Health and nutrition Health and nutrition interventions – Mainstreaming interventions – Mainstreaming

HIV/AIDS preventionHIV/AIDS prevention

Lakshmi Durga ChavaLakshmi Durga ChavaState Project Manager (Health & Nutrition)State Project Manager (Health & Nutrition)

Society for Elimination of Rural Poverty Society for Elimination of Rural Poverty 14.09.0914.09.09

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Outline of the presentationOutline of the presentation

• Overview of SERPOverview of SERP• Health and nutrition: key processesHealth and nutrition: key processes• Mainstreaming HIV/AIDS preventionMainstreaming HIV/AIDS prevention• Impact assessment resultsImpact assessment results• Roll out plan Roll out plan • ConclusionConclusion

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Society for Elimination of Society for Elimination of Rural Poverty (SERP)Rural Poverty (SERP)

Sensitive support organization Sensitive support organization forfor the the poorpoor

Autonomous society set up by Government Autonomous society set up by Government in 2000 in 2000

State wide mandate:State wide mandate:

To induce social mobilizationTo induce social mobilization

To provide facilitation support to institutions of To provide facilitation support to institutions of poor poor

To sensitize all line departments to be inclusive To sensitize all line departments to be inclusive of the needs of the poorof the needs of the poor

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SERSERPP A.P A.P –– poverty eradication through poverty eradication through

empowerment of rural poor women empowerment of rural poor women ((Indira Kranthi Patham - IKP)Indira Kranthi Patham - IKP) Focus: comprehensive poverty Focus: comprehensive poverty

eradication - economic and social eradication - economic and social building self sustaining institutions of building self sustaining institutions of

poorpoor Rs.2100 crores Project - financed by Rs.2100 crores Project - financed by

State Government, World Bank and State Government, World Bank and communities to cover all rural poor in communities to cover all rural poor in the state (over 100 lakh families, special the state (over 100 lakh families, special focus on 26.0 lakh ultra poor) focus on 26.0 lakh ultra poor)

builds on the decade long, statewide builds on the decade long, statewide rural womenrural women’’s self-help movement in A.Ps self-help movement in A.P

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Mandal Samakhyas and V.Os plan and implement the variousMandal Samakhyas and V.Os plan and implement the various

project componentsproject components

Each Mandal is divided into three Clusters of 10-12 Each Mandal is divided into three Clusters of 10-12 habitations.habitations.

A development professional, called Community Coordinator A development professional, called Community Coordinator (CC) is placed in each Cluster. S/he stays in her cluster.(CC) is placed in each Cluster. S/he stays in her cluster.

SERP selects and trains them. After completion of training, SERP selects and trains them. After completion of training, they are contracted by the they are contracted by the MS and are accountable to MS. MS and are accountable to MS.

M.S responsible for social mobilisation, institution building M.S responsible for social mobilisation, institution building and funding the microplans of S.H.Gs/V.Os from C.I.F and funding the microplans of S.H.Gs/V.Os from C.I.F

Micro credit plans are evolved by the S.H.Gs in each village. Micro credit plans are evolved by the S.H.Gs in each village. These plans are fundedThese plans are funded by their own savings, CIF fund and by their own savings, CIF fund and Bank Linkage.Bank Linkage.

V.Os responsible for appraising the microplans and V.Os responsible for appraising the microplans and recommending them to M.S for financing from C.I.F recommending them to M.S for financing from C.I.F

V.Os appraise microplans and also finance them from the V.Os appraise microplans and also finance them from the recycled C.I.F recycled C.I.F

C.B.Os implement the projectA.P Federation Model

SHGs

•Thrift and credit activities

•Monitoring group performance

•Micro Credit Planning•Household inv plans

• E.C -2 from each S.H.G, 5 Office bearers

•Strengthening of SHGs

•Arrange line of credit to the SHGs

•Social action

•Village development

•Marketing and food security

•Support activists – 3 -5

• E.C -2 from each V.O, 5 Office bearers

•Support to VOs

•Secure linkage with Govt. Depts.

