India

Introduction

In January 2010, Real Medicine Foundation (RMF) set off on an ambitious mission to begin eradicating malnutrition Southwestern Madhya Pradesh. Facing extremely high rates of malnutrition and a challenging environment in the field, RMF brought on and trained 55 Community Nutrition Educators, a force of local tribal women with the passion and dedication to combat malnutrition in their communities. With the leadership of these local women, RMF’s team went door to door across 500 of the villages worst hit by childhood malnutrition and identified over 76,000 children with severe and moderate acute malnutrition. In just 12 months of implementation RMF’s Malnutrition Program has become a model for how to bridge the divide between resources available to combat malnutrition and the families who need them the most.

Between January and November 2010 RMF:

• Developed a practical and hands-on method of training field workers and local communities and trained 55 Community Nutrition Educators and Supervisors
• Conducted one of the most comprehensive baseline surveys ever conducted in Southwest MP, covering over 65,000 children
• Held 6857 village nutritional training sessions, training over 68,410 people
• Counseled 91,034 individuals on malnutrition prevention and treatment
• Successfully referred 895 children to the Nutrition Rehabilitation Center (NRC)
• Achieved a 25% reduction in childhood malnutrition across intervention villages, 17994 children who directly improved because of this intervention
• Secured government support for a pilot program integrating RMF’s model within the Integrated Childhood Development Scheme (ICDS) in 2011 with support from DFID, Columbia University, Action Against Hunger, and Google.org

Project Goal

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. 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.

This project will empower communities through health literacy and connect rural communities with the government health and nutrition services available.

Project Objectives

• Choose 500 intervention villages, based on input from government, NGO, and local community assessments as to where the intervention is most needed
• Recruit, hire, and train 55 staff members
• Complete baseline assessments in the targeted village and identify priority villages based on case load
• Refer all children, especially those with severe acute malnutrition (SAM) and Moderate Acute Malnutrition (MAM) to anganwadi centers for additional assessment, supplementary food, growth monitoring, and immunizations
• Refer cases of complicated SAM identified to Nutrition Rehabilitation Centers (NRC) for treatment;
• Track progress of patients referred to NRC and follow up with defaulters and successfully treated patients in their villages;
• Establish relationships between District Coordinators and their counterparts in the NRCs for better follow up, referral and general trouble-shooting of care for patients with SAM;
• Hold monthly community meetings in villages and one-on-one family counseling sessions with SAM and MAM children identified in the baselines by Community Nutrition Educators (CNEs)

Results Accomplished

RMF began the program by conducting one of the most extensive door to door nutrition surveys ever conducted across Southwest Madhya Pradesh, covering 37,141 families and over 65,000 kids. This not only gave RMF an accurate view of malnutrition in the area, but also gave the CNEs the opportunity to get to know their villages and identify the households where children under 5 years old were present and to focus in on the children suffering from SAM and MAM.

Results of the baseline survey by district:

Once the baseline survey was completed in April, each CNE began the intervention phase of the program, visiting each village once every 10 days and returning to the households where children with severe and moderate acute malnutrition were present and counseling their caregivers. Counseling was given to families at their homes on nutritious food, proper preparation of food, hygiene, proper breastfeeding and the importance of supplemental feeding after 6 months, and what health services are available to them for treatment of malnutrition. In addition to the family counseling, the CNEs conducted community meetings in each village to give the entire community, not just the families of malnourished children, lessons on the importance of good nutrition in children under five and providing awareness of malnutrition. The CNEs coordinated with the government village health worker, the Anganwadi, on referrals, feedings, and follow up with cases. When anganwadi centers haven’t been delivering the services they’ve promised, RMF’s team has intervened with supervisors and District Program Officers in order to address these gaps in service delivery.

Over this period RMF:

• Identified 19,661 children suffering from SAM and gave counseling to their caregivers
• Identified 56,801 children with MAM and provided one on one counseling to their caregivers
• Successfully ensured the 14 day treatment of 895 of the most serious cases at local NRCs
• Saw an 29% improvement rate in SAM children counseled and a 21% rate in MAM children counseled, 5545 children whose nutritional status improved directly from our intervention
• Conducted 6857 village nutrition training sessions, with over 68,410 people in attendance
• Conducted 91,034 one on one counseling sessions
• Obtained a letter of support for RMF’s programs from the Department of Women and Child Development

RMF exceeded all of the targets set out at the beginning of the program except the percentage by which overall malnutrition was reduced. We feel that we were overly optimistic of the initial impact our program might have and after rolling out this initiative we’ve learned the lesson that while referrals may be immediate, behavior change does not happen overnight, but over a period of time with sustained, consistent messages. Due not only to the challenges in the field faced by our staff on a daily basis, but the overall, chronic nature of malnutrition, it was not possible to achieve a 50% reduction in malnutrition in the first year, but RMF still believes it will be possible after the 3rd year of intervention. Even this 25% reduction in overall malnutrition exceeds the results of many past initiatives.

Impact this project has on the community

So far this program has directly impacted:

• 895 children who have received life saving treatment
• The families of 76,462 children with SAM and MAM who have been counseled on nutrition and child care
• 17,994 of these children who have improved directly through our intervention
• Almost 68,410 individuals from rural villages who have received training on malnutrition awareness and prevention in their villages

During this time our CNEs have developed a relationship with the communities they work with. This bond is the most important part of our program, as we want the communities to see our CNEs as part of the community rather than workers coming to visit. Most of the CNEs are locals and live close to the villages, so establishing that bond comes naturally to them, however, some communities were reluctant at first. Slowly, with each success story, our CNEs have become trusted members of the community. The communities have started come to the CNEs with nutrition questions, rather than our workers having to seek out SAM cases. Furthermore, as they get to know the communities better, each CNE can track the progress of individual children, and asses their health and family in a more familiar way. For example, during a recent outbreak of measles in Jhabua district, it was RMF’s CNEs that many community members turned to to help refer complicated cases for treatment and to answer questions about the disease.

