Giripragathi Project End Report: Assessment of Health and Nutrition Interventions

Transcription

1 Giripragathi Project End Report: Assessment of Health and Nutrition Interventions March 2009 Society for Elimination of Rural Poverty

2 Table of Contents Introduction 3 Process Documentation 4 Nutrition cum Day Care Center 5 Health Savings and Health Risk Fund 7 Capacity Building 11 CRP Strategy 15 Quantitative Impact Assessment 18 Study aims and methodology 19 Table 1. Demographic comparability of study group and control group respondents 20 Table 2. Maternal and child health and nutrition outcomes 22 Table 3. Impact of H&N Program on utilization of government public health services 22 Table 4. Outcomes of Behavior Change Communication and Health Education strategies 23 Qualitative Impact Assessment 24 Introduction 25 List of VOs from Giripragathi Mandals involved in Focus Group Discussions 25 Question-wise analysis of results from Focus Group Discussions 26 Summary of qualitative assessment

3 Introduction This report provides a comprehensive review of the Health and Nutrition Program implemented in tribal Mandals in Warangal, Khammam, and Adilabad under DFID funding for the Giripragathi project. The report contains three sections: 1) process documentation for the main health and nutrition interventions under Giripragathi 2) quantitative impact assessment based on individual surveys conducted in Giripragathi Districts 3) qualitative impact assessment based on Focus Group Discussions held in Giripragathi Districts Process Documentation The process documents were produced based on field visits to the tribal Mandals under Giripragathi as well as non-tribal Mandals where the Health and Nutrition Program is being implemented through IKP under the Department of Rural Development, Government of Andhra Pradesh. The interventions are similar in both types of Mandals with the exception of particular focus on involvement of tribal populations in the Giripragathi Mandals. Impact Assessment The quantitative and qualitative impact assessment is drawn from results of a comprehensive, state-wide study of the health and nutrition interventions under both IKP and Giripragathi. The study, Assessment of Health and Nutrition Pilot Outcomes under APRPRP, was conducted in collaboration between SERP and the external research agency Society for Human Rights and Social Development (SOCHURSOD). The study consisted of a structured questionnaire administered to SHG women in three study groups: 1) villages with universal health and nutrition interventions, 2) villages with universal interventions plus Nutrition cum Day Care Center, and 3) control villages with no health and nutrition interventions aside from the usual government services. Focus Group Discussions were also conducted in each village covered under the three study groups. The study design and data analysis was carried out in collaboration between SERP and SOCHURSOD while the data collection itself was conducted solely by SOCHURSOD as to prevent introduction of bias from SERP staff

4 Process Documentation - 4 -

5 Intervention: Nutrition cum Day Care Center (NDCC) Establishing and Managing the NDCC The Nutrition cum Day Care Center is established by the SHG members through an intensive 11- step process that is lead by a group of Community Resource Persons (CRPs, experienced best practitioners from neighboring Districts) and assisted by the VO Health Sub-Committee members: 1. Conduct a household survey to identify all pregnant and lactating women and children less than 5 years in the community 2. Hold a session in the VO meeting to explain the importance of nutrition during early childhood and reproductive age and to explain the benefits of the Nutrition cum Day Care Center 3. Visit the households of all eligible women to encourage them to enroll in the Center and counsel their family members (husbands, mothers, in-laws) on the importance of enrollment in the Center 4. Set up a base register with the names and demographic information for all women and children who enroll in the Center 5. Ensure the Mandal Samakhya releases the start up fund of Rs. 2.2 lakh to the VO 6. Prepare a Micro-Credit Plan (MCP) for each beneficiary to track loans taken from the VO to help finance enrollment in the Center 7. Assist the poorest-of-the-poor in taking loans from their SHG to be used for incomegenerating activities to help pay for enrollment in the Center 8. Identify and train an SHG member who will be the cook for the Center 9. Identify a building in the community that can house the Center; procure cooking supplies and food 10. Health Activist prepares the Health Education calendar to cover all health and nutrition topics over the next 18 months 11. Develop Community Kitchen Garden to provide organically grown vegetables for the Center Sustainability Once established, the Nutrition cum Day Care Center is run entirely by the community. The VO Health Sub-Committee members serve as resident CRPs to ensure that the Center runs as follows: Cook prepares nutritionally complete meals twice per day for pregnant and lactating women and children who come and sit together to have food at the Center Twice per month mothers gather at the Center to prepare weaning powder for their children between 6 months and 1 year of age Health Activist maintains base register to track maternal and child health statistics and Demand Collection Balance to track MCP repayment Social Audit of accounts is done by executive committee of the VO and health subcommittee members of the Mandal Samakhya and Zilla Samakhya Health Activist holds once weekly Health Education sessions according to the training calendar Fixed Nutrition and Health Days are held in convergence with the Health Department and Department of Women Development and Childe Welfare twice per month at the Nutrition cum Day Care Center; services include antenatal care, child immunizations, distribution of medicines and oral-rehydration powder, and distribution of supplementary food ration CRPs survey community each month to identify and enroll newly pregnant or lactating women - 5 -

6 The Nutrition cum Day Care Center is funded by the community with part of the fee paid by the beneficiary herself and part paid by the VO. The cost of enrollment in the Center is Rs 25 per woman per day and Rs 15 per child per day. Of this fee, the VO pays Rs 7 per woman per day and Rs 5 per child per day. The beneficiary pays the remaining Rs 18 per woman per day and Rs 10 per child per day. To ease the burden on the beneficiaries of immediate daily payment, a microcredit plan (MCP) is drawn up whereby a loan can be taken from the VO to cover the beneficiary contribution. The beneficiary can then pay back the loan in installments over the course of three years. When the NCDCs were first established, the MCP loan source was a grant given to the VO by SERP. Now, in convergence with the Health Department (Integrated Child Development Scheme), the MCP loan source is entitlement money due to the enrolled women that is routed through the VO. This way, the VO itself no longer has any financial burden to fun the Nutrition Centers. The Centers are sustained financially by government programs and the beneficiaries themselves. Role of Nutrition cum Day Care Center in Behavior Change Communication Aside from providing beneficiaries with nutritionally complete meals, the NCDC serves as a forum for health education aimed at changing behavior of women so that the benefits of the Center extend beyond the period of enrollment. The Health Activist sits with the beneficiaries once a week and uses pictorial flipbooks to discuss health and nutrition topics relevant to pregnancy and child growth and well-being. This method allows for exchange between the women on their experiences during pregnancy and raising their children. It raises awareness about health and nutrition topics relevant to their lives and allows for increased openness and empowerment regarding issues common to all women at this stage in life. Monitoring and Evaluation An important component of the NCDC is the community-based system of monitoring and evaluation. Each NCDC has a base register maintained by the Health Activist that is used to track maternal and child health statistics for each beneficiary. Each month, data from the base registers in each Mandal is consolidated into a Mandal-wise MIS report and sent to the SPMU office. The data is maintained in a database so that health outcomes can be tracked. Monthly reports are generated to monitor a set of health indicators that are comparable to indicators that are monitored routinely by the Health Department. The operational details of the NCDC are also routinely monitored. A Master Book-keeper is positioned to keep track of the MCP, the food supply stock and ordering, and the overhead costs associated with running the Center. This information is also displayed on posters throughout the Center so that beneficiaries have an active role in management of the Center

7 Intervention: Health Savings and Health Risk Fund Health Savings & Health Risk Fund focuses on reducing health related out of pocket expenditures while promoting care seeking behavior among the socially marginalized population. The concept of community managed Health Savings was introduced to the Self Help Groups (SHG), to serve as a discussion forum and support network. Since 90% of the rural women belong to SHGs, high coverage and awareness can be reached effectively. Moreover, these grassroots groups were the optimum place to execute the practice of Health Savings since they are close knit and safeguarded. WHY do Health Savings? In the early implementation of the interventions, it was assessed that an average household health related expenditure was Rs.1000 ($25) per year. If every member can save Rs.1 per day (Rs.360 a year) into a common health fund, the members, especially Poorest of the Poor can avail this fund as a loan at a lower interest rate towards health expenses. It was noted that utilization of this health fund by its members will prevent selling or mortgaging critical assets while providing a stable alternative so their work productivity and livelihood is still preserved. The fund will also further enhance the health seeking behavior of an individual, whereas before the person would be more reluctant to obtain treatment due to high cost. Over a period of time, these Health Savings accumulate since they are collected from various SHGs and become available as loan for any of the SHG member who needs it. Health Savings provides a stepping stone for Health Risk Fund (HRF), which is a onetime large loan sanctioned to the entire Village Organization (VO) by IKP. The role of HRF is to complement existing health insurance programs like Aarogyasree and to have funds for other health related expenditures not covered by the insurance like transportation, doctor fees, medicines, diagnostics tests, and other costs incurred by the relatives of the patient in taking care of the ill person. HRF can be used for any costs incurred by both major and minor illnesses. Infrastructure: Various stakeholders are involved in transforming and continuation of HS-HRF concept in the villages. IKP s Institution Building unit has collectively organized the rural women into valid self governing structure that plays a critical role in monitoring, feedback and discussion forum for IKP activities. Similarly, SERP has taken up evaluating and implementing role in executing this intervention by synchronizing oversight and guidance at all levels of rural IKP structure (Figure 1). Project facilitators are employed by the IKP, whereas community facilitators other then State CRPs are paid by their respective Samkhyas: Zilla, Mandal and Village Organization. Process: Process of implementing the program involves stakeholders in establishing HS-HRF is as follows: Initial discussion is to introduce the concept of Health Savings and Health Risk Fund at the Mandal Samkhya meeting where all the Office Bearers (OB) are present. Following the informational session HA informs and discusses HS-HRF with each SHG during SHG meetings. SHGs and VOs will decide on minimum monthly amount and start collecting HS premiums from each member and place it in a newly opened bank account specifically for HS-HRF. Once the commitment of VO is shown in collection of HS from the SHGs for a minimum period of 6months, the onetime grant of Health Risk Fund (HRF) is released from the MS. Once allocated to the VO, money will be available to SHG members as savings and loans mechanism. SHG members still continue to do their individual health saving irrespective of the availability of HRF. The entire implementation of HS & HRF will take place in twelve to eighteen months