fin institutions, markets

•Auditing of the groups

•Micro Finance functions

10 - 15

SHGs SHGs SHGsSHGs SHGs

V.O 150

- 200

MMS

4000 6000 -

Z S200,000400,000

Village Organization

Mandal Samakhya

Zilla Samakhya

SELF HELP GROUPS

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SHG networkSHG network

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IKP InterventionsIKP Interventions1.1. Targeting – community based targeting.Targeting – community based targeting.2.2. Focus on the poorest of the poor and vulnerable: women, disabled Focus on the poorest of the poor and vulnerable: women, disabled 3.3. Power of scale – bringing all the poor in the state into social Power of scale – bringing all the poor in the state into social

networks networks 4.4. Scaling up through community resource personsScaling up through community resource persons5.5. Institutional design – SHG – V.O – M.S – Z.SInstitutional design – SHG – V.O – M.S – Z.S6.6. Large scale mobilization of bank finances for poor Large scale mobilization of bank finances for poor 7.7. Large scale livelihoods promotionLarge scale livelihoods promotion8.8. Community managed food securityCommunity managed food security9.9. Social issues as an agenda for collective actionSocial issues as an agenda for collective action10.10. Social risk managementSocial risk management11.11. Community managed health interventionsCommunity managed health interventions12.12. Convergence with all line departments Convergence with all line departments

S.E.R.P’s dynamic role – changes in tune with the changes in the S.E.R.P’s dynamic role – changes in tune with the changes in the demands of the C.B.Os demands of the C.B.Os

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IKP health model: Core IKP health model: Core elementselements

Reducing exclusion and social Reducing exclusion and social disparities in healthdisparities in health

organizing health services around organizing health services around people's needs and expectationspeople's needs and expectations

Integrating health into all sectorsIntegrating health into all sectors Pursuing collaborative models of Pursuing collaborative models of

policy dialoguepolicy dialogue Increasing stakeholder participationIncreasing stakeholder participation

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Aims to:Aims to: Improve partnerships between health Improve partnerships between health

facilities and the communities. facilities and the communities. Increase appropriate and accessible health Increase appropriate and accessible health

care and information through training of care and information through training of community health workers. community health workers.

Promote key family practices critical for Promote key family practices critical for child health and nutrition by training and child health and nutrition by training and supporting peer support groups and supporting peer support groups and conducting outreach education campaigns conducting outreach education campaigns training community resource persons training community resource persons

Involve other community institutions and Involve other community institutions and champions to engage in health education champions to engage in health education and planning.and planning.

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Convergence Framework for Improved Convergence Framework for Improved Access to ServicesAccess to Services

Work in collaboration with the existing line departments responsible for enhancement in QOL of the poorest

Look at areas where there are gaps and there is a mismatch between the design of service delivery and the incentives linked to those services

Fill those gaps through ways that can be managed and sustained by the community groups even after the project is over

Have a cadre of internal facilitators, from among the communities to facilitate/accelerate in the empowerment process

Have a cadre of external facilitators to assist in planning and designing sustainable and workable programmes

Enable the communities to have choice and control over the services available for them

Make the service providers more accountable to the communities

Successful pilots to be up-scaled by the line departments for state-wide implementation

Systems

Outputs/outcomePersonnel

Improved access to “effective & available” services

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GoalGoal

Improved health and nutrition status Improved health and nutrition status of the communities in 62 pilot of the communities in 62 pilot mandals of Andhra Pradesh by 2009.mandals of Andhra Pradesh by 2009.

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ObjectivesObjectives

Empowered CBOs:Empowered CBOs: Demand access and availing health & Demand access and availing health &

nutrition services especially among POP nutrition services especially among POP &Poor&Poor

Improve house hold behaviours that help Improve house hold behaviours that help maternal & child survival and control maternal & child survival and control spread of communicable diseasesspread of communicable diseases

Provide financial support during Provide financial support during illnessesillnesses

Reduce expenditure on HealthReduce expenditure on Health

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5 Key strategies5 Key strategies

Continuous capacity building Continuous capacity building Convergence with line deptsConvergence with line depts Community Investment fund Community Investment fund (need (need

based health and nutrition projects)based health and nutrition projects)

Community health resource Community health resource persons (CRPs) strategy for persons (CRPs) strategy for behavior change.behavior change.

Case ManagersCase Managers

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IKP Health Value Chain IKP Health Value Chain towards reaching MDG 4,5 towards reaching MDG 4,5

and 6and 6

Preventive & Promotive Health

CareCurative Care

Financing and Service Delivery

Human/Social Capital• Health activist• Community Resource

Person (CRP)

Nutrition & Health Day (NHD)

Water & Sanitation

Nutrition Centers

Case Managers

Making Services Work for the Poor – Accessing PHCs & Area Hospitals

Community-owned Pharmacy

Community-owned Hospitals

Microfinance Product for NUTRITION

Health Risk Fund/ Health Savings

Health Insurance

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Key playersKey players Village OrganisationsVillage Organisations Mandal Mandals SamakhyasMandal Mandals Samakhyas Zilla SamakyasZilla Samakyas HN CCHN CC Health ActivistHealth Activist AWWAWW ANMANM

