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Directorate of Social WelfareDepartment of EducationDepartment of Health and Family WelfareGovernment of Bihar
Control of NutritionalAnaemia in School going
Adolescent Girls
Experiences in Bihar
Directorate of Social WelfareDepartment of Education
Department of Health and Family WelfareGovernment of Bihar
Contents
Background 4
Project Implementation 9
Training and Capacity Building of Functionaries 13
Local Resource Mobilisation 18
Supply and Logistics Management 20
Monitoring and Evaluation 24
Impact and Challenges 28
Control of NutritionalAnaemia in School going Adolescent Girls
4
BackgroundAnaemia is a serious public health problem, which affects the mental and
physical development, as well as health maintenance and work
performance. Iron deficiency is by far the most common cause of
anaemia worldwide. About 2 billion people suffer from varying degrees of
anaemia in developing countries.
Iron deficiency occurs when insufficient iron is absorbed to meet the
body’s needs. This may be due to inadequate iron intake, poor iron
absorption, increased iron need or chronic blood loss. Prolonged iron
deficiency leads to iron deficiency anaemia (IDA).
Haemoglobin levels recommended
by WHO
Children 6 month-6 years <11g/ 100ml
Children 6-14 years <12g/ 100ml
Adult male <13g/ 100ml
Adult female <12g/ 100ml
Pregnant woman <11g/ 100ml
Chapter1
Anaemia is the most common cause of maternal deaths, accounting for a
fifth of all maternal deaths (more than one lakh women in India die of
pregnancy-related deaths, out of which 22,000 are related to nutritional
anaemia). Severe anaemia accounts for 20.3 per cent of maternal deaths.
The risk of dying from haemorrhage and infection is five to ten times
greater among anaemic women compared with non-anaemic women.
Background
5
Anaemia among women also
compromises infant health by
contributing to intra-uterine growth
retardation, low birth weight and
ultimately perinal mortality, and a
higher risk of irreversible brain damage
in infants.
Anaemia is more likely to occur during:
� Preschool age when growth is
rapid
� Adolescence when there is rapid
growth and menstrual loss of iron
� Pregnancy, when there is rapid
growth of foetus and maternal
tissues
Anaemia in adolescent girlsAdolescence is a critical stage in the
life cycle, when the health of females
is affected due to growth spurt,
beginning of menstruation, poor
intake of iron due to poor dietary
habits and gender bias.
Iron deficiency anaemia affects over
60 per cent of the adolescent girls in
India (NFHS 1992). Anaemia in
adolescent girls has far-reaching
implications. The anaemic adolescent
girls grow into adult women with
compromised growth, both physical
and mental. These women have low
pre-pregnancy weight, and are more
likely to die during childbirth and
deliver low birth weight babies.
Therefore, investing in the adolescent
girls serves a dual purpose, as it helps
to optimise the development of the
girls’ inherent potential and provides a
sound foundation from which to
launch the next generation.
Counteracting the effects of anaemia
can help to further both the above
aims. Efforts to control anaemia in
adolescent girls have adopted a two-
pronged approach—a weekly regimen
of iron supplementation supported by
Control of NutritionalAnaemia in School going Adolescent Girls
6
rigours of pregnancy and child-rearing
can help to minimise the deleterious
impact of anaemia on the offspring.
Hence, controlling anaemia in
adolescent girls is now a national
priority and the government of the
state of Bihar, along with UNICEF,
took the initiative in this direction by
launching a district-based pilot project
in the year 2000. The Anaemia Control
Project (ACP) was launched in five
districts—Gaya, Muzaffarpur, Ranchi,
East Singhbhum and West
Singhbhum. With the bifurcation of
the state, the latter three districts are
now in Jharkhand state.
an interpersonal interaction for
behaviour change in dietary practices,
along with an intensive IEC campaign
that focuses on sustainable strategies
for the control of anaemia.
Pilot initiative for the control ofanaemiaNutritional anaemia has emerged as a
major limiting factor in the
development of adolescent girls, as it
compromises their own growth, and
also has implications for the future
generation. An intervention that can
help to improve the iron status of a
girl before she is subjected to the
Life cycle approach of Dular strategy
Community and family empowerment process
Community-based
MIS for below
3 year age group
Joyful learning in ECE
for 3 to 6 year age
group, linkages
with PSE
Control of nutritional
anaemia in adolescent
girls and quality life
education-”Kishori Shakti”
Maternal nutrition and
safe motherhood
through C B MIS
ICDS - BEP - RCH
ICDS - RCH
ICDS - RCH
Rest, food, iodised salt, safe delivery
practices, 3 check-ups, weight gain, IFA,
TT, care of newborn, prevention of LBW
Infant feeding practices, psycho-social
stimulation, breastfeeding, complementary
feeding, care of girl child, immunisation,
feeding during sickness, ARI, vit A,
growth monitoring and promotion,
safe drinking water, personal
hygiene
Cognitive, motor, psycho-social,
emotional and physical development of
children, linkages with PSE for playway
methods, community monitoring through
VECs, play material with locally available
resources
Weekly supply of IFA, parent
counselling, local resources management,
personal hygiene-menstrual period, AIDS education,
delay age at marriage, personality development,
completion of school, food-diet practices, sanitation,
prevention of worms and malaria
Capacity building
and skill upgradation
for better planning and
implementation
Capacity building
and skill upgradation
for better planning and
implementation
Background
7
✦ Phase-wise approach: The project is being
implemented in two phases. Phase I aims to
reach school-going adolescent girls, who
comprise only a small percentage of
adolescent girls. Phase II aims to reach the
out-of-school girls, who represent the majority
of adolescent girls. In addition to addressing
the health needs of these girls through iron
supplementation, the programme also
envisages educating them about their health
needs and life skills.
✦ Monitoring through compliance cards:
Monitoring of the intake of iron
supplementation is a key feature of the
project. The girls themselves have to fill
compliance cards after taking the iron-folic
acid (IFA) tablets.
✦ Girl-to-girl approach: A girl-to-girl approach
has been adopted, in which the school-going
girls play a pivotal part in contacting their
friends who are not enrolled.