8 Establishment and maintenance of HRF involved the following community members and field staff: Village Self-Help Group (SHG) members: Each SHG will discuss the importance of Health Savings and decide on an amount to be saved each month by each member. In the initial period, there was considerable opposition against HS since SHG members were already doing general savings for other IKP activities and it was hard to convince them to contribute to morbid situations. However, with constant encouragement by the Health Activist, HSC, and CRP strategy, HS concept and awareness improved dramatically. Certain SHGs in the beginning phase decided to save Rs.2 per member then this amount was gradually increased to Rs.10 once people realized the benefits of HS & HRF. Village Organization Deposits in HS premiums and HRF repayments in VO account and issues receipt for those members who contributed HS & HRF recovery. Grants HRF loans to members who need it on monthly meetings. SHG SHG SHG SHG SHG SHG During emergencies, the VO office bearer will have Rs.3000 in hand and meeting among the OBs will be held for loan decisions. Collects monthly Health Savings. One representative from each SHG will attend the VO meeting. Approves individual claim for HRF. Member Member Member Member Member Member Member Member Member Each community SHG member can avail the fund for herself and her family members. Each member contributes Rs per member Figure 1: Process of HS-HRF at village level Each SHG member gets a card that records their monthly savings and HRF repayment, which are collected at the SHG meeting. Usually, HS is collected at the SHG meeting and HRF repayment are individually given to the VO book keeper as per convenience. SHG members designated to represent at the VO meeting will transfer the health savings amount collection to the VO treasurer. The first round of needs assessment for HRF loan will be done by the SHG. Since the groups are small enough with open communication, the validity of a group member s health situation will be authenticated easily. HRF claims will be noted in SHG resolution books and - 8 -

9 will be presented at the VO meeting. Member of the group can also utilize the money for her family members as well. Also, SHG members have the option of retrieving their Health Savings in case they move to a different village or need the fund for other emergency issues. In order to withdraw an individual s contribution to HS fund, the individual has to validate her case in the VO meetings and it has to be approved by the VO officers. Village Organization (VO): In the monthly held VO meetings, discussions and decisions are made on any topics that affect the village and its habitants. HS premiums and HRF loan repayment are collected and placed in the VO account. Each SHG will get a receipt of their dues and individuals will get receipt of their loan repayment issued by the VO book keeper. Before every VO meeting, the VO secretary consolidates all of the members pending requests for second round of HRF approval. Decision is made by the meeting attendants and OBs on every case and this decision is written in the VO s resolution book. Each VO decides on a loan limit for each health issue and they also incorporate the requesting person s urgency and economic status while granting loan. In some districts, the maximum amount issued is Rs.5000 and it s usually for surgeries, whereas in other districts where the cost of living is higher (i.e Ranga Reddy district since its proximity to Hyderabad city which has a network of corporate hospitals) the maximum amount is Rs There is a one month grace period for the borrower and this grace period is extended up to six months for people with the lower economic status Poorest of the Poor (POP). The interest rate for the loans is also decided by the VO and it usually either.5 or 1 %. For emergency health situation, VO health sub-committee member has an impressed amount of Rs.3000 in hand and meeting among the VO Office Bearer (OB) is commenced and decisions will be made to dispense the loan quickly. Mandal Samkhyas (MS): Mandal Samkhyas overlook the activities in all of their VOs. They meet once a month and check the progress of each VO. In case of discrepancies, they will send their own Office Bearers (OB) to the field to resolve confusion and conflicts. They also have taken the responsibility to dispense the one-time HRF grant to the VOs. The eligibility for VOs is based on four major contexts: Socio-economic status of the VO, distance & accessibility to Primary Health Center, incidence of health problems and the procurement of community contributed Health Savings. Zilla Samkhyas (ZS): ZS meetings are held once a month and all of the Mandals Office staff will be represented there. During the meeting, progress and problems will be shared. One of the responsibility of ZS relating to HS-HRF intervention is the facilitation of HRF from IKP to MS. Health Subcommittee Members (HSC Village level): These members are the perfect liaisons between the community and health care. Since these women are natives of the village, they are able to easily approach the members of the community and broach conversation about health care services, education, and health seeking practices either in SHG meeting or in other cultural congregations. These members are identified by the VO and constitute a committee with 5 members. They for further undergo training to sustain the Health and Nutrition interventions in their own village

10 Health Subcommittee Members (HSC Mandal level): These five members, usually in teams of two visit villages in their Mandal that are experiencing conflicts with HRF repayment. They serve as another oversight public group from the community perspective. Health Activist (HA): Health Activists continuously encourage and create awareness on HS- HRF at SHG meetings. They also present the progress of their village s HS-HRF activities to both the CC and at the VO meetings. Health & Nutrition Community Coordinator (CC): The process of acquiring HRF is mediated by the CC since they go through each of VO s documents for validation. Before acquiring HRF grant, CC will go through pass book records every two weeks to see the regular HS deposits. After six months of continuous saving, VOs are eligible to apply for the HRF grant. At this point, CC will confer his report of the VO Health Savings activities to the MS. After the HRF grant is provided to the VO, CC will make periodic visits to the VO meeting for monitoring. Furthermore, CC will also collect HRF beneficiary s demographic information through the HA. The following are collected by the HA: caste, socio economic status, amount borrowed, health reasons, date of borrow, installments and principle amount. This information is composed and presented at the SERP s monthly held state review meetings for discussion and analysis. District Coordinator/Regional Coordinator (DC/RC): These personnel also serve as external oversight agent from the project perspective. Their occasional presence at the villages serves as important factor to motivate people into continuing monthly health savings and prompt repayments of HRF loans

11 Intervention: Capacity Building The main approach of executing intervention is through continuous capacity building of the Health Activist (HA) and Health Sub-Committee (HSC). Both HA/HSC are internal members of a village and they serve as a role model for healthy best practices promoted in interventions besides Community Resource Person (CRP). They are also key resource personnel in case of emergency health situation since they live in the members. Process for Capacity Building of Health Activists Interested individuals who want to become an HA in their village will be summoned at the VO meeting and she is chosen based on her experience, willingness to learn, service to the community, and having no children under five. HAs must belong to either Poor SES or Poorest of the Poor (POP) so this would ensure the below poverty line families to avail the services of a community health worker. HA is considered as a part time job by the project and respectively, most HA hold other positions in their VO or work as daily laborer, tailor, dairy farmer or agents for government public health programs (Reproductive & Child Health) and national programs (Pulse polio campaigns). One of primary roles of HA is to make at least ten house visits everyday in their own village where they inquire for recent illnesses in the family while also observing home practices. HAs are also expected to visit neonates along with government ANMs. They are also expected to do monthly Management Information System (MIS) for activities in the villages, which primarily revolves around Nutrition & Day Care Center. Part of the HA s salary from the VO depends on whether the village has reached 100% Health Savings among all the SHG members and if the HA motivated the pregnant and lactating women to enroll at the NDCC. Other roles of the HA are as follows: o Attend four day training at the Mandal lever every month o Prepare monthly Management Information System o 10 house visits in her village every day o Registering birth and death o Preparation of action plan for the village regarding activities o Assist and accompany in deliveries either home or institutional o Referral of institutional deliveries for women with high risk pregnancy o Train SHG on the topics learned from the trainings o Give health education session during meal time at NDCC o Achieving 100% Health Savings in the community o Encouraging pregnant and lactating women to join the NDCC o Track repayments and explain the HRF loan procedure at VO meetings o Demand Sarpanch to periodically clean & chlorinate the water tank Each chosen HA will attend four day training at Mandal level. This four day training is broken into two sessions in a month one two day session in the beginning and the rest of the two day training at the end of the month both on preselected dates (7 th & 8 th and 29 th &30 th ). The main aim of training is equip the HAs on basic health care and emergency preparedness with locally available medicines and also to transfer this knowledge to SHG members at their weekly meetings. The training sessions are conducted by Master Trainers (MT) and Health & Nutrition Community Coordinators (CC) who are employed by the project. Each Mandal has two MTs and one CC and these training sessions are also monitored by Mandal level Health Sub Committee members. CC and MT draw lessons from two books, Vydyudu Leni Chota (Where there is no Doctor) by Werner et al and Adavalliki Andubatulo Vydyam (Access to women s health care) along with other supplementary reading and learning material provided by the unit. Since trainings are held at the mandal level, there is no need for accommodation since these women go home after each of day of classes. Typically day at the training session constitutes the following: prayer

12 song, introduction, recap of previous session, subject 1, song, tea break, subject 2, group discussion, HA presentation, lunch, recap of lessons learned in that day, submission of MIS forms, and finally, the HA are given travel allowance and dearness allowance of Rs.20 per day. HA gets Rs 100/month towards attending the 4 day training sessions in addition to her monthly honorarium being paid by the VO. HA presentation is an activity where the HA present the topics she has learned to their class as a practice for the SHG meetings. More ever, this method reinforces the information learned during the session. MIS submission is only done during one of the four sessions and since some newly selected HA need assistance in completing the MIS forms, MT and CC have delegated time to review and provide additional help with MIS. During a discussion with one Health Activis, Nagamant, it was noted that Nagamani was illiterate and lacked basic reading and math skills. Nagamani was 58 years old, considerable older than rest of her HA batch. However, upon inquiring with the staff and Nagamani, it was realized that Nagamani is an effective social activist and had reached 100% HS among SHGs in her village early during implementation. She is currently persuading the staff to establish NDCC in her village. Some of the unwritten benefits of becoming a Health Activist include the elevated social status in the community that is further validated by their identity cards provided by the project. Becoming an HA is a stepping stone for woman who would like to become leaders in their community. Since these women get health trainings, they are more likely to be selected as agent for national health campaigns. They also get opportunities to meet with senior officers of various line departments and have gained confidence to address project directors in video conferences or at large meetings. Figure: HA s training SHG members at their weekly SHG meeting Process for Capacity Building of Health Sub- Committee Members Health Sub-Committee members are present at village, mandal and district level to monitor the activities taking place in their village. Their responsibilities include: ensure all the eligible beneficiaries are enrolled for various governmental services available in the villages, helping the HA in coordinating activities, mobilizing people to utilize the services, aiding VO in tracking repayments for HRF and NDCC repayments and monitoring public health service delivery in the village. HSC members are selected by interest, however there are no restrictions on whether they belong to Poor or POP socio economic status. Most women who become village level HSC are older and have older children. Village level HSC roles and responsibilities are as follows: o Motivate and enroll pregnant, lactating and children at the NDCC o Select a member to attend monthly mandal level three day training o Monitor activities at the NDCC o Observe if HA giving training to beneficiaries and SHG o Observe NH day activities o Prepare MCP for NDCC o Help in forming Kishore Ballika groups and make sure training occurs from HA, AWW and ANM

