Transforming Lives:Sustaining the Improvement of Family Health and Sanitation in Marginalized Communities

Improvement of maternal and child

mortality and morbidity outcomes, in a

high-burden state like Bihar, are critical for

India and its ability to achieve its goals of

contributing to Millennium Development

Goals (MDG) 4 and 5. To this end, the Bill and

Melinda Gates Foundation (BMGF)

supported the Ananya initiative and

partnered with the Government of Bihar

(GOB) to accelerate improvements in a

broad range of priority health outcomes –

emphasizing, maternal, neonatal and child

health (MNCH); nutrition; key infectious

diseases; and sanitation and hygiene. Within

Ananya, Project Concern International (PCI)

– in partnership with PATH and the

Foundation for Research in Health Systems

(FRHS) – is implementing a community

mobilization and social accountability grant

(Parivartan). Parivartan provides a platform

for empowering 8 high innovation districts

to engage in processes that catalyze support

networks and enable a shift in behavior and

social norms, which contribute to improved

and sustainable health and sanitation

outcomes in Bihar.

Promoting Behavior Change on

Key Health and Sanitation

Parivartan: Bihar Community Mobilization Project

Behaviors:

Working with Most Marginalized

C o m m u n i t i e s f o r S o c i a l

Accountability and Equity:

Parivartan mobilizes,

organizes, and builds community groups in

Biharwith a focus on: a) strengthening their

ability to shape social norms, promoting

behavior change, and driving demand for

services critical to maternal and child health,

sanitation and hygiene; b) strengthening

accountability and monitoring mechanisms

through community structures for health,

sanitation, and welfare services and

schemes to advance equity and service

access and; c) establishing sustainable

institutional structures and frameworks to

support the state-wide scale up of

community mobilization interventions

focused on maternal, neonatal, child health

and sanitation (MNCHS).

P a r i v a r t a n w o r k s w i t h t h e m o s t

marginalized communities to address

equity issues related to caste, gender, and

other social variables, which can be

determinants of MNCHS outcomes.

Providing Linkages for Sustainability and

S c a l e : F u r t h e r m o r e , P a r i v a r t a n i s

collaborating with the Bihar Rural

Livelihood Project (Jeevika)-to create a

sustainable scale up across the state, and

provides support to 8,000+ matured Jeevika

community groups (see Page 5, on how

Parivartan has collaborated with Jeevika)

Issue October 2013

Health and Nutrition, My Right..A story on how women in a village in

Samastipur submitted an application to

demand the opening of an Anganwadi

Center in their area…..Page 7

Parivartan is currently working in 64

blocks from within 8 high innovation

d i s t r i c t s i n B i h a r, n a m e l y : P a t n a ,

Begusarai, Samastipur, East Champaran,

West Champaran, Gopalgunj, Khagaria,

and Saharsha (See map on the left-hand

side). These blocks were selected using a

vulnerability index, calculated based on

three indicators: percent of Scheduled

Castes and Tribes (SC/ST) population in a

block, literacy rates among women, and

proneness to flooding. Of the 64 blocks, 43

are designated as B-50 (bottom-50) and 21

as T-50 (top-50). B-50 blocks are those

where the percentage of the SC/ST

population is high, female literacy rates are

low, and the areas are more disaster-prone.

In these blocks, Parivartan created 18,000

community groups in more than 2,250

villages. Each community group typically

contains 15-18 women of reproductive age

group. Each village has approximately 5-6

community groups

Issue October 2013

OUTREACH

Parivartan reaches out to

women in

reproductive age group (WRA)

through community

groups in approx

villages. These groups are supported

by Sahelis.

