“Preventing malnutrition in 1000 tribal villages in Kandhmal district, Odisha”

Atmashakti works in the state of Odisha, home to 42 million people, which unfortunately has the dubious distinction of consistently being ranked in the bottom three of India’s 29 states. The state has a large population of indigenous people (tribals), accounting for almost a quarter of the population. These communities live in small remote villages/hamlets, whose average size often does not exceed 50 families. Literacy levels are under 50%, but what most is disturbing is the fact that malnutrition and stunting in children in the under 5 age group is more than 50%. The causes of this malady are multiple but the main ones are

• Dietary problems with the mothers pre and post-partum
• Poor hygiene and sanitation conditions
• Inadequate availability of safe drinking water
• Lack of availability of any primary medical care close to the habitations.

 

We believe in empowering the community to be able to tackle issues on their own strengths and to facilitate this we are seeking your help to work in 1000 villages in Kandhmal district of Odisha. Through a process of community education and mobilization we will cover the following activities in the next three years, which will ameliorate the current dismal scenario.

1. Conduct water testing of the drinking water source(open wells, tube wells, streams, ponds etc) and through a process of collective action ensure that the local administration remedies deficiencies in the current situation
2. The govt. has a scheme called ‘Integrated child development services’ (ICDS) which is supposed to provide pregnant and lactating women with supplementary food, and a crèche to look after 0-3 years children. In practice this is mainly dysfunctional and does not cover the smaller hamlets/villages. We will through people’s pressure make this service more efficient.
3. In addition we will promote the growth of vegetables and fruit, through individual/community kitchen gardens, to supplement the largely carbohydrate diet of rice.
4. Most households do not have or use toilets, and we will work on behavioural change to encourage this practice as also hygiene for the families.
5. Most importantly, we will provide training for setting up primary health kits at the village/hamlet level to provide immediate succour for emergencies such as high fever, dysentery, cuts and wounds etc. Simultaneously we will work to ensure that the Government run primary health care centres function more efficiently and regularly.

 

Overview of Our intervention Through Health Kit formation

1. Introduction

Kandhamal is a district in the state of Odisha. Approximately 71% of the land in the district is covered by forest. It is quite difficult for people from the hilly terrains to access medical facilities as Public Health Centers are far from remote villages and private health system is almost absent in the district. Hence, even for the most basic treatment or medicines, people need to travel long distance giving up their entire day’s wage or labour. Moreover, lack of knowledge of basic preventive medicine and it’s usage further adds to the deterioration of health of the patients in tribal belts. Initiative in health has been one of the strategies to fervently address the issues of malnutrition, unemployment, health, education, infrastructure and other problems through the Sangathan’s approach.

The Health Kit is a programme where basic preventive medicine would be given to the community by the trained village based Swasthaya Sathi (Health worker). The programme was initiated in 2014 in Daringibadi block of Kandhamal district as a pilot study. After 2 years of experimentation and success, it was extended to 3 other blocks, Kotagarh, Baliguda & Tumudibandh. Now the intervention is active in a total of 4 blocks of Kandhamal.The broader objective behind the initiative was to locally sustain it by community contribution and active participation.

2. Area of Operation-

Currently we are working in 4 blocks of Kandhmal district in Odisha namely, Daringibadi, Kotagrah, Baliguda, Tumudibandh. Currently we have formed health kits in 65 gram panchayats of 4 blocks and working with 141 villages

1. Why Kandhmal

Kandhamal is often known for the lack of trained medical help during deliveries, low birth weight, poor nutritional conditions of mother and children and poor post-natal care. The main causes of children death includes diarrhoea, respiratory infection and measles which are curable with access to safe drinking water and basic curative measures.

The age at marriage is a strong determinant of Reproductive and Child Health (RCH). It was found from the primary survey that 16.2 percent women got married at less than 18 years of age. The District Level Household & Facility Survey (DLHS) & RCH data, however indicates that 29.2 percent girls are married before completing 18 years of age.

