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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY STAFF APPRAISAL REPORT INDIA SECOND TAMIL NADU NUTRITION PROJECT MAY 10, 1990 Asia Country Department IV (India) Population, Human Resources, Urban and Water Operations Division Report No IN This document has a restricted distribution and may be used by redpents only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorizaon.

2 CURRENCY EQUIVALENTS US$ Rs 17 Rs 1.00 = USS FISCAL YEAR April 1 - March 31 'ieights AND MEASURES Metric System ABBREVIATIONS AND ACRONYMS CNC - Community Nutrition Center CNI - Community Nutrition Instructress CNS - Community Nutrition Supervisor CNW - Community Nutrition Worker DANIDA - Danish International Development Agency DEAR - Department of Evaluation and Applied Research GOT - Government of India ICDS - Integrated Child Development Services IDA - International Development Association IMR - Infant Mortality Rate MCH - Maternal and Child Health NFI - Nutrition Foundation of India NMC - Nutritious Meals Center NMP - Nutritious Meals Program NNMB - National Nutrition Monitoring Bureau SIDA - Swedish International Development Agency TINP - Tamil Nadu Integrated Nutrition Project UNICEF - United Nations Children Fund VHN - Village Health Nurse WWG - Women's Working Group

3 INDIA FOR O"ICAL USE ONLY SECOND TAMIL NADU NUTRITION PROJECT Table of Contents Page No. CREDIT AND PROJECT SUMMARY.... iii I. BACKGROUND A. Introduction... 1 B. Nutrition Status in Tamil Nadu... 1 C. Existing Nutrition Programs D. Nutrition Funding E. Outstanding Issues in Nutrition and the Government's Strategy F. The Role of Foreign Assistance... 6 II. THE PROJECT... 8 A. Goals and Objectives B. Scope C. Strategy D. Project Description E. Communication and Community Participation F. Project Management G. Monitoring and Evaluation.. i 8... III. ESTIMATED COSTS, FINANCING AND IMPLEMENTATION A. Cost Estimates B. Financing Plan C. Recurrent Cost Implications.. 20 D. Project Implementation E. Disbursements F. Procurement G. Accounting and Auditing IV. BENEFITS AND RISKS V. AGREEMENTS REACHED AND RECOMMENDATIONS This report is based on the findings of an appraisal mission to India from January, 1990 comprising Mr. James Greene (Principal Nutrition Specialist--Mission Leader), Mr. Richard Heaver (Senior Operations Officer), Ms. Jasvir Bhasin (Secretary), and the following consultants: Dr. John Kevany (Public Health Specialist), Mr. H. Laroya (Architect), Mr. Sunil Mehra (Communication Specialist), Ms. Meera Shekar (Monitoring and Evaluation Specialist), and Mr. N. M. Murthy (Financial Analyst). Mr. Jay Satia, Mss. Vivian Mendoza, Eileen Truman, and Paula Walden assisted in preparing the report. This document has a restricted distributon 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.

4 - li - TABLES 3.1 Estimated Project Costs by Component Estimated Project costs by Category of Expenditure Financing Plan ProcuremenL ANNEXES 1. Process Objectives TINP IITINP II: Service Delivery Problems and Responses A Draft Strategy for Health/Nutrition Coordination Organization of Health Services Training Component $.# Comunnications Component Monitoring and Evaluation Detailed Project Cost Estimates Project Implementation Schedule Percentage of Incremental Operating Costs for IDA Financing Forecast of Estimated Expenditures and Disbursements Selected Documents in the Project File CHARTS 1. Organization of Project Management District & Block Level Organization Structure... 81

5 - iii - IDIA SECOND TAMIL NADU NUTRITION PROJECT Credit and Proiect Summary Borrowers India, acting by its President. Beneficiarys Amounts Terms: On-lending terms: Descriptions Government of Tamil Nadu. SDR73.5 (US$95.8 million equivalent). Standard, with 35 years maturity. Government of India to Tamil Nadu: In accordance with standard arrangements for development assistance to States for the development of nutrition projects on terms and :onditions applicable at the time. The project would support the Government's goal of improving the nutrition and health status of children 0-72 months of age, and of pregnant and nursing women. The project would be located in the State of Tamil Nadu. Existing services introduced under the earlier IDA-aided nutrition project (TINP I) would be strengthened and enhanced in 122 of Tamil Nadu's 38f rural blocks. The new service package also would be extended to 194 rural blocks which currently bave no effective nutrition coverage of under-three children and are not served by the Integrated Child Development Services program. The specific objectives of the project would be to reduce severe malnutrition among children 6-36 months by 502 in new project blocks and 251 in TINP I blocks; increase the proportion of children 6-36 months of age in normal nutrition status by 50 in new and 352 in existing project areas; and contribute to a reduction in infant mortality to 55 per 1,000 live births and to a 502 reduction in the incidence of low birth weight. The project would comprise the following components: (a) service delivery, to increase the range, coverage and quality of nutrition and health services to the target groups through improvements in the design of software systems, provision of nutrition and health education and of health referral services, supply of therapeutic food

6 - iv - to the malnourished, increasing the availability of equipment and drugs for maternal and child health, and training for health and nutrition workers and traditional birth attendants; (b) cozmunication and community participation, to stimulate demand for project services, improve child feeding and care practices, and promote community involvement, through support for institutional development, provision of communications equipment and materials, and support for formation of women's groups and community education, and (c) project management and evaluation, to expand and strengthen TINP I's Project Coordination Office, to expand and strengthen the existing monitoring and evaluation system, to develop a new apex institution for nutrition commmnications and training activities in the state and to provide support for operations research. Benefits and Risks: The project would improve nutrition and health status of disadvantaged population groups in Tamil Nadu, with more than five million children under six and two million pregnant and lactating women directlv benefiting from the project's services. In new project areas, about 18,000 women would get training and employment as Community Nutrition Workers, and in the project area as a whole about 20,000 female Traditional Birth Attendants would be trained. The project would also have indirect benefits in terms of testing new technologies and managerial arrangements which may prove replicable elsewhere. The main risk is that coordination between health and nutrition services may not function smoothly and may reduce project impact, as was the case under the First Tamil Nadu Nutrition Project. A wide range of measures is proposed to minimize this risk, including structural reform of the concerned departments, joint training arrangements, and joint field visits for service provision and supervision. The risk to overall impact is also limited to the extent that the project is building on major gains in nutritional status made under TINP I, and further gains can be expected from planned improvements to the nutrition delivery strategy alone.

7 Estimated Costss Local Foreign Total USS million A. Service Delivery 1. Nutrition Health Training B. Communications C. Project Management 1. Project Coordination Office Communication/Training Ctr Monitoring & Evaluation Total Base Cost Contingencies 0.38 Total ProJect Cost * * including taxes and duties of US$5.0 million. Financing Plan: IDA: GOTN: Total Estimated Disbursements: FY91 FY92 FY93 FY94 FY95 FY96 FY97 FY98 Annual Cumulative Economic Rate of Return: Not applicable

8 INDIA SECOND TAMIL NADU NUTRITION PROJECT I. BACKGROUND A. Introduction 1.01 Tamil Nadu's commitment to nutrition reflects both the state's own emphasis on raising the living standards of the poor and India's development priority to poverty alleviation. Tamil Nadu's efforts have met with some success despite incomes and general nutrition status which remain lower than the national average. Infant mortality rates (IMR) are around 202 lower than the average for India; about two-thirds of Tamil Nadu infants have completed necessary immunizations. The 1986 death rate for children 0-4 years of age was estimated at 25.1, among the lowest in India. The state's 1987 'iirth rate was estimated at 23.6 per 1,000 population against 32 for India as a whole Tamil Nadu's nutrition efforts span a quarter century; by the late 1970s, Tamil Nadu was spending about US$8.8m per annum on no less than 25 programs in the nutrition sector, three quarters of which was accounted for by a school meals program reaching around two million children. However, all of the state's nutrition programs combined reached less than 102 of pre-school children, the group that studies had shown to be most affected by malnutrition. Evaluation studies had also shown that existing nutrition programs needed to do more to improve their targeting, to promote better nutrition practices within families, and to strengthen maternal and child health services. Since then, and in response to the desire to improve the quality of services and increase their coverage, the state launched four major nutrition programs, which now absorb almost all nutrition spending: the Tamil Nadu Integrated Nutrition Project (TINP), assisted by IDA, and the Nutritious Heals Program, (NMP), exclusively funded by the state; and the Integrated Child Development Services Scheme (ICDS) and the Public Distribution System (PDS), funded both by the Government of India (GOI) and the state. B. Nutrition Status in Tamil Nadu 1.03 Tamil Nadu nutrition status historically has tended to be lower than for India as a whole. Host surveys by the National Nutrition Monitoring Bureau (NNMB) of the National Institute of Nutrition have indicated comparatively lower levels of food intake, particularly among the poorest and most disadvantaged populations, in Tamil Nadu than in other Indian states at similar levels of income and development. NNMB has not undertaken a Tamil Nadu survey in recent years: however, in 1986 Tamil Nadu itself carried one out in the roughly one half of the state covered by TINP. Children under four (the age group most vulnerable in terms of malnutrition and mortality) were classified as follows: severely malnourished, about 112 (so called grade III and IV children with weight for age of less than 602 of the norm); moderately malnourished, about 322 (so called grade II children with weight for age between 60 and 702 of the norm); and normal and mildly malnourished, about 572. These figures are comparable to other areas of rural India. No recent survey of nutrition conditions elsewhere in the state has been carried out;

9 vii responsibilities more clearly, and begin to tackle pollution and competition issues seriously. Fixially, procurement practices are resulting in costly delays, and need to be improved. 19. Although Costa Rica's social indicators are exceptionally high in Latin America, the economic crisis has slowed their progress in the 1980s. Public spending on social programs remains large, about one-half of the public budget, but spending per capita in education, health, and nutrition has fallen significantly since Moreover, although poor households &dclined as a share of the total population, the absolute number of poor psople increased significantly from 1977 to Population growth, despite significant declines in fertility rates until the mid-1970s, continues to be a concern. In the 1990s, the Government will have to cope with increased demand for services and continued budget restrictions, heightening the importance of improving the efficiency and equity of social programs. In education, spending currently is regressive; priority needs to be given to improving the quality of primary education, and counteracting current trends toward increased inequality of opportunities. Resources should be increased for primary education, teacher pay and pension schemes need to be revised, and assistance programs for poor families should be put in place; user fees should also be introduced at the university level. In health, the Government should improve the quality of service and cost recovery through a variety of measures; coordination and rationalization of Ministry of Health and CCSS programs needs to be improved. Targeting of nutrition programs needs to be improved so that benefits reach those suffering the greatest distress; the school fee X"g program in particular requires reform. The social security system is also in urgent need of reform, if its financial viability is to be protected. Priority actions should include raising the retirement age for all pension schemes and standardizing benefits across programs. Lastly, family planning programs need to be strengthened and expanded, with particular attention to the needs of adolescent mothers. 20. Women's issues occupy an important place in Costa Rican politics, and the Government has supported progressive legislation and programs to defend women's rights. Universal access to social programs since the 1960s has resulted in high social indicators and improvements in human capital formation, particularly among women. Nevertheless, in the workplace women still receive lower positions and salaries than men. Fiscal austerity creates additional problems: restraints on government services affect women disproportionately, as will reductions in government staffing requirements, for the public sector has provided the most attractive employment opportunities for women. Four issues require attention in the future. First, a central institution, such as Centro Nacional para el Desarrollo de la Mujer y la Familia, needs to be strengthened so that it can play an effective coordinating role when dealing with other government agencies, NGOs, and donors. Second, educational and publicity campaigns need to be launched, with the objective of increasing women's awareness of their rights as well as educating private employers and public agencies. Third, policies and programs need to be designed and implemented to facilitate increased labor market participation by women, particularly in the private sector. In the public sector, rationalization of the work force should take into account the importance of women's employment in the sector. Fourth, support for family

10 service training. A Conmnity Nutrition Supervisor (CNS), one for ten CNWs, visits each CNC twice monthly, oversees CNW work, spot checks the weights of children enrolled for supplementary feeding and closely examines children with inadequate weight. At the block level, a Comunity Nutrition Instructress (CNI) is responsible for imparting pre-service and in-service training and supplies CNC medicines. At the rate of one every two blocks, a Project Nutrition Officer oversees on an average the work of two Nutrition Instructesses, 15 supervisors and S50 CNWs. She also liaises with the health services. A District Project Nutrition Officer oversees and coordinates all the nutrition related activities in the district TTNP's strengths and weaknesses were reviewed in a recent draft Project Completion Report which concluded that implementation experience with the project was good. Comnnity natrition centers were set up as planned in about 9,000 villages. Workers' skills and motivation were evaluated as very high. About 2,000 new Health Sub-Centers were constructed. Implementation delays were not significant. A two-year extension of the project (which closed in March 1989) was approved to carry out additional activities in keeping with the project's objectives. Factors responsible for smooth implementation included the state's strong political commitment to the sector; the high quality of the managers assigned to the program by the state; the attention given during project preparation to the design of software systems; and the use of the first project year for field testing of these systems in a small area before rapid subsequent expansion. The project was also evaluated as sustainable; the state decided to continue funding the program from its own resources after project closing, and its annual recurrent cost of US$4.7m represented less than five per cent of the state's spending on nutrition in ' With regard to the program's impact, it is estimated that TINP contributed to a reduction of a third to a half in severe malnourishment among 6-24 month olds and contributed, together with the 10P, to a reduction of about half in severe malnutrition among 6-60 month olds. These achievements surpass those of most other nutrition programs. On the other hand, the project did not achieve its perhaps overly ambitious goal of reducing malnutrition as a whole by 50S. Even in the parts of Tamil Nadu benefitting longest from the project, severe and moderate malnutrition combined fell by 282 (from 53S to 38X) for under sit children, and by only ten per cent for under three children; results were not as good elsewhere. The main problem was difficulty in substantially reducing moderate malnutrition The project's health goals were only partially met. Infant mortality went down by 12-26Z iu different project areas, as against the project goal of 25Z. Success in achieving the targeted reductions in Vitamin A deficiency and anaemia (para 1.04) was not directly evaluated. But the targets could not have been achieved, since process evaluation indicated that less than a quarter of under six children and pregnant and lactating women had been covered by the related health interventions TIMP provided many important lessons. On the nutrition side, the project showed that part-time village workers, if properly trained and supported. can substantially improve their community's nutritional status. Second, the project demonstrated unambiguously that growth monitoring is an

