Strategy Planning for Sanitation and Hygiene

Improvement in Tribal Areas of Andhra Pradesh

(In coordination with UNICEF HFO)

Jun 7-8, 2017 | Rampachodavaram

- A Report

SWACHH MANYAM – SWASTHH MANYAM

(INCLUSIVE DEVELOPMENT)

TRIBAL WEFARE DEPARTMENT

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A Report of the Workshop held on

Strategy Planning for Sanitation and Hygiene

Improvement in Tribal Areas of Andhra Pradesh

(In coordination with UNICEF HFO)

Jun 7-8, 2017 | Rampachodavaram

Executive Summary

A two-day workshop, the first-of-its-kind in the state of Andhra Pradesh on “Strategy

Planning for Sanitation & Hygiene in Tribal Areas of Andhra Pradesh” was organized by

the Tribal Welfare Department, Govt. of Andhra Pradesh, in coordination with UNICEF

HFO during Jun 7-8, 2017 at the premises of the Integrated Tribal Development Agency

(ITDA) – Rampachodavaram, East Godavari district. The workshop, which was also

organized as part of the state government’s prestigious campaign “Nava Nirmana

Diksha” meant for overall restructuring of Andhra Pradesh, aimed to equip the

participants belonging to the various stakeholder departments with necessary

knowledge and skills required to initiate action in the tribal areas to achieve improved

sanitation situation. The most crucial expected output of the workshop was designing

an action plan ITDA wise to improve the sanitation situation in those areas. The concept

and the session plan of the

workshop were conceived and developed by UNICEF HFO and the sessions were

facilitated jointly by the members of the WASH team UNICEF HFO and Tribal Welfare

Department. In all, 62 officials and functionaries belonging to govt. departments and an

NGO named EFICOR took part in the event.

The specific objectives of the workshop were:

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Generate common understanding and appreciation towards addressing

Sanitation and Hygiene issues in Tribal areas of the state.

Review and revise current strategies for improvement in sanitation and hygiene

situation

Appreciate the importance of coordination and convergence among all

stakeholders to achieve sanitation and hygiene goals.

Develop sanitation and hygiene improvement plan suitable to their individual

ITDA areas/ Mandal- GP-Habitation – Institution & HH wise.

The sessions in the workshop during the first day focused on the sanitation situation

analysis of the tribal areas and strengthening the knowledge base of the participants.

The second and final day was fully devoted to the action planning to improve the

sanitation situation and determining the timelines for making the ITDA areas open

defecation free (ODF).

In the end, the participants produced individual action/target plans ITDA wise to

improve the sanitation situation in these areas, clearly mentioning the timelines for

making ITDA areas ODF.

Day Wise Proceedings

Day-1 (Jun 07, 2017)

Inaugural Session

The inaugural session of the workshop was presided over by Mr. A S Dinesh Kumar, IAS,

Project Officer-ITDA, Rampachodavaram and the chief guest for the event was Mr.

Namana Rambabu, Chairperson-Zilla Parishad, East Godavari district. The session began

with Mr. D N Murthy, State

Senior Coordinator - Tribal

Welfare Department, welcoming

the participants and introduced

them to the workshop’s

objectives and the session plan

over the two days. He also spoke

about the evolution of ITDA R C

Varam in implementing various

programs pertaining to inclusive

development.

The expected outcomes of the workshop as presented by Mr. D N Murthy are as

follows:

ITDA wise sanitation and hygiene improvement plans implemented & achieved

saturation of sanitation facilities

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Coordination and convergence(Inclusive Development) established among all the

stakeholder departments towards achieving the sanitation and hygiene goals

Ensured sustained use of sanitation facilities in the ITDA areas.

Then, setting the tone for the workshop, Mr. S R Nalli, WASH Specialist, UNICEF HFO,

spoke about the imperative need of the initiating a campaign in tribal areas to improve

sanitation situation. He said, “This is a campaign, not a one-day event. It will not stop

until the sanitation situation improves in

ITDA areas. However, this is not an easy task

because there are several issues to be

addressed (as compared to the plains) in

tribal areas: material non-availability and

lack of transportation, excess availability of

space (positive factor, though) less access to

water are a challenge. Provision of funds is

also an issue. It is estimated that about an

amount INR 40,000 Cr is required to meet

the saturationof IHHLs in the country,

whereas an amount of only INR 8,000 Cr

was allocated, which was increased from

the earlier INR 5,000 Cr budget allocation. Space is abundant in tribal areas and it is

becoming an obstacle in construction and usage of IHHLs. Water is needed for drinking

and flushing the fecal matter. The strategy that is adopted in the plains may not work

for tribal areas, and, therefore, we will discuss all these issues and formulate an action

plan to improve the sanitation situation in the ITDA areas. Since you come from

different stakeholder departments and work at the grassroots level, you are right

people to discuss the issues in the tribal areas and provide meaningful solutions for the

implementation of the program”.

Later, speaking on the occasion, Mr. A S Dinesh Kumar, PO-ITDA, reminded the

participants that the strategy designed for the plain areas would not work in the tribal

areas, and therefore a unique and separate strategy is the need of the hour for

improving sanitation situation in the ITDA

areas. He further said, “Bringing stakeholders

from all ITDA areas onto one platform for

improving sanitation is the first of its kind in

the history of Andhra Pradesh, and perhaps

even first time in the country. The success rate

of toilet usage depends on the availability of

water. The excess availability of space can

somehow be addressed, but how do we able

to bring in behaviour change..!? The plan of

the campaign should address each person of

the household and their different needs.

Behaviour change communication plays an important role in this. People should be able

to get rid of the taboo associated with shit, and they should talk about it loudly. Take the

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As part of Nava Nirmana Diksha, the participants and the distinguished guests were

taking oath to make tribal areas ODF in the state of Andhra Pradesh by 2019

example of Vizianagaram’s campaign. Hope you all actively participate in the

discussions, brainstorm and provide solutions to the issues. Let me see the good

outcomes emerging out of this workshop”.

While delivering his address, the Chief Guest of the workshop Mr. N Rambabu,

Chairman-Zilla Parishad, East Godavari district,

said, “It is happy to see a workshop on Swachh

Manyam is being organized bringing in all ITDAs

under one umbrella. I am also happy to note that

this program has been taken up under Nava

Nirmana Diksha, which reminds us that sanitation

is also equally important in restructuring the state

of Andhra Pradesh. Since Independence, we still

have been in the process of achieving improved

sanitation in the country. We all have a

responsibility to make swachh villages in our state

to improve our health and well-being. Let us all

get involved in this endeavour”.

Sanitation Pledge, as part of Nava Nirmana Diksha

Session-1 Sanitation & Hygiene Goals: Where We Are

Facilitator Mr. Salathiel R Nalli, WASH Specialist, UNICEF HFO

Speaking on the different perspectives prevail among the personnel of the various govt.

departments, Mr. Nalli said, “It’s not about spraying bleaching powder, or cleanliness, or

sweeping roads, but we would only discuss important issues involved in ODF. Why we

are we preaching safe sanitation to tribal people? What is the need? Why are we

focusing on it? Let us see.

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Sanitation is one of the top priorities of the central and the state governments. The

governments have committed to making the country/state ODF by 2019 or earlier. This

is one of the reasons as to why we are assembled here. There are other reasons as well:

Diarrhea kills 8,00,000 children under-5 every year

Under-nourished children are 925 million

Explaining the comparative trends in the child mortality (NFHS-2005-06 estimates)

between the marginalized communities (SC and ST) and that of general category of

communities, he said, “the rates of neo-natal and infant deaths in children are

somehow equal, but there is an increase in deaths in Under-5 children belonging to

marginalized communities

as compared to that of

general category. It implies

that there is a lesser focus

on health and nutrition in

the marginalized

communities (SC & ST) as the

children grow. Pneumonia

and diarrhea together

contribute about 29% to the

child mortality rate in Under-

5 children. Therefore, we

need to make the tribal

communities aware of the negative consequences of open defecation, which lead to ill

health and malnutrition in children.

