process documentation-ankur project

8/3/2019 Process Documentation-ANKUR Project

1/80

N. Nakkeeran, Ph. D

C. A. K. Yesudian, Ph. D

Assistant Professor

Centre for Research Methodology

&

Professor and Dean

Research and Development

By

TATA INSTITUTE OF SOCIAL SCIENCES, Mumbai

Process Documentation of the ANKUR Project(2001-2005)

Transfer of Home-based Newborn CareFrom SEARCH to Other Organisations

Transfer of Home-based Newborn CareFrom SEARCH to Other Organisations

Process Documentation of the ANKUR Project


2/80

Published by

No part or whole of this work may be copied, reproduced or distributed without the permission

of SEARCH, Gadchiroli in whom thecopyrights of this work vest.

SEARCHSociety for Education Action andResearch in Community Health

Gadchiroli , Maharashtra, India.Pin : 442 605

Ph.no. 91-7138-255407Fax no. 91-7138-255411

e-mail: [email protected] : www.searchgadchiroli.org

Society for Education,Action and Research in Community Health, Gadchiroli - 442605, India

This publication was made possible through support from The Saving Newborn LivesInitiative of Save the Children (US) and The Bill & Melinda Gates Foundation

Cover page drawing : Ms. Anuradha Thakur, Ahemadabad


3/80

Table of Contents

I. Background 1

SEARCH, Gadchiroli 1

Home-based Newborn Care study in Gadchiroli 2ANKUR : The replication study 6

Why Process Documentation? 6

II. Study Methods 8

Two Phases 8

Aim and Objectives 8

Domains of data collection and documentation 9

Methods of data collection 10

Tools of data collection 13

III. Process of Transfer : Planning and Training 14

Introduction 14

Planning process 14

Training 17

Transfer of knowledge and skills 20

Transfer of mission, values, attitudes and leadership 24

IV. Process of Transfer to the Communities : Implementation 27

Introduction 27

Service delivery 27

Working with community 30

Building community ownership 32

Dynamics of stakeholders 34

Human resource management 35

Supervision 37

Materials 40

Information management 41

Conclusion 46

V. Impact and change 47

Introduction 47

Maternal and child healthcare 47

Neonatal morbidity and mortality 59Sustaining HBNC in the Community 65

Conclusion 67

VI. Socioeconomic Context and Implications on HBNC 68

VII.Conclusions 72

References 74

Appendix 75


4/80

1

Chapter - I

BACKGROUND

SEARCH, Gadchiroli :

Society for Education, Action and Research in Community Health (SEARCH) is a non-government

organisation established in 1986. Dr. Abhay Bang, and his wife Dr. Rani Bang, are the founders,

directors and the architects of SEARCH. In the initial seven years, SEARCH was based in Gadchiroli

town in the Gadchiroli district of Maharashtra, and in 1993, its headquarters campus Shodhgram was

set up on a 12-acre agricultural land, 17 kilometres from Gadchiroli town. Shodhgram houses eight

departments viz. Womens reproductive health, Tribal Health and Development, Adolescent Health

Education, De-Addiction, Research, Hospital, Home-

based New born Care, and Administration. The hospital

is of a tribal-friendly architecture and has all the basic

facilities such as X-ray, laboratory, ECG and a pharmacy.

Shodhgram is a residential campus and most of the staff

members stay on the campus, sharing a close commu-

nity life. There are some values collectively held by the

members Gandhian values of simplicity, social self-

sufficiency, and dignity of labour. The work of SEARCH

is strongly founded on three convictions viz., commu-

nity participation, research and advocacy, which are

basically grounded to Dr. Bangs Gandhian values.

SEARCH is committed to active participation of people

in setting priorities, planning activities and implementing programmes. It is basically a political activ-

ity at the grassroots (Bang 1986, p.1394). SEARCH believes that it is the empowerment of womenand men in the villages that can realiseAarogya Swarajand not the costly modes such as doctors,

hospitals, ambulances, which either dont reach or dont function (SEARCH, 2003, Ankur Utsav,

Shodhagram: 31st March 2003, The address by Dr. Abhay Bang).

Along with community participation, research has been an important component of almost all the

interventions of SEARCH, in both health and other (non-health) fields. Besides these, advocacy

remains an important plank of SEARCH, strengthened with its faith in research, its commitment for

active community engagement and hence influencing public opinion.

Contribution of SEARCH to the Area of Child Health :

Child health is an important area in which SEARCH has been involved from the beginning. It hasbeen operating a vital statistics registration system in about 100 villages in the Gadchiroli district from

1988, periodically generating and publishing reliable data on birth rate and child mortality. SEARCH

has been involved in training and supporting male village health workers and traditional birth atten-

dants in 53 villages of Gadchiroli district to provide case management of pneumonia in children (Bang

etal 1990), antenatal care, hygienic deliveries, and treatment for reproductive tract infections (Bang

R. A. 1988). Through its work such as study of Child Mortality in Maharashtra, home-based neonatal

Gate of Shodhgram,

the SEARCH HQ campus


5/80

2

care and the reproductive health, SEARCH has earned wide acclaim and reputation among the

NGOs, academia, medical profession, some sections of bureaucracy and political leaders. Its work

on management of pneumonia in children, gynaecological morbidities, and home-based neonatal

care, has attracted the attention of international public health specialists, planners, and funding agen-

cies.

Home-based Newborn Care (HBNC) Study in Gadchiroli :

The HBNC study was conducted between April 1993 and March 1998. The field area of SEARCH

covered 100 villages in Gadchiroli district, including action area of 53 villages and control area of 47

villages (Bang et al. 1999). The intervention area comprised ultimately of 39 villages out of the 53

action area villages.

The project included the following:

1. Seeking community involvement through obtaining written consent from a range of community

level public bodies like gram panchayat or individuals holding public office at the village / panchayat

level to allow the introduction of the HBNC package in the respective villages and seeking commu-nity involvement at various stages of the HBNC implementation beginning with selection of the

female village health workers (VHWs) to provide home based neonatal care.

2. Studying traditional neonatal care knowledge and practices in the project area through a baseline

survey.

3. Involving traditional birth attendants (TBAs) in the intervention area through training and providing

safe delivery kit and utilizing their capacities to a) reinforce the health education messages given

by VHWs b) encourage mother to access ANC care c) conduct hygienic and safe delivery d)

recognize danger signals in mother (delivery, post-partum) and give referral e) initiate early and

exclusive breast-feeding f) insist that the family calls VHW to be present during birth g) work in

collaboration with VHWs and h) report all births to the project team collecting vital statistics.4. Selecting and training of female Village Health Workers (VHWs) (one VHW for 1000 population)

to provide neonatal care at home and carry out health education amongst the mothers and com-

munity.

5. Provision of HBNC package by the VHWs.

The key components of HBNC provided by the VHWs to the neonates and mothers included the

following:

a) Providing health education to pregnant women and families about maternal nutrition and

health, safe delivery, post-partum and neonatal care; providing advise and encouraging moth-

ers, TBAs and parents to seek care for sick neonates from the VHW.

b) Attending delivery to take care of the baby at birth, examination of the baby and management

of birth asphyxia if necessary. She also identifies high risk babies.

c) Making home visits to normal neonates on specific days and on any other day if the family

called.

d) For high risk babies, making greater number of home visits on specified days and on any other

day if the family called.


6/80

3

e) Undertaking the specified tasks during home visit i.e. taking history, examining mother and

child, weighing the child each week.

f) Managing normal and sick neonates. This included early initiation and exclusive breastfeeding,

managing breastfeeding problems, prevention and management of superficial infections of

the skin and eyes, management of fever, management of high-risk babies and management

of hypothermia.

g) Undertaking sepsis case management for neonatal sepsis.

h) Identification of maternal morbidities during post partum visits and referral if necessary and

i) Maintaining record of her observations and actions during home visits.

Child health components included health education of parents about seeking care for cough and

providing case management to children with pneumonia.

