Questions/Answers

Kutch the largest district of India, bigger in size than Belgium, Denmark and various other countries faced serious issues in the delivery of public health services in general and for vulnerable groups such as women and children in particular. Higher undernourishment among children, MMR & IMR significantly higher than state average were the pressing issues facing District Panchayat responsible for delivery of health and nutrition to expecting and lactating mothers. The answer was initiatives by names of "MATRURAKSHA" and "SHAISHAV". "MATRURAKSHA" aimed to check the higher MMR (100) by focusing on clear identification of target audience, continuous follow up of women to undergo all routine checkups, use institutional health facilities and special care to high risk mothers. The coordination of health workers with elected representatives’, ICDS workers and involvement of community was the peg on which the initiative was built. The training of health workers by master trainers followed by intensive IEC activity resulted in bringing a sea change and great sense of relief for women as maternal deaths reduced to 29 from 43 in intervention years and MMR dropped to 62. SHAISHAV aimed at ensuring children’s health by reducing instances of undernourishment. The lack of coordination between health and ICDS department was the starting point of the strategy adopted to remedy malnutrition. The lack of understanding regarding consequences of malnutrition was also targeted. The detailed meetings, reviews, wide publicity and the adoption of children and Anganwadis by officers and private entities brought focus and accountability in the working of AWs. The result was an astonishing reduction in underweight children from 44858 to 18521 in a span of two years, most of the beneficiaries being from poor and marginalized backgrounds. The success of initiatives combined together improved Infant Mortality by 141 from 861 to 620 during intervention.

The overall objective of the initiative was to create participatory solutions for reducing malnutrition, improve IMR and MMR in the district of Kutch. The initiatives were built on expert opinion of subject matter specialists and implemented by innovative deployment of available resources. The objective of "MATRURAKSHA" was to check the higher maternal mortality rate prevalent in the district. The initiative resulted in putting safe and healthy child birth at the top agenda of health authorities. The lack of prioritization and subsequent lack of attention has caused 43 maternal deaths in the year 2011-12. "SHAISHAV" aimed at ensuring a healthy child to reduce the instances of undernourishment among children using Anganwadi facilities (Integrated Child Development Scheme). The result was an astonishing improvement of 58% in the number of malnourished children. The focus on improving health of mother and children impacted positively the IMR by improving IMR by about 18% points. This massive improvement in IMR furthered the cause of sustainable development among the most vulnerable children and women of the district.

The initiative was primarily aimed to check higher than average MMR, IMR in the Kutch along with significantly higher instances of the malnutrition in children of the district. The participatory approach through which the solutions were envisioned are highly relevant to the category for reaching the poorest and most vulnerable through inclusive services and partnerships as the target group for the initiative was first and foremost the vulnerable and poor groups who approached the government infrastructure for obtaining services related to health and nutrition. In India like many other developing nations the rich and middle class have created their own basic services infrastructure outside the government and use these costly facilities when required which provide quality care as per their definition of quality. This alienation of the rich and aspiring middle class from the public health infrastructure in India have left only poor and those lacking agency as clientele of Public Health Infrastructure. This movement of the rich to private sector for essential services like health, nutrition, education have shrunk the scale of the public services beneficiaries. Thus the initiative perfectly fits into the theme of reaching the poorest and most vulnerable by creating inclusive services and partnerships.

The 2030 Agenda of SDGs have people and planet at its core. It is through healthy, educated, empowered community that we aim to create a happy planet. The development trajectory of India means that a large population is still poor and needs the essential public services like health, nutrition, education, and housing to enable them to contribute to the task of a sustainable planet. This reliance of such a large mass of population on government to provide for essential social infrastructure was equally representative of Kutch. More than 90% of the population (appx.15 lakh) depended upon District Panchayat to access health and nutrition. The existing processes were not able to optimally deliver the public services of the expected quality needed by the population of the district. The initiative developed a novel participatory design through which not only the accessibility component of the delivery was ensured but the design was capable of creating accountability mechanism for the health and nutrition services provider. This focus on creating participatory solutions to remedy the poor MMR, IMR and low levels of Malnutrition enhanced the potential of the population to contribute to the advancement of the SDGs.

