Concurrent Monitoring and Validation of POSHAN-II, Rajasthan, India Authors and Affiliations *Shobana Sivaraman, Senior Research Officer, IIHMR University, Jaipur Laxman Sharma, Assistant Professor, School of Development Studies, IIHMR University, Jaipur Dr D K Mangal, Professor (Public Health) & Dean Research, IIHMR University, Jaipur Abstract Background Severe Acute Malnutrition (SAM) is a life-threatening factor for children because of their lack of immunity to infections and diseases. Community Management of Acute Malnutrition (CMAM) is an evidence-based approach implemented in more than 70 countries to manage and treat SAM and MAM U5 years children. In 2015, National Health Mission, Government of Rajasthan implemented CMAM by adopting POSHAN (Proactive and Optimum care of children through Social Household Approach for Nutrition) strategy to treat SAM children without medical complication using Medical Nutrition Therapy (MNT) Kit. The community-based intervention was implemented in two phases. CMAM POSHAN-II was implemented in 2018, covering 20 districts of Rajasthan. In CMAM, POSHAN-II around 375,533 children were screened and 10,344 children were identified and enrolled for treatment. IIHMR University assessed the implementation effectiveness through concurrent monitoring and validation of the activities performed by ASHA and ANM under POSHAN II. Study methodology It is a concurrent monitoring and validation study. The study area was five districts of Rajasthan selected with geographical importance. POSHAN Phase II programme was implemented in 20 districts. The 20 districts were divided geographically into five regions and from each region, one district was selected. The selected five districts are Ajmer, Baran, Rajasamund, Jaisalmer and Udaipur. From each district, one block was selected using simple random sampling. In each block, eight POSHAN centres were further selected using systematic random sampling. Around 40 POSHAN centres were concurrently monitored in five districts to evaluate the effectiveness of the program. The study design was to evaluate one POSHAN centre in one week (simultaneously in all five districts) and thus 40 POSHAN centres covered in eight weeks. The study tool developed was a semi-structured questionnaire which has a combination of both closed and open-ended questions. The semi-structured questionnaire was filled with the collective responses and observations made from mothers and or caregivers of SAM children, and activities carried out by Auxiliary Nurse and Midwife (ANM) and Accredited Social Health Activist (ASHA). The data collected was the mixture of the respondent response and block coordinator observation. Data was collected using CsPro software (Android version) using tablet. Findings Overall, it was observed that only 68% of POSHAN centres followed the recommended procedure to measure height, weight and MUAC. Around 88% of POSHAN centres in Ajmer and Jaisalmer followed the recommended procedure for anthropometric measurements, followed by Baran (38 %) and Rajasamund (25 %). In 95% of POSHAN centres, MOYO chart is used in the right procedure by the ANM. It was observed that 70 % of POSHAN centres provided counselling to the mothers about feeding EDNS to the child. It was further investigated that 75% of POSHAN centres in Baran provided counselling to mothers on feeding EDNS to the child, followed by Udaipur and Jaisalmer. It was found that only 43 % of POSHAN centres provided counselling on adequate feeding requirements. During home visits, EDNS was found to be consumed by all the SAM children expect a few rare cases. Quantity of consumption of EDNS per day is overall found to be less than anticipated. Initially, mothers placed the EDNS packets in the container, but later, by the third or fourth week, it was found that container was used for some other household purpose. The clips provided to close the EDNS packets got broken and they did not receive any replacement clips. Many of the households reported that ASHA visits their house occasionally. In quite a few households, mothers reported that they wash hands before feeding the child. However, in a few households, mothers did not take any interest in any such behavioural changes. It was observed that behavioural changes were observed prominently in those households where ASHA visits regularly. Non-programme Implementation villages were visited to observe the procedures followed to identify and treat SAM and MAM children. It was found that ANM and ASHA were not aware of the z-score, MUAC and appetite test. They identify the SAM and MAM children using growth monitoring chart. The stadiometers and weight machines were not functioning properly. There were few records maintained for SAM and MAM children. SAM children are referred to MTC. MAM children are followed by ASHA and AWW. Both SAM and MAM children are given extra Poshahar through Anganwadi Centre. Recommendations · ANM’s should be trained well in anthropometric measurements, especially in measurement of Mid Upper Arm Circumference (MUAC). The manual for anthropometric measurements should be used frequently by ANM. · ANM’s may be provided with flash cards which will help them better to conduct POSHAN DIVAS in a systematic way. · District Programme officer from NHM or any senior official from the co-funding agencies should visit during POSHAN DIVAS for supportive supervision. · ANM can also make a few visits to SAM children households to check the status of the child as well as to verify the planned activities performed by ASHA. · ASHA can be trained more systematically on anthropometric measurements such as height, weight and Mid Upper Arm Circumference (MUAC) · ASHA may be trained to observe and identify for any medical complications in the child. · ASHA should be instructed to use the IEC materials on handwashing, hygienic feeding, supplementary foods etc. during household visits. · Along with ASHA, ANM and AWW should also undertake necessary follow-up of defaulter SAM cases to motivate them to visit POSHAN centre and take advantage of nutrition supplementation intervention.