During the baseline (April 1993 March 1995) phase, male VHWs did a census(1993) and baseline

survey in the field area comprising 100 villages (1993-95). Traditional neonatal care practices in the

field area were studied by female social workers. Consent was taken from the community in 53

villages of action area to undertake the study. Female VHWs with 5-10 years of schooling and be-

longing to the respective villages were selected. Out of the 53 villages, 39 villages were finally se-

lected as the intervention area on the basis of population (not being less than 300) and availability of

suitable woman to work as VHW. During the first year of the intervention phase (April 1995 March

1996), female VHWs listed pregnant women in the village, collected data by home visits in the third

trimester, observed labour and neonates at birth, undertook home visits on days 1, 2, 3, 5, 7, 14, 21,

and 28, undertook home visits on any other days if the family (of the neonate) called, took history

during each visit, examined the mother and the child, weighed the child each week, managed minor

illnesses and pneumonia in the neonates. They followed up the neonate for 28 days after birth, until

the mother left the village, or until the neonate died, whichever was earlier. The data thus generated

was used to estimate the natural incidence of neonatal morbidity and need for care.

In the second year of intervention, female VHWs were further trained in home-based management of

neonatal illnesses. Provision of home-based neonatal care by the female VHWs started from April

1996 in addition to earlier tasks. They managed neonatal sepsis (septicemia, meningitis, pneumonia)

from September 1996.

In the third year (April 1997 - March 1998) of intervention, female VHWs gave health education to

pregnant women and other women about care during pregnancy and care for neonates.

Throughout the period of the project, each village was visited by a non-MBBS physician fortnightly, to

verify the data recorded by the VHWs, to correct the records and to educate the VHWs. The physician

did not provide any treatment and referred seriously ill neonates to hospital. The completed neonatal

records were weekly reviewed and diagnoses were made independently by the physician, statistician

and by a computer program specially designed to diagnose neonatal mortalities. In case of differ-

ence, the original records were reviewed. An independent neonatologist reviewed the records of

neonatal deaths (in spite of the neonates having been cared for by the VHWs) in the intervention

area, to assign cause of death as per the criteria similar to that given by the expert group of the

National Neonatology Forum of India (NNFI).


7/80

4

Between 1993 and 1998, births and deaths were recorded in intervention and control area by male

VHWs and their supervisors prospectively as well as through 6-monthly house-to-house surveys. An

external group of neonatologists and paediatricians monitored the ethical aspects and the quality of

the trial including the study design, diagnostic criteria, and training of VHWs and data collection by

meeting once in a year at the SEARCH headquarters. The costs (training, equipment, wages and

incentives, medicines and supplies, records, supervisions and transport) were separated into service

costs and research costs.

The study revealed a huge burden of neonatal morbidity and a large unmet need for neonatal health

care in the community. 48% of neonates suffered from high-risk health problem (Bang etal. 2001). In

the third year of intervention, 93% of neonates in the 39 intervention villages received HBNC. Neo-

natal mortality rate, from the baseline period to the end of the intervention period, in the intervention

area, decreased from 62 to 25.5. In the control area, it had increased from 57.7 to 59.6 between

baseline and the end of the intervention period. Intervention area also registered decline in infant

and perinatal mortality compared to the control area. Case fatality in neonatal sepsis declined from

16.6% to 2.8% (71 cases) before and after the intervention. In the third year, HBNC averted one

death among every 18 neonates cared for.

The birth of ANKUR :

In the year 1999, SEARCH had initiated a study of child mortality in the state of Maharashtra along

with 13 other NGOs from various parts of the state. The study conducted over a population of 2,26,904

spread over 231 villages and 6 slums gave clearer estimates of mortality rates for children (SBR,

NMR, IMR, and CMR) in these selected areas and that for the state as a whole and revealed that

these mortality rates were grossly underestimated till then. The study confirmed the findings of many

other studies that NMR contributes nearly 75% of IMR. The report was published in Marathi under the

title Kovali Pangal (2001).

Efforts were made to reach the findings to the people of Maharashtra through the media. All the major

Marathi newspapers published the news and editorials were written on the study within a week of

publication of the report i.e., between November 24 and 30, 2001. It was covered in the electronic

media as well. Publication of the study generated a mixed reaction in the political as well as adminis-

trative levels of the state of Maharashtra. The minister of health and the bureaucracy from the Health

and Family Welfare department took a defensive posture. A series of meetings was conducted with

the chief secretary, Health and Family Welfare minister, and finally with the Chief Minister of the State

in a rapid succession between November 30 and December 5, 2001. (Bang et al., EPW, 2002).

Subsequently, the Chief Minister of Maharashtra was convinced of the main message of the study

and accepted the goal of 100 per cent recording of child deaths in future and also most of the

corrective measures recommended by the study. He also endorsed the recommendation to start

projects in the state to reduce child mortality using the approach of home-based neonatal care, start-

ing with the 14 worst affected districts.

The HBNC experiment and its outcome in Gadchiroli and the child mortality study in the state gave

birth to the idea of formation of Ankur. In the Pune meeting on 8th and 9th of October 2000, the 13

NGOs who conducted the child mortality study discussed future action. An outcome of this discussion


8/80

5

SEARCH HQStudy Sites in ANKUR

Villages : 91, Slums : 6Population : 88, 311

Gadchiroli

Nagpur

Yavatmal

Osmanabad

Sangli

NasikRural

Rural

Rural

Rural

Tribal

Tribal

U.Slum

was the formation of The Child Deaths Study and Action Group (CDSAG), Maharashtra. Having

established that the child mortality is in reality very high and is being under-reported, the group did

not want to stop at reporting but to go ahead and do something about it. SEARCH also wanted to test

replicability of HBNC. Hence, SEARCH and some members of the CDSAG group decided to launch

a new intervention project, named Ankur (The Sprout) to test the replicability of HBNC and save

newborns and children in the selected villages of their respective field areas.

Selection of the NGOs for the Ankur Project :

The members of the CDSAG group were invited to send their proposal to take part in the Ankur

Project. SEARCH laid out some specifications for NGOs to become part of the project viz. (a) Willing-

ness to undertake the HBNC replication exercise with a research discipline (b) The quality and disci-

pline of work during child mortality

survey (c) Population size and the

level of IMR (d) Capacity to inter-

nalize the community health ap-

proach (e) Capacity to organize

effective training and supervision

in the field (f) Credibility in the com-

munity, acceptance by people and

the capacity to address political

backlash at the local level (g)

Leadership quality and (h) The

potential to become a demonstra-

tion / multiplication site.

7 of the 13 NGOs finally became

part of this multi-site replication

study of Home-Based Neonatal

Care (HBNC). Thus seven NGO

sites, one each in the districts of Gadchiroli and Yeotmal(both tribal), Nasik, Sangli Osmanabad and

Nagpur(all rural) as well as an urban slum site in the city of Nagpur were chosen for the ANKUR

project.

The Research Questions for Ankur :

Following were the research questions of this community based replication study:

a. How can the HBNC be replicated by other NGOs?b. What is the effectiveness of HBNC when replicated ? And what are the inputs required for

replicating HBNC?

c. How replicable will HBNC be in other settings and how sustainable will it be in the seven NGOs?

d. Can selected elements of maternal and child health interventions be integrated with HBNC?

The fact that the study aimed at replication and that it was a research project very significantly

influenced and structured the way the project was implemented.


9/80

6

ANKUR : The Replication Study :

The study demanded (a) High level of leadership skills and guidance from SEARCH to effect a

progressive convergence of vision, values, attitudes and priorities of all the seven NGOs to facilitate

implementation of HBNC (b) Rigorous monitoring and supervision from SEARCH (c) Transfer of

material resources in the form of funds, equipments, training material etc., (d) Transfer of readymadesystems for almost all activities pertaining to HBNC (e) Large scale transfer of knowledge and skills to

different levels of personnel in the NGOs (f) Supportive action to deal with stakeholders in govern-

ment machinery, medical profession, media, other civil society organisations, and at the local

community level.

A research study has requirements of consistency and rigorous data/reporting such as consistency in

terms of input variables, evaluative indicators and control of confounding variables over the entire

period of the project. This introduced the need for development of well worked out systems for almost

all the activities which had to be in place through out the study, higher level of training to all levels of

personnel and strong supervision. Besides, generation and use of adequate and meaningful data

was another feature characterising the project. As a result, it demanded intensive and well definedprocedures of data collection, rigorous monitoring and supervision, efficient channels of communica-

tion and generation and submission of a variety of reports.