✦ Intersectoral convergence: This has been
adopted at every level—state, district, block
and grassroots—involving all social sectors,
including health, ICDS, PHED, BEP, Panchayati
Raj and District Rural Development Agency
(DRDA). This will help to link the programme
with other development programmes such as
water and sanitation, malaria control,
deworming, etc., whose simultaneous
intervention can help to enhance the impact
of anaemia control measures.
✦ Behaviour change strategy: Apart from
focusing on causes, effects and control of
anaemia, messages for behaviour change
with regard to dietary practices are also
included in the awareness campaigns. These
emphasise foods rich in iron, inhibitors (e.g.
tea), and promoters of iron absorption (e.g.
vitamin C).
✦ Social mobilisation and parental counselling:
The programme in its initial phase has
concentrated on environment building and
social mobilisation on the issue of anaemia.
Parents have been counselled on the causes
and prevention of anaemia. Their
misconceptions regarding iron
supplementation have been removed through
meetings—gram sabhas, mahila mandals,
guru goshtis, etc.
Key features
Goals and objectives
Short-term goal: In the short term, the goal is
to provide weekly IFA supplements and ensure
reasonable compliance, thus bringing about
quick reduction in prevalence of anaemia in
adolescent girls.
Long-term goal: In the long term, the project
focuses on sustaining the benefits accrued from
the short-term measures, through intensive IEC
campaigns. Identifying local resources (human,
agricultural, horticultural) that can mitigate the ill
effects of anaemia over a long period (that is,
after the supplementation phase is over), social
mobilisation, and ensuring community
participation are some elements of this strategy.
The targets fixed for achievement by the end
of the project are:
✦ To create awareness and bring behavioural
change in daily dietary practices.
✦ To ensure 90% weekly consumption of IFA
tablets in school-going girls.
✦ To establish regular supply of IFA tablets
to school-going girls for a period of 52
weeks in a year.
✦ To ensure 70% weekly IFA tablet
consumption by out-of-school adolescent
girls.
✦ To ensure interdepartmental coordination
for successful programme implementation.
✦ To promote locally available iron-rich foods.
Anaemia Control Project
Control of NutritionalAnaemia in School going Adolescent Girls
8
Control of nutritional anaemia is an
entry point under the Dular strategy
being implemented in Bihar to improve
mother and child health. The project
has targeted adolescent girls using the
life cycle approach. Innovative
approaches are being developed to
plan, implement and monitor the
scheme.
ACP in selected districts of BiharThe Anaemia Control Project is being
implemented in Gaya and Muzaffarpur
districts of the state. The programme
was inaugurated by the District
Magistrate of Muzaffarpur on 24 March
2000. The inaugural ceremony was
attended by the civil surgeon, medical
officers, CDPOs, ANMs, LHVs,
anganwadi workers, district officials,
Education Department officials, and a
large number of common people. The
occasion served as a good opportunity
to create awareness about anaemia and
the need to target the adolescent girl.
At the same time, it served as a kind of
orientation of functionaries at the
district and sub-district level. Media
reports about the programme also
served to generate awareness about the
programme.
An initiative of the state government
and UNICEF, the programme ensures
the involvement of intersectoral teams
such as ICDS, Health as well as
schools and community, in planning
and implementation.
Bihar
Districts coveredunder ACP
Paschim Champaran
Purbi Champaran
SheoharSitamarhi
Madhubani
SupaulAraria Kishanganj
PurniaKatihar
Madhepura
Saharsa
Bhagalpur
BankaJamuiNawada
Gaya
AurangabadRohtas
Bhabhua
BuxarBhojpur
Patna
JahanabadNalanda
SheikhpuraLuckeesarai Munger
KhagariaBegusarai
Samastipur
Darbhanga
Vaishali
Muzaffarpur
SaranSiwan
Gopalganj
Number of school going and out-of-school girls
covered in Anaemia Control Project
District Total number of school Total number of non
going girls covered school going girls covered
Gaya 29,590 1,26,070
Muzaffarpur 50,000 65,000
Project
Implementation
9
Project implementationIn Bihar, the state nodal agency for the implementation of the programme
is the Directorate of Social Welfare in close collaboration with the Health
Department, Bihar Education Project (BEP) and ICDS. In the districts, the
District Magistrate (DM) holds the overall responsibility for implementing
the project. Because of his background in the field of educational
infrastructure, the BEP coordinator, Muzaffarpur, has been assigned the
responsibility of coordinating the activities of this project, while in Gaya
the Principal, District Institute of Education and Training (DIET) has been
entrusted the task of implementing the programme. In this, he is being
supported by a team of three field coordinators, as well as his own
teams of district, block and cluster-level functionaries.
However, the actual implementers are the identified teachers in each
school of the districts. They are the motivators, guides and promoters for
the targeted adolescent girls in the schools, as well as in the community.
The field-level coordinators are responsible for providing programmatic
support to ensure smooth operationalisation of the project activities as
far as the planning, demand creation, supplies, community awareness
and progressive recording of the coverage are concerned.
District Coordination CommitteeEach district has a District Coordination Committee (DCC) whose
members include heads of different sectors like ICDS, education, welfare,
health, agriculture, etc., principals of anganwadi training colleges, and
representatives of major NGOs active in the district. The DCC meets
every quarter under the chairmanship of the DM. The initial meeting of
the DCC was held to inform the members about the programme and
Chapter2
Control of NutritionalAnaemia in School going Adolescent Girls
10
sensitise them to the problem of
anaemia.
The role of the committee is to ensure
smooth implementation of the project
in the district. Since the members
include key officials from the
departments of Health, ICDS,
Education, Agriculture, PHED, Social
Welfare, etc., they ensure the
complete participation of their
respective departments in the project.
During the meeting of the DCC, the
DM also reviews the progress of the
project, and the difficulties being
encountered.
District Level Core TeamApart from the District Coordination
Committee there is a District Level
Core Team (DLCT) in each district. The
DLCT members are the members of
the DCC, including key officials such
as the Civil Surgeon, District
Programme Co-ordinator (BEP), District
Programme Officer (ICDS) and officials
from the departments of Health, ICDS,
PHED, Education and heads of the
NGOs involved in the project.
