Udalguri District- Dhamapara Char, Dhamapara Char, Pub Mahachara Char, Bilotrihati and Barsimla Village

Non-lending Technical Assistance to Assam: Improving Nutrition and Development Outcomes in Early Years

Public Disclosure Authorized (P168656)

Multi-sectoral Nutrition Action Plans: Public Disclosure Authorized Barpeta, Udalguri and Goalpara districts

Assam

Output submitted to the World Bank by The Coalition for Food and Nutrition Security

Public Disclosure Authorized

This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies Public Disclosure Authorized of the World Bank and its Board of Executive Directors.

Multisectoral Result Based District Nutrition Action Plan- Barpeta District

Accelerating the Progress of SDGs 2, 3 in the State of Assam 2019-2022

Preface Malnutrition (The Hidden Hunger) is widely prevalent in most of the districts of Assam and its manifestation is quite obvious in certain districts of the state also categorized as “Aspirational Districts” by Niti Aayog. These include Dhubri, Goalpara, Baksa, Darrang, Udalguri, Hailakandi and Barpeta. These districts have high prevalence of childhood stunting and wasting. The Government of Assam in its Vision: 2030 document has set a target to make Assam malnutrition free and in this endeavour, the Assam Agenda: 2030 released in 2018 sets the targets for intermittent years with well-defined strategies and actions to be taken. This multi sectoral nutrition plan is based on in-depth situational analysis of current status of malnutrition in the district, based on recommendations from the Nutrition Working Group Report, outcome of 6 policy seminars held during January – June 2019 and consultations with stakeholders from department functionaries and civil society organizations. The plan suggests necessary nutritional interventions for adolescent girls (in school, out of school), pregnant women, children under 5 besides other interventions necessary for creating a healthy environment like safe drinking water, sanitation, prevention of communicable diseases, assured food supply and education. The suggested interventions if implemented meticulously will certainly bring down the high prevalence of existing malnutrition in the district. There are examples from within and outside the country where prevalence of malnutrition has been reduced drastically within a period of 10 years by adopting appropriate strategies and interventions. We hope that implementation of strategies and interventions suggested in this Multi sectoral plan along with robust monitoring will help to achieve a “Malnutrition Free district”

Dr. R.M Dubey

Prof and Head,CSDGs & Dr. Sujeet Ranjan Executive Director, CFNS

Acknowledgements

The Drafting Team

The Result Based Multisectoral District Nutrition Action Plan has been drafted jointly by the following officials with the Coalition for Food and Nutrition Security (CFNS) and the Center for Sustainable Development Goals (CSDGs).

Centre for SDGs 1. Dr. R.M Dubey: Prof. and Head, Centre for SDGs 2. Shri J.C Phukan: Consultant, Centre for SDGs

Coalition for Food and Nutrition Security 1. Dr Sujeet Ranjan: Executive Director, Coalition for Food and Nutrition Security 2. Ms. Akanksha Doval: Knowledge Management Coordinator 3. Mr. Sayan Deori: Program Coordinator

Table of Contents Acknowledgements ...... 3 The Drafting Team ...... 5 List of Tables ...... 7 List of Figures ...... 8 Abbreviations ...... 9 Executive Summary ...... 11 1. Barpeta District Profile ...... 12 2. Conceptual Framework of Malnutrition...... 14 2.1 Barpeta District Problem Tree ...... 15 2.2 Potential Hotspot for Malnutrition in Barpeta District ...... 15 2.3 Nutrition Status of Barpeta, Assam and India ...... 17 2.4 First 1000 Days Analysis of Barpeta District ...... 17 2.5 Status and Determinants of various Malnutrition Indicators ...... 19 3. Objective ...... 20 4. Methodology ...... 20 5. Multisectoral Plan- the Approach, Target Groups and Parameters ...... 21 6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam ...... 24 A. Essential Nutrition Intervention ...... 24 A1: Adolescent Nutrition ...... 24 A2: First 1000 Days ...... 29 A2.1 Pregnant Women ...... 30 A2.2 Lactating Mothers ...... 35 A2. 3 ChildrenAged 0-6 months ...... 37 A2.4 Children Aged 6-24 Months ...... 40 A3. Children Aged 24-59 Months ...... 46 ...... 48 B. Multisectoral Interventions ...... 48 ...... 55 C. Cross Cutting Strategies ...... 55 Annexure 1: Multisectoral framework to Reduce Malnutrition ...... 58 Annexure 2: State Inception Workshop ...... 59 Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition” ...... 59 Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes”...... 60 Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam”...... 62 Annexure 6: MCP Card ...... 63

List of Tables

Table 1: Malnutrition Indicators (NFHS 4 Data) ...... 19 Table 2: BarpetaPopulation Projection for Adolescents aged 10-19 Years ...... 25 Table 3: Essential Nutrition Interventions-Adolescent Nutrition ...... 25 Table 4: Barpeta Population Projection for Pregnant Women ...... 30 Table 5:Essential Nutrition Interventions-Pregnant Women ...... 30 Table 6:Barpeta Population Projection for Lactating Mothers ...... 35 Table 7:Essential Nutrition Interventions - Lactating Mothers ...... 35 Table 8: BarpetaPopulation Projection of Children aged 0-6 months ...... 37 Table 9: Essential Nutrition Interventions - Children aged 0-6 months ...... 37 Table 10: Barpeta Population Projection for Children aged 6-24 Months and 12-23 Months ...... 40 Table 11: Essential Nutrition Interventions -Children aged 6-24 Months ...... 40 Table 12: Barpeta Population Projection for Children aged 24-59 Months ...... 46 Table 13: Essential Nutrition Interventions - Children aged 24-59 Months ...... 46 Table 14: Multisectoral Interventions ...... 49 Table 15: Multisectoral District Nutrition Plan (Cross Cutting Strategies) ...... 55 Table 16: Summary of Interventions - Department Wise ...... 57

List of Figures

Figure 1: Barpeta District Map ...... 13 Figure 2: Barpeta Problem tree ...... 15 Figure 3: Total literacy rate <= 60 ...... 16 Figure 4: Villages with more than 30% of HH with no Assets ...... 16 Figure 5: Comparative Analysis of Nutrition status – Barpeta , Assam and India ...... 17 Figure 6: Performance in indicators of Pregnant woman ...... 18 Figure 7: Performance in indicators of Children ...... 18

Abbreviations

ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist ASRLM Assam State Rural Livelihood Mission AWC Anganwadi Center AWW Anganwadi Worker AAY Antyodaya Anna Yojana BCC Behaviour Change Communication CBO Community based Organization CSR Corporate Social Responsibility CSDG Center for Sustainable Development Goals CFNS Coalition for Food and Nutrition Security HBNC Home Based New-born Care JSY Janani Suraksha Yojana FLW Front Line Workers IEC Information Education and Communication ICDS Integrated Child Development Scheme IFA Iron and Folic Acid IYCF Infant and Young Child Complementary Feeding MAA Mother’s Absolute Affection MAM Moderate Acute Malnutrition MDM Mid-Day Meal MGNREGA Mahatma Gandhi National Rural Employment Guarantee Act MT Million Tonne NRDWP National Rural Drinking Water Programme NGO Non-Government Organization NHM National Health Mission NIPI National Iron Plus Initiative NRC Nutrition Rehabilitation Center NFHS 4 National Family Health Survey (2015-16) PDS Public Distribution System PHED Public Health Engineering Department PHC Public Health Center PMFBY Pradhan Mantri Fasal Bima Yojana PMMVY Pradhan Mantri Matritva Vandana Yojana PRI Panchayati Raj Institution PW Pregnant Women RKVY Rashtriya Krishi Vikas Yojana SAM Severe Acute Malnutrition SAG Scheme for Adolescent Girls SBA Skilled Birth Attendant SBCC Social Behaviour Change Communication SBM Swachh Bharat mission SECC Socio Economic Caste Census SHG Self Help Group

SNP Supplementary Nutrition Program SSA Sarva Siksha Abhiyaan THR Take Home Ration VHSND Village Health Sanitation and Nutrition Day WIFS Weekly Iron and Folic Acid Supplementation

Executive Summary

The Multisectoral district nutrition action plan for Barpeta district has been prepared as a part of work envisaged under developing Multisectoral plan for three aspirational districts of Assam, out of non-lending technical support received from the World Bank. For preparation of this Multisectoral nutrition plan the World Bank engaged Coalition for Food and Nutrition Security for providing technical assistance to the Center for Sustainable Development Goals and this plan is the outcome of joint efforts of both these organizations. This Nutrition plan is divided in the following Six Sections. Section 1of the plan gives a brief profile of Barpeta District from Census 2011. Section 2 covers the conceptual framework of Malnutrition. The section includes a problem tree of Barpeta which shows the problem of malnutrition in the form of a tree highlighting the immediate, underlying and root causes behind the problem and various manifestations in the form of stunting, wasting, underweight and anaemia. The problem tree is based on NFHS 4 data of 2015-16. This section also compares the nutritional status of Barpeta district with that of Assam and India. It also shows the performance of Barpeta district in first 1000 days from conception till child’s two years of age and compares the performance of district in first 1000 days with that of state average and best performing district in state for respective parameters. Section 3 covers the objectives behind the result based multi sectoral plan. Section 4 describes in details the methodology adopted in preparation of this plan. The plan is the outcome of research and analysis conducted during the period of six months (Jan- to June 2019). Feedback was sought from district officials of the concerned departments and nutrition experts. Based on feedback as well as extensive desk research, guidance from the steering group and additional interviews with experts, district officials and community members representing diverse communities residing within the district. Section 5 of the plan describes the lifecycle approach adopted to address the child and maternal malnutrition prevalent in the district. The plan is divided into three following parts A, B and C. Part A focuses on nutrition specific intervention, part B refers to nutrition sensitive interventions and part C presents the cross cutting strategies applicable to both nutrition specific as well as nutrition sensitive interventions. The targeted groups and suggested parameters are also reflected for each part A, B and C separately. Section 6 is the main result based Multisectoral district nutrition action plan for accelerating the progress of SDGs 2 and 3 in the district. The action plan for each of the parts, as mentioned in section 4, has been dealt in detail section wise. For each of the parts A, B the following details are included in a tabular form –proposed indicators, targets for three years (2019-2022), recommended interventions, the lead and support department to executing the stated interventions and intervention related schemes being implemented by the Government of Assam. In part A of the plan, essential nutrition interventions details are provided separately for adolescent girls, and first 1000 days including pregnant women, lactating mothers and infants and young children and 24-59 months old Children. For each of these categories of adolescents, pregnant women, lactating mothers and children, the projected population figures for three years (2019- 2022) have been worked out based on actual figures of census 2011 and average annual growth rate. In part B of the plan, details of Multisectoral interventions to be dealt is long term for addressing underlying and root causes of malnutrition, including water, sanitation and personal hygiene; education, social causes, women’s empowerment and food security are presented. Part Cof the plan details the cross cutting strategies like strengthening of community based events like VHSND, growth monitoring of children at AWCs, organising quality timely home visits by frontline workers, supply chain management and social behaviour change communication strategies.

The persistent problem of malnutrition in the district is proposed to be tackled by ICDS and health sectors jointly giving lead for accelerating improvement in indicators pertaining to essential nutrition interventions in first 1000 days of life and critical maternal child health services. Highest priority will be accorded to households having a woman member who is pregnant or having a child 0-24 months. Additionally, using the life cycle approach, the existing policies for care of preschool children, school, children, and adolescent girls will be also actively implemented. Moreover, for addressing the intermediate and underlying causes of undernutrition, other sectors such as PHED, Social Welfare, Education, Panchayat and Rural Development, Food and Civil Supplies Department will be involved.

1. Barpeta District Profile

Barpeta is one of the seven aspirational districts of Assam. Barpeta district with its H.Q. at Barpeta was created and started functioning from 1st July’1983. Barpeta is a historical district of Assam with a lot

12 of cultural and religious significance. It is surrounded by Bhutan Hills in the north, Nalbari and Baksa districts in the east, Goalpara and Kamrup districts in the south and Bongaigaon and Chirang districts in the west. For the administrative purposes, the entire district is divided into two sub-divisions viz., Barpeta and Bajali. Again each sub-division is divided into revenue circles and under revenue circles there are Mouzas comprising revenue villages. Barpeta district has 9 Revenue Circles with 835 villages. There are 6 statutory towns and 3 census town in the district. Barpeta has a high prevalence of char areas which are predominantly minority population areas and the communities are most vulnerable due to lack of proper communication. The char dwelling communities are mostly dependent on agriculture.

Figure 1: Barpeta District Map

Barpeta District at a Glance (Census 2011) Total Population 16.49 lakhs Total Geographical Area 2282 sq. km Male (%) 51.2% Population Density 742 person / sq. km Female (%) 48.8% Sex Ratio 953 Rural (%) 91.3% Child Sex Ratio 961 Urban (%) 8.7% Revenue Villages General Population (Non SC ST) 43 (Annual Health Infant Mortality Rate (IMR) (%) Survey 2012-2013) SC Population (%) 5.63% Maternal Mortality Rate (MMR)

ST Population (%) 1.61% Literacy Rate 63.81% Hindu Population (%) 29.11% Women Literacy Rate 58.06% Muslim Population (%) 70.74% Christian Population (%) 0.06% Others (%) 0.09%

2. Conceptual Framework of Malnutrition

UNICEF’s (1990) conceptual framework of the causality of child malnutrition illustrates the Multisectoral nature of the problem. The immediate determinants of malnutrition at the individual level (inadequate dietary intake and disease) are products of underlying causes at the family or household level (insufficient access to food, inadequate maternal and child practices, poor water and sanitation, and inadequate access to quality health services). These, in turn, are influenced by basic causes at a societal level, including the quality and quantity of human, economic, and organizational resources and political environment. The problem tree of Barpeta district in the following section 2.1 highlights the conceptual framework of malnutrition in women and children. Malnutrition is manifested in the form of stunting, wasting, underweight, anaemia and low BMI in women. These outcomes are influenced by a set of immediate causes (nutrition specific) and underlying causes (nutrition sensitive) intervention. Dietary intake and disease status, immediate causes of malnutrition, can be addressed through nutrition specific interventions. The underlying causes of malnutrition i.e. food security, care and feeding practices for mothers and children and health services and healthy environment can be addressed through nutrition sensitive interventions. Both the nutrition specific and nutrition sensitive interventions are further influenced by interventions which improve socio economic status of women, domestic violence, and education status.

2.1 Barpeta District Problem Tree

Figure 2: Barpeta Problem tree 2.2 Potential Hotspot for Malnutrition in Barpeta District

In the absence of segregated data on malnutrition, during the field work an attempt was made to identify malnutrition pockets in the district based on indirect evidences and for the purpose pockets of high illiteracy and households with no assets was ident ified. As can be seen from the figures below the pockets more or less coincide with each other. The pockets where illiteracy is high and the households with no assets indicate towards high prevalence of malnutrition. These are the pockets with high prevalence of poverty and hence high prevalence of malnutrition. In order to improve district’s nutritional indicators it is important to focus on these pockets with priority.

Figure 3 and Figure 4 depicts the potential hotspot for malnutrition in Barpeta district, according to Census 2011 data. Though the prevalence may be different now but the data still can be used to identify relatively poor performing pockets.

Figure 4: Total literacy rate <= 60 • The maximum concentration of illiteracy and households with no assets are shown in red.

• These are likely the household with high prevalence of poverty and also malnutrition

Figure 3: Villages with more than 30% of HH with no Assets

Source: Census 2011

2.3 Nutrition Status of Barpeta, Assam and India

Nutriton Indicators of Barpeta compared to Assam and India 50 46.5 41.4 38.4 40 35.8 36.4 33.1 30 21 18.7 20 16.6

10 7.4 4 5.8

0 Stunting Wasting Severely Wasting Underweight

India Assam Barpeta

Figure 5: Comparative Analysis of Nutrition status – Barpeta, Assam and India

2.4 First 1000 Days Analysis of Barpeta District

Figure 4 and 5 indicates the performance of Barpeta district in the first 1000 days from conception till child’s 2 years of age. Figure 4 indicates the performance of district across various indicators related to the care of pregnant mother while figure 4 shows the performance of district in indicators related to child care. The figures also help in comparing the performance of Barpeta districts with that of State average and best performing districts in respective parameters.

Pregnant Woman

Assam Barpeta State best performing

ANC in First trimester 100 Financial assistance 80 At least 4 ANCs under JSY 60 40 20 Institutional delivery 0 Full ANC

Mothers having MCP Protection against card Neonatal Tetanus

IFA consumption for 100 days

Figure 6: Performance in indicators of Pregnant woman

Children

Assam Barpeta State best performing

Breastfeeding within one hour of birth 100 80 60 Vit A dose in the last six 40 Exclusive breastfeeding months (9-59 months) upto six months 20 0

Full Immunization (12- 23 Adequate diet (6-23 months) months)

Figure 7: Performance in indicators of Children

2.5 Status and Determinants of various Malnutrition Indicators The table 1 below shows the indicators of malnutrition for India, Assam, Barpeta District and best performing district of Assam in respective indicators. Table 1: Malnutrition Indicators (NFHS 4 Data)

Indicators India Assam Barpeta State Best Performance

Stunting Under 5 % 38.4 35.3 42% 24.6 (Kamrup Metro)

Wasting Under 5 % 21 16.1 17% 6.2 (Dhemaji)

Severely wasting Under 5 % 7.5 5.9 5.8% 0.8 (Dhemaji)

Underweight Under 5 % 35.7 28.1 33% 15.8 (Dhemaji)

Pregnant Women having ANC in first 58.6 55.1 64.3% 82 (Jorhat) trimester Pregnant Women having at least 4 51.2 46.4 47.5% 75.8 (Jorhat) ANC visit% Pregnant Women receiving Full ANC 21 18.1 10.2% 48 (Jorhat) Care% Pregnant Women Consuming IFA for 30.3 32 18.6% 63.3 (Jorhat) 100 days or more% Mothers receiving financial assistance 36.4 66.1 66.7% 90.2 (Dhemaji) under JSY for institutional Delivery Mothers whose last birth was 89 89.8 86.8% 97.1 (Sonitpur) protected against neonatal TT Mothers having mother and child 89.3 98.6 96.4% 99.3 (Nalbari) protection (MCP) card Women age 20-24 years married 26.8 30.8 43.3% 18.5 (Cachar) before age 18 years (%) Women age 15-19 years who were already mothers or pregnant at the 7.9 13.6 16.2% 7 (Sonitpur) time of the survey %

Women who are literate % 68.4 71.8 67.4% 84.3 (Kamrup M)

Women having 10 or more years of 35.7 26.2 23.9% 48.2 (Kamrup Metro) Schooling

Institutional Births % 78.9 70.6 51.9% 95.9 (Jorhat)

Breastfed within 1 hour of birth% 41.6 64.4 68% 80.5 (Goalpara and Udalguri)

Exclusive Breastfeeding up to 6 54.9 63.5 56.7% 86.2 (Tinsukia) months%

Children receiving adequate diet% 8.7 8.7 9.7% 13.8 (Sivasagar)

Full Immunization % 62 47.1 34.1% 73 (Sivasagar)

Vitamin A supplementation in Last 6 60.2 51.3 41.1% 67.6 (Karimganj) months%

3. Objective

The objective behind this result based multisectoral district nutrition action plan is to study in depth the reasons behind the high prevalence of malnutrition in the district and key challenges before the district administration in This multisectoral plan will ensure strong nutrition focus through institutional and programmatic convergence by integrating it in the planning, implementation and supervision process in all relevant direct and in-direct interventions and programs. Based on these determinants, a multi-sectoral district nutrition action plan is proposed. The rolling out of such a plan is expected to contribute in accelerating improvement in women and child nutrition situation and in achieving the vision of the State enunciated in Assam Vision 2030 and achieving the SDGs 2 and 3.

4. Methodology

The district nutrition action plan for Barpeta district, Assam is drafted by the Coalition for Food and Nutrition Security (CFNS) in collaboration with Center for Sustainable Development Goals (CSDGs), Government of Assam. The documents are based on desk research and analysis in the last five months, views of district officials of the concerned departments and public health nutrition and development experts, The details are summarised below.

• Review of strategic plans and similar planning documents: The team reviewed the framework of Poshan Abhiyaan for multisectoral district planning, relevant indicators from NFHS-4 and similar planning documents like multisectoral district nutrition plan from Dungarpur district, Rajasthan, Aspirational District Plan for Barpeta district, Assam Agenda 2030 of Transformation and Development department, Government of Assam, were also referred to decide on the indicator matrix for the plan. The matrix designed is based on the life cycle approach to address malnutrition with special focus on first 1000 days of life.

 Community Visit: Team visited four diverse villages of Udalguri district- Dhamapara char, Dhamapara char, Pub Mahachara char, Bilotrihati and Barsimla village. The visit was undertaken with the objective to understand the status of various services linked to the nutrition like Health, Water and Sanitation, Education and to gain insights into the socio cultural practices and beliefs of people. Extensive focused group discussions were conducted with the Mother’s group (pregnant and lactating mothers), Adolescent girls’ group, and frontline workers of ICDS and Health sectors (AWWs and ASHAs). Team also visited various AWCs and Crèches particularly in tea garden areas of the district to understand their functioning and status of various services.

• Interviews with officials of selected government departments: These interviews provided an opportunity to understand the challenges of the work of each of the concerned department and to complement the information garnered from the community visit and strategic documents.

• State and District Inception Workshop: The state and district inception workshop was conducted on 2nd Feb and 9thJanuary 2019 respectively. Experts from various fields and very senior officers from the government including Chief Secretary, Assam participated in State inception workshop and presented their views on district nutrition plan.

• Policy Seminars: Six policy seminars on various topics related to nutrition were conducted in Assam in the period from Jan-2019 to June 2019. Each of the policy seminars was attended by top government officials, individual experts, civil society organizations and field level executives. Feedbacks from the seminars were considered for drafting the Multisectoral nutrition plan.

• Monthly Nutrition Working Group Meetings: Coalition for Food and Nutrition Security (CFNS) in collaboration with Center for Sustainable Development Goals (CSDGs) formed a nutrition working group on “Essential Nutrition Intervention” in Assam. Members of the group are part of civil society organizations working at the grass root level, academicians, officials of government departments, subject experts and others. The group act as a think tank for the state on various issues related to district nutrition plan. The members of the working group strongly recommended that there was a need to focus on critical ‘window of opportunity’ of the first 1000 days of life (pregnancy period and early childhood 0-24 months). The discussions in each of the meeting provided valuable insights to the team in drafting of district nutrition plan.

5. Multisectoral Plan- the Approach, Target Groups and Parameters

The plan is based on the lifecycle approach to address child and maternal malnutrition. It is divided into two parts. Part A covers essential nutrition interventions for adolescent girls, pregnant and lactating mothers, and infants and young children addressing immediate causes of malnutrition.

