ICDS BIHAR ICDS Internship Final Report Malnutrition in Patna District Andrew R. Bracken MPP Candidate 2013 University of Michigan Gerald R. Ford School of Public Policy 10/8/2012 Andrew R. Bracken ICDS Report ACKNOWLEDGEMENTS I would like to express my gratitude to all ICDS staff in the State of Bihar for the opportunity to intern in Patna for ten weeks. A special thanks goes to ICDS Director Mr Praveen Kishore for affording me the chance to come to intern for ICDS. Monitoring Officer Ms Abha Prasad helped immensely in understanding ICDS, arranged field visits, and treated me very kindly. Mr Pradeep Joseph helped me focus my research, provided invaluable and insightful feedback, and assisted me with tasks I could not otherwise accomplish. I would like to thank Patna DPO Mr Sudhir Kumar for granting me complete access to any resource and facility I desired in Patna District. I would also like to specially thank the following CDPOs, their Lady Supervisors, and Anganwadi Workers who generously shared their precious time and entertained my every request: Ms Rashmi Chaudari (Fatuha), Ms Anjana Kumari (Masaurhi), Ms Mamta Verma (Dulhin Bazar), Ms Babita Rai (Hajipur Sadar), Ms Madhumita Kumari (Patna Sadar 1), Ms Kanchan Kumari Giri (Patna Sadar 3), and Ms Tarani Kumari (Patna Sadar 4). 1 Andrew R. Bracken ICDS Report CONTENTS ACKNOWLEDGEMENTS ............................................................................................................ 1 CONTENTS .................................................................................................................................... 2 ABBREVIATIONS ........................................................................................................................ 3 EXECUTIVE SUMMARY ............................................................................................................ 4 INTRODUCTION .......................................................................................................................... 7 MALNUTRITION .......................................................................................................................... 7 GROWTH STANDARDS AND MALNUTRITION ..................................................................... 9 DATA COLLECTION ................................................................................................................. 13 DATA ANALYSIS ....................................................................................................................... 15 RECOMMENDATIONS .............................................................................................................. 36 CONCLUSION ............................................................................................................................. 39 2 Andrew R. Bracken ICDS Report ABBREVIATIONS AC Anthropometric calculator AWC Anganwadi Centre CDC Centers for Disease Control CDPO Childhood Development Project Officer DPO District Programme Officer GHI Global Hunger Index HIV Human Immunodeficiency Virus IA Individual assessment ICDS Integrated Child Development Services ISHI India State Hunger Index LS Lady Supervisor MIS Management Information System MGRS Multicentre Growth Reference Study NCHS National Center for Health Statistics NHS National Health Service (United Kingdom) NS Nutritional survey SNP Supplementary Nutrition Programme THR Take Home Ration UNICEF United Nations Children’s Fund WHO World Health Organization 3 Andrew R. Bracken ICDS Report EXECUTIVE SUMMARY Introduction: Despite Bihar’s high growth rate in recent years, malnutrition persists as a barrier to development. The WHO (World Health Organisation) characterises malnutrition as [N]ot enough as well as too much food, the wrong types of food, and the body's response to a wide range of infections that result in malabsorption of nutrients or the inability to use nutrients properly to maintain health.1 The 2008 India State Hunger Index (ISHI) ranked Bihar 15th of 17 states surveyed. Bihar notably ranked below average in the proportion of underweight children (56.1% vs. 42.5%).2 In 2005-6 the WHO found that of Bihari children aged 0-5, 56.4% were -2 standard deviations or more from the ideal weight (mean of 0) and 25.4% were -3 or more standard deviations from the mean.3 A malnourished child is more susceptible to disease and can suffer permanent mental and physical damage. The first 2-3 years are the most critical for preventing long-term damage. Objective: The objective of this report is to define malnutrition and childhood growth standards; present research about the impact of block and sex on malnutrition, supplementary nutrition (SNP), and Take Home Ration (THR) provision in Patna District; and offer recommendations to reduce malnutrition