Document of The World Bank FOR OFFICIAL USE ONLY 4 ;, .1 ., , r, ;, ,; . ; i i ?1: ! I ) Report 'o.10572-IN :: : .;- r:;p it ',:1 Report... ,.F STAFF APPRAISAL REPORT INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT JANUARY 22, 1993 South Asia Country Department II (India/ Population and Human Resources Operations Division is document has a restricted distribution and may be used by recipients only in the performance of !ir official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (as of November 30, 1992) Currency Unit = Rupee Rupee 30.0 = US$ 1.00 Rupee 1.00 = US$ 0.033 METRIC EQUIVALENTS 1 meter (m) = 3.28 Feet (ft) 1 Kilometer (km) = 0.62 Miles FISCAL YEAR April 1 - March 31 ABBREVIATIONS AND ACRONYMS ANTC - Anganwadi Training Center AW - Anganwadi Center AWW - Anganwadi Worker ARI - Acute Respiratory Infection Block - Unit of Administration in state governments CDPO - Child Development Project Officer CSSM - Child Survival and Safe Motherhood Project EC - Empowered Committee GOI - Government of India ICDS - Integrated Child Development Services IMR - Infant Mortality Rate Kcal - Thousand Calories LBW - Low Birth Weight MCH - Maternal and Child Health MDM - Mid-Day Meals MLTC - Middle Level Training Center MM - Mahila Mandal MPWF - Multi-Purpose Worker (Female) NIN - National Institute of Nutrition NIPCCD - National Institute for Public Cooperation and Child Development PDS - Public Distribution System PMC - Project Management Cell RTE - Ready-To-Eat SNP - Special Nutrition Program SSNSAP - Social Safety Net Sector Adjustment Program ST - Scheduled Tribe TINP - Tamal Nadu Integrated Nutrition Project WCD - Women and Child Development FOR OMCIAL USE ONLY INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT Table of Contents Page No. CREDIT AND PROJECT SUMHARY ....... . .... . . . . . i I. BACKGROUND A. Introduction . . . . . . . . . . . . . . . . . . . . . 1 B. National Nutrition Programs . . . . . . . . . . . . . . . 3 C. ICDS in Madhya Pradesh..... 7 D. ICDS in Bihar 8... ..8 E. Learning from Other Experiences . . . . . . . . . . . . . 10 F. Rationale for IDA Involvement . . . . . . . . . . . . . . 12 G. Other Donor Role.. . .. 13 II. THE PROJECT A. Project Goals and Objectives . . . . . . . . . . . . . . 13 B. Project Area . . . . . . . . . . . . . . . . . . . . . . 15 C. Project Approach . . . . . . . . . . . . . . . . . . . . 15 D. Project Description .................. . 16 III. PROJECT COSTS, FINANCING AND IMPLEMENTATION A. Cost Estimates.. 23 B. Financing Plan . . . . . . . . . . . . . . . . . . . . . 25 C. Recurrent Cost and Sustainability Implications . . . . . 25 D. Project Preparation and Implementation . . . . . . . . . 26 E. Disbursements . . ........... 27 F. Procurement . . ........ . 28 G. Accounting and Auditing ............. 31 IV. BENEFITS AND RISKS .... . . . . . . . . . . . . . . . . . . 31 V. AGREEMENTS REACHED AND RECOMMENDATIONS . . . . . . . . . . . . 32 * This report Ia based on the fIndIngs of an appraisal massion whIch vIsited IndIa In March 1992. The mission comprised James Green. (Principal Nutrition Spcialist and mission leader), Ellen Schaengold (Senior Operations Officer) and Aruna Chandran (Resoarch Assistant); consultants were ETd Dib (Procurement Specialist), John Keveny (Nutrition SpecTilist), Jay Satis (Institutional Specialist), Pradeep Kakar (Communication. Specialist), Asoko Bahl (Financial Analyst) and Hilary Standing (Anthropologist). The peer reviewers were: Alan Berg, Emmerich Schebeck, and Knlanidhi Subbarao. The report was endorsed by Mr. Richard Skolnik, Division Chief, India Population and Human Resoures Division, and Heinz Vergin, Director, South Asia, Country Department II. This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. Table of Contents (cont'd) Page No. TABLES 3.1 Costs by Component .......... .......................... .. 24 3.2 Cost by Categories and Expenditures ...............to.. 24 3.3 Summary of Proposed Procurement Ar-angements .......... 30 ANNEXES 1. ICDS Performance in Project Areas ..................... 34 2. Process Objectives ........................ 40 3. Tribal Populations .................................... 42 4. Strategies for Reducing Malnutrition Among Young Children ...... ............... 50 5. Coordination between State Department of Women and Child Development & Health and Family Welfare ....... 54 6. Training ................................................ 61 7. Improving Work Routines in ICDS ...................... 67 8. Plan for Introduction of Services in a New Block ...... 72 9. Communications Component ........ .............................. . 76 10. Monitoring and Evaluation ............................. 81 11. Annual, Midterm and Final Evaluations ................. 84 12. Operations Research .... ...................... ............... 87 13. Detailed Project Cost Estimates ....................... 91 14. Implementation Schedule ............................... 104 15. Forecast of Annual Expenditures and Disbursements ..... 105 16. Supervision Plan . ............... . ..... . ........ .... 106 17. Strategies for Strengthening ICDS Among Tribal Populatm ons ...........ietFie............................. 107 18. Documents in Project File ....................................... 111 ^ iii INDIA SECOND INTEGRATED CHILD DEVELOPHENT SERVICES PROJECT CREDIT AND PROJECT SUNMMRY Borrower: India, acting by its President. Beneficlaries: The States of Bihar and Hadhya Pradesh. Amount: SDR 141.6 million (US$194.0 million equivalent). Terms: Standard, with 35 years maturity. On-lending terms: Government of India to Madhya Pradesh and Bihar in accordance with standard arrangements for development assistance to States and Union Territories. Description: The project would be carried out in Bihar and Hadhya Pradesh, two of India's poorest states. Project beneficiaries would be among India's poorest people, many of whom are tribal. The project would improve the nutrition and hea'.th status of children under 6 years of age, with special emphasis on those 0-3 years old, and pregnant and nursing women. It would also help to improve the capacity of the ICDS to deliver services in the two states, including among tribal people, over the longer term. The project would comprise the followi.ag components: (a) service delivers, to increase the range, coverage and quality of nutrition and health services to target groups through improvements in tne design and implementation of software systems, training for health and nutrition workers, provision of health referral services, and increasing the availability of medicines and equipment for maternal and child health; (b) communications, to provide innovative approaches and new messages to increase demand for the full range of project services and provide health and nutrition education; (c) community mobilization, to promote greater community "ownership" of ICDS services and involvement in meeting program objectives of better health and nutrition and women's and adolescent girls' development schemes; and uroiect management, monitoring and evaluation, to manage, monitor and evaluate the project and conduct operations research to test innovative activities and improve aspects of project design. The project would also include actions to strengthen ICDS among tribal populations. - iv - Benefits: Tlbe msin benefit of the project would be to speed up tLe currently very gradual pace of improvement in pre-school nutrition status in project areas. The project also would contribute to a faster reduction in infant and child mortality. In the last year of the project alone, around 4.0 million pregnant and nursing women and about 12.0 million children under 6 years of age would benefit directly from the project. Risks: The project will be carried out in two of India's poorest states and among some of its poorest people. Thus, it will not be easy to implement. In addition, three particular risks face the project. The first risk is that implementation would be delayed by training and institutional shortfalls, especially in Bihar. The second risk is that additional responsibilities will be imposed on AWs without regard to existing workloads and undermine efforts to focus workers more on case management of malnourished children and improved household food behavior. The third risk is that nutrition-health coordination arrangements will fail to take adequate hold. To reduce these risks: (a) project management staff would be appointed as a condition of effectiveness and empowered committees have been set up in both states; (b) the findings of the mid-term review of the first ICDS project regarding work routines would be incorporated into the implementation of the proposed project; (c) improved health-nutrition coordination would be facilitated; and (d) the project would be subject to very careful and regular monitoring and evaluation, including special monitoring of the impact of the project on tribal people. v Estimated ProJect Costs:\a Components Local Foreign Total -US$ millions------- A. Service Delivery 1. Nutrition 135.0 10.8 145.8 2. Health 15.8 3.7 19.5 3. Training 11.4 0.6 12.0 Subtotal 162.2 15.1 177.3 B. Communications 7.8 0.6 8.4 C. Community Mobilization 7.0 0.2 7.2 D. Project Management 1. Project Organization 11.5 1.2 12.7 2. Monitoring and Evaluation 0.3 0.1 0.4 3. Operations Research 2.5 0.5 3.0 Subtotal 14.3 1.8 16.1 Total Base Costs 191.3 17.7 209.0 Contingencies 35.7 4.1 39.8 Total Project Costs 227.0 21.8 248.8 \a Including taxes and duties equivalent to US$4.7 million. Project Financing Plan: Local Foreign Total -------US $ millions------- Government\a 54.8 0.0 54.8 IDA 172.2 21.8 194.0 Total Project Costs 227.0 21.8 248.8 \a Including taxes and duties. Estimated Disbursements: IDA - FY FY93 FY94 FY95 FY96 FY97 FY98 FY99 FYOO Annual 14.8 11.6 8.4 34.9 31.1 33.7 32.2 27.3 Cumulative 14.8 26.4 34.8 69.7 100.8 134.5 166.7 194.0 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT I. BACKGROUND A. Introduction 1.01 An important component of India's efforts to raise the living standards of its more than 300 million poor people has been lts human resource development programs which have focussed on maternal and child health, nutrition, and education. Several national and state programs operate specifically to improve child health and nutrition of the poor through service delivery. These programs have met with some success. However, India needs to expand and improve the coverage and effectiveness of its service delivery efforts to maximize their impact on child growth and development. 1.02 Abetted by economic development which has tripled foodgrain production and raised national incomes and productivity, life expectancy has doubled since the decade ending in 1951. India has also achieved considerable success in improving child survival, particularly over the last decade, diuring which the infant mortality rate (IMR) is estimated to have declined by about a third, to 86 per thousand live births in 1988. The death rate for children 1-4 years of age also declined from 19 to 11 per thousand during the same period. Largely as a result of these advances, life expectoacy is estimated to have increased from 50 to 57 years. Improvements are widespread over all regions and in both rural and urban areas. However, considerable variations persist. For example, the IMR in Madhya Pradesh (MP) and in the rural areas of Bihar is 111 and 100 per thousand live births respectively, while in Kerala, it is 31 per thousand. In states with high IMN, a predictable pattern of morbidity including diarrhea, respiratory infections, worm infestations and skin diseases afflicts a large proportion of survivors. 1.03 Despite higher rates of child survival, an estimated one-third of India's pre-school children have some form of serious growth deficit from malnutrition. Available data, while inadequate, suggest only a very gradual improvement in nutrition status over the last 20 years. Malnutrition is particularly intense in Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Karnataka, Orissa, and Rajasthan. According to the latest national data, the proportion of children 1-5 years of age with moderate and severe malnutrition (less than 75X weight for age) varied in 1982 from 18.9Z percent in Kerala to 59.61 in Gujarat. The extent of malnutrition among scheduled tribes and castes was higher than averages in most places. The incidence of severe malnutrition (less than 60Z of weight for age) is declining but exists among all classes. Predictably, the incidence of energy deficiency is higher among the children of landless laborers and small farmers. Evidence of gender discrimination is not conclusive; regional figures suggest some discrimination in north India, especially amongst very young girls. 1.04 Children under 3 years are the most vulnerable. The Indian Academy of Pediatrics uses the 50th percentile of the internationally accepted Harvard standard as its weight for age standard and classifies malnutrition status as - 2 - follows: more than 80? as normal, between 71? and 80? as mild (grade I) malnutrition, between 61Z and 70? as moderate (grade II) malnutrition, and below 60Z as severe malnutrition (between 51? and 60? is grade III and below 50? is grade IV). Recent survey results from the project areas of MP show that about 30? of the children 0-6 years suffer from moderate or severe malnutrition. Data from Bihar suggests that about 40? of children age 0-6 years suffer from moderate or severe malnutrition. 1.05 The consequences of malnutrition are lowered potential for physical and mental capacity and greater susceptibility to disease. The risk of premature death among severely malnourished younger children is three times that of better nourished ones. Hospital statistics in Tamil Nadu indic that malnutrition is the underlying cause of death in 10 and an associL 5 cause of death in 75? of deaths in the age group 0-5 years. A large proportion of malnourished children also remain stunted with inadequate height for age. 1.06 A prir;sipal cause of malnutrition, of course, is inadequate food intake due to low household incomes. Latest available data (1975-80) show that average calorie intake in almost all states was lower than the recommended allowance of 2400 Kcal/consuming unit. Further, the calorie intake of scheduled tribes and castes was lower than state averages. Since subsequent poverty decline was the lowest among these social groups, their nutrition has probably not improved substantially over the last decade. Although calorie intake for all income groups shows a modest increase, no trend increase was discernible for the ultra-poor, who spend more than 80? of their income to achieve less than 80? of their calorie needs. Evidsnce also indicates that less developed districts have a preponderance of malnourished children among scheduled tribes and castes. 1.07 However, neither adequate food at the household level nor economic development of a state seems to protect children from malnutrition to the same extent as it does adults. In several states, about 252 of all households had inadequate calorie protein levels, while more than 40Z of the children were malnourished (less than 75? weight for age). 1.08 Beyond inadequate food intake, the main causes of malnutrition among young children are three. First is the high incidence of childhood diseases, particularly acute respiratory infections (ARI), measles and diarrhea. More than one fourth of all infant/childhood deaths are attributed to respiratory infections. An Indian rural child also suffers from several episodes of diarrhea per year. Behavioral factors, particularly faulty breast feeding and weaning practices and inadequate patterns of household food distribution, are a second cause of early childhood malnutrition. Colostrum is often discarded and breast feeding frequently begins only three days after birth. Weaning not only begins late but weaning foods do not contain enough nutrients. Third, low birth weight (LBW), estimated at around 30? of all births for India as a whole, often results either in early infant death or subsequent malnourishment. LBW is largely a result of the low weight of women before, and inadequate weight gain during pregnancy. In addition, children suffer from micro-nutrient deficiencies, particularly Vitamin A. About 30,000 - 40,000 children become blind every year due to Vitamin A deficiency. B. National Nutrition Programs 1.09 The Government of India (GOI) has sought to address nutrition issues in a variety of ways, in addition to income generation. The problem of malnutrition was recognized as early as the First Five Year Plan in 1950 and the first three Plans treated nutrition principally as a component of the health sector. The Applied Nutrition Program, introduced in the Fourth Plan (1969), aimed at raising the nutritional status of the poor by nutrition education and local food production but achieved limited coverage and was abandoned. The Mid-day lieals Program (MDM) was introduced by some states in 1962 to provide supplementary food to primary school children and later (1974) became a part of the Minimum Needs Program. Although its impact on school. attendance, academic performance and nutritional status is not well evaluated, the program continues to operate and currently covers &n estimated 17 million children in India. The Special Nutrition Program (SNP) was introduced in 1970 to provide nutrition supplementation to pre-school children and pregnant and nursing women, primarily from tribal and backward areas and urban slums. An SNP support group was formed in each program village; a village organizer receives a token honorarium to cook and feed beneficiaries. By 1980, the scheme had more than 6 million beneficiaries but the enrolment of children below 3 years of age, the most vulnerable group, was low. In recent years, the program has been implemented in a few states in areas not covered by the Integrated Child Development Services scheme. 1.10 A public distribution system (PDS) to improve the household's access to food has also occupied a central place in public policy since the 1970s. The scheme provides for a network of fair price shops run by the Ministry of Food and Agriculture which provides low-cost staples to poor households against ration cards. However, a substantial share of PDS supplies goes to the cities. In some states, such as Kerala, Tamil Nadu and Gujarat, PDS has succeeded in reaching the poor. But states that account for a substantial proportion of India's poverty population like Bihar, Uttar Pradesh and Madhya Pradesh account for only a small share of PDS offtake. Evidence suggests that a well managed PDS has potential for improving the nutrition status of vulnerable households, although in practice the record is mixed. 1.11 Integrated Child Developmept, Services (ICDS). India's most important national child nutrition intervention is the ICDS scheme, probably the largest program of its kind in the world and certainly one of the most comprehensive and imaginative. ICDS aims to achieve four objectives: (1) to improve the health and nutrition status of children 0-6 years by providing supplementary food to beneficiaries 300 days per year; (2) to provide conditions necessary for child psychological and social development through early stimulation and education; (3) to enhance the mother's ability to provide proper child care through health and nutrition education; and (4) to achieve effective coordination of policy and implementation among the various departments to promote child development. ICDS delivers a package of services comprising supplementary nutrition, immunization, health check ups, referral - 4 - services, and health and nutrition education to children under 6 years of age, pregnant and nursing women, and pre-school education to children between 3 and 6 years of age. Supplementary feeding generally consists of a hot meal of lentils, rice and vegetables or a mixture of grains. CARE provides food supplements of bulgur wheat and oil. ICDS adopts a holistic approach to improved child development to reduce mortality, morbidity, malnutrition and school drop outs. Initiated in 1975 on an experimental basis in 33 blocks, ICDS now covers 2,200 out of a total of 5,500 rural blocks in India. (Blocks have an average population of 110,000.) 1.12 ICDS is centrally sponsored through the Department of Women and Child Development (WCD) in the Ministry of Human Resources Development in the Government of India (GOI) but is administered by the state governmE,vs. The COI and the states also share ICDS costs. The GOI provides training and operating costs including salaries, equipment, supplies, play materials, petrol and oil expenses, and medical kits, estimated at Rs. 1.0 million per block-year. State governments meet the costs of supplementary food, currently estimated at around Rs. 1.7 million per block-year. Some states have funded ICDS blocks independently and pay all the expenses themselves. 1.13 The GOI has followed a gradual ICDS expansion policy, based on targeting to the most disadvantaged areas. The initial geographic focuE has been on tribal, drought-prone areas and blocks with a significant proportion of scheduled caste population. The program has also been targeted towards malnourished children, but in practice most beneficiaries of supplementary feeding are not selected through nutritional screening, but are fed on the basis of attendance at the Anganwadi center. 1.14 The Anganwadi center (AW) is the focal point for delivering ICDS services at the rate of one AW per 1000 population in rural and urban areas, and one per 700 population in tribal areas. AWs are often located in small rented rooms or in open courtyards. The AW is staffed by a locally-recruited woman worker (AWW) and a female helper. The AWW is a part-time honorary worker paid between Rs. 225 and As. 325 per month depending on educational qualifications. 1.15 The AWW is responsible for growth monitoring of children under 6 years of age, conducting quarterly and annual surveys of the village, organizing supplementary feeding, providing non-formal pre-school education for the older children, imparting nutrition and health education to mothers, making periodic house-to-house visits in the village, organizing primary health care for children and mote 's, referring the needy to health personnel, eliciting community support and participation .ncluding the formation of women's organizations known as Mahila Mandals (MMs), and maintaining records and furnishing reports. 1.16 While ICDS has been recognized internationally for its ambitious goals and innovative features, there is considerable variability in its impact on the target population and also in the quality of services provided. There are several aspects of the program which generally need strengthening such as: (a) training; (b) supervision; (c) targeting of supplementary feeding; (d) case management of malnourished children; (e) linkages with the health system; (f) nutrition and health education; and (g) community participation. Available evidence suggests that the impact of ICDS depends mostly on these points; it does not reflect significant differences in tribal compared to non- tribal areas, except in respect of coverage, which is consistently lower in tribal than other areas. A recent national ICDS evaluation by the National Institute for Public Cooperation and Child Development (NIPCCD) reported no significant weight or nutrition status differences between ICDS and non-ICDS children under three years of age in comparable areas, mainly because "under- threes are not that easily being captured by the program." 1.17 Training and Supervision. Both training and supervision can play important roles in improving quality service delivery. In particular, four training areas need strengthening. First, there is considerable unevenness in the quality of the more than 200 training centers spread all over the country. Second, despite good training manuals, the training syllabus and materials need to be adapted to allow for variations in differing rural, urban and tribal conditions. Third, the training of supervisors is very weak. Consequently, although many supervisors are aware of ICDS deficiencies in their areas of responsibility, vigorous actions to remedy the situation through more frequent and more extended visits to AWs are not undertaken. The need to supervise a large number of AWs and inadequate mobility also limit their attention to quality issues. Fourth, existing funding places inaedquate emphasis on in-service training of all categories of field staff. The NIPCCD evaluation called supervision perhaps the "weakest link in the ICDS programme." Cited problems included thin supervisor ratios, infrequent visits to AWs and inappropriate supervisor styles and work patterns. 1.18 Supplementary Feeding. The regularity and targeting of ICDS supplementary feeding remains an area of concern. The NIPCCD evaluation showed wide variations in the number of feeding days; over 60X of all AWs had yearly feeding disruptions of more than 60 days, including 25X which were affected for more than 90 days. The timely delivery of supplies in adequate quantities is one of the main problems encountered. An important problem in the supplementary feeding program is the low coverage of children under three years of age, and even lower coverage of pregnant and nursing women. Proportionately, a much higher percentage of 3-6 year olds receive food than in the more vulnerable under-three age group, partly because younger children cannot come to the AW by themselves. The low coverage of pregnant and nursing women has been a problem because of the low priority placed on their feeding by individual AWWs, the inconvenient timings of the AWs for working women, and the reluctance of some women to accept the food supplementatioll under the program. 1.19 ICDS set feeding quotas per block which usually are fully subscribed in non-tribal but underfllled in tribal areas. Most AW nutritional screening is to identify severely malnourished children, who are entitled to food supplementation but because of listlessness and lack of appetite rarely can consume a double ration. Once enrolled, most child beneficiaries continue to receive food regardless of nutritional status until they reach school age. ICDS maintains with some justification that in locales where poverty levels approach 752, such as many tribal blocks, virtually all pre-school children are at malnutrition risk and warrant continued supplementation. However, the - 6 - cost-effectiveness argument for area targeting rather than individual nutrition screening is weaker in ICDS blocks where poverty levels are substantially lower. 1.20 Case Management. The present supplementation system has other drawbacks. Once a feeding quota is filled, the AWW has little incentive to seek out additional malnourished children for other AW services. Thus, area targeting tends to reduce the emphasis on monitoring individual child growth and can detract from worker focus on case management of malnourished children through health check-ups and referral. NIPCCD found that no more than two- thirds of workers regularly monitor child growth in their AWs. Evaluations have also indicated that long-term supplementation may substitute for food which the child otherwise would receive at home and, thus, run counter to the development of maternal understanding of the special needs of malnourished children and improved family food behavior. On the other hand, the direct impact of the present feeding program on child nutrition may be less than desirable but may induce mothers and children to come to AWs. 1.21 Linkage with Health System. Preventing energy losses from illness is another area of prospective ICDS improvement. Although immunization coverage has increased, both oral rehydration therapy for diarrhea and management of ARI are not systematically practiced at the village level. This situation can partly be attributed to under-utilization or inadequacy of health services. Evidence suggests that the link between health and nutrition services needs strengthening at all levels. The general problem of uneven referral to higher health care levels also affects ICDS; neither the AWW, nor, in most cases, the local health workers keep satisfactory referral records or follow up to ensure that children reach and receive treatment at health facilities. ICDS has taken several steps to improve its linkages with the health system. Coordinating committees with health sector participation have been established at block, district and state levels. Key block and district health professionals have been appointed as technical advisers to ICDS. Joint monthly meetings also take place at and below the block level to review performance; supervisors are expected to plan joint visits. Despite these measures, much remains to be done to ensure coordinated delivery of health and ICDS services at the village level. 1.22 Information, Education and Communications (IEC) and Community Participation. Both nutrition education and community participation need to be strengthened further. According to NIPCCD, only a very low percentage of families provided any form of material support to ICDS; AWW initiative in approaching community representatives appeared lacking. The task of eliciting community particip&-ion is admittedly difficult in villages stratified by social barriers and economic differentials; therefore, health and nutrition activities are rarely conducted in women's working groups, which were envisaged as a major vehicle for community participation. House-to-house visits by the AWW also need to be more regular. Moreover, special efforts are needed for communities to become effective partners with ICDS in overall child development. 1.23 Pre-school for the older ICDS beneficiaries is an integral part of the program, which evaluations have indicated could be strengthened through improved worker training, supervision and materials. A 1987 NIPCCD study of ICDS's social components observed that around one-third of AWs had enough play materials and teaching aids for pre-school; however, workers themselves have reported deficiencies in being taught how to use them properly. In addition, as with other aspects of ICDS, pre-school functions well in some AWs and poorly or not at all in others. 1.24 Other Program Issues. In addition to the technical issues cited above, there are program issues related to the ICDS such as: (a) the extent to which supplementary feeding should be targeted to the nutritionally most needy (e.g., moderate and severely malnourished children under 3 years and pregnant and nursing women) and the costs and benefits of such targeting; (b) the rapid expansion to new blocks which can leave existing ICDS blocks with suboptimal service levels; (c) the lack of a well-developed communication program aimed at improving community participation, improved health and nutrition education, and creating greater demand for the full range of health and nutrition services offered by ICDS; and (d) the lack of clearly defined work routines for AWWs and supervisors to meet the specific health and nutrition objectives of the program. 1.25 PDS-ICDS Complementarity. The Public Distribution System (PDS) and ICDS are complementary elements of India's social safety net. PDS seeks to promote household food security for poor families while ICDS is concerned with the individual growth and development of pre-school children and the nutritional health status of pregnant and nursing women in socially and economically disadvantaged areas. The Government of India is now carrying out an adjustment program that may have at least a transitional and adverse impact on the nutritional status of the poor. In addition, food prices in India have risen by almost 30Z over the last twelve months. In this context, the proposed project would help to strengthen the nutrition and health safety net among some of India's poorest people, in two of India's poorest states. C. ICDS in Madhya Pradesh (HP) 1.26 ICDS faces a special challenge in tribal areas of MP, because of the poor economic conditions, and problems with service delivery due to the widely dispersed population. Tribal populations tend to live in small clusters or hamlets. Thus, about one-third of the villages in Madhya Pradesh have a population of less than 500 and one-eighth of these have less than 200. Its population density is 149 persons per sq. km., about 56? of the India average. A 1982-84 situation analysis of the tribals in Madhya Pradesh by the National Institute of Nutrition (NIN) showed that around a fifth of pre-school children suffered from ARI and nearly half were stunted. The extent of severe anaemia in the population ranged from 4Z to 23?. 