Health and nutrition interventions – Mainstreaming HIV/AIDS prevention Lakshmi Durga Chava State Project Manager (Health & Nutrition) Society for Elimination of Rural Poverty 14.09.09

Outline of the presentation Overview of SERP Health and nutrition: key processes Mainstreaming HIV/AIDS prevention Impact assessment results Roll out plan Conclusion

Society for Elimination of Rural Poverty (SERP) Sensitive support organization for the poor Autonomous society set up by Government in 2000 State wide mandate: To induce social mobilization To provide facilitation support to institutions of poor To sensitize all line departments to be inclusive of the needs of the poor

SERP A.P – poverty eradication through empowerment of rural poor women (Indira Kranthi Patham - IKP) Focus: comprehensive poverty eradication - economic and social building self sustaining institutions of poor Rs.2100 crores Project - financed by State Government, World Bank and communities to cover all rural poor in the state (over 100 lakh families, special focus on 26.0 lakh ultra poor) builds on the decade long, statewide rural women’s self-help movement in A.P

C.B.Os implement the project A.P Federation Model SHGs • Thrift and credit activities Monitoring group performance Micro Credit Planning Household inv plans E.C - 2 from each S.H.G, 5 Office bearers Strengthening of SHGs Arrange line of credit to the SHGs Social action Village development Marketing and food security Support activists – 3 -5 2 from each V.O, 5 Office bearers Support to VOs Secure linkage with Govt. Depts. fin institutions, markets Auditing of the groups Micro Finance functions 10 15 V.O 150 200 MMS 4000 6000 Z S 200,000 400,000 C.B.Os implement the project Zilla Samakhya Mandal Samakhyas and V.Os plan and implement the various project components Each Mandal is divided into three Clusters of 10-12 habitations. A development professional, called Community Coordinator (CC) is placed in each Cluster. S/he stays in her cluster. SERP selects and trains them. After completion of training, they are contracted by the MS and are accountable to MS. M.S responsible for social mobilisation, institution building and funding the microplans of S.H.Gs/V.Os from C.I.F Micro credit plans are evolved by the S.H.Gs in each village. These plans are funded by their own savings, CIF fund and Bank Linkage. V.Os responsible for appraising the microplans and recommending them to M.S for financing from C.I.F V.Os appraise microplans and also finance them from the recycled C.I.F Mandal Samakhya Village Organization SELF HELP GROUPS

SHG network Village Organization-VO (approx. 20 SHGs) 9,646,000 Rural Women in 22 Districts of AP 810,000 Self Help Groups (10-15 women per group) 34,852 Village Organization-VO (approx. 20 SHGs) 1098 Mandal Samakhya-MS (Includes approx. 30-35 villages) 22 Zilla Samakhya-ZS (constitutes 1 district) 1 State Office (State Project Monitoring Unit)

IKP Interventions Targeting – community based targeting. Focus on the poorest of the poor and vulnerable: women, disabled Power of scale – bringing all the poor in the state into social networks Scaling up through community resource persons Institutional design – SHG – V.O – M.S – Z.S Large scale mobilization of bank finances for poor Large scale livelihoods promotion Community managed food security Social issues as an agenda for collective action Social risk management Community managed health interventions Convergence with all line departments S.E.R.P’s dynamic role – changes in tune with the changes in the demands of the C.B.Os

IKP health model: Core elements Reducing exclusion and social disparities in health organizing health services around people's needs and expectations Integrating health into all sectors Pursuing collaborative models of policy dialogue Increasing stakeholder participation

Aims to: Improve partnerships between health facilities and the communities. Increase appropriate and accessible health care and information through training of community health workers. Promote key family practices critical for child health and nutrition by training and supporting peer support groups and conducting outreach education campaigns training community resource persons Involve other community institutions and champions to engage in health education and planning.

Convergence Framework for Improved Access to Services Work in collaboration with the existing line departments responsible for enhancement in QOL of the poorest Look at areas where there are gaps and there is a mismatch between the design of service delivery and the incentives linked to those services Fill those gaps through ways that can be managed and sustained by the community groups even after the project is over Have a cadre of internal facilitators, from among the communities to facilitate/accelerate in the empowerment process Have a cadre of external facilitators to assist in planning and designing sustainable and workable programmes Enable the communities to have choice and control over the services available for them Make the service providers more accountable to the communities Successful pilots to be up-scaled by the line departments for state-wide implementation Systems Outputs/outcome Personnel Improved access to “effective & available” services

Goal Improved health and nutrition status of the communities in 62 pilot mandals of Andhra Pradesh by 2009.

