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Composite programme for women and pre-school children: a joint programme of the government of Kerala, Mahila Samajams, and care

Sneh Rewal. Evaluation Department, CARE-India, New Delhi, India

Abstract
Introduction
The composite programme (CPWPC)
Programme participants
Programme inputs
Conclusions

Discussion

The food mix
Fats in the diet

Abstract

The Composite Programme for Women and Pre-school Children (CPWPC), an upgraded pre-school feeding programme, aims at improving the nutritional status of young children through provision of a package of services. The programme is jointly undertakrn by the Rural Development Department of Kerala, Mahila Samajams, and CAPE.

The recently constructed balwadi building is the focal point for delivery of services. Each CPWPC unit envisages provision of services to 100 children and 40 expectant and nursing women. As of July 1981, 2,161 CPWPC units have been planned.

The programme plans for a food supplement of 312 calories and 12 grams of protein for each enrolled participant. Medical services are provided by the staff of a nearby health centre. The balwadi teacher is expected to impart child-care education to mothers and non-formal education to children.

Assistance is provided for purchasing 10 goats for 10 families, 10 chickens for each of 10 families, and for developing a kitchen garden to 20 families.

Programme evaluation indicates that the majority of enrolled participants are from the lower socioeconomic group. Almost all interviewed mothers indicated that they received the food supplement regularly. Mothers recalled the names of two to three vaccines received by the child. Child-care education sessions have been attended by 75 per cent of the mothers. More than 80 per cent of the mothers participated in nutrition education camps. About 30 per cent of the mothers reported establishing kitchen gardens and an equal percentage of mothers had established poultry units. Lambs were received by 24 per cent of the families.

The successful delivery of services to the intended group is attributed to the mode of operation and response to the changing situation.

Introduction

Literally speaking there are thousands of voluntary agencies, both big and small, involved in various fields of human endeavour at international, national, regional, state, and village levels. In India, though the Government has taken on the task of conducting child nutrition programmes, many international and national agencies provide the assistance necessary for their implementation. The predominant voluntary agencies assisting the Government efforts are Mahila Mandals, Youth Clubs, Child Welfare Councils/Societies, Catholic Relief Society, and CARE. CARE, an international relief and developmental organization, has been providing assistance since 1950 and functions within the framework of Indian Government policy and programmes. Although relief during emergencies remained the base of CAR E's activities during its first decade in India, its attention is increasingly focused on nutrition and health programmes. In recent years, CARE has been encouraging and assisting local voluntary agencies in the development and implementation of nutrition programmes at the grass-roots levels.

The core of this paper is drawn from a case-study of an integrated nutrition health programme in Kerala jointly undertaken by the Rural Development Department of Kerala, Mahila Samajams, and CARE.

The composite programme (CPWPC)

The CPWPC programme has been in operation since 1975 and aims at transforming vertical pre-school feeding, health, pre-school education, and applied nutrition programmes into an integrated maternal child-care programme. Through provision of a package of services comprising the food supplement, non-formal education and medical care for children, and child-care education for mothers, the programme aims at improving the nutritional status of young children. Mahila Samajams have the responsibility of implementing the programme at the village level. CARE provides assistance in the form of food, funding for visual aids for child-care education, equipment for regular monitoring, and evaluation of the programme.

Each CPWPC unit envisages provision of services to 100 pre-school children and 30-40 expectant nursing mothers. As of July 1981, 2,161 CPWPC units had been established. An evaluation component is built into the design of the programme. In 1979, after four years of implementation, a large-scale field survey was conducted to study the efficiency of the delivery of services, the level of programme participation, and the utilization of services, and to measure the impact of the programme on the nutritional status of the participants.

Programme participants

The selection of children on the basis of economic and nutritional status is defined clearly and strictly adhered to. The president of the Mahila Samajam and the medical staff of the nearby health centre select the programme participants. Almost all the participants are below six years of age (table 1), and 13 per cent of them are less than two years of age. Except for a few, the participants are from traditionally lower castes and under-privileged groups (table 2). The source of income of the majority of participant families is labour (table 3).

TABLE 1. Age of Programme Participants on the Survey Day

TABLE 2. Caste of the Programme Participants

TABLE 3. Occupation of Father of Programme Participants

Programme inputs

Balwadi Building

At each CPWPC site a balwadi building is constructed with financial assistance from Mahila Samajams, CARE, and the Government of Kerala. The cost of construction at present is Rs 12,000 (US$1,500). Nearly 30-40 per cent of the funds for land, building material, and construction are generated by the Mahila Samajams, who have legal ownership of the building. The balwadi is the venue for distribution of the nutrition supplement, dispensing of preventive and curative medical services, and imparting child-care education to mothers and non-formal education to children. In short, these structures are the focal point of integrated maternal child health activities in the village. This building has imparted a real sense of performance to the existing ill-housed programmes that were conducted under the shadow of trees or in someone's house.

Food Supplement

The programme is designed to provide an enrolled child a cooked meal of 312 calories and 12 grams of protein for 300 days per year. Children attending the balwadi classes receive an additional meal of 100 calories and 3 grams of protein.

The data suggest that the food is distributed regularly at the centre. The response of mothers to questions on the adequacy and taste of the centre meal, and the purpose of the feeding programme indicates a positive attitude towards the programme (table 4). The vast majority of mothers agreed that the taste of the meal was acceptable to the children. Also, the mothers felt that the food given at the balwadi was adequate. More than 90 per cent of the mothers regarded the objective of providing a meal as "improvement of health" of the children.

