Aila Response

8/2/2019 Aila Response

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MITIGATING THE RAVAGES OF A CYCLONE:SECURING CHILD NUTRITION AFTERAILA

Process Documentation Report

Department of Child Health and Development,Child In Need Institute (CINI),

Daulatpur, via: Joka ,South 24 ParganasWest Bengal, India


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2010

Contents

Page no.

Background 4

Responding to the Disaster 5

Processes for Stakeholder Engagement and Promotion of Community Action 7

Mitigating the Ravages of a Cyclone: Results Achieved 11

Challenges and Lessons Learned 15

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Abbreviations

ANM Auxiliary Nurse cum Midwife

ASHA Accredited Social Health Activist

BMOH Block Medical Officer of Health

BPHN Block Public Health Nurse

CDPO Child Development Project Officer

CINI Child In Need Institute

ICDS Integrated Child Development Services Scheme

MLC Mandra Lions Club

MAM Moderate Acute Malnutrition

MIS Management Information System

MUAC Mid Upper Arm Circumference

NGO Non Governmental Organisation

NRC Nutrition Rehabilitation Centre

PRI Panchayati Raj Institution

SAM Severe Acute Malnutrition

SHG Self Help Group

UNICEF United Nations Childrens Fund

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Background

The afternoon of 25th May 2009 invokes painful memories in the minds of people in

southern West Bengal, India. A severe cyclone by the name ofAila hit the coastal areas

of the state that day, destroying lives and property. Embankments gave way and

seawater gushed in. Farmlands were destroyed overnight. Relief poured in from various

quarters, providing food and temporary shelter to people. However, it dried up after a

few months. The cyclone had upset the lives and livelihood of millions of people in the

area.

Fig 1:Aila affected areas

Months after the cyclone had wrecked havoc in the area, vast parts of land where

houses once stood, lay under water. Access to these areas is still a challenge. Makeshift

bamboo bridges called sanko in Bengali (the local language) connect these areas to the

outside world. In such areas, people measure the distance to destinations by the number

of sankothat are to be crossed. Traversing the sanko is a precarious exercise putting

the lives of people in danger.

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Submerged Land


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This report is a process documentation of the civil society response to mitigate the

effects of the devastating cyclone on the nutritional status of under five children in the

area. It captures the processes undertaken and the results achieved, distilling the

challenges and the lessons learned. Project reports, meetings with a variety of

stakeholders in the project implementation sites, field observations and discussions with

the members of the project team have informed this report. Qualitative fieldwork was

undertaken to explore issues in an iterative manner that helped establish internal validity

of the data.

Responding to the Disaster

Nutritional security was one of the foremost casualties of the cyclone. Many farmlands

could not be cultivated owing to water logging and/ or salination. Livelihoods were

severely affected and people displaced. Many of the local anganwadicentres had been

destroyed by the strong winds and lashing rains1. Food supply was scarce and irregular.

It was under these circumstances that UNICEF, in collaboration with CINI and Mandra

Lions Club, undertook an emergency response initiative to prevent and manage

malnutrition among under five children in three affected blocks and promote community

action on it. The project Emergency Response for Nutrition Action in Aila Affected

Areas to Prevent and Manage Malnutrition including Severe Acute Malnutrition

(SAM) And Promoting Community Based Actionwas popularly known as the Aila

emergency response project. UNICEF, the worlds leading agency for the promotion of

child rights, mobilized funds and provided the technical support in the project. CINI, a

leading NGO of India and a pioneer in the field of child nutrition and community based

programming in the country, was responsible for overall programme implementation.

The third partner, MLC, was responsible for field based activities.

1 An assessment in August 2009 revealed that 464 anganwadicentres had been damaged due to Aila out

of a total of 865 in the three blocks of the project intervention area. Sandeshkhali I was the hardest hit with219 of its 279 anganwadicentres damaged due to the cyclone.

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The project was for a period of six months commencing 1 st July, 2009. The blocks of

Gosaba, Sandeshkhali I and Sandeshkhali II formed the project implementation areas. In

all, the project covered 101 villages spread across 30 Gram Panchayat areas and

covering a population of approximately 4,00, 000.

Table 1: Project Implementation Area

Sl. no District Block GramPanchayats

Villages

1 South 24Parganas

Gosaba 14 49

2 North 24Parganas

Sandeshkhali I 8 30

3 North 24Parganas

Sandeshkhali II 8 22

Total 3 30 101

The Aila emergency response project had the following objectives:

To monitor nutritional status of children (6- 59 months) using MUAC tape

To identify and screen SAM children and provide facility based care and

services to complicated ones.

