Using the HSC Platform for effective convergence of ICDS and Health programs

IFHI/TSU, CARE India, Bihar

30 November 2014

The Health sub-centre as an Effective Platform for Coordinated Capacity Building and Supportive Supervision of Frontline Workers

Sridhar Srikantiah, Sunil Babu

Outline

Background: Need for meaningful convergence1

The Intervention: Utilizing HSC as a platform for review, learning, planning2

What it took to implement the intervention3

Key findings: Processes and Outcomes4

Implications5

Background: Need for meaningful convergence

ICDS, NHM in Maternal-Child Health and Nutrition: identical goals, overlapping

and complementary mandates

Unsatisfactory progress on key service coverage and behavior change indicators

over decades: systemic limitations, especially planning and supervision

AWW, ASHA, ANM: invaluable resource, inadequately optimized

Nutrition interventions need persistent efforts, and tend to fall through cracks

Previous experiments with convergence for improving outreach services were

encouraging

Ananya/CARE/BMGF mandate: help GoB programs accelerate improvements in

health/nutrition outcomes at population level

1

Health Subcenter: an unexplored platform

HSC: smallest population unit delivering health services; it is key to getting population level

results - reaching every mother and child. Typically covers

10000-12000 population

10-12 ASHA

10-12 AWW

1-2 ANM

per HSC – together, an ideal sized group for meaningful planning, learning, contextualizing

and monitoring

Earlier experience with the ICDS sector as a platform for convergence had some success, HSC

is a smaller platform

Challenge: How do we organize this group, at scale, to deliver results?

2

The Bihar Health Subcenter Model: 2012-2014

West Champaran

East Champaran

Gopalganj

Patna

Samastipur

Begusarai

Saharsa

Khagaria

Period May ’12 to Jan ‘14

Coverage

8 districts

28m population

2,300 sub-centres

40,000 ASHA + AWW

4,200 ANM

1,000 LS

Scaled up to entire state starting 2014

2

Main content areas

Service coverage improvement

Behaviour change through IPC

Basic processes to maximize reach

Defining ASHA, AWW

coverage areas, mapping,

enumeration

Name-based tracking

systems (Service registers,

Home Visits Planner)

Immunization, ANC, family

planning, JSY (linkage with

facilities)

Maternal and newborn

care, IYCF, family planning

Use of BCC tools

(designed by BBC Media

Action - Mobile Kunji,

Mobile Academy)

2

• Intervention focus: Direct interventions at the family level• Unit of implementation: Block (Block PHC, ICDS Project)

Main Intervention Processes

Structured monthly HSC meetings, designed for Incremental Learning and supportive supervision

Review: what did we do after the last meeting? (use of field observations, data)

Learning: new topics (What, Why, How; 2 topics each month - optional)

Planning: what do we do next month? (additional activities, related to new topic)

1

Structured monthly ANM meetings

2-4 hour sessions, during weekly ANM meetings at block

Program review, use of data, distribution of materials and ToT for ANM

2

Supervisory follow up in between meetings

By ANM during VHND, by LS/ICDS during village visits

Use of tools and checklists, generation of data

3

Additional project

resources

• Co-facilitator for subcenter meetings

(2/block in 8 districts until Jan 2014)

• Block Coordinator for facilitation of

implementation (1/block)

Covering all key RMNCHN operational

areas incrementally takes about 18-24

months (includes 8-10 HSC meetings per

year, includes breaks for revision)

2

What it took to implement the intervention

The project recognized

• Poor coverage of outreach services and family

level behaviors in RMNCHN, with exceptions

(e.g. immunization, institutional delivery)

