Report No: AUS0001190 . India Community-led Pilot in Meghalaya to Improve Early Childhood Development Outcomes . November 2019 . HNP . Document of the World Bank . . © 2017 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution—Please cite the work as follows: “World Bank. 2019. India: Community -led Pilot in Meghalaya to Improve Early Childhood Development Outcomes. © World Bank.� All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. State Engagement Report: Non-Lending Technical Assistance to Meghalaya (P168752) Community-led Pilot in Meghalaya to Improve Early Childhood Developemnt Outcomes Ashi Kohli Kathuria1 Deepika Anand2 November 2019 1 Senior Nutrition Specialist, The World Bank 2 Nutrition Specialist, The World Bank Contents Acknowledgements………………………………………………………………………………..i List of Acronyms………………………………………………………………………………….ii 1. Introduction ............................................................................................................................... 1 1. The ECD conceptual framework ................................................................................................. 1 2. The Government of Meghalaya’s interest in ECD and request for Technical Assistance (TA) .. 2 3. Overview of the TA: ..................................................................................................................... 3 4. Structure of the report ................................................................................................................. 4 2. The Context and Rationale for the TA .................................................................................... 5 1. The need to focus on ECD: the evidence base ............................................................................. 5 2. The situation of ECD in India...................................................................................................... 7 3. The ECD situation in Meghalaya ................................................................................................ 8 3. Feasibility Study ...................................................................................................................... 10 1. Objectives .................................................................................................................................. 10 2. Technical and institutional arrangements for the study ............................................................ 11 3. Methodology .............................................................................................................................. 12 4. Design of the ECD package....................................................................................................... 17 5. Implementation of the pilot ........................................................................................................ 19 6. Results ....................................................................................................................................... 24 7. Triangulation of results to assess the feasibility of the pilot ..................................................... 29 8. Limitations ................................................................................................................................. 31 4. Policy Implications and Scale-up of ECD interventions in Meghalaya Error! Bookmark not defined. List of Figures and Annexures Figure 1: WHO Nurturing Care Framework (2018) …………………………………………..…. 2 Figure 2: Comparison of Returns on Investment for Education Interventions………………… 7 Figure 3: Structure of MSRLS ………………………………………..………………………….… 10 Figure 4: Study Site and Sample Details……………………………………………………….…..12 Figure 5: Roles and Responsibilities of MSRLS Staff in the Pilot……………………….…...…13 Figure 6: Training Model of the Pilot …………………………………………….………………..14 Figure 7: Comprehensive ECD Package ………………………………………………..…………17 Figure 8: Change in Knowledge of Pregnant and Mothers of Young Children……………….24 Figure 9: Change in Knowledge of Other SHG Women…………..…………………………….. 25 Figure 10: Changes in Practices of Pregnant and Mothers of Young Children………….….. 26 Figure 11: Change in Knowledge Scores of BRT and EC members……………………….……27 Figure 12: The Model for Improvement……………………………………………………………33 Annexure 1: Glimpse into a SHG Meeting…………………………………………………………34 List of Boxes Box 1: Key terms explained………………………………………………………………………..11 Box 2: Stakeholders Views on Low Attendance in Trainings ………………………………..19 Box 3: Observations on the Quality of Training as noted in Process Evaluation…………20 Box 4: Acceptability, outcomes and demand for ECD package……………………………..29 List of Tables Table 1: Advantages and challenges of dissemination strategies……………………………22 Acknowledgements The team thanks the Government of Meghalaya for their partnership and support during the course of this technical assistance (TA). The vision, leadership and commitment of Sampath Kumar, Commissioner and Secretary, Community and Rural Development Department to the Early Childhood Development of children especially in the early years has been a guiding force throughout this engagement. We are grateful to Shantanu Sharma, CEO, Meghalaya State Rural Livelihoods Society (MSRLS), MSRLS officials from the state, West Garo Hills district and Rongram block for anchoring and for ensuring timely and successful completion of the TA activities. We thank the Centre for Early Childhood Education and Development (CECED), Ambedkar University, in particular Vrinda Datta, Monimalika Day, Sheetal Nagpal and Rashim Pal for their technical support in implementation of the TA activities. Vinay Singh provided technical support, Sandhya Paranjpe led the process documentation, and Bakdil, Tura, West Garo Hills supported data collection for the baseline and endline assessments. This work has received financial support from the SAFANSI Trust Fund and from the Government of Japan through the Japan Trust Fund for Scaling Up Nutrition. We are thankful to the peer reviewers, Julieta M. Trias (Economist, HSPGE), Aaron F Buchsbaum (Knowledge Management Officer, HHCDR) and Julie Ruel Bergeron (Nutrition Specialist, HHNGF) for reviewing the draft report and for providing valuable inputs to strengthen the report. i List of Acronyms ANM Auxiliary Nurse Midwifery ASHA Accredited Social Health Activist AUD Ambedkar University Delhi AW Active Women AWW Anganwadi Worker BMMU Block Management Monitoring Unit BRT Block Resource Team CECED Centre for Early Childhood Education and Development CEO Chief Executive Officer C&RD Community and Rural Development Department DMMU District Management Monitoring Unit EC Executive Committee ECD Early Childhood Development FGD Focus Group Discussion IB&CB Institution Building and Capacity Building ICDS Integrated Child Development Services IMR Infant Mortality Rate KAP Knowledge, Attitude and Practices MBDA Meghalaya Basin Development Authority MSRLS Meghalaya State Rural Livelihood Society NCT Government of The National Capital Territory NFHS National Family Health Survey NGO Non-government Organization NRLM National Rural Livelihoods Mission ODF Open Defecation Free PD Process Documentation PSE Primary and Secondary Education PW Pregnant Women RCT Randomized Control Trial ii RSOC Rapid Survey on Children SHG Self-Help Group SMMU State Management Monitoring Unit TA Technical Assistance UNICEF United Nations Children’s Fund VO Village Organization WASH Water, Sanitation and Hygiene WB World Bank WHO World Health Organization YM Young Mothers iii 1. Introduction 1. The ECD conceptual framework 1.1. Early childhood is the most crucial period for the overall development of children. Adequate health care, nutrition, security, safety, responsive caregiving and opportunities for early learning during this period are essential for children to achieve their full human potential. Early Childhood Development (ECD) refers to a child’s growth and development starting from the mother’s pregnancy through the child’s entry to primary school. ECD interventions therefore include services for pregnant and lactating mothers, as well as young children and their families. These services are meant to address the health, nutritional, socio-emotional, cognitive, and linguistic needs during this period. They are essential because a child’s early life forms the basis for future learning, good health and well-being and the ability of the child to work well with others in adulthood (Denboba et al. 2014). 1.2. Poor health and growth during early childhood has life-long consequences. Poor health and nutrition not only retard physical growth but also affect the cognitive, social-emotional, and motor development of an individual leading to reduced school performance and earning potential. Young children with physical, cognitive and socioemotional deficiencies are disadvantaged throughout their life. Global scientific evidence reiterates that children remain at risk of failing to reach their full potential due to the lifelong effects of undernutrition, lack of early stimulation and learning, and exposure to severe stress (violence, neglect, displacement, extreme deprivation). 1.3. Children need nurturing care during their early years to grow into healthy, intellectually capable, socially and emotionally mature individuals. Nurturing care is defined as a stable environment that is sensitive to children’s health and nutritional needs, with protection from threats, opportunities for early learning, and interactions that are responsive, emotionally supportive, and developmentally stimulating. As an overarching concept, nurturing care is supported by a large array of social contexts—from home to parental work, child care, schooling, the wider community, and policy influences (Shonkoff JP, Phillips, 2000). Nurturing care consists of a core set of inter-related components, including: behaviours, attitudes, and knowledge regarding caregiving (e.g., health, hygiene care, and feeding care); stimulation (e.g., talking, singing, and playing); responsiveness (e.g., early bonding, secure attachment, trust, and sensitive communication); and safety (e.g., routines and protection from harm) (Bornstein MH, 2012; Britto PR, Engle P, 2015). The potential benefits of supporting ECD include: improved cognitive development, better schooling outcomes and increased productivity in life (Berk, 2017). 