To prevent and manage malnutrition amongst children 6-59 months in Aila

affected areas

To improve knowledge about child care and feeding practices in the community

To promote effective linkages with community groups, Panchayats and service

provides to promote early and exclusive breast feeding, appropriate

complementary feeding and care of children

To promote appropriate care and feeding for pregnant and lactating women

To facilitate quality improvement of food supported under public funded

programme through monitoring and technical support with special focus on

children

To promote effective functional convergence with various service providers

To facilitate community engagement on the issue of child nutrition

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Major project activities included:

Assessment of nutritional status of under five children through the MUAC tape. A

cadre of community based animators was trained for the purpose

Community based events like nutrition camps, video shows, quiz competitions,

mothers meetings and health checkups to promote awareness of appropriate

cooking and feeding practices for children and promote healthy behaviour

Training of service providers including ICDS personnel, Medical Officers and

nurses on identification and management of childhood malnutrition

Referrals of SAM cases (with complications) to the Nutrition Rehabilitation

Centre at CINI for timely medical intervention

Distribution of supplementary nutrition packets (Nutrimix) for identified SAM

cases in the project implementation areas

Processes for Stakeholder Engagement and Promotion of Community Action

TheAila emergency response had a strong community based team to roll out the project

on ground. There was a cadre of 30 animators, each in charge of a Gram Panchayat.

Block Coordinators supervised the cadre. The programme management unit was

headed by a Project Director (a physician by training) and comprised of a Nutritionist,

MIS Coordinator, Documentation Officer and District Coordinator. Personnel at MLC

included Project Coordinator and two Block Coordinators. The animators were also

recruited by MLC.

Community gatekeepers like Panchayat representatives and local leaders were taken

into confidence at the start of the project and throughout. Rapport was developed with

senior ICDS and medical personnel in the three blocks and their support garnered.

The baseline study, initiated at the start of the project offered an opportunity to talk

about child malnutrition with various stakeholders. The animators went from house to

house in their area to assess the nutritional status of children aged 6-59 months. The

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MUAC tape used for the purpose was a simple and effective tool. It visually displayed

the nutritional status of the child to the parents and other stakeholders. It is interesting to

note that long after the baseline study had ended, animators still toured the area with the

MUAC tapes in their pockets, taking it out to measure a child they came across. On one

such occasion, an animator expressed satisfaction stating that the nutritional status of

the child had improved, red chhilo, ekhon yellow hoyegeche (the child was a case of

SAM and had subsequently improved).

Assessing a childs nutritional status with MUAC tape

A total of 35,360 children were measured during the baseline study. Of these, 92.7%

had normal nutritional status, 6.5% were MAM cases and 0.8% was SAM cases (Table

2)

Table 2: Key Baseline Findings

Block

Children

(6-59months)

Normal Children MAM SAM

Number%

Number%

Number%

Gosaba 16172 14937 92.36 1125 6.96 110 0.68

Sandeshkhali I 10393 9694 93.27 627 6.03 72 0.69

Sandeshkhali II 8795 8170 92.89 532 6.05 93 1.06

Total 35360 32801 92.76 2284 6.46 275 0.78

During and after the baseline study, animators referred under five children identified as

SAM cases with complications to the NRC at CINI. Set up in the 1970s, the NRC at CINI

is a pioneer in India. Here, malnourished children and their primary caregivers spend a

few days and the emphasis is on correct child feeding and cooking practices. Other

features of the NRC include the following:

Providing food to admitted children seven times a day by following a cyclic menu

prepared with locally available low cost nutritious food which can be easily

followed at the household level to ensure sustainable improvement of the

nutritional status of the child

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Daily weight monitoring of the child

Treatment of malnutrition associated complications and common childhood

ailments

Nutrition/health education and feeding counselling for the primary caregivers on a

regular basis

Community based management ofSAM cases (without complications) and MAM

cases was undertaken in the following manner:

Regular home visits for growth monitoring and to ensure correct feeding

practices

Counselling on feeding for primary caregivers as well as for other members of

the household

Distribution ofNutrimixas a supplementary food and demonstration of its cooking

procedure. About 617 packets of Nutrimix (each weighing 500 grams) were

distributed in the three blocks till October 2009.

Seeking support of PRI members and other stakeholders to motivate households

to adopt health promoting childcare practices

Organizing health/ nutrition camps led by a medical doctor and nutritionist in

weak pockets of the project implementation areas.

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Caregivers learning correct

cooking practices at NRC

Distribution ofNutrimix


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The various community based events actively engaged systems functionaries,

especially the anganwadiworkers. The anganwadiworkers mobilized local communities

for events like nutrition camps, quiz shows and mothers meetings. Such events were

usually held at anganwadicentres in the project implementation areas. The local Gram

Panchayats also provided the venue for such community based events. Often, a group

of anganwadi workers would come together for such events, sharing notes on the

nutritional status of children in their respective areas. The MUAC tape had high utility in

such forums, being simple to use and interpret.Anganwadiworkers were instrumental in

referring SAM cases to the NRC for institutional care, as well.

