Innovations & Good Practices In
ICDS:
The West Bengal Experience
6th - 8th November, 2013
NIPCCD Regional Centre
Bengaluru
Malnutrition : A Silent Emergency (0 -3 years)
90
78.3
80
69.3
70
60
50.4
50
45.3
41.8
37.6
40
NFHS -II
NFHS-III
30
20
25
23.7
17.3
19.2
10
0
Children under 3 yrs Children under 3 yrs who Children under 3 yrs who Children under 3 yrs who children age 6-35 months
breastfed within 1 hour
are stunted (%)
are wasted (%)
are underweight (%)
who are anemic (%)
of birth (%)
Malnutrition : A silent emergency (0 -3 years) .. Contd.
Percent
Nutritional status of children in WB
Micronutrient s … the hidden hunger
Source: NFHS 3 2005-06
PACKAGE OF NUTRITION INTERVENTIONS
Maternal
Nutrition:
- ICDS
-1000 days’ window of
opportunity
- Piloting of IGMSY
Child Nutrition:
Adolescent
Nutrition:
- WIFS & Piloting of
RSEAG SABLA
- ICDS
- Community based
management (PD) &
Facility based
management & care (NRC)
- Micronutrient
supplementation ( VAS &
IFA bundled with deworming)
Good Practices in ICDS/ State innovations
Improving Service
delivery of SN
Creation of buffer stock zones at AWC level
•Heath & Nutrition Education
•ECE
Improving
Community
awareness &
participation
Improving Service delivery of
Supplementary Nutrition
Critical Indicators: Maternal & Child nutrition
Impact level:
Reduction in prevalence of underweight <3 yrs. & <5 yrs.
children
– Moderate/ <-2SD ( target: 10% point)
– Severe /<-3SD (target: 50% point)
Process level:
•
Improve % of registered children 6-71 months who
received Supplementary Nutrition for at least 21 days a month
in last 3 months ( Target: 100%)
•
Improve % of registered P&L women who received
Supplementary Nutrition for at least 21 days a month in last 3
months ( Target: 100%)
Strategy: Buffer Stock zone
Objectives
– Facilitate uninterrupted supply of food grains at
AWCs through improved supply chain
management
– Comply with feeding norm of min. 300 days a year
– Influence maternal and child nutrition outcomes
positively
Implementation design
• One AWC over a cluster of 25 AWCs to be
identified in each GP of the project
• The identified AWCs will stock the food grains
/SNP items; and supply in case of requirement
raised by other AWCs in the net
Demonstration/learning phase
SALANPUR
Kulti (U)
BARABONI
JAMURIA
PANDAVESWAR
Asansol (U) - II
Jamuria (U)
Asansol (U) - I
KETUGRAM-I KETUGRAM-II
RANIGANJ
Raniganj (U)
FARIDPUR-DURGAPUR
KATWA- I
ONDAL
KATWA- I
Durgapur (U) - I
AUSGRAM-I
KATWA- II
MANGOLKOTE
Durgapur (U)
KANKSA
- II
PURBASTHALI - II
AUSGRAM-II
BHATAR
MANTESHWAR
PURBASTHALI -I
GALSI-I
GALSI-II
BARDDHAMAN-I
KALNA-I
MEMARI-II
Barddhaman (U)
BARDDHAMAN-II
KHANDAGHOSH
KALNA-II
MEMARI-I
RAINA-I
JAMALPUR
RAINA-II
• Pilot tested successfully by Burdwan district
• Spread over 46 ICDS projects 9278 AWCs in the district
Monitoring
•
A user friendly monitoring tool had been in use
for tracking the status of requirement & supply
•
No. of AWCs providing 21+ days of SNP increased
in the district – from 95.95% in December 2011 to
99.21% in December 2012 (source: DMPR)
Expansion & way forward
•
Going by the success in improving feeding continuity, the
state has asked all districts to identify AWCs to act as buffer
stocks for supply of SNP in respective GPs
•
Currently NIC is supporting Deptt. in developing a web
based solution for monitoring which would help in issuance of
advisory to the projects regarding availability of stock, and
therefore
»
»
»
»
»
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Reduce leakage within the system
Streamline indenting procedure
Reduce data transmission time
Improve food supply chain for SNP
Improve data reliability
Improve quality and coverage of ICDS SNP
Improve Community awareness &
participation
Nutrition & Health Education
Critical Indicators: Child nutrition
• Outcome level:
Children aged 6-9 months receiving semi solid food along with
breast milk(%) : 55.9% (NFHS-3)
• Impact level:
Reduction in prevalence of underweight <3 yrs. & <5 yrs.
