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8/8/2019 MCHN Report Final
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Evaluation Report
Community Based Maternal & ChildHealth Nutrition (MCHN) Project
ORG Centre for Social Research(A Division of ACNielsen ORG-MARG Private Limited)
Lucknow(2006)
Submitted to:
GoUP (Directorate of FW & Directorate of ICDS) andUnicef,Lucknow
Ashish Gupta, MBA
Anamika Misra, PhD
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Evaluation
Community Based Maternal & ChildHealth Nutrition (MCHN) Project
ORG Centre for Social Research(A Division of ACNielsen ORG-MARG Private
Limited)
Submitted to:
GoUP (Directorate of FW & Directorate of ICDS) andUnicef,Lucknow
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Acknowledgement
We are extremely thankful to UNICEF for providing us an opportunity to Evaluate the
Community Based Maternal and Child Health Nutrition (MCHN) Project in four project
districts of Uttar Pradesh. We also thank Dr. L.B. Prasad, DG Family Welfare and ICDS
Directorate along its team for their valuable inputs and necessary support. The technical
inputs received from Dr. Sheila Vir, Project Officer (Nutrition), towards completion of
this assignment, are also appreciated.
We as well wish to express our sincere thanks to Dr. Santosh Jain Passi, Reader in
Nutrition, Institute of Home Economic (University of Delhi) for providing training to the
field investigators on technical aspects related to weighing of children and support in
analysis of data.
We take this opportunity to thank the MCHN Project Conveners of the four districts Dr.
Deoki Nandan (Agra), Dr. Shradhha Dwivedi (Allahabad), Dr. S.B. Gupta & Dr. B.P.
Mathur (Jhansi), Dr. S.C. Mahapatra (Varanasi) SNRC/DNRC of all the four project
districts for providing our field teams with all necessary inputs and cooperation.
Thanks are also due to ANMs, AWWs, Bal-Parivar-Mitra (BPM) and the community for
their cooperation extended during the course of the field work.
We hope the study findings will be useful in planning and executing similar interventions
in the future.
Study teamORG Centre for Social Research,
Lucknow
September 2006
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CONTENTS
Executive Summary
1.Community based MCHN Project-A Background...I.01 I.08
2.Evaluation Methodology-An approach, data collection and analysis.........II.01 II.5
3.Accomplishing the processes-An evaluation of the process objectives..III.01 II.19
4.Achieving the project objectives-An evaluation of the project impact...IV.01 IV.43
5.The outcomes of the project-MCHN concepts..........V.01 V.013
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ORG Centre for Social Research, Lucknow Executive Summary
Community Based MCHN Project An Evaluation I
Executive Summary
Community Based Maternal and Child Health Nutrition Project (referred as MCHN project),
was implemented in response to the grave health and nutrition situation of women and children
in the state of Uttar Pradesh. MCHN project is based on the principle of:
Breaking nutrition and infection cycle
Addressing intergenerational cycle of growth failure.
The strategy emphasised on a multisectoral approach and involved the two major system i.e.
Health and Integrated Child Development Services (ICDS) as well as Panchayati Raj (PRI).
Department of Social and Preventive Medicine of the Medical colleges, located in the selected
four demonstration districts, played the nodal role in the MCHN project management.
Key objectivesof the Community based MCHN project included;
1. Reducing underweight in children
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Community Based MCHN Project An Evaluation II
Target Population " At Risk Families:The MCHN project focused on the most crucial period of life i.e. children below 2 years,
pregnant, lactating women and newly wed. Children below six years with clinical sign of sever
malnutrition were given special attention. Therefore families who had any one member in this
category were accorded priority and were recognised as "At Risk" of undernutrition.
Frontline Volunteers/Workers:A block level facilitator was appointed in each of the project block of the demonstration districts
and was referred as Block Trainer cum Monitor (BTMs). The MCHN project strategy focused on
reaching and establishing regular contact with the selected families 'at risk' of undernutrtion
through a Community Health Nutrition-Sanitation Mobilizers (CHNS), referred as Bal Parivar
Mitras (BPMs). The BPMs, elected project volunteers, worked with an average of 50- 60
households in a village with about 1000 population and one BPM was expected to work with 15-
20 at risk families"in the community cluster for improving care during pregnancy and earlychildhood care i.e. feeding, hygiene, health and child care behavioural practices. Community
mobilizers were not given any honorarium or fees but were paid Rs.100/quarter on submission ofmonitoring reports
Coverage:The project was implemented in four districts of U.P.- Jhansi, Allahabad, Agra, Varanasi. In
each of four districts, two blocks per district (Agra-blocks-Bitchpuri & Fatehpur Sikri,
Allahabad-Jasra & Saidabad, Jhansi-Babina & Bangara and Varanasi- Chiraigaon & Harhua)
were selected and high priority was to be given to selection of blocks with ICDS project in
operation. In Saidabad block (Allahabad) initially ICDS was not there but it was established
later. A total of 907 villages of 8 blocks of 4 districts with a total population of 1,331,549 were
covered under the project.
Duration:The project was conceptualized and developed in 1999. The project commenced with execution
of baseline study between July to December 2000 and the project activities was undertaken
during January 2001 to December 2004. Baseline was conducted by the Medical Colleges of the
respective districts in the project area before the commencement of the project activities i.e.
July-December 2000.Process documentation was done during December 2004 to January 2005
and Evaluation study was done during April -May 2005.
Endline Study:The prime objective of the study was to assess the impact and effectiveness of the community-
based Maternal and Child Health Nutrition (MCHN) project. ORG Centre for Social Research
(A division of ACNielsen ORG-MARG) conducted the evaluation of MCHNs project during April
-May 2005, after a gap of more than 4 months of closing the project. The evaluation was
preceded by a qualitative study on community-based approaches used in Uttar Pradesh for
nutrition and childcare. The qualitative study undertaken, as a part of separate assignment for
studying community based activities in all the four MCHN districts was also undertaken by ORG
Centre for Social Research during December 2004 to January 2005.
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Community Based MCHN Project An Evaluation III
Methodology and Sample Coverage:
a) Qualitative Survey (Process Documentation):In each the four MCHN districts i.e. Allahabad,
Agra, Jhansi and Varanasi, both the project blocks of were covered for the endline study. Thequalitative research techniques such as In-depth Interviews/discussions, Focus group
discussions, Desk Review were undertaken to review the processes of the community based
MCHN projects. In all, 75 In-depth Interviews with the State, District and Block project
functionaries, 81 semi-structured interviewed with the village level project
functionaries/volunteers/target population and 18 Focus Group discussions with mothers of at
risk families and seven case studies were done from the project area.
b) Quantitative Survey (Endline Impact Evaluation): For quantitative surveys as well, both the
blocks from each of the four MCHN districts were covered. The quantitative survey was carried
out among the mothers of children currently aged 0-24 months, newly married women and BalParivar Mitras (BPMs).
Tools of Enquiry: Three separate schedules used Mother of children aged 0-24 months, newly married
women and Bal Parivar Mitras (BPMs) - were designed, pre tested and finalized in consultation with
stakeholders.
Sample size: The required sample size for the survey among the mothers of children aged 0-24 months was
calculated based on the standard formula for one point sample estimation. In each block a multi-stage sampling
procedure was followed to select the respondents. At the first stage, villages were selected followed by the selection
of households and respondents. The number of households selected per village was fixed at 20. Thus, in all 10
villages in each block were selected following PPS sampling procedure using 2001 census. Thus, a total of 1600
households from 80 projects villages were covered for quantitative study.
The total sample of 400 households was equally divided between the two blocks in each district. Thus, in each blocka sample of 200 households were covered for the survey among mothers of below 2 years children.
Each selected village was divided into 4 quadrants and from each quadrant, 5 mothers of children currently aged 0-
24 months were selected for the interviews. In a selected household, if more than one child was there the mother of
the youngest child was contacted for the interview.
Sample size for survey among newly married females: By following the same procedure asfollowed for the identification of mothers, 3 newly married females who got married during last
one year & without having children were selected for the interview in each village (The Project
defined newly married females as less than 2 years & without children). Thus, against budgeted
total sample of 240 newly married females (60 per district), 239 were contacted for the
interview.
Selection of Bal Parivar Mitras (BPMs): Around 1-2 BPMs were randomly selected for the
endline survey): from each selected village.