Group Essential Interventions

Part A- Essential Nutrition Intervention

Adolescent Girls Anaemia Screening /IFA Supplement Deworming/ BMI Correction Health, Nutrition, Sanitation, Hygiene Education Pregnant Women ANC Care Iron and Calcium Supplementation Deworming Supplementary Nutrition/Take Home Ration () Family Planning Counselling Weight& Height Measurement- BMI (for weight gain during pregnancy)

Institutional Delivery Support for Early initiation of breastfeeding Home Delivery by SBA

Lactating Mothers IFA tablets Calcium tablets ICDS Supplementary Nutrition /Take Home Ration Family Planning Services

Low Birth Weight Care/ Kangaroo Mother Care Continuation of Breastfeeding & Exclusive Breastfeeding 0-6 Months Child Diarrhoea Management (ORS, Zinc and access to safe drinking water and sanitation facility) Care / feeding during illness Weight/ Height Monitoring

6-24 Months Children Timely Initiation of Complementary Feeding Appropriate Complementary feeding (Dietary Diversity, appropriate Feeding Frequency and adequate density ) Vitamin A and IFA Supplementation Full Immunization Deworming (as per guidelines) Supplementary Nutrition (THR of ICDS)SAM and MAM Management

IFA Supplementation Deworming 24-59 Months Children Supplementary Nutrition (ICDS) Vitamin A, IFA Part B of the plan covers multisectoral interventions that address underlying and root causes of malnutrition. While implementing a multisectoral plan, priority should be given to essential nutrition interventions and it is only after ensuring their implementation, the district should plan to implement long term multisectoral interventions. Part C of the plans outlines cross cutting strategies for system strengthening.

Part B- Interventions addressing underlying and basic causes of Malnutrition Water AWCs, Health Centers, Villages and Households with adequate water supply Sanitation AWCs, Health Centers, Villages and Households with adequate sanitation facilities

Behaviour change: Hand washing with soap and hygiene practices appropriate hygiene, sanitation practices High school education of Facilitate girls high school education Girls Right age of Prevention of marriage and conception before 18 years of age marriage/conception Women receiving work for 100 days in a year Women’s Livelihood Livelihood generation support to SHGs Homestead food production through Livelihood programs Regular supply of entitled PDS food Access to pulses ,fish , flesh food Food Security Homestead food production, Kitchen Garden, Poultry keeping

PART C- System Strengthening Intervention

Systematic Community based events Monthly VHSND sessions Growth Monitoring sessions Organised Home Visit Cross Cutting Strategies Social Behaviour Change Communication strategy Supply Chain Management Human Resources Capacity Building Monitoring Evaluation Accountability and Learning (MEAL) Knowledge Management Convergence

6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam

Essential Nutrition Intervention

A. Essential Nutrition Intervention

Essential nutrition interventions or programs address the immediate determinants of malnutrition and child development – adequate food and nutrient intake (diets). Additionally, adequate health/prevention of diseases and is also included since maternal child health interventions are critical for addressing immediate determinants of malnutrition. The interventions are presented using different stages of life cycle—adolescent girls, pregnant and lactating women children 0-6 months, 6-24 months and 24-59 months. The plan recognizes and accords highest attention to the first 1000 days of life—from conception to 24 months of age.

A1: Adolescent Nutrition

Box 1: Why Adolescent Nutrition The foundation of adequate growth and development is laid before birth, during early childhood, and in during adolescence. Early marriage and conception below 18 years adversely impacts on women gaining optimum height. In Barpeta District 43.2 % girls are married before 18 years of age and 16.2% of women aged 15-19 years are already mothers (NFHS 4). The high rate of malnutrition in girls not only contributes to increased morbidity and mortality associated with pregnancy and delivery, but also increases the risk of giving birth to low birth-weight babies. This contributes to the intergenerational cycle of malnutrition. Hence, addressing the nutrition needs of adolescents an important step towards breaking the vicious cycle of intergenerational malnutrition.

Table 2: Barpeta Population Projection for Adolescents aged 10-19 Years

Base Population (Census 2011)–189467 adolescent girls-; Average Annual Growth Rate –2.14 %

Population Projection 2019-20 2020-21 2021-22

Total Number of Adolescents 10-19 Years - - - Total Number of Adolescent Girls aged 10-19 Years 201,893 206,213 210,626

Table 3: Essential Nutrition Interventions-Adolescent Nutrition

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019- 2020 2021

20 -21 -22

3.1 School Going Adolescents Lead % of adolescent Departments 10-19 years • Mapping of all private schools, covered with Government schools and junior colleges Health Mobile Block Albendazole in • Ensuring adequate Albendazole supply at Anemia Health Team at the first round in health centers/sub centers one month Education Mukt PHC level to February and Department Bharat cover the

25 second round in prior to the biannual dates fixed for (MoHFW, schools, August each year Albendazole distribution 2018) • Maintenance of the track sheet to ensure Nodal teachers every adolescent has received the due

dosages

• Capacity building of AWWs and nodal teachers on program issues like stock calculations and dissemination, conducting IEC at regular interval • IEC materials to be given to teachers to hold education sessions in schools

• Dissemination of IEC material to all school’s/juniors college Out of School Adolescents Support Department • Listing of all the out of school

adolescents by AWW with the help of Social ASHA Welfare • Micro plan for reaching out to out of Department school children by ASHA and AWW • Ensuring a fixed day distribution of Albendazole to out of school adolescents at AWCs

• Capacity building of AWWs on program

issues like stock calculations and dissemination, conducting IEC at regular interval

School Going Adolescents • Mapping and inclusion of private schools, Government schools and junior colleges Lead • Regular screening (at least twice a year) Department 3.2: for anaemia by teachers/ mobile block Education, % of adolescent health team for school going adolescent Mobile Block girls 10-19 years Health Health Teams screened for Department WIFS anaemia(school Out of School Adolescents ANMs, ASHAs RBSK going +non- • Listing of all the out of school school going ) Support ICDS adolescents by AWW with the help of (throughout the Department SAG- ASHA Social (out of year) • Regular screening (at least twice a year) Department school adolescen for anaemia by AWWs/ mobile block Education t girls) health teams at AWCs for out of school Department adolescent

• Ensuring Weekly distribution Lead Department of IFA tablets with special focus on Health WIFS schools in tea garden areas SAG-for 3.3: Department out of ASHAs, AWWs % of eligible • Teachers and AWWs to ensure schools adolescents 10-19 consumption of IFA tablets for school Support adolescent Nodal Teachers years who receive going adolescent and out of school Department girls at least 4 blue iron adolescent girls respectively. Education Department folate tablets • Display of pictorial communication materials at school for better consumption Social outcome. Welfare Department

Besides IFA and Deworming following Lead interventions should be ensured: Department Health • Promote nutrition, health and sanitation Department education at schools and AWCs 3.4: % of adolescent • Regular health camps for adolescent girls Support 10-19 years for measuring BMI followed by Department whose BMI is counselling sessions Education below normal • Delay age of marriage and conception Department >18 years Social • Promote education and retentions in Welfare schools Department • Ensure tracking of the newly wed girls 3.5: by ASHAs with the help of AWWs % of newly wed adolescent girls • Ensuring that newlywed adolescent girls who have enter pregnancy with correct BMI and Lead Department received family age more than 18 years planning • Strengthening of Adolescent Friendly counselling Health Health Clinics for counselling Department *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

A2: First 1000 Days

Box 1: First 1000 days of life- the critical window of Opportunities

The first 1000 days of life - between a woman’s pregnancy and her child’s second birthday - is a unique period of opportunity when the foundations for optimum health and development across the lifespan are established. Stunting occurring in the first two years of life is irreversible. The right nutrition and care during the 1000 day window influences not only whether the child will survive, but also promote optimum brain and cognitive development. Highest priority is proposed to be accorded to first 1000 days of lie—right from conception to two years of age.

A2.1 Pregnant Women

Table 4: Barpeta Population Projection for Pregnant Women

Base Population (Census 2011) - Birth Rate, Total Population;Average Annual Growth Rate –2.14 (Number of Pregnant Women is estimated 10% more than expected live births) Population Projection 2019-20 2020-21 2021-22 Number of Pregnant Women

Table 5:Essential Nutrition Interventions-Pregnant Women

Data Indicators Baseline* Target* Intervention Department Scheme Resources Source* 2019- 2020- 2021-

20 21 22 • AWWs/ASHAs/ANMs to ensure Lead 100% registration of pregnancies Department

• SHGs to assist ASHAs to register the 5.1: Health ‘Unreached” women in community % of PW who Department had full • Regular organisation of VHSND by Support ASHAs, Aspirational ICDS Antenatal care ( 10.2% AWWs/ASHAS and ANMs for Department ANMs District NHM 4 ANC, at least 1 (NFHS-4) Action Plan ensuring early registration and ANC ASRLM TT, IFA tablet or check-ups Social Welfare AWWs syrup for more Department SHGs • ANCs posts to be 100% filled than 180 days) • Conduct BCC events on importance of P&RD antenatal check-ups and (ASRLM) micronutrients.

Lead Department

Health • ASHAs to ensure 100% registration Department of pregnant women 5.2: • SHGs to facilitate in identification of Out of total unreached pregnant women and ANC registered , Aspirational 64.3%(NFHS- ensure their registration for ANCs ICDS, ASHAs, % registered District 4) PMMVY AWWs within 1st Action Plan • Ensuring early registration of Support trimester(within pregnancy through incentive of Department 12 weeks) PMMVY Social Welfare • Effective implementation and timely Department fund release of PMMVY P&RD(ASRLM)

• Ensuring early registration of Lead 5.3:Out of total pregnancy through incentive of Department ANC registered , PMMVY Social Welfare % registered • AWWs to ensure 100% registration of Department ICDS, ASHAs, within 1st pregnant women PMMVY AWWs trimester(within • Effective implementation and timely Health 12 weeks) fund release of PMMVY Department

• Ensuring Regular supply of THR Lead • Ensuring supply of readymade nutri Department 5.4: Social Welfare % of PW mix as THR and not raw rice-dal registered who • Ensuring safe and hygienic storage of received 21 days THR ASHAs, of SNP in last ICDS ANMs • month and have Involve SHGs in production of THR P&RD access to through micro finance activities (ASRLM) AWWs P&RD(ASRLM) diversified food • Promotion of kitchen gardens at AWCs SHGs through home • Promote establishment of kitchen stead food garden at household level and poultry production keeping by linking with SHG activities

• Regular screening for anaemia levels Lead Department of PW at health centers / VHSND 5.5: % of eligible • Ensuring adequate availability (based Health ASHAs, pregnant women on projected population of PW) of IFA Department NHM ANMs who received at supplies at health centers and sub ICDS least 180 IFA Support ASRLM AWWs tablets during centers Department SHGs the Antenatal • Tracking of all eligible pregnant period women to ensure timely distribution of P&RD/Assam IFA tablets through ANMs or ASHAs RLM

• Appropriate counselling by service providers at the time of distributing IFA tablets for improving compliance • Organise treatment of women with severe anaemia for treatment

• Capacity building of SHGs to engage them in Jan Andolan activities for promoting consumption of IFA. • Regular follow up of PW by ASHA, ANM & AWW for managing side effects and improving IFA compliance • Capacity building of SHGs on basic health & nutrition issues and engaging them for ensuring consumption of IFA • Ensuring adequate availability (based Lead projected population of PW) of Department calcium tablet supplies at health Health centers and sub centers. 5.6: Department % pregnant • Appropriate counselling by service women who providers for promoting regular Support NHM ASHAs, consumed 360 consumption Department ICDS AWWs calcium tablets • Tracking of all eligible pregnant ASRLM SHGs during women to ensure timely distribution of pregnancy calcium tablets through ANMs or Social Welfare Department ASHAs

• Regular follow up of PW by ASHA, P&RD ANM & AWW for compliance

• Capacity building of SHGs to engage them in Jan Andolan activities for promoting consumption of calcium Lead • Adequate number of tablets to be made Department available at all health facilities 5.7: providing ANC Health % of PW who • Health workers to ensure distribution Department were given one ICDS, ASHAs, and consumption of tablet Albendazole NHM AWWs tablet after 1st • Appropriate counselling at VHSND Support trimester for disseminating information and Department

establishing WASH measures Social Welfare Department

• Lead Ensuring age of marriage and Department conception not less than 18 years • Counselling by health and ICDS on Health 5.8: adequate and appropriate diversified Department NHM % of children Aspirational diet ICDS, ASHAs and with low birth District P&RD ANMs weight (< 2.5 Action Plan • Care and day rest during pregnancy Support (ASRLM) kg) • Ensure reduction in physical drudgery Department and domestic violence with help of SHGs Social Welfare Department

*Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

A2.2 Lactating Mothers

Table 6: Barpeta Population Projection for Lactating Mothers

Base Population (Census 2011); Birth Rate –, Total Population –; Average Annual Growth Rate - (Number of lactating mothers are estimated same to be as number of expected live births) Population Projections 2019-20 2020-21 2021-22 Number of Lactating Mothers (0-6 Months)

Table 7:Essential Nutrition Interventions - Lactating Mothers

Data Indicators Baseline* Target* Intervention Department Scheme Resources Source* 2019 2020 2021

-20 -21 -22 • ANM, ASHAs, AWWs to mobilise and Lead Department support PW for institutional deliveries

• Ambulance facility to be strengthened Health ASHAs, 7.1: – Mrityunjoy 108 services, especially Department AWWs, % of 51.9 Aspirational at tea garden areas. ICDS, ANMs, institutional %(NFHS- District NHM, SHGs, Support deliveries in 4) Action Plan • Strengthening the implementation of ASRLM Trained staff Department the last month JSY and PMMVY at each health

• Timely payment on performance based center level Social Welfare incentives to ASHAs for institutional Department deliveries.

• Special higher incentives to ASHAs to be institutionalised in hard to reach areas (border areas) • Engagement of SHGs to promote the importance of institutional deliveries.

7.2: % of deliveries at home Lead attended by • Increasing the number of SBAs Aspirational Department skilled birth 12.3 % • Regular trainings for SBAs District HBNC attendant(Doct (NFHS-4) Health Action Plan • Incentives to SBAs for safe deliveries or, nurse, Department LHV, ANM, Other health personnel) Lead Department

7.3: • Ensuring Regular supply of THR Social Welfare % of lactating • Ensuring safe and hygienic storage of Department mothers THR ICDS, AWWs received 21 Support ASRLM SHGs days of • Involve SHGs in production of THR Department SNP(THR) in through micro finance activities last month P&RD

*Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

A2. 3 ChildrenAged 0-6 months

Table 8: BarpetaPopulation Projection of Children aged 0-6 months

Base Population (Census 2011) 0-6 Years Population – ; 287,829 Average Annual Growth Rate - Population Projections 2019-20 2020-21 2021-22 Number of Children aged 0-6 Months - - -

Table 9: Essential Nutrition Interventions - Children aged 0-6 months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019 2020 2021

-20 -21 -22 • Ensuring early initiation of Lead breastfeeding in 100% institutional Department Health deliveries Department • AWW to support early initiation of

breastfeeding in home deliveries 9.1: NHM- JSY ASHAs, % of children • No marketing of Infant formula Aspirational PMMVY ANMs, initiated 68%(N 100 100 100 • Lactation Management Training to District Support MAA AWWs, breastfeed FHS-4) % % % Action Plan the SBAs Department Health within one • Ensure early initiation of Breast AWWs Centers hour birth Feeding in 100% institutional deliveries Social Welfare • IEC material on breast-feeding to be Department displayed on ANC ward/ delivery ward and other health facilities.

• ANMs/ ASHAs to provide breastfeeding counselling during ANC contact at VHSND

• Educating the mothers and other Lead family members about the importance Department Health of exclusive breastfeeding Department • Every immunisation contact should be utilised for breastfeeding counselling and assessing status. • 10 steps to breastfeeding to be 9.2: % of children displayed in every health centres/ 56.7%( ANMs, under 6 VHSND forums. NHM, NFHS- Support ASHAs, months MAA 4) • Lactation support services/ lactation Department AWWs exclusively counsellors to be provided at health breastfed centers for timely management of any Social Welfare lactation problem Department • ANMs/ ASHAs to provide breastfeeding counselling during VHSND and ANC check ups • Support for breastfeeding to working mothers in areas like tea garden areas • Ensuring supply of adequate ORS Lead 9.3: packets and zinc tablets at AWCs and Department % of children Health 0-60 months with ASHAs Aspirational Department with diarrhoea • VHSND to be used for creating NHM ANMS, District Support in the last two PHED ASHAs Action Plan knowledge about diarrhoea Department weeks who management and preparation of ORS received ORS and minimum 14 days consumption and Zinc Social Welfare of zinc tablets. Department

• Home visits to children with diarrhoea treated by health workers PHED for counselling of family members on diarrhoea management/demonstration • Demonstration on VHSNDs regarding regular hand washing with soap before cooking and eating • Ensuring the coverage of safe drinking water facility • Promote the usage of sanitation toilets • Weighing machine to be made available at all AWCs/VHSND Lead forums for regular weight and height Department measures, 9.4: Social Welfare % of Children • Trainings of all AWWs and ASHAs Department 0-60 months on weight measurement and plotting that have their • Counselling on promotion of mothers AWWs, weight by AWWs with the help of ASHAs on ASHAs and measured, ICDS VHSNC monitored(ente importance of growth monitoring members red in growth • Prioritised home visits to children chart) every whose growth have faltered by Support Department month in the AWWs and ASHAs last quarter Health • Identification of children suffering Department from severe acute malnutrition (SAM) and taking appropriate actions. *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

A2.4 Children Aged 6-24 Months

Table 10: Barpeta Population Projection for Children aged 6-24 Months and 12-23 Months

Base Population (Census 2011) 0-6 Years: 287,829 Average Annual Growth Rate –2.14 Population Projections 2019-20 2020-21 2021-22 Number of Children aged 6-24 Months 77855 79521 81223 Number of Children aged 12-23 Months 51902 53013 54148

Table 11: Essential Nutrition Interventions -Children aged 6-24 Months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019- 2020 2021

20 -21 -22

• Organize Annaprashan Diwas once in a Lead month in AWCs to promote complementary Department 11.1: feeding and demonstrate healthy recipes % of children Social Welfare who were • AWWs and ASHAs to counsel mothers and Department AWWs, initiated family members on adequate diet- quality ICDS ASHAs complementary and quantity NHM Health and VHSNC feeding(Solid or • Encourage preparation of traditional Department members semi- solid food nutrimix through home level preparation and breast milk) after 6 months • Measles fist dose contact with mother to be utilised for assessing the status of complementary feeding of child Support Department

• Undertake regular home visits for counselling on complementary feeding at Assam RLM home level by ASHAs,as per the policy on Home Based Care in Young Children,NHM • Recipe demonstration by AWWs or in VHSND • List of locally available complementary foods to be given to children • Regular trainings for AWWs and ASHAs to ensure knowledge and skill retention on complementary feeding

• Counselling by ICDS and health workers to Lead stress on diet diversity Department

• Promote establishment of SSBs at household ICDS, 11.2: level of such children and poultry keeping by Health % of children linking with SHG activities. P&RD ICDS, consuming at • AWWs, SHGs Training of SHGs to counsel on adequate ASRLM least 4+ food diet- dietary diversity and minimum meal Support groups frequency Department

• SHGs to establish kitchen gardens and Social Welfare provide support to AWCs on demonstration department days 11.3: Lead % of children 41.1% Department • Ensuring adequate stock availability (based NHM AWWs, (9-24months) (NFHS- on population projection) at health centres ICDS ASHAs who received at 4) Health least one dose of department

41 vitamin Ain the • Institutional Bi-annual distribution of preceding 6 Vitamin-A on two fixed months, 6 months Support months apart from each other Department

• AWW to prepare due lists of children 9-60 Social Welfare months with the help of ASHAs and ANMs department • Children not covered in 6 monthly drive to be administered vitamin A doses on VHSND

Lead • AWW to prepare list of beneficiaries with 11.4: Department % children 6-24 the help of ASHA and ANM months provided • Ensuring adequate stock availability (based Social Welfare Anemia AWWs, (IFA) syrup (Bi on population projection) at health centres Department Mukt ASHAs weekly) in the • Ensuring mechanism for distribution of syrup Support Bharat preceding month to mothers during VHSNDs by Department

ANM/ASHAs Health

• ASHA to get list of children to be fully Lead immunised from AWW Department

11.5: • Home visits by ASHAs to follow up for Health Children age 12- mobilizing caregivers for attending Department 23 months fully 34.1 % immunization sessions. NHM, ASHAs, immunized Support (NFHS- • ICDS, AWWs and (BCG, measles, Tracking and micro planning to reach out all Department 4) ASRLM SHGs and 3 doses each children at household level- head count of polio and survey specially at tea garden areas Social Welfare DPT) (%) • Ensuring migratory population and Department, temporary settlements are also included in the immunization plan P&RD

• Engagement of SHGs/ community influencers/leaders to promote awareness regarding full immunization and mobilizing caregivers to attend immunization sessions on fixed days • Scaling up eVIN Lead 11.6: • Introduction of policy for production of Department % children 6-24 Nutrimix as THR supply to ICDS. months Social Welfare • Regular supply of THR to ICDS and weekly registered who department AWWs, ICDS received SNP supply to children Capacity building of SHGs (THR) for 21 SHGs to take up THR as a micro finance Support days in the last activity Department month P&RD

Lead Department 11.7:

% of children 6- • Regular growth monitoring at AWCs AWWs, 36 months Social Welfare ASHAs • ICDS, screened for Training of AWWs to identify MAM and Department VHSND NHM MAM and SAM SAM cases Support committee during last Department members month Health Department 11.8: Lead % of children • Counselling on home based care and Department ICDS, AWWs, with MAM that adequate feeding by AWWs and ASHAs Social Welfare NHM ASHAs receive Department

43 appropriate • Behavioural change sessions on child health Support interventions at and nutrition by AWWs Department community level Health Department • Identifying SAM children who fail appetite Lead 11.9: test or with bilateral oedema, Department % of children • Financial support to mother bringing child Health with SAM and for treatment at NRCs medical • Follow up after discharge from NRC ICDS, AWWs, complications Support • Ensure availability of dieticians at NRC at all NHM ASHAs treated at Department Nutrition times Rehabilitation • Induction training for NRC team (doctor, Social Welfare Centres (NRCs) dietitian/ nutritionist, nurses, cook and Department helpers) to gain proper techniques and skills • Provision of double THR ration of ICDS to SAM cases with no medical complications Lead • Monitoring w eight gain Department

• Imparting nutrition and health education 11.10 Social Welfare through food demonstration and % of children Department with SAM and preparation without medical • Promotion of kitchen garden to ensure complications household level food security treated at • Capacity building of primary caregiver to Support community level look after the child at home Department Health Department

11.11: Lead ICDS % of children • Ensuring adequate Albendazole supply Department WIFS (6-24 months)

44 who received • Maintenance of track sheet to ensure every Social Welfare Albendazole child receives the due 6 monthly dosages • Dissemination of IEC material to community Support centres Department

Health Department *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

A3. Children Aged 24-59 Months

Table 12: Barpeta Population Projection for Children aged 24-59 Months

Base Population (Census 2011) 0-6 Years population -219188; Average Annual Growth Rate –2.14 Population Projections 2019-20 2020-21 2021-22 Number of Children aged 24-59 Months 233,563 238,561 243.667

Table 13: Essential Nutrition Interventions - Children aged 24-59 Months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019 2020- 2021-

-20 21 22 • Organising biannual administration of vitamin Lead A supplements Department 13.1: • AWW to prepare due lists of children with the % of children 41.1% help of ASHA and ANM Social Welfare NHM AWWs, (24-59months) (NFHS- Department ICDS ASHAs who received 4) • Left out children to be given doses on Support Vitamin A VHSND • Ensuring adequate stock availability (based on Department population projection) at health centres 13.2: • AWW to prepare list of beneficiaries with the NHM : % children 24- Lead help of ASHA and ANM Anaemia 59 months Department • Mukt provided (IFA) Ensuring adequate stock availability (based on Social Welfare Bharat syrup (Bi population projection) at health centres Department

46 weekly) in last • Ensuring mechanism for distribution of syrup Support month to mothers during VHSND Department Heath Department 13.3: • Ensuring supplementary feeding to ICDS % children 24- enrolled children 24-36 months 36 months • Engagement of SHGs to ensure production of Lead registered who Department vegetables as micro finance activity received SNP • etc for SNP for 24-36 months children Social Welfare (THR) for 21 enrolled with ICDS Provision of additional Department days in the last SNP to severe underweight children month *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

Part B- Multisectoral interventions to address underlying and root causes of malnutrition

B. Multisectoral Interventions

Multisectoral interventions or programs address the underlying and basic determinants of malnutrition these include measures for improving food security and diet diversity; access to potable water, sanitation facilities and a safe and hygienic environment. The maternal-child health interventions are included in section A since nutrition and health are immediate determinants of malnutrition and are interrelated.

