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close this bookManaging Successful Nutrition Programmes - Nutrition policy discussion paper No. 8 (UNSSCN, 1991, 152 p.)
close this folderPART II: PROGRAMME SUMMARIES
View the document(introduction...)
View the document1. Drought Relief Programme (Human Relief), BOTSWANA
View the document2. National Nutrition and Holistic Care Programme (NNHCP), COSTA RICA
View the document3. Health and Social Development Programme (HSDP), COSTA RICA
View the document4. Institutional Support for Health and Nutrition, THE GAMBIA
View the document5. Improving Child Nutrition, Weaning Food Project, GHANA
View the document6. Integrated Child Development Services (ICDS), INDIA
View the document7. Tamil Nadu Integrated Nutrition Project (TINP), INDIA
View the document8. Family Nutrition Improvement (UPGK), INDONESIA
View the document9. Project COPACA, PERU
View the document10. Alternative School Nutrition Programme (ASNP), THE PHILIPPINES
View the document11. Pilot Food Price Subsidy Scheme, THE PHILIPPINES
View the document12. Barangay Integrated Development Approach for Nutrition Improvement of the Rural Poor (BIDANI), THE PHILIPPINES
View the document13. Joint WHO/UNICEF Nutrition Support Programme (JNSP), IRINGA REGION, TANZANIA
View the document14. Nutrition and Primary Health Care, THAILAND
View the document15. Community Based Nutrition Intervention, NORTH-EAST THAILAND
View the document16. Women, Infants and Children (WIC) Programme, U.S.A.
View the document17. Supplementary Food Production Programme (SFPP), ZIMBABWE
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7. Tamil Nadu Integrated Nutrition Project (TINP), INDIA

Ms J. Balachander

Objectives: To reduce malnutrition and consequent high mortality in children under-three; to improve their health and nutritional status and that of pregnant and lactating women.

Operational objectives:

· Nutrition surveillance through regular growth monitoring of all children in the age group 6-36 months.

· Help rehabilitate the malnourished and head off proximate malnourishment through short term food supplementation.

· Reduce the mortality and morbidity due to protein-energy malnutrition and specific nutrient deficiencies.

· Improve the nutritional status of pregnant and nursing women.

· Strengthen health services to provide adequate back-up support to the nutrition effort.

· Improve home child care and feeding practices through education.

· Improve the efficiency and the impact of the above through sustained performance monitoring and evaluation.

Duration: October, 1980 to March, 1989.

Implemented by: The Government of Tamil Nadu/Department of Social Welfare and TINP Project Coordinator's Office through the Directorate of Social Welfare and the Directorate of Public Health and Preventive Medicine, with external support from the World Bank.

Budget: The programme was designed to be highly cost-effective. It has been estimated that "adjusted" annual costs of TINP are roughly Rs. 113 million, or Rs. 12,500 per centre. This works out to a cost of nearly Rs. 10 per person living in the target area per year. Thus the per capita (not per beneficiary) cost of the program is roughly US$ 0.75 per year at current exchange rates (Dapice, 1986). A detailed budget is included in Annex 7.1.

Programme Components: The project had three major components to achieve the operational objectives already outlined: nutrition, health, and communications. Project implementation was to be continuously monitored by the monitoring wing and periodically evaluated by an outside agency.

· Nutrition services delivery formed the core of TINP I. A Community Nutrition Centre was established in each village (population 1500) and run by a Community Nutrition Worker (CNW). The CNW surveyed all households in the area (survey updated every quarter) and registered target children in the age group 6-36 months. These children were weighed each month and their weights plotted on growth charts to determine their nutritional status on a weight-for-age basis and to monitor their growth. Children determined to be at risk (i.e. with Grade III/IV severe malnutrition, or showing signs of growth faltering - losing weight, failing to gain weight or showing inadequate weight gain between successive weighings) were admitted to a short term supplementary feeding programme. Pregnant women were also selectively fed. The supplement consisted of a cereal-pulse mix which was roasted, ground and sweetened with jaggery. The CNW administered Vitamin A prophylaxis (a 200,000 IU mega-dose every six months) to all children, along with deworming treatment (piperazine citrate, three times a year). Iron and folic acid was distributed to pregnant/lactating women. Monthly weighing sessions also provided workers the opportunity to check on the children's health needs (e.g. immunisation, management of diarrhoeal episodes) and to educate mothers.

