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					                       Plan International India




   Comparative Evaluation of Community Based Health Interventions




Bhaswati Chakravorty
March 2007




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Acknowledgement
I am thankful to Plan International India for supporting this evaluation study. I thank the program
staff of Plan and particularly the Program Evaluation Unit for their cooperation and assistance in
conducting the study.

My sincere gratitude to CASP Delhi, SBMA and URMUL Lunkaransar - and the community
members for their kind support, patience and valuable insights.

The evaluation study has indeed been a learning experience for me and along with Plan partners
and I earnestly hope that it offers lessons in collective efforts towards facilitating community
based health intervention.

I wish Plan and its Partners success in all their future endeavors.




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                                   Executive Summary
1. Objectives of the Evaluation

Over the years, approaches to program evaluation in Plan International India has changed with an
increasing emphasis on involving the primary stakeholders, in the process of deepening their
accountability, search for learning and analysis of outputs and outcomes. Therefore the goal is to
understand the program achievements, failures and missed opportunities across three Program
Units – CASP Delhi (PU# 6001), Urmul Lunkaransar (PU# 6002) and SBMA (PU# 6011).

The evaluation process intended to be a mutual learning exercise to enable Plan partners to
emerge stronger with a better appreciation of the potential and challenges in their respective
projects. The methodology used a broad range of methods, such as in-depth interviews, focus
group discussion, semi-structured interviews to assess the impact of the program.

2. Relevance of the Inte rventions

Over the years, Plan International and its partners have expanded their activities to include non-
institutional services like awareness building on health, education and nutrition. With the thrust
on primary health care, the Plan partners are also shifting the focus to encourage community
participation, seeking inter-sectoral coordination through grass root level workers of various
sectors.

CASP Delhi: CASP‟s health programs and its interventions are based on providing preventive
and promotive health care through awareness building, education, income generation and
community based clinical services.

SBMA – Uttarkashi: SBMA‟s main focus has been in organizing regular health camps for the
entire community. These health camps are also being creatively used to identify specific issues
and generate basic awareness.

URMUL – Lunkaransar: given the poor health infrastructure in western Rajasthan, URMUL has
been useing mass approach on health awareness as a starting point. These mass approaches have
been able to provide awareness about the basic prevention of common diseases among the
community.

2.1 Overall Relevance

In keeping with the specific needs of each location, the relevance of the health program is well
established. Besides improving the service delivery in the health sector, the health program a lso
believes in the potential of such a strategy in which the poor themselves become active agents of
their program. However such shifts in approach and methodology are still in a state of transition.
Further, to make the program more effective the community needs to enhance its capacity in
understanding the systems of governance.

3. Effectiveness of the Strategies

Plan and its partners have developed context specific health interventions recognizing the variable
state of development across the country and the challenges being faced by the communities.




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CASP:

   The organization‟s strategies are centered on community based clinical services and
    promoting health care through awareness building and education. They had started with two
    referral clinics – in Sangam Vihar and Badarpur. While the Sangam Vihar clinic has been
    closed as per Plan‟s guidelines, the one in Badarpur is to be continued till June 2007.
   CASP has also developed a team of trained field workers from the community itself to assist
    its various programs as volunteers which has been registered as a society.

SBMA

   SBMA has focused on developing strong community based groups - MMDs, Bal Panchayat, ,
    kishori sanghs and sanjivanis as community health workers. Formation of these groups is
    meant to reflect on collective empowerment of community to affect changes at the local
    policy levels.
   They have introduced the concept of People Health Security Fund (PHSF) which has
    reportedly benefited a large number of families
   SBMA has also developed an interesting communication material in the form of a Horoscope
    which has all the relevant health messages. These booklets are distributed to the religious
    leaders for the name giving ceremony. There is a huge demand for these booklets.

URMUL

   URMUL‟s health program is anchored by the Nirogi Saathi (NS) – the barefoot doctors. One
    of the organization‟s efforts to reach out to the communities who otherwise have no access to
    health care is through developing a cadre of “Baksa Sanchalak” (BS) as community health
    workers.
   URMUL has also developed strong men‟s SHGs with emphasis on leadership qualities. Many
    of them have become PRI members, involved in monitoring the functioning of government
    representatives (doctors, ANMs, teachers).
   The Balika Shibirs organized by URMUL has done a great service to the entire community of
    girls who were typically the drop outs or those who never went to schools..

3.1 Overall Effectiveness of the Strategies

Comprehensive package: The strategies clearly reflect the approach common to all the partners,
i.e., package of defined interventions.

Mix of service delivery and capacity building: As the community participation had not been easy
in the beginning, the health interventions initially reflected elements of service delivery.
Gradually the focus has been shifted to building capacities of the communities through formation
of CBOs to enable them to influence public health policies.

3.2 Follow up:

   The transition from a delivery approach to community ownership approach would require a
    sustained partnership with the community to strengthen community-managed primary
    healthcare systems that encourage changes in health-related behavior and attitudes.




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   The health program needs to strengthen the conceptual and strategic clarity of how the
    structural causes have a bearing on the health of the population. For instance, analyses of all
    the POs indicate that they are all addressing issues related to women‟s health, but the analysis
    of gender-based inequities impacting on reproductive health is not quite clear.

4 Linkages with the Governme nt

   The PUs have been playing a supportive role to the government while placing more emphasis
    on capacity building of community based organizations. They also have supported
    Government programs with material support – medical instruments and vehicles which
    enable the doctors/ANMs to visit remote areas.
   Although such forms of collaboration between PU and government are encouraging but it
    remains to be seen how far the achievement is going to be sustained after the PO withdrawal.

5 Organizational system: Monitoring and Evaluation (M&E)

   The M&E system has remained at a functional level - the reporting is more in the nature of
    completion of activities. Not much of analysis of what has worked and what has not.
   A substantial part of the M&E system seems to be carried out rather mechanically whereby
    conceptualization, flexibility and more importantly learning from concrete experiences is
    missing.
   M&E system should be dynamic and constantly adjusting to capture the unique feature of the
    health intervention.

6. Program Impact

Increased level of community awareness: one of the greatest impacts has been in terms of
attitudinal changes among the community members on safe health practices and awareness about
preventive aspects of health.
Proactive role of communities: the PUs have sought to build in more community (largely
women‟s) stakes through bringing about a shift in behavior through developing various
community based groups to take on the leadership role in development issues.

