Shakti.pdf
Media
- extracted text
-
FELLOWSHIP FINAL REPORT
submitted in partial fulfilment of the
requirements for the
Postgraduate Diploma
In
Community Health
Shakti Singh Shekhawat
PEKHRI VILLAGE
SOPHEA- SOCHARA
CHLP 2022-23
CHLP 2022
Contents
PART- A............................................................................................................................................................ 3
CHLP Learning ................................................................................................................................................. 3
Introduction and reason to join the fellowship .................................................................................................. 3
Learning objectives ........................................................................................................................................... 4
Learning Objectives....................................................................................................................................... 4
Areas of Interest ............................................................................................................................................ 4
Module reflections and application ................................................................................................................... 4
Mentorship process and reflections ................................................................................................................... 7
Project learning experience ............................................................................................................................... 8
Take away from CHLP ...................................................................................................................................... 8
PART- B ............................................................................................................................................................ 9
Community-Based Health Action-Reflection Project ....................................................................................... 9
Village Background ........................................................................................................................................... 9
Geography ..................................................................................................................................................... 9
Livelihoods .................................................................................................................................................... 9
Infrastructure ............................................................................................................................................... 11
Local Ecology (One Health Perspective) .................................................................................................... 11
Biodiversity (One Health Perspective) ........................................................................................................ 12
Social Context ................................................................................................................................................. 15
General Well-being ..................................................................................................................................... 15
Women ........................................................................................................................................................ 15
Religion ....................................................................................................................................................... 15
Governance and Politics .............................................................................................................................. 15
Education ..................................................................................................................................................... 16
Social Determinants of Health (CSDH conceptual framework)...................................................................... 17
Other Issues ................................................................................................................................................. 17
Possible Interventions .................................................................................................................................. 18
Project Planning Phase .................................................................................................................................... 19
Project Initiation .............................................................................................................................................. 19
Preliminary Visit Activities ......................................................................................................................... 19
Module Trainings ........................................................................................................................................ 20
Community Health Axioms ............................................................................................................................. 24
Results ............................................................................................................................................................. 24
Page
1
Lessons Learnt ................................................................................................................................................. 25
Table of Figures
Page
2
Table 1 Major tree species (excluding fruit trees) .............................................................................. 14
Table 2 Major shrubs and herbs ......................................................................................................... 14
Table 3 Major agriculture crops ......................................................................................................... 14
Picture 1 Shepherd basks in the sun as the animals graze. Only a few continue in this profession .. 10
Picture 2 Patch of old and regenerated forests. Pine and deodar are the main trees of the landscape
............................................................................................................................................................ 12
Figure 1 The Poshan Abhiyaan Modules used for Mahila Mandal Trainings ................................... 22
Figure 2 Takeaway used for role-play ................................................................................................ 23
PART- A
CHLP Learning
Introduction and reason to join the fellowship
As state civil servant in Department of Women and Child Development, I developed a keen interest
in Health, Nutrition and WASH Activities and awareness programmes. I was responsible for
monitoring nutrition and health schemes for women and adolescent girls and executed awareness
campaigns, facilitated supply of supplementary nutrition by supporting and strengthening local
village-based Women SHGs and spearheaded Poshan Abhiyaan (programme to improve nutritional
outcomes for children, adolescents, pregnant and lactating women) for which received Block
Leadership award at National Level from NITI AYOG for effective implementation of Poshan
Abhiyaan. Implementation of schemes and programs in the field like PMMVY (maternity benefit
program by GOI), SAG (aimed at breaking the inter-generational life-cycle of nutritional and gender
disadvantage and providing a supportive environment to out of school adolescent girls) and UNICEF
backed "chuppi todo" programme for menstrual hygiene awareness in schools and villages were
undertaken. Coordination with various stakeholders of development i.e. people, NGOs and SHGs,
various government departments, private organizations, civil societies etc. to conduct WASH
activities (Poshan Pakhwada) and awareness programmes (Swacchata Pakhwada, Suposhan Diwas,
Swacch Bharat Programme) in Schools and Anganwadis were part of the job profile. I have also
undertaken a research titled: “Women Empowerment – The Anganwadi Way – A case study of
Northwestern Rajasthan, India” and presented it in the 3rd International Conference on Future of
Women 2020 by TIIKM.
As part of the DRG (District Resource Group) I was responsible for training of all field functionaries
in the district through ILA (Incremental Learning Approach) under Poshan Abhiyaan (flagship
program of GOI), enhancing and encouraging public cooperation and participation so as to make
project a self-sustaining, public driven movement, and raising resources was a major component. I
was a part of several project initiation committees in the district like “Nutri-garden in the Anganwadi”
& “Anganwadis for the brick kiln workers” in association with Tata Trusts.
