India: Childhood Malnutrition Eradication Program
Q1 2016: “Swasthya Saheli: Catalyst of Change”
July 20, 2016
Prabhakar Sinha and Rakesh Dhole
Summary of Activities
- Through RMF’s rural cadre ‘Community Nutrition Educators (CNE)” foster change through behavior change communication & creating convergence between the community-in-need with the service delivery systems, such as Anganwadi workers, ANMS, ASHAs & Panchayat bodies.
- Continue to provide health and nutrition counselling/education to communities, families, and adolescent schoolgirls
- Continue to identify, treat, refer, and follow up SAM and MAM cases
- Continue to develop ties with government health and nutrition services
- Continue to produce and screen nutrition and health based videos in Khandwa, Madhya Pradesh
- Strengthen institutional capacity with support from World Bank’s India Development Marketplace
- Conduct performance appraisal of the program implementing teams
- Conduct institutional strengthening & capacity building of the teams to take on larger responsibilities so as to add on other thematic areas of public health
- Explore partnership opportunities for program development
Our takeaway from the previous quarter:
“We need to be conscious of the emerging needs in each of the villages for health, education, water and sanitation, electricity, and livelihood. We should continue to prevent and help manage malnutrition.”
New Model Introduced
Implementation of a new strategy
The new model would redistribute and delegate the area villages to each responsible CNE. Each CNE would have a cluster catchment of 10 villages and would cater to a population range of 10,000-15,000. The CNEs would then go into these villages to conduct a survey to ascertain the exact number of severe and moderate cases of malnutrition. The survey would also identify essential health service needs in the communities, such as sanitary napkins.
Community Nutrition Educators
Starting at the Roots
Each CNE would act as a "Catalyst of Change" at the grassroots level through bringing institutions together and raising communities’ levels of education and awareness regarding health and nutrition. Each CNE would also act as a depot holder for affordable products and choices that help communities improve health care practices by adopting hygienic behaviors. Through this practice of offering affordable products, the communities well-being will improve, and in addition "provision of alternative and sustainable source of electricity," would also be part of the CNE depots.
Catalyst of Change
RMF India/RMNT, in collaboration with partner agencies, would help model this "Swasthya Sahelis" in leading the process of change. Each CNE would be an independent entity of her own cluster and may create village-wide cadres of young women to conduct/facilitate activities in their own villages. The CNE would be responsible for creating her own geographic clusters within the villages she is responsible for. This pilot project’s goal would be to cover 98 villages through the involvement of 10 CNEs.
Currently, there are only 4 CNEs on the team and 5 more will be hired for the 48 remaining villages. Each CNE would use a table for training which will have reporting formats, IEC/education/BCC materials and product/service details. They would also wear a uniform apron on top of their saree so that the communities can visually recognize the branding of the CNE as well as the depot for the village (which holds nutritional and hygienic goods).
Materials and Supplies
Each CNE will distribute the following products:
- sanitary napkins
- mosquito nets
- nail clippers
- first aid kits
- pregnancy test strips
- water purifiers
Progress Thus Far
Change is Happening!
- 1,199 households were given counseling services by the CNEs. In these sessions, 1,573 individuals (mainly women and adolescent girls) participated.
- 136 community counseling session were held, in which 1,207 individuals participated.
This project empowers communities through health literacy and connects rural communities with the government health and nutrition services available. This project aims to prove that a holistic, decentralized, community-based approach to malnutrition eradication will have better health outcomes, be more inclusive for children under 5, and will be more cost-effective in the long-run than centralized approaches, especially for rural, marginalized tribal communities. Our team of up to 75 Community Nutrition Educators (CNEs) and 6 District Coordinators has covered enormous ground across 5 districts and 600 villages in Madhya Pradesh.
- To reduce the prevalence of underweight children under 5 years old and to reduce child mortality from malnutrition by strengthening communities and village level government facilities’ capacity to identify, treat, and prevent malnutrition.
- Continue to identify new SAM and MAM cases, refer complicated cases to the NRC and provide home-based counseling for all malnourished children
- Refer 1,000 SAM children to government centers for treatment with a 50% success rate Quarterly
- Conduct 2,500 Community Nutrition Meetings Quarterly
- Conduct 9,000 Individual Family Counseling Sessions Quarterly
- Send CNEs to Nutrition Rehabilitation Centers (NRCs) to help counsel families present
- Continue to develop linkages with government health and nutrition services
- Strengthen institutional capacity with support from World Bank’s India Development Marketplace Award.
