Monitoring and Evaluation Framework for MAA: Mothers’ Absolute Affection

Mothers’ Absolute Affection (MAA): A Nationwide programme of the Ministry of Health and Family Welfare, Government of India initiated in August 2016 aims to revitalize efforts towards promotion, protection and support of breastfeeding practices through health systems to achieve higher breastfeeding rate.

1. Monitoring and Evaluation Framework for MAA: Mothers’ Absolute Affection Presented by: Nand Lal Mishra & Bishwajeet Besra

2. Introduction and Background Goals and Objectives Components & Implementation levels Logical Framework Monitoring of Input and Process Evaluation of Process, Output, Outcome and Impact SWOT Analysis Conclusion Contents

3. Prevents 20% of newborn deaths Prevents 13% of under-five deaths 11 times lesser chance of diarrheal mortality 15 times lesser chance of Pneumonia related mortality Benefits on raising I.Q. Prevention of non-communicable diseases Lesser hospital stay of newborns Maternal benefits (cancer prevention) Sources: UNICEF, WHO and Lancet series on child nutrition and maternal cares, 2003, ’08 & ’12) Breastfeeding…

4. Current Scenario

5. SDG 2.2: By 2030, end all forms of malnutrition, including achieving… the internationally agreed targets on stunting and wasting in children under 5 years of age (Poshan Abhiyan: -2% to -3% annually) SDG 3.2: By 2030, reduce NMR to 12 per 1,000 live births and U5MR to 25 per 1,000 live births SDG 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being (including breast cancer) Relevant SDG Targets

6. Mothers’ Absolute Affection ( MAA ): A Nationwide programme of the Ministry of Health and Family Welfare , Government of India initiated in August 2016 ( NHM  IYCF  MAA) Aims: Promotion of breastfeeding ( early initiation of breastfeeding within one hour of birth & exclusive breastfeeding for the first six months ) and provision of counselling services for supporting breastfeeding through health systems Covering: All States & UTs; Around 3.9 crore pregnant & lactating mothers ; 8.8 lakh ASHAs ; 1.5 lakhs Sub-centers & 17,000 Birthing Facilities/Delivery Points About

7. Goal: To revitalize efforts towards promotion , protection and support of breastfeeding practices through health systems to achieve higher breastfeeding rates . Objectives: Build an enabling environment for breastfeeding through awareness generation activities , targeting pregnant and lactating mothers, family members and society in order to promote optimal breastfeeding practices. Reinforce lactation support services at public health facilities through trained healthcare providers and through skilled community health workers. To incentivize and recognize those health facilities that show high rates of breastfeeding along with processes in place for lactation management. Goal & Objectives

8. Components

9. Implementation Levels Micro Level: At village and community level (ANM’s, AWW’s & ASHA) Meso Level: At health centres (Doctor’s & Nurses) Macro Level: Through mass media (Print & Electronic)

10. Logical Framework Input: Budget (NHM fund + 4.3 lakhs per dist.), mass media content and training of healthcare providers Process: General awareness (mass media campaigning), community level intervention and health facilities strengthening Output: Promotion of initial and exclusive breastfeeding , awareness and breaking taboos Outcome: Decline in early childhood mortality , improvement in nutritional status of children and reduction in prevalence of diseases such as diarrhoea, pneumonia etc . Impact: Better child and maternal health

11. Monitoring Provisions Monitoring and impact assessment is an integral part of MAA programme. Key indicators to measure progress : availability of skilled persons at delivery points for counselling , improvement in breastfeeding practices and number of accredited health facilities Monitoring agencies : UNICEF and Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) lead development partners Provision of reporting by ASHA in prescribed monitoring form and a state wide evaluation survey after one year of implementation.