1.27 According to the 1991 census, Madhya Pradesh has an estimated total population of 66.2 million, 7.8? of India's total population. It has a tribal population of about 12.0 million which is 23? of the country's total tribal population. Of its 46 tribes, 12 account for over an estimated 80? of the total HP tribal population. The birth and death rates in 1990 were estimated to be 36.9 and 12.5 per thousand respectively, more than 20? higher than the average for India. The state also has a very high infant mortality rate, - 8 - 111 per thousand live births. Only about 30Z of females are literate. Madhya Pradesh is also one of the poorest states, with per capita state domestic product in 1987 of about 72? of the Indian average. 1.28 ICDS is targeted to the most disadvantaged areas. Priority has been given to blocks with a high proportion of tribal or scheduled caste populations, and drought prone areas. There are 45 districts and 459 blocks in Madhya Pradesh. ICDS currently covers 115 rural blocks, of which, about 98 are tribal. CARE and the World Food Program (WFP) provide food commodity assistance to 95 and 34 blocks respectively. The remaining blocks are supplied ready-to-eat energy food procured by the state from Karnataka State Agro-Corn Industries. 1.29 Even in the difficult environment of Madhya Pradesh with its scattered population, ICDS coverage of some services is good. The NIN base line survey (Annex 1), carried out in 1990, showed that around 60? of children and 69? of pregnant and nursing women (as compared to a target of 75Z) received supplementary nutrition regularly. However, about a half of the women shared it with others at home. Maternal and Child Health (MCH) service coverage in ICDS areas was much higher than in non-ICDS areas. About half the children under 1 year of age received a full schedule of immunizations, nearly three times the coverage in non-ICDS areas. About 60? of pregnant women received tetanus immunization, and iron and folate tablets, nearly twice that in non-ICDS areas. Similarly, 60Z of women received some health and nutrition education, nearly 6 times that in non-ICDS areas. The AWs were found to be accessible but the accommodations were generally not considered good by the respondents. Growth monitoring was being carried out in most AWs and the AWWs were generally competent to carry it out. There is evidence to suggest that ICDS service delivery in Madhya Pradesh is perhaps somewhat better than but at least comparable to that of the program as a whole in India. 1.30 The reduction of severe malnutrition would remain an important priority for reducing the high infant mortality rates in Madhya Pradesh. After several years of participation in ICDS, around 8? of children under 2 years of age were still severely malnourished (grade III and IV). The base line survey of ICDS areas also showed that the proportion of moderately malnourished children under 6 years of age (grade II) was 24.6Z. Only about a third of the children had normal nutrition status. D. ICDS in Bihar 1.31 Bihar is one of the poorest states in India. In 1987-88, 40.7? of population was estimated to be below the poverty line compared to 29.2? for India as a whole. Base line data from the proposed project areas suggested that 1 in 10 children suffers from severe malnutrition (grade III and IV) in ICDS areas. A third of the children under 6 years of age are moderately malnourished (grade II). Only about a fifth of the children have normal nutrition status. 1.32 According to the 1991 census, the population of Bihar is 86.4 million, 10.32 of India's total. Of this, over 10.0 million are scheduled castes and about 6.0 million are Scheduled Tribes (ST). Twelve of Bihar's 30 - 9 - ST account for more than 952 of the state's tribal population. The birth and death rates in 1990 were estimated to be 32.9 and 10.6 per thousand respectively, about 102 higher than the average for India as a whole. The IMR for rural areas is 104 per thousand live births. Less than a fourth of females are literate. 1.33 Currently, ICDS operates in 168 of the state's 591 blocks; about half of these ICDS blocks are tribal. CARE supplies food commodities to about 100 blocks and the remaining are supplied by the State Food Corporation or the RTE Food supplement. Rice is made available from the public distribution supplies, and lentils are procured from the local market. 1.34 ICDS service delivery and coverage in Bihar is considerably lower than in Madhya Pradesh (Annex 1) and much below the program as a whole. Although about two-thirds of targeted beneficiaries received at least one service, less than a third of children received regular supplementation. Only 112 ever received Vitamin A, and about half the women received some health and nutrition education. Of pregnant and nursing women, 712 received supplementation but less than half consumed it at the AWs and nearly three- fourths of those taking it home shared it with others. MCH service coverage, although higher in ICDS areas, is also very low. Although coverage is increasing rapidly, only 302 of children under 1 year old had received a third dose of diphtheria-polio-tetanus immunization and only 332 of pregnant women received at least one dose of tetanus immunization. Food storage facilities were inadequate and water sources were located far from the AW. Very few AWWs understood the basis for growth monitoring and consequently did not maintain adequate age-weight charts. Coordination between ICDS and the health service at the field level was poor. Supervisors rarely participated in house-to- house visits. 1.35 The base line survey showed that nearly a third of AWs did not reside in the AW center village. A September 1991 analysis of sample monthly monitoring data suggested that (a) about a third of the blocks reported having no food supplies; (b) about 40X of the sanctioned supervisory positions were vacant; (c) although pre-school attendance was reported to be high, population enumeration was inaccurate and growth monitoring of the registered children was irregular; and (d) the house-to-house visits of AWWs in the service area were rarely undertaken. 1.36 The lower ICDS performance in Bihar reflects its overall weak implementation capacity which affects almost all development programs in the state. However, recently the State has taken several steps to strengthen ICDS operations, such as (a) improving government transport arrangements for CARE- supplied commodities so that the proportion of food delivered to AWs has increased from 412 to 592 of the food supplied; (b) arranging for decentralized procurement of lentils in most of the districts; (c) making arrangements with a public sector corporation to supply ready-to-eat food for 35 blocks; and (d) increasing health-ICDS coordination through the scheduling of visits by Multi-purpose Workers (Female) (MPWF) to AWs, distribution of iron and folate through AWs and holding immunization camps at AWs. - in _ E. Learning from Other Experiences 1.37 The lessons of experience incorporated into the proposed Second ICDS project are drawn from the numerous evaluations of the ICDS program which have been conducted over the years, the lessons learned from the ongoing Bank- supported Tamil Nadu Integrated Nutrition'Project (TINP) and those from other Bank-financed projects in the population and health sectors. 1.38 Case Management. The present supplementation system has other drawbacks. Once a feeding quota is filled, the AWW has little incentive to seek out additional malnourished children for other AW services. Thus, area targeting tends to reduce the emphasis on monitoring individual child growth and can detract from worker focus on case management of malnourished children through health check-ups and referral. Evaluations have indicated that long- term supplementation may substitute for food which the child otherwise would receive at home and, thus, run counter to the development of maternal understanding of the special needs of malnourished children and improved family food behavior. On the other hand, the direct impact of the present feeding program on child nutrition may be less than desirable but may induce mothers and children to come to AWs. 1.39 It is estimated that TINP contributed to a reduction of a third to a half in severe malnutrition among 6-24 month olds, and a reduction of about 5O0 in severe malnutrition among 6-60 month olds. While not conclusive, the available data suggest a strong TINP impact in improving children's nutrition status. TINP also reduced inequalities in the incidence of malnutrition among different districts. In project areas, the overall proportion of children in normal and grade I increased substantially; the proportion in grade II remained nearly the same, implying a favorably upward shift in the overall nutrition curve. There is also some evidence that TINP effects persist beyond the age of 36 months. At 5 years of age, children participating in the project's initial block weighed almost 2 Kgs. more than those in a control group. However, the project was less successful in reaching its health goals. This was largely due to service delivery problems with the health system. 1.40 TINP demonstrates that it is possible to reach a high proportion of younger children who are nutritionally the most vulnerable, and significantly reduce the incidence of severe malnutrition through well targeted health and nutrition services aided by communication and community mobilization activities. While it did not achieve all of its goals, the project has an unusual number of lessons for the design and implementation of nutrition programs, particularly in the areas of training, supervision and monitoring. Key features include carefully defined recruitment criteria for local workers; limiting field worker tasks to those which are manageable and high priority; specification of daily and monthly work routines; decentralized training systems; supervisory practices which facilitate on the job training; the u of local women's groups to support project activities; the display of performance information to clients and workers at the village nutrition center; and a management information system which could rapidly detect performers falling below established norms. On the health side, the main lesson is that large-scale investment in health infrastructure and supplies is not sufficient to improve performance. Complementary software measures are - 11 - needed to optimize health workers' performance. With a few design changes in the supplementation criteria, and more focus on maternal nutrition and improved health-nutrition coordination, it may be possible to reduce the incidence of moderate (grade II) malnutrition resulting in a greater proportion of children in normal and grade I category. 1.41 The Bank's assistance to ICDS began in 1991 with the approval of the first ICDS project in Andhra Pradesh and Orissa (Ln. 3253/Cr. 2173), now under implementation. The design of that project takes account of lessons from TINP and other experiences in and outside of India. Disbursements are largely on schedule. It is still too early to determine any lessons of experience from the project, but the results of a mid-term review in 1993 will be incorporated into the implementation of both it and the proposed second project. Implementation of the first project has underscored the importance of early establishment of state-level project management units. It also has shown the need for speedy development of communications activities and for ensuring a good balance between expanding ICDS and strengthening the existing program. The proposed project has been designed largely along the lines of the first project and incorporates preventive measures against the kinds of snags that initially hindered implementation of that project. 1.42 Since 1973, IDA has supported seven population projects and one child survival and safe motherhood project. There is also a major health component in the Second Calcutta Urban Development Project. The First, Second and Third Population Projects have been completed and Project Completion Reports (PCRs) and Project Performance Audit Reports (PPARs) have been issued for all except the Third Population Project for which the PCR is under preparation. The First and Second Population Projects suffered some delays in implementation, but each has been evaluated as having achieved its principal objectives. Nonetheless, the gains were only marginally higher when compared to non-project districts. The third project has done very well in Kerala, but less well in Karnataka. Implementation of the on-going Fourth, Fifth, Sixth and Seventh Population projects has been largely satisfactory, with the Fourth project already having a significant impact on morbidity and contraceptive prevalence. The Sixth and Seventh projects are still relatively new, but initial reviews of implementation have reported progress in most areas. The Sixth Project covers the state of Bihar and the Seventh Project, Madhya Pradesh. Provisions have been made under the proposed Second ICDS Project to ensure coordination between the ongoing Bank-financed projects in each state. The health component of the Calcutta Urban Project has had a significant health impact. It was recently judged by a WHO evaluation to be among the most successful programs of its type in the world. 1.43 The Child Survival and Safe Motherhood (CSSM) Project, which became effective on March 5, 1992, supports the enhancement and expansion of the Government of India's Maternal and Child Health Program for 1991-1995. The project is national in scope but with an emphasis on specific districts where maternal and infant mortality rates are higher than the national average. Its specific objectives are to enhance child survival, prevent maternal mortality and morbidity, and increase the effectiveness of service delivery through strengthening diarrhea control, the control of ARI, prophylaxis against blindness and eye lesions due to Vitamin A deficiency, enhanced newborn care - 12 - and the active promotion of breast feeding. The CSSM Project contains specific guidelines for improved coordination between the health care system and ICDS at the field level (Annex 5). Efforts are being made to ensure that the implementation of the proposed Second ICDS and the CSSM Projects are phased in such a way that services are introduced simultaneously in overlapping project districts. 1.44 The design of the proposed project takes account of both the technical and project implementation lessons learned from the above projects. On the technical side, the project pays particular attention to: developing a strong communications component to promote health and nutrition education and greater community involvement; enhanced training and supervision of workers; refining job descriptions so that they focus on a select number of well focused tasks that the workers can effectively carry out; and sharpening the targeting of food supplementation. In terms of project implementation, the project would support the creation of empowered comuittees to speed implementation; make use of standard bidding documents; introduce annual reviews to assess implementation progress; and build upon an existing program with advanced preparation of many software activities. F. Rationale for IDA Involvement 1.45 IDA's country assistance strategy involves accelerating the pace of India's human resource development and the strengthening of anti-poverty programs, particularly those which comprise a safety net for the poor during adjustment. An important aspect of IDA's human resource strategy is to help reduce excess fertility, mortality and morbidity, increase school enrollment levels and the quality of educational output, and improve nutritional status. IDA's main nutrition objective is to assist the Central and state governments in adopting policies, strategies and cost-effective programs to deal with the nutrition problems of pre-school children and pregnant and nursing women. The proposed project would provide targeted assistance to poor women and children, many of whom are tribal. These are the groups most at risk of falling through the social safety net during the present period of economic adjustment and severe budgetary constraints. As the principal nutrition donor in India today, as well as a financier of structural adjustment, IDA has a comparative advantage in promoting improved effectiveness, efficiency and coverage of Indian nutrition programs. Without the project, the pace of expanding ICDS to beneficiaries would be slower, many of those needing ICDS services would not have access to them, and the program's nutritional impact would be less in both existing and new ICDS areas covered by the project. 1.46 The Government recognizes that a critical aspect of the ongoing transformation of India's development strategy is an effort to speed the national pace of human resource development. The recently approved Credit for the Social Safety Net Sector Adjustment Program (SSNSAP) responds to that opportunity. As part of the Program, the GOI has committed ICDS to focus on particularly disad-vantaged districts with a large proportion of tribal, scheduled caste or slum dwellers and to improve service quality. - 13 - 1.47 The proposed project would assist the achievement of the SSNSAP objectives by promoting the increased effectiveness and efficiency of ICDS services and program expansion to provide targeted assistance to poor women and children, many of whom are tribal. These groups are most at risk of falling through the social safety net during the present period of economic adjustment and seveze budgetary constraints. As the principal nutrition donor in India today, as well as a financier of structural adjustment, IDA has a comparative advantage in promoting improved effectiveness, efficiency and coverage of Indian nutrition programs. Without the project, the pace of expanding ICDS to beneficiaries would be slower, many of those needing ICDS services would not have access to them, and the program's nutritional impact would be less in both existing and new JY'JS areas to be covered by the project. G. Other Donor Role 1.48 External donor involvement in ICDS is relatively small. However, CARE-donated food provides supplementary nutrition for around 5 million ICDS beneficiaries in 7 states. The WFP provides supplementary food for around 2.1 million beneficiaries in 5 states. UNICEF funds, on a one time basis, equipment and training to establish new ICDS blocks not covered under Bans- financed proi3cts. Its assistance in recent years has averaged about US$5.0 million yearly. An innovative USAID-assisted project has supported ICDS expansion and strengthening in one district each of Gujarat and Maharashtra. It seeks to improve ICDS performance in project areas through in-service training, increased supervision, strengthened communication and development of a management information system. Although the results of its mid-term evaluation were vitiated by severe drought conditions, it showed a considerable increase in coverage by various services. It is still early to assess the impact of the project since a final evaluation has not been carried out. More recently, NORAD is assisting ICDS in Uttar Pradesh and SIDA is assisting ICDS in one district in Tamil Nadu. II. THE PROJECT A. Project Goals and Objectives 2.01 The proposed project would be carried out in Bihar and Madhya Pradesh. The project would seek to accelerate the pace of improvement in the nutrition and health status of pre-school children, particularly children under 3 years of age, and pregnant and nursing women, focussing on households with incomes below the poverty line. Specific impact objectives would be: - 14 - Madhya Pradesh Bihar (Percent) Current Current Estimate Target Reduction Estimate Target Reduction Severe malnutrWon among children 6.36 months 8.0 4.0 50.0 11.4 6.8 40.0 Moderate malnutrition among children 6-36 months 24.0 19.0 20.0 32.7 24.5 26.0 Low birth weight incidence 40.0 28.0 30.0 40.0 28.0 30.0 It is projected that the above improvements in nutrition status, along with other MCH interventions, would contribute towards a reduction of 30Z in DMR. 2.02 Process and activity targets (Annex 2) to achieve the above impact have been established for: (a) Children under 3 Years. Regular growth monitoring, immunizations, Vitamin A administration, care of diarrheal diseases and ARI, supplementation of those malnourished, and health care and referral of the severely malnourished; (b) Children 3-6 Years. Regular growth monitoring, pre-school attendance, and health care and referral of those severely malnourished; (c) Pregnant Women. Early registration of pregnant women, antenatal care, and iron and folate supplementation; (d) Pregnant and Nursing Women. Counselling on appropriate and adequate breast feeding, weaning, and birth spacing practices; and supplementation of those with inadequate nutrition status; End of ProJect Targets Process Ob ectives (percentage) Madhya Pradesh Bihar Total registratfon of pregnant women 80 75 Food supplementation of pregnant women with inadequate nutrition status (at least 20 weeks) 80 80 Food supplementation of registered nursing women with malnutrition In pregnancy (at least 16 weeks) 90 75 Regular growth monitoring of children under 3 years of age (quartely) 100 80 Supplementation of moderately and severely malnourished children 6-36 months 90 80 - 15 - B. Project Area 2.03 The project would cover 229 blocks in Madhya Pradesh and 207 blocks in Bihar. In Madhya Pradesh, the project would strengthen services in 98 existing ICDS blocks and extend the program to an additional 131 blocks covering an estimated 7.6 million population. This would improve services in 85Z of the existing blocks and expand the total area under ICDS by 114X. Similarly in Bihar, the project would strengthen services in 72 existing blocks and extend the program to an additional 135 blocks covering a population of 12.4 million. This would improve services in 43Z of existing blocks and expand the total area under ICDS by 802. The blocks were selected on the basis of the percentage of population which was either tribal or scheduled caste. In a few cases, blocks were included which are in drought- prone areas.1 2.04 Bihar and Madhya Pradesh contain substantial proportions of India's Scheduled Tribe (ST) population (Annex 3). These populations are distinguished socio-economically by their preponderance in drought prone, marginal farming areas and their dependence on a range of relatively insecure sources of livelihood. These tribal populations are also characterized by low social and health indicators in relation to literacy levels, child survival and child and maternal nutrition. They are distinguished, to varying degrees. by language and cultural practices. In both states, the ST population is concentrated in the more hilly, forested areas which constitute a more or less continuous ecological zone across Madhya Pradesh and southern Bihar. The largest ST groups in Bihar are the Santals, Mundas, Hos, Oraons and Kharias. In Madhya Pradesh, some of the main ST groups are the Gonds, Baigas, Oraons, Muria and Maria Gonds, and Bhils. The project would cover 112 tribal blocks in Bihar with a total population of about 10.1 million and 156 tribal blocks in Madhya Pradesh, with a total population of about 14.0 million. This represents 100Z of the tribal blocks in Bihar and 892 of the tribal blocks in Madhya Pradesh. C. Project Approach 2.05 The proposed project would take the following approach: - It would build on the existing model of ICDS. That model has shown that it can produce positive results, including in Madhya Pradesh and Bihar, and including in tribal areas, despite the shortcomings of the manner in which the program is sometimes implemented. - The project would seek to enhance the quality and effectiveness of ICDS services, by promoting better worker training, improved supervision of workers, strengthened delivery of health and nutrition services, development of a health and nutrition education program, enhanced monitoring and evaluation, and increased community 1 A tribal block is defined as any block whose tribal population constitutes over 502 of its population, as well as any block with an area covered under the tribal sub-plan of the two states which is in the project area. - 16 - participation. These are the areas most closely associated with a successful outcome for ICDS investments. - The project would aim at expanding ICDS, in its improved form, in areas in which the program is already active in Hadhya Pradesh and Bihar, including tribal areas. - The project would also aim at expanding the enhanced ICDS into some new areas in both states, including tribal areas. - The project would finance efforts to refine further several key areas of ICDS involvement, by operations research, independent review, and impact evaluations. This will be especially the case for supplementary nutrition, community participation, services for remote regions, and services for tribal people. These are all complex areas where no single approach can be used and where it is hoped that the project, over time, will point to a variety of approaches that might be used in the future. - The project should have a positive impact on tribal people and no negative impact. The main ICDS interventions would, in fact, be quite beneficial to the tribal beneficiaries. The project, however, would seek to improve the ability of ICDS to serve tribal people even further by taking a number of steps related to community participation, the start-up of ICDS services in particular blocks, monitoring and evaluation, operations research, and by linking the project with actions to strengthen ICDS among tribal populations. 2.06 Measures were undertaken during project preparation to strengthen participation in the project by tribal people. Project design derives partly from NIPCCD recommendations in respect of ICDS operations in tribal areas as well as from a Bank-initiated review to: (a) make an indicative assessment of ICDS service quality to tribal people in the proposed project areas, and (b) explore methodologies for community participation during implementation. The three-part review comprised: (a) a survey and analysis of literature on the social, demographic and ethnographic characteristics of proposed tribal beneficiaries; (b) a Bihar and Madhya Pradesh field study on the reach and quality of ICDS services and beneficiary attitudes toward them in tribal areas, and (c) a workshop in each project state to verify the findings of the field study and evolve ways of strengthening participation in the project, particularly by indigenous people. The workshops involved tribal people and their leaders, non-government organizations working with tribal people, ICDS personnel and tribal specialists from academic and research institutions and government departments. D. Project Description 2.07 The project would support the strengthening of ICDS service delivery which includes growth monitoring, case management, food supplementation, pre- school education, health and nutrition education, immunization, and health check-ups and referrals. The project would also assist in improving the capacity of Bihar and Madhya Pradesh to deliver ICDS services more effectively - 17 - in the future. The project would comprise four components: service delivery, to strengthen training, work organization, supervision, and the supply of materials and equipment; communications through innovative approaches and new messages to increase demand for the full range of project services and provide health and nutrition education; community mobilization, to promote greater community "ownership' of ICDS services, and develop pilot schemes for women's income generation, adolescent girls' schemes and creche programs; and project management, monitoring and evaluation, including operations research to test innovative activities and improve aspects of project design such ast (a) improved work routines for supervisors and AWs, and (b) testing of options for therapeutic nutrition supplementation for children of different nutritional grade status. The project would also include an action program for strengthening ICDS among tribal populations. Service Delivery (US$211.7 million) 2.08 The project would concentrate on improving the effectiveness and efficiency of ICDS services ir. the project area by: (a) assisting in upgrading the quality of services in existing AWs; (b) providing an enhanced service package to new AWs in ICDS blocks which are currently underserved according to program guidelines; and (c) establishing new AWs also with an improved ICDS package for blocks in which ICDS is not yet active. A minimum target of 75X of population coverage within any block would be established for both states. This component would finance equipment, medicines, furniture, vehicles, civil works, consultant services and incremental operating costs. It is estimated that the cost of service delivery per beneficiary under the age of six is US$10 per year. 2.09 Improved Planning for the Introduction of ICDS. A Plan for the Introduction of Services (PIS) (Annex 8) would be followed for the introduction of each new block in both states. The purpose of the PIS is to ensure that the following are carried out in a well-planned, systematic manner: (a) all field positions from the district down to the AW are filled; (b) mapping of blocks is carried out to determine the number of new AWs; (c) training is carried out for all new staff; (d) community mobilization activities are satisfactorily implemented; and (e) adequate equipment and supplies are provided to the AW. At negotiations, Madhya Pradesh and Bihar provided assurances that they would prepare and, thereafter, implement Plans for the Introduction of Services for each new block covered with content satisfactory to IDA. 2.10 Expansion and Strengthening of AW. The provision of new AWs for existing and new ICDS blocks would be carried out on the basis of distance and population criteria. The project would finance the construction of about 11,000 AWs averaging about 450 sq.ft. The project would also finance civil works construction of block offices and food storage facilities in selected blocks in both states. At negotiations, Madhya Pradesh and Bihar provided assurances that they would select the location of AWs to be constructed under the project in accordance with criteria satisfactory to IDA, including adequate consultation with the concerned local communities. - 18 - 2.11 Deliver* of Supplementary Foods. Improvements in the delivery of supplementary foods would be achieved through the provision c additional storage facilities at the block and district levels, simplifications in the distribution system, and improved monitoring of food distribution by independent consultants. At negotiations, Madhya Pradesh and Bihar provided assurances that they would take necessary steps to make available to Anganwadip adequate supplemental food required for the carrying out of the project. 2.12 Support for Pre-School Education. Although considerable time is devoted to pre-school education, base-line studies and other studies suggest that its quality is uneven. The project would support initial provision and replenishment of educational toys and play materials at AWs. It would also promote use of a more interactive and participatory approach to education through AWW training; and through communications enhance the capacity of parents and other care givers to provide a stimulating environment at home. 2.13 Improving ICDS Supervision. The project would improve the quality of program supervision by strengthening in-service training (see para. 2.17) and through improved mobility by providing mopeds to field supervisors. The project would increase the amount of supervision by adding a block level supervisor with special responsibilities for organizing in-service trairing, communications and community mobilization activities. There are eristing shortages of ICDS personnel at the Supervisory and the Child Development Project Officer (CDPO) levels, and among health personnel at the field level in the existing blocks in both states. At negotiations, Madhya Pradesh and Bihar provided assurances that they would fill, in accordance with a staffing plan, including a time schedule satisfactory to IDA, all vacancies under ICDS and the health programs in the project blocks. 2.14 Improved Health-Nutrition Coordination. Cooperation between ICDS and family welfare workers in the field has improved in recent years. However, much more is needed to strengthen health-nutrition coordination. The project would support additional actions to reinforce and complement coordination activities in such areas as joint supervision, informal joint training, and harmonization of formal training curricula (Annex 5). 2.15 Pharmaceuticals. The project would finance only a modest addition of medicines to health centers and subcenters. These supplies would complement those provided under other Bank-financed projects in the states such as the Child Survival and Safe Motherhood Project. 