· In recognition of the synergism between nutrition and health, it was decided to simultaneously upgrade the infrastructure, supply position, and worker skills in the existing health system, in order to improve the delivery of mother & child health services. The project helped to deploy and train one female multi-purpose health worker (MPHW) in a health sub centre for a population of 5000 (4-5 villages), and in the absence of a village based health care worker, sought to establish a functional linkage between the nutrition and health care systems through the CNW. Specifically, those children who failed to respond to supplementation were to be referred to the health worker by the CNW for diagnosis, treatment and referral upward if necessary. The MPHW was also expected to deliver her package of MCH services through the Community Nutrition Centre, with the help of records and contacts made by the CNW. They were to make joint house visits for the purposes of nutrition and health education.

· Both the health and nutrition components were to be reinforced by a Communications Component which was designed to: i) make mothers more fully aware of the nutritional needs of children; ii) bring about better intra-family food distribution; and iii) enable the community to better handle its health and nutritional needs. The strategy used was to encourage families to adopt a limited number of specific practices to improve the nutrition and health status of children. These included the importance of colostrum and breast feeding, timely introduction of solid foods to supplement breast milk, home management of diarrhoea, immunization, and improved environmental hygiene.

Programme information on specific Workshop themes

Impact Evaluation: The project covered about 43% of the state's rural population, reaching 1.1 million children (in the age group 6-36 months) and 0.28 million pregnant/lactating women. The terminal evaluation of the project found that the results with regard to changes in the nutritional status of children were impressive. A 55.5% reduction in severe malnutrition (Grade III/IV) was noticed over a period of 72 months in Phase I of the project. The reduction in subsequent phases was 24% over a period of 48 months in Phase II, and 35% over a period of 38 months in Phase III. In each phase, there was a corresponding upward shift in the overall grade distribution with an increase in the higher grades. The percentage of children in feeding (number of children fed/number of children weighed) declined from 40% to 25% by the end of the project. The evaluation also found the effect of the project to be long lasting. Children in the age group 37-60 months, who had been in the project, were enjoying better nutritional status than their counterparts who had not. Project impact as measured by the monitoring wing was even more impressive, owing to differences in baseline estimates.

The evaluation results show a spectacular fall in the clinical signs of malnutrition from 21.4% in the pilot block at the time of base line survey to only 3.4% at the time of terminal evaluation. The infant mortality rate in the project districts was found to have declined 29% in Phase I and 27% in Phase II. The reduction in Phase III was estimated to be 13%.

Process Evaluation: The terminal evaluation estimates that the effective participation rate (i.e. % of children weighed) was 77.2%. The measure of coverage as revealed by monitoring data was higher at 89%. The difference arises from the difference in the denominators (i.e. target population). While monitoring data used the CNC survey registers to determine the number of children in the target age group, evaluation was by sampling. The evaluation revealed that the CNWs survey may have been incomplete, excluding hamlets and less accessible areas of the village. However, coverage has increased remarkably and consistently over time so that one may expect that these levels will be reached in the later phases in the next few years. Reasons for exclusion are estimated to be problems of access (78%), refusal by mothers for reasons of sentiment (14%) and social status (3%). Overall coverage of target children has been excellent.

The monthly weighing was found to have been carried out regularly both on the basis of records and enquiry. The participation rate in supplementary feeding was 96.7% for the project area. On the basis of the evaluation sample, it is estimated that the rate of eligible children not participating in feeding was a low 7.5%. Children ineligible but participating was put at 2%. By and large the pattern of food distribution was deemed to have conformed to the ideal. Practically all mothers interviewed for the purpose of evaluation stated that the supplement was palatable and there had been no problems with digestibility. Most reported little sharing of the supplement or substitution for home feeding.

Although growth monitoring by the CNW was found to be regular and accurate, the maintenance of growth cards by mothers was disappointing. Enrollment of pregnant/lactating women in supplementary feeding was also poor, estimated at only 51% of those eligible. The low enrollment was attributed to the assigning of responsibility for their selection to the MPHW, whose multiple responsibilities made her an infrequent visitor to the Community Nutrition Centre.