The DLCT meets regularly to review
and analyse the progress, identify the
problems and find solutions. It
formalises the plan of action and
reviews the monitoring and follow-up
of the project.
Block Level Core TeamFor the smooth implementation of the
project a Block Level Core Team
(BLCT) has been constituted. The
Block Development Officer is the
convenor of the BLCT, whose
members include the BEEO, Block
Medical Officer, CDPO and WDO. The
BLCT meets each month to review and
analyse the project, identify the
problems and find solutions. Its
functions also include drawing up a
plan of action, monitoring and follow-
up of the project.
District Support TeamOnce the nodal agency and officer were
decided upon, the implementation of
the programme began. Before the
formal launch in each district, district
support teams were constituted. DST
members are the key functionaries
responsible for project implementation
in the district. To carry out their role
effectively, the DST members received
an orientation. Their role includes
conducting meetings at the block level,
village-level sensitisation programmes,
orientation of principals, school
teachers and village pradhans, visiting
schools for collecting reports,
conducting orientation of students,
Project
Implementation
11
Gaya moves towards anaemia control
Mr. S.A. Moin has been the District Project Coordinator and Principal, District
Institute for Education & Training (DIET), Gaya, since 1993. He has been involved
in the ACP from the very beginning. Says Mr. Moin, ”With the launch of the
Anaemia Control Project in the district in 1999, a District-Level Coordination
Committee was formed in 1999, chaired by the District Magistrate (DM). The
members include departmental heads of medical colleges, CDPOs, DPO, Civil
surgeon, DSE, and Principal, DIET.
“At the block level, a Block Task Force (BTF) has been constituted, whose members are the BDO
(Convener), BEEO, CDPO, and WDO. In places where there are Mahila Samakhyas, Sahyoginis are
members of BTF. The BTF meets every month to review the project. The report of the same is sent to
the District Project Coordinator (DIET) and District Magistrate.
“Intersectoral convergence is a strong point of the project in our district. During the second phase, we
are targeting non-school going girls. ICDS is the main agency, which is reaching out to the non-
school going girls through its centres. In the five non-ICDS blocks, the intervention is through teachers.
“Under the first phase we had an orientation of students, nodal teachers, VEC members, etc. ACP was
integrated into the BEP programme. We reached the high schools through the headmasters and head
teachers because the high schools are not under BEP/DPEP programme. During the morning assembly
in schools, awareness on anaemia was generated. Apart from these, wall writing was done in schools
and slogan writing, painting competitions were organised in high schools. Regular monthly meetings
were held and the project was discussed during the meetings held at CRC/BRC/district level. Bal melas
were organised at BRC/CRC/district level once a year. At the mela, the DST members put up stalls
where the messages on anaemia control were displayed.
“Monitoring of the activities was done by nodal teachers in coordination with the CRC coordinator/
BRC coordinator. The District Coordination Committee (DCC) meets every three months. There has
been convergence at various levels and with different departments such as health, ICDS, and education.
Among the NGOs, Rotary Club has given tablets for deworming. Medical representatives from
pharmaceutical firms have also given us samples of medicines for deworming.
“Under the project, we have reached out to the adolescent girls through the Jagjagi Kendras, alternate
schools, Apna Vidyalaya (co-ed), Angna Vidyalayas (girls only) and Mata Samitis. An Anaemia Park
has been developed, where plants rich in iron are grown. In the Janta Durbar organised by the DM in
the district, we put up stalls on anaemia and also during the Buddha Mahotsav held at Bodh Gaya each
year. A Jhanki (float) on anaemia was exhibited on Republic Day, which was awarded the 2nd prize.”
According to Mr. Moin, there are several constraints. One of the main constraints is deworming,
which has not had the desired impact because of non-availability of deworming tablets and secondly,
the involvement of high school teachers, especially male teachers, has not been satisfactory.
Control of NutritionalAnaemia in School going Adolescent Girls
12
(IFA) in the school every week. The
tablets are stored with the nodal
teacher in the school. Each adolescent
girl receiving the IFA tablet has been
oriented by the nodal teacher to fill up
the self-compliance card. The nodal
teacher ensures that the cards are
properly filled up.
Strategies� Reaching the adolescent girls in
middle and secondary schools
(Phase I).
� Reaching the adolescent girls out
of school (Phase II).
� Positioning anaemia control for
adolescent girls.
� Advocacy, social mobilisation and
community strategy.
� Strategy for institutional support.
� Strategy for social recognition.
� Strategy for sustainability and
replicability.
� Monitoring and evaluation
strategy.
distribution of IFA, compilation
of reports, reporting at the district
level, etc.
DST members visit schools regularly
and report to the nodal officer in the
district. The DST members are in fact
the lifeline of the whole programme.
There are two DST members (a male
and a female) in each district. They are
graduates with some experience in a
related field.
MethodologyAll the schools in the two districts,
where there was enrolment of
adolescent girls (10-19 years) were
listed and the adolescent girls
enumerated. The principal or a teacher
who volunteered was trained as
school-level implementer of the
programme. Each girl in the school is
being given a tablet of iron folic acid
Better health with IFA
Government High School, Chakand, district Gaya, has a total strength of 1000 students, out
of which 165 are girls. Roqaiyya is a student of class IX and has taken IFA tablets from March
2001 to March 2002. Roqaiyya attributes her renewed interest in studies and her winning
prizes in the annual debate competition to the consumption of IFA tablets. She says, “I was
never attentive in class and used to miss classes very often. I did not feel like coming to school
or taking part in sports. I used to feel tired even after doing a little work. Last year, the ACP
team came to our school and told us about anaemia—since then I have been taking IFA
tablets. I told my parents about the distribution of IFA tablets in our school and they too were
quite impressed with my improved performance in studies and sports.”
She says that the project should also target girls in villages, who do not go to school.
Roqaiyya adds, “I tell my non-school going friends about anaemia control and have also
given them IFA tablets.”
