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.
Saturday, February 13, 2010
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
Wednesday, December 2, 2009
Malnutrition - over and under
While the correct definition of malnutrition is insufficient, excessive, or imbalanced consumption of nutrients, in this blog I almost always refer to the under-nutrition of malnutrition. I'm admittedly only covering one side of the issue, even though over-nutrition, obesity, is a huge and growing (pun intended) problem around the world. All malnutrition is dangerous to health and can lead to serious short-term and long-tem problems.
In India while under-nutrition affects the most people, over-nutrition is of serious concern as well, almost exclusively affecting upper classes.
A new study has been released today in which data from approximately 40,000 men and 60,000 women in Mumbai was analyzed and it was determined that nearly 1 in every 5 men and women were underweight at the same time that another 1 and 5 men and 30% of women were overweight. Thinness was associated with low levels of education while heaviness was associated with higher levels of education. Here's a link to the study: http://www.id21.org/health/h3hs2g1.html
Here are some more statistics from the National Family Household Survey III which I found illuminating on the malnutrition status of Indians:
In India while under-nutrition affects the most people, over-nutrition is of serious concern as well, almost exclusively affecting upper classes.
A new study has been released today in which data from approximately 40,000 men and 60,000 women in Mumbai was analyzed and it was determined that nearly 1 in every 5 men and women were underweight at the same time that another 1 and 5 men and 30% of women were overweight. Thinness was associated with low levels of education while heaviness was associated with higher levels of education. Here's a link to the study: http://www.id21.org/health/h3hs2g1.html
Here are some more statistics from the National Family Household Survey III which I found illuminating on the malnutrition status of Indians:
- -Nationally, 45% of children under three are stunted, 40% are underweight, and 23% are wasted
- 79% of children in India are anemic - risk for anemia is almost the same for wealthy and poor households
- only 28% of children received any services at anganwadi centers in the past year (even though coverage is reported at 62%)
- 33% of women and 24% of men are vegetarians
- the highest prevalence state for obesity in women is Punjab followed by Delhi and Kerala - obesity is on the rise in wealthly women and Sikh women
- 41% of women in rural areas are underweight and 25% of women in urban areas are underweight
- 7% of women in rural areas are overweight and 24% of women in urban areas are underweight
- the more education a woman has, the more likely she is to be obese - 7% of women with no education are obese, compared to 24% of women with more than 12 years of education. same goes for wealth
Monday, November 30, 2009
Malnutrition Exaggerated
http://www.hindu.com/2009/11/28/stories/2009112857052000.htm
An article recently came out in the Hindu which claims that 25 children died from malnutrition in the month of October in just two villages in the Meghnagar district of MP. The deaths are attributed to malaria, anemia, and malnutrition.
The article then goes on to site malnutrition figures from around the state, but gives no clear evidence or authority for the deaths in Jhabua. The author is accusatory of government officials being complacent and the anganwadi system failing.
While I'm usual right on board with many of these criticisms and believe that journalist have an important role in highlighting situations like this, unfortunately I have to say that this article is wrong, and irresponsible journalism.
Meghnagar is our main district in Jhabua. We have health workers and a wide network of contacts throughout the district. When a child has SAM we usually know, when a child dies, we almost always hear. So far in the past month we've recorded 4 children dying from malnutrition. This is a number that has been confirmed by the Joint Director of Health for the area. I consider even 4 children's deaths due to malnutrition alarming. This should be enough to make newspaper headlines and to pressure government officials and social organizations to act.
But creating a panic and over-reporting the problem can cause a negative backlash. More time gets spent investigating and proving the allegations wrong then actually fixing the root of the problem.
We'll try our best over the next few days to further look into these claims to ensure that, God-willing, this article has exaggerated the situation.
An article recently came out in the Hindu which claims that 25 children died from malnutrition in the month of October in just two villages in the Meghnagar district of MP. The deaths are attributed to malaria, anemia, and malnutrition.
The article then goes on to site malnutrition figures from around the state, but gives no clear evidence or authority for the deaths in Jhabua. The author is accusatory of government officials being complacent and the anganwadi system failing.
While I'm usual right on board with many of these criticisms and believe that journalist have an important role in highlighting situations like this, unfortunately I have to say that this article is wrong, and irresponsible journalism.
