World Bank Document

Document of The World Bank

FOR OFFICIAL USE ONLY AA. 3zS3 /4

Public Disclosure Authorized oo iZ / -73 -/ Report No.8568-IN

STAFF APPRAISALREPORT Public Disclosure Authorized INDIA

INTEGRATEDCHILD DEVELOPMENTSERVICES PROJECT

JUNE 1, 1990 Public Disclosure Authorized

Asia CountryDepartment IV (India)

Public Disclosure Authorized Population,Human Resources,Urban and Water OperationsDivision

Thisdocument has a restited distributionand may be usedby redieus ony In the pedormanc of their officiaduties. Its contents may not othenwie be dislosed without Wodd Bank authnoroion. CURRENCYEQUIVALENTS

Currency Unit = Indian Rupee (Rs) US$ 1.00 = Rs 17 Rs 1.00 - USS 0.059

WEIGHTS AND MEASURES

Metric System

FISCAL YEAR

April 1 - March 31

ABBREVIATIONS AND ACRONYMS

AID - United States Agency for International Development AP Andhra Pradesh AR , Anganwadi (Village ICDS Center) AWW = Anganwadi Worker CARE = Cooperative for American Relief Everywhere CDPO = Child Development Project Officer GOI Government of India ICDS = Integrated Child Development Services IEC - Information, Education and Communication IMR - Infant Mortality Rate LBW - Low birth weight MDM = Mid-day Meals Program MM - Mahila Mandal (women's society) NFI = Nutrition Foundation of India NGO = Non-government Organization NORAD Norwegian Agency for International Development NIPCCD = National Institute of Public Cooperation and Child Development NMP Noon Meals Program PDS Public Distribution System PMO Project Management Office SIDA Swedish International Development Agency SNP - Special Nutrition Program TINP - Tamil Nadu Integrated Nutrition Project UNICEF = United Nations Children's Fund WCD - Department of Women and Child Development, GOI WILL 'Women's Integrated Learning for Life program FOR OFCIAL USE ONLY

- i -

INDIA

INTEGRATEDCHILD DEVELOPMENT SERVICES PROJECT

Table of Contents

Page No.

LOANICREDITAND PROJECT SUMMARY ...... ii

I. BACKGROUND

A. Introduction ...... B. National Nutrition Programs ...... 3 C. Nutrition Programs in Andhra Pradesh ...... 7 D. Nutrition Programs in Orissa ...... 8 E. Learning from Other Experiences ...... 9 F. National Nutrition Policy and Strategy ...... 11 G. Other Donor Role ...... 12 H. Bank Role and Assistance Strategy ...... 12

II. THE PROJECT

A. Goals and Objectives ...... 14 B. Scope ...... 15 C. Strategy ...... 15 D. Project Description ...... 17 Service Delivery ...... 17 E. Communications ...... 23 F. Community Mobilization ...... 24 G. Project Management,Monitoring and Evaluation...... 25

III. PROJECT COSTS. FINANCING AND IMPLEMENTATION

A. Cost Estimates ...... 27 B. Financing Plan ...... 29 C. Recurrent Cost Implications ...... 29 D. Project Implementation ...... 30 E. Disbursements ...... 31 F. Procurement ...... 32 G. Accounting and Auditing ...... 34

This report is based on the findings of an appraisal mission to India from January 19-February 22, 1990 comprising of Mr. James Grecne (Principal Nutrition Specialist-MissionLeader), Mr. Richard Heaver (Senior Operations Officer), and the following consultants:Mr. Jay Satia (Management Specialist),Drs. J. Kevany and W. Cutting ( Public Health Specialists),Mr. S. Mehra (CommunicationSpecialist), Ms. H. Chatterjee (Women's Program Specialist),and Mr. M. N. Murthy (FinancialAnalyst). Mss. J. Bhasin (NDO), Vivian Mendoza and Paula Walden assisted in preparing the report.

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. - ii -

Pane h'o.

IV.BENEFITS AIDRISKS ...... 36

V. AGREEMENTSREACHED AND RECOMMENDATION...... 38

TABLES

3.1 Estimated Project Costs by Component ...... 25 3.2 Estimated Project costs by Category of Expenditure . . . . . 26 3.3 Financing Plan ...... 28

ANNEXES 1. Integrated Child Development Services Scheme (ICDS) . . . 37 2. Impact and Process Objectives ...... 43 3. Details of Project Areas ...... 47 4. Training ...... 52 5. Communications Component .. 60 6. Community Mobilization through Women's Programs . . . . 65 7. Detailed Project Cost Estimates ...... 69 8. Project Implementation Schedule ...... 78 9. Percentage of Incremental Operating Costs For Bank Group Financing ...... 82 10. Forecast of Annual Expenditures and Disbursements . . . 83 11. Selected Documents in the Project File ...... 84 - iii. -

INDIA

INTEGRATED CHILD DEVELOPMENTSERVICES PROJECT

Loan/Credit and Project Summary

Borrower: India, acting by its President

Beneficiary: Governmentsof Andhra Pradesh and Orissa

Amountt IBRDt US$10 million equivalent IDA: SDR 93.6 million (US$96 million equivalent)

Terms: IBRD: 20 years, including5 years' grace, at standard variable interestrate

IDA: Standard,with 35 years' maturity

OnlendinigTerms: Governmentof Iadia to Andhra Pradesh and Orissa: In accordancewith standard arrangementsfor development assistancetc States for nutritionprojects on terms and conditionsapplicable at the time

Description: The projectwould support the objectiveof the Central and Andhra Pradesh and Orissa state governmentsof improvingthe nutritionand health status of children under 6 years of age, with specialemphasis on those 0- 3 years old, and pregnant and nursingwomen. Its specificobjectives in project areas would be: (a) to reduce severe malnutritionin those children by 50o in both states; (b) in Andhra Pradesh to reduce moderate malnutritionand increase the proportionof those children in normal or only mild (Grade I) malnutrition status by 35? and help reduce the infant mortality rate (IMR) to 60 per 1,000 live births and the incidenceof low birth weight (LBW) by 302, and (c) in Orissa to reduce moderatemalnutrition and increase the proportion of those children in normal or Grade I status by 25Z and help reduce the IMR to 100 per 1,000 live births and LBW by 20Z. The projectwould comprise the following components: (a) servicedelivery, to increasethe range, coverageand qualityof nutritionand health servicesto target groups through improvementsin the design and implementationof software systems,training for health and nutritionworkers, provisionof nutrition and health educationand health referral services, increasingthe availabilityof drugs and equipmentfor maternal and child health and the supply of therapeutic supplementaryfood to malnourishedbeneficiaries, and constructionof villagenutrition centers, offices and - iv -

residencesfor key field staff; (b) communicationsto stimulatedemand for project services and improvechild feedingpractices and care through productionand disseminationof media messages,provision of equipment and materialsand training;(c) communitymobilization to increaselocal participationin and support for project servicesand activitIesthrough testing of innovativewomen's developmentactivities including activationof villagewomen's groups, developmentof income-generatingactivities, non-formal study courses for women and developmentof training programs for adolescentgirls; and (d) projectmanagement and evaluationto manage, monitor and evaluate the project and conduct operationsresearch to analyzeand improve aspectsof project design.

Benefits and Risks: The projectwould improvethe nutritionand health status of tribal,drought-prone and otherwise disadvantagedpopulation groups in Andhra Pradesh and Orissa. About five million pre-schoolchildren and around three million pregnant and lactatingwomen would directlybenefit from the project'snutrition and health services. Around 45,600 women would obtain trainingand part-timeemployment as workers, helpers or supervisors in project areas. Around 600,000women would be formed into women's groups and would receivetraining both in basic nutritionand health care and how to pass this knowledgealong to their communities. Around 5,600 women's groupswould take part in income-generating activitiesand over 150,000 adolescentgirls would receive apprenticeshiptraining in health and nutrition. An importantindirect project benefitwould be its overall impact on ICDS through testing of innovative software systemsfor broader replication.

The main risks are that implementationcapability may be inadequate,which could adverselyaffect expected servicedelivery coverageand quality, and that authoritiesinvolved with nutritionmay not be willing to accept the merits of supplementarychild-feeding on the basis of verifiablenutrition and growth-faltering criteria rather than on worker-interpretedpoverty grounds. Actions to minimize the implementationrisk include strengtheningICDS organizationat block, district and state levels and training its managers; testingand refiningnew service deliverymodes and contentbefore full-scaleadoption, and a mid-term evaluation. The latter risk would be reducedby (a) assurancesthat modificationsto initially-agreed ICDS supplementaryfeeding criteriawould have to be satisfactoryto the Bank Group, (b) the carrying out of operationalresearch on alternativesupplementation procedures,and (c) the weight of accumulatingevidence that selectivesupplementation is effectiveand efficient. - v -

Estimated Cost8: Local Foreign Total Percent __ _- USS millions ------

A. Service Delivery

1. Nutrition 97.3 5.5 102.8 65 2. Health 10.1 2.1 12.2 8 3. Training 14.9 0.7 15.6 10

Subtotal 122.3 8.3 130.6 83

B. Communications 9.4 0.5 9.9 6

C. Community Mobilization 10.8 0.2 11.0 7

D. Project Management

1. Project Organization 4.6 0.2 4.8 3 2. Monitoring and Evaluation 1.2 0.0 1.2 1

Subtotal 5.8 0.2 6.0 4

Total Project Cost 148.3 9.2 157.5 100

*including taxes and duties of US$4.0 million. - vi -

Project.Financing Plan:

Costs including taxes and duties ------S$ million------

Local Foreign Total 2

IBRD/IDA 96.8 9.2 106.0 67.3

GOI 40.4 0.0 40.4 25.6

Andhra Pradesh 5.5 0.0 5.5 3.5

Orissa 5.6 0.0 5.6 3.6

TOTAL 148.3 9.2 157.5 100.0

Estimated Disbursements: FY91 FY92 FY93 FY94 PY95 FY96 FY97 FY98

Annual 5.0 5.5 14.2 19.3 20.6 18.6 17.0 5.8

Cumulative 5.0 10.5 24.7 44.0 64.6 83.2 100.2 106.0

Economic Rate of Returns Not applicable - 1 -

INDIA

INTEGRATED CHILD DEVELOPMENTSERVICES PROJECT

I. BACKGROUND

A. Introduction

1.1 India's developmentpriorities emphasize poverty alleviation. Human resourcedevelopment programs focussedon child and maternal health and nutritionas well as educationare an importantcomponent of efforts to raise the living standardsof the poor. Moreover, the Nationa' Policy for Children mandates nutrition and health improvementsas primary goveranentduties. Severalnational and state programs currentlyoperate specificallyto imDrove child health and nutritionof the poor through service delivery and, at the household level, subsidiesreduce family food insecurity. These measures have met with some success. However, India needc to expand and improve the outreach and effectivenessof its servicedelivery efforts to maximize their impact on child growth and development.

1.2 Abetted by economic developmentwhich has tripled foodgrainproduc- tion and raised national incomesand productivity,life expectancyhas doubled since the decade ending in 1951. India has also achieved considerablesuccess in improvingchild survivalover the last decade,during which the infant mortality rate (IMR) is estimatedto have declined by about a third, to 86 per thousand live births in 1988. The death rate for children 1-4 years of age also declined from 19 to 11 per thousand during the same period. Largely as a result of these advances,life expectancyis estimatedto have increasedfrom 50 to 57 years. Improvementsare widespread over all regions and in both rural and urban areas. However, considerablevariations persist. For example, the IMR in Andhra Pradesh and Orissa is 79 and 126 per thousand live births respectively,while in Kerala state it is 31 per thousand. In states with high IMR, a predictablepattern of morbidity includingdiarrhea, respiratory infections,worm infestationsand skin diseases afflictsa large proportionof survivors.

1.3 Despite higher rates of child survival,an estimatedone-third of India's pre-schoolchildren have some form of serious growth deficit from malnutrition. Available data, while inadequate,suggest only a gradual improvementin nutritionstatus over the last 20 years. Malnutritionis particularlyintense in Andhra Pradesh, Bihar, Gujarat,Madhya Pradesh, Maharashtra,Karnataka, Orissa, and Rajasthan. According to the latest national data, the proportionof children 1-5 years of age with moderate and severe malnutrition(< 75 percentweight for age) varied in 1982 from 18.9 percent in Kerala to 59.6 percent in Gujarat. The extent of malnutrition among scheduledtribes and casteswas higher than the average in most places. The incidenceof 3everemalnutrition (<60 percent of weight for age) is decliningbut exists among all classes. Predictably,the incidenceof energy deficiencyis higher among the children of landless laborersand small farmers. Evidence of gender discriminationis not conclusive;regional figures suggest some discriminationin north India, especiallyamongst very young girls.

1.4 Children under 36 months of age are the most vulnerable. The Indian Academy of Paediatricsuses the 50th percentileof the internationally acceptedHarvard standard as its weight for age standardand classifies malnutritionstatus as followstmore than 80 percent as normal, between 71 and 80 percent as mild (grade I) malnutrition,between 61 and 70 percent as moderate (grade II) malnutrition,and below 60 percent as severe malnutrition (between51 and 60 percent is grade III and below 50 percent is grade IV). Recent survey resultsfrom the project areas of Andhra Pradesh show that more than a third of the children 0-6 years suffer from moderate or severe malnutrition. PreliminaryOrissa data suggest that nearly 40 percent of children age 0-6 years suffer from moderate or severe malnutrition. This proportionrises sharply to 55 percent for children in the age group 6-36 months. A higher level of malnutritionamong younger children is found in all locations:rural-urban-tribal.

1.5 The consequencesof malnutritionare loweredpotential for physical and mental capacity and greater susceptibilityto disease. The risk of prematuredeath among severelymalnourished younger children is three times that of better nourishedones. Hospital statisticsin Tamil Nadu indicate that malnutritionis the underlyingcause of death in 10 percent and an associatedcause of death in 75 percent of deaths in the age group 0-5 years. A large proportionof malnourishedchildren also remain stuntedwith inadequateheight for age.

1.6 A principalcause of malnutrition,of course, is inadequatefood intake due to low householdincomes. Latest availabledata (1975-80)show that average calorie intake in almost all states was lower than the recommendedallowance of 2400 Kcal/consumingunit. Further, the calorie intake of scheduledtribes and castes was lower than state averages. Since subsequentpoverty declinewas the lowest among these social groups, their nutritionhas probably not improved substantiallyove. the last decade. Although calorie intake for all income groups shows a modest increase,no trend increasewas discerniblefor the ultra-poor,who spend > 80? of their income to achieve < 802 of their calorieneeds. Evidence also indicatesthat less developeddistricts have a preponderanceof malnourishedchildren among scheduledtribes and castes.

1.7 However,neither adequate food at the household level nor economic developmentof a state seems to protect children from malnutritionto the same extent as it does adults. In several states,about 25Z of all householdshad inadequatecalorie protein levels,while more than 40 percent of the children were malnourished(< 75? weight for age).

1.8 Beyond inadequatefood intake, the main causes of malnutritionamong young children are three. First is the high incidenceof childhooddiseases, particularlyacute respiratoryinfections, measles and diarrhoea. More than one-fourthof all infant/childhooddeaths are attributedto respiratory infections. Measles vaccine, introducedat the national level only a few years ago, covers about 25Z of children. An Indian rural child also suffers from severalepisodes of diarrhoeaper year. Behavioralfactors, particularly faulty breast feeding and weaning practicesand inadequatepatterns of household food distribution,are a second cause of early childhoodmalnutri- tion. Colostrumis often discardedand breast feeding frequentlybegins only three days after birth. Weaning not only begins late but weaning foods do not contain enough nutrients. Third, low birth weight (LBW), estimatedat around 30Z of all births for India as a whole, often results either in early infant death or subsequentmalnourishment. LBW is largelya result of low weight of women before and inadequat0oeight gain during pregnancy. In addition, children suffer from micro-nutrientdeficiencies, particularly of vitaminA. in Andhra Pradesh, for example,more than three percent of children suffered clinical eye symptoms from the results of vitamin A deficiency.

B. National NutritionPrograms

1.9 The Governmentof India (GOI) has sought to addressnutrition issues in a variety of ways, in addition to income generation. The problem of malnutritionwas recognizedas early as the First Five Year Plan in 1950 and the first three Plans treatednutrition principally as ; componentof the health sector. The Applied NutritionProgram, introducedin the Fourth Plan (1969),aimed at raising the nutritionalstatus of the poor by nutrition educationand local food productionbut achieved limitedcoverage and was abandoned. The Mid-day Meals Program (MDM) was introducedby some states in 1962 to provide supplementaryfood to primary school children and later (1974) became a part of the Minimum Needs Program.Although its impac -inschool attendance,academic performanceand nutritionalstatus is not well evaluated, the program continuesto operate and currentlycovers an estimated17 millior. children in India. The Special NutritionProgram (SNP)was introducedin 1970 to provide nutrition supplementationto pre-schoolchildren and pregnant and nursingwomen, primarilyfrom tribal and backward areas and urban slums, An SNP support group is .ormed in each program village; a village organizer receives a token honorarium to cook and feed beneficiaries. By 1980, the scheme had more than 6 million beneficiariesbut the enrolmentof children below 3 years of age, the most vulnerablegroup, was low.

1.10 A public distributionsystem (PDS) to improve the household'saccess to food has also occupied a central place in public policy since 1970s. The scheme provides for a network of fair price shops run by the Ministry of Food and Agriculturewhich provide low-coststaples to poor householdsagainst ration cards. However, a substantialshare of ?DS suppliesgoes to the cities. In some states, such as Kerala, Tamil Nadu and Gujarat, PDS has succeededin reaching the poor. But states that account for a substantial proportionof India'spoverty populationlike Bihar, Uttar Pradesh and Madhya Pradesh account for only a small share of PDS offtake. Evidence suggeststhat a well managed PDS has potentialfor improvingthe nutritionstatus of vulnerablehouseholds, although in practice the record is mixed.

1.11 India'smost importantnational child nutrition interventionis the IntegratedChild DevelopmentServices (ICDS) scheme,probably the largest program of its kind in the world and certainlyone of the most comprehensive and imaginative. ICDS aims to achieve four objectives:1) to improve the health and nutrition status of children 0-6 years by providingsupplementary food to beneficiaries300 days per year and by coordinatingwith state health departmentsto ensure delivery of requiredhealth inputs;2) to provide conditionsnecessary for child psychologicaland social developmentthrough early stimulationand education;3) Tc enhance the mother's ability to provide proper child care throughhealth and nutritioneducation; and 4) to achieve effectivecoordination of policy and implementationamong the various departments to promote child development. ICDS delivers a package of services comprisingsupplementary nutrition, immunization, health check ups, referral services,and health and nutritioneducation to childrenunder 6 years of age, pregnant and nursingwomen, and pre-schooleducation to children between 3 and 6 years of age. Thus it adopts a holistic approach to improvedchild development by reduced incidenceof mortality,morbidity, malnutrition and school drop outs (see Annex 1 for details). Initiatedin 1975 on an experimental basis in 33 blo-la, ICDS now covers around 2200 out of a total of 5500 rural blocks in In. sBlockshave an averagepopulation of 110,000.)

1.12 ICDS is centrallysponsored through the Departmentof Women and Child Development (WCD) in the Human ResourcesDevelopment ministry but administereidby the state goverunents. The GOI and the states also share ICDS costs. The GOI provides training and operatingcosts includingsalaries, equipment,supplies, play mater..als,petrol and oil expenses,and medical kits, estimatedat Rs. 0.9 million per block-year. State governmentsmeet the costs of supplementaryfood, currentlyestimated at around Rs. 1.7 million per block-year. States themselvesalso have set up an additional188 ICDS projects for which they pay all the expenses.

1.13 The GOI has followeda gradual ICDS expansionpolicy, based on two kinds of targetting: first to the most disadvantagedareas and, second, within them to vulnerablepre-school children and pregnant and nursing women. The initialgeographic focus was on tribal, drought-proneareas and blocks with a significantproportion of scheduledcaste population. The program is also targeted towardsmalnourished children, but in practicemost beneficiariesof supplementaryfeeding are not selected throughnutritional screening. Selectioncriteria generallydepend upon a combinationof individualworkers' perceptionsof which are the poorest householdsand overall quotas which the Central and individualstate governmentsset for supplementation.Thus there tends to be more area than individualtargeting in ICDS.

1.14 The Anganwadicenter (AW) is the focal point for deliveringICDS services at the rate of one AW per 1000 populationin rural and urban and one per 700 populationin tribal areas. The AW is staffedby a locally-recruited woman worker (AWW) and a female helper. The AWW is a part-timehonorary worker paid between Rs 225 and Rs 275 p.-rmonth dependingon educational qualifications.She is responsiblefor growth monitoringof children under 6 years of age, organizingsupplementary feeding, providing non-formal pre- school educationfor the older children,imparting nutrition and health educationto mothers, includinghome visits, organizingprimary heaLth care for cLildren and mothers, referringthe needy to health personnel,eliciting community supportand participationincluding local women's organizations known as Mahila Mandals (MMs) and maintainingrecords and furnishingreports. Annex 1 describesICDS servicedelivery and organizationin detail.

1.15 More than 600 ICDS evaluationefforts and studieshave taken place from time to time, making it probably one of the world's most reviewed programs. As might be expected,the quality of these efforts is mixed, but several have attemptedcomprehensive and rigorousassessments of the program. The most striking aspect of the findings is the wide variation in ICDS impact by component,region, age and caste status of households. Monitoringdata from the ICDS Ce-tral TechnicalCommittee show that the prevalenceof severe malnutritiondeclined faster in ICDS than in non-ICDS blocks and that IMR was 20 percent lower in ICDS areas, even though ICDS blocks were judged to be poorer than non-ICDS blocks. However,other studies in other areas indicate uneven results. In ICDS areas, about 30 percent of children attendingAws continue to remain moderatelyor severelymalnourished (< 70 percent of weight for age) according to a national ICDS study by the respectedNutrition Foundationof India (NFI). No systematicattempts have been made to explain those variations.

1.16 There is considerablevariability not only in ICDS impact but also in the quality of servicesprovided. Both training and supervisioncan play an importantrole in quality assurance. In particular,four training areas need strengthening. First, there is considerableunevenness in the training impartedby over 200 centers spread all over the country. Second, despite good trainingmanuals, the trainingsyllabus and materialsneed to be adapted to allow for variationsto suit differingrural, urban and tribal conditions. Third, supervisorytraining is very weak. Consequently,although many supervisorsare aware of ICDS deficienciesin their secto.,vigorous actions to remedy the situationthrough more frequentand more extendedvisits to AWs are not undertaken. The need to supervisea large number of AWs and inadequatemobility also limit their attentionto quality issues. Fourth, existing funding places in adequateemphasis on in-servicetraining of all categoriesof functiof.aries.

1.17 The regularityand targetingof ICDS supplementaryfeeding remain areas of concern. A 1988 study by the National Institutefor Public Cooperationand Child Development(NIPCCD) showed that the number of feeding days ranged from 30 to 300 days across blocks. The most importantproblem noted by many observers is the low coverage of children under three years of age, and even lower coverage of pregnant and nursing women. Proportionatelya much higher percentageof 3-6 year olds receive food than in the more vulnerableunder-three age group, partly because younger children cannot come to the AW by themselves. In two Gujarat and Maharashtradistricts, supplementarynutrition failed to reach nearly half of the severely malnourishedunder-threes, according to a 1989 study.

1.18 ICDS sets feeding quotas per block which usually are fully subscribed. Most AW nutritionalscreening is to identifyseverely malnourishedchildren, who are entitled to food supplementationbut because of listlessnessand lack of appetite rarely can consume a double ration. Once enrolled,most child beneficiariescontinue to receive food regardlessof nutritionalstatus until they reach school age. ICDS maintainswith some justificationthat in localeswhere poverty levels approach 752, such as many tribal blocks, virtuallyall pre-schoolchildren are at malnutritionrisk and warrant continuedsupplementation. However, the cost-effectivenessargument for area targetingrather than individualnutrition screening is weaker in ICDS blocks where poverty levels are substantiallylower.

1.19 The present supplementationsystem has other drawbacks. Once a feeding quota is filled, the AWW has little incentiveto seek out additional malnourishedchildren for other AW services. Area targetingthus tends to reduce the emphasis on monitoring individualchild growth and can detract from - 6 - worker focus on case managementof malnourishedchildren through health check- ups and referral. Evaluationshave indicatedthat long- term supplementation may substitutefor food which the child otherwisewould receive at home and thus run counter to the developmentof maternal understandingof the special r.eedsof malnourishedchildren and improved family food behavior. On the other hand, accordingto an NFI study, the direct impact of the present feedingprogram on child nutritionmay be less than desirablebut may induce mo;hers and children to come to AWs.