Page
3
I got interested in CHLP because it provided me an opportunity to explore Health and Nutrition sector
further and identify the engagement and working models to work in the sector. I wished to combine
the health and nutrition sector knowledge with the environmental aspects (which I learned through
the PGD in Environmental law course by NLSIU, Bengaluru) to further work in the area of Health &
Environment. This would not only involve consulting and Govt. advisory projects, but also private
sector CSR Projects revolving around ESG (Environment, Social, Governance). Therefore, I wish to
learn and apply the community health and environmental issues mitigation strategies towards a
holistic developmental model.
Learning objectives
Learning Objectives
a) Acquire Knowledge – Basic concepts, success stories, challenges and changing trends in community
health.
b) Attain Comprehension – Ideas, Models, Tools and techniques to study community health.
c) Application – Apply the knowledge and comprehension so gained to new areas and in solving
community health problems.
d) Analysis – Draw connections between seemingly unrelated health issues, identify policy and
implementation gaps, diagnostic studies, organise data and report on health issues.
e) Evaluation – Appraise, critique and recommend changes in policies, programmes and laws/guidelines
related to health.
f) Develop ability to Synthesise – New ideas, techniques, models, design and innovation in health sector.
Integrate community model of health in all livelihood, CSR, and community-based projects (both
government and donor funded).
Areas of Interest
1.
2.
3.
4.
Environment and Health – interrelations
Policy analysis & formulation
Integration of community health models in donor and government sponsored projects.
Advocate, network and help disseminate community health concepts and ideas.
Key Concept/Takeaways*
Reflections^
*(directly quoted from reference material or modules)
^ (Personal)
Module 2 –
Understanding
Community
Health
Community Health approach to solving
public health issues • Recognises that the
components of action are means and not
ends • Flexible enough to reorient,
reprioritize, disband • Change towards
more relevant actions and directions •
Evolve in the interactions at the
community level
Module 4 – Right
to Health and
Access to Health
Care
In the strategy of imposing the new right
to health paradigm over the old and
obsolete development paradigm, we
have to get involved in a long-haul
capacity building, advocacy, social
mobilization and people’s empowerment
effort so as to influence short-, mediumand long-term health outcomes.
Equitable and Universal Health
Care that encourages community
health perspective & community
participation in the monitoring and
delivery of health services should
be the aim of community health
approach.
Community participation should
also be encouraged through
dialogue and policy planning.
Wealth, education and occupation
are important aspects to access
health as a right. In addition,
religion and caste (including tribal
status) are other aspects of that
influence health and health care
access.
All these factors above influence
health through differences in
access to resources, educational
inequalities, specific sociocultural
norms, discrimination and access
to health services.
Page
Module Name
4
Module reflections and application
Module 8 –
Equity in Health
Module 9 –
Health System in
India
Dynamic Health Systems Framework consisting of ten elements and their
interactions 1) goals & outcomes; 2)
values & principles; 3) service delivery;
4) the population; 5) the context; 6)
leadership & governance; 7) the
financial resources, 8) the human
resources, 9) infrastructure & supplies,
and 10) knowledge & information
The CSDH framework is probably
the most difficult and most
important learning from this
course.
It considers the entire health
system as a social determinant of
health and helps understand socioeconomic setting influences health
access
and
accentuates
vulnerabilities.
Comprehensive primary health
care should include:
• All services - geriatric health
care, palliative care and
rehabilitative care services
• All aspects - reproductive,
maternal, child and adolescent
health
• All diseases - communicable,
non-communicable
and
occupational diseases
Equity in Health goes beyond
access to medical care, it has to be
affordable and of good quality.
Moreover, it includes safe
drinking water and sanitation
(WASH), adequate nutrition,
clothing, shelter and decent
livelihood opportunity. All of
these should be available without
any discrimination on any basis,
be it caste, class, race, gender etc.
• India is going through
economic, demographic and
epidemiological transition.
• Individual health services is
predominantly carried out by
private providers.
• Access to medicines, vaccines
and diagnostic facilities is still
an issue not just in rural but
also
in
urban
areas.
5
Module 7 –
Comprehensive
Primary Health
Care (CPHC)
The CSDH framework departs from
many
previous
models
by
conceptualizing the health system itself
as a social determinant of health (SDH).
