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Strategy Planning for Sanitation and Hygiene
Improvement in Tribal Areas of Andhra Pradesh
(In coordination with UNICEF HFO)
Jun 7-8, 2017 | Rampachodavaram
- A Report
SWACHH MANYAM – SWASTHH MANYAM
(INCLUSIVE DEVELOPMENT)
TRIBAL WEFARE DEPARTMENT
2 | P a g e
A Report of the Workshop held on
Strategy Planning for Sanitation and Hygiene
Improvement in Tribal Areas of Andhra Pradesh
(In coordination with UNICEF HFO)
Jun 7-8, 2017 | Rampachodavaram
Executive Summary
A two-day workshop, the first-of-its-kind in the state of Andhra Pradesh on “Strategy
Planning for Sanitation & Hygiene in Tribal Areas of Andhra Pradesh” was organized by
the Tribal Welfare Department, Govt. of Andhra Pradesh, in coordination with UNICEF
HFO during Jun 7-8, 2017 at the premises of the Integrated Tribal Development Agency
(ITDA) – Rampachodavaram, East Godavari district. The workshop, which was also
organized as part of the state government’s prestigious campaign “Nava Nirmana
Diksha” meant for overall restructuring of Andhra Pradesh, aimed to equip the
participants belonging to the various stakeholder departments with necessary
knowledge and skills required to initiate action in the tribal areas to achieve improved
sanitation situation. The most crucial expected output of the workshop was designing
an action plan ITDA wise to improve the sanitation situation in those areas. The concept
and the session plan of the
workshop were conceived and developed by UNICEF HFO and the sessions were
facilitated jointly by the members of the WASH team UNICEF HFO and Tribal Welfare
Department. In all, 62 officials and functionaries belonging to govt. departments and an
NGO named EFICOR took part in the event.
The specific objectives of the workshop were:
3 | P a g e
Generate common understanding and appreciation towards addressing
Sanitation and Hygiene issues in Tribal areas of the state.
Review and revise current strategies for improvement in sanitation and hygiene
situation
Appreciate the importance of coordination and convergence among all
stakeholders to achieve sanitation and hygiene goals.
Develop sanitation and hygiene improvement plan suitable to their individual
ITDA areas/ Mandal- GP-Habitation – Institution & HH wise.
The sessions in the workshop during the first day focused on the sanitation situation
analysis of the tribal areas and strengthening the knowledge base of the participants.
The second and final day was fully devoted to the action planning to improve the
sanitation situation and determining the timelines for making the ITDA areas open
defecation free (ODF).
In the end, the participants produced individual action/target plans ITDA wise to
improve the sanitation situation in these areas, clearly mentioning the timelines for
making ITDA areas ODF.
Day Wise Proceedings
Day-1 (Jun 07, 2017)
Inaugural Session
The inaugural session of the workshop was presided over by Mr. A S Dinesh Kumar, IAS,
Project Officer-ITDA, Rampachodavaram and the chief guest for the event was Mr.
Namana Rambabu, Chairperson-Zilla Parishad, East Godavari district. The session began
with Mr. D N Murthy, State
Senior Coordinator - Tribal
Welfare Department, welcoming
the participants and introduced
them to the workshop’s
objectives and the session plan
over the two days. He also spoke
about the evolution of ITDA R C
Varam in implementing various
programs pertaining to inclusive
development.
The expected outcomes of the workshop as presented by Mr. D N Murthy are as
follows:
ITDA wise sanitation and hygiene improvement plans implemented & achieved
saturation of sanitation facilities
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Coordination and convergence(Inclusive Development) established among all the
stakeholder departments towards achieving the sanitation and hygiene goals
Ensured sustained use of sanitation facilities in the ITDA areas.
Then, setting the tone for the workshop, Mr. S R Nalli, WASH Specialist, UNICEF HFO,
spoke about the imperative need of the initiating a campaign in tribal areas to improve
sanitation situation. He said, “This is a campaign, not a one-day event. It will not stop
until the sanitation situation improves in
ITDA areas. However, this is not an easy task
because there are several issues to be
addressed (as compared to the plains) in
tribal areas: material non-availability and
lack of transportation, excess availability of
space (positive factor, though) less access to
water are a challenge. Provision of funds is
also an issue. It is estimated that about an
amount INR 40,000 Cr is required to meet
the saturationof IHHLs in the country,
whereas an amount of only INR 8,000 Cr
was allocated, which was increased from
the earlier INR 5,000 Cr budget allocation. Space is abundant in tribal areas and it is
becoming an obstacle in construction and usage of IHHLs. Water is needed for drinking
and flushing the fecal matter. The strategy that is adopted in the plains may not work
for tribal areas, and, therefore, we will discuss all these issues and formulate an action
plan to improve the sanitation situation in the ITDA areas. Since you come from
different stakeholder departments and work at the grassroots level, you are right
people to discuss the issues in the tribal areas and provide meaningful solutions for the
implementation of the program”.
Later, speaking on the occasion, Mr. A S Dinesh Kumar, PO-ITDA, reminded the
participants that the strategy designed for the plain areas would not work in the tribal
areas, and therefore a unique and separate strategy is the need of the hour for
improving sanitation situation in the ITDA
areas. He further said, “Bringing stakeholders
from all ITDA areas onto one platform for
improving sanitation is the first of its kind in
the history of Andhra Pradesh, and perhaps
even first time in the country. The success rate
of toilet usage depends on the availability of
water. The excess availability of space can
somehow be addressed, but how do we able
to bring in behaviour change..!? The plan of
the campaign should address each person of
the household and their different needs.
Behaviour change communication plays an important role in this. People should be able
to get rid of the taboo associated with shit, and they should talk about it loudly. Take the
5 | P a g e
As part of Nava Nirmana Diksha, the participants and the distinguished guests were
taking oath to make tribal areas ODF in the state of Andhra Pradesh by 2019
example of Vizianagaram’s campaign. Hope you all actively participate in the
discussions, brainstorm and provide solutions to the issues. Let me see the good
outcomes emerging out of this workshop”.
While delivering his address, the Chief Guest of the workshop Mr. N Rambabu,
Chairman-Zilla Parishad, East Godavari district,
said, “It is happy to see a workshop on Swachh
Manyam is being organized bringing in all ITDAs
under one umbrella. I am also happy to note that
this program has been taken up under Nava
Nirmana Diksha, which reminds us that sanitation
is also equally important in restructuring the state
of Andhra Pradesh. Since Independence, we still
have been in the process of achieving improved
sanitation in the country. We all have a
responsibility to make swachh villages in our state
to improve our health and well-being. Let us all
get involved in this endeavour”.
Sanitation Pledge, as part of Nava Nirmana Diksha
Session-1 Sanitation & Hygiene Goals: Where We Are
Facilitator Mr. Salathiel R Nalli, WASH Specialist, UNICEF HFO
Speaking on the different perspectives prevail among the personnel of the various govt.
departments, Mr. Nalli said, “It’s not about spraying bleaching powder, or cleanliness, or
sweeping roads, but we would only discuss important issues involved in ODF. Why we
are we preaching safe sanitation to tribal people? What is the need? Why are we
focusing on it? Let us see.
