Directorate of Social Welfare Department of Education …€¦ · Anaemia is the most common cause of maternal deaths, accounting for a fifth of all maternal deaths (more than one

Directorate of Social WelfareDepartment of EducationDepartment of Health and Family WelfareGovernment of Bihar

Control of NutritionalAnaemia in School going

Adolescent Girls

Experiences in Bihar

Directorate of Social WelfareDepartment of Education

Department of Health and Family WelfareGovernment of Bihar

Contents

Background 4

Project Implementation 9

Training and Capacity Building of Functionaries 13

Local Resource Mobilisation 18

Supply and Logistics Management 20

Monitoring and Evaluation 24

Impact and Challenges 28

Control of NutritionalAnaemia in School going Adolescent Girls

4

BackgroundAnaemia is a serious public health problem, which affects the mental and

physical development, as well as health maintenance and work

performance. Iron deficiency is by far the most common cause of

anaemia worldwide. About 2 billion people suffer from varying degrees of

anaemia in developing countries.

Iron deficiency occurs when insufficient iron is absorbed to meet the

body’s needs. This may be due to inadequate iron intake, poor iron

absorption, increased iron need or chronic blood loss. Prolonged iron

deficiency leads to iron deficiency anaemia (IDA).

Haemoglobin levels recommended

by WHO

Children 6 month-6 years <11g/ 100ml

Children 6-14 years <12g/ 100ml

Adult male <13g/ 100ml

Adult female <12g/ 100ml

Pregnant woman <11g/ 100ml

Chapter1

Anaemia is the most common cause of maternal deaths, accounting for a

fifth of all maternal deaths (more than one lakh women in India die of

pregnancy-related deaths, out of which 22,000 are related to nutritional

anaemia). Severe anaemia accounts for 20.3 per cent of maternal deaths.

The risk of dying from haemorrhage and infection is five to ten times

greater among anaemic women compared with non-anaemic women.

Background

5

Anaemia among women also

compromises infant health by

contributing to intra-uterine growth

retardation, low birth weight and

ultimately perinal mortality, and a

higher risk of irreversible brain damage

in infants.

Anaemia is more likely to occur during:

� Preschool age when growth is

rapid

� Adolescence when there is rapid

growth and menstrual loss of iron

� Pregnancy, when there is rapid

growth of foetus and maternal

tissues

Anaemia in adolescent girlsAdolescence is a critical stage in the

life cycle, when the health of females

is affected due to growth spurt,

beginning of menstruation, poor

intake of iron due to poor dietary

habits and gender bias.

Iron deficiency anaemia affects over

60 per cent of the adolescent girls in

India (NFHS 1992). Anaemia in

adolescent girls has far-reaching

implications. The anaemic adolescent

girls grow into adult women with

compromised growth, both physical

and mental. These women have low

pre-pregnancy weight, and are more

likely to die during childbirth and

deliver low birth weight babies.

Therefore, investing in the adolescent

girls serves a dual purpose, as it helps

to optimise the development of the

girls’ inherent potential and provides a

sound foundation from which to

launch the next generation.

Counteracting the effects of anaemia

can help to further both the above

aims. Efforts to control anaemia in

adolescent girls have adopted a two-

pronged approach—a weekly regimen

of iron supplementation supported by


6

rigours of pregnancy and child-rearing

can help to minimise the deleterious

impact of anaemia on the offspring.

Hence, controlling anaemia in

adolescent girls is now a national

priority and the government of the

state of Bihar, along with UNICEF,

took the initiative in this direction by

launching a district-based pilot project

in the year 2000. The Anaemia Control

Project (ACP) was launched in five

districts—Gaya, Muzaffarpur, Ranchi,

East Singhbhum and West

Singhbhum. With the bifurcation of

the state, the latter three districts are

now in Jharkhand state.

an interpersonal interaction for

behaviour change in dietary practices,

along with an intensive IEC campaign

that focuses on sustainable strategies

for the control of anaemia.

Pilot initiative for the control ofanaemiaNutritional anaemia has emerged as a

major limiting factor in the

development of adolescent girls, as it

compromises their own growth, and

also has implications for the future

generation. An intervention that can

help to improve the iron status of a

girl before she is subjected to the

Life cycle approach of Dular strategy

Community and family empowerment process

Community-based

MIS for below

3 year age group

Joyful learning in ECE

for 3 to 6 year age

group, linkages

with PSE

Control of nutritional

anaemia in adolescent

girls and quality life

education-”Kishori Shakti”

Maternal nutrition and

safe motherhood

through C B MIS

ICDS - BEP - RCH

ICDS - RCH

ICDS - RCH

Rest, food, iodised salt, safe delivery

practices, 3 check-ups, weight gain, IFA,

TT, care of newborn, prevention of LBW

Infant feeding practices, psycho-social

stimulation, breastfeeding, complementary

feeding, care of girl child, immunisation,

feeding during sickness, ARI, vit A,

growth monitoring and promotion,

safe drinking water, personal

hygiene

Cognitive, motor, psycho-social,

emotional and physical development of

children, linkages with PSE for playway

methods, community monitoring through

VECs, play material with locally available

resources

Weekly supply of IFA, parent

counselling, local resources management,

personal hygiene-menstrual period, AIDS education,

delay age at marriage, personality development,

completion of school, food-diet practices, sanitation,

prevention of worms and malaria

Capacity building

and skill upgradation

for better planning and

implementation

Capacity building

and skill upgradation

for better planning and

implementation

Background

7

✦ Phase-wise approach: The project is being

implemented in two phases. Phase I aims to

reach school-going adolescent girls, who

comprise only a small percentage of

adolescent girls. Phase II aims to reach the

out-of-school girls, who represent the majority

of adolescent girls. In addition to addressing

the health needs of these girls through iron

supplementation, the programme also

envisages educating them about their health

needs and life skills.

✦ Monitoring through compliance cards:

Monitoring of the intake of iron

supplementation is a key feature of the

project. The girls themselves have to fill

compliance cards after taking the iron-folic

acid (IFA) tablets.

