Sharing of Best Practices IMPROVING MATERNAL, NEW BORN AND CHILD HEALTH IN INDIA

Transcription

1 IMPROVING MATERNAL, NEW BORN AND CHILD HEALTH IN INDIA

2 DISCLAIMER: This pubication does not constitute professiona advice in any form. The information in the pubication has been obtained from organizations beieved by the Federation of Indian Chambers of Commerce and Industry -Aditya Bira CSR Centre for Exceence and Genmark Foundation to be reiabe. The incusion of case stories does not in any way constitute any prejudice towards any individua company. Neither Federation of Indian Chambers of Commerce and Industry -Aditya Bira CSR Centre for Exceence or Genmark foundation accept nor assumes any responsibiity that any facts presented are accurate or compete. Further, a information contained in the document is subject to change without notice. This pubication is intended stricty as a earning document. The handbook compiing team has used their best efforts in coecting and preparing the materia. The information put forth is origina script of what has been shared by organization on the projects.

3 IMPROVING MATERNAL, NEW BORN AND CHILD HEALTH IN INDIA

4 Photo Credit- Hamara Swasthya Hamari Awaz

5 FICCI ADITYA BIRLA CSR CENTRE FOR EXCELLENCE FICCI, the odest and the argest business chamber has been advocating CSR since FICCI, through its two arms: FICCI Aditya Bira CSR Centre for Exceence and FICCI Socio Economic Deveopment Foundation (FICCI-SEDF), has a ong standing practice in designing and impementing CSR Programmes, in partnership with corporate houses and deveopment organisations, as we as directy with the communities. Since then, FICCI has payed an advisory roe to various organisations in deveoping reevant CSR strategies. FICCI ADITYA BIRLA CSR CENTRE FOR EXCELLENCE is a joint endeavour of Federation of Indian Chambers of Commerce & Industry (FICCI), a raying point for free enterprise in India since 1927 and the Aditya Bira Group - a prominent business group with a mission to deiver superior vaue to customers, sharehoders, empoyees and society at arge. It works towards advocacy and capacity buiding for both Corporates and NGOs and awards Companies for exempary CSR practices through annua FICCI CSR Awards. GLENMARK FOUNDATION Themed around 'Heathier Chidren, Heathier Word', Genmark Foundation, the CSR arm of Genmark Pharmaceuticas, is activey working towards improving materna and chid heath. Genmark Foundation aims to encourage a positive heath seeking behaviour among pregnant women and mothers with infants, and caregivers towards right nutrition incuding good hygiene practices and ensuring compete immunization for chidren. Aong with its NGO partners, the foundation has undertaken severa community programs focused towards reducing infant and chid mortaity among the vunerabe popuation groups. The various interventions in chid heath are spread across Madhya Pradesh, Rajasthan, Maharashtra, Himacha Pradesh, Sikkim and Gujarat in India and Nairobi in Kenya. GLENMARK PHARMACEUTICALS: Genmark Pharmaceuticas Ltd. (GPL) is a research-driven, goba, integrated pharmaceutica organization. It is ranked among the top 75 Pharma & Biotech companies of the word in terms of revenue (SCRIP 100 Rankings pubished in the year 2017). Genmark is a eading payer in the discovery of new moecues both NCEs (new chemica entity) and NBEs (new bioogica entity). Genmark has severa moecues in various stages of cinica deveopment and is focused in the areas of oncoogy, dermatoogy and respiratory. The company has a significant presence in the branded generics markets across emerging economies incuding India. Genmark has 16 manufacturing faciities across five countries and has six R&D centers. The Generics business of Genmark services the requirements of the US and Western European markets. The API business ses its products in over 80 countries, incuding the US, various countries in the EU, South America and India.

6 Acknowedgement Foreword Introduction Aahar Aarogyasanvardhan Program Addressing Manutrition Issues among the Women and Chidren Advocacy for Continuum of Quaity of Care in Materna, Newborn Chid Heath Community Based Management of Manutrition Community Participation in Deivery of Famiy Panning services and Capacity Buiding of Service providers on Respectfu Care 7 Ensuring Better Materna Heath Care Outcomes Through Community Action And Socia Accountabiity Mechanisms (Phase 2) 8 Ensuring Chidren Heath and Nutrition Rights in Kaushambi district of Uttar Pradesh 9 Mother's Heath in Mother's Hand Hamara Swasthya Hamari Awaz Heath on Whees for Chidren in East Sikkim

7 12 Indigenous Medicine Use for Sex Seection during Pregnancy and Risk of Birth defects and stibirths 13 Integrated Nutrition Project for Under 5 chidren Konku-Puchiku Project Materna Nutrition Suppementation project for antenata and post-nata women in Paghar District, Maharashtra 16 Capacity Buiding and Training of Mentor Nurses- An initiative to create a resource of 192 master nurse trainers in the state of TN supported by United Way of Chennai (UWC) & Motivation for Exceence (MFE) 17 MIRA Channe: Mobie Phone based Channe for Rura Women on Materna & Chid Heath using RMNCH+A Approach 18 mmitra Project MNCH- Sukshema Muti-Sectora Initiative for strengthening Convergent Actions for Nutrition, Education, and Chid Protection in Mada district, West Benga. 21 Newborn Surviva (NBS) Project Pahe towards empowering women Piot Project to Address Manutrition Chaenges in Kathikund Bock, District Dumka, Jharkhand 24 Poshan-Community Based 1,000 days Initiative Project Kavach- Cick Initiative Rajasthan Nutrition Project Reduce Manutrition and Chidhood Iness Stop Diarrhoea Initiative (SDI) Community Heath Care Management Initiative. Focusing on: Strengthening of Gram Unnayan Samsads and Sef-Hep Groups through PRI in 5 districts of West Benga 30 Tiko Saathi Urban Sum Heath Action [USHA] Program Khushi Baby: Wearabe mheath soution for Materna and Chid Heath Tracking at Last Mie 33 Yukti Yojana Pubic Private Partnership for Expanding Avaiabiity of Safe Abortion Services in Bihar

8 Photo Credit- Association for Sustainabe Community Deveopment (ASSCOD)

9 Acknowedgement We appreciate a the eaders and team members of a the organisations that feature in this compendium, for supporting us in our efforts to deveop a compendium of successfu projects in the fied of Materna Newborn and Chid Heath (MNCH). Each of these projects has contributed significanty towards deveoping groundbreaking service deivery modes and best practices in the area of Materna and Chid Heath in India. 1

10 Foreword Though India has achieved a significant reduction in beow five neonata infant and materna mortaity ratio, the rates are sti very high in many parts of the country. Strengthening neonata heath care is crucia as maximum mortaity and morbidity occurs in beow age five. Even today, efficient Indian heath care systems are sti acking. In addition to eary sepsis, communicabe infections, manutrition forms the main buk for high mortaity. On the other hand, surviva of ow birth weight (LBW) is on the rise due to superior expertise in neonata intensive care units. Under the Nationa Heath Mission (NHM) of Government of India, evidence-based interventions to improve materna and chid surviva are being promoted. Many chaenges are being faced by programme managers whie impementing these programmes. FICCI, the odest and argest business chamber has aways been in the forefront to advance and advocate the socia deveopment goas of the nation. We have been mobiising India Inc's efforts to address various deveopmenta gaps and support the initiatives of the Government through CSR. Being an important stakehoder of India's incusive and sustainabe deveopment journey, FICCI understands the need of the hour is integration of thoughts and ideas and processes in order to meet the humongous chaenge put forth by the heath scenario of the country. It is with this view that FICCI has taken the ead with initiatives such as 'Swasth Bharat', an initiative on pubic heath. This high eve Task Force set up in 2016, incudes members from the government, industry and mutiatera and biatera organisations. The focus areas are Non-communicabe diseases (NCD) & Menta Heath, Road Safety and Emergency care and IISH (Indian Industry in Soidarity for Heath) Kosh. IISH Kosh was aunched by FICCI to work coaborativey with the Government to meet heath chaenges of the country. The aim of the IISH Kosh is to bring under one umbrea, Heath experts, Academics, Industry, Civi Society groups, Financia Institutions, media, donors/ biateras/ mutiateras and others to create a knowedge poo, identify priority areas in the heath sector in aignment with Government goas for appropriate channeization of CSR funds. The IISH KOSH sha work as an aggregator of fund, knowedge and networks with nationwide outreach. IISH Kosh has been endorsed by Ministry of Heath and Famiy Wefare, Government of India. I take this opportunity to extend my appreciation to Genmark Pharmaceuticas Limited for highighting and addressing this important issue of our country and aso our NGOs for sharing their initiatives from the fied. I ook forward to this initiative touching the ives of our chidren and women. Jyoti Vij Deputy Secretary Genera FICCI 2

11 Foreword It is a truism entaiing no further emphasis that India accounts for a significant percentage of the chid deaths under the age of five, notwithstanding the fact that a heathy ife ays the tempate for the firm foundations of a heathy nation. Today's chidren are the foundations of tomorrow's future and so it is incumbent upon us to ensure a heathy atmosphere for the nurturing and deveopment of our chidren. Over the ast decade the percentage of chid deaths have dwinded owing to various interventions incuding better nutrition and medica faciities. To this end, not ony the government but aso the non-governmenta sectors have joined hands. However India sti has an uphi task for remedying this probem of materna and chid heath. Genmark Foundation has been reentessy working to make a difference in the ives of chidren and women given its fervent beief that every individua has the right to ive a heathy ife. This book wi certainy be a reference for those wishing to know and understand the roe of NGOs and civi society organizations a over India (with a focus on 33 case studies) aong with the best practices to support materna and chid heath as we as to promote the Sustainabe Deveopment Goas. It wi be a beginning with regard to this ambitious effort that is been undertaken and of which Genmark Foundation and FICCI happen to be major stakehoders. Best Regards, Chery Pinto Director, Corporate Affairs Genmark Pharmaceuticas Limited 3

12 Introduction Aheathy start to ife is vita in estabishing the foundation of a heathy nation. India contributes to 17.5% of the word's popuation and neary one-fifth of the tota ive births. Even though chid deaths in India have been haved in the ast 15 years owing to better nutrition, heathcare, and standards of iving, even today, India contributes significanty to the annua goba tay of deaths of chidren under five years of age. In India, every 20 seconds a chid under the age of 5 dies due to causes which coud have been prevented, ike pneumonia, preterm compications, new-born infections, diarrhoea, birth compications and maaria. India aso observes over 30 miion pregnancies every year and of this, 27 miion women reach the stage of deivery and over 56,000 mothers die during or within 48 hours of deivery. As per the Medica Counci of India, there is one government aopathic doctor for every 1,668 peope. Strengthening primary heathcare hasn't got the priority it needs and the sick reach hospitas after faith-heaers, quacks and other unquaified practitioners fai to cure them. 4

13 The Government of India (GoI) recognizes heathy mothers and decreasing chid surviva is essentia for the overa deveopment of the society and has progressivey strived for the dramatic reduction in materna and chid mortaity rates over the past two decades. Two important miestones in this direction have been the Nationa Rura Heath Mission (NRHM) which focused on pubic investment in strengthening heath systems. Schemes under it such as Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), Faciity Based New Born Care (FBNC) and Home Based New Born Care (HBNC) are steps towards ensuring zero out of pocket expenditure and improving access to heathcare for the vunerabe sections of society and the Reproductive, Materna, Newborn, Chid and Adoescent Strategy (RMNCH+A Strategy) was deveoped by the Government of India to acceerate progress toward these goas and focus more attention on key high impact interventions in India's 184 High Priority Districts (HPDs) which span 29 states and Union Territories. Standing firm on India's commitment in the 67th Word Heath Assemby, India Newborn Action Pan (INAP) is another step that has been taken towards India's commitment to the goba agenda and affirming its priorities for new born. The poicy outines a targeted strategy for acceerating the reduction of preventabe newborn deaths and stibirths in the country. Compementing this, the Government of India aso aunched Cean India (Swacch Bharat Abhiyan) and Beti Bachao, Beti Padao (Save Girs, Educate Girs) to strengthen the heath of mothers, newborn and chidren. Whie there has been remarkabe growth and innovation in nationa poicies over the ast few decades. There has been significant decrease in neonata mortaity rate even though a arge proportion of newborn deaths are preventabe. India does not have enough hospitas, doctors, nurses and heath workers, and since heath is a state subject, disparities and inequities in the quaity of care and access to heath varies widey not just between states but aso between urban and rura areas. Simiary, a majority of Indian women, especiay in the rura areas, sti ack access to basic heath amenities. Many women are bereft of care during pregnancy and chidbirth due to poverty, distance, ack of information, inadequate services and cutura practices. In the ast decade, significant investments have been made to improve heath care that are ikey to have additiona impact on the status of materna, newborn and chid heath in India. Understanding the need for equitabe, affordabe, accountabe and effective primary heathcare faciities, many nongovernment organizations, socia deveopment organisations, CSR wings of corporates are experimenting and innovating to ensure high quaity, sustainabe, ow-cost materna and chid heathcare services. In the book, we have identified and documented 33 case studies on materna and chid heathcare initiative in India and their different approaches by non-profit organisations. This compendium documents interventions by civi society organisations to strengthen materna, newborn and chid heath in various parts of India. The case studies aso aim to aid non-profit organisations, teachers to educate students in medica, pubic heath and CSR professionas on ways to strengthen materna, newborn and chid heath. 5

14 Aahar SNEHA (Society for Nutrition, Education and Heath) Website : Founder of the Organization : Dr. Armida Fernandez Project Budget : ` 9.8 crores Coverage/ Geographica reach : 10 beats in Dharavi (over 31,000 chidren and 6000 pregnant women 6

15 Project Brief The AAHAR program was impemented in Dharavi, covering 300 Anganwadis (crèches) with the goa of reducing wasting (ow weight for height) by 25% among chidren under three years of age, in partnership with the ICDS and the Municipa Corporation of Greater Mumbai. In tota, the program has directy served 37,480 chidren and pregnant women across 110,468 househods. AAHAR foows the Community-based Management of Acute Manutrition (CMAM) principes and adopts a two-pronged approach to impact and reduce the prevaence of chid manutrition: (a) working with communities to improve care-seeking behavior and increasing access to heath services; (b) working with oca Government stakehoders to ensure high quaity of service deivery. The program pivoted from a daycare centre that was dependent on physica infrastructure to a ight-weight, scaabe, communitybased mode of intervention. The program was deivered at the community eve by SNEHA fied staff, known as Community Organisers, and focused on eary screening and treatment of chidren and behaviour change communication for pregnant women and mothers. As per SNEHA's baseine study, over 30% of chidren under three in Dharavi were stunted and neary 30% of them were underweight. Unheathy iving conditions in Dharavi, incuding ack of access to safe water, visibe open sewers, imited pathways, uncontroed dumping of waste and inadequate sanitation, can pose serious heath risks, especiay for young chidren. SNEHA's experience in Dharavi has shown that environmenta and infrastructura probems affect the heath and nutrition of infants and young chidren. SNEHA's first intervention on Chid Heath and Nutrition commenced in 2009 in Dharavi, one of the argest sums in Asia, with two Day Care Centers catering to approximatey 20 chidren in each center. After gaining some experience in managing this program, SNEHA upscaed its intervention in Dharavi through the Aahar program in November From two centres we expanded to five centres to cater to chidren in the catchment area of 150 Anganwadi in two four phases over a period of two years. We reaized the ack of perceived need of such centres and gaps in the understanding of manutrition in the community. We decided to adopt a mode that devoved greater responsibiity on the community and adopted the WHO CMAM mode. The iterative deveopment of the program saw a change in focus from addressing undernutrition to treating wasting with a RUTF as recommended by WHO; from community vounteers to fu time paid staff and protocoized intervention in a 300 ICDS Anganwadis in Dharavi to intensify the home-based care to ensure changes in the care practices of chidren in the 0-3 years, pregnant and actating mothers. We have earnt to baance the work in communities and with ICDS; to motivate both mothers and famiies as aso ICDS staff; we have stretched ourseves to run the argest urban manutrition project in Asia to deiver a reduction in chid manutrition using an eectronic supervision and monitoring system. The project has covered ti date, an estimated popuation of 300,000 in Dharavi, 300 ICDS Anganwadis, 31,000 chidren in the 0 to 3 years age group, 6000 pregnant and actating mothers. 7

16 Impementation Mode A team of three program coordinators, ten officers, community organizers ran the intervention supported by a pediatrician, monitoring a team of six staff and admin team of two staff and ed by the Associate Program Director and Program Director. The intervention: Screening of chidren was done at the Anganwadi jointy with the ICDS on a monthy basis, using WHO guideines and the metric, weight-for-height (wasting) to determine nutritiona status. The program targets the most vunerabe chidren who are suffering from Severe Acute Manutrition (SAM) or Moderate Acute Manutrition (MAM). Referras are made to a pediatrician, the oca government municipa hospita or the Nutrition Rehabiitation and Research Centre at Urban Heath Centre, Dharavi 8

17 Medica screening in community pediatric heath camps or in the Nutrition Research, Rehabiitation and Training Centre, Urban Heath Centre, Dharavi and at Sion hospita, Appropriate outpatient treatment and referra for inpatient care and foow up, Referra for compete immunization to MCGM heath posts and outreach camps, Enroment in the Community based Management of Acute Manutrition (CMAM) Program, observed feeding and support for improved home feeding and hygiene practices through home visits and weight gain monitoring, Support to pregnant and actating mothers for appropriate antenata and postnata care, Group sessions of mothers for peer earning, community events for sensitization to chid manutrition, Training of ICDS Anganwadi workers and supervisors for improvement in the quaity of their services, Convergence workshops and monthy meetings of ICDS and MCGM to buid rapport, improve coaboration and reduce dupication of effort. A processes were standardized in protocos, rigorous program staff training, on the fied supervision, eectronic documentation, rea-time data coation and feedback of performance to the fied team on a monthy basis and quartery program reviews. Community Outreach AAHAR has been recognized as India's first urban mode project, impemented on the principes of Community-based Management of Acute Manutrition (CMAM). Designed and impemented to bring about a 20% decine in manutrition among chidren under three years of age in Dharavi, the program reinforces sustainabe behavior changes among primary caregivers. Community Organisers (COs) serve as nutrition ink workers within the intervention area to faciitate access and treatment through avaiabe Government services and schemes. COs screen chidren and pregnant women to identify eary signs of manutrition, conduct reguar growth monitoring at Anganwadi centres in conjunction with ICDS and conduct home-based counseing sessions on feeding and care practices. Medica assessments are conducted in community-based pediatric heath camps. Other community processes incude group activities for caregivers and community events for sensitization to chid manutrition. Monthy events such as Khana Khazana, Ustavan, Godbharai and campaigns hed during Breastfeeding and Nutrition weeks aim to bring about behavioura and attitudina changes within the community. Uniqueness of the Project A key facet of the program was that it coaborates with and cosey mirrors the structure of existing government programs, namey the ICDS and its key components, Anganwadi (crèche) and the Anganwadi frontine worker, the sevika. SNEHA not ony invoves the government fied staff in its activities but aso conducts on-going trainings for sevikas to equip them with the required growth monitoring and critica response skis required to tacke manutrition This aignment aowed Aahar to 9

18 provide the government with a repicabe intervention mode with vauabe insights into the resources and activities required to improve nutrition eves in the community. Roe of Information and Communication Technoogies (ICTs) Technoogy-based data coection in deveopment programs poses interesting chaenges: they are often used by Frontine Workers (FLW) with minima technica e x p e r t i s e a n d i n d e n s e y popuated sums where data connectivity might be unreiabe. Eectronic data coection has mutipe benefits incuding rea-time data coection, a potentia for anaysis and processing and more targeted programming, such as behavioura change communications to beneficiaries who actuay need it. In addition, it aso improves the overa quaity of data and maximizes efficiency, accuracy whie aso saving significant resources and time. For the AAHAR project, data was coected on smartphones and stored on the CommCare database, repacing manua registers and data entry. The CommCare software has the abiity to automaticay cacuate the nutritiona status, Estimated Date of Deivery and the age, this minimizes errors in data coection and processing to a great extent. The interface aso has checks to prevent entering of invaid data and does the first eve ceaning of data automaticay. The data is stored in the CommCare Coudbased repository to enabe case management and to monitor activities to improve the intervention. Apart from greater efficiency and transparency, the FLWs mentioned the unexpected benefits of using eectronic data coection methods- having their famiies and communities view them as tech-savvy and productive members of society. Chaenges Faced AAHAR has been recognized as India's first urban mode project, impemented on the principes of Community-based Management of Acute Manutrition (CMAM). Designed and impemented to bring about a 20% decine in manutrition among chidren under three years in Dharavi, the program reinforces sustainabe behavior changes among primary caregivers. Community Organisers (COs) serve as nutrition ink workers within the intervention area to faciitate access and treatment through avaiabe Government services and schemes. COs screen chidren and pregnant women to identify eary signs of manutrition, conduct reguar growth monitoring at aanganwadi centres in conjunction with ICDS and conduct home-based counseing sessions on feeding and care practices. Medica assessments are conducted in community-based pediatric heath camps. Other community processes incude group 10

19 activities for caregivers and community events for sensitization to chid manutrition. Monthy events such as Khana Khazana, Ustavan, Godbharai and campaigns hed during Breastfeeding and Nutrition weeks aim to bring about behavioura and attitudina changes within the community. The foowing are the strategies that the AAHAR program used with a high degree of success: 1. At the core of SNEHA's beiefs is that pubic heath workers want to do their best for the community and given enough support and by working with them to upski their competencies and motivating them, they wi provide optima care and support to the community's heath needs. Rather than working in a sio, AAHAR worked with the ICDS machinery to hep them carry out critica growth monitoring and foow-up activities. 2. SNEHA faciitated ongoing interaction and engagement between ICDS and the community, through joint events, meetings and workshops. This heped motivate the ICDS staff, who were abe to receive rea-time feedback from the community. It aso heped to improve care-seeking behavior among stakehoders in the community and creating a need for sound heath and nutrition as we as a friendy disposition towards the Aahar program. 3. Convergence workshops were hed and attended by SNEHA staff members as we as members from ICDS and MCGM. These workshops incuded activities ike joint capacity buiding, sharing of positive experiences and trading feedback. 4. Impementation protocos went through mutipe iterations based on rea-time feedback, need and anaysis. This added a ayer of compexity to program impementation and the Senior Staff had to ensure carity and expain changing responsibiities and protocos to the fied staff. 5. Intra and inter-sum migration, as we as migration from Mumbai, was a recurring chaenge. It is estimated that the project period saw a 25 to 30% migration and movement. This woud invariaby affect the heath and nutritiona status of women and chidren. Sustaining behavioura changes, such as optima infant feeding, too, was a chaenge due to the above factors. To ensure that no chid from the intervention area is eft out, fied teams were given monthy targets for enroing Outcomes By Juy 2014, the program was successfuy scaed up to a 10 beats covering over 1,10,468 Househods 31,075 chidren and 6,405 pregnant women were screened over the four years. Of its core beneficiary group (chidren), 83% were chidren beow the age of 3. SNEHA trained over 300 Chid Deveopment Project Officers, Anganwadi sevikas and supervisors through the program. In the year 2015 aone, over 500 community mobiization events, 200 heath camps and over 3000 group meetings were hed, reaching over participants 11

20 Outreach & Scaabiity The new Phase of AAHAR is being impemented in Dharavi, since 2016, with a more indirect impementation approach and focusing more on hand-hoding and capacity buiding roe, where SNEHA is working with ICDS and MCGM to deveop the effective impementation skis that affect the heath and nutrition of chidren in the community. SNEHA is aso working towards buiding the community's ownership towards Government services and empowering them to seek services from the Pubic Heath System. SNEHA's Aahar program intervention has worked in partnership with the systems and communities. In the new phase, we have graduay increased the responsibiity of ICDS services to enabe them to undertake critica activities reevant to chid heath and nutrition, with progressivey reduced support from SNEHA Community Organizers and other eves of staff. This has invoved considerabe investment in the capacity buiding of a cadres of ICDS staff by SNEHA staff. Whie we address issues on the suppy side, we accept that we need to address the awareness and uptake of ICDS services by the community. To increase knowedge and bring about behavior change in the community, we have worked on educating mothers and caregivers on different aspects of chid heath and nutrition, sanitation, hygiene and the services they are entited to from ICDS and MCGM. We now buid the capacity of the community to expect, demand and negotiate avaiabiity and improved quaity services from ICDS and on the other hand, to demonstrate their responsibiity for the community mothers and young chidren. We act as faciitators for the community to act as the catayst for sustained change. SNEHA has focused its efforts in the Aahar program on reduction of manutrition i.e on moderate and severey manourished chidren through we supervised protocoized intervention. In the new phase, we have increased the scope of our work to the prevention of manutrition by aso focusing on norma chidren to prevent growth fatering and reduce chidren sipping into moderate and severe manutrition. Repicabiity Aahar has proved to be a high-impact, cost-effective, community-based mode to tacke chid manutrition whie working in partnership with pubic heath systems. Impact Achieved SNEHA conducted quantitative assessments of its program in a 10 beats of Dharavi. A contro area of Wadaa was evauated to determine whether outcomes were possiby affected by secuar trends. The project was abe to reduce eves of wasting from 18% to 13% achieving an overa 29% reduction in the Fu Intervention (FI) beats. The contro area of Wadaa recorded a reduction of 5% in eves of wasting. Adjusting the % reduction in wasting in Dharavi with the reduction seen in Wadaa, SNEHA's Aahar program achieved a 23% net reduction in wasting eves. The program aso saw a significant increase in the coverage of government services in Dharavi, headined by a 109% increase in ICDS services received by chidren. Of a the ICDS mandated services, growth monitoring (weighing) and the provision of nutritiona suppements saw the biggest increases. 12

21 Through its impact assessment studies, SNEHA's AAHAR program has been abe to prove that a we impemented CMAM mode can reduce manutrition prevaence rates in an urban sum setting in a timebound and cost-effective manner. By mirroring the organization and fied staff structure of the ICDS and coaborating with existing pubic heath institutions, SNEHA has impicity demonstrated that the AAHAR mode can be potentiay repicated and scaed across the country. In terms of costeffectiveness, SNEHA's CMAM program recorded an estimated cost of USD 23 per DALY averted. The cost of a DALY averted through the CMAM program compares favoraby against in-patient care cost (treatment in a medica faciity). SNEHA aso found that the cost borne by the parents (of a manourished chid) were ower through the CMAM approach. 13

22 Capacity Buiding Partners of the Project Dasra- Funders (through a group of inidividuas, known as the Dasra Giving Circe) as we as capacity buiding partners. MCGM and ICDS- pubic heath system impementers and deivery of services to target communities. 14

23 Measurement of weight Aarogyasanvardhan Project Aarogyasanvardhan Program Niramaya Heath Foundation Website : Founder of the Organization : Dr Janaki Desai, Founder and Hon. Medica Director Project Budget : ` 32 Lakh Coverage/ Geographica reach : Maro Pipeine, Andheri 15

24 Project Brief It was seen that there are many chidren who are underweight as per our baseine survey. Then Niramaya Heath Foundation tried to ook after the causes of the manutrition in chidren. It was observed that there were many issues in the community from the nutritious diet, hygiene, sanitation, congested houses, water probem and so on. which were eading these chidren to manutrition. It was aso seen that not ony the chidren but their mothers are aso anemic, manourished. So Niramaya Heath Foundation aid down some strategies to fight against this manutrition in chidren and mother. To perform this task Niramaya Heath Foundation depoyed a team of heath workers, a socia worker at the fied eve and a program officer for management part. 1) Home visits identification of key popuation 2) The intervention of key popuation 3) Rigorous foow up of the intervention cases 4) Daiy fiing of Heath card, ANC card, PNC card and updating the Care Mother App with the data. 5) Anayzing the data is done on monthy basis. 6) Monthy meeting with PEER Educator, stakehoders, govt. officias for strengthening referra system, activities and event in the community. 7) Monthy parents meeting of the manourished chidren. Impementation Mode 1. Home visits:- From the day one of the project Niramaya Heath Foundation beieves that home visit is the backbone of the project, it not ony heps in buiding the rapport with the community peope but aso heps to identify the accurate cause behind the probem or issue. Home visits are done reguary to identify key popuation and heath needs and for rapport buiding with adoescents and women. 2. Intervention with chidren (0-2 years):- Intervention camp-aarogyasanvardhan Project Intervention camp-aarogyasanvardhan Project The chidren identified during home visits are then addressed through intervention. The heath worker carries a weighing scae and a heath card of the famiy aong with the growth chart. The 16

25 weighing of the baby is done on monthy basis and if growth is not seen, the heath worker then refer those chidren to a nearby heath faciity. The heath worker aso notes down the immunization status of the chid in the heath card. During the home visit, aong with the weighing the heath worker aso creates awareness about the importance of 1) Excusive breastfeeding practices, 2) Infant, chid and young feeding practices (side effects of botte feed) 3) Immunization 4) Compimentary feeding 5) Demo of Paushtik powder (made from reguar puses at an affordabe cost) In the group session with the hep of fip charts, documentary, songs, raies, events ike Anna Prashan. 3. Intervention with chidren (2-10years):- This group is identified during the home visit; the heath worker takes the weight and height of the chid and pots it on the growth chart. The growth chart is then expained to their parents and then tabet are given accordingy. In most of the cases, first Abendazoe stat dose of 400 mg is given, then iron suppement is given for 10 days and ater foow up is done to rue out any aergies or side effect of the suppements. The iron suppements are given for 100 days. And Tab. Abendazoe is given haf yeary. The intervention is carried out thrice in a year i.e. quartery basis. After the first intervention is done, the Paushtik powder is distributed to the chidren who come in the manutrition grades. Lactating mother intervention- Aarogyasanvardhan Project 4. Intervention with pregnant women:- The pregnant women are identified during home visits, their Antenata card is fied aong with the famiy heath card. ANC card contains detaied history of the pregnant women and the Antenata checkup visits. The pregnant women are counseed about the trimester wise messages on importance diet, rest, ANC visit, investigation to be done during pregnancy. And referra is done for eary registration, investigation, immunization and suppements. The focus is aso given on the importance of institutiona deivery. 17

26 Some of the pregnant women do not get suppements from the faciity, then Niramaya Heath Foundation provides them with IFA and Cacium tabets. 5. Intervention with actating mother:- The identified actating mothers are counseed on importance of excusive breastfeeding for first six months, timey immunization and weaning practices to start after 6 months. The women are advised by the heath workers to foow a famiy panning method through a session. Community Outreach Powder Distribution-Aarogyasanvardhan Project The communities are reached through door to door- home visits, intervention, heath awareness session- in the group and one to one interpersona session, activities ike Annaprashan, Godbharai (baby shower), parents meeting of manourished chidren, Paustik powder demonstration, nutrition recipe demo, Sanitation meeting and through events ike breastfeeding week, nutrition week, chidren's day, youth day, Ceaniness drive and internationa women's day. To reach out to the masses the heath worker, identify the stakehoders and vounteers from the community through stakehoder meeting. 18

27 To address the heath needs of the c o m m u n i t y, N i r a m a y a h e a t h Foundation aso ooks to the get the support from the faciity side i.e. MCGM heath post and dispensary as we as the ICDS who ooks after the nutrition of chidren from 3-6 years age group. This is done through the networking meeting with authorities of MCGM and ICDS by the program officer and project coordinator, whie the heath worker does the fied eve meeting. Uniqueness of the Project Annaprashan- This is a haf-yeary birthday, the mothers of the 6-month-od baby are counseed to start with soft, semisoid food aong with breastfeeding. Godhbharai- The baby shower is ceebrated with ICDS in the community for pregnant women. In this activity the focus on newborn care, birth preparedness, and importance on institutiona deivery. Nutritiona recipe demo- Initiay it was seen that the chidren were in manourishment due to mapractices of cooking practices, so address this Niramaya Heath Foundation started with the demonstration of nutritious recipe at ow cost. Later we had organised nutritious recipe competition for the community women. Paustik powder demo- This is a high protein rich powdered demonstrated by our heath worker in the community for manourished chidren, pregnant women and anaemic adoescent and community women. Heath Libraries- These are the ibraries kept in the community which has bookets on heath topics such as environmenta and persona hygiene, addiction, tubercuosis, ANC care, Anemia, Nutrition etc. Peer Educator- These are the community women, identified by the heath workers of Niramaya Heath Foundation who participates in the activities of Niramaya Heath Foundation on a vountary basis. There is a heath education training for the Peers, ater these Peers themseves address the queries of the community women in groups through heath awareness session. Roe of Information and Communication Technoogies (ICTs) FGDs--Aarogyasanvardhan Project To track high risk pregnancy in the community, Niramaya Heath Foundation use a technoogy which has the sphygmomanometer, foeta Dopper, Hb testing kit, Accu check to rue out diabetes, urine testing, weighing scae, stethoscope and a the reading or the data is fied in the mobie app name CareMother which show the resut by highighting the high-risk pregnancy according to the various categories, such Pregnancy-induced hypertension, pregnancy-induced diabetes or anemia etc. 19

28 Chaenges Faced The project has competed its sixth year in the community. Over these 06 years, the activities have been repicated in new communities of Maro pipeine. The Main constraint of the project are 1. Due to ack of space in communities conducting heath sessions becomes an issue, yet effort is made to conduct the session with the women in their houses or in common areas of the community if avaiabe. 2. Most of the women working as domestic workers are not avaiabe in morning time for any activities. Timings were adjusted for heath sessions and other activities in accordance with the time avaiabe to community women. 3. The major chaenge was to reduce the manutrition Home Visits-Aarogyasanvardhan Project eve to the owest and carry manourished chidren into norma status. This has significanty shown the impact of 50% change. Effort has been made to provide nutrition education and cooking demonstrations to mothers for dietary modification to increase protein intake by chidren; aso address the issue with providing Food Grain Suppements from different donors to the manourished chidren. 4. Timey immunization of every chid is a major chaenge; Team has deveoped a good rapport with community women and chidren. This has heped us a ot in covering chidren to compete immunization with the hep of Community Heath Vounteer. 5. The misconception with respect to breastfeedings and weaning practices. Outcomes The project has deveoped a good ground eve rapport with the community. Women in the community hep in mobiization for behaviour change communication activities, ike heath education sessions, event participation. This project has the strength of 51 Peer Vounteers identified from the community. These Peers are vigorousy trained on heath curricuum and every year through capacity buiding workshop. This is conducted as a part of sustainabiity efforts and to be future community eaders. As per the proposa and annua action pan, Through the 4342 home visits, reached around 6,564 famiies covering around 20,300 beneficiaries for conducting intervention camps for beow 06 years chidren with reguar foowed up, Pregnant and Lactating mother & Women, Identifications of Peer, provided Heath awareness session for community women. Reach out to Pregnant women and actating mothers over a period of 6 years 20

29 Timey Immunization for143 chidren and 95% chidren are competey immunized 100% Hospita registrations and institutiona deiveries Provision of IFA and mutivitamins and cacium to identified actating mothers 25 active Heath ibraries in the community Adoescents trained for Famiy Life Education- 754 Persona Hygiene kit to 100 kids- Maintained by kids Acceptance Famiy Panning Methods- 44 women Peer Vounteers Identified- 52 Peers Capacity Buiding workshop- to strengthen skis Peers support to promote heath Mobiization Job Pacements- 8 peers n n n n n 03 work as Community Heath Vounteer (conduct heath trainings-wvi) 01 works as Heath Supervisor in an NGO (futime in the cinic- Swasth India) 02 work as Bawadi Teachers in an NGO (Mumbai Smie) 01 work as Heath Trainer in an NGO (Mumbai Smie) 01 work as Heath Coordinator in an NGO (mmitra) Outreach & Scaabiity Tota 51 peers identified from the community; vountariy participate in community mobiization. They aso have some added responsibiities: Organizing Heath sessions- min 5 sessions by each pair of peer every month Hep in Organizing Checkup camp- mobiizing communities Hep in panning Marker days- Promoting community participation Getting registered for PARA-Professiona Course - peers to enro on a piot basis- sti open Heath ibraries at househod eve wi be continued through peer vounteers. Use of First AID box- after competing the course, first Aid boxes wi be made avaiabe for emergency care in the community. This woud aso give them additiona recognition and appreciation in the community for their work. Hygiene kit, food grain suppementation program wi be continued by Peers in the community for chidren or manourished chidren 21

30 Repicabiity The program can be easiy integrated into other ocation with a the activities of the program. Impact Achieved Community participation in an increase and demand for heath sessions Coupes being convinced for the usage of famiy panning methods Records of weight and height of manourished kids Increased eves of awareness about the importance of ANC and PNC Increase in the registration of nearby hospitas for deiveries. Community popuation convinced of the benefits of immunization Increased number of chidren immunized, and increased referras for immunization, immunization during pregnancy Behaviour change towards women heath during pregnancy and post-pregnancy care Capacity Buiding Annua Capacity Buiding Program is organized for the staff in the month of June, firsty to brush up, enhance and strengthen their knowedge and skis and secondy to evauate their capacity for ongoing project activities. Conducting exams after the training the sessions to evauate the knowedge gain through the sessions. Caing of renowned resource persons for various taks on heath from renowned organizations, institutes and firms. Workshops are conducted using mutimedia content, such as videos, informationa and demonstrative graphics, and mutipe-choice quizzes, to remind HWs of important materna heath concepts and to educate the pregnant women they attend. This year staff has been asked to make presentations on various heath topics and provide the training. This has changed them from istening mode to presenter. Fortnight meetings are conducted to get the update about the work and to decide the strategies that need to be adopted to overcome the hurdes or issues of the community. Monthy and weeky panning is carried out to make sure the efficient and smooth working of the team. Conducting of monthy meetings of the staff to share their community experience, chaenges and update the management about the current status of their work. The probabe soutions for those chaenges are discussed. 22

31 Conducting training sessions and ectures on severa heath issues for the team members, so that they are aware of the scientific deveopment in the fied of heathcare. Exposure visits aong with peers are conducted to make them aware of deveopment in various sectors. A group caed Lakshvedhi has been created, where staff write a script on themes given to them and form street pay. This training was speciay organized in capacity buiding workshop. Workshops address prevention and education activities reated to: n n n n n Physica activity and nutrition for women and chidren Reproductive heath of women by decreasing the rates of STD's and unintended pregnancies. The importance of breastfeeding during the first six months of age. HIV/AIDS Heathy pregnancy and chidbirth services, and other materna heath issues. The capacity of heath workers to provide safe motherhood and newborn care services in the target area is strengthened through these workshops. They aso hep to buid the capacities of heath workers, particuary in identifying high-risk pregnant women who need higher eves of care. Partners of the Project Genmark Foundation has been the CSR partner for this project. The support from the Genmark has been remarkabe. They had constanty supported the ideas put forth by Niramaya for the betterment of the communities. Participate in the design of the programme Participate in the impementation of the programme Provide technica assistance to the team for impementation Awards/Endorsements Yes, the project has received foowing awards for the work it has carried out in the fied of Materna and Chid Heath 'Best NGO of the Year Award' the year by Genmark Foundation amongst its partner NGO for exceent fied activities and work for marginaized communities. 'Best NGO of the Year Award' the year by Genmark Foundation amongst 11 partners NGO for exceent fied activities and work for marginaized communities. 23

32 Addressing Manutrition Issues among the Women and Chidren 1 Juy, June, 2013 Association for Sustainabe Community Deveopment (ASSCOD) Website : Founder of the Organization : K.Loganathan Project Budget : ` 6, 45,000 Coverage/ Geographica reach : Kattakoathur, Bock of Kancheepuram District, Tami Nadu 24

33 Project Brief As manutrition is one of the serious heath issues among the women (mainy among Pregnant women) and chidren, project was started to address manutrition issues and anemia correction program through adopting Indian System of Medicine (ISM). mainy the pregnant women, newborn and chidren were targetted.the capacity of the heath staff was buit through enabing them to attend the specia training programme organized to address manutrition issues. The training programme was conducted by Taminadu Vountary Heath Association (TNVHA), Chennai. Objectives: 1) To improve materna heath 2) To reduce Materna mortaity and infant mortaity 3) To eradicate anemia among pregnant women and chidren 4) To address the manutrition issues through faciitating the target groups to use ocay avaiabe nutritiona items 5) To raise awareness on Anemia among the target peope. As the organization's approach is impementing the deveopment projects through women sef-hep groups (SHGs), awareness was created on Anemia in both prevention and curative aspects among the sef-hep groups in the target viages. As the target viages are ocated in remote, they had no access to heathcare faciities. Hence, soutions was needed for addressing manutrition issues using the ocay avaiabe nutritious items. So, keeping this in view, programme was started in 15 Viages of Kattankoathur Bock, Kancheepuram District. Pan was made to address manutrition among the pregnant women, actating mothers, and chidren through providing nutritious items women sef-hep groups. 238 pregnant women were identified and tested for their hemogobin eve before the intervention. Simiary, schoo chidren in the age group of 6-14 in 10 schoos and about 300 actating mothers were identified as programme beneficiaries. If the hemogobin eves were equa to 8 or ess than 8, they were enroed as their target groups. Locay avaiabe nutritious items were distributed for 6 months and then post that hemogobin test was conducted. Our intervention heped the beneficiaries to improve their hemogobin eves from 8 to 12. Athough this programme did not benefit the newborns directy, this programme highy benefitted the pregnant and actating mothers. 25

34 Impementation Mode Awareness Component: We raised awareness on Anemia among the Schoo Chidren, Teaching Staff, Pregnant mothers and actating mothers and the members of women Sef-Hep Groups (SHGs). We conducted the programme orientation among the schoo teaching staff and buit their capacity on addressing anemia through using ocay avaiabe nutritiona items such as sesame sweets, dates, drumstick, papaya. We aso introduced energy foods made out of Raggy, miets, sesame and cereas. Action Component Before our intervention, we used to conduct pre hemogobin test to measure hemogobin eves and recorded the same for assessing the impacts. If the hemogobin eves were 8 or ess than 8, they were seected as our target groups for our intervention. After the seection of beneficiaries, we distributed Murukkan Seed to deworm and cean the stomach of anemia patients so that our nutritiona items intake wi be effective in raising the hemogobin eves. After deworming, we schedued a programme of distributing energy food at the viages eve both times in the morning and evening. We aso recorded the weight of each beneficiary. So, we suppied the nutritiona items for continuous 6 months. For the schoo going chidren, we integrated our nutritious food suppy with the noon mea scheme centres run by the Government in schoos. We used to check the weight of each beneficiary every month and record the measurement. If the weight is getting reduced then we referred them to the oca hospitas for heath check up. After the distribution of nutritious food for 6 months, we conducted post hemogobin test and recorded the same against each beneficiaries. Both pre hemogobin and post hemogobin tests resuts were compared and studied to decide the resuts of the programme. We aso conducted externa evauation to assess the impacts of the programme using the expertise of dieticians. Community Outreach As our organization impements any deveopment programme through the women Sef Hep Groups(SHGs), we gave programme orientation to the Sef-Hep Groups (SHGs) first and invoved them fuy in the project impantation. Women Sef-Hep Groups(SHGs) were our strategic toos to impement this programme through reaching out the communities for project intervention and support. We formed a committee of 10 members from the Sef-Hep Groups(SHGs) and that committee faciitated the process of reaching the community to deiver the services panned in the programme. Our Heath Programme Associate coordinated with the committee members and carried out project activities. Uniqueness of the Project Because of manutrition and Anemia, rura women and chidren faced a ot heath issues and spent both money and time in hospitas. It was unfortunate that anemic issues were not addressed though the 26

35 ocay avaiabe nutrition items and Indian system of medicines were avaiabe ocay say in their door steps. The innovative and ground breaking features of the project that the women earnt addressing manutrition issues using ocay avaiabe nutrition items and changed their food pattern and prevented anemia rather than cure. Each famiy deveoped their own kitchen garden so that they panted and cutivated nutrition food pants/trees in their home using the waste water and used the same to address manutrition issues. We integrated kitchen garden programme with our micro finance programme and that resuted in each and every famiy to concentrate on consuming nutritiona food. Unique feature of this project is that communities owned and sustained the activities. Chaenges Faced We had some probems in taking the ab technicians to the viages and schoos for bood testing as they wanted to charge more amount and they woud come ony in their preferred days and time. So, we strugged hard in bridging the gap between the target groups and the ab technicians in scheduing for bood testing. Simiary, in schoos, the teaching staff needed permission from their higher authorities to conduct mass bood testing and this caused some troubes in competing the activities as per the time frame. Whie distributing nutritious food for the anemic patients, genera pubic aso wanted the food and they created some troubes that affected both quaity and timey service to the patients. Lessons earnt: 1) If the simiar project is impemented in the future, we need to have our own ab technicians (Possiby ab aso)/bood testing kits so that bood testing can be done on time and we can save the cost assuring the quaity of testing without compaints 2) It is better to invove the Govt heath officias so that we wi be abe to invove oca Viage heath nurses those who have strong rapport among pregnant and actating mothers. 3) The project activities with impacts shoud be disseminated among a the stakehoders so that we wi be abe to invove a of them and can impement the future projects efficienty. 4) Impementation of simiar project in a areas through networking with ike minded organizations wi increase the outreach and benefit more peope. 27

36 Outcomes 238 pregnant women deivered heathy babies with the norma weight of 3kg. No materna mortaity among the target groups Assured breast feeding for the new borns for 18 months-22 months. 300 Lactating mothers feeded the babies breast mik maintaining hemogobin eve of 12 that ensured the rich feeding among the chidren. No anemia among the target groups/no manutrition issues in the target viages. Raised the hemogobin eves from 8 to 12 among 800 schoo going chidren ensuring heathy growth both in physica and menta aspects Outreach & Scaabiity This programme was one of the highy resut oriented programme of our NGO. We buit the capacity of our staff team and some of the eaders of our SHGs in raising awareness about anemia in the schoos, sef hep groups of other viages. We have shown the impacts created by this programme and discussed the same with the Taminadu Nutrition Integration Project (TNIP) and improved the quaity of suppementary food distributed by them to the pregnant mothers and the babies in the day care centres. We have shared the best practices of this project to other ike minded NGOs in Kancheepuram and Thiruvannamaai Districts of Taminadu. As awareness is the major component and cost effective, we impemented a our deveopment projects and integrated anemia awareness raising activities among the target groups. During the time of disaster, our NGO priority was addressing the anemic issues among the victims and in that way we covered about 30 food affected viages in Kancheepuram during the devastating food in We worked with organisations ike Give India and ICharity and reached neary 1200 chidren to address their anemic issues. We used to submit project proposas if they were soicited by funders, our priority was anemia correction proposa ony. We have shared the project concept note to other funding organizations and they impemented these projects with the support of their fied partners in Viipuram and Cuddaore districts of Taminadu. Repicabiity We can identify heath programme based NGOs and buid the capacity of their staff members to impement this programme. CSR projects on Anemia correction can be impemented massivey to achieve the desired resuts. Concerned State Vountary Heath Associations can be invited to be technica partners in impementing this project. 28

37 We can aso invove the education department higher authorities in other ocations and buid the capacity of teaching and non teaching staff on addressing anemia among the schoo chidren. Impact Achieved This project was panned based on the training programme attended by our heath staff members in Taminadu Vountary heath Association (TNVHA). As the programme was a need based and worthfu one, we deveoped a project proposa tited Anemia Correction Programme and started approaching funding agencies. Bhoomika Trust, Chennai and Give India Mumbai funded this project. This project had 2 major components such as Awareness Component and Action component. Awareness Component: In the awareness component, we trained our heath staff as master trainers and they visited the schoos and sef hep groups in viages and raised awareness on Anemia. We aso printed handbis and distributed among the chidren, women and pubic. In this way, we were abe to achieve the awareness raising among the target groups successfuy Action Component: As part of action component, we conducted pre hemogobin test and those who had the hemogobin eves 8 and beow 8, were identified for our intervention. As part of addressing manutrition issues among the schoo chidren, we divided the target schoos as Experiment group and Contro group. In the experiment group, we just tested the pre-hemogobin test and recorded the bood test findings. Whereas in the contro group, we conducted pre hemogobin test and identified the anemic chidren and provided nutritious food for 6 months. In the contro group, after the distribution of nutritious food, we again conducted post hemogobin test to assess the heath improvement of chidren and the resut showed improved hemogobin eves to 12. We have used ony ocay avaiabe nutritious items such as dates, papaya, sesame seeds and speciay prepared suppementary food and distributed the same for two times every day for the target groups ( anemic schoo chidren, pregnant and actating mothers in the target viages). Even for deworming, we used Murukkan Seed used in Indian System of Medicines (ISM) The major highight of the programme is that we convinced the noon mea scheme department of Taminadu government and integrated some ocay avaiabe nutritious items in the noon mea served to the chidren which wi address manutrition simiary in the day care centres. So, if this project is impemented systematicay, it wi definitey address the manutrition issues and peope wi aso easiy earn how to address manutrition using ocay avaiabe nutritious items. 29

38 Capacity Buiding Taminadu Vountary Heath Association (TNVHA) was our technica partner and they used to refresher training to the master trainers of Anemia awareness. Whenever we conducted the anemia awareness raising programme among the schoo chidren, teaching and non teaching staff and among the Sef Hep Groups members, TNVHA deputed their staff to buid the capacity our staff through conducting practica training sessions. Partners of the Project We had two types of partners in this project. One was technica partner and another one was funding partner. The technica partner known as Taminadu Countary Heath association (TNVHA) buit the capacity of our organization in understanding the concept of correction programme. They supported us to prepare handbis, wa posters, pamphets and bookets on Anemia. They aso heped us evauate the project with their staff team. Whenever we appied for funding with other agencies for impementing Anemia correction programme, TNVHA was the reference agency to recommend the project. Apart from this, they used to depute their staff to cear the doubts whie impementing this programme in the fied. Funding partner heped us to impement the project through reeasing the fund on time. They aso recommended with other funding agencies to hep us to scae up this project 30

39 A woman submitting proposas on materna heath issues during a Gram Sabha in Faasiya, Udaipur Advocacy for Continuum of Quaity of Care in Materna, Newborn Chid Heath Centre for Heath, Education, Training and Nutrition Awareness (CHETNA) Website Founder of the Organization Coverage/ Geographica reach : : Ms. Indu Capoor, Ms. Paavi Pate and Ms. Meenakshi Shuka : The project was initiated in 2014 in eeven districts of Rajasthan-Dungarpur, Udaipur, Sirohi, Jodhpur, Rajsamand, Chittaurgarh, Jhunjhunu, Tonk, Jhaawar, Karaui and Baran. The efforts spanned over 83 viages, 28 Sub Heath Centres, 11 Primary Heath Centres (PHCs) and Eight Community Heath Centres (CHCs) 31

40 Project Brief Rajasthan, one of the argest states of India is among the high focus state of the Nationa Heath Mission (NHM) of Government of India. Under the Nationa Heath Mission, Government has made severa efforts for improving materna and chid heath and addressing the universa barriers to access heath care such as transport, cost, medicines, suppies etc. The Government of Rajasthan has aso initiated state specific efforts such as free medicines, nutrition schemes etc. However, the focus of government's efforts has been on increasing institutiona deiveries. This has ed to inadequate attention to pregnancy and post partum period. High demand for materna heath services at seected hospitas has resuted in massive overcrowding and an inevitabe decine in the quaity of care women and chidren receive. The coverage of care during pregnancy and postpartum is inadequate, fragmented and of poor quaity. As a resut there is a gap in continuum of quaity care. In this context, SuMa- White Ribbon Aiance for Safe Motherhood, Rajasthan, which is anchored by CHETNA since 2002, roed out a project to advocate for continuum of quaity care and promote socia accountabiity for materna heath. The main objectives of the project were: To enhance capacities of SuMa members to advocate for continuum of care. To buid communities/women's voice to ensure service deivery and enhance accountabiity. To anayse gaps in heath faciities; deveop citizen's report card on the status of materna heath services in the intervention areas and share the findings at district and state eves To strengthen the functioning of accountabiity mechanisms- Viage Heath Sanitation and Nutrition Committees (VHSNCs), faciity based panning and monitoring committees known as Rajasthan Medicare Reief Societies(RMRS) and Gram Sabhas ( constitutionay mandated spaces for citizens' participation in oca sef governance). To increase access to and infuence on oca, nationa and internationa SRHR poicy deveopment and impementation Impementation Mode The main components of impementation mode were foowing Mobiising women/communities and istening to their voice Deveoping simpe toos, forming teams of community members and visit to Heath faciities and evidence coection Anaysing gaps and strengths and deveopment of Citizens' report card on Materna Heath Services. Engaging BDOs/Sarpanch to organise Gram Sabhas 32

41 Mobiising women to make proposas at the gram sabha and foowup Strengthening viage heath sanitation and nutrition committees; faciity based panning and monitoring mechanism known as Rajasthan Medicare Reief Society (RMRS). Engaging Department of Medica Heath and famiy wefare, Government of Rajasthan Broady, the methodoogy of the intervention was based on identification of accountabiity mechanisms, strengthening capacities of SuMa members, buiding women's voice, deveoping citizen's report card for evidence based advocacy, strengthening faciity based panning and monitoring mechanism(rmrs), engaging with gram sabha and strengthening women's voice at the gram sabhas and diaogue with Department of Medica Heath and famiy wefare, Government of Rajasthan, and engaging nationa eve guardian institutions. The Viage Heath Sanitation and Nutrition Committees (VHSNC), Rajasthan Medicare Reief Society (RMRS) and Gram Sabhas were identified as accountabiity mechanism. CHETNA hed trainings for SuMa members to strengthen their capacities of evidence coection and conduct evidence based advocacy. SuMa members deveoped action pans to mobiise women, engage with VHSNCs, Gram Sabha and RMRS. They istened to experiences of around two thousand women of accessing materna heath services. Information/evidence regarding materna heath services provided at the Viage Heath and Nutrition Days (VHNDs), Sub centres, Primary Heath Centres (PHCs) and Community Heath Centres (CHCs) was coected from 83 viages, 28 Sub Heath Centres, 11 PHCs and eight CHCs. This evidence was anaysed and Citizens Report Card on materna heath services for each area was deveoped. The report cards were shared with women/ communities and issues were prioritised. These issues were then taken up by the women and SuMa members to the gram sabhas. SuMa partners shared the Citizens report card with duty bearers and demanded actions to fi the gaps in materna heath services of pubic heath faciities. At the state eve, CHETNA submitted Citizens Report Cards to the Mission Director, Nationa Heath Mission (NHM), Government of Rajasthan, and approva was received for strengthening of RMRS. Community Outreach In the beginning, SuMa members hed discussions with around 1200 women from 83 viages from 11 districts and istened to their experiences of accessing materna heath services. Meetings were aso hed with the members of VHSNCs of the viages and RMRS of the heath faciities- PHCs and CHCs. They incuded eected panchayat members, ASHA, Anganwadi Workers, ANM, senior citizens from the oca communities. Information regarding functioning of the VHSNCs and RMRS were coected from them. VHSNC and RMRS members were mobiised for monitoring of materna heath services provided by pubic heath faciities. Throughout the project period, reguar meetings with communities, especiay women were hed in viages, materna heath issues were discussed with them and issues for advocacy with gram panchayats and heath department were prioritised. Before the Gram Sabhas, SuMa members organised meetings with the communities, especiay women, and the issues to be raised in Gram Sabha were identified. To increase community's participation in Gram Sabha, some SuMa partners 33

42 distributed eafets among communities, affixed posters at prominent paces in the viages and made announcement using oudspeaker. To increase women's participation in gram sabhas, SuMa members faciitated transport for the women iving in far/ remote areas of the viage panchayats. Uniqueness of the Project RMRS members conducting monitoring visit of PHC Gangdhar, Jhaawad There were three unique features of this programme 1. Strengthening and ampifying Women's Voice: Meetings were hed with rura women to isten to their experiences of accessing materna and chid heath services. They were then enagaged in the process of articuation of their priorities and asks. Mobiisation was done to ensure their participation at the Gram Sabhas and diaogue with faciity based committees. This faciitated action based on what women want rather than what the providers want eading to a better uptake of services. 2. Engaging with the Gram Sabhas : This initiative engaged with 49 gram sabhas which were hed and saw participation of about 3000 women for the first time. The Gram Sabhas accepted proposas from women, took them up with the heath and women and chid officias. This resuted in opening up of pubic and democratic spaces for women which were once cosed for women's participation and action to improve conditions of the heath faciities and anganwadi centers. 3. Strengthening and engaging with 17 faciity based panning and monitoring committees: This intiative heped in strengthening of oca faciity based committees to isted to women's asks and take action to improve materna and chid heath services at the PHCs and CHCs. 34

43 A coective action pan was deveoped by aiance partners in 2014 to ensure that gram sabhas are hed as per schedue, community, especiay women participate in gram sabha, make proposas on materna heath issues and actions are taken by the gram sabha on the proposas made by women/community. In the first two years SuMa members advocated to seected Sarpanch/ Gram Panchayats for incuding materna heath in the Gram Sabha agenda and ensured submissions of women's demands/proposas in the seected Gram Sabhas. However it was reaised that demand of RH services among women cannot be increased in isoation. Therefore, in 2016, SuMa members advocated to the bock deveopment officer (BDO)/Sub Divisiona Officer (SDO), Chief Executive Officer (CEO) of district counci for issuing orders for organizing Gram Sabhas of entire bock/district and incuding materna heath in the Gram Sabha agenda. Orders to incude materna heath in gram sabha agenda was obtained in eight bocks. It heped women and SuMa partners to articuate their views and interests for quaity materna heath services in arger area. Women were mobiised to make submissions in Gram sabhas. Sarpanch and eected representatives were continuousy engaged and foowed up for action on women's submissions. During , SuMa engaged with a tota of 49 Gram Sabhas in which over 3000 women participated. For most women, it was for the first time that they participated in Gram Sabha. A tota of 188 submissions were made by them, of which 146 resoutions were passed by gram sabhas and 95 resoutions were addressed by gram panchayats. Most of the submissions were for improvement in basic infrastructure, human resource, medicines, equipment etc. and services provided at sub heath centres, anganwadi centres and primary heath centres. Strengthening Capacities of faciity based committees (RMRS) During , eight SuMA members continuousy engaged with RMRS of 17 faciities from ten districts. SuMa deveoped and impemented an action pan to strengthen these RMRS. SuMa Secretariat CHETNA hed diaogue with Mission Director of Nationa Heath Mission for reease of RMRS guideines. A kit for orientation of RMRS members on their roes, responsibiities and functioning of RMRS comittees was deveoped by CHETNA. With support from bock and district chief medica officers and CHETNA, SuMa members organised faciity eve orientation workshops for RMRS members in 2014 and Action pans were deveoped by RMRS which mainy focused on conducting reguar meetings and taking action to improve the services of the faciities. However, it was reaised that overa functionaity of RMRS in the intervention area cannot be improved in isoation. Therefore SuMa made a strategy to cover a RMRSs of entire bock in one orientation workshop. In 2016, SuMa members advocated with bock/district eve officias of heath department, sub divisiona officers/district coectors to organise bock eve orientation in each of the ten districts. Orders for orientation of RMRS of entire bock were obtained in nine bocks and members of tota 77 RMRS were oriented. During tota 42 orientation workshops were organised for tota 618 members from the RMRS of 112 faciities. SuMa members made reguar foow up visits to the faciities and participation in meetings of RMRS. Athough SuMa members had no prior experience of working with RMRS, their rigorous efforts during has resuted in significant infuence on the 17 RMRS. The number of RMRS having SuMa as member increased from none in 2014 to nine in During this period 14/17 RMRS took at east one action for improving materna heath services. RMRS of 16/17 faciities became partiay functiona as 16/17 hed meeting of members; 15/17 RMRS monitored the faciity by using checkist; 14/17 RMRS visited abour room and 12/17 RMRS received women's feedback. 35

44 Chaenges Faced Some chaenge that emerged during project impementations and steps taken to meet them are foowing: The project was impemented in seected faciities and due to imited resources it was a chaenge to fuy operationaise the Gram Sabhas and the faciity based committees. Engaging with RMRS was chaenging as the composition of the committee was compex with the administrators from state government as the chair who have severa priorities. There was ack of carity among the officias of the faciity and administrators regarding functionaity, roes and responsibiities of the committees and invovement of citizen /NGO members in the functioning of the committees. Gender stereotypes and socia norms in the intervention area was a major chaenge for buiding women's voice and ensuring their participation in spaces ike gram sabhas. The chaenge was overcame to a arge extent by organizing reguar meetings with communities, eected representatives and infuentia peope in the viages and mobiizing women in arge numbers for participation in gram sabhas. Some key essons earnt during the project impementation are foowing: Capacity buiding of impementation partners for deveoping coective action pan aso fosters a spirit of coectiveness and soidarity. It faciitates active participation of partners in intervention area as we as in the state eve efforts. Reguar interaction and meetings faciitates cross earning from successes, chaenges and successfu strategies of other partners. Increasing access and presence of women in pubic spaces is an important step to bring about a change in their status. To increase access and presence of women in pubic spaces, mobiising them in arge number is needed. Understanding the poitica context is important for advocacy. If the context is not enabing, one has to constanty track the environment, deveop inkages and strategies and wait for the appropriate opportunity. The process of socia change is sow and since the engagement with the faciity based committees and gram sabha is new, it requires more time and energy, particuary capacity buiding of aiance and strengthening of committees. Outcomes SuMA aiance has been abe to ampify women's voice and articuate interest on continuum of quaity materna heath services at state and district eve. 36