Another distinct feature of the study was the emphasis it laid on outcomes rather than just intermedi-

ate outputs. The replicability was to be reflected in terms of the reduction of IMR with emphasis on

reduction in NMR. Indicators for monitoring or supervision were not so much the distribution of staff,

medicines, expenditure incurred but the number of births observed, neonatal ailments attended and

the number of deaths averted. Sustainability and up scaling were the desired long-term outcomes.

The fact that the project centred on the village women delivering home based services was another

very crucial characteristic of the study. This made it imperative to develop an intensive training system

with detailed training methods and material to impart skills, knowledge and values to these villagewomen.

Why Process Documentation ?

Process documentation of the implementation of this replication and the community changes around

this implementation seemed necessary. As stated earlier, the aim of the Ankur project was to demon-

strate the replicability and generalisability of HBNC approach irrespective of the community context

and the organizational uniqueness (of SEARCH). Ankur was an intermediate process, a step towards

a much broader level of scaling up in terms of geographic coverage. Hence, the processes in this

project had to be documented as a model of replication exercise. Documenting such processes was

essential as it could be a referent for subsequent ventures of transfer. As the mid-term review team

noted, the most important priority for documentation is to understand what changes are occurring in

communities with regard to newborns and their health and why. The purpose was to arrive at more

effective and efficient designs and plans for introducing HBNC elsewhere (2003). The Ankur transfer

process was conceived as a long process spanning about four years. The long duration of the

programme provided an opportunity to learn lessons from the early stages of implementation, and

incorporate the improvements in the later phases of the project.

The Ankur-transfer process was not only long, but was also quite intense and comprised of a number


10/80

7

of processes and sub-processes. This invoked a necessity to document all the processes involved in

detail lest they may not even get registered. Another important reason for documentation was that it

involved intense transfer of skills, knowledge and attitudes to a range of personnel (to the project

coordinators and supervisor trainers and from the trainer-supervisors and project coordinators to the

VHWs and TBAs). In the learning processes, the learning curves do not leave behind imprints of their

own. Except for the mid-term or terminal evaluation, which gave the scores of achievement, the

intermediary levels of learning, and problems in learning, corresponding experiments and nuances in

training methods, tools, management etc would not be registered. These problems in learning and

training would not be unique to this environment alone, but could be faced in future experiments of

transfer too.

The sites to which HBNC was transferred were not uniform, but ranged from tribal, through rural to

even urban area. Hence, the populations covered were widely divergent . In terms of the general

quality of life, infrastructure, economic status, awareness, proximity to alternative health facilities as

also the traditional beliefs, practices and perceptions, the populations varied quite significantly. As a

result, the trajectory of both transfer of skills to the community-based actors as well as the trajectory

of community acceptances of the programme differed across these communities. The responses to

various components of the programme varied. Correspondingly the micro-level strategies used by

the respective NGOs to work through these variations too were divergent. All such diverse substra-

tum (baseline), trajectories, responses and strategies had to be documented as learning for subse-

quent endeavours.

From the beginning of the Ankur project, the need for documentation was understood and it had been

attempted in a number of ways. A three-day workshop on Documentation skills was organised for

the Ankur NGO heads and supervisors in September 2002. Resource persons were invited from

PRIA, an organisation from New Delhi for this workshop. During the mid-term review of the project in

March 2003, Saving Newborn Lives Initiative recommended the need for process documentation to

enable any future efforts towards sustaining HBNC in the project areas as well as enable HBNC to be

expanded to additional regions by other NGOs and by the government (Anne Tinker, SNL, undated).

Therefore, the present process documentation study was initiated.


11/80

8

Chapter - II

STUDY METHODS

Two phases :

By the time the process documentation started in September 2003, a significant part of the transfer

process had been already completed and hence the elapsed part was documented retrospectively.

For this purpose, each of the seven sites (NGOs) to which the transfer took place was visited. The

processes that followed after initiation of the documentation in September 2003 were captured as

part of the prospective documentation. For the purpose of prospective documentation, three selected

NGOs out of the total seven were followed and studied. The three organisations chosen, namely

Amhi Aamchya Arogyasathi (AAA) of Gadchiroli district, Sahayog Nirmiti (SN) of Osmanabad district

and ISSUE in Nagpur city, represented a tribal, a rural and an urban site respectively. The present

document provides both the retrospective and the prospective parts of the documentation.

In the following pages of this section, we outline the methodology used for the process documenta-

tion study.

Aim and Objectives :

Aim :

The process documentation study aimed at documenting the process of transfer of HBNC vision,

leadership and related knowledge, skills and resources from SEARCH to Ankur NGOs. It also aimed

to document the process of implementation of home based neonatal care (HBNC) and the accompa-

nying changes in the community to facilitate refining of the programme for a more effective, and

efficient implementation elsewhere and to reach the programme more widely and deeply.

Objectives :

Separate objectives were formulated for retrospective and prospective studies and are listed below:

The objectives of the retrospective study were to,

a. Document the processes involved in transfer of vision, leadership, knowledge, skills methods, and

resources related to HBNC from SEARCH to 7 Ankur NGOs, the process of interaction among the

7 Ankur NGOs and the process involved in building relationship with external stake-holders.

b. Document the processes involved in transfer of leadership, attitude, necessary skills and knowl-

edge within each of the Ankur NGOs to different levels of personnel involved in HBNC replication

and implementation.

c. Identify best practices which have resulted in desirable changes in the community, the NGO and

SEARCH.

The objectives of the prospective study were to,

a. Bring out the underlying beliefs and cultural practices regarding pregnancy, delivery, and new-

borns among various sections in the community, and to document the process of change in these

beliefs and practices.

b. Document the perceptions and responses of the community to the NGO inputs.

c. Bring out the key events, processes, people, services and interactions that either facilitate or are


12/80

9

responsible for such changes.

d. Document the practices, perception and responses of different health providers in the community,

regarding pregnancy, delivery, new-born care as well as with respect to NGO inputs.

e. Document temporal variations in responses among various ethnic / social / economic groups or

individual families within communities, to understand factors that accentuate acceptance as well

as resistance for change among such groups.

Domains of Data Collection and Documentation :

SEARCH : (a) HBNC conception, designing and implementation (b) Formation of Ankur (c) Transfer

processes

Ankur NGOs : (a) Profile, vision, resources and services (b) Systems, processes, decisions, actions

(c) Community acceptance and how this changes during the period of implementation.

HBNC Programme : (a) Components of the programme, local modification to the programme on the

basis of local need (b) Variations, modifications if any introduced during the course of implementa-

tion, systems for supervision, monitoring and feedback involving collection, storing, analysing and

use of data by the NGO.

Village Health Workers : (a) Personal profiles of VHWs including age, sex, socio-cultural back-

ground, years of experience in the NGO, education level, performance during the period of learning

(b) Degree of acceptance in the community, fluency in relationship among all the sections of the

community, fluency in delivery of services (c) Changes in these dimensions during the period of

implementation

Community : (a) Profile of the community in terms of demographic and socio-cultural composition,

economic activities and differentiation, political structures (b) Access to and use of public and private

health services, education and other activities and cultural practices specially related to health and

new-born care (c) Perception and degree of acceptance of the NGO and its activities and (d) How the

above aspects affect changes during the period of implementation.

Study Design :

The process documentation was conceived in two parts viz., retrospective and prospective. The former

covered the period up to 2003 of the transfer process, which was essentially an intensive vision

building, planning and training phase till April 2003. This phase was retrospectively documented

using existing documents and interviews with SEARCH and the seven Ankur partner NGOs.

Prospective phase covered the period from September 2003 to the end of the project. This was

further divided into two parts i)Baseline study and 2) Quarterly follow up studies. The purpose of the

baseline study was to get the background / baseline information about the HNBC project, NGOs, and

the community. Baseline information regarding availability of care during pregnancy, delivery and

care of new-borns, acceptance / perception of the respective NGOs and HBNC programme were

collected from the community. The baseline study also served for selection of villages for study and

identifying informants. Quarterly follow-up studies were conducted to collect longitudinal data on com-

munity changes happening around HBNC, and to look for changes, patterns and evolution in these

changes across the three study sites and across different communities.

