Transfer of Home-based Newborn Care From SEARCH to Other Organisations

Process Documentation of the ANKUR Project

(2001-2005)
By
N. Nakkeeran, Ph. D
Assistant Professor Centre for Research Methodology &

C. A. K. Yesudian, Ph. D
Professor and Dean Research and Development

TATA INSTITUTE OF SOCIAL SCIENCES, Mumbai

Published by

SEARCH
Society for Education Action and Research in Community Health
Gadchiroli , Maharashtra, India. Pin : 442 605 Ph.no. 91-7138-255407 Fax no. 91-7138-255411 e-mail: search@satyam.net.in website : www.searchgadchiroli.org

Cover page drawing : Ms. Anuradha Thakur, Ahemadabad

Society for Education, Action and Research in Community Health, Gadchiroli - 442605, India

No part or whole of this work may be copied, reproduced or distributed without the permission of SEARCH, Gadchiroli in whom the copyrights of this work vest.

This publication was made possible through support from The Saving Newborn Lives Initiative of Save the Children (US) and The Bill & Melinda Gates Foundation

Table of Contents
I. Background SEARCH, Gadchiroli Home-based Newborn Care study in Gadchiroli ANKUR : The replication study Why Process Documentation? II. Study Methods Two Phases Aim and Objectives Domains of data collection and documentation Methods of data collection Tools of data collection III. Process of Transfer : Planning and Training Introduction Planning process Training Transfer of knowledge and skills Transfer of mission, values, attitudes and leadership IV. Process of Transfer to the Communities : Implementation Introduction Service delivery Working with community Building community ownership Dynamics of stakeholders Human resource management Supervision Materials Information management Conclusion V. Impact and change Introduction Maternal and child healthcare Neonatal morbidity and mortality Sustaining HBNC in the Community Conclusion VI. Socioeconomic Context and Implications on HBNC VII.Conclusions References Appendix 1 1 2 6 6 8 8 8 9 10 13 14 14 14 17 20 24 27 27 27 30 32 34 35 37 40 41 46 47 47 47 59 65 67 68 72 74 75

Chapter - I
BACKGROUND
SEARCH, Gadchiroli :
Society for Education, Action and Research in Community Health (SEARCH) is a non-government organisation established in 1986. Dr. Abhay Bang, and his wife Dr. Rani Bang, are the founders, directors and the architects of SEARCH. In the initial seven years, SEARCH was based in Gadchiroli town in the Gadchiroli district of Maharashtra, and in 1993, its headquarters campus Shodhgram was set up on a 12-acre agricultural land, 17 kilometres from Gadchiroli town. Shodhgram houses eight departments viz. Womens reproductive health, Tribal Health and Development, Adolescent Health Education, De-Addiction, Research, Hospital, Homebased New born Care, and Administration. The hospital is of a tribal-friendly architecture and has all the basic facilities such as X-ray, laboratory, ECG and a pharmacy. Shodhgram is a residential campus and most of the staff members stay on the campus, sharing a close community life. There are some values collectively held by the members Gandhian values of simplicity, social selfsufficiency, and dignity of labour. The work of SEARCH is strongly founded on three convictions viz., community participation, research and advocacy, which are Gate of Shodhgram, basically grounded to Dr. Bangs Gandhian values. the SEARCH HQ campus SEARCH is committed to active participation of people in setting priorities, planning activities and implementing programmes. It is basically a political activity at the grassroots (Bang 1986, p.1394). SEARCH believes that it is the empowerment of women and men in the villages that can realise Aarogya Swaraj and not the costly modes such as doctors, hospitals, ambulances, which either dont reach or dont function (SEARCH, 2003, Ankur Utsav, Shodhagram: 31st March 2003, The address by Dr. Abhay Bang). Along with community participation, research has been an important component of almost all the interventions of SEARCH, in both health and other (non-health) fields. Besides these, advocacy remains an important plank of SEARCH, strengthened with its faith in research, its commitment for active community engagement and hence influencing public opinion.

Contribution of SEARCH to the Area of Child Health :

Child health is an important area in which SEARCH has been involved from the beginning. It has been operating a vital statistics registration system in about 100 villages in the Gadchiroli district from 1988, periodically generating and publishing reliable data on birth rate and child mortality. SEARCH has been involved in training and supporting male village health workers and traditional birth attendants in 53 villages of Gadchiroli district to provide case management of pneumonia in children (Bang etal 1990), antenatal care, hygienic deliveries, and treatment for reproductive tract infections (Bang R. A. 1988). Through its work such as study of Child Mortality in Maharashtra, home-based neonatal

care and the reproductive health, SEARCH has earned wide acclaim and reputation among the NGOs, academia, medical profession, some sections of bureaucracy and political leaders. Its work on management of pneumonia in children, gynaecological morbidities, and home-based neonatal care, has attracted the attention of international public health specialists, planners, and funding agencies.

Home-based Newborn Care (HBNC) Study in Gadchiroli :

The HBNC study was conducted between April 1993 and March 1998. The field area of SEARCH covered 100 villages in Gadchiroli district, including action area of 53 villages and control area of 47 villages (Bang et al. 1999). The intervention area comprised ultimately of 39 villages out of the 53 action area villages. The project included the following: 1. Seeking community involvement through obtaining written consent from a range of community level public bodies like gram panchayat or individuals holding public office at the village / panchayat level to allow the introduction of the HBNC package in the respective villages and seeking community involvement at various stages of the HBNC implementation beginning with selection of the female village health workers (VHWs) to provide home based neonatal care. 2. Studying traditional neonatal care knowledge and practices in the project area through a baseline survey. 3. Involving traditional birth attendants (TBAs) in the intervention area through training and providing safe delivery kit and utilizing their capacities to a) reinforce the health education messages given by VHWs b) encourage mother to access ANC care c) conduct hygienic and safe delivery d) recognize danger signals in mother (delivery, post-partum) and give referral e) initiate early and exclusive breast-feeding f) insist that the family calls VHW to be present during birth g) work in collaboration with VHWs and h) report all births to the project team collecting vital statistics. 4. Selecting and training of female Village Health Workers (VHWs) (one VHW for 1000 population) to provide neonatal care at home and carry out health education amongst the mothers and community. 5. Provision of HBNC package by the VHWs. The key components of HBNC provided by the VHWs to the neonates and mothers included the following: a) Providing health education to pregnant women and families about maternal nutrition and health, safe delivery, post-partum and neonatal care; providing advise and encouraging mothers, TBAs and parents to seek care for sick neonates from the VHW. b) Attending delivery to take care of the baby at birth, examination of the baby and management of birth asphyxia if necessary. She also identifies high risk babies. c) Making home visits to normal neonates on specific days and on any other day if the family called.

d) For high risk babies, making greater number of home visits on specified days and on any other day if the family called.

e) Undertaking the specified tasks during home visit i.e. taking history, examining mother and child, weighing the child each week. f) Managing normal and sick neonates. This included early initiation and exclusive breastfeeding, managing breastfeeding problems, prevention and management of superficial infections of the skin and eyes, management of fever, management of high-risk babies and management of hypothermia.

g) Undertaking sepsis case management for neonatal sepsis. h) Identification of maternal morbidities during post partum visits and referral if necessary and i) Maintaining record of her observations and actions during home visits. Child health components included health education of parents about seeking care for cough and providing case management to children with pneumonia. During the baseline (April 1993 March 1995) phase, male VHWs did a census(1993) and baseline survey in the field area comprising 100 villages (1993-95). Traditional neonatal care practices in the field area were studied by female social workers. Consent was taken from the community in 53 villages of action area to undertake the study. Female VHWs with 5-10 years of schooling and belonging to the respective villages were selected. Out of the 53 villages, 39 villages were finally selected as the intervention area on the basis of population (not being less than 300) and availability of suitable woman to work as VHW. During the first year of the intervention phase (April 1995 March 1996), female VHWs listed pregnant women in the village, collected data by home visits in the third trimester, observed labour and neonates at birth, undertook home visits on days 1, 2, 3, 5, 7, 14, 21, and 28, undertook home visits on any other days if the family (of the neonate) called, took history during each visit, examined the mother and the child, weighed the child each week, managed minor illnesses and pneumonia in the neonates. They followed up the neonate for 28 days after birth, until the mother left the village, or until the neonate died, whichever was earlier. The data thus generated was used to estimate the natural incidence of neonatal morbidity and need for care. In the second year of intervention, female VHWs were further trained in home-based management of neonatal illnesses. Provision of home-based neonatal care by the female VHWs started from April 1996 in addition to earlier tasks. They managed neonatal sepsis (septicemia, meningitis, pneumonia) from September 1996. In the third year (April 1997 - March 1998) of intervention, female VHWs gave health education to pregnant women and other women about care during pregnancy and care for neonates. Throughout the period of the project, each village was visited by a non-MBBS physician fortnightly, to verify the data recorded by the VHWs, to correct the records and to educate the VHWs. The physician did not provide any treatment and referred seriously ill neonates to hospital. The completed neonatal records were weekly reviewed and diagnoses were made independently by the physician, statistician and by a computer program specially designed to diagnose neonatal mortalities. In case of difference, the original records were reviewed. An independent neonatologist reviewed the records of neonatal deaths (in spite of the neonates having been cared for by the VHWs) in the intervention area, to assign cause of death as per the criteria similar to that given by the expert group of the National Neonatology Forum of India (NNFI).

Between 1993 and 1998, births and deaths were recorded in intervention and control area by male VHWs and their supervisors prospectively as well as through 6-monthly house-to-house surveys. An external group of neonatologists and paediatricians monitored the ethical aspects and the quality of the trial including the study design, diagnostic criteria, and training of VHWs and data collection by meeting once in a year at the SEARCH headquarters. The costs (training, equipment, wages and incentives, medicines and supplies, records, supervisions and transport) were separated into service costs and research costs. The study revealed a huge burden of neonatal morbidity and a large unmet need for neonatal health care in the community. 48% of neonates suffered from high-risk health problem (Bang etal. 2001). In the third year of intervention, 93% of neonates in the 39 intervention villages received HBNC. Neonatal mortality rate, from the baseline period to the end of the intervention period, in the intervention area, decreased from 62 to 25.5. In the control area, it had increased from 57.7 to 59.6 between baseline and the end of the intervention period. Intervention area also registered decline in infant and perinatal mortality compared to the control area. Case fatality in neonatal sepsis declined from 16.6% to 2.8% (71 cases) before and after the intervention. In the third year, HBNC averted one death among every 18 neonates cared for.

The birth of ANKUR :

In the year 1999, SEARCH had initiated a study of child mortality in the state of Maharashtra along with 13 other NGOs from various parts of the state. The study conducted over a population of 2,26,904 spread over 231 villages and 6 slums gave clearer estimates of mortality rates for children (SBR, NMR, IMR, and CMR) in these selected areas and that for the state as a whole and revealed that these mortality rates were grossly underestimated till then. The study confirmed the findings of many other studies that NMR contributes nearly 75% of IMR. The report was published in Marathi under the title Kovali Pangal (2001). Efforts were made to reach the findings to the people of Maharashtra through the media. All the major Marathi newspapers published the news and editorials were written on the study within a week of publication of the report i.e., between November 24 and 30, 2001. It was covered in the electronic media as well. Publication of the study generated a mixed reaction in the political as well as administrative levels of the state of Maharashtra. The minister of health and the bureaucracy from the Health and Family Welfare department took a defensive posture. A series of meetings was conducted with the chief secretary, Health and Family Welfare minister, and finally with the Chief Minister of the State in a rapid succession between November 30 and December 5, 2001. (Bang et al., EPW, 2002). Subsequently, the Chief Minister of Maharashtra was convinced of the main message of the study and accepted the goal of 100 per cent recording of child deaths in future and also most of the corrective measures recommended by the study. He also endorsed the recommendation to start projects in the state to reduce child mortality using the approach of home-based neonatal care, starting with the 14 worst affected districts. The HBNC experiment and its outcome in Gadchiroli and the child mortality study in the state gave birth to the idea of formation of Ankur. In the Pune meeting on 8th and 9th of October 2000, the 13 NGOs who conducted the child mortality study discussed future action. An outcome of this discussion

was the formation of The Child Deaths Study and Action Group (CDSAG), Maharashtra. Having established that the child mortality is in reality very high and is being under-reported, the group did not want to stop at reporting but to go ahead and do something about it. SEARCH also wanted to test replicability of HBNC. Hence, SEARCH and some members of the CDSAG group decided to launch a new intervention project, named Ankur (The Sprout) to test the replicability of HBNC and save newborns and children in the selected villages of their respective field areas.

Selection of the NGOs for the Ankur Project :

The members of the CDSAG group were invited to send their proposal to take part in the Ankur Project. SEARCH laid out some specifications for NGOs to become part of the project viz. (a) Willingness to undertake the HBNC replication exercise with a research discipline (b) The quality and discipline of work during child mortality survey (c) Population size and the level of IMR (d) Capacity to interRural Nagpur nalize the community health apU.Slum proach (e) Capacity to organize Nasik Yavatmal Tribal Rural effective training and supervision Tribal in the field (f) Credibility in the community, acceptance by people and the capacity to address political SEARCH HQ backlash at the local level (g) Rural Study Sites in ANKUR Leadership quality and (h) The Villages : 91, Slums : 6 potential to become a demonstraRural Population : 88, 311 Sangli tion / multiplication site. 7 of the 13 NGOs finally became part of this multi-site replication study of Home-Based Neonatal Care (HBNC). Thus seven NGO sites, one each in the districts of Gadchiroli and Yeotmal(both tribal), Nasik, Sangli Osmanabad and Nagpur(all rural) as well as an urban slum site in the city of Nagpur were chosen for the ANKUR project.
ilo ri h c da G

The Research Questions for Ankur :

Following were the research questions of this community based replication study: a. How can the HBNC be replicated by other NGOs? b. What is the effectiveness of HBNC when replicated ? And what are the inputs required for replicating HBNC? c. How replicable will HBNC be in other settings and how sustainable will it be in the seven NGOs? d. Can selected elements of maternal and child health interventions be integrated with HBNC? The fact that the study aimed at replication and that it was a research project very significantly influenced and structured the way the project was implemented.

daba nams O

ANKUR : The Replication Study :

The study demanded (a) High level of leadership skills and guidance from SEARCH to effect a progressive convergence of vision, values, attitudes and priorities of all the seven NGOs to facilitate implementation of HBNC (b) Rigorous monitoring and supervision from SEARCH (c) Transfer of material resources in the form of funds, equipments, training material etc., (d) Transfer of readymade systems for almost all activities pertaining to HBNC (e) Large scale transfer of knowledge and skills to different levels of personnel in the NGOs (f) Supportive action to deal with stakeholders in government machinery, medical profession, media, other civil society organisations, and at the local community level. A research study has requirements of consistency and rigorous data/reporting such as consistency in terms of input variables, evaluative indicators and control of confounding variables over the entire period of the project. This introduced the need for development of well worked out systems for almost all the activities which had to be in place through out the study, higher level of training to all levels of personnel and strong supervision. Besides, generation and use of adequate and meaningful data was another feature characterising the project. As a result, it demanded intensive and well defined procedures of data collection, rigorous monitoring and supervision, efficient channels of communication and generation and submission of a variety of reports. Another distinct feature of the study was the emphasis it laid on outcomes rather than just intermediate outputs. The replicability was to be reflected in terms of the reduction of IMR with emphasis on reduction in NMR. Indicators for monitoring or supervision were not so much the distribution of staff, medicines, expenditure incurred but the number of births observed, neonatal ailments attended and the number of deaths averted. Sustainability and up scaling were the desired long-term outcomes. The fact that the project centred on the village women delivering home based services was another very crucial characteristic of the study. This made it imperative to develop an intensive training system with detailed training methods and material to impart skills, knowledge and values to these village women.

Why Process Documentation ?

Process documentation of the implementation of this replication and the community changes around this implementation seemed necessary. As stated earlier, the aim of the Ankur project was to demonstrate the replicability and generalisability of HBNC approach irrespective of the community context and the organizational uniqueness (of SEARCH). Ankur was an intermediate process, a step towards a much broader level of scaling up in terms of geographic coverage. Hence, the processes in this project had to be documented as a model of replication exercise. Documenting such processes was essential as it could be a referent for subsequent ventures of transfer. As the mid-term review team noted, the most important priority for documentation is to understand what changes are occurring in communities with regard to newborns and their health and why. The purpose was to arrive at more effective and efficient designs and plans for introducing HBNC elsewhere (2003). The Ankur transfer process was conceived as a long process spanning about four years. The long duration of the programme provided an opportunity to learn lessons from the early stages of implementation, and incorporate the improvements in the later phases of the project. The Ankur-transfer process was not only long, but was also quite intense and comprised of a number

of processes and sub-processes. This invoked a necessity to document all the processes involved in detail lest they may not even get registered. Another important reason for documentation was that it involved intense transfer of skills, knowledge and attitudes to a range of personnel (to the project coordinators and supervisor trainers and from the trainer-supervisors and project coordinators to the VHWs and TBAs). In the learning processes, the learning curves do not leave behind imprints of their own. Except for the mid-term or terminal evaluation, which gave the scores of achievement, the intermediary levels of learning, and problems in learning, corresponding experiments and nuances in training methods, tools, management etc would not be registered. These problems in learning and training would not be unique to this environment alone, but could be faced in future experiments of transfer too. The sites to which HBNC was transferred were not uniform, but ranged from tribal, through rural to even urban area. Hence, the populations covered were widely divergent . In terms of the general quality of life, infrastructure, economic status, awareness, proximity to alternative health facilities as also the traditional beliefs, practices and perceptions, the populations varied quite significantly. As a result, the trajectory of both transfer of skills to the community-based actors as well as the trajectory of community acceptances of the programme differed across these communities. The responses to various components of the programme varied. Correspondingly the micro-level strategies used by the respective NGOs to work through these variations too were divergent. All such diverse substratum (baseline), trajectories, responses and strategies had to be documented as learning for subsequent endeavours. From the beginning of the Ankur project, the need for documentation was understood and it had been attempted in a number of ways. A three-day workshop on Documentation skills was organised for the Ankur NGO heads and supervisors in September 2002. Resource persons were invited from PRIA, an organisation from New Delhi for this workshop. During the mid-term review of the project in March 2003, Saving Newborn Lives Initiative recommended the need for process documentation to enable any future efforts towards sustaining HBNC in the project areas as well as enable HBNC to be expanded to additional regions by other NGOs and by the government (Anne Tinker, SNL, undated). Therefore, the present process documentation study was initiated.

Chapter - II
STUDY METHODS
Two phases :
By the time the process documentation started in September 2003, a significant part of the transfer process had been already completed and hence the elapsed part was documented retrospectively. For this purpose, each of the seven sites (NGOs) to which the transfer took place was visited. The processes that followed after initiation of the documentation in September 2003 were captured as part of the prospective documentation. For the purpose of prospective documentation, three selected NGOs out of the total seven were followed and studied. The three organisations chosen, namely Amhi Aamchya Arogyasathi (AAA) of Gadchiroli district, Sahayog Nirmiti (SN) of Osmanabad district and ISSUE in Nagpur city, represented a tribal, a rural and an urban site respectively. The present document provides both the retrospective and the prospective parts of the documentation. In the following pages of this section, we outline the methodology used for the process documentation study.

Aim and Objectives :

Aim : The process documentation study aimed at documenting the process of transfer of HBNC vision, leadership and related knowledge, skills and resources from SEARCH to Ankur NGOs. It also aimed to document the process of implementation of home based neonatal care (HBNC) and the accompanying changes in the community to facilitate refining of the programme for a more effective, and efficient implementation elsewhere and to reach the programme more widely and deeply. Objectives : Separate objectives were formulated for retrospective and prospective studies and are listed below: The objectives of the retrospective study were to, a. Document the processes involved in transfer of vision, leadership, knowledge, skills methods, and resources related to HBNC from SEARCH to 7 Ankur NGOs, the process of interaction among the 7 Ankur NGOs and the process involved in building relationship with external stake-holders. b. Document the processes involved in transfer of leadership, attitude, necessary skills and knowledge within each of the Ankur NGOs to different levels of personnel involved in HBNC replication and implementation. c. Identify best practices which have resulted in desirable changes in the community, the NGO and SEARCH. The objectives of the prospective study were to, a. Bring out the underlying beliefs and cultural practices regarding pregnancy, delivery, and newborns among various sections in the community, and to document the process of change in these beliefs and practices. b. Document the perceptions and responses of the community to the NGO inputs. c. Bring out the key events, processes, people, services and interactions that either facilitate or are

responsible for such changes. d. Document the practices, perception and responses of different health providers in the community, regarding pregnancy, delivery, new-born care as well as with respect to NGO inputs. e. Document temporal variations in responses among various ethnic / social / economic groups or individual families within communities, to understand factors that accentuate acceptance as well as resistance for change among such groups.

Domains of Data Collection and Documentation :

SEARCH : (a) HBNC conception, designing and implementation (b) Formation of Ankur (c) Transfer processes Ankur NGOs : (a) Profile, vision, resources and services (b) Systems, processes, decisions, actions (c) Community acceptance and how this changes during the period of implementation. HBNC Programme : (a) Components of the programme, local modification to the programme on the basis of local need (b) Variations, modifications if any introduced during the course of implementation, systems for supervision, monitoring and feedback involving collection, storing, analysing and use of data by the NGO. Village Health Workers : (a) Personal profiles of VHWs including age, sex, socio-cultural background, years of experience in the NGO, education level, performance during the period of learning (b) Degree of acceptance in the community, fluency in relationship among all the sections of the community, fluency in delivery of services (c) Changes in these dimensions during the period of implementation Community : (a) Profile of the community in terms of demographic and socio-cultural composition, economic activities and differentiation, political structures (b) Access to and use of public and private health services, education and other activities and cultural practices specially related to health and new-born care (c) Perception and degree of acceptance of the NGO and its activities and (d) How the above aspects affect changes during the period of implementation.

Study Design :
The process documentation was conceived in two parts viz., retrospective and prospective. The former covered the period up to 2003 of the transfer process, which was essentially an intensive vision building, planning and training phase till April 2003. This phase was retrospectively documented using existing documents and interviews with SEARCH and the seven Ankur partner NGOs. Prospective phase covered the period from September 2003 to the end of the project. This was further divided into two parts i)Baseline study and 2) Quarterly follow up studies. The purpose of the baseline study was to get the background / baseline information about the HNBC project, NGOs, and the community. Baseline information regarding availability of care during pregnancy, delivery and care of new-borns, acceptance / perception of the respective NGOs and HBNC programme were collected from the community. The baseline study also served for selection of villages for study and identifying informants. Quarterly follow-up studies were conducted to collect longitudinal data on community changes happening around HBNC, and to look for changes, patterns and evolution in these changes across the three study sites and across different communities. Baseline and quarterly-follow up studies involved field visits to the chosen Ankur NGO partners; first

for the baseline study, and thereafter periodically (every three months). Altogether seven rounds of visits were made to the three NGOs. The three NGOs represented one each of tribal, rural and urban setting. Areas of two VHWs from each NGO were selected for the prospective study. These six areas were visited during each of these visits for the prospective study. In addition, in each of these three NGOs, a non-HBNC (control) village was chosen and was periodically visited. Non-HBNC villages chosen were such that these were comparable to HBNC areas except that HBNC was not implemented there. It served as a proxy baseline state of HBNC area. These were also compared with the HBNC villages concurrently as the programme proceeded.