✦ Girl-to-girl approach: A girl-to-girl approach

has been adopted, in which the school-going

girls play a pivotal part in contacting their

friends who are not enrolled.

✦ Intersectoral convergence: This has been

adopted at every level—state, district, block

and grassroots—involving all social sectors,

including health, ICDS, PHED, BEP, Panchayati

Raj and District Rural Development Agency

(DRDA). This will help to link the programme

with other development programmes such as

water and sanitation, malaria control,

deworming, etc., whose simultaneous

intervention can help to enhance the impact

of anaemia control measures.

✦ Behaviour change strategy: Apart from

focusing on causes, effects and control of

anaemia, messages for behaviour change

with regard to dietary practices are also

included in the awareness campaigns. These

emphasise foods rich in iron, inhibitors (e.g.

tea), and promoters of iron absorption (e.g.

vitamin C).

✦ Social mobilisation and parental counselling:

The programme in its initial phase has

concentrated on environment building and

social mobilisation on the issue of anaemia.

Parents have been counselled on the causes

and prevention of anaemia. Their

misconceptions regarding iron

supplementation have been removed through

meetings—gram sabhas, mahila mandals,

guru goshtis, etc.

Key features

Goals and objectives

Short-term goal: In the short term, the goal is

to provide weekly IFA supplements and ensure

reasonable compliance, thus bringing about

quick reduction in prevalence of anaemia in

adolescent girls.

Long-term goal: In the long term, the project

focuses on sustaining the benefits accrued from

the short-term measures, through intensive IEC

campaigns. Identifying local resources (human,

agricultural, horticultural) that can mitigate the ill

effects of anaemia over a long period (that is,

after the supplementation phase is over), social

mobilisation, and ensuring community

participation are some elements of this strategy.

The targets fixed for achievement by the end

of the project are:

✦ To create awareness and bring behavioural

change in daily dietary practices.

✦ To ensure 90% weekly consumption of IFA

tablets in school-going girls.

✦ To establish regular supply of IFA tablets

to school-going girls for a period of 52

weeks in a year.

✦ To ensure 70% weekly IFA tablet

consumption by out-of-school adolescent

girls.

✦ To ensure interdepartmental coordination

for successful programme implementation.

✦ To promote locally available iron-rich foods.

Anaemia Control Project


8

Control of nutritional anaemia is an

entry point under the Dular strategy

being implemented in Bihar to improve

mother and child health. The project

has targeted adolescent girls using the

life cycle approach. Innovative

approaches are being developed to

plan, implement and monitor the

scheme.

ACP in selected districts of BiharThe Anaemia Control Project is being

implemented in Gaya and Muzaffarpur

districts of the state. The programme

was inaugurated by the District

Magistrate of Muzaffarpur on 24 March

2000. The inaugural ceremony was

attended by the civil surgeon, medical

officers, CDPOs, ANMs, LHVs,

anganwadi workers, district officials,

Education Department officials, and a

large number of common people. The

occasion served as a good opportunity

to create awareness about anaemia and

the need to target the adolescent girl.

At the same time, it served as a kind of

orientation of functionaries at the

district and sub-district level. Media

reports about the programme also

served to generate awareness about the

programme.

An initiative of the state government

and UNICEF, the programme ensures

the involvement of intersectoral teams

such as ICDS, Health as well as

schools and community, in planning

and implementation.

Bihar

Districts coveredunder ACP

Paschim Champaran

Purbi Champaran

SheoharSitamarhi

Madhubani

SupaulAraria Kishanganj

PurniaKatihar

Madhepura

Saharsa

Bhagalpur

BankaJamuiNawada

Gaya

AurangabadRohtas

Bhabhua

BuxarBhojpur

Patna

JahanabadNalanda

SheikhpuraLuckeesarai Munger

KhagariaBegusarai

Samastipur

Darbhanga

Vaishali

Muzaffarpur

SaranSiwan

Gopalganj

Number of school going and out-of-school girls

covered in Anaemia Control Project

District Total number of school Total number of non

going girls covered school going girls covered

Gaya 29,590 1,26,070

Muzaffarpur 50,000 65,000

Project

Implementation

9

Project implementationIn Bihar, the state nodal agency for the implementation of the programme

is the Directorate of Social Welfare in close collaboration with the Health

Department, Bihar Education Project (BEP) and ICDS. In the districts, the

District Magistrate (DM) holds the overall responsibility for implementing

the project. Because of his background in the field of educational

infrastructure, the BEP coordinator, Muzaffarpur, has been assigned the

responsibility of coordinating the activities of this project, while in Gaya

the Principal, District Institute of Education and Training (DIET) has been

entrusted the task of implementing the programme. In this, he is being

supported by a team of three field coordinators, as well as his own

teams of district, block and cluster-level functionaries.

However, the actual implementers are the identified teachers in each

school of the districts. They are the motivators, guides and promoters for

the targeted adolescent girls in the schools, as well as in the community.

The field-level coordinators are responsible for providing programmatic

support to ensure smooth operationalisation of the project activities as

far as the planning, demand creation, supplies, community awareness

and progressive recording of the coverage are concerned.

District Coordination CommitteeEach district has a District Coordination Committee (DCC) whose

members include heads of different sectors like ICDS, education, welfare,

health, agriculture, etc., principals of anganwadi training colleges, and

representatives of major NGOs active in the district. The DCC meets

every quarter under the chairmanship of the DM. The initial meeting of

the DCC was held to inform the members about the programme and

Chapter2


10

sensitise them to the problem of

anaemia.

The role of the committee is to ensure

smooth implementation of the project

in the district. Since the members

include key officials from the

departments of Health, ICDS,

Education, Agriculture, PHED, Social

Welfare, etc., they ensure the

complete participation of their

respective departments in the project.

During the meeting of the DCC, the

DM also reviews the progress of the

project, and the difficulties being

encountered.

