lie'Wwork: Ma 7-27, 2001 Final ltqMJl1: lllne 3Q 2001 Esterul E aa..ti•• Team: Dr. Wayne~ T-e~Leat4e:r Laura Bailey, LeddAtilhN Dr. AJ Bartlett Rene Berger Vasant Ca\ale Dr. SUbadra Seshadri Dr. Tina Sa,.gh' i Dr. K. Vijayllajh an TABLE OF CONTENTS List of Abbreviations Acknowledgements and Thanks Road Map Executive Summary I. Introduction II. Methodology Ill. Background: Nutrition and Health in India, ICOS and INHP IV. Evaluation Findings on the Developmental Hypothesis and Strategies A. Program hypothesis on INHP inputs and key interventions i. Role of food ii. Key interventions B. Program hypothesis on INHP strategies - capacity building and sustainability C. Evidence of success V. Evaluation Findings on Documented Coverage, Outcomes, Impact. Attribution VI. Evaluation Findings on CARE's Implementation of INHP A. CARE's working relationship with all partners B. Implementation against plan and expenditure against budget C. Technical interventions i. Interventions ii. Implementation processes iii. Community-based activities D. Support systems i. CARE structure, roles ii. CARE staff and technical support iii. Food iv. Management decision support- Community monitoring, HMIS E. Organizational learning and diffusion F. Capacity building and link to sustainability, replication, and exit strategies VII. Key Issues and Recommendations ANNEXES ANNEX A. ANNEX B. ANNEXC. ANNEXO. ANNEXE. ANNEXF. ANNEXG. ANNEXH. ANNEX I. ANNEXJ. ANNEX K. METHODOLOGY PROGRAM DESCRIPTION & DEVELOPMENTAL HYPOTHESIS DOCUMENTED COVERAGE. OUTCOMES, IMPACT, & ATTRIBUTION COMMODITY & SUPPLY CHAIN MANAGEMENT EXPENDITURE AGAINST BUDGET TECHNICAL INTERVENTIONS SUPPORT SYSTEMS HMIS ORGANIZATIONAL LEARNING & DIFFUSION/REPLICATION CAPACITY BUILDING & SUSTAINABILITY STA TE REPORTS 3 +3 ANC ANM AWC AWW BOO BLAC OLS BMO BN BS BVR CB CDPO CGHS CIHQ CMU CRS CSB DAP DlP DLAC DPO DS DVR DWCD FC FCVR FEW FM FO FPAJ FPIA FRHS GMO GOI HI HIB HVQ ICDS ICMR IFA JNHP IGA IOP !RMS LHV LI LOP MISP MO MOHFW MOH RD MPF MPR ABBREVIATIONS three core JNHP supply-driven interventions plus 3 key messages about infant feeding Antenatal care Auxiliary Nurse Midwife Anganwadi Centre Anganwadi Worker Block Development Officer Block Level Advisory Committee Baseline survey Block Medical Officer Basic Nutrition Birth spacing Block Visit Repo11 Capacity Building Community Development Project Officer Central Government health scheme CARE-India Headquarters Commodity Management Unit Catholic Relief Services Com soya blend Development activity proposal Detailed Implementation Plan District Level Advisory Committee District Prograrrune Officer Demonstration Sites Daily Visit Report Department of Women and Child Development, of the MOHRD Field Coordinator Feeding Centre Visit Report Field Extension Worker Food Monitoring Field Officer Family Planning Association oflndia Family Planning International Assistance Foundation of Research in Health Systems genetically modified organisms Government of India High Impact Health Information Booth Home Visit Questionnaire Integrated Child Development Services, a programme ofWCD Indian Council for Medical Research, under Ministry of Health and Family Welfare Iron and folic acid Integrated Nutrition and Health Project Income Generating Activity Individual Operating Partner Institute for Research in Medical Statistics, under ICMR Lady Health Visitor Leveraged Impact List of provisions Maternal and Infant Survival Project Medical Officer Ministry of Health and Family Welfare Ministry of Human Resource Development Monthly Priorities Fonn Monthly progress report ACKNOWLEDGEMENTS and THANKS The INHP-1 Final Evaluation Team would like to thank the energetic staff of CARE-India whose dedication and openness added so much to our ability to learn about this complex project and contribute the suggestions and insights contained in this report. In particular: > we thank the staff of the Nutrition, Health, and Population Unit at CARE-India headquarters (CIHQ) for their good-natured and flexible response to all our many demands and their excellent organizational work in preparing for our visit > we thank the staff in other CIHQ program and program support units for providing valuable additional information about the organizational context in which INHP operates > we thank the members of the Technical Advisory Group and other national experts for their contributions of time and expertise during our planning and briefing week > we thank our colleagues in the Government of India and in State government agencies, for their commitment of time and energy during our planning and our field visits; they contributed greatly to our understanding of INHP and our suggestions for the future > we thank the INHP program counterparts at state, district, and block levels who took the time to travel with us and help us jointly explore INHP's successes and challenges }i;>o and we extend our heartfelt thanks to the CARE ·field staff working in the eight states where CARE implements INHP - congratulations on both effort and results! A NOTE TO READERS This report is written with a main text supported by detailed technical annexes. Each technical annex was written by one member of the external evaluation team as primary author, with inputs from other team members, and each annex may be read either as a separate document or as a more detailed supplement to the main report. Because of this design, there is some deliberate but unavoidable repetition between the main text and the annexes. ROAD MAP If vou are Interested in this topic: Look In these sections: the "big picture" on INHP Executive Summary Section Ill Section IV Section VII documented coverage, outcomes, impact, and Section V attribution Annex C technical aspects of health and nutrition Section Vl-C interventions Annex F support systems for INHP - organizational Section VI-A aspects of INHP implementation Section Vl-D Annex G commodity supply chain management Section Vl-D.3 Annex D monitoring and evaluation systems, indicators Section V Annex C Section Vl-D.4 Annex H organizational learning and diffusion Section Vl-E Annex I capacity-building Section Vl-F Annex J sustainability, replication, and exit strategies Section Vl-F Annex J methodology for this evaluation Section II Annex A state-specific details Annex K NATIONAL STATE DISTRICT BLOCK IECTOR V\IJ.AGE COMMUNITY ACRONYMS, PRESENTED BY ORGANIZATIONAL LEVEL Mo+fRO-Mfnlstry of Human R"ourc:e O.vek>pment DWCO-O.panment of Women and Chlld Development roart of MOHRDI ICOSslnteglc ~--for CNld GQlsGovernment of India CRS•C4tholie Relief Seivicti FPAl•Fam;1y Planning Assoelatlon of India FRHS•Foondation for Research In Hutti\ Svstema WFP.Worfd Food Pr ramme CIHQ•CARE India htadqualt4,. SMART-Supply ma"-'"""' and raource ndin-I - NfMS&ffa _lional _ F.....,_ ..,,_ S-.,. ~ol-- .lo_POe __ °'_•lri_•_'P_.._.._ m.m_•_""'_- ________ _.l ________ J10..i:,_, omcer 1--------· l~tlfct m-- 1!2!-A.S:2'!.!.r\£llln!.."~'L••1l.fl!!!'!!!."!'tt- - - - ...j I COPO-CommunltydtvelotNnot1tllft!lecl- ··--·---·![~;!12Sk~:;~ftmiii::::::!-----·---fs-1ocl'nt«llul- ~.B-OOaB~--loclt...,.~..,. .... opm ....... on ..... 10.ffl....,ce<---------•- rli"'C"'D"'S_Su,_P!f!_ .. _°'..,.. .... ------------.t---~~-~~::.,JN90=._ .. ._N"'0't9"""•0..,•;.;tt;,;;m;;;;.m-.-...,,.1 ..0!l!!..,. ...- .. ""'.._ ____ _,,J.. .. _ ...__ ........ _ A--..SI C.nbe • ~wolfrer , , , ' ' ,.····'/,/ IFA•lron folic acid RTE• Ready to ea\ SF•Socl feeding (0< SuQOl..,,._l IMdinQ) ·-·------ . THR- home raUoo .. COo TT-loltoOI INHP Area as of October 1996 937 blocks 114,300 AWC 6.63 million beneficiaries EXECUTIVE. SUMMARY I. Introduction Any assessment of development programs in India must be made within the context of India's incredible scale: India is home to 40% of the world's malnourished children; India received 16.5% of USAID's Title II non-emergency food assistance; the Government of India's contribution to CARE is the greatest made by any government in the world to an NGO working in its own country; and CARE-India's budget accounts for 20.2% of CARE-USA's total budget worldwide. CARE developed the Integrated Nutrition and Health Project (INHP) to mobilize resources from USAID, the Government of India (GOI), non-governmental organizations (NGOs), and communities to address the enormous problem of malnutrition in vulnerable women and children. Designed in 1995-6 as CARE's first Development Activity Proposal (OAP) in India, INHP is currently working within the GOl Integrated Child Development Services (ICDS) program in eight states: Andhra Pradesh, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, and West Bengal. To appreciate the scope of INHP, consider this comparison: INHP is operating in a geographical space as large as Indonesia, with a population 2.7 times that of Indonesia. INHP is the largest program of its type In the world. II. Response to the 1999 Mid-Term Review CARE responded enthusiastically to the suggestions of the 1999 Mid-Term Review (MTR). which called for a refinement of program implementation strategy to focus on a narrower range of interventions. Since 1999, INHP staff throughout CARE-India's organization have re-committed themselves to the strategic aspects of INHP - building capacity within communities. systems, and individuals, catalyzing convergence between the government health and ICDS departments, and empowering communities and women. INHP successfully revised the project structure in order to more effectively channel resources for maximum impact and more efficiently scale-up the program's reach. Throughout this process, the CARE field and HQ staff have fostered an environment for creativity, learning, and growth not only within their own organization but in their collaboration with government counterparts, NGOs, and community groups with whom they work. Ill. Final Evaluation Methods and Processes Consistent with the evaluation plan in the OAP, the final evaluation of INHP-1 was undertaken by a multi-disciplinary team of Indian and expatriate specialists who considered a wide range of project documents and reviewed data and analytical results from three sources: ~ a quantitative survey, conducted in all states where INHP works and overseen by a high￾level Technical Advisory Group as recommended by the INHP Mid-Term Review; ,. a qualitative survey. conducted by an external management consulting agency wi1h key informant and focus group interviews in all INHP states; ~ field visits and observations by the external evaluation team and government counterparts during visits to all INHP states. IV. Major Findings . • The conceptualization and implementation of INHP was a programmatic and institutional revolution for CARE and for USAID food support to ICDS. CARE's expertise in health and child survival and in community capacity-building, and their expertise in nutritional interventions, is now recognized and welcome at the state, district, block, and community levels, and CARE is now viewed as a development partner. • INHP has succeeded in bringing together ICDS and health department policies, operations and service delivery, after decades of attempts made by government and other agencies - and government departments have become more effective at reaching high coverage rates for health services as a result. • Conviction about conceptual links between CARE's inputs and improved nutritional status is variable, and is not a driving force across the project. Food clearly does serve other roles - as an incentive for participation in services and as leverage for policy change - but the nutritional focus is important and appears to have been neglected in certain operational decisions. • Where fully implemented, INHP is making important contributions to child survival in India through improving immunization and breastfeeding (including colostrum feeding) practices, and indirect evidence suggests that INHP is helping to reduce the under-nutrition (low weight￾for-age) which increases the risk of children dying from common childhood illnesses. • Changes to management information systems (MIS) have improved routine process monitoring and now provide useful information for field management of INHP. • CARE has been especially impressive in systematizing, monitoring and strengthening processes and at rolling them out to scale. Their management of the commodity supply chain for the Title II food inputs is a prime example of increased institutional capacity. • Social mapping has improved targeting of take home ration (THR) resources and thus improved targeting of program interventions to the most vulnerable - this has increased village ownership of the program activities and, in some cases, reduced social tensions over perceived distributional inequities by making the beneficiary mapping and selection process transparent and public. • INHP's links with self-help groups, newly invigorated mahila mandals, village development committees, and small groups of change agents such as dais and adolescent girls, have empowered village women -- and those women have become effective agents for behavioral change among their peers. • I NH P's efforts to simultaneously strengthen government service delivery while building community capacity are critical for health and nutrition outcomes, sustainability, and empowerment. • Decentralization has empowered state level staff to adapt, innovate and develop creative solutions to local problems, and has allowed Field Officers to play a key role in INHP's success. • CARE has not yet fully defined and articulated the evolution, maturation, and completion processes and sub-strategies that will be needed to finish the work of INHP; in spite of the increasing pressure on planning for CARE's hand-over and transition, there has been only a limited planning for this transition at local, state, and national levels. V. Major Recommendations Reinforce INHP's nutritional focus • Invest in building the commitment of staff, counterparts, and partners at all levels to achieve nutritional improvement through INHP. • Review plans for INHP-11 to balance and sequence nutrition and health interventions, ensuring that the nutritional focus is appropriately achieved. • Carry out focused monitoring plus operations and evaluation research to define the extent and determinants of changes in key feeding behaviors; use the results to strengthen and promote the feeding behavior component of INHP. • Strengthen behavior change capacity and develop a systematic approach and toolkit for dealing with behavior change; this will catalyze not only nutritional interventions but also health interventions such as IFA consumption, care-seeking and disease recognition, etc. • Emphasize community approaches to behavioral change, not simply communication or messages directed to individuals. • Consider the latest information about growth promotion and evaluate the possibility of undertaking a focused pilot on capacity-building for growth promotion under INHP-11. JI • Discuss an explicit focus on improving quality by service providers, including anganwadi workers (AWWs) and auxiliary nurse midwifes (ANMs), through developing quality monitoring and improvement processes at the district and block levels in both ICOS and the Department of health and Family Welfare (HFW). Clarify and ensure availability of technical support for key INHP Strategies • Use participatory processes to clarify and communicate project-wide objectives and strategies for key components, including community behavioral change, capacity building, replication, and phase-out. • Empower and facilitate state offices as they develop appropriate operational plans to achieve these objectives and strategies. • Make more explicit distinctions between core project principles and appropriate local adaptations; identify specific INHP objectives, set standards and guidelines for state plans, and clarify division of responsibility between local and national levels. • Increase technical support for Field Officers(FOs) and encourage peer sharing to strengthen technical capacity and improve the quality of field implementation. • Encourage cross-learning at all levels: FOs to each other, specialists and program managers with other state personnel, and so forth. • Commit to a focus on enhancing technical expertise throughout the states and developing mechanisms for systematically monitoring, diffusing, and replicating INHP successes. Define INHP's end point and develop operational strategies for achieving it • Define INHP evolution, maturation, and graduation - what does a mature and sustainable INHP program site look like in 2006, and how do we get there? • Review current plans to replicate demonstration sites, with a view to developing more concrete plans for diffusion and replication. • Consolidate successful experience in role of catalyst so that even if Title II food commodities phase out or over, CARE can continue to provide assistance in the child survival and nutrition areas. Do not play the role of direct service provider. • Test models for hand-over, such as the local food processing model proposed for funding partially by monetization resources, as a high prtority for INHP-11 to prove the financial feasibility of INHP program blocks •graduating" from Title II food and towards sustainability. • Review and revise INHP-11 implementation plans and scope to better reflect a comprehensive capacity building approach and objectives; maintaining the focus on community-level capacity building. • Develop a plan for and conduct explicit advocacy for phasing over critical INHP functions to government, NGO and community entities - address both the why and the how. • Carefully assess capacity building experiences (training and others). identify those successful in achieving desired outcomes; document and package those proven effective for broader use; and monitor and help adapt their use as appropriate In different situations. • Use CARE's expertise in managing the commodity supply chain operations to assist with optimizing the delivery of other key inputs or to provide consulting expertise to government programs with supply chain problems. • Develop milestones to measure progress in capacity building and sustainability, and provide continued support and motivation to achieve them. • Build a joint exit strategy to gradually phase over INHP functions with key partners at all levels, and develop/use indicators to monitor outcomes of capacity building. iii Develop more flexible monitoring and evaluation approaches • Develop a more "nimble" evaluation and documentation strategy to facilitate focused evaluations. simple problem-solving studies, and perhaps prospective operations research, for key strategic issues such as community behavior change and replication/diffusion. • Consider a strategy whereby large scale surveys would not be necessary to measure impact. This might include dropping the midterm survey for INHP-11 and focusing instead on extracting data from operations research and targeted evaluations. • Consider smaller more targeted surveys for baseline and final to cover key interventions; discuss with experts and consider whether smaller scale, targeted, evaluations can provide measures of attribution of INHP inputs to impact on nutritional status. • Identify methods for capturing policy level changes in relation to INHP implementation and to disseminate these experiences across States in order to affect greater change. • With data already collected, undertake a series of detailed analyses on target activities to assess changes across the INHP implementation period and to relate these changes to program inputs. • Review coverage of individual interventions at the state and, to the extent possible, district levels; identify approaches to achieve better coverage in the context of INHP and other GOI initiatives. • Assess the effects of INHP on overall coverage QQth among THR beneficiaries and beneficiaries of health services. • Identify mothers and children not being reached with immunization and antenatal care (ANC} services and counseling; develop and evaluate approaches to reach them. • Using an internally participative process, review the project's Health Management Information System (HMIS} to assure that information for decision-makers at all levels is available in a user-friendly fashion and consider how information is