State action plan for Micronutrient SuppleMentation · ii State action Plan for Micronutrient SuPPleMentation Purpose of the State Action Plan is to guide planning, monitoring, supervision,

NAT

IONAL HEALTH MISSI O

NEnsuring Last Mile Delivery of Micronutrient Drugs in Jharkhand

Micronutrient SuppleMentation State action plan for

IFA Red, IFA Pink, IFA Blue, IFA Syrup, Calcium, Vitamin A & Albendazole

NAT


N

Ensuring Last Mile Delivery of Micronutrient Drugs in Jharkhand

Micronutrient SuppleMentation State action plan for

IFA Red, IFA Pink, IFA Blue, IFA Syrup, Calcium, Vitamin A & Albendazole

ii State action Plan for Micronutrient SuPPleMentation

Purpose of the State Action Plan is to guide planning, monitoring, supervision,

reporting and review of the performance of all micronutrients under the rMncH+a

programme. the plan will enable the state to be result oriented so as to deliver an

uninterrupted supply and high coverage of micronutrients for all women, children and

adolescents in the state.

User of the State Action Plan will be the State, District and Block level programme

managers, medical officers, store in-charges and supervisors working in nHM, icDS

and education department to systematically plan, implement, monitor, report and

review the performance of micronutrients drugs supply and coverage in the state.

PURPOSE

USER

iii

liSt of abbreviationS

acMo additional chief Medical officer

aMB anemia Mukt Bharat

afHc adolescent friendly Health clinic

anM auxiliary nurse Midwife

aWc anganwadi centre

aWW anganwadi Worker

BaM Block accounts Manager

BDM Block Data Manager

Beo Block education officer

BHaP Block Health action Plan

Bre Block resource envelope

BPM Block Programme Manager

BPMu Block Programme Management unit

cDPo child Development Project officer

cHc community Health centre

DaM District accounts Manager

DDM District Data Manager

Deo District education officer

DH District Hospital

DHaP District Health action Plan

Dre District resource envelope

DrcHo District reproductive and child Health officer

DP Development Partners

DPM District Programme Manager

DPMu District Programme Management unit

iv State action Plan for Micronutrient SuPPleMentation

DSWo District Social Welfare officer

fru first referral unit

HMiS Health Management information System

HSc Health Sub-centre

icDS integrated child Development Services

ifa iron folic acid

ifa Syrup iron folic acid Syrup

iYcf infant and Young child feeding

JMHiDPcl Jharkhand Medical and Health infrastructure Development Procurement corporation limited

JSSK Janani Shishu Shuraksha Karyakaram

lHV lady Health Visitor

lS lady Supervisor

Mo Medical officer

Moic Medical officer in-charge

MPW Multipurpose Worker

nDD national Deworming Day

nHM national Health Mission

obs & Gynea obstetrics and gynaecology

PHc Primary Health centre

PiP Project implementation Plan

rKSK rashtriya Kishori Swasthya Karyakram

rMncH+a reproductive Maternal newborn child Health and adolescent

ri routine immunization

Sahiya (aSHa) accredited Social Health activist

SaM Severe acute Malnutrition

Sn Staff nurse

Sncu Sick newborn care unit

VHnD Village Health and nutrition Day

WifS Weekly iron and folic acid Supplementation

v

contentS

List of Abbreviations iii

Foreword vii

Preface viii

Message ix

Acknowledgement x

Section 1: Introduction 1

Section 2: Coverage of Micronutrient Supplementation in Jharkhand 3

Section 3: State Action Plan for Micronutrient Supplementation: The Rationale 7

Section 4: Areas of Improvement to Achieve the Last Mile Delivery of Micronutrients 9

Section 5: State Action Plan for Micronutrient Supplementation 11

5.1: importance of Micronutrients 11

5.2: objective of the State action Plan 12

5.3: Purpose of State action Plan 13

5.4: user of the State action Plan 13

5.5: action Plan for Micronutrients 13

STEP 1: estimating annual requirement and Microplaning 14

STEP 2: Procurement and Distribution 16

STEP 3: Monitoring and Supervision 20

STEP 4: Performance review 22

STEP 5: capacity Building 23

Annexure I: Formula for Calculating Requirement of Micronutrient Drugs 35

Annexure II: How to Distribute Micronutrient Drugs to the Beneficiaries 41

Annexure III: Routine Monitoring Indicators for Micronutrient Drugs 47

Maternal Health: ifa red, calcium and albendazole 47

child Health: ifa Pink, iron Syrup, Vitamin a and albendazole 48

adolescents Health: ifa Blue and albendazole 49

Annexure IV: Nutrition Dashboard for Review at NHM 51

List of Contributors 53

References 55

vi State action Plan for Micronutrient SuPPleMentation

Figures

figure 1: improving nutrition around life course 1

figure 2: Status of anemia and ifa consumption during Pregnancy 3

figure 3: Status of anemia, ifa consumption and Vitamin a Supplementation among children under 5 4

figure 4: Status of anemia among adolescent Boys and Girls 5

figure 5: Process and actions to ensure Supply of Micronutrient Drugs 10

figure 6: framework for State action Plan 12

vii

Foreword

Jharkhand has taken several important steps to reduce maternal mortality and infant mortality in the past decades. the performance of the state in reduction of maternal mortality ratio and infant mortality rate has been widely appreciated. Still, the nutritional well-being of mothers, infants and children remains a concern for the state. Jharkhand witnesses a high prevalence of anemia among women, children and adolescents. nutrition is a crucial, universally recognized component of every child’s right to the highest attainable standards of health. every woman has the right to optimal nutrition, not only for herself but also her child, through appropriate knowledge and conditions. nutrition has been globally recognized as an important determinant of child survival and development. Maternal undernutrition, including chronic energy and micronutrient deficiencies, contributes significantly to maternal mortality, intrauterine growth restriction and low birth weight babies.

under the rMncH+a program, national Health Mission has the mandate of high impact rMncH+a interventions with high coverage and quality. this includes a wide range of micronutrient drugs like ifa, calcium, Vitamin a and albendazole, cross cutting across programs in Maternal Health, child Health, adolescent Health, Poshan abhiyaan, icDS and education.

i am sure that with the State action Plan for Micronutrient Supplementation, we will be able to guide program managers to achieve their objective of improving nutritional status among women, children and adolescents by strengthening the capacity of health personnel, for delivering nutrition services in health system.

Dr. Nitin Madan Kulkarni, iaSSecretary, Health, Medical education and family Welfare Government of Jharkhand

Dr. Nitin Madan Kulkarni, iaSSecretary, Health, Medical education and family Welfare Government of Jharkhand

viii State action Plan for Micronutrient SuPPleMentation

PreFACe

nutrition has gained significant importance and momentum on the nation’s development agenda in recent years. over the last decade, Government of india has launched a number of flagship programs on Health and nutrition. these investments in public health have led to an improvement in the health and nutrition outcome of mothers and children. national Health Mission Jharkhand is committed to improving the Health and nutrition status of women, children, and adolescents through the rMncH+a program. Micronutrient supplementation for pregnant woman, lactating mothers, children and adolescents with ifa, calcium, Vitamin a along with deworming, is the largest intervention in nutrition besides breastfeeding and diet counselling. the national Health Mission Jharkhand has taken a leadership role in the evolution of the State action Plan for Micronutrient Supplementation as a step towards creating a systematic approach to achieving high coverage of micronutrient drugs in the state. the objectives of the State action Plan is to emphasise on systematic planning, monitoring, supervision, reporting and review of micronutrients under the rMncH+a program. the actions are geared towards implementing operational guidelines for these micronutrient drugs and addressing bottlenecks in the state.

to maintain high coverage of micronutrient drugs in the state, capacity building of health personnel on projection for estimating annual requirement, micro planning for effective distribution, HMiS reporting on coverage and stock updates, effective use of e-aushadhi software, monitoring and supervision and routine review of micronutrient supplementation, are keys to the program’s success. this action plan will guide the state and especially the program managers and supervisors to take result oriented approaches to increase coverage of micronutrient drugs to the last mile. We are extremely confident of bringing positive changes by increasing the supply and distribution of micronutrient drugs to the last mile through the State action Plan for Micronutrient Supplementation.

Shri Kripa Nand Jha, iaSMission Director, national Health MissionGovernment of Jharkhand

Shri Kripa Nand Jha, iaSMission Director, national Health Mission,Government of Jharkhand

ix

MessAge

nutrition is globally recognized as a critical development imperative, which is crucial for the fulfilment of human rights especially of the children, girls and women. nutrition is also central to the achievement of other national and Global Sustainable Development Goals. it is critical to prevent undernutrition, as early as possible, across the life cycle, to avert irreversible cumulative growth and development deficits that compromise maternal and child health and survival. if unchecked, it can limit learning outcomes in elementary education, impair adult productivity and undermine gender equality.

a wide spectrum of national programmes contributes to improved nutrition outcomes, addressing both the immediate and the underlying determinants of undernutrition through nutrition specific and nutrition sensitive interventions. these include PoSHan abhiyaan, integrated child Development Services, national Health Mission including rMncH+a, Janani Suraksha Yojana, Swachh Bharat including Sanitation and the national rural Drinking Water Programme, Matritva Sahyog Yojana, Scheme for adolescent Girls, Mid-Day Meals Scheme, targeted Public Distribution System, national food Security Mission, Mahatma Gandhi national rural employment Guarantee Scheme and the national rural livelihood Mission among others.

State nutrition Mission Jharkhand congratulates the national Health Mission Jharkhand for taking the initiative in developing this State action Plan for Micronutrient Supplementation. Systematic planning, monitoring, supervision, reporting and review mechanism shall improve last mile delivery of these micronutrient supplements to the pregnant women, lactating mothers, infant and young children and adolescents in Jharkhand. We believe that proper implementation of the action plan will definitely help the State to address the issues of malnutrition arising out of micronutrient deficiencies, in an appropriate way.

