Reproductive and Child Health, Nutrition and HIV/AIDS Program (RACHNA)
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Reproductive and Child Health, Nutrition and HIV/AIDS Program (RACHNA) Final Evaluation June 2006 Written by Mary Ann Anderson, Team Leader Narendra Arora Alfred Bartlett Rajesh Kumar Renu Khanna Lalit M. Nath Roberta van Haeften Prepared for CARE/India Contents Acknowledgement…………………………………………….……... vi Abbreviations and Acronyms………………………………………. v Executive Summary…………………………………………….…… viii Introduction…………………………………………………………. 1 Part I: Final Evaluation of Rural RACHNA Program 4 I. Description of the Rural RACHNA Program………………………….…… 4 A. Description of Rural RACHNA Program and GOI Programs it 4 Supports………………………………………………………………….…… B. Effectiveness of Design and Evolution of Rural RACHNA for 6 Achieving Results………………………………………………………………. II. Assessment of Impact of Rural RACHNA Program……………………… 9 A. Overall Impact in Reducing Childhood Malnutrition……………………. 9 B. Assessment of Health and Nutrition Outcomes and related Outputs 9 1. Maternal and Child Health…………………………………….…… 9 2. Maternal and Child Nutrition………………………………….…… 13 3. Family Planning and Reproductive Health Outcomes……………... 18 4. Contacts by AWW, ANM, RHCAs and CAs……………………... 21 C. Assessment of Program Inputs and Processes…………………………… 23 1. Strengthening ICDS and RCH Systems………………………….... 23 2. Community Outreach and Mobilization…………………………… 27 3. NGO Partnerships…………………………………………….…… 28 4. Capacity Building………………………………………………..… 29 5. Behavior Change Communication (BCC)…………………….…… 31 6. Monitoring and Evaluation………………………………………... 32 D. Assessment of RACHNA’s Influence on Policy and Improvements in 34 National Programs………………………………………………….………. E. Assessment of CARE’s Program Management…………………………... 36 F. Program Graduation and Sustainability in INHP II………………….... 38 1. The Food Transition……………………………………………….. 38 2. Local Food Models and Self-Help Groups………………………... 39 3. Graduation…………………………………………………….…… 40 G. Gender Integration and Social Equity Concerns……………………...… 42 1. Gender Integration……………………………………………..….. 42 2. Social Equity……………………………………………………..… 43 ii III. Summary Findings………………………………………………………….. 43 IV. Recommendations……………………………………………….………….. 44 A. Changes in priorities in Title II Phase Out………………………….…. 49 Part II: Final Evaluation of Urban Rachna Program (Chayan 52 HIV/AIDS Prevention) A. Background…………………………………………………………… 52 B. Description of Urban Chayan Program……………………….……… 52 C. Methodology for the Final Evaluation………………………………... 53 D. Approach to implementation in Urban Chayan demonstration– 54 replication……………………………………………………………... E. Assessment of Overall Impact of Urban HIV/AIDS Prevention 55 Interventions…………………………………………………………... F. Assessment of Program Inputs and Processes…………………….…… 56 1. Peer Educators (PE)………………………………………………..…… 56 2. Youth Resource Centers (YRC)……………………………………...…. 57 3. Prevention and Management of Sexually Transmitted and 57 Reproductive Tract Infections……………………………..………….. 4. Access to Condoms………………………………………………..…….. 58 5. NGO partnerships…………………………………..…………………… 59 6. Capacity Building…………………………………...……………………. 59 7. Behavior Change Communication (BCC)……..……………………… 59 8. Advocacy………………………………………………………………….. 60 9. Monitoring and Evaluation……………………………………………... 60 G. Potential to influence the implementation of HIV prevention 62 interventions of SACS………………………………………………... H. What is the extent of unfinished work in HIV/AIDS in RACHNA 63 program areas?………………………………………………………... I. Recommendations for Urban Chayan HIV/AIDS Future Programs…… 63 Annexes Annex 1 Documents Reviewed 65 Annex 2 Methodology for the Final Evaluation of RACHNA 67 Annex 3 Suggestions for Future Reproductive Health Activities in 75 Annex 4 Interviews and References on RACHNA’s Policy and 76 Program Influence Annex 5 Impact Data Tables for Final evaluation 79 iii ACKNOWLEDGMENTS The Final Evaluation Team would like to thank CARE and USAID for commissioning the final evaluation of the RACHNA program and for selecting us to undertake this large task. We are at the same time honored to be chosen to evaluate the program, but humbled by its enormous scale and comprehensive scope. We salute the true heroes of RACHNA, its implementers: the highly committed and competent staff of CARE India, the Government of India, and the NGO and technical assistance partners. We owe you a debt of gratitude for your responsiveness to our many questions and demands and for your openness to constructively discuss lessons learned and make recommendations for the future. The End of Program Documentation and briefings provided by CARE saved the team a great deal of time in quickly learning about the key features and accomplishments of this complex program. The final evaluation was also greatly enriched through the efforts