Q3/2011: Malnutrition Eradication Program Update

November 10, 2011

Michael Matheke-Fischer and Dr. Athar Qureshi

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.

In Year Two, RMF does not just act as a catalyst mobilizing communities to the resources available, but also works on a more intimate level with government health and nutrition workers and Village Health and Sanitation Committees to help build their capacity towards social mobilization, referrals, and provision of effective nutrition counseling.  Throughout the year RMF will gradually transfer the responsibilities of our CNEs to government supervisors and anganwadi workers, helping integrate RMF’s work into the government framework to ensure long-term sustainability.

Project Objectives during this reporting period:

• Continue to identify new SAM and MAM cases, refer complicated cases to the NRC and provide home-based counseling for all malnourished children
  • Review all program data and make necessary changes in program reporting system
  • Conduct Management of Information (MIS) systems training for all program staff
  • Propose RUTF Pilot to government of MP
  • Refer 1,000 SAM children to government centers for treatment with a 50% success rate
  • Conduct 2,500 Community Nutrition Meetings
  • Hold at least 2,500 meetings with anganwadi, giving them on the job support
  • Conduct 9,000 individual Family counseling sessions
  • Ensure timely and accurate reporting from all staff – rolling out new, more streamlined reporting formats based on feedback from last 1 year
  • Send CNEs to NRCs to help counsel families present
  • Continue to develop linkages with government health and nutrition services
  • Launch of Community Management of Acute Malnutrition (CMAM) Pilot program together with DWCD in Jhabua, Alirajpur, Barwani, and Khargone districts

Results and/or accomplishments achieved during this reporting period:

During this period RMF’s Malnutrition Eradication Program continued stronger than ever.  After a full review of learnings and data collection systems from 2011 and a management training of RMF Supervisors, RMF introduced new, more streamlined and intuitive reporting formats in order to ease reporting for staff and facilitate their counseling.  This positioned the team to be ready to integrate more advanced reporting technology into the program.  In order to ensure that the right technology is selected for RMF’s field level reporting, RMF began a pilot program to test different reporting systems.

The CNEs in Barwani district worked directly with anganwadi supervisors and anganwadi workers in a pilot to integrate RMF’s work together with the Department of Women and Child Development (DWCD).  The extra work in this program, including the salaries of 10 new CNEs and a program manager was provided by a supplemental grant from the Department of Foreign International Development (DFID) through their technical support team the Madhya Pradesh Technical Assistance Support Team (MPTAST).  After this pilot finished at the end of May, these staff members were incorporated into the Merck supported Malnutrition Eradication Program, bringing this program staff up to 65 staff in 600 villages.

In addition to the operations of our CNEs, RMF was also invited by the Government of Madhya Pradesh to be a lead partner in the district level plans for the Atal Bal Aarogya Evam Poshan Mission (ABM), the statewide program aimed at fighting malnutrition. Using our insights from running our program, and with inputs from all of our field staff, RMF’s District Coordinators and management staff helped develop district plans with our government counterparts. These plans will be used for the next year as part of the states ongoing mission to fight childhood under nutrition. During these planning meetings, RMF staff was integral in planning:

• Training programs for Government of MP staff, including the use of modules developed by RMF;
  • Protocols for the beginning of Community Management of Acute Malnutrition (CMAM), including the triage models developed for our own pilot using RUTF;
  • Social Marketing, including art demonstrations, to raise awareness of malnutrition.

It is also our hope that by integrating our best practices, the ABM will include our CNE model in longer term strategic modules to fight malnutrition.

During this quarter the program:

• Indentified 930 children suffering from SAM and gave counseling to the caregivers of each of these children
  • Saw an improvement from SAM to MAM in 650 children
  • Identified 1,303 children with MAM and provided one on one counseling to the caregivers of these children
  • Saw an improvement from MAM to normal in 1,366 children
  • Successfully ensured the 14 day treatment of 176 of the most serious cases at local Nutrition Rehabilitation Centers
  • Conducted 1,506 village nutrition training sessions, with over 10,111 people in attendance
  • Conducted 15,716 family counseling sessions
  • Finalized flipbook
    • Various team members met with officials from the Department of Health and the Department of Women and Child Development 16 times to get the approvals and develop the plans for the RUTF pilot

Impact this project has on the community (who is benefiting and how):

So far in 2011 this program has directly impacted:

• 492 children who have received life saving treatment
  • 26,285 children who have improved directly through our intervention this quarter
  • Almost 102,041 individuals from rural villages who have received training on malnutrition awareness and prevention in their villages
  • The families of the 65 women RMF employs as part of this initiative, many of whom are from the intervention villages themselves and use their salary from RMF to support their children’s education and to improving the lives of their families.

Success Stories:

From Mud Huts to the Cutting Edge of Technology

By Michael Matheke-Fischer

In March 2010, Caitlin McQuilling and I were driving around Khandwa district on a motorcycle desperately searching for staff to begin operations of our ambitious “Eradicate Malnutrition” program. In our heads, we had a checklist of criteria for potential new staff, mostly focusing on education levels and any experience in the health, nutrition, or NGO sector. As we drove from hamlet to hamlet, over dried streambeds and through fallow, dusty farmland, the checklist was whittled down to one item: literate.

In July of 2011, 5 of our amazing CNEs from Khandwa are now on the cutting edge of technology, helping Microsoft design their Digital Slate technology for data collection in the field. At the same time, the rest of our Khandwa team is collecting information with an application on their phones specifically designed for RMF called Commcare. After a 3 month study, Microsoft Research will publish a paper based on the inputs of our team comparing these solutions to data collection problems. It seems that my initial pessimism, as it so often is, may have been a bit misguided.

