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									                           Community Managed Nutrition cum Day Care Centers in rural Andhra Pradesh, India
                                                                                                                                      Bringing Health to the Community!
                                                                                               Society for Elimination of Rural Poverty, Indira Kranthi Patham Project Andhra Pradesh – India
                                                                 Lakshmi Durga Chava, State Project Manager, Health & Nutrition Unit, SERP, Hyderabad. Email ID: and visit us at

Introduction:                                                                                                                         How is NDCC established?                                                                                         Monitoring & Evaluation
Indira Kranthi Patham (IKP) is the largest                                                                                            Villages for Health & Nutrition interventions through CRP strategy are                                           -- HN interventions have an inbuilt monthly surveillance
community-based rural poverty reduction                                                                                               identified based on strong Institution Building, Health Savings and Food                                           system, Management Information System (MIS),
project in Southeast Asia, involving 9,646,000                                                                                        Security schemes.                                                                                                  that collects information on input, output and outcome
self-help group (SHG) women throughout                                                                                                Step 1: Team of five External CRPs come to stay in the village chosen for                                          indicators at the Village Organization (VO) level
the state of Andhra Pradesh, India. SHG                                                                                               implementation of HN interventions and one among them is exclusively                                             -- Bookkeepers and Health Sub-Committee are trained at
federated at village as Village Organizations                                                                                         responsible for the establishment of NDCC.                                                                         the village level for data collection
(VO),Mandal as Mandal Mahila Samakhya                                                                                                 Step 2: CRPs conduct survey, establish dialogue between the community                                            -- Information was collected from a sample of 200 NDCC covering 14 districts.
(MMS) and district as Zilla Samakhya (ZS).                                                                                            regarding health and nutrition conditions of women & children.                                                   -- Impact Assessment study in progress.
                                                                                                                                      Step 3:Individual counseling sessions with the beneficiaries; husbands,                                                                                                                                                                             P
IKP targets multi-dimensional causes of
                                                                                                                                      mothers and mothers-in-laws and VO members.                                                                                                                                                                                                         o
Poverty through programs in Microfinance,                                                                                                                                                                                                                                                  Hierarchy of MIS Data Collection
Education, Gender, Land Purchase and                                                                  1 State Office                  Step 4: Preparation of Micro Credit plans (MCPs) including the details on                                                                                                                                                                           l
                                                                                                      (State Project
Sustainable Agriculture, Insurance and                                                                 Monitoring                     duration proposed to take diet at the center, and the amount for monthly                                                                                                                                                                            i
                                                                                                          Unit)                                                                                                                                           Village Organization             Mandal level               District level                      State level
Marketing among others.                                                                                                               installments for each of the beneficiary enrolled.                                                                          level                                                                                                                   c
                                                                                                                                      Step 5: Release of one time grant of Rs 3.00 lakhs to the VO as revolving fund                                                                                                                                                                      y
IKP is under the direction of the Society for Elimination of Rural Poverty (SERP), a                                                  to each NDCC and Rs.50,000 towards capacity building of CRPs.                                                                                         Health Nutrition                                               State Project
                                                                                                                                                                                                                                                              Health Activist                 Community             District Coordinator
unique organization that draws from both governmental and private sector                                                              Step 6: Regular follow up for 6 months by the internal CRPs in the village and                                                                         Coordinator
                                                                                                                                                                                                                                                                                                                                                         Management Unit
personnel and resources to fill gaps in government development programs.                                                                                                                                                                                                                                                                                                                  M
                                                                                                                                      the field staff of the Mandal & Zilla Samakhyas.
Health and Nutrition interventions (HN) is one of the components taken up by IKP                                                      Step 7: Daily health education sessions for the mothers when they come for
and is implemented in 63 pilot Mandals across all of 22 districts in AP. The HN                                                       lunch at the center by the Health activist/ASHA using the flip books and
package of interventions targets health and nutritional status at each phase of the                                                   exclusive films developed.                                                                                                        Collect Data
                                                                                                                                                                                                                                                                                              Consolidate                  Review MIS                     Data Analysis                   r
life cycle approach.                                                                                                                  Step 8: Complete ANC and PNC at the fixed Nutrition and Health Days (NHDs)                                                         via Base
                                                                                                                                                                                                                                                                                               MIS forms                     forms                         & Reports
                                                                                                                                                                                                                                                                         Registers                                                                                                        s
                                                                                                                                      organized at the centers.