6 | P a g e
Sanitation is one of the top priorities of the central and the state governments. The
governments have committed to making the country/state ODF by 2019 or earlier. This
is one of the reasons as to why we are assembled here. There are other reasons as well:
Diarrhea kills 8,00,000 children under-5 every year
Under-nourished children are 925 million
Explaining the comparative trends in the child mortality (NFHS-2005-06 estimates)
between the marginalized communities (SC and ST) and that of general category of
communities, he said, “the rates of neo-natal and infant deaths in children are
somehow equal, but there is an increase in deaths in Under-5 children belonging to
marginalized communities
as compared to that of
general category. It implies
that there is a lesser focus
on health and nutrition in
the marginalized
communities (SC & ST) as the
children grow. Pneumonia
and diarrhea together
contribute about 29% to the
child mortality rate in Under-
5 children. Therefore, we
need to make the tribal
communities aware of the negative consequences of open defecation, which lead to ill
health and malnutrition in children.
Speaking on the Sustainable Development Goals, he briefed the participants about the
definitions of indicators related to the SDG-6, pertaining to water, sanitation and
hygiene management:
SDG-6: Ensure availability and sustainable management of water and sanitation
for all.
Safely managed drinking water: Percentage of population using an improved
drinking water source (MDG definition) which is –
o Located on premises
o Available when needed
o Free of fecal matter (biological) and chemical contamination
Safely managed sanitation: Percentage of population using an improved
sanitation facility which is –
o Not shared with other households, and
o Where excreta is safely disposed or treated off-site
o Plus handwashing facility with soap and water
7 | P a g e
He informed that, out of the amount INR 15,000 that is being provided as an incentive
to the individual household for constructing and using a toilet, an amount of INR 2000 is
being provided towards constructing handwashing facility with soap and water.
Therefore, mere construction of toilet facility is not enough to save children from
mortality: construction of toilet coupled with handwashing facility is required.
Showing the data related to the progress of improved sanitation facilities among the
various income groups in the rural areas, he explained that sanitation has less priority
and the govt. schemes are not reaching the poorest of the poor in rural areas. However,
better progress is not shown even in the group of richest of the rich. Therefore, he
concluded that, it is required to ensure that the tribal communities are empowered in
terms of information related to the link between sanitation and health/nutrition and the
various govt. schemes that are beneficial to them.
Session-2 Why Sanitation and Hygiene for Tribal areas: Perspective Building
Facilitator Mr. Venkatesh Aralikatty, WASH Officer, UNICEF HFO
Stating that sanitation has different connotations, Mr. Venkatesh kick-started the
session, storming the brains of the participants by posing a question “what do you think
of when sanitation comes to your mind?”. The participants responded with the notions
such as “water (contamination), environment (pollution) and personal hygiene (soiled
hands/handwashing), solid and liquid waste” etc. He further asked, “How do you see
these notions, barring solid and liquid waste - as factors or consequences?” They all said
in unison “consequences, and open defecation (OD) is the factor”.
He explained why we wanted to work on reducing OD in tribal areas:
OD leads to death in children
OD is the primary reason for contamination of water
OD is the reason for atrocities on women
One gram of fecal matter contains –
1,00,00,000 (one crore) viruses
10,00,000 (ten lakhs) bacteria
10,000 parasite cysts
100 parasite eggs
Fecal matter will not remain there. It will travel to many places including out homes:
through flies, animal and human legs, insects, pigs, dogs etc.
Breaking fecal-oral cycle is the most crucial factor to improve health.
Why the caveman and the modern man adopting the same procedure of OD?, because:
Both do not know the connection between sanitation and health/nutrition (lack
of awareness)
Modern man does not feel the need (lack of priority)
8 | P a g e
Personal hygiene: two most critical times for handwashing with soap and water
After defecation
Before eating a meal
He concluded that since the tribal areas are more vulnerable than the plains in terms of
awareness and accessibility to WASH facilities, it is more required to spread the
awareness on the negative consequences of OD:
OD implies expenditure on health, vicious poverty cycle, insecurity
Childrens’ feces are more dangerous than that of adults
Session-3 Situation Analysis of Sanitation in Chenchu Habitations: An Overview
Facilitator EFICOR Team, Kurnool
This session was facilitated by three members of EFICOR team: Ramesh Babu – Director
- Programs, Daich Kishore – Manager - Programs, and Ms. Joylin – Program Associate.
The presentation’s highlights are as follows:
Study was conducted in 4 mandals
112 households taken as sample from 19 villages
9 FGD were held with women, children and men
36% Chenchu community members are literates
Only 36% of community members are using toilets
Amalapuram is the only chenchu gudem that was declared ODF in Jan 2017
o Total toilets built : 38
o The Survey done by the SHWETA team showed only 29% usage as on
1/06/2017!!
o Main reasons stated for
non-usage: Smell,
disgust, proximity to the
house, bathroom
combined.
76% of the people stated
that due to lack of money
(financial problems), they
could not build toilets.
56% Chenchu families do
not follow any measures to
keep the drinking water clean because they believe that nature-provided water
will always be clean.
77.67% Chenchu households do not have toilets at home.
Of the 22.33% households that have toilets, only 36% of the Chenchu families are
using toilets consistently.
9 | P a g e
About half of the households did not come across any communication message
regarding construction or usage of toilets during the last six months.
53.5% households prefer TV/Radio as a channel of communication.
The EFICOR team members concluded that they have developed a communication
package on sanitation and hygiene already and that they are going to roll out in the
coming days.
Session-4 Status of Sanitation in Tribal Areas of Andhra Pradesh
Facilitator Ravikanth R Mazumdar, State Consultant for WASH
In this session, Mr. Ravikanth presented the scenario of IHHls to be constructed during
the year 2017-18, based on the data obtained from the state website within the IMIS site
(sbm.gov.in). He briefed the participants (especially those who came from non-
tribal/non-ITDA areas) about the constitution of districts and mandals under scheduled
and plain areas.
The highlights of the presentation were:
Districts that have predominant tribal presence: 9 out of total 13 (50% or more
tribal population in a district)
Scheduled area districts: 5
Plain area districts: 8
Total ITDAs: 9 (Srisailam, K R
Puram, R C Varam, Seethampeta,
Paderu, Nellore, Parvatipuram,
Chintoor, & Plain Areas)
Total tribal population in the state:
27.39 L
Total tribal population in the
scheduled areas: 14.51 L
Total tribal population in the plain
areas: 12.88 L
He presented the data pertaining to
number of IHHLs to be constructed in
each mandal of the tribal areas. He made it clear that the numbers in the data shown
may not be accurate as it depends up on the frequent updating of data.
He concluded that, the participating personnel representing the various ITDAs are
required to bring it to the notice of the POs concerned to take necessary action to
achieve saturation of IHHLs in their respective areas.
10 | P a g e
Session-5 WASH in Institutions
Menstrual Health Management
Convergence for Improved Sanitation in Tribal Areas
Facilitators Mr. Manikanta, Ms. Niharika Singh &Mr. D N Murthy
WASH in Institutions: This session was facilitated by Mr. Manikanta, Consultant for WASH
in Institutions (APKATS). The highlights of this session were:
Important aspects such as infrastructure, IEC & IPC and resource mobilisation etc
related to three crucial domains of WASH in Institutions- WASH in Schools, WASH
in Health Centres and WASH in Anganwadi Centres – were discussed.
The participants were sensitized upon the need of
ODF environment in the institutions.
Various government schemes and guidelines, and the
roles and responsibilities of the relevant
departments’ personnel discussed.
Initiatives such as Kayakalp, Swachh Swastha
Sarvatra, Swachha Vidyalaya and the status of the
facilities, and the way forward were shared for a
better understanding of the participants.
Implementation strategies in tandem with the
Sustainable Development Goals helped devise a
broad action plan.
The stark difference and the urgent need of WASH in
institutions in the tribal areas through various research inputs helped generate a
new level of awareness among participants.
