Now that the training of our Community Nutrition Educators (CNEs) is complete, Real Medicine Foundation Team India has started our field surveys in 500 villages in Southwest Madhya Pradesh. The CNEs are going door to door to find out about nutrition levels among all children under 5 and ask the thousands of families about livelihoods, access to healthcare and public services, and available food. This is the first time a survey of this size and scope is being conducted in these areas.
Our goal is to gain a better understanding of the level of malnutrition for our interventions and acquire as much information as we can to really understand the underlying causes of malnutrition in the villages. Once our surveys our complete, we will have a comprehensive list of which children are malnourished where, data on pockets where malnutrition is especially prevalent, and some understanding of why malnutrition is particularly bad in these areas. After the surveys, our CNEs, who are really the foot soldiers in RMF’s battle against childhood malnutrition, will know exactly where to focus their efforts and which families are most in need of nutrition education, support, and follow up.
These baseline surveys will also be extremely important for monitoring the success of our program. Our program includes stringent monitoring and evaluation of the initiative, with our CNEs submitting weekly reports on their activities in the field. By having a clear picture of where we started, we’ll be able to accurately measure the impact that RMF activities have had in our villages. This is important not only to prove our effectiveness to our donors, but also to gauge the effectiveness for government and other partners so that our program can be replicated throughout the country.
While in the villages, the Educators are also diagnosing and referring cases of Severe Acute Malnutrition (SAM) to treatment facilities throughout the state. In India, cases of SAM are treated in Nutritional Rehabilitation Centers in district and block hospitals. Over 14 days, the children are given micro-nutrient rich therapeutic food at regular intervals of 2 hours under the close supervision of nurses and doctors. The child’s parent, usually the mother, is also given tips on preparing nutritious food, sanitary preparation of food to prevent illness, and guidance on correct breastfeeding. So far the CNEs have referred dozens of children to the centers for care.
Over the past week I met with every district team to get a sense of how the surveys are going in the villages. All of the women were pretty positive, but also shared some of their concerns and difficulties with me, and each other. Actually, I didn’t have that much to say, or much of a chance to say anything at all. By sitting in a room together, and realizing that their peers shared many of the problems they had faced individually, all of the CNEs engaged in problem solving discussions without little guidance. When a problem was raised by one woman that another had faced, and solved, everyone took notes on the new strategies and enthusiastically applied it to their own difficulties. The hardest part of the training process was predicting the nearly infinite local problems that would hamper the surveys, however, team-building exercises such as role-playing gave them some of the tools they would need to handle situations in the field. Combining these skills with on-the ground experience, and conversations about lessons learned with each other, has empowered our CNE’s even more.
Building off of each other, and combining the vast array of talents and backgrounds of our team is the cornerstone of our “Eradicate Malnutrition” program. As we begin the intervention phase of our program we are all confident that we are about to affect some real change in an area deeply in need of it. Our confidence will be tested, however, as the job ahead of us is a daunting one.
Sunday, June 13, 2010
RMF Inaugurates our first Nutrition Rehabilitation Center
After months of negotiating the bureaucratic maze of India; acquiring form after form and signature after signature; tireless hours spent on renovation and beautification by our dedicated staff and volunteers, RMF and its partner, Jeevan Jyoti Health Service Society, who operate Jeevan Jyoti Hospital, proudly inaugurated its Nutritional Rehabilitation Center (NRC) in partnership with the state government of Madhya Pradesh.
After the requisite ribbon cutting and speech by the district’s Chief Medical Officer, we immediately admitted our first 12 patients, who had been waiting (while being looked after by our staff) for hours to be officially admitted.
This Public-Private Partnership (NRC) is one of a handful of its kind in all of India. The Government of Madhya Pradesh will provide the funding while RMF and JJHSS provide the facilities, the staff, and technical support for the difficult task of treating patients with Severe Acute Malnutrition (SAM).
With the capacity to treat 20 children at a time, this center will offer round the clock care to children suffering from the worst forms of malnutrition. The NRC provides the serious patients identified with a 14 day treatment consisting of regular feeding with micronutrient rich food and required antibiotics, de-worming, and treatment of underlying illnesses. Upon referral, the child’s height and weight are measured, a Mid-Upper Arm Circumference Test is performed, and if SAM is present, the child is admitted.
Cases of SAM in Madhya Pradesh are treated with two types of therapeutic food depending on the severity and complications of their condition, and are eased back on to a normal diet by receiving specific amounts of formula, based on weight, during regular feedings every two hours. We have a resident pediatrician regularly assessing the children and providing treatment for any complications, such as respiratory infections, diarrhea, or other illnesses.