2.16 Strengthening Operational Research. The project would support operational research for such areas as: (a) improved work routines for supervisors and AWWs; (b) testing of various options to therapeutic nutrition supplements of children in 14 blocks with different nutrition status; and (c) service delivery for scattered populations. Annex 12 contains a detailed discussion of proposed operations research, the important aim of which is to assist in refining key program areas. At negotiations, the states agreed on a program of operational research and provided assurances that they would carry out that research according to a timetable agreed with IDA and discuss the - 19 - findings of the research in a timely way after the completion of individual studies, including how the results of the study may be incorporated into the delivery of ICDS services. 2.17 Training. To strengthen the expansion of ICDS, the project would provide (a) orientation training to staff of 98 existing ICDS blocks (10,800 helpers, 10,800 AWWS, 750 Supervisors, 98 CDPOs) in Madhya Pradesh and 72 existing ICDS blocks (8,000 helpers, 8,000 AWWs, 550 supervisors, 72 CDPOs) in Bihar; (b) pre-service training to staff of 131 new ICDS blocks (16,375 helpers, 16,375 AWWS, 1,100 Supervisors, 131 CDPOs) in Madhya Pradesh and 135 new ICDS blocks (17,000 helpers, 17,000 AWWs, 1,150 supervisors, 135 CDPOs) in Bihar; and (c) annual in-service training to all the staff. In Bihar, special field-based training would be provided to those whose performance is found deficient after orientation training. Key areas of training for different categories of staff and how they would be organized are given in Annex 6. 2.18 To improve the quality of training, the project would strengthen training institutions and support curriculum review and development. The current ICDS pre-service training pattern is as follows: AWWs at AW Training Centers (ANTCs), supervisors at Middle Level Training Centers (MLTCs) and CDPOs at the National Institute of Public Cooperation and Child development (NIPCCD), which also provides training to trainers. NIPCCD recently carried out a national ANTC evaluation which indicated major differences among ANTCs in quality of training being imparted. Therefore, the project would support strengthening 35 and 26 ANTCs in Madhya Pradesh and Bihar respectively though training of trainers, provision of necessary equipment and supplies, review of their curriculum and implementation arrangements for field placement. In Bihar, an additional MLTC would be set up to handle the increased supervisory training load. 2.19 In-service training to improve program performance would be field- based and linked with program development by focusing on a few key themes. It would emphasize upgrading of technical and problem solving skills and would be conducted jointly for ICDS and health staff. Current refresher training is imparted to staff once in two years by the pre-service training institutions. However, this training is treated as residual after pre-service training obligations are met and remains ad hoc. The project would establish 26 mobile training teams each in Bihar and Madhya Pradesh with specially appointed staff. In collaboration with other district and block level staff and teams being established under the Bank-financed Sixth Population Project in Madhya Pradesh and the Seventh Population Project in Bihar, these teams will train supervisors, who in turn will train village level staff under a team's guidance. The senior block level supervisor would be responsible for organizing these activities at the block level. 2.20 In both states, curriculum preparation, material development, and planning and monitoring of training activities would be the responsibility of project management cells under the project coordinators. To ensure that training is both relevant and effective, the project would also support - 20 - frequent training of trainers and technical assistance for curriculum review and development. Provisions would be made for the introduction of participatory techniques for mobile training teams by qualified NGOs. Communications (US$10.2 million) 2.21 The communications component would consist of the development of a sound data base, the development of a communications strategy, the use of creative skills to implement the strategy, production of materials such as slides, tapes, posters, and the selection of appropriate media and identification of target groups (Annex 9). Knowing the audience is a prerequisite to successful communications. The coverage of tribal areas in Bihar and Madhya Pradesh makes it all the more necessary that a comprehensive and current data base be used to develop this component. There is a need for both quantitative and qualitative data collection including information on signs, symbols, festivals, rituals and taboos. The communications strategy would be particularly important for reaching pregnant and nursing women. 2.22 Communication strategy development which will take place during the first year of the project would address such issues as the selection of the target audience, the setting of objectives for each target audience, the selection of the broad approach with which each would be pursued. There are six main groups to be reached under this component: mothers of children between 6 and 36 months, mothers of children botween 3 and 6 years, pregnant women, potential mothers (adolescent girls) and older women. To be effective, communication must attract attention and generate involvement. Creative inputs can make a significant difference in the quality of the impacts of the communications component. 2.23 The communications strategy, message development and assistance in implementation would be undertaken by a professional consulting firm with experience in communications, mass media and social marketing. A condition of credit effectiveness would be that Madhya Pradesh and Bihar would have appointed consultants with qualifications and terms of reference satisfactory to IDA, to assist in carrying out the communication components. At negotiations, the states provided assurances that a communications strategy would be completed and sent to the IDA for review and approval by October 1, 1993, and that they would thereafter implement such strategy, as agreed with IDA. The project would finance a contract for publicity services which would cover the development of a strategy and specific messages and, pretesting of these messages. It would also finance IEC materials and equipment. Community Mobilization (US$7.9 million) 2.24 To ensure effective delivery and sustainability of the program at village level, the project's community mobilization activities would aim at promoting community "ownership" of ICDS services and encouraging individual and community self-reliance. Currently, community participation is low in both states. ICDS largely relies on formation of women's groups such as Mahila Mandals (MMs). However, these are generally dormant. In Bihar, only half of the existing AWs have established MMs. TINP and other experiences - 21 - show that women's groups can be very effective in gaining community support for project activities. The project would support pilot schemes to develop a system for establishing and sustaining village level groups. 2.25 To continue the search for effective means for community mobilization, the project would encourage pil,t schemes to (a) provide a clearer definition of what can be realistically achieved through increased community mobilization; (b) involve NGOs in the design, planning and implementation of community mobilization activities to take advantage of their successful experiences in this area; (c) provide models which would be replicable on a large scale in such areas as women's income generation, adolescent girls' schemes and creche programs; and (d) develop innovative approaches to integrating other women's activities at the village level. At negotiations, Madhya Pradesh and Bihar provided assurances that they would furnish proposals for the pilot schemes according to timing and criteria agreed with IDA. They also provided assurances that they would select NGOs to assist in carrying out the project, in accordance with criteria and procedures satisfactory to IDA. These criteria and procedures would ensure the transparency of the role of NGOs in the project and the selection procedures. The project would finance consultant and NGO services, equipment, and incremental operating costs. Project Management, Monitoring and Evaluation (US$19.0 million) 2.26 Project Management. A project management cell (PMC) in each state will be headed by an Additional Director drawn from the Indian Administrative Service as Project Coordinator (PC). He or she would report to the state Director, ICDS, and would be in charge of day-to-day project activities. Current fiscal stringency dictates that only an absolute minimum of new staff positions be added. However, to reflect the increasing technical demands of expansion in scope and range of ICDS services, professionalization of state levei management teams is necessary. Therefore, the project, in each state, would support a core PMC group consisting of a nutritionist, a communications specialist, a sociologist/anthropologist with experience in tribal areas, and a training specialist. The PMC would also include an ICDS Plus Unit which would consist of persons trained in .ommunity organization and technical specialists. The Unit will consist of at least two persons located at the PMC headquarters and at least one person located in a minimum of ten district headquarters. The Unit would be responsible for implementing the community mobilization component and the strategies for strengthening ICDS among tribal populations. At negotiations, Madhya Pradesh provided assurances that it would establish a regional directorate, with staffing, facilities, and terms of reference satisfactory to IDA to assist in the implementation of the project in the eastern parts of that state, in which there are several difficult tribal districts. At negotiations, the states provided assurances that they would establish and thereafter maintain an Empowered Committee (EC), chaired by the Chief Secretary and comprising the Secretaries responsible for ICDS, Health and Finance. The committees would approve plans, issue necessary government sanctions for implementation, review the annual implementation plans, and monitor their progress. The EC would be expected to meet on a quarterly basis. The PC would be a Member-Secretary of the EC. The project would finance vehicles, equipment, office furniture, incremental operating - 22 - costs, and consultant services. A Condition of Credit Effectiveness would be that the Governments of Madhya Pradesh and Bihar would establish, with adequate staff, Project Management Cells. 2.27 District Management. As ICDS expands, need for coordination with health, education and other departments, managerial requirements of planning, monitoring, personnel and logistics, and implementation of enhanced communication and community mobilization, all require that district level management be strengthened. The project would support establishment of 17 offices in Madhya Pradesh and 13 offices in Bihar to cover the districts without such offices. All district officers would be trained in planning and management, and guidelines would be developed for their functioning. In collaboration with the project-supported district training teams, these district offices would: prepare district plans in coordination with the health system; monitor performance, enable, empower and motivate service providers through continuing in-service training and ensuring the provision of supplies; and implement the project's communication and community mobilization activities. 2.28 Monitoring and Evaluation. Service statistics would be used to monitor coverage by various services and provision of project inputs. A revised ICDS reporting system is currently being implemented in both the states. It would be adapted to reflect a wider range of services such as the communication and community mobilization activities of the project. However, the main difficulty is the lack of use of this data by program managers for monitoring and taking corrective actions. A USAID-assisted ICDS project has developed a computerized progress reporting system which can provide feedback to program managers on a variety of performance indicators as well as time- series and cross-sectional comparisons. The project would support implementation of this system in both states. Supervisors would be responsible for improving the reliability of data. They would carry out sample checks of field records, train those AWWs who are deficient in record keeping and annually share AW performance data with the community. The project would finance consultant services. 2.29 The first ICDS project includes operations research on supplementation, field-based in-service training, nutritional rehabilitation centers, work routines and supervisory practices, communication and community mobilization, all of which would be evaluated by mid-term. A process of linked annual reviews is planned for both the first and second project states where lessons learned in a state can be shared with others. 2.30 Base line surveys have been carried out in the project areas (Annex 1). Annual and mid-term evaluations to assess progress are planned with the latter taking place in the third year of the project (Annex 11). These evaluations would provide an opportunity to make any necessary mid- course corrections. The annual and mid-term reviews would evaluate ICDS in terms of nutritional status of children under 3, availability of services, community perceptions of ICDS, procurement, logistics, budget releases and the implementdtion of ICDS in tribal areas. A final evaluation would be carried out at the end of the project (Annex 11). At negotiations, Madhya Pradesh and Bihar provided assurances that they would carry out annual and mid-term - 23 - reviews and final evaluations of project operations and provide the final reports to IDA for review; the Government of India provided assurances that it would participate in the carrying out of these reviews and evaluations. 2.31 Indigenous Peoples. The project is expected to have a positive impact on the tribal populations in the project area. Where ICDS already exists in tribal areas, there is demand for its services (Annex 3). This project does not include an indigenous people's development plan. However, measures, including actions set out in "Strategies For Strengthening ICDS Among Tribal Populations' (Annex 17 of the Staff Appraisal Report), were agreed on to ensure that the project is implemented in a manner compatible with the social and cultural values of tribal communities, and includes the informed participation of tribal beneficiaries. Assurances were received at negotiations that the project would be implemented in accordance with the Strategies, which include (a) strengthening community participation of tribal beneficiaries and the implementation of ICDS in remote areas, (b) the introduction of training programs developed for tribal personnel employed by ICDS and (c) the development of a data base on tribal groups covered under the project. The design of monitoring and evaluation instruments would capture differences in process and impact indicators among tribal and non-tribal groups. In order to provide for the informed participation of tribal communities during implementation, at negotiations, Bihar and Madhya Pradesh provided assurances that district and block level ICDS coordination committees would be established or reconstituted to provide adequate representation for tribal communities and that these committees would provide advice on and monitor the implementation of ICDS among tribal populations in the two sates. To assist the state governments in ensuring that the project takes account of tribal social and cultural values during implementation, the Government of India at negotiations provided assurances that it would establish a panel of advisors of national repute in nutrition, maternal and child health and social sciences related to tribal affairs by December 31, 1993, to review annually project implementation in tribal areas in both states and discuss the results with IDA, including proposed steps resulting from the review. 2.32 In Madhya Pradesh, a special regional directorate for implementation is being established under the project to deal with problems of sparsely populated tribal areas in the eastern part of the state. Lessons learned from this center will be applied to the program in other parts of the project areas. The ICDS Plus Unit in the PMC would have primary responsibility ,or implementing the actions for strengthening ICDS among tribal populations under the direction of the PC. III. PROJECT COSTS, FINANCING AND IMPLEMENTATION A. Cost Estimates 3.01 Cost Summaries. The total cost of the project, net of duties and taxes is estimated at about Rs. 7449.1 million or US$244.1 million equivalent. Duties and taxes are around US$4.7 million. A breakdown of costs of the proposed project by component and categories of expenditure appears in Tables 3.1 and 3.2, respectively. Detailed project costs by component, categories of expenditure and year appear in Annex 13. - 24 - Table 3.1: Costs by Component Components Local Foreign Total Local Fore gn Total -----Rupees (millions)----- -----US B (millions)… A. Servce Deltv-ry 1. Nutrition 8538.5 288.9 8819.8 186.0 10.6 145.8 2. Health 414.7 96.7 610.4 16.8 a.7 19.6 8. Training 299.8 16.8 816.4 11.4 0.6 12.0 Subtotal 4260.8 894.8 4e46.6 182.2 16.1 177.8 S. Communications 203.1 18.5 219.6 7.8 0.6 8.4 C. Community Mobilization 183.0 4.7 187.7 7.0 0.2 7.2 D. Projct Mansement 1. ProJect Organization 800.9 82.2 883.1 11.6 1.2 12.7 2. Monitoring A Evaluat. 8.6 0.6 9.0 0.8 0.1 0.4 8. Operations Research 64.4 14.2 78.8 2.6 0.6 8.0 Subtotal 873.8 48.9 420.7 14.8 1.6 16.1 TOTAL BASELINE COSTS 5010.7 482.9 6478.8 191.8 17.7 209.0 Physical Contingencies 884.5 44.6 879.0 12.7 1.7 14.4 Price Contingencies 1680.1 168.3 1788.4 28.0 2.4 26.4 TOTAL PROJECT COSTS 6925.8 665.7 7591.0 227.0 21.8 248.8 NOTE: Inclusive of taxes and duties estimated at US14.7 million equivalent. Figures may not add due to rounding. Table 3.2: Costs by Categories and Expenditures local Foreign Total Local Foreign Total ----- Rupees (millions)----- - m (mi Ions) - I. INVESTMENT COSTS A. Civil Works 818.0 76.8 888.8 23.4 2.9 26.8 B. IEC Materials 72.8 9.9 82.2 2.7 0.4 8.1 C. Furniture 26.8 2.6 27.8 1.0 0.1 1.1 D. Equipment 268.4 35.5 291.4 9.8 1.8 11.1 E. Vehicles 182.1 18.0 178.1 8.2 0.8 8.8 F. Medicines 403.6 100.9 604.6 16.4 3.9 19.8 0. Training 289.8 16.2 304.6 11.0 0.8 .116 H. Publicity 126.8 8.7 188.8 4.8 0.8 5.1 I. NGO A Consultants 114.4 8.0 120.4 4.4 0.2 4.6 Services TOTAL INVESTMENT COSTS 2088.0 268.0 2881.0 78.7 10.8 89.0 ______ ----- ------ ---- ---- ---- II. INCREMENTAL RECURRENT COSTS A. Salaries 2869.6 0.0 2869.6 101.5 0.0 101.5 B. Office Supplies 126.6 8.6 182.1 4.8 0.2 6.0 C. Petroleum, Oil, Lub. 20.1 180.8 200.9 0.8 6.9 7.7 D. Incremental Operating 142.6 7.5 160.0 5.4 0.8 6.7 Costs TOTAL RECURRENT COSTS 2947.7 194.9 8142.6 112.5 7.4 119.9 TOTAL BASELINE COSTS 6010.7 482.9 6478.8 191.8 17.7 209.0 Physical Contingencies 884.5 44.5 879.0 12.7 1.7 14.4 Price Contingencies 1680.1 168.8 1738.4 28.0 2.4 26.4 TOTAL PROJECT COSTS 6926.3 866.7 7691.0 227.0 21.8 248.8 NOTE: Inclusive of taxes and duties estimated at US34.7 million equivalent. Figures may not add due to rounding. - 25 - 3.02 Basis of Cost Estimates. Estimated costs for civil works of Rs. 180-220 per square foot are based on current unit costs of construction. They are comparable to the costs of similar IDA assisted construction in India. Costs of therapeutic nutrition supplementation and other consumables are based on state estimates and reflect current prices. Estimated costs for incremental staff salaries and other operating costs are based on current pay scales and norms used by the government of Madhya Pradesh and Bihar. 3.03 Contingency Allowances. Estimated project costs include physical contingencies estimated at 10? for all physical items and 5? for incremental operating costs, salaries, training and consultants. Price escalation contingencies are estimated as followst for civil works, goods, salaries, and technical assistance-- foreign costst 3.7? in CY92-99; local costs: 10.5t in CY92 8.52 in CY93, and 7.5? in CY94, and 6.5? in CY95-96, 5.0Z in CY97-99. 3.04 Foreign Exchange Component. The estimated foreign exchange component of US$21.8 million is calculated on the basis of estimated foreign exchange proportions as follows: (a) civil works 11Z; (b) furniture and vehicles 9Z; (c) petroleum 90Z; (d) equipment 12?; (e) medicines 20X; (f) training, communication and operating costs at 5?. B. Financing Plan 3.05 The estimated total project cost of US$244.1 million net of duties and taxes would be financed by an IDA credit of SDR 141.6 million (US$194.0 million equivalent) which would cover 84Z of costs net of duties and taxes. The GOI would finance US$54.8 million equivalent to cover remaining project costs including taxes estimated at US$4.7 million equivalent. Cost recovery is not considered feasible because most of the beneficiaries are from households near or below the poverty line. Because the project would support primarily software inputs, recurrent costs account for 57? of total base costs. C. Recurrent Cost and Sustainability Implications 3.06 The GOI presently allocates about 0.8? of GDP to the social sectors. GOI spending on ICDS is about 72 of total GOI social sector spending. By 1997, the GOI would have to increase its budget on ICDS by 9? over present levels to sustain its part of the proposed project. Bihar and Madhya Pradesh now spend about 20 billion rupees per year each on the social sectors, of which less than 1? goes for ICDS. Bihar would have to triple its funding of ICDS to sustain its part of the proposed project. Madhya Pradesh would have to increase by 50? its funding of ICDS to do the same. On the face of it, the project would require quite significant increases in the absolute amount of funding for ICDS which GOI and the states are providing. Nonetheless, the proposed project should be sustainable for several reasons. First, the proposed increases in funding of ICDS would still be an extraordinarily small share of the total GOI and state budgets. Second, the GOI is in the process of carrying out an adjustment process as a part of which it plans to enhance the access to and the effectiveness and efficiency of basic social services. Thus, between now and the full operation of the project, it is anticipated that GOI and the states would have an opportunity to shift resources from - 26 - areas in which the government's role is declining toward programs like ICDS. The GOI FY92/93 budget, for exan:ple, includes an increase in funding for ICDS. Third, related to the adjustment process, GOI is developing a Social Safety Net program and it is anticipated that this program will include additional efforts to enhance ICDS funding. Finally, IDA and GOI are now collaborating on a review of health financing, and a review of nutrition financing is just getting started. The outcomes of these reviews should point to additional measures that can be taken to strengthen the funding of ICDS. D. Project Preparation and Implementation 3.07 Preparation Status. ICDS is a well established program in India with clear guidelines provided to the states by the central government. Thus, the design of most project software systems for the proposed project is well advanced in both states. A considerable amount of preparation of other activities has been undertaken. Settlement mapping and a functional task analysis of ICDS and health workers have been completed in Madhya Pradesh, and baseline studies of nutrition status and communications have been completed in Bihar. Plans have been developed for supplemental feeding procedures, training and the rationalization of drug lists. Standard bid documents which have been approved by the Bank for use in other social sector projects, will be utilized. There will be less than 102 for civil works in the project. Key staff for the project management cells have been identified and the Empowered Committees for both states have been established. 3.08 As noted earlier, there are a number of activities in which the aim of the project is to develop improved approaches. These include: communications strategy, approaches to supplementation, efforts at community mobilization, and the refinement of work routines for supervisory staff. In each of these areas, the strategies for carrying out the work are being developed. 3.09 Implementation. Implementation pace, which drives project phasing, is a product of several important factors. These include recruitment and posting time for workers, supervisors and CDPOs; capacities of training institutions; lead times for supplies and equipment; and the time needed to introduce ICDS services to benefitting communities. Based on an assessment of implementation capacities in each state, and the project's proposed modifications in service delivery software, the implementation phasing envisages establishing 4,800 and 3,170 new AWs each year in Madhya Pradesh and Bihar respectively for the first three years of the project, and the remaining 1,975 new AWs in Madhya Pradesh blocks in the fourth year of the Project. At negotiations, Madhya Pradesh and Bihar provided assurances that they would review with IDA annually by December 31 each year the progress of project implementation over the preceding twelve months and an annual implementation plan for the next twelve months and that they would then carry out that plan. The Government of India provided assurances that it would participate in the reviews. The project would be supervised according to an agreed plan (Annex 16). - 27 - 3.10 Role of Non-Governmental Organizations (NGOs). In both states, the number of NGOs available to work with the project authorities and beneficiaries is limited. The NGO base in Madhya Pradesh is particularly weak, especially in the tribal areas included in the project. Under the national ICDS program, NGOs are encouraged to take up service delivery in whole blocks or to provide training for ICDS staff. NGOs will be utilized under the project in both these areas. In addition, NGOs will be encouraged to assist the project in developing pilot schemes for women's income generating activities, schemes for adolescent girls and creche programs. They would also become involved in the difficult task of group formation at the village level for the community mobilization aspects of the ICDS program. NGOs may also become involved in the communications component of the project. The selection of NGOs and the monitoring of their involvement in the project would be the responsibility of the ICDS Plus Unit in the PMC. E. Disbursements 3.11 Disbursement Percentages. The project would disburse against 100Z of t:e casts of training, publicity services, NGO and consultant services; 90Z of :`vil works; 1002 of CIF and of local ex-factory cost and 80% of other local expenditures on furniture, equipment, IEC materials, vehicles, and medicines; and 75Z of local incremental operating costs. These comprise salaries of new staff to be added as project services intensify and expand, additional office supplies, and vehicle and equipment operating and maintenance costs, including petroleum, oil and lubricants. The percentage of incremental operating costs to be disbursed by the Bank is equivalent to 90% for the first year they are incurred, reduced by around an additional 5% in each succeeding project year up to 1998 and 23Z in 1999. 3.12 Required Documentation. Disbursements in respect of: (i) expenditures under contracts valued at less than US$50,000 equivalent for civil works, furniture, equipment, IEC materials, vehicles, medicines, and training; and (ii) all incremental operating costs would be made against statements of expenditure certified by WCD and the project coordinators in the two states. Documents would be retained by the respective state governments for IDA review during supervision missions. All other disbursements would be made against fully documented withdrawal applications. 3.13 Special Account. In order to accelerate disbursements in respect of IDA's share of expenditures pre-financed by GOI and the concerned states and in order to allow for direct payment of other eligible local and foreign expenditures, a Special Account would be opened in the Reserve Bank of India with an authorized allocation of US$9.0 million equivalent to cover four months' expected disbursements for IDA-financed items. 3.14 Retroactive Financing. Up to SDR 1.5 million (US$2.0 million equivalent) is provided to cover eligible expenditures incurred in implementing appraised project activities after November 30, 1991. Items such as mapping of blocks, communication consultancy, pre-service training, and NIN baseline surveys were reviewed and found appropriate for retroactive financing. - 28 - 3.15 Disbursement Profile. The proposed IDA credit would be disbursed over a seven year period consistent with IDA Group profile for nutrition projects. The profile is realistic in this case because (a) experienced institutions are in place in both states to implement the project; (b) implementation in any one year is on a scale which both states previously have managed; and (c) most of the new blocks would be established and civil works would be completed in the first five years of project operations. The project period therefore encompasses not only the time required to cover new areas but also includes a lengthy operational period. The latter would allow expanded service coverage, improved quality of services and supplementation procedures, and communication, community mobilization and training to have significant impact on nutrition and health status of children under three years of age and pregnant and nursing women. The project is expected to be completed by March 31, 2000, and the credit is expected to be closed on September 30, 2000. A forecast of annual expenditures and disbursements is shown in Annex 15. F. Procurement 3.16 Project-related procurement would be managed by the PMU in each state, following procedures acceptable to IDA. Project-financed consultants would be selected according to the procedures in IDA's Guidelines for the Use of Consultants by World Bank Borrowers. 3.17 Civil Works (US$31.4 million). The main civil works in the project consist of about 7000 new AW Centers costing less than the equivalent of US$4,000 each including contingencies. These are small, widely-dispersed buildings in remote areas for which neither foreign firms nor many local contractors are expected to be interested in competing for construction. In addition, it is proposed to use existing low-cost construction techniques for these buildings. Therefore, the civil works would be carried out through a combination of force account and LCB. In Madhya Pradesh, the procurement would be handled by the Rural Engineering Services (RES) part of the Department of Rural Development, and in Bihar by the Sone Command Area Development Agency (SCADA). Contracts for civil works estimated to cost US$50,000 or more each up to an aggregate of US$11.0 million would be let through LCB procedures, which are satisfactory to IDA. Contracts estimated to cost less than US$50,000 each up to an aggregate of US$20.4 million, would be carried out by force account. Standard Bidding Documents for the procurement of civil works developed under the Second Technician Education Project, already approved by both states, would be used for bidding. 3.18 IEC Materials, Office Supplies and Equipment would be procured on an annual basis in accordance with the phasing of project activities. Equipment would be mainly of three types: utensils and other minor items for Community Nutrition Centers, typewriters and other office equipment for block and higher-level nutrition offices, and equipment for health facilities. IEC materials would be mainly publications, mass media materials, pamphlets, and education materials. Because of the phasing and diversity of items to be procured, they are not suitable for ICB and it is not expected that any individual contract would approach US$200,000 equivalent. Therefore, contracts for equipment estimated to cost US$50,000 or more each up to an - 29 - aggregate of US$10.4 million, and for IEC materials and office supplies estimated to cost US$50,000 or more each up to an aggregate of US$7.2 million would be awarded through LCB. Contracts for equipment and for IEC materials and office supplies estimated to cost less than US$50,000 up to an aggregate of US$2.7 million and US$3.0 million, respectively, would be awarded through prudent shopping over the project implementation period of 7 years for 436 blocks under the project. 