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ATAL BAAL AAROGYA EVAM POSHAN MISSION
(Atal Child Health & Nutrition Mission)
Draft Mission Document

VISION 2020
Department of Women & Child Development
Government of Madhya Pradesh
Bhopal

1
 Abbreviations
Abbreviations used Detail

ABM Atal Bal Mission

ANC Ante-Natal Care
ANM Auxiliary Nurse Midwife
AOs Accounts Officers
ASHA Accredited Social Health Activist
AWC Anganwadi Centre
AWCA Aanganwadi Chalo Abhiyan
AWH Anganwadi Helper
AWTC Anganwadi Training Centres
AWW Anganwadi Worker
BaLA Building as a Learning Aid
BCC Behaviour Change Communication
BEmONC Basic Emergency Obstetric and Neonatal Care
BPL Below Poverty Line
CAC Codex Alimentarias Standard
CBO Community Based Organizations
CDPO Child Development Project Officer
CDR Crude Death Rate
CEmONC Comprehensive Emergency Obstetric and Neonatal Care
CHC Community Health Centre
CNA Communication Needs Analysis
DAP District Action Plan
DLHS District Level Household Survey
DPHFW Department of Public Health and Family Welfare
DPM District Program Manager
DPO District Program Officer
DRC District Resource Centre
DWCD Department of Women and Child Development
EBF Exclusive Breast Feeding
ECE Early Childhood Education
GOI Government of India
GoMP Government of Madhya Pradesh
IAS Indian Administrative Service
IBF Initiation Breast Feeding
ICDS Integrated Child Development Services
IEC Information Education Communication
IFA Iron Folic Acid
IIPS International Institute of Population Science
IMR Infant Mortality Rate
IMSAM Integrated Management of Severe Acute Malnutrition
IPC Inter Personal Communication
IYCF Infant and Young Child Feeding
LHV Lady Health Worker
MCHN Maternal Child Health Nutrition
MCP Mother and Child Protection card
MDG Millennium Development Goal
MDM Mid Day Meal
MIS Monitoring Information System
MMR Maternal Mortality Rate
MLTC Middle Level Training Centre
MO Medical Officer
MP Madhya Pradesh

2
MPR Monthly Progress Report
MOHFW Ministry of Health and Family Welfare
MUAC Mid Upper Arm Circumference
MWCD Ministry of Women and Child Development
NCCS Nutrition Care and Counselling Sessions
NCHS National Council for Health Survey
NFHS National Family Health Survey3
NGO Non Government Organization
NIC National Informatics Centre
NIN National Institute of Nutrition
NIPCCD National Institute of Public Cooperation and Child Development
NMR Neonatal Mortality Rate
NREGA National Rural Employment Guarantee Acts
NRC Nutrition Rehabilitation Centre
NRHM National Rural Health Mission
OBC Other Backward Caste
ORS Oral Rehydration Salt
PDS Public Distribution System
PHC Primary Health Centre
PHED Public Health and Engineering Department
PICU Paediatric Intensive Care Unit
PIP Project Implementation Plan
PMU Project Management Unit
PNC Post Natal Care
PRI Panchayati Raj Institutions
PS Principal Secretary
RCH Reproductive and Child Health
RCCT Randomized Case Control Trial
RUTF Ready to Use Therapeutic Food
SAM Severe Acute Malnutrition
SC Scheduled Castes
SHG Self Help Groups
SGS Swastha Gram Samiti
SNP Supplementary Nutrition Program
SNCU Sick new Born Care Unit
SO Strategic Objective
SRC State Resource Centre
SRS Sample Registration System
SSA Sarva Shiksha Abhiyan
ST Scheduled Tribes
THR Take Home Ration
TNA Training Need Assessment
ToR Terms of Reference
U5MR Under Five Mortality Rate
UNICEF United Nations Children Fund
VHND Village Health and Nutrition Day
VHNSC Village Health and Nutrition Sanitation teams
VSG Village Support Groups
WHO World Health Organization
UP Uttar Pradesh

3
 Table of Content

1. Background
2. Situational Analysis of Nutrition and Health Status of Children in Madhya Pradesh
2.1 Societal Factors
2.2 Household Factors
2.3 Immediate Factors
3. State’s Response to address Malnutrition and Child Mortality
3.1 Initiatives of ICDS program
3.2 Initiatives of state NRHM
3.3 Rationale for Atal Bal Mission
4. Goals and Objectives of Atal Bal Mission
4.1 Goals
4.2 Overall Objective
4.3 Strategic Objectives
4.4 Terms of Reference
5. Components of Atal Bal Mission
5.1 Child Nutrition
5.1.1 Household food security and intra household food distribution
5.1.2 Universalization of ICDS with quality
5.1.3 Strengthening growth monitoring and promotion
5.1.4 Promotion of Infant and Young Child Feeding
5.1.5 Strengthening the existing Supplementary Nutrition Programme
5.1.6 Management of moderately malnourished children
5.1.7 Integrated Management of Severe Acute malnutrition (wasting)
5.2 Special package for tribal and high risk districts
5.3 Child health
5.4 Activities under NRHM
5.5 Proposed activities under Atal Bal Mission
5.5.1 Inclusion of excluded children through mobile health units
5.5.2 Improved micronutrient nutrition and anaemia control in children
5.5.3 Training of all ASHAs on newborn care
5.5.4 AWC to act as a nodal point for, growth monitoring & promotion, biannual vitamin A
supplementation services
5.5.5 Strengthening VHND, ensuring immunization for children
5.5.6 DPH&FW will ensure Early Initiation and Exclusive Breast Feeding (IBF & EBF) at
each Institution Delivery point
5.5.7 All delivery points will be up-scaled to fulfil Baby Friendly certification for following 10
steps to successful breast feeding
5.5.8 All ASHAs will support BCC
5.6 Convergent Planning
6. Development of District Action Plan (DAP)
6.1 Effective Implementation of ICDS programme
6.2 Capacity Building
6.2.1 State Training Policy
6.2.2 Development of State Resource Centre (SRC)
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 6.2.3 Setting up Divisional Resource Centre (MLTCs)
6.2.4 Strengthening existing AWTCs and setting up new AWTCs
6.3 Social Inclusion
6.4 Behaviour Change Communication & Social Mobilisation
6.4.1 BCC & Social Mobilization (SM) interventions plan
6.4.2 Implementation plan for BCC and Social Mobilisation activities
6.5 Monitoring and Evaluation (M & E)
6.5.1 Strengthening and up-scaling of Web-Based Management Information System (WB-
MIS)
6.5.2 Third Party Monitoring/ Concurrent Monitoring
6.5.3 Establishment of Call Centre at District Headquarter
6.5.4 Supervisory Tool
6.5.5 Community Monitoring
6.5.6 Four-tier system of monitoring
6.5.7 Evaluations, Assessments and Operational Research
7. Administrative and Institutional Arrangements
7.1 State Level Structure
8. Financial Arrangements
9. The Way Forward
References
Annexure 1: Status of 142 High Rick Blocks in 20 Districts of Madhya Pradesh

5
 List of Tables

Table Number Title Page Number

Table 1 Madhya Pradesh child health and nutrition indicators 2

Utilization of Health and Nutrition Services by Women and

Table 2 8
Children in MP

Table 3 A sample BCC and Social Mobilization intervention plan 55

List of Figures

Figure Number Title Page Number

Figure 1 Child undernutrition (<3y) in India: 1
no improvement over the last decade
Figure 2 Number of severely wasted children by state, India 3
Figure 3 Percent Prevalence of Malnutrition among Children below 4
Three years in Madhya Pradesh
Figure 4 Causes of Malnutrition 5
Figure 5 Age at Marriage and Fertility Rates in Madhya Pradesh 6
Figure 6 Nutrition throughout the life cycle 6
Figure 7 Prevalence of Anemia Among Women and Children in 7
Madhya Pradesh
Figure 8 Infant and Young Child Feeding Practices in Madhya 9
Pradesh
Figure 9 Leading causes of Death in Under 5 in Developing 10
Countries and the Contribution of Under Nutrition
Figure 10 District Wise Status of Malnutrition and NRC’s in Madhya 34
Pradesh
Figure 11 Communication Mix 53
Figure 12 Ensuring monitoring of AWCs through Call Centres 62
Figure 13 Organization Structure of General Body for Atal Bal 67
Mission
Figure 14 Organization Structure of Executive Body for Atal Bal 69
Mission

6
1. Background

Malnutrition, as a major public health and nutrition challenge faced by many developing
countries, stands as a consequence of several key
social and economic factors such as lack of
education, inadequate health care services and ill-
informed cultural behaviours. Underpinning all these
is the fact that poverty, by and large, is the principal
cause of poor feeding habits. In order to holistically
address the issues surrounding malnutrition, a
comprehensive understanding of the multi-
dimensional complexities at play in society is
crucial.
Malnutrition
Malnutrition is the condition that
develops when the body does not get
the right amount of the vitamins,
minerals, and other nutrients it needs to
maintain healthy tissues and organ
function.
Under Nutrition is a consequence of
consuming too few essential nutrients or
using or excreting them more rapidly
than they can be replaced.

Indicators showing levels of nutritional status in children are often regarded as representative
of the health and general well-being of a society at large. High levels of malnutrition in children,
particularly in those under the age of two, tend to prevail in those countries where levels of
socio-economic development are also low. It is estimated that improved feeding habits aimed
to prevent or treat malnutrition could prevent 11 million child deaths globally per year 1. Thus,
efforts to address this issue are of paramount importance and have political, economic and
cultural implications across all levels of societies for many developing nations.

India holds the dubious distinction of being the

Figure 1: Child undernutrition (<3y) in India:
birthplace of a third of the world’s entire no improvement over the last decade

population of malnourished children. 60

51

Approximately 40 per cent of India’s children are 50

45
43
40
40
underweight, a figure staggeringly higher than in
30
23
other impoverished areas of the world (Figure 1). 20
20

Indeed, the average for developing countries in 10

0
general is 27 per cent 2. In fact, according to
Percentage of underw eight children under age 3
Stunted Wasted Underweight
NCHS reference population
NFHS
Source II
: NFHS NFHSIII
WHO, about fifty percent of infant and child
mortality may be associated with malnutrition 5.

7
Within the country itself, malnutrition occurs unevenly, with the central state of Madhya
Pradesh witnessing very high rates of underweight children (60%) under the age of three. MP
is one of the poorest states with 32.4% of its population living below poverty line as compared
to the national average of 21.8% (NSS, 2007). The state has a sizeable Scheduled Tribe
population (21.4%) and Scheduled Caste population (17.9%) (NFHS III) and development
indices in these sectors of the population are also lower than the rest adding burden to the
existing low child health and nutritional level in Madhya Pradesh.

Vital statistics rates of Madhya Pradesh are typical of a developing state with high burden of
mortality indicating poor state of health of the population (Table 1). Infant Mortality Rate,
Crude Death Rate and Maternal Mortality Ratio in the state are also higher than the national
average.

Table 1: Madhya Pradesh child health and nutrition indicators

Indicators NFHS-III (%)
MORTALITY RATES
IMR (per1000 live births) 70
NMR ( per1000 live births) 45
U-5 MR (per 1000 live birth 94
MALNUTRITION IN CHILDREN UNDER AGE FIVE YEARS
Underweight (Weight for Age) 60
Wasting (Weight for Height) 35
Stunting (Height for Age) 50
Severe Wasting (Weight for Height <-3SD) 12.6
INFANT AND YOUNG CHILD FEEDING PRACTICES
Initiation of Breast feeding within 1 hour (Based on births in last 5y) 15.9
Children (6m-9m) receiving solid/semi-solid food and breast milk (Children
23.5
6-23 months)
IMMUNIZATION STATUS
Fully immunized children (children 12-23months) 40.3

The State Government of Madhya Pradesh is determined to improve child health and nutrition
indicators and realizes that to reduce child malnutrition it needs to make a firm commitment of
both human and financial resources.

8
2. Situational Analysis of Nutrition and Health Status of Children in Madhya
Pradesh

Poor nutritional habits contribute to over half of all

Anthropometric Indicators of
childhood deaths worldwide. However Malnutrition
malnutrition, or more specifically under nutrition,
Wasting - Weight for height below
is very rarely stated as a direct cause of mortality. minus two (moderate and severe) and
Instead it often serves as a backdrop for a host of below minus three (severe) standard
deviations from median weight for height
illnesses and disorders which ultimately claim the of reference population.
life of the child. The immediate correlation
Underweight – Weight for age below
between malnutrition in children and the minus two (moderate and severe) and
increased risk of infant and child death has been below minus three (severe) standard
deviations from median weight for age of
well documented internationally. Poor cognitive reference population.
development in children, a result of malnutrition,
Stunting – Percentage of children under
ultimately leads to lower levels of productivity in 5 years old who fall below minus two
adulthood. Thus, poverty is not only a (moderate and severe) and below minus
three (severe) standard deviations from
fundamental cause of malnutrition, it is also a median height for age of reference
result of it. Developing countries, therefore, need population.
to appreciate the value of preventive measures against the staggering human and economic
loss related to high levels of child malnutrition. By one estimate malnutrition alone costs India
an amount of US$10 billion Figure 2: Number of severely wasted children
annually 8. by state, India
> 60 percent of severely wasted children
live in 6 states hot spots of severe wasting
At any point in time an
1,250,000

average eighty lakh Indian UP

MP
1,194,190
1,049,161
Bihar 1,032,259
1,000,000
children under age five years Rajasthan
Maharashtra
TNadu
596,668
560,150
512,752
JKhand 435,974

(6.4 percent of Indian 750,000

WBengal
Guja rat
387,287
345,309
Karnataka 329,523
APradesh 264,366

children in this age group) - Orissa

Chhattisgarh
209,988
155,223
Assam 137,137
500,000 Kerala 128,110
are severely wasted (Figure
2). These eighty lakh Indian 250,000

children – 42 percent of the

0

9
severely wasted children worldwide11 – are dangerously undernourished and unable to survive,
grow, and develop to their full potential which is the same potential as that of children in
developed countries12. As can be seen from the figure 2, if three states – UP, MP and Bihar-
address the problem of child malnutrition on a war footing, it will be possible to bring about an
overall reduction in child under nutrition in the country.

Figure 3: Percent Prevalence of Malnutrition among Children below Three years in

Madhya Pradesh

In Madhya Pradesh, 35% of children below five years of age are wasted and 12.6 percent are
severely wasted. Therefore, at any point in time on an average 10 lakh children in Madhya
Pradesh suffer from severe wasting3 (Figure 2). In fact if we compare the under-three child
malnutrition rates between NFHS II (1998-99) and NFHS III (2004-05) in the state, it can be
seen that prevalence of ‘underweight’ and ’wasted’ have actually increased over this period
(Figure 3). Hence it is imperative for the State to take urgent action to tackle the problem of
child undernutrition.