In the months of November and December 2009, various stakeholders were oriented

to the issue of childhood malnutrition. In addition, a wide array ofservice providers was

trained on management of malnutrition in the three intervention blocks. The various

capacity building programmes were usually held in the premises of the Block

Development Office, the Block Primary Health Centre and the ICDS offices. Sometimes,

Panchayats also provided the venue for the trainings. Orientation sessions were held for

representatives of the PRI and SHG members. The following categories of service

providers received training on management of malnutrition:

Block Medical Officers of Health

Medical Officers

Nurses

Auxiliary Nurse cum Midwives

Child Development Project Officers

ICDS Supervisors

AnganwadiWorkers

ASHA

SHGs

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Training ofanganwadiworkers in progress


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Mitigating the Ravages of a Cyclone: Results Achieved

Despite the adverse conditions, results began to show soon after the initiation of the

project. Stakeholders like Panchayat members and SHG members would often stop by

and enquire how the project was doing. Senior officials like the BMOH and the CDPO

were very forthcoming with their support, often facilitating meetings with systems

functionaries. Officials wanted a longer presence for the project in the area- an

intervention that could help sustain the benefits longer.

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Case Study

We are not only economically empowered to support our family toovercome the struggles due to Aila but are also capable to help themalnourished children of our villages

Saraswati Garu, President of Sundarban Swanirbhar Gosti

Provision of Nutrimix to the project implementation areas was initially supplied byCINI. However, the demand for the product increased tremendously and meetingit posed a major challenge. Sundarban Swanirbhar Gosti of Sandeshkhali I blockis a homogeneous Self Help Group consisting of seven members fromhouseholds affected by Aila. Most of the members did not have any livelihood

opportunity to fall back upon.

The women were trained under the project to produce Nutrimix. Thereafter, CINIplaced orders with the group to produce specified quantities of Nutrimix,depending on the requirements of the project. This helped the group to tide overits economic hardships and respond to the demand forNutrimix.

Members of the SHG soon became involved in various project activities likeawareness generation on community based management of malnutrition,immunization, etc. They are working as change agents in the community. Theyare also ensuring sustainability of the project through community basedmonitoring.


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A total of 41 referrals took place from the project implementation areas to the NRC at

CINI during the period (Table 3). Most referrals were from Sandeshkhali I and II, the two

blocks that were proximally located to Kolkata. In contrast, Gosaba, despite having the

highest number of SAM cases as identified in the baseline study, recorded few referrals.

The long distance of Gosaba from Kolkata, the deltaic terrain and problems in

transportation were often cited as the major reasons for such low referrals. As a senior

government official said, it is unimaginable that a daughter in law in Gosaba, who has

never ventured out of her island, would go away to distant Kolkata for some weeks.

Efforts were made to partner with an NGO in the area to provide for facility based

nutrition rehabilitation in Gosaba. However, this did not ultimately materialize.

Apart from distance, other reasons cited across the three intervention blocks for not

seeking care at the NRC at CINI included the need to stay at NRC by caregivers for

some days at the expense of household and childcare responsibilities at home, and

displeasure at being made to participate in cooking and feeding practices. The NRC

was not like a hospital a mother had once articulated. The setup was alien to many.

Sometimes, husbands and other senior members of the household objected to the

mother being away at the NRC for a period ranging from a few days to some weeks.

Table 3: Total referrals to NRC at CINI

All the SAM cases admitted to NRC at CINI registered weight gain and

improvement in nutritional status.

Block Referrals Females Males

Gosaba7 5 2

Sandeshkhali I13 9 4

Sandeshkhali II

21 13 8

Total 41 27 14

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Case Study: Successful Rehabilitation in the NRC

The devastating cyclone, Aila had completely destroyed the paddy fieldsleaving eighteen month old Srijoni's father with no work and no money. All theirbelongings had been washed away by the tidal waves rendering them

homeless and vulnerable. At the time of identification, Srijoni was severelymalnourished. She had also contracted skin infections.Srijoni was referred to the NRC at CINI. Her father brought her to the NRC

under the instructions of the project team in Gosaba. Srijoni weighed 6.8kilograms at admission. During her stay at the NRC, Srijoni's appetite graduallyimproved with proper medication and improved feeding pattern. Her weightincreased by 600 grams during the three week stay at NRC. Her incomplete

immunization schedule was soon upgraded. Srijonis improvement made her

mother, Pratima, very happy and she started taking keen interest in variouschildren and nutrition issues subsequently.

Upon return to Gosaba, Pratima shared her learnings with other women in hercommunity, demonstrating the cooking ofNutrimix and explaining the nutritionflag to them. She is active in various community based events promotingnutrition education. When the animator visited her home after a month, Srijoni

weighed 8.2 kilograms, a further improvement of 800 kilograms.