Our dedicated staff of one pediatrician, 3 nurses, 3 caretakers, a cook, and a feeding demonstrator, will not only cater to the medical needs of these acute patients, mostly under the age of 5, but will also work closely with the mothers to address the root causes of malnutrition in their child. The mother’s will stay with their child at our center for the course of their treatment and recovery – usually 14-21 days.
Our staff will take full advantage of this time by offering mothers one on one and group counseling and training on important nutritional issues such as breastfeeding, supplementary feeding, local recipes, sanitation, hygiene, and other topics the women want to learn.
Our goal is that each child treated at our center not only recovers from SAM, but also stays well.
The opening of Jeevan Jyoti’s NRC closes the circle of the Malnutrition Eradication program. At the field level, we work in 100 villages in the area, have already identified hundreds of children in need of treatment, have provided referrals to other facilities in the area, and followed up with children who have already received treatment.
Now, our Community Nutrition Educators have a closer facility that they can work with, can familiarize themselves with the treatment procedures at the NRC to better explain the services in the field, and will participate more closely in the follow ups with treated children to prevent relapse.
While all of our activities are linked closely with government practices already in place, we hope to go a step beyond current activities and to set a standard of excellence that will be adopted by other NRCs in the state.
The opening of the doors of this facility was a real victory for the children of Jhabua and RMF’s staff. Through the hard work of everyone, twelve children started on the road back to health today.
For more information on how SAM is treated in the NRCs in MP and to learn about opportunities to contribute to this program, please visit our website for more information: www.realmedicinefoundation.org
After the requisite ribbon cutting and speech by the district’s Chief Medical Officer, we immediately admitted our first 12 patients, who had been waiting (while being looked after by our staff) for hours to be officially admitted.
This Public-Private Partnership (NRC) is one of a handful of its kind in all of India. The Government of Madhya Pradesh will provide the funding while RMF and JJHSS provide the facilities, the staff, and technical support for the difficult task of treating patients with Severe Acute Malnutrition (SAM).
With the capacity to treat 20 children at a time, this center will offer round the clock care to children suffering from the worst forms of malnutrition. The NRC provides the serious patients identified with a 14 day treatment consisting of regular feeding with micronutrient rich food and required antibiotics, de-worming, and treatment of underlying illnesses. Upon referral, the child’s height and weight are measured, a Mid-Upper Arm Circumference Test is performed, and if SAM is present, the child is admitted.
Cases of SAM in Madhya Pradesh are treated with two types of therapeutic food depending on the severity and complications of their condition, and are eased back on to a normal diet by receiving specific amounts of formula, based on weight, during regular feedings every two hours. We have a resident pediatrician regularly assessing the children and providing treatment for any complications, such as respiratory infections, diarrhea, or other illnesses.
Our dedicated staff of one pediatrician, 3 nurses, 3 caretakers, a cook, and a feeding demonstrator, will not only cater to the medical needs of these acute patients, mostly under the age of 5, but will also work closely with the mothers to address the root causes of malnutrition in their child. The mother’s will stay with their child at our center for the course of their treatment and recovery – usually 14-21 days.
Our staff will take full advantage of this time by offering mothers one on one and group counseling and training on important nutritional issues such as breastfeeding, supplementary feeding, local recipes, sanitation, hygiene, and other topics the women want to learn.
Our goal is that each child treated at our center not only recovers from SAM, but also stays well.
The opening of Jeevan Jyoti’s NRC closes the circle of the Malnutrition Eradication program. At the field level, we work in 100 villages in the area, have already identified hundreds of children in need of treatment, have provided referrals to other facilities in the area, and followed up with children who have already received treatment.
Now, our Community Nutrition Educators have a closer facility that they can work with, can familiarize themselves with the treatment procedures at the NRC to better explain the services in the field, and will participate more closely in the follow ups with treated children to prevent relapse.
While all of our activities are linked closely with government practices already in place, we hope to go a step beyond current activities and to set a standard of excellence that will be adopted by other NRCs in the state.
The opening of the doors of this facility was a real victory for the children of Jhabua and RMF’s staff. Through the hard work of everyone, twelve children started on the road back to health today.
For more information on how SAM is treated in the NRCs in MP and to learn about opportunities to contribute to this program, please visit our website for more information: www.realmedicinefoundation.org
Absentee blogger - with good reason!
It has been a hectic past few months since I last posted. We hired, trained and re-trained the staff, finished our exhaustive baseline survey across 500 villages, measuring over 60,000 children, finding and counseling thousands of malnourished children and referring over 100 children to NRCs for treatment. We also inaugurated and admitted our first patients into one of the first Public Private Partnership Nutrition Rehabilitation Centers in the state. Now that we've got the system set up, the intervention really begins. I promise to blog more regularly on our operational experiences in combatting malnutrition at the community level.