280,000

18,000

2,250

2,600 Mobilizing Most Marginalized

According to the 2011 Census, Bihar (the 3rd

most populous state in India with a

population of 103.8 million) has the highest

decadal population growth rate at 25. Bihar

has 23 castes under the SC category,

constituting 16 percent of the total

population. Among these, Chamar and

Dusadh constitute about 60 percent of the

SC population. Four other castes: Musahar,

Pasi, Dhobi and Bhuiya constitute an

additional 30 percent combined. The

remaining 17 castes constitute about 8

percent of the SC population. Paswan is one

of those smaller castes. They are now

referred to as the "creamy layer" meaning

that they are economically better off

(relative to the other castes) because of the

political patronage they have received. As a

result, there was a political move to create a

group called Mahadalit (In Bihar, the term

‘Dalit’ is used to denote all SC) excluding

Paswans from the Dalit i.e. SC category. The

Mahadalit Commission was formed to serve

the needs of the Mahadalits (excluding the

Paswans). The Parivartan project, however,

remains focused on all SC (Dalit) including

Paswans – who form a very small percentage

of the SC population – and the Pasmunda

Muslims

Patna

Samastipur

Begusarai

Khagaria

Saharsa

West Champaran

East Champaran

Gopalganj

2

Issue October 2013

Sahelis Performance Assessment Criteria

At the grassroots level, Sahelis (village

volunteers) act as catalysts of change and

play a critical role as conduits of information

for the target women. These Sahelis were

selected from among the women in the

target communities with a basic level of

education, leadership and communication

skills, and a willingness to work on the

project. These Sahelis are being trained (on

an ongoing basis) on communication and

leadership skills and key maternal and child

health and sanitation related issues. Sahelis

conduct community discussions on 12 key

maternal and child health and sanitation

related behaviors within community groups.

Sahelis uses various tools such as picture

cards, stories, games etc. to initiate and

moderate discussion in the community group.

A team of 8 District Resource Persons

(DRPs) and 140 Master Trainers (MTs) were

recruited. These DRPs and MTs not only

conduct district trainings, they also visit field

sites to observe Sahelis conducting

community group meetings. MTs use a

standardized checklist to assess the skills

and performance of Sahelis. This checklist

captures data on the quality of the trainings

by Sahelis. The monitoring tools assess the

Sahel is ’ communication ski l ls , the

engagement of training participants, the

Sahelis’ handling of training materials, and

participant learning as evaluated by pre- and

post-training test scores.

Based on analysis of the scores, Sahelis are

categorized into three categories as per

their performance level.

Preparation/operation

Preparation and assessment of target

audience

Developing learning tools

Testing learning tools

Execution of learning tools/roll out

Confidence

Perceived confidence to deliver the

training at the field - before and after.

Learning

Retention of the information/

knowledge, increase in knowledge

from before to after the learning

experience:

Skill and Performance

Communication skills

Use of Information material

Message delivery

Involving women in discussions

Response to quires

Feedback from the trainee

Women attention retention

Challenges and opportunities

Experiences of difficult situations and

the role of training in overcoming

these situations

}

}

}

}

}

}

}

}

}

}

}

}

}

}

A team of 140 Master Trainers train

Sahelis on ongoing basis, and provide

onsite hand-holding and technical

assistance

Sahelis Performance and Skill Monitoring System

Structured interview Obervation

One time information During training On the job

Quantitative data is collected in pre coded structured tool on monthly basis

1 2 3

} Basic information

of trainees

} Identification

} Social profile

} Perception

} Confidence

} Knowledge and

learning

} Preparation

} Skills

} Application of

knowledge

Master Trainers

Sahelis

GroupMembers

DistrictResourcepersons

3

Issue October 2013

ParivartanCompendiumThe Parivartan Compendium consists of

thirteen training modules pertaining to

antenatal care, birth preparedness,

postpartum and newborn care, exclusive

breastfeeding, complementary feeding,

routine immunization, postpartum family

planning, sanitation, village entry, group

formation, equity, social advocacy, and

a cc o u n t a b i l i t y. T h e m o d u l e s w e r e

developed by the Parivartan core team,

which included members from PATH and

PCI. The core team worked on the content,

language, methodology for disseminating

messages, and the collective action (to be

undertaken by the group members to

ensure behavior change and facilitate

service access). The team did a literature

review of the technical content, tested the

appropriateness of the messages in the

context of Parivartan groups, developed

messages with other Ananya grantees (such

as CARE and BBC Media Action), and

finalized the modules.