Dr. Dinesh Kumar Saxena, ifSDirector General, State nutrition MissionGovernment of Jharkhand

Dr. Dinesh Kumar Saxena, ifSDirector General, State nutrition MissionGovernment of Jharkhand

x State action Plan for Micronutrient SuPPleMentation

ACknowledgeMent

nutrition has been globally recognised as an important determinant of child survival and development. Micronutrients play a significant role in different stages of life for averting malnutrition and yielding better health outcomes.

therefore, it gives me great pleasure to present to you the State action Plan for Micronutrient Supplementation within the rMncH+a Program of national Health Mission, which is a result of hard work and collaboration between the Government and Development Partners.

My heartiest thanks to the entire team of the child Health cell, Maternal Health cell, adolescent Health cell, Procurement cell and JMHiDPcl for providing working group members with directions for development of the State action Plan for Micronutrient Supplementation.

i am thankful to the technical team of Wecan Project and uSaiD Supported VriDDHi Project of iPe Global, unicef and JHPieGo for undertaking the demanding task of developing the State action Plan for Micronutrient Supplementation, to help program managers in planning, monitoring, supervising, reporting and reviewing all micronutrients together under rMncH+a. this action oriented plan, developed on the foot-print of the national guidelines, will guide the program managers, supervisors, service providers in state, districts and blocks to be result-oriented and ensure last mile delivery of micronutrient drugs to all women, children and adolescents in the state.

i am also thankful to the Department of Preventive and Social Medicine of rajendra institute of Medical Science and the Poshan abhiyaan of the Department of Woman, child Development and Social Justice, Jharkhand and State nutrition Mission Jharkhand.

i am confident that the implementation of State action Plan for Micronutrient Supplementation across the state will result in achieving high results in distribution, coverage and usage of micronutrient drugs in Jharkhand.

Dr. Rajendra PaswanDirector in chief, Jharkhand Health ServicesGovernment of Jharkhand

Dr. Rajendra PaswanDirector in chief, Jharkhand Health Services,Government of Jharkhand

1

Section 1introduction

nutrition is a crucial, universally recognised component of every child’s right to the highest attainable standards of health. Similarly every woman has the right to not only optimal nutrition for herself, but

also to the appropriate knowledge and condition that enables optimal nutrition for her child. nutrition has been globally recognised as an important determinant of child survival and development. undernutrition is a contributory factor in 45 percent of all deaths taking place in children under five years of age (lancet 2013). Maternal undernutrition including chronic energy and micronutrient deficiencies contributes significantly to maternal mortality, intra uterine growth restriction and low birth weight babies. Maternal undernutrition plays a crucial role in influencing maternal, neonatal and child health outcomes (Mason et al., 2012).

Micronutrients play a significant role in different stages of life for averting malnutrition and yielding better health outcomes (figure 1). Global evidence (WHo, 2013) suggest that during the early life stages i.e. from pregnancy to 2 years age of child (first 1000 days) direct nutrition interventions, health related interventions and other interventions can have a substantial effect on health outcomes of women, infant, and young children. for instance, growth failure during intra uterine life and poor nutrition in the first two

Figure 1: Improving nutrition around life course

20 years

10 years5 years

1 years

28 days

7 days

Birth

Immediate initiation of breastfeeding

Exclusive breastfeeding until 6 months

Adequate complementaryfeeding from 6 months

Micronutrientsupplementationas necessary

Continued breastfeeding

Energy and nutrient adequate diet

Micronutrientsupplementation as

necessary

School meals

Adolescentdietaryadvice

Pre-pregnancy dietaryadvice for adolescent

girls and women

Diet and micronutrientsduring ageing

Diet and micronutrientsduring pregnancy

Source: WHO (2013): Essential Nutrition Action

2 State action Plan for Micronutrient SuPPleMentation

years of life have critical consequences throughout the life course. thus, proper preconception nutrition is important to address the vicious cycle of undernutrition around the life course. Hence, the health and nutrition status of the adolescence stage (10-19 years) is a very crucial, as it has an inter generational effect on future mothers and the raising of children.

the desired nutritional practices around the life course are: breastfeeding, adequate diet (diet diversity and frequency) and micronutrient supplementation. impure water, improper sanitation and hygiene, enteric infections and diarrhoea in children reduce the impact of nutrition. Hence, intervention in water, sanitation and hygiene, deworming and malaria prevention are essential for better nutrition results.

3

coverage of Micronutrient SuppleMentation in Jharkhand

Demographic Health Survey (nfHS-4, 2017) for the state of Jharkhand reveals that a large section of women, children, and adolescents have poor nutritional status. almost half the children under 5 years

of age are stunted and underweight in the state at 45 percent and 48 percent respectively; where as 42 percent of women are either too thin or obese. there is high prevalence of anemia among women, children and adolescents in Jharkhand to the extent that nearly two thirds (65 percent) of women in the state are anemic. children of mothers who have anemia are much more likely to be anemic. thus, 70 percent of children of ages 6-59 months are anemic. Prevalence of anemia among adolescents between 15-19 years is 65 percent in Jharkhand. in the last one decade the prevalence of anemia among women, children and adolescents has not witnessed much change.

� High prevalence of anemia among pregnant women (63 percent).

� only 1 percent of women are severely anemic in the state.

� 69 percent of mothers in their last pregnancy received ifa but only 15 percent consumed the ifa for the recommended 100 days or more.

� 12 percent of pregnant women took an intestinal parasite drug (deworming) during pregnancy.

Pregnant Women

63

49

15

1

15

31.5

0

10

20

30

40

50

60

70

Mild

anem

ia

Preg

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49 y

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Mod

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Perc

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dex

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low

nor

mal

Mot

hers

who

cons

umed

IFA

for

100

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Figure 2: Status of anemia and IFA consumption during pregnancy

� over one third (35 percent) of the pregnant women in the state were provided with 360 calcium tablets during their pregnancy, whereas 20 percent lactating mother received 360 calcium tablets in 2017-18.

� 72 percent pregnant women received 180 ifa tablets, whereas less than one third (30 percent) of lactating mother were provided with 180 ifa tablets during pregnancy in 2017-18.

Source: NFHS 2015-16


Source: HMIS, Jharkhand

Section 2


Perc

ent

70

3237

16.3

53

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10

20

30

40

50

60

70

80

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Chi

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Figure 3: Status of anemia, IFA consumption and Vitamin A supplementation among children under 5

� Prevalence of anemia is very high at 65 percent, among adolescent girls aged 15-19 years.

� 35 percent of adolescent boys aged 15-19 years are anemic in the state.

Adolescents

� 69.9 percent of children aged 6-59 months are anemic in the state.

� 1 percent children under five are severely anemic. 68.9 percent children are suffering from mild to moderate anemia.

� only 6.3 percent were provided with pediatric ifa syrup.

� nearly half of the children under 5 years of age in the state received Vitamin a supplementation in the past six months of the nfHS survey.

� out of children who were suffering from diarrhoea, only 57 percent were taken to the health facility, of those only 45 percent were given orS and 19 percent children were given Zinc.

Children under 5 years of age




5

the findings are limited since published data is unavailable for the following indicators:

� Percentage of pregnant women who consumed 360 tablets of calcium during their last pregnancy.

� Percentage of lactating mothers who consumed 360 tablets of calcium during their last pregnancy.

� Percentage of lactating mothers who consumed 180 ifa tablets during their last pregnancy.

� Percentage of children under 6-59 months who received ifa six months prior to the survey.

� Stock out rates of ifa red, ifa Syrup, ifa Pink, ifa Blue, calcium, Vitamin, Zinc and albendazole are not available.

� over one third (35 percent) of the school going children received four (4) ifa tablets.

Limitations of data

65

35

0

10

20

30

40

50

60

70

Adolescent girls of age 15-19 years who have anaemia

Adolescent boys of age 15-19 years who have anaemia

Perc

ent

Figure 4: Status of anemia among adolescent boys and girls

Source: WIFS 2017-18, Jharkhand


7

State action plan for Micronutrient SuppleMentation: the rationale

Government of india has launched a number of flagship programmes on health and nutrition. the investments made in public health over decades, have led to an improvement in the health and nutrition

outcome of mothers and children. the Government of Jharkhand through national flagship programmes like national Health Mission (nHM), integrated child Development Service (icDS), national nutrition Mission (Poshan abhiyan) and Swachh Bharat Mission (SBM) is committed to improve the health and nutrition status of women, children, and adolescents.

national Health Mission has the mandate of achieving high coverage and improving the quality of health and nutrition services under the rMncH+a programme. Micronutrients like ifa, calcium, Vitamin a and Zinc are critical for nutrition outcomes among women, children and adolescents.

recognizing the existing low coverage of micronutrients and for improving the services for health and nutrition outcomes, the nHM has taken the initiative to develop a State action Plan for micronutrient supplementation. the action plan is a step towards creating systematically planned actions related to micronutrient supplementation under the maternal health, child health and adolescent health objectives of rMncH+a 5 x 5 matrix.

Maternal iron and folic acid deficiencies are associated with neural tube defects, premature delivery, hemorrhage and under weight babies. (less than 2500 gm). iron deficiency in adolescent girls influences their entire life cycle. iron deficiency anemia can result in impaired physical growth, poor cognitive development, reduced physical fitness and work performance, and lower concentration in daily tasks. calcium deficiency increases the likelihood of pre-eclampsia, preterm birth, weak bone development of neonates, and neonatal mortality. intestinal infections of StH deplete body iron content, affect absorption of protein, fats, and nutrients and may lead to severe anemia, malnutrition, growth faltering, and impaired cognitive development of babies. Hence deworming is important for pregnant women, children and adolescents. lack of Vitamin a spearheads impaired physical growth, visual and reproductive functions, causing blindness and higher odds of diarrhoea and measles among children.