The salient findings emerged from qualitative as well quantitative survey has been presented in
the following sections.
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A- Process Objectives (Qualitative Survey): Findings
Malnutrition conceptual framework of UNICEF formed the basis for all the processes project planning, training, implementation as well as monitoring.
A strong conceptual framework helped in defining the project objectives. MCHN projectclearly spelled out both Process Objectives and Impact Objectives to achieve the pre-
defined Expected Outcomes. MCHN project clearly defined all the process objectives to
achieve the project objectives, which helped in proper implementation of the project
A methodical planning process was adopted and a series of planning workshops andmeetings were organized to develop a plan of action for the project. As an outcome a
detailed plan-of-action outlining the detail implementation strategy, sectors involved and
roles/responsibilities of functionaries at different levelswas prepared.
District-level, multi-sectoral orientation and planning workshops were more interestingly
conducted with full participation of various sectors and community-based exercises.These workshops provided an insight into malnutrition and reinforced the concept of
multi-sectoral approach building consensus regarding the strategy, which lead to
formulation of comprehensive plan-of-action of the community based MCHN Project.
District orientation workshops interestingly included community based activities withspecial focus on issues to understand malnutrition problem of children through visits to
families for assessment, analysis and action. Following this exercise, other sectors such
as WES, PRI, Horticulture beside ICDS and Health could understand and appreciate
their role in reducing undernutrition. This led to not only a better understanding of
sectors but also resulted in higher level of involvement.
Towards ensuring and reaching families the most at risk of under nutrition, MCHNproject defined the population segment that need to be reached and counselled urgently
for preventing under nutrition. At risk family approach was a successful idea since the
actions concentrated on selected families within a village, which resulted in focussed
attention for maximum difference.
Community Based Mobilsers (BPMs) were selected by AWWs and ANMs in consultationwith community members as well as leaders/Pradhan. These mobilizers were women
(97%) and about half of them were illiterate.
Community based Mobilisers (BPMs) were trained using special 'case based' trainingmodule to equip them with information and skills to dialogue with communities and
families. For influencing appropriate behavioural changes at family level and also for
creating demand for health and nutrition services. for influencing appropriate
behavioural changes at family level
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Community Based MCHN Project An Evaluation V
BPMs, which were not, paid any honorarium or fees, acted as link person, with frontlineworkers of health, ICDS and block assistant development officers/PRIs.
An innovative pictorial monitoring format was developed under the project. That wasutilised by BPMs for monitoring action at the family level as well as a tool for
counselling. This pictorial card was also used for training and retraining of BPMs.Understanding of pictorial monitoring format and its usage was evaluated by scoring
system, to assess the competence of BPMs. Two third of the BPMs contacted were found
having correct knowledge.
The experience of the community based MCHN project and BSPM resulted in theredesigning of ICDS to reach under threes through the Intensification of Child Health
and Nutrition (ICHN) activities. Thus, policy guidelines for the same was developed
using MCHN concepts. The ICHN also adopted the concept of at risk families of
MCHN project for its Home visit activity to concentrate primarily on families at risk of
undernutrition. ICHN has been further absorbed in the Mission Poshan action plan of
Uttar Pradesh for reduction of protein energy malnutrition and micronutrientmalnutrition.
B- Impact Objectives (Quantitative Survey): Findings
In accordance with the key Project objectives results have been presented as below:
i) Nutritional Status of below 2 years children:
A considerable decline of 43% in the proportion of severely malnourished (IAPclassification method) children (baseline: 25%; endline: 14%). The proportion of
severely and moderate malnourished cases was slightly higher in case of female children
below 2 year of age, in comparison to their male counterparts
An increase in mild & moderate cases (IAP method) is observed in the endline, incomparison to baseline indicating shifting of severe malnourished cases into mild &
moderate category of nutritional status.
The proportion of children with normal nutritional status (IAP method) improved onlyslightly from 25% in baseline to 28% in endline. The normal category children are
generally not perceived at risk of under nourishment hence increase in normal category
children is difficult to achieve in a period of 4 years possibly additional time is required
to shift the mild cases to normal category.
As per the NCHS (Standard Deviation - SD) method, the proportion of children fallingunder 2SD category was 34% and 3SD 32% in the endline. However, a comparison
with baseline could not do due to incomplete data/figures of baseline.
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Community Based MCHN Project An Evaluation VI
ii) Maternal & Newborn & Infant Care
iia) Consumption of IFA tablets:
Overall, a high proportion (88%) of women contacted during study was found possessingknowledge about consuming 100 IFA tablets during pregnancy.
Compared to 6 percent during Baseline 61 percent in the endline confirmed receiving90+ IFA tablets during their index pregnancy.
As far the consumption of 90 or more tablets, it has increases from 9 percent in thebaseline to 22 percent in the endline.
Overall, the consumption of IFA tablets amongst those women, who received any numberof IFA tablets, has increased more than twenty percent in the endline as compared to
baseline.
In line with the findings of qualitative survey, fear of side effects arising from certainmisconceptions was also another reason for low consumption of IFA tablets. Feeling of
vomiting (26%), malaise or bad after taste in the mouth (14%) and very hot/feel giddy
(12%) were certain side effects, reportedly, associated by the mother with the
consumption of IFA tablets that led them to stop taking of these.
iib) Maternal Care
As against 80% of the mothers were aware about three ANC check ups to be done duringthe pregnancy, only 12% of the mothers received all the three antenatal check-up during
their index pregnancy. Not much difference in the baseline and endline proportion was
observed in this regard.
95% of mothers across all the four MCHN districts were found aware about taking twoTT shots during pregnancy. 63% of the mothers, reportedly, received two TT injections
during their index pregnancy, which however improved from 47% of the baseline.
In sharp contrast to high levels of awareness, practice was found quite poor during theendline. Overall, less than a fifth of mothers (as compared to more than three fifth being
aware) confirmed taking one additional meal every day during their index pregnancy
Loss of appetite (48%) and Feeling of heaviness and Indigestion (35%), which areactually pregnancy related issues, were the main reasons cited by most of the women.
78% of mothers contacted during the endline survey were aware of taking at least twohours of rest (during daytime) per day during pregnancy. In line with the same nearly
three-fourth of the mothers reportedly practiced this during their index pregnancy.
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Community Based MCHN Project An Evaluation VII
A high proportion of mothers (87%) confirmed washing of hands, specifically with soap,by the person assisting the delivery. Impact of the project intervention could not be
compared with the baseline due to non-availability data.
iic) Newborn Care
In high proportion of cases (87%) washing of hands with soap by person assistingdelivery was observed in the endline.
Bathing of newborn after third day of birth was reported in 22% cases in the endline.
Regarding birth registration, three-fourth mothers expressed their awareness while birthregistration was actually done in three-fifth cases. In majority cases (63%) birth
registration was done after 7 days of birth.
iid) Infant & Young Child Feeding
The practice of initiating breastfeeding within 1 hour of birth has increased by five times
in the endline (21.9%) than Baseline (4.6%)
78% mothers confirmed having given something or the other (pre-lacteal feeds) to theirchild before initiating the breastfeeding,
Nearly 60% of the mothers were aware about the importance of colostrums feeding. Acomparison with the baseline shows an overall improvement regarding the practice of
colostrum feeding in the endline (baseline: 28%; endline: 53%).
With 78% mothers giving pre-lacteal feeds, the proportion without any pre-lacteal feedwas 22% of which the proportion of children that were breastfeed exclusively up to first 6
months was 10%. (or 2.1% of total 1580 children).
The proportion of such cases where semi-solid food was introduced between 6 to 9months substantially increased from 18% in the baseline to 63% in the endline.
iie) Vitamin A supplementation (VAS):
As per the vaccination card, slightly more than a fourth received one dose of VAS while
the proportion receiving all the three doses was 3 percent. One of the reasons for low
VAS coverage was poor service response from ANMs who got engaged in unexpected
priorities such as pulse polio drives. Also, the supply of VAS was not planned under the
Project and no special effort was made in this regard. VAS programme was totally
dependent on the governmental supplies and on going efforts administration of VAS.
The awareness level of community on importance of VAS was not very encouraging asbarring few of the mothers, none could not respond on this issue.