Click to enlarge
- 8 severe and 11 moderate cases of malnutrition were treated and improved.
- 32 new severe cases and 79 new moderate cases of malnutrition were identified for management either within the community using service delivery platforms or in households and/or referred to Nutrition Rehabilitation Centers.
- 14 cases of severely malnourished children were referred to Nutrition Rehabilitation Centers
- 2 cases of follows ups were mainly conducted for those malnourished children who had sought treatment at NRCs and were discharged from the centers.
Notable Project Challenges
One of the largest challenges facing our CNEs, and the treatment of SAM in MP in general, is getting children requiring treatment to the NRC. Even after successful referrals, the rate of defaulters is very high as many of the mothers cannot stay with their children for the full 14-day course of the treatment. Each child must have a caretaker stay with them for the entire course of treatment. However, many women or family members are not able to stay that long, or even go to the NRC with their child because of family pressure, household responsibilities such as cooking or agricultural work, or the presence of other small children in the household with no other caretaker.
Our CNEs and coordinators try to solve this with a variety of techniques, including:
- Increased counseling in the field about the NRC treatment and why it is important.
- Follow up with successful referrals by our coordinators.
- Coordination with NRC workers to address problems specific to our referrals.
- Follow up with defaulters in the field by our CNEs.
- Suggestions for other caretakers, such as grandparents or siblings.
- Increased communication about the need and specifics of treatment, such as why it takes fourteen days.
With the introduction of CMAM, many SAM children can be treated in the community, circumventing the need for trips to the NRC. Since referral to NRCs is the largest hurdle to our program’s success, RMF expects that this new protocol will change the way malnutrition is treated in India.
Rekha Mawi is a resident of the Barwani tribal district of Madhya Pradesh, India. At an early age, she married a daily wage earner named Anil. Rekha soon realized that her husband was an alcoholic, and his meager daily income coupled with his frequent, compulsive spending on alcohol was not enough to support the family. Rekha was especially concerned for the welfare of their two children.
On April 1, 2011, Rekha met Radha Chouhan, the District Coordinator of RMF India’s Barwani office. Rekha shared her plight with Radha, who recommended her case to RMF’s district management team. With management’s approval, Rekha was hired as a cook for RMF’s Barwani office. During her days as a cook, RMF project management learned that Rekha had studied up to the 12th standard, and noticed that she possessed strong interpersonal and communication skills. With these qualifications, Rekha was capable of serving as a Community Nutrition Educator (CNE). Subsequently, Rekha was given the new role of CNE, to promote health and nutrition in 10 villages in the district of Barwani. She received the required counselling training from RMF, and started conducting home visits to screen children for their malnutrition status and connecting households with service provision centers such as Anganwadi centers and/or Nutrition Rehabilitation Centers. Rekha soon started to recognize her own abilities, and so did RMF’s district team management. In addition to individual and community counseling, Rekha also referred several children to seek lifesaving treatment at NRCs.
The local community, including government workers on the frontline, also began to recognize Rekha’s contributions in fostering behavior change and improving the health of mothers and children. By that time, Rekha had become more confident in her abilities, and was very competent in community-centered communication and helping local people value and access available government services.
In February 2013, the local government appointed Rekha to serve as an ASHA (Auxiliary Social Health Activist) in Rajghat (one of the villages where she worked as an RMF CNE). She showed great commitment and passion in her new role.
As they say, fortune follows those who chase their dreams. In May 2015, based on her progressively more remarkable performance, the Department of Health promoted Rekha as an ASHA supervisor in the same catchment where she served as an ASHA worker. Today Rekha stands as a courageous, committed ASHA supervisor helping women and children live healthy lives. For the year 2015-2016, the state government of Madhya Pradesh awarded Rekha the “Best Cadre Award” for exemplary performance.
Today, Rekha acknowledges the difference RMF India made in her life by helping empower her to accomplish her dreams. Rekha states candidly and confidently, “RMF has helped change my life for a better.” RMF India takes this opportunity to wish her the very