– Moderate/ <-2SD ( target: 10% point)
– Severe /<-3SD (target: 50% point)
Strategy: Annaprashan
Objective
To improve infant and young child nutrition
(initiation of age appropriate complementary
feeding at 6 months)
Coverage
HARISCHANDRAPUR
CHANCHAL
-I
-I
HARISCHANDRAPUR - II
CHANCHAL - II
RATUA - I
GAZOLE
BAMANGOLA
RATUA - II
MANIKCHAK
OLD MALDAH
OLD MALDAH (M)HABIBPUR
ENGLISH BAZAR
ENGLISH BAZAR (M)
KALIACHAK - II
KALIACHAK - I
KALIACHAK - III
• Initiated in Malda - 17th amongst 19 dists. in HDI ranking ( WBHDR 2004)
• Covers 26 projects, 5573 AWCs
• To be intensified as part of District Integrated Nutrition intervention plan
from next year
Activities
– Community level celebration and awareness
camps
– Demonstration of age appropriate complementary
food
– Initiation of Active Feeding
– Counselling of mothers/ care givers
– Financial support by district
Critical Indicators: Maternal Nutrition
• Outcome level:
Percentage of pregnant women who received 3 or more ANC
check ups: (latest status 62.4% - NFHS-3, target : 80%)
Percentage of pregnant women who consumed IFA for 90
days or more: 24.3% (latest status -NFHS-3, target : 80%)
•
Impact level:
Reduction in prevalence of anemia in pregnant women (latest
status : 62.6% - NFHS3, target: 20%)
Strategy : Sadhbhakshan
Objective:
To promote maternal nutrition during
pregnancy
Coverage
HARISCHANDRAPUR
CHANCHAL
-I
-I
HARISCHANDRAPUR - II
CHANCHAL - II
RATUA - I
GAZOLE
BAMANGOLA
RATUA - II
MANIKCHAK
OLD MALDAH
OLD MALDAH (M)HABIBPUR
ENGLISH BAZAR
ENGLISH BAZAR (M)
KALIACHAK - II
KALIACHAK - I
KALIACHAK - III
• Initiated in Malda - 17th amongst 19 dists. in HDI ranking ( WBHDR 2004)
• Covers 26 projects, 5573 AWCs
• To be intensified as part of District Integrated Nutrition intervention plan
from next year
Activities
– Community level awareness on importance of
pregnancy care through
– Community level celebration
– Demonstration of food basket containing samples
of all food groups
– 100 IFA
– IEC booklet on dos & don’ts on care during
pregnancy, (also need for institutional delivery
and essential new born care)
– Counselling
Addressing Child Undernutrition
through Improved Health & Nutrition Education in ICDS
The Positive Deviance Approach
Concept of Positive Deviance (PD) in Nutrition
– An important part of the nutrition gap is information
gap
– People can succeed nutritionally in low-income
communities
– The “positive deviants” utilize their resources
effectively
• beneficial practices amongst families of similar socioeconomic status living under similar conditions are shared
with mothers/ care givers of moderate and severely
underweight children in the age group of 6-36 months
• Emphasizes importance of behavioural change in nutrition
Program Goal & Objectives
Goal
Reduction of
undernutrition
among children
< 3 years
Objectives
– Identification of all
undernourished children for
reduction of undernutrition
– Rehabilitating them to higher
nutrition status , i.e., Normal
grade of nutrition
– Develop capacity of community
for prevention of future
incidence of malnutrition and
birth of LBW babies
Implementation Phases
Phase I: Community Mobilization
•
•
Use of community level child undernutrition monitoring tools
Identification of child undernutrition prevalence and making it visible to the
community
Identification of proper nutritional
status of all children
Use of undernutrition monitoring tools for community
mobilization
Child Undernutrition Monitoring Tool
Community Growth Chart
Social Map
COHORT Register
Mother and Child protection card
Implementation Phases (contd.)
