Indicators for the Monitoring and Evaluation of the Logic Model
Situation

In Fakir Bagan, there is a high prevalence of diarrheal disease, as is the case with most of India and especially slum areas. The most serious result of diarrheal disease is dehydration. There is a belief held by many people that reducing liquid intake during diarrhea will stop the diarrhea, dehydration can happen quickly, leading most people to seek treatment only once the dehydration has become serious. The regular treatment for dehydration caused by diarrhea is intravenous saline, which has a high cost due to the need for admission to a clinic or hospital. The effects of diarrheal disease last for a longer time than the actual diarrheal episode, and a common result is malnutrition due to the inability of the intestinal tract to properly absorb macro and micro nutrients because of the trauma suffered during the diarrheal episode. Malnutrition during the first 1,000 days of life, during pregnancy and the first two years, can lead to serious cognitive and physical impairment as 80% of brain development takes place during this time.

Intended Impact

Reduce the number of children with malnutrition due to diarrhea in order to reduce the overall burden of malnutrition and allow all children the opportunity to fully realize their physical and mental growth potential.

Inputs

Procurement of space
One of the largest challenges we faced with the CKDTC was the procurement of a space for the actual clinic. Legal land adjacent to the slum in which we work is primarily residential buildings. And who would want a clinic for the treatment of diarrhea anywhere near them, especially in their apartment building? It took four months to find a space in which the neighbors were mildly sympathetic to our work and which suited our physical needs. The neighbors demanded that diarrhea patients not enter through the main residential entrance so we promised to do our best to figure out an alternative entrance. The rental cost is higher than we had originally budgeted for, but given the time constraint and our trouble finding a suitable space, we use a section of that space for our Maternal and Young Child Health program (MYCHI) and that program covers the extra rental costs.

Building of CKDTC
The chosen property was a 3 bedroom apartment with one bathroom and kitchen. This residential space had to be converted into a well-lighted open space with a tiled floor (to ensure cleanliness) and two functional bathrooms plus a washing area. Temporary/movable walls were built to create partitions for privacy, and a section of the space was turned into a doctor's chamber and immunization center used by MYCHI. (The DTC and MYCHI area are separated to avoid cross contamination.) One major hurtle we had to face was the demand made by the apartment building that we arrange a separate entrance for our clinic. The clinic space is up one flight of stairs from ground level, so we had to negotiate with the shop below to lease us space for a staircase which would enter directly into the clinic above.

Hiring of doctor
Given the fact that medicine is a lucrative business and usually the greater the patient load, the greater the financial remuneration, it was a challenge to find a doctor who was willing to work full time at a fixed salary. It was also a challenge to find a doctor who was interested in providing preventive rather than curative services. The pool of applicants was very small, but we were able to find a good applicant who became a part of the Calcutta Kids family.

Hiring and training of staff
Calcutta Kids staff along with two Fulbright scholars who were volunteering with Calcutta Kids at the time were sent to ICDDR,B in Dhaka Bangladesh to observe the diarrhea treatment center there and prepare a training for the incoming DTC staff. The makeup of the new staff would consist of 2 social health workers; a nurse and a doctor. Once the team returned from Dhaka, hiring was done and training began immediately.

Adaptation of ICDDR,B database and protocols
The model for the CKDTC was taken from the premier diarrhea hospital, located in Bangladesh at the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B). Oral rehydration solution (ORS) was developed at ICDDR,B and the WHO protocols are based on information from the hospitals. Additionally, when there are outbreaks of cholera, professionals from the hospital are called in to manage the emergency hospitals. Initially, it was thought that we could adapt the database used for recording patient data, however, because of programming rights, it was not possible. However, we were able to meet with database managers to learn about the system in order to help us design a database for the CKDTC. ICDDR,B was generous in giving us access not only to the hospitals, but also to documentation of everything from training manuals to staff manuals to medication lists.

Procurement of equipment
Some of the necessary equipment to procure were: diarrhea cots, a computer for the clinic MIS, a refrigerator, a generator given the frequent power cuts, Salter scales, height machines for measuring the length of young children, regular scales for older patients, ample supply of cleaning materials, benches for caretakers to sit on, a water purifying machine, functional kitchen supplies to cook simple food for patients and caretakers.

Procurement of ORS and pharmacy medicine
Initially, we had the idea of using rice based ORS, however, it was not possible to mill our own rice based ORS, so we instead decided to use Rexlyte and Peditral for treatment. Procurement of zinc tablets was very difficult, and initially supplies had to be ordered from the Delhi based Bibcol, however, we have since found a distributor in Kolkata.

