A REVIEW AND CONSULTATION REPORT ON JSR YOJANA OF MP PARTI-THE STUDY REPORT
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A REVIEW AND CONSULTATION REPORT ON
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PARTI-THE STUDY REPORT
JULY -NOVEMBER 2001
COMMUNITY HEALTH CELL TEAM
BANGALORE
SUPPORTED BY DFID, NEW DELHI
'.
Prof Mohammad
Amulya Nidhi
Dr Shyam Ashtekar
Dr Dhruv Mankad
&
Dr Ravi Narayan
■■■■
i-H .
' ip*
Dr Shashikant Ahankari
Dr Abhay Shukla
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
ACKNOWLEDGEMENTS
The team set up by CHCell Bangalore is indebted to several health
officers, district collectors, CEOs, leaders, doctors, Nurses, MPWs, CHWs
and JSRs, NGOs, panchayat leaders, teachers, village men and women,
Anganwadi workers, AWW supervisors, pharmacists and others whom
we have met and taken their time beyond their expectation. There was
a free and uninhibited exchange of ideas and facts, and this report
would have been far deficient without their genuine participation. The
team is committed to the cause of primary care in India, and looks upon
the MP experience as an important lesson for the team, as well as the
policy makers in India. We are truly indebted to all those who helped us
fathom the scheme and understand the practical difficulties in a large-
scale effort like the JSR programme.
Two Officers from Bhopal's Vallabh Bhavan, Dr Manohar Agnani
IAS, Rajeev Gandhi Mission and Shri Gopalkrishnan, Secretary to the
Hon Chief Minister, MP, have extended all help for liaison and
facilitation. We are grateful to them. They also contributed in the final
discussion session. In the draft discussion session, valuable help came
from Smt Alka Sirohi, Secretary, Health Dept MP, Dr P K Bajaj (Director
of Medical Education & Research MP), Dr Yogiraj Sharma. We thank
them for the contributions. Ashish Jasal in RGM helped in several
logistical matters. Sandeep Dixit, Pooja Gour, and Manish Shankar of
Sanket have also given valuable information for this study.
Finally, this study was the fruit of DFID's initiative. We are
especially thankful to Mr Tim Martineau.
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
CONTENTS
ACKNOWLEDGEMENTS
1
MAP OF SELECTED DISTRICTS OF MP
6
ABBREVIATIONS
EXECUTIVE SUMMARY
7
9
The Challenge
9
The earuer Review
10
Findings of 2001 review
11
RECOMMENDATIONS
12
A: PROCESS.
12
B: CONTENT.
13
THE REVIEW : FINAL PRESCRIPTION
Halt, Review and Redesign
15
Take it to the community..
15
16
PARTI: INTRODUCTION
17
VlLLAGE-AN UNFULFILLED AGENDA IN HEALTH CARE
17
Past efforts & failures in India
17
The challenge: Questions and constraints
18
HOW THE STUDY STARTED
21
Why the study......
21
TOR and Concerns.
21
RoleofCHCell.
21
First Contact Health Care: Factor mapping
PART 2: HEALTH PROFILE OF MADHYA PRADESH
Socio-economic and Demographic profile of Madhya Pradesh
22
25
26
Health Status ofpeople in MP.
26
Health indicators for Women and Children:
27
Health Infrastructure
27
RKS.
29
Provision for Health Sector in the Ninth Plan (1997-2002)
29
Evolution of the JSR Scheme.........................................
29
Village Health Plan.
32
PART 3: MATERIAL AND METHODS
33
the CHCell team
33
Preparatory visit.
33
2
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Selecting districts
33
Time frame
34
Sources of Data.
34
Issues Covered
35
Scheme /Selection
35
Training/T/JSR
35
Work-content.
35
Community
35
Data Collection Methods.
35
Analysis and Report
36
PART 4: RESULTS AND DISCUSSION
38
The JSR Scheme,
38
Selection
39
Distance
40
Aspirations for being a JSR.
41
Education of candidates
41
Gender.
41
Age
43
SC/ST.
43
OidCHWs.
44
TBA selection
45
AWW as JSRs.
45
Previous health expenence of trainees.
46
Selection of Pvt Med Practitioners as JSRs
47
Training and trainees
48
Districts and blocks.
48
Training venue
.
48
Physical facilities...,
48
Training calendars.
49
Hours of training...
49
Batch strength
49
Methods of training.
49
Trainers.
50
Subjects covered and desired
53
A case story ofJSR training...
53
Opinion about training
.
55
Interim tests
55
SkiHs-acquird and desired.
55
Treatment of diarrhoea
56
Fever dignoses and ma/eria dignoses
57
3
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Treatment of malaria
58
Final tests.
58
Certificates.
58
Failures and re-tests
59
Developing JSR work......
59
Desired image
.
59
Training ofJSR- Ws......... .
59
Training of trainers (ToT).
59
JSR manual.....................
60
Other training opportunites........
61
Gender factors in training system.
61
Working of JSRs........................
61
Code of Conduct.
61
Attrition
62
Tasks
62
'Practice'.
63
Time given everyday...................
63
Clinical work and clinical problems
64
Workplace................................
64
Patient attendance......................
64
Women patients.............
64
Serving Deprived sections
64
Referrals.........................
64
Preventive work and National Health programmes.
65
Links, Supports, Sustainance
65
Links
65
Monitoring...........................
66
Continuous Medical Education.
67
Supplies................................
67
Public sector Hnkages-PHC/5C
68
Income.................................
69
Honorarium
70
Loan.
71
Use of kits
71
Relation with village body.............
71
Relation with Pvt Med Practitioners
72
About users
73
Medicines used and desired
73
Medidnes desired by JSR-Ws.
73
Medidnes desired by JSR-T...
73
Injections and saline............
73
4
F
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
74
ISM remedies.
Suggestions and opinions
75
Senior health officers.
75
JSRs about the scheme
76
District/block functionaries
.
76
Sarpanch, gram panchayat members, village people.
77
Other PHC staff ...................................................
78
A WW supervisors
78
Views from JSRs-past and present
79
Political opinion about the scheme
79
Case story of a dropout: A JSR turned EGS Guruji
81
Impact and Potential
83
Impact...
83
Potential.
83
Legal status ofJSRs.
84
Nomenclature
85
Venue for JSR activities.
85
Irrational practice
86
Role of NGOs.......
87
Future ofJSR scheme
Comments on JSR examinations
88
89
Expected answers.
89
Comments
89
Subjects
89
PART 5: RECOMMENDATIONS FROM THE TEAM
90
Overall comment
96
SHARING CONCERNS
97
REFERENCES
98
Appendix
1) Districtwise data of JSR training-100
2) Gist of Govt orders about JSR programme -102
3) List of medicines used by JSRs—104
4) List of medicines and economy brands for JSRs—106
5) Analysys of Exam papers held in June 2001
6) Terms of reference for the study-109
7) An opinion poll on the JSR programme—110
8)
JSR SCHEME A REVIEW—TEXT OF POWERPOINT PRESENTATION—11.6
9) Notes on JSR manul—119
10) CHECKLIST OF INTERVIEW QUESTIONS—134
5
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
MAP OF SELECTED DISTRICTS OF MP
Madhya Pradesh
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6
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
ABBREVIATIONS
ANM
Auxiliary Nurse-Midwife
AV
Audio-visual
AWW
Anganwadi Worker
BMO
Block Medical Officer
CBO
Community-based Organization
CD
Compact Disk
CEO
Chief Executive Officer
CMC
Community Health Center
CH Cell
Community Health Cell
CME
Continuing Medical Education
CMHO
Chief Medical and Health Officer
DFID
Department For International Development
DFO
District Forest Officer
DHO
District Health Officer
DHS
Department of Health Services
DTC
District Training Center
ET
Entry Test
GR
Government Resolution
GS
Gram Sabha
GSS
Gram Swasthya Samiti
HMO
Health Maintenance/ Management Organization
HS
Health Services
I/C
In-charge
IEC
Information, Education, Communication
ISM
Indian System of Medicine
JR
Janpad
JSR
Jana Swasthya Rakshak
JSR-T
Jana Swasthya Rakshak-Trainee
7
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
JSR-W
Jana Swasthya Rakshak-Working
MIS
Management Information System
MOPHC
Medical Officer, PHC
MPW
Multipurpose Worker
MR
Medical Representative
NGO
Non-Government Organization
NHP
National Health Program
OBC
Other Backward Castes
PHC
Primary Health Center
RCH
Reproductive and Child Health
RFWTC
Regional Family Welfare Training Centers
RGM
Rajiv Gandhi Mission
RKS
Rogi Kalyan Samiti
RMP
Registered Medical Practitioner
SC
Scheduled Castes
SJSGY
Swasth Jeevan Seva Guarantee Yojna
SHG
Self-Help Group
SHP
State Health Program
SS
Swasthya Samiti
ST
Scheduled Tribes
TBA
Trained Birth Attendant
ToT
Training of Trainers
VHG
Village Health Guide
ZP
Zilla Panchayat/Janpad
8
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
EXECUTIVE SUMMARY
THE CHALLENGE
Reaching primary health care to village and Adivasi communities all over India has been a
major challenge for the central and state governments in India.
In the early 1970s, inspired by experiments in the voluntary / ngo sector and on the
recommendation of the Srivastava Report the Government of India launched the Community Health
Workers Scheme (see box 1).
the creation of large groups of part-time semi-professional workers selected from amongst the community itself,
who would be close to the people, live with them, provide preventive and promotive health services including
family planning in addition to looking after common ailments
"
- Srivastava Report, 1974
Due to political exigencies, professional neglect and lack of sustained policy support and
initiative, a large half number of the CHWs continue to 'exist' in the country on paper drawing a small
monthly stipend due to legal requirements, but not functional in any other way. The unfulfilled
agenda continues into the next century.
The state of Madhya Pradesh, responding to its own health situation and challenge, which
includes a high unmet need of primary health care in the vast rural / adivasi areas of the state,
launched the Jana Swasthya Rakshak Scheme in November 1995, under the Integrated Rural
Development Programme for unemployed youth to provide round the clock curative and preventive
and promotive health services in every village of Madhya Pradesh.
Objectives of JSR Scheme
"To improve the health in rural areas by providing a trained worker who can give first aid and treat small
illnesses scientifically, in the village itself. Efforts are to be made to have both males and females in the scheme.
To provide a trained worker in the village who can assist in the implementation of National Health Programmes
and health schemes of the government..."
- JSR Scheme Booklet, 1995
Initially, the Scheme was only supported by the Health Directorate as a technical resource
group but a few years after the launch and a review in 1997, the scheme gradually developed closer
links with the health directorate.
In July 2001, the Government launched the more ambitious Rajiv Gandhi Mission entitled
Swasthya Jeevan Seva Guarantee Yojana (SJSGY) of which JSR scheme became an important
component and one out of seven guarantees of services to be provided by the state government
within a specified time framework at village level, (see Box 3)
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
SJSGY
Providing a trained JSR in each village in June 2002.
Providing a TBA in each village by June 2002.
Provision of Universal Immunization.
Three Ante-natal checks for pregnant women.
Provision of safe drinking water-supply.
Provision of nutrition cover to infants, <3 children, pregnant and lactating women.
Sanitation in terms of solid waste management and waste water disposal in the village.
A Village Health Register also leading to a Village Community Health Plan
Development and Implementation of a District Community Health Mission Plan.
- SJSGY Booklet, 2001
THE EARLIER REVIEW
In 1997, a Review of the Jana Swasthya Rakshak Scheme was organised by the Madhya
Pradesh government supported by UNICEF, after part of the training phase was over. The
participatory, interactive review facilitated by Community Health Cell (CHC), Bangalore and entitled
"Reaching Health to the Grassroots" was conducted between July-December 1997 and made
important recommendations on the objectives, administration, selection, linkages, logistic support,
communication, training, criteria for certification, supervision-monitoring-evaluation, examination;
core project team and peer support.
In 2001, this, second Review was undertaken at the request of DFID and with full cooperation
of the government of Madhya Pradesh especially, the new (SJSGY). The initial term of reference was
expanded by the review team so that various policy options and perspectives could be provided for
mid course correction and creative modification of the ongoing scheme.
Six researchers toured six (6) districts that were selected on the basis of HDR as well as to get
a representative sample of the diversity of Madhya Pradesh). The teams studied 2 blocks per
districts, 1 CHC and PHC per block, 2 villages per CHC/PHC were selected. The Review started in end
of July 2001 (initial exploration) and the field investigations were done in three weeks in September.
Qualitative techniques including direct interviews, focus group discussions, case studies and
opinion polls were the main tools. The 226 JSRs contacted responded to semi-structured
questionnaires. The team interviewed all levels of stakeholders from senior government officers to
JSR and community members. The respondents included district collectors, CEOs, nodal officers,
media officers,CMHOs, BMOs, MOPHCs, health department staff including ANM/AWW supervisors and
10
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
old CHWs, PRI leaders, village community including users, NGOs, JSR-Trainers and JSR-workers and
the other village-level health care providers including Bengali doctors and medical shops.
The Review also looked at the revised JSR manual and outlined further additions and
modifications. In addition, to support the policy process, it studied all the JSR related government
orders; provided check lists of medicines recommended for JSR use; possible roles of JSRs in National
Health Programmes; list of recommended skills; and policy options to evolve the scheme further.
After analysing the data and all the documents, the key findings and recommendations are:
FINDINGS OF 2001 REVIEW
JSR Scheme
• The programme is in full pace but the community is not aware of it.
• High attrition (90%) mars the programme right from training phase. The few survivors - the
practicing JSRs - are providing only curative care, that too of dubious quality.
Pace of the programme
The targets of training JSR are being achieved far too quickly, affecting quality.
Selection ofJSRs
It is amply true that both the JSRs and the Grampanchayats think about recruitment rather
than selection of JSR. The DHS has only administrative, not technical control, over the selection
process.
Selection of women JSRs
Women are nearly missing except in one district where AWWs were selected. The problems
are in the scheme framework, not just selection bias. Going entirely by education level keeps out
women candidates.
Promoting quackery
• Many of the small number of JSR who are active in the field are becoming like private
practitioners pushing saline and injections.
• Many quacks and unregistered practitioners have managed to get selected for JSR course to
legitimise their practice.
Training
The training course is highly congested. Skill and attitude training was not adequately
designed. There was a variance in clinical training from very simple empirical approach of diagnostic
11
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
to getting trained for IV injection. The link between Objectives-training-practices was very weak. No
plans for CMEs.
Linkages and preventive programmes
JSR's linkage with PHC is inconsistent and inadequately planned.
Learnfog tools
Right now there are no self learning - interactive tools except the reading of the manual. No
learning by problem solving or doing except injection training and some dressings.
Role of RFWTC
The RFWTCs were well equipped with facilities and motivated training faculty.
Uses of drug
The JSRs are trained for very few drugs. Inevitably, this absence of necessary information
leads JSRs to emulate quacks to build credibility. In addition, no one uses other remedies including
the ISM.
Role of NGOs
No NGO seems to be involved in the scheme.
Flexibility
No special provision in the Scheme for innovations and alternative experiments in training and
programme design or field implementation.
RECOMMENDATIONS
These are summarized in two complementary groups. Recommendations on the process of
redesigning the scheme and recommendations on the content of the redesigned scheme.
A: PROCESS
Phase I: Pause, Consultation and Redesign (3 months)
Given the considerable problems of the existing scheme, new selections and training should be
stopped and the field implementation of the scheme paused until redesigning of the scheme has been
completed.
Organizing public consultations about the scheme (including suggestions for redesigning it),
involving various interested actors including health NGOs, community based organizations and
panchayat representatives could be arranged at the regional level and then at state level.
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Formation of a JSR cell or task committee, which would redesign the programme in a time
bound manner based on suggestions received during consultations. This cell should include experts
from national/state level health NGOs / networks.
Phase II: Groundwork for relaunching the scheme (3 months)
Preparation of community awareness material : Village health committee orientation material
and guidebook for JSR trainers Formalizing modified selection criteria and legal provisions for JSRs.
Organizing parallel groundwork activities
• Orientation of master trainers who would train the trainers
State level information campaign about the scheme, addressing village panchayats
• Dissemination of public awareness material
• Invitation and identification of NGOs / CBOs interested in helping the scheme in their areas.
Phase III: Relaunching the scheme at the field level (3 months)
• Conducting parallel activities at the community level: Inviting applications from village
panchayats interested in the scheme (should fulfil basic conditions including formation of
Village Health Committee)
• Investigation of functioning of existing JSRs in villages / areas from which applications are
received. Joint decision to be taken by Panchayat and public health functionary about
status of existing JSRs.
• Training of JSR trainers at district / block level.
• Orientation of Village Health Committee members including modified JSR selection criteria.
• Commencement of selection of new JSRs by Gram Sabhas using modified selection criteria;
all trainees should be certified by Village Health Committee and block level public health
functionary.
B: CONTENT
Overall framework of the programme
• The redesigned scheme should be put in a system framework and should be well integrated
with the public health system. There may be a 'Collaborative model' with
• Community ownership in opting for the scheme, selection of JSR and monitoring
• NGO / CBO involvement for local supervision and community anchoring processes
• Government health system to give resources for training, work-linked honorarium, basic
medicines and referral support, control of quacks.
13
)
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
• The programme should be anchored in the community, pace of the programme should be
decided by community willingness to take up the scheme and not a top-down 'drive'.
Selection process and criteria for JSRs
• The Gram Sabha should recommend candidates but the village health committee / health
department should ensure that the candidate is not an existing quack or non-resident JSR;
some technical criteria for selection should be developed
• Women should be selected in most of the new villages; deterrents for selection of women
should be removed including by lowering of the educational criteria for them; AWWs may
be encouraged to become JSRs in consultation with ICDS.
•
SC /ST / OBC should be encouraged; age group should preferably be 25-40.
Training process
• The training content could be split into two or three phases; basic to advanced, and the
manual could be redesigned accordingly; continuing medical education should be
organized.
• More practical and clinical content is required along with attitude forming processes like
exposure to NGOs; need for extra reading material, may be JSR library at CHC.
• Less didactic and more problem solving approach, participatory training, training aids
including audio visuals, proper venue, better trainers with more time, skill and involvement
in training.
• Manual needs to be reworked with changes in content focus on attitudinal / social issues
related to health and health care; availability of manual to both old and new JSRs.
•
RHFWTC need to be involved from curriculum design down to field level training and
monitoring; involve Open University, PSM departments and NGOs like MPVHA.
Medicine supplies and practices
•
Prepare essential drug list, may be 3 level list (10/ 20/40 drugs) for basic to advanced
modules; basic drugs (sub centre kit) to be supplied free by PHC to JSRs.
•
Additional supplies from low-cost non-profit pharmaceuticals like LOCOST
•
Encourage home remedies in first module, strengthen non-allopathic systems as per level.
•
Action against quacks to cut down overuse of injection - saline; campaign to stop demand
and prescription of irrational drugs in both private and public sector.
14
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Community anchoring, monitoring and legal issues
•
Need for widespread public information by posters etc.; rate lists and services of JSR to be
publicly displayed; create mechanism for monitoring and control by Gram Sabha.
•
'Gram Swasthya Kendra' board and space by Gram Panchayat.
•
Legal protection is necessary; guidelineb for work only in self-village and use of defined
remedies and procedures; periodic re-licensing based on technical and social performance.
Linkages and support from public health system; supervision
• Systematise linkages with ANM / MPW and PHC; involve JSR in NHPs and Government should
give honorarium for the same which may be routed through Panchayat; adequate public
funds to be made available for various forms of support.
• Discourage quack connection and links with private doctors.
• Develop simple reporting system and relevant, short record formats.
• Technical monitoring by public health system combined with social monitoring by Gram Sabha
I Village Health Committee.
THE REVIEW : FINAL PRESCRIPTION
Halt, Review and Redesign
• The choice of right model JSR
• Think of JSR as a system, rather than individual PMPs
• A special JSR cell
• Legal provision, better identity (logos?)
• NHP support-logistical and financial
• Control quack practice
• Technical reforms
• Comprehensive task-list and problem-oriented training
• Select district centers for training
• Work out drug list for primary care, make rate lists
• Vigorous efforts for inclusion of other healing systems
• Work out monitoring lines and modalities, simple MIS
• Improve training, institute CME.
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Take it to the community
• Educate the village bodies and people about the scheme
. Provide village public space for 'JSR center' and standard equipment
• Try links with district RKS and other schemes
• Involve NGO in experiments - training, management, GSS involvement.
16
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
PARTI: INTRODUCTION
VILLAGE-AN UNFULFILLED AGENDA IN HEALTH CARE
Villages-millions of villages- are where most people stay even in this century in several
countries in Asia, Africa and South America. Several health problems are rooted in the conditions of
villages but an entirely different rural economics precluded the possibility of putting 'doctors' in these
millions of villages. Modern Health services in such countries have always grown top-down through
efforts of the State and have various levels of depth. In rural-predominated countries world over, the
village remained the enigmatic issue in health services. In China a durable & comprehensive health
care facility at the village level was a major success in the framework of its revolution. Several
developing countries tried versions and variations of the Chinese lesson in seventies and especially
post-Alma Ata. David Werner's pathbreaking book Where There is No Doctor arrived around this time.
Seventies was the happening decade in health care at the grassroots. HFA & primary health care at
Alma Ata gave a new framework for such efforts.
PAST EFFORTS & FAILURES IN INDIA
India's major effort at solving this problem came around in 1977, post-emergency and on the
background of IP's movement. But presumably there were efforts within Central ministry towards
making such a scheme. The Community Health Worker (CHW) scheme launched in 1977-78 in most
states of India was a major effort for reaching the villages. There was a matching effort by NGOs in
India for evolving models for such a scheme Jamkhed, Narangwal were new paradigms in health
care. Along with the CHW came the AWW and the latter has persisted till date.
CHW scheme evolved till early eighties but started a downhill course thereafter. The shifting of
the scheme to the family welfare dept was a major devolution where it would be monitored largely by
the language of demographic performance. Health and medicines inputs soon became redundant in
its new home. Till date CHW unions-or whatever is left of them- are struggling to ensure that atleast
the 50 Rs a month stays intact.
The failure of the CHW scheme, needs to be studies against two parallel programmes—a) the
Chinese barefoot doctor and b) the ubiquitous untrained 'quacks' (derogative regretted, they are a
crying need answered by non-state forces) in the entire country. About half a million CHWs continue
to 'exist' in the country on the pages of Health Ministry's reports ($). Very few of them are
functioning in any sense. The scheme withered away, leaving a question-mark on the primary care
front of the country.
The unfilled agenda continues in this century too. Both the 10th Five-year plan and National
Health Policy Draft mention the need to address the issue.
17
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
THE CHALLENGE: QUESTIONS AND CONSTRAINTS
1. The new effort if any is a more complex task since the past experience of the CHW scheme puts
several constraints. New schemes of similar nature may attract legal battles when the old CHWs
are struggling for more honorariums. Any new scheme will have to seamlessly merge with the old
scheme, or at least steer clear of it.
2. On the background of fiscal discipline, need to downsize Govt, apparatus, inefficiency of state
health systems (without reflecting on private system inefficiencies), any new scheme of
employing staff on large scale (part time or full time is no matter) faces a stiff resistance.
3. Even if such a scheme is put in place as a special case, there is no guarantee that it will not go
the CHW way (ANM and MPW systems are not particularly successful is another matter), since
that will be part of the system that is not delivering goods already. The condition of primary
health canters, and subcenters is already pathetic and the causes are not entirely financial.
4. The country has a large private sector, and the rural Private sector is bursting with quacks dotting
the rural centers. A new CHW-like scheme can get catch the quack-germ and go haywire.
Regulatory mechanisms are nearly absent for rural areas and in the absence of alternatives, no
state Govt, can weed out quacks; it is politically impossible and socially not feasible. If any new
CHW system can work as a feeder/tout to the private sector thanks to the pathetic weakness of
public hospitals.
5. IMA and doctors' bodies are urban-metro centric, but the heavy concentration of the private
sector in cities is dependent for fodder on the hinterland. Any serious effort on a CHW like
scheme can jeopardize the economics of private-urban equation. For survival of this sector more
developments must happen at secondary and tertiary level than at primary level. The dominant
and vocal doctor-bodies are therefore against such schemes. On the other hand they are
powerless against the wily quacks and have chosen to co-opt this sector for survival. When the
issue of unserved areas is argued, the doctors bodies ask for creating facilities in the villages so
that doctors can go there (practically this will never happen since villages will always be relatively
far backward compared to cities). They also cite the trickle effect and the increasing number of
medical colleges.
6. It is suitable for State Governments to start short medical courses for stating this cause of
unserved areas and create new pastures. This is seizing the difficult problem from the numbers
end rather than the distribution end.
7. The advent of Consumer Protection Act in medical sector, and renewed efforts the clinic/hospital
registration acts by several states, however relevant, psyche the health administrations against
CHW-like systems.
18
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
The issue therefore is framed: How to institute a working village level health-care-system on
large scale:
a) In the framework of existing Public Health system
b) Without making it look like a monthly-payment scheme on large scale
c) Making it draw some sustenance also from the community (rather than the state alone,
and make it economical and resource-efficient) without burdening the poor or making it
irrelevant for poor unserved areas.
d) Ensuring that it will be sustainable
e) Preventing quack influence on the scheme
0
An optimal combination of curative and preventive-Promotive health, an optimal
combination of allopathic, ISM and other alternative healing systems.
9) Making it legally relevant and safe
h) Framing it in the new concerns of gender
i)
Bringing in the contexts of national health initiatives
j)
And finally how to make this a politically safe, pertinent, and 'popular7
Instituting any such new scheme/programme is therefore dealing with a matrix of challenges,
choices. It calls for new thinking on the background of past failures and new socio-political and
technology environment. It involves a deft exercise in positing the solution with a flexible approach,
accepting some constraints and offsetting them against more significant gains; of choosing a path of
experimentation rather than straightjackets that finally become deadwood and obstacles.
How does the JSR scheme appear in this context, is the issue before us.
19
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
HEALTH MINISTER
RGM
DHS
„JviFyiEAL
SYSTEMS
Jt DHS
Regional Director
RFWTC
District Collector
Zilla Janapad-
Health
CMHO
CEO-Zilla Janpad
(^DT Unit
DHO
JSR Training Center
BMO
CO- Janpad block
MO-PHC
CDPO-ICDS
Janapad (block
level)
HA male/Female
AWW-Supervisor
MPW/ANM
Grampanchayat-GSS
i
AWW
20
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
HOW THE STUDY STARTED
WHY THE STUDY
This study is a result of DFID's initiative on the JSR scheme. Since the scheme is already
halfway, DFID wanted to see some of its prime concerns about the scheme reviewed.
TOR and Concerns
The concerns are listed in table given on page 21. Selection (esp women), training, linkages,
remuneration, preventive programmes were of special importance to DFID.
Role of CHCell
The CHCell team added it own points for study.
21
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
FIRST CONTACT HEAL TH CARE: FACTOR MAPPING
(Shaded arcas are issues listed by DFID, others are listed by the study team)
PLANNERS' CONCERNS
•TTSelectio[i;.gender/age/.e.d.ucatipn
g^yEgn'ks-does JSR fitweiLEWEealth .sySS
Tra)njng7system7books/CDs/Tv' channels/specialty
•
training-
SZffi^nganS^FoOESnlng
•
Supplies/logistics/multi-sourcing/ non-drug healing
•
Works within rational therapeutic framework/CME
Programme
Content:
Skills and tasks,
Attitudes of
providers,
knn\A/loHn£»
PROVIDER
CONCERNS
•
Basic needs-survival
•
Mpneta'n!
gairis/incentives
•
Self worth
COMMUNITY
22
REPORT op CHCPLl STUDY OP KR SCHEME OP MADHYA PRAOESH^epg^^^^
Issues listed by
Possible exercises/possible methods
Sub-issues
DFID
IV JSR,
IV programme officers
FGDs with users esp. women for health problems
Male female
a
proportion?
____________
candidates
Education
Administering tests for required tasks if time permits
Availability of new candidates in villages
2)MS*entiyg
_______________
officials/JSR/MOPHC etc
Work out doable bits from NHP task-list_____________________
3) /irMninfl
Observation and IV trainers
FGDs with JSRs,
4) i§JJperyisiori
_______
.
JSR programme
Suggesting outline of suitable record keeping system. Coding
.
illnesses and remedies.
Outlining a two-way communication system between JSR and
guiding-group in Health dept: PGP with Programme officersJSRs
work
5) Village leyglj
With other
li^kages/con
village HWs
vergence
& Services
convergence
With-
.
Exploring common platforms for some tasks
.
Exploring areas of conflicting interests
-“^iZiZgq^ityyf^^
06
Exploring areas/opportunities of new contacts-Gramsabha?------------
Community
—T^kZZalysis of lSM(free!isting)
6) TsMlrelation
Exploring learning opportunities in ISM
______ ___
---- f^^i^isof^MP(^
(Can we bring RMPs in the fold of JSR programme)___________
'syZlinkages
PHC/CHC
v&SiKealtfi
Defining Referral linkages: IV programme officers for protocols
Detailing NHP linkages: IV programme officers
Pr Med Pract
-----------
Pvt Medical Practitioners for support? That can be pitfall)
23
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
9) Incentives
Appraising
Assessment of local earnings of'co-eds' staying in the village (FGD),
current
and IV co-professionals if any.
levels
Profiling aspirations of JSR (what they can take). IV JSR
Current family spending on comparable health problems (what
people can give). Ref recent surveys. IV families
Modes of payment
Preventive
Ref list of feasible preventive tasks developed in row 2
service
Prepare operational models of listed tasks
payment
IV JSR and health officers on costs/compensations in each case (For
instance what does a school health screening cost per student?)
marketing of
List marketable/available public health goods
public health
Outline strategy for marketing
goods
Identify pitfalls/ solutions
10) JSR literature review
10 ) Meeting/inviting opinions
of other health groups
IV voluntary organizations in the state on all the above points
Workshop with development NGOs
(FGDs) Focussed Group Discussions, OB: Observation, IV: Interview, NHP: National Health programmes, PMP:
Private Medical Practitioner, RMP: Registered Medical Practitioner, ISM: Indian system of medicine,
24
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
PART 2: HEALTH PROFILE OF MADHYA PRADESH
JSR scheme was designed as a special response to the conditions prevailing in MP: a) vast
number of villages without easy access to medical care b) Resource constraint in terms of trained
personnel and finance. C) Health status and needs of rural people. Let us therefore briefly look at
MP's health system.
The general Indian pattern of health services holds good for MP, only that it is sparse. The
usual pattern of service facilities down the district-village line is District Hospital-CHC-PHC-Subcenter.
