VILLAGE HEALTH AND NUTRITION DAY IN COMPLETE CONVERGENCE MODE

1
VILLAGE HEALTH AND NUTRITION DAY IN COMPLETE
CONVERGENCE MODE (VHND) UNAKOTI DISTRICT,
TRIPURA
2
DISTRICT PROFILE

• Most remote district in Tripura (now bifurcated
  into two districts)
• Bordering Bangladesh, Mizoram and Assam
• Formal agriculture in plain areas, subsistence
  shifting agriculture i.e. Jhum in tribal hilly
  areas.
• Numerous habitations without electricity road,
  drinking water, telephone connectivity.
• Hardly any private practitioner doctors, only
  single doctor PHCs in tribal areas

3
FEATURES OF SOCIAL INFRASTRUCTURE

• Physical infrastructure more or less developed
• Most of PHCs run by one medical officer in
  remote tribal areas. So difficult for doctors to
  go into the remote villages.
• Due to low education levels, recruitment
  criterion diluted
• Numerous Anganwadi workers illiterate,specially
  in
• tribal areas, training is scarce and
  ineffective
• Monitoring difficult due to duality of control in
  tribal
• areas, of Tribal Areas Autonomous District
  Council and
• Govt of Tripura

4
BACK GROUND OF THE INITIATIVE

• In April to June 2010, 24 people (19 infants),
  died in Kangrai, a very remote village
• No information filtered out of the village for
  three months, while the deaths were going on.
• No road, no electricity, no mobile connectivity
• NO REACTION from the families, death accepted as
  a way of life.
• No complaints against Health or Social Welfare
  department.
• This was the pivotal force to start VHND in
  complete convergence mode.

5
ANALYSIS FOR IMPROVEMENT IN SERVICE DELIVERY

• There were 8 AWWs, 9 AWHs, and 7 ASHA workers in
  the village.
• As per records, Anganwadi Supervisor, and MPW,
  had both, done meetings in the village. A health
  camp had been done two weeks ago.The Chairman of
  the village, the Headmaster of the school, also
  were supposedly present in the village but
  information did not come to the Block or
  Sub-Divisional level.
• The registers and charts of the MPW, AWW and AWS
  were all fully maintained.
• Meeting of CDPO and MO in PHC had been held.
• Online reports were generated for state portal.
• Due to lack of public awareness, the actual
  service delivery is dependent on personal
  integrity and ground level staff.

6
POSITIVE FEATURES ALREADY AVAILABLE IN TRIPURA

• Government has provided the physical
  infrastructure in each village. (Anganwadi Centre
  Buildings and Health Sub Centres available in
  most villages)
• The staff has been deployed
• Reports are being generated, meetings are held,
  figures are reported.
• A fund of approximately 1 crore was already
  available in the district under NRHM, ICDS and
  IEC funds of other schemes, for awareness
  generation.
• Yet how to monitor and coordinate the activities
  of 1915 Anganwadi workers, 1402 ASHA workers etc,
  is the main challenge?

7
DIFFERENCE b/w NEED and DEMAND FOR SERVICES

• Thus there is need for health services in rural
  areas.
• But there is no demand for the same
• Shockingly, people are not even aware who are
  their
• field level functionaries
• PRI members focus on MGNREGA, IAY etc
• Need to establish accountability of grassroot
  government functionaries
• Need for coordination between and within
  departments like Health, Social Welfare, Drinking
  Water and Sanitation, Rural Development,
  Panchayat and School Education.

8
VHND AS EXISTING IN NRHM, BUT PRACTICALLY NOT
BEING IMPLEMENTED DUE TO

• No awareness of the concept of VHND among general
  public and PRIs
• Distributed amongst all AWCs, meaning 7-8 VHNDs
  per month per village to be held as per paper.
• Rs 125 per AWC given, Rs 300 per AWC given to
  Health
• Hardly 10 to 20 women used to attend (if at all!)
• Complete lack of co-ordination between AWW and
  ASHA, MPW even though 4 out of 6 ICDS services
  need coordination.
• System of data recording was not there, thus no
  monitoring
• No PRI involvement
• No way of checking whether an AWW, MPW, ANM etc
  have gone to a village or not.