13 o Overview the HA in the completion and submission of NDCC s MIS to Mandal Samkhya. o Proper release of funds from MS o Ensure timely and prompt repayments from beneficiaries of interventions o Promote individual kitchen garden o Ensure growth monitoring for pregnant, lactating and children and record in growth card o Serve as health adviser to NDCC benefiaries, children, disabled and people with chronic disease conditions o Attend district level trainings o Ensure children between 2-5 years to join the Angawaddi centers o In case of absence of cook, take up the responsibility to cook at the NDCC o Bring accounts of VO regarding activities to Mandal Samkhya meetings. o Ensure that VO has health agenda as its top priority. o Make sure people who do health savings benefit from HRF accordingly o Maintenance of record books. o Counsel women past 45 years of age on menopausal symptoms and gynecological diseases o Social audit regarding NDCC expenditure and discuss each and every expenditure at the VO and inform everybody about it At the mandal level training, these women get training on the same topics as the HAs. They get additional instructions on how to monitor the staff. Usually trainings also have guest lecturers from line departments, local NGOs, Primary Health Center, and Child Development Project Office. Training sessions are held monthly for three days. Since it s held at the mandal level, first half of the first day is given leeway for those women travel far distances to get to mandal headquarters and similarly the last day of the training ends after lunch for the same reason. Like the HA, village HSC women use their position as a stepping stone for other leadership positions in the project like CRPs, or Mandal (or even District level) Health Sub Committee and higher positions in their community such VO Office bearers or VO president. Although it was noted from the FGDs that women do complain about lack of monetary benefits, becoming a village HSC presents them a lucrative opportunity to hone leadership qualities, boost confidence, and commence exposure to leaders of line departments. Similar to the village level HSC committee, Mandal level and District level HSC members exhibit larger oversight on all the villages that partake in activities in a mandal and district respectively. Their roles and responsibilities are as follows: o Attend Mandal level HA training and monitor/supervise the 4 day training o At least 7-10 days attend and monitor VO meetings and village HSC (also evaluate onroles and responsibilities at village level). o Monitor HA s training to SHG in the community and observe their house visits. o Mandal HSC must visit all the NDCC and give instruction for proper maintenance of the center. o If problem arises within VO/village-HSC, Mandal HSC will immediately dispatch for resolution. Discuss these problems and good practices can be discussed at the Mandal Samkhya meeting. o Verify NDCC records, HS-HRF data. o Visit NDCC at the time of food distribution. o VO OB and village health HSC supervise if they are properly facilitating activities. o Converge with line department services at the NDCC. o Get involved in national/governmental campaigns/health program like pulse polio campaign. o Plan for exposure visit for village HSC/VO on activities to villages that have stabilized program

14 Both mandal and district HSC are a mobile team as their expected to visit at ten villages a month that is undergoing problems with activities. Even if there are not villages with issues, they are still expected to periodically review repayment at NDCC and HRF/HS. Mandal & District HSC have a tour diary that they submit each month to the Mandal Mahila Samkhya and Zilla Samkyha respectively for salary and travel allowance. Mandal HSC receive Rs.100 per field day in addition to the travel/dearness, and district HSC receives Rs. 150 per field day in addition to the travel/dearness allowance. HSC at these levels is considered as a full time position since it involves at least 5-7 active village visits per month plus attendance at monthly held state review meetings. Usually, district HSC spend about half of the month on review meetings and training activities related to staff at mandal, district and state level. For example, in December 2008, there was training of the NDCC cooks were held in Hyderabad and district HSC from respective places came to learn about the training so they can monitor the NDCC cooks in the future. One of their primary work is to emphasize the importance of activities at mandal and district meetings. District HSC have direct contact with project director of IKP in their district. This enables a system of checks and balances on project staff and activities

15 Intervention: CRP Strategy The Health and Nutrition Community Resource Persons (H&N CRPs) train and guide the Self Help Groups in implementation and oversight of the Health and Nutrition components of IKP. The CRPs are specialized in five program areas: 1) SHG Training, 2) Nutrition cum Day Care Center, 3) Health Savings, 4) Social Mobilization, and 5) Health Agenda. When the CRP strategy is implemented in a village, a specialized CRP is assigned to each of the five program areas. The role of the CRP is to provide leadership and technical support to the SHGs as they establish the H&N components. The CRP is also responsible for monthly reports to the Mandal Samakhya and Zilla Samakhya level field staff. External CRPs are trained to implement CRP Strategy according to the following method: 1. Selection of health CRPs: A group of SHG members is selected by Village Organization (VO) to train as External H&N CRPs based on the following criteria: a. working experience in one of the H&N pilot mandals b. practitioner of Health Savings, Food Security, Training in preventative care c. completed orientation at CRHP, Jamkhed d. introduced health into SHG agenda e. experience in another village setting up a nutrition center, water/sanitation activities, and health and nutrition days 2. Training of health CRPs: Selected External CRPs participate in a 10 day orientation and assessment. These trainees are provided with the necessary concept papers with a clear focus on the expected outcomes under each component followed by training on various techniques in order to facilitate the members in the community to help realize the effectiveness of the a particular component. Each CRP is expected to practice and demonstrate it to the entire group during the training program. Based on the demonstration she gives, the CRP is assessed under 4 areas i.e. knowledge, communication skills, clarity on outcomes expected, and conviction in the said component. If any lacuna is observed, the CRP further undergoes training by her co-members. 3. Constitution of health CRP team: Once the training is completed the External CRPs are grouped in team of five. All the teams have experts in each health care component i.e Health Agenda, Health Savings, SHG trainings, Social Mobilization and Nutrition cum Day Care Center. 4. Selection of VOs :Then District Project Management Unit (DPMU) identifies the villages with the following prerequisites where the health CRP strategy will be introduced with the newly formed health CRP team: a. The village is covered by IB CRPs (Institution Building CRPs) b. The VO has constituted 5-member Health Sub-committee and has also positioned a Health Activist c. Health Savings as well as Food Security measures are initiated d. In the Pilot Mandal selected, the DPMU should have positioned CC, Master Trainers and a District Anchor Person Implementation of health CRP strategy: Seven phases Teams of five External CRPs go to villages to conduct training and help with establishment of H&N activities (described in detail below). The goal is to train residents of the villages in each of the H&N program areas so that they can carry out the overall IKP Health and Nutrition program in a sustainable manner at the village level with minimal input from external IKP staff. Training is done in five phases, each of which are 15 days per month over two months

16 1 st phase (15 days): External CRPs introduce each of the five H&N program areas to the SHG members and establish the activities in each village. 2 nd phase (15 days): External CRPs identify health sub-committee members in the village who will serve as potential H&N CRPs specialized in each of the five H&N components; these members are called Internal CRPs. The Trained CRPs give further training and feedback to the Internal CRPs as they implement H&N components. At the end of 15 days, responsibility is turned over to the Internal CRPs 3 rd phase (5 days in CHRP-Jamkhed): In this phase, External CRPs along with the Sarpanch are sent to CRHP, Jamkhed for orientation and exposure. Here on-site training in community-based primary health care for community-level workers is provided to improve health in poor communities served by participating organizations. 4 th phase (2 to 3 days for evaluation): After 2 months, the External CRP teams visit the same village to assess the effective functioning of the health care components. In case any lacunae are noticed, they lend support and help bridge the gaps. 5 th phase (internal CRP to potential external CRP): After 6 months after implementation of the health care activities in their area, the internal CRPs ( Varasulu 1 & 2) will now be selected for the training of external CRPs. 6 th phase (Graduate to external CRPs): Once the 5 phases are successfully completed, the Internal CRPs, identified from the villages covered by the External CRP teams are imparted further training by the SPMU (State Project Management Unit) on all the components covering the Health CRP strategy for about 3 to 4 days. After this, they are tagged on to the team guides to go over to the other Districts attached to them in order to get intensive hands-on training in the field. This is considered probation period that lasts for 4 months i.e 2 rounds in 2 villages. After completion of their probation, the Internal CRPs graduate to the position of External CRPs, now capable of handling all the health care activities independently. 7 th phase (Debriefing session): The SPMU team along with all of the Health CRPs conducts a debriefing session, once every two months to review the groups records, strengths and weaknesses of each team, and based on this assessment, new action plan emergency on how things could have been done more effectively in the future. Debriefing sessions are also conducted to assess the performance of the Health CRPs, first in their own village, and then in the villages allotted to them in other Districts. A team that used the ideas suggested for planning will find it much easier to evaluate their work. The Health CRPs, through the successful implementation of health care activities, are required to make their own village as a model in a period of six months. The same needs to be accomplished in other assigned villages within two months. There are special indicators developed to monitor the program from the state level down to the village level, collected through the training cascade itself, which also function as program support system.the debriefing sessions are attended by Dr. Arole from Jamkhed and the line departments unit heads like Secretaries, Directors and SERP officials. CRP Strategy for each of the five H&N program areas: SHG Training CRP During the first phase of the CRP strategy, the Training CRP teaches good health practices to the SHG members. Training for SHG members covers pregnancy and early motherhood practices, neonatal, infant, and child health, and disease prevention behavior including use of bednets, boiling water, washing hands, etc. During the second 15-week period, the Training CRP selects a health sub-committee member from the village to train as the Internal Training CRP. They design a Training Calendar that the Internal Training CRP will follow to guide her in leading the Training activities for the SHG members. The External CRP will assess the performance of the Internal CRP by visiting households of SHG

17 members to observe their health behaviors and survey their health knowledge. At the end of the second phase, the Internal Training CRP is now responsible for regularly scheduled, ongoing health training activities in the village. Nutrition Day Care Center & Food Security CRP During the first phase of the CRP strategy, the External Nutrition and Day Care Center CRP helps the village establish a Nutrition and Day Care Center and trains SHG members how to run the Center. They begin by surveying all SHG members to find out how many pregnant or lactating women as well as children under 5 there are in the village. They also ask SHG members and their families what they are eating on a regular basis and explain to them the importance of balanced meals with adequate quantities of energy and nutrients. This information guides the sub-committee members in setting up their Center. During the second 15-day period, the External Nutrition and Day Care Center CRP selects a health sub-committee member to become the Internal Nutrition and Day Care Center CRP. The Internal CRP is further trained, and her performance is assessed. She is now responsible for leading the sub-committee members in running the Center and keeping records of the micro-credit payment plan as well as health outcomes such as birth outcomes, infant/child weight, maternal health, etc. Health Savings CRP The External Health Savings CRP spends her two 15-day periods in the village guiding the SHG members in setting up and implementing a Health Savings plan. They decide how much money each member should contribute each month, and they discuss what types of health emergencies/issues the money can be used for. They also decide the terms on which the loans will be repaid. During the second phase, the External Health Savings CRP selects a health sub-committee member to become the Internal Health Savings CRP for the village. The Internal CRP will be responsible for leading the health sub-committee members and other SHG members in keeping a record of the savings and making decisions regarding the use of the savings for loans towards health related emergencies experiences by SHG members. Health Agenda CRP The External Health Agenda CRP spends her two 15-day periods in the village assisting the SHGs in introducing health and nutrition related issues into their regular SHG meeting agenda. During the first phase, the External Health Agenda CRP attends SHG meetings and provides technical information regarding health matters that she has found to be important to the SHG members and their community. By introducing these issues into the SHG meeting agenda she is teaching the members to be health-conscious and also to learn methods that can be used to prevent ill-health in the community. During the second phase, the External Health Agenda CRP selects a health sub-committee member to serve as the Internal Health Agenda CRP for the village. The Internal Health Agenda CRP will be responsible for ensuring that health is discussed in future SHG meetings and that health-related issues remain at the forefront of the activities carried out by the SHGs. Social Mobilization CRP During the first phase of the CRP strategy, the External Social Mobilization CRP assists the SHG members in establishing a number of activities: formation of youth societies, formation of mother and girl groups, Water and Sanitation Days, Health Days, vocational guidance, preparation of weaning powder, set up of community kitchen gardens, etc. During the second phase, the External Social Mobilization CRP selects an Internal CRP to take over the Social Mobilization activities that have been established in the village. The Internal CRP will be responsible for regular scheduling of the activities described above and coordinating activities with government agencies

