Combating Child Malnutrition in Maharashtra - The Marathwada Initiative and
the Road Ahead
V. Ramani
Director General
Rajmata Jijau Mother-Child Health and Nutrition Mission
Aurangabad, Maharashtra, India
( A Mission of the Government of Maharashtra )
THE MARATHWADA INITIATIVE
The impetus for launching a concerted campaign for tackling the scourge of
malnutrition in children in the 0-6 age group had its genesis in the fourteen
child deaths, apparently due to malnutrition, reported from the one village
of Bhadali, taluka Vaijapur, district Aurangabad during the period 2000-2001.
What was unacceptable was that this took place barely seventy kilometres from
a major urban centre like Aurangabad and that this occurred after more than a
quarter century of implementing the Integrated Child Development Scheme
(ICDS) in Maharashtra.
2. The Malnutrition Removal Campaign launched in Aurangabad Division on 14
March 2002 focused on the following important parameters:
Complete (100%) survey of all children in the 0-6 age group.
100% registration of all such children.
100% weighing of all such children.
On the basis of weighing, classification of all children into
normal/grade 1 to 4 categories (as appropriate).
Special concentration on children in Grade 3 & 4 stages of malnutrition;
regular weighing, providing for health & nutrition measures for these
children.
Initiating measures for ensuring health and nutrition of pregnant mothers
to reduce incidence of low birth weight children.
Greater attention to children in the 0-3 age group given the greater
incidence of malnutrition in this age group and its implications for the
future development of the child.
Analysis of data to bring out the relative incidence of malnutrition
based on age, gender & social status (scheduled caste/tribe) etc.
3. The first & most important step was to enhance the coverage of children in
the 0-6 age group in the ICDS scheme, especially in respect of the population
living outside the coverage of the anganwadi area. Statistics showed that
barely 60% of the child population in the 0-6 age group was recorded in the
anganwadi registers. Thereafter arose the issue of timely weighing of
children, especially children who were suffering from Grade 3 & 4 levels of
malnutrition. A major problem here was the availability of weighing scales.
The problem was solved by the provision of 7000 weighing scales to Aurangabad
Division through the intervention of UNICEF. Children in grade 3 & 4 stages
of malnutrition were to be weighed once a month while other children were to
be weighed once every 6 months. The grade 3 & grade 4 children then formed
the core target group for both the ICDS & health machinery. Special attention
was given to devising schemes aimed at improving their nutrition and health
status with the objective of lifting them out of the severe malnutrition
stages. These included provision of supplementary nutrition, counselling of
the mothers as well as regular medical check-up of the children, particularly
those suffering from grade 3 and 4 malnutrition, who were to be weighed and
medically examined every month.
4. The results of the initiative belied the expectations. The initial number
of children in the 0-6 age group in the grade 3 & 4 stages of malnutrition in
Aurangabad Division in July 2002 was 7867, as per the ICDS records. With
improved survey & weighing efficiency, the number of children in grade 3 & 4
stages of malnutrition went up to 10705 in July 2002. The subsequent
concentration on Grade 3 & 4 children has seen the number come down to just
over 3000 in March 2004. As of April 2005, this figure has come down to below
500.
5. The reduction in the incidence of severe malnutrition (Grade 3 & Grade 4
stages) has been possible because of three factors:
Training of staff at all levels on a regular basis over the past three
years. The training programmes focused on all levels right from Collectors &
Chief Executive Officers (CEOs) to Dy. CEOs (ICDS), District Health Officers
(DHO), Medical Officers and Child Development Project Officers (CDPOs) right
upto Anganwadi Supervisors and Anganwadi Workers (AWW). Workshops were also
held for elected officials of Zilla Parishads & Panchayat Samitis to enlist
their active cooperation & support for the campaign.
Motivation of staff at all levels was one of the prime objectives of the
training programmes, apart from imparting skills in implementing & monitoring
the programmes. It was apparent that the ICDS staff had to be convinced and
enthused regarding the critical importance of the tasks they were carrying
out. The involvement right from the top in terms of regular workshops, visits
to anganwadis and the development of an interactive atmosphere for resolving
day to day issues infused new life into the machinery and gave them the
opportunity to take a proactive approach in solving the problems confronting
them. The Star Campaign to appreciate and recognize those anganwadis, blocks
and districts that were able to show no cases of severe malnutrition
introduced a spirit of healthy competition and enthusiasm in the field
workers.