Increased participation of children: the PUs have been concentrating on child rights which have
had a significant impact in terms of involvement and participation of children and youth.

Committed NGO staff: the program has developed a strong, committed and competent staff
cutting across all the PUs – this human resource base is the biggest asset.

7. Key Program Challenges

Institutional Learning: it is a weak link in the program mainly due to a lack of deeper learning
and reflection culture within the organizational set up. It is important to proactively promote and
support mechanisms for sharing experiential learning at various levels - at the community level
and across PUs in a more systematic manner.

Integration: As the PUs have a holistic intervention in the community, they are able to interrelate
the sectors they are working in with the problem of the area. However, the cross-linkages among
various problems and the possible solutions across the domains are not so evident – e.g., linkage
between livelihood security and safe motherhood.


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Gender Equity: Gender equity by and large has been understood as equal participation of men
and women. However, analyses of all the POs indicate that the gender perspective needs further
strengthening.

Community Participation: the extent of participation is found to be varied across different
villages and the focus seems to be mainly on participation of members of these groups and not
necessarily of the entire village. Participation of PRIs in the health intervention seems to be on
the lower sides.

Linkages with service providers: effective and functional linkages with various community level
platforms, institutions like PRI and RPMs are limited and need more work.

8. Sustainability

   Sustainability is a complex issue. Short term access to external support may increase the pace
    of activity without at the same time ensuring the capacity to undertake it in the long run.
   This is illustrated aptly in case of CASP which had opened a clinic in Sangam Vihar but had
    to close down when the PO was closed and subsequently the program lost the momentum.
   A similar fate is awaiting Badarpur clinic if it closes down in June 2007. Unless a proper
    phase out is planned right at the outset with the community‟s active involvement, it is likely
    to affect the community adversely.

9. Recommendations

Program synergy:

Plan level: the program has to have a concrete strategy for convergence of all services at the
community level needs, including health, hygiene, sanitation, nutrition, education, livelihood and
governance
PU Level: the community needs a thorough understanding of the Government program, the way
the system operates, the way they can exercise their rights and so on to make the health
intervention truly “community based”.

Gender

Plan and PU Level:
 Gender sensitization of staff to mainstream gender in planning and implementation.
 Addressing gender at each stage of project management, from information collection to needs
    assessment, to implementation and monitoring, thus ensuring that both men, women and
    children benefit from development interventions
 Clear formulation of measurable goals and outcomes related to gender equity is required.

Monitoring and evaluation

Plan and PU level:
 The M&E systems should also capture qualitative data to understand the complexities in
    health interventions.
 Undertake periodic process documentation and self evaluation
 cross learning among the PUs to be made more systematic.


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Community participation and ownership:

PU level:
 Community participation and their quality of ownership need to be enhanced. Conscious
   efforts to be applied to examine who is participating (are any groups being left out) and at
   what level, This is to ensure that the weakest (migrant families, single women) and less
   articulate ones are not unconsciously excluded from the program
 To ensure that the resources are not just based in the community but also managed by the
   community, the PUs need to build the organizational capability of CBOs.
 The community also has to be prepared to take over some of the operational costs after the
   PU withdrawal – for instance, honorarium for sanjeevanis, baksa sanchalaks, etc.

Participation of PRI and other Government Agencies

PU level:
    The PUs need to develop a framework that would define the exact nature and scope of
       involvement of PRIs and other government staff in the health program.
    Strategies to use school platforms for children‟s health should be used on wider scale..

Capacity enhancement of CBOs

PU level:
    The village health functionaries are the pillars of the health program. The program should
       develop mechanisms to track the changes in the capacity of the CBOs/health
       functionaries over a period of time.

Sustainability:

Plan and PU:

      The sustainability plan either at the Plan or PU level does not seem to be very clear at
       present. Therefore it is suggested that a thorough analysis should be made to have clarity
       on specific aspects of program where time bound funding is sought with a detailed phase
       out strategy.
      Likewise, similar understanding needs to be fostered with the community to enable them
       to place the mechanisms of PU withdrawal in place which at present is yet to receive
       adequate attention in the program.




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1 Background

India is rapidly developing into a world power seeking permanent representation in the UN
Security Council. Yet almost one third of its billion population live on less than a dollar a day,
and the rights of women and children are still far from being realized. Although progress has been
made in some areas of development, notably immunization and school enrolment, indicators
show that other areas remain stagnant. 1 Given the sheer magnitude of the poverty, Government is
searching for ways to improve equity, efficiency, and responsiveness of the health system.

While there is no common agreement on optimum structures and systems to deliver cost effective
services there has been an acceptance of the significance of primary health care which is based on
practical, scientifically sound, and socially acceptable methods through community‟s
participation and at a cost the community can afford to maintain at every stage of their
development in the spirit of self reliance and self determination.

For the past three decades, Plan International (India) has been supporting projects to strengthen
the life situations, knowledge and capacities of children, families and communities in India.
Plan‟s community based health interventions are designed to reach the vulnerable groups in
society – especially children, child bearing women with low cost proven medical technologies
including immunization, systematic prenatal care and treatment of common ailments. At each
level of care, Plan and its partners‟ focus has been on providing services that are needed by the
community and on building linkages with the system.

1.1 Objectives of the Evaluation

Over the years, approaches to program evaluation in Plan International India has changed with an
increasing emphasis on involving the primary stakeholders, in the process of deepening their
accountability, search for learning and analysis of outputs and outcomes. Therefore the objective
of the evaluation is to understand the program achievements, failures and missed opportunities
across three Program Units – CASP Delhi (PU# 6001), Urmul Lunkaransar (PU# 6002) and
SBMA (PU# 6011).

However to achieve these overarching objectives Plan International felt that it was not enough
evaluate projects and programs in isolation. It needed to compare the interventions across PUs to
have a better understanding of the larger social, economic, cultural and political influences on the
project processes, outcomes and impact. Further, such comparative evaluations would enable Plan
to analyse and appreciate the strengths and weaknesses in different Pus, provide opportunities for
cross learning and make assessment on the relative capacities of PU staff and community workers.
At another level, the evaluation finding would enable Plan International (India) management and
PU leadership to make decisions on resource allocation, expectations, risks and opportunities.