The last unit is for five thousand populations, and in tribal areas for 3000 population. The line ceases
here and health peripatetic workers are the last hands of the health system for villages. Aanganwadis
dot almost every village but these serve only the child-welfare services. The old CHW programme is
nearly defunct. The CHCs, esp. after the RKS, are working at many places we observed CHCs are
doing surgeries. PHCs are established, but mini-PHCs (new PHCs) are underdeveloped. For curative
care, village people are dependent on the PHCs and above.
The vast gap of services, is filled and being filled by private practitioners. Almost everywhere
we saw Pvt Med Practitioners, including untrained doctors-called by media and policy experts as
Jholachaap. This implies that an alternative was long due. In one small bazzar center in Bhopal dt, A
team membersaw that a mini-PHC was devoid of patients and the next door Bengali doctor had his
clinic full of patients-men, women and children. Many patients buy their medicines from medical
stores and the stores do comply. 1
JSRs as practitioners or health workers can not work in a vacuum. They need a niche in the
rural health system. On one side they need linkages with PHC. On the other side-As practitioners -
they have to compete with the "jholachhap doctors" and Bengali doctors. Generally, every bazaar
center (center of 15-20 villages) and major village has these Pvt Med Practitioners. In a village center
(town?) of 10000 population, we counted 22 such Pvt Med Practitioners. This block of two-lakh
population has, so says the Health Assistant, "200 Pvt Med Practitioners". If anybody thought of JSRs
as professionals earning on clinical practice, the norms/models/role models/practices are established
and there is some tough competition to face.
1 This system is legalised in Philippines as not only medical stores but even genereal stores sell some
medicines directly without prescription. Getting rid of a doctor thus saves some money for the poor villagers
25
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
SOCIO-ECONOMIC AND DEMOGRAPHIC PROFILE OF MADHYA PRADESH2
Madhya Pradesh, called MP in short, spreads over 443 thousand square kilometers. It accounts
for 14 % of India's land and 8 % of India's population. It was divided into 61 districts including the
districts now in Chhattisgarh. Population density in square kilometers is 149 in 1991, more than
double than 1951, when it was 60. Though it is low compared to other states in India.
Economic features: Agriculture is the main livelihood for most in the state. Agriculture
provided livelihood to 76 % of the working population. (Census, 1991). The major crops include
wheat, rice, jowar, bajra, sugarcane, maize, cotton, groundnut, soyabean, pulses, gram, and tir.
Industry is scattered in MP, mainly surrounding some of the major towns. MP is a major
producer of cement in India. MP is also the second largest producer of minerals in India including
coal, iron ore, and manganese. Other industries are food processing, petrochemical, automobile and
electronics. MP had taken an early lead in optical fiber production for telecommunication
According to the Planning Commission, 41 % of the rural and 48 % of the urban populations in
MP were below the poverty line in 1993-94 (CSO, 1999).
Demographic features: MP had a population of 66.2 million in 1991, up from 52.2 million in
1981. The population sex ratio was 931, marginally higher than the average for India (927). It has
decreased from 971 in 1951. (Census 1991) Also, the proportion of the total SC population is 14 %,
slightly lower in MP than in all of India (16 %). The state, however, has the highest ST population in
India apart from the Northeastern States. It has increased to 23% in 1991 from 20% of the total
population in 1971. Together, SC & ST make 39% of population.
Literacy rate for population of age seven and above was 44% compared with 52% for India as
a whole. (Census 1991) 57% for males and 28% for females in MP compared with 64% and 39% for
males and females, respectively, for India.
Health Status of people in MP
Health Indicators: Crude Birth Rate in Madhya Pradesh was 30.7 per 1,000 population in
1998 and the total fertility rate was 4.0 children. (SRS) Both these rates are fourth highest in the
country, lower only than those for Uttar Pradesh, Rajasthan, and Bihar are.
Infant Mortality Rate in 1998 (SRS est., 1998) was 98 per 1,000 live births - the highest along
with Orissa in the country. In India, the IMR was 72 per 1,000 live births. The life expectancy in MP
was 54.7 for males and 54.6 for females for the period 1991-96, which is lower than that for all of
India (59.7 for males and 60.9 for females).
2 The profile is about the MP state including Chhattisgarh because most of the available data is
for the period Chhattisgarh state was established.
26
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Table 1 Health Indicators in MPf Source: SRSf 1997
Reference period
M.P.
All India
Male
(91-96)
59.24
60.6
Female
(91-96)
57.96
61.7
Crude Birth Rate
(1997)
31.9
27.2
Annual Pop. Growth Rate
(1981-91)
2.68
2.39
Crude Death Rate
(1997)
11
8.9
Infant Mortality Rate per 1000 live birth
(1997)
94
71
Indicator
Life expectancy at Birth (in years)
Health indicators for Women and Children:
Table 2 Nutrition in Women and Child's Health
Indicator
In MP %
In India %
Women with anemia.
54.3
51.8
Women with moderate/severe anemia
16.6
16.7
Children age 6-35 months with anemia
75.0
74.3
Children age 6-35 months with moderate/ severe anemia
53.0
51.3
Children chronically undernourished (stunted)
51.0
45.5
Children acutely undernourished (wasted)
19.8
15.5
Children underweight
55.1
47.0
Source NFHS2, 1998 (excluding the data of Chhattisgarh)
Table 3 Health Indicators for Women and Child's Health
Indicator
Total
(in%)
Preg women with some ANC
60.0
Preg. Women with full ANC
22.4
Institutional delivery
22.6
Safe Delivery
29.3
Child with Complete Immunization
50.3
Child with no Immunization
9.9
Source: RCH Annual Survey, 1998
Health Infrastructure
Most of the people (62%) seek health services from private doctor, poor or not so poor.
(NFHS2, 1998) Only 10% use CHC/PHC for their health problems.
Others using the public health services (22%) prefer the Govt, or a municipal Hospital situated
in a district headquarter.
27
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Few people do take self-medication or approach the nearby source like sub centers, drug store,
traditional healers or other 'pathy' doctors.
Table 4 Utilisation of Health Services
Indicator
Rural
Poor
HH
HH
Public medical sector
34.5
36.6
Govt. Hospital/Disp.
21.5
23.5
CHC/RH/PHC
10.0
11.2
Sub Center
2.3
1.6
Others
0.9
0.3
NGO/Trust
2.9
3.2
Private medical sector
62.2
59.8
Private hosp/clinic/pvt. doctor
60.7
58.6
Vaidya/hakim/homeopath
0.6
0.2
Others
0.9
0.9
Others
0.5
0.5
Source: NFHS2, 1998
There is no major difference between the urban (66%) and rural (62%) community in seeking
health services from private sector. However, there is a big gap in the availability of doctors and
hospital beds in rural and urban areas. Urban areas have 18 times more doctors and 36 times more
hospital beds than in rural areas. This is substantially high more than double than the average
disparity in India.
Table 5 Health Infrastructure in Rural and Urban Areas of Selected 9 States
State
Doctors
Hospital Beds
Per 100,000 Population
Per 100,000 Population
Rural
Urban
I Urban/ Rural
Rural
Urban
Urban/ Rural
. disparity (times)
disparity
I
(times)
Kerala
39
117
|3
198
481
2
Punjab
76
260
| 3
68
233
3
Gujarat
20
115
I5
22
346
16
Maharashtra
24
117
21
308
15
West Bengal
27
155
i6
17
264
16
Andhra Pradesh
13
144
i ii
9
203
23
Tamil Nadu
18
202
11
12
237
20
Madhya Pradesh
3
55
18
4
145
36
All India
____________
F
j
8
__
15
Source: Health Expenditure Patterns in selected major States, by Ravi Duggal, 1995
23
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Govt, of MP has recognized that the major problem of extending medical and health care to the
people of this State are large distances and poor network of communications.
GoMP has made efforts to increase the no. Of sub health centers, primary health centers and
community health centers in the rural areas. The M.P. Govt, has planned to establish 201 new
Community Health Centers with adequate staff, equipment, medicines and other para-medical
facilities, 340 CHC's building to ensure that there is a CHC at each block headquarter where such
facilities does not exist at present. To reduce the patient load in district & other specialized hospital, it
is proposed to upgrade selected sub-divisional level health institution into 100 bedded Rural Hospital
with all diagnostic and treatment facilities. (FRU).
RKS
RKS, a government led NGO, at every level down to PHC, is playing a significant role of
mobilizing community resources with administrative reforms in hospitals. Mainly RKS implies raising
and using funds locally. We saw several such reforms in various DH and CHC. This is very positive
and innovative development at the FRU level.
Provision for Health Sector in the Ninth Plan (1997-2002)
The thrust areas of the Ninth Plan have provisions of basic minimum services, women, and
disadvantage groups empowerment, people's participation process and self-reliance.
Apart from its top-priority to ubiquitous "relentless population growth", the Ninth Plan has
expressed its commitment to "... major share of public investment... (in) health care services, placing
greater emphasis ... on community-based systems." It has also stated
... that training of medical
professionals, willing to work in rural areas, through innovative medical schooling systems would be
given attention."
The Ninth Plan also highlights the need of decentralized planning and implementation and for
'devolution of funds'.
The Ninth Plan has increased its outlay for Social Sector substantially to 8077 crores (from 19%
in 8th Plan to 42% of the total in the Ninth Plan). This shift in its priorities reflects the emphasis on
basic minimum services at the national and at the state level. Basic Minimum Services includes capital
investment for equipment and buildings for Primary Health Care. It also commits to increase the
coverage of ICDS in rural and urban areas. The outlays for basic minimum services during the Ninth
Plan would be 40% of the entire social sector.
Evolution of the JSR Scheme
Considering the cue of the Ninth Plan, the peoples' felt need of easy accessibility of health
service with their participation in planning and implementing the health action, Rajiv Gandhi Mission
introduced an innovative JSR scheme in 1994-95. After reviewing a varied impact of the project by
RGM, the GoMP announced a SJSGY in July 2001.
29
REP0RT 0F CHCELL
0F JSR SCHEME OF MADHYA PRADESH: September -December 2001
SJSGY has three key factors:
SJSGY is a rights-based "framework of a guarantee by the government": a basic minimum health
service would mean provision of a package of essential health services and other health related
needs like nutrition, safe drinking water and sanitation.
SJSGY Planning and implementing at the district, panchayat and village level with he devolution
of funds.
■
Community control and creation of community level skills in managing and/or providing
basic
health care and prevention
The SJSGY is expected to reduction of infant mortality, reduction of maternal mortality,
universal immunization, reduction of birth rate, universal safe water coverage, universal sanitation
coverage and universal nutrition coverage to young children.
The SJSGY includes a District-level Program for Health. It will be built on the basis of a
collective problem definition through a Peoples' Survey of Health. The survey will map the current
status of health provision, providers, burden of disease and the status of the key determinants of
health. These will form the basis of a Village Health Register that would be used at the Panchayat
level. Village-level health indicators contained in the Village Health Register will be aggregated to
form district level Health Plans.
The district level the SJSGY will be guided by a district health committee headed by the
Chairperson of the ZP. It will be implemented by an Implementation Committee headed by the
District Collector The District Health Official will be the Congener of both Committees.
1. Collector (Chairperson and Mission Leader)
2.
Chairperson Health sub-Committee of Zilla Yojana Samiti
3.
Chairperson Health Committee of the Zilla Panchayat
• CEO ZP,
• EE PHED,
• District Women & Child Development officer,
• Civil Surgeon
• District Head of all Health Programs
• Mass Media Officer (health)
• Public Relations Officer
• Two Block Medical Officers
• Two representatives of NGOs in health sector
30
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
• Two representatives from Private Health Practitioners
• CMHO, Congener
SJSGY will be funded through the pooled resources available (a) by converging the funds
within health sector and (b) by provisions for determinants of health like nutrition, sanitation and
drinking water. In addition, funds will be made available as a District Level Community Health Action
Fund for the SJSGY.
Implementing SJSGY: Key Components of the SJSGY are the following:
A Core Set of Services to be guaranteed by the state government within a specified
time-frame at the village level:
1
2
•
Providing a trained JSR in each village by June 2002.
.
Providing a TEA in each village by June 2002.
•
Provision of Universal Immunization.
•
Three Antenatal checks for pregnant women.
•
Provision of safe drinking water -supply
•
Provision of nutrition cover to infants, <3 children, pregnant and lactating women
•
Sanitation in terms of solid waste management and waste water disposal in the village
A Village Health Register leading to a Village Community Health Plan
Development and Implementation of a District Community Health Mission Plan
Gram Swasthya Samiti Implementing SJSGY will be the responsibility of a Gram Swasthya
Samiti created under the GP at the village level. It will have a mandate for health action as well action
for safe water supply, sanitation and nutrition.
Gram Swasthya Samiti is a "stakeholders' committee constituted by the Gram Sabha under the
Panchayat Raj Act that incorporates Gram Swaraj. Gram Sabha will determine the number of
members of the standing committee on health. The number of members prescribed under the Act is
12 of which fifty % of the members shall belong to Scheduled Castes, Scheduled Tribes and Other
Backward Classes, two third of which shall be from Scheduled Castes, Scheduled Tribes and
remaining one third from other Backward Classes. The standing committee on health shall have at
least one-third women members.
The Health committee under the Act shall have a president who shall be elected by the
members of the committee form amongst themselves. The president shall be elected amongst the
members belonging to Scheduled Castes, Scheduled Tribes, Other Backward Classes, Other Category
and from amongst women members by rotation. The term of president shall be one year.
31
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
The Act also provides that the health committee shall elect from amongst the members of
Gram Sabha a Secretary by two-third majority of members of the committee. If there is "resident
Jan Swasthya Rakshak in the village he shall be nominated as Secretary of the Health Committee.
Village Health Plan
In all the 51,806 villages, a Lok Sampark Abhiyan on Health held in February made an effort to
prepare a database on the health status of each village. It still becomes a good starting point. This
survey would help in preparing the Village Health Register. Using this data, the GSS will be able to
carry out its mandate on health covering safe water supply, sanitation, and nutrition. The GSS can
also access resources that are collected by the Gram Vikas Kosh apart from the support provided by
the GoMP.
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
PART 3: MATERIAL AND METHODS
THE CHCELL TEAM
The CHCell team consisted of consultants working in the field of primary care. The team had following members:
1.
Dr Ravi Narayan
2.
Dr Dhruv Mankad
3.
Dr Shyam Ashtekar,
4.
Prof Mohammed
5.
Dr Abhay Shukla,
6.
Dr Shashikant Ahankari,
7.
Shri Amulya Nidhi
Preparatory visit
Two preparatory visits were conducted. The first, by Dr shyam ashtekar in March 2001. This
was an interview with RGM officials. Health dept and a filed visit to PHC/CHC and JSR villages and a
Bengali doctor. The purpose was to understand the likely tasks and nature of the JSR programme.
This helped to build a rapport and also to frame the TOR. Concept of the study was shared with the
RGM CH.
The second visit by the team members (Dt Rajgarh, block Khilchipur) came about in July 2001.
During this visit the team observed some training sessions, met working JSRs, trainers, Health
officers, RFWTCs etc. This gave the team a feel of the programme. It also helped frame actual
methods and questionnaires. Logistical planning was done after this visit.
Sufficient time was allocated between each visit to internalize the issues. Email exchange on
methods and questions helped sharpen the study tools.
Selecting districts
The main aim of the review exercise was to consult various stakeholders. Since, JSR Scheme
was implemented all over Madhya Pradesh, the team decided to visit various places to collect relevant
information.
Following the preparatory visit's experience, sample districts were selected purposefully based
on the following three criteria:
Human Development Index
Region representation
•
Tribal population
Feasibility was another factor considered. Since the stakeholders are present at the district, block and
village levels, samples of all the three locations were essential. In addition, RFWTCs were also
33
F
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
selected because curriculum designing, TOTs and the manual had major contributions from the
faculty.
Considering these criteria, we studied the following
•
6 districts, 2 blocks per districts, 1 CHC and PHC per block, 2 villages per CHC/PHC
•
3 Regional Family Welfare Training Centers
Some changes were made after consulting Dr Agnani, RGM. He was asked for his opinion
about the better districts in the JSR Scheme. The purpose was to look at what innovative, best
practices were implemented and initial problems solved.
After the deliberations among the team members and RGM 6 districts were selected based on
HDI. The blocks, the PHCs and the villages were to be selected in consultation with the CMHO of the
selected districts. Districts, blocks and villages visited by the teams are:
District
Barwani
Block
Name
Silavad
No
2
Villages________________
Name
______________
Seganva, Avali, Rehagun,
Bhutkira, Devali, Shely, Warla
No
6
Team
No.
1
Sendhwa
Bagh
Dhar
Dhar
Jabalpur
Satna
Guna
Bhopal
Dhamnod
Kukshi Nalcha
Barela
Majholi_____
Nagod,
Suhawal
Majhgawan
Maiher_____
Aron
Raghogad
Bairasia
Phanda
5
5
2
Kalgodi, Barha
Pipariya, Khabra_______
Umari Patelan, Sanwalia,
Kothi, Hiroundi
4
3
4
3
Salaya, Miana, Shirsee,
Nandner___________
4
4
1
5
Bagadi, Bagadi phata
Dhamnod,
Ali, Lonera, Patlipur
2
4
2
2
Gandhinagar
Time frame
The study was started in July 2001 (initial exploration); the field investigations done in
September 2-27 and analysis took another 8 weeks. The logistics for visiting selected Districts was
decided on the assumption that the team would cover the selected locations and the stakeholders in
districts 3 days. One buffer day was allowed to complete the logistics or for communicating among
the teams for any changes.
Sources of Data
The evaluation involved all the possible stakeholders at each level. A list was prepared and
they were clubbed as a Group based on their interaction level with the JSR Scheme, their stake level
34
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
and their interests in the actual functioning of the Scheme. The number of respondents with their
Groups is:
Level
Stakeholders
District, Blocks
Collector, CEO, Chairperson ZP, Janpad, members of JPSS
Village
Community, GP, GSS, Teachers, Users
District, Block CHCs , PHCs
CMHO, DHO, BMO, MOPHC
District, Block, PHCs
RFWTC, Trainers, Training I/C
Block, PHCs, Villages
ANM, MPW, Supervisors
Villages
AWW, TBA, Trainee or Practicing JSR
Block, PHCs, Villages
Pvt Med Practitioners, Bengali Doctors, Practicing VHGs, Pharmacists
All the levels
NGO, Journalists
ISSUES COVERED
Scheme /Selection
Gender, Education/ Other social factors, Distance factors, Non clinical Role, Who selected?
Training/T/JSR
Venue, Schedule, Method and Content, Changes, Trainers, TOT, Manual
WORK-CONTENT
Tasks, Illnesses, referral ^workload, Records & reports, NHP, Use of medicines & skills,
Problems/suggestions
Community
Links, NHP Linkage, GP/GS/GSS, Links with PMP, Users, PHC, Supervision/Referral, Feedback/Report,
Economy, Fee/Income, Honorarium, Depot holdership.
Data Collection Methods
This is a qualitative study, doing an in-depth inquiry of the programme over a small sample.
Intensive consultation was done on the methods and samples. Interviews, observations, FGDs were
the main instruments. All narration are recorded on field diaries and some photographs and
documents also collected.
Interviews
The main objective of the evaluation was to consult the stakeholders of JSR Scheme. It was
decided to have Focus Group Discussions with the Groups identified and direct interviews with
individual members. A set of issues addressed while interviewing the respondents was prepared. An
exhaustive list of questions related to each Group was prepared as given in Volume?.
35
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Opinion Poll:
Since the interviews would give the qualitative information about the trends among the
geopolitical levels, it was decided to collect opinions from the key informants representing the
Groups. A questionnaire was designed with 3 questions focusing on their suggestions. The
respondent should be involved in the JSR Scheme. See Volume?
JSRs' perceptions:
The JSRs are the pivots around which the Scheme has evolved. Their perceptions, opinions, experiences and
knowledge form the main plank of the study. This was the outlook of the Evaluation Team. An exhaustive
questionnaire was designed for Trainee JSRs and the Practicing JSRs. (PI See Volume2). Total of 204 Trainee
JSRs and 22 of Working JSRs have responded. (The Working JSR actually means one who has taken training
earlier. The nomenclature comes from the process—the PHC/CHC MO was asked to name any working JSR in the
area, hence the name working-JSR Some of them are not actually not working as JSRs)
Case Studies:
The family background, social milieu, their operational area, and their links with the various
health care providers and with the community form the basis on which the JSR model can be built up.
Profiles of Practicing or Trainee JSRs give insight to these aspects. See Volume2.
Case studies are
presented.
Consultation in the group:
At the end of each leg the team held discussions and at the end of the field study, the 4
members sat at Bhopal for two days discussing various concerns and issues investigated. The
exercise is presented in a table format. It was then circulated on email and finalized. The last
consultant added his remarks on email.
Study of documents
Documents of the JSR scheme, mainly Govt, orders and books published were studied.
ANALYSIS AND REPORT
•
The response sheets from JSRs were rendered into standard phrases evolved on perusal of
sheets. For instances responses to the question "what is your dream" evoked answers like want
to become a doctor, do daktari in village, run a clinic, doctor-ja/se banooetc. These were
converted into the key phrase "become doctor". This rendered the data treatable in Excel format.
•
The major challenge was in interviews. The consultants evolved together a free-list of questions
for each category of respondents, which was used as guiding list for interviews. Each consultant
into a word format converted the field diaries in a 4-Column table style (issue-subissue-response-
remark). The statements were again combed by one researcher, split into issue-wise rows and
then sorted by category. This gave us a bunch of responses from various respondents on each
36
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
issue. Scanning this enabled us to write the major opinion, variants and nuances. This was used
in writing the results and discussion. The full text was shared with all the team before finalization.
•
Two consultants studied the JSR manual and a separate review is enclosed.
•
The documents circulated by the Directorate of Health Services in Bhopal were studied separately
and the major points are listed in table.
•
There were several quotable quotes that describe the situation aptly and lively, we have used in
them in places in Hindi with an English version wherever necessary.
•
Several photographs of JSR situations, health institutes/health system and NHPs have been taken
by the team, and in a Qualitative study like this, we wish to reproduce. Pictures tell what
thousand words may not. Some of them can betray identities; the choice is therefore kept to
minimum.
37
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
PART 4: RESULTS AND DISCUSSION
THE JSR SCHEME
"The/ sche^ne/ iw ^ocrd/, every x/Mo^e/ wi21/ hove/ co vviexJVccdJca/ (xcxdxMYib, bid:
nobody (JSR) worlcy, the/JSR tycohowLeJ^^bird/’ ---A prccdhevnpcvthoJ^ofKu^
hdjh/ schoob
irv co dtscx^ydom/ lavJortpad/ lav Kcdui)
JSR scheme was a response to the gaps in health care services, which could be filled up. Why
not train some youth from the villages in basic medical care and let them earn a living in their villages
was the basic plank of JSR scheme when it was started in MP in 1995-96. TRYSEM loan was
promised, but was rarely given. A CMHO quipped: "Seekho, loan !e Io aurdookan kholo !" (Get
trained, take a loan and open a shop). In 2000, the scheme was re-launched as part of the health
guarantee scheme - SJSGY, placed in hands of the GS. So the scheme was constructed as part of the
primary health care effort. To date some 15000 JSRs have been trained in various districts.
In this study several respondents -mainly officers- have hailed the concept. They also affirm
that it exists only on paper. In the recent Lok Sampark Abhiyaan too, nobody talked about the
scheme. A media source corroborated this. In the entire tour of the State, none of the team members
came across a single slogan- wall writing, poster, and pamphlet about JSR in any villages. Several
villagers we met did not know what this scheme was. In Dhar district, where Smt Soniya Gandhi
launched the JSA scheme in July, the CEO of Zilla Janapad felt it was a 'mixed' picture.
Opinion poll indicates that there is a lack of preparedness / preparation of community for the JSR
Scheme.
An important and positive outcome of this study is that respondents from all levels recognise the
need of a health care provider in unserved villages, and indirectly appreciate the launching of the
JSR scheme. However neither the public health system nor the providers - not even the community
- are happy about implementing the scheme and sharing information about it.
At the level of PHC staff, some confusion about the old CHW and the new JSR scheme exists.
In media reports, and in elite circles, the oft-repeated phrase of" neem hakim, khatara-e-jaan"
signifies a cynical view of the scheme. But the common villager expressed the need for a village
based health care provider in no uncertain terms. That is the real mandate to the JSR scheme.
33
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
SELECTION
ftI wcuy told/ ctbout ^lectCn^ th&JSR i>v 18
(6 SCy and/ 3
per
SC) I dxyv^tknow the/role/ofJSR and/theZr olyjectt^e^. How canthey beexrme/Vr lav
ttvch/fhcort course/?”.. MCfPHC
ateA/ery level/”.. A CMHO
All the 22 JSR-Ws have responded that the gram panchayat and/or Sarpanch selected them. In
a sense this is true because the Sarpanch has to sign the 'avedarf (application) of the candidate. The
JSR-Ts also have responded similarly. The usual process is: a prospective candidate getting news of
(
the scheme from either PHC staff or the Janpad at the block level; making an application to the gram
panchayat and getting an approval. At places, there was some competition for the selection, decided
often in favour of merit. But in majority of places, the selection seems to be uneventful and without
much competition.
Women have been nearly left out, unless like in Guna where the District collector was keen on
AWWs getting the training. In Satna district, women SHGs however said that they were not aware of
the scheme, leave alone women-preference. Otherwise they had suitable women candidates.
The interviews underline similar trends, the candidate makes an application to gram
panchayat/ Sarpanch and then gets an approval for the same. If more candidates presented
themselves, higher education/more marks settled the issue.
What is not evident is the role of GS. Is the GS really involved, and does it have choices? Are
the choices exercised? These are moot questions. The selection process seems limited to giving an
application to Sarpanch/gram panchayat and getting it approved.
The role of medical officers in selection is weak.
From field /interviews and observations various JSR-background features appear.
Gram panchayat and Sarpanch figure frequently, as selectors and the Sarpanch is a proxy for
gram panchayat. In rare cases GS (3 different districts-Satna, Jabalpur, Dhar) is clearly mentioned.
In one case of GS, it was called because of selection-problems (caste? Or factionalism?). In the
second case, it is because of NGO influence. In the last case, GS met to discuss merit. Nomination
happened in two cases. In some cases CMHO + district committee have exercised the power and set
aside gram panchayat nominates. In some cases the Sarpanch has sent candidates from other
villages.
The Survey team (Lok Sampark Abhiyaan) had a role in preparing a list of candidates in one
district. In another district, CMHO was the key person in selection as he says "Anyone with a 10th Std.
Pass, applies to him directly or through the Sarpanch. It is the selection committee consisting of CEO,
39
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Janpad, BMO, SDO (Is the representative also a member? At a CMHO office, the LDC was called and
he said, "No. Gram panchayat has no role. No meetings take place for selection." But there is no
complaint from panchayats about political interference in the selection process.1"
Opinion poll confirms the findings about JSR selection. Also, the respondents felt that
selection at panchayat level is without much interest, and politics is also involved.
It is dear that A) Poor candidates have also been selected. B) Practising Pvt Med Practitioners have
managed an entry C) some selected JSRs are practising in adjoining villages; also non-residents have
been selected. D) Some JSRs are relatives of Sarpanch / member, or Pvt Med Practitioner (particularly
so in Bhopal district). The last three observations are disturbing, indeed.
How to select JSRs? Are there some criteria that can assure a better performance, sustained work
etc? This is an unresolved issue and the MP-JSR scheme can not be entirely blamed for that. Some
genera! framework for selection that emerges is: a woman, who has borne a child or two, some one
who has done some previous work including education, a willingness to work despite low or no
monetary return, a community loving person. How to ensure that women come forward is a proven
difficulty in MP. Partly it is purdah, lack of education and the workload in homes. Partly the system
has not done enough efforts.
The design of the scheme decides how JSRs will later function; the selection by itself can not steer
the programme. Important issues are training, linkages, supports, monitoring and incentives.
Distance
Nearly 67% of JSR-Ts belong to the same village. Surprisingly 33% come from some distance.
About 19% trainees stay more than 3 Kms away from the village of their work. Some candidates hail
from villages as far as 8-25 Kms. whether this last anomaly is a misconceived response to the
question of distance or is true: this is not possible to resolve here. Several Pvt Med Practitioners in
Bhopal, residing far away, have gained entry in the Scheme. This is just to get one more certificate
this one from the Govt.
Similarly not all JSR-Ws are from the village which has selected him. Of the 22 studied, 16 are
local candidates, another 2 within 2 km., 4 stay beyond 4km. We found 2 JSRs 'commuting' 12
km.'for work'. What were the reasons in selecting such distant candidates is unknown. Paucity of
educated candidates in the village could be one reason. Entry of non-resident Pvt Med Practitioners
may also be a cause.
The compulsion to select distant candidates is possibly due to non-availability of lCfh educated
candidates in the respective village. This clearly begs for community control for selecting a local
candidate. In addition, a change in conditions of educational qualification is pertinent. Rather than
selecting a distant candidate just because they are somewhat more educated. A local candidate with
40
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
a lower qualification would ensure availability of the JSR. The handicap of distance is too much to
offer any advantage over education.
Aspirations for being a JSR
About 38% of JSR-Ts could not word their expectations. " To gain knowledge" was the next
common statement. About 8% have frankly expressed the desire to become a doctor. They also
mention about earning and better future. This is understandable as they have family to support and
few other options.
Some statements relate to social service or serve the poor/patients/village etc. Little less than
half have actually stated the desire to serve the cause of community health in various phrases. So it is
not entirely true that everyone has come to become a 'doctor' at least on the response sheet.
Probably the desire to earn is a hidden agenda but no less legitimate. How to convert the positive
expectations into actual gains for the programme is something to be seen.
ttAcu^e' (JocCJJccbr kuchK kctcuvv
yolrv ekhb o^hcu 'KclC”:
Thokbcr, cuJSR tvcdvvcey.
From the interviews "Look for a job" /permission for allopathic practice" etc. recur. To
"develop the village" was another faint response.
Education of candidates
Majority of JSR-Ws is either 12th or graduates. This probably implies that among the available
candidates in the village the higher educated boys were selected. Thus, the selection was merit and
not preference based. So 10th passed candidates could have been selected.
Over half of the trainees in both men and women are 12th educated. Graduates and post
graduates make about 35% (This group can be a source of attrition.). The lowest qualification, which
is 10th, comprise 14% of the trainees. The education pattern is similar for men and women trainees.
Selection of higher-educated candidates mayjeopardise the stability of the programme as the
higher educated will fly off to other courses and opportunities sooner or later. It also has a negative
effect on selection of women since in most villages the men will be more educated. If the selection
peg is education alone, women will be mostly sidelined.
Gender
..(Svx/atkwtyxuhy not-select womewcvy
JS'Ry.ZMa/
41
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
cwd/
pardaK, in old ca^te^ alik^. Purdahwali/
-law ar&iA^
abl&tcr works, but novv-pardah
w owners wdZ bes ables to- do- ^orviethtri^.
