Multi-sectoral Nutrition Action Plans: Barpeta, Udalguri and ...

Non-lending Technical Assistance to Assam: Improving Nutrition and Development Outcomes in Early Years

(P168656)

This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies of the World Bank and its Board of Executive Directors.

Multi-sectoral Nutrition Action Plans: Barpeta, Udalguri and Goalpara districts

Assam

Output submitted to the World Bank by The Coalition for Food and Nutrition Security

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Multisectoral Result Based District Nutrition Action Plan- Barpeta District

Accelerating the Progress of SDGs 2, 3 in the State of Assam

2019-2022

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Preface

Malnutrition (The Hidden Hunger) is widely prevalent in most of the districts of Assam and its manifestation is quite obvious in certain districts of the state also categorized as “Aspirational Districts” by Niti Aayog. These include Dhubri, Goalpara, Baksa, Darrang, Udalguri, Hailakandi and Barpeta. These districts have high prevalence of childhood stunting and wasting.

The Government of Assam in its Vision: 2030 document has set a target to make Assam malnutrition free and in this endeavour, the Assam Agenda: 2030 released in 2018 sets the targets for intermittent years with well-defined strategies and actions to be taken.

This multi sectoral nutrition plan is based on in-depth situational analysis of current status of malnutrition in the district, based on recommendations from the Nutrition Working Group Report, outcome of 6 policy seminars held during January – June 2019 and consultations with stakeholders from department functionaries and civil society organizations. The plan suggests necessary nutritional interventions for adolescent girls (in school, out of school), pregnant women, children under 5 besides other interventions necessary for creating a healthy environment like safe drinking water, sanitation, prevention of communicable diseases, assured food supply and education. The suggested interventions if implemented meticulously will certainly bring down the high prevalence of existing malnutrition in the district. There are examples from within and outside the country where prevalence of malnutrition has been reduced drastically within a period of 10 years by adopting appropriate strategies and interventions.

We hope that implementation of strategies and interventions suggested in this Multi sectoral plan along with robust monitoring will help to achieve a “Malnutrition Free district”

Dr. R.M Dubey Prof and Head,CSDGs

&

Dr. Sujeet Ranjan

Executive Director, CFNS

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Acknowledgements

The Result Based Multisectoral District Nutrition Action Plan was jointly drafted by The Coalition for Food and Nutrition Security (CFNS) and Center for Sustainable Development Goals (CSDGs), Government of Assam in close coordination with all concerned departments of Barpeta district.

We are indebted to Shri Rajeev Kumar Bora (Additional Chief Secretary), Dr. J B Ekka (Principal Secretary) and the entire team of Transformation and Development Department, Govt. of Assam for their continuous guidance and support. Their suggestions put forth during deliberations in various policy seminars have served as useful inputs in preparation of this document.

CFNS and CSDGs teams would like to thank all the external contributors who have helped in preparing the plan document: Shri Jishnu Baruah IAS, Additional Chief Secretary, Shri. Hemen Das ACS, Secretary and Smt. Juri Phukan IAS, Director – Department of Social Welfare, Govt. of Assam.

We are grateful to Shri Munindra Sharma, ACS, Deputy Commissioner, Barpeta District for his valuable coordination. We are also thankful to Dr. Babul Saharia, ACS, DDC and all the officials of department particularly the Joint Director - Health Services & NHM team, District Agriculture Officer & team, Executive Engineer - PHED & team, District Social Welfare Officer & team, Project Director – DRDA & team, District Education Officer & team, District Program Manager - Assam Rural Livelihood Mission & team and Food & Civil Supplies Department. We also highly appreciate the support of ICDS and Health functionaries for extending their cooperation in facilitating community visits.

We would also like to thank all the Individual Experts, State Government officials and Civil Society Organizations working in the Nutrition & Health domain for their valuable inputs. We also like to thank all the members of the Nutrition working Group – Assam for their insights on nutritional scenario in districts of Assam.

Non-Lending technical assistance received from the World Bank Group is acknowledged

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The Drafting Team

The Result Based Multisectoral District Nutrition Action Plan has been drafted jointly by the following officials with the Coalition for Food and Nutrition Security (CFNS) and the Center for Sustainable Development Goals (CSDGs).

Centre for SDGs

1. Dr. R.M Dubey: Prof. and Head, Centre for SDGs 2. Shri J.C Phukan: Consultant, Centre for SDGs

Coalition for Food and Nutrition Security

1. Dr Sujeet Ranjan: Executive Director, Coalition for Food and Nutrition Security 2. Ms. Akanksha Doval: Knowledge Management Coordinator 3. Mr. Sayan Deori: Program Coordinator

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Table of Contents Acknowledgements ......................................................................................................................................... 3

The Drafting Team .......................................................................................................................................... 5

List of Tables .................................................................................................................................................. 7

List of Figures ................................................................................................................................................. 8

Abbreviations .................................................................................................................................................. 9

Executive Summary ...................................................................................................................................... 11

1. Barpeta District Profile ......................................................................................................................... 12

2. Conceptual Framework of Malnutrition................................................................................................ 14

2.1 Barpeta District Problem Tree ...................................................................................................... 15

2.2 Potential Hotspot for Malnutrition in Barpeta District ................................................................. 15

2.3 Nutrition Status of Barpeta, Assam and India ............................................................................... 17

2.4 First 1000 Days Analysis of Barpeta District ............................................................................... 17

2.5 Status and Determinants of various Malnutrition Indicators ........................................................ 19

3. Objective ............................................................................................................................................... 20

4. Methodology ......................................................................................................................................... 20

5. Multisectoral Plan- the Approach, Target Groups and Parameters ....................................................... 21

6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam ..................... 24

A. Essential Nutrition Intervention .................................................................................................... 24

A1: Adolescent Nutrition .................................................................................................................... 24

A2: First 1000 Days ............................................................................................................................. 29

A2.1 Pregnant Women ........................................................................................................................ 30

A2.2 Lactating Mothers ...................................................................................................................... 35

A2. 3 ChildrenAged 0-6 months ......................................................................................................... 37

A2.4 Children Aged 6-24 Months ...................................................................................................... 40

A3. Children Aged 24-59 Months ...................................................................................................... 46

.................................................................................................................................................................. 48

B. Multisectoral Interventions ........................................................................................................... 48

.................................................................................................................................................................. 55

C. Cross Cutting Strategies ................................................................................................................ 55

Annexure 1: Multisectoral framework to Reduce Malnutrition .................................................................... 58

Annexure 2: State Inception Workshop ........................................................................................................ 59

Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition” ............................... 59

Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes”..................................................................................................................................................... 60

Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam”................. 62

Annexure 6: MCP Card ................................................................................................................................ 63

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List of Tables

Table 1: Malnutrition Indicators (NFHS 4 Data) ............................................................................ 19 Table 2: BarpetaPopulation Projection for Adolescents aged 10-19 Years .................................... 25 Table 3: Essential Nutrition Interventions-Adolescent Nutrition ................................................... 25 Table 4: Barpeta Population Projection for Pregnant Women ........................................................ 30 Table 5:Essential Nutrition Interventions-Pregnant Women .......................................................... 30 Table 6:Barpeta Population Projection for Lactating Mothers ....................................................... 35 Table 7:Essential Nutrition Interventions - Lactating Mothers ...................................................... 35 Table 8: BarpetaPopulation Projection of Children aged 0-6 months ............................................ 37 Table 9: Essential Nutrition Interventions - Children aged 0-6 months ......................................... 37 Table 10: Barpeta Population Projection for Children aged 6-24 Months and 12-23 Months ....... 40 Table 11: Essential Nutrition Interventions -Children aged 6-24 Months ...................................... 40 Table 12: Barpeta Population Projection for Children aged 24-59 Months ................................... 46 Table 13: Essential Nutrition Interventions - Children aged 24-59 Months ................................... 46 Table 14: Multisectoral Interventions ............................................................................................. 49 Table 15: Multisectoral District Nutrition Plan (Cross Cutting Strategies) .................................... 55 Table 16: Summary of Interventions - Department Wise ............................................................... 57

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List of Figures

Figure 1: Barpeta District Map ....................................................................................................... 13 Figure 2: Barpeta Problem tree ....................................................................................................... 15 Figure 3: Total literacy rate <= 60 .................................................................................................. 16 Figure 4: Villages with more than 30% of HH with no Assets ...................................................... 16 Figure 5: Comparative Analysis of Nutrition status – Barpeta , Assam and India ......................... 17 Figure 6: Performance in indicators of Pregnant woman ............................................................... 18 Figure 7: Performance in indicators of Children ............................................................................ 18

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Abbreviations

ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist ASRLM Assam State Rural Livelihood Mission AWC Anganwadi Center AWW Anganwadi Worker AAY Antyodaya Anna Yojana BCC Behaviour Change Communication CBO Community based Organization CSR Corporate Social Responsibility CSDG Center for Sustainable Development Goals CFNS Coalition for Food and Nutrition Security HBNC Home Based New-born Care JSY Janani Suraksha Yojana FLW Front Line Workers IEC Information Education and Communication ICDS Integrated Child Development Scheme IFA Iron and Folic Acid IYCF Infant and Young Child Complementary Feeding MAA Mother’s Absolute Affection MAM Moderate Acute Malnutrition MDM Mid-Day Meal MGNREGA Mahatma Gandhi National Rural Employment Guarantee Act MT Million Tonne NRDWP National Rural Drinking Water Programme NGO Non-Government Organization NHM National Health Mission NIPI National Iron Plus Initiative NRC Nutrition Rehabilitation Center NFHS 4 National Family Health Survey (2015-16) PDS Public Distribution System PHED Public Health Engineering Department PHC Public Health Center PMFBY Pradhan Mantri Fasal Bima Yojana PMMVY Pradhan Mantri Matritva Vandana Yojana PRI Panchayati Raj Institution PW Pregnant Women RKVY Rashtriya Krishi Vikas Yojana SAM Severe Acute Malnutrition SAG Scheme for Adolescent Girls SBA Skilled Birth Attendant SBCC Social Behaviour Change Communication SBM Swachh Bharat mission SECC Socio Economic Caste Census SHG Self Help Group

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SNP Supplementary Nutrition Program SSA Sarva Siksha Abhiyaan THR Take Home Ration VHSND Village Health Sanitation and Nutrition Day WIFS Weekly Iron and Folic Acid Supplementation

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Executive Summary

The Multisectoral district nutrition action plan for Barpeta district has been prepared as a part of work envisaged under developing Multisectoral plan for three aspirational districts of Assam, out of non-lending technical support received from the World Bank. For preparation of this Multisectoral nutrition plan the World Bank engaged Coalition for Food and Nutrition Security for providing technical assistance to the Center for Sustainable Development Goals and this plan is the outcome of joint efforts of both these organizations.

This Nutrition plan is divided in the following Six Sections.

Section 1of the plan gives a brief profile of Barpeta District from Census 2011.

Section 2 covers the conceptual framework of Malnutrition. The section includes a problem tree of Barpeta which shows the problem of malnutrition in the form of a tree highlighting the immediate, underlying and root causes behind the problem and various manifestations in the form of stunting, wasting, underweight and anaemia. The problem tree is based on NFHS 4 data of 2015-16. This section also compares the nutritional status of Barpeta district with that of Assam and India. It also shows the performance of Barpeta district in first 1000 days from conception till child’s two years of age and compares the performance of district in first 1000 days with that of state average and best performing district in state for respective parameters.

Section 3 covers the objectives behind the result based multi sectoral plan.

Section 4 describes in details the methodology adopted in preparation of this plan. The plan is the outcome of research and analysis conducted during the period of six months (Jan- to June 2019). Feedback was sought from district officials of the concerned departments and nutrition experts. Based on feedback as well as extensive desk research, guidance from the steering group and additional interviews with experts, district officials and community members representing diverse communities residing within the district.

Section 5 of the plan describes the lifecycle approach adopted to address the child and maternal malnutrition prevalent in the district. The plan is divided into three following parts A, B and C. Part A focuses on nutrition specific intervention, part B refers to nutrition sensitive interventions and part C presents the cross cutting strategies applicable to both nutrition specific as well as nutrition sensitive interventions. The targeted groups and suggested parameters are also reflected for each part A, B and C separately.

Section 6 is the main result based Multisectoral district nutrition action plan for accelerating the progress of SDGs 2 and 3 in the district. The action plan for each of the parts, as mentioned in section 4, has been dealt in detail section wise. For each of the parts A, B the following details are included in a tabular form –proposed indicators, targets for three years (2019-2022), recommended interventions, the lead and support department to executing the stated interventions and intervention related schemes being implemented by the Government of Assam.

In part A of the plan, essential nutrition interventions details are provided separately for adolescent girls, and first 1000 days including pregnant women, lactating mothers and infants and young children and 24-59 months old Children. For each of these categories of adolescents, pregnant women, lactating mothers and children, the projected population figures for three years (2019- 2022) have been worked out based on actual figures of census 2011 and average annual growth rate.

In part B of the plan, details of Multisectoral interventions to be dealt is long term for addressing underlying and root causes of malnutrition, including water, sanitation and personal hygiene; education, social causes, women’s empowerment and food security are presented.

Part Cof the plan details the cross cutting strategies like strengthening of community based events like VHSND, growth monitoring of children at AWCs, organising quality timely home visits by frontline workers, supply chain management and social behaviour change communication strategies.

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The persistent problem of malnutrition in the district is proposed to be tackled by ICDS and health sectors jointly giving lead for accelerating improvement in indicators pertaining to essential nutrition interventions in first 1000 days of life and critical maternal child health services. Highest priority will be accorded to households having a woman member who is pregnant or having a child 0-24 months. Additionally, using the life cycle approach, the existing policies for care of preschool children, school, children, and adolescent girls will be also actively implemented. Moreover, for addressing the intermediate and underlying causes of undernutrition, other sectors such as PHED, Social Welfare, Education, Panchayat and Rural Development, Food and Civil Supplies Department will be involved.

1. Barpeta District Profile

Barpeta is one of the seven aspirational districts of Assam. Barpeta district with its H.Q. at Barpeta was created and started functioning from 1st July’1983. Barpeta is a historical district of Assam with a lot

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of cultural and religious significance. It is surrounded by Bhutan Hills in the north, Nalbari and Baksa districts in the east, Goalpara and Kamrup districts in the south and Bongaigaon and Chirang districts in the west.

For the administrative purposes, the entire district is divided into two sub-divisions viz., Barpeta and Bajali. Again each sub-division is divided into revenue circles and under revenue circles there are Mouzas comprising revenue villages. Barpeta district has 9 Revenue Circles with 835 villages. There are 6 statutory towns and 3 census town in the district.

Barpeta has a high prevalence of char areas which are predominantly minority population areas and the communities are most vulnerable due to lack of proper communication. The char dwelling communities are mostly dependent on agriculture.

Figure 1: Barpeta District Map

Barpeta District at a Glance (Census 2011) Total Population 16.49 lakhs Total Geographical Area 2282 sq. km Male (%) 51.2% Population Density 742 person / sq. km Female (%) 48.8% Sex Ratio 953 Rural (%) 91.3% Child Sex Ratio 961 Urban (%) 8.7% Revenue Villages General Population (Non SC ST) (%) Infant Mortality Rate (IMR) 43 (Annual Health

Survey 2012-2013) SC Population (%) 5.63% Maternal Mortality Rate (MMR)

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ST Population (%) 1.61% Literacy Rate 63.81% Hindu Population (%) 29.11% Women Literacy Rate 58.06% Muslim Population (%) 70.74% Christian Population (%) 0.06% Others (%) 0.09%

2. Conceptual Framework of Malnutrition

UNICEF’s (1990) conceptual framework of the causality of child malnutrition illustrates the Multisectoral nature of the problem. The immediate determinants of malnutrition at the individual level (inadequate dietary intake and disease) are products of underlying causes at the family or household level (insufficient access to food, inadequate maternal and child practices, poor water and sanitation, and inadequate access to quality health services). These, in turn, are influenced by basic causes at a societal level, including the quality and quantity of human, economic, and organizational resources and political environment.

The problem tree of Barpeta district in the following section 2.1 highlights the conceptual framework of malnutrition in women and children. Malnutrition is manifested in the form of stunting, wasting, underweight, anaemia and low BMI in women. These outcomes are influenced by a set of immediate causes (nutrition specific) and underlying causes (nutrition sensitive) intervention.

Dietary intake and disease status, immediate causes of malnutrition, can be addressed through nutrition specific interventions. The underlying causes of malnutrition i.e. food security, care and feeding practices for mothers and children and health services and healthy environment can be addressed through nutrition sensitive interventions. Both the nutrition specific and nutrition sensitive interventions are further influenced by interventions which improve socio economic status of women, domestic violence, and education status.

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2.1 Barpeta District Problem Tree

2.2 Potential Hotspot for Malnutrition in Barpeta District

Figure 2: Barpeta Problem tree

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Figure 4: Total literacy rate <= 60

Figure 3: Villages with more than 30% of HH with no Assets

Source: Census 2011

In the absence of segregated data on malnutrition, during the field work an attempt was made to identify malnutrition pockets in the district based on indirect evidences and for the purpose pockets of high illiteracy and households with no assets was identified. As can be seen from the figures below the pockets more or less coincide with each other. The pockets where illiteracy is high and the households with no assets indicate towards high prevalence of malnutrition. These are the pockets with high prevalence of poverty and hence high prevalence of malnutrition. In order to improve district’s nutritional indicators it is important to focus on these pockets with priority.

Figure 3 and Figure 4 depicts the potential hotspot for malnutrition in Barpeta district, according to Census 2011 data. Though the prevalence may be different now but the data still can be used to identify relatively poor performing pockets.

• The maximum concentration of illiteracy and households with no assets are shown in red.

• These are likely the household with high prevalence of poverty and also malnutrition

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2.3 Nutrition Status of Barpeta, Assam and India

Figure 5: Comparative Analysis of Nutrition status – Barpeta, Assam and India

2.4 First 1000 Days Analysis of Barpeta District

Figure 4 and 5 indicates the performance of Barpeta district in the first 1000 days from conception till child’s 2 years of age. Figure 4 indicates the performance of district across various indicators related to the care of pregnant mother while figure 4 shows the performance of district in indicators related to child care. The figures also help in comparing the performance of Barpeta districts with that of State average and best performing districts in respective parameters.

38.4

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7.4

35.8

46.5

18.7

4

36.441.4

16.6

5.8

33.1

0

10

20

30

40

50

Stunting Wasting Severely Wasting Underweight

Nutriton Indicators of Barpeta compared to Assam and India

India Assam Barpeta

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Figure 6: Performance in indicators of Pregnant woman

Figure 7: Performance in indicators of Children

0

20

40

60

80

100ANC in First trimester

At least 4 ANCs

Full ANC

Protection againstNeonatal Tetanus

IFA consumption for100 days

Mothers having MCPcard

Institutional delivery

Financial assistanceunder JSY

Pregnant Woman

Assam Barpeta State best performing

0

20

40

60

80

100

Breastfeeding within onehour of birth

Exclusive breastfeedingupto six months

Adequate diet (6-23months)

Full Immunization (12- 23months)

Vit A dose in the last sixmonths (9-59 months)

Children

Assam Barpeta State best performing

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2.5 Status and Determinants of various Malnutrition Indicators The table 1 below shows the indicators of malnutrition for India, Assam, Barpeta District and best performing district of Assam in respective indicators.