Box 3: Why Multisectoral Interventions to Improve Nutrition

Water, Sanitation and Personal Hygiene (WASH) - WASH and nutrition programs depend on each other to achieve impact. For example, diarrhoea is one of the biggest killers of children in South Asia. These deaths are largely preventable through good nutrition, hand washing with soap, safe drinking water and basic sanitation, and vaccination. Proper hand washing with soap at critical times, and especially before preparing food and feeding a child, is one of the most effective and cost-efficient ways to prevent diarrhoea. Improvements in sanitation, especially the elimination of open defecation, have been associated with a decrease in stunting .When nutrition programs emphasize water, sanitation, and hygiene—and WASH programs emphasize hand washing before preparing food, feeding a child, and elimination of open defecation—both programs can maximize impact.

Agriculture: Research in India has shown that increased crop diversification improves dietary diversification in the home and helps children recover from growth faltering. As agricultural production grows and diversifies, households experience increased food security and better nutrition, leading to increases in human capital and productivity. Diversified agricultural production has the potential to improve access to more diverse and nutritious foods, a key component of meeting the “Minimum Acceptable Diet” for children. Agricultural programs that focus on producing energy-rich staple foods can also be more effectively designed to reduce undernutrition by promoting crops that reduce vulnerability to droughts and extreme climate, increase yields, or improve nutritional value.5By putting more focus on nutrition outcomes (i.e., by including nutrition objectives at the outset), agricultural interventions can improve the capacity, productivity, and future prospects of agricultural workers—and also contribute to reducing undernutrition.

Education: Children can’t learn and succeed in their education without a solid nutritional foundation: Good nutrition is essential for full development of cognitive and motor skills, behavioural abilities, IQ, and physical growth. Early childhood undernutrition, including poor nutrition in the womb, often results in stunting and can have permanent developmental effects on a child. Stunted children are also less likely to complete school. Studies from 79 countries show that every 10 % increase in stunting corresponds to an 8 percent drop in the proportion of children completing primary school. When education programs invest in nutrition, it improves academic achievement. One example is school feeding programs, which can improve learning and academic performance. Students participating in school feeding and take-home ration programs have improved cognition. These programs yield the greatest impact when coupled with other programs like deworming, micronutrient supplementation, and fortification. Integrating nutrition programs into school curriculum initiates life-long healthy behaviours. Children connect what they learn in school to their broader communities by bringing messages home to their families and promoting good nutrition and healthy habits in the household.

Table 14: Multisectoral Interventions

Data Indicators Baseline Target Intervention Department Scheme Resources Source 2019 2020 2021-

-20 -21 22 Wash

Drinking Water Out of 2970 Lead AWCs in Department Barpeta only • Categorization of AWCs based on PHED 14.1: 1689 current status- Drinking facility % of AWCs available, available but not functional Anganwadi have and not available. In first phase 100 100 ICDS with adequate, proper 100% dysfunctional supplies can be made % % Barpeta Support NRDWP functional and access to functional and in second phase new Department safe drinking adequat supplies could be installed water supply e, • Testing of water supply at AWCs Social Welfare function Department al and safe drinking water 14.2: • Categorization of health Centers based Lead % of health 321 100 100 on current status- Drinking facility Department centres with health 100% NRDWP % % available, available but not functional adequate, centres and not available. In first phase PHED functional and dysfunctional supplies can be made

49 safe drinking functional and in second phase new Support water supply supplies could be installed Department

Health Department

Lead 14.3: • Water purification units to be set up. Department % of PHED villages/wards • Workshops and trainings of village NRDWP with adequate, water committee to undertake minor SKPY functional and repair work and maintenance of water Support safe drinking systems Department water supply P&RD

• Categorization of households based on current status- Drinking facility available, available but not functional 14.4: and not available. In first phase % of Lead 97.8% dysfunctional supplies can be made households with 100 100 Department (NFHS- 100% PHED functional and in second phase new NRDWP improved % % 4) supplies could be installed drinking water PHED sources • Strengthening the implementation Swatch Khuwa Pani Yojana particularly in the riverine/ char areas.

Sanitation • Mapping and prioritizing the left out 14.5: pockets % of villages/ Lead 100 100 • SBCC activities to promote usage of wards which are 100% PHED Department SBM % % sanitation facilities open defecation 100% • free Plan for maintenance of community PHED toilets 50

• Hands on trainings on sanitation to village masons 14.6: • Mapping and prioritizing the left out % of 34.9% pockets with special focus on tea Households 100 100 Lead (NFHS 100% PHED garden areas SBM with access to % % Department 4) • safe sanitation SBCC activities to promote usage PHED facilities sanitation facilities

Out of 2970 Lead Department 14.7: AWCs in • Construction of toilets in AWCs under % of Barpeta Swachh Bharat Mission PHED Anganwadi and only • Categorization of AWCs based on with adequate 1689 current status- Sanitation facility, and functional AWCs available and functional, available but sanitation have 100 100 ICDS not functional and not available. In Support SBM facilities proper 100% % % Barpeta first phase dysfunctional facilities can Department MGNREGA access to be made functional and in second adequat phase new facilities could be Social Welfare e, constructed Department 14.8: function • Convergence with MGNREGA for % of schools al and construction and maintenance of Education with adequate safe sanitation facility and functional drinking P& RD sanitation water facilities 14.9: • Categorization of health centers based Lead % of health 100 100 Department 321 100% on current status- Sanitation facility- centres with Health % % available and functional, available but adequate and facilities not functional and not available. In PHED

51 functional first phase dysfunctional facilities can Support sanitation be made functional and in second Department facilities phase new facilities could be constructed Health Department Personal Hygiene • Providing adequate supplies (soap, 14.10: bucket and mugs) to every AWCs Lead % of • Hand washing posters to be Department Anganwadis demonstrated at AWCs Social Welfare with adequate 100 100 ICDS • Department and functional 100% Community radio to generate awareness ICDS SHGs, AWWs % % Barpeta Hand washing among people Support facilities with • SHGs to create awareness regarding Department water and soap hygiene practices at community level available • Swachhagrahis to demonstrate hygiene practices on VHSND 14.11: % of health • Hand washing posters to be centres with demonstrated at health centres adequate and Lead 100 100 • Community radio to generate awareness functional 100% Department % % among people Handwashing Depart Health facilities with ment of • SHGs members to be part of monitoring Department water and soap Health, team in health centres available Barpeta Education • Awareness programmes through SSA 14.12 • Lead % of women 23.9 % Assam Counselling of girls parents by members of SHGs on importance of girl Department with 10 or more (NFHS- Agenda SSA years of 4) 2030 education schooling • Improvement of sanitation facilities at Education schools for girls Department

• Addressing the root cause for high girls dropout rate

Social Causes

• SHGs should be sensitised and linked to Lead local NGOs & CBOs for creating Department 14.13: awareness in the community for the % of women 43.2 % subject Social Welfare age 20-24 years (NFHS- • Department married before 4) BCC activities in the vulnerable 18 years communities like tea garden areas Support • Promotion of higher education among Department adolescent girls P&RD Livelihood 14.14: % of women • Generating awareness of MGNREGA with job cards among women - Lead MGNREGA who worked for • Strengthening of Women's participation Department 100 days in last in Gram Sabha Planning Meeting P&RD year Food and Nutrition Security 14.15: Lead % of families • Department PDS linked with Inclusion of all eligible families in PDS

PDS

Food & Civil Supplies

Part C- Cross Cutting Interventions

C. Cross Cutting Strategies

Table 15: Multisectoral District Nutrition Plan (Cross Cutting Strategies)

• Establish procurement system and ensure functional weighing machines at all AWCs

• Undertake Weight and height measurement of all the children at regular interval – every month for children aged between 6-24 months and once in 3 months for children aged above 24 months. 15.2: • Identify SAM children with and without medical Growth Monitoring complications and actions for their management • Organise regular training to AWWs for recording , plotting and interpretation of growth • ICDS and health functionaries to educate, counsel and support mothers and families for optimal nutrition, healthcare and development of children

• Home visit calendar of AWW, ASHA and ANM should be planned and reviewed • Home visit tools should be designed for AAAs for effective communication, counselling and information gathering 15.3: • AWW and ASHAS to make home visits for Lead Role Quality Home Visits educating mothers and other family members to Social Welfare and Health play an effective role in child’s growth and Department development with special emphasis on 0-24 months child.

15.4: Social Behaviour Change Communication(SBCC) • Development of SBCC strategy for the state’ • Hire a special expert team /organisation to develop SBCC strategy and provide rollout support. SBCC support training, advocacy and Lead Role communication materials to be standardised Health and Social Welfare Department

• Filling up the positions of all health and ICDS functionaries at all level • Appointment of a consultant District Nutrition Lead Role 15.5: Coordinator for 5 years. Health and Social Welfare Human Resources • Appointment of Block Nutrition Coordinators Department • Population based estimates for stock planning of 15.6: health supplies Supply Chain • Streamlining system for timely procurement of Lead Role Management required supplies Concerned Department • Establishment a state Nutrition Resource Centre (SNRC) --Identification of such an institute to conduct capacity building trainings 15.7: • Training of HR team including Capacity Building • mid-level managers of health and ICDS Lead Role functionaries Social Welfare and Health • Roll out of ILA module in local languages/ Department exposure visits • Establish an MIS system and link to SNRC for analysis of MPR and HMIS data • Ensure inclusion of nutrition linked Multisectoral indicators in the line department monthly progress report 15.8: • Deputy Commissioner to review the status of Lead Role Monitoring Evaluation indicators as a part of regular monitoring with Deputy Commissioner and Accountability and health, ICDS and Multisectoral departments. heads of in line department Learning (MEAL) • Documentation of progress made and analysis of 15.9: on-going best practices Lead Role Knowledge • Regular dissemination of information on analysis Concerned departments Management of local data ,progress and way forward • Formation of convergence committee for nutrition at district and block levels • Coordination meeting of all the line departments including Health, Social Welfare, PHED, Lead Role Agriculture, Education, P&RD, Food and Civil Office of Commissioner 15.10: Supplies in the presence of Principal Secretary, Convergence BTC

Table 16: Summary of Interventions - Department Wise

S.No Department Intervention

Table no

1 Health Department 3.1, 3.2, 3.3, 3.4, 3.5, 5.1, 5.2, 5.3, 5.5, 5.6, 5.7, 5.8, 7.1, 7.2, 9.1, 9.2, 9.3, 9.4, 11.1, 11.2, 11.3, 11.4, 11.5, 11.7, 11.8, 11.9, 11.10, 11.11, 13.2, 14.2, 14.11, 15.1, 15.3, 15.4, 15.5, 15.7

2 Social Welfare 3.1, 3.2, 3.3, 3.4, 5.1, 5.2, 5.3, 5.4, 5.6, 5.7, 5.8, 7.1, 7.3, 9.1, 9.2, 9.3, 9.4, 11.1, 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, 13.1, 13.2, 13.3, 14.1, 14.7, 14.8, 14.13, 15.1, 15.2, 15.3, 15.4, 15.5, 15.7

3 Education 3.1, 3.2, 3.3, 3.4, 14.7, 14.12,

4 P&RD 5.1, 5.2, 5.4, 5.5, 5.6, 7.3, 11.1, 11.2, 11.5, 11.6, 14.3, 14.7, 14.13, 14.14,

5 PHED 9.3, 14.1, 14.2, 14.3, 14.4, 14.5, 14.6, 14.7,

6 Food and Civil Supplies 14.15

7 DRDA 14.14

Annexure 1: Multisectoral framework to Reduce Malnutrition

Annexure 2: State Inception Workshop

The state inception workshop on improved Nutrition, Health and Early Childhood Outcomes was organised by Transformation and Development department, Government of Assam, in collaboration with Center for Sustainable Development Goals (CSDGs) and the Coalition for Food and Nutrition Security (CFNS) on 2nd of February, 2019 at Assam administrative staff college, Guwahati. The objective of the workshop was to introduce and orient key stakeholders on Non Lending Technical Assistance (NLTA) from the World Bank to Government of Assam for improving Nutrition, Health, and Early Childhood Outcomes to accelerate SDGs in the state and to renew to the commitment for the same. The workshop was attended by Mr. Alok Kumar, Chief Secretary, Government of Assam, Shri Jishnu Baruah, Additional Chief Secretary, Social Welfare Department, Shri Anurag Goel, Secretary, Health and Family Welfare Department, Dr. J B Ekka, Principal Secretary, Transformation & Development Department, Shri Bhaskar Barua, Former Secretary, Ministry of Agriculture, Government of India amongst other Government officials from State and Districts, Academicians, Civil society Organizations and individual experts from and outside the State. Four technical sessions on (i)Nutrition Scenario and issues and challenges in implementation of ongoing programs- Assam, (ii) Food Security & Issues and challenges in implementation of ongoing programs – Assam, (iii) Efforts towards developing M&E: System for SDGs tracking and (iv)Eat Right India Movement were conducted during the workshop. Deliberations from each of the sessions have provided valuable inputs which have been incorporated in the plan in the form of suggested interventions.

Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition”

A Policy seminar on multisectoral convergence for improved nutrition was co-organised by CFNS and CSDGs on 25th of January, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended by Senior Government officials of Assam from Health, Education, Social Welfare and Public Health and Engineering Departments, Civil Society Organizations including UNICEF, UNDP, UN Women and Piramal Foundation and Individual Experts in the field of Nutrition.

Key recommendations that emerged from the seminar are:

• Village Health Sanitation and Nutrition Day (VHSND) to be promoted and strengthened as a platform for multisectoral convergence at village level- Ensuring the Participation of ICDS Supervisors and engagement of Panchayat members to prioritize the Nutrition Agenda

• To promote Mother and Child Protection (MCP) Card as a counselling tool for Mothers and Family members and renaming it as “Mother and Child Health and Nutrition Card (MCHNC)”

• Local food mapping to understand the dietary practices of various communities and Promotion of Kitchen garden to ensure nutritional security at household level

• Social audit of Integrated Child Development Scheme (ICDS) and other nutrition linked schemes

• Infrastructure development of health facilities to ensure privacy for Antenatal Check-ups and Child Care ; Solar electrification of AWCs and health sub centers in char areas

• Improving Mobility of ASHA Workers and ANMs in char areas by providing travel support and other incentives – Department of Health and ICDS should ensure timely reimbursement of travel

Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes”

A Policy seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes” was co-organised by CFNS and CSDGs on 26th of February, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended by Shri. Hemen Das, Secretary Social Welfare Department, other government officials, civil society organizations and individual experts.

Recommendations that emerged from the seminar are:

• Panchayats &Rural Development) and engagement of NGOs in taking forward the mission for early completion of construction of 1500 AWCs.

• “Model Anganwadi Centers” to be constructed in every district of the state by merging the funds from MGNREGA, Social Welfare and other sources including CSR, MP/MLA area development fund, Panchayat fund, local interested persons (NRIs and others) to act as a good example for other centres to follow . • Government Portal for creating a fund for development of Anganwadi Centers where individuals residing in country or outside who are willing to spend money for development of their native villages can contribute

• Convergence between Integrated Child Development Scheme (ICDS) and National Crèches Scheme (NCS) in tea garden areas of Assam

• Introduction of community radio station dedicated for creating awareness regarding importance of adolescent nutrition, nutrition and care during pregnancy; infant and young child feeding practices etc.

Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam”

A Policy seminar on “Strengthening Complementary Feeding Practices in Assam” was co-organised by CFNS and CSDGs on 26th of March, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended Senior Government officials of Assam from Health, National Institute of Public Cooperation and Child Development (NIPCCD), Assam State Rural Livelihood Mission (ASRLM) and Social Welfare Department, Civil Society Organizations including Piramal Foundation, UNICEF, Front Line workers from ICDS, Health and ASRLM, Tea Garden Representatives for Assam Brach Indian Tea Association (ABITA), and individual experts in the field of Nutrition.

Key Recommendations that emerged from the seminar are:

• Monitoring of complementary feeding practices at household level by AWWs and ASHAs- Currently the Monthly Progress Report (MPR) submitted to Anganwadi supervisor by AWW do not have provision for capturing any information related to complementary feeding practices

• Integration of Self Help Groups under Rural Livelihood Mission with ICDS and Panchayati Raj Institution for effective delivery of Nutrition Services at AWCs and household level

• Capacity building of AWWs, ASHAs and SHGs using incremental learning modules of Poshan Abhiyaan in local languages

• Need for uniformity in the social behaviour change messages communicated to the communities – different messages from different players for the same topic tends to confuse the people

Annexure 6: MCP Card

Multisectoral Result Based District Nutrition Action Plan- Udalguri District

Accelerating the Progress of SDGs 2, 3 in the State of Assam 2019-2022

Preface

Malnutrition (The Hidden Hunger) is widely prevalent in most of the districts of Assam and its manifestation is quite obvious in certain districts of the state also categorized as “Aspirational Districts” by Niti Aayog. These include Dhubri, Goalpara, Baksa, Darrang, Udalguri, Hailakandi and Barpeta. These districts have high prevalence of childhood stunting and wasting. The Government of Assam in its Vision: 2030 document has set a target to make Assam malnutrition free and in this endeavour, the Assam Agenda: 2030 released in 2018 sets the targets for intermittent years with well-defined strategies and actions to be taken. This multi sectoral nutrition plan is based on in-depth situational analysis of current status of malnutrition in the district, based on recommendations from the Nutrition Working Group Report, outcome of 6 policy seminars held during January – June 2019 and consultations with stakeholders from department functionaries and civil society organizations. The plan suggests necessary nutritional interventions for adolescent girls (in school, out of school), pregnant women, children under 5 besides other interventions necessary for creating a healthy environment like safe drinking water, sanitation, prevention of communicable diseases, assured food supply and education. The suggested interventions if implemented meticulously will certainly bring down the high prevalence of existing malnutrition in the district. There are examples from within and outside the country where prevalence of malnutrition has been reduced drastically within a period of 10 years by adopting appropriate strategies and interventions. We hope that implementation of strategies and interventions suggested in this Multi sectoral plan along with robust monitoring will help to achieve a “Malnutrition Free district”.

Dr. R.M Dubey

Prof and Head, CSDGs

& Dr. Sujeet Ranjan Executive Director, CFNS

Table of Contents Acknowledgements ...... 67 The Drafting Team ...... 67 List of Tables ...... 68 List of Figures ...... 69 Abbreviations ...... 70 Executive Summary ...... 72 1. Udalguri District Profile ...... 74 2. Conceptual Framework of Malnutrition...... 75 2.1 Udalguri District Problem Tree ...... 78 2.2 Potential Hotspot for Malnutrition ...... 79 2.2 Nutrition Status of Udalguri, Assam and India ...... 80 2.3 First 1000 Days: Situation Analysis of Udalguri District...... 80 2.4 Status and Determinants of various Nutrition Indicators ...... 82 3. Objective ...... 83 4. Methodology ...... 83 5. Multi-sectoral Plan- the Approach, Target Groups and Parameters...... 85 6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam ...... 87 A. Essential Nutrition Intervention ...... 87 A1: Adolescent Nutrition ...... 87 A2: First 1000 Days ...... 93 A2.1 Pregnant Women ...... 94 A2.2 Lactating Mothers ...... 99 A2. 3 Children Aged 0-6 months ...... 101 A2.4 Children Aged 6-24 Months ...... 104 A3. Children Aged 24-59 Months ...... 109 B. Multisectoral Interventions ...... 111 C. Cross Cutting Strategies ...... 117 Annexure 1: Multisectoral framework to Reduce Malnutrition ...... 120 Annexure 2: State Inception Workshop ...... 121 Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition” ...... 121 Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes” ...... 122 Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam” ...... 124 Annexure 6: MCP Card (Feeding Practices) ...... 124

Acknowledgements

The Result Based Multisectoral District Nutrition Action Plan was jointly drafted by The Coalition for Food and Nutrition Security (CFNS) and Center for Sustainable Development Goals (CSDGs), Government of Assam in close coordination with all concerned departments of Udalguri district. The team is indebted to the guidance provided by Sri Bhaskar Baruah IAS(Rtd) Former Secretary to the Government of India, Ministry of Agriculture and the member , Executive Body of CFNS through his deliberations made at various policy seminars, the recommendations of which has basically guided the plan preparation. We are indebted to Shri Rajeev Kumar Bora (Additional Chief Secretary), Dr. J B Ekka (Principal Secretary) and the entire team of Transformation and Development Department, Govt. of Assam for their continuous guidance and support. Their suggestions put forth during deliberations in various policy seminars have served as useful inputs in preparation of this document. CFNS and CSDGs teams would like to thank all the external contributors who have helped in preparing the plan document: Shri Jishnu Baruah IAS, Additional Chief Secretary, Shri. Hemen Das ACS, Secretary and Smt. Juri Phukan IAS, Director – Department of Social Welfare, Govt. of Assam. The support and guidance received from the Principal Secretary, BTC and his team of Council officials at BTC secretariat as well as based in Udalguri is highly appreciated and acknowledged. Without their active cooperation and support this plan would not have seen the light of the day. We are grateful to Mr. Dilip Kumar Das ACS, Deputy Commissioner, Udalguri District for his valuable coordination. We are also thankful to Mr. Jatin Bora ACS, ADC and all the officials of department particularly the Joint Director - Health Services & NHM team, District Agriculture Officer & team, Executive Engineer - PHED & team, District Social Welfare Officer & team, Project Director – DRDA & team, District Education Officer & team, District Program Manager - Assam Rural Livelihood Mission & team and Food & Civil Supplies Department. We also highly appreciate the support of ICDS and Health functionaries for extending their cooperation in facilitating community visits. We would also like to thank all the Individual Experts, State Government officials and Civil Society Organizations working in the Nutrition & Health domain for their valuable inputs. We also like to thank all the members of the Nutrition working Group - Assam for their insights on nutritional scenario in districts of Assam. The logistics and other facilities received from Assam Administrative Staff College (AASC), Khanapara provided the team a congenial atmosphere in holding workshops/seminars/trainings etc. the contribution and support from Sri M.K Deka IAS, Director, AASC is highly acknowledged. Lastly the support received from the World Bank in the form of NLTA is also acknowledged.