45 At oca eve, SuMa partners engaged 49 gram sabhas from 11 districts. A tota of 188 proposas were given in the gram sabhas of which actions were taken on 95 proposas. Most of the actions were for improvement in basic infrastructure, human resource, medicines, equipment etc. and heath and nutrition services provided at sub heath centres, anganwadi centres and primary heath centres. SuMa partners strengthened seventeen faciity based monitoring committee-rmrs and increased infuence on their functioning. The number of RMRS having SuMa /NGO member increased from none to 9/17. The number of RMRS hoding meetings increased from 4/17 in 2014 to 16/17 in The number of RMRS taking action to improve materna heath services increased from none to 14/17. Outreach & Scaabiity The initiative of Advocacy for Continuum of Quaity of Care in Materna, Newborn Chid Heath at gram sabha and strengthening of faciity based monitoring Committees- RMRS for improvement in materna heath services can be scaed up in other districts of Rajasthan and it can be repicated in other states aso. At present CHETNA is making efforts to integrate this initiative of strengthening Gram Sabhas to take action for materna heath in the capacity buiding trainings programmes of Panchayat members of Rajasthan. The initiative of strengthening capacities of RMRS or faciity based committees was initiated in partnership with the Department of Medica Heath and Famiy wefare and State Institute of Heath and Famiy Wefare, Government of Rajasthan and has been integrated by the department in reguar monitoring activities. However, given the short duration and imited resources, this intervention coud make the RMRS partiay functiona and there is a need for greater investments to optimay strengthen the RMRS. Repicabiity The project has strengthened the mechanisms aready existing within the pubic heath system. The voices of women can be mobiised through women's groups inked with the nationa iveihood mission department of rura deveopment; the faciity based committees-rogi Kayan Samitis are aready mandated within the Nationa Heath Mission and the heath machinery can be invoved in strengthening these committees at PHCs, CHCs and District Hospitas. Gram Sabhas are aready constitutionay mandated, which can be focussed by the Department of Rura Deveopment and Panchayati Raj as a noda agency. A convergent action is required and partnership with Civi Society organisations and CSRS can enabe their strengthening. CHETNA can pay the roe of a resource agency. Impact Achieved In the target area, this project has been abe to strengthen accountabiity mechanisms- RMRS and Gram Sabha to perform their roe, buid women voice and faciitate diaogues between the women/community to press their demands and engage duty bearers to take action and compy to the 37

46 guideines and standards. The project has aso ed to strengthening of materna and newborn heath services in the intervention areas. Increasing women's participation in Gram Sabha and using this patform for soving the issues of materna heath at viage eve has heped in empowerment of women, especiay from marginaised socia groups. The spaces ike gram sabha and RMRS, in which women hardy participated before this intervention, have opened up their doors for women. Women have started sharing pubic spaces ike Gram Sabha and diaogues with eected representatives and government officias. In the baseine there was hardy any exampe of women's participation in Gram Sabha. Now a significant number of women not ony participate in Gram Sabha but aso raise and discuss their issues of materna heath services and make submissions in Gram Sabha. For most women, it was the first time they participated in gram sabha, discussed materna heath issues and submitted written proposas. The orientation workshops for RMRS members have been hepfu in increasing their knowedge and awareness about their roes and responsibiities. Overa the functionaity of the RMRS of 17 faciities, which were working on papers ony at the time of baseine in 2014, have improved significanty. The RMRS of 16/17 faciities have started organising members' meetings; 15/17 monitored the faciity by using checkist; 14/17 aso visited abour room and 12/17 RMRS received women's feedback. RMRS of nine faciities have incuded SuMa representative in the committee. RMRS of heath faciities have aso initiated diaogue with women. 14/17 RMRS took at east one action for improving materna heath services The actions incuded improvement in infrastructure and ceaniness of faciities, ensuring privacy and respectfu service to women, appointment of human resource, etc. State eve advocacy diaogue with heath department resuted in issue of government's guideines for RMRS which contributed in improving functionaity of the RMRS in the state. CHETNA's engagement with guardian institutions at nationa eve contributed to increased access to and infuence on nationa and internationa SRHR poicy deveopment and impementation. Capacity Buiding During , CHETNA organised four trainings for SuMa aiance members. Their capacities of evidence coection and evidence based advocacy for continuum of quaity care (CQC) was strengthened through participatory training methods. Their skis for engaging with VHSNCs, gram sabhas and faciity based RMRS, making action pans and impementing them, submission of proposas at the gram sabha and engaging with faciity based committees was enhanced. CHETNA provided reguar guidance and handhoding support to faciitate impementation of action pans deveoped by partners. Severa other efforts were made by CHETNA to enhance partners' capacity so that they are sustained and ampify women's voice and articuate interest on CQC and RH. The writing skis of partners were aso increased during CHETNA organised a Writeshop in Hindi anguage for a the partners during December It enhanced partners' capacity to articuate the changes expected at the community and heath system eve and how to write stories of change in context of materna heath. 38

47 Partners of the Project This project was impemented by CHETNA and SuMA- White Ribbon Aiance for Safe Motherhood, Rajasthan. with Danish Famiy Panning Association as the goba partners and Asia- Pacific Resource and Research Centre for Women (ARROW), Maaysia as a regiona partner. SuMa partner organizations' roe was oca eve impementation of project activities ike coection of evidence, mobiising community/ women, strengthening of RMRS, engaging with gram sabha and foow-up for action on women's proposas in gram sabha. They aso participated in state eve joint advocacy actions. CHETNA's roe was to increase capacities of SuMa partner organisation for oca eve advocacy; deveoping advocacy toos and materias, kit for strengthening RMRS; provide mentoring A we-equipped abour room buit by RMRS in PHC Isampur, Jhunjhunu. support to partners in conducting activities, documentation and reporting and monitoring overa progress of the project and expand engagement with Guardian Institutions at state, nationa and internationa eves on CQC and SRHR poicies. 39

48 Training Community Based Management of Manutrition Apri September 2015 Community Deveopment Centre Website : Founder of the Organization : Ameen Chares Project Budget : ` 7,77,600 Coverage/ Geographica reach : 19 Anganwadi centres of 12 viages, Bock Baihar, Baaghat MO 40

49 Project Brief The project area is dominated by tribas, poor transportation, communication and basic heath faciities. This area fas in high manutrition in the district. Ony one PHC is situated in between 54 viages and more than 50 thousand of the popuation, there are no doctors avaiabe since ast many years. NRC is aso 35 km. from connecting point. Chid and materna deaths are high compared to state and nationa rate. Despite government programs, the heath status of the ocas is poor. To understand the issue, CDC conducted severa surveys to know about communities heath-seeking behaviours, ike breastfeeding, cord care, immunization and most important food patterns. After survey reports and discussion at the community, it was observed that there is a probem on both sides, service providers and who are taking services, reated to behaviour and understanding the seriousness of the probem. Another issue that was identified was, change in food pattern, avaiabiity of oca food and impact of market forces on food items. Due to many restrictions and aws reated to forest protection and conservation, the triba/ oca community is not even abe to to harvest their traditiona foods i.e. tuber, eaf, fruits etc. There is a drastic change in food pattern in the rura community. A few years back, popcorn was traditionay prepared by community at home, now packed popcorn is avaiabe in the weeky market and oca shops. Impementation Mode As the project tite, under mode and methodoogy, community-based two-tier approach of the project was used, which was one was to work directy with community and other to work with service providers. The project activities were; Home visits Training programmes Change Agents Coordination at the viage eve Promotion of oca/traditiona foods. Community Meetings/ community growth monitoring Knowedge & Capacity buiding and share with PRI representatives, ASHA, AWW, ANM Through the project, focus was on the coverage area of an Anganwadi centre and to work cosey with AWW, tried to improve her quaity of interaction in home visit, with proper panning and with the suitabe knowedge to her beneficiary. One to one conversation has been deveoped with pregnant and actating women. Invove a famiy members, for caring for a chid or pregnant women. Use different 41

50 modues during home visits. Quaity monitoring of growth of a chid and pregnant women. A pan was prepared to track and support case to case and not in genera. Change agents have been identified and trained on three modues. Their roe has been to supervise and provide feedback to mother, pregnant, actating etc. Community Outreach Panning with service providers Panning with Panchayat representatives Various community eve activities ike Awareness drive, raies, program at Schoo has been organized and tried to spread the messages to a members of the community. Uniqueness of the Project Promote the use of oca foods to treat the manutrition in the community. Under the project, some innovative approach/method has been deveoped. i.e. Feeding Demonstration POUSHTIK LADDU, (Gram, Gud, Peanut) 42

51 PARATHA, (Use of green vegetabes) Powder of ASLI - GUD Roe of Information and Communication Technoogies (ICTs) Technoogy used for tracking to growth monitoring of a chid. Eectronic weight machine for chidren. This machine keeps data and present in exce form. Chaenges Faced The chaenge faced by the community during organizing community meetings or training, mainy during the crop season. During crop season, we focused on home visits and meeting the community at the fied. Outcomes Have worked around 754 chidren's (0-5) age group When the project was started there were 44 chidren in SAM category, by the end of the project there were ony 2 SAM chidren in the project area. MAM chidren's reduced 176 to change agents were trained on heath and nutrition issues. 19 AWW skied on growth monitoring, knowedge has been increased. Outreach & Scaabiity There is need to reach out to more triba areas, the project coud easiy scae up because the organization has good and experienced staffs, earning materia, work experiences and knowedge about oca areas. Organization is trying to find resources for this project. Currenty the project has been integrated with ongoing project, but this kind of intervention needs separate intervention with proper human resources. Repicabiity Definitey! The project coud be repicated in other areas. 43

52 Impact Achieved Overa the project changes ots of behaviour at the community, myths and confusions have been resoved, Most important, that is knowedge of the service providers, this has been increased, which needs to be promoted in other areas aso. We have worked with service providers and try to understand their probems. The probems have been shared with their department's higher eve officers. Panchayat coud work we on proper monitoring and support to nutrition and heath services, which need to integrate with bock officias and interdepartment coordination. Capacity Buiding Staff training on a 7 modues in reguar interva Feeding demonstration Monthy staff meetings Documentation and coection of data and review of data Partners of the Project The Vikas Samvad Samiti was the key partner for the project, they have deveoped and printed materias for distribution, Few capacity buiding training was organized by Vikas Samvad. Poshan Baraat Coordination at state eve done by VSS. Training at Community2 44

53 Community Participation in Deivery of Famiy Panning services and Capacity Buiding of Service providers on Respectfu Care 13 January September 2018 Centre for Catayzing Change ( C3) Website : Founder of the Organization : CEDPA, USA Project Budget : ` 64,954,588 Coverage/ Geographica reach : i. Chhattisgarh: Raipur, Durg, Janjgirchamp, Biaspur, Rajnandgaon, Dhamtari ii. Odisha: Baasore, Boangir, Cuttack, Kaahandi, Khurda, Mayurbhanj 45

54 Project Brief The project 'Community Participation in Deivery of Famiy Panning services and Capacity Buiding of Service providers on Respectfu Care' seeks to ensure that quaity, respectfu and gender-equitabe famiy panning services are avaiabe and accessibe within the pubic heath system by: Increased cient provider interaction where contraceptive needs of men and women are met in the most respectfu and cuturay acceptabe manner within a gender-equitabe framework Increased engagement and participation of communities in promoting access to and usage of famiy panning services Increased accountabiity of the system towards cient through cient feedback on quaity and avaiabiity of services The project aimed at impementing a strategy that addresses the barriers towards community participation and integration of gender concerns in the quaity of FP service deivery by combining capacity buiding of service providers with capacity buiding of and activation of community based patforms such as Rogi Kayan Samitis at the eve of Community Hea Centers (CHCs) and District Hospitas (DHs).The theory of change adopts a twin approach of improving interaction between providers and cients during women's visits to cinics and devising mechanisms for greater invovement of Community Members in ensuring accountabiity and transparency in the deivery of care. Taking into consideration the imitations and imited resources at hand, it aims to equip providers with toos to gauge cient satisfaction from the gender and respectfu care framework, after buiding their understanding of the nuances of gender and unequa power reations. At the same time, in order to secure community participation in improving services, Centre for Catayzing Change (C3) is empowering community members to engage with service providers on an equa patform. Existing Rogi Kayan 46

55 Samitis attached to the DH and CHCs wi be everaged to faciitate this interaction. Additionay, direct feedback wi be sought from community members/women on their experience through new technoogies ike IVRS. A the feedback wi segue into the reviews of DQAC and Quaity Circes for action, thereby assuring the accountabiity of heath services towards women and communities. Impementation Mode Buid the capacity of service providers of various cadres ike CMO, ASHA's, ANMs, Staff Nurses etc. at the CHC eve on FP counseing, informed choice, gender and excusion and its inks with reproductive Heath, understanding Respectfu Care and Women's Access to Famiy Panning Services, and Roe of Heath Care/ Medica Professionas and estabish/strengthen existing heath systems for better interaction. Leverage existing patforms to faciitate processes that buid inkages between the heath system and community. Another strategy is to devise mechanisms for greater invovement of the community ike creating patforms for more interaction and providing cients with a provision of feedback on their experiences. For this, effort is to strengthen the RKS patform and increase interface of these groups with providers to cose the oop and address issues identified by cients. Set-up a ow cost IVR based feedback patform for cients to ca-in to receive information of FP, and provide rating of FP services. This feedback generated from cients and communities wi be coated to produce dashboards which wi be shared with faciity managers and other reevant stakehoders to strengthen the FP program's responsiveness to community perceptions. This cient feedback wi aso be shared with community forums such as District Quaity Assurance Committee (DQAC) and committees which are mandated to utiize feedback for quaity improvement. E-dashboards wi be provided to faciities, DQACs, and Quaity Circes for review and action Community Outreach Designed training packages: Deveoped three training packages on respectfu care and counseing for FP services keeping in view respect, consent and choice for heath providers and frontine workers (ASHAs/ANMs) and Rogi Kayan Samity ( RKS). Capacity Buiding: Conducted trainings and orientation workshops for administrators and decision/poicy-makers, and the training for heath providers and frontine workers, using the designed training packages. Aso oriented ASHAs and ANMs attached to the faciities with higher cient oad, on the content reated to respectfu care and counseing for FP services keeping in view respect, consent and choice. Capture successes and ways to improve trainings: Deveoped brief reports on the observed successes and ways to improve the provider trainings. The key chaenges and aspirations of providers in attending such trainings to provide respectfu care are aso documented. Active community engagement: Leveraged existing patforms to faciitate processes that buid inkages between the heath system and the community ike the Rogi Kayan Samitis in the districts each of Chhattisgarh and Odisha. Capacitated members of RKS and DQAC with community eaders 47

56 ike PRI members and faciitated pan and monitor quaity FP services. Reached out to the community with information around the benefit and uptake of FP. Activated NHM Community based Panning and Monitoring Processes: C3 worked with CSOs in each state to activate NHM's community action for heath mandate which are not currenty functioning to their fu potentia. This woud entai conducting a quick assessment of the status of RKSs, and the effectiveness of the various RKS in ensuring proper functioning and management of the hospita and maintaining the quaity of services. C3 and the NGO partners is working with the RKSs to ensure compiance to minima standard for faciity and hospita care and protocos of treatment as issued by the Government and ensure accountabiity of the pubic heath providers to the community. C3 and the NGO partners aso supported the RKSs to impement other activities as per NHM's Community Action for Heath (CAH), for exampe, dispay a Citizens Charter in the heath faciities, operationaization of a Grievance Redressa Mechanisms, faciitating, and estabishing inkages with Quaity Assurance Ces for Action. Activate and buid capacity of RKS : Effort wi be to capacitate the Rogi Kayan Samiti, by giving Orientation and training workshops in the 12 districts to use of toos ike Community Score Cards which provide forums for direct interaction with cients and systematic usabe evidence for comprehensive community feedback. C3 wi work with oca NGO partners seected in consutation with MCSP and SHRC, in the districts to work to activate the RKS and push the agenda of respectfu care during FP services at faciities in their meetings Present community feedback on quaity of services to DQACs for review and action:. The activated RKSs wi aso be encouraged to meet with the DQAC and Quaity Circe at frequent intervas so that feedback and findings can be discussed and soutions arrived at. Roe of Information and Communication Technoogies (ICTs) IVRS: An Interactive Voice Response System In order to improve informed choice, respectfu care, gender-sensitivity through greater community participation and to address socia factors which affect the uptake of famiy panning methods, C3 has been focussing community engagement through Interactive Voice Response System (IVRS) in 6 districts of Odisha namey Baasore, Boangir, Cuttack, Khordha, Kaahandi and Mayurbhanj. This digita patform provides cients information on the various famiy panning services avaiabe, share their feedback on quaity of services and take appointment for steriization services. The data reported by women receiving famiy panning services is a powerfu feedback oop that turns both women and providers into active contributors towards high quaity famiy panning services deivery. Chaenges Faced There are chaenges in ensuring optimum access and utiization of heath services by a, especiay to marginaized communities. To achieve this, there is a need overcome barriers reated to geographica remoteness, prevaiing gender norms, socia excusion and behavior during heath care deivery by providers. In this context, heath workers especiay ANMs and community eve heath vounteers- 48

57 ASHAs- can pay an important roe in reducing these barriers and inequities as they as the 'first point of contact' between heath system and the community. Famiy panning reated information were not avaiabe in gender sensitive and equitabe manner. Barriers reated to geographica accessibiity and timey avaiabiity of both famiy panning cients and front ine heath worker for counseing services. Rea time data on cient feedback on quaity of FP services. Rogi Kayan Samiti members- a community patform activey engaged to take actions on identified gaps. Outcomes The outcome envisioned in the project caed 'Community Participation in Deivery of Famiy Panning services and Capacity Buiding of Service providers on Respectfu Care' was to ensure that quaity, respectfu and gender-equitabe famiy panning services are avaiabe and accessibe within the pubic heath system by: Increased cient-provider interaction where contraceptive needs of men and women are met in the most respectfu and cuturay acceptabe manner within a gender-equitabe framework Increased engagement and participation of communities in promoting access to and usage of famiy panning services Increased accountabiity of service deivery through cient feedback on quaity and avaiabiity of services Knowedge on various contraceptive methods avaiabe within the heath system in the state has improved among heath workers. Reach and access of famiy panning information and services has significanty improved. The universa right of chid bearing women to quaity, equitabe and respectfu famiy panning service has been ensured. Men are activey invoved as partner, cient and positive change agent in accessing famiy panning services. RKS members are more invoved in ensuring quaity and respectfu care and avaiabiity of equipment and infrastructure which makes the service conducive. Outreach & Scaabiity Adopted for extension/ integration of program intervention S. No District Popuation Popuation growth Rate Tota Eigibe Coupe 1 Khordha % Baasore % Boangir % Kaahandi % Mayurbhanj % Cuttack % Source: State Famiy Panning Pan

58 The project is being impemented in 6 districts of the state Odisha namey Baasore Boangir Cuttack, Khordha, Kaahandi and Mayurbhanj with eigibe coupes from urban, rura and triba areas. A tota of 13,429 frontine heath worker both ASHA and ANMs, 1080 Service Providers incuding Staff Nurses and Medica Officers and 1080 RKS members are covered in the project. Review forums ike Sector eve meetings, Bock Quaity Circes, District Quaity Assurance Committee strengthened under the interventions. Repicabiity The project has demonstrated how working with pubic heath system and communities can deiver quaity of famiy panning services in the most respectfu and cuturay acceptabe manner within a gender-equitabe framework. Impact Achieved There has been increased cient-provider interaction in which contraceptive needs of men and women are met in the most respectfu and cuturay acceptabe manner within a gender-equitabe framework. Up take of famiy panning methods has increased with uninterrupted access to famiy panning information through IVRS. The human factors in access to information been overcome. Further, increased diaogue between heath care panner and communities promoted quaity of famiy panning services. The mechanism for increased accountabiity of service deivery through cient feedback on quaity and avaiabiity of services has been revitaized. Knowedge on various contraceptive methods avaiabe within the heath system in the state has improved among heath workers. Reach and access of famiy panning information and services has significanty improved. The universa right of chid bearing women to quaity, equitabe and respectfu famiy panning service has been ensured. Capacity Buiding Capacity Buiding Programs-Coverage in numbers State District ASHAs ANMs Service Providers RKS Members Chhattisgarh Janjgir Champa Biaspur Raipur Dhamtari Durg Rajnandgaon Odisha Boangir Baasore Cuttack Khurda Kaahandi Mayurbhanj Tota 27,527 1,791 2,360 1,230 50

59 The separate training manuas for Frontine Workers (ASHAs and ANMs), faciity based Service Providers and RKS members on Gender, Socia Incusion and Respectfu Care in famiy panning services were deveoped by Center for Catayzing Change (C3). The contents of the training manua were deveoped based on the gaps in knowedge and u n d e r s t a n d i n g o f k e y stakehoders of the project. A Technica Committee under the Chairmanship of Director of Famiy Wefare, Govt. of Odisha and members invoving senior state eve heath officias from Heath and Famiy Wefare Department and Nationa Heath Mission (NHM) Odisha has approved these 3 training manuas. The cascading approach adopted for successfu impementation of the training programs. The poo of resource persons invoving state eve heath officias trained at state eve were invoved in training Master Trainers from district eve. The trained Master Trainers invoved in faciitating bock frontine heath workers and faciity eve Service Providers training programs. Partners of the Project The Centre for Catayzing Change (C3) under the umbrea of the Materna Chid Surviva Programme(MCSP)/USAID is supporting Government's efforts, in coaboration with Directorate of Heath and Famiy Wefare, Govt. of Odisha, and Nationa Heath Mission (NHM) Odisha to impement the project Community Participation in Deivery of Famiy Panning services and Capacity Buiding of Service providers on Gender, Socia Incusion and Respectfu Care in Famiy Panning Services. The Heath and Famiy Wefare Department, Government of Odisha and Nationa Heath Mission, Odisha are the important partners in this project. The work pan has been approved by the Government of Odisha and necessary directives have been issued from the state eve to district eve for smooth impementation of paned activities. A the training programs incuding system strengthening interventions carried out in cose coordination with district and bock eve heath functionaries. 51

60 Training of FLW in M. Rampur CHC of Kaahandi district Training of FLW in Subarnpur CHC of Cuttack district A Heath Worker- Femae from Tigiria CHC, Cuttack district accessing IVRS 52

61 An ASHA from Tigiria CHC, Cuttack district accessing IVRS 53

62 Ensuring Better Materna Heath Care Outcomes Through Community Action And Socia Accountabiity Mechanisms (Phase 2) March Juy 2018 SAHAJ (Society for Heath Aternatives) Website : Founder of the Organization : Renu Khanna Project Budget : ` 50,07, Coverage/ Geographica reach : Dahod, Panchmaha and Anand districts 54

63 Project Brief Materna heath has remained a woman's issue and a private issue, within the reams of the famiy. We beieve that women fufi an important socia function through reproduction and it is therefore the responsibiity of society to ook after them during this period of vunerabiity. Thus, the community must be made aware of the impications of materna heath and their own responsibiities. By 'community action' we mean any action that the various groups/individuas take which wi promote attention to materna heath, ike, awareness raising campaigns amongst famiies of pregnant women, monitoring of services provided either at the community eve or the faciities, diaoguing with the heath care providers and Bock and District Heath Officers, raising these issues in Panchayat meetings and Gram Sabhas, being part of efforts to report materna deaths and conducting their enquiries as we. In order to achieve these goas, a coaborative project between three NGOs with a goa to visibiise a socia determinants approach to materna heath and promote community action and socia accountabiity in three rura and triba districts of Gujarat, India was initiated in and Phase II from The coaborative project is between SAHAJ, Area Networking and Deveopment Initiatives (ANANDI) in Dahod and Panchmaha districts (amongst the 250 poorest districts of India) and Kaira Society for Socia Service (KSSS) in Anand district. The area covered were 23 viages under Baria and Goghamba bocks in Dahod and Panchmaha districts and 20 viages under Umreth and Anand bocks in Anand district. The objectives incude: a) Enabe communities to monitor access to and quaity of materna heath care with invovement of pregnant and actating women, women's coectives, Viage Deveopment Committee members and Panchayat/Gram Sabha members in prioritizing materna heath in their community. b) Deveop and disseminate too kits, training manuas and other visua materias to the stake hoders, networks and coaitions. c) Advocate with stakehoders in the heath system to faciitate community monitoring of materna heath care and community participation in Materna Death Reviews (MDRs). Impementation Mode The foowing strategies were appied to materna heath issues: A. Conducting surveys on materna heath issues A survey too was deveoped based on changes in knowedge, attitudes and perceptions we hoped to see in the community The too was aso the basis of forming IEC materias 55

64 B. Strengthening community action through- Various IEC toos such as Wari Madi (Heathy Mother) too, posters, wa paintings, games, pamphets P r e p a r i n g w o m e n a n d Panchayat members to take up issues of materna heath in Gram Sabha and Jan Sunwais (pubic hearings) Community mobiization for monitoring of materna heath faciities/services and invovement in MDRs C. Strengthening socia accountabiity by- Training community women as vounteers to fi toos, monitor services, spread awareness, participate in campaigns, being part of MDRs Improving reations with oca fied eve heath worker (ASHA, Femae Heath Worker-FSW, Anganwadi Worker-AWW) and monitoring their service deivery Generating report cards of the services Monitoring the Viage Heath and Nutrition Days (VHND)¹ or Mamta Diwas Increase invovement of community eaders to enhance sense of responsibiity towards materna heath issues Guiding and supporting the Panchayat members to be sensitive to and improve quaity of materna heath services, faciities and infrastructures in their viages and to make bood donors and vehice owners ists in case of emergency Invoving community to meet heath officias for increased poitica wi D. To disseminate widey the toos and methodoogies and essons earnt at community, state and nationa eve. Making coaitions with other NGOs and campaigning groups working on this issue Presenting and promoting our experiences in workshops, conferences, meetings, websites, coaitions and campaigns ¹ Once a month on a designated day, pregnant and actating women are provided ante nata and post nata services by the government heathcare providers. It is aso known as Mamta Diwas. 56

65 Community Outreach A baseine assessment was done to meet various community eaders. The NGOs were aready working with the various women's coectives in the area. Faiya meetings were conducted for greater reach in the community. Aong with this, the ground eve heath care providers (ASHA, FHW, AWW, Auxiiary Nurse Midwife-ANM) were befriended and trust buiding was done with them that the monitoring work was not to point fingers at them but to deveop a good reation between them and the community for the greater common goa of improved materna heath. Uniqueness of the Project Through the mamta toran (that described various ante nata services) that was eventuay made into a poster, women started demanding the services and faciities they were supposed to get on Mamta Diwas. The poster on birth preparedness (it incuded information on basic ante nata and post nata care, high risk symptoms and a space for emergency numbers) was the most appreciated materia of the project, with demands from even the heath care providers to upscae it. It was usefu for the famiy members and the space for emergency numbers heped in severa instances aong with recognizing high risk symptoms. Invoving the Panchayat and Gram Sabha members heped increase visibiity of materna heath as an issue in the community and ed to improvements in the services, faciities and infrastructure reated to materna heath. Invoving the various women's coectives heped in sustainabiity and the ripping effect of transfer of knowedge to other areas as we. Rather than monitoring the heath system by baming them for the ack of services/ faciities or negigence on their part, a supportive encouraging and trusting bridge was created wherein they were aso motivated to work towards this goa with enthusiasm. Our fi e d s t a ff m e m b e r s reported the changes in attitudes in the ASHA's or A N M ' s a n d e v e n a b technicians. One such s t o r y w a s o f a a b technician who aways used to be busy with his mobie after coecting bood. Within a short span, as he was hearing our members discussing materna heath issues with the pregnant and 57

66 actating women coming on Mamta Diwas, he started getting invoved and woud in fact conduct the sessions himsef. This and severa other experiences show that even heathcare providers when motivated and encouraged, can enjoy their work and take things forward. Board games on materna heath issues, entitements and responsibiity of sef, community and Panchayat towards materna heath was we appreciated with women actuay trying to answer questions even if they were wrong, thereby giving a good chance for discussions and information passing in a friendy and interesting way. Wa paintings, turned out to be a simpe, cheap and innovative way of spreading awareness of services and announcing when and where the services were avaiabe. A comprehensive pamphet with practica information reated to different government schemes, the identity documents required, who coud avai it and what benefits one gets, was usefu and much demanded pamphet in the community. In fact we are getting requests from other NGOs to repicate this simpe but practica pamphet. Meetings with Panchayat and Gram Sabha members as a group were usefu in motivating many of them especiay the stronger women eaders amongst them (and mae members as we) to push the materna heath agenda forward. However, this needs to be a reguar feature and inputs and some funding to continue this woud go a ong way. Getting them together as a group and giving them necessary kits (ike posters) and making them aware of how they can hep by simpy monitoring the services and discussing materna heath issues in their meetings woud make a big difference. Thus, by strengthening Panchayat and Gram Sabha vis a vis our materna heath agenda, some actions that took pace: 1. In Anand district money was granted for street ights, water and roads to reduce stress on women during pregnancy; disma condition of heath faciity was pointed out in a Gram Sabha meeting resuting in the government sanctioning a new faciity for deivery and checkups. 2. High risk symptoms are taken seriousy by the fied eve heath workers and Medica Officers (Mos). Because of awareness, at east 1500 women were identified with high risk and treated. 3. ASHA, AWW, MOs and Panchayat members showed interest in the birth preparedness posters. 4. MOs, Nurses, Chief District Heath Officer (CDHOs) and other heath department officias and providers have started showing more interest and care in their efforts for improved materna heath care. 5. Earier Primary Heath Center/Community Heath Center staff used to hide information reated to materna death, but now they share during MDRs. ANANDI has become a part of the officia government MDR committee. 6. Referra services have improved with Nurses and ASHA accompanying the women. Government vehices are used to bring pregnant women to the centers for hemogobin testing. 58

67 7. Mamta cards are fied reguary; VHND has improved and continues to have a stock and required faciities. New cinics have been initiated for women iving in 'seem vistaar' the fieds in the remote outskirts of the viage where the agricutura famiies ive during the farming season (this is an equity effect). Aso due to community monitoring the duration of the VHND has increased from 2.30 to 5pm. 8. Most MOs now more open and ready to attend Gram Sabha meets and reguary supervise the VHND. 9. Cases of negative bood group during pregnancy taken seriousy and injections now avaiabe for it. Roe of Information and Communication Technoogies (ICTs) Ony simpe cuturay appropriate monitoring toos and visua aids (deveoped with community participation) were used throughout the project. The ony technoogy truy used was the mobie to send SMS directy to the CDHO in case of any materna death occurred so that it coud not be hidden and woud have to be investigated. Another way the mobie was used was to note down emergency numbers and mobie numbers of heath workers (ASHA/ANM) in the birth preparedness poster to contact at the time of deivery. This was a highy appreciated part of the poster. Finay, in some viages, emergency bood donors and transport ist with mobie numbers was kept in the Panchayat office to use. So there was indirect use of technoogies in that sense. Chaenges Faced The main chaenge was to bring forth the issue of materna heath from a 'private famiy affair' and making it a 'community issue in the pubic domain'. This was achieved over the years by invoving the community at every step of the process with the NGOs working as faciitators and encouraging community eaders to take issues forward. One important esson was that participatory processes of deveoping consensus around probems, framing entitements, and deveoping toos take time, but they reap deep dividends. However, investments in these processes (time, money, human resources) have to go beyond short project cyces. 59

68 Another earning was that monitoring toos have to be simpe-yet effective-and suitabe at the community eve. The toos can become progressivey more compex as the community groups mature and heath s y s t e m b e c o m e s m o r e responsive- for exampe, initiay just service avaiabiity maybe monitored. Once services are made avaiabe, their quaity becomes the issue and can be monitored. The most important chaenge or esson earnt was that capacity and reationship buiding is required at a eves from the viage eve with the oca heath providers to the Primary Heath Centre, to the bock and district eve heath centers. Winning government heathcare system support especiay at the oca eve was by etting them know that monitoring is not 'finger pointing' but that a supportive mechanism between community and heath workers having a common goa of improving quaity of materna heath care. However, meeting heath officias at state and district eve was a major chaenge. Advocacy with them and interdepartmenta convergence has been the greatest chaenge in the project and not achieved during this period. Finay, some eve of faciitation and organization is required to enabe communities to monitor the situation. In contexts where suitabe NGOs are not present, how can this be done? Outcomes Some important outcomes at community eve: Increased knowedge and understanding of materna heath entitements, services, high risk symptoms and In severa viages, bood donors' and vehice owners' ists are now kept in the Panchayat office for use in emergencies. Increased discussions in Gram Sabha meetings with demands for improved services, faciities and infrastructure During Gram Sabha meetings, due to inputs from the community, in some paces heath faciities were improved or they got government sanction for buiding a new faciity for deiveries 60

69 Increased institutiona deiveries in government faciities Increased community participation in MDRs and its discussions in Gram Sabha meetings Better understanding of the roe of ASHA, Nurse and what shoud be avaiabe/working at various heath faciities Panchayat members too began accompanying women in cases of emergencies Major improvements in quaity of services on Mamta Diwas (time period was increased so that more women coud attend it, machines working, hemogobin testing done etc) Mamta cards were now being fied (not fied earier by the Nurse) Most Medica Officers are now more open and ready to attend meetings reated to materna heath incuding Gram Sabha meetings Nurse and ASHA and Nurse more responsive and supportive to emergencies and deiveries Cases of negative bood groups in pregnant women taken more seriousy now and necessary injection provided (not done earier) Improved water, street ights and road faciities to reduce stress on pregnant women There was increased visibiity of the materna heath issues in and around the project viages The isting of emergency numbers and messages in the birth preparedness poster was of great hep at the time of deivery as the entire famiy was better prepared even in case of emergencies Some important outcomes at organization eve: Understanding, anayzing and documenting materna deaths from a socia determinants perspective increased amongst the team members. Team members were made part of the officia MDR committee; they directy report materna deaths to the CDHO via SMS and hence add pressure on heath officias to do MDRs in a transparent manner. When the team members presented their reviews, gaps in MDR conducted by the government officias became apparent. Earier PHC/CHC staff used to hide information reated to materna death but now they share the information during MDRs. MDRs heped in improvement in faciities, services, and added pressures on Nurse/ASHA to do their work we (now they accompany women at the time of deivery/emergencies). Big improvement in the reationships of organization staff and the Nurse / ASHA worker (strained earier in many viages). Now they share information, coordinate and support each other. Tauka Heath Officer (THO) appreciates efforts of the NGO in bringing about improvements in materna heath 61

70 Outreach & Scaabiity SAHAJ: We continue to promote materna heath issue by training other NGOs (eg. ATAPI, state eve workshop in 2016) in Gujarat and other states (eg. Assam) on these issues; aso through Jan Swasthya Abhiyan (JSA) which is a network of 70 organizations in Gujarat, materna heath issues are promoted (one eg. recenty the issue of bood avaiabiity during deivery was taken up in their consutancy meet in September 2017 and has become a JSA issue; The issue is a part of SAHAJ's urban heath program in sums- aso its adoescent program. SAHAJ is coaborating with Equa Measures 2030 wherein SDG 3 and 5 are focussed and materna heath is incuded as in integra part. Materna heath as an issue wi be promoted where ever possibe in SAHAJ's work and networks. KSSS: They continue the materna heath work through their 400 SHGs; 40 Viage Deveopment Committees and connecting with Panchayat members of 40 viages using posters and games deveoped by us. Aso staff from other projects, reguary discusses materna heath issues in their areas through posters deveoped by us. ANANDI: Materna heath is now an integra part of their organizationa vision. The Sangathans (women's coectives) from 150 viages consisting of over 7000 women members have heath as an important aspect of their meetings and materna heath is integrated into this. Another project starting from January 2018 wi invove 86 Gram Panchayats and they wi discuss materna heath through the posters to ensure that it is seen as a community issue. The Viage Heath and Nutrition and Sanitation Committee (VHNSC) wi be strengthened in this project as we and MH wi be discussed and promoted. In future, they pan to strengthen Viage Deveopment Committee wherein again materna heath issues wi be propagated. A heath and nutrition program wi aso begin to dea with manutrition infants and chidren and they wi incude mothers and hence materna heath issues wi be part of it as we. Overa, in a the three organizations, staff members even if given other project work keep an open eye for issues reated to materna heath and spread awareness and continue to guide the community. Those who have eft the organization, aso continue to promote and spread the importance of materna and women's heath. One staff member who joined a oca schoo as a teacher promotes materna and reproductive heath issue amongst the schoo going chidren. Another member joined a trust based hospita and works towards promoting women and materna heath issues by encouraging the hospita team to conduct heath camps for women. Repicabiity The project design is easiy repicabe and the toos and materias are easy to use. With basic training and periodic reviews, it can be easiy repicated and integrated to other ocations and is being promoted as mentioned above. The practica and doabe essons earnt during the project period need to be pubished and the knowedge needs to be shared through various patforms especiay in the marginaized communities. 62

71 Peope require basic awareness and the Panchayat and Gram Sabha meetings are a good patform for the same. The partner NGOs have ingrained the messages so much that even members working on other projects push the materna heath agenda in their work as we and spread awareness as we. Aso through our other coaitions and heath groups, the agenda gets further outreach and sharing of ideas and earnings take pace. In one such group, the CommonHeath group, meeting was organized in Assam in August end 2016, wherein the women's Sef Hep Groups wanted to use the toos and methodoogies emerging from this project. Athough not a direct sustainabe issue, but it is a case of diffusion of earnings and outcomes of our project in other areas as we. Simiary, some state eve NGOs have shown increased interest in conducting MDRs in their regions after having attended our training workshop on it. Most of our community vounteers and staff in the partner NGOs come from that region and they continue to spread these messages and impart knowedge even after the project period. The system of socia accountabiity makes the heath system and its staff (speciay ground eve) accountabe and answerabe to the society and not just their superiors, and hence they become more responsive to the citizens as has been the experience of our project. A simpe exampe is how the Nurse/ANM/ASHA worker now makes better coordinated efforts to hep the pregnant women of their areas. They accompany them in case of emergencies, make arrangements for vehice to get them to the cinics for check up especiay hemogobin monitoring, to name a few of the changes. Impact Achieved The above objectives/activities were achieved by invoving a) pregnant women and their famiies; b) women from oca sef hep groups; c) Panchayat and Gram Sabha members (especiay women members); and d) heathcare providers especiay at fied eve (AWW, ASHA, ANM, MOs) for increased poitica wi on this issue at viage eve. Based on the rights and poicies issued by the government regarding materna heath services, faciities, infrastructura faciities and entitements, the community especiay the Panchayat members and women's coectives were made aware of these and guided for the same. Strengthening of community action The knowedge, awareness and attitudes of the target groups on issues of materna heath in the project areas have shown significant improvement as per quantitative and quaitative data anaysed. The most important message, that materna heath is a community and Panchayat issue was achieved to a great extent in the project viages, with transfer of knowedge in surrounding contro viages as we. Initiay, the Panchayat and community members did not fee responsibe towards materna heath issues as they fet it was a famiy matter. However, with innovative means of reaching out to them brought marked changes in this attitude. In many viages bood donors' ists were created, use of 108 ambuances increased, ANMs/ASHA workers started accompanying the women to hospitas for 63

72 deiveries or haemogobin testing, and community eaders became more supportive by providing private vehices, money or even accompanying the women. ANC services improved the most. The VHND or Mamta Diwas monitoring checkist used by the community eaders (especiay women eaders) was very usefu in bringing about improved attendance and services. There is now a reguar suppy of medicines, attendance by heath workers incuding ab technicians is reguar, faciities are improved and equipments are in working conditions. Strengthening socia accountabiity Through trust buiding strategies, there is now a better and positive connection between the community, NGO members, oca heath system personne and heath officias at the bock and district eves. Such measures have resuted in a more open, responsive and trusting environment with the community participating in monitoring and supporting the heath system (and vice versa) than before. Invovement of community members and government heath care providers in reporting and investigating materna deaths has improved. Use of report cards and board games on materna heath issues and entitements has become a part of the NGO advocacy efforts with community vounteers using it reguary in the fied to spread awareness. Thus, the community is taking more responsibiity in improving materna heath services and faciities by discussing it in Gram Sabha meetings and panning actions accordingy. Dissemination Efforts are on to scae the posters and other successfu IEC materias. Posters on this issue have been distributed to other non project viages amongst Panchayat offices and women's sef hep groups there. The abstracts for pubications and presentations wi further the issue at various nationa and internationa patforms. Ongoing work wi be taken forward by being part of the project on Sustainabe Deveopment Goas Capacity Buiding Invoving and training vounteers from the community to fi monitoring toos ike the Heathy Mother (Wari madi) too on ante nata care, deivery and post nata care services. This too aso heps in creating awareness amongst the pregnant and actating women. Awareness buiding and motivating the women from various women's coectives to understand their rights. Awareness buiding of Panchayat members and other community eaders. Diaogues with heath care providers and tauka and state eve officers. Reguar review and panning meetings amongst the partner organizations 64

73 Partners of the Project The partners in our project were Area Networking and Deveopment Initiatives (ANANDI) who had been working in Dahod and Panchmaha districts and Kaira Society for Socia Service (KSSS) in Anand district. They were grassroots organizations who were we estabished in these districts with access to many viages that were part of the project. It was through their staff members and community vounteers that we coud reach out to the stake hoders in these areas. Whie SAHAJ provided the technica inputs and monitored and guided the project, it was impemented, monitored and guided at the community eve by these organizations. During the project period, capacity buiding and experience of working on materna heath reated issues from a socia determinants and user perspective was deveoped and internaized by the teams of these organizations. They were we organized, focussed and motivated in terms of its activities and outputs. Coordinated team work and reguar review meets between the organizations heped in achieving the goas set out. Staff from a the three organizations have understood and internaized the importance of improved materna heath and are sustaining the work even post-project period by continuing their aiances with women eaders and groups and the Panchayat members. Awards/Endorsements We have not consciousy or deiberatey sought any endorsements as such. However, the project strategies, achievements and essons earnt have been presented in severa nationa and internationa conferences where they have been recognised as a mode of socia accountabiity and community action in materna heath. 65

74 Ensuring Chidren Heath and Nutrition Rights in Kaushambi district of Uttar Pradesh Partnership since 1999 with CRY-Chid Rights and You; this project was initiated in 2015 CRY-Chid Rights and You (with on ground partner Doaba Vikas Evam Utthan Samiti (DVEUS) Website : Founder of the Organization : Mr. Rippan Kapoor (CRY); Mr. Parvez Rizvi (DVEUS) Project Budget : ` (Period, January-December 2018) Coverage/ Geographica reach : 35 viages under 03 deveopment bocks of Kaushambi District of Uttar Pradesh 66

75 Project Brief Kaushambi district is one of the most backward districts of Uttar Pradesh and deveopment indicators are very poor. Materna and Chid heath status in abysmay poor due to ack of awareness as we as dysfunctiona heath care system. Keeping in view of such beak scenario, the organisation has been working consistenty among the rura communities to improve materna and chid heath scenario. As key strategies for intervention, we keep a track of a pregnant and actating mothers and chidren under 6 years to ensure reguar contact, foow up and inkage to services as per Government norms. The aim of the program is to provide targeted messages to identified famiies of pregnant and actating mothers as we as new born chidren for timey registration in Aanganwadi centres, reguar ANC check ups, identify high risk pregnancies, counseing for adequate diet and rest, advice for institutiona and safe deivery, proper Post Nata check ups incuding care of new born with periodic weight monitoring and immunization. Apart from this the program gives ot of focus on initiation of eary Breast Feeding mandating Coostrum feed for new born, compimentary feeding and proper IYCF practices. The program aso draws its inkages to the issues ike Manutrition and Referra services whenever needed. The issue of Manutrition is very rampant in the intervention areas and it needs eary and proper intervention to prevent the chid from its ong term i effects. The entire program pan demands strong support of oca care givers ike ANM, ASHA and Aanganwadi workers aong with Government Heath officias Medica Officers, BMO and CMO. The program aso takes support from District heath officias to organise heath camps and aso, strengthen monitoring of Govt. programmes. The organisation aso foow up at oca eve to ensure meeting of viage heath sanitation and nutrition committee ( VHSNC) to create community eve awareness as we as ensure accountabiities of duty bearers. Foow up done reguary at district and state eve to address the identified gaps. Death audit based on 3D mode (Deay in decision making, deay in transportation and deay in care and service) done in case of neo-nata/infant/chid and materna deaths to anayse the reason of deaths and sharing hed with heath department to undertake intervention accordingy. Impementation Mode The impementation Mode stand on three main piars: Sef System Society The impementation of the project mode is being done through undertaking initiatives as under: I. Community eve Invoving househods as key unit and oca community. At community eve, methodoogy is argey participatory covering direct community meetings, one-to-one meeting as we as focused group discussion (FGD) on materna and chid heath issues. 67

76 ii. Intervention at oca duty bearer eve Invoving ANM/ASHA and Anganwadi workers and oca officias iii. Stakehoders' engagement with key departments/ministries/n/scpcr and other rights bodies. Direct engagement with stakehoders as we as sharing of evidence based report/fact sheet to address the identified gaps is aso undertaken. Community Outreach The organisation organise reguar community eve meeting as part of mobiization process to discuss range of oca issue aong with materna and chid heath reated issues. Awareness generation meeting being organised on various governments schemes and programmes and aso, faciitate processes for the same through aisioning with government department. Since the reference communities are argey poor and daiy wage earners, effort have been made to organise custer eve meeting/sma group meeting as per their avaiabiity to make them aware about materna and chid heath reated issues as we as other issues incuding safe drinking water, hygiene and sanitation, nationa food security schemes, Materna entitements ike PM Matri Vandana Yojana, and NGREGA. Door to door meetings organised as foow up with pregnant/actating mothers, parents of newborn babies for immunization and care. Aso, coordination heath workers, Aanganwadi workers, ANM and AHSA at oca eve and motivation of community to participate in meeting in VHND organised at Anganwadi centre eve. Adoescent girs groups and chidren groups have been formed in each viage to orient them on the heath, hygiene, sanitation and nutrition issues. Specia emphasis is being given at imparting ife skis training to the adoescent groups for making them understand their sef, increasing their negotiation, decision making and interpersona skis so that they can infuence the community and peers for their own rights as we as for adopting good practices with respect to heath and nutrition. The program aso works towards maintaining equitabe gender reations so as to give the girs and women a dignified space as we as decision making power in communities to take up what is best for them and their chidren. Uniqueness of the Project Some good practices which have seemed to give a push to the entire program can be mentioned as beow Working on Gender reationships Working with Men's groups and Adoescent boys groups for making them a part of the discussion on Heath and Nutrition of Women and Chidren. Behavior Change Communication Understanding the current practices of the community and formation of messages which can te them some 'Possibe Practices' rather than 'Idea Practices'. This has heped in acceptance of the messages and starting of change in Behaviora patterns. Community Nutrition Needs Assessment this is a very focused chid centric community nutrition needs assessment. In this assessment a the sections and stakehoders of the community are met 68

77 with and their views taken on the nutrition and heath component which effect the Materna and Chid Heath. Undertaking Death Audits This practice has heped in understanding the root causes of rampant Materna and Infant deaths and has aso heped in presenting the facts with Government officias to hep them to make required changes. Documenting Stories of Change these stories have heped in cross earning and heping community earn and practice new things from the experientia earning's of others. Focus on Preventive Strategies This is mainy towards identification of High Risk Pregnancies, ensuring timey referras and focused messaging and reguar home visits to identified famiies. Roe of Information and Communication Technoogies (ICTs) IEC through Digita medium: Sharing of Information, Education and Communication through digita means. Chaenges Faced There are mutipe chaenges faced by the organization with regards to impementation of the progamme. One of the major chaenges in the areas is seasona migration of peope which is seriousy impacting ANC/PNC as we as immunization of chidren. Simiary, most of the reference communities are economicay vunerabe; they are dependent on daiy wage earning. Due to severe poverty, both parents need to earn and women are forced to step out for work within 7-15 days of deivering their baby. This keeps the chid away from mother and in turn from excusive breast feeding. Apart from these, there are prevaiing myths and superstition with regards to materna and chid care ike disposa of the coostrum, keeping the mother in cowshed after deivery, restriction on certain food items during pregnancy etc. Efforts have been made by the organization to break such myths/superstition through awareness program and BCC session. 69

78 At the system eve, there are inadequate heath care professiona and most of the ANM are aso overburdened. The services at the PHC, CHC and District Hospitas are not up to the mark and peope are many times forced to go to Private Hospitas and oca quacks. Transportation is aso a major chaenge as some of the viages are very far off and not we connected with the mainstream transport and services. Outcomes Some of the major project outcomes are as outine beow: Decine of infant deaths -from 41 infant deaths (with 868 ive births) in 2015 to 20 infant deaths (with 669 ive births) in 2017 Improvement in institutiona deivery in the intervention areas and from 81% in 2016 to 89 % in 2017 Improvement in 3rd Ante-nata care (ANC) of pregnant women from 27% in 2016 to 37% in 2017 Immunization of pregnant women improved from 73% 2015 to 80% in Immunization of chidren under 0-1 year marginay improved from 78% in 2016 to 80 % in 2017 Reguar vigiance from community worker has increased activity of ASHA/ ANM and anganwadi workers Physica deveopment in the intervention area have been improved incuding 10 bedded Deivery point at NEW PHC Karari, NewBorn care corner (NBCC) has been set up at New PHC Karari, Sanctioning of CHC in Karari of Kaushambi and Hospita buiding is under construction Outreach & Scaabiity Documentation of key chaenges, best practice and these earning's' are being done. Community change makers and oca stakehoders have been created to convince the beneficiaries of the new operationa area. Capacity buiding of stakehoders being done with incorporation of current experiences so as to save time and energy. Repicabiity The earning and experience of this project can be integrated to other ocation incuding the effectiveness of the undertaking BCC as we as uniform messaging and aso, foow up at househod and community eve. Coaborative effort of the organization with oca duty bearer has set exampes to bring positive changes in ives of chidren and above a improved the materna and chid heath scenario. 70

79 Impact Achieved Ante-Nata Care (ANC) and Post Nata Care ( PNC) : The status of ante-nata care improved in the current year as compared to the previous years due to engagement of fied mobiize with the target group as we as with the duty bearer incuding Anganwadi workers and ANM for ante-nata care. As compared to previous year 2016 data, there has been improvement in Antenata care (ANC) of pregnant women from 27% to 37% in 3rd ANC ( in Jan-Dec ANC of 213 pregnant women achieved out of targeted 793 and in Jan- Dec ANC of 289 achieved out of 748 targeted pregnant women ) and from 13% to 19% in 4th ANC ( th ANC- 103 pregnant women out of 793 and in Jan- Dec out of targeted 748 targeted pregnant women). The status of PNC is has itte improved from ast year to current year as 1st ANC is beow 10%. Institutiona Deivery: There has been improvement in institutiona deivery as compared to previous years. The status of institutiona deivery in 2015 was 727 out of 868 pregnant women ( 84%), in the year out of 769 pregnant women ( 81%) and in Jan-Dec institutiona deivery out of 666 pregnant women (89%). The increase in institutiona deivery can be attributed t o i n c r e a s e u n d e r s t a n d i n g o f c o m m u n i t i e s o n i m p o r t a n c e o f institutiona deivery through reguar fied eve mobiization as we as provision of better ambuance service in the areas. 71

80 Immunization of Pregnant women and chidren under 0-1 yr: Immunization of pregnant women improved from 73% to 8 0 % ( o u t o f t a r g e t e d ). Immunization of chidren under 0-1 year marginay improved from 78% to 80 % (592 out of 740 chidren). Infant and chid Mortaity: There is decine in numbers of infant and chid deaths in the project viages, though the figure stis is very aarming. There were 41 infant deaths in 2015 with 868 ive births, in infant deaths reported with 769 ive births and in this year 20 infant deaths reported with 669 ive births. It was found in this year that 09 deaths were neo-nata deaths (deaths within 28 days of birth). Death audits have been done and sharing hed with h e a t h d e p a r t m e n t a n d D i s t r i c t administration. With regards to chid mortaity, there were 7 deaths in 2015, 13 infant deaths in 2016 and 11 infant deaths in Jan-Dec In case of one infant death in Asada viage, interns of Aahabad high court have fied PIL w h i c h r e s u t e d p r e s s u r e o n administration to active heath care services. However, overa services in the areas needs further improvement through ensuring required equipments in hospita, resuming 24x7 services due to ack of require staffs in both CHC/District Hospitas. Capacity Buiding To strengthen the programming on chid heath and nutrition, capacities buiding initiatives of project impementation team have been done on to deveop understanding on issues reated to chid heath, newborn care, and materna reproductive heath issues, materna care incuding fooding practices, ANC and PNC and reated issues. Apart from this, capacity buiding of team members done on deveoping understanding on functioning of heath system incuding Nationa Heath Mission ( NHM), Indian Pubic Heath Standards. Team members were aso capacitated to track each and every pregnant women, actating mothers and chidren for reguar foow up. Training has been provided on maintaining a robust data base at the fied eve. 72

81 B e s i d e t h i s, p r o j e c t t e a m a s o deveoped capacity to undertaken deaths audit based on 3D mode ( Deay in decision making at house hod eve, Deay in transportation and deay in Faciity based care) to anayse the reasons of neo-nata, infant/chid and materna deaths and strategise further intervention at community and heath system eve. To assess the status of chid heath and nutrition, Chid Centric Community H e a t h a n d N u t r i t i o n N e e d Assessment was aso carried out in project areas. At the community eve, capacity buiding initiatives taken up with reference community on materna and chid heath issues as we as reated government schemes and programme so that they coud access the benefits. Partners of the Project The organization is supported by CRY-Chid Right and You, New Dehi. To strengthen the intervention of the project reguar capacity buiding inputs provided to the project team aong with faciitation of externa resource person having thematic expert of materna and chid heath. CRY aso organize quartery visit to the organization for undertaking review against the targeted pan, community eve processes and its outcome. Strategic inputs and guidance provided to the project based on the review process. Fied eve processes are assessed through interaction with reference communities and further discussion hed with the partner to strengthen the programmes. Support to the partners done through providing resource materias as we as faciitating stakehoders engagements. 73

82 Mother's Heath in Mother's Hand Using Sef-Monitoring Too (Gama/ Suraj Sitara Mode) for empowering marginaized mothers to monitor their own heath outcomes August January 2016, Sti continuing Pan Internationa (India Chapter) Address : E-12, Kaiash Coony, New Dehi, , India Phone : Website : Founder of the Organization : Ms. Bhagyashri Denge, Executive Director Project Budget : ` 500, ` 500, ` 500,000 Coverage/ Geographica reach : 10 viages in Muzaffar Nagar district in Bihar. 74

83 Project Brief Every seven minutes a woman dies in India during chid birth. A majority of the materna deaths are due to ack of proper ante-nata and intranata as we as immediate post-nata care. Sti today haf of the pregnant women dionot avai compete antenata services. Ony one-quarter of women received a heath check-up in the first four hours after birth and ony 37% received a heath check-up within the critica first two days after deivery. 80% of materna deaths coud be prevented if women had access to essentia maternity and basic heath care services and timey ANC services Many causes of materna deaths ike APH (30%), anaemia (17%) hypertension/ ecampsia (19%), sepsis (7%) and obstructed abour (10%) can be averted by timey identification of danger signs during pregnancy. Birth preparedness and compication readiness (BP/CR) is considered as important strategic intervention for curtaiing materna deaths. The 1000 days of ife from conception ti 2 years of age of the chid is most critica for the surviva of both mother and chid. Mutitude of heath services needs to be received by the mother to have a heath mother and heathy chid. As in India a arge proportion of the famiies are iiterate hence the compete uptake of the heath services as package is sti acking as the compete ANC is hovering around 30% and other services ike immunization, iron and foic acid uptake, Excusive breast feeding and institutiona deivery, skied birth attendants and chid compete immunization are a not up to the mark. The simpest reason for not avaiing of the services is that women and their famiies cannot remember so many services as they are iiterate and cannot read through the ANC/immunization cards to monitor themseves reguary and further they don't understand on the importance of these services and hence the onus ies on the service providers and not the beneficiary. Further as the cards provided by the heath workers are mosty mispaced as data shows that in neary more than 60% cases no cards where avaiabe, hence monitoring by the heath worker through home visits are aso not fruitfu.. The standard approach to address this issue is the printing and distribution of ANC/immunization cards for sef-monitoring, but the iiterate popuation cannot read these cards, and they are frequenty mispaced. Looking into the constraints of hard to reach areas with ow reach of modern technoogica and AV mode of IEC, a new innovative ocay avaiabe, understandabe mode with no cost, which has been a part of the human deveopment from the ancient prehistoric and pre-anguage human deveopment era was deveoped. This method is the depiction through pictoria diagram to be drawn in the wa/chart paper by the beneficiary/support or by the community heath worker with either chak, penci/cooured pen and was named as Sef-Monitoring Too to monitor her and her chid uptake of heath services thus creating the demand for the services. There are different types of sef-monitoring toos used as per the convenience of the community to draw and how they reate. The Gama mode( Pot with fowers) is being depicted and understood by the farmers community, the mode in the name of the Suraj Sitara( Sun & Star) is better visuaized by the triba communities as they worship Sun as God and dream of their chidren to be gowing and vibrant and fu of energy ike Sun. 75

84 This is being drawn in the wa of the pregnant mother by hersef in the wa/ chart from the day she is registered with Nurse mid-wife for avaiing of the services. For each avaied services she draws a ine and with competion of a the services the Pot gets compete and if any of the services are not avaied the pot (Gama) wi be incompete and the fowers cannot be depicted. Hence the iiterate adies are by themseves understanding and assessing their own and their chid's heath status and seeking heath services accordingy Thus depicting the services through these picture heps to bring the behavior change in the community on importance of each of these heath services as the picture gets compete ony when a the services are avaied and it heps them to monitor their services as they are aware that if it's not taken their chid wi not be ike a fower or ike Sun & stars. The utiity of this simpe toos are many fods : 1. Its cost effective as it's a socia monitoring system, easy to depict. 2. It works as a behaviour change concept as the mother can monitor a the services which they are supposed to take. They are now aware the importance of each of the services as if they do not take then the Pot with a the fowers wi not be deveoped which means the chid which is a fower wi not bossom. 3. This aso improve the engagement of father in the overa deveopment of the foetus and the famiy invovement as a whoe during the pregnancy. 4. The home visits of the community heath vounteers for monitoring aso increases. 5. This has aso enhanced the chid ed monitoring of the services in the community Key Objective To ensure safe motherhood To ensure compete immunization of chidren Resut: A tota of 1300 pregnant mothers were enroed for this sma scae ow cost intervention in 10 viages in a 3 yrs period. Impementation Mode Key Interventiona strategies: To improve materna and chid heath service uptake in the most disadvantaged and marginaized communities of India, the soution is not to appy expensive and modern technoogica IEC, but rather to 76

85 use no-cost, ocay avaiabe, ocay reevant, non-iterate means of IEC, which have been a part of human deveopment from the ancient prehistoric and pre-anguage human times. In this case, the ocay appropriate technoogy is a sef-monitoring pictoria diagram, drawn either on the wa of the residence with chak or on chart paper by the beneficiary with support from the community heath worker. The diagram heps the mother to understand and monitor her and her chid's heath services, thus creating the demand for the services and faciitating comprehensive service deivery in disadvantaged rura communities. The Sef-monitoring too impacts both the behavior change, enhances knowedge, promotes increase in home visits by the community heath vounteers and monitoring the heath services by the famiies and aso create demand for the services. The too was introduced in 10 panchayat viages across Muzaffarnagar districts of Bihar incuding both triba and non-triba communities with the different versions of modes of sef-monitoring toos as reevant and acceptabe and modified to the indigenous needs. This was compared in a period of 3 years with the non-intervention areas with simiar demographic profie and other heath parameters incuding avaiabe service deivery faciities avaiabe. The sef-monitoring toos was aunched in discussion with the community on their preferences and their acceptabiity of the toos through a quaitative situationa anaysis and group discussions with the community. The various activities were interwebbed for introducing this concept into the system and the community and interinking it with service provisions and monitoring which are as foows : Capacity Buiding: Community heath vounteers and government functionaries ike the ASHA (Accredited Socia Heath Activist), Preschoo teacher (AWW), ANM (Auxiiary Nurse Midwife),MPW ( mutipurpose heath workers), Lady heath supervisors( LHVs), Community eaders ike PRI members, reigious eaders and other secondary stakehoders were sensitized on the toos and usage of the tos for the monitoring and BCC and information on the quaity of the heath service provision to be meted for the community. Community sensitization by fiing gender gaps: The community especiay the pregnant women were sensitized through mothers meetings at the Anganwadi Centers, Women sef-hep groups coordination meetings, Saas-Bahu-Pati sammean( Mother in-aw- Daughter in Law Husband) meetings which were hed to increase the gender transformation increasing men invovement in chid rearing practices. Home visit: Reguar home visits by the partner staff, community heath workers & community eaders were promoted to see the progression of the mode and gaps in the services. The continuity of the practice has heped in making it a tradition/ ritua for a the pregnant mother to undertake this activity as a good omen since it's a tradition to make such designs in the rura househods. Use of this tradition for the heath service monitoring has enhanced the uptake and become part existing traditiona practice. Community Outreach This mode was introduced with an objective of deveoping community based monitoring system and for invovement of community for ensuring safe motherhood and chid protection. Pregnant mother aong with their famiy members has become aware about the safe pregnancy and care about their chidren. 77