Methods of Data Collection :

Field Visits : Empirical data were collected through field observation, informal unstructured interviews and group interviews with people in the community, community based actors, stakeholders, local healers, NGO personnel, and SEARCH staff. Initially, open-ended interview schedules were used to collect data from the trainers, NGO heads, supervisors, VHWs, community leaders, stakeholders, beneficiaries, and non-beneficiaries. Different sets of checklists were used at various points to collect and complete information on all the important practices and interventions. Social mapping of the study villages / basties was done locating the facilities available, distribution of households by community, location of VHWs, TBAs, local healers, etc. In each visit to an NGO, the team interviewed the project coordinators, supervisors and other staff members. At least two VHWs from each NGO were visited and detailed interviews were conducted. The interviews captured the skills and knowledge of the VHWs. In addition it also elicited all HBNC related happening in the villages since the last visit. In these two VHW-areas in each NGO, beneficiaries who had received HBNC services since the previous visit, including eligible women, pregnant women, mothers with neonates were interviewed. In addition, interviews were also held with TBAs, local healers and community leaders. Public health staff like ANMs (Auxiliary Nurse Midwife), MPWs (Multipurpose workers), Anganwadi workers, some doctors in PHCs (Public Health Centres) / RH (Rural Hospital) were also interviewed. Documentary Sources : Documents used were largely from SEARCH and to some extent from the partner NGOs. These were important sources of data. These documents included profiles of the NGOs, the project proposal, training materials, progress reports, KP study reports, child mortality study report, published research papers, paper clippings, baseline and 6-monthly surveys and evaluation reports etc. Study Guide and Process Document Matrix : With assistance of Dr. Mary Taylor, a detailed Study Guide and Process Document Matrix were prepared. The Study Guide gave an outline for the whole study, formatting reporting, and the format of the final report, tools of data collection, file structure, time schedule and roles and responsibilities of individual partners in the process documentation study. The HBNC transfer programme was depicted in a matrix with columns indicating the stages of transfer with the entries in each column listing out what would be done at each stage. This matrix provided the basic framework for writing the process documentation report.

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HBNC Transfer Documentation Matrix

to be SEARCH inputs and transfer processes NGO Context What has been transferred? Performance measures (Over time, modifications, (In puts to communities, wider support to program) depth)

SEARCH Leadership and What w as meant Management of Ankur transferred? NGOs (context of project) Vision & Leadership Vision/Mission Attitudes/Values Leadership Motivation Ethos of work culture

Organizational context :

Background Vision & Leadership Initiative Vision, mission, values What they do (core capabilities) Building relationships with Contacts, meetings Sphere of other stakeholders influence

Structure

Inputs: Concepts/ ideas / Vision, mission, values technical information What they do (core Materials (flipcharts, forms, capabilities) curricula) Sphere of influence Funds (money, drugs, How they work as a team equip) How decisions are made Enabling environment thru Building relationships w ith advocacy Historical context: Enabling environment thru external stakeholders Health projects peer learning Government ARI study Supportive actions Medical leadership HBNC study Related technical Political leadership Child Mortality Study information Media (Early relationships) Print media Idea for Ankur Processes: At local/district level only Advocating NGO agreements Community Training Different religious groups Orienting (demonstration) Intellectuals Conducting workshops Professionals Data analysis workshops Womens groups Workshops for Other NGOs in the area documentation skills HBNC Study Characteristics: Role modeling down to Knowledge Aim to replicate VHW level Skills Research requires: Motivating events, Attitudes (VHWs, Supervisors, - Accuracy processes Leading review project coordinators) - Reliability meetings (peer learning) - Cross checking Conducting field visits Systems mechanism - Technical supervision Planning - Data review - Consistency Training - Management/ finance - Added data/reporting Supervision - Others requirements Monitoring Human Resource Management Supervising Emphasis on outcomes Modeling Approach to communities HBNC

VHW, TBA training results

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to be SEARCH inputs and transfer processes Other Projects Systems NGO Context What has been transferred? Performance measures (Over time, modifications, (In puts to communities, wider support to program) depth) Turnover of staff Data quality Successful changes in NGO practice Service statistics (some) Small studies conducted Documenting Photo documentation Process documentation Community engagement Community engagement Selection VHW s Empowerment of VHWs leading to community empowerment Coordination with TBAs Building utilization Building comm. ownership (Ownership transfer was not probably planned) Sustainability potential Meetings held Events held VHW coverage Sustainability plans and actions

SEARCH Leadership and What w as meant Management of Ankur transferred? NGOs (context of project)

Researching w orking Service Delivery - Surveys Information/analysis Staff roles/responsibilities Problem solving & improvement - Census data - NN forms data Researching (who, job descriptions) - Special studies Who they relate to in NGOs

Structure & relationships :

Nature of the relationship

Tools of Data Collection :

Informal Interviews : This was the predominantly used tool to elicit information from the community in both baseline and follow-up studies. Depending on the informants, and the phase of the study, interviews were repeated, progressively making them more focused. Relatively more structured and focused interviews were used to collect data from TBAs, VHWs, other local health providers and the NGO personnel. Group Interviews : The interviews in the community often turned out to be group interviews. This situation was used to collect data on perceptions on TBAs, VHWs, and HBNC as well as on the cultural beliefs surrounding pregnancy and newborn care. Group interviews also helped collection of data on community acceptance, effect of health education etc. Group interviews in different basties / hamlets brought out differences in the perceptions / practices across groups with age, socio-economic and ethnic differences. Case Studies : Case studies were documented to document special cases of neonatal illnesses and other problems. This involved collecting intensive descriptive data on a few selected beneficiaries or those who had experienced maternal / neonatal morbidity / morality. Mapping : This was used to get the background information such as settlement pattern, location of health care facilities and other amenities in the villages / basties. The Team : The process documentation team included two principal investigators and research assistants. The two principal investigators are qualified with doctoral degree in social work and anthropology respectively. At least one of the two principal investigators was part of all the field visits. The two research assistants were with post-graduate degree in anthropology and economics respectively.

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Chapter - III
Process of Transfer : Planning and Training
Introduction :
The process of transfer from SEARCH to the NGOs did not begin with planning. It began much earlier, in the birth of Ankur (see chapter I), which generated a purpose namely the challenge of child deaths in Maharashtra, bringing the NGOs together under the leadership of SEARCH. The motivating vision of transfer of HBNC to their areas to reduce child mortality and to create a SEARCH-like community health program was a powerful dream for the NGOs. The planning and training followed. Transferring HBNC to Ankur NGOs involved elaborate planning, developing systems and training. At this stage, the main role and responsibilities rested mainly with SEARCH. Having successfully implemented HBNC earlier in its intervention area, the challenge was to replicate the model in other areas, where the socio-economic and cultural context were different and through the NGOs, whose work environment was different from that of SEARCH, and test its generalisability. In the following paragraphs we look at the planning process and training of the staff who were to implement the HBNC package, to ensure that the knowledge, skills, values, leadership and attitudes relevant for the Ankur project were transferred to them.

Planning Process :
Although the project was being implemented under the technical guidance and supervision of SEARCH, at local level it was to be administered by the respective NGOs. This was considered important, as the very idea of the project was to test replicability of HBNC through NGOs differing in management styles and in different local conditions. The NGOs were also expected to implement the central components of the programme without much deviation from what was planned. Towards this end, a series of measures were undertaken. First of all, agreements were signed between SEARCH, GreenEarth, a consultant firm from Pune entrusted with some management functions under the ANKUR project and each of the Ankur NGOs. These were besides the main agreement signed between SEARCH and the SNL. A meeting for this pur pose t ook pl ace i SEAR C H subsequent t t Pune m eetng on 8th and 9th of October 2000 n o he i referred earlier. GreenEarth was entrusted with the responsibilities such as preparation of project manual and micro-plan documents, conducting KP (Knowledge Practice) study, arranging process documentation, building management capacity of the partner NGOs, monitoring implementation of the project at the NGO sites, and sorting out financial management problems of the NGOs. While GreenEarth was able to do some of the tasks in the pre-preparatory phase, many of the tasks were either not done in time or the quality of work was not up to the mark. Subsequently, GreenEarth withdrew from Ankur. This was after mutual consent and agreement of all including GreenEarth. SEARCH then undertook the responsibilities entrusted earlier to GreenEarth. An Orientation Workshop was arranged for the NGO-heads in September 2001. The responsibilities of each of the organisations; including SEARCH, GreenEarth and the seven NGOs involved in the

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project were clearly laid down. Management Review Meetings were conducted between SEARCH, GreenEarth and the NGO teams 4 times during the first year. These were aimed at planning, sharing of information and decision-making.

Project Manual :
This was a document to be prepared under the project, detailing each step involved in the implementation of the project, including obtaining community consent, selection of Village Health workers (VHWs), Hamlet Workers(HWs), Neonatal Care Supervisors(NCSes); training of VHWs / HWs / NCSes/Vital Statistics Supervisors (VSSes); obtaining positive cooperation of Traditional birth attendants (TBAs) and designing approaches to handle non-TBA assisted or institutional deliveries.

Time Frame :
A time frame for the entire Ankur project spanning a period from April 2001 to April 2005 was worked out indicating the various phases including the commencement and end of each phase of the project (Later the project was extended till December 2005). These comprised the baseline phase, preparatory phase, training phase, the intervention phase, the final evaluation phase and the dissemination phase.

Activity analysis study :

This was a research study undertaken in the SEARCH field area and also later in the field area of one of the NGOs (ISSUE) for a period of three months (one month in each of the three different seasons) to estimate the time inputs required per neonate and time inputs required per unit service under HBNC. This involved recording of various activities performed by the VHWs and their supervisors against the time expended using time logs. The supervisor monitored the log maintained by the VHWs. The findings of the study were expected to serve as a guideline for planning implementation of the HBNC model elsewhere.

Management Rating System :

GreenEarth was entrusted with the responsibility of preparing a management rating system which in turn would help monitor the management of the project by each NGO every 6 months. The management rating system was designed in consultation with the NGO project coordinators. The four main sections under which the performance was evaluated were: personnel management, community contact, systems and leadership. This was followed by visits by GreenEarth to each NGO to establish financial accounting system and suggest improvement in the management system. A checklist was used to assess the management by each project coordinator and scores were discussed in a participatory manner. In the July 2002 review meeting, following actions were taken: NGO heads were helped to review status of their present activities and visualize and record their dreams. Further, they were guided to think of improvements they felt necessary to realise their dreams. The observations on management rating of the NGOs were presented by GreenEarth during the meeting to the NGO project coordinators. Based on the needs identified, efforts were made to bridge the gaps. These efforts included 1) Motivating them to undertake self learning process through reflexion

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and reading and 2) Nominating the project coordinators to suitable workshops held by other organisations. In addition, GreenEarth and SEARCH provided inputs during their visits to the seven sites. GreenEarth had even planned a research study on the needs of the NGOs and how such needs can be met. During the review meeting, systems such as writing daily diaries, case studies, keeping record and minutes of the meetings, holding review meetings with participation of NCSes and VSSes, holding meetings with VHWs, field visits for supervision, monitoring, community contact were explained to the NGO teams.

Management Information System :

Management Information System (MIS) format was provided to all the NGOs, for sending to SEARCH every month. The NGOs started sending these reports to SEARCH from July 2002. The NGOs were progressively encouraged to understand the MIS, analyse the data, draw conclusions and use it at their level for monitoring and corrective actions. The MIS report, served two purposes 1) It helped SEARCH monitor the progress at each NGO site closely and to give feedback and 2) The analysis reminded the NGOs of the important indicators they had to watch and improve. The MIS became a very good tool for monitoring the progress of the project, finding out the bottlenecks, identifying the impediments and difficulties and finding solutions. Through Let us learn from data workshops conducted in conjunction with the review meetings, the project coordinators gained knowledge and skill of using data and MIS for planning, appreciating hypotheses, developing indicators and target setting. Further, they understood the issue of child mortality in the state, its constituents, and contributing factors.

Micro-planning :
GreenEarth provided guidance and help to individual NGOs to undertake an exercise of drafting micro-plan documents, to serve as a blue-print for planning of the activities. As part of this exercise, GreenEarth and the NGO teams undertook study in respective sites with the following additional aims: 1) To write individual site-specific project documents 2) To identify strategies for linking HBNC with village level community structures and on-going programs of the NGO and 3) Identifying subresearch topics for the research studies that may be undertaken by the NGOs. After GreanEarth withdrew, individual NGOs completed these documents. However, it was found that the micro plan documents were incomplete in many respects. To be of better functional use, concept of Annual rolling plan was introduced from the beginning of 2003-04 in place of micro-plans, Accordingly each NGO was to evolve its annual plan.

Tribal Area

Rural Area

Urban Area

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The micro-planning exercise brought to light the variations in the socio-economic, demographic and geographical situations of the NGOs and hence the need for flexibility in the service provision systems. It clearly suggested that the HBNC model would have to be slightly modified to adjust to the local conditions. One of the issues that it brought to light was that of variation in the population of hamlets in the tribal areas, their distances from the main village and the terrain. This required a flexible system of service delivery, lest it leads either to under provision of services or over staffing. The idea of recruiting hamlet workers was given up. Instead, a flexible system of choice of deployment of VHWs or hamlet workers or training TBAs in certain functions of the VHW was arrived at as per the local needs. Such variations also had implications on the system of remuneration to VHWs. An important aspect brought out by the micro-planning exercise was that in most cases the area served by a VHW was populated by more than one community differing from each other culturally and politically. Therefore, the issue of selecting the VHW who would be acceptable to all the communities in the area became crucial. Another important issue was the variations in the choice of place of delivery and the person attending the delivery. Deliveries took place in marital home, home of the mother or in hospitals. Person who attended delivery could be, a neighbour, a TBA, a local private doctor etc. This had implications on strategies for imparting health education, and on service delivery.

Training :
On the basis of its experience, SEARCH had designed the system to train HBNC personnel including project coordinators, NCSes, VSSes, VHWs, and TBAs. Accordingly the training schedule, curriculum, materials, methods and evaluation procedures were designed.

Training Curriculum :
The SEARCH training team along with a consultant developed the training curriculum. The team had to keep in mind that none of the persons to be trained,(including NCSes / VSSes and VHWs) knew anything about HBNC. Curriculum writing involved many steps. The team rewrote the job description of VHW as given in the project proposal submitted to SNL, into a series of tasks and sub-tasks or List of Competencies of VHW. Through discussions, the team finalised the knowledge, attitudes, and skills that were needed to perform the tasks and sub-tasks. Thus, the team developed outlines for each module of learning as well as individual sessions collaboratively.

Training Material :
The VHW training manual was developed considering the background of the trainees (village women) and the trainers (little or no prior training experience). Emphasis was on refraining from cluttering the training manual with excess and unnecessary information. The training manual was highly structured with purpose, objectives and training methods used to achieve the objectives clearly spelled out for each session of training. Drafts for each of the training sessions were written and commented on by all the members of the team. Structured and unstructured feedback from the trainees, train-

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ers and master trainers of SEARCH were received. Based on the feedback, individual sessions were revised. The training modules were developed first in English and were then translated into Marathi. Although the content of the training curriculum and the training manual were well thought out, planned and developed, there was scope to revise the same as the training progressed, and newer needs were identified. VHW training manual comprised seven training workshops, each covering one to three modules, each dealing with a specific job/ role of the VHW. The other material developed included health education flipchart and a film titled Tanhula for group health education under HBNC.

Training Method :
Training method too was designed keeping in mind the background of the trainees and the trainers. The participatory methods of training included presentations, role plays, case study, demonstration, field visits, practice, modelling, problem solving, group exercises, group learning, games, and songs. The work in the field during the entire training period was viewed as learning by doing.

Training Pattern :
It was decided that VHWs & TBAs would learn best in a staged process, allowing for practice in the field after learning in small doses of knowledge and skills in each workshop. Hence, knowledge and skills had to be given in small doses. The whole training, beginning with training of the NCSes and VSSes was carried out between October 2001 and January 2003, a period of 15 months. The training comprised 7 TWs (Training Workshops) of trainers training (TOT), 7 TWs of VHW training and 3 TWs for TBA training. Master trainers of SEARCH trained NCSes & VSSes of partner NGOs in training and supervision skills as well as the contents to be passed on to the VHWs and the TBAs.. These trainers (NCS & VSS) trained theVHWs in seven training workshops . They also trained TBAs in three TBA training workshops The training was modular and stepladder in fashion and proceeded in the following manner: a. In TOT workshop1 the master trainers trained NCS and VSS in knowledge and skills of participatory training, and also taught them the appropriate part of the VHW/TBA curriculum. b. Immediately following this workshop, the pairs of NCS and VSS of the NGOs trained the VHWs at their respective NGO sites. The VHW training workshop usually was of 2-5 days duration depending on contents of the workshop. c. After this VHW training workshop, the VHWs practiced the skills acquired and used the knowledge gained during the corresponding work in the community for about a month. The supervisor (NCS or VSS) supervised the VHWs in the field by providing them on site support. d. The time was then ripe for the next round of TOT. NCSes and VSSes returned to SEARCH to participate in the next TOT workshop to learn newer training and supervision skills as well as next part of VHW/TBA curriculum. e. They again went back to their individual sites and conducted next round of VHW / TBA training. This process continued till the completion of training of the VHWs and TBAs in all aspects of HBNC. Initially the master trainers attended the TWs for VHWs for all the days and provided support during the VHW training in each NGO.

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For every training workshop, the first session of the first day was devoted to discussion on experiences gained by the trainees during fieldwork done by them in the previous month. The training workshop ended with recapitulation and planning for the work to be done in the field after the TW in addition to what they were doing already. VHWs were also given refresher training, which was built within the schedule of the main training. This was conducted once after the third training workshop and then after the seventh training workshop. The content, the sequence and the period of the different training workshops for the trainer supervisors (NCS and VSS), VHWs and TBAs are presented in the appendix. The trainers of SEARCH who conducted the TOT and then visited trainings of VHWs made certain observations, some of which are reproduced below: 1. Nearly 100% attendance of VHWs at most sites for every training 2. Surprisingly fast development of VHWs who seemed to be weak in the beginning 3. Noticeable improvements in the communication skills of VHWs and confidence with which they participated in the training programmes 4. The friendship developed between the VHWs and their trainers 5. Special efforts by the trainers (NCS and VSS) to ensure that each and every aspect of training content was transferred to the VHWs.

Evaluation of training :
Evaluation of the VHW training : In the month of February 2003, the evaluation of the VHW training was conducted with the following objectives: a. To determine whether the VHWs were competent to deliver HBNC. b. To evaluate the effectiveness of the method of selection of the VHWs, training design, training methods and the training material. c. To identify corrective measures and to provide inputs for revision and improvement of the training package. Evaluation of the NCSes and VSSes as trainer supervisors was also carried out. For this purpose a four-member evaluation team comprising Dr Abhay Bang, two master trainers from SEARCH and the training consultant was constituted. A 7-page questionnaire was prepared to test the knowledge of VHWs in all the components of HBNC. This was constructed for 100 marks. A 5-page schedule was constructed for NCS / VSS to evaluate the skills of VHWs and had total 53 items In order to evaluate VHWs attitudes, quality of work, and strengths, the schedule elicited information on 15 characteristics of VHWs, each on a scale of 0 to 5. This schedule was completed in each NGO by the respective NCS. An 8-page field evaluation guide was prepared exclusively for the purpose of VHWs field evaluation. The guide was constructed on a 100 mark scale, divided into 7 parts covering all the activities of a VHW. The guide also included short one-page interview guide to interview the VHWs and the TBAs. The evaluation team did an in-depth evaluation of two VHWs in each NGO. In each NGO, the team selected these two VHWs (who were caring for a newborn in their area at the time of evaluation) randomly. The evaluation team conducted a detailed evaluation of these VHWs by using the evalua-

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tion training guide. They were also interviewed for their own feeling of self-growth and change. Score of minimum of 70% was considered essential for a VHW to be judged competent to deliver HBNC services. Evaluation of NCSes / VSSes : This was conducted on the basis of 1) Written Test (Knowledge) - Same as the one used for VHWs 2) Growth as a Trainer / Supervisor - Evaluation by the respective NGO Heads and Master Trainers, 3) Personal Growth Done using a self-assessment form. The evaluation team also had in-depth discussions with the NCSes, the VSSes and the project coordinators. Earlier, their level of understanding of the data was evaluated during the data analysis workshop that took place at Shodhgram in October 2002. Evaluation of TBAs : This also was done in January-February 2003. This included interviewing the VHWs about the TBAs behaviour and practices during delivery as well as interview of TBAs on their practices by NCS. The evaluation team also evaluated a sample of TBAs from each NGO by interviewing them. For this purpose also an interview guide was constructed. As we saw in the above sections, extensive and intensive planning and training processes were undertaken to ensure that the Ankur project was established on a firm footing in each of the 7 NGOs. Now let us see how far the planning and training processes enabled transfer of HBNC knowledge and skills and the values, mission and leadership that were necessary to be imbibed by the NGO teams to implement the HBNC.

Transfer of Knowledge and Skills :

It was envisaged that the entire gamut of knowledge and skills of HBNC be transferred to appropriate levels of staff in Ankur, including the project coordinators, the trainer-supervisors (NCSes and VSSes), the VHWs and the TBAs. In addition to knowledge related to HBNC per se, it was also envisaged to transfer knowledge and skills related to general programme implementation, management and conducting community based research to the trainer-supervisors and the project coordinators. These were transferred predominantly through training. In addition, workshops and field supervision by SEARCH members too served the purpose. Although the degree of transfer across all the NCSes, VSSes or VHWs varied, they acquired all the basic skills and knowledge which were intended to be transferred to them. The degree of such transfer to the VHWs and trainer-supervisors was brought out in the results of evaluations done by SEARCH and SNL teams. These skills and knowledge acquired by the NGO personnel were put into efficient use for implementation of HBNC. The degree of knowledge/skill acquired also was reflected in how the NGOs had used these capacities of their personnel for their other programmes as well. Such experience of using these knowledge/skills across programmes was cited by almost all the NGO heads as an important gain. SEARCH, and to some extent the NGOs themselves instilled positive attitudes in the trainer-supervisors and the project coordinators. These values penetrated from the level of project coordinator, to the trainer-supervisors as well as to VHWs.