The modules are used to train community

group members through community

cadres. It is expected that after receiving

training, community members (particularly

pregnant and lactating women) will practice

appropriate behavior – related to maternal

and child health, nutrition, and sanitation –

and access health services from nearby

facility and service platforms. The Equity

and accountability modules are designed to

generate community demand and make

service providers and institutions, such as

Integrated Child Development Scheme

(ICDS) and health facilities, accountable.

The village entry and group formation

modules have been helpful with establishing

rapport and in mobilizing communities to

form groups in about 2300 villages in the 64

blocks of the eight Parivartan intervention

districts. The group formation modules are

introduced to form groups in line with the

Jeevika concept. The group formation

modules have been developed in line with

Jeevika modules so that Parivartan groups can

easily be transitioned into the Jeevika fold.

Snapshot of Parivartan Modules

4

Issue October 2013

Working Collaboratively withJeevikaJoint Planning Exercise:

Joint Capacity Building Activities:

Transitional

process of the Parivartan Groups into the

Jeevika project has been initiated. For this,

the Parivartan and Jeevika teams had a

joint planning exercise that included the

mapping of the groups and clarifying the

roles and responsibilities of Parivartan and

Jeevika staff at the state, district, and block

level.

Parivartan and Jeevika have been jointly

implementing capacity building initiatives.

As per this, Parivartan trained 120 of

Jeevika’s Sahelis while Jeevika supported

the training of the Parivartan’s Block and

Community Coordinators. A Total of 873

coordinators were trained on group

formation and PanchSutras. Specific input

was given on maintaining the books of

accounts and record keeping.

Parivartan has signed a Memorandum of

Cooperation (MOC) with Bihar Rural 1Livelihoods Promotion Society (BRLPS) ,

for health and sanitation integration with

BRLPS’ project Jeevika (Bihar Rural

Livelihoods Project). Jeevika aims at

enhancing the social and economic

empowerment of the rural poor in Bihar by

creating self-managed community

microfinance institutions or self-help

groups (SHGs) at the village level and

enhancing income through sustainable

livelihoods. Parivartan will help Jeevika to

advance a health, nutrition, water and

sanitation agenda within their community

institutions.

Parivartan is focusing on the process

wherein all the Parivartan promoted

c o m m u n i t y g r o u p s w i l l b e c o m e

incorporated into the Jeevika framework

with the retention of the ongoing Health

and Sanitation Agenda. The transition

process, initiated in the month of August

2013, would aim to cover all 18,000

community groups by June 2014.

H o w e v e r, b e f o r e g r o u p s c a n b e

incorporated within Jeevika, Parivartan

has to work towards nurturing groups to

practice f ive essential elements,

(Panchsutras) as prescribed by Jeevika,

namely: (1) weekly meetings, (2) weekly

savings, (3) inter loaning, (4) timely

repayment of loans, and (5) book-keeping

at the group level; in addition to educating

group members on health, nutrition and

sanitation behaviors

Supporting Bookkeeping

Sharing Modules:

Community Resource Person (CRP) drive

- Jeevika has

committed to support Parivartan promoted

groups to equip them with books for record

keeping and accounting. This will help the

community to streamline financial records

and facilitate in opening bank accounts.

Jeevika has supplied SHG

modules to Parivartan, which emphasize the

formation of SHGs, the importance of

Panchsutras, and institutional building.

-

Jeevika is organizing a CRP drive, within

Parivartan areas, to strengthen institutional

building among Parivartan groups and

provide inputs on the importance of financial

services available for the community groups.

The Community Coordinators and Sahelis

will be working very closely with the

Community Mobilizers and CRPs.