Table 1: Malnutrition Indicators (NFHS 4 Data)

Indicators India Assam Barpeta State Best Performance

Stunting Under 5 % 38.4 35.3 42% 24.6 (Kamrup Metro)

Wasting Under 5 % 21 16.1 17% 6.2 (Dhemaji)

Severely wasting Under 5 % 7.5 5.9 5.8% 0.8 (Dhemaji)

Underweight Under 5 % 35.7 28.1 33% 15.8 (Dhemaji)

Pregnant Women having ANC in first

trimester 58.6 55.1 64.3% 82 (Jorhat)

Pregnant Women having at least 4 ANC visit% 51.2 46.4 47.5% 75.8 (Jorhat)

Pregnant Women receiving Full ANC Care% 21 18.1 10.2% 48 (Jorhat)

Pregnant Women Consuming IFA for 100 days or more% 30.3 32 18.6% 63.3 (Jorhat)

Mothers receiving financial assistance under JSY for institutional Delivery 36.4 66.1 66.7% 90.2 (Dhemaji)

Mothers whose last birth was protected against neonatal TT 89 89.8 86.8% 97.1 (Sonitpur)

Mothers having mother and child protection (MCP) card 89.3 98.6 96.4% 99.3 (Nalbari)

Women age 20-24 years married before age 18 years (%) 26.8 30.8 43.3% 18.5 (Cachar)

Women age 15-19 years who were already mothers or pregnant at the

time of the survey % 7.9 13.6 16.2% 7 (Sonitpur)

Women who are literate % 68.4 71.8 67.4% 84.3 (Kamrup M)

Women having 10 or more years of Schooling 35.7 26.2 23.9% 48.2 (Kamrup Metro)

Institutional Births % 78.9 70.6 51.9% 95.9 (Jorhat)

Breastfed within 1 hour of birth% 41.6 64.4 68% 80.5 (Goalpara and Udalguri)

Exclusive Breastfeeding up to 6 months% 54.9 63.5 56.7% 86.2 (Tinsukia)

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Children receiving adequate diet% 8.7 8.7 9.7% 13.8 (Sivasagar)

Full Immunization % 62 47.1 34.1% 73 (Sivasagar)

Vitamin A supplementation in Last 6 months% 60.2 51.3 41.1% 67.6 (Karimganj)

3. Objective

The objective behind this result based multisectoral district nutrition action plan is to study in depth the reasons behind the high prevalence of malnutrition in the district and key challenges before the district administration in This multisectoral plan will ensure strong nutrition focus through institutional and programmatic convergence by integrating it in the planning, implementation and supervision process in all relevant direct and in-direct interventions and programs.

Based on these determinants, a multi-sectoral district nutrition action plan is proposed. The rolling out of such a plan is expected to contribute in accelerating improvement in women and child nutrition situation and in achieving the vision of the State enunciated in Assam Vision 2030 and achieving the SDGs 2 and 3.

4. Methodology

The district nutrition action plan for Barpeta district, Assam is drafted by the Coalition for Food and Nutrition Security (CFNS) in collaboration with Center for Sustainable Development Goals (CSDGs), Government of Assam. The documents are based on desk research and analysis in the last five months, views of district officials of the concerned departments and public health nutrition and development experts, The details are summarised below.

• Review of strategic plans and similar planning documents: The team reviewed the framework of Poshan Abhiyaan for multisectoral district planning, relevant indicators from NFHS-4 and similar planning documents like multisectoral district nutrition plan from Dungarpur district, Rajasthan, Aspirational District Plan for Barpeta district, Assam Agenda 2030 of Transformation and Development department, Government of Assam, were also referred to decide on the indicator matrix for the plan. The matrix designed is based on the life cycle approach to address malnutrition with special focus on first 1000 days of life.

Community Visit: Team visited four diverse villages of Udalguri district- Dhamapara char,

Dhamapara char, Pub Mahachara char, Bilotrihati and Barsimla village. The visit was undertaken with the objective to understand the status of various services linked to the nutrition like Health, Water and Sanitation, Education and to gain insights into the socio cultural practices and beliefs of people. Extensive focused group discussions were conducted with the Mother’s group (pregnant and lactating mothers), Adolescent girls’ group, and frontline workers of ICDS and Health sectors (AWWs and ASHAs). Team also visited various AWCs and Crèches particularly in tea garden areas of the district to understand their functioning and status of various services.

• Interviews with officials of selected government departments: These interviews provided an

opportunity to understand the challenges of the work of each of the concerned department and to complement the information garnered from the community visit and strategic documents.

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• State and District Inception Workshop: The state and district inception workshop was conducted on 2nd Feb and 9thJanuary 2019 respectively. Experts from various fields and very senior officers from the government including Chief Secretary, Assam participated in State inception workshop and presented their views on district nutrition plan.

• Policy Seminars: Six policy seminars on various topics related to nutrition were conducted in Assam

in the period from Jan-2019 to June 2019. Each of the policy seminars was attended by top government officials, individual experts, civil society organizations and field level executives. Feedbacks from the seminars were considered for drafting the Multisectoral nutrition plan.

• Monthly Nutrition Working Group Meetings: Coalition for Food and Nutrition Security (CFNS) in collaboration with Center for Sustainable Development Goals (CSDGs) formed a nutrition working group on “Essential Nutrition Intervention” in Assam. Members of the group are part of civil society organizations working at the grass root level, academicians, officials of government departments, subject experts and others. The group act as a think tank for the state on various issues related to district nutrition plan. The members of the working group strongly recommended that there was a need to focus on critical ‘window of opportunity’ of the first 1000 days of life (pregnancy period and early childhood 0-24 months). The discussions in each of the meeting provided valuable insights to the team in drafting of district nutrition plan.

5. Multisectoral Plan- the Approach, Target Groups and Parameters

The plan is based on the lifecycle approach to address child and maternal malnutrition. It is divided into two parts. Part A covers essential nutrition interventions for adolescent girls, pregnant and lactating mothers, and infants and young children addressing immediate causes of malnutrition.

Group Essential Interventions

Part A- Essential Nutrition Intervention

Adolescent Girls Anaemia Screening /IFA Supplement Deworming/ BMI Correction Health, Nutrition, Sanitation, Hygiene Education

Pregnant Women ANC Care Iron and Calcium Supplementation Deworming Supplementary Nutrition/Take Home Ration () Family Planning Counselling Weight& Height Measurement- BMI (for weight gain during pregnancy)

Institutional Delivery Support for Early initiation of breastfeeding Home Delivery by SBA

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Lactating Mothers IFA tablets Calcium tablets ICDS Supplementary Nutrition /Take Home Ration Family Planning Services

0-6 Months Child

Low Birth Weight Care/ Kangaroo Mother Care Continuation of Breastfeeding & Exclusive Breastfeeding Diarrhoea Management (ORS, Zinc and access to safe drinking water and sanitation facility) Care / feeding during illness Weight/ Height Monitoring

6-24 Months Children

Timely Initiation of Complementary Feeding Appropriate Complementary feeding (Dietary Diversity, appropriate Feeding Frequency and adequate density ) Vitamin A and IFA Supplementation Full Immunization Deworming (as per guidelines) Supplementary Nutrition (THR of ICDS)SAM and MAM Management


IFA Supplementation Deworming Supplementary Nutrition (ICDS) Vitamin A, IFA

Part B of the plan covers multisectoral interventions that address underlying and root causes of malnutrition. While implementing a multisectoral plan, priority should be given to essential nutrition interventions and it is only after ensuring their implementation, the district should plan to implement long term multisectoral interventions. Part C of the plans outlines cross cutting strategies for system strengthening.

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Part B- Interventions addressing underlying and basic causes of Malnutrition

Water AWCs, Health Centers, Villages and Households with adequate water supply

Sanitation AWCs, Health Centers, Villages and Households with adequate sanitation facilities

Behaviour change: appropriate hygiene, sanitation practices

Hand washing with soap and hygiene practices

High school education of Girls

Facilitate girls high school education

Right age of marriage/conception

Prevention of marriage and conception before 18 years of age

Women’s Livelihood

Women receiving work for 100 days in a year Livelihood generation support to SHGs Homestead food production through Livelihood programs

Food Security

Regular supply of entitled PDS food Access to pulses ,fish , flesh food Homestead food production, Kitchen Garden, Poultry keeping

PART C- System Strengthening Intervention

Cross Cutting Strategies

Systematic Community based events Monthly VHSND sessions Growth Monitoring sessions Organised Home Visit Social Behaviour Change Communication strategy Supply Chain Management Human Resources Capacity Building Monitoring Evaluation Accountability and Learning (MEAL) Knowledge Management Convergence

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A. Essential Nutrition Intervention Essential nutrition interventions or programs address the immediate determinants of malnutrition and child development – adequate food and nutrient intake (diets). Additionally, adequate health/prevention of diseases and is also included since maternal child health interventions are critical for addressing immediate determinants of malnutrition. The interventions are presented using different stages of life cycle—adolescent girls, pregnant and lactating women children 0-6 months, 6-24 months and 24-59 months. The plan recognizes and accords highest attention to the first 1000 days of life—from conception to 24 months of age.

A1: Adolescent Nutrition

6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam

Essential Nutrition Intervention

Box 1: Why Adolescent Nutrition

The foundation of adequate growth and development is laid before birth, during early childhood, and in during adolescence. Early marriage and conception below 18 years adversely impacts on women gaining optimum height. In Barpeta District 43.2 % girls are married before 18 years of age and 16.2% of women aged 15-19 years are already mothers (NFHS 4).

The high rate of malnutrition in girls not only contributes to increased morbidity and mortality associated with pregnancy and delivery, but also increases the risk of giving birth to low birth-weight babies. This contributes to the intergenerational cycle of malnutrition.

Hence, addressing the nutrition needs of adolescents an important step towards breaking the vicious cycle of intergenerational malnutrition.

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Table 2: Barpeta Population Projection for Adolescents aged 10-19 Years

Base Population (Census 2011)–189467 adolescent girls-; Average Annual Growth Rate –2.14 %

Table 3: Essential Nutrition Interventions-Adolescent Nutrition

Indicators Baseline* Target* Data

Source* Intervention Department Scheme Resources

2019-20

2020-21

2021-22

3.1 % of adolescent 10-19 years covered with Albendazole in the first round in February and

School Going Adolescents • Mapping of all private schools,

Government schools and junior colleges • Ensuring adequate Albendazole supply at

health centers/sub centers one month

Lead Departments Health Education Department

Anemia Mukt Bharat

Mobile Block Health Team at PHC level to cover the

Population Projection 2019-20 2020-21 2021-22

Total Number of Adolescents 10-19 Years - - - Total Number of Adolescent Girls aged 10-19 Years 201,893 206,213 210,626

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second round in August each year

prior to the biannual dates fixed for Albendazole distribution

• Maintenance of the track sheet to ensure every adolescent has received the due dosages

• Capacity building of AWWs and nodal teachers on program issues like stock calculations and dissemination, conducting IEC at regular interval

• IEC materials to be given to teachers to hold education sessions in schools

• Dissemination of IEC material to all school’s/juniors college

Out of School Adolescents • Listing of all the out of school

adolescents by AWW with the help of ASHA

• Micro plan for reaching out to out of school children by ASHA and AWW

• Ensuring a fixed day distribution of Albendazole to out of school adolescents at AWCs

• Capacity building of AWWs on program issues like stock calculations and dissemination, conducting IEC at regular interval

Support Department Social Welfare Department

(MoHFW,2018)

schools, Nodal teachers

27

3.2: % of adolescent girls 10-19 years screened for anaemia(school going +non-school going ) (throughout the year)

School Going Adolescents • Mapping and inclusion of private schools,

Government schools and junior colleges • Regular screening (at least twice a year)

for anaemia by teachers/ mobile block health team for school going adolescent



• Regular screening (at least twice a year) for anaemia by AWWs/ mobile block health teams at AWCs for out of school adolescent

Lead Department Education, Health Department WIFS

RBSK ICDS SAG- (out of school adolescent girls)

Mobile Block Health Teams ANMs, ASHAs

Support Department Social Department Education Department

3.3: % of eligible adolescents 10-19 years who receive at least 4 blue iron folate tablets

• Ensuring Weekly distribution of IFA tablets with special focus on

schools in tea garden areas • Teachers and AWWs to ensure

consumption of IFA tablets for school going adolescent and out of school adolescent girls respectively.

• Display of pictorial communication materials at school for better consumption outcome.

Lead Department Health Department

WIFS SAG-for out of schools adolescent girls

ASHAs, AWWs Nodal Teachers

Support Department Education Department Social Welfare Department

28

3.4: % of adolescent 10-19 years whose BMI is below normal

Besides IFA and Deworming following interventions should be ensured: • Promote nutrition, health and sanitation

education at schools and AWCs • Regular health camps for adolescent girls

for measuring BMI followed by counselling sessions

• Delay age of marriage and conception >18 years

• Promote education and retentions in schools



3.5: % of newly wed adolescent girls who have received family planning counselling

• Ensure tracking of the newly wed girls by ASHAs with the help of AWWs

• Ensuring that newlywed adolescent girls enter pregnancy with correct BMI and age more than 18 years

• Strengthening of Adolescent Friendly Health Clinics for counselling


*Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

29

A2: First 1000 Days

Box 1: First 1000 days of life- the critical window of Opportunities

The first 1000 days of life - between a woman’s pregnancy and her child’s second birthday - is a unique period of opportunity when the foundations for optimum health and development across the lifespan are established. Stunting occurring in the first two years of life is irreversible. The right nutrition and care during the 1000 day window influences not only whether the child will survive, but also promote optimum brain and cognitive development. Highest priority is proposed to be accorded to first 1000 days of lie—right from conception to two years of age.

30

A2.1 Pregnant Women

Table 4: Barpeta Population Projection for Pregnant Women

Base Population (Census 2011) - Birth Rate, Total Population;Average Annual Growth Rate –2.14 (Number of Pregnant Women is estimated 10% more than expected live births)

Population Projection 2019-20 2020-21 2021-22 Number of Pregnant Women

Table 5:Essential Nutrition Interventions-Pregnant Women

Indicators Baseline* Target* Data Source* Intervention Department Scheme Resources

2019-20

2020-21

2021-22

5.1: % of PW who had full Antenatal care ( 4 ANC, at least 1 TT, IFA tablet or syrup for more than 180 days)

10.2% (NFHS-4)

Aspirational District Action Plan

• AWWs/ASHAs/ANMs to ensure 100% registration of pregnancies

• SHGs to assist ASHAs to register the ‘Unreached” women in community

• Regular organisation of VHSND by AWWs/ASHAS and ANMs for ensuring early registration and ANC check-ups

• ANCs posts to be 100% filled • Conduct BCC events on importance of

antenatal check-ups and micronutrients.


ICDS NHM ASRLM

ASHAs, ANMs AWWs SHGs

Support Department Social Welfare Department P&RD (ASRLM)

31

• Organise ANC sessions ninth of every month as per the PMSMA policy of NHM Pregnant women to be weighed and weight to be entered in MCP card and weight gain should be encouraged as per BMI based guidelines

5.2: Out of total ANC registered , % registered within 1st trimester(within 12 weeks)

64.3%(NFHS-4)


• ASHAs to ensure 100% registration of pregnant women

• SHGs to facilitate in identification of unreached pregnant women and ensure their registration for ANCs

• Ensuring early registration of pregnancy through incentive of PMMVY

• Effective implementation and timely fund release of PMMVY


ICDS, PMMVY

ASHAs, AWWs Support

Department Social Welfare Department P&RD(ASRLM)

32

5.3:Out of total ANC registered , % registered within 1st trimester(within 12 weeks)


• AWWs to ensure 100% registration of pregnant women


Lead Department Social Welfare Department Health Department

ICDS, PMMVY

ASHAs, AWWs

5.4: % of PW registered who received 21 days of SNP in last month and have access to diversified food through home stead food production

• Ensuring Regular supply of THR • Ensuring supply of readymade nutri

mix as THR and not raw rice-dal • Ensuring safe and hygienic storage of

THR • Involve SHGs in production of THR

through micro finance activities • Promotion of kitchen gardens at AWCs • Promote establishment of kitchen

garden at household level and poultry keeping by linking with SHG activities

Lead Department Social Welfare

ICDS P&RD (ASRLM)

ASHAs, ANMs AWWs SHGs P&RD(ASRLM)

5.5: % of eligible pregnant women who received at least 180 IFA tablets during the Antenatal period

• Regular screening for anaemia levels of PW at health centers / VHSND

• Ensuring adequate availability (based on projected population of PW) of IFA supplies at health centers and sub centers

• Tracking of all eligible pregnant women to ensure timely distribution of IFA tablets through ANMs or ASHAs

Lead Department Health Department NHM

ICDS ASRLM

ASHAs, ANMs AWWs SHGs

Support Department P&RD/Assam RLM

33

• Appropriate counselling by service providers at the time of distributing IFA tablets for improving compliance

• Organise treatment of women with severe anaemia for treatment

• Capacity building of SHGs to engage

them in Jan Andolan activities for promoting consumption of IFA.

• Regular follow up of PW by ASHA, ANM & AWW for managing side effects and improving IFA compliance

• Capacity building of SHGs on basic health & nutrition issues and engaging them for ensuring consumption of IFA

5.6: % pregnant women who consumed 360 calcium tablets during pregnancy

• Ensuring adequate availability (based projected population of PW) of calcium tablet supplies at health centers and sub centers.

• Appropriate counselling by service providers for promoting regular consumption

• Tracking of all eligible pregnant women to ensure timely distribution of calcium tablets through ANMs or ASHAs

• Regular follow up of PW by ASHA, ANM & AWW for compliance


NHM ICDS ASRLM

ASHAs, AWWs SHGs

Support Department Social Welfare Department P&RD

34

• Capacity building of SHGs to engage them in Jan Andolan activities for promoting consumption of calcium

5.7: % of PW who were given one Albendazole tablet after 1st trimester

• Adequate number of tablets to be made available at all health facilities providing ANC

• Health workers to ensure distribution and consumption of tablet

• Appropriate counselling at VHSND for disseminating information and establishing WASH measures

Lead Department Health Department ICDS,

NHM ASHAs, AWWs Support

Department Social Welfare Department

5.8: % of children with low birth weight (< 2.5 kg)


• Ensuring age of marriage and conception not less than 18 years

• Counselling by health and ICDS on adequate and appropriate diversified diet

• Care and day rest during pregnancy • Ensure reduction in physical drudgery

and domestic violence with help of SHGs


ICDS, P&RD (ASRLM)

ASHAs and ANMs Support



35

A2.2 Lactating Mothers

Table 6: Barpeta Population Projection for Lactating Mothers

Base Population (Census 2011); Birth Rate –, Total Population –; Average Annual Growth Rate - (Number of lactating mothers are estimated same to be as number of expected live births)

Population Projections 2019-20 2020-21 2021-22 Number of Lactating Mothers (0-6 Months)

Table 7:Essential Nutrition Interventions - Lactating Mothers


2019-20

2020-21

2021-22

7.1: % of institutional deliveries in the last month

51.9 %(NFHS-4)


• ANM, ASHAs, AWWs to mobilise and support PW for institutional deliveries

• Ambulance facility to be strengthened – Mrityunjoy 108 services, especially at tea garden areas.

• Strengthening the implementation of JSY and PMMVY

• Timely payment on performance based incentives to ASHAs for institutional deliveries.


ICDS, NHM, ASRLM

ASHAs, AWWs, ANMs, SHGs, Trained staff at each health center level


36

• Special higher incentives to ASHAs to be institutionalised in hard to reach areas (border areas)

• Engagement of SHGs to promote the importance of institutional deliveries.

7.2: % of deliveries at home attended by skilled birth attendant(Doctor, nurse, LHV, ANM, Other health personnel)

12.3 % (NFHS-4)


• Increasing the number of SBAs • Regular trainings for SBAs • Incentives to SBAs for safe deliveries

Lead Department

Health Department

HBNC

7.3: % of lactating mothers received 21 days of SNP(THR) in last month

• Ensuring Regular supply of THR • Ensuring safe and hygienic storage of


through micro finance activities

Lead Department Social Welfare Department

ICDS, ASRLM

AWWs SHGs Support

Department P&RD


37

A2. 3 ChildrenAged 0-6 months

Table 8: BarpetaPopulation Projection of Children aged 0-6 months

Base Population (Census 2011) 0-6 Years Population – ; 287,829 Average Annual Growth Rate -

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 0-6 Months - - -

Table 9: Essential Nutrition Interventions - Children aged 0-6 months



2019-20

2020-21

2021-22

9.1: % of children initiated breastfeed within one hour birth

68%(NFHS-4)

100%

100%

100%


• Ensuring early initiation of breastfeeding in 100% institutional deliveries

• AWW to support early initiation of breastfeeding in home deliveries

• No marketing of Infant formula • Lactation Management Training to

the SBAs • Ensure early initiation of Breast

Feeding in 100% institutional deliveries

• IEC material on breast-feeding to be displayed on ANC ward/ delivery ward and other health facilities.