3.19 Medicines (US$20.7 million) are at present purchased at the district level from government stores at low prices and if not available, they are purchased from market stores. The First Integrated Child Development Services Project has demonstrated that International Competitive Bidding (ICB) for the procurement of medicines has failed to generate any participation from foreign firms. There are several factors that discourage the use of ICB, in particular: (a) procurement of medicines is decentralized to the district level to ensure both timely resupply to a dispersed network of village facilities and availability of a mix of medications which meet seasonal and less predictable local variations in demand; (b) medicines are ordered in small quantities at a time; and (c) the frequency of resupply is influenced also by a short shelf life resulting from fairly rudimentary storage conditions in rural areas. Therefore, ICB is not recommended for the procurement of medicines as it will not interest foreign bidders. Contracts would be bulked insofar as possible into packages for bulk procurement and awarded through local competitive bidding (LCB) open to foreign participation. Contracts for the purchase of medicines estimated to cost US$50,000 or more each up to an aggregate of US$12.4 million would be awarded through LCB procedures. Contracts valued at less than US$50,000 equivalent up to qn aggregate total of US$8.3 million over the project implementation period could be procured through prudent shopping, with solicitation of price quotations from at least three suppliers. Therapeutic supplementary nutrition totalling US$3.0 million which is included in the total costs for medicines, for 14 blocks under operations research would be procured through prudent shopping. 3.20 Vehicles (US$8.0 million). Procurement of 4-wheel drive vehicles and mopeds mainly for rural use, would be spread over the disbursement period to match the introduction or upgrading of project services and replacement schedules. As project services are being phased over seven years, the small number of vehicles procured at any one time is not likely to attract bidders to compete. Therefore, vehicle contracts would be awarded through prudent shopping. 3.21 Furniture (US$1.2 million) is readily available from local manufacturers and foreign firms are unlikely to bid. Furniture orders would be bulked to the extent possible for LCB procurement. Contracts for the purchase of furniture estimated to cost over US$50,000 each up to an aggregate of US$0.4 million will be awarded through LCB procedures. Contracts estimated to cost less than the equivalent of US$50,000 up to an aggregate amount of US$0.8 million equivalent may be awarded on the basis of prudent local shopping. - 30 - 3.22 Contracts for Hiring of Consultants would be awarded according to IDA Guidelines for the Use of Consultants. Advertisement/publicity services for mass awareness would be procured directly from the Ministry of Information's radio and television stations through procedures satisfactory to IDA. NGO services would be procured in accordance with procedures satisfactory to IDA. 3.23 Bank Review. Contracts for civil works, equipment, vehicles, furniture, IEC materials and medicines estimated to cost US$100,000 equivalent or more also would be subject to prior IDA review and approval. Contracts valued about US$50.0 million representing about 522 of the total value of procurement would be subject to prior review over the procurement period. 3.24 The table below summarizes the project elements and their estimated costs and proposed methods of procurement. Table 3.3: Summary of Proposed Procurement Arrangements (US$ million) …--------------------------------------------------------------__------------__-- Project Element Procurement Method Total ICa LCB Other N.S.F Costs …----------------------------------------------------------------__----------__-- 1. Works 1.1 Civil Works - 11.0 20.4 - 81.4 - (17.4) (9. 3) - (26.7) 2. Goods 2.1 Equipment - 10.4 2.7 - 1. 1 - (8.8) (2.3) - (11. 1) 2.2 Vehicles - - 8.0 - 8.0 - - (8.4) - (8.4) 2.3 Furniture - 0.4 0.8 - 1.2 - (0.4) (0.6) - (1.0) 2.4 Medicines - 12.4 8.8 - 20.7 - (11.2) (7.5) - (18.7) 2.6 IEC Materials - 3.4 0.6 - 8.9 - (2.7) (0.4) - (8.1) 3. Training/Technical Assistance 8.1 Local training - - 13.2 - 18.2 _ _ (13.2) - (13.2) 8.2 Publicity, NGO and - - 14.4 - 14.4 Consultants Services - - (14.2) - (14.2) 4. Miscellaneous 4.1 Incremental Salaries - - 120.1 - 120.1 _ _ (84.0) - (84.0) 4.2 Office Supplies - 3.8 2.6 - 6.8 - (2.6) (1. 8) - (4.4) 4.8 Incremental Operating - - 16.6 - 1686 Costs - - (11.2) - (11.2) TOTAL - 41.4 207.4 248.8 - (43.1) (160.9) (194.0) …------------------------------------------------------------__--------------__- N.B.F.: Not Financed by IDA. NOTE: Figures in parentheses are the respective amounts financed by the IDA Credit. - 31 - G. Accounting and Auditing 3.25 The project would be subject to normal GOI accounting and auditing procedures which are considered satisfactory to the Bank Group. The project cell would maintain separate project accounts and a quarterly statement of expenditures would be provided to the Bank Group. At negotiations, GOI, Madhya Pradesh and Bihar provided assurances that: (a) accounts and financial statements including those for the special account for each fiscal year would be prepared and audited by independent auditors acceptable to the Bank Group; (b) statements of expenditures (SOEs) would be maintained in accordance with sound accounting practices for at least one year after the completion of the audit for the fiscal year in which the last withdrawal was made and a separate opinion on SOEs be included in the annual audit; and (c) certified copies of the audited accounts and financial statements for each fiscal year, together with the Auditor's report would be furnished to IDA as soon as available, but not later than nine months after the end of each fiscal year. IV. BENEFITS AND RISKS 4.01 Benefits. The main benefit of the project would be to speed up the currently very gradual pace of improvement in pre-school nutrition status in project areas. The project also would contribute to a faster reduction in infant and child mortality. In the last year of the project alone, around 4.0 million pregnant and nursing women and around 12.0 million children under 6 years of age would benefit directly from project nutrition, health and education services. Technologies to counter low birth weight, acute respiratory infections and micronutrient deficiencies, to manage diarrhea and for deworming would be more widely available through the project. By increasing family competence to avert and treat malnutrition, the project would contribute over the longer-term to a reduced need for ICDS food supplementation. 4.02 Risks. Because the project is being carried out in two of India's poorest states, and among some of its poorest people, it will not be an easy one to implement. In addition, it would face three particular risks. The first risk is that training and institutional shortfalls, especially in Bihar, would delay implementation. To reduce that risk, the project management staff would be appointed as a condition of effectiveness. Empowered committees would also be established in both states. The second risk is that additional responsibilities will continue to be imposed on AW staff without due regard to existing workloads and that efforts to focus workers more on case management of malnourished children and improved household food behavior will be largely offset by the continuation of suboptimal supplementary feeding criteria. The full extent of the worker focus/behavioral risks will become evident by mid- term review of the first ICDS project in 1993. Corrective measures resulting from that review also would be applied to the proposed project. The third risk is that nutrition-health coordinating arrangements will fail to take adequate hold. This risk can be reduced by efforts to strengthen such coordination based on analysis of the efficacy of those arrangements as part of the regular monitoring and annual review process, which would include special monitoring of the impact of the project on tribal people. - 32 - V. AGREEMENTS REACHED AND RECOMMENDATIONS 5.01 Two conditions of effectiveness would be that both states would: (a) appoint consultants with qualifications and terms of reference satisfactory to IDA to assist in carrying out the communication component (para. 2.23); and (b) establish, with adequate staff, a Project Management Cell (para. 2.26). 5.02 At negotiations, the Government of India provided assurances that it would: (a) establish a panel of advisors of national repute in the fields of nutrition, maternal and child health, and the social sciences related to tribal affairs by December 31, 1993, to review annually the implementation of the project in tribal areas and shall discuss the results of these reviews with IDA, including the steps to be taken as a result of them (para. 2.31); (b) participate in the carrying out of the annual and mid-term reviews and the final evaluation and review the progress of project implementation and annual implementation plans for both states (para 2.30 and 3.09); and (c) maintain statements of expenditures in accordance with sound accounting practices for at least one year after the completion of the audit for the fiscal year (para. 3.25). 5.03 At negotiations, Madhya Pradesh and Bihar provided assurances that they would: (a) prepare and thereafter implement Plans for the Introduction of Services for each new block covered under the project with content satisfactory to IDA (para. 2.09); (b) select the location of AWs to be constructed under the project in accordance with criteria, including adequate consultation with the concerned local communities, satisfactory to IDA (para. 2.10); (c) take necessary steps to make available to Anganwadis adequate supplemental food required for carrying out the project (para. 2.11); (d) fill all vacancies under the ICDS and health programs in the project blocks according to a staffing plan, including a time schedule, satisfactory to IDA (para. 2.13); (e) carry out on a program of operational research according to a timetable agreed with IDA and discuss the findings of that research in a timely way after the completion of individual studies, and incorporate the agreed results into the delivery of ICDS services (para. 2.16); (f) by October 1, 1993, prepare and furnish to IDA a report on a communications strategy with format and content satisfactory to IDA, and shall thereafter implement the strategy, as agreed with IDA (para. 2.23); - 33 - (g) furnish proposals for pilot schemes that would be involved in the project according to timing and criteria agreed with IDA (para. 2.25); (h) select and engage NGOs, in accordance with criteria and procedures satisfactory to IDA, to a3sist in carrying out the project (para. 2.25); (i) maintain an Empowered Committee, chaired by its Chief Secretary and comprising its Secretaries responsible for ICDS, health and finance and the Project Coordinator, to coordinate administrative decision making necessary for the timely implementation of the project (para. 2.25); (j) Madhya Pradesh would establish a regional directorate in its Department of Women and Children, with staffing, facilities, and terms of reference satisfactory to IDA to assist in the implementation of the project in the eastern parts of that state (para. 2.26); (k) carry out annual, mid-term and final evaluations of project operations and provide the final reports to IDA for review (para. 2.30); (1) implement the project in accordance with Strategies for strengthening ICDS among tribal populations (para. 2.31); Cm) establish or reconstitute district and block level ICDS coordination committees to provide adequate representation for tribal communities and that these committees would advise on and monitor the implementation of ICDS among tribal populations (para. 2.31); (n) review with IDA annually by December 31 each year the progress of project implementation over the preceding twelve months and an annual work plan for the following twelve months, which it shall thereafter carry out (para. 3.09); and (o) prepare accounts and financial statements including those for special accounts for each fiscal year which would be audited by independent auditors acceptable to IDA; and furnish to IDA certified copies of the audited accounts and financial statements for each fiscal year not later than nine months after the end of each fiscal year (para. 3.25). 5.04 With the above assurances, the proposed project constitutes a suitable basis for an IDA credit of SDR 141.6 million (US$194.0 million equivalent) to India at standard IDA terms with 35 years maturity. - 34 - Annex I Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT ICDS PERFORMANCE IN THE PROJECT AREAS 1. A service delivery study using survey and qualitative methodologies was carried out by the National Institute of Nutrition (NIN) in the project areas of Madhya Pradesh and Bihar to (i) establish base line for nutritional status of children and their coverage by various services; (ii) understand existing health and nutrition behavior practices of the targeted beneficiary groups. Besides establishing base line, the findings of this study also informed the design of the project activities and are summarized below. 2. For the survey, six districts from the project area were selected in each state. In each selected district, a block was chosen where ICDS had been in operation for 3 or more years and a second block was chosen where ICDS had not yet been started. In each block, 10 villages were chosen for assessing nutritional status. In each village, about 10 households were randomly selected which contained targeted beneficiaries for structured interview. Two of the 10 villages were also selected for qualitative study of providers and consumers. Due to operational problems, the survey could cover only 2 ICDS and 5 non-ICDS blocks in Bihar. However, the study was carried out as planned in Madhya Pradesh. 3. Tables 1 and 2 show distribution of children according to nutrition grade status using Indian Academy of Paediatrics Classification. It uses the 50th percentile of the internationally accepted Harvard standard as its weight for age standard and classifies nutrition status as follows: more than 80 percent of standard weight for age as normal, between 71 and 80 percent as mild (grade I) malnutrition, between 61 and 70% as moderate (grade II) malnutrition, and below 60 percent as severe malnutrition (between 51 and 60% as grade III and below 50% as grade IV). 4. The base line survey shows that overall nutrition status in the ICDS areas is no better than that in non-ICDS areas. Although socio- economically more disadvantaged, having been selected for earlier ICDS implementation, ICDS has helped them achieve the nutrition status levels similar to those in other areas. However, even after several years of operations, around 8% children <2 years of age are severely malnourished (grade III and IV). Clearly reduction of severe malnutrition is an important priority for reducing the prevalent high infant mortality. The proportion of moderately malnourished children <6 years of age (grade II) was 24.6 in ICDS and 21.6% in non-ICDS areas respectively. Only about a third of children have normal nutrition status. 5. In Bihar, ICDS reduces the extent of severe malnutrition as well as improves overall nutrition status, but the malnutrition levels remain high. Base line data from the proposed project areas suggests that 1 in 10 children - 35 - Annex 1 Page 2 suffers from severe malnutrition (grade III and IV) in ICDS areas and 1 in 8 in non-ICDS areas. A third of the children <6 years of age are moderately malnourished (grade II). Only about a fifth of the children had normal nutrition status. Children between 1 and 2 years of age are the most vulnerable, no less than 21.42 in non-ICDS and 14.92 in ICDS areas were severely malnourished. Nutritional Status in Madhva Pradesh Areas Table 1. Distribution of Children According to Nutritional Grade ICDS Area (4620 children) Nutritional Age in Years (Grade) c1 1-2 2-3 3-4 4+ Pooled ----------------------------------------------------------------- Normal 40.2 29.7 29.4 32.1 26.3 31.1 Mild (I) 30.1 38.6 35.5 38.2 45.0 37.8 Moderate (II) 21.2 24.0 27.5 24.1 25.2 24.6 Severe (III) 6.2 6.6 7.0 4.7 3.3 5.5 Severe (IV) 2.3 1.0 0.7 0.9 0.3 1.0 Non-ICDS Area (4783 children) Normal 40.9 27.5 30.7 34.4 30.3 32.5 Mild (I) 29.3 41.4 34.7 39.2 50.2 38.8 Moderate (II) 18.1 19.9 27.7 22.8 17.6 21.6 Severe (III) 8.9 8.8 5.1 3.1 1.6 5.4 Severe (IV) 2.9 2.5 1.8 0.5 0.3 1.6 ----------------------------------------------------------------- Nutritional Status in Bihar Areas Table 2. Distribution of Children According to Nutritional Grade ICDS Area (1466 children) Nutritional Age in Years (Grade) <1 1-2 2-3 3-4 4+ Pooled ------------------------------------------------------------------ Normal 34.8 14.9 19.3 26.0 23.9 22.8 Mild (I) 32.6 33.6 32.3 36.5 40.6 35.5 Moderate (II) 24.5 36.6 37.1 30.1 30.4 32.4 Severe (III) 7.4 13.0 10.1 7.4 5.1 8.6 Severe (IV) 0.7 1.9 1.2 0.0 0.0 0.7 ------------------------------------------------------------------ Non-ICDS Area (1727 children) Normal 38.3 10.5 14.5 17.6 19.2 18.4 Mild (1) 28.2 29.5 33.9 37.7 41.5 35.5 Moderate (II) 22.8 38.6 33.2 32.1 30.2 31.9 Severe (III) 10.7 17.3 16.8 11.8 8.8 12.9 Severe (IV) 0.0 4.1 1.6 0.8 0.3 1.3 -----------------------------------------.------------------------ - 36 - Annex 1 Page 3 Service Coverage 6. Table 3 shows service coverage in ICDS and non-ICDS project areas on Madhya Pradesh and Bihar. ICDS coverage of some services in Madhya Pradesh is good. The survey showed that around 602 of children and 692 of pregnant and nursing women (as compared to a norm of 75X) received supplementary nutrition regularly. But about a half of the women shared it with others at home. MCH service coverage in ICDS areas was much higher than in non-ICDS areas. About half the children <1 year old received a full schedule of immunizations, nearly three times the coverage in non-ICDS areas. About 60% of pregnant women received tetanus immunization, and iron and folate tablets, nearly twice that in non-ICDS areas. Similarly 601 of women received some health and nutrition education, nearly 6 times that in non-ICDS areas. Mission field visits and small scale studies suggest that ICDS operations in MP are comparable to that of the program as a whole. At AWs visited in Bastar, one of the poorest and most dispersed districts (its population density is a fourth of India as a whole), growth monitoring was being carried out regularly. 7. ICDS service coverage in Bihar is considerably lower than in Madhya Pradesh. Although about two-thirds of targeted beneficiaries received at least one service, less than a third of children received regular supplementation, only 111 ever received vitamin A, and about half the women received some health and nutrition education. 711 of pregnant and nursing women received supplementation but less than a half consumed it on the spot and nearly three-fourths of those taking it home shared it with others. MCH service coverage, although higher in ICDS areas, is also very low. Although coverage is increasing rapidly, only 301 children <1 year old had received third dose of Diphtheria-polio-tetanus immunization and 331 of pregnant women received at least one dose of tetanus immunization. 8. While service coverage in ICDS areas is higher than non-ICDS areas; two services seem to be an exception to this: dietary advice to pregnant women and oral rehydration therapy for diarrhoea. ICDS needs to increase emphasis on these services as they have a significant impact on low birth weight and energy losses among younger children respectively. - 37 - Annex 1 Page 4 Table 3. Utilization of Services Madhya Pradesh Bihar Indicator Non- Non- ICDS ICDS ICDS ICDS Sample size 520 462 500 500 1. Any service Z children e3 years 55 n/a 69 n/a Z children 3-6 years 61 n/a 61 n/a 2 pregnant women 57 n/a 68 n/a 2. Supplementary feeding Z children receiving >25 days monthly 59 n/a 31 n/a Z consuming on the spot 50 n/a 55 n/a Z sharing at home 28 n/a 33 n/a 3. Immunization - children<1 year 2 fully immunized 50 17 0 0 I DPT 3 67 33 30 7 4. Growth monitoring s mothers saying weighed regularly 72 n/a 42 n/a Z saying purpose explained 55 n/a 32 n/a 5. Vitamin A I Children ever received 61 11 11 0 6. Referral Z Children referred 22 19 19 10 Z referred children not completing referral 25 25 33 20 7. Antenatal services 2 women with antenatal exam 29 24 22 17 Z tetanus immunization at least one dose 58 27 33 23 Z women received iron and folate 64 31 18 9 Z women receiving supplementary food 69 n/a 71 n/a Z consuming on the spot 18 n/a 46 n/a Z sharing at home 56 n/a 74 n/a 8. Health and Nutrition education Z women ever receiving 59 10 50 4 Z women breast feeding within 24 hr. of delivery 81 71 59 53 Z women eating more when pregnant 4 10 14 16 Z women aware of ORS 8 18 -- -- - 38 - Annex 1 Page 5 Findings of the Qualitative Study 9. The qualitative study in the project areas comprised in-depth interviews of selected providers and consumers, participant observation of selected AWs and focus group discussion of beneficiaries. In Madhya Pradesh, 71 AWs were visited, and 126 ICDS and health service providers and 85 community members including beneficiaries were interviewed. Correspondingly in Bihar, 10 AWu were visited, and 72 ICDS and health service providers and 51 community members including beneficiaries were interviewed. The main findings of this study are summarized below. AW Functioning (a) All the AWs were accessible to the people but only 13 of the 71 AWs visited had good accommodation (MP only). (b) AWs were easily accessible ana only 3 of the 49 AWs visited had good accommodation. Generally food storage facilities were inadequate and water source For many AWs was far away (Bihar only). (c) Most AWWs were aware of ICDS objectives but felt that lack of good accommodation and irregular supply of food supplements hampered their functioning (MP and Bihar). (d) Growth monitoring was being carried out in most of the AWs and AWWs were generally competent in growth monitoring. However, most mothers remained passive observers (MP only). (e) Very few AWWs understood the actual basis for growth monitoring and consequently did not maintain adequate age-weight charts (Bihar only). Providers' Views (f) Many women go to work early in the morning and return only in the evening, so 'on-the-spot' feeding was not always feasible (MP only). (g) Many AWWs were not giving double rations to severely malnourished children as they could not consume it in one sitting (MP only). Health-nutrition Coordination (h) Visits of health workers to the AWs were not regular. However, AWs were often used by health workers for providing services (MP and Bihar). (i) Generally AWWs felt competent to treat minor ailments but felt that medicine supply was inadequate (MP and Bihar). - 39 - Annex I Page 6 (j) Although many health staff had not received orientation towards ICDS, they were familiar with its activities and felt that it was very relevant to the needs of the community (MP only). (k) Although many health staff had received orientation towards ICDS, several were not well aware of its activities (Bihar only). (1) Sector joint meetings with health staff do not function well (MP and Bihar). Community PerceDtions (m) Many mothers felt shy eating food along with children and, in view of inconvenient timings, did not participate in supplementary feeding adequately (MP only). (n) Many mothers felt that food supplements were unacceptable either because of improper storage or improper cooking (Bihar only). (o) The participation in AW activities was good across different population groups and community perceived these services as useful (MP only). (p) The participation in AW activities was moderate and many felt hesitant about accepting some of the health services (Bihar only). (q) About 40Z of the children reported attending AW only for the sake of pre-school education irrespective of the availability of food supplementation (MP only). (r) Mothers do not show interest in sending children for pre-school education. Consequently many children come only at the time of food supplementation (Bihar only). SuDervision (s) During their visits to AWs, supervisors rarely made home visits (MP and Bihar). - 40 - Annex 2 Page 1 XNDR SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT PROCESS OBJECTIVES 1. The project's impact objectives would be achieved over six years of project duration through strengthened service deliveryl increased nutrition and health capability of mothers and communities; and promotion of community participation in the project's nutrition, health and educational activities. Process and activity targets to achieve the above impact have been established for s (a) Children <3 Years. Regular growth monitoring, immunizations, vitamin A administration, care of diarrhoeal diseases and ARI, supplementation of those malnourished, and health care and referral of severely malnourished; (b) Children 3-6 Years. Regular growth monitoring, pre-school attendance, and health care and referral of those severely malnourished; (c) Preanant Women. Early registration of pregnant women, antenatal care, supplementation of those with inadequate nutrition status, and iron and folate supplementation; (d) Pregnant and Nursina Women. Counselling on appropriate and adequate breast feeding, weaning, and birth spacing practices; and supplementation of those with inadequate nutrition status; (e) Adolescent Girls. identification of moderately and severely malnourished and provision of health and nutrition services to them. 2. Table 1 shows the current best estimate and process objectives for the above services for Madhya Pradesh and Bihar project areas. Because of its relatively better ICDS and health service delivery operations, MP is likely to achieve higher coverage levels than those in Bihar. As health service coverage in ICDS areas is generally higher than in non-ICDS areas, it is expected that the project coverage levels in these disadvantaged areas would be comparable to those in the whole of the state. - 41 - Annex 2 Page 2 Table 1. Prolect's Process Obiectives MP Bihar Process Objectives Cur E ar-e Early registration of pregnant women by 16 weeks n.a. 50 22 50 Total registration of pregnant women (29) 80 30 75 Food supplementation of registered pregnant women with (69) 80* n.a. 80 inadequate nutrition status (for at least 20 weeks) Food supplementation of registered nursing women with (69) 90* n.e. 75 malnutrition in pregnancy (for at least 16 weeks) Regular growth monitoring (4 times a year) of children 72 100 42 80 0-3 years Supplementation of monitored children 0-3 years with (59) 90 n.a. 80 grade II-IV malnutrition Completed referral of severely malnourished children 0-3 (25) 80 n.a. 80 years Growth monitoring of children 3-6 years (twice a year) (72) 100 n.s. 80 Completed referral of severely malnourished children 3- (25) 90 n.a. 80 6 years Pre-school attendance (80 percent of working days) n.a 60 n.a. 60 Additional feeds of local weaning food initiated by 6 n.a 50 n.a. 50 months in infants Provision of 4 additional weaning feeds/day by 9 months n.a 50 n.a. 50 in infants Reduction in short (c 3 yrs) birth intervals n.a. 50 n.a. 50 Tetanus toxoid immunization of pregnant women 58 90 33 ** Consuption of iron and folic acid tablets for at least (64) 60* 18 ** 12 weeks by pregnant women Increase in temporary CPR levels 7.5 10 ** Process Objectives Cur. Tar-get Cur. Target est. est. Immunization (UIP-6) (60) 90 0 - 30 " Adninistration of vitamin A semi-annually to children 6- (61) 90 11 80 36 months Household use of oral rehydration in the last incidence na 60 n.a. 70 of diarrhea in children 6 -72 months I Treatment of ARI with co-trimaxazole na 10 n.s. 10 ) closest approximation to specific group levels ; * completed duration of intervention is a requirement of objective. ** to be met in consonance with state targets for the CSSMP. - 42 - Annex 3 Page I INDIA SECOND INTEGRATED CHILD DEVELOPMENT PROJECT TRIBAL POPULATIONS Background Information 1. Bihar and Madhya Pradesh (HP) contain substantial proportions of India's Scheduled Tribe (ST) population. These populations are distinguished socio-economically by their preponderance in drought-prone, marginal farming areas, dependence on a range of relatively insecure sources of livelihood and low social and health indicators in relation to literacy levels, child survival and child and maternal nutrition. They are also distinguished, to varying degrees, by language and cultural practices. 2. In both states, the ST population is concentrated in the more hilly, forested areas which constitute a more or less continuous ecological zone across HP, southern Bihar, northern Orissa and northern Andhra Pradesh. The drought proneness of these regions has intensified over the last century due to the systematic destruction of the forests which originally covered much of the plateau region of central India. This has had major consequences for the livelihoods of the plateau populations. There are important differences between the two states in respects of the degrees of involvement of Christianity and of NGOs. Neither are a significant force in MP. 3. In Bihar, STs are found almost entirely in the South Chotanagpur plateau and Santal Parganas divisions, spread over about five districts. In 1991, the ST population for Bihar was approximately 6 million out of a total population of 86.4 million. (A further 10 million are scheduled castes (SCs), many of whom live admixed with STs and share similar levels of disadvantage.) Population density in considerably lower than in the Gangetic plain region (but considerably higher than in MP). The main urban densities are in the Ranchi and Dhanbad Districts. 4. There are 29 listed STs in Bihar. The most important ones, numerically, are the Santals, Mundas, Hos, Oraons and Kharias. The Santals are found mainly in the Santal Parganas, Hazaribagh and Dhanbad districts and constitute rather more than one third of the total ST population of the state. Santals are allied culturally and linguistically to Mundas, Hos and Kharias and probably constituted part of an earlier, more homogenous ethnic category. Mundas are the next largest group. making up some 162 of the ST population. They are concentrated particularly in Ranchi and its contiguous districts. The Hos constitute about 112 of the ST population and are confined almost entirely to Singhbum, the most southerly district. Kharias are about 2.5Z of the ST population and are found mainly in the Ranchi District. Oraons, who speak a Dravidian language, are about 17? of the ST population and love mainly in the Ranchi and Palamau districts. Each of these groups, with the exception of the Kharias, dominates in particular sub-divisions. - 43 - Annex 3 Page 2 5. Apart from these main groups, there are a number of small STs which tend to be localized to particular areas. They range from cultivators to blacksmiths to semi-nomadic forest dependent groups. With the exception of the latter, who need separate consideration, the general economic and social position of these smaller groups is similar to that of the larger concentrations. 6. Christianity is of major significance in the Chotanagpur region where up to one third of tribals belong to the main Christian denominations. It is largely responsible for the higher literacy rates among this segment of the ST population. However, it is also an important differentiating factor. Christians tend to be better educated and more "progressive" socially and economically, than followers of the indigenous religion. The majority of tribal AWWS are Christian. This does not present a major obstacle to the participation of non-Christians, but more effort is likely to be needed to involve these generally poorer and more traditionally minded families in the ICDS program. 7. According to the 1991 census, STs are 56.22 of the population of the district. This registers a slight fall since 1981 when it was 58Z. The exponential growth this decline. The road and transport infrastructure is relatively developed compared to MP, but there are still areas where road access is difficult or impossible during the rainy season. 8. In MP, the tribal population is large, numbering some 12 million out of a total population of just over 66 million. Unlike Bihar, it is spread across several regions of the state. Some 46 STs are recognized for legislative purposes and the majority of these are concentrated in four main ones. The largest STs are Gonds (about 4 million), Bhils (just under a million), Bhilalas (700,000), Kols (650,000) and Oraons (500,000). The remaining groups range in size from 300,000 down to as low as 900 individuals. 