Speaking on the Sustainable Development Goals, he briefed the participants about the

definitions of indicators related to the SDG-6, pertaining to water, sanitation and

hygiene management:

SDG-6: Ensure availability and sustainable management of water and sanitation

for all.

Safely managed drinking water: Percentage of population using an improved

drinking water source (MDG definition) which is –

o Located on premises

o Available when needed

o Free of fecal matter (biological) and chemical contamination

Safely managed sanitation: Percentage of population using an improved

sanitation facility which is –

o Not shared with other households, and

o Where excreta is safely disposed or treated off-site

o Plus handwashing facility with soap and water

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He informed that, out of the amount INR 15,000 that is being provided as an incentive

to the individual household for constructing and using a toilet, an amount of INR 2000 is

being provided towards constructing handwashing facility with soap and water.

Therefore, mere construction of toilet facility is not enough to save children from

mortality: construction of toilet coupled with handwashing facility is required.

Showing the data related to the progress of improved sanitation facilities among the

various income groups in the rural areas, he explained that sanitation has less priority

and the govt. schemes are not reaching the poorest of the poor in rural areas. However,

better progress is not shown even in the group of richest of the rich. Therefore, he

concluded that, it is required to ensure that the tribal communities are empowered in

terms of information related to the link between sanitation and health/nutrition and the

various govt. schemes that are beneficial to them.

Session-2 Why Sanitation and Hygiene for Tribal areas: Perspective Building

Facilitator Mr. Venkatesh Aralikatty, WASH Officer, UNICEF HFO

Stating that sanitation has different connotations, Mr. Venkatesh kick-started the

session, storming the brains of the participants by posing a question “what do you think

of when sanitation comes to your mind?”. The participants responded with the notions

such as “water (contamination), environment (pollution) and personal hygiene (soiled

hands/handwashing), solid and liquid waste” etc. He further asked, “How do you see

these notions, barring solid and liquid waste - as factors or consequences?” They all said

in unison “consequences, and open defecation (OD) is the factor”.

He explained why we wanted to work on reducing OD in tribal areas:

OD leads to death in children

OD is the primary reason for contamination of water

OD is the reason for atrocities on women

One gram of fecal matter contains –

1,00,00,000 (one crore) viruses

10,00,000 (ten lakhs) bacteria

10,000 parasite cysts

100 parasite eggs

Fecal matter will not remain there. It will travel to many places including out homes:

through flies, animal and human legs, insects, pigs, dogs etc.

Breaking fecal-oral cycle is the most crucial factor to improve health.

Why the caveman and the modern man adopting the same procedure of OD?, because:

Both do not know the connection between sanitation and health/nutrition (lack

of awareness)

Modern man does not feel the need (lack of priority)

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Personal hygiene: two most critical times for handwashing with soap and water

After defecation

Before eating a meal

He concluded that since the tribal areas are more vulnerable than the plains in terms of

awareness and accessibility to WASH facilities, it is more required to spread the

awareness on the negative consequences of OD:

OD implies expenditure on health, vicious poverty cycle, insecurity

Childrens’ feces are more dangerous than that of adults

Session-3 Situation Analysis of Sanitation in Chenchu Habitations: An Overview

Facilitator EFICOR Team, Kurnool

This session was facilitated by three members of EFICOR team: Ramesh Babu – Director

- Programs, Daich Kishore – Manager - Programs, and Ms. Joylin – Program Associate.

The presentation’s highlights are as follows:

Study was conducted in 4 mandals

112 households taken as sample from 19 villages

9 FGD were held with women, children and men

36% Chenchu community members are literates

Only 36% of community members are using toilets

Amalapuram is the only chenchu gudem that was declared ODF in Jan 2017

o Total toilets built : 38

o The Survey done by the SHWETA team showed only 29% usage as on

1/06/2017!!

o Main reasons stated for

non-usage: Smell,

disgust, proximity to the

house, bathroom

combined.

76% of the people stated

that due to lack of money

(financial problems), they

could not build toilets.

56% Chenchu families do

not follow any measures to

keep the drinking water clean because they believe that nature-provided water

will always be clean.

77.67% Chenchu households do not have toilets at home.

Of the 22.33% households that have toilets, only 36% of the Chenchu families are

using toilets consistently.

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About half of the households did not come across any communication message

regarding construction or usage of toilets during the last six months.

53.5% households prefer TV/Radio as a channel of communication.

The EFICOR team members concluded that they have developed a communication

package on sanitation and hygiene already and that they are going to roll out in the

coming days.

Session-4 Status of Sanitation in Tribal Areas of Andhra Pradesh

Facilitator Ravikanth R Mazumdar, State Consultant for WASH

In this session, Mr. Ravikanth presented the scenario of IHHls to be constructed during

the year 2017-18, based on the data obtained from the state website within the IMIS site

(sbm.gov.in). He briefed the participants (especially those who came from non-

tribal/non-ITDA areas) about the constitution of districts and mandals under scheduled

and plain areas.

The highlights of the presentation were:

Districts that have predominant tribal presence: 9 out of total 13 (50% or more

tribal population in a district)

Scheduled area districts: 5

Plain area districts: 8

Total ITDAs: 9 (Srisailam, K R

Puram, R C Varam, Seethampeta,

Paderu, Nellore, Parvatipuram,

Chintoor, & Plain Areas)

Total tribal population in the state:

27.39 L

Total tribal population in the

scheduled areas: 14.51 L

Total tribal population in the plain

areas: 12.88 L

He presented the data pertaining to

number of IHHLs to be constructed in

each mandal of the tribal areas. He made it clear that the numbers in the data shown

may not be accurate as it depends up on the frequent updating of data.

He concluded that, the participating personnel representing the various ITDAs are

required to bring it to the notice of the POs concerned to take necessary action to

achieve saturation of IHHLs in their respective areas.

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Session-5 WASH in Institutions

Menstrual Health Management

Convergence for Improved Sanitation in Tribal Areas

Facilitators Mr. Manikanta, Ms. Niharika Singh &Mr. D N Murthy

WASH in Institutions: This session was facilitated by Mr. Manikanta, Consultant for WASH

in Institutions (APKATS). The highlights of this session were:

Important aspects such as infrastructure, IEC & IPC and resource mobilisation etc

related to three crucial domains of WASH in Institutions- WASH in Schools, WASH

in Health Centres and WASH in Anganwadi Centres – were discussed.

The participants were sensitized upon the need of

ODF environment in the institutions.

Various government schemes and guidelines, and the

roles and responsibilities of the relevant

departments’ personnel discussed.

Initiatives such as Kayakalp, Swachh Swastha

Sarvatra, Swachha Vidyalaya and the status of the

facilities, and the way forward were shared for a

better understanding of the participants.

Implementation strategies in tandem with the

Sustainable Development Goals helped devise a

broad action plan.

The stark difference and the urgent need of WASH in

institutions in the tribal areas through various research inputs helped generate a

new level of awareness among participants.

Menstrual Hygiene Management: This session was facilitated by Ms. Niharika Singh, Young

Professional, WASH - UNICEF. The highlights of this session were:

The session covered the vital components of what constitutes Menstrual Hygiene

Management. A brief on the globally

accepted definition and the multi-

pronged issues concerning safety,

privacy and dignity of girls associated

with MHM were discussed.

Participants were briefed on the grim

reality on the ground through research-

based data insights.

The session helped understand MHM

related practices & issues in context and

relevance with WASH in Institutions.