For now, here are a few blog entries from the RMF website on what we've been up to.
For now, here are a few blog entries from the RMF website on what we've been up to.
Tuesday, March 23, 2010
Jhabua malnutrition in the news again
http://www.ndtv.com/news/india/madhya-pradesh-jhabuas-register-of-death-18247.php
We're finding the same thing at anganwadi centers across the district. In a recent survey in one village, we found 50% malnutrition with 18% severe acute malnutrition - a SAM rate 54% higher than the national average of 3%
We're finding the same thing at anganwadi centers across the district. In a recent survey in one village, we found 50% malnutrition with 18% severe acute malnutrition - a SAM rate 54% higher than the national average of 3%
Saturday, March 20, 2010
The National Food Securities Act
Great background article on the National Food Securities Act:
http://timesofindia.indiatimes.com/india/UPA-gets-food-security-bill-off-the-block/articleshow/5699603.cms
The Act, which will guarantee BPL families foodgrains at extremely discounted rates, will be a national program on par with NREGA and the Mid-Day Meal scheme, and, similarly, will be implemented at the state level.
This Act is a great step in the right direction to promoting greater food security in India, but as always, the devil is in the details. I'm waiting to see the fine print and how this will translate into action - given the deep corruption in the existing PDS system.
http://timesofindia.indiatimes.com/india/UPA-gets-food-security-bill-off-the-block/articleshow/5699603.cms
The Act, which will guarantee BPL families foodgrains at extremely discounted rates, will be a national program on par with NREGA and the Mid-Day Meal scheme, and, similarly, will be implemented at the state level.
This Act is a great step in the right direction to promoting greater food security in India, but as always, the devil is in the details. I'm waiting to see the fine print and how this will translate into action - given the deep corruption in the existing PDS system.
Tuesday, March 2, 2010
Barwani - NGOs galour
Barwani has the luck, or the curse, of having one of the highest rates of NGOs per capita in the state. There are hundreds of NGOs, with hundreds of missions and a fleet of professional NGO staff milling about the district. With this much activity on would think that basic development indicators should be on the rise.
Not exactly.
Our first meeting, like in every other district, was with the District Collector, the senior most official in the district who looks after all programs. He was enthusiastic to hear that we’re going to be starting work on nutrition in his district since he considers malnutrition is a serious and underestimated problem. He told us about an internal district government survey in which they determined that malnutrition is at least 10 times what is being reported. This is the first time I’ve heard of a district conducting this type of internal nutrition analysis and while we couldn’t get our hands on this report, I’m ready to believe the Collector’s opinion and suggestions on where to work in Barwani – Parti block.
At the same time the Collector was friendly and encouraging towards us, he was also quite frank: “Go ahead and start your work in our district, and next time you visit this office make sure you can bring some results from your work on the ground.” This Collector must receive dozens of requests from NGOs a day – for funding, signatures, appearances, etc – but probably doesn’t see many deliver. I hope we can.
Out of the many NGOs in the area local contacts told us that many are radical entities associated political parties or social groups. Others are just NGOs on paper. We did however find a few NGOs doing great work in the area. Swasthay Vardihni is working in empowering communities, providing innovative microinsurance schemes, and advocating for the elderly. One of their dedicated staff members also runs a school for tribal children in Parti block, the most remote area of the district. KDSS’ local arm, ASHA Gram, is also active here, supporting some long standing livelihood programs and running large scale medical camps and facilities throughout the district. While there are other NGOs like these doing great work in the district, no one is working in malnutrition.
Our NGO friends helped guide us to choose underserved villages with high rates of malnutrition to begin our intervention. The eastern half of Barwani is doing fairly well according to most local accounts. There is a major highway running through this area that connects the district easily with Bhopal, Nagpur, and Mumbai. This connectivity means not only ease in getting goods to market, but also that business and industry has developed along this convenient route and all the economies that these small scale ventures can bring. We therefore, decided to focus our intervention in the most remote area of the district, Parti block, where access is extremely limited. An estimated 60% of the block is inaccessible by road and its villages quite spread out and remote. The other 40% are connected fairly well to the one road in the block.
Given the remoteness of Parti block we again decided to plan our intervention around the availability of local staff. With the help of our local NGO friends, we were able to recruit over 30 handpicked women for interviews. I was pleasantly surprised by the level of education amongst many of the tribal women from remote parts of Parti and was touched by their desire to continue working in their villages despite their higher level of education. In a block with many logistical obstacles, we were able to quickly assemble a team I’m excited to work with.
Not exactly.