1.4. The World Health Organization (WHO) nurturing care framework encompasses five key ECD elements - health, nutrition, security and safety, responsive caregiving and opportunities for early learning. As per the WHO, nurturing care is about children, their families and other 1 caregivers, and the places where they interact. It also means giving young children opportunities for early learning, through interactions that are responsive and emotionally supportive. The WHO’s recent nurturing care framework (Figure 1) has five components that outline the set of conditions that provide for children’s health, nutrition, security and safety, responsive caregiving and opportunities for early learning. Nurturing children means keeping them safe, healthy and well nourished, paying attention and responding to their needs and interests, encouraging them to explore their Figure 1: WHO Nurturing Care Framework (2018) environment and interact with caregivers and others. The role of early stimulation and nurturing environment does not only restrict to the early development of the children, rather it has larger implication for human development and economic growth. 2. The Government of Meghalaya’s interest in ECD and request for Technical Assistance (TA) 2.1. Committed to improving the overall development of the state’s children, the state leadership was keen to improve ECD policy, strengthen and expand the outreach of ECD programs at the community level. Recognizing the critical importance of the early childhood period to children’s development and to the realization of their full human potential,and bearing in mind the lack of adequate ECD services in the state, especially in remote tribal areas, the state leadership was committed to strengthen ECD policy and programs in the state. To provide every young child in the state with a holistic set of inputs for their overall growth and development, the Government of Meghalaya’s vision is to ensure a state-wide community-based and community- driven program to deliver an integrated package of ECD interventions, contextualized to the local context. The community-led approach was particularly desirable in the Meghalaya context, given the hilly terrain, the large tribal population, the social and governance context in the state and within that, the importance of community engagement and ownership for effective utilization of public services and promote positive behaviors, such as health, WASH, ECD and nutrition. More details of the situation of ECD and the social and governance context in Meghalaya are provided in section 2, sub-section 3. 2.2. Learning from the experiences of other states, the Government of Meghalaya specifically wanted to test the feasibility of using the Meghalaya State Rural Livelihood Society (MSRLS) platform to promote ECD at the community level. Several states have leveraged their State Livelihoods Mission platforms to improve nutrition and health, e.g., Bihar, Andhra Pradesh, Telengana. The MSRLS, with its network of women’s self-help groups and their federations, called Village Organizations (VOs), works across the state to eliminate poverty among rural people by improving their capacities and opportunities to participate in their own development. The MSRLS thus offered a potential platform to promote ECD through a community-led approach. Recognizing the importance of testing the feasibility of this platform to inform policy and programs, the state Government, as part of the Bank-supported Meghalaya Community-led 2 Landscapes Management Project (P157836), requested the World Bank to provide Technical Assistance (TA) to design and pilot an integrated package of nutrition, health and early stimulation interventions that could be implemented at the community level using a community-led approach. 3. Overview of the TA: 3.1. To be fully responsive to the Government of Meghalaya’s request, the TA activities were designed in close consultation with the state leadership and Meghalaya State Rural Livelihood Society (MSRLS) teams. A series of meetings and discussions were held with senior Meghalaya state officials to jointly identify and plan activities that would, within the short timeframe of the TA, support the state government to demonstrate on a pilot basis the feasibility of using the ready platform of MSRLS and MSRLS-women’s self-help group structures and processes to improve child growth and development outcomes. The key activities agreed under the TA support included: i) learning visit of selected MSRLS staff to the JEEVIKA program3 in Bihar to gain a first-hand experience of the ways in which the women’s self-help group platform could be leveraged for promoting health, nutrition and more; ii) the development a community-based, integrated health, nutrition and early stimulation ECD package contextualized to the local context to create awareness of ECD and to promote the adoption of appropriate ECD practices by parents/families/communities; iii) design and test a pilot in the West Garo Hills district to assess the feasibility of the MSRLS and women’s self-help group structures to promote the ECD package at the community level. The intervention aimed to complement the largely center-based Early Childhood Care and Education provided through the ICDS for children 3-6 years old and to improve on-the-ground coordination; iv) train MSRLS staff and local village women (members of the women’s self-help groups promoted by MSRLS) to reach young parents and communities through group meetings, home visits and community events with information and guidance on actions they could take to improve ECD outcomes for their young children; v) provide implementation and monitoring support; vi) share results of the pilot with key stakeholders in the state and support advocacy for ECD. 3.2. These activities aligned well with the overarching objectives of the TA. The set of activities above support the two objectives of the TA: i) to improve household behaviours and practices related to the full spectrum of young children’s growth and development, focusing particularly on a combined package of early stimulation and nutrition behaviours; and ii) bring about the much-needed convergence of public services to improve child nutrition, health and education outcomes. 3 Jeevika is the local name for Bihar Rural Livelihoods Promotion Society, an autonomous body that spearheads the livelihoods program in the state of Bihar. 3 4. Structure of the report 4.1. Structured into four sections, this report provides a comprehensive description of the TA, the key results and outcomes, and the policy implications. Section I introduces the ECD conceptual framework and provides the background and overview of the TA engagement. Section II, Context and Rationale for the TA incudes a brief discussion of the need for ECD that highlights the evidence base for ECD interventions and the returns on ECD investments, followed by the current situation of ECD in India and Meghalaya. Section III is dedicated to the description of the feasibility study – its components, methodology, design, implementation, assessment and results. Section IV discusses the dissemination of results, the policy implications and the Government of Meghalaya’s proposal to scale-up ECD interventions in the state. 4 2. The Context and Rationale for the TA This section briefly presents the evidence-base for the need for adequate ECD interventions, their life-long benefits and importance for human capital formation, and the economic returns on ECD investments. It then provides the situation of ECD in India and Meghalaya to highlight the key gaps and the urgent need to strengthen ECD policy and programs. 1. The need to focus on ECD: the evidence base 1.1. Almost 80% of the brain connections form during the first two years of life. Healthy development of the brain depends on the care and early stimulation experienced by children during initial years. Children are born ready to learn and during the early years, the brain matures faster than at any other time of life. Nurturing care and stimulation, protection from stress, healthcare and nutrition, and opportunities to play and learn during this period is critical for the holistic development of children (World Bank, 2018). The first thousand days of life - the time period between conception and the second birthday of child is a unique period to lay foundation of the optimal health, growth and neurodevelopment for entire lifespan (Cusick, S. and Georgieff, M.K., 2017). Aboud and Yousafazai (2015) suggest four prerequisites to be taken care of during the first two years of childhood because of their impact on the mental development of the children. These prerequisites are choice of delivery (home or institutional), immunity to common infections (such as malaria and diarrhea), nutrition and psychosocial stimulation. 1.2. Deficits emerge early and have lifelong consequences if children don’t get what they need to thrive in their earliest years. Nurturing care during early years promotes developmental adaptations. These developments have lifelong benefits for children, including an increased ability to learn, greater achievement in school and later life, citizenship, involvement in community activities, and overall quality of life (Boivin M, Bierman KL, 2013 and Ermisch J, Jantti M, Smeeding TM, 2012). Differences in brain development are evident as early as a few months of age. Children may be delayed in speaking. Huge gaps in vocabulary begin to emerge. Children may have trouble focusing, regulating their behavior, sitting still or interacting with their peers. Children struggle with basic tasks at primary school and fall behind peers who have had access to better early learning opportunities (World Bank, 2018). 1.3. There is ample evidence from countries around the world demonstrating that children who attend early learning programs have better education outcomes. A global study of 12 low- and middle-income countries found that adults who attended preschool had stayed in school almost one year longer than adults who hadn’t (holding all else constant). Similarly, another study from 65 countries found that in low and middle-income countries, children who had attended preschool scored, on average, 83 points higher in math and 67 points higher in reading than children who didn’t (holding all else constant) (World Bank, 2018). 