Consequences of poor micronutrient supplementation

Section 3

9

areaS of iMproveMent to achieve the laSt Mile delivery of MicronutrientS

the data for the micronutrients namely – ifa, calcium, and Vitamin a along with deworming (albendazole) reveals that there are gaps in supply and distribution of these drugs at the district and

levels below. the projection and estimation process for drugs are centralised and is done at the state level by the nodal departments for PiP, which is later shared with respective districts. this process can be made more participatory and decentralised by involving the district and block in estimating the requirement of all the drugs, based on population and coverage. the practice of indenting/raising demand varies between districts and blocks based on the knowledge level of the personnel. to streamline this process a set of guidelines can be provided to maintain uniformity and adequacy.

Districts have witnessed shortages of stock for ifa (especially ifa red), calcium and Vitamin a in the last few years. it is important to ensure regular reporting and audit of stock to minimise stock-out situations and wastage of any drug. instead of random distribution of drugs based on the availability at the state warehouse, the supply should focus more on need based distribution to meet the requirement and avoid wastage of any drug. in case of shortage of micronutrient drugs or delay in supply, local purchase is done at the district and block level as an exigency. time taken in local purchase of the drugs at the district level is one month and at the block level it usually takes six months. there is a need to institutionalise mechanism to avoid such delays. Strengthening centralised procurement of micronutrient drugs for the state will help in uninterrupted supply reducing stock-out rates. the facilities should also be oriented or sensitised to maintain a buffer stock of all drugs. Microplanning is a useful tool detailing out the processes, requirements, roles and responsibilities. its usage has been acknowledged during the bi-annual rounds of Vitamin a & nDD. therefore an effort should be made to formalise microplanning for all drugs to ensure availability and adequacy in distribution.

there is a need to strengthen the review and reporting structure for micronutrient drugs at all levels. the existing reporting structure at block and district levels does not include the stock situation and therefore there is no specific way in which the state and district may assess the stock situation. HMiS has an option for entry of stock, but the stock is not being entered at most of the facilities. use of e-aushadhi can be another way to strengthen the reporting system for stocks. there is also a need to strengthen the supportive supervision. the mechanism for supportive supervision exists but is not regular and reflective of stock situations.

Micronutrient drug specific training and capacity building of functionaries is another area that needs focus. Most functionaries are well informed about the dosage of albendazole and Vitamin a for the drive and routine but less informed about ifa and calcium with recent guidelines. training sessions before drives and campaigns are regular, but not as a routine process for all four drugs. tools like job aids and posters can be useful for educating and updating the functionaries on the dosage and frequency of administration of each drug.

Section 4


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11

State action plan for Micronutrient SuppleMentation

Jharkhand state takes a result-oriented approach towards micronutrient distribution such that it increases the coverage of micronutrient drugs and the state’s health personnel are capacitated and motivated to ensure last mile delivery of these drugs.

5.1 Importance of Micronutrients

IFA Red, Calcium Tablets and Albendazole

anemia in pregnancy is associated with adverse outcome in post-partum haemorrhage leading to maternal deaths, neural tube defects, low birth-weight, premature births, still-births and maternal deaths. other nutritional deficiencies besides iron, such as vitamin B12, folate and Vitamin a can cause anemia, although the magnitude of their contribution is unclear. infectious diseases like malaria, helminth infections, tuberculosis and hemoglobinopathies are other important contributory causes to the high prevalence of iron deficiency anemia (WHo and unicef, 2004).

iron and folic acid supplementation along with diverse dietary practices and infection control during pregnancy and lactation are essential intervention. routine deworming through albendazole during the second trimester of pregnancy is essential to prevent infections from Soil transmitted Helminth. calcium supplementation in pregnancy reduces the incidence of pre-eclampsia and other hypertensive disorders in pregnancy.

Micronutrients for Pregnant Women and Lactating Mothers

IFA Pink, Iron Syrup, Vitamin A and Albendazole

Vitamin a supplementation in children 6-59 months of age living in developing countries is associated with a reduced risk of all cause mortality and a reduced incidence of diarrhoea. Vitamin a supplementation may improve gut integrity and therefore decrease the severity of some diarrhoeal episodes. lack of Vitamin a spearheads impaired physical growth, visual and reproductive functions, causing blindness and higher odds of diarrhoea and measles among children.

the manifestation of anemia is seen through symptoms like fatigue, weakness, dizziness and drowsiness to impaired cognitive development of children and increased morbidity. there are many causes of anemia, out of which iron deficiency accounts for about 50 percent of anemia in school children and 80 percent in children 2-5 years of age (unicef and WHo Joint statement 2001). iron and folic acid supplementation along with diverse dietary practices among children above 6 months of age and Soil transmitted Helminth infection control through deworming by albendazole are essential interventions.

Micronutrients for Infants and Children 6 months to 10 years

Section 5


IFA Blue and Albendazole

During adolescence, iron deficiency anemia can result in impaired physical growth, poor cognitive

development, reduced physical fitness and work performance, and lower concentration on daily

tasks. iron deficiency in adolescent girls influences their entire life cycle. anemic girls have lower

prepregnancy stores of iron and pregnancy is too short a period to build iron stores to meet the

requirements of the growing foetus. anemic adolescent girls have a higher risk of preterm delivery

and having babies with low birth-weight. regular consumption of iron folic acid supplements along

with a diet rich in micronutrients is essential for prevention of iron deficiency anemia in adolescent

girls and boys.

Micronutrients for Adolescents (10-19 years)

5.2 Objective of the State Action Plan � Strengthen the missed opportunities under rMncH+a by increasing supply and coverage of

micronutrient drugs and ensuring convergence across all levels.

� Strengthen the capacity of the programme managers and supervisors in estimating annual requirements and microplanning, procurement and distribution, monitoring and reporting, performance review.

Framework for State Action Plan(IFA, Calcium, Vitamin A and Albendazole)

STRENGTHENMISSED

OPPORTUNITIES IN NUTRITION

UNDERRMNCH+A

STATE LEVELNHM, SNM, ICDS, Adolescent, Maternal, Child Health, Community Health, Procurement Cell, Data Cell, Development Partners

DISTRICT LEVELDC,CS, ACMO, DRCHO, DSWO, DEO, DPM, DAM, DDM, Store in-charge

BLOCK LEVELMOIC, MO, CDPO, BEO, BPM, BDM, Store in-charge

COMMUNITY LEVELANM, AWW, Sahiya

Con

verg

ence

& P

artn

ersh

ips

ANNUAL REQUIRMENT& MICROPLANNING

PROCUREMENT & DISTRIBUTION

MONITORING &SUPERVISION

PERFORMANCEREVIEW

CAPACITY BUILDING

Increase in Coverage of

Micronutrients

among adolescent,

pregnantwomen,lactating

mother and children

Figure 6: Framework for State Action Plan

13

THE FIVE STEP PROCESS

1 Estimating Annual Requirement and Microplanning

2 Procurement and Distribution

3 Monitoring and Supervision

4 Performance Review

5 Capacity Building

Convergence among nHM, icDS and education is cross sectional across all these steps, especially distribution, reporting, performance review and capacity building.

5.3 Purpose of State Action Plan

5.4 User of the State Action Plan

Purpose of the State Action Plan is to guide planning, monitoring, supervision, reporting and

review of the performance of all micronutrients under the rMncH+a programme. the plan

will enable the state to be result oriented so as to deliver an uninterrupted supply and high

coverage of micronutrients for all women, children and adolescents in the state.

Purpose

User of the State Action Plan will be the State, District and Block level programme managers,

medical officers, store in-charges and supervisors working in nHM, icDS and education

department to systematically plan, implement, monitor, report and review the performance

of micronutrients drugs supply and coverage in the state.

User

5.5 Action Plan for Micronutrients

With reference to the 5 x 5 matrix of rMncH+a, this action plan is arching over three arms of the matrix i.e. Maternal Health, child Health and adolescent Health, each of which has specific requirements of micronutrient drugs that need to be distributed.


Step 1

Output

availability of microplans for ifa red, calcium and albendazole for pregnant women and lactating mothers; ifa Pink, iron Syrup, Vitamin a and albendazole for children; and ifa Blue and albendazole for adolescents at Districts, cHcs, aPHcs and HScs round the year.

WHAT HOW WHERE WHO

Development of annual projection and microplan templates for ifa red, ifa Blue, ifa Pink, ifa Syrup, calcium and albendazole for routine distribution.

[Vitamin A microplan template already exists as a part of RI microplan and bi-annual microplan]

Maternal Health cell, child Health cell and adolescent Health cell with support from the Development Partners will develop one microplan template, approve and share with districts.

[The RI microplan template may be referred]

Stat

e le

vel

Mission Director, Director-in-chief, Maternal Health, child Health and adolescent Health cell and Development Partners

Sharing of the microplan template with all districts.

Microplan templates with instructions will be sent to all civil Surgeons and DPMs of respective districts. St

ate

leve

l Mission Director, Director-in-chief

orientation of Mos, Moics, DPMu, BPMu and anMs on the annual projection and developing microplan.

orientation of Beos & nodal teachers for school children and cDPos and lS for out of school children on developing microplan for ifa Blue and albendazole.

civil Surgeon will nominate nodal officers (acMo/DrcHo) at district level and cHcs (Moic) to coordinate between Health, icDS and education and ensure the orientation programme, annual projection and microplanning exercise.

to complete the annual projection and microplan exercise within stipulated time, the nodal officer will ensure participation of Beo, nodal teachers, cDPo, lS etc to provide target populations of school children and out of school children.