Our first meeting, like in every other district, was with the District Collector, the senior most official in the district who looks after all programs. He was enthusiastic to hear that we’re going to be starting work on nutrition in his district since he considers malnutrition is a serious and underestimated problem. He told us about an internal district government survey in which they determined that malnutrition is at least 10 times what is being reported. This is the first time I’ve heard of a district conducting this type of internal nutrition analysis and while we couldn’t get our hands on this report, I’m ready to believe the Collector’s opinion and suggestions on where to work in Barwani – Parti block.
At the same time the Collector was friendly and encouraging towards us, he was also quite frank: “Go ahead and start your work in our district, and next time you visit this office make sure you can bring some results from your work on the ground.” This Collector must receive dozens of requests from NGOs a day – for funding, signatures, appearances, etc – but probably doesn’t see many deliver. I hope we can.
Out of the many NGOs in the area local contacts told us that many are radical entities associated political parties or social groups. Others are just NGOs on paper. We did however find a few NGOs doing great work in the area. Swasthay Vardihni is working in empowering communities, providing innovative microinsurance schemes, and advocating for the elderly. One of their dedicated staff members also runs a school for tribal children in Parti block, the most remote area of the district. KDSS’ local arm, ASHA Gram, is also active here, supporting some long standing livelihood programs and running large scale medical camps and facilities throughout the district. While there are other NGOs like these doing great work in the district, no one is working in malnutrition.
Our NGO friends helped guide us to choose underserved villages with high rates of malnutrition to begin our intervention. The eastern half of Barwani is doing fairly well according to most local accounts. There is a major highway running through this area that connects the district easily with Bhopal, Nagpur, and Mumbai. This connectivity means not only ease in getting goods to market, but also that business and industry has developed along this convenient route and all the economies that these small scale ventures can bring. We therefore, decided to focus our intervention in the most remote area of the district, Parti block, where access is extremely limited. An estimated 60% of the block is inaccessible by road and its villages quite spread out and remote. The other 40% are connected fairly well to the one road in the block.
Given the remoteness of Parti block we again decided to plan our intervention around the availability of local staff. With the help of our local NGO friends, we were able to recruit over 30 handpicked women for interviews. I was pleasantly surprised by the level of education amongst many of the tribal women from remote parts of Parti and was touched by their desire to continue working in their villages despite their higher level of education. In a block with many logistical obstacles, we were able to quickly assemble a team I’m excited to work with.
Saturday, February 13, 2010
Khargone and Khandwa - the difference institutions make
Driving from Khandwa to neighboring Khargone its hard to tell where one district stops and another begins. We drove through Pandhana block of Khandwa, another rural and malnourished district, where on our field visits, locals had just enough contact with the government medical system not to trust it. Pandhana's population, a mix between scheduled tribes and schedules castes, are the same people as those across the boarder in Zhirnya block of Khargone, the block with reportedly the highest malnutrition in the district.
We saw a more subtle, yet the most crucial difference between the two districts however, at a town on the border. At the first town in Zhirnya we stopped to ask two woman at a bus stop where the anganwadi center was. One woman turned out to be the anganwadi herself and another the block supervisor. The anganwadi supervisor actually out on a field visit! This is something for the books! While we still found 2 SAM children in a hamlet of the village during a rapid assessment with the staff, the fact that they were at least active was encouraging.
In Khargone we were met by both the Chief Medical Officer and the District Program Officer for Women and Child Development, the two senior officers in charge of malnourished children, who in many districts are cordial at best. Here is Khargone these would-be mortal enemies were friendly and courteous. I attended a coordination meeting, called by the Health Department, but attended by block officers from both departments, where they walked through programs one by one, debating problems, highlighting concerns, and working towards mutually agreed upon solutions. Again, does not sound revolutionary, but this is the first time I've seen cooperation amongst the two departments to this degree at any level of government.
The level of cooperation we received was so great that we became a bit suspicious. The District medical coordinator actually prepared us a clustered list of the villages we should work in in the two blocks with the highest malnutrition, Zhirnya and Berhampura blocks. This was too good to be true. In Khandwa WCD prepared a similar list for us, and when we went to check it out, it turned out the villages on this list are those by the road, with access to health facilities, good farming, low rates of malnutrition and some of them even non-existent. We went out by ourselves to check a random selection of Khargone Health Department's "malnutrition list" and were pleasantly surprised that they are sending us to the right locations (not pleasantly surprised that there is tons of malnutrition in this area, but pleasantly surprised they're making our job easier to get to these places). We also consulted with the only NGOs in the area, Lepra Society and Khandwa Diocean Service Society, and they concurred that these were the villages neglected by government and NGO services and in dire need of a malnutrition intervention.