District Level Core TeamApart from the District Coordination

Committee there is a District Level

Core Team (DLCT) in each district. The

DLCT members are the members of

the DCC, including key officials such

as the Civil Surgeon, District

Programme Co-ordinator (BEP), District

Programme Officer (ICDS) and officials

from the departments of Health, ICDS,

PHED, Education and heads of the

NGOs involved in the project.

The DLCT meets regularly to review

and analyse the progress, identify the

problems and find solutions. It

formalises the plan of action and

reviews the monitoring and follow-up

of the project.

Block Level Core TeamFor the smooth implementation of the

project a Block Level Core Team

(BLCT) has been constituted. The

Block Development Officer is the

convenor of the BLCT, whose

members include the BEEO, Block

Medical Officer, CDPO and WDO. The

BLCT meets each month to review and

analyse the project, identify the

problems and find solutions. Its

functions also include drawing up a

plan of action, monitoring and follow-

up of the project.

District Support TeamOnce the nodal agency and officer were

decided upon, the implementation of

the programme began. Before the

formal launch in each district, district

support teams were constituted. DST

members are the key functionaries

responsible for project implementation

in the district. To carry out their role

effectively, the DST members received

an orientation. Their role includes

conducting meetings at the block level,

village-level sensitisation programmes,

orientation of principals, school

teachers and village pradhans, visiting

schools for collecting reports,

conducting orientation of students,

Project

Implementation

11

Gaya moves towards anaemia control

Mr. S.A. Moin has been the District Project Coordinator and Principal, District

Institute for Education & Training (DIET), Gaya, since 1993. He has been involved

in the ACP from the very beginning. Says Mr. Moin, ”With the launch of the

Anaemia Control Project in the district in 1999, a District-Level Coordination

Committee was formed in 1999, chaired by the District Magistrate (DM). The

members include departmental heads of medical colleges, CDPOs, DPO, Civil

surgeon, DSE, and Principal, DIET.

“At the block level, a Block Task Force (BTF) has been constituted, whose members are the BDO

(Convener), BEEO, CDPO, and WDO. In places where there are Mahila Samakhyas, Sahyoginis are

members of BTF. The BTF meets every month to review the project. The report of the same is sent to

the District Project Coordinator (DIET) and District Magistrate.

“Intersectoral convergence is a strong point of the project in our district. During the second phase, we

are targeting non-school going girls. ICDS is the main agency, which is reaching out to the non-

school going girls through its centres. In the five non-ICDS blocks, the intervention is through teachers.

“Under the first phase we had an orientation of students, nodal teachers, VEC members, etc. ACP was

integrated into the BEP programme. We reached the high schools through the headmasters and head

teachers because the high schools are not under BEP/DPEP programme. During the morning assembly

in schools, awareness on anaemia was generated. Apart from these, wall writing was done in schools

and slogan writing, painting competitions were organised in high schools. Regular monthly meetings

were held and the project was discussed during the meetings held at CRC/BRC/district level. Bal melas

were organised at BRC/CRC/district level once a year. At the mela, the DST members put up stalls

where the messages on anaemia control were displayed.

“Monitoring of the activities was done by nodal teachers in coordination with the CRC coordinator/

BRC coordinator. The District Coordination Committee (DCC) meets every three months. There has

been convergence at various levels and with different departments such as health, ICDS, and education.

Among the NGOs, Rotary Club has given tablets for deworming. Medical representatives from

pharmaceutical firms have also given us samples of medicines for deworming.

“Under the project, we have reached out to the adolescent girls through the Jagjagi Kendras, alternate

schools, Apna Vidyalaya (co-ed), Angna Vidyalayas (girls only) and Mata Samitis. An Anaemia Park

has been developed, where plants rich in iron are grown. In the Janta Durbar organised by the DM in

the district, we put up stalls on anaemia and also during the Buddha Mahotsav held at Bodh Gaya each

year. A Jhanki (float) on anaemia was exhibited on Republic Day, which was awarded the 2nd prize.”

According to Mr. Moin, there are several constraints. One of the main constraints is deworming,

which has not had the desired impact because of non-availability of deworming tablets and secondly,

the involvement of high school teachers, especially male teachers, has not been satisfactory.


12

(IFA) in the school every week. The

tablets are stored with the nodal

teacher in the school. Each adolescent

girl receiving the IFA tablet has been

oriented by the nodal teacher to fill up

the self-compliance card. The nodal

teacher ensures that the cards are

properly filled up.

Strategies� Reaching the adolescent girls in

middle and secondary schools

(Phase I).

� Reaching the adolescent girls out

of school (Phase II).

� Positioning anaemia control for

adolescent girls.

� Advocacy, social mobilisation and

community strategy.

� Strategy for institutional support.

� Strategy for social recognition.

� Strategy for sustainability and

replicability.

� Monitoring and evaluation

strategy.

distribution of IFA, compilation

of reports, reporting at the district

level, etc.

DST members visit schools regularly

and report to the nodal officer in the

district. The DST members are in fact

the lifeline of the whole programme.

There are two DST members (a male

and a female) in each district. They are

graduates with some experience in a

related field.

MethodologyAll the schools in the two districts,

where there was enrolment of

adolescent girls (10-19 years) were

listed and the adolescent girls

enumerated. The principal or a teacher

who volunteered was trained as

school-level implementer of the

programme. Each girl in the school is

being given a tablet of iron folic acid

Better health with IFA

Government High School, Chakand, district Gaya, has a total strength of 1000 students, out

of which 165 are girls. Roqaiyya is a student of class IX and has taken IFA tablets from March

2001 to March 2002. Roqaiyya attributes her renewed interest in studies and her winning

prizes in the annual debate competition to the consumption of IFA tablets. She says, “I was

never attentive in class and used to miss classes very often. I did not feel like coming to school

or taking part in sports. I used to feel tired even after doing a little work. Last year, the ACP

team came to our school and told us about anaemia—since then I have been taking IFA

tablets. I told my parents about the distribution of IFA tablets in our school and they too were

quite impressed with my improved performance in studies and sports.”

She says that the project should also target girls in villages, who do not go to school.