18 Quantitative Impact Assessment 18

19 Specific Aims SERP has initiated a comprehensive Assessment of Health and Nutrition Pilot Outcomes under APRPRP covering all H&N activities being implemented throughout Andhra Pradesh, including tribal areas covered under Giripragathi. The study is being conducted through partnership with the external agency Society for Human Rights and Social Development (SOCHURSOD). The aims of the study are as follows: o The primary aim is to measure the effect of the intensive H&N Program on health and nutrition indicators relevant to MDG 4 (Reduce child mortality), MDG 5 (Improve Maternal Health) and MDG 6 (Combat HIV/AIDS, Malaria and other diseases). o A secondary aim of the study is to measure the specific contribution of the intensive activities (CRP Strategy and Nutrition cum Day Care Center) to the impact of the universal H&N Program. Methodology Study Design A cross-sectional study consisting of three parts was carried out: 1) verbal questionnaire administered to individual respondents 2) focus group discussions with health workers (Health Activist/ASHA, Anganwadi Worker) and village representatives (VO office bearers, health sub-committee members, SHG members) 3) secondary data collected from VO record books and Anganwadi Center registers The study has three arms: two intervention arms and one control arm. The H&N Program has been implemented in two phases such that there are two different groups in which to measure outcomes. Phase I villages have universal H&N approaches including community investment fund (health savings/health risk fund, community gardens, weaning foods), capacity building, convergence with line departments, and case managers at government health facilities. Another subset of villages falls under phase II. Phase II villages are implementing the universal approaches plus a set of intensive activities under a method called CRP Strategy. Under the intensive activities, a set of community resource persons (CRPs) in each village are intensively trained to strengthen the components of the universal H&N program and to establish a community-managed Nutrition cum Day Care Center. The study is designed to separately measure outcomes of both of these approaches through a three-arm design: o + arm: universal H&N Program plus CRP Strategy and Nutrition cum Day Care Center o arm: universal H&N Program only o arm: No H&N Program (control) All villages have access to the same standard public health services provided by the government. Study Population Eligibility criteria Eligible participants are women between age 18 and 35 years who have at least one child under 5 years of age or are currently pregnant (and in at least the 5 th month of pregnancy). Participants in the + arm must be currently enrolled or previously enrolled in the Nutrition cum Day Care Center. The participants for the + arm are randomly selected from the list of beneficiaries that is kept in the base register at the Nutrition cum Day Care Center. Participants for the arm and arm are randomly selected from the VO and Anganwadi record books. Study Area Villages were randomly selected from each of the Giripragathi Mandals in Adilabad, Warangal, and Khammam. Within these Mandals, Phase II villages that have established Nutrition cum Day Care Centers (at least 6 months established) are included in the + arm. Phase I villages that have not yet established a Nutrition cum Day Care Center are included in the arm. Participants for the arm are selected from villages in Mandals that have not yet implemented the H&N Program, but are otherwise similar in socio-economic status to the intervention mandals. Selection of the control mandals was done with consent from the Project Officer, ITDA for each District. 19

20 Data Entry and Analysis Data entry was done by SOCHURSOD. Data cleaning and analysis was done by SERP using SPSS 13.0 statistical analysis software. One-way ANOVA was used to calculate 95% confidence intervals and test for significant differences between means for continuous outcome variables. Pearson s Chi Square statistic was calculated to test for significant differences between categorical outcome variables. Results Demographic and Socioeconomic comparability of study participants The respondents from each of the three study groups were found to be comparable based on a number of demographic and socioeconomic indicators (table 1). Comparability of the study groups with regard to these indicators minimizes the likelihood that selection bias was introduced in the analysis. The average age of respondent is similar across study groups: 25.8 years for the + arm, 24.3 years for the arm, and 24.1 years for the arm. Average duration of SHG membership is also similar across study groups: 2.9 years for the + group, 3.4 years for the group, and 3.2 years for the group. This is important to note because the duration of SHG membership likely correlates with the level of influence of community-managed Health and Nutrition activities on respondents knowledge and behavior. The number of respondents or household members holding a leadership position within IKP is similar across groups: 16.9% in the + group, 22.2% in the group, and 18.9% in the group. Holding a leadership position could reflect how active the respondent is in the communitymanaged programs. The majority of respondents in all three study groups are from scheduled tribes, the target population of Giripragathi: 73.6% in the + arm, 86.4% in the arm, and 73.3% in the arm. This reflects that the study is assessing outputs and outcomes among the intended population. The three groups are comparable on religious association with the majority in each group reporting Hindu. Education level is also similar across groups with the majority of respondents in each group reporting either illiteracy or education up to primary level. There is a trend towards more education among women in the group and group compared to the + group. This could bias the results in a conservative manner towards showing less difference between the + group and other groups than may actually be the case if the groups were better matched on education level. Economic status was assessed both directly (through questions related to income) and indirectly (through questions related to housing and occupation details). The average household income for the + group is Rs. 20,500; group is Rs. 22,650; and group is 18,400. The small difference in income across groups was not found to be statistically significant. In agreement, the proportion of respondents in each study group reporting Poor and Poorest of the Poor for economic status is similar. Indirect indicators of economic status also suggest comparability across study groups with respect to economic status. The majority of respondents in all three groups reported agriculture-related work as the main occupation of the household. There was a difference between the group and the study groups in terms of reporting agricultural laborer versus agriculture as primary occupation. However, land ownership is similar across groups suggesting that a similar percentage of agricultural workers in each group work their own land. In the NH+ group, 29.9% of respondents households own dry land (average amount of 4.1 acres) and 39.1% own wet land (average amount 3.7 acres). In the group 35.2% of respondents households own dry land (average amount of 4.6 acres) and 47.7% own wet land (average amount 3.7 acres). In the group, 27.8% of respondents households own dry land (average amount of 3.2 acres) and 40.0% own wet land (average amount 2.9 acres). The percentage of respondents owning livestock is also similar across groups: 51.8% in the + group, 59.0% in the 20

21 group, and 46.0% in the group. The majority of respondents in all three groups have selfacquired their house, and reported living in either a semi-pucca or thatched home. Housing details were also found to be similar across groups. In the NH+ group, NH group, and group respectively: 92.2%, 91.1% and 83.1% of households have electricity; 5.7%, 3.4%, and 9.0% have an ISL that is used by at least some household members; 5.7%, 12.5% and 6.7% have a household water connection; 3.4%, 3.4% and 8.1% have a closed waste disposal system; 4.6%, 4.5% and 5.6% use LPG or kerosene gas for cooking as opposed to firewood. The demographic and socioeconomic data collected from each participant suggests that the three groups are comparable. None of the differences between the groups were found to be statistically significant. It can be reasonably concluded that differences seen in health and nutrition outcomes and outputs can be attributed to the impact of the H&N program components. Table 1. Demographic comparability of study and control respondents + NDCC N = 87 N = 88 N = 90 Mean age of participant, Years (95%CI) 25.8 ( ) 24.3 ( ) 24.1 ( ) Mean duration of SHG membership, Years (95% CI) Respondent or Household Member holding IKP position, N (%) Religion, N (%) Hindu Muslim Christian Caste, N (%) Scheduled Tribe Scheduled Caste Minority Other Marital Status, N (%) Married Widow Separated Divorced 2.9 ( ) 3.4 ( ) 3.2 ( ) 15 (16.9%) 23 (22.2%) 17 (18.9%) 83 (95.4%) 0 4 (4.6%) 64 (73.6%) 9 (10.3%) 13 (14.9%) 1 (1.1%) 86 (98.9%) 0 1 (1.1%) 0 88 (100%) (86.4%) 3 (3.4%) 8 (9.1%) 1 (1.1%) 87 (98.9%) 1 (1.1%) (96.7%) 2 (2.2%) 1 (1.1%) 66 (73.3%) 11(12.2%) 12 (13.3%) 1 (1.1%) 88 (97.8%) 1 (1.1%) 0 1 (1.1%) Mean age at marriage, Years (95%CI) 17.6 ( ) 17.2 ( ) 17.9 ( ) Education Level of Respondent, N(%) Illiterate Primary Upper Primary Secondary Above Secondary Highest Education Level of Household, N(%) Illiterate Primary Upper Primary Secondary Above Secondary 61 (70.1%) 13 (14.9%) 7 (8.0%) 3 (3.4%) 3 (3.4%) 34 (39.1%) 13 (14.9%) 14 (16.1%) 12 (13.8%) 14 (16.1%) 56 (63.6%) 11 (12.5%) 6 (6.8%) 9 (10.2%) 6 (6.8%) 31 (35.2%) 14 (15.9%) 12 (13.6%) 12 (13.6%) 19 (21.6%) 48 (53.3%) 17 (18.9%) 7 (7.8%) 9 (10%) 9 (10%) 27 (30.3%) 13 (14.6%) 11 (12.4%) 17 (19.1%) 21 (23.6%) 21

