Process Assessment: Hot Cooked Meal in Four Pilot Districts of Madhya Pradesh

72 Pages·2015·1.49 MB·English

by  Ranu Arora

Report on

Assessment of SuPoSHaN

Program (2014-15)

Madhya Pradesh Technical Assistance and Support Team
(MPTAST) under the Madhya Pradesh Health Sector Reforms
Program (MPHSRP)

JULY 2015

SUBMITTEDTO:
DEPARTMENT OF INTEGRATED CHILD DEVELOPMENT SERVICES,
GOVERNMENT OF MADHYA PRADESH

SUBMITTED BY

Madhya Pradesh Technical Assistance and Support Team (MPTAST)

FHI 360
H-5, GROUNDFLOOR, GREENPARK EXTENSION
NEW DELHI 110016
TEL: [phone]
www.fhi360.org
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Principal Investigators

Mr. Nilesh Pandey, Senior Research Specialist, MPTAST, FHI360, Bhopal, India
Ms. Pragnya Das, Nutrition Specialist, MPTAST, FHI360, Bhopal, India

Contributors

Government of Madhya Pradesh
Smt. Pushplata Singh (IAS), Commissioner-Integrated Child Development Scheme (ICDS)
Mr. Akshay Shrivastava, Joint Director-ICDS
Mr. Mahendra Dwivedi, Joint Director-ICDS
Mr. Subodh Garg, Assistant Director-ICDS
District officials, Anganwadi Center functionaries and beneficiaries of the ten study districts

DFID India
Dr. Rashmi Kukreja, Health Advisor DFID India
Mr. Sanjay Sharma, State Representative, Madhya Pradesh
Technical Review
Dr. Shubhada Kanani, Senior Technical Advisor- Nutrition, MPTAST
FHI 360/India Team
Dr. Bitra George, Country Director
Ms. Sumita Taneja, Director - Programs

MPTAST/ Bhopal Team
Dr. S. Krishnaswamy, Team Leader
Mr. Naresh Ramnani, Nutrition Specialist
Ms. Ranu Arora, Program Associate and Documentation Officer
Ms. Dimple Save, Consultant-Nutrition
Ms Seema Jain, Consultant Research

Field Assessment Team

Mr. Brijesh Kumar, District Program Officer, District-Satna
Mr. Subhash Moghe, Technical Officer- Nutrition, District-Sehore
Mr. Altaf Ali, Technical Officer- Nutrition, District-Chattarpur
Mr. Anand Verma, Technical Officer- Nutrition, District-Dhar
Mr. Vivek Upadhayaya, Technical Officer- Nutrition, District-Dindori
Ms. Rashmi Gupta, Technical Officer- Nutrition, District-Jabalpur
Mr. Shiva K. Kishore, Technical Officer- Nutrition, District-Sagar
Mr. Dinesh Kumar Pal, Technical Officer- Nutrition, District-Rewa
Mr. Pankaj Solanki, Technical Officer- Nutrition, District-Damoh
Mr. Santosh Sharma, Technical Officer- Nutrition, District-Tikamgarh
Mr. Raghvendra Pandey, Technical Officer- Nutrition, District-Panna
Mr. Sant Kumar Mahato, Technical Officer- Nutrition, District-Badwani
Mr. Heena Pandey, Technical Officer- Nutrition, District-Jhabua
Mr. Shailendra Mishra, Technical Officer- Nutrition, District-Mandla
Mr. Pratyaksh Pandey, Technical Officer- Nutrition, District-Sidhi
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Mr. Abhilash Tiwari, Consultant
Mr. Abhishek Agrawal, Consultant
Mr. Anant Ram Vishwakarma, Consultant
Mr. Arif Anees, Consultant
Dr. Imteyaz, Consultant
Ms. Harsha Ahirwal, Consultant
Ms. Kirti Kushwah, Consultant
Mr. Mayank Sharma, Consultant
Ms. Neelam Vishwakarma, Consultant
Ms. Payal Chauhan, Consultant
Mr. Piyush Sharma, Consultant
Ms. Preeti Verma, Consultant
Mr. Rahul Gothane, Consultant
Mr. Rajesh Chauhan, Consultant
Mr. Ravi Kasnniya, Consultant
Mr. Sachin Goyal, Consultant
Mr. Satish Sitole, Consultant
Mr. Satyaveer Mishra, Consultant
Mr. Satyendra Bhatt, Consultant
Mr. Shahwar Khan, Consultant
Mr. Shakti Sakre, Consultant
Ms. Shobha Singh, Consultant
Ms. Shweta Dubey, Consultant
Mr. Upendra Singh Jadon, Consultant