1.4. Parenting support programs can substantially augment the positive effects of basic health and nutrition, education, and protection interventions on early child development outcomes. A recent meta-analysis on the parenting programs indicate that such programs increased scores on measures of psychosocial and motor development, in addition to child cognitive development. Further, parenting programs that combine nutrition and stimulation have been effective in improving child cognitive and language development outcomes (Aboud FE, Yousafzai 5 AK, 2015). The most effective parenting programs used several behaviour-change techniques, including media such as posters and cards that illustrate enrichment practices, opportunities for parental practice of play and responsive talk with their child, guidance and support for changing practices, and problem-solving strategies (Aboud FE, Yousafzai AK, 2015). 1.5. Enhancing school readiness and related educational outcomes. A number of different ECD interventions, including those that focus on early education and preliteracy, nutrition, and parenting skills and knowledge, have been shown to positively affect school readiness and academic achievement. For example, participants in a high-quality, active-learning preschool program, High/Scope Perry Preschool, had higher rates of high school completion than the control group (71 percent vs. 54 percent), which in turn resulted in higher monthly earnings (29 percent vs. 7 percent earned US$2000 or more per month) and rate of home ownership at age 27 (36 percent vs. 13 percent) (Schweinhart et al. 2005). 1.6. Integrating ECD into existing service delivery channels to reach parents and children is one of the many ways to promote early stimulation. For programs targeting parents, evidence suggests the most effective programs provide simple messages, opportunities to practice skills, frequent contact and coordination across services. For example (World Bank, 2018): • Mother-Child Education Program in Turkey builds parenting skills to promote child development by engaging mothers in weekly group sessions for six months. Mothers trained in the program speak to their children more and use less violent discipline, and children who benefited from the program performed better in their first five years of primary school and stayed in school longer than children who were not enrolled. • In Zanzibar radio-based interactive audio instruction is used to reach children. Sessions are led by community members with basic training in spaces donated by communities. Local materials, local language and an activity-based curriculum keep children and communities engaged. • In Uzbekistan, program has been designed to promote early reading, engage parents, and expand access to preschool in rural areas. • In Indonesia communities are provided with block-grants to operate community-based playgroups at a cost of just $30 per child per year. 6 1.7. The economic rationale for ECD is strong, the potential returns far exceeds the costs. The specific rate of return on investments in ECD depends on a number of factors, including the focus of a program, duration of exposure and quality; depending on these factors the rate of return for a single dollar invested in ECD can be as high as 17:1 (Naudeau et al, 2011). High returns to investments in ECD have been consistently delivered across a range of contexts, with a typical rate of return between 2:1 and 8:1 per dollar invested (Naudeau et al, 2011). According to Engle et al, (2011), increasing preschool Figure 2: Comparison of Returns on Investment for Education enrolment to 50% of all Interventions children in low- and middle-income countries Source: Heckman and LaFontaine, 2007 could result in an estimated benefit of lifetime earnings ranging from $15-$34 billion. 2. The situation of ECD in India 2.1. While the rate of decline of undernutrition has almost doubled during the period 2007- 2013 compared with the period 1999–2006, undernutrition in India remain unacceptably high. With over a third of its child born with low birth-weight and beginning life with a disadvantage, it is home to about 40 percent of the world’s stunted children under the age of 5 and nearly 21 percent of the wasted children. 35.7 percent of children under 5 are underweight, 38.4 percent are stunted, and 21 percent are wasted. Seventy percent of the country’s districts have stunting rates over 30 percent in more than half of these rates exceed 40 percent, and more than a tenth of them stunting rates are over 50 percent. A fourth of the country’s districts have prevalence rates that are higher than the national average for all three indicators of undernutrition - stunting, wasting and underweight (NFHS-4). Almost 60 percent of children under three are anaemic, 62 percent deficient in vitamin A and over 13 million infants remain unprotected from iodine deficiency disorders. Also, 53 percent of women and 22.7 percent of men are anaemic. 2.2. Early stimulation and primary education lack in appropriate focus and quality. India’s flagship program for children, the Integrated Child Development Services (ICDS) program mandated to provide six core services including health, nutrition, early childhood education, child care and safety in an integrated manner. The ICDS, however, has limited focus on ECD for children under three years of age, with only few states having introduced activities to promote early childhood education for this age group. Awareness of the need for early stimulation and responsive care giving is lacking and there are no parental/family guidance programs to promote early stimulation. For 3-6-year olds attending preschools, pre-school education is largely a downward extension of primary school curriculum, pedagogical practices are inappropriate with limited play, learning & teaching material; teacher training is lacking, and parental expectations 7 and practices are often misplaced. Regulation and monitoring of quality of primary and secondary education (PSE) is inadequate. Further, despite universalization of primary education in the country, at 4.4 years, educational attainment is low, and India still accounts for one-third of all illiterate people worldwide. Enrolment rates for grades 9–12 are just 40 percent; of those enrolled, approximately 15 percent drop out and one-third fail their examinations. 3. The ECD situation in Meghalaya 3.1. Though Meghalaya has shown improvements in infant and child mortality, yet critical indicators for health and nutrition remains poor. Meghalaya, a state with a population of approximately three million (2011), of which 86 percent are from tribal groups and about 80 percent live in rural areas, has its own unique health and nutrition challenges. While Meghalaya has made considerable progress in bringing down the mortality indicators, Infant mortality rate (IMR) (30/1000 live births) and U-5 mortality (40/1000 live births), health and nutrition indicators need considerable improvement. More than 40 percent (43.8 percent) of under-five children are stunted (low height/age ratio), 15.3 percent are wasted (low weight/height ratio) and 29 percent are underweight (low weight/age). Micronutrient deficiencies are high - 48 percent of children aged 6-59 months are anaemic, 56.2 percent of women in the reproductive age group and 32.4 percent in men are anaemic. 3.2. Coverage of health and nutrition services for pregnant women and young children, remain poor and a small proportion of households have access to safe water and sanitation. For example, only around 50 percent of children below five years of age received vitamin A doses and 61.5 percent were fully immunized; only 50 percent of pregnant woman received at least four antenatal check-ups and 51 percent had institutional births (compared to 78.9 percent at national level) (NFHS-4). With regard to nutrition services, in 2012-13 only 34.5 percent of pregnant woman, 25.8 percent of lactating mothers and 62.9 percent of 3-6-year-old children received supplementary food in the state as compared to 42.1 percent, 44 percent and 45.2 percent at the national level respectively (RSOC, 2012-13). Around 70 percent of households have access to improved drinking water source, 60 percent have improved sanitation facility. About 45 percent of the Gram Panchayats are Open Defecation Free (ODF). 3.3. Household behaviours and practices related to ECD are sub-optimal and less than half of Meghalaya’s children attend preschool. For example, only 35.8 percent of children under six months are exclusively breastfed and only 23.6 percent children (6-23 months) receive an adequate diet (Inadequate complementary feeding during the weaning period is thought to be a significant contributor to child malnutrition in India) (NFHS-4). Only 17 percent of children aged 3-5 years attended ICDS run pre-schools (38.7 percent as national average) and 43 percent attended any PSE (69.4 percent as national average) (RSOC, 2012-13). 3.4. The responsibility of governance and service delivery in Meghalaya falls under the ambit of three centres of authority. The governance structure is comprised of institutions representing state government, autonomous (‘District’) councils (ADCs) and traditional tribal heads. The responsibility of governance and service delivery falls under the ambit of three centres of authority. While the state government is formally responsible for the delivery of services, it is legally required to share part of this role with ADCs. Grassroots indigenous institutions, including village councils have significant power in Meghalaya’s society, and their function includes, amongst others 8 undertaking development initiatives. Convergence between formal state government structures and autonomous and tribal institutions down to the grassroots is often a challenge. Given this context, the Government of Meghalaya has focused on community empowerment and community engagement in their development programs including the MSRLS. 9 3. Feasibility Study This section describes the study undertaken as part of this TA to assess the feasibility of the MSRLS platform to promote at the community level an integrated ECD package for parents and children. The scope of the study covered the design and conduct of an intervention pilot, development of an integrated ECD package contextualized to local needs, qualitative and quantitative assessments, and suitable technical and institutional arrangements for the conduct of the pilot and its assessment. The detailed feasibility study report prepared by the research agency, the Center for Early Childhood Education and Development (CECED) is available online at http://ceced.net/ 1. Objectives The objectives of the feasibility study were to: a. design and develop an integrated nutrition, health and early stimulation ECD intervention package for parents with children till three years of age; b. design and conduct an intervention pilot, develop the capacity of the MSRLS and community implementors for the delivery of the package and assess the feasibility of the MSRLS platform based on quantitative and qualitative results; and c. document the processes with a view to understanding the lessons and challenges and to inform areas that may require strengthening during expansion and scale-up of the program. 