5

Issue October 2013

Monitoring, Learning and Evaluation

Baseline Survey Results:

MIS Outcome Indicators Tracking:

K n o w l e d g e M a n a g e m e n t

Framework:

Linking Data to Google Map:

Parivartan’s

baseline survey is complete and key results

and recommendations for each of the

twelve family health and sanitation

b e h a v i o r s h a v e b e e n p r e s e n t e d .

Furthermore, the baseline study also

recommended actions for strengthening

community mobilization, which is the key

mechanism through which Parivartan seeks

to bring about an improvement in maternal

and child health and sanitation behaviors

among the most marginalized women in

rural Bihar. The data has been disaggregated

a t t h e d i s t r i c t l e v e l t o d e v e l o p

recommendations for implementation

Parivartan is currently working on finalizing

a mechanism to track 30 outcome indicators

on a quarterly basis. Of these, 12 would get

collected through project MIS. The GSAP

registers have been modified at the

grassroots level, staff have been trained on

data collection, and reporting on the 12

outcome indicators will begin as of Oct 2013.

Furthermore, a system is being finalized for

the collection of 18 additional outcome

indicators

Parivartan drafted a

knowledge management framework, which

outlines the strategy for building a system of

knowledge transfers for the Project. The

goals are to synthesize knowledge by

connecting various stakeholders with a

focus on the community and to improve

organizational learning by assessing impact.

In

August, Google volunteers helped the

Parivartan team to link the Excel based

Parivartan database with google maps.

Web Based

Parivartan MIS

PortalParivartan created a web based portal,

www.pciparivartan.org, to enable direct

data entry at the district level by

implementing NGOs. The data is then

collated for project level analysis.

In addition, the web portal contains

information on all group members

involved in the project, including socio-

economic and personal details such as

age.

The s i te a ls o con tain s database

information on Sahelis and the grassroots

cadre of Parivartan

Group Attendance Registers

GSAP- Group Service Access

Platform

Data Validation Process

Each group maintains basic SHG registers such

as meeting and attendance registers. Now, as

per the transition plan, saving registers are

being introduced at the group level.

To monitor and report on outcome

indicators, information is collected on group

members using the12 key maternal and

child health indicators at the group level and

reported through a web based Management

Information System (MIS) portal.

Parivartan’s MIS team undertakes a

validation exercise in close coordination

with the program team to validate the MIS

data and report on a monthly basis

Scan the following barcode to go to www.pciparivartan.org

MIS REGISTERS AT GROUP LEVEL

6

Issue October 2013

Collaboration with Bihar Mahadalit Vikas Mission

Since Parivartan works closely with the most

marginalized communities, it is working

closely with the Bihar Mahadalit Vikas

Mission to link the Mahadalit communities

with basic services and empower them

socially, economically, and culturally to

ensure their participation in developing a

strong society. Parivartan established

partnerships with the Bihar Mahadalit Vikas

Mission and coordinated to link the

community groups with the schemes

promoted by the Mission. This will be a

valuable addition to the community groups

especially from a health and sanitation

related input. From the long menu of the

schemes Parivartan is initially focusing on:

1. Mahatma Gandhi National Rural

Employment Guarantee Act (MGNREGA)

cards & Smart Cards

2. Mahadalit Toilet – Construction Scheme

3. Mahadalit Anganwadi

4. Mukhyamantri Nari Jyothi Program

5. Mobile Public distribution system

6. Construction of Community Hall/ Work

Shade

Intensive efforts are being made to link the

community groups with the above-

mentioned schemes. The response from

the departments is very encouraging. The

Principal Secretary has issued letters to all

districts for supporting the Parivartan

team. The Joint Response Plan is being

developed at the block level after arranging

interface meetings with the community

cadres of Parivartan and the Mahadalit

Vikas Mission.

Strengthening Village Health, Nutrition and Sanitation CommitteesPCI has initiated efforts to analyze the

functional status of Village Health, Nutrition

and Sanitation Committees (VHSNCs) and

work to help them effectively address the

health needs in the village level health plan

developed by the VHSNC at the Revenue

village level.