11 - 4 - effective intervention i. large-scale nutrition progra-ss. Third, the project showed that targeted, short-term supplementation for growth-faltering and for severely malnourished children can significantly reduce severe malnutrition; TINP's targeting system meant that only 25S of children were being supplemented at any one time. The program has also been conaended for several features of its software design on the nutrition side. These include carefully defined criteria for recruiting suitable local field staff; limitation of field worker tasks to what is manageable ard high priority; specification of daily and monthly work rottines; its innovative decentralized training system; supervisory ratios which :scilitate on the job training; the display of performance information to clients and workers at the village nutrition center; a management information system which could rapidly detect performers falling below established norms; and the use of women's groups to support project activities. In particular, observers have noted that the women's groups fostered a degree of community involvement the project far greater than in other large scale nutrition programs in India. Several of TINP's features have already been taken up for replication in Bank-assisted nutrition operations in other countries The Project Completion Report also noted a number of weaknesses in the nutrition, health and evaluation components of the program, as follows. (Strategies to deal with these weaknesses in the proposed Second Tamil Nadu Nutrition Pro=ect are summarized in paras below). Four main problems on the nutrition side were identified. First, about 30Z of eligible children in the project areas did not benefit from project services, mainly because they lived too far from the nearest CNC. Second, just over four per cent of children failed to respond to project inputs, and remained in feeding. Though the numbers were small, this was a serious problem, because these were mainly severely malnourished children, at high risk of dying. Third, as noted above, the project did not make a substantial impact on moderate malnutrition. Fourth, around 42Z of children who graduated from feeding (see pati 1.06) required further supplementation within six months because they failed to continue to gain weight. Around 6Z relapsed twice; less than 1 required a third round of supplementation. Thus, while the project succeeded in helping these children, they might have recovered sooner to a normal growth path had they received a longer, unbroken initial period of supplementary feeding The main problems on the health side were institutional. Weak cooperation between the Departments of Health and Social Welfare at the state level was reflected in failure to send appropriate signals to field workers to cooperate. Consequently, health workers did not regularly visit the CNCs and work as a team with the CNVs. One indicator of this was an evaluation finding that only 28Z of pregnant women knew the name of their health worker, as opposed to 69Z for CNWs. With regard to the evaluation component, problems include difficulties in separating project effects from effects of other nutrition programs and from secular trends in the state; these steamed from having a small control area (one hlock) which was not very well matched with the project pilot block against which key comparisons were made in the evaluation. Also, baseline and evaluation surveys were carried out in different seasons A more general finding of the evaluation was that, while TINP's design was flexible during the first project year when different strategies

12 were being tested, the design 'froze' during later years. The consequence was that, while several evaluation findings--such as relative Xailure to deal with moderate malnutrition--became evident during implementation on the bai'is of monitoring data, this infotmation was not used to the full for mid-course correction. A systematic attempt to correct for project weaknesses was not made until the beginning of the preparation process for the proposed second project The Nutritious Meals Program (NMP1. This program was introduced throughout the stata beginning in 1982 to meet social, as well as nutrition and health, goals and provides a regular noon meal to children aged 2-14 years. It also feeds old-age pensioners and desititute widows NMP functions through 63,000 feeding centers; a center with a noon meal organizer and two helpers serves every pre-school children, and a noon meal organizer is also employed part time for every 500 school children. OMP confines itself to feeding, to the exclusion of nutrition education and necessary coordination with health services. Its nutritional impact has not been carefully evaluated. However, since NMP does not fully cover the most nutritionally vulnerable group--very young children and pregnant women--its main developmental benefits are more likely to be social rather than developmental from a physical or intellectual perspective Integrated Child Development Services (ICS. The ICDS scheme offers an integrated package of nutrition, health and pre-school services to under six children in poorer areas of India. Since its inauguration in 1975, it has become the main pre-school child development program, covering 402 of the country. In Tamil Nadu, the development of TIMP pre-dated the national expansion of ICDS, so that ICDe operates on a small scale in only about 26 rural blocks, although it has achieved good coverage in the poorest urban locales. TINP and ICDS together cover just over half of the state's rural areas. The remainder of the state remains unserved by any nutrition program targeted to the most vulnerable groups. It is difficult to compare ICDS and TINP because ICDS covers children up to six years 3f age And includes preschool education, whereas TINP focussed on children under three with nutrition and health services only. Only one study has attempted to compare the costeffectiveness of the two programs as nutrition interventions. It concluded that TINP has had a greater impact on severe malnutrition than ICDS for the same or perhaps lower cost. Both programs have had limited success with reducing moderate malnutrition, and with getting nutrition and health services to work together Public Distribution System. The PDS provides subsidized staple foods to poorer families through a network of 'fair price shops'. It also was founded in the 1970s and has expanded nation-wide. In most states its reach has been more to the urban than to the rural poor, but in Tamil Nadu, along with Kerala and Gujarat, the PDS also serves the rural areas. No systematic evaluation of the PDS's impact on nutrition has been made in Tamil Nadu. But in general, the experience with the program has been that, while it increases families' overall food secutity, it does not significantly reduce malnutrition among very young children. It is therefore not a substitute for targeted nutrition and health interventions to the most vulnerable age groups, like the TINP and ICDS programs.

13 D. Nutrition Funding 1.17 In , the Tamil Na#;u government spent Re million (US$ 104 million) on various nutrition programs, 90 percent of it on the NMP. Of the remaining expenditure, three-fourths was on TINP and one-fourth on ICDS. Nutrition program expenditure accounted for 15.7 percent of expenditure on social services and 5.2 percent of total government expenditure. Social services receive considerabl emphasis in Tamil Nadu. During the last decade ( ), state government expenditure grew at an annual rate of 2.3 percent while expenditure on social services grew at a yearly rate of 7.6 percent. B. Nutrition Issues and the Government's Strategy 1.18 Tamil Nadu's investment in the nutrition sector has led to a substantial reduction in severe malnutrition in the approximately half the state where TINP and ICDS operate. However, no direct nutrition int4rvention is available for the youngest and most vulnerable age group in the other half of the state, where nutrition conditions have yet to catch up with improvements in TINP and ICDS areas. In addition, two other broad deficiencies remain to be resolved: (a) lack to date of a major reduction in moderate malnutrition; and (b) continuing weak cooperation between health and nutrition services in the field The lessons from TINP I suggest that with specific changes in strategy much more could be done to reduce moderate malnutrition and increase healthinutrition coordination; and that these strategic changes plus expansion of the TINP program state-wide are an affordable option for the state. Tamil Nadu's nutrition strategy for the most vulnerable age groups is therefore to build on the strong foundation of TINP. Based on its experience with ICDS, Tamil Nadu intends to build pre-school activities for children aged 3-5 years into the existing network of Nutritious Meals Centers which already serve that age group. To promote cost-effectiveness, the state's strategy is to amalgamate NKCs and CNCs so as to provide integrated child development services at a single center for the under-sixes, along lines similar to the national ICDS program. The longer-term objective is to converge both the TINP and ICDS models by adopting the best features of each. F. The Role of Foreign Assistance 1.20 Donors other than IDA. At the national level, external donor involvement in ICDS is relatively small. CARE donates supplementary nutrition for around five million ICDS beneficiaries in seven states, and the World Food Program supplies around 2.1 million beneficiaries in five states. UNICEF provides equipment and funds all basic training for new ICDS centers. USAID has supported ICDS expansion and strengthening in one district each of Gujarat and Maharashtra. In Tamil Nadu, UNICEF's and recent SIDA support in one district for ICDS and IDA's for TINP have been the only direct donor involvement in the nutrition sector. DANIDA supported a US$12.5 million equivalent health care project in two districts of the state from 1981 to 1987, and a second phase costing US$1 million equivalent will continue the project until The focus is on integrating the delivery of maternal and child health services, improving staff training, education activities, man-agement, maintenance and information systems. UNICEF has also recently

14 sanctioned a small (US$300,000) child survival project in two districts of Tamil Nadu. This will be implemented primarily through the health system, focusing particularly on developing the Traditional Birth Attendant as a link with the population. Key services to be emphasized will include ante-natal services, safe chi'dbirth and nutrition education; better care of the new born, especial' ow birth waight babies; immunization, Vitamin A supplementation and oral rehydration therapy The Bank's Role and Strategy. The US$32m IDA credit for the Tamil Nadu Nutrition Project was IDA's fourth for a free-standing nutrition project, and its first for nutrition in India. IDA's other credits for the human resources sectors in India consist of one vocational training project and six population projects, four of which are still under implementation, and each of which contributes to strengthening maternal and child health services as well as family planning IDA's principal nutrition objective is to assist India to adopt and maintain cost-effective policies, strategies and programs to deal with nutrition problems of pre-school children and pregnant and nursing women. Over the longer term, a broader objective is to ensure that the benefits of Indian food production, subsidy and income generating programs get directed as much as possible toward those at greatest nutritional risk. The Bank's strategy to achieve this objective consists of a blend of sector and project work. Sector work to increase Bam.u and GOI knowledge about the magnitude and location of pre-school malnutrition and their relationship to levels of nutrition program funding and coverage Was undertaken as part of preparation of the Bank's FY89 India Country Economic Memorandum. Over the longer term, the Bank's sector work would focus on filling gaps in our and GOl's understanding of critical variables affecting nutrition policies, strategies and effective design, management and implementation of other intervention programs with possible nutrition consequences Simultaneously with the preparation of the proposed second Tamil Nadu project, the Bank collaborated with GOI and the states of Orissa and Andhra Pradesh in the development of a first project to assist ICDS. The focus of that project, which is proposed for FY91 Board presentation, would be on improving the nutrition and health status of children under three years of age, and of pregnant and nursing women in particularly disadvantaged, especially tribal, areas of these states. Components would include expansion of service delivery into new blocks, and in both new and existing blocks improvement of training and supervision, communication and community mobilization efforts, and monitoring and evaluation. A proposed Second ICDS Project, currently under preparation for Board presentation in FY92, would provide similar assistance to ICDS in similarly disadvantaged tribal areas of Bihar and Madhya Pradesh. It is hoped that policy dialogue building on both project experiences and sector work would help the GaI and state governments to set priorities for resource allocation to nutrition, to apply resources effectively to where they are most needed, and to take nutrition concerns more consciously into account in development efforts.

15 A. Project Goals and Objectives II. THE PROJECT 2.01 The project seeks to improve the nutrition and health status of children 0-72 moths, with particular emphasis on children 0-36 months, and pregnant and nursing women. Its specific nutrition and health impact objectives would be tot (a) reduce severe malnutrition (grade III and IV) among chjldren 6-36 months by 50S and 252 in new and existing project areas, respectively; (b) increase the proportion of children 6-36 months of age in normal and grade I nutrition status by 502 and 35? in new and existing project areas, respectively, and (c) contribute towards a reduction in IMR from around 84 to 55 per 1,000 live births and to a 5O0 reduction in the incidence of low birth weight from present levels The project also would help to increase contraceptive prevalence rates, although no specific project target has been set, by increasing the availability of maternal-child health services which will create a stronger tie between women cf child-bearing age and female family welfare workers, who are also responsibl'4 for delivering both health and family planning services. Moreover, improved child health and nutrition contribute to a favorable climate for smaller family size. While ambitious, the project's quantifiable objectives are considered feasible for the following reasons. First, TINP I succeeded in reducing severe malnutrition by at least a third to a half (see para 1.08) despite gaps in both community and health coverage, which the proposed project would correct. New strategies in the proposed project (paras ) would be expected to lead to a reduction in moderate malnourishment as well; pre-testing of the proposed move to supplementary feeding of all moderately malnourished children in one existing TINP I area already has shown a reduction of over 20? in this grade of malnutrition for children aged 6-36 months. IMR reductions over six years from 84 per 1,000 live births would require annual decreases of 5 per year, which has been achieved in both Kerala and Karnataka and should be possible with improved maternal and child health (MCH) services through the proposed project. Achievement of significant reduction in the incidence of low birth weight is probably the most difficult objective. Progress toward that goal will relate directly to the numbers of at-risk pregnant women who receive early and complete nutrition supplementation and iron deficiency therapy and prophylaxis. However, the relatively advanced stage of Tamil Nadu's delivery systems and the high priority proposed to be given to this feature of the proposed project may permit achievement of the Government's target The above objectives would be achieved over six and a half years through improved service delivery; enhancing nutrition and health capability of mothers and communities; and promotion of community participation in the

16 - 9 - project's nutrition, health, and educational activities. These intermediate goals would be realized by: (a) Increasing the coverage and quality of nutrition and health services for pregnant and nursing wvmen and children 0-72 months of age; (b) developing communication strategies and strengthening communication activities through use oi print and other media and audio-visual support materials; (c) community education, including formation of new and strengthening of existing women's groups; and (d) refining and continuing to adapt suitable software systems for training, supervision, work organization, and monitoring and evaluation. Specific process objectives for service and activity coverage are given in annex 1. D. Scope 2.04 The project would cover a total of 316 of Tamil Nadu's 385 rural blocks. It would strengthen activities in 122 blocks where TINP already operates. It would expand the upgraded TINP model to 194 additional blocks. The remaining blocks would be covered by ICDS and would not be a part of this project. In existing TINP blocks, about 6,400 CNCs would be strengthened and amalgamated with the Nutritious Heals Centers (NMCs) already existing in those villages. In the new blocks, and in about 202 of the villages in existing blocks where there are gaps in the existing coverage of CNCs, a total of about 12,000 existing NMCs would be strengthened by addition of a new worker who would provide TINP services to the under three children. And in about 2,200 villages in new and existing blocks which are currently covered by neither TINP nor the noon meals program, new centers would be established with two workers and a helper to provide both services. The health, communications and community participation and monitoring and evaluation components would establish or strengthen the respective services as appropriate in all 316 blocks. However, health component inputs in areas receiving DANIDA and UNICEF assistance (para 1.20) would be limited to those not already being financed from other sources. C. Strategy 2.05 The proposed project would retain the most successful features of TINP I, improve on others, add new elements and extend the enhanced package to all of rural Tamil Nadu not covered by ICDS. The project would seek to expand the range, increase the coverage, and improve the quality of both nutrition and family welfare (i.e. maternal-child health and family planning) services in the project areas. The main services to be provided to different target groups would be as follows: (a) pregnant women--antenatal care, health and nutrition education, and food supplementation for the malnourished;