Roqaiyya adds, “I tell my non-school going friends about anaemia control and have also

given them IFA tablets.”

Training and Capacity Buildingof Functionaries

13


Trainers were identified to train other functionaries of the project. During

the training of trainers (TOT), the participants were informed about the

high prevalence of anaemia (about 60 per cent: Sheshadri 1996) and the

importance of targeting adolescent girls. The main objectives of the

training were:

� To impart knowledge and basic information to the trainees about the

project, nutritional anaemia, its causes, symptoms, prevention and

control, implementation strategy and plan.

� To help the trainers to acquire skills needed to successfully organise

the trainings of nodal teachers and other groups, as planned under

the project.

The participants in the TOT included experienced and educated field

workers of NYK, NGOs, BEP, and MIS.

Key features of the trainingAll the training sessions were conducted in a participatory manner,

throwing open the issues to the participants, and allowing them to

interact individually with their knowledge and experience. The gaps

existing in their knowledge were filled in by the external resource

persons. In all the trainings, the importance of dietary practices was

emphasised and iron-rich food was displayed.

Chapter3


14

Training manualThe Directorate of Social Welfare,

Bihar, in collaboration with UNICEF,

has developed a training manual, which

has been used by the project districts

to train the functionaries. The manual

is made up of modular units, focusing

on six types of training targeted at

different levels of functionaries and

groups involved in programme

implementation. Each module includes

the training curriculum and design. The

curriculum content, duration and

design are based on the training

requirement of the group to be trained.

Each module is a complete unit,

defining its objectives, target group,

duration, methodology and possible

resource group/person.

Training module unitsThe units of the training module are:

� Module 1—One-day orientation of

district-level heads of various

departments.

� Module 2—Two-day district level

training of block-level functionaries.

� Module 3—Three-day training of

master trainers.

� Module 4—One-day training of school-

level functionaries (nodal teachers)

� Module 5—School-level orientation

of school-going adolescent girls.

� Module 6—One-day orientation and

two-day IEC material development

workshop at the district level (for

village/community level

communicators)

Training at various levelsThe training was carried out at the

state, district, block, school and

community levels.

A workshop on the Anaemia Control

Project was organised by UNICEF in

Patna, which was attended by top-

level functionaries of the project. The

causes, symptoms, prevention and

control of anaemia were discussed

and the concept of the programme

was explained.

A five-day training-cum-workshop on

the programme was organised at

XISS, Ranchi, from 5-9 July 2000 by

UNICEF and Chetna (Ahmedabad). A

total of 30 project staff from all five

districts (Bihar & Jharkhand) attended.

An overall view of the programme was

given to the participants.

A three-day workshop was organised

from 15-17 December 2000, by

UNICEF at Bodh Gaya, in which staff

from all five project districts (Bihar &

Jharkhand) attended. In this

programme, discussions were held on

the training modules of the project,

distribution of IFA tablets and

preparation of annual workplans.


15

� Review and monitoring—filling of

compliance cards by girls, regular

maintenance of registers.

In Muzaffarpur, the District Field

Coordinators, who have been made

full-time field coordinators, have made

extensive visits to the field and met

all concerned officials and

functionaries at the block level. This

was like an extensive orientation-cum-

advocacy programme. It was also an

The trainers included Project Officer

(UNICEF), CMO, consultant from

UNICEF, doctors from medical

colleges, etc. The trainers trained the

block-level functionaries, which

included CDPOs, BEEO,

representatives of NGOs, BMOs, local

panchayat leaders, lady supervisors,

etc. These block-level people trained

people at the community level,

including village mukhiyas, sarpanch,

local village doctors, leaders of Mahila

Samakhyas, village level NGO

representatives, etc. The training

focused on the following aspects:

� Anaemia, its causes, effects, the

life cycle approach.

� Prevention and control by bringing

about change in dietary practices,

behavioural change,

supplementation and intake of

iron-rich food.

� Role and responsibility of nodal

teachers and girls in programme

implementation; proper storage and

distribution of IFA tablets, and

ensuring intake of these by

adolescent girls.

Details of training organised till date under

Anaemia Control Project

Training Gaya Muzaffarpur

Total number of trainings conducted 114 70(including district, block, village/sector level trainings)

Total number of trainers trained 120 65

Total number of functionaries trained 150 120(govt. and non govt.)

Total number of teachers trained 399 1075

Total number of motivator girls trained 399 500


16

effort to enlist their support for the

successful implementation of the

programme. In May 2000, orientation

of block-level functionaries was

carried out at district headquarters,

Muzaffarpur. The participants included

the area officers and Block Education

Extension Officers of the Education

Department, as well as medical

officers and CDPOs of the different

blocks of the district. The resource

persons were drawn from the state

and district levels. An encouraging

aspect of the programme was that a

few medical officers and CDPOs

offered to serve as master trainers.

The field coordinators have been

visiting the CRCs, which are resource

centres for 12-14 schools each under

BEP. They have been attending the

monthly meetings and creating

awareness about anaemia among the

teachers of each cluster. However,

their most important achievement has

been the collection and compilation

of data about all the school-going

adolescent girls in the age-group

10-19 years. This has been done in

respect of middle schools, high

schools, basic schools, Jagjagi

centres, as well as alternative

schools. The field coordinators have

been participating in the one-day

orientation of CRC coordinators at

block level. They have also visited

schools, Mahila Samoohs, Mahila

Mandals, Jagjagi centres and

alternative schools. Thus they have

helped create a conducive

environment for the acceptance of

the project among the target group,

as well as among the implementers.

In Muzaffarpur, an alternative mode of

training school teachers is being

planned, in which two competent

trainers will visit each school and train

all the teachers, and not just one

teacher as planned earlier. Members of

the village education committee (VEC)

will also be invited to participate in

the training. Girls will also participate,

and one monitor will be selected, who

will assist the teacher in administering

the IFA tablets.

In Gaya district, the following

trainings have been conducted:

� One-day training workshop of

district-level officers.