Phase II: Nutritional Counselling and Child Care Sessions
(NCCS)
•
•
•
Use of PD approach to identify local resources and beneficial child care practices
Demonstration, practice and active feeding at AWC with mothers/ Care givers of
undernourished children apart from issue based counselling
Monitoring of weight gain of children till rehabilitation to Normal grade
Identification of
community level child
care practices through
FGD / PDI
Practice of food hygiene
and cleanliness
Involvement of community in
running NCCS
Active child feeding
practices at community
set up
Package of services in NCCS
• 12 day learning by doing technique to adopt correct feeding,
hygiene, health and psychosocial practices
• Package of services
–
–
–
–
–
–
–
Health check up by ANM, de-worming of children
Weighing of children to monitor weight gain
Active feeding of children
Theme based nutrition and health education for 12 days at AWCs
Use of self monitoring tool for mothers to monitor attendance & learning
Counseling of care givers on ten essential nutrition interventions
Referral of severely underweight with medical complications to health facility/
NRC
• 18 days’ of continued practice at household till child shifts to
normal grade of nutrition
Self Monitoring
NHED Issues
Day
Issues for discussion
1
Colostrum feeding and Breastfeeding; Exclusive breastfeeding for
first six months
2
Timely initiation of Adequate Complementary Feeding Quantity, quality, density and frequency
4
Food and feeding hygiene, hand washing with soap, and use of
clean potable water
feeding of child during and after illness
5
Growth monitoring and promotion
6
Child immunization - Primary immunization schedule ,
immunization upto 5 years, , vitamin A and iron supplementation
3
7
8
9
10
11
12
Micronutrients - importance of Iodine and use of adequately
iodized salt, testing of iodine content in household salt using MBI
kits
Diarrhoea and ARI - care of the child
Worm infestation and personal hygiene
Psycho-social development of children - milestones (with focus
on under three)
ANC - check up, household care, diet and rest
PNC - check up, household care, diet and rest; care of the new
born
Self Monitoring Tool for mothers
Monitoring
Individual:
– Child wise tracking : NCCS report
Community:
– Anganwadi- wise : NCCS and GMP report
– Sector - wise : NCCS and GMP report
– Project-wise :NCCS and GMP report
– District-wise: NCCS and GMP report
– State: NCCS and GMP report
Inception: The Pilot Phase of PD
• Introduced by UNICEF in
March, 2001 in collaboration
with DWCD& SW as a pilot
initiative for reduction of
Infant & young child
malnutrition
Murshidabad
South 24 parganas
Map Not to Scale
• CINI was commissioned as a
facilitating agency for
implementation
• Piloting was done in 2 blocks
of Murshidabad – Beldanga- I
and Berhampore; and in 2
blocks of South 24 parganas –
Falta and Bishnupur- I
Upscaling of Pilot experience
Dakshin Dinajpur
Murshidabad
Purulia
South 24 parganas
Map Not to Scale
As the pilot initiative
became successful,
Positive Deviance was
gradually introduced to
Murshidabad, Purulia,
Dakshin Dinajpur,
South 24 Parganas
from 2003 followed by
phase-wise
introduction in other
districts
Darjeeling
Positive Deviance Program in West Bengal
Jalpaiguri
( as of Dec, 2012)
Cooch Behar
Uttar Dinajpur
District
Block / projects
AWC
Training completed
10
133 **
40979
24742
AWCs running
19746
Nutritional
Counselling and Child
Care Sessions (NCCS)
Moderate and
severely
undernourished
236952 (approx)
children 6m–3 yrs.
receiving active
feeding and care
giving services during
NCCS
Dakshin Dinajpur
Malda
Murshidabad
Birbhum
Barddhaman
Purulia
Nadia
Bankura
Hooghly
Paschim Medinipur
Howrah
North24 Parganas
Kolkata
South24 Parganas
Purba Medinipur
** Total no. of ICDS projects ( pre- bifurcation number)
Implementation by Deptt. of CD, GoWB, Financial support mainly from
NRHM, Deptt. of H&FW and part from UNICEF, Technical support by UNICEF
Map not to scale
Evaluation
• Increased weighing
resulting in
increased
identification of
child underweight
• Improvement in
child care practice
• Reduction in child
underweight
Evaluation by National Institute of
Nutrition (NIN), Hyderabad in
2006:
• Positive impact found in:
– Young child care and feeding
practices
– Utilization of health & nutrition
services, quality improvement
of ICDS
– Improved
community
participation in PD areas
• Relatively better nutrition status
of children in PD areas:
– Better mean heights and
weights of <3 yr children,
– Lower
prevalence
of
stunting
Impact : Evaluation Report by NIN
SERVICES
CHILD CARE
PREVALNCE OF
UNDERNUTRITION
PD
CONTROL
NHED
69%
27%
WEIGHING
50%
13%
REFERRAL
37%
18%
COMPLETE
IMMUNIZATION
86%
68%
VIT.A 2ND DOSE
50%
33.1%
BREAST FEEDING
(WITHIN 3 HRS.)