Among the JSR trained so far, men predominate--85 %. The men-preponderance in JSR
programme betrays the hidden bias of the programme. There is no effort of consulting various
sectors of the health system about how women can be enrolled. Even community is unaware of
women-preference. So is it with selectors.
The new trainee sample of 204 also is male dominated, especially if we omit the AWWs
selected because of special initiative by the Collector, Guna. Why is the programme keeping out
women? It is a host of factors - the educational difference between available men and women in the
area, lack of special emphasis/bias for women selection, training requirements (e.g. months away
from home). But probably the most poignant cause came from an ANM. She said "a family values a
girl as useful person in several ways in the family chores, while an educated boy is often good for
nothing, if not farming nor doing any other work; they are loafing around, and parents therefore coax
them take such a course rather than roam here or there''. Though this takes a dim view of the boys'
social/familial profile at this age, there is some truth in it in the context of a 10th passed jobless boy in
most villages in India. Agriculture is poor employment, and there is no other job around that can fill
his mind. This one—of becoming a doctor—is enticing.
The ICf passed-aspirant-young-man is in the entrepreneur mode of life. His view ofJSR work is
ambitious; of a future breadwinner. The current JSR programme is failing to answer this aspiration.
The result is either high attrition or distortion of the JSR model itse/finto quack-mode at the
earliest.
The interviews confirmed the male bias. There is evidence ofstability if the 'bahu' is selected (At
one PHC, 3 out of 12 SC staff, 3 were couples~6 SC staff—and two couples were staying in the
village for over 10 years)
There is a virtue in making the programme a woman-centred one. First of allf they would come in
the JSR frame only after 25+ years of age, because of marriage, village shifting, and child bearing.
That makes them more mature candidates. Secondly, often they are not the only breadwinners of
the family, for the husband is traditionally the money earner even if stereotyped. The aspiration of
earning is for supplementary income, not running the family. Even if this is rather unjust to women
and their work is less valued, the programme can use the virtue and bring some sanity in the JSR
programme.
42
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
That women JSRs would bring a depth to the programme content is another important matter.
Women's Health, Child Health. FW etc can benefit from women-JSRs. Men JSRs will make it an
entirely curative 'pills-for-ills'programme.
Although, it is tempting to make JSR an all-women programme, the situation in MP is already made.
It is a fact that the selection so far and future trainees are mostly young men and not women. The
high attrition can be a blessing in disguise in this context.
The A WW enrolment is a positive development in this direction. Half-employed and poorly paid by
the system, A WWs can benefit from this programme and in turn do a lot ofgood to the entire
programme. But not all A WWs are ready candidates for JSR, as only 10% are somewhat
educationally qualified.
To bring in more women in any such programme, relaxing educational limits, accommodation
facilities, other supports, and some form of regular income are mandatory.
AGE
The age range of JSR-Ws is 21-46 years. The higher end is largely because of old CHWs in the
study sample. Otherwise the range is 21-38 years. The average is 29 years, which means the average
candidate is past his new job seeker age.
For JSR-Ts the mean ages are 24.5 years and 29 years for men and women. The older
candidates are mainly some CHWs and AWWs.
The age signifies entry of mid-twenty year age group candidates. That means the candidates
can stay in the programme if the programme itself is sustainable.
New trainees are generally younger aspirants for any new opportunity around. The JSR programme,
from previous experience, is poor on holding incumbents. While young age entrants are good for
training/learning of academics, their life experience is less than a rich one. It also implies future loss
of candidates if the programme does not ensure its sustainability.
There can be almost a generation gap in the 20+ group and the 30+ group in terms of learning
abilities, life-experience and both the groups demand different kinds of training-learning
mechanisms.
SC/ST
Of the 22 JSR-Ws, 10 are SC/ST. Of the trainees about 26% belong to SC and ST groups, SC
predominating. Some respondents had reservations about caste as selection criterion. Says a CMHO,
"Supervising JSR is a problem if SC/ST are preferred. False report and false work are problems.
Criteria for selection should be beyond caste: BPL from any caste to be preferred. JSR must be
43
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
committed with good moral. JSR should have high education so that people demand service and are
compelled to serve.”
Caste can be important from three angles, a) socialjustice in selection, b) ensuring access to SC/ST
community c) SC/ST will value the opportunity than the others who have more avenues. Several
interviews have suggested that SC/STcandidates will be better JSRs.
Will caste change either way affect the quality of services of a JSR? There is no reason to believe
that. Good training will obviate if at all any such inequalities exist.
OLD CHWs
'Achho/, ye/ vuxye/ vxcdxb, woh/pachas rapiya/waaI^chaJxZye/?,’(O'h/! not the/
new oney, yow wcunt the/ fifty rtcpeewalah^l!) —O rv cwkincy can/ MPW cdyovct jhowCn^
ayold/CHWy iavthe/PHC area/
"Role/erfJSK i^tero-much/
compared/) thcua/CHV”. A BMC?
It looks as if old CHWs are hardly counted for this programme. Only 2 of the trainees are old
CHWs. Because of confusing nomenclature (both new and old schemes are JSR in Hindi), we were
shown two old CHWs as JSR-Ws in Morena district. Both practising like Pvt Med Practitioners was
another matter. But in general the JSR programme from 95-96 is distanced from the old CHW. The
typical old-CHW is in forties, trained in 1978-85 period, educated about 7th, has a full family to look
after, and almost never heeded by the health system so far. The fifty Rs. (paid 600 once annually for
convenience of administration) have kept his thin thread with the health system, but that is all. The
old CHW, says one GR, needs to be given preference in selection. We saw in a village of Aron-Guna
that the health system or the gram panchayat did not even think of the old CHW for JSR in village. He
was a typical plus forty man of family, a farmer with two grown up boys and bahus. His kit bag now
contains important land-records in place of medicines.
A CMHO saw no difference between the CHW and JSR. ("Training of JSR is not much different
from VHGs, their training is basically similar.")
Could such a CHW-elder, even if trained in the new programme befit the JSR role model? This
should have been left to Grampanchayat-nominations and entry tests with sufficient notice. They
have been bypassed, and it looks they do not look upon themselves as natural candidates for the
new programme.
However, if there were a functioning CHW programme, the JSR programme could have updated the
same. Irony is that the current JSR programme is treading the same path of training and linkages,
only minus the 50 RS a month honorarium. Two programmes, 20 years away from each other, the
44
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
first one jinxed and second following the same. There is a lot to learn for the new programme from
the old one—mainly failures.
For some old CHWs, like the two we met in Morena, not getting in the JSR scheme has hardly
mattered and they have clinics with injection practice. Those who were smart made their clinics in
eighties, those who did not can not do it even now. So if clinic is the test for a functioning
JSR/CHW, the CHWs are not good candidates for becoming JSRs.
TBA SELECTION
“Atyccr dot/ v\c/ chhodcu ho-jachiha/ bachha/ kcu kaam/, hcomC ko- kcorvxa/ hogaz. ”
ccrv Official/ fLo^a^o oyo A\\)\\) CwShbvpart village/
Several Government Resolutions direct the health machinery to select TBAs or TBA family
members. Nowhere we found this given an effect. TBAs, the typical old woman without much as
literacy had anyway nothing to do with the new JSR training. If it meant women members, all the
factors and biases listed above in gender are notable. That has remained only a wish.
Then there is some trouble on the TBA front itself, as we noticed a Govt, slogan on an ICDS
centre that mentioned TBAs abandoning the traditional lowly valued work.
AWW asJSRs
“I thought Ct wccy co cjood/ Cdeco, ivcrmeyv cond/ dudxdrcvo v\cexd/ health/ ^^rvCccy
wioreA dl^^ict Collector
Irv co dOytvCct of 2000
obotd: 100 ore/10^ edacccted/<t: A
Collector
",4 ccrey woh/ dcCUycavalt kyco kcccowv karo^C?(Whcut work/ the ‘porrCdcje/
cooking halyyfitter ccurv de-?” - Jccrtpad/ A dhyaksha/
Communities at Jabalpur and Dhar found the AWW helpful Anganwadi. They refer children to
her for treatment. In Dhar she belonged to the same village. The community expressed that she can
be trained as a JSR also. She belongs to the same village and should be equipped with medicines.
The senior bureaucrats and the medical community have different views among themselves.
Some would prefer the AWW than the existing candidates as JSR. In Guna, the Collector has taken an
initiative to send the AWW for the training. The Training Centres at Gwalior and Jabalpur also suggest
AWW as the RFWTCs have already trained the AWW to some extent. Few are skeptical about their
effectiveness because they have a limited knowledge about illnesses and medicines (but can be
trained).
45
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Those who disagree do so because of their social constraints, work schedule and educational
status. They doubted whether there are AWW of VIII standard in tribal area. Similarly, in other area
the AWW also follow the Purdah practice and they would not be provide health care service to men.
The AWW also have heavy workload according to a group of AWW supervisors in Dhar. " Already they
are pareshan working for ICDS, Teekakaran, ANC and surveys, SHG etc" Purdah is significant problem
in case of many AWWs, according a senior PHC staff.
The main problem with AWW doubling up as the new JSR is that only 10% AWWs are lCfh trained.
Some A WWs have Just about primary education.
Differences between AWW scheme and JSR scheme
scheme
Tasks
Defined space
JSR scheme
Care of children and women,
Medical treatment of all adults, men, women,
traditionally already women's
children, bade-bood/e-- traditionally a man's job, BUT
tasks
the preventive tasks is visibly a nurse's job
Within a well defined space-
Exposed to market and entire society
chardiwari
Starting plank
No starting problems.
Some capital, clinic space is essential
Income
Small but definite,
Earning fees from clients is the main source in
supplementary yes, but there will
scheme design. This is difficult in a village even for
always be some woman to work
men, not to speak of women-bahus.
for it.
Selection
Can do with small education
Educated young daughters are going away after
problems
(most AWWs have only primary
marriage, new educated bahusare family-bound till
education)
they have 2-3 children, can be available only after 5-
10 years after marriage.
Legal hassles
Safe, no problem
Professional hazards are inevitable. No defined legal
support or mechanism of back up.
Panchayat
Minimal to nil
management
Major involvement, continuous negotiation through
GSS
Previous health experience of trainees
About 82% of trainees had no previous experience. Nearly 3.5% had either worked with a
private doctor or at a medical store. Some were CHWs Depot holders from malaria and some belong
to Aanganwadis.
The predominant section is of inexperienced candidates. This is good in a way because the
programme can mode! them as JSRs rather than try to undo the habits of experienced private
46
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
doctors. Yet the experience of a depot holder, A WW or NGO is a favourable factor as they are
someway linked to the public health system. On the other hand inexperience also entails a lot of
responsibility on the training system.
Selection of Pvt Med Practitioners as JSRs
Are already practising private doctors (Pvt Med Practitioners) getting selected? And is it good or
bad if they are selected? None among the 22 JSR-Ws were previous Pvt Med Practitioners, but the
fact remains that 2% of JSR-Ts are already Pvt Med Practitioners.
The number is not too big to blame the entire programme. It is difficult to stop this from happening
since village panchayats can opt for such candidates with even good intentions of helping someone
who is helping them. The possibility of survival is also greater for such candidates than other ones.
Fortunately not every village has such candidates to offer. This becomes a limiting factor (some
cases of a village selecting a distant candidate are seen and can be curbed). In the end more of
them will survive and find a foothold.
Yes, there are some Pvt Med Practitioners mingling with the scheme. The trouble is not
in numbers, but in the influence of even small numbers in every batch, the role-modeI
contagion, even colouring the views ofAWWs. So more worrisome is the fact that even
non Pvt Med Practitioner JSRs are adopting themselves to the Pvt Med Practitioner
quack slot and becoming inseparable from the former Pvt Med Practitioners. The
emphasis should be on the system andprocess of the JSR scheme, rather than on Pvt
Med Practitioners or people who joined it.
Typically, the Pvt Med Practitioner turned JSR or JSR turned Pvt Med Practitioner for that matter,
would hardly look beyond injection-saline as the mainstay, care little for preventive-promotive, the
National Health Programmes, the sub-centre staff and the PHC MOs. The aim is for earning a
certificate, a piece ofpaper to brandish in any future trouble. It is not the training; it is the
ratification that matters for Pvt Med Practitioners. This needs attention.
While it is easy to point out this 'fatal' attraction, the remedies are no easy to find in a programme
that makes enterprise its only plank ofsustenance. Several things need to be tried before arriving at
community needs (see Group-consu/tation in part 4). a winning formula that will ensure sustenance
ofJSRs, in the framework of the programme.
47
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
TRAINING3 AND TRAINEES
Districts and blocks
The interview trainees (204) are from 6 Districts and 19 blocks. Over half of these trainees are
from Bhopal and Jabalpur districts. The other half belong to blocks of Barwani, Bairasiya, Fanda and
Mazauli.
Training venue
PHC and CHC comprise 3/4th of the training venues. In Guna and Bhopal the district place was
the training venue for some time. The district hospital was used in Bhopal for training JSRs.
In terms of access, perspective and friendliness PHC/CHC are optimum arrangements. For clinical
experience the DH and the CHC are better. The DH could end up strengthening the doctor model-
JSR. However, the main handicap is lack of the training team at the PHC /CHC. Actually this is a
major constraint of the current programme that the overworked medical officer of CHC/PHC is
saddled with JSR training.
In Jabalpur, the Govt. Nursing College in the DH was the JSR-training venue. This is
exceptional, due to highly a motivated team at the district level including CMHO, DPHN, Principal
Nursing College, and Principal RFWTC. The several advantages- the accommodation, AV aids, training
team, closeness to DH and the clinical work, discipline in training, professional approach as trainers.
This training centre has a reputation, and we saw four candidates waiting for the DPHN to allow them
to take their JSR training here from distant blocks of the district. Can the programme take a cue from
this?
Physical facilities
In most places, there is no special venue for classroom. OPD-clinic, corridor, empty ward are
usual places. There was not even durree supplied in many places. In places blackboard also was not
available. (One MO confessed that he would buy it from contingency!). In many places we saw them
huddled in small rooms, or taking the sitting stool for training hours. Posters or AV aids were nearly
absent.
Accommodation was possible in DH. At most places, students rented private rooms and thus
went the stipend they earned. There were JSR-Ts who travelled daily on bicycle from their villages
3 Here we are discussing only official training venues. However, it is noteworthy that we found
newspaper advertisement and wall posters of private 'J S R' training classes in three cities. Apparently, one such
class charges Rs. 13,000 as training fee.
48
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
situated as far as 25 kms. In some places lunch was the casualty for the JSR-Ts had no money or
time left for cooking. Women candidates had difficulties because of this.
Most places did not have public toilets. If at all, they had to use the ward toilet. This was
another major problem for the women candidates. Rarely, any health facilities have toilets for the
staff. This underlines the existing gender bias in the HS.
Can a CHC be converted as a regular training centre with mandatory though modest physical and
training facilities? This will entail some cost and pace the JSR training.
Training calendars
In the various blocks training calendars has started differently. This is according to local
conveniences but creates a variable gap between course completion and the final tests.
Hours of training
KJobody lacvy tiAVie' to- tvottv, Tuy done/ wiotnly by porccwteciicy, no- doo
wcunty to- do-thby
JSR boyyJnyttho re^tyter ccnJ ^o-to-px/t dooy tolecww. A Lcdrte^dvntclaAvCHC
The official training timetable given in the manual reads thus: 9-12 clinical (OPD+ ward etc),
12-1 lecture, l-3pm lunch and rest, 3-4pm lecture. 4-5pm clinic (OPD). This more or less suits
PHC/CHC work schedule. In one venue the afternoon sessions was inoperative. In JSR training at the
Jabalpur Nursing school, there were full sessions attended by trainers both in the morning and the
afternoon.
The pattern seems to be: sitting in OPD/Lab/dressing room in the morning hours and some
actual discussion/reading in the afternoons. At some places there was no mention of afternoon
training.
Batch strength
The batch strength was 7-75, so go the JSR-W responses. The lower figure speaks of poor
selection process and a compulsion to start training, while the latter speaks about district-centre
batches. The average 22+ is the optimum for participatory training and the PHC/CHC facilities. One of
the trainers suggests that the optimum batch strength is 25. The usual CHC sitting facilities can not
accommodate more.
Methods of training
Trainees spend their prime-time morning in the 'clinical sections'- which is OPD and wards.
Here, observation and some hands-on training are the main methods. Trainee-JSR actually watches
clinical work-examination of patients, lab tests, and injections/saline, dressing, stitching wounds,
childbirth etc. This is, for clinical training, the best method of learning and teaching. This saves active
49
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
trainer-time that the PHC is already short of. Unfortunately, this also underlines the doctor-role model
and the injection/saline procedures as the mainstay of health work.
In the classroom the predominant method is manual reading or lectures.
Interviews have reviewed that nearly all of them, AWWs included wanted to learn injections
and saline. One medical Officer quipped that "they never leave the injection room". Post-mortem
examination was used as a method of training at one CHC.
Fieldwork has been mentioned by some trainees, which meant going with sub centre staff
doing home visits or vaccination clinics. Many trainees have mentioned a subject (like anatomy)
instead of the method of training. The "topics" have recurred in various responses on methods, skills
etc. scant mentions of audio-visual methods, body mapping also is found.
In interviews, most of the trainees and the trainers at the CHC/PHC level recognised that
there is a need of AV aids and models to make the training effective.
Opinion poll expresses that the JSRs should be trained by experienced trainers of which there
is a shortage
Trainers
"B M <9 kcr ter Yna^Yi&kV
. - H eeMh A ^M’cevvt
The medical officer PHC/CHC is the main trainer, and often the sole one. At district places,
other trainers from the DH can be involved. At times and in some places the Second MO has helped.
Nurses, BEE, other health staff share some training tasks. In general, the trainers have little time and
mental space for the JSR training. A CMHO observed that there should be a separate training team.
The trainer-trainee relation is different everywhere. In more than one place, the MOs train
them all in injections and saline-infusion. In one CHC, the MO took them on rounds and created
bonds to increase his network through JSR. This, ostensibly, has helped him with more patients and
more earnings. In other CHC, the MO was completely frustrated by the batch, the worthlessness of
training and the quackery that lay in future. He was barely able to give an hour or two per week for
training, immersed as he was in other administrative work. The CM visited his PHC once, and the
latter was briefed about the difficulties in the programme and possible dangers of such a scheme.
50
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
A typical interview with trainers
Problems
Funds are not coming timely
This batch
40, only 20 turn up. It is 2 and half months. The timing is 9-1 pm. The boys
leave at 1pm, some of them share and stay in private room
Other trainers
Nobody is interested, only a team member can give some time-one hour in
two days. Other MOs are just not responsible for this programme
Methods of training
I like training; A team member even tried the quiz type for ORT, which they
like very much. They are attentive when I teach.
AV aids
None, even district IEC has nothing, not even blackboards
Time
Very difficult. I have several things to do, no breathing time. This is a busy
and VIP place. With difficulty I can give 2 hrs every week.
Ed of JSR
All 10th
Women
None
Previous batch
Oct 2000.only one batch so far. The statistics are 95- 3/15, 96 --17/25,
2000-24/- result awaited.
Passed
So far only 20 have passed in this block, that was from an old batch. The
Oct 200 batch gave final exam but results are awaited even after 2 months
Exam venue
Guna-the district place.
Exam
Gap between training and exam
Anybody for training
from district?_____
Manual
None, never
Yes, and it is ok, but needs modifications
Records/report of JSR
Nothing
Any follow up after
training___________
ANM/MPW linkage
Nobody comes; esp. the failed ones never come.
Posters for health
education
None, even we have little of that. Whatever we have, goes to JSRs through
Practical training
We call them and show the procedures-dressing, dispensing, pathology lab
JSR aspirations
They look upon this as a livelihood, think it is daktari
Preventive
programmes
If we give
honorarium?
Other problems
No JSR is interested, since there is no payment
None, except some medicines are given by them to the JSR
MPWs
Will make a difference
No linkage
No follow up- nobody turns up to the PHC for entire year. I am yet to see
the 97 guys myself
Have become independent
(Son h
07197
_____
CJoi
xo* )»I
51
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Consider themselves superior to sisters
Facilities
Nothing, sit on the floor, there is no durree. The stipend-grant is yet to
arrive
National Health
No-nothing
Programmes
Health education
Nothing
How many JSRs are
Hardly 12
active in this block
Another trainer-PHN Guna
Issues
Response/Observations
Policy/ Scheme
Good scheme, In six months training village level health worker can be trained upto the
need.
Selection
Female should be preferred. If there is female JSR all National Health Programmers can
be implemented through her.
But in villages presently male JSRs have been preferred because they can start practice
and earn money, while women cannot do practice on their own.
Education
10th pass candidates are rarely available in villages. So this condition should be relaxed.
Entrance test will be better.
Linkage with AWW
AWWs should be preferred.
AWW + JSR will be best model.
AWWs are already known in the village, In their duties most of the MCH program is
covered.
Training
Experience of last 5-10 yrs as trainer in MPW training centre.
Manual- good
Methodology
Lecture, Demonstration. They have performed role models.
Use of flipcharts, Blackboards.
OHP, Projector, TV-VCR not used so far.
9a.m. to 3 p.m. continues lectures at one place.
Practical training
For practical training they have been posted in Guna District Hospital in various
departments.
There is demand of training for injections.
Time - table
Some lectures on attitude building, social behaviour should be included. Both of them
teach on these subjects.
Women's Health
Exam of pregnant woman has been taught. No need to train about conducting
deliveries, because there will be one trained Dai in every village.
Examination
They have conducted monthly tests so far. After three months full paper of 100 marks.
Final exam will be after six months.
Suggestions
In service training's, reorientation training should be conducted.
TA/DA should be given.
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Feed back
AWW--Supervisor--CDPO--DPO—Female MPW- Supervisor- BMO-CMHO
Future
If good feedback and proper utilisation will be done, then bright future.
Honorarium
Minimum Rs. 500/-permonth should be given
Subjects covered and desired
Immunisation and malaria overweigh all the other topics. Anatomy, ANC, MCH are also there.
Practical topics like dressing, PBS, sanitation, also figure. The list also includes officially forbidden
things like injections and saline. The free list extends to 113 topics. The range of subjects looks quiet
impressive but Ayurveda is nearly missing. The subjects mentioned very closely resemble the list in
the JSR manual, since manual reading is a common factor. The training is in various phases; for some
it has just started.
However covering the manual is not all. Many trainees feel it is not enough, some feel it is
useless. There are many interviews insisting about diagnostics, protocols, treatment details,
medicines, pharmacology etc. to make them useful in a village. In general, it is not the list of
subjects, but also the range and depth of subjects, orientation and problem solving that are
important.
A CASE STORY OF JSR TRAINING
This is based on interview with Dr. V. who is a specialist in ABC working here since last 5 years.
This CHC covers total of 236 villages in this block of which 227 are occupied.
JSRs have been trained here in previous batches (1995 - 19; 1996 - 18; 1997-98 - 7). All of
these are males. He was unable to give the break-up of SC/ ST and seemed only vaguely aware of
need to give preference to them. The MO was unable to clearly say how many of the trained JSRs are
functional. He vaguely said - less than half. When asked further to name active JSRs he specifically
mentioned only two.
Other medical Training of trainees
Some of the working and some trainees have had other training opportunities: a clinic, Pvt.
hospital, medical store, even at PHC. The period was from 6-month s to 2 years. Some trainees will
look for such training afterwards. Most of them consider some other training cable essential.
Functioning of existing JSRs
About assistance in public health activities, he said we want them to come for monthly
meetings but they do not come. Only 2-3 come for such meetings as no travel cost is given. A few
who are active help in Pulse polio and immunisation? He said that they do not have any effective
monitoring system for JSRs. Many of them are depot holders and have chlorine tablets, ORS packets,
and Nirodh and OC pills. No loans have been disbursed to JSRs in recent batches.
53
F
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Present batch ofJSR trainees
There are 48 trainees in the present batch being trained at this CHC. Selection has been done
primarily on three criteria - Age, education and place of residence. Of these 3 are women. The
training started on 16 July but the full batch was constituted by the end of the month of July.
According to him, about 28-30 of the trainees come regularly.
Training
His major complaint was that there is no place to train the JSRs. From 10 am to 12 noon, they
stand in groups in various rooms -Injection room, X-ray room, Lab / malaria slides, Ophthalmic room,
Dressing room, TB, Registration, OPD. He was unable to say what the trainees do in rooms like
injection, X-ray, registration, he was not clear. He said that since these are activities going on at the
CHC, the JSRs should see them.
Classes are held from 12 to 1 noon. This is done in one of the OPD rooms, which he feels is
not really adequate. When A team member asked him which topic is being taught currently, he did
not know. He said about half of the trainees do not have the training manuals yet. He said' two JSRs
share one manual'. Among 48 trainees there are 28 manuals. There are no training charts, models
etc. for JSR training. According to Dr. V. the attendance of the trainees is not very regular. But they
take 75% attendance as a criterion to give allowance.
For Ayurvedic training, since the last batch they are sent for 1 month to Ayurvedic hospital in
Bhopal.
Suggestions
JSRs should be used for motivation for immunization, FP camps etc. Instead " Apna kaam
chhod kar daktary karne iagte hain. I.V. dene iagte hain. Hamara koi control nahin." (Instead of their
assigned tasks, they start functioning as a doctor, give I.V. We have no control. )"Bataaigayi davaon
ke aiava bhi dava dene iagte hain. /Co/guideline nahi hai. Guideline hona chah/}e." (They give
medicines other than the one they are trained for. There is no guideline. There should be a protocol.)
According to the trainer:
• Training should not be at block level. It should be delegated to PSM departments.
• BMOs do not have time for such training and are not so keenly interested in it.
• There should be separate space at block level, flip charts, training facilities.
• Some honorarium should be given to JSRs.
Comments from other MOs in the CHC - the training venue.
• They are preparing quacks. IV fluids bhi iaga rahe hain." (They are also giving I. V. fluids.)
At least they should participate in National Health Programmes.
54
r
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
• Some minimum honorarium should be given so that a link is maintained. Otherwise "PK?/?
apni practice mein zyada interested hain." (They are more interested in their practice.)
• 6 months is too short a period for training. It should be increased to 1 year. Education should
be 12th pass.
• Selection is faulty. "50% apne gaon ke nahin hain.^Vney do not belong to the village they are
selected from.) " People from the actual villages will not benefit. About 50% are from
Bhopal city or villages other than their own, who have taken a letter from the Sarpanch of
some village
Opinion about training
IVe/
quccbchy, I fe^heTple^, PL do- not cjucote/ wiy ncuneT —co
trcUner
The "good" opinion prevails in the response-sheets and perhaps this is expected as a safe word
on records. However 7 trainees have expressed that it is of no use. Perhaps the true opinions of
trainees can not be known through a written questionnaire. In the interviews many trainees have
opined about poor training conditions and content.
In the Opinion poll, the respondents have expressed that there is alLack of training in proper referral.
Also they feel that there is too much focus on training on medicines and injections. There is
inadequate attention to community level action and community mobilization.
Interim tests
More than half have just begun the training hence there is no interim test. Others have
mentioned of a monthly and three monthly interim tests. There are mentions of both oral and written
tests.
Interim tests have two purposes - a) to remind and to familiarise them about final test formats, b)
Improve the training process after the feedback. The latter is more important. We feit, after looking
at the process that none of these purposes are well served. This is a part of formative assessment.
Therefor there is a need for the trainer-trainee dialogue guiding the trainee for better learning. At
the same time, the results should also lead to dialogue among the trainers for a better training
inputs. There is a need for more inputs and resources to carry out this feedback effectively.
Skills-acquird and desired
Pulse, temperature and PBS are common skills acquired according to JSR-T. Check up, history
taking, breath counting, weight, ORS. Dressing, injection, ANC check-up are some of the other skills
acquired. The concept of skill is not very well defined. Skills are facility of doing something with
hands, communication or use of instruments. In the acquired skills list, JSR-Ts have mentioned a full
55
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
spectrum of necessary skills they should acquire. Interestingly the list includes several skills not
mentioned in the JSR manual.
The foremost amongst the desired skills are giving injection and saline has 79 and 50 of the
Trainee-JSRs expressed it. Others may have not mentioned it. Stitching wounds is a next prominent
topic mentioned. The list makes an interesting repertoire of skills that are directly and indirectly
required for making a JSR effective in the village setting.
Elementary diagnostic skills like pulse, Temperature, blood smear, breath count, are the main
responses. Trainees also mention in general terms "Medical Treatment". There are some other skills
that can be clubbed as preventive-promotive (sanitation, Water purification, Health Education.) Some
8 trainees have learnt about injections and many more probably have declined to put it on paper.
Among the desired skills a thumping majority underlines injections and saline. Some trainees
have mentioned even a surgery, ultrasound, vacuum extraction of baby, X-Ray, ECG, Computers The
use of stethoscope is barely mentioned but may be a subdued desire. Some trainees have frankly
expressed to learn skills of a doctor. The list thinly expresses preventive-promotive skills. The list
makes 422 items of interesting clinical and other skills that JSRs desired to learn.
Healing calls for both knowledge and skills, not to speak of attitudes. Diagnosis also calls for lot
of skills and hand skills too. It is skills that giving the main healing touch the sacred contact between
the healer and the healed. Skills - especially handskills - are therefore central to any learning of
healing. Allopathy at primary care is not just tablets and syrups. It has several other components.
More so about other healing systems (except Homeopathy, which is drug-inquiry, based). There are
entirely hand-skills systems like accupressure/ puncture and massage, and physiotherapy. Here the
JSR can learn lot more and get an edge over the quack-Pvt Med Practitioners. The desired-skills listed
by the JSRs are noteworthy and more can be added to the repertoire to make a truly different
scheme than a quack-making scheme. The JSR cell should think and do positive action on this, and
sooner before the JSRs are lost from the programme or to the quack-pool. (See Volume? for some list
for primary care skills).
Treatment of diarrhoea
ORS, home fluids and SSS predominate in the responses. The mention of tablets like metro,
furazolidine, norflox etc. possibly suggests that they have also considered adult diarrhoea. Or are they
giving it to a child also? The ORS/HF response is heartening. One team found that no trainee could
tell the correct formula for SSS.
From interviews ORS is a common response, but is SSS-mention is infrequent. Injectable
antibiotics are prominent on their minds. DNS+ polybion is also mentioned.
56
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Fever dignoses and maleria dignoses
This question has resulted in a plethora of responses. Predominate mention is of fever chills
and PBS. The training doesn't include any protocol and fever diagnoses and hence the responses are
understandable. The pattern seems to be to think that every fever is malaria.
The same pattern repeats in the question of malaria diagnosis. The sum total is fever= malaria.