                                                                                                                                      Step 9: Trainings for bookkeepers, Health Activists, Health Sub-Committees
                                                                                                                                      Step 10: Periodic Social Auditing for transparency of accounts and community
                                                                                                                                      stewardship.                                                                                                          Maternal & Child Health Outcomes:
                                                                                                                                                                                                                                                                          Enrollment (% of total eligible)
                                                                                                                                                                                                                                                                                                                                   Pregnant women             43.8% (2111/4825)
                                                                                                                                                                                                                                                                                                                                   Lactating women            41.1% (1977/4810)
                                                                                                                                                                                                                                                                                                                                            Children          6.7% (1892/28318)
                                                                                                                                                                                                                                                                          Maternal Health & Service Coverage
                                                                                                                                                                                                                                                                          Deliveries N                                                                                  1098
                                                                                                                                                                                                                                                                          Antenatal Care % of women who delivered (N)*                                           97.4% (1041)
                                                                                                                                                                                                                                                                          Weight Gain during Pregnancy % (N)                                       >10kg          43.3% (475)
                                                                                                                                                                                                                                                                                                                                                  7-10kg          51.2% (562)
                                                                                                                                                                               Health Activist holding a health                                                                                                                                     <7kg           3.8% (42)
                                                                                                                                                                            education session about safe delivery,                                                        Place of Delivery % (N)                                  Institution                    88.5% (972)
                                                                                                                                                                             neonatal and infant care practices.                                                                                                 Home with trained attendant                      9.2% (101)
Community Resource Persons Strategy:                                                                                                                                                                                                                                                                           Home without trained attendant                      2.2% (24)
                                                                                                                                                                                                                                                                          Type of Delivery % (N)                                                Normal            86.2% (946)
Community Resource Persons (CRPs) are the best practitioners identified from                                                           Beneficiaries with their children                                                                                                                                                                       Cesarean           10.5% (115)
SHGs in rural villages. They are trained in all aspects of IKP Health and Nutrition                                                                                                                                                                                                                                                          Complicated           2.2% (24)
interventions with five specific themed areas: 1.Health Agenda, 2.Health Savings-                                                                                                                                                                                         Postnatal Care % (N)*                                                                  99.0% (1058)
Health Risk Fund-Health Insurance, 3.Trainings, 4.NDCC, and 5.Water &                                                                                                                                                                                                     Maternal Deaths N                                                                              0
Sanitation-Fixed NH days-weaning food (via convergence). These women, who                                                                                                  Nutrition cum Day                            Health Activist weighing the
                                                                                                                                                                                                                          pregnant beneficiary                            Neonatal Care & Outcomes
serve as Behavior Change Role Models, are sent to different villages in teams of                                                                                              Care Center                                                                                 Neonatal birth weight % (N )**                                           >3kg           56.2% (514)
                                                                                                                                                                                                                                                                                                                                                 2.5-3kg          42.2% (388)
five for two weeks at a time to motivate the community to take up the Health and                                                                                                                                                                                                                                                                  <2.5kg           1.4% (13)
Nutrition activities.                                                                                                                                                                                                                                                     Neonatal/Infant deaths N                                                                       2
             • Team of 5 external CRP Conduct survey & community meeting.                                                                                                                                                                                                 Neonatal care practices % (N)***                 Colostrum feeding                      98.9% (723)
             • Introduce the concept of HN interventions to SHG members                                                                                                                                                                                                                                                   No pre-lacteal fluids                   96.7% (707)
 Phase 1 -15                                                                                                                                                                                                                                                                                                             Immediate wrapping                       98.5% (720)
             • Motivate the community members to take part in HN activities
                                                                                                                                                                                                                                                                                                                              Delayed bathing                     75.5% (552)
                                                                                                                                                                                                                                                                                                                       Exclusive breastfeeding                    99.0% (724)
             • Next month, the same five member team returns to the village to gauge the quality and
               coverage of HN interventions.                                                                                                                                                                                                                              * Out of 1069 deliveries with complete data
             • Support the community to manage the interventions independently.                                                                                                                                                                                           **Out of 915 neonates with complete data
Phase 2 – 15 • Establish systems to sustain the activities.                                                                                                                                                                                                               ***Out of 731 neonates with complete data
                                                                                                                                         Monthly growth monitoring
   days      • Hand over the responsibility of implementation and monitoring to newly identified internal                                 for children under five at
               CRPs from the village.                                                                                                          Fixed NH days                                                            ANM worker giving TT vaccine to
                                                                                                                                                                                                                       pregnant woman at Fixed NH days.                          Weight Gain During Pregnancy                                     Infant Birth Weight
             •After 2 months, same team of five external CRPs come to the village to the evaluate the
             progress of HN interventions.