The Project revealed that it was critical to introduce a programme design in the state,which would positively influence joint functioning of health and ICDS systems to provide
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Community Based MCHN Project An Evaluation VIII
services to address the problem of micronutrient malnutrition. The low coverage of
children with VAS in MCHN project resulted in defining roles of ICDS & Health and in
the formulation of biannual strategy under the Biannual Child Health & Nutrition Month
(referred as Bal Swasthya Poshan Mah or BSPM), which is currently part of RCH-II and
is being implemented state-wide in 70 districts.
iii) Household level practices
iiia) Consumption of iodized salt:
As far as awareness on benefit of consuming iodized salt is concerned, 12% respondedthat it improves physical and mental health of newborn while one-third reported that it
prevents goitre.
Overall, the proportion of household using salt with iodine (either 15ppm) increased from 31% of baseline to 67% in the endline.
The proportion of households using salt with 0 ppm reduced from 60 percent ofbaseline to 33 percent in endline.
Household where salt was found containing more than 15ppm iodine were 16% in theendline, which also increased from 11% of baseline.
Since the supply of iodized salt packets are incorrectly labelled or have less than 15 ppmiodine, the issue is the authentic supply of iodized salt with appropriate (15 ppm) iodine
iiib) Safe drinking water and Hygiene & Sanitation
An increase in usage of ORS was reported. Use of ORS at the time of diarrohea wasknown to more than one- fourth of the mothers contacted during endline study as
compared to that during baseline (16%).
68.5% of families started using hand pumps as main source of drinking water ascompared to that during baseline (41.5%).
The availability of latrine facility has improved only marginally from 7% of baseline to10% in the endline. The usage of latrines facility (by those having it) increased from
(endline: 82%; baseline: 62 %,) mainly due to increase in awareness in the endline.
A significant increase in the practice of washing hands with soap after defecating(baseline: 35%, endline: 83%).
Washing of hands before other activities such as before preparing any food (81%), beforeeating (70%) was also high. The practice of washing vegetables/fruits before eating was
followed in 86%.
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Community Based MCHN Project An Evaluation IX
Source of Information:
On almost all the issues health, nutrition, water, hygiene & sanitation education as wellas nutritional health services, BPMs (Bal-Parivar-Mitra) emerged as the main source of
information, followed by ANM and AWW.
CONCLUSIONS:
Sound planning of MCHN project was a positive attribute that helped methodicalexecution of all the envisaged activities. Unicefs conceptual framework, which explains
determinant of undernourishment, was used to develop strategies for tackling
undernourishment.
A system needs to be developed so that the State ownership of a Project is sustaineddespite transfers of officials at State or district level. The ownership of project by ICDS &
Health at state and district level remained marginal. In MCHN the problem of Project
ownership was tackled, to a large extent, by involving Medical Colleges (SNRC/DNRC)
at the district. With their regular presence, they provided the necessary technical supportthroughout the implementation of the Project.
The strategy of involving Block-Trainer-cum-Monitor (BTM), who was the additionalstaff, was very effective. Under the supervision of Medical Colleges BTM was the key
person helping Project implementation at grass-root-level.
BPMs (Bal-Parivar-Mitra) meaning friends of families were community basedvolunteers selected and trained by the Project made regular contacts to target groups,
which helped increasing the correct knowledge and practices among them. They also
coordinated and supported ANMs and AWWs in their activities.
Defining the target audience, as Risk-families was an innovative approach that enableseasy management by ensuring identification of the population segments that was to be
reached and counselled urgently. This strategy inspired the Home visit guidelines of
ICDS, in the GoUP plan of action. Some components of MCHN have gone in the strategy
of ICHN (Intensification of Child Health & Nutrition) activities also.
Considering low levels of literacy among the target population, poor access to electronicmedia and electricity supply in rural areas, Inter-Personal Counselling (IPC) was
planned and undertaken as a technique to communicate with the community on MCHN
issues. Thus, Project as a strategy did not use any IEC tool mainly to demonstrate the
impact community-based-workers. IPC would have been possibly more effective if it was
complemented with community level education.
Pictorial monitoring format was developed primarily for the use of illiterate BPMs inundertaking all necessary activities. But, since it carried uniform messages and
pictorially illustrated all the activities using life cycle approach it also substituted the
need for IEC material in the Project to a large extent. The idea is expected to extend to
others.
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Community Based MCHN Project An Evaluation X
The awareness level on majority of the issues was found relatively higher in Allahabadand Varanasi in comparison to Agra and Jhansi. This difference is probably due to
variation in socio-economic conditions impacting the local customs and practices.
However, as far as practice is concerned no significant variation or trend was observed
across four MCHN districts.
It emerged that community changed their behaviour more easily on certain aspects/issuessuch as a) 2 hours rest during daytime during pregnancy, b) registration of pregnancy,
c) ANC services, d) colostrums feeding, e) semi-solid between 6-9 months, f) use of ORS
during diarrhoea, g) consumption of iodised salt, h) hygiene & sanitation practices.
On the other hand, relatively lesser change was observed on issues a) taking oneadditional diet during pregnancy, b) initiating breastfeeding within an hour of birth, c)
exclusive breastfeeding up to 6 months. These issues are closely linked with local customs
and traditional myths & misconceptions that involve lot of unlearning before new and
contradictory knowledge gets completely imbibed and a new behaviour emerges.
No specific and separate strategy was planned or implemented for increasing vitamin Aadministration. Immunization and administration of vitamin A, which is the responsibility
of Health system, could not show good results as the ANMs got diverted in other
unexpected emerging priorities such as polio campaign in year 2000. Further, supply of
vitamin A by Unicef was not envisaged in the Project.
The positive shift in nutritional status can be primarily attributed to adoption of practices pertaining to infant feeding (early initiation of breastfeeding & colostrums feeding),
usage of safe drinking water and other hygiene practices as well as special attention
given to children presenting clinical signs of protein energy malnutrition. Monitoring
growth, using weighing and plotting growth chart was not part of the MCHN project.
However, this could have, possibly, further enhanced the project outcome.
However, nutritional status would have further improved if local customs and traditionalmyths had not hurdled important feeding practices during pregnancy and infancy. In fact,
correct behaviours related to feeding are critical for improving nutritional status, and
hence such behaviours should possibly be addressed with efforts beyond interpersonal
counselling (IPC). Thus, it is recommended that for such issues besides IPC,
communication tools using strong emotional appeal than rational appeal should be
employed to sensitize the target groups. Dramas (Nukat-natkas), folk dances, folklores
with interesting storylines could be used to communicate the messages. Practices related
to infant feeding, safe drinking water and hygiene practices are easy to change through
IPC.
Nodal nutrition officers, attached to Health and ICDS sectors, appear critical incoordinating district level activities and follow nutritional status.
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Evaluation of MCHN Project I-11
1
Overview of Nutrition Situation in U.P.
Uttar Pradesh is the most populous state of the India Union and accounts for almost one
sixth of the countrys population. The state scenario with respect to the status of mother
and child calls for renewed efforts on the part of service providers on one hand and the
community on the other. As per SRS 2004, Uttar Pradesh has a high incidence of Infant
Mortality Rate (IMR) of 72 against the national average of 60. Further, according to
NFHS-II the state has high under-five mortality rate of 123, total fertility rate (TFR for
past three years) of 3.99, and a high prevalence of Protein-Energy Malnutrition (PEM) with
52 percent of children below three years of age being underweight and 55.5 percent are
stunted. Similar estimates at the national level are 47 and 46 percent, respectively. The
proportion of children who are severely undernourished is also very high 22 percent
according to weight-for-age and 31 percent according to height-for-age category (using
International Standard Deviation Norms).
According to WHO estimations, malnutrition is directly or indirectly associated with over
half of all child deaths occurring in developing countries. U.P. has the highest number of
malnourished children in the country with 5 out of 10 children below three years of age
suffering from chronic under nutrition. Malnutrition in children usually sets at the age of 8-
11 months when adequate semi solid complementary foods are not given along with breast
milk. This period is the most vulnerable time for the transmission of faecal pathogens,
resulting in high incidence of diarrhoea and other preventable diseases. A malnourished
child is much more likely to die as a result of common childhood diseases than those who
are adequately nourished.