Thus the following were the specific objectives of the evaluation:

1. Comparatively evaluate efficiency of Plan‟s thematic interventions across different Pus and
   assess whether objectives and outcomes have been achieved
2. Identify the major issues/factors influencing the achievements or non achievements of the
   project objectives
3. Comparatively evaluate the extent to which the project was able to reach its target
   communities

1
    Country strategic plan, Plan International India


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4. Comparatively analyze the processual and knowledge linkages between the project, as also
   their linkages with other thematic interventions within Pus and outside
5. Assess the extent to which the project‟s activities have coordinated with state and other CSOs
6. Review and recommend appropriate organizational structure/systems for the thematic work,
   with particular focus on meeting the needs of the Child Centred Community Development
   (CCCD) approach in the PUs.
7. Give recommendations on how to move forward into project theme related programming
   opportunities within the PU

1.2 Evaluation Methodology

The evaluation process was meant to be a learning exercise that provides an opportunity to reflect
on the past in order to define future direction and actions. It was essentially intended to be a
mutual learning exercise to enable all three project partners of Plan to emerge stronger with a
better appreciation of the potential and challenges in their respective projects. Although the
review was „external‟ in nature, but the process aimed to include an active involvement of all
stakeholders including Plan to gain a better appreciation of the complexit ies in which the
organizations were embedded with the objective that such an approach would also enhance the
ownership of the evaluation at the level of partners.

As a first step, all the background materials related to the program was shared by the team of Plan
International including the formulation and completion project reports. Subsequently, a meeting
with Plan staff in Delhi was held to arrive at a common understanding of the ToR and determine
the parameters of evaluation process. The meeting helped in finalizing the methodology, timeline
including the filed visits.

Field Visits were undertaken in all three PUs. The first day was spent in a meeting with the
project staff to understand the context in which the project was working, its organizational
structure, program strategies and linkages. Documents – process documentation (if any), minutes
of the meetings, training curriculum, annual reports - pertaining to the project were also reviewed.
The last day was spent in sharing and debriefing.

The coverage and selection of villages were left to the discretion of the project staff. In
consultation with Plan and PU, it was decided to visit both strong and weak groups (selected by
the partners) to get a better understanding of the effectiveness of the strategies adopted by the
partners.

The evaluation methodology used a broad range of methods, such as in-depth interviews, focus
group discussion, semi-structured interviews to assess the impact of the program. The
interviewees included women‟s groups, adolescent girls and boys, their family, and community
members. In addition, the team also engaged with the implementing partner organizations,
government officials including Panchayat members, dais (Traditional Birth Attendants)
anganwadi workers (AWW) and teachers.




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1.3 Limitation of the Study

The evaluation approach was serious in its intent to break away from the inherent constraints of
an external evaluation. Therefore what was needed was a more participatory process of review, in
which knowledge, values, the desire for change and plans of action were to be evolved in a spirit
of partnership. Despite strong commitment and involvement of all parties involved, it essentially
remained a Plan sponsored “external evaluation” with limited stake of project personnel of PUs.
For instance, it was quite disheartening to note that the detailed ToR prepared by P lan was not
shared or studied/reflected by the project staff prior to the consultant‟s visit, which not only had
implications in terms of time spent in revisiting the ToR but more importantly, reflected a lack of
ownership in the spirit.

Although two days were scheduled for the field visit, the actual time spent in the field could not
be effectively managed due to varied reasons. In the case of SBMA where it is working in remote
and difficult terrain, the bad weather naturally disrupted the schedule of the field visits. In other
cases, it ranged from logistical arrangement to being occupied with other pressing matters to
communication and so on. For instance, while the change of field visit date from 20 th to 19th
March was reconfirmed on phone with the program Manager, CASP Delhi, in advance, yet it was
not communicated with the project staff resulting in some last minute (avoidable) confusion.

Right from the inception of the study, it was mutually agreed upon that a team of two member
would be responsible for the study, however the actual process was carried out by only one
person with the exception of URMUL where Plan staff had also joined the mission. In retrospect,
it can be concluded that in view of the complexity of the development processes it would have
been desirable to have more than one person doing the study.

2. Relevance of the Inte rventions

2.1 The context analysis

Government Intervention: Since independence, India has created a vast public health
infrastructure of sub-centres, Primary Health Care Centres (PHCs) and Community Health
Centres (CHC). There is also a large cadre of health care providers (ANMs, Mid wives,
community health workers, etc), yet this vast infrastructure is able to cater to only 20% of the
population and the rest rely on private and indigenous health providers. There are many reasons
for dismal performance of Government system both in the rural and urban settings, almost all of
them stem from weak stewardship of the sector which produces a poor incentive framework. The
present structure is extremely rigid, making it unable to respond to local realities and needs.

Plan interventions: In the context, where the government system is characterized by lack of
accountability and responsiveness to the general masses, the partner organizations of Plan
International have been playing a critical role in the promotion of welfare services for the
vulnerable sections specially women and children. Over the years, they have expanded their
activities to include non-institutional services like awareness building on health, education and
nutrition. With the thrust on primary health care, the Plan partners are also shifting the focus to
encourage community participation, seeking inter-sectoral coordination through grass root level
workers of various sectors. They have been trying to bring various programs within the fold of
single unified health care services while strengthening the capabilities of grassroots workers in
building strong community health action plans.




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CASP Delhi

CASP – the Community Aid and Sponsorship Program – CASP, is one of the pioneers in India in
the urban health sector. Urban health facilities in most areas are inadequate lacking in uniform
organizational structure and infrastructure development. CASP‟s health programs and its
interventions are based on providing preventive and promotive health care through awareness
building, education, income generation and community based clinical services. Its mission is to
improve the quality of loves of children and their families in the urban settlements through
community development initiative.

Project areas: CASP is working in the slums of Badarpur and Sangam Vihar in Delhi. Badarpur
is a mix of rural and urban settlements spread over 200 acres of land with a population of about 2
lakhs. The area is characterized by inadequate water and sanitation facilities, poor housing
conditions, inadequate health services (Government hospital is at a distance of 18 kms), only
private doctors are providing basic curative services. This is an unauthorized area with the
exception of Sapera Basti, which is a snake charmers community in existence since 1700 AD.
The people in the area mainly suffer from TB, Asthama, skin infections and RTI.

Sangam vihar, a resettlement colony came into existence in 1978-79, inhabited by one lakh
people residing in 20,000 dwelling units. The community consists of rural and semi-urban
population who came in search of livelihood. The women generally work as domestic help with
their daughters as young as 8-10 years old. A base line survey done by CASP observed that
Sangam Vihar had no provision of electricity and safe drinking water; sanitation facilities were
dismal (common toilets), water logged area and lacking in quality health care facilities. The
government health facilities are at a distance of 10-15 kms. About 33% of the population were
reported to be TB positive.