Emphasis was laid on ‘Breaking the

Silence’ around menstruationand ‘Educating the entire Stakeholders’ alike.

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Simple infrastructural strategies, best practices and innovations in MHM were

disseminated to all participants.

The highlights of Menstrual Hygiene Management Guidelines along with the

specific role of different departments and ministries at Central, State, District and

School level helped participants understand their role better with regard to

MHM.

In essence, the session touched upon disempowerment of girls due to school

dropouts wherein a lack of MHM is a major contributing factor.

Convergence for improved sanitation situation in tribal areas: This session was facilitated

by Mr. D N Murthy. During this session, he shared his experiences of working in the

tribal and plain areas wherein he initiated

many development programs in the areas of

health, education etc for the marginal and

deprived communities. Some of those

programs that he mentioned were- School

on Boat (to reduce the dropout rate), Sarva

Shiksha Abhiyaan (2000), School Health

Program/Jawahar Bal Arogya Raksha (2010),

and Comprehensive School Health (2016).

He shared the challenges he faced during

the implementation of these programs and

how he joined hands with other

departments (health, ICDS, education etc) in

finding solutions to the problems, and how he inculcated the sense of responsibility and

ownership in the functionaries of the other stakeholder departments etc to become a

part of the inclusive development.

He informed the participants that an official letter to this effect (convergence for ODF)

from the Special Commissioner – Tribal Welfare Department has already been issued to

the stakeholder departments (Health, Education and ICDS). He said that UNICEF’s

support would also be sought, if required.

He concluded that, as tribal communities being the most vulnerable population owing

to geographic isolation and other issues, all stakeholder departments are required to

come together in the ITDA areas to improve the sanitation situation.

Manyamlo….Swachh Raatri (A Clean Night in the Wilderness/Tribal Habitat): An

Entertainment Program

Facilitator Mr. Manikanta

An entertainment program Manyamlo….Swachh Raatri, anchored by Manikanta, was

organized during the evening. The aim of this event was to relieve the stressand

entertain the participants who felt exhausted having participated actively in the

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sessions applying their minds and acts together. During this two-hour event, almost all

participants of the workshop took active part voluntarily in singing, saying jokes in

making others smile, and dancing alone and in the group to the blaring music.

And, the birthday of Niharika Singh was celebrated, which fell accidentally on this same

day.

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Day-2 (Jun 08, 2017)

Session-6 Recap of Previous Day’s Proceedings

Facilitator Mr. Manikanta

ITDA Seethampeta

ODF status implies saturation of toilets at household and school and institutions level and the consistent usage.

Need to make MHM a part of the curriculum in schools.

ITDA Parvatipuram

How to take the concept of ODF to the tribal communities and convince them with the awareness related to the link between sanitation and nutrition and health.

How to coin words (which are considered a taboo and shameful to speak) to make them feel the need.

The concept of sanitation and hygiene.

To make a GP ODF, WASH in Institutions is equally important

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ITDA Paderu

Need to educate children about health and nutrition issues through curriculum-based health education.

Constructing toilet alone contribute to ODF but its consistent use will.

ITDA Rampachodavaram

ODF implies death in terms of children dying with diarrhea, women getting raped and tortured to death etc.

ITDA Chintoor

Need to inform and educate the tribal community vis-à-vis deaths related to open defecation.

Need to educate tribal women and girls on menstrual hygiene also during the visits of health workers (ASHA activist, ANM etc)

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ITDA Srisailam

There are several “unexpected” ways of discarded excreta reaching human bodies again through the oral route, causing infections and diseases.

The excessive number of diarrheal deaths in children Under-5 can be prevented with hand washing at critical times.

The situation of consistent under-nutrition in children is affecting the future generations.

Session-7 Introduction to Planning of Sanitation and Hygiene Improvement in

Tribal Areas

Facilitator Venkatesh Aralikatty

In this session, Mr. Venkatesh, geared up the audience mentally to be able to produce

individual plans ITDA wise for sanitation and hygiene improvement in their respective

areas. He motivated them to think about/recall a path-breaking incident that happened

in their career life (especially in the areas health, sanitation, education, and nutrition),

which brought a sea change or a paradigm shift in their approach and served as a good

learning to take it forward. He put forward a 4-point formula (4 Dimensions) to facilitate

organize their thoughts process prior action preparation for their respective areas. The

4-point formula was:

Discover: Recall the incident in your real/career life as to what was the issue,

what triggered the incident, and how it happened.

Dream: How did you see/perceive the issue for resolution? How did you solve

the problem – on your own or sought any outsider’s help?

Design: What efforts did you put to solve the issue? What was your plan?

Deliver: How did you implement the plan to solve the issue?

The participants discussed the issues in sub-groups, and presented to the house sub-

group wise. Those issues majorly revolved around health and sanitation.

While summing up, the facilitator said, “I appreciate the efforts you have/had put in to

resolve the identified issues in your respective areas. You could ultimately find a

solution to the problems. It implies every issue has a solution or many. In the same way,

we can also find solutions to the issues related to sanitation and hygiene in the tribal

areas. Now, before you embark upon preparing an action plan, keep in mind the this 4-

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point formula in identifying the exact issue/problem, what resources are required to see

that the issue resolved, what and how will you make an appropriate plan, and what are

the ways and means you would want to implement the plan”.

Session-8 Key Strategies for Sanitation and Hygiene Improvement in Tribal Areas

(campaign mode): Vizianagaram Experiences

Facilitator Ravikanth R Mazumdar

Sharing the experiences that the ODF campaign named “10000 IHHLs in 100 Hours” that

saw commendable success in the plain and the tribal areas of Vizianagaram district, Mr.

Ravikanth, guided the participants towards internalizing the valuable lessons learnt

during the campaign, different phases of the ODF campaign and the activities to be

carried out in respect of those phases. The final output is as follows:

ProposedAction Plan Template

Campaign for Transforming GPs to ODF

under Swachh Manyam

Timeline: Dec 2018

By what date would you transform your ITDA to ODF ?

Time period for each phase ?

PRE-CONSTRUCTION

Timeline& Budget for each activity to be mentioned

Activities

Choosing GPs/Mandals: How many and on what basis? (identify the criteria)

Designating persons responsible for the campaign 1) Identifying

personnel from stakeholder departments and Third Party Monitors & Documentation

2) Communicating the list to the persons concerned& the dates of the campaign

3) Planning for visits

Creating an identity to the campaign 1) Naming the

campaign

2) Producing Caps, Badges etc

3) Creating WhatsApp group

Pre-visit for situation analysis 1) Meeting with GP

functionaries and preparing a plan for a detailed survey

2) Collecting data to finalize: o No. of households

in total o Households having

toilets o Households having

toilets and using o Households having

toilets and not using o Households having

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(dates, time etc) no space for building toilets

Planning for resource mobilization 1) Men (Masons

and other departments’ personnel)

2) Material (identifying markets and vendor agreements)

Mobilizing funds (identification of channels)

Capacity Building/Orientation 1) Masons

2) Village Functionaries

3) Department Personnel

Third party monitors& their visiting plan

Behaviour change communication 1) Identifying teams

and members for triggering sessions

2) Building capacities of trigger-teams

3) Finalizing a plan for delivery of trigger sessions

Ensure Material and Men reaching sites on time

DURING-CONSTRUCTION

Timeline& Budget for each activity to be mentioned

Activities

Monitoring 1) Teams of

officials and Third Party monitors to monitor the situation

Formation of Vigilance Teams & capacity building

Provision of essential items/tools for monitoring (Whistles, baton, torch, radium jacket etc)

POST-CONSTRUCTION

Timeline& Budget for each activity to be mentioned

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Activities

Monitoring 1) Vigilance

Teams to monitor the situation

Imposing fines on defaulters

Temporary arrangements for visitors, vendors, migrated etc,

Declaration of ODF

Session-9 Planning ITDA wise for Sanitation and Hygiene Improvement in Tribal

Areas

Facilitator Venkatesh Aralikatty, Ravikanth & Manikanta

During this session, the participants worked in their ITDA wise sub-groups on the action

plan and came up with ODF target/deadline plan with respect to the whole ITDA areas

and relevant mandals as well. Since they are not part of the final decision making

authority, the participants said they would discuss this action plan with their Project

Officer and other crucial officials in the ITDA, and submit a details action plan consisting

of activities with timelines and budget.