Monitoring of results was crucial to the success of the campaign.
Detailed block level reviews (going down even to the supervisory level) at
the Divisional Commissioner level and regular follow up visits and reviews at
the blocks level by officers from the Divisional Commissioner’s office
stressed the importance of the campaign and kept it at the forefront of the
district and block level machinery priorities.
6. What is of particular significance is that the entire initiative required
no additional budgetary support from government nor was any additional staff
asked for. The existing ICDS machinery was motivated to perform to its
fullest potential and devise local workable solutions to resolve problems
arising at the local level. Regular medical check-ups of children in the 0-6
age group also showed a distinct improvement after the commencement of the
campaign. Most importantly, the enthusiasm of the field-level workers
translated into a significant community involvement in the campaign with
far-reaching implications for the success and sustainability of the campaign.
EXTENSION OF THE MARATHWADA INITIATIVE TO OTHER AREAS
7. The focus in the media in the past couple of years on deaths of children
allegedly due to malnutrition in the tribal pockets in the districts of
Nandurbar and Amravati highlighted the need to have in place an effective
mechanism for covering all children in the 0-6 age group under ICDS and
health programmes and focusing on reduction of severe malnutrition as the
first goal in the ultimate war against malnutrition and child mortality. The
Marathwada initiative has shown that it can be replicated elsewhere without
any major budgetary support, by focusing on significant improvement of
service delivery systems in the ICDS and health sectors. Such an initiative
would be of particular relevance in areas that show a higher incidence of
grade 3 & 4 malnutrition in the 0-6 age group, arising out of inadequate
physical infrastructure as well as poor service delivery systems,
particularly in the ICDS and health sectors.
ADOPTION OF MALNUTRITION REMOVAL AS A STATE MISSION & CREATION OF A UNIT FOR
IMPLEMENTATION OF THE MISSION
8. Malnutrition reduction and removal requires to be placed at the centre
stage of any State’s priorities. The State of Maharashtra has, therefore,
treated the removal of malnutrition as a MISSION, which is to achieve
quantifiable goals in a specific time frame. The Rajmata Jijau Mother-Child
Health & Nutrition Mission (Mission) functions under the overall guidance and
supervision of the Chief Minister, indicating the highest political sanction
for this important initiative. A Mission Steering Committee under the
Chairmanship of the Chief Minister with Ministers of the concerned
departments like Women & Child Development, Health, Tribal Development, Rural
Development, etc. would review the progress on a regular basis. A second
Committee, the Mission Monitoring & Implementation Committee, under the
Chairmanship of the Minister for Women & Child Development, with Ministers of
all concerned departments as members, would directly oversee the
implementation of the Mission objectives. The Mission Advisory Committee
under the Chairmanship of the Chief Secretary with all concerned departmental
Secretaries represented on the Committee would take stock of the achievement
of project milestones and resolve bureaucratic bottlenecks in the effective
implementation of the Mission objectives. The constitution of these three
Committees is intended to send out a clear message that the goal of
malnutrition removal and child mortality reduction is receiving attention at
the highest levels of government and that the highest level of involvement is
expected from the entire government apparatus.
9. The coordination, training and monitoring functions for successful Mission
implementation require a dedicated full-time unit geared to achievement of
the Mission goals. A State Mission Unit has, therefore, been established to
coordinate the efforts of the various departments and provide feedback on the
measures required for effective implementation of the Mission objectives. To
ensure that the Unit is able to perform its role effectively and to emphasise
the importance given to this Mission by the State, the composition of the
Unit is as under:
Additional CEO rank officer .............. Director (Training)
Dy. CEO rank officer ....................... Director (Monitoring)
DHO rank officer ............................. Deputy Director (Health)
CDPO rank officer ........................... Assistant Director (Child Development)
One accounts officer
Two staff for research & monitoring
Two stenographers (English & Marathi)
Supporting clerical staff (2)
10. The Director General would report on a regular basis directly to the
Chief Minister’s Secretariat, the Minister for Women & Child Development and
the Chief Secretary, with the Department of Women & Child Development acting
as the nodal department at the State level. The intention behind this is to
ensure effective coordination among departments as well as quick
implementation of decisions. The officers and staff comprising the Mission
Unit are to be taken on deputation from the State Government or hired on
contract basis. The Unit is staffed by those officers who were behind the
Marathwada initiative since this would enable the Mission to commence
activities immediately. The Unit has been located at Aurangabad for the
following reasons:
The earlier initiative was launched in this region.