This equation is deep rooted in the health services, no wonder it surfaces here.
From interviews malaria dominates the responses, pneumonia coming next.
An interview with trainees
Time table
5 months here, one month for practical at SC
9-12 we sit in OPD, 12 to 1.30 pm theory lectures, 2.30 t 5 pm again theory
lectures
Selection
Village GS met, and decided from 4-5 candidates on basis of merit
Stipend
not yet
Some say you come
for the 500 pm
stipend__________
Want to learn what
No, we have better wages back home 40 daily. And we have to spend in travel
(10-20 RS daily) and the chai-pani
Stitches, inj, saline, and some medicines (pain/ulti/petdard/anemia/lm/) they
name medicines, diclofenac, baralgan, lomofen, dependal etc
what about the
medicins taught
here__________
Kirana dookan in
every village?
Why not buy
medicines?_____
Training
Any illnesses you
want to learn
Less than what the grocers shop (they keep all the above, even applicaps). How
can we tell people to go get it from the kiranal
No, but 2-3 km away anywhere.
No permission, there is no 'ROK'; 'fir bhi'
Less than the grocer's knowledge of medicines
Ultf dast, malaria, typhoid, foda funsi, malnutrition, measles, white discharge
(the last one upon asking a girl., there are three girls)
Current medicines
Bl powder, ORS powder, paracetomol, chloroquine, condom that is all
Practical
Patti, chitiniikaina, watching the ward work. 9-12 and 4-5. We sit in the OPD in
batches of three.
Any CHW in this
training
There is one, he has only ORS packets, para, chloroquine and bleaching powder
Expenses in training
10 RS for bus fare, 10 for chaipani, so 20 everyday. That takes care of the
from the Govt.
stipend
Fees of Pvt. docs
At least 50 RS taking all costs (fees/travels)
What fees do you
expect from people
10-5 RS. But people already know us, so may not pay fees, so we should get
How many farmers
some honorarium
About half of them, others do wage labour
57
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
in this batch
Women
3 in the batch, one married. The other girls! (What will they do after the are
married off to another village?)
What about
previous JSRs
How many can
afford to attend
training______
Suggestions
70% are not working (bandkar diya}
Most of us. But after 4-5 months like this we should be able to earn something.
Hamart value badhana chahiye
Treatment of malaria
Most trainees are yet to learn this topic hence there is a major component of non-response.
The mention of malaria tablet is round about. Some trainees have named Chloroquine and some
Paracetamol tablet.
Final tests
"I \ucw
“Dcr not keep tke/
centra
I
c^JSR iwBh&pcd/
th& e^vm/ centra cw\d/yow 12/
the/
dtffer&nce/” PrMcCp(tbKFWTC
Final tests are conducted by the dept once in a year, and may happen anytime after the
training. The final test consists of a written paper and requires 50% marks to pass. There is no
practical test. The papers are cyclostyled and photocopied and some are unreadable.
According to a senior trainer, there is lot of malpractice in exam as it is conducted in the
training venue itself. The exam venue should be at district place and well supervised. He advised
printing the papers and sending them sealed. It should be like the MPW tests, which have much
lower incidence malpractice; the results are 'harder'. Upon the issue of MCQs, he feels they should be
only 40% and 60% should be essay type as the latter call for creative writing and are less-copyfriendly.
Certificates
The Janpad issues a certificate to the candidates who have passed the final tests. Many
working JSRs could show the certificate and they had preserved it well. (In some places they had
additional certificates to bolster, like the naturopathy council, Electrotherapy
etc.). One JSR,
belonging to SC, had started using all medicines without test result or certificate. In Jabalpur, 138
certificates had not been collected, showing that there is no much ado/interest about certificates or
that the JSRs may have left the 'scheme'. (No one needs to declare that he is abandoning the ship,
there is no paperwork about that) In a small village, such a certificate is hardly asked for, but carries
value if properly displayed.
58
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
The certificate is official, but not exactly legal. However the humble list of permitted medicines
for JSR's hardly attracts legal problems. In reality, at least some JSRs use several medicines that can
easily attract penalty.
Failures and re-tests
Failed candidates generally do not return to training. A CHC pharmacist said that boys are not
interested in it because of the 100 Rs for exam fee. Probably it is due to lack of promise in the
scheme, rather than the fee itself.
Developing JSR work
The question has evoked the range of answers. Many have mentioned health-education, but
what dominates is medical treatment. Other responses include village development, social service etc.
Desired image
“DcxTcrr bancor our
Kholcv” (Wcwittcr become cv doctor and/
opeAva/ddnayiAvtlrie/vdla^e/.)..
JSK
Many have humbly confined themselves to a JSR- image. Some want to graduate to a
compounder but most have desired to be seen as doctors. Lady doctor, family doctor, JSR-doctor are
other variants of the same.
However, the Opinion poll expresses the general apprehension about Jhola chhap&xtor image will
increase. Several respondents feel that the Diagnostic and therapeutic procedures will become more
irrational.
Training of JSR-Ws
From the interviews it appears that at CHC level, the training was more organized. At PHC
the training is MO-dependant. Probably it is the availability of more trainers rather than PHC/CHC
venue.
Training of trainers (ToT)
The RFWTCs have conducted 3-day sessions for JSR-trainers, but that was 3 years back. The
training was mainly about method of training, rather than 'content-contextulalised' according to one
TOT-trainer. The "MOs come for meeting their friends and relatives in the city and not the TOT " was
another remark. Another prominent trainer said that TOT happened three years back and it was not
contextulalised. Several trainers said they had not attended TOT. ON asking whether TOT staff
actually came to observe/guide JSR training in various centres, the answer was negative both at
RFWTCs and the CHCs.
59
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Without the active link of TOT staff and JSR /training and practices, there can be no
contribution of TOT to the scheme. The TOT staff lamented this. The Jabalpur RFWTC advises that
the centre staff visit the training sessions once a month in every district.
In Jabalpur, there was much enthusiasm about TOT and JSR training and the JSR cell should
profit from consulting the Jabalpur team. The TOT outline here was thus: 2 days workshop. A micro
teaching plan with presentation on a topic. Pre and post evaluation carried out. Participants were
enthusiastic and learnt new skills.
In RFWTC Gwalior, a senior member insisted that attitude building was important for JSR
programme, at least one day should be given for that in actual training.
JSR MANUAL
(In the Volume? there is a detailed note about the JSR manual)
In Barwani district the manual was not available to trainees, apparently the request was sent,
but it was met with a counter enquiry about the stock of previous 'yellow' manual. In the end,
trainees suffered. Surprisingly even in one block of Bhopal the manual had not reached. It has
reached other places in the study. Wherever available, trainees were found using the manual.
Old JSRs have not been given the manual, which is inexplicable. Some JSRs and teachers liken
the manual. One JSR trainee said he read it every evening. The new manual had not reached training
sessions in Barwani and parts of Bhopal.
Some RFWTC teachers felt that the manual needs to be improved, more protocols on MCH be
included and more medicines added. However, one senior IEC Officer had difficulty in remembering
the manual, finally he said.. "Oh the coloured cover .yes I have seen it".
From interviews only one JSR praised it. However some JSRs who were Pvt Med
Practitioners said it was of no use.
Other books
After the training, JSRs seek other books. Common title is "allopathic guide". WTND did find
one user.
IN one RFWTC, a TOT resource person held out his own book as an alternative and actively
promoted it in the JSRs and "other doctors". We did some perusal of this book, and found that on
clinical issues it has more relevant and useful info than the official manual, nut it is mainly clinical. It
does not recognise the barriers for injection/saline. It also has several incorrect details. In Barwani
region, this book was popular among trainees. Its price is quite affordable (Rs. 75/-) The author said
he got some money from selling this book.
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
In Bhopal, bookshops have plenty of such titles and they come quite cheap. They address the
need of a general practitioner and JSRs tend to club themselves as Pvt Medical Practitioners or
nobodies.
Other training opportunites
Some trainee and working JSRs are linked to Pvt Med Practitioners; some have worked in
medical stores. In some cases the Pvt Med Practitioner-connection came after the JSR training. Most
'survivors' have some kind of training in a private hospital/dinic. IN Bhopal, some working Pvt Med
Practitioners with modest formal medical training actually seized the opportunity of this Govt.-run
course and proudly presented themselves for interviews. Most trainees expressed the need/desire to
do a stint at some clinic. Interviews corroborate the responses.
Gender factors in training system
The current trainee batches have very few women, and there are several reasons for their
near-absence. The scheme holds no promise for them as did the AWW is one major reason. (In the
latter case, women stayed away from homes for months.) The JSR training presents several
difficulties for them, for one it is mainly all-men-situation. Families are bound to feel insecure about it.
There are no lodging and food facilities. Even the AWW batch in Guna was uncomfortable about the
somewhat special facilities in Guna.
WORKING OF JSRS
Code of Conduct
Half of the 22 were aware of some code of conduct. But when asked to describe, most of them
ended up saying about some task. The COC itself is weakly structured as given in the book (see notes
on JSR manual). The COC should be a major instrument of self-control and social control of JSRs, to
be displayed on the clinic wall or Grampanchayat.
Even if it exists, at best it remains on paper. There is no public space for JSR work so no one
can enforce that JSRs display it. Grampanchayats can however display it, along with rates of services.
The COC must be more comprehensive (see notes on manual). The training session should have a
special hour for this; but more importantly we need have role models among working JSRs and MO-
PHCs to emulate. The Continuous Medical Education journal can publish pertinent real stories with
names and places to influence JSR conduct, and also bad stories without identity.
61
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Attrition
“Th-eve-' vusM boyy ore/ cufter
career, coyv not stay iav
joW.. Chairvnavu, ofcuZMa/Janpad/
“If they get cu betterJob- ^vnewhere/they wdl/Lecwe/’.. A CMHC
“M c^y of w have^joaved/ the/ EQS yche^ne/” —cvJS'R
It appeared to us in various interviews that only 10% of JSRs trained so far are active. Many
have never started off, and some shifted to other 'jobs'. (GS /shikhsakarmi was a usual alternative). A
JSR turned Sarpanch quipped that there is 'no future' for this scheme. One JSR-W was reluctant to
say that he has both the jobs. This can be encouraged.
From one interview attrition seems to have hit even during training. In Silavad, the coming and
going of trainees for various reasons is pathetic.
The opinion poll highlights that a lack of continuity and constant flux may make the scheme
unable to fulful the needs of the health service in the real sense.
The earlier scheme was an entrepreneurial affair, and the same is true of the 2001 scheme. That is
quite demanding in a single-village framework, without the professional paraphernalia, often
without a loan, and without legal status. 'Making money'in one's own village on some paltry
medicines is not easy. Most survivors had the grit to do it as a jhoiachhap doctor, acquiring all the
odd skills for such a queerjob, a 'ka/ka chhora' turned doctor in six months and asking for money.
Manyjust failed to make it.
If the ubiquitous 'Bengali doctor'(BD) was the mode! for the JSR programme, only few JSR-boys
could make it. The programme has a high attrition rate. It is a difficulty but an opportunity too—to
make a better programme than shape it like the BD.
It is particularly intriguing that all schemes started by the State Govt, at the village level involve
some payment-EGS, Shikshakarmi etc. A WW was already a paying scheme. CHW was paid even if
paltry. Whatever the thinking behind this scheme, this is the only scheme without monthly
payments. Flight to other schemes was therefore expected. Very rarely, some JSRs have continued
JSR work even after taking new assignments.
Tasks
The JSR-Ws list medical treatment, and malaria treatment as the leading tasks. Water
treatment with bleaching powder is the next. Healing, National Health Programmes, family welfare
tasks, immunisation (attending sessions), registration of vital events, MCH are also mentioned. This
62
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
shows that the JSR role is not lost on them altogether, there could be other reasons why these are
not actually practised.
'Practice'
‘‘\V^<^&toldyth^w^are'notcM^e^tapr(u:tCc^’-AJSK tn/Barwcuav
caU&d'Ui',
cwdAxAd;a*yo^
AJSfl u^BixrwcmT.
“A U/ the/ boyy here/ are/ dcri^
p racttce/” - H eulth A
Practice - which is medical practice of treating patient on fees-is the overt and covert main
plank of the JSR theme. The planner, the provider, and the users are unanimous about this. Not
everyone will utter it and may camouflage it under various descriptions. From even peoples' point of
view the test of JSR is in his/her capacity to fulfil needs of medical relief, he is their 'doctor' for all
practical purposes (See for instance the schoolboy in a village saying about the just trained JSR
Komal Kushwaha" Kama! daktar ne injection iagaytT). In plain words, that is medical practice. The
JSR is trying to do what his village people rightfully expect him to do.
That the other aspects of JSR scheme are not fulfilled needs to be discussed, but what is the
situation regarding the quintessential 'practice'?
According to many respondents, the number of 'practising' JSR is small-about 10% of total
trained candidates. Most JSRs are not finding feet, as is evident from the reportedly 'working' JSRs.
There are various adverse factors in the village system against this. From the users, the main
utterances are related to medical relief. In one village, the user complained that the JSR is not ready
to 'practise'. Looking at the harsh reality of'practice' let not the JSR scheme be villainies. If people
need and want it, the scheme should be improved to serve their felt needs apart from the planner-
perceived objectives.
Planners and administrators are equivocal about the list of medicines. Several trainers fee! that JSRs
need more medicines while others fee! 'none more'. But finally the list is ' far less than a grocer's
list'.
Time given everyday
"Half-day's work" is the usual response. About half the JSR-Ws have not answered, and are
probably not very active. There can be no fixed timing for patients in a village. Many of them go
when called as they operate without a formal clinic. Secondly there is little programmed work, as the
scheme is not really linked to the public health system. So what remains is some patients, spread
over the day. Is it a full time job/employment? Most of them feel - NO.
63
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Clinical work and clinical problems
Fever is the most recurring illness mentioned by JSRs-Ws; diarrhoea, vomiting, coughs cold
etc. coming next. JSRs have mentioned about 34 entries in illnesses.
JSR scheme has failed to touch the hardcore problems like TB, Reproductive health problems,
dental, mental, chronic illnesses like anaemia, or National Health Programmes services. The scheme
is not designed for such problems, though the manual mentions them. The fact is that JSRs are
generally not exposed to such clinical experience. In the clinical domain, these areas await good
action from JSR scheme-diagnostics and action protocols for these hard core problems.
Work place
Most of the JSRs work at home. Some have a clinic. Some do home visits. JSR Scheme does
not provide any clinic space. Since the JSRs are supposed to do both clinical and community work,
some kind of formal space for clinical work is mandatory. A mobile JSR with a kit bag is also possible
but this is an infrequent pattern.
Patient attendance
The average number of patients attending is 0 to 8. The monthly average is 48. This volume of
clinical work needs to expand. For a JSR model requiring earnings this could be insufficient volume.
Women parents
Even though all JSRs are men, every month about 15 women (and 33 men) seek JSR services.
However this may not mean reproductive services and probably general illnesses. Keeping patients'
register is mandatory for JSRs; but only about half of them keep register. Among the sample of 22
JSRs in this study only about half are in actual practice. There is no systematic record anywhere
either in the scheme or in the field.
Serving Deprived sections
From the written responses, JSRs mention that weaker sections are taking their services, but
lack medicines are a hindrance. One JSR mentions that it is only poor people who come to him. In
several interviews with users, poor people do seem to buy services from JSRs as otherwise they will
have to spend on travel and access PHC/Pvt Med Practitioner. The cost of JSR services—and no travel
costs—plus Udhanave attractive enough even for the poor. Educating people on needless
injections/saline should mend the matters further.
Referrals
PHC is the most frequent place for referral, CHC coming the next. The listed causes for referral
show a good range of problems (38)- fever, diarrhoea, abdominal pain and some NHP causes like FW,
TB are also seen. Together the 22 JSRs have referred 76 patients in the last month.
64
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
The Pvt Med Practitioner-link of JSRs looks weak but the study brings out clear cases of such
links. In Dhar, a JSR says he sends patients to particular doctors and they send him commission
(which he says he distributes back to patients) and also send back the patients with advice to take
more injections and IVs at JSR's clinic. Some 3 of the 22 JSRs say they refer patients to Pvt Med
Practitioners. JSRs do not seem to be very enthusiastic about Pvt Med Practitioner links.
Referral is potentially a sound link between JSR and PHC/CHC and referral chits and
recognition/comph'ance by the latter will go a long way in instituting linkage. It will brighten JSR
image both in people as well as the public health system.
Preventive work and National Health programmes
The answers JSRs gave show that they are aware of the preventive aspects and of the National
Health Programmes. In actual practice, there is hardly any NHP work except malaria. The reasons are
clear; there is no logistical and funding support for NHP work.
The Public Health System has to seriously try on this front. One will have to list doable tasks, work
out logistical and monetary support before expecting work on this front. See Voiume2 for what are
the possible tasks a JSR can undertake with the help of the Public Health system.
LINKS, SUPPORTS, SUSTAINANCE
Links
JSR-Ws have a feeble link with the health system whatever link they have it is mainly with the
MPW and ANM. Only half of them had some contact with the field staff in the previous month. The
substance of the contact and linkage is not described. But it could be through supply of some
consumable like condoms, chlorine tablets, and chloroquine tabs, etc and immunization clinics. Since
the JSRs are not getting any compensation from the Government there is no formal arrangement for
linkage.
The PHC contact has also been weak. Most of JSR-Ws have attended some of the PHC
meetings. Subjects discussed in the meeting include National Health Programmes; but more than half
the JSR-Ws do not mention any subject.
No JSR got any TA/DA for attending these meetings. Travelling costs could be a major burden
on the poor JSR-Ws. Some material like consumables and posters is presumably supplied at the time
of these meetings. Most JSR-Ws are silent on what they could suggest to improve the meetings for
them. One demand is about inviting "Other Doctors". They also mention income from Govt., TA/DA,
more training and solving actual problems of JSRs.
There is little of help from PHC. Some responses include supply of some consumables. Most
JSR-Ws have little to suggest about how PHCs could help them.
65
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
From interviews, the responses appear to confirm above pattern. ANM/MPW is the key
figure, but the links are not structured. Personal relations with JSR and occasional assignments from
PHCs (pulse polio for instance) are all that count. Referral of patients is another major link with
PHC/CHC. Often the MPW is practicing and this could be a potential area of conflict/cooperation
rather than linkage.
What kind of links and supports and how much support has to be considered in tandem with
monitoring aspects. NHP is the main and broad avenue for links. Maintaining village health data,
and using it for local health plan is another area for interaction. CME at PHC/CHC or through a
house journal is another major mechanism for linkages.
Monitoring
Mo-
(xw\s\M(yrk/ wCthovct
t4
cvUectcn'
Monitoring involves a two way process-feedback from JSRs and communication/messages
from the PHC. There is no formal link between JSR and the PHC. PHC staff collects no records, and
JSR-Ws are keeping only scribble-books at places. The manual prescribes a record format, but no one
follows it.
Government circulars have asked MOs to call the JSRs for monthly staff meetings. Some JSRs
have attended these meetings. But this can not go on for long since the travel costs are borne by the
JSRs and there are no apparent benefits to them from the meeting.
Obviously there is little or no monitoring, as 16 out of 22 JSRs are either silent or denying
existence of any monitoring. The scheme does not provide for any monitoring save a circular from the
DHS about inviting JSRs for monthly meetings.
From the interviews many JSRs actually express a desire for guidance and training. A senior
RFWTC teacher felt that interesctoral (health, education, and women's welfare) team of monitoring
will be effective. In his opinion, select MOs in district should be entrusted the job of monitoring the
scheme.
The gram panchayat /GS is a non-technical body and the latter is hardly operational. Since the
gram panchayat is also not paying the JSR, there is no formal accountability. One suggestion (by a
CMHO) is for a bond given by JSR before training stating a) locational restriction for practice and b)
NHP work. He also suggested that the JSR should be on-contract with gram panchayat or gram
panchayat be given a grant for modest remuneration to JSRs. The gram panchayat and GS need to
undertake some of the monitoring. Ensuring that JSRs get some mandatory services at fixed rates is
possible.
Monitoring is crucial to this scheme else it will degenerate into a chaotic quack system (?) created
by the Govt, itself. Govt, will have to put some funds on this and some special task-staff (may be
66
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
from existing staff). Three clear areas for monitoring are a) clinical work b) National Health
Programmes c) social aspects like costs. The GS can undertake this last part while the first two need
to be regularly monitored. The details of this need to be worked out. Mainly it will be some work
protocols, mandatory records, staff visits.
Continuous Medical Education
Apart from the monthly meetings of PHC/CHC staff, (some of the JSR-Ws have started
attending these meetings recently) there is no continuous medical education. Even the new book has
not been given to the working JSR-Ws trained earlier.
From Opinion poll, the responses expressed that a lack of continuing education may cause
local problems due to wrong treatment practices.
Continuous medical education is an important part of any such programme. It can work through
National Health Programmes channels, and a house journal is strongly recommended. This will
include exchange on all aspects of the programme. The new editions of manual need to go to even
old JSRs and this book should be better than the available books in the market.
Supplies
“H & cccwte/ frcmv tYcuAxCyxcy but did/ not brin^ ccny
- cu
JSR-Ws get very few medicines/consumable from PHC/CHC. ORSZ Chlorine tablets, chloroquine
and slides are the main supplies. Other medicines are bought from the medical stores.
Interviews with private medical storekeepers are revealing. Obviously, all the tablets/injections
which, JSRs use, are from medical shops. The rules of the games are like for all other Pvt Med
Practitioners. Some medical stores specialize in such matters. One such quoted below:
Issues______
No. of JSRs
purchasing
medicines
Frequency and
payment
Opinion
Complaints
Referrals
His business
Common lists
Response_____________ _ _____________________________________________
About 5-10 JSRs purchase medicines from his shop. There are 10 more shops, From various
shops as per his opinion 30 JSRs might be purchasing.
Other stores are also selling them medicines.__________________________________
They come to the shop twice in a week. Every time they pay Rs. 200-300/- or so. In a month
they purchase medicines worth Rs. 1500/__________________________
Better than Bengali docs, JSRs have two wheelers. Travel in the villages and render door to
door services. Most of them have experience in working in private hospitals.
So far no complaints from any dept._________________________________________
If they have some problems/complications they bring patients to the CMC.
No impact on his business. He gives medicines on credit.__________________________
Crocin, Dependal-M, Vikoryl, Clhoroquine, Septran, Ibupara, Diclopar, Ampicillin, Amoxycillin,
Taxim, Cifran, Norflox-TZ
Syrups- Septran, Paracetamol, Ampicillin, Antidiarrheal
Injections- Ampicillin, Cefatoxim, Diclofenac, Dexamethasone, Genticine, Oxytetracydine,
Dicyclomine,IV fluids._____________ ____________________________________
In the Opinion poll the respondents are worried that the impossibility to serve without
availability of drugs.
67
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Public sector linkages-PHC/SC
WoKQJSR.) to- vxet'cu'hcbC',
myukar (JSR
awwb
cwe/jiA^t
scrvowity):.. An/ANM fro-m/co'DKclt CHC “JSR?
(XpvxJht vuJht lyciwicctt (JSR, wTvcct well/ t/w- poor <^iAy (to-? Re/
uJRt
Rcwi^etJ ReJpte^J..
A myther A NM from/ ^me/ dt^trLct
Views of MPW/ANMs about JSR scheme
Issues
Observation/ Response
Duties of JSR
Immunization, Chlorination of wells, Depot holder of Tab Chloroquin, Chlorine, Furazolidine,
ORS packets. Births and Deaths registration. He is expected to help in implementation of
National Health Programmes.
But he is interested in his practice and does not give time to other work
Code of conduct
It is written in manual. They are not allowed to practice injections etc., but they give
injections and do irrational practice.
Selection
Well to do JSRs will not work; they are just for namesake. JSRs from poor families, OBC, BC
s should be selected. But 10th pass candidates from these communities are not available, so
it should be relaxed. 10th attended should be recruited.
There is political intervention and partiality in the village. So no proper selection.
Training
It is going on somehow. Actually nobody is taking classes. Many officers are corrupt. They
are not interested in solving health problems of the community. Actually there should be
separate hall for lectures, but it is not available.
Trainers get separate money for teaching. BMO does not involve them (ANMs) in training
process.
Supervisors should be given responsibility of training. They can train more efficiently than
doctors can as they go in the field regularly.
Stipend
Most of the money is spent on travelling. Few are living in rented rooms.
Remuneration/ Hon.
Some honorarium should be given, otherwise they will not work.
Monitoring
Monitoring is must. It can be done at every level. In the pulse polio program Rs. 90/- were
paid to volunteers who helped. Like this performance oriented money should be given. They
can not come to meetings unless they are given TA/DA
Future
Some JSRs will earn money. But it will not be a solution for health problems of the villages.
so
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Income
" Chzxor
paJuieJw Icclo^vi/ chhod/ d^ya/,
ka/ badas problem' hctt/,
4 yeorybodk/
, cred^CC-due^' are/ cv major problem/; mo^t of our batch/ha^ stopped/ worker^): A
JSR who- ^a^e up lon^ bach
tc
✓
69
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
jebse kabtak kaam karenge? (How long we can we keep loosing money on this?)
"Udhari bahot
hai" are tell tale.
A district collector says
It is a good scheme particularly for inaccessible areas. No one - doctors, other staff do not go to
such area. We only respond to information about deaths due to diarrhea etc. A JSR can serve this
area. However, main problem is its financial feasibility. Would the JSR earn enough to remain in
their village? Also their education level is also a problem in the tribal area. Educated candidates are
not available. Also, can such villagers afford to pay them? A solution is to have a JSR for a duster of
villages - 4/5 villages so that they get enough patients.
Honorarium
All the respondents insisted about some honorarium for JSRs. The JSRs wanted it for
sustenance; the PHC staff wanted it to be able to officially ask the JSRs to help in National Health
Programmes and for monitoring/control. The only opposition came from a RFWTC-principal, who feels
that honorarium, would defeat the very purpose of JSR scheme. The policy-making senior officers are
also against any honorarium.
"How much honorarium?" we asked. The average expectation seems to be about 1500 Rs a
month. This works to about daily wage earned over one month.
One Janpad Adhyaksha suggested a house tax for JSR support.
The issue of honorarium is one of the centra! issues in this scheme. Policy is generally against such
payments and adding any more cadres to the State's burden. With the prevailing inefficiency, why
add one more scheme with recurring expenses? This argument can not entirely be wrong.
There are counter arguments—why should only the JSRs work free? How can we control the
scheme if there is no financial incentive? How can JSR sustain in a 1000 sized population merely on
clinical practice—3-4 patients per day? He would rather sit in a bazaar town and do as other Pvt
Med Practitioners do. Otherwise he has to be given a duster of 2-3 villages, (which defeats the
aspects such as access and community control). An entirely self sufficient village level health care is
unlikely in current Indian village economics, and there can be no lifelong volunteers in thousands.
Secondly, even ifsuch income is realized at some places, the JSR will not look after the preventivepromotive aspects and thus defeat the purpose of 'janswasthya'. Some kind of support is therefore
necessary for sustenance of the JSRs and for health promobon-prevention.
"How much and How to pay"are the real issues. No approach is entirely perfect; there are known
risks and problems for each. A pragmatic solution to this problem, (apart from other technical
aspects of the programme) is centra! to success of the scheme.
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Loan
(Whatlocw\R ..wothlv^l that Cy
“KcChowdca/locctvwealr,
the/werrry!) A JSR-W iwVhar
27000 wc^prcrml^i^thrcni^TRYSTM, very
p
Ly
cu
ger ter
. The,
(Yncuatvt), wtolce/ co subsidy ca^}
thew ger ter Zxxyuk/ owid/ the^v hcwib dere^r wot fCwb cM/ thty ce’edTtvjcrvthy. At mer^t 5
enct of 50 got Ct. A
Except one nobody has got the TRYSEM loan. It could have been worth while to explore how
even one could get it. Interviews have it that there are several difficulties in getting the loan because
of lack of funds, among many other factories, there is an understandable frustration among JSRs.
Use of kits
The JSR kit contains cotton, slide box, bandage, scissors, tape, forceps, artery forceps, pencil,
gauze, forms, tongue depressor, and torch. Not every JSR received it. Many have not used the kit.
The useful part was the bag itself, as a carrier for medicines. The instruments were hardly used. Most
kits of JSR-Ws we opened contained injection-material and some purchased medicines. Some JSRs
have purchased a stethoscope, BP machine, thermometers, even weighing machine, and saline stand.
Giving a full bag may be a waste, as many JSRs go out of work. If medicines are distributed with
the kit, JSRs might consume it for once and again look for more supplies. If a kit is replenished from
Govt, stocks, people may never pay JSRs and always ask for free stock medicines. The best way is
to decide according to the chosen JSR model.
Relation with village body
Most JSRs know about the Gram Swasthya Samiti and can mention how many members GS
has. 8 out of 22 JSR-Ws have mentioned about GS meetings. But the respondents have various
things to say about what GS does and should do. No definite picture emerges about the role and
functioning of GS in the context of JSR scheme.
From interviews except for 2, GS is not mentioned. For the 2, GS is working-discussed water
safety/immunization campaigns.
Gram panchayats and GS seem to have discussed the JSR Scheme in some way, but only some
of them are able to word what was discussed in those meetings.
4 In our field study , no-one said he got the loan
71
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
JSR-Ws seem to have a raised some health issues in the GS /Grampanchayat. One demand
was about establishing a sub center in the village. Another discussion was about medicine Cost, even
age of marriage.
Relation with Pvt Med Practitioners
In the responses, the Pvt Med Practitioner relation looks thin. In in-depth interviews many
types of relations show up. Some Pvt Med Practitioners get into the JSR programme for Govt,
approval, others send their sons into this programme to run the family business; some others send
patients to Pvt Med Practitioners for a consideration, and many become quacks themselves. Others
have to compete with Pvt Med Practitioners to get and retain a share of clinical practice. A CHC staff
member said that 4 of the 5 MOs do Pvt Med Practitioner at home, and have links with JSRs.
During the interviews, we learnt that sadly the CHC itself is often a place for private practice.
In MP CHC table private practice is not common, but most MOs call the patients at their homes (often
the official quarter) and charge money.
This is a dangerous area for JSR scheme- tomorrow if not today. If they are not able to heal,
they may work just as touts for Pvt Med Practitioners and may exploit the villagers. The trends of
CHC using the JSR as its 'links'are already there. According to a CHC CMC, they (the policy makers)
do not know what work to expect from whom, if you tell the CMOs to train JSRs, this is what is
expected" But then if not the CHC/PHC where will be the JSR scheme anchored? This is a system
problem and not particularly JSR scheme problem.