22 Economic Status PoP N (%) Poor N (%) APL N (%) Mean household income (95% CI) Mean income of participant (95%CI) House Ownership by Respondent/Household, N(%) Self-acquired Subsidized by Government Rented + NDCC N = (46.0%) 43 (49.4%) 4 (4.6%) 20,500 (17,750-23,180) 3,700 (2,720-4,750) 61 (70.1%) 17 (19.5%) 9 (10.3%) N = (39.8%) 45 (51.1%) 8 (9.1%) 22,650 (18,210-27,090) 2,700 (2,290-3,190) 65 (73.9%) 20 (22.7%) 3 (3.4%) N = (55.6%) 38 (42.2%) 2 (2.2%) 18,400 (15,990-20,740) 2,600 (2,110-3,130) 61 (68.5%) 24 (27.0%) 4 (4.5%) Housing Details, N(%) Pucca Semi-Pucca Thatched Electricity Individual sanitary latrine in use Household Water Connection Closed waste drainage system Use of non-wood fuel for cooking Land Ownership by Respondent/Household Dry Land, N(%) Mean Acres of Dry Land (95% CI) Wet Land, N(%) Mean Acres of Wet Land (95% CI) Livestock Ownership by Respondent/Household, N(%) Primary Occupation of Household, N(%) Laborer -Agriculture Laborer-Non-Agriculture Agriculture/Dairy/Fishing Business Artisan Service/Salaried Work 10 (11.51%) 42 (48.3%) 35 (40.2%) 83 (92.2%) 5 (5.7%) 5 (5.7%) 3 (3.4%) 4 (4.6%) 26 (29.9%) 4.1 ( ) 34 (39.1%) 3.7 ( ) 13 (14.8%) 31 (35.2%) 44 (50.0%) 82 (91.1%) 3 (3.4%) 11 (12.5%) 3 (3.4%) 4 (4.5%) 31 (35.2%) 4.6 ( ) 42 (47.7%) 3.7 ( ) 15 (16.9%) 32 (36.0%) 42 (47.2%) 74 (83.1%) 8 (9.0%) 6 (6.7%) 7 (8.1%) 5 (5.6%) 25 (27.8%) 3.2 (2.53.9) 36 (40.0%) 2.9 ( ) 44 (51.8%) 52 (59.0%) 41 (46.0%) 25 (28.7%) 5 (5.7%) 44 (50.6%) 6 (6.9%) 0 7 (8.0%) 30 (34.5%) 3 (3.4%) 47 (54.0%) 2 (2.3%) 1 (1.1%) 4 (4.6%) 48 (53.9%) 2 (2.2%) 26 (29.2%) 0 4 (4.5%) 8 (9.0%) Impact on Utilization of government public health services One of the aims of the H&N program under Giripragathi is to raise awareness on public health services available to the tribal populations and to encourage women to take advantage of these services. Awareness and utilization of public health services is promoted by the Health Activists positioned in all villages (including + villages). This awareness campaign is intensified by the Community Resource Persons who are positioned only in the + villages. Thus, it was hypothesized that there would be highest utilization of public health services in the + group compared to both other groups, but utilization should still be higher in the group compared to the group. 22

23 Utilization of public health services during pregnancy was found to be significantly higher among the NH+ group and the group compared to the group (table 2). Compared to the group, a greater proportion of women in both the + and groups registered their pregnancy at a government facility (96.6% and 89.5% compared to 83.7%, p=0.019 for test of no difference between groups) and used government facilities for ante-natal care (81.6% and 75.0% compared to 57.8%, p=0.001 for test of no difference between groups). A similar trend was seen in type of facility utilized for institutional delivery. In the + group, 68.4% of women delivered at government facilities (39.5% at the PHC or CHC and 28.9% at a government hospital) and 31.6% delivered at a private facility. In the group, 51.2% of women delivered at government facilities (43.9% at the PHC or CHC and 7.3% at a government hospital), and 48.8% delivered at a private hospital. In the group, 42.6% of women delivered at government facilities (12.8% at the PHC or CHC and 29.8% at a government hospital), and 57.4% delivered at a private facility. It should be noted that in the group, among women who used a government facility for institutional delivery, the majority of them used the PHC or CHC rather than the government hospital. This was not the case for either the + group or the group. It is possible that by chance the PHC or CHC was very near to one of the villages chosen for the group. Another possibility is that the government hospital near to one or more villages in this group was not up to quality standards and so more women opt for the PHC or CHC. In the NH+ group, 90.8% of women were visited by the ANM following delivery whereas just 72.7% and 73.3% of women in the group and group respectively were received a post-natal check-up by the ANM (p = for test of no difference between groups). This suggests that women in + villages are either more educated and empowered to demand action out of the ANM. An interesting trend is seen between the three study groups in utilization of the Anganwadi Centers. One of the initial concerns of the H&N Program under Giripragathi was that services should not run parallel to or replace other government services. Rather, the objective is to fill in gaps and actually increase utilization of government services. In the early stages of the program, there was a concern that the Nutrition cum Day Care Center might be seen as a parallel service to the Anganwadi Centers in terms of child nutritional supplementation. As a way to investigate this concern in the tribal mandals, the impact assessment looked at enrollment of children in the Anganwadi Centers in each study group. Comparing the + group (where the Nutrition cum Day Care Centers are established) with the group, there is no significant difference in enrollment of children in the Anganwadi Centers. In the + group, 74.1% of women enrolled their children in the Anganwadi Center and 76.1% of women in the group enrolled their children in the Anganwadi Center (p=0.298 for test of no difference between groups). In the + group, 14.1% of women enrolled children in both the Anganwadi Center and the NDCC, suggesting that at least some women see value from both of these programs. A government program that is promoted by the Health Activists (or ASHAs in the villages) and health CRPs is the Janani Suraksha Yojana, or JSY scheme. JSY is a monetary incentive given to the rural poor, with a particular focus on the tribal populations, for institutional delivery. Among women surveyed, there was no significant difference between the groups in receipt of JSY funds. In all three groups, the percentage of women receiving JSY following institutional delivery was alarmingly low; just 26.3% in the + group, 36.6% in the group, and 36.2% in the group (p=0.319 for test of no difference among the groups). Of the few women who received their JSY funds, many women in all three groups reported not receiving the money on the day of delivery but rather many days (over one year in some cases) post delivery when it can no longer be useful for its intended purpose of covering deliveryrelated expenses. Another program available to tribal populations through the Department of Rural Development is Food Security. Enrollment of tribal households in this program is encouraged by the H&N Program and by the CRPs in particular. In the NH+ group 23.0% of women enrolled in the Food Security scheme whereas 23

24 just 4.5% of women in the group and no women in the group enrolled (p < for test of no difference between groups). While enrollment is still relatively low among respondents in the + group, it is still much better than the group or group. Table 2. Impact of H&N Program on utilization of government public health services Women registering pregnancy* at: Government Health Institution Private Health Institution Women with at least one ANC check-up* at: Government Health Institution Private Health Institution Institution chosen for delivery**: PHC/CHC Government Hospital Private Hospital Received JSY financial incentive for institutional delivery** Women received post-natal check-up from ANM** Women with children enrolled in: Anganwadi School only Anganwadi School and NDCC NDCC only Neither AWC nor NDCC + NDCC N = (96.6%) 3 (3.4%) 71 (81.6%) 22 (25.3%) 15 (39.5%) 11 (28.9%) 12 (31.6%) N = (89.5%) 9 (10.5%) 66 (75.0%) 27 (30.7%) 18 (43.9%) 3 (7.3%) 20 (48.8%) N = (83.7%) 14 (16.3%) 52 (57.8%) 39 (43.3%) 6 (12.8%) 14 (29.8%) 27 (57.4%) Chisquare p-value (26.3%) 15 (36.6%) 17 (36.2%) (90.8%) 64 (72.7%) 66 (73.3%) (60.0%) 12 (14.1%) 1 (1.2%) 21 (24.7%) 54 (65.9%) (34.1%) 67 (76.1%) (23.9%) # Women enrolled in Food Security 20 (23.0%) 4 (4.5%) 0 *current pregnancy if respondent was pregnant at the time of survey; otherwise last pregnancy within 2yrs **most recent delivery # chi-square statistic and associated p-value calculated for comparison between enrolled in AWC and not enrolled in AWC Outcomes of Giripragathi H&N Program on health seeking behavior change Health seeking behavior regarding maternal and child health was assessed in the Giripragathi Districts (table 3). There was no significant difference measured among the groups in the percentage of women with three complete antenatal care check-ups (56.3% in the + group, 46.6% in the group and 60.0% in the group; p=0.180). In all three groups the percentage was quite low. More women in each group reported receiving at least one complete check-up compared to three complete check-ups but there was still no difference between groups. There was, however, a significant difference between the groups in percentage of women who took the full course of iron-folic acid tablets provided at the antenatal care check-up. Of women who received IFA tablets, 75.6% of women in the + group took the full course, 66.7% of women in the group took the full course, and 50.0% of women in the group took the full course (p<0.001 for test of no difference between groups). Completing the course of IFA tablets is probably a better measure of behavior change than number of ANC visits as it depends only on the decision of the woman herself rather than external factors like availability and quality of services. The percentage of women who chose to deliver at home rather than an institution was similar among all three groups. In the + group, 54.8% of deliveries were conducted at home, in the group 46.8% of 24

25 deliveries were conducted at home, and in the group 46.0% of deliveries were conducted at home (p=0.453 for test of no difference between groups). However, among women who delivered at home, there was a significant difference in choice of attendant who assisted with the delivery. 61.5% of women in the + group had a trained attendant present during home delivery whereas 34.4% of women in the group and just 25% of women in the group had a trained attendant present (p=0.004 for test of no difference between groups). There was no significant difference between the study groups in terms of child immunization. 86.4%, 74.1%, and 81.1% of children under 1yr in the + group, group, and group respectively were either fully immunized or being immunized as per schedule (p=0.253 for test of no difference between groups). 11.9%, 20.7%, and 18.9% of children under 1yr in the + group, group, and group respectively were partially immunized but not according the recommended schedule. Very few children had not yet received any of the recommended immunizations. There is a trend towards improvement in practice of neonatal and infant care techniques among women covered by the H&N Program. 86.9% of women in the + group, 76.0% of women in the group, and 72.6% of women in the group fed their neonate colostrum immediately after birth (p=0.063 for test of no difference between groups). Similarly, 89.2% of women in the + group, 76.3% of women in the group, and 70.7% of women in the group gave no pre-lacteal fluids to their neonate (p=0.012 for test of no difference between groups). The percentage of women who immediately wrapped their neonate after birth was very high in all three groups (96.4% in the + group, 98.7% in the group, and 100% in the group; p = for test of no difference between groups). However, the percentage of women who delayed bathing of their neonate was very low in all three groups. A slightly higher percentage of women in the + group delayed bathing compared to the other two groups, but the difference was not statistically significant (36.7% compared to 21.2% and 22.7%; p=0.113 for test of no difference between groups). This may be a particularly difficult behavior to change through the Health Education strategy alone. Exclusive breastfeeding of infants for at least 6 months was also slightly low across the three study groups: 53.1% in the + group, 65.3% in the group, and 63.4% in the group. Closer examination of the data showed that most women introduce weaning foods at the recommended time (6 months), but a large percentage of women in all three groups either do not breastfeed or breastfeed for less than 6 months. This issue could be better emphasized in the Health Education sessions. Table 3. Outcomes of Behavior Change Communication strategy on health seeking behavior. + NDCC N = 87 N = 88 N = 90 Chisquare p-value Women received 3 complete ANC check-ups* 49 (56.3%) 41 (46.6%) 54 (60.0%) Women received at least 1 complete ANC check-up* 65 (74.7%) 54 (62.8%) 68 (78.2%) Women who took full course of IFA tablets, N(%) 62 (75.6%) 50 (66.7%) 39 (50.0%) <0.001 Women delivering at home 46 (54.8%) 36 (46.8%) 40 (46.0%) Choice of Attendant for Home Delivery Trained attendant Untrained attendant Child (<1yr) Immunizations Fully immunized or being immunized as per schedule Partially immunized but not on schedule Not immunized 24 (61.5%) 15 (38.5%) 51 (86.4%) 7 (11.9%) 1 (1.7%) 11 (34.4%) 21 (65.6%) 43 (74.1%) 12 (20.7%) 3 (5.2%) 9 (25.0%) 27 (75.0%) 43 (81.1%) 10 (18.9%)

