CLICK TO ADD TITLE The 6 th Global

CLICK TO ADD TITLE The 6 th Global Health Supply Chain Summit One stop shop for improved access, Quality health care and service delivery for rural poor through community managed Nutrition Centers in Andhra Pradesh, India Lakshmi Durga Chava lakshmidurgac@gmail. com [SPEAKERS NAMES] [DATE] Director (CMH&N) Society for Elimination of Rural Poverty(SERP), Hyderabad, India November 18 -20, 2013 , Addis Ababa, Ethiopia

Presentation outline • • • Relevance Background Rationale Paradigm shift Implementation Mobile tracking Results Challenges Replicable Way forward 2

Relevance • Share the experiences in establishing – demand chain – the other side of the health supply chain – mobile tracking system in reaching the unreached • Explore potential networks for partnerships 3

Society for Elimination of Rural Poverty (SERP) • Autonomous organization established by Go. AP in 2000 • Responsible for implementing poverty reduction projects supported by State and Central Govt. ; WB and other national and international donors • Works with people’s institutions (women SHGs) at grassroots level • Works in coordination with the govt. line depts. 4

Institutions of Rural Poor in 16 years 22 Zilla Samakhyas ZS 1, 098 Mandal Samakhyas 45, 046 Village Organizations 10, 72, 627 Self Help Groups 1, 17, 62, 814 Members MS VO SHG Women Members 5

Poverty Reduction Strategy 6

SHG Bank Linkage – Started in 2000, so far, they have availed bank loans of Rs. 52, 950 Crs. Year wise SHG wise 7

Magnitude of the malnutrition • 40. 4% of children with under weight • 37. 3% of children are stunted • 12. 5% of children are wasted • 82. 7% of children are anemic • 37. 5% women with BMI<18. 5 Kg/m 2 • 58. 2% of women are anemic Source: NFHS-3 8

Much concern among poorer sections Stunted (height-for-age) Wasted (weight-forheight) Underweight (weight-for-age) Scheduled Caste 53. 9% 21. 0% 47. 9% Scheduled Tribe 53. 9% 27. 6% 54. 5% Backward Class 48. 8% 20. 0% 43. 2% Other 40. 7% 16. 3% 33. 7% Source : NFHS-3 Figures are presented as percent of children who are below 2 standard deviations from the median growth indicator 9 value calculated from the WHO reference population

SERP model - Health Value Chain towards reaching MDGs Preventive & Promotive Health Care Curative Care Microfinance Product for NUTRITION Human/Social Capital • • Health activist/ASHA Community Resource Person (CRP) Case Managers Fixed Nutrition & Health Day (NHD) Water & Sanitation Nutrition cum Day Care Centers Financing and Service Delivery Making Services Work for the Poor – Accessing PHCs & Area Hospitals – 108, 104 and Aarogyasree services Health Risk Fund/ Health Savings Health Insurance Community-owned Pharmacy Community-owned Hospitals 10

It is important to note that 50% growth failure accrued by Age 2, occurs in womb & 39% babies are low birth weight 270 days 730 days Imaginary line Proportion of children stunted as per NFHS-3 (%) Peak foetal length velocity occurs at around 20 wks Foetal stunting evident by 8 wks Low Birth Weight Peak foetal weight velocity occurs at around 30 wks 11 P&PE Suppl. 2013, UNICEF 2013, Gillespie 1997

Nutrition cum Day Care Center (NDCC) – (1 mt film) • Physical center i. e. , building with Kitchen, Dining and Garden (for growing vegetables) • THREE MEALS a day prepared and served to pregnant and lactating mothers and children <2 years • Cook (Para nutritionist) is an SHG member trained in preparation of nutritious, traditional diet (with focus on use of millets & green leafy Vegetables) • Health activist (Community nutritionist) provides NHED duirng lunch time 12

Wight gain – Birth weight Indicators NDCC Beneficiaries (N = 234) Mean weight gain for pregnant women (kg) 9. 01 (SD = 0. 1557) Anemia detected during pregnancy (%) 35 Mean Birth Weight (kg) 2. 912 (SD = 0. 20) Weight Class (kg) 2. 5 - 2. 99 ≥ 3. 0 28. 7 % 56. 1 % • 90% had normal deliveries • 10% had cesarean section. • 52% of pregnant women gained 9 -10 Kgs weight Note: study conducted in 8 districts inclusive of mandals in 3 ITDAs. Source : External evaluation study by SOCHURSOD 13

Utilization of public health facility 14

Rationale – low uptake • Failure to reach 100% coverage with basic health services is two fold : – no accessibility – lack of quality services • Very little interaction between the departments for – Social mobilization – Service delivery • Fixation of day and time by the service providers often conflict with the work schedules of users. – Users have not had any say in the scheduling process. 15

Paradigm shift • Fix the mis-match between supply and demand – Community to have stake in quality service delivery – Fix a day to deliver the services on a common platform – Complementary roles by service providers and the user groups 16

Fixed Nutrition and Health Day (NHD)- The 5 counters platform AW Helper (Name) Supplementary food Counter 3 ANM (Name) ANC-Immunization & supply of drugs Counter 1 ASHA (Name) Health education Surpanch: Child Counter 4 IKP Health sub committee Names: Counter-5 Mother Counter 2 AWW (Name) Growth monitoring 17

Players Role : Before-During-After ( 2 mt film) IKP Health sub committee Names: Counter-5 Mother Counter 4 Pre-NHD • Due list preparation • Social mobilization During NHD • 100% coverage • Follow up on the drop outs Post NHD • Reconciliation • Exceptional AW Helper (Name) Supplementary food report for review Counter 3 ANM (Name) ANC-Immunization & supply of drugs Counter 1 ASHA (Name) Health education Surpanch: Child Counter 2 AWW (Name) Growth monitoring 18

Tracking- m. NDCC- DSS Individual JARs for each mobile/VO has to be downloaded. New enrollments or editing existing member information possible Encrypted data sent in string format Application program decrypts data which is stored in table format Various reports generated as per program design Alert sent to provide due list etc. Preloaded SHG member wise database maintained by BF in a different server Global Innovation IWG award 2012 19

Impact of m. NDCC • Exceptional reports generation as review tools and take action for – reaching the unreached – escalating the issues if not resolved • Regular review using the exceptional reports showed improved coverage among POP – – – Enrollment from 58% to 72% ANC from 10% to 31% PNC from 5% to 29% Immunization from 16% to 24% Growth monitoring from 12% to 39% Health Education from 14% to 48% 20

Results – Improved service delivery 21

Challenges • Sensitization and coordination among the line depts • Internalization of the concept among stakeholders • Fix a day to every habitation based on ANM Tour schedule • Accountability to CBOs • Bring into the district administration agenda • Consolidation and track the outcomes at member level 22

Way forward – Village level institutions in the driving seat • Recognition of Village Organisation as the nodal institution to monitor health , nutrition and sanitation outcomes (Community) • Institutionalization of VSHNDs under NRHM (Panchayat) • Issue of Government Order – ‘Maapru’ (The Change) to bring all the stakeholders to a common platform (Service providers) 23

Is it replicable ? • Yes, it is. • Pre-requisites – Availability of community based network – Partnership between the CBOs and the line departments – Sensitization & regular capacity building of the stakeholders • Exposure visits • Trainings • Tracking the member based outcomes – Maintenance of supply chain as per the demand – Political commitment to mainstream 24

Thank you 25