1.20 Preventingenergy losses from illnessis anotherarea of prospective ICDS improvement. Although immunizationcoverage has increased,both oral rehydrationtherapy for diarrhoeaand managementof acute respiratoryinfections are not systematicallypracticed at the village level. This situation can partly be attributedto under-utilizationor inadequacyof health services. However, evidence suggeststhat the link between health and nutrition servicesneeds strengtheningat all levels. (Annex 2 describesthe organizationof state health servicesin India). The general problem of uneven referralto higher health care levels also affects ICDS; neither the AWW, nor, in most cases, the local health workers keep satisfactoryreferral recordsor follow up to ensure that children reach and receive treatmentat health facilities. ICDS has taken severalsteps to improve its linkageswith the health system. Coordinatingcommittees with health sector participation have been establishedat block, districtand state levels. Key block and districthealth professionalshave been appointedas technicaladvisers to ICDS. Joint monthly meetings also take place at and below the block level to review performance;supervizors are expected to plan joint visits. Despite these measures,much remainsto be done to ensure coordinateddelivery of health and ICDS servicesat the village level.

1.21 Both nutritioneducation and communityparticipation can be strengthenedfurther. Home visits by the AWW need to be more regular. The task of elicitingcommunity participation is admittedlydifficult in villages stratifiedby social barriers and economicdifferentials; therefore, health and nutrition activitiesare rarely conductedin women's working groups,which were envisagedas a major vehicle for communityparticipation. Special efforts are needed for communitiesto become effectivepartners with ICDS in overall child development.

1.22 Pre-schoolfor the older ICDS beneficiariesis an integralpart of the program,which evaluationshave indicatedcould be strengthenedthrough improvedworker training,supervision and materials. A 1987 NIPCCD study of ICDS's social componentsobserved that around one-thirdof AWs had vnnoughplay materialsand teaching aids for pre-school;workers themselveshave reported deficienciesin being taught how to use them properly. However, as with other aspects of ICDS, pre-school functionswell in some AWs and poorly or not at all in others.

1.23 To sum up, ICDS has succeededin reaching around 402 of rural India, mainly the poorest areas, an achievementin itself. ICDS is well-conceived: provisionof an integratedpackage of health and nutrition servicesthrough village-basedAWs has considerablepotential for improvingchild nutrition and health in India, and pre-schoolcan help promote early childhooddevelopment. However, availablestudies suggest that ICDS impact varies a great deal from block to block. Its trainingand supervision,health linkages,referral - 7 - services,mother counsellingand nutritioneducation, coverage of under- threes, communityparticipation and pre-schoolall need to be strengthenedfor ICDS to achieve its full potential.

C. NutritionPrograms in Andhra Pradesh

1.24 Andhra Pradeshhas an estimatedpopulation of 64 million. The per capita state domestic product is slightly lower than the national average,but its social indicatorsshow a mixed picture. In 1987, the birth and death rates were estimatedto be 29.9 and 9.7 per thousand populationrespectively, about 10% lower than the average for India as a whole. The rurai IMR was estimatedto be 84 per thousand live births, about 80? of the national average. On the other hand, the female literacy rate in 1981 was 20Z lower than the national average. In 1982, the latest year for which data are available,38.52 of adults were estimatedto suffer from protein-calorie inadequacy. However, the vulnerablepopulation suffered higher levels of protein-calorieinadequacies, an estimated45X of the lactatingwomen and 58Z of children 1-4 years of age. While the average intake of individualswas close to the recommendeddaily calorie allowance,pregnant and nursingwomen were estimatedto suffer from 300 and 550 daily calorie intake deficiency respectively.

1.25 CurrentlyICDS operates in 112 of the state's 330 blocks, covering around 910,000children. GOI assists 103 of these blocks and the remaining9 are fully funded by the state government. CARE supplies food supplementation to 63 blocks; the remaining36 projects are suppliedby the ready-to-eatmix procured by the state governmentfrom the Andhra Pradesh (AP) Foods Limited, a public sector company. In addition,centrally sponsored wheat-based projects operate in 50 blocks where only nutritionsupplementation is provided to around 0.42 million children. A mid-day meal scheme for school childrenwas discontinuedin 1984.

1.26 In 1988-89, the total cost of nutritionprograms in Andhra Pradesh, excludingPDS, was Rs. 189 million, nearly double that of 1985-86. ICDS program expenditurewas Rs. 130 million (excludingCARE-donated food), 70 percent of the total. Nutritionprogram expenditureaccounted for 1.14 percent of the expenditureon social servicesand a negligibleproportion of total annual state expenditure. Around 38 percent of state expenditureis on social services. In recent years social serviceexpenditure has grown at about the same rate as total expenditure(7Z), thus retainingits share.

1.27 The state has made a major effort to supplementthe nationally operated PDS through a Rs. 2 per kilogram rice scheme introducedin 1984. Under this scheme,5 kgs of subsidizedrice is provided per month per person to familieswith an annual income of less than Rs. 6000, subject to a ceiling of 25 kgs per month per family. Initiallynearly all rural householdswere covered by the scheme. The scheme'scoverage was graduallytightened to nearly 10 million households,comprising the lowest 70 percent of the population, who continuedto receive rice at substantiallylower than the free market price. However, PDS was estimatedto have met only 34 percent of the minimum requirementsof rice for the poorest segments. A 1987 report on the functioningof the scheme suggeststhat the governmentsupplied only 1.7 million tons of rice against the 2.5 million tons required for eligible families. Thus many families could not obtain their full quotas because of serious supply bottlenecks. Another study based on the dual market in rice showed that the policy improvedthe welfare levels of the poor. But it also pointed out that if the coveragehad been restrictedto the bottom 40 percent of the population,the welfare gains to the poor would have substantially increasedand the supply situationwould have become more manageable,ensuring the scheme's long run sustainabilityin a cost-effectivemanner.

1.28 Despite PDS coverage,and ICDS and other supplementarynutrition programs,levels of child malnutritionremain high. Recent data from the proposed project areas suggeststhat 8.8 percent of children under 6 are severelymalnourished. The same survey indicatedthat moderate malnutrition in pre-sc}oolersranged from 27.1 percent in the ICDS areas to 29.9 in the non-ICDS areas. The inherentcomplexity of the problem is compoundedby deficienciesin the design and delivery of programs.

1.29 ICDS has not been systematicallyevaluated in Andhra Pradesh. However,mission field visits and small studies suggestthat its performance is comparableto that of the program as a whole. Preliminaryresults from the base-linesurvey in the project areas suggestreasonably good overall coverage: 722 of householdswith childrenunder six utilized ICDS services. More than 80 of these householdssingled out feeding as a major service, underscoringa common perceptionthat ICDS is essentiallya feeding rather than child developmentprogram. As discussedin paras 1.16-21, the key issues to be addressedto improve the impact of ICDS on child developmentare how to ensure that (a) the whole range of ICDS services is provided to the targeted beneficiaries,particularly under-threes and pregnantwomen, (b) nutrition supplementationdoes not become largely a substitutefor a part of the home meal, (c) health and nutritionalcompetence of the families is increased accompaniedby better weaning and child feedingpractices, and (d) coverage of necessaryhealth servicesis increased,referrals for malnourishedchildren and at-risk pregnant and nursingwomen are completedand severelymalnourished children are nutritionallyrehabilitated.

D. NutritionPrograms in Orissa

1.30 Orissa has an estimatedtotal populationof 26.4 million;more than one-thirdconsists of scheduledtribes and castes. It is one of India's poorest states. The per capita state domesticproduct is about two-thirdsof the national average. Around 40Z of the populationis below the poverty line. Nearly two-thirdsof the populationis illiterateand, predictably,the IMR is much higher than the national average.

1.31 In view of its economicbackwardness and high levels of malnutrition, the state operates severalnutrition programs. The mid-day meals program covers more than half the primary schoolswith CARE-donatedfood (550,000beneficiaries) and state governmentfunds (200,000beneficiaries) in all districts. ICDS operates in 83 of a total of 314 blocks. Of the 118 predominantlytribal blocks,only 47 have been covered by ICDS so far. SETP covers all the remainingblocks with feedingprograms. In all 2.15 million or nearly half of all pre-schoolchildren are covered. About half the food is provided through CARE donations;the GOI finances one-thirdof the food under a wheat-basedscheme, and the state governmentfunds the remainder. Of Orissa's twelve districts,seven are coveredby CARE, three by the GOI and the remainingtwo by the state government. - 9 -

1.32 In 1988-89, the total cost of these Orissa nutritionprograms was estimatedat Rs. 182 million. Food accountedfor Rs. 96 million, 53? of the total cost. The respectivevalue of food donatedby CAREIWFP and GOI was estimatedat Rs. 58 million (602 of total food value) and Rs. 15 million (16z) with the state governmentbearing the remainingRs. 23 million (24X). As GOI also funds non-food ICDS costs, the state'sexpenditure is only around 13X of the total cost of its nutritionprograms. Orissa's 1988-89 expenditureon social serviceswas estimatedat Rs. 815 million. Although small in absolute terms, the state's annual expenditureon social servicesin recent years has grown (6.9Z)much faster than total state governmentexpenditure (3.9z).

1.33 Orissa's nutritionprograms have helped improvenutrition status but an NFI review identifiedseveral weaknesses--coverage too scatteredand irregular,really vulnerablegroups not reached, lack of educationalefforts, virtual absence of communityinvolvement, inadequate health inputs and poor supervisionwith inadequatemonitoring and internalevaluation. As the program's emphasis is on supplementaryfeeding, for which there is considerabledemand, while other activitiesare weak, expected improvementsin nutritionstatus have not been observed. The NFI review also observed that the general nutrition status of the vulnerablepopulation has shown no significantimprovement over time, although the worst manifestationsof severe malnutritionin pre-schoolchildren, particularly kwashiorkor and marasmus, have declined where nutritionprograms operate.

E. Learning from Other Experiences

1.34 All of India's nutritioninterventions have been evaluated from time to time. More than 600 differentevaluations of various aspects of ICDS alone (see paras 1.15-1.16,1.32) have taken place. While many nutritionevalua- tions have been relativelysmall-scale and of uneven quality,they reflect a consciouseffort to provide useful lessonsfrom program experience. Moreover, a substantialrange of material from Bank Group experiencein and outside of India, as well as from other developingcountry projects,can help point the way to improved service deliveryoutreach and performance,household food behavior and communityparticipation.

1.35 The Tamil Nadu IntegratedNutrition Project (TINP) is the only IDA- assistednutrition project in India. It covers over 10 million population in 173 of the state's 373 rural blocks. Formulatedduring 1978-80,TINP derived from a comprehensivestatewide nutrition survey carriedout in the early seventiesand the state's extensiveexperience in trying out different programs. TINP's main goals were: (a) to halve malnutritionamong children under four years of age; (b) to reduce infantmortality by 25Z; (c) to reduce vitamin A deficiencyin the under fives from about 27? to about 52; and (d) to reduce anemia in pregnant and nursingwomen from about 55Z to about 20Z. The project had four major components:nutrition services,health services, communications,and monitoringand evaluation. The main project strategies were to providenutrition educationand primaryhealth care to pregnant and lactatingwomen and children 6-36 months; to monitor the growth of children in this age group throughmonthly weighing and growth charting;and to provide supplementaryfeeding and health checks to childrenwith falteringgrowth, as well as intensivecounselling to their mothers. To provide these services, nutrition centers staffedby part-timewomen communitynutrition workers were set up in about 9000 villages. These were to be assisted by local women's - 10 - groups created under the project and strengthenedhealth outreach and referral services.

1.36 It is estimatedthat TINP contributedto a reductionof a third to a half in severe malnutritionamong 6-24 month olds, and a reductionof about 50? in severemalnutrition among 6-60 month olds. While not conclusive,the availabledata suggesta strong TINP impact in improvingchildren's nutrition status. TINP also reduced inequalitiesin the incidenceof malnutritionamong differentdistricts. In project areas the overallproportion of children in normal and grade I increasedsubstantially; the proportionin grade II remainednearly the same, implying a favorablyupward shift in the overall nutritioncurve. There is also some evidencethat TINP effectspersist beyond the age of 36 months. At 5 years of age, childrenparticipating in the project'sinitial block weighed almost 2 Kgs. more than those in a control group. However, the project failed to reach its health goals. Although infant mortalitydeclined by 12 to 26 percent in differentareas of the project, similardeclines also occurred in non-projectareas. Just under a quarter of all eligible children receivedfull doses of vitamin A, while 28? of childrenhad not receivedeven one. Half of all eligible pregnantwomen had not receivedanaemia prophylaxis.

1.37 TINP demonstratesthat it is possible to reach a high proportionof younger childrenwho are nutritionallythe most vulnerable,and significantly to reduce the incidenceof severe malnutritionthrougL well targeted health and nutrition servicesaided by communicationand communitymobilization activities. While it did not achieve all of its goals, the project has an unusual number of lessonsfor the design and implementationof outreach programs,particularly in the area of training,supervision and monitoring. Key features include carefullydefined recruitmentcriteria for local workers; limitingfield worker tasks to those which are manageableand high priority; specificationof daily and monthly work routines;decentralized training systems;supervisory practices which facilitateon the job training;the use of local women's groups to supportproject activities;the display of performanceinformation to clients and workers at the village nutrition center; and a management informationsystem which could rapidly detect performersfalling below establishednorms. On the health side, the main lesson is that large scale investmentin health infrastructureand supplies is not sufficientto improveperformance. Complementarysoftware measures are needed to optimizehealth workers' performance. With a few design changes in the supplementationcriteria, and more focus on maternal nutritionand improvedhealth-nutrition coordination, it may be possible to reduce the incidenceof moderate (gradeII) malnutritionresulting in a greater proportion of children in normal and grade I category.

1.38 Comparisonbetween ICDS and TINP is difficult;ICDS covers children under six years of age and includespre-school education whereas TINP focusses on childrenunder three with nutritionand health servicesonly. But several of the observed deficienciesof ICDS - the relativefailure to reach under threes, the poor health and nutritioneducation, and the neglect of home visits and communityparticipation - can be remediedusing systems similarto those in TINP. High levels of TINP worker and supervisormotivation and competencehave resulted from good training,supervision and monitoring systems. Extensive communityparticipation, developed through the communications and community-basedgrowth monitoring,has also contributedto high performancelevels. These features,if incorporatedin ICDS, can increase its - 11 -

cost-effectivenessand speed up the pace of improvementsin child nutrition status.

1.39 Nutrition efforts in other countriesalso provide lesE-ns for prospectiveICDS application. Bank Group-aidednutrition activities in Indonesiahave confirmedthat it is possible to improveweaning and other household food practices. The UNICEF-aidedIringa regionalnutrition project in Tanzania,to be expandedwith Bank Group support,demonstrates the efficacy of communityparticipation.

1.40 The proposed ICDS project, therefore,builds on lessons from ICDS's own rich experience,augmented by lessons from TINP and elsewhere,by: (a) emphasis on in-servicefield-based training, supportive supervisory practicesand simple monitoring systems to ensure high levels of service quality and coverage; (b) community-basedgrowth monitoringand intensive nutrition education; (c) communitymobilization, particularly of women's groups; (d) increasedattention to promotionof behavioralchange, and (e) operationalresearch in alternativemodes of therapeuticsupplementatiDn to arrive at the most efficaciousapproach. The projectwould attempt to remedy some of the observed deficienciesof TINP, particularlyin the areas of health-nutritionworker collaboration,referral and nutritionalrehabilitation, and maternal nutrition.

F. National NutritionPolicy and Strategy

1.41 India's nutritionpolicy and strategyare reflectedin its programs rather than explicit statementsor plans. Nutritionaccounts for around 1% of Central and state plan outlays combined,or around 0.16Z of GDP in 1986/87. (Bank reportshave recommendedincreased social sector fundingand efficiency on poverty alleviationgrounds.) Aside from generalprograms to relieve poverty such as rural development,rural employmentand food for work programs, the Governmenthas two types of nutritionprograms besides ICDS: provisionof vitamin A and iron supplementsby the Ministry of Health and Family Welfare as a part of the primaryhealth care package and PDS by the Ministry of Civil Supplies. Additionally,all supplementaryfeeding programs combined cover an estimated11 million of India's 38 million pre-schoolers. There are relativelylittle hard data about the nutritionalimpact of any of the main types of nutritionprograms but mounting evidence that they can be carried out more cost-effectively.

1.42 Demonstratinga commitmentto human resourcedevelopment, and as a response to persistentlyhigh levels of child malnutrition,the g'vernment doubled ICDS coverage in the Seventh Plan (1985-90)from a base of 1136 blocks and further expansionis likely in the forthcomingEighth Plan. The government is also consideringintegration of and additionsto existing programs with indirectnutrition implications-non-formal education, income generation, and health - benefittingwomen and children in rural areas.

G. Other Donor Role

1.43 External donor involvementin ICDS is relativelysmall. However, CARE-donatedfood provides supplementarynutrition for around 5 million ICDS beneficiariesin 7 states. The World Food Program (WFP) provides supplementaryfood for around 2.1 million beneficiariesin 5 states. UNICEF provides equipmentand funds all basic training for new AW centers. Its - 12 - assistance in recent years has averagedabout US$5 million yearly. An innovativeUSAID-assisted project has supportedICDS expansionand strengthening in one district each of Gujarat and Maharashtra. It seeks to improveICDS performancein project areas through in-servicetraining, increased supervision, strengthenedcommunication and developmentof a management information system. It is still early to assess the impact of the project as terminal evaluationhas not been done. Although the resultsof its mid-term evaluation were vitiated by severe d-ought conditions,it showed a considerableincrease in coverage by various services. More recently NORAD is assistingICDS in Uttar Pradesh and SIDA is assistingICDS in a Tamil Nadu district.

H. Bank Role and Strategy

1.44 The Bank's human resourcedevelopment intentions include assisting India to achieve its national objectivesof reducing excess fertility, mortality and morbidity, and increasingand maintaininghigher levels of school enrollment. Improvednutrition, particularly of younger pre-school children and their mothers, can contributedirectly to improvedhealth and educationoutcomes and indirectlyto lower fertilityrates. IDA's principal nutrition objectiveis to assist the Central and state governmentsin adopting and maintainingpolicies, strategies and cost-effectiveprograms to deal with nutrition problems of pre-schoolchildren and pregnant and nursingwomen. Over the longer term, a broader objectiveis to ensure that the benefits of Indian food production,subsidy and income generatingprograms get directed as much as possible toward those at greatestnutritional risk.

1.45 The Bank is collaboratingwith GOI and five states in the development of proposalsdirected towards improvingthe nutrition and health status of childrenunder three years of age, and pregnant and nursing women. A Second Tamil Nadu NutritionProject (TINP II) has already been appraisedand will extend TINP serviceswith refinementsto the remaining rural areas of Tamil Nadu. In the other four states,the Bank's particular focus is on helping to increase the effectiveness,efficiency and coverage of ICDS, where India's main direct nutritionexpenditures currently take place.

1.46 The proposed projectwould extend coverage of ICDS with some refinementsto disadvantagedblocks of Andhra Pradesh and largely tribal blocks of Orissa. An additionalproject, currently under preparation,would strengthenand enrich ICDS in largelytribal areas of Bihar and Madhya Pradesh. Policy dialogue building on these project experiencesand sector work would help the GOI and state governmentsto set prioritiesfor resource al±ocationto nutrition, to apply those resourceseffectively to where they are most needed, and to take nutritionconcerns more consciouslyinto account in developmentefforts.

1.47 PreparationProcess and EnvironmentalImpact. The proposed project was prepared by the governmentsof Andhra Pradesh and Orissa with assistance from the GOI. Bank missions joined governmentcounterparts in extensivefield visits where interviewswith beneficiariestook place in lieu of formal beneficiaryanalysis or communityparticipation in project design. However, much of the operations researchproposed for the early years of the project is designed to assure a good fit betweenbeneficiary perceptions and needs and ICDS servicesto be provided. The proposed project appears to be neutralwith respect to effects on the environment;therefore, no special environmental assessmentwas undertaken. - 13 -

II THE PROJECT

A. Project Goals and Objectives

2.1 The project seeks to acceleratethe pace of improvementin the nutrition and health status of childrenunder six years of age, with special emphasis on children 0-3 years, and pregnant and nursingwomen within broad ICDS objectivesof overall child development. Specificnutrition and health impact objectivesfor project areas in Andhra Pradesh and Orissa differ (see Annex 2 for details) in accord with each state'scircumstances and conditions:

ProiectAreas

Andhra Pradesh Orissa

Reduction in severe malnutrition(grade III and IV) among children 6-36 months by percent SO 50

Increase in proportionof children 6-36 months of age in Normal and grade I status by percent 25 25

Contributetowards reductionin IMR from present level to 60 100

Contributeto reductionin incidenceof low birth weight by percent 30 20

2.2 The Project'simpact objectivesare ambitiousbut feasible in blocks where the Project maintainsthe specificcoverage levels listed in Annex 3 over four years. The proposed reductionin severemalnutrition over six years in Andhra Pradesh and Orissa derives from outcomes over five years in rural Tamil Nadu at lower participationrates and with less powerful interventions than those to take place under the proposed Project,which seek to reflect the lessons of TINP (see paras. 1.34-1.36). Because of Andhra Pradesh's relativelymore developeddelivery systemsand infrastructure,it is likely to achieve a faster upward shift than Orissa in the overall nutritioncurve. IMR reductiongoals requirean average annual decrementof 4 per 1,000 live births in project areas, already achieved in rural areas of many Indian states and consideredfeasible with the range of interventionsproposed under the project. By means of these interventions,IMR in project areas would decline more sharply and reach levels comparableto the better-offrural areas of both states. Reduction in the incidenceof low birth weight is the most difficult objective;its achievementdepends on early and complete identificationand nutritionalsupplementation of women at risk because of inadequateweight gain in pregnancyor iron deficiency. However, the proposed reductionsare consideredfeasible based on the relative state of delivery systems in Andhra Pradesh and Orissa.

2.3 The above objectiveswould be achievedover six years of project duration throughbetter servicedelivery; increased nutrition and health capabilityof mothers and communities;and promotionof communityparticipation in the project'snutrition, health, and educationalactivities. These intermediategoals would be realizedbyt - 14 -

(a) Increasingcoverage and qualityof nutrition and health services for pregnant and nursingwomen and children 0-6 years of age;

(b) strengtheningcommunication activities through use of various media and audio-visualsupport materials;

(d) developingrobust software systemsof training,supervision, work organization,and monitoringand evaluation.

Specific process objectivesfor serviceand activity coverage appear in Annex 2.

B. Scone

2.4 The projectwould cover 110 predominantlytribal, drought-proneand disadvantagedblocks in Andhra Pradesh and 191 predominantlytribal blocks in Orissa. In Andhra Pradesh, the projectwould strengthenand enrich services in the 44 existing ICDS blocks and extend the program to an additional66 blocks covering an estimated12.9 million population in 13 districts. Similarlyin Orissa, the projectwould strengthenand enrich services in the 69 existing ICDS blocks and extend the program to an additional70 tribal and 52 disadvantagedblocks covering a total populationof 9.53 million in 12 districts. The detailsof the project areas appear in Annex 3.

C. Strategy

2.5 The overall project strategycomprises three elements. First, the projectwould assist ICDS to expand its coverage of existing program features like pre-schooleducation which already are working reasonablywell. Second, it would take lessons learned from TINP and other experiencesin and outside of India (see paras 1.34-40) and adapt these to Andhra Pradesh and Orissa circumstancesto improveICDS performance,particularly affecting children 6- 36 months of age and pregnant and lactatingwomen. Third, it would serve as a proving ground to develop enhanced approachesin areas like communitymobilization where more testing of program conceptsand assumptionsneeds to take place. These adaptive and developmentalactivities are a special feature and the core of the project.

2.6 The strategy to acceleratethe pace of improvementsin the nutritionstatus of pregnant and nursing women and children under 3 years of age consists of four elements: (a) improvingriaternal nutrition through strengthenedantenatal care &ndvwn-site supplementationof high risk women by 20th week of pregnancy; (b) improvinghousehold health and nutritionbehavior through communicationand communitymobilization; (c) increasinghealth service coverage to reduce nutrition losses by infectionsand infestationsand referral of malnourishedchildren to appropriatelevels of the health care system; and (d) providingtherap2e-tic nutrition supplementation to malnourishedchildren under three. - 15 -

2.7 The service delivery strategy uld broadly follow existing ICDS guidelines (see paras 1.11-14 and Annex 1), while strengtheningtraining, communication,logistics, and monitoringand evaluation. In addition,three innovationsare planned to help reach the Project'sambitious impact objectives. First, the quality and quantity of supervisionwould be improved through a combinationof training,reorganized work routines and addition of a special block level supervisor. Second,current supplementationprocedures may have to be modified to deal more effectivelywith the nutritionneeds of malnourishedunder-three children. In view of the complex interactionof severalvariables, promising alternative supplementation procedures would have to be tested in at least 8 blocks in each state for the first three years. Operationalresearch would take place on two alternatives. Under one scenario,an additionaltherapeutic, on-site daily supplementwould be provided to moderately (gradeII) and severelymalnourished (grade III and IV) children. Children falling in grade II or below at monthly weighing would receive therapeuticsupplementation until they are able to maintain grade I or better status for three successivemonthly weighings. Besides providing additionalcalories, this procedurewould focus other project serviceson these malnourishedchildren and their parents. Alternatively,a therapeutic supplementationwould be provided in lieu of current supplementationusing ICDS beneficiaryselection procedures. To gain further insights into household food consumptionbehavior, research on a smaller scale would be conductedby shifting the present SNP supplementsprovided on poverty grounds to take home rations and providingon-site therapeuticsupplementation to children grade II or below until they are able to maintain Grade I or higher status. Third is to enrich ICDS throughwomen's programswhich will optimize communitysupport for and participationin AW activities.