Baseline and quarterly-follow up studies involved field visits to the chosen Ankur NGO partners; first


13/80

10

for the baseline study, and thereafter periodically (every three months). Altogether seven rounds of

visits were made to the three NGOs. The three NGOs represented one each of tribal, rural and urban

setting. Areas of two VHWs from each NGO were selected for the prospective study. These six areas

were visited during each of these visits for the prospective study. In addition, in each of these three

NGOs, a non-HBNC (control) village was chosen and was periodically visited. Non-HBNC villages

chosen were such that these were comparable to HBNC areas except that HBNC was not imple-

mented there. It served as a proxy baseline state of HBNC area. These were also compared with the

HBNC villages concurrently as the programme proceeded.

Methods of Data Collection :

Field Visits :

Empirical data were collected through field observation, informal unstructured interviews and group

interviews with people in the community, community based actors, stakeholders, local healers, NGO

personnel, and SEARCH staff. Initially, open-ended interview schedules were used to collect data

from the trainers, NGO heads, supervisors, VHWs, community leaders, stakeholders, beneficiaries,

and non-beneficiaries. Different sets of checklists were used at various points to collect and complete

information on all the important practices and interventions. Social mapping of the study villages /

basties was done locating the facilities available, distribution of households by community, location of

VHWs, TBAs, local healers, etc.

In each visit to an NGO, the team interviewed the project coordinators, supervisors and other staff

members. At least two VHWs from each NGO were visited and detailed interviews were conducted.

The interviews captured the skills and knowledge of the VHWs. In addition it also elicited all HBNC

related happening in the villages since the last visit. In these two VHW-areas in each NGO, beneficia-

ries who had received HBNC services since the previous visit, including eligible women, pregnant

women, mothers with neonates were interviewed. In addition, interviews were also held with TBAs,

local healers and community leaders. Public health staff like ANMs (Auxiliary Nurse Midwife), MPWs

(Multipurpose workers), Anganwadi workers, some doctors in PHCs (Public Health Centres) / RH

(Rural Hospital) were also interviewed.

Documentary Sources :

Documents used were largely from SEARCH and to some extent from the partner NGOs. These were

important sources of data. These documents included profiles of the NGOs, the project proposal,

training materials, progress reports, KP study reports, child mortality study report, published research

papers, paper clippings, baseline and 6-monthly surveys and evaluation reports etc.

Study Guide and Process Document Matrix :

With assistance of Dr. Mary Taylor, a detailed Study Guide and Process Document Matrix were pre-

pared. The Study Guide gave an outline for the whole study, formatting reporting, and the format of

the final report, tools of data collection, file structure, time schedule and roles and responsibilities of

individual partners in the process documentation study.

The HBNC transfer programme was depicted in a matrix with columns indicating the stages of trans-

fer with the entries in each column listing out what would be done at each stage. This matrix provided

the basic framework for writing the process documentation report.


14/80

11

SEARCHLeadershipand

ManagementofAnkur

NGOs(contextofproject)

Organizationalcontext:

Vision,mission,values

Whattheydo(core

capabilities)

Sphereofinfluence

Howtheyworkasateam

Howdecisionsaremade

Historicalcontext:

Healthprojects

ARIstudy

HBNCstudy

ChildMortalityStudy

(Earlyrelationships)

IdeaforAnkur

NGOagreements

StudyCharacteristics:

Aim

toreplicate

Researchrequires:

-Accuracy

-Reliability

-Crosschecking

mechanism

-Consistency

-Addeddata/reporting

requirements

Emphasisonoutcomes

What

was

meant

to

be

transferred?

Vision&Leadership

Vision/Mission

Attitudes/Values

Leadership

Motivation

Ethosofworkculture

Buildingrelationshipswith

externalstakeholders

Government

Medicalleadership

Politicalleadership

Media

Printmedia

Atlocal/districtlevelonly

Community

Differentreligiousgroups

Intellectuals

Professionals

Womensgroups

OtherNGOsinthearea

HBNC

Knowledge

Skills

Attitudes(VHWs,

Supervisors,

projectcoordinators)

Systems

Planning

Training

Supervision

Monitoring

HumanResourceManagement

SEARC

Hinputsand

transfe

rprocesses

Inputs:

Concepts/ideas/

technicalinformation

Materials(flipcharts,

forms,

curric

ula)

Funds(money,drugs,

equip

)

Enablingenvironmentthru

advocacy

Enablingenvironmentthru

peer

learning

Supportiveactions

Relatedtechnical

inform

ation

Proce

sses:

Advocating

Training

Orien

ting(demonstration)

Conductingworkshops

Data

analysisworkshops

Workshopsfor

documentationskills

Role

modelingdownto

VHW

level

Motivatingevents,

proce

ssesLeadingreview

meetings(peerlearning)

Conductingfieldvisits

-Technicalsupervision

-Datareview

-Management/finance

-Others

Supervising

Mode

ling

NGOContext

Background

Vision,mission,

values

Whattheydo

(core

capabilities)

Sphereof

influence

Structure

Approachto

communities

Whathasbeentransferred?

(Overtime,modifications,

depth)

Vision&Leadership

Buildingrelationshipswith

otherstakeholders

HBNC

Perform

ancemeasures

(Inputs

tocommunities,

widersu

pporttoprogram)

Initiative

Contacts,meetings

VHW,T

BAtrainingresults

HBNCTransferDocum

entationMatrix


15/80

12

SEARCHLeadershipand

ManagementofAnkur

NGOs(contextofproject)

Structure

&

working

relationships:

Staffroles/responsibilities

(who,

jobdescriptions)

WhotheyrelatetoinNGOs

Natureoftherelationship

What

was

meant

to

be

transferred?

ServiceDelivery

Information/analysis

Problemsolving&improvement

Researching

Communityengagement

SelectionVHWs

EmpowermentofVHWs

leadingtocommunity

empowerment

CoordinationwithTBAs

Buildingutilization

Buildingcomm.ownership

(Ownershiptransferwasnot

probablyplanned)

Sustainabilitypotential

SEARC

Hinputsand

transferprocesses

Resea

rching

-Surveys

-Cen

susdata

-NN

formsdata

-Spe

cialstudies

Docum

enting

Photo

documentation

Processdocumentation

NGOContext

OtherProjects

Whathasbeentransferred?

(Overtime,modifications,

depth)

Systems

Communityengagement

Sustainabilityplansand

actions

Perform

ancemeasures

(Inputs

tocommunities,

widersu

pporttoprogram)

Turnove

rofstaff

Dataqu

ality

Succes

sfulchanges

in

NGOpractice

Service

statistics(some)

Smallstudiesconducted

Meeting

sheld

Eventsheld

VHWco

verage


16/80

13

Tools of Data Collection :

Informal Interviews :

This was the predominantly used tool to elicit information from the community in both baseline and

follow-up studies. Depending on the informants, and the phase of the study, interviews were re-

peated, progressively making them more focused. Relatively more structured and focused interviewswere used to collect data from TBAs, VHWs, other local health providers and the NGO personnel.

Group Interviews :

The interviews in the community often turned out to be group interviews. This situation was used to

collect data on perceptions on TBAs, VHWs, and HBNC as well as on the cultural beliefs surrounding

pregnancy and newborn care. Group interviews also helped collection of data on community accep-

tance, effect of health education etc. Group interviews in different basties / hamlets brought out differ-

ences in the perceptions / practices across groups with age, socio-economic and ethnic differences.

Case Studies :

Case studies were documented to document special cases of neonatal illnesses and other problems.This involved collecting intensive descriptive data on a few selected beneficiaries or those who had

experienced maternal / neonatal morbidity / morality.

Mapping :

This was used to get the background information such as settlement pattern, location of health care

facilities and other amenities in the villages / basties.

The Team :

The process documentation team included two principal investigators and research assistants. The

two principal investigators are qualified with doctoral degree in social work and anthropology respec-

tively. At least one of the two principal investigators was part of all the field visits. The two research

assistants were with post-graduate degree in anthropology and economics respectively.


17/80

14

Chapter - III

Process of Transfer : Planning and Training

Introduction :

The process of transfer from SEARCH to the NGOs did not begin with planning. It began much

earlier, in the birth of Ankur (see chapter I), which generated a purpose namely the challenge of child

deaths in Maharashtra, bringing the NGOs together under the leadership of SEARCH.

The motivating vision of transfer of HBNC to their areas to reduce child mortality and to create a

SEARCH-like community health program was a powerful dream for the NGOs. The planning and

training followed.