                                                                                                                                                                                                                                                                        100                                <90 days                    100                                     <90 days
                                                                                                                                                                                                                                                                         90                                90-120 days                 90                                      90-120 days
             •In between phases 1, 2 & 3, the newly identified internal CRPs supervise HN activities to
                                                                                                                                                                                                                                                                         80                                120-150 days                80                                      120-150 days
 Phase 3 – 3 make sure they are prompt and effectively operated.
                                                                                                                                                                             Community Kitchen Garden                                                                    70                                                            70                                      150-180 days
    days     •After six months of experience in their own village, Internal CRPs are selected to train as                                                                                                                                                                                                  150-180 days

                                                                                                                                                                                                                                                                         60                                                            60
             External CRPs as the HN Program is scaled-up.                                                                                                                                                                                                                                                 3rd trimester                                                       3rd trimester
                                                                                                                                                                                                                                                                         50                                                            50
                                                                                                                                                                                                                                                                         40                                                            40
                                                                                                                                          “I wish such Centers would be available to every woman. I would be happy to                                                    30                                                            30
     16 State CRPs/ 20Team                           664 External CRPs-                        Internal CRPs in over 300                                        have such Center in my mother-in-law’s village”                                                          20                                                            20
     Guide – Serve as                                serves as a trainers                      VOs- serve as resource                                              - Chennu Himabindu, Salem Palem, Krishna.                                                             10                                                            10
     troubleshooting                                   who are sent to                         persons in their own                                                                                                                                                       0                                                             0
                                                                                                                                          “The nutritious food I get at the Center like, green leafy vegetables, and a
                                                  villages to establish HN                     community & make sure                                                                                                                                                            10-12 kg      7-10 kg      <7 kg                                 >3 kg       2.5-3 kg        <2.5 kg
     experts in strengthen &
     deepening of the NDCC                              interventions                          the activities are sustained.              variety of other vegetables, fruits, milk and lentils has enabled me to put on                                                 Correlation between weight gained during pregnancy (Left) or infant birth weight (right) and
                                                                                                                                                                                                                                                                         number of days woman was enrolled in the Nutrition Center. Presented as percentage of
                                                                                                                                           weight. Earlier I weighed 47 kilos. Now I weigh 50 Kilos. I get advice and
        **When they are not involved in training, the State CRPs and Team Guides serve as resource persons for their own villages**                                                                                                                                      women who gained the indicated amount of weight out of all women enrolled for each
                                                                                                                                                         information at the Center. I’m very happy now”                                                                  category of time.
                                                                                                                                                                           -Bhupathi Nagavalli, Koduru.