86 ADITHI-Pan staffs were oriented towards the importance of safe motherhood and chidcare and at the same time they were aso briefed about the importance of community based monitoring system and invovement of community especiay beneficiary for ensuring safe deivery and compete immunization. Workers were oriented towards the step wise step deveopment of GAMLA Mode at pregnant and actating women doorsteps. At first there was a ukewarm response from the community as most of the houses were thatched houses and there few peope were having caendars. Chart paper was used as a substitute for the caendar and to promote this mode pregnant woman aong with their adoescent girs and boys and other caretakers were briefed about the importance of this mode. Gama mode was initiated and our workers heped women to draw the GAMLA and sowy and sowy community have reaized the importance and they are themseves drawing the GAMLA for ensuring safe motherhood and compete immunization of their chidren. For the Gama mode, appropriate in iiterate agricutura communities, the drawing is done on the was of the residence or on the back of a caendar or chart paper that hangs on the wa on the day the mother is registered with Nurse mid-wife, and goes as foows: The pot is the mother. The pregnancy is a dot inside the pot. Three ANC visits are 3 was of the pot. Five preparedness steps for safe deivery are five eaves at the bottom of the stem. Leaves from top to bottom repr.esent the routine immunization (BCG, DPT, Meases, Poio) Suraj Sitara: In this mode competion of the mode wi create a smiing Sun and thus uptake of the services wi ead to a baby ike a smiing sun fu of energy and vitaity Through this mode we aso expain the importance of each services. Community is advised that missing one TT injection makes the eye in the eye gone and thus distorting the picture. This makes them understand the importance of the services and increases their compiance. Uniqueness of the Project The sef-monitoring too is the perfect exampe amagamation of scientific knowedge with in the age od cuture and tradition. This Gama mode and the Sun and star are being drawn in the was or the paper and such drawings are part of the community cuture. This has made the too acceptabe, adaptabe and repicabe to the community as a sign of Good omen in the society. Further it has increased the reca of the services strongy and enhanced the uptake of the services and demand for services. During the drawing of such modes the mother and the famiy members are very eager to get 78

87 the picture compete and are constanty asking for the next date of services. Further if any services are missed they can now know it's impication as the mode wi not be compete and may ook weird which increases their chance of compiance. Chaenges Faced 1. Mae invovement was a chaenge. 2. The festivas in India especiay during Diwai the was are repainted thus the sefmonitoring too which is depicted on the wa gets white washed, hence the entire efforts were chaenged a the times. 3. Community meeting were organized and orientation through VHNDs as we as home visits and reguar interface with ANMS and ASHA was organized. 4. Saas Bahu Pati Sammeans were organized and mae invovement was ensured. Further separate orientation of the mae members were aso organized. Outcomes Community after itte hesitant have accepted this mode and today they are practicing the Gama mode on their own with itte hep from our workers and their famiy members. Community has reaized the importance of this mode and most importanty they have become aware about the precautions and necessities for safe motherhood and immunization. Community has reaized the importance of practicing sef-monitoring too. One of the most important aspect is that with the introduction of Gama mode famiy invovement in ensuring safe pregnancy has been observed as mother in aws, eder chidren and husbands of the pregnant are aso heping in drawing the Gama. When Project started the attendance of pregnant and actating mothers during VHND was very poor and was ony 23% which has now increased by doube. Simiary ceebration of Viage heath and nutrition day( VHND)was ony 24 % which has improved to neary 80%. Outreach & Scaabiity At first the sef-monitoring too ike Gama Mode was initiated in Kaparpura and Sarmaspur viage of Kanti Bock, Muzaffarpur, but ater it was repicated a over the project area, due in arge part to the acceptance of peope about the importance of this mode. As the mode is easiy understood by the community and matches with the existing practice of Rangoi made by women as a good omen has enhanced the chance of this same age od practice into heath programming. 79

88 Community action group has been formed to monitor the traditiona fower and Sun diagrams and to see its get competed in their respective community. These committees comprises of eected representatives, teachers, and heath vounteers. The committees has been strengthened by the Pan intervention to.monitor activities in the Preschoos ( Anganwadi center) This Viage heath committee monitors the Heath and Nutrition interventions impemented at the Anganwadi Centre (AWC). This picture heps identifying the number of eft-outs/drop-outs are monitored and counseing done to reduce them. This group works as a 'pressure group' on the community for adopting heathy behaviour practices. Repicabiity This observation from Pan India's experience over the ast few years is what we propose to test using any future grants as we as our routine programs, to refine the mode and support its repication at scae to reach other marginaized, iiterate popuations. The mode hods very strong potentia for adaptation and/or appication in other settings or for other heath care needs, but at the very east it can bring muchneeded materna, neonata and chid heath services and heath-seeking behavior beyond the reach of current practice and modern technoogies, to the viages and communities with persistent high eves of materna and chid mortaity. Pan India work with many externa partners (Nationa and Internationa) to piot, innovate and scae up its interventions. Buiding on its strong presence in the country, Pan India has estabished and nurtured partnerships with oca NGOs in the 16 states. We have a cumuative experience of working with over 100 NGO partners on specific issue-based programs and grants-supported program. Pan India is part of various nationa as we as state eve aiances to carry the advocacy agenda. As it is cost effective mode at the community eve improvisation of the too based on the type of community needs. Impact Achieved This sef-monitoring too besides being simpe and cost-effective, the too has proven to have vaue in engagement of father and famiy in the deveopment of the fetus. One of the most important findings of previous impementation of the approach is famiy invovement in ensuring safe pregnancy, this has been observed as mother in- aws, eder chidren and husbands of the pregnant are aso heping in drawing the Gama. The approach aso faciitates home visit monitoring by community heath vounteers. By buiding the awareness and demand for services by the most disadvantaged mothers, service deivery can aso be improved through comprehensive programming that channes these newy engaged mothers into the appropriate avenues of pre-nata, safe deivery, and post-nata heath care. Pan India has promoted preschoos (Anganwadi Centers) as idea settings to monitor materna and chid heath seeking and heath services, and in communities where the Gama mode was appied, saw the service provision at these centers doube. 80

89 Capacity Buiding 1. Training of the pregnant mothers. 2. Training of the ANMs and AWWs as we as ASHAS on the sef-monitoring toos 3. Orientation of mae members of the famiies on the use of this too 4. Training of SHG and PRIs for peer to peer monitoring and spread of messages. Partners of the Project Loca governance ike Panchayati Raj Institution, Viage Heath Sanitation & Nutrition Committees Department of Heath at the state, district, bock and viage eve incuding Accredited Socia Heath Activist (ASHA), Accredited Nurse Midwives (ANM) ICDS functionaries at state, district, bock and viage eve incuding Anganwadi Workers. Project staff at state, district, bock and viage eve. 81

90 Women presenting their asks to Heath Minister Hamara Swasthya Hamari Awaz December Apri 2017 Centre for Catayzing Change as the secretariat of White Ribbon Aiance India Website : Founder of the Organization : CEDPA, USA Project Budget : Most of the part of the campaign was vountary, the sharing and anaysis was supported by WRA for 20,000 USD Coverage/ Geographica reach : PAN India 82

91 Project Brief Despite a rapid decine of Materna Mortaity Rate (MMR) in the ast 10 years, 15 % of materna deaths around the word occur in 1 India. India's MMR is an estimated 167 deaths per 100,000 ive births (SRS 2013). With around 45,000 women dying each year from pregnancy reated causes, India has among the highest number of materna deaths anywhere in the word. Given that a woman's perception of the quaity of care she is ikey to receive during abour and deivery infuences her decision on whether to seek faciity-based heath care, it is important to ook at what quaity of care means from the woman's perspective. Most accreditation agencies tend to focus on measuring faciity infrastructure, human resources, and safety measures. Some more advanced schemes ook at cinica measures, but few assess the quaity of care through enses most reevant to the woman and her famiy. Few examine aspects of care such as how the woman was treated by faciity staff, whether care was given in a timey fashion, or whether the faciity was cean. WRAI understands that women, especiay the ones iving in rura areas of the country, face mutipe chaenges with materna heathcare services. Hence, it is important to engage women directy and understand the change they woud wish for in terms of a better materna heathcare service, routing towards equity and dignity for a women. The key objectives of the campaign were to Focus on women's needs for the best possibe heath outcomes Focus on women's voices to understand what they want for quaity reproductive and materna care Present these voices to the highest possibe poitica eadership with the expected outcome that there woud be a better understanding of what women vaue and ask for in terms of quaity of care With the objective of ampifying women's voices, their needs and priorities, the WRAI initiated a Campaign 'Hamara Swasthya, Hamari Awaz' which means 'Our Heath, Our Voices'. This campaign reached out to women directy to understand what they woud need for quaity materna heathcare in India and engaged with women directy to put forward their one Ask to improve reproductive and materna heath in the country. Impementation Mode Over the past 4 months from December 2016 to March 2017, WRAI members have spoken to 1,43,556 women across 24 states and UTs directy about their expectations on quaity. Women from a over the country have spoken and submitted their one asks. A these asks coected were coated under arger MNCH umbrea and top five asks were identified. The respective ca to actions were deveoped in response to the top identified asks. Whie coecting the data, women from a sectors of society beonging to different cass, caste, reigion were incuded. The WRAI members gave opportunity to a women in their geographica area of work reaching out to maximum number of women who were wiing to submit their asks. 83

92 Community Outreach WRAI is a vast network of NGOs and individuas committed to improve materna heath. The campaign engaged vountariy WRAI members to sensitize women and coect data on their ask directy. These data were sent to the WRAI secretariat at C3 India. Around 184 member organizations and partners covering 24 states and 143,556 women were engaged. WRAI secretariat ed the process of data coection and coation. The 184+ members and partners coected asks from women whie they were working in their respective fied areas on their on-going materna heath care programs. Uniqueness of the Project WRAI aong with TFTS is staged a theatrica pay, God Ki Deivery that incorporated experiences many women undergo in the process of chid birth. Pay was presented in form of a satire comedy depicting issues brought up by women in the Hamara Swasthya, Hamari Awaz campaign. This 90 minute pay was introduced by the renowned theatre actor Ms. Sushma Seth. Over 200 peope were reached through the pay on Nationa Safe Motherhood Day. The pay was a too to reach out to genera masses on safe motherhood issues and inform them about the key chaenges faced by women during pregnancy and chidbirth Roe of Information and Communication Technoogies (ICTs) Not Appicabe. A forms coected were in hard copy to maintain the authenticity and credibiity ofwomen's ask Chaenges Faced Chaenges faced by agency during program interventions are isted beow Women were not wiing to speak initiay. WRAI members payed a very important roe in sensitizing the women about the campaign and the objectives of coecting their asks. The coection of data was a vountary effort of WRAI members. A ong term reationship and reguar engagement of the members eventuay ed to coecting a arge number of ask Data were coming ti the ast few days of the sharing gaa meeting, hence a ot of effort was put in to incude a data and create coateras based on findings Outcomes Socia media buzz was created and reguar updates were posted on socia media pages ike Facebook, twitter, Instagram. The socia media campaign incuded posts on voices of women, about the campaign, vox-pop on women's ask, nationa safe motherhood day, case studies etc. The socia media reached out to over 4000 peope during the campaign. Press reease were sent out to media for coverage on the campaign 84

93 The findings indicate that a sizeabe 36% of the women have asked for access to m a t e r n a h e a t h entitements, services and suppies, foowed by 23% women who seek services provided with dignity and respectfu care. 20% of the women seek avaiabiity of heath providers whie 16% seek cean and hygienic heath faciities. Anaysis a s o h i g h i g h t s t h a t women desire respectfu b e h a v i o u r b y h e a t h providers; no caste or Women from West Benga participating in the HSHA campaign r e i g i o n - b a s e d discrimination; one bed per woman in a ward; a birth companion during deivery; privacy and confidentiaity during check-ups and treatment; fixed visiting hours and a visiting room to ensure privacy; compete information and counseing; cean toiets and abour rooms; avaiabiity of skied doctors, speciaists and frontine heath workers among others. The asks coected from these women were shared with the Members of Pariament and other key infuentia incuding the nationa highest eve materna heath eader. Key asks incuded (i) invest in generating awareness to ensure that a entitements are known and accessed by women, (ii) Improve time bound payments to ensure that women fuy access the entitements, (iii) strengthen monitoring mechanism to track dispersa of a entitements, (iii) create a cadre of professiona midwives and ensure 24x7 avaiabiity of skied doctors and speciaists, (iv) commit to zero toerance for abuse, to ensure that women receive respectfu care without discrimination and abuse, (v) incorporate respectfu care in Quaity Assurance Guideines and adopt the Respectfu Materna Care (RMC) charter, (vii) form Swachh Bharat Abhiyan fying squads to conduct surprise visits to check ceaniness and hygiene in toiets, wards 85

94 and abour rooms, and (viii) make dispay of free services and suppies mandatory at faciities to ensure easy access to information Responding to the asks the Nationa Heath Minister Hon'be JP Nadda committed for a stronger feedback mechanism to address materna heath issues and concerns faced by women on quaity of care. Outreach & Scaabiity The campaign directy engaged women across India to put forward their one key ask/aspiration to improve reproductive and materna heath in the country. Hamara Swasthya, Hamari Awaz campaign's main objective is to ampify women's voices, their needs and priorities and bring these voices to key high eve infuencers. WRAI members and partners, covering 24 states, reached out to about 1.43 akh women in India. A participation was vountary. WRAI members have spoken to 1,43,556 women across 24 states and UTs directy about their expectations on quaity. Women from a over the country have spoken and submitted their asks. WRAI, currenty, has about 1800 member organizations from across the country. States from where women participated : 1. Andhra Pradesh 2. Assam 3. Bihar 4. Chhattisgarh 5. Dehi 6. Haryana 7. Himacha Pradesh 8. Jammu & Kashmir 9. Jharkhand 10. Karnataka 11. Keraa 12. Madhya Pradesh 13. Maharashtra 14. Manipur 15. Meghaaya 16. Nagaand 17. Odisha 86

95 18. Punjab 19. Rajasthan 20. Tami Nadu 21. Teangana 22. Uttarakhand 23. Uttar Pradesh 24. West Benga Repicabiity Hamara Swasthya Hamari Awaz, an initiative by WRA India, is being scaed up gobay as What Women Want A Goba Campaign Buiding on White Ribbon Aiance India's powerfu campaign Hamara Swasthya, Hamari Awaz (Our Heath, Our Voices) What Women Want wi support women to demand change, bring their demands to decision-makers and generate poitica support, investment and accountabiity for quaity, equity and dignity in heathcare. What Women Want aims to hear directy from at east 1 miion women wordwide about how they define quaity materna and reproductive heath care. The findings wi be aggregated for a goba picture of what women want and disaggregated by country, utimatey distied to refect the top 10 asks aong with specific recommendations about how to drive tangibe improvements for women's heath. The goba campaign wi be formay aunched on Internationa Day for Materna Heath and Rights i.e. Apri 11th, Impact Achieved These asks coected from women across the country were shared with Hon'be Heath Minister Shri JP Nadda on the eve of Nationa Safe Motherhood Day on Apri 10th These were as foows : Key asks put forward by the women were Invest in generating awareness of entitements to ensure that a entitements are known and accessed by women Improve time bound payments to ensure that women fuy access the entitements Strengthen monitoring mechanism to track dispersa of a entitements 87

96 Create a cadre of professiona midwives and ensure 24X7 avaiabiity of skied doctors and speciaists Commit to Zero Toerance for abuse, to ensure that women receive respectfu care without discrimination and abuse, Incorporate respectfu care in Quaity Assurance Guideines and adopt the Respectfu Materna Care (RMC) charter. Form Swachh Bharat Abhiyan fying squads to conduct surprise visits to check ceaniness and hygiene in toiets, wards, and abour rooms. Make dispay of free services and suppies mandatory at faciities to ensure easy access to information. Mr. JP Nadda, Hon'be Heath Minister highighted need of strengthened feedback mechanism to understand women's experiences, and spoke about the need for greater community participation to ensure safe motherhood. At state and district eves, women and partner agencies shared the key asks with decision makers. Capacity Buiding The efforts of the members were vountary. Members were reached out through emais with guidance note, HSHA forms and data coection sheet. Reguar reminder emais were aso sent. In the note it was mentioned that the members who wi be coecting arge number of asks wi get invitation for the gaa event. Interested members got in touch with the secretariat and detai teephonic orientation were provided to many members. Chaenges and earnings were discussed. Different strategies were adopted with various states. In few states, the partners were trained on data coection through training sessions and in remaining states the step-by-step guidance note were given to partners to buid their capacity for impementation of the campaign. Partners of the Project In state of Bihar the campaign was supported through C3's ongoing grant and partners were engaged to do a more intensive data coection. In the state where WRAI has state eve secretariats (ike West Benga, Rajasthan and Jharkhand), the state WRA coordinated mobiizing women and coecting data. Many other member organizations coected data during their reguar visits to community and vountariy supported the campaign. Reguar guidance and support were provided by the secretariat. Awards/Endorsements The project has received acknowedgement at forums ike Nationa Safe Motherhood Day by the Heath Minister on his socia media sites ike Facebook and twitter. In addition to this, there were around 20 coverage on the campaign and its findings. 88

97 Fag Off by the CMO, East District Heath on Whees for Chidren in East Sikkim 1 Apri March 2019 Incusive India Foundation and Vountary Heath Association of Sikkim Website : ( & Vountary Heath Association of Sikkim (vhasikkimind.ngo) Founder of the Organization : Vountary Heath Association of Sikkim Project Budget : A. ` 34,69,300 for B. ` 32,45,070 for C. ` 35,49,245 for Coverage/ Geographica reach : Rumtek-Samik, Tumabong, Radong, Namin, Nami, Chuba, Tshaamthang and Chuja with popuation in East Sikkim District, Sikkim. 89

98 Project Brief The project is being run in East Sikkim district in viages which are in remote ocations and due to topography are not easiy accessibe. There is a shortage of doctors and medica staff, especiay for Mother & Chidcare. The focus of the project is to strengthen the existing government infrastructure and work in coaboration with the centres of the Integrated Chid Deveopment Services Program of the District, District Hospita, PHCs and the PHSCs of the operationa area. Incusive India Foundation & Vountary Heath Association of Sikkim is providing Quaity Primary Heath faciities and awareness among the communities through mobie heath cinic at 30 ICDS areas under 8 viages in East District of Sikkim State. The main target popuation is the Pregnant & Lactating Women and Chidren beow 6 years. The Objectives of the Project Heath on Whees for Chidren To reduce and contro diseases through mobie cinics covering the target popuation/proposed beneficiaries To provide heath care to the poor and needy at their door step To undertake awareness and IEC activities informing the target audience regarding the programme and its operation To provide heath education to the target popuation, especiay women and adoescent girs To provide reproductive heath care incuding immunization to the expectant and actating women To provide compete immunization service for the chidren beow 6 years of age To educate the target popuation on heath and sanitation and the use of safe drinking water and protection of the environment To transport serious pediatric patients and emergency cases to nearby PHCs, District Hospita, Singtam or STNM Hospita, Gangtok or private cinics by Ambuance To strengthen the Viage Heath & Nutrition Day scheme of the Government through its activities in each ICDS Centre (AWC) To strengthen the hands of the Government as a coaborative partner in heathcare service deivery in order to progress towards its objectives of a competey heathy state 90

99 Impementation Mode Areas have been identified through a Need Assessment conducted prior to the starting of the project activities. Meetings have been conducted with the Panchayat Presidents, Ward Members, Angan Wadi Workers (AWW), ASHAs, PHC Doctors, PHSC Functionaries ike the ANMs and MPHWs, and community opinion eaders from the operationa area in which project objectives and how the activities wi strengthen their work have been expained and their confidence gained. Meetings have aso been conducted with the State Leve Heath and Socia Security authorities expaining them the need for our intervention and how it is a coaborative effort that is compementary to the objective of the State Government to bring down the IMR to a singe digit and other socia deveopment objectives. An inaugura function was aso hed with amost a concerned being in attendance where the concerned Government authorities auded the project interventions and expressed their support to the project thereby ensuring the support from the grassroots. The Team conducts Heath Camps at the Angan Wadi Centres/PHSCs/Gram Panchayat Offices/Schoos as per the convenience of the beneficiaries at east once a month in each ocation in which apart from heath check-up, medicines are given free of cost and awareness taks/presentations are made on various reated topics. The Team aso makes Home Visits to ensure reaching the ast beneficiary. Monthy pans are made and executed. The mobie heath van is aso used as an Ambuance as per the need. The project Team comprises of 7 efficient staff members as foows: 1 Program Coordinator (Part-time) having Master's Degree in Socioogy and experience of 10 years of working in Community Heath Program. 1 Medica Officer (Femae) with MBBS & MPH Degree and experience in working with the Communities. 2 Nurses - Quaified GNMs with experience of working in hospitas. 1 Heath Worker with BA and B. Ed. Degree having work experience of 3 years in the fied. 1 Driver - One fu-time driver is in pace 1 Accountant (part-time) with B.Com. degree and pursuing M.Com. through distance mode and having work experience of 2 years. 91

100 One new Maruti Omni Ambuance has been procured and being used in the project. Community Outreach The process undertaken to reach out to the communities is preparing Monthy Action Pan and executing the pans accordingy. The Pans consist of every detai ike date, time and venue of Heath Camps, Home Visits, Heath Awareness Programs, Meeting with Community Peope, stakehoders, PRI Members, Schoo Heads/ Teachers and Government Officias etc. 26 Heath Camps with 5 Heath Awareness Programs in tota per month at various project ocations and Home Visits are schedued every month and shared with the supporting agency. Heath Check Up in progress in a camp Looking upon the turnover of Target Peope, at some ocations, the Heath Camps are on weeky basis and at other ocations, the Heath Camps are on a monthy basis. The Project Team goes to the fied for 5 days a week. Uniqueness of the Project Heath on Whees for Chidren' is one of the first mobie heath deivery service in Sikkim covering materna and chid heath. Initiay, the project was targeted for Mothers and Chidren and the free medicine faciity was there for the target group ony but the peope from non-target popuation aso attend the Heath Camps reguary. Since the PHSCs do not have Medica Officer, peope come to the Heath Camps to meet the doctor with heath probems and to have their BP and Bood Sugar checked. So, the project now provides free medicine for minor aiments ike cod, cough, fever, skin diseases, gas probems etc. to the non-target popuation as we. Besides, the project Heath on Whees has a unique feature i.e. community peope can utiize the Ambuance for free if they need to go the nearby higher institutions for further treatment and in case of emergencies. 92

101 Chaenges Faced Considering the difficut terrain, w h e r e t h e p r o j e c t i s b e i n g impemented, there are mutipe chaenges which emerge from time to time. Over a period, a ot of those chaenges have been taken care of, but some sti remain: A. Initiay, the chaenge was to find a suitabe pace for organizing Heath Camps according to project requirements. We seek c o o p e r a t i o n f r o m G r a m Panchayat Office, PHSCs and A n g a n w a d i C e n t r e s f o r organizing Heath Camps. B. Then, the footfa in Heath Camps was not that good as expected. So, we initiated the The Ambuance for Heath On Whees for Chidren Home Visits to inform the peope about the project and its activities and requested them to take advantage of the project. C. Difficut terrain and weather conditions (Excessive Rain) and bad roads are aso some of the chaenges, but it is beyond our contro. D. Retaining Project personne or finding a suitabe repacement is one of the interna chaenges considering the geography and imited avaiabiity of manpower. Outcomes A. 78 Heath Camps per quarter B. 15 Heath Awareness Program per quarter C. On average, 60 peope do Bood Gucose Testing per quarter 93

102 D. No Materna and Infant Deaths E. 100% Immunization coverage As of this day, the project has made an impact in the ives of the peope it is serving by way of creating awareness on heathy iving. Peope in genera have become heath conscious as they have been made aware that their poor heath is directy affecting their productivity and is affecting the whoe famiy adversey. Peopes eating habits have aso changed for the better. The adoescent girs and women have become more aware about reproductive heath and hygiene practices. Awareness among women about the benefits about breast feeding in the first six months has increased eading to heathier infants. Outreach & Scaabiity Heath on Whees (HoW) Team have extended their support to a the 4 PHSCs under project viages during monthy Immunization programs and encouraged the Anganwadi Centres (ICDS Centre) to observe the Viage Heath & Nutrition Day (VHND) to make their presence fet in the project ocations. The Team aso visits Schoos and convince them for organizing Heath Camps. Sometimes, Gram Panchayats aso invites the team for generating Awareness Program to the pubic on specific Heath Topics. Socia Justice, Empowerment and Wefare department officias aso asked for hep from HoW Team to organize Heath Camps and Awareness Program at some area. Overa, it can be concuded that HoW team have reached where they need to be present. Initiay aso the project started with 6 viages which has been extended to 8 viages. There are aso pans to work on training and empowering community workers to increase the outreach of the project. Repicabiity Peope are very happy with the services provided under HoW Project. In areas ike Lower Chiba and Lower Martam, peope from adjoining area (not incuded in project) aso come to the Heath Camp and awareness program. Looking into this, Sef Hep Group members and Panchayats have started requesting such programs in their viages as we. Within the approved budget, so far, we have organized 1 heath camp each at 2 areas i.e. at Mangthang ICDS Centre and Sangkhoa ICDS Centre. So, there is scope for integration of project to adjoining project viages as we. Impact Achieved In project viages, peope are now aware that there is a project funded by Genmark Foundations, where they can avai free Heath Services and Medicines. They can aso check their BP and Bood Gucose. They 94

103 The MO, HOW giving a tak and demostration on nutrition use to ca Doctor to their home in case of emergency when the patient is unabe to come to the Heath Camp venues. They have started using Project Ambuance when the need is there. Whenever the patients are shifted to nearby heath faciities for higher eve of treatment, project nurse used to accompany them to the Hospita. The project has had a significant impact on the ives of the neary popuation it serves as peope have no access to the services of a Medica Practitioner at reguar intervas which was acking earier. They aso used to trave ong distances in difficut terrains to get the service of a aboratory for the tests ike Bood Pressure, Bood Gucose which are now avaiabe at their doorstep. The project has made great impact in terms of making peope conscious about heathy iving rather than to be unheathy and go for medica treatment. Immunization coverage has improved significanty to neary 98% in which the project has contributed to a certain extent through its Home Visits apart from the heath camps. Puse Poio coverage has been neary 100% through the coaborative efforts of the HOW project thereby ensuring protected chidren beow 5 years against recurrence of the dreaded disease. 95

104 Capacity Buiding A. Weeky update and review meetings are hed every weekend at VHAS Office in presence of Executive Director. He gave his inputs on how to make project effective. B. Quartery Monitoring Visits is done by Socia Deveopment Consutant from IIF and give his inputs and suggestions, fied visits with team members aso is a part of Capacity Buiding initiatives. The IIF Consutant had aso conducted training of the team in Nutrition, Breast Feeding and Prevention Against Certain Cancers. C. Project Staff are aso given in house training on reporting and importance of document and how to keep the evidence of the program. Partners of the Project Genmark Foundation in partnership with Incusive India Foundation & Vountary Heath Association of Sikkim introduced Heath on Whees - HoW Project to create the access to heath care services. 96

105 Indigenous Medicine Use for Sex Seection during Pregnancy and Risk of Birth defects and stibirths January December 2014 Indian Institute of Pubic Heath-Dehi (IIPH-D), Pubic Heath Foundation of India (PHFI), India Website Founder of the Organization Project Budget Coverage/ Geographica reach : : The Pubic Heath Foundation of India (PHFI) is a pubic private initiative that has coaborativey evoved through consutations with mutipe constituencies incuding Indian and internationa academia, state and centra governments, muti & bi-atera agencies and civi society groups. PHFI is a response to redress the imited institutiona capacity in India for strengthening training, research and poicy deveopment in the area of Pubic Heath : ` 17 akhs : A districts of Haryana 97

106 Project Brief Decining sex ratio is a pubic heath concern in this part of the gobe. Besides sex seective abortions, peope use different sex seection techniques to choose the chid of the preferred gender use. Intake of indigenous medicines for having a son is a common practice in north India as reported by previous studies. Since these are consumed during the first trimester which is a critica time for feta growth and deveopment, this study was required. On the request of the poicy makers from the Government of Haryana, a study was Dissemination of messages in oca daiies conceptuaized and undertaken by Pubic Heath Foundation of India (PHFI) with support from Nationa Heath Mission, Haryana to expore the association of intake of sex seection drugs (SSDs) with two outcomes of pregnancy- structura birth defects and stibirths. Impementation Mode Two arge scae popuation based research studies (case contro studies) were conducted across Haryana with an objective to highight the adverse effects of intake of indigenous medicines (sex seection drugs or SSDs) during pregnancy for a mae chid. This was done by: Studying the association of SSDs with birth defects Studying the association of SSDs with stibirths Performing biochemica anaysis to identify the ingredients or active principes present in such sampes Cases (birth defects and stibirths) were seected from the state of Haryana. Contros were ive births from the same area (viage/ ward) as the case. To study the association with CMF, 175 infants with apparent structura deformities and for stibirth study, 325 stiborns (beyond 24 weeks gestation) were seected as cases from the registry. Contros (175 for CMF and 325 for stibirth) were norma ive babies born consecutivey at the same ocation as the case. Consenting mothers of every case/contro were interviewed using a vaidated too at their househods. Bivariate anaysis and ogistic regression modes were used to study the association. Community Outreach The work was faciitated by Government of Haryana. They ony faciitated the process of data coection. Secondy, the findings of the study have been utiized by the state to improve the impementation of its program. 98

107 Uniqueness of the Project Many indigenous practices exist in the community which never catches the attention of poicy makers. Sex seection is a very sensitive topic and not many poicy makers or researchers get invoved in doing such areas since they presume that anything that is indigenous practices is safe. The unique feature of this project is that poicy makers got directy invoved in supporting this study and they are utiizing the study findings for their programs. Chaenges Faced None in particuar. In fact the study has opened up new areas for doing research that we are currenty perusing with support from Department of Science and Technoogy, Government of India and Science and Technoogy Counci, Haryana. The findings from these study reiterates harms of the use of SSDs. Outcomes The prevaence of intake of SSDs varied from 7.3% to 10% among ive born babies without apparent birth defects. However, among babies born with defects, the use rate was as high as 25% whie among stibirths, it was around 16%. These studies have shown that a pregnant woman consuming such drugs was at 3 times more risk of giving birth to a baby with visibe birth defects ike ceft ip/ paate, spina bifida, and cub foot as compared to those who reportedy did not consume such drugs. The risk was found to be higher 99

108 (around 3.5 times) among coupes who aready had a daughter. The findings were simiar to another study conducted in a tertiary hospita in north India on more serious congenita maformations. Another study to ascertain the association of the use of SSDs with stibirths showed that the risk of stibirths increased by more than 2.5 times with an exposure to SSDs during pregnancy. The study aso reveaed that out of every 5 women who get exposed to SSD, one woud have stibirth. An anaysis of the drugs was carried out to detect the presence of phytoestrogens and testosterone. As part of the study a tota of 30 sampes of SSDs were anaysed. Nineteen sampes (63%) were strongy positive for a phytoestrogens (genistein, daidzein, formononetin). Testosterone was detected in three out of the 15 sampes anaysed for testosterone. An average dose of each phytoestrogen was cacuated thereafter based on this data and were as foows: daidzein: mg/g sampe, genistein: 8.52 mg/g sampe, formononetin: 5.09 mg/g sampe. The tota quantity to be consumed represents a ten-fod increase over that recommended for dietary intake. Outreach & Scaabiity The issue deat with here is a pertinent socia probem that has impications on heath. There is a ot of scope and opportunity to generate awareness among the community. We have 1 minute short ad on SSD deveoped that conveys the message very ceary. We are exporing the possibiity of showing it in movie has, raiways and disseminate through radio channes, especiay in north India. This seems to be the most effective way to reach out to masses. 100

109 We are seeking support from organizations who can take part in the dissemination of the messages through these various channes. There are requests from Punjab and Haryana to repeat the ight and sound pay in different viages and districts. There is a ot of opportunity under the fagship program of "Beti Bachao Beti Padhao''. Repicabiity Parae studies can be undertaken in others states to expore this practice since we were informed informay that many peope in other states, mosty deveoped states aso foow such practices Impact Achieved Impact can be assessed in terms of change in poicy, deveopment of new guideines, media coverage or any other reasonabe outcome independent of research. The evidences from our studies have been and continue to be utiized by the Government of Haryana to address the menace of sex seection. Under the ambit of PCPNDT Act, First Information Reports (FIRs) are being odged and raids are being conducted on those who are found to se these spurious medicines or se gender seection kits with the promise of faciitating the birth of a mae chid. A tota of 65 raids have been conducted on peope seing SSDs and 7 have been convicted. Strict enforcement of the Act has resuted in a sow but steady reversa of sex ratios in severa districts. For the first time in history, the sex ratio in Haryana has crossed 900. The visibe commitment of the eadership of the country starting from the Prime Minister at the top to the Chief Minister at the state and District magistrates at the districts have geared up the momentum to the grassroot eve. Partners of the Project Nationa Heath Mission, Haryana Awards/Endorsements The study was captured in a front page news story in Hindustan Times on Aug 2, 2015 and March 7, The Government of Haryana took the initiative to inform the community about the harms of SSD through pubication in oca daiies in vernacuar anguage in Aug-Sep 2015 and in socia media through promos aunched on Aug 13, The study findings were highighted by Research gate, Wa street journa, Guardian and India post. Based on study reports, sting operation was conducted by Aaj Tak and this was teecasted in an episode on Oct 13 and 14, Journaists from India Spend, British Medica Journa, Nationa Geographic, Vice news and New York Times have approached us for a possibe coverage in digita media. 101

110 Integrated Nutrition Project for Under 5 chidren February 1, January 31, 2018 Pan Internationa (India Chapter) E-12, Kaiash Coony, New Dehi, , India Website : Founder of the Organization : Ms. Bhagyashri Denge Project Budget : ` 2,88,43, ` 2,32,51, ` 175,25730 Coverage/ Geographica reach : 70 viages in two Districts of Bikaner and Udaipur in Rajasthan, India 102

111 Project Brief India has the argest popuation of under-5 chidren in the word and contributes neary 2miion under-5 deaths. High prevaence of manutrition contributes to over 50% of chid deaths. Manutrition especiay stunting, severe wasting and Low Birth weight are inked to 2.2 miion deaths and 21% of disabiityadjusted ife years wordwide for chidren under five years. Manutrition is India's sient emergency and one of the most significant human deveopment chaenges. Sub-optimum breast feeding, and compimentary feeding is a eading factor in chidhood morbidity and mortaity. Improved materna nutrition and ANC care positivey impact manutrition eading to reduction in ow birth weight. Further eary initiation of breastfeeding and excusive breastfeeding during the first six months are vita in assuring the growth of the infant. Rajasthan has one of the highest SAM prevaence rates in the country with 8.6 % chidren in Rajasthan being SAM (NFHS 4, ). Athough this prevaence has increased from 7.3 % (NFHS 3, ). However, increase of 3 % has been noticed in wasted chidren from 20 % (NFHS 3, ) to 23 % (NFHS 4, ). Chidren with SAM have a nine times higher risk of mortaity compared to wenourished chidren. Even those who survive have compromised menta and physica growth. The grave situation of the state's chidren warranted immediate and effective action to improve the condition. Pan Internationa (India Chapter) responded to this nutritiona crisis through its financia as we as technica support for three year (2015 ti 2017) running an Integrated Nutrition project for under 5 chidren in 70 viages across one bock of Bikaner and 2 bocks of Udaipur district of Rajasthan. This project covered househods, chidren under 5 yrs., 2784 pregnant mothers. In this project, an integrated approach of heath, WASH as we as Nutrition intervention was provided as a composite package to bring the change in the nutritiona status. The socia change communication mode were used to bring the change in the nutritiona status. This project is comprehensive approach of community management of manutrition (CMM) as we as faciity strengthening at the Anganwadi eve; as we as Manutrition treatment centers (MTCs). The project introduced an additiona human resource in a name of Community Nutrition Worker (CNWs). These CNWs were provided mobie device to capture the behavior pattern of each house hod during home visits and provide appropriate counseing. Further faciity management was aso incorporated with strengthening of the Manutrition centers at the government eve through infrastructure support as we as the software support on training and recurring cost. Through this project two MTCs were estabished and was made sustainabe through our advocacy efforts with the government. 200 SAM chidren have been treated in these centers and brought out of the cyce of manutrition. Project Objective were as foows: 1. Improve materna, new born, chid heath and nutrition by enabing community to access knowedge, change attitudes / practices regarding Water, Sanitation and Hygiene and Infant Young Chid Feeding practices. 103

112 2. Enhance quaity of services especiay suppementary nutrition and heath services in government run eary chidhood deveopment centers or Anganwadis through infuencing government. 3. Increase referra, treatment seeking behavior and management of Severe Acute Manourished chidren at Manutrition Treatment Centre. Impementation Mode Key Interventiona strategies: 1. Introduction of community Nutrition workers (Poshan Prahri) 2. Home visits by Community Nutrition workers (CNWs) to improve the home based nutritiona practices and reguar tracking of nutritiona status as we as behavior change aspects with in the famiy. 3. Use of Mobie App and Digita patform for monitoring and counseing of each chid in the viage and entire project. 4. Capacity buiding for community as we as Government stakehoders 5. Nutritiona Recipe demonstration and training for mothers 6. Heath support through Manutrition treatment centers, VHNDs and heath camps and provision of Deworming tabets as we as micronutrients. 7. Water sanitation and Hygiene especiay food hygiene, safe drinking water, using distribution of chorine tabets as we as water ade and appropriated hand hygiene. To address the root causes of manutrition the project adopted the foowing methodoogies in an integrated fashion : (I) Home based care -Improved knowedge, attitudes and practices amongst famiies on food avaiabiity & consumptions, quaity nutritiona recipes based on the nutritiona needs of the chidren, hygiene through community nutrition vounteers (ii) Institution based:- Improved provision of quaity suppementary nutrition services through either partner run crèches ( Bawadis) or govt run eary chidhood deveopment centers (Anganwadis). (iii) Heath services : - Improved heath services ike immunization, A N C, d e i v e r y a n d P N C s e r v i c e s a n d Manutrition treatment centers for severe manourished chidren. (iv) WASH : addressing the wash aspects in the community through the hygiene and cean water management 104

113 Community Outreach To roe out the project in the communities many community participatory activities were undertaken to mobiize the community and enhance there knowedge and bring socia behavior change. Capacity Buiding : Modue on IYCF, Loca recipes and Gender manua were deveoped with oca context and training imparted to a the stakehoders from ASHA, ANM, AWW, and CNWs aong with Immuniza on with support of ASHAs Sanita on & Hygiene Promo on Manutri on treatment center Bawadis/ AWC for suppementar y nutri on MaNutri on Interven on Home based nutri ona interven on Basakhis/ communit y nutri on worker Trained Birth a endants for ANC & PNC SHG, PRIs and community groups. During the project period 970 IYCF training and 270 WASH trainings with different stakehoders were organized. Formation of Mothers Groups : Different category of mothers ike pregnant and actating and those under compementary feeding were created and sensitized reguary through community nutrition worker on various issues reated on Integrated Infant and young chid feeding practices and WASH. A tota of 126 mothers groups were formed in 70 viages who were reguary caed for meetings and imparted knowedge. Home Visits: Focused home visits by CNWs were conducted on a reguar basis to a the househods with under 5 chidren and specia extra home visits to chidren who are under nourished. Tota number of home visits made to pregnant mother were 13,180 on an average 4.7 visits /pregnant, 1,05,894 visits of chidren on an average 7 visits/chidren. Recipe demonstration: Mothers of under -5 chidren were trained on oca ow cost high caorific vaue age appropriate food recipes. They were aso provided skis on responsive feeding and on the frequency and consistency as we as hygiene of the food. 160 recipe demonstration were organized in the community for the mothers and community members during the project period. WASH & Heath campaign: Various mass media activities were undertaken to mobiize community on the Heath hygiene. Awareness vehice was fagged off (WASH Caravan) was organized in a the project ocations/ viages. Puppet shows, wa paintings wa writings as we as fok theater was organized as part of the campaign. Heath camps: Chidren identified through the home visits and at the AWCs were further investigated through medica doctor at the heath camps to identify various diseases/ deficiencies and provided treatment as we as specific counseing and referra. Under this project 12,000 chidren were provided 105

114 with micro nutrients incuding, iron, vit A as we as deworming tabets. 129 heath camps were organized during the project period. Viage heath and Nutrition Days: Community based monitoring system has been estabished through PRIs to reguarize and streamine the monthy heath and nutrition services at the community eve VHNDs were organized during the project. Manutrition Treatment centers: Project has strengthened 02 MTCs at CHC of project bocks with support of Nationa Heath Mission. Above 200 chidren were treated and recovered at MTCs. Uniqueness of the Project Community Nutrition Worker (CNWs) of 'Poshan Worker' - The project has created a cadre of 93 oca rura women who have been intensivey trained on issues reated to materna and chid heath, nutrition and WASH. These CNWs are and wi continue to be responsibe for creating awareness on these issues, bringing about a socia change and improvement in the status of chidren under five years. The CNWs cover househods of pregnant women and that of chidren under five years in their own viage. In some viages peope ive in much dispersed hamets in that case two or more CNWs have been 106

115 depoyed. Their responsibiities incude conducting home visits to counse mothers, caregivers, identify undernourished chidren and monitor the growth of these chidren, organize monthy mothers meetings at Anganwadi Centres on MCHN Days, do referras and provide support in conducting reguar heath camps etc. For this purpose the CNWs are equipped with communication aids such as fip books, brochures etc. and wi be provided with new materia. Digita Interface and rea time monitoring ( Pan MCH App): The intervention used Mother and Chid Heath App deveoped by Pan India, which supported the CNWs in identifying the condition of the chid, reated factors for his/her condition, advisory for combating the probem and aso provided rea time monitoring to the whoe impementation. Water handing Lade to famiies of manourished chidren: The project aso introduced ade as a prescription for combating the manutrition, due to which hygiene got its expected importance which heped in behavior change. Converting waste to nutrition: An innovative mode for use of waste water (grey) and househod organic waste (composting) in growing kitchen garden at the househods eve was adopted to grow fresh vegetabes and fruits at ow cost and provide added daiy nutrition to chidren. Hygienic Cooking Demonstration- during demonstration community was trained on hygiene and ceaniness. Videos on hygienic cooking habits were shown to the target group to hep them to earn, reate and refect. Use of Tradition Grains- nutritious recipes were introduces using oca grains and produces, which are ow cost and easiy avaiabe. This heped in revving the indigenous/traditiona food grains, which were amost forgotten. Kitchen Gardens - Project has estabished kitchen garden at 575 househods and 25 AWCs of severey and moderatey manourished chidren. Through this ensured avaiabiity of micro-nutrient vegetabes in the house. This intervention in the onger run improve nutritiona security. Parents/care givers were provided with seeds and training on cutivating the vegetabes with ess use of water (using househod waste water), and fencing. Roe of Information and Communication Technoogies (ICTs) Pan India has deveoped an android tabet based Materna and Chid Heath Appication known as 'Pan MCH app' and web based porta as 'Pan MCH porta', under the Integrated Nutrition Project (INP). This appication is deveoped under the project to be managed by viage eve 93 Community Nutrition Workers (CNWs). This appication provides support to CNWs to counse mothers. This app aso provides communication toos and AVs which faciitates the counseing sessions by CNWs. This APP aso heps the CNWs track the most vunerabe chidren (Severe Acute Manourished, Moderate Acute Manourished, Severey underweight incuding Low Birth Weight babies) and High risk pregnancies as the app provides timey notifications to CNWs and informs them about the need for visits to the most vunerabe. 107

116 KEY FEATURES OF THE APP Easy to operate by a fied eve worker having basic reading skis A househod information is avaiabe in one unique bar code User friendy for every one as it does not need typing or writing. A heath and nutrition reated behaviors and practices of materna as we as chidren up to 5 years are tracked. Instant anaysis of growth indicator ike weight-for-age, Height-for-age and weight-for-height and mid upper arm circumference-muac (as per WHO recommended standards). Tracking and nutritiona gap anaysis of food intake incuding frequency, quantity and type of food consumed Questions change automaticay in reation with pregnancy trimester and chid's age Pop-ups for high risk group Automated notification on important indicators Automated counseing support to fied staff Automated anaysis for key preforming indicators GPS profiing of each and every househod Chaenges Faced 1 Poor understanding of the Interreationship between WASH, Heath and Manutrition: Importance of WASH and heath are neither understood nor integrated in most of the nutrition programmes. Hence, it was a chaenge to c o n v i n c e a t h e stakehoders of the project towards increasing their emphasis on sanitation, hygiene, and materna and chid heath as a composite p r o g r a m t o a c h i e v e n u t r i t i o n a g o a s. T h e project tried to ink WASH intervention directy to the nutritiona outcomes. Each undernourished chid was cinicay assessed under 108

117 three aspects named Heath, Nutrition and WASH. Of which WASH was an added parameter to understand WASH reated reasons for the undernourishment which was duy addressed. To emphasize the important of nutrition a the househods having undernourished chidren were provided with reguar home visits and micronutrients as we as water ade. With this sma, innovative intervention added on, the community was sensitized to prevent undernutrition. 2 Zero Access to MTC (Manutrition Treatment Center) Faciities:- before the project was started MTCs in both the project ocations were dysfunctiona and no admissions were being made in these centers. During the project the refurbishment was made of these government centers with HR, infrastructure and ogistica support. Graduay these centers became active through addition of trained staff and severey manourished chidren started staying in these centers through our referras. A tota of 216 SAM chidren were treated and recovered in these two centers. 3 No mode Anganwadi Centers: Most of the AWCs are operating from private buiding and they aso shift ocation depending upon their need. Hence, they ack, space for chidren to eat, utensis were not avaiabe for both cooking as we as serving. Anthropometric measurement was not avaiabe and aso no toiet and hand washing stations. This deprivation restrains chidren to come to the center to avai of services. Considering which the project instaed portabe toiets with running water and hand washing station, water fiters were provided in a the project AWCs and aso provided utensis, growth charts, weighing machines as we as stadiometers and mattresses. This intervention enabed chidren/preschooers to earn and work as agents of change. They conveyed the project messages to their househods. Outcomes Community Knowedge: 93 viage eve community nutrition workers or poshan didi are skied to address medico-socia behaviors and practices. Who are from the community and is we recognized by the community. Reduction in Undernutrition: 31.6% decrease in undernutrition (severe and moderate cases of weight by age) has been reported as a resut of messages given systematicay during home visit, mothers meeting and recipe demonstrations with emphasis on age appropriate feeding behaviors. Reduction in Low Birth Weight: 4 % decine in ow birth weight cases has been noticed due to sustained counseing on Infant and Young Chid Feeding practices during mothers meeting and home visits. (15.1 % in baseine 2015 to 11.1 % in December 2018) Breastfeeding: Improvement of 45.5 % has been found in initiation of breastfeeding practices within one hour of deivery. (44.5 % in baseine 2015 increased up to 90 % in December 2018) Compementary feeding: Increase from 10.7% to 68.5% (57.8 % improvement) in initiation of semi-soid food with breastfeeding on competion of 180 days. 109

118 Reduction in Diarrhoea: Prevaence of diarrhea episode decreased from 18.4 % to 5.0% due to use of water adder and improved hygienic practices. Increase in hand washing with soap after defecation and before eating meas or handing raw and cooked food was found to be gone up to 94.3% respectivey. Treating SAM chidren: 200 chidren treated in two MTCs Rishabdev and Lunkaransar, where project supported Human Resource, ogistics and capacity buiding of MTC staff. Hygiene interventions: Food handing and upkeep has shown significant improvement within the famiies. Famiies that cook in hygienic way and keep food in proper way has increased from 23% to 94% in ast 3 yrs. Further the use of proper water storage and water handing techniques has aso increased from 26% to 96%. Outreach & Scaabiity Government as the key stakehoder: A the district eve officias as we as the state eve functionaries from both the department of heath and ICDS were roped in from the start of the project. State eve start up workshop as we as dissemination workshop were conducted and knowedge disseminated with government, as we as UN and other oca partners As per the new Integrated Chid Deveopment Services (ICDS) restructuring mode an additiona community worker has been proposed at the Anganwadi Centre to support the behavior change activities at the community eve. This project has demonstrated the need and important of additiona community worker to bring in behavior change. This project has aso demonstrated the roes and responsibiity of this community nutrition worker in an integrated manner. Using Nutrition worker the project impemented innovative mode which bridged two Government fagship programmes ike ICDS and Swatch Bharat Mission with reguar Heath interventions. It aso created comprehensive rea time data management and monitoring system incorporating the components of heath, Nutrition and WASH and interpreting on the nutritiona status of chidren. This is a an important community based intervention mode which utiized WASH and heath interventions adequatey at the community eve to change the behaviora practices without a provision of any externa financia or materia support/subsidy to the famiy and sti achieved considerabe sustainabe change in the growth and deveopment of chidren {significant reduction underweight chidbirth (6.5%), overa manourished chidren (18%), and severey manourished chidren (5.8 %), moderatey manourished chidren (15%)}. Pan India has own sponsorship financia mode, an unrestricted fund with the fexibiity to be aocated as per prioritized issues. Further, most of the activities are dovetaied with Government's routine activities at the community eve ike VHNDs, AWCs activities, Immunization programs, Swatchata Missions, Community Managed Manutrition Programme, and Rastriya Ba Swasth Karyakram (RBSK) etc. Most of these programmes have aready being strengthened under this project. Pan India is aso trying to disseminate this project to various donors incuding Corporates to garner support. To cover the management cost and over a support Pan India aready has ongoing programmes, state office, 110

119 reguar interna staff and partner's staff to carry on the good work which has extended under the project. Repicabiity Pan India work with many externa partners (Nationa and Internationa) to piot, innovate and scae up its interventions. Buiding on its strong presence in the country, Pan India has estabished and nurtured partnerships with oca NGOs in the 16 states. We have a cumuative experience of working with over 100 NGO partners on specific issue-based programs and grants-supported program. Pan India is part of various nationa as we as state eve aiances to carry the advocacy agenda. Pan India is aso working with State and Nationa Governments, providing technica support especiay Nationa Heath Mission as we as ICD to roe our best practices and the earnings of the project incuding technica materias deveoped during the project. Pan is aready member of the technica task force to review the IEC materias of ICDS.The sustainabiity component of the project is inbuit and very strong: This project is abe to deveop and nurture Community based institutions and structures ike oca Civi Society Organization, Gram Sabha, Mothers Groups, Chidren's Group and Community Vounteer. CSOs wi be abe to sustain the interventions mobiizing crowd funding. The project has upgraded WASH faciities at the Anganwadis and hence, generated demand for services. Aso created a cadre of trained CNWs in each of the viages it has worked, they are sti continuing under ICDS restructuring mode after the project has phased out. Impact Achieved The project has been abe to mobiize 1.5 akh popuation (of which were chidren beow 6 years and pregnant women) spread across 70 viages in two districts of Rajasthan and supported in reducing manutrition's by introducing safe water, sanitation and hygiene. Project viages achieved open defecation status and aso disposed waste safey by introducing the concept of kitchen garden (25 AWCs and 575 househods), which used grey water from bathrooms and kitchen. In addition, 3536 mothers meeting were conducted with pregnant women and mothers of chidren beow 6 years. Stakehoders trained- 93 CNWs, 75 Aganwadi workers, 26 Sanchaikas and 56 ASHAs on safe WASH and Nutrition practices. 93 CNWs were aso trained on handing and use of Pan MCH app. In a, 168 Community Mae members trained as Master Trainers to sensitize parents on gender issues. 1,029 SHG/PRIs and 5,712 Pregnant and actating mothers trained on preparation of nutritionay rich recipes using oca and seasona ingredient. Further, 5,281 community members were triggered and oriented on the importance of hygiene and sanitation aspects. Heath camps & VHNDs: Project faciitated 1909 VHNDs/MCHNDs to ensure its effective and enhanced reach and organized 129 heath camp for management of critica iness and referras. Aso ensured 111

120 reguar micronutrient to chidren under 6 and supported vitamin A and deworming rounds. Aso provided ORS and zinc suppementation to the chidren with diarrhea episode. Potabe Toiets In addition, 56 portabe toiets were constructed at the Anganwadi eve and 3400 ades were distributed to the househods having manourished chidren beow 6 years. Heath outcome of the project is assessed in terms of reduction of manutrition.this impacted in significant reduction underweight chidbirth (6.5%), overa manourished chidren (18%), and severey manourished chidren (5.8 %), moderatey manourished chidren (15%). Capacity Buiding Modue Deveopment: Deveopment of cuturay appropriate behavior change and communication materia for e.g. IYCF manua in Engish and Hindi, Recipe Manua, Gender in Nutrition manua Fipbooks, Posters, Pamphets. Training of community Nutrition Workers: Seection and capacity buiding of 93 oca women as Community Nutrition Worker as a change agents. Training of SHG and PRI members: 247 members were provided orientation on IYCF, WASH, and Gender. Training of mothers and fathers: Mothers and fathers were capacitated on various issues and skis on breastfeeding, compementary feedings and on various recipes. They were aso imparted training on identifying high risk chidren, compications reated to manutrition and proper referra. Training of Government stakehoders: AWW, ASHA and ANMs were provided training. 126 persons were imparted training. District as we as state eve Workshops: 4 district eve workshops was organized and one state eve dissemination workshop was organized during the project. Partners of the Project Loca governance ike Panchayati Raj Institution, Viage Heath Sanitation & Nutrition Committees Department of Heath at the state, district, bock and viage eve incuding Accredited Socia Heath Activist (ASHA), Accredited Nurse Midwives (ANM) ICDS functionaries at state, district, bock and viage eve incuding Anganwadi Worker/Bawadi sanchaika Project staff at state, district, bock and viage eve incuding Community Nutrition Worker. Two impementing partners namey Sewa Mandir and URMUL for daiy activities under the supervision of Pan staff at the district as we as state eve. 112

121 Konku-Puchiku Project Spandan Samaj Seva Samiti Website : Founder of the Organization : Ms. Seema Prakash Coverage/ Geographica reach : 200 Korku tribe dominated viages of three adjoining districtsnamey Khandwa, Burhanpur and Betu of Madhya Pradesh. 113

122 Project Brief Konku Puchiku (means cute itte chidren in Korku diaect) Project was aunched in 2011 with a shared v i s i o n a m o n g G e n m a r k Foundation and Spandan Samaj Seva Samiti to address the aarming manutrition prevaiing among the U5 Korku chidren. The Project was geared to impement a community-based intervention t h a t w o u d h e p s c o r e s o f manourished chidren recover at homes without having to resort to p r o o n g e d f a c i i t y - b a s e d treatment ike Nutrition Rehab Centers often an urban Hospita annex. Most of the tribas sti are hesitant to eave home and stay onger at the hospita, having to eave her home, farm and other chidren behind. The project intervened with eary nutritiona tracking of chidren and foowing it up with adequate foow-up care ike home visits, nutritiona counseing, diet diversification advice and promptings for immunization. Heath Camps at remote ocations have been usefu at bridging service deivery gaps. Considering the fact that major determinant of manutrition has been the growing househod food & nutrition security. The Project has promoted Backyard Nutrition gardens and Backyard free range indigenous poutry. To further strengthen the food security, a sustained campaign was run to motivate Korku tribe farmers to revert back to growing traditiona crops and Miet that once was the mainstay of community nutrition and coping mechanism in times of food crisis. When the project began the situation of peak hunger times prevaied and most of the poorest famiies had to undergo food shortages forcing them to seasona distress migrate or be indebted. The campaign began with motivating and coecting indigenous Miet seeds and setting up Seed banks at strategic ocations to outreach more number of farmers. It is now a community managed service and the number of Miet growing farmers has been increasing. A coroary initiative was undertaken to evoke the now neary forgotten triba tradition of mutua hep. The neighborhood and and water resources were deveoped through vountary abor contribution and women taking ead. Hundreds of acres of and were amended by picking ide stones and stacking farm fences to check soi erosion, existing wes and ponds were deepened and some new wes were dug by women and water structures ike stop dams were repaired or new sandbag check dams were instaed 114

123 to increase water retention capacities. A this heped in increasing the per acre yied in this hunger prone region. Anganwadis being the soe institution for chid nutrition in a rura area were taken up for revamping. They were given a faceift and equipped with toys and recreationa materias and cothing. The centers turned into genuine chid-friendy spaces where chidren coud be retained for a onger time and so coud access most of the avaiabe services ike suppementary nutrition, immunization and heath checkups. A distinct intervention was the introduction of a range of Teaching Learning Materias in indigenous Korku diaect. The reguar events at the centers have motivated mothers and chidren to engage in center's activities. Another anecdota intervention was to run community crèches for chidren beow three years and ones beonging to wage-earning triba mothers. The wage-earning mothers can eave their chidren and crèche provides feeding and caring services for the whoe day. A reguar heath check is extended. The Project focuses on the Behavior Change Communication. Korku tribe community has been comparativey backward and hed to many myths and superstitious beiefs and practices. Their quacks and priests promoted appeasing of deities. They correated different symptoms of manutrition as the curse of some or other triba deity and its treatment ranged from offering obations to tying taismans with izard's tai. The Project in its proactive process to demystify manutrition have been depoying a range of information, education and communication (IEC) methods to reinforce earning, generate widespread awareness and engage the community in a discussion on the issue in question. Use of oca diaect has been very effective. The community opinion shapers comprise of their informa eaders (Pate), triba priest (Bhumka) and triba heaer (Padiyar) and the eders. The Project has strived a through to transform them into Socia Behavior Change Agents (SBCA). They have been proactivey oriented and trained to know the observabe symptoms of manutrition use MUAC tapes and motivate the victim famiies to prefer scientific treatment over chants and rituas. An innovative method of Wa Comic Posters is used. The efforts aso incude interactions with grassroots government service providers ike Anganwadi Workers, ASHA, and ANM. Reguar meetings, training, and joint visits have heped in forging coaborative actions at tracking, immunization, foow-ups, and referras of mothers and chidren. A distinct coaboration has been to increase the outreach of most eigibe chidren with Vitamin A and Deworming. District and Bock eve meetings with the concerned Departments have been organized. 115

124 Impementation Mode The Project has adopted a ayered approach wherein it tries to reieve the sufferings of currenty manourished chidren on one hand whie on the other hand, it tries to faciitate a food secure environment that can be accessed by most of the poor and needy famiies. It is community-based manutrition management mode that aims at heping most of the manourished chidren recover from homes in a non faciity-based care and in the process capacitate the community to sustain the initiated process. Community Outreach The Project has an underying component of community participation. It provided ampe opportunity for the stakehoders to engage, share, earn from each other and pan and review the progress and resove intervening probems. The key beneficiaries are identified famiies with manourished chidren and ones that are prone to hunger ike andess, frequenty migrating, widows and singe womenheaded famiies. 116

125 Uniqueness of the Project The innovation of the project has been its abiity to see manutrition beyond mere cinica issue and address the major underying causes that have been triggering househod hunger. The consequent activities in the form of reviva of Miet & Traditiona crops, aigning Backyard Nutrition Gardens and Free Range indigenous Poutry as a major source of direct absorption of protein and essentia micronutrients, deveoping neighborhood and and water resources by and buiding a scientific temper among the community opinion eaders coectivey coud address the causative factors effectivey. The community crèches have been trying to prove a point that adequate attention to chidren beow 03 years who are most prone to damages of manutrition can greaty reduce the physica and cognitive osses it can cause. Roe of Information and Communication Technoogies (ICTs) We have introduced Miet processing machines in the community to hep ease the burden of women having to do it on manua mud grinders. With this they wi be abe to process the Miet easiy can in future aso consider surpus marketing. 117