9. In the central zone (Mandla, Jabalpur), the main populations are Gonds, Baigas, Korkus and Kols. In the eastern zone (Surguja, Shahdol, Bilaspur. Raigarh) the main groups are Oraons (these are contiguous with Bihar), Gonds, Korwas and Kanwars. In the southern zone (Baster, Raipur), they are Muria and Maria Gonds, Halbas, Bhattras and Dorlas. In the western zone (Jhubua, Khargaon), the main STs are Bhils, Bhilalas, Barelas and Patliyas. 10. STs in MP represent a range of degrees of economic and cultural integration. However, the infrastructure of the state is extremely underdeveloped and ST populations predominate in the least developed and remotest regions. 11 of the 15 districts with large concentrations of STs have more than 252 of land under forest and this is as high as 712 in Baster. Literacy levels are generally very low among STs (11.52 as against 23? for the population as a whole) but do vary considerably between groups. Gonds and Bhilalas probably have the highest levels of literacy and forma education. Groups such as Bhils and Baigas have extremely low levels of adult literacy. However, schooling is becoming a recognized and desirable goal for young children. Christianity has played a far less significant role in MP and thus - 44 - Annex 3 Page 3 has not had the catalytic effect on educational levels which is found in Bihar. Where present, missionary influence has been strongest among Gonds and Oraons. Gender Issues and the Division of Labor 11. In ST populations, the division of labor between men and women is both flexible and relatively equal with agricultural production. There are few tasks which women are not able to do - plowing is the main exception - and women may be found tending cattle or bringing in and processing the harvest as well as performing the more sex typed activities in paddy cultivation such as transplanting. Both sexes participate in gathering activities and spend long hours away from the village. 12. In Bihar, the major part of women's daily time was spent in fuelwood collection. This is a particularly severe problem in much of Chotanagpur because of the decline of the forested area and the restrictions placed by the forestry department. With the exception of the rainy season and periods of migrant labor, women typically leave early in the morning and collect until it is time for the midday meal, returning around noon when the household eats its first main meal. Women cook usually once a day, either before leaving in the morning or on returning in the evening. 13. In MP, there is a similar pattern in those areas where there is a fuelwood shortage. (This is particularly severe in Jhabua). Both women and men may go out again in the afternoons to gather foodstuffs in the forest, returning only at dusk. Children are left with the elderly and with older, non-school attending siblings. In ICDS villages, these older children generally attend the AW with their charges. Although not intended for the over sixes, this does at least provide some element of education for such children. 14. Water collection provides another constraint, notably on women's time. The situation is worst in the more remote areas of MP, where the nearest potable source may be several kilometers away. It was a common story to find broken hand pumps on villages because no servicing was carried out and none of the villagers were trained to do simple repairs. 15. The constraints on women's time are quite severe and this has implications for the operation of the ICDS program. With the exception of mothers with very young babies, few woman or adolescent girls remain in the village during daylight hours. Indeed, the AV has the status, in many ways, of a creche for mothers of under sixes. If mothers are sought to be involved any further in ICDS activities, consideration must be given to the timing of these, probably through local consultation. Similarly any moves to involve adolescent girls will have to reckon with their extreme invisibility during the daytime, as they carry similar burdens to adult women. It may be that some kinds of activities, like health education, should be targeted for certain times of the year. - 45 - Annex 3 Page 4 Health Linkages 16. In both states linkages with health care delivery were poorly developed, although some instances were found in Mandla of effective co- operation between ICDS officials and health personnel. The reasons for this are similar to the reasons reported elsewhere and are predominantly structural rather than cultural. Health workers are in general seen as unavailable and unsympathetic to village people. They are often of a different social/cultural background from ST villagers. In Bihar, language is a significant barrier (see below). Supplies of medicines are erratic and there were reports of people being asked to pay for medicines. The situation in Bihar was compounded by a recent month-long strike of health workers which severely disrupted vaccination schedules. In MP, a couple complained that health staff refused to treat their baby son's abscess following a routine vaccination, because the women refused to be sterilized. The perceived association, rightly or wrongly, between health care delivery and family planning, acts as a deterrent to some. It is important that this perception of coercion be addressed and it is made clear that access to health services is not contingent on acceptance of terminal or other methods of contraception. 17. In some cases, it was clear that the AWW did provide an important mediating role in health care. However, this largely depended on the level of education and forcefulness of the AWW. If her educational and social status diverged markedly from that of the health staff, it was often difficult for her to operate effectively in the transferral of cases. Problems of communication are not improved by the fact that the working hours of health staff do not coincide with the opening hours of the AW. 18. The majority of births are still attended by traditional birth attendants, few of whom had any training. Even where AWWs are present in the locality they tend to be called upon only if there is a difficult delivery. This was confirmed by a nurse midwife running a Catholic Charities MCH center in the Ranchi District. The popularity of her center provided the clearest indication that allopathic medicine was accepted and appreciated by villagers, provided it was sensitively delivered. (There was a rarely used government PHC in the same village). However, she was not able to persuade pregnant mothers to use the center facilities for childbirth except where complications arose. This points to the need for more effort in house to house visiting. Coverage of tetanus injections among pregnant women was patchy and there were complaints (particularly in Bihar) that it was not offered. Although it is difficult to disentangle this from possible cultural resistance against health interventions in pregnancy, no evidence was found of straightforward rejection. Indeed, injections are regarded by many villagers as a particularly efficacious form of medicine. Pregnancy is not hedged about to any degree with restrictions on diet or activities. Equally, it is not considered a realm of special intervention. Few understood that pregnant and lactating women have particular dietary and caloric requirements. This ties in with a more general absence of a concept of nutrition, which can only be addressed through education. - 46 - Annex 3 Page 5 19. Alcoholism and heavy drinking appear to be potentially serious problems in Bihar. Both distilled and fermented liquors are an important part of social life in tribal populations. However, it was noted that most of the village men encountered during the daytime in Bihar had already significant quantities of spirits. Such daytime drinking was not apparent in rural MP. This may be a possible topic for health education in Bihar, or one which could be raised in women's groups. However, liquor brewing is an important source income for tribal women. 20. Allopathic medicine is now universally accepted in rural areas and there is no evidence that the health component of ICDS collides with existing health and cultural practices. Some people use allopathic medicine exclusively. Others use indigenous remedies/practitioners as a first resort and switch later if it proves ineffective. They may alternatively employ a hierarchy of resort, with some illnesses referred to one type of practitioner and some to the other. 21. However, indigenous forms of healing continue to survive and there are attempts in Bihar in particular to revive herbal medicine and reduce reliance on allopathic drugs. It is difficult to gauge the extent of existing knowledge, or its loss, among ST populations. In most areas there is a tradition of local practitioners with specialized knowledge of both herbal remedies but also of supernatural and magical forms of healing. Among Baigas living in the more remote communities there appeared to be a considerable body of household level knowledge about common ailments and their prophylaxis. Speculatively, it is this household level knowledge which tends to be lost first when allopathic medicine becomes entrenched. 22. In Bihar, a number of agencies, mainl, connected with the Catholic church, have developed an interest in the revival and promotion of indigenous medicine (jhaributi). In Torpa, at the proposed new Catholic sponsored MLTC, the sister in charge is sponsoring a series of training sessions in collaboration with reputable local practitioners. She has started an indigenous pharmacopeia with the aid of a young ST botany graduate to collect and identify herbs and their uses. Training courses are also being held in other parts of the district, with the emphasis on the preventative uses of herbal medicine. The main constraint is the difficulty, in areas of substantial deforestation, in obtaining the requisite plants. 23. This is a promising initiative which could be incorporated into ICDS if structural hurdles can be overcome. Herbal medicines are relatively cheap and have a degree of acceptance among rural people. At the very least, it is important that allopathic medicine is not regarded as antithetical to this type of practice and a dialogue is opened up between the personnel involved. Leadership and Community Structures 24. There is now a high degree of fragmentation of tribal cultures in both states, most particularly in Bihar with its longer history of incorporation into wage labor and better physical communications. The degree - 47 - Annex 3 Page 6 of fragmentation also varies within each state, with more remote groups retaining forms of local organization which have largely disappeared in the more integrated areas. "Traditional" forms of tribal organization are (were) based primarily on territorial precedence, expressed through a clanship idiom. These are, at least more recently, strongest at village rather than regional level. This reflects the way in which the political and administrative incorporation of tribal populations has taken place. Villages became and remain important revenue and administrative units, and traditional structures have dovetailed, to some extent, with those of government. 25. The older structures are, not surprisingly, more intact in unitribe villages than in mixed ones. The common pattern across both states is one where there is a hereditary office holder or headman who is known by a variety of local names (e.g. Minda or Manki in Munda and Ho areas of Bihar, Mukhadam among Baigas in MP). He may combine this with a religious role or there may be a separate religious functionary for the village. The position of the headman is in some ways that of a "first among equals" in that hi3 traditional authority derives from his status as a representative of the original clan settlers. However, where his role has dovetailed with formal structures such as the panchayat, and where he operates as, for instance, the holder of village land records, then his authority has arguably been somewhat enhanced, at least in the administrative sense. 26. The headman's traditional role relates to matters essentially connected with the clan/tribe. He has no jurisdiction over other castes in the village. His authority extends to dispute settlement within the jati and to such things as the negotiation of marriages and associated matters. 27. In villages with relatively homogenous populations there is a ready made structure through which consultation could be set up. Headman can call meetings on matters of general village significance. These will normally be attended by both sexes. Village meetings have certain powers to enforce decisions such as fines. Smaller groups of male elders may also take such powers. Hereditary office holders may also be closely involved in the gram panchayat system. 28. In mixed villages, these jati based positions are less salient and in those visited it was notable that the gram panchayat and its office holders constituted the effective authority. In some ICDS villages, the panchayat was found to be very active and had lobbied for an AW. It was also involved in some cases in providing the building, either through funds of labor or both. If attempts are to be made to create greater community involvement, it will be important to work through whichever structure is the most significant, but in many cases this is likely to be the formal panchayat. 29. The formation of mahila mandals is at a very embryonic stage in both states. There was little evidence of any activity apart from some formal meeting which had been called by AWWs in a few cases. Women themselves did not appear to understand the functions of these groups or wish to take an active role in them (as opposed to being the recipients of information at meetings called by the AW). There are a variety of constraints. One is - 48 - Annex 3 Page 7 clearly time. Another is the unfamiliarity of the concept. There are no indigenous parallels which can readily be drawn upon as sex specific forms of organization are rare. There thus needs to be a considerable period of preparation and raising of awareness of the possibilities of this kind of organization if it is to function other than on paper. It is recommended that particularly on the greater experience of NGOs in Bihar in setting up active women's groups. Communications Issues 30. There is a range of cultural and language issues in relation to ICDS which merit attention. First, it is necessary to ask how the recipients view the program. 31. In both states, ICDS is viewed as an educational cum children's feeding program. The emphasis as between these two varies. Ir Chotanagpur, the AW is known as "ladu school", reflecting both the nature of the food given and its role as a step towards "real school". In MP, it was described as "dhaliya khana" or "prasad", which places the emphasis on the (free) food. However, it is undoubtedly the educational role of ICDS which has caught local imagination - to the detriment, perhaps, of its health and nutritional role. Pregnant and lactating mothers attending the center were found to eat the food only rarely. There ap--ared to be two main reasons for this. First, the food is seen as children's, rather than adults' food. Second, those who did understand that the food was available for them, took it home to share with family members. There was no embargo on eating in the center as such, it was more a case of maternal altruism. As there is little perception that pregnant and lactating mothers require more food, there is little likelihood of persuading them to retain it solely for their own use. This is a matter which requires appropriate nutrition education. 32. What is not in doubt is that ICDS is extremely popular with villagers and it should thus be possible to build on this goodwill to create a more effective all around interventicn. It will be important, therefore to think through ways in which the health/nutrition aspects of ICDS can be given more prominence. 33. In Chotanagpur, language is potentially a serious communications problem. Despite a widespread view to the contrary among local officials, many tribals do not speak or understand Hindi. This is particularly the case in interior villages away from administrative and market centers and where the population is homogeneous and adult literacy levels are very low. Generally, the problem is more severe for women than men as they are less likely to have come into contact with formal structures or to have migrated for wage labor. The groups most affected are Mundas and Hos (and possibly Santals but this needs further research). Among Oraons, who are more integrated, knowledge of Hindi is more widespread. It is an unfortunate finding that young educated tribals are rapidly becoming monolingual in Hindi and thus widening the gulf between educated and uneducated. - 49 - Annex 3 Page 8 34. This problem must be addressed if ICDS is to deliver proper health and nutrition education. There are now some agencies and individuals giving this question attention. The proposed MLTC in Torpa has a very imaginative program of training local balwadi teachers (the balwadi program operates on a similar basis to ICDS but without supplementary feeding), through the local language, using indigenous songs and sayings. They have expressed and interest in developing teaching packages. The Tribal Research Institute in Ranchi has a researcher interested in developing training material in Mundari and there is some interest in this field at the Patna TRI. When the problem was discussed and aired with local officials, there was considerable interest in this possibility. 35. In MP, Hindi was found to be generally understood by both sexes and most people spoke at least a dialect of Hindi. However, though less serious than in Bihar, this does not mean that language is not a problem at all. Most lingua franca communication is through dialect rather than standard Hindi and it should not be assumed that all groups have sufficient nutrition messages. It is suggested that language and ethnographic experts at the Tribal Research Institute in Bhopal be asked to look at this question and make appropriate recommendations. 36. The degree to which local cultural forms retain vitality varies from region to region. In general, this vitality is greater in MP than Bihar. However, in both states, there are possibilities represented by local culture which could be used to improve the communications component of ICDS and to create a more imaginative activities taking place in one or places in Mandla District, where the CDPO had organized a toy bank. On the whole, however, children were found to be sitting in orderly rows repeating rather mechanical formulae for much of the time. While this does have some benefit for older children in preparing them for school, the under threes were mostly very poorly catered for. 37. In Bihar, the dominant cultural forms are expressive. Dancing, drumming and singing remain important in village life. In MP, tribal cultures are both expressive and visual. There is considerable local production of artifacts on both a household and specialized caste level. Houses are painted in a rich variety of local styles. Dancing and music also play a very important part in rural life. There are thus important local sources which could be drawn upon to create symbols for health and nutrition programs and to provide teaching resources for pre-schoolers. A simple example is the need to provide a logo for ICDS to replace the rusty written signboards which are incomprehensible to the non-literate. As with language, it will be necessary to tap existing expertise in the tribal research institutes and cultural agencies, as well as to draw in churches and NGOs with some experience in this field. - 50 - Annex 4 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES SCHEME STRATEGIES FOR REDUCING MALNUTRITION AMONG YOUNG CHILDREN 1. Causes and Expressions of Malnutrition [ Affected Group Causes 11 Consequences Children < 6 months Low birth weight, poor Inadequate weight breast-feeding/ weaning gain, low weight for practices, diarrhea, ARI age/height, cretinism and other infections, lack of maternal access to l______________________ Fiodine Children 6-36 months Diarrhea, ARI and other Tnadequate weight infections, malaria, lack gain, low weight of access to Vitamin A, and/or height for age; poor weaning, poor diet, low weight for height, parental neglect eye damage, enhanced morbidity/mortality Children 3-6 years Inadequate diet, As above, but higher respiratory/parasitic propensity for infections, diarrhea, lack stunting (low height of access to Vitamin A, for age), eye damage, diseases such as TB, enhanced morbidity l ____________________ parental neglect l Adolescent girls Inadequate diet, lack of Low weight/height for iron supplementation, age or weight/height; parasitic and other anemia infections i Pregnant women Inadequate diet; low Low birth weight, l ~~~~~micronutrient intake; 11increased risk of l pregnancies too young, too maternal mortality, often and too closely infant cretinism "paced; hard work in late l ~~~~~pregnancy - 51 - Annex 4 Page 2 2. To deal with the above causes of malnutrition, the project's service package, main problems and project interventions are as follows: Services for Pregnant Main Problems Proloct Interventions Women Health Registration Inappropriate work routines and Revised work and supervisory supervision routines Poor health/nutrition coordination Develop and adopt better mechanismI Lack of client motivation Improve Joint health- nutrition inservice training _____ _____________________ Strengthen IEC Weight Monitoring Not emphasized by ANM/AWW Strengthen worker training and motivation Difficult for some workers Introduce arm-banding as substitute where welghing not Lack of working scales at some feasible facilities Supply scales Tetanus Toxold Inadequately emphasized by Improve joint hoalth- Immunization MPHW/AWW nutrition Tnservice training Develop and adopt better Poor coordination between health/nutrition coordination nutrition and health staff mechanisms Iron and folate Inadeqate distribution due to Distribute through AWWs supplementation lnadequate health-nutrition coordination Lack of beneficiary compliance Combined worker emphasis on education of beneficiaries and IEC campaign Food supplementation of Food supplies irregular and Strengthen administrative those at risk of low- inappropriately stored, arrangements for distribution weight deliveries particularly In Bihar Improvo storge tacilities Emphasize through IEC Women reluctant to sat In Organize at appropriate hours presence of children and foeding at Inconvenient time Change behavior through IEC Family sharing of take-home ration Ante-natal check and Poor nutrition-health Develop and adopt better obstetrical risk referal coordination health/nutrition coordination mechanisms Referrals not completed Strengthen referral system - 52 - Annex 4 Page 3 Services for Main Problem Prolect Intervention actating Women Supplementation of food supplies irregular then lactating women nd inappropriately d saintrative ith malnutrition tored, particularly in rrangements for in pregnancy ihar istribution rove storage acilities omen shy of eating with hasize proper use hildren and inconvenient n commuunicatlons and ours for rganize at upplementation; sharing ppropriate hours f take-home ration ducation to Lack of knowledge and ommunications ptimize different beliefs ctivity for behavior breastfeeding and hange weaning practices :ommunity mobilization ctivities to mphasize appropriate ehavior - 53 - Armex 4 Page 4 Sorvices for childron Main Problems ro ct nterventions wa Y re gular growth rowth monitorin limitod to mnttut quart rly nitoring hildron rogiotorod In Afe nitorlng of *11 children nadoquatoly trainod orkorso and rlntation and in-sorvic- hortage of growth charo, rainingt organize supply of articularly In Blhar rowth charts horapeutic upplem_ntatilon Irrogular trongthon adminltrative uppl_oentation of articularly In Bihar rrangements for supply orately and soverely Inourished .hildron verely mInourished children out provision of energy an not consume double rations rich food and alternato t AW eding mthods (e.g. take- ome combined with on-site) tferral of severely nadequate health check at AW dopt and devolop hoalth- Inourished children y utrition coordination IPH1 wshanisms eftrrals not completed because rnnsport and medicino fund of t CDPO level for lgh opportunity cost to relmbursemnt for such rentre reerrals munization nadequate health-nutrition *volop and adopt mechanisms oordination or improved coordination Over-anumeration *proved coverage monitoring hrough CSSMP dministration of ack of clarity on who Itamin A would be supplied itamin A administers and who suppites AWs by health staff for inistation to children r CSSUP norms ousehold use of oral uo because of Inadequate ounications to alter rehydratlon o_unications *ffort ousehold behavior Not phasized by AW n-service training and nitoring reatment of acute I program has not been would introduce ARI respirstory Infections Iplamented rogrm; AWl to support _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ hose activities Services for 8-4 years Main Problems I Project Interventions Id, In addition to hosefor 0-3 ears _ re-school education Quality of education is poor ln-sorvice training to improve skills of AWs | Supply of pro-school kits nd their regular r_I_ lenshment - 54 - Annex 5 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT COORDINATION BETWEEN STATE DEPARTMENTS OF WOMEN AND CHILD DEVELOPMENT AND HEALTH AND FAMILY WELFARE Introduction 1. Cooperation between ICDS and family welfare workers in the field has improved in recent years. One way in which this has been fostered is by holding immunization sessions at Anganwadi Centers, with workers from both programs assisting. Under the proposed project, efforts will be made to build on this beginning to achieve similar levels of cooperation in implementing other key primary health and nutrition interventions. Both programs stand to gain from improved cooperation since their aims are so similar. For example, the following interventions under the proposed project are already recognized elements of the Family Welfare service package: (a) Anaemia prophylaxis for pregnant and lactating women; (b) Immunization; (c) Ante- and post-natal care including high risk referrals; (d) Diarrheal disease control; (e) Health check/referral for under-fives; (f) Vitamin A prophylaxis for under-fives; and (g) Identification and referral of ARIa. 2. This Annex first summarizes several Government Orders issued in early 1991 with the aim of improving coordination. These orders are important, because they help to clarify roles for workers, and demonstrate to field staff that improving cooperation is seen as a serious issue. But GOs alone may not be sufficient to change time-worn practices in the field. Therefore, measures will be taken under the proposed project in five additional areas to reinforce and complement the existing instructions: (a) joint planning; (b) clarification of task assignments and work routines; (c) joint supervision; (d) informal joint training; and (e) harmonization of formal training curricula. - 55 - Annex 5 Page 2 Recent Government Orders 3. In February, 1991, the following orders were issued by both Famlly Welfare and Women and Child Development Departments: (a) Multi-Purpose Health Workers Female (MPHWFs) to visit each Anganwadi Center (AW) in their area at least once a fortnight, on a predetermined day; (b) Delivery kits to be routed through AWWs to TBAs and pregnant women; (c) Vitamin A to be distributed by AWWs; (d) Health staff to attend monthly meetings held by ICDS staff; (e) Referral of cases from ICDS to health services to be strengthened by: (i) issuing quick 'priority' referral slips for all ICDS cases; (ii) creating an exclusive counter at PHCs/CHCs/district hospitals for attention to ICDS referral cases; and (iii) number of referral cases to be a special agenda item for monitoring and discussion at monthly meetings. Joint Planning 4. ICDS staff should be fully involved in the annual planning process at the district level, since ICDS is an intrinsic and important part of district health services. ICDS staff in particular have an i.iportant substantive contribution to make to target-setting at the district level, since special targets may need to be set for ICDS blocks. As well as the substantive contribution, the process of joint planning will have important benefits. Officials who have worked together to produce a District plan will have greater commitment to jointly achieving its goals. Annex 8 sets out the approach to district planning which is to be adopted for both Family Welfare and ICDS programs during the Eighth Plan period. Task Assignments and Work Routines 5. The proposed distribution of tasks between AWWS, MPHWs, TBAs and VHGs is shown in the table below. The intention is to distribute tasks so as to make maximum use of the comparative advantage of each worker. - 56 - Annex 5 Page 3 Tasks at Village Level for UIP Plus and Safe Motherhood Program TASK MPWF MPW TSA VHW AW A. General Enumeration -Pregnant and Yes Yes Ye lactating women, Infants, children 1 - 5 years. Registration - Births Yes - Assst Aselst Yes Registration - Deaths Infant deaths Child deaths (1-8 A 8-6) Yes Ys Assist - Ye Still births Support mothers' and influencers' meetings Ye Ys Yes Yee Ys 8. Child Survival New born care -Cord care - Ye - - -Identification of LW - - es - Assist -Management (no both, feeding, warmth) Ye - Yes - Yes -Exclusive breast-feeding Y - Yes - Y Detection of at risk under fives - Asslst Assist Yes Immunization -Enumeration of eligibles Yes Y - - Yes -Motivation Yo Yes Yoe Yes Ys -Conduct a session Yes Yes - - Assist -Collect eligibles on the day of session - - Yes Ye Ye -Follow up of drop-outs/ loft outs Ye Ye - Yes -Follow up after session and referral - - Yes Yes Yes if need be -Maintain records and report Yes Ye" - - Assist -Surveillance (watch out for outbreaks of NNT, measles and polio) Yes Ye Assist Assist Assist Diarrhea control -Home management Yes Ye Yes Yes Ye (train mothers and care-givers on fluids, assess child for dehydration, advise mothers on fe*ding/breast-mi k) -Assessment of the child Ys Yes Ye Y Yes -Advise mother/care-giver on management at home Yes Ye Yes Yes Yes -Distribute ORS (1 packet) Ye Ys Ye Yos Yes -Depot-holder Ye Y Yes Yes Yes -Referral Yes Yes Ys Yes Yes - 57 - Annex S Page 4 TASK W TA VS AW Acute respiratory Infection control -Assessment of the child Ye Ys Assist Yes Ye. -Education on home remedy tdwing, fluid, etc. Yes Ye Assist Yes Ye -Referral Ye Ye Assist Yes Yes -Follow up Ye Ye Assist Yes Yoe Vitamin A deficiency control -Nutrition education Yes Ye Assist Assist yes -Early detection of def. Yes Yes - Assist Yes -Follow-up after let contact with MO for troatment Ye Ye - Assist Yes -Distribution of Vit. A *o90 doses to Om to * years Ye Y - Ye Ye -Maintain record on above Yes Y - Assist Yes C. Supplementation of 0-o aund PLWs Quartorly enumration Assist - Assist - Yes Monthly/quarterly growth oon. - - - Yoe F ding - - - Yes Check-up/reforral of malnourished Yes - - - - Mothers' nutrition education Assist - - - Y Nutrition rohabilitation Assist - - - Y D. Safe Motherhood Adolscent girls -weighin - - - - Yes -fe ding _ _ _ y -hoe1th and nutrlilon ed. - - - - Y Ante-natal checks -Identification of pregnancy - - Yes - Yes -ANC exam Yes - Assist - Assist -identification/referral of obstetric complications yes - Assist - Assist Anaomia Control -Identity/referral of severe cae Y Yes Assist - Ye -Nutrition education Yes Ys Assist Assist Yes -Distribution of IFA Ys Yes Yes - Y -Follow up Ye Ys Assist - Yes Delivery -Encourage Institutional deliverie where infrastructure exists Ye Ys Ye Yes Yes -Assist with Institutional delivery Y - Yes - - -Assist at home delivery - - Ye - - Birth spacing -Education/motivation Yes Ye Assilt Ye Ye -Resupply of contraceptives Ye* Y - Yea Yes 6. AWWs would assist the MPHV in the following main ways: (a) alert mothers to the timing of upcoming imuunization/MCH sessions to be held in their village, encourage mothers to come, attend and assist at the sessions, be available to mothers in subsequent days for follow-up; - 58 - Annex 5 Page 5 (b) meet with the MPW on her arrival in the village on home visit days, to brief her on the priority clients to visit. These would in particular include newly pregnant women; children with health problems such as severe ARIs; severely malnourished children, or malnourished children with infection; and clients, especially poor clients, not making use of program services; (c) accompany the MPW on selected home visits in the afternoon (the AWW, who is a part-time, low-paid worker, and who has a full program of work at the AWC in the mornings, cannot be expected to escort the MPHW throughout all of her rounds). AWWs and MPHWFs should especially aim to jointly visit mothers not making use of services; and LBW/malnourished children who may need referral, or special follow-up care from the AWW; and (d) help in the achievement of MCH targets, including birth-spacing, by advising the MPHWF of clients needing particular services, and by educating and encouraging mothers. 