Suaahara II mid-term assessment: qualitative research using the program constraints assessment (2018).

Research Report.

SUMMARY: This Suaahara II (SII) Mid-term Assessment (MTA) had the primary objective of gathering perceptions on SII accomplishments, constraints inhibiting program effectiveness, and suggestions to overcome these constraints. The MTA also sought to capture beneficiaries' perceptions on primary benefits from SII interventions and their greatest remaining problems. To answer these research questions, the qualitative "program constraints assessment" (PCA) method was employed, using focus group discussions (FGDs) and key informant interviews (KIIs). A Nepali survey firm collected qualitative data at the national, district, and sub-district levels with government officials, other stakeholders, SII and partner non-governmental organization (PNGO) staff and beneficiaries in 3 districts representative of the diverse SII intervention areas: Bajhang (representing the far-western upper hills), Bhojpur (representing the eastern hills) and Rupandehi (representing the terai). Central level data were collected during the last week of May 2018 and the first week of June 2018. While, as is often the case with PCAs, study participants expressed perceptions based on inaccurate information, these perceptions, along with SII quantitative monitoring data, are expected to inform operations during the remaining years of SII. The major perceived SII accomplishments and constraints, grouped by SII thematic areas are the following: • Nutrition: SII has been able to improve some key behavioral practices including duration of breastfeeding and IFA tablets during pregnancy. Constraints include the difficulty and/or reluctance of many 1000-day mothers to attend health mothers' group (HMG) meetings, and some continuing dietary issues, particularly the absence of timely introduction of quality complementary food for infants and "eating down" during pregnancy. • Health: SII has contributed to increased immunization coverage, antenatal care (ANC), postnatal care (PNC) visits and facility-based deliveries. A major perceived constraint relates to the inadequacies of health facilities in medical care and reproductive health and in recording and reporting. • Water, Sanitation and Hygiene (WASH): SII's accomplishments were most often noted in this area, and include handwashing, increased use of toilets, and increased water purification, all resulting in a perceived reduction in diarrheal infection. The inadequate availability of water filters was the most commonly mentioned constraint. • Homestead food production (HFP): In some areas, participants noted successful seed distribution resulting from high quality training and logistics, and the moving of chicken coops, often earlier in homes, outdoors. Among the constraints noted were the religious taboos against poultry-raising and egg consumption, severe water shortages and, more generally, sustainability concerns about these HFP initiatives. • Governance: Many district officials spoke positively about their cooperative efforts with SII and indicated important district-specific accomplishments. Among the constraints noted were: nutrition not yet being a high enough priority in the federal government; poor planning and prioritizing by municipal governments; and government frontline workers (FLWs) - particularly female community health volunteers (FCHVs) - being overworked, underpaid and unable to fulfill their responsibilities. • Social and behavior change communication (SBCC): Accomplishments included increasingly effective counseling through interpersonal communication (IPC), home visits, community events and SMS (texting with beneficiaries). Bhanchhin Aama (BA) benefited from better program preparation and improved radio wattage capacity. Low rates of BA listenership by targeted households was identified as an important constraint. • Gender Equality and Social Inclusion (GESI): SII-related accomplishments noted include fewer restrictions on women during their menstrual periods and reduced discrimination against Dalits. GESI-related constraints identified include women's heavy workloads which inhibit both childcare and selfcare and the increasing frequency of husbands working abroad, often leaving women without any possibility of assistance. • Monitoring, Evaluation, and Research (MER): While participants noted the valuable MER information collected and disseminated within SII, they spoke about weak government monitoring and supervision and inadequate local utilization of SII and government data (e.g. to identify and rapidly address shortcomings of municipalities or village development committees (VDCs) not achieving minimum acceptable levels on key indicators). • Operations: One important accomplishment is that SII is well known in most areas and particularly appreciated by government counterparts working in nutrition, health and agriculture. The primary constraints noted were inadequate accounting for differences among districts and within districts, and the belief that SII field supervisors (FSs) do not have adequate time for their field responsibilities, including home visits, because of data collection responsibilities. For the second set of questions of this study regarding beneficiary perceptions of primary improvements and remaining problems, we found the most emphasized SII-related benefits relate to WASH (a better understanding of the importance of hygiene and sanitation leading to improved practices), counseling during pregnancy, and, with greater empowerment, an increased freedom to leave their homes. Their primary remaining problems are associated with their workload, their financial constraints, the distance of many from HMG meeting sites, and the fact that many continue to be confined to separate living quarters during their menstrual periods. With nearly 150 suggestions from participants and recognizing the limited project time remaining, the analysis team offers a set of recommendations which, it believes, have potential for longerrun government adoption and sustainability. The recommendations are categorized into three groupings: (a) Strengthening Household and Community Level perceptions, understandings and behaviors; (b) Improving operations; and (c) shifts and additions needed beyond SII. • Strengthening household and community perceptions, understandings and behaviors: with recommendations relating to: the reluctance of 1000-day mothers to attend HMG meetings; the disinterest of mothers in growth monitoring and promotion (GMP); remaining WASH needs; homestead food production shortcomings; low Bhanchhin Amma listening rates; and the inadequate federal government commitment to nutrition; • Improving operations: with recommendations relating to ward prioritizing and shifting responsibility for data collection; and • Shifts and additions needed beyond SII: with recommendations relating to: inadequate government capacity (specifically municipality governments with budgeting); low utilization of health facilities (addressing facility shortcomings); lack of skills at health facility level and among FLWs, particularly in recording and reporting.;