VOLUNTARY CIVIL SOCIETY ACTION FOR FAMILY PLANNING: Coordinating CSO network, building capacity, and documenting stories of champions who promote family planning
Duration: 2017–2019
Location: Bihar

Forty-five Bihar-based Civil Society Organizations (CSOs) came together to work voluntarily to promote family planning—emphasizing autonomy for women to exercise choice in reproductive matters, particularly in delaying and spacing of children and limiting family size. The objective was to help achieve the Family Planning (FP) 2020 goal for Bihar: ‘71.25 lakh new users of contraception’.

Agragami coordinated this network, building capacity and documenting stories of champions who worked in the field to promote family planning.

The approach used by the network was for each member to incorporate messages on family planning into as many of their ongoing community-based programs as possible. Members also advocated with block- and district-level health officials to improve access to contraceptive services and products. Advocacy events and news stories shared with the press built general awareness of the importance of family planning.

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KHUSHALI – Phases 1 and 2: Integrated health, nutrition, remedial education, skill development, livelihoods and income-supplementation activities, and hygiene and sanitation
Duration: Phase 1 (2012–2015);Phase 2 (2015–2018)
Locations: Madanpur Khadar, NCR Delhi; Bodh Gaya block, and Bodh Gaya town in Gaya district, Bihar

This comprehensive community development project has three pillars—health and sanitation, education for children, and skill development for income generation. It covered multiple locations in Bihar—10 villages in the Mocharim and Bakraur panchayats of Bodh Gaya block, and 7 wards of Bodh Gaya town in Gaya district—amounting to 35,000 rural beneficiaries. In NCR Delhi, the project worked in the low income, urban resettlement colony of Madanpur Khadar covering its 75,000 inhabitants. In all, the project covered over 100,000 people.

Health

Taking a comprehensive approach, the project addressed adolescent, maternal, neonatal and child health. It emphasized the adoption of health-seeking behaviours, and sought to improve access to and utilization of primary health services by the population covered.

Balanced attention was paid to family planning, antenatal and post-partum care for mother and newborn, and nutrition, growth and immunization of children under two. For maximum impact, individuals were addressed at especially needy, vulnerable, or impressionable stages of the life cycle—infancy and early childhood, adolescence, pregnancy, and the post-partum period.

Capacity building and supportive supervision of government frontline workers (anganwadi workers, ANMs and ASHAs) was a key input for improving availability and quality of essential primary health services at the community level. In Delhi, Mahila Arogya Samitis worked closely with community health workers to ensure optimal utilization of these services.

In Bodh Gaya, Agragami re-formed the two village health and sanitation committees (VHSNCs) in the intervention area. The team also formed 10 Nigrani Samitis through participatory processes, so that the VHSNC and Nagrani Samiti members understood that they had a vital role to play in improving the status of health, nutrition and sanitation of the community.

Government frontline workers were trained to communicate on antenatal, post-partum and neonatal care; childhood immunization, and family planning. They received continuing supportive supervision and feedback for performance improvement from Agragami’s trainers.

Sanitation and Hygiene
These activities were undertaken in both Madanpur Khadar and Bodh Gaya. Community engagement occurred through the formation and strengthening of Mahila Arogya Samitis/street sanitation groups whose members took responsibility for calling municipal authorities to request the sanitation services that were needed, and to give feedback on services being rendered. In both Delhi and Bodh Gaya, this resulted in a marked improvement in street sanitation and improvement in the delivery of municipal sanitation services.

Non-formal Education
Children’s activity centres in Madanpur Khadar and Bodh Gaya offered the children membership in libraries with books of different levels of difficulty, to encourage them to read and grow in reading ability and self-expression. Craft, dance, and games were a routine part of the curriculum, and attracted children to join the activity centres.

In Madanpur Khadar, a preschool prepared children from families where parents were not literate, for admission to primary school. Primary school children, who were unable to keep up with school, received remedial inputs in Hindi and arithmetic, so that they would be able to keep up in class.

Skill Development and Income Generation
Girls in Madanpur Khadar were trained in tailoring and beauty culture. Over 250 girls have been trained to date and most of them are using their skills to earn from home.

In Bodh Gaya, 200 poor families from the 10 intervention villages received inputs to increase family income. Families received inputs on improving returns from crops. Kitchen gardening and mushroom cultivation were introduced.

Linkages were improved between farmers and government farm extension services, resulting in flow of information to farmers on good farm practices, and access to subsidized, high-quality seed. Market linkages were developed to enable sale of mushrooms. Over 40 per cent of the beneficiary households increased their income by about 20,000 a year because of project inputs.

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PARIVARTAN – Phase 2: Strengthening Village Health Sanitation and Nutrition Committees
Duration: 2014–2016
Location: Khagaria and Saharsa districts, Bihar,

The goal of this PATH-PCI project was to revitalize and strengthen Village Health Sanitation and Nutrition Committees (VHSNCs) in 102 gram panchayats, in the districts of Khagaria and Saharsa, through training and technical assistance.

At the start of the project, an assessment of VHSNCs was carried out in the two districts using in-depth interviews with Mukhiyas (village headmen), ward members, Auxiliary Nurse Midwives (ANMs) and the Lady Health Supervisors (LHS) of the Integrated Child Development Services (ICDS) department. The findings of the assessment were that most of the VHSNCs existed only on paper as their members had either retired or had been transferred.

Agragami helped to reconstitute the 102 VHSNCs in the intervention areas of the two districts, and also formed 220 Nigrani Samitis (watch groups) through a participatory process that made each member of the committees/samitis understand that he/she had a distinct and important role to play in contributing to improving the status of health, nutrition and sanitation in the community.

