Community managed nutrition cum day care centers

1. Community managed nutrition cum day care centers Lakshmi Durga Chava State Project Manager (Health and Nutrition) 21.04.09 Society for Elimination of Rural Poverty Andhra Pradesh, India Lakshmidurgac@gmail.com

2. Outline of the Presentation • SERP poverty reduction interventions • IKP health value chain • Nutrition cum Day Care Center • Opportunities for integration with ICDS • Scale up to mainstream • Replication process

3. Society for Elimination of Rural Poverty (SERP) Sensitive support organization for the poor • Autonomous society set up by Government in 2000 • State wide mandate • To induce social mobilization • To provide facilitation support to institutions of poor • To sensitize all line departments to be inclusive of the needs of the poor

4. SERP 9,646,000 Rural Women in 22 Districts of AP • A.P – poverty eradication through empowerment of rural poor women (Indira Kranthi Patham - IKP) • Focus: comprehensive poverty eradication - economic and social • building self sustaining institutions of poor • Rs.2100 crores Project - financed by State Government, World Bank and communities to cover all rural poor in the state (80 lakh families, special focus on 26.0 lakh ultra poor) • builds on the decade long, statewide rural women’s self-help movement in A.P 810,000 Self Help Groups (10-15 women per group) 34,852 Village Organization-VO (approx. 20 SHGs) 1098 Mandal Samakhya-MS (Includes approx. 30-35 villages) 22 ZillaSamakhya-ZS (constitutes 1 district) 1 State Office (State Project Monitoring Unit)

5. IKP Interventions • Targeting – community based targeting. • Focus on the poorest of the poor and vulnerable: women, disabled • Power of scale – bringing all the poor in the state into social networks • Scaling up through community resource persons • Institutional design – SHG – V.O – M.S – Z.S • Large scale mobilization of bank finances for poor • Large scale livelihoods promotion • Community managed food security • Social issues as an agenda for collective action • Social risk management • Community managed health interventions • Convergence with all line departments S.E.R.P’s dynamic role – changes in tune with the changes in the demands of the C.B.Os

6. IKP Health Value Chain Preventive & Promotive Health Care Curative Care Financing and Service Delivery Microfinance Product for NUTRITION • Human/Social Capital • Health activist • Community Resource Person (CRP) Case Managers Health Risk Fund/ Health Savings Nutrition & Health Day (NHD) Health Insurance Making Services Work for the Poor – Accessing PHCs & Area Hospitals Water & Sanitation Community-owned Pharmacy Nutrition Centers Community-owned Hospitals

7. Fill those gaps through ways that can be managed and sustained by the community groups even after the project is over Have a cadre of internal facilitators, from among the communities to facilitate/accelerate in the empowerment process Enable the communities to have choice and control over the services available for them Make the service providers more accountable to the communities Successful pilots to be up-scaled by the line departments for state-wide implementation Work in collaboration with the existing line departments responsible for enhancement in QOL of the poorest Have a cadre of external facilitators to assist in planning and designing sustainable and workable programmes Look at areas where there are gaps and there is a mismatch between the design of service delivery and the incentives linked to those services Outputs/outcome Personnel Systems Improved access to “effective & available” services Convergence Framework for Improved Access to Services

8. Community managed health and nutrition interventions • Nutrition cum day care center • Health savings and health Risk Fund • Health Insurance • Best practitioners as Health Community Resource Persons (Health CRPs) • Community Kitchen gardens • Weaning foods • Fixed Nutrition and Health Day (NHD) • Screening camps

9. Community-Managed Nutrition cum Day Care Center Goal • To improve Perinatal and neonatal outcomes and child care practices towards achieving the MDGsin rural Andhra Pradesh Objectives • To provide nutritional and health care for pregnant and lactating mothers. • To encourage improved health care practices for safe deliveries and have no low birth weight babies. • To empower communities to make pregnancy safer and develop change agents to have sustainable impact.

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

11. Nutrition cum Day Care Center (NDCC) The center also doubles-up as a health check-up centre for pregnant and lactating mothers and children <5 years Serves as a venue for health education and behavior change communication

12. NDCC Financing Model • The cost of meal • Rs 25 per day for TWO MEALS for pregnant and lactating mothers • Rs 10 per day for TWO MEALS for Children <5 year • Beneficiaries pay Rs 18 per day for TWO MEALS; The balance Rs 7 is subsidized by the Community-Based Organization/ Government of Andhra Pradesh • The Beneficiary’s contribution is financed via a MICROFINANCE LOAN taken from the Community-Based Organization which will repaid over 24 – 36 months depending on income status of the beneficiary i.e., CONSUMPTION SMOOTHING VIA a CONSUMPTION LOAN

13. Process Discussion with the mothers-mother-in laws Discussion with beneficiaries Grama sabha Day care for children Preparation of MCP Feeding at NDCC