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Implementation planImplementation plan

• @@ 2-5 mandals per district in all 22 2-5 mandals per district in all 22 districtsdistricts

• @ 1 Health Activist per village/habitation@ 1 Health Activist per village/habitation• Health sub Committees of VOs/MMS/ZSHealth sub Committees of VOs/MMS/ZS• @ 2 Master Trainers per mandal with @ 2 Master Trainers per mandal with

ANM training.ANM training.• 1 DPM/APM (HND) per district.1 DPM/APM (HND) per district.• Field Coordinators at SPMUField Coordinators at SPMU• Existing Committees of Line departmentsExisting Committees of Line departments• Functionaries of line departmentsFunctionaries of line departments

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Community Facilitators Project Facilitators

Organgram

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Key outcomesKey outcomes

Reduction in maternal and child Reduction in maternal and child morbidity and mortality (morbidity and mortality (MDG 4 and 5).MDG 4 and 5).

Reduction in morbidity and mortality due Reduction in morbidity and mortality due to communicable diseases (to communicable diseases (MDG 6).MDG 6).

Decreased out of pocket expenditure on Decreased out of pocket expenditure on healthhealth

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Universal and intensive Universal and intensive InterventionsInterventions

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Universal interventionsUniversal interventions

Regular Regular capacity buildingcapacity building of health of health activists, health sub committees and activists, health sub committees and health CRPshealth CRPs

Institutionalization of Fixed Nutrition Institutionalization of Fixed Nutrition and Health Days and Health Days (NHDs)(NHDs) towards towards complete immunization, ANC and PNC.complete immunization, ANC and PNC.

Community Community kitchen gardenskitchen gardens Promotion of Promotion of weaning foodsweaning foods with with

locally available commodities locally available commodities Regular Regular health savings and HRFhealth savings and HRF Community managed Community managed health insurance health insurance

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GoalGoal To improve Perinatal and neonatal outcomes and To improve Perinatal and neonatal outcomes and

child care practices towards achieving the MDGschild care practices towards achieving the MDGs in in rural Andhra Pradeshrural Andhra Pradesh

ObjectivesObjectives To provide nutritional and health care for pregnant To provide nutritional and health care for pregnant

and lactating mothers.and lactating mothers. To encourage improved health care practices for safe To encourage improved health care practices for safe

deliveries and have no low birth weight babies.deliveries and have no low birth weight babies. To empower communities to make pregnancy safer To empower communities to make pregnancy safer

and develop change agents to have sustainable and develop change agents to have sustainable impact.impact.

Community-Managed Community-Managed Nutrition cum Day Care Nutrition cum Day Care

CenterCenter

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Nutrition cum Day Care Nutrition cum Day Care Center (NDCC)Center (NDCC)

Physical center i.e., building with Physical center i.e., building with Kitchen, Dining and Garden (for growing Kitchen, Dining and Garden (for growing vegetables)vegetables)

TWO MEALS a day prepared and served TWO MEALS a day prepared and served to pregnant and lactating mothers and to pregnant and lactating mothers and children children <5 years<5 years

Cook is an SHG member trained in Cook is an SHG member trained in preparation of nutritious, traditional diet preparation of nutritious, traditional diet (with focus on use of millets & greens)(with focus on use of millets & greens)

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Nutrition cum Day Care Nutrition cum Day Care Center (NDCC)Center (NDCC)

The center also doubles-up as a health check-up The center also doubles-up as a health check-up centre for pregnant and lactating mothers and centre for pregnant and lactating mothers and children <5 yearschildren <5 years

Serves as a venue for health education and Serves as a venue for health education and behavior change communicationbehavior change communication

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NDCC Financing ModelNDCC Financing Model The cost of mealThe cost of meal

Rs 25 per day for TWO MEALS for pregnant and Rs 25 per day for TWO MEALS for pregnant and lactating motherslactating mothers

Rs 10 per day for TWO MEALS for Children <5 yearRs 10 per day for TWO MEALS for Children <5 year Beneficiaries pay Rs 18 per day for TWO MEALS; Beneficiaries pay Rs 18 per day for TWO MEALS;

The balance Rs 7 is subsidized by the Community-The balance Rs 7 is subsidized by the Community-Based Organization/ Government of Andhra Based Organization/ Government of Andhra PradeshPradesh