A Case study: Bengali doctor
Dr Biswas hails from West Bengal, led by some relative BD working in this area. He has some
degree from Barashat area of W Bengal. He works here for 12 years and earns about 1000 daily. He
has used 50 oral medicines, also Ayurvedic and about 25 injections and saline. He can do all small
jobs like tooth extraction, wound repair etc.. He refers difficult cases, assists TBAs in deliveries if need
be-only with a Pitocin injection. He (BD is always a he-man !) has a sizeable clientele everyday. When
we visited him, although it was a lean time of the year, but 9 patients were sitting in his small OPD.
(1 with PUO, 2 with deramtitis, 1 for white discharge and 1 child with diarrhea, 1 for wound
dressing). Mothers had brought their babies for some treatment. He does not give any injections to
infants. Charges about 20-35 Rs for every episode. He knew the side effects (eyeball rolling) of
Perinorm. He also makes motorbike visits.
His 3 wastebaskets were full of injections - vials and ampoules.
We asked him if he has any books, NO! But one can always study, he said. There was no
degree on the wall, but a wood carved plate, reading Dr B M Biswas, that is all. He stays next door,
has a family and many relatives in this area - all BDs. Well-connected and street smart!
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
About users
Most JSR-Ws state that all sections of the village society use their services. Some say that the
major limitation is lack of medicines rather than people approaches. One JSR-W says there are many
Pvt Med Practitioners in the village hence people are not using these services. Another JSR says only
poor people use these services.
MEDICINES USED AND DESIRED
Medicines desired by JSR-Ws
are//ewer
. JSR.Ty
Tracer, KFWTC
Although the JSR manual teaches only about 15 allopathic medicines (6 external applications
including gauze, and 9 internal)5 from allopathy about 45 medications find a mention in the 'desired'
list of JSR-Ws. Among them Paracetamol, chloroquine, ORS and cotrimoxazole are the commonest.
Thanks to the previous manual a banned medicine -analgin -is found lingering in the list.
Questionable medicines like betnesol, B plex, sinarest also appear. Injections like dexamethasone,
diclofenac, gentamycin and tetracycline show up. There is also a mention of injection TT. One can
only wonder about whether they can ensure cold chain.
Among the medicines JSR-Ws want to use, antibiotics/antimicrobials, and painkillers, steroid
are the principal items, though 15 out of 22 either remain silent or do not want more medicines.
Medicines desired by JSR-T
Many trainees that are beginners have said "Not yet". Injections and saline are dominant
desire. Antibiotics are variously mentioned in illnesses like TB Typhoid etc. Somebody has desired" A
Safe Antibiotic"! Several illness - wise medicines have been mentioned. These make an interesting list
of about 25 health problems ranging from pains to childbirth and emergencies.
Injections and saune
Many of the JSR-Ws actually and commonly use injections. No injections, so no patients, is
deeply engraved on everybody's mind. This is a hard core problem in the rural medical practice.
Several steps and tricks are necessary to wean away people and JSRs from such practice.
However the use of injections by JSRs can not entirely be banned. The main concern is to decide
s External applications include: Gauze bandage, neosporin powered, tin Iodine, savalon, benzyl
benzoate, gentian violet, and the internal medications are: chloroquine, avil, paracetamol, cotrimoxazole ORS,
ironFA, antacid, mebendazole, OP.
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
what injections and for what conditions. Among the 22 JSR-Ws 5 use injections while 12 JSRs do not
use injections at all. Among the remaining 10, two find it necessary for scorpion bites alone. Two
JSRs give injections only on Pvt. Medical practitioners' advice (is this just a defense statement?).
Eleven injections are in common usage including antibiotics (ampi, genta, and even taxim) anti
malarial, painkiller and anti-spasmodics. About 14 conditions are listed as injection-worthy.
From interviews and observations, some additional injections pop up- cipro, stemetil,
deriphylline, Bplex, paracetomol, penicllin, etamsylate, etc.
Saline infusion, although not officially advised, is mentioned in the JSR-W responses. Ten out
of 22 JSR-Ws use saline and they use injections too. The ones who currently do not use injection/
saline are probably not really working and have been interviewed as 'past-JSRs'. Understandably
some JSRs may have chosen to avoid to mention injection/saline. Common clinical conditions like
fever, diarrhea, vomiting etc 'deserve' a saline infusion.
Says a JSR-T, that inj Dexamethasone is like a potato, can go with any illness or medicines.
In a Morena village, an old CHW of 1985 batch has set up a clinic. He uses lot of injections.
The photograph of the wastebasket is telltale -full of used vials and ampoules. (He was slightly
concerned when we took a photograph of this basket.)
A case story of a fresh JSR
KK is from backward caste, chosen by the gram panchayat over a high caste
candidate, thanks to higher education. He has just completed the training (June 2001) and
yet to get the certificate. He has already started practicing and uses 1-2 injections for every
patient. He and his family feels blessed because of the injections he can give; for which
otherwise the villagers had to travel long distances on foot and pay a lot more. That brings
him 10-20 Rs a patient. We met several happy'users but also met one ailing man who
cautioned us to control the JSR's injections. ”Z have a family to care and can not afford to
die of wrong injections of a half trained village boy" is his remark.
At one PHC on way to Kuxi, we stopped to see the MOs. The compounder was washing the
syringes before giving the injection. The 'simple and humble aseptic precaution' was to pull some
water from the bowl and then squeeze it off, then fill it with the injectable. Some JSRs are quick to
learn this 'easy technique'. But one JSR uses disposable syringes and needles, "they come cheap"
says he.
There is great scope for reorientation, protocols in this area of injection/saline use.
ISM REMEDIES
..ISM c&YVCpcnie^tt ifr i^ripcrKtcvYit', lytctorxly cdlopccthy ii'
—A CE(D
74
F
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
It (ISM) ^^(^wc^t&.,, A BMO
About 30 Ayurvedic medicines and herbal remedies have been listed by JSRs. But not all of
them use these medicines. 7 out of 22 JSRs do not use any and others use very few such remedies.
The manual section on Ayurveda mentions several home remedies and about 74 marketed remedies.
The working JSRs mention about 10 of this list. The mention is occasional and scant.
The medical worth of Ayurveda (ISM) is not fully used by the JSR scheme. The training
component is poor and the supply logistics is absent. Ayurvedic remedies can be socially acceptable
and JSRs can prepare some of them. The fixation to allopathic medicines is questionable and
counterproductive. Ayurveda is also rich in medical as well as non-medical healing ways and JSR
programme needs to use this. Actually, the JSRs should be able to choose medicines from various
systems on the criteria such as affectivity, cost, safety, acceptability, and availability. The current
rejection seems to stem from system-inaction/bias.
SUGGESTIONS AND OPINIONS
Senior health officers
kare^ A chchhcu Tit A chchhoy ho / (It
YeJv ta
xAemo, may
w cM) - A CMHO about the/JSK Scheme/
At the regional, district and block level several officers indicated in various ways including body
language that there was little if any consultation with them anytime on this scheme. "The scheme"
one officer said, "was made by officers sitting in AC rooms". Valuable suggestions could have flowed
from an interaction between field officers and the scheme-makers. Even RFWTCs are uneasy about
the training and the scheme. There is little participation from the RFWTCs beyond occasional ToTs
sometime back. One officer was incredibly stiff and uneasy while talking about the scheme, chose to
give only "officially correct" answers and actually said that everything is going on according to the
plan in the district. In reality his district, seen as model and better district had quite pathetic
conditions about JSR training and working JSRs. "The higher officers do not tolerate any questioning
on this scheme" was another remark. (But one BMO told us that he actually told the CM in his visit to
the CHC that the scheme is faulty).
There should have been an interaction with health officers while conceptualizing the scheme. It
was also necessary for involving the BMOs, BEEs, MOs, CDPOs in the process of the scheme. There is
a feeling that it is just pressing the accelerator without looking back on what is happening to the JSRs
in their villages. Some kind of resistance is expected for any new initiative, but at least some critical
mass of officers need to support the scheme. JSR scheme seems to be wanting even a minimal
support and involvement from these field officers.
75
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
A senior trainer suggested that a training-planning committee at the regional level should be
constituted for reviewing the syllabus and even the budget.
JSRS ABOUT THE SCHEME
Responses are full of negatives like "no money/ no capital, lack of medicines/ equipment, no
permission for injection/saline, can not prevent illnesses, difficulties in diagnosis, poor training, no
patients, no support, no clients, Pvt Med Practitioner threats, Udhari, etc". These responses
meaningfully profile the lacunae of the scheme.
AH these complaints are true and decisive for outcome of the scheme.
District/block functionaries
Among the administrative side, district collectors and some CEOs are well aware of the
scheme. The JSR scheme is politically important scheme. All district collectors are responsibly involved
in the scheme. The team interviewed some officers. The officers were aware of the complexity of the
issue, and the larger system-problems that were plaguing the scheme.
Almost all levels of District/Block level officers as well ZP/Janpad representatives suggested
that the JSR must be given some honorarium.
From almost all the districts, the senior officer also expressed the need for a supervision
system for selection, training and working of the JSRs. They also suggested that the JSR would be
registered and trained JSR should get bonus points for EGS selection.
They suggest that the training should be preferably at the district/block level and not at the
PHC level because this increases the workload of the Mos. They do not get time for preparation of the
lessons etc.
One such interview is given below.
First Reaction
Dhar is doing well in MP on this programme. Slow going scheme, training quality poor,
problem is --what to do after training, but some CHCs may be doing OK
Selection
Often it is tussle between the Sarpanch/Dy Sarpanch (in case of tribal panchayats) AND the
Govt, staff. It is part of decentralization. If the people have their way; staff does not like it
and the vice versa. Either way it becomes a point of friction for long, that may affect work of
JSR later too. AWW should also be selected/trained. Majority caste member should be
selected.
Nepotism in
Some favoritism is likely
selection?
Selection process
Should combine both GS and staff views
Any complaints
May be coming to the CMHO. But not yet
about selection?
Publicity of the
Usually it is just a letter to the Grampanchayat. Public media not involved, no advertisements
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
scheme
for lack of funds. But radio could have been involved (an afterthought)
Coverage
1487 villages, 1300 persons trained so far under the TRYSEM. This is the last batch in Dhar.
Loans
No more now. In 95-96 some got it. 1300-1400 was given from TRYSEM
Training
Needs to be perfect, and practical. The exam should have also practical part.
Stipend
This becomes a problem in selection, many students come because the 3000 Rs, it is free
time, bad season, some cash. I feel there should be no payment for training, let those who
want knowledge come and prove their sincerity in work.
Kits
Yes, Govt, gave them kits
Selection of
Yes, now the entry is relaxed to Sth std, AWW selection is a better way, she is quite
women
competent
Preventive tasks?
A silence. Community awareness is not there for preventive.
Funds
Yes, we have no problem
Political interest
Not much really
Inj /IV
Community wants its a social problem
Legal
Can be a problem
Payment
No payment to JSR, some get it through the Malaria Link worker scheme (SOORs pm)
Suggestions
Impact evaluation before and after training
Sarpanch, gram panchayat members, village people
“People dcr not
that th&JSR d&ai- wyt gfet iatary frcmv Qovt. ” —a/ZP
cXcurmfui/ orvJSR woey
“Kov xuxth/
ruxJvCrv chaJxat’O/ nzxATrv to
! Jha^deht
kot^ho^v, nxrruvy kolw ?”( peoplesnotto-(Xrm^toother..th^y
fLght.Hoxv wM/they tcuk&(leci^or^?)- oavelder
Villages are not quite seized about the scheme. In fact, a lay person does not know about the
JSR scheme. We had to variously describe the scheme so that they finally recognise somebody is a
JSR in their village. (This is a 'nemesis'). There is no propaganda about the scheme, no wall writing,
no posters, no slogan even in grampanchayat. Unsung and unwept the JSR scheme is.
Asked about the work of such boys in villages, who have a JSR-W, the answers are about
illness-treatment, nothing else. Some users are happy about having someone like that in the village
and that they do not have to carry the sick on their backs to the town. Some are cautious about these
"kalaka chhora turning daktar in six months at the sarkari davakhana." Some users have thrown a
bouncer on the JSR scheme; for instance see this one from a Barwani villager—"If I had money, I
would rather go to the town-doctor than this JSR, I go to him because I have no money to pay at
town".
Grampanchayats are not quite aware of the scheme, and so is the average villager. In one
village, we discovered that the Dy Sarpanch, a ST and wage labourer himself, was not fully aware of
77
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
the scheme despite the fact that his own boy has been selected for the forthcoming training. In
Lunera in Dhar, another member of the gram panchayat was also faintly aware of the process,
though his mazara had a JSR who had given up work four year ago. In the same village, the small
high school staff (also the headmaster) was unaware of the selection, though he had heard about the
scheme. After asking him about 10th pass girls in the locality, he comments " why not girls, there are
such girls". He was apologetic about not knowing the scheme fully. (A headmaster could be a natural
member of the Janpad selecting committee).
In some gram panchayats, it is the Mantri (gram panchayat secretary) selected the JSRs, from
the list of applications.
In a village in Guna, the practicing JSR-W is also Dy Sarpanch and the Sarpanch is a SC
woman. After telling him about our desire to meet her, he laughed at the idea saying she is good for
nothing and just a pawn in his party. This man JSR belonged to BJP. We asked him if this scheme will
politically benefit/ harm the ruling party. He said, all party members have availed of the scheme and
can not favour or disfavour the ruling party. Politically, at the village, it is unimportant.
Other PHC staff
In general JSR training is faltering. Two interviews are telltale; one of them unwittingly
admitting the stark realities. The other was purposefully told in anguish. Names can not be quoted. In
one training center, the staff members were very critical about the training and the JSRs. "Paramedics
like us are asked to train.. What do we know about illnesses? MOs are not interested. The JSRs are
not working, just telling lies about preventive work". According to one of the staff member, there
should be special trainers and they should take centers in rotation. Also "stress use of herbal
remedies" was his advice.
In another PHC, the HA was the only staff available around at 10 am. He was very enthusiastic
and outspoken. "Only coward JSRs will not practice" was his pet sentence. He felt that most of the
JSRs around are doing 'high practice'. According to him, all JSRs are doing very well and earning by
"high practice". "Some have bought four wheelers". (We could not go to these villages because of
bad roads). Later, he said the MOs have taken money from these boys' stipends and no one is
teaching them. (He alleged trainees was underpaid stipend, taking receipts for full payment, part
going to MO's pockets.). "The BMOs have no time for training these boys and there is no training at
ail". One JSR trainee said he goes at 11 am, sits and comes back at 1-pm.
AWW SUPERVISORS
Although, all others are enthusiastic about AWW as JSRs, the AWW supervisors are skeptical
about this for two reasons, a) there are not many AWWs that can qualify for a JSR training in several
districts except Indore b) AWWs are not available for this work till afternoon c) Unless there is fixed
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
honorarium, women can not work in such scheme. (Women may not get fees from patients as men
JSRs can possibly get).
Views from JSRs-past and present
From interviews out of 22 interviewed JSRs, 4 have mentioned about some National Health
Programmes; mainly malaria, immunization, and about depot holding.
Political opinion about the scheme
Interview with a Janapad Adhyaksha: Shri Ramsinqh
Scheme
Suggestions
Fund-flow
Medicine supply
problems
Training
Reforms
selecting women
JSR and AWW
Popularity of the
programme?
any Good JSR
National Health
Programmes______
Can JSR get a room
in the village for his
work____________
new trainees_____
Comments
Only on paper..not on ground, sirf a report___________ ___________________
Honorarim.500 at least_______________ _____________________________
No problem
Actually Janpad/villages can generate resources, but the policy should come
from Bhopal, otherwise people may not like another tax
not many medicines does he get___________________ ______________ ____
Govt, docs and nurses are not sincere, they do not stay at HQs, docs do private
practice___________________________________________ —-------------------hasan type something goes on, need to train them about medicines--------------Medicines, better training, money
The Govt, doctor gets 15000 and does not work (he is talking about the PHCs
not this CHC), why should a JSR work without money.
_
Reservation will not work; reservation has made women Sarpanchas and
sarpanch-patis. It has not helped. Education alone will get more women, from
60-62 JSRs now 7 are women
__________ _________________
JSR is more imp than the AWWs, the latter is just for daliya-cooking, JSR
should give medicines------------------ ----------------- ----------------------------------------No, no one is interested, no faith in JSR, Bengali’s have earned faith of people,
outside docs are more respected (than the local lads). There is no practical
training.
It is not a visible programme
_
_
Yes, in Longsari, he runs a dispensary. Inj saline everything. He has worked
with a doctor earlier
Nothing
_____________ ________________________
Yes, possible. GS school works only for 2 hrs. That can be used. But the main
thing is money for the responsibilities Govt, gives him. Today the JSR is not
self-reliant______________________ ________ ______________ _____
Do not learn, only come to eat. The 500 Rs_____________________ ______
No futu re_______________ _______________________________________
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Interview with a ZP Adhyaksha
The scheme?
Looks around, does not know the administrative details it seems, someone from
the hall gets up and starts telling him.
Too many Programmes, difficult to even understand.
Each dept should know better
Selection
Gram panchayat do it. Non-SC villages
Tasks
Treatment of Choti-moti illnesses
Success?
No it is not working, the training is not good, only those who are working as
RMP should get such training, since they are working already. The will to learn
is imp.
Women selection
The Dais are already there. (I remind him it is not JSR).. silence
AWW-JSRs
Now a batch is training in Guna
Your opinion about
Will misuse everything
JSR
Characater-naitikata is crucial factor
But there is gram
The Sarpanch will only give name of JSR, what else he can do/
panchayat to check
What does JP Zilla
Watch that is all. It is the gram panchayat really, it is independent-sivayatefa
do
Why no potential?
Only kit, no honorarium (says one around, which shri XXX echoes
Is JSR visible
We rarely see them
Women
Purdawali kya karegi?
Impact of the
Can not give employment. These new boys are after some career, can no stay
programme
in such jobs. Many have fled to GS as it offers some 1000 rs.
Control
None. In GS we have control, can take action on erring boys
Suggestions
Hon is imp, and control (ankush) is imp.
An impression of
Laughs.. I will not go to a JSR, will you if you fall sick? It is like having a
JSR
monkey shaving you, you have to accept that nose-ears are likely to go (bandar
dadhi banata hai, naak-kaan to kategi)
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
CASE STORY OF A DROPOUT: A JSR TURNED EGS GURUJI
ABC from Lonera is in hurry to go to the nearby mazara for his GSjob. He was trained
in a Dhar PHC in 97-98. The population of three mazaras (hamlets) together is 1100. He has
a small farm of 2 bighas, a buffalo. He hails from ST and has a family of 5, he has a wife
9non-Hterate), a daughter of2 years, a mother, a younger brother at school. He tried
'practice'after the training, bought some medicines and injections. The people used to go
either to the nearby Bengali doctor or the practicing-visiting-MPW for injections. He had no
place to set up clinic. No loan came. The kit he got from the PHC was rarely opened and
most of the instruments were never unpacked. He had already applied for GS and was
selected. So in about 2-3 months ofJSR training, he started working as GS guruji for 500
pm, that gave him something. JSR was a forgotten affair for the village. Some villagers
know he was trained. He has not met MPW or ANM for last six months, and the only time he
met was for some medicines for the sick baby.
His wife had a serious problem of infected ear (mastoid abscess). He took her to
various doctors, spent money and is now advised surgery that he can not afford. The BD
nearby has given him some medicines that he can pull on with. During these sicknesses, he
never went to the PHC/CHC even for advice. In fact after training he has rarely gone to the
PHC. This isjust another case of the 90% dropouts.
Interview with the above JSR
The population
About 1100 taking three mazaras together, I from one Lonera mazara
Training year
97-8, six months. It is already five years
batch
15 of us
working
No
What r u doing now
GS Guruji- five years already
What are others doing?
Just give cholrine (means here chloroquine) tablets
Any kit
Yes, it is kept inside, brings and shows. We photograph. It has cotton, slide box,
bandage, scissors, tape, forceps, artery forceps, pencil, gauze, forms, tongue
depressor, and torch
How many hours did you
Oh, once in 2-3 days.. Hardly any work.
work as JSR everyday
Supply from dept
Only chloroquine they gave last year, and the slides. Nothing now.
Used the kit
Not for last six months, when I did open that time.
Any survivors of your
None
batch
I
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
The manual
Read it
Marriage
Yes, has one daughter.
Ed
12th (1996)
Farmer?
Yes, 2 bigha, one buffalo,
Family
One brother, mother, wife and daughter. Wife is non-literate
Remember anything that
Malaria, then eyes, fractures etc. Like we should give septran for sore eyes (?)
'
was taught
Problems
No medicines, stipend we got but not the TRYSEM loan. People do not pay, udhari
is problem. One private Bengali doctor came and stayed here for a month, doob
gaya and went off. Now he stays at Jirapur
Will you work again as
If I get medicines, and loan of 5-10000 Rs. Then it will run on its own
JSR?
Did you use Injections?
Yes, Genta, Streptomycin (somebody presenbed it for a TB pt and I juts gave it
here), Chloroquine, decadron for tooth pain. I tried for 2-3 months, gave up. He
shows all these injections
tablets
Para, chloro, ibuprofen, septran,bought it from medical store (gayatri stores)
Working pattern
Used to go to the caller's house. Ghar-ghar!
Records?
None
About GS?
10.30 am to 4 pm, except Sunday
What work do you like --
JSR work was good, but no sustenance
"
"
JSR or EGS?
Contact with MPW?
Last month..for my baby who had funsi (boil) in the ear. Otherwise no contact so
far
ANM?
There was one before; now transferred before 6 m. I hardly know the new one.
Kavita is her name.
Contact with the PHC
Thakursaab, one year ago I met him, No-one called me. No contact even with the
doctor
private docs
The fate of new JSRs?
Same as mine. Money problem..Nothing for medicines. What can we give to the
patient?
Where do you go for
Private docs. For my wife-ear problem—I went to bhagadi just 3 days back. Paid
medical treatment
75 rs for one injection and some tablets. This problem is l&half month old, had big
abscess. Had to cut it and paid 600 Rs to the Bengali doc. The ENT doctor in Dhar
was asking for 6000 Rs, which I do not have, (the wound has healed now,, I
photograph)
Q2
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
IMPACT AND POTENTIAL
Impact
“They ca^preve^t
ThoIMR
morhidcfy Tut notary deathT’—A BMO
soJSTi i^hewte/hay
tw- role/ uv thut.. H eeMh expert
It is not fair to measure the success of such scheme in terms of mortality differences, but in
how they have actually alleviated the sufferings of people, how and how much they saved the hard
earned money of their village folks. Such a study has not been planned so far. The impressions are,
they have treated some morbidity, much in the way ordinary private doctors do in rural areas,
perhaps at a significantly lower costs. The long-term impact of JSR scheme on MP's health system is
not fully gauged. The high drop out rate conceals a large addition to the rural PMP pool as the entire
state is training JSRs at several places. Even if 10% survive in whatever form, it could be substantial
addition to the PMP pool. That sadly it is an MP version of the Bengali doctor, something that could
be different.
K dispassionate analysis of the possible impact of even quack-distribution in unserved areas
may be favourable. The first shots of antibiotics, anti-inflammatory medicines can have an impact on
morbidity outcomes, just as the 4 tab presumptive dose of Chloroquine is construed to achieve in
NMEP. Various authors have appealed to take a kinder view of the quack-system for they operate in a
complex situation where few other things work. That becomes a great melting pot where BDs, MPWs,
Old CHVs, new JSRs, RMPs and mobile drug-peddlars look alike. It has an impact.
JSR scheme intended to make a much wider change than that. In that context however, the
scheme has failed make even primary things.
Potential
Vast number of villages in MP is without access to health care. The distances are already long
and bad roads are more tormenting to the sick, esp in rainy seasons. Men, women, children all need
good medical care at affordable cost. The Pvt Med Practitioners are there at clusters-10-15 km away
from such villages. The average cost of treating an illness at these clinics can be 50-100 Rs, sans the
travel costs. Bengali doctors without much formal training and language handicaps dot the rural
bazaars and bigger villages. "If untrained Bengali doctors can answer the need, why not our boys
with some good training and support?" was the pragmatic premise of the JSR scheme. Apart from the
medical relief at affordable cost, the scheme aims at improving outreach of National Health
Programmes. The advent of SJSGY makes JSR all the more relevant and fitting. Great potentials
83
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
indeed, for human needs of a backward state, of employing youth, of giving a broad base to the
health system, of providing alternative to the ubiquitous quacks.
The promise is fading into some weird scheme, mainly because there is no clear-headed plan and
no steering of the scheme. The health infrastructure is unhappy about it's implementation, the hardnosed political leadership staying away from the scheme, bureaucrats not surefooted about it, JSR
candidates—good boys from villages—suffering from a poorly framed and groomed scheme. The
scheme is coming unstuck, sadly.
However it is possible to redesign it, slow the pace, look at its terrain and details and processes,
educate people and users, build supports within and outside the health system fora potentially
good option, do some brainstorming about the choices and the risks and finally choose the optima!
path. If this scheme is rebuilt, it can be an example to several states in India that are looking for a
viable option on primary care at the village. The lCfh plan draft and the National Health Policy draft
are struggling for words to put such an option back in place after the debacle of the CHW scheme.
A new JSR scheme -and not this one-shouid serve to provide some new lines to this issue.
Legal status of JSRs
"We/ were/ colled/ by the/ PHC
owtd/ told/
thatyou/ cawx/t practice/. The/
Police/ Iv^pector wa^ also- pretext. (There/ wcvy arv lYicjutry from/VHS that how
many doctory cwe/practuy/ncy). H e/ threatened/ ay. \X)e were/ afraid/ of drafy-
reactlorv. .
AJSK
In some places, JSRs have asked how can they get permission to use medicines/ practice. In
one place the JSR actually went pale thinking the interviewers were police in civil clothes. He had to
be reassured. Instances where police have threatened the JSRs are reported. This situation can inject
fear of extortion. Pvt Med Practitioners can have a better access in police stations and can book the
JSRs as potential/actual rivals.
The JSR programme intends that JSRs earn for themselves and not bank on Govt, for support. Yet it
makes no preparations for a professional JSR-the list of medicines is short (less than what the
village grocer keeps for sale); the certificate hardly confers any legal status for use of medicines.
When we interviewed higher officers, this issue was not big on their mind. We looked for a new
copy of the medical practitioners' act of MP, but it stands repealed and was not available. There
could be some section in the act to support JSR activity. The Govt, needs to make a good effort and
bring the JSR scheme under some legal cover, so that it becomes stable in several ways.
84
F
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
NOMENCLATURE
I went to a group of youth in a roadside Morena village, asked them about who is the JSR in
this village. They were startled by the long name "Jana Swasthya Rakshak". "Kya Cheez, Hindi me
bo/o Sif was one reply and a loud laughter followed. (There was actually an old CHV working in this
village—practicing fully and running a busy clinic. The old ones are also called as the same Jana
Swasthya Rakshak.) That did not help me. Somebody then I described the scheme and they weighed
a hand at a clinic some 200 ft away and shouted one name, and a dhoti clad CHV with a stetho
hanging on him came out.6
No villager knows JSRs as JSRs or jana-swasthya-rakshak. The usual names are dawawala,
woh daktar, etc. That is a lesson for us in communication. We have been planting administrative
names or 'concepts7 on people. People call a spade a spade. Anybody who gives them medicines is a
doctor for them. The name sister (for a nurse) is fortunately popular. Some imaginative nomenclature
is necessary. Perhaps, the name will be popular if the scheme itself is functional. The Hindi shortform
JASWAR is good enough (people may make it JASWAR-doctor) as it sounds Hindi.
Venue for JSR activities
Some JSRs have asked for a ' Village Swasthya Bhavan'. Many JSRs do home-visits for treating
the ill (which is good in one way) or open their own shops One JSR worked from his grocery shop. In
Badajira, the village members have constructed a clinic for the JSR (A rare case ).
• The idea of making available a village-room is welcome. It will have several advantages:
• Reduce the capita! cost requirements/need for Loan,
• Give JSR a permanent place to work
• Make the JSR accountable to village people,
• People can expect standard facilities and rates at that place,
• Linkage for National Health Programmes will be easier in a public space, the room can be used
for several health functions
& In another Morena village, we changed the word to VHG (the PHC staff calls them as VHG), just to test
an administrative word again. The villager-the Sarpanch's brother in this case- went blank for a moment and
then his eyes sparkled, "you mean VAIDJEE" Oh, there is no Vaidjee in this village. We roUed in laughter at the
way people adopt tongue twisting-administrative words that we are so fond of thrusting on them. Incidentally,
that happens to be the best adoption to date of a God-forgotten-scheme of India. It will be pertinent to note here
that this name was changed several times-VHW/CHW/VHG/CHG/ CHV.. Alas.! Was he/she a worker, a
volunteer, a guide or was it a village or a community'? What a confusion!
85
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Irrational practice
TeTvJcwv S worthycv B haT^Tcvk/
(the/ M(9 PHC) sevid/ they ewe/ cwttvizy like/
hul/l ”
cvjkexi/ t<y- elcCbovGUte/ Ke/
ewid/ harm/ vnytead/ of heat.
(You/ewe/
a/wuynkey to-jhxx^e/you/WiXKcura^yyr} (xttuvxtythe/ veo^e/or exw
no-
These two are two comments one can never forget about JSRs. Irrational practices will hurt in
several ways. JSRs are using several medicines and injectable, just like any Pvt Med Practitioners that
abound. Pain killers, steroids, antimalarials, antibiotics are all there. Some relief of symptoms, some
subjugation of infection/inflammation may happen with that. Users have acclaimed the 'cures'.
"There is some strange wisdom in some of these practices. The ubiquitous chloroquine
injection is one such matter. Chloroquine orally is bitter and causes stomach upset. The injection
bypasses this problem. But that can also give fatal reactions. When so many JSRs are using the
injection everyday, how come no untoward effects are showing up? (Or there is not report?). So are
some other injectables like ranitidine and reglan commonly used. I pray these things stop one day,
and let reason dawn on them" (from a field diary).
"Irrational practice is common, but so many doctors are doing it. It is not possible to control
JSR-malpractice it without curbing malpractice of others. The collector has to do something",
observes one medical officer.
The irrational practices are too glaring and too common to ignore even for any sympathizers. How
do we bring these things under control? Is it possible? Is it well nigh a runaway horse? Is it because
they are not being paid by the state? (But even MPWs are doing malpractice).
And why so much demand for injections and saline? Is it because people want it that way? But then
who started it—doctors or people? Anyway, why people want it? Is there something sinister/y
attractive in injection-saline? Is it the healing touch people are rooting for? Is it some pleasant pain
sick people want to experience? Is the cost of irrational treatment some perceived compensation for
neglect of the family and the beloved? Several layers of health science—medical,
psychological, social, etc need to be studied before giving stock answers on misuse of
injection-saline. The JSR is merely answering a social need, according to Collector Dhar.
