Improving child health and nutrition by mikeholy

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									     Improving child survival, growth and
                   nutrition




Proposal submitted to Association for India’s Development

                    by Jan Swasthya Sahyog

                         February, 2010




Jan Swasthya Sahyog,
Village and PO Ganiyari, 495112
Bilaspur district
Chhattisgarh
Background

Jan Swasthya Sahyog (JSS) is a not-for-profit organization located in Bilaspur
district in Chhattisgarh in Central India. Since 2000, it has been providing
primary health care services in parts of Kota and Lormi blocks of the district,
establishing a three-tier health care system based on women health workers at
the village level, supported by subcentre clinics and a base clinic at Ganiyari.

The population served is largely of a poor socio-economic status, with a high
proportion of tribals, scheduled castes and other backward castes. The main
tribes are Gonds, Oraons and Baigas. People from about 50 villages around each
subcentre access the weekly doctor-run clinic, which is staffed by senior health
workers on other days. The base clinic at Ganiyari is accessed by patients from
all over the district, as well as people from further away and even from,
Mandla, Dindori, Shahdol and Anuppur districts of Madhya Pradesh.

The economy depends almost exclusively on rain-fed agriculture producing a
single crop; with significant migration occurring in the non-agricultural season,
and also like in the current year when the monsoon has been deficient. Most of
the illnesses seen are a direct result of poverty and deprivation, worsened by a
lack of access to good quality affordable health care. Communicable diseases
include malaria, tuberculosis, leprosy, diarrhoea, sometimes cholera; and in
children also outbreaks of measles and whooping cough. Diabetes,
hypertension, malignancies, sickle cell disease, and rheumatic heart disease
are among the commoner non-communicable diseases seen. Underlying all
these diseases is malnutrition, widely prevalent both in children and in adults.
Malnutrition increases susceptibility to any illness and worsens the course and
the outcome of the illness.

Most deliveries occur at home, with less than 10% of women delivering in a
hospital. Therefore traditional birth attendants play a significant role in the
community. Government provision of antenatal care is limited to tetanus
toxoid injections in those villages that are reached by the ANM. Access to
emergency obstetric care is severely limited, with poor roads and no public
transport available.

There is a high level of childhood malnutrition, contributed to by various
factors: delayed introduction of complementary feeding; misconceptions about
how much and what food young children can eat; no adult being present with
the child to feed it five to six times a day; repeated illnesses; and finally
inability of the parents to purchase adequate and appropriate food, especially
given the recent steep hike in the price of foodgrains.

Malaria is a significant health problem in the area, with a preponderance in the
winter season. The region has unstable malaria which is seasonal and has high
mortality rates.


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The group seeks, through its work, to reduce inequity in health care and to
contribute to reducing rural indebtedness due to health care costs.

The work of JSS so far

Jan Swasthya Sahyog works in parts of Kota and Lormi blocks of Bilaspur district
in Chhattisgarh, running a three-tier community health programme through a
network of village health workers in 53 villages; three subcentres, and a base
clinic at Ganiyari. The subcentres and the clinic at Ganiyari provide referral
support to the village health workers. The subcentres are at Shivterai, Bamhni
and Semariya, and are staffed by two senior health workers who run a clinic
daily and are supported by a weekly visit by a clinician.
The field clinics are accessed by people from about 150 villages, and around
1500 villages access the services at Ganiyari. There are an average of 240
consultations on each outpatient day, with a significant number of seriously ill
patients.
JSS also runs crèches as part of its community programme. These crèches
provide day care to children between 6 months and 3 years of age, including
supplementary nutrition, while also allowing parents to work, as well as
allowing older siblings to go back to school. Their primary aim is to reduce the
incidence and prevalence of malnutrition in this vulnerable age group. At
present there are 794 children in 47 creches in 25 villages. This represents
roughly 40% of eligible children. We hope to increase this number by 50% over
the next three years.
Our work in women’s health includes antenatal care services; improving
delivery care at home through training of birth attendants; post-natal care by
village health workers, as well as increased availability of contraceptive
services to reduce the incidence of unwanted pregnancies and unsafe
abortions. Our activities also include conducting screening camps for cancer of
the uterine cervix, as well as screening women for hypertension.
Given that the majority of our programme population is malnourished, and
understanding the close link between nutrition and health, JSS has also
initiated activities to improve agricultural yield through the system of rice
intensification (SRI) that has been shown to vastly increase crop yields while
using less water.
JSS has been able to carry out research on various issues related to poverty and
health, based on its observations and learnings over the past decade, which has
led us to question some of the current practices in public health in India. We
have been able to develop low cost appropriate technology which is easy to use
and also helps to reduce the cost of health care.
We have gained credibility with the local and state health authorities, and are
represented in various committees at the state level. We are also regularly
consulted by the Planning Commission on issues related to health care in India.