10 2. Technical and institutional arrangements for the study 1.1. The MSRLS and the women’s self-help group structures were used as the implementation platform. For reasons explained earlier (in subsections 2 and 3 of Section I) the use of MSRLS Chief Executive Officer (CEO), was agreed as the platform to promote ECD MSRLS interventions at the community level. The MSRLS aims to work towards eliminating poverty among rural people State Management Monitoring in Meghalaya by improving their capacities and Unit (SMMU) opportunities to participate in their own development; strengthening village-level institutions so that they District Management collaborate effectively with and influence relevant Monitoring Unit (DMMU) democratic institutions to become more inclusive, accountable and effective; and bring about coordination, Block Managment Monitoring convergence and synergy among the various poverty Unit (BMMU) alleviation programs of the state and central government with a view to alleviate rural poverty in the state. Figure Village Organization (VO) 3 depicts the structure of the MSRLS. (5-15 SHGs federate into 1 VO) 1.2. An exposure visit for selected MSRLS staff to Bihar provided valuable first-hand experience of Self Help Groups leveraging community-based platforms to improve (10-15 households make 1 SHG) health and nutrition. The visit to the JEEVIKA multi- sectoral convergence program in Bihar, organized as one Community of the first activities helped the staff understand the way in which the Livelihoods Mission in Bihar was being leveraged to improve nutrition and health outcomes. Figure 3: Structure of MSRLS This helped the staff to draw upon the learnings from that program and visualize the potential of the MSRLS to improve early childhood development outcomes using the MSRLS community-engagement platform. 11 1.3. Research and technical arrangements for the study: The CECED, Ambedkar University, Delhi, a recognized national level institution with specialization in the area of early childhood development (ECD) and education was appointed as the technical and research agency for the study. The Bank also engaged an independent consultant to carry out the process documentation for the pilot. A reputed local NGO, Bakdil, undertook translation of the assessment tools from English to Garo, the local language, as well as the quantitative data collection (including the training and supervision of personnel for data collection). Box 1: Key terms explained MSRLS: Meghalaya State Rural Livelihoods Society or MSRLS is designated as the Nodal Agency for implementing National Rural Livelihood Mission (NRLM) in Meghalaya. The basic purpose of forming this society is to put in place a dedicated and sensitive support structure from the State level down to the sub-district level to focus on building strong and self-managed institution of the poor at different levels. BRT: Block resource team or BRT is the dedicated MSRLS support team at the sub-district level led by a Block Project Manager to catalyze actions at the block level. SHG: The SHGs or self help groups are homogenous groups, with the members belonging to the same community and living in the vicinity of each other. Each SHG consists of 10-15 women. These women voluntarily come together for a social or economic purpose. VO: A Village Organization or VO is a federation of SHGs at village/hamlet or Panchayat level (depending on the number of SHGs). In Meghalaya, the number of SHGs in a VO range from 5-30. 3. Methodology 1.4. Design of the pilot The pilot was designed in close consultation with the MSRLS team and factored in relevant inputs for sampling, the composition of the master training team, the implementation and training mechanisms, capacities and workload of staff and the like. a) Locale: The pilot was undertaken in the Rongram block of the West Garo Hills district in the State of Meghalaya. The area is predominantly occupied by the Garo tribe, with total population of about 643,000. The literacy rate of West Garo Hills district is 55.76 percent as compared to about 74.5 percent for Meghalaya. Rongram is one of the eight blocks of West Garo Hills, having a total population of approximately 1.37 lakh and a female population of 66,642 (Census, 2011). The study site and sample details (selected through a purposive sampling technique using the selection criteria below) are shown in Figure 4. 12 Figure 4: Study Site and Sample Details b) Sample for the feasibility assessment: i. All 61 pregnant women (PW) and young mothers (YM), i.e., mothers of children below 3 years of age), the target beneficiaries and primary recipients of the ECD package were selected (out of a total of all 351 women from 37 SHGs in the target area) ii. A total of 60 ‘other SHG women’, i.e., those women who were neither pregnant nor mothers of children under three, and who regularly attended SHG meetings and community events were selected. The primary reason for selecting them was for the pivotal role they could play in spreading ECD messages across the community through snow-ball effect. iii. All six block resource team members of MSRLS, all 74 EC members and all nine AW were included in the sample. c) Sample selection criteria: The following criteria were used for selection of VOs: • The SHGs should be active and federated at the VO level • The VOs should be operational for a minimum of 6 months to1 year. • The Villages should not be in a geographically difficult terrain or remote areas. It should be connected by road and easily accessible. • The SHGs should be in proximity or within 5 km from each other. 13 d) Implementation mechanisms The pilot was implemented through the MSRLS platform. The roles and responsibilities of MSRLS team for implementation are illustrated in Figure 5. Figure 5: Roles and Responsibilities of MSRLS Staff in the Pilot e) Training design Training of MSRLS functionaries was a key input for successful program implementation. Face- to-face training was provided to all the trainees including MSRLS functionaries, EC members and AW working in the selected five villages. Initially, a 6-day, three-tier cascade training model – as outlined below - was planned for the pilot (Figure 6). • Tier 1: The CECED team delivered a two-day training (for two modules) to all BRT members at the block office in English language. • Tier 2: The BRT members trained AW (two days for two modules) in Garo language at the block office. • Tier 3: The AW then trained EC members in Garo language at the village level (two-day training). 14 During the Tier 3 training at the village level, it was found that although the training was meant only for EC members, women also attended the initial training module along with EC members as the training was held in the villages. This unfortunately affected the pace and efficiency of the delivery of the training module. Also, the AW were not found to be suitable as trainers. To address these challenges, the training model was revised (Figure 6), and the remaining training sessions were made residential and held at the block level in a two-tier design conducted over four days (as outlined below) with the fifth day dedicated to field exposure. • Tier 1: The CECED team provided training to six BRT members of MSRLS in English language for two days (for two modules). • Tier 2: The BRTs provided training to AW (10) and EC members (74) of the selected 37 SHGs (each SHG comprised of 2 EC members) and about 8 Anganwadi workers and Asha workers from the villages in their local language (Garo) at the block level (for two days). Three-tier Training Model Two-tier Training Model Tier 1 Trainers: CECED team Tier 1 Trainees: BRT team Trainers: CECED team Language: English Duration: 2-days Trainees: BRT members Venue: Block Office Language: English Duration: 2-days Venue: Block – Bakdil Training Centre Tier 2 (Residential training) Trainers: BRT members Altered to Trainees: Active Women Tier 2 Language: Garo Duration: 2-days Trainers: BRT members Venue: Block Office Trainees: BRT team, EC members, AWW, ASHA workers Tier 3 Language: Garo Duration: 2-days Trainers: Active Women Venue: Block – Bakdil Training Centre Trainees: EC members (Residential training) Language: Garo Duration: 2-days Venue: Village Figure 6: Training Model of the Pilot f) Assessment design In order to assess the feasibility of the MSRLS platform to deliver the integrated ECD package at the community level, the following assessments were planned and appropriate assessment tools for each were developed: • Needs assessment: this was undertaken to understand the culture of Garo communities, their family structures, home environment of the young children, major occupation of the people, traditional practices of feeding, caregiving practices for pregnant and lactating women and for the children from birth up to three years of age, locally available foods in the villages, SHG structure and possible mechanisms to deliver the package. Such information was collected 15 from the beneficiaries as well as from the MSRLS functionaries. CECED had the primary responsibility to carry out this assessment. • Baseline and end line assessment: A KAP assessment before and after the intervention was planned with: (i) the target beneficiaries (pregnant women and mothers of young children); and (ii) with the sampled other SHG women from villages in the study area to document the effects of the ECD package. The KAP tools were developed in English by CECED and Bakdil undertook translation of the tools to Garo language, collected the information from the field in Garo, and translated the information back to English. The data translated into English was then provided to CECED for analysis. • Pre-post knowledge assessment of MSRLS functionaries: A knowledge test was administered before and after each training session to document the change in the participants’ knowledge after the training sessions. • Process documentation: A detailed process