Details for Reform Option "Model District Reproductive and Child Health Services Project, Pune, Maharashtra"
Despite its position as one of the more advanced states, Maharashtra has a poor record in public health. Reproductive and Child Health (RCH) is an area of particular concern in the state. A high number of women, particularly those living in rural areas suffer from anaemia; the infant mortality rate is high; low birth weight is prevalent and the rate of institutional deliveries low - especially amongst tribal women.
To improve the coverage and quality of RCH services in Pune District, the Model Reproductive and Child Health District Project has been implemented by the KEM Hospital Research Centre and 11 partner NGOs, since March 2004.
All NGOs have developed a Model RCH Programme Action Plan in one selected Primary Health Centre (PHC) / urban slum. This action plan comprises activities to be conducted by the NGOs independently, as well as in coordination with the government staff [Health, Education and Integrated Child Development Service (ICDS) workers] and the Zilla Parishads (District Panchayats).
A review of the existing practice and system of RCH care delivery and its infrastructure revealed there was limited trained manpower resource at the Sub Centres (SCs) and PHCs. Thus under the Model RCH project, one of the main activities undertaken was the selection and training of ‘Parivartaks’ (change agents) from Community Based Organisations (CBOs). These volunteers carry out house-to-house visits which help them generate demand and plan RCH services in their respective areas.
The information they gather enables PHC staff to provide needs-based comprehensive RCH care on fixed days and times through ‘Health Service Sessions’ in every village (261 villages under this project). This is in addition to the fixed-day weekly clinics held at PHCs.
Other activities of the NGOs in coordination with health staff include:
(i) Forming and attending block level co-ordination committees and village health committees.
(ii) Ensuring proper registration of births, deaths and marriages.
(iii) Set up of village RCH fund to manage emergencies.
(iv) Ensuring 100% registration of ante-natal care (ANC) cases and their follow up.
(v) IEC activities such as painting wall slogans and conducting dindis (processions with children chanting RCH slogans).
(vi) Inter sectoral coordination activities such as refresher training to school and ICDS staff.
(vii) Ensuring that there are no dropouts and 100% attendance at primary schools.
(viii) Ensuring all deliveries are conducted by trained personnel and where necessary, provide training and reorientation of Dais.
(ix) Adolescent health education.
To ensure that the programme achieves its objectives, the following four guidelines were adhered to during the selection process for the NGOs; the project should be:
(iii) implemented in coordination with the various government departments, and
(iv) avoid duplication of services provided by the government.
Since the initiative only began recently, the full benefits will take some time to materialise, but already the following are apparent:
(i) Effective coordination between the government staff of various departments and implementing partner NGOs.
(ii) NGOs have identified ‘Parivartaks’ who are willing to participate in the programme without any honorarium.
(iii) Improved quality of services from the PHC staff.
(iv) Fixed day clinics have been established at PHC level and in almost all villages, health service sessions (lasting 4 to 6 hours) are being conducted regularly.
(v) The NGOs have been able to establish Village Health Committees (VHCs) in each village and have set up the village health fund for management of emergency health problems. This activity has not been initiated in urban areas as the need is not so great because there is better accessibility to health services.
The estimated cost for the project is INR 2.31 crores over two years.
Eleven blocks (rural area) and one urban area of Pune district, Maharashtra covering a population of 3.5 lakh since March 2004.
Depends on the PHC medical officers’ (MOs) motivation and involvement of CBOs.
After launching the project, it took six months to function smoothly. Should be possible to replicate elsewhere within a year.
Needs specific: Provision of services based on the type of the area.
Awareness raising: Improves health education and knowledge of availability of health services and facilities.
Increases community ownership: by establishing and conducting village health committees, creation of village health funds and involvement of all gram panchayat members and health volunteers from CBOs in RCH activities.
Demand generation: These put pressure on the government to provide services and improve quality.
Inter-sectoral coordination: Effective coordination with state level schemes implemented by various government departments, specifically education and ICDS staff.
Complimentary: coordinates with the work of government health staff and enables them to concentrate on provision of quality services.
Possible Opposition: From the PHC MO and his/her staff who may not want to cooperate and from other govt officials for example ICDS staff.
Community reliant: Relies on the availability of volunteers to work as Parivartaks.
Challenging perceptions: Many partner NGOs found it hard to accept that household planning would work or that volunteers would work without renumeration.
Good coordination between government (both at state & district), PHC staff and NGOs.
A good network of reliable NGOs to carry out the services.
Community participation and willingness of community members to volunteer.
Who needs to be consulted
Officials at the Government Health & Family Welfare Department, Municipal Corporation, partner NGOs, local community, body imparting technical assistance (in this case KEM Hospital Research Centre)
Sustainability and ability to replicate were the guidelines taken into consideration during selection of the NGOs.
It was decided to initially implement the project under European Commission-supported Sector Investment Programme for two years and subsequently make it a part of RCH II programme for the next 5 years to cover the entire district.
More specifically, a good liaison between government staff and Parivartaks, community awareness and demand for services will ensure the sustainability of this initiative.
Chances of Replication
Replicable, although dependent on funding and available and reliable NGOs in the area. If proper training and motivation of government health providers in both demand generation and quality services is done, then the chances of replication of the project is easy. The role of gram panchayat and VHCs is crucial and if they are made aware of their responsibilities, then the chances of replication of this project are very high.
KEM has had a long history of delivering rural health services. For more see “King Edward Memorial Hospital Rural Health Project” publication of the Anubhav series.
Sara Joseph, Researcher, ECTA, New Delhi, February 2005.