PHA-Exchange> Work of PHM affiliate Arogya Iyakkam in Tamil Nadu recognized

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From: Balaji Sampath <kb at eth.net>
Arogya Iyakkam reported as one of the ten best programmes in the World.


Dear Friends,

Some of you are aware of the work on health - Arogya Iyakkam - being done by
the Tamilnadu Science Forum.  This work has be going on in about 500
villages in 10 blocks.  Now with the help of Association for India's
Development, we are expanding it to more than 30 blocks in Tamilnadu and 13
blocks in Bihar.

You might have read earlier reports on the programme that I had sent on
email.
Some of you have even visited a few of these programme areas and have been
financially helping sustain this programme.

Sometime back a team from UNICEF (United Nations Children's Fund) visited
the
programme and evaluated the work done.

The Arogya Iyakkam programme was selected as one of the ten best in India
and forwarded to the UNICEF office in New York.  There it was selected as
the ten best programmes in the world and has been reported in the UNICEF's
Innovations report.

I want to share this happy news with you.  Below is the report from the
UNICEF document which describes our work.

This recognition adds to the encouragement we get from seeing children we
are able to save. With this expansion to more blocks we have to and will
work much harder and build up a larger team committed to eliminating
malnutrition.

We now need your support - moral, physical and financial - more than ever
before.

Thanks once again for your interest in this work.

Bye,
Balaji Sampath


A SYNOPSIS OF INNOVATIONS AND LESSONS LEARNED IN UNICEF COOPERATION

AN EDITED SELECTION FROM THE 2001 COUNTRY OFFICE ANNUAL REPORTS (4th
Edition)

MARCH 2002

Compiled for UNICEF staff members by the Programme Group, NYHQ.

Community Initiatives to Improve Child Health and Nutrition in Tamil Nadu,
India: Strategies and Preliminary Results on Nutritional Impact - India

Background

This programme was started in May 1999, and is being implemented in roughly
500 villages in 10 blocks in Tamil Nadu. Supported by UNICEF, the programme
is executed by the NGO Tamil Nadu Science Forum. The programme has three
main aims:

- Improve the use of primary health care services;
- Improve children's health and nutritional status; and
- Organise and empower women around their health needs.

The programme organised village health committees (VHCs), which each
selected a local health activist. These voluntary health activists were
trained together, and more intensively in the field, in talking to mothers
about nutrition and diseases, and to pregnant women about nutrition,
delivery, breast-feeding and other health matters. The VHCs also met to read
and discuss health books, and helped the health activist to promote
nutrition and health education.

The main strategies used to address child health are:

At the family level:
- identify children at risk by weighing each child
- constantly follow up each child at risk and assist families to prevent
malnutrition or reverse it by appropriate health education and better use of
existing health services

At the community level:
- strengthen primary health care and Tamil Nadu Integrated Nutrition
Programme (TINP) services through advocacy
- make child malnutrition the most important index of health for local
planning, and sensitise panchayat members as to its significance.

The activists were given intensive training in child health and nutrition
to: analyse the combination of factors that led to particular cases of
malnutrition; identify those factors that can be addressed in that
individual and social context; discuss with the family about the child's
risk factors and the importance of addressing those factors; and reinforce
the initial message by repeated visits at the family level as well as
through cultural programmes and village-level meetings.

Programme principles:

The interaction between the health activist and the mother is central to the
programme, and is based on principles derived from experience:

1. Respect . The mother and pregnant woman are seen as intelligent people
coping with difficult conditions, and not as ignorant people who won't
listen to sensible advice.

2. Understanding . The focus is therefore on understanding why a mother does
not follow advice, rather than blaming her for not doing so. She already has
a world-view, formed by her own experiences and what she has learned from
her community. That world-view guides her health practices for herself and
her child. The advice she is given by the programme often differs from her
own information; to succeed, one must integrate this advice with her
world-view, by discussing in detail why it makes sense and how it can be
adopted within the limits of her resources.