7. In order for AWWs to have an incentive to assist MPWs in the above way, it is important that their cooperation be reciprocated by help from the MPW, in the following main ways: (a) advise on appropriate care/referral for children who have either persistent malnutrition or malnutrition complicated by infection. These are cases likely to be beyond the AWW's skills to treat; (b) help in reducing malnutrition by using the opportunity of her regular ante-natal care visits to stress to mothers the importance of eating more during pregnancy; taking advantage of supplementary feeding at the AWC; and of regular growth monitoring for the child; (c) use her greater education/IEC skills/social standing to assist the AWW to put across key messages at group meetings; to encourage the participation of resistant clients; and to develop the support of local influential persons for both FW and ICDS programs; and (d) help the AWW with the completion of her records. This will be particularly important in tribal areas where AWWs are often not fully literate. Joint Supervision 8. Greater cooperation can also be fostered by joint supervision of field workers. This has both substantive benefits, in terms of greater understanding of each others' program; and process benefits, in that if field workers are visited by their supervisor from both programs simultaneously, this sends a clear message about the importance of working together at the village level. It is proposed that ICDS and health staff at the district level should carry out at least one joint supervisory field visit a month; BHOs/CDPOs at least four per month; and MOs/Mukyha Sevikas at the PHC level at least four per month. - 59 - Annex 5 Page 6 Joint Informal Training 9. Revised task assignments and work routines, along with the new special emphases of the family welfare program on the UIP Plus/Safe Motherhood interventions, can best be communicated by training workers from both programs together in the groups in which they will cooperate. At the higher levels of the two services, it is proposed that this should be done through a series of two-day annual workshops, for both program managers and trainers. For managers, separate workshops will be held at the State and district level, to orient them to the UIP Plus/Safe Motherhood program, prior to the holding of the first district planning exercise. 10. For trainers, three types of workshops will be held. One, at the regional level, will bring together trainers from Middle-Level ICDS Training Centers with principal trainers from Health and Family Welfare Training Centers, plus the National Core Training Team to be formed under the proposed project. The second, at the State level, will bring together the Medical College consultants and other trainers used by the ICDS Central Technical Committee to conduct the Integrated Training Scheme for ICDS, the trainers of State Anganwadi Training Centers, and the State Core Training Team. The third, at the district level, will bring together the District Training Team to be created under the proposed project, with the medical consultants attached to the ICDS blocks in the district. In each case, the purpose would be orient the participants to the priorities to be adopted by the family welfare program under the Eighth Plan, and to ensure that a common approach to training workers of both services is taken. In each case also, state or district managers from both programs would be asked to participate, to promote the exchange of experience between the field and classroom. 11. At the field level, MOs and CDPOs would have received joint orientation at the district-level workshops. Thereafter, a series of workshops would be held at the block-level to bring together all ICDS and family welfare field staff in a given sector- i.e. a group of up to three supervisors (two HAs and an MS), ten MPWs (male and female) and 20-25 AWWs. The trainers would be the BMO and the CDPO, assisted by a member of the District Training Team. The purpose would be to orient the group as a team to the proposed family welfare priorities; work out plans for the sector area in the context of the district and block level plans already developed; and to address problems in service delivery, IEC or inter-departmental cooperation in the local area. Such workshops would be carried out on annual basis to review progress and problems, and to draw up plans for the succeeding year. Harmonizing Basic Training Curricula and Operational Strategies 12. The orientation training summarized above would be informal, based on curricula to be developed jointly by MOHFW and WCD. In addition, there is a need to ensure that on-going formal training course curricula in both family welfare and ICDS, as well as ICDS operational strategies, reflect the priorities of the proposed Eighth Plan family welfare program. Issues which must be addressed include, for example, the need to reflect the special emphases of the UIP Plus program; to incorporate the new strategies for IFA and Vitamin A; to develop a new module for Safe Motherhood, including a consistent set of guidelines for identifying obstetric complications and for - 60 - Annex 5 Page 7 referrals; and to revise ICDS training curricula to follow the new policy guidelines on diarrhoeal disease control developed by MOHFO. In these and other areas, changes will need to be made to the basic and in-service training curricula for both MPWs and AWs, and therefore also in supervisor training curricula at all levels. A Committee from MOHFW and WCD will be set up to systematically identify needed changes, which will then be pursued with relevant authorities such as NIPCCD and the Nursing Council. - 61 - Annex 6 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT TRAINING 1. The main objective of training is to ensure that project staff develop, strengthen and retain capabilities to perform their jobs well. Training is a critical element for ensuring quality services, creating and maintaining staff motivation and improving staff communication and community mobilization skills. The specific objectives of training are to: (a) create an understanding of the roles of different worker cadres; (b) develop requisite knowledge and skills; (c) develop and sustain favorable attitudes and motivation; (d) increase communication and community mobilization skills; and (e) promote teamwork among nutrition and health personnel. 2. For all categories of staff, the project would support four types of training: pre-service for new staff, orientation training for existing staff in the project areas, regular in-service training and problem solving workshops. In addition, special field-based training would be provided to those found deficient. To improve quality of training, the project would strengthen training institutions. It would establish mobile training teams for in-service training. The responsibility of managing the training activities would be that of the project-supported technical program cells under the project coordinators. Pre-Service Training 3. Pre-service training of AWWs and supervisors in both Bihar and Madhya Pradesh would follow the established ICDS pattern (see Table 1, below) and would take place through the existing network of training centers in each state. Bihar and MP, respectively, have 26 and 35 Training Centers (ANTCs) for AWWS. For supervisor training, Bihar has one Middle Level Training Center (MLTC), and will set up a second under the project, and NP has two. Pre- service training for block-level managers--Child Development Project Officers (CDPOs)--would take place at the National Institute for Child Development and Public Cooperation (NIPCCD) in Delhi or its regional centers. - 62 - Annex 6 Page 2 Table 1 - Pre-service Training Category Institution Type of Training Duration AWW ANTC Basic training in each of 3 months (35 in MP, the program components, 26 in Inter-personal Bihar) communication skills Supervisor MLTC Program components 2 months (2 in MP, supervisory and monitoring 2 in Bihar) skills CDPO NIPCCD Program components, 3 months Monitoring and administration 4. The above pattern of training works well for establishing ICDS projects but requires strengthening to ensure sustained quality of services and desired coverage. Specifically the following weaknesses have been identified: (a) ANTCs are often run by NGOs and are paid depending upon actual training carried out. Many AWTCs do not have adequate numbers of trained instructors, facilities or equipment. The linkages between the program and the AWTCs is weak. Therefore, field placement to improve skills in work-settings remains weak. Together they reduce the quality of training. (b) Even though NIPCCD, as an apex institution, has both operations research and training tasks, there is no systematic mechanism to fe-d operations research findings into training. Similarly, the linkages between the program mangers and training institutions is weak. Therefore, the cycle of program needs determining operations research leading to findings being disseminated through training breaks down. (c) Although health and nutrition staff are expected to work closely, and in many cases they do, they neither receive joint training nor the training is harmonized at pre-service level. In TINP I, despite structural difficulties, joint training helped improve their coordination. Recently GOI has also initiated joint in-service training. But it needs to be expanded, made more systematic and strengthened. (d) In-service training is largely ad hoc and in the nature of refreshing pre-service training. It is not used to ensure sustained delivery of quality services by remedying deficiencies in or upgrading technical skills, developing problem solving Lkills and for dissemination of operations research findings. - 63 - Annex 6 Page 3 5. The project would strengthen training institutions. NIPCCD recently carried out a national evaluation of all AWTCs in terms of numbers trained, staff and other physical infrastructure and judgment on quality of training. The NIPCCD review found major qualitative differences among AWTCs both within and between states. To strengthen the AWTCs in Bihar and MP, the project would fund frequent training of trainers, provision of necessary equipment and supplies and technical assistance for curriculum review and development and to improve implementation arrangements for field placement. In both states, curriculum preparation, material development, and planning and monitoring training activities would be the responsibility of project- supported technical program cells under the project coordinators. Orientation/In-service Training 6. Training to orient existing ICDS staff to the objectives and content of the project would be mainly field-based at the block and district level. It would also involve joint training of : (a) AW'Js and female heulth workers; (b) ICDS and health supervisors, and (c) CDPOs and Medical Officers. CDPOs, district and state-level ICDS officials would receive orientation at NIPCCD and the network of state training institutions. 7. In-service training to improve program performance would mainly be field-based and would focus on a relatively few themes directly linked to program development. It would emphasize upgrading of technical and problem solving skills, exposure to new ideas and feedback on performance and would be conducted jointly for ICDS and health staff. Currently, refresher training is imparted to staff for around 7-10 days once in two years by the pre-service training institutions. However, this training is treated as residual after pre-service training obligations are met and remains ad hoc. 8. For in-service training, the project would establish 26 mobile training teams each in Bihar and Madhya Pradesh with specially appointed staff. Each team will cover around ten blocks and will train supervisors, who in turn, and uaider the team's guidance, will train village level staff. The teams will work in close collaboration with other district and block level staff and teams being established under the IDA-aided sixth and seventh population projects in Madhya Pradesh and Bihar, respectively. The teams would report administratively to district ICDS officials acting on behalf of the state Deputy ICDS director responsible for training. Service delivery, supervisory and managerial personnel also would receive refresher training in state institutions every three years. Provisions would be made for the introduction of participatory training techniques for mobile training teams by qualified NGOs. 9. Training of TC and MLTC trainers also would take place for three days in the first and fourth years of the project. Yearly training workshops would promote communication of successful train'ng techniques and problem- solving approaches to institutional and field-based training staff and to service delivery personnel, supervisors and managers. In each state, a training cell headed by a Deputy Director would be responsible for curriculum - 64 - Annex 6 Page 4 review and development and for the planning, overall scheduling and monitoring of training activities. Table 2 - Orientation Training Staff Where Content How Duration AWW ANTC Project orientation, Batch of 15 days MCH and Family welfare 50 comunicationf, recording and reporting Helper Block Conducting action songs, Batch of 1 week weighing children, sanitation 25 use of disposable delivery kits and hygienic food preparation Supervisor MLTC Project orientation, Batch of 15 days communication, community 30 mobilization, and monitoring and reporting CDPO NIPCCD Project orientation, and Batch of 1 week monitoring and reporting 30 MO Management of nutrition Batch of 2 weeks disorders and project orientation Part of the orientation training would be conducted jointly for ICDS and health staff. - 65 - Annex 6 Page 5 Table 3 - In-service Training taff Where Content How Duration per year Dint NIPCCD Managerial and supervisory Batch of 1 week DPO/HO skills 30 Dint sup/ Block Supervisory practices MTT 8 days Aint MPWFI Block Coordinated working super- 7 days -JW visors int AW Coordinated working MPWF/ANW 2 days ?lper/dai 1st/nut Trng Managerial and Batch of 1 week talth off. Inst. supervisory skills 20 .her dist Dist. Orientation Workshop 2 days :aff .ate selected Observe successful study .ficers states practices tours - 66 - Annex 6 Page 6 Table 4 - Training of Trainers Training of trainers would consist of technical and training kills. Additional training content for specific categories is indicated elow. taff Where Content How Many Duration ategory NTC NIPCCD Field experiences Batch of 3 weeks rainers 20 re-service ITC Selected Exposure to new ideas Batch of 1 week .ainers insts. 20 per year l-service rT Selected Exposure to new ideas batch of 1 week insts. 12 teams per year .TC NIPCCD Field experiences Batch of 3 weeks -ainers 20 -e-service .TC Selected Exposure to new ideas Batch of 1 week -ainers insts. 20 per year l-service - 67 - Annex 7 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT IMPROVING WORK ROUTINES IN ICDS 1. Baseline surveys in project areas show that service coverage needs to be substantially improved. Simultaneously, addition of new services, particularly through the Child Survival and Safe Motherhood Project (CSSMP), would make additional demands on worker's and supervisor's time. Existing guidelines for Anganwadi (AW) functioning, AW worker (AWW) routines and supervisors' monthly work plans, all need to be refined to: (a) ensure that available manpower can deliver the desired services while increasing service delivery coverage; (b) beneficiaries conveniently get the services they need, and (c) services are delivered efficiently, optimizing the use of both worker and beneficiary time. Anganwadi Worker Routines 2. As a first step towards improving AWW routines, it is necessary to prepare an inventory of tasks to be carried out by the AW. An illustrative list of services to be provided, when and how they should be provided and to whom is given in Table 1. Table 1. Services to be Provided Services When Where/How To Whom Supplementary feeding Daily (specify At AW Beneficiary to children time) selected using specified criteria Immunization Once a week At AW According to immunization schedule Growth monitoring Quarterly for Selected All children 6-36 months locations and six- monthly for 3- 6 year old children - 68 - Annex 7 Page 2 Services When Where/How To Whom Home management As needed AW and home All families with of diarrhoea visits pre-school children Vitamin A Once in six Jointly with All children 6 months growth months to 6 years monitoring Minor ailments As needed At AV and Women and children home visits Case management and As needed To MPWF and Severely referral PHC malnourished and those needing Pre-school education daily (hours) At AW Selected children 3-6 years of age Supplementary feeding daily At AW Women celected to pregnant and according to a nursing women specified criteria Antenatal care Once a week During MPWF Pregnant women visit Iron and folate As needed At AW or at Pregnant women home visits Birth weight Within 1 week At home All births of birth Health and nutrition Once a month Home visits Families with education per family malnourished children Health and nutrition Once a month Women's group Members education per women's meetings group Survey Once a year Home visits Community settings Community As planned According to Entire community mobilization guidelines Records Daily At AV By AWW - 69 - Annex 7 Page 3 Work Methodology 3. The above services can be grouped according to their frequency of provision: Daily Supplementary feeding Pre-school education Follow-up of severely malnourished Health and nutrition education to women Minor ailments (as needed) Register births and deaths Take birth weight (if a birth has occurred) Records Iron and folate (as needed) Case management and referral (as needed) Weekly Immunization day Antenatal care Monthly Women's group meeting Growth monitoring of severely malnourished Records and reports Sector/block meeting Quarterly Growth monitoring of children Health check-up by medical officer Update survey Annual Revise survey of entire population 4. The daily routine for AWWs involves a combination of work at the AW for specified hours and home visits. All weekly activities are to be carried out in collaboration with health staff. As Wednesday has been specified as immunization day, health activities can be carried out on that day. All remaining activities have to be scheduled according to the local situation. Quarterly and annual activities have to be specifically scheduled. - 70 - Annex 7 Page 4 Supervisor Work Routines 5. Generally a supervisor visits each AW in her sector once a month. Each AW visit takes a day. Therefore, around 17 days a month would need to be spent on AW visits. The remaining time of supervisors is spent in preparing reports and attending meetings. 6. It is difficult to develop supervisory work routines in the absence of a functional study determining how supervisors currently spend their time and why. Therefore, such a study should be carried out before revised supervisor work routines are developed and tested. Testing Work Routines 7. Work routines need to be tested for their feasibility and efficacy in realistic field settings before their program wide implementation. A procedure for the field testing in selected blocks is briefly described below. 8. To initiate the process, an agency to carry out the study needs to be identified and a study advisory committee needs to be established, consisting of senior ICDS managers, a trained behavioral scientist preferably familiar with operations research, a CDPO and a supervisor. 9. The study would consist of five phases: functional analysis, refining the work routines, implementing new work routines in testing areas, evaluation of new work routines and final revision of work routines before their program wide implementation. The process would be expected to take a total of around 20 months as follows: designing the study, 3 months; functional analysis, 3 months; refining work routines, 2 months; implementing work routines, 8 months (6 weeks to design training, 2 weeks' training, 6 months for routines to stabilize); evaluation of new routines, 3 months; refinement and preparation of final work routines, one month. Each phase is discussed below. 10. Phase 1. Functional Analysis. Functional analysis is carried out to assess how functionaries spend their time and why. Each functionary needs to be observed for about a week in the selected areas. In addition, infrequent events also need to be observed. Generally functional analysis would proceed as follows: (a) Each activity is categorized (such as pre-school education, community contact, home visits, immunization); (b) The observer records beginning and ending of each activity as it occurs and comments on this activity in as much detail as possible. This information is summarized for the day as to how much time is spent on each activity; (c) At the end of the week, the observer summarizes the findings of the study and discusses it with the functionary being observed. - 71 - Annex 7 Page 5 Their recommendations to improve quantity and quality of their activities are also recorded; (d) From the above record, the proportion of time spent on each category of activity is estimated for different types of the functionaries being observed; and (e) The analysis should take place in a sample of 4 AWs in each of at least 6 blocks representing different geographic and sociocultural circumstances. 11. Phase 2. Refining the Work Routines. Based upon the above study, work routines need to be refined, incorporating realistically the constraints encountered in the field situation. It may also be possible to remove some of these constraints by strengthening support systems such as logistics and information. 12. Phase 3. Implementing New Work Routines. Staff in the test areas need to be trained in new work routines and guided by supervisors in following these work routines. Difficulties or bottlenecks in following the new work routines need to be resolved as they arise. 13. Phase 4. Evaluation of New Work Routines. Once the new work routines stabilize (usually in about six months), they need to be evaluated through a repeat analysis of functional analysis as in phase 1. In addition, the impact of new work routines on performance needs to be examined. 14. Phase 5. Refining the Work Routines. Usually the above evaluation would reveal opportunities for minor improvements in the work routines. These need to be incorporated and final work routines prepared for wider implementation. Implementing New Work Routines 15. A careful process of institutionalizing the new work routines would be necessary. This process would involve preparation and dissemination of guidelines for the new work routines. It also needs to be incorporated in the training curriculum. Feedback from use of new work routines needs to be obtained until they are institutionalized. - 72 - Annex 8 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT PLAN FOR INTRODUCTION OF SERVICES IN A NEW BLOCK 1. Introducing ICDS services in an appropriate manner is critical for achieving desired high performance levels. Investment of additional resources and time at the introduction stage can accelerate improvements in health and nutrition status. Special attention needs to be given to instill good working habits in AW workers (AWWs) and helpers, prepare the community, establish community linkages, and set up a good quality data base on health and nutrition status in the AW area. 2. A large number of preparatory activities are required for making an ICDS project operational. These are listed below and broadly could be grouped in three phases: administrative set up and community preparation, training and operationalization. (a) Establishing Administrative Set Up Appointment of CDPO and Supervisoros Orientation camps of district, state and block officials to tribal considerations and communirty participation; * Mapping each block with attention to accessibility of villages and of hamlets in every village, and the social composition of these habitations /; Accurate estimation of total number of AWs and AWW and supervisors' posts required in block on the basis of the detailed mapping and with attention to covering remote habitations; Selection of villages for AWs; ** Selection of AWWs and Helpers; and ** Selection of Anganwadi Center locations. (b) Community Awareness Creation and Mobilization Activities * The CDPO and/or supervisor shall contact official and non-official village leaders, especially traditional tribal leaders and opinion-makers in villages with tribal populations, to familiarize them with health and nutrition issues and ICDS services; 'Acdvies maked wh fthe same number of ases wlmocacu smubarooly - see S*dule fotrodducton of SerAs' - 73 - Annex 8 Page 2 ** The CDPO and/or supervisor shall hold village meetings to make all villages, all communities within villages and their separate habitations, and the majority of members of each community aware of health and nutrition issues and ICDS services. They shall discuss the communities' expectations and roles in the functioning of ICDS, and seek community participation in activities including the selection of the AWW, location of AW, introduction of services, and management of AWs; Formation of Village-level Committees (VLC)Q to assist in and oversee the management of AWs */, based on interest generated through initial village meetings; and Formation of Block-level Committees@ to advise on and monitor the introduction and delivery of services. (c) Training Pre-service training of CDPO, eupervisors, AWWe and helpers; and Joint orientation training of health-nutrition staff in the block. (d) Supplies Procurement and supply of equipment and material such as weighing scales, growth registers, dhurries, almirah, cooking vessels and utensils, Jeep, typewriter and other office equipment. (e) Service Initiating Activities in the Community - Household survey by AWW and VLC; - Regular home-based contacts between AWWs and pregnant women and infants; - Establishment of women's groups@ by the supervisors and AWWe and VLCs; and - Meetings of small groupse of village people, especially but not limited to target mothers and mothers of target children, with AWWs, VHNs and, whenever possible, supervisors to discuss nutrition issues. (f) Regular Activities at the AW The supervisors shall contact official and non-official village leaders to familiarize them with health and nutrition issues and ICDS services; 2Comn*te and goups maied @ sa icLde rba person at ea t sam prpoitn as t populatof ft village block, hI to ca of the bkck-I conmmte) - 74 - Annex C Page 3 Hold village meetings to make community aware of health and nutrition issues, ICDS services and the role of community in ICDS functioning and seek community participation in the introduction of services; and Begin regular operation of AW activities, including weighing and growth monitoring. (g) Attention to Severely Malnourished Children When ICDS services are being introduced, there may be a large number of severely malnourished children requiring attention. It would be useful initially to focus on them through the following activities: Health check-up of children with special focus on grade III and IV children; Initiation of double rations for severely malnourished children; Intensive education of their families; and Health referral of severely malnourished children who do not respond to supplementation. 3. The above activities need to be carried out in a synchronous manner to ensure optimum utilization of resources. For instance, selection of AWWs and their training should be synchronized so that the time gap between the recruitment and training is not large. Careful community preparation activities are necessary for securing participation in AW services. - 75 - Annex 8 Page 4 Schedule for Introduction of Services (PIS) Months 1 2 8 4 6 7 8 s 9 10 11 12 1a 14 16 18 17 18 Phase 1. AdmInistrativ, and Community Preparatlon Appoint CDPO Appoint Supervisors Train CDPOs Train Supervisors Orient Toam to Tribal A CP Map Block Contact Village Leaders Select Villages for AWs Hold Village Meetings Select AWW and Helpers .... Select Anganwadi Locations Form Village Comlittees (VLCs) .. Monthly Meetings of VLCs Form Block Level Committoes (BLCs) Si-Monthly Meetings of BLCs Arrange for Supplies Phase 2. Training of Primary Staff Train AWW (Three-month module) Train Helpers: Joint ICOS-Hesith Training (AWW Batch 1)4, Phaso 8. Operationallzatlon Small Group Meetings Formation of Women's Groups Household Survey Preparation of Registers Home visits to PW and Infants Start AW Activities Weigh Children Education of Mnd. Ch. Families Health Check up of Mnd. (ANM A AWW) Referral of Severely Mnd. 3. To be done In Second year approximately 3 onths afterend of firs tining. - 76 - ANNEX 9 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT COMMUNICATIONS COMPONENT Introduction 1. The overall objectives of the project cannot be achieved without strong support to make beneficiaries aware of ICDS services; mobilize their participation; and change health and nutrition behavioral practices in the home. The communications component aims to stimulate demand for project services, alter household child feeding and care practices, encourage pregnant women to register early, prepare adolescent girls to effectively perform their roles as future mothers, motivate village level workers by enhancing their image and credibility withln the community and promote community involvement. 2. Currently communications support for ICD8 in both states is very weak. AWWs have inadequate counselling skills for health and nutrition education of women. They are neither supported by appropriate audio-visual aides nor other media is used to reinforce their communication with the community. Constraints on effective communications include lack of an institutional set-up or appropriate communications planning skills either within WCD or at the state ICDS directorates; insufficient differentiation of both ICDS and family welfare communications activities to respond to the different cultural contexts of the many tribal groups in the project area; and a tendency for 'nformation, education and communication (IEC) interventions to be 'supply-driven', focusslng on materials production and distribution, rather than on specific program goals and target groups naeds. 3. The component design would deviate from this 'supply-driven, tradition. Instead of striving to meet quantltative targets such as numbers of posters and film shows, it would emphasize qualitative context of what improvements in behavior and attitude should occur in the home and the community. It would r rner the existing resources, skills and expertiss both within public and private agencies to Lmplement an effective communications program. It uses behavioral outcomes as measure of effectiveness of communication inputs, establishes research and communication interface, integrates product marketing approaches and would use communications services from marketing research and advertising agencies. 4. The component not only seeks to develop communications materials but also emphasizes development of communleations processes and systems from a long-term perspective. It would develop necessary institutional capacity within each state for communications planning, strategy development, research implementation, monitoring and evaluation so that cotraunications support addresses needs in each state, optimally develops and utilizes resources and creates relevant expertise. - 77 - ANNEX 9 Page 2 5. The appropriateness of the communication strategy depends on a number of factors, among whlch the following are important: * An understandLng of the needs, problems and opportunLties; * Rellable data base to assist ln the development of a relevant strategy; * Realistic goals and objectives; * An assessment of capabilities and expertise and mechanisms for strengthenLng main shortfalls: * An understandLng of reach, access and credlbllity of various medla and methods among beneficiaries. 