Comprehensive package: Over the years, CASP has provided supportive services like installation
of hand-pumps, pre-school education services, formation of savings and credit societies, road
repairs, provision of street lights and so on. Likewise in Sapera Basti too, CASP had started with
a service delivery approach to not only mobilize the communities but also to respond to their
basic needs. given that the communities in both the locations have little or no access to quality
primary, secondary or tertiary health services, CASP had established RCH clinics in both Sangam
Vihar and Badarpur areas.

The major causes of ill health in these communities are due to environmental factors, addict ion,
reluctance to adopt positive health seeking behavior, myths and misconceptions and no access to
quality services and information. The government programs have done nothing to either reach out
to the community effectively or to raise their awareness levels. In this context, CASP Delhi has
tried to provide the much needed services to the community through a comprehensive package of
MCH, immunization, family planning, treatment of STDs and HIV/AIDS besides awareness
programs on safe water, hygiene and sanitation.

The community feels beholden to CASP for reaching out to the people who needed the services
most. As one of the CBO members said, “We had no Government facilities in the area. ANMs
also did not come regularly. All we had were the “jhola chaap” doctors (the quacks) – the only
service providers. CASP was the only organization to understand our needs and fulfill them.
Since CASP came into this area with its programs and RCH clinics, we are now getting on to the
track of seeking and practicing positive health behavior”




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SBMA - Uttarkashi

From a shelter home in 1977 for women and children of Garhwal hills, SBMA has over the years
evolved into a comprehensive people‟s institution. The organization has undertaken major
development interventions related to women and child health, education and natural resource
management. SBMA‟s mission is to work with children and their families and presently it is one
of largest civil society organizations in Indian Himalayan states. It is working in Gairsain and
Uttarkashi in Uttarakhand.

Status of health in project areas: The population in the SBMA project areas is largely engaged in
agricultural and dairy activities. The main problems in the context of development in the Garhwal
region are related to fragmented small and marginal land holdings, tough hilly terrain, soil erosion,
landslides, fragile mountain eco system and under developed infrastructure. Given the large scale
male migration, women are over burdened.

On the health front, non-availability of services has a direct bearing on the poor health status of
women and children in the project areas. Low status of immunization, prevalence of malnutrition,
ARI, high incidence of anemia, absence of family planning services, unsafe deliveries and lack of
basic knowledge on preventive measures are some of the major health issues in the region. TB is
highly prevalent – the state health census shows that the BCG coverage is only 52%. This is
further compounded by poor hygienic practices, consumption of contaminated water and lack of
quality health care services at the community level. Poor knowledge and misconceptions among
the adolescents towards reproductive and sexual health is also a critical issue.

Inadequate services of the Government Health system: Poor health infrastructure is a major
cause of high mortality. Given the tough terrain, there is a scarcity of Doctors in the region. Even
the ANMs are not available for the remote villages. Most of the health facilities created by the
government are centred at the district hospital while the secondary or tertiary level facilities are
available only in the state capital. Also this is a population where almost no one is really rich and
often they find it extremely difficult to mobilize cash for health emergencies or hospitalization.
The need for health insurance is felt very acutely in the region.

Given this context, SBMA in Uttarkashi is working in 72 villages of Bhatwari and Dunda blocks,
covering more than 4700 families in which 2500 are the sponsored families of Plan. Most of these
72 villages are situated on a high altitude which entails about 2-3 hours of walk from the main
road. The organizational infrastructure consists of 1 central coordinating office in Uttarkashi and
10 cluster offices, each covering 8-10 villages located in the remote hilly areas.

SBMA’s health intervention: SBMA‟s main focus has been in organizing regular health camps
for the entire community. These health camps besides being used as service delivery instruments
are also creatively used to identify specific issues and generate basic awareness. An elderly man
at Dhungi village remarked that “SBMA staff mobilized us with love, sincerity and
commitment…earlier we were reluctant to meet them, but they were persistent and used to hold
long village meetings…the health camps organized by them were a boon….we are so grateful to
them for awakening us…”

Additionally they are helping the Government departments with regard to immunization. The
organizations‟ field staff accompanies the ANMs to all the remote villages which otherwise
remained under serviced. One of the unique features of SBMA‟s interventions has been the
“People Health Security Fund” (PHSF) provided to more than 50 women‟s groups (MMDs) for
health emergency purposes. They are also providing orientation training to DOT providers and


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PRI members to encourage TB patients to come forward for treatment. Further, SBMA is also
trying to link them with the VHCs so that these efforts can be institutionalized.

URMUL – Lunkaransar

To educate the rural poor masses of desert regions in Rajasthan, URMUL Rural Health Research
and Development Trust was formed in 1986. The Trust started its work from Lunkaransar and
worked primarily with health issues. URMUL Setu Sansthan was created as a result of a
decentralization process in which the four branches were registered as separate entities in 1993-
94.

Status of health in Western Rajasthan: Health of a community is directly associated with
awareness, knowledge, attitude, behavior and practice. Among the rural communities in
Rajasthan, these prerequisites of health are lacking resulting in poor adoption of health practices
and health status of the people. The western Rajasthan with its vast stretches of desert looks very
desolate with no roads, no sub-centres and no government infrastructure in sight. Immunization is
a major issue as the ANMs do not cover the inaccessible villages lying in the desert tract.

While the delivery of high quality social service to the poor is never easy, there are several factors
that make health care very difficult and this is especially true of woman for whom her health is
seldom a priority. People are largely dependent on the private practitioners including the RMPs.
As one of the community members reported that public facilities are quite unpredictable (whether
the centre is open or not), leaving people to guess whether it is worth their while to walk all that
distance. Thus the poor are more likely to go to the local healer or a private practitioner even
while they may be charging quite high.

URMUL’s Health intervention: The organization has used mass approach on health awareness as
a starting point. It was extremely difficult at the beginning to engage the women and girls in their
awareness campaigns but by forming women‟s and men‟s groups they were able to gain the
community‟s acceptance. They have not only made inroads into the remote villages but have also
trained their 26 health workers as “Nirogo Saathi” who act as the bridge between the community
and the organization. The entire program is anchored by these 26 Nirogi Saathi in line with
“where there is no doctor”.