Transferring HBNC to Ankur NGOs involved elaborate planning, developing systems and training. At

this stage, the main role and responsibilities rested mainly with SEARCH. Having successfully imple-

mented HBNC earlier in its intervention area, the challenge was to replicate the model in other areas,

where the socio-economic and cultural context were different and through the NGOs, whose workenvironment was different from that of SEARCH, and test its generalisability. In the following para-

graphs we look at the planning process and training of the staff who were to implement the HBNC

package, to ensure that the knowledge, skills, values, leadership and attitudes relevant for the Ankur

project were transferred to them.

Planning Process :

Although the project was being implemented under the technical guidance and supervision of SEARCH,

at local level it was to be administered by the respective NGOs. This was considered important, as the

very idea of the project was to test replicability of HBNC through NGOs differing in management

styles and in different local conditions. The NGOs were also expected to implement the central com-ponents of the programme without much deviation from what was planned. Towards this end, a series

of measures were undertaken.

First of all, agreements were signed between SEARCH, GreenEarth, a consultant firm from Pune

entrusted with some management functions under the ANKUR project and each of the Ankur NGOs.

These were besides the main agreement signed between SEARCH and the SNL. A meeting for this

purpose took place in SEARCH subsequent to the Pune m eeting on 8th and 9th of October 2000

referred earlier. GreenEarth was entrusted with the responsibilities such as preparation of project

manual and micro-plan documents, conducting KP (Knowledge Practice) study, arranging process

documentation, building management capacity of the partner NGOs, monitoring implementation of

the project at the NGO sites, and sorting out financial management problems of the NGOs. WhileGreenEarth was able to do some of the tasks in the pre-preparatory phase, many of the tasks were

either not done in time or the quality of work was not up to the mark. Subsequently, GreenEarth

withdrew from Ankur. This was after mutual consent and agreement of all including GreenEarth.

SEARCH then undertook the responsibilities entrusted earlier to GreenEarth.

An Orientation Workshop was arranged for the NGO-heads in September 2001. The responsibilities

of each of the organisations; including SEARCH, GreenEarth and the seven NGOs involved in the


18/80

15

project were clearly laid down. Management Review Meetings were conducted between SEARCH,

GreenEarth and the NGO teams 4 times during the first year. These were aimed at planning, sharing

of information and decision-making.

Project Manual :

This was a document to be prepared under the project, detailing each step involved in the implemen-

tation of the project, including obtaining community consent, selection of Village Health workers (VHWs),

Hamlet Workers(HWs), Neonatal Care Supervisors(NCSes); training of VHWs / HWs / NCSes/Vital

Statistics Supervisors (VSSes); obtaining positive cooperation of Traditional birth attendants (TBAs)

and designing approaches to handle non-TBA assisted or institutional deliveries.

Time Frame :

A time frame for the entire Ankur project spanning a period from April 2001 to April 2005 was worked

out indicating the various phases including the commencement and end of each phase of the project

(Later the project was extended till December 2005). These comprised the baseline phase, prepara-

tory phase, training phase, the intervention phase, the final evaluation phase and the dissemination

phase.

Activity analysis study :

This was a research study undertaken in the SEARCH field area and also later in the field area of one

of the NGOs (ISSUE) for a period of three months (one month in each of the three different seasons)

to estimate the time inputs required per neonate and time inputs required per unit service under

HBNC. This involved recording of various activities performed by the VHWs and their supervisors

against the time expended using time logs. The supervisor monitored the log maintained by the

VHWs. The findings of the study were expected to serve as a guideline for planning implementation

of the HBNC model elsewhere.

Management Rating System :

GreenEarth was entrusted with the responsibility of preparing a management rating system which in

turn would help monitor the management of the project by each NGO every 6 months. The manage-

ment rating system was designed in consultation with the NGO project coordinators. The four main

sections under which the performance was evaluated were: personnel management, community con-

tact, systems and leadership. This was followed by visits by GreenEarth to each NGO to establish

financial accounting system and suggest improvement in the management system. A checklist was

used to assess the management by each project coordinator and scores were discussed in a partici-

patory manner.In the July 2002 review meeting, following actions were taken:

NGO heads were helped to review status of their present activities and visualize and record their

dreams. Further, they were guided to think of improvements they felt necessary to realise their dreams.

The observations on management rating of the NGOs were presented by GreenEarth during the

meeting to the NGO project coordinators. Based on the needs identified, efforts were made to bridge

the gaps. These efforts included 1) Motivating them to undertake self learning process through reflexion


19/80

16

and reading and 2) Nominating the project coordinators to suitable workshops held by other

organisations. In addition, GreenEarth and SEARCH provided inputs during their visits to the seven

sites. GreenEarth had even planned a research study on the needs of the NGOs and how such needs

can be met. During the review meeting, systems such as writing daily diaries, case studies, keeping

record and minutes of the meetings, holding review meetings with participation of NCSes and VSSes,

holding meetings with VHWs, field visits for supervision, monitoring, community contact were ex-

plained to the NGO teams.

Management Information System :

Management Information System (MIS) format was provided to all the NGOs, for sending to SEARCH

every month. The NGOs started sending these reports to SEARCH from July 2002. The NGOs were

progressively encouraged to understand the MIS, analyse the data, draw conclusions and use it at

their level for monitoring and corrective actions. The MIS report, served two purposes 1) It helped

SEARCH monitor the progress at each NGO site closely and to give feedback and 2) The analysis

reminded the NGOs of the important indicators they had to watch and improve. The MIS became a

very good tool for monitoring the progress of the project, finding out the bottlenecks, identifying theimpediments and difficulties and finding solutions. Through Let us learn from data workshops con-

ducted in conjunction with the review meetings, the project coordinators gained knowledge and skill

of using data and MIS for planning, appreciating hypotheses, developing indicators and target set-

ting. Further, they understood the issue of child mortality in the state, its constituents, and contribut-

ing factors.

Micro-planning :

GreenEarth provided guidance and help to individual NGOs to undertake an exercise of drafting

micro-plan documents, to serve as a blue-print for planning of the activities. As part of this exercise,

GreenEarth and the NGO teams undertook study in respective sites with the following additional

aims: 1) To write individual site-specific project documents 2) To identify strategies for linking HBNC

with village level community structures and on-going programs of the NGO and 3) Identifying sub-

research topics for the research studies that may be undertaken by the NGOs. After GreanEarth

withdrew, individual NGOs completed these documents. However, it was found that the micro plan

documents were incomplete in many respects. To be of better functional use, concept of Annual

rolling plan was introduced from the beginning of 2003-04 in place of micro-plans, Accordingly each

NGO was to evolve its annual plan.

Tribal Area Rural Area Urban Area


20/80

17

The micro-planning exercise brought to light the variations in the socio-economic, demographic and

geographical situations of the NGOs and hence the need for flexibility in the service provision

systems.

It clearly suggested that the HBNC model would have to be slightly modified to adjust to the local

conditions. One of the issues that it brought to light was that of variation in the population of hamlets

in the tribal areas, their distances from the main village and the terrain. This required a flexible system

of service delivery, lest it leads either to under provision of services or over staffing. The idea of

recruiting hamlet workers was given up. Instead, a flexible system of choice of deployment of VHWs

or hamlet workers or training TBAs in certain functions of the VHW was arrived at as per the local

needs. Such variations also had implications on the system of remuneration to VHWs.

An important aspect brought out by the micro-planning exercise was that in most cases the area

served by a VHW was populated by more than one community differing from each other culturally and

politically. Therefore, the issue of selecting the VHW who would be acceptable to all the communities

in the area became crucial. Another important issue was the variations in the choice of place of

delivery and the person attending the delivery. Deliveries took place in marital home, home of the

mother or in hospitals. Person who attended delivery could be, a neighbour, a TBA, a local private

doctor etc. This had implications on strategies for imparting health education, and on service delivery.

Training :

On the basis of its experience, SEARCH had designed the system to train HBNC personnel including

project coordinators, NCSes, VSSes, VHWs, and TBAs. Accordingly the training schedule, curricu-

lum, materials, methods and evaluation procedures were designed.