disseminated within and across the project. Involve government and NGO counterparts as appropriate. • Encourage and support expanded community-managed monitoring as an essential step towards sustainability post-INHP. • Continue with social mapping and updates involving the community, and increase the focus of those mapping events on reaching the marginalized and distant families in the anganwadi center (AWC) catchment area. Strengthen CARE's Implementation of INHP • Reflect on the main budget line items, especially those where costs have risen rapidly or are higher than is standard -- analyze the benefits achieved with 'those resources and shift resources if necessary. • Assess AWW (and ANM) workload issues, and seek to help them carry out existing and new tasks in ways that are not disincentives for their effective participation. • Continue the pursuit of internal gender equity, perhaps adjusting work conditions to overcome identi'fied constraints to the employment, retention and advancement of female staff in critical field positions. • Retain intermediate positions between FOs and the state level, but primarily for technical support; consider a possible peer support system, in which FOs within a sector team support and critique each other's work, with only occasional support from higher levels. iv INHP FINAL EVALUATION REPORT -- June 2001 I. Introduction The Integrated Nutrition and Health Project (INHP) was launched on October 1, 1996 and currently operates in more than 100,000 anganwadi centers (AWCs) in eight states in India: Andhra Pradesh, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, and West Bengal. INHP seeks to reach more than 7 million women and children, primarily in rural and tribal blocks with supplementary food and with health and nutrition services. In the first phase, INHP has drawn resources from USAID (Title II food and monetization, Farmbill 202e grant monies, and container funds) and from the Government of India (GOI) for operations. In INHP-11, additional resources from USAID's child survival program are proposed for intensification of key health and nutrition interventions, building on the achievements of INHP-1. In FY 2000, INHP managed more than 188,000 MT of Corn Soya Blend (CSB) and 25,000 MT of soybean oil, valued at $US 67 million. The annual budget of INHP, approximately $76 million (food and cash), represents 20.2% of CARE-USA's worldwide budget. Over the five-year implementation of INHP, CARE-India has managed $350 million in food resources and $30 million in cash. INHP is the largest project of its type in the w orld. II. Methodology INHP was conceived as a ten-year effort, and this evaluation focuses on assessing the progress and achievements of the first phase (INHP-1, 1996-2001 ).; Based on our findings and observations , this report provides suggestions for CARE-India as it prepares to implement INHP-11. Thus, while the external evaluation team did seek to assess key aspects of INHP-1 and to link those findings to recommendations on implementing INHP-11, this evaluation did not undertake to critique or assess the overall design for INHP-11 as expressed in the new Development Activity Proposal (DAP-2). Consistent with the OAP for INHP-1, this final evaluation was conducted by a multi-disciplinary team of Indian and expatriate specialists who considered a wide range of project documents and reviewed data and analytical results from three sources: • a quantitative survey, conducted in all states where INHP works and overseen by a high-level Technical Advisory Group as recommended by the INHP Mid-Term Review; • a qualitative survey, conducted by an external management consulting agency with key informant and focus group interviews in all INHP states; • field visits and observations by the external evaluation team during visits to all INHP states. Each technical specialist on the INHP Final Evaluation team was assigned a particular set of evaluation topics from the Terms of Reference, and field visits were guided by topic protocols designed by each specialist. The detailed synthesis of each technical topic, presented in the annexes to this report, was authored by the assigned technical specialist from the team, while the major findings and recommendations presented in the main text were discussed and agreed to by the entire team. Ill. Background: Nutrition and Health in India, ICDS and INHP The Context of /CDS and India: INHP works within the context of GOl's Integrated Child Development Services (ICDS) program, the largest program of its kind in the world, in which government health and family welfare services and donor resources are jointly leveraged to battle the persistent and troubling challenges to improving the lives of poor women and children in India. The ICDS nutrition and health Interventions focus on the anganwadi center (AWC), a village-based entry point operated by an honorary community worker, the anganwadi Worker (AWW). India is home to less than 20% of the world's children but has more than 40% of the world's malnourished children. Malnutrition varies widely across regions. states, age, gender, and social group, being worst in children under two, in women, in populous northern states. in rural areas, in tribal populations, and among scheduled castes - and while poverty explains the high level of malnutrition in India, additional social factors concentrate the problem among women and children. The policy and resource context of INHP and ICDS includes several paradoxes: • India is food secure at the national level but food insecure at the household level - millions of poor families lack access to adequate food and nutrition. INHP FINAL EVALUATION REPORT - June 2001 • India is continuing a steady move towards economic liberalization and support for market-oriented economic growth, but the current fiscal crisis affecting the central and state governments is putting increased pressure on programs serving the most vulnerable - the same poor families with whom CARE works. The Context of CARE-India: The conceptualization and implementation of INHP was a programmatic and institutional revolution for CARE and for USAID food support to ICDS. It changed: • how CARE operates as an institution • how CARE staff see themselves and their program • how CARE cooperates with and is viewed by central and state governments • the role that CARE staff and CARE program resources play within ICDS at both the policy and operational levels CARE's expertise in health and child survival and in community capacity-building, in addition to their expertise in nutritional interventions, is now recognized and welcome at the state, district, block, and community, and CARE is now viewed as a development partner. Their institutional transformation from a food management group to a nutrition and health development partner has been impressive, and can be best completed by reaffirming and refining the INHP program vision. R'ecommendations: • Commit to a focus on enhancing technical expertise throughout the states and developing mechanisms for systematically monitoring, diffusing, and replicating INHP successes. • Define INHP evolution, maturation, and graduation -- what does a mature and sustainable INHP program site look like in 2006, and how do we get there? IV. Evaluation Findings on the Developmental Hypothesis and Strategies INHP underwent considerable strategic revisions after the 1999 Mid-Term Review, and now targets six key interventions to two major target groups, a) pregnant and nursing mothers, and b) children under two years of age. The project is currently implemented in eight states of India: Andhra Pradesh, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, West Bengal, and Uttar Pradesh, covering 7 million women and children in approximately 100,000 villages, which is about 25% of all the population covered by India's massive ICDS program. CARE staff play chiefly a facilitator role in achieving the goal of improved health and nutrition of women and children through strengthening and building the capacity of ICDS staff, NGOs and community members; and by improving the delivery of services through the government. The available data from India and other developing countries clearly show that much of the growth retardation that occurs in early childhood (0-6 years) takes place between 6 and 24 months. Further, data on infant and under-five mortality due to various diseases also indicate a very strong synergistic relationship between malnutrition and mortality, especially in infancy -- mortality rising sharply in malnourished, and dropping equally sharply when malnutrition declines in a community. Therefore, two major hypotheses have been articulated in the INHP program. A. Program hypothesis on INHP input.sand key interventions: The first hypothesis, articulated consistently in INHP program design documentation, is that nutritional improvement can occur by improving infant feeding practices (colostrum feeding, exclusive breast feeding for first 6 months and appropriate complementary feeding beginning at 6 months), and by focusing on improved delivery of food and health services to the vulnerable groups. This hypothesis is captured in the stated goal of the INHP project, "to improve the nutritional and health status of the vulnerable groups of women and children". I. Role of food - At the individual level, the CSB and oil are targeted nutritional supplementation for vulnerable women and children. At the community level, the Title II food used in INHP acts as an incentive for community engagement with and ownership of ICDS activities, and as an entry point for INHP interventions supporting improved health and nutrition practices. At the district, state, and national level, the Title II food and CARE's technical and systems expertise are resources that figure prominently in the policy and program debates about maternal and child health and nutrition in the context of ICDS. II. Key interventions -- Population-based strategies replace center-based ones for supplementary food distribution, using Take Home Rations (THR) to reach the most vulnerable target groups (pregnant and lactating women, children under two}. Nutrition Health Days {NHD) are organized once a month by the AWW, the 2 INHP FINAL EVALUATION REPORT -- June 2001 ANM, and the community as a nexus for key service delivery. Convergence of services at the village level is facilitated by promoting sustainable co-ordination between the Department of Women and Child Development and the Ministry of Health & Family Welfare, creating institutionalized mechanisms for joint planning andl problem￾solving and improved upward and downward communications. Innovations at different levels are pursued to enhance service utilization and behavior change. Community mobilization and empowerment are sparked through village development committees (VDC), adolescent groups, invigorated Mahi/a Mandals, and other mechanisms for creating community ownership. The capacity of individuals, community, institutions and systems to support and promote improved health and nutrition practices is built through the development of INHP￾supported AWCs into Demonstration Sites (DSs) -- learning centers and examples of INHP best practices. Cross fertilization, visits to other areas, and clustering of villages around the DS are undertaken as replication strategies. B. Program hypothesis on /NHP strategies -- capacity building and sustainability. The second foundation of the INHP program posited that sustained improvements in health and nutritional status would not be possible without strengthening the capacity of communities to support women and families to practice key nutrition and health behaviors, improving the capacity of government counterparts to deliver supplementary food and health services, and building capacity of NGOs to facilitate the work of institutions in the community. Therefore, it was hypothesized that sustainable capacity building will lead to behavioral and system changes that will result in improved nutritional and health status. C. Evidence of success: INHP is making important contributions to child survival in India, through improving immunization and breastfeeding (including colostrum feeding) practices, and reducing the under￾nutrition (low weight-for-age) which synergistically increases the risk of children dying from common childhood illnesses. The basic INHP package of 3+3 is effective and has showed results; the narrowed focus after the MTR is paying off. Small Miracles Last year, in a village of Domakooda block in Andhra Pradesh, a one year old boy was stricken with "brain fever" - whether il was meningitis or encephalitis is now hard to tell. He survived, but when he returned to his village from the hospital, he was not only blind but could not walk or even hold his head up. Over the next several months, his parents returned with him to be examined by a number of doctors, including visitlng specialists from Hyderabad. The concluslon was that the child had suffered serious and lasting neurological impairment. Before being stricken ill, the mother had been bringing the boy to Nutrition-Health Days at the anganwadi center near his home, which was one of the INHP demonstration sites. When he returned home from the hospital, the anganwadi worker had vi siled. She encouraged the mother to continue participating in the Nutrition-Health Days, so that the boy could at least benefit from immunization and supplementary feeding. When the boy was brought to the center after an absence of two months, she ploUed his weight and found him to have become markedly malnourished -since his illness he had declined from being well in the normal range to grade Ill malnutrition. During the boy's first few months out of the hospital, the anganwadi worker continued to encourage the mother, but took no additional action. ·1 was confused." she says, "while he was seeing so many doctors." Then she decided to act. Beyond providing a double ration, she taught the mother to make a gruel that the weakened child could take in small, patient feedings. She also encouraged the mother to feed the child other nutritious foods prepared from home ingredients. Recalling that the child had not been present on the centre's last Vitamin A Day, and that vitamin A was associated with vision, she administered the child a dose of vitamin A, and a second dose six months later. She plotted and monitored his weight every month. For the first six months, the little boy's nutritional status improved steadily, but only sloYAy. Then it began to improve faster. One day in the anganwadi centre, both the anganwedi worker and the mother saw the boy looking at an object -wilh life in his eyes.· "I think he can see!" the anganwadi worker told the mother. The rest of the story is short. Progressively the little boy regained strength - he began to move, to hold his head up, to talk, and finally to walk. Today, almost a year and a half later, he is a healthy three-year-old child of normal appearance, developmentally normal. He is still in the middle of the Grade I malnutrition category, but Is on his way back to the normal range. In the centre the mother sits on the floor near the anganwadi worker, her smiling soo standing by her side. "He has been given back his life,• the mothef' says. Looking at the anganwadi woriler, she repeats, "She gave it back to him." 3 INHP FINAL EVALUATION REPORT -- June 2001 INHP has also succeeded in finally bringing together ICDS and health department policies, operations and service delivery, after decades of attempts made by government and other agencies - and governmental departments ha.ve become more effective at reaching higher coverage rates for health services as a result. Interestingly, although INHP has galvanized the ICDS system in clear ways with visible results, confidence among partners - government functionaries, field and program staff - about the conceptual links between INHP inputs and improved nutritional status was variable, and needs this strengthening to become a driving force across the project. • Recommendation: Invest in building the commitment of staff, counterparts, and partners at all levels to achieving nutritional improvement through INHP, including a review of INHP-11 to balance and sequence nutrition and health interventions. V. Evaluation Findings on Documented Coverage, Outcomes, Impact, Attribution CARE should be proud of their efforts and achievements in quantifying and documenting the outcomes and impact of the INHP interventions; few, if any, other projects have attempted to collect the range of information from such a large sample as in the INHP, and using such high-quality resources and technical inputs. CARE has made a tremendous effort in undertaking consistent quantitative surveys to measure program impact. However, given the rolling nature of the project, each quantitative survey has led to more questions than answers in terms of generalizability to the current operating environment when compared to the previous survey{s). Additionally, in ways that are described more thoroughly elsewhere in this report, CARE has made significant efforts to change the way it assesses and measures •routine" activities. The approach of monitoring process. with periodic large surveys to assess outcome and impact, remains sound. However, feedback from the field suggests that at some level, outcomes should be monitored in a targeted and periodic fashion {though not on a monthly or quarterly basis as with the old Home Visit Questionnaire). This should not be seen as moving backwards, rather as further refining the systems which CARE has worked hard to set in place. As CARE looks towards the second five years of INHP (INHP-11), it should be prepared to accept that outcomes and impact will need to be shown at a block level. Regardless of the survey mechanism chosen, comparisons should be done in such a fashion as to provide a measure of impact for the entire block. If measured through surveys, assessment of "DS areas'' should be considered as secondary to the block level and should only be used to provide an inference on where the entire block can expect to be once all areas have achieved comparable implementation times (e.g. 7 years - MTR of INHP-1 through end of INHP-11). Coverage and Outcome Measures: Data from the quantitative survey can be reviewed in at least two distinct fashions - comparison to baseline and midterm surveys and comparison to the National Family Health Survey - II data (NFHS-11, conducted in 1998/99). It should be noted, though, that NFHS-11 data may in fact be closer in timing to the midterm quantitative survey than to the final evaluation. Also, while INHP concentrates on backward and tribal areas, the NFHS-11 sample represented the whole range of each state. Comparison of results from survey data: Baseline vs. Final • Coverage rates for supplementary feeding (pregnanVlactating women and children 6-24 months) increased from baseline in 6 of 7 states (except both pregnant and lactating mothers in West Bengal). • Coverage rates for focus interventions (ANC, iron folic acid (IFA), tetanus toxoid (TI), and childhood immunizations) increased from baseline in 5 of 7 states (except in Uttar Pradesh where IFA rates were the same or lower than baseline in DS and ALL areas). • Coverage rates for breastfeeding and weaning practices increased from baseline in 6 of 7 states (except for exclusive breastfeeding rates in Andhra Pradesh and for complementary feeding rates in Andhra Pradesh ). • Across almost all states, indicators for "DS" had higher coverage rates than "ALL" areas (which covers both OS and non-OS). ANC, IFA, and TI coverage rates.were higher in 5 of 7 states for "OS" as compared to "ALL" {except IFA in Andhra Pradesh and Uttar Pradesh), however, child immunizations, breastfeeding, and complementary feeding rates 'Cl id not show the same consistent trends. 