• Potential of HSC as a platform to organize

outreach RMNCHN services of health and ICDS

District and state level leadership of the two

departments recognized need and potential, and

agreed to implement at 8 district level with

Ananya/CARE support; issued joint directives

Elaborate microplanning at block levels to schedule

HSC meetings

Elaborate program monitoring to gather evidence of

coverage and outcomes

Additional human resource in initial districts;

minimized in scale up

Small fund for running each HSC meeting

GoB requested scale up across state, was included in

2013 NRHM PIP, approved by GoI (Rs 300 per HSC

meeting for incidental expenses)

Quick assessments / pilots confirmed feasibility,

acceptability

.. Activities in 2011 .. Activities in 2012

3

Key Process Findings

Feasibility, acceptability high

> 90% of planned HSC meetings took place

AWW, ASHA attendance consistently ~ 70 %, AWW attendance better than ASHA

1

Learning opportunity is a key driver for ASHA, AWW, ANM participation2

ASHA, AWW manage overlapping mandates easily: no major conflicts3

Consistent focus on universal coverage and IPC drove performance: existing programs can be effective4

Learning and doing take time: need to balance campaign and program approaches5

Supervisory follow up remains weakest link: a matter of program priority and strategy6

4

Key Outcomes in Monitoring Data (1/4)

14

42 4433

59

71

42

69

82

0

20

40

60

80

100

R3 R4 R5

Introduction to semi-solid, solid foods

6 month % 7 month % 8 month %

8

3237

30

5769

0

20

40

60

80

100

R3 R4 R5

Minimum Dietary Diversity

6-8 % 9-11 %

4

8

2935

29

5462

0

20

40

60

80

100

R3 R4 R5

Minimum Acceptable Diet

6-8 % 9-11 %

Key Outcomes in Monitoring Data (2/4)

4

27 7 10

17

0

20

40

60

80

100

R1 R2 R3 R4 R5

Children receiving Animal Foods

1220 23

4653

3344

54

7281

0

20

40

60

80

100

R1 R2 R3 R4 R5

Children receiving pulses

6-8 % 9-11 %

4 7 917

25

9 1319

2132

0

20

40

60

80

100

R1 R2 R3 R4 R5

Hand washing with soap – reported practice

6-8 % 9-11 %

Key Outcomes in Monitoring Data (3/4)

4

1 4 6 3 6 74 9 11 9 11 13

0

20

40

60

80

100

6 months % 7 months % 8 months % 9 months % 10 months % 11 months %

Children consuming recommended amounts

R4 R5

57

71 74

5360 5958

65 6858 60 61

0

20

40

60

80

100

6 months % 7 months % 8 months % 9 months % 10 months % 11 months %

Children consuming at least half the recommended amounts

R4 R5

Key Outcomes in Monitoring Data (4/4)

73

59

50

60

38

22

13

21

28

0

10

20

30

40

50

60

70

80

Fed solid or semi-solid food*** CF initiated at 6mo*** Fed from separate bowl yesterday***

Ad

just

ed

Per

cen

tage

Ad

op

tin

g G

ive

n B

ehav

ior

FLW visited with relevant advice FLW did not visit with relevant advice Adjusted difference

Note: ***= adjusted difference significant at the 1 percent level. Regression-adjusted estimates account for rural location, SC/ST status, religion, education, age, parity, SES quartile, and husband’s education.

FLW efforts correlate well with outcomes:Advice from FLW with corresponding practice

4

(children 6-11months)

Conclusions and Implications: From Despair to Hope

HSC is a useful subunit platform for systematic program review, learning,

planning related to outreach interventions common to Health, ICDS

The incremental learning approach has potential as core process for HSC or

other platforms:

• agnostic to content

• enables perpetual improvement

• integrates learning with implementation: brings together practical

learning, supportive supervision, data use, convergence at

subcenter/block/district levels

High potential for implementation and tracking of multi-sectoral

approaches for improving nutrition

5

Acknowledgements

• State and District leadership of Health and ICDS departments,

Government of Bihar, for being open to change and to evidence

• ASHA, AWW, ANM of Bihar, for their passion for learning

• Ananya partners and field teams, for the lessons we are learning