17

Girls feel the change after taking IFA

Chandni Kumari is a student of class VIII in Salha Jalalpur Dwarka Middle School, in village

Salha Dwarka Nagar, block Musahari, district Muzaffarpur. Chandni says, “I have consumed

IFA for almost 3 months now. We get IFA once a week and we are asked to consume it in the

school itself.” On being asked how she feels after taking IFA tablets, she says, “Earlier I used

to feel weak and did not take interest in studies. I could not play for long and started feeling

tired but now I have started feeling more energetic. I have also begun to take keen interest

in studies and have scored better in the exams.”

Radha Rani Girls’ High School in Mohalla Amali Gola, in Muzaffarpur district, is no ordinary

school. The students of this old school in the heart of the city are an enthusiastic lot. The

teachers, students and parents have shown great enthusiasm in the programme. The students

of the school were given IFA for 52 weeks and they have utilised the whole lot given to

them. They have coined slogans for anaemia control, which they enthusiastically recite.

Khushboo Kumari, a student of class VII says, “When the DST members first came to our

school almost a year ago, we were quite apprehensive about the programme. Many girls

resisted taking IFA tablets and many complained of vomiting tendency and resistance by

their parents. But our teachers and nodal girls along with the UNICEF staff removed our

misconceptions regarding intake of IFA.”

� Two-day training of block-level

officers.

� Two-day training of master trainers.

� One-day training of nodal teachers

at block level.

� One-day training for ICDS sevikas,

ANMs and LHVs at block level.

� One-day training for school

motivators at block level.

� Three-day workshop for IEC

material development.

� One-day training of Sahelis of

Jagjagi centres (Mahila Samkhya,

BEP Gaya).

� One-day training of girls and didis

of alternative schools.

� One-day training for VEC mobilisation.

� One-day orientation of BRC and

CRC coordinators.

� One-day training for mobilising

team for awareness generation.


18

Local Resource MobilisationBoth Gaya and Muzaffarpur districts have developed IEC materials like

pamphlets, posters, banners, wall paintings, etc., to create mass

awareness. One of the notable features of the project has been the local

mobilisation of resources. There has been a remarkable convergence

between ICDS, banks, NGOs (such as Rotary Club, NYK, Narijagran

Manch, Jeevan Deep, Adithi etc.), and BEP for generating awareness

among the community.

Activities for community awarenessThe Anaemia Control Project focused not only on weekly

supplementation of IFA tablets, but also on bringing about suitable

dietary practices to include iron, folic acid, vitamin C, and protein-rich

food. It was felt that merely supplying IFA tablets and ensuring intake

would not make a sustainable impact. For sustainability, it was essential

to create awareness and bring about community ownership of the

programme, and initiate change in dietary practices of families.

Chapter4

At the state level, UNICEF developed

two booklets on anaemia. One of

them was circulated among school-

going adolescent girls, giving details

about anaemia, its symptoms,

causes, prevention, dietary practices,

IFA tablets and the role of school

girls in controlling anaemia. The

second booklet was meant for

creating awareness among school

teachers, emphasising their role in

Local Resource

Mobilisation

19

the prevention of anaemia. This

booklet explains the reasons for the

educational and nutritional

programmes for adolescent girls.

At the local level, a number of steps

were taken to generate awareness

among the community. These included

wall writing campaigns, weekly

prabhat pheris at the school level, and

distribution of pamphlets and booklets

among all the school motivators. The

pamphlets are distributed through

medical retail counters. Awareness

campaigns have also been held at

Jagjagi centres, Mahila Samoohs,

Mata Samitis, and Angna Vidyalayas.

Kishori Melas and Balika Melas have

been held at the BRC and CRC level.

Drawing, slogan and essay writing

competitions have been held at the

BRC and CRC level.

In Gaya during the famous “Buddh

Mahotsav” held in Bodh Gaya a stall

on Anaemia Control Project was put

up displaying iron rich foods. An

anaemia park has been created in the

DIET campus in Gaya displaying plants

rich in iron.

In all the campaigns, iron-rich foods

have been displayed and their

importance emphasised. Programmes

were also broadcast on TV and radio

and newspaper advertisements were

brought out.

Regular meetings have been organised

of block level officers, and

coordinators of BRCs and CRCs.

Meetings of principals, as well as guru

goshtis, have been held in the blocks.

VECs have also contributed in

mobilising parents and society.

The project is unique in the sense that

it has set an example for local

resource mobilisation. All compliance

cards and other materials such as

banners, wall paintings, stickers, ads

on TV and print media were sponsored

by various corporate houses and

government agencies such as LIC,

GIC, Transport Department, banks,

etc. NGOs such as NYK, Rotary Club,

Narijagran Manch, Amar Jyotivihar,

Jeevan Deep, etc., have also

contributed in the IEC activities.

Among the NGOs, Rotary Club has

given tablets for deworming. Medical

representatives from pharmaceutical

firms have also given samples of

medicines for deworming.

Banks (State Bank, Punjab National

Bank, India Overseas Bank, etc.) have

sponsored pamphlets, which were

distributed during melas, and

newspaper advertisements, etc.


20

Supply and Logistics ManagementIn Bihar, the state government has given UNICEF the go-ahead for the

purchase of IFA tablets for the whole state. At the state level the

procurement and distribution of IFA tablets is being organised through

ICDS, World Bank–II Project. The procurement and distribution of IFA is

being done not only in the Dular districts but in the whole state.

Each girl in the school is given a tablet of IFA every week in the school.

These tablets are stored with the nodal teacher in the school. Each girl

receiving the IFA supplementation is oriented by the nodal teacher to fill

up the self-compliance card. The nodal teacher ensures that these cards

are properly filled up, corresponding to the actual consumption of IFA

tablets.

The training programmes have also covered the intake of IFA tablets. The

participants, including nodal teachers and the adolescent girls, have been

briefed about the utility of weekly intake of IFA tablets. They have also

been informed that these tablets should not be taken on an empty

stomach. In a few cases, there might be symptoms of nausea,

constipation and change in colour of stools, but these should not cause

concern. These problems will go away after regular intake of the tablets.