The output ITDA wise is as follows:

Target Plan – ITDA Rampachodavaram

S.NO Name Of Mandal

No. of GPS

Achieved

(ODF)

Phase-1 Phase-2 Phase-3

1 Rampachodavaram (19) 4 3 6 6

2 Maredumilli (12) 2 3 3 4

3 Devipatnam (14) - 2 6 6

4 Addathegala (22) 1 7 7 7

5 Gangavaram (17) 4 4 5 7

6 Rajavommangi (19) 2 5 6 6

7 Yramavaram (14) 1 3 5 5

Total 117 14 27 38 38

S.NO Phases Mandal From TO No.of GPs

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1 Phase-1 7 Jun-17 Dec 31-2017 27

2 Phase-2 7 Jan-18 Jun 30-2018 38

3 Phase-3 7 Jul-18 Dec31-2018 38

Target Plan – ITDA Paderu

S.NO Phases No. of Mandals Total no.of GPS ODF date

1

Phase-1

(1.7.2017 to

26.12.2017)

2 30 26-12-2017

2

Phase-2

(1-7-2017 to

23.06.2018)

5 98 23-06-2018

3

Phase-3

(1.7.2017 to

18.12.2018)

4 116 18-12-2018

Total 11 244

Target Plan – ITDA Seethampet

Phases Mandal GP Habitations Date

From TO

1

Jul 1 -2017

to

Dec 31 -2017

Seethampet 7 135 01-07-2017 31-12-2017

Kotturu 9 40 01-07-2017 31-12-2017

bhamimni 5 30 01-07-2017 31-12-2017

Pathapatnam 3 24 01-07-2017 31-12-2017

Hiramandalam 3 17 01-07-2017 31-12-2017

Meliputti 8 52 01-07-2017 31-12-2017

Mandasa 3 32 01-07-2017 31-12-2017

Total 7 38 330

2

jan 1-2018

to

jun 30 -2018

Seethampet 9 214 01-01-2018 30-06-2018

Kotturu 17 44 01-01-2018 30-06-2018

bhamimni 9 31 01-01-2018 30-06-2018

Pathapatnam 6 25 01-01-2018 30-06-2018

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Hiramandalam 5 18 01-01-2018 30-06-2018

Meliputti 12 53 01-01-2018 30-06-2018

Mandasa 5 33 01-01-2018 30-06-2018

Total 63 418

3

Jul 1-2018

to

31 dec-2018

Seethampet 8 214 01-07-2017 31-12-2018

Kotturu 17 44 01-07-2017 31-12-2018

bhamimni 8 31 01-07-2017 31-12-2018

Pathapatnam 6 25 01-07-2017 31-12-2018

Hiramandalam 4 17 01-07-2017 31-12-2018

Meliputti 11 53 01-07-2017 31-12-2018

Mandasa 9 33 01-07-2017 31-12-2018

Total 63 417

Target Plan – ITDA Parvatipuram

S.NO Mandal

Total

no. of

GPS

Achieved

Phases

1

Oct 2 -

2017

2

Feb 28 -

2018

3

Jun7 -

2018

4

Oct 2 -

2018

1 Parvathipuram 26 2 4 8 6 6

2 Kurupam 23 4 4 5 5 5

3 JMValasa 31 2 5 8 8 8

4 GLPuram 27 4 3 6 8 6

5 Komarada 31 3 3 9 9 7

6 Saluru 29 3 6 7 7 6

7 Makkuva 21 3 6 6 6 nil

8 Pachipenta 28 4 6 9 9 nil

Total 216 25 37 58 58 38

Target Plan – ITDA Chintoor

S.NO Mandal Name No. of

GPs

Phases

ODF Date Phase

1

Phase

2

Phase

3

Phase

4

Phase

5

Phase

6

1 Chintoor

31-12-2018 15 3 3 3 3 3 -

15-06-2017

to

31-12-2018

2 Kunavaram

31-12-2018 16 3 3 3 3 4 -

3 VRPuram

31-12-2018 11 2 3 3 3 - -

4 Yetapaka

31-12-2018 21 3 3 3 4 4 4

Target Plan – ITDA Srisailam

21 | P a g e

S.NO District No.of Mandals No. of GPS Chenchu

Gudems

1 Kurnool 14 28 42

2 Guntur 6 37 48

3 Prakasam 7 32 81

Total 27 97 171

Mandal Dates Gudems

Phase-1 27

20-06-2017

to

31-7-2017

27

Phase-2 27

10-09-2017

to

31-03-2018

81

Phase-3 27

10-04-2017

to

31-11-2018

63

Total 171

Session-10 Participants’ Feedback & Vote of Thanks

Facilitator Manikanta

Two persons from the entire lot of participants – one male and the other female - were

asked to provide their feedback on the workshop proceedings.

Mr. Shyam Sundar, MPDO, Vizianagaram: “I liked this program very much. I earlier worked

in the private sector and I enjoyed a vibrant life style and went through a very good

learning curve. This workshop – despite organized by a govt. department – reminded

me the life I spent in the private sector in terms of enjoyment (Swachh Raatri) and

learning (awareness on sanitation and hygiene). We are eager to achieve ODF in tribal

areas. Please provide us the handholding support”

Ms. Krishna Jyothi, Joint Director, Child Protection Cell: “I earlier used to feel shy when

happen to speak about shit in the local language/words. Now, I no longer feel shy.

These workshop deliberations made me strong and shed inhibitions. I personally liked

22 | P a g e

the 4-point formula (4 Dimensions) put forward by Mr. Venkatesh. It will certainly help

us to be ready before we embark upon any task”.

Later, Mr. Manikanta presented the vote of thanks to all and sundry that were

instrumental in organizing the workshop successfully.

With this, the two-day workshop on “Strategy Planning for Sanitation & Hygiene

Improvement in Tribal Areas” ended.

Way Forward: The action/target plans formulated ITDA wise will be refined by the

UNICEF HFO in consultation with Tribal Welfare Department - Andhra Pradesh, to

support improve the sanitation situation in the ITDA areas.

---

Annex-1 :: Program Schedule

DAY-1 :: JUN 7, 2017

Time Session Method Facilitator

09.30 – 10.00 Registration Filling up the details

of participants

ITDA R C Varam Team

10.00 – 11.30 Inaugural Session

Welcome Address & Program

Objectives, Agenda

Interactive AV

Show/PPT

D N Murthy, State

Senior Coordinator

Tribal Welfare

Department

Sanitation and Hygiene

Campaign in Tribal Areas: Need

& Way Forward

Interactive talk S R Nalli, Wash

Specialist, UNICEF

23 | P a g e

Key Note Address Interactive talk PO-ITDA, R C Varam

Chief Guest Address

Interactive talk

N Rambabu, ZP

Chairperson

11.30 – 11.45 Tea/Coffee Break

11.45 – 12:30 Sanitation & Hygiene Goals:

Where We Are

Interactive AV

Show/PPT

S R Nalli

12.30 – 13.30 Why Sanitation and Hygiene for

Tribal areas?