The role of the health system becomes
particularly relevant through the issue of
access, which incorporates differences in
exposure and vulnerability, and through
intersectoral action led from within the
health sector. The health system plays an
important role in mediating the
differential consequences of illness in
people’s lives.
Primary Health Care has an important
role in the primary and secondary
prevention of several disease conditions,
including non-communicable diseases.
The provision of Comprehensive
Primary Health Care reduces morbidity
and mortality at much lower costs and
significantly reduces the need for
secondary and tertiary care. For primary
health care to be comprehensive, it needs
to span preventive, promotive, curative,
rehabilitative and palliative aspects of
care. Primary Health Care goes beyond
first contact care and is expected to
mediate a two-way referral support to
higher-level facilities and ensure follow
up support for individual and population
health interventions.
Page
Module 5 – Social
Determinants of
Health
The focus of the voluntary health sector
is to bring:
• The People back into the centre of
primary health care
• The Public back into Public health
systems
• The Community back into the health
policy discourse.
Module 13 – Food Community level: regular observation of
and Nutrition
village health sanitation and nutrition
committee meetings, and village and
health nutrition days, monitoring of the
regular and good quality supply of
supplementary food at Anganwadi
centers and mid-day meals in schools,
regular and continuous supply of safe
drinking water, and strengthened open
defecation free (ODF) campaign,
sustainable and good animal farming and
agricultural practices, and availability of
nutritious, good quality, and fresh foods
in the local markets
Module 15 –
Antenatal care, Anaemia, Post-partum
Women’s Health
care still remain an issue in India.
Heath policies and programmes have
neglected several issues, especially for
women from marginalized communities,
and safe abortion.
Institutional bias against migrants is yet
another problem that affects women the
most.
Module 17 –
Key differentiation between abnormal
Mental Health
mental
health and
‘off-moods’/
‘emotional upsets’:
Undernutrition (wasting, stunting
and underweight), overnutrition
(imbalanced nutrition) along with
iron and calcium deficiencies
impacts health of women and
children of all ages. No specific
govt. programme addresses these
holistically, only separate drives
exist.
Status of women education and
health
outcomes
closely
interrelated.
Malnutrition, food insecurity and
specific nutritional deficiencies
such as anaemia add to maternal
and child health issues.
Mental health is probably the most
significant addition to the health
concerns of the country Post-
6
Module 12 –
Understanding
Voluntary Health
Sector
• Health care services should be
accessible and affordable to all sections
of Indian society, especially the
vulnerable section of the population.
• Health care services should be
equitably distributed between urban and
rural India, between men and women,
between rich and poor, between the
castes and among the States.
• Health care services should be aimed at
maximizing health gain
Page
Module 11 –
Universal Health
Care and
Universal Health
Coverage
Affordability and quality
issues add to the concern.
Critical areas to promote UHC:
• health
financing
and
increasing public spending on
health
• health service norms ad
guidelines
• human resources for health –
quality and standards
• community participation and
citizen engagement
• access to medicines, vaccines
and diagnostic technology
• management and institutional
reforms
The information asymmetry that
exists between the health care
providers and community at large
should be bridged through efforts
from voluntary health sector.
Module 21 –
Palliative Care
Module 22 –
Climate Change
and Health
1. Abnormal changes in one’s thinking,
feeling, memory, perceptions and
judgements resulting in changes in
talk and behaviour
2. These changes cause distress and
suffering to the individual or others
around him or both
3. The abnormal changes and the
consequent
distress
cause
disturbance in day to day activities,
work and relationship with important
others (social and vocational
dysfunctioning)
Difference between convention care and
palliative care:
Palliative care recognizes that people are
much more than organs put together;
their mind, spirit and emotions are all
part of who they are. It also recognizes
the patient’s families and communities.
So, the problems faced by a sick person
and his/her family are not just confined
to the disease; there may be pain and
other symptoms in conjunction with
psychological, social and spiritual
concerns.
India is particularly vulnerable to health
risks from climate change, given its large
population,
dependence
on
the
monsoons for livelihood, and relatively
low socioeconomic development.
COVID,
ignored.
which
was
hitherto
It is no longer urban or a problem
associated with urban lifestyle
alone.
I learnt about the various
initiatives and agencies working in
the area of mental health for
decades.
Palliative care interventions range
from tertiary care services to
community health services to care
at the patient's home. They aim to
provide patients with pain and
symptom treatment along with
counselling and psychosocial
support.
Monsoons
have
become
unpredictable and erratic, possibly
due to climate change, and this has
implications
on food and
nutritional security, diseases and
thereby health.