Dis

tric

t le

vel,

Blo

ck l

evel

civil Surgeon, acMo, DrcHo, DPMu, Moic, BPMu, Beo and cDPo

completion of annual projection and microplanning at blocks and districts by January-february every year.

cHc will compile the annual projection and microplan prepared by HSc and aPHc.

cHc will prepare the microplan for the school and icDS for supply of ifa (Blue & Pink) and albendazole and submit to the respective districts.

Blo

ck a

nd

Dis

tric

t le

vel

civil Surgeon, acMo, DrcHo, Deo, DSWo, Moic, Beo, cDPo, BPM, DPM, DDM, and BDM

eStiMating annual reQuireMent and Microplaning

15

WHAT HOW WHERE WHO

Key Performance Indicators

1. number of Health Sub-centres, additional PHcs, community Health centres and District Health offices which has microplans available for all micronutrient drugs.

2. number of HScs and cHcs which has updated lists of pregnant women, lactating mothers, infants and children.

Refer:

annexure i: formula for calculating requirement of micronutrient drugs.annexure ii: How to distribute micronutrient drugs to beneficiaries.

Districts and cHcs will review the microplans and finalise by March each year.

[All the facilities should have their respective microplan for micronutrient drugs]

Districts and Blocks will ensure quality of the annual projection and microplans by cross checking with the census population and identify the left outs.

[Denominators need to be checked with census population]

Blo

ck a

nd

Dis

tric

t le

vel

civil Surgeon, acMo, DrcHo, Moic, BPM, DPM, DDM, and BDM


Output

availability of the ifa red, ifa Pink, ifa Blue, ifa Syrup, calcium, Vitamin a and albendazole at the facilities and VHnDs round the year.

annual projection for estimating requirements of ifa red, ifa Pink, ifa Blue, ifa Syrup, calcium, Vitamin a and albendazole.

[Refer Annexure I: Formula for calculating requirement of micronutrient drugs]

[Annual requirement of digital haemoglobinometer as per Anemia Mukt Bharat Guideline specification needs to be done]

Maternal Health, child Health and adolescent Health cell will conduct annual projection of respective micronutrient drugs, based on population with support from Development Partners. this exercise will be completed during the months of December-January before PiP.

Stat

e le

vel

Mission Director, Director-in-chief, Maternal Health, child Health and adolescent Health cell

Budgetary allocation for micronutrient drugs and digital haemoglobinometer in the PiP.

Maternal Health, child Health and adolescent Health cell will propose the annual requirement and budget in the PiP for approval. St

ate

leve

l Mission Director, Director-in-chief, Maternal Health, child Health and adolescent Health cell

Districts and Blocks will ensure enough budgetary provision for all micronutrients in the BHaP and DHaP based on microplan and projection.

Dis

tric

t le

vel,

Blo

ck l

evel civil Surgeon, acMo,

DrcHo, Moic, DPMu and BPMu

requisition to JMHiDPcl for annual procurement of these micronutrient drugs

Maternal Health, child Health and adolescent Health cell will send the approved requisition to JMHiDPcl based on annual projection and approved budget for annual procurement. St

ate

leve

l

Mission Director, Director finance, Maternal Health, child Health, adolescent Health cell, Procurement cell, JMHiDPcl

WHAT HOW WHERE WHO

Step 2 procureMent and diStribution

17

annual procurement of the listed micronutrient drugs.

JMHiDPcl will initiate central procurement of the micronutrient drugs by finalising rate contract with the supplier through open tendering normally for a period of one year. Purchase order shall be issued to the supplier based on annual projection and stock in hand of the micronutrient drugs based on district wise supply and distribution plan.

Stat

e le

vel

Mission Director/Managing Director (JMHiDPcl), Director finance, JMHiDPcl Procurement cell, Maternal Health, child Health and adoloscent Health cell.

JMHiDPcl will expedite the selection of the supplier, rate finalisation, placement of order and follow up on supply for all micronutrient drugs. St

ate

leve

l Mission Director, Director-in-chief, Procurement cell Director finance and JMHiDPcl

Proper warehousing facilities at the district and cHcs.

District and cHcs will provide proper warehousing facilities adequate space, environment, appropriate light and room temperature, accessibility, security, etc., for micronutrient drugs storage.

Dis

tric

t le

vel

civil Surgeon, acMo, DrcHo, Moics, store in-charge

ensure availability of updated stock records for micronutrient drugs at Districts, cHcs and HScs.

Stock records of all micronutrient drugs will be maintained in stock register at all the facilities. in addition to stock register, District and cHc will update stock position of all micronutrient drugs in e-aushadi and HMiS every month to inform the state.

Dis

tric

t, c

Hc

s,

HSc

, aPH

c

civil Surgeon, acMo, DrcHo, Moics, DPMu, BPMu, Store in-charges and anMs

ensure timely distribution of all micronutrient drugs to the last beneficiary.

[Refer Annexure II: How to distribute micronutrient drugs to beneficiaries]

annual indenting of stock requirement of all micronutrient drugs from districts to state.

Dis

tric

t le

vel,

Blo

ck l

evel

civil Surgeon, acMo, DrcHo, Moics, DPMu, BPMu and store in-charge

Bi-annually supply of stocks from the State Warehouse / Supplier to the districts, based on annual indent.

Stat

e le

vel JMHiDPcl, State

Warehouse, Maternal Health, child Health and adolescent Health cell

District store will distribute micronutrient drugs from district stores to cHcs bi-annually.

Dis

tric

t le

vel District Store

in-charge and DPMu

WHAT HOW WHERE WHO


cHc stores will distribute the micronutrient drugs to the HScs quarterly. this should be done during the anM monthly meeting at cHcs. B

lock

lev

el cHc Store in-charge

and BPMu

anM will distribute the ifa red, calcium and albendazole as per the distribution protocol during the anc and Pnc at VHnD and HSc, based on the due list. V

illag

e le

vel anM, Sahiya, aWW

anM will distribute ifa syrup bottle to the mothers/ caregivers of 6-59 months children at VHnD and HSc, based on the line listing of under 5 years children [Routine Immunization].

Vill

age

leve

l

anM, Sahiya, aWW

anM will administer the Vitamin a dosage to the 9-59 months old children, based on the ri microplan and biannual round microplan V

illag

e le

vel anM, Sahiya, aWW

Supply and Distribution from CHCs to BEO and CDPO offices under WIFS

District and Block level coordination between Health, education and icDS for ifa Blue under WifS programme and albendazole during nDD.

civil Surgeon will nominate nodal officers (acMo/DrcHo) at District and cHcs (Moic) to facilitate the supply and distribution of ifa and albendazole from cHcs to cDPo and Beo offices. D

istr

ict

leve

l and

B

lock

lev

el

civil Surgeon, acMo, DrcHo, DPM, Moic and BPM

assessing the annual requirement of ifa Blue and albendazole for boys and girls of 6-12 standard in school.

acMo/DrcHo will coordinate with the District education Department and facilitate the process of estimating the requirement of ifa Blue and albendazole for the entire district.

Dis

tric

t le

vel

acMo/DrcHo, civil Surgeon, DPM and Deo

Refer:

annexure i: formula for calculating requirement of micronutrient drugs.annexure ii: How to distribute micronutrient drugs to beneficiaries.

WHAT HOW WHERE WHO

WHAT HOW WHERE WHO

19

assessing the annual requirement of ifa Blue for out of school adolescent girls.

assessing the annual request of albendazole for out of school adolescent boys and girls.

acMo/DrcHo will coordinate with the DSWo and facilitate the process of estimating the annual requirement of ifa Blue and albendazole for the entire district. D

istr

ict

leve

l acMo/DrcHo, civil Surgeon, DPM and DSWo

Supply of ifa Blue and albendazole from the cHc to the Beo and cDPo office.

the nodal officer (Moic) at the cHc will facilitate and ensure quarterly supply of stock to the respective Beo and cDPo office, based on the annual estimate and microplan.

Blo

ck l

evel

nodal officer, Moic, BPM, Beo and cDPo

Distribution of ifa Blue in School. nodal teacher of the school will supervise and ensure weekly administration of ifa for boys and girls. Bl

ock

leve

l Beo, nodal teacher

Distribution of albendazole in school. nodal teacher of the school will supervise and ensure administration of albendazole for boys and girls biannually during nDD rounds. B

lock

lev

el Beo, nodal teacher

Distribution of ifa Blue to out of school adolescent girls.

aWW will administer ifa Blue to out of school adolescent girls at aWc on every Wednesday and Saturday of the week.

Vill

age

leve

l aWW

follow up on the distribution of ifa Blue to the target groups and reporting back from education department and icDS.

the nodal officer of the respective cHcs will attend the Block level Monthly coordination Meeting (BlMc) and ensure collection of report including supply and distribution from education and icDS.

Blo

ck l

evel

Moic, BPM, Beo, cDPo


1. number of facilities with no stock-out of ifa red, ifa Pink, ifa Blue, ifa Syrup, calcium, Vitamin a and albendazole at state, district and block levels.

2. increase in the coverage of ifa red, ifa Pink, ifa Blue, ifa Syrup, calcium, Vitamin a and albendazole in the state. [indicators as mentioned in HMiS]

WHAT HOW WHERE WHO


Output

1. Supportive supervision using the facility and community assessment checklist for nHM in aspirational districts.

2. Monthly coverage and stock data entry of ifa red, ifa Pink, ifa Blue, ifa Syrup, calcium, Vitamin a and albendazole in HMiS.

