11

Community managed nutrition cum day care centers

Lakshmi Durga ChavaState Project Manager (Health and Nutrition)

21.04.09

Society for Elimination of Rural PovertyAndhra Pradesh, India

Lakshmidurgac@gmail.com

22

Outline of the Presentation

SERP poverty reduction interventions

IKP health value chain

Nutrition cum Day Care Center

Opportunities for integration with ICDS

Scale up to mainstream

Replication process

33

Society for Elimination of Rural Poverty (SERP)

Sensitive support organization for the poor

– Autonomous society set up by Government in 2000

– State wide mandate

– To induce social mobilization

– To provide facilitation support to institutions of poor

– To sensitize all line departments to be inclusive of the needs of the poor

44

SERPA.P – poverty eradication through empowerment of rural poor women (Indira Kranthi Patham - IKP) Focus: comprehensive poverty

eradication - economic and social building self sustaining

institutions of poor Rs.2100 crores Project - financed

by State Government, World Bank and communities to cover all rural poor in the state (80 lakh families, special focus on 26.0 lakh ultra poor)

builds on the decade long, statewide rural women’s self-help movement in A.P

55

IKP Interventions1. Targeting – community based targeting.2. Focus on the poorest of the poor and vulnerable: women, disabled 3. Power of scale – bringing all the poor in the state into social

networks 4. Scaling up through community resource persons5. Institutional design – SHG – V.O – M.S – Z.S6. Large scale mobilization of bank finances for poor 7. Large scale livelihoods promotion8. Community managed food security9. Social issues as an agenda for collective action10. Social risk management11. Community managed health interventions12. Convergence with all line departments

S.E.R.P’s dynamic role – changes in tune with the changes in the demands of the C.B.Os

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IKP Health Value ChainIKP Health Value Chain

Preventive & Promotive Health

CareCurative Care

Financing and Service Delivery

Human/Social Capital• Health activist• Community Resource

Person (CRP)

Nutrition & Health Day (NHD)

Water & Sanitation

Nutrition Centers

Case Managers

Making Services Work for the Poor – Accessing PHCs & Area Hospitals

Community-owned Pharmacy

Community-owned Hospitals

Microfinance Product for NUTRITION

Health Risk Fund/ Health Savings

Health Insurance

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Convergence Framework for Improved Access to Services

Work in collaboration with the existing line departments responsible for enhancement in QOL of the poorest

Look at areas where there are gaps and there is a mismatch between the design of service delivery and the incentives linked to those services

Fill those gaps through ways that can be managed and sustained by the community groups even after the project is over

Have a cadre of internal facilitators, from among the communities to facilitate/accelerate in the empowerment process

Have a cadre of external facilitators to assist in planning and designing sustainable and workable programmes

Enable the communities to have choice and control over the services available for them

Make the service providers more accountable to the communities

Successful pilots to be up-scaled by the line departments for state-wide implementation

Systems

Outputs/outcomePersonnel

Improved access to “effective & available” services

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Nutrition cum day care centerHealth savings and health Risk FundHealth InsuranceBest practitioners as Health Community Resource Persons (Health CRPs)Community Kitchen gardensWeaning foodsFixed Nutrition and Health Day (NHD)Screening camps

Community managed health and nutrition interventions

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Goal To improve Perinatal and neonatal outcomes and child care practices towards achieving the MDGs in rural Andhra Pradesh

ObjectivesTo provide nutritional and health care for pregnant and lactating mothers.To encourage improved health care practices for safe deliveries and have no low birth weight babies.To empower communities to make pregnancy safer and develop change agents to have sustainable impact.