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Contents

Executive Summary ......................................................................................................................................... 1
CHAPTER 1 Background ............................................................................................................................... 8
Overview of Nutritional Scenario in Madhya Pradesh .......................................................................... 8
Demographic and Socio-Economic Profile of the State ......................................................................... 9
ICDS Program in Madhya Pradesh ........................................................................................................ 10
ICDS in Mission Mode in Madhya Pradesh .......................................................................................... 10
Nutritional Status of Children in Madhya Pradesh ............................................................................. 11
Assessment of Nutritional Status of Children below 5 years in Madhya Pradesh, 2010 ................ 11
Management of Severe Acute Malnutrition (SAM) – National scenario .......................................... 12
Management of Severe Acute Malnutrition (SAM) in Madhya Pradesh .......................................... 13
Community based management of Severely Underweight Children in Madhya Pradesh ............. 13
State- launch of SuPoSHaN program by Govt. of MP in January 2014 ........................................... 13
Objectives .................................................................................................................................................... 14
Strategy ........................................................................................................................................................ 14
Activities ...................................................................................................................................................... 14
Preparedness and roll-out of the program (six months/ 100 days) .................................................... 15
Assessment of SuPoSHaN Programme ................................................................................................... 17
Chapter 2 Assessment Study – Objectives and Methodology ................................................................. 18
Objectives of the Assessment .................................................................................................................... 18
Study Area ................................................................................................................................................... 19
Methodology ................................................................................................................................................ 19
Sampling ...................................................................................................................................................... 19
Tools ............................................................................................................................................................. 20
Limitations of the assessment ................................................................................................................... 21
CHAPTER 3 FINDINGS .............................................................................................................................. 22
3.1 Changes in Nutritional Status of Children ...................................................................................... 22
3.2 Who benefited most? ........................................................................................................................... 28
3.3 Factors effecting changes in weight/nutrition status ...................................................................... 34
CHAPTER 4 Management of Sneha Shivir cum SuPoSHaN Program ................................................ 40
Availability of Human Resource and their training ............................................................................. 40
Availability of Measuring Instruments ................................................................................................... 41
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Availability of Utility Materials ............................................................................................................... 41
Status of Records Maintenance ................................................................................................................ 42
Sneh Shivirs Preparatory Work .............................................................................................................. 43
Home Visits during Sneha Shivirs ........................................................................................................... 44
Provision of Cooked Meal for Children in Sneha Shivir ..................................................................... 45
Monitoring & Supervision Visits ............................................................................................................. 45
CHAPTER 5 Mothers Knowledge Attitude and Practices ...................................................................... 48
Profile of the Respondent .......................................................................................................................... 48
Number of Children in Respondents Family ......................................................................................... 49
Care during Pregnancy ............................................................................................................................. 50
Status of Safe Child Birth ......................................................................................................................... 51
Awareness about the Growth Monitoring of Child .............................................................................. 52
Awareness on SuPoSHan Sneha Shivir .................................................................................................. 52
Respondents Awareness on Hygiene Education .................................................................................... 53
Orientation and Group Discussions with Mothers during SuPoSHan Sneha Shivir ...................... 55
Status of Breast Feeding ............................................................................................................................ 56
Complementary feeding of Infants .......................................................................................................... 57
Information about Childhood Illness ...................................................................................................... 58
Respondents Knowledge & Attitude on Food Intake ........................................................................... 60
Knowledge & Attitude of Hand Washing............................................................................................... 62
CHAPTER 6 CONCLUSION/WAY FORWARD .................................................................................... 64
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Acronyms
ABM Atal Bal Mission
AHS Annual Health Survey
ANC Ante Natal Care
ASHA Accredited social health activist
AWC Anganwadi Centers
AWH Aanganwadi Helper
AWW Aanganwadi Worker
BCC Behavioral Change Communication
CDPO Child Development Project Officer
C-MAM Community based management of malnutrition
DFID Department for International Development
DPO District Program Officer
DWCD Department of Women and Child Development
FHI360 Family Health International -360
GDP Gross Domestic Product
HCM Hot Cook Meal
HDI Human Development Index
ICDS Integrated Child Development Scheme
IDA Iron Deficiency Anemia
IDD Iodine Deficiency Disorders
IFA Iron Folic Acid
IMR Infant Mortality Rate
INR Indian Rupees
IYCF Infant and Young Child Feeding
MMR Maternal Mortality Ratio
MPHSRP Madhya Pradesh Health Sector Reform Project
MPTAST Madhya Pradesh Technical Assistance Support Team
NIN National Institute of Nutrition
NRC Nutrition Rehabilitation Centers
PEM Protein Energy Malnutrition
RSOC Rapid Survey on Children
SAM Severe acute malnutrition
SERP Society for Elimination of Rural Poverty
SRS Sample Registration System
SS Sector Supervisor
SuPoSHaN Supportive Program on Sustaining Health and Nutrition
SUW Severely underweight
THR Take Home Ration
VAD Vitamin A Deficiency
VHND Village health and nutrition day
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Executive Summary