Interactive AV

Show/PPT

Venkatesh Aralikatty

WASH Officer,

UNICEF – INDIA

13:30 – 14:30 Lunch Break

14.30 – 15.15 SHWETA – Situation analysis of

sanitation in Chenchu

Habitations in Kurnool district

Interactive AV

Show/PPT

EFICOR Team, Chenchu

Sanitation Project

15:15 – 16:00 Status of Sanitation in ITDA

Areas of Andhra Pradesh

Interactive AV

Show/PPT

Ravikanth Mazumdar

State Consultant for

WASH Andhra Pradesh

(Supported by UNICEF)

16:00 – 17:00 Institutional Sanitation in ITDA

Areas & MHM –An Overview

Interactive AV

Show/PPT

Manikanta

Niharika Singh

DAY-2 :: JUN 8, 2017

09.00 – 09.30 Recap of previous day’s(Day-1)

proceedings: Presentation of

Learnings

Group discussions

and sharing

Manikanta

09:30 – 10:30 Introduction to Sanitation and

Hygiene Improvement Planning

in Tribal Areas

Large group

discussion

Venkatesh Aralikatty

10:30 – 11:15 Key strategies for Sanitation and

Hygiene Improvement in Tribal

areas : Vizianagaram

Experiences

Interactive AV

Show/PPT

Venkatesh Aralikatty

Ravikanth

11.15 – 11.30 Tea/Coffee Break

11.30 – 13.30 Planning ITDA wise for

Sanitation and Hygiene

Improvement in Tribal Areas

Action Planning; Area

Wise Individual Team

Work; Chart

Presentations

Venkatesh

Ravikanth

Manikanta

13.00 – 13.30 Participants’ Feedback &Vote of

Thanks

Interactive Talk Manikanta

Annex-2 :: List of Participants

State Level Officials

S.No. Name of the officer Designation

Contact Details

Phone E-Mail ID

1 S. R. Nalli WASH Specialist - 9908007645 snalli@unicef.org

24 | P a g e

UNICEF

2 A. Venkatesh WASHOfficer -UNICEF 9494412789 varalikatty@unicef.org

3 Ravikanth R Mazumdar State Consultant WASH

4 P.Manikanta

WINS Consultant -

UNICEF 9866942783 manikanta.deva76@gmail.com

5 Niharika Singh

Young Professional

Wash 9813656600 niharika.nsp@gmail.com

6 Naga Bhushanam

State Co-ordinator -

Nabcons 98160583595 nagu_wuge@yahoo.co.in

7 DNMurthy State Sr.Co-ordinator 9492482116 dnmurty@ymail.com

8 P. Vidya CSHP -Manager 9494371576 schoolhealthrbsk.rksk@gmail.com

V. Rakesh CSHP-Analyst 9490904009 schoolhealthrbsk.rksk@gmail.com

ITDA - Seethampet

S.No. Name of the officer Designation Contact Details

Phone E-Mail ID

1 N.Syama Sundar Nabcon Consultant -

Social Sector 9700478097 samsundar2003@gmail.com

2 Dr.K.L.Abhishek CAS 7680881777 aby.pro@gmail.com

3 Dr. Pragada Eeswara rao Medical officer 7901021948 pragadaeswar.43@gmail.com

4 K.Venkata Ramana ATWO 9441943355 atwomeliaputti15@gmail.com

ITDA - Parvatipuram

S.No. Name of the officer Designation Contact Details

Phone E-Mail ID

1 Y.Ssankara Rao CMO 8500093333 sankar.yegireddi@gmail.com

2 K.Srinivasa rao

APO

NREGS 7702076326 srinu_k_2007@gmail.com

3 A.Naveen AE/RWSGS 9100120741 naveenkmr213@gmail.com

4 G.GowriSankar AE/RWS/lepm 9100120738 gopgowri@gmail.com

5 Dr.M.M.Ravi Kumar reddy Dy.DMHO 9502629929 sai.anudeep@gmail.com

6 N.Ravi THPM-NHM 9704701424 dydmhopvp@gmail.com

7 S.C.Praha Raj

Jr.Consultant

Nabcons 9437235869 sarojpraharaj99@gmail.com

25 | P a g e

8 L.Vara Lakshmi

ATWO

GLP 9494167470

9 B.Vidya Rani ATWO -Saluru 9490957348 rani.atwo@gmail.com

10 T.Krishna Veni ACDPO 8143857198 krishna.cdpo@gmail.com

11 P.Venkata lakshmi ACDPO 9493819836 venkatalakshmiparvata@gmail.com

12 K.VijayaLakshmi MPDO 9491035826

13 K.Savithri Addl.PD 8008201414 kuradasavithri@gmail.com

14 S.D.Shyam Sundar MPDO 9491035822 sundar.sangamreddy@gmail.com

15 A.ganapathy

Panchaayat

Secratery 9440477154 alugoluganapathi@gmail.com

16 G.Arundhathi MPDO 9491035839 arundhathisan@gmail.com

ITDA Paderu

ITDA Rampachodavaram

S.No. Name of the officer Designation Contact Details

Phone E-Mail ID

1 Dr.M.Pavan kumar ADMHO

2 A.Venkateswarlu ATWO 9490785788 avp.rpcm@gmail.com

3 CH.Rama Thulasi ATWO 9491385592 thulasichaganti@gmail.com

4 K.Satish Babu TEIC manager 9000660529 teiceastgodavari@gmail.com

5 A.Srinivas

TEIC

Spl.education 9494130494 teiceastgodavari@gmail.com

S.No. Name of the officer Designation Contact Details

Phone E-Mail ID

1 B.Murali Krishna NABCONS 9441142207 murali.bollapragada@gmail.com

2 A.Suresh Kumar APO (PTG) 9440803567 apoptspdr@gmail.com

3 P.Durga Vara lakshmi

CDPO

GKVeedhi 9441249287 icdsgkveedhi@gmail.com

4 E.Gauthami CDPO 9491051539 icdskoyyuru@gmail.com

26 | P a g e

6 D.Deva Raju Nabcons 9440396200 ddevaraju80@gmail.com

7 Dr.K.S.S.B.Harsha MO 9490278549

8 B.Raju MPHEO 9491386131 rajubmpheo@gmail.com

9 P.Tirupathi

Jr.Consultant

Social

Consultant 9492293445 tirupathi.pasala@gmail.com

10 TVS Rama Prasad

Dy.EE

RWS/RCVM 9494961316 dyeerwsrcvaram@gmail.com

11 G.Raghavulu CDPO 8333027709

12 L.Venkateswarlu Co-Ordinator 9493957065 landavenkateswarlu9394@gmail.com

13 GVRG Acharyulu Co-Ordinator 9494021465 rcvaramtsp17@gmail.com

14 U.Arunkumar

Consultant

Nabcons 8332932908 ungaral.ak@gmail.com

15 Y.Satyam naidu APD Velugu 9421220061 ysdpmib@gmail.com

16 MVR reddy APRO 9493740500 apoprcvm@gmail.com

17 k.annapurna APMHD 8008201377 apmhdrcvm@gmail.com

18 B.s.Kumar AMO PMRC 9441563065 pmrcitdarcvm@gmail.com

19 J.Sambhudu ATWO - GRRM 9441385364 atworcvm@gmail.com

20 K.Sujatha ATWO-RCVM 9441370697

ITDA Chintoor

S.No. Name of the Officer Designation Contact Details

Phone E-Mail ID

1 S.Devaprasad ATWO 9440149840 sdprasad65@gmail.com

2 Dr.Pragada Eeswar Rao C.A.S 7901021948 pragadaeeswararao65@gmail.com

3 Dr.N.Kranthi kiran C.A.S 8978870733 tulasipakaphc@gmail.com

4 G.Usha CDPO 9949485385 ushagulivindala@gmail.com

5 A. Gaja Lakshmi CDPO 8500758785 cdpokunavaram111@gmail.com

ITDA Srisailam

S.No. Name Of the Officer Designation Contact Details

Phone E-Mail ID

1 K.Mohan Rao

Jr. Consultant Social

Sector 8500473074 kotamohan74@gmail.com

2 K.T.Uma mahesh APO-NREGS 9059025007 ktumahesh@gmail.com

3 A.Kaleswara Rao Project Lead 9935072678 kaleswararao@gmail.com

4 Joylin Niruba Project Associate 7702079140 joylin.niruba@gmail.com

5 Daich Medhavi Manager 7798877884 daichkishore@eficor.org.com

27 | P a g e

Others

S.NO Name Of The

Officer Designation

Contact Details

Phone E-Mail ID

1 N.Hema Swaccha Sankalpam

Mission Co-ordinator 9063702463 hema3663@gmail.com

2 G.Menaka Dutt Swaccha Sankalpam

Mission Co-ordinator 9949054574 menakadutt.2006@yahoo.co.in

3 P.Manohara Reddy ZSBP EG

9665447679 eastgodavari.zsbp@gmail.com

4 J. Shalam Raju Fact Project, World

Vision-India 9966082669 M&E_india_fact@wvi.org

5 T. Ramesh ATWO -Vijayawada 8985599234 atwo.vijayawada@gmail.com

6 M.Ramesh babu Director - Programs -

EFICOR 9910398601 rameshbabu@eficor.org

___

Guidelines for Control ofIron Deficiency Anaemia

Adolescent DivisionMinistry of Health and Family Welfare

Government of India

Acknowledgements

The National Guidelines for Control of Iron Deficiency Anaemia emerged out of wide based consultation. Preparation of the guidelines would not have been possible without the valuable contributions of Maternal and Child Divisions of the Ministry of Health and Family Welfare and domain experts.