documentation was undertaken to gain more in- depth understanding about the intervention implementation processes, to systematically capture and document lessons and identify areas for strengthening and gather perspectives for various stakeholders on the ECD package and its delivery were also gathered as part of the process documentation. g) Monitoring mechanisms The monitoring arrangements included: Dedicated monitoring visits were planned alongside each of the three training sessions to oversee implementation of the intervention on field. - Monitoring visits were undertaken to observe the SHG meetings, home visits and community events. Specific monitoring tools were designed to monitor these contact sessions. - Monitoring and feedback forms to be filled by EC members, AW and BRT members at least twice during the intervention period were compiled. - Dedicated monitoring and feedback sessions with the BRTs, Active Women and EC members were planned during the training sessions to discuss the challenges faced by the team in conducting the intervention as well as to provide feedback and help further contextualize the ECD package if required. The following monitoring and feedback tools were developed: i. Attendance sheet for SHG meetings (to be filled by EC members); ii. Record of home visits (to be filled by EC members); iii. Checklist for Active Women for monitoring SHG meetings; iv. Checklist for Active Women for monitoring home visits; v. Monitoring form for BRTs regarding SHG meetings; vi. Monitoring form for BRTs regarding home visits; vii. Monitoring forms for BRTs regarding community events; 16 viii. Checklist for Active Women and EC members to give feedback regarding flipbooks and pamphlets; ix. Feedback form for Active Women and EC members regarding community events; and x. Feedback form for BRTs regarding overall ECD intervention package delivery. 4. Design of the ECD package a) Research and consultations to inform the design: A series of consultations, meetings and state visits were undertaken before developing the ECD package. In-depth discussions were had with other partner organizations such as UNICEF and PATH India who are actively involved in the sector and are working at the state-level. The task team consulted UNICEF state teams (Chhattisgarh, Rajasthan and Maharashtra) and undertook a visit to Chhattisgarh to understand the ECD package being used and the implementation arrangements for the same. The pilot drew upon existing ECD packages, including the one used in the Pakistan Early Childhood development Scale-up Trial (PEDS trial) to develop a holistic package for the pilot. The team also attempted to draw upon the ECD package used in Odisha for an ECD randomized control trial (RCT), but were not able to access the package from the Odisha RCT research team. The health and nutrition package used in the JEEVIKA program and ECD package, Khilte Phool, used by CARE/India in Bihar. b) Description of the package A comprehensive ECD package integrating nutrition, health and nurturing care messages was developed to cover pregnancy, lactation and childhood age group 0-3 years. The ECD package included information on the following three themes: i. Health, hygiene, nutrition, quality caregiving, and early stimulation and learning for the birth – 3-year age group, based on the characteristics, developmental milestones and needs of the children in this age group; ii. Prenatal development of children and care of the mother during pregnancy and the lactation period; iii. The role of the entire family in supporting pregnant and lactating mothers and participating in childcare. The essential messages related to each theme were identified and were classified in five age-wise sections - pregnancy, birth to 6 months, 6 months to one year, one to two years, and two to three years. In all, five flipbooks were prepared to communicate relevant messages in simple language to pregnant women and mothers of young children. It was decided to disseminate these messages to parents and communities in West Garo Hills in Meghalaya through three different strategies: a. SHG meetings; b. Home visits; and c. Community events The five flipbooks developed were central to the ECD package as were the pamphlets, home visit and community event guidelines and resource booklets (Figure 7). 17 Contents of the ECD package: Following the life cycle approach, the contents of the package were divided into five modules corresponding to the different stages of infant development. These modules were: Module 1: Care during Pregnancy Module 2: Birth to six months: Care of the mother and the child Module 3: Six months to One year: Care and Early Stimulation of the Child Module 4: One to Two years: Care and Early Stimulation of the Child Module 5: Two to Three years: Care and Early Stimulation of the Child •To be kept at home •To be used by EC by parents - to members during reinforce the SHG meetings and messages home visits Pamphlets Flipbooks (n=6) (n=5) Guidelines Resource (to conduct booklets home visits, (n=5) community events) •Detailed resource • Guiding the trainers material for the on how to organize trainers - explaining SHG meetings, home concepts in detail visits and community events Figure 7: Comprehensive ECD Package Module 1: Care during pregnancy: The purpose of this module was to provide information regarding appropriate practices to be followed during preconception period and pregnancy. The module emphasized on the measures to be undertaken by young couples for planning, confirming and ensuring healthy pregnancy. It described the signs of pregnancy-related complications and preparations needed for safe delivery. The importance of birth spacing and various methods of family planning, importance of nutrition were also discussed in the module. Module 2: Birth to six months: Care of the child and the mother: This module described vividly the criticality of the first six months after delivery and post-partum health care needed by the mother and the new born during this period. The emphasis in this module was on messages related to the importance of exclusively breastfeeding the child, following an on-demand feeding schedule, ensuring appropriate immunization, growth monitoring, health check-ups and infant care 18 during illness, and diet for lactating women. Developmental milestones of a child from birth up to six months and various early stimulation activities that can be done with children of this age were also discussed in the module. Module 3: Six months- one year: Care and Early Stimulation of the child: This module described the needs of babies in terms of hygiene, health, nutrition, responsive care and early stimulation aspects from the age of six months to one year. For appropriate nutrition of babies, it stressed on continuing with breastfeeding up to 2 years of age but with complementary feeding alongside from the age of 6 months. Various complementary foods that could be introduced in the child’s diet at this age were discussed. The module also gave details about the hygiene practices, growth monitoring, health check-ups, immunization, safe and stimulating environment for babies of this age, developmental milestones and early stimulation activities that could ensure optimal development of the babies of this age. Module 4: One – two years: Care and Early Stimulation of the child: This module outlined the needs of children between 1 and 2 years of age and described appropriate hygiene practices, toilet training, family foods, responsive feeding, health care, safe, language rich and stimulating environment for them. It also provided details about developmental milestones and quality caregiving by parents for overall development of the children of this age. Module 5: Two-three years: Care and Early Stimulation of the child: This module focused on responsive care and early stimulation of children between 2 to3 years of age. It contained messages related to hygiene, toilet training, appropriate nutrition, responsive feeding, health care, and safe and stimulating environment for the children in early childhood years. Developmental milestones of children at this age and activities that can be done by the parents at home for the holistic development of children at this age were also described. 5. Implementation of the pilot This section provides details about the on-ground implementation of the pilot, highlighting the challenges encountered and remedial measures undertaken. Qualitative information in the form of findings and learnings noted in this section will be important to consider during the scale-up of the pilot. a) Trainings As mentioned in the methodology section, the training model was altered (from a three-tier structure to a two-tier structure) after the first round of training. The low attendance of EC members along with drop-out of some trainees during the training period were the key challenges faced across all three rounds of training. The process documentation tried to understand reasons for low attendance at the trainings. Box 2 shows the feedback on the training sessions from various stakeholders. This feedback should be considered while designing the training modules when scaling up the intervention. FGDs and interviews with EC members, AW and BRT members were conducted to get their perceptions about the overall training methodology. The key findings from these FGDs and interviews (from the process evaluation) are outlined in Box 3. 