An analysis of causative factors associated with nutritional status of children of Uttar
Pradesh reveals an association of underweight children with the three essentials health,
Community Based MCHN Project
- A Background
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Evaluation of MCHN Project I-12
Inadequate Dietary Intake Disease
Inadequate Inadequate Care Insufficient HealthAccess to for Mothers services & UnhealthyFood and Children Environment
Resources & ControlHuman, Economic & Or anisational
Potential Resources
Malnutrition
Inadequate Education
Political & Ideological Superstructure
Economic Structure
Basicdeterminants
Underlyingdeterminants
Immediate
determinants
Outcome
Figure 1.1: Conceptual framework of MCHN strategy *
* UNICEFConceptualframework
hygiene and sanitation a
situation further complicated
by a lack of awareness on
maternal and childcare andnutrition. Poor food hygiene
combined with lack of ready
access to water and
environmental sanitation,
further contributes to
malnutrition and is therefore
considered important
underlying causes of
malnutrition.
Besides, children, malnutrition in form of Chronic Energy Deficiency is very high in
women in the reproductive age group. 30 percent of the women are reported to have Body
Mass Index (BMI) less than 18.5 (IASDS, 1998), and on an average 80 percent of pregnant
women are anaemic. Maternal malnutrition is often the major contributing cause of Low
birth weight (LBW). It is estimated that every third child in U.P is low birth weight.
Early marriage combined with early conception contributes to CED in Women. As per
NFHS-II, the median age at the first birth among women in 20-49 years age group is 19.1
years. The relationship of adolescent pregnancy and low birth weight babies is well
established. These young mothers, often anaemic and malnourished have low birth babies.
Moreover, malnutrition in women combined with poor antenatal services results in high
incidence of maternal mortality. The coverage of Antenatal Care (ANC) services is
reported to be rather poor in U.P. with only 63% of women utilizing these services.
Coverage with iron supplement have also been found to be low i.e. less than 3 percent of
pregnant women receiving full doses of IFA supplement (IASDS, 1998).
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Evaluation of MCHN Project I-13
Community Based Maternal and Child Health Nutrition Project (referred as MCHN
project), was implemented with a view to deliver a community based model addressing the
poor nutritional status of women and children in the state of Uttar Pradesh. The project
has been conceptualized and developed in 1999 with the active participation of theDirectorate of Health and Family Welfare, Directorate of Women and Child development,
Departments of Social and Preventive medicine of state medical colleges and UNICEF.
For reducing the under-nutrition the MCHN project aimed at prevention of malnutrition
by addressing issues related to prevention of infections, intergeneration cycle of
malnutrition, poor birth weight and poor start in life.
The PROJECT STRETAGY:
Multi-sectoral (Health, ICDS, Rural
Development/ Panchayat Raj
Institution (PRI) participation, for
addressing immediate and underlined
determinants of malnutrition,
promoting community mobilization
and concentrating on selected atrisk families who are reached through
elected community volunteers
(Community Health Nutrition
Sanitation Mobilizers i.e. CHNSMs)
or Bal Parivar Mitra (BPMs). MCHN project is based on the principle of:
Addressing intergenerational cycle of growth failure.
Breaking nutrition and infection cycle
Converging of sectors of Health and Family Welfare, ICDS and Rural Development-
Water, Sanitation, Panchayat Raj Institutions.
Bichpuri & Fatehpur Sikri(Agra)
Babina & Bangara(Jhansi)
Jasra & Saidabad(Allahabad)
Figure 1.2: AREA OF PROJECT
Harahua &Chiraigaon(Varanasi)
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PROJECT COVERAGE:
The project was to be implemented in
four districts of U.P. - Jhansi,
Allahabad, Agra, Varanasi. In each of
four districts, two blocks were selected
and high priority was given to blocks
with ICDS project in operation.
However, in block Saidabad
(Allahabad) ICDS was not there
initially but it came in after sometime.
A total of 907 villages of 8 blocks of 4
districts were covered under the
project (Table 1.1 and Figure 1.2).
The community based
MCHN plan of action
(PoA) was developed in
1999. The roles of sectors
were defined along with
Social and Preventive
Medicine (SPM)
Department of medical
colleges in the PoA. The
medical colleges focused
on supporting planning,
and in coordination
implementation with MCHdepartment, Directorate of
Family Welfare. Directorate of Family Welfare was the nodal agency at state level.
Besides promoting holistic approach model for services (Figure 1.1), project also envisaged
the involvement of Community Health Nutrition and Sanitation Mobilisers (CHNSMs)
Table 1.1: Population covered by the Project
District Blocks No. ofvillages
PopulationSNRC/DNRC
Bichpuri 57 146625Agra
FatehpurSikri
95 154876
SNMedicalCollege,
Agra
Babina 108 188473Jhansi
Bangara 80 165637
MLBMedicalCollege,Jhansi
Jasra 113 162540Allaha-
bad Saidabad 119 207000
MLNMedicalCollege,
Allahabad
Harahua 176 166466Varanasi
Chiraigaon 159 139932
IMS,BHU,
VaranasiTotal 907 1331549 -
Figure 1.3: Organograme of CB-MCHN Project
MCHN PROJECT
State Based Institution (Medical Colleges)
Community Mobilisers
(Community Demand and Behavioural Change)
District CMO
WESSPRI
Services- Infant/child/Maternal Care
Directorate of Family Welfare
ICDS Block Trainers cum Monitor
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Evaluation of MCHN Project I-15
named as Bal Parivar Mitra (BPM). In each village of 1000 to 1500 population, 4 to 5
CHNSMs were identified using Cluster Community Participatory Approach. In order to
facilitate them in performing their major functions training was organized at sector level
for all the selected CHNSMs.
IMPLEMENTATION PROCESS:
The elected project volunteers, community mobilizers
referred as (CHNSMs/ BPMs) work with 50- 60
households in the community cluster and focus on
identified 15- 20 at risk families" (Box 1A) for
improving family feeding, Hygiene, health and childcare behavioural practices. Community mobilizers were not given any honorarium or fees
but were paid Rs.100/quarter for monitoring reports.
These volunteers were trained to reach the
identified at risk families and counseled on
appropriate behavioural change and also
create demand for health and nutrition
services. Provision of services at family level
by (BPMs) was linked person with the
frontline workers of health, ICDS, PRI and
other relevant sectors. Presented in Figure
1.3, an innovative pictorial format was used
by the BPMs for promoting appropriate
behavioural practices and monitoring action
at the family level.
For effective multisectoral implementation, the process involved joint training of
representatives of the concerned departments as well as joint monitoring at district, block
sector level (refer organogram). Sensitization of all sectors (district to grass root level)
regarding their roles in addressing malnutrition was achieved by using the UNICEFs
Fi ure 1.3: Pictorial Monitorin Card
Box 1A: At Risk Families
Newly Wed
Pregnant/Lactating Mothers
Children
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conceptual framework of malnutrition (Figure 1.1) and using innovative participatory
training methodology. The emphasis of training was not merely on food and feeding but
role of various sectors (Health, Family Welfare, Agriculture, Water and Sanitation) in
preventing under nutrition was actively discussed. Investing in nutrition and addressingmalnutrition by all sectors was promoted as childrens right to good nutrition and health.
PROCESS OBJECTIVES:
In order to effectively implement the project activities, in turn, achieve the project
objectives, below mentioned process objectives were designed and undertaken as a part of
project strategy.
Develop capacity of the state based medical colleges (Department of Social and
Preventive Medicine) in the prevention and management of malnutrition of women
and children
Strengthen the linkages of Health- ICDS-Panchayati Raj Institutions (PRI), WES
programme services at block/community/family level for addressing malnutrition
using multi-sectoral approach. Undertake joint training to bring their convergence at
district/block/sectoral and village level.
Identify minimum 3 to 4 community health nutrition and sanitation mobilisers(CHNSMs) per 1000 population and strength the community capacity for
identification and prioritization of problems as well as utilization of available child
and maternal health and nutrition care services for prevention of malnutrition
Influencing behavioural care practices (maternal-child health, nutrition, sanitation and
hygiene) at family level with the help of community based mobilisers (CHNSMs)
(later referred as Bal Parivar Mitra) selected in the community with the help of ICDS
and Health functionaries.
Establish a community based intervention and monitoring system for improving
maternal and child health and nutrition.
Based on Thailand model of Community Based Approaches developed by Dr. Krisid Tontisirin.
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Liking community demand with the health and ICDS sectors with a view to ensure
timely services are provided.