26 Women practicing neonatal and infant care: Colostrum feeding No pre-lacteal fluids Immediate wrapping Delayed bathing (7 days) Exclusive breastfeeding (6 months) 73 (86.9%) 74 (89.2%) 81 (96.4%) 22 (36.7%) 43 (53.1%) 57 (76.0%) 58 (76.3%) 75 (98.7%) 11 (21.2%) 49 (65.3%) 61 (72.6%) 58 (70.7%) 85 (100%) 15 (22.7%) 52 (63.4%) *complete ANC check-up defined as: three visits with each visit including BP measurement, weight measurement, and abdominal check plus distribution of IFA tablets at one of the visits and at least one tetanus toxoid vaccination Outcome of the Health Education strategy for health and nutrition knowledge under the Giripragathi H&N Program A greater percentage of women in the + and groups were found to be knowledgeable on a number of health topics covered by the Health Activists and CRPs compared to women in the group. In the + group and group, 93.1% and 96.6% of women respectively have some knowledge on methods adopted to prevent diarrhea, compared to just 60.0% of women in the group (p<0.001 for test of no difference between groups). Among specific methods stated, a greater percentage of women in the + and group know to boil drinking water and cover water vessels whereas most women in the group know only to wash hands to prevent diarrhea. Similarly, 83.9% of women in the + group and 90.9% of women in the group have some knowledge of home remedies for treatment of diarrhea compared to 65.6% of women in the group (p<0.001 for test of no difference between groups). Knowledge on malaria is generally high among all three groups but there is still a significant difference among the groups. 94.3% of women in the + group and 97.7% of women in the group have knowledge of malaria symptoms compared to 86.7% of women in the group (p=0.014 for test of no difference between groups). While most women in all three groups know fever and chills are malaria symptoms, more women in the + and groups know that body/head ache and nausea are also malaria symptoms. Knowledge is high across all groups on transmission of malaria (96.6% in the + group, 92.0% in the group and 87.8% in the group; p = for test of no difference between groups). In all three groups, out of respondents who have any knowledge, all said mosquitoes were a mode of transmission. No women know of mother-to-child transmission of malaria, suggesting this is a topic to focus on in the Health Education sessions by the Health Activist. Significantly more women in the + and groups know that bednets should be used to prevent malaria compared to the group (63.2%, 58.0%, and 38.9% respectively; p=0.003 for test of no difference between groups). Even more encouraging is the finding that significantly more women in the + and groups actually use bednets for sleeping. 64.4% and 60.2% of women in the + group and group respectively reported that all household members sleep under bednets compare to just 32.2% of women in the group (p<0.001 for test of no difference between groups). A few more respondents in each group reported using bednets than reported knowledge of bednets to prevent malaria. It may be that some women know that bednets can prevent insect-borne illness but do not know what illnesses are transmitted by insects. Knowledge on HIV is also significantly higher among women in the + group and the group compared to women in the group. 95.4% of women in the + group, 88.5% in the group, and 77.8% of women in the group have heard of HIV (p = for test of no difference between groups). A similar trend is seen with knowledge of transmission of HIV: 93.1% of women in the + group, 86.4% of women in the group, and 71.1% of women in the group (p<0.001 for test of no difference between groups). For each possible mode of transmission of HIV, more women in the + group had knowledge compared to both of the other groups. Similar to malaria transmission, mother-to

27 child is a mode of transmission that women in all three groups are not aware of, further suggesting that this important topic should be given emphasis in the Health Education sessions by the Health Activist. Table 4. Outcomes of Health Education strategy. Chi-square statistic was calculated for each indicator by comparing any knowledge with no knowledge. The percentage of women reporting each response was calculated by using the number of women who had any knowledge as the denominator. Methods to prevent diarrhea Any Knowledge Regular hand washing Breastfeeding children for 2yrs Covering water vessels Boiling drinking water No defecation near water sources Clean eating vessels Knowledge of home remedies for treatment of diarrhea Any Knowledge Clean water Coconut water Continued breastfeeding Liquid foods Oral rehydration solution Knowledge on malaria symptoms, N(%) Any Knowledge Intermittent fever, chills Body or head ache vomiting and nausea Knowledge on malaria transmission Any Knowledge Mosquitoes Mother-to-child + NDCC N = (93.1%) 41 (50.6%) 2 (2.5%) 34 (42.0%) 36 (44.4%) 5 (6.2%) 17 (21.0%) 73 (83.9%) 22 (30.1%) 5 (6.8%) 13 (17.8%) 9 (12.3%) 51 (69.9%) 82 (94.3%) 75 (91.5%) 55 (67.1%) 10 (12.2%) 84 (96.6%) 84 (100.0%) 0 N = (96.6%) 48 (56.5%) 2 (2.4%) 36 (42.4%) 23 (27.1%) 0 14 (16.5%) 80 (90.9%) 21 (26.3%) 4 (5.0%) 9 (11.3%) 4 (5.0%) 66 (82.5%) 86 (97.7%) 78 (90.7%) 48 (55.8%) 10 (11.6%) 81 (92.0%) 81 (100.0%) 0 N = (60.0%) 40 (74.1%) 0 13 (24.1%) 12 (22.2%) 7 (13.0%) 6 (11.1%) 59 (65.6%) 17 (28.8%) 1 (1.7%) 6 (10.2%) 4 (6.8%) 46 (78.0%) 78 (86.7%) 75 (96.2%) 24 (30.8%) 2 (2.6%) 79 (87.8%) 79 (100.0%) 0 Chisquare p-value <0.001 < Knowledge of bed nets to prevent malaria 55 (63.2%) 51 (58.0%) 35 (38.9%) Use of bednets by All household members Parents only Children only No one 56 (64.4%) 3 (3.4%) 17 (19.5%) 11 (12.6%) 53 (60.2%) 8 (9.1%) 10 (11.4%) 17 (19.3%) 29 (32.2%) 1 (1.1%) 13 (14.4%) 47 (52.2%) <0.001 Knowledge on HIV heard of HIV tested for HIV Knowledge of HIV transmission Any Knowledge Unprotected sex Used needles Unscreened blood transfusion Mother-to-child 83 (95.4%) 53 (60.9%) 81 (93.1%) 42 (51.9%) 68 (84.0%) 48 (59.3%) 1 (1.2%) 77 (88.5%) 39 (44.8%) 76 (86.4%) 34 (44.7%) 56 (73.7%) 32 (42.1%) 2 (2.6%) 70 (77.8%) 46 (51.1%) 64 (71.1%) 26 (40.6%) 55 (85.9%) 27 (42.2%) <

28 Impact of H&N Program on Maternal and Child Health Indicators Although the Giripragathi H&N Program has only been implemented for two years, the assessment measured some indicators of long-term impact to investigate any small differences in the early stages and to establish a baseline for future comparison. The study attempted to estimate the average weight gain during pregnancy, though it is difficult to obtain accurate measurements for this indicator. The data shows no statistically significant difference between the groups in average weight gained during pregnancy, though in the group the estimate was 1.5kgs more weight gain than the two H&N groups. The 95% confidence intervals overlapped for all three groups so it can not be concluded that the difference is significant. For some women, the first ANC check-up was during the 3 rd month and for others it was during the 4 th month. This results in a potential difference of two months in the time of weight measurement, and could bias the results. There was a trend towards significant difference in type of delivery between the three groups. In the NH+ group 85.7% of women had a normal delivery, 11.9% had a cesarean delivery, and 2.4% had a complicated delivery. In the NH group 76.6% of women had a normal delivery, 16.9% had a cesarean delivery, and 6.5% had a complicated delivery. In the group, 67.8% of women had a normal delivery, 25.3% had a cesarean delivery, and 6.9% had a complicated delivery (p = for test of no difference between groups). An attempt was made to gather data on birth weight among the study respondents but, similar to weight gain by the pregnant woman, it was difficult to obtain accurate data. In the + group, data was obtained from the Nutrition Center base register and in the other two groups data was obtained from the Anganwadi Center books. In either case, the appropriate infant scale is often not available or not functional. The majority of weights recorded are rounded to the nearest kg or half kg and many are likely to have been made using an adult-type scale. Based on the data available, there was no statistically significant difference in birth weight among the three groups. Average birth weight in the NH+ group was 2.88kg, in the group it was 2.80kg, and in the group it was 2.78kg. The assessment attempted to collect data to be used towards estimating neonatal, infant, and child mortality. However, these events were too rare to capture an accurate estimate with the relatively small sample size. There was one neonatal death in the + group and one infant death in each of the and groups. Table 5. Maternal and Child Health and Nutrition. All indicators were calculated using details from the most recent completed pregnancy or youngest child for each respondent Chisquare + NDCC N = 87 N = 88 N = 90 p-value Weight gain during pregnancy* 7.0 ( ) 7.0 ( ) 8.5 ( ) - Type of delivery, N(%): Normal Cesarean Complicated # 72 (85.7%) 10 (11.9%) 2 (2.4%) 59 (76.6%) 13 (16.9%) 5 (6.5%) 59 (67.8%) 22 (25.3%) 6 (6.9%) Mean Birth Weight**, kg 2.88 ( ) 2.80 ( ) 2.78 ( ) - (95%CI) Child Malnutrition, N(%) Underweight Stunted Wasted 28