Some part of irrational practice can be surely corrected with better training on pharmacology, more
choices from allopathic as well as other healing systems, more leverage in the hands of users and
monitoring mechanisms, better administration of drugstores and market. Public education on the
scheme and also understanding the rightful concerns ofJSRs. This aspect is beyond the ambit of
this study, but surety calls for a in-depth research.
86
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
B
Exam process
B
Other books
B
Use of
Infotech
Too close to training
venue,
Several batches were
dropped
No formative
assessment
Knowledge not
trainees' goal. Copying
reported
Need for extra reading
felt by trainees and
trainers
No trainers manual
No self-learning,
interactive tools
Conduct at district HQ
Fixed dates twice a year.
Formative assessment
Results based on points or
grades ind. skills, attitude tests
Make a JSR library at CHC
and stock additional books
List recommended books
Develop CDs as a self
learning and self assessing
process, interactive
diagnosis exercises
No MIS software
B
Role of other
institutions
B
Drugs used
No institute with
expertise in education
and grass-root work
involved
Trained for very few
drugs. Leads JSRs to
quackery to build
credibility.
No one using other
remedies
B
Drug supply
Access to Irrational
drugs by JSR high
Existing supply system
inaccessible and costly
B
Injections
/saline
Irrational use of
injection
B
Ayurveda
Prepare manual for trainers
Records and MIS for analysis at
CHC level
Involve Open University
health NGOs like MPVHA/
PSM departments
EDL based on
Prepare separate list for
each module (Three level 10
/ 20 / 40 drugs)
Encourage home remedies
in the first module: herbal +
accu pressure
Publish approved list for
JSRs to begin with
Basic drugs (sub center kit)
to be supplied by PHC to
JSRs free
Revamp the protocols, allow
program-required injections
& ADR treatment injections
Charges more than the
cost as a source of
income particularly for
quacks
High public demand
Publish rate list
start action on quacks ,
quietly to begin with
Not yet introduced in
several batches
Home remedies as basic I
module leading to Ayurveda
in Basic II module and also
as a advanced training
focus on simple herbal
remedies rather than
marketed preparations
Add Other systems in basic or
advanced or specialist training (
Ayurveda, Homeopathy,
Acupuncture, Yoga) as per the
additional time, skill and
knowledge required
Develop local stores with
support from quality drugs
supplied by non-profit
pharmaceuticals like LOCOST,
Vadodara, Gujarat
campaign to stop irrational
drugs used both in private and
public HS
93
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
C
Community
control
No control by
community
C
Community
IEC
C
Legal issues
Community not aware
of the role of JSR,
responsibilities of gram
panchayat/ GSS/ GS
No legal status for JSR
for social partnership
C
Relicencing
No provision for
continuous testing for
JSR
C
Area size (to
make the
scheme feesustainable)
Great variance in
coverage area for JSR.
Not sustainable as fee
based model
C
Village
selection
Targets achieved
quickly
Community not
prepared
C
Links with
Other PMP
C
Linkages with
ANM/MPW
No system for links
with private medical
practitioners
Inconsistency with
linkage with
ANM/AWW
C
Clinic site
Clinic space invested
by JSR increases the
cost
C
Boards
System
identity,
Identity no different
from "Zola Chhap
Doctors"
c
Clinical work
JSRs doing
now
Not satisfactory
Empirical decisions
Public information by
posters, messages on walls,
rate lists and services
offered to be displayed in
gram panchayat, school,
Anganwadi, SC, Janpad etc
Ongoing community IEC
work should help
Directed to protect users
create administrative tools for
gram panchayat control
Legal protection is
necessary
based on self-village based
work and drug-use
Issue clear GR on use of
remedies
look for provisions for certificate
courses for JSRs
Design Specified IEC for
awareness building
Necessary every three years
based on both technical
performance and community
feedback
2000, ideally for sustenance
on fees
let it be decided by GS/gram
panchayat if it can support
the JSR differently (like
insurance)
Take villages as they ask &
prepare for the scheme
make it a ongoing scheme,
not the fight to finish kind of
scheme
discourage quack connection
Internship in trust hospitals,
PHC, CHCs and Civil Hospitals.
As colleagues, to mobilize
community to uptake NHP
linked services of staff
Prepare a simple reporting
system
gram panchayat space must
be available, but let them
work also from home for
odd hour services
'Gram Swasthya Kendra'
board specifying name of
JSR; may be prepared by
gram panchayat in standard
format; let gram panchayat/
HMD decide
A logo OR a standard kit
with a logo gives a workrelated identity
Increase both depth and
range—through training
/support
A
94
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
C
Clinic model
Variance in clinical
model depending on
what JSR, can afford
Develop a standard set - an
HMD.
Let RKS like bodies build the
centers if and when possible,
this will give some credence to
the JSR as system
D
Clinic records
Variance in clinical
record: nil to
professional
D
Supervision
monitoring,
Quality
control
No supervision system
E
Honorarium
for JSRs
Near consensus about
need for honorarium to
JSR
E
Minimum
income for
surviving as
JSR
Survival rate
--Working
JSRs out of
trained
Social
marketing of
preventive
services/
goods
1500 plus* Only fee
based model financially
unsustainable
As a part time activity from
various sources (fees + NHP
link + HE/HP activities)
~10% survive. Varies
somewhat from area
to area
Above recommendations to
improve survival rate
Variance in social
marketing through JSR
Community not aware
Basic preventive services are
practically never sold by the
public health system and
should not be
E
E
Work out simple, standard,
user friendly, relevant,
scannable, analysable, small
MIS friendly record-formats
Supervision/ monitoring:
Social: village. Health
committee / Gr. Sabha
Technical: public health
system
NHP linked honorarium
Legal/ Support: NGO/ CBO
JSR should be supported by
public health system through
Panchayat for health promotion,
health education
Possible only if a regular clinic
space is available
List articles/services other than
basic preventive services that
the community can buy or the
JSR can sell
5 Here the calculation is : Min wage for skilled laborer @ Rs. 100 per day; Time required = 2 hours for
clinical tasks, no of patients seen - treated or referred = 12; Therefore cost = 100/8*2 = 25 Therefore the JSR can
charge Rs. 2 to 3 per person as service charge
95
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
No
47.
48.
49.
50.
51.
>527
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
Form
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
Tab
List*of medicines working JSR's use
Gripe water_____________________
Himalaya drugs ?_________________
Ibugesic_______________________
Iron capsules____________________
Lassix_________________________
livina,_________________________
lomofen,_______________________
loperamide,_____________________
Mebendezole
_________________
Metchlopromide__________________
Metrodinazole,___________________
Mexaform______________________
Norfloxacin_____________________
Optoneuron_____________________
Oxytetracycline__________________
Paracetamol,____________________
Perinorm____ __________________
Polybion_______________________
Primaquine_____________________
Quinine________________________
RB tone_______________________
Rcine_________________________
Reg Ian _______________________
Rinosted (?)_____________________
Roxithromycin___________________
some Ayurvedic med.______________
Stemetil,______________________
syn-spas______________
sypalfin
____________________
T.T._______
Taxim
♦This list is compiled as pooled from JSR-W interviews
105
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
APPENDIX 4: LIST OF MEDICINES AND THEIR ECONOMY BRANDS FOR
JSRS
Generic name (mg)
Economy brand names1
Price Rs per
Tab/cap/pack
Albendazole 400mg_________
Alluminium Mag salt________
Amoxicillin 500 mg__________
Aspirin* 325 (in combinations)
Low dose aspirin 75 mg______
Bisacodyl (laxative) 5mg_____
Hyoscine Butyl Bromide______
Calcium
Albrodo, albendol, alford______
Centacid MPS, Embesil, Logascid
Amoxybid, PureMox, Cidomex,
Micropyrin, Disprin___________
Lodosprin, delisprin__________
Bidlax-5, Julax M____________
Belloid, Buscopan____________
B-Cal, Calciriv-Z,, Omical, Cal-
8.00/ 8.90
0.15 to 0.21
3.10-3.5 0
0.25______
0.50, 0.60
0.16, 0.60
1.70,1.75
0.25 - 0.32,
Locost2 price
per T, for
bulk & (strip
pack)_______
1.00 (1.20)
0.07 (0.12)
1.90 (2.10)
0.08
0.07
De-Ce_____________________
Chloramphenicol eye applicaps
Eye drops (sulpha or ciproflox)
Chloroquine 250
Ciprofloxacin 500
Codeine Linctus 60 ml______
Cotimoxazole SS__________
CPM 4mg________________
DEC 50mg_______________
Syrup___________________
Domperidone 10 mg_______
Doxycycline IQOmg________
Eardrops antifungal-antibiotic
5ml__________________ __
Erythromycin 250_________
Famotidine 20mg__________
Phenazopyridine__________
Iron mg + Folic acid_______
Furazolidine IQOmg________
Gama Benzene HC 100 ml
Ibuprofen 400mg
Isobarbide IQmg T________
Mebendazole 100 mg______
Methyl Ergometrine 0.125mg
Metronidazole 400mg
Paraxin, Chloromycetin________
Optisol, Syncula, Ciprowin,
Ciprobid,___________________
Laquin, Mellubrin____________
Ciprozol Ciprocap, Ciprolet,
Ciprotum
Ciiplin, colizole, kombina
Cadistin, Piriton_______
Heterazan, Banocide
Heterazan___________
Nudom, Domeperi DT
Doxycyclin, LAA_______
Mycotic, candibiotic
Erase, Erolcid, Restomycin_____
Peptac, Famon, Famtac_______
Pyridactil___________________
Macrofolin Iron, Fen/it,________
Fudon,Furoxan______________
Scabex, scaboma____________
Ibugesic, Ibysynth, Emflam,
Brufen_____________________
Ditrate, cardicap_____________
Mebazole, Helex_____________
Ematrin, Uterowin___________
Aldezole, Unimezole, Metrodana,
Flagyll
0.50, 0.70
4.00-6.00
0.35, 0.60
0.3.00—4.00
24.00
0.65, 0.80
0.05-0.10
0.25, 0.30
12.80
1.25, 1.5
1.60______
16.75, 18.50
2.65, 2.75, 3.00
0.40_________
0.60_________
0.14, 0,26
0.22_________
18.00________
0.55-0.60
0.10, 0.11
0.60, 0.85
2.00
0.63
0.35 (0.39)
1.70
0.37________
0.04________
0.15 (100 mg)
0.85
0.07________
0.10________
100.00 (4.5 L)
0.37
0.17
0.38
J
1 As given in 'Drug Today7, and quoted in 'Health & Healing- a manual for primary care'
2 LOCOST: Po Box 134, Vadodara 390001, Office Premananda Sahitya Sabha Hall, Opp Lakadi Pool, Dandiya
Bazaar, Tel 0265 413319, Fax 830693 email: locostdnjqs@email.com web: www.loscotdnjgs.com
106
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
OC medium dose
Oral Penicillin
ORT____________
Paracetomol 500mg
Primaquin 7.5_______
Promethazine 25mg
Providone iodine 100ml
Salbutomol 2mg_____
Soda-mint__________
Tetracycline 250
Tinidazole 300mg
Vit A 50000 iu
Vit Bl (thaiminl) IQOmg
B2 Riboflavin IQOmg________
B6 (Pyridoxin) IQOmg_______
B12 (Cynocobalamin) 250 mcg
Folic Acid 5mg_____________
Multivitamin_______________
Vit C 500_________________
Vit D____________________
Whitfiled ointment 5gm tube
Mala D____________________
Kaypen (PhMe:125mg), Penivoral
(V:65)___________
Prolyte, Leclyte W, Emlyte_____
Parazine,Patmin, Ifimol, Cetanil,
Bepamol,__________________
Malarid, PMQ-INGA__________
Thazine, Promet, avomine_____
Vokadine__________________
Salbetol, Asthalin
Subamycin, Achromycin,
Tetramac__________________
Amebamagma, Tinicide, Camitol,
Trag______________________
A-vit, Aquasol-A, (Arovit drops
7.5ml)_______
Berin______________________
Lipabol____________________
B-long_____________________
Vita cure___________________
Flitab, FH-12, Foli-5__________
Vimgran, Manavite___________
Cell-C, Celin, Redoxon________
Alphadol, Alphaset
2.00
0.87, 0.64
5.91, 6.02, 8.20
0.16, 0.19, 0.30,
0.34, 0.40
1.09. 1.20
0.83, 1.01
26.00_________
0.11, 0.13
0.05__________
0.64, 0.80,1.00
0.80, 0.90, 1.20,
1.23__________
1.10, 1.20,
(10.76)
1.00__________
0.50__________
4.00
0.14 (0.20)
0.10 (4 mg T)
1.50
1.50__________
1.20__________
0.67, 0.72
0.23, 0.27
0.80 - 0.82
1.62, 4,75
5.00
7.00 (25 gm
tube)______
All prices are for single Tab/ Cap/ Pack, but buy as per the number prescribed^ esp anti-infective drugs
107
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
APPENDIX 5 : ANALYSIS OF EXAM (2 PAPERS) HELD IN JUNE 2001
Expected type of answer
Descriptive_____________
Listing_________________
MCQ
______________ __
Naming______________
Unclassifiable____________
Total
Comment_______
Incorrect_______
Needless_______
OK____________
Rather simple
should be practical
Vague__________
Why___________
Total
Subject_____
Human biology
Nutrition_____
Child health
EPI_________
FW_________
Mother Health
NMCP_______
AIDS________
NTCP________
NBCP________
NLCP_______
Birth_________
STDs________
Minor illnesses
First Aid______
Comm illnesses
Role_________
Sanitation_____
Total
Fr
26
Percent
38
50
23
2
139
27.3
36.0
16.5
1.4_____
100.0
Fr
~3__
Percent
2.2 ___
18.7
~6__
~97
~28
2__
' 1__
2__
139
4.3 ___
69.8
20.1
1.4
0.7____
1.4 ___
100.0
Fr
Percent
~4
'19____
'22_____
~26.6
'72_____
'65_____
65_____
'65_____
~3
~37
'10
~9
9
9
7
7__
6
6__
2__
1__
9__
4_
10
2__
4__
139
SO___
SO_____
4.3_____
4.3 _____
1.4 _____
0.7_____
6.5 _____
2.9_____
72_____
1.4_____
2.9_____
100.0
Group__________
Human Biology
Human biology
~NHP_________
~NHP_________
~NHP_________
~NHP_________
~NHP_________
NHP_________
NHP_________
NHP_________
NHP_________
NHP__________
NHP__________
Other illnesses
Other illnesses
Other illnesses
Role_____________
Village improvement
108
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
APPENDIX 6: TERMS OF REFERENCE
A
Explore selection criteria and objectives of JSR
a) for increasing women's participation
b) for assessing education standard and age mix
c)
B
for exploring level and range of preventive services JSR should provide
Assess training and supervision
a) For assessing the quality in training method and of trainers
b) Assessing changes recommended in the previous review
C
Explore relationship of JSR with village level structures for analyzing the
a) Linkages with M\/VJ and TBA
b) Convergence of service delivery approaches of different programs
c)
Scope strengthening institutional relationship between JSR and village communities
d) Scope for JSR to work with RMPs and ISM practitioners
D
Appraise current linkage of JSR with overall health system considering
a) Supervision of JSR, their referral system
b) Feedback systems for epidemic alertness, NHP coverage
E
Assess current incentives (formal, informal including perverse) including
a) Current level and sources of income and whether it is adequate as a full time income
b) Options for JSR involvement in NHRs
c)
JSR's role in social marketing of public health goods
109
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
APPENDIX 7: AN OPINION POLL ON THE JAN SWASTYA RAKSHAK
(JSR) SCHEME
As a complementary exercise, in addition to the formal JSR Review described in this report, an
opinion poll ws also carried out to ascertain qualitatively the strengths and weaknesses of the
Scheme and suggestions for immediate improvement as well as long term policy issues that
needed to be addressed.
An English and Hindi version of a simple opinion poll (see annexure to this opinion poll report)
was distributed by the team members during the field visit to all those who were willing to put
their suggestions down on paper. At the end of the exercise 40 forms were received. In a
section of the opinion poll form respondents were invited to mention the capacity in which they
were involved in the JSR Scheme to help us contextualise their suggestions. The respondents
included administrators (6); trainers (16); doctors/health service providers (26); NGOs/civil
society (9) and other capacities including researchers (3). To maintain confidentiality in the poll
signature at the end of the form ws made optional but 18/40 signed it both indicating a high level
of enthusiasm and transparency. The sample included collector, panchayat leaders, DHOs, PHCMos, MPWs and trainers. It was decided to use the opinion poll qualitatively and not
quantitatively because of the opportunistic nature of the sample (self selected volunteers). A
qualitative check list of expectations and suggestions for the JSR Scheme to be available to policy
makers and administrators in Madhya Pradesh who deal with the JSR Scheme at different levels,
to address or utilize as they operationalise the scheme, was built up. Similar suggestions in each
section have been amalgamated into broader categories or shown as sub-categories or items.
A : STRENGTHS OF THE SCHEME
Health Services available in the community
Health person available, easy reachability, local grassroots level presence, primary health
care at every village, trained person at village level, direct intervention at community
level.
Variety of services at village level
Personal Hygiene awareness; treatment of minor ailments and illnesses at low cost;
health education; proper treatment at early stage of illness; medical help in emergency;
awareness and management of Diarrhoea and Malaria at village level; MCH and family
welfare services at village level; help various national programmes being effective at
community level; good agency for monitoring health programmes at village level; referral
in time to right person at right level; provide information on government programmes.
110
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Linkage with government health services
Stronq link between health services and community; enhance access and availability and
affordability of government programmes; field link for national programmes; keeps
government health services informed about village level problems and disease.
Community mobilization and cooperation promoted
Local problems - local solutions; helps government in its aim for community coordination
and cooperation; village panchayat level mobilization and involvement is enhanced.
❖
Potential for utilizing training resources, trainers, institutions and partnership
with and other resources of government, NGOs and civic society is enhanced.
B : PROBLEMS OF SCHEME / CONCERNS ABOUT SCHEME
Selection problems
Every village not having 10th pass candidate;
Participation of women, very little
♦
Wrong selection of candidates — not suited for JSR
•
Working quacks take training of JSR to authenticate practice.
Lack of Community Preparation
❖
Lack of preparedness / preparation of community
❖
Selection at panchayat level without interest, and politics is also involved
❖
Lack of coordination at village level after training - no links with panchayat after
training.
Training concerns
❖
Should be trained by experienced trainers of which there is a shortage
❖ Training centres not well equipped
❖ Teaching of subjects in curriculum not properly done
111
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
<* Lack of training in proper referral
Too much focus on training on medicines and injections
Inadequate attention to community level action and community mobilization
Problems of Support
♦:*
Impossibility to serve without availability of drugs
❖
Needs continuing education and supportive supervision
Non availability of funds to support training in a timely manner may affect scheme.
Problem of financial remuneration and security
❖ Difficulty to work without payment or monetory help
❖ Needs some financial or monetary incentive from government or panchayat.
Distortion in role and identity
<♦
May focus on injections / saline practice rather than other activities
Jhola chhap doctor will increase and loot the poor villagers
Diagnostic and therapeutic procedures will become more irrational
❖ Will add to the existing quacks in the community
*:•
May begin to practice like doctor and create complications.
Continuing problem
*:*
JSR leave work if they get other job
❖
No feedback from JSRs and lack of continuity after training
v
Lack of continuing education may cause local problems due to wrong treatment
practices.
Finally lack of continuity and constant flux may make the scheme unable to fulful the
needs of the health service in the real sense.
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
C : SUGGESTIONS FOR IMMEDIATE IMPROVEMENT
Training
Should be at District Training Centre
Exams should be held at DTC / RTC
Training should be by clinical or public health doctors (experts)
Should work in PHC for a while after training
Practical experience of how to handle problems not only theory should be given
Should be participatory with audio visual aids
Should be attached to experienced doctor / NGO before independent in.
Selection
More females should be selected
❖
More needy persons should be selected
❖
Person selected should be of that village or should stay in it
❖
Every village should have one male and one female JSR
❖
Local worker who is interested in service should be selected
❖
Middle school should be basic qualification
❖
Pre-evaluation by simple entrance test and practical skill level assessment.
Support and Supervision
Should be recognised by Sarpanch and gram sabha after training
Supportive supervision and constant training by PHC staff
Should be linked part-time with PHC or NGO.
Should have drugs for seasonal diseases
Should get basic medicines and health education materials for village work.
Financial security
❖
Should be paid per month; or
❖
Should be given some financial assistance and or incentive.
113
OF JSR SCHEME Of MADHYA PRADESH: Septemte -o^ 20M
JSR Ro/e Clarity
❖
Should be responsible for all health problems in the village
Health education should be important skill
❖
Should be resident in village and available during need / emergency
❖
More female JSRs will enhance the focus of activity on women and children.
Directorate level
❖
Put a think-tank at directorate level to look at scheme in all aspects
❖
Evolve a comprehensive training - retraining - monitoring system for JSR scheme
Prepare protocals for clinical / community problem solving
❖
Prepare IEC protocols for campaigns to increase awareness.
D : LONG TERM POLICY OPTIONS OR INITIATIVES
Roie / Scope
*:*
More participator! of c.mmppi,,, in seleaion,
❖
Monthly .nypiyement of hea,th c(lmn„tteK
*:*
(JSR to iocai coM^nrty telth
sM
p|anMng
Training
Duration of training should be for one year
❖
Trainers must be free of other work during training phase
Should be trained in Indian systems of medicine as well
❖
Field visits in the community where they will eventually work
Training should be need based.
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Support / Security
♦♦♦
Should have regular updating of skills and knowledge
❖
Should be paid or given financial assistance from panchayats
Health department should monitor closely - use of essential drugs and limiting practice
with other drugs.
❖
Should be paid for involvements in different national programmes
❖
Financial incentives to JSR through co-payment systems.
Long term sustainability
❖
Recognition of good workers
❖
Disincentives to others who misuse scheme or take unnecessary risks / irrational
practices.
❖
Refresher course atleast once a year or at regular intervals.
❖
A good supervision, continuing education and regulatory mechanism is essential to
prevent distortions and deviations.
To summarise
the above suggestions and perceptions are very similar to those we have listed out in the main
body of the report. What they indicate and endorse are two main conclusions.
1. There is a wide consensus of opinion recognising the need, scope, challenge and
relevance of the JSR cadre in Madhya Pradesh's health system development.
2. There is also a wide consenses of opinion that as the process stands today there is wide
scope for urgent action as well s long-term policy consensus to prevent the scheme from
getting deviated or distorted from its basic philosophic assumption of being a relevant
Primary Health Care human resource responses for every village in Madhya Pradesh.
Jana Swastya 'Rakshaks' and not Jana Swasthya 'Nakshaks' is the challenge ahead!
115
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
APPENDIX 8: JSR SCHEME - A REVIEW
Text of the PowerPoint presentation
Slide 1
Slide 2
Slide 3
JSR Scheme - A review
CHC_______________
Changing Reality
Slide 4
Approach of JSR Scheme
Slide 5
'Epidemiology' of CHW
Slide 6
Slide 7
Current Profile: JSR
Slide 8
Study in Brief
Slide 9
Slide 10
Study Area________
Findingsl-JSR factors
Slide 11
Findings?- few 'successful'
JSRs
> JSR SCHEME...__________________________
• Aims to address village level gap of health care - a
nationwide problem_______________
• Aims to promote health, increase outreach of health
care & National Health Programmes_______________
• Train & certify village youth, one time kit.._________
• Provide clinical, preventive, Promotive health services
• Started from 1994-95, now part of SJSGY__________
• Several variations in developing countries__________
• Chinese model as barefoot doctor (now Rural
Doctor) 1952__________
• Indian programme started in 1977, now nearly
defunct_________________________
• JSR scheme in 1994_________________
• Brazil started in 1995
Planners called : (Margadarshak) Guides, (Swayamsevak)
Volunteers), (Sevak) worker, {Doot) messanger,
Mitra/Saathi/Mith^
Auxiliary, helper {Sahayak),
paramedic, Vaidya,... anything but a doctor
Village people simply call 'Daktaf (So did Mao., 'barefoot
doctor') or a sister/nursebai/PaXrter77/for a woman health
worker______________________
• About 15000 villages covered_________
• Training in progress_________________
• Over half the MP villages yet to be covered_________
• High attrition (Guesstimate 90%)_________________
• Qualitative-Interviews and observations____________
• Six districts- Barwani, Bhopal, Dhar, Guna, Jabalpur
Satna and also Morena__________
• Visits to Panchayats, PHC/CHC/SC, villages
• Covered all stakeholders_____________
• 6 researchers, September to November 2001________
(MAP of MADHYA PRADESH)________________________
• 'Education & marks' as main selection pegs_________
• Men, most of them______________________
• High dropout rate ____________ _____________
• Pvt practitioner is the role model for survivors_______
• Mainly inj/saline practice like Bengali doctors/any Pvt
Practitioner_________________ ________
• Fees ranging from 2-30 Rs, income 500 to few
thousands a month______________________
• Little NHP work, and little link with/ support from
PHC/SC/GP
116
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Slide 12
Findings 3-User factors
Slide 13
Findings 4..Training
Slide 14
Findings 5-Linkages
Slide 15
Findings 6 -PRI Member
Views
Slide 16
Findings 7- Gender
Slide 17
Findings 8- Health Officers
Say
Slide 18
Diagnosis and Prognosis
Slide 19
Suggestions 1- Policy
Little programme awareness among users_________
In most villages, JSR sidelined___________________
'patients' usually happy thanks to pricks/saline coming
cheaper and nearer
________________________
Some unwilling to pay_________________________
Some wary of these 'new quacks'________________
Inadequate facilities___________________________
MOs have little time for training__________________
Trainees'hang around' in injection rooms__________
Manual yet to reach some trainees_______________
Manual needs improvements____________________
Too small a list of medicines____________________
Most JSRs are defunct-no question of linkage..
For survivors...
_______________________
Little active link with PHC/SC____________________
No serious NHP support________________________
GSS barely exists, and JSR hardly connected_______
Some links with Pvt Practitioners and drug stores
(Many not aware--esp. village GP members)________
"Scheme relevant.BUT not working, no future.."
Maandeya is necessary________________________
Women not available_________________________
neemhakim khatara e jaan..____________________
The programme is male biased-selection, training,
demands of working, lack of supports_____________
Few (10%) AWWs qualify______________________
Women users of JSR services scant, RH services thru
JSR nearly absent
_________________________
Purdah, family chores hinder____________________
Little consultative process
Producing quacks
________________________
All kinds of problems in this scheme______________
Some support is necessary for JSRs_______________
Monitoring necessary
_____________________
Special training staff necessary
VERY RELEVANT -TINA________________________
Inadequate design and detailing_________________
Little matching of needs-objectives-training-working
High attrition, and survivors going by irrational
practices________________
Poor outcome without serious reforms
Pause, review, redesign
_____________________
Choose a right model
_____________________
Think of JSR-as a system-not individuals__________
Create special JSR cell_________________________
Legal provision/identity________________________
Special NHP support____________________
Control quacks & quackery-within and outside
117
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Slide 20
Suggestions 2- Technical &
Managerial
Slide 22
Suggestions 4-Sustenance
Slide 23
BTW: Craving for saline and
injection
Slide 24
Slide 25
We are grateful to
Slide 26
CHC Team
• Comprehensive task-list______________________
• Expand drug listr make rate lists________________
• Include other healing systems__________________
• Select and improve training systems & manual,
institute CME___________
• Monitoring and MIS__________________________
• Help JSRs to get professional knowledge & skills, so
that users value them.___________
• Give state support through GP, based on NHP/SHP
(e.g. school health) tasks,___________
• Provide NHP consumables_____________________
• Declare economy drug-list____________________
• Explore primary care insurance,________________
• Increase women participation, SHG support______
• This is serious problem--not only in India but even
the Dragonland..this picture from a township health
center in China 1998. This boy had fever! The other
woman had cough!__________________________
• Two waste baskets__________________________
• Clinic of JSR(old) in Morena___________________
RGM, District officers, MP Health Dept-,Awes, Panchayat
& other leaders, JSRs, Villagers & patients, PRMPs,
pharmacists, DFID______________________________
Dr Ravi Narayan, Dr Shyam Ashtekar, Dr Dhruv Mankad,
Dr. Shashikant Ahankari, Dr. Abhay Shukla, Prof. A S
Mohammed, Amuiya Nidhi
118
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
APPENDIX 9: NOTES ON THE JSR MANUAL
A) Placing the manual in JSR proramme
A manual is an essential part of any technical programme. It embodies the language, style,
substance, priorities, and emphasis of the entire programme. It is something to fall back upon
and a virtual meeting place for the policy-community and the readers/users. In a programme like
the JSR, WE think such a manual needs to occupy a central place. But one needs to look at its
biological relation within the entire training system and working pattern of the JSR programme.
Thematically, for a JSR like programme, let us 'place' the manual.
It is central to the initial training course for JSR, and secondly a referring text to buttress
the CME effort later.
No manual can, as a stand-alone device, serve as the omnibus book. The overall need
assessment for training material is:
trainers
For trainees
Phase
The initial
course
Working
phase
Knowledge/facts/attitudes
skills
Textbo^jJfeJan^.tEainind
material
Skills-handbook,
CD/visuals
Panchayat
/ users
TOT book
House journal/ (channels if
available)
what to
expect/
how to
manage
We are not aware at this moment whether other elements of this table are available.
B) Within the covers of the JSR manual
Writing such a book is a daunting task, esp if the task framework is nascent, the readers
yet to get established, training systems new and not well honed. For the group that began this
exercise, it has been a big involvement.
Following criteria are relevant:
•
What is the intended task-list of a JSR? -Does the content addresses the tasklist?
•
What are the elements it is addressing-knowledge, attitudes, and skills?
•
The language, style of communication of the book, user-friendliness.
•
Does it fit the bill for a handbook or a distance training material?
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
C) Other books
Private books
In the field study, we found that working JSRs are using some other books, almost
keeping aside the manual, and the books include:
•
Adhunik Allopathy guide (Harnarayan Kokcha, Pub: Dehati Pustak Bhandar Delhi)
•
Swasthya Nirdeshika: OP Bansal
WTND Hindi: David Werner
Govt publications
Manual for Health Worker (male) is a useful publication, it is a surprise, why MP Govt
did not use this book with little updating
Assessment of the substance of the manual
Chapter
Remark
Topic
Page
1
1.1- objectives
Good, curative role has primary place
10
duties of JSR-
Repetitive, should have been categorized-
12
Code of
Incomplete (see WD doc)
conduct
13
medicines
Only 8 internal medicines-severely incomplete list (see WD doc)
14
Clinical skills
So few? (see knowing CHW)
(diagnostic!)