126 Chaenges Faced The initia chaenge was to demystify the manutrition among the community. Secondy, it was needed to prove that ow-cost non-faciity based care was the need of the hour to hep scores of chidren who were either victim or exposed to becoming one. The major effort was directed to estabish a viabe reationship with the community. They were engaged in various persona and group interactions. A concerted effort was directed to gauge vita information on their own perception of manutrition and various practices that deveoped and ay embedded in their ora tradition. This gave us a deeper understanding that went into deveoping a range of communication toos and methods. The use of oca diaect heped in increased participation. The focus on buiding a scientific temper among their community opinion shapers showed a good response. Now they can observe the obvious signs of manutrition, use MUAC tapes and provide right counseing to victim famiies. Most of the mothers have been heeding their advice on preferring scientific treatment of manutrition over rituas and chants they practiced earier. Many mothers now know the current nutritiona status of their chidren and have been trying to diversify diets with Miet and vegetabes and poutry. Outcomes The Project over time has been abe to engage the community in the process. They have contributed their knowedge and traditiona wisdom to hep the reviva of Miet. The Miet has been forging its way back in the farms and pates of the famiy. The direct absorption of protein and essentia micronutrients through increased accessibiity to vegetabes and poutry and eggs has been crucia in reducing extensive protein-energy manutrition (PEM). 118

127 The increased awareness on causes and consequences of manutrition among the community at arge has heped famiies to access food and nationa entitements, opt for proper treatment and have been consciousy trying to diversify diets with most of the avaiabe food items they can coect from the neighborhood or grow themseves. There has been a gradua increase in a number of famiies reverting back to growing Miet and other traditiona crops. This is rebuiding the nutrition base of the community. There has been a significant decine in the rates of manutrition. Especiay the rate of underweight chidren has decreased and so the IMR. The atest NFHS IV data records 49% chidren underweight, 23% wasted and 43% stunted. The community crèche has been appreciated with daiy wage earner mothers not because they are being taken care of rather they have been showing sustained growth and are ess prone to iness. Outreach & Scaabiity The project outreaches on an average 2000 U5 manourished chidren every month and neary 2500 Pregnant and Lactating mothers and 5000 famiies. The coverage is 200 viages across 03 adjoining bocks and districts namey: Khawa (Khandwa district), Khaknar (Burhanpur district) and Bhimpur (Betu) district. Repicabiity The Project has estabished its efficacy by being abe to reach 3000 chidren every month physicay and engage mothers and the community eders in the process. It's a ow cost and does not empoy anything that is not cuturay sensitive or wi require import or high costs. The project design aows the capacity buiding of knowedge sharing among a the stakehoders. It has potentia to be sustained. It can be best suited for triba communities that face the highest burden of manutrition in the state. Impact Achieved The overa impact of the project can be assigned firsty to the reation that coud be estabished with the target community. It heped in not having them depend too much on externa support or doe outs. The Project had a dua focus immediate and far-reaching. The former has been to aeviate the suffering of the chidren aready manourished and atter to create a food secure environment. This mix has been abe to make it more effective. 119

128 Capacity Buiding The Project ays great emphasis on capacity buiding of stakehoders. It invoves training and workshops, panning & reviews, group meetings and awareness campaigns. The Thematic training is done both in-house and through externa training. The community eve training incudes training of mothers on breastfeeding and care, diet diversification, technica inputs on nutrition gardens and poutry, various pubic entitements reated to food & empoyment. A specific focus is on orientation and training of Community opinion eaders to deveop the right understanding of causes and consequences of manutrition and equipping them with skis to become Socia Behavior Change Agent (SBCA). The interactions with grassroots service providers an especiay Anganwadi worker, ASHA and ANM have been to reinforce coaboration and updating their perspectives and skis in managing manutrition cases. Various joint programs ike home visits and foow-ups and referras an event at Anganwadis and administration of Vitamin A and Deworming has been effective. The campaigns ike Miet Campaigns have been very effective at faciitating discussions, generating new knowedge and information and motivation that have gone ong way in reviving the Miet. The diaogues and deiberations have been done at Bock and State eves to share knowedge and infuence poicymakers. Partners of the Project Partners of the Project incude Genmark Foundation Mumbai that has provided resources and guidance whie Spandan Samaj Seva Samiti has been responsibe to impement it on the ground with a shared vision Heathy Chidren- Heathier word. GOONJ New Dehi had been an active partner and has been providing toys, cothing and other materias support that has been usefu at mobiizing the community. The occasiona hep from Genmark Empoyees too has been usefu in meeting materia needs. Awards/Endorsements The Project received foowing Awards : Best NGO partner Award by Genmark Foundation Mumbai CSR Impact award for Heathcare Stree Shakti Samman Rani Laxmibai Puruskar by W&CD Ministry GOI 120

129 121

130 Materna Nutrition Suppementation project for antenata and post-nata women in Paghar District, Maharashtra May June 2017 Impact India Foundation (IIF) Website : Founder of the Organization : Mrs. Zema Lazarus, Founder Director & CEO Project Budget : Approximatey ` 50 akhs. Coverage/ Geographica reach : Mavada Primary Heath Centre (PHC) Area, Vikramgad Bock, Paghar District, Maharashtra. 122

131 Project Brief In India, under nourishment poses a key chaenge that remains to be tacked. The dietary intake of energy, micronutrient and protein in mothers is generay found to be ow. Low purchasing power, arge famiy sizes, gender bias etc. are some of the determinants of a compromised nutritiona status. To improve this situation, various strategies were put forth: Objectives: - To provide access to a nutritious diet for mothers in antenata and post-nata stages to support their heath during pregnancy and actation. To promote the reguar consumption of the foods by the mothers and hep them overcome the dietary gap by nutrition education and counseing. Impementation Mode The mode was impemented as a part of Impact India Foundation's preventive heath programme: The Community Heath Initiative (CHI) in Paghar District, Maharashtra. A tota of 110 beneficiary mothers were identified from different sub-centres in the area under Mavada PHC. This short-term cohort intended for the proposed suppementation and education, was targeted for foow-up ti the birth of their infants and six-months of post-nata period. The outputs and outcomes were to be assessed in reevance to the foowing variabes: Gestationa weight gain of mothers for the period of suppementation Mean weight gain of the mothers in reation to the suppements intake. Materna Haemogobin status Materna haemogobin eves noted over the gestationa period. Birth outcomes- Mean birth weight, aong with the reduction in the incidence of Low Birth Weight and other unfavourabe resuts of pregnancy. Weight gain in infants Mean weight gain of infants in reation to the consumption of suppements. Registration of mothers: Confirmation and registration of pregnancy in genera, often occurs as ate as the second trimester in the Mavada Bock (Tehsi). This is due to ignorance and ack of pro-activeness amongst femaes, due to which ante-nata care in turn, is deayed. Therefore the maximum no. of mothers (n=110) were incuded in their fourth month of pregnancy (second trimester), which is the imitation of the project. A tota of 95 beneficiary mothers were the project beneficiaries after taking into account drop-outs and migration. Provision of suppementary food: To proffer a maximum intake of nutrients, mothers were suppemented with daiy hot cooked meas aong with fortified Laddoos. The Laddoos were high in caories (550 Kca) and with an incusion of vegetabes increased dietary diversity, otherwise unaffordabe to mothers daiy. Mothers were guided to the nearest ZihaParishad (Z.P.) schoos in their respective areas to receive the day time meas by the CHI fied team. The other nutrient dense foods ike eggs, peanuts, etc. with a reative arger shef- ife were distributed by means of home visits. An assured amount of 1570 kca was thus provided daiy in the antenata stage, with different combinations 123

132 of the foods. This was increased to 1724 kca for the postnata period to augment actation. In addition Iron & Foic Acid & Cacium tabets were given. Compiance of suppementation: The CHI fied team ensured that the foods reached beneficiary mothers and were consumed reguary by means of home visits. Laddoos were distributed by IIF's CHI team. Nutrient and Heath Education: The importance of the consumption of these food items were stressed at each home visit and mothers were thus motivated to adhere to routine intake of the provided suppementary foods. The significance of diet diversification, improving eves of nutrient intake and other reevant ante and post-nata care practices were emphasized. Community Outreach Reguar monitoring of weight gain and Haemogobin (Hb) tests were done in the ante-nata period ti birth. Weight gain in infants was checked monthy, for a period of six months post birth. However, mothers were unavaiabe for weight checks at certain days due to which there were discrepancies in recording. The birth data of a the infants is aso not avaiabe for reasons ike mothers moving to their materna homes for deivery, etc. Uniqueness of the Project To proffer a maximum intake of nutrients, mothers were suppemented with a Laddoos high in caories (550 Kca) and counseed on the intake of vegetabes to increase dietary diversity, otherwise unaffordabe to mothers on a daiy basis. The other nutrient dense foods ike eggs, etc. were distributed by means of home visits. An assured amount of 1570 kca was thus provided on a daiy basis in the antenata stage, with different combinations of the foods in form of Laddoos. This was increased to 1724 kca for the postnata period. Roe of Information and Communication Technoogies (ICTs) Information Technoogy was used to maintain a database of the beneficiaries. Chaenges Faced Migration of the antenata and post-nata women is common in Triba bet of Paghar District for work in factories, brick kins and to cities. Learning from this experience IIF adopted the criteria of seecting w o m e n, i n f u t u r e M a t e r n a N u t r i t i o n Suppementation projects, who woud not migrate. Parameter Vaue Outcomes Percentage of women reported Hb ess than or equa to 11gm/dc when registering for Ante Nata Care (ANC) at PHC in the month of May 2016 (N= 110) HB Mean 9.13gm/d SD Range- Minimum Maximum 8.0 gm/d 11gm/d 124

133 Diagram No.1 depicts a Histogram showing the percentage of ANC women reporting Hb ess than or equa to 11gms/dc at PHC in the month of May (N=110) Average weight of women when registered for ANC at PHC in the month of May 2016 (N=110) Parameter Vaue ANC mean weight (in Kgs) 40.01kg SD Range- Minimum 31.0kg Maximum 60.0kg 125

134 Average increase in weight of women during pregnancy in month of Juy 2016 (N=110) Parameter Vaue ANC mean weight (in Kgs) 42.69kg Standard Deviation (SD) Range- Minimum 34.0kg Maximum 62.0kg Comparison of May and Juy 2016 graphs 126

135 Percentage of infants reporting weight greater than or equa to 1.6 kgs to 3 kgs and above at birth in different months (N=95) Variabe Vaue Frequency % September kg to 2kg 0 2.1kg to 2.4kg 1 2.5kg to 3kg above 5 Tota 6 (5.7%) October kg to 2kg 2 2.1kg to 2.4kg 2 2.5kg to 3kg above 17 Tota 21 (19.95%) November kg to 2kg 4 2.1kg to2.4kg 3 2.5kg to 3kg above 24 Tota 31 (29.45%) December kg to 2kg 4 2.1kg to 2.4kg 5 2.5kg to 3kg above 14 Tota 22 (20.9%) January kg to 2kg 2 2.1kg to 2.4kg 1 2.5kg to 3kg above 6 Tota 9 (8.55%) February kg to 2kg to 2.4kg to 3kg above 2 Tota 5 (4.75%) March kg to 2kg 0 2.1kg to 2.4kg 0 2.5kg to 3kg above 1 Tota 1 (0.95%) No. of babies with weight minimum 2kg:- 14 No. of babies with weight in range of 2.1kg to 2.4kg- 13 No. of babies with weight in range of 2.5kg to 3kg and above- 68 Average increase in weight of infant in six months (N=95) Variabe Frequency Minimum 5kg increased 9 Minimum 6kg 35 Minimum 7kg 46 Maximum 8kg 05 Mean 6.47 SD Range- Minimum 5kg Maximum 8kg 127

136 Histogram shows the average weight gain in chidren after 6 months Number of Miscarriages or wastage pregnancy- 11 Chid death- 2 Sti birth- 2 Outreach & Scaabiity IIF has signed a ten-year MoU with the Paghar District administration to scae up Reproductive, Materna, Newborn& Chid Heath + Adoescent projects in the remaining 43 PHC areas of the Triba District (popuation: 30,00,000). Repicabiity The earning obtained from the outcome and impact of this project has informed the strategies of a simiar Materna Nutrition Suppementation project being impemented in another ocation in Paghar District. Impact Achieved Gestationa weight gain of mothers for the period of suppementation - Mean weight gain of the mothers in reation to the suppements given effective to weight gain during the antenata and postnata periods. Materna Haemogobin status - Materna haemogobin eves noted over the gestationa period. 128

137 Birth outcomes- Mean birth weight, aong with reduction in the incidence of Low Birth Weight and other unfavorabe resuts of pregnancy. Weight gain in infants - Mean weight gain of infants in reation to consumption of suppements by their mothers. Capacity Buiding Before the initiation of the project, the capacity buiding of the of the CHI Team was conducted on various thematic areas, which incuded the conduct of Body Mass Index surveys, Hb estimation, identifying signs and symptoms of high-risk cases for timey referras to Doctors, Persona counseing to rest between work, breast feeding practices, training for famiy members on the creation of a supportive environment for the pregnant mother at home. Partners of the Project Johnson and Johnson Pvt. Ltd. Awards/Endorsements The Breach Candy Hospita Trust has supported a simiar project on Materna Nutrition Suppementation in Paghar District for 15 months. The extra month was added to incude best weaning (compementary feeding) practices after the competion of six months of breast feeding. Johnson & Johnson has expressed interest in the support of a simiar project which incudes the capacity buiding of Government CHI staff (in bue cap) hands over a package of suppementary nutrition to a pregnant woman beneficiary. Heath Staff (Anganwadi Workers, Accredited Heath Activists - ASHAS and Auxiiary Nurse Midwives) to support Mother and Chid Heath. This wi promote sustainabiity of the gains achieved. 129

138 CHI staff uses educationa videos on aptops to sensitise new mothers and their famiies and augment persona and famiy counseing on Mother & Chid Heath. Dr.Nitesh Sharma, Project Director, Impact India Foundation's Community Heath Initiative, March 5,

139 Mentor fied training_tn_madurai District Capacity Buiding and Training of Mentor Nurses- An initiative to create a resource of 192 master nurse trainers in the state of TN supported by United Way of Chennai (UWC) & Motivation for Exceence (MFE) March 2015 to present Ekam Foundation Founder of the Organization : Dr. Saiakshmi Beijepai Project Budget : ` 3,75,31,049 Coverage/ Geographica reach : Tami Nadu across a districts 131

140 Project Brief In 2012, a Government Order to designate Mentor Nurse at the state eve and district for training 4000 nurses was passed by the Government of TN. This set a patform to provide a mandate for significant intervention in heathcare, particuary materna and infant care at the viage eve. Seected from the districts it, the mentor nurses were identified to train, work with the nurses in PHCs across TN as an interface between the District and the Bock Leve Hospita authorities, thereby eading to improved nursing deivery. In ate February 2015, United Way signed an MOU with Ekam Foundation, a heathcare based NGO working within the Materna and Chid Heath spectrum. The project, which is run under the auspices of Directorate of Pubic Heath, Tami Nadu aims to buid the capacity, empower and mentor 200 nurses from the Government heath centers and enabe them to take the knowedge and skis forward to the existing framework of nurses stationed within a the Government Hospitas in the state. These nurses are being trained and mentored by speciaists and experts in the fied of Obstetrics, Pediatrics and Neonatoogy from premier heathcare institutes in the country. The project, panned over a two year period has been conceptuaized keeping in mind that training these Master Trainers wi essentiay strengthen their skis and competencies and thereby make way for provision of quaity care services for materna and chid heath care. The program is committed for exceence and was conceptuaized with the soe intention of bringing down IMR and MMR in government heathcare settings and utimatey, that of TN. It is expected that the program wi hep buid a resource poo of the best, the most quaified, skied, knowedgeabe trainers who wi be masters in the fied. Impementation Mode The project aimed to create a cascading effect of the spread of knowedge and improving the standards of deivery of nurturing care from the 184 Master trainers to the 3808 staff Nurses and 2000 ANMS and finay, for this knowedge to tricke down to the community. This was done in phase 1 of the program. 132

141 TRAINING METHODOLOGY The training was given to the Staff Nurses in the form of interactive ectures and hands-on training by the speciaists (doctors) in Obstetrics & Gynaecoogy, Neonatoogy and Paediatrics. As per schedue, a the activities were successfuy executed without any interruption. Enthusiasm of the staff nurses was seen throughout the training program. Pre and post training tests were conducted. Pre test was conducted to understand the eve of knowedge with regard to technica skis during the start of the program. Post training test was conducted to evauate the impact by finding the difference in their knowedge. In addition to the technica sessions, change management workshop was aso conducted. Subsequenty, separate session for obtaining their feedback was aso conducted to understand the pros and cons of the training programme. Community Outreach Tota Number of Nurses Trained 184 No Of Days of Training given in a 90 No of training sessions conducted 5 No of days of training /session 18 No of PHCs visited Gap Assessment forms fied 746 Data entry and anaysis competed 220 Data entry competed 700 in a Uniqueness of the Project Out of the 184 nurses trained, around 90 percent of the nurses were reguar mentor staff nurses who went about their duties staff nurses were trained in a trainings were conducted across Neonata, Obstetric and Pediatric speciaities. 133

142 Roe of Information and Communication Technoogies (ICTs) Motivation Motivation is a fundamenta part of focus as the Mentors are ceary disiusioned by the everyday banaity of their job. Externa factors which can drive motivation and change behaviour, for exampe, the provision of incentives or penaties can perhaps be recommended. But interna factors, such as the nurses' sef motivation, drive and desire to improve are very important too. Intentions and goas can impact on how much these nurses actuay want to change. Nurses priorities and commitments may aso interfere with their abiity to change. Acceptance and beiefs The nurses' individua attitude and beief wi significanty affect their behaviour. Perceptions of the views of others [Word View] may aso have an impact. Some nurses may find it difficut to accept new inputs if it is in confict with their inbuit beief or earnings [unearning]. A person's beief in their own abiity to adopt a new behaviour aso has an impact on whether a change can be impemented. Skis Nurses wi need to know not ony about what change is required, but aso how best to competenty carry out the change. The nurses wi need further training to ensure they have the skis to deiver best practice, time to earn new skis and practice them. Individua abiities, interpersona skis and coping strategies wi aso affect how easy or difficut it wi be for individuas to earn new skis. Practica barriers ike situations in Government Hospitas can invove a ack of resources or personne, or difficuties in estabishing service deivery Another practica difficuty is maintaining change in the ong term. If key members of staff eave or priorities shift it may be difficut to maintain any changes that have been introduced. Chaenges Faced Identification of Trainers on a reguar basis despite having the necessary permissions from reguatory bodies 134

143 Some of the nurses sent by the Govt to the centra trainings were not Mentor nurses but reguar staff nurses Nurses unhappy with ong schedue of trainings Trainers not at a satisfied with honorarium paid. Ski ab in IPH not competey equipped. Trainers fee the training centres not upto the mark and hence, they have to rey on didactic training approaches. Teething probems regarding food suppy during Trainings 1 and 2. Sorted Chaenges Post Training Mentor fied training_tn_madurai District Decision making at the Government eve was sow. Permissions not reaching the concerned authorities on time. Doctors in PHCs not briefed about project by the Govt. As some of the nurses are not mentor nurses, they are sti doing cinica duty. Govt not providing nurses with the recommended TA/DA reguary. Nurses unwiing to trave. Ekam needs to consistenty push the nurses to trave Gap assessments are not being encouraged by doctors in PHCS. Unresponsive and unreceptive to change. Learnings Roes of supportive staff, supervisory and mentoring staff shoud be reviewed and discussed in the training. Supervisory guideines and checkists aso need to be deveoped. In concurrence with earier evidence based reviews, capacity-buiding of Mentor Nurses shoud argey focus on important eements of change management shoud incude the reevance of PHC visits, the estabished schedue regarding PHC visits, skis needed to conduct the visits, cutura, equity and gender norms, and record keeping on PHC visits It has been noted that in addition to technica or speciaty trainings, adequate focus on change management is priority. Outcomes Some of the observed outcomes incude Lowered number of infant, chid, materna deaths. Improved standards of nursing care within the PHCs in TN. 135

144 Lower rates of infection reated deaths. Fewer rate of morbidities in RMNCHA spectrum. Timey referras of cases without compromising on quaity of care. Partners of The Project 1. United Way of Chennai (UWC) - Supported for training (centra/in house) of Mentornurses 2. RGMFE - RG Manudhane Foundation for Exceence - Motivation for Exceence - Supported for Monitoring of Mentor Nurses & on fied training, community institution buiding On fied training_tn_kancheepuramdistrict Regiona officer, Ekam giving his feedback on mentor's training_tn_tiruvaur District PHC nurses getting trained by Mentor_Theni District Mentor fied training_tn_madurai District 136

145 India_MIRA MIRA Channe: Mobie Phone based Channe for Rura Women on Materna & Chid Heath using RMNCH+A Approach Apri 2012 On-going (March 2020) ZMQ Deveopment Website : Founder of the Organization : Mr. Himi Quraishi Project Budget : ` 5 Crores Coverage/ Geographica reach : India Haryana, Rajasthan, Orissa; LIC (Low Income Countries): Afghanistan, Uganda and Rwanda 137

146 Project Brief MIRA Channe is an integrated mobie phone channe which provides heath communication and information to rura women; and timey connects them with pubic heath system for critica heath service deivery. MIRA has mutipe channes ike Pre-nata, Chid Immunization, Newborn Care, Famiy Panning and Adoescent Gir Heath to improve MCH using RMNCH+A approach. MIRA uses icon based interactive heath bots with timey advisory toos based on Artificia- Inteigence using heath-cacuators-trackers ike pregnancy-week-by-week-tracker, menstruacyce-cacuator, ANC-cacuators, immunizationcacuators, and high-risk-forecasters; providing customized-ocaized audio-visua toos as 'Taking Uganda_MIRA Tookit' for miions of semi-iterate women. It estabishes connect with service provisioning and deivery-system. MIRA has two eve interfaces-one for individuas and ASHA workers-'mira-tookit Mode' for sef-management of heath. It is used by ASHAs/MIRAs to deiver weeky messages on diet, medication, dons and dons and captures weekyhigh-risk-pregnancies. Another mode 'MIRA-PHCConnect Mode' is used by ANMs to track Live-progress of pregnancies, High- Risk-Pregnancy-status, ANC-check-ups and immunization-foow-ups, weeky-activity-(ive) of beneficiaries and MIRAs. ANMs are provisioned with monitoring-tookit which provides timey action based on High Risk Pregnancy status, ANC check-ups, Immunization etc. Here, beneficiaries get connected with pubic heath service-system for basic heath services needs of pregnant-women, ensuring institutiona-deiveries and the newborn-care. MIRA patform provides muti-tier 'Live-Activity' dashboard for a hierarchica eves of pubic-heath-system. The system produces instantaneous 'Live-Data' for the state to take timey decisions and action. This dashboard is viewed by the state office on a minute-to-minute basis to review the status of women, ASHA activities, ANC check-ups, High Risk Pregnancies and ANM working. The state can then immediatey take action based on the status of the women and/or performance of ASHA and ANM. Apart from core toos, patform provides numerous Vaue Added Services (VAS) toosfor capacity buiding of rura women using story-teing and decision-making toos on critica heath issues, buiding sustainabe behaviour change. Impementation Mode We used both MIRA Tookit Mode and MIRA-PHC Connect Mode for impementation. In the beginning of the project, we recruited 100 MIRA workers in Mewat. MIRA Workers are Community Heath Workers 138

147 just ike the ASHA workers. They were trained to use the MIRA tookit which carried iconic information with ocaized audio support. Each MIRA was assigned a viage and they registered each and every househod in the viage, and aso identified pregnant women, chidren in the age group of 0-5 years for immunization and adoescent girs. MIRAs do a weeky visit and deiver iconic messages to pregnant women for that particuar week. It deivers 5 critica messages for that week of pregnancy - status of the women in that week, medication/tests required; dietary information of the week, dos and dons. Every week women is aso asked 5 questions reated to high-risk pregnancy. The information is then stored and sent over the coud which goes to the Midwife (ANM) through the ANM Tookit under the MIRA- PHC Connect Mode. ANM needs to take an immediate action based on the information received which is conveyed back to the MIRA to do necessary action as instructed by the ANM. MIRA mode recommends 40 visits during the whoe period of pregnancy. One of the atest studies done based on the 'Gateway Behaviour Theory', pregnant women who have been visited at east 12times during the tota period of her pregnancy (in MIRA program, one visit per week is mandatory and a MIRA is expected to be foow it), the women wi 98.7% wi deiver baby at the hospita and neither the mother nor the wi die at the time of the birth. MIRA aso operationaize through in individua MIRA Tookit Mode. It is being used under the Haryana Rura Heath mission with over 2,500 SHG groups. It has aso been impemented in schoos with adoescent girs on reated topics of Menstrua Hygiene, Adoescent Reproductive and Sexua Heath, Life-skis and WASH. Through Community Radio Stations (CRS) MIRA has been impemented in the interiors of Mewat. Community Outreach Dedicated Community Heath Workers ike ASHAs and MIRAs work with the communities, do the househod registration, identifies beneficiaries and make weeky visits to deiver information reated to pre-nata care, immunization, post-nata care, famiy panning and adoescent gir's heath. So the technoogy of MIRA and its workers are in direct connects with the communities on a day to day basis. Apart from the mobie tookit, MIRAs aso carry physica registers to register every activity being done. Apart from deivery of information, MIRAs aso motivate women go for ANC check-ups and opt for institutiona deiveries. MIRAs aso assist women at the time of ANC check-ups. Uniqueness of the Project a. MIRA is a hoistic channe which has moved away from away from the traditiona concept of an App. An App is a singe stand-aone appication for a very specific need. MIRA Channe is based on a channe approach with mutipe sub-channes ike Pre-nata care, Chid immunization, Newborn care, Famiy panning and Adoescent heath issues with an objective to improve materna and chid heath through RMNCH+A approach. The content system is dynamic where the new content gets downoaded on the mobie phones. It is one stop-channe for a the heath needs of women in rura areas. 139

148 b. The distinguishing innovation of MIRA Channe is its highy graphica icon-based interactive tookits, heath cacuators and trackers such as pregnancy week-by-week tracker, immunization tracker, menstrua cyce cacuator, famiy panning tracker and infection prevention tookit. Use of iconic messaging system throughout the channe enabes women with ow or no iteracy eves understand issues easiy and quicky. It aso has oca anguage audio support messages. The system works as a 'Taking Machine' but in ow-resource settings. No content of type has ever been made avaiabe on ow-resource phones with such interactivity, icons and audio. c. This tookit enabes the heath workers to provide consistent messaging and information to beneficiaries. Provisioning of messages through the mobie phones creates a eve of trust among the communities. The system aso brings in adequate amount of transparency in operations at various eves. d. The channe is deveoped in 3 modes to reach to as many peope as possibe. First mode, 'MIRA Individua App' is made avaiabe on mobie phones of the communities for their individua sefmanagement of heath. This mode aso has a faciity for mutipe registrations on a singe device, seeing the fact that not every woman in a rura area has a mobie phone. This concept comes from our experience of working with SHG groups where group eader had a mobie phone and acts as peer eader to supports other women. Second mode is a 'MIRA Worker' tookit content, communication and service provisioning. We have set up a chain of heath workers caed MIRA workers who go from house-to-house to do househod registrations and identify pregnant women and 0-5 year chidren for RI (routine immunization) using mobie phones. Third mode 'MIRA-PHC Connect' of works as a tota communication, information, management and service deivery system for Nationa Rura Heath Mission of the state. This tookit has two appications - one for ASHA workers and another for ANM. The pairing of ANM and ASHA heps in monitoring and timey deivery of services. e. The system produces instantaneous 'Live-Data' for the state to take timey decisions and action. This dashboard is viewed by the state office on a minute-to-minute basis to review the status of women, ASHA activities, ANC check-ups, High Risk Pregnancies and ANM working. The state can then immediatey take action based on the status of the women and/or performance of ASHA and ANM. f. MIRA channe aso has numerous vaue-added services (VAS toos) ike the stimuating socia mobie games, story-teing toos and decision-making stories which provide edutainment to women on socia heath issues. The story teing engine creates decision-making stories where the stories are presented as interactive decision-tree with different situations (decisions) to choose from. Each situation (decision) has its aternate course of action and sequence of story with its own possibe consequence. This enabes the user to see the consequence of their decision, thus incucating sustainabe behaviour change by observing correct and incorrect decisions. This is based on 'Sabido' methodoogy of entertainment-education which has shown a unique capacity for raising awareness among arge numbers of peope on critica heath issues and motivating audiences to adopt new behaviours. g. MIRA Channe is aso provisioned in different skins for different community members ike customized skins for various beneficiaries ike pregnant mother, adoescent girs and women seeking famiy panning services based on their needs. 140

149 h. MIRA Channe provides hoistic onestop channe to meet a the needs of rura women in India. The channe aso has non-heath content ike skis deveopment, vocationa training, and e n t r e p r e n e u r i a d e v e o p m e n t programs for rura women. Such programs ensure that when a woman d o e s n ' t n e e d a n y s e r v i c e s o r information reated to heathcare, she shoudn't eave the channe, and opt for other non-heath channes ike edutainment, skis etc. i. The arger socia objective of MIRA Channe is to aso make mobie phones women friendy, which is being achieved by provisioning serious and usefu content for women to manage their heath and ives. The biggest innovation is to create a mobie channe for rura women in ow resource settings. The goba objective of the channe is to improve the standard of iving of rura women across the gobe. Mobie content and technoogy has aways been 'gender-biased', which is deveoped by men for men. By creating a women's specific channe and provisioning usefu ifeine toos increases the uptake of mobie phones by women. There is a huge digita divide when it comes to women and mobie phones. In India aone out of 850 miion mobie, amost 520 miion mobie phones are owned by women and ony 330 miion mobie phones are owned by women, that is amost 37% ess women use mobie phones as compared to men. This divide is much arger in the rura areas. Launch of this channe create a movement for making gender-neutraizing phones. The impact is huge as it is changing the ives of rura women by improving their heath, increasing iteracy eves, providing iveihood opportunities and overa increasing the standard of iving. Roe of Information and Communication Technoogies (ICTs) Yes it has a universa backend system which interacts with DHIS-II. It has mutipe mobie tookits which support Java, Windows and Android. MIR aso has a robust dashboard which gives instantaneous 'Live- Data' for the state to take timey decisions and action. Chaenges Faced Some of the chaenges and its mitigation strategies are as foow: a. Being a mae dominated society, majority of the phones in the community are owned by men. One of the chaenges was to ensure that there is acceptance of this soution in the community and more 141

150 women use this. This was mitigated by engaging with the so caed "Infuencers" of the community and bringing in mae in the soution design. b. Deveopment and vaidation of contextuaized content for the communities was a chaenge. This was mitigated by conducting workshops and trainings with the communities to get appropriate content and reevant messages in oca anguages. c. Finding a right impementation partner is aways a chaenge. It is essentia to have ethicay correct partners to work with. This was mitigated by meeting as many partners as possibe, doing due diigence and aso meeting the network of Ashoka (Innovators for Pubic) finding ethicay correct organizations. d. Tying with the government and their buy-in is very important. We did piot programs and shared with the government success of the program to bring them on board/. e. Training arge number of CHWs is aways a chaenge. We trained initia set of CHWs as peer trainers (Training of the Trainers - ToTs) who in turn further trained more CHWs and community mobiizers for the program. f. There was a need to have a "change-in-the-process" reated to the impementation of the MIRA Channe. The number of visits made by the CHWs is 3-4 visits in 9 months of pregnancy. MIRA Channe provisions a weeky visit for a of the 40 weeks of pregnancy. One of the atest studies done based on the 'Gateway Behaviour Theory', pregnant women who have been visited at east 12times during the tota period of her pregnancy, the women wi deiver baby at the hospita and in in 98.7% cases neither the mother nor the wi die at the time of the birth. For additiona visits by CHWs, we have created an incentive mode to compensate the CHWs through sponsorships and by offering interactive content as Vaue Added Services (VAS) to the communities. g. MIRA is a hoistic channe based on RMNCH+A approach. As it is a growing channe which addresses critica needs, we don't want our vauabe beneficiaries to be eaving the channe after their needs ike pregnancy or chid immunization are over. For this, we use have created a digita VAS channe which provides decision-making stories, socia mobie games and capacity buiding interactive toos for other members of the community to keep hooked to MIRA Channe. This approach has a potentia to convert MIRA Channe into sustainabe revenue generation mode. h. One of the chaenges is to bring the government on board. We generate ot of data and reports from the MIRA Channe. The sharing of the data with the government and their acceptance is aways a chaenge. We have successfuy achieved this by providing access of 'Live-Dashboard' to the department 142

151 so that they can see ive data on a reguar basis which heps them in decision making and taking timey action. Outcomes MIRA is operationa in Mewat district of Haryana. IN ast 4 years MIRA has impacted 850,000 women, chidren and girs. It has been roed out through SHG Federations with 511,000 women. MIRA is aso distributed through tecos, re-charge kiosks, OEMs and CR stations to 106,000 women and girs. Through 67 schoos, we have reached to amost 20,000 girs. A set of dedicated 100 MIRA worked in 128 viages covering amost 144,000 peope. In the intervention area, there is an increase in ANC visits by 55%, institutiona deiveries by 49% and immunization rates by 41%. MIRA PHC connect mode has been pioted in the Haryana state with 47 ASHAs and 10 ANMs reaching to 69,000 women and chidren. Prompt action has been taken by ANMs in 84% of the High Risk Pregnancy (HRPs) queries raised by ASHAs. Live data produced by the patform enabes the state to take timey action. Outreach & Scaabiity MIRA Channe has scaed to Uganda and Afghanistan. Uganda MIRA project has been impemented in the district of Jinja in oca anguages - Lusoga and Luganda (Eastern Uganda). After the successfu piot, the government has request ZMQ to scae the program in 3 more districts of Uganda - namey Mbrara, Mbae and Kabaroe in the Western Uganda. There is a tak with the Ministry that successfu program in the 3 new districts may trigger its nationa adoption by Ministry of Heath Uganda. The Afghanistan MIRA project has been impemented in the Heart province in the western zone of Afghanistan (near the Iran border) in Dari anguage. There is a demand by the partner to repicate the mode in the Pashto speaking areas especiay Kabu and Ghazni. We are trying to reach out to partners to scae the program in Pashto region. The MIRA project bridges the gap in information, decision making and timey service deivery. The project proposes to adapt and test its India mode in Uganda and Afghanistan to improve MCH indicators there. With its operations in Uganda and Afghanistan, MIRA has reached to amost 66,000 popuations in Uganda and amost 43,000 popuation in Afghanistan indirecty. The number of women who have successfuy competed their pregnancies through MIRA has been 2900 in Uganda and 1700 in Afghanistan respectivey. Amost 4200 chidren for immunization and 6000 girs in Uganda; and 2700 chidren for immunization and 3500 adoescent girs have been reached in Afghanistan. In ast 18 months, in the area of project impementation, there has not been a singe materna death reported in Uganda and ony one materna death has been reported in Afghanistan. 143

152 With CSRs, we are aso taking MIRA Channe intervention in other states of India ike Karnataka and Odisha. We have created different modes and strategies for scaing MIRA in different areas and ocations. Some of them coud be: a. Technoogy Transfer; b. Technoogy Adaptation and Tweaking; c. Impementing MIRA on behaf of the donor, funder or support partners in their project region and in specific anguages; d. Buiding capacities of oca NGOs and grass-root organizations to impement MIRA in their specific region e. Coaborating with the government to impement with them f. Supporting the program externay as O&M partner (Operation and Maintenance), and assisting as technoogy partner. Repicabiity We have the foowing strategies used in phases to integrate projects in other ocations. Projects can have different points and may vary, not a the points beow are required for one project. a. Conducting Need Anaysis b. Contextuaizing content as per oca needs (anguage etc.) c. Technoogy adaptation d. Setting up Hierarchica mode for the program e. Initia buk data entry f. Recruiting teams g. Training and capacity buiding h. Ground impementation i. Setting up Dashboard and Reports j. Training the program team to ook into data k. Monitoring & Evauation Impact Achieved Overa the project has heped in improving the foowing indicators Afghanistan_MIRA 144

153 Increase in ANC visits by the pregnant mothers Increase in uptake of IFA tabets and TT vaccine Increase in institutiona deiveries Increase in institutiona deiveries Increase in identifying danger signs eary (just after the birth) Incucate heathy habits in communities eading to adopt heathy behaviours Consistent deivery of messages by MIRA eads to correct deivery of messages Deivery of information through technoogy toos more acceptabe to communities to adopt heathy behaviours Monitor the performance of Community Heath Workers Live-data generated through Dashboard heps state to take timey action, eading to poicy eve change in heath systems Overa resuting in reduction of MMRs and IMRs in the project Capacity Buiding The capacity buiding of the project can be categorized in 3 stages: a. Content Design and Anaysis: The content of MIRA has been created after doing a thorough research. Once the research was competed, the messages were to be converted into iconic-graphica messages. Then we conducted severa Focus Group Discussions (FGDs) with the communities to create ocaized graphics and icons which can easiy be understood by the communities especiay who are iiterate or semi-iterate. We trained the communities to deveop their ocaized icons which can be easiy understood by the peope. The same exercise we did in Afghanistan and Uganda where we trained communities to deveop ocaized contextua graphics and icons for easy understanding. b. Training and Capacity Buiding for Dissemination: Once the tookit is ready for depoyment, ZMQ trains Community Heath Workers (CHWs) and buid their capacities to use the MIRA tookit. They are trained for mutipe activities - using the tookit for content dissemination, registration of beneficiaries on the tookit, submitting the data, monitoring & report generation etc. The same process was adopted for teams in Uganda and Afghanistan. c. Transfer of Technoogy: If the program continues in any region or community, the oca teams which comprises of managers and coordinators are trained to become sef-sufficient to manage the MIRA and it different components. In 145

154 order to transfer the technoogy and buid the capacities of oca partners, we provide them ot of technica manuas and guides so that they can manage the system on their own. Partners of the Project There have been severa partners in the project. For government connection, we have Haryana Heath Mission; and Haryana Liveihood Mission. From technoogy support end, we have Vodafone Foundation, Airte (Uganda), Roshan Teecom (Afghanistan), Microsoft and Nokia. From donor's perspective, we have Miennium Aiance, USAID, UKAID& FICCI. From foreign impementation perspective, we have Heath Chid (Uganda), Afghan Institute of Learning (Afghanistan), RMS (Rwanda), Ministry of Heath Uganda and Department of Heath Herat. From dissemination perspective, we have SHG Federations Mewat and Community Radio Station Afaz-e-Mewat. Awards/Endorsements The project has received severa awards. Some of them are as foows: Ashoka Gobaizer Feowship 2018: MIRA as one of the most impactfu strategy for Materna & Chid Heath and Word's most exciting Socia Innovation. Winner of UNESCO-Pearson Initiative for Digita Literacy 2017 : MIRA Channe as one of the most impactfu digita strategy to tacke Materna and Chid Heath gobay. Winner of India Rwanda Innovation Growth Programme in 2017 instituted by FICCI and Department of Science & Technoogy, Government of India: MIRA as a Goba Strategy to tacke Materna and Chid Heath in Rwanda. Winner of Goba South eheath Observatory (ODESS) Award 2017 instituted by Fondation Pierre Fabre, France: MIRA as a Goba Strategy to tacke Materna and Chid Heath in the deveoping countries. Finaist of India Innovation Growth Programme 2.0 in 2017 instituted by Dept. of Science & Technoogy, Government of India, Lockheed Martin, Tata Trust and IIM, Ahmedabad: ZMQ's MIRA Channe. Finaist Socia Entrepreneur of the Year India 2016 instituted by Schwab Foundation and Word Economic Forum, Geneva, Switzerand: ZMQ's MIRA Channe. Winner of Business Action on Heath Award 2015 for Innovation /Technoogy to Improve Heath instituted by Goba Heath Counci and GBC Heath New York: ZMQ's MIRA Channe. Winner of Miennium Aiance Round 2 Award 2014 instituted by USAID, FICCI and Technoogy Deveopment Board (Ministry of Science & Technoogy, Government of India) for scae-up in Uganda and Afghanistan in 2015: Women Mobie Lifeine Channe as No.1 mheath Soution in India. 146

155 Yae Schoo of Management's Goba Socia Entrepreneurship Feow , New Haven, USA: Best 5 Socia Enterprises Winner of Mobie for Good Award 2013 by Vodafone Foundation and DEF: Women Mobie Lifeine Channe as No.1 mheath Soution in India. Winner of Miennium Aiance Award 2013 instituted by USAID, FICCI and Technoogy Deveopment Board (Ministry of Science & Technoogy, Government of India): MIRA Channe then Women Mobie Lifeine Channe as No.1 mheath Soution in India. MIRALiveDataPoster MIRA PHC connect mode 147

156 MIRA Live Data Poster 148

157 mmitra Project 2014 onwards ARMMAN Website : Founder of the Organization : Dr. Aparna Hegde Project Budget : Average Budget over the ast three years: ` 9,33,00,000 Coverage/ Geographica reach : 1.6 miion women reached across nine states. 149

158 Project Brief In India, the materna mortaity ratio (MMR) and infant mortaity ratio (IMR) is unacceptaby high at 167 and 40 respectivey. A woman dies in chidbirth every ten minutes in India. More than 300,000 infants do not ive beyond the first 24 hours after birth in India. A significant proportion of materna deaths and 50-70% of chid deaths are however preventabe. In addition, 38.4% and 46% chidren in India under the age of three are stunted and underweight respectivey (NFHS-3). About 6% of the chidren suffer from severe acute manutrition (SAM) and over haf a miion chidren die before their fifth birthday due to SAM. One contributing factor responsibe for these woefu numbers is the ack of access to basic preventive care information during pregnancy and chidhood. In order for behaviour change communication (BCC) to be effective, it must be timed and targeted to reach the right peope at the right time. Counseing can ead to behaviour change ony when the information is specific to the month of pregnancy or chidhood as we as cuturay specific and reinforced by repetition over a period of time in order to enabe the beneficiary to fuy accept the message. However, due to the overcrowding in hospitas and ack of training, motivation and incentivisation of heath workers to offer counseing, access to information is scarce. The high mobie phone penetration in India (over biion in 2016, ranked 2nd in the word) accords a strategic opportunity to provide timed and targeted crucia ifesaving information directy to women through their mobie phones in a gender-sensitive manner when they need it. A voice ca service is an easy to use technoogy even for iiterate end users as opposed to text messages. The service provides this information to women through easiy understood voice messages in a warm sistery voice, in a anguage that they understand, at a time when it is convenient. Thus these voice cas buid awareness, educate and empower women to achieve heathy outcomes for themseves and their infants. Aso, the enroment into the program through trained women eaders in the viages and hospitas ensures that the program foows a 'tech pus touch' mode. Whereby the program is introduced to the women through a friendy intermediary. The three tries for every message, missed ca system and ca center ensure deep engagement with the women. The customized manutrition add-on to the main mmitra program provides additiona focus on nutrition and is taiored to not just the age of the chid but aso the dietary preferences of the region. Aso the direct weeky/biweeky cas to the mothers of SAM chidren from trained ca center counseors ensures not just adherence to the treatment but aso proper rehabiitation in the next six months so that the chid again does not reapse. The mmitra cas target underserved pregnant women and mothers of chidren under age five, who reside in urban sums or rura India, are not highy educated and do not have ready access to heath care information. Impementation Mode The mmitra program began from a singe government hospita in Mumbai in 2013 and is now present across nine states. 150

159 This rapid scae up of services throughout Mumbai and other cities has been possibe through a successfu partnership with 16 Municipaities, 50+ hospitas, 32+ community based NGOs and Sakhis (heath friends) enroing women directy in the communities. The enroment of women in urban areas takes pace through two verticas: Hospita vertica - heath workers posted in the ANC/PNC cinics of government hospitas and maternity homes register women on to the program when they come for their first checkup visit and Community Vertica - ARMMAN has formed partnerships with community NGOs working in sum communities and have seected and trained women eaders in the sums as Sakhis (heath friends) who enro women directy from the sums in the eary stages of pregnancy for a sma incentive. In rura areas, women are enroed into the service by the government heath workers (ASHAs) in the viages. Uniqueness of the Project Features of the service: 1. Frequency of voice cas: Pretested, individuaized voice cas of seconds duration (145 voice messages in a) are sent through pregnancy and infancy with the foowing frequency: twice a week from the first month of pregnancy unti birth, once a day in the first seven days after birth, twice a week unti the infant is three months of age and once a week unti the infant is one year of age. 2. Three attempts are made for every message: once daiy for three days in the enroed woman's chosen timesot. If she misses a three attempts by the system, she can give a missed ca to our missed-ca system and the service wi ca her back immediatey with the message she has missed. 3. Timed & Targeted: Voice Cas are deivered to the mobie phone of the woman and specific to the gestationa age in a anguage of their choice. 4. Ca center: mmitra aso has a ca center that monitors the cas sent and aso enabes the enroed woman to inform the service regarding a change in her phone number, change in the preferred time sot, when she has deivered or if she has had an abortion/stibirth. The woman can give a missed ca to the ca center and the ca center personne wi ca her back within 24 hours to take the necessary detais. 5. Voice message creation: The messages were deveoped foowing a rigorous process. A preiminary study was first performed, foowed by message creation by ARMMAN and Baby Center aong with a group of experts drawn from nationa medica bodies. These were then focus-group tested amongst pregnant women and women with infants to determine their ease of understanding and whether the anguage and diction used was appropriate and if the content addressed their perceived needs. 151

160 The voice messages were then vaidated by experts FOGSI (The Federation of Obstetric and Gynecoogica Societies of India) and NNF (Nationa Neonatoogy Forum). Roe of Information and Communication Technoogies (ICTs) mmitra voice cas are stored on an in-house voice patform and sent to women using an agorithm that assigns the correct message for the right week through a third party aggregator, IMI Mobie. Information on the preferred time to make the ca and the pregnant woman's phone number gathered during registration and is accessed from the database for sending cas as per the agorithm. In case of missed cas, the agorithm is designed to make repeat ca three times in the next consecutive days. To send automated cas, our patform is connected to the API of a third party aggregator who sends simutaneous cas to the registered women. The caing system uses Primary Rate Interface (PRI), the most robust system that aows for the simutaneous transmission of voice and data over pubic teephone networks. The centra system has been buit using an open source software bunde known as LAMP (Linux, Apache, MySQL, and PHP). Our system thus consists of the Linux operating system, an Apache HTTP server, a MySQL database, and the PHP scripting anguage necessary for web deveopment. Tabeau software enabes rea-time monitoring of the number of cas sent, missed, dropped or cut short, ength of cas heard and number of missed cas to the system. The QA/QC division on the other hand is responsibe for the overa monitoring of the entire Technica Patform which incudes the Ca Centre monitoring as we as ensuring that the service is robust. Chaenges Faced Setup of a technoogy patform for rea-time monitoring: When ARMMAN was impemented, there was no avaiabiity of a software that wi enabe rea-time monitoring and updates. Since the ca voume was extremey high due to a rapid scae-up, the ack of a technoogy patform was proving to be a hurde. ARMMAN engaged a technoogy partner to design a customized patform for effective monitoring. This heped us monitor detais ike the percentage of cas being received, the average duration for a women istens to a ca and so on. Cas getting missed due to DND (Do Not Disturb) activation: The software put in pace highighted the fact that any cas were not going through because the number had DND activated. To resove this issue, a separate hepine number has been instituted. Women who wish to avai mmitra voice ca service give a missed ca on this number and this is taken as an ectronic consent to receive mmitra cas. In parae, a diaogue has been initiated with the Teecom Reguatory Authority of India (TRAI) to exempt mmitra from DND. 152

161 Outreach & Scaabiity ARMMAN's five-year expansion pan for mmitra incudes enroing 2.2 miion women in ten major tier I and tier II cities and spreading across rura areas in five states. These rura ocations and tier I and tier II cities have been seected on the basis of proportion of underserved popuation and poor materna and chid heath indicators. Tier 1 cities have been seected owing to their arge migrant and sum popuations. Tier II cities and rura ocations are chosen from a ist of 100 cities/districts with the worst MMR and IMR statistics. We have managed to achieve economies of scae through efficient management of the program and the distribution strategy: per beneficiary cost for sending voice cas through pregnancy and infancy (145 voice cas) in the genera mmitra program is ony Rs 350 (approximatey 5). Addition of the customized manutrition program (additiona voice cas ti the chid is five years of age and handhoding of mothers with SAM chidren for 8 months of the manutrition treatment and rehabiitation process) increases the cost per woman by ony Rs 100 ( 1.5/-) as most of the costs of enroment and maintenance of the tech program are absorbed within the primary mmitra program. Economics of scae wi itsef ensure sustainabiity as cost per beneficiary reduces as the ca voumes rise. Further, we intend to everage teecom service providers' CSR programs to ower ca costs. We hope to deepen our engagement with the state governments so that enroments can be done through government heath workers (ASHA and Anganwadi workers) eading to cost reductions. We aso pan to diversify the donor base and become a mode exampe of private-pubic partnership so that different corporate donors can be responsibe for particuar cities, reducing per-donor costs. Our decentraized hub and spoke mode with four regiona hubs (north, south, east and west with the head office in Mumbai) wi aso hep to keep costs per hub ow. Individua hubs wi be responsibe for program management and fundraising. We are aso running a piot project in Hubi (Karnataka) where the women are charged party for the service. We have been abe to enro 650 women for the paid service so far. Going forward we wi be ooking at retai sponsorships, a midde cass service (cross-subsidy mode) and 'Sponsor a Mother for mmitra' as ways to make the program sef- sufficient. 153

162 Repicabiity mmitra everages technoogy for deivery of voice cas and to measure the success rate. It can be easiy offered as an integrated part of other MCH services. Impact Achieved ARMMAN conducted a three-year Randomized Custer tria, funded by UKAID, in 250 viages in Osmanabad, Soapur and Washim districts of rura Maharashtra, from January 2013 unti December 2015, in which one of the tested interventions was mmitra. In addition to voice cas, the intervention incuded eight animation videos coded onto the phones of heath workers to invove the famiy in the care of the woman and chid. End-of-pregnancy impact: a. 36% increase in the proportion of women who knew the importance of taking 100 days of IFA (iron foic acid) tabets during pregnancy (p < 0.05) b % increase in the number of pregnant women who took IFA (iron foic acid) tabets for 100 days (p < 0.05) c % increase in the proportion of women who knew at east three methods of famiy panning (p < 0.05) d % increase in the proportion of women who knew that consistent condom use can reduce chances of contracting HIV/AIDS (p < 0.05) e % of the enroed women received 70% of the voice messages and were satisfied with the content End-ine survey (conducted at the end of infancy) impact: a % increase in the proportion of infants who received ORS for an episode of diarrhoea (p < 0.05) b % increase in the proportion of infants who were excusivey breastfed (p < 0.05) c. 43.4% increase in the proportion of infants who had their weight checked at east thrice in infancy (p < 0.05) d. 13.5% increase in the proportion of infants who triped their birth weight at the end of one year (p < 0.05) Some findings pubished in the Indian Journa and Materna and Chid Heath can be accessed here: pty2gub3jnfhd3d3xnedoxywi xzmu3otaymtbmnzcw Resuts of an end-of-pregnancy midine survey conducted among mmitra beneficiaries at an urban tertiary care center (Sion Hospita) in Mumbai indicate that mmitra voice cas (without animations) have impact: 154

163 a. 96% of women sought treatment for compications during pregnancy as opposed to ony 72% of women in the baseine study (p < 0.05). b. Ony 9% of women suffered from pregnancy-reated compications in the midine survey as opposed to 38% in the baseine study (p < 0.05) c. 27% of women in the midine survey knew that IFA suppementation needs to be taken for 100 days as opposed to ony 0.5% women in the baseine (p < 0.01). d. 83% of women were aware of the period of excusive breastfeeding as compared to 66% during the baseine study (p < 0.01) e. 91% of women were aware of the importance of giving coostrum to the baby in the midine survey as opposed to 72% in the baseine (p < 0.01) f. 88% of women in the midine survey were aware of the harmfu effects of pre-actea feeds as opposed to ony 41.35% in the baseine study. g. Amost 97% of women were aware about the importance of immunization during pregnancy upon foow-up compared to the 61% at baseine (p < 0.01). h. About 93% of respondents were aware about immunization schedues during infancy during the foow-up compared to 71% at baseine (p < 0.01). I. Amost a the respondents were satisfied with the voice messages (99%), information received in voice messages (99%), quaity of the voice cas (99%) message ength (98%), anguage (99%), frequency (97%), timeiness (95%) and reevance of the information (95%) provided. Focus group discussions conducted through the 'Impact of mmitra Voice Ca Service on Women's Invovement in Heath Care Decision Making' study in Mumbai indicate high eves of satisfaction with voice cas. 155

164 Capacity buiding Reguar training of heath workers at NGOs and other project staff are conducted for a successfu impementation. Partners of the Project The mmitra cas were created by ARMMAN and Baby Center and vaidated by FOGSI and NNF. Other partners incude, but are not imited to, Dasra, Johnson & Johnson, JSW, Aditya Bira Financia Services; Genmark; Tata Trusts; MCGM - Municipa Corporation of Greater Mumbai and Inscripts Technoogy Private Limited, SBI. ARMMAN has partnered with more than 40 NGO partners to impement its programs across the country. Awards/Endorsements ARMMAN won the WHO 'Pubic Heath Champion' 2017 award in the Innovation Category. ARMMAN received Zee Media's Transform India 2017 award. mmitra won the GSK-Save the Chidren Heath Innovation Award mmitra was one of the four awardees in the word and the first Indian NGO to receive this award out of 170 appicants from 40 countries. mmitra won the Siver award for the Best Use of Mobie for Socia & Economic Deveopment at the Indian Digita Awards 2017 by IAMAI forum. mmitra was a finaist at Vodafone Foundation's 'Mobie for Good Awards 2015'. mmitra won the Peope's Choice Award at Saving Lives At Birth event in 2011 organised by USAID, Bi and Meinda Gates Foundation, Word Bank, Government of Norway and Grand Chaenges, Canada. ARMMAN received the Best NGO of the year Award for the year 2016 by Genmark Foundation 156

165 Supportive Community monitoring MNCH- Sukshema Technica assistance to improve materna, neonata and chid heath outcomes through the Nationa Rura Heath Mission in Karnataka, India Karnataka Heath Promotion Trust (KHPT) Website : Founder of the Organization : Mr. Mohan H L, Managing Trustee Project Budget : ` 34,34,26, Coverage/ Geographica reach : 8 high priority districts of northern Karnataka- Koppa, Bagakote, Kaaburgi, Baari, Bidar, Raichur, Yadgir & Vijayapura 157

166 Project Brief The disparities between northern and southern Karnataka districts with respect to accessibiity, quaity and coverage of critica materna, neonata and chid heath (MNCH) services affected state eve progress. Particuary, the frontine workers acked skis, toos and support systems to reach out, communicate effectivey and ink target groups to care across materna and chid care continuum. The focus on most vunerabe popuation groups was missing on the ground. The faciities faied to estabish credibiity due to the poor quaity of care and referra inkages with higher systems. Heaviy dependent on trainings aone for quaity improvement, there was a need to do much more to acceerate provider preparedness and faciity readiness to render cient centric care and quaity. Lack of ownership and community eve accountabiity on MNCH issues affected utiization and coverage. The heath systems faced chaenges to coect, coate popuation eve data and use it effectivey for program panning on a rea time basis. KHPT through a Bi and Meinda Gates Foundation/ University of Manitoba funded technica assistance grant principay worked with two stakehoders i.e. Government of Karnataka on the systems deivery side and communities/ famiies on the demand side to bridge the inequities that existed during The project upon scaing up across the region, covered about 212,000 pregnant women annuay through frontine workers, /7 PHCs and 16 FRUs during the years Impementation Mode Project impementation mode: Leves of change Heath Systems (Distribution of functiona faciities, staff, equipments, drugs, suppies, incentives) Faciity (Primary Heath Centers) Community (Frontine workers, Viage Heath and Sanitation Committees, Arogya Raksha Samitis) Objectives of change Process of change Prioritize technica interventions and soution evers Piot/ fied test technica interventions and soutions Diffuse/ scae up innovations from piot areas to rest of the project districts Knowedge Transation Karnataka India Knowedge transation through the estabishment of earning sites, knowedge products, sharing forums, and technica assistance mechanisms 158

167 The project mode incuded interventions at the foowing eves Faciity eve to enabe improvement in the quaity of MNCH services for rura popuations through onsite mentoring. Community eve to enabe expanded utiization and popuation coverage of critica MNCH services for rura popuations through strengthening Frontine workers (FLWs) and Community structures Heath system eve to enabe expanded avaiabiity and accessibiity of critica MNCH interventions for rura popuations. The guiding approach of the project mode focussed on continuum of care i.e. antenata, intrapartum, and postpartum period and ti the infant attained an age of 12 months. Since most of the deaths occur during deivery and the 48 hours to 1 week after birth, priority was given to have interventions during this period. At the faciity eve, the key objective was to improve the quaity of care during deivery and immediate postpartum period. Onsite mentoring was impemented using a dedicated cadre of nurse mentors heped to improve provider preparedness and faciity readiness around critica MNCH services. Sef assessment toos heped staff identify gaps in faciity systems and deveop action pans. Cinica mentoring was provided with the hep of simpified case sheets as job aids, ski stations, case vignettes, audio-videos, etc. Bed side coaching, hands on support and teephonic mentoring heped to improve confidence of staff in managing compications. In addition, the emergency dris, quaity improvement committees, additiona support by speciaist mentors from oca medica coeges heped to improve care in the first referra units. At the community eve, the focus was to strengthen the frontine heath workers and community structures to improve management and deivery of outreach services. The project did this through providing simpe job aids and processes that heped the ASAH workers enhance their outreach panning for providing services, quaity of interaction with the beneficiaries and cross departmenta coordination with other FLWs ike the Anganwadi worker and Junior Heath Assistant (JHA). At the community eve, efforts were made to enhance community accountabiity, participation and ownership. The provision of simpe toos and processes to support the community structures ike Viage heath Sanitation and Nutrition Committee (VHSNCs) improved their engagement in heath deivery and monitoring of heath services. At the heath system eve, the project worked cosey with the state's heath department to capacitate government staff to infuence poicy and program panning. It worked towards strengthening data management and use, particuary the Heath Management Information System (HMIS) and the Mother and Chid Tracking System (MCTS). Community Outreach Through forma agreement with the state's NHM and support of the eadership within the heath department, the project was abe to cosey engage with a the front ine heath workers. A series of consutations were hed with frontine heath workers ike the ASHAs, Anganwadi workers, Junior Heath Assistants (JHAs), community representatives and faciity staff to understand their chaenges in 159

168 the fied and evove joint soutions with them to effectivey address the gaps. The toos and processes deveoped for the project is a resut of consutative discussions with the front ine workers. The project reached out to the communities (pregnant women and actating mothers and their famiy members) ony through the existing front ine heath workers within the system. The community eve activities focused on buiding perspective, skis and capacities of the FLWs, increase coordination and coaboration on the ground, improving the effectiveness of outreach through easy to use panning and tracking toos. Our processes for community engagement was based on the beief that confident, motivated and skied FLWs woud be abe to reach the unreached and deiver the fu package of MNCH services across the care continuum to the communities. Uniqueness of the Project A unique aspect of the project was that our intervention package were both pioted and demonstrated at scae. The piot itsef invoved two districts of North Karnataka and the scae up covered 8 districts of north Karnataka. Some innovative toos deveoped at the community eve incude: The ASHA DIARY toos deveoped for frontine workers were: v fuy ASHA centric and simpe to use v abe to repace 13 registers used by ASHAs significanty simpifying her work v not ony reporting but panning and refection toos. ASHA has never been exposed to a panning and a refection process before. Pictoria ASHA reminder cards and Home visit checkist Birth Preparedness caendar for Beneficiary The community eve interventions worked on setting a strong foundation by addressing attitudes and perspectives around gender, caste and other structura aspects of MNCH. The Three sisters concept and the AROGYA MANTAP for the first time brought functionaries from three Departments together (from the President/ member of Panchayat, Anganwadi worker from the department of Women and Chid Deveopment and JHA and ASHA from the Heath Departments) The Supportive community monitoring processes (SCM) was activated through VHSNCs using simpe visua too caed the Supportive Community Monitoring Too (SCMT) which coud be used by iiterates and heped create engagement. This enhanced community accountabiity. Innovation at the faciity eve: n Nurse Mentoring Intervention: For the first time, Quaity was ooked at very hoisticay and comprehensivey invoving the provider, the cient and the systems. 160

169 The quaity Assurance systems were imiting and instructive in nature but the nurse mentoring intervention brought in eements of sef-assessment, joint review and joint probem soving This intervention too was demonstrated and pioted at scae Cinica mentoring, generay is impemented ony at arge faciities but we were abe to impement this quaity assurance mode right from the most basic faciity set up ike the PHC and aso at arger faciities ike the district hospitas. n Case sheet: A simpified case sheet that integrates safe birth checkist and bed head ticket which has been tested in the faciities and found to be effective in screening and management of compications was used to hep the PHC staff. Roe of Information and Communication Technoogies (ICTs) Concurrent monitoring of the program was undertaken through reguar observationa surveys, where mobie technoogy for data coection was used. This heped the program to receive quick feedback to modify the fied strategies. Chaenges Faced Buiding confidence among the officias and staff of the department of Heath and Famiy Wefare both at the state & district eve was chaenge. We offered our expertise in data use and management which Famiy focussed communication by ASHA at home 161

