Working with Most Marginalized C o m m u n i t i e s f o r S o c i a l Accountability and Equity:

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1 Transforming Lives: Sustaining the Improvement of Family Health and Sanitation in Marginalized Communities Parivartan: Bihar Community Mobilization Project Improvement of maternal and child mortality and morbidity outcomes, in a high-burden state like Bihar, are critical for India and its ability to achieve its goals of contributing to Millennium Development Goals (MDG) 4 and 5. To this end, the Bill and Melinda Gates Foundation (BMGF) supported the Ananya initiative and partnered with the Government of Bihar (GOB) to accelerate improvements in a broad range of priority health outcomes emphasizing, maternal, neonatal and child health (MNCH); nutrition; key infectious diseases; and sanitation and hygiene. Within Ananya, Project Concern International (PCI) in partnership with PATH and the Foundation for Research in Health Systems (FRHS) is implementing a community mobilization and social accountability grant (Parivartan). Parivartan provides a platform for empowering 8 high innovation districts to engage in processes that catalyze support networks and enable a shift in behavior and social norms, which contribute to improved and sustainable health and sanitation outcomes in Bihar. Promoting Behavior Change on Key Health and Sanitation Behaviors: Parivartan mobilizes, organizes, and builds community groups in Biharwith a focus on: a) strengthening their ability to shape social norms, promoting behavior change, and driving demand for services critical to maternal and child health, sanitation and hygiene; b) strengthening accountability and monitoring mechanisms through community structures for health, sanitation, and welfare services and schemes to advance equity and service access and; c) establishing sustainable institutional structures and frameworks to support the state-wide scale up of community mobilization interventions focused on maternal, neonatal, child health and sanitation (MNCHS). Working with Most Marginalized C o m m u n i t i e s f o r S o c i a l Accountability and Equity: P a r i v a r t a n w o r k s w i t h t h e m o s t marginalized communities to address equity issues related to caste, gender, and other social variables, which can be determinants of MNCHS outcomes. Providing Linkages for Sustainability and S c a l e : F u r t h e r m o r e, P a r i v a r t a n i s collaborating with the Bihar Rural Livelihood Project (Jeevika)-to create a sustainable scale up across the state, and provides support to 8,000+ matured Jeevika community groups (see Page 5, on how Parivartan has collaborated with Jeevika) Health and Nutrition, My Right.. A story on how women in a village in Samastipur submitted an application to demand the opening of an Anganwadi Center in their area..page 7

2 2 OUTREACH Parivartan reaches out to 280,000 women in reproductive age group (WRA) through 18,000 groups in approx community 2,250 villages. These groups are supported by 2,600 Mobilizing Most Sahelis. Patna Samastipur Begusarai Khagaria Saharsa West Champaran East Champaran Gopalganj Marginalized Parivartan is currently working in 64 blocks from within 8 high innovation d i s t r i c t s i n B i h a r, n a m e l y : P a t n a, Begusarai, Samastipur, East Champaran, West Champaran, Gopalgunj, Khagaria, and Saharsha (See map on the left-hand side). These blocks were selected using a vulnerability index, calculated based on three indicators: percent of Scheduled Castes and Tribes (SC/ST) population in a block, literacy rates among women, and proneness to flooding. Of the 64 blocks, 43 are designated as B-50 (bottom-50) and 21 as T-50 (top-50). B-50 blocks are those where the percentage of the SC/ST population is high, female literacy rates are low, and the areas are more disaster-prone. In these blocks, Parivartan created 18,000 community groups in more than 2,250 villages. Each community group typically contains women of reproductive age group. Each village has approximately 5-6 community groups According to the 2011 Census, Bihar (the 3rd most populous state in India with a population of million) has the highest decadal population growth rate at 25. Bihar has 23 castes under the SC category, constituting 16 percent of the total population. Among these, Chamar and Dusadh constitute about 60 percent of the SC population. Four other castes: Musahar, Pasi, Dhobi and Bhuiya constitute an additional 30 percent combined. The remaining 17 castes constitute about 8 percent of the SC population. Paswan is one of those smaller castes. They are now referred to as the "creamy layer" meaning that they are economically better off (relative to the other castes) because of the political patronage they have received. As a result, there was a political move to create a group called Mahadalit (In Bihar, the term Dalit is used to denote all SC) excluding Paswans from the Dalit i.e. SC category. The Mahadalit Commission was formed to serve the needs of the Mahadalits (excluding the Paswans). The Parivartan project, however, remains focused on all SC (Dalit) including Paswans who form a very small percentage of the SC population and the Pasmunda Muslims