Coverage for deworming was estimated to have been good, while Vitamin A coverage, which had improved after the responsibility was transferred to the CNW from the MPHW midway through the project, was still beset with problems of supply.

In respect to health services delivery, it was determined that there had been a reduction in the infant mortality rate and a clear decline in the incidence and hospital treatment of diarrhoea. DPT immunization was found satisfactory. In respect to other services, however, the coverage was determined to have been quite low and the nature of services provided quite weak. The input special to the project on the health side (i.e. the referral of children to the Primary Health Care system on failure to respond to supplementation) was also poorly implemented. Health service delivery was hampered by a number of structural problems within the health department, including multiple directorates, duality of control over key functionaries, a large number of vacancies, frequent transfers and lack of adequate training. The Government of Tamil Nadu has independently appointed an expert committee to go into the structural deficiencies of the health system. It is likely that significant changes in the existing structure will be recommended.

The Communications Component was evaluated to have been fairly effective. Significant improvements in knowledge, attitudes, and practices (KAP) of diarrhoea management and immunization were recorded. A wide range of skillfully packaged, appropriately targeted and appealingly presented communication materials was developed. Instructional materials for project functionaries and their training in communication skills have been particularly good. The component also played a significant role in bringing about inter-agency coordination at various levels in the organization. It was felt that consistent monitoring and the development of a coherent communication strategy with frequent feedback of results could improve the effectiveness of the component.

Planning: The Government of Tamil Nadu has been among the most aggressive of Indian States in its concern about malnutrition and interventions to effectively deal with the problem. Between 1970 to 1973, a Tamil Nadu Nutrition Survey (TNNS) was carried out under the joint auspices of the Central and State Governments and the United States Agency for International Development (USAID). The study was both a nutrition status report and an applied research study, and one of the most comprehensive and systematic efforts ever undertaken to assess the nutrition situation in the State. The TNNS principal conclusions were:

· About half the families in Tamil Nadu consume less than 80% of their calorie requirements.

· While some protein shortages occur, the most pressing need was for calories.

· Although economic growth and greater food production were necessary to close the calorie gap in the long run, some groups required urgent attention.

· The highest priority was for children under-three in whom malnutrition was a major cause of mortality.

· Pregnant/lactating women were the next highest priority because of the influence on the health and growth of the infant

· Food habits are major nutrition status determinants in Tamil Nadu, particularly among weaning children whose growth faltered dramatically across all income groups.

In addition, the Institute of Child Health at Madras had established the morbidity patterns among infants in the state which are contributing factors to malnourishment and a TNNS testing of a weaning supplement in one Tamil Nadu district demonstrated that food habits were amenable to change.

The Government of Tamil Nadu was fortunate to have its nutrition problems so clearly defined and the priorities spelt out However about 25 nutrition projects were already being implemented in the State at an annual cost of about $ 9 million. The Government was therefore unable to make any substantial additional commitment financially speaking, for nutrition and there was some uncertainty about the efficiency and impact of the existing interventions. Tamil Nadu sought IDA support to develop and install an improved system which would improve the targeting and lower the unit cost of the intervention.

The Government of Tamil Nadu proposed an intervention drawing on its own experience and from lessons learned in other developing countries. The project was discussed over 16 months of intense dialogue between IDA and the Government of Tamil Nadu and there was substantial refinement of the original project design.

The project adopted a focussed approach both in determining objectives and in ways of achieving them. The project was implemented on a block-by-block basis and phased in gradually over five years. In the first year the project design was tested in the pilot block and changes were made based on the pilot block review. The detailed monitoring and evaluation systems provided good information on aspects that worked and those that did not and sufficient flexibility was built into project design to make changes as necessary. After the pilot block, the village rather than the population of 1500 was treated as the catchment for a CNC. It was originally proposed that the supervision would check weigh children and confirm the CNWs selection of children for supplementation. This was dropped in favour of enhancing the skills of the CNW and enabling her to do the job right. Instead of an average of three weights for selection to supplementation, a single weight was used for practical considerations. The communications component that was to be run by outside consultants was retained in-house and made use of the vast human resources within the project. The Project Coordinator was allowed a small discretionary Project Management Fund to carry out innovative experiments. The delay and uncertainty of bureaucratic procedure was side stepped by an Empowered Committee consisting of principal secretaries to Government to clear proposals expeditiously. Recruitment and training of personnel and procurement of materials was carefully scheduled in advance of each phase so that project implementation could proceed apace. In general, planning enabled the smooth transition of the project from a single block phenomenon to a programme covering 173 blocks in nearly one half of Tamil Nadu.

