World Bank Document...The system of tracking key process and outcome data, with built-in data...

Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No.: 17755

IMPLEMENTATION COMPLETION REPORT

INDIA

SECOND TAMIL NADU INTEGRATED NUTRITION PROJECT(CREDIT 2158-IN)

April 24, 1998

Health, Population and Nutrition UnitSouth Asia Region

T}iis document has a restricted distribution and may be used by recipients only in theperformance of their official duties. Its contents may not otherwise be disclosed withoutWorld Bank authorization.

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

CURRENCY EQUIVALENTS(as of January 23, 1998)

Currency Unit = Indian Rupee (Rs.)Rupee 1 = US$0.025US$1.00 = Rupee 39.50

GOVERNMENT FISCAL YEARApril 1 - March 31

ABBREVIATIONS AND ACRONYMS

APERP Andhra Pradesh Economic Restructuring ProjectANM Auxiliary Nurse-MidwifeCDPO Child Development Project OfficerCNC Community Nutrition CenterCNS Community Nutrition SupervisorCNW Community Nutrition WorkerCNI Community Nutrition InstructressCSSM Child Survival and Safe Motherhood ProjectCTC Communications and Training CenterCWO Community Welfare OrganizersDEA Department of Economic AffairsDWCD Department of Women and Child DevelopmentDWCRA Developing Women and Children in Rural AreasGOI Government of IndiaGOTN Government of Tamil NaduICDS Integrated Child Development ServicesIDA International Development AssociationIEC Information Education and CommunicationIMR Infant Mortality RateLBW Low Birth WeightMTS Mid Term SurveyNCHS National Center for Health StatisticsNFHS National Family Health SurveyNGO Non-Governmental OrganizationNNMP Nutritious Meals ProgramNMC Nutritious Meals CenterNNMB National Nutrition Monitoring BureauPMU Project Management UnitSAR Staff Appraisal ReportSRS Sample Registration SystemTINP Tamil Nadu Integrated Nutrition ProjectVHN Village Health NurseWCDP Women and Child Development Project

Vice President Mieko NishimizuDirector Edwin LimSector Manager : Richard SkolnikTeam Leader Anthony Measham

FOR OFFICIAL USE ONLY


1NDIA

SECOND TAMIL NADU INTEGRATED NUTRMTON PROJECT(CREDIT 2158-IN)

CONTENTSPage No.

Preface i

Evaluation Summary ii

PART I: Project Implementation Assessment

A. Project Objectives 1B. Achievement of Project Objectives 3C. Major Factors Affecting Project Implementation 12D. Project Sustainability 13E. Bank Performance 13F. Borrower Performance 14G. Assessment of Outcome 14H. Future Operation 15I. Lessons Leamed 15

PART II: Statistical Tables

Table 1: Summary of Assessments 18Table 2: Related Bank Credits 20Table 3: Project Timetable 23Table 4: Credit Disbursements: Cumulative Estimated and Actual 24Table 5: Key Indicators for Project Implementation 25Table 6: Studies Included in the Project 26Table 7A: Project Costs 28Table 7B: Project Financing 29Table 8: Status of Legal Covenants 30Table 9: Compliance with Operational Manual Statements 35Table 10: Bank Resources: Staff Inputs 36Table 11: Bank Resources: Missions 37

APPENDICES

Appendix A. The ICR Mission's Aide-MemoireAppendix B. Borrower's Contribution to the ICR

This document has a restricted distribution and may be used by recipients only in theperformance of their official duties. Its contents may not oth'erwise be disclosed without.World Bank authorization.

i


INDIA


PREFACE

This is the Implementation Completion Report (ICR) for the Second Tamil NaduIntegrated Nutrition Project in India (Credit No. 21 58-IN). A total IDA credit of US$95.8 million(SDR 73.5 million equivalent) was approved on June 14, 1990 and made effective on December5, 1990. This amount was subsequently reduced to US$72.8 million.

The credit closed on the original closing date of December 31, 1997. The credit amountwas fully disbursed, with the last disbursement taking place in January 1998.

This ICR was prepared by Anthony Measham (Team Leader) and Stuart Gillespie(Consultant), with technical assistance from Kathleen Finn, Meera Priyadarshi, R. Sethuraman,Alaka Singh, P. Subramaniyam, and Krishna D. Rao. Nira Singh provided office technologyassistance. The ICR was reviewed by Richard Skolnik (Sector Manager, SASHP) and KazukoUchimura (Project Advisor, SARRI).

Preparation of this ICR began during the October 1997 supervision mission. It is based onmaterial in the project files, field visits, and discussions with beneficiaries, project staff,Government officials and Bank staff. The Borrower contributed to the preparation of the ICR bypreparing its own evaluation of the project's preparation and execution. Comments on the reportdrafts were received from the Borrower and taken into account in the final version.

The cooperation and assistance of Government of India (GOI) and the Government ofTamil Nadu (GOTN) are gratefully acknowledged.

i

I[MPLEMENTATION COMPLETION REPORT

INDIA


EVALUATION SUMMARY

Introduction

1. The Second Tarmil Nadu Integrated Nutrition Project (TINP II), launched in 1991, was thesecond nutrition operation supported by the World Bank in India. Its predecessor, TINP I,became well-known in international nutrition circles during the 1980s as a "success story", havingachieved a highly significant reduction in severe early childhood malnutrition. Implementation ofTINP II largely overlapped with that of two other IDA-supported Integrated Child DevelopmentServices (ICDS) projects. ICDS I, approved in 1990, covered the states of Andhra Pradesh andOrissa, while ICDS II, approved in 1993, covered the states of Bihar and Madhya Pradesh.

Project Objectives

2. The overall goal of TINP II was to improve the nutrition and health status of children 0-72months of age, with particular emphasis on 0-36 month olds, and pregnant and lactating women.Specifically, the project aimed to (i) reduce severe malnutrition among 6-36 month old children by50% and 25% in new and existing project areas, respectively; (ii) increase the proportion of 6-36month old children in normal and Grade I nutritional status by 50% and 35% in new and existingproject areas, respectively; and (iii) to contribute towards a reduction in infant mortality rate from84 to 55 per 1,000 live births and to a 50% reduction in the incidence of low birth weight.

3. The project covered a total of 318 of Tamil Nadu's 385 rural blocks in 19 of 23 districts,including the strengthening of activities in 122 existing (i.e., TINP I) blocks and expansion to 194additional blocks. The remaining rural blocks were covered by the ICDS program.

4. The core strategies intended to realize these objectives were regular growth monitoring,nutrition eduction and health checks for all children, with therapeutic supplementary feeding ofmoderately and severely malnourished and growth-faltering children, and high-risk pregnant andlactating women.

5. Learning from TINP I, several new or strengthened strategies were proposed for TINP II,including (i) the inclusion of moderately malnourished children in the supplementary feedingprogram; (ii) improved coverage and quality of antenatal services aimed at improving maternalnutrition and reducing low birth weight incidence; (iii) improved coverage of small hamlets andoutlying habitations through appropriate coverage strategies; (iv) strengthening of health referralservices for diagnosis and treatment of severely malnourished children and high-risk pregnant

ii

mothers; (v) improved child feeding and care practices through effective communications; (vi)improved co-ordination between nutrition and health personnel through effective joint trainingand supervision; and (vii) community education including the formation of new, and strengtheningof existing, women's groups.

Implementation Experience and Results

6. The project was successful in achieving its severe malnutrition and infant mortality ratereduction objectives. The moderate malnutrition reduction objective, which in retrospect was tooambitious, was not achieved, although some progress was made. Limited data render it difficult tocome to a conclusion with regard to the low birth weight incidence objective. Although there issome evidence to suggest a significant improvement, it seems doubtful that the project made amajor contribution to this change. It appears that the gender gap in child nutritional status whichhas existed since the inception of TINP I has narrowed. With regard to geographical targeting, forthe hamlets that were covered, project performance was as effective as in larger, more accessiblevillages. Districts which were under TINP I in the 1 980s performed better on average than thosenewly-included in TINP II.

7. Service delivery was patchy with some of the most important process objectives not beingachieved. Block-level training worked well, though there was a significant backlog in refreshertraining which compromised quality and led to serious gaps in knowledge and awareness. Theexistence of significant inter-district variations in some aspects of service delivery performancesuggests the need for a modular, site-specific approach to training.

8. The communications component, which was based on sound formative research, waslimited by its bias towards mass media approaches. More attention is required to the developmentof the CNW's inter-personal counseling skills. The geographical variation, as with servicedelivery, again suggests that strategies should be flexible, decentralized and problem-focused.

9. After a slow start, community mobilization, and women's group formation and training inparticular, began to pick up in the latter stages of the project, although working groups needstrengthening if real and sustainable community ownership is to be achieved. Linkages to othergovernment-supported income-generation schemes for women are needed. Opportunities wererealized to orient newly-elected panchayat members who themselves became advocates for theproject.

10. The monitoring system remains one of the strengths of TINP II, as it was with TINP I.The system of tracking key process and outcome data, with built-in data quality checks and astreamlined set of registers, is efficient and action-oriented. Blocks that are found to be laggingare followed up by district-level officers, and project management is kept informed of district-level performance through a wall chart that is updated every month. However there are someserious gaps in monitoring implementation which need to be addressed. Evaluation has been

iii

weak throughout the project, seriously delaying and limiting judgement of progress on objectives.

11. Overall, the timeliness, quality and utility of operational research was unsatisfactory.Improved assessment criteria for bidding agencies and better monitoring of progress is required toensure timely, high quality work and results which can be used to improve the program during itslifetime.

12. Tamil Nadu is one of the five states involved in the forthcoming Woman and ChildDevelopment Project. From January 1998, all the 318 TINP I blocks were incorporated into theICDS program, which is being universalized throughout India.

13. Overall, during the mid-project period from 1993-1995, there was a significant fall-off incominitment, integrity and supervision from project management which percolated down to alllevels, adversely affecting morale and motivation. This fall-off reflected major political turmoilwhich affected every sector in Tamil Nadu during the period. These problems were addressed in1996 by a new project team which successfully set about revitalizing the project. Qualityimprovement planning, an open, action-oriented management style and supportive supervisionwere all institutionalized to this end.

14. Given the turbulent environment in which the project operated, it continued to functionreasonably well. This owed much to the solid human resource foundation built by TINP I whichwas resilient in the face of deteriorating project management. The terminal evaluation impactfindings provide some support for this supposition in that TINP I districts performed particularlywell, and far better than the Phase V districts introduced in 1995.

15. Bank performance was mixed. On the plus side, assistance was satisfactory throughappraisal and supervision missions were thorough and proactive in dealing with problems.However, in the several instances where action was not forthcoming, e.g., on emphasizing qualityimprovement as much as project expansion, in dealing with the problems of non-resident villageworkers, and on procurement irregularities, the Bank should have been more forceful in seekingappropriate remedies. Bank performance and Borrower performance both improved in the finaltwo years of the project. Borrower performance compared unfavorably with that under TINP I ona number of counts, notably in not emphasizing quality of services, the key to reducing moderatemalnutrition.

Key Lessons Learned

16. The main lesson learned from TINP II is that the strategies adopted to deal with moderatemalnutrition were broadly appropriate, but there is a continuing need to intensify the focus onlocalized capacity-building, community mobilization and targeted, inter-personal comnmunications.Severe malnutrition is now minimal but moderate malnutrition, with all its detrimentalconsequences, remains significant. There needs to be greater emphasis in future on improvinghome-based care and feeding of the youngest children to prevent them from becoming

iv

malnourished. Geographically, targeting to remote hamlets needs to be prioritized, for example,through the establishment of mini-centers.

17. Community ownership should remain a priority goal. The experience in the latter half ofthe project with social mobilization should be drawn upon to facilitate active involvement of moreof the community.

18. Overall, supportive counselling of caregivers and high-quality service delivery, allied witha concerted move towards social mobilization and participatory planning, should be the pillars offuture nutrition improvement strategy. Decentralization, quality and ownership are key overridingconcerns. For the most part, these lessons have already been woven into the project strategies ofthe forthcoming Woman and Child Development Project in Tamil Nadu, and indeed in otherstates, though they will need to be vigilantly monitored during its implementation.

19. Most of these substantive lessons are relevant beyond Tamil Nadu. Nutrition interventionswhich are targeted using nutritional criteria, integrated within a broader health system, andeffectively supervised and managed can significantly reduce severe malnutrition. TINP has shownthis. It has also shown that to go further and prevent children from becoming moderatelymalnourished is in many ways a harder task and one that requires a significant shift in emphasis.Nutrition programming in Tamil Nadu is still evolving towards such an approach which stresseshuman capacity-building for home-based action, a pro-active integration with the health system,and the mobilization of communities to sustain the process beyond the project.

20. For the Bank, the main lesson learned from TINP II is the need for firmer action in dealingwith chronic and persistent problems, such as the failure to carry out the mid-term evaluationsurvey in a timely way or the construction of additional nutrition centers in the old blocks of theproject. When delays or persistent problems endanger the achievement of the project'sdevelopment objectives, the Bank must be ready to take a firm stand rather than wait in the hopethat agreed actions will be taken.

Assessment of Outcome

21. The project outcome was marginally satisfactory in that the development objectives werelargely achieved, thus consolidating the gains made by TINP I. However, a marked shift ofemphasis is now required towards support for home-based care if a sustainable reduction in themoderate malnutrition prevalence is to be achieved.

