(Originally written in 2013)
I always wanted to be a ‘cardiac surgeon’. Being amongst the toppers in my Medical College (Government Medical College, Chandigarh) and interest for surgery proved meaningless before destiny. I appeared for the IAS examination and landed up practicing ‘development’, including public health. The initial years in service allows an IAS a hands-on experience in rural/urban development, of which health forms a vital part.
There are different views on whether professionals such as doctors should join IAS and it can be debated either way. Each stream of education, besides the content part, imparts some ‘skills’. Medical education trains mind to diagnose and then treat. It also conditions for very hard work. Both these attributes prove useful in administration.
The Opportunities to work and deliver results in the field of health and ICDS increased tremendously with the concepts of decentralized planning taking roots under the RCH II and NRHM. I have discussed below briefly the district wide work done in this field when I was CEO of Zilla Parishad of Jalna (2004-2007), a backward district of Maharashtra. The health interventions are categorized under the following heads- A. Public Private Partnership in delivering quality Ante-natal care and training at the grass roots B. Infant and Young Child Feeding spreading across the district in villages C. Adolescent Girl Training D. Supplementary nutrition and Therapeutic food in Anganwadis through SHGs
- PUBLIC PRIVATE PARTNERSHIP IN ANTE-NATAL CARE DELIVERY AT THE GRASS ROOTS
When Dr. Christopher Moses and Dr. Shobha Moses of the Mission Hospital Jalna, a leading medical institution of Jalna, asked me this, ‘Why do some women from rural areas have to approach us at the delivery time, sometimes in life threatening conditions, and we feel so helpless…had they been given proper antenatal care, or referred in time, life of such mothers and new borns could be so much less in risk!’ we realised that irrespective of our efforts at improvement in service delivery, we fell short. We fell short, not only in terms of the motivation levels of the personnel at the cutting edge, but also in a real and meaningful effort in training them well to upgrade their skills, instill confidence in them, and trying to provide them all logistic support and good working environment. We enquired Mission Hospital if together we could do something. This preliminary discussion resulted in a project which was to create a significant dent in the poor image of primary health care delivery, especially ante-natal care delivery in the village sub-centres primarily.
What was done?
There are 211 sub-centres and 38 PHCs in Jalna district. In this project, we took up 44 sub centres and 8 PHCs in the first phase. A team of gynecologists and nurses from Mission Hospital visited these selected centres about once in one and a half months. On this selected day, ante -natal check up, along with required investigations was carried out of all the antenatal mothers in the jurisdiction. To further improve the quality of ante-natal care and detect high risk patients, a potable USG machine was purchased under the Maharashtra Human Development Mission, and ultrasounds started in these sub-centres. Advice and treatment, if any was offered to antenatal mothers. The High-risk pregnant women were identified and the cause of High Risk managed adequately, including advice for timely referral, if required. Our ANMs and MPWs were thus trained on-the –job. Most importantly, because they work under supervision of experts, they acquired skills and confidence in whatever areas they were deficient. Besides, a 6 day comprehensive residential training module on ante natal care was developed and the health staff of such subcentres was trained. In addition, during each visit by Mission hospital , one additional health related activity was taken up. To ensure that no pregnant woman is left out without ante-natal care, a vehicle is being deployed by the village to bring all beneficiaries to the sub-centre during such camps.
How was this achieved?
Firstly, the selection of sub centres for this programme was done carefully. 4-5 sub centres in each Block were selected, primarily on the basis of the quality of the manpower working there. These were places, where the ANMs were staying in Head Quarter, and were competent in conducting deliveries, but because the sub centres were not upgraded, or because they were not motivated enough, they were going to the houses of the beneficiaries to conduct deliveries! Second criterion of such village selection was where the village had become Open Defaecation free, and in the process, become very positively oriented towards development.
Secondly, the health staff and the Sarpanches/ other village people were motivated, guided and explained about this project. Because of the earlier work done with people in the field of sanitation, the people readily realised the advantage to the village because of this project and extended their whole-hearted support.