Empower community with information on maternal and childcare as well as create
community demand to utilize the existing services of Reproductive and child health(RCH), ICDS, WESS towards prevention of malnutrition in women and young
children.
IMPACT OBJECTIVES:
Key objective of the MCHN project were as follows:
Reducing protein-energy malnutrition in young children below 2 years by 20% of the
current level in a period of 2 years.
Improving coverage of children in the 9 months-3 years age group with doses of
vitamin A supplements to 80%.
Ensuring that 100% households use only iodized salt.
Ensuring 60% women consume a minimum of 100 IFA tablets.
EXPECTED OUTCPMES:
Reduction in moderate malnutrition in children 20years of age 80%
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PROJECT DURATION:
The project plan of Action was approved on 25th June 2000. The project commenced with
execution of baseline study between July to December 2000. The implementation of
project activities was undertaken during January 2001 to December 2004. A mid termsurvey was conducted by all the four DNRCs to review the project progress and the
project continued up to December 2004.
STRUCTUREOF THE REPORT:
Chapter I, Preceded by Executive Summary, dealt with the project background. The
subsequent sections of the report would consist of 5 chapters. Chapter II contains the
detailed evaluation survey methodology. The evaluation of process objective has been
presented in Chapter-3, while the evaluation of impact objectives has been discussed in
Chapter-4. Chapter-5 presents the Discussion and Conclusion based on the study findings.
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Evaluation of MCHN Project II-1
2
As a part of project strategy, evaluation was carried out to assess the impact and
effectiveness of the community-based Maternal and Child Health Nutrition (MCHN)
project. At behest of UNCIEF, ORG Centre for Social Research (A division of ACNielsen
ORG-MARG) conducted the evaluation of this project during April and May 2005 i.e. four
months after closing of the project in December 2004. The evaluation was preceded by a
qualitative study on community-based approaches used in Uttar Pradesh for Nutrition and
Childcare. The qualitative study was also undertaken by ORG Centre for Social Researchduring December 2004 to January 2005 in all the four MCHN districts. The evaluation
report therefore includes the findings of qualitative as well as quantitative study. The
research methodology and sample coverage of both qualitative and quantitative phase i.e.
Process documentation and Impact study are described in the following sections.
Methodology and Sample Coverage
A) Qualitative Survey (Process Documentation)
The qualitative research techniques such as In-depth Interviews/discussions, Focus group
discussions, Desk Review were undertaken to review the processes of the community
based MCHN projects. While in-depth discussions were done with the State, District and
Block project functionaries, semi-structured interviewed were undertaken with the village
level project functionaries/volunteers. Focus Group Discussions and In-depth interviews
were conducted on the target population of each of the projects.
Two blocks each from four MCHN districts i.e. Allahabad, Agra, Jhansi and Varanasi were
covered for this assignment. Table 2.1 presents the details of functionaries and target
population contacted for the study. The study was conducted from 9th December 2004 to
20th January 2005.
Evaluation Methodology
- An Approach, Data Collection & Analysis
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Table 2.1: Sample covered during qualitative phase
Village Level
ProjectsUniceflevel
officials
Statelevel
officials
Districtlevel
officials
Blocklevel
officialsFunctionaries
(ANM/AWW/VDO)
TargetPopulation
BPMs
MCHNProject
2 3 12 30 25 66 28
In addition, 18 Focus Group discussions and seven case studies were done from the
project area (refer detail reports). Since the project envisages the multisectoral approach,
perception of the functionaries of ICDS, Health and Family Welfare, PRI/DUDA, UPJN
at each level were sought. Beside, 3-4 community-based volunteers (referred as Bal Parivar
Mitras, BPMs) were interviewed at village level. The population group interviewed
comprised Currently pregnant women, Mothers of children upto 24 months.
B) Quantitative Survey (Endline Impact Evaluation)
For quantitative surveys, both the blocks from each of the four MCHN districts viz. Agra
(blocks-Bitchpuri & Fatehpur Sikri), Allahabad (Jasra & Saidabad), Jhansi (Babina &
Bangara) and Varanasi (blocks Chiraigaon & Harhua) were covered. The quantitative
survey was carried out among the mothers of children currently aged 0-24 months, newly
married couples and Bal Parivar Mitras (BPMs). The MCHN project was withdrawn or got
completed in December 2004 but the fieldwork of quantitative evaluation study was
undertaken after a gap of around 4 to 5 months in the months of April to May 2005.
Tools of Enquiry: Three separate schedules Mother of children aged 0-24 months,
newly married couples and Bal Parivar Mitras (BPMs)- were designed for the study.
Finalization of Tools of enquiry
The survey schedules were finalized in three steps. Draft schedules were developedafter reviewing baseline schedules and other secondary literature. The draft
schedules were discussed in a meeting organized for this purpose where all the
stakeholders shared their views and gave their joint suggestions. During this meeting
the sampling and research methodology was further refined. On the basis of this
meeting, all the schedules were revised and were then field-tested. Necessary
changes from field-testing were incorporated and the schedules were finalized after
suggestions from the Unicef.
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Size for survey among the Mothers: The required sample size for the survey among the
mothers of children aged 0-24 months was calculated based on the standard formula for
one point sample estimation:
The Formula
n = Z2 1-/2 * P * (1- P)
d2
where:
n = required sample size
Z1- = Standard normal value at (1-a) % level of confidence i.e. the Z -
score corresponding to '' level of confidence, i.e., 1.96p = Anticipated Proportion of the indicator
d = Standard Error
To ensure coverage of minimum required sample size for estimating different outcome
indicators of the project the value of P was assumed as 50%. With the above assumption
the required sample size at 95 percent level of confidence with 5 percent of permissible
error in the estimates, was worked out as:
n = 1.962 * 0.5 * 0.5 / 0.052 = 384
Since the analysis was required district wise, the minimum required sample per district was
fixed at 400 households having 0-24 month old child. So in all 4 districts a total of 1600households were selected for the interview.
The total sample of 400 households was equally divided between the two blocks in each
district. Thus, in each block a sample of 200 households were covered for the survey
among mothers of below 2 years children.
In each block a multi-stage sampling procedure was followed to select the respondents. At
the first stage, villages were selected followed by the selection of households and
respondents. The number of households selected per village was fixed at 20. Thus, in all 10
villages in each block were selected following PPS sampling procedure. Prior to the
selection of villages all the villages in a block were arranged in ascending order of their
population size (as per 2001 census). Thus, a total of 1600 households from 80 projects
villages were covered for quantitative study.
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Procedure for Selection of Households: Each selected village was divided into 4
quadrants and from each quadrant, 5 mothers of children currently aged 0-24 months were
selected for the interviews. In each cluster, to select the required number of respondents
the field supervisor moved to the centre of the quadrant and selected a householdrandomly. In the contacted household, it was verified whether the household had a child
who was aged 0-24 months of age. If the child and the mother were present there then the
household was selected and the structured household questionnaire was canvassed. If not,
the investigator moved to the immediate next household and a similar enquiry was made.
This process continued till the required sample size of 5 mothers in each quadrant was
achieved.
Selection of Respondents: In each selected household where the child aged 0-24 months
was identified, the mother of the selected child was contacted for the interviews. In a
selected household, if more than one child was there the mother of the youngest child was
contacted for the interview.
Sample size for survey among newly married women: In each village, 3 newly married
women who got married during last one year were selected for the interview. Thus, against
budgeted total sample of 240 newly married women (60 per district), 239 were contacted
for the interviews. The selection of household for interviews among newly married women
was made following the same procedure followed for selection of the households for
interviews among the mothers of children aged 0-24 months.
Selection of Bal Parivar Mitras (BPMs): In order to get the perspectives of Bal Parivar
Mitra about the programme, their role in the programme and their level of understanding
about the core issues covered under the MCHN project, from each selected village around
1-2 BPMs were randomly selected for the endline survey.
Recruitment Of Field Staff: The concerned professionals of ORG-CSR in association with
the field executives looked after the recruitment of female investigators/ male investigators
and supervisors. The recruitment was made from the existing panel of trained and
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experienced field supervisors and investigators. Candidates having prior survey experience,
especially in conducting large-scale surveys were recruited for the survey. The candidates
having at least a bachelor degree in any discipline were recruited as supervisors and
interviewers. Candidates having social science degree and prior survey experience weregiven preference.