There is a significant element of departmental imprint in delivery of public services particularly in provisioning of pure public goods. Hitherto in Kutch health of expectant mother was exclusively a responsibility of the medical team being consulted by the patient and the malnutrition levels an exclusive responsibility of the ICDS wing. This division of responsibility in design is good to ensure focus in delivery of the basic services but the excessive departmentalization of objectives meant sub optimal results for the district as a whole. The initiative had Synergy written all over it in Bold. The ability of the initiative to brought all the departments, private sector together and transforms the issue to social agenda instead of departmental agenda ensured significant improvement in the delivery of the public services. The broad basing of the agenda meant closer scrutiny, in built accountability which automatically translates into better targeting and delivery. The Kutch model could deal successfully with the last mile delivery issues and thus was able to substantially improve the nutritional status and check the maternal mortality rates.

Kutch, other than being the largest administered district of India also is representative of the diversity of India. The region is home to a variety of ethnic groups with their varied belief system which at times disregards scientific facts such as importance of institutional delivery, practices such as supplementary nutrition et.al. Thus the initiative faced an aggravated challenge to make an impact. The ability of the intervention to impact such a diverse group and in such large numbers was possible due to the inventiveness in the design taking all on board. Through this it was able to reach out to the most poor and vulnerable section of the population, often located in the most remote places of the district. The initiative was able to improve level of nutrition and reduce the number of malnourished children from 44,861 to 18,521 during intervention years. Similarly the initiative was able to check the significantly higher MMR of the district from 100 to 62, along with reduction in Infant Mortality from 861 to 620 and thus was able to impact positively such a large group of expectant and lactating mothers along with thousands of children using government run ICDS facilities

The biggest innovation that the DDO did was to ensure that the initiative does not remain simply a departmental object. The involvement of private sector, community and elected representatives in the IEC phase and implementation phase gave the uniqueness to the initiatives. The result was that a health and ICDS issue was seen from a new light of a social issue. This new definition meant that the solution too would be grounded in society rather than one department. The ability to transform a department agenda to social agenda using persuasion and leadership made the initiative successful. The clean slate approach where all measurements were done afresh brought the real picture and thus helped to formulate new solutions. This newness in definition of problem and then devising innovative arrangements such as public private arrangements, adoption of anganwadis and malnourished children by senior government officers, personal monitoring of all maternal death cases and wide publicity to those involving in unscrupulous healthcare practices thereby cautioning unsuspecting villagers lent the success to the initiatives.

The innovation was original and the novelty of the initiative was one of the factors that made the solution click. The ability of the DDO Mr. Harshad Patel to create interdepartmental synergy built on novel organizational linkages gave the required originality to the initiative.

The approach involved creating a sense of ownership among all stakeholders implementing the initiative and seeing the big picture instead of getting trapped in narrow departmental visions. The focus on involvement helped solve the biggest problem of qualified human resources. The lack of proper training to Anganwadi workers was remedied by a well designed training of trainers through UNICEF and NGOs working in health sector. The utilization of different department officials for adoption of severely malnourished children and Anganwadis brought additional qualified human resources. The supplementary nutrition kit (Shaishav Kits) comprised of sprouted grams(500gms), besan laddus(300gms), dates(500gms), groundnut and sesame chikki (750) and bournvita (200gms) costing around Rupees 250(4$). This expense was borne by involving private donors, utilizing funds received under Corporate Social Responsibility (CSR) charters. The reduction in MMR and IMR was achieved by wide scale percolation of Gynecologists and Obstetricians technical competence with doctors, midwives and other health staff working at the level of the PHC through various training camps where large scale dissemination about issues arising during child birth were explained in detail by the senior OBG professionals along with explanation of methods for early identification of high risk mothers.