Community-Managed Community-Managed Nutrition cum Day Care CenterNutrition cum Day Care Center

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Nutrition cum Day Care Center Nutrition cum Day Care Center (NDCC)(NDCC)

Physical center i.e., building with Kitchen, Physical center i.e., building with Kitchen, Dining and Garden (for growing vegetables)Dining and Garden (for growing vegetables)TWO MEALS a day prepared and served to TWO MEALS a day prepared and served to pregnant and lactating mothers and children pregnant and lactating mothers and children <5 years<5 yearsCook is an SHG member trained in preparation Cook is an SHG member trained in preparation of nutritious, traditional diet (with focus on use of of nutritious, traditional diet (with focus on use of millets)millets)

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Nutrition cum Day Care Center Nutrition cum Day Care Center (NDCC)(NDCC)

The center also doubles-up as a health check-up centre The center also doubles-up as a health check-up centre for pregnant and lactating mothers and children <5 yearsfor pregnant and lactating mothers and children <5 yearsServes as a venue for health education and behavior Serves as a venue for health education and behavior change communicationchange communication

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NDCC Financing ModelNDCC Financing Model

The cost of mealThe cost of meal– Rs 25 per day for TWO MEALS for pregnant and lactating Rs 25 per day for TWO MEALS for pregnant and lactating

mothersmothers– Rs 10 per day for TWO MEALS for Children <5 yearRs 10 per day for TWO MEALS for Children <5 year

Beneficiaries pay Rs 18 per day for TWO MEALS; The Beneficiaries pay Rs 18 per day for TWO MEALS; The balance Rs 7 is subsidized by the Community-Based balance Rs 7 is subsidized by the Community-Based Organization/ Government of Andhra PradeshOrganization/ Government of Andhra Pradesh The Beneficiary’s contribution is financed via a The Beneficiary’s contribution is financed via a MICROFINANCE LOAN taken from the Community-MICROFINANCE LOAN taken from the Community-Based Organization which will repaid over 24 – 36 Based Organization which will repaid over 24 – 36 months depending on income status of the beneficiary months depending on income status of the beneficiary i.e., CONSUMPTION SMOOTHING VIA a i.e., CONSUMPTION SMOOTHING VIA a CONSUMPTION LOANCONSUMPTION LOAN

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ProcessProcess

Grama sabha Discussion with beneficiaries

Discussion with the mothers-mother-in laws

Preparation of MCP Feeding at NDCC Day care for children

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Supportive universal interventions

Regular capacity building of health activists, health sub committees and health CRPsCommunity kitchen gardens Promotion of weaning foods with locally available commodities Institutionalization of Fixed Nutrition and Health Days (NHDs) towards complete immunization, ANC and PNC.Regular health savings and HRFCommunity managed health insurance Pre-Primary schools with focus on early child hood education and provision of nutrition.

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Coverage

2007-08 : 200 centers

2008-09 : 600 centers

2009-10 : 2500 centers

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Coverage against survey

As per enrolment at 600 NDCCs with 332 day care centers.– 3,220 BPL pregnant 3,220 BPL pregnant

women; 1,967 women; 1,967 SC/ST SC/ST

– 3,148 BPL lactating 3,148 BPL lactating mothers; 1,991 mothers; 1,991 SC/STSC/ST

– 3,440 BPL children 3,440 BPL children 0-3yrs; 2,167 SC/ST0-3yrs; 2,167 SC/ST

As per survey at 600 AWCs

– 5092 pregnant women from all categories

– 6043 lactating mothers from all categories

– 9960 children 0-3yrs from all categories.

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Utilization of ICDS by people of

lowest two wealth quintiles

72

36

30

22

23

11

19

9

0 10 20 30 40 50 60 70 80

AWC coverage

.

Any services

Food Supplements

Immunization

.

Suppl. Food

Health and nutrition edu.

.

Suppl. Food

Health and nutrition edu.

Children’s use of ICDS

Pregnant women use of ICDS

Breastfeeding women use of ICDS

Area covered by ICDS

181818

Child Nutritional Status by Wealth quintiles and caste, India

20

34

41

49

5755

48

43

33

0

10

20

30

40

50

60

Richest Q2 Q3 Q4 Poorest . ST SC OBC Others

Percentage of children age 0-35 months underweight

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Underweight children among Poor and PoP

Percentage of Children age 0-35months Underweight

0%

10%

20%

30%

40%

50%

60%

Per

cen

t

NDCCBeneficiaries(POP &Poor)

AWCbeneficiaries

(PoP)