Mentorship process and reflections
Mr. Sunil Kaul along with Karthik, Janelle and Radhika provided the perfect support and guidance.
There were instances when I felt stuck, not able to grasp concepts, or felt left behind, and the mentors
provided me that gentle nudge to keep going.
I found Mr. Sunil to be quite accessible and approachable. It was a long time ago when I was in a
teacher-student setup, and I found the entire process to be quite engaging and fruitful.
Page
7
I suggest that the mentors should be a part of the orientation CHCC, or if possible, should be assigned
at the beginning of CHLP to provide enough time to deliberate and understand the nuances of field
work.
Project learning experience
Project work offered immense satisfaction and learning experiences:
a) Conceptual clarity - contextualising CHLP module learning
b) Skills - leadership, teamwork and communication skills
c) Aesthetics – landscape, experiential learning, opportunity to observe ecological effects of
environmental change, sustainable development
d) Social and personal development
Take away from CHLP
Page
8
CHLP is not just about community health, it is much more comprehensive in terms of:
a) A different approach to co-learning
b) Innovative curriculum and delivery
c) Flexible programme of study
d) Application based
e) One providing great networking opportunity
PART- B
Community-Based Health Action-Reflection
Project
Village Background
Geography
Pekhri, Panchayat Pekhri, Tehsil Banjaar, District Kullu
About 300-370 households live in the village, with the total population of 1338 (As per Census 2011).
Livelihoods
Page
9
Agriculture and pastoralism are the two main livelihood sources. Most people have lands, wheat and
corn are the two main grains and among fruits - apricots and apples, along with pears, plums,
persimmons. Peas and french-beans also provide a secondary source and are grown as cash-crops.
Other crops, vegetables, dairy and honey are for house-hold consumption only. Other sources of
livelihood include handicrafts and collection of medicinal herbs. Goat and sheep rearing is the main
practice, with a few cows in almost every household. A handful of families get work outside the
village, running shops in the Gushaini market, or working in various government and private jobs.
Picture 1 Shepherd basks in the sun as the animals graze. Only a few continue in this profession
Page
10
Tourism is seen as an emerging source of livelihood, to this effect, many have built homestays in
anticipation. This is in keeping with the general trend in Tirthan valley. In fact, I stayed in one such
home stay with proper toilets and heating facilities.
Infrastructure
Energy: Electrification is complete for almost all house-holds, and in addition to lights and devicecharging, it is slowly being adopted for heating purposes; mainly water and room. Firewood is still
very important for heating in winters and also for cooking to various degrees. Every house-hold also
has LPG cylinders.
Water: Taps are shared by multiple (4-5) households, fed by one of two storage tanks, in turn fed by
the two very small streams running through the village. They are used in a rough rotation through the
day. Everyone manages a more continuous supply by using individual overhead storage tanks along
with storage drums.
Other: Primary school is in the village. For Secondary school, children go to Gushaini, which is where
there is a health center, veterinary doctor, market, panchayat office, etc.
Housing, Food (eating habits) and Daily Needs: Till a few decades ago, before the road came, people
depended on their local ecology for almost all basic needs other than salt and perhaps metal vessels.
Grains, flour, lentils, cooking oil, vegetable, dairy, fodder, meat, honey, firewood, timber, roof slates,
other construction materials, medicine, community, religion, learning, entertainment, clothes, shoes,
bags, and so on.
As the road has increased the connection to the public distribution system and distant markets,
relationships with the local ecology have reduced. Traditional ecological knowledge has languished.
There are still some customs like collecting rhododendron flowers when they’re in bloom to adorn
doorways of all houses that connect daily life to the seasonal rhythms of the forests in a non-utilitarian
way. In terms of dependencies, the commons and forests are still the source of all fodder, firewood,
grazing lands, timber, dairy, honey and also a partial source of animal feed, vegetables, lentils, meat
and construction material.
People have to travel further and further for timber and even firewood as the population has increased
and the local ecology degraded. People have responded by planting fast growing exotic firewood
species like robinia and toona on their fields, and by planting patches of traditional timber trees like
deodar and blue-pine in nearby commons. The latter has been successful only to a degree as it requires
cooperation with respect to harvesting, fire-management, and grazing.
Local Ecology (One Health Perspective)
Page
11
Based on the age of traditional houses, the village is more than 200 years old, since then, it has grown
from a few households to its present form. There seems to be not much history remembered from
before colonial times, when large tracts of forest were probably cleared. Since then, the areas around
the village have been in a state of ecological degradation. In the last few decades there has been some
awareness about the need to safeguard forests, augment them with planting native trees, checking
wild-fires, etc.