Si

The success of the initiative in an inhospitable district such as Kutch gave credence to the design of the initiatives. The results and the process were shared with the State Government departments and all the District Panchayats of the State in detail by publishing a book and its sharing with all. The departments of the state government associated with women and child issues incorporated the design element of the initiatives in their schemes. Also, many District Panchayats utilized the learning's to customize their solutions targeting malnutrition and higher infant and maternal deaths in the area with appropriate changes suitable to their topography and level of challenge they faced.

The first semblance of sustainability appeared with the DDO Mr. Harshad Patel promoted and appointed as the District Collector of the Kutch. This continuity in the tenure was essential to ensure that the initiative is able to acquire its own standing and thus develop some resilience to be sustained over a longer period of time. Further the most significant innovation by the DDO of evolving an approach to have all the stakeholders involved in the battle against the Malnutrition and Infant and Maternal Mortality gave the required social sustainability to the initiative. The issue of departmental goals was transformed into a socially relevant and desirable outcome. This further enhanced the ability of the effort to raise finances required in the long run for the economic sustainability of the initiative. There is a significant presence of corporate entities in the district however all of them were struggling to find out a channel partner who can really design something meaningful to fulfill their corporate social responsibility charters. This was done by the District Panchayat in the initiatives which on one hand ensured adequate financial support for the efforts being undertaken and on other hand provided corporate entities a partner which could be trusted and was accountable. The initiative was customized keeping in mind local dietary patterns, availability of local food grains, practices continuing over decades to have a design which came up organically. This emphasis meant that issues of environmental sustainability were mainstreamed in the process giving required attention to the planet and making the initiatives socially, economically and environmentally sustainable and equally desirable.

The biggest strength of Indian Bureaucracy lies in its ability to institutionalize things and the ability of the incumbents to draw wisdom from repository of institutional memory which the system preserves over the years. This is possible only when innovations are documented well and disseminated widely to give them a far reaching recall. The ability of the DDO to have every bit of the initiative documented and stored in all formats for the easy recall when needed along with capacity building of the providers of health and nutrition. The efforts undertaken, the scientific background to all the efforts including medical and nutritional background to all the initiatives, along with responsibility mapping of all the stakeholders was documented in a simple to understand language and formats. All these were circulated widely to ensure that all stakeholders are well versed with their roles. This have resulted in making the initiatives time proof in a sense that whoever stays in the positions have a job description to follow and the adherence to that shall bring the required result. This was perhaps the most significant aspect granting the durability required over longer periods of time. The initiative has been institutionalized in the district over the tenure of Mr. Harshad Patel and significant improvements have been made resulting in district being able to contain MMR, IMR and along with continuously reducing instances of the malnutrition, thereafter.

Si

The biggest evaluation of any initiative in a functional mature democracy is by the elected representatives speaking for the people. The initiatives were appreciated by none less than the current Prime Minister of India Mr.Narendra Modi (then Chief Minister of Gujarat) during his visit to the district. Also he congratulated the team headed by the DDO Mr. Harshad Patel and asked for widespread circulation of the success story. The initiative got thumbs up from Ministers, Member of Parliament, Member of Legislative Assembly and all local elected leaders. Further an independent third party evaluation was done by SARASWATAM trust in the month of January 2013 covering over 25 points in a detailed evaluation form. The third party evaluation gave the required credibility to the effort. Also, the CSR teams of the corporate entities being associated with the efforts kept on doing concurrent evaluation in the form of social return on expenditure incurred and their continues association was a proof that the returns were good.