Menstrual Hygiene Management: This session was facilitated by Ms. Niharika Singh, Young
Professional, WASH - UNICEF. The highlights of this session were:
The session covered the vital components of what constitutes Menstrual Hygiene
Management. A brief on the globally
accepted definition and the multi-
pronged issues concerning safety,
privacy and dignity of girls associated
with MHM were discussed.
Participants were briefed on the grim
reality on the ground through research-
based data insights.
The session helped understand MHM
related practices & issues in context and
relevance with WASH in Institutions.
Emphasis was laid on ‘Breaking the
Silence’ around menstruationand ‘Educating the entire Stakeholders’ alike.
11 | P a g e
Simple infrastructural strategies, best practices and innovations in MHM were
disseminated to all participants.
The highlights of Menstrual Hygiene Management Guidelines along with the
specific role of different departments and ministries at Central, State, District and
School level helped participants understand their role better with regard to
MHM.
In essence, the session touched upon disempowerment of girls due to school
dropouts wherein a lack of MHM is a major contributing factor.
Convergence for improved sanitation situation in tribal areas: This session was facilitated
by Mr. D N Murthy. During this session, he shared his experiences of working in the
tribal and plain areas wherein he initiated
many development programs in the areas of
health, education etc for the marginal and
deprived communities. Some of those
programs that he mentioned were- School
on Boat (to reduce the dropout rate), Sarva
Shiksha Abhiyaan (2000), School Health
Program/Jawahar Bal Arogya Raksha (2010),
and Comprehensive School Health (2016).
He shared the challenges he faced during
the implementation of these programs and
how he joined hands with other
departments (health, ICDS, education etc) in
finding solutions to the problems, and how he inculcated the sense of responsibility and
ownership in the functionaries of the other stakeholder departments etc to become a
part of the inclusive development.
He informed the participants that an official letter to this effect (convergence for ODF)
from the Special Commissioner – Tribal Welfare Department has already been issued to
the stakeholder departments (Health, Education and ICDS). He said that UNICEF’s
support would also be sought, if required.
He concluded that, as tribal communities being the most vulnerable population owing
to geographic isolation and other issues, all stakeholder departments are required to
come together in the ITDA areas to improve the sanitation situation.
Manyamlo….Swachh Raatri (A Clean Night in the Wilderness/Tribal Habitat): An
Entertainment Program
Facilitator Mr. Manikanta
An entertainment program Manyamlo….Swachh Raatri, anchored by Manikanta, was
organized during the evening. The aim of this event was to relieve the stressand
entertain the participants who felt exhausted having participated actively in the
12 | P a g e
sessions applying their minds and acts together. During this two-hour event, almost all
participants of the workshop took active part voluntarily in singing, saying jokes in
making others smile, and dancing alone and in the group to the blaring music.
And, the birthday of Niharika Singh was celebrated, which fell accidentally on this same
day.
13 | P a g e
Day-2 (Jun 08, 2017)
Session-6 Recap of Previous Day’s Proceedings
Facilitator Mr. Manikanta
ITDA Seethampeta
ODF status implies saturation of toilets at household and school and institutions level and the consistent usage.
Need to make MHM a part of the curriculum in schools.
ITDA Parvatipuram
How to take the concept of ODF to the tribal communities and convince them with the awareness related to the link between sanitation and nutrition and health.
How to coin words (which are considered a taboo and shameful to speak) to make them feel the need.
The concept of sanitation and hygiene.
To make a GP ODF, WASH in Institutions is equally important
14 | P a g e
ITDA Paderu
Need to educate children about health and nutrition issues through curriculum-based health education.
Constructing toilet alone contribute to ODF but its consistent use will.
ITDA Rampachodavaram
ODF implies death in terms of children dying with diarrhea, women getting raped and tortured to death etc.
ITDA Chintoor
Need to inform and educate the tribal community vis-à-vis deaths related to open defecation.
Need to educate tribal women and girls on menstrual hygiene also during the visits of health workers (ASHA activist, ANM etc)
15 | P a g e
ITDA Srisailam
There are several “unexpected” ways of discarded excreta reaching human bodies again through the oral route, causing infections and diseases.
The excessive number of diarrheal deaths in children Under-5 can be prevented with hand washing at critical times.
The situation of consistent under-nutrition in children is affecting the future generations.
Session-7 Introduction to Planning of Sanitation and Hygiene Improvement in
Tribal Areas
Facilitator Venkatesh Aralikatty
In this session, Mr. Venkatesh, geared up the audience mentally to be able to produce
individual plans ITDA wise for sanitation and hygiene improvement in their respective
areas. He motivated them to think about/recall a path-breaking incident that happened
in their career life (especially in the areas health, sanitation, education, and nutrition),
which brought a sea change or a paradigm shift in their approach and served as a good
learning to take it forward. He put forward a 4-point formula (4 Dimensions) to facilitate
organize their thoughts process prior action preparation for their respective areas. The
4-point formula was:
Discover: Recall the incident in your real/career life as to what was the issue,
what triggered the incident, and how it happened.
Dream: How did you see/perceive the issue for resolution? How did you solve
the problem – on your own or sought any outsider’s help?
Design: What efforts did you put to solve the issue? What was your plan?
Deliver: How did you implement the plan to solve the issue?
The participants discussed the issues in sub-groups, and presented to the house sub-
group wise. Those issues majorly revolved around health and sanitation.
While summing up, the facilitator said, “I appreciate the efforts you have/had put in to
resolve the identified issues in your respective areas. You could ultimately find a
solution to the problems. It implies every issue has a solution or many. In the same way,
we can also find solutions to the issues related to sanitation and hygiene in the tribal
areas. Now, before you embark upon preparing an action plan, keep in mind the this 4-
16 | P a g e
point formula in identifying the exact issue/problem, what resources are required to see
that the issue resolved, what and how will you make an appropriate plan, and what are
the ways and means you would want to implement the plan”.
Session-8 Key Strategies for Sanitation and Hygiene Improvement in Tribal Areas
(campaign mode): Vizianagaram Experiences
Facilitator Ravikanth R Mazumdar
Sharing the experiences that the ODF campaign named “10000 IHHLs in 100 Hours” that
saw commendable success in the plain and the tribal areas of Vizianagaram district, Mr.
Ravikanth, guided the participants towards internalizing the valuable lessons learnt
during the campaign, different phases of the ODF campaign and the activities to be
carried out in respect of those phases. The final output is as follows:
ProposedAction Plan Template
Campaign for Transforming GPs to ODF
under Swachh Manyam
Timeline: Dec 2018
By what date would you transform your ITDA to ODF ?
Time period for each phase ?