17 (b) nursing women--postnatal care, health and nutrition education, including family planning education and food supplementation for the malnourished; (c) children 6-36 months--growth monitoring, immunization. vitamin administration, deworming, acute respiratory infection management, health check-ups, referral and rehabilitation, and therapeutic nutrition supplementation; A (d) (e) children months--growth monitoring, immunization, vitamin A administration, deworming, acute respiratory infection management, health check-ups, referral and rehabilitation, and pre-school education and all women and community leaders--nutrition and health education In addition, several changes to TINP I's strategy are proposed in response to the evaluation findings summarized in paragraphs above. With regard to the problem of exclusion of beneficiaries, three approaches are proposed. First, would be in-filling of uncovered areas with additional CNCs (para 2.12). Second, would be redrawing of the boundaries of CNC areas so that outlying hamlets are assigned to their nearest service center. Third, would be operations research with different methods of service outreach to outlying hamlets, such as use of mothers' groups in the hamlets to collect supplementary food from the CNC, and to assist with child weighing and nutrition and health education With regard to the problem of severely malnourished children who fail to graduate from the feeding program, two approaches are proposed. First, operations research would be carried out with new kinds of food supplements--such as amylase enriched foods--which are less bulky or less viscous than existing foods and therefore may allow severely malnourished children to absorb more calories. Second, many of the severely malnoiirished children remain so not only because their families are too poor to feed them properly, but because they have health problems. The project would make a systematic effort to upgrade health referral facilities through provision of equipment, supplies and training in diagnostic techniques for doctors. It also would experiment with the provision of transport cost payments to referred patients so as to increase the frequency with which recommended referrals are actually completed. The project would also experiment on a small scale in one district with the development of 12-bedded MCH annexes attached to block-level Community Health Centers. These would be simple accommodations where women with high risk pregnancies could stay with a fanily member while awaiting birth, and where mothers with severely malnourished children could stay while the child was rehabilitated under the guidance of a pediatrician Improved referral services would also help solve the problems of some children who remain moderately malnourished or who relapse into supplementary feeding after initial graduation. In addition, two innovations will be made to deal specifically with these problems. First, the project

18 would place special emphasis on improving the health and nutrition status of pregnant and nursing women, so as to reduce the incidence of low birth weight and related infant malnutrition. This would be achieved by attempting to identify pregnant women by the third month of pregnancy, and providing them with a full range of ante-natal services, including iron supplementation and food supplementation for women at high nutritional risk. Second, food supplementation would be provided to all under-three children with moderate malnutrition in addition to those, as at present, whose growth is faltering or who have severe malnutrition. On-going operations research in a few TINP I blocks suggests that this measure, while adding initially to recurrent costs, should have a significant effect on moderate malnutrition. In view of the importance of appropriate supplementation procedures to the success of the project, assurances were received at negotiations that Tamil Nadu would by January 1, 1991 adopt and apply beneficiary selection crizeria and methodology mutually agreed to by Tamil Nadu and IDM, for provision of therapeutic supplements to children under 36 months of age and for pregnant and lactating women in the project area (para 5.01(a)) With regard to the problems of health/nutrition service coordination, five new measures are proposed In addition to those for referral services described above. First, the state is in the process of carrying out at its own initiative a structural reform of the state health and family welfare and social welfare departments so that for the first time health and nutrition workers at the field level would be under a single chain of command. Second, a more appropriate division of tasks would be made between health and nutrition field workers. Third, work routines would be revised so that both workers and supervisors would spend more time in the field together (para 2.22). Fourth, maternal and child health records would be kept at the CNC rather than, as at present, at the higher level health facility, giving health workers an added incentive to center their outreach efforts on the CNC. Finally, health and nutri'.ion field workers would be given twice-annual refresher training jointly, instead of separately as at present, a move which should improve teamwork as well as technical skills. A detailed draft strategy for ImprovAng health/nutrition coordination is given in Annex Measures are also proposed to improve the quality of project evaluation, and to increase project responsiveness to monitoring and evaluation findings, and to communities' felt needs. The project would strengthen the state's Department of Evaluation and Applied Research (para 2.34). In addition to a formal midterm project review, project management and IDA would carry out a detailed annual review of project progress, and ensure that mid-course corrections would be built as appropriate into the work plan for the subsequent year (para 3.11). Regular qualitative surveys of project clients would be carried out under the communication component (para 2.27), and the project would attempt to strengthen village women's groups to take on more responsibility for planning local initiatives for health and nutrition improvement (para 2.28). D. Prolect Description 2.11 The project would consist of the following components, as described belows service deliveryg commnications and community participation; training; monitoring and evaluation; and project management.

19 Service Delivery (US$127.7 million) 2.12 The project would support upgrading, integration and expansion of village level nutrition services; improvements in tuerapeutic food supplementation strategies; in work organization and supervision: and in health-nutrition collaboration; strengthening of the referral and nutritional rehabilitation systems; and the introduction of pre-school education services. Annex 2 provides a description of TIMP I's main services, achievements and problems and how these ill change under the proposed project Village Level Services. Combined CNCs and NHC9 would be the focal point of village nutritiok and health services, and for the first time would also provide pre-school services for month olds, along the lines of those provided by the ICDS program. Each center would be staffed by two locally recruited nutrition workers plus one female helper. The project would finance furniture and equipment and incremental operating costs for salaries, drugs, therapeutic food, building maintenance and consumable items such as record-keeping forms of upgrading existing NMP centers to CNCs in non-tinp areas, of integrating them where both centers now exist, and of establishing new centers to fill coverage gaps of both services More than a quarter of existing CNCs, all of which are currently in rental accommodation, are too small or otherwise unsuitable for their purpose. The project would therefore finance incremental rent for better accommodation for existing CNCs, as well as rent for all new CNCs. The project also would finance construction, furnishing and equipping of about 500 new CNCs, with a floor area of square feet, in villages where suitable rented accommodation cannot be found. Additional CNCs may be constructed if the need is found during implementation, and experience in the early years of the project indicates that construction capacity is adequate The project would provide additional MCH drugs for acute respiratory infections, referrals from CNCs, deworming, and vitamin A supplementation. Standard drug and medical supply kits will be developed for use at CNCs, Health Sub-Centers (HSCs) and Primary Health Centers (PHCs). A manual for diagnosis and treatment for common mother/child ailments and nutritional disorders would also be developed. As described in paragraph 2.23, the project would emphasize referrals from CNCs to higher levels of the health system and would support provision of necessary equipment at Health Sub- Centers, Primary Health Centers and Comunity Health Centers Therapeutic Nutrition Supplementation. Nutritional surveillance would be used for pregnant women and children under three years of age for nutrition education, and, if necessary, for entry into the therapeutic food supplementation program. Recent Indian research indicates that regular therapeutic supplementation for about 180 days during the pregnancy of at-risk women can increase infants' birth weights by an average of 230 gms., thereby reducing the risk of low birth weight (less than 2.5 kg) by at least a third. Therefore, the project would finance therapeutic supplementary food for such women from the 20th week of pregnancy up to six months after delivery. Postnatal supplementation would help ensure adequacy of breast milk during the critical early months of infancy. As noted above, the project would also

20 finance supplementation for children under three years of age who are grade II or below until they are able to maintain normal or grade I status for at least three successive monthly weighings. In addition, growth falteriag criteria would continue to be used for entry into supplementation. Children aged 3-6 years will continue to receive a noon meal as part of the e3tablished preschool package, funded outside the project In TINP, the supplementary food provided for the under threes is a ready-to-eat pulse/cereal mix procured from three sources. Karnataka State Agro Corn Products Limited supplies about three-fourths of the requirements from its food processing plant. ADout 20 Women's Food Cooperative Societies have recently begun production of the supplement. In addition, more than 300 Women"s Working Groups produce supplement for use in the surrounding CNCs. Production by local women has had the benefit not only of providing employment but also nutrition education. However, problems emerged under TINP with maintaining the quality of the food and its accountability, and the state therefore proposes to procure incremental food for the second project from factory production. Work is under way to develop a new supplement more suitable for severely malnourished children (para 2.07). In view of the importance of this to the success of the project, assurances were received at negotiations that by January 1, 1991, Tamil Nadu will provide in the project area and thereafter maintain provision of therapeutic food supplements whose composition is satisfactory to IDA (para 5.01 (b)) Work organization and supervision. The wide range of services envisaged in the project requires a team effort of health and nutrition staff. The allocation of duties and enabling work routines have been developed and were reviewed at appraisal. They would be tested during the first year of the project in one district and implemented in all project areas after necessary modifications. In general, the CNW would be responsible for registration of pregnant women, iron supplementation, nutritional surveillance of pregnant women and children 0-36 months of age, therapeutic nutritional supplementation, administration of vitamin A, and health referral of malnourished children and severe acute respiratory infection cases. In addition she will assist in counselling for birth spacing and immunization. Village health nurses would provide antenatal and postr tal care, immunizations, family planning services, health check ups, and if necessary, refer children to higher levels of the health system. Traditional Birth Attendants would provide quality natal care and motivation for family planning. While essential elements of the service delivery strategy, changes in work organization would be introduced to staff through routine in-service training, and have no additional financial implications for the service delivery component Supervision is critical for ensuring consistent, high quality services; for promoting community mobilization; and for ensuring effective coordination with the health services. Supervisors provide necessary guidance to village-based staff on a day-to-day basis, conduct in-service training, hold sector meetings to monitor performance and resolve problems, liaise with the health staff, and promote involvement of women's working groups and other influential community members. As at present, a supervisor would provide support to 15 CNCs and a Community Putrition Instructress (CNI) at the block level would supervise the supervisors and support CNWs, wherever necessary.

21 The Community Health Nurse and Medical Officer (MCH) at the community health center would be responsible for health services at the block level (see Annex 3 and Chart 2). Block level coordination between the health and nutrition sectors would be achieved through Block Project Officers who would be responsible for project services in the block. At the district level, the District lmmunization Officer would oversee project activities and would be supported by a District Project Nutrition Officer, a Public Health Nurse, a District Child officer, a statistician and other staff For nutrition staff supervision, the project would support investmentlincremental operating costs as appropriate for equipment and furniture; and for salaries, rent, utilities and consumables of 194 block project offices and 14 district offices. It would also finance the costs of additional staff needed to provide a supervisor for 15 CNCs. The project would finance one four wheel drive diesel vehicle in each project block, which would be available both for supervisory visits by health and nutrition staff, and for the transport of urgent referral cases (para 2.28); and mopeds and bicycles for staff willing to buy these on a hire purchase basis to increase their mobility Training. Training would be a key instrument for ensuring quality services, creating and maintaining staff motivation, and improving their communication and community mobilization skills. The project would finance the costs of four different types of training; pre-service for new staff, orientation training for existing staff in the project areas, regular inservice training, and problem solving workshops. All training for staff below the block level would be carried out at the block, rather than at more distant training institutions. But training would be carried out at the block not just by the CNI as in the first project, but by a training team consisting of the CNI, the Community Health Nurse, the Block Extension Educator and the Block Health Supervisor. As well as ensuring that nutrition staff learn necessary health skills and vice versa, training by joint teams of health and nutrition supervisors will help stimulate coordination and teamwork in the block Newly recruited nutrition workers at the CNC level would receive eight weeks' pre-service training, of which the last week would be joint training with the local VHN. CNWs in existing TINP areas would receive a week's orientation training in the new priorities for the second project. All these workers would receive a week's in-service training every six months jointly with their VHN, beginning in year two of the project. Helpers would receive a week's training in the first project year, with a two day refresher each year thereafter. The block training team would also be responsible for training community groups; it is planned that 40 women, adolescent girls and community leaders in each village would receive a two day training annually. The VHN and her supervisor would organize refresher training at the block once in three years for Traditional Birth Attendants, for whom there is currently no refresher training program Pre-service training for newly recruited Community Nutrition Supervisors would take place at four regional training institutionst Gandhigram, Laksbmi Training College, Sri Avinashilingam College and Christian Medical College, Vellore. This would last eight weeks, and would be followed

22 by a week's joint training in the field with their health supervisor counterparts, who are already in place. In-service training would consist of a week's joint training every six months, carried out by the block training team. Newly recruited CNIe would receive a month's pro-service training at the Communications and Training Center (see para 2.33). To prepare the block training teams, each team as a group would receive one month's training in one of the existing regional training centers in the state, and a week's inservice training annually at the same institutions. Curricula for trainer training are being developed as a pre-project activity At the managerial level, Block Project Officers would receive a two week institution-based training in project management. Doctors at the block level would receive a two or three day workshop-type training on the project, with special reference to its referral needs, given by district staff at the district level. District Project Officers, District Nutrition Officers, District Communication Officers and Statistical Inspectors all would receive specialized orientation training in their particular responsibilities. Inservice training for district level staff would consist of a yearly joint week long workshop, which would focus on review, problem-solving and planning activities. Details of training plans are given in Annex With service delivery expansion through the proposed project to almost the whole of Tamil Nadu, training loads will sharply increase, as will the importance of carefully planning, monitoring and evaluating the training program as a whole. The project would therefore finance an expansion of the role of the Communications and Training Center established under TINP I (para 2.26) s0 as to make it an apex institution for both communications and training activities. In addition to incremental staff, equipment and operating costs for the new training wing of the institution, the project would finance construction of an additional floor for the building, which is situated in a suburb of Madras. The additional space would be used as hostel accommodation for the supervisors and managers who would receive short term training under the proposed project at the Communication and Training Center Health-Nutrition Coordination. As nutrition and health services have synergistic impact, they need to be delivered in a coordinated manner. Despite coordination committees and other functional linkages, healthnutrition coordination in TINP remained unsatisfactory (para 1.12). If VHRNs receive more support from CNWs, they will more easily achieve their antenatal care, immunization and family planning goals. If CNWs receive more support from Village Health Nurses (VHNs), they will be able to do more for children who are malnourished as well as have health problems. Although closer collaboration would benefit both health and nutrition systems, this has not been perceived as an opportunity. Also there are other difficulties. The work routines of both workers reflect their own priorities and are not synchronized. Joint tour plans of supervisors are difficult to implement as their work areas and supervisory needs may not always coincide. A more comprehensive approach, going beyond the traditional approach of coordination, is needed for the workers to collaborate at the village level Better cooperation between departments will partly be achieved by structural reform (para 2.09). A series of process-oriented measures would also be taken. Agreement would be sought between the Departments of Health