NHM- JSY PMMVY MAA AWWs

ASHAs, ANMs, AWWs, Health Centers


38

• ANMs/ ASHAs to provide breastfeeding counselling during ANC contact at VHSND

9.2: % of children under 6 months exclusively breastfed

56.7%(NFHS-4)

• Educating the mothers and other family members about the importance of exclusive breastfeeding

• Every immunisation contact should be utilised for breastfeeding counselling and assessing status.

• 10 steps to breastfeeding to be displayed in every health centres/ VHSND forums.

• Lactation support services/ lactation counsellors to be provided at health centers for timely management of any lactation problem

• ANMs/ ASHAs to provide breastfeeding counselling during VHSND and ANC check ups

• Support for breastfeeding to working mothers in areas like tea garden areas


NHM, MAA

ANMs, ASHAs, AWWs


9.3: % of children 0-60 months with diarrhoea in the last two weeks who received ORS and Zinc


• Ensuring supply of adequate ORS packets and zinc tablets at AWCs and with ASHAs

• VHSND to be used for creating knowledge about diarrhoea management and preparation of ORS and minimum 14 days consumption of zinc tablets.


NHM PHED

ANMS, ASHAs Support


39

• Home visits to children with diarrhoea treated by health workers for counselling of family members on diarrhoea management/demonstration

• Demonstration on VHSNDs regarding regular hand washing with soap before cooking and eating

• Ensuring the coverage of safe drinking water facility

• Promote the usage of sanitation toilets

PHED

9.4: % of Children 0-60 months that have their weight measured, monitored(entered in growth chart) every month in the last quarter

• Weighing machine to be made available at all AWCs/VHSND forums for regular weight and height measures,

• Trainings of all AWWs and ASHAs on weight measurement and plotting

• Counselling on promotion of mothers by AWWs with the help of ASHAs on importance of growth monitoring

• Prioritised home visits to children whose growth have faltered by AWWs and ASHAs

• Identification of children suffering from severe acute malnutrition (SAM) and taking appropriate actions.


ICDS AWWs, ASHAs and VHSNC members

Support Department Health Department


40

A2.4 Children Aged 6-24 Months

Table 10: Barpeta Population Projection for Children aged 6-24 Months and 12-23 Months

Base Population (Census 2011) 0-6 Years: 287,829 Average Annual Growth Rate –2.14

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 6-24 Months 77855 79521 81223 Number of Children aged 12-23 Months 51902 53013 54148

Table 11: Essential Nutrition Interventions -Children aged 6-24 Months



2019-20

2020-21

2021-22

11.1: % of children who were initiated complementary feeding(Solid or semi- solid food and breast milk) after 6 months

• Organize Annaprashan Diwas once in a month in AWCs to promote complementary feeding and demonstrate healthy recipes

• AWWs and ASHAs to counsel mothers and family members on adequate diet- quality and quantity

• Encourage preparation of traditional nutrimix through home level preparation

• Measles fist dose contact with mother to be utilised for assessing the status of complementary feeding of child

Lead Department Social Welfare Department ICDS

NHM

AWWs, ASHAs and VHSNC members

Health Department Support Department

41

• Undertake regular home visits for counselling on complementary feeding at home level by ASHAs,as per the policy on Home Based Care in Young Children,NHM

• Recipe demonstration by AWWs or in VHSND

• List of locally available complementary foods to be given to children

• Regular trainings for AWWs and ASHAs to ensure knowledge and skill retention on complementary feeding

Assam RLM

11.2: % of children consuming at least 4+ food groups

• Counselling by ICDS and health workers to stress on diet diversity

• Promote establishment of SSBs at household level of such children and poultry keeping by linking with SHG activities.

• Training of SHGs to counsel on adequate diet- dietary diversity and minimum meal frequency

• SHGs to establish kitchen gardens and provide support to AWCs on demonstration days

Lead Department ICDS, Health P&RD ICDS,

ASRLM AWWs, SHGs Support Department Social Welfare department

11.3: % of children (9-24months) who received at least one dose of

41.1% (NFHS-4)

• Ensuring adequate stock availability (based on population projection) at health centres

Lead Department Health department

NHM ICDS

AWWs, ASHAs

42

vitamin Ain the preceding 6 months

• Institutional Bi-annual distribution of Vitamin-A on two fixed months, 6 months apart from each other

• AWW to prepare due lists of children 9-60 months with the help of ASHAs and ANMs

• Children not covered in 6 monthly drive to be administered vitamin A doses on VHSND

Support Department Social Welfare department

11.4: % children 6-24 months provided (IFA) syrup (Bi weekly) in the preceding month

• AWW to prepare list of beneficiaries with the help of ASHA and ANM


• Ensuring mechanism for distribution of syrup to mothers during VHSNDs by ANM/ASHAs


Anemia Mukt Bharat

AWWs, ASHAs Support

Department Health

11.5: Children age 12-23 months fully immunized (BCG, measles, and 3 doses each of polio and DPT) (%)

34.1 % (NFHS-4)

• ASHA to get list of children to be fully immunised from AWW

• Home visits by ASHAs to follow up for mobilizing caregivers for attending immunization sessions.

• Tracking and micro planning to reach out all children at household level- head count survey specially at tea garden areas

• Ensuring migratory population and temporary settlements are also included in the immunization plan


NHM, ICDS, ASRLM

ASHAs, AWWs and SHGs

Support Department Social Welfare Department, P&RD

43

• Engagement of SHGs/ community influencers/leaders to promote awareness regarding full immunization and mobilizing caregivers to attend immunization sessions on fixed days

• Scaling up eVIN

11.6: % children 6-24 months registered who received SNP (THR) for 21 days in the last month

• Introduction of policy for production of Nutrimix as THR supply to ICDS.

• Regular supply of THR to ICDS and weekly supply to children Capacity building of SHGs to take up THR as a micro finance activity

Lead Department Social Welfare department ICDS AWWs,

SHGs Support Department P&RD

11.7: % of children 6-36 months screened for MAM and SAM during last month

• Regular growth monitoring at AWCs • Training of AWWs to identify MAM and

SAM cases

Lead Department Social Welfare Department ICDS,

NHM

AWWs, ASHAs VHSND committee members


11.8: % of children with MAM that receive

• Counselling on home based care and adequate feeding by AWWs and ASHAs


ICDS, NHM

AWWs, ASHAs

44

appropriate interventions at community level

• Behavioural change sessions on child health and nutrition by AWWs


11.9: % of children with SAM and medical complications treated at Nutrition Rehabilitation Centres (NRCs)

• Identifying SAM children who fail appetite test or with bilateral oedema,

• Financial support to mother bringing child for treatment at NRCs

• Follow up after discharge from NRC • Ensure availability of dieticians at NRC at all

times • Induction training for NRC team (doctor,

dietitian/ nutritionist, nurses, cook and helpers) to gain proper techniques and skills

Lead Department Health

ICDS, NHM

AWWs, ASHAs Support


11.10 % of children with SAM and without medical complications treated at community level

• Provision of double THR ration of ICDS to SAM cases with no medical complications

• Monitoring w eight gain • Imparting nutrition and health education

through food demonstration and preparation

• Promotion of kitchen garden to ensure household level food security

• Capacity building of primary caregiver to look after the child at home



11.11: % of children (6-24 months)

• Ensuring adequate Albendazole supply Lead Department

ICDS WIFS

45

who received Albendazole

• Maintenance of track sheet to ensure every child receives the due 6 monthly dosages

• Dissemination of IEC material to community centres

Social Welfare



46

A3. Children Aged 24-59 Months

Table 12: Barpeta Population Projection for Children aged 24-59 Months

Base Population (Census 2011) 0-6 Years population -219188; Average Annual Growth Rate –2.14

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 24-59 Months 233,563 238,561 243.667

Table 13: Essential Nutrition Interventions - Children aged 24-59 Months



2019-20

2020-21

2021-22

13.1: % of children (24-59months) who received Vitamin A

41.1% (NFHS-4)

• Organising biannual administration of vitamin A supplements

• AWW to prepare due lists of children with the help of ASHA and ANM

• Left out children to be given doses on VHSND



NHM ICDS

AWWs, ASHAs

Support Department

13.2: % children 24-59 months provided (IFA) syrup (Bi

• AWW to prepare list of beneficiaries with the

help of ASHA and ANM • Ensuring adequate stock availability (based on

population projection) at health centres


NHM : Anaemia Mukt Bharat

47

weekly) in last month

• Ensuring mechanism for distribution of syrup to mothers during VHSND

Support Department Heath Department


• Ensuring supplementary feeding to ICDS enrolled children 24-36 months

• Engagement of SHGs to ensure production of vegetables as micro finance activity

• etc for SNP for 24-36 months children enrolled with ICDS Provision of additional SNP to severe underweight children



48

B. Multisectoral Interventions

Multisectoral interventions or programs address the underlying and basic determinants of malnutrition these include measures for improving food security and diet diversity; access to potable water, sanitation facilities and a safe and hygienic environment. The maternal-child health interventions are included in section A since nutrition and health are immediate determinants of malnutrition and are interrelated.

Part B- Multisectoral interventions to address underlying and root causes of malnutrition

Box 3: Why Multisectoral Interventions to Improve Nutrition

Water, Sanitation and Personal Hygiene (WASH) - WASH and nutrition programs depend on each other to achieve impact. For example, diarrhoea is one of the biggest killers of children in South Asia. These deaths are largely preventable through good nutrition, hand washing with soap, safe drinking water and basic sanitation, and vaccination. Proper hand washing with soap at critical times, and especially before preparing food and feeding a child, is one of the most effective and cost-efficient ways to prevent diarrhoea. Improvements in sanitation, especially the elimination of open defecation, have been associated with a decrease in stunting .When nutrition programs emphasize water, sanitation, and hygiene—and WASH programs emphasize hand washing before preparing food, feeding a child, and elimination of open defecation—both programs can maximize impact.

Agriculture: Research in India has shown that increased crop diversification improves dietary diversification in the home and helps children recover from growth faltering. As agricultural production grows and diversifies, households experience increased food security and better nutrition, leading to increases in human capital and productivity. Diversified agricultural production has the potential to improve access to more diverse and nutritious foods, a key component of meeting the “Minimum Acceptable Diet” for children. Agricultural programs that focus on producing energy-rich staple foods can also be more effectively designed to reduce undernutrition by promoting crops that reduce vulnerability to droughts and extreme climate, increase yields, or improve nutritional value.5By putting more focus on nutrition outcomes (i.e., by including nutrition objectives at the outset), agricultural interventions can improve the capacity, productivity, and future prospects of agricultural workers—and also contribute to reducing undernutrition.

Education: Children can’t learn and succeed in their education without a solid nutritional foundation: Good nutrition is essential for full development of cognitive and motor skills, behavioural abilities, IQ, and physical growth. Early childhood undernutrition, including poor nutrition in the womb, often results in stunting and can have permanent developmental effects on a child. Stunted children are also less likely to complete school. Studies from 79 countries show that every 10 % increase in stunting corresponds to an 8 percent drop in the proportion of children completing primary school. When education programs invest in nutrition, it improves academic achievement. One example is school feeding programs, which can improve learning and academic performance. Students participating in school feeding and take-home ration programs have improved cognition. These programs yield the greatest impact when coupled with other programs like deworming, micronutrient supplementation, and fortification. Integrating nutrition programs into school curriculum initiates life-long healthy behaviours. Children connect what they learn in school to their broader communities by bringing messages home to their families and promoting good nutrition and healthy habits in the household.

49

Table 14: Multisectoral Interventions

Indicators Baseline Target Data Source Intervention Department Scheme Resources

2019-20

2020-21

2021-22

Wash

Drinking Water

14.1: % of Anganwadi with adequate, functional and safe drinking water supply

Out of 2970 AWCs in Barpeta only 1689 AWCs have proper access to adequate, functional and safe drinking water

100%

100% 100% ICDS

Barpeta

• Categorization of AWCs based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed

• Testing of water supply at AWCs

Lead Department PHED

NRDWP Support


14.2: % of health centres with adequate, functional and

321 health centres

100%

100% 100%

• Categorization of health Centers based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made


NRDWP

50

safe drinking water supply

functional and in second phase new supplies could be installed


14.3: % of villages/wards with adequate, functional and safe drinking water supply

• Water purification units to be set up. • Workshops and trainings of village

water committee to undertake minor repair work and maintenance of water systems


NRDWP SKPY

Support Department P&RD

14.4: % of households with improved drinking water sources

97.8% (NFHS-4)

100%

100% 100% PHED

• Categorization of households based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed

• Strengthening the implementation Swatch Khuwa Pani Yojana particularly in the riverine/ char areas.


NRDWP

Sanitation

14.5: % of villages/ wards which are open defecation free

100%

100%

100% 100% PHED

• Mapping and prioritizing the left out pockets

• SBCC activities to promote usage of sanitation facilities

• Plan for maintenance of community toilets


SBM

51

• Hands on trainings on sanitation to village masons

14.6: % of Households with access to safe sanitation facilities

34.9% (NFHS 4)

100%

100% 100% PHED

• Mapping and prioritizing the left out pockets with special focus on tea garden areas

• SBCC activities to promote usage sanitation facilities


SBM

14.7: % of Anganwadi and with adequate and functional sanitation facilities

Out of 2970 AWCs in Barpeta only 1689 AWCs have proper access to adequate, functional and safe drinking water

100%

100% 100% ICDS

Barpeta

• Construction of toilets in AWCs under Swachh Bharat Mission

• Categorization of AWCs based on current status- Sanitation facility, available and functional, available but not functional and not available. In first phase dysfunctional facilities can be made functional and in second phase new facilities could be constructed

• Convergence with MGNREGA for construction and maintenance of sanitation facility


SBM MGNREGA

Support Department Social Welfare Department Education P& RD

14.8: % of schools with adequate and functional sanitation facilities 14.9: % of health centres with adequate and

321 Health facilities

100%

100% 100%

• Categorization of health centers based on current status- Sanitation facility-available and functional, available but not functional and not available. In


52

functional sanitation facilities

first phase dysfunctional facilities can be made functional and in second phase new facilities could be constructed


Personal Hygiene

14.10: % of Anganwadis with adequate and functional Hand washing facilities with water and soap available

100%

100% 100% ICDS

Barpeta

• Providing adequate supplies (soap, bucket and mugs) to every AWCs

• Hand washing posters to be demonstrated at AWCs

• Community radio to generate awareness among people

• SHGs to create awareness regarding hygiene practices at community level

• Swachhagrahis to demonstrate hygiene practices on VHSND


ICDS SHGs, AWWs Support Department

14.11: % of health centres with adequate and functional Handwashing facilities with water and soap available

100%

100% 100%

Department of Health, Barpeta

• Hand washing posters to be demonstrated at health centres


• SHGs members to be part of monitoring team in health centres


Education

14.12 % of women with 10 or more years of schooling

23.9 % (NFHS-4)

Assam Agenda 2030

• Awareness programmes through SSA • Counselling of girls parents by

members of SHGs on importance of girl education

• Improvement of sanitation facilities at schools for girls

Lead Department Education Department

SSA

53

• Addressing the root cause for high girls dropout rate

Social Causes

14.13: % of women age 20-24 years married before 18 years

43.2 % (NFHS-4)

• SHGs should be sensitised and linked to local NGOs & CBOs for creating awareness in the community for the subject

• BCC activities in the vulnerable communities like tea garden areas

• Promotion of higher education among adolescent girls

Lead Department Social Welfare Department Support Department P&RD

Livelihood 14.14: % of women with job cards who worked for 100 days in last year

• Generating awareness of MGNREGA

among women - • Strengthening of Women's participation

in Gram Sabha Planning Meeting

Lead Department P&RD

MGNREGA

Food and Nutrition Security

14.15: % of families linked with PDS

• Inclusion of all eligible families in PDS Lead Department

PDS

54

Food & Civil Supplies

55

C. Cross Cutting Strategies

Table 15: Multisectoral District Nutrition Plan (Cross Cutting Strategies)

Program Management Activities Accountability

15.1: VHSND

• Conduct regular joint VHSNC meeting by ANM,AWW for execution of health and nutrition activities

• Ensure participation of ICDS supervisors and Panchayati Raj members in the meeting

• Identify all households with pregnant women and children 0-24 months and mobilise them to attend VHNSDs

• Promote regular use of mother-child protection (MCP) card (renaming it “Mother and Child Health and Nutrition Card (MCHNC)”) for entry of data and monitoring progress as well as for counselling

Lead Role Health Department


15.2: Growth Monitoring

• Establish procurement system and ensure

functional weighing machines at all AWCs • Undertake Weight and height measurement of all

the children at regular interval – every month for children aged between 6-24 months and once in 3 months for children aged above 24 months.

• Identify SAM children with and without medical complications and actions for their management

• Organise regular training to AWWs for recording , plotting and interpretation of growth

• ICDS and health functionaries to educate, counsel and support mothers and families for optimal nutrition, healthcare and development of children

Lead Role Social Welfare Department

15.3: Quality Home Visits

• Home visit calendar of AWW, ASHA and ANM

should be planned and reviewed • Home visit tools should be designed for AAAs for

effective communication, counselling and information gathering

• AWW and ASHAS to make home visits for educating mothers and other family members to play an effective role in child’s growth and development with special emphasis on 0-24 months child.

Lead Role Social Welfare and Health Department

Part C- Cross Cutting Interventions

56

15.4: Social Behaviour Change Communication(SBCC)

• Development of SBCC strategy for the state’ • Hire a special expert team /organisation to develop

SBCC strategy and provide rollout support. SBCC support training, advocacy and communication materials to be standardised

Lead Role Health and Social Welfare Department

15.5: Human Resources

• Filling up the positions of all health and ICDS functionaries at all level

• Appointment of a consultant District Nutrition Coordinator for 5 years.

• Appointment of Block Nutrition Coordinators


15.6: Supply Chain Management

• Population based estimates for stock planning of health supplies

• Streamlining system for timely procurement of required supplies

Lead Role Concerned Department

15.7: Capacity Building

• Establishment a state Nutrition Resource Centre (SNRC) --Identification of such an institute to conduct capacity building trainings

• Training of HR team including • mid-level managers of health and ICDS

functionaries • Roll out of ILA module in local languages/

exposure visits


15.8: Monitoring Evaluation Accountability and Learning (MEAL)

• Establish an MIS system and link to SNRC for analysis of MPR and HMIS data

• Ensure inclusion of nutrition linked Multisectoral indicators in the line department monthly progress report

• Deputy Commissioner to review the status of indicators as a part of regular monitoring with health, ICDS and Multisectoral departments.

Lead Role Deputy Commissioner and heads of in line department

15.9: Knowledge Management

• Documentation of progress made and analysis of on-going best practices

• Regular dissemination of information on analysis of local data ,progress and way forward

Lead Role Concerned departments

15.10: Convergence

• Formation of convergence committee for nutrition at district and block levels

• Coordination meeting of all the line departments including Health, Social Welfare, PHED, Agriculture, Education, P&RD, Food and Civil Supplies in the presence of Principal Secretary, BTC

Lead Role Office of Commissioner

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Table 16: Summary of Interventions - Department Wise

S.No Department Intervention

Table no

1 Health Department 3.1, 3.2, 3.3, 3.4, 3.5, 5.1, 5.2, 5.3, 5.5, 5.6, 5.7, 5.8, 7.1, 7.2, 9.1, 9.2, 9.3, 9.4, 11.1, 11.2, 11.3, 11.4, 11.5, 11.7, 11.8, 11.9, 11.10, 11.11, 13.2, 14.2, 14.11, 15.1, 15.3, 15.4, 15.5, 15.7

2 Social Welfare 3.1, 3.2, 3.3, 3.4, 5.1, 5.2, 5.3, 5.4, 5.6, 5.7, 5.8, 7.1, 7.3, 9.1, 9.2, 9.3, 9.4, 11.1, 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, 13.1, 13.2, 13.3, 14.1, 14.7, 14.8, 14.13, 15.1, 15.2, 15.3, 15.4, 15.5, 15.7

3 Education 3.1, 3.2, 3.3, 3.4, 14.7, 14.12,

4 P&RD 5.1, 5.2, 5.4, 5.5, 5.6, 7.3, 11.1, 11.2, 11.5, 11.6, 14.3, 14.7, 14.13, 14.14,

5 PHED 9.3, 14.1, 14.2, 14.3, 14.4, 14.5, 14.6, 14.7,

6 Food and Civil Supplies 14.15

7 DRDA 14.14

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Annexure 1: Multisectoral framework to Reduce Malnutrition

59

Annexure 2: State Inception Workshop

The state inception workshop on improved Nutrition, Health and Early Childhood Outcomes was organised by Transformation and Development department, Government of Assam, in collaboration with Center for Sustainable Development Goals (CSDGs) and the Coalition for Food and Nutrition Security (CFNS) on 2nd of February, 2019 at Assam administrative staff college, Guwahati.