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Has our work made a difference to children?

                            Child Survival Trends, 2003-2009

  120
           110       108
  100
           86        84.3                                                   IMR
   80                                    79      81.4
                               76.9
                                                                            U5MR
           67.8
           65.2
   60                          61.1      61                58               Still Birth Rate
                     54.2                        56
                                                 51.2    43.7
                               44.4      44                44.8      46.7
                                                                     46.4   NMR
   40                39.1
                                         32      33.7
                                                 33                  36     PNMR
                               30.5
                               27                         24.7       29.5
           25.4      23.5
   20                                   27              25.3
                                                                     12.4
    0
        2003      2004      2005      2006    2007      2008      2009



In our programme villages, child survival has improved steadily over the years.
The infant mortality rate has reduced from 86 / 1000 live births to the current
29.5 / 1000 live births, which is significantly lower than the current rate for
rural Chhattisgarh which is at 59/1000 live births (SRS Bulletin, October 2009,
Rural IMR). We have achieved this through sustained efforts in various aspects
of maternal and child health.

First, the improved reach of antenatal services has enabled us to prevent
malaria in pregnant women, thus increasing the birth weight of newborns. In
2009, we were able to get birth weights of 88% of newborns, and 80% of them
weighed over 2.5 kg. Antenatal services have also enabled us to detect those
with risk factors that can be addressed during pregnancy (like severe anaemia
or pregnancy induced hypertension), and also those who need to deliver in an
institution (eg abnormal presentation; rheumatic heart disease; multiple
pregnancy).

However, utilization of antenatal services varies between village clusters. The
forest cluster of Bamhni and Achanakmaar still have fairly low utilization rates.
One of the reasons for this is the huge distances that women have to travel to
access the service – even though outreach clinics are held in a central village in
these areas, other villages are scattered, and often cut off during the rains.
Our interaction with these far-flung villages too needs to be strengthened.

The steep fall in the neonatal mortality rate has been the result of improved
care provided to newborns at the community level and early identification and
treatment of illnesses; as well as prompt referral to a facility when required.
All our health workers, as well the TBAs we work with know the importance of



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warmth and breastfeeding in newborn care. Postnatal visits are made for the
first ten days by the village health worker, who checks whether the baby is
feeding well, and looks for signs of infection. Ensuring a clean delivery, as well
as Improved cord care, have reduced the incidence of neonatal sepsis.
Pneumonia is treated with oral amoxicillin, for example, and the baby is
referred if there are any signs of severe pneumonia.

Infant and under-five mortality rates have also shown a steady decrease across
the years. Treatment of infections, screening of children if a family member
has been diagnosed to have tuberculosis; management of illnesses in children
by the village health worker or referral to the senior health worker or the
Ganiyari – have all contributed to reducing death rates in this vulnerable group.
Regular growth moniroting to detect growth faltering, and providing
supplementary nutrition to children between 6 months and 3 years of age have
been other contributory factors.

The malaria control programme implemented by JSS, which includes promotion
of bednet use, early diagnosis and prompt treatment of infection, and referral
of children with severe malaria – has been a major factor in reducing child
deaths due to this disease. In 2009, only 3% of under-five deaths were due to
malaria.