23 and Social Welfare on a clear allocation of responsibilities. assignment of priorities, monitoring procedures and work routines. The current monthly work routines of health functionaries do not take maximum advantage of CNWs' close contact with the clients. Specific days need to be set aside for the CNW and YHN to work together. Joint planning, joint training and joint supervision all can motivate workers to collaborate. Formats and procedures would be developed for joint planning at district, block and sector levels, and specific days may also be set aside for joint supervision by nutrition and health supervisors. With the exception of joint training, these processoriented measures for health-nutrition collaboration do not require significant financial outlays. During negotiations assurances were received that by January 1, 1990, Tamil Nadu will introduce and thereafter maintain arrangements agreed to by IDA and Tamil Nadu for coordination between health and nutrition services in project areas (para 5.01 (c)) Strengthening the Referral System. Neither TIN? ncr ICDS has yet been able to develop effective arrangements for health referrals. During the first two years of the project, operations research on how best to strengthen the health referral system would be undertaken in Madurai diprict, one of the original TINP districts with an established nutrition infrast.-ucture. The project would finance the establishment of 11 MCH annexes at Community Health Centers for care of at risk pregnant women and severely malnourished children (para 2.07). In addition, the project would finance construction and equipment of 12 new Primary Health Centers in the same district, so that experiments with revised referral procedures can take place unhampered by gaps in the infrastructure network (staff are already in place for these Primary Health Centers, but are working in unsatisfactory rented quarters). If a successful system can be developed, the same approach would be replicated in other districts. Funds have been included in the project for additional equipment and drugs for Health Sub-centers and Primary Health Centers in the project area to meet the expected increased demand for services from referral cases. Assurances were received at negotiations that Tamil Nadu will by September 30, 1991 undertake and complete operations research on the efficacy of different approaches to strengthening obstetrical and child nutritional risk management at referral facilities in Madurai district, the operations research to be conducted according to terms of reference agreed to by the IDA and Tamil Nadu (para 5.01 (d)) Pre-school Education. Pre-school education is provided to month olds in ICDS but not in TINP or NMP centers in Tamil Nadu. While having only collateral nutritional or health consequences, regular attendance at preschool can both stimulate the mental and emotional development of the child and increase the chances that parents will later send their children for formal schooling. Since workers are in place and month old children are already caming on a daily basis to NVW centers throughout Tamil Nadu, the additional cost of providing pre-school services at the centers is minimal. The project would introduce pre-school education Into all integrated CCs/NsMCs in the project areas, an4 apgrade its quality. A manual for a theme-based approach to learning has been developed by an NGO and successfully tested. The project would provide these manuals to all the CNCs. There is also a high degree of consensus that a more interactive, participatory approach should be used in pre-school education, based oan the principle of guided learning through active experience in which Individuals are helped to construct their

24 own knowledge. This approach would be emphasized in project-financed preservice and in-service training of workers and supervisors. In addition, the project through its communication activities would improve the capacity of parents and other care givers for providing a stimulating environment at home. Thus actions to improve quality of pre-school education would be an integral part of the training and communication and community participation components of the project. S. Communication and Community Particigation Activities (US$3.5 million) 2.30 TINP I succeeded in reducing severe malnutrition partly because its communication activities increased community understanding of services provided and promoted their involvement, especially through the Women's Working Groups (WWGs) created in each project village. The proposed second project would continue to provide support to comprehensive communications and community participation activities. Broadly, the component would aim to stimulate demand for project services, alter household child feeding and child care practices, motivate village level workers by enhancing their image and credibility within the community, and promote community involvement. The component would include support for community education, audio-visual materials to support nutrition education activities of workers and community groups, fonmative research, and monitoring and evaluatior. (see Annex 6 for details) TINP I's communication activities were extremely successful in terms of creating awareness and acceptance of project services, and in creating v en's Working Groups supportive of the project in every project village. However, the project's impact on households' nutrition and health behavior was variable. Therefore, TINP II's communication strategy would focus particularly on reaching household and community decision-makers, both through interpersonal and mass media methods of communication. As an extensive network of theaters already exists and most villages have community video players, the project would support development and distribution of films and video cassettes. It would also support production of a news bulletin for workers, and flash cards, posters, and flip charts for use by program staff and WWGs. The project would develop the institulional support for the communications program by financing salaries and other operating costs of the Communications and Training Center, constructed in the final year of TINP 1 as a state level apex institution for the planning, monitoring and evaluation of nutrition communications programs For effective communications, the messages and materials produced should be relevant and of high quality. Social marketing approaches involving qualitative research and other proven design techniques from commercial marketing would be utilized for developing relevant and effective communications content, structure, materials, and media-mix. The materials would be extensively pre-tested for their efficacy before large-scale production. In addition, the project would support formative and summative evaluation of the communication activities to continually refine them The project's community mobilization activities would aim not only at ensuring that communities utilize the services provided, but also to enable community representatives and nutritionihealth staff to jointly study local

25 child health and nutrition problems, pool knowledge and resources, and take actions to resolve them. Nutrition workers would therefore be trained to involve WWGs more actively in planning local project activities and solving local implementation problemc, with the goal of increasing individual and community self-reliance. WG members would also be trained to take a more proactive role in spreading their nutrition and health care knowledge, found to be high by the TINP evaluations, through the broader community. F. Project Management and Evaluation (US $7.4 million) TINP I was managed on a day-to-day basis from a Project Coordination Office, headed by a Project Coordinator (an Indian Administrative Service officer holding the rank of Head of Department), assisted by a Joint Director (Communications) and an Assistant Director (Monitoring and Evaluation). For TINP II, this structure would be modified in two ways. First, coordination of the proiect with the work of the Department of Health would be facilitated by appointment of a Joint Project Coordinator of the rank of Joint Director in the Department of Public Health. Second, in v_nw of the geographic expansion of project activities, the project office would be strengthened by appointment of Joint Coordinators for Nutrition; Operations Research and Monitoring; Training; and Communications. These officers would be responsible for their respective subject areas, with the last two having responsibility also for the respective wings of the Communications and Training Center. Chart 2 shows the proposed organizational structure of the project office The Project Coordinator would report to the Director cf Social Welfare and have the necessary authority to implement day-to-day project activities. An Empowered Committee, chaired by the Chief Secretary and comprising the key development secretaries, including health and social welfare, was constituted for TINP1 to approve plans, issue necessary government sanctions for implementation, and monitor progress; this committee would continue to oversee and assist the proposed second project. The project coordinator would be member-secretary of the Empowered Committee. The project would finance salaries and other operating costs of the Project Coordination Office and a fund for innovative activities. As in TINPI, the project would fund innovative activities through the Project Coordinator's office, mainly to test new interventions or program design modifications. Assurances were received at negotiationu that Tamil Nadu will (a) prior to undertaking innovative studies, operations research and activities, furnish terms of reference, work plans and proposed budgets for them satisfactory to IDA; and (b) discuss the results of the innovative studies, operations research and activities with IDA (para 5.01 (e)). G. Monitorint and Evaluation 2.36 Coverage by various services and provision of project inputs would be monitored regularly. The current TINP monitoring system would be refined and adapted for the whole of Tamil Nadu. One change in the existing monitoring strategy would be a reduction in both the numbers of registers kept at CNCs and the numbers of indicators used for monitoring. Another important change would be the decentralization of routine monitoring and feedback from the state to the district level, with the state level concentrating more on overall program progress, operations research requirements and mid-course

26 adjustments to project strategy. Further details of proposed monitoring and evaluation arrangements appear in Annex 7. The project would finance an additional vehicle and equipment plus salary and operating costs of the monitoring and operations research cell in the Project Coordination Office (see para 2.37)5 operations research activitiess computers for data analysis at the district level; and training for staff at state and central level responsible for project monitoring In order to improve project evaluation capacity, the project would finance strengthening of Tamil Nadu's Department of Evaluation and Applied Research (DEAR), the independent go ernment agency responsible for the evaluation of TINP I. This would involve support for additional furniture and equipment, staff, trainlag. transportation and other operating costs for DE&R's head office in Madras, and establishment of small regional offices at Salam, Madurai and Trichy. A Technical Advisory 04mmittee would be set up to ensure that the best available expertise goes into the design of project evaluation, and the project would finance consultant assistance to develop the methodology for the proposed baseline and other surveys Assurances were received at negotiations that Tamil Nadu, in consultation with GOI and IDA, and in accordance with terms of reference and methodology satisfactory to IDA, undertake and complete (a) collection of baseline survey data in each Health Unit District In the project area before the commencement of project-financed servica delivery activities in that Health Unit District; (b) by December 31, 1993 a mid-term review and evaluation of the progress of the projects and (c) by September 30, 1997 a final review and evaluation of the project (para 5.01 (f)). The mid-term evaluation, while reviewing all project activities, would pay special attention to (a) the new supplementation approaches being adopted under the project; (b) the revised referral procedures and the MCl annex system being tested in Madurai district; and (c) the new arrangements for health/nutrition coordination. After completion of the terminal evaluation and before the project closing date, Tamil Nadu would hold a national level workshop to discuss the lessons learned from the project.

27 A. Cost Istmates tii. PlAhRC? COSTM. FiNMC= ND U 3.01 Cost Sumaries. The total cost of the project, net of duties and taxes, is estimated at about Rs. 3,135 million or US$134.1 million equivalent. Duties and taxes are around US$5.0 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 expenditures and year appear in Annex B. C- 'cm Table 3.t C hr C C n A. _ = W _ TO" I Cost Nutrition 1, " ,0W 1, H"lt% IU ,120 Training DLK "S ATW 83. no Project Coordination Mice on a W7 e_iotial & Training Catr 17, #ta}n itrn S Susuaie 1 3a 2J8.J L 41.. M*. Sub l ii1i Man I s a Total tstm CStS t I7016 1t00 Continan..e ' 'W TOTAL FROJWr C S 1J9.0, Table 8.2: C h C _ie ef _edltur. - i n.m0 *aaml N_o r _ ~ ~ ~ _ ~ ~ ~~~oa i-i_ io Ttdl ie. F.ral.. Toa Ca I. DWMWI cot A. Civil Works mrsiture M C. isquipsont l.U on 7.'f ' 8 3.Dray S J it:e r.#.win ,481 U 40 4,69 4 P. Training au5 $ Ibteial 41,111 2I1'. 4$7M Conewltt oe o9 - o 0.Studies *ad Research *.Su 2.6W 186 is186 t:.prjeot Neoae.et Fund Subtotl,SR ; a,,t ;.0 tldrowl CBDSe I IWt A. 1salries ( t a S. taobs I " 'o9 8 C. R..t D. Nenteneac? U0 42 Sal I F. Utiities is 80s 0 F. Petrol Oil LUAbriesat 48.0, 4, l Oter Oerating Cast 'so a 'a 0 H. Therapeutie Nbtrition _.ZI... 7ML314 4LI _..? 4dLZd U Subtota 1, , Oa TOTAL a11lni c t s870s 100 Conti ngsies a a TOTAL i t 6m S0 s w

28 Basis of Cost Estimates. Estimated costs for civil works of Rs per square foot are based on current unit costs of designs for similar types of facilities. They are comparable to the costs of similar IDA-assisted construction in India. Costs of therapeutic 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 Tamil Nadu Taxes and Duties. All imported goods are subject to Customs duties and taxes. The cost of the project includes customs duties and taxes estimated at about US$5.0 million Contingency Allowances. Estimated project costs include ph)ocal contingencies (US$5.1 million) estimated at 5 on goods and civil works. For locally produced items, price contingencies are estimated at 72 for FY91 and FY92; 6.62 for FY93; 6.52 for FY94 and FY95, and 6.12 thereafter. For foreign produced items, price contingencies are estimated at 4.9Z for the first five years of the project and 3.72 for the final year Foreign Exchange Component. The estimated foreign exchange component of US $7.1 million is calculated on the basis of the following estimates: (a) civil works, 11X; (b) furniture, 9X; (c) locally-produced equipment, vehicles and consumable materials (including drugs)--122, 92 and 201, respectively; (d) operation and maintenance of vehicles, 1O2; and (e) other operation and maintenance costs and costs of training, 52. B. Financing Plans 3.06 The estimated total project cost of US$139.1 million would be financed by an IDA credit of US$95.8 million equivalent, which would cover about 71 percent of costs net of duties and taxes. Tamil Nadu would finance US$ 43.3 million equivalent to cover the remaining project costs, including all rents and utilities. Cost recovery from user charges is not considered feasible in view of the poverty of most project beneficiaries. The financing plan is given in table 3.3. Table 3.3: Project Financing Plan Costs including taxes and duties -US$ million Local Foreign Total I IDAs GOTN: TOTAL

29 C. Recurrent Cost Implications 3.07 When fully operational in 1996, the project's annual recurrent costs would be about Rs. 396 million in 1990 prices, about 202 of current expenditures on nutrition programs in Tamil Nadu. Tamil Nadu's real social welfare expenditures would have to grow at 3Z per year for the nutrition part of the project to be sustainable. Its real social welfare expenditures have grown at over 7Z annually in recent years. Whether the state could sustain that growth rate over the long-term is uncertain, but a 32 yearly growth scenario for social welfare could be accepted as a reasonable lower bound. Under those assumptions, the project would imply an addition to the state's nutrition budget just equal to the estimated recurrent costs of the project in That level of additional expenditure appears feasible, particularly in light of Tamil Nadu's commitment to the project and that, by 1996, the state would have achieved good coverage of its vulnerable groups. TINP and ICDS would have blanketed rural Tamil Nadu with a child development program; ICDS and NMP already cover the poorest urban areas. About 30Z of the incremental costs of the project are for therapeutic supplementation; as community capability Increases and levels of malnutrition decline, these costs should continue to fall, as experienced in TINP I areas, thus reducing the long term recurrent cost burden. Based on TINP I results, costs of therapeutic nutrition supplementation would fall by around 142, for example, between in those CNCs which got set up in Given Tamil Nadu's high priority for full coverage of the most vulnerable population groups with nutrition services, the long-term recurrent costs of the project are sustainable and reasonable. D. Proiect Implementation 3.08 Preparation Process and Status of Preparation. By the end of the appraisal mission, clear strategies had been developed for responding to the design and implementation problems identified in the evaluation of TINP I, together with a phased implementation plan for the new project. Plans to strengthen staffing of the project office had been drawn up, and the recruitment process was planned to be under way before project negotiations. A detailed training plan for pre-service, orientation and refresher training under the project had been prepared, as had a broad strategy for the communications component. Work on training curriculum development was planned to start before project negotiations. Architectural designs for the proposed additional storey to be added to the Communication and Training Center (para 2.33) had been completed and furnished to the Bank for approval. The proposed project appears to be neutral with respect to effects on the environment. Therefore no special environmental assessment was undertaken So that the project can start promptly, the state government plans to carry out the following activities over the next few months: ti) baseline epidemiological and nutrition status surveys in the first project areas to be developed; (ii) redrawing of the boundaries of existing CNCs and definition of CNC boundaries in Phase 1 new blocks so as to minimize beneficiary exclusion and to align with Health Sub-center boundaries; (iii) training of trainers; (iv) preparation of a detailed communication strategy based on qualitative surveys of project clients; and (v) preparation of designs for low-cost construction of CNCs.

