India

Project Background:

RMF's Childhood Malnutrition Eradication Initiative has the largest field presence of any NGO working in malnutrition in the region, a result of strong partnerships with government, NGOs, business, and most importantly, local communities. Into its second year, our program continues stronger than ever.  Our team of 75 Community Nutrition Educators (CNEs) is covering enormous ground every week across 5 districts and 600 villages in Madhya Pradesh.  Madhya Pradesh carries India's highest malnutrition burden, with 60% of its children under 5 malnourished – approximately 6 million children whose futures are at risk.  Our strategy continues to be closing the gap between the resources available and the families who need them by focusing on the basics of malnutrition awareness, identification, treatment, and prevention and inserting simple, but innovative technologies and practices. 

Photo: Community Nutrition Educator, Ghenda Didi, with one of our program's beneficiaries, Sagar.

In Year Three of this program, 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 this 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
• Refer 1,000 SAM children to government centers for treatment with a 50% success rate
• Conduct 2,500 Community Nutrition Meetings
• Conduct 9,000 individual Family Counseling Sessions
• Send CNEs to NRCs to help counsel families present
• Continue to develop linkages with government health and nutrition services

Results and/or accomplishments achieved during this reporting period: 

During the Fourth Quarter of 2012, RMF’s Malnutrition Eradication Program continued to be a strong presence in Madhya Pradesh (MP). The CNEs are continuing their day-to-day activities of counseling, identification and referrals, while RMF staff work to improve the rollout of Madhya Pradesh’s Atal Bal Mission state nutrition mission (ABM). By collecting feedback on the implementation of the ABM in our 5 target districts, and presenting our findings to policymakers in Bhopal, RMF is integrating field level observation with our model to change the landscape of malnutrition treatment in MP. 

For instance, under the 2012 implementation plan for the ABM, all Anganwadi workers were scheduled to receive additional training for master trainers trained in Bhopal. After consultations with district officials, and observations from our field staff, RMF observed that in many districts these trainings had not been scheduled, much less implemented. After working with officials at the state and district levels, RMF was able to facilitate the scheduling of these trainings in early 2013, and several of RMF’s staff have been selected by the government to become master trainers.

This inclusion of RMF staff into the training cadre presents an oppurtunity to integrate RMF practices into Anganwadi services in our target districts. In 2011, with support from the Government of MP and the Madhya Pradesh Technical Assistance Team (MPTAST), RMF designed and finalized a training module for Anganwadi workers. This easy to use module integrates best practices and is divided into separate sub-modules; each section can be completed in one day, allowing for Anganwadi supervisors to provide continual on the job training at monthly sector meetings.

CommCare by Dimagi

After successfully training and rolling out CommCare with all of RMF’s CNEs, RMF management was able to more actively follow up with children in need of our support. Previously, our response relied on phone call alerts from CNEs to their managers, which were then relayed to the program managers for assistance. However, with the real-time data available on CommCare, RMF management is now able to identify serious cases of malnutrition, the children’s names, and villages remotely and then actively follow up with the respective CNE immediately. In addition to the regular reports received by our CNEs, this combination of top down supervision with bottom up reporting has made our program more responsive, versatile, and effective.

Since RMF’s CNEs started using the phones to collect data, RMF now has a digital database on containing the vital information of over 6,000 children we are currently tracking. On each visit, each CNE updates the status of the child, and from our web-based dashboard, CommCare HQ, and the downloadable data, we are able to get a clearer understanding of how many children are malnourished, where they live, whether they have any complications (such as diarrhea or other illnesses), and how they are improving over time.

CommCare HQ also allows RMF program management staff to monitor the day-to-day activities of each CNE. For instance, follow up rates with malnourished children is a critical component of our program, and everyday management receives a daily email update of the percentage and number of visits each RMF CNE has conducted.

In the community, CommCare and its verbal prompts have improved the counseling and interaction with family members. Because of the new technology, each “interview” has been revitalized and many of the families respond more effectively.

In October of 2012, RMF also began roll out a pilot study with Dimagi to test the efficacy of a “call-center” supervision model. During this pilot, each CNE will receive weekly phone calls from a remote center run by Dimagi that provides feedback on their performance based on the CommCare indicators. The aim of this study is to see how welll this remote supervisory support will improve the performance of our CNEs. During November 2012, field fellows from Dimagi visited our project sites to collect mid-line information and fix application errors on individual CNE phones.

Based on the feedback from the mid-line assessment, Dimagi Inc has decided to fine-tune and re-design the RMF application. This upgrade and subsequent training is scheduled to begin in January 2013.

CMAM Pilot

In parallel, RMF management staff also worked diligently towards securing the permissions required for the upcoming CMAM (Community Based Management of Acute Malnutrition) pilot using Ready to Use Therapeutic Food (RUTF) for community based treatment of malnutrition in our target villages. 

In December of 2012, RMF’s pilot received official sanction from both the Executive Committee of the ABM and the Chief Minister of Madhya Pradesh. Production of the RUTF for this pilot will be undertaken by MPAGRO, a government run corporation currently producing Take Home Rations for the Integrated Child Development Scheme (ICDS). After several individual meetings with stakeholders within the Department of WCD in Bhopal, a final stakeholder consultation and official meeting for CMAM in MP has been called for February 5, 2013. During this meeting, it is expected that representatives from RMF will be officially invited to join the Madhya Pradesh Technical Steering Committee on CMAM. RUTF for this pilot is scheduled to be available in June 2013, and RMF will begin training over 800 AWWs in the spring of 2013 prior to rollout of this pilot.

After a successful demonstration of CMAM with RUTF, RMF hopes to change the landscape of SAM treatment in India. Previous programs using RUTF in Africa and other Asian countries have shown that, with proper counseling and monitoring, the use of RUTF in CMAM programs has a success rate as high as 80%.