3 3 At the grassroots level, Sahelis (village volunteers) act as catalysts of change and play a critical role as conduits of information for the target women. These Sahelis were selected from among the women in the target communities with a basic level of education, leadership and communication skills, and a willingness to work on the project. These Sahelis are being trained (on an ongoing basis) on communication and leadership skills and key maternal and child health and sanitation related issues. Sahelis conduct community discussions on 12 key maternal and child health and sanitation related behaviors within community groups. Sahelis uses various tools such as picture cards, stories, games etc. to initiate and moderate discussion in the community group. Master Trainers District Resource persons A team of 8 District Resource Persons (DRPs) and 140 Master Trainers (MTs) were recruited. These DRPs and MTs not only conduct district trainings, they also visit field sites to observe Sahelis conducting community group meetings. MTs use a standardized checklist to assess the skills and performance of Sahelis. This checklist captures data on the quality of the trainings by Sahelis. The monitoring tools assess the Sahelis communication skills, the engagement of training participants, the Sahelis handling of training materials, and participant learning as evaluated by pre- and post-training test scores. Based on analysis of the scores, Sahelis are categorized into three categories as per their performance level. Sahelis Performance Assessment Criteria Preparation/operation } Preparation and assessment of target audience } Developing learning tools } Testing learning tools } Execution of learning tools/roll out Confidence } Perceived confidence to deliver the training at the field - before and after. Learning } Retention of the information/ knowledge, increase in knowledge from before to after the learning experience: Skill and Performance } Communication skills } Use of Information material } Message delivery } Involving women in discussions } Response to quires } Feedback from the trainee } Women attention retention Challenges and opportunities } Experiences of difficult situations and the role of training in overcoming these situations Sahelis Sahelis Performance and Skill Monitoring System Group Members Structured interview } Basic information of trainees } Identification } Social profile } Perception } Confidence } Knowledge and learning Obervation } Preparation } Skills } Application of knowledge A team of 140 Master Trainers train Sahelis on ongoing basis, and provide onsite hand-holding and technical assistance 1 One time information 2 During training 3 On the job Quantitative data is collected in pre coded structured tool on monthly basis

4 Snapshot of Parivartan Modules Parivartan Compendium The Parivartan Compendium consists of thirteen training modules pertaining to antenatal care, birth preparedness, postpartum and newborn care, exclusive breastfeeding, complementary feeding, routine immunization, postpartum family planning, sanitation, village entry, group formation, equity, social advocacy, and a cc o u n t a b i l i t y. T h e m o d u l e s w e r e developed by the Parivartan core team, which included members from PATH and PCI. The core team worked on the content, language, methodology for disseminating messages, and the collective action (to be undertaken by the group members to ensure behavior change and facilitate service access). The team did a literature review of the technical content, tested the appropriateness of the messages in the context of Parivartan groups, developed messages with other Ananya grantees (such as CARE and BBC Media Action), and finalized the modules. 4 The modules are used to train community group members through community cadres. It is expected that after receiving training, community members (particularly pregnant and lactating women) will practice appropriate behavior related to maternal and child health, nutrition, and sanitation and access health services from nearby facility and service platforms. The Equity and accountability modules are designed to generate community demand and make service providers and institutions, such as Integrated Child Development Scheme (ICDS) and health facilities, accountable. The village entry and group formation modules have been helpful with establishing rapport and in mobilizing communities to form groups in about 2300 villages in the 64 blocks of the eight Parivartan intervention districts. The group formation modules are introduced to form groups in line with the Jeevika concept. The group formation modules have been developed in line with Jeevika modules so that Parivartan groups can easily be transitioned into the Jeevika fold.