30 Project Implementation. Since this would be a state rather than Centrally-financed project, the Tamdl Nadu Ministry of Social Welfare would have implementation responsibility, under the overall guidance of the Empowered Comimttee (para 2.35) The state has Included adequate funds in its fiscal year budget to allow a prompt start to project activities to be made. The structural arrangements for management of different project activities are set out in paragraph 2.34 and Chart 2, and the steps taken to ensure cooperation between nutrition and health departments In paragraph The role of community groups in project implementation is described in paragraph A project implementation schedule appears in Annex 9. 3,11 Monitoring and Evaluation. Arrangements for monitoring program activities appear in paragraph Project monitoring in Tamil Nadu would be the responsibility of the Project Coordinator, and hence of the Department of Social Welfare. Assurances were received at negotiations that Tamil Nadu will furnish to IDA for review and discussion (i) quarterly and annual progress reports within three months of the relevant implementation period and (ii) a prospective annual work plan by January 31 of each year for the succeeding Indian fiscal year (para 5.01 (g)). These reports and plans would cover all project components with particular attention to training, staffing. service coverage, construction, food supplement availability and offtake, operations research and comunication activities, and would be in a format satisfactory to IDA. Arrangements for project evaluation and related assurances appear in paragraphs The Borrower would prepare a Project Completion Report within six months of the credit closing date. E. Disbursements 3.12 Disbursement Percentages. The project would disburse against 1001 of CIF and of es-factory cost or 80S of other local expenditures on furniture, equipment, drugs and medicines, books and materials, 901 of the cost of civil works, consultants' services and training, 65Z of the cost of vehicles, and 602 of the costs of therapeutic nutrition supplementation and other incremental operating costs. These other incremental operating costs comprise salaries of new staff to be added as project services intensify and expand, and additional supplies and vehicle operating costs and maintenance. The percentage of incremental operating costs to be financed by the Bank is equivalent to full financing in the first year they are incurred, reduced by around 251 in each succeeding project year. (See Annex 10 for details) Required Documentation. Disbursements in respect of expenditures, under contracts for civil works, furniture. equipment, vehicles. drugs. medicines, therapeutir nutrition supplements, consultant services and training estimated to cost less than US$ 200,000 equivalent would be made against statements of expenditure certified by the Tamil Nadu Department of Social Welfare and Project Coordinator. Documents would be retained by the state government for review by IDA during the course of supervision missions. All other disbursements would be made against fully documented withdrawal applications Special Account. In order to accelerate disbursements in respect IDA's share of expenditures pre-financed by GOI and the State of Tamil Nadu, 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

31 with an authorized allocation of US$4 million equivalent to cover four months' expected requirements for IDA-financed items Retroactive Financing. Up to US$1.3 million is recommended to cover eligible expenditures incurred in Implementing appraised project activities after September 30, 1989, and the expected date of loan and credit signing, around the end of September (see para 3 09 for proposed activities) Disbursement Profile. The proposed IDA credit would be disbursed over a seven and a half year period. This is a someshat shorter period than the IDA disbursement profile for India or for the nutrition sub-sector as a whole. However, it is realistic because (a) strong and experienced institutions are in place to implement the project; (b) the proposed project follows a first operation in which project activities were Implemented fully with minimal delays; and (c) most of the new blocks would be established and civil works would be completed in the first three years of project operation. The project period therefore encompasses not only the time required to cover new areas but also includes a lengthy operational period during which the impact of expanded service coverage, improved quality of services and supplementation procedures, and communication, community mobilization and training would have significant impact on nutrition and health status of the project's key beneficiary groups. The project is expected to be completed by March 31, 1997 and the credit closed on December 31, 1997, permitting time for final evaluation at the completion of project operations. A forecast of annual expenditures and disbursements is shown in Annex 11. F. Procurement 3.17 Project-related procurement would be managed by the Project Coordination Office, following procedures laid down by the Governments of India and Tamil Nadu, and accepted by IDA. Project-financed consultants would be selected according to the procedures in the Bank's Guidelines for Use of Consultants by World Bank Borrowers and by the World Bank as Executing Agency. Proposed procurement methods by category of project expenditure are summarized in table Civil Works (USS3.1 million). The main civil works in the project consist of about 500 new Community Nutrition Centers costing less than the equivalent of US$6,000 each. These are small widely dispersed buildings for which neither foreign firms nor domestic contractors are expected to be interested in competing for construction. This work would therefore be carried out by force account. Construction work on the new floor for the Commnications and Training Center (para 2.33), 12 Primary Health Centers and the 11 experimental MCI annexes (para 2.23), which together totals less than US$1.0 million, would be let through LCB procedures, which are satisfactory to TDA, since the work is too smll to be of international interest Drugs (US$14.2 million) contracts would be bulked insofar as possible into packages estimated to cost the equivalent of US$200,000 or more and awarded through international competitive bidding (ICI). For drugs procured under ICB, local manufacturers would be afforded a domestic preference of 15 or the prevailing rate of duty, whichever is lower. Procurement under ICB would be subject to prior IDA review and approval. Drugs valued at US$50,000 equivalent or less up to an aggregate total of

32 US$3.0 million over the project implementation period could be procured through prudent local shopping, with solicitation of price quotations from at least three suppliers Equipment (US$7.5 million) would be procured on an annual basis in accordance with the phasing of project activities. It would be mainly of three typess 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. 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, equipment contracts would be awarded through LCB. Equipment valued at US$50,000 equivalent or less up to an aggregate total of US$2.0 million over the project implementation period could be procured through prudent local shopping Furniture (US$6.0 million) would be procured through a combination of LCB and prudent shopping. Furniture is readily available from local manufacturers and foreign firms are unlikely to bid. Furniture orders would be bulked to the extent possible in packages of more than US$200,000 equivalent for LCB procurement. Contracts for furniture estimated to cost less than the equivalent of US$50,000 may be awarded on the basis of prudent local shopping. Since most furniture will be of simple construction and bought and installed in remote rural areas, around 702 of furniture probably would be procured through prudent local shopping Four-wheel drive vehicles, mopeds and bicycles (US$4.9 million), for for use in rural project areas, would be procured in multiple lots of less than US$50,000 since purchases would have to be phased at the rate at which new blocks come on stream and existing assets need replacement over the project's six and a half year life. In addition, there is currently only one domestic supplier for the diesel four wheel drive vehicles which are required for project purposes, and the vehicle maintenance system in rural areas is geared to the existing standardized fleet of these vehicles. Competitive bidding would not be practicable under these circumstances. Vehicles would therefore be procured under prudent shopping procedures Procurement of therapeutic nutritious food supplements (US$41.1 million) would be shifted mainly to LCB, thereby encouraging the development of food processing and marketing systems. LCB is appropriate because international suppliers are unlikely to be able to provide the supplementation formula to rural areas in a timely way and rapid supplier response to shifting demand patterns is essential since, even with the best planning, unforeseeable seasonal or other variations are likely. To encourage experimentation with production through women's cooperatives and other community-based systems, contracts for therapeutic nutritious food supplements valued at less than the equivalent of US$50,000 may be awarded on the basis of prudent local shopping up to the equivalent of US$5.0 million during the project implementation period. Direct contracting up to a total of US$5.0 million equivalent also would be permitted during Tamil Nadu's transition to LC8 from its present reliance on single-source procurement from the state-owned Agro-Industries Corporation in neighboring Karnataka Contr.acts for consultant services and for specific studies would be awarded according to IDA guidelines and would be subject to prior IDA review

33 _ 26 - and approval if the cost exceeds US$20,000. Contracts for civil works, therapeutic nutritious food supplements, equipment, furniture and vehicles estimated to cost US$200,000 equivalent or more also would be subject to prior IDA review and approval. A total of around 70 contracts representing around 55 of the total value of prccurement would be subject to prior review over the procurement period. G. Accountin. and Auditing 3.25 The project would be subject to normal 001 accounting and auditing procedures which are considered satisfactory to IDA. The project cell would maintain separate project accounts and a quarterly statement of expenditures would be provided to IDA. Assurances were received at negotiations that: (a) accounts and financial statements for each fiscal year would be prepared and audited by independ 'nt auditors acceptable to IDA; (b) statements of expenditures (SOBs) 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 auditad 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.

34 Table 3.4: Procurement Method Categories of ICB LCB Other VIA Total Cost Expenditure US$ iillion Civil Works (2.82) (2.82) Equipment (4.36) (1.60) (5.96) Furniture (1.44) (3.33) (4.77) Vehicles (3.95) (3.95) Training, Consul tants, Studies (6.25) (6.25) and Research Innovative Activities (2.64) (2.64) Drugs and Medicines (11.18) (2.40) (13.58) Therapeutic Nutrition Supplementation (18.63) (6.00) (24.63) Other Incremental Operating Costs (31.20) (31.20) TOTAL (11.18) (28.38) (25.04) (31.20) (95.80) Figures in parentheses are amounts to be financed by IDA.

35 IV. BENEFITS AND RISKS 4.01 Benefits. The project will have an important impact on nutrition and health status of young children. Despite substantial reductions in infant and child mortality in Tamil Nadu, the nutrition status of children lags behind the national average (para 1.03), and is improving only gradually. The project would substantially accelerate the pace of this improvement and also contribute towards a further reduction in infant and child mortality. It is estimated that over five million relatively disadvantaged children 0-6 years of age in the project areas would directly benefit from the project's nutrition, health and educational services. Through the project, several health technologies--acute respiratory infection management, oral rehydration therapy, deworming, and vitamin A and iron supplementation--would become more widely available. By increasing family and community competence to avert and treat malnutrition, the project would help bring about a reduced need over time for therapeutic supplementation The project would also have a significant impact on women's health, nutrition and competence at child care. It is estimated that abcut two million pregnant and lactating women would directly benefit from the project's health and nutrition services. In the new project blocks to be developed, an estimated 18,000 women would obtain training and employment as Community Nutrition Workers and helpers, plus an additional 1,600 women at supervisory levels. These workers would be responsible for forming new Women's Working Groups with a total membership of about 300,000 women, who would be trained both in basic health and nutritional care and in how to pass on their knowledge to other women in the community. In addition, over 20,000 female Traditional Birth Attendants would receive refresher training under the project The project would also have indirect benefits in terms of testing new technologies and managerial arrangements which may prove suitable for replication in India and elsewhere. These include the project interventions to reduce low birth weight and moderate malnutrition; arrangements for coordinating health and nutrition services; and new approaches for dealing with referrals of severely malnourished children and obstetrical risk cases. Additional indirect benefits can be expected in the form of increased acceptance of contraception generated through the increased availability and use of maternal and child health services under the project Risks. The main risk is that organizational arrangements for health-nutrition collaboration will not function as smoothly as necessary and thereby reduce achievement of project impact objectives. The risk would be particularly acute for severely malnourished children who are failing to gain weight because they have health problems; for this small group of children, delayed referral or inadequate treatment can lead to death. But the risk in terms of overall project impact is limited, to the extent that major gains in nutritional status can be expected from improvements to the nutrition service delivery strategy alone, such as the project measures to improve maternal nutrition and to extend therapeutic nutrition supplementation to all moderately malnourished children. A wide range of innovative measures to improve health and nutrition service collaboration has been proposed in the project. Assurances were received at negotiations that health and nutrition coordination arrangements satisfactory to IDA would be introduced by October 1, 1990, and maintained thereafter (see para 2.22). Special attention to

36 monitoring and adjustment of these measures will be paid during project supervision. V. AGREEMENTS REACIED AND RECOOENKDATIONS 5.01 The following assurances were received at negotiations: (a) Tamil Nadu would by January 1, 1991 adopt and apply beneficiary selection criteria and methodology, mutually agreed to by IDA and Trmil Nadu, for provision of therapeutic supplements for children under three years of age and pregnant and lactating women in project areas (para 2.08); (b) by January 1, 1991, Tamil Nadu will introduce and thereafter maintain the provision of therapeutic food supplements whose composition is satisfactory to IDA (para 2.17)t (c) by January 1, 1991, Tamil Nadu will introduce and thereafter maintain arrangements agreed to by IDA and Tamil Nadu for coordination between health and nutrition services in the project areas (para 2.27); (d) Tamil Nadu will by September 30, 1991 undertake and complete operations research on the efficacy of different approaches to strengthening obstetrical and child nutritional risk management, at referral facilities in Madurai district, the operations research to be conducted according to terms of reference agreed with IDA (para 2.28); (e) Tamil Nadu will (i) prior to undertaking innovative studies, operational research and activities, provide IDA with terms of reference, work plans and proposed budgets for them satisfactory to IDA, and (ii) discuss the results of the innovative studies, operations research and activities with IDA (para 2.35); (f) Tamil Nadu will, in consultation with GOI and IDA and in accordance with terms of reference and methodology satisfactory to IDA, undertake and complete (i) collection of baseline survey data in each health unit district in the project area before the commencement of project-financed service delivery activities in that health unit district, (ii) by December 31, 1993, a mid-term review and evaluation of the progress of the project, and (iii) by September 30, 1997, a final review and evaluation of the project (para 2.38); and (g) Tamil Nadu will furnish to IDA for review and discussion (i) quarterly and annual progress reports within three months of the relevant implementation period and (ii) a prospective annual work plan by January 31 of each year for the succeeding Indian financial year (para 3.11) With the above assurances, the proposed project constitutes a suitable basis for an IDA credit of SDR73.5 million (US$95.8 million ^quivalent) to India at standard IDA terms with 35 years maturity.