76%
44%
COLOSTRUM
90%
82%
EXCLUSIVE BREAST
FEEDING
70%
61%
INITIATION OF
COMPLEMENTARY
FEEDING AT 7 MONTHS
44%
28.8%
OVERALL PREVALENCE OF
UNDERNUTRITION AS
PER IAP CLASSIFICATION
55%
64%
PREVALENCE OF
STUNTING AS PER SD
CLASSIFICATION
26.5%
32%
Source: PD evaluation by NIN, 2006
Taken at sale as Sneha Shivir
by GOI
To improve
Counseling and Child care services of
ICDS
Going beyond: Linkage with facility based care
Identified malnourished children (6 m-3 yr)
Severely malnourished
With medical
complication
Infection
NRC/ MTC
Moderately malnourished
without medical
complication
No improvement
To
NCCS
Practice of health seeking behaviour at
household / Focussed home visit &
follow up at household level
To be continued till the child(ren) attain normal level of nutrition
AWCs as Vibrant ECD
Centre
Objectives
• Prioritize ECE within the daily activities of AWC, in light
of RtE Act 2009
• Review of Existing ECE curriculum and gap analysis
with reference to National Level Documents
• Development of a revised curriculum – with reference
to National Policy and Curriculum Framework
• Development and roll out of a capacity building plan
for implementation of the newly developed ECE
curriculum
Processes Adopted
• August 2011: Formation of State Level Core Committee on ECE:
Convergence between DWCD&SW, SSA, Unicef
• March 2012 : 2 day Consultation -overview of national and
international trends in ECE. Guiding principles finalized
• May 2012 : 5 Day Curriculum Development Workshop in– 35
member Core group identified, Consensus on curriculum
design, design of AWW’s handbook and implementation
strategy
• July 12: 5 Day Curriculum Finalization Workshop in - working
group reviewed feasibility of draft curriculum and AWW
handbook, National level RPs (including NCERT and NIPCCD)
reviewed
Processes Adopted (contd.)
• September 2012 : Curriculum finalized and Piloted as part of
NIPCCD’s pilot study project in 16 states of India. Participation
in Regional workshop at NIPCCD Guwahati
• February 2013: field testing and data analysis workshop at 2
projects
• May 2013: 2 days’ sharing workshop on ECE curriculum and
capacity building strategy of West Bengal
• July 2013: Field testing of training modules for AWWs at S-24
Parganas
Shifts in Curricular Approach
•
•
•
•
•
Domain based to activity based
Thematic Approach incorporated
New routine break up
Move away from 3Rs to School Readiness
Emphasis on Early Language Learning
Curriculum Design
ACTIVITY BASED
ECE
AGE APPROPRIATE –
based on Early
Learning
Development
Standards
CURRICULUM
EMBEDDED
THEME
Sample Routine
Pilot Process
• Pilot - 100 centers (50 rural and 50 urban) for 8
weeks from Rural and Urban projects as per
guidelines provided by NIPCCD Guwahati
• Frequent monitoring and on-site support
• Peer to peer support for AWWs
• Monitoring visit by NIPCCD and CECED
• Data Analysis workshop at project level after
completion of Field Test
Pilot Findings
• Impact of curriculum on AWW and children
There is a specific, visible rhythm in the daily classroom process and a clear
progress can thus be seen in children’s participation and learning
• Use of Handbook by AWW’s
Although it is designed for AWWs, handbook may prove to be a valuable
resource for all levels of ICDS officials –a ready reckoner for what is
appropriate for pre-school
• Impact of shift from Domain Centered to Activity Centered Curriculum
• Impact & Use of books in the Centre
• Impact of suggested material display (4 corners)
Lessons Learnt
• The inclusion of field knowledge of AWWs and
Supervisors has made the curriculum and handbook
more hands on and easy to implement
• Structured routine with activities and materials
aligning principles of
– i. age appropriate,
– Ii. thematic, and
– Iii. activity based learning
made children more enthusiastic and better tuned
in towards the routine
Influencing Factors
• Involvement of parents, local community to know about
curricular shift
• Mothers’ meeting by AWWs to convince the parents
• AWWs should be enthusiastic and open to Activity based
processes
• Availability of space and time to conduct all suggested
activities
• Additional support for Student Teacher ratio – more than
30
Way forward
• Revision of routine from 2.5 hours to 4.5 hours
including SNP
• Development of training manual and piloting of
training design as per suggestions received from
MWCD, NIPCCD and NCERT during sharing workshop
(3rd- 4th May 2013)
• Formation and Capacity building of State and District
Resource Groups (400 individuals, selected from
officials and functionaries of Deptt. of CD and WD
&SW) – SRG 1 batch over, 1 going on, DRG planned
Community Participation in PSE
Other innovative measures
• COHORT tracking of
individual beneficiaries
to establish a
continuum services for
the first 1000 days
Other innovative measures (contd.)
• Mobilizing corporate support in improving delivery of
services and model AWCs as visualized in Mission
• Establish vertical and parallel linkage with other
departments and within the same deptts. between
program interventions
How are we looking at Innovations &
Good practices
• Instrumental in leading a catalytic effect
• District level variations and requirements to be given due
importance in district intervention plan with some semblance
in planning and introduce key innovations/ good practices
• District planning exercise already initiated for Fy 2014-15 with
additional focus on developing Integrated Nutrition
Intervention plan for 2 focus backward districts- Malda and
Purulia
• Develop convergence models and leverage program funds for
a pool of funds for integrated interventions in the focus
districts
Thank You