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Village Health Worker (VHW) : VHWs were trained in identifying pregnant women, and registering their names in the list of pregnant women, followed by filling up the forms in respective months and administering health education. In the corresponding training sessions, knowledge pertaining to identifying danger signs during pregnancy such as, swelling on feet, bleeding etc was imparted to the VHWs. VHWs were provided knowledge and skills in diagnosing and managing the health problems of neonates including birth asphyxia, sepsis, pneumonia, hypothermia etc. They were trained in identifying and managing high risk babies. VHWs were also given the knowledge and skill of determining and measuring out correct doses of medicines and injections, stock keeping, and record keeping. The training evaluation in February 2003 revealed that in a written examination to test knowledge, out of 92 VHWs who were evaluated, average score was 86.1 %, with only 6 VHWs scoring 70% or below. As many as 94 % of the VHWs scored marks above the passing level of 70%. On examining the results in the light of the area of the NGOs, it was found that there were no significant differences in the performance of VHWs on the basis of the area be it tribal, rural or urban although the VHWs of urban areas did a little better than VHWs of rural and tribal areas. The difference in performance on the basis of the educational levels of the VHWs too was not all that significant. The average scores for VHWs with education up to 7 years of schooling was 83% and of those with more than 7 years of schooling was 89%. Even those VHWs, who had schooling only up o 5 years, scored 81.2 %. Results of the written test showed a good understanding of the basic principles of home-based neonatal care. Ninety percent of the VHWs could calculate EDDs correctly in five examples and 87% could state the temperature for a newborn to be considered hypothermic. All the VHWs stated that a newborn did not need a bath on the first day; the cord should be painted with gentian violet and 97% knew that frequent breastfeeding was the solution for mothers perception of insufficient milk for breast feeding. It is important to note that most VHWs had 4 to 10 years of schooling. Many of them were first generation learners, belonging to the most backward regions, poor, rural, dalit or tribal. For some of the VHWs, the NGO had to take special efforts to revive the skills of reading, writing and basic arithmetic. Checking time using a wristwatch was a novelty for some VHWs as they had touched a wristwatch for the first time in their life during the training under HBNC. Starting almost from the scratch, the VHWs were trained to reach a level sufficient to provide HBNC services competently. They were able to interact with the community and the visitors to the Ankur sites, and even deliver speech in public functions. All the essential skills of HBNC package were transferred by the NGOs to the VHWs through training, informal meetings, and face-to-face instructions. Broadly, these skills could be divided into 3 categories -Medical, Non -Medical and Communication skills. Medical skills : These skills included skills to identify complications in pregnancy, examining newborn, identifying and managing neonatal ailments, identifying and managing high risk babies including skills in measuring temperature, counting respiratory rate, weighing the baby and giving injection.

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Non- Medical technical skills : These included skills related to record keeping, stock maintenance, skills of hygienic practices when handling newborn, and checking time using a wrist watch. Interpersonal skills : These included skills in delivering health education to the pregnant woman and her family effectively, convincing the community to avail the services provided under HBNC, skills to arrange meetings in the villages and ensure villagers participation in the meetings, work in coordination with TBAs, amicably handling / solving problems in crisis situations and in situations requiring concerted / cooperative action from the concerned family members and the neighborhood, and dealing with stakeholders in and around the village. VHWs were trained to maintain useful relationship with other VHWs and supervisors to facilitate congenial environment for learning. The evaluation looked into all the necessary skills that were transferred to VHWs. The overall performance was 94% with 72% achieving 90% marks. However, it was observed that the complex tasks such as treating sepsis and birth asphyxia needed more practice. Filling Form A (antenatal), Form B (delivery) Form C (1st examination at 1 hour) and Form D (home visiting after delivery) were generally very good (i.e., > 95% when adjusted for no cases). The VHWs themselves recognized that they had grown substantially in their ability and their personality in general. This was articulated by almost all the VHWs interviewed by the process documentation team. Desheeribai of AAA articulated that her personality had completely changed ever since she started working as VHW at AAA. Especially the group learning processes had made her very confident and it helped her in providing services also. Attitude / Quality of work / Strength of VHWs : Along with the knowledge and skills, it was expected of the VHW to imbibe / develop certain values / attitudes to deliver the services in the community. Certain qualities which were actively sought while selecting the VHWs included the following: (a) Kind and sympathetic to beneficiaries including mothers, children and general patients (b) Non-discrimination treating everybody equally irrespective of caste, religion, economic status (c) Prompt in performing duty (d) Eagerness to learn, work, and provide services (e) Calm, composed and soft spoken (f) Honest at work (g) Ready acceptance of mistakes (h) Caring of newborns (i) Confident (j) Capable of convincing people (k) Neat and tidy (l) Courteous (m) Assertive (n) Cooperative and (o) Values gaining acceptance from community Attitude / quality of work / strength of VHWs were evaluated by the respective trainer supervisors (NCS /VSS). Altogether 96 VHWs were assessed. The assessment was done in three sections. The first one assessed the VHWs attitude towards her work in general, and how she treated the people she served. The second section looked at the VHWs quality of work, her punctuality, her neatness and the completeness of her service provision. The third section assessed her strengths and capacity to work. Each section contained 25 points, and each response was assessed on a scale of 0-5. The results revealed that most of the VHWs got more than 90% marks in the attitude test and over 85% for quality of work. There appeared to be slight difference in attitude by area, with scores lower in tribal and somewhat lower in rural areas than urban areas. It was observed that VHWs working in urban area got about 97% marks followed by VHWs of rural area whose average score was 92.3%,

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but the VHWs working in tribal areas could score only 84%. The differences could partly be due to better capacity of articulation in the urban VHWs. When reviewed by master trainers, the findings were consistent; the exception being one VHW who received a C grade from the NCS but the master trainers felt she deserved a B grade, and 7 cases where the master trainers thought that the NCS scored too high against 6 VHWs receiving A grades, they felt B grade was appropriate, and 1 VHW with a B grade was judged as of C grade.

Trainer-Supervisors :
They unequivocally stated that they had imbibed important attitudes and values essential for commitment and involvement towards implementation of HBNC programme. The values of attaching importance to saving newborn lives was inculcated in all of them. They realised it as the prime commitment in their work. They provided all possible support to the VHWs to work in the community and deliver services. NCSes did not restrict themselves to the strict working hours. They were prepared to provide service to the community through the VHWs supported by them even at night, realising that there were no other facilities nearby. During their stay in SEARCH for each training workshop, they left behind their families and concentrated only on learning. Absenteeism was rare. During the review meetings, (which usually were three to four-days period of intensive learning), the NCSes and VSSes showed full attendance and attention. In these review meetings all the trainer-supervisors, without an exception, exhibited meaningful interaction and participation. They were open to learning, criticism, and correction. They became bold and mature after undergoing the training. It is important to appreciate the fact that many of them used the training and supervisory skills acquired by them under HBNC in other programmes of their respective organisation. They were ready to accept their mistakes and work towards rectifying their mistakes without unnecessarily arguing. This attitude helped them to understand themselves better and also to gain a sound knowledge of HBNC package and to minimize the mistakes during field visits. This attitude of supervisors also helped collection of accurate data. To check the quality of data collected during the vital statistics survey, VSSes of all the NGOs were usually asked to bring their data to SEARCH HQ to crosscheck the data set. To reduce the number of mistakes they (VSSes) voluntarily decided to pay a penalty of small token amount of money for every mistake that was found in their data set. Almost all the supervisors were very comfortable with the community they worked with. They were at ease with important persons in their respective area. Organising village meetings and group health education sessions required commendable rapport with the community. Owing to their good relationship with the community and leaders, the supervisors with the support of VHWs, easily identified and located the important people in the community, managed meeting community leaders, find a place to have a discussion or for having food, and working out logistics. They were also aware and sensitive to local norms such as those related to caste, women, and religion, as infringing these could jeopardise NGOs relationship with the community. Although social background of the supervisors varied, they were inculcated with a value of non discrimination and did not discriminate on the basis of caste, religion or ethnicity and provided services to all the families irrespective of their social background, on the basis of their need. They were found

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to work and interact with the VHWs and the TBAs from different communities. In the area of SN for instance, caste polarisation was found to be intense, yet the supervisors were able to reach out to everybody. Invariably, in all the NGOs, NCS and VSS gelled into a good team without having any superiority/inferiority complex or hesitation in working with a team member of an opposite sex . Often male VSS provided logistical support for the female NCS and facilitated her visit to the villages at any time of the day. On the other hand the VSSes gained confidence to supervise provision of treatment by the VHW and also learn medical aspects in the presence of NCSes.

Project Coordinators :
Project Coordinators held the apex position in the ANKUR project at the NGO level. As members of Ankur team, they were also provided orientation and training. Every project coordinator made efforts to improve rapport with the community, to have a clear grasp of social composition of the villages / basties, and established a good relationship with the community leaders, some of the stakeholders, public health personnel and individuals with philanthropic values in the project area. This was evident through various programmes, and functions, which they conducted with the support of the community. A good teamwork and coordination among project coordinator and other personnel was visible in the NGOs studied. Even for attending review meetings, the project coordinators preferred to travel along with their team members and also allowed space for their VSS and NCS to articulate their views and make decisions.

Transfer of Mission, Values, Attitudes and Leadership :

It has been SEARCHs mission to address the problem of child mortality. With complete involvement in the child mortality study and subsequent partnership in Ankur, all the NGOs imbibed the gravity of the problem of child mortality in the state especially in tribal, rural and poorer settlements in urban areas. The NGO personnel acknowledged the importance of reducing infant mortality, especially neonatal mortality for overall improvement of health status of the community. Project coordinators and the supervisors were able to relate the relationship between the lack of minimum health care services and the high levels of neonatal and infant mortality. All the three NGOs chosen for the prospective process documentation placed HBNC as the most important programme in their developmental agenda. The mission of empowering the community through transferring necessary basic skills was considered by these NGOs to be the most significant way of addressing the issue of lack of access to basic health care including neonatal care. SEARCH also wanted to transfer important un-stated values and attitudes to the Ankur NGOs. Some of these are (a) Empowering the community with knowledge and skills as large population of the country especially living in rural, tribal and even in urban slums has poor or no access to institution based facilities (b) Need for NGOs to appreciate the strength of good research and data. (c) Importance of advocacy - through sustained and concerted efforts it is possible to get the support of the community, civil society organizations such as community based organizations, media, and professionals, as well as from bureaucracy and the government. (d) Importance of rigor in all aspects of

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project planning, developent and implementation, and (e) importance of training and of trained human resource. Through their partnership with SEARCH, orientation and rigorous training, the Ankur NGO staff imbibed the values that were to be transferred. At least three of the NGOs took up other projects (apart from HBNC), which believed in empowering community through transfer of knowledge and skills. All the partner NGOs came to appreciate the importance of good research and data not only in the HBNC project but also started collecting and using data in many of their other projects. Most of these NGOs began to identify community problems and solutions through community interaction. The NGO personnel began to attend Gram Sabhas where people air their problems. The NGOs looked to the community as partners and allowed priorities to emerge from them. This became the essential approach of all the NGOs. Importance of advocacy was imbibed by the NGOs through their involvement with SEARCH. All the 3 NGOs studied by the process documentation team during the prospective study, entered a phase wherein they had begun to play important role in the formation and working with network of NGOs, such networking through NGOs being another channel for advocacy. Basic skills of management and planning were transferred to the NGO heads and supervisors. In addition to acquiring these skills, most of these personnel had also come to appreciate the importance of planning, rather than doing something just because it was to satisfy the funding agencies. All the NGOs adopted and used systems like pro-forma, supervision schedules, and defined job responsibilities, not only in the Ankur project but also in other programmes. NGOs started to attach importance to training and trained human resource. Some of the NGOs allowed their personnel to get trained in additional special skills. They also allowed their staff to develop into master trainers so that the lower level staff in their organisations could be trained adequately. In AAA, the VSS was allowed to train staff from other NGOs on community based rehabilitation of people with disability. HBNC demanded leadership skills to deal with community, create community support for the project, gain the support of stakeholders, motivate the staff including VSS, NCS, and VHWs, anticipate and identify problems and solve them, take decisions in life-and-death situations, and above all maintain the required level of rigour in implementing the programme. The ultimate aim of the project was to transform each NGO partner into learning centres. Leadership skills, aspiration and the desire to take up leadership role and initiative were transferred through training, orientation, workshops, review meetings, and by suggesting and distributing reading material. This transfer was not limited only to the NGO heads / project coordinators but also to the supervisors. This was evident from the manner in which the NGO heads were conducting their NGOs. Each NGO head had his/her respective style of leadership. Except for crucial decisions, the NCS-VSS team used to do the day-to-day planning and implementation of the programme. One of the distinguishing features of SEARCH as an NGO has been its work culture. Emphasis on rigorous and meticulous mode of work, a strong flavour of community life stressing interdependence and self-reliance are some of the important ethos of work culture shared by all the members of SEARCH. Many of the Ankur team members took up this workaholic spirit. It was reported by supervisory personnel that almost all the NGO heads had very long working hours throughout the year. They kept shuffling between travelling and office-based work. Not only the NGO heads, but the super-

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visors too were workaholic. Peer group formation amongst the ANKUR partners was facilitated through different training sessions and workshops. These groups displayed very strong interaction. These informal interactions played a very important role in facilitation of each other, motivation, and setting up group norms for achievement, aspiration and compliance. The Ankur NGOs had indeed gelled into a cohesive group. This was evident in the extremely informal and friendly relations the personnel shared with each other. There had been instances of NGOs providing support to each other, even financial support at times of need, or getting FCRA clearance. Ankur NGOs were paired and personnel of one NGO of the pair visited the other and vice versa as peer group visits. The purpose of such visits was learning from the experiences / innovations / problems faced by each other and joint problem solving.

Conclusion :
The findings under this chapter have brought out clearly the identification of a challenge which became the mission; the meticulous and minute planning exercise carried out to ensure that nothing was left out in transfer of HBNC to the Ankur NGOs and the training details in terms of curriculum, training materials and training methodology were chalked out very clearly before launching the training. The modular and step-ladder format for training was very innovative and effective to transfer the HBNC knowledge and skills. Further, the training was institutionalized within the Ankur NGOs rather than SEARCH continuing to play the role of trainer. On the whole, the transfer process was very elaborate, viable and sustainable. Thus, all the preparations for implementing the Ankur project by the 7 NGOs in their respective areas were completed and they were ready to start the implementation of HBNC.

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Chapter - IV
Process of Transfer to the Communities : Implementation
Introduction :
Having completed the preparation for implementing the Ankur project, the next challenge was of delivering the HBNC package in the chosen areas of the 7 Ankur NGOs. Though SEARCH had experimented the HBNC successfully in its own intervention area in Gadchiroli district, it was difficult to predict the results of implementing the HBNC not only in a different environment but also by the 7 NGOs, which were different from SEARCH in terms of their leadership, values, knowledge, skills and resources. In this chapter, we look at the processes to motivate the NGOs to deliver the HBNC package in their areas. Further, the chapter focuses on the efforts to ensure that right persons were placed at the right place and right time; and were motivated to deliver HBNC effectively.

Service Delivery :
Delivery of Home-based Neonatal Care
For the ANKUR project, the entire package of HBNC, mode of delivery, and selection of personnel to deliver the HBNC was designed based on the GadchiroliHBNC field trial. The home-based neonatal care by the VHWs was introduced in the community in an incremental fashion. During the training phase, first 9 months were used only for home visiting, collecting data, observing delivery and neonates, examination and recording the findings . The data collected during the period provided the pre-intervention morbidity rates. The VHWs performed the following activities in relation to mother and neonate during January to October 2002: a) Preparation of list of eligible women b) Preparation of list of pregnant women; registering them and filling information regarding their previous deliveries in Form A c) Attending delivery and recording observations or details of delivery including condition of the mother and the newborn in Form B d) Examining the baby at 30 seconds / 5 minutes / within 6 hour and recording observations in Form C e) Making home visits to examine the mother and the newborn and recording information in Form D, f) Recording still births, births and deaths within the neonatal period g) Injection Vitamin K to newborns, h) Treatment of fever, aches and pains to community members. From October 2002, the VHWs started the first intervention i.e. providing health education to pregnant women and providing help in respect of breast-feeding problems. From November 2002 onwards they started thermal control and management of high-risk babies. From December 2002 they started management of asphyxia and sepsis. Although theoretically HBNC had to be offered to the complete population in the chosen area, as on January 2003, 98.2 % of the total population was covered under Ankur. Less than 100% coverage was

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reported in two NGOs namely VACHAN and SRUJAN for the reason of non-availability of VHWs in some villages and impracticability / inability of the VHW from the nearby village to attend these villages because of problem of long distance and difficult terrain. After the review of the situation in the month of January 2003, it was decided that at least certain minimum services must be provided to such population by the VHWs nearest to this population. These are: Visit and health education during pregnancy, giving information on danger signals to the family, visit on the 7th day of birth, injection vitamin K to the neonate, and visit on the 28th day. Some components of the treatment of childhood illnesses were incorporated into HBNC package. VHWs were trained for treating diarrhoea with ORS, and dysentery with Furozoludin tablets, treating pneumonia in children by using co-trimoxazole and giving nutrition education to parents of the under 5 children in addition to education on diarrhoea and pneumonia. Advice on preventing rise in babys body temperature due to high atmospheric temperatures in summer months was another task added to the tasks of the VHWs. In the review meeting of January 2004, criteria for diagnosis of sepsis was revised. NCSes and VSSes were first trained and they in turn trained the VHWs to identify sepsis using the revised criteria from March 2004. Accordingly, the newborn form was revised to incorporate the revised diagnostic criteria. This was done to increase the reporting of true positive cases and reduce the reporting of false positive cases of sepsis.

Approach to handle non-TBA assisted or institutional deliveries

Significant percentage of hospital deliveries in some of the project sites, resulted in a situation where in such cases HBNC could not be given to the mother and child till their arrival home from the hospital. This was recognized in the project proposal itself. An approach to deliver relevant components of HBNC in case of institutional births or births not attended by the TBA was devised. All pregnant women received education about notifying the VHW at the time of labor even if the birth was not to be attended by a TBA. In case of institutional deliveries, the families were requested to notify the VHW immediately on return of the mother and the child home from the hospital.VHW was expected to make a home visit within 3 hours of return of the neonate and mother from the hospital. Baby was weighed immediately and the VHW checked whether vitamin K was administered to the baby in the hospital and took corrective action if necessary.

Health Education
Content of Health education : The health education material was developed based on the experience of SEARCH in Gadchiroli trial and adapted to the local need and culture based on the knowledge practice study that was undertaken in each site. The content included instructions, advice and encouragement on a) Nutrition during pregnancy b) Care during pregnancy c) Danger signals during pregnancy and in delivery d) Care during post-partum period e) Neonatal care f) Seeking the services of VHW for neonatal, child and maternal care g) Notifying the VHW at the time of labour and in case of institutional deliveries, on returning home.

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Health education material : It was designed, developed, printed and supplied to the NGO partners by SEARCH. The materials comprised a flip Chart and pamphlets. A 50 minute film titled Tanhula in Marathi and Nanhisi Jaan in Hindi was also produced for group health education. This film has been specially designed to conduct interactive sessions during these health education programmes Mode of delivering health education : The mode of delivery of health education to pregnant women, mothers / mother-in-laws was one-toone counseling to individual beneficiaries by the VHW during home visits as well as in the form of group health education in the community by NCS. Health education was also imparted to the TBAs during their training who in turn were expected to reinforce the health education received by the beneficiaries from the VHWs. One to one health education sessions were held thrice during pregnancy, and once on the second day of birth. Group health education by the NCS assisted by the VHW, was conducted once in 4 months for a group of pregnant women and their caretakers including mother in laws, sister in laws of the pregnant women. The practice of pregnant women migrating to mothers place for first few deliveries seriously affected the delivery of HBNC. If a woman came from her mother-in-laws place (in a non ANKUR area) to her mothers place (in the Ankur area) for delivery, she would not have received any health education. Therefore, she had to be given all the appropriate health education messages in the remaining period of pregnancy after her arrival. Similarly, a woman from ANKUR area who migrated out would miss the remaining sessions of health education. Therefore, such women who were expected to migrate out had to be given health education earlier. The efficacy of the health education was evaluated by keeping the knowledgepractice follow up. Two weeks after the group health education, the VHW visited each mother and recorded her level of retention of messages given in the health education session. The NCS, during her/his home visit observed and recorded the health behaviors. This information was used to assess the effect of health education.

Motivating Villagers to Accept HBNC

To encourage the villagers to accept the neonatal care services given by the VHW, various measures were undertaken by the NGOs. The VHWs were made to participate in all the important village functions such as the Independence Day celebrations. Taking such opportunities, they tried to explain the project activities and its importance in saving life of newborn. Self-Help Groups of pregnant women were attempted. The NGOs kept contact with village leaders and reported to the villagers (Gram Sabha) the activities carried out under HBNC programme. During the training period, periodic meetings with villagers were held in the presence of VHW, who would inform the villagers about the new skills she had acquired. The HBNC programme also had component of giving medicines for minor ailments, to any member of the community. This gave entry point and access for the NGO / VHW to the community and motivated villagers to seek the VHWs services.

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Increasing the Utilisation

The most explicit and direct way of increasing utilisation of HBNC services was through the beneficial effect of the very service itself. As there was very high incidence of neonatal morbidities and mortality in all the sites of the project, a very high inherent priority among the communities was present and hence the utilisation was naturally high. Adjunct services such as pneumonia treatment for under-five children, and the service of treating minor ailments in general population too acted as important factors increasing utilisation of HBNC services. The services being offered under HBNC package were expanded later to include treatment of problems such as diarrhoea. Reaching out to people through health education sessions, group health education sessions, educational pamphlets, posters, and public functions were other activities that promoted community utilisation of HBNC services. Involving the community in selection of VHWs, coordinating with TBAs, legitimising the programme by taking consent from the gram sabha and keeping the gram sabha informed about HBNC related developments were other related measures that had promoted community support, acceptance and utilisation. Sahayog Nirmiti (SN) used vitamin K as a focal point to promote utilisation. SN emphasized to the community the cost of vitamin K injection, its importance and the fact that it was not available in local public health institutions. This created a sense of need in the community to avail HBNC services. ISSUE created awareness among people by distributing pamphlets on HBNC and services being provided by the VHWs in the project area. While on a home visit, the VHW always kept some pamphlets with her. On meeting a new person, she gave the pamphlet. ISSUE also utilised its Child Line Project to provide support to the families with child-health problems. SRUJAN presented clothes and knitted woollen cap/ hood to newborns who completed 28 days, as a celebration of newborn health in its area. It served as a way of reaching out and increased the degree of acceptance and utilisation of HBNC services. SN had organised a public speech by Dr. Bang in Hipparga Tad, a day before review meeting in January 2004. Around 300 people attended this function from the local community. Dr. Bang spoke on many related issues with emphasis on HBNC and the services being offered by the NGO and especially the VHWs in each village. Such functions too helped build a sense of consensus on the need to respond to the problem of neonatal deaths and therefore higher utilisation. NIWCYD organised a public function on HBNC which was addressed by the president of the Zilla Parishad and Dr. Bang. Most NGOs had intensified their contact with the community through an array of programmes such as SHGs, EGSs, and Grain Banks. In each village, the NGOs had established working relationship with greater number of women and families. This had intensified the relationship the NGO had with the VHWs and the TBAs. All this had, in general, given more visibility to the VHWs, the NGO and to the HBNC programme. These activities too had increased the utilisation of the programme.