37 Page 1 IND1 SEC01=D SAMIL NADU NUTRITION PROJECT Process Obsectives and Related Service Packages No*e: The following process objectives are indicative, based on the kinds of coverage that should be achievable with the package of interventions and the service delivery infrastructure proposed under the project. They may be modified for all or part of the project area during implementation depending on the findings of the baseline surveys with regard to nutrition status, epidemiology and existing levels of service coverage in different areas. Coverage Targeted % Early registration of pregnant women 50 Total registration of pregnant women 80 Obstetrical and nutritional risk assessment of those registered 100 Tetanus toxoid immunization of pregnant women 80 Consumption of iron and folic acid tablets for at least 12 weeks by pregnant women 60 Administration of post-partum vitamin A to attended deliveries 100 Food supplementation for at least 16 weeks to registe;:ed pregnant women with inadequate nutrition status 60 Food supplementation for at least 16 weeks of registered lactating women with malnutrition in pregnancy 90 Immunization (UIP-6) of children 100 Vitamin A megadose (100, ,000 i.u.) semi-annually to children 6-36 months 90 Regular growth monitoring (>9 times in a year) of children 0-3 years 90

38 _ 31 - ANNEX I Page 2 Supplementation of monitored children 0-3 years with grade II-IV malnutrition 100 Supplementation of children 0-3 years with growth faltering 100 Monitor referral of sever ly malnourished children (grade III and IV) or non-responding children 0-3 years to VHN and PHC 100 Growth monitoring, weighing and charting of children 3-5 years 70 Referral of severely malnourished children 3-5 years of age to VHN/PHC 90 Administration of vitamin A megadose semi-annually to children 3-5 years of age 70 Pre-school attendance (> 80 percent of working days) 70 Routine deparasitization of monitored children in heavily infected communities as determined by parasite surveys 90 Household use of oral rehydration in the last incidence of diarrhea in the target group 60 Treatment of pneumonia by VHN/CNW with co-trimaxazole in cases of acute respiratory infection (ARI) 30 Additional feeds of local weaning food initiated by 6 months in infants 50 Provision of 4 additi.onal weaning feeds/day by 9 months in infants 50 Active womens' working groups (> 9 meetings a year) 80

39 ANNEX Page 3 Service Package for Pregnant Women Impact objectives Early prenatal registration Iron-folate supplementation Assessment of maternal nutrition Reduction in incidence of low birth weight Food supplementation and weight gain monitoring of malnourished Service Package for Children 0-3 years Growth monitoring - Therapeutic supplementation Referral of severely malnourished children Immunization of children Deparasitization Reduction in severe and moderate malnutrition Treatment of acute respiratory infections Health and nutrition education MCH Services Antenatal check, obstetrical risk assessment and referral Maternal tetanus toxoid Attendance by trained personnel at delivery and post-partum follow-up Immunization with 6 UMP vaccines Reduction in infant mortality Diagnosis and treatment of acute respiratory infections Health examination and referral

40 -tw*- Prelti bmul UhLcm- main Ukbme wrsun uufruaa sa M"1oa 1.SI.tS1_s 512 t_ 7r "te hwetth Revised work uperry 80t woet, w tis M outlewes. 4 Veighwt baierlag Met DPotol bo asw bettes her eod tlt betwe dt cn. totew" is-service MA tralalos. 1e hou_ t 8X. tro a roita ge"seioir eoeker o4afee. gaghsie on iducat efo 60O of beamtsarks.s & Suptpmmettla ommmaltlosa owolses. toaums tassid sit Iaprrat elth Revise work sad supervisory got supowleos. FteeOrIMaOs betweo Delup _adopt bettor helth nd mxtrktis saff. Oo.rdiatt lo _1aas. t4.~~~~~~~~~~~~~~~~~tao4 weight emitora ow* met ooosler priorltl. ti in work 4oi NW e0t db_t a" ik lee.upegwisorp sorvite. coutlns. sox ta-esewice troaiw 1. sugpilsanmtlo of 563L.5o Weight imitating prebeme. top""s weight MMU^cLns. 90 of %bass at CIs,k.lw *llglbte. Rmagrov Coordination hetwes elil&ibl hltth MA utritu i*taff blrt weight babies to RssUr early willls.- _s likely to nee tasla A is"t actor not a" 1lided. Mew Featur. 100o atting detvery. loodd. Supplmmstatlos of Met not hpei.ctd. N0e ete ib wl 4Abl-* In" _om witlb _ kta e totlat L w nert r t O _in

41 AtNiEX 2 Pane 2 ~~~a -9, "E bt -1 i1 s!r z ~ ~ i,, S #3 2g.Y: 2W ;!1~ ~~~~~~~b "~ ~ ~. i"- t' ll I S a.! ' j~ ~. i t 1x 1 0 l 03l i

42 *.tt.osum womb.4". lot ftvvxm 0 no6 IC) lot Over" TO@P62 lot v i lot IiduU VI 32ww8 MMEmolqoxa nton oo*t&2 1

43 -36-ANE Page 1 INDIA SECOND TAMIL NADU NUTRITION PROJECT A Draft Strategy for Health/Nutrition Coordination 1. For a number of reasons, management and implementation of projects such as TINP are inherently difficult. TINP shares the problems of most social sector projects in that it involves a very large number of workers, a large number of widely dispersed implementation units across rural areas, and requires a serious demand creation effort to promote the project among the target group. Most important, the inputs are multisectoral and their coordinated delivery can be seriously hampered, if the concerned agencies fail to work together to achieve project objectives. Further, there is very little experience in the field of effective coordination of implementing agencies in multisectoral projects. 2. One of the established strategies for circumventing problems of coordination or working through "regular" channels has been the establishment of vertical programs. In the case of nutrition, such a strategy would be highly undesirable. First, it would be quite complicated, delinking a number of programs from concerned departments such as health, rural development, social welfare. Secondly, the linkages between the various sectors are so strong and run so deep that it will be difficult to isolate all the relevant strategies under a single implementing agency. Thirdly, vertical programs violate the principles of grass root:s planning which involves integration at the block level of various inputs/programs/services. 3. The alternative is to create an enabling and workable model of integrated dervice delivery. Such an approach will involve nominating the department implementing the core project inputs as the nodal agency, vesting that agency with the responsibility of achieving project objectives and also with the authority to review implementation by different agencies and to ensure adequate performance on their part. It will involve the functional integration of the department through a series of linkages at levels of service delivery, training, project management and supervision. It will require the inculcation of the concept of achieving project objectives through a team approach among project functionaries. 4. The use of the CNC as the focal point for delivery of all services at the village level is one strategy for integration. The CNW and the MPW, along with the Noon Meal Organizer will each be allocated a physical space in the CNC to maintain records/registers/supplies. All the services proposed under the project umbrella will be delivered from the CNC. Similarly, the CNC will be the repository of all village level health and nutrition records. 5. Coordinated by a Secretaries' Committee, several discussions were held to make practical arrangements to improve collaboration between health and nutrition workers in the field. The move for rollaboration was based on two assumptions.

44 -37- ANNEX 3 Page 2 6. First, it was assumed that closer collaboration presents an opportunity, rather than a threat, to the departments concerned. If VHNs receive more support from CNWs, they will more easily achieve their immunization, antenatal care and family planning goals. If CNWs receive more support from VHNs, they will be able to do more for children who have health problems, as well as malnutrition. Both departments will benefit. 7. The second assumption was that, to achieve closer collaboration, something stronger is needed than the traditional approach to coordination, which emphasizes block and sector meetings between workers and seems to make little difference to workers' actual behavior. A range of specification in five areas which together could give workers a strong incentive to cooperate was discussed. These actions would require significant changes in the way that the departments of social welfare and health and family welfare operate at present. They will, therefore, require careful consideration, negotiation and modification, issuing of new GOs and instructions, and strong commitment to implementation. Such a collaboration will facilitate both departments in achieving their objectives but special efforts will undoubtedly have to be made by both departments to ensure that this coordination is actually effected in the field. On the basis of this discussion, the following mechanisms for coordination was proposed. Area 1: Defining Priorities 8. The following were defined as the overall health and nutrition priorities for the departments of Family Welfare, Public Health and Social Welfare (to be achieved through the available nutrition/healthierarchy already in place). The priority objectives under each broad heading are as follows: (a) Fm ily Welfare: (i) Reduction of birth rate (ii) The adoption of the small family norm (iii) Ensuring availability of all methods of contraception (iv) Family welfare education (b) Child Survival: (i) Reduction of INR, particularly neo-natal deaths (ii) Improved immunization services (especially BCG, measles, completion of full course of DPT and early coverage) (iii) Diarrhoea management (iv) ARI control (v) Prevention of malnutrition and deficiency diseases (vi) Improved referral services

45 AMEEX 3 Pagp 3 (c) Safe Motherhood: DD (i) Ante natal care (ii) Referral of high risk mothers (iii) Safe delivery by TBAs through training and provision of kits (d) Area 2: Allocating Responsibilities: The second step was to agree on the allocation of tasks in these priority areas between workers. (a) ANC screening and referral (b) Use of DDKs (c) Cord care (d) Clearing airway (e) Use of colostrum (f) Prevention of hypothermia (g) FP motivation (a) ANC identification (b) Iron supplementation (c) Maternal growth monitoring and food supplementation (d) Birth spacing motivation and identification of potential cadres (e) Taking birth weights and referral of LBWs to VHN (f) Growth monitoring 0-6 month child and weaning education (g) Vitamin A supplementation (h) Identification of children for immunization (i) Referral of moderate, referral of severe ARI cases to VHN (j) Diarrhoea management (k) Depot holder for contraceptives (1) Maintenance of basic health records (m) Nutrition and health education (a) Antenatal checkups and identification/referral of high risk pregnancies (b) Supply of temporary contraceptive methods (c) Check up of LBW babies (d) Immunization (e) Treatment/referrals of malnourished children with suspected health problems (f) Treatment/referrals of several ARI cases (g) Treatment/referral of severe/chronic diarrhoea (h) Nutrition and health education

46 ANNEX 3 Page 4 Area 3: Work Routines: 9. The kind of mutual support between health and nutrition workers, which is hoped for, will not come about by exhortation. It will require adoption of and training in new work routines which will both promote collaboration and wske collaboration monitorable. The questions to be decided are: When should CNWs and VHNs work together? For what exact purposes? And how often? 10. Both CNWs and VHNs already have clearly defined monthly work routines. But, they are not currently planned so that VHNs can take maximum advantage of CNWs' close contact with clients, and hence their ability to identify target clients for the VHNs' attention. It would make sense to experiment in two or three different blocks with two or three different approaches before the next project begins. (a) A children's day. Wednesday is already set aside as immunization day. Immunization coverage could be substantially increased, if on Tuesdays CNWs identified non-immunized children and motivated their mothers to being them the following day; if the immunization clinic was held at the CNC as a sort of satellite health center; and if the CIW followed up immunized children on the Thursday with reassurance for fever cases. In return, the VHN could help the CNW by taking time to see malnutrition cases with health complications on the Wednesday. The CNW would motivate affected mothers to bring their children on that day; joint home visits could be made by the VHN and CNW to affected children, or children due for immunization, who did not come. (b) A mothers' day. A specific day each month per CNC would be set aside for a visit from the VHN to meet with antenatal and postnatal cases. As with immunization, the CNW would use the day before to motivate the women to come. A group meeting could be held with mothers coming to the center, and joint home visits could be made by the VHN and CNW to mothers not coming. The additional contact with this target group that this would offer the VHN could significantly increase TT coverage. Holding a children's day and a mothers' day at each CNC each month would take up eight days a month for the VHN, and five days a month for the CNW. (c) Using weighing days. CNWs already set aside three days a month for weighing 0-3 children. Mothers are aware of these days in advance, and are more likely than usual to be around. On these days there is a contact with almost every young child. VHNs could take advantage of this opportunity to do their antenatal care and family planning work, and could help the CNW by providing health checkups to children identified by weighing as malnourished. A weekly immunization/children's day plus making use of weighing days in this way would take up 16 days a month of the VHN's time if she attended all three weighing days, 12 if she attended two weighing days per CNC.