Nutrition & Day Care Center (NDCC):
Aim: To improve perinatal and neonatal outcomes in rural Andhra Pradesh                                                               Cost Estimate of a NDCC:                                                                                         Scale-Up Plans:
-- Physical center i.e., building with kitchen, dining and a garden for                                                                                                                                                 Start-up                           Recommendations                                   SERP Targets                            Activities & Status
                                                                                                                                              Component                               Details                                                                                                                                                     •2007-08 Goals achieved.
   growing leafy vegetables                                                                                                                                                                                               Cost                          1. Investment in Social                         2007: 500 CRPs
-- Two meals in a day prepared and served to pregnant, lactating women                                                                                                                                                                                     Capital: Continuous                          2008: 1500 CRPs                           •Funding released from
   and children < 5 years.                                                                                                                                                 Microfinance Loans for the                                                                                                   From 2009                                 Health Department under
                                                                                                                                         Seed capital to the                                                                                               capacity building of
-- Each meal includes rice, dhal, 2 types of vegetable curry, green leafy vegetables,                                                                                      beneficiaries.                            Rs.200,000                                                                         onwards 2000                              NRHM & APHSRP for scale
                                                                                                                                         Village Organization                                                                                              CRPs, Health Activist                                                                  up of capacity building.
   egg, yogurt, fruit, and a cup of milk.                                                                                                                                                                                                                                                               additional CRPs will
                                                                                                                                                                                                                                                           and Health Sub-                              be developed and
-- Serves as a health education center where the Health Activist holds daily
   sessions on a number of maternal and child health topics.
                                                                                                                                                                                                                                                           Committees.                                  trained every year .
-- Cost of meals:                                                                                                                        Capacity Building of              Monthly State trainings &
                                                                                                                                                                                                                     Rs. 50,000
           * Rs 25 per day for TWO MEALS for pregnant and lactating                                                                      CRPs                              review.
           * Rs 10 per day for TWO MEALS for Children <5 years                                                                                                                                                                                          2. Government                                   2007: 200 NDCC                            •2007-08 Goals achieved
                                                                                                                                                                           Cook, room rent, kitchen
-- Pregnant and lactating mothers pay Rs 18 per day for two meals the                                                                    Initial Operating                                                                                                                                              2008: 1000 NDCC                           •Funding released from
                                                                                                                                                                           utensils, community                                                             Commitment:
   balance of Rs 7 is subsidized by the Community-Based Organization.                                                                    Expenses                          kitchen garden, weaning                                                                                                      2009: 2500 NDCC                           Health Department under
                                                                                                                                                                                                                     Rs. 50,000                            Convergence &                                                                          NRHM & APHSRP for scale
   and also dovetailing the funds from line departments of the Government of                                                                                               food, toy & play                                                                                                             2010: 5000 NDCC
                                                                                                                                                                                                                                                           coordination of                                                                        up of NDCC
            Andhra Pradesh.                                                                                                                                                equipments.                                                                                                                  By 2013: coverage
                                                                                                                                                                                                                                                           various public health                        of entire AP state                        •Institutionalization of
-- The beneficiary’s contribution
   is financed via a microfinance                                                                                                                                                                                                                          services and                                                                           Fixed NH days.
   loan which is repaid over 24–36                                                                                                                                                                                                                         programs: ICDS,
   months depending on income                                                                                                            Poorest of the Poor
                                                                                                                                                                                                                                                           Health Department,
                                                                                                                                                                           Support exclusively for POP
   of the beneficiary.                                                                                                                   Fund to Village                   with longer grace period to               Rs.50,000                             NRHM.
-- So far, 400 NDCCs have been                                                                                                           Organization                      repay the installments.
   established in 20 Districts of AP.                                                                                                                                                                                                                                                                   Impact assessment                         •Publishing periodic
                                                                                                                                                                                                                                                        3. Impact Assessment                                                                      progress reports about
                                                                                                                                                                                                                                                                                                        study underway
                                                                                                                                                                                                                                                                                                        and will be                               the HN interventions for
                                                                                                                                                                                                                                                                                                        published in April                        policy implications &
                                                                                                                                                      TOTAL                                                          Rs.350,000                                                                         2009                                      replication purposes.

  Acknowledgments: Funding for Health and Nutrition interventions under IKP is provided by National Rural Health Mission, Government of India, Andhra Pradesh Health Sector Reform Program, Department of Rural Water
  Supply, Department for International Development & World Bank.

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