Briefing of Main Survey Teams: All the investigators and supervisors recruited for the
survey were given two-day intensive training by the professionals. The training of
investigators comprised both classrooms as well as field practice. An experienced
Nutritionist was involved in explaining the technical details and nitty-gritty of the
project. Instructions in quantitative data collection, field procedures and a detailed
discussion of each item in the interview schedule were done. Mock calls were also done
in the classroom before taking them to field for trial calls. Only those trainees
performing satisfactorily in the entire training process were retained for final survey.
Data Entry and Analysis: Data entry package namely, Integrated System for Survey
Analysis (ISSA) was used for data entry. A data entry programme with built-in consistency
and range checks was prepared to ensure data cleaning. One programmer monitored the
entire data entry and data cleaning operation. The required tables were generated using
SPSS (version 10.0). The results of the Household survey were compiled in the required
format and compared with the baseline to understand the impact of the project. However,
since the raw data of baseline was not available the statistical test of significance could not
be done to compare the baseline results with the endline results on different indicators.
Total Sample SizeSn Coverage (Area)
Mothers of
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3
BACKGROUND
Appraising the facts related to high incidence of malnutrition among children, MCHN project was
conceptualized to address the problem by adopting a multi-pronged approach involving
community participation and fostering multisectoral collaboration. UNICEF conceptual
framework formed the basis for all the processes project planning, training, implementation and
monitoring.
PLANNING
Planning is the most crucial and deciding factor in the success of every mission. MCHN project
sets an example of better planning. A methodical planning process was adopted and a series of
planning workshops and meetings were organized to develop a plan of action for the project. As
an outcome a detailed plan-of-action outlining the detail implementation strategy, sectors involved
and roles/responsibilities of functionaries at different levels was prepared. MCHN project
proceeded in a methodological manner. Two State Nutrition and Resource Centres (SNRCs) at
Lucknow and Agra and three District Nutrition and Resource Centres (DNRCs) at Allahabad,
Varanasi and Jhansi were established by Government of Uttar Pradesh. The two SNRCs also
functioned as DNRCs.
First, a state-level workshop held at Sarojni Naidu Medical College, SNRC Agra on 23rd
December 1998. Participants included; key officials and representative from district and Medical
College, Health, ICDS of U.P., UNICEF. The workshop focused at recognizing the multisectoral
nature of malnutrition using conceptual framework of malnutrition (Figure 1.1), appreciating
various cause of malnutrition and the trans-generational cycle of growth failure. The workshop
followed up with a series of core group meetings towards formulation of the strategy and
operation plan to address malnutrition in children.
Accomplishing The Processes- An evaluation of the process objectives
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This was followed by district-level, multi-
sectoral orientation and planning workshops of
three days duration, which were organized at
Agra, Varanasi, Allahabad, Jhansi and Lucknowby the departments of Social and Preventive
Medicines (SPM) of the respective Medical
Colleges. These workshops were more
interestingly conducted with full participation of
sectors and community-based exercises. The community based activities focused on the issues to
understand malnutrition problem of children through visits to families for assessment, analysis and
action. Following this exercise various other sectors such as WES, PRI, Horticulture beside ICDS
and Health could understand and appreciate their role in reducing undernutrition. This resulted in
various sectors appreciating the Unicefs conceptual framework of malnutrition and recognizing
their roles in addressing malnutrition. This led to not only a better understanding of sectors but
also resulted in higher level of involvement. These workshops provided an insight into
malnutrition developing a strong conceptual framework and building consensus regarding the
strategy, which lead to formulation of comprehensive plan-of-action of the community based
MCHN Project.
Defining the Objectives
Use of UNICEFs conceptual framework of
malnutrition helped in defining the project
objectives. MCHN project clearly spelled out
both Process Objectives and Impact
Objectives to achieve the pre-defined
Expected Outcomes. Key objectives on which
project envisaged to make an impact were
clearly spelled because it is against clear objectives and measurable outcomes that a projects
impacts as well as success or failure can be monitored and evaluated. Besides, measurable broad
objectives defining the process objectives helps in taking appropriate action and evaluating the
project in terms of various processes that project was expected to undertake. MCHN project
Box 3b: Process objectives avoided
deviations from planned execution
besides Impact objectives, defining the
process objectives not only helps in methodical
implementation but also in measuring the
process/stages of implementation. Dr. S.C.
Maha atra, DNRC Varanasi
Box 3a: Plan-of-action a prerequisite
to effective implementation process
Developing a blueprint for the project is lengthy
but a methodical process. It requires several
iterations and suggestions from all the sectors &
officials involved. Several planning workshops in
MCHN project were undertaken before the
overall design of the project was laid down.
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Evaluation of MCHN Project III- 3
clearly defined all the process objectives to achieve the project objectives, which helped in proper
implementation of the project.
Reaching the families most At Risk of undernutrition
Towards ensuring and reaching families the most at
risk of undernutrition, MCHN project defined the
population segment that need to be reached and
counseled urgently for preventing under nutrition.
These families were referred as Risk families or
Khatare Wale Pariwar and included 4 groups (See
Box 3c). This resulted in reducing the number of families to be reached by Bal Parivar Mitra to
only 40-50-families/1000 population instead of 200 families. The identification of such families by
Bal Parivar Mitra was not difficult and they could be visited and counseled frequently.
Establishing Linkages
The Nodal agency for the project was Directorate General of Family & Welfare (DGFW) at State
level. At district level, ICDS played a major role. Medical Colleges at district level and Unicef
provided technical and financial support to the project. A multifaceted approach at district level
brought together various sectors beside Health and ICDS i.e. PRI and UP Jal Nigam. Involvement
of grass root functionaries ANM, AWW and Gram Panchayat Vikas Adhikari (GPVA) was
considered very effectual, as they are the first source of services at community level.
Observation of processes and discussions with functionaries revealed that in practice the block
level involvement of health and ICDS was high while Jal Nigam remained almost negligible and
WES activities could not be undertaken as enthusiastically as envisaged. Involvement of District
level official was not very useful, as almost in all the MCHN districts, many of the officials who
undertook the orientation, had got transferred. Moreover, due to demise of Director General of
Family Welfare who was initially involved, the ownership of the nodal agency in the Project
declined at the State level. Further, the ANMs also got diverted to unexpected emerging priorities
like polio campaign in year 2000 due to which service response of health services also declined.
Although special effort was made to sensitize and involve Pradhans of Panchayati Raj Institutions
(PRI) yet their participation remained minimal in the Project.
Box 3c: Families at Risk of undernourishment:
Pregnant women
Less than 2 year children (including
lactating mother)
Newly married women (within one year
and without any child)
Severely malnourished children < 6 years
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Identifying nodal person at Project Block level
A total of 907 villages (total
population being 1,331,549) were
covered across 2 blocks in each of
the project district. Necessity of a
link person at each project block
was well thought of during the
planning workshops for smooth
implementation of project. Each DNRC identified Block Trainer-cum-Monitor (BTM) who
worked under the supervision of respective DNRCs and coordinated with ICDS and Healthsectors from block to grass root level. The BTMs were involved in identifying the community-
based volunteers, provide support in training and during project implementation period provide in-
service training, necessary timely support and guidance to undertake their defined roles and closely
monitor their work. Also, BTMs were to coordinate with both grass-root level and block-level
functionaries of various departments ICDS, Health, PRI etc. to ensure the effective delivery of
services at village level. BTMs were also responsible to ensure quarterly monitoring meetings that
were planned and executed with their support.
IMPLEMENTATION
Appropriate selection of an entry point proved to be success factor in project designing and
planning. The baseline survey, when first contact was made with the community, served as an
appropriate entry point to the project implementation process. Community was contacted through
qualitative techniques like PLA and FGD. Cluster mapping, including resource and beneficiary
mapping, at this stage helped in identifying clusters (for project implementation) and also the
BPMs (the grass-root voluntary community worker). The information gathered at this stage alsohelped in developing background/material for the development, orientation and capacity building
of functionaries at various levels.
Box 3e: Supervision & capacity building by BTM
Project appointed an additional staff at block level called
Block-trainer-cum-monitor (BTM) who regularly trained and
kept a close watch on the activities of the community-
mobilisers. BTMs overall supervised the BPMs and were link
between the community and SNRC/DNRC and also
coordinated with other sectors.