3. Skilled and patient negotiation . This kind of dialogue is difficult,
time-consuming and requires considerable skill and confidence on the part of
the person giving the advice. Training the activist in dialogue takes time;
she must learn not only to advise, but to counter arguments and elaborate
ways in which advice can be adopted in a resource-poor setting. The activist
needs support from a group of trainers who visit her regularly, provide her
work with legitimacy and constantly encourage and provide her with further
training.

4. Peer discussion and reinforcement . One-to-one sessions between the
activist and mother are complemented by group meetings called by the
activist to discuss specific issues (e.g. feeding the colostrum). In such a
meeting, a mother will invariably say they have fed the baby with colostrum
and the baby is healthy; this can be used as  "proof of concept" to convince
others. This kind of negotiation with a larger group also requires skill,
and often the block-level trainers help the activist to conduct such
discussions.

Preliminary results on child malnutrition

As part of programme activities, children aged under five were weighed at
the beginning of the programme, and again roughly 1.5 years later (in
October-December 2000). Of 7,133 children weighed during both periods, the
percentage of children with a "normal" weight increased from 34.5% to 45.8%.
The percentage of "grade 1" children increased by 1.3 percentage points,
while the percentage of children in grades 2-4 decreased by 12.6 points.

If one compares each child's status at the two times of measurement, one
finds that 34.9% of children improved their category, while 13.5%
deteriorated; the remainder stayed in the same category. That is, there was
a net categorical improvement among 21.4% of the children.

These results understate the programme's impact, in that the nutritional
status of a cohort of under-fives is not static in the absence of positive
interventions in their favour. Rather, one expects their nutritional status
to worsen. In areas of the State where the programme is not being
implemented, one finds that the overall nutritional status of a cohort of
children aged under five deteriorates over a 1.5 year time period; indeed
this pattern is commonly found throughout India.

Organisational insights

Explanations for these positive results can be found in the actions of the
health activist: the programme's design and operations place great emphasis
on motivating her and making her effective:

· When measuring the activist's work, she is not blamed for children who are
malnourished or in poor health. The emphasis is rather on measuring her
work, i.e. talking to mothers and pregnant women. If children have worsened,
the reasons are sought in her training or in programme design. Investigation
sometimes reveals that there are underlying factors beyond her control, such
as diarrhoea epidemics.

· The activist is always praised in front of the mothers. To boost her
respect in the village and her self-confidence, village meetings are
organised in which she is honoured and called to talk to the village
community. These measures gain her respect locally and motivate her to work
harder.

· An egalitarian and intensive relationship between the trainers and the
activists is important. The motivation of these trainers, and their
willingness to meet with mothers, often over a period of days, are crucial
to providing the activist with a good example as well as the skills she
needs.

· The activists' voluntary status is important to their motivation. The
activists and the village understand that the work is done for the sake of
improving children's nutrition.

· To ensure that the focus of the activist is on actually meeting mothers
and pregnant women, administrative tasks such as report writing and
maintaining records are kept to a minimum. The trainer is responsible for
monitoring the programme, and is primarily responsible for administrative
tasks; the activist is asked to maintain only one page from which all
relevant data are gathered.

While the preliminary results will need to be independently verified, they
suggest that this programme might provide a viable model to reduce child
malnutrition. More time will be required to determine how long it takes to
raise a community's capacity sufficiently to address malnutrition without
ongoing support from an NGO; and to determine the cost of this model.

There are three further considerations relating to sustainability and
replicability. First, the model requires supportive primary health care and
nutritional services, which have traditionally been provided by the State.
These services need to be reinforced. Second, this model is predicated upon
intensive outreach counselling and personal relations. While resource
constraints play a role in malnutrition, much of child malnutrition can be
explained by behaviours. Poor feeding practices are common, and the in-home
management of illness can be much improved. These problems can only be
addressed through a dialogue that intensively and repeatedly seeks to ensure
that the right behaviour has been understood and is being practised. There
does not appear to be a shortcut or substitute for this approach. Third, the
community's involvement is important: it provides support to the activist
and examples of positive behaviour for others.

Sincere thanks to Tami Farber for her work in support of this collection.
And our thanks to all Country Offices that provided write-ups on innovations
and/or emerging lessons in the 2001 Annual Reports.