Picture 2 Patch of old and regenerated forests. Pine and deodar are the main trees of the landscape
In the past this area had dense forests of oak along with other broadleaves (rhododendron, holly,
horse-chestnut, maple, mulberry, wild apricot, wild pear, walnut, ash, celtis, cornus, elm, toon,
alder, birch, willow, machilus) and mixed conifers (blue pine, deodar, yew, fir, rarely spruce).
Biodiversity (One Health Perspective)
Floral diversity: Along with the tree species mentioned above the natural heritage of these mountains
also includes climbers, epiphytes and ferns, along with many shrubs and herbs.
Page
Herbaceous plants of the aster, mint and plantain family abound along with wild turmeric, the latter
mostly in moist patches. Absence of bamboo-grass (Sinarundinaria), once in abundance and used for
basket making, is conspicuous.
12
Thorny shrub species of the genus Berberis and the family Rosaceae (rosehips, raspberry, black-berry,
etc) dominate because of the grazing pressure. Additionally, there are shrubby species of legumes like
Indigofera, Desmodium. There are also numerous species of the sage family and in the more moist
understory areas there is sarcococca.
In terms of cultivated species, there are multiple species of amaranth, along with barley, wheat, and
possibly buckwheat, and of course many species and varieties of lentils. While the crop diversity is
decreasing, the diversity in fruit cultivars of apples, pears, plums, persimmon, etc is perhaps
increasing.
S.No Scientific name
Local name
English name
Uses
1
Cedrus deodara
Deodar
Himalayan Cedar
Timber for
construction
house-
2
Pinus wallichiana
Kayil
Blue Pine
Timber for
construction
house-
3
Quercus floribunda
Moru
Green Oak
Fodder,
Firewood,
Agroforestry
4
Prunus armeniaca
Khumani, Saadi
Wild Apricot
Fruit, Kernel
Firewood
5
Rhododendron
arboreum
Buransh
Rhododendron
Flowers
6
Juglans regia
Akhrot
Walnut
Nut, Furniture
7
Toona
chinensis Lenth/Daral
(mostly planted)
Toon
Firewood,
growing
Fast
8
Robinia pseudoacacia Ravinia
(exotic, planted)
Robinia
Firewood,
growing
Fast
9
Morus serrata
Chimu
Himalayan Mulberry
Fodder, Fruit
10
Pyrus pashia
Shegul, Naak
Wild Pear
Wild fruit, Rootstock
for Cultivated fruit
11
Quercus
semecarpifolia
Kharsu
Brown Oak
Fodder, Firewood
12
Pinus roxburghii
Chil
Chil Pine
Firewood
13
Alnus sp.
Kosh
Alder
Timber, Fodder
14
Populus ciliata
Poplar
Poplar
Timber
15
Aesculus indica
Khnor
Horse-chestnut
Soap, Wild edible
16
Celtis australis
Khadak
Nettle Tree
Fodder, Agroforestry
17
Taxus wallichiana
Rakhal, Thuna
Himalayan Yew
Medicinal, Timber
18
Ilex dipyrena
Khadoocha
Himalayan Holly
Page
13
Oil,
19
Cornus sp.
Chhoon
Dogwood
20
Ficus palmata
Phoogu
Wild Fig
21
Rhus/Toxicodendron
punjabensis
Arkhol, Rikhal
Chinese Varnish Tree Medicine
/Punjab Poison Oak
22
Quercus
leucotrichophora
Baanj
White Oak
Fodder, Firewood
23
Salix sp.
Madnu
Willow
Fodder
Vegetable, Fodder
Table 1 Major tree species (excluding fruit trees)
S.no Local Name
1
Chidchidi
2
Thalnu
3
Bandari
4
Saryara
5
Kupda
6
Pharan
7
Gada Saryaru
8
Garnala
9
Amarbel
10
Kathu
Table 2 Major shrubs and herbs
S.no
Name
1
Rajma
2
Corn
3
Jau (barley)
4
Soya Bean
5
Massal
Page
14
Table 3 Major agriculture crops
Social Context
General Well-being
Most of the families are connected through matrimonial or familial ties and the social fabric is quite
tightly woven. People support each other in daily domestic activities and spend a lot of time with each
other.
Women
The culture in the village is patriarchal. While both men and women work in the fields, some men
have jobs outside Pekhri, whereas for women, there is little to no outward mobility. Women are
primarily tied to their household, cutting grass, collecting firewood, and looking after livestock. While
men do share this work, they are not tied to it. The decision making is mostly concentrated with the
male members of the family.
