2. MARVI Nutrition Integrated Model Balakot, District Mansehra

3. Intervention initiated in three Union Councils of Tehsil Balakot in district Mansehra Pilot Phase = 6 months (April 15 – October 14, 2015) Implementation phase = 18 months (October 15, 2015 – March 14, 2015) 20 villages in pilot phase and 30 villages in implementation phase Target Beneficiaries – Pregnant women = 1125 – Lactating women = 2250 – Adolescent girls = 2250 – Children Under 5 year =4500 Introduction

4. Intervention is focused on Nutrition counseling for behavior change to improve the feeding practices of women and Children Prevention of iron deficiency anemia and other micro-nutrient deficiencies Main objectives: Improved nutritional knowledge of the women in pregnancy, lactation, adolescent girls and children feeding Improved dietary practices for women and children Improved nutritional status of women and children Introduction

5. 35-40% population is not covered by the Lady Health worker program (LHW) in Pakistan ( http://www.emro.who.int/pak/programmes/service-delivery-lady-health-workers.html) http://www.emro.who.int/pak/programmes/service-delivery-lady-health-workers.html As HANDS has developed and tested a model of community based health worker called MARVI, for non-LHW areas for promotion and provision of reproductive health, nutrition and Family planning basic services The MARVI model is a solution to improve access for the rural remote uncovered and underprivileged communities. She remains accessible and source of information and guidance to the community on nutritional issues The MARVI workers work under the close supervision of qualified and trained Lady Health Visitors (LHV) Innovation

6. Approach MARVI key to community intervention Linkages and referral to Public Health Facilities Provision of Iron & Folic Acid Tablets Screening and growth monitoring women and children Group Counseling on nutrition and diet Home visits for Individual counseling Record keeping of all enrolled women

7. MARVIs are selected through community dialogue MARVIs are trained and skilled in behavior change communication They form a bridge between community and government health facilities through referral mechanism Approach

8. They use Information and education material for group and individual counseling to improve the dietary diversity and dietary intake Approach The MARVI health house is established to make a center/ hub of counseling and provision of iron-folate supplements, growth monitoring of women and children, and record keeping of all clients and activities

9. Public Sector Involvement through lens Consultation with Provincial Health Department Monitoring by LHW Program Review of IEC materialDHO during MARVIs training

10. Community Involvement through lens Male community session Women group meetingCounseling with female

11. Expected Outcomes: Short Term: Number of women with appropriate weight gain during pregnancy Reduction in low birth weight Improvement in ANC visits to the public sector health facilities Number of women taken iron-folate supplements regularly during pregnancy and lactation Number of children on exclusive breast feeding for 6 months Improved knowledge of women about nutrition and proper diet for women and children both Long Term: Reduction in malnourished and under-weight children, women and adolescent girls Reduction in anemia among women and adolescent girls Intended Outcomes

12. Motivated MARVI worker can bring some change through consistent counseling 28 years old Educated up to grade 12 Trained under the project Faced resistance while performing routine activities Kept herself motivated and continued counseling local families to attend sessions Convinced families for measurement Educated families on correct dietary practices Referred and accompany women to nearby BHU for ANC Experience from the Field Nadia Bibi – MARVI Worker Village Katwi Char

13. MARVIs through counseling sessions addressing the following myths for correction Women have many myths related to intake of certain foods (cold and hot foods) Women don’t disclose pregnancy till 5 months (Nazar) They don’t feed colostrum ( perceived it as bad for newborn) Perceive iron and folic acid tablets as Family Planning tablets Introduce ghutti (Korichar patta - local leaves) to newborns (for better digestion of the newborn) Role of MARVIs addressing local misconceptions

14. Poor access due to mountainous terrain and poor infrastructure Frequent disruptions due to land slides during rainy season and snowfall during winter No women medical officer available at nearby BHUs Female avoid to consult with male doctors Mobility of females is restricted without husband consent Prefer home deliveries due to lack of financial resources Challenges

15. Continuous liaison and progress sharing with the Government partners has build a trust and now they are more supportive Engagement and involvement of the local political, religious and local administrative leadership help in getting buy-in of these community leaders and their communities Community dialogues and subsequent large community meetings with the male members help in creating conductive environment Lesson Learned

16. The MARVIs may be sustained as a trained, skilled human resource for providing basic Nutritional advices and services in LHW uncovered areas. MARVIs may be selected by the health department and inducted in LHW program as LHWs, after completion of the project. HANDS social marketing program will support these MARVI workers through training and provision of other RH products. Social marketing program provide products on subsidized cost MARVI generate income by selling these products Sustainability

17. Continuous linkages with the Government health department Evidence based advocacy Some livelihood schemes in future to improve the household earning especially of the community women, Scale-up the pilot in other non-LHW areas in the same district and other districts Way Forward

18. THANKS