47 ANNEX 3 Page Whatever the particular pattern of joint work that is chosen, there are two clear advantages to setting aside specific days in the month for CNWs and VHNs to work together. One is that the days will be predictable for mothers, so they can plan to be there to get services. The other is that the days will be predictable for supervisors, so they know where to go to check that services are being provided as planned, and to help workers with any problems. 12. There are two essential preconditions for setting up effective collaborative work rcutines. The first is that CNW areas would have to be redefined as coterminous with VHN work areas. This would require a substantial mapping exercise to reallocate hamlets between CNC areas, which should be planned and completed before the start of the project. 13. The second and much more challenging precondition would be a major change in the way VHNs use their time with regard to family planning. As everyone knows, the current emphasis on sterilization targets monopolizes the VHN's time, and reduces the attention she can pay to MCH. Moreover, the seasonality of family planning campaigns means that this work is full time for the VHN in the last few months of the financial year. This work pattern has been followed for years. It is deeply engrained, and will be hard to change. But, unless it is changed, the idea of regular, collaborative work between VHNs and CNWs is a non-starter, at least during the final months of the year. 14. Fortunately, there are reasons why the traditional approach to family planning can and should change. First, it can change because Tamil Nadu has been allowed by the Center to dispense with the national family planning and target system for the eighth plan period, and been given the freedom to develop its own approach. Second, it should change because, as policy-makers realize, the current approach is both ineffective (in terms of reducing the CBR as opposed to increasing the CPR), and running out of steam (in terms of a plateauing of sterilization acceptors). 15. The answer to both of these problems, as policy makers also well realize, is to reach younger and, hence, lower parity potential acceptors, and this means an increased focus on the temporary methods. Here cooperation between social welfare and health and family welfare has tremendous potential benefits. CNWs' contact and relationship with mothers make them well placed to identify potential acceptors and motivate them to approach the VHN. And, every birth spacing acceptor in the village will help achieve the CNW's goals of better maternal nutrition and less LBW. Joint work routines for CNWs and VHNs not only require an end to the traditional approach to family planning, they probably also offer the best chance of success for a new approach to family planning based on spacing. 16. It was agreed that new work routines will have to be formally adapted to ensure that the CNWs and VHNs work together for some exact purpose and at predefined intervals. It was agreed that the best way to do this would be to conduct workshops with field personnel so that the practical difficulties and advantages of such an arrangement are fully taken care of. The objective is to set aside specific days in the month for the CNWs and VHNs to work together and to ensure that these work routines are observed in practice. Once the days are specified, mothers will be able to avail of the

48 ANNEX 3 Page 6 joint services in a predictable way and supervisors will be able to carry out joint supervision to provide suitable assistance to the front line workers. Area 4: Record-keeoing and Reporting 17. Since the CNC will become the base from which the health worker will operate, it has been agreed that basic MCH records will be maintained at the CNC. The VHN could be instructed to visit the CNC and update the records relating to family surveys, immunization, ANC and child health services. It was decided that the consultant appointed to devise the monitoring system for TINP-Il could be given the responsibilities of determining what records will be maintained by the CNW and the VHN, respectively. The basic premise would be that the registers should be as simple and as few as possible without duplication. 18. Two simple additions to the reporting system might help to increase accountability and hence performance. First, a monthly report could be made to the PHC of whether VHNs were in fact coming to the villages on the specified days to work with the CNWs. Performance in this regard could be reviewed at the monthly PHC meeting. Second, the CNW's and VHN's supervisor could be asked to provide a report on the reasons fo- any infant or maternal death in the villages to the PHC MO (plus perhaps a representative of the Danchayat). Such "verbal autopsies" would be aime; not just at establishing medical cause of death, but why the service dellv:y and IEC systems failed to prevent it, and what could be done to avoid recurrences. Area 5: Joint Traini&g 19. Systematic in-service training will be required to ensure that the new priorities, responsibilities and work routines are properly implemented by the field staff. Under TINP I, some joint training was conducted for CNWs and AHNs which was quite effective. It is now decided to use the joint training mechanism to inculcate a team spirit between the workers of two departments at the field level and to familiarize them with project objectives. The Director of Public Health has agreed, in principle, to making the VHN and the SHN available for joint training one week every six months with the CNW and CNS, respectively, and the CHN and BEE for a 30-day trainer's training program in the first year of the project. Subsequently, the training team will be trained for one week each year. The Director of Public Health also confirmed that the CHN would be available as a full fledged member as a training team for about 15 weeks of training. Similarly, the Directorate of Family Welfare will make the BEE available for 20 training weeks in the year. The logistics regarding deputation for training will have to be carefully worked out. Area 6: Joint Suervxision 20. Just as work routines must be developed for the first line workers, so supervision routines will need to be developed for CNS and SHNs. Once again, collaboration between health and nutrition could be fostered if a specified number of days a month were set aside for joint supervision. These days should be chosen to correspond with the days when CNWs and VHNs would be working together in the field. The exact pattern of these routines would, therefore, have to depend on the routines chosen for front line workers. But in principle, it is suggeated that SHNs might spend eight days a month

49 ANNEX 3 Page 7 supervising jointly with CNS. Since there are about twice as many CNS as SHNs per CNC, this would mean that each CNC would receive a visit from a CNS once a month, and from an SHN every two months. 21. The above system might be appropriate for routine supervision of the CNS, focused on checking that tasks were being adequately done, and on help and problem solving. The block level supervisors making up the four person training team might take more of a "management by exception" approach to supervision, focusing their time on a relatively small number (?10%) of low performing CNCs, which they would be able to visit frequently and for long periods to provide necessary supervision for on-the-job training. 22. While the general principles of these supervisory routines are agreed upon, the health and nutrition managers and trainers at each block would need to work out the specifics each month for their block, depending on the needs of their CNCs. 23. Just as work routines are to be developed for front line workers, supervisory routines will have to be developed for supervisory workers, namely, the CHN and SHN. Joint supervision by the supervisors on the days in which joint visits are carried out by the CNW and PHN will have to be planned. Clearly, the details have to be worked out at the sector level. But, once agreed to in principle, clear instructions calling for such collaboration will have to be conmunicated. Oriizational Structure 24. Although detailed mechanisms have thus been devised for facilitating collaboration between the two departments, these arrangements have to be closely monitored and facilitated by project managers at key points in the hierarchy. The following proposals were made to ensure that this happens; (a) At block level, the Community Health Nurse (CHN) will also be the block project officer (BPO). The CNI will function as her deputy and will be in direct charge of nutrition services. (b) At district level, the District Immunization Officer (DIO) will be the District Project Officer. He will be assisted by a Dist. ct Nutrition OFficer from the social welfare line. The female worker, supervisor and CHN will come under the administrative and technical control of the DIO. The DIO will report to Project Coordinator on project items and to DPH as part of the health line. (c) At the State level, the Project Coordinator TINP will function as an independent office. The nutrition workers and supervisors, including ICDS workers, will function under a Joint Project Coordinator JPC(N) reporting to the Project Coordinator. Another JPC functioning under the Project Coordinator will be a Joint Director, Public Health deputed from the Directorate of Public Health. The JPC(M) will supervise and monitor project health activities. Jolit Project Coordinator (H) will interact with DPH on technical issues. There will be an Additional Director (PH) in

50 ABU 3 Page 8 charge of all Mother and Child Health activities in Directorate of Public Health. (d) Interaction between CHN, SHN, VHN and CNI, CNS with Medical Officer, Primary Health Centre will be ensured so that the project gets full support of PHC. One Medical Officer (PHC), preferably a woman doctor, will be a block consultant to the project as in ICDS. 25. The arrangement involves dual (and sometimes multiple) control of some functionaries. For instance, the CHN is answerable both to the District Project Officer and the BDO; the District Project Officer reports to the DPH, the Project Coordinator and the Director of Family Welfare (DFW). Moreover, the MO has recently been "delinked" from paramedical staff, with control passing to the BDO, and hence the nature of the interaction envisaged may be difficult to implement. The nature of the links to be established, therefore, have to be carefully defined. 26. The Communications and Training Centre constructed under TINP I will have two wings headed by Joint Coordinators, Communications and Training. The same Joint Coordinator will work out of the PC's office in charge of the respective administration lines of training and communication to ensure maximum linkages between the planning and executing functions. The CTC will be under the overall control of the PC who will be assisted by a Board consisting of Government officials, voluntary agencies and academics and media. The committee will be chaired by the Secretary, Social Welfare. 27. At the State level, several heads of department (HOD) now operate budgets and projects for MCH activitiet. Different donor agencies also fund different agencies for the purpose. It is, therefore, proposed that the Project Coordinator convenes a quarterly meeting of at least the following HODs to coordinate MCH activities and strategies: Director of Public Health Director of Family Welfare Project Director, DANIDA 28. The Empowered Committee that functioned in TINP I will continue. It will meet half yearly, once to approve an annual plan, and a second time to review progress against plan targets and help facilitate project implementation. 29. Attention will be paid to service matters including recruitment procedures, promotion opportunities, training and motivation to ensure optimal performance by project staff. Considerable delegation to Deputy Directors is envisaged in the day-to-day functioning of the project. Computerization of service particulars and the laying of ground rules will facilitate matters of tran,fer for the larve body of nutrition staff. Special attention will be paid to inter and inura agency communication and coordination.

51 Page 1 INDIA SECOND TAMIL NADU NUTRITION PROJECT OrganiZation of Health Services 1. According to the Indian constitution, health care is principally a state rather than central government responsibility. But, because of a large number of centrally sponsored and either fully or partially funded vertical programs, the responsibility for health, in practice, is shared between the central and the state governments. The centrally sponsored programs include family welfare, malaria, tuberculosis and blindness prevention. Policy making for these programs is the joint responsibility of the Government of India (GOI) and the states, while implementation is the responsibility of states. At the Center, the Ministry of Health and Family Welfare, under a Secretary of GOI, is responsible for overall program management. Within the Ministry, The Department of Family Welfare is headed by a Special Secretary and the Department of Health Services by an Additional Secretary. 2. Tamil Nadu's health service structure at the state level consists of nine directorates, whose directors report to the Secretary, Health, who in turn is responsible to the Chief Secretary of the state. Of the directorates, those for Public Health, Family Welfare and Primary Health Centers are the most important for the proposed project. The first two together control the health staff below the block level responsible for the provision of MCH service.. The third is responsible for administration of Primary Health Centers, which would be key referral institutions for the project. For purposes of the project, instructions to staff would be issued jointly by the Directors of Public Health, Family Welfare and Social Welfare. in order to avoid conflicting instructions being issued to field staff from the different directorates. 3. There are 25 Health Districts in the proposed project area, each of which has a Chief Medical Officer (CMO) or District Health Officer (DHO) in charge of the health infrastructure. In each district, there is a hospital of beds with specialist services, catering to local needs and providing services to those referred from the periphery. The tasks of the CMO or DHO are basically managerial, including planning and monitoring of various programs, supervising service units in the district, communication activities, and administration. They are assisted by specialized staff including a District Communication Officer, a District Immunization Officer (DIO) and Statistical Officers. The DIO would be the officer in overall charge of implementing the proposed project at the district levels since his work centers on maternal and child health (MCH). 4 Community Health Centers (CHC) are established at a sub-district level and cater to populations of about 100,000. They provide in-patient as well as out-patient care, and referral and specialist services including those

52 AM= Page 2 of a physician, surgeon, gynecologist, and, in some cases, a pediatrician. Formerly, Primarv Health Centera (PHCs) served a population of 100,000, but as the service network. expands now are to cover an average population of 30,000. In Tamil Nadu, PHCs have been established throughout the project area, although many are in rented accommodation not ideally suited to their purpose. The PHC is the nucleus from which curative and preventive services in the rural areas are supported. It is staffed by a medical doctor (designated as officer-in-charge), a community health nurse with administrative and supervisory duties, a Block Extension Educator who organizes training, education and mass media programs, male and female health assistants who supervise field workers, a laboratory technician and a data processor. Below the PHC is the sub-center which covers a population of 5,000 and is staffed with a male and female health worker. The female worker, the Village Health Nurse, is primarily responsible for maternal and child health services. At the village level, trained birth attendants (TBA) or Dais are paid a token sum for each assisted delivery. The TBA is also given a replenishable delivery kit. Chart 2 (page 81) shows the organization of health and nutrition services at the block level and below in Tamil Nadu.

53 ANNU S Page 1 SECOND MANIL NMDU NUXRITION PROJECT Training 1. The overall goal of training is to ensure that project staff develop capabilities to perform their jobs well. It would be a key instrument for ensuring quality services, creating and maintaining staff motivation, and improving staff communication and community mobilization skills. Specifically the objectives of the training would be as follows: (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. 3. TINP I developed a successful system of training CNWs and supervisors. While CNW training was continuous, other functionaries received only preservice training. Health staff were not trained in monitoring and therefore, were not able to use data generated from the field. In addition, joint training of nutrition and health personnel would have been useful when the turnover of health staff increased. The project would seek to remedy these deficiencies while building upon the strengths of the TINM I system. The details of the training content, responsibilities and duration are given in tables 1 and 2. Acronyms used in the tables are as follows: BTT Block Training Team RHTC Rural Health Training Center CTC Communications and Training Center, Madras Inst Institutional Training at Regional Training Center Wkshp Workshop at local level

54 ANEX 5 Page 2 Table 1. Pre-service and Orientation Training Staff Category Where Content Trainer Duration CNW Block - Job skills, CNI and 60 days - Project Orientation BTT Helper Block - Job skills; CNI 7 days - Project orientation MPWF RHTC - Job skills; 18 mos - Project orientation - Nutrition education CNS and CTC - Technical, communication 30 days CNI and supervisory skills BPO Inst - Managerial and leadership 15 days skills, project orientat ion Orientation Trainin HS Block - Technical, communication 7 days and supervisory skills; - Project orientation BTT Inst - Communication and training 30 days skills; - Project orientation; - Supervision and coordina- 30 days tion skills; - Training village workers MO Wkshp - Leadership development 2/3 days - Performance monitoring - Project orientation DPNO/ - Managerial, leadership 10 days DCO/ and training skills; DIO/PHN - Project orientation

55 ANEXS Page 3 Table2. Tn-saeriiSA Training In service training for all categories would consist of technicalskills development, exposure to new ideas and feedback on performance. Additional content for specific categories is indicated below. Staff Category Where Content Trainer Duration CNW Block CNI/BTT 2 days Helper Block CNI 2 days MPIWF PHC CNI/BTT/ 2 days MO TBA PHC CNI/BTT/ 1 day MO CNS/HS Block/dist -Supervisory skills DTT/BTT 14 days CNI/BEE/ Inst - Managerial and training 7 days CHN/BPO skills Mo Wkshp 2/3 days Distr. Wkshp 7 days Staff In addition, once a year problem solving workshops would be held for 4 days at sector, 2 days at block and 1 week at district levels.

