Using the HSC Platform for effective convergence of ICDS and Health programs
IFHI/TSU, CARE India, Bihar
30 November 2014
The Health sub-centre as an Effective Platform for Coordinated Capacity Building and Supportive Supervision of Frontline Workers
Sridhar Srikantiah, Sunil Babu
Outline
Background: Need for meaningful convergence1
The Intervention: Utilizing HSC as a platform for review, learning, planning2
What it took to implement the intervention3
Key findings: Processes and Outcomes4
Implications5
Background: Need for meaningful convergence
ICDS, NHM in Maternal-Child Health and Nutrition: identical goals, overlapping
and complementary mandates
Unsatisfactory progress on key service coverage and behavior change indicators
over decades: systemic limitations, especially planning and supervision
AWW, ASHA, ANM: invaluable resource, inadequately optimized
Nutrition interventions need persistent efforts, and tend to fall through cracks
Previous experiments with convergence for improving outreach services were
encouraging
Ananya/CARE/BMGF mandate: help GoB programs accelerate improvements in
health/nutrition outcomes at population level
1
Health Subcenter: an unexplored platform
HSC: smallest population unit delivering health services; it is key to getting population level
results - reaching every mother and child. Typically covers
10000-12000 population
10-12 ASHA
10-12 AWW
1-2 ANM
per HSC – together, an ideal sized group for meaningful planning, learning, contextualizing
and monitoring
Earlier experience with the ICDS sector as a platform for convergence had some success, HSC
is a smaller platform
Challenge: How do we organize this group, at scale, to deliver results?
2
The Bihar Health Subcenter Model: 2012-2014
West Champaran
East Champaran
Gopalganj
Patna
Samastipur
Begusarai
Saharsa
Khagaria
Period May ’12 to Jan ‘14
Coverage
8 districts
28m population
2,300 sub-centres
40,000 ASHA + AWW
4,200 ANM
1,000 LS
Scaled up to entire state starting 2014
2
Main content areas
Service coverage improvement
Behaviour change through IPC
Basic processes to maximize reach
Defining ASHA, AWW
coverage areas, mapping,
enumeration
Name-based tracking
systems (Service registers,
Home Visits Planner)
Immunization, ANC, family
planning, JSY (linkage with
facilities)
Maternal and newborn
care, IYCF, family planning
Use of BCC tools
(designed by BBC Media
Action - Mobile Kunji,
Mobile Academy)
2
• Intervention focus: Direct interventions at the family level• Unit of implementation: Block (Block PHC, ICDS Project)
Main Intervention Processes
Structured monthly HSC meetings, designed for Incremental Learning and supportive supervision
Review: what did we do after the last meeting? (use of field observations, data)
Learning: new topics (What, Why, How; 2 topics each month - optional)
Planning: what do we do next month? (additional activities, related to new topic)
1
Structured monthly ANM meetings
2-4 hour sessions, during weekly ANM meetings at block
Program review, use of data, distribution of materials and ToT for ANM
2
Supervisory follow up in between meetings
By ANM during VHND, by LS/ICDS during village visits
Use of tools and checklists, generation of data
3
Additional project
resources
• Co-facilitator for subcenter meetings
(2/block in 8 districts until Jan 2014)
• Block Coordinator for facilitation of
implementation (1/block)
Covering all key RMNCHN operational
areas incrementally takes about 18-24
months (includes 8-10 HSC meetings per
year, includes breaks for revision)
2
What it took to implement the intervention
The project recognized
• Poor coverage of outreach services and family
level behaviors in RMNCHN, with exceptions
(e.g. immunization, institutional delivery)
• Potential of HSC as a platform to organize
outreach RMNCHN services of health and ICDS