Additional Secretary & Mission Director, NRHM Ms. Anuradha Gupta’s encouragement was our inspiration and her strategic vision shaped the guidelines.

Joint Secretary, RCH, Dr. Rakesh Kumar provided valuable insights and facilitated technical discussions which were critical for finalizing the guidelines.

List of Contributors

Ms. Anuradha Gupta Additional Secretary & Mission Director, NRHM

Dr. Rakesh Kumar Joint Secretary, RCH

Dr. Virender Singh Salhotra Deputy Commissioner, Adolescent Health

Ms. Anshu Mohan Programme Manager, Adolescent Health

Dr. Sheetal Rahi Medical Officer, Adolescent Health

Technical Experts

Professor Umesh Kapil, Department of Community Medicine, AIIMS

Dr. HPS Sachdev, Paediatrician, Sita Ram Bhartia Institute of Science & Research

Dr. PV Kotecha, Professor, Preventive and Social Medicine, Government Medical College, Vadodara

Prof. Suneeta Mittal, Gynaecologist & Obstetrician, Fortis Hospital

Dr. Prema Ramachandran, Director, Nutrition Foundation of India

Dr. Abha Singh, Head, Deptt. of Gynaecology and Obstetrics, LHMC & SK Hospital

Dr. Vartika Saxena, Deptt. of Community Medicine, AIIMS, Rishikesh

Special Mention: Rajat Ray, Sr. Advocacy & Communication Officer, UNFPA, was instrumental in the designing and printing of this document.

Message

Anaemia is a significant public health challenge in India. It has devastating effects on health, physical and mental productivity affecting quality of life, particularly among the vulnerable. Urgent action from all concerned is called for since Anaemia could translate into significant morbidities for affected individuals and consequent socio-economic losses for the country.

Prevention and control of anaemia is one of the key strategies of the Health, Nutrition and Population Sector Programmes for reducing maternal, neonatal and childhood mortality and improving maternal, adolescent and childhood health status.

I am confident that if the comprehensive sets of actions identified in National Guidelines for Control of Iron Deficiency Anaemia are fully implemented; children, adolescents and women in India will have improved health outcomes and be able to achieve their fullest potential. Implementation of this initiative in the right earnest would move us closer to reaching the Millennium Development Goals with regard to bringing down maternal and child mortality.

The challenge before us now is to ensure the implementation of this initiative in its entirety and to further build upon it. Prevention and control of anaemia requires a coordinated response among multiple stakeholders and partners, and I request all to come forward to support interventions in line with the National Guidelines.

(Ghulam Nabi Azad)(Ghulam Nabi Azad)

P.K. PRADHANSecretaryDepartment of Health & FWTel.: 23061863 Fax : 23061252e-mail : secyhfw@nic.in

National Rural Health Mission

GOVERNMENT OF INDIAMINISTRY OF HEALTH & FAMILY WELFARE

NIRMAN BHAVAN, NEW DELHI - 110108

- 110108

Message

India is among the countries with high prevalence of anaemia. It is widely prevalent in all age groups, being particularly high among the most vulnerable; nearly 58 per cent in pregnant women, 50 per cent among non-pregnant non-lactating women, 56 per cent among adolescent girls, 30 per cent in adolescent boys and around 80 per cent in children under two years of age.

Anaemia, thus poses a major threat to maternal and child survival, contributes to low birth weight, lowered resistance to infection, poor cognitive development and decreased work productivity. The magnitude of anaemia together with the associated adverse health, development and economic consequences, highlights the need for intensified action to address this public health problem.

Success in prevention and control of anaemia will contribute to reduction of maternal and child mortality and improve health outcomes for population as a whole. In this context, “National Guidelines for Control of Iron Deficiency Anaemia” has been developed to identify strategies and comprehensive actions needed across the life cycle to eliminate this serious obstacle to survival, health and development.

The guidelines have been designed to be handy and user friendly for service providers across levels and will be a useful tool in planning and implementing this initiative. I urge States and key stakeholders to prioritize implementation of Iron+ Initiative which will have long term impact on the health status of India’s population.

(P.K. Pradhan)

Place: New Delhi 15th January, 2013

(P.K. Pradhan)

Anuradha Gupta, IAS

Additional Secretary &Mission Director, NRHMTelefax : 23062157E-mail : anuradha&gupta@hotmail.com

Government of IndiaMinistry of Health & Family WelfareNirman Bhavan, New Delhi - 110108

110108

Preface

Anaemia is a major public health challenge in India. Yet, a comprehensive plan of action to combat this problem has been missing. There are certain existing guidelines for control of Iron Deficiency Anaemia with regard to children and pregnant women and lactating mothers. However, many critical age groups have been missing from this strategy. For instance, adolescents have received no attention so far. There have also been crevices by way of actual administration of IFA to children with several operational issues constraining the prescribed interventions.

The National Iron+ Initiative is an attempt to look at Iron Deficiency Anaemia comprehensively across all life stages including adolescents and women in reproductive age group who are not pregnant or lactating. The schedule of IFA supplementation has also been reviewed to make both administration and compliance much simpler. For children, 6 months to 5 years, there is now a bi-weekly schedule of IFA supplementation with ASHA being responsible for administering the prescribed dosage under her direct supervision. For children of class I to class V in Government/Government aided schools, there is a much simpler weekly schedule of IFA supplementation, under the supervision of teachers. Similarly, adolescents from class VI to class XII receive weekly IFA supplementation in school itself. For women in reproductive age group who are neither pregnant nor lactating, ASHA shoulders the responsibility of providing IFA supplementation.

Clearly, the National Iron+ Initiative builds on the gains of the NRHM, more particularly the strong work force of 8,80,000 ASHAs who have shown excellent potential to mobilise community for a large scale uptake of health services. The fact that ASHAs are now undertaking home visits under the recently rolled out HBNC programme and are also doing home delivery of contraceptives to couples in the reproductive age group opens up several exciting opportunities for ASHAs to render additional services such as IFA supplementation. This initiative makes use of this wonderful opportunity in its bid to reach to all age groups seamlessly.