5 5 Parivartan has signed a Memorandum of Cooperation (MOC) with Bihar Rural 1 Livelihoods Promotion Society (BRLPS), for health and sanitation integration with BRLPS project Jeevika (Bihar Rural Livelihoods Project). Jeevika aims at enhancing the social and economic empowerment of the rural poor in Bihar by creating self-managed community microfinance institutions or self-help groups (SHGs) at the village level and enhancing income through sustainable livelihoods. Parivartan will help Jeevika to advance a health, nutrition, water and sanitation agenda within their community institutions. Parivartan is focusing on the process wherein all the Parivartan promoted c o m m u n i t y g r o u p s w i l l b e c o m e incorporated into the Jeevika framework with the retention of the ongoing Health and Sanitation Agenda. The transition process, initiated in the month of August 2013, would aim to cover all 18,000 community groups by June H o w e v e r, b e f o r e g r o u p s c a n b e incorporated within Jeevika, Parivartan has to work towards nurturing groups to practice five essential elements, (Panchsutras) as prescribed by Jeevika, namely: (1) weekly meetings, (2) weekly savings, (3) inter loaning, (4) timely repayment of loans, and (5) book-keeping at the group level; in addition to educating group members on health, nutrition and sanitation behaviors Working Collaboratively with Jeevika Joint Planning Exercise: Transitional process of the Parivartan Groups into the Jeevika project has been initiated. For this, the Parivartan and Jeevika teams had a joint planning exercise that included the mapping of the groups and clarifying the roles and responsibilities of Parivartan and Jeevika staff at the state, district, and block level. Joint Capacity Building Activities: Parivartan and Jeevika have been jointly implementing capacity building initiatives. As per this, Parivartan trained 120 of Jeevika s Sahelis while Jeevika supported the training of the Parivartan s Block and Community Coordinators. A Total of 873 coordinators were trained on group formation and PanchSutras. Specific input was given on maintaining the books of accounts and record keeping. Supporting Bookkeeping - Jeevika has committed to support Parivartan promoted groups to equip them with books for record keeping and accounting. This will help the community to streamline financial records and facilitate in opening bank accounts. Sharing Modules: Jeevika has supplied SHG modules to Parivartan, which emphasize the formation of SHGs, the importance of Panchsutras, and institutional building. Community Resource Person (CRP) drive- Jeevika is organizing a CRP drive, within Parivartan areas, to strengthen institutional building among Parivartan groups and provide inputs on the importance of financial services available for the community groups. The Community Coordinators and Sahelis will be working very closely with the Community Mobilizers and CRPs.

6 6 Monitoring, Learning and Evaluation MIS REGISTERS AT GROUP LEVEL Group Attendance Registers Each group maintains basic SHG registers such as meeting and attendance registers. Now, as per the transition plan, saving registers are being introduced at the group level. GSAP- Group Service Access Platform To monitor and report on outcome indicators, information is collected on group members using the12 key maternal and child health indicators at the group level and reported through a web based Management Information System (MIS) portal. Data Validation Process Parivartan s MIS team undertakes a validation exercise in close coordination with the program team to validate the MIS data and report on a monthly basis Baseline Survey Results: Parivartan s baseline survey is complete and key results and recommendations for each of the twelve family health and sanitation b e h a v i o r s h a v e b e e n p r e s e n t e d. Furthermore, the baseline study also recommended actions for strengthening community mobilization, which is the key mechanism through which Parivartan seeks to bring about an improvement in maternal and child health and sanitation behaviors among the most marginalized women in rural Bihar. The data has been disaggregated a t t h e d i s t r i c t l e v e l t o d e v e l o p recommendations for implementation MIS Outcome Indicators Tracking: Parivartan is currently working on finalizing a mechanism to track 30 outcome indicators on a quarterly basis. Of these, 12 would get collected through project MIS. The GSAP registers have been modified at the grassroots level, staff have been trained on data collection, and reporting on the 12 outcome indicators will begin as of Oct Furthermore, a system is being finalized for the collection of 18 additional outcome indicators K n o w l e d g e M a n a g e m e n t Framework: Parivartan drafted a knowledge management framework, which outlines the strategy for building a system of knowledge transfers for the Project. The goals are to synthesize knowledge by connecting various stakeholders with a focus on the community and to improve organizational learning by assessing impact. Linking Data to Google Map: In August, Google volunteers helped the Parivartan team to link the Excel based Parivartan database with google maps. Web Based Parivartan MIS Portal Parivartan created a web based portal, to enable direct data entry at the district level by implementing NGOs. The data is then collated for project level analysis. In addition, the web portal contains information on all group members involved in the project, including socioeconomic and personal details such as age. The s ite also contains database information on Sahelis and the grassroots cadre of Parivartan Scan the following barcode to go to