A look at the causal analysis of malnutrition would help in identifying the factors that need to be
addressed on a priority and outlining the steps that require to be taken in order to bring about a
reduction in malnutrition. An in-depth analysis of the causes of malnutrition brings to the
forefront many underlying and overlooked elements. At least three main levels of causation
can be identified: causes linked to societal factors, household factors and immediate factors
(Figure 4).

10
 Figure 4: Causes of Malnutrition

Causes at societal
Limited utilization of potential resources:
environment, technology, people

level
Discrimination and inadequate knowledge limit quality
and quantity of actual resources available to families

Causes at household/
family level
Poor water/
Insufficient Inadequate
sanitation and
access to maternal and
inadequate
food child care
health services

Immediate
causes
Inadequate dietary Disease
intake

Final outcomes
Child malnutrition,
disability and death

2.1 Societal Factors

As can be seen from figure 4, a society’s potential resources and the access people have to
them are limited by political, economic and religious systems 9. When resources are scarce,
discrimination and inadequate knowledge tend to dictate the flow of goods and services, as a
result of which women and children are the most deprived and fewer actual resources reach

11
the hands of the neediest households, leading to higher rates of malnutrition among these
sections of the population.

The NFHS III survey shows that over half the women (20-24years) in Madhya Pradesh were
married by the age of 18 years Figure 5: Age at Marriage and Fertility Rates in Madhya Pradesh
(Figure 5). The young girl gets
married early, becomes pregnant at
an early age and often also has
frequent, closely spaced
pregnancies. The problem is
compounded by high rates of
anaemia and low rates of education
among women all of which lead to
NFHS III
high rates of child malnutrition.

The cycle of malnutrition perpetuates itself across generations as is very effectively

demonstrated by Figure 6: Nutrition throughout the life cycle
Figure 6. Young
girls who are
themselves poorly
nourished become
stunted women,
enter pregnancy
with a poor
nutritional status,
have a low
gestational weight
gain, all of which
heightens the risk of
Source:- 4th Report on The World Nutrition Situation: Nutrition throughout the Life
low birth weight Cycle (IFPRI - UNSSCN, 2000, 136 p.)

12
babies. The low birth weight infant grows into a malnourished child and has a higher probability
of infectious morbidities and mortality. The cycle continues when this malnourished female
child grows into an undernourished woman.

2.2 Household Factors

Major household factors leading to malnutrition relate to poor access to food, lack of clean
potable water, lack of toilets and poor sanitary habits.

Poor sanitary conditions and poor access to safe drinking water lead to increased morbidities
and hence increase the prevalence of malnutrition. In Madhya Pradesh, only around one-fourth
(27%) of the population has access to toilet facilities as compared to 44.6% in India. One-
fourth of the population in the State does not have access to safe drinking water. Incidence of
diarrhoeal diseases is naturally high among children increasing the burden of malnutrition
(NFHS III).

The problems enumerated above get compounded by a low utilization of health services, all of
which increase the risk of high rates of child malnutrition and ultimately, mortality.

Health services such as Figure 7: Prevalence of Anaemia among Women and Children
immunization, de- in Madhya Pradesh
worming, micronutrients
supplementation and
antenatal care help to
protect against
diseases, provide
support to vulnerable
pregnant women and
thus contribute to overall
well being of children.
However, less than half NFHS III
of all children and women receive the recommended primary health services (Table 2). Over
half the pregnant women and most of the children below 3 years in the State (Figure 7) are

13
anaemic (Hb <11g/dl). Severe anaemia during pregnancy has been correlated with increased
incidence of low birth weight babies and increased maternal mortality rates and thus needs to
be focused on.

Table 2: Utilization of Health and Nutrition Services by Women and Children in MP

Percent
S. No. Services
Utilization

1 Antenatal Checkups - 3 or more 40.7%

2 Pregnant women consuming 90 or more IFA tablets 12.4%

3 Percent institutional deliveries 26.2%

4 Percent children (12-23months) who received all basic immunization 40.3%

Percent children (6-59 months) covered for vitamin A

5 14.1%
supplementation in last six months

Percent children (13-59 months) covered for deworming in last six

6 4%
months

7 Percent households consuming adequately iodized salt 36.3%

Source: NFHS III

The onset of child malnutrition takes place very early in the life during pregnancy and further
rapid deterioration takes place during first two years of life. Once this damage is done, the
catch up and recovery are almost impossible. Hence investing in maternal health, nutrition and
care during pregnancy become vital to child survival. Hence there is a uttermost need to
address the issue of child health and nutrition simultaneously for the wellbeing of the children
in the State.

2.3 Immediate Factors

Inadequate dietary intake: Inadequate dietary intake is one of the leading causes of
malnutrition. According to the National Family Health Survey III, the overall rural per capita per
day calories intake has dropped from 2164 Kcal in 1993-94 to 1929 Kcal in 2004-5 in Madhya

14
 Pradesh, which is well below the prescribed norm of 2400 Kcal. This has happened due to
changes in dietary pattern and high rates of inflation in prices of food grains. This situation has
affected the food security, per capita food consumption pattern, intra household food
3
availability and consumption and access to food. Large sectors of child population lack the
following:

Access to enough food both in quantity and quality, especially for children < 2 years of
age,

Age-appropriate energy, protein and micronutrient rich foods especially for infants and
young children,

Appropriate foods for severe acute malnourished children.

The food intake of young children is also affected by lack of knowledge among the community
and family members on timely introduction of complementary foods, frequency of feeding,
quality of diet and age appropriate nutritious food required by children to make them healthy
and well nourished. Also, many studies have shown that the head of the family consumes the
larger portion of food leaving the young child deprived.

Inadequate and inappropriate breast feeding and complementary feeding practices are critical
factors in the persistence of widespread under nutrition in the state (Figure 8). Majority of
infants are deprived of the benefits of early breast feeding and colostrum. The practice of

Figure 8: Infant and Young Child Feeding Practices in feeding pre-lacteals is

Madhya Pradesh popular, which not only
exposes infants to early
infections but also
interferes with
establishment of early
breast feeding. This
problem is further
Source : NFHS III aggravated due to low rates
of exclusive breast
feeding. After six months
NFHS III
15
of age breast milk alone is not sufficient and at this point the child requires to be given
complementary foods in addition. Although introduction of complementary feeding is close to
the national average, there are many issues related to appropriateness, quality and adequacy
of the food 4.

It has been shown that through the use of a few critical effective child health and nutrition
interventions a significant number of child deaths can be prevented. Optimal breast feeding
and complementary feeding practices can together prevent about 20 % of under five child
deaths in India 13.

Prevalence of Diseases: Communicable diseases like pneumonia, diarrhea, malaria and

measles account for almost half of the under five Figure 9: Leading causes of Death in
mortality (Figure 9). Madhya Pradesh is one of the Under 5 in Developing Countries and
the Contribution of Under Nutrition
three worst malaria affected states and diarrhea,
which is an important cause of high infant Pneumonia
20%
Other
22%
mortality, also accounts for about 28% of all infant
deaths in the State6. High prevalence of Deaths attributable
to undernutrition Diarrhoea
communicable diseases among children and low 53%
15%

levels of immunization against vaccine Malaria

11%
preventable diseases need to be handled on Perinatal Measles
23% HIV/AIDS 5%
priority through the ICDS programme in order to 4%

address the problem of child malnutrition. Reference: - WHO 2003 and Caulfield et al 2004

The above analysis of the situation though alarming poses an immense challenge to the State
Government which accepting it is committed to making a difference in the health and nutritional
status of children. Thus addressing child malnutrition and health has top most priority and is
high on the political agenda of the Government of Madhya Pradesh. The State’s commitment
has translated into many actions and programmes in recent years which have made some
impact in reducing the mortality rate and improving the nutritional status of children.

16
3. State’s Response to address Malnutrition and Child Mortality

Government of Madhya Pradesh has taken several initiatives in last few years in addressing
critical interventions of high child mortality rates and high levels of malnutrition in the state.
These initiatives have gained significant impetus in recent years. These initiatives have been
implemented by ICDS program and state NRHM.

3.1 Initiatives of ICDS program

Universalization of ICDS –Strong efforts have been made by ICDS program to set up AWCs
and mini AWC in all villages and small pockets to improve the accessibility practically to most
of the habitations ensuring that each village, majra and tola should have AWC . As on today
there are 78929 AWCs and 12070 mini AWCs are functional in the state, which are as per the
GoI norms.

Aangan Wadi Chalo Abhiyan – To improve the enrolment of the children and monthly growth
monitoring Angawadi Chalo Abhiyan was initiated in 2009 with the objectives of strengthening
the delivery of ICDs services and improving the attendance of children at AWCs.

Bal Sanjivani Abhiyan - Madhya Pradesh has conducted 12 bi-annual rounds for six years for
malnutrition detection along with vitamin A supplementation and immunization termed as Bal
Sanjivani Abhiyan. This Abhiyan covered all the children across the state and streamlined the
growth monitoring activities. This initiative was started to address the high prevalence of under
nutrition among the children 0-5years of age.

Sanjha Chulha- ICDS addressed the delivery of SNP by initiating a joint supplementary
feeding program called Sanjha Chulha with MDM for AWC’s children. Sanjha Chulha is a joint
feeding programme aimed at providing two hot cooked meals i.e., breakfast and lunch to
children in the age group of 3-6 years prepared with the help of local self help groups. This
allowed AWWs and helpers to spend more time with children for preschool education activities
and home visits.

17
Take Home Ration- Recently state has introduces THR for 6 months to 36 months old
children. THR is a tasty, nutritious and micro nutrient fortified food which is distributed for six
days. The food contains different varieties and all efforts are made to maintain good quality.

Increasing timings of AWCs and honorarium of workers- State has increased their share
of funds for AWWs and helper’s honorarium significantly and has also increased the timing of
AWCs from 3 hrs to five hours. This gives more time for fun filled activities.

Mapping current nutritional status through NIN - National Institute of Nutrition is developing
a district wise profile on the nutritional status of children under five along with causal analysis.
This analysis will be the base line survey for districts.

Organization of Mangal Diwas activities- Mangal Diwas activities have provided a strong
platform to women to discuss and learn about issues on a every Tuesday. Themes taken up in
Mangal Diwas related to nutrition among children and women. Popular perception among the
community about AWCs being a Dalia (porridge) distribution centre has now changed. Though
an appraisal of the Mangal Diwas programs has not been carried out but experience from the
field shows that awareness among community about childhood malnutrition has increased and
there is a good response to the programme.

Project Shaktiman - A special program for tribal children was initiated in 2007-08 called
Shaktiman with the objective to reduce malnutrition among tribal children. The project covered
19 districts and benefited about 60, 000 children in 997 villages of 38 Blocks.

Implementation of use of new WHO Growth standards - Madhya Pradesh is the first State
in India to roll out the implementation of new WHO Growth standards across the State. This
has helped in mapping the nutritional status of the children and made it easier for the
Anganwadi Worker to plot the nutrition standard of children.

Web enabled MIS - A web enabled MIS system has been designed and piloted to reduce
drudgery of manual data transmission and support correct and timely reporting.

Breast feeding promotion – ICDS is working through different strategies for the promotion of
appropriate breast feeding practices for the last few years. These include three in one IYCF

18
counselling skills training, Radio publicity, periodic release of informative magazine, cinema
slides, mother’s meetings and counselling, distribution of IEC material to AWCs, organizing
competitions in various institutions and many other methods.

Jagruti Shivir – Each district organizes village level women awareness camps in which local
women and community members are mobilized and sensitized about government schemes,
health and nutrition issues.

Home visits – Initiatives have been taken to strengthen the home visits particularly, visits to
families of moderately and severely malnourished children discharged from NRCs and ANC
and PNC of mothers. Home visits are also organized to sensitize young mothers, there
mothers-in-law and other members of the community.

3.2 Initiatives of state NRHM

Infant Young Childhood Feeding promotion activities - State NRHM has rolled out the
training of frontline workers on three in one IYCF counselling skills in 22 districts for building
the skills of workers and promotion of breast feeding practices.

Setting up New Born Corners – Efforts have been made to set up New Born corners at Basic
Emergency Obstetric and Neonatal Care (BEmONC) facilities and Primary Health Centres
(PHCs) to support essential new born care.

Scaling up Sick New Born Care Units - The State has made impressive progress in setting
up 14 level-2 SNCUs at the District hospitals to provide appropriate and essential care for
newborns suffering from severe clinical complications. The initiative helps to reduce neonatal
deaths.

Nutrition Rehabilitation Centres - For the management of severe acute malnutrition among
young children at facility based units the state took the lead and set up more than 200 NRC
that now provide facility based treatment and care to SAM children.

Bal Suraksha Month- NRHM has institutionalized the biannual drive named Bal Suraksha
Maah and which is organized across the state to cover all children 9 months to 5 years of age

19
for Vitamin A supplementation, de-worming, Iron and folic acid supplementation and
immunization

Setting up pediatric intensive care unit - NRHM is setting up Paediatric Intensive Care Units
(PICU) in district hospitals, 11 PICUs have already been initiated.

Village Health and Nutrition Day - Many initiatives have been made for strengthening Village
Health and Nutrition Days (VHNDs) in every village once a month for the delivery of
Immunization, antenatal care, and counselling.

3.3 Rationale for Atal Bal Mission

While the above initiatives have shown promising results, the State still continues to face the
challenge of high ratio of child malnutrition. No State can take this lying down and there is an
urgent need to address the problem in a Mission made Government of Madhya Pradesh has
accepted the challenge of addressing high rates of malnutrition in children and is no more in
denial mode.

There is an increased political will, policy prioritization and preparedness for budget allocation
to address malnutrition in children of Madhya Pradesh which for the state is a “A matter of
state shame”. The State has therefore decided to launch the Atal Bal Aarogya Evam Poshan
Mission to bring about a systematic reduction in child malnutrition and make the States
children healthy and happy. This dedicated Mission will make a vast difference in the lines of
children across Madhya Pradesh. The Mission will be able to experiment pilot, replicating
upscale ideas and draw on outside talent while simultaneously draw on resources whether
internal or external. This Mission will provide a political umbrella, a focal point to the fight
against child malnutrition.

On 14th May 2010, the State Assembly adopted a set of 70-point resolutions which includes
setting up an ATAL BAAL AAROGYA EVAM POSHAN MISSION. This Child Health and
Nutrition Mission, hereinafter referred to as Atal Bal Mission, will work in an integrated and
coordinated manner to bring about an improvement in the nutrition and health status of
children in Madhya Pradesh and address the problem of child malnutrition.