1


INDIA


PART I: PROJECT IMPLEMENTATION ASSESSMENT

I. Tamil Nadu has been a leader in community-based nutrition programs for the last twodecades. The first IDA-supported nutrition project in India was the Tamil Nadu IntegratedNutrition Project (TINP I) which had a highly significant and well-documented impact on earlychildhood malnutrition between 1980-89. In 1982, the state-funded Nutritious Meals Program(NMP) was introduced. This program provides a noon meal to children aged 2-14 years andfunctions through a state-wide network of feeding centers (NMCs) run by a cadre of ChildWelfare Organizers (CWOs). The Second Tamil Nadu Integrated Nutrition Project (TINP II) waslaunched in Tamil Nadu in 19 of 23 districts in January 1991.

2. Implementation of TINP II largely overlapped with that of two IDA-supported IntegratedChild Development Services (ICDS) projects. ICDS I (approved in 1990) covered the states ofAndhra Pradesh and Orissa, while ICDS II (approved in 1993) covered the states of Bihar andMadhya Pradesh. In addition, the Bank appraised two new nutrition projects in 1997/98: theICDS component of the Andhra Pradesh Economic Restructuring Project which is scheduled forthe Board in June 1998, and the Woman and Child Development Project (WCD) in Kerala,Maharashtra, Rajasthan, Tamil Nadu and Uttar Pradesh, which awaits Government of India (GOI)clearance. Other related Bank-assisted projects in India include seven population projects and theChild Survival and Safe Motherhood operation, which aimed at improving family health andreducing maternal and child morbidity and mortality.

A. PROJECT OBJECTIVES

3. The overall goal of TINP II was to improve the nutrition and health status of children 0-72months of age, with p.articular emphasis on 0-36 month-olds, and pregnant and lactating women.

4. Project Coverage. TINP II was intended to cover a total of 316 of Tamil Nadu's 385rural blocks, including the strengthening of activities in 122 existing (i.e. TINP I) blocks andexpansion to 194 additional blocks. The remaining rural blocks are covered by the ICDS program.In existing TINP bloc]ks, about 6,400 Community Nutrition Centers (CNCs) were to beamalgamated with the existing NMCs. In new blocks and 20% of villages in existing blocks wherethere existed significanat coverage gaps, a total of 12,000 NMCs were to be strengthened by theaddition of a new worker who would provide TINP services to under-three year-old children.Finally, in 2,200 villages in new and existing blocks which were not covered by either TINP or theNMP, new centers were to be established with two workers and a helper.

5. Specific Objectives. The impact objectives of TINP II were:

2

* to reduce severe malnutrition (Grade III and IV) among children 6-36 months by 50%and 25% in new and existing project areas, respectively;

* to increase the proportion of children 6-36 months of age in normal and Grade Inutritional status by 50% and 35% in new and existing project areas, respectively; and

* to contribute towards a reduction in infant mortality rate from 84 to 55 per 1,000 livebirths and to a 50% reduction in the incidence of low birth weight.

Key process objectives are summarized in Table 5.

6. Project Strategy. The core strategies intended to realize these objectives were:

* regular growth monitoring, nutrition education and health check-up of all children;and

* therapeutic supplementary feeding of moderately and severely malnourished andgrowth-faltering children and high-risk pregnant and lactating women.

7. On the basis of lessons learned from TINP I, TINP II had several new or strengthenedstrategies, including:

* inclusion of moderately malnourished children in the supplementary feeding program;

* improved coverage and quality of antenatal services aimed at improving maternalnutrition and reducing low birth weight incidence;

* improved coverage of smaller hamlets and outlying habitations through strategies suchas women's working groups, adolescent girls, etc.;

* strengthening of health referral services for diagnosis and treatment of severelymalnourished children and high-risk pregnant mothers;

* improved child feeding and care practices through effective communications;

* pre-school education for 3-6 year-old children;

* improved co-ordination between nutrition and health personnel through effective jointtraining and supervision; and

* community education including formation of new, and strengthening of existing,women's groups.

3

B. ACHIEVEMENT OF PROJECT OBJECTIVES

8. Of the four impact objectives, two were definitely achieved - namely, reduction in severemalnutrition of 6-36 nnonth-old children and reduction in the infant mortality rate. The moderatemalnutrition reduction objective - which was arguably most important -- was not achieved,although with hindsight it appears to have been too ambitious. Ex-TINP I districts notablyperformed better than newer districts, and there is evidence that girls are no longer moremalnourished than boys. Finally, limitations with birth weight data recording preclude an accurateassessment of progress towards this objective, but there is evidence that suggests a significantimprovement. However, it seems unlikely that the project made a major contribution to thischange, given the relatively poor performance in providing ante-natal services, e.g., iron folate,Vitamin A and supplementary food.

9. To place the irnpact objectives in context, they can be compared with the secular trend ofa 5.6% annual reduction in the prevalence of severe malnutrition (i.e., Grade III and IV weight-for-age) in Tamil Nadu during the 1980s, according to National Nutrition Monitoring Bureau(NNMB) data. This improvement occurred during the time that TINP I was underway inapproximately half of the rural blocks of the state. TINP II sought to reduce severe malnutritionby 50% in seven years in new blocks - an annual decline of just over 7% and an achievable goal.Given the progress already achieved with TINP I, the other target of 25% severe malnutritionreduction in existing (ex-TINP I) blocks was also realistic. Importantly though, TINP II placedparticular emphasis on reducing moderate malnutrition (i.e., Grade II weight-for-age), thusincreasing the proportion of children in the combined Normal/Grade I category.

10. All currently available nutritional status data are presented in the table below. Asexpected, there is a strong similarity between the TINP-II (Phase I-III) baseline and the NationalFamily Health Survey (NFHS) data collected during 1992-93. The Phase IV and V baselinecarried out in 1995 shows a better nutritional situation than either of these latter surveys, implyingappropriate early-targeting of TINP II in its first phases to blocks with high proportions of childmalnutrition. Monitoring data suggest the nutrition situation was improving steadily over time,with prevalence consistently lower than reported in independent surveys. The one significantoutlier data point comes from the 1996 mid-term evaluation survey which shows particularly highlevels of severe malnutrition, but there are major concerns about the validity of these data. Thesedoubts have since been confirmed by the terminal evaluation which reports significantly lowersevere malnutrition prevalences, just a year later.

4

Table A: Comparison of 0-36 Month Child Nutritional Status (°/)Between Various Surveys and Monitoring Data'

Baseline (Phase I-III) survey (1992-93)* . 41.4 34.9 18.8 4.9National Family Health Survey (1992-93) 43.8 33.0 19.1 4.1Baseline (Phase IV and V) survey (1995) 54 6 29 6 13 1 2 8Monitoring data (December 1995) 1 40 0 39.4 16.8 3 8Mid-term Survey (April/May 1996) 44 7 26.5 19 0 9.8Momitorinn data (April 1996) 43 8 40.7 14.3 1.2Monitorin data (December 1996) 45.4 40.0 13.5 11Terminal evaluation (October 1997)** 81.8 15.1 3 1

* The age group at 1992-93 baseline and 1997 endline surveys was 6-36 months, which wouldbe expected to give slightly higher figures than the 0-36 month aggregate.

** The terminal evaluation figures refer to 9 districts for which data was available at the time ofICR preparation.

11. Progress towards the impact objectives is best assessed using the interim report of theterminal evaluation, despite this only having covered nine districts. The full report covering alldistricts will only be available after the Implementation Completion Report submission deadline.Comparing district-wise trends in nutritional status of 6-36 month olds, the terminal evaluationshows the following:

* Severe Malnutrition. There has been an aggregate 44% decline in severemalnutrition since the 1992-93 baseline, i.e., nearly 9% per year. Only two of the ninedistricts (Thiruvarur and Nagapattinam) failed to reach the severe malnutritionreduction objective. Monitoring data suggest significantly lower figures for severemalnutrition at all data points, and thus a correspondingly greater achievement of a78% aggregate decline over this period. On balance, the severe malnutrition objectivecan be considered to have been achieved.

* Moderate Malnutrition. The picture regarding moderate malnutrition (i.e. Grade II) ismore complex. On the one hand, the rate of moderate malnutrition reduction has notbeen rapid enough to achieve the second impact objective of Normal/Grade Ipercentage improvement. In five years, a 23% decline in moderate underweightprevalence was achieved, with just over a 9% increase in the Normal/Grade Icombined category, i.e., 1.9% per year. More than one child in seven in Tamil Naduremains moderately malnourished.

All anthropometric data unless otherwise specified are classified according to the Indian Academy of Paediatrics(IAP) system which grades children with respect to the percentage deficit in weight, at a given age, from areference standard. In the IAP system, "normal" is 80% or above, Grade I is 70-80%, Grade II, 60-70%, Grade III,50-60% and Grade IV below 50% of the reference median.

5

12. However, this particular objective seems in retrospect to have been too ambitious, for tworeasons. First, the secular trend in the percentage of 1-5 year-olds in the Normal/Grade I categorycomprised a mean annual increase of 2% during the 1980s in Tamil Nadu, according to theNNMB. The TINP II objective as worded specifies a 5-7% annual rise. Second, given the 1992-93 baseline percentage of 76.3% in the combined Grade I and Normal category, the secondimpact objective is statistically impossible, implying, as it does, greater than 100% in thesecategories by project close. This objective had originally been set in 1990 on the basis of the 1989TINP I terminal evaluation figure of 30% moderate malnutrition, not the 1992-93 baseline figureof 18.8%. A reasonable, yet challenging objective with hindsight might have been to achieve amean prevalence of 90% in the Normal/Grade I category by project close, i.e., a 3.6% annual rise- thus nearly doubling the 1980s secular trend.

13. Impact in ex-TINP I districts was significantly better than non-TINP I districts. The bestperforming districts in the terminal evaluation were the four ex-TINP I districts which, takentogether, achieved a 17% increase in Normal/Grade I prevalence, i.e., close to the 3.6% targetmentioned above.

14. Was the project design - increased emphasis on at-home prevention versus center-basedcure - flawed with respect to reducing moderate malnutrition, or was the relative lack of successdue to implementation problems? Clear evidence is lacking, but the weight of the evidencesuggests that implementation problems, especially emphasizing quantity (expansion) over quality,are the more likely explanation.

15. Gender. Both the TINP I terminal evaluation (1989) and the 1992-93 NFHS showedhighly significant gender differentials in child nutritional status, with girls faring worse. Five yearslater, the TINP II terminal evaluation shows (at least for 9 districts), that this differential nolonger exists. The pooled percentage of children below the 75% of the NCHS weight-for-agenorm was 31% for girls and 38% for boys. Assuming no major gender differentials in mortality(though data are not yet available on this), it would appear that neglect of the girl child may nolonger be demonstrable by weighing the youngest children.

16. Location. Villages which were not covered by TINP II at the time of the mid-term surveyin 1996 had significantly higher levels of malnutrition. The two districts with by far the lowestproject coverage were among the districts with the worst child nutritional status, namelyTiruvannamalai and Dharmapuri. No significant difference was found between the situation inmain villages and in smaller hamlets, which implies that where the project did succeed in reachinghamlets, it was as effective as in larger villages. In mid-1996, however, a significant proportion ofthese hamlets remained unreached.

17. Low Birth Weight. The situation regarding the ambitious objective of halving low birthweight incidence is unclear owing to a lack of reliable data. 1992-93 NFHS data provide a figureof 23% low birth weight incidence in Tamil Nadu, almost identical to the 23.5% figure arrived atin the 1996 MTS from a limited sample of institutional data. Antenatal care indicators suggestsuch an improvement is plausible. Birth weight recording in general is not well carried out anddata are usually both scarce and unreliable. Although it is not possible to judge the degree of

6

improvement, it is clear that low birth weight incidence has declined from its baseline level ofabout 30%.

18. Infant Mortality Rate. The infant mortality rate (IM) reduction target has been achieved.According to the nationwide Sample Registration System, the IMR for Tamil Nadu in 1996 was54 per 1000 live births. The marked declines in severe malnutrition suggest that TINP IIcontributed significantly to this decline, although absolute attribution is not possible.

19. Conclusion. In sum, although not all impact objectives have been achieved, there hasclearly been a significant positive impact on severe malnutrition, and on infant mortality.Moderate malnutrition reduction has not achieved its ambitious objective, although progress hasbeen made, particularly in ex-TINP I districts. Limited data render it difficult to come to aconclusion with regard to the low birth weight incidence objective. It appears that the gender gapin child nutritional status which has existed since the inception of TINP I has narrowed. Withregard to geographical targeting, for the hamlets that were covered, project performance was aseffective as in larger, more accessible villages.

Service Delivery Objectives

20. Actual coverage. According to MTS data, 84% of the rural population of TINP IIdistricts are actually covered by the project. Coverage is particularly low in two districts --Tiruvannamalai (46%) and Dharmapuri (55%). Monitoring data from the TINP project officemake a further differentiation. Within covered areas, there are certain "unreached" populations,usually residing in small outlying hamlets, which do not have ready access to TINP-II services.According to the MTS, this "unreached" population varies from 1% in the district of Dindigul to29% in Periyar district. While progress has been made with the coverage of hitherto inaccessiblehamlets, outreach is still patchy in some districts and needs improvement.

21. Process objectives. The terminal evaluation provides a mixed picture. On the positiveside, 90% of all pregnant women were registered (target: 80%), 81% of whom before 20 weeksgestation (target: 50% of all pregnancies). 90% women reported having received at least oneante-natal check-up, which was a major improvement from the 39% at baseline, and 56% womenhad at least four check-ups. Tetanus toxoid immunization coverage reached 99% for at least onedose and 89% for both doses, surpassing the target of 80%. On the negative side, iron and folicacid supplement coverage of pregnant women was 71% but only 10% total had received at least90 tablets as against a target of 60%. Post-partum maternal vitamin A supplementation coveragewas only 14% of attended deliveries, as against a target of 100%. Sustained food supplementation(i.e., for at least 16 weeks) was 45% for pregnant women (target: 60%) and 30% for lactatingwomen (target: 90%).