AWCbeneficiaries

(Q4)

26%

57%49%

2020

Perinatal outcomes*Perinatal outcomes*

Against the 1800 deliveries happened:Against the 1800 deliveries happened:– 99%of women had safe deliveries. [Institutional(91%) 99%of women had safe deliveries. [Institutional(91%)

/trained personnel(8%)]/trained personnel(8%)]– 90% had normal deliveries90% had normal deliveries– 10% had cesarean section.10% had cesarean section.– 87% women had complete ANC 87% women had complete ANC – 99% women had PNC99% women had PNC– 46% of pregnant women gained 10-12Kgs weight; 47% 46% of pregnant women gained 10-12Kgs weight; 47%

gained 7-10kgs weightgained 7-10kgs weight

No maternal deaths reported among the women No maternal deaths reported among the women enrolledenrolled

* * Source: Internal MISSource: Internal MIS

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Neonatal outcomes*Neonatal outcomes*

97% of babies born with >2.5Kgs97% of babies born with >2.5Kgs– 54% babies with >3Kgs54% babies with >3Kgs

Neonatal care practicesNeonatal care practices– 97% neonates are fed with Colostrum 97% neonates are fed with Colostrum

and no pre-lacteal fluidsand no pre-lacteal fluids– 82% delayed bathing the baby for 7 82% delayed bathing the baby for 7

days.days.

* * Source: Internal MIS dataSource: Internal MIS data

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FAQs about results

Accuracy of the measurements?

Technical person for supervision?

Authenticity of the data?

Empirical evidence ?

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Maternal OutcomesMaternal Outcomes

Beneficiaries in intervention

villages N=237

Beneficiaries in non-

intervention villages N=242

Three ANC visits 95.6% 88.6%

Safe Delivery 88.6% 81.3%

Type of Delivery:Normal

Cesarean79.1%20.9%

71.9%28.1%

Birth weight:>2.5kgs<2.5kgs

93.0%7.0%

85.5%14.5%

PNC check-up 68.3% 62.3%

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Neonatal care practicesNeonatal care practices

Beneficiaries in intervention

villages N=237

Beneficiaries in non-intervention

villages N=242

Colostrum feeding 79.9% 68.9%

No pre-lacteal fluids 86.0% 66.8%

Exclusive breastfeeding for at least 6 months

84.3% 81.2%

Delayed bathing 7 days 32.0% 31.3%

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Health knowledge and health seeking behavior

Beneficiaries in

intervention villages 237

Beneficiaries in non-

intervention villages N=242

Knowledge of methods to prevent diarrhea 97.9% 83.9%

Knowledge of methods to treat diarrhea 75.1% 58.3%

Knowledge of malaria symptoms 86.9% 72.7%

Knowledge of modes of transmission of malaria 89.0% 78.1%

Knowledge of bed nets to prevent malaria 61.2% 35.5%

Use of bed nets at home 65.8% 41.7%

Heard of HIV/AIDS 95.4% 86.8%

Knowledge of modes of transmission of HIV 92.0% 75.6%

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Issues & challenges in ICDS

Inadequate coverage and location of AWC

Corruption in supplies and of patronage in recruit.

Frequent supply chain breakdowns

Poor convergence with Health dept.

No community participation

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Can NDCC address issues & challenges at AWC?

NDCC AWC

Community (demand) driven Supply driven

Focus on enrollment of Poor and PoP No special focus on most at-need women/children

Health Activist/ CRPs are enthusiastic to learn the techniques

Book-keeping for growth monitoring not always up-to-date

Health Activist hold regular health education sessions

No focus on Nutrition and health education sessions

Serves as venue for Fixed NH Days conveniently located.