Working with Community :

It was important that a VHW enjoyed higher stature in the eyes of the villagers for better acceptance of her services. This stature usually resulted from her skills as well as from the attention she got. Most direct form of empowerment of VHWs was through training given by the NGOs for acquiring skills and

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knowledge essential for the delivery of HBNC. This also involved skills of interaction with the community and delivering health messages. It was also decided to conduct felicitation programmes for honouring/felicitating the VHWs on completion of the training successfully. This was done by all the NGOs. On these occasions, important guests like government officers such as district health officials, staff of PHC, community leaders or representatives of SEARCH were invited for distributing certificates and gifts. During the felicitation programme, the VHWs were asked to come forward to narrate their experience of training and service delivery. NGOs also conducted other functions; (secular or religious) in which the VHWs were given important roles to perform. SN formally celebrated the Independence day and the Republic day. On these days, VHWs, TBAs and community members; especially women, were invited and one of them was asked to hoist the flag. Haldi-Kumkum function was arranged on these occasions. During review meetings too, VHWs were asked to deliver a short speech, narrating their experience. During public functions (e.g. the meeting held before the review meeting in Sahayog Nirmiti) held in front of the local villagers, the VHWs were asked to honour the guests by offering flowers. They were asked to narrate their experiences. By various methods, the VHWs were given prominence and visibility in the eyes of local people in such public meetings. VHWs were asked to sing songs in a group. NGOs made it a point to give prominence to the VHW whenever a visit was made by any team of visitors e.g. visit by a group of doctors to the HBNC villages of NIWCYD. Such visits often involved spending considerable time with the VHW in her home, accompanying the VHW on a home visit to observe delivery of HBNC by her, interaction of the visiting team with important people in the village (including Anganwadi worker, ANM). Sometimes the visit would include a short function of felicitating the visitors during which the VHW introduced the team. If a doctor happened to be a member of the visiting team, the visit would involve some villagers consulting the doctor for treatment. Such visits too raised the stature of the VHW in the eyes of the villagers. Most of the NGOs also gave priority to the VHWs while recruiting members for their other programmes. For example, in most project villages, VHWs were members of the SHGs. They were also given priority in other programmes such as womens empowerment activities, employment generation schemes, water-shed management, and savings groups. All the NGOs made efforts to build strong relationship with the families of the VHWs. In all the villages where the process documentation team visited, the team had no problem in interacting with the family members of the VHWs. There was not a single case of resistance to its visits. There was no problem of finding a place to sit and have a meal in the house of the VHW. The hospitality they offered reflected the support the family members of the VHWs offered to the VHWs as well as to other personnel of the NGO. The NGOs always supported the family members of VHWs visiting the NGOs office either during the training sessions of VHWs or even subsequently. VACHAN had extended an open-invitation to the close relatives of the VHWs to visit the NGO office any time. VACHAN had arranged a special function for the family members of all the VHWs and presented wall clocks to the husbands and sari-choli to the mother-in-laws of the VHWs. During the review meeting at VACHAN, VHWs were invited for a special meal along with other participants. NGOs also provided informal support to the families of

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VHWs in the form of limited support for childrens education and health care for any of the family members. Empowerment of VHWs essentially means empowering the community through VHWs. This was indeed observed as some of the examples below illustrate.

Health
In the basties where ISSUE was operating, provision of immunization services by the government was completely stopped. One of the VHWs, Lata Sonsate along with other women of the community, went to the office of the corporator and demanded resumption of the immunisation services. After protracted and concerted efforts on the part of the VHW and the community women, the service was resumed.

Economic development
The collective benefit to the community through empowerment of VHWs is not limited to the realm of health care alone. In SRUJAN, one of the VHWs took up the problem of low price offered by the merchants for the agricultural produce. The chief agricultural produce in question was chilli. She asked the villagers not to sell chilli below a certain price and haggled with the merchants to raise the price offer. She was indeed successful in substantially raising the price offer for chilli.

Development
Most of the NGOs involved VHWs in other activities such as SHGs, saving groups, and employment generation schemes. The degree of awareness gained by the VHWs facilitated a meaningful participation by them in such activities. For instance, in the village Arabali of SN area, VHW, Beeby Nadaf helped a family to obtain loan from the SHG group for availing hospital treatment for their children. Such collateral mediation between programmes could make these schemes more meaningful than being promoted as unrelated / segmented developmental programmes.

Political Empowerment
The VHWs exposure and the awareness led to their own political empowerment, and of the community. In AAA, one of the VHWs was elected as vice-president of the panchayat. She used her position to promote HBNC. She addressed meetings to promote HBNC in the community as well as to gain the support of other local body officials.

Building Community Ownership :

Building community ownership of HBNC as an objective of ANKUR was not part of ANKUR. The community was expressly involved in the project only for giving consent letter and recommending 2-3 persons from the village for selection as VHW. The project addressed only the pregnant women, neonates, TBAs, and under 5 children. The entire population of the village was not consciously under consideration(except for provision of treatment for minor ailments). It was left to the individual NGOs to make efforts for building community ownership. Community own-

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ership is an important aspect of sustainability. In certain circumstances, communities had expressed their willingness to support the programme in case the financial support for HBNC ceased. On many occasions, community indeed provided support in different forms to the NGO and HBNC personnel to facilitate the programme implementation. In Alitola village of AAA, Police Patil (Rajimsai Paikuboga) and Sarpanch had offered commendable support to the VHW (Dharambabai) in her conflict with another woman who had also unsuccessfully competed to become VHW. This woman used to dissuade women from approaching the VHW and had also threatened the VHW. The problem was solved by the intervention of the Police Patil and the Sarpanch. During review meeting conducted in Hipparga Tad (SN), the local community had provided a wide range of support including labour, in making all the necessary arrangements, maintaining absolute silence for three days around the place where the meeting was taking place (otherwise a noisy area), providing accommodation in public buildings for conducting the meeting, arranging for the participants accommodation, and gracefully attending the function held on the occasion.

Co-ordination with TBAs

It was necessary that the VHWs maintain a healthy relationship with TBA and attend deliveries alongwith her. Based on its experience in Gadchiroli trial, SEARCH had suggested strategies to obtain TBA involvement. As per the package, TBA training included sessions on safe and hygienic delivery and a kit was also provided to them. TBAs were also given monetary remuneration (Rs 5) for reporting births. Every NGO had to convince the TBAs that VHW would not conduct delivery but will only take care of the child. Despite these formal ways of associating the TBAs, initially many of them did not invite the VHWs to be present during delivery as they harboured an apprehension that the VHWs would learn all their skills of conducting delivery and ultimately replace them and deprive them of the remuneration they receive from the families. This resistance from the TBAs was experienced by all the NGOs. For example, the VHW of Hipparga Tad (SN) Chandrakala Panchal expressed that Simintha Sakara, a TBA did not provide sufficient cooperation. To alleviate this sense of insecurity, individual NGOs employed a number of strategies. For example the NGOs invited the TBAs for functions conducted in the village or in the NGO. On these occasions or sometimes during festivals TBAs were given gifts. In ISSUE, a TBA, Yashodabai Chandrakar of Panchavati Nagar, was unwilling to call the VHW to attend deliveries. She belonged to the Chhatisgarhi community. VHW Mangala Ghodeswar is a Hindu. Except for about 25 houses in Panchavati Nagar, all other houses were of Chhatisgarhi community. Yashodabai used to attend all the deliveries but never called the VHW in time. She used to call her after the delivery for examining the newborn. Everybody (NCS, VHW, and project coordinator) tried to convince her about the importance of VHWs presence at the time of delivery. She did not pay attention. In May 2003, a public awareness meeting was organized. In this meeting, important individuals from the community, VHWs and TBAs were present. The entire meeting was conducted in Chhatisgarhi language by the team from Garib Nawaz Nagar under the guidance of NCS and the project coordinator. TBA from Garib Nawaz Nagar explained the importance of attendance of the VHW at the time of delivery and how it was helpful for the TBA. The community as well as Yashodabai was convinced. AAA conducted a felicitation programme exclusively for TBAs (Daincha Satkar), in September 2002. On this occasion, around 38 TBAs were honoured by offering them Saree and Choli. It was an elaborate function attended by local leaders. The gifts were given at the hands of these leaders.

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Some of the TBAs were also asked to share their views / experiences. The occasion was also used to explain to them about the HBNC programme and the activities of the VHWs. VACHAN organised an eye check-up for all the TBAs and those who required corrective surgeries were provided support and spects were given free in cooperation with National Association of Blind. In VACHANs area, women traditionally wear gold beads tied in a black thread. So, VACHAN presented gold beads to the TBAs. In most of the Kolam poads (hamlets) of SRUJAN area, the family members themselves take care of the delivery and there is no system of TBAs. Among Gond population and other communities where TBAs were functional, SRUJAN asked these TBAs to be part of celebration of life ceremony conducted after a child attained 28 days. Some NGOs provided remuneration to the TBAs for giving message to the VHWs to attend delivery. SN associated some of the TBAs in the implementation of their PACS programme..

Dynamics of Stakeholders :
Each Ankur NGO had to deal with a variety of stakeholders, who could significantly affect the implementation of the HBNC package. The stakeholders included medical professionals in the government and the private sector including health workers already working in the project villages, community leaders, political activists etc. The dynamics of working and personal relationship of the Ankur project workers with them was crucial to the success of the project. The participating NGOs tried to maintain good rapport with the government medical facilities and their personnel. They considered the support of doctors in the government facilities essential for the implementation of the HBNC package. AAA maintained very good relationship with the medical officer of the rural hospital in Korchi. He participated in the functions of AAA and encouraged the project workers. SN had good relationship with the PHC doctor of Andoor. He provided a lot of support to the VHWs and acknowledged the importance of their role. He also respected the referrals from the VHWs. He even agreed to display some of the HBNC messages in the PHC. In some places, the presence of the government ANM and the Ankur VHW in the same village created tension and conflict. In the village Umarga of SN, the ANM was the wife of the local money lender. She spread rumours against the VHW. The NCS tried to solve the problem and over a period of time, the degree of acceptance of the VHW increased considerably in the village. Similarly the Anganwadi workers in the project villages of SN created problems of coordination. In village Hipparga of SN, the local ANM tried to spoil the relationship between the VHW and AWW. In some of the project areas, there was political interference and resistance from the community. ISSUE, working in urban slum in Nagpur, could not get the consent of the local municipal councillor but had to work on him for a while to get his support. ISSUE also experienced a peculiar problem from the community. As per the HBNC guidelines, the VHW had to wash her hands and air dry them (by holding the hands in proper position-fingers pointing up and elbows pointing down). But this posture was misinterpreted as a posture of praying to Christ and the NGO was accused of proselytising. In the case of SN also, the name SEARCH created a misunderstanding in some of the villages that SEARCH was a Christian organization. Therefore, SN, instead of referring to SEARCH by its name referred it as Shodhgram, the name of SEARCH head quarter campus. SN also had problem with a local politician in village Yevati, who opposed the VHW vehemently. However when the VHW saved the life of a dying neonate in the village, she received legitimacy and acceptance from the politician.

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Administering Vitamin K injection was a contentious issue in one of the Ankur project area. Since the injection is given almost immediately after birth, the NGO thought that it may face opposition from the community and any health problem of the neonate thereafter would be attributed to administration of Vitamin K injection. This opinion was based on two cases which had occurred in the area, of death of children after administration of an injection by a village doctor. Under these circumstances, initially the VHWs of VACHAN were scared to give this injection and VACHAN delayed initiation of administering the Vitamin K injection. Normally, the project workers received good response in those areas, where NGOs were already active. Caste difference between the VHW and the target population sometimes came in the way of implementing the HBNC package through her. In the RSP project area, some Maratha families in Savali village were reluctant to seek services from the VHW, who was an OBC. Some affluent Jain families did not seek the services of the VHWs (but this may have been because they could avail services of a private doctor).

Human Resource Management :

The population-personnel ratio, eligibility criteria, selection procedures, job responsibilities, and activity profile, of different HBNC personnel including VHW, NCS and VSS were elaborately worked out based on HBNC experience of SEARCH. The approximate population to be served by different levels of personnel had been worked out to be one VHW for one thousand population and one NCS per study site. The eligibility and selection criteria for personnel implementing HBNC including VHW and NCS were standardised.

Selection and recruitment of VHWs

Model of selection and recruitment of VHWs suggested by SEARCH with necessary variations demanded by local conditions, was adopted in all the seven NGO sites. Following were the eligibility criteria for a VHW a) Resident of the village b) Married woman with children, c) Family support d) Acceptable to whole of the community e) Ready to provide service to whole of the community irrespective of caste or creed f) 5-10 years of schooling and g) Suitable personality as identified by the results of the tests administered at the time of selection. The NCSes and VSSes were trained in the method of selection of the VHWs. The community was apprised of the criteria and duties of the VHW. The names of at least three candidates were obtained from the village. The residential selection camp was of three days duration, during which the candidates were tested for their ability to read Marathi, write clearly and legibly without mistakes, memorize items and events, verbally communicate with a group, and build community contact. A variety of techniques were used to evaluate these skills. These included formal exercises, games, and observations by the selection team. Three different examiners marked the performances. The best performer from each village, subject to a minimum acceptance performance of 60 % overall, was selected as the VHW. In case no VHW could be selected from a particular village, the process was repeated. The number of VHWs in the tribal areas was increased, as the concept of hamlet worker was not found viable. In the tribal areas, compromise had to be made in the selection of the VHW. In some cases only one name emerged from the village. Sometimes the criteria of educational level had to be relaxed so that a VHW could be selected.

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It was agreed that the scale of remuneration to the VHWs be on the basis of local conditions. SEARCH provided a remuneration model but left the matter to individual NGOs to decide on how they would remunerate their VHWs. AAA gave Rs. 100 as a basic amount to all the VHWs. Over and above this amount, all components of the services were taken into consideration and remuneration was on the basis of quantum and quality of services provided. For a village of larger population, the basic amount was increased to Rs.150. ISSUE, being an urban area, gave Rs.700 as basic and resorted to cuts for mistakes in service delivery. SN gave a fixed amount of Rs. 500 per month. Area assignment to the VHWs had to be reorganized and reassigned. In spite of these efforts, it was found that some of the hamlets were left out. To address this issue, a number of alternative strategies were thought of viz., hamlet worker, specially trained TBA (Maha dai) and messenger at various points of time during the implementation.

VHW Turnover
Some NGOs faced the problem of turnover of VHWs (Four out of 100 selected). Resignations of VHWs were at different point of time, right at the beginning of training or later. Reasons for the drop out were varied. Common reasons were: opposition from husband, mother-in-law or other family members; not being able to cope up with increased domestic burden after birth of a child; illness of a family member or her own indifferent health; migration out of the project area. There was also an incidence of unfortunate event of demise of a VHW (SRUJAN). Different NGOs had responded differently to this problem depending on the availability of alternative candidates and the stage at which the vacancy arose. There were instances when some of the VHWs wanted to quit for different reasons but the respective NGO heads visited VHWs family, and successfully convinced her family to reconsider the decision. Dropout in the early phase did not pose major problem as the training had just begun and / or was still in progress. They could recruit new VHWs and train them along with the rest. A dropout in a latter phase was however a different matter. This had to be tackled by re-assigning the area to the VHW of the adjoining villages. In some NGOs, where dropout was either late in the training phase or after the training or when adding the area to another VHW was not feasible, a new VHW was recruited and trained by the NCS intensively in a short duration either separately or during revision training workshops for other VHWs.. The new VHWs were also asked to accompany other well-trained VHWs on home visits during the initial days. This form of crash-course, and peer-learning was the strategy of training new VHWs.

Selection and recruitment of NCS

The following were the criteria for selection of NCS a) Qualified staff nurse, ANM or Non MBBS doctor b) Willingness to travel in the rural area and train and supervise village women and c) Having personal attributes suitable for the task. An advertisement was placed in the newspapers. Applications were short listed and candidates called for interview. Selection tests and interviews were held at each site with a member from the SEARCH or Green Earth team present. However, there were variations in number of applicants and those who had appeared for interview in different NGOs. In Sahayog Nirmiti, there were a large number of candidates while in AAA, the advertisement in newspaper was in vain and the candidate chosen was contacted through a SEARCH team member. In SRUJAN, the chosen person left on the day of joining and another NCS had to be recruited. NCS selection test included interview to check the technical knowledge of the candidate. Tests through role-plays, case analysis, memory recall test and group discussions were also used. The selection

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process was designed by GreenEarth and SEARCH, but they allowed variations in different NGOs. NCS received a salary of Rs. 5600 per month + 10% increment every year. SEARCH, GreenEarth and Ankur NGOs drew the terms of employment of NCS. The terms included a condition that NCS would have to deposit Rs.50,000 as a refundable deposit with the NGO. The deposit would be returned at the end of the project. However this was not possible to implement. As an alternative, an amount of Rs.1,000 was held back from the salary of the NCS every month till the amount reached a value of Rs. 50, 000.

Vital Statistics Supervisor (VSS)

For the purpose of collection of vital statistics, the VSS was used. He was a person trained in each NGO during the child mortality survey of the CDSAG referred earlier. VSS, thus, was not a new recruit under ANKUR but an existing staff in each NGO. He also was a trainer of the VHWs along with the NCS. It was decided during the review meet in July 2002 that the VSSes also would be given role of field supervision of VHWs besides the role as a trainer which they were already performing. In 5 NGOs (after excluding one NGO where the VSS as a supervisor would have been very weak or ineffective and other where the project coordinator doubled up as a VSS) the VSSes were assigned at least one VHW. They of course could seek help from their respective fellow NCSes in maters such as supporting VHWs for administering injections. This use of VSS as supervisor was to test whether non-medical persons can function as supervisors in HBNC. It was observed during the process documentation that the involvement of VSS in HBNC was much lower than that of NCS in all the three NGOs studied for prospective documentation and it further declined over the period of our observation. The VHWs were much closer, comfortable with the NCS than the VSS. Even during the training phase, the VHWs were able to relate better to the NCS than the VSS. NGOs have utilized their training skills rather than neonatal care supervisor skills imparted to them. In each village, a Vital Statistics Worker (VSW) was recruited temporarily to conduct the six-monthly vital statistics survey and was trained for the purpose. They were not full-time staff.

Supervision :
Supervisory Checklist for the NCS to Supervise VHWs
A standardized supervisory checklist for the NCS to supervise the VHWs had been developed. It was based on a checklist used by SEARCH in the Gadchiroli trial. The new checklist was field tested by the the NCSes and the project coordinators and was validated by the experienced supervisor from SEARCH. To establish an unambiguous line of command for supervision, it was decided that NCS will work under the guidance and supervision of the project coordinator. A checklist for the project coordinator to supervise the work of the supervisors(NCS/VSS) and the VHWs in the field, was also designed. Mother-Newborn record is a system for collection of data on mother and child pertaining to pregnancy, still births, births, deaths, illnesses, case management and changes in the behavior or improved knowledge as a result of health education. This booklet containing different forms had to filled and maintained by the VHWs. This booklet is the primary source of data on mothers and newborns. This also served as an important instrument for supervision of the VHWs. This also served as

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a tool for the project coordinator and SEARCH team members to supervise the work of the VHWs and their supervisors. The systems for supervision of the VHWs work by the NCSes/VSSes were set up. Accordingly, the NCS/VSS had to visit each neonate twice in a month. The supervisor had to periodically complete a Mother and Neonate form in parallel with the VHW. This served as a tool for the supervisor to find the mistakes of the VHWs and to take corrective action. The project coordinator in turn could use this tool to identify mistakes by the supervisor. The concept of supportive supervision was made an integral part of the supervision. The presence of the master trainers from SEARCH during the VHW training workshops was considered essential in initial period. The master trainers attended VHW training at every NGO for each of the 7 VHW training workshops. However, the duration of presence of the master trainers gradually diminished, finally reaching a stage where they were present only for the last two days of the training workshop. In addition, immediately after the end of each of the VHW training workshop, the master trainers visited the VHWs in their villages. During these visits, the master trainers evaluated VHWs knowledge and skills. This visit also offered them an opportunity to evaluate the NCS and the VSS as trainer and supervisor. The NGO heads attended at least a part of the training at their respective sites, and visited each VHW in the field during the training year. With the aim of inculcating the concept of supervision as a support, and co-learning experience, a special workshop was held for the NCSes, VSSes and the project coordinators at SEARCH in August 2002. To ensure that there was no confusion arising out of difference in interpretation of various entries in the Mother and Newborn form, a special manual was prepared by SEARCH team and administered to the participants of the supportive supervision workshop.

Field Visits
In addition to the visits by the master trainers, SEARCH staff visited the sites periodically for a multitude of other purposes such as monitoring, data collection, quality check of data collected, supervision of management systems and financial matters. SEARCH members also conducted field visits along with the SNL team at the time of mid-term review. To review the quality of data, a staff member from SEARCH made periodic visits to all the NGOs. Another staff visited all the Ankur NGOs every three to four months to examine the entries in the mother and newborn forms, correct the entries, coding and data entry in the computers of the respective NGOs and to carry the forms to SEARCH. GreenEarth visited the Ankur NGOs before the release of every installment of grant, checked the accounts and made recommendation for the release of subsequent installment of funds. GreenEarth also advised on general administration and matters such as stock keeping, maintenance of records, problems in supervision of VHWs by NCS / VSS and that of the latter by the project coordinator. After GreenEarth withdrew, SEARCH undertook this responsibility through its personnel.

Public Ceremonies and Communication

SEARCH conducted two public functions in Shodhgram. These events were conducted in a grand scale inviting all the partner NGO heads, HBNC personnel including VHWs, important persons from the field of social service, NGOs, funding agencies, medical profession, central and state bureaucracy and political leaders. Such functions served as important motivating events for all levels of personnel participating in Ankur.

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Ankur Launch : Ankur project was officially launched on 1st January 2002, in a public ceremony at SEARCH. Personnel from SEARCH and the 7 Ankur NGOs, including newly recruited VHWs, prominent village leaders from Ankur villages, VHWs and TBAs from SEARCH attended the program. The purpose of organizing a big ceremony for launching Ankur project was to show the new recruits (and the village leaders) that women similar to them were successfully handling neonatal care and saving their lives. It helped build confidence in the new recruits. There was a conscious attempt to encourage comradeship and a feeling that they were an important part of the larger cause, which is noble and has blessings of revered person like Baba Amte. Mango saplings were handed over to the ANKUR VHWs by the SEARCH VHWs, symbolising transfer and acceptance of responsibility of saving newborn lives. The launch was held on 1st January 2002, at daybreak. Eminent social worker, Padma Bhushan Baba Amte and Prof. Thakurdasji Bang, a freedom fighter and Gandhian, graced the occasion. In an atmosphere charged with emotion, Baba Amte administered the oath of dedication and determination to save neonates and children of their villages to the 133 VHWs (of SEARCH and the 7 NGOs), about 60 TBAs of SEARCH and all others connected with the ANKUR project. Dr. Bang briefly explained the issue of child mortality and the importance of HBNC in providing maternal and child care services. The project coordinators, in brief speeches, expressed their commitment to the project. This was followed by speeches from the guests. The launch programme also included a field visit to SEARCH-HBNC villages, meeting with VHWs and TBAs of SEARCH, and cultural events. The function attracted extensive coverage in widely read 10 newspapers and 2 weekly magazines in Maharashtra and also 3 television news channels. Ankur Utsav : Ankur Utsav was celebrated in Shodhgram, Gadchiroli on 31st March 2003. This utsav marked the successful completion of training of VHWs and the beginning of delivery of the full package of HBNC intervention in Ankur villages. The beginning of the delivery of full package under HBNC was announced to the world by symbolically rocking the cradle of a newborn from a village near Gadchiroli. On this day, 94 ANKUR VHWs who had successfully completed the training in HBNC received their certificate in a convocation ceremony and were initiated in to service delivery. The commitment to saving every newborn child in the villages/slums was renewed through the oath delivered by the famous Marathi writer-social worker, Dr. Anil Awachat. Nearly 1000 children from 39 villages of HBNC field trial in Gadchiroli, who were saved due to the HBNC and were now grown up, were invited with their mothers and village leaders to celebrate the gift of life, and to formally donate the Gratitude fund they had collected. A two day meeting on the theme Reduction of IMR attended by national leaders of neonatologists and paediatricians, representatives of the Indian Council of Medical Research, NGOs, funding agencies and media - was inaugurated by the Secretary, Health and Family Welfare,

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Govt. of India. In this Utsav, eminent personalities; President of the National Neonatology Forum of India, Executive Director of CRY, and Justice C.S. Dharmadhikari were invited to bless barefoot neonatologist. The presence of eminent personalities motivated the NGO heads and the VHWs, VSSes, and NCSes to go ahead on the path of HBNC programme by overcoming all the obstacles, to save the newborns. The public function also provided legitimacy to the VHWs to provide new type of care in their villages. VHWs were also motivated through various functions. Functions were held by all NGOs at various points of time during the implementation, to felicitate the VHWs. Ankur Utsav was conducted in individual Ankur villages. Innovative experiments such as publicly celebrating the successful completion of 28 days of life by a newborn, arranging get together of married women and pregnant women, were carried out by the NGOs. On occasions such as review meetings at NGO sites, and Ankur Utsavs, VHWs were given visibility in the form of either being honoured with flowers or provided opportunity to honour other VIPs. The VHWs were also given opportunity to publicly speak out their experiences or sing in a group. The VHWs also started enjoying incentive based on their performance. All such measures motivated VHWs to play their role efficiently. Encouraging the NGO Heads : In addition to the grant given for HBNC, a special motivation for the NGO heads / project coordinators was the skills and knowledge transferred to them through various workshops, review meetings, and by giving / suggesting reading material. The fact that they were associated and working with SEARCH in itself was an important motivation for these NGO heads. Through this association with SEARCH during the child mortality study and Ankur training, these NGOs gained visibility through media and public functions..