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A detailed strong and comprehensive strategy will be worked out after the mission document
for the implementation of the Atal Bal Mission plan and state will ensure adequate allocation of
financial and human resources to meet the goals and objectives of the mission

Addressing child nutrition in Madhya Pradesh is --

Central to state development with equity/inclusion
Central to state pride, self respect and dignity
Central to achieving MDG1 and therefore MDG4 nationally

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4. Goals and Objectives of Atal Bal Mission

4.1 Goals
The Atal Bal Mission will support the state of Madhya Pradesh in reducing child malnutrition
and thereby help India achieve the MDG goals, by reinforcing its commitment of achieving the
following goals.

Reducing mortality rate for children under five years (U5MR) from 94.2 to 60 per one
thousand live births;

Reducing the percentage of underweight children in the same age group from 60% to 40%
percent by 2015 and further from 40% to 20 % by 2020;

Reducing prevalence of Severe Acute Malnutrition (SAM) in children < 5 years from 12.6
percent to 5 percent by 2015 and to negligible by 2020.

4.2 Overall Objective

The purpose of the Mission is to render an enabling mechanism for prevention and reduction
of malnutrition and under five mortality rates in the children of the State through coordinated
and concerted efforts by the key stakeholders. The Mission will also oversee the existing
nutrition and health services and will ensure that corrective actions are taken to strengthen all
components of service delivery, including timely and appropriate utilization of financial
resources and mobilization of additional resources to achieve the set goals.

4.3 Strategic Objectives

The State Government has set out the following strategic objectives (SOs) to be pursued by
the Atal Bal Mission:

SO-1 Convergent Action: Process of integration of planning by key departments, i.e., Women
and Child Development, Health and Family Welfare, Rural Development, School Education,
Public Health Engineering etc. to be instituted at state, district and sub-district levels and the
implementation strategy to be agreed upon by all stakeholders so as to achieve enhanced

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coverage and reach.

SO-2 Evidence-based Interventions: Enhance the capacity of lead Departments (Women

and Child Development and Public Health and Family Welfare) at all levels so as to implement
evidence-based, high quality programmatic interventions with special emphasis on the most
marginalized and vulnerable segments of the population.

SO-3 Performance Enhancement of Human Resources: Provide technical and managerial

guidance and support to the departments in developing the revised and need based Human
Resources Management and Development strategy for techno-managerial capacity building so
as to optimize overall performance and contribute towards enhancement of coverage and
quality of the healthcare and nutrition services.

SO-4 Community Engagement and Empowerment: Provide strategic guidance to the

departments of Women and Child Development and Public Health and Family Welfare in
developing a strategy to catalyze and involve community level structures and organizations
and galvanize their actions. These are aimed at bringing a shift in the health and nutrition
related behaviours towards desired ones, and also in supporting the preventive and promotive
aspects of child nutrition and primary health care systems so as to achieve an expanded
coverage and improve the quality of key health and nutrition services.

SO5- Research, Innovations and Information Management: Provide guidance to the

Departments of WCD and DoPH&FW to manage the programmatic information for analysis of
the programme performance, and also identify the research areas for evidence-based planning
which in turn will further help the departments to devise context- specific innovations.

4.4 Terms of Reference

The following Terms of Reference (TOR) define the mandate for the Atal Bal Mission:-

TOR 1. Interdepartmental Coordination: Enhance and ensure effective interdepartmental

coordination in planning, implementation, monitoring and supervision of nutrition services and
health services for under five children. This will result in improved delivery of services for
reduction of malnutrition and reduction of neonatal, infant and under five mortality rates

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through integrated approach of the departments of WCD, PH&FW, Rural Development School
Education and Tribal Welfare.

TOR 2. Technical and Managerial Support: The Atal Bal Mission is mandated to provide
technical and managerial support at all levels in all components of ABM to the department of
WCD for improving the quality of program implementation.

TOR 3. Inclusion of Socially vulnerable groups: The Mission will facilitate the adoption of
inclusive approaches so as to ensure coverage of schedule caste, schedule tribes, migrant
population, backward and marginalized population and other marginalized and vulnerable
sections of the population in all its programmatic interventions.

TOR 4. Evidence based interventions: The Atal Bal Mission will support the WCD in
identification and piloting of innovative interventions and scale up of high quality, evidence
based critical nutrition interventions to make an impact on the nutritional status of children. The
aim is to achieve systematic reduction of malnutrition.

TOR 5. Reforms and Policies: The Mission is entrusted with the responsibility to inform the
departments of WCD and PH&FW on required programmatic/architectural corrections/reforms
based on operational research, and also to provide technical support in developing or revisiting
the implementation strategy of such corrected intervention approaches.

TOR 6. Addressing high rates of Malnutrition: The Mission will support reorientation of
ICDS to prevent early onset of malnutrition especially in the crucial age group 0-2 years, It will
support development and effective implementation of protocols for community/home-based
management of moderate under-nutrition and Severe Acute Malnutrition (SAM). It will also
suggest approaches for growth promotion in normal children to prevent under nutrition.

TOR 7. Addressing under 5 Child Mortality: The Mission will facilitate all approaches to
strengthen the existing maternal and child health services through convergent action with
Department of PH&FW which shall contribute to reduction in mortality rates among children.

TOR 8. Community Empowerment and Participation: The Mission will support the ICDS in
developing strategies of engaging the community for improving demand for nutrition services

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and to change prevailing social norms that prevent adopting of better care practices for
children. It will also introduce community monitoring and social audit for increased
accountability of nutrition and child health services.

TOR 9. Decentralized Planning: The Mission will emphasize and provide technical support
for development of area specific and realistic convergent district action plans with the
involvement of related sectors and implementation of the same.

TOR 10. Monitoring and Evaluation: The Mission will analyze, monitor and oversee all
programmatic components of Nutrition and Child Health using the existing implementation
framework, or independently, if so needed. The Mission will also review and evaluate existing
programmes and interventions.

TOR 11. ICDS System Strengthening: The Mission will support the Department of WCD in
universalization of ICDS with quality. Support will also be extended to strengthen the financial
systems of the ICDS, mechanism for monitoring and evaluation and supply chain management
for supplementary nutrition programme.

TOR 12. Strengthening of Human Resource Management and Development: The Atal
Bal Mission will study and analyze the existing human resource gaps and submit relevant
recommendations for strengthening the system of its management and development. The
Mission will propose investments in strengthening the existing infrastructure and expanding it
to ensure the effective capacity building of ICDS functionaries at all levels and provide
opportunities for developing their potential.

TOR13. Knowledge Management: The Mission will facilitate and provide the platform for
learning to the functionaries of the Departments of WCD and PH&FW through scientific and
academic workshops, e-learning systems and exposure visits to other states and such other
opportunities. The Mission can draw upon technical support from International and national
experts as and when required.

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5. Components of Atal Bal Mission

For effective implementation and achievement of its goals and strategies the Atal Bal Mission
shall have the following components. This document will lay down the road map for each of
these components which will then be detailed out in individual programmes and strategies for
which the Mission will seek funds through the Department of WCD.

5.1 Child Nutrition

Nutrition is the vital force catalyzing the proper functioning of the mind and physique of a
human being. As in the case of poverty, nutritional deficiency itself forms a vicious circle
sowing the seed for extended deficiency from generation to generations. There is widespread
prevalence of malnutrition among children in the form of underweight, low birth weight,
wasting, stunting, anaemia, and other manifestations of micro- nutrient deficiencies among
different age groups of the population in Madhya Pradesh, specifically so among children
below five years of age.

The GOMP has adopted the life cycle approach to address the high rates of malnutrition, in a
holistic manner through targeted high impact critical nutrition interventions, both preventive and
curative. These interventions are for adolescent girls, pregnant and lactating mothers and
children in the age-group of 0-6 years and include Take Home Ration for 6 months to 3 year
children, two hot cooked meals for 3-6 year olds, a third meal for severely malnourished
children, iron folic acid supplementation for children, vitamin A and deworming biannually,
preschool education, nutrition health education and counselling for mothers and the
community. Recently the ICDS programme has expanded its range of interventions to include
components focused on adolescent girls’ nutrition including iron folic acid supplementation and
deworming, health, awareness, and skills development.

This section will focus on differential approaches for preventing and reducing malnutrition,
especially in the age group of 0-2 years. Since malnutrition actually sets in at an early age, a
preventive approach to malnutrition would mean a very intensive focus on this age group.

Through the Atal Child Health and Nutrition Mission, the Government of Madhya Pradesh

26
commits itself to fill the gaps in the existing system, through the focus of human and financial
resources on the following priority areas for the prevention and reduction of malnutrition
through:

Household food security and intra household food distribution

Universalization of ICDS with quality

Growth monitoring and promotion

Promotion of infant and young child feeding

Strengthening the existing supplementary nutrition program

Management of moderately malnourished children

Integrated management of Severe Acute Malnutrition

5.1.1 Household food security and intra household food distribution

This is defined as sustainable access to safe food of sufficient quality and quantity (including
energy, protein and micronutrients) to ensure adequate intake and a healthy life for all
members of the family.

According to World Bank, food security is ‘Access at all times to enough food of a sufficient
quality to ensure an active healthy life”. Household food security depends on access to food,
including its financial, physical and social aspects, as distinct from its availability. For instance,
there may be abundant food available in the market, but poor families unable afford it remain
food in secure.

Sometimes food is available but intra household food distribution remains a challenge with
women and children not getting their fair share. For this the Atal Bal Mission will develop a
communication strategy linked with SNP and complementary feeding messages on educating
the parents about appropriate quantity and quality of food required by the mother and children
and to be distributed at household level.

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Both purchasing power and food availability are closely linked and are the major underlying
causes of malnutrition especially for families living on the edge of survival. Such families
require support from government through safety net programmes like:

National Rural Employment Guarantee for All

Targeted public distribution system

Targeted program for the tribal population

Micro finance initiatives

Livelihood initiatives

Supplementary Nutrition Program.

NREGA: Under the Atal Bal Mission linkages will be developed by DWCD with Rural
Development Department to ensure at least 100 days employment for parents of all severely
malnourished children. Efforts will also be made to increase employment under NREGA to 200
days. This will help to improve food security at the household level.

Targeted Public Distribution System: The PDS targets the disadvantaged population. Often
these disadvantaged groups of the population do not have the means to purchase monthly
rations as is provided under the PDS. The Atal Bal Mission will work to sensitize the PDS
system about this issue and explore different approaches through which this issue can be
addressed, such as the possibility of providing weekly or fortnightly rations instead of monthly.

Targeted program for the tribal population – Apart from all the other components described
above, special efforts will be made by the ABM to coordinate with the Tribal Welfare
Department to ensure household food security for tribal families by mobilizing funds to provide
full weekly ration at subsidized rates through PDS for tribal families. The families in the tribal
areas will be benefited, especially those families having moderately and severely malnourished
children, through the special schemes of the Tribal Welfare Department.

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Micro finance initiatives – ABM will recommend micro finance initiatives to be undertaken
through the Mahila Arthik Vitt Vikas Nigam for mothers and adolescent girls. Such initiatives
would not only help in improving their economic condition and household food security, but
also empower them to take finance related decisions. Economic empowerment of women will
lead to them social employment and both will together help to improve the lot of women and
children.

Livelihood initiatives – The Atal Bal Mission will initiate measures to ensure that the existing
schemes of livelihood initiatives get linked with the families of moderately and severely
malnourished so as to urgently address this needs.

Supplementary Nutrition Programme (SNP) – the SNP will be strengthened at all levels with
a special focus on quality, quantity, frequency and regularity. For this it is important that all
targeted child population should be covered by ICDS. For this universalization of ICDS with
quality is critical and will be addressed comprehensively through the Mission. This subject is
detailed in the next section on Universalization of ICDS with quality.

5.1.2 Universalization of ICDS with quality

Universalization of ICDS has been achieved by the Department of Women and Child
Development in Madhya Pradesh. However, there may be some pockets which have been left
out and may require the opening of new AWCs under “AWC on Demand”. The Atal Bal Mission
will coordinate with the Department of Women and Child Development to identify these needs.
In each district, a mapping exercise will be carried out to identify and map the areas which are
still uncovered by ICDS or there is a felt need for an AWC, with the objective of reaching out to
each child in the community, especially in inaccessible areas and in marginalized population
pockets. In each of the identified areas, the required number of mini AWCs/AWCs will be
established, staffed and made functional with trained functionaries equipped to deliver all
services with quality. The Atal Bal Mission will ensure and fill up all the gaps in setting up mini
AWC/AWC universally across the state, so that all children below five years are covered and
benefit from the ICDS Services.

A concerted effort will be made in creating good, lively, child friendly infrastructures for the

29
young child. The overarching goal is ‘universalization with quality and equity’ of services being
provided.

The Atal Bal Mission will ensure that all anganwadi centres are equipped with basic facilities
such as a permanent structure, either of ICDS itself or a rented building, storage space
(cupboards/cabinets/chests) for storing essential items, floor mats for children to sit on, brightly
coloured child sized chairs, black board painted on the anganwadi centre wall at a height low
enough for the children to write on, low cost boundary walls, preschool education kits, safe,
unbreakable toys, utensils (plates, glasses, bowls, spoons), functional hand pumps (Linkages
with PHE), child friendly toilets (Linkages with PHE), outside play equipment/material for
children such as slides, merry go round, jungle gyms, see-saws, swings, sand pit, display of
relevant and important messages on child survival, wall painting with child relevant pictures,
use of various building components like the floor, wall, door, window or even spaces like
corridor and open space or the natural environment as a means to fun-filled teaching–learning
and so on.

Standards will be developed for AWCs for delivery of quality services.

Setting up Standards for Functionality of Anganwadi Centres (AWCs)

Around one-third of the current AWCs are housed either in their own buildings or in
government buildings with a permanent structure. Like primary schools and Panchayat
buildings the rest are almost all in rented premises which, budgetary allocation for rent,
because of low are frequently found to be housed in small and/or unhealthy locations.

Under the guidance of the Atal Bal Mission a mapping exercise will be carried out to identify
the exact number of AWCs which work out of rented buildings, schools, Panchayat building or
semi-permanent structures. Based on the information obtained, the Atal Bal Mission, along
with the Department of Women and Child Development, will:

Ensure construction of all unconstructed AWCs by raising funds either through GoI or State
Government.

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 Make attempts with the Government of India to have the funds allocated for rental of AWCs
increased.

Explore with the state to find the funds for paying higher rental for AWCs, where required,
till the time this is accepted and agreed by the GOI.