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Evaluation of MCHN Project III- 6
Baseline survey
Comprehensive evaluation of the
impact of the project not only involves
comparison with the defined objectives
but also a comparison with the baseline
situation on all the outcomes laid down
at the beginning of the project.
Adequate and methodical collection of
baseline data, in all the MCHN districts,
was done before the launch of MCHN
project i.e. July-December 2000.
Similarly, methodical mid term evaluation was also envisaged and subsequently done.
Meticulously developed and pre tested common format
was used in all the project districts to get the status on
different indicators and to ensure homogenous collection
of information. A sample of 4400 households was
A village is not a homogenous unit. The village
population is divided into socio-cultural clusters
on the basis of religion, caste and creed. The
intra communication in clusters is better than
the inter cluster communication. In each cluster
there are normally 2-3 socially active persons
who are respected and their advice is sought.
These persons can act as influencers at the
cluster level and act as important agents for
behaviour change communication. This is the
underlying concept adopted by the MCHNProject where primarily active women were
identified and trained as key change agents and are known as Bal Parivar Mitras (BPMs).
Schedules used in baseline:-
Village Schedule,
Household Schedule and
Child Schedule.
Newl married women
Box 3f: Baseline and end line survey are must
to systematically measure impact of Project
Baseline survey is a methodical way of assessing the
existing situation. But, information collected through
baseline is helpful in several ways. Firstly, it gives theexisting position of various issues covered in the project.
Secondly, it throws light on strategy that could be
followed while addressing the issues in project. Thirdly, it
becomes an easy starting point. Fourthly, it provides an
opportunity to interact with the community. And lastly, it
helps in evaluating project when it has completed its
lanned course
Figure III.2: Cluster Community Approach
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Evaluation of MCHN Project III- 7
Table 3.1: Profile of BPMs
surveyed in each of the MCHN district. SNRC, Lucknow, acted as the nodal agency that
supervised the baseline survey for each of the project districts. Baseline findings were well
documented by respective DNRCs.
Agent of Change Accessible to Community Bal Parivar Mitra (BPM)
MCHN Project was visualized
as a demonstration project
where the unique feature was a
fairly simple idea an agent of
change always accessible to the
at risk families of
undernutrition - a member of
the community who is ready to
provide voluntary services, a
friend and guide, who is respected, knowledgeable and wise. This agent of change, identified,
trained and nurtured by the project was called Bal-Parivar-Mitra meaning friend of families
with children. Each block had an average of 560-570 BPMs. Thus, over 4500 community
mobilisers were involved in 8 blocks of 4 MCHN districts.
Selection of BPMs was carried out
right from the baseline survey
stage in the project areas. The
investigators were asked to
identify and record vocal persons
with high level of acceptability in
the village. Both community as
well as village level functionaries of different departments especially ANM and AWWs were
involved in the identification of BPMs.
Box 3g: BPM the Change Agent of the community
The community at large commonly knows some active women or
men, who have good knowledge on nitty-gritty of various
traditional practices. These are confident & vocal women or men
who are looked upon with respect and are heard by everyone in
the village. They are approached for expert advice of various
issues, as they are perceived wise and well informed as well as
carrying some basic knowledge on issues. Their good interactions,
knowledge and love for the community have earned them the
wide acceptability.
Male FemaleDistrict
No. ofBPMs
No % No. %
Jhansi 1139 23 2 1116 98
Allahabad 1192 108 8 1284 92
Varanasi 1354 6 1 1348 99
Agra 0831 0 - 831 100
Total 4516 137 3.0 4579 97.0
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Box 3h:
Although methodical, the selection of BPMs was not that easy.
Mr. Davendra Singh, BTM of Bichpuri block in Agra told us in some
villages the authoritative people tried their best to influence thefair selection of the BPMs. A Pradhan attempted to push the
names of the ladies from his family for the BPMs, which were not
in the list of ANM. But, when they were explained about the
objective of MCHN and the exact roles and responsibilities of
BPMs and that it was an unpaid job, they withdrew silently. They
not only helped the BTMs to proceed in their way of selecting the
BPMs but also assisted them wherever required.
This approach helped the
acceptance of the selected
worker by the community and
the existing functionaries. Atsome places FGDs were
directly conducted with the
villagers to identify potential
BPMs, while in others ANMs
and AWWs were asked first to
prepare a list of potential BPMs
in their area in some places and
then FGDs were undertaken by the BTMs with the suggested BPMs. Finally those having positive
attitude on influencing social issues pertaining to children and women and were vocal, dynamic
and respected were selected. Excepting Agra, other three DNRCs selected small proportion of
males as BPMs (Table 3.1). This was an effort to ensure the involvement of male members, also
because the MCHN issues such as intake of additional meal, at least two hours of rest per day by
pregnant women or family planning issues require adequate support from male members.
Box 3i: Social recognition is better motivator than monetary compensation in long run
Community-based workers remain engaged and work till the
duration of project. Once the project is over their involvement
gradually declines in the absence of any motivation. The monetary
compensation for their work also ceases to exist as a motivator for
them. To provide for long lasting involvement of local resource
created in form of trained BPMs the project adopted a different
strategy. Uplifting the social image and recognition of BPMs was
adopted as prime motivators. The BPMs were given name plates
bearing their name and designation. The small ones were tuckedon their sarees while big square tin plates were put on their doors. A
low cost cloth bag bearing name & logo of projects was also given for carrying necessary materials
for fieldwork. To enhance their status, MCHN project designated them as BPMs. Uplifting their image
in their own community attempted their continuance even after the withdrawal of the project.
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The BPMs were not paid any honorarium but were paid fees of Rs. 100 per quarter for completing
the pictorial monitoring formats. There was continuous demand for some fees. Initially some
training honorarium, badges and bags kept this demand low, but as the project progressed BPMs
demanded regular remuneration on a monthly basis. However, the motivation from BTM, AWWand ANM kept their involvement high. Apart from the motivation for gaining social recognition,
mentioned above, this voluntary work was also seen to have a possible pay-off in terms of higher
visibility for Pradhanelection, any govt. or social field jobs, etc. coming up in future.
Training & Capacity Building
Systematic training was planned from
district to village functionary level. A
state level training task force was
formed to look into the training
requirements for the MCHN Project.
Taking into consideration the strategy
and role of the functionaries at
various level three training modules,
titled Mobilising for Change, to
train the trainers, programme managers & functionaries were developed:
District level : Module I Training module for trainers
Block level : Module II Training module for block/sector level programme
managers functionaries
Community level : Module III Training module for community mobilisers (BPMs)
These training modules were developed by an expert agency with technical and financial support of
UNICEF. A core group comprising of representatives from Health & ICDS departments,
SNRC/DNRCs and UNICEF, undertook a series of review and provided inputs in the finalization
of the training module. For the BPMs and prospective workers, module III was developed using a
case study format. The modules were prepared in both Hindi and English. Hindi modules were
developed for usage in the State and English versions were developed for wider dissemination. The
Box 3j: Appropriate capacity building improves
the performance of project functionaries
Capacity building at all levels is important. It is theresponsibility of any large-scale project to seek to build
capacity through experts of the field. And, if the project
fails to do so, quality is jeopardized during the life of the
project, and it will become unsustainable once the external
support (financial and technical) ends. Equally important is
the involvement of technical expertise matching with the
level at which capacity building is targeted. MCHN project
achieved this through a structured and a systematic
trainin /ca acit buildin .
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modules are very illustrative, simple and easy to follow. Inclusion of case studies in Module-III
made it a very interesting and effective methodology. An important aspect of the modules is the
focus on standardized 27 messages relating to different aspects of the maternal childcare and
nutrition. Training was planned for all levels of functionaries. BTMs or representatives of medicalcolleges were expected to be present during various trainings. The training plan details are
presented in Figure III.3.
