Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study.

BACKGROUND: Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. METHODS: We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. RESULTS: In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges. CONCLUSIONS: Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

Father Involvement in Early Childhood Care: Insights From a MEL System in a Behavior Change Intervention Among Rural Indian Parents.

Introduction: Fathers' involvement in care and early initiation of cognitive development activities have a positive impact on a child's social-behavioral, cognitive-academic and emotional-psychological development. This research study, conducted in Tamil Nadu in south India (2017-19), employed a Cluster Randomized Trial to test the impact of techno-social innovations in improving the involvement of fathers in child-care on child development outcomes. Qualitative studies were used to inform the trial and provide insights into pathways of change. Objective: This paper discusses the design, implementation and results of the study through the monitoring, evaluation and learning (MEL) framework to provide an understanding of the perceptions among parents and service providers surrounding early child development, the adaptations and learnings through the intervention period, and changes that were brought about through the intervention. Methods: The study was at a Proof of Concept stage, and the primary learning objective was to keep the learning process going through the period of the study, as well as obtain evidence to inform future model development. The measurement for change process in the study occurred in three distinct yet interconnected stages. In the first stage, the program was planned, and the design was refined for both the implementation and evaluation of the project. The next stage was the actual implementation: with a learning loop during the execution of the main intervention. The third stage was intended to reflect on the adaptations and pathways to change through the project period and collate evidence for model refinement. Results and Discussion: The data collected from the formative research was used to design, develop and implement the intervention. Lessons in coordination with the government program not only brought policy visibility, access to secondary data, and enabled field research, but also provided access to a workforce with immense field knowledge and presence in the rural underserved population. In order to continuously inform the implementation process of the intervention, the feedback loops allowed for adaptions to be made at each stage. The findings provide insights for programming early childhood development interventions, especially interventions regarding improving father's involvement in child-care, and ways to leverage evidence in these interventions.