PRE-CONSTRUCTION
Timeline& Budget for each activity to be mentioned
Activities
Choosing GPs/Mandals: How many and on what basis? (identify the criteria)
Designating persons responsible for the campaign 1) Identifying
personnel from stakeholder departments and Third Party Monitors & Documentation
2) Communicating the list to the persons concerned& the dates of the campaign
3) Planning for visits
Creating an identity to the campaign 1) Naming the
campaign
2) Producing Caps, Badges etc
3) Creating WhatsApp group
Pre-visit for situation analysis 1) Meeting with GP
functionaries and preparing a plan for a detailed survey
2) Collecting data to finalize: o No. of households
in total o Households having
toilets o Households having
toilets and using o Households having
toilets and not using o Households having
17 | P a g e
(dates, time etc) no space for building toilets
Planning for resource mobilization 1) Men (Masons
and other departments’ personnel)
2) Material (identifying markets and vendor agreements)
Mobilizing funds (identification of channels)
Capacity Building/Orientation 1) Masons
2) Village Functionaries
3) Department Personnel
Third party monitors& their visiting plan
Behaviour change communication 1) Identifying teams
and members for triggering sessions
2) Building capacities of trigger-teams
3) Finalizing a plan for delivery of trigger sessions
Ensure Material and Men reaching sites on time
DURING-CONSTRUCTION
Timeline& Budget for each activity to be mentioned
Activities
Monitoring 1) Teams of
officials and Third Party monitors to monitor the situation
Formation of Vigilance Teams & capacity building
Provision of essential items/tools for monitoring (Whistles, baton, torch, radium jacket etc)
POST-CONSTRUCTION
Timeline& Budget for each activity to be mentioned
18 | P a g e
Activities
Monitoring 1) Vigilance
Teams to monitor the situation
Imposing fines on defaulters
Temporary arrangements for visitors, vendors, migrated etc,
Declaration of ODF
Session-9 Planning ITDA wise for Sanitation and Hygiene Improvement in Tribal
Areas
Facilitator Venkatesh Aralikatty, Ravikanth & Manikanta
During this session, the participants worked in their ITDA wise sub-groups on the action
plan and came up with ODF target/deadline plan with respect to the whole ITDA areas
and relevant mandals as well. Since they are not part of the final decision making
authority, the participants said they would discuss this action plan with their Project
Officer and other crucial officials in the ITDA, and submit a details action plan consisting
of activities with timelines and budget.
The output ITDA wise is as follows:
Target Plan – ITDA Rampachodavaram
S.NO Name Of Mandal
No. of GPS
Achieved
(ODF)
Phase-1 Phase-2 Phase-3
1 Rampachodavaram (19) 4 3 6 6
2 Maredumilli (12) 2 3 3 4
3 Devipatnam (14) - 2 6 6
4 Addathegala (22) 1 7 7 7
5 Gangavaram (17) 4 4 5 7
6 Rajavommangi (19) 2 5 6 6
7 Yramavaram (14) 1 3 5 5
Total 117 14 27 38 38
S.NO Phases Mandal From TO No.of GPs
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1 Phase-1 7 Jun-17 Dec 31-2017 27
2 Phase-2 7 Jan-18 Jun 30-2018 38
3 Phase-3 7 Jul-18 Dec31-2018 38
Target Plan – ITDA Paderu
S.NO Phases No. of Mandals Total no.of GPS ODF date
1
Phase-1
(1.7.2017 to
26.12.2017)
2 30 26-12-2017
2
Phase-2
(1-7-2017 to
23.06.2018)
5 98 23-06-2018
3
Phase-3
(1.7.2017 to
18.12.2018)
4 116 18-12-2018
Total 11 244
Target Plan – ITDA Seethampet
Phases Mandal GP Habitations Date
From TO
1
Jul 1 -2017
to
Dec 31 -2017
Seethampet 7 135 01-07-2017 31-12-2017
Kotturu 9 40 01-07-2017 31-12-2017
bhamimni 5 30 01-07-2017 31-12-2017
Pathapatnam 3 24 01-07-2017 31-12-2017
Hiramandalam 3 17 01-07-2017 31-12-2017
Meliputti 8 52 01-07-2017 31-12-2017
Mandasa 3 32 01-07-2017 31-12-2017
Total 7 38 330
2
jan 1-2018
to
jun 30 -2018
Seethampet 9 214 01-01-2018 30-06-2018
Kotturu 17 44 01-01-2018 30-06-2018
bhamimni 9 31 01-01-2018 30-06-2018
Pathapatnam 6 25 01-01-2018 30-06-2018
20 | P a g e
Hiramandalam 5 18 01-01-2018 30-06-2018
Meliputti 12 53 01-01-2018 30-06-2018
Mandasa 5 33 01-01-2018 30-06-2018
Total 63 418
3
Jul 1-2018
to
31 dec-2018
Seethampet 8 214 01-07-2017 31-12-2018
Kotturu 17 44 01-07-2017 31-12-2018
bhamimni 8 31 01-07-2017 31-12-2018
Pathapatnam 6 25 01-07-2017 31-12-2018
Hiramandalam 4 17 01-07-2017 31-12-2018
Meliputti 11 53 01-07-2017 31-12-2018
Mandasa 9 33 01-07-2017 31-12-2018
Total 63 417
Target Plan – ITDA Parvatipuram
S.NO Mandal
Total
no. of
GPS
Achieved
Phases
1
Oct 2 -
2017
2
Feb 28 -
2018
3
Jun7 -
2018
4
Oct 2 -
2018
1 Parvathipuram 26 2 4 8 6 6
2 Kurupam 23 4 4 5 5 5
3 JMValasa 31 2 5 8 8 8
4 GLPuram 27 4 3 6 8 6
5 Komarada 31 3 3 9 9 7
6 Saluru 29 3 6 7 7 6
7 Makkuva 21 3 6 6 6 nil
8 Pachipenta 28 4 6 9 9 nil
Total 216 25 37 58 58 38
Target Plan – ITDA Chintoor
S.NO Mandal Name No. of
GPs
Phases
ODF Date Phase
1
Phase
2
Phase
3
Phase
4
Phase
5
Phase
6
1 Chintoor
31-12-2018 15 3 3 3 3 3 -
15-06-2017
to
31-12-2018
2 Kunavaram
31-12-2018 16 3 3 3 3 4 -
3 VRPuram
31-12-2018 11 2 3 3 3 - -
4 Yetapaka
31-12-2018 21 3 3 3 4 4 4
Target Plan – ITDA Srisailam
21 | P a g e
S.NO District No.of Mandals No. of GPS Chenchu
Gudems
1 Kurnool 14 28 42
2 Guntur 6 37 48
3 Prakasam 7 32 81
Total 27 97 171
Mandal Dates Gudems
Phase-1 27
20-06-2017
to
31-7-2017
27
Phase-2 27
10-09-2017
to
31-03-2018
81
Phase-3 27
10-04-2017
to
31-11-2018
63
Total 171
Session-10 Participants’ Feedback & Vote of Thanks
Facilitator Manikanta
Two persons from the entire lot of participants – one male and the other female - were
asked to provide their feedback on the workshop proceedings.
Mr. Shyam Sundar, MPDO, Vizianagaram: “I liked this program very much. I earlier worked
in the private sector and I enjoyed a vibrant life style and went through a very good
learning curve. This workshop – despite organized by a govt. department – reminded
me the life I spent in the private sector in terms of enjoyment (Swachh Raatri) and
learning (awareness on sanitation and hygiene). We are eager to achieve ODF in tribal
areas. Please provide us the handholding support”
Ms. Krishna Jyothi, Joint Director, Child Protection Cell: “I earlier used to feel shy when
happen to speak about shit in the local language/words. Now, I no longer feel shy.
These workshop deliberations made me strong and shed inhibitions. I personally liked
22 | P a g e
the 4-point formula (4 Dimensions) put forward by Mr. Venkatesh. It will certainly help
us to be ready before we embark upon any task”.
Later, Mr. Manikanta presented the vote of thanks to all and sundry that were
instrumental in organizing the workshop successfully.
With this, the two-day workshop on “Strategy Planning for Sanitation & Hygiene
Improvement in Tribal Areas” ended.
Way Forward: The action/target plans formulated ITDA wise will be refined by the
UNICEF HFO in consultation with Tribal Welfare Department - Andhra Pradesh, to
support improve the sanitation situation in the ITDA areas.