TABLE 4 Attitudes of Mothers towards the Programme

In analysing the data it was found that a child attending the balwadi received a meal of 404 calories and 22 grams of protein. A meal of 320 calories and 17 grams of protein is given to non-balwadi participants. The entire quantity of food, according to 73 per cent of the mothers, is fed to the enrolled child (table 5). Another 24 per cent reported feeding between "half" and "most" of the food the participant child.

TABLE 5. Quantity of Centre-food Reported to be Fed to the Programme Child

Medical Services

Both preventive and curative medical care is to be provided to programme beneficiaries by a medical doctor once a month and an auxiliary nurse mid-wife (ANM) once a week. Evidence collected suggests that on an average a child received protection against two-three childhood diseases such as diphtheria, whooping cough, pertusis, polio, and tuberculosis (table 6). More than half the mothers recalled receiving prophylactic doses of vitamin A for their enrolled child. Also, mothers of one-fifth of the children mentioned receiving preventive doses against worms for the participant child. Although the majority of children experienced two-three episodes of illness in a year, less than 10 per cent of the children were treated for illness at the balwadi centre.

TABLE 6. Utilization of Health Services

Child-care Education

Important concepts concerning certain practices that contribute to child malnutrition, morbidity, and mortality are communicated to mothers of the enrolled children through fortnightly sessions at the balwadi centre, home visits to participants homes, and six monthly camps of two days' duration. The balwadi teacher, trained for a period of one month, has the responsibility of imparting child-care education. For effective communication, posters and pamphlets have been developed. As a tool for personal instructions to the mothers about the health and nutritional requirement of the young child, a coloured growth chart is provided for each programme child.

TABLE 7. Frequency of Attendance at Child-care Sessions

About 73 per cent of the interviewed mothers reported participating in the fortnightly education sessions (table 7). Nearly 22 per cent of the mothers attended the sessions once a month. Another 40 per cent participated in the educational activity whenever they found time. The majority of the 27 per cent of mothers who never attended the education sessions mentioned "time" as a constraint for their participation. Nutrition camps were attended by about 80 per cent of the mothers (table 8), and about 74 per cent attended more than once.

TABLE 8 Frequency of Attendance in Child-care Camps

The growth chart used for monitoring the body weight of the child was seen by 72 per cent of the mothers, and 70 per cent of them understood what it conveyed. in a similar programme in Pondicherry, although the children were weighed regularly, the growth charts were seen by less than one-fourth of the participants' mothers. Data on awareness and knowledge of selected child-care practices indicated that a large number of mothers grasped the messages that were being conveyed in the education sessions.

Economic Activities

Mahila Samajams are encouraged to organize economic activities to increase the income of mothers. Assistance is planned for 20 mothers per balwadi in a year to develop a kitchen/backyard garden. Ten families of the participant children are given 10 chickens each on the condition that they provide 100 eggs to the Mahila Samajam. These eggs in turn are supplied to 5 families for hatching and rearing. Provision is made for supplying goats to 10 families. These families are to return a female lamb to the Mahila Samajam for supply to other mothers.

Evidently 30 per cent of the families have established a garden in their backyard (table 9). Goats and poultry units have been received by 26 and 30 per cent of the families respectively.

TABLE 9. Economic Activities Undertaken by Mahila Samajams

TABLE 10. Comparison of Perceived Advantages by Mothers and the Purpose of Their Visit to the Balwadi

Besides these three types of activity, some of the Mahila Samajams are organizing radio assembly units. tailoring classes, and dairy units.

Conclusions

In evaluating the programme efforts, it was observed that the implementers are able to transfer the project plan to an operationally viable programme. The efficiency of delivery of most of the services is high. Also, the programme has been successful in reaching young children, especially in the age-group of six months to three years. And, having reached the intended group, the services are well utilized. The families of participant children were not only beneficiaries but also partners in the programme implementation. In this programme the participant families are not treated as dependants but encouraged to help themselves and others from the community.

The CPWPC programme has been successful in bringing together interests and resources of different agencies. The key to successful programme operation is freedom in the mode of operation. Also, the implementers were in a capacity to experiment with innovative approaches even at the risk of failure.

Discussion

The food mix

The relatively smaller increase over the last 25 years in the price of fine cereals like rice and wheat, compared to those both of coarse cereals like jowar and bajra and of pulses, has adversely affected the nutrition of the poor. Even at a 1,500-calorie-per-day level, the data show a willingness to buy more costly foods, and at 1,800 calories, a shift to purchase non-food items is noticeable. Thus simply the provision of a larger income may not bring about better nutrition, and one may have to consider other measures to correct this tendency, either through the agency of the ration system or by payment of wages in kind.

In drawing up health cards for use in the CARE project in Kerala, red has been shown as the zone of danger. Yet in the Poshak study in Madhya Pradesh, red was perceived by local mothers as a sign of health and well-being.

Fats in the diet

What would be the critical minimum requirement of external fat? In practice the answer was probably nil, since invisible fat in Indian cereal diets is substantial and, fortunately, high in essential fatty acids as well. Indeed many people, perhaps a third of the Indian population, eat no external fat at all. Consumption of just 400 grams of any Indian cereal alone would furnish at least 10 grams of latent fat.

Of course addition of fat would raise the calorie density of children's foods, but the cost of this world be high. The soybean is important in agriculture. especially in Madhya Pradesh, but has little role as a food that would help the poor as it cannot be consumed directly. On the other hand, when processed the oil would of course find use, but the protein cake must necessarily be incorporated into processed foods, which then go out of reach of the needy.