22. With regard to under-three year-old children, most targets have not been met. Completeimmunization coverage was 88% against a target of 100%. Regular growth monitoring was 69%(target: 90%), although this figure only refers to the 50% of mothers with growth cards.Supplementation of eligible children was found to be 58% for 6-36 month-olds (revised target:95%) and 48% for 36-60 month-olds. 57% of children took longer than 90 days feeding to

7

"graduate" into a higher nutritional grade, while 7% did not graduate. Having graduated, 26%children relapsed within one year, with a particularly high proportion from the youngest children,indicating weak counseling.

23. The terminal evaluation found that 31% of 12-23 month-olds with "any morbidity" werereferred, though this does not permit assessment against the referral objective which was framedwith regard to severely malnourished children. Vitamin A coverage was low, with only 17% of12-23 month-olds having received the recommended two six-monthly doses (target: 90%), and29% having received one dose in the last year.

24. Health service coverage. TINP has a clearly defined organizational structure with a built-in platform for coordination with the health sector through matching workers at different levels.In addition to nutrition-related services, the CNC was intended to be the focal point for key healthservices such as immunization, ante-natal and post-natal care. The CNW liaised with the VillageHealth Nurse (VHN) to organize immunization sessions every Wednesday, ante-natal and post-natal care services on Mondays and joint home visits every Thursday.

25. According to the MTS, home visits by the CNW were regularly undertaken, with morethan 85% of mothers on average reporting that either the CNW or Village Health Nurse (VHIN)visited them following referral. The mixed results on process indicators suggest that inter-personalcommunications were not adequate in some areas, which may be related to lack of refreshertraining. Joint CNW/VHN visits were occurring frequently in most districts. These findings weresupported by the termninal evaluation. The MTS however reported the existence of problems withcoordination at block level between health and nutrition officials, and irregular participation injoint review meetings.

26. Training. The intensive block-level approach to decentralized training of village-basedfunctionaries has largely been successful. The Communications and Training Center (CTC) haseffectively undertaken training of supervisors and other higher-level workers, although thereremained a heavy backlog of refresher training throughout the duration of the project - which wasrelated to the fact that expansion of the project into new areas was treated as a higher prioritythan quality improvement in existing areas.

27. Decentralized joint training of health functionaries along with the Community NutritionWorkers has in recent years given greater emphasis on communications for behavioral change -particularly with regard to home-based care and feeding practices for children and women,complementary feeding strategies, early pregnancy registration and ante-natal care. However, thisshould have been emphasised right from the start of the project.

28. Quality remains a problem. The CNWs' own awareness of the different tasks they arerequired to undertake was found to be limited in certain districts at the time of the MTS. Ingeneral, most CNWs knew the purpose of weighing and the criteria for selection intosupplementary feeding, although there were significant inter-district variations. Such differencessuggest the need for a modular approach to training to enable appropriate skills and knowledge tobe linked to local problems.

8

29. Pre-school education. Regular pre-school attendance was found in the terminal evaluationto be 47% as against a target of 80%. The project also provided orientation training on pre-schooleducation to Child Welfare Officers (CWOs) and teaching/learning materials to CNCs.

30. Conclusion. In sum, service delivery was patchy with some of the most important processobjectives not being achieved. Block-level training worked well, though there was a significantbacklog in refresher training which has compromised quality and led to serious gaps in knowledgeand awareness. The existence of significant inter-district variations in some aspects of servicedelivery performance suggests the need for a modular, site-specific approach to training.

Communications Objectives

31. The TINP II communications strategies derived from formative research, the findings ofthe baseline survey and a communications needs assessment study conducted in 13 districts byDistrict Communication Officers. During the early years of TINP II, the emphasis was on state-wide mass media communications on selected themes. A considerable amount of printedmaterials, including a newsletter, was produced, widely disseminated and undoubtedly had apositive effect on popular awareness of malnutrition and its causes. However, inter-personalcommunications and counseling were relatively negected.

32. The 1996 MTS assessed the degree of maternal knowledge of various aspects of nutritionas a proxy for the impact of the communications component. Findings were mixed. Most womenwere found to be aware of the existence of growth monitoring within TINP II but the majority didnot know that growth monitoring was intended to be carried out monthly. The great majority ofwomen believed that supplementary feeding of malnourished children was intended either toimprove weight or improve health or both. Maternal knowledge of at least one cause of diarrhearanged from 25-93% between districts. In fact, the pronounced inter-district variation was one ofthe main findings. This calls for a more decentralized topic-specific, area-focused communicationsstrategy, not one biased towards mass media campaigns.

33. The 1997 terminal evaluation showed that communication gaps persist but that someprogress is evident in the last one to two years. 70% of women reported receiving healtheducation, mostly from the CNW (74%) or VHN (16%), mostly at home. With regard to caringpractices, 90% of mothers initiated breastfeeding within first six hours, but 29% of newbornswere given liquids, mainly sugar water. Only 9% of mothers were found to discard colostrum.Only 35% 1-2 year-olds were introduced to complementary foods at the recommended time of 5-6 months, with a further 11% between 3-4 months. A disturbing 29% of such children had notreceived any complementary foods by 10 months of age. Among the 7% of mothers not feedingcomplementary foods to their 12-23 month-old children, the main reason cited was perceivedbreastmilk adequacy (3 8%), and the perception that the child cannot eat solids (17%).

34. A situation-specific, "mini-campaign" approach to targeted communications was adoptedin the latter part of the project period, focusing on such areas as growth monitoring, on-sitefeeding, ante-natal care, micronutrient supplementation, breastfeeding and complementary

9

feeding, and the prevention and management of diarrhea and acute respiratorY infections. Inaddition, EEC efforts directed at the community resulted in an increase in the weighing of newbornbabies soon after birth.

35. Certain innovations, such as special sensitization workshops for newly married couples,village priests and village barbers, were important contributions. Traditional practitioners ofSiddha, Unani and homeopathic medicine were oriented and involved in supporting lEC.Participatory planning workshops for NGOs were convened, and traditional media also used forcommunicating project messages. On the other hand, there was little attempt to systematicallymonitor behavior change, though this is planned for the future. Also there is a need to expandsuccessful small-scale EEC-related pilot efforts.

36. The project focused on knowledge dissemination but failed to focus on attitudes andpractices with the same vigor, in contrast to TINP I. Attention was focused on materialsproduction, and use of techniques such as Participatory Rapid Appraisal (PRA) with communities,and inter-personal communication skills training for field staff only came late in the project.

37. Conclusion. The communications component, which was based on sound formativeresearch, was to some extent limited by its bias towards mass media approaches. More attention isrequired on the development of the CNW's inter-personal counseling skills. The geographicalvariation, as with service delivery, suggests that strategies should be flexible, decentralized andproblem-focused. This has been recognized by project management in the last two years and thebalance has shifted towards participatory appraisal to reveal communication priorities, and thedevelopment of the CNW's communication skills. Interesting community-based innovations,taking advantage of localized opportunities, have also been tried out with some success, providinglessons for wider replication.

Community Mobilization Objectives

38. In the early years of the project, little attempt was made to mobilize communities andcatalyze a more active form of involvement. Social mobilization really only took off during thesecond half of the project when NGOs, opinion-leaders and newly-elected village panchayatmembers were oriented towards the goals of the project and motivated to generate furthergrassroots support. This led to both cash and kind contributions frompanchayats and repair andmaintenance of CNCs. An estimated $300,000 was raised for IEC and facility maintenance bycommunity contributions. One example of an innovative approach, funded by panchayats, was acampaign to improve birth weight recording by providing every mother with a birthday card forher newbom child.

39. Special training and orientation sessions were organized for women's working groupmembers in group dynamics, self-confidence, formation of self-help groups and thrift and creditactivities. 4430 thrift and credit societies were formed and, by project close, savings werereported to be about $400,000. The terminal evaluation found that 79% of CNC villages had awomen's working group, but participation was somewhat weak. Only 15% of the womeninterviewed actually participated in these meetings, and just 3% in the women's self-help groups.

10

75% of villages had adolescent working groups. Sustainable linkages, such as with ongoingincome-generation schemes like Developing Women and Children in Rural Areas (DWCRA),were not achieved.

40. Conclusions. After a slow start, community mobilization, and women's group formationand training in particular, began to pick up in the latter stages of the project, although workinggroups need strengthening if real and sustainable community ownership is to be achieved.Linkages to other government-supported income generation schemes for women are needed.Opportunities were taken to orient newly-elected panchayat members who themselves becameadvocates for the project.

Monitoring and Evaluation Objectives

41. Monitoring. The monitoring system of TINP II is of a generally high quality design, aimedat producing timely reports and supportive feedback. Key indicators are tracked regularly andblock-level performance monitored by district-level officers who take responsibility for followingup with blocks which lag on any particular indicator. Data quality is also monitored by regularinspections of registers maintained at the CNCs, and reliability checks of weight data areconducted every month by monitoring staff in selected centers.

42. The system has been streamlined, with the number of CNC registers reduced from fifteento seven during the project in order to prioritize the collection of key quality data. These havebeen further reduced to four registers which will be used during the forthcoming Woman andChild Development (WCD) Project.

43. However, substantial problems are evident. The terminal evaluation found that only 75%of CNCs had working weighing scales and health cards, and inconsistencies were reportedbetween CNC-recorded data and the evaluation survey with respect to some service deliveryparameters. In Trichy and Coimbatore districts, the quality of monitoring and growth promotionactivities in 1995-96 was adversely affected in some centers by a 15-month delay in purchasing2500 weighing scales which were then found to be defective and replaced. Other weak aspectsinclude the limited community-level monitoring and the poor birth weight recording. Birth weightis both a prospective marker of the child's nutritional and health status and a retrospective markerof the mother's nutritional and health status, and should be a pivotal measure of projectperformance.

44. Evaluation. Performance in this area was weak, which is especially disappointing giventhe national and international interest in such questions as TINP II's focus on reducing moderatemalnutrition. The reasons are several. First, despite having an expert committee to overseeevaluation, all surveys were substantially delayed, by over two years in the case of the baselineand mid-term surveys. Second, the conduct of the surveys and the quality of the analysis left muchto be desired. As a result of these two factors, this report is unable to draw definitive conclusionsregarding project impact, e.g., on moderate malnutrition. Procurement of evaluation work onHNP projects in India regularly fails to yield high quality survey work. The Bank was remiss in

11

not taking firmer action, when delays and low quality work persisted, to enforce the covenants onresearch and evaluation studies.

45. Conclusion. In sum, the monitoring system remains one of the strengths of TINP II, as itwas with TINP I, The system of tracking key process and outcome data, with built-in data qualitychecks and a streamlined set of registers, is efficient and action-oriented. Blocks that are found tobe lagging are followed up by district-level officers, and project management is kept informed ofdistrict-level performance through a wall chart that is updated every month. However there aresome serious gaps in monitoring implementation which need to be addressed. Evaluation has beenweak throughout the project.

Operational Research Objectives

46. Thirteen operational research studies were undertaken during TMNP-II and all but twowere concluded. Several among them were only finished in 1996 and the findings have informedthe forthcoming Woman and Child Development Project in the state. These studies included acomparison of child stunting in project and non-project areas, a study to correlate severe childmalnutrition with household level food security risk, and a rapid assessment of the effectiveness oftraining on birth weight recording. Other studies are detailed in Table 6 of the Appendix. As wasthe case with TINP I and ICDS I, the quality and timeliness of the research was generally low. Asmentioned, the mid-tern review, apart from being delayed by two years, was also of a generallylow quality, rendering an assessment of impact impossible.

47. Conclusion. Unsatisfactory performance on operational research in this and other Bank-financed nutrition projects in India calls for action in ongoing and future projects. First, morerigorous pre-qualification of bidders on research and evaluation studies will be needed. Second,special oversight, e.g., by a national panel of experts should help ensure higher quality and moretimely work.

Physical Targets

48. 18,500 centers were functioning at project close, each staffed by two nutrition workersand a helper. 483 CNCs were constructed out of a targeted number of 500. None of theoriginally planned 4,500 CNCs for in-filling were actually built, despite this figure having beenrevised down to 1,400 in late 1996. This seriously constrained project outreach and led to thepatchy results regarding hamlet coverage. The Government of Tamil Nadu says the main reasonthe CNCs were not built was the agreement between GOI and the Bank in 1991, and again in1993, to recycle IDA funds. This resulted in cancelation of exchange rate savings in manyprojects, and $30.5 million in the case of TINP II. While the Government of Tamil Nadu didreceive the full rupee amount of the credit, less the amount of $1.8 million canceled formisprocurement, they were counting on using exchange rate savings for constructing the CNCs,having over-spent in other budget categories, e.g., incremental operating costs. With the benefitof hindsight, the Bank should have insisted on the completion of the planned construction. Theproject authorities continued to press GOI to reinstate the credit proceeds that were canceled,

12

claiming that there were insufficient resources for the construction. The cancelation clearlylowered the morale of project officials.

49. To meet increasing demand for hostel facilities for trainees, a second floor wasconstructed in the hostel wing of the Communications and Training Center. Under this project,Maternal and Child Health Annexes in 9 Primary Health Centers in four districts, and 10PrimaryHealth Centers were constructed at a cost of Rs. 16 million. A computer center wasinstalled in the Project Management Unit.