Maintaining recordsAt the time of distribution of IFA tablets, a register is supplied to the

nodal teacher of each school for maintenance of records of distribution

and intake. Using the specified format, the nodal teacher indents the IFA

tablet requirement, prepares monthly reports of number of tablets

Chapter5

Supply and LogisticsManagement

21

Jagjagi Kendra: Lighting up lives

Mahila Samakhya is playing a pivotal role in the Anaemia Control Project.

The Jagjagi centres, managed by “Sahelis” under the Mahila Samakhya,

are not only providing education to non-literate children, especially girls,

but also IFA supplementation to adolescent girls. The Bihar Education

Project provides free textbooks to the enrolled children. In some centres,

some women who are first generation learners, are also enrolled.

Madhopur village, in Musahari block of Muzaffarpur district, has a Jagjagi

Kendra managed by a Saheli, Smt Usha Devi. Madhopur is a non-ICDS

block. There are 32 children, including 16 non-school going adolescent

girls, enrolled in the Kendra, most of them from very poor background. Apart from these, six women,

some of whom are SHG members, are also enrolled.

Eleven-year-old Anita Kumari has been attending the Kendra for the past one year. Anita, whose

father is a daily wage labourer, used to work in the fields as a labourer, earning a mere Rs. 30-40 per day

for around 8-10 hours of physical labour and supplementing her father’s income. “Didi motivated my

father to send me to school. Neither my parents nor my brothers or sisters had ever been to school. But

I was determined to go to school and learn,” Anita says.

Apart from learning, Anita has been consuming IFA tablets regularly for 52 weeks at the Kendra. “Didi

told us that adolescent girls like us need IFA tablets, since we do not have enough iron in our body.

Since I started taking IFA tablets I have begun to feel strong and confident. Earlier I used to feel very

weak since I had to work in the fields most part of the day. I used to return home tired. We could not

even afford to visit the local doctor. When I started attending the Jagjagi Kendra, I got the first tablet,

which I consumed. I also asked my Didi to give me some more for my elder sister, who complains of

weakness.”

Another girl, Kaushalya Kumari (12 years), has been attending the Kendra for the past one year.

Kaushalya says, ”What I like about the Kendra is that we are taught games and are made to learn

through playway method. Didi makes us feel very comfortable so much that I could not miss attending

the Kendra any day. She adds further, “Once just after joining, Didi gave all of us a tablet saying it was

for strength. We had never taken any such tablet without consulting the local village doctor. I did not

consume the tablet at the Kendra and took it home to show it to my parents.”

According to the Saheli, “Kaushalya’s parents were worried as to why these tablets were being given

to adolescent girls only and not to boys. The father spoke to me and I allayed all his fears about the

tablet causing infertility. These people are quite suspicious about the IFA tablets, as well as the polio

drops, which they do not give to their children.” Kaushalya is now taking the tablets regularly and says

she is feeling more confident and energetic.


22

“Let’s get rid of anaemia…”

Malini Sinha is a class IX student of Government High School, Chakand, Gaya, who has been

consuming IFA tablets for the past one year. Malini knows that anaemia is caused due to iron deficiency

in blood. She has started taking part in games and has also coined slogans on anaemia control. She

says, “When I started taking IFA tablets, I used to complain of vomiting tendency and drowsiness, and

so did many of my friends. However, soon things were normal and we started feeling the benefits of

IFA intake. Earlier we used to feel exhausted but now we do not feel so. The boys in our school are an

envious lot. They are demanding that they too be given IFA tablets. In our school many children have

prepared posters and pamphlets in their classrooms on anaemia control. The students have also

planted saplings of lemon, guava, amla, etc., in the school garden.

“My mother is an Anganwadi sewika and I help her in distribution of IFA tablets,” adds Malini. She

recites some slogans coined by her and her classmates on anaemia:

“Aao kamzori bhagayein

Ankurit chana khaein”

“Hamein saag subzi khana hai

Anaemia door bhagana hai”

“Loh yukt aahar khana hai

Anaemia door bhagana hai”

Supply and LogisticsManagement

23

received, number consumed and

the number required in the

following month. This becomes

a monitoring tool for the nodal

teacher at the school level, and

when consolidated, for the block

and district level. At the district

level, the Project Coordinator

ensures the supply of IFA

tablets and their regular

distribution.

Compliance cardA compliance card has been

supplied for each beneficiary,

i.e., the adolescent girl, which

has to be filled by the girl

herself. The girls have been

imparted training on how to fill

the cards. Those having difficulties are

helped by the motivator girls in filling

the cards.

Reaching the unreachedThe Anaemia Control Programme has a

special strategy to reach the large

number of adolescent girls who have

dropped out of school or who never

enrolled. In Muzaffarpur, there are

about 3.50 lakh girls in the 10-19 age

group, out of which 1.30 lakh are

IFA distribution system

District—DIET/BEP

Block—BRC

Cluster—CRC 2nd Phase

School

School-going girls Non-school-going girl(with the help of schoolvolunteers, AWWs, membersof village institutions, head/sub-centres)

1st Phase

2nd Phase

(Weekly dosages)

Distribution of IFA in Gaya and Muzaffarpur districts

including enrolled and out of school girls

District Total IFA distributed % of IFA consumption(till mid 2002) (till mid 2002)

Gaya 20,12,120 72%

Muzaffarpur 20,00,000 70%

dropouts or have never enrolled in

school. In both Muzaffarpur and Gaya,

such girls are being reached through

the girl-to-girl approach, in which the

selected motivator girls in each school

have been assigned the responsibility

of reaching the out-of-school

adolescent girls in their respective

localities and ensuring that they

participate in the weekly consumption

of IFA tablets.


24

Monitoring is an essential and integral part of the project, which helps to

ensure progress and identify gaps. It enables programme managers and

functionaries to analyse and take corrective action. In the Anaemia

Control Programme, monitoring is carried out at four levels—at the state,

district, block and school level.