The Drafting Team

Centre for SDGs 3. Dr. R.M Dubey : Prof. and Head, Centre for SDGs 4. Shri J.C Phukan : Consultant, Centre for SDGs

Coalition for Food and Nutrition Security 4. Dr Sujeet Ranjan : Executive Director, Coalition for Food and Nutrition Security 5. Ms. Akanksha Doval : Knowledge Management Coordinator 6. Mr. Farhad Hussain : Program Coordinator

List of Tables

Table 1: Malnutrition Indicators (NFHS 4 Data) ...... 82 Table 2: Udalguri Population Projection for Adolescents aged 10-19 Years ...... 89 Table 3: Essential Nutrition Interventions-Adolescent Nutrition ...... 89 Table 4: Udalguri Population Projection for Pregnant Women ...... 94 Table 5: Essential Nutrition Interventions-Pregnant Women ...... 94 Table 6: Udalguri Population Projection for Lactating Mothers ...... 99 Table 7: Essential Nutrition Interventions - Lactating Mothers ...... 99 Table 8: Udalguri Population Projection of Children aged 0-6 months ...... 101 Table 9: Essential Nutrition Interventions - Children aged 0-6 months ...... 101 Table 10: Udalguri Population Projection for Children aged 6-24 Months and 12-23 Months ... 104 Table 11: Essential Nutrition Interventions -Children aged 6-24 Months ...... 104 Table 12: Udalguri Population Projection for Children aged 24-59 Months ...... 109 Table 13: Essential Nutrition Interventions - Children aged 24-59 Months ...... 109 Table 14: Multisectoral Interventions ...... 112 Table 15: Multisectoral District Nutrition Plan (Cross Cutting Strategies) ...... 117 Table 16: Summary of Interventions - Department Wise ...... 57

List of Figures

Figure 1: Udalguri District Map...... 75 Figure 2: Udalguri Problem Tree ...... 78 Figure 3: Total literacy rate <=60 ...... 79 Figure 4: Villages with more than 50% of HH where source of Drinking water is away from HH ...... 79 Figure 5: Comparative Analysis of Nutrition status - Udalguri, Assam and India ...... 80 Figure 6: Performance in indicators of Pregnant Women ...... 81 Figure 7: Performance in indicators of Children...... 81

Abbreviations 70

SSA Sarva Siksha Abhiyaan THR Take Home Ration VHSND Village Health Sanitation and Nutrition Day WIFS Weekly Iron and Folic Acid Supplementation

Executive Summary

The multisectoral district nutrition action plan for Udalguri district has been prepared as a part of work envisaged under developing multisectoral plan for three aspirational districts of Assam, out of non-lending technical support received from the World Bank. For preparation of this multisectoral nutrition plan the World Bank engaged Coalition for Food and Nutrition Security for providing technical assistance to the Centre for Sustainable Development Goals and this plan is the outcome of joint efforts of both these organizations. This Nutrition plan is divided in the following Six Sections. Section 1of the plan gives a brief profile of Udalguri District from Census 2011. Section 2 covers the conceptual framework of malnutrition. The section includes a problem tree of Udalguri which shows the problem of malnutrition in the form of a tree highlighting the immediate, underlying and root causes behind the problem and various manifestations in the form of stunting, wasting, underweight and anaemia. The problem tree is based on NFHS 4 data of 2015-16. This section also compares the nutritional status of Udalguri district with that of Assam and India. It also shows the performance of Udalguri district in first 1000 days from conception till child’s two years of age and compares the performance of district in first 1000 days with that of state average and best performing district in state for respective parameters. Section 3 covers the objectives behind the result based multisectoral plan. The objective behind this result based multisectoral district nutrition action plan is to study in depth the reasons behind the high prevalence of malnutrition in the district and key challenges before the district administration. Section 4 describes in details the methodology adopted in preparation of this plan. The plan is the outcome of research and analysis conducted during the period of six months (Jan- to June 2019). Feedback was sought from district officials of the concerned departments and nutrition experts. Section 5 of the plan describes the lifecycle approach adopted to address the child and maternal malnutrition prevalent in the district. The plan is divided into three following parts A, B and C. Part A focuses on nutrition specific intervention, part B refers to nutrition sensitive interventions and part C presents the cross cutting strategies applicable to both nutrition specific as well as nutrition sensitive interventions. The targeted groups and suggested parameters are also reflected for each part A, B and C separately. Section 6 is the main result based multisectoral district nutrition action plan for accelerating the progress of SDGs 2 and 3 in the district. The action plan for each of the parts, as mentioned in section 4, has been dealt in detail section wise. For each of the parts A, B the following details are included in a tabular form –proposed indicators, targets for three years (2019-2022), recommended interventions, the lead and support department to executing the stated interventions and intervention related schemes being implemented by the Government of Assam. In part A of the plan, essential nutrition interventions details are provided separately for adolescent girls, and first 1000 days including pregnant women, lactating mothers and infants and young children and 24-59 months old Children. For each of these categories of adolescents, pregnant women, lactating mothers and children, the projected population figures for three years (2019- 2022) have been worked out based on actual figures of census 2011 and average annual growth rate. In part B of the plan, details of multi-sectoral interventions to be dealt is long term for addressing underlying and root causes of malnutrition, including water, sanitation and personal hygiene; education, social causes, women’s empowerment and food security are presented. 73

Part C of the plan details the cross cutting strategies like strengthening of community based events like VHSND, growth monitoring of children at AWCs, organising quality timely home visits by frontline workers, supply chain management and social behaviour change communication strategies. The persistent problem of malnutrition in the district is proposed to be tackled by ICDS and health sectors jointly giving lead for accelerating improvement in indicators pertaining to essential nutrition interventions in first 1000 days of life and critical maternal child health services. Highest priority has been accorded in the plan to households having a woman member who is pregnant or having a child 0-24 months. Additionally, using the life cycle approach, the existing policies for care of pre-school children, school children, and adolescent girls need to be vigourosly implemented. Moreover, for addressing the intermediate and underlying causes of undernutrition, other sectors such as PHED, Social Welfare, Education, Panchayat and Rural Development, Food and Civil Supplies Department need necessarily to be involved in a big way.

6. Udalguri District Profile

Udalguri district is one of the seven aspirational districts of Assam with Udalguri town as the district headquarters. The district is situated in the central part of Assam, on the northern side of the mighty river Brahmaputra. The district is bounded by Bhutan and Arunachal Pradesh in the north, Sonitpur district in the east, Darrang district in the south and Baksa district in the west. Udalguri was a sub-

divisional headquarters in Darrang district. But after signing of the Bodo Accord an Autonomous Territory called the Bodoland Territorial Autonomous District (BTAD) was created and Udalguri district became one of the four districts under the BTAD. The new district was formally inaugurated on 14th June, 2004.

Figure 8: Udalguri District Map

Udalguri District at a Glance (Census 2011) Total Population 8.31 lakhs Total Geographical Area 2012 square km Male (%) 50.60% Population Density 413 persons/square km Female (%) 49.40% Sex Ratio 973 Rural (%) 95.48 Child Sex Ratio 972 Urban (%) 4.52 Revenue Villages 802 General Population (Non SC ST) (%) 63.19 Infant Mortality Rate (IMR) 70 SC Population (%) 4.67% Maternal Mortality Rate (MMR) 254 ST Population (%) 32.14% Literacy Rate 65.41% Hindu Population (%) 73.64% Women Literacy Rate 58.05% Muslim Population (%) 12.66% Christian Population (%) 13.25% Others (%) 0.27%

7. Conceptual Framework of Malnutrition

and sanitation, and inadequate access to quality health services). These, in turn, are influenced by basic causes at a societal level, including the quality and quantity of human, economic, and organizational resources and political environment. The problem tree of Udalguri district in the following section 2.1 highlights the conceptual framework of malnutrition in women and children. Malnutrition is manifested in the form of stunting, wasting, underweight, anaemia and low BMI in women. These outcomes are influenced by a set of immediate causes (nutrition specific) and underlying causes (nutrition sensitive) intervention. Dietary intake and disease status, immediate causes of malnutrition, can be addressed through nutrition specific interventions. The underlying causes of malnutrition i.e. food security, care and feeding practices for mothers and children and health services and healthy environment can be addressed through nutrition sensitive interventions. Both the nutrition specific and nutrition sensitive interventions are further influenced by interventions which improve socio economic status of women, domestic violence, and education status.

7.1 Udalguri District Problem Tree

Source: NFHS 4

Figure 9: Udalguri Problem Tree

2.2 Potential Hotspot for Malnutrition

figures below the pockets more or less coincide with each other. The pockets where illiteracy is high and the drinking water facility in not adequate indicate towards high prevalence of malnutrition. These are the pockets with high prevalence of poverty and hence high prevalence of malnutrition. In

order to improve district’s nutritional indicators it is important to focus on these pockets with priority.

Figure 3 and Figure 4 depicts the potential hotspot for malnutrition in

the Udalguri district, according to Census 2011 data. Though the prevalence may be different now but the data still can be used to identify relatively poor performing pockets.

• The maximum concentration of Figure 10: Total literacy rate <=60 illiteracy and drinking water facility, far away from the source coincide in Harisinga, Udalguri and Mazbat blocks as shown in red

• These are likely the household with high prevalence of poverty and also malnutrition

Figure 11: Villages with more than 50% of HH where source of Drinking water is away from HH

Source: Census 2011

7.2 Nutrition Status of Udalguri, Assam and India

Comparitive Analysis 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 % Stunting U5 % Wasting U5 % Severely Wasting U5 % Underweight U5 Udalguri 39.1 18.3 8.1 31.8 Assam 35.3 16.1 5.9 28.1 India 38.4 21.0 7.5 35.7

Udalguri Assam India

Figure 12: Comparative Analysis of Nutrition status - Udalguri, Assam and India

7.3 First 1000 Days: Situation Analysis of Udalguri District

Figure 4 and 5 indicates the performance of Udalguri district in the first 1000 days from conception till child’s 2 years of age. Figure 4 indicates the performance of district across various indicators related to the care of pregnant mother while figure 4 shows the performance of district in indicators related to child care. The figures also helps in comparing the performance of Udalguri districts with that of State average and best performing districts in respective parameters.

Pregnant Women

ANC in first trimester (%) 100

Financial Assistance Under 80 At least 4 ANC Visit (%) JSY (%) 60 40 20 Institutional Delivery (%) 0 FULL ANC (%)

Mothers having MCP Card Protection Against Neonatal (%) Tetanus (%)

IFA Consumption for 100 days or more (%)

Assam Udalguri State Best Performance

Figure 13: Performance in indicators of Pregnant Women

Children

Breastfeeding within 1 hour of birth 100 80 60 Vitamin A dose in last 6 40 Exclusive Breastfeeding upto months (9-59 months) 6 months 20 0

Full Immunization (12-23 Adequate Diet (6-23 months) Months)

Assam Udalguri State Best Performance

Figure 14: Performance in indicators of Children

7.4 Status and Determinants of various Nutrition Indicators

The table 1 below shows the indicators of malnutrition for India, Assam, Udalguri District and best performing district of Assam in respective indicators. Table 17: Malnutrition Indicators (NFHS 4 Data) All figures in table 1 are in percentage (%)

Indicators India Assam Udalguri State Best Performance Stunting Under 5 38.4 35.3 39.1 24.6 (Kamrup Metro) Wasting Under 5 21 16.1 18.3 6.2 (Dhemaji) Severely wasting Under 5 7.5 5.9 8.1 0.8 (Dhemaji) Underweight Under 5 35.7 28.1 31.8 15.8 (Dhemaji)

Pregnant Women having ANC in 58.6 55.1 45.2 82 (Jorhat) first trimester Pregnant Women having at least 4 51.2 46.4 37 75.8 (Jorhat) ANC visit Pregnant Women receiving Full 21 18.1 13.3 48 (Jorhat) ANC Care Pregnant Women Consuming IFA 30.3 32 29.9 63.3 (Jorhat) for 100 days or more Mothers receiving financial assistance under JSY for 36.4 66.1 77.1 90.2 (Dhemaji) institutional Delivery Mothers whose last birth was 89 89.8 94.4 97.1 (Sonitpur) protected against neonatal TT Mothers having mother and child 89.3 98.6 96.3 99.3 (Nalbari) protection (MCP) card Women age 20-24 years married 26.8 30.8 28.6 18.5 (Cachar) before age 18 years Women age 15-19 years who were already mothers or pregnant at 7.9 13.6 10.8 7 (Sonitpur) the time of the survey

Women who are literate 68.4 71.8 66.6 84.3 (Kamrup M)

Women having 10 or more years 35.7 26.2 21.2 48.2 (Kamrup Metro) of Schooling

Institutional Births 78.9 70.6 72.2 95.9 (Jorhat)

Breastfed within 1 hour of birth 41.6 64.4 80.5 80.5 (Goalpara and Udalguri) Exclusive Breastfeeding upto 6 54.9 63.5 70.3 86.2 (Tinsukia) months Children receiving adequate diet 8.7 8.7 3 13.8 (Sivsagar)

Full Immunization 62 47.1 52.8 73 (Sivsagar)

Vitamin A supplementation in Last 60.2 51.3 61.3 67.6 (Karimganj) 6 months

8. Objective

The objective behind this result based multisectoral district nutrition action plan is to study in depth the reasons behind the high prevalence of malnutrition in the district and key challenges before the district administration. This multisectoral plan will ensure strong nutrition focus through institutional and programmatic convergence by integrating it in the planning, implementation and supervision process in all relevant direct and in-direct interventions and programs. Based on these determinants, a multi-sectoral district nutrition action plan is proposed. The rolling out of such a plan is expected to contribute in accelerating improvement in women and child nutrition situation and in achieving the vision of the State enunciated in Assam Vision 2030 and achieving the SDGs 2 and 3.

9. Methodology

The district nutrition action plan for Udalguri district, Assam is drafted by the Coalition for Food and Nutrition Security (CFNS) in collaboration with Center for Sustainable Development Goals (CSDGs), Government of Assam. The documents is based on desk research and analysis in the last five months, views of district officials of the concerned departments and public health nutrition and development experts, The details are summarised below.

• Review of strategic plans and similar planning documents: The team reviewed the framework of Poshan Abhiyaan for multisectoral district planning, relevant indicators from NFHS4 and similar planning documents like multi-sectoral district nutrition plan from Dungarpur district, Rajasthan, Aspirational District Plan for Udalguri district, Assam Agenda 2030 of Transformation and Development department, Government of Assam, were also referred to decide on the indicator matrix for the plan. The matrix designed is based on the life cycle approach to address malnutrition with special focus on first 1000 days of life.

• Community Visit: Team visited five diverse villages of Udalguri district- Orangajuli Tea Estate, Tokankata village, Shikari Danga Village, Udalguri Nepali Gaon, and Machkunti

village. The visit was undertaken with the objective to understand the status of various services linked to the nutrition like Health, Water and Sanitation, Education and to gain insights into the socio cultural practices and beliefs of people. Extensive focused group discussions were conducted with the Mother’s group (pregnant and lactating mothers), Adolescent girls’ group, and frontline workers of ICDS and Health sectors (AWWs and ASHAs). Team also visited various AWCs and Creches particularly in tea garden areas of the district to understand their functioning and status of various services.

• State and District Inception Workshops: The state and district inception workshops were conducted on 2nd Feb and 5th January respectively. Experts from various fields and very senior officers from the government including Chief Secretary, Assam participated in State inception workshop and presented their views on district nutrition plan.

• Policy Seminars: Six policy seminars on various topics related to nutrition were conducted in Assam in the period from Jan-2019 to June 2019. Each of the policy seminar was attended by top government officials, individual experts, civil society organizations and field level executives. Feedback from the seminars was considered for drafting the multisectoral nutrition plan.

10. Multi-sectoral Plan- the Approach, Target Groups and Parameters

Group Essential Interventions

Part A- Essential Nutrition Intervention Adolescent Girls Anaemia Screening /IFA Supplement Deworming/ BMI Correction Health, Nutrition, Sanitation, Hygiene Education Pregnant Women ANC Care Iron and Calcium Supplementation Deworming Supplementary Nutrition/Take Home Ration ()Family Planning Counselling Weight& Height Measurement- BMI (for weight gain during pregnancy)

Institutional Delivery Support for Early initiation of breastfeeding Home Delivery by SBA Lactating Mothers IFA tablets Calcium tablets ICDS Supplementary Nutrition /Take Home Ration Family Planning Services

Low Birth Weight Care/ Kangaroo Mother Care Continuation of Breastfeeding &Exclusive Breastfeeding 0-6 Months Child Diarrhoea Management (ORS, Zinc and access to safe drinking water and sanitation facility) Care / feeding during illness Weight/ Height Monitoring

Supplementary Nutrition (THR of ICDS)SAM and MAM Management

PART C- System Strengthening Intervention

6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam

Essential Nutrition Intervention

D. Essential Nutrition Intervention

Essential nutrition interventions or programs address the immediate determinants of malnutrition and child development – adequate food and nutrient intake (diets).Additionally, adequate health/prevention of diseases and is also included since maternal child health interventions are critical for addressing immediate determinants of malnutrition. The interventions are presented using different stages of life cycle—adolescent girls, pregnant and lactating women children 0-6 months, 6-24 months and 24-59 months. The plan recognizes and accords highest attention to the first 1000 days of life—from conception to 24 months of age.

A1: Adolescent Nutrition

Box 1: Why Adolescent Nutrition The foundation of adequate growth and development is laid before birth, during early childhood, and in during adolescence. Early marriage and conception below 18 years adversely impacts on women gaining optimum height. In Udalguri District 28.6 % girls are married before 18 years of age and 10.8% of women aged 15-19 years are already mothers (NFHS 4). The high rate of malnutrition in girls not only contributes to increased morbidity and mortality associated with pregnancy and delivery, but also increases the risk of giving birth to low birth-weight babies. This contributes to the intergenerational cycle of malnutrition. Hence, addressing the nutrition needs of adolescents an important step towards breaking the vicious cycle of intergenerational malnutrition.

Table 18: Udalguri Population Projection for Adolescents aged 10-19 Years Base Population (Census 2011) -90772; Average Annual Growth Rate - 0.976%

Population Projection 2019-20 2020-21 2021-22 Total Number of Adolescents 10-19 Years 198,012 199,945 201,897 Total Number of Adolescent Girls aged 10-19 Years 99,006 99,973 100,948

Table19: Essential Nutrition Interventions-Adolescent Nutrition

Baseline Data Indicators Target* Interventions Department Scheme Resources * Source* 2019- 2020 2021

20 -21 -22

3.1: % of School Going Adolescents Lead Departments adolescent 10-19 • Mapping of all private schools, years covered Government schools and junior colleges with Albendazole Health Mobile Block in the first round • Ensuring adequate Albendazole supply at Anemia Health Team at in February and health centers/sub centers one month Education Mukt PHC level to Department Bharat cover the

89 second round in prior to the biannual dates fixed for (MoHFW, schools August each year Albendazole distribution 2018) • Maintenance of the track sheet to ensure Nodal teachers every adolescent has received the due

dosages

• Dissemination of IEC material to all schools/juniors college Out of School Adolescents Support • Listing of all the out of school Department adolescents by AWW with the help of ASHA Social • Micro plan to include strategy for Welfare reaching out to out of school children by Department ASHA and AWW • Ensuring a fixed day distribution of Albendazole to out of school adolescents

at AWCs

• Capacity building of AWWs on program issues like stock calculations and dissemination, conducting IEC at regular interval

School Going Adolescents • Mapping and inclusion of private schools, Government schools and junior colleges Lead • Regular screening (at least twice a year) Department Mobile Block 3.2: % of for anaemia by teachers/ mobile block Education, Health Teams adolescent girls health team for school going adolescent 10-19 years Health ANMs, ASHAs screened for Department and 1065 WIFS anaemia(school Out of School Adolescents ASHAs RBSK going +non- • Listing of all the out of school school going ) Support ICDS adolescents by AWW with the help of (throughout the Department SAG- ASHA Social (out of year) • Regular screening (at least twice a year) Department school adolescen for anaemia by AWWs/ mobile block Education t girls) health teams at AWCs for out of school Department adolescent

• Ensuring Weekly distribution Lead Department of IFA tablets with special focus on Health WIFS schools in tea garden areas Department SAG-for 1065 ASHAs, 1439 AWWs 3.3: % of eligible • Teachers and AWWs to ensure out of adolescents 10-19 consumption of IFA tablets for school Support schools years who receive adolescent Nodal Teachers going adolescent and out of school Department at least 4 blue iron girls adolescent girls respectively. Education folate tablets Department • Display of pictorial communication materials at school for better consumption Social outcome. Welfare Department

Besides IFA and Deworming following Lead interventions should be ensured: Department Health • Promote nutrition, health and sanitation Department education at schools and AWCs

3.4: % of • Regular health camps for adolescent girls Support adolescent 10-19 for measuring BMI followed by Department years whose BMI Education is below normal counselling sessions • Delay age of marriage and conception Department >18 years Social • Promote education and retentions in Welfare schools Department • Ensure tracking of the newly wed girls 3.5: % of newly by ASHAs with the help of AWWs wed adolescent • Ensuring that newlywed adolescent girls girls who have enter pregnancy with correct BMI and Lead received family Department age more than 18 years planning counselling • Strengthening of Adolescent Friendly Health Health Clinics for counselling Department *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

A2: First 1000 Days

Box 1: First 1000 days of life- the critical window of Opportunities

A2.1 Pregnant Women

Table 20: Udalguri Population Projection for Pregnant Women Base Population (Census 2011) - Birth Rate 20.5, Total Population 8.3 lakhs; Average Annual Growth Rate - 0.976% (Number of Pregnant Women is estimated 10% more than expected live births) Population Projection 2019-20 2020-21 2021-22 Number of Pregnant Women 20,296 20,494 20,694

Table 21: Essential Nutrition Interventions-Pregnant Women

Data Indicators Baseline* Target* Intervention Department Scheme Resources Source* 2019- 2020- 2021-

20 21 22 • AWWs/ASHAs/ANMs to ensure Lead 100% registration of pregnancies Department

• SHGs to assist ASHAs to register the Health 5.1: % of PW ‘Unreached” women in community Department who had full 1065 • Regular organisation of VHSND by Support Antenatal care ( Aspirational ICDS ASHAs, 13.3% AWWs/ASHAS and ANMs for Department 4 ANC, at least 1 40% 60 % 75% District NHM ANMs (NFHS-4) TT, IFA tablet or Action Plan ensuring early registration and ANC ASRLM Social Welfare syrup for more check-ups 1439 AWWs Department than 180 days) • ANCs posts to be 100% filled 5000 SHGs

• Conduct BCC events on importance of P&RD antenatal check-ups and (ASRLM) micronutrients.