In order to ensure that all the Anganwadi centres conform to certain standards in terms of day-
to-day functioning as well as in relation to activities, infrastructure and logistics, the Atal Bal
Mission will develop guidelines and protocols on aspects which will help in improving the
functioning of the Anganwadi centres with quality such as:

Guidelines on physical infrastructure which will spell out minimum area for the AWC,
ventilation and illumination standards, cleanliness of surroundings, availability of other
key facilities;

Functioning of Anganwadi centres, with special reference to adherence to the timings

and regularity;

Upgrading Anganwadis and using principles of BaLA (Building as a Learning Aids), in

the AWCs and for making these centres enjoyable places for children to learn through
the coordination and use of available funds with the Departments of School Education,
Tribal Welfare and DWCD;

Guidelines for ensuring that the weighing scales are in working condition and are
calibrated periodically;

Guidelines for proper storage of food commodity, and about condition and cleanliness of
cooking utensils, and also on food hygiene;

Guidelines pertaining to provision facilities such as safe drinking water, child-friendly

toilets;

Guidelines to facilitate and improve the quality of interactive play sessions for
psychosocial and motor development in children;

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 Guidelines for pre-school activities and age appropriate learning outcomes;

Similarly, other infrastructure related guidelines will be defined such as insect control
measures and environmental sanitation etc.

For child friendly AWCs, which maintain the standards as specified in the above points, will
receive an accreditation from the Mission. This accreditation will be translated into a reward
system, aimed at encouraging all AWCs to maintain and achieve high standards of physical
infrastructure, timings and regularity, safe and child friendly environment, provision of safe
drinking water and child friendly toilets, making the Anganwadi malnutrition free, ECE and
adoption of play-way methods for learning etc.

5.1.3 Strengthening growth monitoring and promotion

Growth monitoring activities are hampered by poor access to appropriate equipment, such as
weighing scales, growth registers and community growth charts. The Atal Bal Mission along
with DWCD will coordinate to ensure that weighing scales in all AWCs are in working condition
and are periodically calibrated.

Even with regular weighing, growth monitoring is effective only if accompanied by

communication for behaviour change of parents that results in improved growth of the
malnourished child. Previous studies have noted that growth monitoring and promotion remain
a challenge and does not often occur, perhaps because many AWWs are not fully competent
with respect to the skills to take and record weight, interpretation of growth charts, effectively
communicate with and counsel the parents, particularly mothers and care providers. Atal Bal
Mission will take up the following activities in a Mission mode:

Screening for identification of malnourished children

The Atal Bal Mission will provide support to the Department of WCD for adopting and
promoting high coverage of interventions related to screening of children under different
categories; normal, moderately under weight and severely underweight. These interventions
include:

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 ALL children 0- 5 years will be weighed regularly every month particularly Under Twos.
Essentially, this activity will require complete survey of all children and 100%
registration and weighing on an ongoing basis. Efforts will be made to ensure that all
children, including those residing in hamlets, are enrolled and their growth monitored on
a regular basis. The Atal Bal Mission will support grading of villages based on the
proportion of children who are undernourished and will provide priority support to the
under-performing villages / blocks.

The Atal Bal Mission will ensure all logistics for smooth conduct of growth monitoring
and promotion activity. The key supplies in this regard are weighing scales (including
baby weighing scales), growth monitoring charts, record registers, tapes for measuring
Mid Upper Arm Circumference (MUAC Tapes); and IEC material for behavior change
communication etc. The Atal Bal Mission will provide required support for the repair and
maintenance/ purchase of standard weighing scales, periodic calibration of weighing
scales.

Techniques will be evolved for mapping households for different indicators such as
dropouts in weighing, immunization, absenteeism at Anganwadi centres etc. and
identification of households with SAM children based on MUAC as well as pockets of
malnutrition in the village. Village level maps will be maintained at each Anganwadi
centre. The AWW will maintain the village resource map with the help of community
members.

Growth monitoring and promotional activities

Each month nutritional status of all children below 5y of age will be assessed after weighing
using the New WHO growth Standards and plotted in the Mother and Child Protection (MCP)
cards and their individual growth charts, as well as on the community growth chart. The
children will be classified as having normal weight for age, moderately underweight or severely
underweight. After weighing and plotting trained AWW will assess the growth and will counsel
the mothers and motivate them for corrective actions. Preventive approach will be used for
promoting growth to prevent a child from becoming malnourished through tracking the growth
faltering. Serial weight recording helps in early detection of growth faltering. When growth

33
faltering is detected early even small changes in practices and family’s means can make a
critical difference.

The Atal Bal Mission will provide support in improving the quality of weight records, and also
on the areas of increasing Anganwadi Workers’ ability to effectively carry out counselling, or
imparting nutrition and health education through organized sessions. The AWW will also be
trained on analysis for cause of growth faltering, assessing the child’s feeding and deciding the
actions needed for the child.

5.1.4 Promotion of Infant and Young Child Feeding

There are adequate global evidences that optimal IYCF practices contributes significantly in
bringing down NMR, IMR and U5MR and also in reducing malnutrition and infant morbidity.
Researches have also proved that optimum IYCF practices enhance the growth &
development of children clearly linked to psychosocial care, and active learning capacity. It is
therefore important that proper knowledge and practice of breastfeeding is imparted to the
mother and the community.

Even among households that are relatively well-off in economic terms, child under-nutrition is
not uncommon. The reasons for this can range from low birth weight and poor breastfeeding
practices to lack of health care or gender discrimination. This is why a range of complementary
interventions are required.

There is enough global research to prove that improving breastfeeding practices and the
quality of complementary foods and feeding practices through a continuum of care is the most
important intervention for child survival, growth and development. Global evidence for
expanding the coverage of IYCF interventions in different programmatic settings indicate that
(i) effective partnerships, (ii) mainstreaming interventions into existing programmes; (iii)
effective communication strategy through a variety of communication channels) and (iv)
interpersonal counselling skills are the key elements in achieving success.

It is therefore important that Atal Bal Mission should have a comprehensive plan of action with
the clear cut goal and objectives for the promotion of IYCF practices in partnership with all
partners and stake holders.

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The IYCF programme in Madhya Pradesh has been scaled up in the past two to three years
jointly by the Department of Health and Women and Child Development. Under the Atal Bal
Mission updated and adapted Infant and Young Child Feeding Guidelines will be integrated in
all sectors and joint training programmes of RCH, ICDS, Panchayati Raj Institutions, tribal and
rural welfare program. Updated and adapted IYCF guidelines will also be integrated further
especially in the ICDS State Specific Training Curriculum.

Looking at the importance of IYCF practices and the available evidences, promotion of
appropriate IYCF practices (early initiation of breast feeding within one hour of birth, exclusive
breast feeding for the six months of life, timely and age appropriate complementary feeding)
will be an integral part of the Atal Bal Mission. The Atal Bal Mission will focus on developing
the action plan for the promotion of IYCF practices through differential strategies focusing on
building the capacity of ANM and AWW on three in one Infant & Young Child Feeding
counselling skills and generating the awareness among the care providers and the community
at large. IYCF component of the Atal Bal Mission will be in the context of a framework for
promoting integrated early child development and nutrition assuring the best possible start to
life with support to families and communities, in a life cycle approach to address the
intergenerational cycle of malnutrition.

Linkages will be developed by the Atal Bal Mission with the State IEC bureau, Health
Department, media, civil society organizations and academic and training institutes for
integrating the IYCF as an important component in their program interventions.

5.1.5 Strengthening the existing Supplementary Nutrition Programme

Currently in the state, the two supplementary feeding programmes, i.e. the supplementary food
for the AWCs and the Mid Day Meal for school children, are being implemented through a
common kitchen called Sanjha Chulha, a joint effort of WCD and Rural Development
Department. Two types of supplementary nutrition are provided to children; Take Home Ration
(ready to eat) and hot cooked meal. In addition there is also provision for the third meal for
severely underweight children by the Department of Women and Child Development.

35
Take Home Ration (THR)

THR is given to younger children, 6m-3y, and to pregnant and lactating women on a weekly
basis. This THR is a cereal based ready to eat mix fortified with micronutrients supplied by
MPAgro. The Atal Bal Mission will build the capacity of the workers to use the weekly
distribution of THR as a contact point for growth monitoring and promotional activities through
counselling of caregivers. Also there will be a focus on nutrition counselling of mothers and
care providers on how to make best use of THR for the child for optimum growth and
development.

Efforts will be made under the Atal Bal Mission to also reach out to those children who are
either not currently enrolled in the AWCs or are enrolled but do not come to the AWC for some
reason. This would include all those children who live in hamlets, belong to migrant
populations, are socially excluded, stay at home to look after younger siblings, go with their
mother to the construction site or other places of work or are engaged in other activities which
prevent them from coming to the AWC. All such children, regardless of their age, would be
given THR. It is also proposed that the THR to children, 6 to 36 months of age, would be given
six days a week instead of the current five days.

There is an urgent need to revisit the composition of THR so as to increase its nutritive
content, particularly that of milk and oil. The THR will be made more nutritive, tasting and
protein enriched. For this there would be a need to increase the rate of manufacture of THR.
This increase in the cost would be used towards increasing the milk and oil components of Bal
Aahar specially meant for children under twos so as to meet the nutritional requirements and to
reduce the incidence of under nutrition in this critical age group. Also the nutritive contents of
other THR will also be visited and changes made where necessary. Further Bal Aahar can be
given for a larger number of days as compared to Halwa or khichdi.

Supply of Ready to Eat Breakfast

Experience has shown that the hot cooked breakfast almost never reaches AWCs by 9-
9.30am which is the stipulated breakfast time. To overcome this problem ABM will explore the
possibility of giving a ready to eat breakfast like boiled eggs, boiled potatoes, bhuna chana,

36
sprouts, fruit, milk, soya milk, soya snacks of a large variety or nutritionally dense, ready to eat,
protein rich food. This can be bulk manufactured and variety introduced for taste and nutrition.

Hot Cooked Meals

Children 3 years - 6 years of age participating in the AWCs, are given hot cooked meals twice
during the AWC timing, one morning snack and one lunch meal prepared and supplied by local
SHGs through Sanjha Chulha. This is the recent initiative launched in 2009 by CM and scaled
up across the state. The Atal Bal Mission will ensure strengthening the system of Sanjha
Chulha. Currently there are many challenges in ensuring the quality and quantity of hot cooked
meals, not to speak of regularity in provision of the meals. Provision will be made to set up a
comprehensive monitoring system both external and community based to make the system
more efficient for the provision of two hot cooked meals with quality.

The Atal Bal Mission will consider increasing the cost of the afternoon supplementary food so
as to make it equal to the Mid Day Meal. The Atal Bal Mission will also look into the possibility
of giving to the SHG involved in the Sanjha Chulha an additional Rs. 1000 month, on the
following conditions:

Supplementary food is served on time – Snacks between 9.00-9.30 am and hot

cooked meal at 12.00 noon

If the snack is not served on time by the SHG, they will not receive payment for that
snack for that day, instead the AWW will open a THR packet and serve it to the
children.

The supplementary food will be transported by the SHGs to the AWCs, and the
AWW will not have to go and collect it from the Sanjha Chulha point.

Third Meal for Severely underweight children

There is a provision of a third meal for severely underweight children under the state program.
Current practices have shown that it is difficult for Self Help Groups (SHGs) to cook third meal
and supply to AWCs, as the number of severely underweight children varies from 2-20 from

37
one AWC to another. The Mission will explore alternatives like eggs, bananas, boiled potatoes,
milk and evidence based high density, protein and energy rich, micronutrient fortified foods as
take home rations. This will ensure that children get to eat a nutritive their meal and thus
malnutrition can be effectively addressed. This can be consumed either in the Anganwadi or
taken as THR. The present rate of Rs 2 per day per child can be increased to meet the cost of
the above.

Promotion of Food Fortification

State will explore the possibilities of food fortification especially for wheat flour fortification with
the objective to improve the micro nutrient composition of wheat flour supplied to Sanjha
Chulha SHGs to prepare Hot Cooked Meal.

Food Safety Mechanism

The Atal Bal Mission will reinforce operationalisation of guidelines for proper storage of food at
all levels for food safety mechanism and would build the capacity of ICDS officials and
workers. A monitoring and quality check mechanism will be developed and implemented for
efficient supply of supplementary food. The Mission will also support development of a
reporting system for SNP both for THR and hot cooked meal and assist the department to
develop strategies to increase coverage and reach out to excluded children specially those
sick and malnourished.

Specific attention will be given to any discrepancies related to:

Availability of raw ingredients from Public distribution systems

Fund availability to Self Help groups supplying hot cooked meal

Distribution mechanisms for both THR and Hot cooked meal

Quality and Quantity of food supplied

Storage and safety of Take Home Rations as per standard norms

Standards of hygienic cooking and feeding environment

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 Timely and regular supply of THR, breakfast and Hot Cooked Meals.

5.1.6 Management of moderately malnourished children

Under Atal Bal Mission, for addressing the problem of moderate malnutrition at the community
level, Nutrition Care and Counselling Sessions approach will be introduced. The use of NCCS
approach helps communities to take responsibility for sustainability in rehabilitating
malnourished children. The approach has been helpful in changing the conventional wisdom in
communities regarding feeding, caring, and health-seeking behaviour, thus benefiting
generations of children to come.

The basic underlying principle of the NCCS approach is community based management of
malnutrition through improved caring practices which include counselling of mothers of all
children enrolled in the AWCs, to take initiative for exclusive breast feeding, growth monitoring,
care during illness, Vitamin A supplementation and Deworming, complementary feeding with
quality, hygiene and water sanitation, IFA after supplementary food intake at AWCs, activities
for early child hood development.

A nutrition surveillance system will be also be set up to track each malnourished child, both
moderate and severe. Each child on the list will be tracked by the ICDS supervisor and AWWs
to check the action taken for each child and the current status of the child - whether the child
has been referred to the NRC, enrolled in the NCCS, the progress in the weight gain of the
child and improvement in the nutritional status. A tracking card can be issued for each child,
which will have information on the nutritional status of the child along with the weight of the
child, the dates when the weights were taken, till the time the child comes into the normal
category of nutritional status.

Health and nutrition education will be given to mothers of moderately malnourished children
and other care providers once per month (counselling session per month) to orient them about
correct feeding practices and hygiene. Feeding demonstration will be organized once per
month during mangal diwas at each AWC by supervisors to trained mother on use of locally
available food and correct complementary feeding practices.

Using approaches to engage community based groups and mothers groups for finding cases

39
of malnutrition, community members from different sections of the village would be sensitized
about malnutrition and will be engaged in active tracking of children who are underweight and
identifying families where key Infant and Young Child Feeding (IYCF) behaviours are
suboptimal.

The Mission will support the DWCD in designing these focused interventions for reduction in
moderate under weight. Special nutrition counselling sessions and hands on training for
caregivers of these children will be introduced at Anganwadi centres. The Mission will also
ensure the capacity building of frontline workers and community groups for management of
moderate under weight.