Mahila Mandal: For the last many months, the Pragatisheel Mahila Mandal Pekhari has been fairly
active. There are regular meetings and now with HET’s support, they are carrying out knitting
activities (mainly woollen socks)
Marriage system: There is marriage within the village families. The reason behind the “same village
marriage” is that the bride is already familiar with the landscape, natural resources and village system
so she needn’t spend time re-learning these.
Religion
Like most villages in the district, religion plays an important role in the functioning of the village.
There are elements of animism in how certain trees are worshipped, certain landscape-features house
gods, and each house has its own god residing in the upper floors which are out of bounds for outsiders
and people of different castes. Feasts and ceremonies are organised by families in turn, idols are
carried in processions, and there are committees that facilitate this rotation of responsibility. In fact
these activities are what organise the village’s collective decision making.
Caste: Pekhari village has mostly one dominant caste which is Rajput/ Thakur and non-dominant
castes are not permitted in the dominant caste areas/inside their houses.
Governance and Politics
Page
15
The committee involved in religious ceremonies is in a way the most active collective organisation.
The village-level governance is a lot more haphazard though with mostly governed by elderly men.
There is not much awareness about Govt. run programmes, even most common one’s like deworming, anaemia, other ICDS activities like Poshan Abhiyaan etc.
Education
There are very few who have studied up till the undergraduate level and even fewer up till
postgraduation. I personally did not notice any special disregard for women education, in general
there is a very not-so-serious attitude towards education.
Page
16
In the current school-going generation all the male and female children go to school, but the lockdown
caused a major discontinuity in their education which was furthered by the lack of facilities in the
village.
Social Determinants of Health (CSDH
conceptual framework)
Structural Determinants
Intermediary Determinants
Governance Factors: More focus on day to
day needs and curative health
Remote Location, accessibility
Policy Factors: Anganwadi seen with limited
scope & services. Awareness regarding
changing role & services of ICDS lacking.
Inadequate Housing & Food
Cultural & Gender Factors: Women
Education & Nutrition Secondary in family
Unpaid work (women)
Limited knowledge & belief led health
behaviour (eg. iron deficiency does not exist
in this village)
Maternal &
child health
outcomes
Iron deficiency
Diet imbalances
Poor pregnancy
preparedness
Poor Hygiene
Low birth weight
Developmental
delays
Diet imbalances
Other Issues
School: The village has a primary school that is regularly attended. Post this, when children reach
class 5 they have to travel long distances to Gushaini (which they often do on foot because there is
only one bus) and Banjar. The distance and time taken to go and come back from school in Banjar is
too much; parents rent rooms there for children to stay during the week.
Horticulture: Growing fruit has over time become a highly technical affair with multiple rounds of
pesticide and fertilizer sprays, assisted pollination, various graft varieties, etc. Despite following
protocol, the yields might be poor. This kind of high input, variable output agriculture is risky and
costly and is the bane of small farmers throughout the country and globe. As in other places, the
markets also don’t offer steady prices. Often locals travel all the way to Delhi with the trucks to try
and get a better price.
NTFP: The ecological degradation of the common lands close to the village has reduced the scope
for earning through NTFPs. These lands only give fodder. Medicinal herbs are very rare now.
Handicrafts based on other plants don’t have a market, and these plants have also become rare. This
reduces the incentive to repair the local ecology also.
Page
Veterinary Doctor: Many in the village voiced that requesting the veterinary doctors to come
everytime they need them and then bearing their transport bill makes it difficult for them to ensure
health care for their animals. More regular visits that are sponsored by the govt. can help with this.
17
Income: opportunities for steady income are limited within the village, and this puts a lot of pressure
on people to travel out of the village everyday and even start staying in towns. Reforestation,
education, handicraft and health related-services are all needed within the village and these can in
turn provide good supplementary sources of income.
Possible Interventions
1.
2.
3.
4.
5.
Education Interventions
Animal health Interventions
Knowledge and awareness around women and child health and nutrition
Agriculture/Horticulture based livelihood interventions
Apiculture
During my first meeting with the Mahila Mandal, I quickly realised that the priority for women
was health and nutrition. Also, this was one of the areas I was most comfortable with (agriculture
was another area where my expertise lies), seeing my background. Additionally, other initiatives
like agriculture or education were more time taking and could not be initiated during the short
project work duration.