• Organise ANC sessions on 9th of every month as per the PMSMA policy of NHM Pregnant women to be weighed and weight to be entered in MCP card and weight gain should be encouraged as per BMI based guidelines

Lead Department

• ASHAs to ensure 100% registration of Health pregnant women Department • SHGs to facilitate in identification of 5.2:Out of total ANC registered , unreached pregnant women and Aspirational 1065 % registered 45.2%(NFHS- ensure their registration for ANCs ICDS, 95% 98% 100% District ASHAs, within 1st 4) PMMVY Action Plan • Ensuring early registration of 1439 AWWs trimester(within pregnancy through incentive of 12 weeks) Support PMMVY Department • Effective implementation and timely fund release of PMMVY Social Welfare Department

P&RD(ASRLM)

Lead 5.3:Out of total Aspirational • Department 1065 ANC registered , 45.2%(NFHS- Ensuring early registration of ICDS, 95% 98% 100% District Social Welfare ASHAs, % registered 4) pregnancy through incentive of PMMVY Action Plan Department 1439 AWWs within 1st PMMVY

95 trimester(within • AWWs to ensure 100% registration of Health 12 weeks) pregnant women Department • Effective implementation and timely fund release of PMMVY

• Ensuring Regular supply of THR Lead • Ensuring supply of readymade nutri Department Social Welfare 5.4:% of PW mix as THR and not raw rice-dal registered who received 21 days • Ensuring safe and hygienic storage of 1065 of SNP in last THR ASHAs, ICDS month and have • ANMs Involve SHGs in production of THR P&RD access to through micro finance activities (ASRLM) diversified food P&RD(ASRLM) 1439 AWWs • Promotion of kitchen gardens at AWCs through home 5000 SHGs stead food • Promote establishment of kitchen production garden at household level and poultry keeping by linking with SHG activities

Lead • Regular screening for anaemia levels Department of PW at health centers / VHSND 5.5:% of eligible • Ensuring adequate availability (based Health 1065 pregnant women Department ASHAs, on projected population of PW) of IFA NHM who received at ANMs supplies at health centers and sub Support ICDS least 180 IFA Department centers ASRLM tablets during 1439 AWWs the Antenatal • Tracking of all eligible pregnant P&RD/Assam 5000 SHGs period women to ensure timely distribution of RLM IFA tablets through ANMs or ASHAs

• Appropriate counselling by service providers at the time of distributing IFA tablets for improving compliance • Organise treatment of women with severe anaemia for treatment

• Ensuring adequate availability (based Lead projected population of PW) of Department calcium tablet supplies at health Health centers and sub centers. Department 5.6: % pregnant • Appropriate counselling by service women who 1065 providers for promoting regular Support NHM consumed 360 ASHAs, consumption Department ICDS calcium tablets 1439 AWWs ASRLM during • Tracking of all eligible pregnant 5000 SHGs pregnancy women to ensure timely distribution of calcium tablets through ANMs or Social Welfare Department ASHAs

• Regular follow up of PW by ASHA, P&RD ANM & AWW for compliance

• Capacity building of SHGs to engage them in Jan Andolan activities for promoting consumption of calcium Lead • Adequate number of tablets to be made Department available at all health facilities Health 5.7: % of PW providing ANC Department who were given • Health workers to ensure distribution 1065 ICDS, one Albendazole and consumption of tablet ASHAs, NHM tablet after 1st • Appropriate counselling at VHSND Support 1439 AWWs trimester for disseminating information and Department

establishing WASH measures Social Welfare Department

• Lead Ensuring age of marriage and Department conception not less than 18 years • Counselling by health and ICDS on Health 5.8: % of adequate and appropriate diversified Department Aspirational NHM children with diet ASHAs and 10% 8% 5% District ICDS, low birth weight ANMs Action Plan • Care and day rest during pregnancy Support (< 2.5 kg) • Ensure reduction in physical drudgery Department and domestic violence with help of SHGs Social Welfare Department

*Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

A2.2 Lactating Mothers

Table 22: Udalguri Population Projection for Lactating Mothers Base Population (Census 2011); Birth Rate – 20.5, Total Population – 8.3 lakhs; Average Annual Growth Rate - 0.976% (Number of lactating mothers are estimated same to be as number of expected live births) Population Projections 2019-20 2020-21 2021-22 Number of Lactating Mothers (0-6 Months) 8,580 8,664 8,748

Table 23: Essential Nutrition Interventions - Lactating Mothers

Data Indicators Baseline* Target* Intervention Department Scheme Resources Source* 2019 2020 2021

-20 -21 -22 • ANM, ASHAs, AWWs to mobilise and Lead support PW for institutional deliveries Department

• Ambulance facility to be strengthened Health – Mrityunjoy 108 services, especially Department 1065 at tea garden areas. ASHAs, 7.1: % of 1439 AWWs, Aspirational • Strengthening the implementation of ICDS, institutional 72.2%(NF ANMs, 5000 76% 86% 96% District JSY and PMMVY NHM, deliveries in HS-4) Support SHGs, Action Plan ASRLM the last month • Timely payment on performance based Department Trained staff incentives to ASHAs for institutional at each health deliveries. Social Welfare center level • Special higher incentives to ASHAs to Department be institutionalised in hard to reach areas (border areas)

• Engagement of SHGs to promote the importance of institutional deliveries

7.2: % of deliveries at Lead home attended • Increasing the number of SBAs by skilled birth Aspirational Department 3.2%(NFH • Regular trainings for SBAs attendant(Doct 61% 71% 81% District HBNC S-4) Health or, nurse, Action Plan • Incentives to SBAs for safe deliveries Department LHV, ANM, Other health personnel) Lead Department

7.3: % of • Ensuring Regular supply of THR Social Welfare lactating • Ensuring safe and hygienic storage of Department mothers THR ICDS, AWWs received 21 Support ASRLM SHGs days of • Involve SHGs in production of THR Department SNP(THR) in through micro finance activities last month P&RD

*Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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A2. 3 Children Aged 0-6 months

Table 24: Udalguri Population Projection of Children aged 0-6 months Base Population (Census 2011) 0-6 Years Population – 1.13 lakhs; Average Annual Growth Rate - 0.976% Population Projections 2019-20 2020-21 2021-22 Number of Children aged 0-6 Months 8,580 8,664 8,748

Table 25: Essential Nutrition Interventions - Children aged 0-6 months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019 2020 2021

-20 -21 -22 • Ensuring early initiation of Lead breastfeeding in 100% institutional Department Health deliveries Department • AWW to support early initiation of

breastfeeding in home deliveries 9.1: % of NHM- JSY ASHAs, children • No marketing of Infant formula 80.5%( Aspirational PMMVY ANMs, initiated 100 100 100 • Lactation Management Training to NFHS- District Support MAA AWWs, breastfeed % % % 4) Action Plan the SBAs Department Health within one • Ensure early initiation of Breast AWWs Centers hour birth Feeding in100% institutional deliveries Social Welfare • IEC material on breast-feeding to be Department displayed on ANC ward/ delivery ward and other health facilities.

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• ANMs/ ASHAs to provide breastfeeding counselling during ANC contact at VHSND

• Educating the mothers and other Lead family members about the importance Department Health of exclusive breastfeeding Department • Every immunisation contact should be utilised for breastfeeding counselling and assessing status. • 10 steps to breastfeeding to be 9.2: % of displayed in every health centres/ children under 70.3%( ANMs, VHSND forums. NHM, 6 months NFHS- Support ASHAs, MAA exclusively 4) • Lactation support services/ lactation Department AWWs breastfed counsellors to be provided at health centers for timely management of any Social Welfare lactation problem Department • ANMs/ ASHAs to provide breastfeeding counselling during VHSND and ANC check ups • Support for breastfeeding to working mothers in areas like tea garden areas • Ensuring supply of adequate ORS Lead 9.3: % of packets and zinc tablets at AWCs and Department children 0-60 Health months with with ASHAs Aspirational Department diarrhoea in 100 100 • VHSND to be used for creating NHM ANMS, 70% District Support the last two % % PHED ASHAs Action Plan knowledge about diarrhoea Department weeks who management and preparation of ORS received ORS and minimum 14 days consumption and Zinc Social Welfare of zinc tablets. Department

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• Home visits to children with diarrhoea treated by health workers PHED for counselling of family members on diarrhoea management/demonstration • Demonstration on VHSNDs regarding regular hand washing with soap before cooking and eating • Ensuring the coverage of safe drinking water facility • Promote the usage of sanitation toilets • Weighing machine to be made available at all AWCs/VHSND Lead forums for regular weight and height Department measures, 9.4: % of Social Welfare Children 0-60 • Trainings of all AWWs and ASHAs Department months that on weight measurement and plotting have their • Counselling on promotion of mothers AWWs, weight by AWWs with the help of ASHAs on ASHAs and measured, ICDS VHSNC monitored(ente importance of growth monitoring members red in growth • Prioritised home visits to children chart) every whose growth have faltered by Support Department month in the AWWs and ASHAs last quarter Health • Identification of children suffering Department from severe acute malnutrition (SAM) and taking appropriate actions. *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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A2.4 Children Aged 6-24 Months

Table 26: Udalguri Population Projection for Children aged 6-24 Months and 12-23 Months Base Population (Census 2011) 0-6 Years Population -1.13 lakhs; Average Annual Growth Rate - 0.976% Population Projections 2019-20 2020-21 2021-22 Number of Children aged 6-24 Months 30,905 31,207 31,512 Number of Children aged 12-23 Months 17,160 17,327 17,496

Table 27: Essential Nutrition Interventions -Children aged 6-24 Months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019- 2020 2021

20 -21 -22

• Organize Annaprasanna Diwas once in a Lead month in AWCs to promote complementary Department 11.1: % of feeding and demonstrate healthy recipes children who • AWWs and ASHAs to counsel mothers and Social Welfare were initiated Department AWWs, family members on adequate diet- quality ICDS complementary ASHAs and quantity NHM feeding(Solid or Health and VHSNC

semi- solid food • Encourage preparation of traditional Department members and breast milk) nutrimix through home level preparation after 6 months • Measles fist dose contact with mother to be utilised for assessing the status of complementary feeding of child Support Department

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• Undertake regular home visits for counselling on complementary feeding at Assam RLM home level by ASHAs, as per the policy on P&RD Home Based Care in Young Children, NHM • Recipe demonstration by AWWs or in VHSND • List of locally available complementary foods to be given to children • Regular trainings for AWWs and ASHAs to ensure knowledge and skill retention on complementary feeding

• Counselling by ICDS and health workers to Lead stress on diet diversity Department

• Promote establishment of SSBs at household Health 11.2: % of level of such children and poultry keeping by P&RD children linking with SHG activities. Social Welfare ICDS, consuming at • department AWWs, SHGs Training of SHGs to counsel on adequate ASRLM least 4+ food diet- dietary diversity and minimum meal Support groups frequency Department • SHGs to establish kitchen gardens and provide support to AWCs on demonstration Social Welfare days department 11.3: % of Lead children (9- 61.3% Department • Ensuring adequate stock availability (based NHM AWWs, 24months) who (NFHS- on population projection) at health centres ICDS ASHAs received at least 4) Health one dose of department

105 vitamin Ain the • Institutional Bi-annual distribution of preceding 6 Vitamin-A on two fixed months, 6 months Support months apart from each other Department

• AWW to prepare due lists of children 9-60 Social Welfare months with the help of ASHAs and ANMs department • Children not covered in 6 monthly drive to be administered vitamin A doses on VHSND

Lead • AWW to prepare list of beneficiaries with 11.4: % children Department 6-24 months the help of ASHA and ANM provided (IFA) • Ensuring adequate stock availability (based Social Welfare Anemia AWWs, syrup (Bi on population projection) at health centres Department Mukt ASHAs weekly) in the • Ensuring mechanism for distribution of syrup Support Bharat preceding month to mothers during VHSNDs by Department

ANM/ASHAs Health

• ASHA to get list of children to be fully Lead immunised from AWW Department

11.5: Children • Home visits by ASHAs to follow up for Health age 12-23 Aspiratio mobilizing caregivers for attending Department months fully nal immunization sessions. NHM, ASHAs, immunized 52.8%( 100 Support 98% 99% District • ICDS, AWWs and (BCG, measles, NFHS-4) % Tracking and micro planning to reach out all Department Action ASRLM SHGs and 3 doses each children at household level- head count Plan. of polio and survey specially at tea garden areas Social Welfare DPT) (%) • Ensuring migratory population and Department, temporary settlements are also included in the immunization plan P&RD

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• Engagement of SHGs/ community influencers/leaders to promote awareness regarding full immunization and mobilizing caregivers to attend immunization sessions on fixed days • Scaling up eVIN Lead • Introduction of policy for production of Department 11.6: % children Nutrimix as THR supply to ICDS. 6-24 months • Regular supply of THR to ICDS and weekly Social Welfare registered who supply to children department AWWs, received SNP ICDS SHGs (THR) for 21 • Capacity building of SHGs to take up THR Support days in the last including eggs for all as a micro finance Department month activity P&RD

Lead Department 11.7: % of AWWs, children 6-36 • Regular growth monitoring at AWCs Social Welfare ASHAs months screened • ICDS, Training of AWWs to identify MAM and Department VHSND for MAM and NHM SAM cases committee SAM during last Support members month Department Health Department 11.8: % of Lead children with • Counselling on home based care and Department ICDS, AWWs,

MAMthat adequate feeding by AWWs and ASHAs Social Welfare NHM ASHAs receive Department

107 appropriate • Behavioural change sessions on child health Support interventions at and nutrition by AWWs Department community level Health Department • Identifying SAM children who fail appetite Lead 11.9: % of test or with bilateral oedema, Department children with • Financial support to mother bringing child Health SAM and for treatment at NRCs medical • Follow up after discharge from NRC ICDS, AWWs, complications Support • Ensure availability of dieticians at NRC at all NHM ASHAs treated at Department Nutrition times Rehabilitation • Induction training for NRC team (doctor, Social Welfare Centres (NRCs) dietician/ nutritionist, nurses, cook and Department helpers) to gain proper techniques and skills • Provision of double THR ration of ICDS to SAM cases with no medical complications Lead • Monitoring w eight gain Department

• Imparting nutrition and health education 11.10: % of Social Welfare through food demonstration and children with Department SAM and preparation without medical • Promotion of kitchen garden to ensure complications household level food security treated at • Capacity building of primary caregiver to Support community level look after the child at home Department Health Department

11.11: % of Lead ICDS children (6-24 • Ensuring adequate Albendazole supply Department WIFS months) who

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received • Maintenance of track sheet to ensure every Social Welfare Albendazole child receives the due 6 monthly dosages • Dissemination of IEC material to community Support centres Department

Health Department *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

A3. Children Aged 24-59 Months

Table 28: Udalguri Population Projection for Children aged 24-59 Months Base Population (Census 2011) 0-6 Years population -1.13 lakhs; Average Annual Growth Rate - 0.976% Population Projections 2019-20 2020-21 2021-22 Number of Children aged 24-59 Months 84,136 84,957 85,787

Table 29: Essential Nutrition Interventions - Children aged 24-59 Months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019 2020- 2021-

-20 21 22 13.1: % of 61.3% Lead • Organising biannual administration of vitamin NHM AWWs, children (24- (NFHS- Department A supplements ICDS ASHAs 59months) 4)

109 who received • AWW to prepare due lists of children with the Social Welfare Vitamin A help of ASHA and ANM Department • Left out children to be given doses on VHSND • Ensuring adequate stock availability (based on Support population projection) at health centres Department

13.2: % children 24-59 • AWW to prepare list of beneficiaries with the Lead Department months help of ASHA and ANM NHM : Social Welfare provided (IFA) • Ensuring adequate stock availability (based on Anaemia Department syrup (Bi population projection) at health centres Mukt weekly) in last • Ensuring mechanism for distribution of syrup Support Bharat month to mothers during VHSND Department Heath Department 13.3: % • Ensuring supplementary feeding to ICDS children 24-36 enrolled children 24-36 months months • Engagement of SHGs to ensure production of Lead registered who Department vegetables as micro finance activity received SNP • etc for SNP for 24-36 months children Social Welfare (THR) for 21 enrolled with ICDS Provision of additional Department days in the last SNP to severe underweight children month *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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Part B- Multisectoral interventions to address underlying and root causes of malnutrition

E. Multisectoral Interventions

Box 3: Why Multisectoral Interventions to Improve Nutrition

Education: Children can’t learn and succeed in their education without a solid nutritional foundation: Good nutrition is essential for full development of cognitive and motor skills, behavioural abilities, IQ, and physical growth. Early childhood undernutrition, including poor nutrition in the womb, often results in stunting and can have permanent developmental effects on a child. Stunted children are also less likely to complete school. Studies from 79 countries show that every 10 percent increase in stunting corresponds to an 8 percent drop in the proportion of children completing primary school. When education programs invest in nutrition, it improves academic achievement. One example is school feeding programs, which can improve learning and academic performance. Students participating in school feeding and take-home ration programs have improved cognition. These programs yield the greatest impact when coupled with other programs like deworming, micronutrient supplementation, and fortification. Integrating nutrition programs into school curriculum initiates life-long healthy behaviours. Children connect what they learn in school to their broader communities by bringing messages home to their families and promoting good nutrition and healthy habits in the household.

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Table 30: Multisectoral Interventions

Data Indicators Baseline Target Intervention Department Scheme Resources Source 2019 2020 2021-

-20 -21 22 Wash

Drinking Water

Lead • Categorization of AWCs based on Department current status- Drinking facility 14.1: % of available, available but not functional PHED Anganwadi and not available. In first phase with adequate, 100 100 District 100% dysfunctional supplies can be made functional and % % Office Support NRDWP functional and in second phase new safe drinking Department supplies could be installed water supply • Testing of water supply at AWCs Social Welfare Department

• Categorization of health Centers based Lead on current status- Drinking facility Department 14.2: % of available, available but not functional health centres and not available. In first phase PHED with adequate, dysfunctional supplies can be made NRDWP functional and functional and in second phase new Support safe drinking supplies could be installed Department water supply

Health Department

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• Water purification units to be set in Lead 14.3: % of labour lines of tea gardens under Department villages/wards SKPY PHED with adequate, District NRDWP 802 802 802 • Workshops and trainings of village functional and Office water committee to undertake minor SKPY safe drinking repair work and maintenance of water Support water supply systems Department P&RD

• Categorization of households based on current status- Drinking facility available, available but not functional and not available. In first phase 14.4: % of dysfunctional supplies can be made Lead households with 100 100 functional and in second phase new Department improved 100% PHED NRDWP % % supplies could be installed drinking water PHED sources • Strengthening the implementation Swatch Khuwa Pani Yojana in tea garden areas with the help of tea garden management

Sanitation • Mapping and prioritizing the left out pockets

14.5: % of • SBCC activities to promote usage of Lead villages/ wards District sanitation facilities 802 802 802 Department SBM which are open Office • Plan for maintenance of community defecation free toilets PHED • Hands on trainings on sanitation to village masons

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14.6: % of • Mapping and prioritizing the left out

Households 53.8% pockets with special focus on tea 100 100 Lead with access to (NFHS 100% PHED garden areas SBM % % Department safe sanitation 4) • SBCC activities to promote usage PHED facilities sanitation facilities

Lead • Construction of toilets in AWCs under Department 14.7: % of Swachh Bharat Mission Anganwadi and • PHED with adequate Categorization of AWCs based on and functional current status- Sanitation facility, sanitation available and functional, available but facilities 100 100 District not functional and not available. In Support SBM 100% % % Office first phase dysfunctional facilities can Department MGNREGA be made functional and in second phase new facilities could be Social Welfare constructed Department 14.8: % of • Convergence with MGNREGA for schools with construction and maintenance of Education adequate and sanitation facility functional P& RD sanitation facilities • Categorization of health centers based Lead on current status- Sanitation facility- Department 14.9: % of available and functional, available but health centres not functional and not available. In PHED with adequate first phase dysfunctional facilities can and functional Support be made functional and in second sanitation Department phase new facilities could be facilities constructed Health Department

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Personal Hygiene • Providing adequate supplies (soap, 14.10: % of bucket and mugs) to every AWCs Lead Anganwadis • Hand washing posters to be Department with adequate demonstrated at AWCs Social Welfare and functional 100 100 District • Department 100% Community radio to generate awareness ICDS SHGs, AWWs Hand washing % % Office among people Support facilities with • SHGs to create awareness regarding Department water and soap hygiene practices at community level available • Swachhagrahis to demonstrate hygiene practices on VHSND 14.11: % of health centres • Hand washing posters to be with adequate demonstrated at health centres Lead and functional • Community radio to generate awareness Department Handwashing among people Health facilities with • SHGs members to be part of monitoring Department water and soap team in health centres available Education • Awareness programmes through SSA • Counselling of girls parents by members of SHGs on importance of girl 14.12: % of education Lead 21.2% Assam women with 10 23.90 • Improvement of sanitation facilities at Department (NFHS- 36% Agenda SSA or more years % schools for girls 4) 2030 of schooling • Addressing the root cause for high girls Education dropout rate Department

Social Causes

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• SHGs should be sensitised and linked to Lead local NGOs & CBOs for creating Department 14.13: % of awareness in the community for the women age 20- 28.6% subject Social Welfare 24 years (NFHS- • Department married before 4) BCC activities in the vulnerable 18 years communities like tea garden areas Support • Promotion of higher education among Department adolescent girls P&RD Livelihood 14.14: % of • Generating awareness of MGNREGA women with job Lead among women - cards who Department MGNREGA • worked for 100 Strengthening of Women's participation P&RD days in last year in Gram Sabha Planning Meeting DRDA Food and Nutrition Security Lead 14.15: % of Department families linked • Inclusion of all eligible families in PDS PDS with PDS Food & Civil Supplies

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Part C- Cross Cutting Interventions

F. Cross Cutting Strategies

Table 31: Multisectoral District Nutrition Plan (Cross Cutting Strategies)

Program Management Activities Accountability • Conduct regular joint VHSNC meeting by Lead Role ANM,AWW for execution of health and nutrition Health Department activities • Ensure participation of ICDS supervisors and Panchayati Raj members in the meeting • Identify all households with pregnant women and children 0-24 months and mobilise them to attend VHNSDs • Promote regular use of mother-child protection (MCP) card (renaming it “Mother and Child Health Support Department and Nutrition Card (MCHNC)”) for entry of data Social Welfare Department and monitoring progress as well as for counselling 15.1: VHSND Lead Role • Establish procurement system and ensure Social Welfare Department functional weighing machines at all AWCs • Undertake Weight and height measurement of all the children at regular interval– every month for children aged between 6-24 months and once in 3 months for children aged above 24 months. • Identify SAM children with and without medical complications and actions for their management 15.2: Growth • Organise regular training to AWWs for Monitoring recording , plotting and interpretation of growth • ICDS and health functionaries to educate, counsel and support mothers and families for optimal nutrition, healthcare and development of children

• Home visit calendar of AWW, ASHA and ANM should be planned and reviewed • Home visit tools should be designed for AAAs for 15.3: Quality Home effective communication, counselling and Lead Role Visits information gathering Social Welfare and Health • AWW and ASHAS to make home visits for Department educating mothers and other family members to play an effective role in child’s growth and

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development with special emphasis on 0-24 months child.