5.1.7 Integrated Management of Severe Acute malnutrition (wasting)

Severe wasting in children, a widespread form of severe acute malnutrition, remains a major
killer of children as mortality rates in severely wasted children are nine times higher than those
in well nourished children. Severe wasting is defined as weight-for-height below minus 3 z-
score of the median weight-for-height in the 2006 WHO reference population. Severe acute
malnutrition (SAM) is defined by the presence of severe wasting and/or the presence of
nutritional edema.

Considering the estimated number of children with SAM and the numbers that can be treated
in the existing NRCs there is an urgent need to develop a comprehensive approach which
may include preventive, promotive and curative aspects and links families of SAM children with
the health support system. Currently, the response to severe acute malnutrition (SAM) in
Madhya Pradesh is restricted to facility-based care and relies on a network of about 210
Nutrition Rehabilitation Centres (NRCs) as the only mode of intervention. Children with SAM
stay in the NRC for 14 -21 days and receive therapeutic care following the guidelines for the
management of severe acute malnutrition.

The Atal Bal Mission through a consultative process with eminent experts shall developed a
state protocol for integrated management of SAM children which include facility and
community based care. The mission will also explore the possibilities of trying innovative
evidence based intervention in limited high risk areas to assess the impact and feasibility of the

40
intervention.

Facility based Management of SAM Children

The Mission will also support expanding the network of facilities providing such treatment and
will ensure that all such facilities conform to the accreditation standards, which will be
developed by the Department of Health.

The Mission will ensure the improvement in the existing system of referral of SAM children to
the facilities for effective management. To this effect, if needed, the Atal Bal Mission will
consider the option of providing additional provisions and support to the areas having higher
proportion of SAM.

5.2 Special package for tribal and high risk districts

Since the prevalence of malnutrition is very high in tribal children and also reported in tribal
districts, blocks and high risk sectors, there is an urgent need to develop and implement a
special package of services in a focused and comprehensive manner with the objective to
address food security, availability of safe drinking water and provision of health and nutrition
services in identified districts.

Figure 10: District Wise Status of Malnutrition and In Madhya Pradesh a total of
NRC’s in Madhya Pradesh 142 blocks having high
percentage of malnutrition rate
among young children has been
identified for special package of
services. These blocks include
tribal dominated areas as well as
nutritionally backward areas.
The names of the districts and
blocks are given in annexure1.

The recommended package of

services shall be developed in

41
annual action plans and can include, but need not be limited, to the following:

Three meals could be provided to all children including a) A nutritionally dense

protein rich, ready to eat breakfast b) hot cooked lunch and c) either
egg/potato/Banana/ milk, soya milk or high density protein energy rich food as THR .
The Third meal can either be consumed in the Anganwadi or taken as THR. The cost
of the meals will be work out as and when required.

Provision can be made of subsidized free food grain to all BPL families, at least to
families of malnourished children.

Incentives can be given to AWWs, helpers and supervisors for making special efforts
through home visits and counselling to make and declare their village free of severely
underweight children.

Services of social animators/ mothers group/ CBOs can be recognized, promoted

and supported (including financial incentives) for the monitoring and regular
functioning of AWCs.

Anganwadi-cum-Crèches can be opened for at least 8 hours to take care of children

of working mothers (forest workers, daily wage labourers, migrant workers,
agricultural labourers and others) with an additional full time worker and financial
allocations to cover the cost of additional food and other expenses. Anganwadi-cum-
Crèches can start on an experimental basis in the very backward areas based on
need and then, based on the experience and feedback, they can be opened all over
the State. Anganwadi-cum-Crèches will be a new but essential strategy to overcome
child malnutrition.

5.3 Child health

Current Child Health Strategies under NRHM

Continuum of child health care from community level to facility level through evidence based
interventions and establishment of essential cross-linkages and referral systems.

42
 Referral Transport

Community Interventions Facility Interventions

Integrated Management of Baby Friendly Hospital Initiative

Neonatal Childhood
Sick and Newborn Care Unit
Illnesses

Nutrition Rehabilitation Centre

Home Based Newborn Care

New Born Corners at delivery

Village Health & Nutrition
points
day

Essential Newborn Care &

Immunization
Neonatal Advance Life Support
Infant & Young Child
Navjat Shishu Suraksha
Nutrition
Karyakram

Facility-IMNCI

5.4 Activities under NRHM

Establishment of Sick New born Care Unit Level-I in identified institutions

Up-scaling Sick New born Care Unit (SNCU) Level-II at all District Hospitals

Setting up SNCU Level-III at medical colleges

43
 Strengthening existing Nutrition Rehabilitation Centres (NRC)

Establishing NRCs at every block of the state in a phased manner

Addressing Infant and Young Child Nutrition through promotion of IYCF practice

Micronutrient supplementation ( vitamin A supplementation and iron folic acid ) from 9

months to 5 years

Delivering newborn care through ANM and ASHA on Village Health and Nutrition Days

Addressing vaccine preventable diseases by strengthening routine immunization

Up-gradation of Paediatric wards

Implementation of IMNCI, F-IMNCI and HBNC through training of frontline workers

(ASHA/AWW)

5.5 Proposed activities under Atal Bal Mission

Focussed interventional strategies for reducing malnutrition in the State as follows:

5.5.1 Inclusion of excluded children through mobile health units

It has been felt by the DoPH&FW and DoWCD that there should be a State specific policy to
address the needs of excluded child populations like, children in urban slums, temporary
settlements, nomadic populations, street children, orphans, children of prisoners and
vagabond children thriving at populous places like railway stations, bus-stands etc. These
children are highly prone to childhood diseases including TB, HIV/AIDS and nutritional
deficiencies leading to malnutrition. This requires special approach to ensure their inclusion in
health and nutrition service delivery. As there is no organized structure to cater to the needs of
such vulnerable groups, it is important that package of preventive, promotive and curative child
health services are taken to such groups through an active approach.

The concept of integrated service delivery by using mobile health clinics by the tentative name
of “Chalit Arogya Evam Poshan Vahan”, specifically for such areas, has been proposed by

44
both the department. The Mission will provide all necessary technical support required for
developing such models, and will ensure effective interagency coordination, public-private
partnership for devising the implementation strategy of such models.

5.5.2 Improved micronutrient nutrition and anaemia control in children

The Atal Bal Mission will support the DWCD in improving measures for malnutrition prevention
including addressing micronutrient deficiencies in children.

Control of anaemia in children: As per the national recommendation and policy, all
children 6m-60m should be administered iron folic acid (IFA) syrup/tablets on a daily
basis for 100 consecutive days. While the state has already included this as a
priority intervention in child health component of NRHM, efforts will be made by the
Mission to streamline and strengthen the system and create awareness in the
community.

Control of Vitamin A deficiency: The state has adopted the national guidelines on
the control of vitamin A deficiency and undertakes biannual rounds of vitamin A
supplementation for children 9m-60m of age along with deworming for children 1-5y
of age. This is done on VHND with the AWC as the focal point. The Mission will
make efforts to address existing gaps in the system.

Promotion of use of iodized salt: A strong action plan will be developed to

promote the availability and consumption of adequately iodized salt across the state
in partnership.

5.5.3 Training of all ASHAs on newborn care

Madhya Pradesh state has envisaged training of ASHAs in New born care and she will be
responsible for promotion of Initiation and Exclusive breast feeding. The state is also in the
process of strengthening facilities by setting up Sick and New Born Care Unit (SNCUs) Level-
II, at all district hospitals for providing such care.

45
5.5.4 AWC to act as a nodal point for, growth monitoring & promotion, biannual
vitamin A supplementation services

The Arogya-Poshan Kendra will be operationalized in selected high priority blocks and then
districts. The centres will station ASHA and AWW for providing child health and nutrition
services. The mission will provide all necessary technical support for defining these models
after carefully assessing the operational feasibility.

5.5.5 Strengthening VHND, ensuring immunization for children

Considering the significance of AWC as the only organised infrastructure for delivering
Maternal and Child Health Services which is available at village level, therefore, both the
departments will initiate joint models of integrated service deliveries for preventive and curative
services using AWC as the focal point.

5.5.6 DPH&FW will ensure Early Initiation and Exclusive Breast Feeding (IBF &
EBF) at each Institution Delivery point

Breast feeding counsellors will be positioned in all BEmONCs and CEmONCs for promoting
IBF and counselling of mothers on appropriate infant and young child feeding practices.

5.5.7 All delivery points will be up-scaled to fulfil Baby Friendly certification for
following 10 steps to successful breast feeding

The Mission, through the department of PH&FW will ensure promotion of breast feeding
backed by international initiatives by implementing the Baby Friendly Hospitals. Every facility
providing maternity and newborn care services in the State will follow the Ten steps to
Successful Breast feeding.

5.5.8 All ASHAs will support BCC

For improving IYCF practices during second and third Tuesdays under Mangal Diwas Yojna
(Mangal diwas – Annaprashan & Janm Diwas). For this activity, ASHAs will be given additional
performance based incentives.

46
5.6 Convergent Planning

ICDS is a centrally funded scheme and GOI has provided the guidelines for the planning of
ICDS activities across all the states. These guidelines are important tools to ensure that there
is uniformity in the process of planning. However, these guidelines render very little scope for
adopting the differential approaches to address area-specific problems. Vast States like MP
have different socio-cultural, demographic, geophysical determinant and it is very difficult to
have a single solution which could address all complexities. The current ICDS planning
framework needs to be revamped to provide scope for innovations and search for local
solutions to local issues and problems.

Convergence of services, especially of the health and nutrition services, is a crucial element of
the success of any malnutrition reduction program. The key Departments chiefly involved in
the implementation of the ABM will be:

The Department of Women and Child development (ICDS project)

The Department of Public Health and Family welfare
Panchayat and Rural Development along with office bearers of the gram sabha of the
village
Tribal Welfare Department
Food and Civil Supplies Department
Public Health and Engineering Department
School Education Department

Micro planning for implementation of a program is as important as the conceptual model of the
program. Best conceived programs can falter due to inadequate or lack of micro planning.
Micro planning consists of a series of coordinated and orchestrated events relating to the
implementation of a conceptual model of the program and involves decentralized planning
processes, assigning of specific responsibilities, fixing dead lines for monitoring at different
levels, sector wise service delivery by teams and follow up action through camps and home

visits.

47
The important activities under this component to achieve the objective of strengthening
convergent planning are as under:

State, district and sub district consultations involving concerned departments to have their
inputs on the approaches to strengthen the planning and implementation of Child health
and nutrition related services and identify the roles which different sectors feel they can
play towards this effect.
Based on the inputs thus generated, develop revised guidelines which spell out the precise
roles and responsibilities for each sector and its key functionaries towards strengthening of
services.
Circulation of these guidelines in the form of joint Government Order for scrupulous
adherence to and compliance by concerned sectors as specified.

Address tackling of existing inequities and poor access to services by ensuring that the
plans:

o Articulate the equity and access issues and concerns related to nutrition and health
of the district.

o Require consultation with vulnerable and marginalized populations to capture their

perceived experiences, aspirations, priorities and proposed solutions with regard to
the package of ICDS services.

Every year annual action plan will be prepared at all levels, based on the goals of the Atal Bal
Mission. The action plan will include innovations and draw upon positive experiences within
the state, other states and countries. The interventions tested out in limited geographic areas
showing high impact will be scaled up in other districts to achieve the goals of ABM.

48
6. Development of District Action Plan (DAP)

The Collector of every district, as the District Mission Director will be responsible for the
formation and implementation of the district action plan every year for reducing malnutrition. It
shall be the primary responsibility of the District Collector to systematically reduce child
malnutrition through effective implementation of the ICDS and child health programmes. For
this purpose he/she shall formulate a district action plan, set up a Nutrition Task Force in the
district, keep track of malnutrition status, ensure that all AWCs open regularly regulate the
quality and quantity of the food secured in AWCs, strictly supervise the activities of AWWs,
Helpers and Supervisors monitor the activities of CDPOs, DWCDOs and DPOs set up call
centres and involve all district personnel for effective implementation of the district action plan,
strict supervision and close monitoring of the ICDS and health programmes.

The work of the District Collectors will be assessed on the basis of achievement of goals and
objectives of the Atal Bal Mission as reflected in their district action plan.

Objectives and components of district action plan:

The Atal Bal Mission will facilitate district planning process to use a bottom up approach
with planning of actions at the Block level as the first level of planning.

To develop a comprehensive and realistic DAP formulated through a participatory process

that essentially addresses the local nutrition and child health priorities.

The planning process shall be built upon comparison of performance of different blocks so
as to help derive differentiated Block Plans.

DAP will provide an opportunity to pool innovative ideas, ensure multi-stakeholder

commitment and strengthen inter sectoral coordination for addressing existing constraints
and problems.

DAP will emphasize on development of area-specific and realistic doable plan for the basic
administrative units the ICDS projects, involving all relevant sectors.

The DAP will ensure that specific roles and responsibilities of all involved sectors are
49
clearly spelled out and are well understood by the functionaries of concerned sectors.

District and block level mission functionaries (District and block mission coordinator) will
facilitate this DAP process.

The action plans of individual ICDS project area will be consolidated to produce Integrated
District Action Plan for ICDS.

The Mission will have the provision to provide necessary technical and financial support for
the implementation of DAP.

The Atal Bal Mission will work towards strengthening of district and block capacity to
prepare need-based, decentralized DAP with a special focus on social inclusion and the
under twos.

It is proposed to engage the community through interface with Panchayati Raj Institutions
and other stakeholders like field functionaries from relevant Departments like Dept of Public
Health & Family Welfare Services (DoPHFW), PHED (Water & Sanitation), Tribal
Department , School Education, Rural Development and NGOs to ascertain their specific
needs, problems in accessing ICDS services and possible solutions as relevant to the local
population, especially for the underserved/marginalized population.

Village mapping, placing of the health nutrition teams at proper locations, ensuring
availability of VHND services, facilities for the monthly growth monitoring and delegation of
supervisory and monitoring responsibilities will be all chalked out in DAP.

The objectives and strategies will be formulated keeping in mind, sound evidence-based
and cost effective interventions which are responsive to local needs.

The DAP will emerge from an assessment of current preventive and curative interventions,
barriers in accessing services and role of various existing community opinion leaders.

Measurable quantifiable indicators for malnutrition reduction should be reflected in the

district action plan in line with the ABM goals.

50
The integrated district action plan will be designed to address the multi- dimensional
causes of malnutrition with the aim to reduce malnutrition and provide for the holistic growth
and development of the child through an integrated approach to all basic nutrition services for
children below 5 years of age.

6.1 Effective Implementation of ICDS programme

The ICDS program in spite of its good design hierarchy of service provider and good budget
provision has often failed to deliver the requisites services and analysis of this failure shows
that the major contributors towards this failure has been the indifferent implementation of the
program therefore if the Mission is to achieve its objective of reduction of child malnutrition in
Madhya Pradesh, it will have to focus on effective implementation of the program at all levels.