170 the officias needed for program panning. The project staff started giving reguar feedback to a the heath faciities on HMIS & MCTS. This in turn heped in buiding rapport and confidence with a eves of officias and fied eve staff. Series of consutations were hed with the department staff and community representatives to discuss upon the fied chaenges and evove with soutions. The staff of the department were getting frustrated and discouraged due to issues ike overburden of work, ack of appreciation and recognition of their work. Hence project staff started giving recognition and appreciation of efforts of the department staff to prevent them from getting frustrated, discouraged and tired of their work. This heped them to deiver quaity services both at the faciity and community eve. Project had adopted peer ed approach took time to estabish itsef in a strongy hierarchica set-up which has been, unti now, used to a supervisory approach rather than a supportive one. Eiciting support for impementation from the department and the panchayat needed continuous effort and engagement. There was ack of trust, cooperation, coordination among the heath department staff and Panchayath Raj. There was monitoring approach than the supportive monitoring of the heath by the community structures (VHSNC, Arogya Raksha Samithi ).Project had focussed on convergence of Heath and Famiy Wefare, Department of Women and Chid Deveopment and Panchayath Raj through strengthening community structures. This heped them to address many system and community eve chaenges ocay. Outcomes Outputs: Basic case sheet uptake increased from 36.4 % to 86.9% of tota arrivas and compications sheet uptake increased from 15.4% to 71% of tota compications. Documentation of critica materna and neonata care significanty improved as seen by better hemogobin testing (39.5% vs. 33.3%), AMTSL (99.2% vs. 96.2%), Vitamin K administration (80.2% vs. 66.6%), diagnosis of proonged and obstructed abour using Partograph (65.7% vs. 40.0%), recording BP and administration of antihypertensive in severe PIH/ preecampsia/ ecampsia (53.8% vs. 36.5%). The women who were isted in ASHA diary shown the chance of having received continuum of care (i.e. 3 or more times Antenata check- up, institutiona deivery, 48 hours stay post -deivery, and PNC visits by ASHA ) was more by 4.6 times by the women who were not isted in ASHA diary. Outcomes: An externa evauation through baseine (2013) and end-ine surveys (2016) indicated one of the fastest decine in mortaity rates: Neonata mortaity rate reduced from 40.8 to 30.4; Infant mortaity rate from 162

171 53.5 to 43.5; Institutiona deivery rates moved up from 69% to 78%; FHR monitoring (on arriva), 39 to 67%; Materna BP monitoring (post-deivery), 34 to 64%; Weighing of the newborn, 33 to 70%; Cean cord care, 30 to 63%. Reach: The project reached 212,000 pregnant women annuay through frontine workers, x 7 PHCs and 16 FRUs, 1150 Staff Nurses, during the years Outreach & Scaabiity Right from the inception of the project, sustainabiity was configured. KHPT entered into an MoU with the NRHM at the inception stage of the project ceary articuating the areas of focus, approaches, specific gap areas and the testing component of the project. At every critica stage of the project, high eve consutations were hed invoving the Mission Director and key officias from the Department at state and district eves to ensure joint decisions and continuous buy in from the State. District eve staff of the project were co-ocated within the Department office embedded within the Government teams. A program toos and processes were jointy conceptuaized with the end users ike the ASHA workers, staff nurses as we as the beneficiaries. Nurse mentoring concept has been incorporated in the state NHM quaity care guideines. ASHA Dairy and Viage Heath Sanitation and Nutrition Committee (VHSNC) toos has been adopted by the state government for a districts. The program was abe to make sustainabe contribution to the existing program by forming a strong District Resource Persons (DRP) team. This was done by identifying and training the best performing ASHAs, ASHA Faciitators and Femae Junior Heath Assistants (JHA-F) to impement the programs through intensive perspective buiding and handhoding We supported the NHM to conduct a Nationa eve Dissemination and Learning workshop to share the findings and the innovation of the project for a wide spectrum of audience invoving the representatives from different state governments. Repicabiity In the first year the project was pioted in two districts and then scaed up to other six high priority districts. The toos and interventions were adopted by the state. NGOs were invoved to sustain the community eve interventions. The quaity improvement processes were integrated into the state quaity assurance systems. Beyond the state, the interventions were repicated in Uttar Pradesh; they aso informed MNCH programs in Bihar, Rajasthan, Teangana and outside of India (Kenya). 163

172 Onsite mentoring Impact Achieved An externa evauation through baseine (2013) and end-ine surveys (2016) indicated one of the fastest decine in mortaity rates: Neonata mortaity rate reduced from 40.8 to 30.4; Infant mortaity rate from 53.5 to 43.5; Institutiona deivery rates moved up from 69% to 78%; FHR monitoring (on arriva), 39 to 67%; Materna BP monitoring (post-deivery), 34 to 64%; Weighing of the newborn, 33 to 70%; Cean cord care, 30 to 63%. The impact can be attributed to a comprehensive program scientificay designed addressing gaps at a eves and impemented through the eadership of the skied and motivated front ine heath workers from within the existing heath system structures. Capacity Buiding To impement the community interventions project formed the District Resource Person (DRP) team by identifying and training the best performing ASHAs, ASHA Faciitators and Femae Junior Heath Assistants (JHA-F). These DRPs underwent an in depth perspective buiding training and were provided 164

173 with cose handhoding support in the fied by project staff. The DRPs ed the trainings of FLWs and community structures and provided handhoding support to them to use the toos and processes. To impement the faciity eve interventions, the project recruitednurse mentors. These nurse mentors underwent 5 weeks of comprehensive training at St. Johns Medica coege and hospita, Bangaore on cinica, mentoring, communication and probem soving skis. These nurse mentors visited the faciity and worked with faciity staff to identify gaps and soutions using sef -assessment checkist. They taught staff nurses about cinica topics through demonstrations and hands on experience to manage materna and newborn compications, partograph to diagnose proonged and obstructed abour etc. Project had recruited District Monitoring & Evauation Speciaist to work with the district and bock eve officers of the department to hep them to do data anaysis and use of data in program panning. Eventuay Government recruited district and bock eve M & E managers. These M& E managers were trained by the project on doing quaity checks, data anaysis and use of data in program panning at a eves of faciities. Partners of the Project The project worked in cose coaboration with the foowing partners: St. John's Medica Coege was invoved to train the project's nurse mentors on cinica aspects, mentoring skis and heath system probem soving. Karuna Trust supported the advocacy initiatives of the project with the government departments at the district eve. University of Manitoba was the ead technica partner IntraHeath supported the documentation initiatives of the project. Nationa Heath Mission, Government of Karnataka provided overa guidance to impement the project in northern Karnataka. Awards/Endorsements The project received the Nationa eve Impact award in August 2017 by Sambodi for deepy impacting the ives of communities through exceence in program impementation and innovations under the Pubic heath category. 165

174 Muti-Sectora Initiative for strengthening Convergent Actions for Nutrition, Education, and Chid Protection in Mada district, West Benga January, December, 2018 Chid in Need Institute Website : Founder of the Organization : Dr. S.N. Chaudhuri Project Budget : ` 1, 40, Coverage/ Geographica reach : 65 Gram panchats (GPs) and 2577 Anganwadi Centres spread across six bocks (Kaichak III, Gazoe, Ratua I, Harishchandrapur I, Chancha I and Habibpur) of Mada district, West Benga 166

175 Project Brief The project tited Mutisectora Initiatives for Strengthening Convergent Actions for Nutrition, Education and Chid Protection was undertaken in six high priority bocks of Mada district in West Benga (India) during It was steered by a partnership between the District Administration (Mada), UNICEF West Benga Office and Chid in Need Institute (CINI). The project aimed to enhance impementation of fagship programmes and missions (particuary ICDS, RMNCH+A, SSM and ICPS) with an emphasis on convergent actions for empowering communities regarding their rights and entitements to demand and access government services and promote service deivery, improved coordination, decentraized joint panning, monitoring and feedback mechanisms. Intervention specific to combating the intergenerationa cyce of Manutrition: The RMNCH+ strategy positions nutrition as a critica underying and intersectora eement essentia for reaising the continuum of care across the ife cyce. The interventions incuded working with pregnant and actating women, promoting Infant and Young Chid Feeding and hygiene practices and supporting responsive actions for community based management of manourished chidren. Biannua VAS and de-worming rounds as we as IFA suppementation (NIPI) for chidren were supported. Adoescent girs constituted another key target group. Efforts focused on enhancing their awareness of nutrition reated issues and services. This was situated within a broader emphasis on promoting adoescent participation and empowerment. The objectives of the project for management of chid manutrition with active engagement of communities and community based institutions are as foows: Increase avaiabiity and accessibiity of key materna, chid and adoescent nutrition services through convergent actions at different eves 167

176 Enhance capacities and capabiities of service providers and community based institutions for empowering famiies about their rights and entitements on government services Advocate with government and deveopment partners to scae up mutisectora evidence-based practices of nutrition programmes Impementation Mode The project design was buit on the principes of faciitation, systemic strengthening, improving governance and ensuring transparency and accountabiity to the oca communities. It was conceptuaised in keeping with the district pan of action priorities. It essentiay sought to enhance impementation of fagship programmes and missions (particuary ICDS and RMNCH+A) with an emphasis on convergent actions. It prioritised identifying and bridging of gaps in awareness and resources; decentraised panning, action and review and demonstrating evidence based good practices/modes that coud be repicated. CINI faciitated at mutipe eves with the intention of enhancing access to services, promoting community ownership and strengthening convergent patforms from the viage to the district eve. It aso undertook evidence based periodic reviews and feedback processes. Community Outreach The foowing processes were undertaken to achieve the project objectives. Periodic understanding of quaity service deivery and coverage- A nutrition monitoring tookit was deveoped to enhance understanding and action on critica issues and barriers that impacted nutritiona service deivery and coverage. The checkists were fied by project team members based on observation; inputs from the AWWs, ANMs, ASHAs and existing records. The data from these checkists heped identify gaps and barriers which were shared for discussion and action at mutipe patforms - Fourth Saturday Meetings (GP eve), Third Saturday Meetings (sub centre eve) and Bock Convergence Meetings (bock eve). Behavior change communication drive: BCC aids were used in community meetings, feeding demonstrations and other awareness activities. Feeding Demonstration and Counseing Sessions constituted a key component for enhancing IYCF and hygiene practices and community based management of manourished chidren. Enhancing Capacities of ICDS and heath personne: Capacity buiding activities spanned the spectrum of structured trainings, handhoding support and providing other specific inputs as needed to ICDS and heath functionaries in the six project bocks. The ICDS Supervisors, supported by project team members, faciitated joint orientations for AWWs and ASHAs to equip them for conducting the AWC based sessions and foow up activities. These orientations aso heped situate the proposed sessions within the broader purpose of promoting IYCF and hygiene practices for combating chidhood manutrition. Bock eve trainings of AWWs and ASHAs on a gamut of issues regarding intergenerationa cyce of manutrition were aso undertaken. Further, a district eve Refresher TOT was designed based on a Training Needs Assessment exercise. The Refresher ToT enabed the participants to discuss fied eve concerns, seek carifications and aso expore means of enhancing coective actions further. 168

177 Overa, 1246 AWWs, and 667 ASHAs were covered through the trainings. The training inputs were backed with handhoding support. This incuded an emphasis on coectivey strengthening the monthy VHNDs to maximise coverage of services. Aspects identified from the periodic gap anaysis were utiised to provide supportive inputs to enhance service deivery. Promoting Community Awareness and Access: Existing patforms, particuary meetings with pregnant and actating women at the AWCs during NHED, were used to deepen the diaogue on materna and chid nutrition reated issues and services. Registration of pregnant women within the first trimester of pregnancy, importance of antenata care and accessing reated services were consistenty stressed. The importance of consuming IFA and Cacium tabets was outined. The need for adequate weight gain during pregnancy was highighted using the MCP cards. The fourth ANC, in particuar, was promoted incuding its ink in encouraging institutiona deivery. Overa, pregnant and actating women were reached through the community eve meetings. Nutrition Week, Breastfeeding Week, and socia events were commemorated as we. Strengthening Micronutrient Suppementation for Chidren: The project supported micro-panning process for the bi-annua VAS and de-worming rounds and IFA under the Nationa Iron Pus (NIPI) initiative. The status on indenting, suppy and coverage was coated through the checkists. The data was used to understand the gaps and bottenecks and drive diaogue and reated actions. The gaps were discussed at the bock convergence meeting and monitoring and foow up was stepped up. Stepping up for severey manourished chidren: The project team members supported discussions on status of SM and MM chidren among ICDS and heath functionaries. They encouraged the personne to review the data on SM chidren shared by the DIO-NIC and ensure that there were no discrepancies with 169

178 their interna records. They shared the procedura aspects reated to admission, stay and foow up for chidren at the two NRCs operationa in Mada with AWWs and ASHAs. The team members aso disseminated information about the NRCs at the convergent meeting at different eves These discussions and combined efforts of the frontine workers heped in sending severey manourished chidren from the project bocks to the NRCs. Working with Adoescents: Trainings of adoescent girs (particuary Sakhis and Saheis under the SABLA scheme) were organised. ICDS Supervisors, AWWs and project team members faciitated the trainings that covered 2015 girs across six bocks in the district. Nutrition reated issues and services were stressed. A tookit was aso provided. It incuded a notebook (Ami Kishori) with key messages on nutrition and chid protection and a Frequenty Asked Questions (FAQ) booket on these topics. These aids faciitated reca and articuation of the key messages. Uniqueness of the Project Community ed process for care of manourished chidren: AWC based 12 day feeding demonstration and counseing sessions constituted a key activity to promote infant and young chid feeding practices and encourage community based care of moderatey and severey manourished chidren without medica compications. The current practices of compementary feeding were identified through participatory earning action. The existing recipes given to young chidren were modified adding the ocay avaiabe nutritious foods (oi, seasona green eafy vegetabes, red/yeow vegetabes, puses, seasona fruits, dairy, eggs and iodized sat) to make it more caorie dense with micro-nutrients rich. Each day, ow cost age appropriate recipes prepared from famiy food baskets by the mothers and served to underweight chidren. The AWWs and ASHAs jointy discussed a range of key topics reated to infant and young chid feeding practices and persona hygiene with the mothers and other caregivers using message cards. By October 2017, 1225 sessions had been hed covering 7657 chidren across the six bocks of Mada district. Of this number, 5700 chidren were tracked up to 90 days with reassuring resuts with their graduation to suppementary feeding and reguar growth monitoring at AWCs. Weight oss was noted for 6% of the chidren after 30 days and 6.7% at 90 days. The reasons for the weight oss incuded frequent episodes of iness, ack of hygiene and the growing practice of giving chidren fast food. In some cases, the mothers had conceived again and were hence unabe to take care due care of the chidren Roe of Information and Communication Technoogies (ICTs) A robust monitoring system was deveoped for this project based on the existing district monitoring system to measure the effectiveness of convergent actions at a eves for improved materna, chid and adoescent nutrition. Data on progress against the indicators was reported from bottom to top initiating from community eve to district eve. At each eve, data was reported by bottom ine was anayzed and coated for feedback at upper eve. To make the monitoring system user friendy, a web based MIS was deveoped in new technoogy environment having good performance to gather data of 1020 AWCs, 4080 Househod, 408 Sub- Centers, and 204 VHNDs for the project period with faciity of master entry and reporting modue. The Reports was generated in such a manner so that mutidimensiona data coud be obtained and fitted in different sections of the MIS. 170

179 Chaenges Faced At the community eve: 1. The bock wise variations for fu antenata care and IFA consumption by pregnant women represent aspects that needed more attention. Awareness and uptake of cacium tabets among pregnant and actating women was aso found to be extremey uneven. Whie systemic issues possiby contributed to the scenario, more awareness activities highighting the need and benefits of these services were possiby required. Moreover, the continuing hod of deep seated patriarcha and gendered norms wherein women do not prioritise their own heath and nutrition needs and access to services coud aso be at pay. 2. Compementary feeding among chidren represented another key area for improvement. The growing and indiscriminate tendency, within famiies, to feed chidren biscuits and fast food items were pointed out by severa frontine workers as one of the key reasons endangering the nutritiona status of infants. Messages on quantity, quaity and frequency of food items were yet to percoate to a famiies equay. Use of ocay avaiabe nutritious snack items, to promote diversity and as aternatives to fast food, remained uneven. Lack of persona hygiene, for mothers/caregivers and other famiy members as we as chidren, aso continued to impair nutritiona status of chidren. The reated messages needed to be emphasised more. At the systemic eve: 1. Lack of consistent suppy of IFA and Cacium impacted uptake by pregnant women. This aso created situations where the avaiabe suppy was prioritised to meet the needs of pregnant women and the actating women then had to be eft out (this happened in case of Cacium tabets) or where the suppy was distributed among them in a manner that none got the requisite amount. Suppy issues aso pagued avaiabiity of IFA and suppementary food for adoescent girs at the AWCs and contributed to a scenario where outcome indicators for adoescent nutrition were compromised. 2. AWCs which operated from rented areas did not aways have sufficient space to undertake a the mandated services effectivey. There were shortfas in human resources as we. Outcomes The inputs and processes narrated beow ed to change at the outcome and impact eve comparison with first quarter and end quarter project monitoring data as we as comparison with NFHS4/DLHS 4 data of Mada depicted in the tabe. Impact eve Indicators for Materna and Chid Nutrition Impact eve Indicators First quarter Last quarter NFHS-4 Madah/DLHS-4 Percentage of under five chidren who are underweight (weight for age) 171

180 Outcome Leve Indicators for Materna Nutrition Outcome Indicators First quarter Last quarter NFHS-4 Madah/DLHS-4 Mothers who had antenata check-up in the first trimester (%) Mothers who had at east 4 antenata care visits (%) Mothers who had fu antenata care (%) Mothers who consumed iron foic acid tabets for 100 days or more when they were pregnant (%) Pregnant women whose weight gain (AWC register) during entire pregnancy is tracked. (%) Chidren whose birth weight is ess than kg (%) Outcome Leve Indicators for Chid Nutrition Outcome indicators First quarter Last quarter NFHS-4 Madah/DLHS-4 Chidren under age 3 years breastfed within 1 hour of birth Chidren under age 6 months excusivey breast fed. Chidren age 6-8 months receiving soid or semi soid food and breast mik. Micro pan and suppies (aong with IEC) (RCH-register) for bi-annua VAS and De-worming round avaiabe in a 6 intervention bocks Chidren age 9-59 months received a vitamin A dose in ast 6 months) % Chidren age 6-59 months received chid (RCH-register) IFA syrup Outcome Indicators for Adoescent heath and Nutrition Outcome indicators First quarter Last quarter NFHS-4 Madah/DLHS-4 Ags eigibe for suppementary food (%) (SABLA MPR) Ags received suppementary food (%) (SABLA MPR) Ags ( out of schoo) consume IFA for (SABLA MPR) 4 weeks in a month Ags consumed de-worming tabet (SABLA MPR) during bi-annua round. Ags attended NHE counseing session (SABLA MPR) Note: The decision was taken that NFHS4, DLHS4, and Independent survey data of the district woud be considered for setting the baseine of this project. No separate end ine survey woud be done at the end of project. The project impact as mentioned here woud be comparing referring to NFHS-5 report, which wi be avaiabe every two years. Since NFHS 5 data was not avaiabe at the end of the project, the first and ast quarter monitoring data were compared referring to NFHS 4 data as baseine 172

181 Resuts from community ed process for care of manourished chidren: According to WHO growth chart, chidren's nutritiona status was measured. Under weight based on chid's weight for-age is a composite measure of stunting and wasting and was hence the chosen indicator to assess changes in the magnitude of manutrition over time. On starting day of nutrition demonstration and counseing, 1977 severe and 3723 moderate under-weight chidren were identified based on data from ICDS. At the end of the nutrition counseing and demonstration session the chidren were foowed up to 90 days. 386 chidren graduated from severe to moderate (295) and moderate to norma weight (91) after foow-up of 30 days and further 409 chidren graduated from severe to moderate (240) and moderate to norma weight (169) after foow-up of 90 days thus vaidating the possibiity of improved nutritiona status of chidren through effective interventions right in their homes. Foow up mechanism estabished in 1246 AWCs inked to monthy NHED session. Outreach & Scaabiity: The frameworks can now be considered for scaing up within Mada as we as other districts in West Benga. Significanty, the emphasis on mutisectora convergence and inkages between communities and systemic service providers proved to be one of the significant supportive factors here. Repication and scaing up efforts, particuary within other districts, must account for and faciitate this. This community ead intervention for care of manourished chidren has been adopted by GoI for its scae-up in the country with the name given as "Sneha Shivir Impact Achieved Growth of mutisectora patforms as sites for data based reviews: The project supported VHNDs, Fourth Saturday Meetings, Third Saturday Meetings and VLCPCs and BLCPCs to function more effectivey. Besides these mandated patforms, it aso worked with and through Bock Convergence Meetings. Findings from the gap anaysis were utiised for channeising discussions. The performance on key indicators, particuary reated to nutrition, was shared and heped prioritise efforts where needed. Further, district eve reviews (incuding DPAC and ICDS reviews) reaffirmed this emphasis on institutionaising data based, mutisectora reviews for maximising coverage and impact. Coaborative panning and impementation boosted: The enhanced coective review processes faciitated coaborative panning and impementation across sectors. This was particuary noticeabe in the improved eves of micro-panning and coverage for micronutrient suppementation for chidren (especiay Vitamin A Suppementation) and the growing effectiveness of VHNDs. The sub centre eve panning aso received a boost. Improved service deivery incuding coverage of most vunerabe groups: Mutisectora convergent efforts bore fruit as the coverage of key services improved. This was borne by the data on the materna and chid nutrition outcomes and impact. These improvements signify increased inkages with the oca communities and offer greater promise of breaking the intergenerationa cyce of manutrition, deprivation and poverty among communities that are, typicay, affected the most. There is sti a ot to be done though particuary in terms of impacting adoescent nutrition and empowerment - a crucia 173

182 investment that must be made for a range of immediate and intergenerationa gains. Evidence based modes demonstrated that can now be repicated/scaed up: The feeding demonstration and counseing mode inking to monthy NHED at AWC emerged as repicabe frameworks. The project earning indicated need for certain additiona eements that can be incorporated for enhancing their effectiveness. Capacity Buiding Buiding on the foundation of the Mada DPAC and project's efforts, the foowing pointers can be considered. These may acceerate progress to the stage of integration wherein deveopment actors work coaborativey to ensure that sectora interventions have some shared indicators that are panned and impemented in a concerted manner. Some of the actions are to 1. Ensure prioritization, tracking and ownership of themes and actions from the district eve 2. Coectivey outine and agree on process, output, outcome and impact indicators. Ensure monitoring and documentation of muti-sectora convergent progress: 174

183 ASHA faciitating a mother group meeting Newborn Surviva (NBS) Project 1 October March 2018 CARE India Soutions for Sustainabe Deveopment Website : Founder of the Organization : Mr. Waace Justin Campbe, Mr. Arthur C. Ringand Project Budget : ` 1.95 CRORE Coverage/ Geographica reach : The NBS project is intended to benefit the targeted beneficiaries of pregnant women and mother of newborns of a viages of Ajaygarh Bock of Panna District of Madhya Pradesh. 175

184 Standard HBNC Record Register Ro out Project Brief Context and background: A key indicator of deveopment is Infant Mortaity figures. India has shown progressive improvement in IMR since It has registered a decine of 34.3% from 58.8 to 38.7 during to Simiary, the status of Under 5 Mortaity Rate (U5MR) of India has aso shown improvement but sti very high. U5MR has reduced from 52 in 2012 to 43 in 2015 (SRS). Neonata deaths contribute to more than two-third of a Infant deaths in India. Panna district has one of the poorest heath and nutrition indicators in Madhya Pradesh which again scores poorest in India. The Neonata Mortaity Rate is 61 (AHS ) in Panna; IMR is 85 (AHS ); U5MR is 127 (AHS ); and Materna Mortaity is aso very high at 322(AHS ). Poor heath seeking behavior: There is 'Deay in taking decisions for seeking heath care'; there is 'Deay in reaching appropriate heath care faciity' and aso there is 'Deay in initiating appropriate treatment'. The above theory of 3D hods true in the context of eary detection and management of pregnancy & new-born compications in the district of Panna which is contributing to high mortaities among mother and chid. High mortaity rates is a direct manifestation of poor heath seeking behavior, difficuty in access, poor quaity of services at heath faciities and high cost of care in private heath faciities, couped with a the 3Ds affecting heath outcome of a pregnant women and newborn. 176

185 Gender Discrimination: The above context gets further compounded by gender discrimination with respect to gir chid which impacts their surviva. Ony around 41 % gir chidren are admitted against approx. 60 % of mae chid, in the first few days of ife. The report aso suggests that mortaity among femae newborn is higher than that of mae newborns. The report from UNICEF's Integrated Management of Chidhood & Neonata Iness (IMNCI) shows that girs with birth defect (for eg: Ceft Lip Ceft Paate) are denied breast mik, and this denia eads to their eary death. Gir chidren have ow birth weight, and the discriminatory practices further reduce their chances of surviva. Socia and poicy interventions have improved awareness but the gaps are persistent. High Risk Newborn: Whie ooking at the admission pattern in the SNCUs of Madhya Pradesh, it is cear that out of tota admissions during 2016, 60 percent of them were Low Birth Weight (LBW) babies. This though is good in terms of those getting admissions but if we ook at the tota number of LBWs taking birth in the state, we need to further strengthen the referra particuary community referra of LBWs and Preterms to Sick Newborn Care Units (SNCU). Project objectives: With the above context, CARE India with corporate funding from GaxoSmithKine (GSK) is impementing the Newborn Surviva (NBS) Project in the Ajaygarh bock of Panna district with an overa goa to reduce newborn mortaity among poor and marginaized communities with the foowing objectives: 1. Improve birth preparedness and newborn care in communities 2. Improve quaity of heath services deivered by frontine workers (ASHAs and ANMs) through training and mentoring 3. Strengthening deivery practices and NavjaatSishu Suraksha Karyakram (NSSK) aso known as essentia newborn care and resuscitation package through Mentoring of Birth Attendants, primariy the ANMs 4. Strengthening ASHA & ANM networks for institutiona deivery and Home Based Newborn Care (HBNC) 5. Improving access of women from marginaized communities to heath faciities, and improved tracking of babies with LBW, Birth Asphyxia and Infection Impementation Mode NBS project is designed and panned with gender integrated intervention strategies in continuum of care approach aiming to bring about improvements in pubic heath faciities for providing deivery and newborn care services; as we as to generate awareness and demand for safe pregnancy and newborn care in communities of Ajaygarh bock. Foowing are some of the important project interventions through which we try to address the MCH care probems in the region: 177

186 1. Faciity based interventions are aimed at improving capacity of nursing staff at a the sixbirthing faciities in the Ajaygarhbock, ed by a skied & quaified Nurse Mentor through an Incrementa Learning Approach (ILA) and mentoring of nursing staff in improving safe institutiona deivery and newborn care based on NavjaatShishu Suraksha Karyakram (NSSK) program of Government of India. 2. Community based interventions ed by 10 fied staff is supporting and mentoring Accredited Socia Heath Activist (ASHAs) / Frontine Workers (FLWs) in improving Home Based Newborn care (HBNC) services and aso undertake activities to generate awareness and demand for safe and institutiona deivery and newborn care in the viages. The project aso focuses on creating positive attitude and support among famiy members for surviva of newborn, with emphasis on femae newborn. 3. Trainings: Onsight trainings of nurses on safe deivery practices and essentia newborn care, Training of nurses on Essentia newborn care and resuscitation (NSSK); Training of ASHA Supervisors and ASHA workers on Homebased Newborn care (HBNC) to buid capacity of service providers. Improvement in the foowing four broad areas positivey infuences newborn heath outcome: Increased community awareness and changes in pregnancy care and newborn care incuding Enhanced skis, knowedge and capacities of Nurses in pregnancy care, safe deivery practices and essentia newborn care & resuscitation Enhanced skis, knowedge and capacities of ASHAs in pregnancy care, birth preparedness and essentia newborn care. Strengthened HBNC services. System strengthening and improved pregnancy and newborn care service deivery Community Outreach Community interventions: n n n Community Awareness events - to increase awareness on pregnancy care, birth preparedness, institutiona deivery, newborn care and generate demand. Formation of Mothers Group in viages - as an interactive patform in viages for buiding eadership and capacity of women to advocate for appropriate care of newborn & pregnant women; to ensure that they receive desired services from pubic heath system and aso to ensure sustainabiity of project interventions. Interactive meetings with the mother groups to buid eadership and capacity of pregnant, actating & women members 178

187 Strengthening existing pubic heath patform: n n n Monitoring and supportive supervision visits of Viage Heath & Nutrition Days (VHND) to strengthen capacity of ANMs and ASHAs/AWWs to deiver antenata care and newborn care & counseing Advocating and ensuring monthy Sub centre eve meeting: This was to improve coordination among the AAA team (ANM, ASHA & AWW) in the forefront of heath care deivery at gram panchayat eve. This aso heped identifying gaps at individua eve and taking steps to improve. Sensitization and capacity buiding of Viage Heath Sanitation Committee (VHSC) members who are important stakehoders and responsibe to ensure better heath at viage eve. Tracking of newborn and pregnant women through supportive supervision househod visits to strengthen HBNC services: n n Innovative mechanism to ensure daiy deivery data recording and priority tracking of high risk newborns - The project deveoped an innovative daiy deivery reporting and tracking mechanism wherein vita information of newborns deivering at 6 birthing faciities of intervention bock of Ajaygarh are being coected on daiy basis which automaticay highights a high-risk newborns ike ow birth weight (LBW) babies, pre-term or who had birth asphyxia etc. requiring prioritized home visits and foow up. This information is passed on to project fied staffs who then ensures the needed screening, counseing and referra through ASHA workers. This process improved deivery of essentia care to newborn and specia care ike Kangaroo Mother Care (KMC) for LBW or weak newborn baby. Deveoped and roed out a standard HBNC record register to further strengthen recording of HBNC services and inkage with referra. Integrating gender in a project interventions: To address widespread gender discriminatory practices, norms adversey impacting chid and materna surviva, a project interventions highight on gender issues and advocate for equitabe breast feeding, seeking heath care in case of compications among mae and femae newborn; ensuring Kangaroo mother care (KMC) by heathy famiy members incuding father of the LBW baby; ensuring househod eve support to pregnant women for adequate nutrition and rest etc. A trainings have integrated gender issues "When I heard that awareness event wi be hed again in the viage, I aong with my wife came to participate in the awareness program from another purwa because we got to know so many things on care of pregnant women and how to take care of baby" -Laa Bhaiya Lodh, husband of a pregnant women of Prakwapurwa, Nikain Mothers and famiy members in my viage have become more aware and is ensuring ceaniness, hygiene, handwashing whie hoding baby and breast feeding; They have aso started to come out of socia customs and norms and practices which are bad for newborn heath -Apana Ahirwar, ASHA worker of Chandranagar Viage 179

188 Uniqueness of the Project Onsight nurse mentoring and training: capacity buiding of nurses working at abour rooms through nurse mentoring and t r a i n i n g i n t h e i r s k i s, knowedge, and practices to ensure safe deivery practices critica to saving pregnant w o m e n w i t h p o s t - p a r t u m h a e m o r r h a g e, s e v e r e i f e threatening compication due to p r e g n a n c y i n d u c e d h i g h pretension etc ; and providing e s s e n t i a n e w b o r n c a r e & resuscitation programmaticay caed NavjaatShishuSuraksha Karyakram (NSSK) critica to saving babies with birth asphyxia ( d i ffi c u t y i n b r e a t h i n g ), infection, specia care of weak pre-term new-borns and Low birth weight (LBW) babies ike ensuring kangaroo mother care (KMC) Mentoring on newborn resuscitation to nurse Daiy Deivery Reporting and Tracking of births: Innovative mechanism to ensure daiy deivery data recording and priority tracking of high risk newborns - The project deveoped an innovative daiy deivery reporting and tracking mechanism wherein vita information of newborns deivering at six birthing faciities of intervention bock of Ajaygarh are being coected on daiy basis which automaticay highights a high-risk newborns ike ow birth weight (LBW) babies, pre-term or who had birth asphyxia etc. requiring prioritized home visits and foow up. This information is passed on to project fied staffs who then ensures the needed screening, counseing and referra through ASHA workers. These had improved deivery of essentia care to newborn and specia care ike Kangaroo Mother Care (KMC) for LBW or weak newborn baby. Deveoped and roed out a standard HBNC record register to further strengthen recording of HBNC services and inkage with referra. There was no standard uniform register for recording HBNC visiting information resuting in oss of critica information of heath status of newborns, screening and referras during HBNC visits which are very important for sef-tracking of visits by ASHAs and monitoring by Supervisors. 180

189 Roe of Information and Communication Technoogies (ICTs) During the mentoring sessions of the nursing staff on safe deivery practices and newborn care; Mamanataie and Neonataie simuators were used to demonstrate proper management of abor & deiveries, and ENBC (essentia newborn care) & resuscitation. Chaenges Faced Govt priority programs deaying impementation of trainings: The project faced chaenge in competing trainings for nurses and ASHAs due to their engagement in priority programs ike Mission Indradhanush, Dastak programme etc. and thus coud not be reeased by bock officias. However, the project was successfu in undertaking most of the panned trainings with continued foow up and coordination with district and bock officias. Staff Recruitment and Attrition: It was difficut to get suitabe candidates to work in a remote ocation and additionay there were few attritions. Mitigation: It took time to seect project staffs and but with repeat efforts, project coud compete staff on boarding. Simiary, with dissemination and branding of NBS project and CARE India, repacements were not so difficut eventuay. Deay in decision making at sub district eve: Bock officias from Heath department take a ot of time in reaching to a decision or reeasing the etters for organizing trainings. Outcomes Increase in percentage of Institutiona deiveries from current eves Increase in percentage of home deiveries attended by SBAs Increase in front ine worker's knowedge reated to new- born compications, eary identification of probems and timey referra in appropriate heath care centers Increase in detection of high risk pregnant women & their management at heath faciity Increase in foow up coverage of SNCU & LBW Babies graduates to improve newborn surviva The above stated interventions have heped to address the MCH care probems in the region; foowing evidences justify the same: 45 newborn ives with birth asphyxia saved by nurses through resuscitation in There was no record of any newborns saved through resuscitation at heath faciities of intervention bock. Newborn Stabiization Unit (NBSU) at CHC Ajaygarh is now functiona from December 2017 Eary initiation of breastfeeding within 1 hour after birth has improved from 65.0 % in Jan - March quarter to 89.2 % in Oct - Dec 2017 (N=796 newborn tracked) Excusive breast feeding has improved to 80.9% in Oct-Dec 2017 from 74.2 in Apri-June 2017 (N=796 newborn tracked) 181

190 Supportive Supervision HBNC visit Gender gap in excusive breast feeding (EBF) of newborns has significanty narrowed to amost equitabe eve with foow up visits. EBF has improved to 50.4% in femae and 49.6% in mae in 3rd foow visit compared to 45.8% in femae and 54.2% in mae in the 1st visit. Awareness of Danger Signs in Newborns and among mothers has improved from 26.0% in the first visit to 65.8% in the third visit (N=796 newborn tracked). Institutiona deiveries at the six pubic heath faciities improved from 2021 in 2016 to 2346 in 2017 for the period Apri-December. Knowedge on Skin to Skin Care among nurses has improved from 14.3% during Jan - Mar 2017 to 83.3% during Oct - Dec Simiar improvement can be observed in case of Newborn Examination. Their knowedge on Newborn Wrapping has gone up to a whopping 82.5% during Oct - Dec 2017 from a ow of 0.0% during Jan - Mar 2017 (N=10 nurses) There is marked Improvement in essentia ski sets and practices of nursing staff on Pre-Deivery & Birth Preparedness, during deivery care and essentia newborn care and resuscitation (for which there are data based evidences). 33 ASHAs out of 35 coud score in the range of % in counseing mothers on breastfeeding practices and danger signs among Newborns during HBNC visits in the current round of assessment. Outreach & Scaabiity The project focused on the foowing strategies to address the issues reated to Newborn surviva - Generate community awareness and demand for safe and institutiona deivery, and newborn care. Create positive attitude and support among famiy members for institutiona deivery and newborn care. 182

191 Training and skis deveopment of ASHAs on HBNC services; and Nurses on NSSK (Essentia newborn care and resuscitation). Mentoring of ANMs and ASHAs on ante-nata and post-nata care, with key focus on newborn care as per Government of India's India Newborn Action Pan (INAP) guideines. Materna Heath Referra inkages and transportation services - strengthening existing pubic system for safe deivery. Networking for institutiona deivery - focus on strengthening pubic heath system, based on our experience from Bihar in creation of Famiy Friendy Hospitas, to improve quaity of materna and newborn heath services. Whie dedicated efforts from NBS project is beginning to yied positive resuts/ improvement in deivery of pregnancy and newborn care services; awareness and demand in communities; and mother and famiies ensuring care of newborn and pregnant women; there is continued need of efforts/investment in the geography due to the persisting barriers and gaps in addition to poorest heath and nutrition indicators impacting materna and chid mortaity as evident from secondary data. It is important to note that a the 5 districts under Sagar Division of MP fas under current high priority ist. In addition to widespread socio -cutura barriers negativey impacting newborn and pregnancy care, there are compeing Statistics of heath indicators critica to newborn surviva and materna heath in Madhya Pradesh and Panna District which cas for urgent wider investment and scae up of project of this nature in the geography. With the above strategies in a continuum of care approach, project interventions primariy focused to strengthen capacity and skis of nurses, ANMs and ASHAs in deivering better pregnancy care, safe deiveries and essentia newborn care; aso focused to improve monitoring and supportive supervision. With the adopted strategies and interventions mix, the project is best suited to scae up in a the 5 high burden districts of Sagar division. Major Project activities ti December Training of 181 ASHAs on HBNC for 2 days 2. Training of 8 ASHA Supervisors and 10 project staffs on HBNC for 8 days 3. Training of 8 nursing staffs on NSSK and safe deivery practices; and 8 ANMs on pregnancy care, safe deivery and newborn care mentoring sessions for nursing staffs community awareness events Mother Group formed and 270 meetings faciitated supportive supervision VHND visits VHSC and 18 SHC meetings faciitated ASHA Custer meetings faciitated househod visits incuding 1578 for newborn and 1468 for pregnant women NBS Project reach at a gance femaes in age groups and 2213 maes were reached directy through project interventions Indirecty project has been abe to touch the ives of femaes Working in 195 viages 183

192 Mother Group meeting Repicabiity The project's system strengthening approach, strategies and interventions by compementing the existing pubic heath system efforts to improve pregnancy and newborn care; couped with simiar poor heath and nutritiona status in other geographies particuary in a 5 bocks of Panna District of Madhya Pradesh gives the advantage, opportunity and suitabiity to integrate the project interventions in other ocations as we. Impact Achieved For 2783 ive births in six deivery points during 2017, we coud manage 45 cases of birth asphyxia. With reference to AHS (2012-'13) data, the neonata mortaity rate of Panna is 61 per 1000 ive births. Considering the AHS data, about 170 out of 2783 newborns woud have died before reaching the 28th day of their age. Managing 45 birth asphyxia cases out of 170 potentia neonata death cases (attributed to birth asphyxia) accounts for a reduction of about 26.5% in the neonata mortaity rate for the area. Eary initiation of breastfeeding within 1 hour after birth has improved from 65.0 % in Jan March quarter to 89.2 % in Oct Dec 2017 (N=796 newborn tracked) 184

193 Excusive breast feeding has improved to 80.9% in Oct-Dec 2017 from 74.2 in Apri-June 2017 (N=796 newborn tracked) Gender gap in excusive breast feeding (EBF) of newborns has significanty narrowed to amost equitabe eve with foow up visits. EBF has improved to 50.4% in femae and 49.6% in mae in 3rd foow visit compared to 45.8% in femae and 54.2% in mae in the 1st visit. There is significant improvement in ski, knowedge and practice areas among nurses in ensuring safe deivery and essentia newborn care & resuscitation practices; and ASHA workers in HBNC services. There is improvement in awareness eves among mothers on newborn care. The above with improvement in system eve in HBNC services, essentia newborn care and resuscitation couped with enhanced community awareness indicates sustainabe changes towards improving newborn care and pregnancy care. Capacity Buiding The project has a great focus on capacity buiding of ASHAs, ANMs and the nursing staffs. Provision for better quaity training and ski deveopment sessions woud enabe them to cevery identify and manage compex cases of pregnancies and provide appropriate care to high risk newborns. Ski enhancement of FLWs aso provides them the confidence to manage compexities on their own than immediatey referring cases to higher faciities. This aso reduce the time taken to seek immediate care during emergencies. In addition to innovative soutions to buid ski capacity the project foowed the training programmes institutionaized by GOI: Training of 181 ASHAs on HBNC for 2 days Training of 8 ASHA Supervisors and 10 project staffs on HBNC for 8 days Training of 8 nursing staffs on NSSK and safe deivery practices; and 8 ANMs on pregnancy care, safe deivery and newborn care. 210 mentoring sessions for nursing staffs 185

194 Awards/Endorsements 186

195 187

196 Mentoring to ANM of PHC Khora in essentia newborn care and resuscitation Dr. L.K. Tiwari, CMHO Panna and Dr. Sribash Saha, Project Manager, CARE India roing out the standard HBNC register Interactive faciitation meetings with mothers group members at Naikain supported by NBS project team Supportive supervision of HBNC visits by project staff at Nabastha 188

197 Pahe towards empowering women 2007 ti date Centre for Catayzing Change (Formery CEDPA India) Website : Founder of the Organization : CEDPA, USA Project Budget : Period September 2010 August, ` 5.1 Crores Coverage/ Geographica reach : Initiated in two Bocks of Patna District (Punpun and Musaurhi) in 2007 and the project was scaed up to six bocks in three districts. Currenty the geographic coverage is in districts of Aurangabad, Muzaffarpur, Nawada and Sitamarhi reaching approximatey 2000EWRs from a three tiers of Panchayati Raj Institutions. 189

198 Project Brief Context - The state of Bihar poses a significant chaenge in the impementation of interventions targeting reproductive heath outcomes and services. Of critica concern in terms of heath service deivery in Bihar are the high MMR (208 per 100,000 ive births SRS 2013) as compared to the nationa average of 167 and a continued high Tota Fertiity Rate (3.4) that further impacts on the MMR in the state. Bihar continues to be one of the poorest states in the country, despite, high poitica eading to severa incusive, pro-peope and effective governance poicies, schemes, and reforms that have ed to improvement in the severa deveopment indicators..bihar is aso the first state to formay reserve 50 percent of seats for women in oca governance. There are currenty more than 120,000 EWRs in the state at the three eves of oca governance (district Zia Parishad¹, bock- Panchayat Samiti² and viage GramPanchayat³). Currenty Bihar is in its third cohort of EWRs and the State Government has structured training programmes for a eected representatives of Panchayati Raj Institutions. Aims and Objectives - The current Pahemode, combines the twin objectives of improving reproductive and materna heath (RH/MH) services by empowering eected women representatives from Panchayati Raj Institutions (PRI) as heath advocates and in the process buids their voice, participation and eadership in oca governance. Long Term Outcome is to strengthen the voice, participation, eadership and infuence of Eected Representatives (ERs) in decision making in Panchayats to enabe them to improve Reproductive and Materna Heath (RH/MH) services at viage, bock and district eves, assisted with a mobie phone based IVR patform that coects and disseminates data entered by EWRs to inform improvement efforts on RH/MH. Impementation Mode Centre for Catayzing Change, has been working with women and young peope for over a decade in Bihar. For Pahe, strategic partnerships were formed with community based NGOs and advocacy with government departments at district and state eve. Capacity deveopment of EWRs (three day trainings on PRI structures/processes, gender inequaity and pubic heath deivery system in the context of FP/RH) to support better participation in Panchayat meetings and more pro-active roe around issues of heath, education, etc. A three day, 18 hour training modue was created for transaction with EWRs through a cadre of femae master trainers. Support to take panned, concrete actions on improving FP/RH/MH services and uptake, based on evidence generated through administration of checkists Mentoring through coective forums, quartery MahiaSabhas and support to interface with government officias and strategise coectivey to raise heath and other deveopment issues in Panchayat Meetings ¹ Zia Parishad: Loca government body at the district eve in India ² Panchayat Samiti: Loca government body at the tehsi (tauka)/bock eve in India ³ Gram Panchayat: Loca sef-governments at the viage or sma town eve in India 190

199 Ward members attend a mahia sabha to share their experiences and draft their action pans Working with Departments of PRI and Heath at district eve to hep fi the gaps and impement soutions EWRs use pictoria checkists to monitor heath services in their areas and raise findings at Panchayat meetings Convergence meetings at district and bock eve where pace their findings and demands before officias Exposure visits for EWRs inside and outside the state Piot IVRS mshakti for monitoring services to test the feasibiity of EWRs using their mobie phones to give feedback over phone that transates into a reatime dashboard which can be accessed by government officias at mutipe eves Monitoring by C3 team and systematic third party evauation to track impact. Community Outreach As a first step, C3 deveoped a training manua in Hindi for use by Trainers consisting of a three day modue. A poo of 24 femae master trainers was trained who in turn conducted residentia trainings for 1200 EWRs. The modue covered a range of topics - information on PRI structure, meetings, and committees; roes and responsibiities of eected representatives; gender inequaity and ow status of 191

200 women; components of Reproductive Heath (RH) and options for Famiy Panning (FP); information about different eves of pubic heath service deivery system, benchmarks and entitements. Four checkists were deveoped - Viage Heath Sanitation and Nutrition Day (VHSND), Heath Sub- Centre (HSC), Primary Heath Centre (PHC) and District Hospita (DH). EWRs were trained in using the checkists and these were administered with support from the three NGOs. These checkists served as a too to support EWRs to monitor and act as heath advocates in their respective constituencies and to bring an understanding/ insight in to the progress made so far in the usage, accessibiity and quaity of FP and RH services. Tracking and mentoring of EWRs was an integra part of the intervention design. Tracking sheets were deveoped to enabe reguar feedback on participation of EWRs in different activities - participation in VHSNDs, monitoring of heath services, participation in PRI meetings, vocaization of issues on FP/RH and Girs' Education during these meetings, sharing of heath service data during PRI meetings as we as convergence meetings with department of heath and Pubic Heath and Engineering Department (PHED) and Integrated Chid Deveopment Services (ICDS), and meeting with heath providers. To faciitate monitoring of services by EWRs, C3 ater deveoped pictoria checkists to enabe iiterate and neo-iterate EWRs to use them effectivey. An Interactive Voice Response System (IVRS) was introduced as a piot in January The EWRs used pictoria checkists to monitor the heath faciities and used the IVRS to provide their observations using their mobie phones. Uniqueness of the Project Four checkists - were deveoped as toos to gauge the quaity of services at the Viage Heath Sanitation and Nutrition Day (VHSND), Heath Sub-Centre (HSC), Primary Heath Centre (PHC) and District Hospita (DH). EWRs were trained in using these checkists that they administered with support from the three oca NGOs. These checkists served as a too to support EWRs to monitor and act as heath advocates in their respective constituencies by ooking at the usage, accessibiity and quaity of FP and RH services. The checkists were administered in three rounds and pictoria checkists were ater deveoped to enabe iiterate and neo-iterate EWRs to use them effectivey. An Interactive Voice Response System (IVRS), mshakti was introduced as a piot in January The piot was impemented with 805 EWRs. Evidence sharing at Panchayat meetings The EWRs raised issues on FP/RH services and conducted reguar foow-ups during the Gram Sabha and Panchayat meetings and urged the Mukhiya (Gram Sabha Chairperson) to pace the gaps identified at the eve of the oca HSC during the Panchayat Samiti⁴ bi-monthy meeting to ensure action by the Medica Officer In-Charge. Evidence sharing with Heath Department authorities Annua district and bock eve convergence meetings of EWRs from a three eves were organised under the project as patforms for district eve advocacy, where EWRs' shared their findings supported ⁴ Panchayat Samiti: Loca government body at the tehsi (tauka)/bock eve in India. A bock is a sub unit of District eve administration that operates at the eve of 100 viages with a popuation of a 1000 each 192

201 with the data coected via the checkists with officias from different departments (Heath, Socia Wefare and Pubic Heath Engineering Department/PHED). Many of these meetings resuted in positive coaborations between the EWRs and the heath workers on use of untied funds, sanction of referra transport and reguar services at HSCs. Interface with heath workers The mentoring support provided under the project use of the checkist instied new confidence in the EWRs. Over time, as the interface between the EWRs and heath workers became more frequent, their reationship improved and a eve of mutua trust has evoved. They have together found soutions - such as instaing curtains for privacy during ANC, and using untied funds for purchase of basic equipment. The heath workers in turn have requested for the EWRs assistance for mobiization and awareness generationon FP/RH issues. Roe of Information and Communication Technoogies (ICTs) mshakti: IVRS piot : to test efficiency of a ow cost tech soution as a suppementa add on was pioted : A too to coect and exchange information--takes information in, and pushes information out A method for rating service avaiabiity and quaity of care and getting that feedback into the ecosystem Incoming and outgoing possibe, to free Audio earning pack Rea time data anaysis Process of Training EWRs on using mshakti Preparatory: isting GP members with phone number and generating MIS with viage name Training: first eve of training NGO fied animators and coordinators by Gram Vaani, door to door training of EWRs by fied animators and handhod support to respond to survey Chaenges Faced Low iteracy and gender were the biggest barriers. Women acked confidence; they were dependent on their husbands to take decisions about them. Their mobiity was restricted. It was a chaenge to organize residentia training programs; women faced criticism from their famiy members. These chaenges were overcome by buiding trust with famiy members. To counter iteracy the training content used was more graphic and pictoria and simiary pictoria checkists were deveoped for monitoring of FP/RH services. The other approaches which heped in achieving resuts were using nonconfrontationa and coaborative approach with mutipe stakehoders. The government functionaries such as ASHA and ANM who initiay saw them adversaries ater became supportive as they saw EWRs were meant to compement their work and to improve quaity of heath services. 193

202 Outcomes EWRs taking action on FP/RH issues - One of the key areas of intervention aimed at empowering EWRs to ensure avaiabiity of and access to heath care services, particuary FP/RH reated services. 62 percentage points increase is reported among EWRs reporting attending a VHSND in the ast 3 months in the intervention group (Ib⁵ ⁶ : 11%, IE⁷ : 73%) as compared to an increase of 19 percentage points (CB⁸ : 5%, CE⁹ : 24%) in the contro group indicating a 43 percentage points higher increase in EWRs attending VHSNDs in the intervention area. EWRs reported meeting with Auxiiary Nurse Midwife (ANM)/ Accredited Socia Heath Activist (ASHA) and Anganwadi Workers (AWWs) more frequenty than they did prior to Paheprogram. 59 percentage points increase is reported in EWRs who reported meeting with ANM in ast 3 months prior to the endine in the intervention group (IB: 27%, IE: 86%), whie a 35 percentage points increase is reported on the same among EWRs in the contro group (CB: 26%, CE: 61%). %). EWRs in the intervention group have shown an increase in meetings with ANM in ast 3 months which is 24 percentage points higher than EWRs in the contro group. 53 percentage points increase is reported in EWRs who reported meeting with ASHAs/AWWs in ast 3 months prior to the endine in the intervention group (IB: 36%, IE: 89%), whie a 39 percentage points increase is reported on the same among EWRs in the contro group (CB: 32%, CE: 71%). Paheaimed to specificay increase EWRs participation in access to heathcare services through reguar interactions and meetings with ANM/ASHA/AWW. Impact of the intervention is evident as many more (84%) EWRs who participated in Pahe reported that they provided support to ANM/ASHA/AWW in some form or the other as compared to sighty more than haf (55%) EWRs in contro area, which is a difference of 29 percentage points at the time of endine survey. Higher number of EWRs in intervention group reported providing support to frontine heath workers in specific services. For exampe, a higher number of EWRs (Comparative Difference, CD: 134) provided support in registration of pregnant women; on RH reated services (CI: 135); 100 points in ensuring distribution of money to Janani Suraksha Yojana (JSY) beneficiaries (CI: 100) and in conducting activities reated to VHSND (CI: 114). These changes can be attributed to Paheprogram as the training and reguar monitoring and tracking of EWRs aimed to strengthen their abiity to perform their roe as PRI effectivey. Pahe buit capacities of EWRs to engage with Medica Officers (MOs) in-charge and raise oca issues and concerns. A positive change was observed among the intervention group. Among the EWRs who had a meeting with the MO a higher number of EWRs in intervention group reported raising issues - supervision of HSC (CD¹⁰ : 26), suppies of IFA tabets (CD: 46), visits by ANMs (CD: 38), reguarity of ⁶ Intervention Baseine ⁷ Intervention Endine ⁸ Contro Baseine ⁹ Contro Endine ¹⁰ CD: Contro District 194

203 Ward members of a panchayat in Muzaffarpur express their soidarity VHSNDs¹¹ (CD: 37) and suppies of contraceptives (CD: 40). In addition, EWRs in the intervention group were found to be more active on issues ike avaiabiity and use of untied funds (CD: 26) and counseing during VHSND (CD: 28) as compared to the contro group. Pahe aso created an opportunity for EWRs to interact with Civi Surgeon (CS) through annua convergence meetings. 41% EWRs had met with the district Civi Surgeon in the intervention group as compared to 18% in the contro group. An overa 23 percentage point higher engagement is reported in the intervention group. EWRs who met with the CS in the intervention group focused on avaiabiity and use of untied funds, meetings of Patient Wefare Committee, suppy of contraceptives, reguarity of VHSND, suppies of Iron Foic Acid - IFA. Impact of IVR patform - The mshakti package incuded an audio earning pack on FP, RH and materna heath care aong with a survey to report back on corresponding services avaiabe at the HSC, PHC and VHSNDs. A pictoria checkist was deveoped to match with the IVR survey questions so that it can be used independenty by EWRs. Centre for Catayzing Change covered 6 PHC, 94 HSC and 415 VHSNDs through 800 EWRs at Panchayat eve. 85% EWRs that were interviewed during endine were a part of mshakti. 98% of these EWRs had istened to information and entertainment programs on IVRS, 95% had provided information on faciities assessment and 100% had received support from the fied animators to navigate through IVR and 81% shared that they can navigate through IVR independenty. Resuts from pioting ow cost IVRS patform for monitoring of FP/RH services with seect cohort of EWRs has shown that it is possibe to scae the intervention at state eve. The aim was to use mshakti as ¹¹ VHSND: Viage Heath Sanitation and Nutrition Day 195

204 a reporting too on heath services, wherein data coud be anaysed and distied into an information dashboard. The IVRS activities were compemented with the EWRs engaging with heath officias and Panchayats at ground eve to initiate actions. There was a unanimous support from EWRs who engaged in this patform and a majority of them reported istening to information packs (98%) and provided information on faciities assessment (95%). Whie a the EWRs reported having received support from the fied animators to navigate through IVR a majority of them (81%) fet confident in navigating the IVR independenty. With support on negotiating IVRS, this program can be scaed up to become an effective instrument for receiving direct and rea time feedback on community based monitoring processes that can be integrated within existing MIS of the Heath Department. Outreach & Scaabiity Pahe was initiated in 2007, with ony 2 bocks and 300 EWRs and based on encouraging evauation resuts currenty Pahe has scaed up operations in 10 bocks of four districts (Aurangabad Muzaffarpur, Sitamarhi and Nawada) reaching neary 2000 EWRs and about 300 eected mae members who are members of the Viage Heath Sanitation and Nutrition Committee. Creating a cadre of master trainers and monitoring the quaity of training. Linking EWRs to the State Grievance Redressa Systems so that peope's representatives can use the faciity to sove probems reated to the heath system service deivery. For the three project cyces, Centre for Catayzing Change has widey shared resuts of the project at severa nationa and internationa forums incuding the Gender and Evauation Community India, American Evauation Association and European Evauation Conferences in Both quaitative and quantitative methodoogies have been used to measure resuts. The good practices have been shared not ony with government but aso with civi society organisations. The Pahe mode has been used to mobiise EWRs across the state and mentor them as heath advocates for a state eve campaign on quaity of care, HamaraSwasthyaHamariAwaz. The Pahe mode has been presented and shared over the NHSRC Innovation Porta (Nationa Heath Systems Resource Centre) and seected as best practice. Learnings from Pahe have been pubished by the Panning Commission Evauations for Sustainabe Learning: Experiences and Learning, 2017 and Second Edition of the Annua UN Women Pubication on Gender and Evauation Repicabiity The project evauations have demonstrated far reaching impact and a new district has been added on from As a demonstration mode, it achieved resuts and has scope of repication into other ocations. The government can integrate the training modues into its training programs for EWRs in other states. The program earning indicates that for scae up of the mode integrating community based monitoring ed by eected representatives of the PRI as part of the curricuum for training eected representatives, can be an effective strategy. The toos especiay deveoped for ow iterate/iiterate women eaders can be adapted to the context of other states and other issues beyond heath and education. In fact under Pahe a pictoria schoo monitoring checkist has aso been created. 196

205 Impact Achieved The changes brought about by the project are significant considering the fact that a majority of the EWRs had imited exposure and had not received any training/orientation from concerned department on their roes and responsibiities as PRI members. Despite the intention to serve the peope they represented, the EWRs acked the information on their roe and confidence to vocaize their opinion. Opportunity to bridge this gap between intention and ack of knowedge, skis, information source and guidance came through Pahe in the intervention group and through the Department of PRI in the contro group. Most of the EWRs (in intervention area as we as contro area) reported receiving information on their rights and roe, and information on heath, education and deveopment programs with the exception of foow-up support which was provided by the project staff in the intervention area. EWRs in both the groups had simiar eves of awareness and knowedge but a stark difference is visibe in the foowing areas: Many more EWRs in intervention group advised community members on FP/RH issues, attended VHSNDs and reported provision of services during VHSNDs Many more EWRs in intervention group interfaced with ANM/ASHA/AWWs, MOs and CS as compared to contro group. Pahe activities empowered EWRs to participate activey in Gram Sabha (GS) /Panchayat meetings and were motivated to raise issues on key areas of concern. EWRs in the intervention group have shown an increase in abiity to raise issues during the GS/Panchayat meetings which is 38 percentage points higher than EWRs in the contro group. Key to effective administration and fufiing responsibiities is abiity to take independent decisions. EWRs who participated in Paheshowed that they were abe to take decisions independenty on FP/RH reated issues with a difference of 38 p e r c e n t a g e p o i n t s a t e n d i n e b e t w e e n intervention and contro groups of EWRs. Pahe has shown that it is possibe to effectivey empower EWRs to perform their roe as eected representatives of their constituencies, especiay in the domain of heath services. Athough training has been given a ot of emphasis in capacity buiding incuding awareness about specific roes and responsibiities as we as knowedge about heath and education services, reated government schemes, but monitoring and support are equay essentia to buid their capacities to take decisions independenty and vocaise themseves. Findings of evauation of Pahe are encouraging and indicate that Pahe can be an effective mode for everaging the roe of eected representatives in Women eaders in Pahe using mobie technoogy to improve heath services 197

206 community based monitoring of heath services within the framework of Nationa Heath Mission. Another innovation in Pahe is an emerging mode where EWRs can coaborate with heath service providers to find quick soutions to oca probems by using untied funds, raising access, suppy and procurement issues at meetings of Gram Panchayat and PanchyatSamiti and during their meetings with the officias of the concerned departments. Capacity Buiding Trainings - The training modue deveoped by C3 focused on information on FP/RH with the view that if PRI members are aware of different methods of FP and components of RH, they wi be better equipped to ensure heath service deivery. Pahe buit capacities of EWRs to engage with Medica Officers (MOs) in-charge and raise oca issues and concerns. A positive change was observed among the intervention group. Among the EWRs who had a meeting with the MO a higher number of EWRs in intervention group reported raising issues - supervision of HSC (CD: 26), suppies of IFA tabets (CD: 46), visits by ANMs (CD: 38), reguarity of VHSNDs (CD: 37) and suppies of contraceptives (CD: 40). In addition, EWRs in the intervention group were found to be more active on issues ike avaiabiity and use of untied funds (CD: 26) and counseing during VHSND (CD: 28) as compared to the contro group. Pahe aso created an opportunity for EWRs to interact with Civi Surgeon (CS) through annua convergence meetings. 41% EWRs had met with the CS in the intervention group as compared to 18% in the contro group. An overa 23 percentage point higher engagement is reported in the intervention group. EWRs who met with the CS raised simiar issues athough EWRs in the intervention group focused more on avaiabiity and use of untied funds (IE: 30%, CE: 7%), meetings of Patient Wefare Committee (IE: 35%, CE: 28%), suppy of contraceptives (IE: 78%, CE: 69%), reguarity of VHSND (IE: 70%, CE: 66%), suppies of Iron Foic Acid - IFA (IE:74%, CE: 72%), whereas EWRs in the contro group reported higher emphasis on ANMs visits (IE: 73%, CE: 78%), supervision of HSC by officias (IE: 51%, CE: 62%), non-avaiabiity of gynecoogist (IE: 51%, CE: 62%), etc. Partners of the Project Roe of partners - this intervention was in partnership with oca partners based in coverage area of the project. Their roe was to mobiize EWRs and buiding rapport with them. They faciitated capacity buiding initiatives ike training programs and handhoding support. They organized exposure visits, faciitated ward Sabha and custer eve meetings. They expained checkists and hed hands whie fiing them. They provided support in inking with government functionaries. Awards/Endorsements The Pahe mode has been presented and shared over the NHSRC Innovation Porta (Nationa Heath Systems Resource Centre). Learnings from Pahe have been pubished by the Panning Commission Evauations for Sustainabe Learning: Experiences and Learning, 2017 and Second Edition of the Annua UN Women Pubication on Gender and Evauation 2014.Pahe was seected by Ministry of Heath and Famiy Wefare a best practice showcased at the 3rd Nationa Summit on "Good and Repicabe Practices and Innovations in Pubic Heathcare System". 198