6. Accordingly the broad outllnes of the component strategy have been derived from current understanding of these factors. However, lnformatlon on several of these aspects is not available and a data base ln terms of exlstlng studles and communLcatLons resources is currently in progress. It would need to be supplemented by a base-line study and formative researches durlng the flrst year of the project. Prevlous Experiences 7. Major issues raised by a recent revlew of previous experLences of IEC actlvlties for improving women's health ln India are as follows : (a) IEC efforts under the family welfare program have generally not been successful. As a result IEC programs have little credibility with key decLsion-makers and influentials at various administratLve levels; (b) private sector involvement and participation in IEC should be increased; (c) IEC programs should be flexible and responsive to state's needs; (d) State, district and block-level personnel need motivatlon and technlcal strengthenlng to support and implement IEC activitles more satisfactorily; and (e) the communications skills of field level personnel need upgrading. I 'Improving Women's Health in India: Experiences and New Initiatives through IEC Programs", a report prepared by Marcla Griffiths, Wilma Lynn and Susan Brems of the Manoff Group for the Population, Human Resources, Urban and Water Operations Division of the India Country Department, The World bank, May 1991. - 78 - ANNEX 9 Page 3 8. TINP I and a USAID-assisted project to strengthen ICDS operations in one district each of Gujarat and Maharashtra have special lessons for this project, which are briefly summarized below. 9. The IEC strategy for TINP I involved advocacy for the project and its objectives; nstitutional strengthening in terms of training; program support, particularly in relation to the goal of integrating health services with the community nutrition efforts; and behavioral change. The media strategy included mass media, interpersonal communications, primarily involving the community nutrition workers (CNWs) and the multi-purpose health workers and community participation through women's working groups. The content of the communication covered the many project priority areas: growth monitoring, breast feeding, weaning, anaemia, vitamin A, antenatal care, sanitation and diarrhoeal diseace control. 10. A wide range of mass media material was produced in the project. But careful pretesting of this material would have improved their quality. Both, community nutrition workers and women's working groups emerged as powerful vehicle for communication. The lessons from this communication effort are: community workers can be trained to become effective communicators; strategies for communication should be developed after client perceptions have been carefully studied; a systematic approach should be used for development of communications; home visits are potentially important educational opportunities; and carefully formed women's working groups can be very effective in gaining project acceptance. 11. An assessment of communications activities being carried out in ICDS, as a part of USAID-assisted project in Gujarat and maharashtra, revealed that AWWs had neither received training in counselling nor any audio-visual material. Moreover she felt that she does not have enough time for these activities. There were message inconsistencies at various levels, some of these also were in conflict with AWWs' own beliefs. Formative research in pregnant women's behavior was carried out through in-depth interviews and focussed group discussions. Based on findings of this research, a communication strategy was drawn up which used a credible authority figure as a communicator to build on positive beliefs held by women. AWWs were specially trained and counselling cards were developed to support their inter- personal communication. After seminars of higher level officials were carried out and communications activities monitoring was incorporated in the regular monitoring systen., the quality of these communication activities improved. 12. The project was successful in achieving most of its nutrition improvement objectives. However, communication support had not reached the desired level. Although AWWs were well informed about desirable health and nutrition behavior, this information had not percolated to women adequately. While highlighting difficulties in strengthening communication activities, the project also provides several valuable lessons: the extensive formative research is invaluable; AWWs perceptions of her role as an educator can be altered by training; communication activities should be monitored along with other ICDS activities; and private sector firms can be involved but administrative arrmngements need to be streamlined. - 79 - ANNEX 9 Page 4 Base-line Findings 13. The base line findings regarding service coverage in the project areas is summarized in Annex 1. However, it also provided some insights in the health and nutrition behavior: (a) Lack of awareness is a major reason for underutilization of various services: 18% mothers were not aware of immunization services, and 48% were not aware of the need for antenatal services. (b) Growth monitoring is not utilized for nutrition education as less than half the mothers had been explained its purpose. (c) Very few women ate more during pregnancy and only about a half restricted their activities. (d) About 10 to 20% women delayed breast feeding for 2 or more days after the birth. (e) Tribal groups are highly differentiated buz the IEC activities are undifferentiated. 14. The qualitative and other studies have revealed the potential of well organized communication activities for making services more widely known and acceptable as well as generating some community participation in AW activities. Communications component 15. In view of the above base line findings, lessons learnt from previous experiences and available institutional capacity for communication, the main features of the communications component are that it would: (a) be simple in the first years of the project, focusing on a few priority themes and directly related to project goals; (b) build on successful communications experiences in each state, and draw on a variety of communications resources in the public, voluntary and private sectors; (c) be flexible geographically to respond to different client needs, and flexible over time to respond to changing program priorities; and (d) emphasize constant formative evaluation of results in the field, feeding back into strategy design. - 80 - ANNEX 9 Page 5 16. Knowledge and behavioral objectives for the communications component are still being finalized. However, an illustrative list of these objectives are as follows: - % of the community members able to mentlon 6 YCDS services - % of community members identifying conditions when supplementary nutrition would be needed - % of mothers who can state at least two benefits of growth monitoring - % of 5-12 month old children who received weaning food from 6 months of age - % of newborns weighed within 10 days of birth - t of women knowing when to register in case of pregnancy - % of women registering by 16 weeks of pregnancy - % of pregnant women who can state at least three benefits of antenatal care - % of pregnant women who know correctly how much they should eat - % of husbands/mother-in-law who can state three benefits of pregnant or nursing women eating more food - % of mothers who can state advantage of vitamin A administration - % of adolescent girls who can mention advantages of delaying marriage to 18 years 17. The components in both states would include support for institutional development, research and evaluation, community preparation before initiating ICDS activities, several experimental modules and expansion of those found successful and development of print materials, posters, flip books and folk programs in support of interpersonal communication activities. In addition, all staff would receive communications training as a part of their regular pre-service, orientation and in-service training. 18. In Madhya Pradesh, the experimental modules planned are radio broadcasts and formation of listeners groups, provision of cassette-cum- radios, support for folk programs, village campaigns, and support for developing materials in support of interpersonal communication. The communicationo component in Bihar would be more modest in view of limited institutional capacity within the state. It includes provision of audio systems, desk top publishing systems and printing newsletters, exhibitions At village fairs, baby shows and folk performances. 19. The project's communication activities need to be coordinated with MCH and family planning communications, particularly with those of CSSMP, for ensuring consistency of messages, economy in operations and reinforcing each others messages. - 81 - Annex 10 Page 1 INDIA SECOWD INTEGRATED CHILD DEVLOPMENT SERVICES SCHEME MONITORING AND EVALUATION 1. The primary objective of monitoring will be to: (a) help program managers to monitor service delivery and identify bottlenecks (as well as new/more efficient delivery modes); (b) give program managers continuous feedback on program outputs; and (c) develop channels for the flow of program information from the field to the program managers and, equally important, from the managers to the field. 2. Different levels of program management need to focus on monitoring different aspects. Whia the block level should focus on monitoring critical activities, district x-view should monitor critical outcomes and the state level should deal with impact objectives. 3. The project coordinator's office would be responsible for monitoring overall project inputs, activities and outcomes. Statistical assistants would be responsible for compllation of data at the field level and supporting the process of feedback for the lower levels. They would receive traLning in analysis and utilization of data generated by the monitoring system. Supervisors would be responsible for ensurLng reliability of data. They would carry out sample checks of field records, train those AWWs who are deficient in record keeping and annually share AW performance with the communLty. 4. ICDS has revsLed its reporting system which is currently being implemented in the two states. A USAID-assisted project has developed a computerized progress reporting system whlch can provLde feedback indicators as well as time series and cross sectional comparisons. The project would support implementation of this system and supplement lt for monitoring project supported communication, community mobllizatlon and adolescent girls' activities. 5. The progress towards process objectives of the project would be monitored using a monthly progress reporting system, as follows: (a) Early registration of pregnant women by 16 weeks--number registered compared to number estimated to be more than 16 weeks in pregnancy; (b) Total registration of pregnant women--total new reglstered during the perlod compared to estlmated number of pregnancLes during that period; - 82 - Annex 10 Page 2 (c) Food supplementation of registered pregnant women with inadequate nutrition status (for at least 20 weeks)--number of pregnant women received supplementation compared to estimated pregnant with more than 16 weeks in pregnancy; (d) Food supplementation of registered nursing women with malnutrition in pregnancy (for at least 16 weeks)--number of nursing women supplemented compared to estimated number of such women; (e) Regular growth monitoring (4 times a year) of children 0-3 years-- number of children classified by nutrition grade status compared to enumerated number of children 0-3 years; (f) Supplementation of monitored children 0-3 years with grade II-IV malnutrition--number supplemented compared to number in these grades of malnutrition; (g) Completed referral of severely malnourished children 0-3 years-- number completing referral compared to number referred; (h) Growth monitoring of children 3-6 years (twice a year)--number of children classified by nutrition grade status compared to enumerated number of children 0-3 years; (i) Completed retfrral of severely malnourished children 3-6 years-- number completing referral compared to number referred; (j) Pre-school attendance (80 percent of working days)--pre-school attendance compared to number registered and number registered compared to number of eligible children; (k) Additional feeds of local weaning food initiated by 6 months in infants--currently not reported; (1) Provision of 4 additional weaning feeds/day by 9 months in infants- -currently not reported; (m) Reduction in short (< 2 yrs) birth intervals--currently not reported but available in AW records, perhaps could be summarized by MPWF. 6. The following objectives should be monitored jointly by health and ICDS staff (using monitoring system similar to CSSMP): (a) Tetanus toxoid immunization of pregnant women; (b) Consumption of iron and folic acid tablets for at least 12 weeks by pregnant women; (c) Increase in temporary CPR levelsl - 83 - Annex 10 Page 3 (d) Immunization (UIP-6); (e) Administration of vitamin A semi-annually to children 6-36 months; (f) Household use of oral rehydration in the last incidence of diarrhea in children 6 -72 months; and (g) Treatment of pneumonia with co-trimaxazole. 7. Annual progress reports would be used to monitor provision of project inputs. Generally the information is available for the following inputs or activities: (a) Staff position; (b) Supplies; (c) Training; (d) Space for AWs; (e) Community participation. 8. The project supported inputs and activities for (i) family referral; (ii) enhanced medicine kits; (iii) construction of AWs and godowns; (iv) therapeutic supplementation supply; (v) communications, and (vi) adolescent girls scheme would need to be added to the above reports. - 84 - Annex 1 1 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT PROJECT ANNUL. MIR-TERN AND FINAL 3VAUAIONS 1 * In addition to regular progress monitoring, three kinds of special reviews will take place under the projects - an annual project review to help gulde formulation of the project work plan for the next financial yearl - a mid-term evaluation to take stock of multi-year project accomplishments and guide course correction of fine-tuning for the remaining project years; and - a final evaluation to assess overall achievement of project impact and process objectives. Each is summarized below: Annual Reviews 2. RevLews or project implementation will take place in November of each year until the project closes. The first review will take place in November 1993. Annual reviews will focus principally on year-to-year progress toward the achievement of project impact and process objectLves and functioning of the support systems to achieve those goals. The review will assess changes in both quantitative and qualitatlve aspects of ICDS including: - nutritional status of chLidren <3 years of age; - availability of services; - community perceptions of and support to ICDS; - anganwa,di functioning and operations, ineluding regularity of growth monitoring, household visits, conduct of pre-school programs; - conduct operations research and special studies; - coordination between health and nutrition services; - effective service delivery in tribal areas. - 85 - Annex 11 Page 2 3. Project support function. to be covered by the annual reviews includes - accomplishments under the annual project work plan, including numbers of new blocks initiated and adherence to plans for training and introduction of services; - procurement and logiLtics, including availability of drugs and nutritional supplementation at service delivery points, civil works construction and maintenance; - staffing and working of the project management unit; - budgeting, fund releases and expenditures; - accounting and auditing; - nutrition and health staffing at and below district levels. Mid-term and Final Evaluations 4. The mid-term and final evaluations will assess the same factors as the annual reviews as well as other lndLcators for which changes are more likely to be observable on a multi-year than annual basis. These additional factors include changes in and diarrhoea management, and reductions in low birth weight. The mid-term and final evaluations will take place in November 1996, and November 1999, respectively. The evaluations wlll replace the annual project reviews in those years. Methodoloav 5. A baseline anthropometric and qualitative survey oimilar to the one carried out by the National Institute of Nutrition (NIN) in 1989-90 would take place in proposed project areas. It would take place by the end of July, 1992, and would distinguish between areas where ICDS already operates and those where it is to be introduced. The deadline is to assure seasonal consistency with future annual surveys, which need to take place specific indicators to be measured in the annual, mid-term and final review/evaluations. The survey also would take place in two control areas outside the project: one where ICDS currently operates, and one where it does not. Inclusion of control areas ie to account for secular nutrition changes whlch should not be attributed to project inputs. The baseline survey would be repeated in 1996 and 1999 as the basis for the mid-term and final evaluations. A smaller sample. confined to areas where project service had been introduced, would be surveyed in the intervening years and would exclude variables better assessed on a multi-year basis. - 86 - Annex 11 Page 3 6. Supplementing the survey findings would be information from the state ICDS monitoring system, from financial records, from the project management cell and internal reviews of health/nutrition coordination and other particularly important aspects which monitoring and survey data cannot adequately capture. 7. An independent consultant would carry out the analysis and draft the reports of the annual review and mid-term and final evaluations. - 87 - Annex 12 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES OPERATIONS RESEARCH 1. More than 600 ICDS evaluation efforts and studies have taken place from time to time, making it probably one of the world's most reviewed programs. As might be expected, the quality of these efforts is mixed, but several have attempted comprehensive and rigorous assessments of the program. However, there are very few operations research studies which have experimented with alternative program software options or supplementation strategies. 2. To remedy this situation, TINP II and ICDS I had included several operations research studies to introduce, test or modify strategies. Since operations research is generally carried out in close collaboration with program managers and deals with program needs, the results are more likely to be applied to improving the program performance. TINP II Overations Research 3. The most important operations research in TINP II is the supplementation strategy to be followed for accelerated improvement in nutrition status of malnourished children. Early indications from this research are that a supplementation criteria based upon growth faltering, plus those moderately malnourished, can lead to significant improvements in overall nutrition status over a short period. ICDS I Operations Research 4. Alternative Systems of Theraoeutic Suoplementation. In view of the complex interaction of several variables, promising alternative supplementation procedures would be tested in at least 8 blocks in each state for the first three years. Operations research would take place on two alternatives. Under one scenario, an additional therapeutic, on-site daily supplement would be provided to moderately and severely malnourished children. Children falling in grade II or below et monthly weighing would receive therapeutic supplementation until tbsy are able to maintain grade I or better status for successive monthly weighings. Alternatively, a therapeutic supplementation would be provided in lieu of current supplementation using ICDS beneficiary selection procedures. - 88 - Annex 12 Page 2 5. Supervision. A study would be carried out during the first project year to diagnose the causes of shortfalls in the quantity and quality of supervision and identify actions to remedy them. 6. work Organization. Development of optimal work routines requires a better understanding of how workers now spend their time. Therefore, operations research to assure a better fit between priority tasks and time to perform them was planned during the first year of the project. 7. Nutrition Rehabilitatlion Centers. Some NGOs have experimented with nutrition rehabilitation centers which provide residential facilities for mothers and children. Besides medical care, the child receives an appropriate diet under the guidance of a nutrition supervisor and the mother is educated in child nutrition using locally available food. ICDS I supports establishing a few experimental centers. 8. Women's Literacy Courses. Courses for Women's Integrated Learning for Life (WILL), emphasizing functional literacy and health and nutrition education, were planned in 14 blocks on an experimental basis. The courses comprising about 15 women, would meet every working day for 10 months and would cover functional literacy, health and nutrition, and other skills for improving their quality of life. The classes would be conducted by the AWW in the evening for about an hour. Depending upon the evaluation of this experience, a decision would be taken regarding expansion of this scheme to other project blocks. 9. Adolescent Girl's Scheme. Under this scheme, the AWW would select three girls for involvement in AW activities. After initial training, each girl would assist in AW activities for two days a week and serve as its link with the community. 10. Income Generation Schemes. Two different kinds of credit programs for women would be tested under ICDS I to assess their viability and effectiveness. 11. In addition, studies are planned to deal with special problems such as anaemia, low birth weight and worm loads. CSSMP ODerations Research 12. CSSMP project also includes a program of operations research which would have a bearing on the project's operations. CSSMP includes support for several researches dealing with childhood diseases and safe motherhood interventions. Of particular interest, however, would be the following two researches which have a direct effect on the project's activitiest - 89 - Annex 12 Page 3 (a) Anaemia Prophylaxis. Evaluation of a series of related issues including roasons underlying and ways to overcome compliance with iron and folate supplomentation; assuming compliance, effectiveness of varying levela of dosage; and importance of deparasitLzation. (b) District Planning. Options for developing successful district planning mechanisms. Proiect9s Operations Researgh 13. This project would primarily emphasize utilization of the findings from the above researches. However, a few operations research studies would be required to assess the nature of local problems and develop their remedies. The project has provided for funds to commission operations research studies with appropriate outsLde agencies. Whlle the studies to be done would depend upon program needs as they emerge, an indicative list of operations research planned follows. 14. Serice peliver for Sagttergd Eonulations. It is not cost- effective to establish AWe in population settlements of less than 400 persons. To extend coverage to these populations, which may have the most serious malnutrition problems, a comblnation of strategies may have to be planned. One possibility is to have assistant AWW provide a few key services in these settlements. Operations research would be carried out to determine how to organize such a delivery system and its efficacy. This research would be undertaken in conjunction with the development of strategies for tribal populations in remoto areas (Annex 17). 15. Zhe raoeutic PEdiina Procedures. Existing procedures for food supplementation of severely malnourished children 6-36 months of age present problems in terms of consumption of double rations on site. Food volume is too gteat for consumption at one sitting and part of the ration is taken home. Currently, there li no way to verify consumption of take-home food and, therefore, there is no assurance of compliance and effectiveness. Three options are possible to resolve this problems (i) to extend the time and supervision provLded for consumption of the double ration; (ii) to change the energy density of the supplement so that volume is reduced to a point where a double ration can be consumed on-site during service hours; or (iii) change the viscosity of the supplement independently of density so that the same volume can be assimilated more easily. 16. The first option could be met by having two feeding sessions, one at the usual time and second at the end of the morning session. The second optlon could be met by introducing a ready-to-eat high energy density food, probably enriched with oll, to provLde additional calories. One such supplement is undergoing trLals ln Andhra Pradesh. The third option is to apply the new technology developed at the College of Home Science at Baroda using starch amylase to partLally digest carbohydrate, converting it to semi- - 90 - Annex 12 Page 4 liquid form. Gruels prepared in this way have the same energy density as the original food but the more liquid consistency allows them to be ingested more easily. Preparation of amylase food is laborious. Therefore, the feasibility and cost of ready-made flour ("power flour") needs to be investigated. 17. The project would support experimentation of these options in selected AWs. Depending upon the findings of this reaearch, project strategy for therapeutic supplementation of severely malnourished children would be evolved. 18. ParticiDation and Exclusion Study. It is critical to know whether all the malnourished children in the community are receiving the project's health and nutrition services. Therefore, a study is planned to assess level of participation in and exclusion from services in selected AWs. Interventions to remedy problems would depend upon magnitude of the problem and reasons for exclusion. 19. Extent of Parasite Problem. A worm load study in representative areas to design appropriate interventions would be carried out. - 91 - Annex 13 Page 1 INDIA SECOND INTOGRATED CHILD DEOPMEN! SERVICES PROJECT DETAILED PROJECT COST ESTIMATES Costs by Comoonent Coumonents Local Forelan Total Local Forelan Total -----Rupees (millions)----- ------US S (millions)------ A. Service Detivery 1. Nutrition 3339.4 148.3 3487.7 127.5 5.7 133.1 2. Health 472.5 107.4 579.9 18.0 4.1 22.1 3. Training 499.9 27.3 527.2 19.1 1.0 20.1 Subtotal 4311.8 283.0 4594.8 164.6 10.8 175.4 B. Communications 2 1 7 0.6 8L4 C. Prolect Maneaement 1. Project Organization 207.3 5.4 212.7 7.9 0.2 8.1 2. Monitoring & Evaluat. 9.0 0.0 9.0 0.3 0.0 0.3 3. Operations Research 78.6 0.0 78.6 3.0 0.0 3.0 Subtotat 29. 5.4 300. lt.3 0 11.5 TOTAL BASELINE COSTS ,4810.1 304.5 5114.6 1J. 11.6 14 Physical Contingencies 331.0 27.8 358.9 12.6 1.1 13.7 Price Contigencies 1777.2 117.9 1895.1 24.7 1.8 26.5 TOTAL PROJECT COSTS 6918.4 450.2 7368.6 22. 14.5 235A ......... .. ....... ...... ......... ..... .... ........ ..... NOT: Inclusive of taxes and duties estimated at US$7.4 million equivalent. Figures may not add due to rounding. - 92 - Annex 13 Page 2 Costs by Cateaories and Expenditures Local ForgIm Total Local Foreemn TotaL -----Rupees (millions)----- -- US S (millif ). -- 1. INVESTMENI COSTS A. Civil Works 526.3 65.0 591.3 20.1 2.5 22.6 S. Departmental Changes 60.3 10.6 71.0 2.3 0.4 2.7 C. Furniture 17.4 1.7 19.1 0.7 0.1 0.7 D. Equipment 283.6 38.7 322.3 10.8 1.5 12.3 E. Vehicles 254.7 25.2 279.9 9.7 1.0 10.7 F. Drugs 383.9 96.0 479.8 14.7 3.7 18.3 G. Training 477.2 25.1 502.3 18.2 1.0 19.2 H. Publicity Services 126.6 6.7 133.3 4.8 0.3 5.1 1. Studies & Surveys 98.0 0.0 98.0 3.7 0.0 3.7 TOTAL INVESTMENT COSTS 2228.0 MALQ Z24LOl DiL Ilu fnt ...... ..... ...... .... ~~.... ... II. RECURRENT COSTS A. Salaries 1908.2 0.0 1908.2 2.6 0.2 72.8 B. Consumables 115.8 6.1 121.9 4.4 0.2 4.7 C. Petroleum* Oil, Lub. 168.7 8.9 177.5 6.4 0.3 6.8 D. Incremental Operating 389. LIm fiM12 14. QL i. Costs TOTAL RECURRENT COSTS 2582.1 35. 2lA 9. l4 9. TOTAL BASELINE COSTS 4810.1 30. 5114.6 1836 11. 19L Physical Contingencies 331.0 27.8 358.9 12.6 1.1 13.7 Price Contigencies 177.2 117.9 1895.1 24.7 1.8 26.5 TOTAL PROJECT COSTS 6918.4 450.2 7ZII aual iLl M35. ...... ....... ...... . ... ...... ........ ..... ....... ... NT_E: Inclusive of taxes and duties estimated at USS7.4 mIllion *quIvalent. Figures may not add due to rounding. INDIA Integrated Child Dmvlopmmnt Services - 2 Bihar and asdhiy Pr'esdh Rups Project Cowpqnents by Yeer 8one Costs Total ........... .................................,...... _..................... 1992 1993 1994 1995 1996 1997 1998 Rupees US$ A. Service Delivery 1. Nutrition 363665.32 821743.48 609423.72 586066.26 500357.26 474897.26 463652.26 3819805.56 145794.11 2. Health 67153.30 84540.50 70311.00 76200.20 70721.00 70721.00 70721.00 510368.00 19479.69 3. Training 107283.60 74217.70 59998.00 49635.35 8654.15 7796.15 7796.15 315381.10 12037.45 ....................;ii......;.... ... ...........ii...................................................... Sub-total 538102.22 98501.68 739732.72 7901.81 579732.41 553414.41 542169.41 4645554.66 Im1731.25 S. ComminicatIons 9085.03 21386.76 21375.18 53139.78 41691.08 36448.08 36448.08 219573.99 8380.69 C. Comm.ity Nobitizaton 187743.00 0.00 0.00 0.00 0.00 0.00 0.00 187743.00 7165.76 D. Project Management 1. Project Organizatfon 87607.02 40918.42 40918.42 40918.42 40918.42 40918.42 40918.42 333117.54 12714.41 2. Monitoring & Evaluation 8600.00 0.00 0.00 200.00 0.00 0.00 200.00 9000.00 343.51 3. operations Research 4598.40 11594.00 25453.60 23572.00 12106.00 640.00 640.00 78604.00 3000.15 .............................................................................................................. Sub-total 100805.42 52512.42 66372.02 64690.42 53024.42 41558.42 41758.42 420721.54 16058.07 .... .......... ... .... ...... ....................... .. ... .. .. . .. ...... . . ... Total BASELINE COSTS 83575.67 1054400.85 827479.92 829732.01 674447.91 631420.91 620375.91 5473593.18 208915.77 Physical Contingencies 577n.63 85181.46 59336.74 56262.15 43325.86 39104.21 37989.71 378973.76 14464.65 Price Contingencies 44557.24 171404.53 216441.35 294813.43 299500.06 333302.14 378393.67 1738412.42 25381.27 ;; ; .. . . .. . . . . . .. . . . . . . . . . .. . . . . . . ... ... . . . .... ...... ... . . . . . . Total PROJECT COSTS 938066.55 1310986.84 1103258.00 1180807.59 1017273.84 1003827.26 1036759.29 7590979.37 248761.69 Taxes 16095.97 35677.10 23434.82 21758.14 16364.53 14239.27 14278.46 141848.28 4710.11 Foreign Exchange 67630.49 126701.54 101350.23 105129.56 89226.40 85901.22 89761.52 665700.97 21780.93 .. . . . . .. . . . . .*.--.. .. . . . . .. . . . . . . . . . . . .. _ ...... .. ......... . ... 2. I . . ...... .... .. . . . . . . . . . Values Scaled by 1000.0 1/13/1993 18:25 IW W INDIA Integrated Child Development Services - 2 Bihar Project Cost Summary Rupees USS X Total ----------------------.......... --------. - ---------------------- Foreign Base Local Foreign Total Local Foreign Total Exchange Costs A . Service Delivery 1. Nutrition 1561471.7 126093.1 1687564.8 59598.2 4812.7 64410.9 7.5 69.8 2. Health 168249.1 39707.1 207956.2 6421.7 1515.5 7937.3 19.1 8.6 3. Training 150861.6 7940.1 158801.7 5758.1 303.1 6061.1 5.0 6.6 ........... ...................... ..................... ......... ................... ----------------------.................................................................... . Sub-Total 1880582.4 173740.3 2054322.7 71778.0 6631.3 78409.3 8.5 85.0 B . Communications 80581.9 9761.1 90343.0 3075.6 372.6 3448.2 10.8 3.7 C . Community Mobilizaton 91522.5 2349.0 93871.5 3493.2 89.7 3582.9 2.5 3.9 D . Project Maagement 1. Project Organization 122622.7 12887.3 135510.0 4680.3 491.9 5172.1 9.5 5.6 2. Monitoring & Evaluation 4275.0 225.0 4500.0 163.2 8.6 171.8 5.0 0.2 3. Operations Research 32177.2 7124.8 39302.0 1228.1 271.9 1500.1 18.1 1.6 ................. .................................................. .............................. ---------------------- Sub-Total 159074.9 20237.1 179312.0 6071.6 772.4 6844.0 11.3 7.4 ................. .................................................. .............................. ...................... Total BASELINE COSTS 2211761.7 206087.5 2417849.2 84418.4 7865.9 92284.3 8.5 100.0 Physical Contingencies 147834.9 19947.0 167781.9 5642.6 761.3 6403.9 11.9 6.9 Price Contingencies 716570.9 73665.4 790236.3 10331.1 1120.7 11451.7 9.8 12.4 ................. .................................................. .............................. ...................... Total PROJECTS COSTS 3076167.5 299699.9 3375867.4 100392.0 9748.0 110139.9 8.9 119.3 .................. .................................. _ ____ ..................___.. __.......... .............. ....I Values Scaled by 1000.0 - 1/13/1993 18:31 410 (D 0. a IND.A Integrated Child Devetlmnent Services - 2 Bihar Sumuury Accounts Cost Swumry RIupees USS Total --------------------------------- .............................. X Foreign Base Local Foreign TotaL Local Foreign Total Exchange Costs I. INVESTMENT COSTS ................ A. Civil Works 266968.0 32996.0 299964.0 10189.6 1259.4 11449.0 11.0 12.4 S. Furniture 11312.8 1118.8 12431.6 431.8 42.7 474.5 9.0 0.5 C. Equipment 97020.0 13230.0 110250.0 3703.1 505.0 4208.0 12.0 4.6 D. IEC Materials 69080.9 9420.1 78501.0 2636.7 359.5 2996.2 12.0 3.2 E. Vehicles 66376.3 6564.7 72941.0 2533.4 250.6 2784.0 9.0 3.0 F. Medicines 176165.6 44041.4 220207.0 6723.9 1681.0 8404.8 20.0 9.1 C. Training 150861.6 7940.1 158801.7 5758.1 303.1 6061.1 5.0 6.6 H. Publicity Services 10887.0 573.0 11460.0 415.5 21.9 437.4 5.0 0.5 1. NGO & Consultant Services 57336.3 3017.7 60354.0 2188.4 115.2 2303.6 5.0 2.5 Total INVESTMENT COSTS 906008.4 118901.9 1024910.3 34580.5 4538.2 39118.7 11.6 42.4 11. RECURRENT COSTS ................... A. Incremental Salaries 1215351.3 0.0 1215351.3 46387.5 0.0 46387.5 0.0 50.3 S. Office Supplies 48799.8 2568.4 51368.2 1862.6 98.0 1960.6 5.0 2.1 C. Petroleum, Oilt Lubricant 9212.5 82912.5 92125.0 351.6 3164.6 3516.2 90.0 3.8 D. Incremental Oper. Costs 32389.7 1704.7 34094.4 1236.2 65.1 1301.3 5.0 1.4 Total RECURRENT COSTS 1305753.3 87185.6 1392938.9 49837.9 3327.7 53165.6 6.3 57.6 Total SAS.ILINE COSTS ?211761.7 206087.5 2417849.2 84418.4 7865.9 92284.3 8.5 100.0 Phyricat Contingencies 147834.9 19947.0 167781.9 5642.6 761.3 6403.9 11.9 6.9 Price Contingencies 716570.9 73665.4 790236.3 10331.1 1120.7 11451.7 9.8 12.4 ................................. .............................. ...................... .............. ........................ ............. Total PROJECTS COSTS 3076167.5 299699.9 3375867.4 100392.0 9748.0 110139.9 8.9 119.3 ...... ..........__.._._.... ___.........__..___.... . . . . . . . .. . . . _ . . . .. . . _ . . . . .. . . . . . . . .. . . . . . . . . Values Scaled by 1000.0 - 1/13/1993 18:32 (D1 uSIA Integrated Child Dveltopimnt Services - 2 Nadhya Pradesh Project Cost Su mary Rupees USS X Total ................ ................- ....- % Foreign Base Local Foreign Total Local Foreign Total Exchange Costs A S service Delivery 1. Nutrition 1975006.7 157234.1 2132240.8 75381.9 6001.3 81383.2 7.4 69.8 2. Heatth 246434.5 55977.3 302411.8 9405.9 2136.5 11542.4 18.5 9.9 3. Training 148750.4 7829.0 156579.4 5677.5 298.8 5976.3 5.0 5.1 ..... ......... .................................. ......... .................. ... .... .. ............ ............ ....... .... Sub-Total 2370191.6 221040.3 2591232.0 90465.3 8436.7 98902.0 8.5 84.8 B . Coummciatfons 122514.2 6716.8 129231.0 4676.1 256.4 4932.5 5.2 4.2 C . Commity Mobilization 91522.5 2349.0 93871.5 3493.2 89.7 3582.9 2.5 3.1 0 . Project Management 1. Project Organization 178289.1 19318.4 197607.5 6804.9 737.3 7542.3 9.8 6.5 2. Monitoring & Evaluation 4275.0 225.0 4500.0 163.2 8.6 171.8 5.0 0.1 3. Operations Research 32177.2 7124.8 39302.0 1228.1 271.9 1500.1 18.1 1.3 ......... ..................... .......................... ...................... SutrTotal 214741.3 26668.2 241409.5 8196.2 1017.9 9214.1 11.0 7.9 ........................... ........... ........... ............ ...... ......... .......... Total BASELINE COSTS 2798969.6 256774.3 3055743.9 106830.9 9800.5 116631.4 8.4 100.0 Physical Contingencies 186623.2 24568.8 211191.9 7123.0 937.7 8060.8 11.6 6.9 Price Contingencies 863518.1 84658.0 948176.1 12634.8 1294.7 13929.5 9.3 11.9 ......................... .... ........ ............................... ..... ........... _............. ....... __----.....-----------.- Total PROJECTS COSTS 3849110.8 366001.1 4215111.9 126588.8 12033.0 138621.7 8.7 118.9 ............................................................................................................................ Values Scaled by 1000.0 - 1/13/1993 18:34 a JJ INDIA Integrated Child Devltopmnt Services - 2 Padhys Pradesh SSry AccwLnts Cost Siry Rupe.s USS X Total ,,,, F g............................... .............................. X Foren _ Loet Foreign Total Local Foreign Total Exehnwge Costs 1. INVSTMNT COSTS ................... A. Civil Vorka 346072.9 42773.1 388666.0 13206.9 1632.6 1481.5 11.0 12.7 B. Furnitur 14014.0 1386.0 15400.0 534.9 S2.9 587.8 9.0 0.5 C. Equipment 159411.4 21737.9 131149.3 6064.4 829.7 6914.1 12.0 S.9 P. IEC Materials 3206.5 437.5 3646.0 122.5 16.7 139.2 12.0 0.1 E. Vehicles 95713.3 9466.2 105179.5 3653.2 361.3 4014.5 9.0 3.4 F. edicines 227454.4 54863.6 264318.0 8681.5 2170.4 10651.8 20.0 9.3 G. Training 136400.2 7264.2 145464.4 5282.4 278.0 5560.5 5.0 4.8 H. Publelity Servies 115738.5 6091.5 121630.0 4417.5 232.S 4650.0 5.0 4.0 t. NOW * Consultant Services 57013.3 3000.7 60014.0 2176.1 114.5 2290.6 5.0 2.0 Total ISNEN CSTS 115706.5 149040.7 1306067.2 44161.3 5668.6 49649.9 11.4 42.7 ................................. .............................. ............................................................. II. IRECUIIRRENT COSTS ................... ........................ A. Increental Salarfes 1444179.1 0.0 144179.1 SS121.3 0.0 55121.3 0.0 47.3 B. Office Supplies 76741.S 4039.0 80780.5 2929.1 1S4.2 3083.2 5.0 2.6 C. Petroteum, Oil, Lubricant 10877.5 97897.5 108775.0 415.2 3736.5 4151.7 90.0 3.6 D. Incr_ental Oper. Costs 110145.1 5797.1 115942.2 4204.0 221.3 4425.3 5.0 3.8 Total RECURRENT COSTS 1641943.1 107733.6 1749676.8 62669.6 4112.0 66781.6 6.2 57.3 Total BASELINE COSTS 2796969.6 256774.3 30SS743,9 106830.9 9800.5 116631.4 8.4 100.0 Physical Contingences 186623.2 24568.8 211191.9 7123.0 937.7 8060.8 11.6 6.9 Price Contingencles 863518.1 84658.0 948176.1 12634.8 1294.7 13929.5 9.3 11.9 .ii...... . .. .. . i; ----- -- i; ;.. .......... . .....T ------------ Total PROJECTS COSTS 3849110.8 366001.1 4215111.9 126588.8 12033.0 1361.7 8.7 118.9 .. ................................................ . ..... ..... ......... .. .... ... .. . .. ------......................................................... -- Values Scated by 1000.0 - 1/13/1993 18:35 Cw I--j INDIA Integrated Child Development Services - 2 Bihar and Madhya Pradesh Project Cost Sumary Rupees US$ % total - -... --------------..---- X Foreign Base Local Foreign Total Local Foreign Tot:l Exchange Costs .................................~~~~ ~~~~~~~~... .............. .................. .................. A Service Delivery 1. Nutrition 3536478.38 283327.17 3819805.56 134980.09 10814.01 145794.11 7.42 69.79 2. Health 414683.60 95684.40 510368.00 15827.62 3652.08 19479.69 18.75 9.32 3. Training 299612.04 15769.05 315381.10 11435.57 601.87 12037.45 5.00 5.76 ....... .............._ .......................... ................................ .................................. ................... _-.__.-.......-------------.. Sub-Tctal 4250774.03 394780.63 4645554.66 162243.28 15067.96 1M11.25 8.50 84.87 B . Cmmiunications 203096.16 16477.83 219573.99 7751.76 628.92 8380.69 7.S0 4.01 C . Conunity Nobilizaton 183045.00 4696.00 187743.00 6986.45 179.31 7165.76 2.50 3.43 D . Project Management 1. ProJect Organization 300911.78 32205.76 333117.54 11485.18 1229.23 12714.41 9.67 6.09 2. Monitoring & Evaluation 8550.00 450.00 9000.00 326.34 17.18 343.51 5.00 0.16 3. Operatfons Research 64354.40 14249.60 78604.00 2456.27 543.88 3000.15 18.13 1.44 Sub-Totat 373816.18 46905.36 420721.54 14267.79 1790.28 16058.07 11.15 7.69 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. ........ ................ ........... .. .............................. ............... Total BASELINE COSTS 5010731.37 462861.81 5473593.18 191249.29 17666.48 208915.77 8.46 100.00 Physical Contingencies 334458.03 44515.73 378973.76 12765.57 1699.07 14464.65 11.75 6.92 1 Price Contingencies 1580089.00 158323.43 1738412.42 22965.89 2415.38 2538 .27 9.52 12.15 vO oD Total PROJECTS COSTS 6925278.40 665700.97 7590979.37 226980.75 21780.93 248761.69 8.76 119.07 Values Scaled by 1000.0 - 1/13/1993 18:21 co INDIA Integrated Child Develonpmnt Services - 2 Bihar and Nadhys Pradesh Swumry Accounts Cost wuaRry Rupees USS X Total ------------------------------------ ................................. X Foreign Base Local Foreign Total Local Foreign Total Exchange Costs . ........................... .. ._. . _. ......... '. INVESTMENT COSTS .......... ............... A. Civil Works 613040.90 75769.10 688810.00 23398.51 2891.95 26290.46 11.00 12.58 B. Furniture 25326.76 2504.84 27831.60 966.67 95.60 1062.27 9.00 0.51 C. Equipnent 256431.38 34967.92 291399.30 9787.46 1334.65 11122.11 12.00 5.32 D. IEC Naterials 72289.37 9857.64 82147.01 2759.14 376.25 3135.38 12.00 1.50 E. Vehicles 162089.65 16030.84 178120.50 6186.63 611.86 6798.49 9.00 3.25 F. Kedicines 403620.00 100905.00 504525.00 15405.34 3851.34 19256.68 20.00 9. G. Training 289261.79 15224.30 304486.10 11040.53 581.08 11621.61 5.00 5.56 N. Publicity Services 126625.48 6664.50 133289.98 4833.03 254.37 5087.40 5.00 2.44 1. NGO & Consultant Services 114349.60 6018.40 120368.00 4364.49 229.71 4594.20 5.00 2.20 ...................................................................... _-_ Total INVESTNENT COSTS 2063034.94 267942.55 2330977.49 78741.79 10226.81 88968.61 11.49 42.59 ............ ........................ .. ....... ..................... ------------- 11. RECURRENT COSTS .................. A. Incremental Salaries 2659530.40 0.00 2659530.40 101508.79 0.00 101508.79 0.00 48.59 S. Office Supplies 125541.26 6607.43 132148.70 4791.65 252.19 5043.84 5.00 2.41 C. Petroleum, Oil, Lub ricant 20090.00 180810.00 200900.00 766.79 6901.15 7667.94 90.00 3.67 D. Incremental Oper. Costs 142534.77 7501.83 150036.60 5440.26 286.33 5726.59 5.00 2.74 . ................................... ................................. ------------------------ Total RECURRENT COSTS 2947696.43 194919.26 3142615.70 112507.50 7439.67 119947.16 6.20 57.41 ................................... .................._....... ..._ Total 5ASELINE COSTS 5010731.37 462861.81 5473593.18 191249.29 17666.48 208915.77 8.46 100.00 Physical Contingencies 334458.03 44515.73 378973.76 12765.57 1699.07 14464.65 11.75 6.92 Price Contingelcies 1580089.00 158323.43 1738412.42 22965.89 2415.38 25381.27 9.52 12.15 ................................... . . ................................. . ---------...---------... Total PROJECTS COSTS 6925278.40 665700.97 7590979.37 226980.75 21780.93 248761.69 8.76 119.07 ................... ..................................__._.__................__........................................ Values Scaled by 1000.0 - 1/13/1993 18:22 I(D INDIA Integrated Child Development Services - 2 Bihar and Madhys Pradesh Summary Account by Project Component Rupees ConmImfty r.oject Monitoring Communicat fobilizato Organizati a Operations Nutrition Heatth Training ions n on Evaluation Research 33U3flUUUUUuU3U3uUU3U3w-3UU-------- 1. INVESTMENT COSTS ,. ........................... ... A. CIvit Works 684810.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 S. Furniture 15370.00 0.00 0.00 0.00 0.00 12461.60 0.00 0.00 C. Equipment 201795.30 79665.00 0.00 0.00 0.00 9739.00 0.00 0.00 D. IEC Materials 0.00 0.00 0.00 78559.01 0.00 3588.00 0.00 0.00 E. Vehicles 157220.50 0.00 0.00 0.00 0.00 20900.00 0.00 0.00 F. Medicines 5226.00 430503.00 0.00 0.00 0.00 0.00 0.00 68796.00 G. Training 0.00 0.00 304361.10 125.00 0.00 0.00 0.00 0.00 H. Publicity Services 0.00 0.00 0.00 132689.98 0.00 0.00 400.00 0.00 1. NWO & Consultant Services 0.00 0.00 0.00 8000.00 93960.00 0.00 8600.00 9608.00 ,.. ........ . . . .. ; . .. ... i;.; . .. --- . --. .--... .. .. ..... .. . .... . . . .. Totat INVESTMENT COSTS 1068421.80 510368 00 304361.10 21973.99 93960.00 46688.60 9000.00 73604.00 11. RECURRENT COSTS .____.__ ......................._F A. Incremental Salaries 2331597.96 0.00 0.00 0.00 93763.00 234149.44 0.00 0.00 B. Office Supplies 132131.20 0.00 0.00 0.00 0.00 17.50 0.00 0.00 C. Petroleum OIlt Lubricant 171500.00 0.00 0.00 0.00 0.00 29400.00 0.00 0.00 D. Incremental Oper. Costs 116154.60 0.00 11020.00 0.00 0.00 22862.00 0.00 0.00 Total RECORRENT COSTS 2751383.76 0.00 11020.00 0.00 93783.00 286428.94 0.00 0.00 Total SASELINE COSTS 3819805.56 S10366.00 315381.10 219513.99 187743.00 333117.54 9000.00 78604.00 Physical Contingencies 259592.93 51036.80 15769.05 14906.65 9387.15 20461.18 450.00 870.00 Price Contingencies 1269663.71 182178.55 62670.57 88624.78 10181.61 100495.26 648.32 23949.61 .............................................................. ...............................-... Total PRoJECT COSTS 5349062.19 743583.35 393820.72 323105.42 207311.76 454073.96 10098.32 109923.61 Taxes 82850.27 42640.18 304.34 4800.71 0.00 5403.07 0.00 5849.71 Foreign Exchange 406047.92 143123.18 19594.27 25173.92 5024.16 45985.98 491.57 20259.97 ............................................................. ........................................................................................................ ..... ............. Values Scated by 1000.0 1/13/1993 18:22 IoD INDIA Integrated Child bDlopemnt Services - 2 SBwhr and NMdhey Pradmbs Summary Account by Project Component ml'es. Ph"iecl Prico ContingencIes Contingencfes ....... ...... ;;;........ Total X A tu X Aount 1. INVESTNET COSTS ,................... A. Cfvil Works 688810.00 10.00 68881.00 23.18 159646.23 B. Furniture 27831.60 10.00 27M3.16 11.48 3195.33 C. Equfpmmnt 291399.30 10.00 29139.93 14.68 42766.95 D. IEC Naterials 82147.01 10.00 8214.70 41.14 33793.18 E. Vehicles 178120.50 10.00 17812.05 14.15 25199.6S F. Medieines 504525.00 10.00 50452.50 38.67 19f112.67 0. Training 304486.10 S.00 15224.30 19.39 59050.75 N. Publicity Services 133289.98 5.00 6664.50 39.70 52921.96 1. NCO & Consultant Services 120368.00 5.00 6018.40 8.19 9863.87 .... ..... ... ........................................ Totat INVESTMENT COSTS t,?977.49 8.80 205190.54 24.95 581548.59 II. RECURRENT COSTS .. ,,,,,,,,,,,, ................ o A. Incremental Salaries 2659530.40 5.00 132976.52 36.34 966569.29 8. Office S pWlies 132148.70 10.00 13214.87 39.34 51988.86 C. Petroleum, Oil, Lubricant 200900.00 10.00 20090.00 42.10 84573.77 D. Incremental Oper. Costs 150036.60 5.00 7501.83 35.81 53731.94 .............................................................. Total RECURRENT COSTS 3142615.70 5.53 1733.22 36.81 1156863.83 Total BASELINE COSTS 5473593.18 6.92 378973.76 31.76 1738412.42 Physical Contingencies 378973.76 Price Contingencies 1738412.42 6.25 108594.30 ............................................................. Total PROJECT COSTS 7590979.37 6.42 487568.06 22.90 1738412.42 m_ _mauuaumamuuuuauuuuuausuuuz-------- Taxes 141848.28 8.96 12712.38 Foreign Exchange 665700.97 8.79 58520.24 ................. ....................................0 Values Scated by 1000.0 1/13/1M9 18:22 F.-Iw INDIA Integrated Child Development Services - 2 Bihar and Hadhya Pradesh Sumfary Accounts by Year Totals Including Contingencies Rupees 1992 1993 1994 1995 1996 1997 1998 Total 1. IIVESTMENT COSTS .................... A. Civil Works 20952.68 483220.03 219859.22 117503.23 57259.70 18540.37 0.00 917335.23 B. Furniture 21591.98 5796.43 3386.95 3034.73 0.00 0.00 0.00 33810.09 C. Equipment 151902.30 121305.40 47995.05 42103.43 0.00 0.00 0.00 363306.18 D. IEC Materials 7868.32 9173.36 6509.42 27369.83 27888.10 22090.35 23255.51 124154.88 E. Vehicles 102077.85 65613.56 28522.26 24918.52 0.00 0.00 0.00 221132.20 f. atedicines 35235.39 83945.55 119008.09 138748.77 129808.46 118435.40 124908.51 750090.17 G. Trrining 116538.74 87644.78 76447.94 67285.15 10642.04 9849.58 10352.91 378761.15 H. Publicity Services 4478.74 15164.59 19812.98 47196.84 34477.89 34818.10 36927.28 192876.44 t. WGO & Consultant Service 120151.96 2076.66 5122.30 2195.51 1843.25 2369.74 2490.84 136250.27 Total INVESTMENT COSTS 580797.97 873940.36 526664.23 470356.02 261919.44 206103.55 197935.06 3117716.62 11. RECIRRENT COSTS ... ... ...... .......................I A. Incremental Salaries 313551.86 358558.28 480862.26 597750.00 635062.34 669898.28 703393.19 3759076.20 B. Office Supplies 10630.95 20564.94 26417.00 32013.35 34030.52 35928.99 37766.67 197352.41 0 C. Petroleu, Oiit, Lubricant 17979.11 31373.83 40011.17 48543.20 52091.42 55820.73 59744.31 305563.77 D. Incremental Oper. Costs 15106.65 26549.44 29303.35 32145.03 34170.12 36075.72 37920.06 211270.37 Total RECURRENT COSTS 357268.58 437046.49 576593.77 710451.57 755354.40 797723.71 838824.23 4473262.75 Total PROJECT COSTS 938066.55 1310986.84 1103258.00 1180807.59 10172'3.84 1003827.26 1036759.29 7590979.37 ................................................ ................................................................................................................. ............................ __:: ------------------ Values Scaled by 1000.0 1/13/1993 18:24 INDIA Integrated Chitd Development Services - 2 Bihar and Madhya Pradesh Sumary Accounts by Year Totals Including Contingencies USS 1992 1993 1994 1995 1996 1997 1998 Total 1. INVESTMENT COSTS .................... A. Civil Works 799.72 17135.46 7377.83 3766.13 17m2.75 555.10 0.00 31406.99 R. Furniture 824.12 205.55 113.66 97.27 0.00 0.00 0.00 1240.59 C. Equipment 5797.80 4301.61 1610.57 1349 4*7 0.00 0.00 0.00 13059.45 0. IEC MaterIals 300.32 325.30 218.44 877.24 863.41 661.39 674.07 3920.16 E. Vehicles 3896.10 2326.72 957.12 798.67 0.00 0.00 0.00 7978.62 F. Medicines 1344.86 2976.79 3993.56 4447.08 4018.84 3545.97 3620.54 23947.64 G. Training 4448.04 3107.97 2565.37 2156.58 329.47 294.90 300.08 13202.41 M. Publicity Services 170.94 537.75 664.87 1512.72 1067.43 1042.46 1070.36 6066.52 I. NGO & Consultant Services 4585.95 73.64 171.89 70.37 57.07 70.95 72.20 5102.07 Total INVESTMENT COSTS 22167.86 30990.79 17673.30 15075.51 8108.96 6170.76 5737.25 105924.44 II. RECURRENT COSTS ........ ................. A. Incremental Salaries 11967.63 12714.83 16136.32 19158.65 19661.37 20056.83 20388.21 120083.85 B. Office Supplies 405.76 729.25 886.48 1026.07 1053.58 1075.72 1094.69 6271.54 C. Petroleum, Oil, Lubricant 686.23 1112.55 1342.66 1555.87 1612.74 1671.28 1731.72 9713.04 0 0. Increniental Oper. Costs 576.59 941.47 983.33 1030.29 1057.90 1080.11 1099.13 6768.82 w Total RECURRENT COSTS 13636.21 15498.10 19348.78 22770.88 23385.59 23883.94 24313.75 142837.25 Total PROJECT COSTS 35804.07 46488.90 37022.08 37846.40 31494.55 30054.71 30050.99 248761.69 . ........... .................... ............................................. ... ..... _ _.................... Values Scaled by 1000.0 1/13/1993 18:24 wjw - 104 - Annex 14 INDIA SECOND INTEGRATED CHILD DEVELOPMENT PROJECT IMPLEMENTATION SCHEDULE TARGETTED ANNUAL CONTRACTUAL AND OTHER PAYMENTS Pr_- Totel Project Elment project 1 2 8 4 5 6 7 Payson" Remarks ____________________________________________________________ Local Timing Si8n/Effectivensofs Closing so so * Works Construction 0.8 17.1 7.4 S8. 1.6 0.6 81.4 LCB%Forc Account Incremental Operating Costs 1.8 2.2 2.4 2.5 2.6 2.7 2.8 16.6 Forco Acount Goods lEqupment and FurniturC 6.6 4.6 1.8 1.4 14.8 LCB and Shopping IEC Materials, Medicines 2.1 4.0 5.1 6.s 6.9 5.8 5.4 84.1 LC3 and Shopping and Office Supplies oooee.ooooeeosoeoeeee *eeeee* Vehicles 3.9 2.8 1.0 0.8 6.0 Local Shopping eeao*oeOOOe***oOOO**O* ConsultaciTes Local Training 4.4 8.1 2.2 2.2 0.8 0.8 0.8 18.2 eeeeeeos..eeeesooo.osseo*4**eoeeoeoeoeo Publicity Services 0.2 0.5 0.7 1.5 1.1 1.0 1.1 6.1 According to ***oseeeeeeoeeeeo*oee*Oc***eeee*eoeeo*S NBO and Consultant Services 4.5 0.1 0.1 0.1 0.1 0.1 0.1 5.1 IDA Guideline. eooo*eeoooe**e*e*O**e**O*O*OOc*OcC0000 Miscellaneous Additional Salaries 12.0 12.7 16.1 19.2 19.7 20.0 20.4 120.1 ooaseee*.ee.oeooeeeeeee***eooeaeeoo.ee*e TOTALS 86.8 48.6 87.0 87.8 81.5 80.1 80.1 248.8 (Bank Financed) (29.6)(37.8)(29.2)(29.4)(23.6)(22.4)(22.0) (194.0) - 105 - Annex 15 INDIA SECOND INTEGRATED CHILD DEVELOPMENT PROJECT FORECAST OF ANNUAL EXPENDITURES AND DISBURSEMENTS Semester IDA Cumulative from Fiscal Year As I of Appraisal and Semester Expenditures Disbursements Total Date Semester. Cumulative Semester Cumulative (USS millions) FY 93 Jan 93-Jun 93 6.00 6.00 - - 2 FY 94 Jul 93-Dec 93 29.80 35.80 9.0 9.0\a 5 3 Jan 94-Jun 94 23.24 59.04 8.6 17.6 9 4 FY 95 Jul 94-Dec 94 23.24 82.28 8.6 26.2 14 5 Jan 95-Jun 95 23.24 103.52 8.6 34.8 18 6 FY 96 Jul 95-Dec 95 28.66 134.18 17.4 52.2 27 7 Jan 96-Jun 96 28.44 162.62 17.5 69.7 36 8 FY 97 Jul 96-Dec 96 26.02 188.64 15.5 85.2 44 9 Jan 97-Jun 97 15.03 203.67 15.6 100.8 52 10 FY 98 Jul 97-Dec 97 15.03 218.70 16.8 117.6 61 11 Jan 98-Jun 98 15.05 233.75 16.9 134.5 69 12 FY 99 Jul 98-Dec 98 15.05 248.80 16.1 150.6 78 13 Jan 99-Jun 99 - - 16.1 166.7 86 14 FY 00 Jul 99-Dec 99 - - 27.3 194.0 100 15 ----------------------------------------------------------_-----------__---_-__- Closing Date: September 30, 1999 \a: Including Special Account and Retroactive Financing. - 106 - Annex 16 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT SUPERVISION PLAN Calendar Yr. Expected Skills Staff Weeks (quarters) Activity Required Equivalent Estimates 93 I SPN TASK MANAGER, N, 8 SS, C 93 II SPN TASK MANAGER, N, 6 T, SS 93 IV SPN TASK MANAGER, N, 8 PH, SS 94 II SPN TASK MANAGER, N, 9 PH, SS 94 IV SPN TASK MANAGER, N, 9 Ss, C 95 II SPN TASK MANAGER, N, 9 PH, SS 95 IV MTR TASK MANAGER, N, 10 PH, C, SS 96 II SPN TASK MANAGER, N, 9 PH, SS 96 IV SPN TASK MANAGER, N, 9 Ss, C 97 II SPN TASK MANAGER, N, 9 PH, SS 97 IV SPN TASK MANAGER, N, 9 SS, C 98 II SPN TBD TBD 98 IV SPN TASK MANAGER, N, 9 PH, C 99 II PCR TBD TBD _______________________________ Required Skills N Nutrition Specialist PH Public Health Specialist C Communications Expert SS Social Scientist (Sociology, Anthropology) T Training Specialist Activity PCR Project Completion Report SPN Supervision MTR Mid-term Review - 107 - Annex 17 Page 1 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICBS PROJECT STRATEGIES FOR STRENGTHENING ICDS AMONG TRIBAL POPULATIONS 1. The project as a whole provides for strengthening the delivery of ICDS services. The strategies described below represent complementary actions to further strengthen the effective delivery of ICDS services among tribal populations through the participation of tribal people in project design and implementation. Strategy Development 2. At the inception of the project, state and district-level officers in both states will receive a five-day orientation to the special problems of tribal people and to evolving programme strategies to address these problems with the participation of tribal people. These Orientation Camps will be organized by a group of well-qualified professionals with in-depth knowledge of ICDS in tribal areas and of participatory planning techniques. This group of professionals (or a similarly qualified NGO) will be identified by the Project Management Cell. As new senior officers are appointed, they too will undergo this orientation training along with other ICDS staff (below). 3. All CDPOs and Mukhya Sevikas in the project will undergo a similar orientation training in area teams. Those already in position will be trained within the first six months of the project. New CDPOs and Mukhya Sevikas will receive such field-based orientation in the week immediately following their job training. The objective of this orientation is to provide ICDS personnel at all levels with first-hand experience of the situation of tribal areas and of undertaking participatory, problem-solving planning and management. 4. Strategies to strengthen the participation of tribal communities in project design and the participation of tribal beneficiaries in the implementation and local monitoring of ICDS and ICDS-Plus programs will be developed by June 30, 1993, and will seek to incorporate ways of reaching and involving remote populations. The development of the strategies will take place with the informed participation of tribal communities and AWWs as well as NGOs working among tribal populations. 5. To design and implement these strategies effectively, a data base on tribal populations in the project areas, including existing geographic, demographic, ethnographic, health and linguistic and nutritional data, will be developed by December 31, 1993. This data base will be maintained throughout the project implementation period and updated every six months. The data base will be used for the planning of assessments and studies during the project. Conversely, studies will be carried out during the project to provide addi- tional data or information as required for the management and rmonitoring of the project among tribal populations. Special studies will also be undertaken 108 - Annex 17 Page 2 to obtain information and feedback from Anganwadi Workers in the project in both tribal and non-tribal areas. The information obtained on all project blocks through the mapping process described in paragraph 8 below, will be fed into this data base and used to monitor the program. 6. To prepare and help implement these strategies and develop and maintain the data base, the state governments will employ consultants with appropriate qualifications to work on a regular and continuous basis with the staff of the Project Management Cells. In addition to these consultants, the state governments will utilize the ICDS Plus Units to be formed in their respective Project Management Cells and Districts to assist DPOs and CDPOs to implement the strategies. The Department of Women and Child Development, jointly with the Bihar and Madhya Pradesh departments concerned with ICDS, would review implementation progress of the strategies as part of the annual reviews described in paragraph 17 below, and discuss the results and proposed modifications of the strategies arising from the reviews with the Bank. Strategy Implementation 7. The CDPOs and Mukhya Sevikas in position (as well as new staff) will visit all the villages in their areas systematically within nine months of assuming charge and conduct village level meetings with all groups in the villages to inform them about the ICDS program, discuss their community's needs and obtain their guidance on how the ICDS services should be initiated and implemented. They will also solicit the involvement of the communities in the actual implementation and further planning of the program. 8. The first visits to the villages (i.e., within three months) will be used by the concerned staff to obtain detailed information from the village community on its population, distribution and habitations. This information will be assembled by the CDPO into a detailed block-level map of tribal populations as well as of other groups, such as Scheduled Caste and Non-SC/ST people. She/he will have discussed with the village communities the strategies required to cover distant habitations. On the basis of all this information and a time-distance norm, the CDPO will assess the requirement for anganwadis in the block and the number of supervisors necessary to provide effective supervision in the block. The CDPOs will convey this information to the district and state level Project Management Cells which will in turn utilize the information to sanction an appropriate number of posts, prepare training plans, etc. 9. On their visits to the villages, the CDPOs and Mukhya Sevikas will collaborate with the village communities in the selection of the Anganv-'di Worker(s) and the specific location of the anganwadi(s). They will en( irage and assist the village communities to establish village committees with proportionate representation of all social groups in the village to partici- pate in the planning, implementation and monitoring of anganwadi activities. The participation of traditional tribal leaders in these committees will be sought. On subsequent visits they will seek the advice and assistance of these village-level committees, who will ultimately guide the Anganwadi Worker and assist and monitor her work. - 109 - Annex 17 Page 3 10. The CDPOs will also form (or activate existing) block-level committees to assist and oversee the implementation of the ICDS program in the block. These Block-level committees will also have tribal leaders or representatives as members, reflecting the proportion and composition of tribal populations in the block. Local NGO representatives who are working with tribal communities will also be inducted into these committees. The CDPOs will be responsible for collecting information from the village level about the formation, membership composition, and functioning of village-level committees. They will relay this information quarterly, along with information on the Block-level committees, to the Project Management Cells at the state and Central levels. 11. The Project Management Cell will be responsible for overseeing the formation of the block-level committees and for providing assistance wherever necessary. The Project Management Cell will ensure that: (a) tribal representatives are fully informed of their role in the committees and the timings of the meetings, and are given allowances as per the state government rules to attend such meetings; (b) the committees meet on a regular basis; and (c) the committees actively participate in the implementation and local monitoring of ICDS. 12. The state governments will carry out workshops (along the lines of the pilot workshops held during the review of ICDS in tribal areas) every other year in each project district during the project implementation period to obtain feedback from tribal people, their leaders, NGOs and tribal specialists on project performance. The workshops will solicit suggestions for improvements in project design and implementation, which will be discussed with Bank progress review missions and, if deemed useful and feasible by this joint review, will be incorporated into the project. 13. The state government will engage NGOs and other experts with extensive experience in participatory training techniques to provide: (a) advice on the aspects of curriculum to which participatory techniques can be applied and a methodology to do so; and (b) to train trainers in such techniques. The recommendations on the curriculum would be finalized by September 30, 1993, and training would be carried out thereafter. 14. The general curriculum for training of ICDS functionaries at the district, block and circle levels will include tribal, social and cultural aspects as they relate to ICDS so as to strengthen the implementation of ICDS among tribal populations. 15. In addition, special literacy training for Anganwadi Workers who are not literate will be provided in tribal areas. This will be carried out under existing government programs such as that being undertaken by the Literacy Mission, Lucknow. The CDPOs will be responsible for identifying Anganwadi Workers who require this literacy training and organizing it for them along with the Project Management Cell. 16. The data base and special field studies will be undertaken to identify areas for special communications messages and programs for tribal people. As part of the communications component, special field testing of messages will be carried out among tribal populations, and programs will be - 110 - Annex 17 Page 4 developed in local languages to be targeted directly to tribal women. Studies of tribal medical knowledge which will assist in the health communications and service delivery components will also be undertaken by qualified consultants. Annual and Mid-Term Reviews 17. Nutrition and process indicator surveys and special studies will be conducted as part of annual and mid-term reviews in both states. The sample frame for these surveys and studies will ensure adequate coverage of both tribal and non-tribal populations. As part of these reviews, independent consultants/agencies engaged by the states will review the implementation of ICDS among tribal populations. The review will include an assessment of the program's compatibility with social and cultural values of tribal communities and the process of consultation with tribal communities during implementation. The annual and mid-term reports would be made available by the Borrower to IDA and the National Advisory Panel (DCA, Section 3.03). - 111 - Annex 18 INDIA SECOND INTEGRATED CHILD DEVELOPMENT SERVICES PROJECT SELECTED WORKING PAPERS AND DOCUMENTS AVAILABLE IN THE PROJECT FILE 1. Project Proposals for the World Bank assisted ICDS Project in Bihar. 2. Project Proposal for Expansion and Enrichment of ICDS Projects with World Bank assistance in Madhya Pradesh. 3. Information on Proposed World Bank-assisted ICDS Project in Bihar and Madhya Pradesh, Government of India, Department of Women and Child Development, May 13, 1992. 4. Report of the Working Group on Development and Welfare of Scheduled Tribes During Eighth Five Year Plan, 1990-95, Government of India. 5. Summary of Findings of the National Review of ICDS as conducted by NIPCCD during 1991-92. 6. "Genetic, Socio-Cultural and Health Care among Tribal Groups of Jagdalpur and Konta Tehsils of Bastar District (Madhya Pradesh). 7. "Background Paper on Tribal Development", Provisions in the Constitution of India for Scheduled Tribes, Government of India. 8. "Monitoring Social Components of Integrated Child Development Services, a Pilot Project", Adarsh Sharma, 1987. 9. "Research on ICDS: an Overview", Volume 1, 1975-85, NIPCCD. 10. "Health and Nutritional Status of Tribals in Madhya Pradesh", NIN, 1986. 11. ICDS--Evaluation and Research, 1975-1988, Government of India. 12. ICDS--Service Delivery among Tribal Populations in Bihar and Hadhya Pradesh, Meera Chatterjee, October 1992.