2.8 These innovationswould take place experimentallyduring the first three project years. After evaluationin the third year, decisionson these innovationswould be taken regardingtheir extensionto remainingproject areas and their possiblewider applicationto other tribal blocks, bearing in mind implicationsfor sustainabilityfrom both cost and operational perspectivesin the broader ICDS context. Assuranceswere receivedat negotiationsthat by September30, 1994, Andhra Pradesh and Orissa would complete and discusswith the Bank Group the findingsof operations research on alternateapproaches to the provisionof therapeuticnutritio:i supplementation for growth-faltering,moderately and severelymalnourished children under three years of age (para.5.1(a)). A mid-term review and evaluationof project processesand operationalso would take place in the third year as the basis for more generalmodification, if necessary,of project design. At negotiations,assurances were receivedthat (a) Andhra Pradesh and Orissa would maintain beneficiaryselection criteria and procedures for nutrition supplementationacceptable to the Bank group in project areas (para.5.1 (b)), and (b) by December 31, 1993, Andhra Pradesh and Orissa will conductmid-term reviewsand evaluationsof project operationsin consultationwith the GOI and the Bank Group under terms of referenceand a methodologysatisfactory to the Bank Group and will discuss their findingswith the Bank Group (para. 5.1(c)).

2.9 Conditionsin the projectareas of the two states differ somewhat from each other. Both the rural health infrastructureand institutional capacity for training and communication activities are better developed in Andhra Pradesh than Orissa. Andhra Pradeshhas also expanded its PDS coverage (para 1.26). On the other hand, Orissa project areas consistmainly of tribal - 16 -

ICDS blocks with dispersedvillages and relativelysmall populations. Orissa also provides state-widedaily feedingto 75Z of tribal childrenand 40Z of rural children under six years of age througha combinationof CARE, central- wheat based, and state-fundedfood (para 1.31), principallyon poverty grounds. Orissa impact and process objectivesare also somewhatmore modest than in Andhra Pradesh (para 2.01 and Annex 2). Therefore,some differences will occur in project activitiesbetweer the two states.

D. ProiectDescription

2.10 The projectwould consist of four components,as describedbelow: servicedelivery, communications,community mobilization and project management.

ServiceDelivery (US$130.6million)

2.11 The projectwould expand the range, increasethe coverage,and improve the quality of servicesin the project areas. Nutritionand health services to be provided to differenttarget groups would be as follows:

(a) pregnantwomen - antenatalcare, health and nutritioneducation, and food supplementationfor those at risk of deliveringlow birth weight babies and referralof those at obstetricalrisk;

(b) nursing women - postnatalcare, health and nutritioneducation, and food supplementationfor the malnourished;

(c) childrer.6-36 months - growth monitoring,immunization, vitamin A administration,deworming, acute respiratoryinfection management, health check ups, referraland rehabilitation,and therapeutic supplementation;

(d) children 3-6 years of age - growth monitoring,pre-school education, and health check ups; and

(e) all women, includingadolescent girls - nutritionand health education.

2.12 The project would extend servicedelivery to all the projectblocks so far not covered by ICDS in each state. Work organization,supervision, additionalmobility for functionaries,medicine supplies,therapeutic food supplementation,and constructionof facilities,where needed, would optimize the functioningof the service deliverysystem in all project areas. Strengtheningreferral and nutritionalrehabilitation would increase the effectivenessof nutritionand health servicesfor severelymalnourished children. Finally improvedhealth-nutrition collaboration would ensure coordinateddelivery of servicesto beneficiaries.

2.13 Structure. The AW will be the village focal point for project nutrition,health and pre-school services. It will be staffed by two women: an AW and a helper. In view of widely dispersedtribal populationsand small settlementsizes, an AV center would be set up on average for a populationof 700 in tribal areas as compared to 1000 in other rural areas. To cater to different settlementpatterns, the projectprovides for establishingup to an - 17 - additional10 percent AW centers. The projectwould provide salary and other incrementaloperating costs for around 9,350 new AWs in Andhra Pradesh and 12,400 new AWs in Orissa. The projectwould also finance additionalsupplies and, when necessary,increased rental costs for 4,400 old AWs in Andhra Pradesh and 5,600 old AWs in Orissa. The supervisorystructure would follow the ICDS pattern. But an additionalsupervisor would be provided at the block level during the first two years cf project operationin each block to ensure specialemphasis on communitymobilization, in-service training and communication activities,and to technicallyassist poor performingAWWs and supervisorsin upgradingtheir performance. A study would be carried out during the first project year to diagnose the causes of shortfallsin the quantity and quality of supervisionand identifyactions to remedy them. If necessary,funds provided for programdevelopment and research in the project would support subsequentoperational research in alternativesupervisory patterns. The projectwould also supportestablishment and incremental operatingcosts of 66 block and 8 district offices in Andhra Pradesh,and 122 block and 11 district offices in Orissa, along with small warehouses to store nutrition supplements. Assuranceswere receivedat negotiationsthat in Andhra Pradesh and Orissa an additionalsupervisor would be placed in each project block for the first two years of project implementationin that block (para. 5.1(d)).

2.14 Work Organization. The wide range of servicesenvisaged in the project can only be deliveredby a team effort of health and nutrition staff. The allocationof duties and enablingwork routineshave been developed for both states. Broadly speaking,the AWW would be responsiblefor registration of pregnantwomen, iron supplementation,nutritional surveillance of pregnant women and children 0-3 years of age, therapeuticnutritional supplementation, administrationof vitaminA, and health referral of malnourishedchildren and severe acute respiratoryinfection (ARI) cases. In addition she will assist in counsellingfor birth spacingand immunization. Female multipurpose workers (MPWVs)would provide antenataland postnatalcare, immunizations, family planning services,health check ups, and if necessary,refer children to higher levels of the health system. Dais (traditionalbirth attendants) would be encouragedto provide quality natal care and 'motivationfor family planning. However, de'3lopmentof optimalwork routines requires a better understandingof how workers now spend their time. Therefore,operations research to assure a better fit betweenpriority tasks and time to perform them would take place during the first year of the project and draft terms of referencewere reviewedat negotiations. Assuranceswere receivedat negotiations that by September30, 1991, Andhra Pradesh and Orissa will carry out operationsresearch on nutritionand health staff work routines at and below the block level under terms of referencesatisfactory to the Bank Group and discuss the resultswiLh the Bank Group (para. 5.1(e)).

2.15 Supervisionis critical for ensuring consistent,high quality services;promoting community mobilization, and effectivecoordination with the health services. Supervisors(1 for 17 AWs in tribal and 20 AWs in rural areas) provide necessaryguidance to village-basedstaff on day-to-daybasis, conduct in-servicetraining, hold sectormeetings to monitor performanceand resolve problems,liaise with the health staff, and promote involvementof women's working groups and other influentialcommunity members. The level of communityparticipation is low and distancesto be covered are large. Therefore,the projectwould both increasethe amount of supervision - 18 -

(para. 2.13) and improve its quality. All supervisorswill receive in-service training (para 2.34). For improvedmobility, the projectwould provide mopeds to those supervisors,about half of the total, who can utilize them effectively.

2.16 Facilities. Ideallyevery village should have an adequateAW to provide servicesand serve as a focal point for related communityactivities. The problem of inadequatefacilities is particularlyacute in the project areas. A variety of facilitiesincluding community halls, schools,private houses, or rented rooms are used. The projectuould partiallyremedy this situationby supportingconstruction of 1,750 AWs in Andhra Pradesh and 2,000 AWS in Orissa (about 122 of all AWs); the averageAW size would be 450 sq.ft. It Js also anticipatedthat about 25S of the constructedAWs will not have a nearby source of safe water and the projectwould finance tube wells in such AWs. Criteria for tube well installationwill includeincidence of water- borne diseases,community access to safe water and feasibilityof installa- tion. The communitieswould be involved in their constructionand low cost materials and techniqueswould be utilized.

2.17 Supplies and Equipment. The project would provide additionalMCH drugs needed for treatmentof acute respiratoryinfections, referrals from AWs, deworming,and vitamin A eupplementation.Standard medicine kits have been developed for use at AWs, health sub centers and Primary Health Centers. Medical and paramedicalstaff would be given necessary training. The project would emphasizereferrals from AWs to higher levels of the health system and would finRncenecessary equipment at subcenters,PHCs and CHCs as well as supplies and equipmentto increaseand maintain immunizationcoverage.

2.18 TherapeuticFood Supplementation.Nutritional surveillance would be used for pregnantwomen and childrenunder three years of age for nutrition education. During the first three years of the project, operationsresearch would take place in Andhra Pradesh and Orissa on alternativesupplementation proceduresfor children under three years of age (paras2.7-8). The project would finance the costs of therapeuticnutrition supplementation for growth- falteringmoderately and severelymalnourished children under three years of age as part of operationsresearch. The supplementwould be a grain-pulseor other commoditymixture deliveringat least three caloriesper gram. Experimentationto increasecaloric density of the supplementalso would take place.

2.19 Health-NutritionCoordination. As nutritionand health services have synergisticimpact, they need to be deliveredin a coordinatedmanner. Despite coordinationcommittees and other functionallinkages, health- nutritioncoordination in ICDS remainsunsatisfactory. If MPWFs receivemore support from AWWs, they will more easily achieve their antenatalcare, immunizationand family planning goals. If AWs receivemore supportfrom MPWFs, they will be able to do more for childrenwho are malnourishedas well as have health problems. Although the collaborationwould benefit both health and nutrition systems, it is not perceivedas an opportunity. Also there are other difficulties. The work routinesof both workers reflect their own prioritiesand are not synchronized. Joint tour plans of supervisorsare difficultto implementas their work areas and supervisoryneeds may not always coincide. A more comprehensiveapproach, going beyond the traditional - 19 -

approach of coordination,is needed for the workers to collaborateat the village level.

2.20 Allocationof responsibilities,assignment of ptiorities,work routines,and monitoringprocedures, all influenceworker behavior. Joint planningwould facilitatecollaborative work and both joint trainingand joint superviFioncan motivate workers to collaborate. Therefore,an approach to achieve closer collaborationsMnuld begin with clear job descriptionsand an agreementamong the managers ' the two programs on the relativepriorities to be assigned to differenttasks. Formatsand proceduresneed to be developed for joint planniingat district,block and sector levels. The currentmonthly work routinesof health functionariesdo not take maximum advantageof AWWs close contactwith the clients (para. 2.14). Specificdays may need to be set aside for the AWW and MPWF to work together. Specificdays also may be set aside for joint supervisionby nutritionand health supervisors. Most of the above mentionedmeasures for health-nutritioncollaboration are process oriented,and, except for joint training,do not require significantfinancial outlays. They would be kept under continualreview during project implementation and would be a formal part of the mid-term (para.2.8) and final (para. 2.39) project reviews and evaluations.

2.21 NutritiGnalRehabilitation. Therapeuticsupplementation and routine health check-upsmay not suffice for childrenwith persistentsevere malnutrition. In view of its developedtransportation system, Andhra Pradeshwould emphasizereferrals to higher levels of health care. The projectwould support a family referral scheme for malnourishedchildren and at risk women, under which familieswill be compensatedfor bus fare and cost of medicines for completedreferrals. In addition,four 12-beddedMaternity and NutritionalRehabilitation Homes will be establishedon an experimentalbasis in che tribal areas for those who need prolongedattention. In Orissa, however, hospitalization,which is both expensiveand suboptimal,is the only alternative. Some NGOs in other states have experimentedwith nutrition rehabilitationcenters which provide residentialfacilities for mothers and children. Besidesmedical care, the child receivesan appropriatediet under guidance of a nutrition supervisorand the mother is educated in child nutritionusing locallyavailable food. In Orissa, the projectwould initiallysupport the establishmentof a few experimentalcenters attached to CommunityHealth Centerswhere pediatricwards already exist. If successful in the first three years, then more nutritionalrehabilitation centers in each states would be added in the fourth year of the Project.

2.22 Pre-schoolEducation. Although considerableworker time is devoted to pre-schooleducation, its quality is uneven (see para.l.22). The project would support initialprovision and replenishmentof educationaltoys and play materials at AWs. A manual for theme-basedapproach to learninghas been developedby an NGO and tested. The projectwould provide these manuals to all the AWs. There is also a high degree of consensusthat a more inter- active, participatoryapproach should permeate the non-formalpre-school componentbased on the principleof guided learning through active experience in which individualsare helped to constructtheir own knowledge. This approachwould be emphasizedin both pre-serviceand in-servicetraining of workers and supervisors. In addition,the project through its communication activitieswould improvecapacity of parents and other care givers to provide a stimulatingenvironment at home. Thus actions to improvequality of pre- - 20 - school educationwould be an integralpart of the training,communication, and communitymobilization components of the project.

2.23 Training. Trainingwould be a key instrumentfor ensuring quality services,creating and maintainingstaff motivation,and improvingtheir communicationand communitymobilization skills. For all categoriesof staff. the projectwould support four types of training;pre-service for new staff, orientationtraining for existing staff in the project areas, regular in- service training,and problem solvingworkshops. While most trainingwould be carried out by governmentinstitutions. some trainingwould be carried out by non-governmentorganizations as well.

2.24 In Andhra Pradesh, the staff of 66 new blocks (9.350helpers. 9,350 AWWS, 820 supervisors,and 66 CDPOs) would receivepre-service training. Similarlyin Orissa, the staff of 122 new ICDS blocks and additionalAWs in the existing ICDS blocks,who have not yet receivedany training (10,400 helpers, 10,400 AWWs, 870 supervisorsand 102 CDPOs),would be given pre- service training. Special courseswould be organizedfor about 25Z of AWWs whose educationqualifications are likely to be deficient. Orientation trainingwould be provided to the staff of the existing 44 and 69 blocks in Andhra Pradesh and Orissa respectively. All the nutritionand health staff would receive joint, in-servicetraining at the field level for about a week. Key areas of trainingfor differentcategories of staff and how they w.'.llbe organizedare detailed in Annex 4.

2.25 In-servicetraining would be field-basedand would be conducted jointlyfor nutritionand health staff. The pattern of training in Andhra Pradesh and Orissa differ. In Andhra Pradesh, 26 Information,Education and Communication(IEC) centerswill be establishedat the district level. Each would be staffedby nine trainers and would be responsiblefor all the additionaltraining for helpers and supervisors. In Orissa, district training teams would be constitutedby speciallyappointed staff. In collaboration with other district and block level staff, these teams will train supervisors, who in turn will train village level staff under the teams' guidance.

2.26 In both states,curriculum preparation, material development,and planningand monitoring the training activitieswill be the responsibilityof project-supportedtechnical program cells under the Project Coordinators. To ensure that training is both relevant and effective,the project would also supportperiodic in-servicetraining of trainers,necessary strengtheningof the training institutions,and technicalassistance for curriculumreview and development.

Communication(US$9.9 million)

2.27 The projectwould support a comprehensivecommunications component. It would aim to stimulatedemand for project services,alter householdchild feeding and child care practices,encourage pregnant women to register early at the AWs, prepare adolescentgirls to effectivelypla- their roles as future mothers, motivate village level workers by enhancingtheir image and credibilitywithin the communityand promote communityinvolvement. The componentin both states would include supportfor strengtheninginstitutional capability,community education, audio-visual materials to supportnutrition - 21 - educationactivities of workers and communitygroups, formativeresearch, and monitoring and evaluation(see Annex 5 for details).

2.28 WCD has added a communicationsexpert to the ICDS Directoratein recognitionthat the communicationsaspects of current ICDS servicesneed to be strengthened. However, the institutionalcapacity for managing communication activities in both states is weak. Therefore,the projectwould establisha communicationscell in the State ICDS Directorate. It will comprise an AssistantDirector supportedby two program officers. Communica- tions researchwill be overseenby an officer from the monitoringand evaluation cell. Its staff capabilitywould be developedthrough specialized training. The project also would fund tectnicalassistance contracts with local commercialadvertising and market researchagencies for staff development through attachments,formulation of a detailedcommunication plan, and design and developmentof materials.

2.29 Communicationactivities would concentrateon a few selectedthemes in a phased manner. These themes includegrowth monitoring,weaning and child feeding, diarrheamanagement, antenatal and child health care, and utilization of ICDS and key health services. The projectwould financeproduction and distributionof counsellingcards, flip charts,wall posters, booklets,and three-dimensionalmodels to assistworkers in their interpersonalcommunica- tion activities. Village exhibitions,folk performancesand well baby shows would be used as events around which communityeducation activities would be centered. The projectwould also supportproduction of audio cassettesin local dialects for use at AWs and by women's working groups. It will provide for productionof radio programsand encourageformation of listeners'groups. Districtswould be providedwith video sets for use in orientationworkshops of community leadersand other governmentfunctionaries. The communication strategy is similar in both the states. But in view of Andhra Pradesh'smore developed institutionalinfrastructure, its communicationscomponent is more ambitious.

2.30 For effectivecommunications, the messages and materials produced should be relevant and of high quality. Both in Andhra Pradesh and Orissa, social marketing techniquesof formativeevaluation using qualitativeresearch would be utilized for developingrelevant and effectivecommunications content, structure,materials, and media-mix. The materialswould be extensivelypre-tested for their efficacybefore large scale production. In addition,the project would supportmonitoring and summativeevaluation of the communicationactivities to continuallyrefine them.

Communityl4obilization (US$11.0 million)

2.31 The project'scommunity mobilization activities aim not only at ensuring that communitiesutilize the servicesprovided, but also to enable communityrepresentatives and nutritionlhealthstaff to jointly study child health and nutrition problems in the community,pool knowledge and resources, and take actions to resolvethem. These activitiesshould encourage individualand communityself-reliance.

2.32 Communityparticipation is low in both the states. Therefore,the projectwould test innovativewomen's developmentactivities consisting of activatingmahila mandals (Women'sgroups, MM); income generatingactivities; - 22 - confederationof MMs; courses for Women's IntegratedLearning for Life (WILL) emphasizingfunctional literacy and health and nutritioneducation; and adolescentgirls' training (see Annex 6). The first three activitiesare closely linked in that they would operate throughthe phased establishmentof MMs in all projectvillages, with a subset taking up differentscales of income generationactivities facilitated by their confederations. These innovativeactivities would be evaluatedin the third year of the project (see para. 2.8) and expanded subsequentlywith necessarymodifications.

2.33 The project would activateMMs and strengthentheir involvementin AW activities. The AWWs and the supervisorswould form these groups, each consistingof at least 20 members. A non-recurringgrant of Rs. 1000 (US$53) would be made to each MM which has assisted the AW^Win achievingthe desired levels of service coverage. They will be encouragedto use these funds to purchaseequipment and materialsfor nutritionand health activitiesconducted by the group. Among the functioningMMs, some will be in a position to activate their members to undertakeincome generatingactivities. In order to encouragethese activities,MMs who show interest and potentialand develop specific proposalsfor income generationwould be given an additionalgrant of Rs. 3000 (US$158). Of these, a limitednumber (about a quarter of all MKs) would be in a position to expand their activitiesfurther and would be given an additionalgrant of Rs. 15,000 (US$790)as a fund for providing small credits to its members. CDPOs would be responsiblefor providingthese grants ollowing guidelinesdeveloped for this purpose. The income generationscheme would only operate in areas which are not currentlycovered by other programs of credit for women's groups. In Orissa, to strengthengroups of MMs engaged in income generatingactivities, the projectwould assist in settingup their confederationsby providinga start-upgrant of Rs 50,000 for working capital and sharing in their operatingcosts with the member MMs. The confederations will assist MKs in procurement,skill training and marketing. In Andhra Pradesh, similar assistancewould be provided by the Andhra PradeshWomen's cooperativeFinance Corporation'sdistrict level multipurposeproduction centers (PranRanams).

2.34 In addition,special educational programs for two groups-women in the age group 15-34 and adolescentgirls- would be tried in pilot areas. The project would support additionaloperating costs of WILL courses for adult women in those AWs where the ANW has the necessaryqualifications. The course, comprisingabout 15 women, would meet every working day for 10 months and would cover functionalliteracy, health and nutrition,and other skills for improvingtheir quality of life. The classeswould be conductedby the AWW in the evening for about an hour. Under the adolescentgirls training scheme, the AWW would select three girls for involvementin AW activities. After initial training,each girl would assist in AW activitiesfor two days a week and serve as its link with the community. Periodic refreshertraining would be conducted.

2.35 The communitymobilization component is similar in both states, except for three differences. First, WILL courses at the AWs in Andhra Pradesh would be conductedfer only two years but the proportionof AWs offering these courseswould be higher than in Orissa. Second,Pranganams in Andhra Pradesh and confederationsin Orissa would assist MMs in income generatingactivities. Third, in Andhra Pradesh, a few training-cum-production centers for adolescentgirls will be establishedas outreach facilities - 23 - of the district level Pranganams. It is anticipatedthat during the project, a total of 31,750 MMs would be activated,5,600 women's groups would receive assistancefor income generatingactivities, 13,250 AWs would conductWILL classes, and 23,500 AWs would have establishedadolescent girls' activities.

Project Management.Monitoring and Evaluation (US$6.0million)

2.36 Proiect Management. Tie projectmanagement unit (PMU) in each state would be headed by an additionaldirector drawn from the Indian Administrative Service as project coordinator. He or she would report to the State Director ICDS and would be in charge of day-to-dayproject activities. The PMO head would be supportedby four deputy/assistantdirectors, one each in charge of communications,training, health, and women and child development. Each deputy/assistantdirector would be supportedby about three professionalsand other staff. A separate cell would also be responsiblefor monitoring, researchand evaluation. An EmpoweredCommittee, chaired by the Chief Secretaryand comprisingthe secretariesof health, social welfare, and finance,would be constitutedin each state to approveplans, issue necessary governmentsanctions for implementation,and monitor the progress. The project coordinatorwould be a member-secretaryof the EmpoweredCommittee. The projectwould financevehicles, equipment and office furniture,and incrementalsalaries and other operatingcosts of the two PMOs. Assurances were receivedat negotiationsthat by January 1, 1991, the governmentsof Andhra Pradesh and Orissa will establishand thereaftermaintain project managementunits in accordancewith a key staffingplan satisfactoryto the Bank Group (para 5.1(f)).

2.37 Monitoring and Evaluation. Coverage by various servicesand provisionof project inputs would be monitoredregularly. The field level recordingsystem for ICDS is well established. It would need to be adapted to include the wider range of services to be provided under the project, particularlyfor communicationsand communitymobilization activities. Supervisorswould be made responsiblefor improvingthe reliabilityof the data. First, they would carry out sample checks of the field records and report their findingsto the CDPOs. Second,they would train those AWs who are deficientin record keeping. Third, annually they would share AW performance data with the community.

2.38 Currently,district and state level involvementin monitoring is minimal; the project would support actionsto remedy the situation. Different levels should focus on differentaspects. While the block level should focus on monitoringof critical activities,district review should monitor critical outcomes and the state level should deal with iapact objectives (annex 8). Reports from selectedAWs (about 50 in each district)would be computerizedto monitor critical outcomes. Based on the USAID-assistedproject and other experiences,the governmentis developinga computer-basedmonitoring system. This system will be utilized to provide feedbackto blocks and districts. Finally the staff involved in collectingand processingthe data would be trained. The in-servicetraining programs (see paras 2.26-7)would also increase skills cf staff at various levels in the use of data. The project would finance training for monitoringand evaluationpersonnel, office furnitureand equipment,including a desktop computer for each state, local consultant servicesin systems engineering,surveys and studies and incrementalsalaries and other operatingcosts. - 24 -

2.39 Baseline surveysare currentlyin progress in the project areas and their resultswould be availableby negotiations. In addition,a few studies of specificproblems such as incidenceof low birth weight and extent of anemia and worm loads among childrenwould be carried out in selectedblocks. A mid-term evaluationto assess progress is planned in the third year of the project (see para 2.8). The impact of several innovativeinterventions--the system of therapeuticsupplementation, field-based in-service training, communications,and communitymobilization--needs to be carefullyevaluated. Therefore,the mid-term evaluationwould also evaluatethese innovationsfor modificationsand subsequentexpansion (see para 2.8). As malnutritionlevels decline, differentinterventions would be requiredto further improve nutrition status. Therefore,a program of operationsresearch would be launched in selectedareas specificallydesignated for this purpose. A terminal evaluationwould be carried out at the end of the project. During negotiations,assurances were received that by September30, 1997, Andhra Pradesh and Orissa in consultationwith the GOI and the Bank Group will conduct a final evaluationof the project in accordancewith terms of referenceand methodologysatisfactory to the Bank Group (para. 5.1(g)).