The objective of the workshop was to introduce and orient key stakeholders on Non Lending Technical Assistance (NLTA) from the World Bank to Government of Assam for improving Nutrition, Health, and Early Childhood Outcomes to accelerate SDGs in the state and to renew to the commitment for the same.

The workshop was attended by Mr. Alok Kumar, Chief Secretary, Government of Assam, Shri Jishnu Baruah, Additional Chief Secretary, Social Welfare Department, Shri Anurag Goel, Secretary, Health and Family Welfare Department, Dr. J B Ekka, Principal Secretary, Transformation & Development Department, Shri Bhaskar Barua, Former Secretary, Ministry of Agriculture, Government of India amongst other Government officials from State and Districts, Academicians, Civil society Organizations and individual experts from and outside the State.

Four technical sessions on (i)Nutrition Scenario and issues and challenges in implementation of ongoing programs- Assam, (ii) Food Security & Issues and challenges in implementation of ongoing programs – Assam, (iii) Efforts towards developing M&E: System for SDGs tracking and (iv)Eat Right India Movement were conducted during the workshop. Deliberations from each of the sessions have provided valuable inputs which have been incorporated in the plan in the form of suggested interventions.

Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition”

A Policy seminar on multisectoral convergence for improved nutrition was co-organised by CFNS and CSDGs on 25th of January, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended by Senior Government officials of Assam from Health, Education, Social Welfare and Public Health and Engineering Departments, Civil Society Organizations including UNICEF, UNDP, UN Women and Piramal Foundation and Individual Experts in the field of Nutrition.

Key recommendations that emerged from the seminar are:

• Village Health Sanitation and Nutrition Day (VHSND) to be promoted and strengthened as a platform for multisectoral convergence at village level- Ensuring the Participation of ICDS Supervisors and engagement of Panchayat members to prioritize the Nutrition Agenda

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• To promote Mother and Child Protection (MCP) Card as a counselling tool for Mothers and Family members and renaming it as “Mother and Child Health and Nutrition Card (MCHNC)”

• Local food mapping to understand the dietary practices of various communities and Promotion of Kitchen garden to ensure nutritional security at household level

• Social audit of Integrated Child Development Scheme (ICDS) and other nutrition linked schemes • Infrastructure development of health facilities to ensure privacy for Antenatal Check-ups and Child

Care ; Solar electrification of AWCs and health sub centers in char areas • Improving Mobility of ASHA Workers and ANMs in char areas by providing travel support and other

incentives – Department of Health and ICDS should ensure timely reimbursement of travel

Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes”

A Policy seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes” was co-organised by CFNS and CSDGs on 26th of February, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended by Shri. Hemen Das, Secretary Social Welfare Department, other government officials, civil society organizations and individual experts. Recommendations that emerged from the seminar are:

• Panchayats &Rural Development) and engagement of NGOs in taking forward the mission for early completion of construction of 1500 AWCs.

• “Model Anganwadi Centers” to be constructed in every district of the state by merging the funds from

MGNREGA, Social Welfare and other sources including CSR, MP/MLA area development fund, Panchayat fund, local interested persons (NRIs and others) to act as a good example for other centres to follow

. • Government Portal for creating a fund for development of Anganwadi Centers where individuals

residing in country or outside who are willing to spend money for development of their native villages can contribute

• Convergence between Integrated Child Development Scheme (ICDS) and National Crèches Scheme (NCS) in tea garden areas of Assam

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• Introduction of community radio station dedicated for creating awareness regarding importance of adolescent nutrition, nutrition and care during pregnancy; infant and young child feeding practices etc.

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Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam”

A Policy seminar on “Strengthening Complementary Feeding Practices in Assam” was co-organised by CFNS and CSDGs on 26th of March, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended Senior Government officials of Assam from Health, National Institute of Public Cooperation and Child Development (NIPCCD), Assam State Rural Livelihood Mission (ASRLM) and Social Welfare Department, Civil Society Organizations including Piramal Foundation, UNICEF, Front Line workers from ICDS, Health and ASRLM, Tea Garden Representatives for Assam Brach Indian Tea Association (ABITA), and individual experts in the field of Nutrition. Key Recommendations that emerged from the seminar are:

• Monitoring of complementary feeding practices at household level by AWWs and ASHAs- Currently the Monthly Progress Report (MPR) submitted to Anganwadi supervisor by AWW do not have provision for capturing any information related to complementary feeding practices

• Integration of Self Help Groups under Rural Livelihood Mission with ICDS and Panchayati Raj

Institution for effective delivery of Nutrition Services at AWCs and household level

• Capacity building of AWWs, ASHAs and SHGs using incremental learning modules of Poshan Abhiyaan in local languages

• Need for uniformity in the social behaviour change messages communicated to the communities –

different messages from different players for the same topic tends to confuse the people

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Annexure 6: MCP Card

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Multisectoral Result Based District Nutrition Action Plan- Udalguri District


2019-2022

65

Preface



This multi sectoral nutrition plan is based on in-depth situational analysis of current status of malnutrition in the district, based on recommendations from the Nutrition Working Group Report, outcome of 6 policy seminars held during January – June 2019 and consultations with stakeholders from department functionaries and civil society organizations. The plan suggests necessary nutritional interventions for adolescent girls (in school, out of school), pregnant women, children under 5 besides other interventions necessary for creating a healthy environment like safe drinking water, sanitation, prevention of communicable diseases, assured food supply and education. The suggested interventions if implemented meticulously will certainly bring down the high prevalence of existing malnutrition in the district. There are examples from within and outside the country where prevalence of malnutrition has been reduced drastically within a period of 10 years by adopting appropriate strategies and interventions.

We hope that implementation of strategies and interventions suggested in this Multi sectoral plan along with robust monitoring will help to achieve a “Malnutrition Free district”.

Dr. R.M Dubey

Prof and Head, CSDGs

&

Dr. Sujeet Ranjan

Executive Director, CFNS

66

Table of Contents Acknowledgements ....................................................................................................................................................... 67

The Drafting Team ........................................................................................................................................................ 67

List of Tables ................................................................................................................................................................. 68

List of Figures ................................................................................................................................................................ 69

Abbreviations ................................................................................................................................................................ 70

Executive Summary ....................................................................................................................................................... 72

1. Udalguri District Profile ....................................................................................................................................... 74

2. Conceptual Framework of Malnutrition................................................................................................................ 75

2.1 Udalguri District Problem Tree .................................................................................................................... 78

2.2 Potential Hotspot for Malnutrition ............................................................................................................... 79

2.2 Nutrition Status of Udalguri, Assam and India ........................................................................................... 80

2.3 First 1000 Days: Situation Analysis of Udalguri District............................................................................ 80

2.4 Status and Determinants of various Nutrition Indicators ............................................................................. 82

3. Objective ............................................................................................................................................................... 83

4. Methodology ......................................................................................................................................................... 83

5. Multi-sectoral Plan- the Approach, Target Groups and Parameters...................................................................... 85

6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam ...................................... 87

A. Essential Nutrition Intervention ................................................................................................................... 87

A1: Adolescent Nutrition .................................................................................................................................... 87

A2: First 1000 Days ............................................................................................................................................. 93

A2.1 Pregnant Women ........................................................................................................................................ 94

A2.2 Lactating Mothers ...................................................................................................................................... 99

A2. 3 Children Aged 0-6 months ...................................................................................................................... 101

A2.4 Children Aged 6-24 Months .................................................................................................................... 104

A3. Children Aged 24-59 Months .................................................................................................................... 109

B. Multisectoral Interventions ........................................................................................................................ 111

C. Cross Cutting Strategies ............................................................................................................................. 117

Annexure 1: Multisectoral framework to Reduce Malnutrition ................................................................................... 120

Annexure 2: State Inception Workshop ....................................................................................................................... 121

Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition” .............................................. 121

Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes” ..................................................................................................................................................................................... 122

Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam” ................................ 124

Annexure 6: MCP Card (Feeding Practices) ............................................................................................................... 124

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Acknowledgements

The Result Based Multisectoral District Nutrition Action Plan was jointly drafted by The Coalition for Food and Nutrition Security (CFNS) and Center for Sustainable Development Goals (CSDGs), Government of Assam in close coordination with all concerned departments of Udalguri district.

The team is indebted to the guidance provided by Sri Bhaskar Baruah IAS(Rtd) Former Secretary to the Government of India, Ministry of Agriculture and the member , Executive Body of CFNS through his deliberations made at various policy seminars, the recommendations of which has basically guided the plan preparation.

We are indebted to Shri Rajeev Kumar Bora (Additional Chief Secretary), Dr. J B Ekka (Principal Secretary) and the entire team of Transformation and Development Department, Govt. of Assam for their continuous guidance and support. Their suggestions put forth during deliberations in various policy seminars have served as useful inputs in preparation of this document.

CFNS and CSDGs teams would like to thank all the external contributors who have helped in preparing the plan document: Shri Jishnu Baruah IAS, Additional Chief Secretary, Shri. Hemen Das ACS, Secretary and Smt. Juri Phukan IAS, Director – Department of Social Welfare, Govt. of Assam.

The support and guidance received from the Principal Secretary, BTC and his team of Council officials at BTC secretariat as well as based in Udalguri is highly appreciated and acknowledged. Without their active cooperation and support this plan would not have seen the light of the day.

We are grateful to Mr. Dilip Kumar Das ACS, Deputy Commissioner, Udalguri District for his valuable coordination. We are also thankful to Mr. Jatin Bora ACS, ADC and all the officials of department particularly the Joint Director - Health Services & NHM team, District Agriculture Officer & team, Executive Engineer - PHED & team, District Social Welfare Officer & team, Project Director – DRDA & team, District Education Officer & team, District Program Manager - Assam Rural Livelihood Mission & team and Food & Civil Supplies Department. We also highly appreciate the support of ICDS and Health functionaries for extending their cooperation in facilitating community visits.

We would also like to thank all the Individual Experts, State Government officials and Civil Society Organizations working in the Nutrition & Health domain for their valuable inputs. We also like to thank all the members of the Nutrition working Group - Assam for their insights on nutritional scenario in districts of Assam.

The logistics and other facilities received from Assam Administrative Staff College (AASC), Khanapara provided the team a congenial atmosphere in holding workshops/seminars/trainings etc. the contribution and support from Sri M.K Deka IAS, Director, AASC is highly acknowledged.

Lastly the support received from the World Bank in the form of NLTA is also acknowledged.

The Drafting Team

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The Result Based Multisectoral District Nutrition Action Plan has been drafted jointly by the following officials with the Coalition for Food and Nutrition Security (CFNS) and the Center for Sustainable Development Goals (CSDGs).

Centre for SDGs

3. Dr. R.M Dubey : Prof. and Head, Centre for SDGs 4. Shri J.C Phukan : Consultant, Centre for SDGs

Coalition for Food and Nutrition Security

4. Dr Sujeet Ranjan : Executive Director, Coalition for Food and Nutrition Security 5. Ms. Akanksha Doval : Knowledge Management Coordinator 6. Mr. Farhad Hussain : Program Coordinator

List of Tables

69

Table 1: Malnutrition Indicators (NFHS 4 Data) ............................................................................ 82 Table 2: Udalguri Population Projection for Adolescents aged 10-19 Years ................................. 89 Table 3: Essential Nutrition Interventions-Adolescent Nutrition ................................................... 89 Table 4: Udalguri Population Projection for Pregnant Women ...................................................... 94 Table 5: Essential Nutrition Interventions-Pregnant Women ......................................................... 94 Table 6: Udalguri Population Projection for Lactating Mothers .................................................... 99 Table 7: Essential Nutrition Interventions - Lactating Mothers ..................................................... 99 Table 8: Udalguri Population Projection of Children aged 0-6 months ....................................... 101 Table 9: Essential Nutrition Interventions - Children aged 0-6 months ....................................... 101 Table 10: Udalguri Population Projection for Children aged 6-24 Months and 12-23 Months ... 104 Table 11: Essential Nutrition Interventions -Children aged 6-24 Months .................................... 104 Table 12: Udalguri Population Projection for Children aged 24-59 Months ................................ 109 Table 13: Essential Nutrition Interventions - Children aged 24-59 Months ................................. 109 Table 14: Multisectoral Interventions ........................................................................................... 112 Table 15: Multisectoral District Nutrition Plan (Cross Cutting Strategies) .................................. 117 Table 16: Summary of Interventions - Department Wise ............................................................... 57

List of Figures

70

Figure 1: Udalguri District Map.................................................................................................................... 75 Figure 2: Udalguri Problem Tree .................................................................................................................. 78 Figure 3: Total literacy rate <=60 ................................................................................................................. 79 Figure 4: Villages with more than 50% of HH where source of Drinking water is away from HH ............. 79 Figure 5: Comparative Analysis of Nutrition status - Udalguri, Assam and India ....................................... 80 Figure 6: Performance in indicators of Pregnant Women ............................................................................. 81 Figure 7: Performance in indicators of Children........................................................................................... 81

Abbreviations

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ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist ASRLM Assam State Rural Livelihood Mission AWC Anganwadi Center AWW Anganwadi Worker AAY Antyodaya Anna Yojana BCC Behaviour Change Communication CBO Community based Organization CSR Corporate Social Responsibility CSDG Center for Sustainable Development Goals CFNS Coalition for Food and Nutrition Security HBNC Home Based New-born Care JSY Janani Suraksha Yojana FLW Front Line Workers IEC Information Education and Communication ICDS Integrated Child Development Scheme IFA Iron and Folic Acid IYCF Infant and Young Child Complementary Feeding MAA Mother’s Absolute Affection MAM Moderate Acute Malnutrition MDM Mid-Day Meal MGNREGA Mahatma Gandhi National Rural Employment Guarantee Act MT Million Tonne NRDWP National Rural Drinking Water Programme NGO Non-Government Organization NHM National Health Mission NIPI National Iron Plus Initiative NRC Nutrition Rehabilitation Center NFHS 4 National Family Health Survey (2015-16) PDS Public Distribution System PHED Public Health Engineering Department PHC Public Health Center PMFBY Pradhan Mantri Fasal Bima Yojana PMMVY Pradhan Mantri Matritva Vandana Yojana PRI Panchayati Raj Institution PW Pregnant Women RKVY Rashtriya Krishi Vikas Yojana SAM Severe Acute Malnutrition SAG Scheme for Adolescent Girls SBA Skilled Birth Attendant SBCC Social Behaviour Change Communication SBM Swachh Bharat mission SECC Socio Economic Caste Census SHG Self Help Group SNP Supplementary Nutrition Program

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Executive Summary

SSA Sarva Siksha Abhiyaan THR Take Home Ration VHSND Village Health Sanitation and Nutrition Day WIFS Weekly Iron and Folic Acid Supplementation

73

The multisectoral district nutrition action plan for Udalguri district has been prepared as a part of work envisaged under developing multisectoral plan for three aspirational districts of Assam, out of non-lending technical support received from the World Bank. For preparation of this multisectoral nutrition plan the World Bank engaged Coalition for Food and Nutrition Security for providing technical assistance to the Centre for Sustainable Development Goals and this plan is the outcome of joint efforts of both these organizations.


Section 1of the plan gives a brief profile of Udalguri District from Census 2011.

Section 2 covers the conceptual framework of malnutrition. The section includes a problem tree of Udalguri which shows the problem of malnutrition in the form of a tree highlighting the immediate, underlying and root causes behind the problem and various manifestations in the form of stunting, wasting, underweight and anaemia. The problem tree is based on NFHS 4 data of 2015-16. This section also compares the nutritional status of Udalguri district with that of Assam and India. It also shows the performance of Udalguri district in first 1000 days from conception till child’s two years of age and compares the performance of district in first 1000 days with that of state average and best performing district in state for respective parameters.

Section 3 covers the objectives behind the result based multisectoral plan. The objective behind this result based multisectoral district nutrition action plan is to study in depth the reasons behind the high prevalence of malnutrition in the district and key challenges before the district administration.

Section 4 describes in details the methodology adopted in preparation of this plan. The plan is the outcome of research and analysis conducted during the period of six months (Jan- to June 2019). Feedback was sought from district officials of the concerned departments and nutrition experts.


Section 6 is the main result based multisectoral district nutrition action plan for accelerating the progress of SDGs 2 and 3 in the district. The action plan for each of the parts, as mentioned in section 4, has been dealt in detail section wise. For each of the parts A, B the following details are included in a tabular form –proposed indicators, targets for three years (2019-2022), recommended interventions, the lead and support department to executing the stated interventions and intervention related schemes being implemented by the Government of Assam.


In part B of the plan, details of multi-sectoral interventions to be dealt is long term for addressing underlying and root causes of malnutrition, including water, sanitation and personal hygiene; education, social causes, women’s empowerment and food security are presented.

74

Part C of the plan details the cross cutting strategies like strengthening of community based events like VHSND, growth monitoring of children at AWCs, organising quality timely home visits by frontline workers, supply chain management and social behaviour change communication strategies.

The persistent problem of malnutrition in the district is proposed to be tackled by ICDS and health sectors jointly giving lead for accelerating improvement in indicators pertaining to essential nutrition interventions in first 1000 days of life and critical maternal child health services. Highest priority has been accorded in the plan to households having a woman member who is pregnant or having a child 0-24 months. Additionally, using the life cycle approach, the existing policies for care of pre-school children, school children, and adolescent girls need to be vigourosly implemented. Moreover, for addressing the intermediate and underlying causes of undernutrition, other sectors such as PHED, Social Welfare, Education, Panchayat and Rural Development, Food and Civil Supplies Department need necessarily to be involved in a big way.

6. Udalguri District Profile

Udalguri district is one of the seven aspirational districts of Assam with Udalguri town as the district headquarters. The district is situated in the central part of Assam, on the northern side of the mighty river Brahmaputra. The district is bounded by Bhutan and Arunachal Pradesh in the north, Sonitpur district in the east, Darrang district in the south and Baksa district in the west. Udalguri was a sub-

75

divisional headquarters in Darrang district. But after signing of the Bodo Accord an Autonomous Territory called the Bodoland Territorial Autonomous District (BTAD) was created and Udalguri district became one of the four districts under the BTAD. The new district was formally inaugurated on 14th June, 2004.

Figure 8: Udalguri District Map

Udalguri District at a Glance (Census 2011) Total Population 8.31 lakhs Total Geographical Area 2012 square km Male (%) 50.60% Population Density 413 persons/square km Female (%) 49.40% Sex Ratio 973 Rural (%) 95.48 Child Sex Ratio 972 Urban (%) 4.52 Revenue Villages 802 General Population (Non SC ST) (%) 63.19 Infant Mortality Rate (IMR) 70 SC Population (%) 4.67% Maternal Mortality Rate (MMR) 254 ST Population (%) 32.14% Literacy Rate 65.41% Hindu Population (%) 73.64% Women Literacy Rate 58.05% Muslim Population (%) 12.66% Christian Population (%) 13.25% Others (%) 0.27%


UNICEF’s (1990) conceptual framework of the causality of child malnutrition illustrates the multisectoral nature of the problem. The immediate determinants of malnutrition at the individual level (inadequate dietary intake and disease) are products of underlying causes at the family or household level (insufficient access to food, inadequate maternal and child practices, poor water

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and sanitation, and inadequate access to quality health services). These, in turn, are influenced by basic causes at a societal level, including the quality and quantity of human, economic, and organizational resources and political environment.

The problem tree of Udalguri district in the following section 2.1 highlights the conceptual framework of malnutrition in women and children. Malnutrition is manifested in the form of stunting, wasting, underweight, anaemia and low BMI in women. These outcomes are influenced by a set of immediate causes (nutrition specific) and underlying causes (nutrition sensitive) intervention.