Not only did the Health Department provide us with a list of villages, but they also helped us line up interviews with some great staff members. Khargone has a University offering a Masters in Social Work program so there are many local men and women with a high degree of education who are also interested in social work in their home district. While in other districts we cannot afford MSWs as staff members, in Khargone we found them willing to work for us in order to gain experience with an NGO in their home district (here being one of the only NGOs has its benefits).
Khargone still has a large malnutrition problem, but the difference here as opposed to other districts, is that the district administration is willing to recognize the problem and address it head on, bringing in partners to help them in this process.
We saw a more subtle, yet the most crucial difference between the two districts however, at a town on the border. At the first town in Zhirnya we stopped to ask two woman at a bus stop where the anganwadi center was. One woman turned out to be the anganwadi herself and another the block supervisor. The anganwadi supervisor actually out on a field visit! This is something for the books! While we still found 2 SAM children in a hamlet of the village during a rapid assessment with the staff, the fact that they were at least active was encouraging.
In Khargone we were met by both the Chief Medical Officer and the District Program Officer for Women and Child Development, the two senior officers in charge of malnourished children, who in many districts are cordial at best. Here is Khargone these would-be mortal enemies were friendly and courteous. I attended a coordination meeting, called by the Health Department, but attended by block officers from both departments, where they walked through programs one by one, debating problems, highlighting concerns, and working towards mutually agreed upon solutions. Again, does not sound revolutionary, but this is the first time I've seen cooperation amongst the two departments to this degree at any level of government.
The level of cooperation we received was so great that we became a bit suspicious. The District medical coordinator actually prepared us a clustered list of the villages we should work in in the two blocks with the highest malnutrition, Zhirnya and Berhampura blocks. This was too good to be true. In Khandwa WCD prepared a similar list for us, and when we went to check it out, it turned out the villages on this list are those by the road, with access to health facilities, good farming, low rates of malnutrition and some of them even non-existent. We went out by ourselves to check a random selection of Khargone Health Department's "malnutrition list" and were pleasantly surprised that they are sending us to the right locations (not pleasantly surprised that there is tons of malnutrition in this area, but pleasantly surprised they're making our job easier to get to these places). We also consulted with the only NGOs in the area, Lepra Society and Khandwa Diocean Service Society, and they concurred that these were the villages neglected by government and NGO services and in dire need of a malnutrition intervention.
Not only did the Health Department provide us with a list of villages, but they also helped us line up interviews with some great staff members. Khargone has a University offering a Masters in Social Work program so there are many local men and women with a high degree of education who are also interested in social work in their home district. While in other districts we cannot afford MSWs as staff members, in Khargone we found them willing to work for us in order to gain experience with an NGO in their home district (here being one of the only NGOs has its benefits).
Khargone still has a large malnutrition problem, but the difference here as opposed to other districts, is that the district administration is willing to recognize the problem and address it head on, bringing in partners to help them in this process.
Kalwa - Second try
A week after our first failed attempt at hiring in Khandwa we returned to Khandwa with a new strategy. We ditched our jeep in the city and jumped on motorcycles with one of our new friends, an accountant with a heart of gold who lived in Kalwa for years and who still has deep ties to the community.
Kalwa is a spectacularly beautiful backdrop to the abject poverty it holds. Rolling hills, thick forests, and whimsical rivers surround villages ignored by development, struggling to match crop yields with the rising prices of foods, and with limited connectivity to markets, schools, and hospitals. Off the road, the scenery gets more spectacular and the malnutrition more severe.
Our plan for Kalwa is to choose our villages based on the good workers we can find. We’re requiring basic literacy – enough to fill out simplified reporting formats – and the charisma and communication skills to carry our messages. We’re going to hire women from larger villages (still pretty remote) who will cover the more rural villages within reach of their village. The larger villages are where we were able to find a handful of literate women and are usually located in the center of a cluster of smaller villages (small is still 1000 people). We’ll provide used bicycles to the Kalwa staff so that they can cover the substantial, but usually flat, distances between villages (we’ll call it a green initiative!).
By spending the day stopping through larger villages in the middle of rural ones, following contacts and hunting down leads we were able to find 5 staff members to cover almost 50 villages in the most remote areas of Kalwa. While many people said we wouldn’t be able to find women willing to cover more than a few villages, our new staff happily gave us a list of 10+ villages within a 10km radius of their village that they would cover.
We still need to do one more swoop of Khandwa to find the rest of our staff there, but we’re confident that this cluster approach will yield effective staff and a sustainable model.
Kalwa is a spectacularly beautiful backdrop to the abject poverty it holds. Rolling hills, thick forests, and whimsical rivers surround villages ignored by development, struggling to match crop yields with the rising prices of foods, and with limited connectivity to markets, schools, and hospitals. Off the road, the scenery gets more spectacular and the malnutrition more severe.