District and state level leadership of the two
departments recognized need and potential, and
agreed to implement at 8 district level with
Ananya/CARE support; issued joint directives
Elaborate microplanning at block levels to schedule
HSC meetings
Elaborate program monitoring to gather evidence of
coverage and outcomes
Additional human resource in initial districts;
minimized in scale up
Small fund for running each HSC meeting
GoB requested scale up across state, was included in
2013 NRHM PIP, approved by GoI (Rs 300 per HSC
meeting for incidental expenses)
Quick assessments / pilots confirmed feasibility,
acceptability
.. Activities in 2011 .. Activities in 2012
3
Key Process Findings
Feasibility, acceptability high
> 90% of planned HSC meetings took place
AWW, ASHA attendance consistently ~ 70 %, AWW attendance better than ASHA
1
Learning opportunity is a key driver for ASHA, AWW, ANM participation2
ASHA, AWW manage overlapping mandates easily: no major conflicts3
Consistent focus on universal coverage and IPC drove performance: existing programs can be effective4
Learning and doing take time: need to balance campaign and program approaches5
Supervisory follow up remains weakest link: a matter of program priority and strategy6
4
Key Outcomes in Monitoring Data (1/4)
14
42 4433
59
71
42
69
82
0
20
40
60
80
100
R3 R4 R5
Introduction to semi-solid, solid foods
6 month % 7 month % 8 month %
8
3237
30
5769
0
20
40
60
80
100
R3 R4 R5
Minimum Dietary Diversity
6-8 % 9-11 %
4
8
2935
29
5462
0
20
40
60
80
100
R3 R4 R5
Minimum Acceptable Diet
6-8 % 9-11 %
Key Outcomes in Monitoring Data (2/4)
4
27 7 10
17
0
20
40
60
80
100
R1 R2 R3 R4 R5
Children receiving Animal Foods
1220 23
4653
3344
54
7281
0
20
40
60
80
100
R1 R2 R3 R4 R5
Children receiving pulses
6-8 % 9-11 %
4 7 917
25
9 1319
2132
0
20
40
60
80
100
R1 R2 R3 R4 R5
Hand washing with soap – reported practice
6-8 % 9-11 %
Key Outcomes in Monitoring Data (3/4)
4
1 4 6 3 6 74 9 11 9 11 13
0
20
40
60
80
100
6 months % 7 months % 8 months % 9 months % 10 months % 11 months %
Children consuming recommended amounts
R4 R5
57
71 74
5360 5958
65 6858 60 61
0
20
40
60
80
100
6 months % 7 months % 8 months % 9 months % 10 months % 11 months %
Children consuming at least half the recommended amounts
R4 R5
Key Outcomes in Monitoring Data (4/4)
73
59
50
60
38
22
13
21
28
0
10
20
30
40
50
60
70
80
Fed solid or semi-solid food*** CF initiated at 6mo*** Fed from separate bowl yesterday***
Ad
just
ed
Per
cen
tage
Ad
op
tin
g G
ive
n B
ehav
ior
FLW visited with relevant advice FLW did not visit with relevant advice Adjusted difference
Note: ***= adjusted difference significant at the 1 percent level. Regression-adjusted estimates account for rural location, SC/ST status, religion, education, age, parity, SES quartile, and husband’s education.
FLW efforts correlate well with outcomes:Advice from FLW with corresponding practice
4
(children 6-11months)
Conclusions and Implications: From Despair to Hope
HSC is a useful subunit platform for systematic program review, learning,
planning related to outreach interventions common to Health, ICDS
The incremental learning approach has potential as core process for HSC or
other platforms:
• agnostic to content
• enables perpetual improvement
• integrates learning with implementation: brings together practical
learning, supportive supervision, data use, convergence at
subcenter/block/district levels
High potential for implementation and tracking of multi-sectoral
approaches for improving nutrition
5
Acknowledgements
• State and District leadership of Health and ICDS departments,
Government of Bihar, for being open to change and to evidence
• ASHA, AWW, ANM of Bihar, for their passion for learning
• Ananya partners and field teams, for the lessons we are learning