Procurement

50. There were irregularities in the procurement of drugs and supplementary foods financedby the project. Bank staff investigated a complaint in March 1995 that a pharmaceutical companyhad been prevented from bidding to supply drugs to the project. It was also discovered that theselected bidder had not met the qualifying criteria. Mis-procurement of drugs was subsequentlydeclared and US$1.8 million of the credit proceeds were canceled. With respect to procurementof food, the chosen supplier was blacklisted by the then project coordinator in November 1995and new supply orders entrusted to alternative suppliers. Food supplies were delayed for severalmonths, and then found to be sub-standard by an independent laboratory analysis commissioned atthe request of the Bank. The original supplier was reinstated and food supply of acceptable qualityresumed in June 1996 after a total delay of 6 months. The project coordinator who blacklisted thesupplier was subsequently transferred.

51. There were other irregularities with regard to the procurement of weighing scales, cups,toys and furniture which were found to be delayed or defective. These problems were rectifiedafter intervention by Bank staff.

C. MAJOR FACTORS AFFECTING PROJECT IMPLEMENTATION

52. On the positive side, the use of nutritional status criteria to select children for feeding, asopposed to only poverty criteria, resulted in better targeting to those children who were mostlikely to benefit from extra food. The focus on growth faltering placed an important emphasis onthe prevention of malnutrition as opposed to merely a therapeutic post-hoc strategy. Anotherpositive factor was the built-in structural coordination between the health system and TINP II atall levels, with a well-defined system of information flow, management and supervision.

53. Several factors negatively affected project implementation. One of these was theexhaustion of project funds in May 1997 related to cancelation of $30.5 million because ofexchange rate savings and US$1.8 million because of misprocurement. This led to refreshertraining and communications activities being stalled for approximately five months. Another wasthe fact that contrary to recruitment regulations, a significant proportion of CNWs were residentoutside the village they worked in, which compromised community mobilization, communicationsand service delivery. There were also problems with the training and supervision of a significantproportion of Community Welfare Organizers (CWOs) who were promoted to CommunityNutrition Supervisors and then to the block-level position of Community Nutrition Instructress

13

(CNI), despite their not meeting the educational qualifications for the CNI post. Simultaneously,many of the original TINP I CNIs who were excellent trainers were transferred elsewhere.

54. Overall, during the mid-project period from 1993-1995, there was a significant fall-off incommitment, integrity and supervision from project management which percolated down to alllevels, adversely affecting morale and motivation. This fall-off reflected major political turmoilwhich affected every sector in Tamil Nadu during the period. These problems were addressed in1996 by a new project team which successfully set about revitalizing the project. Qualityimprovement planning, an open, action-oriented management style and supportive supervisionwere all institutionalized to this end.

55. Given the turbulent environment in which the project operated, it continued to functionreasonably well. This owed much to the solid human resource foundation built by TINP I whichwas resilient in the face of deteriorating project management. The terminal evaluation impactfindings provide some support for this supposition in that TINP I districts performed particularlywell, and far better than the Phase V districts introduced in 1995.

D. PROJECT SUSTAINABILITY

56. The prospect for sustainability is good and the state is poised to take up the Woman andChild Development Project (WCD) during 1998, although this is based on a one-worker model,rather than the two-worker model widely considered to be a major factor in the success of TMNP.The rate of attrition of the second worker in the existing two-worker model however is low andmost of the second workers will remain for 10 years. The capacity built during TINP II,particularly human skills and capabilities through training, will certainly benefit WCD, as will theinfrastructure already created.

57. The Government of Tamil Nadu approached the GOI in mid-1997 to take over therecurrent costs of TINP II as part of universalization of the ICDS program. The stategovernment met the recurrent costs of TINP II until they were assumed by GOI from January 1,1998, and is financing the food costs. GOTN has pledged to sustain the women's groupsestablished under TINP II and to strengthen linkages with ongoing income-generation programsin the state.

E. BANK PERFORMANCE

58. Bank performance was mixed. Assistance during preparation and appraisal wassatisfactory. But TINP staff complained that they did not receive the extensive technical supportearly in TINP II that they had enjoyed under TINP I. Supervision missions were regular andthorough, and consistently discussed and agreed on ways of overcoming implementationproblems, although these actions often were not taken. But Bank staff could have done more,perhaps, to restore the balance, when project staff neglected existing project areas relative toexpansion areas, i.e., emphasized quantity over quality. This emphasis may explain in part why theproject did not achieve greater gains against moderate malnutrition.

14

59. During the first half of the project, Bank staff became aware of irregularities and broughtthese to the attention of GOTN at very high level. However, being unable to corroborate theirregularities, these were not brought out in aides-memoire or supervision reports. Subsequently,in the second half of the project, Bank staff did report and take action on irregularities, e.g., onthe procurement of drugs, goods, and other items. The greater proactivity in the project's laterstages may also reflect greater emphasis on these matters by Bank management. With the benefitof hindsight, Bank staff should have acted more forcefully to deal with the poor quality andtimeliness of operational research and evaluation studies.

F. BORROWER PERFORMANCE

60. Project management under TINP II compares unfavorably with that in TINP I on anumber of counts. Most fundamentally, project staff emphasized expansion (quantity) overquality, e.g., new areas over "in-filling" of CNCs, refresher training, and IEC in TINP I areas.This was one of the reasons the project did not do as well as had been hoped in relation toreducing moderate malnutrition and low birth weight deliveries. A second problem area wasfailure to act on problems such as 25% of CNWs living outside their villages, despite this havingbeen raised repeatedly by supervision missions. Third, project management did not follow theconcept of "management by exception", despite repeated recommendations from supervisionmissions, until the last year of the project.

61. It should be noted that TINP II operated in a far less favorable political environment thanTINP I and project management performance did improve in the final two years of the project.Nevertheless, TINP II management added much less value than was the case of TINP I, and wasunable to deal with a number of key problems. On balance, the overall performance has to berated as unsatisfactory.

62. The Government of India complied with all of the covenants in the Development CreditAgreement while the Government of Tamil Nadu complied with all covenants of the ProjectAgreement, except the requirement to complete the mid-term review by the end of 1993. Thereview finally took place in 1996. The delays in both the baseline and mid-term surveys preventedproject management from making important and timely mid-course corrections.

G. ASSESSMENT OF OUTCOME

63. The project outcome was satisfactory in that it achieved two of the four majordevelopment objectives and consolidated the gains made by TINP I. However, the key moderatemalnutrition objective was only partly achieved. While this objective appears over-ambitious, inhindsight, greater gains could have been achieved with stronger project implementation. Thelessons learned from TINP I and TINP II were valuable in the design and preparation of the WCDproject in which Tamil Nadu and four other states will participate.

15

H. FUTURE OPERATION

64. Tamil Nadu is one of the five states involved in the forthcoming Woman and ChildDevelopment Project. From January 1998, all the 318 TINP II blocks were incorporated into theICDS program, which is to be universalized throughout India. The TINP II blocks are now underthe general ICDS program and the PMU has merged with the ICDS Directorate. In keeping withthis, TINP II blocks will convert from a two-worker to a one-worker model to be in line withICDS. The Governmernt of Tarmil Nadu insists that it cannot sustain the cost of two workers, andGOI ICDS norms preclude it from picking up the cost. In addition, GOTN makes the valid pointthat it should be possible to reduce recurrent costs after 18 years of TINP. But that would requireGOI to adopt the selective feeding approach of TINP, which is has never been willing to do, or toreallocate funds from other nutrition programs to ICDS. Both of these issues are being discussedin the context of ongoing nutrition sector work.

L LESSONS LEARNED

65. TINP I had a marked impact on the prevalence of severe malnutrition in Tamil Naduduring the 1980s, as borne out by an impact evaluation, and later corroborated by the NationalFamily Health Survey (NFHS). This success was founded on several factors including selectivefeeding, favourable worker-supervisor ratios, clear job descriptions and a well-focused monitoringsystem, used to improve project management and implementation.

66. The NFHS however also showed that levels of moderate malnutrition remained high inTamil Nadu. TINP II failed to move beyond reducing severe malnutrition to also make a majordent in moderate malnutrition. Of its new strategies, only the two relating to health-nutritioncoordination were clear successes. Others made some inroads, but were not implemented aseffectively.

67. The main lesson learned from TINP II is that the strategies used to combat moderatemalnutrition are broadly appropriate, but that the site of the main action needs to shift from thecenter to the home and the quality of implementation overall needs to be significantly improved.Quality has to take precedence over quantity, consolidation over expansion. As recognized by theend of TINP I, there remains a need to intensify the focus on localized capacity-building,community mobilization and targeted, inter-personal communications. While severe malnutritioncan be reduced with center-based therapeutic feeding (providing the child comes to the center),such a strategy in itself will not sustainably reduce moderate malnutrition. For this to happen, theemphasis needs to be on improving home-based care and feeding of the 6-24 month-old childrento prevent them from becoming malnourished.

68. Given the progress made since the inception of TINP I, a thorough re-assessment of thecauses of remaining malnutrition is overdue. How much of the current problem is related tohousehold food insecurity, how much to health-related factors, and how much to constraints onadequate caring capacity and practice? Such a study would ensure that the design of theforthcoming project remains relevant and appropriate.

16

69. Community ownership should remain a priority, requiring an involvement of more peoplein more direct nutrition-improving action, in addition to resource contributions by panchayats.Community self-monitoring is just one example, whereby a core set of key indicators could betracked by community organizations to increase the visibility of progress.

70. One significant factor behind the generally high-quality training within TINP is thepresence of a block-level officer - the Community Nutrition Instructress (CNI) - who is herselfassisted by Community Nutrition Supervisors (CNS) at a ratio of 1 per 15 CNWs. This ratiobetween facilitators and mobilizers has been found to exist in several other successful nutritionprograms worldwide, such as in Thailand. An important lesson learned in TINP II is that thequalifications for the CNI post cannot be compromised if the quality of training and supervision isto be maintained.

71. The TINP II management information system worked relatively well, but evaluation waspoorly implemented. One possible solution to this recurring problem would be to constitute anevaluation panel, including external expertise, to design terms of references, identify implementingagencies, monitor field implementation and data analysis and ultimately ensure quality andtimeliness of baselines, mid-term reviews and terminal evaluations. The quality control and datavalidation checks of child age and weight estimation procedures, and the methods of training andsupervising field workers in anthropometry in particular, require greater scrutiny in future. Thesame panel could be charged with overseeing key operational research.

72. Other lessons follow. Particular attention needs to be paid to reaching the youngestchildren who are at greatest risk. With regard to area-targeting, many remote hamlets, with highproportions of scheduled caste groups, still need to be reached through the establishment of mini-CNCs. The phenomenon of lagging districts, particularly in the north of the state, has been knownfor some time. The recommendation of supervision missions of joint action-planning with districtstaff and block-level problem mapping, is still valid.

73. In sum, for Tamil Nadu, supportive counselling of caregivers and high-quality servicedelivery, allied with a concerted move towards social mobilization and participatory planningshould be the pillars of a future nutrition improvement strategy. Decentralization, quality andownership are key overriding concerns. For the most part, these lessons have already been woveninto the project strategies of the forthcoming Woman and Child Development Project in TamilNadu, though they will need to be vigilantly monitored during its actual implementation. Oneoutstanding issue is whether the one-worker model followed in ICDS, and the forthcoming WCDproject, can achieve results comparable to those of TINP. The international experience suggeststhat this is unlikely and that India may need to reconsider the two-worker TINP model. The two-worker model can be cost-effective and affordable, but only if the TINP selective feedingapproach is also adopted, a politically difficult decision when the predominant approach is to feedall of the children attending nutrition centers. This key nutrition strategy issue is among the mainareas of focus of ongoing sector work.

74. Most of these substantive lessons are relevant beyond Tamil Nadu. Nutrition interventionswhich are targeted using nutritional criteria, integrated within a broader health system, and

17

effectively supervised and managed can significantly reduce severe malnutrition. TINP has shownthis. It has also shown that to go further and prevent children from becoming moderatelymalnourished is in marny ways a harder task and one that requires a significant shift in emphasis.Nutrition programming in Tamil Nadu is still evolving towards such an approach which stresseshuman capacity-building for home-based action, a pro-active integration with the health system,and the mobilization of communities to sustain the process beyond the project.

75. For the Bank, the main lesson learned from TINP II is the need for firmer action in dealingwith chronic and persistent problems, such as the failure to carry out the mid-term evaluationsurvey in a timely way or the construction of additional nutrition centers in the old blocks of theproject. When delays or persistent problems endanger the achievement of the project'sdevelopment objectives, the Bank must be ready to take a firm stand rather than wait in the hopethat agreed actions will be taken.