4 /NHP FINAL EVALUATION REPORT - June 2001 Midterm vs. Final Comparison between midterm and final data includes the changes in approach from high impact areas (HI) to Demonstration Sites (OS) areas. Due to differences in the way the questions were asked, the comparison of midterm and final does not include questions on child supplementary feeding, and complementary feeding practices for children 6-9 months of age. Not all HI areas are OS, but it is likely that the preponderance of these sites are in common. • Coverage rates for supplementary feeding (pregnanVlactating women) were higher in all HI blocks as compared to ALL blocks at midterm - though rates were very low in West Bengal for lactating mothers. • Coverage rates were higher in the final survey as compared to midterm in all areas and all states except in Bihar, Madhya Pradesh, Uttar Pradesh and West Bengal. In most of these states, the supplementation rate for lactating women was more often greater than that for pregnant women in the comparison of the two time frames. • Coverage rates for focus interventions (ANC, IFA, TT, and Immunizations) vary widely by State. In some states, the rates are virtually unchanged between midterm and final (Andhra Pradesh, Orissa, and Uttar Pradesh), while in other states, the midterm rates are higher than final (e.g. ANC and IFA in HI blocks of Bihar), while in still other states the final evaluation rates were higher than midterm (e.g. initiation of breastfeeding and exclusive breastfeeding rates in West Bengal). Final vs. NFHS II Comparison between final survey and NFHS II data: • Coverage rates for focus interventions (ANC, IFA, TT, Immunizations) increased in comparison to NFHS II in 5 of 7 states for ANC (except Orissa and West Bengal) • Coverage rates for breastfeeding and weaning practices increased in comparison to NFHS 11 in 3 of 7 states (except Madhya Pradesh, Orissa, Uttar Pradesh, and West Bengal - Note: initiation of breastfeeding within one hour after birth was the key indicator which was most variant from NFHS II data). The hypothesis behind the original INHP strategy, and the subsequent unified capacity building strategy. is that the demonstration sites will show greater level of change than the non-demonstration sUes. To a great extent, this can be seen in the differences between Demonstration Sites (OS) and all INHP program areas (ALL) as compared to baseline information. While there certainly are some outliers, on the whole the hypothesis seems to be born out by the data. The so-called "supply-side" interventions (targeted supplementary feeding, immunizations and antenatal care} have shown greater improvements than behavior change interventions. For example, supplementary feeding for pregnant or lactating mothers, or children 6-24 months of age, has almost universally improved across the program, and is even higher in OS as compared to ALL areas. Antenatal care has also improved across most program areas; the "dose response" is seen between OS and ALL areas. where the dose is measured in terms of INHP inputs. INHP also conducted a panel survey in which they tracked the changes in program indicators in a specific block across the implementation period. As initially conceptualized, this block was considered "High Impact", or HI, and was a focus of intensive efforts. Only one block per state was sampled in the panel survey, so the results are generalizable only to that block. In almost every intervention area, and across all the states, the coverage rates are higher in the final evaluation as compared to the baseline survey. As most former HI blocks are likely to have a number of demonstration sites in them, this may prove to be at least a partial "picture" of where INHP can hope to be as more of the demonstration sites come on-line. Impact Measures: INHP's goal was to improve the nutritional status of women and children. While changes in nutritional status have occurred, it is not always clear whether this is due to INHP interventions. Overall. nutritional status improved in 5 out of 7 states as compared to baseline (except Madhya Pradesh and Orissa (and the OS blocks of Bihar}. Malnutrition rates in INHP areas were lower than the NFHS II data in 4 of 7 states (except Bihar, Madhya Pradesh, and Orissa}. Other measures of impact exist which are not captured in a quantitative survey (e.g. leverage of State level implementation of THR, implementation of adolescent girls strategies, etc.), and are likely to be associated with INHP inputs. Attribution: The attribution of program inputs to outcomes and impact in any project is a challenge. In a project like INHP and in a country like India, where there has been such a high degree of change in both program implementation and the operating environment of the program (floods, drought, political changes, etc.) attribution becomes an even greater challenge. This is not meant to imply that programs should not attempt to measure impact - rather that in difficult operating environments, measuring the attribution of any program will be .difficult. 5 INHP FINAL EVALUATION REPORT - June 2001 Qualitative and anecdotal evidence at all levels supports the association of the changes seen since baseline to INHP inputs: • Over~ll feeling that THR/NHDs helps to bring women and children to the AWC and is therefore associated with increased coverage rates of the INHP interventions • This pullingn of beneficiaries into the AWCs for services leads to improvements in overall health and nutritional status of both women and children. Documenting Impact: After three surveys and perhaps as much confusion as clarity, CARE should consider whether there is really any benefit to implementing large-scale surveys. To date, the value added of these large￾scale (in terms of cost, coverage, and investment of time) efforts is less than clear. As a revised strategy, CARE should consider whether smaller, more targeted evaluations would provide the level of data necessary to assess program impact without leading to further questions; given that INHP-11 proposes further geographic shifts, the issue of comparability across blocks will be persistent. In INHP-11, CARE should look at the role of targeted operations research and how it can be utilized across the program to provide a gauge of program changes based on the activities being implemented. In adopting such a strategy, caution should be taken such that a re￾proliferation of indicators does not occur; learn from the experiences in INHP-1, and do not repeat the mistakes! If CARE adopts a strategy of smaller, more targeted evaluations, it should then consider, in consultation with USAID, whether a revised baseline is required. If a new baseline survey is undertaken, CARE should pay particular attention to the choice of blocks to be served (if further consolidation of the project is to occur) and the time of year when it is conducted with an eye toward the timing for any final evaluation survey and its utility in any potential further program development (i.e. timing of survey within the USAID program calendar). Recommendations: • CARE should consider adopting, and USAID approving, a strategy whereby large scale surveys would not be necessary to measure impact. Targeted operations research (OR), with defined evaluation criteria, could be used on a smaller scale basis to determine the degree of change associated with the intervention. • Much smaller surveys could be done for baseline and final to cover key interventions without collecting a number of other indicators which may not be used for program implementation or as data for decision makers. Further, CARE should discuss with experts and consider whether smaller scale, targeted, evaluations can provide measures of attribution of INHP inputs to impact on nutritional status. • CARE and USAID should consider dropping a midterm survey for INHP-11 and instead focus on extracting data from operations research and targeted evaluations. • CARE should identify methods for capturing policy level changes in relation to INHP implementation and to disseminate these experiences across states in order to affect greater change. • To the extent practicable, CARE should consider adopting community-based strategies for monitoring INHP interventions. • With the data already collected, CARE should consider undertaking a series of detailed analyses on target activities, to assess changes across the INHP implementation period and to relate these changes to program inputs. VI. Evaluation Findings on CARE's Implementation of INHP A. CARE's working relationship with all partners CARE-India's chosen role in INHP - catalyst, facilitator, capacity-builder, technical supporter - is appropriate and has made an outstanding contribution to the convergence of health and nutrition services both in INHP and beyond to other ICDS sites. Recommendations: • CARE should consolidate their successful experience in these roles so that even if Title II food commodities phase out or over, CARE can continue to provide assistance in the child survival and nutrition areas. • CARE should not play the role of direct service provider. 6 INHP FINAL EVALUATION REPORT - June 2001 State government counterparts, under severe budgetary pressures due to the ongoing fiscal crisis, are resistant to discussing concrete plans for phase-out of CARE food inputs and hand-over of responsibility for further replication of the INHP model. • Recommendation: Test models for hand-over, such as the local food processing model proposed for funding partially by monetization resources, as a high oriority for INHP-11 to prove the financial feasibility of INHP program blocks "graduating" from Title II food and towards sustainability. B. Implementation against plan and expenditure against budget CARE has delivered the majority of INHP project inputs on time in most states, an impressive achievement considering the external constraints such as natural disasters and changing government counterparts. In analyzing the expenditures under INHP as against the INHP budget, it is obvious that some items have risen sharply in the past two years. In addition, some budget line items, such as travel and use of outside agencies/ technical resources, appear quite high when broken down to a per-employee per-day cost and compared to standards in non-NGO sectors. We note that these increases in line items, and high levels of some of them, may be quite appropriate because of implementation of recommendations of previous evaluations and approved program revisions. • Recommendation: Reflect on the main budget line items, especially those where costs have risen rapidly or are higher than is standard -- analyze the benefits achieved with those resources and shift resources if necessary. (Annex E provides an analysis of expenditures.) Implementation of many of the recommendations contained herein will require cash resources. Although with the available data the team was not able to make a detailed judgment about the optimal current or future cash-vs.- food balance in INHP, it seemed clear that INHP has leveraged substantial results with the small amount of cash in the INHP-1 budget. The team believes that the value-added of the cash-funded activities has been substantial, and that additional processes to implement the recommendations herein can be instituted at reasonable cost for value. C. Technical interventions The final evaluation team took a broad look at the basic technical interventions of the INHP program. examining the evidence that the project's inputs were likely to achieve improved coverage, behavioral change, and ultimately impact. It also included assessment of what elements might enhance achievement of such impact, in order to inform future activities under INHP-11. i. Interventions Coverage and utilization of the three supply-side interventions (antenatal care, immunization, and targeted supplementary feeding) appear to have substantially increased among INHP participants. There is still substantial room for further improvement, however, especially for some elements of the intervention package, since performance on some of the supply-side interventions is still relatively low (only one in two children is fully immunized by the first birthday and coverage for measles immunization is stubbornly low ). • Recommendation: CARE and its partners should review coverage of individual interventions at the state and, to the extent possible, district levels; identify approaches to achieve better coverage in the context of INHP and other GOI initiatives (such as maximizing the positive effect on routine immunization and vitamin A supplementation, and better using information on individual children and organization of attendance at NHDs to increase coverage beyond present levels). CARE needs to explicitly examine the possibilities that INHP services are not adequately reaching important subsets of INHP participants (socially or geographically marginalized households), that the participant group excludes vulnerable village women and children, or that children between ages two and three are being ·1osr. INHP appropriately targets the poorest and most vulnerable families; however, for villages where government health services are not located, the NHD may be the sole time during a month when services including antenatal care and immunization are offered, and therefore INHP must accept responsibility for supporting broadest possible coverage for the whole population. Deferring NHD services to the sub-center level may be reinforcing the differential use of services, with the poorest and most backward possibly receiving those services less. Recommendations: • CARE and its partners should assess the effects of INHP on overall coverage b.Q1!:l among THR/ICDS beneficiaries and non-beneficiaries. This might begin with field officers and supervisors reviewing ANM INHP FINAL EVALUATION REPORT -- June 2001 and AWC records and carrying out focused interviews to identify groups that possibly are not being reached. This effort could be complemented by spot surveys. • Mothers and children not being reached with immunization and ANC services and counselling should be identified, and approaches to reach them developed and evaluated - this should include serious consideration of re-focusing the INHP target age group to children under three. INHP has made serious efforts to ensure best possible targeting of the food supplement. The usocial mapping" exercise, aimed at identifying all eligible participants, has introduced greater transparency at the community level regarding eligibility and inclusion. • Recommendation: The effectiveness of these targeting strategies deserves continued attention; this may be in the form of informal monitoring through interactions with village leaders such as the panchayat; raj, community members, and front line workers. The effect of the INHP approach on the three key infant-child feeding behaviors is less clear than on the supply￾driven interventions; however, there is subjective and anecdotal evidence that in some sites important positive changes are occurring. The three child feeding behaviors promoted under INHP - with or without supplementary food - are the best hope for improving child nutrition in the poor population of India. In field visits, the team frequently found that colostrum feeding, exclusive breastfeeding, and even complementary feeding of THR are increasing in INHP sites where AWWs have learned appropriate counseling approaches and are supported by community women's participation. Recommendations: • CARE should carry out focused monitoring plus operations and evaluation research to define the extent and determinants of changes in key feeding behaviors. • The results of these activities should be used to strengthen and promote the feeding behavior component of INHP. The project does not yet have adequate or systematic approaches for behavior change, or the ability to monitor the changes in key behaviors; these will be essential to achieve maximal impact on the key feeding behaviors and child nutrition, and on other health and nutrition related behaviors. Even the approach to the identified behavioral elements of the "3+3" package are unevenly understood and implemented across the project. Without a stronger and more systematic approach, the project is almost certainly under-achieving in these and other key behavioral areas. CARE needs a better-defined behavior change approach and some key tools for use in the field. • Recommendation: Strengthen the behavior change capacity and develop a systematic approach and toolkit for dealing with behavior change. Among options for this are technical support from Delhi, CARE/Atlanta, or other USAID cooperating agencies; development and application of state-specific behavior change strategies and approaches, using project wide guidelines; and use of local resources or addition of local capacity. CARE's community engagement and empowerment activities are among the most powerful tools for behavior change. Changing behaviors through community engagement is now considered "state-of-the-art". These approaches - even though not yet maximized in INHP - are already demonstrating their potential for contributing to health and nutrition outcomes. Continued strengthening of "traditional" IEC and communication capacities aimed at individuals - such as stronger media strategies, better materials and message development, improved counselling, and other "supply side" behavior change/communication activities - is appropriate; however there needs to be more specific emphasis on, and a structured approach for, inducing and supporting behavior change through these community engagement activities rcommunity behavior change", or CBC). • Recommendation: CARE should give greatest emphasis to building upon, strengthening, and systematizing its ·community behavior change" approach with inputs from relevant experts. Effective growth monitoring and growth promotion are central to addressing problems with child nutrition. INHP has not explicitly tackled this issue, as ICDS has been plagued system-wide by an inability to move beyond weighing and measuring towards counselling and growth promotion. There is an ongoing debate about the effectiveness of growth monitoring, within and outside India. Growth monitoring as generally practiced has not been associated with improvements in child feeding or child nutrition; analysis has shown that the key missing elements are the understanding of the information and the "action step" - the provision of effective inputs that result in positive nutritional change. 