MCHN Report Final

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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Community Based MCHN Project An Evaluation IV

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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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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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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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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Evaluation of MCHN Project III- 1

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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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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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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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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Evaluation of MCHN Project III-17

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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Evaluation of MCHN Project III-18

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.

Documents

MCHN Report Final