2.2 Overall Relevance

Well established Relevance: Given the broad development and health context as described in the
above sections, Plan International has developed with its partner organizations the much needed
community health intervention for meeting the challenges related to health of the most vulnerable
population. In keeping with the specific needs of each location, the relevance for the health
program is well established. Besides improving the service delivery in the health sector, the
health program also believes in the potential of such a strategy in which the poor themselves
become active agents of their program. However such shifts in approach and methodology are
still in a state of transition in the absence of having reached a clearly crystallized institutional
concept.

2.2.1 Follow up:

Governance is at the core of the right and entitlements debate - it is at the heart of all
development dialogue - poverty, inequality, illiteracy, disease, and environmental degradation. It
is the policies that government adopts that affect the economic and social well being of the


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citizen. However, there is generally a lack of understanding in the community about the systems
and how they operate. This would include how the informal systems of government and other
institutions work; the degree to which citizens can exercise their rights, have access to
information and government programs, and influence governance processes. Thus much remains
to be done in enhancing capacities of communities with regard to governance in the Plan Program
intervention.

3. Effectiveness of the Strategies

Plan and its partners have developed context specific health interventions recognizing the variable
state of development across the country and the challenges being faced by the communities. Such
an approach has allowed the partners to address those issues most relevant to the local specific
needs. The program objectives have had a direct bearing on women and children in responding to
the root causes and symptoms of poverty.

Core strategies: In designing a comprehensive health package, the Plan partners have placed
emphasis on:
 Enhancing capacities of the communities and empowering them to sustain the health services
 Introducing the concept of people‟s health security fund – this is being piloted only in SBMA
 Developing appropriate health IEC materials for mass awareness generation on basic health
   issues
 Networking with civil society organizations and
 Advocacy with Government

To achieve these objectives, community involvement is essential. Each of the PUs has developed
its own unique strategy to mobilize the community and spread health awareness messages. The
following section details out the specific health strategies and approach promoted by the PUs.

CASP: “Clinic has been the best strategy of CASP…”(by a CBO member)

   Multiple strategies: CASP Delhi is essentially working in the slums as discussed earlier.
    Generally urban poverty is characterized by congestion, acute poverty, deprivation, high
    infant mortality rate, high fertility, no infrastructure and unhealthy living conditions. To
    combat this bleak scenario, CASP‟s strategies are centered on community based clinical
    services and promoting health care through awareness building and education of community
    based organizations.

   Clinic based health services: The organization had started with two clinics – in Sangam
    Vihar and Badarpur – for immediate treatment, follow up, counseling and referral for
    complicated cases. While the Sangam Vihar clinic has been closed as per Plan‟s guidelines,
    the one in Badarpur is to be continued till June 2007. The communities are extremely happy
    with the clinical services which include OPD facilities for children, ANC, PNC check up,
    contraceptive use, general ailments and referral. Apart from these, there are facilities for
    counseling, basic lab facilities, distribution of IEC and other follow up services.

    The clinic is the life line of the area given that no government facilities are in place. CASP‟s
    awareness programs are centred on the clinic as it provides a ready forum where women, men
    and children come together to voice their concerns. Such an effort has been successful in
    mobilizing communities and empowering women of the locality. However, as the clinic is




                                                                                                 14
    proposed to be closed in June, there is a general sense of restlessness in the community which
    needs to be critically looked into.

   CBO managed health services: CASP has also developed a team of trained field workers
    from the community itself to assist its various programs as volunteers. The CBO essentially
    works as a link between the community and CASP. They quite competent in managing and
    running the clinic (along with the doctor, nurse and laboratory technician), dispensing of
    medicines, counseling and doing follow up work with the target group especially with the
    STD patients and their partners in addition to supervising meetings.

    CASP has quite effectively built upon a CBO managed health system consisting of Dais,
    health guides and CBO members with a view to provide health related curative and
    preventive measures in a sustained manner. Having a significant percentage of migratory
    population, CASP has realized the need to have in place a cadre of grassroots level force of
    secondary health workers who can continue to provide services in case of migration or drop
    out.

    The CBO of Badarpur seems to be fairly active and also entrepreneurial in terms of exploring
    funding opportunities to sustain the health activities. They have submitted a proposal to
    NTPC for co funding of the clinic. This is a team of 25 members with an annual fee of Rs 25,
    they have been able to mobilize Rs 12000 from various sources including individual
    contribution. They are presently taking care of water, electricity and rent of the clinic. This is
    a very articulate group aware of their rights and various schemes of Government and they
    need to be nurtured more to be able to function as a self reliant entity.

SBMA: “feeling more secure with the PHSF…need to know more about the Government
schemes” (by a MMD member)

   Community managed health interventions: SBMA has been focusing intensively on issues
    facing the women and children in the remote isolated hilly regions of Uttarakhand for the past
    three decades. They have been focusing on building strong community based groups –
    Mahila Mandal Dals (MMDs), Bal Panchayat, Kisan Seva samitis, kishori sanghs and
    sanjivanis as community health workers. Formation of these groups is meant to reflect on
    collective empowerment of community to affect changes at the local policy levels.

   Piloting PHSF: SBMA has also been working closely with the MMDs in developing and
    testing the concept of People‟s Health Security Fund (PHSF). Rs 5000 has been kept aside for
    PHSF and is given to groups who have met the five core indicators – 100% immunization,
    100% ANC, 100% UBR, 0% IMR and 0% MMR in their communities.

    The total fund in PHSF is reported to be Rs 19000 with community contribution. The MMDs
    have made their own rules for disbursement of this fund. On paper, they are supposed to
    support even the non members charging a higher rate of interest but in practice, it is found
    that they are barely able to meet the needs of their own members as the volume of total fund
    is rather small and inadequate. However, regardless of the quantum of fund, PHSF has
    certainly touched the lives of many women and they are now keen to augment their corpus
    through other schemes including micro insurance.

    Community health workers: MMDs and panchayat have also played a critical role in
    selection of community health workers – Sanjeevani.. The Sanjeevanis are the interface
    between community and SBMA. They are treated like the barefoot doctors and evidently well


                                                                                                   15
      respected in the community. The sanjeevanis also maintain MIS of their villages which help
      them in identification of TB patients and their subsequent link up with DOT providers.