The success of ABM is dependent on community empowerment and demand for services from
the stakeholders so as to ensure the effective implementation of the ICDS programme.
Essential to achieve this are improvement in the quality of delivery of all ICDS services,
ensuring coverage and reach to all children and quality of the service delivered. To ensure
these following actions shall be undertaken:

Championship

Launching of ABM at the highest political level to send an effective message across
the state;

Involving public representatives in implementation and championship of the cause of

ICDS;

Involving intellectuals, opinion makers and the media;

Mobilizing civil society to create a demand for quality services.

Partnerships (national and international):

Strengthen the evidence base critical nutrition interventions;

51
 Inform the policy formulation process;

Scale up program implementation;

Strengthen program monitoring, evaluation and learning.

Leadership by ABM team and ICDS program

Focus on high burden areas and marginalized community groups;

Focus on children 0- 24 months;

Message from ICDS on impact of less food intake on the nutritional status of child,
intergenerational malnutrition, loss of productivity etc.

To ensure adequate intake of THR by the child focus on counselling to the mothers of 6
months to 24 months old children;

Raise awareness and knowledge of mothers and care providers on appropriate

complementary feeding practices;

Scale up focus on integrated management of SAM both through facility and community
based strategy.

Convergence with Health and its flagship NRHM program

Link Nutrition and Health through Village Health & Nutrition Days for immunization and
care of sick children by health team;

Converge training of Health and Nutrition frontline workers on all nutrition component
highlighted in child nutrition section;

Converge for community and facility based management of SAM in Children.

Synergy with Water, Hygiene, and Sanitation

Linkage with Total Sanitation Campaign to provide toilets in all AWCs;

52
 Linkages with PHE for access to safe drinking water at AWCs;

Scale up BCC for hand-washing with soap and link it to Infant Feeding and Survival.

Community ownership

Mobilize local resource persons and social animators to extend and reinforce the work
of frontline nutrition and health workers;

Community Monitoring by PRIs, local community groups/opinion leaders in the villages

for the opening of AWCs regularly and provision of quality services.

Ensuring opening of AWCs

Establishment of a Call Centre at every District Headquarter with a toll free helpline;

Involvement of PRIs to ensure opening of AWCs;

Supervisors to be given a fixed reimbursement of calls for monitoring the regular

opening of AWCs and will be held accountable for not opening of AWCs;

Provide willing supervisors with mopeds/two wheelers through interest free loan for
better supervision and control;

Use of social animator/ volunteers to ensure regular opening of AWCs;

Cross Monitoring by DC through a team of representatives of other departments;

Linkages with primary school teachers for attendance of AWWs and number of children
attending AWCs;

Action by the District Mission on non functional AWCs.

PPP Model for better functioning of AWCs

Community and people with standing within the community, SHG groups, mothers
societies, companies with CSR component, and others will be encouraged to adopt

53
 AWCs to show quick efficient results;

Within Aganwadis the policy of adopt-a-SAM-Child will be encouraged.

Improving implementation of SNP

Take Home Ration

Monitoring the supply of THR to projects , their storage and regularity in supply to
AWCs (300 days in a year);

Ensure maintenance of buffer stock of THR;

Random checking of the quality and quantity of THR;

Monitor intake of THR for children 6 months - 3 years by community groups and PRIs;

Include counselling as integral part of THR for ensuring adequate intake of THR by the
child and not the family. Supervised feeding at AWC as and when possible. Spot
checking by AWWs and helpers during home visits to ensure the child is eating THR.

Hot Cooked Meal

Atal Bal Mission to put in place a mechanism for checking the proper provision of the
hot cooked meal at all AWCs;

The District Mission to ensure the effective implementation of the Sanjha Chulha;

Empowerment of SHGs with knowledge through training and monitoring about Sanjha
Chulha;

Supervisors to check and give feedback on implementation of Sanjha Chulha in all

block and district level meeting;

Disruption in fund flow and availability of raw ingredients to Self Help Groups will also
be checked and corrective measures will be adopted;

54
 Community groups to be engaged in monitoring of the quality of food supplied by the
Self Help Groups, timings for meals, coverage of children etc;

Atal Bal Mission to work out alternative strategies like THR for provision of food to
children unable to come to AWCs.

Provision of Third Meal and Ready to Eat Breakfast

Provision of some form of Ready to Eat Breakfast to all children in AWCs;

Ensure continuous supply, check quality and quantity with a system of checks and
balances;

Encourage children to eat third meal in AWCs and if not possible, give as THR.

System of Rewards for good performance and accountability for poor performance

Mission will launch “Atal Bal Puruskar” to award the effective work executed by the
DWCD and Mission functionaries. This will include preparation and implementation of
the scheme of awards and financial incentives for AWWS, AWHs, supervisors, CDPOs
and DPOs, Joint Directors for good performance of ICDS and reduction in Malnutrition;

A system of accreditation for outstanding AWCs will be developed on the basis of

services rendered to be put in place;

Annual Award to best performing District Collector;

Accountability to be fixed by the District Collector for non performing AWWs and
Supervisors with suitable severe actions where necessary;

Zero tolerance and strict action against non performing village, block and district officials
of ICDS.

Improving Monthly growth monitoring and promotion

Ensure regular weighing, growth monitoring along with counselling to mothers;

55
 Target 100% weighment of all children 0-5 years, thus enabling tracking of growth
faltering children and early detection and prevention of malnutrition;

Making AWWs fully competent with respect to the interpretation of WHO growth cards
and charts;

Equipping all AWCs with baby weighing scales for children below 6 months and Salter
scales;

Community sensitization on the importance of monthly weighing of children and self

monitoring of weight gain by mothers/ family members.

Improving Home Visits

Special emphasis on improving interpersonal communication skill of AWWs and

supervisors;

Prioritized home visit by AWWs and supervisors;

Specialized trainings on Infant and young Child feeding practices.

6.2 Capacity Building

For effective implementation of the Atal Bal Mission, it is imperative that the functionaries
involved at all levels are equipped with the necessary knowledge and skills. Hence, the
launching of the program will be followed by a series of workshops at the state, district, block
and sector levels to equip the ICDS, Health and other department functionaries with
knowledge and skills for the implementation of ABM.

The achievement of the goals envisaged in the mission document largely depends upon the
effectiveness of frontline workers and their supervisors in improving delivery of health and
nutrition services.

In last few years, ICDS has expanded its coverage and there are around 90000 Anganwadi
Centres in the state and thus bringing the total strength of ICDS functionaries to around 2

56
Lakhs. This large human resource base poses an enormous challenge to provide quality
training and refresher training to front line functionaries and supervisors.

The challenge is to train all these functionaries so that the full potential of the workforce is
tapped and the envisaged functional competence is effectively reached.

6.2.1 State Training Policy

The mission will draft a state training policy for ICDS after carrying out a detailed situational
analysis on the status of existing training infrastructure and quality of training currently being
imparted.

Specific Objectives of Training Policy

The purpose of having a training policy is to achieve specific objectives which are as under:

To develop an efficient and effective training system and human resources to provide
quality services and effective implementation to ICDS;

To develop a training infrastructure including a state resource centre at Bhopal and

divisional level training institutes with requisite capacity and facilities andf to develop
district level training institutes with directly or through NGO participation in every district;

To promote and support all efforts towards enhancement of trainers’ competence and to
develop a pool of motivated trainers at all levels;

To develop partnerships with distance learning centres, NGOs, academic and other
training institutes;

To develop the annual training calendars and facilitate timely organization of earmarked
trainings;

To institutionalize mechanism of regular monitoring of trainings conducted to measure

the impact of training on quality of services;

57
 To promote a culture of learning performance, orientation, monitoring and effective
delivery of services;

A continuous Training Need Assessment (TNA) of ICDS functionaries, based on their

gaps in functional competence, for programmatic requirements would be carried out in
order to develop need-based comprehensive training plans. There would be emphasis
on planned ‘refresher training’ so as to optimize programme performance;

To ensure quality of training and better participation in the programme, existing financial
norms at all levels of training at AWTCs and MLTCs would be reviewed and revised
with a provision of incremental increase in the honoraria of the trainers periodically as
well as in the food expenses of the trainees and other recurring costs;

Various training methodologies, including decentralized training model and mobile

training teams will be developed and scaled up to ensure on job/re-orientation training
of all ICDS functionaries using Public Private Partnership;

To use the innovative methods for scaling up of trainings such as through

SATCOM/Video-Conference;

To develop teaching learning material, training modules and training material required
for different levels of training, different duration of courses and for different level of
workers;

To print and distribute the training and teaching learning materials for training packages.

6.2.2 Development of State Resource Centre (SRC)

A SRC will be developed in Bhopal with state of the art facilities, library, hostel, basic
infrastructure, equipments etc. Training functions will then be planned, implemented and
monitored at state and divisional levels by the resource centres. SRC will review and frame
guidelines for training content, methodology, training of trainers, research, conferences from
time to time and will be fully aligned to carefully determined programme priorities. The purpose
is to develop the capacities of ICDS functionaries so as to achieve the goals of ABM.

58
6.2.3 Setting up Divisional Resource Centre (MLTCs)

The existing 2 MLTCs in Jabalpur and Indore will be upgraded to divisional resource centres
and additional centres developed in Ujjain, Gwalior, Sagar and Rewa. Efforts will be made to
set up the new MLTCs in a phased manner so that by end of five years all the divisional
headquarters listed above have at least one MLTC or Divisional Resource Centre.

6.2.4 Strengthening existing AWTCs and setting up new AWTCs

The staff and capacity of existing AWTCs will be strengthened along with setting up new
AWTCs in uncovered areas as and when required.

Partnership will be built with the regional National Institute of Public Cooperation and Child
Development (NIPCCD) centre based at Indore for skill development and training
programmes.

6.3 Social Inclusion

Madhya Pradesh is the second largest state of India. It has five distinct cultural regions:
Bundelkhand, Baghelkhand, Rewanchal, Malwa and Mahakoshal. The state, therefore,
presents a fascinating mosaic of culture and regional languages. But the cultural diversity also
poses challenges for designing an appropriate program for children. On an average, a Gram
Panchayat covers 2.4 revenue villages, each having an average population of less than 850. A
revenue village could consist of a number of separate habitations known as tola, falia or majra,
especially in tribal areas. Since the population norm of GoI for opening an AWC is 400-800,
small population size of an average village and existence of satellite habitations located at
some distance from the main population cluster poses problem of geographical and population
coverage by AWCs, as a result of which a large number of children remain excluded from the
services provided by AWCs which is one of the reasons for high rate of child malnutrition.

A sizeable proportion of population of the state lives in a state of utter poverty. Roughly
speaking, one in every three persons in the state lives below the poverty line. Regionally, there
is less poverty in the Gwalior region, Western Bundelkhand and around Bhopal, moderate
levels in the Malwa region and extreme poverty in the eastern parts and parts of

59
Bundelkhand18. In recent years the State has tried to identify BPL families and by December
2006 15.64 lakhs families have been issued yellow ration cards ensuring higher rate of grain
allocation to families below poverty line19.

The general state of human development in the state is progressive but still backward in some
parts of Madhya Pradesh. Within M.P., rural areas and the areas in its southwest, southeast,
northwest and central belts are more backward than the rest of the state7. These are also
regions which are forested, have a large Scheduled Tribe population, have an undulating
terrain and agriculture is not as advanced as in other areas. Because of their topography and
forests these areas have poor access to services like health and nutrition.

Prevalence of U5 underweight children as reported by NFHS-III is higher in rural areas (62.7%)

than in urban areas (51.3%); higher among scheduled tribes (71.4%) and scheduled caste
(62.6%) than higher caste (45.3%); and, although underweight is pervasive throughout the
wealth distribution, the prevalence of underweight was highest (68.2%) amongst lowest quintile
of wealth index as compared to the highest quintile (36.7%). The above analysis lays down the
road map for ABM. It is self evident that there is an urgent need to address the excluded
population like the poor, the socially backward and those living in isolated and separate
dwellings.

The Mission will support and strengthen inclusive approach for the delivery of services
for the excluded groups, such as children of SC/ST families, migrant families, tribal and daily
wage labourers, forest area and other disadvantage groups in the following manner:

a) Mapping of all inaccessible pockets and areas district wise and incorporating
specific plans for socially excluded groups in respective district action plans to ensure
the delivery of health and nutrition services to all categories of children and women;

b) Exhaustive exercise on a regular basis (once in two years) for the development and
implementation of micro-plan for each socially excluded pocket/ majra/ tola/ pala
attached to the villages identified in the mapping exercise to ensure enrolment of all
marginalized children for receiving services;

c) Ensuring the utilization of services by empowering all socially excluded groups

60
 through differential strategies including communication for behaviour change to take
care of their children’s health and nutrition. This will be done through community
participation and community monitoring;

d) Revision of the state policy for the supply of THR for all children < 5 yrs of
marginalized identified families/ who are unable to come to the AWCs as their
parents are either migrating for short spells or taking the children daily to the
employment sites in the absence of adequate support systems at home;

e) Ensuring the coverage of services (immunization, SNP, growth monitoring and other
nutrition interventions) for children of other district/ block/ sector/ village taking up
temporary residence in the village for any reason. This will be done through
amendments in the existing state policy under Atal Bal Mission;

f) Anganwadi-cum-Crèche Centres for Children: The ABM will explore the possibilities
of setting Anganwadi-cum-Crèche centres specially in rural areas and tribal pockets for
the welfare and development of children below the age of 5 years, whose both parents
are working and consequently these children are deprived of essential health and
nutrition services. Very often working parents either take the children to the work site or
leave them in the care of an older sibling who is then also deprived of the opportunity
will be able to address the problem of exclusion effectively.

6.4 Behaviour Change Communication & Social Mobilisation

In the context of Atal Bal Mission, the behaviour change communication (BCC) and social
mobilisation interventions will play a central role in addressing nutrition and health issues while
keeping the empowerment of families and communities in the centre. It has been seen that
making laws and setting down policies do not often result in behaviour change and a more
concerted and inclusive strategy involving print, radio, electronic and virtual media is
necessary to bring about desired changes in society. Towards this end ABM will develop a
comprehensive and inclusive BCC policy.