Our plan for Kalwa is to choose our villages based on the good workers we can find. We’re requiring basic literacy – enough to fill out simplified reporting formats – and the charisma and communication skills to carry our messages. We’re going to hire women from larger villages (still pretty remote) who will cover the more rural villages within reach of their village. The larger villages are where we were able to find a handful of literate women and are usually located in the center of a cluster of smaller villages (small is still 1000 people). We’ll provide used bicycles to the Kalwa staff so that they can cover the substantial, but usually flat, distances between villages (we’ll call it a green initiative!).
By spending the day stopping through larger villages in the middle of rural ones, following contacts and hunting down leads we were able to find 5 staff members to cover almost 50 villages in the most remote areas of Kalwa. While many people said we wouldn’t be able to find women willing to cover more than a few villages, our new staff happily gave us a list of 10+ villages within a 10km radius of their village that they would cover.
We still need to do one more swoop of Khandwa to find the rest of our staff there, but we’re confident that this cluster approach will yield effective staff and a sustainable model.
Tuesday, January 26, 2010
Khandwa - the challenges of Kalwa Part I
We had a breeze of a time hiring staff in Alirajpur. After interviewing over 60 women we were able to settle on 11 who had varying degrees of experience, but almost all whom are tribal, educated, and willing to work and live in the remote areas we're targeting.
Moving east to Khandwa, we experienced challenges and road blocks I never thought we would.
Khandwa, specifically its tribal block Kalwa, became notorious last year for malnutrition deaths, making headlines around the world and causing panic within the state government (see: http://www.nytimes.com/2009/03/13/world/asia/13malnutrition.html). This is the same district where UNICEF got in trouble for using RUTF in an attempt to save lives in response to those lost (see my former posting http://malnourishedmillions.blogspot.com/2009/09/rutf-and-its-absence.html).
I expected that moving into Khandwa we would find a lot of NGO action in the Kalwa block, where over 100 malnutrition deaths occurred within a 3 month span and where they still reportedly continue. We expected to, like other districts, tap into the NGO network to help us find staff and get the lay of the land, ruling out intervening in villages which are already covered by other NGOs. I was perplexed to find that there are hardly any NGOs working on the ground in Kalwa. Jhabua, Alirajpur, and Barwani districts are just as poor as Khandwa, but have 100s of NGOs. So many that NGO in-fighting is the best gossip in town. Khandwa, where the need is arguably higher, has hardly any.
We did find old friends, Spandaan, a grassroots NGO focusing on malnutrition awareness in the area, but who only have funding for interventions in a few model villages. The Khandwa Diocesan Social Society (KDSS), run by the Catholic church is the single most active non-governmental organization in the district providing education and health services but their reach in Kalwa is limited as well. As we spoke to these NGOs and government officials we discovered the reason for so few NGOs working in the Kalwa. Its really really difficult. Difficult to staff, difficult to travel to and from, and difficult to monitor.
We interviewed some great young women who lived in Khandwa’s center, among them staff from UNICEF’s now closed program in the district and despite the warnings from our friends in Khandwa, were optimistic about staffing our program. That is until we made our first field visits and realized the distances between Khandwa’s main town and Kalwa block. While I've visited Kalwa on numerous occasions, I was almost always riding in a jeep and only paying attention to the tragic stories I heard from locals on the way out to field sites, not assessing the distances from place to place with a program in mind. The drive from Khandwa’s center, where all the staff we interviewed are based, is 2 hours by jeep to just the center of Kalwa, 4 – 5 hours to many of the remote villages. Kalwa block is forested, spread out, and mostly inaccessible by roads. There is extremely limited to no bus connectivity. Since we cannot afford to provide jeeps or motorcycles to all our staff and bus connectivity is so poor, the only feasible way to work in this area we decided, is to staff our program with women living in Kalwa block itself.
We started our search by entering the bigger towns of Kalwa and began asking local contacts at PHCs, CHCs, and church mission stations (the only non-governmental organization in the region) to refer any 12th pass women who would be interested in our position. "12th pass?" the locals laughed incredulously. "There are no women who have 12th pass here". "Ok, 10th pass". More laughs. "Basic literacy?" "Hmmm, come back in a week and we'll see if we can find anything." Quite a strong indicator development indicator for this area.
In villages where we could find a literate woman willing to consider taking on our work, we hit our next obstacle. The tribal group of Kalwa block, the Kurkos, are an extremely shy and backward tribe, whose language, culture, and traditions have a rich, but isolated history. The women in this tribe typically do not venture far from home, let alone leave their villages. Many of the locals we spoke to told us we would have a hard time finding a literate, Korku, woman willing to travel to 5 neighboring villages let alone our goal of 10.