This close relationship with the local communities has allowed RMF to successfully educate thousands of individuals and to motivate and mobilize them to access the services they require within the government health system, bridging the divide between the families of malnourished children and the resources available.

Number served/number of direct project beneficiaries

Number of indirect project beneficiaries

Notable Project challenges and obstacles

Remoteness

Southwestern Madhya Pradesh includes some of the most remote and poor areas in all of India. Many development indicators are similar to sub-Saharan Africa, and education levels in the districts are generally low. Qualified staff, both for the CNE and DC positions, were difficult to locate, particularly in Khandwa district, which lengthened the interview and hiring process more than expected. This was overcome by coordinating with established NGOs already working in the areas and using local networks to locate qualified women.

Throughout all 5 districts the connectivity to the remotest villages is extremely poor, often requiring a round trip of over three hours by bus, jeep, and foot for some CNEs. In order to best serve the needs of the community, locally based village women were engaged as CNEs. The advantage of the local women is their familiarity with the areas in which they are working, their proximity to targeted communities, and fluency in local tribal dialects. However, locating qualified women in the remote areas was extremely difficult, and the capacity building and training period was longer than expected for Khandwa district in particular.

During the monsoon CNEs again had connectivity problems, with flooding cutting off some villages and the height of corn and other crops making walking through villages more time consuming.

Disruptions in schedules

Throughout the past 12 months of implementation, a number of holidays and other events cut into the staff’s time in the field. The beginning of the scheduled Baseline Survey period coincided with the local festival period in the area. Holi, the local festival called “Bagoria”, Diwali, Dushera, and other regional holidays cost staff days in the field. During holiday times even though the mood is celebratory and festive, there is a large amount of alcohol consumption and rowdiness, which may have exposed the CNEs to some danger, so field time was limited.

NRC Referrals

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 women cannot stay with their children for the entire fourteen day course of the treatment. Each child must have a caretaker stay with them for the entire course of treatment. However, many of the women are not able to stay that long, or even go at all, because of family pressure, household responsibility such as cooking or agricultural work, or the presence of other small children in the household with no other caretaker.

The 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 by our coordinators 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.

Despite these challenges, RMF was able to meet our referral targets for severe acute malnutrition.

Disease

During the intervention period, RMF saw a large number of children suffering from complications of malnutrition such as malaria and measles. In Jhabua district in particular, RMF’s team discovered a measles outbreak and immediately reported this to the Department of Health and WHO. As district authorities responded with increased measles surveillance and a vaccination drive, RMF staff took time out from their daily counseling schedule and helped in active case identification, referrals to immunization drives and follow ups with infected children, especially on the look-out for complicated cases. To date, RMF’s team has identified over 100 children with measles and ensured that thousands get vaccinated.

Success Stories

Sonu's Story

On one of her visits to Antevelia, Salma, one of Jhabua’s star CNEs, heard about a child who had just returned from migrating to the village and who was “very weak.” Salma was led to the house by local women who had attended Salma’s village level nutrition training sessions. As soon as Salma saw Sonu she knew he needed to be referred to the NRC immediately. With successful counseling, Salma convinced Sonu’s mother to bring him to the Jhabua District Hospital NRC immediately. When they arrived at the NRC, Sonu was hardly conscious at 5 kg and 2 years old. Dr. Fabian Toegel, RMF’ Team India’s Country Director, was at the hospital with Sonu until after midnight making sure that the doctor gave him proper treatment.

Sonu, upon arrival at the NRC

While he got the right dose of anti-biotics and was seen by the right doctor at the district hospital, the conditions at the district hospital were horrible. With 3 patients per bed in the pediatric ward, Sonu’s family, from a rural village in Jhabua, were extremely uncomfortable. After a nurse at the district hospital yelled at the family for not taking care of their child, the family left the hospital. When RMF found out about this we sent out a car and our CNE Salma immediately to the village to get Sonu and his family and bring them back to our Jeevan Jyoti NRC treatment center.

RMF made sure the family was as comfortable as possible and brought the doctor from Jhabua to Meghnagar to look after Sonu and the other children at the NRC. Sonu’s mouth was covered in soars so bad it was painful for him to even drink milk. All members of the RMF team took turns sitting with Sonu and his mother and painstakingly used an eye-dropper to feed him F75.
After almost a month in the NRC, Sonu gained over 2 kilos. He gained energy and an appetite and was playing with his mother and other children. While he was in the NRC, RMF staff members took turns talking to Sonu’s mother and grandmother daily and teaching them about how to keep Sonu healthy after discharge.

In the 2 months that followed, Sonu and his mother did not miss one of their scheduled follow-up visists at the NRC and on each viist he gained more and more weight. Salma visited the family in their village a number of times in between the follow up visits to see how they were doing at home and saw that Sonu’s mom had taken our advice and adopted the practices taught to her by the RMF team.

Sonu, 2 months later

Now, after almost 3 months, Sonu seems like a different child completely. At any given moment he either has food in his hands or is crawling around causing mischief. His mother is proud of her son and his incredible transformation and has referred friends and relatives in her village to RMF’s team and has become an informal “NRC Ambassador.”