19 - The training duration of two days for BRTs and for AW and EC members was considered suitable by nearly all the participants. - Most of the trainees reported that all the trainers used the lecture mode, followed by the discussion. When asked, one of the BRT members mentioned that the training should have more of group work as people really enjoyed doing so. - All the BRT members were quite happy with the trainers. They had received a lot of interesting and detailed information which had been communicated clearly and led to an increase in their knowledge. They were satisfied with the content in all the modules and the way the content was delivered to them. One of the BRT members observed that “the videos were interesting so were the discussions that followed the PPTs�. Box 2: The issue of poor attendance for trainings: Stakeholders views 20 Box 3: Observations on the Quality of Training as noted in Process Evaluation By BRT members: - “All the modules were good, but I liked and also found modules 1 & 2 the most useful. I got to know many new things about taking care of pregnant and lactating mothers. Some things we already knew about but I understood things better like immunization as in the training we were told about the immunization chart etc. - The trainings have definitely increased my knowledge and skills. One teacher working in the primary school asked me- are you working in the medical department? I felt very happy and proud. - The trainings were very useful for me as I came to know small details about breast feeding, taking care of the young child and new- born babies, which I had no idea about at all. A little more time for our level of training would have been better. - The modules were explained to us very well and was informative and easy to understand and follow. Other materials were also given which I also found very useful. I have come to know many new things and details about important aspects which I already knew. I enjoyed the videos they were interesting and a change from presentations. The puppet- making session was one of the best in all the three trainings and I enjoyed this session a lot.� By EC members and Active Women: - “The trainings provided us a lot of information about health and hygiene, nutrition and child- care. We also got to know a lot of recipes so that we have nutritious food and so many little things but that which is important like sleeping on the left side. (EC member, Rongchigre) - In the trainings, all the explanations and discussion clarified our doubts about different ideas that were shared ways of delivering the ECD concepts to the pregnant and young mothers through different activities in a participatory manner. (Active Woman). - We got to know new ways of making supplementary food and practicing healthy habits for our children and pregnant mothers and good practices in health, hygiene, and nutrition. (EC member Rengsangre) - The first training was very good and effective as we got a lot of new information on pregnant and lactating mother which is very helpful to our women. All the modules are important and written well. The discussions were useful, and I liked the videos and the puppet making session a lot. (Active Woman) - I enjoyed the puppet making session it was very interesting and videos were good, though Garo people were not shown. The guidelines for conducting home visits and organizing the community events also helped us in doing our work. (EC member Aguragre) - We have learnt about the importance of different types of food that is nutritious and how to make new recipes using locally available food for the young child. I have also learnt the importance of pregnant women taking rest and good care of themselves. (Active Woman)� 21 In conclusion, the documentation reveals that all three rounds of training conducted by CECED were appreciated and found to be interesting and beneficial by BRT members, EC members and AW. It was the training venue, duration and timings that posed a challenge since these factors affected the attendance and participation of the MSRLS functionaries, in particular EC members. b) Roll-out of ECD package The ECD package was delivered using three modes: (i) at SHG meetings, (ii) during home visits; and (iii) through community events. The EC members of each of the selected SHGs by AW, AWW and ASHA workers played a key role in the delivery of the intervention package. The three strategies used to disseminate the ECD package are described below: 1. Weekly SHG meetings: Weekly SHG meetings are already a key feature and a critical component of the ongoing MSRLS approach in villages. Each ECD module was delivered by the EC members during one month through four weekly SHG meetings. This helped to disseminate information directly to a large number of beneficiaries within short span of meeting hours. Annexure 1 provides a glimpse of a SHG meeting. The process documentation highlighted two important observations in this context. (i) Completing two modules in one month i.e., dedicating two SHG meetings for one module was difficult as it left no time for discussion and thus, the dissemination strategy was altered to disseminate only one module in one month. With this change, during the pilot out of five modules only three modules could be disseminated. (ii) Not all SHG women attended all the weekly meetings. Although this is common with all SHG meetings, the pilot ensured that in every SHG meeting a recapitulation session was done to bring on board the women who missed the previous sessions. 2. Home visits: Home visits were undertaken by the EC members to each target household with a gap of 15 days in between – at least thrice during the project duration. AW supported EC members during home visits and assisted BRTs in monitoring. The purpose of home visit was to strengthen the key message delivered during SHG meeting and to observe the extent to which target beneficiaries were able to practice the key messages in everyday life. One of the major benefits of conducting home visits as reported by EC members during FGDs was that they could observe and find out about any changes in practice being adopted by the target beneficiaries, such as taking better care of themselves by taking rest, eating nutritious food and going for medical check-ups, getting registered for an institutional delivery, lactating mother taking care of the supplementary foods, health and hygiene of themselves as well as that of their new born baby. 3. Community events: Three community events at the village level were planned as part of the delivery of 3 modules of ECD package. These aimed to create awareness about the care during pregnancy, importance of institutional delivery, complementary feeding of the infants, and early stimulation of young children in the community. The purpose was to reach out to the entire community and the maximum number of villagers easily at one time and place. It was appreciated by the beneficiaries as an informative event. Community events are quite entertaining and informative for all of us in my village. They should happen more frequently, so that we can get more information and enjoy. (Lactating Mother, Rensangre). 22 Table 1 provides a snapshot of the advantages and challenges of the three different strategies adopted for the dissemination of the ECD package. Table 1: Advantages and challenges of dissemination strategies Advantages Challenges SHG meetings (i) No additional burden: ECD (i) Irregular meetings Module dissemination integrated (ii) High rate of absenteeism in regular SHG meeting (iii)Difficult to cover a Module in schedule. one month’s SHG meetings (ii) Easy dissemination: Key especially for illiterate women. messages in module can be given to all SHG members attending the meeting. Home Visits (i) One to one interaction with (i) Many times, women not target group beneficiary. available at home. (ii) More time and easier to discuss (ii) Sometimes difficult to discuss problems and observe and modules in detail – guests at discuss changes in practice. home or family members not (iii)Pamphlets seen as more useful interested. as compared to Flipbooks by beneficiaries as they can be seen daily as stuck on walls. (iv) Roll over effect at times to other family members. Community (i) The reach and coverage is (i) Organizing the event is difficult, events maximum as compared to the as many people are involved in other strategies. conducting the event and thus (ii) Useful as everyone in the village not easy to coordinate. can be exposed to the messages. (ii) Had to be rescheduled, re - (iii)Different activities make the planned, arrangements redone event interesting and thus the due to other commitments. learning. (iii)Very low participation of male members as often it is looked upon as a women’s event affecting their participation. (iv) Difficulty in informing all the villagers about the event. 23 6. Results 1.4.1. The results of the KAP assessment (quantitative change) showed improvements (statistically significant) in some knowledge and practices. Given the short intervention period of four months, large changes in KAP were not expected amongst target beneficiaries. Figures 8 and 9 show the changes in knowledge of target beneficiaries and other SHG women, figure 10 shows the changes in practices of target beneficiaries respectively. Significant improvements (p<0.01) were seen in the knowledge scores of target beneficiaries specifically to issues pertaining to causes of water contamination and methods to prevent contamination, causes of diarrhea, foods to be given to the infant after birth, appropriate child bearing age, dietary diversity for lactating women and importance of play for development of children as tested by chi-square analysis. For other SHG women significant improvements were seen in knowledge pertaining to measures to prevent illness, first food for the child immediately after birth, breastmilk as most nutritious food for first six months, appropriate age for introduction of solid or semi-solid food, diverse diet for lactating women and importance of play for development of children. Figure 11 shows the change in knowledge scores of the BRT members and EC members. 1.4.2. The qualitative data gathered through FGDs and interview showed some interesting information on the pilot and ECD package. By the Block Resource Team (BRT): The Block Resource Team who were directly responsible for the delivery of the ECD package shared the main benefits of the pilot which have been categorized into three areas: • Knowledge Gained - All the MSRLS staff and beneficiaries unanimously stated that they had all gained new and also more information about health, hygiene, nutrition and care of children. More importantly, it was the care to be taken by pregnant women and what lactating mothers should do that really helped to improve the quality of lives of the target beneficiaries in the five villages. • Change in attitude and thinking: One of them mentioned - I think differently now about what I should do and not do for myself as I am pregnant and for my small child too. • Change in Practice - The target beneficiaries shared changes in what they practiced and some of them were also reported by others involved in the pilot based on what they had observed during their visits to the homes of targeted women. A number of different practices were shared some were very small and minute but all important as they were a direct result of the information provided in the ECD package. The ideas were being followed and had been adopted by them in their daily lives. 