8 INHP FINAL EVALUATION REPORT -- June 2001 The key to transforming "weighing and plotting" into counselling and behavior change is the development of training approaches that teach recognition and understanding of growth patterns, and support for building the nutritional problem-solving skills required to counsel mothers. Because the weighing and record keeping are already being done in most sites - but done without much effect - the marginal effort for an effective approach is not great, if the skill can be engendered. One way to economize on AWW time would be to focus the growth monitoring and promotion efforts on children under two, with less frequent weighing of older pre-school children. • Recommendation: With partners, CARE should consider the latest information about growth promotion and evaluate the possibility of undertaking a focused pilot on capacity-building for true growth promotion, under INHP-11 - perhaps initially as an operations research activity in a limited subset of project sites where ANM and AWW success and collaboration is already proven. CARE has done a commendable job in increasing participation levels and ensuring food availability, primarily by facilitating convergence, but effectiveness in terms of improved health and nutritional outcomes depends greatly on the quality of interactions between ANMs. AWWs, and mothers. Quality particularly affects educational efforts, including growth promotion. and any activity requiring routine household implementation. Effective quality assurance, in tum. depends heavily on appropriate quality-focused supervision within the ICDS and primary health care systems, which is currently lacking in the field implementation of INHP. lmportanUy, INHP does not yet have an explicit approach for building the capacity of CARE's partners to assess or improve quality. • Recommendation: Discuss an explicit focus on improving quality by service providers (AWWs and ANMs} through developing quality monitoring and improvement processes at the district and block levels in both ICDS and the Department of Health & Family Welfare (HFW). The block level may be particularly important, because it is the intersection point between administration and implementation, and because in some cases technical capacity and quality at this level appeared limited. At the service delivery level, the greatest system constraints on achieving project objectives appear to be personnel-related rather than supply-related. While shortages and stock-outs of key commodities such as IFA tablets have clearly existed in the past, at this time the team did not find these to be prevalent On the health side, the greatest constraint seemed to be vacant ANM posts. While in theory the system has means to ·cover" for a missing ANM (such as use of the male multi-purpose worker, or cross-coverage by another ANM), in practice these mechanisms are unlikely to fill the void. On the !COS side, the greatest issue seems to be overload of the AWW; the multiple tasks of AWWs are compounded by the fact that few of them are likely to have all the capacities and skills needed for these diverse tasks. However, in field interviews AWWs in INHP areas did not complain that project activities had increased their workload. In fact. several observed that their workload had decreased (or their efficiency had improved); in part because they now have the support of women's groups who help them. AWWs also reported that the Nutrition-Health Day lets them work with the ANM efficiently in a group setting. rather than accompanying her in time-consuming house-to-house visits as was earlier customary. • Recommendation: INHP initiatives should take into account AWW (and ANM) workload isSues, and seek to help them carry out existing and new tasks in ways that are not disincentives for their effective participation. Sites where the program is operating and effective in the basic "3+3" package of interventions appear capable of taking on additional interventions that could increase the nutrition and health impact of INHP. High impact child health interventions - including immunization (already in the INHP package}, as well as prevention and treatment of common infections associated with infant and child illness and mortality including diarrhea, pneumonia, and malaria - contribute to both survival as well as improved nutritional status. Thus, there is a larger package of interventions that can enhance achievement of the INHP nutrition and health objectives, if it can be feasibly implemented. Where it is well established, INHP has built a system and community "platform· that can be used to sequentially introduce some of these additional high impact interventions. The DAP-2 proposal for the second phase of INHP recognizes this potential and proposes additional health and nutrition interventions aimed at women and children. Interventions that would maximize nubjtion Impact include: Vitamin A supplementation (one of the most straightforward and urgent, given the malnutrition and probable high levels of vitamin A deficiency in the target population; this is already being done in some states} Iron supplementation of young children (noting the high prevalence of child anemia found in NHFS II), possibly linked to de-worming Iron supplementation of adolescents 9 INHP FINAL EVALUATION REPORT -- June 2001 Child feeding during and after illness Community-based management of severe malnutrition (present practice is often medical referral) Low birthweight reduction (improved nutrition of adolescent girls; delayed pregnancy and increased birth spacing; increased food intake during pregnancy; intermittent presumptive treatment during pregnancy in malaria-endemic areas). Additional interventions that are largely within the community context and that would maximize ~ impact include: Oral rehydration therapy, including fluids, breastfeeding, and feeding (also being done in some states) Routine newborn care (adding cord care, stimulation/resuscitation of the depressed newborn, warmth, and hygiene to maternal tetanus immunization, colostrum feeding, and exclusive breastfeeding). Important health interventions that require additional inputs for case management - and that are therefore programmatically more complex - are: Detection and treatment of acute respiratory infections, malaria, and neonatal infections (operationally linked to detection and management of pregnancy, delivery, and post-partum complications). ii. Implementation processes INHP's core program elements- Nutrition-Health Days. Take-Home Rations and convergence of ANM and AWW services, supported by coordinated planning and monitoring by ICDS and HFW at the block, district and state levels and by community participation and capacity building - appear to be a recipe for success and should remain the core of INHP-11. At the same time, there should be substantial room for innovation in tenns of achieving greatest effectiveness. replication, and institutionalization of the core elements, in the context of strengthened systems and empowered communities. Such innovation - and the effects of adding other technical or process elements - should be systematically evaluated in terms of value added and cost-effectiveness. • Recommendation: As introduction of additional interventions is considered, it is essential that CARE and its partners consider the appropriate sequencing and timing. It is especially important to consider the absorptive and operational capacity of the health system, the ANMs and AWWs, and the community itself; otherwise, the "platfonn" can be overloaded and may collapse. Given the skills and current workload of CARE staff, implementation of new technical interventions will likely require additional technical capabilities and probably staff. Such additional capabilities - along with development of relevant approaches and materials, operations research, monitoring, and diffusion - may be appropriate uses for Child Survival funds. iii. Community-based activities INHP's focus on involving communities and building their capacities is critical for health and nutrition outcomes, sustainability, and empowerment. Strengthened service provision by responsible government agencies will remain an important element of nutrition and health programming in India. However, INHP gives evidence that demand for and utilization of these services, as well as changes in key behaviors, provision of material resources and support, and improved health and nutrition outcomes can best result when the energy and resources of communities are engaged. The active use of community-managed health funds initiated under INHP is an indication of the success of community engagement. Recommendations: • This community focus should be maintained and systematically strengthened. Best practices and innovations should be identified, evaluated, and shared. • As INHP-11 evolves, the broadening and institutionalization of community involvement - such as the involvement of other community groups and of men, and the development of self-sustaining women's groups supporting woman. child, and adolescent health and nutrition - should become an increasing focus of field activity. 10 INHP FINAL EVALUA TJON REPORT - June 2001 The "place with no worries" Nischintpur village, Jhumpara block, Keonjahr district, Orissa: The name Nischintpur means • place with no worries', and this snganwadi center truly seemed so. Healthy kids thronged the center, and the anganwadi worker Sumati Mahanto and the Lady Health Visitor Nonni Bala Mahanto used a "bonny baby" competition to reward moms whose children were fully immunized and registered a consistently normal weight and growth pattern. The women's committee was quite active in counseling mothers, and they were planning to cultivate mushrooms for sale, adding to their current sales of stitched leaves used for serving food in the market. D. Support systems i. CARE structure, roles A core aspect of CARE-India's institutional transformation has been decentrali.zation. This has facilitated essential adaptation to India's complex settings, especially the existing variations in state ICDS policies, the availability of NGO partners, and the degree to which ICDS and health systems provide effective programmatic support. Where decentralization has not been so positive, however, is where it has led to diversity outside a commonly accepted conceptual framework and set of objectives. Decentralization has empowered state level staff to adapt, innovate and develop creative solutions to local problems, but it has not yet been optimized - more quality guidance and technical support is needed to develop operational approaches for nutrition improvement, community behavioral change, capacity building, and replication. INHP has proven certain project elements and approaches, but it equally has much to learn about effective community mobilization, behavior change, replication, etc. Innovation and filling the gaps within established procedures should particularty be encouraged for these areas. Well-defined systems, as for food logistics. financial management, and certain aspects of reporting, should be standardized; but less well-developed ones, and those subject to local conditions (including targeted "nimble" evaluation) should be relatively more open. Each state must continue to participate in evolution of the national strategy, not deviating from agreed national principles and standards but reporting innovations. critiquing the national strategy, and helping the program-wide specialist to make refinements. In other words, the state program should accept a project-wide responsibility: both loyalty to mutually agreed norms and responsibility for contributing to evolution of the national strategy. • Recommendation: INHP needs more explicit distinctions between core project principles and appropriate local adaptations. We suggest that this issue be discussed specifically with regard to the core program hypothesis - nutritional supplementation combined with health services and behavior change resulting in improved nutritional status of women and children. The evaluation team identified four areas in which both leadership and innovation are essential: community mobilization, behavior change, capacity-building, and replication. INHP needs mutually agreed objectives and strategic frameworks, but the essential technical expertise need not reside in Delhi. The team feels strongly that these are not control issues but rather technical ones: how to get the job done efficiently and effectively. Annex I provides detailed suggestions on how this balance of technical leadership and quality control at the programmatic level and local/state innovation and learning can be approached. • Recommendation: CIHQ should provide leadership in at least the four key technical areas mentioned above, but should be prepared to tum over responsibility for technical support outside Delhi (e.g., within one of the states) if someone at that level is prepared to take the lead. An internally participatory approach should be applied to identify specific INHP objectives, to set standards and guidelines for state plans, and to clarify division of responsibility between local and national levels. The gender composition of CARE field staff is more evenly balanced in some states than in others, and efforts to improve this have had more success in certain states than in others. Certainly. there are constraints to greater hiring of women in the field, especially the need for frequent local travel as well as cultural taboos. INHP remains a predominantly male organization in the field, almost certainly more so than two of three key partners: ICDS and the Department of Health and Family Welfare. CARE as an organization remains committed to equity, and appropriately so, but does not believe (nor does the team) that there is a clear gender difference in the effectiveness of male vs. female Field Officers' and Coordinators in their primarily catalyst role vis-a-vis government and community partners. 11 INHP FINAL EVALUATION REPORT - June 2001 • Recommendation: CARE should continue the pursuit of internal gender equity, perhaps adjusting work conditions to overcome identified constraints to the employment, retention, and advancement of female staff in critical field positions. ii. CARE staff and technical support Much of INHP's success rests on the facilitative skills and creativity of Field Officers. The most successful FOs have established excellent relations with district and block ICDS and health officials, and where they have worked at the community level, many have had good insight into social processes and strategies for involving communities in achieving INHP objectives. Their apparent, although variable, talent for innovation rests heavily on their solid knowledge of community life and ICDS/health processes. In many ways, Field Officers are INHP's most valuable assets. Many Field Officers, however, are working without routine technical support or recognition for such key areas as community mobilization and behavioral change, capacity-building and replication. Some Field Officers do not currently receive adequate technical guidance and expressed interest in peer sharing: facilitating direct contact, and perhaps work sharing, between individual FOs. Many Field Coordinators are still operating more as supervisors and data managers than as technical support personnel, problem solvers and facilitators of innovation. Recommendations: • INHP, especially at the state level, should seek ways to formally recognize Field Officers who are particularly effective or innovative, perhaps through an "FO of the month· award. • INHP should not introduce technical interventions without providing continuous support for its field staff (beyond formal training}, and should explicitly acknowledge that learning goes both ways. Efforts to upgrade operational planning for community mobilization, behavior change, etc., should include plans for technical support. • INHP should retain intermediate positions between FOs and the state level, but primarily for technical support. INHP should consider a possible peer support system, in which FOs within a sector critique and support each other's work, with only occasional involvement from higher levels. iii. Food CARE has been especially impressive in systematizing, monitoring and strengthening processes, and at rolling them out to scale. Their management of the commodity supply chain for the Title II food inputs is a prime example of this institutional capacity: availability for the past year has been quite good, food arrives from the US in a timely manner, primary distribution from port to block is efficient and timely. Secondary distribution from blocks to AWCs, a link in the supply chain where CARE relies heavily upon government systems, is not always as good. CARE has encouraged community involvement in supply chain improvements, such as support for the proposal that village development communities and mahila mandals taking up secondary distribution of food (from blocks to the AWCs). In some states, CARE has persuaded state officials to sign transport contracts in a more timely fashion and at market driven rates and to settle transport bills on time to avoid disruption in stock movement. • Recommendation: Optimize CARE supply chain and use CARE's expertise in managing commodity supply chain operations to improve delivery of other key inputs or to provide consulting expertise to government programs with supply chain problems. , iv. Management decision support systems A great deal of change in INHP's monitoring system has been made since the MTR, and the team applauds the streamlining and rationalization of routine monitoring systems. HMIS development has clearly been a participatory process, though the use of information varies across the states. Field staffs satisfaction with the new HMIS, and the degree of utilization of the information for management and action, seem to vary based on the degree of input states provided during its inception and the extent to which FCs and State INHP program managers are inclined to use it pro-actively. Some Field Coordinators say that they use HMIS actively for feedback, management, and problem solving, sharing reports with the CDPOs and discussing the observations with government counterparts to solve problems more quickly. The focus of HMIS is, appropriately, on Inputs, outputs, and processes; it does not currently capture quality, outcomes, or behavior change. The evaluation team strongly warns against re-burdening the routine HMIS with many new indicato~s, but suggests instead, as outlined In section V and Annex D, that 12 INHP FINAL EVALUATION REPORT - June 2001 targeted operations research be used to fill perceived gaps between monitoring processes and quantitative surveys. The evaluation team commends such innovations as self· monitoring tools for mothers, social mapping for communities (updated regularly), and monthly monitoring of INHP health activities by mothers' committees (post-card campaigns to ensure ANM service delivery). Recommendations: • Using an internally participative process such as that used in HMIS design, review the HMIS to assure that information for decision-makers at all levels is available in a user-friendly fashion and consider how information is disseminated within and across the project. Involve government and NGO counterparts as appropriate. • Encourage and support expanded community-managed monitoring as an essential step towards sustainability post-IN HP -· spread the examples of mothers' self-monitoring tools and strategies, household monitoring of children's nutrition and health, community monitoring and pressure on government service delivery through post-card campaigns, etc. • Continue with social mapping and updates involving the community, and increase the focus of those mapping events on reaching the marginalized and distant families in the AWC catchment area. E. Organizational learning and diffusion The evaluation team found numerous innovations at the state and Anganwadi level, but inadequate means for documenting them, evaluating them for quality and potential use, and sharing them systematically. Sharing of "better practices" tends to be descriptive and promotional rather than instructional (processes followed, steps taken, costs in terms of manpower and time). Transforming innovations from examples into systems is essential for effective replication either within CARE-supported areas or in government programs. There is also tittle or no prospective testing of potentially feasible solutions to common problems, nor operations research to test the feasibility of new interventions or strategies. Diffusion occurs easily and frequently within state offices, but sharing between states appears inadequate. CARE cannot complete its evolution from a feeding to an integrated health and nutrition organization without a much clearer learning approach to issues and innovations. We endorse the demonstration site approach to INHP and partner learning, but note that explicit pro-active replication strategies are often inadequate. • Recommendation: INHP should review its current plans to replicate demonstration sites, with a view to developing more concrete plans for diffusion and replication. While local innovations are widespread, INHP has a limited capacity to evaluate them with any rigor or to diffuse information regarding innovative approaches. • Recommendation: As described elsewhere in this report, INHP should develop a more "nimbie" evaluation and documentation strategy to facilitate focused evaluations, simple problem-solving studies, and perhaps prospective operations research, for key strategic issues. These efforts should particularly focus on INHP's leading issues such as community behavior change and replication/diffusion. Field personnel may have more to learn from each other on certain technical and implementation issues than they do from CARE headquarters. However, routine methods for cross-learning have not been developed. • Recommendation: INHP should encourage cross-learning at all levels: FOs to each other, specialists and program managers with other state personnel, and so forth. Detailed explanations of the team's findings on institutional learning and diffusion are provided in Annex I, along with specific suggestions and recommendations. See How Healthy I Am! In Orissa, CARE INHP Field Officer