Consolidation of the earlier initiative is possible; apart from
establishing the feasibility of the model, it would also serve as a useful
demonstration of the model, which can be studied by groups from elsewhere in
the State and country.
The team, which spearheaded the earlier initiative, can be rapidly
assembled with minimum cost and effort.
Coordination of the activities across the State would be possible from
this central location, with regular field visits and coordination meetings at
divisional and district headquarters ensuring that the tempo of activity is
maintained.
The Mission Unit would function as an autonomous unit, with financial and
administrative autonomy, to ensure effective functioning. The Director
General would bring to the notice of the State Government the corrective
measures/further policy decisions required for successful realisation of the
Mission objectives.
11. A three-stage approach has been envisaged for the implementation of the
malnutrition reduction programme:
The first stage would, over the first year, cover the five tribal
districts of Thane, Nasik, Nandurbar, Amravati & Gadchiroli.
In the next stage, spread over the next two years, the ten other
districts with a high percentage of tribal population would be the focus of
attention.
The final stage, again over a two-year period, would involve extension of
the Mission to the rest of the State, especially areas like urban slums that
have hitherto received lesser attention.
The Mission, therefore, envisages a five-year period for significantly
reducing the level of child malnutrition and mortality in the State. It needs
to be pointed out that the phases are not mutually exclusive. While
implementation is going on in one phase, survey and weighing of the child
population in the areas covered by the subsequent phases would be commenced
along with necessary training for the concerned personnel. However, to
maintain the focus, areas earmarked for a particular phase will receive the
full package of measures during that phase. Obviously, there would be
continuing involvement with implementation aspects in an area even after the
conclusion of a phase along with ongoing evaluation to establish the
sustainable nature of the changes brought about by the Mission.
12. The Mission programme involves the following aspects:
Assessing and improving the survey efficiency in the blocks to ensure that
all children in the 0-6 age group are brought within the ambit of the
programme.
Significantly improving the weighing efficiency in the blocks.
Preparation and maintenance of growth charts of the children and special
monitoring of the children who are in Grade 3 and 4 stages of malnutrition,
with the objective of attempting to remove altogether such malnutrition.
Special focus on antenatal care for expectant mothers and children in the
0-3 age group in respect of immunisation, nutrition and health care access.
Implementation of pilot schemes for Integrated Management of Neonatal &
Childhood Illnesses (IMNCI) [the Central Government-WHO/UNICEF initiative]
and Home-Based Newborn Care (HBNC) [modelled on the Gadchiroli SEARCH
pattern] for impacting on infant mortality. This would require close
coordination between the ICDS and health departments. Studies have revealed
that the prime causes of infant and child mortality include diarrhoea,
pneumonia, measles and malaria. The greater proneness of underweight children
to disease requires special focus on this group. Regular follow-up visits to
the homes of these children by the AWW & Auxiliary Nurse Midwife (ANM),
interactions with the mother and provision of advice on good feeding
practices as well as making available prompt medical treatment and
supplementary nutrition would greatly help in reducing the incidence of child
mortality.
Education of adolescent girls to reduce the incidence of child marriages,
promote spacing between two issues and developing awareness on various
aspects of malnutrition.
Seeking to evolve a social consensus on the measures, both short and
long-term, required to combat malnutrition and child mortality with the
ultimate aim of transferring the ownership of the programme to civil society.