1II. PROJECT COSTS, FINANCINGAND IMPLEMENTATION

A. Cost Estimates

3.1 Cost Summaries. The total cost of the pro act, net of duties and taxes, is estimatedat about Rs. 3,509 million or US$153.5million equivalent. Duties and taxes are around US$4 million. A breakdownof costs of the proposed project by componentand categoriesof expenditureappears in Tables 3.1 and 3.2 respectively. Detailed project costs by component, categoriesof expenditureand year appear in Annex 7. Table .l: COSTSBY COMPONENT ICOSProject

X Base % Base Local Foreign Totel Cost. Local Foreign Total Cost -- (RS '000)------(US 000) ------

A. ServiceD0 l vory Nutrition 1,053,051.7 98,811.0 1,747,402.7 e6 97,275.0 6,518.8 102,791.9 86 Health 171,027.8 35,001.9 206,629.7 8 10,095.6 2,056.9 12,154.7 S Training 253,243.5 12.678.2 285,916.7 1o 14.896.7 739.6 16,640.4 10 Subtotal Service Delivery 2,078,528.1 141,36.1 2,219,909.1 8s 122,206.1 6,816.6 130,652.9 6s 8. Comunications 1,59,214.0 6,888.6 107,647.6 6 9,86.6 490.2 9,865.7 6 C. Comunity Mobilization Women IncomGencmrston 124,145.0 - 124,145.0 6 7,802.0 - 7,802.6 6 n Women'eIntegrated Learning for Lif. (WIL) 23,910.6 1,000.7 24,911.5 1 1,406.5 69.9 1,465.4 1 Adolescent Girls" Program (AGATE) 38.07B.s 2,211.2 as,25.0 1 2,122.0 180.1 2,252.1 1 SubtotalCommunity Mobilization 184,129.5 3,211.9 187,841.4 7 10,881.1 180.9 11,020.1 7 0. Project Mangement: Project Orgenization 76,915.4 2,648.1 81,458.5 8 4,042.1 149.8 4,791.7 8 Monitoring and Evaluation 20,741.8 749.4 21,490.0 a 1,220.1 440 1.204.1 1 Subtotal Projoct Managment 99.66j.0 8,291.5 102,948.5 4 6.862.2 193.6 6.0S6.8 4 Total Baseline Cost. 2,521,628.5 168,223.0 2,677,740.8 100 Physical Contingencies 126,076.2 7,911.2 183,60T.8 6 Price Contingencies 618,512.0 83,990.8 697.602.s 20 TOTALPROJECT COSTS 8.281.111.7 248,026.0 8.609.18.7 1831 14824.9 9,189.6 157,514.5 100 Table 3.2: COSTSB^Y CATEGORIES OF EXPENDITURE ICOS Project

% Base S Base Local Foreign Total Costs Local Foreign Total Cost" --(-----RS 000) ------(USS o00) ------

Investment CoSt Civil Works 800,027.0 87,082.0 387,109.0 1s 17,648.8 2,181.8 19,829.9 18 Furniture 18,787.4 1,860.6 15,096.0 1 808.1 79.9 888.0 1 Equipment 188,700.1 19,281.8 151,981.9 6 ,884.7 1,072.5 8,987.2 6 Vehicle. 64,710.1 8,399.9 71,110.0 8 8,806.5 378.6 4,182.9 3 Dru 114,806.8 28,651.8 148,257.8 6 8,741.5 1,885.4 8,426.9 6 Training 212,852.7 11,176.5 223,529.2 8 12,491.3 657.4 13,148.8 8 Cogmunications Production and Dissemination 157,481.5 8,288.5 186,770.0 8 9,283.6 487.8 9,761.2 8 Studiesand Surveys 14,068.8 - 14,068.8 1 827.6 - 827.6 1 Grants 124,145.0 - 124,146.0 6 7,802.6 - 7.802.6 6 Total Investmont Costs 1,184,628.4 111,188.8 1,246,017.2 47 66,764.6 6,540.5 73,296.1 47 Physical Contingencies 58,741.4 5,569.4 62,800.9 2 Price Contingencioe 227,167.4 55,502.6 282,660.0 11 Total Including Contingencies 1418727.8 172,260.8 1.5s90978.1 59

Recurrent Costa Salaries 942,093.8 - 942,098.3 35 66,517.3 - 55,417.3 35 Consumables 114,975.8 28,748.9 148,719.7 6 6,763.8 1,690.8 8,464.1 5 Petroleum, Oil and Lubricants 38,654.6 4,295.0 42,949.6 2 2,278.8 252.6 2,526.4 2 Other Operating Costs 116,288.0 6,064.9 121,297.9 5 6,778.4 856.8 7,185.2 6 Therapeutic Nutrition 83,060.0 - 68,060.0 2 8,709.4 - 8,709.4 2 Rent 112,878.8 5s980.6 118,609.0 4 8.828.2 848.9 6,977.0 4

Total Recurrent Costa 1,388,895.1 45,084.2 1,481,729.4 58 81,570.8 2,649.1 84,219.4 58 Physical Contingencies 69,334.8 2,261.7 71,586.6 8 Price Contingencies 38B.364.8 28,488.2 4142.8 16 Total Including Contingencies 17842.884.4 75,774.1 1.918,150.6 72 Total Baeellne Costs 2,621,523.5 156,228.0 2,677,748.6 0oo Physical Contingencies 126,076.2 7,811.2 188,807.8 6 Price Contingencies 813,612.0 83.990.8 e97.602.s 26 Total Projoct Coste 8,261,111.7 248.026.0 8,509,188.7 131 148,324.9 9,199. 1567,514.6 100 - 27 -

3.2 Basis of Cost Estimates. Estimatedcosts for civil works of Rs 180- 200 per square foot are based on current unit costs of designs for similar types of facilities. They are comparableto the costs of similar Bank Group- assisted constructionin India. Costs of therapeuticsupplementation and other consumablesare based on state estimatesand reflectcurrent prices. Estimatedcosts for incrementalstaff salariesand other operatingcosts are based on current pay scales and norms used by the governmentsof Andhra Pradesh and Orissa.

3.3 ContingencyAllowances. Estimatedproject costs includephysical contingenciesestimated at 52 for all physical items. For locallyproduced items, price contingenciesare estimatedat 7S for the first two years of the project; 6.62 for the third year; 6.5Z for the fourth and fifth years; and 6.12 for the final year. For foreignproduced items, price contingenciesare estimatedat 4.92 for the first five years of the project starting in FY90 and 3.72 for the final year.

3.4 Foreign Exchange Component. The estimatedforeign exchange componentof US$9.2 million is calculatedon the basis of the following estimates: (a) civil works, 11Z; (b) furniture,9Z; (c) locally-produced equipment,vehicles and consumablematerials (includingdrugs)--122, 92 and 202, respectively;(f) operationand maintenanceof vehicles,102; and (g) other operationand maintenancecosts and costs of training,5Z.

B. FinancingPlan

3.5 The estimatedtotal project cost of US$153.5 million net of duties and taxes would be financed by an IBRD loan of US$10 million equivalentand an IDA credit of SDR 73.6 million (US$96million equivalent)which togetherwould cover about 70 percent of costs net of duties and taxes. The GOI and the states of Andhra Pradesh and Orissa would financeUS$51.5 million equivalent to cover remainingproject costs. The financingplan appears in table 3.3. Cost recovery is not consideredfeasible because most of the beneficiariesare from householdsnear or below the poverty line. - 28 -

Table 3.3: PROJECTFINANCING PLAN

Cost Including Taxes and Duties - ---- US$ million------

Local Foreign Total Z

IBRDIIDA 96.8 9.2 106.0 67.3

GOI 40.4 0.0 40.4 25.6

Andhra Pradesh 5.5 0.0 5.5 3.5

Orissa 5.6 0.0 5.6 3.6

TOTAL 148.3 9.2 157.5 100.0

C. RecurrentCost Impligations

3.6 The GOI now spends around US$117 million equivalentyearly on ICDS. When fully operationalin 1996, the project'srecurrent cost to GOI will be around US$16.5 million equivalent,14Z of present GOI o-utlayson ICDS. During the last five-yearPlan, ICDS's budget virtuallydo-.bled. Even if ICDS were to grow at a more modest overall rate of 15Z yearly during the Eighth Plan, the project would account for under 82 of GOI spending on ICDS in 1996. Although this is still a significantshare of ICDS resources,the GOI is clearly committedto the project and tte project areas merit high ICDS priority as it covers largelytribal, drought-proneor otherwisedisadvantaged rural blocks. Moreover, the incrementalcost representsa small share of overall GOI social sector spendingthat was about an estimated0.672 of GDP in 1986/87.

3.7 The incrementalcosts of the project to the states in 1996 would be for supplementarynutrition (see para. 1.12). In Orissa,which spends US$1.3 million equivalentyearly to augment food donationsvalued at US$4.3 million for supplementarynutrition programs throughoutthe state (see para. 1.32), includingall project areas, the additionalcosts would be negligible. However, those additionalcosts would amount to around US$3 million equivalent in Andhra Pradesh,where supplementarynutrition would need to get startedand be maintained in the 44 new ICDS blocks under the project. Andhra Pradeshnow spends around US$110 million equivalent (aroundfour percent of total state expenditure)yearly on social security and nutrition. State expenditureon community servicesand nutritionhas been keeping pace with the seven percent annual increase in total state governmentoutlays. Even if state expenditure for communityand nutritionservices were to grow at half its present rate of increase,in 1996 the projectwould absorb just under one-sixth of that increase. Operations researchon supplementation(see para. 3.8) may identify ways to increase the cost-effectivenessof supplementationin the outer years - 29 - of the project. Additionally,as communitycapability increases and malnourishmentrates fall, the need to provide supplementarynutrition in both states should decline.

D. ProjectImplementation

3.8 PreparationProcess and Status of Preparation. By the end of the appraisalmission, clear strategieshad been developedfor respondingto the ICDS design and implementationproblems and for acceleratingthe pace of improvementin the nutritionstatus of children under three. A phased implementationplan for the projecthas been developed. Baseline surveys are nearlng completion. A detailed trainingplan for pre-service,orientation and refreshertraining under the projecthad been prepared,as had a broad strategy for the communicationscomponent. However,operational research plans leading to possible refinementof supplementationstrategies for malnourishedchildren need to be detailed and tested in the first three project years (see paras 2.07-8).These will includethe addition of therapeuticsupplementation for all moderatelyand severelymalnourished children under three years of age to existing ICDS supplementaryfeeding or shiftingto a calorie-densesupplement for all ICDS beneficiaries.A third researchtrial would be to shift to take-homerations for all under-threeICDS beneficiariesand inauguratetherapeutic on-site supplementationfor those who are moderately or severelymalnourished. At negotiations,the GOI provided draft terms of referencefor the trial of optional approachesto therapeutic on-site supplementationfor growth-falteringand grade II-IV malnourished children aged 6-36 months.

3.9 So that the project can start promptly,the state governmentsplan to carry out the followingactivities between project negotiationsand loan and credit effectiveness: (i) finalize reportsof baseline epidemiological and nutritionstatus surveys in the project areas; (ii) finalize arrangements with NGOs for additionalAW training centers in Orissa; (iii) develop training materialsand conduct pre and in-servicetraining for some workers and supervisors;(iv) establishproject management units; (v) prepareprototype designs for low-cost constructionof AWs.

3.10 Project Implementation. The Departmentof Women and Child Development (WCD) in the Ministry of Human ResourcesDevelopment in GOI and the Women's Development,Child Welfare and Labor Departmentin Andhra Pradesh would be responsiblefor implementingthe Andhra Pradesh part of the project. SimilarlyWCD in GOI and the Ministry of CommunityDevelopment and Rural Reconstructionin Orissa would be responsiblefor implementingthe Orissa part of the project. Project implementationwould be the responsibilityof the respectivestate project coordinatorsin the PMU of each state (para 2.36). A project implementationschedule appears in Annex 8. Non-governmentorganizations would help carry out trainingprograms (para. 2.23) and village-level women's groups are key actors in communitymobilization activities (paras.2.32-33).

3.11 Monitoringand Evaluation. Arrangementsfor monitoringprogram activitiesare discussedin paras 2.37-39. WCD would have overall responsibilityfor both the states. Within the states the project coordinatorswould be responsiblefor monitoringand evaluation. Assurances were obtained at negotiationsthat Andhra Pradesh and Orissa will furnish to - 30 - the Bank Group for review and discussion (i) quarterlyand annual progress reportswithin three months of the end of the relevantimplementation period and (ii) a prospectiveannual work plan by January 31 of each fiscal year on the activitiesto be carried out under the project in a format satisfactoryto the Bank Group (para 5.1(h)). Arrangementsfor project evaluationand related assurancesare discussedin paras 2.08 and 2.39. The GOI would prepare a ProjectCompletion Report within six months of the project closingdate.

E. Disbursements

3.12 DisbursementPercentages. The projectwould disburse against 1002 of the costs of training,communications production and dissemination, consultants,studies and research;90X of civil works; 100? of CIP and of ex- factorycost or 802 of expenditureson furniture,equipment, materials, vehicles,drugs and medicines; 602 of the incrementalcost of therapeutic nutrition supplements,and 60Z of other incrementaloperating costs. These comprise salariesof new staff to be added as project servicesintensify and expand, and additionalsupplies and vehicle operatingcosts and maintenance. The percentageof incrementaltherapeutic nutrition supplemertsand incrementaloperating costs to be financedby the Bank is equivalentto 1002 financingfor the first year they are incurred,reduced by around an additional25? in each succeedingproject year (see Annex 9).

3.13 Required Documentation. Disbursementsin respect of expenditures under contractsvalued at less than US$200,000equivalent for civil works, furniture,equipment, vehicles, drugs and medicines,therapeutic nutrition supplements,consultant services and trainingwould be made against statements of expenditurecertified by WCD and the project coordinatorsin the two states. Documentswould be retainedby the respectivestate governmentsfor Bank Group review during supervisionmissions. All other disbursementswould be made against fully documentedwithdrawal applications. 3.14 SpecialAccount. In order to acceleratedisbursements in respectof the Bank Group's share of expenditurespre-financed by GOI and the concerned states and in order to allow for direct payment of other eligible local and foreign expenditures,a SpecialAccount would be opened in the Reserve Bank of India with an authorizedallocation of US$5.0 million equivalentto cover four months, expected requirementsfor Bank Group-financeditems.

3.15 RetroactiveFinancing. Up to SDR 1.5 million (US$2.0million equivalent)is prorided to cover eligible expendituresincurred in implementingappraised project activitiesafter September30, 1989, and the expected date of Loan and Credit signing, around the end of September,1990. (See para 3.9 for details).

3.16 DisbursementProfile. The proposed IDA credit and Bank loan would be disbursedover a seven and a half year period consistentwith the Bank Group profile for nutritionprojects. The profile is realisticin this case because (a) experiencedinstitutions are in place in both states to implementthe project; (b) implementationin any one year is on a scale which both states previouslyhave managed; and (c) most of the new blocks would be established and civil works would be completed in the first four years of project opera- tion. The project period thereforeencompasses not only the time required to cover new areas but also includesa lengthy operationalperiod. The latter - 31 - would allow expanded servicecoverage, improved quality of services and supplementationprocedures, and communication,community mobilization and training to have significantimpact on nutrition and health status of children under three years of age and pregnant and nursingwomen. The project is expected to be completedby March 31, 1997 and the loan and credit is expected to be closed on December 31, 1997, permittinga year for final evaluationat the completionof project operations. A forecastof annual expendituresand disbursementsis shown in Annex 11.

P. Procurement

3.17 Project-relatedprocurement would be managed by the Project ManagementUnit in each state, followingproceeures acceptable to the Bank Group. Project-financedconsultants would be selected accordingto the proceduresin the Bank Group's Guidelinesfor Hiring Consultants.

3.18 Civil Works (US$19.8million). The main civil works in the project consist of about 3,750 new AW Centers costing less than the equivalentof US$5,000 each. These are small, widely-dispersedbuildings for which neither foreign firms nor large domestic contractorsare expected to be interestedin competingfor construction. In addition,it is proposed to use low-cost constructiontechniques for these buildings. Therefore,the civil works would be carriedout through a combinationof force account and LCB. Most of the Aws are expected to be built throughforce account. In Andhra Pradesh, this work would be carried out by the Tribal Welfare Department,Andhra Pradesh InfrastructureDevelopment Corporation and Weaker Section Housing Corporation. In Orissa, a comtinationof agencies--Block DevelopmentOffice, selectedNGOs and Housing and Urban DevelopmentCorporation--ere proposed to be utilized. Constructionwork for offices and warehouses (para 2.13). and experimental maternal and rehabilitationhomes (para 2.21), would be let throughLCB procedures,which are satisfactoryto the Bank Group, since each building costs less than the equivalentof US$ 10,000 each and is too small to be of internationalinterest.

3.19 Equipment (Us$8.9million) would be procured on an annual basis in accordancewith the phasing of project activities. Equipmentwould be mainly of three types: utensils and other minor items for CommunityNutrition Centers, typewritersand other office equipmentfor block and higher-level nutrition offices, and equipmentfor health facilities. Becauseof the phasing and diversityof items to be procured,they are not suitablefor ICB and it is not expected that any individualcontract would approachUS$200,000 equivalent. Therefore,equipment contracts would be awarded through LCB. Equipmentvalued at US$50,000 equivalentor less up to an aggregatetotal of US$2.0 million over the project implementationperiod could be procured through prudent local shopping.

3.20 Drugs (US$8.4million) contractswould be bulked insofaras possible into packages estimatedto cost the equivalentof US$200,000or more and awarded through internationalcompetitive bidding (ICB). For drugs procured under ICB, local manufacturerswould be affordeda domestic preferenceof 152 or the prevailingrate of duty, whichever is lower. Procurementunder ICB would be subject to prior Bank Group review and approval. Contractsfor the purchase of drugs valued at less than US$200,000equivalent each up to an aggregatetotal of US$1 million during the project implementationperiod would - 32 - be awarded on the basis of LCB proceduresacceptable to the Bank Group. Drugs valued at US$50,000 equivalentor less up to an aggregatetotal of US$3.0 million over the project implementationperiod could be procured through prudent local shopping,with solicitationof price quotationsfrom at least three suppliers.

3.21 Procurementof 4-wheeldrive vehicles (US$4.2million) mainly for rural use, would be spread over the disbursementperiod to match the introduction or upgradingof project servicesanid replacement schedules. As project services are being phased into 25 Districtsover five years, the number of vehicles procured at any one time is not likely to exceed five and foreignand local suppliersare unlikely to be Interestedin bidding. Therefore,vehicle contractswould be awarded throughprudent shopping.

3.22 Furniture (US$0.9million) is readilyavailable from local manufacturersand foreign firms are unlikely to bid. Furnitureorders would be bulked to the extent possible for LCB procurersnt. Contractsfor furniture estimatedto cost less than the equivalentof US$50,000up to an aggregate amount of US$800,000 equivalentmay be awarded on the basis of prudent local shopping. Since most furniturewill be of simple constructionbought and installedin remote rural areas, most of the furnitureprobably would be procured through prudent local shopping.

3.23 Procurementof therapeuticsupplementary nutrition (US$2.1million. see para. 2.18) would be throughprudent shopping,since amounts to be provided at any one time for operationsresearch are likely to be too small to attract bidding intcrest.

3.24 Local contractsfor productionof communicationsmessages and for specific studieswould be awarded accordingto Bank Group guidelines. Contracts for civil works, equipment,vehicles and furnitureestimated to cost US$200,000equivalent or more also would be subjectto prior Bank Group review and approval. A total of around 40 contractsrepresenting around 36Z of the total value of procurementwould be subject to prior review over the procurement period.

G. Accountingand Auditing

3.25 The projectwould be subjectto normal GOI accountingand auditing procedureswhich are consideredsatisfactory to the Bank Group. The project cell would maintain separateproject accountsand a quarterlystatement of expenditureswould be provided to the Bank Group. The GOI, Andhra Pradesh and Orissa would be asked to agree that: (a) accounts and financialstatements for each fiscal year would be prepared and audited by indenendentauditors acceptableto the Bank Group; (b) statementsof expenditures(SOEs) would be maintained in accordancewith sound accountingpractices for at least one year after the completionof the audit for the fiscal year in which the last withdrawalwas made and a separateopinion on SOEs be includedin the annual audit; and (c) certifiedcopies of the audited accounts and financialstatements for each fiscal year, togetherwith the Auditor's report would be furnishedto the Bank Group as soon as available,but not later than nine months after the end of each fiscal year. - 33 -

Table 3.4: PROCUREMENT METHOD

Categories of ICB LCB Other N/A Total Cost Expenditure -S------US$ million ------

Civil Works 0.0 2.1 17.7 0.0 19.8 (0.0) (0.0) (17.5) (0.0) (17.5)

Equipment and Materials 0.0 6.9 2.0 0.0 8.9 (0.0) (5.3) (1.6) (0.0) (6.9)

Medicines and Drugs 4.4 1.0 3.0 0.0 8.4 (4.4) (0.8) (2.7) (0.0) (7.9)

Vehicles 0.0 0.0 4.2 0.0 4.2 (0.0) (0.0) (3.3) (0.0) (3.3)

Training, Consultant 0.0 0.0 23.7 0.0 23.7 Services, Studies and Reeearch (0.0) (0.0) (23.3) (0.0) (23.3)

Furniture 0.0 0.0 0.9 0.0 0.9 (0.0) (0.0) (0.6) (0.0) (0.6)

Grants to Women's Groups 0.0 0.0 0.0 7.4 7.4 (0.0) (0.0) (0.0) (0.0) (0.0)

Incremental Therapeutic 0.0 0.0 3.7 0.0 3.7 Nutrition Supplementation (0.0) (0.0) (2.1) (0.0) (2.1)

Other Incremental 0.0 0.0 0.0 80.5 80.5 Operating Costs (0.0) (0.0) (0.0) (44.4) (44.4)

Total 4.4 10.0 55.2 87.9 157.5 (4.4) (6.1) 51.1) (44.4) (106.0) - 34 -

IV. BENEFITSAND RISKS

4.1 Benefits. The projectwill have an importantimpact on nutrition and health status of young children. Despite reductionsin infant and child mortality,the nutrition status of children is improvingonly gradually,thus hamperingtheir development. The project would substantiallyaccelerate the pace of this improvementand also contributetowards a faster reductionin infant and child mortality in poor areas of Andhra Pradesh and Orissa. It is estimatedthat around five million relativelydisadvantaged children 0-6 years of age in the project areas would directlybenefit from the project'snutrition, health and educationalservices. Through the project, severalhealth technologies--acuterespiratory infection management, oral rehydration therapy,deworming, and vitaminA and iron supplementation--wou:dbecome more widely available. By increasingfamily and communitycompetence to avert and treat malnutrition,the projectwould help bring about a reducedneed over time for therapeuticsupplementation.

4.2 The project would also have a significantimpact on the health, nutritionand maternal competenceof women. It is estimatedthat about three million pregnant and nursing women would directlybenefit from the project's health and nutritionservices. In the new project blocks to be developed,an estimated 44,000women would obtain training and part-timeemployment as AWWs and helpers, plus an additional1,600 women at supervisorylevels. These workers would be responsiblefor formingnew Women's Groups with a total membership of about 600,000women, who would be trainedboth in basic health and nutritionalcare and in how to pass on their knowledgeto other women in the community. Around 5,600 women's groups would participatein income generationactivities. In addition,over 150,000 adolescentgirls would receive apprenticeshiptraining in health and nutritionunder the project.

4.3 But a more significantand long term indirectbenefit of the project is its likely impact on ICDS which currentlycovers around 40 percent of India's rural blocks. By testing innovativeways of therapeuticsupplementation and nutritionalrehabilitation, it would lead to more effectivenutrition services. The software systems--training,supervision, communication, communitymobilization, and monitoringand evaluation--developedunder the project, if successful,would lend themselvesto a wider replicationwhich would increase the pace of improvementin child nutritionand reductionin infant and child mortality. If so, then it is expected to result in improved physical and mental capacity and, therefore,an improvementin the quality of Andhra Pradesh and Orissa'shuman capital.