 

Odisha – Kandhamal   – Infant & Child Deaths – Apr’13 to Mar’14
	Infant Deaths within 24 hrs of birth	Infant Deaths between 24 hrs & under 1 week	Infant Deaths between 1 week & under 1 month	Child Deaths between 1 month & under 1 year	Total Infant Deaths	Child Deaths between 1 yr & under 5 years	Total Deaths
Total Reported	19	165	101	129	414	50	464
% against total deaths	4.1%	35.6%	21.8%	27.8%	89.2%	10.8%

 

Odisha – Kandhmal  – Causes of Infant & Child Deaths – Apr’13 to Mar’14 –  Total Deaths – 445
Sepsis			Asphyxia			LBW (Low Birth Weight)
Up to 1 Week of Birth	Between 1 week & 4 weeks of birth	Total	Up to 1 Week of Birth	Between 1 week & 4 weeks of birth	Total	Up to 1 Week of Birth	Between 1 week & 4 weeks of birth	Total
5	8	13	37	9	46	84	45	129
Pneumonia			Diarrhoea			Fever related
Between 1 month and 11 months	Between 1 year & 5 years	Total	Between 1 month and 11 months	Between 1 year & 5 years	Total	Between 1 month and 11 months	Between 1 year & 5 years	Total
40	8	48	1	0	1	7	3	10
Measles			Others ( For age up to 4 weeks of Birth)			Others( For age from 1 month to 5 yrs)
Between 1 month and 11 months	Between 1 year & 5 years	Total	Up to 1 Week of Birth	Between 1 week & 4 weeks of birth	Total	Between 1 month and 11 months	Between 1 year & 5 years	Total
–	–	–	39	39	78	81	39	120

3. Key focus of intervention

 

• Formation and Promotion of Health Kit
• Promotion of Nutrition Kitchen garden
• Promotion of Herbal Kitchen garden
• Demand generation for livelihood promotion through Government schemes and Programmes
• Activation of service delivery point
• Targeting entire population to prevent problems and to promote health & wellbeing for all
• Educate people in the community, men, women, children & adolescent girls about health

 

4. Objective of the intervention 

• The primary focus is to reduce malnutrition in the affected areas through awareness and orientation.
• To open community health kit to provide basic & immediate health services through villager’s contribution.
• To bring behavioural change in terms of using toilets, hand washing, drinking boiled water, using mosquito net and eating habits.
• To promote kitchen garden at village level to curb malnutrition.
• To promote herbal garden and to revive and promote the use of traditional medicinal practices
• To empower women by building up strong women Sangathan to monitor food and nutrition issues.
• To activate Government Stakeholders such as ASHA, ANM & ICDS workers and to regularize the public service delivery systems.
• To facilitate the villagers to avail various Government schemes related to health.
• To initiate a locally sustainable model through community contribution, ensure active participation and involvement of primary stakeholders.
• To link the communities to the state and central government health schemes and entitlements.

5. The Process of Implementation

After several round of meetings and discussions with the field team and community leaders the potential villages were identified. One of the main criteria in identifying villages for the Health Kit was the location and remoteness of the village and their accessibility to health centers. The team was oriented on how to conduct the survey format and the process of filling up the survey form.

After the orientation, a detailed field survey was conducted in the selected villages by the Jan Sathis. Alongside with the survey, the Jan Sathis also ascertained any health-related issues/status of the identified villages, for example, type of diseases prevalent in the village, type of medicines used, availability of medical services, approximate expenditure of households on medicines etc.

After completing the survey, the findings were documented and compiled for a detailed analysis. The findings were shared with the communities, following which village level committees (VLC) were formed and community contribution started for the procurement of the Health Kit. A resolution was passed by the VLC stating their willingness and approval for the start of the Health Kit and the VLC taking full responsibility of the running of the Health Kit programme.

