village health and nutrition day in complete convergence mode (vhnd) unakoti district, tripura

VILLAGE HEALTH AND NUTRITION DAY IN COMPLETE

CONVERGENCE MODE(VHND)

UNAKOTI DISTRICT, TRIPURA

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

FEATURES OF SOCIAL INFRASTRUCTUREPhysical infrastructure more or less developedMost of PHC’s 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 dilutedNumerous Anganwadi workers illiterate,specially in

tribal areas, training is scarce and ineffectiveMonitoring difficult due to duality of control in tribal

areas, of Tribal Areas Autonomous District Council and

Govt of Tripura

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.

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.

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?

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 sameShockingly, people are not even aware who are their

field level functionariesPRI member’s focus on MGNREGA, IAY etcNeed to establish accountability of grassroot government functionariesNeed for coordination between and within departments like Health, Social Welfare, Drinking Water and Sanitation, Rural Development, Panchayat and School Education.

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

No awareness of the concept of VHND among general public and PRI’s

Distributed amongst all AWCs, meaning 7-8 VHND’s 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.

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.

CONVERGENCE OF FUNDExisting funds PUT TO USE in a planned mannerFrom 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.

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

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,

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

OPTIONAL ACTIVITIES CARRIED OUT IN VHND DAY

Blindness Control BoardMalaria Eradication ProgramRevised National Tuberculosis Control ProgramAIDS preventionAll health camps School health camp by doctorsDistrict Disability Rehabilitation Centre activitiesFirst Aid Training under Disaster Management

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

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.

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.)

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.

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

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.

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.

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.

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.

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.

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.

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.

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

DISTRICT WEBSITE SNAP SHOT

OUTCOMES OF PROJECTParameter 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 VH&N Days per village over past 18 months, meaning that in some months either some scheduled VHND’s have not been held or not been reported or data not uploaded. Some gaps due to local festivals/elections etc have been recorded

Parameter Before Start of the Project(Figures for 2009-10)


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 VHND’s (total district population is 693281) out of which 268730 were children.



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..



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 Hon’ble Chief Minister, held at six monthly intervals.



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.

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



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.

Year Diarrhoea Detection

Diarrhoea Death

2009-10 25252 4

2010-11 83665 8

2011-12 52598 4

DIARRHOEA DETECTION AND DEATHS



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.

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



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.

MATERNAL DEATH

Year No. of deaths

2009-10 18

2010-11 8

2011-12 9

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

FULL IMMUNIZATION

Year % of full Immunization (For children up to 11 months)

2009-10 48.65

2010-11 53.37

2011-12 71.16



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.

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.

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.

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

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

THANK YOU

village health and nutrition day in complete convergence mode (vhnd) unakoti district, tripura

Documents

village health

remote tribal areas

tribal hilly areas

rural areas

plain areas

remote district

health services

govt of tripura slide