Development of BCC campaign materials and protocol
The BCC materials were created in-house using materials from various organizations throughout the world. The majority of this work was done by an intern who was working with Calcutta Kids from George Washington University. The BCC materials are a work in progress constantly being updated and changed based on the experience of the social health workers who are implementing the BCC.

Outputs (Services provided)

Rehabilitation of patients carried out using ORS
Percentage of children successfully rehabilitated at the CKDTC using ORS
All patients who are admitted to the CKDTC are treated in the clinical setting with closely monitored administration of oral rehydration solution (ORS) as per WHO treatment guidelines. Once the patient is stable, the mother or caretaker is counseled in appropriate ORS administration and care practices and behaviors that will prevent diarrheal infection. Throughout the time at the CKDTC, the patient continues receiving an appropriate amount of ORS and is fully hydrated by the time he or she is discharged. The two main reasons that a patient is not successfully rehabilitated are that the mother or caretaker insists on returning home against the advice of the medical personnel and that the patient's dehydration diagnosis deteriorates due to severity of illness or non-compliance with oral rehydration therapy (ORT). Not included in the total are patients that are immediately referred to outside institutions for intravenous saline treatment for cases that are untreatable with ORS or have too many complicating factors.

Intensive and effective prevention counseling for mothers or caretakers
Average change in 'knowledge score' of mothers or caretakers on key indicators
Mothers or caretakers of admitted patients are counseled in ORS administration and general care practices, as well as behaviors that will prevent diarrheal infection. The counseling that is given varies depending on the age of the patient, the informally assessed knowledge of the mother and the season. Currently, the efficacy of the counseling is not being formally measured; however, a monitoring system is in development that will allow for proper measurement. The proposed monitoring system includes both a pre-counseling conversation assessing the mother or caretakers knowledge on key indicators and a follow-up conversation that takes place during the follow-up assessing the same indicators.

Follow-up home visits by Social Health Workers (SHWs)
Percentage of admitted patients who have a home visit with a SHW within four days of discharge
After a patient is discharged, one of the trained SHWs will make a home visit to follow up on patient recovery, medication administration, and when implemented, the follow-up assessment of counseling.

Community Outreach
Percentage of admitted patients who have been reached through a community outreach activity
There have been several community outreach activities including school activities. However, we hope in the future to engage in community outreach through other NGOs, increase the school based activities and engage with the males of the community.

Intermediate Outcomes

Dehydration decreases in patients
Percentage of children discharged from CKDTC with a normal hydration assessment
A patient's dehydration status is assessed during triage, during treatment, and again at discharge. The primary criteria for patient discharge is proper rehydration and a normal hydration assessment, and therefore the dehydration in the patient has decreased.

Patients rehabilitated
Percentage of children discharged after complete treatment (ORS, zinc supplementation, BCC and no dehydration at discharge)
Admitted patients are only discharged once they have been rehabilitated and have completed the full treatment at the CKDTC. Full treatment includes: ORS, zinc supplementation (which helps with repairing damaged tissue in the gut and has been shown to prevent future episodes of diarrhea) and counseling (with a focus on hygiene, sanitation, prevention of diarrhea and early detection of diarrhea). The patient must also have a normal hydration status at the time of discharge.

Increase in knowledge and understanding of diarrhea causes and prevention
Increase in knowledge and understanding related to diarrhea causes and prevention comparing baseline and interim surveys
It is necessary for individuals and the community to understand both the causes of diarrhea and how to prevent diarrhea in order for actions to be taken to reduce the prevalence of the disease. Through our counseling and integration BCC campaign, we hope to achieve an increase in the knowledge and understanding of the community in general, and especially the mothers or caretakers of the individuals enrolled in the MYCHI program.

Increase in early detection and treatment of diarrhea
Percentage of successfully rehabilitated children returning to the CKDTC within 48 from the onset of a subsequent episode of diarrhea
The CKDTC advocates the early detection and treatment of diarrhea as the lasting effects of episodes are fewer and less severe. As we are primarily counseling the mothers and caretakers of admitted patients, the success of the counseling regarding early detection and treatment will only be measured in returning patients. As we expand our outreach, the indicator will, in turn, include all patients. For this indicator, early detection and treatment is classified as coming to the CKDTC within 48 hours of onset of a new episode of diarrhea.

Increase coverage in catchment area
Percentage of admitted patients without a previous Calcutta Kids association
Through our community outreach, we hope to be able to reach a larger section of the population, not only those who have established Calcutta Kids associations through other programs.