The nodal teacher, through the use of the specified format, indents the

IFA tablet requirement, and prepares monthly reports of the number of

tablets received, the number consumed and the number required for the

next month. This format is used as a monitoring tool for the nodal

teacher at the school level, and when consolidated, for the block and

Monitoring and Evaluation

Chapter6

MonitoringMonitoring

Individual(Self-monitoring using

compliance card)

District level

(DSE, DEO, DPO,

CS, etc.)

Group(Volunteer girls)

Community level(Volunteers, Local inst. heads

ANM, AWW, VEC members)

Block level(BDO, CO, CDPO, BEEO, AEO,

MO, NGOs)

School level(Teacher, monitor,

volunteers)

Monitoring andEvaluation

25

district levels. The monthly meetings

at the block and district levels are

used for submitting the monitoring

report. At the district level, the project

coordinator ensures the supplies of

IFA tablets, and monitors their

distribution in addition to regularly

monitoring the progress of the project.

At the state level, the Directorate of

Social Welfare is overall in charge of

monitoring and implementation.

Representatives from the Directorate

participate in the meeting of the

District Coordination Committee, as

well as of the Core Committee, to

review the status of interdepartmental

coordination in the programme.

The quarterly progress reports and

workplans submitted by the districts

are reviewed at the Directorate level

and forwarded to UNICEF, Patna,

regularly. These are reviewed by the

Project Officer, Child Development and

Nutrition, UNICEF, Patna. Continuous

support and guidance are also

provided by the Project Officer,

UNICEF, Patna.

For monitoring purpose, a two-day

joint state level review-cum-strategy

planning workshop is organised every

alternate month at the state

headquarters, under the chairmanship

of the Project Officer, UNICEF, Patna.

Representatives from the Directorate

of Social Welfare, DPOs, CDPOs,

DEOs, Core Committee members, and

selected lady supervisors of the

districts participate in the workshop.

In the workshop, members of each

Reporting system

District—DIET/BEP

Block—BRC

Cluster—CRC

Schools

1st Phase

Class monitors School volunteers/

Local inst. heads

2nd Phase


26

Mahila Shiksha Kendra: Bringing hope in the lives of girls

Mahila Shiksha Kendra is a functional unit under Mahila Samakhya, being run in the DIET campus in

Gaya. The centre was started in July 2002 to help train poor girls in vocational courses. Many of the

enrolled girls at the centre are first generation learners. Some of them are divorced or forced out of

their homes by their parents or in-laws. Here the girls are learning to stand on their own feet, away

from their home for at least 3-4 months. The girls are made to follow a strict discipline at the centre,

where they learn cycling, cooking, sports, etc.

Janki Kumari is an 18-year-old girl at the centre, who had never been to school but feels very comfortable

at the Mahila Shiksha Kendra. She has learnt cooking, cycling, and has even started writing letters to

her parents. Janki hails from a very poor family and does not wish to go back to her house. She knows

that the symptoms of anaemia include nails turning yellow, weakness, etc.

Reena Kumari also hails from a very poor family, who was brought to the Mahila Shiksha Kendra after

being rescued from a 45-year-old man in her village, to whom she had been married off. Reena knows

about anaemia and its causes. She adds, “Girls need more iron than boys because they do greater

amount of work. They undergo physical changes during menstruation, during which iron is lost.”

Reena asks inquisitively as to why they have not been provided with deworming tablets as yet.

Monitoring andEvaluation

27

Muzaffarpur: Getting the project off the ground

The Anaemia Control Project in Muzaffarpur district has seen a lot of

changes in its administrative set-up of late. Mr. Amarendra Singh is the

Officer on Special Duty (OSD), who has been in charge of the project

in the district since June 2002. According to Mr. Singh, at the block

level, there is a Block Elementary Education Office (BEEO), which meets

each month to review education projects in the district. Anaemia control

is a major item in the agenda of the district.

“Through the BEEOs, we are trying to regulate ACP through review of

school-going girls. We have alternative schools (ALS) for children in the

age group 9-14 years, where the major thrust is on education and mainstreaming of children. The

Jagjagi centres are also giving thrust to social and health issues, including distribution of IFA tablets.

“At the district level, the District Magistrate (DM) organises Janta Durbar in the blocks, where the

programmes are reviewed. From next month onwards, we are going to involve PRIs and ward members

in the awareness campaign. The monitoring of the programme is done by the BEEOs and the area

officer for the middle and high schools, while for the Jagjagi Kendra, the monitoring is done through

the Sahyogini and Saheli. For every 10 ALS centres, there is an academic Support Resource Group,

which is responsible for its monitoring. As regards the resource mobilisation, we have taken the help of

animators in VECs and School Management Committees. A support group has been formed, comprising

CDPOs and MOs to oversee the implementation of the programme.”

district present their reports and plan

of action for their district. Future plan

of action is developed and target of

achievement is fixed.

Monitoring at the state level is done

not only through meetings, workshops

and reports, but also at the field level.

State Coordinator, Directorate of

Social Welfare, visits schools and

participates in the different training

programmes and distribution of IFA

tablets in schools.

Targeting out-of-school girlsUnder phase II of the project, non-

school going girls are being targeted

in both the districts through school

volunteers, teachers, AWWs, VEC

members, Mahila Samakhya. In non-

ICDS areas the adolescents are being

reached through the VEC members

and teachers. Mata Samiti and Mahila

Samoohs have been formed in

villages, which are also playing an

important role in reaching out-of-

school girls.


28

The Anaemia Control Programme aims to have a major impact on the

health, nutrition status and well-being of the adolescent girls in the

project area. It is expected that the prevalence of anaemia will reduce by

50 per cent among the adolescent girls, improving their work productivity

and school performance, as well as reducing absenteeism in schools. In

the married adolescent girls, increased pre-pregnancy stores of iron will

result in reduced maternal mortality, maternal morbidity and reduce the

risk of low birth weight babies. Other benefits include increased

awareness of diet and improved dietary practices, thus leading to better

learning capacity, confidence and self-esteem.