Training Curriculum :

The SEARCH training team along with a consultant developed the training curriculum. The team had

to keep in mind that none of the persons to be trained,(including NCSes / VSSes and VHWs) knew

anything about HBNC. Curriculum writing involved many steps. The team rewrote the job description

of VHW as given in the project proposal submitted to SNL, into a series of tasks and sub-tasks or List

of Competencies of VHW. Through discussions, the team finalised the knowledge, attitudes, and

skills that were needed to perform the tasks and sub-tasks. Thus, the team developed outlines for

each module of learning as well as individual sessions collaboratively.

Training Material :

The VHW training manual was developed considering the back-

ground of the trainees (village women) and the trainers (little or no

prior training experience). Emphasis was on refraining from clutter-

ing the training manual with excess and unnecessary information.

The training manual was highly structured with purpose, objectives

and training methods used to achieve the objectives clearly spelled

out for each session of training. Drafts for each of the training ses-

sions were written and commented on by all the members of the

team. Structured and unstructured feedback from the trainees, train-


21/80

18

ers and master trainers of SEARCH were received. Based on the feedback, individual sessions were

revised. The training modules were developed first in English and were then translated into Marathi.

Although the content of the training curriculum and the training manual were well thought out,

planned and developed, there was scope to revise the same as the training progressed, and newer

needs were identified. VHW training manual comprised seven training workshops, each covering one

to three modules, each dealing with a specific job/ role of the VHW. The other material developed

included health education flipchart and a film titled Tanhula for group health education under HBNC.

Training Method :

Training method too was designed keeping in mind the background of the trainees and the trainers.

The participatory methods of training included presentations, role plays, case study , demonstration,

field visits, practice, modelling, problem solving, group exercises, group learning, games, and songs.

The work in the field during the entire training period was viewed as learning by doing.

Training Pattern :

It was decided that VHWs & TBAs would learn best in a staged process, allowing for practice in the

field after learning in small doses of knowledge and skills in each workshop. Hence, knowledge and

skills had to be given in small doses. The whole training, beginning with training of the NCSes and

VSSes was carried out between October 2001 and January 2003, a period of 15 months. The training

comprised 7 TWs (Training Workshops) of trainers training (TOT), 7 TWs of VHW training and 3

TWs for TBA training.

Master trainers of SEARCH trained NCSes & VSSes of partner NGOs in training and supervision

skills as well as the contents to be passed on to the VHWs and the TBAs.. These trainers (NCS &

VSS) trained theVHWs in seven training workshops . They also trained TBAs in three TBA training

workshops

The training was modular and stepladder in fashion and proceeded in the following manner:

a. In TOT workshop1 the master trainers trained NCS and VSS in knowledge and skills of participa-

tory training, and also taught them the appropriate part of the VHW/TBA curriculum.

b. Immediately following this workshop, the pairs of NCS and VSS of the NGOs trained the VHWs at

their respective NGO sites. The VHW training workshop usually was of 2-5 days duration depend-

ing on contents of the workshop.

c. After this VHW training workshop, the VHWs practiced the skills acquired and used the knowledge

gained during the corresponding work in the community for about a month. The supervisor (NCS

or VSS) supervised the VHWs in the field by providing them on site support.

d. The time was then ripe for the next round of TOT. NCSes and VSSes returned to SEARCH to

participate in the next TOT workshop to learn newer training and supervision skills as well as next

part of VHW/TBA curriculum.

e. They again went back to their individual sites and conducted next round of VHW / TBA training.

This process continued till the completion of training of the VHWs and TBAs in all aspects of HBNC.

Initially the master trainers attended the TWs for VHWs for all the days and provided support during

the VHW training in each NGO.


22/80

19

For every training workshop, the first session of the first day was devoted to discussion on experi-

ences gained by the trainees during fieldwork done by them in the previous month. The training

workshop ended with recapitulation and planning for the work to be done in the field after the TW in

addition to what they were doing already. VHWs were also given refresher training, which was built

within the schedule of the main training. This was conducted once after the third training workshop

and then after the seventh training workshop.

The content, the sequence and the period of the different training workshops for the trainer supervi-

sors (NCS and VSS), VHWs and TBAs are presented in the appendix.

The trainers of SEARCH who conducted the TOT and then visited trainings of VHWs made certain

observations, some of which are reproduced below:

1. Nearly 100% attendance of VHWs at most sites for every training

2. Surprisingly fast development of VHWs who seemed to be weak in the beginning

3. Noticeable improvements in the communication skills of VHWs and confidence with which they

participated in the training programmes

4. The friendship developed between the VHWs and their trainers5. Special efforts by the trainers (NCS and VSS) to ensure that each and every aspect of training

content was transferred to the VHWs.

Evaluation of training :

Evaluation of the VHW training :

In the month of February 2003, the evaluation of the VHW training was conducted with the following

objectives:

a. To determine whether the VHWs were competent to deliver HBNC.

b. To evaluate the effectiveness of the method of selection of the VHWs, training design, training

methods and the training material.

c. To identify corrective measures and to provide inputs for revision and improvement of the training

package.

Evaluation of the NCSes and VSSes as trainer supervisors was also carried out. For this purpose a

four-member evaluation team comprising Dr Abhay Bang, two master trainers from SEARCH and the

training consultant was constituted.

A 7-page questionnaire was prepared to test the knowledge of VHWs in all the components of HBNC.

This was constructed for 100 marks. A 5-page schedule was constructed for NCS / VSS to evaluate

the skills of VHWs and had total 53 items In order to evaluate VHWs attitudes, quality of work, and

strengths, the schedule elicited information on 15 characteristics of VHWs, each on a scale of 0 to 5.

This schedule was completed in each NGO by the respective NCS. An 8-page field evaluation guide

was prepared exclusively for the purpose of VHWs field evaluation. The guide was constructed on a

100 mark scale, divided into 7 parts covering all the activities of a VHW. The guide also included short

one-page interview guide to interview the VHWs and the TBAs.

The evaluation team did an in-depth evaluation of two VHWs in each NGO. In each NGO, the team

selected these two VHWs (who were caring for a newborn in their area at the time of evaluation)

randomly. The evaluation team conducted a detailed evaluation of these VHWs by using the evalua-


23/80

20

tion training guide. They were also interviewed for their own feeling of self-growth and change. Score

of minimum of 70% was considered essential for a VHW to be judged competent to deliver HBNC

services.

Evaluation of NCSes / VSSes :

This was conducted on the basis of 1) Written Test (Knowledge) - Same as the one used for VHWs 2)Growth as a Trainer / Supervisor - Evaluation by the respective NGO Heads and Master Trainers, 3)

Personal Growth Done using a self-assessment form. The evaluation team also had in-depth dis-

cussions with the NCSes, the VSSes and the project coordinators. Earlier, their level of understand-

ing of the data was evaluated during the data analysis workshop that took place at Shodhgram in

October 2002.

Evaluation of TBAs :

This also was done in January-February 2003. This included interviewing the VHWs about the TBAs

behaviour and practices during delivery as well as interview of TBAs on their practices by NCS. The

evaluation team also evaluated a sample of TBAs from each NGO by interviewing them. For this

purpose also an interview guide was constructed.

As we saw in the above sections, extensive and intensive planning and training processes were

undertaken to ensure that the Ankur project was established on a firm footing in each of the 7 NGOs.

Now let us see how far the planning and training processes enabled transfer of HBNC knowledge and

skills and the values, mission and leadership that were necessary to be imbibed by the NGO teams to

implement the HBNC.

Transfer of Knowledge and Skills :

It was envisaged that the entire gamut of knowledge and skills of HBNC be transferred to appropriate

levels of staff in Ankur, including the project coordinators, the trainer-supervisors (NCSes and VSSes),

the VHWs and the TBAs. In addition to knowledge related to HBNC per se, it was also envisaged to

transfer knowledge and skills related to general programme implementation, management and con-

ducting community based research to the trainer-supervisors and the project coordinators. These

were transferred predominantly through training. In addition, workshops and field supervision by

SEARCH members too served the purpose.

Although the degree of transfer across all the NCSes, VSSes or VHWs varied, they acquired all the

basic skills and knowledge which were intended to be transferred to them. The degree of such trans-

fer to the VHWs and trainer-supervisors was brought out in the results of evaluations done by SEARCH

and SNL teams. These skills and knowledge acquired by the NGO personnel were put into efficient

use for implementation of HBNC. The degree of knowledge/skill acquired also was reflected in how

the NGOs had used these capacities of their personnel for their other programmes as well. Such

experience of using these knowledge/skills across programmes was cited by almost all the NGO

heads as an important gain. SEARCH, and to some extent the NGOs themselves instilled positive

attitudes in the trainer-supervisors and the project coordinators. These values penetrated from the

level of project coordinator, to the trainer-supervisors as well as to VHWs.