There have been many communication efforts in past in the State resulting in greater

61
awareness, service utilization and social mobilization. The BCC and Social Mobilization
strategy for Atal Bal Mission, while amalgamating the lessons and best practices of past, will
primarily include formulating a comprehensive, inclusive BCC and Media Policy. This policy will
aim at:

a) Behaviour change communication targeted at improving knowledge, attitudes and

practice of families and changing social norms. Interpersonal and group communication
will be the main tools, while infotainment based mass media programme will provide the
synergistic support.

b) Social mobilization and Community dialogue targeted at social norms and community
empowerment. Use of informal (and also formal) social groups, duly mapped according
to community groups, will be the main tool.

c) Advocacy will be done at family, society, community and political levels for creating an
enabling environment that is pro children and pro women. For this purpose professional
support groups, brand ambassadors, socio-political structures and different forms of
mass media will be the key tools.

This BCC package and policy will be an intensive strategy

Figure 11: Communication
Mix harnessing the strengths of the multiple actors like family,
community, opinion leaders, PRIs, religious bodies,
academia, universities, colleges, organized and unorganized
youth (such as NSS, NYKS, Bharat Scouts and Guides). In
addition to creating awareness among the target groups, it
will contribute in creating and maintaining demands within the
community and in creating conducive social, cultural and
political environment. It will have different solutions for
different problems or needs. Caste, religion, language,
habitation etc. will be addressed through using variety of media and social agents depending
on the local suitability. The multi pronged campaign will be aimed at addressing issues like
breast feeding, IYCF, complementary feeding, best nutrition practices, child health and
immunisation, early childhood care and education, pre-school activities, intergenerational

62
malnutrition, gender discrimination, child marriage, care of the girl child and related issues. It
will build the systemic capacity of the State to promote child nutrition and health related
behaviours in a time-bound communication campaign.

6.4.1 BCC & Social Mobilization (SM) interventions plan

The mix of behaviour change communication, social mobilization and advocacy will be
implemented through using a variety of communication strategies. In order to effectively
support ABM, the BCC & social mobilization strategy will broadly contribute in two areas:

a) Prevention of malnutrition through improving family level practices through empowering

families with necessary skills and behaviours to avoid malnutrition specially among the
younger children; and

b) Promotion of services of both DWCD and Health for optimum utilisation of services and
creation of demand with the purposes of both prevention and medical management of
malnutrition.

The BCC & Social Mobilization interventions need to focus at some key audiences including
the young girls, mothers, mothers-in-laws, husbands, parents and families, the community and
the service providers. Each one has a critical role in the fight against malnutrition. The parents
need to understand adopt nutrition enhancing behaviours and access the nutrition services
offered. The community needs to act as a catalyst and supportive change agent and the
system and service providers need to facilitate the process of change through provision of
client - friendly services. Keeping these different needs in mind, ABM will act through the three
levels indicated in the Figure-11 through a mix of communication methods that will include
interpersonal communication, social mobilization and mass and outdoor media.

In order to create optimum results, the target audience should be prioritized according to what
we are promoting. For example, the communication targeted at promoting exclusive
breastfeeding will identify lactating mothers as primary audience. The mothers in law, elderly
women of the family, husband, peers and service providers or frontline workers will become
secondary audience. Knowing the critical role of social influence on individual behaviours, the
local medical practitioners, traditional healers, priests, members of PRIs, members of SHGs,

63
CBOs and NGOs will be duly included as tertiary target audience.

Under Panchayati Raj system there are 23,651 Panchayats functioning in the state. These are
statutory institutions representing decentralized democratic set up for carrying out
development work in villages. A VHSC (Village Health and Sanitation Committee) has also
been formed in every village which could be potential instruments for promotion of BCC
activities at village level.

The BCC and Social Mobilisation interventions plan also provides ways and means to
strengthen the available channels of social mobilization like Village Health & Nutrition Day
(VHND), Mangal Diwas etc. It is also recommended to use radio and some critically important
outdoor media to generate overall awareness and create enabling environment. A suggestive
list of interventions has been given in the table 3 which is an example to promote initiation and
exclusive breastfeeding and nutrition practices.

Table 3: A sample BCC and Social Mobilization intervention plan

BCC & Social Interventions

Mobilization
strategy

Interpersonal Continuum of person to person counselling (to mothers/ parents/

Communication family members) by service providers using client oriented messages
and skills: starting with pregnancy and till the time child becomes 5
years. Special focus on children upto 2 years of age,

Improved service provider-client interaction (AWW and young

mothers or ANM and child/mother) through providing interpersonal
communication (IPC) skills training to the service providers, job aids
(like flip books), give aways (like educational flier, toys etc.).

64
Social Making VHND and Mangal Diwas educational, client-friendly,
Mobilisation/ attractive and festive,
Community
dialogue/ Involving social influencers like elderly women and men, traditional
Advocacy healers, priests and religious leaders, teachers etc. Dialogue among
the affected families, neighbourhood and service providers (popularly
known as Tri-logue in social mobilization) will be highly useful,

Recognition and rewards to early acceptors i.e., through Healthy baby

quiz, baby shows,

Sharing of success stories of change (using Most Significant Story

technique) at the community level through video, radio and pictorial
publications. Example- the success stories of children benefitted by
NRC.

Using local (folk) media, especially in the media dark areas, identified
through communication needs analysis and stake holder mapping.

Mass awareness Production of a media mix (Radio and TV programmes supported by

through Mass outdoor media, IPC, video shows, community level drive and
Media/ mid media meetings),

Partnership with Mass media i.e. Radio, television and newspapers

for reinforcing key messages effectively through frequency and
quality using brand ambassadors and iconic figures,

Baby-friendly hospital initiative or child friendly AWCs,

Appoint a brand ambassador for breastfeeding and other key

messages,

Develop daily, weekly programmes around social issues including the

programmes with phone-in components on both Radio and
Television,

Advocacy calendar to celebrate important days will be released and

executed. Media interest stories, advertorials etc will be used
extensively,

Periodically appeal, advertorials, Press Ad from the highest offices

like CM, Governor, Ministers and brand ambassadors will be
released.

65
6.4.2 Implementation plan for BCC and Social Mobilisation activities

The multi-year mission should set into motion the following to administer the desired
communication strategy in the state;

a) Form an inter-agency sub-group for BCC & Social Mobilization within ABM: for
strengthening systems and provide technical guidance to the formulation and
implementation of communication strategy. Main stake holders will include WCD,
DoPH&FW, Development partners and Experts. The core group will set out necessary
guidelines, procedures etc for converging the existing BCC & social mobilization
resources within the departments. Based on assessment, it will advocate with the
highest authorities in the state to allocate needful staff and budget for BCC
interventions.

b) Setting up technical capacity for BCC & SM within the mission: A project team will
be in place comprising of a team leader and specialists like communication planning,
training, materials development, Monitoring & evaluation.

c) Capacity building of mission functionaries, including lead departments like WCD,

DoPH&FW, in the area of interpersonal communication (IPC) and social mobilization

d) Research based campaign design and implementation: Production of media

materials and media buy. Rapid Communication needs analysis (CNA) for developing
area (cultural zone) specific communication messages will be required. The analysis will
include barriers (to desired behaviours) and mapping of available and preferred
communication channels and stake holders.

e) Alliance with professional and civil society organizations: Networks like NSS,
Bharat scouts & Guides, NYKS, Universities, Medical associations, Pvt. Hospital bodies
etc Govt. And development bodies working through SHGs (like MPRLP, Mahila Vitta
Nigam etc) will be key allies.

f) Monitoring and evaluation of BCC & social mobilization activities – A mechanism

of timely reporting of activities right from font to the state level will be in place.

66
 Communication specific indicators for monitoring inputs, outputs and outcomes will be
put into place. It will be wise to set the concurrent and end-line evaluation specific
communication indicators of the mission.

6.5 Monitoring and Evaluation (M & E)

Any Mission or projects effectiveness must be evaluated simultaneously to ensure effective

performance, achievement of the objectives visualise, robust concurrent monitoring and course
correction where ever required. To achieve this M & E is an efficient and effective tool, a tool
which helps in identifying problems and its causes, suggests possible solutions to problems,
raises questions about risks or assumptions and strategy; encourages reflection on the
progress and its directions; provides information and insight into the programme; stimulates
action on information and finally enhances the likelihood of positive and sustainable impact.
The M&E Framework will enable Atal Bal Mission to address questions such as:

Whether the State and the Mission are on the right track vis-à-vis their objectives,

Whether ABM is having an impact on the health and nutrition status of children,

Whether it is working efficiently and also be able to draw lessons for learning in order to
bring about effective performance improvement.

For this purpose an M & E unit will be set up under the ABM which will ensure timely
compilation and uploading of monthly data by the District Mission office. Analysis of monthly
reports for effective decision making and maintenance of high quality data. Specifically the M &
E unit will:

Assist in development of annual nutrition plan by ensuring accurate data availability for
situational analysis;

Assist District Program Managers and ABM team in designing reporting formats
according to the needs –as and when required;

Ensure linkages between reporting format and software;

67
 Ensure availability of resources (human, financial and material) and equipments at
State, Districts and Block levels;

Capacity building on data management of State, District and Block level staff;

Monitoring of performance of the staff associated with the data management;

Compilation of data of different programs;

Analysis of collected data;

Checking data quality and verification of data;

Feedback to the Mission;

Repository for compiled reports, surveys and studies;

Facilitate electronic transmission of data to all levels;

Sharing of performance, obstacles, etc with the policy makers for decision making on
the basis of analysis of data;

Management of Dashboard;

Conduct review and evaluation of programs;

Development and publication of Annual Report on the basis of decided indicators

(primary and secondary like NFHS, SRS, evaluations report, etc).

In nutshell, M & E unit will analyze data and share with Mission and policy makers for
decision–making.

6.5.1 Strengthening and up-scaling of Web-Based Management Information

System (WB-MIS)

DWCD has developed a web based MIS system and some very useful reports are being
generated. However, this system needs to be universalized and strengthened so that reliable

68
data from across the state may be generated and analyzed for good decision making. Since
the State has addressed malnutrition as its focus area, the Mission will scale up the Web
based monitoring system to capture the true picture of the level of malnutrition particularly
amongst children in the state. This will further help in planning and decision making
accordingly. It would call for the capacity building of all categories of staff and ensuring
availability of sufficient number of human resources and block level band IT equipments.

6.5.2 Third Party Monitoring/ Concurrent Monitoring

As part of Management Information System, third party monitoring will be conducted through
an independent / external professional agency. This agency will annually conduct sampled
concurrent monitoring of various nutrition and child health related indicators in the State as
agreed with the department. It will provide report on availability, accessibility and utilization of
services in general and specifically related to nutrition. It will provide information related to
outcomes to provide district and state estimates on key health and nutrition indicators on the
one hand and comparison with reported data on service delivery. It will also focus on the
mission interventions in terms of relevance, performance, problems affecting implementation,
and suggestions for evidence-based decision making.

A Monitoring Cell consisting of members of different external agencies like UNICEF, DFID,
UNDP, WHO and others will be set up for concurrent monitoring. The monitoring by this cell
will be carried out on monthly basis in the State. The monitoring team will cover the districts on
rotation or as may be decided by the Mission. It will also check the veracity of the reports sent
by the District Mission Offices.

6.5.3 Establishment of Call Centre at District Headquarter

A call centre will be established in Figure 12: Ensuring monitoring of AWCs through
each district at the District Project Call Centre

Office (DPO) under the supervision

of DPOs. Call centre will function 24
x7 days to receive
complaints/information from different

69
areas of the district.

6.5.4 Supervisory Tool

A standard supervisory tool will be developed at block and district offices to monitor the
functions of every AWC. This tool will be developed to identify the standards of child
malnutrition status, physical infrastructure, timings and regularity, safety provisions, child
friendly environment, safe drinking water status, toilet cleanliness, ECE, usage of play-way
methods for learning etc vis-a-vis the guidelines or norms set by the Mission. Gaps identified
during supervisory visit will be tackled on the spot if possible or solved at a later stage by
concerned authorities. After the visit, a copy of the status report and the improvement plan of
AWCs will be submitted to the Anganwadi Worker for further improvement. The copy of the
same will also be communicated to the Monitoring and Evaluation Unit for analysis and
accreditation.

All the AWCs will be evaluated by means of the supervisory tools against the norms and shall
be graded accordingly. The accreditation grading shall be the guiding source for reward
system.

6.5.5 Community Monitoring

“Swasthya Gram Samiti “(SGS) will play an important role at the field level as a part of
community monitoring. SGS will mainly be responsible to observe the functioning of the AWCs
and comment on the quality of services being provided at the AWCs. SGS will ensure that
AWC opens and functions as per norm. At the same time, the SGS will bridge gaps between
community and AWWs to ensure enrolment of children at the AWC according to the survey
completed by anganwadi worker. In case, SGS observe any weak point of AWC then Samiti
will be responsible to communicate problem to the supervisor and project office by using toll
free number. To involve the community in monitoring of the functioning of the AWCs, the
services being rendered at the AWCs will be displayed at the prominent public places in the
villages. Not only the SGS but other CBOs, SHGs, mother groups and the vigilant youth should
also be encouraged to get the true feedback about the AWCs.

70
6.5.6 Four-tier system of monitoring

Monitoring is essential at every level to maintain quality of the program and achieve results.
Above paragraphs presented various approaches of monitoring which will be used under Atal
Bal Mission. In order to deal with the existing challenges with regards to programme
performance and up gradation of skill of supervisory staff, four-tier monitoring mechanism
along with necessary facilities has been proposed, which are as follows:

Levels of Monitoring

Anganwadi Centre (AWC) Level: Each AWC will be visited by Sector Supervisors as per
norms to observe functioning of AWC. It is proposed that Sector Supervisors will have their
office at the sector headquarter along with the facilities of phone and mobility support to ensure
regular monitoring of each AWC falls under the project area. Provision has been made under
Bal Mission to assess performance of each anganwadi centre on the basis of agreed criteria
by group of experts after defined periods. The performance may be assessed with regards to
coverage, service package, quality of services, regular functioning of AWC, etc. Further, each
AWC will be given a rank (or accredited) in the State on the basis of performance. It is believe
that this strategy will motivate anganwadi workers to perform better and serve religiously to the
community.

Project Level: Functioning of supervisors will be monitored by the Block Mission Coordinator
in coordination with CDPOs every month through monthly meeting and field visits on the basis
of standard checklist. The status will be reported to the M&E policy makers through standard
mechanism. Under the ABM all project will be equipped with functional vehicles to ensure
effective monitoring. If require additional vehicles will be procured based on the requirements.
Under Atal Bal Mission provision will be made to provide performance based incentives
(monetary/non monetary) particularly to the supervisory staff to keep up their motivation level
high and ensure quality services. Performance will be assessed on the basis of pre-determined
criteria.

District Level: Performance of each block will be monitored by District Mission Director
(Director) in coordination with District Programme Officer on the basis of standard checklist.