9
BASIC IDEA OF VHND IN CONVERGENCE MODE

• Instead under new initiative, ALL the Anganwadi
  Centres in 3-4
• habitations will come together for VHND.
• All the functionaries of various departments will
  come together.
• Schedule of VHND will be painted on walls of
  Panchayat in
• advance.
• EVERY activity related to health, nutrition,
  drinking water and
• sanitation, irrespective of scheme or deptt
  which requires
• mobilisation of people or awareness generation
  to be merged.
• Fund for IEC activities merged.
• Onus on PRI bodies.
• All women, children in Anganwadis, Schools
  attend.

10
CONVERGENCE OF FUND

• Existing funds PUT TO USE in a planned manner
• From health dept. Rs.300 per VHND per month x 5
  Rs.1,500.
• From ICDS Rs.125 per AWC per VHND per month i.e.
  X 5 Rs.625.
• Total fund available Rs.2125 per VHND per month x
  2 X 182 villages X 12 months Rs 1.32 crores
  
• Additional fund for IEC activities from
• District Blindness Control Program, AIDS
  society,
• Tuberculosis Program, Malaria Control Board,
• Drinking Water Scheme, Total Sanitation
  Campaign,etc.

11
SCHEDULE OF VHND

• The CDPO, MOIC, Deputy Inspector of Schools and
  Sub ZDO meet quarterly and make draft schedule.
• Location, Date, Names and Mobile numbers of
  village level functionaries of 5 key deptts given
  village wise.
• The village programs where health camps of PHC,
  Disability Rehab, TB, AIDS, Malaria, Blindness
  Control, Mobile Medical Unit etc are to be merged
  are shown
• Schedule approved, sometimes with amendments, by
  Block level PRI body, known as BAC/Panchayat
  Samity.
• Painted on walls of Panchayat/Schools

12
CONVERGENCE OF STAFF

• AWW
• AW Supervisor
• MPW / MPS
• ASHA
• Pump operator of Drinking Water Department
• GRS under MGNREGA and RPS
• Gram Pradhan
• Field facilitator
• Livelihood facilitator
• Youth volunteers
• Dalabandhu
• Headmaster of School
• Teacher of Mid Day Meal
• Mid day meal cook and helper
• Disaster Management
• District Disability Rehabilitation Centre
• Awareness volunteers of District Administration
  etc,

13
COMPULSORY ACTIVITIES CARRIED OUT IN VHND DAY

• Awareness discussion on 14 issues of preventive
  health care for the community , using the VHND
  FLIP CHART by Headmaster of School
• Small quiz for mothers and children on health
  issues
• Immunization of children
• Ante Natal Check up and health monitoring of
  pregnant mothers.
• Weighment of children and plotting of WHO chart
• School Health Program
• Chlorination/ Cleaning of water sources and
  discussion regarding their maintenance and
  repair.
• Filling up of forms for fresh issuance and
  renewal of RSBY smart card.
• Supplementary nutrition, Mid Day Meal

14
OPTIONAL ACTIVITIES CARRIED OUT IN VHND DAY

• Blindness Control Board
• Malaria Eradication Program
• Revised National Tuberculosis Control Program
• AIDS prevention
• All health camps
• School health camp by doctors
• District Disability Rehabilitation Centre
  activities
• First Aid Training under Disaster Management

15
INVOLVEMENT OF SCHOOL EDUCATION DEPTT

• All HeadMasters given 1 day training on
  modalities of VHND
• The school health program is also merged in the
  VHND.
• The students up to 10th class attend the VHND
  with Headmaster and teacher in-charge of mid day
  meal.
• The headmaster has been given the responsibility
  of giving an awareness talk using the 14 flip
  charts under the project.
• The mid day meal is merged with community meal
  cooked during VHND and supplementary nutrition
  program of ICDS

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BENEFIT OF CONVERGENCE OF MID DAY MEAL INTO VHND

• Thus parents and villagers partake of the food
  distributed in MDM/SNP of AWC, on day of VHND and
  if there is divergence in quality of food
  distributed normally in school/AWC vis-à-vis
  that, on day of VHND, the students report the
  same, as happened in a few villages, thus leading
  to overall improvement in quality of Mid Day
  Meal.

