The Start Strong Project: Improving access to maternal healthcare and reducing malnutrition for 1,000 women and their children in Bajura, Far West Nepal.

18-month Start Strong Project Progress Update: 1 April 2022 – 30^th September 2023

Background

The Start Strong Project is a three-year integrated sustainable development project combining maternal healthcare, agricultural support to increase the availability of high-value foods and nutrition support for the most vulnerable mothers and their children under the age of 5 delivered by our trusted local partner PHASE Nepal (https://phasenepal.org/)

Due to the high levels of maternal mortality and child malnutrition in the remote and rural areas of Rugin and Bichhaya, Bajura, this vital work was requested by the local communities and chosen for development funding by UK Aid Match. UK Aid Match brings charities, British people, and the UK government together to change the lives of some of the world’s poorest and most vulnerable people.

The generous support of the British public, PHASE Worldwide supporters and various Trusts and Foundations aligned with our goals of the prevention and relief of poverty and the advancement of health and saving of lives came together to fund Start Strong – together we are changing lives in Nepal.

These endeavours and project milestones support our overall goals of working towards some of the life-changing Sustainable Development Goals 2030 of No Poverty, Zero Hunger, Good Health and Well-being and Gender Equality (https://sdgs.un.org/goals).

The Start Strong Project has been made possible through the UK Aid Match programme where money raised by the general public was match-funded by the UK Government.

Start Strong Year 1 Health Outcomes

Our impact at the end of 12 months evidences the reduction in child malnutrition, the increase in correct knowledge of ‘Safe Motherhood, increase in knowledge & practice of Golden 1,000 Days ‘Sunaula Hazar Din’, the increase in new mothers practicing exclusive breastfeeding for 6 months and increase in women using super flour ‘Sarbottam Pitho” as weaning food for their children ensuring sharing knowledge changes behaviours: https://phaseworldwide.org/start-strong-1-year-of-impact/

We are now at the half-way point of the three-year integrated project which will give all children living in these areas a strong start in life, improving access to maternal healthcare for mothers and reducing malnutrition in children. Despite challenging circumstances in both Year 1 and Year 2, as devastating landslides and earthquakes destroyed and damaged both Health Posts and homes and livelihoods in Rugin and Bichhaya, the Start Strong Project has maintained its momentum, completing work plan targets on time, and responding flexibly to beneficiary needs, feedback and reporting back to Donors.

We are excited to share with you our highlights at this crucial half-way point of the Start Strong Project:

1 April 2022 to 30 September 2023 and looking ahead to completion of Year 2 on 31^st March 2024.

Output 1. Improving Maternal Healthcare Knowledge and Behaviours and First 1,000 days practice of 1,000 women in Rugin and Bichhaya across 36 months

Progress: The PHASE Nepal project team has continued to organize community health-focused meetings with the mothers of Golden 1,000 days (focus on the crucial development period from conception to 2 years of age) and maternal healthcare orientation to pregnant women and their caregivers (mothers-in-law and husbands).  A priority throughout has been to continue identifying severely/moderately malnourished children and providing them with food supplements, saving lives.

As a primary focus for improving community health for the most vulnerable, the Start Strong Project provides primary health care services with a specific focus on improving access to antenatal, intra-natal and postnatal care services in Rugin and Bichhaya and the surrounding remote communities.

• 12,422 patient consultations (female 7,063, male 5,359)

Start Strong Project Health Major Indicators Progress Update at 18 months:

1. 276 Antenatal Care (ANC) first visit (pregnant women)
2. 191 Antenatal Care (ANC) fourth visit (pregnant women)
3. 214 Reported birth deliveries in the project area:
   70. 151 Institutional deliveries attended by Skilled Birth Attendant (SBA) (70.6 %)
   71. 63 Home deliveries (29.4%)
4. 51 x meetings of Antenatal Care (ANC) Orientation (Attended females 721)

Output 2. Increasing Availability of High Value Foods and Diet Diversification through Agricultural Activities with 625 women across 36 months.

Progress: The PHASE Nepal project field team continuously works to select beneficiaries, train and support them with vegetable seeds, chickens and coops, mushroom spore kits, and other agricultural materials such as polytunnels, watering cans and water butts for irrigation and organic pesticides. The Agriculture Technicians and Social Mobilisers visit the homes and fields of female beneficiaries regularly for technical support to ensure that they are confident and competent with their activities.

Start Strong Project Agriculture Major Indicators Progress Update at 18 months:

1. 699 female farmers received vegetable seeds and agricultural materials
2. 229 female farmers received Oyster mushroom cultivation support
3. 190 female farmers received poultry (chicken) breeding support

Start Strong Agricultural Support Outcomes to improve family nutrition and income.

Providing agricultural support to vulnerable mothers to become Female Farmers and join Female Farmer Groups for peer support and learning to produce more nutritious food for their families to combat lack of dietary diversity and food insecurity due to the difficulties of growing food in mountainous areas with multiple Monsoon seasons. Junior Technical Agricultural Assistants (JTAs) support the most vulnerable mothers to prepare land, build polytunnels, sow vegetable seeds or breed chickens with home-made chicken coops for meat and eggs, or cultivate Oyster mushrooms from spores to harvest multiple crops for extra protein.