7 7 Collaboration with Bihar Mahadalit Vikas Mission Since Parivartan works closely with the most marginalized communities, it is working closely with the Bihar Mahadalit Vikas Mission to link the Mahadalit communities with basic services and empower them socially, economically, and culturally to ensure their participation in developing a strong society. Parivartan established partnerships with the Bihar Mahadalit Vikas Mission and coordinated to link the community groups with the schemes promoted by the Mission. This will be a valuable addition to the community groups especially from a health and sanitation related input. From the long menu of the schemes Parivartan is initially focusing on: 1. Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) cards & Smart Cards 2. Mahadalit Toilet Construction Scheme 3. Mahadalit Anganwadi 4. Mukhyamantri Nari Jyothi Program 5. Mobile Public distribution system 6. Construction of Community Hall/ Work Shade Intensive efforts are being made to link the community groups with the abovementioned schemes. The response from the departments is very encouraging. The Principal Secretary has issued letters to all districts for supporting the Parivartan team. The Joint Response Plan is being developed at the block level after arranging interface meetings with the community cadres of Parivartan and the Mahadalit Vikas Mission. Strengthening Village Health, Nutrition and Sanitation Committees PCI has initiated efforts to analyze the functional status of Village Health, Nutrition and Sanitation Committees (VHSNCs) and work to help them effectively address the health needs in the village level health plan developed by the VHSNC at the Revenue village level. With the above mentioned objective, PCI has entered into a service agreement with Praxis to work towards strengthening the functionalities of VHSNCs among the 8 priority districts in Bihar, covered under the Ananya Program, as a strategy towards effective community-led action for better health outcomes. Health and Nutrition Services, my right Mala Devi, member of the Radha Community Group, Samastipur district, shared her tragic story: Despite already having 4 children, I became pregnant once again and delivered a low birth weight baby having only 2 kg of weight. The baby died within one month because of poor nourishment as I was very weak and unable to produce enough milk and there was no AWC (Aanganwadi Centre) in my ward of residence to get nutrition supplementation. Since I come from a Dalit community, neither the ASHA [Accredited Social Health Activist], nor the Aangandwadi Worker provided me with any services nor counseled me for family planning and it was quite difficult to benefit from AWC facilities about 1 km away from my residence. After associating with the Radha group, under the Parivartan program, I came to know that we are entitled to seek help from AWC facilities. I feel that I wouldn t have experienced the tragedy if I had had proper access to the AWC. Hence, we the members of the Radha group have approached the Child Development and Protection Officer (CDPO) to request for the opening of an AWC in our ward with a population of about 1100 people (consisting mainly of Dalit/Mahadalit communities). We are firmly determined and will continuously work to get this center opened in our ward so that my story won t be repeated with any of our community members.

8 8 Parivartan Partners P C I i s t h e L e a d P a r t n e r a n d r e s p o n s i b l e f o r overall program implementation and compliance with Bill and Melinda Gates Foundation (BMGF) grant requirements. PCI also serves as a clearinghouse and synthesizer of lessons learned and promising practices. PCI leads the c o m m u n i t y - b a s e d a c t i o n b e i n g implemented by 8 local NGOs, focusing on district-wide interventions to foster and strengthen community groups and community-based actions (CBA). PATH serves as the Technical Advisory Partner, leading the efforts related to: learning, the transfer of learning for sustainability and scale up (KAT stream), and the collaboration with MLE partners to document and disseminate knowledge and learning. PATH advises and guides the CBA stream on proven models and interventions, such as Sure Start, assimilating knowledge and learning and transferring lessons and best practices to stakeholders to achieve sustained impact across Bihar. For Further Information, please contact: Parivartan Project Office Dr Vikas Aggarwal Chief of Party, Parivartan Nirmal House 2 & 3rd Floors, Nalanda Nagar,I.E.Road, Kurji, Patna, Bihar Tel: /12 Fax: vikas@pciindia.org PCI India Country Office Edward Scholl Country Director C32, Panchsheel Enclave, New Delhi Tel: Fax: escholl@pciindia.org PCI International Office Janine Schooley Senior Vice President 5151 Murphy Canyon Road, Suite 320 San Diego, CA Office: , ext 311 jschooley@pciglobal.org FRHS functions as the Implementing Partner for Research, and focuses on implementing operational research pilots at select villages for strengthening community groups Parivartan Information Booklet PCI Main Contributors: Vikas Aggarwal, Dr. Nirmala Murthy, Rajshree Das, Sanjeev Bhanja, Brijesh Rao and V J Rao. Editors: Ed Scholl and Jennifer Keller Photo Credits: Ed Scholl, Janine Schooley, Vikas Aggarwal, Rajshree Das and Brijesh Rao Design and Concept: Vikas Aggarwal and Ajith Kumar