Materials :
Training, Health Education and Reading Materials
SEARCH developed, produced and distributed a variety of materials for use during training at SEARCH and at NGO sites, and for use during implementation of HBNC package in respective sites. These included a set of training manuals used for training NCS, VSS, VHWs and TBAs; video CDs, slides, photo album; demonstration / practice kit consisting items such as dolls, flipcharts used by the VHWs to give individual health education; posters for health education; motivational materials such as volunteer badges, and song books, a medical textbook on neonatal care, a monthly newsletter named Shod Arogyacha and Marathi translation of the book Goal Analysis (a book by Robert Mager )

Forms and Registers

Various forms and registers to maintain records were developed for the ANKUR project. Some of them were produced and distributed by SEARCH while others were produced / prepared by individual NGOs. The booklet of Mother-Newborn Form was the most important record in which data on pregnancy, delivery, neonatal care and neonatal ailments were recorded. Pregnant women register, treatment book and stock book were designed by SEARCH and individual NGOs prepared these based on SEARCH guidelines. Census registers and under-5 childrens registers were for recording the census data and vital statistics information respectively.

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Kits
VHW Kits were, assembled and distributed by SEARCH to all the NGOs so as to save costs and to maintain uniformity. It included the flipchart, photo album, wristwatch, disposable mucus sucker, tube and mask (later replaced with bag and mask), weighing scale, thermometer, blanket, warm bag, breast pump, paladay/ spoon, records and files, soap, cotton, spirit, Gentian Violet, 1%, Tetracycline eye ointment, disposable syringes and needles, Gentamicin injection vials (40 mg/ml), Co-trimoxazole syrup, tab Paracetamol, tab Aspirin, tab Furazolidin, , Vitamin K (1 mg ampoules), a torch with cells and a trunk. Medicines and consumables were bought by the NGOs. Some NGOs added other items such as a brush for clearing nails and hands, and a piece of cloth to place the kit material during home visits. TBA Kit was safe delivery kit which included cotton, , thread, disposable-blades, soap, G. V. paint etc. The consumables and medicines in the VHW and TBA kits were replenished by the NCS either during her/his visit or when VHWs visited the NGO office.

Information Management :
Elaborate mechanisms were established to collect, edit, and analyse data for various purposes. The processed information was used for monitoring, research and dissemination purposes.

Monitoring
A number of systems for the purpose of monitoring the implementation of HBNC in individual sites were established. These included monitoring of outcome indicators, MIS, recording formats, checklists, reports, registers, monitoring visits and data analysis system. Indicators : Indicators included process / output indicators for community consent, selection of VHWs/NCSes, training of VHWs/NCSes, positive cooperation of TBAs, behaviour indicators for observing the work of TBAs, approaches to handling non-TBA assisted or institutional deliveries, coverage, sepsis diagnosis and management, activity input estimation, management indicators to monitor the progress and management of the project in each site, quality indicators to assess the quality of data collected, maternal health indicators; descriptive indicators of social development to group the seven sites into three categories of development, indicators to evaluate the effect of health education (Knowledge Practice Indicators); outcome indicators to rate the outcome of the project in terms of reduction in mortalities (NMR, PNMR, IMR), morbidities (neonatal and maternal), knowledge and practice change in the community, level of utilization., sustainability. Formats / Registers / Checklists / Reports : A Monthly Report Form was maintained for continuous collection of data and monitoring on important aspects such as morbidities, mortality, coverage and management. This format had to be filled and sent by all the NGOs every month to SEARCH. The format included information on a set of indicators as well as provided scope for collecting an abstract of information on progress occurring in each site.

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To monitor and evaluate the quality of HBNC, task checklists for the VHWs and NCSes were prepared. The monitoring checklists of VHWs were filled by the NCS and the project coordinators filled that of the NCS. SEARCH team members checked these during their visits. SEARCH and GreenEarth prepared a Management Checklist to monitor the 7 NGOs. Registers such as stock registers served as systems for monitoring at different levels in the NGO (for kit, medicines and registers). SEARCH, Green Earth and NGOs generated a number of internal reports meant for internal circulation. This included monthly report by NGOs, six-monthly report by each project site coordinator, six-monthly report by GreenEarth. Besides, the SNL team conducted a mid-term review. This served as a form of an external monitoring system. Management Report : A separate management report for each NGO was prepared by GreenEarth every 6 months till they were associated. Later SEARCH team made management review visits and generated reports. Peer Review : The peer review team consisted of experts on reproductive health, health research, management, paediatrics, and NGOs. The team carried out end of the project review of the Ankur project.

Research
HBNC being a research project, a strong emphasis was on collection of meaningful, reliable and valid data. It had developed and aimed to transfer systems for collection of data including indicators, formats, reporting systems, documentation systems, and data collection, monitoring and analysis systems. For the purpose of collection and analysis of data, a number of systems and procedures had been designed and put in place. These were in the form of surveys / studies, formats / registers, indicators and computer based systems for data entry and analysis. As part of Child Mortality Study all the 7 NGOs had collected baseline vital statistics data for a period of two years. This data provided the baseline rates for all the crucial outcome indicators against which the achieved rates were compared for evaluation of the efficacy of the intervention. Baseline Knowledge-Practice Study : This involved studying traditional knowledge and practices regarding pregnancy, childbirth and neonatal and childcare in all Ankur sites. The study was documented in the form of a report of the findings at each site. Six-monthly Survey : In each NGO, vital statistics were being collected independently twice in a year by VSWs supervised by VSS. Activity analysis study : This was a research study undertaken in the SEARCH field area to estimate the inputs required per neonate and inputs required per unit service for HBNC. This involved continuous recording of activities done by VHWs and NCS and time expended using time logs. A similar study was also done in ISSUE.

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Case Studies
Case study was a format to collect qualitative data on implementation process, positive and negative deviants, problems and solutions (like non-cooperation of the TBAs). These were generated by the project coordinator, NCS as well as by SEARCH / GreenEarth team members at the time of their visits. Population Registers, Mother-baby Records and Monthly Report Forms were also other important systems used for information / analysis.

Data Entry
A data entry operator of SEARCH used to visit each study site every 4 months in the first year and every 3 months from the second year onwards to code and enter the data on site. Problems of quality or discrepancy of data were detected and corrected at the study site itself. This enabled immediate and on-site data validation and crosschecking. The forms were brought to SEARCH for double checking of the coding, doing double data entry, and to confirm internal data consistency and overall trends.

Data Analysis
Dataset was being collated, maintained and analyzed at SEARCH headquarters. For the purpose of data analysis, SEARCH had formed a data analysis team comprising a demographer, a statistician and a programmer, who worked under the supervision of chief study coordinator.

Data Analysis Plan

SEARCH had also prepared a Data Analysis Plan. Accordingly, tabulation had to be done every 2-3 months by the data analysis team. The results were fed back in the form of reports during the review meets. Detailed data analysis was done on a periodic basis. Data analysis included the following: a) Analysis of different mortality rates b) Analysis of cause of death c) VHW performance e) Effect of health education f) VHW knowledge and skill test score g) NCS performance h) Site performances i) Documentation of processes j) Record of positive and negative deviants, with the reasons and explanations and k) Management culture by analysing data from case-studies and process documentation.

System for Quality Control of Data

All the data collected by VHWs and the NCS, and VSS was checked by the project coordinator. The SEARCH team members visited every site once in 4 months in the first year, and once in 6 months thereafter to scrutinize the data collected and get it entered into a database programme. SEARCH team also visited each NGO at the time of collection of vital statistics (retrospective survey), once every 6 months to verify vital statistics data collected.

Classification of the study sites

For the purpose of meaningful analysis, the seven study sites were classified in to three categories of development; tribal, urban and rural. For each category, data analysis as above was done Based on the data collected and its analysis, it was possible to assess the achievement of the project in quantitative terms in a time series data. Thus, contributory factors for absence of the VHWs at deliveries were identified. These included; not getting the message at all or getting it late; non-availability of a resident VHW in some of the smaller villages, especially in the tribal areas, and absence of

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VHWs from the village for various reasons (visit to HQ for training / monthly meeting /special meeting with teams from SEARCH / SNL / illness / personal reasons). On analysing the data collected during the mid-term review, SEARCH identified variations in achievement among VHWs and relationship between achievement and other characteristics (e.g. education level), identification of poorly (and better) performing personnel, and under utilisation of service in some areas leading to change in service delivery systems (Messenger, Maha- dai).

Census
The census of the area under Ankur was conducted in January 2002 and it covered 91 villages and 6 urban slums in seven project sites. Using the information obtained from census, two types of registers were prepared for each village and each urban slum. These were: The Census Register and the Childhood Population Register: The census register provided village-wise data on population size, literacy level, marital status and availability of consumer goods at the given point of time. The childhood population register gave the distribution of child population in each village or urban slum at the given point of time. Both, the census register and childhood population register were revised after each bi-annual survey.

Designing of Household Census Format

Household census format was designed to collect information on a variety of demographic and socioeconomic indicators including the Standard of Living Index (SLI) for each household. The VSSes from the 7 NGOs were trained on the importance of census, methods of age calculation, and census data collection procedure. Later on VSSes trained the VSWs at their respective NGO sites. Census registers and under 5 childrens registers for each village were printed and supplied to Vital Statistics Workers (VSW). Actual survey was conducted in each NGO by the VSWs over a period of 2 weeks. The survey work was supervised by the VSS. Quality of census data collection was supervised by a trainer from SEARCH by visiting each of the 7 NGO sites, and physically monitoring the data collection activity in randomly selected villages at each site. VSWs prepared population registers for each of the 91 villages and 6 urban slums at 7 NGO sites. For each village and urban slum, separate Under 5 childrens population registers were also prepared using the information collected during the census. Vital statistics were being collected from all the HBNC villages every six months as bi-annual survey. Vital statistics workers supervised by Vital Statistics Supervisor collected the data. This six monthly activity helped in getting near complete recording of vital statistics. VSS and SEARCH trainers intensively monitored the survey quality. Detailed data on pregnancy, birth, and neonatal illness were being recorded for all births taking place in the HBNC area using newborn form, which was an elaborate comprehensive form.

Dissemination
For the purpose of dissemination of the progress, outcome and the results of the project, SEARCH brought out a number of reports, publications, electronic / visual documents, and had sought the media to cover the project. Public functions inviting community members, bureaucrats, political leaders, medical professionals and people representing media were organised. SEARCH also believed that SNL also had a role in ensuring dissemination of information about this study at various stages.

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Pamphlets on the Ankur project and HBNC were prepared in Marathi and English to reach out to community leaders, elected members, government officers and civil society organizations. Pamphlets were distributed during utsavs and other functions. These were also sent as a part of invitation to attend these utsavs. Copies of Kowali Pangal were sent to nearly 500 prominent citizens, social workers, voluntary organisations and politicians in the state. Research publications on HBNC were distributed particularly to reach out to medical professionals and academicians. Apart from this, the HBNC activities were covered widely in regional and national dailies and monthly magazines. A monthly newsletter in Marathi ,Shodh Arrogyacha, was brought out and distributed to all HBNC villages, other like minded organisations and friends of Ankur. The newsletter mainly included human stories about the work of VHWs in their respective field areas.

Photo-documentation
For this purpose a photographer was appointed. However, this process got delayed. Apart from this one-time photo-documentation effort, the NGOs had been encouraged to undertake photo documentation through the supervisors on a continuous basis. The supervisors were equipped with aim and shoot cameras. A film on HBNC had been commissioned by SEARCH. This film entrusted to M/s Swati Visuals, New Delhi could not be completed due to demise of the director producer team of M/s Swati Visuals in an accident.

Process Documentation
Documentation of all the processes in Ankur HBNC including community changes surrounding implementation of HBNC was done by external team from Tata Institute of Social Sciences of Mumbai.

Advocacy
It was important for Ankur project to build a healthy relationship with external stakeholders for implementing, sustaining and up scaling HBNC model. SEARCH had exemplified this through a series of interactions with concerned people at different levels in the State Government, central agencies such as ICMR, and Ministry of Health and Family Welfare, Government of India. SEARCH had convincingly disseminated facts on reducing IMR, NMR, and HBNC to a larger audience through conducting workshops, delivering lectures, meeting politicians, bureaucrats and doctors in person, bringing out reports, publications in academic / medical journals and in popular media. During the review meeting in Hipparga Tad (Jan 2004) Dr. Bang had addressed a gathering of more than three hundred local people. In his speech he emphasised the need for neonatal care, the need for HBNC, the role of the NGOs, its personnel, VHWs, TBAs and the ways in which the community can support this endeavour towards arogya swaraj. His speech was complete with scientific facts, explained using traditional cultural symbols and similies, delivered in a well-modulated passionate and appealing tone. Media Visits : On two occasions, media personnel were significantly involved. First in November 2001 when the Child Death Study and Action Groups findings were published (the baseline for the ANKUR project) and then again during the launch of ANKUR in January 2002. Both the events got prominent and wide coverage in Maharashtra, and to some extent, at the national level print and electronic media.

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Personal meetings with political leaders and bureaucrats for dialogue

Immediately after the release of Kowali Pangal, Dr. Bang had a series of meetings with the Chief secretary of the State, State Health and Family Welfare minister, and the Chief Minister of the State (between November 30 and December 5, 2001). The focus of these meetings was primarily on the actual magnitude of child deaths in Maharashtra. The Central Government too showed interest in studying and replicating HBNC. Meetings/ workshops were held in New Delhi to finalise the research project to replicate HBNC in 5 states on a pilot basis. The project was granted to the ICMR. SEARCH was asked to provide the training support. Subsequently, the training of trainers for the ICMR project was conducted at SEARCH.

Supportive Action
As the HBNC project was being implemented at the village level, with focus on the village health workers, supportive action was considered to be an important input by SEARCH. For instance, SEARCH, on request from Ankur NGOs, made efforts to meet local / regional health officials or doctors practising in and around HBNC sites to solve problems if any between them and the NGO staff and to facilitate building of better rapport among them. During review meetings conducted at project sites (not in SEARCH) the entire Ankur team made village visits. This not only familiarised them with the project area but also increased stature of the host NGO in the eyes of the local communities and leaders. During such visits Dr. Bang delivered public address, or met villagers, staff in government setups such as anganwadi centre, sub-centre, PHC etc. These efforts too helped build a better rapport between these people and the NGO staff. During the January 2004 review meeting in Hipparga Tad, Dr. Bang invited the District Health Officer (DHO) of Osmanabad, Dr. Pandge to Hipparga Tad, where Sahayog Nirmiti is working. Dr. Pandge joined the group for lunch and was introduced to some of the Ankur members.

Conclusion :
Ankur leadership understood the strengths and weaknesses of the Ankur NGOs very well and provided support accordingly. Further, the differences found in the target areas of different NGOs were well recognized and appropriate changes in the HBNC package were made. The complex HBNC package was implemented in an incremental fashion to ensure that every component of HBNC was institutionalized in the participating NGOs. Supervision was given utmost importance. Detailed checklists and elaborate procedures to record events and outcomes were prepared clearly. Apart from documentation, site visits were streamlined to provide supportive supervision to the VHWs. SEARCH recognized the need of the NGOs to be affiliated and recognized for the work they were doing. For this, melas and utsavs were organised and the workers as well as the leaders of the participating NGOs were honoured. SEARCH monitored the implementation in detail and ensured that the transfer was complete in every detail. On the whole, the replication of HBNC in the Ankur NGOs was meticulously carried out.

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Chapter - V
Impact and Change
Introduction :
After the chapter on implementation of the HBNC package in the Ankur project sites, we will now look at the impact it made in terms of changes in some of the maternal and child health practices as well as in the management of neonatal morbidities. In this chapter, we document the efforts made by the VHWs to save the lives of the neonates. We also describe some of the traditional beliefs and practices that hindered the neonatal health and the interventions that attempted to change these beliefs and practices of the communities to improve the maternal and child health.

Maternal and Child Health Care :

This section deals with the intensive work by the VHWs with pregnant women and their family members during pregnancy, at the time of delivery and after the delivery for care of the mother and the neonate and in the community for care of under 5 children.

Ante-natal Care (ANC) Practices :

The care under HBNC begins early in the pregnancy, primarily involving educating and creating awareness among the pregnant women to avail ANC, avoiding heavy work and having proper diet during the pregnancy. It also involves screening of the pregnant women by asking questions and identifying danger signs and referral if necessary. Enabling Role : Since the government health system provides ANC, Ankur did not aim to duplicate the same but only supported the government run programme through creating awareness and encouraging pregnant women to avail ANC services offered free of cost by the government health centres. The principal component through which seeking of ANC was promoted was through health education. Health education to pregnant women was started with registration of pregnancy as soon as the woman completed 4 months of pregnancy. Subsequently, two sessions of health education were given, one each in seventh and ninth month of pregnancy. NGOs also disseminated the importance of availing ANC during various public functions organised by them in the villages. Group health education for preg-

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nant women and their mother-in-laws or mothers was carried out by the supervisor once in 4 months during which the messages were reiterated. In addition to these components, HBNC programme had established rapport with the government health centres and facilitated women to access the health services of these health centres for registration of pregnancies and subsequently availing ANC. Such rapport, especially through the VHWs had also enabled ANMs locate / contact and reach out to pregnant women more efficiently, for distribution of IFA tablets and administering TT injections. Similarly VHWs had also facilitated a better service provision to pregnant women from the Anganwadis by establishing very good rapport with AWWs. Besides, women were also educated regarding identification of signs of onset of labour, informing VHW and TBA, signs of complications during pregnancy and delivery, preparation for delivery, avoiding heavy work and proper diet during pregnancy. Based on the field observations made in the three NGO areas where prospective documentation was done, we found that there was a wide variation in acceptance / changes across the different components of ANC as well as across different communities. Among the different components of ANC, consumption of IFA was the element for which women had shown the least level of acceptance while the other components had better acceptance / change. Most common reason cited by women for not consuming IFA was nausea / vomiting sensation on consuming IFA in the tablet form. Other reasons cited were loss of appetite and the belief that consuming the tablet would increase the size of the foetus, which could complicate the delivery. Resistance to consume IFA was of course not shown by all women. Even among those who had shown resistance, it was not that they totally abstained from consuming them. They had shown irregularity in consuming IFA tablets. Resistance to consume IFA was irrespective of social position, community or parity. However, acceptance of IFA was marginally better in urban area compared to rural and tribal areas. For various reasons and to a great extent due to the presence of VHW, the awareness of her activities, her health education sessions, care during pregnancy (ANC), and various components of ANC had become part of common knowledge among women in the villages. To a great extent this awareness was also explicit in the behaviour of individual women towards these components of ANC. Acceptance of TT injection during pregnancy was very high among all the communities. Perhaps, one reason for this was the general tendency in families of lower socio economic status to perceive injections with higher medical value / efficacy. Higher acceptance of TT was also due to the fact that it was tied to the process of registration of pregnancy in the government hospitals. This was necessary, if a family planned for hospital delivery or sterilisation pocedure. Moreover, unlike IFA, which had to be started early, TT could be administered later. It was noted that the initial months of pregnancy did not evoke as much attention and importance as evoked by advanced pregnancy. The facilitative role played by the VHWs in all the three areas, for public health system to reach the pregnant women, as well as for pregnant women to avail ANC services from (or reach) public hospitals deserves a particular mention. Thus, in AAA and SN, while the VHWs referred pregnant women to the sub centre or the PHC to avail ANC; the ANMs used the registers maintained by the VHWs to locate and reach out to the pregnant women. In SN, VHWs assisted ANMs by informing pregnant women about the arrival of ANM in the respective villages for immunization. There was also a practice of ANM handing over IFA tablets to the VHWs (through AWW) for distribution in the villages. ISSUE distributed IFA in their area through their VHWs.

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The VHWs used to inform the pregnant women the arrival of mobile clinic in the basties(slum) for providing ANC services. Most families approached healthcare facilities having facility to test blood and urine and accepted these tests as part of ANC. There was no resistance expressed at the health care institutions. However, some families reported that they did not get the test done as they were asked to wait for a long time, or were required to visit again. This was not so much a problem in the urban area. In SN, some families had undergone the urine and blood tests in private facilities.

Diet During Pregnancy

Among some of the communities, there was a belief that the size of the foetus would become large if the mothers food intake was more and it would make the delivery complicated. As a result, food intake was even deliberately lowered during pregnancy. There was also taboo among certain communities on eating certain specific food items. Fruits like papaya and non-vegetarian food (including eggs) was avoided during pregnancy. It was reported that intake of hot (as against cold) items during pregnancy might result in miscarriage. Health education tried to address these issues by emphasizing the importance of diet in proper growth of the child and suggesting alternative food available locally. During health education sessions, VHWs advised women to keep their diet nutritious and balanced. Roti, rice, green vegetables, fruits, milk, curd and even non-vegetarian items were recommended during pregnancy. Generally pregnant women complain of nausea, lack of appetite and hence difficulty in having proper diet. This was noted in all the study areas. To address this problem, VHWs encouraged women to eat in smaller quantities but many times in a day, so that adequate food intake was maintained. In the villages of AAA, although cattle population was high, milk or milk products were never consumed. Moreover, animals maintained were largely drought animals. But in the villages of SN, milk and milk products formed part of daily food for both children and adults.