      Adolescent Groups: The strategy to work exclusively and intense with the adolescent groups
      under the NANDA project has proven to be quite effective mainstreaming health concerns.
      The adolescent groups met seem to have developed an understanding on reproductive and
      sexual health needs of women. They also have tried to link it up with women‟s issues which
      reflect the need for solidarity on such issues.

      Innovative strategy (Best practice): SBMA has developed an interesting and unique
      communication material in the form of a Horoscope which has all the relevant health
      messages. As Horoscopes are widely used in this region, SMBA has printed a booklet with
      dummy forms of birth registration, highlighting the significance of breast feeding and
      immunization. It also contains short bullet points on child development, particularly with
      regard to girl child. These booklets are distributed to the Pandits (religious leaders) who use
      these for the naamkaran (name giving ceremony). Approximately 1000 copies have been
      distributed and there is an increasing demand for more copies. Such a powerful
      communication tool in the long run would certainly contribute to behavioral and attitudinal
      changes at the community level.

URMUL: “once when the PHC doctor had failed to attend the Gram Sabha meeting, he was
not allowed to sign later…” 2 (SHG member)

     Anchored by barefoot doctors: URMUL Lunakaransar‟s health program is anchored by the
      Nirogi Saathi (NS) – the barefoot doctors who have been trained by medical Doctors. Given
      the dismal health situation in western Rajasthan, 60% of the organization‟s budget is invested
      in health activities. These include immunization, ANC, PNC, RCH and family planning,
      HIV/AIDs, training of dais and health workers, etc.

     Baksa Sanchalak: One of the organization‟s efforts to reach out to the communities who
      otherwise have no access to health care is through developing a cadre of “Baksa Sanchalak”
      (BS) on behest of communities who make formal request (in writing). The BS keeps essential
      medicines for general ailments, besides being responsible for health awareness and family
      planning. The BS and Nirogi saathis work in close coordination and they are the “point
      people” for health aspects in the communities.

     Men’s SHGs: URMUL has also developed strong men‟s SHGs with emphasis on leadership
      qualities. Many of them have become PRI members and they are believed to be monitoring
      the functioning of government representatives (doctors, ANMs, teachers) quite closely. The
      women PRI members are also involved in accessing government health programs (JSY,
      Antyodaya) and helping the community with the required paper work and follow up.

     Balika Shibirs: The Balika Shibirs organized by URMUL has done a great service to the
      entire community of girls who were typically the drop outs or those who never went to
      schools. These camps have produced articulate and confident girls who have formed Kishori
      Prerna Samuh to reach out to the other girls in the community. They have now become one of
      the critical pillars of the health intervention. As the project coordinator said, “a new



2
    CBOs monitoring the attendance of Govern ment functionaries


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    generation has been developed to take the program ahead”. However, to make the
    adolescents the future leaders of the communities, it is essential to work with the boys too.

3.1 Overall Effectiveness of the Strategies
Comprehensive package: The strategies discussed above clearly reflects the approach common to
all the partners, i.e., package of defined interventions, namely, building of community level
organizations and awareness generation; preventive action, hygiene and sanitation, RCH and
referral support. Although the community participation is the main tenet but given the difficult
conditions, it has not been easy to have the community‟s involvement right at the outset.
Mix of service delivery and capacity building: Therefore, to get the community‟s acceptance, the
health interventions initially reflected elements of service delivery – clinics, health camps,
immunization, construction of soak pits, installation of hand pumps, etc - which also gave the
PUs appropriate entry points. There was an overwhelming response to this strategy in terms of
community participation as direct benefits reached the communities. Gradually the focus has been
shifted to building capacities of the communities through formation of CBOs to enable them to
influence public health policies. Thus there has been a shift from direct benefit approach to rights
based development approach.
3.2 Follow up:

Transition from delivery approach to community ownership: although the PUs have sought to
ensure that the resources are not just based in the community but also managed by the community,
this transition from a delivery approach to community ownership approach has been a slow
process as it calls for a change in attitude among the community members. It would require a
sustained partnership with the community to strengthen sustainable community-managed primary
healthcare systems that encourage changes in health-related behavior and attitudes.
Lack of conceptual clarity: The health program still lacks the conceptual and strategic clarity of
how the structural causes have a bearing on the health of the population. For instance:

   Analyses of all the POs indicate that they are all addressing issues related to women‟s health,
    but the analysis of gender-based inequities impacting on reproductive health is not quite clear
    - like their limited access to health care, low nutritional status, workload, lack of control,
    repeated pregnancies, etc.
   Likewise, it is well known that the multiple demands on women‟s time lead to exceedingly
    long working hours. Therefore the program which seeks to improve women‟s reproductive
    choices cannot confine themselves to the limited parameters of family planning, they need to
    understand the social conditions in which these choices are made and develop strategies
    accordingly.
4 Linkages with the Governme nt

Linkages with the Government though a serious issue often assumes a rhetorical role in
development dialogue. If the government was truly responsive then there would have been no
need for the civil society organizations to step in with a mix package of service delivery and
health education program. However, with the growing realization that civil society organizations
(CSO) are not to replicate government programs, that infrastructure development is primarily a
government‟s responsibility and that it has a huge cost implication, the CSOs are talking of
constructive cooperation with government health institutions to improve the public health
services.




                                                                                                 17
Strategy for Linkages: The PUs mentioned above have also followed the same trajectory –
playing a supportive role to the government while placing more emphasis on capacity building of
community based organizations. So far, most of the PUs have been working closely with the
government to sensitize them to community needs. In Lunkaransar, URMUL has organized
coordination meetings with PHC staff, ANMs and Anganwadi workers to make a health action
plan for the community. The PUs have also supported Government programs with material
support – medical instruments and vehicles which enable the doctors/ANMs to visit remote areas.

Problems in Linkages: However, there are some practical problems faced by PU in strengthening
their own appropriate networks and in failure to develop strong linkages with programs run by the
government. According to PU staff in Lunkaransar, while government‟s effective service delivery
could be a potential factor in achieving the desired outcomes but it is a reality that the rigid
government structure and its poor resource management are outside the control of PU. As a result
of which, several of the health activities of partners are running to the Government ones.

5 Organizational system: Monitoring and Evaluation

It needs to be stated that while systems should not exist for their own sake, what perhaps needs to
be considered is strengthening the existing “learning climate”. Presently, it is reported that
planning of project activities start at the in the village level as an interactive process in which
village level organizations and partners participate. Subsequently decision making takes place by
the program coordinator in consultation with the project staff.