Not accessible to the needy beneficiaries

Provides complete meals paired with kitchen garden; supervised meals

Provides only supplementary nutrition as take-home ration

Regular monitoring by the community. Poor monitoring system

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Complimentary areas of AWC to address challenges at NDCC

AWC NDCC

High enrollment coverage in 74000 villages in 22

Districts

Not yet scaled up to cover all villages (600 villages in 22

districts)

AWW is trained in early childhood education

Focus mainly on day care with nutrition

AWW is trained in child growth monitoring

Book-keeping for growth monitoring of children yet to

be strengthened

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Costing for one village:Costing for one village:NDCC vs. AWCNDCC vs. AWC

Nutrition cum Day Care Nutrition cum Day Care CentreCentre ( (one time grantone time grant))

Unit cost Unit cost (Rs)(Rs)

Consumption loan Consumption loan corpus for 30 BPL corpus for 30 BPL beneficiariesbeneficiaries

250,000 250,000 ($5000)($5000)

Health CRPs Health CRPs resource fee & resource fee & Health activist Health activist incentivesincentives

20,000 20,000 ($400)($400)

Non –recurring Non –recurring expenditureexpenditure

80,000 80,000 ($1600)($1600)

TotalTotal350,000 350,000 ($7000)($7000)

AnganwadiAnganwadi CentreCentre ( (Every year)Every year)

Unit cost Unit cost (Rs)(Rs)

SNP cost for 80 SNP cost for 80 APL+BPL APL+BPL beneficiariesbeneficiaries

72000 72000 ($1440)($1440)

Salary component Salary component for AWW and AWH for AWW and AWH

40800 40800 ($816)($816)

House rentHouse rent24002400($48)($48)

TotalTotal115200 115200 ($2300)($2300)

Note: Additional cost for monthly training at NDCC and induction/ refresher training at AWC

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Additional costs (every year)

Regular capacity building of stakeholders at NDCCs.

Induction and refresher training for the AWWs /AWHs.

Human resources to provide supportive supervision and guidance

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Cost estimates for universalisation in Andhra Pradesh

74000 AWCs require 858.42 crores ($171,684,000) per year and Rs 2557 crores ($511,400,000) for 3 years and Rs 4262 crores ($852,000,000) in 5 years and for 7 years……………

But,

NDCCs require one time grant of Rs 2590 crores ($518,000,000) to reach 74000 villages with focus on 35000 VOs.

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Potential for Integration of IKP (NDCC) with ICDS (AWC)

Overlapping characteristics: – Focus on reproductive-age women and young children– Physical building– Collaborative role in Fixed NH Days– Similar record-keeping system to cover same H&N indicators

Complementary characteristics:– Health Activist and materials for teaching pregnant and lactating

women (IKP)– Anganwadi worker for early childhood education (ICDS)– Demand and support from CBOs (IKP)– Wide coverage; nearly all pregnant/lactating women and

children in AP (ICDS)– Special focus on poor and PoP population (IKP)– Provision of complete, balanced meals (IKP)– Community ownership and accountability systems (IKP)

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Integrated model accountable to communities (IKP & ICDS)

Demand driven, community owned program (IKP) with full financial support from the public health system (ICDS) throughout APPooling of funds to support poor women and children and reduce the financial input from the communityTwo complete meals per day prepared by SHG-member cookDaily health education sessions focused on maternal and child health & nutrition by Health ActivistEarly childhood education by Anganwadi teacherChild growth monitoring by Anganwadi teacherOne simplified record-keeping system to monitor health and nutrition indicators among beneficiariesWeb based monitoring tools to establish accountability to the communities (IKP).

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Financial benefits of integrating IKP H&N with ICDS

Reduced beneficiary burden

Reduced costing of NDCC

Reduced costing for human resources

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Scale up plans to mainstream

NRHM support for community owned NDCCs (1000 to 2500 centers).Support for institutionalization of Fixed NHDs to strengthenDovetail the support for SNP from ICDS.Natural attrition of NDCCs over period with shift in dietary practices at households.Social audit to establish more accountable systems at community level.

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Replication

Pre-requisites– Community based organizations– Village level committee to take forward HD issues– Openness to community owned models– Committed political will

Selection of few blocks/few states for replicationDuring replication– Support of technical agency (SERP)– Internal (CRPs) and external facilitators– Dovetail of human and financial resources– Community based nutrition monitoring and surveillance system

to include growth monitoring of children and anemia levels among adolescents and women.

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Thank You