18


INDIA - SECOND TAMIL NADU INTEGRATED NUTRITION PROJECT (Cr. 2158-IN)

PART H: Statistical Tables

Table 1: Summary of Assessments

A. Achievement of Objectives Substantial Partial Negligible Not applicable

(/) (//) (8/~~~~0) (V)

Macro Policies ClE FX2ISector Policies a El) ElFinancial Objectives [] C [El

Institutional Development a 21 S ElPhysical Objectives 5 3 5Poverty Reduction [x 5 D

Gender Issues 1El S0Other Social Objectives a 5 0

Enviromnental Objectives 5 5 IXPublic Sector Management 5x El S z

Private Sector Development a ooOther (specify) 5 5 5

(Continued)

B. Project Sustainabilitv Likely Unlikely Uncertain(/) (/) -t(/)

Table 1: Summary of Assessments (continued)

19

C. Bank Performance satisfactory Satisfactorv Deficient(1) (1) (1)

Identification E] Ix E]

Preparation Assistance [x E]

Appraisal Q Q

Supervision 5 [3

HighlvD. Borrower Performance satisfactory Satisfactor Deficient

Preparation a El

Implementation E E [3

Covenant Compliance E E ]

Operation (if applicable) E I3 E

HIiglly Marginallv HighlyE. Assessment of Outcome satisfactorv Satisfactory Unsatisfactorv Unsatisfactorv

El) El) El)(

20



Table 2: Related Bank Loans/Credits

Loan/credit title Purpose Year of StatusapprovalI

1. First Population To support the family welfare program in 1972 Credit closed June|Project CR 312-IN five districts of Mysore (now Karnataka) 30, 1980l

and six districts of Uttar Pradesh. Prjc omlto

Report (PCR) 6/81;PAR 1/82

2. Second Population To support the family welfare program in 1980 Credit closed MarchProject six districts of Uttar Pradesh and three 31, 1988

districts of Andhra Pradesh

PCR 1/90; PPAR8/90

3. Tanil Nadu To improve the nutrition and health status 1980 Credit closed MarchIntegrated Nutrition of preschool children and pregnant and 31, 1989Project I (TINP I) CR nursing women1003-IN

PCR 1/91; ImpactEvaluation Report12/94

4. Third Population To support the family welfare program in 1984 Credit closed MarchProject CR 1426-IN six districts of Karnataka and four districts 31, 1992

of Kerala IPCR 8/93

5. Fourth Population To support the family welfare program in 1985 Credit closed MarchProject CR 1623-IN four districts of West Bengal 31, 1994

PCR 12/94

6. Fifth (Bombay and To reduce infant, child and maternal 1988 Credit closed MarchMadras) Population morbidity and mortality and to moderate 31, 1996Project CR 1931-IN fertility in the cities of Bombay, Madras and .el

other urban areas of Tarnil Nadu, and to Implementation lassist the Municipal Authorities in Completion Reportdesigning and implementing improved 10/96health and family welfare programs.

21

Table 2: Related Bank Loans/Credits (continued)

7. Sixth (First National To support the family welfare program in 1989 Credit closed MayFamily Welfare Training the states of Uttar Pradesh, Andhra Pradesh, 31, 1997and Systems and Madhya PradeshDevelopment) PopulationProject CR 2057-IN

8. Integrated Child To improve the nutrition and health 1990 Credit closed onDevelopment Services standards of pre-school children and December 31, 1997Project (ICDS I) CR mothers in tribal, drought-prone and2173-IN otherwise disadvantaged areas of Andhra

Pradesh and Orissa

9. Seventh (Training) To support lower-income women in the 1990 Credit is scheduledPopulation Project CR rural areas of Bihar, Gujarat, Haryana, to close June 30,2133-IN Jannu, Kashmir and Punjab, through the 1998

training of new and existing health workersand non-Health Department personnel

10. Eighth (Ffamily To help the Government of India increase 1991 Credit scheduled toWelfare Urban Slums) the supply of family welfare services in the close June 30, 2001Population Project CR slum populations of Andhra Pradesh,2394-IN Karnataka, West Bengal and Delhi

II. Child Survival and To increase child survival and promote safe 1991 Credit closed onSafe Motherhood Project motherhood, including establishing first September 30, 1996CR 2300-IN referral units for secondary-level care of ICR 3/97

mothers and their newborns

12. Second Integrated To improve the nutrition and health status 1993 Credit scheduled toChild Development of pre-school children and their mothers by close September 30,Services Project T (fCDS strengthening and increasing the outreach of 2000II) CR 2470-IN the ICDS program in Bihar and Madya

Pradesh.

13. National AIDS To support the Government's efforts in 1992 Credit scheduled toControl Project controlling the HIV/AIDS epidemic with the close March 31,CR 2350-IN objective to slow the spread of HIV in India 1999

so as to reduce future morbidity, mortalityand impact of AIDS

14. Ninth (Family To support the family welfare program in 1994 Credit scheduled toWelfare Assam, the states of Assam, Rajasthan and close December 31,Rajasthan and Karnataka 2001Karnataka) PopulationProject CR 2630-IN

15. Andhra Pradesh First To (i) improve efficiency in the allocation 1994 Credit scheduled toReferral Health System and use of health resources through policy close March 31,Project CR 2663-IN and institutional development: and (ii) 2002

improve system performance of health carethrough improvements in quality,effectiveness and coverage of health servicesat the first referral or secondary level to

22

1 ~~~~~~~better serve the neediest sections of society. 1

23

Table 2: Related Bank Loans/Credits (continued)

16. National Leprosy To eliminate leprosy as a public health 1994 Credit scheduled toElimination Project problem in India by the turn of the century close March 31,

CR 2528-IN and to reduce the impact of leprosy 2000disability

17. Cataract Blindness To upgrade the quality of cataract surgery, 1994 Credit scheduled toControl Project expand services to underprivileged sectors close June 30, 2001

CR 261 -IN and reduce the backlog of cataract

18. Second State Health To (i) improve efficiency in the allocation 1997 Credit scheduled toSystems Development and use of health resources through policy close March 31,Project CR 2833-IN and institutional development; and (ii) 2002

improve performance of the health caresystem through improvements in the quality,effectiveness and coverage of health servicesat the first referral level and selectivecoverage at the primary level to better servethe neediest sections of society.

19. TB Control Project To reduce mortality, morbidity and 1997 Credit scheduled toCR 2936-IN disability due to TB and to reduce the close December 31,

incidence of infectious TB by focusing on 2002the cure of infectious patients

20. Malaria Control To reduce death, morbidity and social and 1997 Credit scheduled toProject CR 2964-IN economic losses from malaria through and close March 31,

improved malaria control program 2003including: (i) using a better mix of effectivemalaria control interventions responsible tolocal needs; and (ii) strengthening theDirectorate of the National Malaria Program(NMP) and modifying its orientation

21. Reproductive Health To improve quality, coverage and 1997 Credit scheduled toProject CR NOI 80-IN effectiveness of existing Family Welfare close March 31,

(FW) services and expand their scope to 2003include more elements of a defined packageof reproductive and child health (RCH)services

22. Rural Women's To strengthen processes that promote the 1997 Credit scheduled toDevelopment Project economic development of women and create close June 30, 2002CR 2942-IN an environment for social change, including

improving access to better health care

24



Table 3: Project Timetable

Steps in Project Cycle Date

Identification (Executive Project Summary) April 26, 1988

Preparation November 1, 1989

Appraisal January 12, 1990

Negotiations May 4, 1990

Board Presentation June 14, 1990

Signing September 14, 1990

Effectiveness December 5, 1990

Midterm review (if applicable) October 29, 1996

Loan Closing December31, 1997

25


INDIA - SECOND TAMIL NADU INTEGRATED NUTRITION PROJECT (Cr. 2158-IN-)

Table 4: Credit Disbursements: Cumulative Estimated and Actual(US$ millions)

FY91 FY92 FY93 FY94 FY95 FY96 FY97 FY98

Appraisal Estimate 4.00 6.00 15.30 31.40 57.40 77.90 93.20 95.80Formally Revised * 36.93 51.90 63.90 65.82Actual 6.24 8.48 14.73 25.70 41.73 53.58 69.39 72.80Actual as %ofEstimate 156 141 96 82 113 103 108 111Date of Final Disbursement January 28, 1998

* Credit in the amount of USS32.3 equivalent was canceled.

26



Table 5: Key Indicators for Project Implementation

Estimated ActualI. Key Implementation Indicators in SAP] President's Report (staret (9tal

l ~~~~~~~~~~~~~~~~~~~~~~(SAR target) (1997 stattus)

Impact IndicatorsI. Reduce severe malnutrition (Grade III and IV) among children 6-36 months in Mean 44%new and existing project areas

New 50% New 21%Old 25% Old 56%

II. Increase in proportion of children 6-36 months in normal and Grade I Mean 9%nutrition status in new project and existing project areas

New 50% New 3%Old 35% Old 17%

III. (a) Reduction in infant mortality rate 55/1000 54/1000*(b) Reduction in incidence of low birth weight by 50% 23%

Process Indicators1. Early registration of pregnant women 50% 73%2. Total registration of pregnant women 80% 90%3. Tetanus toxoid immunization of pregnant women 80% 89%4. Consumption of iron and folic acid tablets for at least 12 weeks by pregnant 60% 10%women.5. Administration of post-partum vitamin A to attended deliveries 100% 14%6. Food supplementation for at least 16 weeks to registered pregnant women with 60% 45%inadequate nutrition status7. Food supplementation of at least 16 weeks of registered lactating women with 90% 30%malnutrition in pregnancy8. Immunization (UIP-6) of children 100% 88%9. Vitamin A megadose (100,000-200,000 i.u.) semi-annually to children 6-36 90% 46%months10. Regular growth monitoring (>9 times a year) of children 0-3 years 90% 69%11. Supplementation of monitored children 6-36 months with Grade II to IV 100% 58%malnutrition12. Pre-school attendance (>80 percent working days) 70% 47%13. Household use of oral rehydration in the last incidence of diarrhea 60% 82%14. Additional complementary foods introduced by 6 months of age 50% 35%15. Active women's working groups (>9 meetings a year) 80% 79%

* 1996 Sample Registration System ( SRS)

27



Table 6: Studies Included in Project

Purpose as DefinedStudy at Appraisal/Redefined Status Impact of Study

1. Base line survey for TINP II To collect base line survey data Completed Used to measure project(Phase I to III districts). in the project area. achievements.

2. Base Line Survey for TINP -- do -- Completed -- do --II (Phase IV and V districts).

3. Mid-term review and While reviewing all project Completed Provided nutritionalEvaluation of TINP II (Phase 1 activities, special attention would and status of 6-36 monthsto III districts). be paid to: reanalyzed by age group and status of

a) the new supplementation Bank all project activities,approaches being adopted under consultant guided follow-upthe Project; measures to reduceb) the revised referral procedures severe malnutrition.and the Maternal and ChildHealth annex system being testedin Madurai district and;c) the new arrangements forhealth/nutrition coordination

4. Social assessment study for To identify the different social Completed Study identifiedimproving health and and economic groups in the immediate needs of thenutritional status in Tamil project areas and describe their communities, andNadu numbers, distribution and recommended broader

relevant characteristics for the issues of strategy andproposed Woman and Child program orientation.Development (WCD) project.. Main recommendations

utilized for WCD project.

5. Study of child stunting in To measure the prevalence of Completed Study helped developprogram and non-program stunting (height for age) in 10 IEC strategy forproject areas. project districts and compare promoting colostrum

with non-project areas. feeding and safe birthintervals.

6. Formative research and Aid in the design and conception Completed Findings used in mid-strategy design for of materials and pre-testing for course corrections and tocommunication component. fine-tuning of the materials. modify existing EEC

strategies and developnew strategies forproposed WCD project.

7. Condition report on bar To assess the working condition Completed Findings used inscales by monitoring wing, of bar-scales in different districts. assessing scaleTINP. requirements.

28

Table 6: Studies Included in Project (continued)

Purpose as DefinedStudy at Appraisal/Redefined Status Impact of Study

8. Rapid assessment survey on To assess the effectiveness of Completed Periodic training ofthe effectiveness of training on birth-weight recording before CNW's improved theirbirth weight recording. training and after training of skill and attitude.

CNWs.

9. Study on severely To assess the percentage of Completed Study enabled the projectmalnourished children in severely malnourished children to better combatselected CNCs to observe if they 0-36 months in at-risk families. malnutrition.belong to at-risk families andcorrelation to income andliteracy.

10. Survey to assess To identify the most effective Completed Study showed thateffectiveness of functioning of model for service delivery resident worker and two-one-worker model vs. two- worker model workworker model and resident vs. better.non-resident worker model.

11. Study on the extent of To find out the reason for low Completed No significant differencemigration of ante-natal/post- registration of ante-natal between actual number ofnatal mothers, by monitoring mothers; wheather it is due to ante-natal women andwing, TINP. mothers migrating at time of number registered.

delivery.. Migration was only 7%.

12. Study on the effectiveness of To find out effectiveness of OngoingLaddu vs. Payasam to children supplementation in the form ofof 7 - 12 months Laddu or Payasam'.

13. Terminal Evaluation of To assess achievements and OngoingTINP II and base line survey for impact of TINP on nutritionalWCD. status of children.

Laddu is a solid sweet snack for older children and Payasam is a semi-solid gruel for younger children.

29



Table 7A: Project Costs

Appraisal Estimate (US$M) Actual/Latest Estimate(US$M)

Local Foreign Total Local Foreign Total*Item Costs Costs Costs Costs

Service Delivery

1. Nutrition 89.08 1.93 91.09 - - 103.29

2. Health 26.05 4.07 30.12 - - 9.07

3. Training 6.28 0.33 6.61 - - NA

Communications 3.25 0.28 3.53 - - 3.93

Project Management

1. Project 4.95 0.04 4.99 - - 5.39Coordination Office

2. Communication/ 1.01 0.06 1.07 - - NATraining Center

3. Monitoring and 1.33 0.05 1.38 - - 1.74Evaluation

Total Base Costs 131.95 6.76 138.71 - - NA

Contingencies 0.38 - - NA

Total Project Costs 139.09* 139.54

* GOI maintains records only in Rupees; a blended rate of Rs.3 1 per US$ was used to convert actual GOI financing into US$

** including taxes and duties of US$5.0 million

30



Table 7B: Project Financing

Appraisal Estimate (US$M) ActualLLatest Estimate(US$M)

Local Foreign Total Local Foreign TotalSource Costs Costs Costs Costs

IDA 87.4 8.4 95.8 - - 96.28

GOTN 43.3 0.0 43.3 - - 43.26

Total 130.7 8.4 139.1 139.54

31



Table 8: Status of Legal Covenants

Agreement Section Covenant Present Original Revised Description of Commentstype status fulfillment fulfillment covenant

date date

CREDll 3.01(a) 03,04,05 c The Borrower to cause Provided.the Project State toperform its obligationsunder the ProjectAgreement and provideresources as necessary.