in Bihari children though ICDS. Data collection: Child growth and malnutrition data are from visits to 34 Anganwadi Centres (AWCs) in Patna and Vaishali Districts. Block-level data are from ICDS’s MIS (Management Information System). AWC growth and malnutrition data were analysed with WHO Anthro software and two-tailed t-tests in Excel to determine malnutrition levels and if there was a gender bias in malnutrition. Block-level data from 2011-12 were analysed with chi-squared (X2) tests in Excel to determine if malnutrition rates, SNP, and THR provision were independent of sex. AWC data were not collected from randomly selected AWCs. Block-level data were not available for all blocks in Patna District, nor were all block-wise reports complete. Data analysis and results: The analysis in this report yielded the following results: AWC gender malnutrition independence analysis 3 of 22 AWCs with sufficient data showed malnutrition to be dependent on gender at an alpha of 0.05. In each case males were more malnourished than females. 1 http://www.who.int/water_sanitation_health/diseases/malnutrition/en/ 2 http://www.ifpri.org/publication/comparisons-hunger-across-states-india-state-hunger-index 3 http://www.who.int/nutgrowthdb/database/countries/who_standards/ind.pdf 4 Andrew R. Bracken ICDS Report The best AWC had average weight-for-age -1.19 standard deviations from the ideal mean (11.7th percentile); the worst AWC had average weight-for-age -3.64 standard deviations from the ideal mean (0.0001th percentile). A weighted average of weight-for-age standard deviations for the 22 AWCs showed results almost identical to the WHO’s for Bihar in 2005-6:4 o -2 or more standard deviations below the mean: 57.05% (vs. 56.4% WHO). o -3 or more standard deviations below the mean: 23.28% (vs. 25.4% WHO). Patna District malnutrition, SNP, and THR gender independence analysis SNP provision favoured: o Females 31.75% of the time and males 2.38% (all ages). o Females 21% of the time and males 5% (6 months –1 year). o Females 14% of the time and males 2% (1-3 years). o Females 60% of the time and males 0% (3-6 years). THR provision favoured: o Females 22.62% of the time and males 23.81% (all ages). o Females 19% of the time and males 26% (6 months –3 years). o Females 26% of the time and males 21% (3-6 years). For malnutrition, the sexes worst affected were (Normal, Grade I, Grade II, Grade III, Grade IV), by percentage of statistically significant cases: o Females 19%, 5%, 10%, 14%, 5%; males 0%, 5%, 0%, 0%, 0% (0-1 years). o Females 10%, 5%, 5%, 33%, 24%; males 10%, 33%, 10%, 5%, 5% (1-3 years). o Females 10%, 5%, 10%, 5%, 5%; males 5%, 5%, 5%, 19%, 5% (3-6 years). Conclusions from the analysis: Data analysis yielded the following conclusions: AWC gender malnutrition independence analysis Even the best AWCs had extremely high rates of malnutrition. Weight-for-age data are not uniformly collected by sevikas and thus it is difficult to make firm conclusions. However, the data in this report are very close to the WHO’s, although this shows almost no change in malnutrition since 2005-6. Patna District malnutrition, SNP, and THR gender independence analysis SNP: In most cases there is no difference between sexes, but females are more favoured than males, especially at ages 3-6. This is probably because families send older males to private or primary schools while females remain in AWCs. 4 http://www.who.int/nutgrowthdb/database/countries/who_standards/ind.pdf 5 Andrew R. Bracken ICDS Report THR: There is not obvious district-wide gender bias in THR. In some blocks females are favoured, in others males, but overall there is not a large difference. This is probably because families benefit equally from females and males receiving THR. Malnutrition: While females and males suffer high rates of malnutrition, females tend to be overrepresented in the worst grades (III and IV). Only at ages 3-6 do males show higher levels of malnutrition in Grade III. This is probably because the males remaining in AWCs are the poorest of the poor because wealthier males attend private or primary schools. Females remaining in AWCs are from all income levels. Recommendations: This report makes the following recommendations: Use standard growth measures: Sevikas do not use standard growth measures. Each AWC follows its own procedures. ICDS must train sevikas to all use the same measures which will allow for improved data analysis at block, district, and state levels. Properly train AWWs (Anganwadi Workers) on growth measurements: AWWs do not take growth measurements correctly. The WHO provides a Training Course on Child Growth Assessment5 which could serve as a model. Without good growth data, ICDS will not know the situation in AWCs and will not properly