24/80

21

Village Health Worker (VHW) :

VHWs were trained in identifying pregnant women, and registering their

names in the list of pregnant women, followed by filling up the forms in

respective months and administering health education. In the correspond-

ing training sessions, knowledge pertaining to identifying danger signs dur-

ing pregnancy such as, swelling on feet, bleeding etc was imparted to the

VHWs. VHWs were provided knowledge and skills in diagnosing and man-

aging the health problems of neonates including birth asphyxia, sepsis, pneu-

monia, hypothermia etc. They were trained in identifying and managing high

risk babies. VHWs were also given the knowledge and skill of determining

and measuring out correct doses of medicines and injections, stock keep-

ing, and record keeping.

The training evaluation in February 2003 revealed that in a written examina-

tion to test knowledge, out of 92 VHWs who were evaluated, average score

was 86.1 %, with only 6 VHWs scoring 70% or below. As many as 94 % of the VHWs scored marks

above the passing level of 70%. On examining the results in the light of the area of the NGOs, it was

found that there were no significant differences in the performance of VHWs on the basis of the area

be it tribal, rural or urban although the VHWs of urban areas did a little better than VHWs of rural and

tribal areas. The difference in performance on the basis of the educational levels of the VHWs too

was not all that significant. The average scores for VHWs with education up to 7 years of schooling

was 83% and of those with more than 7 years of schooling was 89%. Even those VHWs, who had

schooling only up o 5 years, scored 81.2 %. Results of the written test showed a good understanding

of the basic principles of home-based neonatal care. Ninety percent of the VHWs could calculate

EDDs correctly in five examples and 87% could state the temperature for a newborn to be consid-

ered hypothermic. All the VHWs stated that a newborn did not need a bath on the first day; the cord

should be painted with gentian violet and 97% knew that frequent breastfeeding was the solution formothers perception of insufficient milk for breast feeding.

It is important to note that most VHWs had 4 to 10 years of schooling. Many of them were first

generation learners, belonging to the most backward regions, poor, rural, dalit or tribal. For some of

the VHWs, the NGO had to take special efforts to revive the skills of reading, writing and basic

arithmetic. Checking time using a wristwatch was a novelty for some VHWs as they had touched a

wristwatch for the first time in their life during the training under HBNC. Starting almost from the

scratch, the VHWs were trained to reach a level sufficient to provide HBNC services competently.

They were able to interact with the community and the visitors to the Ankur sites, and even deliver

speech in public functions.

All the essential skills of HBNC package were transferred by the NGOs to the VHWs through training,informal meetings, and face-to-face instructions. Broadly, these skills could be divided into 3 catego-

ries -Medical, Non -Medical and Communication skills.

Medical skills :

These skills included skills to identify complications in pregnancy, examining newborn, identifying

and managing neonatal ailments, identifying and managing high risk babies including skills in mea-

suring temperature, counting respiratory rate, weighing the baby and giving injection.


25/80

22

Non- Medical technical skills :

These included skills related to record keeping, stock maintenance, skills of hygienic practices when

handling newborn, and checking time using a wrist watch.

Interpersonal skills :

These included skills in delivering health education to the pregnant woman and her family effectively,

convincing the community to avail the services provided under HBNC, skills to arrange meetings in

the villages and ensure villagers participation in the meetings, work in coordination with TBAs, ami-

cably handling / solving problems in crisis situations and in situations requiring concerted / coopera-

tive action from the concerned family members and the neighborhood, and dealing with stakeholders

in and around the village. VHWs were trained to maintain useful relationship with other VHWs and

supervisors to facilitate congenial environment for learning.

The evaluation looked into all the necessary skills that were transferred to VHWs. The overall perfor-

mance was 94% with 72% achieving 90% marks. However, it was observed that the complex tasks

such as treating sepsis and birth asphyxia needed more practice. Filling Form A (antenatal), Form B

(delivery) Form C (1st examination at 1 hour) and Form D (home visiting after delivery) were generally

very good (i.e., > 95% when adjusted for no cases).

The VHWs themselves recognized that they had grown substantially in their ability and their person-

ality in general. This was articulated by almost all the VHWs interviewed by the process documenta-

tion team. Desheeribai of AAA articulated that her personality had completely changed ever since she

started working as VHW at AAA. Especially the group learning processes had made her very confi-

dent and it helped her in providing services also.

Attitude / Quality of work / Strength of VHWs :

Along with the knowledge and skills, it was expected of the VHW to imbibe / develop certain values /

attitudes to deliver the services in the community. Certain qualities which were actively sought while

selecting the VHWs included the following: (a) Kind and sympathetic to beneficiaries including moth-

ers, children and general patients (b) Non-discrimination treating everybody equally irrespective of

caste, religion, economic status (c) Prompt in performing duty (d) Eagerness to learn, work, and

provide services (e) Calm, composed and soft spoken (f) Honest at work (g) Ready acceptance of

mistakes (h) Caring of newborns (i) Confident (j) Capable of convincing people (k) Neat and tidy (l)

Courteous (m) Assertive (n) Cooperative and (o) Values gaining acceptance from community

Attitude / quality of work / strength of VHWs were evaluated by the respective trainer supervisors

(NCS /VSS). Altogether 96 VHWs were assessed. The assessment was done in three sections. The

first one assessed the VHWs attitude towards her work in general, and how she treated the people

she served. The second section looked at the VHWs quality of work, her punctuality, her neatness

and the completeness of her service provision. The third section assessed her strengths and capacity

to work. Each section contained 25 points, and each response was assessed on a scale of 0-5.

The results revealed that most of the VHWs got more than 90% marks in the attitude test and over

85% for quality of work. There appeared to be slight difference in attitude by area, with scores lower

in tribal and somewhat lower in rural areas than urban areas. It was observed that VHWs working in

urban area got about 97% marks followed by VHWs of rural area whose average score was 92.3%,


26/80

23

but the VHWs working in tribal areas could score only 84%. The differences could partly be due to

better capacity of articulation in the urban VHWs.

When reviewed by master trainers, the findings were consistent; the exception being one VHW who

received a C grade from the NCS but the master trainers felt she deserved a B grade, and 7 cases

where the master trainers thought that the NCS scored too high against 6 VHWs receiving A grades,

they felt B grade was appropriate, and 1 VHW with a B grade was judged as of C grade.

Trainer-Supervisors :

They unequivocally stated that they had imbibed important at-

titudes and values essential for commitment and involvement

towards implementation of HBNC programme. The values of

attaching importance to saving newborn lives was inculcated

in all of them. They realised it as the prime commitment in their

work. They provided all possible support to the VHWs to work

in the community and deliver services. NCSes did not restrict

themselves to the strict working hours. They were prepared toprovide service to the community through the VHWs supported

by them even at night, realising that there were no other facilities nearby. During their stay in SEARCH

for each training workshop, they left behind their families and concentrated only on learning. Absen-

teeism was rare. During the review meetings, (which usually were three to four-days period of inten-

sive learning), the NCSes and VSSes showed full attendance and attention. In these review meetings

all the trainer-supervisors, without an exception, exhibited meaningful interaction and participation.

They were open to learning, criticism, and correction. They became bold and mature after undergoing

the training. It is important to appreciate the fact that many of them used the training and supervisory

skills acquired by them under HBNC in other programmes of their respective organisation. They were

ready to accept their mistakes and work towards rectifying their mistakes without unnecessarily argu-ing. This attitude helped them to understand themselves better and also to gain a sound knowledge

of HBNC package and to minimize the mistakes during field visits. This attitude of supervisors also

helped collection of accurate data. To check the quality of data collected during the vital statistics

survey, VSSes of all the NGOs were usually asked to bring their data to SEARCH HQ to crosscheck

the data set. To reduce the number of mistakes they (VSSes) voluntarily decided to pay a penalty of

small token amount of money for every mistake that was found in their data set.