• Filling up the positions of all health and ICDS functionaries at all level • Appointment of a consultant District Nutrition Lead Role Coordinator for 5 years. Health and Social Welfare 15.5: Human Resources • Appointment of Block Nutrition Coordinators Department • Population based estimates for stock planning of health supplies 15.6: Supply Chain • Streamlining system for timely procurement of Lead Role Management required supplies Concerned Department • Establishment a state Nutrition Resource Centre (SNRC) --Identification of such an institute to conduct capacity building trainings • Training of HR team including 15.7: Capacity Building • mid-level managers of health and ICDS Lead Role functionaries Social Welfare and Health • Roll out of ILA module in local languages/ Department exposure visits • Establish an MIS system and link to SNRC for analysis of MPR and HMIS data • Ensure inclusion of nutrition linked Multisectoral indicators in the line department monthly progress report 15.8: Monitoring • Deputy Commissioner to review the status of Lead Role Evaluation indicators as a part of regular monitoring with Deputy Commissioner and Accountability and health, ICDS and Multisectoral departments. heads of in line department Learning (MEAL) • Documentation of progress made and analysis of on-going best practices Lead Role 15.9: Knowledge • Regular dissemination of information on analysis Concerned departments Management of local data ,progress and way forward • Formation of convergence committee for nutrition at district and block levels • Coordination meeting of all the line departments including Health, Social Welfare, PHED, Lead Role Agriculture, Education, P&RD, Food and Civil Office of Commissioner Supplies in the presence of Principal Secretary, 15.10: Convergence BTC

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e Table 32: Summary of Interventions - Department Wise

S.No Department Intervention

Table no

3 Education 3.1, 3.2, 3.3, 3.4, 14.7, 14.12,

4 P&RD 5.1, 5.2, 5.4, 5.5, 5.6, 7.3, 11.1, 11.2, 11.5, 11.6, 14.3, 14.7, 14.13, 14.14,

5 PHED 9.3, 14.1, 14.2, 14.3, 14.4, 14.5, 14.6, 14.7,

6 Food and Civil Supplies 14.15

7 DRDA 14.14

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Annexure 1: Multisectoral framework to Reduce Malnutrition

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Annexure 2: State Inception Workshop

The state inception workshop on improved Nutrition, Health and Early Childhood Outcomes was organised by Transformation and Development department, Government of Assam, in collaboration with Center for Sustainable Development Goals (CSDGs) and the Coalition for Food and Nutrition Security (CFNS) on 2nd of February, 2019 at Assam administrative staff college, Guwahati. The objective of the workshop was to introduce and orient key stakeholders on Non Lending Technical Assistance (NLTA) from the World Bank to Government of Assam for improving Nutrition, Health, and Early Childhood Outcomes to accelerate SDGs in the state and to renew to the commitment for the same. The workshop was attended by Mr. Alok Kumar, Chief Secretary, Government of Assam, Shri Jishnu Baruah, Additional Chief Secretary, Social Welfare Department, Shri Anurag Goel, Secretary, Health and Family Welfare Department, Dr. J B Ekka, Principal Secretary, Transformation & Development Department, Shri Bhaskar Barua, Former Secretary, Ministry of Agriculture, Government of India amongst other Government officials from State and Districts, Academicians, Civil society Organizations and individual experts from and outside the State. Four technical sessions on (i)Nutrition Scenario and issues and challenges in implementation of ongoing programs- Assam, (ii) Food Security & Issues and challenges in implementation of ongoing programs – Assam, (iii) Efforts towards developing M&E: System for SDGs tracking and (iv)Eat Right India Movementwere conducted during the workshop. Deliberations from each of the sessions have provided valuable inputs which have been incorporated in the plan in the form of suggested interventions.

Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition”

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Key recommendations that emerged from the seminar are:

• To promote Mother and Child Protection (MCP) Card as a counselling tool for Mothers and Family members and renaming it as “Mother and Child Health and Nutrition Card (MCHNC)” • Local food mapping to understand the dietary practices of various communities and Promotion of Kitchen garden to ensure nutritional security at household level

• Social audit of Integrated Child Development Scheme (ICDS) and other nutrition linked schemes

• Infrastructure development of health facilities to ensure privacy for Antenatal Check-ups and Child Care ; Solar electrification of AWCs and health sub centers in char areas

• Improving Mobility of ASHA Workers and ANMs in char areas by providing travel support and other incentives – Department of Health and ICDS should ensure timely reimbursement of travel

Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes”

Recommendations that emerged from the seminar are:

• Panchayats &Rural Development and engagement of NGOs in taking forward the mission for early completion of construction of 1500 AWCs.

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• Convergence between Integrated Child Development Scheme (ICDS) and National Crèches Scheme (NCS) in tea garden areas of Assam

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Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam”

A Policy seminar on “Strengthening Complementary Feeding Practices in Assam” was co- organised by CFNS and CSDGs on 26th of March, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended Senior Government officials of Assam from Health, National Institute of Public Cooperation and Child Development (NIPCCD), Assam State Rural Livelihood Mission (ASRLM) and Social Welfare Department, Civil Society Organizations including Piramal Foundation, UNICEF, Front Line workers from ICDS, Health and ASRLM, Tea Garden Representatives for Assam Brach Indian Tea Association (ABITA), and individual experts in the field of Nutrition.

Key Recommendations that emerged from the seminar are:

• Integration of Self Help Groups under Rural Livelihood Mission with ICDS and Panchayati Raj Institution for effective delivery of Nutrition Services at AWCs and household level

• Capacity building of AWWs, ASHAs and SHGs using incremental learning modules of Poshan Abhiyaan in local languages

• Need for uniformity in the social behaviour change messages communicated to the communities – different messages from different players for the same topic tends to confuse the people

Annexure 6: MCP Card (Feeding Practices)

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For further details please refer to “Indigenous recipes from locally available foods in Assam (Training cum Counselling Tool)

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Multisectoral Result Based District Nutrition Action Plan Goalpara District

Accelerating the Progress of SDGs 2, 3 in the State of Assam 2019-2022

Preface

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Malnutrition (The Hidden Hunger) is widely prevalent in most of the districts of Assam and its manifestation is quite obvious in certain districts of the state also categorized as “Aspirational Districts” by Niti Aayog. These include Dhubri, Goalpara, Baksa, Darrang, Udalguri, Hailakandi and Barpeta. These districts have high prevalence of childhood stunting and wasting. The Government of Assam in its Vision: 2030 document has set a target to make Assam malnutrition free and in this endeavour, the Assam Agenda: 2030 released in 2018 sets the targets for intermittent years with well-defined strategies and actions to be taken. This multisectoral nutrition plan is based on in-depth situational analysis of current status of malnutrition in the district,based on recommendations from the Nutrition Working Group Report, outcome of 6 policy seminars held during January – June 2019 and consultations with stakeholders fromdepartment functionaries and civil society organizations. The plan suggests necessary nutritional interventions for adolescent girls (in school, out of school), pregnant women, children under 5 besides other interventions necessary for creating a healthy environment like safe drinking water, sanitation, prevention of communicable diseases, assured food supply and education. The suggested interventions if implemented meticulously will certainly bring down the high prevalence of existing malnutrition in the district. There are examples from within and outside the country where prevalence of malnutrition has been reduced drastically within a period of 10 years by adopting appropriate strategies and interventions. We hope that implementation of strategies and interventions suggested in this Multi sectoral plan along with robust monitoring will help to achieve a “Malnutrition Free district”.

Dr. R.M Dubey, Dr. Sujeet Ranjan

Professor and Head, Executive Director Centre for Sustainable Development Goals, Coalition for Food & Nutrition Security Guwahati, Assam New Delhi, India

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Table of Contents Acknowledgements ...... 129 The Drafting Team ...... 130 List of Tables ...... 131 List of Figures ...... 132 Abbreviations ...... 133 Executive Summary ...... 135 1. Goalpara District Profile ...... 137 2. Conceptual Framework of Malnutrition...... 138 2.1 Goalpara District Problem Tree ...... 139 2.2 Potential Hotspot for Malnutrition ...... 140 2.3 Nutrition Status of Goalpara, Assam and India ...... 141 2.4 First 1000 Days Analysis of Goalpara District ...... 141 2.5 Status and Determinants of various Malnutrition Indicators ...... 143 3. Objective ...... 144 4. Methodology ...... 145 5. Multisectoral Plan- the Approach, Target Groups and Parameters ...... 146 6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam ...... 148 A. Essential Nutrition Intervention ...... 148 A1: Adolescent Nutrition ...... 149 A2: First 1000 Days ...... 154 A2.1 Pregnant Women ...... 155 A2.2 Lactating Mothers ...... 160 A2. 3 Children Aged 0-6 months ...... 162 A2.4 Children Aged 6-24 Months ...... 165 A3. Children Aged 24-59 Months ...... 170 B. Multisectoral Interventions ...... 172 C. Cross Cutting Strategies ...... 179 Annexure 1: Multisectoral framework to Reduce Malnutrition ...... 181 Annexure 2: State Inception Workshop ...... 182 Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition” ...... 183 Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes”...... 184 Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam”...... 186 Annexure 6: MCP Card ...... 187

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Acknowledgements

The Result Based Multisectoral District Nutrition Action Plan was jointly drafted by Coalition for Food and Nutrition Security (CFNS) and Center for Sustainable Development Goals (CSDGs), Government of Assam in close coordination with the all the concerned departments of Goalpara district. We are indebted to Shri Rajeev Kumar Bora, IAS, Additional Chief Secretary, Transformation and Development Department and Dr. J B Ekka, IAS, Principal Secretary, Transformation and Development Department and their entire team for guidance and continuous support as well as for offering various suggestions through their deliberations made in various policy seminars which were used as useful inputs in preparation of this document. The CFNS and CSDGs team would like to thank all the external contributors who have helped in preparing the plan document Shri Jishnu Baruah, IAS, Additional Chief Secretary, Social Welfare Department, Shri. Hemen Das, ACS, Secretary, Social Welfare Department and Smt. Juri Phukan,IAS, Director, Social Welfare Department for their constant support and guidance. We thank Smt.Varanali Deka, IAS, Deputy Commissioner and Shri IndreswarKolita, ACS, District Development Commissioner, Goalpara District, for their valuable time and support. We are also grateful to all the officials of department particularly the Joint Director, Health Services and his team; the Agriculture Officer and his team, Executive Engineer, PHED and his team; Social Welfare Officer and her team; Project Director, DRDA and his team, Education Officer and his team, District Program Manager, Assam Rural Livelihood Mission and officers of the their team, and the staff of Food & Civil Supplies Department. We are also thankful for ICDS and Health functionaries for extending their support to us during community visit. We would also like to thank all the Individual Experts, State Government officials and Civil Society Organizations working in the Nutrition domain in the state who participated in various policy seminars whose recommendation provided valuable inputs to the plan. We would also like to thank all the members of the Nutrition working group who met and deliberated providing valuable insights into the nutritional scenario of districts of Assam. Non Lending technical Support received from the World Bank is acknowledged.

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The Drafting Team

The Result Based Multisectoral District Nutrition Action Plan has been drafted jointly by the following officials with theCoalition for Food and Nutrition Security (CFNS) and the Center for Sustainable Development Goals (CSDGs).

Coalition for Food and Nutrition Security.

7. Dr Sujeet Ranjan: Executive Director, Coalition for Food and Nutrition Security 8. Ms. Akanksha Doval : Knowledge Management Coordinator 9. Mr. Deepak Ranjan Mishra : Program Coordinator

Centre for SDGs

5. Dr. R.M Dubey : Prof. and Head, Centre for SDGs 6. Shri J.C Phukan : Consultant, Centre for SDGs

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List of Tables

Table 1: Malnutrition Indicators (NFHS 4 Data) ...... 143 Table 2: GoalparaPopulation Projection for Adolescents aged 10-19 Years ...... 150 Table3: Essential Nutrition Interventions-Adolescent Nutrition ...... 150 Table 4: GoalparaPopulation Projection for Pregnant Women ...... 155 Table 5: Essential Nutrition Interventions-Pregnant Women ...... 155 Table 6: GoalparaPopulation Projection for Lactating Mothers ...... 160 Table 7: Essential Nutrition Interventions - Lactating Mothers ...... 160 Table 8: GoalparaPopulation Projection of Children aged 0-6 months ...... 162 Table 9: Essential Nutrition Interventions - Children aged 0-6 months ...... 162 Table 10: GoalparaPopulation Projection for Children aged 6-24 Months and 12-23 Months .... 165 Table 11: Essential Nutrition Interventions -Children aged 6-24 Months ...... 165 Table 12: GoalparaPopulation Projection for Children aged 24-59 Months ...... 170 Table 13: Essential Nutrition Interventions - Children aged 24-59 Months ...... 170 Table 14: Multisectoral Interventions ...... 174 Table 15: Multisectoral District Nutrition Plan (Cross Cutting Strategies) ...... 179

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List of Figures

Figure 1: Goalpara District Map ...... 137 Figure 2: Goalpara Problem Tree ...... 140 Figure 3: Total literacy rate <= 60 ...... 140 Figure 4: Villages with more than 25% of HH with no Assets ...... 141 Figure 5: Comparative Analysis of Nutrition status - Goalpara, Assam and India ...... 141 Figure 6: Performance in indicators of Pregnant Women ...... 142 Figure 7: Performance in indicators of Children ...... 143

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Abbreviations

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SBA Skilled Birth Attendant SBCC Social Behaviour Change Communication SBM Swachh Bharat mission SECC Socio Economic Caste Census SHG Self Help Group SNP Supplementary Nutrition Program SSA Sarva Siksha Abhiyaan THR Take Home Ration VHSND Village Health Sanitation and Nutrition Day WIFS Weekly Iron and Folic Acid Supplementation

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Executive Summary

The multisectoral district nutrition action plan for Goalpara district has been prepared as a part of work envisaged under developing multisectoral plan for three aspirational districts of Assam, out of non-lending technical support received from the World Bank. For preparation of this multisectoral nutrition plan the World Bank engaged Coalition for Food and Nutrition Security (CFNS) for providing technical assistance to the Center for Sustainable Development Goals (CSDGS)and this plan is the outcome of joint efforts of both these organizations. This Nutrition plan is divided in the following Six Sections. Section 1of the plan gives a brief profile of Goalpara District from Census 2011. Section 2 covers the conceptual framework of malnutrition. The section includes a problem tree of Goalpara which shows the problem of malnutrition in the form of a tree highlighting the immediate, underlying and root causes behind the problem and various manifestations in the form of stunting, wasting, underweight and anaemia. The problem tree is based on NFHS 4 data of 2015-16. This section also compares the nutritional status of Goalpara districtwith that of Assam and India. It also shows the performance of Goalpara district in first 1000 days from conception till child’s two years of age and compares the performance of district in first 1000 days with that of state average and best performing district in state for respective parameters. Section 3covers the objectives behind the result based multi sectoral plan. Section 4 describes in details the methodology adopted in preparation of this plan. The plan is the outcome of research and analysis conducted during the period of six months (January toJune 2019). Feedback was sought from district officials of the concerned departments and nutrition experts. Based on feedback as well as extensive desk research, guidance from the steering group and additional interviews with experts, district officials and community members representing diverse communities residing within the district. Section 5 of the plan describes the lifecycle approach adopted to address the child and maternal malnutrition prevalent in the district. The plan is divided into three following parts A, B and C. Part A focuses on nutrition specific intervention, part B refers to nutrition sensitive interventions and part C presents the cross cutting strategies applicable to both nutrition specific as well as nutrition sensitive interventions. The targeted groups and suggested parameters are also reflected for each part A, B and C separately. Section 6 is the main result based multisectoral district nutrition action plan for accelerating the progress of SDGs 2 and 3 in the district. The action plan for each of the parts, as mentioned in section 4, has been dealt in detail section wise. For each of the parts A, B the following details are included in a tabular form –proposed indicators, targets for three years (2019-2022), recommended interventions, the lead and support department to executing the stated interventions and intervention related schemes being implemented by the Government of Assam.

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In part A of the plan, essential nutrition interventions details are provided separately for adolescent girls, and first 1000 days including pregnant women, lactating mothers and infants and young children and 24-59 months old Children. For each of these categories of adolescents, pregnant women, lactating mothers and children, the projected population figures for three years (2019- 2022) have been worked out based on actual figures of census 2011 and average annual growth rate. In part B of the plan, details of multisectoral interventions to be dealt is long term for addressing underlying and root causes of malnutrition, including water, sanitation and personal hygiene; education, social causes, women’s empowerment and food security are presented. In Part Cof the plan details the cross cutting strategies like strengthening of community based events like VHSND, growth monitoring of children at AWCs, organising quality timely home visits by frontline workers, supply chain management and social behaviour change communication strategies. The persistent problem of malnutrition in the district is proposed to be tackled by ICDS and health sectors jointly giving lead for accelerating improvement in indicators pertaining to essential nutrition interventions in first 1000 days of life and critical maternal child health services. Highest priority will be accorded to households having a woman member who is pregnant or having a child 0-24 months. Additionally, using the life cycle approach, the existing policies for care of preschool children, school, children, and adolescent girls will be also actively implemented. Moreover, for addressing the intermediate and underlying causes of undernutrition, other sectors such as PHED, Social Welfare, Education, Panchayat and Rural Development, Food and Civil Supplies Department will be involved.

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11. Goalpara District Profile

The district of Goalpara is situated on the South bank of River Brahmaputra, and it covers an area of 1,824 square kilometres and is bounded by West and East Garo Hills districts of Meghalaya on the South, Kamrup District on the East, Dhubri District on the West and, River Brahmaputra all along the North. The geographical location of the district is between 25053' N to 26030' N latitude and 90007' E to 91005' E longitude. In 1983, Goalpara Civil sub-division was separated from original Goalpara district to form the present Goalpara district. The district thus consists of only one sub division namely Goalpara (sadar) sub-division divided into five revenue circles - Lakhipur, Balijana, Matia, Rangjuli and Dudhnai, and eight development blocks namely Jaleswar, Lakhipur, Kharmuja, Balijana, Krishnai, Matia, Dudhnai and Kushdhowa. There are three towns’ viz. Goalpara (Municipal Board), Lakhipur (Town Committee) and Kharijapikon (Census town) in the district. The total number of villages in the district is 837, of which, 761 are inhabited. There are 81 Gaon Panchayats in the district. The district Goalpara is the home of large number of ethnic and religious communities. In addition to a sizeable section of the Muslim population, the district is inhabited by the ethnic communities such as the Rabha, the Bodo, the Garo, and the Koch Rajbongsi.

Figure 15: Goalpara District Map

Goalpara District at a Glance (Census 2011) Total Population 1,008,183 Total Geographical Area ( In Sq. KM) 1,824 Male (%) 51 Population Density 553 Female (%) 49 Sex Ratio 962 Rural (%) 86 Child Sex Ratio 963 Urban (%) 14 Revenue Villages 837 General Population (Non SC ST) (%) 85.85 Infant Mortality Rate (IMR) 53 SC Population (%) 2.92 Maternal Mortality Rate (MMR) 254 ST Population (%) 11.23 Literacy Rate 63.37 Hindu Population (%) 34.5 Women Literacy Rate 63.13

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Muslim Population (%) 57.4 Christian Population (%) 7.7 Others (%) 0.4

12. Conceptual Framework of Malnutrition

UNICEF’s (1990) conceptual framework of the causality of child malnutrition illustrates the multisectoral nature of the problem. The immediate determinants of malnutrition at the individual level (inadequate dietary intake and disease) are products of underlying causes at the family or household level (insufficient access to food, inadequate maternal and child practices, poor water and sanitation, and inadequate access to quality health services). These, in turn, are influenced by basic causes at a societal level, including the quality and quantity of human, economic, and organizational resources and political environment. The problem tree of Goalpara district in the following section 2.1 highlights the conceptual framework of malnutrition in women and children. Malnutrition is manifested in the form of stunting, wasting, underweight, anaemia and low BMI in women. These outcomes are influenced by a set of immediate causes (nutrition specific) and underlying causes (nutrition sensitive) intervention. Dietary intake and disease status, immediate causes of malnutrition, can be addressed through nutrition specific interventions. The underlying causes of malnutrition i.e. food security, care and feeding practices for mothers and children and health services and healthy environment can be addressed through nutrition sensitive interventions.

Both the nutrition specific and nutrition sensitive interventions are further influenced by interventions which improve socio economic status of women, domestic violence, and education status.

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12.1 Goalpara District Problem Tree

Source: NFHS 4

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Figure 16: Goalpara Problem Tree

12.2 Potential Hotspot for Malnutrition

In the absence of segregated data on malnutrition, during the field work an attempt was made to identify malnutrition pockets in the district based on indirect evidences and for the purpose pockets of high illiteracy and households with no assets was identified. As can be seen from the figures below the pockets more or less coincide with each other. The pockets where illiteracy is high and the households with no assets indicate towards high prevalence of malnutrition. These are the pockets with high prevalence of poverty and hence high prevalence of malnutrition. In order to improve district’s nutritional indicators it is important to focus on these pockets with priority.