Avoiding Heavy Work During Pregnancy

As a part of the health education, pregnant women were advised to avoid heavy and cumbersome work like lifting heavy load, fetching water and carrying fire wood. This was also traditional teaching although elders also advised that a pregnant woman should do some mild work regularly for smooth delivery. Hence, there were no major problems in making women accept this practice. However, in many households where there was no other adult female member, the pregnant woman had to engage in heavy work during pregnancy. The patriarchal relations and the fact that a woman usually spends the early pregnancy in her marital home (and not with her mother) aggravates the problem. As a result, even if a woman wants to abstain from hard and laborious work it would not be possible for her to do so. Women living in joint families were placed relatively better in this respect as other women in the family could take care of some of the work. In the area of AAA, it was found that during the peak seasons of collection of mahua, tendu, or jammon, almost every family member was involved in collection of these forest products. These are the most remunerative times for them. Hence, they want to exploit it to the maximum by involving everyone in the family in this work. As a result, pregnant women too had to be involved in such intensive work involving long hours. In case they were left behind at home, they had to do all the chores of home including fetching water and washing. Usually, no adult male or female members were seen in the tolas (hamlets) and villages during the day in AAA villages. Only young children, very

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old persons, pregnant or nursing mothers were seen in the villages. Hence, a pregnant woman at home, being alone in the neighbourhood had to carry out all the essential chores of her house. In the area of ISSUE, women were largely involved in agarbathi making. This involved squatting for long hours. This again could prove harmful for pregnant women especially in the advanced stage of pregnancy. In the area of SN, it was involvement of women in agricultural activities and the arduous work offered under the employment guarantee schemes (EGS) during the drought years that affected pregnant women. With better rains in the second year of our study, this hardship was relatively mitigated. Further, the belief that a pregnant woman should be involved in some or other work for a smooth delivery could get pushed a little further and the pregnant woman might be asked to engage in relatively arduous and riskier work including those involving bad postures and bending down. Work might also make women vulnerable to accidents and injury, resulting in miscarriage or stillbirth.

Child Birth
Place of Delivery : Geographical location, transport facilities, economic status of the family, access to medical facilities, social background, health of the pregnant woman, and traditional beliefs and practices were some of the factors that influenced the decision regarding the place of delivery. The field area under AAA was purely a tribal one, comprising largely of Gond and Chhatisgarhi Kawar population; the area under SN was rural, dominated by Dalit, Maratha, Lingayat and a few Muslim families and the area under ISSUE was an urban slum, with a majority of population belonging to Chhatisgarhi, Muslim and Baudh communities. It became clear from the field reports that cultural differences across tribal, non-tribal / rural populations influenced the choice of place of delivery. Presence of well-accepted traditional birth attendants promoted home deliveries. In addition, movement to maternal home for delivery, complications during pregnancy / delivery, history of earlier complications, time of onset of labour (e.g., night time), presence of efficient VHW, parity, decision on undergoing sterilization after the delivery, etc influenced familys choice of place of delivery. It was observed that in each field area, there existed a peculiar trend with regard to place of delivery. In the tribal area of AAA, PHCs were at distances of two to six kilometres from the hamlets. Rural hospital was about 6 to 12 kilometres. Public transport was infrequent and the point where one could board public transport was far away from all but one hamlets. As a result, there was lesser keenness to opt for hospital delivery. Presence of a number of close kins in the neighbourhood, families related by close kinship to VHW / TBA, and availability the VHWs on call were a few additional aspects, which facilitated choice of home deliveries in the area of AAA. In the area of ISSUE there was preference for delivery at government hospitals (urban health centres or the Medical college hospital) as they were reachable in a short time using public transport. Autorickshaws were available right at the entrance of the basties. Hence, the proportion of home delivery was low and women increasingly preferred delivery in hospital. According to Ms. Throrat, the project coordinator, 64% of deliveries took place in hospitals in ISSUEs area. The remaining were home deliveries attended by TBAs. However it was noted that with increased access to modern health care institutions, the traditional midwifery institutions had fallen into disuse. In the case of the rural area (SNs area) people preferred home delivery. The next choice was of delivery in private hospital. Some opted for delivery in PHC. Affluent families preferred delivery in private hospital. Poor households more often opted for home delivery except when medical attention was required (especially to undergo sterilisation). In such cases they opted for the PHC.

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Awareness regarding VHWs services during delivery, availing her services during pregnancy, having faith in her service, and proximity to her had significantly contributed to peoples decision on place of delivery. Although one cannot say that VHWs presence affected broad patterns of choice, VHWs presence had influenced the decision on place of delivery in two important ways 1) The VHWs referred the complicated cases to hospitals in all the NGOs. 2) In ISSUE area they facilitated reaching and availing hospital facilities. There were many cases where the VHWs had identified the signs of possible complications in delivery and had referred the case to hospital in time. The fact that VHWs were capable of identifying complications in delivery had given families a sense of higher comfort and confidence. There had also been many instances where the family had decided (and registered in hospitals) to have the delivery at a hospital but the labour pain had started at night or the delivery was sudden and therefore delivery had to be conducted at home. Preparation for Delivery : Great importance was laid on preparations for delivery under HBNC. It was observed that, many families didnt pay much attention to the preparations for delivery before the introduction of HBNC programme. So it became necessary for the VHWs to instil the importance of such a practice among the communities through health education in this regard. Preparation for delivery comprised keeping a separate clean room ready for delivery; keeping new sets of clothes for the new-born; setting aside a blanket to wrap the baby after birth; and saving some amount of money for emergency, i.e., for hospital delivery. In addition, VHW advised family members to be aware that TBAs should use a new razor (blade), and new (sterilized) thread for tying the cord. Preparation for the delivery in advance definitely helped in reducing the tension during delivery process and making the delivery safe and hygienic. The TBA was required to keep a set of a new (sterilized) blade and thread. It was also noted that in some cases, ANM had supplied pregnant women with new blade and thread. Some families had also procured and kept ready a new blade at home before the delivery. From the field report, it was evident that pregnant / recently delivered women (or their families) were aware of importance of preparing for delivery. In general, women were able to recall the messages given by the VHW regarding preparation for delivery. Thus, the health education had proved helpful in creating awareness with regard to preparation for delivery. However when it came to actual practice of preparation, there was difference across communities and socio-economic status. In all the three areas, especially among families of lower socio-economic status, preparing a room exclusively for delivery was incompatible with their economic status and housing structure. In ISSUE, for instance, most families lived in one-room tenements. In AAA, although the houses were large with many rooms, they were generally poorly lit, and not sufficiently clean. Houses were mud walled, and floors were plastered with cow dung. Agricultural equipments or produce and fowls etc were kept in these rooms. Hence, keeping a sufficiently clean room ready for delivery appeared difficult for most families. The situation was relatively better among the Kawar community than among Gonds. In SN, the situation was relatively better in terms of having a separate space as well as keeping it clean. Here too, , there was a difference between dalit families and relatively better off non-dalit families. Many families did not keep clothes, sheets and blankets ready. Only relatively affluent families did it. This was relatively better in SN and to some extent in ISSUE. In AAA, Gond families were the least prepared in this regard and not much different were the Kawar families. Trained TBAs almost always carried with them a set of safe delivery kit. Untrained TBAs depended on

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whatever the family was able to provide at the time of the delivery to cut and tie the cord. There were cases wherein the delivery happened suddenly. In such circumstances, many families were found unprepared. Practices During Delivery : Safe and Hygienic delivery was one of the main components of HBNC programme. During training period, TBAs were taught to handle the deliveries in a safe and hygienic manner. They were trained to wash hands with soap before delivery, to use sterilized razor and clean thread to cut and tie the cord, and to apply G.V. paint to the cord and nothing else. The TBAs were expected to carry the kit provided to them by the NGOs while going to attend delivery. Training imparted to the TBAs under Ankur had instilled in them a sense of discipline to always use sterilized blade and thread and always to wash their hands before attending delivery. The VHWs also always washed their hands before they touched the child. The supervisors too washed their hands before touching a neonate. The interviews conducted with the TBAs during the first field visit in October 2003, revealed that safe and hygienic delivery (use of sterilized blade & thread, TBAs and others attending the delivery washing their hands before attending the delivery) had gained much attention. Earlier, the TBAs who attended deliveries never paid attention to using new razor or sterilized thread. It was also reported that even in non-HBNC areas, some of the trained TBAs were aware of conducting safe and hygienic delivery but individual women interviewed did not express such a level of awareness. In HBNC area, almost all the families were aware of the need to use sterilised blade and thread to cut and tie the cord respectively. Almost universally, in all births attended by the VHWs, the cord was reportedly cut using sterilized blade and sterilized thread was used to tie the cord. In the HBNC area, there were only a stray cases where sterilized blade and /or thread were not used. Out of these was a birth not attended by either the VHW or the Ankur trained TBA. It was attended by an untrained TBA. There was another case in which Ankur trained TBA had used un-sterilised blade. This was in the beginning of the Ankur programme. Both these cases were in AAA area. In SN, there was a case in which the birth was an emergency one, not attended by the VHW or the Ankur trained TBA. It was attended by an untrained TBA. In the area of ISSUE too, a case was reported in which un-sterilised blade was used. But this too was a case of an emergency delivery. Neither the TBA nor the VHW was informed in time and hence, they could not attend. All the TBAs and the VHWs were also particular about keeping their nails short and clean. The practice of digging the pit to give bath to the mother and the neonate and to dispose off the placenta and the cord had come down. In a few cases, families dug the pit to bury the placenta and the cord but it was not for bathing and toilet needs In HBNC villages, the families were expected to inform the VHW as well as the TBA as soon as a woman went into labour. This was one of the most important requirement of HBNC as it decided to a great extent whether the VHW was able to attend the birth or not. Attending a birth by the VHW had the most significant impact on the delivery of HBNC services to the newborn at the time of birth and later. VHWs presence at the time of birth also influenced the outcome of the birth. Once a TBA received the information about an impending delivery in a village, she was expected to inform the VHW about it. The TBAs were trained (and in some cases also got remuneration) for calling the VHWs to attend the delivery.

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All the study areas showed a strong acceptance on informing and calling the VHWs to attend births. This was true across all the communities (barring cases of hospital deliveries). It was observed that in the villages / bastis where the home deliveries were more common, calling the VHW and the TBA had almost become a norm. After 3 years of implementation of the HBNC programme, people were aware of the importance of VHW during delivery. It was also found that a good relationship had been established between the VHWs and the TBAs and the latter usually informed the VHWs in time to be present at the time of birth. Usually the TBA got to know about the impending delivery first and she sent a word to the VHW. The TBAs in almost all the field areas insisted that family members call VHW during delivery. TBAs reported that VHWs presence was of utmost importance. It was opined by them that while they took care of the mother, VHWs took care of the child. Hence, the mother and the child, both were cared for in time. The TBAs also recalled the role of the VHWs in case of complicated births especially if the child was asphyxiated. In the absence of the TBA, family members themselves called the VHW to attend the delivery. Families conceded the importance and facilitative role of the VHWs presence during delivery. Reasons cited by the families for calling the VHW to attend delivery were essentially based on the services she had been rendering in the neighbourhood such as supporting the TBA during deliveries, referring complicated deliveries to hospitals, managing asphyxiated births, and high-risk children. Her role, in handling sicknesses including pneumonia, sepsis, fever, and diarrhoea too had contributed to this high level of acceptance. Moreover, the families had come to understand that during delivery the TBA would look after the mother and the VHW would examine the neonate. One can say that VHWs sustained role in the villages in saving neonatal lives, referring women to hospital if deliveries were complicated and visible demonstration of medical competency had increased the general acceptance of the VHWs. As a result, the sense of indifference and resistance shown in the initial phase by certain communities was mitigated as the VHWs got themselves entrenched strongly in the villages. Many families recalled that the VHW had saved the lives of neonates which had breathing problem at the time of birth (asphyxiated babies). Along with the VHW and the TBA, sometimes a local or visiting doctor too was called to assist in the delivery, primarily for administering injections to quicken the labour process. In the tribal area of AAA a local vaidu who was a specialist in handling delayed deliveries was also called. In a few cases, the families had attempted to inform the VHW but she could not be reached. Families, which deliberately refrained from informing the VHW were just a few and that too mostly in the earlier phase of the project. Cases were reported where, in case of hospital delivery, families did not inform the VHW on return of the mother home. Similarly, some families did not, on their own, report arrival of the pregnant woman in their homes. In some cases the families could not send message to the VHW since the delivery had taken place at night. Strained relationship of the VHW with the family at the personal, family or community level and the unpleasant experience of the VHW on previous occasions during HBNC service delivery were reasons for some families not calling the VHW to attend delivery. In the case of AAA, if the labour pain started in the night, the community found it difficult to send message to the VHW, especially if she did not belong to the hamlet but was a resident of another hamlet or the main village. The reason could be that the path passed through a place /tree haunted by spirits, or sheer danger of attack by wild animals or even naxalites. Sometimes, the reason could be

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absence of a male member to carry the message. In the initial period of the project, this area also had the problem of a few Gond families having differences with the VHW. Similarly a Gond TBA had differences with the VHW in the initial period, which resulted in the VHW not getting message in case of one delivery. One of the VHWs was keeping indifferent health for a considerable period. This too affected VHWs attendance at delivery. In the case of SN, logistic reasons were unimportant as the villages were single units and not distributed in hamlets. Here the reason for non attendance of VHW at delivery was differences between the VHW and the untrained TBA in one case and the other case was that of an affluent family not calling the VHW to attend the birth. In case of ISSUE, the deliveries were mostly conducted in hospitals. Home deliveries usually were those which occurred in the night. These were attended by the VHWs. In a few cases the reason for the VHWs not getting message was the desire of the families to hide pregnancies / deliveries. In a few cases the family sent message to the VHW but she could not attend as she was not present in the village, or was not well. It was also noted that there were a few cases in which the VHW was not informed about the arrival of a pregnant woman (into her natal home) from other village. In the area of ISSUE, some families chose not to inform the VHW after coming back from the hospital. Therefore, either the VHW did not get information at all or she got the information late from the neighbours. This affected delivery of care to the newborn by the VHWs.

Neonatal Care
Bathing and Wrapping : The most common and widespread practice which was observed in almost all the communities in each of the three field areas was of giving bath to a newborn immediately after the birth. Depending on the weather, the child was bathed in warm, tepid or even cold water immediately after birth. If the birth was in the night, bathing would be delayed till the morning. Traditionally, after the bath, the child was dried with a dry cloth and wrapped. Depending on the weather, the child was either wrapped in warm / thick sheet or a thin sheet. Wrapping was usually done using whatever sheets were available in the home, such as a piece of an old sari in the summer or a thick bed-sheet in the winter. Many families used cheap woollen-caps to cover the head of the child in winter. Alternatively, the thick sheet used for wrapping was pulled up to cover the ears as well. No special baby clothes (generally used in affluent urban families) were used. The child was given a new dress after a ceremony on fourth or fifth day. Even after this ritual, newborn was usually wrapped only in sheets and not dressed. In the HBNC and the non-HBNC areas there seemed to be very less difference in respect of practice of bathing and wrapping of the newborns. However, in case of high-risk babies, on account of VHWs insistence, bathing was delayed till end of the first week after birth. Families were to be discouraged from bathing the child immediately after birth. This was emphasised because bathing a newborn immediately after birth may cause hypothermia. Breastfeeding can be initiated even before the delivery of placenta. These factors assume greater importance if the child is pre-term and low birth weight. A pre-term and low birth weight baby is vulnerable to morbidities and requires initiation of breastfeeding as early as possible. Accordingly, VHWs and TBAs were imparted the knowledge and skills regarding cleaning, drying and wrapping a newborn. Wrapping of child was emphasized to keep the child protected from cold. All the three areas experience moderate to severe winters. In the summer months, which are also severe, families were asked to cover the child with thin cotton sheets and not thick warm sheets.

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The interviews in the three field areas revealed that bathing of the newborn immediately after the birth continued to be a widely prevalent practice. The VHWs or the TBAs presence did not seem to affect this practice. Families gave bath to the newborn in spite of VHWs advice and even in her presence. However, in the case of high-risk babies, VHWs managed to prevent giving bath to the neonate in the initial few days. Families extended cooperation in this respect. Even the trained TBAs firmly believed that there was nothing wrong in giving bath to the newborn immediately after birth, if the baby was normal. But if the baby was high-risk, the TBAs also insisted that it should not be bathed for first few days. However, families did not appreciate the difference between a normal baby and a high-risk baby and did not appreciate the difference in gravity of the two situations with respect to giving bath. In case of those births, which were not attended by a VHW or a trained TBA, even high-risk babies were given bath immediately after birth. Untrained TBAs also contributed to this practice. There were cases of births attended by untrained TBAs where babies were given bath immediately. Since the practice of giving bath to the newborn was strongly prevalent, the NGOs too adopted the strategy whereby if the birth was normal and if the weather was not very cold they (VHW and NCS) did not insist strongly against giving bath. But if the baby was high-risk (pre-term, LBW or breastfeeding problem), and if the weather was chilly, then the VHWs and the NCS insisted very strongly that the families should avoid bathing the baby immediately after birth. Instead, they were advised to clean the child with dry cloth and wrap the child in thick sheets. The baby was also asked to be kept covered well including covering its ears. In the area of ISSUE, since the proportion of hospital deliveries was more, bathing was delayed till the mother and child reached home after three or four days. It is important to note that in practice, breastfeeding is not greatly delayed only because of the practice of bathing. Even after giving a bath, initiation of breastfeeding was reported to take about one or one-and-half hour after the birth. Cord Care Proper care of the cord in the initial few days of a newborn is very vital to prevent infection of the umbilicus. G. V. Paint (Gentian Violet 1%) was applied to the cord from the day of the birth and during the subsequent visits of the VHW in the neonatal period. Applying anything else, such as oil, vermilion, turmeric, and talcum powder was discouraged. G.V. Paint stock was also given to the TBAs. TBAs trained under HBNC had started using (and demanding from NCS / VHW) G. V. Paint for cord care of children even outside the HBNC area. The interviews conducted during field visits and the observations made revealed that there was high acceptance of G.V. Paint in HBNC villages, for cord care. People had almost taken it as a matter of necessity and there was generally no opposition for application of G.V. Paint. Though there was high acceptance of G.V. Paint, proper cord care depended strongly on VHWs presence on the first day. In cases where VHW was not present, cord care too was not generally proper, unless the TBA took extra care. To some extent it also depended on proper follow up visits in the first week. In hamlets, where there was higher chance of less number of stipulated follow up visits, there was a higher chance of families trying out other substances on the cord. In some villages / basties the VHWs followed the practice of handing over some G.V.paint in a small bottle to the family. Sometimes the stock available with the TBA was used. G.V. paint was also used for treatment of wounds in older children and adults. In the areas of AAA and SN, one would invariably see children of all ages with stains of G.V. paint on their body (applied on wounds and boils) playing around in the village. Women coming to collect G. V.

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Paint in small bottles (for their own use or for other family members) were also witnessed very often in these field areas. However, in conjunction with G.V. Paint, sometimes, oil was used on the navel of the baby, as giving oil-massage was a common practice. Oil was more commonly used after the cord had fallen. In the filed area of SN, G.V. Paint was not kept with the TBAs but only with the VHWs. In ISSUE, where the population was denser, and because some families may have better access to the TBA than the VHW (on account of familiarity with the TBA and proximity) keeping a small supply of G.V. Paint with the TBA had helped. However, there was a problem of the TBA misusing G.V. Paint in such cases. There were cases where TBAs had not followed proper cord care practices (especially one TBA in AAA). Eye Care Infection of the eyes was identified as one of the problems suffered by newborns and eye care of newborns was a component of immediate care for the newborn in HBNC implemented through the VHWs. The VHWs were supplied with Tetracycline eye ointment as part of their kit. If the VHW found during the home visit, development of any eye infection she was trained to apply the ointment. It was found that applying ointment to eyes was considered by the families as a medical treatment. Hence, there was no opposition to this practice from the community. No serious / common traditional practice was observed that could lead to eye infection. In general, in the neonatal period, use of kajal for the eyes was not reported. Initiating Breastfeeding In general the people believed the colostrums was unfit for the child. Hence, it was extracted out and thrown in a pit as part of a ritual. As a result, the child was not breastfed for the initial three to five days. Instead, the child was given other liquids such as water (plain or mixed with jiggery), honey or castor oil. Even if the family was convinced of initiating breast feeding on the day of birth, it was anyway delayed because of practice of breast feeding the child only after bathing. The child was bathed only after complete delivery of placenta followed by cutting of the cord. Thus, if the delivery of placenta was delayed, beast-feeding too was delayed. Another traditional practice / belief was not allowing the mother to eat full meal immediately after childbirth. The purported reason was that heavy meal would render the breast-milk heavy for the child to digest. It was necessary to dissuade the community from such practices and to initiate breastfeeding soon after delivery. The HBNC programme aimed to promote initiation of breastfeeding of the newborn at least within one hour of the birth. It also aimed to promote exclusive breastfeeding from the beginning. It wanted to promote that the child can be breastfed even before cutting the cord. In fact, early initiation of breastfeeding helps early delivery of placenta. Further, in case of pre-term, low-birth weight babies and those with fever, mothers were encouraged to breastfeed the child as frequently as possible. A child with weak suckling is one of the symptoms in the diagnosis of sepsis. Both VHWs and TBAs were entrusted with the responsibility of promoting early and exclusive breastfeeding. VHWs were trained and were expected to manage breastfeeding problems including cracked or inverted nipple. If the child was not able to feed, the VHW advised extraction of breast milk in a cup and feeding the child with a spoon. During the field visits, we found that the traditional norm of initiating breast-feeding after 2-3 days of delivery had changed to some extent. In AAA area, there was substantial resistance to initiation of

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breastfeeding on the first day. Resistance was lesser to some extent, in the areas of SN and much less in ISSUE area. Among different communities in AAA area, the Gonds were relatively more traditional and intransigent than the Kawars. In ISSUE area, Chatthisgarhi families were relatively more traditional than Baudh or Muslim families. In SN area, Muslim families were relatively backward than other communities in this respect. Breastfeeding was initiated early in most hospital deliveries. Since number of hospital deliveries was more in the area of ISSUE, the norms prescribed in hospital diffused into the community. Hence there was lesser resistance to initiating early breastfeeding even among families opting for home delivery. Though traditional beliefs and practices delayed initiation of breastfeeding among some communities, presence of VHWs / Ankur trained TBAs made a difference. Presence of a VHW at the time of delivery was the single most important aspect that determined the early initiation of breast-feeding. It was observed that the practice of going to mothers house for delivery existed in all the three field areas. In such cases of deliveries conducted outside HBNC area, families sometimes had shown a tendency to follow traditional practice of initiating breastfeeding after two days despite health education having been given to the mother during pregnancy by the VHW. Besides, presence of influential elderly women in a family often led to delayed breast-feeding, especially in the tribal and the rural areas and more so in case of births outside HBNC area. Even in cases of home delivery, although there were some families showing resistance to early initiation of breastfeeding, there was no resistance to managing breast-feeding problems. Families provided almost unconditional access to the VHWs intervention as far as managing breastfeeding problems was concerned. Similarly, resistance was less in the case of high-risk babies where the family understood the vulnerability of such babies. These were the occasions where the VHWs displayed higher medical skills, and hence perhaps the higher degree of acceptance. Solving breastfeeding problems led to a better acceptance of the VHW subsequently in that family as well as in the neighbourhood.