National Guidelines for Control of Iron Deficiency Anaemia has four purposes:

1. To bring to attention of program managers of health and health related activities the serious negative consequences of anaemia for the health and physical, mental, and economic productivity of individuals and populations

2. To layout IFA supplementation protocols across the life cycle (preventive strategy)

3. To define a minimum standard treatment protocol for facility based management of mild, moderate and severe anaemia segregated by levels of care (curative strategy)

4. To broadly identify platforms of service delivery and indicate roles of service providers

These guidelines have been developed taking cognizance of scientific evidence as well as considerable consultation with domain experts. It builds on past and continuing work on anaemia prevention and control in India and has been developed in the context of existing policies and strategies of the health, nutrition and population sector. It identifies comprehensive strategies and interventions for high risk groups, in particular infants and young children, adolescent girls, women in reproductive age, and pregnant and breastfeeding women, and for the population as a whole.

I am certain that the states on their part will do the utmost to ensure that appropriate linkages and mechanisms for training, monitoring and operationalizing this initiative are put in place at the earliest and implementation taken up in real earnest so that together we can build a healthy, anaemia free India.

Anuradha Gupta

Foreword

Anaemia, a manifestation of under-nutrition and poor dietary intake of iron is a serious public health problem among pregnant women, infants, young children and adolescents. Data suggests that 7 out of every 10 children aged 6-59 months in India are anaemic. Three per cent of children aged 6-59 months are severely anaemic, 40 per cent are moderately anaemic, and 26 per cent are mildly anaemic. In fact the percentage of children with any anaemia increased from 74.3 per cent in NFHS-II to 78.9 per cent in NFHS-III.

India is among the countries with high prevalence of anaemia in the world. It is estimated that anaemia directly causes 20 per cent of maternal deaths in India and indirectly accounts for another 20 per cent of maternal deaths.

Taking cognizance of this, the Ministry of Health and Family Welfare has developed the National Guideline for Control of Iron Deficiency Anaemia to holistically address both preventive and curative aspect of this challenge across all life stage and various levels of care.

The document provides a guide for all stakeholders and partners on how policy makers, health professionals, community members and families can take action to prevent and control anaemia. I call upon all stakeholders and partners for their continued support in this respect.

I sincerely hope that States will proactively work on this initiative which will have a long term impact on the health of India.

(Dr. Rakesh Kumar)

Dated: 15th January, 2013

Dr. RAKESH KUMAR, I.A.SJOINT SECRETARYTelefax : 23061723E-mail : rkumar92@hotmail.com

Government of India

Healthy Village, Healthy Nation

Ministry of Health & Family WelfareNirman Bhavan, New Delhi - 110108

Contents

1. Anaemia – A Public Health Challenge 1 1.1. What is Anaemia? 1 1.2. Aetiology of Anaemia 2

2. Background 5 2.1. Global Overview 5 2.2. Indian Scenario 6

3. Impact of Anaemia on Health Outcomes 11

4. Existing Policies and Strategies 13 4.1. Interventions by Ministry of Health and Family Welfare (MoHFW) 13 4.2. Key Programmes and Schemes of Other Ministries 13 4.3. National Iron+ Initiative 14

5. Approach – What Would It Take to Fight Iron Deficiency and IDA More Effectively? 15 5.1. What Are Diet Diversification, Food Fortification and Supplementation? 16 5.2. Ministry of Health and Family Welfare’s Revised Strategy 16

6. Supplementation through the Life Cycle 17 6.1. Supplementation for Children 6–60 months 18 6.2. Supplementation for Children 5 (61 months onward)–10 years 19 6.3. Weekly Iron and Folic Acid Supplementation (WIFS) Programme for Adolescent Girls and Boys (10–19 Years) 20 6.4. Pregnant Women and Lactating Mothers 21 6.5. Women in Reproductive Age Group (WRA) (15–45 Years) 22

7. Therapeutic Approach through the Life Cycle 23 7.1. Six Months – 60 Months 23 7.2. Children 5–10 Years 26 7.3. Adolescents in the Age Group 10–19 Years 27 7.4. Pregnant and Lactating Women 29

References 33

Annexures 34 1. Dietary Diversification for Prevention of Nutritional Anaemia 34 2. Amount of Food to Offer at Different Ages 37 3. Enhancing Iron Content of Food at Different Ages 38

AcronymsAG Adolescent GirlANC Antenatal CareANM Auxiliary Nurse MidwifeASHA Accredited Social Health ActivistAWC Anganwadi CentreCHC Community Health CentreCNS Central Nervous SystemDALY Disability Adjusted Life YearsDH District HospitalF-IMNCI Facility-based Integrated Management of Neonatal and Childhood IllnessFRU First Referral UnitGDP Gross Domestic ProductHb HaemoglobinICDS Integrated Child Development ServicesIDA Iron Deficiency AnaemiaIFA Iron and Folic AcidIMNCI Integrated Management of Neonatal and Childhood IllnessITBN Insecticide Treated Bed NetsKSY Kishori Shakti YojanaLBW Low Birth WeightLHV Lady Health VisitorLLIN Long Lasting Insecticide NetsMCP Card Mother Child Protection CardMO Medical OfficerMoHFW Ministry of Health and Family WelfareMUAC Mid Upper Arm CircumferenceMWCD Ministry of Women and Child DevelopmentNFHS National Family Health SurveyNNMBS National Nutrition Monitoring Bureau SurveyNPAG Nutrition Programme for Adolescent GirlsPHC Primary Health CentrePNC Postnatal carePW Pregnant WomanRBC Red Blood CellsVHND Village Health and Nutrition DayWIFS Weekly Iron and Folic Acid SupplementationWRA Women of Reproductive Age

1

Anaemia – A Public Health Challenge

1.1. What is Anaemia?

Anaemia is a condition in which the number of red blood cells (RBCs), and consequently their oxygen-carrying capacity, is insufficient to meet the body’s physiological needs. The function of the RBCs is to deliver oxygen from the lungs to the tissues and carbon dioxide from the tissues to the lungs. This is accomplished by using haemoglobin (Hb), a tetramer protein composed of haem and globin. Anaemia impairs the body’s ability for gas exchange by decreasing the number of RBCs transporting oxygen and carbon dioxide. Anaemia results from one or more of the following process: defective red cell production, increased red cell destruction or blood loss. Iron is necessary for synthesis of haemoglobin. Iron deficiency is thought to be the most common cause of anaemia globally, but other nutritional deficiencies (including folate, vitamin B12 and vitamin A), acute and chronic inflammation, parasitic infections, and inherited or acquired disorders that affect Hb synthesis, red blood cell production or red blood cell survival can all cause anaemia. Iron deficiency anaemia results in impaired cognitive and motor development in children and decreased work capacity in adults (Figure 1.1). The effects are most severe in infancy and early childhood. In pregnancy iron deficiency anaemia can lead to perinatal loss, prematurity and low birth weight (LBW) babies. Iron deficiency anaemia also adversely affects the body’s immune response.

Fig. 1.1: Adverse effects of anaemia

ANAEMIA

Reducedphysical

development

Impaired sexual and

reproductive development

Reduced cognitive

development

• Decreased work output• Decreased work capacity

• Diminished concentration• Disturbance in perception• Poor learning ability

• Irregular menstruation• Low pre-pregnancy iron stores• LBW babies and preterm delivery

1

Guidelines for Control of Iron Deficiency Anaemia

2

Table 1.1: Haemoglobin levels to diagnose anaemia (g/dl)

Age groups No Anaemia Mild Moderate Severe

Children 6–59 months of age ≥11 10–10.9 7–9.9 <7

Children 5–11 years of age ≥11.5 11–11.4 8–10.9 <8

Children 12–14 years of age ≥12 11–11.9 8–10.9 <8

Non-pregnant women (15 years of age and above) ≥12 11–11.9 8–10.9 <8

Pregnant women ≥11 10–10.9 7–9.9 <7

Men ≥13 11–12.9 8–10.9 <8

Source: Haemoglobin concentration for the diagnosis of anaemia and assessment of severity. WHO

1.2. Aetiology of Anaemia

The commonest causes of anaemia in developing countries, particularly among the most vulnerable groups (pregnant women and preschool age children), are nutritional disorders and infections. Hence the causes of anaemia could be segregated as nutritional and non-nutritional, underscoring the aetiological importance of dietary deficiency as the major causative factor.