Objectives Empowered CBOs: Demand access and availing health & nutrition services especially among POP &Poor Improve house hold behaviours that help maternal & child survival and control spread of communicable diseases Provide financial support during illnesses Reduce expenditure on Health

5 Key strategies Continuous capacity building Convergence with line depts Community Investment fund (need based health and nutrition projects) Community health resource persons (CRPs) strategy for behavior change. Case Managers

IKP Health Value Chain towards reaching MDG 4,5 and 6 Preventive & Promotive Health Care Curative Care Financing and Service Delivery Human/Social Capital Health activist Community Resource Person (CRP) Microfinance Product for NUTRITION Case Managers Health Risk Fund/ Health Savings Empower the CBOs to: Demand and access services from public health system Influence household behaviours for maternal and child care practices Nutrition & Health Day (NHD) Health Insurance Making Services Work for the Poor – Accessing PHCs & Area Hospitals Water & Sanitation Community-owned Pharmacy Nutrition Centers Community-owned Hospitals

Key players Village Organisations Mandal Mandals Samakhyas Zilla Samakyas HN CC Health Activist AWW ANM

Implementation plan @ 2-5 mandals per district in all 22 districts @ 1 Health Activist per village/habitation Health sub Committees of VOs/MMS/ZS @ 2 Master Trainers per mandal with ANM training. 1 DPM/APM (HND) per district. Field Coordinators at SPMU Existing Committees of Line departments Functionaries of line departments

Organgram Community Facilitators Project Facilitators

Key outcomes Reduction in maternal and child morbidity and mortality (MDG 4 and 5). Reduction in morbidity and mortality due to communicable diseases (MDG 6). Decreased out of pocket expenditure on health

Universal and intensive Interventions

Universal interventions Regular capacity building of health activists, health sub committees and health CRPs Institutionalization of Fixed Nutrition and Health Days (NHDs) towards complete immunization, ANC and PNC. Community kitchen gardens Promotion of weaning foods with locally available commodities Regular health savings and HRF Community managed health insurance

Community-Managed Nutrition cum Day Care Center Goal To improve Perinatal and neonatal outcomes and child care practices towards achieving the MDGs in rural Andhra Pradesh Objectives To provide nutritional and health care for pregnant and lactating mothers. To encourage improved health care practices for safe deliveries and have no low birth weight babies. To empower communities to make pregnancy safer and develop change agents to have sustainable impact.

Nutrition cum Day Care Center (NDCC) Physical center i.e., building with Kitchen, Dining and Garden (for growing vegetables) TWO MEALS a day prepared and served to pregnant and lactating mothers and children <5 years Cook is an SHG member trained in preparation of nutritious, traditional diet (with focus on use of millets & greens)

Nutrition cum Day Care Center (NDCC) The center also doubles-up as a health check-up centre for pregnant and lactating mothers and children <5 years Serves as a venue for health education and behavior change communication

NDCC Financing Model The cost of meal Rs 25 per day for TWO MEALS for pregnant and lactating mothers Rs 10 per day for TWO MEALS for Children <5 year Beneficiaries pay Rs 18 per day for TWO MEALS; The balance Rs 7 is subsidized by the Community-Based Organization/ Government of Andhra Pradesh The Beneficiary’s contribution is financed via a MICROFINANCE LOAN taken from the Community-Based Organization which will repaid over 24 – 36 months depending on income status of the beneficiary i.e., CONSUMPTION SMOOTHING VIA a CONSUMPTION LOAN

Process Discussion with the mothers-mother-in laws Discussion with beneficiaries Grama sabha Day care for children Preparation of MCP Feeding at NDCC

NDCC Coverage 2007-08 : 200 centers 2008-09 : 400 centers

Coverage against survey As per enrolment at 600 NDCCs with 332 day care centers. 3,220 BPL pregnant women; 1,967 SC/ST 3,148 BPL lactating mothers; 1,991 SC/ST 3,440 BPL children 0-3yrs; 2,167 SC/ST As per survey at 600 AWCs 5092 pregnant women from all categories 6043 lactating mothers from all categories 9960 children 0-3yrs from all categories.

Perinatal outcomes* Against the 2890 deliveries happened: 100 %of women had safe deliveries. [2559 Institutional(88.5%) /331 trained personnel(11.5%)] 2599 had normal deliveries (89.9%) 291 had cesarean section (10.1%). 87% women had complete ANC 99% women had PNC 46% of pregnant women gained 10-12Kgs weight; 47% gained 7-10kgs weight No maternal deaths reported among the women enrolled * Source: Internal MIS

Neonatal outcomes* 1497 girls (51.7%) and 1398 are boys (48.29%) 97% of babies born with >2.5Kgs 56.5% babies with >3Kgs Neonatal care practices 97% neonates are fed with Colostrum and no pre-lacteal fluids 82% delayed bathing the baby for 7 days. * Source: Internal MIS data

FAQs about results Accuracy of the measurements? Technical person for supervision? Authenticity of the data? Empirical evidence ?

Early outcomes

Mainstreaming HIV/AIDS prevention Complementary roles of the Societies. Development of CRPs as TOTs. Regular capacity building of stakeholders at all levels integrated with HN training plans. Exclusive Health CRPs to focus on SHG trainings and referrals. Scale up plans integrated with HN interventions. Knowledge levels and referrals rates are impressive in intervention areas.

Roll out plan : 2009-2012 Expansion of mandals (62 to 458) Entire district saturation with universal interventions (6) Coverage of all tribal mandals and disability mandals piloted under IKP.

Please visit www.serp.ap.gov.in/HN for more details Thank You