Training and Capacity Buildingof Functionaries
13
Training and Capacity Buildingof Functionaries
Trainers were identified to train other functionaries of the project. During
the training of trainers (TOT), the participants were informed about the
high prevalence of anaemia (about 60 per cent: Sheshadri 1996) and the
importance of targeting adolescent girls. The main objectives of the
training were:
� To impart knowledge and basic information to the trainees about the
project, nutritional anaemia, its causes, symptoms, prevention and
control, implementation strategy and plan.
� To help the trainers to acquire skills needed to successfully organise
the trainings of nodal teachers and other groups, as planned under
the project.
The participants in the TOT included experienced and educated field
workers of NYK, NGOs, BEP, and MIS.
Key features of the trainingAll the training sessions were conducted in a participatory manner,
throwing open the issues to the participants, and allowing them to
interact individually with their knowledge and experience. The gaps
existing in their knowledge were filled in by the external resource
persons. In all the trainings, the importance of dietary practices was
emphasised and iron-rich food was displayed.
Chapter3
Control of NutritionalAnaemia in School going Adolescent Girls
14
Training manualThe Directorate of Social Welfare,
Bihar, in collaboration with UNICEF,
has developed a training manual, which
has been used by the project districts
to train the functionaries. The manual
is made up of modular units, focusing
on six types of training targeted at
different levels of functionaries and
groups involved in programme
implementation. Each module includes
the training curriculum and design. The
curriculum content, duration and
design are based on the training
requirement of the group to be trained.
Each module is a complete unit,
defining its objectives, target group,
duration, methodology and possible
resource group/person.
Training module unitsThe units of the training module are:
� Module 1—One-day orientation of
district-level heads of various
departments.
� Module 2—Two-day district level
training of block-level functionaries.
� Module 3—Three-day training of
master trainers.
� Module 4—One-day training of school-
level functionaries (nodal teachers)
� Module 5—School-level orientation
of school-going adolescent girls.
� Module 6—One-day orientation and
two-day IEC material development
workshop at the district level (for
village/community level
communicators)
Training at various levelsThe training was carried out at the
state, district, block, school and
community levels.
A workshop on the Anaemia Control
Project was organised by UNICEF in
Patna, which was attended by top-
level functionaries of the project. The
causes, symptoms, prevention and
control of anaemia were discussed
and the concept of the programme
was explained.
A five-day training-cum-workshop on
the programme was organised at
XISS, Ranchi, from 5-9 July 2000 by
UNICEF and Chetna (Ahmedabad). A
total of 30 project staff from all five
districts (Bihar & Jharkhand) attended.
An overall view of the programme was
given to the participants.
A three-day workshop was organised
from 15-17 December 2000, by
UNICEF at Bodh Gaya, in which staff
from all five project districts (Bihar &
Jharkhand) attended. In this
programme, discussions were held on
the training modules of the project,
distribution of IFA tablets and
preparation of annual workplans.
Training and Capacity Buildingof Functionaries
15
� Review and monitoring—filling of
compliance cards by girls, regular
maintenance of registers.
In Muzaffarpur, the District Field
Coordinators, who have been made
full-time field coordinators, have made
extensive visits to the field and met
all concerned officials and
functionaries at the block level. This
was like an extensive orientation-cum-
advocacy programme. It was also an
The trainers included Project Officer
(UNICEF), CMO, consultant from
UNICEF, doctors from medical
colleges, etc. The trainers trained the
block-level functionaries, which
included CDPOs, BEEO,
representatives of NGOs, BMOs, local
panchayat leaders, lady supervisors,
etc. These block-level people trained
people at the community level,
including village mukhiyas, sarpanch,
local village doctors, leaders of Mahila
Samakhyas, village level NGO
representatives, etc. The training
focused on the following aspects:
� Anaemia, its causes, effects, the
life cycle approach.
� Prevention and control by bringing
about change in dietary practices,
behavioural change,
supplementation and intake of
iron-rich food.
� Role and responsibility of nodal
teachers and girls in programme
implementation; proper storage and
distribution of IFA tablets, and
ensuring intake of these by
adolescent girls.
Details of training organised till date under
Anaemia Control Project
Training Gaya Muzaffarpur
Total number of trainings conducted 114 70(including district, block, village/sector level trainings)
Total number of trainers trained 120 65
Total number of functionaries trained 150 120(govt. and non govt.)
Total number of teachers trained 399 1075
Total number of motivator girls trained 399 500
Control of NutritionalAnaemia in School going Adolescent Girls
16
effort to enlist their support for the
successful implementation of the
programme. In May 2000, orientation
of block-level functionaries was
carried out at district headquarters,
Muzaffarpur. The participants included
the area officers and Block Education
Extension Officers of the Education
Department, as well as medical
officers and CDPOs of the different
blocks of the district. The resource
persons were drawn from the state
and district levels. An encouraging
aspect of the programme was that a
few medical officers and CDPOs
offered to serve as master trainers.
The field coordinators have been
visiting the CRCs, which are resource
centres for 12-14 schools each under
BEP. They have been attending the
monthly meetings and creating
awareness about anaemia among the
teachers of each cluster. However,
their most important achievement has
been the collection and compilation
of data about all the school-going
adolescent girls in the age-group
10-19 years. This has been done in
respect of middle schools, high
schools, basic schools, Jagjagi
centres, as well as alternative
schools. The field coordinators have
been participating in the one-day
orientation of CRC coordinators at
block level. They have also visited
schools, Mahila Samoohs, Mahila
Mandals, Jagjagi centres and
alternative schools. Thus they have
helped create a conducive
environment for the acceptance of
the project among the target group,
as well as among the implementers.
In Muzaffarpur, an alternative mode of
training school teachers is being
planned, in which two competent
trainers will visit each school and train
all the teachers, and not just one
teacher as planned earlier. Members of
the village education committee (VEC)
will also be invited to participate in
the training. Girls will also participate,
and one monitor will be selected, who
will assist the teacher in administering
the IFA tablets.
In Gaya district, the following
trainings have been conducted:
� One-day training workshop of
district-level officers.