Post-natal Care and Practices

Diet After Delivery : A good diet after the delivery is one of the important practices, which HBNC promotes. This has a strong link with mothers health and also the newborns health as the mothers diet has direct relationship with production of breast milk. As part of the health education, the programme advised the women to eat full; and eat whatever type of food was available. Better food intake by the mother helped in taking care of the child better since they were able to feed the child better and frequently. In all the three study areas, a common prevalent belief was that a nursing mother should avoid heavy intake of food in the initial days after delivery. They believed that heavy intake of food would make the breast milk heavy, which in turn would lead to the problem of indigestion for the neonate. This belief was widespread in all the three HBNC areas as well as in non-HBNC villages. For instance, in the area of AAA, among the Gond community, this belief was very strong. Among the Kawar community, although this was a traditional belief, it was not strong anymore. In this community, contrary to this belief they gave the mother a mixture of dry-fruits (laddu of Khurak). The ingredients for this were bought from market and the cost would be around Rs. 200/. Not all families could afford to procure this. So they gave it for shorter duration. In the field area of SN, recently delivered women were given laddu made of ahliv (common cress) and the juice of Kadulimba leaves (neem leaves) to increase

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the quantity of breast milk. Many Kawar women reported that they had started to have full meal from the day of delivery. In the urban area of ISSUE, post delivery intake was much better among most communities. Since the deliveries were mostly in hospitals, food intake was initiated immediately after delivery in these hospitals. In Garib Nawaz Nagar, where there were relatively more number of home deliveries, the belief of having less intake of food to protect the baby from health problems was reported among a few Chhatisgarhi and Muslim families. Dalit (Baudh) families in both the basties recalled that this used to be a practice earlier but in the recent times women did not believe in such practices. In the area of SN too this belief was reported as a traditional practice. The belief was relatively strongly expressed among the handful of Muslim families in the villages as well as among the dalits. On the other hand, among the Lingayat and Maratha communities, women reported that they started having proper meal after delivery. This belief has to be examined in conjunction with the practice of confining women to the delivery room for a few days after the delivery. A woman was considered polluting in the first few days after delivery. This was very strongly expressed in almost all the communities except perhaps among better off families in SN and ISSUE. During this period, a woman was not expected to be involved in cooking, interaction with outsiders and she was not allowed to move outside the house. As a result, a woman had to carry out all her chores including bathing and washing inside the delivery room. Even going out for answering natures call was severely restricted. Thus, to avoid occasions of stepping out of the house frequently, women tended to avoid having larger quantities of food. The end of polluting period was marked with a ritual on fifth (Pachvi) or sixth (Chatti) day. Among Maratha and Dalit communities, a mother started having regular meals from the 5 th day. The Gonds and the Chhatisgarhies performed 6th day Chhatti function and then the mother started having full meal. The rigour of implementation of this practice of confinement has become weak in the recent years. Although the change can not be fully attributed to the health education given by the VHWs, one can not deny a significant role played by it. Changes noted among the Chatisgarhi families of Garib Nawaz Nagar, Dalit families in SN, and Kawar families in AAA can be significantly attributed to HBNC. There was also a practice of avoiding certain kinds of food items immediately after delivery and even during nursing period by the mother. This was because of the belief that consumption of such food items can trigger indigestion, dysentery or stomach pain in the child. For instance, the mothers among almost all the communities including the Muslims generally avoided non-vegetarian food items. Vegetables such as brinjal, potato and beans were also avoided. It was also observed that, though Gond and Chhatisgarhi mothers did have rice before the delivery, they refrained from having rice after delivery for about 15-17 days. It was believed that intake of rice increased the chances of infection of wounds and that wounds would take longer time to heal. Hence, instead of rice they consumed roti and suji. One more practice that could have implications was that of Muslim women observing fast (roza) in the month of Ramzan. Although no case was observed in which women observed fasting immediately after delivery, there were cases of pregnant women observing fast. Work After Delivery : In all the three study areas, it was found that the women did take rest for at least one month after the delivery. They were supposed to stay indoors and to resume lighter domestic tasks such as sweeping and cleaning the house after a few days. Communities were found to follow the notion of defilement

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period, which varied from one community to another. During this period, the mother was confined to a room and isolated. No one in the family was allowed to touch the woman and her meals were served in her room. This mainly extended up to 10-12 days of delivery. Among Gonds and Muslims the defilement period was for a longer period. The mother usually carried out lighter and easier household tasks during this period except cooking and other major work. There were of course a few cases in which the family had no other woman in the family and therefore the mother had to start doing the domestic chores almost immediately after delivery.

Neonatal Morbidity and Mortality :

Neonatal morbidities
Management of Asphyxia : Asphyxia was found to be one of the important causes of neonatal death in the study areas. As a result, home-based management of asphyxia became an important and essential intervention to save neonatal lives. Asphyxiated baby is referred in local Marathi as gudamarlele bal (suffocated baby). A number of traditional practices to deal with an asphyxiated baby were reported in the villages. These practices were undertaken by the TBA or other elderly women who attended the delivery as part of midwifery activities. Apart from these women there was no other traditional specialist to manage birth asphyxia. For obvious reason of urgency of the situation, all these practices involved only physical manipulation of the child and no other religious or magical rituals were involved. Under HBNC, asphyxia management involved cleaning the mucus from the airways with an orally operated mucus extractor having a mucus trap, tactile stimulation, and if necessary giving artificial respiration by mouth to mask or by tube and mask (Bang, 1999). If the child did not cry, did not breathe or did not make any movement despite efforts to revive, then it was considered as a stillbirth. Asphyxia management had certain peculiarities making it rather distinct and important from other components of HBNC services. In the eyes of the community it was a medically intensive intervention in the sense that it involved the VHW exhibiting high level of medical knowledge, skills and use of technical equipments., beyond their comprehension, experience and expertise. The intervention is required immediately after the birth and is of very short duration. Under the HBNC programme, the VHWs were trained in the skill of identifying the asphyxiated baby and managing asphyxia at home. As part of their kit, VHWs were provided with mucus extractor to clear mucus, and tube-and-mask, for giving artificial respiration. In January 2004 review meeting, it was decided to provide Ambu bag to replace the tube-and-mask. In the subsequent weeks VHWs were trained to use Ambu bag. One needs to stress that the relationship between the TBA and the VHW is extremely crucial in asphyxia management. As it was noted in some of the cases, TBAs rather than the family members played vital role in sending a word for the VHW to attend the delivery in time. Hence, a cordial and mutually facilitative relationship between them was essential. In case of differences between the two, the VHW had to take charge of the situation even if the TBA opined otherwise. This required the wholehearted support from the family members. Thus, in the case of asphyxia management, besides managing birth asphyxia, the VHWs had to deal with the family of the mother, the TBA, as well as local healers / practitioners. Over the period of HBNC implementation, families became aware of the possibility of reviving an asphyxiated child and that the VHW was capable of doing it.

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On some rare occasions, especially in the initial phase, some TBAs had proved to be very vital where the VHW was unable to handle asphyxiated babies due to lack of training. Competent TBAs had managed asphyxiated neonates.(Probably these TBAs were trained to give mouth to mouth respiration during their training by the government. HBNC training of TBAs did not include this component). In the ISSUE area, in the field area of VHW, Mrs. Siddhi Milan Shahu in Garib Nawaz Nagar, one Radha Bhuvanlal Verma was interviewed during September 2004 visit of the process documentation team. She had delivered a few months earlier. The delivery was attended by the VHW and it was a case of twins. Since it was a case of twins, the delivery was a difficult and complicated one. The labour pain was prolonged and the woman required a lot of support. When the first child came out, the child was breathing but did not cry immediately. While the TBA was attending the second childs delivery, VHW began to take care of the first child. VHW recognized the case of asphyxia and started the procedure to revive. In the meantime second baby also was born and unfortunately that child too was in an asphyxiated state. VHW had to continue with the first child. As a result the second child could not be saved. Meanwhile the first child, under the care of VHW showed some sign of life after 15-20 minutes of VHWs efforts and finally the child started to cry. Management of pneumonia in children : Pneumonia is identified locally as Dabba or Dabba Bemari. This vernacular term is used in all the three study areas for pneumonia. Although the term dabba is associated with the most important symptom associated with pneumonia i.e. high respiratory rate, the term is also used for a continuum of childhood discomforts. At the community level, dabba is characterised by symptoms such as strained movement of chest or strained movement of abdomen while breathing; gasping; severe / persistent cold and cough; not feeding properly; constant crying; sleeplessness or being very weak (to cry or be actively awake) and fever. Causes attributed to pneumonia include strained breathing (dhap lagane), loss of vitality, possession by spirit and evil eye. In the study area of SN, pneumonia was also identified by the term potatale yene. Since it was a part of the traditional health culture of these communities, there were also traditional practices and practitioners to deal with dabba. In most cases, care from the traditional healers was sought simultaneously with consultation of the VHW or other modern health care provider. In the area of AAA, there were a number of local healers who were approached by the people to get treatment for pneumonia. There were individuals who were perceived by the local community as specialist in healing pneumonia. The healing practices of the different healers varied quite widely. Pneumonia in children (1 month to 5 years age) and neonatal sepsis were two important childhood illnesses being addressed by the HBNC programme. Under HBNC programme, if the VHW found the respiratory rate in the neonate to be 60 or more per minute or if the baby had chest in drawing then she treated the neonate with co-trimoxazole. If the neonate showed two symptoms of sepsis as defined under HBNC simultaneously (among neonates), the neonate was treated for neonatal sepsis (referral to hospital and if parents were not willing for hospital treatment, VHW initiated treatment after taking consent. The treatment involved administering genatamicin injection and co-trimoxazole) Two aspects of health seeking behaviour were observed in case of treatment for pneumonia and sepsis. Since the cause of the illness was not perceived only physiological but spiritual as well, the

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medical intervention was often perceived to be insufficient to address the spiritual cause and hence medical treatment was used in conjunction with other traditional practices such as warding off evil eye or spirits. This behaviour did not pose serious problem to the HBNC programme, since medical treatment was anyway availed. The other behaviour concerned treatment shopping. People did not wait till a treatment showed effect. A series of treatment / healing practices was attempted in quick succession. The pattern of treatment-seeking ranged from seeking services of modern health service providers including VHWs to traditional magico-religious and herbal healers. Firstly, it is important to note that because of the pre-existence of a culturally equivalent term for pneumonia, the cases were identified and reported quickly as against sepsis. Relatively more people, on their own, sought treatment for pneumonia. HBNC programme not only had the responsibility to introduce a new set of practices to manage pneumonia, but also had to deal with culturally rooted inappropriate practices. It had to make people unlearn those practices. Another problem associated with pneumonia was that of over reporting or excessive demand for treatment. From observing the different cases of pneumonia and its management, it was evident that over the two years of process documentation study, VHWs skill, confidence and communitys acceptance of the VHWs treatment for pneumonia had improved substantially. In the initial phase of the project, especially when the VHWs training was not completed and they were not fully equipped with the skills to treat pneumonia, there were cases of VHWs not being confident and community members too did not have faith in their ability. In the case of AAA, the local healers still held sway and remained the most common source of treatment for pneumonia. However, VHWs had made in-roads into the treatment seeking behaviour, a result of many a cases in which pneumonia was successfully handled by the VHWs. Though families continued to approach the traditional healers, simultaneously they also sought treatment from the VHWs. In other words, the traditional healers were not anymore exclusive care providers but their role was in addition to that of the VHWs. In the case of ISSUE, VHWs had not totally replaced the private practitioners or hospital care, but in some pockets, acceptance of VHWs treatment for pneumonia was very high. In the case of SN, one could say that VHWs were the predominant source of treatment for pneumonia except for a handful of affluent Maratha and Lingayat families. These differences in acceptance of VHWs treatment for pneumonia and sepsis across the three NGOs could also be related to a corresponding gradient of difference in socio-economic status of communities as one moved from the predominantly tribal area of AAA, through urban-poor area of ISSUE to relatively better off area of SN. When the daughters of the village, came to their mothers home for delivery, their exposure to the VHW and her services was very brief. Hence, awareness of VHWs services was very low among them as compared to the daughters-in-law of a village. Similarly, awareness of VHWs services was better among women who had already undergone a delivery under HBNC. This had especially a strong bearing on seeking care for pneumonia. Not only that the seeking of care for a neonate improved with prior exposure to the VHW in earlier deliveries, but also seeking care for older children (U5) for pneumonia improved if a younger child was covered under HBNC.

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Management of Sepsis : The infections including sepsis may be due to several direct or indirect reasons and may include practice of giving bath, poor cord care, the practice of ear piercing in neonates and many other reasons of unhygienic conditions in which the neonate grows. Initially, the VHWs were finding it difficult to diagnose sepsis. People on their own did not report sepsis. The term jantudosh had not become part of the local vocabulary. Either sepsis was reported as dabba or as only individual symptoms such as child not feeding, and fever. As a result, there was delay in referral or initiation of treatment for sepsis. This had resulted in deaths too (Kowsila Dassu Poodu in AAA). Certainly the onus of death should not be completely on the VHW. The situation was analysed in the Ankur review meeting. In order to keep false positives to the minimum and true positives to the maximum, the symptoms were revised. Refresher training of VHWs was arranged. To better the performance of the weaker VHWs, more competent VHWs were asked to accompany them to help them (SN). Felicitation of successful VHWs and other incentives were introduced. In one of the NGOs (SN) a Mahila Melawa was arranged in which a case of a child saved by the VHW from sepsis was discussed and the VHW was felicitated. This not only helped better the acceptance of the VHWs but also made the term jantudosh relatively familiar in the village. The VHWs were under relatively higher level of stress in handling sepsis than handling pneumonia. It used to be a hard decision for them to make. A decision to initiate the treatment meant administering a series of injections whereas failure to treat could prove fatal for the child. The VHWs wanted some support and wanted someone else to confirm the decision. Initially the VHWs tried to get the diagnosis confirmed by the NCS. Even Dr. Bang was consulted once. In one case, a VHW of another village was asked to visit the case and diagnose it . These apprehensions were reported more in the earlier phases. These were less in case of VHWs with better acceptance in the community or VHWs with higher level of competency. Towards the later phase, the VHWs had become very competent in diagnosing and going ahead with the decision of treating. A few VHWs of SN continued to consult the NCS. Acceptance and compliance to VHWs treatment for sepsis was high. There were cases of refusal or discontinuation of treatment in all the three study areas, but these were isolated cases and were largely in the initial phase. Unlike pneumonia, the interference of traditional healers was minimal. Successful treatment of sepsis case, demonstration of the skill of giving injections and saving a seriously ill child provided a lot of visibility to the programme and acceptance in the neighbourhood. For the villagers, it was a medically intensive episode. The VHWs immensely gained esteem in the eyes of the family and the neighbourhood. Affluent families wanted to avail costlier care in the towns, although it was noted that it did not necessarily mean better treatment than that was provided by the VHW. ISSUE: Tara Raut, a resident of Sanjay Gandhi Nagar was visited as a follow up case. Tara chronically suffers with sickle cell anaemia. She has 5 children. Four months earlier she delivered a baby at home in the presence of her mother-in-law. Neither the VHW nor the TBA was present during the delivery. TBA Kantabai Telang had reached a few minutes after the delivery at home. Shashikala

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Dekate, the VHW reached much later. Taras name was not registered in the pregnant womens list. Tara narrated that she couldnt identify the pregnancy, as menses were regular and after 3 months she came to know about her pregnancy when she approached the doctor for some other illness. Though she was aware about VHWs services, she didnt inform her. The VHW informed that on the contrary, she had informed the VHW that she had already undergone family planning operation. This was confirmed by the NCS as well. But Tara denied this and stated that she was availing treatment from a private medical practitioner, Dr. Palandurkar. She further added that because she was consulting a doctor during pregnancy, she felt that there was no need to inform the VHW. However, it was interesting to note that subsequent to the delivery, she had been availing services from the VHW regularly. The VHW attended the baby after receiving the message and applied G.V Paint on navel. Tara had already applied vermilion to the cord and subsequently started applying mustard oil. Breastfeeding was initiated on the same day. The baby was given bath on the same day. On the second day after birth, the child showed symptoms of pneumonia and she promptly informed the VHW. The VHW started cotra medicine(cotrimoxazole). On the 4th day, it developed into sepsis. This again was identified by the VHW and she informed the NCS. The VHW and NCS immediately started sepsis treatment after receiving the written consent from the family. Now the baby is in good health. Management of Hypothermia : HBNC programme gave due importance to management of hypothermia, along with other neonatal problems. Hypothermia is the physical state where the temperature of the neonate drops below 950 F (Bang et al, 2001). The VHWs, in their routine examination of babies, can easily identify this state by measuring the temperature of the baby. The pre-term and low birth weight babies have greater risk of developing hypothermia. In the interviews conducted with the VHWs, it was found that, the VHWs always insisted that a pre-term and low birth weight baby should be kept warm. Early initiation of breastfeeding at regular and shorter intervals was another measure suggested by the VHWs to prevent/ manage hypothermia. Specific explicit mention of cases of hypothermia was not common. Very few specific cases of hypothermia were noted from the field visits. While talking to the VHWs it was found that if a baby suffered from hypothermia, VHW had to give visits on three consecutive days and measure the temperature. In most cases, across communities and across study area, families had not shown any major resistance to the VHWs efforts to manage hypothermia. As the family was able to perceive that the child was not well (most often in case of pre-term, low birth weight babies with or without breastfeeding problem), they submitted to the intervention of VHW without much resistance. Management of High Risk Babies : As per the HBNC guidelines, a neonate was considered to be high risk if the birth was premature or if the baby was low birth weight or if baby had breast feeding problem. As per HBNC, if the birth was normal, VHW paid total of 8 home visits including visit at the time of delivery. If the child was high risk, then the VHW made 14 visits including visit at the time of delivery. A high risk baby was cleaned with a dry cotton cloth immediately after the delivery and the mother was

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advised to keep the baby warm by wrapping in a blanket / warm bag and to initiate breastfeeding on a regular and frequent basis. The family was strongly advised not to give bath to a high-risk child till the baby weighed above 2 kgs. Mothers were advised to keep the child clean, avoiding handling the child by anybody with unclean hands or clothes. If the mother had feeding problems (such as inverted nipple or cracked nipple) the VHW managed the problems and if the child was unable to feed, milk was extracted in a cup and the baby was fed using a paladay/spoon. In all the three field areas, families perceived the seriousness of a high-risk neonate and the need for higher level of intervention than normal babies. Within the traditional midwifery knowledge, a severely low-birth weight or a pre-term baby was considered to be vulnerable and difficult to survive. This belief had set in a sense of fatalism in the local midwifery traditions. Hence, the biggest challenge for HBNC in this respect was to address this sense of apathy and indifference among the old women and traditional birth attendants. This apathy among the TBAs was best addressed through a systematic training of TBAs, not only on safe and hygienic delivery but also on danger signs during delivery, health education messages for the care of the newborn, the importance of weighing the child, breastfeeding, and temperature control. Their exposure to the services given by the VHW to the highrisk babies too had provided them with knowledge regarding the possibility of saving the high-risk newborns. Health education among the community, including the mothers and aged women had contributed significantly to the awareness regarding the seriousness of low birth-weight, pre-term babies and the importance of proper breastfeeding practices. Among the communities in ISSUE, SN and to some extent among the Kawars in AAA, families were now aware of the seriousness of highrisk births as well as the skills in the hands of the VHW to intervene and save the life of such children. This had contributed to lower resistance to the VHWs to deliver their services in such cases. Moreover, the VHWs intervention of suggesting more frequent breastfeeding, avoiding bathing the child, keeping the child covered in a warm bag, and handling of breastfeeding problems were seen as more intensive in terms of skills. This again seemed to have evoked stronger conformity from the community. In most cases, one noted a sense of voluntary submission on the part of the families to the VHWs intervention. This was the result of knowing the seriousness of the situation and the skills that the VHW had demonstrated in similar situations in the neighbourhood. There had been only stray instances where the families did not appreciate this and did not pay heed to the VHWs advice. Such cases resulted in sepsis and posed serious threat to the life of the neonates. Unlisted and untrained TBAs had contributed to the resistance to the VHWs services by the families with high-risk babies. Here too, the basic reason was that the VHW was not present for these deliveries as the VHW was not informed by the untrained birth attendant or because the women wanted to hide their pregnancy and hence did not contact the VHW.

Neonatal Mortality
The number of cases of neonatal death on which data could be collected by the process documentation team from the areas of total six VHWs of the three Organisations was very limited. Even out of the cases on which data was collected, not all were during the phase when VHWs service had begun after completion of training. Further, some deaths were in the form of stillbirths where the role of VHW was limited, or the death had taken place outside HBNC area. In some other cases, the woman did not receive HBNC although the death had taken place within HBNC area. This also implied that the way a neonatal death was perceived by the family members / community and their reactions vis--vis

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VHW / HBNC could vary widely depending on the context in which the death had taken place. Thus, we have a range of reactions from the community: creating a strong antagonistic sentiment in the community which held sway for a long time, absolving the VHW from any responsibility for the death, or even praising the role of the VHW under the circumstances. SN - Khairum Qadir Shaikh, 26 years of age is basically from Khanpur and her in-laws belong to Yevati. She was pregnant for the 4th time. Both she and her husband were in Karnataka working as agricultural labourers. Her first pregnancy resulted in stillbirth. Second time she gave birth to a daughter and the 3rd pregnancy was a miscarriage. Khairum didnt go for ANC check up when she was in Karnataka. She worked very hard in the field and was undernourished due to lack of proper intake of food. She didnt receive ANC. In the 6th month of pregnancy, her feet were swollen; BP was high and she was very anaemic. She came to her mothers home in the 9th month of her pregnancy and delivered on the next day of her arrival. The VHW couldnt be informed at that time as the delivery was preterm(sudden). But her mother Anwarbi Sikandar Patel, called Gangabai Yamajale, the VHW later. The baby was a low birth weight (1 kg and 650 grams). The baby was also visited by two more VHWs of SN. The baby suffered breastfeeding problem too. As the baby was unable to breastfeed, the VHW fed milk to the baby using a spoon. In the first three days the baby showed symptoms like grunting and chest in-drawing. The VHW started medication with Cotra(cotrimoxazole). On the 5th day, the VHW observed fever. Khairum wanted to take the baby to the hospital where her maternal uncle works under a paediatrician. But as it was a Sunday, the family couldnt go there and the child succumbed before the next morning. When asked about the circumstances in which the death had taken place, the family related it to the fact that they could not take the child to the hospital in time. On enquiring a little deeper, it was also recalled that she had travelled from Karnataka very late in the pregnancy, and her work was arduous. The family however did not relate the death with the fact that she did not avail any care during pregnancy (ANC). Mother of Khairum also pointed out that her daughter had been generally weak and she had had problems in one of her previous pregnancies too. Perhaps for the following reasons the family or the community no way tried to relate the event with VHW or HBNC. Khairum did not receive HBNC during pregnancy; had come into the HBNC area only a day before the delivery; the delivery was preterm; the VHW was not informed in time to attend the birth, the child had breastfeeding problem; and On the contrary they appreciated that the VHW was able to offer whatever service she was able to give and that the NGO had asked three VHWs and the NCS to come and attend the child

Sustaining HBNC in the Community :

One way of defining sustainability of HBNC is to see whether it created a need in the community for neonatal care so that the community was able to and was willing to spend money to meet this need. The private sector may then respond to this demand. Another possibility was to make the HBNC programme financially sustainable by linking it to some form of employment generation scheme. NGOs had thought of / were suggested activities like goat rearing and bangle selling for VHWs. They could be given assistance to buy the necessary assets and facilitate the marketing of their products. The idea was that the VHW being the central functionary of the programme, if her remuneration could be met by any such alternative financial source, the programme could be made self-sustainable to that extent.