Mr. Sandipta Bisawal developed a self-monitoring tool and the women in Jhumpura block have really taken it to heart! It is a figure to be drawn on the wall of the house by a pregnant mother to keep track of her essential health inputs - IFA tablets, ANC visits, TT injections, all the actions and events needed for the protection of the mother and the child. If you visit the houses of pregnant women in the village, you will see them keeping a count of their interventions using a picture they themselves draw on their wall, and they will tell you - "see how healthy I am!" 13 IFA Consumption # ofTimes Weighed Malnutrition Status 0 I 2 3 4 INHP FINAL EVALUA T/ON REPORT -- June 2001 ~ 888 D ...,----- TT # of IF A Packets Received Chloroquine During Pregnancy THR During Pregnancy THR During Lactation Receipt of Colostrum Birth Weight BC DPT/OP Measles VitA F. Capacity building and link to sustainability, replication, and exit strategies The evaluation team reviewed evidence of capacity building, and looked broadly for lessons about what program components were linked to improved capacity. The objective was to identify what did or did not work, and recommendations for further improvement. The main findings are shown in bullet points with a ·brief discussion, and relevant recommendations follow: • INHP-1 recognized that building capacity of communities and individuals is as important as reaching short￾term nutrition and health targets (e.g. DAP-1). In the design of INHP the purpose of building capacity in communities and Individuals was to assure ·that women and children would, a) benefit from ICDS and health services in INHP, and b) have the ability to continue to improve their nutritional and health status beyond the tenure of the INHP project. Recommendation: The evaluation team fully endorses this hypothesis and encourages INHP-11 to continue to achieve these objectives through even a more comprehensive and systematic CB strategy. • INHP-1 appropriately selected three main channels for the focus of CB efforts, community structures and change agents; government departments and institutions, and NGOs The evaluation team endorsed the choice of institutions on which CB activities were focused. These are: - Community based organizations and change agents (e.g. Mahila Mandals, SHGs, Village Development Committees, Panchayat leaders and their committees, adolescent girls etc) 14 INHP FINAL EVALUATION REPORT -- June 2001 - Government departments and institutions. Particularly after the MTR, a concentrated effort was made in the following areas, THR, NHDs and other forms of convergence, in addition to the ongoing focus of CB activities in planning, monitoring, supervision, food commodity management, nutrition and health education. - NGOs. These were viewed initially as implementers of CARE activities, but in some states INHP found the need to build their organizational capacity and/or capacity in health and nutrition activities before they could become fully effective. Recommendation: Based on the valuable CB experience gained in INHP-1, and a clearer appreciation of what specific skills and capacities are needed in key institutions at various operational levels, it would be valuable for INHP-11 to specify milestones and indicators of capacity for critical functions in key counterparts. CB activities can then be prioritized and linked to achieving these. At this point in the development of INHP, the following questions can begin to be answered: - What capacity is needed for key program functions? - What does adequate capacity look like at the mid-point and end of INHP-11 ? - What specific outcomes and targets should be aimed for? • INHP succeeded in building capacity in all states to some level even though the evaluation team did not find detailed operational guidelines for linking activities to capacity outcomes. General guidance was provided by CARE/HQ, and the supportive manner in which INHP was implemented at all levels in all states clearly demonstrated a commitment to building capacity. INHP succeeded in raising awareness at various levels within program areas, about the importance of nutrition and child survival interventions, and that ICDS can make a difference in the health and nutrition of mothers and children. The commitment to improving nutritional status and capacity to do so among partner institutions (government and NGO) needs to be further strengthened. Examples of areas where capacity was built, included awareness of key nutrition and health behaviors at all levels (state through community/household); understanding of the importance and effective planning strategies for convergence of government ICDS and health activities at the community and block levels; and food commodity management to community level. Gains in women's empowerment were also made. Most !CDS/health department functionaries and community members trained/provided information and skills were women, and the program therefore supported women's empowerment and advancement. In some states specific efforts were made and these appear to have succeeded in developing adolescent girls capacity, formation/strengthening of SHGs and MMs. Areas in which the evaluation team did not find equally strong evidence of capacity being transferred/built, and which are key to sustained nutrition and health improvements include: communi·ty (and household) behavior change or CBC focused on health and nutrition behaviors, routine self-monitoring of coverage and quality, advocacy for nutritional status improvement. Recommendations: Carefully assess capacity building experiences (training and other), identify those successful in achieving desired outcomes, document and package those proven effective for broader use. Review and revise CB approaches as the knowledge and learning base change and the program/policy environment changes. • The intention of CARE to build capacity for long-term sustainability of key INHP components through phasing over critical components to state, district, block and community entities was not consistently and clearly understood by key stakeholders. The feedback from state and district level partners to the evaluation team about the need for indefinite continuation of CARE in INHP, while a testimonial to the high caliber of CARE's work and the great value and esteem accorded to CARE as an institution, also raised some concern among team members about phasing over and building capacity and commitment for long-term continuation of key INHP activities that are essential for ICOS to produce health and nutrition results. This suggests that capacity building objectives (i.e. including phaseover and sustainability, in addition to achieving scale and quality) need to be jointly discussed and developed and systematically reinforced. Recommendation: Develop a joint plan for and conduct explicit advocacy for phasing over critical INHP functions to government. NGO and community entities- address both the why and the how. 15 INHP FINAL EVALUATION REPORT -- June 2001 • Although early in INHP, project documents refer to a broad range of potential actions for CB, perhaps unintentionally, training appears to have become the predominant approach explicitly stated as the INHP strategy for building capacity. The evaluation team was concerned that INHP may not progress as r"3pidly with phasing over key functions (including routine training functions of states for AWWs for example), if CARE/IN HP became a substitute for these functions rather than a 'facilitator, coach, guide, promoter, enabler'. Focus at the community level was considered important by the evaluation team. Recommendation: INHP should maintain its focus on capacity building at the community level (through government and NGO structures). It should not substitute for lapses in AWW training functions of the states. It can however facilitate the process through finding more effective training and supervision approaches for performance improvement, and by helping to strengthen key components e.g. testing/OR to improve CS package of interventions, routine monitoring, CBC, nutrition advocacy etc. within existing training strategies. • Though not explicitly identified as a capacity building approach, CARE's collaborative working style that includes joint planning, frequent joint field visits, and frequent joint reviews of field monitoring information was an effective tool that led to improved capacity at all levels in certain program components. Community level capacity was also improved through NGO partnership activities. Useful experiences and tools have been developed that can be consolidated into an effective strategy for capacity building both, for the purpose of defining and operationalizing "the INHP approach" with all its vital components, and also for the purpose of achieving sustainability and successful INHP graduation. Recommendation: Use a broader approach to capacity building than training (e.g. Appendix M in DAP-2 lists appropriate components for the training but not other CB activities). Routinely monitor indicators for training activities plus other CB activities, and even more importantly, monitor outcomes of the training/other CB activities in terms of key functions {not inputs and outputs alone). • It is now possible to link CB activities to the main stages of INHP development (details of the modet to be defined as more program learning occurs), and these stages include: identification and enhancements {e.g. adding new CS interventions) of the model, replication of the model/enhancements, phase over of critical functions. The team was impressed with successful experiences in all states in implementing the revised strategy after MTR. There is a strong commitment to expanding lessons learned from demonstration sites more broadly and also to sustainability. Capacity building activities can now be linked to stages of INHP evolution in each state. The team was concerned that a focus on results and quality be maintained throughout this process. State INHP teams could benefit from acquiring capability in approaches such as continuous quality improvement techniques (based on principles of self-assessment and teamwork to solve problems systematically). Recommendation: Capacity building should be more closely linked with stages of INHP development and graduation, with defined outcome indicators. These should aim to secure coverage/scale, quality and long-term sustainability of proven effective technical interventions for ICOS. • CIHQ and INHP/states have an important role to play in building capacity at the national level in ICDS, MOHFW, and NGOs. The team observed the interest and opportunity in national level institutions for wider application of INHP experiences beyond CARE/INHP locations. This has begun to occur spontaneously and can be systematized and further developed. Areas where transfer of skills and capacity can occur include: commodity planning and management, convergence strategies and tools, management of TH Rs and NHDs, and routine monitoring. Recommendation: INHP could have a broader impact on ICDS beyond the 8 states where CARE is involved and this opportunity should be taken up through developing a portfolio of areas of excellence in INHP and a pro-active approach that includes packaging, marketing/promotion, and transfer of the experience of INHP in a strategic manner. • Capacity building is particularly important at this stage of INHP for certain components, which include: monitoring and small studies/OR, community (and household) behavior change, and advocacy for improving nutritional status. 16 INHP FINAL EVALUATION REPORT -- June 2001 Designing and carrying out small, OR activities and assessments to systematically and rigorously evaluate prospective (e.g. newborn health package, delivery of 2 doses of vitamin A annually) and existing innovations (e.g. CBC +3 interventions) is important. The team felt that capacity exists in institutions at national and state levels to carry out small focused studies on the above listed topics, particularly with the guidance of CARE and. its consultants. Their engagement in the INHP/ICDS program as problem-solvers and guides for decision￾making could be strengthened. For community (and household) behavior change, national and state agencies currently involved in ICDS/INHP could benefit from understanding and developing skills in an approach that includes elements such as use of formative research methods to define constraints/barriers and motivations for key behaviors; identifying options for removing constraints/barriers; defining key audiences to be reached, community-level structures/entities to be engaged, policies/program guidelines to be changed, etc.; and monitoring the implementation of program inputs, outputs, processes and outcomes. In the area of policy/advocacy, a clear link needs to be continuously made within and outside CARE and its immediate counterparts regarding the role of nutritional improvement in reducing child mortality (e.g. Pelletier's studies, PROFILES nutrition advocacy tools), and the role of ICDS/INHP in improving nutritional status. Recommendation: Within the context of an overall strategy linking CB activities to stages of INHP development, and in addition to it, build capacity in selected key elements such as using small studies/OR for problem solving, community (and household) behavior change, and advocacy for nutritional status improvement. In conclusion, as the INHP program model is finalized with its components of community mobilization, behavior change, replication, and graduation, it should become clearer as to what types and level of capacity are needed in the ICDS and health systems, in communities (particularly in women's empowerment and appropriate role of the Panchayat), in NGOs, and at policy/advocacy levels to achieve quality and impact and to assure sustainability. CB activities in INHP-11 should be targeted to achieving these capabilities. The team identified some constraints to moving ahead rapidly with capacity building for successful INHP graduation. These include: Need to complete the MINHP model" and its vital sub-components e.g. technical content (e.g. addition of vitamin A and newborn care), behavior change strategy, replication approach and tools. Lack of broad awareness and clarity among counterparts on why/how/who of phasing over of CARE/INHP inputs to community, NGO, and government functionaries. Need to identify suitable partners for capacity building. In developing a comprehensive capacity building approach for INHP-11, a crucial step is participatory planning with institutions whose capacity is to be strengthened. The strategy and subsequent INHP-11 documentation (e.g. monitoring tools, training pJans, advocacy materials, operational plans, progress reports) should explicitly recognize that CB includes not only knowledge transfer, but empowerment, encouragement of innovation, support for problem-solving, diffusion of best practices, positive feedback, supportive supervision, and learning by doing. CARE can look within its own programs for good examples and approaches and also obtain technical assistance from projects working in other regions and countries for tools and approaches of how other programs have achieved scale with impact. Overall, the evaluation team was greatly impressed by the dedication of INHP teams at HQ and in the states to build capacity in counterpart institutions and at community level, and the effectiveness of the participatory working style employed by CARE in implementation of the INHP program at all levels. There is a marked improvement in the capacity of ICDS institutions at various levels where CARE/INHP has worked in the past 5 years; several of these improvements can be linked to INHP activities. Some of the INHP enhancements have been taken up in non-INHP locations by state governments and at the national level, illustrating the potential for larger scale benefits resulting from INHP. Detailed explanations of the team's findings on capacity building are provided in Annex J, along with specific suggestions and recommendations. INHP FINAL EVALUATION REPORT -- June 2001 VII. KEY FINDINGS ANO RECOMMENDATIONS The evaluation team found evidence that INHP is making important contributions to child survival in India, through improving immunization and breastfeeding (including colostrum feeding) practices, and may be reducing the under-nutrition that exponentially increases the risk of children dying from childhood illnesses. The narrowed focus of INHP a'fter the MTR has paid off; the basic INHP package of 3+3 is effective and has showed results. The evaluation team also found that the respect among partners (GOI, donors, NGOs) for CARE's previously acknowledged expertise in commodity supply-chain management has broadened to include an appreciation of CARE's systems strengthening and in technical aspects of nutrition and health. CARE's role as a catalyst, a capacity-builder, a technical advisor, and a contributor to the policy discussions, is respected and welcomed. CARE's focus on capacity building and on community empowerment has been essential to the success of INHP-1 to date, and increased attention to systematizing these strategies will be equally essential to fully achieving the objectives of the project in the second phase. KEY FINDINGS Examples and Observations • Recommendations The conceptualization and implementation of INHP was a programmatic and Institutional revolution for CARE and for USAID food support to ICDS. CARE's expertise in health and child survival and in oommunity capacity-building, in addition to their expertise in nutritional interventions, is now reoognized and welcome at the state, district, block, and communitv, and CARE is now viewed as a develooment oartner. CARE's institutional transformation from a food • Commit to a focus on enhancing technical expertise in management organization to a nutrition and health states and developing mechanisms for systematically development group has been impressive, and can be monitoring, diffusing, and replicating INHP successes. best completed by revisiting the INHP program vision. • Define INHP evolution, maturation, and graduation - what does a mature and sustainable INHP program site look like in 2006, and how do we aet there? CARE-India's chosen role in INHP - catalyst, facilitator, • CARE should not play the role of direct service provider. capacity-builder, technical supporter - is appropriate and • CARE should consolidate their successful experience in has made an outstanding oontribution to the convergence these roles so that even if Title II food commodities of health and nutrition services both in INHP and beyond phase out or over, CARE can continue to provide to other ICDS sites. assistance in the child survival and nutrition areas. State government counterparts, under severe budgetary • Test models for hand-over, such as the local food pressures due to the ongoing fiscal crisis, are reluctant to processing model proposed for funding partially by discuss concrete plans for phase-out of CARE food monetization resources, as a high priority for INHP·ll to inputs and hand-over of responsibility for further prove the financial feasibility of INHP program blocks replication of the INHP model. "graduating" from Title II food and towards sustainability. INHP has succeeded in bringing together ICDS and health department policies, operaUons and service delivery- and aovernmental departments have become more effective at reachina hiah ooveraae rates for health services as a result. Conviction among partners - government functionaries, • Invest in building the commitment of staff, field and program staff - and confidence about the counterparts, and partners at all levels to achieving conceptual links between INHP inputs and improved nutritional improvement through INHP, including a review nutritional status were variable, and need strengthening of INHP-11 to balance and sequence nutrition and health to beoome a driving force across the project. interventions. CARE has been especially impressive in systematizing, • Use CARE's expertise in managing the commodity monitoring and strengthening processes, and at supply chain operations to assist with optimizing the rolling them out to scale. delivery of other key inputs or to provide