Almost all the supervisors were very comfortable with the community they worked with. They were at

ease with important persons in their respective area. Organising village meetings and group health

education sessions required commendable rapport with the community. Owing to their good relation-

ship with the community and leaders, the supervisors with the support of VHWs, easily identified andlocated the important people in the community, managed meeting community leaders, find a place to

have a discussion or for having food, and working out logistics. They were also aware and sensitive to

local norms such as those related to caste, women, and religion, as infringing these could jeopardise

NGOs relationship with the community.

Although social background of the supervisors varied, they were inculcated with a value of non dis-

crimination and did not discriminate on the basis of caste, religion or ethnicity and provided services

to all the families irrespective of their social background, on the basis of their need. They were found


27/80

24

to work and interact with the VHWs and the TBAs from different communities. In the area of SN for

instance, caste polarisation was found to be intense, yet the supervisors were able to reach out to

everybody. Invariably, in all the NGOs, NCS and VSS gelled into a good team without having any

superiority/inferiority complex or hesitation in working with a team member of an opposite sex . Often

male VSS provided logistical support for the female NCS and facilitated her visit to the villages at any

time of the day. On the other hand the VSSes gained confidence to supervise provision of treatment

by the VHW and also learn medical aspects in the presence of NCSes.

Project Coordinators :

Project Coordinators held the apex position in the ANKUR project

at the NGO level. As members of Ankur team, they were also pro-

vided orientation and training. Every project coordinator made ef-

forts to improve rapport with the community, to have a clear grasp

of social composition of the villages / basties, and established a

good relationship with the community leaders, some of the stake-

holders, public health personnel and individuals with philanthropicvalues in the project area. This was evident through various

programmes, and functions, which they conducted with the support

of the community. A good teamwork and coordination among project coordinator and other personnel

was visible in the NGOs studied. Even for attending review meetings, the project coordinators pre-

ferred to travel along with their team members and also allowed space for their VSS and NCS to

articulate their views and make decisions.

Transfer of Mission, Values, Attitudes and Leadership :

It has been SEARCHs mission to address the problem of child mortality. With complete involvement

in the child mortality study and subsequent partnership in Ankur, all the NGOs imbibed the gravity ofthe problem of child mortality in the state especially in tribal, rural and poorer settlements in urban

areas. The NGO personnel acknowledged the importance of reducing infant mortality, especially

neonatal mortality for overall improvement of health status of the community. Project coordinators

and the supervisors were able to relate the relationship between the lack of minimum health care

services and the high levels of neonatal and infant mortality. All the three NGOs chosen for the pro-

spective process documentation placed HBNC as the most important programme in their develop-

mental agenda. The mission of empowering the community through transferring necessary basic

skills was considered by these NGOs to be the most significant way of addressing the issue of lack of

access to basic health care including neonatal care.

SEARCH also wanted to transfer important un-stated values and attitudes to the Ankur NGOs. Someof these are (a) Empowering the community with knowledge and skills as large population of the

country especially living in rural, tribal and even in urban slums has poor or no access to institution

based facilities (b) Need for NGOs to appreciate the strength of good research and data. (c) Impor-

tance of advocacy - through sustained and concerted efforts it is possible to get the support of the

community, civil society organizations such as community based organizations, media, and profes-

sionals, as well as from bureaucracy and the government. (d) Importance of rigor in all aspects of


28/80

25

project planning, developent and implementation, and (e) importance of training and of trained hu-

man resource.

Through their partnership with SEARCH, orientation and rigorous training, the Ankur NGO staff im-

bibed the values that were to be transferred. At least three of the NGOs took up other projects (apart

from HBNC), which believed in empowering community through transfer of knowledge and skills. All

the partner NGOs came to appreciate the importance of good research and data not only in the HBNC

project but also started collecting and using data in many of their other projects. Most of these NGOs

began to identify community problems and solutions through community interaction. The NGO per-

sonnel began to attend Gram Sabhas where people air their problems. The NGOs looked to the

community as partners and allowed priorities to emerge from them. This became the essential ap-

proach of all the NGOs.

Importance of advocacy was imbibed by the NGOs through their involvement with SEARCH. All the 3

NGOs studied by the process documentation team during the prospective study, entered a phase

wherein they had begun to play important role in the formation and working with network of NGOs,

such networking through NGOs being another channel for advocacy. Basic skills of management and

planning were transferred to the NGO heads and supervisors. In addition to acquiring these skills,

most of these personnel had also come to appreciate the importance of planning, rather than doing

something just because it was to satisfy the funding agencies. All the NGOs adopted and used sys-

tems like pro-forma, supervision schedules, and defined job responsibilities, not only in the Ankur

project but also in other programmes.

NGOs started to attach importance to training and trained human resource. Some of the NGOs al-

lowed their personnel to get trained in additional special skills. They also allowed their staff to develop

into master trainers so that the lower level staff in their organisations could be trained adequately. In

AAA, the VSS was allowed to train staff from other NGOs on community based rehabilitation of

people with disability.

HBNC demanded leadership skills to deal with community, create community support for the project,

gain the support of stakeholders, motivate the staff including VSS, NCS, and VHWs, anticipate and

identify problems and solve them, take decisions in life-and-death situations, and above all maintain

the required level of rigour in implementing the programme. The ultimate aim of the project was to

transform each NGO partner into learning centres. Leadership skills, aspiration and the desire to take

up leadership role and initiative were transferred through training, orientation, workshops, review

meetings, and by suggesting and distributing reading material. This transfer was not limited only to

the NGO heads / project coordinators but also to the supervisors. This was evident from the manner

in which the NGO heads were conducting their NGOs. Each NGO head had his/her respective style

of leadership. Except for crucial decisions, the NCS-VSS team used to do the day-to-day planning

and implementation of the programme.

One of the distinguishing features of SEARCH as an NGO has been its work culture. Emphasis on

rigorous and meticulous mode of work, a strong flavour of community life stressing interdependence

and self-reliance are some of the important ethos of work culture shared by all the members of

SEARCH. Many of the Ankur team members took up this workaholic spirit. It was reported by super-

visory personnel that almost all the NGO heads had very long working hours throughout the year.

They kept shuffling between travelling and office-based work. Not only the NGO heads, but the super-


29/80

26

visors too were workaholic.

Peer group formation amongst the ANKUR partners was facilitated through different training sessions

and workshops. These groups displayed very strong interaction. These informal interactions played a

very important role in facilitation of each other, motivation, and setting up group norms for achieve-

ment, aspiration and compliance. The Ankur NGOs had indeed gelled into a cohesive group. This

was evident in the extremely informal and friendly relations the personnel shared with each other.

There had been instances of NGOs providing support to each other, even financial support at times

of need, or getting FCRA clearance.

Ankur NGOs were paired and personnel of one NGO of the pair visited the other and vice versa as

peer group visits. The purpose of such visits was learning from the experiences / innovations / prob-

lems faced by each other and joint problem solving.

Conclusion :

The findings under this chapter have brought out clearly the identification of a challenge which be-

came the mission; the meticulous and minute planning exercise carried out to ensure that nothingwas left out in transfer of HBNC to the Ankur NGOs and the training details in terms of curriculum,

training materials and training methodology were chalked out very clearly before launching the train-

ing. The modular and step-ladder format for training was very innovative and effective to transfer the

HBNC knowledge and skills. Further, the training was institutionalized within the Ankur NGOs rather

than SEARCH continuing to play the role of trainer. On the whole, the transfer process was very

elaborate, viable and sustainable. Thus, all the preparations for implementing the Ankur project by

the 7 NGOs in their respective areas were completed and they were ready to start the implementation

of HBNC.


30/80

27

Chapter - IV

Process of Transfer to the Communities : Implementation

Introduction :Having completed the preparation for implementing the Ankur project, the next challenge was of

delivering the HBNC package in the chosen areas of the 7 Ankur NGOs. Though SEARCH had

experimented the HBNC successfully in its own intervention area in Gadchiroli district, it was difficult

to predict the results of implementing the HBNC not only in a different environment but also by the 7

NGOs, which were different from SEARCH in terms of their leadership, values, knowledge, skills and

resources. In this chapter, we look at the processes to motivate the NGOs to deliver the HBNC

package in their areas. Further, the chapter focuses on the efforts to ensure that right persons were

placed at the right place and right time; and were motivated to deliver HBNC effectively.

Service Delivery :

Delivery of Home-based Neonatal Care

For the ANKUR project, the entire package of HBNC, mode o