Training and Capacity Buildingof Functionaries
17
Girls feel the change after taking IFA
Chandni Kumari is a student of class VIII in Salha Jalalpur Dwarka Middle School, in village
Salha Dwarka Nagar, block Musahari, district Muzaffarpur. Chandni says, “I have consumed
IFA for almost 3 months now. We get IFA once a week and we are asked to consume it in the
school itself.” On being asked how she feels after taking IFA tablets, she says, “Earlier I used
to feel weak and did not take interest in studies. I could not play for long and started feeling
tired but now I have started feeling more energetic. I have also begun to take keen interest
in studies and have scored better in the exams.”
Radha Rani Girls’ High School in Mohalla Amali Gola, in Muzaffarpur district, is no ordinary
school. The students of this old school in the heart of the city are an enthusiastic lot. The
teachers, students and parents have shown great enthusiasm in the programme. The students
of the school were given IFA for 52 weeks and they have utilised the whole lot given to
them. They have coined slogans for anaemia control, which they enthusiastically recite.
Khushboo Kumari, a student of class VII says, “When the DST members first came to our
school almost a year ago, we were quite apprehensive about the programme. Many girls
resisted taking IFA tablets and many complained of vomiting tendency and resistance by
their parents. But our teachers and nodal girls along with the UNICEF staff removed our
misconceptions regarding intake of IFA.”
� Two-day training of block-level
officers.
� Two-day training of master trainers.
� One-day training of nodal teachers
at block level.
� One-day training for ICDS sevikas,
ANMs and LHVs at block level.
� One-day training for school
motivators at block level.
� Three-day workshop for IEC
material development.
� One-day training of Sahelis of
Jagjagi centres (Mahila Samkhya,
BEP Gaya).
� One-day training of girls and didis
of alternative schools.
� One-day training for VEC mobilisation.
� One-day orientation of BRC and
CRC coordinators.
� One-day training for mobilising
team for awareness generation.
Control of NutritionalAnaemia in School going Adolescent Girls
18
Local Resource MobilisationBoth Gaya and Muzaffarpur districts have developed IEC materials like
pamphlets, posters, banners, wall paintings, etc., to create mass
awareness. One of the notable features of the project has been the local
mobilisation of resources. There has been a remarkable convergence
between ICDS, banks, NGOs (such as Rotary Club, NYK, Narijagran
Manch, Jeevan Deep, Adithi etc.), and BEP for generating awareness
among the community.
Activities for community awarenessThe Anaemia Control Project focused not only on weekly
supplementation of IFA tablets, but also on bringing about suitable
dietary practices to include iron, folic acid, vitamin C, and protein-rich
food. It was felt that merely supplying IFA tablets and ensuring intake
would not make a sustainable impact. For sustainability, it was essential
to create awareness and bring about community ownership of the
programme, and initiate change in dietary practices of families.
Chapter4
At the state level, UNICEF developed
two booklets on anaemia. One of
them was circulated among school-
going adolescent girls, giving details
about anaemia, its symptoms,
causes, prevention, dietary practices,
IFA tablets and the role of school
girls in controlling anaemia. The
second booklet was meant for
creating awareness among school
teachers, emphasising their role in
Local Resource
Mobilisation
19
the prevention of anaemia. This
booklet explains the reasons for the
educational and nutritional
programmes for adolescent girls.
At the local level, a number of steps
were taken to generate awareness
among the community. These included
wall writing campaigns, weekly
prabhat pheris at the school level, and
distribution of pamphlets and booklets
among all the school motivators. The
pamphlets are distributed through
medical retail counters. Awareness
campaigns have also been held at
Jagjagi centres, Mahila Samoohs,
Mata Samitis, and Angna Vidyalayas.
Kishori Melas and Balika Melas have
been held at the BRC and CRC level.
Drawing, slogan and essay writing
competitions have been held at the
BRC and CRC level.
In Gaya during the famous “Buddh
Mahotsav” held in Bodh Gaya a stall
on Anaemia Control Project was put
up displaying iron rich foods. An
anaemia park has been created in the
DIET campus in Gaya displaying plants
rich in iron.
In all the campaigns, iron-rich foods
have been displayed and their
importance emphasised. Programmes
were also broadcast on TV and radio
and newspaper advertisements were
brought out.
Regular meetings have been organised
of block level officers, and
coordinators of BRCs and CRCs.
Meetings of principals, as well as guru
goshtis, have been held in the blocks.
VECs have also contributed in
mobilising parents and society.
The project is unique in the sense that
it has set an example for local
resource mobilisation. All compliance
cards and other materials such as
banners, wall paintings, stickers, ads
on TV and print media were sponsored
by various corporate houses and
government agencies such as LIC,
GIC, Transport Department, banks,
etc. NGOs such as NYK, Rotary Club,
Narijagran Manch, Amar Jyotivihar,
Jeevan Deep, etc., have also
contributed in the IEC activities.
Among the NGOs, Rotary Club has
given tablets for deworming. Medical
representatives from pharmaceutical
firms have also given samples of
medicines for deworming.
Banks (State Bank, Punjab National
Bank, India Overseas Bank, etc.) have
sponsored pamphlets, which were
distributed during melas, and
newspaper advertisements, etc.
Control of NutritionalAnaemia in School going Adolescent Girls
20
Supply and Logistics ManagementIn Bihar, the state government has given UNICEF the go-ahead for the
purchase of IFA tablets for the whole state. At the state level the
procurement and distribution of IFA tablets is being organised through
ICDS, World Bank–II Project. The procurement and distribution of IFA is
being done not only in the Dular districts but in the whole state.
Each girl in the school is given a tablet of IFA every week in the school.
These tablets are stored with the nodal teacher in the school. Each girl
receiving the IFA supplementation is oriented by the nodal teacher to fill
up the self-compliance card. The nodal teacher ensures that these cards
are properly filled up, corresponding to the actual consumption of IFA
tablets.
The training programmes have also covered the intake of IFA tablets. The
participants, including nodal teachers and the adolescent girls, have been
briefed about the utility of weekly intake of IFA tablets. They have also
been informed that these tablets should not be taken on an empty
stomach. In a few cases, there might be symptoms of nausea,
constipation and change in colour of stools, but these should not cause
concern. These problems will go away after regular intake of the tablets.