4.4 Risks. There are two main risks. First is inadequateimplementa- tion capacity,which may result in lower than desired service coverageand quality. The second is constraintsto replacingworker-determined socio- economic criteriawith verifiablenutrition and growth-falteringcriteria as the basis for supplementarychild feeding. Four project actionswould reduce the first risk. First, organizationat block, districtand state levels would be strengthenedand staff would receivenecessary training. Second, the new modes and content of servicedelivery would be tested and refined in pilot blocks and evaluatedas the basis for wider replication. Third, the results of a mid-term evaluationafter two years of project operationwould be discussedwith the Bank and would guide both modificationsof project content - 35 - and the subsequentimplementation pace. The latter risk would be reducedby assurancesthat initially-agreedICDS supplementaryfeeding criteria or any modificationsto them would have to be satisfactoryto the Bank Group (see para. 2.8), the carrying out of operationalresearch on alternative supplementationprocedures (see para.s 2.7-2.8) and the weight of accumulating evidence that selectivesupplementation is more effectiveand efficientthan near-universalfeeding in promotingchild developmentand growth.

V. AGREEMENTSREACHED AND RECOMMENDATION

5.1 The followingassurances were receivedduring negotiations:

(a) by September30, 1994, Andhra Pradesh and Orissa will complete and discusswith the Bank Group the findingsof operationsresearch on alternativeapproaches to the provisionof therapeuticnutrition supplementationfor growth-faltering,moderately and severely malnourishedchildren under three years of age (para. 2.8).

(b) Andhra Pradesh and Orissa would maintain beneficiaryselection criteria and proceduresfor nutritionsupplementation acceptable to the Bank Group in project areas (para 2.8);

(c) by December 31, 1993, the Andhra Pradesh and Orissa will conduct mid-term reviews and evaluationsof project operationsin consultationwith the GOI and the Bank Group under terms of referenceand a methodologysatisfactory to the Bank Group (para. 2.8);

(d) in Andhra Pradesh and Orissa, an additionalsupervisor would be placed in each project block for the first two years of project implementationin that block (para. 2.13);

Ce) by September30, 1991, Andhra Pradesh and Orissa will carry out a functionalanalysis of nutritionand health staff work routinesat and below the block level under terms of referencesatisfactory to the Bank Group and discuss the resultswith the Bank Group (para. 2.14);

(f) by January 1, 1991, Andhra Pradesh and Orissawill establishand thereaftermaintain ProjectManagement Units in accord with a key staffing plan satisfactoryto the Bank Group (para 2.36);

(g) by September30, 1997, Andhra Pradesh and Orissa in consultation with the GOI and the Bank Group will conduct a final evaluationof the project in accord with terms of referenceand a methodology satisfactoryto the Bank Group (para. 2.39); and

(h) Andhra Pradesh and Orissa will furnish to the Bank Group for review and discussion (i) quarterlyand annual progress reportswithin three months of the end of the relevant implementationperiod and (ii) a prospectiveannual work plan by January 31 of each fiscal - 36 -

year on the activitiesto be carried out under the project, in a format satisfactoryto the Bank Group (para 3.11).

5.2 With the above assurances,the proposedproject constitutesa suitablebasis for a Bank loan of US$10 million equivalentto India for 20 years, including5 years of grace, a standardvariable interest rate and an IDA credit of SDR 73.6 million (US$96million equivalent)to India at srandard IDA terms with 35 years maturity. - 37 - ANNEX 1 Page 1 of 6

INDIA

INTEGRATEDCHILD DEVELOPMENTSERVICES PROJECT

IntegratedChild DevelopmentServices Scheme (ICDS)

1. ICDS evolved as a coordinatedprogram effort for integrateddelivery of a package of nutrition,health and educationalservices. The blueprintof the scheme was drawn by the Ministry of Social Welfare, GOI, in 1975. Broadly the objectivesof the ICDS are:

a. To improve the nutritionaland health status of children under 6 years of age;

b. To lay the foundationfor proper psychological,physical and social developmentof the child;

c. To reduce the incidenceof mortality,morbidity, malnutrition and school drop-outs;

d. To achieve effectivecoordinated policy and its implementationamong concerneddepartments to promote child development;and

e. To enhance the capabilityof the mother to look after the normal health and nutritionalneeds of the child through proper nutrition and health education.

The scheme called for coordinatedand concertedefforts by different Ministries,Departments and voluntaryorganizations.

Services

2. ICDS envisagesdelivery of the followingpackage of services: supplementarynutrition, immunization,health check-up,referral services, nutrition and health education,and non-formalpre-school education. The administrativeunit for an ICDS project is a communitydevelopment block (populationabout 100,000),a tribal developmentblock (populationabout 50,000) or a group of urban slums similar in size to rural block. Each project is headed by a full-timeChild DevelopmentProject Officer (CDPO). An Anganwadi (AV) center is set up on an average for a populationof 1,000 in rurallurbanareas and for a populationof 700 in tribal areas. Supplementary feeding, non-formalpre-school education, and nutritionand health education are provided through AWs. Immunization,health check-upsand referral services also are deliveredat AWs through the network of health services in the area. The service coverage sought for differentbeneficiary segments is given in table 1.

3. A local woman AU worker (AWW) runs the AW. She works part-time (e.g. around 6 hours per day) on an honorary basis and is paid Re. 225 or Rs. 275 a month dependingupon her educationalqualifications. She is selected by -38- ANNEX 1 Page 2 of 6 a committeeof governmentand non-governmentofficials. Upon selection,she undergoesa three-monthcourse and starts the AW. The AW is responsiblefor organizingpre-school activities in the AW for about 40 children in the age group 3-5 years, arrangingsupplementary feeding for children 6 months to 5+ years and pregnant and nursingwomen, health and nutritioneducation to mothers, visiting homes for educatingparents, elicitingcommunity support and participation,assisting the health staff in immunization,health check-up, referral services,family planning and health educationprogram, liaisingwith other institutionsand agencies in her area, and maintainingroutine files and records. The AWW is assisted by a local femalehelper who receivesa monthly honorariumof Rs. 110.

4. SupplementarlNutrition is given to children below 6 years of age and pregnant and nursing women from low-incomefamilies according to establishedguidelines. Generally,the aim of ICDS is to supplementdaily nutrition intake by about 200 calories and 8-10 grams of protein for children below 1 year, 300 calories and 15 grams of protein for children between 1 and 5+ years of age, and 500 calories and 25 grams of protein for pregnant and nursing women. Severelymalnourished children should receive double the supplementof other children. The type of food supplementvaries but locally availablefood is preferred. Supplementaryfeeding is provided to beneficiariesfor 300 days annually. The AWW is responsiblefor organizing supplementarynutrition activities. The helper assists the AV in cooking and distributionof food. Mothers may also be involved in feeding activities.

5. Beneficiariesfor supplementaryfeeding are to be selected so as to ensure coverage of the most needy and malnourished. All moderatelyor severelymalnourished children below 6 years of age and those from families below the poverty line should be registeredfor supplementaryfeeding at the AW. All children 3-6 years of age attendingthe AW for pre-schooleducation should also receive supplementaryfeeding. Pregnant and nursing women from poor familiesare eligible for supplementarynutrition. In addition,children and pregnant and nursing women from higher-incomehouseholds can be eligible for supplementaryfeeding on the basis of specifiedhealth criteria or if referred by health staff. There are no explicit exit criteria for supplementaryfeeding other than reaching6 years of age. However, ICDS guidelinesstate that childrenwho are normal or only mildly malnourisheddo not requireAV supplementation.AWs are to encouragemothers of such children to withdraw them voluntarilyfrom ICDS feeding.

6 Immunization. The AWW, in collaborationwith the female multipurpose health worker (MPWF),should organize immunizationfor childrenbelow 1 year of age with six Universal Programof Immunizationvaccines (BCG, diphtheria-whoopingcough-tetanus, polio,and measles), and booster doses of diphtheria and tetanus for older children. Near-universalcoverage (85X) of pregnant women by two doses of tetanus toxoid is also sought.

7. Health Check-ups. Local health staff are responsiblefor the followingservices- antenatal care of pregnantwomen, post-natalcare of nursing mothers, care of new-bornsand childrenunder 6 years of age. At- risk children are to be provided with prophylacticmeasures againstmicro- nutrient deficiencies such as anaemia and vitamin A, deworming,and treatment for the widely prevalent diseases like diarrhea,respiratory infections and -39 - ANNEX 1 Page 3 of 6 skin and eye diseases. Serious and high-riskcases should be referred to higher levels of health care. The AW is respondiblefor follow-upto ensure that necessary serviceshave been provided and maintainsrecords of those services. She also receivesmedicine kit to provide simple care to AV beneficiaries.

8. Referral Services. The AWW should refer childrenwith severe malnutritionand growth falteringto the MMPW who in turn may refer them to higher levels of health care. In practice,referrals are often not completed althoughAVW is expected to follow-upreferral cases.

9. Non-formalPre-school Education seeks to lay the foundationfor proper physical,psychological, cognitive and social developmentof the child. It is impartedat the AW to children in the age group 3-5+ using flexible program content and methods to stimulateand encouragethem to grow at their own pace. The emphasis is on use of locallyproduced materials and toys.

10. Nutritionand Health Educationis offered to all women of child- bearing age. It aims at effectivecommunication of selectedbasic health and nutritionmessages to enhance the mother's competencein child nutritioncare through speciallyorganized courses and campaigns,home visits by AWWs, cooking demonstrations,use of mass media and other availablemeans of informationdissemination. ICDS also envisagesthe involvementof loc&l groups such as women's groups known as Mahila Mandals (MK), youth organizationsand other governmentfunctionaries in educationaltasks.

Organizationand Administration

11. AWs are supervisedby female supervisors(Mukhya Sevikas, MS), 1 for 20 AWs in rural/urbanareas and 1 for 17 in tribal areas. Through regular field visits, the MS is responsiblefor checking recordsand stocks, guiding AWWs, helping AWs in developingcommunity contacts and assistingCDPOs. The CDPO, as the leader and coordinatorof the ICDS team in the block, supervises and guides the work of MSs and AWWs through periodic field visits and staff meetings. He/she ensures a regular flow of supplies,liaises with other block staff, promotes communityinvolvement in ICDS activitiesand convenesblock level ICDS coordinationconumittee meetings. The CDPO's office is staffedby an accountant,a statisticianand other support staff. At the district level, a District Social Welfare Officer (DSWO)or District Project Officer (DPO), under the overall guidance of Collector,who usually heads the district administration,is responsiblefor ICDS implementationand coordinationwith other district officers.

12. At the state level, an ICDS Directoratein a departmentdesignated by the state government,usually Social Welfare or Women and Child Development,has overall implementationresponsibility. It is headed by a Director and staffedby a project officer, accountantand other supportpersonnel. In the Governmentof India (GOI), a nucleus secretariatin the Departmentof Women and Child Development(WCD) in the Ministry of Human ResourcesDevelopment is responsiblefor budgetary control, directionof implementation,and monitorilg of ICDS. - 40 - ANNEX 1 Page 4 of 6

13. Training is under the overall guidanceof the National Instituteof Public Cooperationand Child Development(NIPCCD), a semi-autonomouspublic agency. A network of over 200 AV Training Centers (AWTC),either government or grant-in-aidnon-government (NGO) institutions,provides training to AWWs using a curriculumand methodologyspecified by NIPCCD. Each state has also set up one or more Middle Level TrainingCenters (MLTC),either state or grant-in-aidinstitutions, to train MSs. NIPCCD trains CDPOs and trainersof AWTCs and MLTCs. UNICEF provides financialassistance for ICDS training activities.

14. Coordination. ICDS seeks to promote a coordinatedinter-sectoral approach to child developmentand, to that end, has set up coordinating committeesat block, district, state and centralgovernment levels. The block level committee is headed by the subdivisionalofficer of the area and comprisesthe Block DevelopmentOfficer, Medical Officer, CDPO and selected other block officers. The districtcoordination committee functions under the chairmanshipof the collector,District DevelopmentOfficer or Deputy Commissioner. At the state level, an ICDS coordinationcommittee is set up under the chairmanshipof the co-cernedMinister.

15. CommunityParticipatj n in ICDS is a broader concept, intendedto involvenot only utilization its servicesor contributionsfor the program but also in its planning and implementation. While recognizingseveral constraints,the main mechanismsfor elicitingcommunity participation are communityeducation, involvement of MMs, recruitmentof local staff and contributionstowards providing a facility for AW.

16. Monitoringand Evaluation. The AW maintains several registers- weight chart register,survey or family register,attendance register, and immunizationregister - and daily diary and supervisionrecords. In addition, the MPWF maintains records for antenatal,postnatal, and child care. The AWW submits a monthly progress report to the CDPO vho consolidatesthis informationwith the ICDS informationavailable from PHC and submits a monthly report to the State Governmentwith a copy to the national ICDS monitoring cell. Technicalmonitoring of health and nutrition servicesis carriedout by the ICDS Central TechnicalCommittee. Key health personnel serve as advisers at state, district and block levels and are responsiblefor technical monitoring at the field level. The data analysis cells at the state headquarterscompile the state data. The Program EvaluationOrganization (PEO) of the PlanningCommission and several research organizations periodicallyevaluate ICDS.

17. FinancialArrangements. ICDS is a centrally-sponsoredscheme, framed and partially financedby GOI. The state governmentsimplement the scheme according to budgetarypatterns and broad guidelinesprescribed by the GOI. ICDS costs are shared between the Central and state governments. State governmentspay for food and the central governmentfor all other costs. The cost of supplementaryfeeding per day is estimatedat Rs. 0.50 to 0.70 for a child, Rs. 1.05 for a pregnant or nursing women, and Rs. 1.20 for a severely malnourishedchild. The average annual cost of an ICDS block is Rs. 0.9 million for infrastructureand Rs. 1.7 million for supplementary food (see table 2 for details). - 41 - ANNEX 1 Page 5 of 6

Source:Various ICDS documentsin files.

Table 1. TargetedCoverage by ICDS services in an AV

Target Service Rural/UrbanAW Tribal AV Group Total Target 2 Total Target Z pop pop coy pop pop coy

Children Immunization 170 170 100 120 120 100 0-5 years Health Check-up 170 170 100 120 120 100 Supp. nutrition 170 68 40 120 90 75 Referral as necessary as necessary

Children pre-schooled. 80 40 S0 56 42 75 3-5 years

Pregnant Supplementary 16 8 50 12 9 75 women nut (6 months) Health check-up 24 24 100 17 17 100 TT immunization 24 24 100 17 17 100

Nursing Supplementary 16 8 50 12 9 75 mothers nut. (6 months)

Women Nutrition& 200 200 100 140 105 75 15-45 years health education - 42 - ANNEX 1 Page 6 of 6

Table 2. Estimatesof Annual ICDS Costs (Rs. in ,00O0)

Infrastructure Typical Rural/UrbanBlock (100 AWs)

Salaries and honoraria CDPO 44 Supervisors 160 AWWs 318 Helpers 132 Block Office 113

Other Operating Costs 85

Subtotal 852

SupplementaryFood

Children 6-36 months (Rs. 0.60 per day) 504 Children 3-6 years (Rs. 0.60 per day) 720 Pregnantand Nursing women (Rs. 1.05 per day) 480

Subtotal 1,704

Total 2,556 - 43 _ ANNEX 2 Page 1 of 4

INDIA

INTEGRATEDCHILD DEVELOPMENTSERVICES PRQJECT

Impact and Process Obiectives

1. The Project'simpact objectivesare ambitiousbut feasible in blocks where the Projectmaintains over four years the specificcoverage levels listed below. The proposed reductionin severe malnutritionover six years in Andhra Pradesh and Orissa derives from outcomes over five years in rural Tamil Nadu at lower participationrates and with less powerful interventionsthan those to take place under the proposed Project,which seek to reflect the lessons of TINP (see paras. 1.35-1.37). Moreover,nutrition conditions in some of the early TINP areas were similar to those which appear to obtain in the ICDS areas proposed for Bank Group assistance. Proposed upward shifts in the Normal+Mildmalnourishment curve also stem from Tamil Nadu experience includingthe outcome of recent pilot supplementationof moderately malnourished6-36 month-olds. Monitoringand evaluationdata indicated, dependingon location,an upward shift of 10-202 in the Normal+Mildcurve under TINP; one year of recent supplementationof moderately-malnourished under-threesin a TINP area has further increasedthe proportionof Normal+Mildchildren by an additional202. Because of Andhra Pradesh's relativelymore developeddelivery systems and infrastructure,it is likely to achieve a faster upward shift than Orissa in the overallnutrition curve.

2. IMR reductiongoals requirean average annual decrementof 4 per 1,000 live births in project areas, already achieved in rural areas of many Indian states and consideredfeasible with the range of interventionsproposed under the project. By means of these interventions,IMR in project areas would decline more sharply and reach levels comparableto the better-off rural areas of both states.

3. Reduction in the incidenceof low birth weight is the most difficult objective; its achievementdepends on early and complete identificationand nutritionalsupplementation of women at risk because of inadequateweight gain in pregnancy or iron deficiency. However, the proposed reductionsare consideredfeasible based on the relative state of delivery systems in Andhra Pradesh and Orissa. _ 44- ANNEX 2 Page 2 of 4

TargetedCoverage (percent) Process Objectives Andhra Pradesh Orissa

Early registrationof pregnantwomen 50 50

Total registrationof pregnantwomen 80 80

Obstetricaland nutritionalrisk assessment of those registered 100 100

Tetanus toxoid immunizationof pregnantwomen 90 80

Consumptionof iron and folic acid tablets for at least 12 weeks by pregnantwomen 60 60

Administrationof post-partumvitamin A to attended deliveries 80 80

Food supplementationfor at least 20 weeks to registeredpregnant women with inadequate nutrition status 80 60

Food supplementationfor at least 16 weeks of registeredlactating women with malnutrition in pregnancy 90 90

Immumization(UIP-6) of children 90 85

Vitamin A megadose (100,000- 200,000 i.u.) semi-annuallyto children 6-36 months 80 s0

Regular growth monitoring(>9 times in a year) of children 0-3 years 80 60

Supplementationof monitored children 0-3 years with grade II-ITVmalnutrition 90 90

Completed referral of severelymalnourished children (grade III and IV) or non-respondingchildren 0-3 years to VHNIMPWF and PRC 80 80 -45 ANNEX 2 Page 3 of 4

Targeted Coverage (percent) Process Objectives Andhra Pradesh Orissa

Quarterlygrowth monitoring,weighing and charting of children 3-5 years (>3 times per year) 80 60

Referral of severelymalnourished children 3-5 years of age to MPWFIPHC 90 90

Administrationof vitamin a megadose semi- annually to children 3-5 years of age 80 70

Pre-schoolattendance (> 80 percent of working days) 80 60

Routine deparasiticationof monitoredchildren in heavily infectedcommurities as determined by parasite surveys 90 80

Householduse of oral rehydrationin the last incidenceof diarrhea in the target group 60 S0

Treatmentof pneumoniaby MPWF/AWW with co-trimaxazolein cases of acute respiratory infection (ARI) 30 20

Additional feeds of local weaning food initiatedby 6 months in infants 60 50

Provisionof 4 additionalweaning feeds/day by 9 months in infants 60 50

Active women's working groups (> 9 meetings a year) 80 70 - 46- ANNEX 2 Page 4 of 4

Service Package for PregnantWomen Impact objectives

Early Prenatal Registration

Iron-folateSupplementation Reductionin incidenceof low Assessmentof Maternal Nutrition birth weight

Food Supplementationand weight gain monitoring of malnourished

Service Package for Children 0-3 years

Growth Monitoring

TherapeuticSupplementation

Referral of Severelymalnourished Children Reduction in Severe Immunizationof children and moderate malnutrition Deparasitization

Treatmentof Acute Respiratory Infections

Health and NutritionEducation

MCH Services

Antenatal check, obstetrical risk assessmentand referral

Maternal tetanus toxoid

Attendanceby trainedpersonnel at delivery and post-partum follow-up Reduction in infant mortality Immunizationwith 6 UIP vaccines

Diagnosisand treatmentof acute respiratoryinfections

Health examinationand referral - 47- ANNEX3 Page 1 of 5

INDIA

INTEGRATEDCHILD DEVELOPMEN?SERVICES PROJECT

Details of Proiect Areas

Table 1. Types of Blocks

Type of Block Existing New Total

Andhra Pradesh

Tribal 24 -- 24 Drought Prone 10 33 43 Other Rural 10 33 43

Total 44 66 110

Orissa

Tribal 47 70 117 Rural 22 52 74

Total 69 122 191

The following explains acronyms used tm the table

Et Existing ICDS Block N: New Block T: Tribal Block Rt Rural Block D: Drought Prone Area Block -48 - ANNEX3 Page 2 of 5

Table 2. List of Blocks

District/Block EIN TIDIR District/Block E/N T/D/R Atmakur E D Srikakulam Adoni N D Seethampet E T Yemmiganur N D Veeragattam E R Alur N D Shermohanmadpuram N R Nandikotkur N D Tekkali N R Nandyal N D Kasibugga N R Koilkuntala N D Sarvakota N R Banganapally N D Kothuru N R Allagadda N D Kodumuru N D Vizianagaram Pattikonda N D Parvathipuram I R Kurupam E R Anantpur Bhadragiri E T Dhramavaram E D Pachipenta E T Kambadur E D Gajapathinagaram N R Raidurg E D Salur N R Madakasira E D Singanamala N D Vishakhapatnam Kudair N D Arsku I T Tadipatri N D munchingput E T Gooti N D Anantagiri E T Urvakonda N D Paderu E T Kalyandurg N D G. Madugula E T Chinnakothapalli N D Peddabayalu E T Kanekal N D Chintapalli E T Kadiri (East) N D Koyyuru E T Kadiri (West) N D H'adugula N R Penukonda N D Hindupur N D East Godavari Rampochodavaram E T Cuddapah Maredumilli E T Lakkireddipalli E D Addateegala E T Pullivendla E D Rajavonmmangi E T Kamalapuram N D Rangampeta N R Jammalamadugu N D Shankavaram N R Rayachoti N D Kothapeta N R Muddanur N D Korukonda N R Chittor West Godavari Thamballapally E D Chantalapudi E K Bangarupalem N R Koyayalagudem E R Madanapally N D Polavaraz K T Vayalapad N D Buttayagudem K T Chowdepally N D Paluaner N D Kurnool Chinnagottigallu N D Kurnool E D Punganur N D Dhone E D Table 2.(contd.) Andhra Pradesh - 49 - ANNEX 3 Page 3 of 5

Table 2. List of Blocks- Orissa Districtlllock E/N TIDIR District/Block EIN TIR Kuppam N D Koraput Karimnagar Kolnara E T Mahadevpur E R Potangi E T Mallial N R Narayanpatna E T Sulthanabad N R Laxmipur E T Gangadhara N R Bandhugam E T Peddapalli N R Umerkote E T Gudari E T Adilabad Chandrapur E T Boath E R Malkangiri E T Chinnur E R Podia E T Utnoor E T Mathili E T Wankhidi E T Khairaput E T Adilabad N R Kudumulugumma E T Asifabad N R Rayagada N T Khanapur N R K.Singhpur N T Laxattipeta N R Kashipur N T Sirpur N R Koraput N T Nirmal N R Semiliguda N T Dasmanthpur N T Warangal Lamptaput N T Gudur E R Nandapur N T Eturnagaram E T Chandahandi N T Hahabubabad N R Dabugaon N T Wardhannapet N R Jharigaon N T Chityal N R Kosagumunda N T Narsampet N R Nandahandi N T Mulug N R Nowrangpur N T Papadahandi N T Khammam Raighar N T Aswaraopet E T Tentulikhunti N T Sudimella E R Jeypore N T Bhadrachalam E T Boipariguda N T Kunavaram E T Kundra N T V.R.Puram E T Boriguma N T Kalluru N R Gunupur N T Kothagudem N R Padmapur N T Illandu N R Kotpad N T Venkatapuram N R Korukonda N T Burgumapahad N R Kalimela N T Ramanguda N T B.Cuttack N T Muniguda N T

Table 2. List of Blocks- Orissa -50- ANNEX Page 4 of 5

Table 2(contd) Orissa DistricttBlock E/N XTR

Xalahandi Lanjigarh E T District/Block E/N TIR Komna E N Rhariar E N Khallikote E N Boden E N Xukudakhandi E N Sinapali E N R.S. Nagar K N Th. Rampur E T Buguda E N Golamunda E N Mohana N T Xoksara E N Parlakhemundi N N M.Rampur N N Kasinagar N N Nawapara N N Bhavanipatna N N Bolangir Xesinga N N Khaparakhole E N Narla N N Patnagarh E N Dharamgarh N N Birmaharajpur E N Junagarh N N Tureikela K N Jaipatna N N Titilagarh N N Xalampur N N Muribahal N N Karlamunda N N Bangamunda N N Belpara N N Phulbani Saintala N N Phulbani E T Ulunda N N Khajuripada E T Guduvela N N Phiringia E T Deogaon N N Nuagaon E T Loisinga N N Kothagarh E T Agalpur N N Daringibadi E T Puintala N N Chakapada N T Bolangir N N Tikabali N T Tarava N N Raikia N T Sonepur N N G. Udayagiri N T Balliguda N T Sambalpur Tumudibandha N T Padmapur E N Kantamal N N Paikmal K N Harbhanga N N Naktideul K N Boudh N N Govindapur E T Jamankira E T Ganjam Sohella N N Rayagada K T Rairakhole N N R. Udayagiri E T Jujumura N N Nuagada E T Jharsuguda N N Gumma E T Laikera N N Kirimira N N Kolabira N N Lakhanpur N N -51 - ANNEX3 Page 5 of 5

Table 2 (contd)Orissa Table2 (contd)Orissa

District/Block EIN TIR District/Block E/N TR

Bhatli N N Jhumpara E T Ambabhona N N Joda E T Kuchinda N N Keon3har N T Gaisilet N N Telkoi N T Bijepur N N Patna N T Jharbandha N N Champua N T Barkote N N Hatadihi N N Tileibani N N Reamal N N Mayurbhanj Samakhunta E T Sundargarh Morada E T Rajgangpur E T Tiringi E T Kutra E T Jamada E T Subdega E T Bijatola E T Lahunipara E T Thakurmunda E T Gurundia E T Joshipur K T Lathikata E T Khunta E T Lefripara N T Udala E T lemgiri N T Kuliana N T Sundargarh N T Suliapada N T Bargaon N T Baripada N T Balisankara N T Barasahi N T Tangarapalli N T Rasgovindapur N T Koira N T Betnoti N T Bonaigarh N T Bangriposi N T Bisra N T Sarasakana N T Nuagaon N T Bahalda N T Kuarmunda N T Rairangpur N T Kusumi N T Dhenkanal Bisol N T Kankadahad E N Raruan N T Athamallik E N Sukruli N T Kishorenagar E N Karanjia N T Pallalahara E N Gopabandhunagar N T Kamakshyanagar N N Kaptipada N T Bhuban N N Udala N T Kaniha N N Parjang N N Cuttack Sukinda E N Keonjhar Dangadi N N Ghatgaon E T Harichandpur E T Puri Banspal E T Gania N N Saharapada E T - 52 - ANNEX 4 Page 1 of 8

INDIA

INTEGRATEDCHILD DEVELOPMENTSERVICES PROJECT

Training Component

1. The overall goal of training is to ensure that project staff develop capabilitiesto perform their jobs well. Trainingwould be a key instrument for ensuring quality services,creating and maintainingstaff motivation,and improvingstaff communicationand communitymobilization skills. The specific objectivesof trainingwould be to: (a) create an understandingof the roles of differentworker cadres; (b) develop requisiteknowledge and skills; (c) develop and sustain favorableattitudes and motivation; (d) increase communicationand communitymobilization skills; and (e) promote teamwork among nutritionand health personnel.

