2002 IDS: Evaluation of Posyandu Revitalization
Author: Center for Health Research, University of Indonesia
In response to the economic crisis, UNICEF has started the Rapid Response Complementary Food Initiative (CFI), which distributed micronutrient-fortified complementary food packets called Vitadele (VTDL) through Posyandu to benefit over 150,000 infants for a period of six months.
At the same time, the Crisis Response Program provided the opportunity to restore the Posyandu's function of growth monitoring and promotion and to provide added incentive for community attendance at Posyandu, which was experiencing a decline. This has become a start-off for the Posyandu Revitalization Program (PRP).
In addition, a training program for health cadres has been established. The goal of the program is to strengthen the capability of the health staff to detect growth faltering and provide follow-up nutrition education/counseling. Improved skills of the cadres and CFI availability may increase the coverage and quality of Posyandu services. The present evaluation sought to assess the impact and efficiency of the Posyandu Revitalization Programme.
Purpose / Objective
To measure the effectiveness of the PRP in delivering nutrition interventions to targeted groups and evaluate the overall impact on malnutrition in four provinces: West Java, Central Java, East Java and West Sumatra.
- Effectiveness of CFI program in reaching target groups
- Impact on nutritional status of beneficiaries (weight-for-age)
- Impact on proportion of children growing at the appropriate rate
- Effectiveness of training on cadres' knowledge and skill, particularly regarding growth monitoring and nutrition counseling
- Impact on mothers' knowledge and practice of adequate infant feeding
- Improvement in quality of posyandu services
- Improvement in coverage of posyandu services
The evaluation compared posyandus that received support through the Posyandu Revitalization Program and those that did not receive support as a control group. The control group was matched according to socio-economic status. In total, 211 posyandus were visited, 358 (61.5%) cadres interviewed and 1,748 mothers/children (90.1%) interviewed and measured (children). 16 focus group discussions and 32 in-depth interviews were held in the intervention area, with 9 focus group discussions and 18 in-depth interviews conducted in the control area.
Key Findings and Conclusions
The program has reached most of the target groups, as measured by monthly VTDL received, age range of receivers and mothers' perception on sufficiency of VTDL supply. However, most of the children received VTDL for less than 6 months, and most of them received less than 10 sachets. About half of the children consumed VTDL as recommended (at least 3 times a day). The percentage of children who always finished VTDL meal was 41%, and about 45% stated that sometimes the children didn't finish. Reasons for left over varied including and in particular, the portion per serving was too big (54.9%), the children did not like the taste (14.0%) and children were sick or loss of appetite (15.1%). Mothers knew how to prepare VTDL mostly from the written information on the sachet, followed by from cadres and health providers.
The most obvious barriers to the success of the CFI program to reach target groups were the supply and distribution mechanisms. There were irregularities in supply, lack of reporting/recording, monitoring and supervision system, and lack of transportation funds to distribute VTDL from sub-district to the lower level.
Price was apparently not a barrier to get VTDL; according to mothers, most of them who paid perceived the price of VTDL as cheap. However, there was also a different perception regarding the price, which was connected by the mothers with "perceived quality". Mothers, especially in West Sumatra, perceived that the nutrition content of VTDL was low because the price was cheap.
There was no significant difference in children's nutritional status between intervention and control groups, except in Central Java in which the nutritional status of children in intervention groups was slightly better than control groups. Since there was no baseline data, we cannot conclude whether the current nutritional status has changed. We also do not know whether the nutritional status of intervention groups was similar to those of control groups at the beginning of the intervention. Additionally, in all 4 provinces, there were similar food supplementation programs of other organizations (for example: SUN, Katresna, Delvita, etc.).
Comparing the weight of children less than two years of age before and after the intervention will allow us to evaluate whether the program has increased the proportion of children growing at an appropriate rate. The weight of the children, theoretically, can be obtained from KMS. However, many of the children (for example, 30% in intervention group) did not have KMS and for those who have KMS, the weight was incompletely recorded. Therefore, no conclusion can be made.
In general, the perception of mothers regarding services provided by cadres was good, which was similar in intervention and control groups. Within the last 6 months, half of mothers visited a posyandu for at least 6 times, in both intervention and control groups. Home visit and counseling activities conducted by cadres were similar in both groups. However, the number of mothers who have never attended posyandu was higher (10.1%) in intervention as compared to the control group (2.6%).
Overall, the training has not reached the expected objective. Almost 40% of cadres did not have the skills to record weight on KMS - which is a very crucial skill as a cadre. The ability of cadres to interpret weight on KMS was better in intervention than in control groups; however, in both groups, the proportion was low. The ability of cadres to detect growth faltering was better in control groups. Besides the training program under PRP, similar training programs for cadres with similar objectives (JPSBK/Social Safety Net in Health) also exist; therefore, no clear-cut conclusion of the effect of PRP alone can be made.
It is important to have data on nutritional status before and after the intervention.
The supply and distribution system should be in place prior to the implementation of the food supplementation program. Monitoring and Evaluation should be a part of the program from the beginning.
It is important to give sufficient and correct information regarding VTDL to mothers and cadres.
Periodic training is important to strengthen cadres' knowledge and skills, especially new cadres. Coordination with other similar programs regarding the content and methodology of training will complement each other and avoid duplication.
The benefit and the content of home visit and counseling should be emphasized more in the training material.
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