Maintaining recordsAt the time of distribution of IFA tablets, a register is supplied to the
nodal teacher of each school for maintenance of records of distribution
and intake. Using the specified format, the nodal teacher indents the IFA
tablet requirement, prepares monthly reports of number of tablets
Chapter5
Supply and LogisticsManagement
21
Jagjagi Kendra: Lighting up lives
Mahila Samakhya is playing a pivotal role in the Anaemia Control Project.
The Jagjagi centres, managed by “Sahelis” under the Mahila Samakhya,
are not only providing education to non-literate children, especially girls,
but also IFA supplementation to adolescent girls. The Bihar Education
Project provides free textbooks to the enrolled children. In some centres,
some women who are first generation learners, are also enrolled.
Madhopur village, in Musahari block of Muzaffarpur district, has a Jagjagi
Kendra managed by a Saheli, Smt Usha Devi. Madhopur is a non-ICDS
block. There are 32 children, including 16 non-school going adolescent
girls, enrolled in the Kendra, most of them from very poor background. Apart from these, six women,
some of whom are SHG members, are also enrolled.
Eleven-year-old Anita Kumari has been attending the Kendra for the past one year. Anita, whose
father is a daily wage labourer, used to work in the fields as a labourer, earning a mere Rs. 30-40 per day
for around 8-10 hours of physical labour and supplementing her father’s income. “Didi motivated my
father to send me to school. Neither my parents nor my brothers or sisters had ever been to school. But
I was determined to go to school and learn,” Anita says.
Apart from learning, Anita has been consuming IFA tablets regularly for 52 weeks at the Kendra. “Didi
told us that adolescent girls like us need IFA tablets, since we do not have enough iron in our body.
Since I started taking IFA tablets I have begun to feel strong and confident. Earlier I used to feel very
weak since I had to work in the fields most part of the day. I used to return home tired. We could not
even afford to visit the local doctor. When I started attending the Jagjagi Kendra, I got the first tablet,
which I consumed. I also asked my Didi to give me some more for my elder sister, who complains of
weakness.”
Another girl, Kaushalya Kumari (12 years), has been attending the Kendra for the past one year.
Kaushalya says, ”What I like about the Kendra is that we are taught games and are made to learn
through playway method. Didi makes us feel very comfortable so much that I could not miss attending
the Kendra any day. She adds further, “Once just after joining, Didi gave all of us a tablet saying it was
for strength. We had never taken any such tablet without consulting the local village doctor. I did not
consume the tablet at the Kendra and took it home to show it to my parents.”
According to the Saheli, “Kaushalya’s parents were worried as to why these tablets were being given
to adolescent girls only and not to boys. The father spoke to me and I allayed all his fears about the
tablet causing infertility. These people are quite suspicious about the IFA tablets, as well as the polio
drops, which they do not give to their children.” Kaushalya is now taking the tablets regularly and says
she is feeling more confident and energetic.
Control of NutritionalAnaemia in School going Adolescent Girls
22
“Let’s get rid of anaemia…”
Malini Sinha is a class IX student of Government High School, Chakand, Gaya, who has been
consuming IFA tablets for the past one year. Malini knows that anaemia is caused due to iron deficiency
in blood. She has started taking part in games and has also coined slogans on anaemia control. She
says, “When I started taking IFA tablets, I used to complain of vomiting tendency and drowsiness, and
so did many of my friends. However, soon things were normal and we started feeling the benefits of
IFA intake. Earlier we used to feel exhausted but now we do not feel so. The boys in our school are an
envious lot. They are demanding that they too be given IFA tablets. In our school many children have
prepared posters and pamphlets in their classrooms on anaemia control. The students have also
planted saplings of lemon, guava, amla, etc., in the school garden.
“My mother is an Anganwadi sewika and I help her in distribution of IFA tablets,” adds Malini. She
recites some slogans coined by her and her classmates on anaemia:
“Aao kamzori bhagayein
Ankurit chana khaein”
“Hamein saag subzi khana hai
Anaemia door bhagana hai”
“Loh yukt aahar khana hai
Anaemia door bhagana hai”
Supply and LogisticsManagement
23
received, number consumed and
the number required in the
following month. This becomes
a monitoring tool for the nodal
teacher at the school level, and
when consolidated, for the block
and district level. At the district
level, the Project Coordinator
ensures the supply of IFA
tablets and their regular
distribution.
Compliance cardA compliance card has been
supplied for each beneficiary,
i.e., the adolescent girl, which
has to be filled by the girl
herself. The girls have been
imparted training on how to fill
the cards. Those having difficulties are
helped by the motivator girls in filling
the cards.
Reaching the unreachedThe Anaemia Control Programme has a
special strategy to reach the large
number of adolescent girls who have
dropped out of school or who never
enrolled. In Muzaffarpur, there are
about 3.50 lakh girls in the 10-19 age
group, out of which 1.30 lakh are
IFA distribution system
District—DIET/BEP
Block—BRC
Cluster—CRC 2nd Phase
School
School-going girls Non-school-going girl(with the help of schoolvolunteers, AWWs, membersof village institutions, head/sub-centres)
1st Phase
2nd Phase
(Weekly dosages)
Distribution of IFA in Gaya and Muzaffarpur districts
including enrolled and out of school girls
District Total IFA distributed % of IFA consumption(till mid 2002) (till mid 2002)
Gaya 20,12,120 72%
Muzaffarpur 20,00,000 70%
dropouts or have never enrolled in
school. In both Muzaffarpur and Gaya,
such girls are being reached through
the girl-to-girl approach, in which the
selected motivator girls in each school
have been assigned the responsibility
of reaching the out-of-school
adolescent girls in their respective
localities and ensuring that they
participate in the weekly consumption
of IFA tablets.
Control of NutritionalAnaemia in School going Adolescent Girls
24
Monitoring is an essential and integral part of the project, which helps to
ensure progress and identify gaps. It enables programme managers and
functionaries to analyse and take corrective action. In the Anaemia
Control Programme, monitoring is carried out at four levels—at the state,
district, block and school level.