Where we don’t seem to have made much progress is in reducing still birth
rates and perinatal mortality rates. Our still birth rates have been in the range
of 20 to 40 per 1000 births, which is the usual range in developing countries.
While early neonatal deaths are few, our perinatal mortality continues to
remain high due to the high still birth rate.

Causes of still births are varied, and sudden late foetal deaths are still difficult
to avoid unless very close monitoring of the mother is done. Reasons for
intrauterine death include, in our area, malaria, sickle cell disease, severe
anaemia in the mother, PIH, Fresh still births, though fewer, have been due to
birth asphyxia due to various reasons. Most early neonatal deaths have been in
preterm, low birth weight singleton or twin babies. Improved care of the low
birth weight infant, including warmth, feedin and prevention of infection may
reduce some of the early neonatal deaths.

What has made this possible is also the referral system that has been put in
place. No amount of training of health workers or TBAs in isolation will be
effective unless there is a system of regular supervison and training in place, as
well as a transport facility to a referral centre where further care can be
provided, if necessary. The ambulance service that JSS runs daily connecting
the off-the-road villages to Kota, Ganiyari and Bilaspur has played a key role in
timely transport of sick newborns, infants and children (and adults) and has
helped save many lives.



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                               SRS October 2009          JSS project villages
                               Rural Chhattisgarh               2009
CBR                                   27.6                      24.2
CDR                                    8.5                       5.5
IMR                                    59                       29.5

                          Deaths by age, 2003


                          0% 9%

                   28%             9%                    neonatal deaths
                                                         post-neonatal
                                       7%                1-<5yrs
                                                         5-15 yrs
                                       7%                16-60 yrs
                                                         >60 yrs
                                                         age not known
                         40%




                          Deaths by age, 2009


                          2% 6%
                                  8%
                                                         neonatal deaths
                                       8%                post-neonatal

                                       3%                1-<5yrs
                 46%                                     5-15 yrs
                                                         16-60 yrs
                                                         >60 yrs
                                   27%                   age not known




A comparison of the causes of death between 2003 and 2009 shows a significant
reduction in the proportion of deaths among those between 5 and 60 years of
age, and a larger proportion of deaths among those who are older (over 60
years).

Deaths due to preventable causes seem to be reducing, if we assume that most
deaths below 60 years should be preventable. The largest gain in survival is
among the economically productive age group of 16 to 60 years: deaths among
this group have reduced from 40% of all deaths to 27% of deaths.

We attribute this change in age distribution of deaths to one or more of several
factors:




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             a. Earlier care-seeking: due to better transport facilities
                available, both at the village, and through the ambulance
                services run by JSS.
             b. Increased range of services provided at the clinic at Ganiyari.
             c. Subsidies given to programme village patients for drugs and
                other treatment.

The negative side of this is that there could be less care sought for older
members of the family due to economic constraints. We have seen this
sometimes where the family of an elderly patient took them home choosing not
to get them treated, even if the condition was treatable. The decision to spend
money and time on an economically unproductive member of the family is
difficult to make in the face of already overwhelming poverty.


                           causes of under-5 deaths, 2009



                          20%
                                                                       pneumonia
                                                                       diarrhoea
                                             44%
                                                                       malaria
                                                                       sickle crisis
                    20%                                                preterm
                                                                       other reasons
                          3%
                            3%     10%




The predominant cause of under-five deaths in our programme villages
continues to be pneumonia. This remains a challenge and we believe that care-
seeking and a high index of suspicion in this case is as important as care
provision. We find that the standard training algorithms for health workers
presume that cough is an essential symptom that parents will being the child
with. All further assessment stems from this. However, we find that the more
severe cases present with other symptoms like abdominal distension or
vomiting or excessive crying, when the parent may not remember to mention
the cough at all. Many of these children are taken to a “doctor” for injections
for the vomiting, and not brought to the health worker. Education of parents
about these symptoms is something that needs more attention.

Therefore, while we find that our work has made significant improvements in
child survival, there are still areas that need our attention. Reducing still births
and maternal deaths, and reducing deaths due to preventable causes among
the community require more focus and attention in our future work.