consulting expertise to government programs with supply chain problems. When INHP works well, it achieves good results and makes important contributions to child survival in India, through improved immunization and breastfeeding (including colostrum feeding) practices. There is indirect evidence that INHP is reducing the under-nutrition (low weight-for-age) which synergistically increases the risk of children dying from oommon childhood illnesses. The basic INHP oackaoe of 3+3 is effective; the narrowed focus after Mid-term Review is oavina off. 18 INHP FINAL EVALUATION REPORT - June 2001 KEY FINDINGS Examples and Observations • Recommendations Coverage and utilization of the three "supply side" • Develop systematic approaches for community behavior interventions - IFA supplementation (part of ANC), child change - not just communication of messages - in order immunization. and targeted supplementary feeding-- have to achieve maximum impact on the key feeding improved substantially among INHP participants, while behaviors and child nutrition and health practices. results from the three key infant feeding "behavior change" interventions are less clear and need improvement. INHP establishes a solid institutional and community • In a phased, carefully sequenced, manner, add these "platform" for additional high impact maternal and new interventions-vitamin A supplementation, child health and nutrition interventions, including newborn care, intensified quality control on antenatal maximizing impact of USAID resources including both care, measles prevention. Title II food and dollars from Child Survival CSD account. Where fully and consistently implemented, INHP has • Conduct a focused evaluation of the extent and demonstrated the conditions required to promote actual determinants of changes in key feeding behaviors improvement in nutritional status; as it moves to expand and nutritional status changes; use the results to its health impact in INHP-11, CARE should not lose this strengthen and promote current and future feeding opportunity to achieve & document nutrition Impact. behavior interventions. Demonstration sites are working both as examples of best • Develop, communicate, and operationalize clear practices and as sources of learning and program strategies and approaches for these three key INHP diffusion; mechanisms for systematizing the process of elements: community behavior change, capacity replication will accelerate the process of taking INHP's building, and replication/diffusion. success to scale. Chanaes to MIS have lmoroved routine orocess monitorlna and now provide useful information for field manaaement. Although the large-scale quantitative surveys have • Restrict use of large surveys to end-of-project been of good quality and high intellectual rigor, these evaluations. mammoth efforts are not nimble or focused enough to provide rapid feedback on program interventions and innovations. While a large-scale quantitative survey is appropriate for the end of INHP-11, a similar survey at midtenn would not be a cost-effective use of M&E resources. The missing element in the overall INHP is a range of • Develop and add measurement mechanisms and more agile operations research and targeted indicators for behavior change, capacity building, evaluation tools that could validate the success of past replication and diffusion to the overall M&E portfolio. innovations, test prospective intervention strategies, and measure results of program activities such as capacity buildina and behavior chanae. Social mapping has improved targeting of THR resources and thus improved targeting of program interventions to the most vulnerable - it has increased village ownership of the program activtties, and in some cases reduced social tensions over perceived distributional inequmes by makinQ the beneficiarv maooina and selection process transparent and oubic. THR is a vital strategy for reaching pregnant and lactating • Conduct a focused assessment of the issues of women and children under 2. However, at AWCs with eligibility-enrollment-participation in selected INHP sites catchment areas including remote hamlets, even THR has with remote or marginal hamlets to assess 1) coverage/ not always been able to reach those vulnerable women participation among target participants and 2) outreach and children. to vulnerable women and children in outlyina areas. INHP links with self-help groups, newly invigorated mahila manda/s, village development committees, and small groups of change agents such as dais and adolescent girts, have empowered village women - and those women have become effective aaents for behavioral chanae amona their oeers. The emphasis wtthin INHP in general has been on 1 • Increase the attention of both INHP staff and quantity of services - such as the delivery of adequate govemmenUNGO counterparts to quality of services - 19 INHP FINAL EVALUATION REPORT - June 2001 KEY FINDINGS Examples and Observations • Recommendations supplies of IFA tablets to pregnant women and the such as extended counselling & community support that communication of kev messaQes about iron consumotion. are needed to ensure consumption of 90+ IFA tablets. Implementation of many of our recommendations will require cash resources. Although with the available data we are not able to make a detailed judgement about the optimal current or future cash-vs-food balance in INHP, we note that INHP has leveraoed substantial results with the small amount of cash in the INHP-1 budoet. Some budget line items, such as travel and use of outside • Reflect on the main budget line items, especially those agencies/ technical resources, are very high when broken where costs have risen rapidly or are higher than is I down to a per-employee per-day cost and compared to standard -- analyze the benefits achieved with those standards in non-NGO sectors. These high levels may be resources and shift resources if necessary. necessary due to recommendations from previous evaluations or aooroved proQram revisions. INHP's focus on strengthening government service delivery systems and on involving communities and building their caoacities are both critical for health and nutrition outcomes, sustainability, and empowerment. Where capacity building was most effective, it was • Carefully assess capacity-building experiences, more than just training and knowledge transfer; it was document successful efforts, and develop milestones for empowerment, hands-on skills building, and support monitoring capacity at both community and systems for problem-solving. levels. Decentralization has empowered state level staff to adapt, innovate and develop creative solutions to local problems, and has allowed Field Officers to play a key role in INHP's success. Fully functional decentralization will require strong • Support Field Officers - provide increased technical supportive leadership from Delhi, and adequate support through flexible resources, and encourage peer accountability, monitoring, and quality assurance sharing to strengthen capacity and improve quality of systems that avoid command-and-control but flexibly field implementation of INHP. deolov the needed technical and managerial resources. While local innovations are common, INHP has limited • Develop a more systematic approach for identifying, capacity to evaluate them, to disseminate information testing, documenting, and sharing information about regarding innovative approaches, or to prospectively test innovative approaches. new approaches -- systematic approaches to cross- • Develop one or more District or Block models based on learning are needed to fully exploit field innovations. INHP successes for replication across INHP and for wider reolication bv ICDS nationwide. 20 ANNEX A ANNEX A: METHODOLOGY INHP was conceived as a ten-year effort, and this evaluation focuses on assessing the progress and achievements of INHP-1 (1996-2001) and, based on the findings and observations of that assessment, on providing suggestions for CARE-India as it prepares to implement the second phase of the project, INHP-11. Thus, while the external evaluation team did seek to assess key aspects of INHP-1 and to link those findings to recommendations on implementing INHP-11, this evaluation did not undertake to critique or assess the overall design for INHP-11 as expressed in the new Development Activity Proposal (DAP-2). Consistent with the OAP for INHP-1, this final evaluation was conducted by a multi-disciplinary team of Indian and expatriate specialists who considered a wide range of project documents and reviewed data and analytical results from three sources: • a quantitative survey, conducted in all states where INHP works, by five independent external agencies supervised by the Institute for research in Medical Statistics under overall guidance from a high-level Technical Advisory Group as recommended by the INHP Mid￾T erm Review; • a qualitative survey, conducted by an external management consulting agency with key informant and focus group interv,iews in all INHP states; • field visits and observations by the external evaluation team during visits to all INHP states. Each technical specialist on the INHP Final Evaluation team was assigned a particular set of evaluation topics from the Terms of Reference, and field visits were guided by topic protocols designed by each specialist. The detailed synthesis of each technical topic, presented in the annexes to this report, was authored by the assigned technical specialist from the team, while the major findings and recommendations presented in the main text were discussed and agreed to by the entire team. 1. Project Name TERMS OF REFERENCE INHP FINAL EVALUATION Integrated Nutrition and Health Program 2. Point Person 3. Project Funding Cycle Manish Subharwal, M&E Officer (HMIS), CARE India - Delhi October 1996 to September 2001 4. Donors USAID & Gal Background of Integrated Nutrition and Health Program CARE-India's Integrated Nutrition and Health Program is a five year initic;i ive supported by the USAID Food for Peace Program that was launched on October 1, 1996. Goal: "To improve the health and nutritional status of women and children" The three intermediate goals of the project are: 1. Prevention and rehabilitation from Malnutrition. 2. Promotion of women's health and nutrition. 3. Management and prevention of infections and diseases. Specifically, project activities focus on achieving sustainable improvements in "key outcome indicators of healthy behavior," which include the percentage of: A- ANNEX A • pregnant and lactating women and children 6 to 24 months who receive and consume a supplemental meal • children 12 to 24 months who were completely immunized by age 1 • pregnant women who receive and consume 90 or more IFA tablets before delivery • receipt of two TT before delivery • newborns breastfed within 6 hours of delivery • infants exclusively fed breast milk for the first 6 months • infants initiated on complementary foods in addition to breast milk by 6 to 10 months Final Evaluation Objectives: The evaluation will assess both (i) the development hypothesis and causal links between the strategies and impact and (ii) the implementation of the project. The specific objectives are: • To assess achievement of outcomes/coverage rates and health impact, since the baseline and mid-term. • To assess achievement in enabling sustainable institutions, governmental and non￾governmental, that can make continuous improvements in health status. • To assess the success of key strategies, processes, staff, structures, and systems (including monitoring systems) of the program in achieving outcomes and sustainable impact. · • To assess as to what extent can the changes in perfonnance indicators be attributed to the project. • To assess implementation according to plan; and expenditure according to budget (money and food resources). • To assess the efficiency of food management, logistics, and monitoring; and reductions in food loss. • To summarize the project and its achievements in a stand-alone executive summary, and to make recommendations for on-going e·fforts, and compile a more detailed report of· the assessment. The final evaluation will include three components: 1. A Quantitative Survey 2. A Qualitative Assessment 3. An External Team Evaluation 1. Quantitative Survey The quantitative survey plan primarily consists of comparisons across time but also includes some comparisons between INHP program areas and non-INHP areas using secondary data. In addition, comparisons can be made between project areas of higher and lower intensity effort. Each of these approaches have their own strengths and weaknesses. In this manner, the final evaluation is expected to document and analyze the effect size from baseline to mid-term and final evaluation and between areas of varying program effort. Secondary data sources such as the National Family Health Survey (NFHS) and the Multi￾indicator Cluster Survey results will be used as a secondary source of data, where available. Other sources of secondary data that may be used for comparison include NCAER's and other agency evaluation of ICDS. CARE will contract with national agencies to conduct the surveys in seven states. To maintain objectivity and ensure appropriate methodology and quality control CARE will constitute a Technical Advisory Group {TAG) with representatives from CARE, USAID, FANTA and External A- 2 ANNEX A Experts in the field of designing population-based evaluations of large public health programs. Meetings of this group will be convened to review the survey design and to assist CARE in consolidating the results obtained from the surveys in seven states. 2. Qualitative Assessment The focus of the Qualitative Assessment is on the interventions and strategies under the INHP Capacity Building strategy. The objective is to assess these interventions at the process and outcome levels. The key informant model (John Paji, Mexico) would be adapted as the primary method of data collection for the qualitative assessment. This methodology involves in-depth interviews and focus group discussions with a sample of selected community members and counterparts at various levels to help the investigators to arrive at an understanding of the project strengths and weaknesses. 3. Final Evaluation Team: CARE will contract a final evaluation team of experts in the field of health, nutrition, food security, and project management and evaluation who are external to CARE. To the extent possible, this will include representatives from the 1995 impact evaluation, and the Mid Term Evaluation team. Key stakeholders, Govt. of India and USAID representatives may also participate in the external team in a limited capacity. If possible, the Team Leader or other member(s) of the external team will be involved in reviewing the components of the evaluation (e.g., quantitative survey, qualitative assessment), prior to the external team evaluation. Methodology I Process: If possible, the External Team Leader will aid in the development of Terms of Reference (ToR) for each of the components of the final evaluation. CARE will also seek inputs from outside evaluation experts, USAID, GOI, CARE USA, and other key stakeholders. If possible, the Team Leader will also assist in identifying and coordinating the external evaluation team, including finalizing their terms of reference, schedules, and methodology for the external evaluation. The purpose of the team is to bring an outside perspective and their scope of work include: Meet with staff from CARE, GOI and USAID to understand the project, and the key questions to be answered. Review project documents, (including 1995 Impact Evaluation, Annual Plans, Annual Results Reports, Monitoring Data, Baseline and Mid-term evaluations), to understand the project. Review and prioritize the key evaluation questions and include additional questions, which the reviewers feel are relevant to the review of the project. Review the quantitative survey and qualitative assessment data. Elaborate and agree upon a methodology and tools to collect and analyze both primary and secondary data to answer the key questions. Visit the states to collect primary data from participants, staff, and counterparts, as required. Analyze the primary and secondary data. Compile and summarize findings and recommendations into a report. Sources of Data Primary Sources of Data This include data gathered directly by the external team through meetings with • Project participants (mothers, fathers, pregnant women) • Project counterparts and partners (village, block, district, state and national level) • ProjecVCARE staff A- 3 ANNEX A • Donors Secondary sources of information • Project documents, generated by the project staff: • Planning documents: Proposal, PAAs, Program Updates, implementation plans • Progress Reports: Results Reports • NFHS, SRS, or other surveys and studies done in India. • Data from the MIS of Govt. of India Reports Available to the External Team • 1995 Impact Evaluation Report • 1996 Baseline survey report, compiled by FRHS • 1999 Mid-term quantitative survey report, compiled by FRHS • 1999 Qualitative project assessments related to sustainability, partnership, convergence, etc. • 1999 Mid-term external team's summary report. • 1999 Report on comparability of Baseline and Mid Term Quantitative Survey by Ors. Mavalankar and Rao. • 1999 Results Report • 2000 PAA Final Evaluation Time-line: The final quantitative and qualitative assessments are expected to be completed by February 2001. The External Evaluation Team is planned to work during April 2001. The draft report of t e h eva I uat1on . . 1s expec t e d b ,Ya I t e A 1pn ·1 2001 Activity Months (2000 Months 2001) A s 0 N D J F M A M Finalize Terms of Reference for Final Evaluation Finalize Terms of Reference for Quantitative Survey Finalize Terms of Reference for Qualitative ... . '· I Assessment Finalize Scope of Work for External Team Identify External T earn Finalize design of quantitative Survey .. - ... Finalize instruments for auantitative Survey Identify & Finalize agencies for quantitative survey Identify & Finalize agencies for qualitative assessment Quantitative data collection • l· .• Qualitative data collection ,, . Draft report of quantitative survey Final report of quantitative survey Draft report of qualitative assessment Draft report of quantitative assessment . External Team Evaluation · ' Final Evaluation Team Report " . ___:_.;'!;".