Surplus produce can be sold to the local community for family income for the first time, increasing the respect they receive for self-sufficiency and economic independence. Female Farmers Groups give collective voice to their agricultural achievements as women in remote and rural areas are often excluded from owning adequate agricultural resources and lack opportunities to access training and share knowledge to increase food production. Food insecurity is a major driver of malnutrition in areas far from market access in Bajura. Evidence of increase in dietary diversity and polytunnel usage for increase in off-season vegetable crops: https://phaseworldwide.org/start-strong-1-year-of-impact/

• Number of women who can produce enough food from their land to meet their families’ needs for 6-12 months of the year = 50.7% exceeding our initial target of 48% (Year 1 Survey results)

Output 3. Embedding Nutritional Expertise and Knowledge in the Community through 120 Key Stakeholders across 36 months.

Number of key stakeholders (Female Community Health Volunteers, Traditional Healers, Chairs of Mothers Groups, Government Health Workers, Government Teachers, Government Officials, and other Community Leaders) involved in District Level Meetings, Workshops, and Health Programme Management Committee meetings = 151 key stakeholders (target was 120 key stakeholders / year)

1. 23 Health Facility Operation and Management Committee (HFOMC) Meetings
2. 43 Female Community Health Volunteer (FCHV) Meetings

Community collaboration and co-operation from each Health Post service in Rugin and Bichhaya to ensure transparency of project progress and share goals at both individual and community level for knowledge transmission and embedding of best practice for sustainability beyond Start Strong project.

Monitoring, Evaluation, and Lesson Learning (MEL)

Monitoring visits have been continued by the PHASE Nepal central team. PHASE Nepal conducts its all staff learning and sharing workshop twice a year in Kathmandu to ensure best practice for safeguarding – refreshers on policy and procedure for all staff and technical advice on health, agriculture and nutrition topics from up-to-date sources and recommendations linked to government policy and goals.

From the beginning of the Start Strong project, PHASE completed the following MEL activities:

1. 1 Baseline survey – Pioneering census-style survey that captured data for entire population
2. 1 Annual survey – snapshot questionnaires to test logframe indicator progress against targets
3. 3 Semi-annual staff workshops – to share best practice and refresh safeguarding mechanisms
4. 6 Public audits – Opportunities for Beneficiary Feedback Mechanism in project areas
5. 1 District/Gaunpalika level learning and sharing workshop (municipal and federal government)
6. 6 Monitoring visits by PHASE Nepal central team (including 1 joint visit with PHASE Worldwide)

Specific learning points to date:

• The popularity of chicken and egg production over mushrooms as a preferred income source for mothers, despite their popularity for self-consumption, evidencing the flexibility in options for sale of eggs, meat, and potential for breeding as progress towards self-sufficiency with improved breeds of poultry provided increasing more income per female farmer. This beneficiary feedback from the female farmers has resulted in a pivot in Year 2 project activities towards increasing our poultry support where this has been demanded, partly due to the year-round potential as opposed to mushrooms which can only be grown in warmer weather and where there is less market potential due to the remoteness of the project areas and the difficulty of transport during Monsoon seasons which limit local travel.
• The importance of working with respected community members to strengthen rural health systems through the positive engagement and training of Female Community Health Volunteers and Traditional Healers ensures more consistent and timely referrals to Health Posts. It also encourages more health-seeking behaviours at an earlier stage which can be critical in remote and rural areas before people are too unwell to travel the long and difficult distances from their home to the Health Post.
• Building on existing positive attitudes created through increased access to antenatal care support to increase collaboration to reduce the risk of home births without support, increase exclusive breastfeeding and support from caregivers so that mothers have increased maternal healthcare choices that reduces the risk of maternal mortality and child malnutrition.
• Agricultural support increases gender equality, dietary diversity and household income for vulnerable mothers and their children in remote, rural areas where women and children often eat least and last and lack access to resources.
• Embedding nutritional knowledge and expertise within the community at all levels to ensure better nutrition for the most vulnerable is a community concern. Efforts to ensure that malnutrition is identifiable and referred for immediate treatment to ensure healthy development, particularly during the first 5 years to avoid stunting and wasting – reducing vulnerability to disease and infection that can occur from global acute malnutrition which is prevalent with lack of dietary diversity and food security, particularly in remote and rural areas.

Community Health Promotion and Engagement Activities during the Start Strong Project

• 514 x Door to door visits (benefited – female 2,897, male 1,450, total 4,347)

Door to door visits and health education delivered by PHASE health workers (50% outreach work) reaching those facing additional barriers to access Health Post.

• 4 x Street Drama

Street Dramas are accessible street theatre with public health messaging, ensuring that no one is excluded from health promotion activities due to low literacy.

Street dramas are one of the most effective activities and are implemented where many community people can attend. This accessible information session caters for those without sufficient literacy to read posters or access to other information sources such as radio or internet.

The street dramas focussed on Chhaupadi (isolation culture during the menstrual period and after birth), child marriage and various maternal health related issues. These sessions are significant in highlighting the ways in which violence against women and girls can perpetrate within communities under the context of cultural practices, despite being outlawed by the Nepali government. It is therefore important to continue to engage with the local community to maintain awareness of the rights of women and girls at every life stage. It is also important to engage with the male community members in highlighting these issues so they can support their sisters, wives, mothers, and daughters going forward from a rights-based perspective and challenge any misconceptions that may still exist.

• 2 x Vulnerable Person Protection Orientation training – including child protection.

This embeds a safeguarding culture within communities.

Representatives from the local children’s club, teachers, ward offices, FCHVs, Traditional Healers and Mothers’ Groups attended the sessions. During the session the participants were briefed about the human rights of people especially of children, various laws/regulations related to child rights and the steps to be taken if a child appears to be vulnerable, at risk of abuse and in need of a safeguarding response. The attendees are expected to contribute at their workplace to protect the vulnerable from abuse.