Figure 3 and Figure 4 depicts the potential hotspot for malnutrition in the Udalguri district, according to Census 2011 data. Though the prevalence may be different now but the data still can be used to

identify relatively poor performing pockets. • The maximum concentration of Figure 17: Total literacy rate <= 60 illiteracy and household with no

assets coincide in Lakhipur and Balijana blocks, shown in red • These are likely the household with high prevalence of poverty 140 and also malnutrition

• NRC Data for 2018-19 shows that out of 98 admission in the year 72 (73%) % are from

Figure 18: Villages with more than 25% of HH with no Assets

Source: Census 2011 12.3 Nutrition Status of Goalpara, Assam and India

Comparitive Analysis 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 % Severely % Underweight % Stunting U5 % Wasting U5 Wasting U5 U5 Goalpara 42.7 22.1 8.9 39.5 Assam 35.3 16.1 5.9 28.1 India 38.4 21.0 7.5 35.7

Goalpara Assam India

Figure 19: Comparative Analysis of Nutrition status - Goalpara, Assam and India

12.4 First 1000 Days Analysis of Goalpara District

Figure 6 and 7 indicates the performance of Goalpara district in the first 1000 days from conception till child’s 2 years of age. Figure 6 indicates the performance of district across various indicators related to the care of pregnant mother while figure 7 shows the performance of district in indicators related to child care. The figures also helps in comparing the performance of Goalpara districts with that of State average and best performing districts in respective parameters.

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Pregnant Women

ANC in first trimester 100 married before age 18 years 80 4 ANC visit% (%) 60 40 20 Having childFigure protection 20: (MCP) Performance in indicators of Pregnant Women Full ANC Care% card 0

Last birth was protected Consuming IFA for 100 days or against neonatal TT more%

Financial assistance under JSY for institutional Delivery

Goalpara Assam State Best Performance District

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Figure 6: Performance indicators of Pregnant Women

Breastfed within 1 hour of birth 100 80 60 Vitamin A supplementation in 40 Exclusive Breastfeeding up to 6 Last 6 month 20 months 0

Full Immunization Children receiving adequate diet

Goalpara Assam State Best Performance District

Figure 21: Performance in indicators of Children

12.5 Status and Determinants of various Malnutrition Indicators

The table 1 below shows the indicators of malnutrition for India, Assam, Goalpara District and best performing district of Assam in respective indicators. Table 33: Malnutrition Indicators (NFHS 4 Data)

Indicators India Assam Goalpara State Best Performance Stunting Under 5 % 38.4 35.3 42.7 24.6 (Kamrup Metro) Wasting Under 5 % 21 16.1 22.1 6.2 (Dhemaji)

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Severely wasting Under 5 % 7.5 5.9 8.9 0.8 (Dhemaji) Underweight Under 5 % 35.7 28.1 39.5 15.8 (Dhemaji)

Pregnant Women having ANC in 58.6 55.1 57.5 82 (Jorhat) first trimester Pregnant Women having at least 4 51.2 46.4 42.1 75.8 (Jorhat) ANC visit% Pregnant Women receiving Full 21 18.1 16.4 48 (Jorhat) ANC Care% Pregnant Women Consuming IFA 30.3 32 31.6 63.3 (Jorhat) for 100 days or more% Mothers receiving financial assistance under JSY for 36.4 66.1 71.4 90.2 (Dhemaji) institutional Delivery Mothers whose last birth was 89 89.8 83.4 97.1 (Sonitpur) protected against neonatal TT Mothers having mother and child 89.3 98.6 97.2 99.3 (Nalbari) protection (MCP) card Women age 20-24 years married 26.8 30.8 35.8 18.5 (Cachar) before age 18 years (%) Women age 15-19 years who were already mothers or pregnant at the 7.9 13.6 27.2 7 (Sonitpur) time of the survey %

Women who are literate % 68.4 71.8 70.7 84.3 (Kamrup M)

Women having 10 or more years of 35.7 26.2 22.6 48.2 (Kamrup Metro) Schooling

Institutional Births % 78.9 70.6 71.2 95.9 (Jorhat)

80.5 (Goalpara and Breastfed within 1 hour of birth% 41.6 64.4 80.5 Goalpara) Exclusive Breastfeeding up to 6 54.9 63.5 59.6 86.2 (Tinsukia) months% Children receiving adequate diet% 8.7 8.7 12.3 13.8 (Sivsagar)

Full Immunization % 62 47.1 43.7 73 (Sivsagar)

Vitamin A supplementation in Last 60.2 51.3 56.9 67.6 (Karimganj) 6 months%

13. Objective

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14. Methodology

The district nutrition action plan for Goalpara district, Assam is drafted by the Coalition for Food and Nutrition Security (CFNS) in collaboration with Center for Sustainable Development Goals (CSDGs), Government of Assam. The documents is based on desk research and analysis in the last five months, views of district officials of the concerned departments and public health nutrition and development experts, The details are summarised below.

• Review of strategic plans and similar planning documents: The team reviewed the framework of Poshan Abhiyaan for multisectoral district planning, relevant indicators from NFHS4 and similar planning documents like multisectoral district nutrition plan from Dungarpur district, Rajasthan, Aspirational District Plan for Goalpara district, Assam Agenda 2030 of Transformation and Development department, Government of Assam, were also referred to decide on the indicator matrix for the plan. The matrix designed is based on the life cycle approach to address malnutrition with special focus on first 1000 days of life.

• Community Visit: Team visited five diverse villages of Goalpara district- Agia, Balijana, Budhipara, Rokhapara and interacted with the communities, minority dominated villages and Assam MaeghalayaBoder area villages.The visit was undertaken with the objective to understand the status of various services linked to the nutrition like Health, Water and Sanitation, Education and to gain insights into the socio cultural practices and beliefs of people. Extensive Focused Group Discussions (FGDs) were conducted with the Mother’s group (pregnant and lactating mothers), Adolescent girls’ group, and frontline workers of ICDS and Health sectors (AWWs and ASHAs) and the members of the VHNSCs. Team also visited various AWCs, Health Centers and participated in several VHNSD particularly in border areas of the district to understand their functioning and status of various services.

• State and District Inception Workshop: The state and district inception workshop was conducted on 2nd Feb and 5th January respectively. Experts from various fields and very senior officers from the government including Chief Secretary, Assam participated in State inception workshop and presented their views on district nutrition plan.

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• Policy Seminars: Six policy seminars on various topics related to nutrition were conducted in Assam in the period from Jan-2019 to June 2019. Each of the policy seminar was attended by top government officials, individual experts, civil society organizations and field level executives. Feedbacks from the seminars were considered for drafting the multisectoralnutrition plan.

15. Multisectoral Plan- the Approach, Target Groups and Parameters

Group Essential Interventions

Part A- Essential Nutrition Intervention Adolescent Girls Anaemia Screening /IFA Supplement Deworming/ BMI Correction Health, Nutrition, Sanitation, Hygiene Education

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Pregnant Women ANC Care Iron and Calcium Supplementation Deworming Supplementary Nutrition/Take Home Ration ()Family Planning Counselling Weight& Height Measurement- BMI (for weight gain during pregnancy)

Low Birth Weight Care/ Kangaroo Mother Care Continuation of Breastfeeding&Exclusive Breastfeeding 0-6 Months Child Diarrhoea Management (ORS, Zinc and access to safe drinking water and sanitation facility) Care / feeding during illness Weight/ Height Monitoring

IFA Supplementation Deworming 24-59 Months Children Supplementary Nutrition (ICDS) Vitamin A, IFA Part B of the plan covers multisectoral interventions that address underlying and root causes of malnutrition. While implementing a multisectoral plan, priority should be given to essential nutrition interventions and it is only after ensuring their implementation, the district should plan to implement long term multisectoral interventions.Part C of the plans outlines cross cutting strategies for system strengthening.

Part B- Interventions addressing underlying and basic causes of Malnutrition

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Water AWCs, Health Centers, Villages and Households with adequate water supply Sanitation AWCs, Health Centers, Villages and Households with adequate sanitation facilities

PART C- System Strengthening Intervention

6. District Nutrition Action Plan- Accelerating the Progress of SDGs 2, 3 in State of Assam

Essential Nutrition Intervention

G. Essential Nutrition Intervention Essential nutrition interventions or programs address the immediate determinants of malnutrition and child development – adequate food and nutrient intake (diets).Additionally, adequate health/prevention of diseases and is also included since maternal child health interventions are critical for addressing immediate determinants of malnutrition. The interventions are presented using different stages of life

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cycle—adolescent girls, pregnant and lactating women children 0-6 months, 6-24 months and 24-59 months. The plan recognizes and accords highest attention to the first 1000 days of life—from conception to 24 months of age.

A1: Adolescent Nutrition

Box 1: Why Adolescent Nutrition The foundation of adequate growth and development is laid before birth, during early childhood, and in during adolescence. Early marriage and conception below 18 years adversely impacts on women gaining optimum height. In Goalpara District 35.8 % girls are married before 18 years of age and 27.2% of women aged 15-19 years are already mothers (NFHS 4). The high rate of malnutrition in girls not only contributes to increased morbidity and mortality associated with pregnancy and delivery, but also increases the risk of giving birth to low birth-weight babies. This contributes to the intergenerational cycle of malnutrition. Hence, addressing the nutrition needs of adolescents an important step towards breaking the vicious cycle of intergenerational malnutrition.

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Table 34: GoalparaPopulation Projection for Adolescents aged 10-19 Years

Base Population (Census 2011) -1,008,183; Average Annual Growth Rate –2.27%

Population Projection 2019-20 2020-21 2021-22 Total Number of Adolescents 10-19 Years 208320 210558 211976 Total Number of Adolescent Girls aged 10-19 Years 102768 103173 103868

Table35: Essential Nutrition Interventions-Adolescent Nutrition

Data Baseline Schem Indicators Target* Source Intervention Department Resources * e * 2019- 2020 2021 2020 2021 2022 89% 100%. 100% 100% DPM, School Going Adolescents % of adolescent ( HMIS NHM Mobile Block 10-19 years 2018 -19, • Mapping of all private schools, Lead Anemia Health Team at covered with Goalpara) Government schools and junior colleges Departments Mukt PHC level to Albendazole in Bharat cover the the first round in • Ensuring adequate Albendazole supply at Health (MoHF schools February and health centers/sub centers one month prior W,2018) second round in to the biannual dates fixed for Albendazole Education Nodal Teachers August each year distribution Department

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• Maintenance of the track sheet to ensure every adolescent has received the due dosages • Capacity building of AWWs and nodal teachers on program issues like stock

calculations and dissemination, conducting

IEC at regular interval

• IEC materials to be given to teachers to

hold education sessions in schools • Dissemination of IEC material to all schools/juniors college Out of School Adolescents Support Department • Listing of all the out of school adolescents by AWW with the help of ASHA Social Welfare • Micro plan for reaching out to out of school Department children by ASHA and AWW • Ensuring a fixed day distribution of Albendazole to out of school adolescents at AWCs

• Capacity building of AWWs on program

issues like stock calculations and dissemination, conducting IEC at regular interval

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% of adolescent 67% 100% 100% 100% DPM Lead WIFS Mobile Block girls 10-19 years Department RBSK Health Teams ( HMIS School Going Adolescents screened for 2018 -19, • Mapping and inclusion of private schools, ICDS anaemia(school Goalpara) Education, SAG- ANMs, Government schools and junior colleges going +non- (out of ASHAs and school going ) • Regular screening (at least twice a year) for Health school 1072 ASHAs (throughout the anaemia by teachers/ mobile block health Department adolesc year) team for school going adolescent ent girls) Out of School Adolescents Support • Department Listing of all the out of school adolescents by AWW with the help of ASHA Social Welfare • Regular screening (at least twice a year) for Department anaemia by AWWs/ mobile block health teams at AWCs for out of school adolescent Education Department % of eligible 100% 100% 100% DPM • Ensuring Weekly distribution Lead adolescents 10-19 Department WIFS of IFA tablets with special focus on schools 1072 ASHAs, years who receive SAG-for in tea garden areas 2433 AWWs at least 4 blue iron Health out of foliate tablets • Teachers and AWWs to ensure consumption Department schools Nodal Teachers of IFA tablets for school going adolescent adolesce nt girls and out of school adolescent girls Support

respectively. Department

• Display of pictorial communication Education Department materials at school for better consumption Social Welfare outcome. Department Lead % of adolescent • Besides IFA and Deworming following Department 10-19 years whose interventions should be ensured: Health BMI is below • Promote nutrition, health and sanitation Department normal education at schools and AWCs

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• Regular health camps for adolescent girls Support for measuring BMI followed by Department Education counselling sessions Department • Delay age of marriage and conception >18 years Social Welfare • Promote education and retentions in Department schools % of newlywed • Ensure tracking of the newlywed girls by Lead adolescent girls ASHAs with the help of AWWs Department who have received • Ensuring that newlywed adolescent girls family planning Health counselling enter pregnancy with correct BMI and age Department more than 18 years • Strengthening of Adolescent Friendly Health Clinics for counselling *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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A2: First 1000 Days

Box 1: First 1000 days of life- the critical window of Opportunities

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A2.1 Pregnant Women

Table 36: GoalparaPopulation Projection for Pregnant Women

Base Population (Census 2011) - Birth Rate 20.5, Total Population 10.08 lakhs; Average Annual Growth Rate –2.27% (Number of Pregnant Women is estimated 10% more than expected live births) Population Projection 2019-20 2020-21 2021-22 Number of Pregnant Women 27249 27869 28645

Table 37: Essential Nutrition Interventions-Pregnant Women

Data Indicators Baseline* Target* Intervention Department Scheme Resources Source* 2019- 2020- 2021-

2020 2021 2022 % of PW who 16.4% 80% 85% 95% Aspirational • AWWs/ASHAs/ANMs to ensure Lead ICDS 154 ANM (NFHS4) (27642PWs) 1072 ASHA had full District 100% registration of pregnancies Department NHM Antenatal care Action Plan ASRLM 2433 AWWs • SHGs to assist ASHAs to register the ( 4 ANC, at least Health 2487 AWCs 2497 VHNCs 1 TT, IFA tablet ‘Unreached” women in community Department 6745 SHGs or syrup for more • Regular organisation of VHSND by Support than 180 days) AWWs/ASHAS and ANMs for Department ensuring early registration and ANC check-ups Social Welfare Department • ANCs posts to be 100% filled

• Conduct BCC events on importance of P&RD antenatal check-ups and micronutrients. (ASRLM)

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• Organise ANC sessions ninth of every month as per the PMSMA policy of NHM Pregnant women to be weighed and weight to be entered in MCP card and weight gain should be encouraged as per BMI based guidelines Out of total ANC 57.2% 95% 97% 100% Aspirational • ASHAs to ensure 100% registration of Lead ICDS, 154 ANM registered , % (NFHS4) (27642 PWs) District pregnant women Department PMMVY 1072 ASHA registered within Plan. 2433 AWWs • SHGs to facilitate in identification of 1st Health 2487 AWCs trimester(within unreached pregnant women and ensure Department 6745 SHGs 12 weeks) their registration for ANCs • Ensuring early registration of Support pregnancy through incentive of Department PMMVY Social Welfare Department • Effective implementation and timely

fund release of PMMVY P&RD(ASRLM) % of PW 47% 100% 100% 100% DSWO • Ensuring Regular supply of THR Lead ICDS 154 ANM registered who (MIS, Department P&RD 1072 ASHA • Ensuring supply of readymade nutri received 21 days DSWO) Social Welfare (ASRLM) 2433 AWWs of SNP in last mix as THR and not raw rice-dal 2487 AWCs month and have • Ensuring safe and hygienic storage of 6745 SHGs access to THR diversified food • Involve SHGs in production of THR through home through micro finance activities stead food P&RD(ASRLM) production • Promotion of kitchen gardens at AWCs • Promote establishment of kitchen garden at household level and poultry keeping by linking with SHG activities

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% of eligible 31.6% 100% 100% 100% DPM • Regular screening for anaemia levels of Lead NHM 154 ANM (NFHS4) (29096 PWs) 1072 ASHA pregnant women PW at health centers / VHSND Department ICDS who received at ASRLM 2433 AWWs • Ensuring adequate availability (based 2487 AWCs least 180 IFA Health on projected population of PW) of IFA 6745 SHGs tablets during the Department Antenatal period supplies at health centers and sub centers • Tracking of all eligible pregnant women to ensure timely distribution of IFA tablets through ANMs or ASHAs • Appropriate counselling by service providers at the time of distributing IFA tablets for improving compliance Support Department • Organise treatment of women with

severe anaemia for treatment P&RD/Assam • Capacity building of SHGs to engage RLM them in Jan Andolan activities for promoting consumption of IFA. • Regular follow up of PW by ASHA, ANM & AWW for managing side effects and improving IFA compliance • Capacity building of SHGs on basic health & nutrition issues and engaging them for ensuring consumption of IFA % pregnant 75% 100% 100% 100% DPM • Ensuring adequate availability (based Lead NHM 154 ANM women who ( HMIS 2018 - (29096 PWS) Department ICDS 1072 ASHA 19, Goalpara) projected population of PW) of calcium consumed 360 ASRLM 2433 AWWs tablet supplies at health centers and sub calcium tablets Health 2487 AWCs centers. 6745 SHGs during Department pregnancy Support Department

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• Appropriate counselling by service providers for promoting regular consumption Social Welfare Department • Tracking of all eligible pregnant

women to ensure timely distribution of P&RD calcium tablets through ANMs or ASHAs • Regular follow up of PW by ASHA, ANM & AWW for compliance • Capacity building of SHGs to engage them in Jan Andolan activities for promoting consumption of calcium % of PW who 59.5 %( 100% 100% 100% DPM • Adequate number of tablets to be made Lead ICDS, 1072 ASHA 2433 AWWs were given one (HMIS 2018 (29096 PWs) available at all health facilities Department NHM Albendazole -19, Health providing ANC tablet after 1st Goalpara) Department trimester • Health workers to ensure distribution and consumption of tablet Support • Appropriate counselling at VHSND for Department disseminating information and Social Welfare establishing WASH measures Department % of children 13.25% 11% 10% 9% Aspirational • Ensuring age of marriage and Lead NHM - Skilled men Power ( HMIS 2018 -19 with low birth District Plan Department ICDS, (MO/ANM/GNMs) Goalpara) conception not less than 18 years weight (< 2.5 kg) P&RD are available at • Counselling by health and ICDS on each level. Health (ASRLM) adequate and appropriate diversified diet Department - 10 nos. MOs, 46 • Care and day rest during pregnancy GNMs & 163 ANMs are trained.

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• Ensure reduction in physical drudgery and domestic violence with help of Support SHGs Department

Social Welfare Department

*Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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A2.2 Lactating Mothers

Table 38: GoalparaPopulation Projection for Lactating Mothers

Base Population (Census 2011); Birth Rate – 20.5, Total Population – 10.08 lakhs ;Average Annual Growth Rate – 2.27% (Number of lactating mothers are estimated same to be as number of expected live births) Population Projections 2019-20 2020-21 2021-22 Number of Lactating Mothers (0-6 Months) 26642 27262 27882

Table 39: Essential Nutrition Interventions - Lactating Mothers

Data Indicators Baseline* Target* Intervention Department Scheme Resources Source* 2019 2020 2021

2020 2021 2022 % of 71.2% 90% 95% 100% DPM • ANM, ASHAs, AWWs to mobilise and Lead ICDS, - Trained & institutional (NFHS4) 26181P Department NHM, Skilled men Ws) support PW for institutional deliveries deliveries in ASRLM Power • Ambulance facility to be strengthened – (MO/ANM/G the last month Health Mrityunjoy 108 services, especially at NMs) are Department available at tea garden areas. each level. • Strengthening the implementation of - At present 22 JSY and PMMVY nos. of PHCs Support providing • Timely payment on performance based Department 24x7 hr incentives to ASHAs for institutional delivery deliveries. services, out Social Welfare of 31 no’s of • Special higher incentives to ASHAs to Department PHCs be institutionalised in hard to reach conducting Institutional areas (border areas) Delivery,

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• Engagement of SHGs to promote the - 10 nos. MOs, importance of institutional deliveries 46 GNMs & 163 ANMs are trained.

% of deliveries 6.5% 85% 95% 100% Aspirational • Increasing the number of SBAs Lead HBNC at home ( HMIS 2018 District Plan. Department -19, • Regular trainings for SBAs attended by Goalpara) skilled birth • Incentives to SBAs for safe deliveries Health attendant Department

% of lactating 47% 100% 100% 100% DSWO • Ensuring Regular supply of THR Lead ICDS, AWWs MIS, DSWO mothers • Ensuring safe and hygienic storage of Department ASRLM SHGs received 21 THR days of Social Welfare SNP(THR) in • Involve SHGs in production of THR Department last month through micro finance activities Support Department

P&RD

*Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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A2. 3Children Aged0-6 months

Table 40: GoalparaPopulation Projection of Children aged 0-6 months Base Population (Census 2011) 0-6 Years Population – 1.72 lakhs; Average Annual Growth Rate –2.27% Population Projections 2019-20 2020-21 2021-22 Number of Children aged 0-6 Months 26642 27262 27882

Table 41: Essential Nutrition Interventions - Children aged 0-6 months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019 2020 2021

2020 2021 2022 % of children 80.5% 100% 100% 100% Aspirational • Ensuring early initiation of Lead NHM- JSY - Skilled men (NFHS -4) District Plan initiated breastfeeding in 100% institutional Department PMMVY Power breastfeed Health MAA (MO/ANM/G deliveries within one Department NMs) are • AWW to support early initiation of available at hour birth AWWs each level. breastfeeding in home deliveries .No - 10 nos. MOs, marketing of Infant formula 46 GNMs & • Lactation Management Training to 163 ANMs are Support trained.1072 the SBAs Department ASHA & 2433 • Ensure early initiation of Breast AWWs are in the field. Feeding in100% institutional deliveries Social Welfare • IEC material on breast-feeding to be Department displayed on ANC ward/ delivery ward and other health facilities.