- A- 4 ANNEXB ANNEX B: PROGRAM DESCRIPTION AND DEVELOPMENT HYPOTHESES Introduction CARE India's main focus in the INHP program is to work within the broader mandate of the Government of India's ICDS and RCH programs with the main goal of improving the nutrition and health status of the vulnerable groups of pregnant and lactating mothers and children below the age of 2 years belonging to the poorer income groups. The INHP designed in 1996 as CARE's first Development Activity Proposal (OAP), went through major changes after the mid-term evaluation in May 1999, and currently focuses on six key interventions for the two major target groups, a) pregnant and nursing mothers, and b) children <2 years. As of now INHP is implemented in eight states of India. These are: Andhra Pradesh, Chhattisgarh , Jharkhand, Madhya Pradesh, Orissa, Rajasthan, West Bengal, and Uttar Pradesh, covering 7 million women and children in approximately 100,000 villages, which is about 25% of all the population covered by India's massive ICDS programme. CARE staff play chiefly a facilitator role in achieving the goal of improved health and nutrition of women and children through strengthening and building the capacity of ICDS staff, NGOs and community members; and by improving the delivery of services through the government. Developmental Hypotheses Developmental concerns underlying the INHP are related to the links between malnutrition in children and impaired physical growth, compromised cognitive development and reduced · resistance to infections which in turn can be further worsened by low birth weight if infants that is a common feature in India due to maternal malnutrition. The intergenerational cycle of malnutrition produces stunted adults with lowered work and income earning capacities, thus leading to the perpetuation of the malnutrition and poor functional performance cycle. The available data from India and other developing countries clearly show that much of the growth retardation that occurs in early childhood (0-6 years), takes place between the ages of 6m￾24m. Further, early childhood mortality rate due to various diseases also indicate a very strong exponential relationship between malnutrition and mortality, mortality rising sharply in malnourished, and dropping equally sharply when malnutrition declines in a community. Thus nutritional status ts an indicator of the development of the community. The causes of malnutrition are many. Frequently they are classified into three groups, the immediate ones are low dietary intakes and inadequate access and utilization of health services. The intermediate or underlying causes are household food insecurity (it may be noted here that malnutrition in children is seen in food secure households also), lack of environmental sanitation leading to enhanced infections and inadequate care of children and women. The basic causes, however, have to do with the economic and political structure of a country with a substantial number of the people living in poverty and lacking the skills for employment and income generation. Despite the basic causes, there is evidence to show that malnutrition can be reduced by intervening at the immediate and intermediate levels. The interventions generally found to contribute to a positive effect have included the convergence of supplementary food ( to compensate for the low dietary intake) and health services, combined with improved infant feeding practices through community capacity building and empowerment. Therefore, two major hypotheses have been articulated in the INHP program. B- ANNEXB The first one articulated consistently in all INHP reports is that nutritional improvement can occur by focussing on improved delivery of food, and health services to the vulnerable groups and by improving infant feeding practices (colostrum feeding, exclusive breast feeding for first 6 months and appropriate complementary feeding starting from 6 months. This in fact is stated as the broad goal of the INHP project "to improve the nutritional and health status of the vulnerable groups of women and children". The second hypothesis relating to capacity building was based on the understanding that sustained improvements in health and nutritional status will not be possible without strengthening the capacity of communities to support women and families to practice key nutrition and health behaviours, improving the capacity of government counterparts to deliver supplementary food and health services and building capacity of NGOs to facilitate the work of institutions in the community. Therefore, it was hypothesized that sustainable capacity building (CB) at the individual, household and community level on the one hand and CB at the institutional level will lead to behavioural and system changes that will result in improved nutritional status. Several key strategies were used by the project to attain these. Key Strategies Population based strategies replaced center based one for food distribution. The main change with respect to food delivery was to adopt the 'Take Home Ration' (THR) to reach the un￾reached i.e. the pregnant and lactating women and children< 2y. Nutrition Health Days (NHD) organized once a month brought together the AWW - ANM - and the community, making it possible for convergence of all services. Convergence of Services at the village level was facilitated by promoting sustainable co￾ordination between the Department of Women and Child Development's (DWCD) ICDS programme and the MoHFW's RCH programme and by facilitating the co-ordination of NGOs at the community and govt. level. The co-ordination promoted at different levels allowed for joint planning and problem solving and for upward and downward communications. Innovations at different levels were pursued to enhance service utilization and behaviour change. Community mobilization and empowerment through village development committees (VDC) adolescent groups, and invigorated Mahila Mandals were envisaged for creating community ownership. Building the Capacity of individuals, community, institution and systems through development of 'Demonstration Sites' and their use for diffusion of best practices was floated as one of the replication strategies. Cross fertilization, visits to other areas were other replication strategies. For social mobilization, continuous training, monitoring and other quality improvement strategies were used. B - 2 ANNEXB Role of Food Food supplement is intended to fill the gap in the dietary intake of pregnant and lactating women and children <2 years thereby expected to contribute to nutritional improvement. While coverage for supplementary food has shown a marked improvement in most INHP projects, evidence for nutritional improvement is less clear. It is apparent from the other sections that success rate of behaviour change in infant feeding practices was low and the need to pursue this component more Vigorously and systematically with appropriate inputs is evident. Food (especially THR) is also expected to act as an incentive to get more women and children to the AWC, thereby making it possible for them to avail of the health services and the behavior change communications. There is more consistent evidence to support the role of food as an incentive in all project areas. The value of food being considerable (around Rs. 50 crores per year $10 million in several states), it has enabled CARE to be recognized as a major resource contributor and, advocacy by CARE is likely to become more effective. Observations from Field Visits While the intended target groups reported consistently that they received the food supplements and other health services and this was also corroborated by observation at different levels of the systems, clarity and conviction about the link between INHP inputs and nutritional outcome was variable. Appropriate tools for behaviour change and support for this was highly inadequate. Quantity in relation to service delivery was emphasized but 'quality of services' ne~ded to be strengthened, especially with reference to the behaviour change messages. It is not only important and necessary to communicate appropriate messages about infant feeding but it is also necessary to follow up mothers at the community level with counseling and support. Nutritional status was assessed using the measurement of weight-for-age. There were other service components such as IFA the impact of which may need to be assessed using smaller community units rather than large quantitative surveys. Recommendations 1. Invest in building conviction at all levels about the links between INHP inputs and nutritional outcome so as to make this a driving force of the project. 2. Anemia interventions for young children seline IBLS\ and Final Ev:o(w>tion IDS ALL\ IBa"'"lina =RI S Demonstration Site= OS. All Sites = ALL\ .o.p RI UD no 1:u llD ..,.,. 1~,,.~~•~r "'" n<> Al I lo•<> Inc: ' .0.1 1 cu" Inc: All lcu c: Inc: Al I sic: Inc: IAt I "' .,. ne> ... Bl c: 0" ALL fAedlnn - 10·-n"n' wnmon rr 77 7n ->n .,., :," "" AA 7n 4" R1 "" .,n "" nn ">7 A? .... •O "r L4 11<'!11 ..... ~·-- ...................... "" OA 7n 37 Rn .•'>o 1R n 'i1 ..... 711 "" ?n '"' "" ,,. "" An . ., '>4 18 lrharlron "-"4 months c,7 DA !;<; c;n 70 AA 24 57 59 .,., "" 7n :\7 QA ...,. "" An R1 . .,"'" ""'- AN< - ..... ""-"" "~· on no AA ... o 5R "" 2Q c::A '>.? co .,., "" •u AA "-7 77 ?7 ..... ., ... fl? "" TT 01 QA 01 CA llQ ll7 50 7'i "" "" Q') 77 "" .. ., llR 47 !;? RC:: .,., °" 91 I~ ... 11l .,,, .,., 0 '.\? ·'19 4 42 ?A 26 ll7 "" 7 ?7 15 11 7 Q ')C AC ., .. .r.hll" ""·-·1 .. •"N• tritlon Full lmmunin1t•A-• Al< "7 "" 7 ln .... .,., ... ?? 74 'i6 - inn w/in 8 ho ·~ '>.7 40 cc R !;? 44 42 61 C"- 40 A::! 70 .,., '>1 . .,A 1A 14 47 76 67 COf • 4 m--•ho "' ::IA •n 7 ?!; ~,?n '>.R AA 61 An 7<; ""' 5 11 1? ?Q .. , .... '>? <;? 27 n•~-• fAAdj~ t: n mnntho "" '" '" "" .. ., ·77 41l "'" "" ?!; '!'.? .. ., An ""' 57 . "" .. ., . . .49 ' ,., .... , cn "" 111 __ . .,,.. •;rn '"' AC rn C<; M:ol~ •rish1>d IWPinhl.fnr »nPI 4A "-1 .,, Y 61 74 AA cn "'" 'i7 - .,1 -""' "" en .4n '>n A1 .- "' ... ~ cc 41 45 NAIA<: 1. - . and I IP data are for HI and All blocks tnnt indudina n"'· C - 2 ANNEXC Table I, above, further elaborates on the points mentioned, and highlights the changes since baseline as compared to final in both demonstration sites and all areas (with "All" including both demonstration and non-demonstration sites). The hypothesis behind the original INHP strategy, and still seen with the unified capacity building strategy, is that the demonstration sites will show greater level of change than the non-demonstration sites. To a great extent, this can be seen in the differences between Demonstration Sites "OS" and All "ALL" program areas as compared to baseline information. While there certainly are some outliers. on the whole, the hypothesis seems to be born out by the data. What has been termed, "supply side" interventions (targeted supplementary feeding, immunizations and antenatal care) have shown greater improvements than behavior change interventions. For example, supplementary feeding for pregnant or lactating mothers, or children 6-24 months of age, has almost universally improved across the program, and is even higher in "OS" as compared to "ALL" areas. Antenatal care has also improved across most program areas, with again, the "dose response" seen between "OS" and "ALL" areas, where the "dose" is measured in terms of INHP inputs. Table II provides a comparison between the final evaluation data for the "OS" and "ALL" areas as compared to data from NFHS II. Additional columns have been added to this table to highlight the indicators where INHP interventions are higher (have theoretically improved more) as compared to the NFHS II. Table II. Comparison of Coverage Rates In Baseline (BLS) and Flnal Evaluatlon (OS ALL (National Family Health Survey- U = NFHS U, Demonstration Site• DS, All Sites "' Al.LI I I I I I I I I I I I I I I I I Ai' Bl MP OR RJ ' UP'·· .• W8 Indicator NFHSll OS AU. NFHSll DS All NFHSll OS AU. NFttSll OS AU. NFHSll OS ALL NFHSll OS AU. NFHSll OS ALL Supplementary F...Slna ~ ~ .. IPrAnnant wQmen - n 70 - s: 45 - 84 70 - 81 62 - 96 99 ~=-~·j - '42 A:l - 36 44 ll.aclatina women - 84 70 - I![ 29 - n 51 - 76 50 - 99 9911·'' - 30 "° - 24 18 IChilcnn fl..24 mont!is - 84 65 - 71 56 - 57 59 - 65 70 - 68 64 • - "° 61 - 65 58 ~ OS ALL 3+0>ed<·~ 80 93 88 18 56 55 28 54 37 47 82 69 23 48 37 15 27 38 ST Q 58 7n 617 TT 82 94 91 58 e; 67 55 75 59 74 92 n 52 83 66 51 62 65 82 95 91 7f7 7n IFA 71 26 26 20 "" 19 38 42 28 62 Q 54 31 27 15 21 7 1l 56 45 25 317 on Child SuMval/Nutrttlon Full Immunizations 59 67 65 11 52 ~ 22 61 42 44 34 24 17 23 20 21 26 34 44 74 567f7 617 Breastfeedina wlin 1 hour 10 7 8 6 32 20 10 15 11 25 26 23 5 24 20 7 g ' 25 10 12 317 3f7 EBF • 4 months 75 34 "° 55 26 20 64 56 61 58 75 66 53 11 12 57 NFHSll 317 317 m 617 7f7 517 617 517 617 517 517 4f7 517 4f7 I Mal nutrition INo be "bell«" lhan NFHS if ii W11$ al - 2 pe t>ave - coverage niles and~ flllll(lullilion rates. While the National Family Health Surveys do not collect information on supplementary feeding from Anganwadi centers, they do collect information on other "supply side" interventions. For example, antenatal care (as measured through the number of check-ups that a pregnant woman receives) is higher in all "OS" and 6 of 7 (6/7) states in general. Variations still exist across states with some states having achieved higher rates than NFHS across all indicators, and some achieving higher rates on just over 50% of the targeted indicators. Table Ill provides a comparison between baseline and final for what was initially an "HI" block, through a "Panel Survey." C - 3 Table Ill. Comparison of Coverage Rates in Baseline {BLS) and Final Evaluation {FE) for the Panel Survey {Baseline = BLS, Anal = FE) /IP Bl MP OR RJ UP we Indicator BlS FE BlS FE BlS FE BlS FE BlS FE BLS FE BLS FE Supplemeotaty Feeding Ptegnan v.()lllert 63 75 30 75 13 84 61 100 45 96 21 42 44 Lac:tat.ing ~ 54 76 26 71 8 71 51 100 28 99 19 42 39 Olildren 6-24 months 57 83 55 70 11 57 55 100 56 64 22 40 37 ANC J.+~14J15 89 92 23 53 JO 53 62 75 <15 <16 30 34 eo TT 94 95 58 68 60 76 79 70 71 64 36 64 92 IFA 18 Z7 14 24 7 24 32 El6 15 18 16 7 37 Ctllld SurvMlllNUllttlon FuNI~ 35 74 22 36 28 54 - 50 36 Zl 14 32 - Breaslfeeding \lol'ln 8 hours 29 48 7 48 El6 48 37 n 38 28 8 16 62 EBF • 1 5 d no. 91 3 1189 1583 3595 5284 % ofBPL 50 58 61 77 79 % of age 37 42 32 39 41 Eligible BPL = Below Poverty Line Source: Hargaon Block, Sitapur Dist., UP, CDPOs Monthly Report for 4/01 K- 41 ANNEX K: STA TE REPORTS Most interventions should reach all age-eligible target groups e.g. breastfeeding and complementary feeding counseling, immunizations, iron/folic acid, ANC for public health impact. Only the food component is aimed at families below the poverty line. However, the 'A WC-centric' nature of the program tends to miss a large segment of the target population. CARE's INHP focuses on achieving high coverage with the following: • Targeted supplementary feeding The basic model for enrolling and reaching beneficiaries needs to be re-examined. CARE has been effective in operationalizing this model as far as commodity management and field monitoring. There is a visible difference in the effectiveness and management efficiency of CARE monitored blocks as compared with non-CARE ICDS blocks. In the basic model being implemented, the role of the food appears to be as an incentive to draw families in to the center for health services and health/nutrition education. It also provides an important in-kind transfer for food insecure families through THR distribution. THR are distributed to other family members so the direct impact on key target age groups is likely to be limited. AWWs have selected among the BPL beneficiaries on their own initiative, leading to misunderstanding and lack of trust in the program. Because communal sentiments are widespread in UP and the recent Panchayat elections have heightened caste and polrtical divisions, the AWW (who belongs to one or another of these groups) is even more distrusted. The location of AWCs in the AWW workers home has been a problem as well, proving to be a disincentive for broad participation. Full participation is important for changing health and nutrition practices. • lron/folic acid supplements This intervention appears to be implemented well according to international guidelines. However, anemia levels are very high in UP in young children and the focus appears to be exclusively on anemia prevention among pregnant and lactating women. This appears to be a gap that should be addressed urgently through I CDS/health collaboration. Iron supplementation for young children combined with bi-annual de-worming (with vitamin A supplementation) is a relatively simple intervention with potential high payoffs for health and nutrition. Adolescent girls are being given weekly iron supplements in some states and would be another anemia control intervention worth exploring in INHP-11. • Immunizations (childhood and TI) The potential for improving measles and TI coverage further needs to be examined. THR, NHD and convergence fostered by CARE appears to have increased immunization coverage in the enrolled beneficiaries. AWW and helpers actively promote immunizations in their enrolled groups and monitor coverage of this group. However further improvements may be possible if the center (AWC)-based focus and limitations of selecting only a small proportion of eligible women and children for the AWC program can be broadened to other members of the community and surrounding small hamlets for behavior change, community mobilization, and convergence activities. • Infant feeding practices (early initiation of breastfeeding, exclusive breastfeeding, and appropriate complementary feeding). These components were weak or non-existent and do not reach the majority of the target population. In some demonstration sites AWWs have received communication tools and have received some orientation on the Importance of these behaviors. K - 42 ANNEX K: STA TE REPORTS A common incorrect message observed in several places in Sitapur and Lakhimpur is to feed dal water to infants from 6 months of age. The use of diluted goats milk to newborns for the first 4-6 days and diluted buffalo milk to infants from 6 months onwards is common. Another harmful behavior in U.P. is witholding food from postpartum mothers for 4-5 days. AWW and ANMs are advising mothers to give 1 or 1112 teaspoons of food per day from 6-9 months. Growth monitoring is not being used to support improved infant feeding practices (the common message for a case of growth faltering is to send the child to a doctor}. A major effort is needed urgently to develop a strategic approach to behavior change that reaches households beyond the few who are enrolled as AWC beneficiaries. Private doctors and ISMPs play an important role in defining health and nutrition practices and need to be engaged in health/nutrition awareness raising. Implementation processes The main implementation processes are: • Assuring delivery of food commodities to the AWC center level. An elaborate system of monitoring, random AWC visits, year end audits, godown visits, monthly monitoring of beneficiaries rosters helps keep the commodities moving to the AWC relatively on schedule. • Planning and Implementation of Nutrition and Health Days. BLAC and DLACs are mechanisms used to plan these activities. • Developing and financing NGO sub-gra_nts for community mobilization. Identifying potential NGOs, helping plan their activities and providing management support are important components. Time delays from initial discussions to signing a grant can take up to 6 months. • Information systems and monitoring. New systems are being put in to place. Meanwhile GOUP has engaged their own HMIS staff under the Wortd Bank project and coordination will be needed between the new CARE and DWCD systems. • Capacity building and training for AWW, CDPOs, and ANMs • Evaluation and documentation Community CARE/UP supports community mobilization through a total of 11 NGOs, including Manav Sevar Santhan and Sarvodaya Ashram In Sitapur District.. The latter two groups build generalized community capacity and "ownership;" they encourage health activities to flow from community initiatives but do not appear to provide specific guidance. Their efforts are seriously impeded by factional disputes attributed to recent panchayat elections (but almost certainly related to pre-existing divisions). AWWs are often associated with one group or another, reportedly causing members of other groups fo boycott her services; to remedy this problem, the Sitapur District Magistrate has directed that AWCs be moved to public locations (panchayat offices, schools, etc.). This has not yet been enforced. While any community mobilization is certain to be difficult in UP, the evaluation team questioned whether the broad, relatively undirected, approach taken in Sitapur was likely to produce tangible health benefits for even the medium term. The strategy should reflect the inevitable presence of communal tensions, addressing these constraints where feasible but working toward concrete and potentially achievable outcomes even where full community Mownership" and management are not yet possible. Support systems: CARE structure, roles We were unable to meet with the state INHP Manager due to a death in his family. Field Coordinators work from a base in Lucknow. permitting frequent interchange among staff but undoubtedly weakening direct support for Field Officers or their activities. The Field Officers that we met were all male and appeared to spend the majority of their time in coordination meetings and direct support for demonstration sites. K- 43 ANNEX K: STA TE REPORTS The UP program would benefit from increased technical support and opportunities for learning in the critical areas of community capacity-development and behavior change. The current personnel structure should be examined carefully to optimize support for these emerging strategies. The great staff effort needed to