24 • Attitudinal Change -The beneficiaries target 8: Figure shared that there Change in Knowledge was some of Pregnant andkind of a change Mothers of Young Children 25 Figure 9: Change in Knowledge of Other SHG Women 26 Figure 10: Changes in Practices of Pregnant and Mothers of Young Children 27 By the Executive Committee Members: During the FGDs with EC members they all appreciated the ECD pilot program started by the World Bank and MSRLS has not only impacted positively on pregnant and lactating mothers in their villages but also on themselves. Most of them perceived that there was also a change in their own mindset about the way they looked at things related to health, hygiene, nutrition and child- care and about the importance of looking after pregnant women. Others had started paying more attention to lactating mothers and what they were doing to take care of themselves and also their young children. As one of them said 'we never thought nor realized the importance of paying attention to pregnant women about their rest, food habits and also the importance of supplementary feeding, amongst other things.' By the active women: The FGD with six out of eight active women working in the pilot corroborates the changes that have been highlighted by the EC members. AW also reported having noticed changes in the practices followed by pregnant and lactating mothers in their villages. They and the target beneficiaries appreciated the positive effects of the pilot on their lives and that of their young children. The AW reported that the beneficiaries had reported that the pilot had led to their keeping the environment and their children cleaner, becoming more hygienic themselves and also their family members to eat nutritious food, keep themselves and their children clean and live in more hygienic conditions. Pregnant mothers were more careful that they took rest, ate a more nutritious diet, went for regular check-ups and opted for institutional deliveries. Mothers of young children were happy to try out new supplementary foods and recipes, taking them for medical check-ups and vaccinations etc. The knowledge gained from the modules is being followed by most of the targeted women and they also do like and try to put it into practice. The modules have also given them information about early childhood stimulation which is not a general practice in Garo community. As one Active woman explained- Garo people don’t like to sing a song or play with children as it is not a practice in Garo villages. They love children but don’t express much. They have also come to know the importance of talking with children and telling them stories. One AW shared that one of the lactating mothers told her that – After the pilot started, I have started telling stories to my children. They enjoy this very much and sleep only after hearing a story from me, every day. 28 7. Triangulation of results to assess the feasibility of the pilot 1.4.3. Three key parameters, acceptability, outcomes and demand, used to assess feasibility of the pilot indicate that the MSRLS platform is an appropriate platform to roll-out the ECD package in Meghalaya. The findings for each of the parameter is discussed below: i. Acceptability: This refers to the extent of reception and practicability of the using MSRLS as a platform for intervention. This answers the key question - What is the perception and experience of MSRLS team about the intervention package and its implementation? The MSRLS team found the intervention package to be very useful for the community. Some of them, mostly AW and EC members, had limited exposure to early Childhood Development (ECD) concepts prior to this intervention. Thus, the package proved to be useful in developing their understanding on different ECD concepts according to the developmental stages. Further, the women’s SHG platform was reported to be a beneficial platform for delivery of the intervention because number of women, who are primary caregiver of children’ can be targeted collectively at one place. Although the community event approach was appreciated by the MSRLS team, they also experienced number of challenges to organize the community events, in particular (i) Mobilization of community people, especially the male members of the community was found to be biggest challenge; and (ii) time and venue suitable to everyone, especially for the pregnant women as travelling long distance was an issue with them. ii. Outcomes: This parameter focuses on the changes in the knowledge and skills of MSRLS teams a result of capacity building program conducted during the intervention. The post- training scores of BRT members were significantly higher than their baseline scores. This indicates that the training was successful in improving the knowledge of BRT members. However, similar was not the case with EC and AW where the change was marginal indicating that this group requires more intensive support for bringing about change in their knowledge levels. An important point to note here is that knowledge assessment was done immediately post training. It is anticipated that the change in knowledge levels of the BRT, AW and EC members would have been much greater with repeated exposure to the contents of the ECD package during the intervention activities on field. iii. Demand: This includes reflections from MSRLS team about the requirement of implementation for scaling up of the program in future. This addresses to the question - What are the suggestions of MSRLS team for scaling of the intervention in future? There was a consensus amongst all stakeholders that the ECD pilot was ‘useful’, ‘needed to be continued in the next year’ and even ‘spread across the State’. Reasons given were that it would help increase the knowledge about health, nutrition and child -care, pregnant women and those feeding their young children would learn ways of doing things in a better way. These practices would help change and improve their lives and that of their children. Few excerpts from the beneficiaries and functionaries about the acceptability, outcomes and demand for the ECD package is presented in box 4. 29 BOX 4: Acceptability, outcomes and demand for ECD package On the ECD Module: On Delivery mechanism: 1.4.4. Overall, the MSRLS platform was assessed as a feasible one to promote ECD at the community level through the three-pronged approach of the pilot. The acceptability of the intervention was high as the MSRLS team perceived it to be very useful for the community. It was felt that such interventions should be expanded for the whole state. The three-pronged strategy of using SHG meetings, home visits and community events for the ECD package delivery was perceived very positively. The MSRLS functionaries felt that through SHG meetings, one could directly disseminate information to a large number of beneficiaries within the meeting time. Similarly, home visits were found to be useful for monitoring changes in the practices of the target beneficiaries and for reinforcing the key messages. Community events helped in reaching out to the maximum number of villagers at one place and time. The key issues that were reported in using these strategies were– absenteeism of the SHG members in the meetings, time expended in reading from the flipbooks in the meetings, non-availability of the beneficiaries during the home visits, difficulty in mobilizing villagers esp. male members for participation in the community events. Nevertheless, the demand for the ECD intervention 30 was high. MSRLS functionaries and the beneficiaries felt that the appropriate mother and child- care practices as informed by the ECD intervention would improve the lives of the women and children in the communities. 8. Limitations The key limitation of the study was the short time period available for the pilot – its design and development and implementation. Given this limitation, and the field realities, it was decided to roll out only three of the five modules of the ECD package and assess the KAP related to the topics covered in the three modules. Given the purpose of the study – to assess the feasibility of the MSRLS platform for implementation of the ECD package – it is unlikely that this limitation has affected results, if at all they would have been more enhanced with more implementation time. Feasibility has been assessed using three parameters – acceptability, demand and outcomes, using quantitative and qualitative results. 31 4. Policy Implications and Scale-up of ECD interventions in Meghalaya 4.1 The results of the pilot, implications for policy and options for scale-up were discussed at a workshop at the end of the TA. The results and learnings from the pilot were shared with various stakeholders through a dissemination workshop organized at Shillong, Meghalaya with support from the MSRLS team. The purpose of the workshop was to share results from the pilot, engage with MSRLS teams from other districts, get their inputs for possible ways to address the challenges faced during the pilot implementation, and suggestions for any changes/modifications to be considered for upscaling the model across the state. The workshop was chaired by the Chief Minister of the State, Mr. Conrad K. Sangma along with Commissioner-cum-Secretary (C&RD), Mr. Sampath Kumar and CEO of MSRLS, Mr. Shantanu Sharma. The workshop was attended by over 50 participants including MSRLS district-level teams from various districts of Meghalaya. It was a mix of presentations, experience sharing by the Rongram block team members, beneficiaries and a panel of district managers to gauge how they could take the pilot forward in their state. 4.2 The workshop exposed the state leadership as well as MSRLS teams from all districts across the state to the critical need for ECD interventions to ensure the full human development potential of children. The workshop effectively highlighted the concept of ECD, its lifelong benefits, and the critical need to ensure that all children get the full set of inputs for their holistic development. 