3.01(b) 03 c The Borrower to make Made available.the Credit proceedsavailable to the ProjectState.

3.02 05 c Procurement to be Governed by thegoverned by the provisions of theprovisions of Schedule I project agreement.to the Project Agreement.

3.03 10 c The Borrower to cause Carried out.the Project State to carryout obligations relating toinsurance, use of goodsand services, plans andschedules, records andreports, maintenance, andland aquisition.

4.01(a) 01 c For all SOE expenditures, Maintained.the Borrower: (i) tomaintain adequaterecords and accounts; (ii)to retain all recordsevidencing suchexpenditures at least oneyear after IDA hasreceived the audit report;and (iii) to enable IDArepresentatives toexamine such records.

4.01(b) 01 c The Borrower: (i) to have The financial recordsfinancial records and and accounts haveaccounts audited; (ii) to been audited byfurnish to IDA an audit Accountant General,report; and (iii) to furnish Chennai.to IDA other reasonableinformation concerningfinancial records andaccounts.

32

Table 8: Status of Legal Covenants (continued)

Agreement Section Covenan Present Original Revised Description of Conmmentst type status fulfillmen fulfillment covenant

t date date

PROJEC 2.01(a) 05, 10 c The Project State to Being carried out.carry out the Projectwith due dilligence andefficiency and inconformity withappropriate practices,and

2.01(a) 04 c Provide promptly the Provided.resources required forthe project.

2.01(b) 05 c The Project State to Implemented ascarry out the Project in per the agreedaccordance with the terms.agreed Implementationin Schedule 2 to theP.A.

2.02 05 c Project State to procure Procurements aregoods, works, and as per the projectservices in accordance agreements.with Schedule I to theP.A.

2.03 10 c Project State to carry out Being carried out.obligations relating toinsurance, use of goodsand services, plans andschedules, records andreports, maintenance,and land acquisition.

2.04(a) 09 c Project State to Being done.exchange views withIDA with regard toProject Progress.

2.04(b) 09 c Project State to promptly Shortage of fundsinforn IDA of any for softwarecondition interfering activities - issuewith Project progress. resolved - activities

ongoing.

33



date dateSch. 2- 12 c 01/01/199 Project State to adopt and Children showing growth1(a) I apply mutually agreed faltering, i.e., growth

beneficiary selection line moving uppercriteria and methodology, tranjectory in case offor provision of normal and Grade I andtherapeutic supplements all children falling underto children under 36 Grade II, m and IV aremonths of age, and given supplementationpreganant and lactating for a period of 90 dayswomen, and initially. Pregnant

women are also givenfeeding on selectivebasis from sixth monthof pregnancy followingselection criteria and it iscontinued for six monthsafter delivery. Childrenin Grade m and IV aregiven therapeuticfeeding.

Sch. 2- 12 c 01/01/199 Project State to introduce Therapeutic foodl(b) I and maintain provision of supplementation hs been

theraputic nutrition introduced as persupplements which have composition approved bya composition satisfactory the Bank.to IDA.

Sch. 2-2 12 c 01/01/199 Project State to introduce In all districtsI and thereafter maintain health/nutrition

mutually agreed coordination has beenarrangements for strengthened. Jointcoordination between Director Health Serviceshealth and nutrition is designated as Districtservices. project Coordinator and

Deputy Director HealthServices are designatedas District ProgrammeOfficers. Regularmonthly reviews areconducted at districtlevels. At sector level,Medical Officers PrimaryHealth Centers conductjoint review meetings onthe second Tuesday ofevery month forhealth/nutrition workersand the supervisory staff.

34



date date

Sch. 2-3 10 c 09/30/199 Project State to undertake Report on MCHl I and complete operations utilization study has

research on the efficacy been furnished to theof different approaches to World Bank afterstrengthening obstetrical discussions with theand child nutritional risk Health Department.management at referralfacilities in accordancewith mutually agreedterms of reference andcriteria.

Sch. 24 09 c Project State prior to Operations Researchundertaking innovative activities and otherstudies, operations studies were carried outresearch, and activities to as per Bank's guidelines.(a) furnish terms ofreference, work plans,and proposed budgetssatisfactory to IDA, and(b) discuss the results ofinnovative studies,operations research, andactivities with IDA.

Sch. 2-5 09 c Project State to furnish to Quarterly progress reportIDA, for review and for the quarter endingdiscussion, in satisfactory September 30, 1997, hasformats: a) quarterly and been sent to the Worldannual progress reports Bank.within three months ofthe relevantimplementation period,and

Sch. 2-5 10 c 01101/94 (b) prospective annual The Annual Plan ofwork plans. Action and Procurement

Plan are sent regularly tothe World Bank.

Sch. 2-6 10 cd The Project State in The base-line surveys forconsultation with the IDA Phase IV and V districtsand in accordance with of TINP II was entrustedterms of reference and to M/s. Mode Researchmethodology satisfactory (P) Ltd. The finalto IDA, to undertake and reports have beencomplete: (a) collection received and given to allof base-line survey(BLS) component managers.data for each health unitdistrict in the ProjectArea prior to thecommencement of projectservice delivery andcommunicationsactivities in that healthdistrict.

35



date date

Sch. 2-6 09 cd 12/31193 (b) a mid-term review The mid-term evaluationand evalutation of the survey in Phase I, II andProject, and m districts was carried

out by M/s Research andDevelopment Council.The study was discussedin a workshop organizedon October 29-30, 1996and the re-analysis ofcertain portions of thereport was carried outby Mr. Stuart Gillespie(international Bankconsultant) and Mr.Nadumuni Naidu(National Institute ofNutrition). The finalreport "Review ofProgress to Mid-term"was completed in May1997.

Sch. 2-6 09 NYD 09130/97 (c) a final review and TORs were agreed uponevaluation of the Project. by the expert committee

and the Bank andcommunicated to theNational Institute ofNutrition (NW). Thefield surveys have beencompleted and the datais being compiled byNIN. The final reportwould be available inearly 1998.

Covenant types:

I. = Accounts/audits 8. = Indigenous people2. = Financial perfonnance/revenue generation from 9. = Monitoring, review, and reporting

beneficiaries 10. = Project implementation not covered by categories 1-93. = Flow and utilization of project funds 11. = Sectoral or cross-sectoral budgetary or other resource4. = Counterpart funding allocation5. = Management aspects ofthe project or executing 12. = Sectoral or cross-sectoral policy/ regulatory/institutional

agency action6. = Environmental covenants 13. = Other7. = Involuntary resettlement

8. Present Status:

C = covenant complied withCD = complied with after delayCP = compliedwithpartiallyNC = not complied with

36



Table 9: Compliance with Operational Manual Statements (OMS)

The ICR did not identify any deviation of substance from the relevant OMS.

37



Table 10: Bank Resources: Staff Inputs in Staff Weeks

Stage of TotalProject Cycle

86 87 88 89 90 91 92 93 94 95 96 97 98*Lending 0.1 0.2 2.0 2.3DevelopmentPreappraisal _ 7.9 66.2 58.7 132.8Appraisal 28.9 = = _ X = X 28.9Negotiations = = 4.2 _ 4.2Supervision 11.0 2.3 31.6 25.4 16.2 23.3 31.3 21.3 141.1Procurement = = =_=_1.1 0.5 0.9 __2.5

Completion XT T __ 11.3 _

Total 0.1 0.2 9.9 66.2 91.8 11.0 2.3 31.6 26.5 16.7 24.2 31.3 32.6 344.4

* as of April 21, 1998

38



Table 11: Bank Resources: Missions

Peforace Rating-

Number Total Specialized Implemen- Develop-mentStage of MontW of Days in Staff Skills tation Objectives Types of

Project Cycle Year Persons Field Represented- Status Problems-1

Through Appraisal Nov/ Dec 6 52 C, F, H, M, N, _ - _89 TM

Appraisal through Jan/ Feb 7 35 A, C, H, M, ME, _ _ _Board Approval 91 TM

Board Approvalthrough Effectiveness

Supervision I June 1991 3 19 H, N, TM 2 1

Supervision 2 Oct 1992 5 10 C, H, N, TM 2 1

Supervision 3 April 1993 4 9 N, O, PH, TM 2 1

Supervision 4 Nov 93 4 10 C, H, N, TM 2 1

Supervision 5 January 4 C, PH, N, TM 2 11994

Supervision 6 April 1994 4 5 C, ME, N, TM 2 1

Supervision 7 November 6 C, M, N, PH, S HS1994 TM, W

Supervision 8 March 3 7 C, M, PH S HS1995

Supervision 9 November 5 4 C, F, M, PH S HS1995

Supervision 10 June 1996 3 F, M S HS

Mid-term review 11 October 6 32 F, M, N, TM S S M, S1996

Supervision 12 May 1997 5 25 F, M, N, TM S S AF

Implementation November 4 2 F, H, N _ _

Completion Report 13 1997

/1 A=Architect, C=Communications, F=Finance, H=Health, M=Management, ME=Monitoring & Evaluation N=Nutrition, O=Operations, PH= Public Health, TM=Task Manager, W=Women in Development

/2 l=No Significant Prolems, 2=Moderate Problems (i.e., there are significant, but not critical problems fromappraisal expectations), HS=Highly Satisfactory, S=Satisfactory.

/3 AF=Availability of funds, M=Project Management, S=Studies Progress

Appendix APage 1 of 5

INDIASECOND TAMIL NADU INTEGRATED NUTRITION PROJECT

(CREDIT 2158-IN)

WORLD BANK IMPLEMENTATION COMPLETION MISSIONNOVEMBER 1997

AIDE-MEMOIRE

1. A World Bank implementation completion mission visited Chennai from November 24 to25, 1997. The field tearn consisted of Mr. R. Sethuraman (Finance Specialist), Ms. MeeraPriyadarshi (Nutrition Specialist), Dr. Stuart Gillespie (Consultant) and Mr. P. Subramaniyam(Consultant and Team Leader). Mr. A.K. Nanda from the DWCD of the Government of Indiaaccompanied the mission. This aide-memoire sets out the main findings of the mission.

2. The mission wishes to express its appreciation to the State of Tamil Nadu for their fullcooperation, work facilitation and hospitality. The mission had detailed discussions with theProject Coordinator of TINP and his staff members in Chennai. The mission also visited theCommunication and Training Centre (CTC). Wrap-up meeting was chaired by the Secretary,Social Welfare Department, Government of Tamil Nadu.

Mission Objectives and Overall Progress

3. The objectives of the mission were to undertake a final review of progress before the closeof the project on December 31, 1997 and to:

(a) provide advice and support to the Borrower in the preparation of itscontribution to the Implementation Completion Report (ICR); and

(b) record the views of the Borrower and the Bank on projectimplemenitation

4. Overall progress in the implementation of the project since the last review mission wasjudged as good. The performance against key indicators appears to be good with the twomalnutrition reduction objectives achieved as per monitoring data, although this needsconfirmation by the endline evaluation. The prospect for project sustainability is good and thestate is poised for taking up the proposed WCD project. The gains already achieved under IECand training are being consolidated and fine tuned to effectively address the remaining problemareas. However, in order to make an assessment of the impact of the project against its objectivesthere is need to await the findings of the endline evaluation currently being analysed. Details ofstatus of service delivery, health nutrition coordination etc., are in Annex 1.


5. The State has spent Rs. 88.35 crores more than the approved outlay of Rs. 321.34 crores(actual expenditure as on October, 1997 was Rs. 409.69 crores). For implementation of projectactivities till the close of project, the project authorities have estimated an additional requirementof Rs. 16.00 crores. In the circumstances, the balance credit will get fully disbursed beforeNovember, 1997 once all the pending claims are fully filed and adjusted. The only item of civilworks pending is the construction of an additional floor in the CTC. Work orders for this havealready been placed and the work has already been started. Details of the financial status are inAnnex 2.

Project Issues

6. Continued Implementation of IEC. Training. MIS etc. The project authoritiesagreed tothe continued implementation of all software components under the project likejIEC, training,MIS etc till the close of the project regardless of whether IDA credit is available or not. Furthercontinuance of the activities beyond that date will be covered by the proposed retro-activefinancing, which can be availed of for eligible expenses back to July, 1997.

7. Weighing Scales. The issue relating to the supply of weighing scales was discussed withthe project authorities and the Secretary. The State prefers to continue with bar scales in view oftheir precision. However the state authorities admitted the need for better training to the workersin the proper use of weighing scales.

Implementation Completion Review

8. Mission reviewed and commented on the draft contributions to the ICR from the projectauthorities. The draft is found to be very useful; however, it needs abridgement and editing.Further, it would be useful to incorporate in the write-up the main findings of the endlineevaluation which will be available by December, 1997. The State has promised to prepare thewrite-up in about 10 pages and send it to Bank through GOI in December, 1997.