29 Neonatal (<28 days) deaths, N Infant (<1yr) deaths, N Child (>1yr; <5yrs) deaths, N * weight gain calculated for first ANC check-up (3 rd or 4 th month) through delivery **birthweight includes only children weighed within 7 days of birth # obstructed labor, prolonged labor, hemorrhage, fits Comparison of Current Outcomes in Giripragathi Districts with Baseline Survey Data A qualitative survey was conducted in April 2007 as part of a Needs Assessment activity done prior to designing the health and nutrition interventions under Giripragathi. The survey was done by conducting a group-based questionnaire among SHG women in each of the Mandals covered by Giripragathi. While the study methodology and question structure was not the same as the current quantitative study, a few comparisons can be made to roughly assess the change in health and nutrition status over time (table 5). The results of the two surveys suggest that satisfaction with both the quality and supply of supplementary nutrition provided by the Anganwadi Centers may have improved over time. Though this could be simply due to changes in the ICDS program over time, it could also reflect demand for more quality services by the community. There is evidence of a trend towards increased use of government facilities for registration of pregnancy and antenatal care. In the baseline survey, 41.3% of women responded that they register their pregnancies at the PHC or government hospital and 60.3% said they prefer the government hospital for ANC. In the current survey, 93.1% of women said they registered their last pregnancy at the PHC or government hospital and 78.3% used government facilities for at least one ANC check-up during their last or current pregnancy. The questions regarding antenatal care in both surveys were slightly different in nature, but some comparison can be made. In the baseline survey, 19.3% of respondents knew that at least three ANC check-ups are recommended. Just 6.3% of respondents knew what constitutes complete ANC. In the current study, 51.4% of women had three complete ANC check-ups. Both surveys included a question on place of delivery. In the baseline survey, women were asked what they thought was an appropriate delivery place, but they were allowed multiple responses so the majority of women selected all options given. It is not known what the preferred place of delivery was. In the current survey, women were asked where they delivered for their most recent delivery. Thus, the questions are not really comparable. In both surveys, women were asked about neonatal care practices. In the baseline survey, 39.1% of women fed their neonate colostrum compared to 81.3% of women in the current survey. A difference was also seen in women giving no pre-lacteal fluids to neonates: 30.8% of women in the baseline survey compared to 82.5% of women in the current survey. There was a difference in the percentage of women who waited 6 months before introducing weaning foods to infants. In the baseline survey, 18.6% of women introduced weaning foods before 6 months compared to 4.8% of women in the current survey. A few common questions were asked in both surveys regarding communicable disease and HIV. There was no difference in knowledge of home remedies for treatment of diarrhea. In the baseline survey, 86.4% of women knew of some home remedy compared to 87.4% of women in the current survey. There was a difference in knowledge on HIV. In the baseline survey, 69.3% of women had heard of HIV compared to 91.4% of women in the current survey. There are some differences in the percentage of women who know of HIV transmission routes between the two surveys, but in the baseline survey, the respondents were probed for answers rather than given open-ended questions so the responses were likely to be higher for these types of questions. 29

30 Table 5. Comparison of health and nutrition inddicator in Giripragathi villages between baseline and current surveys Baseline Survey* (April 2007) Current Survey** (January 2009) N = 2703 N = 175 Quality of supplementary food at AWC Satisfied Not satisfied Supply of supplementary food at AWC Satisfied Not satisfied Institution where pregnancy is registered, N(%) PHC/government facility AWC Private facility Preferred facility for ANC Government facility Private facility Home visit from ANM Public Health Services 2060 (76.2%) 643 (23.8%) 2057 (76.1%) 646 (23.9%) 1116 (41.3%) 1039 (38.4%) 410 (15.2%) 1629 (60.3%) 738 (27.3%) 321 (11.9%) Quality of supplementary food at AWC Satisfied Not satisfied Supply of supplementary food at AWC Satisfied Not satisfied Institution where pregnancy is registered, N(%) PHC/government facility Private facility Women with ANC check-up at: Government facility Private facility Knowledge and practice on maternal and child health Women who know 3 ANC visits are necessary 523 (19.3%) Women who know what constitutes complete ANC 170 (6.3%) Appropriate place for delivery, N(%) # Government health facility 2250 (83.2%) Private health facility 1530 (56.6%) Home with trained attendant 1174 (43.4%) Home with untrained attendant 2057 (76.1%) Women practicing neonatal care, N(%): Colestrum feeding No pre-lacteal fluids Introduction of weaning foods: Before 6 months 6-8 months after 8 months Measures taken in case of child with diarrhea # 1056 (39.1%) 832 (30.8%) 502 (18.6%) 2038 (75.4%) 163 (6.0%) Women who had 3 complete ANC checkups Place chosen for last delivery, N(%): Government health facility Private health facility Home with trained attendant Home with untrained attendant Women practicing neonatal care, N(%): Colestrum feeding No pre-lacteal fluids Introduction of weaning foods: Before 6 months 6-8 months after 8 months Knowledge on communicable disease and HIV Measures taken in case of child with diarrhea # Any knowledge Clean water Coconut water Continued breastfeeding Liquid foods Oral rehydration solution Do not know 111 (91.7%) 10 (8.3%) 111 (99.1%) 1 (0.9%) 161 (93.1%) 12 (6.9%) 137 (78.3%) 49 (28.0%) 90 (51.4%) 47 (29.4%) 32 (20.0%) 35 (21.9%) 36 (22.55) 130 (81.3%) 132 (82.5%) 7 (4.8%) 127 (86.4%) 13 (8.8%) Any knowledge Give fluids Give coconut water Give rice water Give other food Do not know 2335 (86.4%) 617 (22.8%) 947 (35.0%) 1540 (57.0%) 1027 (38.0%) 368 (13.6%) 153 (87.4%) 43 (28.1%) 9 (5.9%) 22 (14.4%) 13 (8.5%) 117 (76.5%) 22 (12.6%) Women who have heard of HIV, N(%) 1874 (69.3%) Women who have heard of HIV, N(%) 160 (91.4%) Women who know how HIV is transmitted #, N(%) Sex with an infected person Injection drug use Unscreened blood transfusion Mother-to-child 2020 (74.7%) 1177 (43.5%) 1114 (41.2%) 883 (32.7%) Women who know how HIV is transmitted #, N(%) Unprotected sex Used needles Unscreened blood transfusion Mother-to-child 76 (43.4%) 124 (70.9%) 80 (45.7%) 3 (1.7%) 30

31 *includes women living in the same mandals covered by the current impact assessment study **includes women from both the NH+ group and group # multiple responses possible Discussion The results of this early study of outcomes of the H&N Program under Giripragathi are encouraging. The biggest differences between the study groups and the group are seen in the health knowledge and a few of the behavior change indicators, as expected for the early stages of this type of program. This is important as it is an indication of the strength of the Health Activists and CRPs. One of the main focuses of the H&N interventions is capacity building of these health workers and the community (SHG members) as a whole. So, it is encouraging to find that the biggest impacts so far are coming from these efforts. For some of the behavior change indicators there is little or no difference between the study groups and the group. For example, there was no significant difference between the groups in the percentage of women who received complete ante-natal care. It is not known if this is due to lack of awareness among some women or if it is related more to deficiencies in the quality or type of services provided at the health care facilities. A similar issue may explain the lack of impact on the proportion of women delivering at home rather than an institution. It is possible that the high percentage of women who delivered at home in all three study groups is a reflection of the facilities available. This could be masking a potential difference between the groups in the preferred practices of the women. With a number of indicators, it seems that there is a greater impact of the H&N Program on practices that do not depend on health service facilities but rather depend only on the knowledge and decisions of the women themselves. There are also encouraging effects on utilization of government services and health facilities over private facilities. More women in the study groups used government facilities for antenatal care. Similarly, among women who chose institutional delivery, more women in the study groups delivered at government facilities. More women in the study groups also participated in the Food Security scheme. These outcomes reflect the strength of the convergence activities under Giripragathi. There is a focus on raising awareness of government services and in holding service providers accountable. The fixed NH Days bring the government health workers in contact with the community and allow the community to voice any concerns they might have regarding gaps in services being provided. This could be building more trust between the community and the government service providers, leading to increased utilization of the government facilities. Another explanation for the increase in use of government facilities could be related to health expenditure. The Health Activist and CRPs encourage the SHG women to try to reduce expenditure on health by using government services over private services whenever possible. The percentage of women who received the JSY entitlement in all three study groups was disappointingly low, suggesting several possible problems with utilization of this scheme. One possibility is that awareness is low among the tribal population as a whole and the Health Activists (or ASHAs in villages) and CRPs are not having any impact on raising awareness. Another possibility is that these health workers are in fact raising awareness but this awareness is masked by inefficiencies in the JSY program itself. Even if women are aware that they are entitled to JSY funds, the hospital may not be filing the correct paperwork or the local government may not be receiving and/or releasing adequate funds to distribute to every eligible woman. The funds for JSY are made available from the District to the Medical Officers at the PHCs based on the estimated BPL population under each PHC catchment area. The money is supposed to be dispersed to the beneficiary at the time of delivery by either the ANM or ASHA. There are a number of points in this chain where problems can arise regardless of whether the beneficiary is aware of her entitlement. 31

32 For a number of the indicators there was a significant difference between the + group and the group, suggesting that the additional intensive approaches taken in these villages are having an additional impact on outcomes. One possible explanation is that the presence of the health CRPs in these villages could be having an additional impact on awareness of health and access to health services. For a number of indicators measured by this study, there appears to be a dose-dependent effect of the H&N Program where the most favorable outcomes are seen in the + group compared to the other two groups, but still some effect is seen in the group compared to the group. This supports the hypothesis that the intensive CRP strategy contributes to outcomes above and beyond the universal H&N program. It also supports the hypothesis that the Nutrition Center serves not just as a feeding center but as a forum for discussion among women on health and health services that could lead to increased awareness and behavior change. The additional strategies in the + villages are expected to build upon the universal approaches, adding a more intensive means of reaching the same outcomes. This is particularly seen in the health knowledge indicators. For example the highest knowledge on HIV is seen among women in the + group (95.4%), followed by slightly less knowledge among the women in the group (88.5%) and even less knowledge among women in the group (77.8%). One possible explanation is that the CRP strategy may be helping to motivate the Health Activist to follow the regular schedule of Health Education sessions. The added benefit could also be coming from the Nutrition cum Day Care Centers where women spend a significant amount of their day not only having meals but sitting with the Health Activist for extra sessions and sitting amongst other women who are interested in improving their health knowledge and behavior. It should be noted though that there is a chance for selection bias in the + group as the women in this group chose to enroll in the NDCC and may therefore be inherently more health-conscious than women in the group or group. However, enrollment is often dependent upon very active and dedicated CRPs, so the better outcomes in the + groups likely reflect the effect of the CRP Strategy more so than any residual selection bias. There were no significant differences detected regarding outcome indicators such as neonatal, infant and child death, birth weight, or weight gain during pregnancy. For the indicators of mortality, a longer implementation period and larger study sample size are likely needed to detect any real impact. The lack of measurable difference between the groups in weight gain during pregnancy and infant birth weight was surprising. It may be that a longer implementation period is need for the Nutrition Centers to have an impact in this area. When the centers first opened, many women did not enroll until the last trimester so impact on weight gain during entire pregnancy may not be evident yet. Now centers are enrolling women earlier in the pregnancy so future studies may show increased weight gain among these women. The results could also reflect gaps in utilization of the Centers by beneficiaries. Some women enroll but only have meals at the Center for a portion of the month. A similar situation may be true for children. This problem should be further assessed and rectified at each Center as it could become a major impediment in the program achieving its objective of reducing child malnutrition. Overall, the health component of Giripragathi appears to be making progress towards the stated objectives. As the health program itself was not fully implemented until one year after the Giripragathi project started, it may take more time to see some of the longer-term impacts. However, the changes seen in health related knowledge and health seeking behavior are encouraging. The lack of change seen in some of the indicators is also informative and can be used to guide strengthening activities in the future. 32