Increase in percentage of patients with diarrhea coming to CKDTC
Number of patients during the two weeks prior to GMP compared to the number of diarrhea cases reported at GMP
Ideally, all patients with diarrhea will come to the CKDTC.

Impacts

Reduction of costs related to diarrhea treatment
Percentage of children being treated without the use of intravenous saline
The cost of treating dehydration related to diarrhea with intravenous saline is approximately Rs. 1,500 ($30). This cost is unnecessary given the low cost of ORS and the safety of administration. A doctor does not need to prescribe ORS and a patient does not need to be admitted to receive ORS as it is primarily a home based treatment. Initially, the CKDTC had planned to charge for services, however, for many reasons it was decided that free treatment was a better choice. (Click here for more information on why we chose not to charge. Link to text from WB midterm indicator 3) This makes it difficult to determine the actual reduction in costs because the patients are not bearing the actual cost of treatment when they come to the CKDTC. Therefore, as a proxy indicator, we have decided to look at the percentage of children being treated without the use of IV saline as an indicator of a reduction of costs, no matter who is bearing the actual monetary burden.

Diarrhea prevention related behaviors change
Increase in positive behaviors related to diarrhea prevention comparing baseline and interim surveys
While diarrhea treatment is necessary, can be done at a low cost, and can be done early and effectively, the long term sustainable change would be in behaviors that prevent diarrhea so that treatment is not necessary. Our counseling and commitment to an integrated behavior change communication campaign are working towards this individual behavior change. When living in a slum area where the population is surrounded by open sewers, animals, trash and constant barrages from infectious agents, individual behavior change is required to live a healthy life. Until the environmental situation changes, our best hope is to encourage best practices, developed by those who are successfully raising a family in the actual catchment area.

Young child malnutrition due to diarrhea decreases
Percentage of children in catchment area with weight/age z scores >-2SD
The primary purpose in establishing the CKDTC was to address a gap in Calcutta Kids' child nutrition program. We are hopeful that the CKDTC will help Calcutta Kids to reduce malnutrition in our catchment area and allow all children the opportunity to fully realize their physical and mental growth potential.

Assumptions

Diarrhea prevalence changes seasonally
Fluctuations in variables affecting prevalence of diarrhea necessarily affect the prevalence of diarrhea. Therefore seasonal fluctuations are part of diarrhea treatment and prevention.

A critical mass of patients with diarrhea will come to treatment center
It was not known how the CKDTC would be received by the community, and our conceptual framework (covered to this logic model) was based on the idea that a critical mass of patients with diarrhea would attend the CKDTC. After eight months of operation, we have had over 450 patients and have seen that this assumption was correct.

External Factors

Cultural practices and beliefs
Diarrhea is not a new disease. Long standing traditional remedies are common in our catchment area. One of the most prevalent practices is giving children less to drink and less to eat during episodes of diarrhea, the thought being that if there is less going into the body, then less will come out. However, this leads to dehydration and unbalanced electrolytes. Such practices and beliefs make it difficult to have sustainable behavior change. Counseling and education cannot ensure behavior change, and we work to show tangible benefits of behavior change to our beneficiaries.

Slum environment
Working in a slum, with open sewers, a lack of toilets (and a pitiable state of the available toilets) located on illegal land, is a challenge. Although an informal infrastructure exists and there are water access points that have been provided by the state, further infrastructure development is limited because of the illegal nature of the slum. The environment is not conducive to the healthy growth of children as the immune system is constantly attacked by pathogens. However, we believe that those who are able to take on the best practices, it is possible for children to grow healthy and happy. The fact that +70% of our beneficiaries are growing normally shows this to be true.

MYCHI program efforts
The MYCHI program works together with the CKDTC to promote best practices and to provide preventive and curative treatments to mothers and children. Therefore, the effects of the CKDTC cannot always be extracted from the overall effects of the combined programs.

Lack of community burden sharing
The catchment area where Calcutta Kids works is more of a geographic definition than a community. The transient nature of the population adds to this feeling, and there is a sense of self interest rather than of building and sustaining a community. While a community might come together to petition the state to develop proper infrastructure, or to work together to find solutions on a large scale, in this population, there are times when even a child crying in the street will not be taken care of by neighbors because of the lack of community. Calcutta Kids is trying to work to reduce the barriers to forming a community and perhaps to encourage a small community among beneficiaries. (Read more about our efforts with community mobilization here.)