3. Monthly stock update of ifa red, ifa Pink, ifa Blue, ifa Syrup, calcium, Vitamin a and albendazole in e-aushadhi.

Supportive supervision using the facility and community assessment checklist of aspirational District operational Guidelines for improving Health and nutrition Status.

Maternal Health, child Health and adolescent Health cell with support from Development Partners train the nodal officers, programme managers at State, District and Block level on the assessment checklist.

Stat

e le

vel a

nd

Dis

tric

t le

vel

Mission Director, Maternal Health, child Health and adolescent Health cell and Development Partners.

Supportive supervision visits to districts.

at least two supportive supervision visits per month to poor-performing districts to be undertaken by Maternal Health, child Health, adolescent Health cell and SPMu with support from Development Partners. St

ate

leve

l

nodal officer and consultants from Maternal Health, child Health, adolescent Health cell, SPMu team, Medical colleges (PSM dept) and Development Partners.

District monitoring visit to facilities and VHnD.

District team conducts at least one visit per week to facility and VHnD using the facility and community assessment checklist.

Dis

tric

t le

vel acMo/DrcHo and

DPMu

Block monitoring visit to facilities and VHnD.

Moic and BPM should conduct at least two visits per week to the HScs and VHnD using facility and community assessment checklist. B

lock

lev

el Moic and BPM

WHAT HOW WHERE WHO

Step 3 Monitoring and SuperviSion

21

HMiS reporting on micronutrient drugs.

Districts and cHcs will ensure entry of coverage and stock updates of all micronutrient drugs in the HMiS every month.

Dis

tric

t le

vel,

Blo

ck l

evel

civil Surgeon, DPM, DDM, Moic, BPM, BDM and Store in-charges

nodal officer at District and cHcs will follow up with education Department and icDS every month and ensure reporting on ifa Pink, ifa Blue and albendazole as per WifS reporting format.

Dis

tric

t le

vel,

Blo

ck l

evel

civil Surgeon, DPM, DDM, Moic, BPM, BDM and Store in-charges

Stock data entry in e-aushadhi every month.

Store in-charges, DPM and BPM will ensure updated stock register in the facilities and entry of stock for all micronutrient drugs in the e-aushadhi. D

istr

ict

leve

l, B

lock

lev

el civil Surgeon, DPM,

DDM, Moic, BPM, BDM and Store in-charge

Submission of coverage and stock report by anM.

anM will submit the coverage and stock status report of all micronutrient drugs to the Moic and BPM during monthly meeting. B

lock

lev

el anM, BPM and Moic


1. number of districts and cHcs timely reporting on coverage and stock availability of micronutrient drugs in HMiS.

2. number of districts and cHcs timely reporting on stock entries of micronutrient drugs in e-aushadhi.

3. number of monitoring and supervision visits conducted as per plan at facilities and VHnD.

Refer:

annexure i: formula for calculating requirement of micronutrient drugs.

WHAT HOW WHERE WHO


Output

1. all nutrition indicators including micronutrients incorporated and reviewed at rMncH+a review meetings in the state.

2. all nutrition indicators including micronutrients incorporated and reviewed during District convergence Meeting chaired by Deputy commissioners.

institutionalise review mechanism for nutrition indicators at State nHM.

review of nutrition dashboard (including micronutrients indicators) at the rMncH+a quarterly review meetings at State nHM.

[Refer: Annexure- IV]. Stat

e le

vel

Secretary, Mission Director, Director-in-chief, Directors and consultants from MH, cH, aH, SPMu, State Data cell, Medical colleges (PSM), Procurement cell and Development Partners

institutionalise review mechanism for nutrition indicators at Deputy commissioner convergence meetings.

review of nutrition indicators (including micronutrient indicators) at the District convergence Meeting chaired by Deputy commissioners. D

istr

ict

leve

l Deputy commissioner, civil Surgeon, DSWo, Deo, DPMu-nHM and Development Partners

institutionalise review mechanism for nutrition indicators at civil Surgeon monthly meetings.

integrate review of nutrition indicators during the monthly meetings at civil Surgeons office based on HMiS and e-aushadhi data. D

istr

ict

leve

l civil Surgeon, acMo, DrcHo, DPMu, Store in-charges

institutionalise review mechanism for nutrition indicators at Moic monthly meetings.

integrate review of nutrition indicators during the cHc monthly meetings based on HMiS and e-aushadhi data.

Blo

ck l

evel

s Moic, BPMu and anMs and Store in-charges

Key Performance Indicators1. number of performance review meetings of nutrition indicators held at State nHM.

2. number of performance review meetings of nutrition indicators held at the Deputy commissioner’s office.

3. number of Districts nHM and cHcs reviewed performance of nutrition indicators at their monthly meetings, respectively.

WHAT HOW WHERE WHO

Step 4 perforMance revieW

23

Output

1. all health personnel, managers and supervisors in nHM, icDS and education Department are trained on micronutrients, guidelines and action plans for micronutrients supplementation and reporting.

2. all store-keepers, store in-charges and data managers at state, districts and blocks are trained on e-aushadhi, stock recording and reporting.

Development of content for training and orientation of health personnel based on relevant guidelines.

training cell in collaboration with the Maternal Health, child Health and adolescent Health cells will develop training content and job-aids on micronutrient drugs for the health personnel.

Stat

e le

vel

training cell, Maternal Health, child Health and adolescent Health cells and Development Partners

training of existing and new master trainers on anemia Mukt Bharat and other micronutrients.

Master trainers from the state and districts will be identified and trained on micronutrients.

Stat

e le

vel,

Dis

tric

t le

vel training cell, Maternal Health, child Health and adolescent Health cell, Medical college (PSM) and Development Partners

orientation of key personnel from Health, icDS and education Department.

one day orientation of all Moics, Mo DPMu, BPMu, Store in-charges/Pharmacists in the district on anemia Mukt Bharat and other micronutrients. D

istr

ict

leve

l civil Surgeon and DPM

one day orientation of all Sn, lHV, MPW, anM, Sahiya, aWW, lS, nodal School teachers on anemia Mukt Bharat and other micronutrients. B

lock

lev

el Moic and BPM

training of Store-keepers, Store in-charges, Data Managers etc. on e-aushadhi.

training of all store in-charges, DDMs and BDMs on e-aushadhi.

Stat

e le

vel,

Dis

tric

t le

vel,

Blo

ck l

evel

training cell, Procurement cell and JMHiDPcl

WHAT HOW WHERE WHO

Step 5 capacity building



1. number of Districts, cHcs, aPHcs and HScs having nutrition related training materials and job-aids available.

2. number of master trainers trained in the State and Districts on Maternal nutrition, infant and Young child nutrition, anemia Mukt Bharat, adolescent nutrition including micronutrients.

3. number of health personnel, managers and supervisors from Health, icDS and education oriented on nutrition including micronutrients across the state.

4. number of store in-charges, DDM and BDM trained on e-aushadhi.

convergence among national Health Mission (nHM), integrated child Development Services (icDS) and education Department is essential to increase the coverage of micronutrient drugs to the last beneficiary in the state. the nature of convergence is cross-sectional across the five action steps. the line listing, annual projection and microplan exercise done by anM is primarily in consultation with the aWW and Sahiya of the area. nHM and icDS works closely to improve the quality of health and nutrition services at the VHnD. Similarly, the nHM, education Department and icDS at the district and block level should work in partnership under the WifS programme to ensure maximum coverage of the ifa and albendazole among the adolescent girls and boys. these three departments should work closely to ensure timely reporting under WifS program and nDD. the nHM should provide training content on micronutrients to master trainers to train the school teachers and icDS staff at the block level. the district level convergence meeting, chaired by the Deputy commissioner is the platform where all the departments should come together and review performance of the nutrition indicators (including micronutrients) among various other district performance indicators.

Convergence

25

1

2

3

4

5

Four ANC check up are essential for pregnant women.

One extra meal daily during pregnancy is recommended.

Weight gain during pregnancy should be around 9-11 kg.

Women should eat at least one food from each group daily along with rice and roti:

Recommended dose of micronutrient � 1 tablet of Folic Acid daily during first trimester. � 180 IFA tablets from 2nd trimester during pregnancy. � Additional 180 IFA tablets during lactation. � 360 Calcium tablets from 2nd trimester during pregnancy. � Additional 360 Calcium tablets during lactation. � One Albendazole tablet for deworming preferably in second trimester of

pregnancy.

pregnant WoMen and lactating MotherS

Things to Remember

Dark green leafy vegetables

egg, fish and meat

cook food with iodised salt

orange/yellow vegetables and fruits

Daal, nuts or other legumes

oil/ghee in the food for energy requirement

Milk, curd, paneer and any milk product

Credit: Alive and Thrive

27

Do’s and Don’ts for IFA and Calcium tablets

� Consume one IFA tablet daily from second trimester, preferably at night before going to bed, with water or lemon water.

� Don’t consume IFA tablet with tea, coffee or milk.

� Don’t consume tea or coffee one hour before or after IFA consumption.

� Don’t consume IFA tablets and calcium tablets together.

� Consume calcium tablet one after breakfast and one after lunch.

1 hour


29

Update due list of pregnant women in your catchment area monthly.

Conduct Haemoglobin test in every ANC to detect anemia level.

Distribute 180 IFA tablets to every non-anemic pregnant women.

Administer one tablet of Albendazole to every pregnant women preferably during the second trimester through Direct Observation Treatments (DOTS).

Refer severely anemic pregnant women to FRU/DH for treatment using Parental Iron by Medical Officer.

Patients with sickle cell diseases should not be administered with this Parental Iron.

Sahiya should distribute the IFA, Calcium and Albendazole tablets to those pregnant women and lactating mothers who don’t come for ANC or have delivered at home.

Distribute additional 180 IFA tablets during lactation.