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

15. Coverage • 2007-08 : 200 centers • 2008-09 : 600 centers • 2009-10 : 2500 centers

16. As per enrolment at 600 NDCCs with 332 day care centers. 3,220 BPL pregnant women; 1,967 SC/ST 3,148 BPL lactating mothers; 1,991 SC/ST 3,440 BPL children 0-3yrs; 2,167 SC/ST As per survey at 600 AWCs 5092 pregnant women from all categories 6043 lactating mothers from all categories 9960 children 0-3yrs from all categories. Coverage against survey

17. Utilization of ICDS by people of lowest two wealth quintiles Breastfeeding women use of ICDS Pregnant women use of ICDS Children’s use of ICDS Area covered by ICDS 17

18. Child Nutritional Status by Wealth quintiles and caste, India 18 Percentage of children age 0-35 months underweight

19. NDCC Beneficiaries (POP &Poor) AWC beneficiaries (PoP) AWC beneficiaries (Q4) Underweight children among Poor and PoP 57% 49% 26%

20. Perinatal outcomes* Against the 1800 deliveries happened: 99%of women had safe deliveries. [Institutional(91%) /trained personnel(8%)] 90% had normal deliveries 10% had cesarean section. 87% women had complete ANC 99% women had PNC 46% of pregnant women gained 10-12Kgs weight; 47% gained 7-10kgs weight No maternal deaths reported among the women enrolled * Source: Internal MIS

21. Neonatal outcomes* 97% of babies born with >2.5Kgs 54% babies with >3Kgs Neonatal care practices 97% neonates are fed with Colostrum and no pre-lacteal fluids 82% delayed bathing the baby for 7 days. * Source: Internal MIS data

22. FAQs about results • Accuracy of the measurements? • Technical person for supervision? • Authenticity of the data? • Empirical evidence ?

23. Maternal Outcomes

24. Neonatal care practices

25. Health knowledge and health seeking behavior

26. Issues & challenges in ICDS • Inadequate coverage and location of AWC • Corruption in supplies and of patronage in recruit. • Frequent supply chain breakdowns • Poor convergence with Health dept. • No community participation

27. Can NDCC address issues & challenges at AWC?

28. Complimentary areas of AWC to address challenges at NDCC

29. Costing for one village:NDCC vs. AWC Note: Additional cost for monthly training at NDCC and induction/ refresher training at AWC

30. Additional costs (every year) • Regular capacity building of stakeholders at NDCCs. • Induction and refresher training for the AWWs /AWHs. • Human resources to provide supportive supervision and guidance

31. Cost estimates for universalisation in Andhra Pradesh • 74000 AWCs require 858.42 crores ($171,684,000) per year and Rs 2557 crores ($511,400,000) for 3 years and Rs 4262 crores ($852,000,000) in 5 years and for 7 years…………… But, • NDCCs require one time grant of Rs 2590 crores ($518,000,000) to reach 74000 villages with focus on 35000 VOs.

32. Potential for Integration of IKP (NDCC) with ICDS (AWC) • Overlapping characteristics: • Focus on reproductive-age women and young children • Physical building • Collaborative role in Fixed NH Days • Similar record-keeping system to cover same H&N indicators • Complementary characteristics: • Health Activist and materials for teaching pregnant and lactating women (IKP) • Anganwadi worker for early childhood education (ICDS) • Demand and support from CBOs (IKP) • Wide coverage; nearly all pregnant/lactating women and children in AP (ICDS) • Special focus on poor and PoP population (IKP) • Provision of complete, balanced meals (IKP) • Community ownership and accountability systems (IKP)

33. Integrated model accountable to communities (IKP & ICDS) • Demand driven, community owned program (IKP) with full financial support from the public health system (ICDS) throughout AP • Pooling of funds to support poor women and children and reduce the financial input from the community • Two complete meals per day prepared by SHG-member cook • Daily health education sessions focused on maternal and child health & nutrition by Health Activist • Early childhood education by Anganwadi teacher • Child growth monitoring by Anganwadi teacher • One simplified record-keeping system to monitor health and nutrition indicators among beneficiaries • Web based monitoring tools to establish accountability to the communities (IKP).

34. Financial benefits of integrating IKP H&N with ICDS • Reduced beneficiary burden • Reduced costing of NDCC • Reduced costing for human resources

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

36. Replication • Pre-requisites • Community based organizations • Village level committee to take forward HD issues • Openness to community owned models • Committed political will • Selection of few blocks/few states for replication • During replication • Support of technical agency (SERP) • Internal (CRPs) and external facilitators • Dovetail of human and financial resources • Community based nutrition monitoring and surveillance system to include growth monitoring of children and anemia levels among adolescents and women.

37. Thank You