The nutritional status of most SAM and MAM cases improved by the end of the

project period (Table 4).Parents and household members can see the visible changes

in their children. This is often attributed to the consumption of Nutrimix. The local

animator is seen as a vital resource for guiding caregivers on good childcare practices.

Many caregivers voluntarily seek Nutrimixpackets from the animators.

There is enthusiastic participation of members of the household in various communitybased events and activities. Often, service providers and stakeholders actively support

such events. In many Gram Panchayats across the three blocks, ANMs and the BPHNs

attend the community based events and encourage mothers to adopt better childcare

practices.

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However, many households are still resistant to the adoption of improved childcare

practices. Unfortunately, pockets in the project implementation area have also been

missed out.

Table 4: Nutritional status of SAM and MAM cases by the end of project period

Nutritional Status Block Total

Sandeshkhali I Sandeshkhali II Gosaba

Status ofSAMcases

Total SAM casesidentified during baselinestudy

72 93 110 275

Cases remained SAM12 17 5

34

Cases turned to MAM34 29 45

108

Cases turned to normal22 31 55

108

Total cases of migration(lost to follow up) 3 16 5

24

Deaths1 0 0 1

Number ofnew SAMcases identified afterbaseline study

1 0 6 7

Status ofMAMcases

Total MAM casesidentified during baselinestudy

627 532 1125 2284

Cases remained MAM176 83 172

431

Cases turned to normal 439 396 926 1761

Total cases of migration(lost to follow up) 12 53 25

90

Deaths0 0 2

2

Number ofnew MAMcases identified afterbaseline study

24 0 21 45

It was widely reported by anganwadiworkers from the three blocks that they proactively

seek out cases of SAM and MAM and counsel the caregivers. Some workers also

recounted that they make it a point to see that such cases receive the supplementary

nutrition provided at ICDS centres. If the children are unable to come to the anganwadi

centres for the purpose, then, the food is delivered to them.

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Challenges and Lessons Learned

The Aila emergency response project was aimed at arresting the deterioration of the

nutritional status of under five children in the face of the devastating cyclone.Interventions of such nature, struggling as they do to protect citizens entitlements on the

face of disasters, are necessarily challenging. The sudden disruption of normalcy and

the ensuing chaos offer a disturbing backdrop. Challenges faced in the effective

implementation ofAila emergency response project were:

Putting the team in place for the intervention posed a major challenge in the

beginning. Human resources had to be mobilized overnight and project

personnel had to be oriented to the project on a war footing. Human resourcescontinued to be a challenge throughout the six month project implementation

period. Constant staff attrition, especially at the animator level, often hampered

field activities. The sudden and untimely demise of Bappaditya Samanta, Block

Coordinator Gosaba of CINI, was shocking and temporarily halted the operations

in the block.

The cyclone was followed by the monsoons, further hampering operations.

Continual rains worsened the situation further, the water claiming vast tracts ofland and rendering thousands homeless. The conduct of the baseline census

was hindered in such conditions.

Numerous anganwadi centres had been destroyed in the cyclone bringing

activities like provision of supplementary nutrition and community based nutrition

promotion activities to a halt. In the initial stages of the project, it was especially

challenging to mobilize anganwadiworkers on the issue.

Striking a common understanding of the project objectives and activities

among the partner NGOs remained a persistent challenge. Partners brought in

differing levels of expertise and experience into the project. The short period in

which the project was unfolded on ground often provided little time to forge and

sustain effective sharing mechanisms.

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Gosaba block was particularly challenging. The block comprises of several

islands in the deltaic region and the block headquarters is located about 100

kilometres from Kolkata. Boats are the means of transportation from one island to

another of the block. Some islands are located well into the Bay of Bengal and

take several hours to reach by boat from the block headquarters. Gosaba poses

many challenges in normal times, which were exacerbated afterAila.

The Aila emergency response project offered many lessons. The following are the

majorlessons learned from the project:

Community based cadre of animators is a valuable and sustainable

resource. The animators are the face of the project in the local communities and

the repository of the knowledge. Local communities trust them and access them

for queries and stocks of Nutrimix. Increasing the knowledge and skills of

animators greatly enhances their functioning and leaves behind a sustainable

resource in the communities.

The trainings of service providers were scheduled towards the end of the

project implementation period. This left little time to follow up on the trainings to

understand participants increase in knowledge and subsequent application to

their work. Further, the scheduling of trainings towards the end resulted in losing

out on a valuable resource that could have been tapped into earlier to garner

support and maximize on project activities.

The role of the civil society is to strengthen the state and ensure citizens

entitlements. Working with the system, even during such trying times like in the

aftermath of the cyclone, is necessary and fruitful. As the Aila emergency

response project demonstrated, it is essential to come together on common

platforms like the nutrition demonstration camps or the maternal health checkup

camps and speak in a common voice, thereby complementing one another.

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Aila Response

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