The project was closely monitored, and after each round of visits by the Mission hospital, we all sat together [including the sarpanches from such villages] and reviewed the progress made, sorted out any coordination/other problems, and planned for the next round.
The project was funded out of the training expenditure of the approved PIP of RCH II. At the time of plan preparation, we had not anticipitaed that such an opportunity of working in collaboration with the private institution would arise. But because of the flexibility of the plan, we were able to avail of the opportunity.
Lastly, to maximise results, we diverted all resources towards these sub-centres on a priority. We knew that to support such a service, the sub centre needs to be repaired, have minimum furniture and material, including delivery tables [some deliveries used to happen on floor earlier!], equipment required to conduct deliveries, electricity and water supply. So we have pooled all the resources available with the Zilla Parishad. We are happy to note that to save costs, at some places, our staff repaired and painted themselves out-of-use delivery tables! At another place, the flooring material lying waste because of repairs done in a PHC was transported to a sub-centre for use.
Goals to be achieved
The first goal was that we wanted our own staff working in these sub centres to become ‘expert’ in delivery of ante-natal care. The fact is that but for any such conscious effort, our services remained mainly on paper. Thus we may achieve statistics of very good percentage of ante natal care delivery, but how is the quality of those services remains unanswered. We wanted that during the course of these 6-8 months, the selected sub centres should get ‘used to’ delivering such good quality services, develop confidence, and acquire skills.
The second obvious goal was the direct service of ante natal care at the village level through specialist doctors. Because of this, more and more beneficiaries queued up to these sub-centres. They also realised much more the benefits of institutional delivery, and schemes such as Janani Suraksha Yojana were implemented in a much better way.
Thirdly, the other health interventions were also expected to be delivered in a much more qualitative way in such villages.
The project was evaluated by UNICEF, Mumbai in 2008, which noted-
‘Between October 2006 and July 2008, the infant mortality rate went down from 50 to 21…the still birth rate went down from 27 to 8’
There was a dramatic response in the decrease in severe and moderate cases of anaemia in most centres because of treatment. There was a positive effect on the working of our staff, and the record keeping and number of visits by them improved. The awareness levels of patients increased and they became regular in ANC visits. Because of this initiative, the State Govt. sanctioned Rs. 32 lakh for construction of delivery rooms in these sub centres, a work which was completed.
The health staff became much more trained. At one place, even a high risk patient was given lifesaving medicine and only then referred to higher centre. One of our Medical Officers, on observing that flexion [bending forward] of head is advocated during delivery of child to avoid injury to the mother remarked, ‘I learnt that similarly flexed head [representing an attitude of service and soft-hearted] should be practiced in our lives too!’
The response from the community also was very good. They extended utmost cooperation to this project and realized its benefits. Through this project, we also found a way of getting a 3rd party feedback about the work of our health staff, problems faced by them, and attitude and response of the community.
2.INFANT AND YOUNG CHILD FEEDING[IYCF]
In Chikaldhara, Amravati district a workshop was called by Commissioner ICDS in 2005. In this workshop, a presentation on IYCF really impressed me. This was to be the beginning of a long term association of BPNI[Breast Feeding Promotion Network of India] with Jalna district. BPNI is an organisation promoting the cause of Breast feeding and young child feeding. It has on its rolls few paediatric doctors, counsellors, and what they call ‘mother support group’ members. This team is dedicated and committed and handles the subject extremely professionally. When we realised, that early and exclusive breast feeding alone would contribute maximum to the prevention of child deaths, we sat thinking. Something had to be done urgently.
What was done
Although I am an MBBS, I did not know many things about this subject, usually passed off as mundane, or too well known to be discussed. Although breast-feeding was a common practice in rural areas, it was neither early, nor exclusive. Nor were the weaning practices understood. But more importantly, the BPNI’s training module made us realise why we had not been able to achieve something significant so far. Most of our training programmes were one way knowledge thrusting ones. But this training module was skill based and with emphasis on counselling. Plus it hammered the details of this subject in the minds of participants. Thus from a simple ‘do early and exclusive breast feeding’ lectures, our staff began to move to –when to approach, how to approach the beneficiary, who else to approach, how to initiate discussion, how to explain the minute details etc.