Impact and Challenges

Well-being &

productivity

IMPACTIMPACT

Improved IQ

scores

Reduced anaemia

Increased

attention in school

Increased

enrolment in school

Better growth

Reduced absenteeism

in school

Chapter7

Impact andChallenges

29

CoverageIn Gaya district, 28,581 adolescent

girls were targeted in 399 high and

middle schools. Out of these, the

coverage was 82 per cent in high

schools and 85 per cent in middle

schools. In the second phase (non-

school going), 2,26,350 adolescent

girls in 1805 ICDS centres were

targeted. Out of these, 1,18,160 were

covered in 1688 ICDS centres. The

weekly consumption of IFA tablets at

Anganwadi centres was 72 per cent.

ChallengesThe project has faced a number of

stumbling blocks in the way of

smooth implementation, such as

shortage of field staff, lack of proper

infrastructure, storage facility,

transport and lack of cooperation from

some of the functionaries. In

Spreading the word about anaemia

Rizwana is a student of class VIII in Rameshwar Prasad High School in

Belaganj block, Gaya. In her school, the distribution of IFA started in the

year 2000 and after nearly one year of distribution, it has now been stopped.

Rizwana feels that IFA has helped improve the girls’ health and has ensured

regular attendance in schools. She says, “We girls study in the school and

when we go back home we have to help our mother in the household

chores. Thus we end up doing more work than our brothers do. Therefore,

we needed some medicine that could give us energy. Consumption of IFA tablets has helped us get

back our lost energy.

“There are several girls in my locality who seem anaemic and I have taken some tablets for them. After

consuming the tablets they said they felt better but since they belong to poor families, they cannot

afford to purchase IFA tablets from the market. I have counselled them about proper consumption of

green leafy vegetables and fruits rich in iron, which are available in plenty in our village.”

Rizwana says she is thankful to her teachers and the Anaemia Control Project staff for having given

her this valuable information about anaemia.

Shanti Kumari studies in class VIII in the same school. She says, “We never knew about anaemia but

thanks to ACP in our school, we now not only know about anaemia but can now tell others—our

family members and friends—about how we can control anaemia.” Shanti adds, “The symptoms of

anaemia are lack of appetite, nails turning yellow, etc. We have been told that we need not depend on

IFA tablets alone but can control anaemia by increasing intake of green leafy vegetables, which are

rich in iron. We have also been taught that we should not consume tea or coffee for at least after 1- 1½

hours after taking a meal.”


30

Breaking myths and spreading knowledge

The Jagjagi Kendra in Jalalpur village in Musahari block in Muzaffarpur district has been running for

the last three years. The Kendra has 31 adolescent girls, of which 25 are Muslims and six are SCs.

There are six women enrolled in the kendra. Jalalpur is a village inhabited mainly by poor Muslims.

According to Smt. Krishna Devi, Saheli of the kendra, “The villagers, especially Muslims, do not send

their children to school. Instead these young children work as labourers in the field during cropping

season, thereby supplementing their family income. The project had a difficult time motivating the

children to attend school and also start intake of IFA tablets. Poverty is not the only issue—there is a

strong misconception in the minds of the villagers that the tablets may cause infertility. But gradually,

this myth has been broken. Now we are getting requests from more and more parents to get their

children enrolled at the Jagjagi Kendra.”

Krishna Devi adds, “Now, the girls are not only more conscious about their health, they have also

started resisting any attempts to get themselves married off at an early age. They now pressurise their

parents to send them to the Jagjagi Kendra for learning.”

The enthusiasm among the girls is heartening. Silam Kumari is a 20-year-old girl who is suffering from

polio, whose parents were against sending her to the Jagjagi centre. She crawls laboriously on foot to

attend the centre some 3 km away from her home. She has completed 52 weeks of the IFA course. She

also counsels other girls about it.

Similarly, 13-year-old Ajmeri and 14-year-old Sabiha Khatoon faced opposition from their parents

but the Saheli convinced them about the importance of IFA supplementation. Smt. Krishna Devi and

the Sahyogini, Smt. Chintamani Devi, are no doubt, very pleased to see the enthusiasm among the

girls. The distribution of IFA tablets each Monday has generated great enthusiasm among the students

attending the centres. Most of them also request that they be given more tablets so that they can give

it to their sisters who do not attend school or the Jagjagi Kendra being run in the village.

Muzaffarpur, the influence of criminal

elements, which has created an

atmosphere of fear in some areas, has

also hampered the project. However,

despite these obstacles, the whole

team is determined to fight the

menace of anaemia and improve

the health and well-being of

mothers and future generations.

Looking aheadIn Muzaffarpur, now that IFA tablets

have been supplied in the districts, a

fresh round of orientation programmes

has been planned for the block-level

officials. It is also planned to hold yet

another TOT for master trainers. Some

of the master trainers will be selected

from among those who underwent

Impact andChallenges

31

training in the last round. Fresh

trainers who have the requisite

qualification and experience are being

identified from various organisations.

An alternative mode of training of

school teachers is being planned, in

which two competent trainers will

visit each middle school and train all

the teachers of the school instead of

just one teacher, as planned earlier.

Members of the VEC will be invited to

participate in the training. Not only

this, girl children of the school will

also participate in the training, and

one monitor will be selected from

among them, to assist the teachers in

administering the IFA tablets. Besides,

each VEC and school will be provided

a set of postcards, to enable them to

send feedback to the Anaemia Control

Project Office.

In Gaya, the future plans include

various trainings, including that of

block-level officials, nodal teachers,

school motivators, and community-

level communicators. Awareness

generation activities such as wall

writing, kishori/balika melas, prabhat

pheris and rallies are planned.

After covering the school-going girls

of basic, middle and high schools in

the first phase, the programme will be

extended to cover the girls of

government primary schools, private

schools, alternative schools and

Jagjagi centres of Mahila Samakhya.

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Directorate of Social Welfare Department of Education …€¦ · Anaemia is the most common cause of maternal deaths, accounting for a fifth of all maternal deaths (more than one