15
Technical skills
Some are diagnostic/investigative; while some are first aid. The first aid
skills do not say what are skills, only mentions conditions (should be
wound wash instead of dogbite as a skill). Some mix up. Skills are
activity sequences—like in checking BP or wound suturing.
16
Motivation
Not very clear, is it same as communication skills?
skills?
17
Referral skills
these are really diagnostic skills
community
are really communication skills
skills
"The skills"
better grouped as detection skills, hand skills, verbal skills or according
to function-diagnosis, therapy, prevention, health education etc
120
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2QQ1
18-20
Responsibilities
Duplication., like malaria is separately mentioned while communicable
illnesses exist, as a section (is malaria not communicable?). Vaccination
also is part of C-illnesses. We would recommend better grouping of
responsibilities, like curative, preventive, promotive, administrative etc
or patient services, NHPs, School health etc
Some language problems like- (Is JSR a Govt, servant? or a volunteer
helping Govt?)
needless repetition of first aid problems
25
25-26
illnesses list
Better grouping is called for (see manual/red book). One way is
feasibility and second way is systemic grouping. And, are these all
illnesses to be handled?
2
28
health
OK
infrastructure
human biology
3
•
Needs a different perspective- needs a better plan/approach.
•
Lot of needless details-like how many bones/names of bones
everywhere. Often goes like Grey's anatomy (anterior organs/post
organs/lateral —etc)
circulation
•
Needs figures at places (see for instance chambers of heart)
•
A CD may help learning/teaching this section
the section 2 is mostly about blood, but wrongly titled as heart/vessels (
also there is style problem of subheads- leveling is imp)
56
Excretion
Why talk of weights of kidney?
56
57
Is parotid an excretory organ really? ( and at health worker's level)
male genital
no labels to diagram
Needless description of penis
61
62
female genital
Why not Hindi names for organs?
66
Nervous
Insufficient
System
4
67
questions
Relevant? Need for questions that test for each section comprehensively
68-
diagnosis
Objectives not given..why diagnose an illness?
Poor organization/protocol. It should be systematic- either top to down
or system-wise, or general/systematic format
picture of child not matching description (skin)
73
78
illustration of
•
Wrong side for right handed examiners.
pain/abdomen
•
random selection of abd pain points-must be regionwise
checking
5
84
food
classification
name category/ common factor- 3lld|S-l4^)^4l
sudden switching from general nutrition to child nutrition
121
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
malnutrition
describe two categories-marasmus/kwashirkor
treatment of
Feeding advice not enough- porridges/addition of oils is not mentioned.
malnutrition
94
Vit A def
Tourniquet-bleeding in anemia is not relevant/correct
95
96
Why THTyT is not mentioned as an illness? But mentioned on pl54
Vit A soln (last
Advises to see picture, but where is it?
line)
99
Need to advise on preservation of iodine in salt at home-cover etc.
Iodine
also check facts on salts sold in bazaars6
105
programme
Avoid national/regional stats,
statistics
ANC protocol
Needs reorganization
113
PEToxemia is- <|cb4IJl ?
114
Is FP advice an emergency
is really
115
3rd para, first
<49)1
Not clear
sentence
116
8
FRU
use one term (pratham stareeya/FRU/)
eclampsia
Is it infective
fciMIctddl
Actually this is
What is this? Perineum or vagina?
117
^5%
119
Risk factors
Incomplete list, and not organized in pre/intra/post natal factors
123
preventing
list of 6 is incomplete without good nutritional practices
Io AHI
child deaths
Replace this word (abnormal) with
126
Resuscitation
Rewrite para 2 sentence
para 3
Suction is good help.
135
three illnesses
Repeated probably from proof correction
136
Co-Trimexo-
use shortforms for drug-names ( also p 140)
132
9
zole
141
diarrhea
why not SSS, why only ORT,
control-para 1
Suggest using
Hvil=M For ORT
122
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
use <^41
10
153
Vit A units
say it in mis ( many zeroes intimidate)
157
point no 6
repetition
162
milestones-
Is it mixed up at places
columnl
11
166
STDs
Syndromic approach is helpful.
What about other STDs-LGV, Soft sore/ Herpes Genitalis?
167
Is JSR treating STDs? If so with what drugs-see drug list
Mention syphilis to be imp. cause of repeated abortions
169
AIDS
symptoms-major minor/child adult
Stress sex/health education in schools
oral pills
12
If JSR is giving pills, distinction between absolute/relative
contraindications is needless(all are Cis)
oral pills
Is one-month gap not advised these days? (Continuous use for 5 years?)
Tubectomy
TL by Laparotomy + GA need not be mentioned.
Why not mention safe period as a method?
13
193
TB
Bacterial name to be shortened if at all necessary, use simple word like
TB for the illness
what is
194
?
table
Are TB death rates necessary?
age of TB
Childhood TB is to be mentioned not glossed over.
incidence
195
last para:
second sentence should lead para, to avoid confusion
symptoms
197
Prevention -
Isolation need not be overplayed.
paral
200
NTCP
15 days to be replaced by 3 weeks (chr cough)
201
phases of DOT
words like iTpT
202
categories of
Explain the categories
need replacements
TB illness
Are JSR giving DOT? If so, include the side/untoward effects of drugs.
Use English code like SHRZE do not hindiise!
14
204-5
Rx cards
Use filled cards, not empty
207
illustration
Good!
214
leprosy
Is JSR treating leprosy? Why discuss dose of MDT?
222
G worm
Removing steps of wells is mandatory-pl mention that
123
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
15
224
eye-fig
wrong labels
PI use same words in fig and text
What about other eye-illnesses- FB, dacryo, trachoma, squint, sty
229
16
17
230
Disease triad
OTWT is 3TRHT dIdldJul is qfrfeCT
241
Typhoid
Does Typhoid start with catarrhal symptoms?
250
water-
Use after 30mins (2-4 hrs?)
chlorination
251
sanitary latrine
WJ SINKI^ (also p 253)
soak pit
soak pit is only for avoiding pools-mosquito breeding, it can not avoid
deep-water source contamination. In fact it should be away from
borewells, (use illustration)
254-
Responsibilities
Is the language right if Govt is not paying JSRs?
water &
Illustrations are very pleasant
55
sanitation
256
'-ddcb
'Jldcb S^TT
261
bats
How to prevent contact of dogs with bats?
264
splenomegaly
Swelling yes, but no ascites.
?
picture
266
treatment of
malaria
•
wfcr % cr^TFT ’J^IrT
•
Treatment does not even mention paracetamol-why?
Should discuss side effects of antimalarials
267
tablets-table
Which tablet is this..Primaquine, column-head missing
Treatment differs for vivax / falciparum (see NMCP litrature)
269
first line
first line should go to previous page
270
Illustration
Gives an impression that humans and mosquitoes take 10-15 days each
to develop infective forms (gametocytes and sporozoites respectively).
Immediate next bite can not infect, and acute stage malaria is yet to
develop gametocytes.
273
neck-rigidity
Not always present in encephalitis unless there is meningism, but in
(NR)
meningitis it is always there. NR should be tested lying down
Impregnated bed-nets and guppy fish need mention
275
Filariasis
JSR can do Filariasis treatment-needs emphasis and details of
treatment- also a place in drug list
also mention mass treatment
124
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
19
E5RT HET
needs classification on UTZT ^TT WT 3m (see my classification on
this)
Only 16 illnesses- how were these selected? any criteria?
278
Boil
•
Aspirin is better than paracetomol for anti-inflammatory effect, but
not mentioned, in list! In fact aspirin is a layman's medicine
•
Why not anti-infective agents like Co-Tr/Tetracycline
•
small lesions can be punctured/incised and drained/ also herbal
treatment for bursting the boil are used (also poultices)
Constipation
Several herbs are advised-triphala, amaltas etc (see your own Ay
section)
What is it?
Is not the same. Call for different approaches. Cough needs a protocol to
atleast separate URT causes from LRT ones. The treatment here looks
like addressing URT cause.
In general, we need to decide whether the illness is mentioned
is symptom or diagnosis
279
Ear pain
Calls for diagnosis: external ear illness or middle ear infection? Both
need different. Drops are not for ASOM with burst drum.
Strangely, anti-infective drugs are missing again..
Fever
•
Calls for a systematic approach, all fevers are not malaria.
•
Fevers can be split on age/cough/non cough, then again into
separate conditions. Simple flow charts are available (see CEHAT
booklet)
•
Headache
If it is malaria-takes longer than 24 hrs even after chloroquin.
In addition Acupressure points are useful, and also increase JSR's
rapport with patients
280
280-1
•
Illustrated position is for which illness? Indigestion?
•
Why the illustration shows a naked person?
Joint pain/back
•
Both are different illnesses, can not be clubbed.
pain
•
Bulleted description is related to PID/spondylysis-which should be
Indigestion
referred. Ref is not mentioned, but only bed rest!
•
Aspirin yes, but why not mentioned in drug list? Mention precautions
with aspirin?
•
Why naked women in illustration?
•
Mention referral for last bulleted item- TB spine
125
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
281
Abdominal
•
Needs systematic diagnostic protocol-regionwise.
pain
•
Need to detect acute abdomen problems
•
Mag hydroxide is for acidity or constipation. For acidity we need a
combination of Mg and Al salts.
•
Coloin(?) and MagPhos are tissue remedies- then say about
strength/dose/period etc.
282
milk-Acidity
controversial issue, almost settled in favor of No milk for APDisease
sore eyes
•
Pain is mentioned as a risk factor-but generally it is there, need to
mention photophobia and corneal ulcer
•
Do we need eye pad for sore eyes? We believe it is only for Corneal
Ulcer
Aspirin is better than paracetomol
Toothache
Belladonna/merksol are homeoremedies- listed? Informed?
Look for abscess, caries, tooth-fracture pain etc
283
Ulcer(skin
Say it is W
sore)
specify it is skin sore and not peptic ulcer
Several herbal treatments are found useful-aloe, neem, unripe
papaya
284
ORS is not the treatment for any/every vomiting. Domstal can be a
vomiting
symptomatic treatment
Herbal treatments must be mentioned/so also home remedies
(several)
Treatment no 3 is for morning sickness, not other causes.
Why the dividing horizontal line?
mention treatment for motion sickness
•
Worms? then say
H cbl
? What is it? Homeo rem?
Why not albendazole/mebendazole?
126
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
286
The list of 20
Looking back, there are many dangerous conditions even in previous
dangerous
list of WT
illnesses
<Jhi<hi
Any criteria for listing dangerous illnesses at the level for JSR?
Symptoms/signs/illnesses all mixed
We think this is list of some ACUTE SERIOUS conditions,
But then few chronic serious illnesses (anemia/TB) are also
mentioned- like chronic ulcer on skin (non-healing wound), chronic
weight loss, inability to take feeds for more than one day.
•
Pt nol- cTgrf TfTTT
. Not quite, the site is also imp- ENT bleed,
urinary bleed, untimely vaginal bleed in pregnancy etc are imp too.
The apparent cause is also imp (for instance snakebite). Big bleed
can not be a good criterion.
288
Acute
•
Random sequence (urine problem listed at 7, another at 17
•
Needs systematic listing- top to bottom/or system-wise
•
Pt 12, says acute pain lasting for 3 days-do we wait so long?
•
Pt 14, Convulsions-why more than one, why not even one?
•
Subhead problems- diverse problems fall under this major heading
(like poisoning, scorpion, diabetes etc)
abdomen
•
Calls for systematic regional-anatomical approach (like rt lower
quadrant pain can be appendicular, Rt Upper q can be gall-bladder
pain, all q pain can be peritonitis etc.
288-9
Peptic ulcer
•
Distension is not mentioned in signs
•
tender/ non tender is also important
•
Milk/ milk products are not recommended except mi/k in pregnancy
acidity.
•
Treatment with antacids is missing, not to mention antibiotics.
290
Poisoning
Is it a problem only among children?
291
Scorpion
Two types—
•
only pain- OR
•
Pulmonary edema/bloodspit (if this type is found in MP-then
mention tablets prazocin)
293
Diabetes
•
(is second bite in adults fatal? pl check literature)
•
Two types- NIDDM, IDDM
•
Treatment of even NIDDM may require oral antiD agents. The last
para of p 293 gives wrong impression
127
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
294
High BP
Needs new heading, looks a subhead in diabetes
Deserves to be a screening cause in JSR tasklist- so train them to
measure BP, and about primary care/prevention/first aid (also in list
of
qlMPjqi
Treatment for acute high BP-Nifedipine SL
STPTWT
295
296
Obesity
Asthma
is relaxation/anxiety free/shavasan?
•
Separate heading
•
Define by weight/skinfold
•
Elaborate exercise-fat burningexercise >15minute aerobics
Not even first aid? talk about inhalationsprays/ salbutamol tab
•
What about other
dHHNl
Needs an epidemiological approach to such a listing, apply some
framework and decide tasks in each
21
297
list too poor (only
Medicines
Tabulate all info-name/indications / dose/ frequency/ duration/ side
effects/ toxic effects/precautions/contraindications/ & available
cheap brand names (see appendix)
Sulfa
Is not same as Cotri...
•
Remember also syndrome-severe stomatitis- in reaction,
298
Paracetamol
Dosage-- three times daily
299
Anti-
•
Heading goes haywire-
histaminics
•
CPM is sedative and NOT least sedative
•
Dosage needs to be tuned to cause- just one tab (motion sickness)
or for three -four days (for allergies).
300
Mag Hydrox
•
Combination of Mg+AI is universally recommended for mutually
neutralizing effects
Chloroquin
•
The dose schedule is already given in malaria, avoid duplication if
possible
301
302
•
Explain side effects, CI, precautions ...everything
•
Treatment for Presumptive/radical regimens
IFA
Elaborate various aspects listed WE general for all drugs
Mebendazole
Contraindicated in early pregnancy and infants
Ext
Subheads styling
applications
303
Mg Hydrox
Repeated ( see p 300)
Gention violet
Imp use is vaginitis-esp fungal/candidial
128
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
22
304
Coordination
with MPW
•
W 3T
HlHdl : Strange wording!
•
Needs task list matrix of various workers. For instance underweight
baby is already with AWW, what will MPW do for that? And why JSR
should duplicate work?
305
heading no 2
Needs blue screen like other similar titles
306
Stock of
•
Then why not include them in the drug-kit/list and give all relevant
information?
primaquine/DD
S/MV
^nisiicbi
High order, review langauge! (Try to help/ involve!) The next page
illustration advises differently
TWT ’zl4IMI
23
318
319
chapter
Overall good, needs illsutrations!
Accidents/
•
Column headings are essential-problem, tretment, referral
First aid
•
Illustrate skills-like helping drowned person
Fractures
•
How to recognize fracture?
•
Ref to CHC, not PHC
7
Mentions "treat shock" and also "refer if shock". Instead say "offer
Insect bite
first aid and refer"
•
320
mention CPM for allergy
Sprain
How to rule out fracture? Mention signs here or in fracture.
snakebite
•
Tourniquet is outdated, use pressure bandage
•
incision/cuts also outdated
•
ASV, not twdlcJHU
Tourniquet
UT4
•
) is dangerous
Stick plaster is generally no good , except for small wound
apposition
•
Illustrate all techniques
321
322
335
Stitching/suturing can be taught.
nosebleeds
proper pressing/cold water splash are usual methods-mention them
hand-bleeding
illustration misplaced with nosebleed
registration of
Who keeps? Grampanchayat, is it not?
vital events
336
patient
•
registration
Improve record pattern so that health data is easily complied.
BTW, is
•
is same as JSR? Elsewhere it means MPW
The monthly worksheet layout needs improvements-heads and
subheads, boxes for figures etc
129
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Ayurveda
Part?
This chapter has several good points and quite a rich listing of
•
remedies
The specific remedies for illnesses need to be woven into the larger
•
book- not to be segregated in this chapter. Only general principles
to be mentioned here. The JSR can not switch from Allopathic
system to Ayurvedic system at will, but can practically think of
alternatives for each problem faced. This would also take care of
needless duplications (see p 10 pages ranging from 363-372)
The list of
Mentions some problems for no reason-like snake bite/drowning when
illnesses
there is no particular treatment in Ayurveda for these problems.
354-5
Sanskrit verses
Not necessary/useful
356-7
Swasthya
Good chapter
353
364-
•
Needless repetition of earlier text from part one/
5-6-7
•
Often contrary to part one (see ATT injection),
•
Only three lines of para? on p365 &. 366, three lower lines on 367
are Ayurvedic
Snake bite
No Ayurvedic point- repetition of outdated treatment (sadly also in part
one)
370-1
heat stroke &
•
(paste of channa vegetable)
Dog bite
•
374
list of fever
Needles repetition, and the only Ayurvedic is too time consuming
Dog bite-nothing special
Say they are alternatives, and give doses/duration
remedies
374-
malaria
Plasmodium parasite is confused with anopheles mosquito
Fever mentioned is rather high. (103-6?)
375
^5 ’jwr % (?)
Hepatomegaly (liver swelling?) is this true?
Fall of BP-only in algid malaria- not all cases
Quinine is not the choice of treatment and
Quinine is not sold as chloroquin
375
Diarrhea
One LM is not consistent with definition of diarrhea -even in a child
Causes mentioned for Diarrhea are debatable
for a child?
378-
Dysentery
Good repertory for dysentery
Cholera
Cause is indigestion?
380
381
Good repertory- but for a serious illness can we rely on these?
130
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
385
Worms
Good repertory
386-
anemia/jaundi
Why clubbed?
388
ce
Causes of anemia are irrelevant, may be except pica
Same thing for causes of jaundice
Jaundice-stools are not always white (only in the rare obstructive, or
late hepatitis)
Alternative remedies they are-must be so mentioned. (BTW can we
do a priority listing among the remedies)
Why mention blood transfusion?
389
Cough
? Use of word
•
Cause of which cough are listed- all
•
How to select remedies- good list!
391-2
cold
393-4
Abdominal
Cause must be ascertained before treatment
pain
Causes mentioned are not rigorous
Constipation
Good!
398-9
I
Good!
Ichhabhedi is strong at this level of care
castor is also irritant
403
Ear illnesses
Types well said
Treatment can not be general/same
Middle ear perforation-instillation of cow-urine may be reviewed.
406
Nasal illnesses
Septum deviation is not same as Sinusitis
Treatment options make good list
407
Eye complaints
causes of sore eyes/ other illnesses not 'sustainable'
Why discuss cataract if there is no specific Ayurvedic treatment?
131
I
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
411-3
Women's
•
Big topic, but several problems
illnesses
•
very negative about menarche
•
Sterility treatment needs to be placed in some diagnostic
perspective
•
Enhancing labour by using chhomacounting quinine..needs second
look, esp when other cheap effective remedies are available, and
anyway referral is mandatory
•
What is tflM<c|l£i in childbirth?
•
Leucorrhea is not necessarily
(|c| cJHRI
Treatment advises "stay and work at home"-which is very biased in
this age. (If women stop farm work?)
Dosages not written/ nor durations given in treatment ( see
Even advises treatment for a male son (Betrays an Ayurvedic's
gender bias)
_______________________________ Important general observations_____________________________
•
The layout is not space-economical, one line format wastes space, two column format should save space
and also help better visual grasping as reading-span is smaller (see for instance all bulleted or indented
items, a word or two and it is over see eg pl81, also 413)_______________________________________
•
Blue screen for subhead is pleasant and helpful________________________________________________
•
Typographic errors abound- almost 1-2 every page.____________________________________________
•
Nomenclature problems- Sanskrit names replace English one at many places-the effect is no different—
equally difficult to incomprehensive. Spoken language is better in such interactive learning, see :
_______
•
•
•
•
•
Lot of subheading problems- the matter needs to be properly headed/subheaded. There is no distinction in
subheads 1,2,3- stylistically they are all same. That causes comprehension problems, this confusion is also
evident on several pages like 196 (TB)___________ ___ _______________________________________
Some writing protocols are mandatory. A general approach to writing is:
one para for each idea/issue
first sentence of each para should herald the para- highlight/attract
first word of each sentence should flash the sentence- (see my correction on p
Order of word is imp- see for instance last sentence of para 1 of p 48)_____________________________
•
•
•
Phrase-making is frequently problematic for instance Immunity is not TT
ffTHcTT
Illustration is very scant, forcing authors to be wordy. This hurts effective communication______________
Different words for the same concept—for instance/ 4151. 4^4 / Mdc MM /
Tm / tfefr
/
•
<4vll^-ldl (4d5il,Jldl /
•
•
•
•
R-'ddd
Too frequent use of pronouns—^
even at start of paragraphs. The right word should replace this
pronoun in most places (for instance, see page 50-51). _______________________________________
Too many English words-peristalsis, movement, carbohydrate, bile pigment, epiglottis and countless others
like sphincter, epidermis, dermis, capillary blood vessels, ejaculatory ducts, epidydimus, nephrons, vas
deferense, urethra, salt, balance, heavy metals, sebaceous gland, resuscitaion, subcostal, collarbone,
cornea, conjunctiva keratomalacia, scar, note, chlorinated and so on.
Good Hindi substitutes are available/or can be constructed for effective communication (translation is not a
dire duty, it is a solemn cause).____________________________________________________________
sentence construction like on p 62 ^TH WTH foTHT rRTI 5 is problematic-needs hindikaran,
132
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
«
Lack of vertical slash 5^ in many places (see p 198- 2nd last para has 66 words)
•
Use simple spoken words like
•
«
•
Use bullets wherever necessary (eg p!29. 138, 139, 140)________________________________________
Use indent style wherever necessary (eg pp 149)
_________________________________________
Several words are used incorrectly (eg fdcbRid WTT (page 150).
see page 136). 3WTF4 TfKT
page 141).
•
•
•
Hlo<MI/i^cbli^d % Wff
gUSTflT see p 167 also d^dfeTT). oMNH
W(p 169)________
198_________________________
Make smaller meaningful and easy sentences, review sentences for correct communication eg see page 146
last sentence) (see p 198- 2nd last para has 66 words), see also complex sentences like the last of the 1st
para on p 199 about TB.
_____________________________________________________________
Explain logic for actions, for instance why mother should clean baby's nose for better feeding (p 139) (pl66
first para)______________________________________ ________________________________________
Why not mention Ayurvedic remedies with allopathic remedies: like in diarrhea management? This is better
if you really men to encourage use of Ayurvedic treatment._______________________________________
•
Avoid use of words Hike cfodd tlMI 201
«
•
Problems of addressing the reader ( JSR or people?)—( see p226)__________________________________
While giving treatment (for instance p 278-281), say whether the various treatments are options OR
components of the same treatment package. (One or all advises together?)_______________
para space is rather large, does not allow visual clustering of points________________________________
In general, we would advise the authors of both/all the sections to work together on each section,
share/check ideas and evolve a wholesome, clear and pragmatic approach for each problem. Otherwise
duplication, mistakes, contradictions are bound to occur. ______________________________________
Too few illustrations for a book like this need to fine-tune.________________________________
xHow to use' is not given_________________ _ _______________________________________________
Index is not very helpful as it almost matches list of contents._____________________________________
Binding is good, and so is paper and printing.
___________________________________________
•
•
•
•
»
•
133
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
APPENDIX 10: CHECKLIST OF INTERVIEW QUESTIONS
Health Secretary/DHS/RGM etc
1 Policy & adm
2 Policy & adm
3 Policy & adm
4 Policy & adm
5 Policy & adm
6 Policy & adm
7 Policy & adm
8 Policy & adm
9 Policy & adm
10 Policy & adm
11 Policy & adm
12 Policy & adm
13 Policy & adm
14 Policy & adm
15 Policy & adm
16 Policy & adm
17 Policy & adm
18 Role
19 Role
20 Role
21 Role
22 Role
23 Role
24 Role
25 Role
26 Role
27 Role
28 Role
29 Role
30 Selection
31 Selection
32 Selection
33 Selection
34 Selection
35 Selection
36 Selection
37 Selection
general impression about this scheme
_
Fund flow
________________________________________
(CHC report—recommendations..any action-ask particular issues)
NGO participation in TOT________________ __________________________
Feedback systems
Logistical/ supplies
_____
____________________________
Loans?
_________________________
Kits?_____________________________ ___________________________________
Training rules/schedules/guidelines________________________________________
Adequate preparation?
_________________________________
Supervision systems
_____________________________
Ownership of the programme
________________________________
Any cell looking after the scheme?
_________________________________
Training (basic/CME/Refresher/advanced training)
Sustainabilty?..details
________________________________
Complaints about old jsr.. redress
_________________________________
Pace/phasing/midcourse corrections______________________________________
What role. JSR—A doctor, Bengali Doc, HW, assistant to health system, a
community Workers
_ _______________________________
Is it different from CHWs..how
______________________________
Code of conduct
Need/vision -> Role definition <- actual role?
Volunteers..Professionals..
_______________________________
What tasks they are expected?
What more training is necessary to answer the community needs
What happens to the preventive aspects of jsr role..Can it be realised..How?
What happened to the evaluation., like the one asked by DHS by a letter of 11-52000_____________________________ __________________________________
Is the role realised..to what extent ( say %)
Which parts of the role are realised..Which are less realized?___________________
Is it possible to correct the 'wrong' roles some JSR s are assuming., like quacks..And
How?________ __________________ ________________________________ ____
Risks/advts of male selection?
Difficulties in getting women candidates-distance, family, children, education,
safety..___________ __________________ _ ____________________________ _—
Criteria for selection _______________ ___________________________________
Issue of overqualified persons___________________________________________
Do you think of some formula for male: female .. Selection (will selecting both be
better?)
_________________ ____________________________________
What happened to TBA family kin policy?___________________________________
How to enroll more women?________
What about old VHG selection?
134
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH:
September -December 2001
38 Selection
39 Selection
40 Selection
41 Selection
42 Selection
43 Selection
44 Selection
45 Selection
46 Selection
47 Selection
48 Selection
49Selection
SOlTraining
AWW selection..implications
What about SC/ST selection?
~
___ About BPL/Non BPL selection.
"
"
Does BPL/Non BPL make a difference to the work of JSR
__ Are locality candidates available? ~
Were lists of likely candidates made by GSS?
__ Publicity for jsr selection
"
-----------__ L5 a rcupte better than single (how to select a couple)
— Is
grampanchayat really involved in the selection process?
About voluntarism..professionalism
‘
~
Age issue.,any comments twenties/thirties
Nepotism? How does it affect work-standards.. Does "it?
__ Contents..
51 Training
TOT and further links
"
52lTraining
__ Venue
53 [Training
Physical facilities, AV aids
~~
54[Training
_ Practical training..
~
------------—
55[Training
_ 1$ the training process satisfactory?
~
56[Training
(Injection/saline training)
'
57[Training
CME-possibilities..How/periodicity
’
--------------581 Examination Does the Exam address to task list?
"
----------59[Examination Failed candidates..policy /implications/
601 Examination Results of re-exam
-- -------------------61 [Examination Periodic reiicensing exam
~
"
62[Monitoring
Any report on evaluation /monitoring
63 [Monitoring
Who monitors the jsr regularly
64|Monitoring
Redress mechanisms
"
------------65 Monitoring
Monthly meetings/ 3 monthly meetings? Content-messages..exDectarions
661 Monitoring
Getting medicines..costs
67 Logistics
Honoraria for travel to monthly meetings
68 Logistics
Depot holders for NHPs
~69 Logistics
getting health education material
70 Clinical work What are the tasks JSR is expected?
71 [Preventive
Any of these tasks realized..
72 [Preventive
Other tasks not realized., causes
73 Preventive
Helping health staff on visits
74 [Preventive
Posters/pamphlets/HE aids?
--------------75 [Preventive
National Health programmes
'
76 [Preventive
IEC to users/community
"
----------77 Preventive
What should be the earning of a JSR?
’ "
78 Earning/F
Possibility of earning on preventive services
79 Earning/F
Any attempt at public display/transparency
80 Earning/F
How can JSR help AWW-what tasks
------------- -------------81 Links_______ How can AWW help JSR-what ways
’
------------82 Links_______ How can JSR help TBAs-------------------------------------83 Links
How can TBAs help JSRs
-------------------------------84 Links
How can ANM help JSRs ~
-----------------------
135
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
85 Links
86 Links
87 Stability
88 Legal
How can JSRs help ANM
__________________________________
Referrals from JSR to PHC/CHC (check with PHC/CHC records- has the work
increased?)
____________________ _______________ ______
Attrition factor—Are old jsrs still in place
______________________
Check with various authorities-MP medical Council
136
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Collector/CEO/ZP chairman/Health com chairman________________
Issue__________ ______________________________________________
Group_____
1 Policy & adm. general impression about this scheme_______________________________
2 Policy & adm. Fund flow_____________________________________________________
3 Policy & adm. Feedback systems_______________________________________________
4 Policy & adm. Logistical/ supplies______________________________________________
5 Policy & adm. Loans?______ _________________________________________________
_____________________________________________________
6 Policy & adm. Kits?
7 Policy & adm. Sustainabilty?..details____________________________________________
8 Policy & adm. Complaints about old jsr.. redress__________________________________
9 Policy & adm. Pace/phasing/midcourse corrections_________________________________
10 Policy & adm. Political process around jsr scheme..how..if not why?___________________
11 Role_______ Code of conduct _______________________________________________
Risks/advts of male selection?_____________________________________
12 Selection
Difficulties in getting women candidates-distance, family, children, education,
13 Selection
safety.._______________________________________________________
How to enroll more women?_______________________________________
14 Selection
About BPL/Non BPL selection.______________________________________
15 Selection
Were lists of likely candidates made by GSS?__________________________
16 Selection
Is GSS/ grampanchayat really involved in the selection process?___________
17 Selection
Publicity for jsr selection__________________________________________
18 Selection
Any report on evaluation /monitoring________________________________
19 Monitoring
Redress mechanisms_____________________________________________
20 Monitoring
Role of community/Grampanchayat/GSS_____________________________
21 Monitoring
Possibility of earning on preventive services___________________________
22 Earning/F
Any attempt at public display/transparency___________________________
23 Earning/F
ANY SUGGESTIONS?
137
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
CMHO/DTT
_______________________________________
Issue________________________________________________________
Group______
1 Policy & admin Does this scheme gel with the public health system of MP
2 Policy & admin Fund flow_______________
3 Policy & admin Feedback systems__________
4 Policy & admin Logistical/ supplies _____________
5 Policy & admin Kits?
6 Policy & admin Sustainabilty?..details________ __
7 Policy & admin Complaints about old jsr.. redress_____________________________ _
8^ Policy & admin (CHC report—recommendations..any action-ask particular issues)
____________
9 Policy
& admin NGO participation in TOT_________________________________________
10 Policy & admin Training rules/schedules/guidelines_________________________________
11 Policy & admin Adequate preparation?__________________________________________
12 Policy & admin Supervision systems_________________________________________ _
13 Policy & admin Ownership of the programme_________________________________ ____
14 Policy & admin Any cell looking after the scheme?______________________________ _
Is it different from CHWs..how____________________________________
15 Role
Need/vision -> Role definition <- actual role?________________________
16 Role
What tasks they are expected?___________________________________
17 Role
What more training is necessary to answer the community needs
18 Role
What happens to the preventive aspects of jsr role..Can it be realised..How?