2. For all categoriesof staff, the projectwould support four types of training:pre-service for new staff, orientationtraining for existing staff in the project areas, regular in-servicetraining, and problem solving workshops.

Training in Andhra Pradesh

3. In Andhra Pradesh, pre-servicetraining would follow the ICDS pattern. All the staff in the existingICDS blocks in the project areas would receiveorientation training. The Sri AvinashlingamInstitute of Home Science and Higher Education for Women, Coimbatorehas considerableexperience in training and would be utilized for pre-serviceand refreshertraining of CDPOs and supervisors. The Pranganamsat the district level have adequate accommodationand classroomspace for training. The projectwoul3 establisha total of 26 Training centers (TCs), two for each of the 13 project districts. These would be staffedby 7 instructresses,a vice-Principaland a Principal. The TCs would be responsiblefor pre-service,orientation and refresher training of all the AWWs and Helpers. Annual joint trainingof the health and ICDS staff would be conductedin the field. The details of the training content, responsibilitiesand durationare given in tables 1 and 2.

Training in Orissa

4. In Orissa,pre-service training would follow the ICDS pattern but would be supplementedby an additionalperiod for project orientation. In- service trainingwould be field-basedand would be conductedjointly for nutrition and health staff. The pattern of in-servicetraining in Andhra Pradesh and Orissa differ. In Orissa, district training teams will be constitutedby speciallyappointed staff. In collaborationwith other district and block level staff, they will conduct trainingof supervisors,who in turn will conduct training for village level staff under the guidance of the district trainingteams. The in-servicetraining would be jointly conductedfor health and nutrition staff. The details of content, duration and training arrangementsare given in tables 3 and 4. - 53 - ANNEX 4 Page 2 of 8

InstitutionalArrangements

5. Curriculumpreparation, material development,and planning and monitoringthe training activitieswill be the responsibilityof an Assistant Director under the Project Coordinator. To ensure that training is both relevant and effective, the project would also support periodic in-service trainingof trainers,necessary strengthening of the training institutions, and technicalassistance.

The followingexplains the acronymsused in the tables:

DTT District Training Team AWTC AWTraining Center MLTC Middle Level Training Center NIPCCD The National Institute for Public Cooperation and Child Development AIHHW Sri AvinashlinghamInstitute of Home Scienceand Higher Education for Women, Coimbatore TC Training Center - 54 - ANNEX 4 Page 3 of 8

Table 1. Andhra Pradesh Pre-serviceand OrientationTraining

Staff Category Where Content How Duration

Pre-service Training

AW TC Job training, project Batch of 90 days orientation 45

Helpers TC Job training,project Batch of 8 days orientation 45

Super- AIHHW Job training and project Batch of 90 days visor orientation 40

CDPO AIHHW Job training and project Batch of 2 months orientation 30

Orientation Training

AWW TC Project orientation, Batch of 15 days knowledgeof MCH and family 45 welfare, communicationand recordingand reporting helper TC Conductingaction songs, Batch of 8 days weighing children, 45 sanitation,use of disposabledelivery kits and hygienic food preparation

Super- AIHHW Project introduction, Batch of 18 days visor communication,community 40 mobilization, and monitoring and reporting

CDPO AlHHW Project orientation,and Batch of 18 days monitoring and reporting 22 - 55 - ANNEX 4 Page 4 of 8

Table 2. Andhra Pradesh In-serviceTraining

In service training for all categorieswould consist of technicalskills development,exposure to new ideas and feedback on performance. Additional trainingcontent for specificcategories is indicatedbelow.

Staff Trainer/ Category Where Content How Duration

Joint AIHHW managerialand supervisory Batch of 1 week CDPO/MO skills 30 per year

Joint Block Supervisorypractices MO 3 days sup/HAP per year

Joint Block Coordinatedworking Super- 4 days MPWFIAW visors per year

Joint AWW Coordinated working MPWF/AW 2 days helper/dai per year

Dist nut/ Trng managerial and supervisory Batch of 3 days health off Inst. skills 50 per year

State Selected observe successful study officers states practices tours

RefresherTraining

CDPO AIHHW Refresher Batch of 18 days/ 22 3 years

Supervisor TC Refresher Batch of 8 days/ 40 2 years

AW TC Refresher Batch of 18 days/ 45 2 years

Helpers TC Refresher Batch of 8 days 45 2 years - 56 - ANNEX 4 Page 5 of 8

Table 3. Orissa Pre-serviceand OrientationTraining

Staff Category Where Content How Duration

Pre-service Training

AW AWTC Job training, project Batch of 105 days orientation 50

Helpers Block Job training,project Batch of 1 week orientation 25

Edu.def. AWTC Reading,writing, and Batch of 1 month A'WW record keeping and reporting 50

Supervisor MLTC Job training and project Batch of 106 days orientation 30

CDPO NIPCCD Job trainingand project Batch of 2 months orientation 30

Orientation Training

AW AWTC Project orientation, Batch of 15 days knowledge of MCH and Family 50 welfare, communicationand recordingand reporting

Helper Block Conductingaction songs, Batch of 1 week weighing children,sanita- 25 tion, use of disposable deliverykits and hygienic food preparation.

Supervisor MLTC Project introduction, Batch of 16 days communication,community 30 mobilization,and monitoringand reporting

CDPO NIPCCD Project orientation,and Batch of 1 week monitoring and reporting 30

MO RHTC Managementof nutrition Batch of 2 weeks disordersand project 30 orientation - 57 - ANNEX4 Page 6 of 8

Table 4. Orissa In-serviceTraininR

In service training for all categorieswould consist of technicalskills development,exposure to new ideas and feedbackon performance. Additional training content for specific categoriesis indicatedbelow.

Staff Trainerl Categoryn here Content How Duration

Joint NIPCCD managerial and supervisory Batch of 1 week CDPOIMO skills 30 per year

Joint Block Supervisorypractices DTT 8 days sup/RAF per year

Joint Block Coordinated working Super- 7 days MPWF/AW visors per year

Joint AW Coordinated working MPWF/AW 2 days helper/dai per year

Dist nut/ Trng managerial and supervisory Batch of 1 week health off Inst. skills 20 per year

Other Dist Orientation workshop 2 days dist staff per year

State Selected observe successful study officers states .ractices tours - 58 -

ANNEX4 Page 7 of 8

Table 5. Training of Trainers

Training of trainerswould consist of technicaland training skills. Additional training content for specificcategories is indicatedbelow.

Staff Category Where Content How Duration

Orissa

AWTC NIPCCD Field experiences Batch of 3 weeks trainers 20 pre-service

AWTC Selected Exposure to new ideas Batch of 1 week trainers insts. 20 per year in-service

DTT Selected Exposure to new ideas batch of 1 week insts. 12 teams per year

IHLTC NIPCCD Field experiences Batch of 3 weeks trainers 20 pre-service

N-LTC Selected Exposure to new ideas Batch of 1 week trainers insts. 20 per year in-service

Andhra Pradesh

IECC AIHEW Pre-servicetraining Batch of 22 days Trainers 40

IECC AIHUW In-servicetraining Batch of 3 days/ 40 3 years - 59 -

ANNEX 4 Page 8 of 8

Table 6. Numbers to be Trained

Staff Andhra Pradesh C issa category Pre-ser Orienta In-ser Pre-ser Orienta In-ser vice tion vice vice tion vice

AW 9350 4400 13750 12420 5598 18020

Helper 9350 4400 13750 12420 5598 18020

Supervisors 600 220 820 877 316 1193

CDPO 66 44 110 122 69 191 -60- ANNEX 5 Page 1 of 5

INDIA

INTEGRATEDCHILD DEVELOPMENTSERVICES PROJECT

Communication Component

1. Desirablebehavioral changes related to nutritionand child care in the home and the communitycan be initiatedand sustainedonly through effectivecommunications support for program activities. Therefore,a comprehensivecommunication component is critical for realizingoverall project goals and objectives. Broadly the componentaims to stimulatedemand for project services,alter householdchild feeding and care practices, encouragepregnant women to registerearly, prepare adolescentgirls to effectivelyplay their roles as future mothers, motivate village levelworkers by enhancing their image and credibilitywithin the communityand promote communityinvolvement.

2. These goals have to be translatedinto specificknowledge and behavior objectives. An illustrativelist is given below:

- 2 of mothers who know where to take their children for regular weighing - z of mothers who can state at least two benefits of regular weighing - X of children (0-3 years) weighed regularlyfor 3 out of the last 4 months - X of newbornsweighed within 10 days of birth - 2 of mothers who can correctlystate when to start giving weaning foods to her child - 2 of mothers who can state appropriateweaning foods to give a 5 month old baby - Z of babies (5-12months) who have receivedweaning foods from 5 months - 2 of mothers who can properly prepare and feed weaning foods - 2 of householdmembers who can state appropriateweaning foods - 2 of women registeredfor antenatalcare within 20 weeks of pregnancy - I of women who know where to get TT vaccinations - 2 of pregnantwomen who take iron and folic acid tablets regularly - 2 of mothers who can state at least three precautionsto prevent diarrhoea - 2 of mothers/fatherswho can properly prepare ORS - I of mothers who can state when to give vitamin A - X of mothers who know how to manage childrenwith ARI - I of eligible children receivingsupplementation at the AWs

During the first years of the project, these behavioralobjectives will be refined using data from the base line surveysand formativeresearch.

3. WCD has recently added a commmnicationsexpert to the ICDS Directorateto strengthencommunications support to ICDS services. The past efforts in social communicationin family welfare, where more efforts have - 61 - ANNEX 5 Page 2 of 5 been made compared to ICDS, suffered from four main weaknesses,which social marketing techniquesunder the project can help overcome. First, the belief is that as long as the populationis 'exposed'frequently and 'saturated'with communicationmessages their effectivenessis inevitable. The desired outcomes in terms of behavioralchanges are often not clearly stated. Second, they have focussedon hardware aspectsby buildingproduction facilities, without commensurateattention to the contentof messages so produced. Shifting to procurementof professionalservices from outsidehelps the departmentsto focus on developingthe softwareside of communicatiuns. The programneeds to move away from the 'media'and 'equipment'orientation in social comuunicationsto improvingthe creativity,research, strategies and productionquality. Third, interfacebetween researchand creative/developmentaland managementpersonnel involved was weak. To use communicationresources effectively, communication research should focus on the clients and their environmentto provide relevant informationfor developingstrategies and materials,and for observingchanges that may occur from their applications. Fourth, decision-makingregarding methods and waterialswas too centralized.

4. To remedy the above deficiencies,the componentwould emphasizethe following:

(a) formativeresearch studiesand field testing of all new concepts and materials to be conductedby professionalagencies;

(b) preparationof audio, video and print materials for each activity and theme with regionalvariations;

(d) regularbeneficiary feedback to make promotionalprograms realistic to the needs of the target population;and

(e) specialcampaigns and sequentialintroduction of themes as opposed to daily blanket promotionof all activities.

5. The componentin both states would include supportfor strengtheninginstitutional capability, community education, audio-visual materials to supportnutrition education activities of workers and community groups, formativeresearch, and monitoringand evaluation.

6. Messages directed towards target audienceswould emphasize the following:

(a) Nutrition-encourage mothers to participatein regularweighing of children,educate mothers to take care of malnourishedchildren or those with growth faltering,explain project supplementation procedures;

(b) Diarrhea-promote use of oral rehydrationtherapy;

(c) Household Behavior-encourage colostrum feeding, breast feeding and adoption of desirableweaning practices,promote personal and - 62 - ANNEX S Page 3 of 5

communityhygiene, encouragefamilies against gender discrimination in terms of feeding and health care;

(d) Health Services-promote 6 UPI immunizationsfor children and tetanus toxoid for pregnantwomen, encourageparticipation in vitamin A, dewormingand iron supplementationactivities, develop mother's competencein managing ARI cases;

(e) Delivery Services-encourage pregnant women to registerearly and use antenataland postnatalservices, and educate pregnantwomen on safe deliverypractices, self assessmentof risk, referral for high risk cases and use of deliverykits;

(f) Family Planning-influence young couples to space births, educate familieson relationshipbetween family size and family health, and

(g) CommunityParticipation- encourage influential persons in the communityto participatein planning and implementationof nutritionand health education,and service deliveryactivities.

7. The level of current ICDS communicationactivities is low in both the states. In Orissa, the institutionalcapability for managing communicationactivities is weak and there is a lack of experiencedcommercial marketingand productionagencies within the State. The Family Welfare Department is developing an IEC Center with funding support from ODA; its productioncapabilities could be utilized by ICDS. But both because of lack of data and capabilities,sound decisionsregarding strategy and materials is difficult.

S. In Andhra Pradesh, the commercialmarketing sector and professional communicationresources are well developed. Therefore,while the strategies for communicationcomponent would be similar in both the states, communication activities in Andhra Pradeshwould be more ambitious.

9. Initiallythe project would focus on developingan institutional base and capabilitywithin the ICDS Directoratesof both the states. A Communicationcell consistingof three professionalsand a research officer would be part of the project managementorganization. Both formal and informalopportunities would be utilized to train state level personnel in social communications/marketing.These include formal training courses, visits to other projects and placementwith appropriateNGOs or commercial agencies. The project would also support technicalassistance by local commercialadvertising and market research agencies for staff development through apprenticeships,formulation of a detailed communicationsplan, and design and developmentof materials. To strengthenprofessional backup, a small committeewould be constitutedincluding communications professionals from other departments,commercial marketing agencies and NGOs to advise on strategy and standardsand criteria for selectionof appropriateagencies for research,development and production.

10. The communicationactivities would concentrateon a few selected themes in a phased manner. These themes include growth monitoring,weaning - 63 - ANNEX 5 Page 4 of 5

and child feeding,diarrhea management, antenatal care and key health services. Each AW would be suppliedwith counsellingcards, flip charts,wall posters, booklets,and three-dimensionalmodels to assist workers in their inter-persoualactivities. The projectwould supportvillage exhibitions, annual well-baby shows at sector and block levels and folk performances,which would be used as events around which communityeducation activities would be centered. Radio-cum-cassetteplayers would be provided to the supervisorsin Orissa and to AWWs in Andhra Pradesh. The projectwould also support productionof audio cassettes in local dialects for use at AWs and by women's working groups. Each districtwould be providedwith video sets for use in orientationworkshops of communityleaders and other governmentfunctionaries.

11. Relevance and quality of messages and materialswould be ensuredby utilizingsocial marketing techniquesof formativeevaluation using qualitativeresearch to develop communicationscontent, structure,materials, and media-mix. The materialswould be extensivelypretested before their large scale production. Care would be taken that communicationsdevelopment and summativeevaluations are done by differentor independentagencies so that it becomes a effectivelearning process. Although tentativedecisions about media have been indicatedabove, flexibilityin media selectionwould be retainedbased on regular inputs from communicationsresearch. -64 ANNEX S Page 5 of 5

Table 1. CommunicationThemes and Target Groups

Themes Content Area/ Topic Target Audiences

ICDS Growth Monitoring Pregnant and nursing mothers, Services fathers Early registrationof pregnant Pregnant and child bearing women age women Supplementarynutrition Family elders, fathersand mothers Antenatal services,check ups, Pregnant and child bearing age Tetanus immunization,high women risk screening,safe delivery Iumunization,vitamin A, Family and elders deworming,ARI

Household Weaning Mothers, grandmo:4hers behavior Breast feeding, colostrum Mothers, grandmothers Diarrhea management Family and elders Maternal Nutrition Pregnant and nursing women, grandmothers, fathers Safe delivery,high risk TBAs, grandmothers, pregnancy child bearing age women Hygiene and sanitation Community leaders and members

Pre-school Importance of pre-school Family and elders activities

Women's Literacy Women's groups,women and programs elders Income generation Women's groups, family and elders Adolescent girls Families,elders and adolescentgirls - 65 - ANNEX 6 Page 1 of 5

INDIA

INTEGRATED CHILD DEVELOPMENTSERVICES PROJECT

ConmiunityMobilization Through Women's Programs

1. The main mechanism for communitymobilization envisaged in ICDS is women's groups known as Mahila Mandals (MM) formed at the village level. They are expected to persuademothers (a) to bring children for immunization, health check-upsand supplementarynutrition; (b) help the AW staff to prepare supplementarynutrition and keep the childrenclean; (c) help AWW to provide health and nutrition educationto women; (d) supplementAWW's efforts in pre- school educationfor 3-6 year old children;and (e) report cases of illness among mothers and children (especiallyunder 3 years of age). Although efforts have been made in the past to establishMfs, most do not function effectivelybecause of a lack of clarity in objectivesand sustainedinterest.

2. Hence the project seeks more active involvementof women's groups in ICDS activities. It would test innovativewomen's developmentactivities consistingof activatingMMs, income generatingactivities for selectedMHs, forming confederationsof MKs, courses for women's integratedlearning for life (WILL)and adolescentgirls' training. The first three activitiesare closely linked in that they would operate through the phased establishmentof MKs in all project villages,with a subset taking up different scales of income generationactivities facilitated by their confederations. These innovativeactivities would be evaluatedin the third year of the project and expanded subsequentlywith necessarymodifications.

3. Mahila Mandals. An MM is to consist of at least 20 members, organizedand supportedby the AWW with the assistanceof her supervisor. In the past, MM members have tended to be women from well-to-do segments of the village. However, in the project areas, AWWs would encourageparticitation of women whose children are the prime targets for ICDS. The role of MMs would be redefinedand expanded to include their more active involvement. In addition to helping the AWW in her activities,They may take responsibilityfor the following:

(a) monitoring children for diarrhea and educatingmothers about oral rehydrationtherapy;

(b) collectingchildren for growth monitoring,immunization, health check-ups,vitamin A prophylaxis,and iron-folatesupplementation;

(c) educatingmothers of severelymalnourished children about child nutrition care and assist in completingtheir referral to higher levels of health system; and

(d) serving as a link between AU and by informingcommunity of the services availableand AW of events such as pregnancyand sickness. - 66 - ANNEX 6 Page 2 of 5

4. The MM is the basic unit on which other women's development activitiesare based. Therefore,it is anticipatedthat MMs will be formed in all 31,850 AWs in the project area. To encourageclose collaborationbetween the AW and the MK, a one-time grant of Rs. 1,000 will be given to each of those HMs which has actively assisted the AW in achievingpre-specified service coverage levels. The MMs will have freedomto use this money for a variety of worthwhile purposes but would be encouragedto purchase equipment and materialsnecessary for nutritionand health activitiesconducted for or by the group. After the first two years of the project, a study will be conductedto assess their functioningand to identifyadditional measures to assist the process of their activation.

5. Women's Income GeneratingActivities. The Governmentcurrently operates a program called 'Developmentof Women and Children in Rural Areas (DWCRA)'as a part of the national IntegratedRural DevelopmentProgram (IRDP). Under the DWCRA program, 30 MHs in each block are providedwith a grant of Rs. 15,000 to be used as a revolvingfund to give loans to members for individualor group income generatingactivities. CurrentlyDWCRA covers about half the project areas. Although the program has not been systematicallyevaluated, anecdotal evidence suggestsmixed success. Several OMIshave been able to undertakeactivities which have provided additional income to the members. However, one of the major problem encounteredis the dissipationof loan funds because of ill preparednessof MHs to sustain activitiesthat generate int:omeand permit the borrowingmembers to repay the loan. In many instances,the activitiesdid not become viable because of a paucity of raw material, skills or marketing channels.

6. The projectwould modify this approach to enable MMs to prepare for income generationand provide support to those groups which are able to developviable schemes. Among the functioningMMs, about half may be in a position to activate their members for income-generatingactivities. These groups may be encouragedto develop specific proposalsfor approval by appropriateICDS and IRDP functionaries. The participantswould be from poor householdswho are also ICDS target beneficiaries. The proposalswould be evaluated for their viabilitybased on extant skills, raw materialsand marketing channels. If approved,these MMs would be given an initiatinggrant of Rs. 3,000.

7. Of the MMs who have initiatedincome-generating activities, it is expected that about half (one-fourthof all MMs in a block) would be able to expand their activities further, for which an additionalgrant of Rs. 15,000 would be given to be used as a loan fund. In Orissa, this scheme will operate in the blocks not covered by DWCRA program. In Andhra Pradesh, all the blocks would be covered but only 20 groups would be constitutedin each block. In DWCRA areas, links between existing groups and ICDS would be strengthenedby seeking their involvementin AW activities. Although it is difficultto predict the progress of income-generatingactivities, the number of WMs expected to be developedis as follows: -67 - ANNEX 6 Page 3 of 5

Project year No. of MKs receiving No. of MMs receiving first grant (Rs. 3,000) grant of Rs. 15,000 Andhra Pradesh Orissa Andhra Pradesh Orissa

1 2 530 1,300 265 650 3 970 1,300 485 650 4 1,300 1,400 650 700 5 800 1,400 400 700 6 800 1,400 400 700

Total 4,400 6,800 2,200 3,400

8. Confederationsof MMs. In Orissa, to further strengthenMMs in their income generatingactivities, their confederationsare proposed to be set up at block levels to provide assistancein procurement,skill training, marketing and other support activities. Each federationwould receive an initialgrant of Rs. 54,000 (Rs. 50,000 for working capital and Rs. 4,000 for furniture). Half of the estimatedannual recurringexpenditure of Rs. 12,000 would be met by contributionsfrom the MM members. The confederationsare to be linked to the existing procurementagencies such as the Large Agricultural Multi-purposeSocieties, and marketing organizationssuch as the Tribal DevelopmentCooperative Corporation or Rural CooperativeMarketing Societies. These confederationsare to be establishedin a phased manner in all the 191 blocks and will follow the establishmentof MMs. In Andhra Pradesh,multipurpose productioncenters (Prangnams)have already been establishedby the Women's CooperativeFinance Corporation. They will supportMM's income generatingactivities. Once again both income-generatingactivities and functioningof confederationswould be evaluatedin the second year of the project to determinepace and modality of further expansion.

9. Women's IntegratedLearning for Life (WILL). The contributionof women's non-formaleducation to the effectivenessof health and nutrition activitiesis widely acknowledged. One way to provide non-formaleducation to women and build close linkageswith ICDS is to organize 10-month courses by AWWs which impart and protect literacyskills, increaseknowledge of good health, hygiene, nutritionand family planning practices,provide training in home managementand child care, and foster civic awareness.