Madhya Pradesh (MP) has a Human Development Index (HDI) value of 0.375 (2011), which is
below the national average. According to the Sample Registration System (SRS)1, the infant
mortality rate (IMR) in MP stands at 59 per 1,000 live births, compared to national average of
44:1,000. The State’s maternal mortality ratio (MMR) is 310 per 100,000 live births, compared
to the national average of 3012. Similarly, under five (U5) mortality also continues to be high
(NFHS III recorded U5 mortality rate in MP as 94)3. In Madhya Pradesh, of the 52%
undernourished, 32% are in mild-moderate grades (who may slip to severe grade) and 20 % are
in severe grade. (Source NIN Survey 2010).

Realizing that equal attention is required to all grades of nutritional status, and that emphasis
should be on increasing the number of well-nourished children, the Department of Women and
Child Development (DWCD), GoMP launched a state wide initiative in phases, built on Govt. of
India's Sneh Shivir model of community based management of malnutrition (C-MAM) and gives
equal emphasis to the prevention of malnutrition. Christened as SuPoSHaN (Supportive Program
on Sustaining Health and Nutrition) and launched on 21st January, 2014; the program aims at a)
rehabilitation of severely underweight (SUW) children (0-5 years) in day care centers called
Sneh Shivirs located at the Anganwadi Centers; and b) prevention of under-nutrition with focus
on helping the mild to moderately undernourished to move towards normal nutrition.

After the program was rolled out in March 2014, 3,174 SuPoSHaN Sneha Shivirs (Phase I) have
been conducted during March to August 2014 and 1555 Shivirs (Phase II) during July to
December 2014 covering approximately 60,000 severely underweight children. For mid-strategy
corrections, Department of ICDS planned for an assessment through an external agency.
MPTAST provided the TA to conduct SuPoSHaN Assessment.

Objective of the study

The objective of assessment is to study the outcome and impact of initial phase of SuPoSHaN –
Sneh Shivirs already rolled out in March 2014 and July 2014 and identify strengths and gaps in
the SuPoSHaN Program implementation, so that mid-course corrections can be made and the
program suitably modified for greater impact on malnutrition in Madhya Pradesh.

Study design

Mixed method approach adopted for assessment of SuPoSHaN Program. A combination of both
quantitative and qualitative methods were used to elicit the required information. Over all 200
SuPoSHaN Shivirs were sampled for the survey, of which 132 SuPoSHaN shivirs were from
March 2014 and 68 SuPoSHaN Shivirs from July 2014.

1 Office of the Registrar General of India (2012), SRS Bulletin, Sample Registration of India, New Delhi: Ministry of Home
Affairs, Government of India.
2 Office of the Registrar General of India (2011), Annual Health Survey 2010–2011 fact sheet, Madhya Pradesh, New Delhi:
Ministry of Home Affairs, Government of India.
3 International Institute for Population Sciences (IIPS) and Macro International.2007. National Family Health Survey (NFHS-3),
2005–2006: India: Volume I. Mumbai: IIPS
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In the first stage 10 districts were sampled from 10 ICDS divisions, one district sampled using
SRS from each ICDS division. In second stage, district wise stratification of SuPoSHaN Shivirs
was done for Rural, Urban and Tribal Projects. Area wise (Rural, Urban and Tribal)
proportionate number of Shivirs (March and July 2014) are calculated from the total district
sample. Shivirs in each of the rural, urban and tribal projects were selected by using probability
proportion to Size sampling (PPS). All children of identified SuPoSHaN Shivir were taken up for
weight measurement and their parents (Mother) for interview.

Data were gathered using Shivir checklist (200 Shivirs) which covered details of facilities,
services, SuPoSHaN activities, coverage, human resource and training, maintenance of record
and registers etc, Child profile (2193 Sneh Shivir Children) which includes information of Sneh
Sivir Child Profile Card maintained by AWW and weight of the child (1250) on the date of visit,
In-depth Interview of mothers (1373) of identified Sneh Sivir Children) and IDI of Service
Providers.

Analysis of the findings have been presented in terms of mean weight children, nutrition status of
children according to weight for age by Standard Deviation classification recommended by
WHO, Normal: >Median -2SD, Moderate underweight: <Median -2SD to <Median -3SD, Sever
Underweight: <Median -3SD, appropriate significant test and Percentage.