 During this quarter the program:

• Identified 1,375 children suffering from SAM and gave counseling to the caregivers of each of these children
• Saw an improvement from SAM to MAM in 487 children
• Identified 1,185 children with MAM and provided one-on-one counseling to the caregivers of these children
• Saw an improvement from MAM to normal in 1,097  children
• Successfully ensured the 14 day treatment of 53 of the most serious cases at local Nutrition Rehabilitation Centers
• Conducted 690 village nutrition training sessions, with over 5,361 people in attendance
• Conducted 13,128 family counseling sessions

Since our program began in 2010 this program directly impacted:

• 2,157 children who have received lifesaving treatment
• 24,822 children who have improved directly through our intervention
• 329,780 individuals from rural villages who have received training on malnutrition awareness and prevention in their villages

The families of the 66 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 improve the lives of their families.

Success story(s) highlighting project impact: 

Update: Jitendra

When RMF first identified Jitendra, he was an 8-month-old child suffering from Severe Acute Malnutrition (SAM) in Nani Barwani in Barwani district. In addition to his malnutrition, the family revealed that he had suffered from a constricted anal opening since birth. Although the problem was surgically addressed at the hospital where he was born, Jitendra was still unable to pass stool and had a large mass in his abdomen. 

RMF staff first took Jitendra to the MY Hospital in Indore, a large government hospital with specialty care facilities and a pediatric surgeon. Because of his malnutrition, the doctors were not ready to place Jitendra under anesthesia to perform corrective surgery. Instead, they provided his family with medication and a dilation kit to remove the mass and allow Jitendra to pass stool. 

With RMF support, Jitendra was taken back to MY hospital on July 25^th for admission and surgery to correct his congenital problem. However, after keeping him under observation, the anesthesiologist was still not comfortable proceeding with the surgery. After a long wait, and several complications with the family’s obligations at home, Jitendra was again going back home with just a dilation kit to gain more weight. 

However, neither his family nor RMF’s CNEs were willing to give up on him. With diligent follow-up from our CNEs, and exceptional will from his family to see him improve, Jitendra continued to gain weight at home with food and breastfeeding. His mother continued the dilation treatment to ensure that no other masses formed, and his father coordinated with RMF staff to replenish his dilation kits. Although it was a high burden on both his parents and Jitendra, his treatment continued daily. 

In total, Jitendra completed two rounds of treatment at the Nutritional Rehabilitation Centers (NRC) in Barwani and Indore to stabilize his weight and manage his complications. Nurses at MY Hospital counseled Jitendra’s mother on the dilation, and the pediatric surgeons continued to increase the size of each dilator to slowly improve his condition. As he continued to gain weight at home, his parents stayed in close contact with RMF’s CNEs to ensure a prompt response if complications developed again. 

With RMF support, Jitendra was taken to MY Hospital for a total of 4 follow up visits. With his family’s diligent care, and the support of RMF’s Community Nutrition Educators, after examining Jitendra in December, the surgeons assessed his condition and concluded his condition will improve with dilation alone. Although he still needs follow up visits, his color and weight have improved dramatically since RMF first identified him, and he is on his way to leading a healthy, normal life. His continued treatment and follow up is the foundation of RMF’s program in MP, based on our philosophy of treating an individual and family as a whole, and continuing to follow up with them throughout the course of their treatment. 

Lakshmi – Diligence Helps Bring a Child Care

In Barwani District of Madhya Pradesh, distance is one of the largest challenges RMF faces. Covering 206 villages, our team in Barwani covers a huge geographical area, with many villages hours from the nearest health facility by jeep. These distances are often a barrier for the families that is too difficult for our staff to overcome when referring children to care for SAM, but sometimes there are other barriers as well. 

Lakshmi is an 18-month-old girl from Pichoddi in Barwani Block. When RMF’s CNE, Koushaliya Malwia, first discovered Lakshmi in December of 2012, she weighed less than 2 kilograms. Despite desperate counseling her parents would not take her to the NRC because they had been treated poorly by the staff there when Lakshmi was born. In Barwani District Hospital many of the staff are not from the same tribal communities that surround Barwani, and often they do not treat the members of these communities very well. Unfortunately, this is a problem throughout India, and it contributes to both the low numbers of institutional deliveries (in Barwani district, only 53.5% of deliveries happen in facilities[1]) and RMF’s ability to refer children to public facilities for care. Right now, the only chance for children with SAM to recover is to be referred to public facilities, so RMF works hard to continue to counsel children and their families to go, even if they are not willing on initial diagnosis. 

For Lakshmi, it took a village. Koushaliya followed up with her and her family three times throughout December, the last visit with Barwani District Coordinator Radha Chouhan. They coordinated with the Anganwadi worker, the local village nutrition worker, to also follow up, providing Lakshmi and her family double take home rations of nutritious food. Finally, after three visits, Radha and Koushaliya took Lakshmi to the Mangel Dewas, the weekly village ration distribution day and immunization day, where they met with the Auxiliary Nurse Midwife and ASHA workers, and convinced the family to go to the NRC. In total, four government workers from two departments and two of RMF’s most senior staff were finally able to overcome the damage done by the hospital’s attitude at Lakshmi’s delivery. Lakshmi was admitted to the NRC on January 10, almost a month after she was first identified by RMF. Radha followed up with the family every evening in the NRC to make sure their stay was comfortable and they were receiving proper care. 

On her discharge from the NRC 14 days later, Lakshmi’s weight was still low, but was slowly increasing. With diligent follow up from RMF, the Anganwadi worker in Pichoddi, and regular visits every two weeks at the NRC, Lakshmi in on the road to recovery and a healthy life.