---
Annex-1 :: Program Schedule
DAY-1 :: JUN 7, 2017
Time Session Method Facilitator
09.30 – 10.00 Registration Filling up the details
of participants
ITDA R C Varam Team
10.00 – 11.30 Inaugural Session
Welcome Address & Program
Objectives, Agenda
Interactive AV
Show/PPT
D N Murthy, State
Senior Coordinator
Tribal Welfare
Department
Sanitation and Hygiene
Campaign in Tribal Areas: Need
& Way Forward
Interactive talk S R Nalli, Wash
Specialist, UNICEF
23 | P a g e
Key Note Address Interactive talk PO-ITDA, R C Varam
Chief Guest Address
Interactive talk
N Rambabu, ZP
Chairperson
11.30 – 11.45 Tea/Coffee Break
11.45 – 12:30 Sanitation & Hygiene Goals:
Where We Are
Interactive AV
Show/PPT
S R Nalli
12.30 – 13.30 Why Sanitation and Hygiene for
Tribal areas?
Interactive AV
Show/PPT
Venkatesh Aralikatty
WASH Officer,
UNICEF – INDIA
13:30 – 14:30 Lunch Break
14.30 – 15.15 SHWETA – Situation analysis of
sanitation in Chenchu
Habitations in Kurnool district
Interactive AV
Show/PPT
EFICOR Team, Chenchu
Sanitation Project
15:15 – 16:00 Status of Sanitation in ITDA
Areas of Andhra Pradesh
Interactive AV
Show/PPT
Ravikanth Mazumdar
State Consultant for
WASH Andhra Pradesh
(Supported by UNICEF)
16:00 – 17:00 Institutional Sanitation in ITDA
Areas & MHM –An Overview
Interactive AV
Show/PPT
Manikanta
Niharika Singh
DAY-2 :: JUN 8, 2017
09.00 – 09.30 Recap of previous day’s(Day-1)
proceedings: Presentation of
Learnings
Group discussions
and sharing
Manikanta
09:30 – 10:30 Introduction to Sanitation and
Hygiene Improvement Planning
in Tribal Areas
Large group
discussion
Venkatesh Aralikatty
10:30 – 11:15 Key strategies for Sanitation and
Hygiene Improvement in Tribal
areas : Vizianagaram
Experiences
Interactive AV
Show/PPT
Venkatesh Aralikatty
Ravikanth
11.15 – 11.30 Tea/Coffee Break
11.30 – 13.30 Planning ITDA wise for
Sanitation and Hygiene
Improvement in Tribal Areas
Action Planning; Area
Wise Individual Team
Work; Chart
Presentations
Venkatesh
Ravikanth
Manikanta
13.00 – 13.30 Participants’ Feedback &Vote of
Thanks
Interactive Talk Manikanta
Annex-2 :: List of Participants
State Level Officials
S.No. Name of the officer Designation
Contact Details
Phone E-Mail ID
1 S. R. Nalli WASH Specialist - 9908007645 [email protected]
24 | P a g e
UNICEF
2 A. Venkatesh WASHOfficer -UNICEF 9494412789 [email protected]
3 Ravikanth R Mazumdar State Consultant WASH
4 P.Manikanta
WINS Consultant -
UNICEF 9866942783 [email protected]
5 Niharika Singh
Young Professional
Wash 9813656600 [email protected]
6 Naga Bhushanam
State Co-ordinator -
Nabcons 98160583595 [email protected]
7 DNMurthy State Sr.Co-ordinator 9492482116 [email protected]
8 P. Vidya CSHP -Manager 9494371576 [email protected]
V. Rakesh CSHP-Analyst 9490904009 [email protected]
ITDA - Seethampet
S.No. Name of the officer Designation Contact Details
Phone E-Mail ID
1 N.Syama Sundar Nabcon Consultant -
Social Sector 9700478097 [email protected]
2 Dr.K.L.Abhishek CAS 7680881777 [email protected]
3 Dr. Pragada Eeswara rao Medical officer 7901021948 [email protected]
4 K.Venkata Ramana ATWO 9441943355 [email protected]
ITDA - Parvatipuram
S.No. Name of the officer Designation Contact Details
Phone E-Mail ID
1 Y.Ssankara Rao CMO 8500093333 [email protected]
2 K.Srinivasa rao
APO
NREGS 7702076326 [email protected]
3 A.Naveen AE/RWSGS 9100120741 [email protected]
4 G.GowriSankar AE/RWS/lepm 9100120738 [email protected]
5 Dr.M.M.Ravi Kumar reddy Dy.DMHO 9502629929 [email protected]
6 N.Ravi THPM-NHM 9704701424 [email protected]
7 S.C.Praha Raj
Jr.Consultant
Nabcons 9437235869 [email protected]
25 | P a g e
8 L.Vara Lakshmi
ATWO
GLP 9494167470
9 B.Vidya Rani ATWO -Saluru 9490957348 [email protected]
10 T.Krishna Veni ACDPO 8143857198 [email protected]
11 P.Venkata lakshmi ACDPO 9493819836 [email protected]
12 K.VijayaLakshmi MPDO 9491035826
13 K.Savithri Addl.PD 8008201414 [email protected]
14 S.D.Shyam Sundar MPDO 9491035822 [email protected]
15 A.ganapathy
Panchaayat
Secratery 9440477154 [email protected]
16 G.Arundhathi MPDO 9491035839 [email protected]
ITDA Paderu
ITDA Rampachodavaram
S.No. Name of the officer Designation Contact Details
Phone E-Mail ID
1 Dr.M.Pavan kumar ADMHO
2 A.Venkateswarlu ATWO 9490785788 [email protected]
3 CH.Rama Thulasi ATWO 9491385592 [email protected]
4 K.Satish Babu TEIC manager 9000660529 [email protected]
5 A.Srinivas
TEIC
Spl.education 9494130494 [email protected]
S.No. Name of the officer Designation Contact Details
Phone E-Mail ID
1 B.Murali Krishna NABCONS 9441142207 [email protected]
2 A.Suresh Kumar APO (PTG) 9440803567 [email protected]
3 P.Durga Vara lakshmi
CDPO
GKVeedhi 9441249287 [email protected]
4 E.Gauthami CDPO 9491051539 [email protected]
26 | P a g e
6 D.Deva Raju Nabcons 9440396200 [email protected]
7 Dr.K.S.S.B.Harsha MO 9490278549
8 B.Raju MPHEO 9491386131 [email protected]
9 P.Tirupathi
Jr.Consultant
Social
Consultant 9492293445 [email protected]
10 TVS Rama Prasad
Dy.EE
RWS/RCVM 9494961316 [email protected]
11 G.Raghavulu CDPO 8333027709
12 L.Venkateswarlu Co-Ordinator 9493957065 [email protected]
13 GVRG Acharyulu Co-Ordinator 9494021465 [email protected]
14 U.Arunkumar
Consultant
Nabcons 8332932908 [email protected]
15 Y.Satyam naidu APD Velugu 9421220061 [email protected]
16 MVR reddy APRO 9493740500 [email protected]
17 k.annapurna APMHD 8008201377 [email protected]
18 B.s.Kumar AMO PMRC 9441563065 [email protected]
19 J.Sambhudu ATWO - GRRM 9441385364 [email protected]
20 K.Sujatha ATWO-RCVM 9441370697
ITDA Chintoor
S.No. Name of the Officer Designation Contact Details
Phone E-Mail ID
1 S.Devaprasad ATWO 9440149840 [email protected]
2 Dr.Pragada Eeswar Rao C.A.S 7901021948 [email protected]
3 Dr.N.Kranthi kiran C.A.S 8978870733 [email protected]
4 G.Usha CDPO 9949485385 [email protected]
5 A. Gaja Lakshmi CDPO 8500758785 [email protected]
ITDA Srisailam
S.No. Name Of the Officer Designation Contact Details
Phone E-Mail ID
1 K.Mohan Rao
Jr. Consultant Social
Sector 8500473074 [email protected]
2 K.T.Uma mahesh APO-NREGS 9059025007 [email protected]
3 A.Kaleswara Rao Project Lead 9935072678 [email protected]
4 Joylin Niruba Project Associate 7702079140 [email protected]
5 Daich Medhavi Manager 7798877884 [email protected]
27 | P a g e
Others
S.NO Name Of The
Officer Designation
Contact Details
Phone E-Mail ID
1 N.Hema Swaccha Sankalpam
Mission Co-ordinator 9063702463 [email protected]
2 G.Menaka Dutt Swaccha Sankalpam
Mission Co-ordinator 9949054574 [email protected]
3 P.Manohara Reddy ZSBP EG
9665447679 [email protected]
4 J. Shalam Raju Fact Project, World
Vision-India 9966082669 M&[email protected]
5 T. Ramesh ATWO -Vijayawada 8985599234 [email protected]
6 M.Ramesh babu Director - Programs -
EFICOR 9910398601 [email protected]
___
Guidelines for Control ofIron Deficiency Anaemia
Adolescent DivisionMinistry of Health and Family Welfare
Government of India
Acknowledgements
The National Guidelines for Control of Iron Deficiency Anaemia emerged out of wide based consultation. Preparation of the guidelines would not have been possible without the valuable contributions of Maternal and Child Divisions of the Ministry of Health and Family Welfare and domain experts.