The process was started in 2006, with a three day T.O.T for 33 trainees, mainly Anganwadi supervisors and some health staff. This was followed by a one day sensitisation in batches for all the Anganwadi workers. The initial trainers were followed up through repeated knowledge and counselling tests and continuously evaluated. To give them exposure of real counselling, they regularly visit maternity homes. Three of our trainers were certified as State level trainers.
What distinguished the process in Jalna district from other districts was that in Jalna, funds under various schemes such as RCh, Jalswarajya were utilized to carry such trainings to the community.
In a village in Jalna district, the mother of a newborn had expired. Unfortunately in that family the other daughter-in-law had also expired. [Otherwise, she might have breast fed the newborn]. Our Anganwadi supervisor in that village held a meeting of all lactating women in that village and convinced them to breast feed that newborn by rotation. All this was done without informing the mother –in-law of the deceased mother. When she came to know of this however, she quarreled with our Anganwadi supervisor, but ultimately everybody could convince her of the benefits of breast feeding and she allowed other lactating women to breast feed her grandchild. Such was the high motivation amongst our staff, and when they were so committed, societal changes wouldn’t take long.
There was a huge public awareness on this issue in Jalna district, and even mothers would answer correctly questions such as how long should breast feeding be continued.
BPNI termed the efforts ‘Jalna Pattern’.
3. ADOLESCENT GIRL TRAINING
Who can discount the fact that all maternal and child health is to a large extent influenced by the awareness levels, knowledge and empowerment of adolescent girls in rural India. The issue is so widely recognised, so much desired to be addressed; yet the ‘how’ of it has probably kept desired results away. We came across an organisation called Media Matters that works with UNICEF. And we started the process.
What was done
A batch of 25 trainers was developed through a 12 day residential training. This training again like the IYCF training was an activity based training in which through a series of games and songs, the trainees went through the whole gamut of adolescent issues. We had earlier come across big training modules, but they all centred around the medical and biological aspects of adolescence, and did not touch issues such as ‘rights of a girl’, or say ‘what is gender’. More than the content, the technique of this training was such that out trainees adopted it whole heartedly.
Next was the stage of taking the training to villages. We were very sceptical, because the training involved adolescent girls, and we were not sure of the response we would achieve. We started with two positive villages, took the local Panchayat and parents into confidence, managed logistics well. The response was overwhelming. In these trainings, of which nearly 10 batches were done initially, involving more than 300 trainees [mostly adolescent girls], we intended to train at least one trainer from each of the 10-15 villages. These participants after a 10 day module were to take up such trainings, nay, it shall be a campaign, to train and empower maximum adolescent girls in their villages over a period of next 6 months.
After 10 such modules, there were reports from two villages of woman sarpanches hoisting the National Flag, a variation from their husbands doing so earlier, and that too after breaking a coconut [a practice done customarily by men only!]. So much to speak about their understanding of gender! ]. At 7 places, these ‘empowered’ women could persuade families to postpone marriages of less than 18 year old girls. Some even planned to take a ‘morcha’ (procession); but then they postponed it as they could manage to convince the parents otherwise! These trainees also began to promote institutional deliveries, and intervene in other health issues such as motivating TB patients to take regular medicines.
From a stage of apprehension about participation, to a stage where people brought recommendations of people’s representatives to include their names in such trainings, to applications under Right to Information Act, as to how these trainees were being selected, a good start had been made.
4.SUPPLEMENTARY NUTRITION THROUGH SHGs
Why does it take so long to take an obvious sensible decision such as decentralizing the provision of supplementary nutrition in Anganwadis? On the one hand, the scheme such as ICDS speaks so clearly about the desired supplementary calories and proteins, that must go to beneficiaries; on the other hand, dependence on an external agency does not serve the purpose. If not for any other reason, the monotony of diet would ensure in case of delivered packaged food that the children in Anganwadis do not eat enough.