4.3 The Honorable Chief Minister expressed his full commitment and support to make ECD a priority in the state. Acknowledging as sad but true that Meghalaya has one of the worst health and nutrition indicators in the country, the Hon’ble Chief Minister noted that the high infant mortality rates, adolescent pregnancies and high fertility rate in the state need urgent attention. He emphasized on the need of making the families especially women of the family financially and economically stronger so that she can be a part of the decision-making process. Appreciating the current pilot and the World Bank support as very timely, he acknowledged ECD as a priority and committed that the pilot will be scaled up across the state. He also noted that MSRLS is one of the most powerful platforms available to reach the community and is the perfect platform to bring about positive changes in the community especially the women. 4.4 A strategy to strengthen ECD and integrate the ECD interventions in the existing system post the pilot was proposed. The design and the work done under the pilot was appreciated by the Commissioner-cum-secretary, Government of Meghalaya. He explained how the pilot builds on the global experience from the Perry school project in America which shows that ECD interventions especially during 3-4 years of age has life positive effects. Based on the results demonstrated through the pilot, he proposed a two-phased strategy to scale-up the ECD interventions in the state – in terms of immediate term and the longer term. • Immediate strategy: To layer the ECD interventions on the existing MSRLS platform and to scale it up across the state ensuring contextualization to the varying contexts in the state as needed; • Longer term strategy: To set up a knowledge institution in the state, either in MSRLS or Meghalaya Basin Development Authority (MBDA) to build the capacity for ECD in state and to coordinate among various departments for ECD. 32 4.5 Scaling-up options need to balance the urgency for action, the need to build capacity for ECD and continued learning during scale up. The Meghalaya Government is very keen to improve early childhood services at the community level in the state as soon as possible. This interest was the main driver behind their request to the Bank to help them assess the feasibility of the women’s self-help group platform, supported by the MSRLS, as a vehicle to create awareness about ECD at the community level and promote the adoption of an integrated set of parental/household actions to improve ECD outcomes. Committed to improving ECD, and fully aware of the evidence of the long-term benefits of ECD and the efficacy and effectiveness of ECD interventions to improve ECD outcomes, the near absence of any such interventions in the state, and recognizing that the Rongram pilot had demonstrated the feasibility of the MSRLS platform to promote the integrated ECD package developed and the limitations of the pilot, the state government wants to adopt an approach that allows for sale-up action in the immediate term and provides for flexibility to refine, revise based on learning during implementation. 4.6 The Government of Meghalaya proposed a two-pronged approach to address the needs and factor in the concerns. It was proposed: i) to replicate a strengthened model that incorporates the learnings from the feasibility study and the in-depth process evaluation in a phased manner in other areas in Meghalaya; ii) build a strong learning and capacity building component that continually supports learning cycles of testing, learning, adapting and refining while expanding in a phased manner. They proposed setting up a knowledge institution in the state to support the above approach, build the capacity for ECD in the state, including research and learning, and to coordinate amongst various departments for ECD and requested Bank support for it. In essence, the idea is to use the ‘prototyping’ approach, which is different from ‘piloting’. Prototyping is built on the idea of plan, do, study, act (PDSA) cycles. Plan, do, study, act cycles come from evidence-based improvement science and are formalised in the model for improvement (Langley, G. Nolan, K and Nolan, T, 1994) and has been effectively used in large scale change models such as in the National Health System (NHS), England. The PDSA figure below further illustrates this approach (NHS England, 2017). Figure 12: The Model for Improvement 33 4.7 The state leadership requested for continued Bank support to scale up the pilot. The Hon’ble Chief Minister, the Commissioner-cum-Secretary (C&RD), and the CEO of the MSRLS expressed keen interest in and requested the World Bank and CECED to support their efforts to scale up. Given the diversity of cultures and languages in the state, they further requested support in contextualization of the package developed to other regions. Overall, the pilot was successful in not only developing a comprehensive ECD package, implementing it through MSRLS platform but with results convinced the leaders of the state to scale it up across the state through MSRLS platform. 34 Bibliography Aboud, F.E. and Yousafzai, A.K. (2015). Global health and development in early childhood, Annual Review of Psychology, 66: 433-457. Berk, L, E (2017). Development through the life span. (7th ed.). Boivin M, Bierman KL, eds (2013). Promoting school readiness and early learning: implications of developmental research for practice. New York, NY: Guilford Publications. Britto PR, Engle P (2015). Parenting education and support: maximizing the most critical enabling environment. In: Marope PTM, Kaga Y, eds. Investing against evidence: the global state of early childhood care and education. Paris: United Nations Educational, Scientific and Cultural Organization, 157–76. Cusick, S.,and Georgieff, M.K., (2017). Retrieved from https://www.unicefirc.org/article/958-the-first-1000- days-of-life-the-brains-window-of-opportunity.html Denboba A, Sayre R, Wodon Q, Elder L, Rawlings L, Lombardi J (2014). Investing in young children: key interventions and principles to ensure all young children reach their full potential. Washington, DC: World Bank Group. Engle, P. L., L. C. H. Fernald, H. Alderman, J. Behrman, C. O’Gara, A. Yousafzai, M. Cabral de Mello, M. Hidrobo, N. Ulkuer, and the Global Child Development Steer Group (2011). “Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries.� The Lancet, Early Online Publication. Doi:10.1016/S0140-6736(11) 60889-1. Ermisch J, Jantti M, Smeeding TM, eds (2012). From parents to children: the intergenerational transmission of advantage. New York, NY: Russell Sage Foundation. Heckman and LaFontaine (2007). In: Investing Early: What Policies Matter? A Framework Paper for Systems Approach for Better Education Results (SABER) – Early Childhood Development Human Development Network World Bank, January 2013 Langley, G. Nolan, K and Nolan, T (1994). The Foundation of Improvement Quality Progress. In: National Health Survey (NHS), England (2017). Leading Large scale Change: a practical guide. National Family Health Survey-4 (2015-16). Ministry of Health and Family Welfare, Government of India. National Health Survey (NHS), England (2017). Leading Large scale Change: a practical guide, available at https://www.england.nhs.uk/wp-content/uploads/2017/09/practical-guide-large-scale-change-april-2018- smll.pdf Naudeau, S, N. Kataoka, A. Valerio, M. J. Neuman, L. K. Elder (2011). Investing in Young Children: An Early Childhood Development Guide for Policy Dialogue and Project Preparation. World Bank, Washington, DC. Rapid Survey on Children (2013-14). Ministry of Women and Child Development, Government of India. Schweinhart LJ, J Montie, Z Xiang, WS Barnett, CR Belfield and M Nores (2005). Lifetime effects: The High/Scope Perry Preschool Study through Age 40. Ypsilanti, MI: High/Scope Educational Research Foundation. Shonkoff JP, Phillips DA, eds (2012). From neurons to neighborhoods: the science of early childhood development. Washington, DC: National Academies Press (US), 2000. Bornstein MH, ed. Handbook of Parenting. New York, NY: Psychology Press. WHO (2018). Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential (p.8). ISBN 978- 92-4-151406-4 35 Annexure 1 Glimpse into a SHG meeting One of the SHG meetings was held on 7 June, 2019 at 4:15 p.m. in village Ronchingre, in the open. Women were engaged in conversation amongst themselves and little children were busy playing with dogs, cats and chicks. When the meeting started, all the SHG members sat in a round circle There were eleven members present, out of which two were EC members. At the start of the meeting, they discussed about some social work what work was pending. One of the members who called the Book Keeper was writing down whatever the group was discussing. They spoke about saving money and if any member wanted a loan. Money was also collected for savings and a record maintained. The Book Keeper also wrote about some agendas which they would be discussing later. The next item on the agenda was to disseminate the key messages in the ECD module that had been focused on by CECED in the training at Bakdil. One of the EC members read out Module 5 in Garo in front of other SHG members. She told them that although they know many things already, but she would still read out the content and tell them what she had learnt in the training. She asked them about the number of times they gave food to their young children. She informed them that according to the module a young child should be given food at least 4-5 times daily. One of the women shared that “My baby takes more than that because he plays and takes less quantity and therefore gets hungry easily.� That woman also asked to see the pictures given in module. They all saw the pictures in the module. Only two topics, in the module were read out by the EC member- Needs of 2-3-year-old children and Characteristics of 2-3-year-old children. The EC member then went on to inform all the members about the target households that they had gone to visit. A pregnant mother twice and had pasted pamphlets on the wall of her house. There was also one lactating mother with a seven-month old baby while there was no young mother with a2-3-year-old child in the village. They also planned about the next home visit. At the end of the meeting, they all practiced hand washing with soap at the water source provided there. The EC members told them how to wash hands according to the steps given in the module. The SHG members practiced it happily and assured the EC member that they will teach the same steps to their children also. 36 Funding support from for this work was provided by: Contributions of: (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies of the World Bank and its Board of Executive Directors. The Government of Japan through the Japan Trust Fund for Scaling Up Nutrition.