1. CLICK TO ADD TITLE [DATE][SPEAKERS NAMES] The 6th Global Health Supply Chain Summit November 18 -20, 2013 Addis Ababa, Ethiopia One stop shop for improved access, Quality health care and service delivery for rural poor through community managed Nutrition Centers in Andhra Pradesh, India Lakshmi Durga Chava lakshmidurgac@gmail.com Director (CMH&N) Society for Elimination of Rural Poverty(SERP), Hyderabad, India,

2. Presentation outline Relevance Background Rationale Paradigm shift Implementation Mobile tracking Results Challenges Replicable Way forward 2

3. Relevance Share the experiences in establishing – demand chain – the other side of the health supply chain – mobile tracking system in reaching the unreached Explore potential networks for partnerships 3

4. Society for Elimination of Rural Poverty (SERP)SERP Autonomous organization established by GoAP in 2000 Responsible for implementing poverty reduction projects supported by State and Central Govt.; WB and other national and international donors Works with people’s institutions (women SHGs) at grassroots level Works in coordination with the govt. line depts. 4

5. 22 Zilla Samakhyas 1,098 Mandal Samakhyas 45,046 Village Organizations 10,72,627 Self Help Groups 1,17,62,814 Members ZS MS VO SHG Women Members Institutions of Rural Poor in 16 years 5

6. Poverty Reduction Strategy 6

7. SHG Bank Linkage – Started in 2000, so far, they have availed bank loans of Rs. 52,950 Crs. Year wise SHG wise 7

8. Magnitude of the malnutrition 40.4% of children with under weight 37.3% of children are stunted 12.5% of children are wasted 82.7% of children are anemic 37.5% women with BMI<18.5Kg/m2 58.2% of women are anemic Source: NFHS-3 8

9. Much concern among poorer sections Stunted (height-for-age) Wasted (weight-for- height) Underweight (weight-for-age) Scheduled Caste 53.9%21.0%47.9% Scheduled Tribe 53.9%27.6%54.5% Backward Class 48.8%20.0%43.2% Other 40.7%16.3%33.7% Source : NFHS-3 Figures are presented as percent of children who are below 2 standard deviations from the median growth indicator value calculated from the WHO reference population 9

10. Preventive & Promotive Health Care Curative Care Financing and Service Delivery Human/Social Capital Health activist/ASHA Community Resource Person (CRP) Fixed Nutrition & Health Day (NHD) Water & Sanitation Nutrition cum Day Care Centers Case Managers Making Services Work for the Poor – Accessing PHCs & Area Hospitals – 108,104 and Aarogyasree services Community-owned Pharmacy Community-owned Hospitals Microfinance Product for NUTRITION Health Risk Fund/ Health Savings Health Insurance SERP model - Health Value Chain towards reaching MDGs 10

11. 730 days270 days Low Birth Weight Imaginary line It is important to note that 50% growth failure accrued by Age 2, occurs in womb & 39% babies are low birth weight Proportion of children stunted as per NFHS-3 (%) Peak foetal weight velocity occurs at around 30 wks Peak foetal length velocity occurs at around 20 wks Foetal stunting evident by 8 wks P&PE Suppl. 2013, UNICEF 2013, Gillespie 1997 11

12. Physical center i.e., building with Kitchen, Dining and Garden (for growing vegetables) THREE MEALS a day prepared and served to pregnant and lactating mothers and children <2 years Cook (Para nutritionist) is an SHG member trained in preparation of nutritious, traditional diet (with focus on use of millets & green leafy Vegetables) Health activist (Community nutritionist) provides NHED duirng lunch time 12 Nutrition cum Day Care Center (NDCC) – (1mt film)

13. Indicators NDCC Beneficiaries (N = 234) Mean weight gain for pregnant women (kg) 9.01 (SD = 0.1557) Anemia detected during pregnancy (%)35 Mean Birth Weight (kg) 2.912 (SD = 0.20) Weight Class (kg) 2.5 - 2.9928.7 % ≥ 3.056.1 % 90% had normal deliveries 10% had cesarean section. 52% of pregnant women gained 9 -10Kgs weight Note: study conducted in 8 districts inclusive of mandals in 3 ITDAs. Source : External evaluation study by SOCHURSOD Wight gain – Birth weight 13

14. Utilization of public health facility 14

15. Rationale – low uptake Failure to reach 100% coverage with basic health services is two fold : –no accessibility –lack of quality services Very little interaction between the departments for –Social mobilization –Service delivery Fixation of day and time by the service providers often conflict with the work schedules of users. –Users have not had any say in the scheduling process. 15

16. Paradigm shift Fix the mis-match between supply and demand –Community to have stake in quality service delivery –Fix a day to deliver the services on a common platform –Complementary roles by service providers and the user groups 16

17. Fixed Nutrition and Health Day (NHD)- The 5 counters platform Counter 1 ASHA (Name) Health education Counter 2 AWW (Name) Growth monitoring Counter 3 ANM (Name) ANC-Immunization & supply of drugs Counter 4 AW Helper (Name) Supplementary food Counter-5 IKP Health sub committee Names: Surpanch: MotherChild 17

18. Players Role : Before-During-After ( 2mt film)film Counter 1 ASHA (Name) Health education Counter 2 AWW (Name) Growth monitoring Counter 3 ANM (Name) ANC-Immunization & supply of drugs Counter 4 AW Helper (Name) Supplementary food Counter-5 IKP Health sub committee Names: Surpanch: MotherChild Pre-NH D Due list preparation Social mobilization During NHD 100% coverage Follow up on the drop outs Post NHD Reconciliation Exceptional report for review 18

19. Preloaded SHG member wise database maintained by BF in a different server Encrypted data sent in string format Application program decrypts data which is stored in table format Individual JARs for each mobile/VO has to be downloaded. New enrollments or editing existing member information possible Various reports generated as per program design Tracking- mNDCC- DSS Alert sent to provide due list etc. 19 Global Innovation - IWG award 2012

20. Impact of mNDCC Exceptional reports generation as review tools and take action forExceptional reports –reaching the unreached –escalating the issues if not resolved Regular review using the exceptional reports showed improved coverage among POP –Enrollment from 58% to 72% –ANC from 10% to 31% –PNC from 5% to 29% –Immunization from 16% to 24% –Growth monitoring from 12% to 39% –Health Education from 14% to 48% 20

21. Results – Improved service delivery 21

22. Challenges Sensitization and coordination among the line depts Internalization of the concept among stakeholders Fix a day to every habitation based on ANM Tour schedule Accountability to CBOs Bring into the district administration agenda Consolidation and track the outcomes at member level 22

23. Way forward – Village level institutions in the driving seat Recognition of Village Organisation as the nodal institution to monitor health, nutrition and sanitation outcomes (Community) Institutionalization of VSHNDs under NRHM (Panchayat) Issue of Government Order – ‘Maapru’ (The Change) to bring all the stakeholders to a common platform (Service providers) 23

24. Is it replicable ? Yes, it is. Pre-requisites –Availability of community based network –Partnership between the CBOs and the line departments –Sensitization & regular capacity building of the stakeholders Exposure visits Trainings Tracking the member based outcomes –Maintenance of supply chain as per the demand –Political commitment to mainstream 24

25. Thank you 25