The Beneficiary’s contribution is financed via a The Beneficiary’s contribution is financed via a MICROFINANCE LOAN taken from the MICROFINANCE LOAN taken from the Community-Based Organization which will repaid Community-Based Organization which will repaid over 24 – 36 months depending on income status over 24 – 36 months depending on income status of the beneficiary i.e., CONSUMPTION of the beneficiary i.e., CONSUMPTION SMOOTHING VIA a CONSUMPTION LOANSMOOTHING VIA a CONSUMPTION LOAN

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ProcessProcess

Grama sabha Discussion with beneficiaries

Discussion with the mothers-mother-in laws

Preparation of MCP Feeding at NDCC Day care for children

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NDCC CoverageNDCC Coverage

2007-082007-08 :: 200 centers 200 centers

2008-092008-09 :: 400 centers 400 centers

2009-102009-10 :: 2500 centers2500 centers

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Coverage against surveyCoverage against survey

As per enrolment at As per enrolment at 600 NDCCs with 600 NDCCs with 332 day care 332 day care centers.centers. 3,220 BPL pregnant 3,220 BPL pregnant

women; 1,967 women; 1,967 SC/ST SC/ST

3,148 BPL lactating 3,148 BPL lactating mothers; 1,991 mothers; 1,991 SC/STSC/ST

3,440 BPL children 3,440 BPL children 0-3yrs; 2,167 SC/ST0-3yrs; 2,167 SC/ST

As per survey at 600 As per survey at 600 AWCsAWCs

5092 pregnant 5092 pregnant women from all women from all categoriescategories

6043 lactating 6043 lactating mothers from all mothers from all categoriescategories

9960 children 0-3yrs 9960 children 0-3yrs from all categories.from all categories.

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Perinatal outcomes*Perinatal outcomes* Against the 2890 deliveries happened:Against the 2890 deliveries happened:

100 %of women had safe deliveries. [2559 100 %of women had safe deliveries. [2559 Institutional(88.5%) /331 trained personnel(11.5%)]Institutional(88.5%) /331 trained personnel(11.5%)]

2599 had normal deliveries (89.9%)2599 had normal deliveries (89.9%) 291 had cesarean section (10.1%).291 had cesarean section (10.1%). 87% women had complete ANC 87% women had complete ANC 99% women had PNC99% women had PNC 46% of pregnant women gained 10-12Kgs weight; 47% 46% of pregnant women gained 10-12Kgs weight; 47%

gained 7-10kgs weightgained 7-10kgs weight No maternal deaths reported among the women No maternal deaths reported among the women

enrolledenrolled

* * Source: Internal MISSource: Internal MIS

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Neonatal outcomes*Neonatal outcomes* 1497 girls (51.7%) and 1398 are boys (48.29%)1497 girls (51.7%) and 1398 are boys (48.29%) 97% of babies born with >2.5Kgs97% of babies born with >2.5Kgs

56.5% babies with >3Kgs56.5% babies with >3Kgs

Neonatal care practicesNeonatal care practices 97% neonates are fed with Colostrum and no 97% neonates are fed with Colostrum and no

pre-lacteal fluidspre-lacteal fluids 82% delayed bathing the baby for 7 days.82% delayed bathing the baby for 7 days.

* * Source: Internal MIS dataSource: Internal MIS data

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FAQs about resultsFAQs about results

Accuracy of the measurements?Accuracy of the measurements?

Technical person for Technical person for supervision?supervision?

Authenticity of the data?Authenticity of the data?

Empirical evidence ?Empirical evidence ?

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Early Early outcomes

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Mainstreaming HIV/AIDS Mainstreaming HIV/AIDS preventionprevention

Complementary roles of the Societies.Complementary roles of the Societies. Development of CRPs as TOTs.Development of CRPs as TOTs. Regular capacity building of stakeholders Regular capacity building of stakeholders

at all levels integrated with HN training at all levels integrated with HN training plans.plans.

Exclusive Health CRPs to focus on SHG Exclusive Health CRPs to focus on SHG trainings and referrals.trainings and referrals.

Scale up plans integrated with HN Scale up plans integrated with HN interventions.interventions.

Knowledge levels and referrals rates are Knowledge levels and referrals rates are impressive in intervention areas.impressive in intervention areas.

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Roll out plan : 2009-2012Roll out plan : 2009-2012

Expansion of mandals (62 to 458)Expansion of mandals (62 to 458) Entire district saturation with Entire district saturation with

universal interventions (6)universal interventions (6) Coverage of all tribal mandals and Coverage of all tribal mandals and

disability mandals piloted under IKP.disability mandals piloted under IKP.

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Please visitPlease visit www.serp.ap.gov.in/HN

for more detailsfor more details

Thank YouThank You