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78

7.1 Udalguri District Problem Tree

Figure 9: Udalguri Problem Tree

Source: NFHS 4

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2.2 Potential Hotspot for Malnutrition

Source: Census 2011

Figure 10: Total literacy rate <=60

Figure 11: Villages with more than 50% of HH where source of Drinking water is away from HH

Figure 3 and Figure 4 depicts the potential hotspot for malnutrition in the Udalguri district, according to Census 2011 data. Though the prevalence may be different now but the data still can be used to identify relatively poor performing pockets.

• The maximum concentration of illiteracy and drinking water facility, far away from the source coincide in Harisinga, Udalguri and Mazbat blocks as shown in red


In the absence of segregated data on malnutrition, during the field work an attempt was made to identify malnutrition pockets in the district based on indirect evidences and for the purpose pockets of high illiteracy and poor source of safe drinking water was identified. As can be seen from the figures below the pockets more or less coincide with each other. The pockets where illiteracy is high and the drinking water facility in not adequate indicate towards high prevalence of malnutrition. These are the pockets with high prevalence of poverty and hence high prevalence of malnutrition. In order to improve district’s nutritional indicators it is important to focus on these pockets with priority.

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7.2 Nutrition Status of Udalguri, Assam and India

Figure 12: Comparative Analysis of Nutrition status - Udalguri, Assam and India

7.3 First 1000 Days: Situation Analysis of Udalguri District

Figure 4 and 5 indicates the performance of Udalguri district in the first 1000 days from conception till child’s 2 years of age. Figure 4 indicates the performance of district across various indicators related to the care of pregnant mother while figure 4 shows the performance of district in indicators related to child care. The figures also helps in comparing the performance of Udalguri districts with that of State average and best performing districts in respective parameters.

% Stunting U5 % Wasting U5 % Severely Wasting U5 % Underweight U5Udalguri 39.1 18.3 8.1 31.8Assam 35.3 16.1 5.9 28.1India 38.4 21.0 7.5 35.7

0.05.0

10.015.020.025.030.035.040.045.0

Comparitive Analysis

Udalguri Assam India

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Figure 13: Performance in indicators of Pregnant Women


0

20

40

60

80

100ANC in first trimester (%)

At least 4 ANC Visit (%)

FULL ANC (%)

Protection Against NeonatalTetanus (%)

IFA Consumption for 100days or more (%)

Mothers having MCP Card(%)

Institutional Delivery (%)

Financial Assistance UnderJSY (%)

Pregnant Women

Assam Udalguri State Best Performance

0

20

40

60

80

100

Breastfeeding within 1 hourof birth

Exclusive Breastfeeding upto6 months

Adequate Diet (6-23 months)Full Immunization (12-23Months)

Vitamin A dose in last 6months (9-59 months)

Children

Assam Udalguri State Best Performance

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7.4 Status and Determinants of various Nutrition Indicators

The table 1 below shows the indicators of malnutrition for India, Assam, Udalguri District and best performing district of Assam in respective indicators.


All figures in table 1 are in percentage (%)

Indicators India Assam Udalguri State Best Performance

Stunting Under 5 38.4 35.3 39.1 24.6 (Kamrup Metro)

Wasting Under 5 21 16.1 18.3 6.2 (Dhemaji)

Severely wasting Under 5 7.5 5.9 8.1 0.8 (Dhemaji)

Underweight Under 5 35.7 28.1 31.8 15.8 (Dhemaji)

Pregnant Women having ANC in first trimester 58.6 55.1 45.2 82 (Jorhat)

Pregnant Women having at least 4 ANC visit 51.2 46.4 37 75.8 (Jorhat)

Pregnant Women receiving Full ANC Care 21 18.1 13.3 48 (Jorhat)

Pregnant Women Consuming IFA for 100 days or more 30.3 32 29.9 63.3 (Jorhat)

Mothers receiving financial assistance under JSY for

institutional Delivery 36.4 66.1 77.1 90.2 (Dhemaji)

Mothers whose last birth was protected against neonatal TT 89 89.8 94.4 97.1 (Sonitpur)

Mothers having mother and child protection (MCP) card 89.3 98.6 96.3 99.3 (Nalbari)

Women age 20-24 years married before age 18 years 26.8 30.8 28.6 18.5 (Cachar)

Women age 15-19 years who were already mothers or pregnant at

the time of the survey 7.9 13.6 10.8 7 (Sonitpur)

Women who are literate 68.4 71.8 66.6 84.3 (Kamrup M)

Women having 10 or more years of Schooling 35.7 26.2 21.2 48.2 (Kamrup Metro)

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Institutional Births 78.9 70.6 72.2 95.9 (Jorhat)

Breastfed within 1 hour of birth 41.6 64.4 80.5 80.5 (Goalpara and Udalguri)

Exclusive Breastfeeding upto 6 months 54.9 63.5 70.3 86.2 (Tinsukia)

Children receiving adequate diet 8.7 8.7 3 13.8 (Sivsagar)

Full Immunization 62 47.1 52.8 73 (Sivsagar)

Vitamin A supplementation in Last 6 months 60.2 51.3 61.3 67.6 (Karimganj)

8. Objective

The objective behind this result based multisectoral district nutrition action plan is to study in depth the reasons behind the high prevalence of malnutrition in the district and key challenges before the district administration. This multisectoral plan will ensure strong nutrition focus through institutional and programmatic convergence by integrating it in the planning, implementation and supervision process in all relevant direct and in-direct interventions and programs.


9. Methodology

The district nutrition action plan for Udalguri district, Assam is drafted by the Coalition for Food and Nutrition Security (CFNS) in collaboration with Center for Sustainable Development Goals (CSDGs), Government of Assam. The documents is based on desk research and analysis in the last five months, views of district officials of the concerned departments and public health nutrition and development experts, The details are summarised below.

• Review of strategic plans and similar planning documents: The team reviewed the framework of Poshan Abhiyaan for multisectoral district planning, relevant indicators from NFHS4 and similar planning documents like multi-sectoral district nutrition plan from Dungarpur district, Rajasthan, Aspirational District Plan for Udalguri district, Assam Agenda 2030 of Transformation and Development department, Government of Assam, were also referred to decide on the indicator matrix for the plan. The matrix designed is based on the life cycle approach to address malnutrition with special focus on first 1000 days of life.

• Community Visit: Team visited five diverse villages of Udalguri district- Orangajuli Tea

Estate, Tokankata village, Shikari Danga Village, Udalguri Nepali Gaon, and Machkunti

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village. The visit was undertaken with the objective to understand the status of various services linked to the nutrition like Health, Water and Sanitation, Education and to gain insights into the socio cultural practices and beliefs of people. Extensive focused group discussions were conducted with the Mother’s group (pregnant and lactating mothers), Adolescent girls’ group, and frontline workers of ICDS and Health sectors (AWWs and ASHAs). Team also visited various AWCs and Creches particularly in tea garden areas of the district to understand their functioning and status of various services.

• Interviews with officials of selected government departments: These interviews

provided an opportunity to understand the challenges of the work of each of the concerned department and to complement the information garnered from the community visit and strategic documents.

• State and District Inception Workshops: The state and district inception workshops were conducted on 2nd Feb and 5th January respectively. Experts from various fields and very senior officers from the government including Chief Secretary, Assam participated in State inception workshop and presented their views on district nutrition plan.

• Policy Seminars: Six policy seminars on various topics related to nutrition were conducted

in Assam in the period from Jan-2019 to June 2019. Each of the policy seminar was attended by top government officials, individual experts, civil society organizations and field level executives. Feedback from the seminars was considered for drafting the multisectoral nutrition plan.


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10. Multi-sectoral Plan- the Approach, Target Groups and Parameters





Pregnant Women ANC Care Iron and Calcium Supplementation Deworming Supplementary Nutrition/Take Home Ration ()Family Planning Counselling Weight& Height Measurement- BMI (for weight gain during pregnancy)

Lactating Mothers

Institutional Delivery Support for Early initiation of breastfeeding Home Delivery by SBA IFA tablets Calcium tablets ICDS Supplementary Nutrition /Take Home Ration Family Planning Services

0-6 Months Child

Low Birth Weight Care/ Kangaroo Mother Care Continuation of Breastfeeding &Exclusive Breastfeeding Diarrhoea Management (ORS, Zinc and access to safe drinking water and sanitation facility) Care / feeding during illness Weight/ Height Monitoring


Timely Initiation of Complementary Feeding Appropriate Complementary feeding (Dietary Diversity, appropriate Feeding Frequency and adequate density ) Vitamin A and IFA Supplementation Full Immunization Deworming (as per guidelines)

86

Supplementary Nutrition (THR of ICDS)SAM and MAM Management



Part B of the plan covers multisectoral interventions that address underlying and root causes of malnutrition. While implementing a multisectoral plan, priority should be given to essential nutrition interventions and it is only after ensuring their implementation, the district should plan to implement long term multisectoral interventions. Part C of the plans outlines cross cutting strategies for system strengthening.












Food Security


PART C- System Strengthening Intervention

87

Cross Cutting Strategies


D. Essential Nutrition Intervention Essential nutrition interventions or programs address the immediate determinants of malnutrition and child development – adequate food and nutrient intake (diets).Additionally, adequate health/prevention of diseases and is also included since maternal child health interventions are critical for addressing immediate determinants of malnutrition. The interventions are presented using different stages of life cycle—adolescent girls, pregnant and lactating women children 0-6 months, 6-24 months and 24-59 months. The plan recognizes and accords highest attention to the first 1000 days of life—from conception to 24 months of age.





The foundation of adequate growth and development is laid before birth, during early childhood, and in during adolescence. Early marriage and conception below 18 years adversely impacts on women gaining optimum height. In Udalguri District 28.6 % girls are married before 18 years of age and 10.8% of women aged 15-19 years are already mothers (NFHS 4).



88

89

Table 18: Udalguri Population Projection for Adolescents aged 10-19 Years

Base Population (Census 2011) -90772; Average Annual Growth Rate - 0.976%

Table19: Essential Nutrition Interventions-Adolescent Nutrition


Source* Interventions Department Scheme Resources

2019-20

2020-21

2021-22

3.1: % of adolescent 10-19 years covered with Albendazole in the first round in February and



health centers/sub centers one month


Anemia Mukt Bharat

Mobile Block Health Team at PHC level to cover the


Total Number of Adolescents 10-19 Years 198,012 199,945 201,897 Total Number of Adolescent Girls aged 10-19 Years 99,006 99,973 100,948

90

second round in August each year

prior to the biannual dates fixed for Albendazole distribution




• Dissemination of IEC material to all schools/juniors college



• Micro plan to include strategy for reaching out to out of school children by ASHA and AWW

• Ensuring a fixed day distribution of Albendazole to out of school adolescents at AWCs



(MoHFW,2018)

schools Nodal teachers

91

3.2: % of adolescent girls 10-19 years screened for anaemia(school going +non-school going ) (throughout the year)

School Going Adolescents • Mapping and inclusion of private schools,

Government schools and junior colleges • Regular screening (at least twice a year)

for anaemia by teachers/ mobile block health team for school going adolescent



• Regular screening (at least twice a year) for anaemia by AWWs/ mobile block health teams at AWCs for out of school adolescent

Lead Department Education, Health Department WIFS

RBSK ICDS SAG- (out of school adolescent girls)

Mobile Block Health Teams ANMs, ASHAs and 1065 ASHAs

Support Department Social Department Education Department

3.3: % of eligible adolescents 10-19 years who receive at least 4 blue iron folate tablets

• Ensuring Weekly distribution of IFA tablets with special focus on

schools in tea garden areas • Teachers and AWWs to ensure

consumption of IFA tablets for school going adolescent and out of school adolescent girls respectively.




1065 ASHAs, 1439 AWWs Nodal Teachers


92

3.4: % of adolescent 10-19 years whose BMI is below normal

Besides IFA and Deworming following interventions should be ensured: • Promote nutrition, health and sanitation

education at schools and AWCs • Regular health camps for adolescent girls

for measuring BMI followed by counselling sessions





3.5: % of newly wed adolescent girls who have received family planning counselling

• Ensure tracking of the newly wed girls by ASHAs with the help of AWWs





93

A2: First 1000 Days



94

A2.1 Pregnant Women

Table 20: Udalguri Population Projection for Pregnant Women

Base Population (Census 2011) - Birth Rate 20.5, Total Population 8.3 lakhs; Average Annual Growth Rate - 0.976% (Number of Pregnant Women is estimated 10% more than expected live births)

Population Projection 2019-20 2020-21 2021-22 Number of Pregnant Women 20,296 20,494 20,694

Table 21: Essential Nutrition Interventions-Pregnant Women


2019-20

2020-21

2021-22

5.1: % of PW who had full Antenatal care ( 4 ANC, at least 1 TT, IFA tablet or syrup for more than 180 days)

13.3% (NFHS-4) 40% 60 % 75%








ICDS NHM ASRLM

1065 ASHAs, ANMs 1439 AWWs 5000 SHGs

Support Department Social Welfare Department P&RD (ASRLM)

95

• Organise ANC sessions on 9th of every month as per the PMSMA policy of NHM Pregnant women to be weighed and weight to be entered in MCP card and weight gain should be encouraged as per BMI based guidelines

5.2:Out of total ANC registered , % registered within 1st trimester(within 12 weeks)

45.2%(NFHS-4) 95% 98% 100%







ICDS, PMMVY

1065 ASHAs, 1439 AWWs

Support Department Social Welfare Department P&RD(ASRLM)

5.3:Out of total ANC registered , % registered within 1st

45.2%(NFHS-4) 95% 98% 100%




ICDS, PMMVY

1065 ASHAs, 1439 AWWs

96

trimester(within 12 weeks)

• AWWs to ensure 100% registration of pregnant women


Health Department

5.4:% of PW registered who received 21 days of SNP in last month and have access to diversified food through home stead food production

• Ensuring Regular supply of THR • Ensuring supply of readymade nutri






ICDS P&RD (ASRLM)


P&RD(ASRLM)

5.5:% of eligible pregnant women who received at least 180 IFA tablets during the Antenatal period

• Regular screening for anaemia levels of PW at health centers / VHSND




ICDS ASRLM



97



• Capacity building of SHGs to engage

them in Jan Andolan activities for promoting consumption of IFA.



5.6: % pregnant women who consumed 360 calcium tablets during pregnancy

• Ensuring adequate availability (based projected population of PW) of calcium tablet supplies at health centers and sub centers.





NHM ICDS ASRLM

1065 ASHAs, 1439 AWWs 5000 SHGs

Support Department Social Welfare Department P&RD

98


5.7: % of PW who were given one Albendazole tablet after 1st trimester

• Adequate number of tablets to be made available at all health facilities providing ANC



Lead Department Health Department ICDS,

NHM 1065 ASHAs, 1439 AWWs Support


5.8: % of children with low birth weight (< 2.5 kg)

10% 8% 5% Aspirational District Action Plan



• Care and day rest during pregnancy • Ensure reduction in physical drudgery

and domestic violence with help of SHGs


NHM ICDS,

ASHAs and ANMs Support



99


Table 22: Udalguri Population Projection for Lactating Mothers

Base Population (Census 2011); Birth Rate – 20.5, Total Population – 8.3 lakhs; Average Annual Growth Rate - 0.976% (Number of lactating mothers are estimated same to be as number of expected live births)

Population Projections 2019-20 2020-21 2021-22 Number of Lactating Mothers (0-6 Months) 8,580 8,664 8,748

Table 23: Essential Nutrition Interventions - Lactating Mothers


2019-20

2020-21

2021-22

7.1: % of institutional deliveries in the last month

72.2%(NFHS-4) 76% 86% 96%


• ANM, ASHAs, AWWs to mobilise and support PW for institutional deliveries






ICDS, NHM, ASRLM

1065 ASHAs, 1439 AWWs, ANMs, 5000 SHGs, Trained staff at each health center level


100

• Engagement of SHGs to promote the importance of institutional deliveries

7.2: % of deliveries at home attended by skilled birth attendant(Doctor, nurse, LHV, ANM, Other health personnel)

3.2%(NFHS-4) 61% 71% 81%



Lead Department

Health Department

HBNC

7.3: % of lactating mothers received 21 days of SNP(THR) in last month

• Ensuring Regular supply of THR • Ensuring safe and hygienic storage of




ICDS, ASRLM

AWWs SHGs Support

Department P&RD


101

A2. 3 Children Aged 0-6 months

Table 24: Udalguri Population Projection of Children aged 0-6 months

Base Population (Census 2011) 0-6 Years Population – 1.13 lakhs; Average Annual Growth Rate - 0.976%

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 0-6 Months 8,580 8,664 8,748




2019-20

2020-21

2021-22

9.1: % of children initiated breastfeed within one hour birth

80.5%(NFHS-4)

100%

100%

100%



• AWW to support early initiation of breastfeeding in home deliveries

• No marketing of Infant formula • Lactation Management Training to

the SBAs • Ensure early initiation of Breast

Feeding in100% institutional deliveries




ASHAs, ANMs, AWWs, Health Centers


102


9.2: % of children under 6 months exclusively breastfed

70.3%(NFHS-4)


• Every immunisation contact should be utilised for breastfeeding counselling and assessing status.

• 10 steps to breastfeeding to be displayed in every health centres/ VHSND forums.


• ANMs/ ASHAs to provide breastfeeding counselling during VHSND and ANC check ups

• Support for breastfeeding to working mothers in areas like tea garden areas


NHM, MAA

ANMs, ASHAs, AWWs


9.3: % of children 0-60 months with diarrhoea in the last two weeks who received ORS and Zinc

70% 100%

100%



• VHSND to be used for creating knowledge about diarrhoea management and preparation of ORS and minimum 14 days consumption of zinc tablets.


NHM PHED

ANMS, ASHAs Support


103


• Demonstration on VHSNDs regarding regular hand washing with soap before cooking and eating

• Ensuring the coverage of safe drinking water facility

• Promote the usage of sanitation toilets

PHED

9.4: % of Children 0-60 months that have their weight measured, monitored(entered in growth chart) every month in the last quarter

• Weighing machine to be made available at all AWCs/VHSND forums for regular weight and height measures,

• Trainings of all AWWs and ASHAs on weight measurement and plotting

• Counselling on promotion of mothers by AWWs with the help of ASHAs on importance of growth monitoring

• Prioritised home visits to children whose growth have faltered by AWWs and ASHAs

• Identification of children suffering from severe acute malnutrition (SAM) and taking appropriate actions.





104


Table 26: Udalguri Population Projection for Children aged 6-24 Months and 12-23 Months

Base Population (Census 2011) 0-6 Years Population -1.13 lakhs; Average Annual Growth Rate - 0.976%

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 6-24 Months 30,905 31,207 31,512 Number of Children aged 12-23 Months 17,160 17,327 17,496




2019-20

2020-21

2021-22

11.1: % of children who were initiated complementary feeding(Solid or semi- solid food and breast milk) after 6 months

• Organize Annaprasanna Diwas once in a month in AWCs to promote complementary feeding and demonstrate healthy recipes




Lead Department Social Welfare Department ICDS

NHM


Health Department Support Department

105

• Undertake regular home visits for counselling on complementary feeding at home level by ASHAs, as per the policy on Home Based Care in Young Children, NHM




Assam RLM P&RD

11.2: % of children consuming at least 4+ food groups





Lead Department Health P&RD Social Welfare department

ICDS, ASRLM AWWs, SHGs


11.3: % of children (9-24months) who received at least one dose of

61.3% (NFHS-4)



NHM ICDS

AWWs, ASHAs

106

vitamin Ain the preceding 6 months

• Institutional Bi-annual distribution of Vitamin-A on two fixed months, 6 months apart from each other




11.4: % children 6-24 months provided (IFA) syrup (Bi weekly) in the preceding month



• Ensuring mechanism for distribution of syrup to mothers during VHSNDs by ANM/ASHAs


Anemia Mukt Bharat

AWWs, ASHAs Support

Department Health

11.5: Children age 12-23 months fully immunized (BCG, measles, and 3 doses each of polio and DPT) (%)

52.8%(NFHS-4) 98% 99% 100

%

Aspirational District Action Plan.

• ASHA to get list of children to be fully immunised from AWW

• Home visits by ASHAs to follow up for mobilizing caregivers for attending immunization sessions.