207 In a heath camp - members checking heath status of their chidren Piot Project to Address Manutrition Chaenges in Kathikund Bock, District Dumka, harkhand November 2014 onwards Website Founder of the Organization Project Budget : : Mr. Deep Joshi and Mr. Vijay Mahajan : ` 50 akh from Nov 2014 ti date Coverage/ Geographica reach : 11,300 Women 190 Viages 12 Panchayats Kathikund Bock Dumka District, Jharkhand 199

208 Project Brief The causes of manutrition among women and chidren are muti-factoria and muti-dimensiona. Issues of poverty, gender, socio-economic discrimination, iveihood opportunities, and poor state of services reguary contribute to the condition of manutrition. The interinked issues of poverty, food and nutrition security, heath, and gender equaity need to be addressed simutaneousy and comprehensivey. It is aso we understood that the issues of women's heath and nutrition and that of chidren are cosey intertwined since women give birth to chidren and remain their main takers. The project area ies in the Santha Pargana region of Jharkhand where 90% of rura women are in anemic condition. The project aims to improve the heath and nutrition status of women and chidren through a muti strategy approach, (i) working with women's group, (ii) systems strengthening, and (iii) everaging the agricutura and iveihood practices towards improving human nutrition. The intervention foows the beief that community invovement can make heath services more accessibe and sustainabe, and that enabing communities to expore the consequences of heath behaviour can yied asting improvement in heath outcomes. Thus, there can be a significant reduction in manutrition eves among women and chidren through community mobiization, systems strengthening and community based management of manutrition. The interventions engage with individua househods and women to hep understand the underying causes and practices reated to manutrition and i heath. Additionay it is needed to work with the community and pubic systems/institutions to ensure that services of pubic heath and nutrition programmes are avaiabe and accessibe in the project area. Additionay, working with PRADAN's existing iveihood patform as a strategy is to buid inkages between iveihoods and nutrition. The overa change in the existing condition of manutrition wi be indicated with the change in Body Mass Index (BMI) of women and decrease in the number of Severey Acute Manutrition (SAM) chidren. The increase in awareness eve of women around good practices of mother and chid care, the entitements and rights, contro over income and househod decision making wi ead towards better condition of heath and nutrition. This can be achieved by incuding the agenda of nutrition in discussion of sef hep groups (SHGs) and the viage organizations (VOs) promoted by PRADAN. The initia perspective buiding around the subject was carried out for PRADAN professionas and the community members, which is done with the hep of our partner organization, Pubic Heath Resource Network (PHRN). Impementation Mode Impementation Mode: The intervention incudes two major dimensions Nutrition Sensitive and Nutrition specific. To achieve the goa a pathway is designed as per the buckets of intervention which is as foows. 200

209 The investments are around Master trainers (in Nutrition), Ajivika Krishi Mitra (cadres in agricuture) and community coectives. ROLE OF COMMUNITY COLLECTIVES 201

210 Support System Function Methods Nutrition Master Provide training around step by Stories, Picture Cards, BMI camps, Pays Trainers step moduar trainings to VO and Videos, Exposure visits to subcommittee members and in Manutrition Treatment Centre (MTC) foow-up discussions in SHG centers and hospitas, Games on 'Diet Diversity', Sharing of success stories. VO subcommittee Conduct focused discussion -Use of visua toos ike picture cards members in VOs and SHGs around Nutrition and stories and sharings, wa paintings and making action points. Take action against Liquor consumption, vioence against women and corrupt practices around services ike PDS. Participate in convergence program of government to provide ration to primitive tribe groups (PTGs) -Raies -PDS shop SHG members Conduct discussion on issues and Use of visua toos ike picture cards awareness around Nutrition and stories and sharing, wa paintings Support System Function Methods AKM(Ajivika Krishi Conduct training on Package of Exposure visits to farm and market. Mitra) Practices (POP) of crops with Ajivika subcommittee members Picture cards, stories and Videos. and SHG members. Community Outreach Ensure practice of Kitchen Garden with seasona crops. Ensure production of Nutrition sensitive crops with promotion of Agricuture Productive Custers (APCs) Promote practice of Organic Farming and Non Pesticide Management(NPM) POP trainings, handhoding and support in input management -viage eve demonstration Because of PRADAN's continuous effort there is presence of community institution in the area. The theme of nutrition was integrated with each tiers of the community organization. For a community ed initiative the theme of nutrition was mandated in the Aam Sabha or the Annua Genera Body meeting of the federation which is an apex body of the SHGs. This created an informed choice to work in nutrition. The seection of oca community eaders increased the acceptabiity of the intervention. The use of oca anguage, pictoria depictions and terms heped to connect with the community. The different processes undertaken are: 202

211 a) Community Need Anaysis b) Perspective Buiding c) Transaction of Training Modues d) Community Leve Awareness Programs e) BMI Camps f) Monthy Evauation and Review of Master Trainers g) Viage and Hamet Leve Trainings h) Capacity Buiding of Trainers and Vounteers With Reguar Refresher Trainings. i) Reguar Home Visits. j) Handhoding Support in Fied. k) SHG wise panning for different cropping season. Emphasis on crop diversity with focus on nutritiona requirement of the famiy Uniqueness of the Project Introduction of Red and Green bands in BMI camps Use of more symboic and visua methods; ess ectures and more sharings. Incusion of adoescent girs and chidren in training programs Deveoping oca songs around nutrition Exposure visits to Manutrition Treatment Centre in Government Hospitas Orientations of trainers by physicians. Connecting the trainings with oca stories and ive issues Converting compex messages into oca and simpified versions ike expaining the benefit of food and their nutrients in simpe anguage and toos. Viage eve video show with pico projectors Wa paintings Input support for nutrition sensitive agricuture and kitchen gardening Use of organic fertiizers Reguar sharing of success stories and cases of change 203

212 Nutrient Benefit Simpified terms used Carbohydrate and fats Protein Mineras and Vitamins Energy giving Body Buiding food Food to protect from disease and increase bood kkjhj dks rkdr vksj mtkz nsus okyk [kkuk kkjhj dh o`f) djus okyk [kuk fcekjh s cpkus okyk vksj [kwu cukus okyk [kkuk *TRI-Coour (Saffron for proteins, White for carbohydrates and Green for mineras and vitamins) 204

213 Roe of Information and Communication Technoogies (ICTs) Use of mobies and tabets by community cadres for BMI cacuation. Chaenges Faced The concept of nutrition is compex. There was no such too to measure it or make visibe identification to show increase or decrease in nutrition. The effect of nutrition or manutrition was aso not immediate due to which one coud expain the importance. It was ony expained in terms of good or bad heath which was not enough as a person may ook heathy but she may be affected by one or other kind of manutrition. There were initia hiccups among professionas (as many of us are men) to start a discussion on breast feeding and as soon we used start the discussion the women in the meeting woud eave the meeting one by one, as they aso used to fee hesitation. It was very difficut to start the discussing the issues of coostrum feeding and excusive breast feeding. Major chaenges faced were: a) Starting the discussion around nutrition. As the importance of nutrition was difficut to expain without any short term benefit or parameter to measure b) Breaking the myths, taboos and intergenerationa practices around Mother and Chid care c) Change of food habit and consumption pattern 205

214 Working On Soution: We conducted sensitization camps around BMI as an entry point activity. We started discussion and sharings on rea ife situations and on 'Consequences of Bad Practices'. We encouraged sharing of good practices, used toos of picture cards and storyteing. These stories heped to reate them with daiy ife. We connected the issues of myths and taboos with discrimination of women. We aso taked more about habit that have i effect on chid heath. We did exposure visits to areas having good practices and to MTCs. Reguar practice and brain storming was aso done at the team eve. Learnings Key messages are difficut to retain in mind and in practice. There is need for reguar discussion on the issues and key messages in the community forums. Discussions with interactive and symboic toos and stories are more effective. Peope reate more when there is quaity training by skied workers who tak with oca and simpe exampes. A compex expanation and use of difficut terms do not retain messages in mind. Outcomes The outcomes are around five buckets of intervention (aready described in the mode above): BUCKETS OUTCOMES 1. Production of Nutritious food 1. Increase in production of nutrition sensitive Traditiona Crops ike spinach, okra, tomatoes, puses incuding horse gram, Benga gram, and pigeon pea. 2. Kitchen garden: Papaya, Moringa, Lemon, tomato, spinach, chii, okra and seasona vegetabes. 3. Increase in cutivation of oiseeds such as Mustard. 4. Intensive use of organic farming and women drudgery reduction equipments 5. Integrated ivestock rearing for intake of protein. 6. identification of oca fruits and vegetabes incuding forest products 2. Diet diversity, ensuring hygienic 1. Increase in daiy diet diversity and nutritious food and Individua 2. Increased awareness around nutrient vaue of food groups. heath and Sanitation 3. Behavior change around: - Consumption of Four food groups of Cereas, Puses, ois, Green Leafy vegetabe - and transating production into consumption - Heathy practices of hand wash, use of iron utensis, Discouraging junk foods, ceaniness, Washing before cutting vegetabes. -Use of toiets 206

215 BUCKETS OUTCOMES 3. IYCF, Care of Infants, Pregnant Behavior change around:-increased adaptation of practices and actating mothers around IYCF incuding Eary Initiation of Breast feeding incuding coostrum feeding, Excusive Breast feeding, and Compementary feeding. Awareness around immunization. -Increased awareness around eary marriage, anemia. 4. Access to and functioning of Identification of Severe Acute Manutrition in chidren beow pubic services 5years and referras. Strengthening of services -around THR(Take home ration) and hot cooked mea at anaganwadi, -Proper functioning of PDS (Pubic Distribution system) Provision of PDS card and Ration. -Proper Growth monitoring of chidren(prevention before faing into SAM/MAM category) 5. Women's empowerment Participation of woman in househod decision making, contro over income, chaenging patriarchy. Outreach & Scaabiity Increased roe of women in Agricuture Kathikund is situated in the foothis of Rajmaha, an extreme poverty stricken and triba dominated pocket of Jharkhand state. In Kathikund bock, Santha (ST) community is one of the argest prevaiing communities. It comprises the 60% of the tota popuation of Kathikund. The program is community ed initiative. The women coectives in the area are the torch bearers of the program. The program extends and is impemented through the patform of community institutions ike SHGs, VOs (Viage Organization), CLFs (Custer eve Federation) and BLF (Bock Leve federation). There is presence of PRADAN promoted CBO and arge scae socia mobiization in Kathikund. Institution at a Gance Institution Leve Member Frequency of meeting SHG( Sef Hep Group) Hamet 10 to 15 Primary Weeky Member Viage Organization Viage Representative of Twice a month 8 to 12 SHG Custer Leve Federation Muti-panchayat Representatives Twice a month of VO Bock Leve Federation Bock Representatives Twice a month from Panchayats 207

216 The institutions of women coectives with primary members have 10 to 15 women at hamets is known as SHG. The next tier is the viage eve institution is Viage Organization and constitutes representative members from SHG. A viage organization (VO) constitutes members from 8 to 12 SHG. After VOs Panchayat or muti-panchayat eve Custer Leve Federation. This tier constitutes 20 to 25 VOs. The representatives of Custers eve Federations constitute the Bock eve Federation. The tier at Bock eve is Bock Leve Federation or BLF. The members foow the principa of subsidiary. There is no hierarchy among the members and tiers. The fow of discussion, issue and decisions are taken at each eve and shared at a eves. Each Viage organization constitutes four sub-committees. Each SHG in a viage sends one member for each subcommittee at the meeting of VO. Thus from each SHG four members go for VO meeting. The members of Subcommittee have vountary function.one of the subcommittee, Nyay Evam Adhikaar Samitee (Subcommittee for rights and Justice) discusses around the theme of nutrition. They initiate discussion around Women and Chid nutrition in the primary members in SHG and take up issues and agendas of their SHG in VO meeting. These members aso make action points around the issues, visit viage eve pubic institutions ike anaganwadi and schoos to monitor and strengthen their functions. These members aso initiate the discussion around women and chid nutrition in their SHG meetings. They aso hep in organizing, handhoding trainings and orientation events around nutrition with primary group by master trainers in the Viage. There are Master trainers for Nutrition in each VO. These subcommittee members aso receive oriented by Master trainers and Professionas. Thus there is a team consisting of PRADAN Professionas, PHRN BPO, Master trainers and Subcommittee members to reach out to the remotest area in the bock. There are currenty at 190 viages in Kathikund with 874 SHGs, 80 VOs, three Custer Leve Federations and 1 Bock Leve Federation. We wi reach up to 11,300 rura women and their househod. PRADAN Professiona in conversation with SHG member in the eafy vegetabe fied 208

217 Current outreach and presence of PRADAN Bock Tota Tota Tota Tota Tota Custer Bock Leve Tota Rura Name Viages Panchayats Househod SHGs Vos Leve Federations House Hod (as per Federations Reached census 2011) Kathi ,300 kund We have aready done training on nutrition sensitive agricuture with 6,600 househod and another 3,500 women have received initia orientation on Nutrition. In there were 4,800 househod to whom we have supported with preparing their kitchen gardens. Simiar piots are aso being undertaken in others parts of PRADAN's operationa areas. Once the prototype is deveoped and we see positive impact on a sustainabe basis on materna and chid heath we wi adopt and take it to a our operationa areas which is today more than 6 akh women and 3 miion peope. Repicabiity a) Perspective buiding exercises and orientation of professionas and community eaders around nutrition and manutrition with support from partner PHRN b) Adding to it the training materias, modues and visua toos are shared to other ocations. c) Exposure visits from other ocation to Kathikund hep to buid prospective. Impact Achieved a) The arge scae socia mobiization and presence of community institution at different eve heped to create awareness. It gave potentia strength to the program. The mandate to work on nutrition was taken up in Annua Genera Meeting of the federation. This heped to create an informed choice to work around nutrition. b) The focus on issues of women and chidren heped the program to gain momentum. The institution of women coectives heped and acted as a rich patform to generate reguar discussion and awareness on the subject. The arge scae and coective effort heped to raise severa issues. c) The theme of nutrition found its pace in stas and BMI camps of arge gathering event of federation. These gatherings are Meas (congregations) and Adhiveshans (Assemby) of Federation. Here arge number of women witnessed skits and songs around nutrition. d) The presence of chidren and adoescent girs in the training events in VOs and SHGs gave wings to the program as they are fast earners. The hand wash events and stories with pictures were major attraction. In one of the case the chidren have forced the teachers to provide soaps for hand wash before mid-day meas in schoo. 209

218 A Nutrition Workshop e) Contextua stories around women ife cyce, nutrition garden were shared with actors having oca names.these names ike SONI, MADHAV, SILVANTI, ROPNI and MADHU are now famous in the viages. f) Key messages of i effects of eary marriage, education ti 12th and care during pregnancy receiving wide attention. Eary marriage is a stigma to the society and a sient kier. The discussion on women ife cyce gave voice to the issues. There have been 10 to 15 cases where the mothers took decision not to for eary age marriage of their chid. It contributed in saving the girs from eary marriages. In some cases women coectives took action against the houses of Gram Pradhan who is the head of triba community. g) BMI camps heped to initiate the discussions around nutrition. After taking weight and height we cacuated BMI and then tied hands with RED ribbon to the women with ow or high BMI and a green ribbon on one in correct range of BMI. The the red and green coors caught visua attention and created disturbance. h) Pays reated to food diversity and nutritive importance of different food groups were conducted with demonstration of ive foods from fieds and forest. I) The movement and actions of SHG and Federation around PDS and Liquor ban created arge scae awareness in pubic and in ine departments. 210

219 j) The referras of SAM chid and quick recovery of chidren generated interest to work around nutrition. This action aso heped to create pressure in Anaganwadi to refer the SAM chidren and strengthen the growth monitoring process. k) The effects of manutrition are mutidimensiona. Thus integration with various themes is needed to address the issue. The intervention of integrated ivestock rearing heped to reach out to andess non-agricutura famiies. The economic gains from the ivestock are transated to consumption of nutritious food. ) There were focused discussion around socia determinants of manutrition.the interventions have heped to break taboos around breast feeding in which severa things ike honey, goat mik were given to baby and sometimes babies were treated with heated iron rods to keep away stomach disease. Myths around keeping the women in fasting for few days to cean her impurities are now being chaenge. There were myths reated to consumption of moringa, papaya that it wi create anemia etc. The awareness around benefit of foods has heped to cear such myths. The oca shrubs and forest pants were aso identified in such exercises. m) The capacity buiding around ski gap and deivery method of trainers. Emphasis were given methods to make training and orientations catchy and attractive. n) The pathways of intervention have ed to change in the current situation. i. The increase in production of food and nutrition sensitive crops -have compemented in the behavior change around consumption of tri coor food-this change in behavior is eading towards better heath condition of mother and chidren. ii. The awareness around IYCF, reguar discussion in community forums has increased demand towards services in Anaganwadi and Mid-Day -Mea. The movement around PDS and Liquor Ban has aso heped in changing the condition of food security and mother and chid care. The empowerment of women in taking househod decision has given her choice of food for consumption and production. Their identity as a member of SHG, VO, Custer and BLF has infuenced the parameters in Production, Chid and Mother Care, services deivery of pubic institution. Capacity Buiding I. Capacity Buiding of Community Leaders and master Trainer: The PHRN BPO and PRADAN professionas conduct these capacity buiding program Phase wise orientation program- The whoe program is bifurcated into phases caed Perspective Buiding 1,2 and 3 In each phase there are three days residentia Prospective Buiding and orientations. There are modues for each PB exercise.these modues are roed out in form of stories with rura context. 211

220 The modues are compemented with pictures cards of story and pays. The Cassroom session of three days is foowed by fied exercise to check the ski gap of the trainers and provide them feedback. The fied exercise consists of 2 to 3 days stay of trainers in seected viages to conduct the training. ii. The Capacity Buiding of VO subcommittee members The members of VO subcommittee aso undergo orientation for three days These members aso go through the orientation and training of modues with stories and pictures. These subcommittee members are provided with training materias of Picture cards of stories and text. iii. The training and discussions in forums of SHGs and Vos. The master trainers with support from subcommittee members ro out VO eve and SHG eve trainings. After the trainings the subcommittee members generate the discussion at SHG and VO eve to keep the agenda aive. They use the interactive picture cards and refer to the stories to reate to their rea ife situations. Partners of the Project Broad activities of PHRN (PUBLIC HEALTH RESOURCE NETWORK) our partner organization which coaborates with us as a Technica Resource Agency incude: A baseine study to understand the extent and nature of manourishment in the area. Deveop micro eve impementation strategies of interventions for community mobiization and systems strengthening. Design and deveop training modues on various heath and nutrition issues for master trainers and deveop training tookits for Community Resource Persons. Training and capacity buiding on heath and nutrition issues for (i) PRADAN staff of a eves; and (ii) impementation of training for BPO, executives and members of the Nutrition Monitoring committee, who wi be the master trainers and mentors to Community Resource Person. Conduct refresher trainings, as required. Handhoding PRADANs staff; executives and members of the Nutrition Monitoring Committee/Community Resource Person to take these issues forward to the community and to engage with the service providers. Ensure reguar monitoring and handhoding for project impementation. 212

221 Periodica review and reporting of project activities. Use earning from the sma piots that successfuy ink nutrition with iveihoods to engage with the community and faciitate their action towards new practices. PHRN and PRADAN teams are working cosey to incorporate nutritiona objectives into agricutura and iveihood practices and interventions. This woud invove the fied teams of PRADAN and PHRN exporing ways to synergize the contribution of PRADAN's current projects and initiatives to nutritiona outcomes. This coud invove sma piots that wi feed in to the arger intervention. Awards/Endorsements Not yet, however we consider FICCI considering us to present our work in this conference is an endorsement. Story of Change PHULOWATI DEVI LEADING THE PATH -to a better heath for a the mothers and chidren of Joraam Viage Haraa haraa khayenge, haraa haraa ehrayenge (we wi eat green and our fieds wi sway with greenery), a oud voice of Phuowati devi now reaches every househod in Joraam viage. Phuowati devi is a member of Gayatri Mahia Manda, a sef hep group in Joraam Viage in Bartaa Panchayat of Kathikund Bock in Dumka. She stays with her husband and two chidren, both boys. The eder one studies fifth standard and the younger in second sandered in a oca government schoo in the viage. Women taking care of their Poshak Batikas 213

222 The meaning of her sogan you can see in her backyard and in her farm. She grows a variety of green eafy vegetabes ike spinach, amaranth, coriander eaves, papaya, moringa and emon round the year for househod consumption and the essence of greenery to her house. She is a master trainer in our Nutrition programme. The picture was not the same two years ago when her food pate ony consisted of one or two items. She shares, "I can reca those days when the coor of our pate was white, we used to eat ony rice and potatoes in amost every mea.. The ony benefit that we coud get from such food is to fi our stomach and feed our hunger. We hardy used to consume from the nutrition rich pants surrounding us and in fact negected their presence". Ignorance, iiteracy and myths payed evi in these remote and unreachabe hiy viages of Kathikund bock. Whie oca food items were ignored due to superstitious beiefs attached to it. For instance moringa and most of the green eafy vegetabes (ike severa varieties of spinach) was not eaten as it is beieved that it wi increase probem of cough and cod. Moringa was aso attached with beief that it wi weaken the body. Puses ike masoor da(red entis), kuthi daa(horse gram) were not consumed with beief that it wi increase skin probem, wounds woud not hea if it is consumed. Papaya is not eaten with beief that it wi increase cod probems. Lemon was not aowed during periods as it wi increase it. A heathy food was aways regarded as a matter of expense (meat, fish, egg, fruits, etc). Heath was a matter of fate and a business of doctors. Few years ago Phuowati attended a BMI checkup camp conducted by PRADAN. After the camp she received a red band in her hand. She had aready gone through an orientation programme, so she shares her state of mind after the camp, "I was nervous to find out that I am not in a range of good heath and the red band provided by PRADAN dada increased my curiosity to know what I shoud do to get a green band". To deveop consciousness towards heath and nutrition PRADAN conducts sensitization camps around BMI check and provides red band to women with ow BMI and green band to women with optima BMI. The visua input through coor symbos has a deep impact among these women. Attending the orientation and an interactive session after the BMI camp Phuowati shares, "my concerns found soution when I attended interactive session with experts to understand the benefits of different foods, their groups and the importance of ocay avaiabe nutrient rich foods. We understood their importance as body buiding foods, energy giving foods and foods to protect from disease and increase bood in our body. I aso understood the concept of tricoor food pate and I coud reate my food pate with the coours of our nationa fag. Now I recite the sogan in every group meeting with other women, ACHHEY KHANEY KI THALI TEEN RANGO WALI (A good pate has three coors), with major emphasis on eating green eafy vegetabes." Thus sogans, coors and simpification of compex messages into oca terms payed an important roe in deivering key messages that PRADAN wanted to give these women. The consumption pattern sowy began to change in her famiy as she shares that, "The interactive sessions around nutrition by PRADAN heped us to understand the concept in a step by step manner. With increased curiosity after every meeting, I coud now find time to think about my heath and aso started discussing on this theme in SHG meetings." She further shares that, "Even after gaining insight 214

223 from the meetings our sous were disturbed to find that there was very itte scope for cutivation of round the year vegetabe. Due suboptima eve of agricuture it was hardy possibe for cutivation of round the year crops. The area is rain fed and the ands were unduating. We coud hardy aspire for cutivating food crops in seasons other than kharif(rainy). Thus the ony option was to buy vegetabe which was hard for our pockets". Both Phuowati and her husband se vegetabes in oca market in Kharif season but for them aso the idea of round the year consumption of green vegetabes was beyond imagination. The major portion of their pate was thus fied with rice and potato.. But she was determined as she understood the necessity to eat heathy food. Her famiy was often stricken by diseases. Jaundice and Maaria are invited diseases in her house every year. Her husband aso reguary compained of weakness after a day's hard abour in fied. So she attended further orientations around nutrition and nutrition sensitive crop organized by PRADAN. A ow cost mode of kitchen garden was introduced to her where severa vegetabes and few varieties of oca puses coud be grown. She earnt that she coud use the waste water in her house and oca organic fertiizers to sow few seeds of 8 to 10 crops in her backyard. These crops needed very itte irrigation and the use of organic fertiizers heped to retain moisture and productivity of the and. Now it's no more a dream, it's a reaity. Phuowati shares, Every morning I rise with fresh mind to see greenery in my backyard. I now incude green vegetabes in my famiy's everyday mea. My chidren have shining faces and they enjoy the variety in food. We have aso started consuming forest shrubs, one of them famousy known as Bindi Araa (Santha Name of a vegetabe).this vegetabe has heped to retain my bood pressure eve. I aso serve emon water to my husband after he comes from work and it is the best use of emon pant in my backyard. Phuowati understood that a weathy ife is not a precondition to consume heathy food, fighting ignorance coud aso ead the road to heathy iving.phuowati Devi in her kitchen garden with a basket of Brinja Within a span of two year her ife became a song in which she added few more ines and sings it as, Haraa haraa khayenge, haraa haraa Lahrayenga, sabkuchh ghar mein ugayenge, karidkar kuchh nahi khayenge (We wi eat green and sway in greenery, we wi cutivate everything at home and wi not buy anything from market). Today ike Phuowati, 40 women from the 6 sef hep groups of Joraam* viage have infuenced their famiy to have kitchen gardens in their backyard and eat heathy. *Joraam is a viage with 46 househods and 218 popuation. 215

224 Phuowati Devi in her kitchen garden with a basket of Brinja Professiona Assistance for Deveopment Action (PRADAN) was founded in 1983 by young professionas inspired by the beief that we-educated peope, with empathy towards the poor, must work directy with them at the grassroots to aeviate mass poverty in rura India. They reaised that the critica gap in creating change was the absence of capabe peope, not materia resources. PRADAN seeks to reaize its vision of creating a just and equitabe society where everyone ives and work with dignity by buiding robust coectives of women that wi strive for arge-scae change in human condition. PRADAN works with 588,289 famiies in 7,434 viages spread across 37 districts in 7 States, ~70% of who beong to most vunerabe groups such as daits and tribas (indigenous community). Promotion of sustainabe iveihoods is integrated with work on issues of gender, governance and access to rights and entitements. Starting with a piot project to improve the fied 216

225 impementation of the Government of India s (GoI) rura deveopment programs in 1987, PRADAN has payed a design improvement roe in a major programs ike the IRDP, NREP, SGSY, NRY, and Nationa Rura Liveihood Mission (NRLM). Today PRADAN is the Nationa Support Organisation to NRLM, the fagship rura deveopment programme of the GoI. Besides creating socia capita, our iveihoods improvement work with our communities produces incomes of Rs 1,250 miion annuay and our sectora programmes on sma-hoder poutry and tasar sik rearing are the argest organised efforts in the country. PRADAN aso has made semina contribution to professionaising the deveopment sector through its structured programme to induct, groom and depoy the best and the brightest for the poorest (Leadership for change programme). Ti date professionas have gone through this programme and 80% of them are sti in this sector. PRADAN has been an organisation of socia entrepreneurs; 18 of our aumni are eading their own organisations. Today PRADAN has 400 pus trained deveopment professionas working in far fung remote viages in most chaenging conditions dedicated to the task of nation buiding. With more than 34 years of engagement on issues of rura poverty, PRADAN visuaizes a just and equitabe society to sustain the transformation of the human condition that it catayzes. PRADAN s aim, therefore, is to stimuate and enhance the sense of agency of coectives of poor peope, especiay women, eading to occupying their rightfu space as equas in society and taking on responsibiities of citizenship. To fructify the vision our pan is to expand five-fod to be with 1.5 miion rura poor famiies (~10 miion peope) by 2022, this is 15% of poor famiies in the poorest 52 districts of India. Change at this scae wi substantiay impact the conception and deivery of pubic programmes and create mutipe impact nucei that wi trigger economic vibrancy ocay, aowing many more to emerge out of poverty as a consequence. PRADAN is supported by prominent actors in the deveopment ecosystem, incuding the GoI and state governments, UN Agencies, TATA Trusts, Bi and Meinda Gates Foundation, IKEA Foundation and corporate foundations ike Axis Bank, HUF, Inter Gobe Aviation Ltd (Indigo) etc. Much of the success of our work is attributabe to our partners who have enriched our work. Integra to PRADAN s resource utiisation approach are everage and efficiency. Every rupee that PRADAN spends on its own costs resuts in Rs 4 of Programme Investment in creating assets and capabiities for the poor. This is combined with a highy efficient operating mode, in which ony 4% of the overa investments are nondirect costs. Our work is currenty being supported by over 80 donors. 217

226 Poshan-Community Based 1, days Initiative January December 2019 Foundation for Mother and Chid Heath Website : Founder of the Organization : Ms. Piyasree Mukherjee Project Budget : ` 57,00,00 Coverage/ Geographica reach : Kura West, Mumbai; Popuation covered: 55,

227 Project Brief FMCH addresses the issue of materna and chid heath and nutrition among vunerabe communities through a hoistic approach of preventive care, treatment, community education, and partnership training programs. The organization's vision is "Heathy mothers and thriving chidren for a word of unimited possibiities". This is being achieved by Promoting preventive heath, nutrition and hygiene practices Infuencing change in behaviours around heath, nutrition and hygiene by presenting updated, accurate, actionabe knowedge to the community Deveoping strategic partnerships with community, other organizations and government to scae the reach of our nutrition and heath modues and practices In India's current heathcare scenario, institutions tend to focus more on treatment deivery, and the importance of nutrition and preventive care tends to take a back-seat. The heath seeking behaviour of the popuation aso contributes to this. FMCH focuses on these components with a specia emphasis on nutrition, which is critica in the heath and economic deveopment as we to achieve a number of Sustainabe Deveopment Goas. FMCH's mode is to promote materna and chid heath and nutrition through knowedge-based interventions and devising strong strategic partnerships with government and non-government agencies. Based on FMCH's experience on the ground with existing systems in an urban setting, Project Poshan was designed to ensure timey intervention for mothers and chidren in socio-economicay vunerabe communities through the First 1,000 Days approach. First 1000 days is a period of chid's ife from their conception unti their second birthday. Proper nutrition during first 1000 days of a chid's ife is the key factor in ensuring that they survive and reach their compete potentia. Right nutrition and heath inputs during pregnancy and in the first years of a chid's ife provides the essentia buiding bocks for brain deveopment, heathy growth and a strong immune system. It aso impacts materna mortaity since the focus is on ensuring the mother receives timey ante and post-nata care, which incudes vaccinations, vitamin suppements and proper nutrition. Through this approach FMCH is impementing aninnovative intervention by engaging with famiies of pregnant women and actating mothers and their chidren. Poshan project is being impemented in partnership with the ICDS team and deveoping inkages with governmenta heathcare agencies. The primary purpose is to optimise existing resources and buiding a strong and sustainabe structure. FMCH beieves in buiding capacities of famiies, communities and existing systems and heping bridge the gaps and not buiding parae systems. Here are the specific objectives of the project: Reaching out to600 pregnant women/actating mothers and 800 chidren (0-2 years) by March 2019 Preventing manutrition during the first 6-months after chidbirth by ensuring 85% of mothers with new-borns receive first breast-feeding assessment and counseing service within first 45 days after birth Successfuy impement the First 1000 Days program by ensuring 85% of chidren who graduate the program are in 'We Chid status' as per the WHO guideines 219

228 (meaning their weight for height wi be above -2 percenties on Z Score chart) Disseminating actionabe knowedge to the community through specia education modues to 75% mothers through pregnancy cub, nutrition course and Achha Bacchasessions designed to disseminate accurate, actionabe knowedge on ante & post-nata care, IYCF and Chid Deveopment The aim is to focus on promoting preventive heath and nutrition, thereby, buiding a sustainabe structure by bridging the gap between demand and suppy aspects of heath ecosystem. Impementation Mode The emphasis is on impementing a sustainabe mode that addresses chaenges of ensuring proper input during first 1000 days of a chid's ife. This mode is community based, and accesses the existing systems and services provided by the Government, inking them to pregnant/actating woman and their chidren under age two by fiing the knowedge gap as we as deivery of certain services which are not presenty avaiabe. Anthropometric monitoring- Growth monitoring through reguar anthropometric measurements ike height, weight and mid-upper arm circumference for mother and chidren undertaken at the ICDS center. Home visits- Breastfeeding assessment and support, compementary feeding and weaning support, nutrition counseing, immunization counseing and referra, counseing of famiy members on importance of both ante and post-nata care, advocacy for the mother and the chid with famiy take pace through reguar home-visits. Critica care cinic- For chidren who fa within the first 1000 days with critica issues (stunting/underweight/ acute manutrition) or any high-risk pregnancy, providing appropriate treatment and referra. High risk pregnancies are identified using the Care Mother Kit, a potabe medica kit and mobie appication used by the frontine workers to identify high risk cases and inking them to appropriate referra points. Chidren with acute or chronic manutrition are (what do we do with them?) Knowedge dissemination- Conducting sma and arge scae community engagement activities, as we as the education modues designed by FMCH based out of the ICDS centres. Training and capacity buiding of ICDS team- To ensure ong-term sustainabiity of the program. Forming community-based heath and nutrition committees- To support in mobiizing and infuencing famiies and buiding capacities within the community. Community Outreach Linkages with governmenta and non-governmenta agencies - Buiding strong reationship with existing governmenta and non-governmenta agencies is the first step towards getting to know a community. Baseine and Endine survey - Before initiating any intervention in a new project area, there are few 220

229 steps foowed by FMCH. It starts with conducting a baseine survey to give an in-depth understanding of the current scenario. These indicators are aso hepfu in anaysing impact of the intervention when compared with end-ine resut. It heps gather information of not just the quantitative indicators but aso quaitative information ike, socio-economic profie of the popuation, chaenges faced etc. Community Mapping and Focus Group Discussions- This is conducted aong with various community stakehoders ike the oca community and government representatives. Community mapping heps in a better understanding of ayout of the area, identifying new and od resources, identifying partners for coaboration, and most of acknowedging individuas and oca institutions who have the capacity to create rea change. FGDs heps gather information on strengthens and chaenges in the community and devise an appropriate pan of action for intervention. Househod screening- A door to door survey aids in identifying famiies under the target groups. This is aso used as an opportunity to introduce FMCH to the famiies. During this process a rapid nutritiona assessment method heps in screening chidren suffering from acute manutrition and appropriate action is taken. Community awareness and education- Sma and arger scae events are conducted to mobiise the community by fostering communication and information exchange. This is used as an opportunity in spreading knowedge about need for good nutrition, heath and hygiene practices. Community support systems- Creating support groups and identification of community change agents and infuencers to hep create a sustainabe community system. Uniqueness of the Project Simpifying nutrition into actionabe information to educate famiies and communities through knowedge dissemination activities. The aim is to bring back oca knowedge reated to nutrition and heath into the mainstream. This is being done through impementing various education modues deveoped by FMCH Infuencing key decision makers in the famiies ike fathers and grandparents, especiay mother-inaw, by engaging with them through various innovative initiatives. This heps in buiding a strong support system for the mother and chid. Integrating preventive and promotive strategies into existing systems. This wi not ony reduce the financia burden on famiies and state, but aso have a positive impact on individuas being abe to reach their fu potentia. Introducing technoogy ike Saesforce and Care Mother kit for successfu impementation and monitoring of intervention project. Roe of Information and Communication Technoogies (ICTs) a. Saesforce- Saesforce is a web-based customer management system that has been customized specificay for the organization. This software not ony heps FMCH for monitoring of activities and progress of chidren, but aso in donor reporting. The system provides rea-time, individua and aggregated data for a FMCH programs, and is used to capture data for a FMCH projects. b. Care Mother- Care Mother is a portabe kit and mobie appication deveoped for the frontine heath 221

230 workers. This kit enabes them to provide critica antenata care at door the doorstep, thus encouraging heath seeking behaviour and creating a strong referra system with the heathcare provider. Chaenges Faced There is an urgent need for promoting the need of preventive heathcare and improving heath seeking behaviour among the popuation. This is observed to be not just a chaenge in marginaised communities but aso among the affuent popuation. One of the specific chaenges faced in the project area was deay in approaching heathcare provider to receive antenata care. Most of the pregnant women register pregnancies at a heath faciity and avai services ony by 6th or 7th month of pregnancy. This means that they have aready missed out on receiving crucia support ike nutritiona suppements and assessment of current heath condition. This aso incudes their resistance towards receiving tetanus immunizations during pregnancy which they beieve causes infertiity. Women tend to not consume essentia pre-nata suppements ike iron, foic acid and cacium which further eads to putting the woman at heath risk. This is aso contributing to high incidence of anaemia among pregnant women being reported. To address this issue, FMCH focuses on identification of pregnant women eary on in their pregnancy, refer them to the primary heathcare centre and cosey monitor their we-being by providing nutrition education and support. The next key focus area is to engage with the entire famiy, to educate them and advocate for the mother so that famiy members, especiay the decision makers provide a the support they need. We aso buid a trusting connecting with individua women to supportthem in making decisions regarding their own heath. Outcomes Direct Reach In the first phase of the project, through screenings and assessment, FMCH has identified and registered 800 women and chidren in the program. These incude pregnant women, actating mothers, chidren under the age of two years, and chidren under the age of five identified with acute manutrition. Improved Nutritiona Status The term manutrition is mutifaceted. It encompasses both over-nutrition, associated with overweight and obesity, and undernutrition, referring to mutipe conditions incuding acute and chronic manutrition and micronutrient deficiencies.who defines Wasting or Acute manutrition as ow weight for height/ength. This condition is associated with increased morbidity and mortaity in chidren thus making it a serious concern of manutrition in chidren. Chidren with severe acute manutrition are at 9 timeshigher risk of dying due to increased susceptibiity to suffer from infections because of extremey ow immunity. 222

231 Figure1. Baseine Wasting StatusFigure. Current Wasting Status Figure 1 shows the wasting status of chidren when they were first registered at FMCH and Figure 2 presents their ast measured status. The graph very ceary shows significant decrease in the number of chidren suffering from severe and moderate acute manutrition and increase in chidren under 'We Chid' or heathy category. Reguar growth monitoring, appropriate nutrition counseing and support is crucia in promoting behaviour change and thus improving the nutritiona status of chidren. Reach through Educationa Activities Educating communities is key in infuencing communities and behaviours. Since the beginning of intervention, the primary focus was to create awareness among a famiies in the community regarding various nutrition, heath and hygiene reated aspects impacting ives of mothers and chidren. This supports in mobiising communities and engaging with a much arger group of popuation. In the first phase of intervention cose to 7,000 individuas have attended 430 sma and arge activities and events conducted in the community. Adequate nutritiona intake The First 1,00 Day's in chid's ife is a time of critica growth in which proper nutrition is absoutey necessary. Chidren who have poor diets, whether because of a ack of food or because of patterns of eating that ead to inadequate intake of nutrients, are prone to significant short-term and ong-term heath impacts. And the period of transition from excusive breastfeeding to soid food is a crucia phase in this period. As per NFHS 4, ony 8.7 chidren in India between the age of 6 to 23 months have adequate diets. Since the initiation of Poshan project, 20% chidren have been reported to have adequate diet. Though this number is not as desirabe, there has been a significant improvement and it demonstrates success of the strategies. Improved average birth weight Birth weight is a key indicator in assessing birth outcomes and used as a foundation for panning the goa 223

232 for achieving required growth of a chid as per the standards. Low birth weight is defined by Word Heath organization as weight ess than 2.5 kgs. A steady improvement in the birth weights has been observed in mothers who have had reguar interactions and reported an average birth weight of 2.6kgs. Outreach & Scaabiity FMCH engages and educates the famiies and community through various activities. The emphasis is on creating a heathy ecosystem within the community. Aong with this it focuses on strengthening the existing heathcare service system instead of dupication. The intervention can be scaed through buiding strong partnerships and inkages with various stakehoders. The project design is unique in nature as it is devised to integrate first 1,000 Days approach into one of India's biggest government systems. As per a report reeased by Niti Ayog, ICDS today covers 8.4 crore chidren under the age of 6 in the country, 1.91crore pregnant women and actating mother through 7,066 projects and akh Anganwadi centres. Hence, it gives an opportunity to scae-up through a strong and sustainabe system. One of the components of the project is to provide simiar capacity buiding support to frontine workers of heath department and other NGOs who cater to the same popuation in different capacities. E.g. an organization working on pre-schoo education aso becomes a channe in educating famiies on the need for good nutrition and heath choices. As this directy impact physica and inteectua potentia of the chid. Repicabiity This project can be easiy integrated to other ocation as the FMCH modues are designed in a such a manner that it gives scope for customising it based onthe popuation profie. At the same time emphasises on principe of essentia nutrition actions accepted internationay. Eg. Practica sessions on preparation of nutritious compementary food by incorporating oca, inexpensive ingredients in recipes making it more acceptabe. Impact Achieved The resut framework of Poshan project is defined to achieve the foowing impact Positive Socia Behaviour Change in the heath ecosystem Bridged gap between demand and service aspects in heath ecosystem Reduced manutrition in manutrition Improved heath and nutrition indicators for reproductive, materna, chid and adoescent heath towards achieving Sustainabe Deveopmenta Goas. 224

233 Buit capacities of stakehoders ike famiies, communities, government and non-government agencies. As impact evauation is a ong-term deiverabe, it wi be anaysed after competion of the project. Capacity Buiding FMCH Frontine - FMCHfrontine workers are identified and recruited from the community. The aim is to provide empoyment opportunities, encourage ownership and buiding stronger reationship within the community. These frontine workers receive intensive training on reguar intervas to make them heath and nutrition ambassador for the community. They are aso trained on using technoogy and making them independent in executing their responsibiities. Capacity buiding of the ICDS team is an integra component ofintervention design. The approach is to engage with them on a reguary basis and train them on various topics reated to the project. It covered topics ike basics of nutrition, Infant and Young Chid Feeding practices, Breastfeeding, Antenata care, Science of manutrition and using anthropometric measurements and WHO growth charts. The AWWs shared that they gained new information on nutrition and heath which woud be beneficia for impementation of their programs. Educating stakehoders - This incudes educating key change agents and infuencers from the community and partner organization who are instrumenta in mobiising the community. The community support group members are aso trained Partners of the Project ICDS - ICDS team is the primary impementing partners of Poshan project. FMCH team members wi be works with the ICDS centres in order to identify eigibe women and chidren. These beneficiaries are registered both at the ICDS centre as we as FMCH for accurate foow-up work. Government Primary Heathcare Centres and Maternity Home- FMCH has partnered with these agencies of department of heath under Municipa Corporation for buiding strong referra system. The high-risk pregnancy cases are cosey monitored bysupporting their team. Chidren identified with inesses and serious nutritiona deficiencies are referred to their centres for further investigation and treatment. Nutrition Rehabiitation Center - Chidren identified with severe acute manutrition(sam) who need urgent medica care are referred Nutrition Rehabiitation Centre run at the tertiary care government hospita in Mumbai. These are chidren who cannot be treated for SAM at community eve due to underying medica conditions which need urgent attention. Awards/Endorsements Not yet 225

234 Project Kavach- Cick Initiative Apri March 2019 Institute for Goba Deveopment Website : Founder of the Organization : Dr. Suni Mehra Coverage/ Geographica reach : Baddi, Naagarh Bock, Himacha Pradesh 226

235 Project Brief IGD in association with Genmark Foundation is working towards improved nutrition, heath and webeing of infants, chidren & women by optima Infant & young chid feeding practices and provision of basic/ primary heath care services and heath awareness through provision of sustainabe integrated services to socio-economicay marginaized community in the Soan District of Himacha Pradesh. Primary Heathcare services incuding basic diagnostic and referra services are provided at the target geography through Mobie Medicare Unit & Behaviour Change Communication for the pregnant mothers, caregivers, adoescent girs on issues reated to nutrition, immunization and persona heath and hygiene as we as sensitizing the other stakehoders in the heath system and oca governance, for reducing chid mortaity in the bock. Impementation Mode The methodoogy of Behavioura Change Communication is the basic component by way of reguar visits to the fied, active engagement with the pregnant women and actating mothers. There are reguar home visits that are done after identifying the women going through any compication during or after the deivery or towards the immunization and proper care of the new born chidren. The foow ups are done by inking the beneficiary to the pubic heath system through Anganwadis, ASHA workers and the community heath care centre. The structure is made such that a heath worker of IGD is working with the Community Heath Care Centre to assist them and the community to seek heath faciities especiay towards the heath of mother and chidren. Technoogy and mobie App namey CareMother is aso being used as an intervention mechanism through which the heath indicators are tracked and accordingy foow ups are done. Other than this, the primary heath care services are provided to the targeted viages with the assistance of ICDS system and through the hep of our Heath Workers. Community Outreach There is recognition of important days where ceebration is conducted within community especiay women and chidren and the government heathcare faciity. There is reguar foow up by way of fied visits, primary heathcare services through which the women come to seek heathcare not ony in terms of their physica webeing but aso their reproductive heath which and the heath of the chidren between 0-6 years. With the fied intervention, the tracking of pregnant women and the pregnant women with compicated pregnancy are targeted and reguar counseing and information sharing is done with them. The inkage is buit between the pubic heath services and women as beneficiaries. Further, reguar home visits are done towards the care and webeing of pregnant women with compicated pregnancy, chidren between 0-6 years with medica conditions or actating mothers with medica issues and in need of assistance. IGD works with the famiy members to give and comfortabe space to the chidren and the woman for heathy iving. 227

236 Uniqueness of the Project One of the ground breaking feature of the project is its abiity to provide services at the interior of the viages and to bridge the gap between pubic heath system and the beneficiary. The service deivery system is intended to be accessibe for women especiay pregnant women and actating mothers can avai services through Medica Mobie Unit aong with a doctor, assistant and ab technician as we faciitating immunization process and buiding inkages with the pubic heath deivery system, and making the ast mie deivery at difficut to reach ocations. The approach which is adopted is to increase the shared decision making at the househod eve to improve MNCH practices. The intention is to increase women's voice in househod decision making about MNCH and encouraging invovement of their partners in the care and attention. Roe of Information and Communication Technoogies (ICTs) The targeted region of Himacha Pradesh is constant in having migratory workers and their famiies. It is then when it becomes difficut for them to foow up with their pregnancy or to give fu information to the present heath worker. With the Caremother appication, IGD has been abe to reach such women, track the risk they have towards their pregnancy and assist In foow up with these pregnancy either by way of connecting them to the pubic heath system and heath functionaries and provide required counseing and support system. This onine patform has been deveoped with a vision to provide 228

237 hoistic soution to pregnancy reated compications and is being used in many states across the country. If a beneficiary gets migrated to another state where our patform is being used, she coud sti be abe to get the services and care she needs. Chaenges Faced The team sti come across cases where the chid birth is happening in the house without the support and assistance of trained midwife even after constant counseing and reguar meetings. To overcome this situation, we are trying to increase our accessibiity in the fied to ensure that more attention goes to the fied and to strengthen the trust buiding mechanism. With increasing number of persons seeking medica hep there remains shortage of medicines and staff to attend them. Though this is a positive sign that the response from Mobie Medica Unit is immense in its approach but the shortage of medicine remains a constraint. To overcome this, we are reaching out to the organisations to provide medicina assistance to ensure it. Outcomes If ooking at the recent outcome, we have a strong reach in six viages of Baddi. The number of patients provided with primary heath care were 4000approx in the previous quarter. The trainings and capacity buiding programmes are conducted for the fied eve heath workers and separatey for pregnant and actating mother and other care caregivers. The indirect beneficiaries became the chidren between 0-23 months. During the quarter 3748 pregnant and actating mothers were benefitted from Materna heath programme, 559 pregnant women have been registered through the CareMother App out of which 294 are high risk pregnancy. Proper monitoring and case is continued to be provided to women with high risk pregnancy. Reguar intervention is done by way of Viage Heath Committees to encourage behaviour change among the underserved persons addressing issues of pregnancy, new born and chid care and faciitating access to obstetric and new born care at pubic and private faciities. Outreach & Scaabiity At the beginning of the program the ocation and objectives of the project were the Bock area of Naagarh. With continuous work and intervention based on the Rapid Assessment of Materna and Chid Heath Situation and Pubic Heath Service Utiization in Naagar bock of Soan district, Himacha Pradesh, the objectives and activities of the intervention were set out and marked for impementation process. With time, the resuts were showing and with the end ine survey, tremendous change was seen. With this, the reach was increased to the interiors of Naagarh Bock. Baddi, which has an extensive migration from the states of Uttar Pradesh and Bihar the famiies especiay the young coupes with imited knowedge and information on materna and chid heath. Aong with the pubic heath functionaries in Baddi, the interventions are panned aong the ine of need and resources required to strengthen heath system in Baddi. With reguar visits to the fied and home visits aong with fufiing the need for primary heath care. 229

238 Repicabiity IGD is activey working in 10 viages of Baddi and the sum ocations around the office buiding. Further, with active reationship with other organisation working in the area, the interventions on short term basis in the form of events are conducted. Further, the simiar project can aso be repicated to the other districts of Himacha Pradesh for better performance. Impact Achieved The project has heped in improving the heath indicators of the ocation and abe to serve the migratory popuation in the targeted geographica ocations. Capacity Buiding The trainings for the IGD staff is conducted on a reguar basis with the assistance of the technica team. Further, the trained staff under the supervision of Doctor further disseminate the information on the important issues. Partners of the Project Genmark Foundation is the supporting partner in terms of funds to keep the work going in the fied. 230

239 CNA Participated In Nationa Dissemination Workshop Rajasthan Nutrition Project January December 2016 Freedom from Hunger India Trust Website : Project Budget : Coverage/ Geographica reach : 3 Bocks of 2 Districts, Sirohi(1 Bock) and Banswara (2 Bocks) in Rajasthan, covering 68 Panchayats with 316 viages, 670 SHGs and impacting more than 8000 women members of SHGs, through a vounteer namey, Community Nutrition Advocates' (CNAs). 231

240 Project Brief Rajasthan is India's argest state by area and is in the north-west of the country, bordering Pakistan. Rajasthan's economy reies primariy on agricuture, with cotton and tobacco as its key cash crops; it is one of India's poorest states, with its poverty concentrated in its western and southern districts. In the 2011 census, Schedued Tribes constituted approximatey 13 percent of the tota popuation in Rajasthan, making Rajasthan one of the top four states in terms of the concentration of the Schedued Tribe popuation in India. Schedued Tribe popuations are often defined by their historic geographic isoation from the genera popuation in India, which has manifested in reative as we as absoute deprivation. Schedued Tribe househods generay face the greatest poverty and hunger, owest eves of education attainment, and the poorest heath outcomes. Seventy-six percent of the popuation in Banswara district in Rajasthan is Schedued Tribe, making Banswara the district with the highest concentration of Schedued Tribes in the state. Within the Indian state of Rajasthan, women face poor heath outcomes and gender constraints, often at eves greater than the nationa average. Approximatey 60 percent of chidren and 46 percent of women suffer from anaemia, 39 percent of chidren under the age of five are stunted. Stunting is highest among triba chidren in the region compared to non-triba chidren (54 percent compared to 45 percent, respectivey); severe stunting was greatest among triba girs compared to triba boys (31 percent vs. 27 percent, respectivey), ceary indicating gender discrimination in intra-househod feeding patterns. The chid sex ratio is one of the owest in India: there are 888 girs to every 1000 boys. Moreover, women's empowerment status fas beow the nationa average in Rajasthan as measured by a Gender Empowerment Index. Rajasthan scores 0.4, compared to the nationa average of 0.5, on a scae of 0-1 where 1 represents greater empowerment. Ony 25 percent of married women make decisions about their own heathcare; ony 35 percent of women participate in the workforce. The Rajasthan Nutrition Project ed by Freedom from Hunger India Trust (FFHIT) impemented its fagship project with a muti-sectora and integrated approach: Linking Nutrition, Heath, Agricuture and Financia services, focusing nutrition and househod food security. FFHIT impemented the project, aong with two impementing partners, Vaagdhara in district Banswara and Pradan in district Sirohi. The objectives of the project were: To improve knowedge, behavior and access to oca services reated to nutrition for women, adoescent girs and young chidren. To faciitate diaogue that wi ead to increased women's empowerment and more gender equitabe resource management and food distribution within the househod. To improve women's financia iteracy, resource management abiity and skis reated to panning for better househod nutrition 232

241 Four impact areas and targets were chosen to guide the RNP and measure its success at achieving improved food security and heath-seeking behaviours among the rura Rajasthan popuation during its two-year impementation period: 1. Infants breastfed within first hour after birth and excusivey for six months: Target was to reach Rajasthan's breastfeeding rate for breastfeeding in the first hour 2. Use of ORS and increased fuids in treating diarrhoea: Target was to reach Rajasthan's ORS use-rate 3. Improved househod food security: Target was to improve upon the baseine rate by the end ine 4. Improved inkages and use of oca heath and nutrition services, such as the Integrated Chid Deveopment Services (ICDS) program, an Indian government wefare program which provides food, preschoo education, and primary heathcare to chidren under 6 years of age and their mothers: Target was to improve upon the baseine rate by the end ine. Impementation Mode Impementation Mode: Project Methodoogy: Formative Research: To understand food consumption, crop patterns, services avaiabiity and such. Baseine: To understand current status for comparison with end ine. Mapping faciities: for buiding inkages Designed PLC materia: based on earning from the above (simpe doabe messages were deveoped) Buiding capacity: of partner organizations and CNAs on Nutrition Reguar Monitoring: With handhoding support to partners and CNAs End ine: for comparison 233

242 Community Outreach To reach out to communities we focussed on SHG as a patform to have discussions and dissemination of information. The carriers of messages were the seected community nutrition vounteers seected through a community process by the impementing partners. So, it foowed the basic three steps: Capacity buiding of impementing partners i.e PradanandVaagdhara. Capacity buiding of CNAs through impementing Partners Capacity buiding of SHGs and other community institutes for by CNAs. Supporting processes: Monitoring and review of trainings at community eve. Addressing pubic services gaps through community anaysis 234

243 Uniqueness of the Project As women being argey the care takers of food cooked and consumed at home, muti-dimensiona approach through women's SHG patform was considered to be of vaue, through buiding capacity of a vounteer cadre from the SHG group itsef, namey CNAs, These CNAs, faciitated conversations and hand-hoding with the oca sef-hep groups members on nutrition, and on reated areas of materna and chid heath, hygiene, and gender-equitabe resource management. The key strategies features under the RNP were: Muti-sectora: Linking Agricuture, Nutrition, Heath & Financia Services on a Women's SHG Patform. (focusing Househod Food Security) Buiding on Partner's existing programming and capacities Leveraging SHG groups as a patform for mutipier effect for reaching out to women on nutrition and heath messages. CNAs as Vounteers were seected from SHG groups whose capacities were buit to spread newy earnt messages, within SHG members. It heped to retain the Messages at SHG eve in oca access. Gender being cross cutting in a key messages and interventions for addressing gender equity on intra-househod food distribution. It was the key thought that gender is not in isoation, the issues are percoated in every sector. So, keeping gender equaity messages in every modue in exampe the key strategy to address the issue. Buiding Linkages with Government faciities for improved coverage and sustainabiity. Community Score Card introduced to asses' pubic services and to bring necessary changes for the betterment of services. Roe of Information and Communication Technoogies (ICTs) Not in both the districts but in Sirohi, Pradan used mobie based community data coection system around retention of messages in SHGs. Chaenges Faced Some chaenges faced in the Project, such as an inadequate invovement of men, understanding and 'compensating' vounteers, and imited time, the RNP presents a mode easiy repicabe, scaabe, and sustainabe since (i) it is about an issue which has direct reevance to peope's ives (ii) presents them with doabe and effective ways to address their situation (iii) buids on avaiabe community patforms and is hence (iv) cost effective. The initia strategy of the project was to invove men to bring house hod eve changes but after doing formative research and seeing gender gaps, it seems impossibe to bring men on this patform to engage with. So, we deveoped another strategy to reach men. We promoted CNA's to have diaogues at common spaces ike Panchayats, Schoos and even trainings in such paces attracted to men to sit for 235

244 a whie an isten messages. The community institutes organised mass campaigns at viage and Panchayat eve and through songs and act they gave messages about required behavioura changes. We understood that to expand and bring resuts we need a good poo of CNA's but seeing the iteracy eves in women we accepted it as chaenge and designed our training modues in TLC and PC approaches so that it can be we understood by a. We simpified the key messages to retain by CNA's. Both the partners were different approach wise. One wanted to train SHG's Directy and other wanted direct training at VO's (Viage organisations). We accepted both the strategies and deveoped separate training kits for both partners as no. of participants at both patforms i.e (SHG and VO) were different. Time was a chaenging factor. The project time was ony 2 years and said objectives and resuts requires time to bring action. But through accommodating innovations, different strategies by different partners and through strong community based monitoring a resuts became possibe to bring. Outcomes Food security improved from 23% to 53%. Skip entire day without eating from 22% to 12% 236

245 53% of famiies taking meas together at east once a day Increase in green eafy vegetabes from 13% to 58%. Increase in intake of other vegetabes from 33% to 84.6% ORS used to treat diarrhoea 34% to 84%. Deayed medica treatment for chidren in past year due to cost from 55% to 15.9% Deayed medica treatment for hersef (respondent) in past year due to cost from 62% to 28.4% Source of nutrition information from CNAs: 95% Positive changes brought about by the Rajasthan Nutrition Project (RNP) The RNP has ensured that nutrition is on the agenda of the impementing partners and of the women invoved. The women have made definite efforts towards diversifying what they sow in their fieds, to use the 'adjacent unused ands' to grow green vegetabes & medicina pants for their own consumption, to send their chidren to ICDS centers to 'sit and eat' and not to 'go and bring', to fight out their rights at the PDS even if it means to go to the district eve to resove the matter, to ensure that a new mother is breastfeeding the chid within the first hour of the chidbirth, to cook a separate mea for their sma chidren, and not give them a piece of a chapatti and et them be on their own, to go buy an iron cooking pot in groups of women from the same vendor at a cheaper price to count a few of them. Outreach & Scaabiity 237

246 Even the best outcomes of a project, if not repicabe have a imited vaue. Aso, no best practices can be up scaed as a Xerox-copy, the arger things have to be possibe with reevant contextua needs of the area. As a project, RNP has as an evidence based demonstrated that it has a great potentia to be repicated for the foowing reasons: 1. The SHG Credibiity Advantage: SHGs aready exists as a patform in thousands in viages across the states in India, under both Government and non-governmenta programs, which can be easiy everaged for a mutipier effect to spread key nutrition, heath and reated messages of contextua importance to them. 2. Environment buiding for community eve changes: Sending messages across to arge numbers creates an environment for change, as the other members in the community is aso adopting the same, therefore it adopts an incusive approach rather than a secuding approach and expedites behavioura change. 3. Community ead change (CNAs): As the CNAs are part of the community, once they gain trust, the behavioura changes among communities become possibe and the change is aeged to be more sustainabe, as it is ed by the community members itsef. 4. Monitoring by SHGs: As SHG members become aware and invoved there is demand generation, creating aso community monitoring mechanisms. Repicabiity RNP has demonstrated that it is possibe to move the poor famiies towards nutrition security using SHG patform for education and inkage, using CNAs to sustain the processes. There are SHG federations in Rajasthan which can be further strengthened with technica and handhoding support to focus on the muti-sectora approach engaging Panchayat, Loca NGOs and frontine providers of ICDS, Heath and Agricuture. Severa sma piots reevant to the needs of ICDS programming can be undertaken, to provide enough evidence based impact to utimatey repicate and scae up across the state Freedom from Hunger India Trust has both the expertise and the experience in providing necessary technica support to the system, based on the earning and chaenges from RNP. Based on experiences of RNP, a Poicy brief and a Technica guide was deveoped to introduce this muti-sectora approach with other stake hoders for wider repication. Freedom from Hunger India Trust through Community of Practice on Heath & Microfinance (mosty SHGs), aong with other nationa and internationa organisations, is committed to expanding the understanding of the SHG movement, and demonstrate its impact beyond financia incusion and sustenance for poor communities and individuas. Impact Achieved Capacity Buiding: Strategy for bringing behavioura Change Knowedge buiding is the first step towards bringing behavioura changes and this can happen ony when a person understands and is conscious regarding the need for change. For this buiding 238