Targeting: TINP was a highly targeted programme. Although caloric deficiencies are common almost across the board in Tamil Nadu, the Tamilnadu Nutrition Survey (TNNS) identified the weaning child (under threes) and the pregnant and nursing mothers as the most vulnerable groups. Amongst these groups it was decided to identify those at risk by applying a set of entry criteria for supplementary feeding. For the under threes, these included at risk grade classification (grades III/IV - immediate entry into feeding) or signs of growth faltering -i.e. if a child loses weight or maintains the same weight between 2 successive monthly weighings in the case of children 6-12 months and three successive weighings in the case of those 12-36 months. There was also an inadequate weight gain criteria for children who gained less than 300 gins. on the basis of weighings as above. In that case, a child was placed in special observation for a month after the necessary weighings and brought into supplementation in the succeeding month if weight gain continued to be less than 300 gms. The child would exit the feeding program after 90 days if he/she had gained 500 gms. If not, she would continue on supplementation and would be referred to the health worker to determine reasons for nonresponse. The weight gain was preferred over the grade method for selection after the pilot project in 1980. However since the impact of the project on moderate malnutrition (grade II) has been lesser and slower than on severe malnutrition, it is proposed to modify entry criteria to include those with moderate malnutrition, for feeding, rather than only those who fail to gain weight.

In the case of PNW's a set of six criteria was used for selection to feeding:

i) having a child currently enrolled for supplement
ii) lactating simultaneously with pregnancy
iii) fourth or more pregnancy
iv) having oedema
v) one parent families and
vi) having twins

Targeting greatly improved the nutrition education component of the programme. Growth monitoring and promotion was implemented since feeding hinged on the results of weighing and mothers had to be educated as to why some children were selected for feeding and not others. It led to cost effectiveness since the percentage of children being fed was only a third of all children (the percentage further fill to use fourth of all children at the end of the project). Further, selectivity ensured that the few children who required special attention got it There was an active effort to recruit those at risk by house visits rather than operate the centre on a drop in basis. Targeting also helped maintain the CNW's workload at a manageable level, enhancing the quality of her output. Selection was important in terms of preventing social and psychological dependency on the supplement and caused the project to focus on information and education as a means of sustaining community interest.

Human Resources Development: The success of TINP is in large part due to the outstanding human resources development of the nutrition staff. The focus, motivation and training of the individuals was clearly and consistently maintained to ensure excellent service delivery. The key players were the CNW and the CNI (Community Nutrition Instructress), both categories recruited exclusively for the project (see Annex 7.2). For the CNW, great emphasis was placed on her residence in the village and age and educational qualifications were often overlooked at the time of recruitment in order to meet this criterion. As a local woman and mother of a healthy child, the CNW enjoyed considerable credibility in the community and her own motivation to serve was high. Her presence in the village made it possible to establish contact with mothers outside normal working hours when most of them were unavailable or preoccupied with other duties.

An outstanding innovation in the project was the methodology of training for CNWs. Instead of the usual residential program in a training institution, CNWs were trained at the block headquarters (population 0.1 million). This arrangement enabled the CNW to commute daily and obviated the necessity of requiring village mothers to stay away from their families for any length of time. Secondly, the syllabus and training plan were designed by the CNI's who were both instructresses and second level supervisors. This had a double advantage: i) the training programme exhibited great familiarity with field situations; and ii) it enabled the instructress to continue to monitor the trainees and provide support in the field after the formal training was over. Great emphasis was placed in developing the communication skills of CNWs during training. Role play, group discussions and training in the use of communication materials were all carried out.

The last ten days of the CNWs training was done jointly with the Multipurpose Health Worker (MPHW) and the workers were taught to put project objectives in the context of their own villages. The training culminated in a meeting of the CNW with the village leaders to explain the programme and win endorsement for the project A comprehensive manual for the field workers was developed by the communication wing.