NHM, ICDS, ASRLM

ASHAs, AWWs and SHGs


107


• Scaling up eVIN



• Regular supply of THR to ICDS and weekly supply to children

• Capacity building of SHGs to take up THR including eggs for all as a micro finance activity

Lead Department Social Welfare department ICDS AWWs,

SHGs Support Department P&RD

11.7: % of children 6-36 months screened for MAM and SAM during last month


SAM cases

Lead Department Social Welfare Department ICDS,

NHM



11.8: % of children with MAMthat receive



ICDS, NHM

AWWs, ASHAs

108

appropriate interventions at community level



11.9: % of children with SAM and medical complications treated at Nutrition Rehabilitation Centres (NRCs)





dietician/ nutritionist, nurses, cook and helpers) to gain proper techniques and skills


ICDS, NHM

AWWs, ASHAs Support


11.10: % of children with SAM and without medical complications treated at community level



through food demonstration and preparation

• Promotion of kitchen garden to ensure household level food security

• Capacity building of primary caregiver to look after the child at home



11.11: % of children (6-24 months) who

• Ensuring adequate Albendazole supply Lead Department

ICDS WIFS

109

received Albendazole

• Maintenance of track sheet to ensure every child receives the due 6 monthly dosages

• Dissemination of IEC material to community centres

Social Welfare




Table 28: Udalguri Population Projection for Children aged 24-59 Months

Base Population (Census 2011) 0-6 Years population -1.13 lakhs; Average Annual Growth Rate - 0.976%

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 24-59 Months 84,136 84,957 85,787




2019-20

2020-21

2021-22

13.1: % of children (24-59months)

61.3% (NFHS-4)

• Organising biannual administration of vitamin A supplements

Lead Department

NHM ICDS

AWWs, ASHAs

110

who received Vitamin A

• AWW to prepare due lists of children with the help of ASHA and ANM

• Left out children to be given doses on VHSND


Social Welfare Department

Support Department

13.2: % children 24-59 months provided (IFA) syrup (Bi weekly) in last month






Support Department Heath Department







111

E. Multisectoral Interventions

Multisectoral interventions or programs address the underlying and basic determinants of malnutrition these include measures for improving food security and diet diversity; access to potable water, sanitation facilities and a safe and hygienic environment. The maternal-child health interventions are included in section A since nutrition and health are immediate determinants of malnutrition and are interrelated.




Agriculture: Research in India has shown that increased crop diversification improves dietary diversification in the home and helps children recover from growth faltering. As agricultural production grows and diversifies, households experience increased food security and better nutrition, leading to increases in human capital and productivity. Diversified agricultural production has the potential to improve access to more diverse and nutritious foods, a key component of meeting the “Minimum Acceptable Diet” for children. Agricultural programs that focus on producing energy-rich staple foods can also be more effectively designed to reduce undernutrition by promoting crops that reduce vulnerability to droughts and extreme climate, increase yields, or improve nutritional value.5By putting more focus on nutrition outcomes (i.e., by including nutrition objectives at the outset), agricultural interventions can improve the capacity, productivity, and future prospects of agricultural workers—and also contribute to reducing undernutrition.

Education: Children can’t learn and succeed in their education without a solid nutritional foundation: Good nutrition is essential for full development of cognitive and motor skills, behavioural abilities, IQ, and physical growth. Early childhood undernutrition, including poor nutrition in the womb, often results in stunting and can have permanent developmental effects on a child. Stunted children are also less likely to complete school. Studies from 79 countries show that every 10 percent increase in stunting corresponds to an 8 percent drop in the proportion of children completing primary school. When education programs invest in nutrition, it improves academic achievement. One example is school feeding programs, which can improve learning and academic performance. Students participating in school feeding and take-home ration programs have improved cognition. These programs yield the greatest impact when coupled with other programs like deworming, micronutrient supplementation, and fortification. Integrating nutrition programs into school curriculum initiates life-long healthy behaviours. Children connect what they learn in school to their broader communities by bringing messages home to their families and promoting good nutrition and healthy habits in the household.

112



2019-20

2020-21

2021-22

Wash

Drinking Water

14.1: % of Anganwadi with adequate, functional and safe drinking water supply

100%

100% 100% District

Office

• Categorization of AWCs based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed



NRDWP Support


14.2: % of health centres with adequate, functional and safe drinking water supply

• Categorization of health Centers based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed


NRDWP Support Department Health Department

113

14.3: % of villages/wards with adequate, functional and safe drinking water supply

802 802 802 District Office

• Water purification units to be set in labour lines of tea gardens under SKPY

• Workshops and trainings of village water committee to undertake minor repair work and maintenance of water systems


NRDWP SKPY


14.4: % of households with improved drinking water sources

100%

100% 100% PHED

• Categorization of households based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed

• Strengthening the implementation Swatch Khuwa Pani Yojana in tea garden areas with the help of tea garden management


NRDWP

Sanitation

14.5: % of villages/ wards which are open defecation free

802 802 802 District Office

• Mapping and prioritizing the left out pockets





SBM

114

14.6: % of Households with access to safe sanitation facilities

53.8% (NFHS 4)

100%

100% 100% PHED

• Mapping and prioritizing the left out pockets with special focus on tea garden areas



SBM

14.7: % of Anganwadi and with adequate and functional sanitation facilities 100

% 100% 100% District

Office

• Construction of toilets in AWCs under Swachh Bharat Mission




SBM MGNREGA


14.8: % of schools with adequate and functional sanitation facilities

14.9: % of health centres with adequate and functional sanitation facilities

• Categorization of health centers based on current status- Sanitation facility-available and functional, available but not functional and not available. In first phase dysfunctional facilities can be made functional and in second phase new facilities could be constructed



115

Personal Hygiene

14.10: % of Anganwadis with adequate and functional Hand washing facilities with water and soap available

100%

100% 100% District

Office

• Providing adequate supplies (soap, bucket and mugs) to every AWCs






ICDS SHGs, AWWs Support Department

14.11: % of health centres with adequate and functional Handwashing facilities with water and soap available

• Hand washing posters to be demonstrated at health centres




Education

14.12: % of women with 10 or more years of schooling

21.2% (NFHS-4)

23.90% 36%

Assam Agenda 2030

• Awareness programmes through SSA • Counselling of girls parents by

members of SHGs on importance of girl education

• Improvement of sanitation facilities at schools for girls

• Addressing the root cause for high girls dropout rate


SSA

Social Causes

116

14.13: % of women age 20-24 years married before 18 years

28.6% (NFHS-4)




Lead Department Social Welfare Department Support Department P&RD

Livelihood

14.14: % of women with job cards who worked for 100 days in last year

• Generating awareness of MGNREGA

among women - • Strengthening of Women's participation

in Gram Sabha Planning Meeting

Lead Department P&RD DRDA

MGNREGA


14.15: % of families linked with PDS

• Inclusion of all eligible families in PDS

Lead Department Food & Civil Supplies

PDS

117

F. Cross Cutting Strategies


Program Management Activities Accountability

15.1: VHSND

• Conduct regular joint VHSNC meeting by ANM,AWW for execution of health and nutrition activities




Lead Role Health Department


15.2: Growth Monitoring

• Establish procurement system and ensure

functional weighing machines at all AWCs • Undertake Weight and height measurement of

all the children at regular interval– every month for children aged between 6-24 months and once in 3 months for children aged above 24 months.





15.3: Quality Home Visits

• Home visit calendar of AWW, ASHA and ANM

should be planned and reviewed • Home visit tools should be designed for AAAs for

effective communication, counselling and information gathering

• AWW and ASHAS to make home visits for educating mothers and other family members to play an effective role in child’s growth and



118

development with special emphasis on 0-24 months child.

15.4: Social Behaviour Change Communication(SBCC)

• Development of SBCC strategy for the state’ • Hire a special expert team /organisation to develop

SBCC strategy and provide rollout support. SBCC support training, advocacy and communication materials to be standardised


15.5: Human Resources

• Filling up the positions of all health and ICDS functionaries at all level




15.6: Supply Chain Management




15.7: Capacity Building




exposure visits


15.8: Monitoring Evaluation Accountability and Learning (MEAL)





15.9: Knowledge Management




15.10: Convergence

• Formation of convergence committee for nutrition at district and block levels



119

Table 32: Summary of Interventions - Department Wise

e

S.No Department Intervention

Table no

1 Health Department 3.1, 3.2, 3.3, 3.4, 3.5, 5.1, 5.2, 5.3, 5.5, 5.6, 5.7, 5.8, 7.1, 7.2, 9.1, 9.2, 9.3, 9.4, 11.1, 11.2, 11.3, 11.4, 11.5, 11.7, 11.8, 11.9, 11.10, 11.11, 13.2, 14.2, 14.11, 15.1, 15.3, 15.4, 15.5, 15.7

2 Social Welfare 3.1, 3.2, 3.3, 3.4, 5.1, 5.2, 5.3, 5.4, 5.6, 5.7, 5.8, 7.1, 7.3, 9.1, 9.2, 9.3, 9.4, 11.1, 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, 13.1, 13.2, 13.3, 14.1, 14.7, 14.8, 14.13, 15.1, 15.2, 15.3, 15.4, 15.5, 15.7

3 Education 3.1, 3.2, 3.3, 3.4, 14.7, 14.12,

4 P&RD 5.1, 5.2, 5.4, 5.5, 5.6, 7.3, 11.1, 11.2, 11.5, 11.6, 14.3, 14.7, 14.13, 14.14,

5 PHED 9.3, 14.1, 14.2, 14.3, 14.4, 14.5, 14.6, 14.7,

6 Food and Civil Supplies 14.15

7 DRDA 14.14

120


121




The workshop was attended by Mr. Alok Kumar, Chief Secretary, Government of Assam, Shri Jishnu Baruah, Additional Chief Secretary, Social Welfare Department, Shri Anurag Goel, Secretary, Health and Family Welfare Department, Dr. J B Ekka, Principal Secretary, Transformation & Development Department, Shri Bhaskar Barua, Former Secretary, Ministry of Agriculture, Government of India amongst other Government officials from State and Districts, Academicians, Civil society Organizations and individual experts from and outside the State.

Four technical sessions on (i)Nutrition Scenario and issues and challenges in implementation of ongoing programs- Assam, (ii) Food Security & Issues and challenges in implementation of ongoing programs – Assam, (iii) Efforts towards developing M&E: System for SDGs tracking and (iv)Eat Right India Movementwere conducted during the workshop. Deliberations from each of the sessions have provided valuable inputs which have been incorporated in the plan in the form of suggested interventions.


A Policy seminar on multisectoral convergence for improved nutrition was co-organised by CFNS and CSDGs on 25th of January, 2019 at

Assam Administrative Staff College, Guwahati. The seminar was attended by Senior Government officials of Assam from Health, Education, Social Welfare and Public Health and Engineering Departments, Civil Society Organizations including UNICEF, UNDP, UN Women and Piramal Foundation and Individual Experts in the field of Nutrition.

122



• To promote Mother and Child Protection (MCP) Card as a counselling tool for Mothers and

Family members and renaming it as “Mother and Child Health and Nutrition Card (MCHNC)”


• Social audit of Integrated Child Development Scheme (ICDS) and other nutrition linked

schemes • Infrastructure development of health facilities to ensure privacy for Antenatal Check-ups and

Child Care ; Solar electrification of AWCs and health sub centers in char areas • Improving Mobility of ASHA Workers and ANMs in char areas by providing travel support

and other incentives – Department of Health and ICDS should ensure timely reimbursement of travel



• Panchayats &Rural Development and engagement of NGOs in taking forward the mission for early completion of construction of 1500 AWCs.

123

• “Model Anganwadi Centers” to be constructed in every district of the state by merging the funds from MGNREGA, Social Welfare and other sources including CSR, MP/MLA area development fund, Panchayat fund, local interested persons (NRIs and others) to act as a good example for other centres to follow

. • Government Portal for creating a fund for development of Anganwadi Centers where

individuals residing in country or outside who are willing to spend money for development of their native villages can contribute



124




• Integration of Self Help Groups under Rural Livelihood Mission with ICDS and

Panchayati Raj Institution for effective delivery of Nutrition Services at AWCs and household level

• Capacity building of AWWs, ASHAs and SHGs using incremental learning modules of

Poshan Abhiyaan in local languages

• Need for uniformity in the social behaviour change messages communicated to the communities – different messages from different players for the same topic tends to confuse the people

Annexure 6: MCP Card (Feeding Practices)

125

For further details please refer to “Indigenous recipes from locally available foods in Assam (Training cum Counselling Tool)

126

Preface

Multisectoral Result Based District Nutrition Action Plan

Goalpara District


2019-2022

127



This multisectoral nutrition plan is based on in-depth situational analysis of current status of malnutrition in the district,based on recommendations from the Nutrition Working Group Report, outcome of 6 policy seminars held during January – June 2019 and consultations with stakeholders fromdepartment functionaries and civil society organizations. The plan suggests necessary nutritional interventions for adolescent girls (in school, out of school), pregnant women, children under 5 besides other interventions necessary for creating a healthy environment like safe drinking water, sanitation, prevention of communicable diseases, assured food supply and education. The suggested interventions if implemented meticulously will certainly bring down the high prevalence of existing malnutrition in the district. There are examples from within and outside the country where prevalence of malnutrition has been reduced drastically within a period of 10 years by adopting appropriate strategies and interventions.

We hope that implementation of strategies and interventions suggested in this Multi sectoral plan along with robust monitoring will help to achieve a “Malnutrition Free district”.

Dr. R.M Dubey, Dr. Sujeet Ranjan Professor and Head, Executive Director Centre for Sustainable Development Goals, Coalition for Food & Nutrition Security Guwahati, Assam New Delhi, India

128

Table of Contents Acknowledgements ..................................................................................................................................... 129

The Drafting Team ...................................................................................................................................... 130

List of Tables .............................................................................................................................................. 131

List of Figures ............................................................................................................................................. 132

Abbreviations .............................................................................................................................................. 133

Executive Summary .................................................................................................................................... 135

1. Goalpara District Profile ..................................................................................................................... 137

2. Conceptual Framework of Malnutrition.............................................................................................. 138

2.1 Goalpara District Problem Tree .................................................................................................. 139

2.2 Potential Hotspot for Malnutrition .............................................................................................. 140

2.3 Nutrition Status of Goalpara, Assam and India .......................................................................... 141

2.4 First 1000 Days Analysis of Goalpara District ........................................................................... 141

2.5 Status and Determinants of various Malnutrition Indicators ...................................................... 143

3. Objective ............................................................................................................................................. 144

4. Methodology ....................................................................................................................................... 145

5. Multisectoral Plan- the Approach, Target Groups and Parameters ..................................................... 146

6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam ................... 148

A. Essential Nutrition Intervention .................................................................................................. 148

A1: Adolescent Nutrition .................................................................................................................. 149

A2: First 1000 Days ........................................................................................................................... 154

A2.1 Pregnant Women ...................................................................................................................... 155

A2.2 Lactating Mothers .................................................................................................................... 160

A2. 3 Children Aged 0-6 months ...................................................................................................... 162

A2.4 Children Aged 6-24 Months .................................................................................................... 165

A3. Children Aged 24-59 Months .................................................................................................... 170

B. Multisectoral Interventions ......................................................................................................... 172

C. Cross Cutting Strategies .............................................................................................................. 179

Annexure 1: Multisectoral framework to Reduce Malnutrition .................................................................. 181

Annexure 2: State Inception Workshop ...................................................................................................... 182

Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition” ............................. 183

Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes”................................................................................................................................................... 184

Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam”............... 186

Annexure 6: MCP Card .............................................................................................................................. 187

129

Acknowledgements

The Result Based Multisectoral District Nutrition Action Plan was jointly drafted by Coalition for Food and Nutrition Security (CFNS) and Center for Sustainable Development Goals (CSDGs), Government of Assam in close coordination with the all the concerned departments of Goalpara district.

We are indebted to Shri Rajeev Kumar Bora, IAS, Additional Chief Secretary, Transformation and Development Department and Dr. J B Ekka, IAS, Principal Secretary, Transformation and Development Department and their entire team for guidance and continuous support as well as for offering various suggestions through their deliberations made in various policy seminars which were used as useful inputs in preparation of this document.

The CFNS and CSDGs team would like to thank all the external contributors who have helped in preparing the plan document Shri Jishnu Baruah, IAS, Additional Chief Secretary, Social Welfare Department, Shri. Hemen Das, ACS, Secretary, Social Welfare Department and Smt. Juri Phukan,IAS, Director, Social Welfare Department for their constant support and guidance. We thank Smt.Varanali Deka, IAS, Deputy Commissioner and Shri IndreswarKolita, ACS, District Development Commissioner, Goalpara District, for their valuable time and support. We are also grateful to all the officials of department particularly the Joint Director, Health Services and his team; the Agriculture Officer and his team, Executive Engineer, PHED and his team; Social Welfare Officer and her team; Project Director, DRDA and his team, Education Officer and his team, District Program Manager, Assam Rural Livelihood Mission and officers of the their team, and the staff of Food & Civil Supplies Department. We are also thankful for ICDS and Health functionaries for extending their support to us during community visit.

We would also like to thank all the Individual Experts, State Government officials and Civil Society Organizations working in the Nutrition domain in the state who participated in various policy seminars whose recommendation provided valuable inputs to the plan. We would also like to thank all the members of the Nutrition working group who met and deliberated providing valuable insights into the nutritional scenario of districts of Assam.

Non Lending technical Support received from the World Bank is acknowledged.

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The Drafting Team

The Result Based Multisectoral District Nutrition Action Plan has been drafted jointly by the following officials with theCoalition for Food and Nutrition Security (CFNS) and the Center for Sustainable Development Goals (CSDGs).

Coalition for Food and Nutrition Security.

7. Dr Sujeet Ranjan: Executive Director, Coalition for Food and Nutrition Security 8. Ms. Akanksha Doval : Knowledge Management Coordinator 9. Mr. Deepak Ranjan Mishra : Program Coordinator

Centre for SDGs

5. Dr. R.M Dubey : Prof. and Head, Centre for SDGs 6. Shri J.C Phukan : Consultant, Centre for SDGs

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List of Tables

Table 1: Malnutrition Indicators (NFHS 4 Data) .......................................................................... 143 Table 2: GoalparaPopulation Projection for Adolescents aged 10-19 Years ............................... 150 Table3: Essential Nutrition Interventions-Adolescent Nutrition .................................................. 150 Table 4: GoalparaPopulation Projection for Pregnant Women .................................................... 155 Table 5: Essential Nutrition Interventions-Pregnant Women ....................................................... 155 Table 6: GoalparaPopulation Projection for Lactating Mothers ................................................... 160 Table 7: Essential Nutrition Interventions - Lactating Mothers ................................................... 160 Table 8: GoalparaPopulation Projection of Children aged 0-6 months ........................................ 162 Table 9: Essential Nutrition Interventions - Children aged 0-6 months ....................................... 162 Table 10: GoalparaPopulation Projection for Children aged 6-24 Months and 12-23 Months .... 165 Table 11: Essential Nutrition Interventions -Children aged 6-24 Months .................................... 165 Table 12: GoalparaPopulation Projection for Children aged 24-59 Months ................................ 170 Table 13: Essential Nutrition Interventions - Children aged 24-59 Months ................................. 170 Table 14: Multisectoral Interventions ........................................................................................... 174 Table 15: Multisectoral District Nutrition Plan (Cross Cutting Strategies) .................................. 179

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List of Figures

Figure 1: Goalpara District Map ............................................................................................... 137 Figure 2: Goalpara Problem Tree ................................................................................................. 140 Figure 3: Total literacy rate <= 60 ................................................................................................ 140 Figure 4: Villages with more than 25% of HH with no Assets .................................................... 141 Figure 5: Comparative Analysis of Nutrition status - Goalpara, Assam and India ...................... 141 Figure 6: Performance in indicators of Pregnant Women ............................................................ 142 Figure 7: Performance in indicators of Children .......................................................................... 143

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Abbreviations

ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist ASRLM Assam State Rural Livelihood Mission AWC Anganwadi Center AWW Anganwadi Worker AAY Antyodaya Anna Yojana BCC Behaviour Change Communication CBO Community based Organization CSR Corporate Social Responsibility CSDG Center for Sustainable Development Goals CFNS Coalition for Food and Nutrition Security HBNC Home Based New-born Care JSY Janani Suraksha Yojana FLW Front Line Workers IEC Information Education and Communication ICDS Integrated Child Development Scheme IFA Iron and Folic Acid IYCF Infant and Young Child Complementary Feeding MAA Mother’s Absolute Affection MAM Moderate Acute Malnutrition MDM Mid-Day Meal MGNREGA Mahatma Gandhi National Rural Employment Guarantee Act MT Million Tonne NRDWP National Rural Drinking Water Programme NGO Non-Government Organization NHM National Health Mission NIPI National Iron Plus Initiative NRC Nutrition Rehabilitation Center NFHS 4 National Family Health Survey (2015-16) PDS Public Distribution System PHED Public Health Engineering Department PHC Public Health Center PMFBY Pradhan Mantri Fasal Bima Yojana PMMVY Pradhan Mantri Matritva Vandana Yojana PRI Panchayati Raj Institution PW Pregnant Women RKVY Rashtriya Krishi Vikas Yojana SAM Severe Acute Malnutrition SAG Scheme for Adolescent Girls

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SBA Skilled Birth Attendant SBCC Social Behaviour Change Communication SBM Swachh Bharat mission SECC Socio Economic Caste Census SHG Self Help Group SNP Supplementary Nutrition Program SSA Sarva Siksha Abhiyaan THR Take Home Ration VHSND Village Health Sanitation and Nutrition Day WIFS Weekly Iron and Folic Acid Supplementation

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Executive Summary

The multisectoral district nutrition action plan for Goalpara district has been prepared as a part of work envisaged under developing multisectoral plan for three aspirational districts of Assam, out of non-lending technical support received from the World Bank. For preparation of this multisectoral nutrition plan the World Bank engaged Coalition for Food and Nutrition Security (CFNS) for providing technical assistance to the Center for Sustainable Development Goals (CSDGS)and this plan is the outcome of joint efforts of both these organizations.