17
CULTURAL ACTIVITIES DONE TO ENSURE LARGER
PARTICIPATION

• Local Dance
• Group song.
• Quiz on health issues.
• Fully immunized baby show.
• Sports activities for children and mothers.
• Street drama.
• (All done using the Rs.10,000 per village
  given to Village Health and Sanitation Committee
  from 13th Finance Commission fund.)

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FOCUS ON MALNOURISHED CHILDREN

• Training of AWWs on plotting of WHO chart for
  identification of malnourished children.
• As per SW SE dept, GR-III and GR-IV
  malnourished children will be given double
  ration.
• During the few hours of duration of VHND, to
  create awareness amongst the parents and
  villagers regarding malnourishment a yellow
  ribbon is tied on the wrist of malnourished
  children.

19
IEC MATERIAL DEVELOPED

• 14 Sheets of large size plastic printed material
• To be used as a flip chart by the headmaster to
  talk about health issues so that vital points are
  not missed out
• In Local language
• 42 sheets given per village
• Also put up as posters for mass dissemination

20
MOVIE FOR AWARENESS GENERATION

• A national award winning director, Father P.
  Joseph has made a movie in Kaubru, Kokborok
  language, English subtitles, of 28 minutes
  duration Better Tomorrows
• The setting is the Primitive Tribal village of
  Kangrai
• Issues like drinking water, sanitation, malaria,
  avoiding witchdoctors etc dealt with.
• SHG of Reang boys is showing the movie on
  incentive based payment pattern in remote tribal
  villages using DG set and projector etc.

21
TEAM OF AWARENESS VOLUNTEERS

• A team of boys age group 18 to 22 mostly 12th
  passed or in college from Reang community have
  been trained regarding various health related
  activities organized in four groups of 5 each.
• They are formed into an SHG and paid as per
  performance and in their free time they also
  attend the VHNDs in the remote areas.
• They are called in the district and
  sub-divisional level workshops and meetings held
  quarterly.

22
INTEGRATION OF DISASTER MANAGEMENT AND JICA
After recent earthquake at Sikkim, Disaster
Management team is also being participated in
VHND to show the various first aid measure. In
some VHND specially in the hilly area the JICA
facilitator is also encourage to participate and
create awareness activity regarding their various
scheme to the public.
23
TRAINING IMPARTED

• Preparatory meeting with health, ICDS and other
  related dept.
• Sensitization of top level PRI leaders.
• Standardized training module with CDPO / MO I/C
  as resource person, BDO as organizer for 100
  Gram Pradhans, and AWWs, Health Panchayat
  staff, at PHC level, with training material and
  checklists.
• Training of Headmasters of all Schools
• Preparation of pamphlet in Bengali and quarterly
  calendar of VHND
• Sub-Divisional level training for officers..
• TRAINING MOVIE of 8 minutes in Bengali for
  showing an ideal, converged VHND to grassroot
  workers.(recently developed)
• Intensive trainings for 2 months.

24
CHECKLIST USED DURING TRAINING OF FIELD STAFF

• To ensure coordination between various
  functionaries, necessary to fix specific
  responsibility on each functionary
• For Example, Anganwadi Worker should know her
  specific role
• Checklist given in Bengali language.
• Detailed Checklist for every functionary in the
  chain, including CMO down to ASHA worker and
  including Headmasters, CDPO, AW Supervisors, Gram
  Pradhans, NYK volunteers, dalabandhus under SGSY
  etc.

25
ADMINISTRATIVE ORDERS FROM STATE LEVEL TO ALL
PARTICIPATING DEPARTMENTS

• The project was started after approval in
  District Level Health Society co-chaired by DM
  Sabhadipati.
• However, resistance was encountered due to
  additional work and responsibility.
• Thus, Chief Secretary, Principal Secretary,
  School Education, ICDS, Health, Drinking Water
  etc all issued written instruction to their
  departments for participation, on written request
  of DM for the same.

26
MONITORING PROCEDURES

• Any project which involves convergence of
  schedules, funds and manpower of multiple
  departments needs robust monitoring procedures
  for sustainability.
• Thus village level VHND Register provided which
  is to be maintained in the village Panchayat by
  Rural Panchayat Secretary.
• Reporting Register with duplicate perforated
  sheets for sending upwards upto CDPO level where
  they are entered into online website
• Validation of data entered by health department
• Register to be counter signed by gram pradhan and
  various deptts to avoid figure fudging
• Discrepancy in figures reported by various deptts
  analysed systematically, thus cooking of figures
  not possible and quality of health data is much
  more reliable and robust.
• Block level and Sub Divisional committees active
  headed by BDO and SDM with compulsory attendance
  of commensurate PRI leaders for monitoring the
  VHND reports.
• Online website put on public portal for 100
  transparency in reporting.