As already mentioned, the CNI made continuous in-service training of the CNW possible throughout the life of the project. Bimonthly review sessions were used to sharpen skills in taking weights, plotting charts and keeping records. Special attention was paid to workers whose performance was identified as weak. As the basic skills and knowledge of the CNWs improved, in-service training was formalized by devising modules for training in specific skills and using district training teams of nutrition, health and communication staff in each block.

The high quality of the CNWs in TINP is directly attributable to the CNI. A young and highly qualified hand, she was expected to play two distinct roles - that of trainer and of "supervisor of supervisors", monitoring program implementation. Each task enhanced her capacity to do the other better and both linked her directly to individual workers and the CNCs. Since she was not the first level supervisor, she could perform the dual functions quite comfortably. It was also possible to remove her periodically from the field to update her skills without disrupting programme implementation.

Community Participation: The very design of TINP necessitated the full cooperation and acceptance of the community for project implementation. Basic to project design were at least three activities that flouted convention and were highly unacceptable to the community. The first was weighing, that was thought to attract the evil eye; the second, selection for supplementation that went contrary to all other feeding programmes then implemented; and the third was nutrition education by the relatively young CNW in the face of conventional wisdom and traditional practices recommended by village elders. The success of TINP can be judged by the extent to which these three activities have become fully institutionalised. It is indeed remarkable that the project staff were able to persist with an unpopular design and subsequently win full acceptance and participation in the project.

The project employed a series of mechanisms to be able to win community support. First, the CNW was a local mother who had a healthy child of her own and, as such, enjoyed high credibility in the community to begin with. Her ability to communicate effectively was a criteria for her selection and these skills were further enhanced by constant training and a wide range of communication materials to assist her in her role as educator. She received back-up support and reinforcement from the MPHW, the Community Nutrition Supervisor (CNS) and the Community Nutrition Instructress (CNI), the block level trainer, in her recruitment and education activities.

A second mechanism to win community support was the Women's Working Group (WWG). A group of 15-20 women identified by the CNW as progressive, capable of working together and interested in the activities of the CNC was formed to promote project activities. The group was initially given health and nutrition training and some members are now quite proficient in using flipcharts and flannelgraphs. The group meets once a month at a cooking demonstration where nutritious and easy-to-make weaning food recipes are demonstrated by the CNW. To sustain the interest of the WWG members over the years, the project recently experimented with community self-survey and "adoption" of families by the WWG members.

One of the most significant experiments in the project was the use of the WWG for local food production. The preparation of the weaning food for supply to local centres by WWG members under the guidance and supervision of the Taluk Project Nutrition Officer brought the community much closer to actual project implementation. It also had the side benefit of providing some economic incentive to women who had been actively promoting the project activities on a voluntary basis. The educational impact in terms of the preparation of appropriate weaning foods must also have been considerable. Local food production met about a third of the project's need for the supplement. Standardization and quality control were problems with this type of production and it is now proposed to transfer local production to better equipped and better monitored women's cooperative societies in each block.

A later innovation in the communications effort was the formation of children's working groups. The facility with which children communicate and the enthusiasm with which they learn and relay project messages in the form of poems, songs and skits made this a highly successful activity. The project also arranged for workshops for village leaders and village influentials (presidents, teachers, village accountants, etc).

In TINP, a wide variety of communication materials was produced and used effectively as a back-up support to the interpersonal contact established by the front line project functionaries. The use of mass media such as films, filmstrips, slides, posters and a wide range of printed matter (including flipcharts, flashcards, pamphlets, etc.) was effective. Traditional folk media was used not only by enabling project messages to be incorporated in scripts used by professional troupes but also by organizing competitions, skits and performances in the villages.

TINP Phase I did not envisage any major role for the community in needs assessment, planning, supervision or evaluation of the program.

Political Commitment: As a government sponsored project, TINP enjoyed the full support of authorities at all levels. Two existing government departments - the Directorates of Social Welfare and of Public Health and Preventive Medicine were responsible for implementing the nutrition and health components respectively. The Project Coordination office, which was set up exclusively for the project, was responsible for coordination and communication and monitoring activities. On the nutrition side, project activities did not overlap with any other programmes in the Directorate, most of which were small, scattered and directed at older children. Some of these programs were discontinued when the project began. An excellent hierarchy was also newly established and project implementation proceeded apace. Mid-way through the project, nutrition services were further strengthened by the appointment of the Project Coordinator as Additional Director of Social Welfare.