Meghnagar is our main district in Jhabua. We have health workers and a wide network of contacts throughout the district. When a child has SAM we usually know, when a child dies, we almost always hear. So far in the past month we've recorded 4 children dying from malnutrition. This is a number that has been confirmed by the Joint Director of Health for the area. I consider even 4 children's deaths due to malnutrition alarming. This should be enough to make newspaper headlines and to pressure government officials and social organizations to act.
But creating a panic and over-reporting the problem can cause a negative backlash. More time gets spent investigating and proving the allegations wrong then actually fixing the root of the problem.
We'll try our best over the next few days to further look into these claims to ensure that, God-willing, this article has exaggerated the situation.
Wednesday, November 4, 2009
New "Community Kitchen" scheme launched in MP
http://www.thaindian.com/newsportal/politics/scheme-to-tackle-malnutrition-launched-in-madhya-pradesh_100269553.html
Today we went to visit the anganwadi center in Umri, a town close to Jhabua's district center but rife with malnutrition. When I asked the anganwadi the standard question about the supplements she was providing to the children, she led me around to the back of the school adjacent to the center to a smoke-filled kitchen. The room was so poorly ventilated that I couldn't see without squinting and couldn't stand in the room without holding my breath, but through red eyes, I was able to see a delicious looking pot of dal and fresh rotis being cooked on a skillet.
The three women who braved these kitchen conditions were part of a newly formed local self-help group (SHG) who are now in charge of making the meals for the anganwadi center and the elementary school next door.
This is part of the Chief Minister's new solution for malnutrition, Sanjha Chulha, creating community kitchens to prepare full, hot meals as midday meals and anganwadi supplements instead of pre-packaged foods.
First week on, things seem to be going pretty well. The former system, which relied on many centrally located self-help groups to prepare ready-made food, was problematic and rife with corruption. I often saw wheat meant for schools on sale at the market. Common were stories of SHGs who made substandard food and profited from their economy. Anganwadis, who are already overburdened with responsibilities in health, nutrition, and education, spent large portions of their days cooking. There is plenty room for corruption in this model as well, but at least there will be more visibility and accountability will be placed with the community. While communities aren't always the best monitors or good at demanding the services they deserve, they're more reliable than a hand full of government inspectors and monitors. This will also provide a small income to women in the community (many mothers of small children themselves) and will foster greater community involvement in the centers.
While I don't agree that this program is revolutionary, nor will it greatly affect the incidence of severe acute malnutrition (those kids aren't going to the anganwadi centers), this is certainly a great concept and an improvement to the system.
Today we went to visit the anganwadi center in Umri, a town close to Jhabua's district center but rife with malnutrition. When I asked the anganwadi the standard question about the supplements she was providing to the children, she led me around to the back of the school adjacent to the center to a smoke-filled kitchen. The room was so poorly ventilated that I couldn't see without squinting and couldn't stand in the room without holding my breath, but through red eyes, I was able to see a delicious looking pot of dal and fresh rotis being cooked on a skillet.
The three women who braved these kitchen conditions were part of a newly formed local self-help group (SHG) who are now in charge of making the meals for the anganwadi center and the elementary school next door.
This is part of the Chief Minister's new solution for malnutrition, Sanjha Chulha, creating community kitchens to prepare full, hot meals as midday meals and anganwadi supplements instead of pre-packaged foods.
First week on, things seem to be going pretty well. The former system, which relied on many centrally located self-help groups to prepare ready-made food, was problematic and rife with corruption. I often saw wheat meant for schools on sale at the market. Common were stories of SHGs who made substandard food and profited from their economy. Anganwadis, who are already overburdened with responsibilities in health, nutrition, and education, spent large portions of their days cooking. There is plenty room for corruption in this model as well, but at least there will be more visibility and accountability will be placed with the community. While communities aren't always the best monitors or good at demanding the services they deserve, they're more reliable than a hand full of government inspectors and monitors. This will also provide a small income to women in the community (many mothers of small children themselves) and will foster greater community involvement in the centers.
While I don't agree that this program is revolutionary, nor will it greatly affect the incidence of severe acute malnutrition (those kids aren't going to the anganwadi centers), this is certainly a great concept and an improvement to the system.
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