Distribute double dose of IFA tablets (360 tablets) to mild or moderate anemic pregnant women.

1

2

3

4

5

6

7

8

9

10

Counsel on diet, weight gain and consumption of IFA, Calcium and Albendazole.

SERVICES FOR PREgNANT WOMEN AND LACTATINg MOTHERS

frontline health WorkerS – anM & Sahiya

Things to Do

31

1

2

4

9

6

7

8

Initiate breastfeeding within one hour of delivery or as early as possible.

No prelacteal to be given to the newborn.

Introduce complementary food immediately after the completion of 6 months.

Exclusive breastfeeding of infant till the age of 6 months, not even a drop of water to be given.

To avoid contamination, wash hands with soap before handling the food and feeding the child.

Always keep infant and young children away from dust, dirt, soil, flies, mosquitoes and animals.

Administer 1 ml IFA syrup bi-weekly, using auto-dispenser of the bottle.

5

Children of 6-24 months should include at least 4 food groups in their daily diet in addition to breastfeeding and should atleast 3-4 meals per day:

Grains, roots and tubers

Dairy products (milk, yogurt, cheese)

Vitamin a rich fruits and vegetables

other fruits and vegetables

legumes and nuts

egg, flesh foods (meat, fish, poultry and liver/organ meats)

Administer Albendazole from one year of age and continue every six months during NDD rounds to deworm the child.

Do’s and Don’ts for IFA Syrups

� ifa syrup should not be administered in an empty stomach.

� iron should be withheld in case of acute illness fever, acute diarrhoea, pneumonia etc.

� ifa should not be administered to SaM children initially and require doctor’s consultation.

3


Mother of infant and young child

Things to Remember

33

Don’t administer IFA syrup to SAM children until the child has gained a good appetite and body weight.

Demonstrate mothers on correct position, attachment and expression of breastmilk.

Follow up and motivate mothers on exclusive breastfeeding for first six months.

Demonstrate the first dose of the IFA syrup to the mothers before handing over the bottle.

ANM or Sahiya should administer Vitamin A using standard spoon provided with the bottles.

Use Vitamin A bottles within 28 days from the date of opening the lid.

Identified SAM children should be immediately sent to the nearest Malnutrition Treatment Centre (MTC) for treatment.

Demonstrate mothers on complementary feeding techniques on completion of six months.

Counsel mothers on handwashing with soap before handling complementary food.

1

3

4

5

6

7

8

9

1011

Update due list of children under two years of age in your catchment area monthly.

SERVICES FOR MOTHERS OF CHILDREN UNDER TWO

2

Assist the mother to initiate breastfeeding within one hour of the birth or as early as possible.

frontline health WorkerS – anM & Sahiya

Things to Do

35

formula for calculating requirement of Micronutrient drugs

Formula for calculating requirement of IFA Red, Calcium and Albendazole for pregnant women and lactating mothers

MICRONUTRIENTS CALCULATION FOR ESTIMATINg PROCUREMENT AND SUPPLy

Iron and Folic Acid Red(Half number of PW as per HMiS x 180 tablets) + (half number of PW as per HMiS x 360 tablets) + (number of live births as per HMiS x 180 tablets) + additional 10 percent buffer stock

Calcium tablets (number of pregnant women as per HMiS x 360 tablets) + (number of live births as per HMiS x 360 tablets)

Albendazole tablets estimated number of albendazole tablets (400 mg) = (1 x number of estimated pregnancies as per HMiS) + additional 10 percent as buffer stock*

* an additional 10 percent of total requirement is to be added as buffer (for wastage and spoilage).

Formula for calculating requirement of IFA Red and Albendazole for women of reproductive age (non-pregnant, non-lactating) under Mission Parivar Vikas yojana


Iron and Folic Acid Redestimated iron and folic acid tablet supply = (number of eligible couples registered under Mission Parivar Vikas Yojana x 52 tablets) + additional 10 percent as buffer stock*

Albendazole tabletsestimated number of albendazole tablets (400 mg) for one deworming round = (1 x number of eligible couples registered under Mission Parivar Vikas Yojana) + additional 10 percent as buffer stock


practice Sheet name of the District: _______________________________

name of the facility: ________________________________

financial Year: ____________________________________

Requirement of Iron and Folic Acid Red for Pregnant Women and Lactating Mothers

Half number of PW as per HMiS 180 tablets

x =

Half number of PW as per HMiS 360 tablets

x =

number of live births as per HMiS 180 tablets

x =

Total

Total 10% Buffer Stock Total Requirement

+ =

Requirement of Calcium tablets for Pregnant Women and Lactating Mothers

number of PW as per HMiS 360 tablets

x =

number of live births as per HMiS 360 tablets

x

=

Total Requirement =

Requirement of Albendazole tablets Pregnant Women

number of estimated pregnancies as per HMiS 1 tablet

x =

additional 10% as Buffer stock =

Total Requirement =

Requirement of IFA Red for women of reproductive age (non-pregnant, non-lactating)

number of eligible couples registered under mission Parivar Vikas Yojana 52 tablets

x =

10% Buffer stock =

Total Requirement =

Requirement of Albendazole tablets for women of reproductive age (non-pregnant, non-lactating)

number of eligible couples registered under Mission Parivar Vikas Yojana 1 tablet

x =

10% as Buffer stock =

Total Requirement =

+

+

+

+

+

+

Annexure 1

Formula for calculating requirement of IFA Pink, IFA Syrup, Vitamin A and Albendazole for children


Iron Syrup (6-59 months)

estimated iron and folic acid syrup bottle (of 50 ml each) supply = 2 x number of children 6-59 months + additional 10 percent as buffer stock + additional as 10 percent buffer stock*

IFA Tablets Pink (5-10 years)

[In School]

estimated iron and folic acid tablet supply = (number of children aged 5-10 years registered in schools x 52 tablets) + (52 tablets/teacher/year) + additional 10 percent as buffer stock

IFA Tablets Pink (5-10 years)

[Out of School]

estimated iron and folic acid tablet supply = (number of children aged 5-10 years registered with icDS x 52 tablets) + (52 tablets/year for each aWW + 52 tablets/ year for aSHa) + additional 10 percent as buffer stock

Vitamin A

estimated Vitamin a solution (of 100 ml each)

(number of children 9 months to 5 years / 50 + 10 percent as buffer stock)*

50 children will be supplemented with Vitamin a from one bottle of 100 ml




financial Year: ____________________________________

Requirement of IFA Syrup, for children (6-59 months)

number of children 6-59 Months 2 Bottles

x =

10% Buffer stock =

Total Bottles Required =

+

Requirement of Vitamin A for children (9 months - 5 years)

number of children 9 Months to 5 years

÷ 50 =

10% Buffer stock =

Total Requirement =

+

Requirement of IFA Pink tablets for children (5-10 years) in School

number of children aged 5-10 years registered in school 52 tablets

x =

52 tablets/teacher/year =

10% as Buffer stock =

Total Requirement =

+

+

Requirement of IFA Pink tablets for children (5-10 years) Out of School

number of children aged 5-10 years registered with icDS 52 tablets

x =

52 tablets/year for each aWW =

52 tablets/year for Sahiya =

10% Buffer stock =

Total Requirement =

+

+

+

+

37

Formula for calculating requirement of IFA Blue for adolescents


Iron and Folic Acid Blue

[In school]

estimated iron and folic acid tablet supply = [52 x total number of adolescent (both girls and boys) in 10-19 years] + [52 tablets/per teacher/year] + additional 10 percent as buffer stock

Iron and Folic Acid Blue

[Out of school]

estimated iron and folic acid tablet supply = (number of adolescent girls registered with icDS x 52 tablets) + (52 tablets/year for each aWW + 52 tablets/year for aSHa) + additional 10 percent as buffer stock*

Formula for calculating requirement of Albendazole for children and adolescents

DEWORMINg DRUgS CALCULATION FOR ESTIMATINg PROCUREMENT AND SUPPLy

Albendazole tablets estimation number of albendazole tablets (400 mg) for one deworming round

Children 1-19 years

(1 x number of adolescent in the age group 1-19 enrolled/registered in government and government-aided schools + (1 x number of children in the age group 1-19 years unregistered and out of school children in Anganwadi centres) + (1 x number of children in the age group 6-19 years enrolled in private schools) ** + additional 10% as buffer stock*

* an additional 10 percent of total requirement is to be added as buffer (for wastage and spoilage)

* an additional 10% of total requirement is to be added as buffer (for wastage and spoilage)**In states where NDD is also being implemented in private schools



financial Year: ____________________________________

Requirement of IFA Blue for Adolescents

IN SCHOOL

number of adolescents (both girls & Boys) in 10-19 years 52 tablets

x =

52 tablets/per teacher/year =

10% Buffer stock =

Total Requirement =

OUT OF SCHOOL

number of adolescent girls registered with icDS 52 tablets

x =

52 tablets/year for each aWW =

52 tablets/year for each Sahiya =

10% Buffer Stock =

Total Requirement =

+

Requirement of Albendazole for children and adolescents

number of children in the age group 1-19 years enrolled/ registered in government and government-aided School 1 tablet

x =

number of children in the age group 1-19 years unregistered and out of school children in Anganwadi centres 1 tablet

x =

number of children in the age group 6-19 years enrolled in private school 1 tablet

x =

10% Buffer Stock =

Total Requirement =

+

+

+

+

+

+

+

39

41

1. Pregnant Women and Lactating Mothers

Iron and Folic Acid Red tablets for pregnant women and lactating mothers

Target group When How many (Recommended dose)

By Whom

Where

Pregnant women

Second trimester 90 Tablets (60 mg elemental iron + 500 mcg folic acid) sugar-coated, red colour.

anM anc clinics including Pradhan Mantri Surakshit Matritva abhiyan (PMSMa), VHnD

third trimester 90 Tablets (60 mg elemental iron + 500 mcg folic acid) sugar-coated, red colour.

anM anc clinics including Pradhan Mantri Surakshit Matritva abhiyan (PMSMa), VHnD

Lactating mothers of 0-6 months child

after delivery

(at the time of Zero dose of polio for the infant)

90 Tablets(60 mg elemental iron + 500 mcg folic acid) sugar-coated, red colour.

anM labour room, Post-natal check-up, immunisation clinics, VHnD

at the time of DPt Dose 3 for the infant

90 Tablets(60 mg elemental iron + 500 mcg folic acid) sugar-coated, red colour.

anM immunisation clinics, VHnD

180

tab

lets

180

tab

lets

how to distribute Micronutrient drugs to the Beneficiaries

Annexure 2

Pregnant women detected with mild and moderate anemia is advised to have two tablets of iron and folic acid tablet (60 mg elemental iron and 500 mcg folic acid) daily, orally given by the health provider during the anc contact.