On the health side, there was considerable overlap with existing MCH services and the project was mainly seen as providing additional infrastructure and drugs. Although the MPHW (female) was originally hired under the project, she was soon entrusted with a gamut of public health responsibilities, including those of the male workers, many of whom were not in place. Further, she was also made responsible for achieving family planning targets set by the Directorate of Family Welfare.

A series of mechanisms to bring about coordination between health and nutrition personnel at various levels were planned. The MPHW was intended to supervise and visit the CNW frequently. At the Primary Health Centre, monthly meetings were to be convened by the Medical Officer with the health and nutrition supervisors. The Taluk Project Nutrition Officer, the Medical Officer and the District Health Officer were also expected to meet once a month. Similarly, monthly component manager's meetings were planned at the state level and meetings of Secretaries to Government through an empowered committee chaired by the Chief Secretary were planned for each quarter, more often if necessary.

Management Information Systems (MIS): The MIS was devised to support the regular collection, interpretation and appropriate dissemination of analytic information required by the Project Manager. Project monitoring and evaluation was intended to cover seven areas:

· Input delivery
· Recruitment of target groups
· Input utilization
· Adoption of recommended behaviour
· Nutritional status changes Health status changes
· IMR changes

Monitoring was intended to measure, concurrently with the project, the degree to which nutrition, health and communication services were producing desired results. A set of key indicators (ratios of the number of recipients of particular services to the target population) was developed for different project components on a monthly, quarterly or half yearly basis. These included: percentages of children weighed, children in feeding, children graduating from the feeding programme, registration of pregnant women, immunization coverage over time, and trends in the nutritional and health status of the target population. It also helped provide timely identification of areas requiring special attention because of emerging or continuing nutrition problems.

The information for compilation of the indicators flows from the CNWs and the MPHWs through the first level supervisors to the CNIs and the block health supervisors respectively. The CNIs and the block health supervisor at the PHC forward the information to the statistical inspector of the monitoring unit in each district. The statistical inspectors in turn send the information to the Project Coordination office where a review of the key indicators is undertaken.

The MIS feedback loops are many. At the village center, an information blackboard is maintained by the CNW which gives the village health and nutrition profile. On the 25th of each month, a group of 10 CNWs meet with their supervisor to furnish monthly figures and discuss their implications. Around the 28th, the supervisors meet the CNIs and consolidate the block report. A monthly performance review is conducted in each district on the 3rd of each month. Instructions following from the review then flow back at a meeting of the CNIs with all the CNWs in the block on the 5th or 6th of each month. (Incidentally, this is also the meeting where the CNWs salary is disbursed).

Special studies were also entrusted to the monitoring wing, on the basis of reviews of the monitoring data by the Project Coordination office and on expert advice, especially of visiting World Bank Missions.

Replicability and sustainability: The project is highly replicable, but dependent on successfully training and motivating the CNW and establishing a cadre of well qualified nutrition instructresses. Administrative systems also need to be in place and working well to ensure delivery of service inputs and flow of information.

Being a cost-effective approach to the problem of malnutrition, the project makes only a modest demand on resources and to that extent, is fairly sustainable. The emphasis on nutrition education, likewise, is expected to influence knowledge, attitudes, and practices sufficiently to reduce the need for the intervention over time. However, greater "community ownership" of the programme will be the key to ensuring its long term sustainability and in this respect a future project is in a good position to build on the foundation laid in TINP Phase I.

Annex 7.1: Budget (1980-89)

Externally funded

Rs.

$

% of total cost (in millions)

Civil Works

185

15.4

18.3

Drugs & Supplies

135

11.3

13.4

Vehicles, equipment & furniture

57

4.8

5.7

Training

34

2.8

3.4

Project Management

28

2.3

2.8

Contract services & Technical Asst.

7

0.6

0.7

Total

446

37.2

44.3

State funded




Food supplement

168

14.0

16.6

Staff salaries & POL

395

32.9

39.1

Total

563

46.9

55.7

Grand Total

1009

84.1

100.0


Annex 7.2: Organizational Chart for TINP