Section 1of the plan gives a brief profile of Goalpara District from Census 2011.

Section 2 covers the conceptual framework of malnutrition. The section includes a problem tree of Goalpara which shows the problem of malnutrition in the form of a tree highlighting the immediate, underlying and root causes behind the problem and various manifestations in the form of stunting, wasting, underweight and anaemia. The problem tree is based on NFHS 4 data of 2015-16. This section also compares the nutritional status of Goalpara districtwith that of Assam and India. It also shows the performance of Goalpara district in first 1000 days from conception till child’s two years of age and compares the performance of district in first 1000 days with that of state average and best performing district in state for respective parameters.

Section 3covers the objectives behind the result based multi sectoral plan.

Section 4 describes in details the methodology adopted in preparation of this plan. The plan is the outcome of research and analysis conducted during the period of six months (January toJune 2019). Feedback was sought from district officials of the concerned departments and nutrition experts. Based on feedback as well as extensive desk research, guidance from the steering group and additional interviews with experts, district officials and community members representing diverse communities residing within the district.


Section 6 is the main result based multisectoral district nutrition action plan for accelerating the progress of SDGs 2 and 3 in the district. The action plan for each of the parts, as mentioned in section 4, has been dealt in detail section wise. For each of the parts A, B the following details are included in a tabular form –proposed indicators, targets for three years (2019-2022), recommended interventions, the lead and support department to executing the stated interventions and intervention related schemes being implemented by the Government of Assam.

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In part B of the plan, details of multisectoral interventions to be dealt is long term for addressing underlying and root causes of malnutrition, including water, sanitation and personal hygiene; education, social causes, women’s empowerment and food security are presented.

In Part Cof the plan details the cross cutting strategies like strengthening of community based events like VHSND, growth monitoring of children at AWCs, organising quality timely home visits by frontline workers, supply chain management and social behaviour change communication strategies.

The persistent problem of malnutrition in the district is proposed to be tackled by ICDS and health sectors jointly giving lead for accelerating improvement in indicators pertaining to essential nutrition interventions in first 1000 days of life and critical maternal child health services. Highest priority will be accorded to households having a woman member who is pregnant or having a child 0-24 months. Additionally, using the life cycle approach, the existing policies for care of preschool children, school, children, and adolescent girls will be also actively implemented. Moreover, for addressing the intermediate and underlying causes of undernutrition, other sectors such as PHED, Social Welfare, Education, Panchayat and Rural Development, Food and Civil Supplies Department will be involved.

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11. Goalpara District Profile

The district of Goalpara is situated on the South bank of River Brahmaputra, and it covers an area of 1,824 square kilometres and is bounded by West and East Garo Hills districts of Meghalaya on the South, Kamrup District on the East, Dhubri District on the West and, River Brahmaputra all along the North. The geographical location of the district is between 25053' N to 26030' N latitude and 90007' E to 91005' E longitude. In 1983, Goalpara Civil sub-division was separated from original Goalpara district to form the present Goalpara district. The district thus consists of only one sub division namely Goalpara (sadar) sub-division divided into five revenue circles - Lakhipur, Balijana, Matia, Rangjuli and Dudhnai, and eight development blocks namely Jaleswar, Lakhipur, Kharmuja, Balijana, Krishnai, Matia, Dudhnai and Kushdhowa. There are three towns’ viz. Goalpara (Municipal Board), Lakhipur (Town Committee) and Kharijapikon (Census town) in the district. The total number of villages in the district is 837, of which, 761 are inhabited. There are 81 Gaon Panchayats in the district. The district Goalpara is the home of large number of ethnic and religious communities. In addition to a sizeable section of the Muslim population, the district is inhabited by the ethnic communities such as the Rabha, the Bodo, the Garo, and the Koch Rajbongsi.

Figure 15: Goalpara District Map

Goalpara District at a Glance (Census 2011) Total Population 1,008,183 Total Geographical Area ( In Sq. KM) 1,824 Male (%) 51 Population Density 553 Female (%) 49 Sex Ratio 962 Rural (%) 86 Child Sex Ratio 963 Urban (%) 14 Revenue Villages 837 General Population (Non SC ST) (%) 85.85 Infant Mortality Rate (IMR) 53 SC Population (%) 2.92 Maternal Mortality Rate (MMR) 254 ST Population (%) 11.23 Literacy Rate 63.37 Hindu Population (%) 34.5 Women Literacy Rate 63.13

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Muslim Population (%) 57.4 Christian Population (%) 7.7 Others (%) 0.4


UNICEF’s (1990) conceptual framework of the causality of child malnutrition illustrates the multisectoral nature of the problem. The immediate determinants of malnutrition at the individual level (inadequate dietary intake and disease) are products of underlying causes at the family or household level (insufficient access to food, inadequate maternal and child practices, poor water and sanitation, and inadequate access to quality health services). These, in turn, are influenced by basic causes at a societal level, including the quality and quantity of human, economic, and organizational resources and political environment.

The problem tree of Goalpara district in the following section 2.1 highlights the conceptual framework of malnutrition in women and children. Malnutrition is manifested in the form of stunting, wasting, underweight, anaemia and low BMI in women. These outcomes are influenced by a set of immediate causes (nutrition specific) and underlying causes (nutrition sensitive) intervention.


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12.1 Goalpara District Problem Tree

Source: NFHS 4

140

F

Figure 16: Goalpara Problem Tree

12.2 Potential Hotspot for Malnutrition

Figure 17: Total literacy rate <= 60

Figure 3 and Figure 4 depicts the potential hotspot for malnutrition in the Udalguri district, according to Census 2011 data. Though the prevalence may be different now but the data still can be used to identify relatively poor performing pockets.

• The maximum concentration of illiteracy and household with no assets coincide in Lakhipur and Balijana blocks, shown in red


• NRC Data for 2018-19 shows that out of 98 admission in the year 72 (73%) % are from

In the absence of segregated data on malnutrition, during the field work an attempt was made to identify malnutrition pockets in the district based on indirect evidences and for the purpose pockets of high illiteracy and households with no assets was identified. As can be seen from the figures below the pockets more or less coincide with each other. The pockets where illiteracy is high and the households with no assets indicate towards high prevalence of malnutrition. These are the pockets with high prevalence of poverty and hence high prevalence of malnutrition. In order to improve district’s nutritional indicators it is important to focus on these pockets with priority.

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Source: Census 2011

12.3 Nutrition Status of Goalpara, Assam and India

Figure 19: Comparative Analysis of Nutrition status - Goalpara, Assam and India

12.4 First 1000 Days Analysis of Goalpara District

Figure 6 and 7 indicates the performance of Goalpara district in the first 1000 days from conception till child’s 2 years of age. Figure 6 indicates the performance of district across various indicators related to the care of pregnant mother while figure 7 shows the performance of district in indicators related to child care. The figures also helps in comparing the performance of Goalpara districts with that of State average and best performing districts in respective parameters.

% Stunting U5 % Wasting U5 % SeverelyWasting U5

% UnderweightU5

Goalpara 42.7 22.1 8.9 39.5Assam 35.3 16.1 5.9 28.1India 38.4 21.0 7.5 35.7

0.05.0

10.015.020.025.030.035.040.045.0

Comparitive Analysis

Goalpara Assam India

Figure 18: Villages with more than 25% of HH with no Assets

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Figure 20: Performance in indicators of Pregnant Women

0

20406080

100 ANC in first trimester

4 ANC visit%

Full ANC Care%

Consuming IFA for 100 days ormore%

Financial assistance under JSYfor institutional Delivery

Last birth was protectedagainst neonatal TT

Having child protection (MCP)card

married before age 18 years(%)

Goalpara Assam State Best Performance District

Pregnant Women

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Figure 6: Performance indicators of Pregnant Women


12.5 Status and Determinants of various Malnutrition Indicators

The table 1 below shows the indicators of malnutrition for India, Assam, Goalpara District and best performing district of Assam in respective indicators.


Indicators India Assam Goalpara State Best Performance

Stunting Under 5 % 38.4 35.3 42.7 24.6 (Kamrup Metro)

Wasting Under 5 % 21 16.1 22.1 6.2 (Dhemaji)

020406080

100Breastfed within 1 hour of birth

Exclusive Breastfeeding up to 6months

Children receiving adequate dietFull Immunization

Vitamin A supplementation inLast 6 month

Goalpara Assam State Best Performance District

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Severely wasting Under 5 % 7.5 5.9 8.9 0.8 (Dhemaji)

Underweight Under 5 % 35.7 28.1 39.5 15.8 (Dhemaji)

Pregnant Women having ANC in first trimester 58.6 55.1 57.5 82 (Jorhat)

Pregnant Women having at least 4 ANC visit% 51.2 46.4 42.1 75.8 (Jorhat)

Pregnant Women receiving Full ANC Care% 21 18.1 16.4 48 (Jorhat)

Pregnant Women Consuming IFA for 100 days or more% 30.3 32 31.6 63.3 (Jorhat)

Mothers receiving financial assistance under JSY for institutional Delivery

36.4 66.1 71.4 90.2 (Dhemaji)

Mothers whose last birth was protected against neonatal TT 89 89.8 83.4 97.1 (Sonitpur)

Mothers having mother and child protection (MCP) card 89.3 98.6 97.2 99.3 (Nalbari)

Women age 20-24 years married before age 18 years (%) 26.8 30.8 35.8 18.5 (Cachar)

Women age 15-19 years who were already mothers or pregnant at the time of the survey %

7.9 13.6 27.2 7 (Sonitpur)

Women who are literate % 68.4 71.8 70.7 84.3 (Kamrup M)

Women having 10 or more years of Schooling 35.7 26.2 22.6 48.2 (Kamrup Metro)

Institutional Births % 78.9 70.6 71.2 95.9 (Jorhat)

Breastfed within 1 hour of birth% 41.6 64.4 80.5 80.5 (Goalpara and Goalpara)

Exclusive Breastfeeding up to 6 months% 54.9 63.5 59.6 86.2 (Tinsukia)

Children receiving adequate diet% 8.7 8.7 12.3 13.8 (Sivsagar)

Full Immunization % 62 47.1 43.7 73 (Sivsagar)

Vitamin A supplementation in Last 6 months% 60.2 51.3 56.9 67.6 (Karimganj)

13. Objective

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The objective behind this result based multisectoral district nutrition action plan is to study in depth the reasons behind the high prevalence of malnutrition in the district and key challenges before the district administration in This multisectoral plan will ensure strong nutrition focus through institutional and programmatic convergence by integrating it in the planning, implementation and supervision process in all relevant direct and in-direct interventions and programs.


14. Methodology

The district nutrition action plan for Goalpara district, Assam is drafted by the Coalition for Food and Nutrition Security (CFNS) in collaboration with Center for Sustainable Development Goals (CSDGs), Government of Assam. The documents is based on desk research and analysis in the last five months, views of district officials of the concerned departments and public health nutrition and development experts, The details are summarised below.

• Review of strategic plans and similar planning documents: The team reviewed the framework of Poshan Abhiyaan for multisectoral district planning, relevant indicators from NFHS4 and similar planning documents like multisectoral district nutrition plan from Dungarpur district, Rajasthan, Aspirational District Plan for Goalpara district, Assam Agenda 2030 of Transformation and Development department, Government of Assam, were also referred to decide on the indicator matrix for the plan. The matrix designed is based on the life cycle approach to address malnutrition with special focus on first 1000 days of life.

• Community Visit: Team visited five diverse villages of Goalpara district- Agia, Balijana,

Budhipara, Rokhapara and interacted with the communities, minority dominated villages and Assam MaeghalayaBoder area villages.The visit was undertaken with the objective to understand the status of various services linked to the nutrition like Health, Water and Sanitation, Education and to gain insights into the socio cultural practices and beliefs of people. Extensive Focused Group Discussions (FGDs) were conducted with the Mother’s group (pregnant and lactating mothers), Adolescent girls’ group, and frontline workers of ICDS and Health sectors (AWWs and ASHAs) and the members of the VHNSCs. Team also visited various AWCs, Health Centers and participated in several VHNSD particularly in border areas of the district to understand their functioning and status of various services.

• Interviews with officials of selected government departments: These interviews

provided an opportunity to understand the challenges of the work of each of the concerned department and to complement the information garnered from the community visit and strategic documents.

• State and District Inception Workshop: The state and district inception workshop was conducted on 2nd Feb and 5th January respectively. Experts from various fields and very senior officers from the government including Chief Secretary, Assam participated in State inception workshop and presented their views on district nutrition plan.

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• Policy Seminars: Six policy seminars on various topics related to nutrition were conducted

in Assam in the period from Jan-2019 to June 2019. Each of the policy seminar was attended by top government officials, individual experts, civil society organizations and field level executives. Feedbacks from the seminars were considered for drafting the multisectoralnutrition plan.


15. Multisectoral Plan- the Approach, Target Groups and Parameters





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Pregnant Women ANC Care Iron and Calcium Supplementation Deworming Supplementary Nutrition/Take Home Ration ()Family Planning Counselling Weight& Height Measurement- BMI (for weight gain during pregnancy)

Lactating Mothers

Institutional Delivery Support for Early initiation of breastfeeding Home Delivery by SBA IFA tablets Calcium tablets ICDS Supplementary Nutrition /Take Home Ration Family Planning Services

0-6 Months Child

Low Birth Weight Care/ Kangaroo Mother Care Continuation of Breastfeeding&Exclusive Breastfeeding Diarrhoea Management (ORS, Zinc and access to safe drinking water and sanitation facility) Care / feeding during illness Weight/ Height Monitoring


Timely Initiation of Complementary Feeding Appropriate Complementary feeding (Dietary Diversity, appropriate Feeding Frequency and adequate density ) Vitamin A and IFA Supplementation Full Immunization Deworming (as per guidelines) Supplementary Nutrition (THR of ICDS)SAM and MAM Management



Part B of the plan covers multisectoral interventions that address underlying and root causes of malnutrition. While implementing a multisectoral plan, priority should be given to essential nutrition interventions and it is only after ensuring their implementation, the district should plan to implement long term multisectoral interventions.Part C of the plans outlines cross cutting strategies for system strengthening.


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Food Security


PART C- System Strengthening Intervention Cross Cutting Strategies


G. Essential Nutrition Intervention Essential nutrition interventions or programs address the immediate determinants of malnutrition and child development – adequate food and nutrient intake (diets).Additionally, adequate health/prevention of diseases and is also included since maternal child health interventions are critical for addressing immediate determinants of malnutrition. The interventions are presented using different stages of life



149

cycle—adolescent girls, pregnant and lactating women children 0-6 months, 6-24 months and 24-59 months. The plan recognizes and accords highest attention to the first 1000 days of life—from conception to 24 months of age.



The foundation of adequate growth and development is laid before birth, during early childhood, and in during adolescence. Early marriage and conception below 18 years adversely impacts on women gaining optimum height. In Goalpara District 35.8 % girls are married before 18 years of age and 27.2% of women aged 15-19 years are already mothers (NFHS 4).



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Table 34: GoalparaPopulation Projection for Adolescents aged 10-19 Years

Base Population (Census 2011) -1,008,183; Average Annual Growth Rate –2.27%

Table35: Essential Nutrition Interventions-Adolescent Nutrition

Indicators Baseline* Target*

Data Source

* Intervention Department Schem

e Resources

2019- 2020

20202021

20212022

% of adolescent 10-19 years covered with Albendazole in the first round in February and second round in August each year

89% ( HMIS

2018 -19, Goalpara)

100%. 100% 100% DPM, NHM



health centers/sub centers one month prior to the biannual dates fixed for Albendazole distribution


Anemia Mukt Bharat (MoHFW,2018)

Mobile Block Health Team at PHC level to cover the schools Nodal Teachers


Total Number of Adolescents 10-19 Years 208320 210558 211976 Total Number of Adolescent Girls aged 10-19 Years 102768 103173 103868

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• Dissemination of IEC material to all schools/juniors college

Out of School Adolescents • Listing of all the out of school adolescents

by AWW with the help of ASHA • Micro plan for reaching out to out of school

children by ASHA and AWW • Ensuring a fixed day distribution of

Albendazole to out of school adolescents at AWCs



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% of adolescent girls 10-19 years screened for anaemia(school going +non-school going ) (throughout the year)

67% ( HMIS 2018 -19, Goalpara)

100%

100% 100% DPM School Going Adolescents

• Mapping and inclusion of private schools, Government schools and junior colleges

• Regular screening (at least twice a year) for anaemia by teachers/ mobile block health team for school going adolescent

Out of School Adolescents • Listing of all the out of school adolescents

by AWW with the help of ASHA • Regular screening (at least twice a year) for

anaemia by AWWs/ mobile block health teams at AWCs for out of school adolescent

Lead Department Education, Health Department

WIFS RBSK ICDS SAG- (out of school adolescent girls)

Mobile Block Health Teams ANMs, ASHAs and 1072 ASHAs

Support Department Social Welfare Department Education Department

% of eligible adolescents 10-19 years who receive at least 4 blue iron foliate tablets

100%

100% 100% DPM • Ensuring Weekly distribution of IFA tablets with special focus on schools

in tea garden areas • Teachers and AWWs to ensure consumption

of IFA tablets for school going adolescent and out of school adolescent girls respectively.




1072 ASHAs, 2433 AWWs Nodal Teachers


% of adolescent 10-19 years whose BMI is below normal

• Besides IFA and Deworming following interventions should be ensured: • Promote nutrition, health and sanitation

education at schools and AWCs


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• Regular health camps for adolescent girls for measuring BMI followed by counselling sessions




% of newlywed adolescent girls who have received family planning counselling

• Ensure tracking of the newlywed girls by ASHAs with the help of AWWs





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A2: First 1000 Days



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A2.1 Pregnant Women

Table 36: GoalparaPopulation Projection for Pregnant Women

Base Population (Census 2011) - Birth Rate 20.5, Total Population 10.08 lakhs; Average Annual Growth Rate –2.27% (Number of Pregnant Women is estimated 10% more than expected live births)

Population Projection 2019-20 2020-21 2021-22 Number of Pregnant Women 27249 27869 28645

Table 37: Essential Nutrition Interventions-Pregnant Women


2019- 2020

2020-2021

2021-2022

% of PW who had full Antenatal care ( 4 ANC, at least 1 TT, IFA tablet or syrup for more than 180 days)

16.4% (NFHS4)

80% (27642PWs)

85% 95% Aspirational District Action Plan







ICDS NHM

ASRLM

154 ANM 1072 ASHA 2433 AWWs 2487 AWCs 2497 VHNCs 6745 SHGs Support

Department Social Welfare Department P&RD (ASRLM)

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• Organise ANC sessions ninth of every month as per the PMSMA policy of NHM Pregnant women to be weighed and weight to be entered in MCP card and weight gain should be encouraged as per BMI based guidelines

Out of total ANC registered , % registered within 1st trimester(within 12 weeks)

57.2% (NFHS4)

95% (27642 PWs)

97% 100% Aspirational District Plan.