The first meeting focussed mainly on:
a) Mahila Mandal meetings and agenda
b) Main activities of Mahila Mandal – weaving, knitting
c) Getting to know their thoughts on nutrition and health
d) Identifying with them the main health issues
e) Discussion on Govt. institutions – Anganwadi, PHC, School etc.
Capacity Building:
Any transformation in a village will necessitate capacity building and behaviour change of the
people to realise self-help, community work, health/nutritional improvements and activities and
the belief that they can do. This would involve exposure visits, interaction and discourses with
identified local leaders who show great potential in leading the intervention in the future.
Behavioural changes were initiated as part of the capacity building initiatives for implementing
the development initiatives.
Page
18
One of the Mahila Mandal member was chosen as leader and co-facilitator for all the
trainings/modules. Later, she is to give the remaining module trainings on her own, with a doubtclearing online interaction with the facilitator before the session.
Project Planning Phase
This phase mainly consisted of compiling secondary information of the village, people, customs,
natural resources, voluntary persons/organisations involved in the area, broad contours of schemes
under implementation in the area of women and child health. Other activities in Preparatory/Project
Planning Phase included:
•
•
•
•
•
•
•
Establishing rapport with Mahila Mandal members and make contacts with other key people
in the village.
To get information about general layout of the community (location of specific groups/other
infrastructure facilities/presence or absence of water sources /other useful general data
concerning social groups).
To identify and prioritise health issues and plan development activities accordingly.
To identify interventional activities that are culturally relevant to the population.
Identifying potential partners to facilitate the planned activities
To identify leader(s) who would work and coordinate with the larger Mahila Mandal members
for interventional activities and take the efforts forward.
Understand different population groups (Women/Men/Youth/Old other key leaders in the
village) for viewpoints and interests of different population groups.
The timelines and scope needed to be worked out based on the socio cultural and demographic context
of the village. Based on the preliminary understanding and priorities appropriate activity timelines
were planned as below:
Components
Preliminary Visit
Project Initiated
October
November
Documentation
Scope/Timeline
September 10 days
15 days (2 Modules Delivered, Facilitation training)
10 days (2 Modules Delivered, Facilitation training 2)
Village Profile etc.
Project Initiation
Preliminary Visit Activities
Page
19
The preliminary visit focused on getting accustomed to the village culture and tradition; and getting
acquainted with the Mahila Mandal members. The main objective was to explore the health issues
and identify
Activity 1
Mahila Mandal Awareness Meeting
1
Objective: Prepare to mobilise
• Highlight need for the women and child nutrition
• Motivate members for behaviour change
Household Visit
Activity 3
Social mapping in the Village
2
Objective: Explore Health issues
and set priorities
• Process is empowering, horizontal and give voice to the
unheard members of community
• Emphasis shifts from persuasion and transmisison of
information to support for dialogue on issues raised by
members of community.
Activity 4
Development of Micro Plan
Activity 5
3
Community ownership and
sustainability
Activity 2
Co-learning
Collective Action
Co-operation
Objective: Plan with community
and community action
• Empower Members to learn and help learn
• Community members are their own change agents
Trainer's Training
Module Trainings
The content on the maternal, child health and nutrition umbrella under the POSHAN Abhiyaan have
been organised in thematic modules (Figures 1 and 2 below) or flipbooks, which contain detailed
technical information related to each topic. A total of 21 such modules exist, out of which 18 were of
particular interest to the community/project. The key feature of these modules is the simple manner
in which the technical information is explained. It also addresses locally prevalent myths and
misconceptions.
The initially 4-6 modules were primarily conducted by me, as facilitator, with chosen Mahila Mandal
member as co-facilitator. Each module was first discussed between facilitator and co-facilitator to
build the capacity of the co-facilitator for taking future modules. As part of the project, total 6 modules
were conducted through in-person trainings facilitated by me, further 2 more were conducted by the
co-facilitator taking the lead, supported by me online.
Page
20
Here onwards, all the remaining modules will be solely conducted by co-facilitator alone, with prior
online doubt clearing session/discussion with me. Thus, community transfer of the entire project will
be complete.
21
Page
22
Page
Figure 1 The Poshan Abhiyaan Modules used for Mahila Mandal Trainings
Conducted by a facilitator (I, in this case) and a co-facilitator (member chosen from the Mahila
mandal to be the future facilitator), each session encompassed three crucial steps, as illustrated below.