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Objectives of initiatives to improve child health and nutrition
over the next three years.

   a. Support and promote crèches to improve under-3 nutrition and prevent
      malnutrition. This includes community education to improve infant and
      young child feeding.
   b. Advocate for scaling up by other organizations and most importantly by
      Government.
   c. Support initiatives to improve routine immunization in the programme
      villages where it is required.
   d. Improve early child survival and growth in neonates and older infants.


Geographical area of work:

Currently in 53 forest and forest-fringe villages in Kota and Lormi blocks of
Bilaspur district. We may be able to expand to another ten villages, but not
many more than that.

a. Support and promote crèches to improve under-3 nutrition and prevent
malnutrition. This includes community education to improve infant and
young child feeding.

At present there are nearly 800 children in the crèches, which is around 40% of
the total children in the age group of 6 months to 3 years. We hope to increase
this by 50% over the next three years. We have not done it mainly due to
shortage of resources; also because in some villages the community has not
been able to find someone willing to take care of the children. Obviously there
needs to be more community education in this regard.

The number of children in the crèches keeps fluctuating too, for various
reasons. When there is a lot of work available, eg in the agricultural season at
times of sowing or harvesting; or when the NREGA works are on, there is a
demand for crèches to work and for longer hours. When people are out of
work, some parents are reluctant to send the children to the crèche. Therefore
it is difficult to track the nutritional improvement (or lack of it) of a child who
is irregular at the crèche. Numbers also drop when older children are sent to
the Anganwadi, and before the newer cohort of six-month olds is sent to the
crèche.

b. Advocate for scaling up by other organizations and most importantly by
Government.

Careful documentation of the process that has been undertaken so far, the
lessons learnt, and the costs – will be useful for other organizations that are
interested in issues of childhood undernutrition. That these crèches have been


                                                                                  8
most popular in the least well-off villages indicates the need for a place where
parents are assured of not only the safekeeping of their children when they go
to work, but also of a place where reasonable nutrition is provided. (as several
parents have told us: “we can no longer afford to buy daal, but our children get
khitchdi everyday; we like it that the children get eggs twice a week” , and as
a father sadly told us “Aap ne to iske pet mein aag laga di. Yeh har samay
khana chahta hai. Mein kahaan se laaoon?”

We have been trying to get the state government interested in this initiative.
Implementing this effectively will mean breaking down long-standing barriers
to inter-departmental co-ordination, which is difficult to do. However, we
need to put in more efforts towards this. Can panchayats be given the
responsibility of procuring food / payment of wages? Can the PDS allocate
foodgrains for children – who are, after all, a part of the community it is
supposed to help? Can the ICDS take on a separate person to take care of
under-3s whose needs are different from those of older children? Can the
health department provide the necessary support? All these need political will
and a strong administration. The possibility of corruption in every aspect of this
operation is also something that worries us.

We had mentioned earlier in our note about measuring the effectiveness of the
crèches: in terms of reducing malnutrition and in sending older siblings back to
school. The latter is being demonstrated continuously. For the former, data
collation, cleaning and analysis is under way.


c. Support initiatives to improve routine immunization in the programme
villages where it is required.

Chhattisgarh has reported an improvement in vaccination coverage between
the 2nd and 3rd National Family Health Surveys (conducted in 1998-99 and 2005-
06 respectively). The proportion of children between 12 and 23 months who are
fully immunized more than doubled from 22 % to 49%. However, among
children immunized, those belonging to scheduled castes or tribes are much
more poorly covered compared to others. (All-India data shows that 26% of
tribal children are fully immunized; in Chhattisgarh this stands at 42.2%).

The Government’s Reproductive and Child Health programme under the
National Rural Health Mission has childhood immunization as a major activity
for child survival. However, coverage is less than optimal, especially in rural,
forest-fringe and forest areas. Most forest villages are off the road and some
are difficult to reach in the absence of public transport. The block health
authorities do make attempts to visit and immunize children in these villages,
but some villages are left out altogether. The reason given is lack of transport,
and a hesitation to go alone to these villages; also the fact that not many
children are available there for vaccinations when the teams reach.