ICDS, PMMVY

154 ANM 1072 ASHA 2433 AWWs 2487 AWCs 6745 SHGs

Support Department Social Welfare Department P&RD(ASRLM)

% of PW registered who received 21 days of SNP in last month and have access to diversified food through home stead food production

47% (MIS,

DSWO)

100% 100% 100% DSWO • Ensuring Regular supply of THR • Ensuring supply of readymade nutri






ICDS P&RD (ASRLM)


P&RD(ASRLM)

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% of eligible pregnant women who received at least 180 IFA tablets during the Antenatal period

31.6% (NFHS4)

100% (29096 PWs)

100% 100% DPM • Regular screening for anaemia levels of PW at health centers / VHSND





• Capacity building of SHGs to engage them in Jan Andolan activities for promoting consumption of IFA.




NHM ICDS ASRLM



% pregnant women who consumed 360 calcium tablets during pregnancy

75% ( HMIS 2018 -19, Goalpara)

100% (29096 PWS)

100% 100% DPM • Ensuring adequate availability (based projected population of PW) of calcium tablet supplies at health centers and sub centers.


NHM ICDS ASRLM


Support Department

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Social Welfare Department P&RD

% of PW who were given one Albendazole tablet after 1st trimester

59.5 %( (HMIS 2018

-19, Goalpara)

100% (29096 PWs)

100% 100% DPM • Adequate number of tablets to be made available at all health facilities providing ANC




ICDS, NHM

1072 ASHA 2433 AWWs


% of children with low birth weight (< 2.5 kg)

13.25% ( HMIS 2018 -19

Goalpara)

11% 10% 9% Aspirational District Plan



• Care and day rest during pregnancy


NHM ICDS, P&RD (ASRLM)

- Skilled men Power (MO/ANM/GNMs) are available at each level.

- 10 nos. MOs, 46 GNMs & 163 ANMs are trained.

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• Ensure reduction in physical drudgery and domestic violence with help of SHGs



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Table 38: GoalparaPopulation Projection for Lactating Mothers

Base Population (Census 2011); Birth Rate – 20.5, Total Population – 10.08 lakhs ;Average Annual Growth Rate – 2.27% (Number of lactating mothers are estimated same to be as number of expected live births)

Population Projections 2019-20 2020-21 2021-22 Number of Lactating Mothers (0-6 Months) 26642 27262 27882

Table 39: Essential Nutrition Interventions - Lactating Mothers


2019 2020

20202021

20212022

% of institutional deliveries in the last month

71.2% (NFHS4)

90% 26181PWs)

95% 100% DPM • ANM, ASHAs, AWWs to mobilise and support PW for institutional deliveries






ICDS, NHM, ASRLM

- Trained & Skilled men Power (MO/ANM/GNMs) are available at each level.

- At present 22 nos. of PHCs providing 24x7 hr delivery services, out of 31 no’s of PHCs conducting Institutional Delivery,


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• Engagement of SHGs to promote the importance of institutional deliveries

- 10 nos. MOs, 46 GNMs & 163 ANMs are trained.

% of deliveries at home attended by skilled birth attendant

6.5% ( HMIS 2018

-19, Goalpara)

85% 95% 100% Aspirational District Plan.


Lead Department

Health Department

HBNC

% of lactating mothers received 21 days of SNP(THR) in last month

47% MIS, DSWO

100% 100% 100% DSWO • Ensuring Regular supply of THR • Ensuring safe and hygienic storage of




ICDS, ASRLM

AWWs SHGs



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A2. 3Children Aged0-6 months

Table 40: GoalparaPopulation Projection of Children aged 0-6 months

Base Population (Census 2011) 0-6 Years Population – 1.72 lakhs; Average Annual Growth Rate –2.27%

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 0-6 Months 26642 27262 27882




20192020

20202021

20212022

% of children initiated breastfeed within one hour birth

80.5% (NFHS -4)

100% 100% 100% Aspirational District Plan


• AWW to support early initiation of breastfeeding in home deliveries .No marketing of Infant formula

• Lactation Management Training to the SBAs

• Ensure early initiation of Breast Feeding in100% institutional deliveries





- 10 nos. MOs, 46 GNMs & 163 ANMs are trained.1072 ASHA & 2433 AWWs are in the field.


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% of children under 6 months exclusively breastfed

59.6% (NFHS-4)

70%


• Every immunisation contact should be utilised for breastfeeding counselling and assessing status.10 steps to breastfeeding to be displayed in every health centres/ VHSND forums.


• ANMs/ ASHAs to provide breastfeeding counselling during VHSND and ANC checkups&Support for breastfeeding to working mothers in areas like tea garden areas


NHM, MAA


- 10 nos. MOs, 46 GNMs & 163 ANMs are trained.1072 ASHA & 2433 AWWs are in the field. Support


% of children 0-60 months with diarrhoea in the last two weeks who received ORS and Zinc

100% ( HMIS 2018 -19, Goalpara)

100% 100% 100% Aspirational District Action Plan


• VHSND to be used for creating knowledge about diarrhoea management and preparation of ORS


NHM PHED

Sufficient ORS packets are available in the drug Store and distributed to the ANM, AWW & ASHA.

Support Department

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and minimum 14 days consumption of zinc tablets.


• Demonstration on VHSNDs regarding regular handwashing with soap before cooking and eating

• Ensuring the coverage of safe drinking water facility&Promote the usage of sanitation toilets

Social Welfare Department PHED

% of Children 0-60 months that have their weight measured, monitored(entered in growth chart) every month in the last quarter

• Weighing machine to be made available at all AWCs/VHSND forums for regular weight and height measures & Trainings of all AWWs and ASHAs on weight measurement and plotting

• Counselling on promotion of mothers by AWWs with the help of ASHAs on importance of growth monitoring. Prioritised home visits to children whose growth have faltered by AWWs and ASHAs & Identification of children suffering from severe acute malnutrition (SAM) and taking appropriate actions.





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Table 42: GoalparaPopulation Projection for Children aged 6-24 Months and 12-23 Months

Base Population (Census 2011) 0-6 Years Population -1.72 lakhs; Average Annual Growth Rate –2.27%

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 6-24 Months 39963 40893 41823 Number of Children aged 12-23 Months 20145 20487 21228




2019-2020

20202021

20212022

% of children who were initiated complementary feeding(Solid or semi- solid food and breast milk) after 6 months

12.3% NFHS -4

• Organize Annaprashan Diwas once in a month in AWCs to promote complementary feeding and demonstrate healthy recipes




• Undertake regular home visits for counselling on complementary feeding at home level by


ICDS NHM


Health Department

166

ASHAs,as per the policy on Home Based Care in Young Children,NHM




Support Department Assam RLM

% of children consuming at least 4+ food groups





Lead Department ICDS, Health P&RD

ICDS, ASRLM

AWWs, SHGs


% of children (9-24months) who received at least one dose of vitamin Ain the preceding 6 months

56.9% (NFHS - 4)

DPM • Ensuring adequate stock availability (based

on population projection) at health centres • Institutional Bi-annual distribution of

Vitamin-A on two fixed months, 6 months apart from each other



NHM ICDS

154 ANM, 2433 AWW available. 1100 VHNDs can be used as a platform.


167


% children 6-24 months provided (IFA) syrup (Bi weekly) in the preceding month

100% ( HMIS 2018 -19, Goalpara)

DPM • AWW to prepare list of beneficiaries with the

help of ASHA and ANM • Ensuring adequate stock availability (based

on population projection) at health centres • Ensuring mechanism for distribution of syrup

to mothers during VHSNDs by ANM/ASHAs


Anemia Mukt Bharat

154 ANM, 2433 AWW available. 1100 VHNDs can be used as a platform.

Support Department Health

Children age 12-23 months fully immunized (BCG, measles, and 3 doses each of polio and DPT) (%)

43.7% (NFHS-4)

97% 99% 100% Aspirational District Plan • ASHA to get list of children to be fully

immunised from AWW • Home visits by ASHAs to follow up for

mobilizing caregivers for attending immunization sessions.




• Scaling up eVIN


NHM, ICDS, ASRLM

Availability of the Man power along with the vaccine and cold chain points good supply & management of the vaccine in the district.


168

% children 6-24 months registered who received SNP (THR) for 21 days in the last month


• Regular supply of THR to ICDS and weekly supply to children Capacity building of SHGs to take up THR as a micro finance activity

Lead Department Social Welfare department

ICDS AWWs, SHGs


% of children 6-36 months screened for MAM and SAM during last month


SAM cases


ICDS, NHM



% of children with MAMthat receive appropriate interventions at community level




ICDS, NHM

AWWs, ASHAs


% of children with SAM and medical complications



ICDS, NHM

AWWs, ASHAs

169

treated at Nutrition Rehabilitation Centres (NRCs)




dietitian/ nutritionist, nurses, cook and helpers) to gain proper techniques and skills


% of children with SAM and without medical complications treated at community level



through food demonstration and preparation • Promotion of kitchen garden to ensure

household level food security • Capacity building of primary caregiver to

look after the child at home



% of children (6-24 months) who received Albendazole

• Ensuring adequate Albendazole supply • Maintenance of track sheet to ensure every

child receives the due 6 monthly dosages • Dissemination of IEC material to community

centres


ICDS WIFS



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Table 44: GoalparaPopulation Projection for Children aged 24-59 Months

Base Population (Census 2011) 0-6 Years population -1.72 lakhs; Average Annual Growth Rate –2.27%

Population Projections 2019-20 2020-21 2021-22 Number of Children aged 24-59 Months 95680 97975 99560




20192020

2020-2021

2021-2022

% of children (24-59months) who received Vitamin A

• Organising biannual administration of vitamin

A supplements • AWW to prepare due lists of children with the

help of ASHA and ANM • Left out children to be given doses on

VHSND • Ensuring adequate stock availability (based on

population projection) at health centres


NHM ICDS

AWWs, ASHAs

Support Department

% children 24-59 months provided (IFA) syrup (Bi weekly) in last month






Support Department Heath

171

% children 24-36 months registered who received SNP (THR) for 21 days in the last month






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H. Multisectoral Interventions

Multisectoral interventions or programs address the underlying and basic determinants of malnutrition these include measures for improving food security and diet diversity; access to potable water, sanitation facilities and a safe and hygienic environment. The maternal-child health




Agriculture: Research in India has shown that increased crop diversification improves dietary diversification in the home and helps children recover from growth faltering. As agricultural production grows and diversifies, households experience increased food security and better nutrition, leading to increases in human capital and productivity. Diversified agricultural production has the potential to improve access to more diverse and nutritious foods, a key component of meeting the “Minimum Acceptable Diet” for children. Agricultural programs that focus on producing energy-rich staple foods can also be more effectively designed to reduce under nutrition by promoting crops that reduce vulnerability to droughts and extreme climate, increase yields, or improve nutritional value.5By putting more focus on nutrition outcomes (i.e., by including nutrition objectives at the outset), agricultural interventions can improve the capacity, productivity, and future prospects of agricultural workers—and also contribute to reducing under nutrition.

Education: Children can’t learn and succeed in their education without a solid nutritional foundation: Good nutrition is essential for full development of cognitive and motor skills, behavioural abilities, IQ, and physical growth. Early childhood under nutrition, including poor nutrition in the womb, often results in stunting and can have permanent developmental effects on a child. Stunted children are also less likely to complete school. Studies from 79 countries show that every 10 percent increase in stunting corresponds to an 8 percent drop in the proportion of children completing primary school. When education programs invest in nutrition, it improves academic achievement. One example is school feeding programs, which can improve learning and academic performance. Students participating in school feeding and take-home ration programs have improved cognition. These programs yield the greatest impact when coupled with other programs like deworming, micronutrient supplementation, and fortification. Integrating nutrition programs into school curriculum initiates life-long healthy behaviours. Children connect what they learn in school to their broader communities by bringing messages home to their families and promoting good nutrition and healthy habits in the household.

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interventions are included in section A since nutrition and health are immediate determinants of malnutrition and are interrelated.

174



20192020

20202021

2021-2022

Wash

Drinking Water % of Anganwadi with adequate, functional and safe drinking water supply

2491 AWCs

2491 AWCs

2491 AWCs

PHED • Categorization of AWCs based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed



NRDWP


% of health centres with adequate, functional and safe drinking water supply

199 Healt

h Institutions

199 Healt

h Institutions

199 Health Institut

ions

PHED • Categorization of health Centers based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed


NRDWP


175

% of villages/wards with adequate, functional and safe drinking water supply

837 village

s

837 village

s

837 Village

s

PHED • The water supply schemes should possibly be implemented on community basis and demand driven wherever feasible. Public participation is mandatory with the VWSC’s for source selection and sustainability framework, social mapping, household beneficiaries, estimate preparation, etc. The transparency will create a massive awareness among the communities which would further create a sense of ownership amongst the beneficiaries which will be helpful in effective monitoring and O&M for its sustainability purpose.

• Workshops and trainings of village water committee to undertake minor repair work and maintenance of water systems.


NRDWP SKPY


% of households with improved drinking water sources

87.1% 217077 HHs

217077 HHs

217077HHs

PHED • The water supply schemes should possibly be implemented on community basis and demand driven wherever feasible. Public participation is mandatory with the VWSC’s for source selection and sustainability framework, social mapping, household beneficiaries, estimate preparation, etc. Categorization of households based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed.

• Create a sense of ownership amongst the beneficiaries which will be helpful in effective monitoring and O&M.


NRDWP

Sanitation

176

% of villages/ wards which are open defecation free

837 village

s

837 village

s

837 villages

PHED • Mapping and prioritizing the left out pockets





SBM& MGNREGS

% of Households with access to safe sanitation facilities

46.2% 217077 HHs

217077 HHs

217077

HHs

PHED • Mapping and prioritizing the left out pockets with special focus on tea garden areas



SBM& MGNREGS

% of Anganwadi and with adequate and functional sanitation facilities

2491 AWCs& 1598 Schools



PHED • Construction of toilets in AWCs under Swachh Bharat Mission




SBM MGNREGA


% of schools with adequate and functional sanitation facilities

% of health centres with adequate and functional

199 Health Institutions



PHED • Categorization of health centers based on current status- Sanitation facility-available and functional, available but not functional and not available. In first


177

sanitation facilities

phase dysfunctional facilities can be made functional and in second phase new facilities could be constructed


Personal Hygiene % of Anganwadis with adequate and functional Hand washing facilities with water and soap available

2491 AWCs

2491 AWCs

2491 AWCs

PHED • Providing adequate supplies (soap, bucket and mugs) to every AWCs






ICDS SHGs, AWWs

Support Department

% of health centres with adequate and functional Handwashing facilities with water and soap available

199 Healt

h Institutions

199 Healt

h Institutions

199 Health Institut

ions

PHED • Hand washing posters to be demonstrated at health centres




Education % of women with 10 or more years of schooling

Assam

Agenda 2030

• Awareness programmes through SSA • Counselling of girls parents by members

of SHGs on importance of girl education • Improvement of sanitation facilities at

schools for girls • Addressing the root cause for high girls

dropout rate


SSA

Social Causes

178

% of women age 20-24 years married before 18 years

31.38 (NFHS-4)






Livelihood

% of women with job cards who worked for 100 days in last year

• Generating awareness of MGNREGA among women -

• Strengthening of Women's participation in Gram Sabha Planning Meeting

Lead Department P&RD

MGNREGA


% of families linked with PDS

• Inclusion of all eligible families in PDS Lead Department Food & Civil Supplies

PDS

179

I. Cross Cutting Strategies


Program Management Activities Accountability VHSND • Conduct regular joint VHSNC meeting by

ANM,AWW for execution of health and nutrition activities




Lead Role Health Department Support Department Social Welfare Department

Growth Monitoring

• Establish procurement system and ensure functional weighing machines at all AWCs

• Undertake Weight and height measurement of all the children at regular interval– every month for children aged between 6-24 months and once in 3 months for children aged above 24 months.





Quality Home Visits

• Home visit calendar of AWW, ASHA and ANM should be planned and reviewed

• Home visit tools should be designed for AAAs for effective communication, counselling and information gathering

• AWW and ASHAS to make home visits for educating mothers and other family members to play an effective role in child’s growth and



180

development with special emphasis on 0-24 months child.

Social Behaviour Change Communication(SBCC)

• Development of SBCC strategy for the state’ • Hire a special expert team /organisation to

develop SBCC strategy and provide rollout support. SBCC support training, advocacy and communication materials to be standardised


Human Resources • Filling up the positions of all health and ICDS functionaries at all level




Supply Chain Management




Capacity Building




exposure visits


Monitoring Evaluation Accountability and Learning (MEAL)





Knowledge Management




Convergence • Formation of convergence committee for nutrition at district and block levels



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The workshop was attended by Mr. Alok Kumar, Chief Secretary, Government of Assam, Shri Jishnu Baruah, Additional Chief Secretary, Social Welfare Department, Shri AnuragGoel, Secretary, Health and Family Welfare Department, Dr. J B Ekka, Principal Secretary, Transformation & Development Department, Shri Bhaskar Barua, Former Secretary, Ministry of Agriculture, Government of India amongst other Government officials from State and Districts, Academicians, Civil society Organizations and individual experts from and outside the State.

Four technical sessions on (i)Nutrition Scenario and issues and challenges in implementation of ongoing programs- Assam, (ii) Food Security & Issues and challenges in implementation of ongoing programs – Assam, (iii) Efforts towards developing M&E: System for SDGs tracking and (iv)Eat Right India Movement were conducted during the workshop. Deliberations from each of the sessions have provided valuable inputs which have been incorporated in the plan in the form of suggested interventions.

183


A Policy seminar on multisectoral convergence for improved nutrition was co-organised by CFNS and CSDGs on 25th of January, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended by Senior Government officials of Assam from Health, Education, Social Welfare and Public Health and Engineering Departments, Civil Society Organizations including UNICEF, UNDP, UN Women and Piramal Foundation and Individual Experts in the field of Nutrition.



• To promote Mother and Child Protection (MCP) Card as a counselling tool for Mothers and

Family members and renaming it as “Mother and Child Health and Nutrition Card (MCHNC)”


• Social audit of Integrated Child Development Scheme (ICDS) and other nutrition linked

schemes • Infrastructure development of health facilities to ensure privacy for Antenatal Check-ups and

Child Care ; Solar electrification of AWCs and health sub centers in char areas • Improving Mobility of ASHA Workers and ANMs in char areas by providing travel support

and other incentives – Department of Health and ICDS should ensure timely reimbursement of travel

184



• Panchayats &Rural Development) and engagement of NGOs in taking forward the mission for early completion of construction of 1500 AWCs.

• “Model Anganwadi Centers” to be constructed in every district of the state by merging the

funds from MGNREGA, Social Welfare and other sources including CSR, MP/MLA area development fund, Panchayat fund, local interested persons (NRIs and others) to act as a good example for other centres to follow

. • Government Portal for creating a fund for development of Anganwadi Centers where

individuals residing in country or outside who are willing to spend money for development of their native villages can contribute

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186




• Integration of Self Help Groups under Rural Livelihood Mission with ICDS and

Panchayati Raj Institution for effective delivery of Nutrition Services at AWCs and household level

• Capacity building of AWWs, ASHAs and SHGs using incremental learning modules of

Poshan Abhiyaan in local languages

• Need for uniformity in the social behaviour change messages communicated to the communities – different messages from different players for the same topic tends to confuse the people

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Annexure 6: MCP Card

For further details please refer to “Indigenous recipes from locally available foods in Assam (Training cum Counselling Tool)

Multi-sectoral Nutrition Action Plans: Barpeta, Udalguri and ...

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