The nodal teacher, through the use of the specified format, indents the
IFA tablet requirement, and prepares monthly reports of the number of
tablets received, the number consumed and the number required for the
next month. This format is used as a monitoring tool for the nodal
teacher at the school level, and when consolidated, for the block and
Monitoring and Evaluation
Chapter6
MonitoringMonitoring
Individual(Self-monitoring using
compliance card)
District level
(DSE, DEO, DPO,
CS, etc.)
Group(Volunteer girls)
Community level(Volunteers, Local inst. heads
ANM, AWW, VEC members)
Block level(BDO, CO, CDPO, BEEO, AEO,
MO, NGOs)
School level(Teacher, monitor,
volunteers)
Monitoring andEvaluation
25
district levels. The monthly meetings
at the block and district levels are
used for submitting the monitoring
report. At the district level, the project
coordinator ensures the supplies of
IFA tablets, and monitors their
distribution in addition to regularly
monitoring the progress of the project.
At the state level, the Directorate of
Social Welfare is overall in charge of
monitoring and implementation.
Representatives from the Directorate
participate in the meeting of the
District Coordination Committee, as
well as of the Core Committee, to
review the status of interdepartmental
coordination in the programme.
The quarterly progress reports and
workplans submitted by the districts
are reviewed at the Directorate level
and forwarded to UNICEF, Patna,
regularly. These are reviewed by the
Project Officer, Child Development and
Nutrition, UNICEF, Patna. Continuous
support and guidance are also
provided by the Project Officer,
UNICEF, Patna.
For monitoring purpose, a two-day
joint state level review-cum-strategy
planning workshop is organised every
alternate month at the state
headquarters, under the chairmanship
of the Project Officer, UNICEF, Patna.
Representatives from the Directorate
of Social Welfare, DPOs, CDPOs,
DEOs, Core Committee members, and
selected lady supervisors of the
districts participate in the workshop.
In the workshop, members of each
Reporting system
District—DIET/BEP
Block—BRC
Cluster—CRC
Schools
1st Phase
Class monitors School volunteers/
Local inst. heads
2nd Phase
Control of NutritionalAnaemia in School going Adolescent Girls
26
Mahila Shiksha Kendra: Bringing hope in the lives of girls
Mahila Shiksha Kendra is a functional unit under Mahila Samakhya, being run in the DIET campus in
Gaya. The centre was started in July 2002 to help train poor girls in vocational courses. Many of the
enrolled girls at the centre are first generation learners. Some of them are divorced or forced out of
their homes by their parents or in-laws. Here the girls are learning to stand on their own feet, away
from their home for at least 3-4 months. The girls are made to follow a strict discipline at the centre,
where they learn cycling, cooking, sports, etc.
Janki Kumari is an 18-year-old girl at the centre, who had never been to school but feels very comfortable
at the Mahila Shiksha Kendra. She has learnt cooking, cycling, and has even started writing letters to
her parents. Janki hails from a very poor family and does not wish to go back to her house. She knows
that the symptoms of anaemia include nails turning yellow, weakness, etc.
Reena Kumari also hails from a very poor family, who was brought to the Mahila Shiksha Kendra after
being rescued from a 45-year-old man in her village, to whom she had been married off. Reena knows
about anaemia and its causes. She adds, “Girls need more iron than boys because they do greater
amount of work. They undergo physical changes during menstruation, during which iron is lost.”
Reena asks inquisitively as to why they have not been provided with deworming tablets as yet.
Monitoring andEvaluation
27
Muzaffarpur: Getting the project off the ground
The Anaemia Control Project in Muzaffarpur district has seen a lot of
changes in its administrative set-up of late. Mr. Amarendra Singh is the
Officer on Special Duty (OSD), who has been in charge of the project
in the district since June 2002. According to Mr. Singh, at the block
level, there is a Block Elementary Education Office (BEEO), which meets
each month to review education projects in the district. Anaemia control
is a major item in the agenda of the district.
“Through the BEEOs, we are trying to regulate ACP through review of
school-going girls. We have alternative schools (ALS) for children in the
age group 9-14 years, where the major thrust is on education and mainstreaming of children. The
Jagjagi centres are also giving thrust to social and health issues, including distribution of IFA tablets.
“At the district level, the District Magistrate (DM) organises Janta Durbar in the blocks, where the
programmes are reviewed. From next month onwards, we are going to involve PRIs and ward members
in the awareness campaign. The monitoring of the programme is done by the BEEOs and the area
officer for the middle and high schools, while for the Jagjagi Kendra, the monitoring is done through
the Sahyogini and Saheli. For every 10 ALS centres, there is an academic Support Resource Group,
which is responsible for its monitoring. As regards the resource mobilisation, we have taken the help of
animators in VECs and School Management Committees. A support group has been formed, comprising
CDPOs and MOs to oversee the implementation of the programme.”
district present their reports and plan
of action for their district. Future plan
of action is developed and target of
achievement is fixed.
Monitoring at the state level is done
not only through meetings, workshops
and reports, but also at the field level.
State Coordinator, Directorate of
Social Welfare, visits schools and
participates in the different training
programmes and distribution of IFA
tablets in schools.
Targeting out-of-school girlsUnder phase II of the project, non-
school going girls are being targeted
in both the districts through school
volunteers, teachers, AWWs, VEC
members, Mahila Samakhya. In non-
ICDS areas the adolescents are being
reached through the VEC members
and teachers. Mata Samiti and Mahila
Samoohs have been formed in
villages, which are also playing an
important role in reaching out-of-
school girls.
Control of NutritionalAnaemia in School going Adolescent Girls
28
The Anaemia Control Programme aims to have a major impact on the
health, nutrition status and well-being of the adolescent girls in the
project area. It is expected that the prevalence of anaemia will reduce by
50 per cent among the adolescent girls, improving their work productivity
and school performance, as well as reducing absenteeism in schools. In
the married adolescent girls, increased pre-pregnancy stores of iron will
result in reduced maternal mortality, maternal morbidity and reduce the
risk of low birth weight babies. Other benefits include increased
awareness of diet and improved dietary practices, thus leading to better
learning capacity, confidence and self-esteem.