10. However, two major questionsarise: is there demand among village women for 'WILL' classes and can AWWs cope with the additionalload without adverselyaffecting their other tasks? Unfortunatelyanswers to both of these questionsare not clear. The current operationsof the Adult Education Program (emphasizingliteracy skills) seem to have reasonabledemand and face problems of lack or absence of teachers and facilities. About one-fourthof the adult educationcenters for women also employ AWs. Although holding WILL classes may increaseAWW workload, it is also an opportunityto provide health and nutrition educationto women in an organizedway which in the long term may improve the health and nutrition status of the community.

11. In view of these uncertainties,the project proposes to introduce WILL courses in a phased and selectivemanner permitting developmentof its - 68 - ANNEX 6 Page 4 of 5 concept and operationaldesign during the first two years of the project. The state governments,preferably in collaborationwith an experiencedNGO, would experimentwith WILL classes in 1050 and 720 AWs in Andhra Pradesh and Orissa respectively. Although the basic structureof the 10-monthcourse would be maintained,the timing and duration of the classeswould be flexibledepending on local conditions. Women would be encouragedand provided the means (instruction,materials, peer group interactions)to acquire the skills they are interestedin. An experientialrather than didactic approach is the best way to ensure that women participatein and benefit from such a scheme. Each AW will be p&id an additionalmonthly honorariumof Rs. 100 to run WILL classes. Th.,project would also supportother recurrentcosts including teachingm±aerials.

12. Consequenton an evaluationof in the third year of the project, the scheme may be expanded,with necessary improvements. In Andhra Pradesh, each AW would operateWILL classes only for two years but 60 percent of all AWs would be covered. In Orissa, an estimated5,040 AWs in 50 X of the blocks would have establishedWILL classes. In the remainingareas, Adult Education Centers would be operating. The projectwould coordinatewith the national Adult EducationProgram and its field level functionariesto ensure close linkagesbetween AWs and adult educationcenters.

13. AdolescentGirls ApprenticeshipTraining and Education. Recognizingthe importanceof improvinghealth and nutrition-relatedskills of adolescentgirls aged 11-16 years, ICDS has been consideringways to link thc. with AW activities. Consequentto a NIPCCD workshop on this topic, a detailed scheme is being worked out. The current proposal envisagesthat 3 girls will be selected in each village (from poor households,school drop-outs). Each girl will assist the AWW for two days a week and would act as a link between the AW, MK and the community. All three girls would receivea daily food supplementsimilar to those for pregnant and nursingwomen. They would receive three-dayinitial training,followed by refreshertraining for one day every quarter. The duration of the apprenticeshipwould be two years. The revised scheme will be implementedon an experimentalbasis in 2400 AWs in the first two years. Later on it may be expanded to cover the remainingAWs with requisitemodifications. Additionally,in Andhra Pradesh, a few training- cum-productioncenters will be establishedfor adolescentgirls as outreach facilitiesof the existing district-levelPranganams.

14. To achieve the broader objectivesof ICDS, communitymobilization through closely integratedwomen's developmentactivities is essential. The project's three tier approach-establishing MMs and linkingthem with AWs, startingthem on income generation,and finally supportingthem to carry on viable income generationactivities through loan funds and support from confederations-is expected to overcome some of the difficultiesexperienced in these activities. In addition,the experimentalapproach to WILL and adolescentgirls training can point a way to significantlyimprove effectivenessof ICDS activitiesand women's overall development. less. OaissA asO auuOua PKSOaS Project Cponts by Tosr (aS 'OOO Seas Cost$ total

1990 192 10992 193 19994 1991 Its tosSsIGNP . SEARYICEKLI WEET 30tRI7 9 164,SIS. 2 330. 182.4 432.22. 4 M1,438.9 2m. 864.9 254.S31. S 1.747,462.t 102.TO9. 9 WEAlsT 43.622.? 38.9087. 40,325.3 28, 19S.0 28. 9o.0 2 198. 0 20. 629. 12.1S4. I TUIlWiW 46.034.4 62.89.3 N8.216.932,711.3 33, t63. 5 32.3s1.3 265.816.1 I,6S6. 3 Sub-total SERVICEELItER? 2M4.472.3430,B79.4 ;.30.77t.6 326,348.2 321.,26.4 3tS,51t.2 2.219.909.1 130.582.9 el e it s.tIOW 20.01S.4 31,91I.3 It.613. 1 33.ei3.1 26,697. ItW087.1. 167,s47.1s 9.81.I C. COWIT? ultIZATIOW W COEPI GEtItEETON 1,254.0 25,844.0 31,S14.0 33.254.0 19,8t9.0 8,400.0 124.145.0 t.302.6 WoWEWSINTttt TED LEMWINGFOtR LIFE lulL? 6.131.9 3,71s.9 3. s.9 3.ns.19 3.755.9 3.75s.9 24 911.S 1,465.4 8OLESCEWIIslos P0M" I ATE 2. 392. 6 4.787.5 IL8t0. 7,b73.7 7.94.?7 8 728.2 38.2SS.0 2.252.t Sub-totbl CONtmio IsILIZATIOW 13.?7T&4 34.387.4 42,000.2 44.683.8 31.520.6 20.m82. 187.341.4 11,020.1 D. POOECTf*IAo=EWET P_CCT OeSuIZAIIO 16,721.0 12.947.5 12.947.1 12.947.5 12.947.5 12,947.5 81.4u8.s 4.791.? ltaRlltO MDsEVAtUATIO 4.30.0 2,732.0 S.432.0 2,832.0 1,332.0 4.532.0 21,480.0 t.264. 1

S.b-otaI PIOJECTItMWIEET 21,31.0 ts,679.1 21379. IS , 77S. 14.279. S 1t49. S 102.948.15 8. 8.$ ------.--. -,---,_.- - --.-..--... -- -- _. - ...... Total BASEIWtECOSTS 309.61'.2 512,897.6 628,04.1.1459,894.4 394.432.6 372,880.3 2.877.746.6 157.?14b Ph"ica2 Cwbonti fcl, e15.480.9 21,644.9 31.402.2 22,994.7 19,721.6 10.643.0 133,887.3 7.87t. 7 Price Coat l..$ 17,881.6 70,011.4 137,933.8 38.488.2 113.138.0 180,070.0 69sts02.s8 -s9.Sea total PRWECtCOSTS 342.979.7 608.53. 9 797,380.3 621,317.3 567,2m. 2 571,173.3 3.S09. 136.7 155,781.3 :555:::55 :3:33:333 33::a::t: :3::::::: :3::::::: 33:::::::53:333:33::: :3:353:333 Taxes 21.861.4 23. 318.9 23,761. 3 7,8 77. 0 4, 426 8 6. I98. 7 8. 452.2 4,020.1So Foreign Exchan 31t,003.9 '10,239.8 68.906.1 38.934.7 21.848.6 32,0910. 248,025.0 1122,126 fty 0.3,I99O 09:53

0 MiI. [COS, ORISSA U11 61*M P*0SN Stuny Accour,ts by Yare Totals Including Contiqgacis* Totals Includifg Conti p cis, IASIOO CusS, ION) 1990 199l 1992 1993 1994 9m Total 990 1991 1992 1993 1994 1995 Total ::::::::::::na ::::::::: ::::::::: :::::::::tttfl ::::::::: :#:::h::::: ::S::::: utS:sS3: S;t;S:t: nf:;;.:: :s:;.::: :::::::: fin;:;;::

1. INVSTMNETCOSTS A. CIVIL MAS 33, 059.1 123.289.3 OL6.263. ? 69. S71. 7 10.772.7 l. M. 0 424,954.3 1.612.6 .78s6.2 8.428.2 3.036.2 454.5 81.4 19.403.3 6. UITUIK9E s.6rs.0 4.019.2 31s8.s0 - - - 1.5IS.2 472.1 191.s 100 - - - 833. C. £01ti3 t 65 004.7 s110. 3 4n.921. tl3 s9l9.:370.s 353.3 163.s3.9 3,171.0 2.397.4 2,254.1 S20.5 226.6 14.4 6.554.5 0. tEIItCLES 29,604.8 27 12 .7 22.940.o 3,072.6 - 4,14S. 3 67,083.4 l.453.9 1,273.3 1.038.0 134.2 - t69.2 4.966.s £. 96 ANDNEDOCINES 22.nS7.3 33,550.6 36s933.t 31,717.1 33,914.1 36.241.9 195.214.0 I.111.0 1. 71. I 1.671.2 1,385.0 1.431.0 1.479.3 8.656.6 F. lR11ItIG 32, 49. 2 65,430.4 66, m. 1 38.741.3 42. 119.? 43,013. s 2819, . 3 1. S4. 9 3,071.9 3.004.3 1,691.9 1,777.2 1 Mss.7 12 685. 9 C. CUNIMIC*TIONS,PUO810TIOM S ISSENIMATIOC 21 638M.1 37281.7 46,063.9 44.287.1 38.022.9 28,s68.4 216.1to. S ,s051.S 1,750.3 2,964.3 1,933.9 1.604.6 . 179. 0 9.S07.9 ". STUDIES8 SNIVETS 3,728.9 16.3M.I 1,493.0 1,245.2 333.6 ,091.1 17S6.ta4 tot.9 93.2 248.6 14.4 14.1 207.8 600.0 1. 6IIS . S,7 .1 30,.136.2 39.320.3 44,309.9 26,2m.t7 12,700.6 160,40.0 276, t. 414. 6 1. M. 2 t.934.9 1.19.68 S11.4 7. 11.1 Total INSrMuNI COSTS 223,980.6 33,936. 6 456. 992.3 244.673.0 IS6 766.6 132,426.9 1.S90.97M. I 10,925.9 17,555. 8 20,676.4 10,693.1 6689.0 5.405.2 71.97S.

II. £CURET COSTS 6. S^t*LIES 268.0527145.093.2 219.98O.4251.7089.6 273,92S.0 291,730.2 1,215.672.0 3.312.6 6,611.9 9,9S3.9 11.226.6 11.SS.6 114,007.4 54.171.4 S. cIsIM sBES 14,690.7 24,737.1 31,921.8 39048.2 41,753.1 44,616.8 200,769.5 716 1,16t.4 1625.4 1.t70s.2 1.76t.?7 1,21.2 6.791S. C. PETOL. OIL 8 1MItCANTS 4, 64.5 1S0.2 10,522.9 1, 25S.5 12,013.4 12,815.6 W8292. 1 203.1 312.6 476.1 491.5 506 9 523. t 2.51S.4 o. OTHEROKETI1G COSTS 6,732.4 17.123.1 23,626.8 30,086.3 39.447.3 45.s7976 161.ss6.s 426.0 832.1 t.069.2 1,313.8 1.664. 4 1,66.7 7.1922 E. TNE£PUITIC UTOI1ION 15 1.07.0 19.37S.6 20,643.3 7,271.3 7,14s.8 7,932.0 77.s7. 1 736.9 909.7 934.1 317.s 318.4 323.6 3.540. 3 F. SEt 6,2s1. 7 20, 17. 4 29,690.9 3t,733.2 33,041.0 36,071.2 119,763.4 402.1 947.2 1,343.5 1,385.7 1,427.9 1,472.3 6.979. Total RECURREtTCOSTS 116.999. 234. M. 2 340. 38. 376,484.3 408.121. 7 439. 146 4 1.91t6.18.6 S.804.6811014.6 15,402.2 16.440.4 17.237.4 17,924.3 a3.s23.9 n.at.aa:ta:tta ;:a ttX sta fiatS ananas St tt saa ata at; taat.a tat::. taa.t atta S t: aataa.uaa Total POOJECTCOSTS 342.,979.t 606 ,3.9 797,360.3 62t1,357. 3 567, 2n9.2.. 1.253. 3 3,509. 136.37 16, 730. 7 28. 17 0. 36. 08. 6 2?. 133.5 23.4936.4 23. 329. 5 IS,S781..3 0

ay 30. 1990 09: 53

to INDIA ICOS, ORISSAAND ANDHRA PRADESH Ssey Accoutafby Pfojoct Cwonefh IRS'0001 CONITY H0l6tizATIRN ------S------PROJECT MANAGEMENT

SERVICEDELIVERY INTEGRATEDADOLESCENT ONITORING ------WKE INCONEtEARNING FOR GIRLS PROGRA PROJECI OPERATIONS AND NUTRITION HEALTH TRAINING COMHINNICAIIONSGENERATION LIFE tILtt I AATE I ORGANIZA1IONRESEARCH EVALUATION total ;taat:2a:t-=::::,:a:: a tt::=:5 ;::t::a:s::::::: a:aas::: : :;:: f::::::: as,,:t*as:::: t ::ta:::::::: :::a:::a:::::: :t:t:: ::::::::::: 1. INVESINENTCOSTS

A. CIVILtOS 332. 434.0 - - - - 4.675.0 - 337. t09. 0 B. IURITilIRE 9.328.0 - 5.200.0 - - - - 568.0 - - 5. 0960 C. EQUIPNENT ltt 791.75 38.415.0 2.600.0 - - s47.4 8n.0 563.0 - 120 0 lts.931 9 0. VEHICLES 66. tso.0 ------4.960.0 - - 71. I19.0 E. MUGSAND NEDICINES 20.340.0 122.917.3 ------43.257.3 f. TRAINING I88. 284. 900.0o - 31,544.S - - 2. S0 0 223,529. 2 C. COOMINCATIONS.PROOUCTION A OISSENINATION - - 185. 770 0 - - * - 165.770.0 H. STUDIESA SURVEYS - - - 877.s 741.3 * - * 12.450.0 14,068.8 I. GRANTS 124. 145.0 - - 124,145.0 Total INVESTMENTCOSTS 537.043.5 161.332.3 196.084.7 167.547 5 124.145.0 1.288.7 37. 114 5 6.091 o - 5, 370 0 1.246.017 2 Ih. RECURRENTCOSIS

A. SALARIES 818,985 3 2.565 0 55.848.0 - * 10.038.0 924.0 50,853.0 - 2.800 0 942.092 3 S. CoNSUnA8LtS 101.538 5 24.480.0 11.2320 - - 1.7052 - 1.84.0 - 2,88.0 143.719 7 C. PETROL.OLt A LUBRICANTS 33.555.0 ------9,394.5 - 42.949 5 0. OTHEROPERATING COSTS 76.111.5 18.252.4 2,652.0 - - 11.879.6 246 s 11.796.0 - 360.0 121,297.9 E. THERAPEUTICNUTRITION 63.060.0 * ------63,060 0 F. RENT 117,169.0 - - - - 1.440 0 118.600 0 TotalRECURRENT COSTS 1.210.419.2 45.297.4 69, 732 0 - 23, 622.6 ; .170.5 75 367.5 .120 0 1.431 729 4 F Total BASELINECOSTS 1,747,462.7 206.629.7 265.816.7 167,547.5 124.145.0 24.11.5 36.285 0 81.458.5 2140o.0 2.677.746.6 PthysicastContitngarel 87,373.1 10,331.5 13.290.8 8.377.4 6.207 3 1,245.6 1,914.2 4.072 9 1.074 5 133.81? 3 A Pruca Contingencies 462. 888 2 57,624.6 61,319.8 42,533.4 30.055 8 5,901.6 11.924 5 20. 041 6 5,213.5 697.502 8

Total PRJECTCOSTS 2.297.724.0 274.58. 8 340.427 3 218,458.3 160.408.0 32,058.6 52. 123.7 to.573. 0 - 27. 778.0 3.5so. 13 7

TaRxt 70,000.5 12,802.2 1.056.5 - - 133.5 267 9 2.977.8 - 204.7 87.452 2 foretign Excharge 147,036.7 56.256.7 19.819.9 13.519.1 - 1.520.8 3,769.4 3.994.3 1.208.0 248.025.0

Ray 30. 1990 09:53

II ICOS. ANDNRAPRAOESH STATE Project Cto. ents by Tear IRS I 00) Base Costs Total t990 1991 1992 t993 1994 1995 eS (US$ 0001 A, SERVICEDELIVERY NUtRITION 100.680. 0 171,600. 5 192.57S. 5 112,490. 0 t07, 832.0 108.240. 0 793.419. 0 46.671. 7 HEALTN 7,280.0 8, 554.0 4, t88. 0 - - - 20. 020.0 t, 177.6 TR614tING 35.149. 26. 38.4 27,828.8 18 547.2 20, 089 3 18 547.2 147.000.5 S 647. 1 Sub-Total SERVICEDELIVERY 143.109.8 206,992.9 224.59t. I 131,037. 2 127,921.3 126.787.2 960.439.5 56. 496.4 6. COtttNICATIONS 14,777.4 25,588.3 S0. 156.t 22. 424. t 19.204. t 13,570.5 125.720.5 7. 395.3 C. CONIWMITY IlIZATIONt

ttNht INCOtIEGENERAT ION t, 650.0 8,590. 0 14,260. 0 16. 150.0 10.900.0 8,400.0 59. 950.0 3, 526.5 WNOEWS INTEGRATEOLEARNING FOR LIFE itIL) 3.948.0 - - - - - 3.940.0 232.2 ADOLESCENTGIRLS PROGRAN I A11E I 602.0 704.0 1.442.0 1.663.0 t,684.0 2,715.5 9.010.5 530.0 ------...... Sub-Total COMUIITt NOILIZAION 6,200.0 9,294.0 15.702.0 17,613.0 t2,784.0 tl, 1tt.5 72,90t.5 4.288.7 0. PROJECTNANAGENENT

PROJECTORGANIZATION 9,002.5 6,653.S 6.653 5 6,653.5 6.653.5 6.653.5 42.270 0 2,486.S NOITORINGAND EVALUATION 2.140.0 1,016.0 2,51t.0 1, 216.0 SlS.0 2. 11S.0 9.620 0 585.9 Sub-total PROJECTtNAAGENENT It.142.5 7,669.5 9,169.5 7,869.S 7.269 5 8,769.5 51.690.0 3.052.4 Total BASELINECOSTS 175,229.7 249,544.7 279. 618.7 179, 143.8 167.178.9 160,242.7 1.210.958.5 71,232.9 Physical Coati,nencies 8.761.5 12.477.2 13.S80.9 8.957.2 8,358.9 8,012. 1 60,547.9 3,561.6 Price Contintegncies 9,890.9 34,325.4 61,246.2 53, 707.9 55.010 9 77?528.0 301.,09.2 -4,626.4 Total PROJECTCOSTS ;93,882.1 298.347 3 354,845.9 24t.808.9 240.548.7 245.782.8 ;,573.215.7 70,168.I Tax 8,592.0 11.691.6 8,S77. 5 2, 033.5 1,837.4 1,990.4 34.622.4 1, 608.2 forign Exchaue 16.974.8 25.741. 9 27.993.9 14,239.5 13,953.4 14, 41. 7 113.444.2 5, 107.3 t;ay --- ;---0------9---- Ray 30. I99 09:54 ------

Ia ICOS.ANDHRA PRADESH STATE Suinry Accounts by l"-

Total* Ineluding Contingencies Totals Including Contingencses IRS '000) tUSS'000) 1990 1991 1992 1993 1994 1995 total 1990 1991 1992 1993 1994 1995 total

1. INVESTRENTCOSTS A. CIVIL HOmIS 28.871 7 61.571.0 73.082.1 11,669.6 1,245.8 1,994.0 t78.434 2 1.408 4 2,890.7 3.306 9 509.6 52 6 81.4 A,249.5 D. FURNITURE 9.403.0 4.079.2 3,758.0 - - - 17.240.3 458.7 191.5 170 0 - - - 820.2 C. EQUIPIIENT 23.750.3 24.951.2 17,001 4 206 7 220.7 353.3 66.483.6 1.158 D 1,171 4 769.3 9.0 9 3 14.4 3.132 0 0. VEHICLES 9.998.9 13. 140.9 6.899.0 - - - 30,038.8 487. 8 616 9 312 2 - - - t,416.9 E. DRU6SANDO EDICINES 10.763.2 15.085.0 11.082 6 3.715.9 3.973.3 4.246.0 48.865 8 525.0 708.2 501 5 162 3 167.6 173 3 2.237 9 f. tRAINING 17.954.6 1S,311I 21.117.0 10,852.5 13,511.8 :2.504.9 94.252 6 875.8 859.7 955 5 473 9 570.1 510.4 4.245.S G. COMIWNICATIONS.PRDUCTIOtN 8 DISSEMINATION 16.099 3 29,951 3 37.43.0 30,096.8 27,459.2 20,725.5 162.175 0 785 3 1.406.2 1,712.4 1,314 3 .l158 6 845 9 7,222.7 H. STUDIESA SURVEtS 2,150.9 702 6 2.623.3 446.4 191 7 2,370.1 8,484 8 104.9 33.0 1t8 7 19 5 8 I 96 7 380 9 I. GRANtS 1. 795.7 10.016 7 17.792.3 21. 519.4 IS,475.0 12,700. 8 79.299.9 87.6 470.3 805 1 939 7 653 0 518.4 3.474.0 ------...-...... ------...... total INVESTtNEtCOSTS 120,787 6 177,809 6 191.198.6 78,507.3 62,077 4 54,894 C 685. 275.1 5 .92. t 8,347 9 8,651 5 3,428 3 2.619 3 2,240 6 31. 179 6

It. RECURRENTCOSTS A. SAtARIES 41, 141.9 71.094 9 99.660.? 106.430 9 t13,400.4 120.771.5 552,500.4 2,006 9 3,337 8 4. 509.5 4.647 6 4,784.8 4.929 4 24,216 2 8 CONSUtUtLES 11,502.6 18.821 9 27.724.8 29.704.3 31,762 0 33,942.0 153,457 6 561 t 683.7 1,254.5 1,297 t 1.340.2 1.385 4 6,722.0 C. PETROt.OIl A lUBRICANTS 2,690 0 4,197 9 S,361 t 5.735 2 6. 121 3 6,530 1 30.636 4 131 2 197 t 242 6 250.4 258 3 266 5 1.346 2 0. OTHEROPERATING COStS 1,390.3 1,699 6 7.974 6 6,253.9 11,002 2 12,392.6 35,7t3 2 67.8 79 8 134 6 273 1 464 2 505.8 1,525.4 E THERAPEUTICIIUIRIltON tt.971 6 12.826 9 13.724 8 - 38.523 3 584 0 602.2 621 0 - - - 1.807 2 F. RE1N 4.398 0 9.896 5 14.200 5 .5,177 3 16,165 4 17,252 t 77,109.7 214 5 464 6 642.6 662 8 682 9 704.2 3,371 6

Total RECURRENTcosts 73.094 5 118.537 8 163.647. 3 t63, 301. 6 178. 471.3 190.8882 8t7. 940 6 3.565.6 5,565 2 7,404 9 7.131 t 7,530 4 7.791 4 38, 98. 5 :::::::: ::: ::::::: :=::e::--- :::::=: ::::::-- =. Total PROJECTcosts 193,882. 1 296,347.3 354,845.9 241,808.9 240,548.7 245. 782 8 1.573,215.7 9.457.7 13.913 0 16,056.4 10,559 3 tO.149.7 10,032.0 70. 168.1

May 30. 1990 09:54

Hi 0 INDIA ICOS. ANDURAPRADESH STATE Simey Account by Project Component (itsI 000) coWHIIY loIttzATION ------PlOJECTItNACEIENT "KRICS ------; SERVMCDCti,)ED? IN1EGRATEDADOESCEUT RONITORTWG ------MOEININCONE LEARNING fCR GIRLSPROGf PROJECT OPERATIONS AND NUTRITION HEAI.tN lRAINGi COWAHIUATIONSGENERATION IftE (MitLl AGATEI ORGAIZNATtONRESEARCH EVAtUtAION Total :::-:s.:-::ss:: ...... ::::::::= :.=. t :s , S ...... 5.-...., ......