19 Role
Evaluation?, like the one asked by DHS by a letter of 11-5-2000
20 Role
Is the role realised..to what extent ( say %)__________________________
21 Role
Which
parts of the role are realised..Which are less realized?
22 Role
Is it possible to correct the 'wrong' JSR roles some .. like quacks..And How?
23 Role
Any
role models in your knowledge (Try to meet this JSR and profile)
24 Role
Any failures..try to contact and interview
25 Role
Code of conduct____________________________________________ __
26 Role
Risks/advts of male selection?_____________________________________
27 Selection
Difficulties for women -distance, family, children, education, safety..
28 Selection
How to enroll more women? ____________________________________
29 Selection
About
BPL/Non BPL selection._____________________________________
30 Selection
Were lists of likely candidates made by GSS?_________________________
31 Selection
Is GSS/ grampanchayat really involved in the selection process?
32 Selection
Criteria for selection
33 Selection
Issue
of overqualified persons_____________________________________
34 Selection
What happened to TBA family kin policy?____________________________
35 Selection
What about old VHG selection?____________________________________
36 Selection
AWW selection..implications ____________________________________
37 Selection
What about SC/ST selection?_____________________________________
38 Selection
Does BPL/Non BPL make a difference to the work of JSR_______________
39 Selection
Are
locality candidates available?__________________________________
40 Selection
Publicity for jsr selection_____ ____________________________________
41 Selection
Is
a couple better than single (how to select a couple)__________________
42 Selection
Nepotism? How does it affect work-standards..Does it ?
43 Selection
About voluntarism..professionalism
44 Selection
138
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
45 Selection
46 Selection
47 Selection
48 Selection
49 Selection
~50 Stability
51 Training
52 Training
53 Training
54 Training
55 Training
56 Training
57 Training
58 Training
59 Training
60 Training
61 Training
62 Training
63 Examination
64 Examination
65 Clinical work
66 Clinical work
67 Earning/F
68 Earning/F
69 Earning/F
70 Earning/F
71 Links
72 Links
73 Links
74 Logistics
75 Logistics
76 Monitoring
77 Monitoring
78 Monitoring
79 Monitoring
80 Monitoring
81 Monitoring
82 Preventive
83 Preventive
84 Preventive
85 Preventive
86 Preventive
87 Preventive
88 Preventive
89
Age issue..any comments twenties/thirties________________________
About lowering educational standards for entry_____________________
Is there a selection process/choice or otherwise?___________________
Can there be a better mechanism selection?_______________________
Why should candidates come JSRs..What JSR/community aspirations..
Attrition factor—Are old jsrs still in place__________________________
Is the training process satisfactory?_____________________________
RFWTC's role in training..present and future_______________________
TOT and further links________________________________________
Physical facilities, AV aids_____________________________________
Methods of training/ training design and organization._______________
Scheduling_________________________________________________
Subcenter training-time/tasks/trainer/opinion______________________
Ayurveda training____________________________________________
Hands on training____________________________________________
"Other7 sources of training for JSRs (docs/ Bengalis etc)______________
(Other books)_______________________________________________
Certificate__________________________________________________
About the current process of examination_________________________
What changes would you suggest in the exam system_______________
What are the tasks JSR is expected?_____________________________
Caste angle.Do deprived sections get treatment in this scheme?_______
Possibility of earning on preventive services_______________________
Any attempt at public display/transparency about cost control_________
How can JSR help AWW-what tasks_____________________________
Are the new JSRs angling for monthly payment from Govt)___________
How can AWW help JSR-what ways_____________________________
How can ANM help JSRs_______________________________________
How can JSRs help ANM_______________________________________
getting health education material________________________________
Depot holders for NHPs_______________________________________
Any report on evaluation /monitoring_____________________________
Redress mechanisms_________________________________________
Role of community/Grampanchayat/GSS__________________________
Who monitors the jsr regularly__________________________________
Monthly meetings/ 3 monthly meetings? Content-messages..expectations
Records kept by JSRs_________________________________________
Other tasks not realized., causes________________________________
Helping health staff on visits___________________________________
Posters/pamphlets/HE aids?____________________________________
National Health programmes___________________________________
IEC to users/community______________________________________
What should be the earning of a JSR?____________________________
Any of these tasks realized..____________________________________
Any suggestions
139
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH:
September -December 2001
RFWTC
__ Group
__ Issue__________
1 Clinical work __ What are the tasks JSR is expected?
2 Training
__ Is the training process satisfactory?
3 Earning/F
How can JSR help AWW-what tasks_____
4 Links______ __ How can AWW help JSR-what ways
5 Links______ __How can ANM help JSRs______
6 Links______ _ How can JSRs help ANM
7 Links______ _ How can JSR help TBAs
8 Links______
How can TBAs help JSRs
9 Clinical work
Desired 'more skills7 to learn____________
10 Clinical work
'Permission limit7 for village treatment..days
11 Clinical work
What more illnesses should find place in the curriculum
12 Preventive
National Health programmes
13 Training
Methods of training/ training design and organization,
14 Training
Subcenter training-time/tasks/trainer/opinion
15 Training
Hands on training
16 Training
'Other7 sources of training for JSRs (docs/ Bengalis etc)
17 Training
Contents..____________
18 Training
Practical training..__________
19 Training
(Injection/saline training)______________
20 Training
Physical facilities, AV aids
21 Training
_ Ayurveda training____________
22 Training
(Other books)
~~
23 Training____ Venue
24 Examination
The process..relation of monthly to final exam
25 Examination _ Assessment of MCQs sets
26 Clinical work
'desired drugs7 apart from the list
27 Clinical work
(frequently used injections by JSR)..information from whom
28 Clinical work
Use of diagnostics..naming symptoms/illnesses
29 Logistics
Frequently encountered illnesses
30 Preventive
IEC to users/community
31 Earning/F
Are the new JSRs angling for monthly payment from Govt)
32 Training_____ Attitude training
33 Clinical work _ frequently referred illnesses
34 Clinical work
Clinical work in terms of National programmes
35 Clinical work
Use of Ayurveda /herbs/home remedies
36 Clinical work
Frequently used drugs from the kit
37 Clinical work
Frequently required skills
38 Training_____ Scheduling
39 Examination
Practical skills tests..
40 Policy_______ Training rules/schedules/guidelines
J
41 Training______ Book..use of books
42 Training______ other recommended books_______
43 Examination
Unfair practices if any
44 Examination
Passing level________
45 Training
Lesson plan
140
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
46 Training
47 Training
48 Examination
49 Examination
50 Monitoring
51 [Training
52 Policy
53 Training
Decision making: instructions based training, criteria based training
TOT and further links____________________________________
Failed candidates..policy /implications/
Results of re-exam______________________________________
Any report on evaluation /monitoring________________________
RFWTC's role in training..present and future__________________
Training (basic/CME/Refresher/advanced training)
CME-possibilities..How/periodicity
141
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
MO
----------- —---------------------------------0 Group
Issue
- ---------------------__ 1 Policy
__ Fund flow
"
__ 2 Policy
Feedback systems
"
__ 3 Policy
__ Logistical/ supplies
-----------------__ Kits? ~~
--------------------__ 4 Policy
__ 5 Policy
Complaints about old jsr.. redress
__ 6 Role______ Code of conduct
__ 7 Selection __ Risks/advts of male selection?
_ 8 Selection
Difficulties for women -distance, family, children, education, safety?
_ 9 Selection __ Publicity for jsr selection
------------------10 Selection
How to enroll more women?
~
11 Selection __About BPL/Non BPL selection.
~
"
12 Selection _ Were lists of likely candidates made by GSS?_____
13 Selection _ Is GSS/ grampanchayat really involved in the selection process?
14 Monitoring
Redress mechanisms
'
15 Clinical work What are the tasks JSR is expected?
"
~
16 Earning/F
Any attempt at public display/transparency____
17 Monitoring
Role of community/Grampanchayat/GSS
~~
18 Policy_____ Training rules/schedules/guidelines
"
19 Policy_____ Adequate preparation?
20 Policy_____ Supervision systems
~
~
21 Role
Is it different from CHWs..how
--------------------------22 Role_______ Need/vision -> Role definition <- actual role?
23 Role
What tasks they are expected?
~
~
24 Role________ What more training is necessary to answer the community needs
25 Role_______ What happens to the preventive aspects of jsr role..Can it be realised..How?
26 Role
What happened to the evaluation., like the one asked by DHS by a letter of 11-5-
27 Role
28 Role
29 Role
30 Selection
31 Selection
32 Selection
33 Selection
34 Selection
35 Selection
36 Selection
37 Selection
38 Selection
39 Selection
40 Selection
41 Training '
42 Training
43 Training
Is the role realised..to what extent ( say %) ~
"
Which parts of the role are realised..Which are less realized?
correcting the "wrong" JSR roles ..like quacks..And How?
Criteria for selection
"
Issue of overqualified persons
What happened to TBA family kin policy?
What about old VHG selection?
AWW selection,.implications
_____
What about SC/ST selection?
Does BPL/Non BPL make a difference to the work of JSR
Are locality candidates available?
Is a couple better than single (how to select a couple)
'
Nepotism? How does it affect work-standards ..Does it ?
Age issue..any comments twenties/thirties
Is the training process satisfactory?
TOT and further links
Physical facilities, AV aids
----------------
~
"
“
“
142
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
44 Monitoring
45 Monitoring
46 Logistics
47 Logistics
48 Preventive
49 Preventive
50 Preventive
51 Preventive
52 Preventive
53 Preventive
54 Preventive
55 Earning/F
~56 Links
Who monitors the jsr regularly
____________________ _____________
Monthly meetings/ 3 monthly meetings? Content-messages..expectations
getting health education material__________________________ _—
Depot holders for NHPs_______________
Any of these tasks realized.._____________________________ ___________
Other tasks not realized., causes
Helping health staff on visits
Posters/pamphlets/HE aids?
National Health programmes________________ ___________
IEC to users/community _______________________
What should be the earning of a JSR?
How can JSR help AWW-what tasks_________________________________
How can AWW help JSR-what ways______________________________
_________________ ______________
57 Links______ How can ANM help JSRs
How
can
JSRs
help
ANM
__________________
58 Links______
'
Attrition
factor
—
Are
old
jsrs
still
in
place
_________________
____________
59 Stability
Any
role
models
in
your
knowledge
(Try
to
meet
this
JSR
and
profile)
60 Role______
61 Role______ ' Any failures..try to contact and interview
About lowering educational standards for entry
62 Selection
Is there a selection process/choice or otherwise?
63 Selection
Can there be a better mechanism selection?______________ ____________
64 Selection
JSRs
expectations..What JSR/community aspirations..
65 Selection
'
Methods
of training/ training design and organization.
66 Training
Scheduling____________
_________________
67 Training
'
Subcenter
training-time/tasks/trainer/opinion
68 Training
Ayurveda training
________________
69 Training
Hands on training_______________________________________________
70 Training
'Other
1 sources of training for JSRs (docs/ Bengalis etc)
71 Training
(Other books)
_________
72 Training
Certificate
____________
73 Training
Records kept by JSRs
74 Monitoring
~
Are
the new JSRs angling for monthly payment from Govt)
75 Earning/F
___________
76 Policy_____ Loans?
~ What role JSR—A doctor, Bengali Doc, HW, assistant to PHC, a community W
77 Role______
~ Formula for male: female .. Selection (will selecting both be better?)
78 Selection
Contents..
79 Training
Venue
__________________________
80 Training
Practical
training..
_
______________
____________
81 Training
~ (Injection/saline training)_____
82 Training
83 Examination ~ Failed candidates..policy /implications/
________
84 Examination Results of re-exam__________
Getting
medicines..costs
85 Monitoring
Honoraria for travel to monthly meetings
86 Logistics
How can JSR help TBAs
_____________
~~87 Links
How
can
TBAs
help
JSRs
___________
88 Links
89 Links_____ ~ Referrals from JSR to PHC/CHC (check with PHC/CHC records
90 Role
Aspirations of JSR _______________________
143
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
91 Training
Lesson plan______________________________________________________
92 Training
Book..use of books________________________________________________
93 Training
other recommended books__________________________________________
94 Training
Attitude training___________________________________________________
95 Training
Attendance/ attention______________________________________________
96 Examination The process..relation of monthly to final exam___________________________
97 Examination Assessment of MCQs sets___________________________________________
98 Examination Unfair practices if any______________________________________________
99 Examination Practical skills tests.._______________________________________________
100 Examination Passing level_____________________________________________________
101 Clinical work frequently referred illnesses_________________________________________
102 Clinical work "desired drugs' apart from the list_____________________________________
103 Clinical work Desired "more skills' to learn_________________________________________
104 Clinical work (frequently used injections by JSR)..information from whom_______________
105 Clinical work "Permission limit' for village treatment..days_______________________ .
106 Clinical work Use of diagnostics..naming symptoms/illnesses__________________________
107 Clinical work Clinical work in terms of National programmes___________________________
108 Clinical work Use of Ayurveda /herbs/home remedies________________________________
109 Clinical work What more illnesses should find place in the curriculum___________________
110 Clinical work Community satisfaction/ meeting the needs?____________________________
111 Clinical work Comparison with other nearby healers..ranking__________________________
112 Clinical work Gender angle..do women use male JSR services..for what., and what not..then?
What are the rates/user fees/ justification?______________________________
113 Earning/F
114 Earning/F
Do they find remuneration engaging?
144
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Group
1 Policy_____
2 Role______
3 Selection
4 Selection
5 Selection
6 Selection
7 Selection
8 Selection
9 Selection
10 Clinical work
11 Earning/F
12 Monitoring
13 Role______
14 Role______
15 Role______
16 Role______
17 Selection
18 Selection
19 Selection
20 Selection
21 Selection
22 Selection
23 Selection
24 Selection
25 Training
26 Monitoring
27 Monitoring
28 Logistics
29 Preventive
30 Preventive
31 Preventive
32 Preventive
33 Preventive
34 Preventive
35 Earning/F
36 Links
37 Links
38 Links
39 Stability
40 Role______
41 Role______
42 Selection
43 Selection
44 Selection
ANM/MPW________________________ ________________ ____________
Issue
__________________________________ ______________________
Complaints about old jsr.. redress__________________ ______________________
Code of conduct
____________________ _____________
Risks/advts of male selection?
_
_
_
Difficulties in getting women candidates-distance, family, children, education, safety..
Publicity for jsr selection
How to enroll more women?
_________
About BPL/Non BPL selection.
Were lists of likely candidates made by GSS?
Is GSS/ grampanchayat really involved in the selection process?
What are the tasks JSR is expected?______________ ____________
Any attempt at public display/transparency
Role of community/Grampanchayat/GSS________________________
Is it different from CHWs..how
________________________
What tasks they are expected?
______________
What more training is necessary to answer the community needs
What happens to the preventive aspects of jsr role..Can it be realised.. How?
What happened to TBA family kin policy?
What about old VHG selection?_____________________ __________
AWW selection..implications___________________
____________
' Does BPL/Non BPL make a difference to the work of JSR___________
Are locality candidates available?
__________
Is a couple better than single (how to select a couple)
Nepotism? How does it affect work-standards..Does it ?
Age issue..any comments twenties/thirties
Is the training process satisfactory?
' Who monitors the jsr regularly__________________ ____________ _
Monthly meetings/ 3 monthly meetings? Content-messages..expectations
getting health education material------------------------------- ------------------ ------------------' Any of these tasks realized..
Other tasks not realized., causes
~ Helping health staff on visits_____________
Posters/pamphlets/HE aids?
' National Health programmes______________________
What should be the earning of a JSR?_____________________________________
' How can JSR help AWW-what tasks
~ How can AWW help JSR-what ways
How can ANM help JSRs
__
How can JSRs help ANM
_____________ ______________________
Attrition factor—Are old jsrs still in place_______________________________
~ Any role models in your knowledge (Try to meet this JSR and profile)
~ Any failures..try to contact and interview
~ About lowering educational standards for entry
~ Can there be a better mechanism selection?_____________________ _____—------~ Why should candidates offer themselves as JSRs..What JSR/community aspirations..
145
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
45 Training
46 Training
47 Training
48 Training
49 Training
50 Monitoring
5? Role
52 Training
53 Training
54 Training
55 Links
56 Links
57 Links
58 Training
59 Training
60 Examination
61 Clinical work
62 Clinical work
63 Clinical work
64 Earning/F
65 Role______
66 Training
Methods of training/ training design and organization._________________________
Scheduling___________________________________________________________
Subcenter training-time/tasks/trainer/opinion ________________________________
Hands on training________________
'Other7 sources of training for JSRs (docs/ Bengalis etc)________________________
Records kept by JSRs____________________
What role. JSR—A doctor, Bengali Doc, HW, assistant to health system, a community
Workers_____________________________________________________________
Contents..
________________________________________________________
Practical training.._____________________________________________________
(Injection/saline training)_______________________________________________
How can JSR help TBAs_________________________________________________
How can TBAs help JSRs________________________________________________
Referrals from JSR to PHC/CHC (check with PHC/CHC records- has the work
increased?)___________________________________________________________
Lesson plan__________________________________________________________
Attendance/ attention__________________________________________________
Practical skills tests..___________________________________________________
Community satisfaction/ meeting the needs?_____
Comparison with other nearby healers..ranking______________________________
Gender angle..do women use male JSR services..for what., and what not..then?
What are the rates/user fees/ justification?_________________________________
Ranking of village level health workers..AWW/TBA/JSR________________________
Decision making: instructions based training, criteria based training
146
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Group
1 Policy
2 Role______
3 Selection
4 Selection
5 Selection
6 Selection
7 Selection
8 Selection
9 Selection
10 Clinical work
11 Earning/F
12 Monitoring
~13 Role______
14 Role______
15 Selection
16 Selection
17 Selection
18 Selection
19 Selection
20 Selection
21 Training
22 Preventive
23 Preventive
24 Preventive
25 Earning/F
26 Links______
27 Links
28 Links______
29 Role_______
30 Selection
31 Selection
32 Selection
33 Monitoring
34 Role
35 Links
36 Links
37 Links
38 Clinical work
39 Clinical work
40 Clinical work
41 Role______
42 Monitoring
GSS/GP/SHGs_______________________________________________________
Issue_______________________________________________________________
Complaints about old jsr.. redress_________________________________________
Code of conduct_______________________________________________________
Risks/advts of male selection?____________________________________________
Difficulties in getting women candidates-distance, family, children, education, safety..
Publicity for jsr selection________________________________________________
How to enroll more women?_____________________________________________
About BPL/Non BPL selection.____________________________________________
Were lists of likely candidates made by GSS?________________________________
Is GSS/ grampanchayat really involved in the selection process?_________________
What are the tasks JSR is expected?_______________________________________
Any attempt at public display/transparency__________________________________
Role of community/Grampanchayat/GSS____________________________________
What tasks they are expected?___________________________________________
What more training is necessary to answer the community needs________________
What about old VHG selection?___________________________________________
AWW selection..implications______________________________________________
Are locality candidates available?__________________________________________
Is a couple better than single (how to select a couple)_________________________
Nepotism? How does it affect work-standards..Does it ?________________________
Age issue..any comments twenties/thirties__________________________________
Is the training process satisfactory?________________________________________
Any of these tasks realized..______________________________________________
Other tasks not realized., causes__________________________________________
What should be the earning of a JSR?______________________________________
How can JSR help AWW-what tasks________________________________________
How can AWW help JSR-what ways_______________________________________
How can ANM help JSRs_________________________________________________
How can JSRs help ANM_________________________________________________
Any role models in your knowledge (Try to meet this JSR and profile)_____________
About lowering educational standards for entry_______________________________
Can there be a better mechanism selection?_________________________________
Why should candidates offer themselves as JSRs..What JSR/community aspirations..
Records kept by JSRs___________________________________________________
What role. JSR—A doctor, Bengali Doc, HW, assistant to health system, a community
Worker ____________________________________________________________
How can JSR help TBAs_________________________________________________
How can TBAs help JSRs________________________________________________
Referrals from JSR to PHC/CHC (check with PHC/CHC records- has the work
increased?)_____
Community satisfaction/ meeting the needs?_________________________________
Comparison with other nearby healers..ranking_______________________________
Gender angle..do women use male JSR services..for what., and what not..then?
Ranking of village level health workers..AWW/TBA/JSR_________________________
Redress mechanisms
147
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
43 Selection
44 Selection
45 Logistics
46 Selection
47 Policy
48 Monitoring
49 Clinical work
50 Clinical work
51 Clinical work
52 Earning/F
53 Policy_____
54 Earning/F
55 Policy______
56 Clinical work
57 Policy
58 Role_______
59 Logistics
60 Earning/F
61 Earning/F
Criteria for selection__________________
Issue of overqualified persons_____
Depot holders for NHPs
Is there a selection process/choice or otherwise?
Loans?______________
~
_ Getting medicines..costs______
Desired 'more skills' to learn__________ __
'Permission limit' for village treatment..days
What more illnesses should find place in the curriculum
Do they find remuneration engaging?
Sustainabilty?.,details
Possibility of earning on preventive services
Ownership of the programme__________
Caste angle.,as above
Political process around jsr scheme..how,.if not why?
Recognition of JSR in village
"
Frequently encountered illnesses_________
What were people spending on health problems now JSRs are tackling. What is the
saving like?______________________
How does the community gauge JSR sen/ices: affordable/costly/ same as before
148
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Group
1 Policy_____
2 Role______
3 Earning/F
4 Clinical work
5 Clinical work
6 Clinical work
7 Role______
8 Clinical work
9 Earning/F
10 Earning/F
11 Earning/F
Users___________________
_______________________________________
Issue_______________ ____________________________________________
Complaints about old jsr.. redress________________
Code of conduct
___ ___________________________________
Any attempt at public display/transparency________________________________
Community satisfaction/ meeting the needs?_______
Comparison with other nearby healers..ranking
__________________________
Gender angle..do women use male JSR services..for what., and what not..then?
Ranking of village level health workers..AWW/TBA/JSR
Caste angle..as above_________________
Peoples' expenditure on health problems now JSRs are tackling.. What is the saving
like?________ _____________________ _______ __________________________
How does the community gauge JSR services: affordable/costly/ same as before
What are the rates/user fees/ justification?
149
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
1 Role
2 Role
3 Role
4 Role
5 Role
6 Role
7 Role
8 Role_____
9 Role_____
10 Role
11 Selection
12 Selection
13 Selection
14 Selection
15 Selection
16 Selection
17 Training
18 Training
19 Training
20 Training
21 Training
22 Training
23 Training
24 Training
25 Training
26 Training
27 Training
28 Training
29 Training
30 Training
31 Training
32 Examination
33 Examination
34 Examination
35 Examination
36 Examination
37 Links
38 Links
39 Links
40 Links______
41 Links______
42 Policy_____
43 Policy_____
44 Policy
JSR-Ts_____________________________________
Code of conduct______________________________________________________
Ranking of village level health workers..AWW/TBA/JSR________________________
What more training is necessary to answer the community needs_______________
Any role models in your knowledge (Try to meet this JSR and profile)____________
What role. JSR—A doctor, Bengali Doc, HW, assistant to health system, a community
Worker ?___________________________________________________________
Recognition of JSR in village_____________________________________________
Any failures..try to contact and interview_____
Aspirations of JSR________________________________
Volunteers.. Professionals..______________________________________________
Self-identity..within the village and the health system_________________________
Publicity for jsr selection_______________________________________________
Is GSS/ grampanchayat really involved in the selection process?_________________
Is a couple better than single (how to select a couple)_________________________
Why should candidates offer themselves as JSRs..What JSR/community aspirations..
Criteria for selection_______________________________________________
About voluntarism, professionalism_______
Is the training process satisfactory?______ __ _______ ______________________
Methods of training/ training design and organization._________________________
Scheduling______________________________________________________
Subcenter training-time/tasks/trainer/opinion
__________
Hands on training__________________________________________________
'Other' sources of training for JSRs (docs/ Bengalis etc)________________________
Contents.._________________________________________________________
Practical training..______________________________________________________
(Injection/saline training)_________________________________________
Physical facilities, AV aids________________________________
Ayurveda training______________________________________________________
(Other books)_____________________________________
Venue_______________________________________________________________
Book..use of books_____________________________________________________
other recommended books____________________________
Practical skills tests..____________________________________________________
The process..relation of monthly to final exam_______________________________
Assessment of MCQs sets________________________________________________
Unfair practices if any___________________________________________________
Passing level__________________________________________________________
How can AWW help JSR-what ways
___________________________________
How can ANM help JSRs________________________________
How can JSRs help ANM_________________________________
How can JSR help TBAs________________________
How can TBAs help JSRs_____________________________ ___________________
Loans?_______________________________________________________________
stipend______________________________________________________________
Training rules/schedules/guidelines
150
REPORT OF CHCELL STUDY OF J5R SCHEME OF MADHYA PRADESH: September -December 2001
45 Clinical work
46 Clinical work
47 Clinical work
48 Clinical work
49 Clinical work
50 Clinical work
51 Clinical work
52 Earning/F
53 Preventive
54 Preventive
What are the tasks JSR is expected?
Desired 'more skills' to learn
--------------. Permission limit' for village treatment..days
.What more illnesses should find place in the curriculum---------'desired drugs' apart from the list
(frequently used injections by JSR)..information from whom ~
Use of diagnostics..naming symptoms/illnesses
How can JSR help AWW-what tasks-----------------What should be the earning of a JSR?
National Health programmes
-TSi' 5- ‘
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VA 'S
07197
Qoi
V
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
JSR-Ws
1 Role
~2 Role
Code of conduct__________________________________________
Ranking of village level health workers..AWW/TBA/JSR
_______________________
3 Role
What more training is necessary to answer the community needs_______
4 Role
Any role models in your knowledge (Try to meet this JSR and profile)
5 Role
What role. JSR—A doctor, Bengali Doc, HW, assistant to health system, a community W
6 Role
Recognition of JSR in village_______________________________________________
~ Role
Any failures..try to contact and interview_____________________________________
8 Role
Aspirations of JSR________________________________________________________
9 Role
Volunteers..Professionals.._________________________________________________
10 Role
Self-identity..within the village and the health system____________________
11 Role
What tasks they are expected?
______________________
12 Role
Is it different from CHWs..how______________________________________________
13 Role
What happens to the preventive aspects of jsr role..Can it be realised..How?_________
14 Role
Is the role realised..to what extent ( say %)____________________
15 Role
Which parts of the role are realised..Which are less realized?
16 Selection
Is a couple better than single (how to select a couple)___________________________
17 Selection
Why should candidates offer themselves as JSRs..What JSR/community aspirations..
18 Selection
About voluntarism..professionalism
______________________
19 Training
Is the training process satisfactory?__________________________________________
20 Training
Methods of training/ training design and organization._______________________
21 Training
Subcenter training-time/tasks/trainer/opinion__________________________________
22 Training
Hands on training______________________________________________________
23 Training
'Other' sources of training for JSRs (docs/ Bengalis etc)__________________________
24 Training
Contents..
25 Training
Practical training..____________________________________________________
26 Training
(Injection/saline training)__________________________________________________
27 Training
Physical facilities, AV aids__________________________________________________
28 Training
Ayurveda training________________________________
29 Training
(Other books)____________________________________________________________
30 Training
Venue___________________________________________________
31 Training
Certificate__________________________________________
32 Training
Attitude training
33 Examination [The process..relation of monthly to final exam___________________________
34 Examination Assessment of MCQs sets___________________________________________
35 Clinical work What are the tasks JSR is expected?
36 Clinical work Desired 'more skills' to learn_________________________________________
37 Clinical work 'Permission limit' for village treatment..days____________________________
38 Clinical work What more illnesses should find place in the curriculum___________________
39 Clinical work 'desired drugs' apart from the list_____________________________________
40 Clinical work (frequently used injections by JSR)..information from whom_______________
41 Clinical work Use of diagnostics..naming symptoms/illnesses________________________
42 Clinical work Community satisfaction/ meeting the needs?____________________________
43 Clinical work Comparison with other nearby healers..ranking__________________________
44 Clinical work Gender angle..do women use male JSR services..for what., and what not..then?
45 Clinical work Caste angle..as above
152
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
46 Clinical work frequently referred illnesses_______________
47 Clinical work Clinical work in terms of National programmes
48 Clinical work Use of Ayurveda /herbs/home remedies_____
49 Clinical work Frequently used drugs from the kit_________
50 Clinical work Frequently required skills___________________________________________________
51 Links______ How can AWW help JSR-what ways__________________________________________
52 -inks______ How can ANM help JSRs____________________________________________________
53 -inks______ How can JSRs help ANM
54 Links______ How can JSR help TBAs____________________________________________________
-low can TBAs help JSRs___________________________________________________
55 Links
56 Links______ Referrals from JSR to PHC/CHC (check with PHC/CHC records- has the work increased?)
Depot holders for NHPs____________________________________________________
57 -ogistics
What
should be the earning of a JSR?_________________________________________
58 Preventive
59 Preventive National Health programmes________________________________________________
601 Preventive Any of these tasks realized..________________________________________________
61 Preventive Other tasks not realized., causes_____________________________________________
62 Preventive Helping health staff on visits________________________________________________
63 Preventive Posters/pamphlets/HE aids?________________________________________________
64 Preventive IEC to users/community___________________________________________________
Frequently encountered illnesses____________________________________________
65 Logistics
getting health education material____________________________________________
66 Logistics
Honoraria for travel to monthly meetings______________________________________
67 Logistics
68 Monitoring Records kept by JSRs_____________________________________________________
69 Monitoring Getting medicines..costs___________________________________________________
70 Monitoring Monthly meetings/ 3 monthly meetings? Content-messages..expectations___________
71 Policy
Loans?_________________________________________________________________
Sustainabilty?..details_____________________________________________________
72 Policy
73 Policy
Kits?___________________________________________________________________
74 Policy_____ Supervision systems______________________________________________________
How can JSR help AWW-what tasks__________________________________________
75 Earning/F
Any attempt at public display/transparency____________________________________
76 Earning/F
Expenditure on health problems now JSRs are tackling.. What is the saving like?______
77 Earning/F
How does the community gauge JSR services: affordable/costly/ same as before_____
78 Earning/F
What are the rates/user fees/ justification?____________________________________
79 Earning/F
Do they find remuneration engaging?________________________________________
80 Earning/F
Possibility of earning on preventive services___________________________________
81 Earning/F
Are the new JSRs angling for monthly payment from Govt)
82 Earning/F
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