The reporting seems to be more in the nature of completion of activities devoid of analysis – no
reflection (documented) of what has worked and what has not. Therefore much of it remains
anecdotal in the absence of process documentation and outcome mapping. Likewise, the meetings
in the field are fairly rudimentary and contain only the names of participants attending the
meeting and the topics discussed. No reflection on discussions undertaken, dialogue with the
participants, the problems encountered etc.

A substantial part of the M&E system currently being used seems to be carried out rather
mechanically whereby conceptualization, flexibility and more importantly learning from concrete
experiences is missing. The emphasis must be on such data gathering techniques, which capture
the complexities and uniqueness of the program processes. The fact that development is a
complex non-linear process certainly in the context of health makes the M&E process a
knowledge-based endeavour.

6. Program Impact

Increased level of awareness: The target groups all across the PUs feel that one of the greatest
impacts has been in terms of attitudinal changes among the community members on safe health
practices and awareness about preventive aspects of health. Increase in immunization (risen from
35% to 80% in Lunkaransar), enhanced status of community health workers (swasthya Vakil –
health advocate - as known in Badarpur), knowledge building among the teachers and parents in
adopting joyful learning techniques and giving primacy to children‟s needs (SBMA). In Tehri
Garhwal, the children managed to get a primary school opened in their village.
Likewise in all the PUs have verified that more than 60 percent of mothers have started regularly
using health centres while the women in the community feel more confident to discuss their
health needs than ever before. Although the “culture of silence” around the problems that women




                                                                                                18
face continues to pervade, but the areas where the adolescents are active (SBMA), they are able to
act as catalysts to discuss the sexual and reproductive health issues openly with women.
As discussed with the PU staff it appears to be a significant achievement considering that initially
the communities were more interested in direct benefits like income generation program or land
development than going in for health or education. It entailed a long and intensive process of
generating awareness among the community towards learning – that included, knowledge and life
skills in order to contribute to the development of their communities. Rigorous door to door
interaction and long village meetings by the PU staff have helped in developing the rapport and
subsequently encouraged community‟s involvement in the process.

Proactive role of communities: SBMA has sought to build in more community (largely women‟s)
stakes through bringing about a shift in behavior through developing various community based
groups to take on the leadership role. The community has been accessing programs under
SWAJAL on their own initiative. This has brought about some positive changes in terms of
enhanced consciousness towards promotional aspect of health rather than focusing on curative
health. It has ushered in a major attitudinal change in terms of community making demands for
better health services from the government and also the Sanjeevanis have fostered cordial
relationship with the ANMs and PHCs. Thus, the government is also perceived to be behaving in
a more responsive manner in some cases.

Increased participation of children: CASP has been concentrating on child rights has also had
significant impact in terms of involvement and participation of children and youth. Bal Manch in
Lunkaransar had been largely been initiated by the PUs as there was no direct perceived need by
the community. But having sensitized the communities about importance of rights, it is
encouraging to observe that more children and parents are coming forward as seen in Badarpur to
not only join the initiative but also demanding more activities related to children – games,
recreation, quiz on health issues, etc. The positive changes among the children manifest in the
form of increase in confidence.

Committed NGO staff: Finally, it must be acknowledged that the program has developed a strong,
committed and competent staff cutting across all the PUs – this human resource base is the
biggest asset. Thus the program stands to gain if their energy and interests levels are nurtured and
appreciated. It is well known that staff capacity cannot be limited to a few training – it requires
constant mentoring to enhance their learning and self confidence which have a direct bearing on
the sustainability of the program.

7. Key Program Challenges

Institutional Learning: The institutional learning at present is a weak link in the program mainly
due to a lack of deeper learning and reflection culture within the organizational set up. It calls for
people to define and take greater responsibility for their own development, on their own terms
and pursue their own way. This would entail capturing and documenting processes of what works
and what does not at community level, PU level and Plan level – the enabling and constraining
factors for setting up a strong basis institutional learning.

Integration: As the PUs have a holistic intervention in the community, they are able to interrelate
the sectors they are working in with the problem of the area. They are able to link the health
program to nutrition, hygiene and sanitation. However, the cross-linkages among various
problems and the possible solutions across the domains were not so evident. For instance,
intervention on safe motherhood has to take into account the need for livelihood related



                                                                                                   19
supportive interventions, but, the linkage between livelihood security and reproductive health is
not sharply defined. It would require a coherent program strategy for further integration where
objectives and outputs of one domain like health could be strengthened by actions in livelihood
domain.

Gender Equity: Gender equity by and large has been understood as equal participation of men
and women. The Partners are committed to promote development of girl child in all spheres.
However, analyses of all the POs indicate that the gender perspective needs further strengthening.

For instance, some behavioural changes are evident in terms of more girls were being enrolled in
schools and are also getting married later in age. According to most partners, if girls have access
to higher education (schools within 8 km of radius), parents are motivated to send them for higher
studies. However, a deeper analysis revealed that the gender relations have not changed much.
The girls even while going to schools has the additional task of taking care of household chores
on return from the school, while the boys could play cricket. In many instances it is observed that
girls were eating after the male members had their meal contrary to popular belief of more
egalitarian practice.

Community Participation: With community participation in planning and implementation as a
core principle, the program has invested considerable time and effort in identifying, mobilizing
and organizing the community as SHGs, adolescent groups, community health workers
(Sanjeevanis, Baksa sanchalak, Nirogi sathi, etc) to prepare the ground for their effective
participation. However, the extent of participation is found to be varied across different villages
and the focus seems to be mainly on participation of members of these groups and not necessarily
of the entire village. Mention may be made of Rajaser cluster in Lunkaransar where the SHG and
PRI women members met were extremely articulate about their rights and so on. But the question
is how far have they been able to influence the women who are not part of any group remains a
big question.

Further, monthly meetings at the community level are the main fora for planning and decision
making. As per the meeting registers, participation in numbers vary from average to high and
seems to be influenced by expectation of direct and personal benefit in some cases (e.g., need for
a Baksa Sanchalak or Sanjeevanis or PHSF, etc). Also it is not clear as to how much space is
available to those who may find it difficult to be physically present in such meetings (migrant
workers). These are some of the issues for future reflection as community participation is the key
to sustainability of the program.