With the above mentioned objective, PCI

has entered into a service agreement with

Praxis to work towards strengthening the

functionalities of VHSNCs among the 8

priority districts in Bihar, covered under the

“Ananya Program,” as a strategy towards

effective community-led action for better

health outcomes.

Health and Nutrition Services,

my rightMala Devi, member of the Radha

Community Group, Samastipur district,

shared her tragic story: “Despite already

having 4 children, I became pregnant once

again and delivered a low birth weight baby

having only 2 kg of weight. The baby died

within one month because of poor

nourishment as I was very weak and unable

to produce enough milk and there was no

AWC (Aanganwadi Centre) in my ward of

residence to get nutrition supplementation.

Since I come from a Dalit community,

neither the ASHA [Accredited Social Health

Activist], nor the Aangandwadi Worker

provided me with any services nor

counseled me for family planning and it was

quite difficult to benefit from AWC facilities

about 1 km away from my residence.

After associating with the Radha group,

under the Parivartan program, I came to

know that we are entitled to seek help

from AWC facilities. I feel that I wouldn’t

have experienced the tragedy if I had had

proper access to the AWC. Hence, we the

members of the Radha group have

approached the Child Development and

Protection Officer (CDPO) to request for

the opening of an AWC in our ward with a

population of about 1100 people (consisting

mainly of Dalit/Mahadalit communities).

We are firmly determined and will

continuously work to get this center opened in

our ward so that my story won’t be repeated

with any of our community members.”

7

Issue October 2013

ParivartanPartners

P C I i s t h e L e a d

P a r t n e r a n d

r e s p o n s i b l e f o r

overall program implementation and

compliance with Bill and Melinda Gates

Foundation (BMGF) grant requirements. PCI

also serves as a clearinghouse and

synthesizer of lessons learned and

promising practices. PCI leads the

c o m m u n i t y - b a s e d a c t i o n b e i n g

implemented by 8 local NGOs, focusing on

district-wide interventions to foster and

strengthen community groups and

community-based actions (CBA).

PATH serves as the

Technical Advisory

Partner, leading the

efforts related to: learning, the transfer of

learning for sustainability and scale up (KAT

stream), and the collaboration with MLE

partners to document and disseminate

knowledge and learning. PATH advises and

guides the CBA stream on proven models

and interventions, such as Sure Start,

assimilating knowledge and learning and

transferring lessons and best practices to

stakeholders to achieve sustained impact

across Bihar.

FRHS functions as

the Implementing

Partner for Research,

and focuses on implementing operational

research pilots at select villages for

strengthening community groups

For Further Information, please contact:

Parivartan Project Office

Dr Vikas Aggarwal

Chief of Party, Parivartan

Nirmal House 2 & 3rd Floors,

Nalanda Nagar,I.E.Road, Kurji,

Patna, Bihar – 800010

Tel:+91-612-2270211/12

Fax:+91-612-2270207

vikas@pciindia.org

PCI International Office

Janine Schooley

Senior Vice President

5151 Murphy Canyon Road,

Suite 320

San Diego, CA 92123

Office: 858-279-9690, ext 311

jschooley@pciglobal.org

PCI India Country Office

Edward Scholl

Country Director

C32, Panchsheel Enclave,

New Delhi–110017

Tel: +91-11-46058888

Fax:+91-11-26187545

escholl@pciindia.org

Parivartan Information Booklet © PCI

Main Contributors: Vikas Aggarwal, Dr. Nirmala Murthy,

Rajshree Das, Sanjeev Bhanja, Brijesh Rao and V J Rao.

Editors: Ed Scholl and Jennifer Keller

Photo Credits: Ed Scholl, Janine Schooley, Vikas Aggarwal,

Rajshree Das and Brijesh Rao

Design and Concept: Vikas Aggarwal and Ajith Kumar

8