247 knowedge of the partners and CNAs was focused upon, by deveoping reevant educationa materia reated to their needs, based on the formative research findings. As CNAs were iiterate, hence pictoria earning communication was deveoped with simpe doabe messages that can bring behavioura changes. Handhoding support was provided throughout the project period, to ensure things moved in desired direction and make mid-course corrections. Technica expertise was provided by Freedom from Hunger India Trust in designing reevant training materia and messages, for capacity buiding of the impementing partners in the areas of the foowing: Formative research to identify rea time specific gaps on nutrition security Design of context specific user-friendy picture based education materias on mother on a series of reated aspects on Nutrition, Heath, Nutri-sensitive agricuture and financia services. Systematic monitoring and supervision using simpe toos and key indicators to measure progress and chaenges. The Rajasthan Nutrition Project: Empowering Poor, Marginaized Women in Rajasthan for Improved, Gender-Equitabe Househod Nutrition" had a huge impact on women and their househod to pick up basic practices for better nutrition and heath. FFHIT with the hep of its partners created a poo of community cadres caed as CNAs (Community Nutrition Advocates) in the bocks, identified from SHGs by the Viage organisations to faciitate the information and to engage with community institution as agents of change. These CNAs created an enabing environment in viages and faciitated behaviour change through their intense engagement with the feow women members of the SHGs and the other viagers. This ed to improved changes in heath practices and nutrition status. CNAs are successfu in estabishing basic behaviour changes and practices in majority of househods. Few practices are isted beow: Women having 4 different coours of food in their pate. Women growing at east one nutritious herb in their farm/courtyard. Men and women eating at east one mea sitting together. SHG eaders in diaogue with the service providers. Every member inked with PDS getting food as per entitement RNP Key Messages The foowing 12 messages are those that were refected in the sessions provided by the CNAs but were aso used with the SHGs to create songs and other mechanisms to remember the messages: 1. Initiate breastfeeding within 1 hour of birth. 2. Excusivey breastfeed an infant for 6 months. Infants do not need any water. 3. The benefit of giving birth in the government heath centers is to prevent compications and avai of JSY and JSSK8 benefits 239

248 4. Eating seasona fruits and vegetabes is beneficia for better heath and nutrition of every famiy. 5. Every famiy shoud start a "poshanwadi" (kitchen garden) in their backyard to ensure food security and better nutrition of the famiy. 6. Use ORS to treat diarrhea at the househod eve. 7. Wash hands with soap and water before eating and after defecation to prevent diarrhea and other inesses. 8. Every pregnant woman, actating woman and adoescent girs must consume IFA tabet to prevent anaemia. 9. Every famiy is encouraged to cook their meas in an iron pot to ensure intake of iron for prevention of anaemia. 10. Adopt the practice of eating together for better nutrition of women and girs and promote famiy bonding. 240

249 11. Visit Anganwadi, Mamata Diwas9 (MCHND) Sub-centre and PDS to deveop strong rapport with service providers such as ASHA, ANM, AWW. 12. Adopt the habit of heath savings among SHG members to address emergency heath care expenses. These simpe messages and intervention were retained by CNA's, which were chosen from community itsef. These CNA's are SHG members and monitored the progress in Viage eve organisations and random house hod visits. This enabing monitoring heped the program to retain its foundation and accepted by a. The messages invoved were actionabe and very cear to understand. It heped community to adhere them to make simpe changes in their practices and house hod chorus. These are key factors that heped to take interventions to homes, which generay eft my members at the discussion spaces. Capacity Buiding A Socia and behavior change centered (SBCC) approach enabes change in behaviors, incuding service utiization, by positivey infuencing knowedge, attitude and socia norms. SBCC is a strategic, systematic and targeted approach that uses science and data to reach mutipe eve sof societyindividua, community and institutiona. It is systematic, evidence-based, participatory, and strengthens the stakehoders' capacities. The SBCC approach focuses on: Changing or positivey infuencing socia norms, in support of ong-term, sustainabe behavior change at the popuation eve Fostering ong-term, normative shifts in behavior, in support of increasing the practice of heathy behaviors, Improving the services of provider-cient interactions, Strengthening community responses to issues, Infuencing decision-makers, and famiy and peer networks, Increasing the demand for services and products, Increasing the correct use of services and products, Infuencing poicy, and Encouraging an increased capacity for oca panning and impementation of heath improvement efforts. 241

250 SBCC Access to Food & Linkages to other Financia Approaches better nutrition sectors/services services Interpersona/ Encourage homestead Provide Promote gender individua/ /backyard cutivation of information and sensitivity encourage househod vegetabes & fruits women to access among men to approach the heath and ensure that women nutrition services manage the househod that are avaiabe, finances, especiay Communicate on how to especiay for food procurement increase the shef ife of materna heath food by processing and and chidren increasing bio-avaiabiity through germination and fermentation Community Deveop a mode farm Encourage the Encourage the approaches or nutrition gardens community to community to form to showcase dietary monitor SHGs or microfinance diversity at ow costs government groups for increasing using ocay grown services to get access to finance crops/vegetabes their entitements. Partners of the Project Identify community Monitor schoo Encourage the advocates to promote mea program, creation of common/ good feeding and if any, to ensure socia fund that coud nutritiona care that chidren be used for meeting practices access nutritive out of pocket food expenditure to access heath services PROFESSIONAL ASSISTANCE FOR DEVELOPMENT ACTION (PRADAN) PRADAN was estabished in 1983 and is a widey-recognized nationa-eve organization that speciaizes in promoting iveihood opportunities among SHGs of women. PRADAN foows a four-pronged approach to achieve its goas: 1) Promoting and nurturing SHGs of poor women and strengthening them as organizations to everage institutiona finances for members' iveihoods; 2) Deveoping and introducing ocay suitabe economic activities to increase productivity and income among SHG members and buiding synergic coaboration with a wide variety of stakehoders; 3) Mobiizing finances for iveihood assets and infrastructure from government bodies, donors, banks and other financia institutions; and 4) Setting up mechanisms to sustain the iveihood gains made by the poor communities. In Sirohi, Rajasthan, PRADAN currenty is reaching over 450 women's SHGs and impementing a variety of agricuture, ivestock improvement, and nutrition and heath projects. Roe: Impementing Agency for the project. Pradan impemented the project in 1 bock of Sirohi distrct with the community based patforms ike SHG's and VO, through their human resource whose capacities were buit by FFHIT in Nutrition & Heath topics. 242

251 V O L U N TA R Y A S S O C I AT I O N O F A G R I C U LT U R A L G E N E R A L DEVELOPMENT HEALTH (VAAGDHARA) VAAGDHARA was formed in the 1980s to augment iveihood sources and options through improving traditiona agricutura practices among the triba popuation and other marginaized groups in Rajasthan. VAAGDHARA has broad expertise in deveoping and impementing programs that ink interventions across mutipe sectors to address poverty, women's empowerment, chid protection, agricutura deveopment and iveihood deveopment and poverty aeviation. VAAGDHARA is currenty reaching thousands of famiies in Banswara with iveihood, agricuture and food security initiatives and wi use this as the foundation for increased focus on heath, nutrition and gender. Roe: Impementing Agency for the project. Vaagdhara impemented the project in Banswara district with 2 bocks with their community based patform ike SHGs through their human resource whose capacities were buit by FFHIT in Nutrition & Heath topics. FREEDOM FROM HUNGER INDIA TRUST Estabished in 2012, Freedom from Hunger India Trust (FFHIT) is an independent Indian nonprofit organization based in New Dehi with offices in West Benga and Madhya Pradesh. The technica staff of FFHIT oversee heath, nutrition, financia incusion, vunerabe youth and savings group methodoogies, and provide expert advice on eamer-centered curricuum design. FFHIT's goa is to achieve nutrition and food security, reduce poverty and improve economic and socia status of poor and marginaized women and their famiies through increased integration of financia services with other essentia services such as heath, nutrition and iveihood opportunities. FFHIT is aso an active member of Nationa Coaition of Food and Nutrition Security. Roe: Overa project design, deveoping training content and design, buiding capacities of partners, defining process, designing monitoring indicators and project review and pan. CENTRE FOR HEALTH, EDUCATION, TRAINING AND NUTRITION AWARENESS (CHETNA) CHETNA, which means awareness in severa Indian anguages, addresses issues of women's heath and deveopment in different stages of their ives from a rights-based perspective. CHETNA supports government and non-governmenta organizations through buiding the management capacities of educationists, heath practitioners, supervisors, and managers enabing them to impement their programs reated to chidren, young peope and women from a hoistic and gender perspective and advocates for peope-cantered poicies. CHETNA aso does advocacy, deveopment and dissemination of materias. CHETNA is based in Ahmedabad, Gujarat and primariy works in Gujarat and Rajasthan States. Roe: Partnered as resource agency and heped the project in training CNA's, Deveoping training modues and project design. Awards/Endorsements The project has not received any award but recognized by goba and nationa media ike BBC, The Hindu. Times of India etc and success stories are pubished by them. 243

252 Rajiv Gandhi Nagarf Reduce Manutrition and Chidhood Iness October September 2020 Word Vision India Website Founder of the Organization Project Budget : : Word Vision was founded in 1950 by Mr. Robert Pierce. Word Vision started operations in India and subsequenty set up its office in Kokata in Currenty Word Vision India works in 185 districts impacting 26 akh chidren and their famiies in over 6200 communities spread across 25 states and the Nationa Capita Region of India. : Being a five-year project we have observed a spending of more than ` crore. Coverage/ Geographica reach : Spread across 60 ocations among 17 states. With a direct reach of about 27, 77,314 peope (consisting 567,709 Boys, 618, 400 Girs, 784,018 Men and 807,187 Women). 244

253 Project Brief India has been emerging as one of the countries among the G20 group of countries with Economic growth of around 7.5 per cent¹ ;however, we aso notice that its huge popuation does not participate in this economic growth owing to their poor heath and nutrition indices. The state of materna heath refects the current state of the country whie that of chid and adoescent heath refects the future state of the country. About 0.75 miion neonates die every year in India, the highest for any country in the word. The neonata mortaity rate (NMR) decined from 52 per 1000 ive births in 1990 to 28 per 1000 ive births in 2013, but the rate of decine has been sow and ags behind that of infant and under-five chid mortaity rates. Under the Indian Constitution, Pubic heath being a state subject as per the Indian constitution, each state has its own heathcare deivery system in which both pubic and private payers operate and most often, there is sub optima avaiabiity and utiisation of services across most of the states. Given this background, Word Vision India focusses on a muti-sectora approach to tacke chid mortaity and morbidity by reducing undernutrition and chidhood iness. This technica programme is impemented with four objectives. The first objective focusses on improving the materna chid heath and nutrition (MCHN) practices by providing better access to ante and post-nata care services, improved feeding practices incuding promotion of excusive breastfeeding and compementary feeding. The second objective emphasises on increasing the coverage, access and utiisation for sustainabe water sanitation and hygiene (WASH) practices by providing better access to cean drinking water, sanitation faciities and creation of open defecation free communities. Since food insecurity is one of the contributing factors for manutrition, this is the third objective that aims at increasing nutrition resiiency at the househod eve through targeted food security programmes. The fourth objective of this programme is the strengthening of systems and structures especiay the functiona eements of Anganwadicenters, Primary Heath Care centers, Nutrition Rehabiitation centers and the oca governance systems by strengthening the Viage Heath Sanitation and Hygiene committees. Impementation Mode Word Vision India drafted the theory of change through a consutation workshop with interna and externa Kaa vidhya Mandirf ¹ OECD Economic surveys India (201 ) Overview. Avaiabe at https: eco surveys INDIA-201 -OECD-economicsurvey-overview.pdf, retrieved on 1 th March, M J Sankar, S B Neogi, J Sharma, M Chauhan, R Srivastava, P K Prabhakar, A Khera, R Kumar, S Zodpey, V K Pau 2016, State of new born heath in India, J Perinato Dec 6(Supp ): S -S8. Pubished onine 2016 Dec. doi: jp

254 stakehoders and experts. This enabed us to deveop the pathway of change through improved food security, improved materna neonata chid heath and nutrition practices, water sanitation and hygiene practices and systems strengthening that wi contribute to the reduction of undernutrition and chidhood iness. Maruti Chaw3 Based on this theory of change, a ogica framework was drafted at the country eve suitabe for customisation as per the demands and needs of the community. A baseine assessment was conducted across these 60 ocations during March 2016 which enabed in the customisation and adaptation of the ogica framework in each of the operationa sites. To achieve programme outcomes, Word Vision India, chose project modes few of which are, timed and targeted counseing (ttc), Positive Deviance Hearth (PD Hearth), Community Led Tota Sanitation (CLTS) and Citizens Voice and Action (CVA). In addition, we impement activities that emphasises and reiterates promotion of Infant Young Chid Feeding (IYCF) practices, provision of cean and safe drinking water, promotion of food diversity through food security programmes and system strengthening through community mobiisation process. Community Outreach Materna Chid Heath and Nutrition: Word Vision India has been impementing the Timed and Targeted Counseing mode (ttc) over the past one year in forty-two ocations across the country. The ttcmode uses a Community heath worker (CHW) approach, extending primary heath care counseing at the househod eve to reach pregnant women and mothers with chidren aged ess than two years (first 1,000 days) with messages pertaining to heath, nutrition and water, sanitation and hygiene, at the right time, (just before they need to practice them) through ten schedued househod visits. Not ony is ttc targeted in time (when each message is deivered), but it is aso targeted in ocation. A messages are deivered by visiting a woman's home so that key decision makers in the famiy, such as mae partners, mothers-in-aw and grandmothers, aso receive the information. The information itsef is targeted and individuaised, with messages focusing on the circumstances of each specific famiy. The counseing aspect of ttc uses positive and probem stories and probing questions to identify barriers to recommended heath practices. A househod handbook heps the CHW foow-up with the famiy and track their behaviour change in subsequent visits. The ttc mode aso heps obtain data on key nutrition and heath outcomes on a quartery basis. om sai chawf 246

255 In addition, the community heath workers are aso engaged in quartery growth monitoring of chidren, both in terms of weight and acute manutrition. Those chidren with severe acute manutrition are referred to Nutrition Rehabiitation Centers (NRC) and a monthy food basket (a combination of cereas, puses, ois and a heath mix) is given to these famiies for a period of six months and foowed up with heath, nutrition, hygiene messages and counseing. These community heath workers are trainedin Ratna bhoomi schoo partnership with the respective State Food and Nutrition board and provide them with the recipes, which have a combination of ow cost nutritious foods. Apart from these, the Community Heath Workers identify the mothers with positive deviant behaviours in terms of appropriate heath care and feeding practices and organise tweve-day sessions to repicate those positive behaviours across the community. Creating access to food materias woud address one off causa pathways of undernutrition and this technica programme has been providing food security programmes based on the context. We aso promote nutrition garden, poutry (in meat and egg consuming communities) and other food-based programmes that woud enhance food avaiabiity at the househod eve. In order to achieve scae up the intervention in the operationa area and sustain our efforts, Word Vision India has been incentivising these community heath workers based on the services provided. The incentives range within ` 2000 to 3200 on a monthy basis, who are monitored by the project staff to ensure the quaity and the rigour of the program impementation. Care group mode is yet another goba mode impemented in its fu essence for the first time in India in ine with goba program design. It is being roed out in nine ocations across the country to bring in the desired behaviour change among the women during the first 1000 days of importance and strives to achieve cent percent coverage of pregnant women and mothers of chidren under two years. Care group creates a mutipying effect, by reaching every beneficiary househod through neighbour-toneighbour peer support using behaviour change activities. Care group vounteers provide peer support to one another, deveop stronger commitments to impement heath activities. During the course of impementation, the care group vounteers find more soutions to chaenges as a group compared to individua vounteers expected to work independenty. The unique structure of care group heps in efficienty and effectivey cascading heath promotion messages from the promoter, to the care group vounteer, and finay to the neighbour women through peer education. ¹ ASHA:Accredited Socia Heath Activist is one of the key components of the Nationa Rura Heath mission is to provide every viage in the country with a trained femae community heath activist ASHA. Seected from the viage itsef and accountabe to it, the ASHA works as an interface between the community and the pubic heath system. 247

256 Addressing chronic undernutrition among communities: Care group session on quaity and quantity of feeding Since water, sanitation and hygiene has been identified as a pathway to change the nutritiona status of chidren, Word Vision India is impementing Community Led Tota Sanitation (CLTS) across the country to promote the use of atrines for defecation, hygiene and handwashing to address chronic undernutrition (stunting) among the communities we serve. Supporting the nationa campaign on 'Cean India Movement' and through everaging of resources, househods have been heped to tap the Government resources to construct the toiets covering 2,485 viages/ sums. As a resut,592 communities is decared as Open Defecation Free (ODF). Uniqueness of the Project We woud caim ttc and care group mode as innovative modes due to the uniqueness of these programs in ine with socia behaviour change communication, barrier anaysis at the househod eve, provision of continuous and ong-term foow up to ensure behaviour change, purposive incusion of infuencers (mothers in aw, grandmothers) and decision makers (men) in the programme. Over the past one year, ttc is impemented in 42 ocations across the country, reaching over 9,500 pregnant women and 9,240 infants. We do observe that some of the indicators reated to materna and chid heath has been increasing due to the impementation of ttc. Especiay at Khariar Area Deveopment Programme, Odisha, our initiatives have been contributing to a major shift in the number of institutiona deiveries from 553 to 781 and home deiveries have reduced from 347 to 255 during the year This reduction coud be due to the househod visits made by the community heath workers and good rapport created by them with the ASHA (Accredited Socia Heath Activist)¹ in this community. Simiary use of Intra-Uterine Devices for birth spacing has increased from 603 to 795 and there has been a considerabe increase in the use of condom, use for birth spacing among men as shared by the hospita authorities. Care group is another innovative mode being impemented in nine ocations across the country. A compiation of monitoring data from the care group program impemented at Bardhaman Area Deveopment Project, West Benga is presented. In this site seven community heath workers were chosen to work as Supervisor (1 person) and Promoters (6 persons) as a part of the staffing structure required for this project mode. Through this mode the ADP has 91 care group eaders and 1165 mothers. Every promoter has about 15 to 16 care group eaders. Under every care group eader, there are 12 to 15 neighbourhood mothers. At the start of the programme impementation, there were some concerns reated to care during pregnancy, negigence for immunisation of infants, maintaining ceaniness and proper feeding for chidren, which ed to manutrition among chidren. After the initiation of the care group, the mothers started interacting in their sma groups and shared their experience from pregnancy to feeding their chidren. The care group vounteers bring about behaviour change through skit, songs and games. Due to this approach the community is abe to see visibe changes in terms of 248

257 immunisation, antenata care, excusive breast feeding, compementary feeding and consumption of IFA tabets. Another mode that we beieve has worked we is the Community based Management of Acute Manutrition (CMAM) impemented at Chas and Chandenkiyari bocks of Bokaro District, Jharkhand, for chidren with Severe Acute Manutrition (SAM). The current programme at Bokaro District commenced from January 2017, has screened 20,525 chidren within six months to five years. Word Vision India, worked aong with the ICDS system and re-designated 51 Anganwadi Centers as Out- Patient Therapeutic centers and buit on the Anganwadi workers potentia to impement CMAM. This programme invoved eary detection of chidren with severe acute manutrition (SAM) and referra of SAM chidren with medica compications to the NRCs. As on September 2017, about 61 per cent of the SAM were cured with 11.5 cm MUAC (Mid Upper Arm Circumference) with no cases of chid deaths being reported during this period. Roe of Information and Communication Technoogies (ICTs) The programme did use mobie technoogy for an exhaustive baseine assessment across the country, we expect the same technoogy and too to be foowed during the midterm assessment and end term assessment. Chaenges Faced System strengthening and working aong with the Government system is key to deiver asting soutions. In some cases, this has not been possibe as the priority and the wiingness of the officias imited the scope for partnerships and in some instances, we face chaenges from new officias who are unaware of the work aready done, and this affects achieving our deiverabes. At times, buiding the ski set of the frontine workers, improving the infrastructure faciities and joint impementation of programmes becomes a chaenge. In those cases, additiona efforts have been taken to meet with the heads of the departments to convince them and cear the barriers that obstruct in joint impementation of the program. In some of the drought prone communities, dry and arid regions many of the residents migrate. In cases where the men of the famiy migrate there are chances for the entire famiy to migrate with their chidren or eave back their chidren with edery parents which disrupts the food security, feeding and caring practices that have been buit on among those famiies. During such instances, the webeing of the chidren in the famiies become critica. Despite having focussed behaviour change programmes we are unabe to reach the famiies, which have migrated during the drought seasons. This has been a trend in Sainath Schoo 249

258 some of the operationa sites in Maharashtra, Odisha and Rajasthan. The registration and foow up of pregnant and actating women becomes difficut as they migrate to other viages to earn and therefore ose out on foow up. When these famiies eventuay return back to their communities the chidren and women are often undernourished. Counseing sessions are resumed and the foow up is brought back on track. Outcomes Based on the theory of change and the interventions roed out we envisage MP Addressing and encouraging Dharavi Community improved materna chid heath and nutrition (MCHN) practices, increased coverage, access, utiisation for sustainabe WASH practices, increased nutritionay resiient househods, strengthened systems and structures towards reduction of chidhood manutrition and morbidity that woud resut in reduction of mortaity and morbidity among chidren under 5 years. Based on the timeines for impementation of this program, we woud be having our end term assessment during September, 2020 which hep is assessing the impact of this country wide program. Outreach & Scaabiity Partnership with the different government departments such as the Ministry of heath and famiy wefare, Department of women and chid deveopment is critica and this engagement has been scaed up to the state eve in the states namey Madhya Pradesh, Andhra Pradesh, Chattisgarh, Jharkhand and Uttar Pradesh. We work with the respective state, district and bock Government Departments to impement and scae up their programmes, ike the Swatch Bharat Abhiyan, Weeky Iron and Foic Acid suppementation (WIFS) programme,icds, Mission Indradhanush, at the state eve. Word Vision India has memorandum of understanding (MoU) in 14 Bocks and 19 districts with the Department of Women and Chid Wefare. Simiary, with the Ministry of Heath, Word Vision India has ninemous at the Bock and sixmous at the district eve. These MoUs has buit in the eements of partnership, system strengthening and scae up wherever possibe. Community ownership in a our programmes are critica and we enhance their participation through strengthening of Viage Heath Sanitation and Nutrition Committee. In addition, we buid on the oca resources by hiring the community heath workers from the same community and equip them through the technica training programmes. Even after the withdrawa of our programme, they continue to stay as an asset to these communities. Repicabiity ttcmode is one of the programme modes which has a greater chance of repication across the country 250

259 through the ASHA as there are areas of overap in terms of ante nata care, post-nata care. Since ttc has robust monitoring it can be considered appropriate for the ASHA mentors and supervisors to foow up on the most vunerabe and excuded popuation who are often missed out in the mainstream. Simiary, we aso recommend care group as one of the scaabe mode and in fact, we are scaing it up in four bocks of our operationa area in Odisha. Being a ow investment programme with opportunities for scae and coverage it can be scaed up by the Government, ike minded organisations, simiar to women sef-hep groups with a primary intent of ensuring care during the first 1000-day period. As detaied above, our CMAM intervention has been creating an evidence base for impementation in bocks with high burden of severe acute manutrition. With the scae of Anganwadi centers across the country, the operationa mode experimented by Word Vision India proves that it is feasibe to impement CMAM with imited resources in co-ordination with the Department of Women and Chid wefare and Ministry of heath and famiy wefare with the guidance of the District Officias. Impact Achieved With the baseine assessment conducted during the month of March 2016, the programme did the Lot Quaity Assurance Survey (LQAS) during September Over these 17 months, we found that institutiona deiveries increased from 81.3 per cent to 87.3 per cent, antenata visits increased from 56.7 per cent to 83.4 per cent and excusive breast feeding increased from 58.4 per cent to 63.9 per cent. The progress in indicators reated to institutiona deivery, antenata visits and excusive breast feeding can be due to the intense efforts taken in the ro out of ttc and care group in addition to the capacity buiding investments for the frontine workers working with the heath system. We aso observed that the use of atrines for defecation increased from 23.3 per cent to 39.5 per cent and access to safe drinking water has increased from 61.6 per cent to 64.5 per cent during these time points. Under the banner of the nationa campaign on Swatch Bharat Abhiyan programme our programmes has contributed to the improvement of these indicators. Capacity Buiding Intense capacity buiding efforts have been done in this technica programme, some of them are deveopment of the technica materia for ro out of ttc, care group, CMAM, strengthening of viage heath sanitation and nutrition committee. Simutaneousy efforts are taken to buid the knowedge of the programstaff across the country on each of these interventions. Series of training programs that emphasised on program modes, monitoring and supervision which are critica for program quaity are roed out. Cascading training approachwas adopted, by training the technica team consisting of 18 staff ater engaged in training the program staff there by training more than 380 programme staff. In addition, we have a 'Faciitators manua for materna new born and chid heath' as a training curricuum for buiding the ski sets of the Anganwadi Workers, ASHA and ANMs. Based on the memorandum of understanding with the Ministry of heath and famiy wefare and Department of women and chid wefare, the programstaff co-ordinate and jointy train the community heath workers with the technica team. In addition, the technica team aso constanty monitors the knowedge eve of CHWs and provides on-going refresher trainings. 251

260 Partners of the Project As a part of the technica impementation, we have been coaborating with various stakehoders through Memoranda of Understanding (MoU), coordination committees, networks and coaitions, with the shared goa of addressing chid manutrition and its contributing factors. This ist incudes stakehoders both government andnon-governmenta organisations at various eves. At the country eve, we represent the Coaition for Sustainabe Nutrition Security in India, (CSNSI)- Ministries and we are part of the two working groups namey Essentia Nutrition Interventions and WASH. In addition, we are active members of the India Sanitation Coaition and White Ribbon Aiance, which is a nationa eve coaition. At the state eve, we have MoUs with Andhra Pradesh Department of ICDS, State Nutrition Mission of Jharkhand. We aso have partnerships with the district and bock departments, especiay the Department of women and chid wefare, Ministry of heath and famiy wefare, state food and nutrition board which enabes us to co-ordinate and strengthen the existing government interventions. In addition, we have estabished partnerships in a the operationa districts with ike-minded organisations at the bock and district eve to scae up our interventions. Awards/Endorsements At the project eve, Word Vision India has been receiving appreciation etters from the Department of heath and wefare, women, and Chid Deveopment for promotion of heath, reduction of manutrition, support in the formation of open defecation free communities. A mirace chid Living a happy and peacefu ife is a dream for every person. In the Sundarbans region, a pace where peope ive in great need, that dream is remote. MP Varsha Gaikwad appreciating Sunita - MCI Mumbai Dharavi Team member 252

261 In the southernmost part of the Basanti Bock, ies a sma viage. This is one of the government's unreserved area. There is no heath faciity and heath workers cannot reach the interior parts of the viage. Here ives Saraa Sarkar aong with her daughters. Her husband eft them, when he came to know that the second chid was aso a gir. Saraa did not have proper food to eat, neither did she have any ante nata check-ups. Hence, she was so weak that was unabe to breastfeed her chid. She strugged hard to raise her chidren. The famiy survived on abour work. She borrowed money from the community during emergencies. The Community Deveopment Faciitator from Word Vision India visited Saraa's famiy and found that her baby, Sandhya, ooked swoen and weak. He referred the chid immediatey to the Nutrition Rehabiitation Centre (NRC). She was manourished and had serious heath compications. Her body was swoen and she had stopped defecating. With the hep from Word Vision India, she was immediatey taken to a hospita in Kokata as the NRC was not equipped to treat her. When they arrived at the hospita, the doctors refused to admit the chid as her condition was critica. They referred her to the Cacutta Nationa Medica Coege. Sandhya was admitted there at midnight. She was discharged from the hospita after severa days of treatment. The hospita staff and doctors were amazed and happy to have saved Sandhya. Dr.PK Das, who treated the chid said, She is a mirace chid because when she was brought to the hospita, there seemed to be no hope. Baby Sandhya Sarkar with her mother Baby Sandhya Sarkar with her mother Word Vision India further buit a toiet for Saraa's famiy and aso provided iveihood assistance to ensure food and iveihood security. Today Saraa ives happiy with both her daughters. If it wasn't for Word Vision, my chid woud not be in my arms now. The INR 10 in my hands was never sufficient to save her ife, she says thankfuy. 253

262 Schoo Chidren Learning Hand washing Stop Diarrhoea Initiative (SDI) Apri March 2019 Save the Chidren India Website Founder of the Organization Project Budget : : Egantyne Jebb Save the Chidren India on 1st Apri 2008, started functioning as an independent Indian member of the Save the Chidren Internationa Aiance under the name Ba Raksha Bharat. About a hundred years ago (1919), as the Word War 1 drew to a cose, a woman named Egantyne Jebb aunched a movement which became the eading voice of the most marginaised and disadvantaged chidren across the word - Save the Chidren Fund. : ` 47 Crores for 4 years 254

263 Coverage - Geographica Reach Project Brief Diarrhoea and Pneumonia in genera account for amost one quarter of tota under five chid deaths gobay and particuary in countries with imited access to heath services, basic sanitation and hygiene and nutrition. In India, diarrhoea deaths among under five chidren contribute to around 22 per cent of tota goba diarrhoea deaths. More than 320 chidren aged under five die every day due to diarrhoea diseases accounting to amost 10 per cent of tota under-five deaths in India. Approximatey, 70 per cent of these under five chid deaths occur in the first two years of a chid's ife. The Word Heath Organization (WHO) estimates that 88% of deaths from diarrhoea are attributabe to four issues: consumption of unsafe water; inadequate sanitation; poor persona hygiene and the ack of access to chidhood immunisation as a preventative measure. To sustainaby tacke these issues and eiminate diarrhoea as a pubic heath burden, the WHO and UNICEF have proposed a 7 point pan for diarrhoea prevention and contro. The pan is focused upon providing adequate coverage of interventions necessary to eradicate diarrhoea as a pubic heath probem that resuts in the unnecessary deaths of chidren under-five. The pan comprises: 1. Treatment package: Fuid repacement to prevent rehydration; Zinc suppementation. 2. Prevention Package Rotavirus and meases vaccinations; Promotion of eary and excusive breastfeeding; 255

264 Vitamin A suppementation; Promotion of hand washing with soap; Improved water suppy quantity and quaity and community wide sanitation promotion. To assist the Government of India to tacke diarrhoea as a pubic heath chaenge and reduce the number of chidren who die from this preventabe disease, Save the Chidren with the funding support of Rickett Benckiser (RB), in partnership with the Government of India (GoI) impements the WHO/UNICEF 7 point pan as a Signature Programme. The programme wi contribute to Save the Chidren's goba ambition of removing diarrhoea as a top five eading cause of death amongst chidren by This programme tests the effectiveness and efficacy of the WHO/UNICEF 7 point pan; coate evidence to demonstrate proof of concept and vaue for money, and advocate for the state and nationa government and its partners to repicate and scae up the approach nationay. In order to test the effectiveness the WHO/UNICEF 7 point pan, Save the Chidren is demonstrating proof of concept from severa states which represent the socio-economic diversity of the Indian context. Save the Chidren designed an intervention for the WHO/UNICEF 7 point pan to be impemented and tested across four states: Dehi, Uttarakhand, Uttar Pradesh and Kokata in West Benga. Stop Diarrhoea Initiative's Contribution to the Sustainabe Deveopment Goas (SDGs) SDI project cumuativey contributes to SDG 3, 6 and 17 by ways to improving deivery to community based services primariy reated to chidhood vaccination, improving suppy chain and ogistics of commodities such as Ora Rehydration Soution (ORS) and zinc and aso promoting positive behaviour changes reated to infants and young chid feeding practices; improving access to water and sanitation service aong with persona hygiene, and coaborating effective partnerships for meeting the goa. 256

265 Impementation Mode The impementation mode is focused upon providing adequate coverage of interventions necessary to prevent and contro diarrhoea as a pubic heath probem that resuts in the unnecessary deaths of chidren under-five. It has been designed to achieve a 100% coverage at ward eve in urban areas and bock eve in rura areas, which is more than the 80% coverage recommended by WHO for a targeted ocation. Save the Chidren has demonstrated the effectiveness of the bock eve operationa mode in India, where it has been used to bring visibe and measureabe changes in reation to heath and nutrition. This is we recognised by the Government of India and is now being adopted by other Internationa Non-Governmenta Organisations. Thus operating at ward and bock eve was an acceptabe operationa patform for producing evidence to everage the WHO/UNICEF 7 point pan to the Government of India. These four states are a fair representation of the socio-economic status of India, as two (Uttarakhand and Uttar Pradesh) are part of the Empowered Action Group (EAG) States. As EAG states are government priority states having highest infant mortaity rates. Coverage of these seven interventions (both Treatment and Prevention package) in the target ocations is beow the WHO/UNICEF recommended standard of 80%. Through this Programme, Save the Chidren works with the Union and State Governments, RB and other partners such as Word Heath Organisation, UNICEF, ingos ike Aga Khan Foundation (India), Cinton Heath Access Initiative (CHAI), Famiy Heath Initiative (FHI) 360, Micronutrient Initiative, PATH, Water Aid, WASH United etc. to increase coverage from the baseine to 80%. Successfu impementation offers the unique opportunity for this to be the generation that contributes to stopping chidren dying from diarrhoea, by demonstrating how it can be eiminated as a pubic heath probem and infuencing the Government and other major stakehoders to take the approach to scae. Chidren Learning WASH Behaviors though TSBAK 257

266 Community Outreach Save the Chidren engagement in reaching out directy to the communities can be understood from the beow given framework: Save the Chidren has been invoved in the foowings: Contextuaized Socia and Behavior Change Communication (SBCC) strategies ro out for intended sustainabe behavior change in the community. Conducted formative research to assess prevaent behavior in the different States, and used the evidence to design, create, impement, monitor and evauate impact of these bespoke evidence-based interventions, focusing on socia norms, cutura beiefs and attitudes in managing diarrhoea at the community eve. Counseing, demonstration and education sessions at househod and community eve on hand washing, safe handing and storage of drinking water, chid feces management. Estabished a community accountabiity and monitoring system to improve the responsiveness and quaity of heath service provision for the prevention and treatment of diarrhoea using Community Score Card too. Save the Chidren has aso adapted other accountabiity 258

267 mechanisms such as Compaints and Redress system faciitated by a non-emergency hepine and verba autopsy of chid mortaity and diarrhoea incidents. Demonstration of innovative, sustainabe modes ike Community Managed Toiet (CMT), Individua Toiets and Schoo Sanitation Bocks (SSBs) compexes in order to generate demand at community eve for repication. System strengthening for streamining suppy chain to ensure adequate and timey suppy of ow osmoaity ORS and Zinc whist creating demand at community eve. Ski and capacity buiding of frontine workers and service providers. Strengthening WASH services and behaviors in schoos through use of innovative infrastructures ike age appropriate hand washing patforms, renovation of schoo sanitary bocks, incucating chid participatory earning toos in the earning curricuum of chidren. Community mobiization through Community Heath Vounteers (CHVs) for raising community awareness about the prevention and contro of diarrhoea and in infuencing improved individua, famiy and community practices across the 7 point pan through a raft of interventions. These incude: interpersona communication (house to house visits and faciitation of community groups); two-way diaogue for coective action using the participatory earning & action cyce and Mother's Groups, User Groups, Youth's Groups, Chidren's Heath and Hygiene Cubs (CHHCs) created in schoos and Viage Heath and Nutrition Days (VHNDs) as a patform heping oca group members to mobiize wider community members in soidarity and confidence to take action in the prevention and contro of diarrhoea. Creating Chid Champions - Chidren are key stakehoders in the programme and are seen as effective agents for behavior change. Meaningfu and effective chidren's participation has been ensured through CHHCs to bring their earning from schoo and take positive action as peer educators and agents for change in their respective communities. Uniqueness of the Project Stop Diarrhoea Initiative project has many unique features buit in it. The major ones are as foows: Integrated mode for diarrhoea contro and prevention As mentioned earier, Stop Diarrhoea Initiative is based on the WHO-UNICEF 7 point pan which is a mode of integrated approaches for diarrhoea contro and prevention. Approaches under prevention package are impemented in a concerted way, since singe interventions aone are ikey to resut in esser overa impact. For exampe, diarrhoea caused by rotavirus cannot be prevented soey by improvements in water and sanitation. And rotavirus vaccine does not prevent other pathogens (such as E. coi and Shigea) from causing diarrhoea. The package is accompanied with cear, targeted and integrated behavior and socia change communication strategies to improve uptake by famiies and communities. 259

268 Accountabiity mechanism for improving chid heath reated services Under the project, Save the Chidren has roed out accountabiity mechanisms ike community score card which is an on-going participatory too for assessment, panning, monitoring and evauation of services. It brings together the demand side ( service user ) and the suppy side ( service provider ) of a particuar service or program to jointy anayse issues underying service deivery probems and find a common and shared way of addressing those issues. It is an exciting way to increase participation, accountabiity and transparency between service users, providers and decision makers. Further, project aso introduced non-emergency hepine with an aim to use information communication and technoogy for enhancing the quaity of care, bridge the gaps in heathcare services and improve access to reiabe and actionabe heathcare information reated to chid heath iness speciay diarrhoea. Chid Participating Learning Approach The activity is reated to participatory work with chidren for heath promotion. It is more than using activity based earning and thinking as it invoves chidren in decision-making in the design of specific, reevant actions that can be taken at famiy and community eve. It is aso reated to using their natura creativity, abiity and enthusiasm to communicate effectivey with other chidren and it recognises and supports vita responsibiity chidren often have at famiy eve in the care of younger sibings. Hardware structures as a demonstration mode Save the Chidren constructed Individua Toiet, Community Managed Toiet, schoo sanitation bocks and community toiet compex in order to generate demand at community eve and demonstrate incusive and innovate designs of toiets for repication. Project has constructed an 80 seated community toiet compex at Bhanwar Singh Camp, Vasant Vihar, New Dehi. This structure wi cater the need of around 3000 sum residents. The toiet compex comprises technica features of bio-digester for treating the sewage, recycing the water received from washing, bathing and ceaning using Decentraised Waste Water Treatment System (DEWAT) and Water ATM by which residents can have RO water at a very nomina rates. ORS Zinc Counseing at ORS Zinc Corners 260

269 Roe of Information and Communication Technoogies (ICTs) Stop Diarrhoea Initiative project reies on successfu use and adaption of technoogy for deivery of targeted interventions. Some of Key technoogies and innovations under impementation are: Mobie tabet based interna monitoring system (BRISK) which is innovative Monitoring, Evauation, Accountabiity and Learning (MEAL) too used by Save the Chidren to strengthen project impementation though a robust case tracking mechanism and supports evidence based reporting of impact. BRISK synchronizes o ine data entry system with onine mode of operation, and has a strong project management component. The appication is secure and scaabe in both space and time. Web based onine and o ine modue on 7 point pan: It promotes continuous earning of the heath and deveopment workers, encourages sef-earning ensures simpification of compex topics and easy presentation of the content using animation, graphics and voice over and provides opportunity of engagement of the participants on the topics by way of virtua interaction. Soar based Water purifier: A Fuy automated, compact, ow cost, soar energy based community water treatment system is instaed in Haridwar, Uttarakhand. This ow cost and very ow maintenance green energy based water treatment system designed speciay to cater the needs of rura India where there is no/irreguar eectricity and avaiabiity of trained manpower is negigibe. Unike Reverse Osmosis (RO) pant, there is no water wastage here and is a very effective for water scarce areas too. It is an automated system incuding dosing of chemica with automatic switch off button, does not require operator. The system is based on a continuous water treatment process, using innovative coaguation/foccuation and disinfection technoogies. The Project has aso used Information and Communication Technoogy to bring capacity buiding sef-earning heath and deveopment modues to improve quaity of continuous earning of heath workers at community and faciity earning. The initiative brings the earning resources to masses at free of cost. Chid ed advocacy through Photo Voice: Every chid has the capacity to bring in new insights, new earning. In partnership with Photo Voice, UK a premiere organization in the word that heps chidren weave their own stories, using a camera and not ony imiting to use but teaching them to interpret the voices of their photos. Non Return Vave technoogy in hand pump: In the rura areas to ensure running water in the Community Managed Toiets (CMT) buit under the SDI, Non Return Vave (NRV) technoogy is used to ift the water from hand pump to overhead tanks. Happy bo / Team Swachh Bharat Action Kit: In Partnering with WASH United, Save the chidren roed out Happy box, an interactive game based methodoogy to deiver WASH reated messages in Chidren. This was roed out in 73 schoos, training 338 teachers and 1,376 students in our project areas. This has proved to be great success in promoting hygiene and sanitation behaviours among schoo chidren and disseminating key WASH messages through them to their famiies and communities. 261

270 Community Accountabiity Too: Community Score Card, an on-going participatory accountabiity too for assessment, panning, monitoring and evauation of services provided to the community, is roed out in the project impementation areas in the SDI. The objective to ro out the activity is to positivey infuence the quaity, efficiency and accountabiity of the services which are provided to the community at different eves. It heps in bringing together the service user (community) and the service provider to jointy anayse the issues underying service deivery probems and heps in finding a common and shared way of addressing those issues. Age appropriate hand washing patforms: The hand washing patforms constructed under SDI are chid friendy hand washing patforms. Generay in a primary schoo there are chidren from 5-10 age groups and of different height. The idea behind this hand washing patform was that every chid in schoo can access this patform for hand washing. Keeping this in mind we constructed hand washing patform with chid accessibe height. Each patform has 3-4 hand wash basins of different heights so that smaest chid in the schoo can aso wash his hands thoroughy. Chaenges Faced The major chaenges faced by the programme were: Ensuring inter-sectora coaboration and convergence between reated departments on issues reated to heath and WASH and the 7 point pan. The project works around the key determinants to prevent, contro and treat diarrhoea at the community eves, Heath Department, ICDS, Rura Deveopment, Education Department, Pubic Works/Pubic Heath Engineering/ Ja Nigam and NGOs. In order to hat the spread of diarrhoea, an integrated response to the disease, is required for asting impact on chid heath. This therefore requires joint panning, execution, monitoring, reporting and reviews for efficient resource utiization and programme effectiveness. This has been a great chaenge to bring a the stakehoders on one patform and to work together on integrated panning, impementation and monitoring as various departments are invoved. The SDI project has envisaged a bock/viage eve convergence mode to deiver on this project. The proposed mode invoves forming a bock/viage eve committee headed by Bock /viage administrative head. The committee is proposed to have representation from a the key departments concerning the heath, education and water and sanitation and ICDS and other departments such as rura deveopment and pubic works. The committee aso propose to have representation from other NGOs working on the heath and community deveopment issues. The mode promotes joint panning, execution, monitoring and review on a quartery basis and cooperating in fied operations on matters concerning chid heath. It reies on creating and sustaining a patform for sharing, earning, cooperating and joint probem soving for improved chid heath panning. Increasing coverage of Zinc utiization : The utiization of zinc for 14 days during diarrhoea episodes of chidren has aways been chaenging and hardy 20% of chidren suffering from diarrhoea received Zinc. On other hand ORS utiization has been more than 65%. To address the issue of Zinc utiization, SDI project has taken up severa innovations ike introduction of copackage of Zinc and ORS in fied, estabishing Zinc ORS corners and depots in community, ski 262

271 Outcomes buiding of frontine heath workers on counseing foow up of beneficiaries, improving suppy chain management of Zinc, feasibiity of prescribing Zinc syrup, SBCC campaigns highighting importance of Zinc. By the end of the project we aim to contribute to at east a 50% reduction in the prevaence and incidence of diarrhoea in the project ocations. The intermediate key outcomes of the project are: Outcome 1: Access to quaity diarrhoea prevention and contro services for at east 80% of househods in target areas of nine districts by the end of the programme. Outcome 2: Community awareness and practices for prevention and contro of diarrhoea in target areas improved by the end of the programme Outcome 3: District, Bock and community accountabiity and ownership for increased access to diarrhoea prevention and contro and scae up at a eves enhanced by the end of the programme. Outreach & Scaabiity The approach Save the chidren has undertaken for outreach and scaabiity of SDI is based on Save the Chidren's Theory of Change, which comprises of the foowing eements: 1. Buiding strong partnerships with government authorities and stakehoders; 2. Leveraging goba and oca expertise to impement innovative soutions to strengthening oca heath systems; 3. Being the voice by advocating and campaigning for better practices and poicies to fufi chidren's rights and ensure chidren's voices are heard, particuary those most marginaised; 4. Achieving resuts at scae by improving access to proven and essentia chid heath interventions. Save the Chidren has demonstrated the effectiveness of the bock eve operationa mode in India, where it has been used to bring visibe and measureabe changes in reation to heath and nutrition. Thus operating at ward and bock eve as an acceptabe operationa patform that wi produce evidence to everage the WHO/UNICEF 7 point pan. SDI is designed to work in continuum with existing programs of various Ministries of GOI and Departments of State. The program adapts and innovates processes and toos for fostering the program impementation for better resuts, reaching the unreached and scaabiity of program. Innovative infrastructure modifications ike age appropriate hand washing patforms in schoos is contributing towards improving hand washing behaviours of chidren in schoo and community and the same is highy appreciated by schoo management and officias for its repication across a the schoos and this contributing impactfu towards Swachh Bharat Mission. Simiary the community managed toiets constructed / renovated and managed by project though community user groups in urban areas are modes highy appreciated by municipa cooperation's and ooking ahead for guideines for adaption 263

272 across the urban areas. Co-package of Zinc and ORS, innovative way of suppy chain management and diarrhoea management, has provided district heath officias a way to increase the coverage of Zinc in their areas. Accountabiity toos ike community score card and non-emergency hepine are providing evidences to government for its integration in their existing programs. Socia behaviour change communication materias deveoped under the project are now being adapted by government for their arger campaigns ike IDCF for arger outreach and impactfu scaabiity. Advocacy for Stop Diarrhoea Initiative aims to ensure the government's existing and new commitments towards diarrhoea prevention and contro are infuenced with the integrated approach of WHO/UNICEF 7 point pan. Broady, this means to advocate for the aignment of government poicies with this agenda and Save the Chidren's broader priorities. Repicabiity Sustainabiity to ensure a asting impact for chidren has been integrated into our programme design at every eve. The impementation design brings together a key stakehoders, incuding communities, CSOs and oca institutions and Government Department to form a partnership network to ensure the asting impact of our interventions. Sensitizing service providers and changing the behaviour of famiies and communities in a way that can be sustained in the ong term is centra to this project. We have undertaken a formative research with the intended beneficiaries to investigate their responses to a number of basic questions around the seven points before designing the project. The project design is capabe of sustainaby modifying hygiene, treatment and protection seeking behaviour. We monitor such progress with independent househod surveys of our key process indicators. As part of our Socia behaviour change communication (SBCC) strategy we use interpersona, mid media and mass media toos to ensure a asting change within targeted communities. The project is designed to produce working mode at gram panchayat and bock eve for its repication in other ocations. The project wi produce series of process documents, guideines and standard operating procedures contextuaized for government departments and deveopment agencies for integrating the project and its interventions. Further, SDI project is working towards infuencing the key poicy eve changes ike introduction of co-package, minimum wash faciities in schoos, and chid friendy WASH infrastructures for its smoother integration in other ocations. Impact Achieved The project is currenty on its third year of impementation of its four year ife cyce. We have progressed significanty on amost a of our key performance indicators and targeted outcomes from our baseine. The KPIs and outcome indicators are measured based on independent surveys in partnership with technica agencies to ascertain the effectiveness of the 7 point pan in the target areas. The Baseine has provided with the outcome and output indicators in treatment and contro areas at the time of initiation of project and wi provide a base from which impact can be measured on annua Key Performance Indicators (KPI) and the end-ine evauation. The end ine evauation sha use a quasi-experimenta approach to evauate the impact of the programme. To do this we sha measure the impact of the components on the target popuations and a contro group. Tracking the performance of both the 264

273 intervention and contro groups wi aow us to measure the programme's impact. The End ine wi have the same treatment and contro group seected by matching key socia indicators as in baseine. The measurement of the impact wi use a Difference-in-Difference (DD) approach. We wi cacuate the mean difference between the Baseine and End ine vaues of outcome and impact indicators for both intervention and contro areas. Then, we wi cacuate the difference between these two mean differences. The second difference (the difference-in-differences) is the estimate of the impact of the programme. Ti date, we have been abe to capture the reduction in the prevaence of diarrhoea in the past years. Capacity Buiding Save the Chidren through its Stop Diarrhoea Initiative has buit capacity of faciity and community eve heath and deveopment workers on severa topics reated to Diarrhoea contro and prevention using Information, Communication and Technoogy (ICT) based modues on diarrhoea prevention and contro. Modues have been deveoped based on a comprehensive training and capacity needs assessment and anaysis across four intervention states. These modues have been deveoped in Hindi, Banga and Engish and are compatibe with a range of devices. Aso SCI supports in capacity buiding of Government functionaries, oca bodies and community. Save the Chidren buids capacity of Integrated Chid Deveopment Scheme (ICDS) supervisors on participatory approaches used in group activities, monthy meetings of Mothers' Groups ed by Anganwadi Workers. Save the Chidren through oca partners aso buids the capacity to: Support pubic heath service providers organising VHNDs to incorporate the 7 point pan for diarrhoea management and contro (e.g. hand washing, breastfeeding, treatment w i t h O R S a n d Z i n c, V i t a m i n A suppementation, uptake of rotavirus); Ensure the capacity and functionaity of Viage Heath Sanitation and Nutrition Committees (VHSNCs) by conducting functionaity assessments; 265

274 Buid capacity and sensitize VHSNCs on roes and responsibiity in Diarrhoea Prevention and Contro incuding importance of ODF viages (as per government guideines) Support and supervise WASH cadre to faciitate understanding and provide counseing to the community on safe water handing practices, water quaity issues, sanitation reated issues and hygiene behaviour such as promoting hand washing; Conduct refresher training to orient User Groups and Youth's Cubs on participatory earning and action approaches to identify, prioritise, impement and evauate actions in diarrhoea prevention and contro; Support exchange of experiences meeting between Women's Groups, User Groups, Youth's Cubs, and CHHCs on VHNDs to review successes, chaenges and essons and ways forward in community efforts for diarrhoea prevention and contro; Deveop community-based networks to hep support appropriate infant and young chid feeding at the community eve. Save the Chidren, through supporting active participation of CHHC members ensures better interface with Schoo Management Committees and teachers for functiona and hygienic WASH faciities in schoos and better hygiene education. Through capacity buiding, we have reached: 3375 faciity and community heath workers; 800 Mother to Mother Support Groups trained on Infant and Young Chid Feeding Practices (IYCF); 347 community workers through training on community WASH; 800 WASH Paraprofessionas; 800 Laboratory technica and community workers; 720 oca engineers; 72 oca masons and hand-pump mechanics; 200 district and bock eve government authorities; 400 CHHC; Partners of the Project Buiding robust partnership is a crucia feature for the impementation of this programme. In the ast programme impemented on WASH, Save the Chidren has deveoped important partnerships with reevant government departments for repication and scae-up of our WASH initiative. Save the Chidren is impementing the programme with support of 7 NGO partners having good experience in impementing materna and chid heath projects. 266

275 Furthermore, key ministries, deveopment agencies, internationa organisations, academic institutions are key stakehoders of this programme. Government In addition to state and district governments, the Ministry of Heath and Famiy Wefare (MoHFW), Ministry of Drinking Water and Sanitation (MDWS), Ministry of Urban Deveopment (MoUD), Ministry of Women and Chid Deveopment (MWCD) are the key stakehoders for supporting in impementation of the programme. Our government stakehoders ro-out their existing programmes providing access to necessary heath services, safe drinking water and sanitation faciities to compement Save the Chidren work in diarrhoea prevention and treatment. Save the Chidren supports MoHFW in increasing the coverage of routine vaccination, suppies and uptake of ORS and Zinc, and raising awareness about the importance of hand washing and excusive breastfeeding during reguar VHNDs. The MoHFW supports Save the Chidren to deiver quaity training to faciity and frontine heath workers whist providing support and supervision to ensure appropriate diarrhoea case management. Deveopment Agencies Both WHO and UNICEF have been engaged in the programme since the beginning of the inception phase and pay a key roe in providing technica support to the programme. They are aso our advocacy partners for promoting the 7 point pan. Additionay, Save the Chidren has been coaborating with the Aga Khan Foundation (India), Cinton Heath Access Initiative (CHAI), Micronutrient Initiative, FHI 360, PATH, Defeat Diarrhoea Diseases (Defeat DD), WASH United and Water Aid. Save the Chidren partnered with PATH and its Defeat DD team for showcasing SDI key interventions by shooting videos intending to highight the momentum around diarrhoea disease and disseminating through consutation. Non-Government Organisations Save the Chidren aso works with the Indian Medica Association, Indian Academy of Paediatrics, Nationa Neonatoogy Forum and Breast Feeding Promotion Network of India to infuence poicy making and impementation at nationa and state eve. Academic Institutions Save the Chidren estabished strong working reationships with the A Indian Institute of Hygiene and Pubic Heath, the Nationa Institute of Choera and Enteric Diseases (NICED) Kokata, the Indian Counci for Medica Research (ICMR), Jawahara Nehru University Dehi, Indian Institute of Technoogy Dehi etc. Save the Chidren works with these institutions for seeking technica insights on programme and research component. At the grass roots eve Save the Chidren partners with Accredited Socia Heath Activists (ASHAs), Anganwadi Workers, Panchayat Raj Institutions, Youth Cubs and Mothers' Groups for deivering our community based activities. 267

276 Awards/Endorsements For its contribution in making Uttarakhand 4th Open Defecation Free (ODF) state, Save the Chidren work on diarrhoea prevention and contro was acknowedged by Uttarakhand government in June Over the ast two years, Save the Chidren has been recognized for its efforts on Sanitation in Uttarakhand. Save the Chidren aong with its partner organizations initiated the work by conducting a viage based survey of the most marginaized communities. Series of meetings were then hed with the community members motivating them to make their viages open defecation free. Awareness on benefits of sanitation and impact of open defecation on chid heath was disseminated through IEC activities and various campaigns ike Word Toiet Day and Goba Hand washing Day. One of our Intervention Schoo in Barampur district of Uttar Pradesh has been awarded with Swachh Vidyaaya award by Ministry of Human Resource and Deveopment under Swacch Bharat- Swacch Vidyaaya campaign. The schoo has been awarded 5 star rating at district eve after fied survey and physica verification by Government. SDI Community Heath Vounteers have received specia recognition by Swachh Bharat Mission and have represented their viages for better WASH faciities. SDI is key member of technica task force and committees at district, state and nationa eve. SDI is recognized for contribution towards Integrated Diarrhoea Contro Fortnight, campaign run by Ministry of Heath and Famiy Wefare, Government of India. The key endorsements by internationa pubic heath journas are as foows: n n n n Paper tited Assessing critica gaps in impementation of WHO and UNICEF'S 7-point diarrhoea contro and prevention strategy in Uttar Pradesh, India pubished in Annas of Tropica Medicine and Pubic Heath in August Research paper entited Do community eve interventions work in the same way on incidence and ongitudina prevaence of diarrhoea among under-five chidren in rura and urban sum settings? - Insights from Stop Diarrhoea Initiative in India accepted for pubication in the journa of goba heath reports. ICT enabed E-earning course using 15 modues on comprehensive diarrhoea contro, deveoped by SDI project, accepted by Humanitarian Leadership Academy, London, a goba non-profit e earning provider, for aunching this aunching this course gobay to arger pubic heath fraternity. The onine course woud be hepfu in buiding the knowedge of the heath professionas not ony in India but aso in other deveoping countries' with simiar setting and chaenges pertaining to chid heath and nutrition, water and sanitation. Paper tited ICT Enabed Bended Learning for Frontine Heath Workers A Case of Capacity Buiding in Stop Diarrhoea Initiative in India accepted for - The Goba Pubic Heath Conference (Gobe HEAL) Revitaizing Resiience towards the Emergence of Heathy Communities hed in February 2018 at Kuaa Lumpur, Maaysia. 268

277 n Four papers accepted for presentation in Internationa Conference on Pubic Heath hed on 28th-29th Juy, 2016 at Coombo, Sri Lanka a. A Quaity Enquiry into Enabers and Barriers to Behaviors Reated to 7 Point Pan on Comprehensive Diarrhoea Contro in 4 districts of India b. Exporing Suppy Chain Management issues in chidhood diarrhoea prevention and treatment research findings into Stop Diarrhoea Initiative of Save the Chidren in four States in India c. Exporing Capacity Buiding Needs for Comprehensive Diarrhoea Contro in Four States in India under Save the Chidren 'Stop Diarrhoea Initiative d. Is Mothers sef-reporting as good as Community Heath Vounteers reported data for chidhood diarrhoea? 269

278 Community Heath Care Management Initiative Focusing on: Strengthening of ram Unnayan Samsads and Sef-Hep roups through PRI in 5 districts of West Benga March February 2013 Chid In Need Institute Website : Founder of the Organization : Dr. Samir Narayan Chaudhuri Project Budget : ` /- Coverage/ Geographica reach : The project was faciitated by CINI in 5 districts of West Benga 270

279 Districts Sub-divisions Bocks Gps Sansads Japaiguri Mada Murshidabad South 24 Parganas Uttar Dinajpur Tota Project Brief The Community Heath Care Management Initiative (CHCMI) programme was aunched jointy by the Panchayet & Rura Deveopment Department and the Department of Heath & Famiy Wefare in Community's heath in Community's Hands being the motto of the programme, the panned intervention sought to drive home a sense of responsibiity among common peope towards their own heath care management under the eadership of Panchayati Raj Institutions. The roe of PRI is viewed as crucia towards panning, impementing and monitoring of NRHM programmes. In March 2010, CHCMI was scaed up in ten districts covering 155 bocks and 1494 GPs in the state. With communitisation as the driving phiosophy behind the inception of this programme, it was envisioned that by strengthening the Viage Heath Sanitation and Nutrition Committees (VHSNCs), a process of decentraized heath panning coud be initiated by creating a patform where the issues of the community coud be resoved through micro-panning and oca eve resources. Emphasis was aso paced on increased community monitoring and intersection of departments through strengthening of the various convergent patforms (3rd Saturday and 4th Saturday meetings) and capacity deveopment of the sef-hep groups. The interpay of this faciitation and capabiity deveopment, it was beieved woud heaviy improve the overa pubic heath-nutrition service deivery and consequenty, its utiisation pattern by the communities. This approach forms the foundation phiosophy of 'The CINI Method' which reaizes that sustainabe deveopment is possibe ony by co-operation, coaboration and association with communities, service providers, government officias, eected representatives and civi society members. 'The CINI Method' through its mission of deveoping 'Chid Friendy Communities '(CFC) payed a predominant roe in this faciitation since the method reies on giving a chid a protected environment through the convergence of community, panchayet and the service providers. The objectives of the programme were: a. To improve the capacity of eected members of PRI and Gram Unnayan Sansad (GUS) representatives for effectivey managing and monitoring materna and chid heath situations in their fied b. To sustainaby Invove Sef Hep Group (SHG) members in advocating for basic Mother and Chid Heath (MCH) issues at the community eve In 2004 the CHCMI programme was aunched by the Government of West Benga. The one year piot 271

280 study was done by CINI in 12 gram panchayats (GPs) in Murshidabad district and was supported by P&RD, Government of West Benga. It was greaty infuenced by the ongoing discussions on NRHM. The basic objective was to strengthen invovement of PRIs and women SHGs in panning, impementing and monitoring action on oca heath and nutrition issues and reated determinants. It aso promoted inkages with government service providers. Then foowed by the findings of the piot study by CINI, the Government of West Benga decided to scae up the programme in 10 districts of the state. CINI was entrusted by the Government of West Benga for scaing and faciitating the programme in 5 districts of West Benga for a period of 3 years. Impementation Mode The objectives coud be achieved by generating a team of efficient peope (Faciitator team) at the district and bock eve, who sha support the impementation of the CHCMI program at the districts, bocks, Gram panchayat and up to SHG eve (viage eve) through faciitating coordination and interinkages of the PRI members, District Pubic Heath Ce, NGOs and community. The strategy sha mainy incude sensitization of eected representatives, rounds of trainings foowing participatory methods, handhoding support at the fied eve, supportive supervision during impementation at fied eve, frequent discussion with poicy makers at a eve. The impementation mode and the strategy incuded: SHGs wi be oriented on basic MCH issues and they woud be abe to disseminate the same messages at their respective community. SHG mothers woud then be abe to contribute significanty during heath pan preparation at the viage eve. GUS woud be continuousy oriented and sensitized so as to enabe them to monitor the progress in MCH situation of their area and take necessary action. The road map for impementation of these strategies were: Step I: Need Assessment with concerned stakehoders Step II: Modue Deveopment for Training in a cascading mode Step III (A): Preparatory phase Generation of Training team at State, district and Bock eve Step III (B): Orientation of the Training team Step IV: Preparation and finaization of participant ist from GP eve Step V: Capacity Buiding process of the participants Step VI: Post Training phases An interpay of a these strategies and processes was carried out through the basic mode of 'The CINI method' which emphasizes on acting as a faciitator by creating a bridge between the receivers and the providers for service deivery and consequenty their utiisation. This entire programme stood on the basic premise of improving the overa quaity of pubic heath service deivery through community based monitoring and strengthening community based institutions. 272

