Objective="Improve access of health care services to undeserved regions."
Details for Reform Option "Comprehensive Healthcare Outreach Services to the poor using mobile approach, Madhya Pradesh."
In Dewas district of Madhya Pradesh, a baseline survey of the selected population revealed low level of immunization, family planning and antenatal care (ANC) a preference for home deliveries; a high prevalence of low birth weight and malnutrition; low levels of awareness about pneumonia, diarrhoea, Sexually Transmitted Diseases (STDs) and HIV/AIDS. A large section of the population is tribal and the undulating terrain makes it difficult for the poor in Dewas district to access health care services.
The Ranbaxy Community Health Care Society (RCHCS) is a non-profit registered society set up in 1994 by Ranbaxy Laboratories Ltd, a leading pharmaceutical company.
It planned to provide a package of preventive and curative services through mobile vans in Dewas Block in November 2001 with the objective of increasing access to essential reproductive and child healthcare including adolescent health, prevention and treatment of Reproductive Tract Infections RTIs/STIs as well as AIDS awareness and health education on various health issues.
The service is very convenient for women and children, who are otherwise dependant on men to take them to hospital to access basic health care services. Even though the catchments area of RCHCS have 4 Primary Health Centres (PHCs - Barotha, Sunwani Gopal, Double Chowki & Vijayganjmandi) and one district Hospital in Dewas town, which is the first referral unit within the service area of RCHCS. Population Foundation of India (PFI), New Delhi funded this project. The RCHCS office at Dewas is located within the campus of Ranbaxy.
The service area of RCHCS was identified in partnership with PFI.
Once a week on a regular basis two mobile health care vans visit the villages. Two 14-seater vans were procured and converted into 4-seater ambulances with a check-up table suitable for gynaecological use. Sufficient storage space was also included.
The van included collapsible furniture including television and CD Player to show educational programmes and had provisions for doing minor procedures like Copper-T, insertion, Non-Scalpular Vasectomy (NSV) operations, gynaecological / ANC check ups, immunisation etc. inside.
The first step is to ask permission from Panchayat to set up a mobile clinic in their village. A team of doctor and paramedical staff manages the outreach services. The ‘Gram Swasthya Samiti’ members are also given training on health matters and sanitation. They notify the villagers (through the Village Chowkidars) about the visits of a mobile clinic. The Sarpanch is often the Chief Guest at ‘Health Camps’ and other functions like puppet shows, street plays etc.
In addition, the sum of INR18,000/- was given to each Panchayat of 36 village health centres as an advance for providing transport assistance to high risk obstetrical and neonatal emergencies for referral to hospitals.
In order to bring about changes in health seeking behaviour the village community was involved by organising meetings of various groups formed by the project. Examples are Breast Feeding Support Groups, Adolescent Groups for both male and female, Women Group and Health Committees. Distribution of pamphlets, video shows, group discussions and demonstrations are other methods used to promote better hygiene practices as well as street plays, puppet shows, poster exhibitions and workshops.
RCHCS maintains records of all vital events like live births, infant deaths and maternal deaths in its areas to determine the health status of the community and monitor such events on a continuous basis. Information about deaths is obtained from direct home visits by RCHCS staff and also by collating information from Community Health Volunteers (CHVs)/ Anganwadi workers (AWW)/ Auxiliary Nurse Midwives (ANMs). This helps RCHCS to plan specific interventions for preventing deaths.
Medicines are bought from wholesale dealers in Indore according to need and the budget allocated by RCHS and PFI. Some medicines like Iron tablets, Oral Rehydration Salts (ORS), Family Planning measures like condoms, Copper T (CuT) oral pills are obtained from District Hospital, Dewas, which also carries out maintenance of vehicles and general administration.
Local Registered Medical Practitioners are informed about all the initiatives started by RCHCS. They are invited to workshops organised by RCHS and educative materials are distributed to them on a regular basis.
Linkages have also been established with local charitable hospitals for referral of patients. Poor patients referred by doctors of RCHS are given concessions at private clinics/hospitals.
From the villages, CHVs are identified with the objective of sustaining the efforts started even after the project ends. The CHVs have been given training on how to deal with some common health problems. Besides, they also function as depot holders for family planning methods, ORS, ‘Environmental Health and Sanitation’, ‘HIV/STD/AIDS’. CHVs are identified from the educated villagers (they must have a minimum of 10th standard pass) and who are interested in Social Work. They are paid an honorarium of INR.100 (€ 1.87) per month. The dais (untrained birth attendants) was also given training on safe deliveries.
The Chief Medical Officer (CMO) of the District Hospital is the chairperson of the Project Implementation Committee (PIC) of RCHCS. The RCHCS takes part in all National Health Programmes like Pulse Polio, Bal Sanjeevani Mission for malnourished children, Malaria Eradication Programme etc. The doctor of RCHCS is a member of District Health Committee.