Participation of PRIs in the health intervention seems to be on the lower sides, though not due to
lack of effort by the PUs. The strengthening of the local governance and the CBOs to effectively
influence the policies of local panchayat is an important element of institutional building.
Although several cases were cited where the community was able to get a favorable response
from the community, but in the absence of a framework which specifies the scope and provides
space for PRI participation, it is difficult to expect meaningful results.

Linkages with other service providers: The endeavor of the program to link up with wider
community has been successful to a certain extent. But effective and functional linkages with
various community level platforms, institutions like PRI and RPMs are limited and need more
work. Conducting capacity building activities or sensitization programs has clearly not resulted in
any concrete outcome. These capacity building or sensitization program need to be backed by
defined follow up activities to promote and ensure creation of effective linkages and adopting
safe practices.


                                                                                                20
8. Sustainability

The long term goal of the Government has been to provide health care to rural communities
through PHC. As discussed earlier even with adequate funding these centers have not been
successful for a variety of reasons that include lack of decent facilities, equipment for performing
simple laboratory tests etc. even more important is the social reality: there are just not enough
trained doctors to adequately serve the rural masses of India.

Therefore the whole issue of sustainability has to be examined within this social reality. In
contrast to some other development tasks, health care provision will need to be an ongoing
responsibility that has to be sustained long term. However, if the capability for undertaking this
task is largely dependent on external donors like Plan International in this case, the health system
tends to remain vulnerable.

Short term access to external support may increase the pace of activity without necessarily
ensuring the capacity to undertake it in the long run. This is illustrated aptly in case of CASP
which had opened a clinic in Sangam Vihar but had to close down when the PO was closed. After
the closure of the clinics, Community health guides got busy with other work, and as a result, the
program lost its momentum and the target community according to CASP staff regressed back to
its earlier status of low awareness about health issues. A similar fate is awaiting Badarpur clinic if
it closes down in June 2007. Unless a proper phase out is planned right at the outset with the
community‟s active involvement, it is likely to hurt the community badly.

9. Recommendations

It has to be acknowledged that given the harsh conditions in which the Plan partners are working,
it has been a huge challenge to work on behavioral and attitudinal change with regard to health.
The extreme poverty and high levels of vulnerability in Rajasthan, Uttarakhand and urban slums
reinforce a deeply conservative social system in which poor and particularly women and girl
children have to deal with intense social and economic inequality. Each PU has developed its
own strategy in response to the community needs. Their dedication and sincerity cannot be
questioned. The recommendations are therefore to be treated within Plan International‟s overall
strategic considerations and institutional development.

Program Synergy:

   Plan International: As health has socio-political implications; the program has to have a
    concrete strategy for convergence of all services at the community level needs, including
    health, hygiene, sanitation, nutrition, education, livelihood and governance.

   PU level: the community needs a thorough understanding of the Government program, the
    way the system operates, the way citizens can exercise their rights and so on to make the
    health intervention truly “community based”. Essentially, the governance and management of
    health need to be effectively dovetailed.

Gender

   Plan and PU: Gender has to be located by both Plan International and Partner organizations in
    the larger development context, as a part of the critical framework, which sees empowerment



                                                                                                   21
    of socially and economically marginalized groups as central to sustainable development. The
    key pointers are as follows:

       Gender sensitization of staff to mainstream gender in planning and implementation.
        Addressing gender at each stage of project management, from information collection to
        needs assessment, to implementation and monitoring, thus ensuring that both men,
        women and children benefit from development interventions
       Clear formulation of measurable goals and outcomes related to gender equity is required.
        This would entail focusing on changes in values and attitudes rather than number of
        women participating in a program, impact - rather than completion of activities.

Monitoring and evaluation

Plan and PU: The M&E systems should be able to capture the complexities in health
interventions.
      This requires systems and procedures which do justice to both the process and the
        outcome of activities.
      Therefore, equal attention to paid to quantitative and qualitative data.
      Undertaking periodic process documentation and annual self evaluation would certainly
        be effective instruments of organizational learning.
      Encourage cross learning among the PU and document the best practices

Community participation and ownership

PU level:
    Community participation and their quality of ownership need to be enhanced. Conscious
       efforts to be applied to examine who is participating (are any groups being left out) and at
       what level, This is to ensure that the weakest (migrant families, single women) and less
       articulate ones are not unconsciously excluded from the program

       To ensure that the resources are not just based in the community but also managed by the
        community, the PUs need to build the organizational capability of CBOs so as to ensure
        effective management and sustainability of the health intervention even after the PU
        withdrawal.

       The community also has to be prepared to take over some of the operational costs after
        the PU withdrawal – for instance, honorarium for sanjeevanis, baksa sanchalaks, etc.
        Besides developing effective linkages with the government, this may also entail tapping
        resources from external agencies.

       Besides management of the health system, a sustained partnership is required to
        encourage changes in health-related behavior and attitudes among all community
        members

Participation of PRI and other Government Agencies

PU level:
       Given the need as well as existing policy framework with regard to health care and the
        role assigned to the PRI and government agencies, Plan and its partners need to develop a



                                                                                                22
       framework that would define the exact nature and scope of involvement of PRIs and
       other government staff in the health program.
      Strategies to use school platforms for children‟s health should be used on wider scale.
       Sporadically, this has been tried out. Those who have already established a linkage with
       the system should try to strengthen this platform.

Capacity enhancement of CBOs

      The village health functionaries are the pillars of the health program. The program should
       develop mechanisms to track the changes in the capacity of the CBOs/health
       functionaries over a period of time.
      Participatory review exercise should be undertaken periodically to evaluate their
       performance with regard to their motivation, sense of self confidence and knowledge
       base.
      The idea is to sustain their energy so that they continue to function even after the PU
       withdraws.

Sustainability:

Plan and PU:

      The sustainability plan either at the Plan or PU level does not seem to be very clear at
       present. Therefore it is suggested that a thorough analysis should be made to have clarity
       on specific aspects of program where time bound funding is sought with a detailed phase
       out strategy.
      Likewise, similar understanding needs to be fostered with the community to enable them
       to place the mechanisms of PU withdrawal in place which at present is yet to receive
       adequate attention in the program. As discussed earlier, the Badarpur clinic of CASP
       should not be closed down in a hurry - proper phase out should be worked out in
       consultation with the community before the funding support is withdrawn.
      Community financing in the form of micro health insurance could be explored to sustain
       the health program. However community‟s sense of ownership vis-à-vis the program
       would be a necessary precondition for that.




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