Impact and Challenges
Well-being &
productivity
IMPACTIMPACT
Improved IQ
scores
Reduced anaemia
Increased
attention in school
Increased
enrolment in school
Better growth
Reduced absenteeism
in school
Chapter7
Impact andChallenges
29
CoverageIn Gaya district, 28,581 adolescent
girls were targeted in 399 high and
middle schools. Out of these, the
coverage was 82 per cent in high
schools and 85 per cent in middle
schools. In the second phase (non-
school going), 2,26,350 adolescent
girls in 1805 ICDS centres were
targeted. Out of these, 1,18,160 were
covered in 1688 ICDS centres. The
weekly consumption of IFA tablets at
Anganwadi centres was 72 per cent.
ChallengesThe project has faced a number of
stumbling blocks in the way of
smooth implementation, such as
shortage of field staff, lack of proper
infrastructure, storage facility,
transport and lack of cooperation from
some of the functionaries. In
Spreading the word about anaemia
Rizwana is a student of class VIII in Rameshwar Prasad High School in
Belaganj block, Gaya. In her school, the distribution of IFA started in the
year 2000 and after nearly one year of distribution, it has now been stopped.
Rizwana feels that IFA has helped improve the girls’ health and has ensured
regular attendance in schools. She says, “We girls study in the school and
when we go back home we have to help our mother in the household
chores. Thus we end up doing more work than our brothers do. Therefore,
we needed some medicine that could give us energy. Consumption of IFA tablets has helped us get
back our lost energy.
“There are several girls in my locality who seem anaemic and I have taken some tablets for them. After
consuming the tablets they said they felt better but since they belong to poor families, they cannot
afford to purchase IFA tablets from the market. I have counselled them about proper consumption of
green leafy vegetables and fruits rich in iron, which are available in plenty in our village.”
Rizwana says she is thankful to her teachers and the Anaemia Control Project staff for having given
her this valuable information about anaemia.
Shanti Kumari studies in class VIII in the same school. She says, “We never knew about anaemia but
thanks to ACP in our school, we now not only know about anaemia but can now tell others—our
family members and friends—about how we can control anaemia.” Shanti adds, “The symptoms of
anaemia are lack of appetite, nails turning yellow, etc. We have been told that we need not depend on
IFA tablets alone but can control anaemia by increasing intake of green leafy vegetables, which are
rich in iron. We have also been taught that we should not consume tea or coffee for at least after 1- 1½
hours after taking a meal.”
Control of NutritionalAnaemia in School going Adolescent Girls
30
Breaking myths and spreading knowledge
The Jagjagi Kendra in Jalalpur village in Musahari block in Muzaffarpur district has been running for
the last three years. The Kendra has 31 adolescent girls, of which 25 are Muslims and six are SCs.
There are six women enrolled in the kendra. Jalalpur is a village inhabited mainly by poor Muslims.
According to Smt. Krishna Devi, Saheli of the kendra, “The villagers, especially Muslims, do not send
their children to school. Instead these young children work as labourers in the field during cropping
season, thereby supplementing their family income. The project had a difficult time motivating the
children to attend school and also start intake of IFA tablets. Poverty is not the only issue—there is a
strong misconception in the minds of the villagers that the tablets may cause infertility. But gradually,
this myth has been broken. Now we are getting requests from more and more parents to get their
children enrolled at the Jagjagi Kendra.”
Krishna Devi adds, “Now, the girls are not only more conscious about their health, they have also
started resisting any attempts to get themselves married off at an early age. They now pressurise their
parents to send them to the Jagjagi Kendra for learning.”
The enthusiasm among the girls is heartening. Silam Kumari is a 20-year-old girl who is suffering from
polio, whose parents were against sending her to the Jagjagi centre. She crawls laboriously on foot to
attend the centre some 3 km away from her home. She has completed 52 weeks of the IFA course. She
also counsels other girls about it.
Similarly, 13-year-old Ajmeri and 14-year-old Sabiha Khatoon faced opposition from their parents
but the Saheli convinced them about the importance of IFA supplementation. Smt. Krishna Devi and
the Sahyogini, Smt. Chintamani Devi, are no doubt, very pleased to see the enthusiasm among the
girls. The distribution of IFA tablets each Monday has generated great enthusiasm among the students
attending the centres. Most of them also request that they be given more tablets so that they can give
it to their sisters who do not attend school or the Jagjagi Kendra being run in the village.
Muzaffarpur, the influence of criminal
elements, which has created an
atmosphere of fear in some areas, has
also hampered the project. However,
despite these obstacles, the whole
team is determined to fight the
menace of anaemia and improve
the health and well-being of
mothers and future generations.
Looking aheadIn Muzaffarpur, now that IFA tablets
have been supplied in the districts, a
fresh round of orientation programmes
has been planned for the block-level
officials. It is also planned to hold yet
another TOT for master trainers. Some
of the master trainers will be selected
from among those who underwent
Impact andChallenges
31
training in the last round. Fresh
trainers who have the requisite
qualification and experience are being
identified from various organisations.
An alternative mode of training of
school teachers is being planned, in
which two competent trainers will
visit each middle school and train all
the teachers of the school instead of
just one teacher, as planned earlier.
Members of the VEC will be invited to
participate in the training. Not only
this, girl children of the school will
also participate in the training, and
one monitor will be selected from
among them, to assist the teachers in
administering the IFA tablets. Besides,
each VEC and school will be provided
a set of postcards, to enable them to
send feedback to the Anaemia Control
Project Office.
In Gaya, the future plans include
various trainings, including that of
block-level officials, nodal teachers,
school motivators, and community-
level communicators. Awareness
generation activities such as wall
writing, kishori/balika melas, prabhat
pheris and rallies are planned.
After covering the school-going girls
of basic, middle and high schools in
the first phase, the programme will be
extended to cover the girls of
government primary schools, private
schools, alternative schools and
Jagjagi centres of Mahila Samakhya.
Documentation and Design
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