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• ANMs/ ASHAs to provide breastfeeding counselling during ANC contact at VHSND

% of children 59.6% 70% • Educating the mothers and other Lead NHM, - Skilled men (NFHS-4) under 6 months family members about the importance Department MAA Power exclusively Health (MO/ANM/G of exclusive breastfeeding breastfed Department NMs) are • Every immunisation contact should available at each level. be utilised for breastfeeding - 10 nos. MOs, counselling and assessing status.10 46 GNMs & steps to breastfeeding to be displayed 163 ANMs are in every health centres/ VHSND trained.1072 ASHA & 2433 forums. AWWs are in • Lactation support services/ lactation Support the field. counsellors to be provided at health Department centers for timely management of any Social Welfare lactation problem Department • ANMs/ ASHAs to provide breastfeeding counselling during VHSND and ANC checkups&Support for breastfeeding to working mothers in areas like tea garden areas % of children 100% 100% 100% 100% Aspirational • Ensuring supply of adequate ORS Lead NHM Sufficient ORS 0-60 months ( HMIS District Department PHED packets are 2018 -19, packets and zinc tablets at AWCs and available in the with diarrhoea Action Plan Health Goalpara) with ASHAs drug Store and in the last two Department distributed to weeks who • VHSND to be used for creating Support the ANM, AWW received ORS knowledge about diarrhoea Department & ASHA. and Zinc management and preparation of ORS

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and minimum 14 days consumption Social Welfare of zinc tablets. Department • Home visits to children with PHED diarrhoea treated by health workers for counselling of family members on diarrhoea management/demonstration • Demonstration on VHSNDs regarding regular handwashing with soap before cooking and eating • Ensuring the coverage of safe drinking water facility&Promote the usage of sanitation toilets % of Children • Weighing machine to be made available ICDS AWWs, 0-60 months at all AWCs/VHSND forums for regular Lead ASHAs and that have their weight and height measures & Trainings Department VHSNC weight of all AWWs and ASHAs on weight members measured, measurement and plotting Social Welfare monitored(ente • Counselling on promotion of mothers by Department red in growth AWWs with the help of ASHAs on chart) every importance of growth monitoring. month in the Prioritised home visits to children whose last quarter Support growth have faltered by AWWs and Department ASHAs & Identification of children Health suffering from severe acute malnutrition Department (SAM) and taking appropriate actions. *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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A2.4 Children Aged 6-24 Months

Table 42: GoalparaPopulation Projection for Children aged 6-24 Months and 12-23 Months Base Population (Census 2011) 0-6 Years Population -1.72 lakhs; Average Annual Growth Rate –2.27% Population Projections 2019-20 2020-21 2021-22 Number of Children aged 6-24 Months 39963 40893 41823 Number of Children aged 12-23 Months 20145 20487 21228

Table 43: Essential Nutrition Interventions -Children aged 6-24 Months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019- 2020 2021

2020 2021 2022 % of children 12.3% • Organize Annaprashan Diwas once in a ICDS AWWs, NFHS -4 who were month in AWCs to promote complementary Lead NHM ASHAs initiated and VHSNC feeding and demonstrate healthy recipes Department complementary members • feeding(Solid or AWWs and ASHAs to counsel mothers and Social Welfare semi- solid food family members on adequate diet- quality and Department and breast milk) quantity after 6 months • Encourage preparation of traditional nutrimix through home level preparation • Measles fist dose contact with mother to be

utilised for assessing the status of Health complementary feeding of child Department • Undertake regular home visits for counselling on complementary feeding at home level by

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ASHAs,as per the policy on Home Based Support Care in Young Children,NHM Department • Recipe demonstration by AWWs or in Assam RLM VHSND • List of locally available complementary foods to be given to children • Regular trainings for AWWs and ASHAs to ensure knowledge and skill retention on complementary feeding

% of children • Counselling by ICDS and health workers to Lead ICDS, AWWs, SHGs consuming at stress on diet diversity Department ASRLM least 4+ food • Promote establishment of SSBs at household groups ICDS, level of such children and poultry keeping by Health linking with SHG activities. P&RD • Training of SHGs to counsel on adequate diet- dietary diversity and minimum meal Support frequency Department

• SHGs to establish kitchen gardens and Social Welfare provide support to AWCs on demonstration department days % of children (9- 56.9% DPM • Ensuring adequate stock availability (based Lead NHM 154 ANM, 2433 24months) who (NFHS - 4) Department ICDS AWW available. on population projection) at health centres 1100 VHNDs can received at least Health • Institutional Bi-annual distribution of be used as a one dose of department platform. Vitamin-A on two fixed months, 6 months vitamin Ain the Support preceding 6 apart from each other Department months • AWW to prepare due lists of children 9-60 Social Welfare months with the help of ASHAs and ANMs department

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• Children not covered in 6 monthly drive to be administered vitamin A doses on VHSND

% children 6-24 100% DPM • AWW to prepare list of beneficiaries with the Anemia 154 ANM, 2433 ( HMIS months provided Lead Mukt AWW available. 2018 -19, help of ASHA and ANM 1100 VHNDs can (IFA) syrup (Bi Department Bharat Goalpara) • Ensuring adequate stock availability (based be used as a weekly) in the platform. preceding month on population projection) at health centres Social Welfare • Ensuring mechanism for distribution of syrup Department to mothers during VHSNDs by ANM/ASHAs Support Department

Health

Children age 12- 43.7% 97% 99% 100% Aspirational • ASHA to get list of children to be fully Lead NHM, Availability of the 23 months fully (NFHS-4) District Plan Department ICDS, Man power along immunised from AWW with the vaccine immunized ASRLM • Home visits by ASHAs to follow up for and cold chain (BCG, measles, Health points good mobilizing caregivers for attending and 3 doses each Department supply & of polio and immunization sessions. management of DPT) (%) • the vaccine in the Tracking and micro planning to reach out all district. children at household level- head count survey specially at tea garden areas Support • Ensuring migratory population and Department temporary settlements are also included in the immunization plan Social Welfare • Engagement of SHGs/ community Department, influencers/leaders to promote awareness regarding full immunization and mobilizing P&RD caregivers to attend immunization sessions on fixed days • Scaling up eVIN

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% children 6-24 • Introduction of policy for production of Lead ICDS AWWs, months Nutrimix as THR supply to ICDS. Department SHGs registered who • Regular supply of THR to ICDS and weekly received SNP Social Welfare supply to children Capacity building of SHGs (THR) for 21 department days in the last to take up THR as a micro finance activity month Support Department

P&RD

% of children 6- • Regular growth monitoring at AWCs Lead ICDS, AWWs, 36 months Department NHM ASHAs • Training of AWWs to identify MAM and screened for VHSND SAM cases MAM and SAM Social Welfare committee during last Department members month Support Department Health Department

% of children • Counselling on home based care and adequate Lead ICDS, AWWs, with MAMthat feeding by AWWs and ASHAs Department NHM ASHAs receive Social Welfare • Behavioural change sessions on child health appropriate Department interventions at and nutrition by AWWs Support community level Department Health Department % of children • Identifying SAM children who fail appetite Lead ICDS, AWWs, with SAM and test or with bilateral oedema, Department NHM ASHAs medical complications Health

168 treated at • Financial support to mother bringing child for Support Nutrition treatment at NRCs Department Rehabilitation • Follow up after discharge from NRC Centres (NRCs) Social Welfare • Ensure availability of dieticians at NRC at all Department times • Induction training for NRC team (doctor, dietitian/ nutritionist, nurses, cook and helpers) to gain proper techniques and skills % of children • Provision of double THR ration of ICDS to Lead with SAM and SAM cases with no medical complications Department without medical • Monitoring w eight gain complications Social Welfare • treated at Imparting nutrition and health education Department community level through food demonstration and preparation • Promotion of kitchen garden to ensure household level food security Support • Capacity building of primary caregiver to Department look after the child at home Health Department % of children (6- • Ensuring adequate Albendazole supply Lead ICDS 24 months) who Department WIFS • Maintenance of track sheet to ensure every received child receives the due 6 monthly dosages Albendazole Social Welfare • Dissemination of IEC material to community Support centres Department

Health Department *Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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A3. Children Aged 24-59 Months

Table 44: GoalparaPopulation Projection for Children aged 24-59 Months Base Population (Census 2011) 0-6 Years population -1.72 lakhs; Average Annual Growth Rate –2.27% Population Projections 2019-20 2020-21 2021-22 Number of Children aged 24-59 Months 95680 97975 99560

Table 45: Essential Nutrition Interventions - Children aged 24-59 Months

Baseline Data Indicators Target* Intervention Department Scheme Resources * Source* 2019 2020- 2021-

2020 2021 2022 % of children • Organising biannual administration of vitamin Lead NHM AWWs, (24-59months) A supplements Department ICDS ASHAs who received • AWW to prepare due lists of children with the Vitamin A help of ASHA and ANM Social Welfare • Left out children to be given doses on Department VHSND Support • Ensuring adequate stock availability (based on Department population projection) at health centres % children 24- • AWW to prepare list of beneficiaries with the Lead NHM : 59 months help of ASHA and ANM Department Anaemia provided (IFA) • Ensuring adequate stock availability (based on Social Welfare Mukt syrup (Bi population projection) at health centres Department Bharat weekly) in last • Ensuring mechanism for distribution of syrup month to mothers during VHSND Support Department Heath

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% children 24- • Ensuring supplementary feeding to ICDS Lead 36 months enrolled children 24-36 months Department registered who • Engagement of SHGs to ensure production of Social Welfare received SNP vegetables as micro finance activity Department (THR) for 21 • etc for SNP for 24-36 months children enrolled days in the last with ICDS Provision of additional SNP to month severe underweight children

*Baseline, Target and Data Source to be filled by lead department district officials based on department’s target for subsequent years

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Part B- Multisectoral interventions to address underlying and root causes of malnutrition

H. Multisectoral Interventions

Box 3: Why Multisectoral Interventions to Improve Nutrition Water, Sanitation and Personal Hygiene (WASH) - WASH and nutrition programs depend on each other to achieve impact. For example, diarrhoea is one of the biggest killers of children in South Asia. These deaths are largely preventable through good nutrition, hand washing with soap, safe drinking water and basic sanitation, and vaccination. Proper hand washing with soap at critical times, and especially before preparing food and feeding a child, is one of the most effective and cost- efficient ways to prevent diarrhoea. Improvements in sanitation, especially the elimination of open defecation, have been associated with a decrease in stunting .When nutrition programs emphasize water, sanitation, and hygiene—and WASH programs emphasize hand washing before preparing food, feeding a child, and elimination of open defecation—both programs can maximize impact. Agriculture: Research in India has shown that increased crop diversification improves dietary diversification in the home and helps children recover from growth faltering. As agricultural production grows and diversifies, households experience increased food security and better nutrition, leading to increases in human capital and productivity. Diversified agricultural production has the potential to improve access to more diverse and nutritious foods, a key component of meeting the “Minimum Acceptable Diet” for children. Agricultural programs that focus on producing energy- rich staple foods can also be more effectively designed to reduce under nutrition by promoting crops that reduce vulnerability to droughts and extreme climate, increase yields, or improve nutritional value.5By putting more focus on nutrition outcomes (i.e., by including nutrition objectives at the outset), agricultural interventions can improve the capacity, productivity, and future prospects of agricultural workers—and also contribute to reducing under nutrition. Education: Children can’t learn and succeed in their education without a solid nutritional foundation: Good nutrition is essential for full development of cognitive and motor skills, behavioural abilities, IQ, and physical growth. Early childhood under nutrition, including poor nutrition in the womb, often results in stunting and can have permanent developmental effects on a child. Stunted children are also less likely to complete school. Studies from 79 countries show that every 10 percent increase in stunting corresponds to an 8 percent drop in the proportion of children completing primary school. When education programs invest in nutrition, it improves academic achievement. One example is school feeding programs, which can improve learning and academic performance. Students participating in school feeding and take-home ration programs have improved cognition. These programs yield the greatest impact when coupled with other programs like deworming, micronutrient supplementation, and fortification. Integrating nutrition programs into school curriculum initiates life-long healthy behaviours. Children connect what they learn in school to their broader communities by bringing messages home to their families and promoting good nutrition and healthy habits in the household.

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interventions are included in section A since nutrition and health are immediate determinants of malnutrition and are interrelated.

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Table 46: Multisectoral Interventions

Data Indicators Baseline Target Intervention Department Scheme Resources Source 2019 2020 2021-

2020 2021 2022 Wash

Drinking Water % of 2491 2491 2491 PHED • Categorization of AWCs based on Lead AWCs AWCs AWCs Anganwadi current status- Drinking facility Department NRDWP with adequate, available, available but not functional functional and and not available. In first phase PHED safe drinking dysfunctional supplies can be made water supply functional and in second phase new Support supplies could be installed Department • Testing of water supply at AWCs Social Welfare Department

% of health 199 199 199 PHED • Categorization of health Centers based Lead NRDWP centres with Healt Healt Health Department h h Institut on current status- Drinking facility adequate, Instit Instit ions available, available but not functional functional and utions utions and not available. In first phase PHED safe drinking dysfunctional supplies can be made water supply functional and in second phase new supplies could be installed Support Department

Health Department

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% of 837 837 837 PHED • The water supply schemes should possibly Lead NRDWP villages/wards village village Village be implemented on community basis and Department SKPY s s s with adequate, demand driven wherever feasible. Public PHED functional and participation is mandatory with the safe drinking VWSC’s for source selection and sustainability framework, social mapping, water supply Support household beneficiaries, estimate Department preparation, etc. The transparency will create a massive awareness among the P&RD communities which would further create a sense of ownership amongst the beneficiaries which will be helpful in effective monitoring and O&M for its sustainability purpose. • Workshops and trainings of village water committee to undertake minor repair work and maintenance of water systems.

% of households 87.1% 21707 21707 21707 PHED • The water supply schemes should possibly Lead NRDWP with improved 7 HHs 7 HHs 7HHs be implemented on community basis and Department drinking water demand driven wherever feasible. Public sources participation is mandatory with the VWSC’s PHED for source selection and sustainability framework, social mapping, household beneficiaries, estimate preparation, etc. Categorization of households based on current status- Drinking facility available, available but not functional and not available. In first phase dysfunctional supplies can be made functional and in second phase new supplies could be installed. • Create a sense of ownership amongst the beneficiaries which will be helpful in effective monitoring and O&M.

Sanitation

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% of villages/ 837 837 837 PHED • Mapping and prioritizing the left out SBM& wards which are village village villages MGNREGS s s pockets Lead open defecation • SBCC activities to promote usage of Department free sanitation facilities • Plan for maintenance of community PHED toilets • Hands on trainings on sanitation to village masons % of 46.2% 21707 21707 21707 PHED • Mapping and prioritizing the left out SBM& Households 7 HHs 7 HHs 7 MGNREGS HHs pockets with special focus on tea Lead with access to garden areas Department safe sanitation • SBCC activities to promote usage PHED facilities sanitation facilities % of 2491 2491 2491 PHED • Construction of toilets in AWCs under SBM Anganwadi and AWCs AWCs AWCs& MGNREGA & 1598 Swachh Bharat Mission Lead with adequate & 1598 1598 Schools • Categorization of AWCs based on Department and functional Schoo Schoo current status- Sanitation facility, sanitation ls ls available and functional, available but PHED facilities not functional and not available. In first phase dysfunctional facilities can be Support made functional and in second phase Department new facilities could be constructed % of schools • Convergence with MGNREGA for Social Welfare with adequate construction and maintenance of Department and functional sanitation facility sanitation Education facilities

P& RD % of health 199 199 199 PHED • Categorization of health centers based on Lead centres with Healt Healt Health Department h h Institut current status- Sanitation facility- adequate and Instit Instit ions available and functional, available but PHED functional utions utions not functional and not available. In first

176 sanitation phase dysfunctional facilities can be Support facilities made functional and in second phase Department new facilities could be constructed Health Department

Personal Hygiene % of 2491 2491 2491 PHED • Providing adequate supplies (soap, Lead ICDS SHGs, AWWs AWCs AWCs AWCs Anganwadis bucket and mugs) to every AWCs Department with adequate • Hand washing posters to be Social Welfare and functional demonstrated at AWCs Department Hand washing • Community radio to generate awareness Support facilities with among people Department water and soap • available SHGs to create awareness regarding hygiene practices at community level • Swachhagrahis to demonstrate hygiene practices on VHSND % of health 199 199 199 PHED • Hand washing posters to be Lead centres with Healt Healt Health Department h h Institut demonstrated at health centres adequate and Instit Instit ions • Community radio to generate awareness Health functional utions utions among people Department Handwashing • SHGs members to be part of monitoring facilities with team in health centres water and soap available

Education % of women Assam • Awareness programmes through SSA SSA with 10 or more Agenda • Counselling of girls parents by members Lead years of 2030 of SHGs on importance of girl education Department schooling • Improvement of sanitation facilities at schools for girls Education • Addressing the root cause for high girls Department dropout rate

Social Causes 177

% of women age 31.38 • SHGs should be sensitised and linked to Lead 20-24 years (NFHS- local NGOs & CBOs for creating Department married before 4) awareness in the community for the 18 years subject Social Welfare • BCC activities in the vulnerable Department communities like tea garden areas Support • Promotion of higher education among Department adolescent girls P&RD Livelihood

% of women • Generating awareness of MGNREGA Lead MGNREGA with job cards among women - Department who worked for • Strengthening of Women's participation P&RD 100 days in last in Gram Sabha Planning Meeting year Food and Nutrition Security

% of families • Inclusion of all eligible families in PDS Lead PDS linked with PDS Department

Food & Civil Supplies

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Part C- Cross Cutting Interventions

I. Cross Cutting Strategies

Table 47: Multisectoral District Nutrition Plan (Cross Cutting Strategies)

Program Management Activities Accountability VHSND • Conduct regular joint VHSNC meeting by Lead Role ANM,AWW for execution of health and Health Department nutrition activities • Ensure participation of ICDS supervisors and Support Department Panchayati Raj members in the meeting Social Welfare • Identify all households with pregnant women Department and children 0-24 months and mobilise them to attend VHNSDs • Promote regular use of mother-child protection (MCP) card (renaming it “Mother and Child Health and Nutrition Card (MCHNC)”) for entry of data and monitoring progress as well as for counselling

• Establish procurement system and ensure Lead Role functional weighing machines at all AWCs Social Welfare Department • Undertake Weight and height measurement of Growth Monitoring all the children at regular interval– every month for children aged between 6-24 months and once in 3 months for children aged above 24 months. • Identify SAM children with and without medical complications and actions for their management • Organise regular training to AWWs for recording , plotting and interpretation of growth • ICDS and health functionaries to educate, counsel and support mothers and families for optimal nutrition, healthcare and development of children

Quality Home Visits • Home visit calendar of AWW, ASHA and Lead Role ANM should be planned and reviewed Social Welfare and Health • Home visit tools should be designed for AAAs Department for effective communication, counselling and information gathering • AWW and ASHAS to make home visits for educating mothers and other family members to play an effective role in child’s growth and

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development with special emphasis on 0-24 months child.

Social Behaviour • Development of SBCC strategy for the state’ Lead Role Change • Hire a special expert team /organisation to Health and Social Welfare Department Communication(SBCC) develop SBCC strategy and provide rollout support. SBCC support training, advocacy and communication materials to be standardised

Human Resources • Filling up the positions of all health and ICDS Lead Role functionaries at all level Health and Social Welfare • Appointment of a consultant District Nutrition Department Coordinator for 5 years. • Appointment of Block Nutrition Coordinators Supply Chain • Population based estimates for stock planning Lead Role Management of health supplies Concerned Department • Streamlining system for timely procurement of required supplies Capacity Building • Establishment a state Nutrition Resource Lead Role Centre (SNRC) --Identification of such an Social Welfare and Health institute to conduct capacity building trainings Department

• Training of HR team including • mid-level managers of health and ICDS functionaries • Roll out of ILA module in local languages/ exposure visits Monitoring Evaluation • Establish an MIS system and link to SNRC for Lead Role Accountability and analysis of MPR and HMIS data Deputy Commissioner and Learning (MEAL) • Ensure inclusion of nutrition linked heads of in line department Multisectoral indicators in the line department monthly progress report • Deputy Commissioner to review the status of indicators as a part of regular monitoring with health, ICDS and Multisectoral departments. Knowledge • Documentation of progress made and analysis Management of on-going best practices Lead Role • Regular dissemination of information on Concerned departments analysis of local data ,progress and way forward Convergence • Formation of convergence committee for Lead Role nutrition at district and block levels Office of Commissioner • Coordination meeting of all the line departments including Health, Social Welfare, PHED, Agriculture, Education, P&RD, Food and Civil Supplies in the presence of Principal Secretary, BTC

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Annexure 1: Multisectoral framework to Reduce Malnutrition

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Annexure 2: State Inception Workshop

The state inception workshop on improved Nutrition, Health and Early Childhood Outcomes was organised by Transformation and Development department, Government of Assam, in collaboration with Center for Sustainable Development Goals (CSDGs) and the Coalition for Food and Nutrition Security (CFNS) on 2nd of February, 2019 at Assam administrative staff college, Guwahati. The objective of the workshop was to introduce and orient key stakeholders on Non Lending Technical Assistance (NLTA) from the World Bank to Government of Assam for improving Nutrition, Health, and Early Childhood Outcomes to accelerate SDGs in the state and to renew to the commitment for the same. The workshop was attended by Mr. Alok Kumar, Chief Secretary, Government of Assam, Shri Jishnu Baruah, Additional Chief Secretary, Social Welfare Department, Shri AnuragGoel, Secretary, Health and Family Welfare Department, Dr. J B Ekka, Principal Secretary, Transformation & Development Department, Shri Bhaskar Barua, Former Secretary, Ministry of Agriculture, Government of India amongst other Government officials from State and Districts, Academicians, Civil society Organizations and individual experts from and outside the State. Four technical sessions on (i)Nutrition Scenario and issues and challenges in implementation of ongoing programs- Assam, (ii) Food Security & Issues and challenges in implementation of ongoing programs – Assam, (iii) Efforts towards developing M&E: System for SDGs tracking and (iv)Eat Right India Movement were conducted during the workshop. Deliberations from each of the sessions have provided valuable inputs which have been incorporated in the plan in the form of suggested interventions.

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Annexure 3: Policy Seminar on “Multisectoral Convergence for Improved Nutrition”

Key recommendations that emerged from the seminar are:

• Social audit of Integrated Child Development Scheme (ICDS) and other nutrition linked schemes

• Infrastructure development of health facilities to ensure privacy for Antenatal Check-ups and Child Care ; Solar electrification of AWCs and health sub centers in char areas

• Improving Mobility of ASHA Workers and ANMs in char areas by providing travel support and other incentives – Department of Health and ICDS should ensure timely reimbursement of travel

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Annexure 4: Policy Seminar on “Enabling Environment for Anganwadi Centers for Improved Nutrition Outcomes”

Recommendations that emerged from the seminar are:

• Panchayats &Rural Development) and engagement of NGOs in taking forward the mission for early completion of construction of 1500 AWCs.

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• Convergence between Integrated Child Development Scheme (ICDS) and National Crèches Scheme (NCS) in tea garden areas of Assam

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Annexure 5: Policy Seminar on “Strengthening Complementary Feeding Programs in Assam”

A Policy seminar on “Strengthening Complementary Feeding Practices in Assam” was co- organised by CFNS and CSDGs on 26th of March, 2019 at Assam Administrative Staff College, Guwahati. The seminar was attended Senior Government officials of Assam from Health, National Institute of Public Cooperation and Child Development (NIPCCD), Assam State Rural Livelihood Mission (ASRLM) and Social Welfare Department, Civil Society Organizations including Piramal Foundation, UNICEF, Front Line workers from ICDS, Health and ASRLM, Tea Garden Representatives for Assam Brach Indian Tea Association (ABITA), and individual experts in the field of Nutrition.

Key Recommendations that emerged from the seminar are:

• Integration of Self Help Groups under Rural Livelihood Mission with ICDS and Panchayati Raj Institution for effective delivery of Nutrition Services at AWCs and household level

• Capacity building of AWWs, ASHAs and SHGs using incremental learning modules of Poshan Abhiyaan in local languages

• Need for uniformity in the social behaviour change messages communicated to the communities – different messages from different players for the same topic tends to confuse the people

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Annexure 6: MCP Card

For further details please refer to “Indigenous recipes from locally available foods in Assam (Training cum Counselling Tool)

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