33 Qualitative Impact Assessment 33

34 Summary of Focus Group Discussions held in Warangal, Adliabad and Khammam Districts As a part of the comprehensive Assessment of Health and Nutrition Pilot Outcomes under APRPRP, focus group discussions involving a range of stake holders including ANC and PNC mothers, key functionaries of VOs, health sub-committees, NDCC and frontline health functionaries, were held in the three Districts covered by the Giripragathi project. There has been a slow but steady trend in the increase on awareness of health issues which has resulted in a consistent growth in the utilization of health services, over the last decade. This upward trend in utilization of health services can be attributed to a number of factors. Prime among them are the an increase in the number of front line health care personnel, more number of health service delivery points, enhanced range of medical services, better infrastructure and communication facilities, higher level of general and health awareness among people, besides the range of general and focused health centered programs undertaken by the government. VOs involved in Focus Group Discussion in Warangal, Adliabad and Khammam Districts District Mandals Village Organizations Type of VO Bhulaxmi + Jainoor Sriram + Siddeswar Adilabad Mahadevi + Sirpur-U Maheswari + Jyothi Lakshmi Thiryani Jangubai Jayalakshmi Dharalamma + Chintur Jayam Gs + Saibaba Khammam Chintaregupalli Gis + V.R.Puram Ummadivaram Gis + Mulakanapalli Bhadrachalam Bhadradri Gis Kristavaram Gs Sitanagaram + Gudur Sneha + Ushakiranam + Bhagyasree Warangal Durgabai + Kothaguda Chaitanya Khanapur Siri Srilakshmi 34

35 Key findings emerging from the Focus Group Discussions of the H-N interventions 1. General community health and nutrition situation over the last five years + There has been an overall change for the better in the general community health and nutrition situation, over the last five years, in all areas. The following are some of the key areas of change in health and nutrition situation in the + and villages: Increased health and nutritional awareness Increase in utilization of health care facilities Better access to health care facilities Dependence on trained personnel for health care Increased availability of front line health functionaries Availability of emergency health fund (health and general savings) These changes can largely be attributed to the programs being undertaken in these places. Though these changes can also be seen in the control areas, the degree of change is relatively smaller. 2. Health and nutrition situation of women in the reproductive age group, particularly, currently pregnant and lactating mothers and under-5 children over the last 5 years + Shift from home to institutional deliveries Increased and regular ANC check ups Increase in immunization of mother and child Greater utilization of NDCC services More enrollment of mother and child in Anganwadi Centers Utilization of medical and nutritional services on NH days Increased dependence on trained health personnel Same as above, with the exception of NDCC services Same as above, with the exception of NDCC services, but on a relatively smaller scale 35

36 3. Ante-natal care practices + All ANC cases are being registered with the active role of the Health Activist, Health Sub-Committee and CRPs. Also, ASHA, Anganwadi workers and ANMs are lending a hand in mobilizing ANC cases for registration. Fixed NH Day service points are the nodal points for convergent services involving ANC registrations, regular medical checkups, issue of IFA tables and administering of TT injections and nutrition services. Nutrition Centers, besides providing nutrition services, also facilitate interaction between beneficiaries and front line health workers, thereby promoting health awareness and health seeking behaviour of ANCs. Same as above, but on a slightly smaller scale, with the exception of services rendered through the Nutrition Center. ANC cases are being registered by ASHA, Anganwadi workers and ANMs. However, it has been observed that utilization of ANC services is low to moderate in these areas, owing to lack of adequate number of health functionaries to mobilize ANCs for regular check ups. 4. Changes in delivery practices There has been a marked shift from home to institutional deliveries. This can be attributed to the mobilization of ANCs for institutional deliveries by the Health Activists, Health Sub-Committees apart from ASHA workers, Anganwadi workers and + ANMs. The Nutrition Centers are proving to be ideal places where ANCs can be informed of health issues, on a day to day basis, and can be motivated for institutional deliveries, Here too, a shift from home to institutional deliveries can be observed. However, the day to day follow-up of ANCs is not possible, as done in case of areas with Nutrition Centers. By and large, there is a shift from home to institutional deliveries. In the absence of regular follow-up services of the health functionaries and health sub-committees, not all ANCs are mobilized for institutional deliveries. With the exception the periodic services of the ANM, ASHA and the Anganwadi workers, ANCs in areas do not receive any other health follow-up services promoting ANC care and institutional deliveries. 36

37 5. Neo-natal care & practices + As most of the deliveries are institutional, immunization of the new born is assured. Also, mothers are provided advice on neo-natal care by trained health personnel. The following practices can be observed: Colostrum feeding of the baby within the first hour of birth Wrapping of new born children in clean, soft cotton clothing Abstaining from giving of pre-lacteal fluids to infants Giving bath to the infant after 5-7 days areas too demonstrate the practices stated above. However, respondents were less consistent in adhering to neo-natal care & practices, owing to lack of regular follow up on monitoring of adherence to prescribed neo-natal practices. Mothers in areas too have access to information on neo-natal care. However, actual adherence to these practices is left to the mothers, as there are no health functionaries to provide the necessary follow-up. 6. Post-natal services and practices + Exclusive feeding of mothers milk to the children. Registration at the Anganwadi Centers and utilization of Anganwadi Supplementary nutrition by the lactating mothers Facilitation of timely immunization of children by Health Activists, Health Subcommittee, ASHA workers, AWWs and ANCs. Nutrition support and health counseling to PNCs in Nutrition Centers With the exception of nutrition support extended to PNCs in Nutrition Centers, areas exhibit practices similar to + areas. In the absence of regular follow-up of PNCs by health functionaries, immunization of children in areas is less than that of + and areas. Though PNCs are aware of the place of immunization, they need reminders from health functionaries regarding the times and schedule of immunization of children. Note: In many cases Vaccination Cards were not available with respondents as they were either misplaced or lost. 7. Recent illness episodes and infant/child/maternal mortality in the community + There were a few cases of infant/child/maternal mortality in the community but the incidence of these cases was small and not enough to draw inferences. 37

38 8. Awareness of communicable diseases The awareness level ranged from moderate to high, owing to the health counseling provided by external trainers and internal health frontline workers. Prevalence rates of diarrhea, malaria TB and was low. There were a few random cases of HIV reported. + Though medical care was being availed in case of incidence of diseases, not much emphasis is being placed on prevention of diseases. The awareness level of communicable diseases ranged from low to moderate. Many of the respondents were unaware of steps needed to prevent communicable diseases such as diarrhea and TB. Respondents had a fair awareness of the AIDS epidemic. The awareness level of communicable diseases, the ability to distinguish between diseases, and the types of diagnostic tests needed was low. Respondents had a fair awareness of the AIDS epidemic. The general tendency is to seek the assistance of health functionaries in event of any type of ailment. No precautionary steps were being taken for prevention of diseases. 9. Hygiene practices being adopted in the community Awareness of hygiene practices was high. This can be attributed to the health training + provided by CRPs (internal and external) and health activists. However, implementation of hygiene practices ranged from moderate to high. Awareness of hygiene practices was ranged from moderate to high. However, implementation of hygiene practices ranged from low to moderate. Awareness of hygiene practices was just moderate. This can be attributed to the fact that there are no special health functionaries available to provide information on hygiene practices and to monitor implementation, besides the AWW. There is ample scope for improvement in implementation of hygiene practices. 10. Sanitation situation in the village + Most villages lacked proper public sanitary infrastructure and policies for solid and liquid waster disposal systems. Most homes do not have toilets and homes with toilets do not have running water. Homes and streets lack a proper system of solid and liquid waste disposal. It is common to see drains left out into the open giving rise to stagnant pools. There were a few instances where community sanitation works such as cleaning of overhead water tanks, prevention of water logging near public taps, and sprinkling of waste oil on stagnant water pools to prevent breeding of mosquitoes. Concerted efforts by village organizations in improving the sanitation situation in villages were few and far between. 38

39 11. Role of CBOs in promoting healthy behaviour of the people The VO and the Health Sub-committee play a major role in setting up and managing the day to day activities of the Nutrition centers. Also, a health agenda has been introduced in each CBO meetings where current health issues are discussed and + follow-up action is taken. The VO Office Bearers / Health Sub-committee and SHG leaders are being imparted health training by the Master Trainers, as per the schedule in the training calendar. Same as above. There is no special focus on health issues by the CBOs. Though health issues are discussed in the VO and SHG meetings, no specific health promotional activities are being taken up. 12. Knowledge of health facilities and services available + People have a high level of awareness of the health facilities and services available within the village. They have a moderate level of awareness of health facilities and services available at the mandal level, and a limited level of awareness of health facilities and services available at the district level. Generally, the guidance of health functionaries is sought in availing services from health facilities outside the village. 13. Satisfaction with the public health facilities / services + In general there has been an increase in the utilization of public health facilities/services, over the years. By and large, the beneficiaries are satisfied with the current public health facilities/services available. In some cases beneficiaries have reported that the medical care being received in public health facilities as being cursory and in a few cases drugs were reported to be in short supply. In some cases it has been reported that availing in-patient treatment from public health facilities is as expensive as that of availing the same services from private health facilities, barring bed charges. The practice of availing services of RMPs for general ailments is also prevalent as they are more accessible and affordable. Those who are more solvent prefer services from private health facilities as they feel that get better medical care. Summary In the health and nutrition study, the characteristics of + and villages were, by and large, similar, in a wide range of issues. However, + villages were relatively better off than villages. This can be attributed to the fact that Nutrition Centers function as nodal points for health functionaries to interact with beneficiaries, on a day to day basis. Nutrition Centers in + villages are providing ample opportunities to health functionaries to meet and counsel beneficiaries regarding health care and mobilize 39

40 them for availing a range of health services. This has brought about an increase in the knowledge levels of beneficiaries, promoted health seeking behaviour and has resulted in timely and optimal utilization of health services. Also, day to day interaction between the health functionaries and beneficiaries in Nutrition Centers is seen to promote a sense of fraternity and bonding as a community among the health functionaries and beneficiaries In villages with just activities and no Nutrition Centers, health functionaries lack the opportunity to meet beneficiaries in groups, convergent at a point, on a day to day basis. Though days and SHG meetings do provide opportunities to meet beneficiaries, the frequency of these meetings is restricted to one or two, in a month. Alternatively, health functionaries have to distribute their time in making home visits and this has a bearing on the frequency of visits and the amount of time that can be spent with the beneficiaries during each visit. This has resulted in a lower level of health awareness and a less than optimal utilization of health services. villages, with relatively fewer health functionaries, do find it difficult to meet the health and nutrition service demands. Here the interaction between front line health functionaries and beneficiaries of health and nutrition services is limited, both in terms of frequency and duration of meetings. This limited interaction between the health functionaries and beneficiaries has resulted in low level of health awareness, less than satisfactory level of health seeking behaviour and only a marginal to moderate level of utilization of health services. Introduction of health and nutrition intervention activities in these areas could bring about the desired changes in the existing health trends. 40