Key findings

Changes in Nutritional Status of Sneh Shivir Children

Significant difference has been observed between the nutritional status of children at the time of
visit/post (December 2015) and at the time of start of shivir during screening/ pre (March and
July 2014) (𝑥2 = 337.59, P<.001). At the initiation of shivirs, of the admitted children, 66 percent
were severely underweight and 28 percent were moderately underweight (on borderline of
severe-moderate under nutrition). This proportion changes to severe 36 percent and moderate 43
percent on day of survey. There was significant improvement in nutritional grade of the severely
underweight children, nearly 30 percent of the severe malnourished children moved to moderate
or normal category. Before initiation of the Shivir only 5.6 percent children were in normal
category, this figure shows increase to 22 percent on the day of visit.

Phase wise data shows that, for Phase I, 26 percent of severe malnourished children moved to
moderate or normal category over a period of 10 months and for Phase II, 38 percent of severely
malnourished children moved to moderate malnourished or normal category over the six months.
A statistical significant difference observed on the nutritional status of Phase I (𝑥2 = 220.48,
P<.001) and Phase II (𝑥2 = 122.94, P<.001) children between screening (March 2014 for Phase I
and July 2014 for Phase II) and date of visit (December 2014).

District wise analysis of child nutrition status for Phase I children shows variations across
districts on improvement in Children nutrition status. Districts which are below the total/state
average (22%) on normal category children are Bhind (9.7%), Harda (14%), Alirajpur (14.7%),
Gwalior (13.7%) and Rajgarh (17.5%). Districts which are above than state average on
improvement in child nutrition level at normal category are Seoni (35%) and Singroli (35%).
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Gender wise analysis shows the upward shift in nutritional status is more among boys as
compared to girls. Age wise analysis shows the upward shift in nutritional status is more in lower
aged children than the higher aged children. Social category wise analysis shows the upward
shift in nutritional status is more in General Caste category than Scheduled caste (SC) and
Scheduled Tribe (ST) category children. Economic Category wise analysis shows the upward
shift in nutritional status is more in APL (above Poverty Line) category children than BPL
(Below Poverty Line) category children. Birth weight wise analysis shows the upward shift in
nutritional status is more in Birth weight less than 2.5 kg children than birth weight above 2.5kg
children. Analysis by number of days children participated in 12 days Sneh Shivir shows the
upward shift in nutritional status is more in children participated maximum number of days in
Snhe Shivirs than who participated less number of days in the Sneh Shivirs.

Children’s participation in Sneh Shivir Activities

In around 80 percent the shivirs, children participated regularly for 12 days in the Sneh Shivir
activities. Around 70 percent mothers regularly participated in the 12 days Sneha Shivir. As per
Sneha Shivir records weight of around 80 percent children taken regularly for 12 days. As per
Child Profile Card, complete record of growth monitoring was maintained for 66 percent
children and counselling of mother (65 percent) on child growth monitoring was done. Around
60 percent Phase I children received breakfast, lunch and third meal and around 70 percent
received three meals during Phase II.

Home Visits, Mangal Diwas and IEC preventive activities

During preventive phase of SuPoSHan Programme, as per the child profile card available at
Sneha Shivir, reported percentage of children home visits range from 70 percent to 60 percent
during different periods of visit (from 18th day to 6 months) in Phase I and II of Program,
children weight measured ranges from 70 percent to 56 percent and counseling with mothers
ranged from 60 percent to 40 percent. During discussion with mother it was found that these
visits were merely for taking weight of the children.

During preventive activities of SuPoSHan Abhiyan, 20 mangal (Tuesday) diwas and 20 days IEC
activities were organized. Two-third of the mothers never participated in any mangal diwas and
same was found in both Phase (Phase I & II). Average 17 to 18 percent mothers participated 4 in
four Mangal Diwas each month and around 18 percent participated in 2 or 3 mangal diwas
activities. Three-fourth of the mothers never participated in any IEC activities and same was
found in both Phase (Phase I & II). On an average around 10 percent mothers participated in two
days IEC activities per month and only 7 to 8 percent mothers participated in four IEC activities
each month.

Training of stakeholders on SuPoSHaN

On an average three member Gram Sabha Swasth Gram Tadarth Samiti (GSSGTS) and Poshan
Mitra in all Sneha Shivirs AWCs, received one day training on Sneh Shivir. AWW and two
Poshan Mitra who received training on preparing Sneh Shivir work plan was 82 percent for phase
I and 71 percent for phase II. Only in 27 percent Sneha Shivir AWW and Poshan Mitra received
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