Review
Input
Planning
• Status of the topic
in village
• Problems &
Challenges
• Discussion related
to current status
• Operational steps
to address the
problems
• Action plan to
overcome the
problem/challenge
in question
At the start of the session, usually the status of the issue was discussed along with the associated
problems and challenges. During this part of the session, real life examples and past-experience of
the participants were brought to light and members were encouraged to share their stories.
This was followed by covering the content of the day, and focus would be on acquiring knowledge
on the topic. Lastly, solutions and expected outputs were discussed with a concrete community action
plan. At this stage of the session, the emphasis was laid on how over a period of time, these practices
can lead to behaviour change and improvement in health indicators.
Figure 2 Takeaway used for role-play
Page
23
In order to make these sessions interactive and interesting, participatory methods of training, such as
role-play, group discussion, and periodic question and answer sessions were conducted. The
takeaways were extensively used for role-play and dramatization.
Community Health Axioms
Rights &
Responsibilities
It is not only a right of every villager to use resources and benefits according to their health
needs, but also a responsibility which is shared between villagers and health care system
Integration of health &
development activities
It is very important to align the health education/initiative with some economic activity.
Ultimately, time spent on any activity should compensate for the income loss. In this case,
mahila mandal was alreday engaged in knitting and weaving activities with the help of HET.
Building equity and
empowering
community beyond
social conflicts
Through these module trainings we were able to address primarily wealth or income,
occupational, educational, rural-urban inequities.
We were not able to address caste inequities at this point of time, maybe, when the mahila
mandal spreads the information and learnings further among the villagers, this will be
addressed as well.
Confronting the
existing super structure
of medical/health care
to be more people and
community oriented
Information w.r.t. nutrition and best practices (for pregnant and lactating mothers) was so
far limited to Anganwadi workers and ASHAs. Inadequate understanding of their roles and
responsibilities, poor training and supervision, poor monetary compensation and inadequate
incentive structure led to inefficient delivery of these services and information.
This information asymmetry was somewhat addressed through these module trainings.
Results
Knowledge of the Mahila Mandal members regarding care of weak new-borns, care of pregnant
women, exclusive breastfeeding and improved practice among lactating women on exclusive
breastfeeding increased. The members felt that there has been improvement in terms of clarity on the
subject matter, their approach to health, and perceived effectiveness of little behavioural
changes/practices. They would give information to the right beneficiaries even if they met them on
the way to cutting grass or community meeting. Also, they make sure to engage the family members
in the discussion.
“Earlier we were not taking proper food, iron tablets, or
Page
Further awareness regarding prevalent issues like Anaemia, Deworming, malnutrition has resulted in
greater satisfaction among the participants as well as increased engagement during the trainings. This
warrants an endline survey/perception/impact study towards the end of these trainings (by 2023 end)
on their day-to-day well-being.
24
rest during the day (during pregnancy). But now we
would ensure that all the pregnant women of village
practice it. I guess it is partly because we have now
understood the importance of doing so, with proper
reasoning.”
- Mahila Mandal member
Lessons Learnt
1. Participatory method
The modules include in-built questions, discussion points, and exercises to guide the
facilitators. When followed, the sessions are delivered more effectively ensuring better
understanding among the participants.
2. Community Action
3. Frequent Sessions
4. Strong Community Acceptance
In hindsight, one of the most crucial challenges is building trust. There is mistrust of outsiders.
Although the tendency might be to build the program faster, we must work at the speed of trust.
The following are some of my learnings on process:
1. As social workers we might tend to favour processes that are more neutral, inclusive and
democratic, and that is as it should be. But special care is required to map the existing power
structures (formal and informal) and include those that already enjoy influence.
In the case of this village, these are the committees handling the deolis (ceremonies around
local gods) that already are in the habit of calling meetings, facilitating collective decision
making, getting signatures, etc. These are mostly the older men of the village.
2. The work should begin with a public meeting called and organised by these influential people
after they have been briefed about the plan. They will have to be sensitized about the need to
work exclusively with the women. This might be challenging.
3. The selected group (Mahila Mandal in this case) should be a part of the surveying,
interviewing, and planning should be done with them.
4. There should be a basic plan drawn up based on the discussion that follows, and if possible,
discussed with other villagers to build consensus.
5. Once a basic consensus has been reached, then the training sessions should start. If possible,
involve authorities also at this stage (Anganwadi staff for instance in this case). This way
hopefully petty politics is kept to a minimum.
Page
25
6. The group should decide a rough timeline of the sessions. In this case it was easy because the
Mahila Mandal was already meeting on a fixed date every month to discuss their own
progress. Our sessions were held during the same meeting.
Position: 1797 (2 views)