9. Mission held detailed discussions with the project staff and other experts regarding theoutcome of the project and the factors considered responsible for success or failure. The presentassessments will be finetuned after the availability of the endline evaluation findings expected byDecember, 1997. Dr. Stuart Gillespie will be responsible for drafting the Bank's contribution tothe ICR, with the assistance of the other members of the mission, and will make it available to theNDO in January, 1998 for review and comments. A first draft of the Bank's contibution will bemade available in February, 1998 to the Government of India and the state Government ofTamilnadu for their views and comments, and after finalization will be submitted to the Bankheadquarters by March 31, 1998.

Key Factors affecting Project Implementation and Impact

10. The specific nutrition and health impact objectives of the project are:


(a) reduce severe malnutrition (grade III and IV) among children 6-36 months by 50%and 25% in new and existing project areas, respectively;

(b) increase the proportion of children 6-36 months of age in normal and grade Inutrition status by 50% and 35% in new and existing project areas, respectively, and

(c) contribute towards a reduction in IMR from around 84 to 55 per 1,000 live birthsand to a 50% reduction in the incidence of low birth weight from levels at the startof the project

11. Project Impact. In order to assess progress of project with respect to its above mentionedimpact objectives, it will be necessary to wait for the findings of the endline survey which hasrecently been completed and is currently being analysed. Monitoring data suggest that the twomalnutrition reduction objectives have been achieved. Regarding the ambitious objective ofhalving low birth weight incidence, the situation is unclear owing to a lack of reliable data. Theinfant mortality rate reduction target has been achieved, although it is impossible to assess thespecific contribution of the project.

12. Service Deliveiy. Project monitoring data for October 1997 point to high levels of servicedelivery coverage and the achievement of many of the process objective targets. 60% of pregnantwomen are registered before 16 weeks, all of whom were assessed for obstetrical and nutritionalrisk. Tetanus toxoid immunisation coverage has achieved its target of 80% unlike iron and folicacid supplement coverage which is at 53%. Sustained food supplementation to pregnant andnursing women is virtually universal, according to monitoring data.

13. With regard to children, most targets have been, or are close to being, met. Completeimmunization is at 96%, regular growth monitoring at 94% and supplementation of those eligible,at 99%. Referrals of severely malnourished or non-responding children is 94%. Only vitamin Aappears to be lagging at 53% although this may be at least partially due to the fact that VHN alsoprovides supplements.

14. IEC and Training. IEC appears to have been quite effective not only in reducingmoderate malnutrition but also in addressing other issues like early registration of pregnantwomen, immunization, growth monitoring and intra-family feeding practices. IEC has also beensuccesful in certain innovative areas like special sensitization workshops for newly marriedcouples, village priests and village barbers. A lot of printed materials including a newsletter havebeen produced and widely disseminated. Traditional media are effectively being used forcommunicating project messages. IEC has been particularly successful in community mobilizationlike for instance weighing of newborns. However, measurment of behavioural change has notbeen systematically done. This is something which the project proposes to do in future. As fortraining, the intensive block-level decentralized training has been successful in impartingqualitative training to the functionaries. The CTC has been implementing training for Supervisorsand functionaries above that level. However, there is still a heavy backlog of refresher training.This has to be focussed upon in the coming months. The project has plans to do this. Training willalso have to focus on q[uality improvement, particularly on the correct and proper use of the bar


weighing scale.

15. Women 's Empowerment. Training in aspects like group dynamics, thrift etc, has beenimparted to women's working group members in some blocks. However, these have been mainlyNGO initiatives.

16. Monitoring and Evaluation. The monitoring system of TINP II is of generally highquality, producing timely reports and supportive feedback. Key indicators are tracked regularlyand block-level performance monitored. District-level officers take responsibility for following upwith blocks which lag with respect to an indicator. TINP II has an expert committee onmonitoring and evaluation which oversees the evaluative process, preparing terms of referenceand reviewing draft reports. Unfortunately, however, the delayed mid-term review, finally carriedout in 1996, was not of a high quality. A re-analysis of existing data was undertaken when doubtswere expressed about the quality of the anthropometric data. The final endline survey shouldclarify the picture.

17. Operational Research. Seven operational research studies have been undertaken duringTRNP II's life span and all but one have been concluded. Several among them were onlyconcluded in 1996.The quality of studies carried out by external agencies have not been upto themark; in contrast, the in-house studies conducted by the PMU have been useful in focussingattention on problem areas. It is hoped that the relevant and useful findings will be used toimprove implementation of the forthcoming Women and Child Development Project in the State.These studies included a comparison of child stunting in project and non-project areas, a study tocorrelate severe child malnutrition with household level food security risk and a rapid assessmentof the effectiveness of training on birth weight recording among others.

18. Targeting. While commendable efforts have been taken by the project for targeting theunder threes and those that are malnourished, the problem of reaching the hamlets and theunreached like tribals has remained elusive. The project authorities propose to address theseissues in the forthcoming WCD project.

19. Capacitv Building. The project has been quite successful in capacity building in terms ofplanning and managing components like IEC, training and MIS. The decentralized block leveltraining and the technical backstopping proided by CTC forneeds assessment serve a models for other States to study. The project will sustain these gains inthe coming years.

20. Infrastructural Base. The project has successfully expanded the infrastructural base at thefield level. These will be sustained in the future years. Further fine-tuning of the service deliverysystem with focus on pre-school early childood education, programs for women's empowermentand adolescent girls is sure to result in the State's reaching higher levels of nutrition and healthparticularly for women and chidren.


21. Comments on the performance of the Bank will be included in the draft ICR. The projectauthorities generally felt that the Bank review missions were useful in supporting areas likeinternalizing the mechanics of training needs assessment, more focussed use of traditional mediafor communiction and PMU-undertaken operational research on several issues of importance tothe project.

22. The experience gained in this project has informed the preparation process of theforthcoming WCD project for the State.

23. Conclusions

* Delays in completion of operational research studies should be avoided in future; andbetter criteria for selection of suitable agencies should be developed and adopted forfuture studies

* Monitoring data indicate the achievement of the two malnutrition reductionobjectives. As for halving low birth weight incidence, the situation is not clear duemainly to lack of reliable data. The endline survey should clarify the picture.However, in mission's judgement, the development objectives of the project aremost likely to be achieved

* The project is judged as sustainable. The infrastructure created under the project willbe sustained. Eventhough the State has opted for the one-worker model from thepresent two-worker model, the rate of attrition of the second worker is so low thatmost of the workers will be there for another at least 10 years or so. The gains incapacity building like planning and management skills acquired under the project forcomponets like IEC, Training and MIS will be sustained. Similarly, the nutritioninputs will also be sustained.

Next Steps

24. The timely completion of the endline evaluation has to be pursued and ensured by theState. The State should also finalize its contribution to ICR on the lines discussed. The mission,on its part, will prepare and present its ICR contribution for review and comment by GOI, theproject authorities, the State Government and Bank management as per the time scheduleindicated earlier in this aide-memoire.

25. The mission appreciates the efforts taken by the project authorities for consolidating thegains achieved by the project and for sustaining them.

New DelhiDecember 3, 1997

Appendix BPage 1 of 12


INDIA


Government of Tamil NaduBorrower's Evaluation

Introduction

1. The Second Tramil Nadu Integrated Nutrition Project was launched in 1991 coveringinitially 11 blocks and later expanded to 318 blocks in five phases spread over 24 districts by theclose of the project in December 1997.

2. The main services for providing health and nutrition care for 0-72 months and pregnantand nursing mothers were (i) supplementary feeding for 6-36 months and mothers on selectioncriteria; (ii) education on nutrition and health; (iii) immunization and micronutrientssupplementation; and (iv) medical referral services.

Nutrition Intervention and Impact

3. The project was providing therapeutic supplementary food containing a minimum of 14gof protein per 100gm till June 1996. Later on, the Project switched over to IS-7021-1973specifications which contained 15gms. of Protein per lOOgms. of food. For the severelymalnourished, a special supplementary food containing milk proteins and malted ragi wassupplied. This food was supplied as a nutritional therapy in the mornings preferably as the firstfood for the malnourished children at the Community Nutrition Centres (CNCs). Though, thepractice of feeding the children at the centre itself suffered a set back for a couple of years in themiddle of the project, it was brought back with some difficulty. This was not only to avoidsharing of the food in the families, but also to provide the opportunity to mothers to learn caringpractices and share experiences with one another. Special training sessions were undertaken tofield functionaries at all levels to bring about an attitudinal change. The CNCs were made torealize that they were not merely service providers but have the responsibility to play the role of"foster-mothers" for the severely malnourished children.

4. The quality of food procured and the regularity of supply ran into difficulty during 1994-95 and 1995-96. This was also later sorted out and the food were being supplied directly to theCNCs at the appointed time. Samples of food were taken from CNCs and sent to CFTRI,Mysore for tests and the quality of food supplied was ensured. From January 20, 1991 toDecember 31, 1997, 67,861.955 metric ton (MT) of weaning food was supplied at a cost ofRs.95.37 crores including the transportation charges. Similarly, 2993.042 MT of specialsupplementary food was supplied at a cost of Rs.5.84 crores including transportation charges. TheCommunity Nutrition Workers (CNWs) were trained to feed the severely malnourished children


and other young malnourished infants with supplementary food made into "Payasam" (sweetporridge). The change in the attitude of the functionaries and their approach to the severelymalnourished children as "foster-mothers" had resulted in the CNWs and the mothers spendingmore time with the severely malnourished children for feeding them. The workers and supervisorsstarted accompanying the parents to hospitals for medical intervention for the severelymalnourished. When the functionaries saw with their own eyes the improvements in the healthand nutrition status of these children, they started sending photographs of these children withtheir success stories to the Project Coordination Office (PCO). The study taken up comparing theeffectiveness of "Payasam" versus "Ladoos" (food flour mixed with hot water and made to sizesof 50 gms. balls) confirmed that "Payasam" was more effective as young infants and severelymalnourished consumed this without wastage. Letters of appreciation and advice were also sentfrom the PCO to these workers. This gesture kept up the tempo and encouraged the staff. Over aperiod of one and a half year, the levels of severely malnourished children were brought downconsiderably even in the districts like Thiruvannamalai and Villupuram which did not fare well inthe Mid-Term Evaluation as seen in the Terminal Evaluation Report.

Percent Distribution of Children Severely Malnourished (Weight for Age) by IAPClassification

Table 1

District Mid-Term Grade HI & IV Terminal (0-36(6-36 months) months)

Villupuram 16.1 6.0Tiruvannamalai 17.4 3.3Salem 12.6 2.9Dindigul 11.2 3.5

5. IEC support through mass media, group meetings and inter-personal communications oncomplementary feeds, the number of times a day a young child is to be fed and other tips oncaring practices during fever, common cold, diarrhoea, etc., has contributed to reduce the numberof episodes of relapses. A comparison of the status during the Mid Term Evaluation andTerminal Evaluation with regard to moderate malnutrition in some districts is given below:

Percent Distribution of children Moderately Malnourished (Weight for Age) by IAPClassification

Table 2

Districts Mid Term Grade II Terminal Grade II(6-36 months) (0-36 months)

Madurai 20.5 15.7Dindigul 20.5 13.9Salem 22.4 14.4Tiruvannamalai 24.0 13.3Dharmapuri 21.1 10.9


6. The growth performance of children born in January 1995 and -A.vho completed 36months in the programme without any interruption like drop-out, death, migration, etc., in sixdistricts viz., Tiruvannamalai, Cuddalore, Erode, Madurai, Tirunelveli, an-d Toothukudi werestudied retrospectively. In January 1995, the project was implemented only in 16 districts. PhaseV of TINP-II in Nagapattinam, Thanjavur and Kanyakumari districts came into existence in July1, 1995 only. A total of 6968 children were studied. Out of those, 1656 children entered theprogramme as Grade I malnutrition in January 1995. When they left the programme in December1997, 50.79% of them had entered grade Normal. 201 children entered as Grade TI malnourishedin January 1995, and in. December 1997, 37.8% had entered Normal and 40.8% had graduated toGrade I. Similarly, 77 children entered the programme as Grade III malnutrition and when theyleft the programme in December 1997, 35.1% were Normal grade, 41.6% graduated to Grade Iand 15.5.% graduated to Grade II. Out of 14 children who entered as Grade IY malnutrition,14.3% became Grade II. The gradings are done as per weight for age under lAP clariication (asgiven below) These improvements were made possible through the various interventions in theproject.

TOTAL GRADE-I GRADE-H GRADE-Ili GDE-GRADE-IV 0.07 0.13 0.50 1.30 0.00GRADE-E 0.56 0.82 1.99 6.49 14.29GRADE-il 6.80 9.40 18.91 15.59 _ 14.29GRADE-I 35.28 38.86 40.80 41.56 i 57.13NORMAL 57.29 50.79 37.80 35.06 14.29

NO.OF CHILDREN 6961 1585 201 77 14

Growth Faltering and Supplementary Feeding

7. Analysis of the number of children who had one or more episodes of goro7th faltering andtheir response to nutrition intervention in the six districts mentioned above revealed certaininteresting features. (A child in the Normal or Grade I is said to falter in growth, if he comesdown to a lower trajectory from his original growth curve. He is said to have graduated if he goesback to his original trajectory. Once selected for feeding, he would be given food for minimum 90days). A total of 1894 children had entry into the project in January 1995 either in Normal orGrade I malnutrition. These children have left the project in December 1997 a ter completion of36 months. Out of these 202 (11%) children completed 36 months vithout any growth faltering.The maximum number of episodes of growth faltering was four in any given child. 1692 childrenhad supplementary feedings for 1 to 4 episodes of growth faltering. 59% of these children hadgraduated after different number of episodes, but 41% continued to be in the feeding programmefor a prolonged period in different episodes. It is also to note that 28% of children nevergraduated. The table below shows this pattern:


Table 3

Growth Number of Children Graduated Number offaltering children in

With Without Total continuous Totalrelapse subse- feeding up

quent to 31.12.97relapse

I episode 768 450 1218 474 1692(45.4%) (26.6%) (72%) (28%) (100%)

II episode 258 354 612 156 768(33.6%) (46.1%) (79.7%) (20.3%) (100%)

III 46 153 199 59 258episode (17.8) (59.3%) (77.1%) (22.9%) (100%)

IV 36 36 19 46episode (78.2%) (78.3%) (21.7%) (100%)

8. Hence we find that 67% of the children under feeding graduate within 180 days after Iepisode and 33% graduate later on as shown in the table below: (The number of children incontinuous feeding are excluded). The proportion of recovery within 180 days increases with theincrease in the number of episode and ranges from 67% to 97%. Therefore, the exit criterion sofar followed in TINP needs a rethinking.