Agragami’s master trainers bridged the gap between the committees and the members of the community, and made the committees understand the intentions of the Government. Members of the VHSNCs, and Nigrani Samitis were trained to take collective decisions during monthly meetings. In all, 581 monthly meetings were held and 145 village health action plans were developed.

The committees/samitis were familiarized with the systems to follow to effectively utilize the small untied funds given to each village by the Government for minor village works. All VHSNCs were assisted in opening/reviving bank accounts where the Government’s untied funds could be received and withdrawn for spending. This required liaison with bank managers and with the Medical Officers of the Primary Health Centres, so that lists of authorized signatories could be updated (for already existing accounts) or put in place (for newly opened accounts).
Untied funds were spent, spending was properly documented, and utilization certificates were submitted to the Government.

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ANANYA: Changing social norms related to child marriage
Duration: 2014–2015
Location: Mohanpur block, Gaya district, Bihar

This project designed by Save the Children and implemented by Agragami sought to change social norms related to child marriage using a multi-pronged approach. It formed and strengthened child protection committees (CPCs) at the district level. These committees were chaired by the District Magistrate.

Agragami staff trained selected members of the CPCs to speak up for and support children in resisting child marriage. They built the capacity of 3960 adolescent aged 13 to 20 years in 66 villages to be discussion leaders who, in turn, built awareness in communities about the ills of child marriage. The adolescent discussion leaders were supported in this task by frontline community health workers of the Government who were also trained by Save the Children to conduct community meetings to discuss the issue of child marriage.

These discussion sessions and other project events led to increased awareness and sensitivity among adolescents to issues in their own lives. The changes in girls were noteworthy. They reported increased confidence in their ability to discuss and negotiate with parents on issues of mobility outside the home. Several reported negotiating with parents to continue their studies and delay marriage. They participated in large numbers in social and community events organized by the project.

Adolescent girls also reported increased discussion with their peers on reproductive and sexual health issues and on their rights. Even mothers of adolescent girls reported a heightened awareness of their own tendency to discriminate against girls, and demonstrated greater comfort in allowing daughters to participate in project sponsored activities.
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STRENGTHENING MATERNAL, NEWBORN AND CHILD HEALTH AND NUTRITION (MNCHN) SERVICES
Duration: 2012–2015
Location: Mohanpur block, Gaya district, Bihar
Save the Children conducted an assessment of the MNCHN situation in Mohanpur block prior to the start of the intervention. The results showed a great need for an MNCHN intervention:

• 48 per cent of pregnant women had not received the recommended three antenatal visits during pregnancy
• 23.1 per cent of mothers took at least 90 capsules of iron and folic acid during their last pregnancy
• 62.4% of women in Mohanpur block gave birth in a hospital
• 38.4 per cent of children under three years of age were stunted (too short for their age)
• 46 per cent were underweight

The project designed by Save the Children and implemented by Agragami India covered 59,010 people in 60 villages. The project put pregnant and lactating women, neonates, infants (0–12 months) and children under the age of two, at the centre of the intervention and focused on improving survival, health and nutrition outcomes for children from conception up to the age of two years.

Three convergent approaches were used—strengthening the capacity of government’s frontline health workers (such as auxiliary nurse midwives (ANMs), accredited social health activists (ASHAs) and anganwadi workers(AWWs) to deliver MNCHN services and to report data on delivery of key MNCHN services; mobilizing community groups and instituting processes to stimulate the block-level health system to improve service-delivery; and, advocating with block and district health systems to improve service-delivery and the quality of services.
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PROJECT: BUNIYAAD: Reducing infant mortality in Bihar through optimal infant feeding practices
Duration: 2012–2015
Location: Six blocks of Samastipur district in Bihar

The project aimed to reduce neonatal and infant mortality through improving breastfeeding and complementary feeding practices for infants and children up to the age of two years.
A strong behaviour change communication program was implemented through 150 women and men drawn from the community, who played the roles of peer educators and supervisors. The project mobilized and empowered mothers and caregivers to adopt good infant and young child feeding (IYCF) practices. Peer educators supported mothers in overcoming infant feeding problems.

The project coordinated with block and district health and ICDS authorities to involve government community health workers (accredited social health workers (ASHAs) and anganwadi workers) in project activities. In all, 158 community health workers supervisors were trained by the project on IYCF to address IYCF issues as a part of their routine responsibilities. The focused behaviour change communication efforts of this project, targeting a specific area of health practice, achieved a positive impact.

In its three years of implementation, the project reached and changed infant feeding behaviour over 100,000 mothers from the poorest and most marginalized communities through 106,980 group meetings and 154,849 home visits.

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PARIVARTAN Phase 1: Capacity building of 4,500 Sahelis and Cluster Coordinators to communicate and catalyse collective action on key health issues
Duration: 2013–2014
Location: The districts of East and West Champaran, Khagariya, Saharsa, Begusarai, Samastipur, Gopalgunj, and Patna, in Bihar

The goal of the PATH-PCI Parivartan project was to strengthen community structures and catalyse collective action to change social norms and increase the adoption of those behaviours that would have the greatest positive impact on the health status of the community:

• Birth preparedness
• Safe home delivery
• Institutional delivery
• Post-partum and neonatal care
• Early and exclusive breastfeeding
• Complementary feeding till the child is two years old
• Post-partum family planning
• Routine immunization
• Hand-washing
• Safe storage and handling of drinking water
• Access to, and use of, toilets
• Safe disposal of waste

Agragami’s role in the Parivartan project was to build the capacity of the project’s 4,500 Sahelis and Cluster Coordinators, to communicate with members of self-help groups and with the community at large on these issues and to encourage the adoption of healthy behaviour.

Capacity building went beyond classroom training to on-site observation. They communicated with, and mobilized, their communities to adopt health-seeking behaviours; and provided mentoring and support for performance improvement.