build demonstration sites appears to be paying o·ff, but does not appear replicable. Field officers are the critical factor in generating convergence, but they are spread thinly and need additional opportunities to strengthen their technical skills. There is inadequate technical review and content in nutrition, public health, and communications. Food UP is the only state with ready-to-eat (RTE) commodities supplied to AWCs. A food processor collects the CSB and oil from Calcutta port godowns, processes it with the addition of sugar, finally delivering it to block level. There have been commodity stock-outs due to a change over in the food processor/supplier (from Modem Food to Khandelwal). In the past few years food supplies were interrupted during March-April when new tenders were issued. There is a problem with moving supplies from block to AWC. AWW are paid Rs.50 per trip, but this is inadequate especially since the volume of commodities increased after THR was introduced. In non-CARE sites the food (India Mix) is less well accepted than CARE's CSB/oil. India Mix is finely milled and contains about 100 fewer calories per 100 grams. There appeared to be inadequate focus on how to use the CSB/oil and/or focal foods for young children in the critical age group of 6-24 months. HMIS The state CARE office has recently hired a highly qualified demographer to develop data systems and improve managerial applications. We were unable to find anyone making e'ffective use of the recently revised HMIS. The focus is largely on food commodities, food beneficiaries and NHDays held, and not on community participation, behavior change, or data on nutritional status from growth monitoring. Organizational learning and diffusion Internal The presence of Field Coordinators within the Lucknow office certainly facilitates ongoing exchanges, and the state director confirmed that learning within UP functions well. Coordinators learn quickly of innovations and problems, as reported by other Coordinators. The State Director indicated that learning from other state programs was weak, however, leading to a suggestion of regular exchange programs between states (by counterparts as well as by CARE staff). External The newly hired Deputy ICDS Director for UP joined us in Sitapur and expressed great interest in learning from CAR E's evolving experiences, especially for behavior change. More importantly, the Secretary for Women and Child Development requested CARE to consider the possibility of extending technical assistance from CARE to non-CARE blocks as a practical means of facilitating replication. Capacity building and sustainability Systems Two main accomplishments of the CARE UP INHP are building capacity for commodities management (this has already proven useful in non-CARE sites), and facilitating convergence between DWCD and DOH. The BLACs and DLACs initiated by CARE are important for convergence and likely to remain functional even without CARE. Though training activities are considered the main CB strategy, joint field visits and meetings focused on problem-solving are important CB mechanisms. K- 44 ANNEX K: STATE REPORTS CARE has been less effective in strengthening technical skills in nutrition, public health, communication and behavior change. Technical modules have been developed through a partnership with an NGO on nutrition, and health. UNICEF has also developed training modules through regional resource centers in Lucknow and Agra. How effective these are and the process used is not known. A key potential for capacity building is at the District leadership level. Ongoing advocacy and awareness raising for OM/DC, district chiefs of DWCD, Health and rural development remain to be addressed adequately by CARE. Analysis of CARE's experience, its systematic documentation, and transfer to counterparts are important activities that CARE recognizes and aims to address in the near future. Community In order to meet CARE targets for the designation of demonstration sites, rapid formation of community structures/groups was undertaken by NGOs supported with CARE grants in the past few months. The sustainability of these structures remains to be seen. Within the training and CB category, the largest number of participants in training activities are community-based individuals (AWW, helpers, change agents). However the content, focus, and effectiveness of capacity building activities is not known. From presentations made to the evaluation team by NGOs and AWW skills and knowledge observed, the activities have not been effective so far. Beyond providing knowledge and skills to functionaries, the community-level capacity building needs to be expanded to include ownership and participation of community members and leaders in INHP activities. These include the newly elected Panchayat leaders and members, school teachers, priests and other key community functionaries Gender equity iss,ues The gender issue for UP as well as elsewhere is less one of equity than it is of optimal effectiveness: can the program achieve its objectives without placing women in front line as well as supervisory positions? The UP program employs only male Field Coordinators, and few Field Officers are female. The evaluation team did not observe any special activities focused on raising awareness in the communities about caring for girl children. Recommendations 1. Targeting Special study of CARE AWCs who is benefiting and who is left out? Implications for improving nutritional status? Working beyond those enrolled in the food program. 2. The "core/minimum/basic package" of interventions. Number and choice. Phasing in and clusters of mutually reinforcing interventions that are easy to implement and with synergies in impacts. Quality standards, routine self-assessment, team problem-solving Linkages with UNICEF on girl child initiatives. Nutrition education based on home food - not only center food. 3. Role of CARE: Develop future role of FO teams as district level technical advisory and assessment unit for nutrition and health improvement for women and children; staff up accordingly to deal effectively with DM/DCPO/CMO level counterparts. Main focus on capacity building. CARE is an independent monitoring entity for the government's field programs, because DWCD has too many social programs to do a thorough job. Technical assistance beyond CARE/food blocks e.g. WFP and State/food blocks. Advocacy and data use to generate awareness at high admin.levels and general public awareness. Develop priority issues topics based on real field constraints and suggest innovations for testing. K- 45 ANNEX K: STA TE REPORTS 4. Closer alliances between the State MOHFW and ICDS, because: of the interactions between health and nutrition problems, interventions and outcomes the need to focus both health and nutrition interventions on children under one MOHFW can promote key ICDS messages in villages with less than 1000 population (which ICDS currently excludes) 5. BLACs and DLACs will be crucial channels for diffusion and replication of new ideas. 6. Consolidation still remains to be done, capacity building, advocacy/awareness, community engagement are unfinished. Some functions are already being diffused and capacity has been built (e.g. food commodity management). WEST BENGAL STATE REPORT Background Situation of Nutrition, Health, ICDS, and INHP Summary infonnation and Methodology CARE INHP field staff in West Bengal consists of 3 FCs and 23 FOs, including 4 women. lNHP targets pregnant and lactating mothers and children under 2. The project covers 13 districts, 119 blocks, and reaches 1,093,000 beneficiaries. The State Director has been in place for only B months but comes with many years of experience with PVOs. The lNHP manager has been in place for 5 years. During the fieldwork, Ors. Vivek Adhish and O.K. Ghorai, Mr. Kalyan Mookerjee, and Ms. Anita Boral joined the evaluation team, led by Rene Berger. The team split into two groups to cover Bankura, Burdwan, and Purulia Districts approximately 300+ kilometers from Calcutta. Prior to departure from Calcutt.a, the team met with the Principal Secretary OWCD, Mrs. Gupta, and the Joint Secretary Mr. Roychowdhury. The team also met with Joint Director and State Family Welfare Officer, Dr. D.K. Ghoral. Within Bankura, the team visited 4 blocks (Chhatna, Patrasayer, Saltora, and Sonamukhi. In Burdwan the team visited one block, and in Purulia, the team also visited one block. At the village level, the team met with the AWW and the ANM where available, the NGO working in the area, Panchayat members and beneficiaries. The team also met with the CDPOs, supervisors as well as Medical Officers and Public Health Nurses depending on the block. In Bankura, the team also met with the Additional OM, the COMO, DPO, BMOs, CDPOs and others. Within CARE, in addition to meeting with the State Director and Project Manager, the team met with 2 Field Coordinators and had brief discussions with the Field Officers. Description: what were the hypothesis and key strategies Role of food Food seems to be used as a nutritional supplement for women and children in the program. At the community level, there does not seem to be much of an incentive effect for food. • Both monitoring data and AWVVs reporting confirm that women attend the AWC for supplementary feeding outside of THR. Key interventions . The Project Manager noted that a great deal of effort went into taking the INHP proposal and determining how it should be implemented. In the end, partnerships (NGOs) came through as a key intervention. Project staff also focus on the 3+3 interventions as per the UCB, but there is definitely a clear focus on building partnerships. • Both the State Director and the Project Manager highlighted CARE's expertise in food logistics and management as a key strength that they bring to the project The capacity building hypothesis and sustainability K- 46 ANNEX K: STATE REPORTS CARE West Bengal has taken the capacity building idea to heart. A great deal of their effort is focused on establishing women's groups and capacitating NGO partners. Staff clearly feel that building up these two areas will lead to sustaining activities at a local level. • Project hopes to reach targets for NGO partners by Sept. 2001. Documented coverage, outcomes, impact, attribution Coverage information from the final evaluation shows improvements in most of the target indicators including a substantial decrease in malnutrition rates. Coverage data from the HMIS suggest that while many pregnant and lactating mothers and children under 2 receive supplementary feeding, attainment of NHDs is low. INHP has also formed a number of women's groups and is currently working with 29 NGO partners. • Given that during a number of the purported NHD's reviewed, it was found that ANMs do not provide immunizations for fear that there are already too many activities going on, it is not clear how improvements in coverage of NH Os will be achieved. CARE's Implementation Big picture, key actors, partners The focus of CARE WB has been to build sustainable partnerships. They noted that the Panchayat is very strong and feel that building up women's groups and local NGOs to take over the catalyst role is the key to improving the health and nutrition status of mothers and children in West Bengal. Also trying to integrate CASHE (micro-credit) project into the INHP areas as they believe this will further streng"lhen ·the program. • Staff have rephrased the INHP acronym to note the key actors and partners: 1-ICDS N-NGO H- Health P - Panchayat Implementation against plan and expenditure against budget The State Director noted that while the budget was sufficient, the allocation process was problematic at times. They were told at CIHQ that they would have to meet certain targets to receive their full budget request (which they did), but during the initiation of INHP they had been told that the State budget was to be reduced. • Project reduced the number of blocks covered at two different times, from 200 blocks to 177, then to 119. Now plan to reduce to 100 blocks as they have found it difficult to implement activities in Darjeeling District and therefore plan to phase out from the District. Technical intervention: Interventions WB is implementing THR as a means to further coordination and to provide better access by women to the program. • NHD rates are low across the State. AWWs note that they find the NHDs too hectic to have an ANM also providing immunizations. • Not clear now the State will achieve their goal of 50% NHD as ANMs are not providing this service at NHDs (which by definition requires immunizations (and ANC) to be provided). • Growth monitoring is not being carried out systematically across the project areas. In Bankura, none of the sites visited were consistently taking and recording weights and neither Supervisors nor AN Ms seemed to be in a position to correct the problem (Note: Mr. Mookerjee notes that there has been a shortage of scales in the State and that they have worked with UNICEF to obtain more - these are expected in the State by July. Still, many AWWs have a Mbathroom" style scale at the AWC which, while not as accurate as a Salter type scale, would be sufficient to obtain information for recording trends on the cards. In two sites lilisited the AWW noted or was observed to write the weights that she did take on a sheet of paper and not the growth monitoring form. • One AWW noted that she just looks at the children and decides who should get double rations. • Exclusive breastfeeding did appear to be common (according to women's reports) but the age of weaning was very high (8, 9, even 10 months). Knowledge of INHP interventions was good. K- 47 ANNEX K: STATE REPORTS Implementation process • THR was provided, but according to the definition of NHD (including supplementary feeding rations as well as ANC including immunizations, are not conducted as the ANM believes there are too many activities currently going on to include immunizations). When an AWW covered more than one village, it was not clear how she determined who would receive THR but distance seemed to play a role - this is not consistent with the idea that foods serves as an means for participation in the program. • ANMs and AWWs do coordinate activities in terms of having the ANM being in the village during the THR distribution, only all activities are not undertaken. • One site visited was adjacent to the sub-center and the AWW noted that she does not come over very often, but rather the AWW sends participants to the sub-center. • One CDPO noted that immunizations were special and deserved a special day focused solely on their provision. Community There appear to be varying levels of community participation. According to the AWWs in many villages, women with young children are willing to come for spot feeding on a semi regular basis (and therefore don't get THR). The project has also spent a great deal of time working on developing community women's groups and working with the NGOs. • In one village the AWW noted she was having a difficult time getting the women to contribute for the health fund. The women were saying that there was no need for them to be paying for the food as it was provided by the government. • Panchayat was available In the villages we visited, but they did not appear to be overly interested in the activities of the AWC. One member noted that the pre-school education was not very good, but that the feeding and the immunizations were on going. Behavior Change AWWs report that knowledge and awareness has improved regarding child health practices over time. Weaning practices are late for both girls and boys. • It is not clear whether adequate input Is being provided for behavior change to be affected. The focus on NGOs and women's groups is to capacitate them to work with the AWWs to provide appropriate health messages. Coverage rates for basic services have improved, however some practices are still poor. Support systems CARE structure, roles staff and technical support It is clear that the FCs have a strong hand on the FOs. FOs view their role as working with the NGOs and that the NGOs in turn will undertake many of the activities at the community level. • State Director mentioned that he's not too sure what the role of the FC is. Food Food was usually available and transported by the CDPO to the AWC. AWWs noted that if a month was missed they were sent double the amount in the next month. However, the AWWs also noted that if a month was missed they would not provide double the ration to make up for what was missed. In general, most of the sites visited appeared to have relatively good storage facilities, though bags were often on the floor and against the wall and the integrity of the roof overhead was not clear at more than one site. HMIS Data is fed up the chain on a monthly basis. FOs are encouraged to try cover more than the 3% of AWCs per month. FCs note that they provided input into the development of the HMIS and noted how it helps them to understand the problems which the FOs are facing. Organizational learning and diffusion Internal: FOs and higher levels share experiences with each other in various fora. External: The Project Manager noted that it was a long process to work with the NGOs but that it would pay off in the end. FOs noted that in one particular block where they had been working with women's groups, the group had come together and was able to get the contract to distribute the commodities from K- 48 ANNEX K: STA TE REPORTS the COPO to the AVVWs. Where it used to take 10-12 days for the entire block to receive the food, the women's group is able to cover the block in one day. • Cross visits of women's groups have been undertaken to this block in order to see how these women have organized themselves. Capacity building and sustainability (exit strategies) The State Director noted that if they are able to continue to work with women's groups as they have been doing, and with the NGOs, then he believes in another 5 years they will be able to phase out their assistance. Discussions with a number of CDPOs suggested that a longer time frame would be necessary in order to bring about the level of awareness that could be sustained, however the ADM noted that they could not expect to receive external support indefinitely and that they would need to be able to continue the activities themselves. Gender Equity Issues Women do appear to be able to leave their homes on a consistent basis in order to collect the rations from the AWC, this could imply that there is a good level of empowerment among women such that they are able to control how they spend their time. The balance of CARE State staff suggests that further effort needs to go into staff recruitment and retainment. It is not clear to what extent the NGO activities will build up the status of women to the point where they are empowered to demand services, though some NGOs point out this should be their goal. Innovations One women's group that CARE worked with has requested and received from the CDPO the contract to distribute the food commodities across t}Je block. They have been able to decrease the time from CDPO godown to AWC from 10-12 days to one day. Recommendations • Staff skills should be upgraded so that all FCs and FOs can provide technical input on all INHP interventions. This includes how to work different staff levels (Al/VW, Supervisor, ANM, and NGOs) on providing technical assistance at the community level. • Staff time allocation should be reviewed with an eye toward allowing FOs to spend more time at the AWC level and less time at the District level. • FCs may need to be re-trained on how to undertake supportive supervision of activities. • Methods of providing training to AWWs, ANMs, Supervisors and CDPOs on the INHP interventions is critical, including how to undertake growth monitoring activities: • INHP should assure that all AWCs have the appropriate equipment - particularly scales. Where GoWB input is slow, CARE should work with local women's groups to purchase scales locally (this does not mean that CARE should have to purchase the scales - women's groups may need assistance in identifying suppliers and in distributing stocks, but CARE should not purchase the supplies). K- 49