27
VILLAGE LEVEL REGISTER CONTAINS..

• Resolution by village committee to hold VHND
• Attendance Chart
• Visitor Sheet
• Awareness Generation
• Immunization, Ante Natal Check Up and other
  health activities
• Accounts of expenditure

28

DISTRICT WEBSITE SNAP SHOT
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OUTCOMES OF PROJECT
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Regularity of holding VHND Was very dispersed, and due to difficulty of monitoring no data was available regarding frequency or regularity of holding such camps 4648 VH N Days held till March, 2012. i.e. around 26 VHN Days per village over past 18 months, meaning that in some months either some scheduled VHNDs have not been held or not been reported or data not uploaded. Some gaps due to local festivals/elections etc have been recorded
30
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Public mobilisaton Very Sparse, 10-20 women at the most. On an average, around 149 women and children actively attended each VHND. A total of 690465 people attended in 4648 VHNDs (total district population is 693281) out of which 268730 were children.
31
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Public Awareness on health issues hygiene and sanitation Lack of basic awareness and good health practices especially in the remote tribal villages It is very difficult to gauge difference in level of public awareness, and even more difficult to change cultural stereotypes. However, regular discussions on health issues, especially to the school going children, has yielded some change in levels of consciousness on these issues. Holding of health quiz, cultural program, street drama, healthy baby show etc has helped increase attendance and emphasized public focus on health issues..
32
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Institutionalisation of the concept of VHND in the village There was hardly any recognition amongst the general public or PRIs regarding this facet of NRHM. Even though fund was available, none was aware that a program like VHND is present. Today, in North Tripura district, ANY and EVERY gram pradhan, even the inactive and illiterate ones, and most panchayat members, will recognize the english acronym of VHND. As the same has been replicated within next 10 months in other districts of the state, in partial forms, most of the Ministers are aware of the initiative, and it was one of the listed agenda points in the district level review meeting of Honble Chief Minister, held at six monthly intervals.
33
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Conversion of the NEED for health care into a DEMAND for the same The general public,especially in the remote tribal areas, were not aware of their rights under various schemes like ICDS and NRHM, there was no expectation from the village level functionaries to stay in the village or attend in any monthly program and there was no accountability in the system. Recently, a team of 40 district level officers visited, possibly, the remotest village in the state which required a walk of 3 hours, (Simluang in Jampui ) but the public reported the first item of complaint that VHND is not being regularly held and that the CDPO (block level officer) has attended VHND only once. This is a sea change from the earlier scenario. As Health, and ICDS programs are implemented by dispersed functionaries, who are uneducated, ill-trained and monitoring and accountability procedures remain on paper, the only way to ensure performance is to generate public demand and awareness of the same, leading to pressure from PRI bodies and public in general.
34
FEVER DETECTION AND DEATHS
Year Fever Detection Fever Death
2009-10 54229 47
2010-11 76169 24 (This includes mass outbreak in Kangrai which triggered the project)
2011-12 66988 4
35
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Detection of diseases like fever In 2008-09, 56,771 cases of fever were detected, while in 2009-10, a similar number of 54229 cases were detected. Thus, when averaged, 55,500 cases of fever were detected. In 2010-11, a 37 increase in detection of fever cases was reported, with the number rising to 76,196. Again, in 2011-12, the number of cases detected was 66988. It would be irrational to allege a cause-effect relationship to these statistics, and there may be only a correlation tendency. It may be speculated that due to more public interface of the village level health functionaries, more such cases, which earlier went undetected, have been reported.
36
DIARRHOEA DETECTION AND DEATHS
Year Diarrhoea Detection Diarrhoea Death
2009-10 25252 4
2010-11 83665 8
2011-12 52598 4
37
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Detection of Diarrohea In 2008-09, 44,281 cases were reported, in 2090-10, the number was 25,252. This averages to 34,766 cases of diarrohea. In 2010-11, there has been a quantum jump, and 240 cases were detected ie 83,665 cases. Again, the explanation may be that greater interface of health deptt functionaries with the villagers may have led to greater detection of diarrhoea cases which earlier went undetected.
38
MALARIA

• District was 2nd highest in Malarial deaths in
  the country in 2009-10.
• PF malaria is widespread.