Table 4

Episode Graduation within days Total0-90 91-180 > 180

I 533 287 398 1218(43.8%) (23.5%) (32.7%) (100%)

II 333 156 123 612(54.4%) (25.5%) (20.1%) (100%)

III 126 57 16 199(63.3%) (28.6%) (8.1%) (100%)

IV 31 4 1 36(86.1%) (11.1%) (2.8%) (100%)

9. This pattern seen in the six districts, viz. Madurai, Tirunelveli, Toothukudi,Tiruvannamalai, Cuddalore and Erode is expected to be present in the other districts also.


Gender Discrimination

10. The Govemment of Tamil Nadu have launched certain schemes to eradicate the problemof female infanticide and to remove the discrimination towards girl children. TINP had severalIEC activities to create awareness in the state over the gender discrimination in some pockets ofcertain districts.

11. It is interesting to find as to how in certain districts, the number of male children in severegrade of malnutrition are lower in different age groups compared to female children. However,this difference is not so significant among Normal, Grade I and II, e.g., the number of severelymalnourished children during December 1997 according the monitoring data were:

Table 5

Age Male Female Total0-5 817 884 17016-12 757 1186 1943

13-24 1660 2711 437125-36 1120 1851 2971

12. There was a marked gender imbalance with inter-district variations. Four types-patternappear to be present (Fig. 1).

Fig. 1

PREVALENCE OF SEVERE MAL-NUTRITION - GENDER (MALE-FEMALE!IMBALANCE (DECEMBER 1997)

Type-Pattern A

M A DURAI

160140120 1

ILLu 100

z 60 .....4020

00 - 5 6 - 12 13 - 24 25 - 36

AGE IN MONTHS


13. During the period of 0-12 months, the community appears to have shown more concernand effort to improve the nutritional status of male infants than female infants. During the periodof 13-24 months, when the prevalence of malnutrition is usually seen in its peak, there is a widegap in the numbers of male and female children in these areas. Nine districts, viz, Madurai,Virudhunagar, Veilore, Dharmapuri, Dindigul, Tiruchirapalli, Toothukudi, Tiruvannamalai andSivagangai fall in this Type-pattern.

Type-Pattern 7S

ERO DE

5 0

4 u 3 9 -:-- :-w--.:-- z - ------ :- : -- /- - - :: ~~~~~~~~~~~~~~~~.......... 3 6

m 3 0~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.....,,,. .,_j ... ..............

....... ...................... .. ~~... . ........... ..1 20

10

0 -5 6- 12 13 -24 25 -36

A G E IN M O N T HS

14. Here, during the period of 0-12 months, the community appears to have shown equalconcern and effwort without any gender bias to improve the severely malnourished. However,between 13-24 months, the gap in the numbers of male and female children is very large. Erode,Coimbatore and Salem fall in this Type-pattern.

Tvne-Pattern C

C UDDALORE

1 40

1210 - -

I 0 0 ---/C-IL

m 8 0E E 7 --- - - - - . -7~~~~~~~~~~~~~~71

D 6 0

4 0

20 .... . .......

00 -5 6 -12 13 -24 25 -36

AGE IN M ONTHS


15. Here, the caring practices for children from 0-24 months is equally bad irrespective of thesex for the severely malnourished. Villupuram, Cuddalore, Tirunelveli, Thanjavur, Nagapattinamand Ramanathapuram fall in this type-pattern.

Type-Pattern D

KAN NIY AKUM A RI

3 0 3 --0' .ig .i .g ..tt .. . .. .... ................ . ...,., .. .. ., ,, . g ..... ..

2 5 - B .. - _ . , ......... - ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.... ....

2 5--- 0 0 l- B B ~~~~~~~~~~~~~~~~~~~~~~. B..... ...... . ...... . ......':

- 2 0 ~ _ . . . ....2 0 .. E ; 2< - .......... .... .... ....15

1 0

5

0 5 6 1 2 1 3 - 24 25 - 36

A G E IN M O NT HS

16. This is an interesting pattern and appears to be model for other districts to emulate on thisissue. Irrespective of sex, the community is showing equal concern and making all efforts toimprove the nutritional status of severely malnourished children. Kanyakumari district falls intothis pattern.

17. These 4 Types-Pattern also indicate the level of knowledge and caring practices of thepeople. These problems are to be addressed with area specific IEC activities and training forstaff.

18. However, looking at the patterns with regard to Normal, Grade I and Grade IImalnourished children, one can find no difference in pattern between sexes. This may probablyindicate that by and large sex discrimination is not alarming in the normal course of events. Butwhen special efforts, extra time and additional money are required in combating a chronicdisease like severe malnutrition, the caring practices of parents towards male and female childrendiffer from place to place.

Health - Nutrition Coordination

19. A calendar of activities has been worked out for joint visits of CNW and Village HealthNurse (VHN) to families on particular days in addition to other centre based activities on fixeddays for Immunisation, ante-natal/post-natal care, micro nutrient, Vitamin 'A' and Iron Folic Acidand ORS are stocked in the CNCs so that a VHN can dispense them on specified dates. Themonthly review Meetings for Health and Nutrition staff at the Primary Health Centres (PHCs)have helped the staff to work together successfully during special campaign like "Pulse Polio".


The report developed during this joint visits and special campaigns has helped in increasing thenumber of cases referred to the PHCs and other higher medical Institutions.

20. Immunisation coverage for all vaccines range from 76.9% to 95.5%. The usage of ORSfor combating diarrhoeal diseases has increased to 82% and ranges from 50% to 98.1%. ARIprogramme which picked up recently has also done well 82% of cases have taken treatment asper Terminal Evaluation Report.

Communication and Community Participation

21. TINP II Communication strategies were suitably modified and developed to address variousissues in Mother and Child Care. The main objectives and purposes of communication component asspelt out in Staff Appraisal Report have been achieved through certain gaps exist in a few behaviouralissues.

22. Communication activities have succeeded largely in creating awareness and acceptance ofproject services. Motivation and counselling techniques are followed in interpersonal contacts by fieldstaff to change the attitude and practice of resistant mothers. The findings of formative researchindicate that there is positive (1996-97) attitude in respect of ante natal registration and breast feeding.The practice of taking extra quantity of food during lactation is with all the mothers. In the early yearsof the project mothers were not willing to disclose their pregnancy at the early stage with amisconception that disclosure may cause harm to the foetus. After continued interpersonal contact andcounselling of mothers during campaign on "All About Ante-Natal Care" positive attitude towardsearly registration of pregnancy and widespread practice of availing ante-natal check-up have improved.The terminal evaluation conducted by NIN also reveals that the proportion of pregnant women whowere registered before 20 weeks of pregnancy is 80% and 90% of women availed ante-natal check-upas compared to about 39% at the time of baseline survey.

23. After the elections to local bodies were over in the state all the Working Women Groups(WWG) were restructured and strengthened. During the WWG meeting specific focus was made onbirth weight recording, regular monthly weighing, spot feeding. Now WWG members are takingactive part in motivating mothers by forming groups, each group being in-charge of one ward of thePanchayat. It was emphasised that supplementary food is like a therapy for malnutrition and not foodfor hunger. As a result of such motivational approach mothers have developed positive attitudetowards centre feeding. The encouraging aspects is that 95% of these receiving the supplementary foodwere consuming the food at the centre itself (DTC by NIN)

24. Since findings of various studies show that there are inter-district variations in certain areas forwhich decentralised, theme specific and area focused strategies are adopted to address the local needsand problems. Decision makers like mothers-in-law and husbands are sensitized.

25. The WWGs of TINP have been converted as self help groups to strengthen and sustain theirinterest in the project. Credit and Thrift Societies formed by them have been activated during the lasttwo years of the project. Some of the groups in most of the districts have been involved in incomegenerating activities. Others are involved in intra-micro credit activities. Linkages of these groups


with Developing Women and Children in Rural Areas (DWACRA), are taken up with the help ofDistrict Collectors, community mobilisation efforts which created a lot of enthusiasm both among thepublic and the functionaries are continued with the same vigour Participatory RapidAppraisal/Participatory Learning and Action (PRA/PLA) training to functionaries are imparted in aphased manner so as to ensure more community participation in assessing, analysing and solving theproblems by themselves. This strategic approach will pave way for long term sustainability andcommunity ownership in future.

Training

26. The training component has successfully completed almost all training programme. Thecurriculum for the training was developed in a systematic manner through a careful task analysis of theresponsibilities of each functionary. On completion of the initial training the Communication andTraining Centre (CTC) organized a number of additional training programme based on the needs suchas early childhood stimulation, sandwich training for Child Welfare Organiser (CWO) promoteeCommunity Nutrition Instructress (CNI)/and promotee Community Nutrition Supervisors (CNS). Themain objective of these training was to improve their skill in training, supervision and to bring about anattitudinal change.

27. There was a backlog in giving refresher training due to paucity of fund and time constraint.Now the training wing is completing the refresher training for districtlblock level functionaries, but itwill be in a position to complete the same in the case of grass-root level workers on receipt ofretroactive finance under the proposed Woman and Child Development Project.

28. The training programme of the project has created a great impact among all functionariesthrough its modular approach in refresher training and has concentrated on behavioural and attitudinalchanges especially on birth weight, growth monitoring, spot feeding, preparation of Amylase rich foodas therapeutic food for management of moderate, and severe malnutrition and also as the diet duringillness and after. The training wing has found the participatory methodology as a very effectivemethod in bringing about attitudinal changes among functionaries in order to change the attitudes ofcare givers. The co-ordination between Health and Nutrition Staff has been considerably strengthenedthrough joint training of Block Training Teams. The training wing has concentrated on the holisticdevelopment of children besides the regular Health and Nutrition Service.

29. The detailed list of training programmne completed is given below.(1991-98)


Training particulars To whom Duration break up Organised by Physical achievement

District levelOrientation Training DPNO-DCO-SI 5 days CTC 19Re-orientation training DPNO-DCO-SI 3 days CTC 15Orientation training DPHN-DEE-MEIO 5 days CTC 48Zonal levelOrientation training ZPNO 5 days CTC 26Block levelJob training CNI (new recruits) I month CTC 272Orientation training CNI (existing) 15 days CTC 149Block training team CNI-CHN-BEE-BHS I month CTC/Other institution 925(BTT) CNI 5 days CTC 296Refresher training CNI-CHN-BEE-BHS 5 days CTC 782Joint refresher training(BTT) CNI 15 days CTC 384

Refresher training onearlychildhood education CNI 5 days CTC 296

Refresher training onimproved services for 0-3 CWO promotee CNI 10 days CTC 96years children


Training particulars To whom Duration break up Organised by Physical achievement

Sandwich courseCNS (new recruits) 8 weeks CTC/other institutions 980

Sector level CNS (existing) 3 weeks CTC/other institutions 664

Job training CNS-SHN 1 week BTT 1302-1379

Orientation training CNS 3 days BTT 1071

Joint training CNS-SHN 5 days BTT 499-401

In-service trainingJoint refresher trainingVillage levelJob training CNW (new recruits) Total 56 days

Theory + Practical = 42 days BTT 12397Joint training days = 7 daysField preparation = 7 daysJoint training = 7 days

CNW (Existing Field preparation = 7 days BTT 7214Total 56 daysTheory + Practical = 45 days

CWO Joint training = 7 days BTT 19196Field preparation = 4 days

CNW-CWO-VHN BTT 17093-16141-6973

Orientation training Helpers 1 week BTT 16954Sector level

Refresher training CNW 5 days BTT 2074

ICWO 5 days BTT 1679

Joint refresher CNW-CWO-VHN 2 days BTT 916-661-316


Innovative Approaches:Apart from the training mentioned in SAR, the Project has organised the following training programmes in innovative approach to improve the qualservices of the field functionaries.1) CWO promotee CNI sandwich course 10 days2) CWO promotee CNS sandwich course 10 days3) Refresher training to CNIs on improved services for 0-3 years children : 5 days4) Refresher training on Early childhood education to CNIs 15 days5) Trainers training on pre-school (play for child development) 7 days

Workshops:1) CNS curriculum revision workshop2) Process workshopTraining to other organisation:1) Training on health and nutrition for Jawadhu hills TRC Volunteers2) Orientation on TINP-II strategy to B.Sc., nursing students of various institutions: 10 days

World Bank Document...The system of tracking key process and outcome data, with built-in data...

Documents

Transcript of World Bank Document...The system of tracking key process and outcome data, with built-in data...