State Directorate of Family Welfare
DG/Joint Directors MCHState Nodal Officer
State/District Nutrition Resource Centre(SNRCs/DNRCs)
Chief Medical Officer(CMO)
Training of Trainers (3 days)
- Deputy Chief Medical Officers (Dy CMO)- Reps. from SPM department- Medical Officer In charge (MOIC)- Block Trainer cum Monitor (Project BTM)- NGO Representative
Sensitisation Trainingof Pradhans
(2 trainings / block)- day training
Block Level Training (2 days)
- Medical Officer (MO)- Lady Health Visitor (LHV)- Asst. Development Officer (ADO)- Block Development Officer (BDO)- Child Development Project Officer (CDPO)- District Programme Officer (DPO)- Representative of Local NGOs
Sectoral Level Joint * Training (3 daysor 2 days)
- BPMs- Anganwadi worker (AWW)- ANM
Figure III.3 : Plan of Training
* (BTMs & DNRCs played nodal role)
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District as well as Block level functionaries of all the
concerned departments participated in the training
sessions. Almost all the functionaries contacted during
the process of study, expressed their satisfaction with thequality of training given and the Training module design
was well-accepted. A similar reaction was observed from
the ANMs and AWWs who expressed that despite of
being involved in the similar role since years, training was
indeed very informative and clear about their roles and responsibilities. ANM, Manorama Devi
of village Khalisipur, block Chiraigaon in Varanasi said that Group Discussions helped me
understand how to answer to the questions and refutations presented by the community-level functionaries and
beneficiaries. Imparting training to BPMs was most critical component as they were the primary
person reaching the at risk families and the success of project laid. Considering low levels of
literacy among BPMs, a three-day extensive and easy to understand training was imparted. The
training aimed at imparting right knowledge along with sensitizing them on MCHN issues and
their involvement as a BPM. Group discussions using posters, charts and booklet was appreciated
by most of the BPMs in the understanding the issues. BPMs interviewed said that demonstration
method helped them registering various issues specially the right technique of holding the child
during the breastfeeding.
Box 3K:
During the discussion with the Shusheela Pandey, BPM in Allahabad district, showed the training
module, properly kept in her cupboard. On being asked to comment on usefulness of the
training module, she said This is a proof that I undertook the trainingIts very easy to
understand with the help of photos and diagram shown in the bookletI dont readmy son
reads it for meYes many times he read it for me whenever I faced problemsI keep it very
safely
Following completion of training, the community mobilisers were awarded a certificate, badge and
a bag. These items were not given together but at an interval of 3-4 months. This kept the
motivation levels high of the BPMs. Moreover, they not only felt empowered but their social image
got uplifted.
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Box 3L:Clearly Defined Roles: BPMs
Responsible for 50 household
(about 20-25 at risk families
Identifying and updating the
target families
Counseling and motivating target
population
Refer case to ANM/PHC, AWW
Water testing using simple kits
Salt testing using salt testing kits
The BPMs also linked up with the ANMs fixed
routine immunisation (RI) day. In 2004, these
BPMs also participated in the biannual child health
and nutrition activities launched in the State. The
BPMs regularly participated in Pulse Polio drives
and family health awareness camps for
HIV/AIDS that were organized by the Health
Department. They also participated in salt-testing
and water-testing activities.
Box 3N:
Sincere Workingan opinion
BPMls rks cgqr enn feyrh gS (We receive lot of help from BPM)- Maya Pandey (ANM)
oSls rks lc lkFk gh dke djrh gSa ijoSls rks lc lkFk gh dke djrh gSa ijoSls rks lc lkFk gh dke djrh gSa ijoSls rks lc lkFk gh dke djrh gSa ijBPM yksxksa ds lkFk ls lgkjk jgrk gSyksxksa ds lkFk ls lgkjk jgrk gSyksxksa ds lkFk ls lgkjk jgrk gSyksxksa ds lkFk ls lgkjk jgrk gS- (Although we all worktogether, but we get all of support from the BPM)
- Chandra Prabha Devi (AWW)
BPM dks xkao esa fdldks D;k nsuk gS] T+;knk vPNh rjg ls irk jgrk gS- (BPM is better awareregarding what is to be given to whom in village)
- Susheela Devi (ANM)
Box 3M:
Water-testingTo demonstrate the community about
the dirty and unsafe water obtained
from open-well and other unsafe
sources, water testing was also planned
and carried out in the Project. However,
due to inadequate supply of good
condition water-testing kits, this activity
could not be pursued for long.
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Box 3Q:
Participatory monitoring brings success
Participatory monitoring refers to self- monitoring
undertaken by community to assess their development
goals. Taking into account the literacy levels of the
BPMs, MCHN project developed and used a unique
monitoring tool- pictorial monitoring card.
Monitoring of the Project
To ensure smooth and objective
progress a joint multisectoral meeting
was facilitated by the block project
person i.e. BTM on a quarterly basis
with BPMs, AWWs, and ANMs toshare their experiences. However, as far
as Gram Panchayat Viaks Adhikari (GPVA) is concerned they did not often participate.
The quarterly monitoring meeting provided an opportunity to BPMs to share their experiences as
well as problems with others and learn from each other. Specific subject pertaining to the
scheduled fixed monthly theme was also discussed. The BTMs checked the monitoring formats
filled by the BPMs and encouraged them to improve their performance. This provided direct
motivation to those who performed well, and indirectly encouraged other to do well. This most
positive aspect of the project was the use of pictorial monitoring card and quarterly reports and
discussion with multisectoral representations that allowed everyone to get noticed. The pictorial
monitoring card was also used as training and counselling tools by BTMs during their monthly
Box 3P: Achieving the Innovative Convergence
It was absolutely impossible for me to comprehendthe integration of ICDS and Health, at first. Although
both of them worked towards improving the overall
health of mother and child, yet there convergence
appeared a distant goal. But, I am surprised and
delighted that I was wrong. I congratulate Dr. Sheila
Vir from Unicef and everyone involved in the
successful implementation of the MCHN project
emphasizes Prof. S. C. Mahapatra, Prof and Head
Department of Social and Preventive Medicine,
Banaras Hindu University, Varanasi.
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meeting with BPMs. There was provision of Rs. 100/- per quarterly session per BPM, following
submission of monitoring forms.
Similarly, for monitoring at block level a Coordination Committee comprising the MOIC, CDPO,
BDO, PRIs officers, Jal Nigam and Education Department, BTM, representative of DNRC met
once in a quarter and shared the progress of the project. The block meeting was organized with the
help of medical colleges and was held regularly. To review the progress of the project at district
level an Advisory Committee comprising representatives of Health, ICDS, PRIs, Education
Department and Project Coordinator from the DNRC was created. Though, this committee was
supposed to meet at every four months under the chairmanship of Chief Development Officer, it
could not happen as envisaged.
Four monitoring formats were planed but only Format-A was used. This monitoring card was
pictorial and developed using the life- cycle- approach, depicting messages through coloured
instructions. The BPMs easily recorded the information and was used as monitoring- cum-
counseling format. It was divided in 6 sections (Figure III.4).
Box 3R: Monitoring Formats
Format A: For BPMs, filled every month at village level used in the Project
Format B: Compilation of Format A on quarterly basis at sector level
Format C: Compilation of data at the block level once a quarter
Format D: Compilation of data at the district level once every quarter
Planned butnot used
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Section 1: Information of the clusterand messages for newly weds
Section2:Pregnant women &key messages to be given to her
Section3:Care of newborn
Section 4: Care of children inthe 6- 24 months a e rou
Section 6: Key messages (27)communication uniformly
Section 5: Messages for households-water, sanitation, iodized salt
Figure III.4
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Box 3T: BPMthe best byproduct of MCHN
Dr. Amita Jain, Deputy Director (IEC), ICDS III, UP feels
BPM is best byproduct of the MCHN project. They
underwent extensive orientation and training equipping
them with the knowledge and skills at the local level. They
are sensitized to the extent that they have been working
without any remuneration. We should explore the possibility
of internalizing this concept in the ICDS system, U.P..
Box 3U: Sociological Assessment Package (SAP) Study
DNRC, Varanasi, took initiative to computerize the system of tracking BPMs
progress. Under the guidance of Prof. S. C. Mahapatra, a Sociological
Assessment Package (SAP) was developed to assess BPMs performance
both in quantitative and qualitative terms. It was well tested and results from
it were consistent with the actual findings.
Competence of BPMsBPMs understanding of monitoring card and their overall knowledge on record keeping was
evaluated by the field researchers interviewing them. The BPMs were asked to explain and
demonstrate the use of pictorial monitoring card. On the basis of their responses to different
parameters their understanding of monitoring card was given scores. Two-third of the BPMs
scored well i.e. either excellent or good.
BPM a valuable human resource created locally
Having heard the community and
analysed the sources of positive
change on various aspects of
maternal-child care, covered in
MCHN project, the contribution ofBPM stand out, significantly.
Recommended