This staffing problem isn't an obstacle we just stumbled into. The district’s Chief Medicial Officer told me that they have a large number of ASHA and ANM posts vacant in Kalwa block and have had a very difficult time filling these postings (which require a 10th pass education).
Distances, lack of education, lack of mobility, little access to health care, no NGO presence. Every reason not to work in Kalwa block. And every reason we have to try.
While we were disappointed in not being able to staff our program in one swoop as we had done in Jhabua and Alirajpur, this is to be expected in an area this difficult. We placed a bunch of feelers out throughout remote villages, with plans to follow up on potential leads within a week.
Moving east to Khandwa, we experienced challenges and road blocks I never thought we would.
Khandwa, specifically its tribal block Kalwa, became notorious last year for malnutrition deaths, making headlines around the world and causing panic within the state government (see: http://www.nytimes.com/2009/03/13/world/asia/13malnutrition.html). This is the same district where UNICEF got in trouble for using RUTF in an attempt to save lives in response to those lost (see my former posting http://malnourishedmillions.blogspot.com/2009/09/rutf-and-its-absence.html).
I expected that moving into Khandwa we would find a lot of NGO action in the Kalwa block, where over 100 malnutrition deaths occurred within a 3 month span and where they still reportedly continue. We expected to, like other districts, tap into the NGO network to help us find staff and get the lay of the land, ruling out intervening in villages which are already covered by other NGOs. I was perplexed to find that there are hardly any NGOs working on the ground in Kalwa. Jhabua, Alirajpur, and Barwani districts are just as poor as Khandwa, but have 100s of NGOs. So many that NGO in-fighting is the best gossip in town. Khandwa, where the need is arguably higher, has hardly any.
We did find old friends, Spandaan, a grassroots NGO focusing on malnutrition awareness in the area, but who only have funding for interventions in a few model villages. The Khandwa Diocesan Social Society (KDSS), run by the Catholic church is the single most active non-governmental organization in the district providing education and health services but their reach in Kalwa is limited as well. As we spoke to these NGOs and government officials we discovered the reason for so few NGOs working in the Kalwa. Its really really difficult. Difficult to staff, difficult to travel to and from, and difficult to monitor.
We interviewed some great young women who lived in Khandwa’s center, among them staff from UNICEF’s now closed program in the district and despite the warnings from our friends in Khandwa, were optimistic about staffing our program. That is until we made our first field visits and realized the distances between Khandwa’s main town and Kalwa block. While I've visited Kalwa on numerous occasions, I was almost always riding in a jeep and only paying attention to the tragic stories I heard from locals on the way out to field sites, not assessing the distances from place to place with a program in mind. The drive from Khandwa’s center, where all the staff we interviewed are based, is 2 hours by jeep to just the center of Kalwa, 4 – 5 hours to many of the remote villages. Kalwa block is forested, spread out, and mostly inaccessible by roads. There is extremely limited to no bus connectivity. Since we cannot afford to provide jeeps or motorcycles to all our staff and bus connectivity is so poor, the only feasible way to work in this area we decided, is to staff our program with women living in Kalwa block itself.
We started our search by entering the bigger towns of Kalwa and began asking local contacts at PHCs, CHCs, and church mission stations (the only non-governmental organization in the region) to refer any 12th pass women who would be interested in our position. "12th pass?" the locals laughed incredulously. "There are no women who have 12th pass here". "Ok, 10th pass". More laughs. "Basic literacy?" "Hmmm, come back in a week and we'll see if we can find anything." Quite a strong indicator development indicator for this area.
In villages where we could find a literate woman willing to consider taking on our work, we hit our next obstacle. The tribal group of Kalwa block, the Kurkos, are an extremely shy and backward tribe, whose language, culture, and traditions have a rich, but isolated history. The women in this tribe typically do not venture far from home, let alone leave their villages. Many of the locals we spoke to told us we would have a hard time finding a literate, Korku, woman willing to travel to 5 neighboring villages let alone our goal of 10.
This staffing problem isn't an obstacle we just stumbled into. The district’s Chief Medicial Officer told me that they have a large number of ASHA and ANM posts vacant in Kalwa block and have had a very difficult time filling these postings (which require a 10th pass education).
Distances, lack of education, lack of mobility, little access to health care, no NGO presence. Every reason not to work in Kalwa block. And every reason we have to try.
While we were disappointed in not being able to staff our program in one swoop as we had done in Jhabua and Alirajpur, this is to be expected in an area this difficult. We placed a bunch of feelers out throughout remote villages, with plans to follow up on potential leads within a week.
Jhabua - Unlearning malnutrition?