Additional Secretary & Mission Director, NRHM Ms. Anuradha Gupta’s encouragement was our inspiration and her strategic vision shaped the guidelines.
Joint Secretary, RCH, Dr. Rakesh Kumar provided valuable insights and facilitated technical discussions which were critical for finalizing the guidelines.
List of Contributors
Ms. Anuradha Gupta Additional Secretary & Mission Director, NRHM
Dr. Rakesh Kumar Joint Secretary, RCH
Dr. Virender Singh Salhotra Deputy Commissioner, Adolescent Health
Ms. Anshu Mohan Programme Manager, Adolescent Health
Dr. Sheetal Rahi Medical Officer, Adolescent Health
Technical Experts
Professor Umesh Kapil, Department of Community Medicine, AIIMS
Dr. HPS Sachdev, Paediatrician, Sita Ram Bhartia Institute of Science & Research
Dr. PV Kotecha, Professor, Preventive and Social Medicine, Government Medical College, Vadodara
Prof. Suneeta Mittal, Gynaecologist & Obstetrician, Fortis Hospital
Dr. Prema Ramachandran, Director, Nutrition Foundation of India
Dr. Abha Singh, Head, Deptt. of Gynaecology and Obstetrics, LHMC & SK Hospital
Dr. Vartika Saxena, Deptt. of Community Medicine, AIIMS, Rishikesh
Special Mention: Rajat Ray, Sr. Advocacy & Communication Officer, UNFPA, was instrumental in the designing and printing of this document.
Message
Anaemia is a significant public health challenge in India. It has devastating effects on health, physical and mental productivity affecting quality of life, particularly among the vulnerable. Urgent action from all concerned is called for since Anaemia could translate into significant morbidities for affected individuals and consequent socio-economic losses for the country.
Prevention and control of anaemia is one of the key strategies of the Health, Nutrition and Population Sector Programmes for reducing maternal, neonatal and childhood mortality and improving maternal, adolescent and childhood health status.
I am confident that if the comprehensive sets of actions identified in National Guidelines for Control of Iron Deficiency Anaemia are fully implemented; children, adolescents and women in India will have improved health outcomes and be able to achieve their fullest potential. Implementation of this initiative in the right earnest would move us closer to reaching the Millennium Development Goals with regard to bringing down maternal and child mortality.
The challenge before us now is to ensure the implementation of this initiative in its entirety and to further build upon it. Prevention and control of anaemia requires a coordinated response among multiple stakeholders and partners, and I request all to come forward to support interventions in line with the National Guidelines.
(Ghulam Nabi Azad)(Ghulam Nabi Azad)
P.K. PRADHANSecretaryDepartment of Health & FWTel.: 23061863 Fax : 23061252e-mail : [email protected]
National Rural Health Mission
GOVERNMENT OF INDIAMINISTRY OF HEALTH & FAMILY WELFARE
NIRMAN BHAVAN, NEW DELHI - 110108
- 110108
Message
India is among the countries with high prevalence of anaemia. It is widely prevalent in all age groups, being particularly high among the most vulnerable; nearly 58 per cent in pregnant women, 50 per cent among non-pregnant non-lactating women, 56 per cent among adolescent girls, 30 per cent in adolescent boys and around 80 per cent in children under two years of age.
Anaemia, thus poses a major threat to maternal and child survival, contributes to low birth weight, lowered resistance to infection, poor cognitive development and decreased work productivity. The magnitude of anaemia together with the associated adverse health, development and economic consequences, highlights the need for intensified action to address this public health problem.
Success in prevention and control of anaemia will contribute to reduction of maternal and child mortality and improve health outcomes for population as a whole. In this context, “National Guidelines for Control of Iron Deficiency Anaemia” has been developed to identify strategies and comprehensive actions needed across the life cycle to eliminate this serious obstacle to survival, health and development.
The guidelines have been designed to be handy and user friendly for service providers across levels and will be a useful tool in planning and implementing this initiative. I urge States and key stakeholders to prioritize implementation of Iron+ Initiative which will have long term impact on the health status of India’s population.
(P.K. Pradhan)
Place: New Delhi 15th January, 2013
(P.K. Pradhan)
Anuradha Gupta, IAS
Additional Secretary &Mission Director, NRHMTelefax : 23062157E-mail : anuradha&[email protected]
Government of IndiaMinistry of Health & Family WelfareNirman Bhavan, New Delhi - 110108
110108
Preface
Anaemia is a major public health challenge in India. Yet, a comprehensive plan of action to combat this problem has been missing. There are certain existing guidelines for control of Iron Deficiency Anaemia with regard to children and pregnant women and lactating mothers. However, many critical age groups have been missing from this strategy. For instance, adolescents have received no attention so far. There have also been crevices by way of actual administration of IFA to children with several operational issues constraining the prescribed interventions.
The National Iron+ Initiative is an attempt to look at Iron Deficiency Anaemia comprehensively across all life stages including adolescents and women in reproductive age group who are not pregnant or lactating. The schedule of IFA supplementation has also been reviewed to make both administration and compliance much simpler. For children, 6 months to 5 years, there is now a bi-weekly schedule of IFA supplementation with ASHA being responsible for administering the prescribed dosage under her direct supervision. For children of class I to class V in Government/Government aided schools, there is a much simpler weekly schedule of IFA supplementation, under the supervision of teachers. Similarly, adolescents from class VI to class XII receive weekly IFA supplementation in school itself. For women in reproductive age group who are neither pregnant nor lactating, ASHA shoulders the responsibility of providing IFA supplementation.
Clearly, the National Iron+ Initiative builds on the gains of the NRHM, more particularly the strong work force of 8,80,000 ASHAs who have shown excellent potential to mobilise community for a large scale uptake of health services. The fact that ASHAs are now undertaking home visits under the recently rolled out HBNC programme and are also doing home delivery of contraceptives to couples in the reproductive age group opens up several exciting opportunities for ASHAs to render additional services such as IFA supplementation. This initiative makes use of this wonderful opportunity in its bid to reach to all age groups seamlessly.