1. INVESTNEITCOSTS

I. CIVit HORNS 140.250.0 - - - - 4. 65. 0 - - - 144,92.0 B. FUIRNITUIRE 9,328. 0 S..200. 0 ---- 32*0.0 14. DID. C. EQUIFNENT 1969. 0 2.600.0 24t.5 825.0 69.0 60.0 5S. 764.5 0. VEHICLES 23. 000.0 * - - - - - 1,960.0 - - 24. 960.0 E. DRtlSAND NEDICINES 20.340.0 t7. 820.0 ------38. 100.0 F. TRAINING - * 69.468.5 - 3,264.0 t,400.01* 74. 132.5 G. COINICATIONS. PRODtCTIONS DISSENINATION - - - 124,843.0 ------124,843.0 H. STUDIESA SURVEYS - - - 877.S - 741.3 - - - S. t00. 6,718. 8 1. GRANTS -- - .980.0 - - 59 950.0 Total I1VESTHENTCOSTS 244. 87. 0 17. 820. 0 77,268.5 125, 720.5 9. 9S0. 0 982.8 8,764. 0 2,349.0 - 6. 560.0 844. 301.8 tl. RECURRENTCOSTS

A. SALARIES 330.,i94.0 - 55,848.0 - t1,260. 0 - 29. 130.0 - 1,440.0 4IS, 272. 0 8. CONSMISA8LES 93,663.0 t ,232.0 1 705 2 1.8M.0 t.440.0, 109t924.2 C. PETROL.OIL 8 LUSRICANTS 37S.0 - - - - - * 7.332.0 - - 22,707.0 D. OTHEROPERATING COSTS 19.992.0 2.200.0 2,682.0 - - - 246.5 135.0 - 180.0 28,40S.5 E. THERAPEUTICNUTRITION 33,000.0 ------33 000.0 F. REINT 5s:90a - - 1,440.0 - .348.0 lotal RECURRENTCOSTS 5468.532.0 2.200.0 69.732.0 i- 2968.2 246.5 39,921.0 3,060.0 666,556.7 Total DASEt.INECOSTS 793,419.0 20,020.0 147,000. S 125.720.S 59.980.0 3, 946. 0 9.010.5 42,270.0 - 9.620. 0 t. 2 10t "S. S Pyical Contingencies 39,67t.0 1.001.0 7.380.8 6,266.0 2,997.8 197.4 450.8 2,113.5 - 4S1.0 608.47.9 Price Contingenci., 201,571.2 3,120.7 33,318.9 3t1277.8 16,352.4 238.4 3,11t.S .10,342. 2,375.6 30t1,t9.2

Total PROJECTCOSTS 1tOU. 60t. 2 24, 141.7 187,669.4 163,264.4 79,299.9 4.363.8 12,872.85 84.726.2 - 12.476.6 1. S73,2S. 7 :s:s:s:: ,=:ss;s=::: ::::::::: s:s:.:acsssc: :5:s::::::: :5555255:s55 S:5S::::::c:: :::::5,;:::: 5,5:::: ::::: :::::::: s* 5:5:::e Taxes 30. 962. 4 . 07. 6 1.056.5 - - 113.0 263.3 1,246.3 - 102.3 34.822.4 Foreign Exchange 83.137.4 S,2t4.5 10.340.6 10,O0.1 - 488.4 1.361.0 2.221.2 - 604.0 113,444.2

May 30, 1990 09:S4

to tCOS,CttSSaING, SI*IEsat Proect Caone.t: by Tar IRS'0001

BaseCosts Total 1990 1991 1992 1993 1994 1995 RS IUS$'000) .:,::2?: 22::::: ::::::nr :ss:::::: ::::::::: .. ::::: ::::,:a:- .. :.. . I. SERVICE (tEtlYEg

RUTRItION 64.135.2 tS8,581 9 239,652 9 192,948.9 152.032.9 146.691 9 954,043.1 56.120.2 EALtaN 36. 342.t 29. 533.7 36, 139.3 28. 98. 0 28 198.0 28. 198 0 186.609. 7 tO. 7. 0 T1U9llG 10.884.E 35. 770.S 30.368.3. 14.164 2 t3,774. 2 13.,34. 2 11.816. 2 6. 98 2 Su-Total SERVICEDELIVERY ;;;,362 5 223,t886.4 306, 1;0.5 235.31t;.; 194005.1 18.;724. ;1,259.459.6 74,086.4 B. CUOMMNICAIONS 5.238.0 6,363 0 6.657.0 tW.659.te 7,493.0 5.417.0 41.827.0 2.460.4 C. CwuIuITY mlaIcATIOl

tMEt INCOMEGENERATION 3.604 0 17.254.0 17 254.0 17 104.0 8,979 0 - 64. 195.0 3,776.2 tONE1'S INTEGCRTEOLEANING fOR LIFE It)Il 2,t13.9 3,.755.9 3.755.2 3,755.9 3 755.9 3. 55 9 20.963.5 1.233.1 ADOLESCENTGIRLS PROGRUt I AATE I 1. 790.6 4.083.5 5, 368. 3 S.010. 7 6,010.7 6.010.7 29. 274.5 1 722.0 SDb-TOtECCONITY IE ILIZATION 7,576.4 25.03.4 26,378.2 26870.86 t1,745.6 9.766.6 114,432.9 6;731.3 0. PRECT .ANGNT

PROJECTORGANIZAtION 7.718.5 6.294.0 6,294.0 6.294.0 6,294.0 6,294.0 39 t88.5 2,305. 2 RoNITORINGAND EVAtUATION 2,490.0 1. 716.0 2. 9g6 0 1,616.0 716.0 2,416.0 t1.870.0 696.2 Svb-Total PROJECTNtlGEtRENT 10;208.S 8,010.0 9,210.0 7.9S0.0 7;010.0 6,710.0 510 S9.5 3,003.4 Total BASELINECOSIS 134.387.5 263.352.9 348,425.6 2S0.750.7 227.253.7 212,617 7 1.466,7SS.0 S6,261.6 Pb"tcal Contihlgsic:S. 6,7t9.4 13.367.6 7, 421.3 14,037.5 It,362. 7 10,630.9 73,339.4 4,34. t Prue Contuotpcies 7,990.7 35.686.0 76,607.4 8.4760.3 S6S127.2 102,542.0 395,793.6 -4,9S2.5 Total PROJECTCOSTS 149.097.6 312.206.5 442.534.4 379,548.5 326.743.5 325,790.5 1.935.92t.0 65.613.2 ::::::::: 2222::fi::, 5::::::: :2:::::::: 22fl,fl: ::::::2: :;S::::::::2 ::::::::2-2 laoes 3,273.5 tt,627.3 tS.087.8 5,843.5 2 S91.4 4,206,3 52,629.7 2,412.3 foriton EJ_camp 14,029.1 24,49S.9 35,912.6 24,696.2 t7, 95.3 17,549.8 134,580.8 6009.3

Oby 1990 0.-%3 .

to INDIA ICOS.ORISSA STATE Suwry Acconts by Yea Totals IncludIng Contingencies Total$ Including Conteinsnci.. Ws$ '0002 IRS I'0002 ...... ------...... 190 1t991 1992 t193 1994 1995 Total 190 t1991 t992 1993 1994 1995 total sat..... S:t::4 ,=,.t::::::::: :tx::: ::,::::...... :::: ...... :.. :..,.,,: ::.... :,::: s . ..t.: s;.ts,:: satatast t..t....

1. linsinut COStS A. CIVIL NORXS 4,187.4 61,718.3 tt3.1t1.6 57.906.0 9.52&.9 . 246.520.2 204.3 2.897.6 5,121.3 2.528.6 402.0 - 1,153.8 B. IfURntURE 275.0 - - - - 275.0 13.4 - - - - 13.4 C. ECttlPIEIE 41,254.4 26.114 1 32.23.9 t.t712.8 S.ISO.t - 117.035.3 2,012.4 1.226.0 1,485.2 S12.1 217.3 - S412.4 0. VEHICLES 19,801.9 13.979.7 16.041.0 3.072.6 - 4. 145.3 57.044.6 966. 1 656.3 725.8 134.2 - 169.2 2,651.1 E. OUCS noMNOICINES 12,094.0 28,461. 6 25.850.5 28,001. 2 29.940.9 31. 991.9 t46.348. I S90.0 866.9 ,. 169. 2, 222.8 1,263.3 t 306.0 6,848.6 f. TRAINING 14.536.7 47,. 18.7 45,278.1 27,892.8 28.607.9 30.508.6 193.942.7 709.1 2,212.1 2,048.8 1.218.0 1.207. 1.245.2 8.640.4 G. COISttCATXONS,PRODICTION 8 DISSE1INAttON 5 S39.g3 7,330.4 8,220.9 14,290.2 10.573.8 8.61.60 14,021.1 20.2 344. 1 372.0 619.t 446.2 333.2 2.385.3 N. STUDIESA SURVEYS 2.178.21 t.282.1 2.86.7* 799.1 142.0 2. 22. 6 9.393 6 77.0 60.2 129.9 34.9 6.0 1t1.I 4t9.0 1. GtRATS 3,922.3 20.119 6 221.28.0 22.790.5 12.747.7 - 8t. 108. I 191.3 944.6 974.1 991.2 537.9 - 3.643. 1 total INVESIltENTCOSTS 103. 193.0 196.129. t 265.193 7 166.365. 8 96. 689.2 77.532.3 905. 703.0 1. 033.8 9.207.9 12.026.9 7,264.9 4.079.7 3, 164. 6 40. 77. 8

II. RtCURREtNtCOSTS A. SALARIES 26,920.7 73.999.0 120.319.7 10.0618.9 160,524.6 170.958. 7 703,372.6 1. 32. 7 3.474 1 5,40' 3 I !79.0 6.773. 2 6.977. 9 30,561.3 B. CONSUNAStES 3. 188.1 1.921. 1 .8197.0 9.343.8 9.991.1 10.676.8 47,311.9 211.1 277.7 370. 408.0 421.6 435.8 2.069.1 C. PETROL,OIL LtU8RICANTS 1.474.4 3.312 3 S. 161.0 S.520 4 1.892. 1 6.285.5 27.645.7 71 9 155.5 233.5 241.1 248.6 216.6 1.207.2 0. OtHEROPERAtIMG COSTS 7. 342. t 16.023. 5 20. 654. 1 23.832 4 28. 445. 1 33. 586.0 229.883.3 358.2 752.3 934.6 1, 040.7 1,200.2 2, 370.9 1. 656. 8 E. TIERAKEUTICNUTRIIION 3,135.1 6,548 7 6.918 5 7. 271.3 7.145.1 7.932.0 39, 31. 8 152 9 307.1 313.1 317.S 318.4 323.8 1 733. 1 f. RENT 3.853.7 0,02788 S.1490 4 16.555.9 27,655.6 28.819.2 82,613.7 288.0 482.6 700.9 723.0 745.0 768.1 3,607.5 Total RECURRENTCOSTS 41,904.6 126.077.15 76. 740.7 223, 282.7 230.054.4 248.258.2 1.030.218.0 2,239.2 S,449.6 7.997. 3 9,309.3 9,706.9 20. 33.0 44,835.4 Total PROJECTCOSTS 249,097.6 322.206.5 442.534.4 379.548.1 326.743.5 325,790.5 1,931,922.0 7.273. 14,657.62 20,024.2 16.574.2 23,786.6 13.297 6 81,623.2

Nly 30. 1990 09:53

'0 INDIA ICOS,ORISSA STATE S.mry Account by Project Caqlonnt IRS 0001 COIOIIITY NOBItIZATION ------r- ro-----l---tt-f-tt-l t ------PROJECTNAAGENtENT tOttES -...... SERVICEDELIVERY INTEGRAtEDADOtESCENT NONITORING ------11MEtNINCONE LEARNING fDR GtRlS PROGRAN PRODECT OPERATIONS AND NUlRITION HEALtH TRAINING COMMIICATIONSGENERATION LIFE (IItI I AGATEI ORGANIZATIONRESEAfCH EVALUATION totcl

1. tIVESTRENtCOSTS

A. CIVLt ttORS 192. 184.0 ------* - - 192.184 0 S. FUINITURE ------248.0 - - 248 0 C. EOUIPNENT 56.822 5 38. 4t5.0 - - 305.9 70.0 494.0 - 60.0 96, 167.4 P. VEHICLES 43. SO.0 ------3.000.0 - - 46, SO.O0 E. DRUCSAID tEDICINES - 10S.097.3 ------105,097.3 f TRAINtiG - - 11.816 2 900.0 - - 28. 280.5 - 1.400.0 149.396.7 G. CONICNATIONS.PRODUCTION 8 DISSENtINAtION - - - 40,927.0 ------40.927.0 N. STUDIESa StRvErS ------7, 350. 0 7. 350 0 1. GRAttS 64. 195.0 64195.0E- Total IWNESTENtECOSTS 292, 156.5 143,512. 3 IS, S6. 2 41.827.0 64. 195.0 305.9 28,350.5 3,742.0 - 8.810 0 701,71S.4 11. RECURfEtNtCOSTS A. SALtRIES 489,391.3 2, 565.0 - - 8. 778.0 924.0 21,723.0 - 1.440.0 523.821 3 8. COUStt8tLES 7.B75.5 24.480.0 - - 1.440.0 33,795.5 C. PETROL.OIlt 8 Il8ORICftttS 18,.t80 0 ------2,062.5 - - 20. 242.5 0. OTHEROPERATING CoStS 56. 119.5 16.052.4 - - 11,879.6 - 11,661.0 - 180.0 95.892 4 E. THERAPEUTICNUTRITtON 30.060.0 ------30.060.0 F. RENT 61. 261. 0 - - - 8 261. 0 Total RECtRENTCOSTS 661.887.2 43,097.4 - - 20,657.6 924.0 35,446.5 3,060.0 765.072.7 Total 8ASELINECOSTS 954,043.7 186.609.7 11t8816.2 41.827.0 84,t95.0 20,963.5 29,274.5 39.188.5 - tt,870.0 1,466.78800 Physical Continglegiss 47.702,2 9,330.5 5,940.8 2,091.4 3,209.8 1,048.2 1.463.7 1.959.4 - 593 5 73.339.4 ' Price ContingmnceI 261.317.0 54.503.9 28.000.9 11,255.5 13.703.4 5. 663.2 8,813.0 9. 698.9 - 2, 837.9 395.793.6 Total PROJECTCOStS 1.263.062.9 250,444.1 152.757.9 55,173.9 8t,108.1 27,874.8 39.551. t 50,646 8 - 15,301.4 1.935.921.0 :; -::;::::: :: ;- - -:- : :: :: .. .: ::-::::: : .:: ZX ::::--- :::-. :-- . :::: :: laxs. 39,047.1 11.723 7 - - - 20.5 4.7 1,731. 4 - 102.3 52,629.J f6rotp Exchanga 64,799.3 5t. 042.2 9,479.3 3.439.0 1.035.4 2.408.4 1,773. t - 604.0 134,580.6

Nay 30. 1990 09:S3

0 I.

to -78- ANNEX 8 lPage 1 of 4

INDIA

INTEGRATEDCHILD DEVELOPMENTSERVICES PROJECT

Prolect ImPlementationSchedule

Andhra Pradesh

Year Activity I II III IV V VI QlQ2Q3Q4QlQ2Q3Q4Q1Q2Q3Q4QlQ2Q3Q4QlQ2Q3Q4Q1Q2Q3Q4

Service Delivery

Expand to New Areas *xhxxux uxxxxzxxz Infill with New AWs xuxxxu x Establish Block Offices uu uu EstablishDist Offices x-zxxxxxxxxxxxxxxxxxx ------Work Organization FunctionalAnalysis xx Test work routines xxxx--xx Review xx Implement xxxixs Supervision Appoint Block Sup. SupervisionStudy --x -- Other actions XXXuxxxx Civil Works AW Centers xxxzxzxxxxxxxxxcxxxx-u- SupervisorQtrs *xzxx xXXXXX CDPO Qtrs ------u------Office Buildings xxx -- codowns xxxxxxxxxxxxxxxxzXXXXXXXXXXxx Upgrading AWs ------. Upgrading Offices xxxx-xr TherapeuticSupplem. Finalize Composition xxXX Test Supp. Strategies * 7aaxxaxxxxxx TmplementProjectwide xXXX Health-NutritionCoord. Develop Arrangements xxxxx*-- ImplementProjectwide xxxxxxxx NutritionalRehab. Test mat. cum nut.homes *uxzxxiuxxxxx Expand _ Pre-schoolEducation Supply ed. kits - 79- ANNEX 8 Page 2 of 4

Year Activity I II III IV V VI QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4Q1Q2Q3Q4 Communication

Staff Development FormativeStudies u-u-u---*_- -*-_ Prod and dist material xxxxxxx------uxxxX-u------Special programs Monitoring xXxxxxxx xxxxxxxx SummativeEvaluation xxXX XXXX

CommunityMobilization

EstablishMMs u------Income generatinggrants WILL Test xxxxxxxxxxxzxxxx Evaluate xxxZ Expand Jxxx------uxx=ZXXuu AdolescentGirls Progs

Trainin8

Pre-service Orientation ZxuZ- x In-service _ Training of trainers Curriculum Review

Monitoringand Evaluation

District monitoring XXXXXXXX ZxxxxxxZ Beneficiary data banks xuxxxxxx XXXXX-3. State Level -xxx-xxx Base Line xxxZ Mid-term Evaluation XXX Final Evaluation xxxi

Project ManaRement

Establishoffice xxxm Est. EmpoweredComm. Zs - 80 - ANNEX 8 Page 3 of 4

Orissa. Year Activity I II III IV V VI QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4

Service Delivery

Expand to New Areas Infill with New AWs ---- EstablishBlock OfficesO EstablishDist Offices u Work Organization FunctionalAnalysis xx Test work routines ------Review xx Implement xxxxx Supervision Appoint Block Sup. SupervisionStudy zxxxxxxx Other actions xxxxxxxz Civil Works AW Centers SupervisorQtrs xxx CDPO Qtrs ------x Office Buildings x------Godowns ------x------u ----- UpgradingAWs xxxxxxxX Upgrading Offices _xxxxxMZ Therapeutic Supplem. Finalize Composition xxxx Test Supp. Strategies u ImplementProjectwide x Health-NutritionCoord. DevelopArrangements xxxxxxxx ImplementProjectwide xxxxxxxx NutritionalRehab. Test NR centers ------Expand _ Pre-schoolEducation Supply ed. kits

Communication

Staff Development Formative Studies -zzzzxxx- - *xxxx Prod and dist material ------h------Special programs Monitoring XXXXxz SummativeEvaluation zxx x.XX -81 ANNEX 8 Page 4 of 4

Year Activity I II III IV V VI QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4QlQ2Q3Q4 CommunityMobilization

EstablishMMs Income generatinggrants WILL Test ------Evaluate xxx Expand -xu------x---- xuxxxxx AdolescentGirls Progs

Training

Pre-service Orientation In-service - _ Training of trainers Curriculum Review

Monitoring and Evaluation

Districtmonitoring ux-x-x-- xxxx Beneficiarydata banks xxxxxxux xxxTx State Level ------t Base Line xxx Mid-term Evaluation xxx Final Evaluation xxxi

ProjectManagement

Establishoffice xxx Est. EmpoweredComm. xx - 82 - ANNEX 9

IntegratedChild DevelopmentServices Project

IncrementalOperating Costs Decrementedby 25? per year

Year Costs (USS '000) Total First Incurred 1991 1992 1993 1994 1995 1996

Year 1 5,068 3,801 2,534 1,267 0 0 12,670. Year 2 5,037 3,777.8 2,518.5 1,259.2 0 12,592.5 Year 3 4,363 3,272.3 2,181.5 1,090.7 10,907.5 Year 4 1,654 1,240.5 827 3,721.5 Year 5 797 597.8 1,394.8 Year 6 681 0

Total 5,068 8,838 10,674.8 8,711.8 5,478.2 3,196.5 41,286.3 -83 - ANNEX10

INDIA

INTEGRATEDCPTLD DEVELOPHENTSERVICES PROJECT

Forecast of Annual Expendituresand Disbursements

Expenditures Disbursements IBRD Fiscal Year Semester Cumulative Semester Cumulative ------US$ Million------____-_____

FY91

1st (7-12190) 4.4 4.4 5.0 5.0 2nd (1-6/91) 6.2 10.6 0.0 5.0

FY92

1st (7/91-12/91) 8.2 18.8 1.5 6.5 2nd (1/92-6/92) 8.4 27.2 4.0 10.5

FY93

1st (7/92-12/92) 10.6 37.8 7.0 17.5 2nd (1/93-6/93) 12.8 50.6 7.2 24.7

FY94 lot (7/93-12/93) 14.4 65.0 9.0 33.7 2nd (1194-6164) 16.6 81.6 10.3 44.0

FY95

1st (7/94-12/94) 19.2 10r.8 10.8 54.8 2nd (1/95-6/95) 18.1 11d.9 9.8 64.6

FY96

1st (7/95-12195) 14.2 133.1 9.4 74.0 2nd (1/96-6196) 12.3 145.4 9.2 83.2

FY97

1st (7/96-12/96) 10.4 155.8 8.8 92.0 2nd (1/97-6/97) - 155.8 8.2 100.2

FY98 lot (7/97-12/97) - 155.8 5.8 106.0 - 84 - ANNEX 11 Page 1 of 3

INDIA

INTEGRATEDCHILD DEVELOPMENTSERVICES PROJECT

Selected Documents in the ProiectFile

A. Reports and Tables Relevent to the Project

Andhra Pradesh

A-1. Project Proposal--EnrichedIntegrated Child DevelopmentServices Project in 110 Blocks of 13 Districtsof Andhra Pradesh. Govt. of Andhra Pradesh. October/November,1989.

A-2 Strategies for EffectiveCommunication with Regard to Enriched ICDS Project (in Andhra Pradesh).Administrative Staff College of India. Hyderabad, 1989.

Orissa

A-3 Project Proposal--Multi-state ICDS Projectwith World Bank Assistance. CommunityDevelopment and Rural ReconstructionDepartment. Government of Orissa. January, 1990.

A-4 NutritionPrograms in Orissa State. NutritionFoundation of India. Undated.

A-5 'Food Habits, Nutritionand Health Status of the Lanjia Saoras-A PrimitiveTribe of Orissa.*Almas Ali in Vol. 33, Proceedingsof the Nutrition Society of India, 1987.

A-6 "Area DevelopmentApproach for PovertyTermination (ADAPT)'. Government of Orissa. 1988.

ICDS General

A-7 'Impactof TherapeuticNutrition on Rehabilitationof the Severely MalnourishedChildren in ICDS--AResearch Report". National Institute for Public Cooperationand Child Development.New Delhi. 1987.

A-8 IntegratedChild DevelopmentServices. A Study of Some Aspects of the System. NutritionFoundation of India. 1988.

A-9 Monitorint and ContinuingEducation System. IntegratedChild development Services.Central TechnicalCovmittee, All-India Instituteof Medical Sciences.New Delhi. 1988.

A-lO Monitoring Social Componentsof IntegratedChild DEvelopmentServices. Sharma, Adarsh. National Institutefor Public Cooperationand Child Development.New Delhi. 1987. - 85 - ANNEX 11 Page 2 of 3

A-li 'Summaryof Findings of USAID-AssistedICDS Impact Evaluation.Second Follow-upSurvey 1987-88 in Panchmahalsand Chandrapur.MS Universityof Baroda. 1989.

A-12 'Statusof NutritionComponent of ICDS'. TechnicalBulletin No.2, March, 1989. National Institutefor Public Cooperationand Child Development.New Delhi.

A-13 'The Impact of ICDS on the Status of Child Health in India.' Tandon, Dr. B.N. of All-IndiaInstitute of Medical Sciences,New Delhi. 1986.

A-14 'NutritionalInterventions through Primary Health Care: Impact of the ICDS Projects in India".Bulletin of the Vorld Health OrganizationNo. 67 (1). 1989.

A-15 'Managementof SeverelyMalnourished Children by VillageWorkers in IntegratedChild DevelopmentServices in India',Journal of Tropical Pediatrics,Vol. 30, 10/84.

A-16 IntegratedChild DevelopmentServices. An Assessment.Krishnamurthy, Dr. K.G. and Nadkarni,Dr. M.V. UNICEF, New Delhi. 1983.

A-17 'InterimEvaluation of WFP-AssistedProject (SupplementaryNutrition for pre-schoolchildren, pregnant women and nursingmothers)". World Food Programme,New Delhi. 1987.

A-18 A Handbook of InstructionsRegarding Integrated Child Development Services Programme (as on 31.12.1988).Department of Women and Child Development.Government or India.

A-19 A Guide-Book for AnganwadiWorkers. Departmentof Women and Child Development.Government of India. 1986.

B. Consultantand General Reports and Studies

B-1 Civil Works (AndhraPradesh and Orissa). Laroya, H. February,1990. (ConsultantReports).

1-2 Communications(Andhra Pradesh and Oruissa).Mehra, S. March, 1990 (ConsultantReports).

B-3 Health and NutritionService Delivery (Orissa). Kevany, Dr. John. March, 1990. (ConsultantRepoert).

B-4 Monitoring and EvaluationComponent in Orissa. Murthy, Dr. Nirmala. March, 1990. (ConsultantReport).

B-5 'Nutritionand Budgets of Central and State Governmentsin India'. Murty, Prof. M.N. (ConsultantReport).

B-5 ImprovingNutrition in India. Policies and Programs and Their ImRact. X. Subbarao. World Bank DiscussionPaper No.49, 1989. - 86 - ANNEX 11 Page 3 of 3

B-6 Collection.Modtfication and Disseminationof Nutritionand Health EducationMaterials. A Research Report. National Instituteof Public Cooperationand Child Development.India. March, 1989.

B-7 DevelopingNutrition Service and TrainingCasabilities. National Instituteof Health and Family Welfare. India. 1987.