of CARE, USAID and various partners to collect, analyze, and make available to the team a wealth of impact data and results of a qualitative assessment. The focus on establishing a solid evidence base for the effectiveness of RACHNA interventions was refreshing. We were impressed by CARE’s continual learning and critical thinking using these data to improve the program and influence policy. We greatly enjoyed the chance to see the RACHNA program in action on our field trips and thank CARE for organizing them so well, accompanying us, and enhancing our learning. We would like to thank the officials of the Ministries of Women and Child Development and Health and Family Welfare at central and state level who took time out of their busy schedules to accompany the team, meet with us, and share valuable insights. We were very encouraged by the exemplary coordination between the two ministries, the convergence of ICDS and RCH services on the ground, and the excellent partnership forged with CARE to strengthen these programs. The Final Evaluation Team would like to thank CARE for the outstanding administrative support provided to the team and their excellent organizational work in preparing for our visit. We congratulate all involved in the RACHNA program for your accomplishments in improving the health and nutritional well-being of millions across nine states of India. iv Abbreviations and Acronyms AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ANM Auxiliary Nurse Midwife AP Andhra Pradesh ASHA Accredited Social Health Activist AWC Anganwadi Center AWW Anganwadi Worker BCC Behavior Change Communication BCG Bacillus Calmette-Guérin vaccine B-E Baseline vs. Endline Surveys BI Bihar BLAC Block Level Advisory Committee BLRM Block Level Resource Mapping BSS Behavioral Surveillance Survey BTT Block Training Team CA Change Agent CBMS Community-based monitoring system CBO Community-based Organization CDPO Child Development Project Officer CG Chhattisgarh CHC Community Health Center CPW Currently Pregnant Woman CSB Corn Soy Blend DAP Development Assistance Proposal DLAC District Level Advisory Committee DPT Diptheria, Pertussis, Tetanus vaccine DTT District Training Team ER Evaluation Research FANTA Food and Nutrition Technical Assistance Project FP Family Planning FSW Female Sex Worker FY U. S. Fiscal Year (October-September) GEAC Genetic Engineering Approval Committee GOI Government of India GOMP Government of Madhya Pradesh HFW Health and Family Welfare HIV Human Immunodeficiency Virus HMIS Health Management Information System HRBG High-risk Behavior Group ICDS Integrated Child Development Services IEC Information, Education, Communication IFA Iron and Folic Acid IFPRI International Food Policy Research Institute IMR Infant Mortality Rate v INHP Integrated Nutrition and Health Project ISOFI Inner Spaces, Outer Faces Initiative IUD/IUCD Intra-uterine Device/Contraceptive Device IYCF Infant and Young Child Feeding JH Jharkhand LHV Lady Health Visitor LOA Life of Activity MCH Maternal and Child Health M&E Monitoring and Evaluation MIS Management Information System MOHFW Ministry of Health and Family Welfare MOST Micronutrient Operations Strategy and Technology Project MOWCD Ministry of Women and Child Development MP Madhya Pradesh MPW Male Multi-Purpose Health Worker MSM Men who have Sex with Men MTR Mid-term Review NA Not Applicable NACO National AIDS Control Organization NACP National AIDS Control Project NCC National Cadet Corps NFHS National Family Health Survey NGO Non-governmental Organization NHD Nutrition and Health Day NIPCCD National Institute of Public Cooperation and Child Development NRHM National Rural Health Mission OR Orissa PE Peer Educator PHC Primary Health Center PRI Panchayati Raj Institution PSI Population Services International PTT Performance Indicator Tracking Table R1 Round 1 of Rapid Appraisal R2 Round 2 of Rapid Appraisal R3 Round 3 of Rapid Appraisal RA Rajasthan RACHNA Reproductive and Child Health, Nutrition and HIV/AIDS Program RAPS Rapid Appraisal Survey RCH Reproductive and Child Health Program RH Reproductive Health RHCA Reproductive Health Change Agent RTI Reproductive Tract Infection SACS State AIDS Control Society SEARO Southeast Asia Regional Office, WHO SHG Self-help Group SM Social Marketing vi SNP Supplementary Nutrition Program STI/STD Sexually-transmitted Infection/Disease TA Technical Assistance TBD To be determined THR Take-home Ration TOT Training of Trainers TT Tetanus Toxoid UNICEF United Nations Children’s Fund UP Uttar Pradesh US United States USAID United States Agency for International Development WAZ Weight for Age Z Score WB West Bengal WCD Women and Child Development WHO World Health Organization vii Executive Summary RACHNA, INHP II and Chayan. The $160 million Reproductive and Child Health, Nutrition and HIV/AIDS Program