Year PF positive cases No. of deaths
2009 2331 39
2010 2065 4
2011 1006 4
39
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Incidence of Malaria and PF malaria, and death due to malaria In 2009 there were 2320 cases of Malaria , and 2331 cases of PF malaria, There were 11 deaths in 2008 and 39 deaths in 2009 due to Malaria and PF Malaria respectively. In 2010, there were 1995 cases of malaria and 2065 cases of PF malaria. The number of deaths due to malaria reduced from 11 deaths and 39 deaths in past two years, to 4 deaths in 2010. In 2011, the figure of PF positive cases reduced, though the number of deaths remained the same at 4. Again, it would be irrational to establish cause effect reasoning to this data, without a full scope study into the findings, and this may be purely correlational, but greater awareness on necessity to prevent water from stagnating, greater usage of mosquito net, more effective spray of DDT etc which was a part of the VHND agenda as well as greater awareness, MAY have contributed to this. Alternatively, it may be purely coincidental.
40
MATERNAL DEATH
Year No. of deaths
2009-10 18
2010-11 8
2011-12 9
41
IMMUNIZATION STATUS
Vaccine of achievement during 2009-10 of achievement during 2010-11 of achievement up to March, 2012
BCG 74.70 92.11 95.40
DPT3 71.11 82.37 103.13
OPV3 71.11 82.29 103.32
Measles 66.37 88.29 97.70
Full immunization 48.65 53.37 71.16
TT10 40.53 81.25 55.51
TT16 39.10 54.82 45.32
42
FULL IMMUNIZATION
Year of full Immunization (For children up to 11 months)
2009-10 48.65
2010-11 53.37
2011-12 71.16
43
Parameter Before Start of the Project (Figures for 2009-10) Effect of Project Implementation (Figures of 2010-11 and 2011-12)
Quality of health data reported The figures of immunization achieved/ health statistics were collected, compiled by health deptt alone and monitored by state level health deptt. Only a perfunctory discussion was done annually in the district level health and family welfare committee. Quality of data reported, including instances of diseases found or deaths occurred or vaccination achieved is much, much better as the data of each village, is every month, reported by three deptts, simultaneously, counter signed by gram pradhan, and monitored intensely at the block and sub-divisional level.
44
Weaknesses in Implementation

• The formats of reporting and online reporting
  website, have further scope of improvement
• Monitoring of quality of services like Ante natal
  check up, haemoglobin testing etc.
• Keeping up the enthusiasm, month after month,
  requires regular workshops, trainings,
  monitoring.
• Wastage of vaccine vials is a possibility,
  maintenance of cold chain is to be closely
  monitored.

45
SUSTAINABILITY

• Now a demand has been generated in the rural and
  tribal areas for regular VHND every month
• The number of complaints against Govt
  functionaries of health and ICDS deptt of all
  levels has skyrocketed, which in itself is a
  positive feature, showing public is demanding
  service delivery
• In the PIP under NRHM for year 2010-11, GOI has
  given fundas to the district as per our new
  pattern of implementation
• All young officers presently holding posts of
  BDO, SDM have received hands on training in
  running this program
• There is 100 PRI support to the program, with
  Sabhadipati involved in its design and
  implementation at every step and upto Chief
  Minister level the program has been recognized
  and is now reviewed.

46
REPLICABILITY

• As the program received stupendous public
  response in first 3 months itself, Chief
  Secretary asked all other districts in the state
  to implement the same program
• A committee formed by health deptt to study the
  same
• Independent evaluation by NRHM Consultants from
  GOI
• Already being implemented in other districts of
  Tripura in abridged forms
• Is encouraged by a vibrant PRI presence

47
TRANSPARENCY

• No large funds involved in implementation
• Funds of few hundred Rupees distributed to each
  Panchayat
• The same accounted for by the Panchayat Secretary
  in VHND Register
• Performance of VHND put in public portal on
  website
• Fudging of figures becomes difficult as each
  health indicator is now possible to break down to
  village level

48
THANK YOU