The project also used government buildings like PHCs, Subcentres, Panchayat buildings, schools in villages to hold health care camps. The Dais training was organised by using the Government Hospital, Dewas. The district administration has provided the project with requisite supplies from the District Hospital - vaccines, family planning products and also trained staff on RCH. The project involved Govt. Medical Officers to train village level health workers, specialists and health education material.
During 2003-2004, a total of 12,900 beneficiaries used the mobile-based health care services in 301 field visits.
A total of 44 untrained Dai, 80 CHVs, 94 AWWs and 30 gram swasthya samitis were given orientation training on essential new born care. In addition, to facilitate normal working at the labour room at Barotha PHC in Dewas block, one 5 KV generator set was installed.
All infant and maternal deaths were thoroughly investigated to find out the probable causes of death. Since RCHCS started operating, no malaria death has been reported so far from the RCHCS service area.
Other improvements noted are :
The immunization coverage has improved among children aged 12 – 18 months. Complete vaccination increased from 61.2% (baseline) in 1998 to 92.2% in 2004.
Supplementation of Vitamin A prophylaxis for prevention of nutritional blindness also showed an increase from 59.6% (baseline) in 1998 to 93.4% in 2004.
Coverage of family planning methods increased from 56% in 1998 to 76.9% by end of 2004.
The coverage of Tetanus also increased from 79.5% in 1998 to almost 100% in 2004.
The percentage of malnourished children in the age group 0-1 year showed a decline from 37.6% baseline in 1998 to 13% in 2004.
The service statistics of RCHCS show a decline in the number of births and infant / maternal deaths. The birth rate reduced from 23 per 1000 population in 1998 to 17 per 1000 population in 2004. Significant reduction in infant deaths from 45 per 1000 live births (1998) to 20 per 1000 live births. Maternal mortality in RCHCS area declined from 4.5 per 1000 live births (1998) to 1.8 per 1000 live births. They conclude that the overall reduction in mortality has resulted from improved health status including greater health consciousness among the community and speaks itself about the availability, utilisation and effectiveness of the services rendered by RCHCS.
The project is now in the process of doing a survey to explore the possibilities of appointing sanitary operators or sweepers in collaboration with the Panchayats.
(Cost of health care van, medical / surgical INR 8 lakh
equipment, collapsible furniture (curtain included),
Audio- visual equipment etc.)
B. Recurring INR 7 lakh (€ 13073.62)
Cost of personnel (one doctor, one ANM,
one Social Worker, one Driver)
Total INR 15 lakh (€ 28,011.45)
Recurring INR 7.5 lakh (€ 14009.22)
Dewas, Madhya Pradesh. This initiative is also operational in Mohali, Beas, Toansa (Punjab), Paonta Sahib (Himachal Pradesh), Gurgaon (Haryana) and Delhi.
About two years. The project was approved on 10 November 2001 and activities were started in January 2002.
Coverage: Can reach the un reached and otherwise inaccessible population especially women whose health needs so far had remained neglected by the existing public sector.
Behavioural Change: Provision of services at the doorstep coupled with health education through audio-visual means increased utilisation of the services.
Outcome: Better results through focussed integrated approach and targeting of precise groups for specific problems.
Women friendly: Specialist doctors especially services of lady gynaecologist and paediatrician can be made available even in remote areas.
Existence of motorable roads. In many areas there is also no place to set up a clinic especially in bad weather.
Cost: In the long run this is not a cost-effective means of providing services.
District Health Administration.
Panchayat Raj Members.
Who needs to be consulted
Medical Officers RCHCS Dewas.
District health authorities - civil surgeon / Chief Medical Officer CMO / Senior Medical Officer SMO of the respective area.
Panchayat Raj Members.
Prominent persons from the community like social workers, teachers, dais, Aganwadi workers and volunteers.
Medical College (Community Medicine Department) if there is any Social Welfare department.
‘Nehru Yuva Kendra’ and ‘Dept Of Women and Child Development’-run Anganwadi centres (they organise camps for malnourished children, provide ‘dalia’ (porridge) to pregnant/lactating women and keep records.
Population Foundation of India, New Delhi.
Partially self-sustainable at grass root level through the availability of trained members of the community.
Chances of Replication
The project has been started in other parts of the country simultaneously – All RCHCS centres provide mobile health care units and run Reproductive and Child Health Programmes.
The CHVs approach was not very successful as most of them are ‘Daughters-in-law’ of the village; hence their mobility in the village is restricted. Also they are not always available as they also work in the fields especially during the farming season.
Initially the project was meant for a period of three years. There are indications that the project is likely to be extended for next five years, so that the project can make much more of an effect on the lives of the people of Dewas.
Dr. Nandini Roy, HS-PROD Research Consultant, NIMS, March 2006.