National Guidelines for Control of Iron Deficiency Anaemia has four purposes:
1. To bring to attention of program managers of health and health related activities the serious negative consequences of anaemia for the health and physical, mental, and economic productivity of individuals and populations
2. To layout IFA supplementation protocols across the life cycle (preventive strategy)
3. To define a minimum standard treatment protocol for facility based management of mild, moderate and severe anaemia segregated by levels of care (curative strategy)
4. To broadly identify platforms of service delivery and indicate roles of service providers
These guidelines have been developed taking cognizance of scientific evidence as well as considerable consultation with domain experts. It builds on past and continuing work on anaemia prevention and control in India and has been developed in the context of existing policies and strategies of the health, nutrition and population sector. It identifies comprehensive strategies and interventions for high risk groups, in particular infants and young children, adolescent girls, women in reproductive age, and pregnant and breastfeeding women, and for the population as a whole.
I am certain that the states on their part will do the utmost to ensure that appropriate linkages and mechanisms for training, monitoring and operationalizing this initiative are put in place at the earliest and implementation taken up in real earnest so that together we can build a healthy, anaemia free India.
Anuradha Gupta
Foreword
Anaemia, a manifestation of under-nutrition and poor dietary intake of iron is a serious public health problem among pregnant women, infants, young children and adolescents. Data suggests that 7 out of every 10 children aged 6-59 months in India are anaemic. Three per cent of children aged 6-59 months are severely anaemic, 40 per cent are moderately anaemic, and 26 per cent are mildly anaemic. In fact the percentage of children with any anaemia increased from 74.3 per cent in NFHS-II to 78.9 per cent in NFHS-III.
India is among the countries with high prevalence of anaemia in the world. It is estimated that anaemia directly causes 20 per cent of maternal deaths in India and indirectly accounts for another 20 per cent of maternal deaths.
Taking cognizance of this, the Ministry of Health and Family Welfare has developed the National Guideline for Control of Iron Deficiency Anaemia to holistically address both preventive and curative aspect of this challenge across all life stage and various levels of care.
The document provides a guide for all stakeholders and partners on how policy makers, health professionals, community members and families can take action to prevent and control anaemia. I call upon all stakeholders and partners for their continued support in this respect.
I sincerely hope that States will proactively work on this initiative which will have a long term impact on the health of India.
(Dr. Rakesh Kumar)
Dated: 15th January, 2013
Dr. RAKESH KUMAR, I.A.SJOINT SECRETARYTelefax : 23061723E-mail : [email protected]
Government of India
Healthy Village, Healthy Nation
Ministry of Health & Family WelfareNirman Bhavan, New Delhi - 110108
Contents
1. Anaemia – A Public Health Challenge 1 1.1. What is Anaemia? 1 1.2. Aetiology of Anaemia 2
2. Background 5 2.1. Global Overview 5 2.2. Indian Scenario 6
3. Impact of Anaemia on Health Outcomes 11
4. Existing Policies and Strategies 13 4.1. Interventions by Ministry of Health and Family Welfare (MoHFW) 13 4.2. Key Programmes and Schemes of Other Ministries 13 4.3. National Iron+ Initiative 14
5. Approach – What Would It Take to Fight Iron Deficiency and IDA More Effectively? 15 5.1. What Are Diet Diversification, Food Fortification and Supplementation? 16 5.2. Ministry of Health and Family Welfare’s Revised Strategy 16
6. Supplementation through the Life Cycle 17 6.1. Supplementation for Children 6–60 months 18 6.2. Supplementation for Children 5 (61 months onward)–10 years 19 6.3. Weekly Iron and Folic Acid Supplementation (WIFS) Programme for Adolescent Girls and Boys (10–19 Years) 20 6.4. Pregnant Women and Lactating Mothers 21 6.5. Women in Reproductive Age Group (WRA) (15–45 Years) 22
7. Therapeutic Approach through the Life Cycle 23 7.1. Six Months – 60 Months 23 7.2. Children 5–10 Years 26 7.3. Adolescents in the Age Group 10–19 Years 27 7.4. Pregnant and Lactating Women 29
References 33
Annexures 34 1. Dietary Diversification for Prevention of Nutritional Anaemia 34 2. Amount of Food to Offer at Different Ages 37 3. Enhancing Iron Content of Food at Different Ages 38
AcronymsAG Adolescent GirlANC Antenatal CareANM Auxiliary Nurse MidwifeASHA Accredited Social Health ActivistAWC Anganwadi CentreCHC Community Health CentreCNS Central Nervous SystemDALY Disability Adjusted Life YearsDH District HospitalF-IMNCI Facility-based Integrated Management of Neonatal and Childhood IllnessFRU First Referral UnitGDP Gross Domestic ProductHb HaemoglobinICDS Integrated Child Development ServicesIDA Iron Deficiency AnaemiaIFA Iron and Folic AcidIMNCI Integrated Management of Neonatal and Childhood IllnessITBN Insecticide Treated Bed NetsKSY Kishori Shakti YojanaLBW Low Birth WeightLHV Lady Health VisitorLLIN Long Lasting Insecticide NetsMCP Card Mother Child Protection CardMO Medical OfficerMoHFW Ministry of Health and Family WelfareMUAC Mid Upper Arm CircumferenceMWCD Ministry of Women and Child DevelopmentNFHS National Family Health SurveyNNMBS National Nutrition Monitoring Bureau SurveyNPAG Nutrition Programme for Adolescent GirlsPHC Primary Health CentrePNC Postnatal carePW Pregnant WomanRBC Red Blood CellsVHND Village Health and Nutrition DayWIFS Weekly Iron and Folic Acid SupplementationWRA Women of Reproductive Age
1
Anaemia – A Public Health Challenge
1.1. What is Anaemia?
Anaemia is a condition in which the number of red blood cells (RBCs), and consequently their oxygen-carrying capacity, is insufficient to meet the body’s physiological needs. The function of the RBCs is to deliver oxygen from the lungs to the tissues and carbon dioxide from the tissues to the lungs. This is accomplished by using haemoglobin (Hb), a tetramer protein composed of haem and globin. Anaemia impairs the body’s ability for gas exchange by decreasing the number of RBCs transporting oxygen and carbon dioxide. Anaemia results from one or more of the following process: defective red cell production, increased red cell destruction or blood loss. Iron is necessary for synthesis of haemoglobin. Iron deficiency is thought to be the most common cause of anaemia globally, but other nutritional deficiencies (including folate, vitamin B12 and vitamin A), acute and chronic inflammation, parasitic infections, and inherited or acquired disorders that affect Hb synthesis, red blood cell production or red blood cell survival can all cause anaemia. Iron deficiency anaemia results in impaired cognitive and motor development in children and decreased work capacity in adults (Figure 1.1). The effects are most severe in infancy and early childhood. In pregnancy iron deficiency anaemia can lead to perinatal loss, prematurity and low birth weight (LBW) babies. Iron deficiency anaemia also adversely affects the body’s immune response.
Fig. 1.1: Adverse effects of anaemia
ANAEMIA
Reducedphysical
development
Impaired sexual and
reproductive development
Reduced cognitive
development
• Decreased work output• Decreased work capacity
• Diminished concentration• Disturbance in perception• Poor learning ability
• Irregular menstruation• Low pre-pregnancy iron stores• LBW babies and preterm delivery
1
Guidelines for Control of Iron Deficiency Anaemia
2
Table 1.1: Haemoglobin levels to diagnose anaemia (g/dl)
Age groups No Anaemia Mild Moderate Severe
Children 6–59 months of age ≥11 10–10.9 7–9.9 <7
Children 5–11 years of age ≥11.5 11–11.4 8–10.9 <8
Children 12–14 years of age ≥12 11–11.9 8–10.9 <8
Non-pregnant women (15 years of age and above) ≥12 11–11.9 8–10.9 <8
Pregnant women ≥11 10–10.9 7–9.9 <7
Men ≥13 11–12.9 8–10.9 <8
Source: Haemoglobin concentration for the diagnosis of anaemia and assessment of severity. WHO
1.2. Aetiology of Anaemia
The commonest causes of anaemia in developing countries, particularly among the most vulnerable groups (pregnant women and preschool age children), are nutritional disorders and infections. Hence the causes of anaemia could be segregated as nutritional and non-nutritional, underscoring the aetiological importance of dietary deficiency as the major causative factor.