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Another idea suggested by ISSUE was to absorb the VHWs as anganwadi workers (as part of government run ICDS programme) and implement HBNC through them. However, none of these models were tried by any of the NGOs. One more model of sustainability suggested was implementing the HBNC programme as it was being implemented and charging nominal fee from the families for the services provided, the fee charged to be sufficient to meet the remuneration of VHW, TBA, supervisor and other expenses on consumables. No data was collected on this matter explicitly by the process documentation team. However it was possible to put together data on ability and willingness of the families to pay for care during pregnancy and on neonatal care. In AAA, the population was predominantly Gonds. Kawar who constituted the second largest population were relatively better off. Gond families were relatively much poorer. However it was observed that the families did spend considerable amount of money on care during pregnancy and neonatal care. Families visited Bengali doctors who provided allopathic care of sorts. In addition, they also spent money on visiting doctors of various qualifications for emergency care during pregnancy and problems like delayed delivery. Calling such doctors for the problem of delay in delivery was very common. The families reported that the treatment from the local healers was not free of cost and small amount of money had to be paid to the healers. Some families reported that, even in the primary health centres / sub-centres, they had to pay some amount and buy medicines from the market. In addition there were families in these villages that availed care for neonates from private doctors. In ISSUE, the use of private care was extensive. Despite the availability of public health hospitals, the families approached the private practitioners in the vicinity of the slums for care during pregnancy, delivery as well as for neonatal care. In the slums that were studied, the clinics of private practitioners were crowded with women with infants in their arms. During one of our visit to the clinic of one Dr. Agarwal, there were around 20 individuals, of whom, more than 15 had come with children. These doctors charged a fee ranging anything between Rs.20 and Rs.200 depending upon treatment given. Especially in ISSUE, the practice of calling a doctor to administer injection to speed up the labour process was so common that one gets a feeling that largely it was an unnecessary intervention. However, the families were willing and were able to pay for such expenses. Many families reported visiting private doctors for neonatal ailments such as pneumonia and other infections. Thy also showed the process documentation team, the medicines they were asked to buy from the market. Thus, the families easily spent anything from Rs.50 to Rs.150 for each episode of ailment. There was also a rampant practice of families hopping from one provider to another thereby ending up spending much more. In SN, some of the families were very affluent. These included Lingayat and Maratha and some Muslim families. Their usual place of treatment during pregnancy, delivery as well for neonatal ailments was private hospitals, especially in Sholapur. These families were only small in number. Among the rest of the families, except the dalit families, most others were in a position to spend for newborn care. They mainly sought care from the nearby towns such as Naldurg and Tuljapur. The practice of doctors visiting the village was less but not completely absent. They visited especially to attend deliveries to speed up labour. The families were able to meet such expenses. Families also paid money to public health staff, who administered injections and gave medicines in the village. Dalit families were the poorest in these villages. Their ability and willingness to contribute financially for HBNC could be doubted. They did constitute a significant proportion of families in the villages.

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Conclusion :
This chapter documented the impact and changes that took place in the project areas/communities due to the implementation of the HBNC package. For ANC, VHWs played an enabling role in the form of encouraging the pregnant women to register for ANC and seek all the ANC related services from the existing healthcare facilities in their vicinity. Through the group health education and the health education at the individual level, the VHWs and the NCS dealt with some of their beliefs and practices that would adversely affect the outcome of the delivery. At the time of delivery, the VHWs played an important role of taking care of the newborn and sometimes saving the life of the newborn. As the TBAs focus was delivery and the mother, the VHW took care of the newborn in the crucial early period of life. After the delivery, it was the VHW, who regularly visited the mother and the neonate and took care of their health problems. In dealing with the neonatal morbidities, the VHWs played a life saving role. The work was highly technical and intensive and at the same time, she had to deal with the communitys beliefs and practices to prevent morbidities and treat neonatal health problems, which were often life threatening. Sustaining HBNC after Ankur is an important issue. Sustaining HBNC in the Ankur project sites has implications on replication and generalisability of HBNC elsewhere in the country. There were suggestions to link the work of VHW with other income generation activities in the villages. The scope of paying for services (fee for services) was explored. The next phase of HBNC (beyond Ankur) should explore these aspects.

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Chapter - VI Socioeconomic Context and Implications on HBNC

Introduction :
Previous chapters have documented the planning and implementation of the HBNC package in the Ankur Project area by the NGOs as well as the changes it brought about in the maternal and child health practices in the communities and its impact on saving the lives of neonates. We also analyzed some of the key factors that have either facilitated or hampered the implementation of HBNC. We will now critically look at the socio-economic context within which HBNC was implemented and its impact on the success of the programme. These discussions will lead to the key issue of replicating HBNC in a larger population/community.

Socio-economic Context :
One of the aims of Ankur programme was to establish the replicability of the HBNC programme from SEARCH to the seven Non Governmental organizations in Maharashtra. Through a systematic transfer process, such as streamlined training, supervision, and rigorously maintained systems, HBNC was attempted to be replicated as uniformly as possible in all the NGO sites. However, the socioeconomic settings of the areas in which these seven organizations worked varied to a great extent. These variations in the socio-economic context had introduced palpable differences in the way the programme was implemented and accepted. As a result, despite the programme being strongly based on rigorous use of standard and uniform procedures and systems, the programme at individual sites had taken on local characteristics. This was however not surprising. The replication sites were chosen, so as to observe the replicability of the programme outside the area in which originally it was tested (at SEARCH). As expected, the variations in the socio-economic settings in the three sites (AAA. ISSUE and SN) introduced peculiarities to the way the programme was introduced, implemented and accepted. In the following pages we will see how the varied socio-economic settings affected the HBNC programme. The study area under AAA is a tribal area with all the typical characteristics of a tribal society. The main communities are Gond, Kawar, and dalits. Gond community was found to be economically and socially backward compared to the other communities. Dalit families were only a few. Kawar families were relatively better off economically as well as in terms of awareness. The communities in general (especially Gonds) were relatively traditional, rooted in traditional customs, with very low levels of literacy and exposure to modern life. Health related or any other public commitment of the people was least among the three areas, as the basic livelihood and sustenance took away their time and energy unlike in other two areas. Access to private health facilities was very limited only in the form of visiting doctors or a few Bengali doctors. Public health facilities were available in the form of sub centres, PHCs and rural hos-

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pital. However commuting was relatively hardest among the three field areas. The area had the poorest transport system with hamlets far away from each other. Transporting patients / pregnant women in an emergency situation was almost impossible. During the day time, there was hardly anybody present in the hamlets if there was a need to send message to the VHW or anybody else. It was economically the most backward of the three regions. People were largely engaged in agriculture as marginal farmers and to a less extent as landless labourers. In addition they also eked out their living through collection of seasonal forest produce. Level of living was close to subsistence. Purchasing power and use of money was relatively limited. Many families lived almost on the threshold of starvation. Starvation for some families was a seasonal and recurrent fact. Food availability and consumption was very limited. Milk was not used at all for domestic consumption. Regular food was just rice and dal with very little use of vegetables and nonvegetarian items. Fruit intake too was very limited except the locally available ones. Under these circumstances, health messages on food intake had very little impact. Weather was extreme in winter and in summer (similar was the case with ISSUE). This again took a toll of health of people, especially women and newborns. Home deliveries were maximum. VHWs were very committed and skilled, but they had to work almost in isolation, unlike in other two areas where the support from communities was much more than that here. It was not a case of any sort of resistance from the community but was a case of lack of awareness and hence non-participation in a meaningful way. It was a case of passive acceptance (which was very high) rather than active involvement in matters of their own health. TBAs were still relatively traditional. There was a strong influence of other community actors such as traditional healers who still held sway to some extent (compared to the other two areas). Awareness and compliance was more in hamlets where VHWs were able to reach more frequently than those hamlets which were far away. An undercurrent of social divide also was evident, if the community of the families in a hamlet was of different caste than that of the VHW. The field area of ISSUE was typically urban. The main communities were Chhatisgarhi, Muslim, Buddh, caste Hindus and a few Christian families. This area was populous. Community was more heterogeneous, yet one could see that most often families belonging to the same community lived in proximity of each other. Living space was extremely limited and life was cluttered. The VHW had lesser rapport with the families, who were recent migrants. Therefore, active support for HBNC or VHW was not significantly perceptible among these families - much like that in AAA but for different reasons but unlike that in SN. Some of the families especially Chatisgrahi and Muslims were traditional, yet when compared to communities in AAA and even those in SN, they were relatively more aware, and exposed to modern life and healthcare services. This in a way helped the VHWs in disseminating health education more effectively. There was relatively higher acceptance of certain selected services provided by the VHW, especially that of general treatment, pneumonia, and use of G.V Paint. The demand was relatively

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more active than in AAA for these selected services. Since the community was urban and exposed to alternative views and opinions, the Ankur was cautious in using the VHW for giving certain services. VHWs were not allowed to give injections. Giving injections was job of the NCS. Women were mostly engaged in making agarbathi. Men were employed in a plethora of wage earning activities and small time self employment. Economically, the families were poor, and their diet was also very poor. In this respect, the situation was just marginally better than in AAA and was worse than in SN. There were a number of private doctors and public hospitals in the area. Connectivity to the hospitals was very good. Attendance in the clinic of the private doctors was very high. The doctors did attend children as well as neonates. However here too, an emergency delivery at night had to be at home. The fact that there were multiple options available for families to seek health care general as well those related to children, the importance of the VHW and the NCS was much less significant than in SN and AAA. The fact that the proportion of hospital deliveries was very high and there was no strong tradition of midwifery added to this fact. However the VHWs played an important role in referring and even escorting pregnant women to public hospitals. The area being urban, there were no community leaders with strong links with the community. Such community leaders could have given good support to the NGO and the programme, and the community would have responded collectively to such persons. ISSUE had no such benefit. VHWs were relatively more educated and aware. The field area of SN, was a rural area with villages with multiple castes and largely agrarian. The villages were numerically dominated by dalits, Maratha, Muslims, OBC and Lingayats. Marathas and Lingayats dominated economically. This area also had bad roads and poor transport facility. The main highway was very good and close to the villages while the roads connecting the villages to the highway were often in very bad shape. Frequency of public buses was very poor. Therefore, going to the PHC which was just about 6 km away and coming back would take a whole day. Private share taxies were available. but these plied only along the main roads and did not connect the villages. In terms of transport, the situation was better than in AAA but worse than in ISSUE. The area was badly hit by severe drought during the major part of project implementation period. Water supply, even for drinking, was very badly hit for many years. In the last phase of the project, the drought situation improved. The drought badly affected the employment situation. Poorer families had to travel far from the village daily for work. Earnings were very meagre. This badly affected the general standard of life and of course the food intake. However on the whole, the communities were better off in terms of general standard of living as compared to the families in AAA and ISSUE. In terms of income, expenditure, food intake and hous-

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ing, the situation was much better than in the other two areas. Many families owned cows. Milk was part of everyday diet. The villages were self-contained. VHWs did not have to trek long distances to cover the village population. Hence, the attention of the VHWs was very high and equally distributed throughout the area unlike in AAA. Unlike in ISSUE, the VHWs were familiar with all the parts of the village and were able to reach there. They had established a good rapport with all the communities. There were no marked cultural differences or heterogeneity unlike in AAA or ISSUE. Marathi language was the single common language. Hence, there was no barrier between the VHW and any community in terms of culture or social distance. Although there were many caste groups and political affiliations, these differences did not show up in acceptance of HBNC. The VHWs did not experience any significant resistance from any quarters of the community. The NGO had been actively implementing many programmes in the same villages. Hence, the support base for the NGO in each village was significantly large. Moreover, for a variety of reasons, the villages looked more vibrant than in AAA. At least some persons would be present in the villages (while in AAA area, the villages had a deserted look for the major part of the day in most seasons). As a result, VHWs found it easy to meet people or send for somebody in case of need. Hence, the VHWs had better reach. This also progressively helped build strong rapport. The rapport of the VHWs with the community was strongest here. There were some families who were relatively very affluent. These families had ties with nearby towns. They also had financial and logistical support to reach the towns conveniently. These families rarely sought VHWs services. Some of the affluent individuals were politically important in the region / respective villages. The NGO had established good rapport with these individuals. This facilitated the NGO and the programme very much. Incidentally, the father of the VSS was an influential person. As a result, the VSS and the NCS were able to forge good relationship with important / affluent individuals in almost all the villages. Thus, we had three different socio-economic contexts in which HBNC was being implemented. The contexts were widely different in many dimensions. The contexts had influenced the way HBNC was implemented and accepted. In nutshell, implementation was relatively easier in SN, followed by ISSUE and then AAA for very many non-programmatic reasons, stemming from the socio-economic contexts over which neither the programme nor the NGO had any control.

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Chapter - VII Conclusions

The present study brings out interesting insights about replicating the concept of HBNC to varied environments and communities (tribal, rural and urban). The successful transfer and adaptation of the HBNC approach by the Ankur NGOs has implications for the replicability and generalisability of the model at the state and national level in India and even in other developing countries. The successful implementation of the Ankur Project has many positive, pragmatic, and futuristic implications for neonatal care, care of children under-5 years age and womens health, as well as for public health services. These are: The HBNC can be extended to poor, tribal, rural and urban communities. One may attempt to incorporate the HBNC into public health systems, for instance through the Reproductive and Child Health Programme / National Rural Health Mission to bring down neonatal morbidities and mortality. Although the approach is replicable in different settings, for an efficient adoption, the transfer strategy should take into consideration the local socio-economic context and evolve the relevant processes accordingly. The strong leadership provided by SEARCH as the source of inspiration, technical inputs, training, quality control and evaluation was very important. These roles will need to be played either by a single or multiple agencies in any replication. The vehicle of replication was small, local NGOs without much medical expertise or any hospital back up. Their strengths were-their presence at the grassroots, interest in reducing child mortality, and leaderships willingness to learn this new approach and implement without sacrificing quality or the value and the culture of HBNC. HBNC training was highly focused, distinct and outcome oriented. It has created a set of second line of trainers cum supervisors, who in turn transformed many ordinary village women into efficient, skilled, and dynamic VHWs and even improved the practices of uneducated TBAs. The modular, and stepladder pattern of training, interspacing the training with actual field work has been found to be very efficient. Government organizations can integrate similar model of training into other health service programmes and by the NGOs to create a cadre of capable community based health care providers. The rigor in selection, training and supervision of the VHWs and the levels of attainment of knowledge, skills and empowerment were key to the successful transfer of HBNC model to the Ankur NGOs. They are now the pillars of replicability and gerneralisability of HBNC to the larger community. The project has shown that the VHWs can be equipped with further skills and knowledge including medical skills of sepsis and asphyxia management. The existing model of HBNC has scope for incorporating other knowledge and skills in terms of coverage beyond the neonatal period say till Under-5 children and /or even maternal health.

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 Involvement of the community in the selection of the VHWs enabled the VHWs and the HBNC approach to acquire communitys support and co-operation in utilization, which were essential for the successful implementation of the approach. This pattern of community involvement for selection of community based health workers can be emulated by the Government, and other NGOs working in the rural and tribal communities. Government schemes such as ASHA in National Rural Health Mission can benefit from such selection process. Although the programme was implemented through external funding, an alternative source of funding needs to be worked out to make it self-sustaining. The experience in Ankur has indicated some such possibilities which need to be further explored: The very experience of SEARCH networking with seven partner NGOs and the way SEARCH coordinated with the partners to transfer the knowledge and skills and implement the programme successfully in all the sites itself is a learning which will be useful in similar endeavours of networking, partnering, sharing, and transfer.

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REFERENCES :
Published Material (English) 1. Bang, A, Community Participation in Family Planning Programme in Uttar Pradesh, EPW, August 9, 1986. 2. Bang, A. T., Bang, R. A., Voluntary Health Programs Should Not Try to Become Economically SelfSufficient, World Health Forum, Vol. 7, 1986, 194-198. 3. Bang, R., An Approach to the Gynaecological Problems of Rural Women: Epidemiological Study and Intervention Through Primary Health Care Research Paper number 9, First Annual Meeting of Community Epidemiology/Health Management Network, Khon Kaen, Thailand, February 1-4, 1988 4. Bang, A. T., Bang, R. A., Against Liquor Gadchiroli and Gorbachev, Medico Friends Circle Bulletin, Sep & Oct (167 &168) 1990, 1-8. 5. Bang A. T., Bang R.A., et al., Reduction in Pneumonia Mortality and Total Childhood Mortality by Means of Community-Based Intervention trial in Gadchiroli, India, The Lancet, Vol. 336, pp. 201206. (1990) 6. Bang A. T., Bang R.A., and SEARCH Team, Diagnosis of Causes of Childhood Deaths in Developing Countries by Verbal Autopsy: Suggested Criteria, Bulletin of World Health Organization, 70 (4) 1992, pp.499-507. 7. Bang, A. T., Bang, R. A., Community Participation in Research and Action against Alcoholism, World Health Forum, vol. 12, 1999, 104-109. 8. Bang A. T., Bang R, Baitule S.B., Reddy M. & Deshmukh M.D., Effect of Home-Based Neonatal Care and Management of Sepsis on Neonatal Mortality: Field Trial in Rural India, The Lancet, Vol. 354, December 4, 1999. 9. Bang A.T., Bang R.A., Baitule A., Deshmukh M., Reddy M.H., Burden of Morbidities and the Unmet Need for Health Care in Rural Neonates A Prospective Observational Study in Gadchiroli, India, Indian Paediatrics, Vol. 38. September 17, 2001. 10. John, T. J & Bodhankar, Uday., Editorial - Birth Attendants: One or Two, Indian Pediatrics, Vol. 38, 2001, pp. 327-331. 11. Bang, A., Reddy, M. H., Deshmukh, M.D., Child Mortality in Maharashtra, EPW, December 7, 2002, pp.4947-64. 12. Dadhich, J.P & Paul, V (Eds), State of Indias Newborns. Save the Children, New Delhi, 2004. Published Material (Marathi) : SEARCH, Kowali Pangal, (2001) Balmrithyu Moolyankan Samiti Balmrithyu Va Kuposhanavar Upay (Second and Final Part), 24th March, 2005, Government of Maharashtra, Mumbai Online Material : Saving Newborn Lives Project, Essential Newborn Care Training Competencies, Washington, DC: Save the Children, December 16, 2003.

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Appendix
Contents and Schedule of Training in ANKUR
TOT Workshops
TOT TW1 (October 2001) : Principles of participatory training,Training methods demonstration & practice, supportive supervision, field visit and daily & monthly report, Selection of VHWs Planning of training TOT TW2 (December 2001) VHW TW 1 - Modules 1, 2, 3 of VHW curriculum, evaluation of VHW at work site TBA TW 1 - Module 1 TOT TW 3 (February 2002) How to write training report, VHW TW 2 - Modules 3 (evaluation), module 4, 5, 6 of VHW training VHW TW 3 - Module 7 of VHW curriculum, evaluation of VHW at work site, field visit and daily & monthly report

VHW Training Workshops

VHW TW1 (January 2002) Module 1: Introduction, Roles & responsibilities of VHW, job description Module 2: Registering mothers during pregnancy Module 3: Treatment of minor ailments in the community

TBA Training Workshops

TBA TW 1 (December 2001) Module 1: Introduction to program; Clean & safe delivery, delivery kit, cooperation with VHW, Registration of births, and treating white discharge with G.V. paint

VHW TW 2 (February 2002) Module 3: Minor wounds treatment, Using Aspirin & Paracetamol to treat fever & body ache (Revision & Evaluation) Module 4: Be present at delivery & observe. Fill the examination form B Module 5: Form C - First examination of baby Module 6: Maintaining stock & keeping treatment record book VHW TW3 (March 2002) Module 7: Making home visits - Form D refresher (April 2002)

TOT TW 4 (June 2002) VHW TW 4 Modules 8, 9, 10 of VHW curriculum, evaluation of VHW at work site

VHW TW4 (June 2002) Module 8 : Managing acute respiratory infections (ARI) Module 9: Interpersonal communication Module 10: How to give vitamin K injections VHW TW 5 (September 2002) Module 11: Breastfeeding Module 12: Using visual aids for health education VHW TW 6 (October 2002) Module 13: Temperature control Module 14: High risk assessment & LBW VHW Module Module Module TW 7 (December 15 : Asphyxia, 16 : Sepsis, 17: Referral Criteria TBA TW 2 (October 2002) Module 2: Safe delivery (Normal delivery & identifying prolonged labour, bleeding, retained placenta) G.V. paint on cord, Health education messages- Iron folic by ANM / VHW. Good diet during pregnancy, Danger signs during pregnancy and delivery

TOT TW 5 (September 2002) VHW TW 5 Modules 11, 12, VHW TW 6 - Modules 13, 14 of VHW curriculum, evaluation of VHW at work site TBA - Module 2

TOT TW 6 (November 2002) VHW TW 7Module 15, 16, 17 of VHW curriculum, evaluation of VHW at work site Evaluation of TOT TBA TW 3 - Module 3 TOT TW 7 (January 2003) Refresher of entire training

2002) TBA TW 3 (December 2002) Module 3: Care of the newborn Health Education messages, breastfeeding, temperature control

Refresher Training (January 2003) Evaluation (February 2003)

Evaluation

(February 2003) Evaluation of entire training

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A. The ANKUR Team

SEARCH, Gadchiroli
1) Dr. Abhay Bang - Project director 2) Dr. P.P. Paranjpe - Management 3) Ms. Priya Paranjpe - Master trainer 4) Dr. S. B. Baitule - Master trainer 5) Dr. Hanimi Reddy - Statistician 6) Mr. Mahesh Deshmukh - Statistician 7) Mr. Hemant Pimpalkar - Computer programmer 8) Mr. Kamalkishor Khobragade - Data entry operator

B. The partner NGOs and project coordinators

1) Dr. Satish Gogulwar, Amhi Amchya Arogyasathi, Kurkheda, Dist : Gadchiroli 2) Smt. Rajeshree Thorat, ISSUE, , Nagpur 3) Mr. Rajeshkumar Malviya, NIWCYD, Nagpur 4) Shri Ramakant Kulkarni, Sahayog Nirmitee, Hipparga (Tad), Dist Usmanabad 5) Ms. Ashwini Kulkarni, VACHAN, Nashik 6) Smt. Yogini Dolke, SRUJAN, Pandharkawada, Dist Yavatmal 7) Dr. Bhalchandra Sathaye, Rugna Seva Prakalpa, Miraj, Dist Sangli

ANKUR Project
Maharashtra State
Nagpur

Nasik

Yawatmal

Gadchiroli

SEARCH HQ Selected study sites Villages : 91

Sangli

Slums : 6 Total population : 88,311

Society for Education, Action and Research in Community Health Gadchiroli - 442 605 Maharashtra, India E-mail : search@satyam.net.in www.searchgadchiroli.org