56 ANNEX 6 Page 1 SECOND TAXIL NADU NUTRITION PROJECT Communicatkon Componen A. Introduction 1. Desirable behavior changes related to nutrition and child care in the home and the communlty can be initiated and sustained only through effective communication support for program activities. Therefore, a comprehensive communications component is critical for achieving project objectives. Broadly, the communications component aims to stimulate demand for project services, encourage better household child feeding and care practices, motivate village level workers by enhancing their image and credibility within the community and promote community involvement. 2. TINP I developed a strong communications program to support project activities on which TINP II proposes to build. The main purposes and features of the TINP II communications component are to: (a) Strengthen institutional capability in communications research, production, evaluation and monitoring by strengthening the Communications and Training Centre, and (b) Develop communications inputs through a multi-media systems strategy to: i) promote health and nutrition services, ii) enhance credibility and image of CNWs iii) improve maternal/child care practices in the home iv) encourage community participation and mobilize communities to support project activities v) place the understanding of recipients at the centre of communication development efforts 3. During TINP II, the emphasis will shift toward the use of social marketing techniques and emphasis on creativity, research, strategies and production quality. The interface between research, creative development and strategic planning will be strengthened. Research inputs will focus on the formative data needs in the development of r-thods and materials and also on independent monitoring and evaluation of efl...;.iveness of communications inputs. To use communications resources effectively, communication research will focus on the clients and their environment to provide relevant information for developing strategies and materials, and for observing changes that may occur from their application.

57 ANNEX 6 Page 2 4. Formative research using qualitative methods would be used to develop relevant and effective communications content, structure, materials and media mix. The materials would be extensively pretested before largescale production. In addition, the project would support monitoring and summative evaluations of the communication activities to continually refine them. The communication strategy in Tamil Nadu would include special emphasis on changing household health and nutrition behavior by reaching decision makers and promoting community participation. 5. The Communications and Training Centre built under TINP I would implement the communications activities. Its operating costs would be funded under the Project Management Component. B. Strategy 6. Aims and Obiectives. TINP I evaluations have shown that communication activities succeeded more in imparting knowledge and making the project acceptable to target families than in generating specific behavioral changes in the home and the community. This means that the communications strategy has to move beyond the level of imparting knowledge to more systematic efforts to influence nutrition and health behavior. A greater effort must be made to influence decision makers su,.h as men, older women and community leaders. Communication coverage has to be strengthened considerably to hamlets, illiterate women and scheduled caste families. Deliberate efforts are required in this direction both by workers, Women's Working Groups (WWGs) and Children's Working Groups (CWGs). 7. While most of the key TINP I interventions I will be continued, new ones are also proposed in view of broader project objectives, encompassing maternal nutrition and health and coverage of adolescent girls. Communications has an important supporting role for project interventions directed to the following areas: - Encouraging participation in growth monitoring utilization of the nutritional supplement and appropriate child feeding practices at home; - Pregnant women's early identification and care including registration by the second trimester, utilization of antenatal checkups, immunization against tetanus, consumption of iron and folic acid tablets, consumption of nutrition supplement, utilization of trained dais for safe delivery; - Diarrhoea management, including provision of ORT, continued breast feeding and soft foods consumption during diarrhoea, and hygienic and sanitation to prevent diarrhoea; - Utilization of other health services including immunization, early detection and treatment of ARI, periodic deworming;

58 - S1 - Page 3 - Promoting family welfare services, including discouragement of early marriage and promotion of child spacing; - Promoting child-stimulating environment and activities at home; and - Promoting community participation to support the project. 8. These intermediate goals form the basis for developing communications delivery strategies. In the context of overall TINP objectives, the communications component aims to address the areas listed above through: - Strengthened interpersonal communication through house visits. - Development of supportive mass media and social support groups. - Active involvement of village influentials. - Backup from training and audio visual materials. - Applying social marketing techniques in the design of communication component in general and specifically in message formulation, design and presentation. 9. Social marketing is an important ingredient of the TINP II communication strategy because it recognizes: - the importance of creating demand; - the need for focus on behavior change rather than knowledge dissemination; - the importance of understanding prevalent behavior, beliefs, and attitudes of people and focussing communications on resolving the major "resistance points" impeding the acceptance of desirable behaviors; - utilizing information on consumer media habits to create comprehensive media strategy; - effectively utilizing creativity in presenting messages in a motivating, likeable, memorable and persuasive manner. 10. Media Strategy. TINP II will provide for a multi-media strategy which will include: interpersonal communications, traditional and folk media, radio and audio, films, television, display materials (wall paintings, posters, and tin plates) and printed media. C. Sgecific Media Areas 11. Internersonal Communications. CNUs play an effective role in interpersonal communications. It is also proposed that the roles of Community Nutrition Supervisors (CNS) and female village health Worker (VHN) be ftirther strengthened in interpersonal communication, to support the efforts of the CNW. For all the communication themes to be addressed by TINP II, only two types of interpersonal aids need to be developed:

59 ANNEX 6 Page 4 (a) A set of counseling cards, meant to be used for individual communication (one-to-one), (b) A set of group demo teaching aids for group communications. 12. Traditlonal Folk Media. A regular program of yillg2attu song-anddance plays will be organized in each village. Songs conveying the messages will be produced, taped in audio-cassettes by the project and distributed to the block level. Under CNWs supervision, local talented informal groups wii1 be organized to perform the program once every three months. 13. RadLo. Given the relatively short attention span of mothers, short messages (spots) will be developed to communicate the key behavioral message, address the resistance points and motivate the mother. About 10 radio spots for each of the six communication themes will be aired on the radio, as well as put on cassette to be distributed among supervisors to be played during group sessions and other suitable situations. A monthly program of about minutes for radio will also be developed. These programs will be taped and provided to the supervisors for their use during fortnightly visits to each CNC. In total, 36 radio programs will be developed. 14. Films and Television. Films are popular in rural areas with most mothers seeing at least one commercial film a month. During TINP II, sharply focussed, slngle message films of shorter duration (about one minute) will be produced in 35mm. 16mm versions of the same films will be produced for screening in villages and for special programs. Television was not used in TINP I as a communications medium. Studies reveal that the recall of health and nutrition programs among rural TV viewers is quite encouraging. As there is a proposal to provide TV and VCR sets to each ganuhauot through the Rural Development Department, the one minute film spots produced in 35mm will be transferred in OUJ matic cassette and telecast through Doordarshan. 15. Wall Paintings. Posters and Tin Plates. During TINP II, metal stencils with project messages would be provided at the block level. The community leaders in each village would be encouraged by the CNWs to paint the walls using stencils. Reprints of selected existing posters and new posters (total 12 posters) are planned. Multi-color posters of 20" x 30" in size with lamination and corner eyelets will be produced. These will be supplied to all health and nutrition centres. Posters normally need to be put in places protected from sun and rain and are not suitable for outdoor use. Therefore, tin plates would be produced and supplied (two for each centre). One could be displayed at the centre and the other at school or any other prominent village location. 16. Printed Media and FILn Charts. A set of counseling cards covering all the themes, meant to be used for individual communication (one-to-one). These cards will be able to facilitate an individually tailored message based on the very precise needs of the individual mother. The worker selects card(s) to meet the specific information needi of that mother. Twelve sets of flip charts with a flip chart case are proposed as a training support material for the block level trainers.

60 ANNEX 6 Page Newsletter, During TINP I, good use was made of the newsletter for informing workers, particularly CNWs and their supervisors. About 20,000 copies are to be printed every two months. 18. Cassette Players and Taoes. In view of the greater training role envisaged at the block level in the second project, three cassette players will be supplied for each block. The CNS too would make use of them for playing jingles and radio program cassettes, during their centre visits. D. Communications Training 19. Trained personnel are the key to proper planning and implementation of communication activities. Of special importance is the training of CNWs, their supervisors and VHNs on the effective use of communication materials. Activities include: (a) Defining the job functions under communications and community participation for workers at all levels; (b) Development of modules for communication training; (c) Development and pretesting of the curriculum for training of trainers - CNI, CHN, BEE, and BHS; and (d) Study of attributes of the more successful CNUs. E. Research for Communications Develogment 20. The project proposes two kinds of research studies for communications development: = Formative research studies, to aid in the design and conception of the materials; and = Pretesting exercises to aid in fine tuning of the materials. 21. The formative research studies will be carried out for all interventions proposed under the project. Each study will cover 2-3 major areas and will utilize not only survey methods but techniques such as focus group discussions or in-depth interviews. Pretesting will involve either testing of the revised materials based on the formative research, or of the new materials developed. Pretesting will be spread over the first three years of the project period. F. Monitoring and Evaluation 22. The project plans to establish an effective monitoring system to ensure that the communication effort are reaching the target audience according to the plan and working towards achievement of communication objectives. The system will consist of: - Periodic field report from CNWs and their supervisors on their communication-related activities. - Field reports on the working of other communication channels such as screening of films, arranging folk theatre performances. - Special monitoring research studies to assess the audience reach and reaction to communications inputs.

61 ANNEX 6 Page A moritoring system will be set up to assess the actual broadcast of messages over radio, TV or in the cinema halls, in comparison with the broadcast schedule. The monitoring systems described so far basically monitor the "delivery" of communication services. However, monitoring of actual consumer exposure to the messages and their reactions to it will be done through special monitoring research studies among the relevant target groups. 24. It is proposed that the communications component of TINP II be evaluated comprehensively. The evaluation studies proposed will consist of: Baseline information against which the changes occurring could be measured; a mid-term evaluation in the third year and a summative evaluation in the sixth year of the project. 25. While the Communication and Training Centre will be responsible for defining the objectives of the evaluation studies and overseeing the progress, the design of the studies and its implementation including data analysis and report writing will be contracted out. G. Organization and Management 26. Block and District Levels. Block Extension Educators will be used for communications activities under TINP II. The CNI will be nodal officer for communications at the block level. A district Communications Officer (DCO) will be stationed in each Health Unit District. The DCO will work in close coordination with the DEEs and MEIOs and will be responsible for the management of communication activities at the district level. 27. Coordination at Block and District Levels. CNIs and DCOs will be made members of the block and district IEC committees, respectively. The CNI and DCO will apprise the committees of all TINP II communications activities and seek their cooperation in implementation. 28. State Level, The Project Coordinator's office will include the position of a Deputy Director Communications. The Deputy Director will assist the Project Coordinator in day-to-day management of the communication activities. Senior staff proposed for CTC include five officers for curriculum development and training, research and evaluation, materials production, community participation, and planning and management. A statelevel Communication Coordination Committee will be established, including representatives from Family Welfare; Health Education Bureau, private/ngos sector; SEARB; Gandhigram Institute of Rural Health and Family Welfare; Doordarshan and All-India Radio. H. Summary Costs 29. Summary costs for the communications component are as follows: Rs '000 Printed Materials 27,260.0 A V Materials 12,737.0 PR Materials 3,310.0 Equipment & Maintenance 3,240.3 Folk & Other Programs 11,850.0 REM/Consultants 1,900.0 Total

62 ANNEX Page 1 INDIA SECOND TAMIL NADU NUTRITION PROJECT Monitoring and Evaluation 1. The primary objective of monitoring (as in TINPI) 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. (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. (d) provide information for mid-project design modifications, and (e) build a resource for expertise in program management for use in future programs in India. 2. A Monitoring and Operations Research Cell will be set up in the Project Coordination Office. This cell will be headed by a Joint Coordinator (H & OR). The JC (M & OR) is expected to have training and experience in state-of-the-artechniques for large-scale data-management and use. Familiarity with data-analysis/interpretation techniques will be an added advantage. It is anticipated that the M & OR Cell will have a very close working relationship with the PCO. In addition to drawing up and implementing an overall functional monitoring strategy, it is envisaged that the monitoring and operations research cell will have four primary responsibilities. (a) Overall coordination of project monitoring activities (which will include coordination linkages within and between Health Unit Districts (HUDs), as well as HUD-state level coordination); assessment of critical monitoring data at the state level; and translation of this information into a form that can be incorporated into the annual program implementation plan. (b) Training of HUD and State-level staff to develop expertise tailored to the overall strategy. (c) Undertake operations research geared towards program development and modification. Where in-house expertise is available, either in the 1 & OR cell, or other sections of the project coordination office, the 1 & OR cell will use the expertise to conduct operations research. Where such expertise is not available inhouse, the h & OR cell will coordinate the identification of appropriate consultant inputs for operations research. This cell

63 Page 2 will also have the primary responsibility to ensure that results from all operations research feed back lnto project design, either through the annual implementation plan, or otherwise. (d) Maintain liaison with the evaluating agency i.e. DEAR. This would include sharing of data, output reports, and computer literacy expertise. Routine process/component monitoring (currently done by the monitoring wing in TINP1) will be delegated to the Health Unit District (HUD) level, while the new cell will involve itself with more detailed and critical action-oriented analyses. At the HUD level, the statistical inspectors and the assistant statistical inspectors will undertake the major monitoring responsibilities under the guidance of the District Immunization Officer. Ad hoc surveys by statistical and assistant statistical inspectors will be continued as in TINPI to check on accuracy of recorded and reported data. 3. All monitoring information will be computerized (both at the HUD and the state levels) to facilitate retrieval, detailed analyses and future access to these data. In order to achieve this objective, all concerned personnel in the X & OR cells as well as those at the HUD level will receive pre-service and in-service training in the use of computers for program monitoring. Training support will be sought from consultants/other support agencies. HUD level staff will be trained to use the key indicators for monitoring as was done by state-level staff in TINPI. The main use of monitoring data, as in TDIP1, would be to facilitate management by exception. HUD staff will need to be oriented to look for centers with abnormally bad or abnormally good indicators. The ones with bad indicators will help point out problems in program management/implementation while centers with abnormally good indicators will hold lessons for other centers. EZaluation 4. Program evaluation will aim to: (a) Measure the impact of TINP II on the health and nutritional status of beneficiary children. (b) (c) Identify the relative contribution of specific program inputs towards the changes in health and nutritional status of benefleiaries. Identify lessons for program expansion and future program design in similar socio-cultural settings. (d) Identify more general lessons for the design of health and nutrition interventions. (e) Build expertise in evaluation and design of social and health programs.