1.2.1 Iron deficiencyIron status can be considered as a continuum from iron deficiency with anaemia, to iron deficiency with no anaemia, to normal iron status with varying amounts of stored iron, and finally to iron overload which can cause organ damage when severe. Iron deficiency is the result of long-term negative iron balance. Iron deficiency anaemia (IDA) should be regarded as a subset of iron deficiency, that is, it represents the extreme lower end of the distribution of iron deficiency.

Storage iron

Transport iron

RBC iron

Normal Iron depletionIron deficienterythropoiesis

Iron deficiencyanaemia

Iron deficiency adversely affects

• The cognitive performance, behaviour and physical growth of infants, preschool and school-age children;

• The immune status and morbidity from infections of all age groups;

• The use of energy sources by muscles and thus the physical capacity and work performance of adolescents and adults of all age groups.

Anaemia – A Public Health Challenge

3

Iron requirements are highest for pregnant women –1.9 mg/1,000 Kcal of dietary energy in the second trimester and 2.7 mg/1,000 Kcal in the third trimester. These are followed by iron requirements in infants (1.0 mg), adolescent girls (0.8 mg), adolescent boys (0.6 mg), non-pregnant women (0.6 mg), preschool and school age children (0.4 mg), and adult men (0.3 mg).

Iron deficiency is a consequence of:

• Decreased iron intake

• Increased iron loss from the body

• Increased iron requirement

Iron requirements increase during the period of active growth in childhood, especially from 6 months to 3 years. In infancy, iron deficiency is most often the result of lack of exclusive breast feeding and use of unsupplemented milk diets which contain inadequate amounts of iron. Milk products are very poor sources of iron and prolonged breast or bottle feeding of the infant without complementary feeds after 6 months of age frequently lead to iron deficiency unless there is iron supplementation. Iron requirements are proportionately greater in premature and underweight babies. In older children, a predominantly milk and cereal based diet and food fads can also lead to IDA.

Blood loss during menstruation and increased iron requirements during pregnancy and lactation predispose women to poor iron stores. Traditionally, the Indian housewife eats last, after all male members and children have eaten and in many families, the women eat only the leftovers. Hence, even though the food prepared for the family is the same, women are more prone to develop IDA than other members of the family.

1.2.2 Other micronutrient deficienciesVitamin B12 is necessary for the synthesis of RBCs and its deficiency has been associated with megaloblastic anaemia. Diets with little or no animal protein, as is often the case in our country, coupled with malabsorption related to parasitic infections of the small intestine, might result in Vitamin B12 deficiency and anaemia.

Folic acid is also essential for the formation and maturation of RBCs and is necessary for cell growth and repair. Deficiency of folate reduces the rate of DNA synthesis with consequent impaired cell proliferation and intramedullary death of resulting abnormal cells; this shortens the lifespan of circulating RBCs and results in anaemia.

1.2.3 Helminthic infestation Helminths such as hookworm and flukes cause chronic blood loss and consequently iron loss from the body, resulting in the development of anaemia. A hookworm burden of 40–160 worms (depending on the iron status of the host) is associated with IDA.

Guidelines for Control of Iron Deficiency Anaemia

4

1.2.4 MalariaMalaria, especially by the protozoa Plasmodium falciparum and vivax, causes anaemia by rupturing RBCs and suppressing production of RBCs. Decreased RBC production results from marrow hypoplasia seen in acute infection. Plasmodium falciparum is the primary cause of severe malaria in regions where malaria is endemic. Malarial anaemia can cause severe morbidity and mortality especially in children and pregnant women infected with Plasmodium falciparum. Malaria in pregnancy increases the risk of maternal anaemia, stillbirth, spontaneous abortion, LBW and neonatal deaths.

1.2.5 Sickle cell disease and thalassemia Sickle cell disease is an inherited disorder of haemoglobin. It is among the most common genetic diseases in the world and results in recurrent haemolytic anaemia. Thalassemia is one of the major haemoglobinopathies among the population all over the world. It is caused due to decreased or negligible amount of globin chain of haemoglobin. About 10 per cent of the world’s thalassemia patients belong to the Indian subcontinent and 3.4 per cent of them are carriers. In India, about 32,400 infants are born with haemoglobinopathies every year1.

1.2.6 Infections Certain chronic diseases, such as cancer, HIV/AIDS, rheumatoid arthritis, Crohn’s disease and other chronic inflammatory diseases, can interfere with the production of RBCs, resulting in chronic anaemia. Kidney failure can also cause anaemia.

5

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Fig. 2.1: Global picture – Anaemia as a public health problem in preschool children by country

Guidelines for Control of Iron Deficiency Anaemia

36

Red Gram Dhal

Arhar

Plantain Green

Kuchcha Kela

Black Gram, Dhal

Urad Dal or Kaskalay

Water Melon

Tarbooz

Pumpkin

Seethaphal

Mutton

Gosht

Common Vitamin C Rich Foods

Cabbage

Patta Gobhi

Drumstick Leaves

Saijan Patta

Coriander Leaves

Dhaniya

Gooseberry

Amla

37

Annexure 2

Amount of Food to Offer at Different Ages

AgeEnergy needed per day in addition to

breast milkTexture Frequency

Average amount of each meal

6–8 months 200 Start with thick porridge, well mashed foods

2–3 meals per day plus frequent breastfeed

Start with 2–3 tablespoonfuls

9–11 months 300 Finely chopped or mashed foods, and foods that baby can pick up

3–4 meals plus breastfeed.

Depending on appetite offer 1–2 snacks

½ of a 250 ml cup/bowl

12–23 months 550 Family foods, chopped or mashed

if necessary

3–4 meals plus breastfeed.

Depending on appetite offer 1–2 snacks

3/4 to one 250 ml cup/bowl

If baby is not breastfed, give in addition: 1–2 cups of milk per day, and 1–2 extra meals per day. The amounts of food included in the table are recommended when the energy density of the meals is about 0.8 to 1.0 Kcal/g. If the energy density of the meals is about 0.6 Kcal/g, recommend to increase the energy density of the meal (adding special foods) or increase the amount of food per meal. Find out what the energy content of complementary foods is in your setting and adapt the table accordingly.

38

Annexure 3

Enhancing Iron Content of Food at Different Ages

Age

Iron requirement

(mg/day)1 (ICMR RDA)

Iron content(Assuming frequency of meals/day as advised in

column 4 above)

Food-iron content gap

(mg/day)

Amount of raw green leafy vegetables (to be cooked and

added to food) (g/day)2

6–8 months

5 1.0–2.0 mg 3–4 25

9–11 months

5 2.0–2.5 mg 2.5–3.0 25

12–23 months

9 2.5–3.5 mg 5.5–6.5 40

1 Iron requirement is based on 5 per cent bio-availability from cereal-pulse based diets.

2 Green leafy vegetables like amaranth (chaulai sag/dantu), spinach (palak), turnip leaves (shalgam ka sag), mint leaves (pudhina) and small amounts of tamarind (imli) added to the diet daily will together provide the amount of iron recommended. These are broad guidelines. Recipes should be adapted based on local customs and availability of specific vegetables.