Parental iron (iV iron Sucrose or ferric carboxy Maltose (fcM) may be considered as the first line of management for pregnant women who are detected to be anemic late in pregnancy or in whom compliance is likely to be low (high chance of lost to follow-up).

Pregnant women detected with severe anemia will be treated using iV iron Sucrose/ferric carboxy Maltose (fcM) by the medical officer at PHc/cHc/fru/DH.

Refer:

anemia Mukt Bhart-operational Guidelines, table 8: anemia management protocol for pregnant women.


Calcium tablets for pregnant women and lactating mothers


By Whom Where

Pregnant women

Second trimester 180 Tablets(500 mg elemental calcium and 250 iu Vitamin D3)

anM anc clinics, VHnD

third trimester 180 Tablets(500 mg elemental calcium and 250 iu Vitamin D3)


Lactating mothers of 0-6 months child

after delivery

(at the time of Zero dose of polio for the infant)

180 Tablets(500 mg elemental calcium and 250 iu Vitamin D3)


at the time of DPt dose 3 for the infant

180 Tablets(500 mg elemental calcium and 250 iu Vitamin D3)


360

tab

lets

360

tab

lets

Albendazole (Deworming) tablets for pregnant women


By Whom

Where

Pregnant women

after first trimester (preferably during second trimester)

Single dose 400 mg iP of albendazole

(Direct observation treatment)


all women in the reproductive age group in the preconception period and upto the first trimester of the pregnancy is advised to have 400 mcg of folic acid tablets, daily, to reduce the incidence of neural tube defects in the foetus.

1 t

able

t

43

2. Women of Reproductive Age

Iron and Folic Acid Red tablets for women of reproductive age (non-pregnant, non-lactating)


By Whom Where

Women of reproductive age (non-pregnant, non-lactating) 20-24 years

20-24 years

eligible under Mission Parivar Vikas Yojana

1 iron and folic acid tablet, weekly

each tablet containing (60 mg elemental iron + 500 mcg folic acid) sugar-coated, red colour

anM immunization day/VHnD; Providing ifa tablet in nayi Pehal Kit

Vitamin A to children below 5 years of age


By Whom Where

Children less than 5 years

9 -12 months (along with measles vaccine in routine)

100,000 i.u

(1 ml or ½ spoon Vitamin a)

one Dose


12-59 months 200,000 i.u (2 ml or 1 spoon Vitamin a)

one dose every 6 months during ‘Jharkhand Matri-Sishu Swastha Poshan Maah’


3. Children

Albendazole (Deworming) tablets for women of reproductive age (non-pregnant, non-lactating)


By Whom Where

Women of reproductive age (non-pregnant, non-lactating) 20-24 years

20-24 years

eligible under Mission Parivar Vikas Yojana

Bi-annual dose of 400 mg albendazole (1 tablet)

anM Bi-annual

Deworming during nDD

52 t

able

ts


Iron and Folic Acid Syrup and IFA Pink tablet for children 6 months to 9 years of age


By Whom Where

Children age 6 months to 9 years

children 6-59 months of age

1 ml iron and folic acid syrup bi-weekly

[each ml of iron and folic acid syrup containing 20 mg elemental iron+100 mcg of folic acid]

Bottle [50 ml] to have an auto-dispenser and information leaflet as per MoHfW guidelines in the mono-carton]


children 5-9 years of age

Weekly, 1 iron and folic acid tablet

[each tablet containing 45 mg elemental iron + 400 mcg folic acid, sugar-coated, pink colour]


recommended dose for children age 6-59 months detected with mild and moderate anemia:

� 3 mg of iron/kg/day for 2 months � for children 6-12 months (6-10.9 kg): 1 ml ifa syrup, once a day � for children 1-3 years (11-14.9 kg): 1.5 ml ifa syrup, once a day � for children 1-5 years (15-19.9 kg): 2 ml ifa syrup, once a day

recommended dose for children age 6-59 months detected with severe anemia:

� refer urgently to District Hospital/first referral unit

recommended dose for children age 5-9 years with mild moderate anemia:

� 3 mg of iron/kg/day for 2 months

recommended dose for children age 6-59 months detected with severe anemia:

� refer urgently to District Hospital/first referral unit

Refer:

anemia Mukt Bharat – operational Guidelines, table 6: anemia management protocol for children.

45

Albendazole tablets for children 1 to 9 years of age


By Whom Where

Children 1 to 9 year


Bi-annual dose of 400 mg albendazole

½ tablet to children 12-24 months

anMs immunisation clinics, VHnD (Bi-annual nDD*)



1 tablet to children 24-59 months

anM, aWW

immunisation clinics, VHnD

(Bi-annual nDD*), aWc

children 5-9 years of age


1 tablet to children 5-9 years

anM, aWW

immunisation clinics, VHnD

(Bi-annual nDD*), aWc

[*excluding the areas which fall under lf (filariasis eradication programme) which has the protocol to administer albendazole to children]

IFA Blue supplementation for adolescent girls and boys


By Whom Where

School-going adolescent girls and boys (RKSK) (Class 6-12 standard)

every Wednesday 1 iron and folic acid tablet, weekly

[each tablet containing 60 mg elemental iron + 500 mcg folic acid], sugar-coated blue colour

nodal School teacher

School

Out of school adolescent girls (10-19 years of age)

every Wednesday 1 iron and folic acid tablet, weekly

[each tablet containing 60 mg elemental iron + 500 mcg folic acid], sugar-coated blue colour

aWW aWc

4. Adolescents


Albendazole to adolescent girls and boys


By Whom Where

School-going adolescent girls and boys (RKSK) (Class 6-12 Standard)

august and february during nDD rounds

Bi-annual dose 400 mg albendazole (1 tablet)

nodal School teacher

School

Out of school adolescent girls and boys (10-19 years of age)

august and february during nDD rounds

Bi-annual dose 400 mg albendazole (1 tablet)

aWW aWc

all school going adolescents 10-19 years in government/government-aded schools with mild and moderate anemia is recommended to have two ifa tablets (each with 60 mg elemental iron and 50 mcg folic acid), once daily, for 3 months, orally after meals.

Management of severe anemia in adolescents 10-19 years is to be done by the medical officer at fru/DH based on investigation and subsequent diagnosis.

Refer:

anemia Mukt Bharat – operational Guidelines, table 7: anemia management protocol for adolescents.

47

Maternal Health: IFA Red, Calcium and Albendazole

Sl. Micronutrient Indicators Source Frequency

1 Percentage of PW given 180 iron folic acid (ifa) tablets HMiS Monthly

2 Percentage of PW given 360 calcium tablets HMiS Monthly

3 Percentage of PW given one albendazole tablet after 1st trimester HMiS Monthly

4 Percentage of mothers provided with full course of 180 ifa tablets after delivery

HMiS Monthly

5 Mothers who consumed iron and folic acid for 100 days or more when they were pregnant*

nfHS 5 years

6 Percentage of mothers provided with 360 calcium tablets after delivery HMiS Monthly

7 Percentage of women of reproductive age (Wra) 20–24 years, provided albendazole (under Mission Parivar Vikas)

aMB Quarterly

8 Percentage of women of reproductive age (Wra) 20-24 years, provided 4 iron and folic acid (ifa) tablets (under Mission Parivar Vikas)

aMB Quarterly

9 Percentage of pregnant women having Hb level <11 (tested cases) HMiS Monthly

10 Percentage of pregnant women having Hb level <7 HMiS Monthly

11 Percentage of pregnant women having severe anemia (Hb level <7) treated

HMiS Monthly

12 Stock: albendazole 400 mg tablet HMiS Monthly

13 Stock: calcium tablets HMiS Monthly

14 Stock: ifa tablets red HMiS Monthly

* HH Survey not routine monitoring.

routine Monitoring indicators for Micronutrient drugs

Annexure 3


Child Health: IFA Pink, Iron Syrup, Vitamin A and Albendazole


1children aged 9-59 months who received a Vitamin a dose in last 6 months*

nfHS 5 Years

2 Percentage of child immunisation – Vitamin a dose – 1 HMiS Monthly



5Percentage of children (6-59 months) given 8-10 doses (1 ml) of ifa syrup (Bi-weekly)

HMiS Monthly

6 Percentage of children (12-59 months) given albendazole HMiS Monthly

7Percentage of children covered under WifS Junior (6-10 years) given 4-5 ifa tablets in schools

HMiS Monthly

8 Percentage of children (6-10 years) given albendazole in schools HMiS Monthly

9Percentage of out of school children (6-10 years) given 4-5 ifa tablets at Anganwadi centres

HMiS Monthly

10Percentage of out of school children (6-10 years) given albendazole at anganwadi centres

HMiS Monthly

11 Stock: ifa- Pink ( Junior 6-10 years) HMiS Monthly

12 Stock: ifa Syrup (Paediatric) HMiS Monthly

13 Stock: Vitamin a syrup HMiS Monthly

* HH Survey not routine monitoring.