281 Community Outreach The programme aimed at improving the service deivery of the heath and nutrition services by strengthening the community based institutions for increased utiisation of the pubic services. This was achieved primariy through the process of communitisation which is the core emphasis of 'The CINI Method'. The programme sensitized the viage women for forming sef-hep groups among themseves. This was faciitated at the GP eve where the GP members were trained for forming of such groups. These SHGs were then capacitated and extensivey trained regarding the various domains of heath, nutrition and iveihood. They were made aware regarding the importance of maintenance of basic ceaniness and hygiene. They were aso sensitized regarding the various entitements from the system and the mode of service deivery from the pubic systems. These SHG women then reached out to the other group members and viage women and generated awareness regarding the same. Moreover, the SHG women aso tracked each and every pregnant & actating women, new-borns and aso were invoved in househod eve surveys. The issues of the community were duy raised at the 3rd Saturday meetings and it was the responsibiity of the GUS members to monitor that these issues were raised at the 4th Saturday meetings, faciitate the formation of VHSNCs and their functioning for resoution of oca eve heath nutrition probems. Uniqueness of the Project Communitisation is an aternative approach in governance. It refers to a contract between the government and the community. Community becomes the owner of the government assets and is granted powers to manage and maintain institutions. Active invovement and participation of members ensures that peope recognize their own needs and work towards fufiing them. This was the primary ground-breaking feature of this programme that through community ed processes and community based institutions an improvement in the overa pubic service deivery was obtained together with increased utiisation of services that ed to a deveopment in the heath and nutrition indices of the community. Some of the promising initiatives of the programme were: Number to Name' Tracking Mechanism for Beneficiaries A Piot Initiative: Organising Nutrition Demonstration Camps Coectivey: Nutrition demonstration camps were organised across the five districts. Loca communities were encouraged to provide the ingredients and other required items. Expenditure, if any, was covered through the VHSNC heath pan budget. The SHG women aso payed a key roe. Initiation of Migration Card: In December 2011, a the GPs in Sagardighi bock in Murshidabad started issuing migration cards. This system was initiated with the support of CHCMI staffs who faciitated sansad, GP and bock eve meetings to evove consensus on this issue. The BDO, in particuar, encouraged the initiative. The oca SHGs aso pitched in at the sansad and GP eves. The response has been overwheming. Moreover, it has proved to be a vauabe aid in working on unsafe migration and combating trafficking of chidren and women. SHGs as cataysts for change: The trained SHG women acted as cataysts for change by directy intervening in cases of manourishment and bringing changes, resoving changes with the SNP 273

282 BMOH/BDO Target vs. achievement anaysed with the hep of Parishistha 1(data coec on format used in 4 th Saturday mee ngs) in 4th. Sat. mee ng faciita ng effec ve panning and stocktaking List shared in 3rd. Sat. mee ng to iden fy LO/DO and prepare impemen ng strategy SHG, AWW & ASHA coec vey prepare ist of target beneficiaries by compiing SHG tracking registers SHG update two tracking register from Mother Chid Protec on cards and by home visits service of the AWCs, promoting positive chid caring and feeding practices and finay for preventing eary marriages. Roe of Information and Communication Technoogies (ICTs) The project did not require the invovement of any technoogies since it was a community based programme that reied on the basic premise of strengthening pubic heath service deivery through community ed processes and initiatives. Chaenges Faced Severa chaenges and constraining factors continue to cast their effect. These are inked to topography, proximity and access issues reated to service deivery points, oca dynamics and ensuring that a the inks in the decentraized panning and action chain (from the sansad to the district) are in pace. CHCMI has certainy heped in aying the foundation for community ed, convergent processes for improved outcomes. It is now important to hod on to the gains and buid on this foundation. Outcomes It was found that by October 2012, VHSNCs had been formed for more than 95% of the sansads in the intervention bocks of Japaiguri, Uttar Dinajpur, Murshidabad, Mada and South 24 Parganas. Mada brought up the rear at 89.8%. The VHSNC members were given inputs through orientations, workshops and continuous handhoding support VHSNC were covered in a joint orientation with SHG members where key messages on heath and nutrition and reated determinants and functiona aspects were discussed. Aso, by October 2012, 8016 SHGs had been seected and trained through propery panned structured sessions across the five districts. 274

283 The project intervention saw a massive boost in reguarization of monthy VHSNC meetings with 82% to 100% of the sansads across the five districts were engaged in deveoping the pans in October Impementation of these pans required financia assistance and accordingy fund utiisation was aso improved to a massive extent in these districts. The continuous faciitation aso resuted in reguarizing the convergent patform meetings. In March 2010, 41% to 73% of the GPs across the five districts were conducting the meeting. By, October 2012, more than 90% of the GPs were conducting this crucia meeting. This proved to be yet another success of the programme. Improved systemic functioning, increased demand from the community together with invovement of the PRIs resuted boosting up the overa indicators of heath and nutrition. Key outcome indicators such as institutiona deivery, weighing of chidren within 48 hours of birth and fu immunization of chidren up to one year of age witnessed a positive trend. Overa, recording of birth weights showed most consistent improvement (vaue ranges for March 2010: 44%-57%, November 2011: 63%- 75%, October 2012: 75%-89%). Birth registration aso showed a positive trend with Japaiguri as the soe exception. The roe of SHGs in reiterating key messages and connecting famiies with service deivery points coud be seen as a key contributory factor in most cases. Improvements in service deivery systems backed by a poicy emphasis on materna and chid heath issues aso payed a key roe. Outreach & Scaabiity The programme was scaed up after the piot initiative for 1 year in Murshidabad district of West Benga by CINI. Foowing the success of the piot initiative, the programme was scaed to 10 districts. This was a huge success for pacing reiance on the strength of the community ed processes and the roe of community in deveoping ownership towards their own systems and institutions. The frameworks deveoped under this programme was aso encouraged by the district administrations and used in their programmes. Repicabiity Since the basic premise of the programme is communitisation, this programme can very we be repicated in other ocations and states and integrated with the existing processes. Impact Achieved The programme ed to the overa strengthening of the pubic system through the ownership and invovement of the community based institutions. This programme was abe to generate and imbibe the understanding that a concerted effort by the communities for improving their overa quaity of ife wi definitey ead to improved service deivery by the systems. Thus, the evovement and sustenance of community based monitoring processes was the main impact of this programme which resuted in achieving improved materna heath and nutrition indicators. Moreover, the empowerment of the SHG women through continuous capacity deveopment resuted in them invoved in the communitisation process by generating a feeing of ownership towards the systemic entitements within the community and aso by sustained awareness generation regarding various heath-nutrition indices. It aso resuted in increased mobiity of these women with them going 275

284 over to the bock offices, panchayet set-up, interacting with officias and voicing their demands. Thus, together with deveoping their knowedge base regarding systemic entitements regarding heath and nutrition, this programme aso managed to everage their sef-confidence paying a major roe in their empowerment. Capacity Buiding This programme operated through extensive capacity buiding initiatives for successfu impementation of the programme objectives. This invoved: Intensive training to the GP members for faciitating formation of SHGs. At the GUS eve, the members were trained for monitoring and supervising the functioning of the 4th Saturday meetings together with faciitating formation of VHSNC and their effective functioning. Exhaustive training of the SHG women for deveoping their basic knowedge on heath and nutrition and sensitising them on ways to dea with the community for advocating on MCH issues. Partners of the Project This diagram provides a description of the engagement process of key stakehoders of the programme. The programme was managed and hed by the Panchayat & Rura Deveopment Department and faciitating partner was CARE, India. WBSRDA at P&RD Secretariat, WB ORGANISATIONAL STRUCTURE State Pubic Heath Ce (SPHC) Janasasthya O Paribesh Sthayee Sami (Zia Parisad) Dist. Pubic Heath Ce, Dist. Leve Training Team (DLTT), Dist. Resource Team (DRT) Janasasthya O Paribesh Sthayee Sami (Panchayat Sami ) Bock Leve Training Team (BLTT) Siksha O Janasasthya Upa-Sami (Gram Panchayat) GP eve Faciitators Team (GPFT) Gram Unnayan Sami (GUS) Func ona Commi ee, Sef Hep Groups (SHG). 276

285 Tiko Saathi August December 2017 Popuation Services Internationa (PSI)/India Website : Project Budget : 1 Miion USD Coverage/ Geographica reach : Awar, Jaipur, Dausa, Ajmer (Raj) and Agra (UP) 277

286 Project Brief Neary a third of peope in and around cities in India ive in sums with poor hygiene, sanitation, and an absence of heath services. Women and their famiies strugge to access basic, affordabe heath services and products. In India, 56,000 women die each year in chidbirth one every eight minutes. This accounts for 19% of materna deaths around the word, 70% of which coud be prevented with access to quaity heath care and skied birth attendants. Many socia businesses and NGOs are entering the market to improve access to heathcare, finance, and technoogy. These new market actors are deveoping impactfu products, but are unabe to deiver them to the ast mie. There is a market gap to enabe customers to access high quaity, ow cost, sociay-impactfu products that they want and need, and there are many women ready and abe to take up that chaenge. In 2015, with private seed funding through Maverick Coective and working aongside mobie technoogy innovation partner Triggerise, PSI aunched Tiko Saathi a three-year piot to deveop a socia entrepreneurship ecosystem in five districts in Rajasthan and Uttar Pradesh. PSI, in partnership with technoogy organization Triggerise India, deveoped an innovative piot to address the heath needs of women and their chidren focusing on the first 1,000 days of pregnancy, chidbirth and infancy a critica window of opportunity. With phianthropic seed investment from 278

287 Maverick Coective Founding Member Martha Daring, PSI and Triggerise buit a network of oca women socia entrepreneurs to reach women in urban areas with a basket of heath products and services, which is named/branded Tiko Saathi. The vision is to create a heath ecosystem that brings care to the front door wherever possibe, providing accurate information and advice, and financia incentives in the form of subsidized cinic services and products and the abiity to earn points (known as Tiko Mies) redeemabe for heath products. The ecosystem served as a testing ground for a nove business mode that integrates heath impact with economic empowerment, whie everaging the power of mobie technoogy. Through this piot, PSI sought to promote entrepreneurship, take a user-centered approach, prototype and iterate throughout the course of impementation, and integrate new products and services wherever possibe with a particuar goa of increasing the number of ANCs. In setting up the product basket under Tiko Saathi, PSI identified gaps in heath products and services avaiabe prior to, during and after pregnancy from the consumer perspective. These incuded the expense of diagnostic tests recommended during antenata care visits and post-partum famiy panning. As a resut, these services were made avaiabe to hoders of the Tiko Saathi card at a discounted rate from doctors and cinics who registered to be part of the network. Impementation Mode Together PSI and Triggerise have been abe to create a vaue proposition for a stakehoders and actors invoved in the ecosystem. Both entities joined hands to create strategies for a sustainabe mode and they shared various resources to achieve positive resuts under this project. The Tiko Saathi ecosystem consists of a network of diverse users (from end-consumers to private cinics, pharmacists and whoesaers) who are registered via a mobie app and given the abiity to perform actions : Consumers ( Sarita ) are at the center of the ecosystem. Women in the community have the abiity to buy Tiko cards that provide discounts on a range of products and services before, during and foowing pregnancy. Tiko cards aso offer the opportunity to earn points or Tiko Mies as an incentive for heathy actions (e.g. attending antenata care visits) which can ater be used to pay for products. Each of Sarita's interactions with the ecosystem is recorded via a mobie app, which heps the system to profie her behavior, providing customized offers and rewards Providers are seected based on the services offered and on a quaity assessment. Each provider is 279

288 registered in the ecosystem based on a prior assessment and their wiingness to participate in the program. The providers offer discounted fees directy to women in the community Saritas Pro Agents (Last Mie Distributors) are oca women entrepreneurs who earn an income for deivering heath messages, referring cients to services, promoting specia heath offers and seing heath impact products. Recruited from the community, they receive training on saes techniques as we as basic heath messaging. They pay a key roe in the ecosystem as they proactivey engage women at their doorstep and encourage them to adopt heathy behaviors Whoesaers agree to accept Tiko Mies as payment by Pro Agents when they restock their baskets of goods. At the end of the month, PSI redeems a points by transferring the corresponding monetary amount to the whoesaer. Community Outreach As mentioned above, Pro-agents are key stakehoders in this project who connect with Sarita (archetype of target group), Services Providers and Whoesaers. These pro-agent cater services in particuar area and reguary interact with Sarita. The Pro Agents se comprehensive heath membership cards that ink women with quaity heath care services in cinics during the critica 1000-day window of pregnancy (ante-nata care consutations, diagnostics and tests, utrasonography, postpartum famiy panning options, and two consutations for the newborn). Women earn Tiko Mies for every service they access and for using their mobie phones to confirm pregnancy miestones and 280

289 these points can then be used to buy products from the Pro Agents or to pay for services at the dedicated Tiko Cinics in the network. Uniqueness of the Project In order to increase the vaue fowing within the eco-system and ensure it reaches Sarita, three associated innovations are impemented around three piars, based on three major assumptions: I E A PSI India and Triggerise are deveoping a network of women entrepreneur (branded as Pro Agents) aimed at addressing these chaenges, by: Deivering high quaity heath information as required by Sarita at right time with the hep of standard too. Promote high quaity heath impact products and referring to service providers as per the need of Sarita. Aowing rea-time tracking of purchases within the network, enabing the passing of instant commissions to women entrepreneurs every time they purchase an impact commodity. Deveoping a ean suppy chain, using existing sma scae retaiers and stockists; monitored through Movercado software. Deveoping a powerfu brand, encouraging Women to join and grow the network. 2. Loyaty Points (branded Tiko) PSI India and Triggerise introduced a socia marketing oyaty program branded Tiko. Its aim it to encourage Sarita to become a consistent cient/user by offering her direct discounts, rewards, and benefits in an eco-system made of different actors. This creates vaue for Sarita, as it gives her the opportunity to save, by accessing necessary products and services at a preferentia price, using points rather than cash. On top of it, she can earn more, by registering her behavior therefore fee rewarded. This creates aso vaue for the providers and the stockiest, by increasing demand at ow cost, providing them with an access to a Customer Reationship Management system ce phone based and offering innovative financing options (Heath services in buk, incrementa incentive for service provision). For PSI India, it gives a unique opportunity to know more Sarita by tracking her behavior and enabing direct contact (by sms or ca). It provides the team wi rea time monitoring data, enabing dynamic project management through fast iterations, rapid tests and reguar improvements. 281

290 3. Heath service membership package (branded Tiko Saathi) Using behaviora economics theories as we as agie project management principes, PSI India and Triggerise are impementing a seing of membership program branded Tiko Saathi card. It functions as a heath service membership offer, made of a bunde of products and services. The subscriptions are defined around specific heath needs, such as Ante-nata Check-up, Famiy Panning, non-communicabe diseases etc. Its cost to Sara is ow but pays an important roe as it stresses the importance of the membership. It aso heps to potentiay segment the offer and propose severa eves of memberships. The memberships card (Tiko Saathi Card) distributed at first by PRO Agents, in order to everage the power of interpersona communication based on how she uses her Tiko Saathi Card and what she decides to access, Sara wi receive oyaty points which she can use for foow up products and services, or to access a different subscription. Roe of Information and Communication Technoogies (ICTs) The eco-system was powered by Movercado, software capabe of managing referra systems, monitoring, retaiing, communication and virtua oyaty schemes to improve the heath of bottom of the pyramid users. The access to Movercado is via any basic ce phone and uses SMS to trigger momentum. Chaenges Faced Require reguar foow up to keep pro-agents active and sef-reiant- A major chaenge: With increasing numbers of pro agents in the network, it has been observed that constant support is required on a daiy basis with these pro agents by their program officers. This was causing difficuty in smooth impementation of project activities. Hence, a decision was taken to initiate faciitation of custer meetings in particuar areas where pro agents operate. Pro agents beong to different cuture and community requires constant motivation and support to become active in the eco-system. They have been foowed up with different strategy incuding sending SMS through movercado technoogy for ensuring participation in the reguar custer eve meeting to update and addressing their chaenges. The project aso introduced variety of merchandise to motivate pro agents and sustain their behaviour for onger. Introduce new schemes for pro agents for increasing their income. 282

291 Use of Technoogy in Urban and peri urban areas A major shift: The project initiay introduced SMS based registration system for Sarita, which was not found very successfu due to ack of knowedge of sending messages and the cost of SMS messages. To address this probem, the project introduced movercado technoogy to capture interactions and save SMS costs of Sarita. A key transactions ike visit vaidation for ante-nata care check-ups requires the target group to ony give a missed ca. However pro agent faced chaenges in using Movercado technoogy such as registering cients, saes transaction and knowing tiko baance. Thus project deveoped Apps for Pro-agents and Stockiest which provided soution to many operationa chaenges. To increase the use of App, the project tied up with the mobie vendor to suppy the smart phone on discounted rates to Pro agents. The vendors were aso prepared accepting Tiko Mies which boosted motivation among pro-agents. Through this initiative many pro agent started buying smartphones and now using new Pro-apps for their transactions. Outcomes Some of the key outcomes from the three-year piot incude: Creation of an active network of more than 1,400 motivaterd Pro Agents across five districts in Rajasthan and Uttar Pradesh. This exceeded our initia projection of 1,000 Pro Agents. Successfu strategies that heped recruit and retain Pro Agents incuded offering specific incentives to Pro Agents for referring friends as potentia Pros, capacity-buiding and skis training, custer meetings and on-site support, and quartery rewards and recognition. 8% of Pro Agents earn more than INR 2,500 per month. This figure demonstrates substantia economic empowerment from the Tiko Saathi mode and highights the success of training and capacity-buiding efforts with the Pro Agents to give them the necessary business skis and knowedge to succeed as entrepreneurs and maximize their earnings. More than 33,000 Tiko Saathi cards were sod during the piot period and more than 24,000 women benefited from discounted services as a resut. The Tiko mode has shown success in increasing monthy antenata care visits at private cinics in the project districts, from 11 in 2015 to 4,292 in 2017, a substantia increase. 283

292 Outreach & Scaabiity The mode has been pioted as a component part of severa other projects impemented by PSI in India. Movercado and Tiko was used for incentivizing toiet motivators for seing toiets at Bihar. The system was used by eight key actors toiet motivators and cement ring manufacturers - and resuted into 188 toiet saes and 28,000+Tiko mies as incentive. Sanitation team has aso shown interest to use the mode in Feca Sudge Management project. PSI impemented Tubercuosis (TB) program where Union is prime donor. PSI has presented the Pro mode to the Union and they iked it and are keen to adopt it in one of the TB project districts, where Pro can se products and screen TB patients. In Jaipur, PSI roed-out nutrition distribution to TB cients, which was inked to movercado for monitoring and reporting purpose. The Tiko mode has shown great promise as a mode for socia entrepreneurship that both empowers women to reach their fu economic potentia and has potentia to deiver sustainabe heathcare in future. Over the next three years, we have the opportunity to innovate and expand the mode further to move towards a commerciay sustainabe and scaabe business. To accompish this, The Dutch Ministry of Foreign Affairs has funded our technoogy impementing partner (Triggerise) to create an "impact investment patform" that wi aow traditiona donors, foundations, and private donors to contribute to measurabe impact by investing in Tiko -- therefore opening the door for further investments into the existing ecosystem in Rajasthan and Uttar Pradesh. Future vision for Tiko Saathi Project: Expand the Pro network to 2,500 women entrepreneurs by 2020; Expore different funding options, such as commerciaization; corporate investment; and integrating this approach into government-funded heath schemes, to reduce reiance on traditiona funding and phianthropy; 284

293 Expand the network across Uttar Pradesh (horizonta) and voume in Rajasthan (depth); Expanding Tiko Mies to be a motivationa too for a actors of the ecosystem; Adopting an approach of sef-enroment and ong-term heath journeys; Repicabiity PSI and Triggerise continue to refine severa eements of the mode to work towards commerciaization, corporate buyout, or takeover by the government. Through such a partner, particuary someone with experience with venture phianthropy and socia enterprise, we beieve there is a cear opportunity to take the Tiko mode to the next eve. Our vision is to create a proven mode for how socia entrepreneurship can deiver sustainabe heath impact for women and girs, and move countries towards universa heath coverage. Some of the key areas where we are ooking for support and guidance from an experienced investor incude: Deveoping a cear 'go to market' strategy; Gathering additiona data on voume and coverage; Reducing dependency on tiko mies for Pro Agents; Creating an articuated vaue proposition and strategy for corporate partnerships; and Gathering data on standard coverage, such as the number of cinics per Pro Agent and socioeconomic coverage of cients (toensure we continue to meet the needs of ow-income women and girs). With additiona investment, we wi expand the products and services that can be added to address women's heath needs and expand Pro Agents' profit margins, such as non-communicabe diseases (diabetes and high bood pressure); tubercuosis; adoescent sexua heath; insurance (to address the issue of high out-of-pocket expenses for accessing heathcare); menstrua hygiene; screening for cervica cancer and breast cancer, and primary heath care. Impact Achieved Deivering heath care services with subsidized rates: Improved ANC registration in Private Heath care Institutions: The goa of Tiko Saathi Project is to deiver heath products and services to the urban poor, specificay adoescent women and girs iving in these areas. At the heart of the ecosystem is a branded network of women entrepreneurs from the community (caed Pro Agents ) who se quaity heath products and services door-to-door. Their basket incudes a range of products: 285

294 Heath Impact Products Ora Contraceptive Pis Pregnancy Test Kits Sanitary Pads Ora Rehydration Soutions Condoms Baby Products Diapers & Wipes Oi, Soap & Shampoo Generic Products Face Wash Mosquito Repeent Body Lotion Hand Sanitizer Gucose Antiseptic Cream Thermometers In addition, the Pro Agents se comprehensive heath membership cards that ink women with quaity heath care services in cinics during the critica 1000-day window of pregnancy (ante-nata care consutations, diagnostics and tests, utrasonography, post-partum famiy panning options, and two consutations for the newborn). Women earn Tiko Mies for every service they access and for using their mobie phones to confirm pregnancy miestones and these points can then be used to buy products from the Pro Agents or to pay for services at the dedicated Tiko Cinics in the network. The piot focused on combining socia and heath impacts and works under severa key principes: Promoting entrepreneurship Empoying a user-centered approach Iterating quicky and being agie Integrating reated heath areas 286

295 There are now 1,400 Tiko Pro Agents in the ecosystem; 63 cinics; and 14+5 stockists across five districts. These Pro Agents have reached to 1, 57,000 women with 45,000 + heath membership cards; 1,36,617 sanitary pads; 2,67,348 ora rehydration soutions; 1,37,764 condoms. This distribution network has resuted in antenata care consutations. This mode has not ony provided heath products to women's doorsteps, but aso generated weath for ow-income women with a wide range of ow margin, high-margin, fast-moving and high-impact products from oca whoesaers. We have estabished this network of women entrepreneurs, but we need to innovate and continuousy iterate to bring sustainabiity to the ecosystem, add diverse heath soutions that cater to women's needs, and drive more income for women entrepreneurs. Capacity Buiding In order to capacitate pro-agents PSI made protoco to train Pro-Agents by creating a training pan and kit, which constituted a haf-day cassroom session on the project, product knowedge, technoogy, and seing techniques, and a second haf on fied training. Aso providing hand hoding support to each pro agent in fied by PSI's program officer to motivate and providing on hand experience to pro agents. Partners of the Project a. Loca Organization: PSI/India: Popuation Services Internationa (PSI) working on heath issue in India since The programs mainy targeting reproductive heath, chid surviva, tubercuosis, sanitation, HIV, maaria, gender based vioence, and non-communicabe diseases. Working in partnership with the private & 287

296 pubic sector and harnessing the power of the markets, PSI provides ifesaving products, cinica services and communications that empower the word's most vunerabe popuations to ead heathier ives. PSI tested Tiko Saathi mode in five district of Rajasthan and Uttar Pradesh. PSI created eco system of pro-agents, 60+ private providers and 12+ stockiest. More than 31,000 sarita have been provided heath care services at private providers. Triggerise India: Triggerise provided technoogica support through Movercado software for project operations, and is proprietary to Triggerise; Aso Terms ike Tiko and Pro Agents were aready being used by Triggerise in other countries. Triggerise used it's patform to reward beneficiaries, agents, providers, retaiers, stockist and any other reevant actor for adopting and promoting behaviours that ead to increased impact under PSI's project. Martha's investment has been cataytic in demonstrating proof-of-concept for the Tiko mode. The goa from the beginning has been for other donors or government to take up the program. In this case, Triggerise has taken up the mode and is generating income to sustain the mode, as we as securing further subsidy from the Dutch Government to sustain operations. Private heath care Provider: More than 60 private providers have become part of Tiko Saathi Network. The providers have payed a key roe in providing quaity heath care services to Sarita at subsidized rate. They have aso supported the project by expanding the heath care services. Stockist: More than 12 stockiest have become part of the Tiko Saathi network. They have supported pro agents in providing different heath and non-heath impact products on good margin rates. They have aso agreed to accept tiko mies against products. b. Maverick Coective Member: Martha Daring showed her interest in deveoping women entrepreneurship mode that can provide heath products and services at Sarita's door steps. Throughout the project period, together we tested a new mode of phianthropic partnership. From the first country visit, it was evident that Martha was truy invested in the project, not just financiay, but with her skis, passions, and persona connection. She was not interested in simpy being a bystander. She wanted to be invoved in a aspects of the project, incuding meeting with our partners, advocating on behaf of the project to key stakehoders and potentia funders. She met Pro-agents, Sarita, Providers and stockiest in her two different visit in India. She gave her fu time to meet and understand the project perspective. 288

297 heath cinic USHA project Urban Sum Heath Action USHA Program To reduce & Prevent Anemia and Manutrition amongst mothers [15-49] yrs and Chidren [0-6] yrs through comprehensive approach. September 2015 August 2018 SUKARYA Website : Founder of the Organization : Mrs. Meera Satpathy Project Budget : ` 5000,000 Coverage/ Geographica reach : 10 sum ocations of Dehi /NCR, area popuation is approx Coverage through this program- 10,000 mothers & chidren receives direct reguar services on preventive and curative materna and chid heath issues. 289

298 Benifits of emon Project Brief Project is to hep strengthen the detection, treatment, and prevention of manutrition & Anemic conditioning amongst Mother & Chidren and to hep combat some of the major causes of chid mortaity, through immunization and improved care at the community eve. The project aims to support the provision of basic heath services, contribute to the response to the nutrition issues and ensure that the marginaized popuation has access to basic heath checkups, vaccines and essentia medicines. Key Services under the Project: Detection, treatment and prevention of Manutrition & Anemic conditioning amongst mother & chidren. Providing basic heath care services ike Pregnancy, ANC & PNC heath checkups aong with counseing. Ensuring timey immunizations incuded in Nationa Immunization Program. Promoting adequate Nutrition for mothers, infants and young chidren. Promote Basic Micro nutrients. Promoting home based and community based Nutrition soutions /Dietary interventions to combat Manourishment and anemic conditioning amongst mothers and chidren 290

299 Key activities under the project: Monthy Heath Cinic at each ocation Counseing by Doctor and Nutritionist Laboratory check ups Medicine disbursements /suppements Disbursement of Nutrition suppements Cooking demonstrations Heath awareness sessions Sanitation drive/campaign Cooking demonstration session at JJ Bandhu Ceebrating Mother and Chid heath day Home visits and Foow ups Referras Impementation Mode It is a targeted direct impementation mode in which materna chid heath services are provided to the targeted group of mothers yrs and chidren -0-6 yrs. Basic heath services ike Ante nata checkups, post nata checkups, pregnancy test and aboratory checkups ike hemogobin test, bood pressure, bood group and bood sugar test are done aong with height & weight measurement during the Heath cinic which is organized on monthy basis at each project ocations. Counseing on Materna chid heath & Nutrition is an important segment under the project. Further to it Home visit /Foow up of targeted patients are done by recruited /trained community heath workers across each project ocation. And referra mechanism are deveoped and inked with government heath system. And Quartery basis cooking demo /Nutrition casses are conducted with pregnant and actating women by Nutritionist to promote ocay avaiabe ow cost adequate source of nutrition. The Nutrition food suppement is aso provided to the identified anemic & manourished mothers and chidren. The monthy routine immunization by government heath department is inked with our Heath cinic and day is ceebrated as Mothers and Chid Heath day in which targeted group /beneficiaries receive a services under one roof.medica /Heath services by Sukarya and Immunization is by Government. Additionay every quarter sanitation drive ike Community Ceaniness and Hand hygiene demo sessions are organized. MIS system is estabished and reguar capacity buiding trainings for project team & fied staff is conducted. 291

300 Diagnosis of new born chid by dr. Jethra Community Outreach The foowing processes are maintained whie impementing this project Identification of ocation /community Community need assessment Basic data coection /indicator wise from Heath & ICDS department Invoving community, Stakehoder, PRIs and other oca representatives whie panning to execute the project. Focus group discussion [FGDs] with targeted groups e.g. pregnant women, Lactating women and Mother in Laws. Overa community assessment, KPA [Knowedge, practice and Attitude] on materna chid heath & Nutrition and associated issues. Base ine survey Uniqueness of the Project [1] Speciaized medica heath excusivey for targeted mothers and chidren. [No others] [2] Designated trained Community heath workers across a project ocations [3] Creation of Mother's group forum to earn, share and care about motherhood, pregnancy and actation period across a project ocations 292

301 [4] Convergence with government heath system [Ceebration of Mother and Chid heath day], Our Heath cinic conducted with govt.routine immunization Roe of Information and Communication Technoogies (ICTs) mmitra voice ca services that is technoogy intervention inked with this program to make the intervention more comprehensive. Coaborated with mmitra Voice ca program for materna and chid heath.at each ocation targeted pregnant and actating women receives customized voice ca on preventive heath measures. Chaenges Faced We faced chaenges in setting up our heath cinics aong with government's routine immunization as they have same day for each ocation. Aso faced chaenges in setting fine tune between heath & ICDS department Facing chaenge in deveoping strong referra mechanism with government hospita Learnings: Targeted intervention is very effective Trained community heath workers are key for successfu impementation particuary for foow ups and home visits Cooking demo/ nutrition casses are of great hep making awareness about nutrition and food habits. Promotion of Iron kadai for cooking is of great impact for iron promotion Outcomes Around 10,000 Mothers and Chidren are getting reguar and sustained materna and chid heath services across a project ocations. Over a ANC [Ante nata care] & PNC [post nata care] services are increased Routine Immunization coverage increased Institutiona Deivery increased Intake iron foic acid IFA increased TT vaccination increased Excusive breastfeeding & coostrums feeding improved Reduction in anemia amongst pregnant and actating women Hc2 293

302 hb Better care and service soution for manourished chidren Dietary food habits /cooking technique and adequate Nutrition recipe being adopted by targeted popuation Mother and Chid heath day aong with Government routine immunization making services under one roof for community ed improved immunization and materna chid heath service coverage. Overa Knowedge practice and attitude of community /targeted popuation on MCH & Nutrition have been positivey improved Outreach & Scaabiity Program is on for up scaing. This project is an extension and repication of piot project aunched by Sukarya at 4 sums in Based on success, it was re-aunched with extension in Repicabiity It can be integrated with other ocation by providing heath cinics across a ocation in inkage with PHCs mmitra Voice ca services for MCH can be integrated other ocations as we. 294

303 Cooking demo/nutrition casses shoud be integrated with ICDS Impact Achieved Overa materna chid heath & nutrition knowedge, awareness, attitude and practice have been improved Improved the overa engagement of Heath & ICDS across project ocations Enhanced demands for MCH & Nutrition services Improved suppy of MCH & Nutrition services Greater awareness on Anemia & Manutrition issues Capacity Buiding Quartery Capacity buiding sessions are kept for project team and fied staff. Monthy Review & Panning meeting with fied staff Supportive supervision Partners of the Project No partner. But mmitra [ARMMAN] voice ca services are integrated to make it MCH intervention more comprehensive and target specific. Awards/Endorsements No Heath cinic under USHA project 295

304 ANM with Tabet Khushi Baby: Wearabe mheath soution for Materna and Chid Heath Tracking at ast Mie Currenty we are doing second Randomized Contro Tria that started in September 2016 and going to be ended summer of 2018 but as a project we are going scae up from 365+ viages currenty to viages from Oct 2018 Khushi Baby Website : Founder of the Organization : Mr. Ruchit Nagar, Founder & President and Current CEO Mr. Mohammed Shahnawaz, COO Project Budget : For the second tria Approx 300,000 USD (excuding the cost of technoogy deveopment) Coverage/ Geographica reach : 375 Viages in 5 administrative bocks of Udaipur district. Currenty mothers and chidren are being tracked through the system in past one year which is expected to reach by end of this year. 296

305 Project Brief Khushi Baby (KB) is a nove technoogy patform to monitor and foow-up with materna and chid heath at the ast mie, based out of Udaipur, India. The patform consists of a cuturay-symboic, digita, wearabe heath record for the mother and chid; an Android appication for both panning and for point of care decision making for the community heath worker; a dashboard for heath officias to foow-up with suppy side gaps and highest risk patients; a community outreach patform of programmabe and personaized voice ca reminders in the oca diaect to improve awareness and adherence for patients and their famiies; and curated WhatsApp groups to faciitate communication between heath workers, supervisors, and officias for data-driven responses. The KB system centers around an innovative heath record and heath symbo for materna and chid heath the KB Neckace. The neckace is wearabe, battery-free, waterproof, durabe, ess than 0.80, and tied with a cuturay symboic back thread known throughout India as kaaa dhaaga to protect the chid from evi eye. The KB neckace contains a Near Fied Communication (NFC) chip, which stores compete heath data of the pregnant women during her antenata care and intranata care periods. It further stores the history of immunization, growth, breastfeeding, and infection for the chid as per the Government of India's centraized requirements. The heath record is encrypted, ony accessibe via the Khushi Baby Android Appication by authorized heath workers, and ony editabe after unocked with the mother's biometric. Most importanty this system is decentraized and patient-centric: a patient can trave to any heath provider with the KB App and present their most updated heath history, regardess of which tabet the heath worker is using, and regardess of if/when the heath worker ast synced her data. Doing so aows for continuity of care as the mother traves from viage-heath camp for antenata care to community heath center for deivery back to the viage-heath camp for her chid's routine immunizations. Impementation Mode We hypothesize: The KB Neckace can serve as a better-retained, physica reminder to improve awareness around chid immunizations and thereby improve adherence 297

306 The KB Neckace can recruit others within the community to attend viage-based heath camps for their chidren The KB App can improve due-ist panning, point-of-care decision making, and accountabiity via interna data quaity monitoring for the heath worker The KB Voice Cas can hep ensure patients are adherent to their foow-up throughout pregnancy and infancy KB Whatsapp Groups and KB Dashboard actionabe reports can direct heath workers and supervisors to better attend to dropout and high risk patients We have empoyed a randomized, ongitudina prospective cohort anaysis framework to assess how varied entry points and exposure to our whoe intervention may predict heath outcomes incuding: competion of four antenata care checkups, competion of birth at a hospita, timey competion of infant immunizations through meases, as we as instances of stibirth, infant death, and infant infection after adjusting for confounders reated to suppy-side faiures, heath worker performance, and invididua sociodemographic status. Sub-group anaysis wi aso be performed to understand which patients benefitted the most by checking for interactions between factors. These quantitative anayses are supported by mixed methods impementation research to understand mechanism, causaiity, barriers, and scaabiity in a feasibe, iterative, and ethica fashion. Specificay, we are conducting camp-eve observations to record heath worker preparedness, adherence to protocos, and use of the KB App before, at midine, and at endine of the study period. We have shadowed a sampe bock medica officers and heath supervisors for a 1 week period to document their 298

307 workfow, identify gaps and barriers for integration of our new KB system modues at the community heath center at baseine, midine, and endine. We are conducting focus-group interviews with heath workers on a bi-monthy basis to improve the system's user interface and experience. We wi additionay incude key informant interviews of mothers, fathers, heath workers, socia workers, heath supervisors, data entry operators, heath officias, and suppy managers who a touch the KB interface in their own respective manner at midine and endine. Community Outreach Mother Baby Khushi Baby is an ecosystem attempting to address the chaenges of effective heathcare deivery at the ast mie, where the patient popuation is mosty iiterate and beow poverty ine. Whie deveoping this system we worked on understanding demand and the issues faced by peope at the frontine. We decided to use the form of a neckace for our digita medica record storage device as it is an integra part of the prevaiing cuture of the peope we are trying to reach. The KB neckace uses a back thread which hods the reevance of protecting the chid from nazar (evi eye). As a resut, this wearabe marries tradition with technoogy and attempts convert a superstitious beief into evidence-backed heath seeking behavior. The KB system aso ooks to buid upon approaches to connect the data back to the community. We beieve our diaect-specific automated voice-based reminders have an advantage over text-based approaches, given iteracy and SMS usage patterns. We further beieve we have improved upon the mode of voice reminders. Instead of simpy sending messages according to the time of pregnancy/infancy, we furthermore send automated, patient-specific cas, specific to their pattern of heath care competion and risk stratification. For heath worker engagement, instead of soey reying on Web-based dashboards for non-computer users, we have activated WhatsApp Group channes to not ony compete the data oop, but to spark specific data-driven engagements and to-do-ists. Uniqueness of the Project Accountabiity: use of Near Fied Communication and Biometric Authentication to prevent frauduent creation or manipuation of patient records. Every heath care visit has a digita paper trai that can now be audited back to the patient (without needing connectivity). The Khushi Baby systems aso empoys GPS, time-tracking, and automated data quaity checks to detect and prevent manipuative data entry behaviors by heath workers, known to take pace, yet sedom discussed, in paper and other digita systems. Ease of use: heath workers no onger have to type to search for patients; simpy scanning the Khushi Baby Pendant retrieves the record, and can even ink the data between mother and chid; the 299

308 appication has been designed for 60+ year od Auxiiary Nurse Midwives (ANMs) with no prior smartphone experience and mimics the paper-based registers they aready are accustomed to with reevant overays to guide action. Machine Learning/AI: with process in pace to stricty contro data quaity, accuracy, and competeness, for the first time we wi be abe to unock big data anaytica techniques to predict (and hopefuy prevent) probabe cases of stibirth and eary infant death. Decentraization: other mheath apps require heath workers to sync data before going into the fied or run-the-risk of a dupication when a beneficiary comes from a different viage; heath workers and patients move and even ceuar connectivity is never guaranteed. With KB, the data is aways accessibe by scanning the patients' KB Pendant. This remains true even as a high risk patient moves from the viage camp to a government referra center and back. Form factor: use of a cuturay appropriate and customizabe pendant to shown to generate demand and curiosity around the heath camps within vaccine-hesitant rura viages, supported by 3 years of fied research and hundreds of interviews with mothers in rura Udaipur. The neckace is tied with a cuturay symboic back thread known throughout India as kaaa dhaaga, worn to prevent buri nazar (the evi eye) across a major reigious sects. Engagement: our diaect-specific automated voice-based reminders have an advantage over textbased approaches, given ow iteracy and SMS usage patterns. We further improved upon the mode of voice reminders. Instead of simpy sending messages according to the time of pregnancy/infancy, we additionay send automated, patient-specific cas, commensurate with their pattern of heath care competion and risk stratification. To engage heath workers and improve responsiveness, KB has integrated into an aready sticky WhatsApp framework. Roe of Information and Communication Technoogies (ICTs) We are using eectronic chip to hod the materna and chid heath record. This interacts with android based appication through Near Fied Communication (NFC) technoogy. We are aso using biometric tabets to make the system more accountabe. Chaenges Faced Rebuiding our entire patform from scratch after 1 year of depoying a stabe mobie app for infant immunization tracking. Upon presenting our work to the Chief Medica Heath Officer, he took out a arge book and put it in our arms. We were informed we had to incorporate the entire 200 coumns of data required by the Nationa Reproductive Chid Heath Register (covering the entire continuum of care for materna and chid heath). We spent the next year redesigning our entire mobie and web patform. Aong this time we aso had to transition our tech team from student deveopers to probono deveopers to saaried offsite contractors. Working as a "piot": given that we are not universay depoyed across the district, our users are sti competing reguar required tasks on paper, and by defacto are doing doube work where our 300

309 intervention has been roed out. Ony when we have fu district approva can we standardize the data coection to be imited to our patform, eiminate the paperwork, automate reporting requirements to the State, and present the fu potentia of our anaytics that takes advantage of the entire data set in rea-time. Adjusting our mobie patform to a wide band of users - varying in age from and aso in their experience/exposure to smart phones Outcomes Our Midine Resuts aready show process outcome improvements: 4 hour median time to sync data (vs. 30 days with PCTS), 82% retention of the KB Pendant (vs. 76% for the paper heath card, p=0.2), 95% data consistent from fied to database (vs. 71% on PCTS p<0.001), 96% data compete required fieds (vs. 58% on PCTS, p<0.001), and improved proportion of materna chid heath camps hed with the KB system in pace (up from 43% to 80% in the past 10mo). We can do more. We hypothesize the KB system has the potentia to achieve a 10 point IMR drop (40 to 30) across 24 months by predicting and preventing high risk pregnancies. Outreach & Scaabiity We have the approva of the District of Udaipur, Chief Medica and Heath Officer to universay ro-out our patform across the District of cover 150,000 annua beneficiaries, as a Mode District Project for Districts across India to repicate, adopt, and scae. We have buit our patform according to Nationa Heath Mission guideines, aready foowed by over 250,000 government ANMs servicing over 25M pregnancies and infancies annuay, and to directy integrate into the State PCTS system. Repicabiity we estimate cost per beneficiary of the system and the human resources required to run to be 325 INR (5 USD, of which we woud profit $0.50) to yied a net benefit to the State of 33 INR (0.50 USD), with savings from averted mortaity, morbidity, and suppy wastage aone. Our modeing does not factor in the net-benefits from digita incusion or empowerment of these communities, which woud suggest a higher yied. As a B2G-facing, Patform as a Service, we ook to diversify our saes revenue from a soe arge government customer via: integration of our core Near Fied Communication technoogy into other scaed MCH apps (in taks with UNICEF), supporting generaized Heath Cards (in taks with Udaipur District under Smart Cities Initiative), rura heath tracking with CSR partners, heath insights and consutancy services for Ministries of Heath and rura chain hospitas. Impact Achieved In our current RCT, fied monitors have observed severa positive outcomes of the KB system in the fied. For exampe, ANM absenteeism has decreased, even during the current monsoon season, because ANMs are hed accountabe for missed camps by KB monitors at reguary hed bock meetings. Phone ca reminders to mothers prior to camp are successfuy drawing unprecedented numbers of women to camps, and in one case, caused a mother to change her trave pans due to receiving a ca reminder 301

310 about the camp the next day. Aso, those ANMs who are activey using the KB appication are more cosey foowing the vaccination schedue through the app's 'Vaccinations Due for Today' page, thereby foowing the directions for each patient. ANMs are aso making use of the 'Scan Mother Tag' feature, which reduces their time of data entry when registering the chid whie at the same time inking the mother and chid record. Further, as a resut of our appication's suppy side faiure report, which is highighted during bock meetings, ANMs have received the equipment they require to carry out their duties. Finay, mothers are in fact starting to identify the pendant as their heath card, which is an association that is critica for the success of the transition from a paper to a digita record. The pendant has become a desired object within the communities, thereby strengthening the aim for the neckace to become a widey-recognized symbo for good heath. In the one year since our aunch: beneficiaries across 300 viages have been registered 70,000+ voice ca reminders and educationa messages in the oca Mewari diaect have been received by beneficiary famiies Capacity Buiding 150+ heath workers and officias have been trained on how to use the KB app and dashboard Partners of the Project We are supported by word-cass partners, incuding: IDEMIA, the organization with the biometrics and hardware behind AADHAAR - India's competed campaign for 1 biion digita, biometric identities; GAVI; the Vaccine Aiance: has seected Khushi Baby as one of the Pacesetter through GAVI Infuse programme. Funding KB's scae up strategy to make Udaipur a mode district. Heping to ink KB to CSR initiatives in India. Johnson and Johnson: KB is the Grand winner of GenH Chaenge, heping to overcome technoogy and management chaenges UNICEF Innovation: Heping with funding, initia incubation, and strategizing outreach in African and other LMICs Awards/Endorsements Awards to date: Johnson and Johnson GenH Grand Winner 2018 Goba South e-heath Observatory Awards 2017 (presented by the Pierre Fabre Foundation) SPO Emerging NGO Award 2017 (presented by Union Minister of Socia Justice and Empowerment, Government of India) 302

311 Digita India Summit presented by Times Network (with Chief Guest Minister of IT, RS Prasad): Tech for Good, E-heathcare category NFC Innovation Prize: Best Mobie App of 2017 Aquent Design for Good Winner Canada Grand Chaenges Stars in Reproductive Materna Newborn and Chid Heath Grant Nominet Trust Top 100 Socia Enterprises Digita India Traibazer: Nationa Award Winner (presented by Hon RS Prasad) UN Day Featured Innovation, Dehi, India, 2016 Digita India Traibazer: Rajasthan (presented by CM Vasundhara Raje) Internationa Society Innovation Fund Technica Scae-up Grant Cisco Grand Innovation Chaenge Semi Finaist Eric Mood New Professiona Award from the Yae Schoo of Pubic Heath GAVI INFUSE Pacesetter Cassy Awards Finaist 2016 Forbes 30 under 30 Heath care and Forbes 30 under 30 Asia for Heath care and Life Sciences UNICEF Wearabes For Good Winner 3ie Rapid Impact Evauation Grantee Human Nature Lab, Yae Department of Socioogy Summer Research Award Johns Hopkins Future Heath Systems Young Researcher Award Yae Thorne Prize for Socia Innovation in Heath 303

312 Private provider accredited under ukti ojana counseing a woman on the avaiabe contraceptive options (2) ukti ojana Pubic Private Partnership for Expanding Avaiabiity of Safe Abortion Services in Bihar 2011-ongoing Ipas Deveopment Foundation Website : Founder of the Organization : Mr. Vinoj Manning Project Budget : Average annua budget: ` 2.65 crore Government investment: ` 2.05 crore Donor funds to IDF: ` 60 acs Coverage/ Geographica reach : Bihar 304

313 Project Brief Bihar's materna mortaity ratio (MMR) of 208 (208 deaths per 100,000 births) is consideraby higher than the nationa figure of 167.¹ Unsafe abortions continue to be a major contributor to materna mortaity and morbidity in the state. Approximatey 3,96,956 induced abortions take pace in Bihar every year,¹ yet data from the Government of Bihar (GoB) shows ony 704 pubic-sector faciities that are eigibe to offer abortion services. However, many of these faciities are unabe to provide CAC services because of a shortage of trained certified providers. Given this ack of pubic-sector cinics, women frequenty seek services from the private sector. However, private-sector abortion services are often inaccessibe or inadequate, especiay to the rura poor, for many reasons incuding : Services are not avaiabe everywhere, especiay in rura areas Over-pricing of services Non-compiance with the aw Provision of inadequate and/or inappropriate treatment As a resut, the majority of abortions in Bihar take pace outside government-recognized heath centers, often performed by untrained providers and/or under unhygienic conditions. Recognizing the need to increase access to safe abortion services and thereby reduce MMR, the GoB decided to everage the private sector to make avaiabe safe abortion services in the private sector free of cost. The GoB invited IDF to provide technica assistance for this initiative. In 2011, IDF assisted the State Heath Society Bihar (SHSB), GoB to conceptuaize and initiate a pubicprivate partnership (PPP) mode for safe abortion services. Yukti Yojana is a unique PPP that makes avaiabe high-quaity abortion care free-of-cost to women through accredited private cinics. These cinics are reimbursed by the state government for services provided. Yukti Yojana aims to compement safe abortion services in the pubic-sector of Bihar by making avaiabe high-quaity abortion services to women free-of-cost through accredited private cinics. Community Outreach Launch event: The aunch of Yukti Yojana in Apri 2011 was chaired by the State Heath Minister and attended by more than 100 oca stakehoders, incuding state and district officias, private providers, and the media, demonstrating commitment among stakehoders from the beginning. For the aunch, IDF worked with the GoB to deveop pubicity materias incuding newspaper advertisements, press reeases, radio jinges for the government to use to announce the program, as we as information, education and communication (IEC) materias - incuding signs, eafets, and posters for dispay at the private cinics. ¹ RGI SRS MMR for Banerjee SK. Estimating induced abortion through indirect method Aich P, Banerjee SK, Jha TK, Aggarwa A. Situation anaysis of MTP services in Bihar. New Dehi: Ipas India Banerjee et a. Expanding avaiabiity of safe abortion services through private sector accreditation: a case study of the ukti ojana program in Bihar, India. Reproductive Heath (2015) 12:10 305

314 Hepine: Estabishment of a to-free hepine ( ) to provide program reated information and respond to queries from the community and providers, and to guide women in accessing services at accredited cinics. Initia pubicity: Demonstrating their strong support for the program, the state government instaed hoardings with a photograph of Nitish Kumar, Bihar's Chief Minister, endorsing the program, aong with other informationa outdoor advertisements. The government's IEC campaign payed an important roe in integrating the program with other state-run wefare programs. Ongoing communication and awareness-buiding activities: To encourage private providers to seek accreditation for their cinics and women to use the safe private-sector cinics, the state government: n Pubicizes the program through newspaper advertisements on a periodic basis n Faciitates wa paintings with information about Yukti Yojana to reach the arger community and encourage more women to seek services at the cinics n Orients community-heath intermediaries on Yukti Yojana aong with providing information about the program to women in the community, the intermediaries aso accompany women to the accredited cinics to avai services and receive a transport subsidy to cover their trave cost n Prints eafets with information about the program for distribution to women in the community through the community-heath intermediaries Impementation Mode 306

315 Uniqueness of the Project Ownership within the state: Providing technica assistance to GoB, IDF has been a catayst, faciitating primary ownership by the state government, and ensuring sustainabiity and impementation at ower eves of the heath system. IDF strengthened capacities of state officias to administer and monitor the program's progress, soidifying their continued commitment to the program. Loca NGO partner: Our oca NGO partner has faciitated our unique partnership between the state government, the district officias and private providers, who are supportive and committed to the program's success, and have heped in smoothening the reimbursement process. Increasing awareness: Community awareness directy infuences utiization of services under the program and contributes to its success. The we-pubicized aunch of the program foowed by deveopment of communication materias, radio jinges, wa paintings, and newspaper advertisements ed to increased awareness about the program. Reguar monitoring and dissemination: Reguar monitoring of services provided by the accredited private cinics ensures quaity and heps assess the rea impact of the services. Dissemination of evauation study findings is necessary for informing a key stakehoders on program progress and is an important feedback mechanism for ong-term success. Cient feedback mechanism: To record women's perceptions on the quaity of the services received at the Yukti Yojana faciities in Bihar, Interactive Voice Response System (IVRS) technoogy is being used. The primary purpose of this initiative is to understand the quaity of services currenty being given at the accredited faciities, and then use the feedback received to improve the quaity further. IDF's efforts to pubicize Yukti Yojana: in addition to IDF's continued advocacy with the GoB, we made efforts to improve visibiity of Yukti Yojana at the nationa eve (detais in 19). We aso faciitated visits by senior officias of the Ministry of Heath & Famiy Wefare (MoHFW) to accredited cinics to introduce them to this innovative program. Cost effectiveness n For the pubic heath system: Ony reimbursing the variabe cost to the private cinics Makes compementary services avaiabe for women reducing the burden on the pubic heath system Reduces the financia burden on the pubic heath system by making safe abortion services avaiabe for poor, rura women who are at a greater ikeihood of deveoping postabortion compications 307

316 n For women: Makes safe abortion services avaiabe for poor, rura women who woud have otherwise sought services from untrained providers Roe of Information and Communication Technoogies (ICTs) As part of our efforts to capture women's perception/feedback of quaity of abortion services provided at the accredited cinics, we worked towards deveoping an innovative technoogy-based system the Interactive Voice Response System (IVRS). Using this IVRS technoogy, we deveoped a system to provide women the opportunity to give feedback on their experiences at private, accredited cinics by caing on a to-free number. The primary purpose of this is to record women's perception on the quaity of the services received, and then use the feedback received to improve the quaity further. This IVRS was aunched on December 2015 as per the atest avaiabe, 91% of the women who caed reported being satisfied with the services under Yukti Yojana. Chaenges Faced Streamining reimbursement to accredited cinics, especiay in districts where the reimbursement totas accumuated to arge amounts Some of our strategies to address this: n We do routine tracking of the caim amounts and share the information with the officias periodicay n As the amounts start to accumuate, we aert concerned district officias on the status, and maintain reguar foow-up to expedite the process A woman as she receives information about ukti ojana through wa paintings and signages pubizing the program 308

317 n Given the frequent transfer of the various officias invoved in the reimbursement process, we conduct ongoing orientations of these officias on the program, the reimbursement process and on their specific roe in the process. Limited poo of eigibe private-sector providers, that is further reduced due to the state government's directives prohibiting the participation of private cinics operated by providers who aso serve the pubic sector n Recognizing the shortfa in the avaiabe poo of providers, we coaborated with an externa agency to conduct training of eigibe and interested private providers. So far, we have conducted training of and certified 13 providers. Maintaining motivation eves of the private providers to ensure their ong-term commitment to the program n We conducted regiona workshops to brought together providers, support staff, and cinic owners to a series of zona technica workshops where we feicitated seected cinics that consistenty offered high-quaity abortion services to women. We aso used the patform to strengthen their technica skis and updated them on use of atest technoogies. Outcomes Key outcomes: Yukti Yojana is currenty active in 16 districts through 64 accredited cinics that reguary offer services under the program It has resuted in free CAC services for more than 88,000 women. Of these, 93% women received a modern contraceptive method after abortion and postabortion care The program captures cient feedback on quaity of services through an interactive voice response system where women ca in to a to-free number as per the atest avaiabe data, 91% of the cients who caed reported being satisfied with the services under Yukti Yojana As per the atest avaiabe data, private cinics received a tota of ` 5.67 crore as reimbursements for expenses under Yukti Yojana Outreach & Scaabiity Some strategies for extension of the program to other districts with the state: Ongoing mapping of private sector cinics in districts with no accredited cinics under Yukti Yojana, and providing assistance to ensure that they meet the eigibiity criteria to enro into the program Training and certification private doctors as ega abortion providers to expand the poo of eigibe providers in the private sector 309

318 Private provider accredited under ukti ojana providing information to a woman about the program Faciitating formation of and periodic meetings of the accreditation committees that are responsibe for accreditation of private cinics as per requirements of the aw Repicabiity Yukti Yojana has been firmy estabished into Bihar's heath system and has gained nationa visibiity. Aong with comprehensive impementation guideines to ensure standardized processes and quaity of services, the program has robust systems that ensure smooth impementation and cient satisfaction. Some key steps for integration of the program to other ocations incude: Needs assessment to gauge the need of the program in the new ocation Mapping of private cinics that meet the eigibiity criteria for enroment into the program Adapting the accreditation pan to suit the oca context aong with possibe integration with aready existing accreditation programs Panning and aocation of adequate financia resources for the program in the state's program impementation pan (PIP) under NHM Estabishment and operationaization of the reevant committees to impement and monitor the program Forging partnership between the government across different eves state, district and bock with the private providers 310

319 Impact Achieved Yukti Yojana is the first-ever pubic-private partnership for abortion services that compements existing pubic-sector services and makes avaiabe high-quaity abortion services free-of-cost to women in Bihar. Recognized at the nationa eve as a good, repicabe practice and innovation by the MoHFW (Pease refer 19), the program makes the private sector accessibe to poor women, thereby addressing a crucia gap for women in need of abortion services. Yukti Yojana marks the successfu coaboration of key pubic and private partners coming together for improving women's heath. This partnership is a key factor in the growing success of this innovative program, as it greaty contributed to bridging a crucia gap that hindered poor women in need of abortion services to approach the private sector for services. Another key factor in the program thus far has been IDF's continued advocacy with the GoB. This advocacy has resuted in the state's annua pan incuding adequate funding eves for the reimbursement of services at accredited cinics. Program outcomes ceary show that Yukti Yojana has been abe to meet its primary objective of serving the poor women by making abortion services accessibe and avaiabe for them in the private sector. In 2013, cient exit interviews conducted to assess the profie of beneficiaries and perceived quaity of abortion services under the program reveaed: One-fourth of the beneficiaries were ess than 25 years of age Majority of beneficiaries beonged to schedued caste/ schedued tribe (19%) or other backward cass (65%) More than haf of the beneficiaries reported hoding a card identifying them as iving beow the poverty ine Around 69% rated the quaity of services as high or moderate, whie more than 90% beneficiaries expressed very high or moderate eves of satisfaction. In summary, the program serves women who are: The study ceary demonstrated that Yukti Yojana is indeed successfu in expanding CAC services, especiay for poor women. Capacity Buiding Orientating key state and district officias to the initiative: IDF worked cosey with the core team SHSB to orient key Society officias in one-on-one meetings and to improve their understanding of a aspects of the program, incuding impementation POOR YOUNG 53%(Women with BPL cards) 25%( 25years) MARGINALIZED 84%(SC/SCT/OBC) 311

320 Woman providing feedback on services received at the ukti ojana accredited cinic by caing on to-free number (the to-free number has been cahnged now) We oriented civi surgeons and district magistrates of a 38 districts of Bihar on the program, especiay on the reimbursement process, as they are the key functionaries faciitating reease of payments to the cinics We orient district-eve officias charged with the responsibiity of managing Yukti Yojana across a districts having accredited cinics. This incudes orientation of newy appointed/transferred district officias through one-to-one meetings; and other officias on an on-going basis to carify their roes and emphasize the need for their active participation. In addition to improving the officias' understanding of the program and addressing queries around impementation for their continued focus on the program, these meetings are an opportunity to update the officias on the status of accreditations and reimbursements, and the importance of ensuring timey reimbursements for the smooth functioning of the program Training of private-sector doctors: To address the chaenge of ack of certified abortion providers in the private sector, and thereby increase the base of private providers eigibe to accredit their cinics under the program, we focused on creating training opportunities for private providers in accordance with the Medica Termination of Pregnancy (MTP) Act. 312

321 Partners of the Project State Heath Society Bihar, Government of Bihar (SHSB): Impementing Agency Key roe in: n Conceptuaization of the program n Deveopment and dissemination of comprehensive impementation guideines n Budgeting of resources in state annua heath pan under nationa heath Mission n resource materias to pubicize the program n Monitoring of the program n Accrediting cinics n Reeasing payments Ipas Deveopment Foundation: Technica Assistance n Technica assistance during conceptuaization and ro out n Ongoing assistance to improve quaity of service n Evauation of scheme under the guidance of the Technica Advisory Group n Feedback to state on the status of scheme n Hepine to inform women about services Loca NGO Partner- On Ground Faciitation n Motivate private providers for site accreditation n Support providers for accreditation, reimbursements & documentation Private Sector- Service Providers n Provide safe abortion services incuding post-abortion contraception to women as per Yukti Yojana guideines n Ensure documentation in compiance with the MTP Act Awards/Endorsements Yukti Yojana was showcased at the Third Nationa Summit on Good, Repicabe Practices & Innovations in Pubic Heath Care Systems in India organised by MoHFW in August 2016 Yukti Yojana aso featured in the book 'Winds of Change: Good, Repicabe, and Innovative Practices' reeased by the MoHFW (pease see Figure 1). The book is a compendium of programs and innovations that are reevant to heathcare needs of the popuation, especiay those who are 313

322 disadvantaged and marginaized; and those that faciitate better heathcare in terms of accessibiity, affordabiity, quaity, and equity. Importanty, these programs have been identified as having the potentia for wide-scae appication In August 2015, Yukti Yojana was featured in a compendium, tited Good Practices around the Gobe (pease see Figure 2, reeased by the Prime Minister of India, Narendra Modi, at a Ca to Action summit in New Dehi, India a goba meeting aimed at ending preventabe chid and materna deaths. 314

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324 Contact us Federation House, Tansen Marg, New Dehi , India T : / F : E : csrcfe@ficci.com W : Contact us Genmark Foundation Genmark House, B D Sawant Marg Andheri (E), Mumbai T : E : CSR@genmarkpharma.com W :