinipur

Purba Medinipur

Map not to scale

Evaluation

Evaluation by National Institute of Nutrition (NIN), Hyderabad in 2006:

• Positive impact found in:– Young child care and feeding

practices– Utilization of health & nutrition

services, quality improvement of ICDS

– Improved community participation in PD areas

• Relatively better nutrition status of children in PD areas:– Better mean heights and

weights of <3 yr children,– Lower prevalence of

stunting

• Increased weighing resulting in increased identification of child underweight

• Improvement in child care practice

• Reduction in child underweight

Impact : Evaluation Report by NINPD CONTROL

SERVICES

NHED 69% 27%

WEIGHING 50% 13%

REFERRAL 37% 18%

COMPLETE IMMUNIZATION

86% 68%

VIT.A 2ND DOSE 50% 33.1%

CHILD CARE

BREAST FEEDING (WITHIN 3 HRS.)

76% 44%

COLOSTRUM 90% 82%

EXCLUSIVE BREAST FEEDING

70% 61%

INITIATION OF COMPLEMENTARY FEEDING AT 7 MONTHS

44% 28.8%

PREVALNCE OF UNDERNUTRITION

OVERALL PREVALENCE OF UNDERNUTRITION AS PER IAP CLASSIFICATION

55% 64%

PREVALENCE OF STUNTING AS PER SD CLASSIFICATION

26.5% 32%

Source: PD evaluation by NIN, 2006

Taken at sale as Sneha Shivir by GOI

To improve Counseling and Child care services of

ICDS

Going beyond: Linkage with facility based careIdentified malnourished children (6 m-3 yr)

Severely malnourished Moderately malnourished

With medical without medicalcomplication complication Infection

NRC/ MTC No improvement To NCCS

Practice of health seeking behaviour at household / Focussed home visit & follow up at household level

To be continued till the child(ren) attain normal level of nutrition

AWCs as Vibrant ECD Centre

Objectives

• Prioritize ECE within the daily activities of AWC, in light of RtE Act 2009

• Review of Existing ECE curriculum and gap analysis with reference to National Level Documents

• Development of a revised curriculum – with reference to National Policy and Curriculum Framework

• Development and roll out of a capacity building plan for implementation of the newly developed ECE curriculum

Processes Adopted

• August 2011: Formation of State Level Core Committee on ECE: Convergence between DWCD&SW, SSA, Unicef

• March 2012 : 2 day Consultation -overview of national and international trends in ECE. Guiding principles finalized

• May 2012 : 5 Day Curriculum Development Workshop in– 35 member Core group identified, Consensus on curriculum design, design of AWW’s handbook and implementation strategy

• July 12: 5 Day Curriculum Finalization Workshop in - working group reviewed feasibility of draft curriculum and AWW handbook, National level RPs (including NCERT and NIPCCD) reviewed

Processes Adopted (contd.)

• September 2012 : Curriculum finalized and Piloted as part of NIPCCD’s pilot study project in 16 states of India. Participation in Regional workshop at NIPCCD Guwahati

• February 2013: field testing and data analysis workshop at 2 projects

• May 2013: 2 days’ sharing workshop on ECE curriculum and capacity building strategy of West Bengal

• July 2013: Field testing of training modules for AWWs at S-24 Parganas

Shifts in Curricular Approach

• Domain based to activity based• Thematic Approach incorporated• New routine break up• Move away from 3Rs to School Readiness• Emphasis on Early Language Learning

Curriculum Design

ECE CURRICULUM

ACTIVITY BASED

EMBEDDEDTHEME

AGE APPROPRIATE – based on Early

Learning Development

Standards

Sample Routine

Pilot Process

• Pilot - 100 centers (50 rural and 50 urban) for 8 weeks from Rural and Urban projects as per guidelines provided by NIPCCD Guwahati

• Frequent monitoring and on-site support• Peer to peer support for AWWs• Monitoring visit by NIPCCD and CECED• Data Analysis workshop at project level after

completion of Field Test

• Impact of curriculum on AWW and children There is a specific, visible rhythm in the daily classroom process and a clear

progress can thus be seen in children’s participation and learning

• Use of Handbook by AWW’s Although it is designed for AWWs, handbook may prove to be a valuable

resource for all levels of ICDS officials –a ready reckoner for what is appropriate for pre-school

• Impact of shift from Domain Centered to Activity Centered Curriculum

• Impact & Use of books in the Centre

• Impact of suggested material display (4 corners)

Pilot Findings

Lessons Learnt

• The inclusion of field knowledge of AWWs and Supervisors has made the curriculum and handbook more hands on and easy to implement

• Structured routine with activities and materials aligning principles of – i. age appropriate, – Ii. thematic, and– Iii. activity based learning made children more enthusiastic and better tuned

in towards the routine

Influencing Factors

• Involvement of parents, local community to know about curricular shift

• Mothers’ meeting by AWWs to convince the parents• AWWs should be enthusiastic and open to Activity based

processes• Availability of space and time to conduct all suggested

activities • Additional support for Student Teacher ratio – more than

30

Way forward

• Revision of routine from 2.5 hours to 4.5 hours including SNP

• Development of training manual and piloting of training design as per suggestions received from MWCD, NIPCCD and NCERT during sharing workshop (3rd- 4th May 2013)

• Formation and Capacity building of State and District Resource Groups (400 individuals, selected from officials and functionaries of Deptt. of CD and WD &SW) – SRG 1 batch over, 1 going on, DRG planned

Community Participation in PSE

Other innovative measures

• COHORT tracking of individual beneficiaries to establish a continuum services for the first 1000 days

Other innovative measures (contd.)

• Mobilizing corporate support in improving delivery of services and model AWCs as visualized in Mission

• Establish vertical and parallel linkage with other departments and within the same deptts. between program interventions

How are we looking at Innovations & Good practices

• Instrumental in leading a catalytic effect• District level variations and requirements to be given due

importance in district intervention plan with some semblance in planning and introduce key innovations/ good practices

• District planning exercise already initiated for Fy 2014-15 with additional focus on developing Integrated Nutrition Intervention plan for 2 focus backward districts- Malda and Purulia

• Develop convergence models and leverage program funds for a pool of funds for integrated interventions in the focus districts

Thank You