1.2.1 Iron deficiencyIron status can be considered as a continuum from iron deficiency with anaemia, to iron deficiency with no anaemia, to normal iron status with varying amounts of stored iron, and finally to iron overload which can cause organ damage when severe. Iron deficiency is the result of long-term negative iron balance. Iron deficiency anaemia (IDA) should be regarded as a subset of iron deficiency, that is, it represents the extreme lower end of the distribution of iron deficiency.
Storage iron
Transport iron
RBC iron
Normal Iron depletionIron deficienterythropoiesis
Iron deficiencyanaemia
Iron deficiency adversely affects
• The cognitive performance, behaviour and physical growth of infants, preschool and school-age children;
• The immune status and morbidity from infections of all age groups;
• The use of energy sources by muscles and thus the physical capacity and work performance of adolescents and adults of all age groups.
Anaemia – A Public Health Challenge
3
Iron requirements are highest for pregnant women –1.9 mg/1,000 Kcal of dietary energy in the second trimester and 2.7 mg/1,000 Kcal in the third trimester. These are followed by iron requirements in infants (1.0 mg), adolescent girls (0.8 mg), adolescent boys (0.6 mg), non-pregnant women (0.6 mg), preschool and school age children (0.4 mg), and adult men (0.3 mg).
Iron deficiency is a consequence of:
• Decreased iron intake
• Increased iron loss from the body
• Increased iron requirement
Iron requirements increase during the period of active growth in childhood, especially from 6 months to 3 years. In infancy, iron deficiency is most often the result of lack of exclusive breast feeding and use of unsupplemented milk diets which contain inadequate amounts of iron. Milk products are very poor sources of iron and prolonged breast or bottle feeding of the infant without complementary feeds after 6 months of age frequently lead to iron deficiency unless there is iron supplementation. Iron requirements are proportionately greater in premature and underweight babies. In older children, a predominantly milk and cereal based diet and food fads can also lead to IDA.
Blood loss during menstruation and increased iron requirements during pregnancy and lactation predispose women to poor iron stores. Traditionally, the Indian housewife eats last, after all male members and children have eaten and in many families, the women eat only the leftovers. Hence, even though the food prepared for the family is the same, women are more prone to develop IDA than other members of the family.
1.2.2 Other micronutrient deficienciesVitamin B12 is necessary for the synthesis of RBCs and its deficiency has been associated with megaloblastic anaemia. Diets with little or no animal protein, as is often the case in our country, coupled with malabsorption related to parasitic infections of the small intestine, might result in Vitamin B12 deficiency and anaemia.
Folic acid is also essential for the formation and maturation of RBCs and is necessary for cell growth and repair. Deficiency of folate reduces the rate of DNA synthesis with consequent impaired cell proliferation and intramedullary death of resulting abnormal cells; this shortens the lifespan of circulating RBCs and results in anaemia.
1.2.3 Helminthic infestation Helminths such as hookworm and flukes cause chronic blood loss and consequently iron loss from the body, resulting in the development of anaemia. A hookworm burden of 40–160 worms (depending on the iron status of the host) is associated with IDA.
Guidelines for Control of Iron Deficiency Anaemia
4
1.2.4 MalariaMalaria, especially by the protozoa Plasmodium falciparum and vivax, causes anaemia by rupturing RBCs and suppressing production of RBCs. Decreased RBC production results from marrow hypoplasia seen in acute infection. Plasmodium falciparum is the primary cause of severe malaria in regions where malaria is endemic. Malarial anaemia can cause severe morbidity and mortality especially in children and pregnant women infected with Plasmodium falciparum. Malaria in pregnancy increases the risk of maternal anaemia, stillbirth, spontaneous abortion, LBW and neonatal deaths.
1.2.5 Sickle cell disease and thalassemia Sickle cell disease is an inherited disorder of haemoglobin. It is among the most common genetic diseases in the world and results in recurrent haemolytic anaemia. Thalassemia is one of the major haemoglobinopathies among the population all over the world. It is caused due to decreased or negligible amount of globin chain of haemoglobin. About 10 per cent of the world’s thalassemia patients belong to the Indian subcontinent and 3.4 per cent of them are carriers. In India, about 32,400 infants are born with haemoglobinopathies every year1.
1.2.6 Infections Certain chronic diseases, such as cancer, HIV/AIDS, rheumatoid arthritis, Crohn’s disease and other chronic inflammatory diseases, can interfere with the production of RBCs, resulting in chronic anaemia. Kidney failure can also cause anaemia.
5
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Fig. 2.1: Global picture – Anaemia as a public health problem in preschool children by country
Guidelines for Control of Iron Deficiency Anaemia
36
Red Gram Dhal
Arhar
Plantain Green
Kuchcha Kela
Black Gram, Dhal
Urad Dal or Kaskalay
Water Melon
Tarbooz
Pumpkin
Seethaphal
Mutton
Gosht
Common Vitamin C Rich Foods
Cabbage
Patta Gobhi
Drumstick Leaves
Saijan Patta
Coriander Leaves
Dhaniya
Gooseberry
Amla
37
Annexure 2
Amount of Food to Offer at Different Ages
AgeEnergy needed per day in addition to
breast milkTexture Frequency
Average amount of each meal
6–8 months 200 Start with thick porridge, well mashed foods
2–3 meals per day plus frequent breastfeed
Start with 2–3 tablespoonfuls
9–11 months 300 Finely chopped or mashed foods, and foods that baby can pick up
3–4 meals plus breastfeed.
Depending on appetite offer 1–2 snacks
½ of a 250 ml cup/bowl
12–23 months 550 Family foods, chopped or mashed
if necessary
3–4 meals plus breastfeed.
Depending on appetite offer 1–2 snacks
3/4 to one 250 ml cup/bowl
If baby is not breastfed, give in addition: 1–2 cups of milk per day, and 1–2 extra meals per day. The amounts of food included in the table are recommended when the energy density of the meals is about 0.8 to 1.0 Kcal/g. If the energy density of the meals is about 0.6 Kcal/g, recommend to increase the energy density of the meal (adding special foods) or increase the amount of food per meal. Find out what the energy content of complementary foods is in your setting and adapt the table accordingly.
38
Annexure 3
Enhancing Iron Content of Food at Different Ages
Age
Iron requirement
(mg/day)1 (ICMR RDA)
Iron content(Assuming frequency of meals/day as advised in
column 4 above)
Food-iron content gap
(mg/day)
Amount of raw green leafy vegetables (to be cooked and
added to food) (g/day)2
6–8 months
5 1.0–2.0 mg 3–4 25
9–11 months
5 2.0–2.5 mg 2.5–3.0 25
12–23 months
9 2.5–3.5 mg 5.5–6.5 40
1 Iron requirement is based on 5 per cent bio-availability from cereal-pulse based diets.
2 Green leafy vegetables like amaranth (chaulai sag/dantu), spinach (palak), turnip leaves (shalgam ka sag), mint leaves (pudhina) and small amounts of tamarind (imli) added to the diet daily will together provide the amount of iron recommended. These are broad guidelines. Recipes should be adapted based on local customs and availability of specific vegetables.