What was done
As per the Apex Court’s directions in this regard, our Anganwadi supervisors explained the concept in each village and motivated at least one self-help group (SHG) in the village to take up this project. Then at the district level, a set of recipes was finalized, keeping all details in mind such as the advantage of jaggery over sugar, a mix of sweet and salty dishes, use of groundnuts and soyabean. This was followed by two trainings at the Block level of all such SHGs, where practical demonstration of such recipes was done. And then, all Anganwadis began to be supplied supplementary nutrition through these SHGs.
On a query whether they were making profit, an SHG remarked – ‘we can’t say now ; but we are happy that our children are getting good food now’. Once a day soyabean rich recipe was also given. And therapeutic home-made recipes [to be given to malnutrition children] replaced the market ones. We tried to hand hold such SHGs and change the mentality of our own staff so that they encouraged these SHGs.
This project has had extremely good effect on the reduction in the number of Grade II malnutrition children.
What clinched success? The implementation issues
A desire to realize where we actually stand and what are the expectations of the people. As this gap is understood, the ways to bridge it may be found. The existing programmes, policies provide ample space to utilize them to bridge this gap. This desire has to be ‘pure’ and not ‘selfish’. This desire must come from within, it cannot be forced. Forced work may result in achievement of targets, but may still fall short of bridging the gap.
As this desire peaks, it needs a good team building to deliver results. There are many ‘jewels’ in the Government service who need to be put in their proper place and they can do wonders. We formed a ‘core team’ consisting of all good and talented health and ICDS staff to be a think tank for all programmes. The genuine feedback from this think tank was very useful to fine tune the implementation strategies. The team had few basic principles and characteristics- non corruption, motivation, hard-working and go- getters. That was our team. And this team was built. Patiently. In the beginning all were welcome to be part of it. Many criticized the long meetings…many said nothing would change. They left in between…or were left out. Those who had faith and conviction in themselves continued…continue to this date the good work. The newly recruited staff- most of those who were selected had tears in their eyes, that they could be selected without spending a penny, on pure merit- did very good job.
Our ground army was the one we were proud of really. We started out all projects with the best manpower. Mostly if they are supported and motivated, they give results. Then we move on to the next category, slightly less competent and motivated and bring them at par with the best. Thus the cycle continues. The wrong monitoring systems and administration work may leave very little opportunities to pat the back of those who deserve it.
Our monitoring system was more of a solution finding exercise than a fault finding exercise. The areas where we had to work, we had personally visited. Thus what was to be done and how was fairly clear to all so that there could be no deception. Those who were performing well were congratulated immediately and decorated in important functions/ review meetings also. They became ‘heroes’ amongst their peers. During the review meetings, we questioned the seniors as much as the juniors. Many a times, while there is no guidance/motivation of the juniors [staff which actually implements]; at the time of reviews, they are made the scape goats. And the seniors would just say- ‘we had instructed! Just instructions do not work. The supervisory staff also must support and motivate the implementing staff for good results.
We used to analyse in detail as to how our services fared from the point of view of a common man. A common reply to as to why our sub centres and PHCs were not visited enough would be “the ‘mentality’ of people who wanted more ‘injections’ as treatment”! On being asked- ‘Where do we visit if we fall ill-Government or Private hospital?’ ‘Private’…as they said it they realized their folly. We all agreed that once our services improved, people would throng to us because good service is appreciated. Our routine monitoring system, where we just monitored one or two indicators, say family planning targets, needed improvement, as it had resulted in the health staff just doing the targets. We discussed, as to how our roles were much bigger than the mere attainment of FP targets, how the entire rural population especially the children and women need cost effective health services, which can be provided best by us in the Government only.
With this team in place we were ready to grab any good opportunity for work. Also, we tried to use professional help in all programmes. We as Government must be open to all help from professionals and NGOs [the genuine ones!], as well as well-meaning organizations. In the market there are experts for most service. But for the support of Sewagram Medical College, Mission Hospital, BPNI, Media Matters, we would not have achieved much quality in the programmes mentioned above.