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It has been our policy not to duplicate services that are already provided
through Government as far as possible, hence JSS does not carry out routine
immunization programmes itself. However, as we see cases of measles and
whooping cough regularly, we would like to support the Government staff in
providing vaccination services to these areas. We would help in providing
transport, as well as in organizing the community in these villages. We hope,
over a period of three years, to have over 80% of infants fully immunized by the
age of one year.

We would like to strengthen routine immunisation in the programme villages
through the following:

   a. Document baseline immunization coverage through LQA sampling.
      (comparison can be made with the reported data from government
      records)
   b. Discuss the plan for increasing coverage with the block medical officer.
   c. Discuss in the villages regarding immunization services and decide on a
      date for vaccination.
   d. Provide transport support (hire a jeep or use JSS jeep with fuel, driver
      and maintenance costs covered) to the Govt staff for covering the
      selected villages.
   e. Actual vaccination, record keeping, supervision and monitoring will be
      done by the Government staff themselves.
   f. JSS will monitor coverage through periodic LQAs.


d. Improve early child survival and growth in neonates, and older infants.

Although we have made significant progress in reducing infant mortality, we
still have a fairly high early neonatal mortality, and post-neonatal infant
mortality.

We would therefore like to further improve child survival by following a cohort
of children through infancy, which will enable us to document illnesses, as well
as child care practices.

This will also enable education of parents and care-givers about child care and
nutrition, and early care seeking during illnesses.

Main activities in this would be
    Village health workers to be trained in providing immediate newborn
      care
    8 additional volunteers to be trained in newborn and young child care
      and feeding



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           schedule of visits to each house with a newborn, what is to be done at
            each visit – monitoring growth, feeding, care-seeking
           follow up and referral

All newborns will be followed up for a year in the following manner:
     Identify each newborn, especially low birth weight infants.
     Ensure adequate care of LBW and VLBW infants – especially warmth,
       feeding and prevention of infection.
     Follow up each family with an infant once in 15 days (more frequently in
       the neonatal period).
     Teach parents identification of early signs of sickness / severe illness in
       a child, and encourage care-seeking promptly. (will need teaching aids –
       flip charts, models, etc)
     Inform and support parents to start complementary feeding at six
       months, also crèche care if available.
     Ensure primary immunization.
     Ensure regular growth monitoring.
     Identification of illnesses and treatment, early referral
     All sick newborns and children will be offered free / highly subsidized
       treatment at the health facilities of JSS.


Monitoring indicators:

Process indicators
a Proportion of eligible children attending creches
b Proportion of creches functioning at least 24 days a month
 c Number of older siblings rejoining school
    Number of creches with toys and early childhood learning
d materials
 e        Number of children in creches who are weighed monthly
 f        Number of parent meetings held with regard to child nutrition
          Proportion of children at 18 months who have received measles
 g        vaccination
 h        Proportion of children at 18 months with 3 doses of DPT
  i       Number of cases of pertussis reported
  j       Number of cases of measles reported
          Proportion of newborns with birth weight recorded within 24
 k        hours
  l       Proportion of LBW newborns provided with thermal care
          Proportion of parents of LBW neonates who know about
m         warmth, feeding and prevention of infection
n         Number of sick neonates needing hospital care
          Number of infants who received complementary feeding at 6
 o        months
 p        Number of newborns with birth weight                            >2.5
                                                                          2 - 2.5


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                                                                   1.5-2
                                                                   <1.5

Impact indicators – to reduce by 50% of current levels
                                                    2009    2012
a. Neonatal mortality rate                           12.4
b Post-neonatal mortality rate                       46.4
c Infant mortality rate                              29.5
d Child mortality rate                               17.1
e Under-five mortality rate                          46.7
   Proportion of children with age-specific
f  wts <-2z                                      >50%




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Application for grant for improving child survival, growth and nutrition
from Jan Swasthya Sahyog to Association for India’s Development February 2010