Staff interviews - day 1, district 1, 70 women
In Jhabua we had the good luck that a prestigious organization has just shut down its three year malnutrition intervention in the district and we therefore had an excess of extremely qualified candidates coming out for our job interviews. These trained women joined dozens of others, with varied experience and qualifications, in our soon-to-be NRC, to interview for our 11 Jhabua posts.
The Jhabua group had done their homework and this made my day miserably boring. Every other woman who came in could recite the malnutrition workers' manifesto front and back, dropping all the key buzz words, but when asked to think of an original approach or to think critically about elements of nutrition programs, they were stumped. When we asked "what approaches don't work?" and "do you have any ideas that have never been done before about how to prevent malnutrition in the village?" - most women were silent.
Interestingly, and retrospectively predictably, some of the most interesting answers and ideas we received were from women with little background in malnutrition.
In selecting our staff now out of the many qualified and deserving women, we're faced with a dilemna. Do we chose the women with the most training and experience in malnutrition? Do we run the risk then of making all the same mistakes that their previous employer made before? Will we be able to get rid of these stale ideas and approaches that proved not to be effective in the field? Its not helpful to just read laundry lists of ideas to women in villages to educate them on malnutrition, we have to find ways to help to help turn awareness building into practical application. We need staff who will look for challenges and nuance, adapting and changing to what works and what doesn't.
Do we chose women who are untrained in nutrition but who have a keen sense of the communities and who can communicate any message? With fresh minds, will we finally be able to do something different in malnutrition and break the 30 years of 1% improvements in India? Or will our staff be overwhelmed and not prepared for this task even after our trainings?
In Jhabua we had the good luck that a prestigious organization has just shut down its three year malnutrition intervention in the district and we therefore had an excess of extremely qualified candidates coming out for our job interviews. These trained women joined dozens of others, with varied experience and qualifications, in our soon-to-be NRC, to interview for our 11 Jhabua posts.
The Jhabua group had done their homework and this made my day miserably boring. Every other woman who came in could recite the malnutrition workers' manifesto front and back, dropping all the key buzz words, but when asked to think of an original approach or to think critically about elements of nutrition programs, they were stumped. When we asked "what approaches don't work?" and "do you have any ideas that have never been done before about how to prevent malnutrition in the village?" - most women were silent.
Interestingly, and retrospectively predictably, some of the most interesting answers and ideas we received were from women with little background in malnutrition.
In selecting our staff now out of the many qualified and deserving women, we're faced with a dilemna. Do we chose the women with the most training and experience in malnutrition? Do we run the risk then of making all the same mistakes that their previous employer made before? Will we be able to get rid of these stale ideas and approaches that proved not to be effective in the field? Its not helpful to just read laundry lists of ideas to women in villages to educate them on malnutrition, we have to find ways to help to help turn awareness building into practical application. We need staff who will look for challenges and nuance, adapting and changing to what works and what doesn't.
Do we chose women who are untrained in nutrition but who have a keen sense of the communities and who can communicate any message? With fresh minds, will we finally be able to do something different in malnutrition and break the 30 years of 1% improvements in India? Or will our staff be overwhelmed and not prepared for this task even after our trainings?
the challenges of finding the right staff
Back to writing after a long hiatus filled with wrapping up 2009, starting up 2010 and even taking 2 days off!
Over the past two weeks I've been hard at work, banging my head against the wall at times, trying to scale-up our malnutrition program from one district, Jhabua, to 500 villages throughout 5 districts in Southwest Madhya Pradesh, Jhabua, Alirajpur, Khandwa, Khargone, and Barwani. This includes not only the standard, but painful process of getting the proper government permissions, streamlining financials, and finalizing training curriculums, but also the daunting task of hiring 55+ people to work with us on the ground.
We're excited about hiring our new staff, especially since most will be from the communities in Southwest MP who we're trying to help, so we will not only be serving communities with malnutrition identification, treatment, and prevention, but will also be empowering and uplifting cool local women.
Over the next series of entries I will write about the challenges, some predicted, but many unexpected of bringing on new local staff into a nutrition program
Over the past two weeks I've been hard at work, banging my head against the wall at times, trying to scale-up our malnutrition program from one district, Jhabua, to 500 villages throughout 5 districts in Southwest Madhya Pradesh, Jhabua, Alirajpur, Khandwa, Khargone, and Barwani. This includes not only the standard, but painful process of getting the proper government permissions, streamlining financials, and finalizing training curriculums, but also the daunting task of hiring 55+ people to work with us on the ground.
We're excited about hiring our new staff, especially since most will be from the communities in Southwest MP who we're trying to help, so we will not only be serving communities with malnutrition identification, treatment, and prevention, but will also be empowering and uplifting cool local women.
Over the next series of entries I will write about the challenges, some predicted, but many unexpected of bringing on new local staff into a nutrition program
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