|Subject Area="Community participation."
||Objective="Community health workers."
|Details for Reform Option "Mitanin Programme, Chhattisgarh"
Poor health education and the prevailing cultural practices of those living in rural areas of Chhattisgarh led to high levels of disease and a low use of health services.
The community needed to be encouraged to address its own health needs by requesting and taking part in health programmes as well as using the health services already on offer.
The first step was to organise and empower women in the community as well as the Panchayati Raj institutions. This was done by establishing a state-wide Community Health Volunteer (CHV) programme.
The CHV is a woman called a Mitanin (a special kind of friend in local tradition) who was a married woman from the same community, not necessarily formally educated, but with a background in social work, selected by the community and endorsed by the panchayat.
The Mitanin is trained (20 days of camp-based training and 30 days on-the-job training) and supported by a block training team and the Auxiliary Nurse Midwife (ANM) and Anganwadi Worker (AWW).
Her main role is to provide:
(i) Elementary health education.
(ii) First aid help and over-the-counter drugs.
(iii) Treatment for minor ailments.
(iv) Prompt referral advice if necessary.
(v) A central role in community level health by setting up women's committees and helping the panchayats in health initiatives.
Mitanins are working on a purely volunteer basis - no remunerations have been paid to them. Future plans envisage compensation for Mitanins who miss work time to attend training and some performance-based incentives. It is envisaged this will come to about two days a month.
The programme is run by a state-civil society partnership at the state, district and block levels.
At the state level this takes two forms:
(i) A state advisory committee.
(ii) An innovative institution called the State Health Resource Centre (SHRC) - formed as an additional technical capacity of the directorate to design and guide the Mitanin programme, as well as the entire reform programme of the state. This has been set up under a memorandum of understanding between the government and ActionAid India.
The most important aspect of the Mitanin programme is that it is integrated with the entire range of health sector reforms that aim to strengthen the “supply side” rather than work on “demand generation” and community health aspects in isolation.
For more details on the Mitanin training programme and activities, see References.
The initial programme was launched in May 2002 and subsequently the selection and deployment of Mitanins was initiated in two phases: 81 development blocks are covered including 16 pilot blocks under Phase-1 of the programme (launched between September and December 2002). The programme was expanded to the remaining 65 blocks of the state during Phase-2 (launched in December 2003).
The initial estimate was to have 54,000 Mitanins in the state. Gradually, the total number of Mitanins selected has reached 60,092 (around 32,000 in phase-1 and about 28,000 in phase-2).
Of these, 55,830 have now had various levels of training and training for the rest is to be initiated soon. Of the 55,830, more than 29,101 have completed 15 days of training (5 rounds) and another 24,275 have nearly completed 8 days of training (3 rounds). About 20,000 Mitanins from Phase-1 have started to provide first contact care using Mitanin Dawapeti (drug kit) and the remaining Mitanins will be provided with this after achieving the appropriate training level.
Other results include:
(i) About 70 per cent of Mitanins are visiting every single newborn family on the first day of childbirth and delivering a package of health messages/practices to the new parents.
(ii) About 60 per cent of Mitanins meet every pregnant woman's family in the last month of pregnancy to ensure the birth is planned for and Antenatal Care is completed. However institutional delivery is being contrained by supply side problems.
(iii) Children with diarrhoea and fever are being visited and many being referred.
(iv) More than 75 per cent of Mitanins are taking part in Immunisation Days, bringing new children and women to be vaccinated.
(v) More than 60 per cent of practicing Mitanins are delivering appropriate counselling to mothers with malnourished children and carrying out home visits.
(vi) Some Mitanins are delivering Directly Observed Treatment Short courses (DOTS) for TB patients (about 15 per cent).
(vii) About 48 per cent of Mitanins are holding hamlet level health meetings.
A mid-term evaluation of the programme was conducted by community-based NGOs and is available in the References section. This indicates enhanced health awareness within the community and improvement in some of the health related practices. An external evaluation of the programme by the Society for Community Health Awareness, Research and Action (SOCHARA) was published in December 2005. This makes a number of recommendations for strengthening the programme and points out many weaknesses but acknowledges it as a huge human resource which should be built upon and not lost. The full report can be found in the References section.
||For the first phase of the programme(from May 2002-March 2005) total budget was INR 24 crores (INR16.6 lakhs per block for 146 blocks)
The second phase, from April 2005 (for five years) has a yearly budget of INR 22.5 crores for the programme and INR 15 crore for the (first contact care) drugs.
The annual programme cost per Mitanin is estimated at INR 3750 (€67) and the annual drug cost per Mitanin is estimated at INR 2500 (€43.5).
||Chhattisgarh State (in all 16 districts and 146 blocks) since May 2002.
||Pilot phase of 18 months (for the selection and first round training of 30,000 Mitanins).
It is planned as a 60-month programme – 18 months to select, train and deploy the Mitanin, followed by 44 months of support in the community.
Popular: Enjoys political support at the highest level, since this is a state-sponsored scheme.
Extends healthcare: Effectively increases outreach of all existing programmes by overcoming demand constraints.
Community based: Because the Mitanins come from the communities they serve they are more committed to their jobs. The proof is a less than 5 per cent drop out rate.
Good quality training materials: These have been developed in Hindi and are well illustrated and widely distributed.
State Health Resource Centre: The development of this innovative institution which is autonomous and outside the government to guide and support this programme has been essential.
Training: Continued training and support ensures sustainability of the programme.
Partnership: State-civil society partnership at all levels ensures ownership and cooperation.
Slow to establish: Requires sustained political support for at least 5 years if substantial changes are to be achieved. Support must also be at all levels - State and district - if it is to succeed.
Supply constraints: Reforms which require an increase on the supply side often fail to keep pace with demand, which can lead to unfulfilled expectations. In particular, Mitanins need regular drugs refills.
Evaluation: Needs external evaluation if meaningful results are to be quanitified.
Confidence: Need to persuade the community that the Mitanin is here to stay and is therefore worth supporting.
Selection: Different types of selection of the Mitanin have shown varying degrees of success. For instance Mitanins who have been selected solely by the ANM/AWW without community input have been less successful because they are not accepted. The community must be informed in the selection process.
Volunteerism: In some cases, poor village women have been given unreal promises of getting government jobs and payment after becoming Mitanins to persuade them to join the programme. This deception undermines the programme.
State - civil society partnerships with adequate tradition of rights based work in the area of health and community health action.
|Who needs to be consulted
Community-based NGOs and state, district and village level government officials/ functionaries.
Requires support for at least 5 years - subsequent sustainability depends on the success of the last three years and the establishment of long-term support for the voluntary workforce.
Requires funds. This programme has had funding from the Reproductive and Child Health (RCH) programme, European Commission, Danida and the State Government.
|Chances of Replication
Good. The scheme is now being expanded to cover the entire state and is being used as one of the working models for the Government of India's National Rural Health Mission's Accredited State Health Activist (ASHA) scheme.
The state is also working towards linking all districts with leading health care institutions by a dedicated telephonic link.
J.P. Mishra, Programme Advisor, ECTA, New Delhi. November 2003. Last updated March 2006.