On a motorcycle in 100 degree heat, it was hard for me to imagine solutions to the multitudes of challenges our program would face. How would we train our staff? Would they understand the material and the importance of our task? Would they be able to accurately report what they were seeing and doing, and, if so, how would our small team process this information? We knew that none of our team was lacking in passion or enthusiasm, but how well would we adapt to new challenges? I couldn’t imagine, in my own head, solutions to all of the problems I could invent. I should have had more faith in the Korku women of Khandwa.

After our initial consultations, the team from Microsoft decided that a two day training session would be the best to cover all the topics and ensure that our CNEs know how to use the device, since it is a prototype of new technology. It took our team an hour. The rest of the weekend was spent by our CNEs training every member of the hotel staff where the training was held. After that, they also held an impromptu malnutrition awareness raising session, educating everyone and anyone who would listen about our program and the needs of the surrounding community.

As has always been the case over the past year and a half, I am constantly amazed by the abilities of our staff to process new information and technology. Besides the children we help in our program, the empowerment of tribal women is one of the most satisfying aspects of our program. With just a small push, and the framework of opportunity, all of our CNEs continue to inspire us on a daily basis. Their ability to master new technology far exceeds that of even myself; on the long trip back from our initial visit in Khandwa in 2010, I managed to neatly deposit Caitlin from the back of the motorcycle into a rather large pile of mud in front of about 50 people.

Real Medicine Foundation Mobile Data Collection

Currently, the Real Medicine Foundation India is running the largest community based malnutrition program in Madhya Pradesh, covering a total of 600 villages across 5 districts with over 65 field staff. RMF’s “Eradicate Malnutrition” program covers over 65,000 children, diagnosing cases of Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM) and providing linkages to government of MP treatment services, such as referrals to Anganwadi Centres (AWCs) and Nutritional Rehabilitation Centres (NRCs) for inpatient treatment. RMF’s Community Nutrition Educators (CNEs) also provide counseling services to communities and families at risk or affected by malnutrition.

One of the largest problems facing RMF’s management team is a timely compilation and analysis of data collected by our CNEs. Currently, each CNE uses multiple paper reporting formats covering interactions with the communities and families. These diaries are then collated at weekly meetings and the aggregate data entered into computers by data entry officers. The lag time from data collection to analysis under optimum conditions is 1 month, hampering RMF’s abilities to quickly adapt and respond to unique situations and efficiently supervise field staff.

Streamlining Data Collection with Dimagi’s CommCare Application and Microsoft’s Digital Slate

RMF is currently in the test phase of two new forms of data collection tools utilizing low end mobile phones: Commcare by Dimagi and a prototype of Microsoft’s Digital Slate.

Digital Slate by Microsoft

Microsoft’s Digital Slate is a new form of technology that allows paper records to be copied and the information sent to a central database instantaneously. The Digital Slate is a device that converts written text into digital data. As our CNEs conduct their routine work and record their information, every entry is converted into a digital file by the slate. We have developed a special diary specifically for this application that records:

• Child’s name
 • Village
 • Mid-Upper Arm Circumference (MUAC)
 • Complications such as fever, cough, or rash.

There is also an open field for notes that converts written comments into images that are stored in each case file.

All of the information is sent instantly to our supervisors via SMS. Once the information is recorded, we have the ability to instantly process data, giving RMF’s management team a clearer picture of which CNE is handling which case and how many children we currently have enrolled in our program.

Commcare by Dimagi

Using forms developed specifically for RMF’s program and installed on each mobile phone, the CNEs collect information by answering questions in each form that is sent via SMS to a central database in real-time. Commcare provides each CNE with:

• Entry points for child registration such as child name and village, important indicators such as Mid-Upper Arm Circumference (MUAC) and complication history, and verbal prompts from the phone that instruct the CNE to refer the child based on these inputs;
 • Easily accessed case histories for repeat visits with children that track previous treatments and counseling given and improvement or deterioration of the child’s nutritional status;
 • Referral tools to track recommended treatment for SAM and MAM children and required follow up by dates.
 • Counseling and referral tools that follow Integrated Child Development Services (ICDS) and National Rural Health Mission (NRHM) guidelines.

RMF supervisors can access this information from any location anytime via an internet based dashboard. The dashboard provides real-time displays of each form submitted by each , a list of cases currently registered by name, village and CNE, and a downloadable excel file of raw data for instant analysis by RMF’s M&E officer. Pockets of malnutrition and complications by village are flagged so that RMF may investigate further. In addition, RMF can monitor staff activities remotely as all entries are visible by CNE and stamped with a date and time, minimizing the need for spot checks.


Plans for next reporting period:

• Refer 1,000 SAM children to government centers for treatment with a 50% success rate
• Conduct 2,500 Community Nutrition Meetings
• Hold at least 2,500 meetings with anganwadi, giving them on the job support
• Conduct 9,000 individual Family counseling sessions
• Ensure timely and accurate reporting from all staff – rolling out new, more streamlined reporting formats based on feedback from last 1 year
• Send CNEs to NRCs to help counsel families present
• Continue to develop linkages with government health and nutrition services
• Launch of Community Management of Acute Malnutrition (CMAM) Pilot program together with DWCD in Jhabua, Alirajpur, Barwani, and Khargone districts
• Finish mapping of all districts using Google Android phones

Country Page: India Initiative Page: Childhood Malnutrition Eradication Program