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Evaluating health and nutrition programmes in Rajasthan

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Rajasthan, largest state in India, records a high proportion of maternal and infant deaths along with a high prevalence of low birthweight and malnutrition among children. Nutrition intake among pregnant women remains inadequate and uptake of ante natal care (ANC) services is limited. Children’s Investment Fund Foundation (CIFF) in partnership with the Government of Rajasthan seeks to improve maternal and child health outcomes through multi-faceted programmes:

  • The Born Healthy programme, implemented by Jhpiego, aims to improve quality of public ANC services through capacity building of ANC providers and introduction of point-of-care diagnostics for key maternal infections.
  • The Indira Gandhi Matritva Poshan Yojana (IGMPY), implemented by IPE Global, offers a conditional cash transfer and behaviour change counselling to pregnant and lactating women to improve their nutritional intake and feeding practices.

Both programmes primarily seek to reduce prevalence of low birthweight. IGMPY also targets child wasting as an additional outcome.

We are conducting an independent evaluation of these two individual programmes and their combined effect through ‘layered’ evaluation in select areas to assess whether interactions between the two programmes generate incremental benefits in terms of positive impact on birthweight and other key outcomes. The overarching evaluation includes assessment of impact, process, cost-effectiveness, and sustainability of both the programmes.

Challenges

The multi-stakeholder programmes have undergone significant design changes since inception, particularly in terms of intervention sites and eligibility criteria for ‘treatment’. Delays in implementation rollout of one of the programmes have led to subsequent revisions in evaluation strategy, timelines, and budget; these delays have also reduced the combined exposure time of both Born Healthy and IGMPY programmes in ‘layered’ areas.

A key challenge with the evaluation is related to measurement of key indicator: birthweight. Data collection during baseline highlighted concerns with measurement and recording of birthweights in facilities (such as heaping of data and data entry errors). In response, partners agreed upon standardisation of birthweight measurement through supply of digitised scales along with training and mentoring of staff in the labour rooms of all the public facilities identified as delivery points in the study areas of both treatment and control districts. However, this has methodological implications for impact assessment of prevalence of low birthweight at endline and has required further adaptations to the evaluation strategy.

Our approach

Our evaluation has three arms: Born Healthy intervention area, IGMPY intervention area, and ‘Layered’ area for both interventions. Impact evaluation will compare changes in indicators in treatment areas with changes in matched control areas (quasi-experimental, differences-in-differences specification). Process evaluation will assess fidelity of implementation to the proposed design and quality of implementation.

At baseline, conducted in 2018, the evaluation used two sources of quantitative data on women and children: i) a retrospective primary survey of households with pregnant women and/or mothers of children under three, and ii) extraction of public sector facility records on birthweight for children in the primary sample, since facility records are expected to be more accurate than relying on survey recall. Qualitative interviews with health providers and pregnant women at baseline assessed relevance of the programmes.

After implementation rollout, a continuous concurrent panel (cohort) of pregnant women will be set up to track receipt of interventions and changes in secondary outcomes. The cohort study will also allow for interim findings and mid-course correction throughout the implementation cycle. Data from cohort will contribute towards part of the endline data and will be complemented by a retrospective cross-sectional survey.

Outcome

Based on our recommendations from the baseline survey in six districts, standardisation of birthweight is being implemented by programme partners. The cohort study for the Born Healthy programme began in late 2019 and is currently ongoing. Findings from the first cohort of pregnant women have also been shared with partners. Data collection for qualitative process evaluation for the Born Healthy programme has been planned and is expected to be undertaken towards the end of 2020. Timelines for IGMPY and 'Layered' programmes will be finalised upon confirmation of its implementation timelines.