At the same time, 2 Swasthya Sathis, a male and a female were identified and selected from each village. The goal to have Swasthya Sathis from both genders was to ensure that everyone in the village was comfortable to come forward to talk to either one of them, thereby ensuring more inclusiveness & reach of the programme. The Swasthya Sathis selected were to be from the same village and should be a resident of the village for more than 90% of their time. They were also expected to have basic reading & write skills.

Once selected, the Swasthya Sathis were trained and oriented on basic knowledge & skill sets on general health problems (syndromic treatment), maintenance of register, usage of general medicines as per age groups, information on good food habits, water & sanitation practices etc at the community level. The Swasthya Sathis were further trained on how to enter records in the register of the villagers coming in for treatment, give general medicines as per the ailments, and collect the basic cost of the medicine from the villagers at the time of disbursement. They were instructed not to repeat the medicines twice in case of no improvement and to refer the villagers for immediate medical check-up to higher medical facilities.

After the orientation, medicines were purchased from the medical stores and the Health Kit was started.

To support and monitor the Swasthya Sathis, one Health Animator was appointed for every block. The responsibility of the Health Animator was to follow up with the Swasthya Sathis on regular intervals for proper maintenance of the Register and to ensure that medicines were made available to the villagers.

6. Major Milestone

• Initially we started working in 1 Block but now our work has expanded to 4 Blocks
• Out of 635 villages, we have presence in 440. The remaining 195 villages are to be covered in the coming days
• Till now, 186 Health Kit have been formed, based on 100% community contributions. This number is inclusive of the 61 Health Kit which was formed in both blocks during the period April to July, in the first year of our intervention. Creation of many more Health Kit are in the pipeline
• Swasthya Sathis were selected in consultations with Sangathan members followed by collection of resolutions
• Health Kit usage & maintenance training given to 104 Swasthya Sathis. In the later part of the programme, in house training will be imparted to all team members
• 43,590/- was collected from the community for the formation of Health Kit, 799 families contributed from 51 villages
• Health Kit updates were collected from 99 Health Kit and medicines were refilled 39 times
• During this period 1658 persons from 1373 households benefitted from the Health Kit
• Indirectly able to save pocket money Rs.331.600/- through this interventions of the community members. (1658H.H @ Rs.200/-) Minimum
• Development of 2 Model Garden in both blocks to grow different plants
• Completed baseline survey on usages of IRON tablets & report submitted
• Collected profile of 45 different stakeholders and data shared
• Consultations with all Asha , Anganwadi workers & SHG members regarding the base line survey, further interventions & their role
• Selection of 23 volunteers in 2 GPs
• Formation of 160 new Village Level Committees (VLC) in both blocks
• Village survey completed in 8 Health Kit villages. Because of the lockdown, survey forms are still yet to be collected
• Selected 200 households for Nutrition Kitchen Garden (NKG) in both blocks & collected seeds from community for promoting NKG.
• 126 wall writing organized on Education, PDS, MGNREGA, NKG & COVID-19 in different strategic locations
• Awareness drive on COVID -19 in the Health Kit villages
• 132 children & 296 mothers reportedly practiced hygiene during critical period after our interventions
• During the period of our intervention, a number of villagers suffering from various ailments like diarrhoea, malaria, cold & cough were treated by the Swasthya Sathis
• 3 Drinking water issues & 2 Anganwadi services issues were resolved during this period

Besides the above quantitative & measurable changes that has happened because of the programme, one change that we are proud of is getting the villagers to participate, contribute and own the programme collectively at the community level. The Health Kit programme & its successful implementation has in some ways brought about a belief amongst the villagers about the strength of working together, building pressure collectively through Sangathans on local and district administration and the need for village development.

Having said that, the Health Kit programme has had it’s challenges like low community response despite regular interaction, lack of trust from the villagers because of their past experiences, expectation that all medical services will be free. The remoteness of the villages and the lack of road, transport facilities also added to the problem. These challenges are ongoing and will continue to exist in different scales as we continue on with the programme.

7. Organogram of the Intervention