12. Inbuilt Monitoring Indicators Number and % of ASHAs for whom sensitization on IYCF was conducted in block meetings Number of districts conducted launch of MAA programme Number of Mothers’ meetings held Number and % of Pregnant & lactating mothers who attended mother’s meetings Number and % of ASHAs having IYCF infokit Number and % of ASHAs provided incentive for mothers’ meetings Number and % of ANMs for whom one day sensitization was undertaken Number & % of ANMs & nurses trained on 4 day trainings. Number and % of delivery points, where healthcare providers have been oriented using one day sensitization module Number of Facilities received MAA awards (at State level)

13. Key Themes of M&E Photo: NHM Website

14. Monitoring of Input Inputs: Budget Mass media content Training of healthcare providers Dimensions/ Indicators: Amount of budget per pregnant women registered Quantity and quality of content Number of participants and training sessions Data sources: HMIS MAA Website Training records Methods: Financial auditing Vignette & PPDT KI & In-depth Interviews

15. Monitoring of Process Process: General awareness (mass media) Community level intervention Health facilities strengthening Dimensions/ Indicators: Frequency of publications and broadcasts Community engagements and activities Different facilities available at health centers Data sources: DAVP & BARC Reporting by healthcare providers HMIS Methods: Descriptive statistics Geotagged photo analysis Health facility index & dashboard

16. Evaluation of Process Process: General awareness (mass media) Community level intervention Health facilities strengthening Dimensions/ Indicators: Outreach of publications and broadcasts Impact of community engagements Different facilities available at health centers Data sources: DAVP, BARC & NFHS KI & In-depth Interviews/NFHS Feedback collected Methods: Statistics and Propensity score matching (PSM) Qualitative analysis/PSM Feedback analysis

17. Evaluation of Output Output: Promotion of early initiation of breastfeeding Promotion of Exclusive breastfeeding up to 6 months Dimensions/ Indicators: Percent children under age 3 breastfed within one hour of birth Percent children under age 6 months exclusively breastfed Data sources: NFHS & HMIS Methods: Percent growth and Multiple Classification Analysis

18. Evaluation of Outcome Outcome: Decline in early childhood mortality Improvement in nutritional status of children Reduction in prevalence of diarrhoea, pneumonia etc. Dimensions/ Indicators: NMR, IMR & U5MR Percent children stunted, wasted & underweight Prevalence of diarrhoea, pneumonia etc. Data sources: NFHS & SRS Methods: Percent growth, Multiple classification analysis & Two-stage least square methods

19. Evaluation of Impact Impact: Better child and maternal health Dimensions/Indicators: Relevant SDG/NHM/NNM targets and indicators Data sources: NFHS, SRS, HMIS etc. Methods: Target oriented analytical approach & Various statistical methods and analysis Photo: Mukesh Kumar

20. SWOT Analysis: Strength Vast Coverage to the public through mass media Strong policy support from government Human resource friendly Financial resource friendly Doesn’t require extra infrastructure

21. SWOT Analysis: Weakness Traditional beliefs and practices Lack of funds Improper functioning of health centers Additional burden on health workers Less baby friendly facilities Low female literacy & media exposure Corruption or improper implementation

22. SWOT Analysis: Opportunity Capacity building of health workers Focus on complementary feedings Community & NGO engagements Social media coverage Adult education at AWC More incentives and lack of motivations for ASHAs

23. SWOT Analysis: Threat Pre-existing taboos & refusal of community Effect of societal gatekeepers Limited access to social media Extra burden of adult literacy on AWW Inadequate working environment for health care workers

24. Conclusion MAA was initiated recently in august 2016 and hence only baseline report can be generated at present. Monitoring is a default part of Mothers’ Absolute Affection programme. So there is no need of separate monitoring system. Also there is no need of separate or specific evaluation survey for the same as various statistical methods can be applied to NFHS, HMIS and SRS data in order to assess the program's output and impact. Or evaluation of this program can be merged with the evaluation of policies and programs such as NHM, ICDS, Poshan Abhiyan etc.

25. References http://nhm.gov.in/nrhm-updates/536-maa-programme.html http://unicef.in/AddNewPage/PreView/19 http://vikaspedia.in/health/health-campaigns/mothers-absolute-affection#section-1 http://nhm.gov.in/MAA/Operational_Guidelines.pdf https://www.unicef.org/about/annualreport/files/India_2016_COAR.pdf http://rchiips.org/nfhs/report.shtml https://nrhm-mis.nic.in/SitePages/Home.aspx

26. Thank You !