1. 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. 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. 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. 4 SERP 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 1 State Office (State Projec t Monit oring Unit)

5. 5 IKP Interventions 1. 1. Targeting – community based targeting. 2. 2. Focus on the poorest of the poor and vulnerable: women, disabled 3. 3. Power of scale – bringing all the poor in the state into social networks 4. 4. Scaling up through community resource persons 5. 5. Institutional design – SHG – V.O – M.S – Z.S 6. 6. Large scale mobilization of bank finances for poor 7. 7. Large scale livelihoods promotion 8. 8. Community managed food security 9. 9. Social issues as an agenda for collective action 10. 10. Social risk management 11. 11. Community managed health interventions 12. 12. 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. 6 IKP Health Value Chain Preventive & Promotive Health Care Curative Care Financing and Service Delivery Human/Social Capital Health activist Community Resource Person (CRP) Nutrition & Health Day (NHD) Water & Sanitation Nutrition Centers Case Managers Making Services Work for the Poor – Accessing PHCs & Area Hospitals Community-owned Pharmacy Community-owned Hospitals Microfinance Product for NUTRITION Health Risk Fund/ Health Savings Health Insurance

7. 7 Convergence Framework for Improved Access to Services Work in collaboration with the existing line departments responsible for enhancement in QOL of the poorest 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 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 Have a cadre of external facilitators to assist in planning and designing sustainable and workable programmes 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 Systems Outputs/outcome Personnel Improved access to “effective & available” services

8. 8 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 Community managed health and nutrition interventions

9. 9 Goal To improve Perinatal and neonatal outcomes and child care practices towards achieving the MDGs in 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. Community-Managed Nutrition cum Day Care Center

10. 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. 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. 12 NDCC Financing Model The cost of meal 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 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 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. 13 Process Grama sabha Discussion with beneficiaries Discussion with the mothers-mother-in laws Preparation of MCPFeeding at NDCC Day care for children

14. 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. 15 Coverage 2007-08: 200 centers 2008-09:600 centers 2009-10:2500 centers

16. 16 Coverage against survey 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.

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

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

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

20. 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. 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. 22 FAQs about results Accuracy of the measurements? Technical person for supervision? Authenticity of the data? Empirical evidence ?

23. 23 Maternal Outcomes Beneficiaries in intervention villages N=237 Beneficiaries in non- intervention villages N=242 Three ANC visits95.6%88.6% Safe Delivery88.6%81.3% Type of Delivery: Normal Cesarean 79.1% 20.9% 71.9% 28.1% Birth weight: >2.5kgs <2.5kgs 93.0% 7.0% 85.5% 14.5% PNC check-up68.3%62.3%

24. 24 Neonatal care practices Beneficiaries in intervention villages N=237 Beneficiaries in non-intervention villages N=242 Colostrum feeding79.9%68.9% No pre-lacteal fluids86.0%66.8% Exclusive breastfeeding for at least 6 months 84.3%81.2% Delayed bathing 7 days32.0%31.3%

25. 25 Health knowledge and health seeking behavior Beneficiaries in intervention villages 237 Beneficiaries in non- intervention villages N=242 Knowledge of methods to prevent diarrhea97.9%83.9% Knowledge of methods to treat diarrhea75.1%58.3% Knowledge of malaria symptoms86.9%72.7% Knowledge of modes of transmission of malaria89.0%78.1% Knowledge of bed nets to prevent malaria61.2%35.5% Use of bed nets at home65.8%41.7% Heard of HIV/AIDS95.4%86.8% Knowledge of modes of transmission of HIV92.0%75.6%

26. 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. 27 Can NDCC address issues & challenges at AWC? NDCCAWC Community (demand) drivenSupply driven Focus on enrollment of Poor and PoPNo special focus on most at-need women/children Health Activist/ CRPs are enthusiastic to learn the techniques Book-keeping for growth monitoring not always up-to-date Health Activist hold regular health education sessions No focus on Nutrition and health education sessions Serves as venue for Fixed NH Days conveniently located. Not accessible to the needy beneficiaries Provides complete meals paired with kitchen garden; supervised meals Provides only supplementary nutrition as take-home ration Regular monitoring by the community.Poor monitoring system

28. 28 Complimentary areas of AWC to address challenges at NDCC AWCNDCC High enrollment coverage in 74000 villages in 22 Districts Not yet scaled up to cover all villages (600 villages in 22 districts) AWW is trained in early childhood education Focus mainly on day care with nutrition AWW is trained in child growth monitoring Book-keeping for growth monitoring of children yet to be strengthened

29. 29 Costing for one village: NDCC vs. AWC Nutrition cum Day Care Centre (one time grant) Unit cost (Rs) Consumption loan corpus for 30 BPL beneficiaries 250,000 ($5000) Health CRPs resource fee & Health activist incentives 20,000 ($400) Non –recurring expenditure 80,000 ($1600) Total 350,000 ($7000) Anganwadi Centre (Every year) Centre (Every year) Unit cost (Rs) SNP cost for 80 APL+BPL beneficiaries 72000 ($1440) Salary component for AWW and AWH 40800 ($816) House rent 2400($48) Total 115200 ($2300) Note: Additional cost for monthly training at NDCC and induction/ refresher training at AWC

30. 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. 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. 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. 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. 34 Financial benefits of integrating IKP H&N with ICDS Reduced beneficiary burden Reduced costing of NDCC Reduced costing for human resources

35. 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. 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. 37 Thank You