71
The status will be updated though M & E for performance measures.

State Level: State level monitoring will mainly focus on mission performance and suggest
possible options/ strategies to overcome from challenges. Monitoring will be done through
various ways such as monthly meeting under the Chairmanship of Mission Director of the
Mission. Performance monitoring will also be conducted by the General Body and the
Executive Committee at agreed intervals.

6.5.7 Evaluations, Assessments and Operational Research

Atal Bal Mission will plan and execute the need based assessments, live case studies, studies,
evaluations to assess the quality of Mission interventions. Subject and area of the studies will
be decided by the Mission. Studies may also be carried out in terms of programs and
schemes being implemented by the DWCD having an impact on the nutritional and health
status of women and children.

The outcome of the above mentioned assessments will be shared for performance
enhancement of the activities under the Mission.

72
7. Administrative and Institutional Arrangements

There is strong evidence in favour of bringing about an institutional mechanism for pursuing
the intended mission mode to address child malnutrition, both at the National and State levels.
Experience of the State has shown that where social problems have assumed gigantic
propositions it is often difficult to effectively address them in the routine manner in which State
programmes are normally implemented. A prime example of this has been the problem of
school education where the setting up of the literacy mission followed by the Sarva Shiksha
Abhiyan in 1999 have shown very positive results. Similarly when child and women health
needed more effective interventions GoI set up the National Rural Health Mission which has
been operational since 2005. Within the state too missions like Mission for Control of
Diarrhoeal Diseases, Elimination of Iodine Deficiency Disorders, Mission for Watershed
Management, and Mission for Community Health Action have served the purpose of
addressing the issue at both the policy as well as implementation levels in an effective and
time bound manner. It is observed that missions, formed through the society mode have the
strength and authority of the government while at the same time provide the flexibility and
autonomy which is needed for effective implementation with innovation. It is in this context that
the need for a child health and nutrition mission was felt.

ATAL BAL AROGYA EVAM POSHAN MISSION is envisaged to be set up as a society under
the MP Society Registrikaran Adhiniyam, 1973 (No. 44 of 1973) under the Department of
Women and Child Development.

The Atal Bal Mission is expected to create a momentum for efficient delivery and management
of the ICDS programme in order to improve the nutritional status of the children of the State.
The Mission will specifically support the strengthening of certain specific areas e.g., effective
and regular distribution of SNP, improvements in the quality and quantity of SNP, development
of model AWCs, convergent planning, preparation of Annual District Plans, capacity building,
supportive supervision and monitoring of community based management of moderately
malnourished children and SAM children with the express purpose of reducing child
malnutrition. Overall the role of the Mission will be to ensure universalization of ICDS with
quality. To address the above mentioned components it is essential to create a separate set up

73
that is free from the responsibilities of regular administrative management and has the time
and the ability to come up with creative and quality thinking and inputs for giving new
dimensions to ICDS.

The Atal Bal Mission will act as an overarching institution at the state level and bring the
nutrition agenda to the forefront in all relevant sectors of the State. It will create the necessary
urgency and expediency at the district and block levels so that the problem can be handled on
a war footing. The following paragraphs discuss the societal framework of ABM.

7.1 State Level Structure

At the state level, given its mandate and importance of the issue of nutrition and child health, it
is proposed that the General Body for the Atal Bal Mission be headed by the Honourable Chief
Minister of the State with the Ministers for Women and Child Development, Public Health and
Family Welfare and Panchayat and Rural Development as the Co-Chairpersons. The other
members of the general body can be as given in Figure 13. The General Body will provide
policy and strategic directions to WCD and allied departments for accelerating and
implementing the Mission agenda. The General Body shall at least meet twice in the first year
and once in a year thereafter.

74
Figure 13: Organization Structure of General Body for Atal Bal Mission

General Body Headed by Chief Minister

Co-Chairs:
Minister DWCD Minister Minister
Health Panchayat &RD

PS School PS PS PHED PS Health PS Panchayat

Education Finance & RD Welfare

PS Food & Civil PS Tribal Commissioner PS WCD

Supplies Welfare Public Relation

4 Civil society
Mission Director 2
representatives,
and Member Secretary Representatives
including
Director DWCD from Academic
International
bodies
organizations

Executive Director of the Atal

Bal Mission, IAS

The Executive body for the Mission shall be headed by the Chief Secretary, GoMP with
Principal Secretary of department of WCD as Vice Chairman and Principal Secretaries/
Secretaries of other related departments, i.e., Health, School Education, Finance, PHED,
Panchayat and Rural Development, Tribal Welfare, Food and Civil Supplies as members of the
executive committee (Figure 14). The Executive Committee shall approve the annual work
plan and budget of ABM, appraise the planned performance, guide the programme
implementation and sanction the technical, logistical, administrative and financial resources
required by ABM for the attainment of its goal. The powers of the Executive Committee will be
as described in the bye-laws of the ABM society.

The Executive Committee will meet at least once in every quarter and the Mission Director of
the ABM will be the Member Secretary, who would also act as the Mission Director for the Atal
Bal Mission.

75
Figure 14: Organization Structure of Executive Body for Atal Bal Mission

Executive Body Headed by Chief Secretary

Vice Chairman: PS DWCD

Members

PS PS Panchayat & RD PS Tribal PS PHED

Finance welfare

PS Food & Civil PS School PS Health

Supplies Education

Mission Director
and Member Secretary ,Director DWCD

Executive Director of ABM

IAS officer

At the operational level, there will be a Mission Director who would be the Commissioner /
Director DWCD and an Executive Director who would be an IAS Officer deputed to the Mission
on an exclusive basis. He would be supported by a mix of contractual and on-deputation
officials at the State, District and Block levels.

76
8. Financial Arrangements

The State Government of Madhya Pradesh will provide the financial, administrative and other
support necessary to meet the goals and objectives of the Atal Bal Mission. To this end GoMP
will support the Mission and its different components as listed in different sections of the
document. It will also provide the resources for institutional and administrative arrangements to
facilitate the smooth functioning of the Atal Bal Mission. Development Partners like WHO,
DFID, UNDP, EC, JICA, UNICEF etc. can also assist the Mission by providing technical,
financial, administrative, logistical support and resources.

To ensure flexibility for realistic planning and budgeting towards achieving the goals of ABM,
the Mission will formulate Annual Action Plans along with financial details and will submit these
proposals through Department of Women & Child Development to the appropriate authority for
approval and allocation of funds.

77
9. The Way Forward

Atal Bal Mission is a visionary strategic document that provides the programmatic directions for
improving the nutritional and health status of the children of Madhya Pradesh in the next 10
years. It is an overarching, open and flexible document with a clear goal to guide State’s
efforts for the elimination of malnutrition and for improved health status of the children. In no
instance should the Mission Document be viewed or used as a limiting document. It is
designed to inspire, motivate and to guide and it should not constrain the vision and views of
future policy makers and nutrition and health experts. There should always be scope for
innovation, creativity, experimentation, new ideas and continuous evidence based
programming, monitoring and evaluation.

The challenge now is to translate this document into successful action with positive impact on
children. Under the general framework of the ABM, annual action plans will be developed to
include concrete and well defined evidence based interventions. Each annual work plan will
build upon the previous year’s plan and will use the experience gained and lessons learned
through the implementation of ABM.

78
References

1
Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet, 2008 ; 371 (9608): 243-
60

2
Chatterjee P. Child malnutriton rises in India despite economic boom. Lancet, 2007; 369: 1417-8

3
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-
2006, Volume 1. International Institute for Population Sciences, 2000. Mumbai, India.

4
International Institute for Population Sciences (IIPS) and Macro International. District Level Household & Facility Survey
(DLHS 3); 2007-08. International Institute for Population Sciences (IIPS); 2000, Mumbai, India

5
www.who.org/india/countryhealthsystemprofile

6
A report on Rajiv Gandhi Misssion for Control of Diarrhoea Diseases, Department of Health & Family Welfare, GoMP, 2000.

7
Madhya Pradesh Human Development Report, 2007, Page 1333-1334

8
Study on Malnutriton by World Bank India; Cited on http://www.indiaonestop.com/general.htm

9
United Nations Children’s Fund (UNICEF), State of the World’s Children 1998 report. United Nations Children’s Fund
(UNICEF), 1998, New York. http://www.unicef.org/sowc98/

10
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-2)
1998-99 . International Institute for Population Sciences, 2000. Mumbai, India.

11
United Nations Children’s Fund (UNICEF) State of the World’s Children 2008. United Nations Children’s Fund (UNICEF),
2008, New York.

12
Bhandari N, Bahl R, Taneja S, de Onis M, Bhan MK. Growth performance of affluent Indian children is similar to that in
developed countries. Bulletin of the World Health Organization, 2002; 80: 189-95.

13
Lancet series (3rd series) on Child Survival, India analysis-2004

14
Desert Flowers: Contributed by Manjaree Pant and Gujarat State Team. Published on May 8, 2010: Building as a Learning
Aid (BaLA)

15
Maternal and child undernutrition: Effective action at national level. Lancet, 2008; 371 (9608): 510-526

16
World Health Organization, United Nation’s Children’s Fund. 2009. WHO child growth standards and the identification of
severe acute malnutrition in infants and children; a joint statement by the World Health Organization and the United Nation’s
Children’s Fund

17
Indian Academy of Pediatrics (IAP). IAP guidelines 2006 on hospital-based management of severely malnourished children
(adapted form WHO guidelines). Indian Pediatrics, 2007: 443-461.

18
A study on the health sector in Madhya Pradesh, HLSP Consulting Ltd and MSG, 2002

19
Madhya Pradesh ka Aarthik Sarvekshan, 2006-07, Directorate of Economics and Statistics, MP

79
Annexure 1: Status of 142 High Rick Blocks in 20 Districts of Madhya
Pradesh

AWCs
No. of No. of
Name of No. of
S.No Division Name of Block ICDS Sector No. of
District Mini
Projects s AWCs
AWCs
1. Sehore
1
Urban
2 Bhopal & 2. Budhni
3 Hoshangaba Sehore 3. Icchhawar 9 45 1109 189
4 d Division 4. Ashta
5 5. Shyampur
6 6. Narullaganj
7 1. Susner
8 2. Shujalpur
9 3. Agar
10 4. Nalkheda
11 Shajapur 5. Kala Pippal 9 38 1369 166
12 6. Barod
13 7. Barodia
Ujjain
8. Berchha
14 Division
(Shajapur)
15 1. Ratlam
16 2. Sailana
17 3. Piplauda
Ratlam 10 70 1620 382
18 4. Jaura
19 5. A lot
20 6. Bajna
21 Indore 1. Jhabua
22 Division 2. Rama
23 3. Meghnagar
Jhabua 6 64 1606 705
24 4. Petlawad
25 5. Thandla
26 6. Ranapur
27 1. Alirajpur
28 2. Sondawa
29 3. Bhabra
Alirajpur 6 45 1121 523
30 4. Jobat
31 5. Kathiwada
32 6. Ambua
1. Dhar
33 Dhar 16 129 3248 94
Urban
34 2. Dhar Rural
35 3. Gandhwani
36 4. Badnawar
37 5. Sardarpur
38 6. Kukshi
39 7. Manawar
40 8. Nisarpur
41 9. Nalcha
42 10. Umarban

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43 11. Bagh
44 12. Dahi
45 13. Tirla
AWCs
No. of No. of
Name of No. of
S.No Division Name of Block ICDS Sector No. of
District Mini
Projects s AWCs
AWCs
1. Khargone
46
Urban
2. Khargone
47
Rural
48 3. Kasrawad
49 4. Goganwa
Khargone 11 78 1857 121
50 5. Sengaon
51 6. Bhikangaon
Indore
7.
52 Division
Bhagwanpura
53 8. Jhiraniya
54 9. Sanawad
55 1. Burhanpur
56 2. Shahpur
57 Burhanpur 3. Khaknar 6 29 725 40
58 4. Dhulkot
59 5. Nepanagar
60 1. Malthon
61 2. Deori
62 3. Rahatgarh
63 4. Bina
64 5. Khurai
65 6. Rehli
66 Sagar 7. Sagar 16 58 2007 334
67 8. Gadakhota
9.
68
Sagar Jaisinghnagar
69 Division 10. Shahgarh
70 11. Kesli
71 12. Banda
72 1. Tikamgarh
73 2. Jatara
74 3. Palera
75 Tikamgarh 4. Niwadi 8 57 1406 205
76 5. Prithvipur
77 6. Baldevgarh
78 7. Badagaon
Rewa 1. Rewa
79 Rewa 15 112 2791 552
Division Rural
80 2. Sirmour
81 3. Jawa
82 4. Theothar
83 5. Gangev
6. Raipur
84
Karchuliyan
85 7. Naigadi
86 8. Mauganj

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87 9. Hanumana
88 1. Annupur
89 2. Jaithari
Annupur 4 41 1030 83
90 3. Kotma
91 4. Pushprajgarh
AWCs
No. of No. of
Name of No. of
S.no Division Name of Block ICDS Sector No. of
District Mini
Projects s AWCs
AWCs
92 1. Sidhi
93 2. Rampur
94 Sidhi 3. Sihawal 7 72 1772 1583
95 4. Kusmi
96 5. Majholi
97 1 Vijayragavgar
2. Katni
98
(Murwara)
99 Katni 3. Dhimarkheda 7 52 1509 231
100 4. Rithi
101 Rewa 5. Bohriband
102 Division 6. Badawara
103 1. Satna
104 2. Suhawal
105 3. Nagaon
106 4. Uchhera
107 5. Maihar
Satna 9 104 2591 746
108 6. Amarpatan
109 7. Ramnagar
8. Rampur
110
Baghelan
111 9. Chitrakoot
Gwalior & 1. Shivpuri
112
Chambal Urban
Division 2. Shivpuri
113
Rural
114 3. Badarwas
115 Shivpuri 4. Pichore 9 74 1850 432
116 5. Khaniyadana
117 6. Karera
118 7. Pohari
119 8. Narvar
120 9. Kolaras
1. Sheopur
121
Urban
Sheopur 6 36 894 286
122 2. Vijaypur
123 3. Karahal
124 Morena 1. Morena 11 82 2058 372
125 2. Porsa
126 3. Ambah
127 4. Khadiyar
128 5. Banmor
129 6. joura
130 7. Kailaras
131 8. Sabalgarh

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132 9. Pahadgarh
133 1. Datia
134 2. Sewdha
Datia 7 31 766 123
135 3. Indargarh
136 4. Bhander
AWCs
No. of No. of
Name of No. of
S.no Division Name of Block ICDS Sector No. of
District Mini
Projects s AWCs
AWCs
137 1. Bhind
138 2. Lahar
Gwalior &
139 3. Gohad
Chambal Bhind 10 81 2022 359
140 4. Roun
Division
141 5. Ater
142 6. Mehgaon
Grand Total of 142 Blocks in 20 High risk districts 182 1298 33351 7526

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