49

Adolescents Health: IFA Blue and Albendazole


1Percentage of girls (6th -12th class) provided with 4 ifa tablets in schools

HMiS Monthly

2Percentage of boys (6th -12th class) provided with 4 ifa tablets in schools

HMiS Monthly

3Percentage of girls (6th -12th class) provided with albendazole in schools

HMiS Monthly

4Percentage of boys (6th -12th class) provided with albendazole in schools

HMiS Monthly

5Percentage of out of school adolescent girls (10-19 years) provided with 4 ifa tablets at anganwadi centres

HMiS Monthly

6Percentage of out of school adolescent girls (10-19 years) provided with albendazole at anganwadi centres

HMiS Monthly

7 Stock: ifa- Blue (adolescent 10-19 years) HMiS Monthly

Monitoring indicators and reporting for albendazole during the nDD rounds shall be followed as per the national Deworming Day operational Guidelines of Govt. of india.

51

Programs Area of review Review Indicators

Maternal Health

Coverage

Percentage of pregnant women registered within 1st trimester

Percentage of pregnant women given 180 iron and folic acid tablet

Percentage of lactating mothers provided with 180 iron and folic acid tablet

Percentage of pregnant women given one albendazole tablet

Percentage of pregnant women given 360 calcium tablets

Percentage of lactating mothers provided with 360 calcium tablets

Percentage of women in reproductive age (Wra) 20–24 years, provided albendazole (under Mission Parivar Vikas)

Percentage of Women of reproductive age (Wra) 20–24 years, provided 4 iron and folic acid (ifa) tablets (under Mission Parivar Vikas)

Percentage of pregnant women treated for severe anemia

Stock-out

Percentage of districts with ifa red stock out in the previous quarter

Percentage of districts with calcium stock out in the previous quarter

Percentage of districts with albendazole stock out in the previous quarter

Child Health

Coverage

Percentage of new-borns breastfed within 1 hour

Percentage of infants provided with Vitamin a 1st dose

Percentage of children provided with 8-10 doses of ifa syrup

Percentage of children provided with albendazole

Stock-out

Percentage of districts with Vitamin a syrup stock out in the previous quarter

Percentage of districts with ifa syrup stock out in the previous quarter

Percentage of districts with albendazole stock out in the previous quarter

Percentage of district with ifa Pink stock out in the previous quarter

nutrition dashboard for review at nhM

Annexure 4


Programs Area of review Review Indicators

Adolescent Health

Coverage

Percentage of girls (6th-12th class) provided with 4 ifa tablets in school

Percentage of boys (6th-12th class) provided 4 ifa tablets in schools

Percentage of girls (6th-12th class) provided albendazole in schools

Percentage of boys (6th-12th class) provided albendazole in schools

Percentage of out of school adolescent girls (10-19 years) provided 4 ifa tablets at anganwadi centres

Percentage of out of school adolescent girls (10-19 years) provided albendazole at anganwadi centres

Percentage of children covered under WifS Junior (6-10 years) provided 4-5 ifa tablets in schools

Percentage of children (6-10 years) provided albendazole in schools

Stock-out Percentage of district with ifa Blue stock out in the previous quarter

[Source: HMIS & e-aushadhi]

53

liSt of contributorSName Designation Organisation

Dr. J. P. Singh Director – Maternal Health nHM, Govt. of Jharkhand

Dr. Bina Sinha Director – child Health nHM, Govt. of Jharkhand

Dr. Deepawali Medical officer, Maternal Health nHM, Govt. of Jharkhand

Dr. Ajit K Prasad Medical officer, child Health nHM, Govt. of Jharkhand

Dr. Jaya Prasada Deputy Director, adolescent Health nHM, Govt. of Jharkhand

Ms. Surabhi Singh asst. Director WcD, Govt. of Jharkhand

Dr. Devesh Kumar asst. Professor, PSM Department rajendra institute of Medical Science, ranchi, Jharkhand

Mr. Shailendra Srivastava officer on Special Duty JMHiDPcl, Govt. of Jharkhand

Mr. Jwala Prasad State Program Manager nHM, Jharkhand

Ms. Akai Minj State Programme coordinator nHM, Jharkhand

Mr. Neel Ranjan Singh State cold chain officer nHM, Jharkhand

Ms. Anamika Chandra consultant – child Health nHM, Jharkhand

Ms. Rafat Farzana consultant – adolescent Health nHM, Jharkhand

Mr. Nalin Kumar consultant – Maternal Health nHM, Jharkhand

Ms. Rajbir Kaur consultant- Maternal & child Health nHM, Jharkhand

Ms. Keya Chatterjee nutrition Specialist unicef, Jharkhand

Mr. P. K. Nayak nutrition officer unicef, Jharkhand

Mr. Suranjeen Prasad Senior advisor-Programs JHPieGo, Jharkhand

Mr. Sumitro Roy State team leader iPe Global, Wecan Project, Jharkhand

Dr. Jaya Swarup Mohanty State team leader iPe Global, VriDDHi Project, Jharkhand

Mr. Sraban Kumar Badanayak State M&e Manager iPe Global, Wecan Project, Jharkhand

Dr. Prafull Kushwah State Programme Manager iPe Global, Wecan Project, Jharkhand

Ms. Neha Saigal associate Director iPe Global, Wecan Project, new Delhi

Ms. Komal ganotra national team leader iPe Global, Wecan Project, new Delhi

Ms. Rupa Prasad Programme Manager iPe Global, Wecan Project, new Delhi

Mr. Abhimanyu Shankhdhar communications lead iPe Global, Wecan Project, new Delhi

55

referenceS

1. caulfield, l. e., richard, S.a., rivera, J.a., Musgrove, P., & Black, r. e. (2006). Stunting, Wasting, and Micronutrient Deficiency Disorders. in D.t. Jamison, J.G. Breman, a.r. Measham, et al. (eds), Disease Control Priorities in Developing Countries (2nd ed., pp. 561-567). new York: oxford university Press.

2. indian council of Medical research, Public Health foundation of india, institute for Health Metrics and evaluation. (2017). India: Health of the Nation’s States — The India State-Level Disease Burden Initiative. new Delhi.

3. international institute for Population Sciences (iiPS) and icf. (2017). national family Health Survey (nfHS-4), 2015-16: india. Mumbai: iiPS.

4. international institute for Population Sciences (iiPS) and icf. (2017). national family Health Survey (nfHS-4), india, 2015-16: Jharkhand. Mumbai: iiPS.

5. Jharkhand rural Health Mission Society, Govt. of Jharkhand. (2018). Health Management Information System Data. ranchi.

6. Mason, J., Saldanha, l., & Martorell, r. (2012). the importance of Maternal undernutrition for Maternal, neonatal, and child Health outcomes: an editorial. Food and Nutrition Bulletin, 33(2_suppl1), S3-S5.

7. Ministry of Health and family Welfare, Govt. of india. (2006). IFA & Vitamin A Supplementation (pp. no.Z.28020/30/2003-cH). new Delhi.

8. Ministry of Health and family welfare, Govt. of india. (2012). Operational framework, Weekly Iron and Folic Acid Supplementation program for Adolescents. new Delhi.

9. Ministry of Health and family Welfare, Govt. of india. (2014). National Guideline for Calcium Supplementation During Pregnancy and Lactation. new Delhi.

10. Ministry of Health and family Welfare, Govt. of india. (2014). National Guideline for Deworming in Pregnancy. new Delhi.

11. Ministry of Health and family welfare, Govt. of india. (2016). Operational Guideline, National Deworming Day, Child Health Division, Ministry of Health and family welfare. new Delhi.

12. Ministry of Health and family Welfare, Govt. of india. (2018). Operational Guidelines: Intensified National Iron Plus Initiative (I-NIPI) for Programme Managers. new Delhi.

13. Ministry of Women and child Development, Govt. of india. (2018). Jan Andolan Guidelines: Poshan Abhiyan. 2018.

14. national Health Mission, Department of Health and family Welfare, Govt. of Jharkhand. (2008). Operational Guideline Jharkhand Matra Sishu Swasthaya evam Poshan Maah. ranchi.


15. national Health Mission, Ministry of Health and family Welfare, Govt. of india. (2013). Handbook on improving maternal and child health through RMNCH+A approach. new Delhi.

16. niti aayog, Govt. of india. (2017). Nourishing India: National Nutrition Strategy. new Delhi.

17. Press information Bureau, Govt. of india. (2017). Cabinet approved setting up of National Nutrition Mission. retrieved from http://pib.nic.in/newsite/Printrelease.aspx?relid=174025

18. taylor-robinson, D., Maayan, n., Soares-Weiser, K., Donegan, S., & Garner, P. (2015). Deworming drugs for soil-transmitted intestinal worms in children: effects on nutritional indicators, haemoglobin, and school performance. Cochrane Database Of Systematic Reviews.

19. the registrar General & census commissioner of india. (2017). Sample Registration System (SRS) Bulletin. new Delhi.

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february 2019

not for Sale

National Health Mission (NHM)Jharkhand rural Health Mission society (JrHMs)department of Health, Medical education and Family welfare government of Jharkhandgovernment Vaccine Institution, tata road namkum ranchi-834010, JharkhandPhone number: +91-651-2261000/2261001website: www.jrhms.jharkhand.gov.in

NAT


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Documents

State action plan for Micronutrient SuppleMentation · ii State action Plan for Micronutrient SuPPleMentation Purpose of the State Action Plan is to guide planning, monitoring, supervision,