COMPONENTS OF THE MISSION
13. The Mission would focus on the following four objectives:
Training & Motivation: A basic requirement is the need to infuse a sense
of purpose in the field-level workers of different service delivery
departments, especially the ICDS and health departments. There is also need
to upgrade the skills and capabilities of the staff at different levels so
that they are able to meet the Mission goals. Above all, it is essential to
sensitise the entire machinery to the human aspects of the issue so that they
look for solutions rather than treating their job as a routine exercise. Four
levels of training are contemplated, at the State, district, block/PHC and
village levels. The State training module would cover all State and district
officers upto the level of Deputy CEOs, ICDS and DHOs and would focus on
policy and coordination issues. The district training module would include
all staff at the district level, officers like Project Officers, Tribal
Development, CDPOs and Medical Officers and select Anganwadi Supervisors,
AWWs and ANMs who could then function as Master Trainers for other staff at
PHC and village level. The district training would focus on operational
issues, including survey and weighing of children and inputs on monitoring
the health and nutrition status of children. The block/PHC training would
enable dissemination of information and sharing of experience amongst all
AWWs/ANMs and aim at promoting maximum cooperation and coordination between
the ANM and AWW in systematic coverage of the entire mother/child population
in the village. Village-level training would draw in the community itself to
internalize the goals of the Mission.
Coordination: The Mission cannot hope to succeed in its objectives unless
there is a high degree of cooperation and coordination among the different
departments involved. This coordination would need to exist right from the
village to the State Government level. In particular, coordination at the
implementation and supervisory levels is a must. The AWW-ANM link has already
been dealt with earlier. At the block level, the CDPO and the Medical Officer
would have to work in close liaison to ensure fulfillment of the common
objectives. The same applies at the district level to the Dy. CEO (ICDS) and
the DHO. The Collector and the Chief Executive Officer of the Zilla Parishad
are key officers in ensuring the highest possible degree of coordination
amongst the departments, since departments like Tribal Development, Water
Supply and Public Works are also entrusted with crucial service delivery
responsibilities. An important aspect of the coordination is to devise common
reporting systems for the ICDS and Health departments in respect of
indicators relating to mother and child health and nutrition.
Monitoring & Evaluation: While data is copiously gathered at field level
and transmitted periodically to the levels above, very little analysis of
this data aimed at corrective action is undertaken. The different reporting
formats for the ICDS and Health departments are one of the major contributory
factors to this situation. Consistent evaluation of block-level data,
disaggregated to even lower levels, can form the basis for meaningful policy
interventions. It can also help in identifying crucial gaps or deficiencies
in service delivery systems in order to rectify these. The Mission would aim
at developing an online reporting system that minimizes paperwork and enables
two-way communication between the field machinery and the policy levels.
Community involvement & participation: All government efforts would be
ineffectual in the absence of community involvement. Promoting healthy
feeding practices like early and sustained breast-feeding and complementary
nutrition as well as hygiene and ensuring complete immunisation and prompt
treatment of illnesses like diarrhoea through ORT require an active community
initiative. Local government representatives as well as non-government
organizations (NGOs) would have to be involved in these efforts to promote
community participation as well as to address issues related to changing
social attitudes and beliefs.
14. With the State Government taking the initiative in operationalising the
Mission and UNICEF, the premier multilateral agency involved with maternal
and child care, supporting the Mission, both financially and in terms of
technical assistance, the Mission represents a comprehensive and
collaborative effort to significantly impact on child malnutrition and
mortality aimed at achieving the United Nations Millennium Development Goals
for the State by the year 2010 itself. The Mission’s activities comprising
training activities, monitoring and coordination would also, in due course,
aim to draw on funding from multilateral agencies like UNFPA and the World
Bank as also bilateral agencies like the DFID and GTZ. In fact, the
commitment of the State Government in making child malnutrition and mortality
removal its priority mission is expected to lead to enhanced assistance from
these agencies to the programmes of different departments which contribute to
the removal of malnutrition. Discussions are also currently under way for
creating a public-private partnership involving the government, corporate
sector and community-based and non-government organisations, which would work
in close liaison with the concerned communities (UNICEF & Unilever are taking
the lead in this regard in association with the Government of India and the
Government of Maharashtra).
15. In the context of the focus today on the issue of child malnutrition and
mortality and maternal health, the Rajmata Jijau Mother-Child Health &
Nutrition Mission represents a low-cost, viable strategy for tackling these
issues while ensuring that the State evolves a coordinated and integrated
approach in its efforts to significantly reduce child malnutrition and
mortality.
04 March, 2008
Rajmata Jijau Mother-Child Health & Nutrition Mission
First Floor, "Bhaskarayan", Plot No. 7 E/1, Town Centre, CIDCO,
Aurangabad - 431 003 India
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