The political class unanimously appreciated the impact of the initiatives. The Prime Minister of India Mr. Narendra Modi(who was then the Chief Minister of Gujarat) personally wrote a appreciation letter and asked to share widely the efforts being undertaken by DDO Kutch for the benefits of the other districts. The independent third party evaluation by SARASWATAM trust in the month of January 2013 covering over 25 points in a detailed evaluation form. The key findings of the third party evaluation echoed the feelings of elected representatives. The Anganwadi Workers were regularly visiting homes and all children were given adequate supplementary nutrition along with clear documentation of their growth in growth chart and three SHAISHAV registers were maintained by all centres. The findings affirmed the effectiveness of the IEC activities in improving levels of undernourishment. The safe mother initiative was investigated through cross departmental and inter regional teams consisting of members drawn from multiple departments. This diversity in formation of teams was to prevent group think and yield true picture. The evaluation confirmed the findings discusses earlier of the success of the initiative in checking the Infant and Maternal mortality rates and raising nutritional status of the children.

In order to correctly quantify nutrition status was important for identifying the burden caused by malnutrition and initiate interventions. The various indicators used to measure include Anthropometrirc, Biochemical and Clinical indicators along with social determinants of Malnutrition. Anthropometric Indicators The basic measurements taken from children include • age, • sex, • weight, • length, • height, • Mid Upper Arm Circumference(MUAC) • Body Mass Index(BMI) and which were then compared to the sex-specific National averages and WHO-guided international reference population as a way to assess the level of malnutrition. Biochemical Indicators The deficiencies caused due to lack of Micro-nutrient are not easily diagnosable unless they are severe enough to result in visible disorders or illnesses. Low levels of Hemoglobin were measured using micro photometer. Clinical Indicators The identification of Goiter and night blindness based on standard WHO questionnaire • Does your child have any problem seeing in the daytime? • Does your child have any problem seeing at nighttime? • If (2) is yes, is this problem different from other children in your community? • Does your child have night blindness?

District Panchayat Kutch like all elected bodies works with a state government appointed administrative head as District Development Officer who is a senior time scale IAS officer and an elected President along with other elected representatives forming various committees. The DDO is assisted by senior officers of the district Panchayat from health, education, ICDS, agriculture, engineering, accounts, and finance divisions. The most important contribution is of the DDO for he is the one responsible for the overall planning, coordination and thus takes all responsibility and overall ownership of all the initiatives whether successful or not. Mr. Harshadkumar Patel (IAS) was the DDO under whose leadership the District Panchayat Kutch could envision an initiative focusing on improving maternal and children health. The leadership style of Mr. Patel contributed immensely to the success of all the initiatives for he could foresee the potential bottlenecks and thus act in time to save the projects from emerging challenges. The DDO would plan in detail and come up with innovative participatory models such as adoption of anganwadis, adoption of malnourished children, raising finances using the social capital and tapping into private resources available in the form of CSR and PPP. The other officials of the district panchayat particularly from health, ICDS and education department contributed significantly in reaching out to actual beneficiaries. The private foundation Adani foundation, global bodies such as UNICEF, NGOs helped with man, material and money. The anganwadi workers, ASHAs, ANMs who dedicated themselves fully to the vision of DDO were able to measure the correct extent of malnutrition and then work meticulously along with clear documentation of all the children falling under malnourished category continuously over the years. This along with proactive participation from village elders, community leaders and elected representatives further improved the implementation of the initiative.

This initiative continues to be successful as a result of the commitment from the local government and key community leaders. Without this, the initiatives would not have been accepted by the public nor would behavioral change have occurred so quickly. Another important learning was that trust between partners is a precondition to success. Recognizing local community as a tremendous resource and a major agent of change for maternal and child health outcomes became a significant factor in the success of the initiative. The new concept of GSR (Government Social Responsibility) and CSR (Corporate Social Responsibility) by the DDO Mr.Harshad Patel helped in complementing each other’s efforts and thus channelize right amount of resources in right direction. Harmonization of GSR-CSR efforts along with complementing money, material, and human capital proved to be a game changer in coming out of resource constraints. A learning which emerged was the importance of communication for sustainable outcomes. Changing cultural traditions requires an approach in line with the customary practices. Recognition of social status & responsibility of leaders at the village level & their importance in the cultural fabric of the community positioned them well to influence behavior and promote wider coverage of safe delivery practices.