A       Improving child nutrition through creches
        Recurring costs for 10 children in a creche
                                              Monthly      Annual           3 years
        A. Food supplements
        Sattu                                       600              7200
        Eggs twice weekly                           350              4200
        Oil 10 ml / day / child                     310              3720
        Rice and daal for khitchidi                 740              8880
        transportation of food                        70              840
        FOOD                                       2070             24840         74520

        B. Wages for caretaker
        Rs. 100 per day X 26 days per
        month                                      2600             31200

        C. Medicines / others
        Iron and albendazole                         50               600
        Soap                                         30               360

        D. Rent for managing the creche             100              1200

        Recurring monthly costs                    4850             58200        174600
                                                                                      0
        F. Other annual supplies                                                      0
        One-time costs                                                                0
        Preschool learning material                                   500          1500
        Utensils                                                      300           900
        Mats, buckets, plates etc                                     700          2100
        Mosquito net 6X 3                                             300           900
        One time annual costs                                        1800          5400
                                                                                      0
        Recurring costs for 10 children
        per month                                                    4850         14550
        Once a year costs, calculated for
        10 children per month                                         150             450
                                                                                        0
        Total cost per month for 10
        children                                                     5000
                                                                                      0
        Total cost per year for 10 children   USD 1200              60000        180000

        Total cost for 1200 children                           7200000         21600000

        Cost in USD for 1200 children                           144000           432000




                                                                                            13
2 Co-ordination, advocacy and documentation
                                                           Annual           3 years
1   Documentation of 20 case studies                           150,000           150,000
2   Reports and records, stationery                              50,000          150000
3   Monitoring and supervision                                 100,000           100000
    Co-ordinator for creche programme
    @ 10,000 pm (with 25%hike in year
4   2 and year 3)                                              120,000           457500
    Travel costs for co-ordinator @ 2000
5   pm                                                           24,000           72000
    Co-ordinator for child cohort
6   programme                                                  120,000           457500
    Travel costs for child cohort prog co-
7   ord                                                          24,000           72000
8   Travel for advocacy                                          50,000          150000
    Workshop on young child survival
9   and devpt (yr3)                                            200,000            200000
    Total                                                      838,000         1,809,000

4 Improving immunization coverage
                                                           Annual           3 years
    Assessment of RI coverage LQA in 12 villages @
    Rs 5000 per village incl transport, forms,
1   supervision (Year 1)                                         60,000           60000
    Transport (fuel) costs for 1 visit / week Rs. 1500 X
2   4 wks X 8 mths / yr X 3 years                                   48000        144000
3   Assessment Year 3                                                             60000
    Total                                                      108,000           264000

3 Improve early child survival and growth in neonates and older infants
                                                           Annual           3 years
    Training of 8 youth in newborn and
1   child care
    Rs 300 / day X 15 days                                          36000         36000
2   Monthly meeting for review @ 500                                 6000         18000
    Honorarium for volunteers@ 1000
3   pm                                                              96000        288000
    Equipment - weighing scales,
4   thermometer etc                                             75000             75000
5   Health education materials                                 100,000           100000
6   Stationery                                                  20,000            60000
7   Mobility support @ Rs. 300 pm                               28800             86400
    Thermal maintenance - hot water
    bottles, blankets, woollens, warmer
    bags @ 500 / newborn X 300 (40%
8   of births being LBW)                                        150000           450000
    Incentive for VHWs for early
    reporting (within 12 hours) of
    newborns with weights and status of
9   newborn * 750 @ Rs 50                                           37500        112500


                                                                                           14
     Treatment of serious illness @ 5000
     for 60 children per year (8% of
     newborns) incl travel, drugs,
10   treatment costs                            300000         900000
     Total                                      849300        2125900


                                                                         USD
     Budget for 3 years                                                  1yr
                                           Annual         3 years
     Creche programme                          7200000       21600000        144000
     Co-ordination, documentation,
     advocacy                                   838,000     1,809,000        16760
     Immunization strengthening                 108000         264000         2160
     Improving young child survival and
     growth                                     849300        2125900        16986


     Total budget in INR                   8,995,300      25,798,900         179906


     Cost in USD ( 1 USD = 50 INR)         180,000        516,000




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