REACHING HEALTH TO THE GRASSROOTS REVIEW OF THE, JAN SWASTHYA RAKSHAK SCHEME OF THE GOVERNMENT OF MADHYA PRADESH JULY - DECEMBER 1997
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- Title
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REACHING HEALTH TO THE GRASSROOTS REVIEW OF THE,
JAN SWASTHYA RAKSHAK SCHEME OF THE
GOVERNMENT OF MADHYA PRADESH
JULY - DECEMBER 1997
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CPHE
REACHING HEALTH TO THE
GRASSROOTS
THE JAN SWASTHYA RAKSHAK SCHEME
OF THE
GOVERNMENT OF MADHYA PRADESH
A PARTICIPATORY INTERACTIVE REVIEW
JULY - DECEMBER, 1997
Community Health Cell,
Society for Community Health Awareness, Research and Action,
No.367, Srinivasa Nilaya, Jakkasandra I Main, 1 Block, Koramangala,
Bangalore - 560 034.
\ Phone : (091) - 080 - 553 15 18
Fax : (091) - 080 - 553 33 58 (Attn. CHC) /
December 1997
H
ACKNOWLEDGEMENTS
The CHC team would like to thank:
the Madhya Pradesh Government and UNICEF - Bhopal for inviting us to
review the JSR Scheme in partnership and through an interactive dialogue.
All the senior policy makers and decision makers at all levels who have
given time and shared perspectives with the field study team and made the
review possible.
All the JSRs, community members, community leaders, CMOs, medical
officers, health team members whose enthusiastic participation in the
review made the process mutually rewarding for all concerned.
All the CHW trainers who participated in the peer review especially of the
JSR manual, and sent their comments and suggestions so readily and in
solidarity.
All the CHC team and Associates whose support at different levels and in
different tasks helped the process greatly.
1
u
CHC REVIEW TEAM
Field Review Team
Dr. Pankaj Mehta & Team
Support Team
Dr. Ravi Narayan
Dr. C.M. Francis
Dr. Shirdi Prasad Tekur
Dr. A. R. Sreedhara
Peer Review Team
Dr. Dhruv Mankad, VACHAN, Nasik
Dr. Ashok Bhargava, IDEAL, Ahmedabad
Dr. Anant Phadke, MFC, Pune
Dr. Shyam Ashtekar, BVS, Dindori.
Dr. Ulhas Jajoo, MGIMS, Wardha
Dr. Abhay Bang, SEARCH, Gadchiroli
Dr. Abhay Shukla
Dr. Prabir Chatterjee, CHAD, CMC-Vellore.
Office support
V.N. Nagaraja Rao
Aparna Chintamani
S. John
M. Kumar
Madhya Pradesh
JSR Review
Workshop participants_____________
CHC Team and Associates
Mr. R. Gopalakrishnan,
Secretary to the Chief Minister,
Government of Madhya Pradesh
Dr. C.M. Francis,
Consultant-Planning & Management,
Community Health Cell, (CHC).
Mr. R. Parshuram, IAS,
Secretary, Panchayat & Rural Development,
Government of Madhya Pradesh.
Dr. Ravi Narayan, Coordinator, CHC.
Dr. Shirdi Prasad Tekur,
Consultant-Training & Communication, CHC.
Mr. Ashok Das, IAS,
Health Commissioner,
Government of Madhya Pradesh.
Dr. A.R. Sreedhara,Training Coordinator,CHC
Dr. Ashok Sharma,
Divisional Joint Director, Indore,
Dr. Pankaj Mehta, HOD
Department of Community Medicine,
Manipal Hospital, Bangalore.
Dr. Manu N. Kulkami,
State Representative, UNICEF, Bhopal.
Mr.
As Mohamad,
Asst.
Professor
Statistics,St.John’s Medical College, Bangalore.
Dr. Y.N. Mathur,
Project Officer, UNICEF, Bhopal
Government / NGO project invitees
Dr. D.K. Srinivasa, Consultant, RGUHS,
Bangalore.
Dr.Dhruv Mankad, Director, VACHAN, Nashik.
Dr. Ashok Bhargava, Coordinator, IDEAL, A’bad.
Dr. H.R. Kadam, Director, IPP-VIII, Bangalore.
1
INDEX
SI.
No.
I.
II.
III.
IV.
V.
Contents
Page No.
Background
1.1. Policy Initiatives
1.2. CHW - the Indian Experience (GOI)
1.3. CHW - the Indian NGO Experience
1.4. CHW - the Global Experience
1.5. The JSR Scheme in context
6
6
7
Introduction
2.1. Brief profile of Madhya Pradesh
2.2. Objectives of the JSR Scheme
2.3. Terms of reference of the review
8
9
12
Methodology of Review Process
3.1. Field evaluation
3.2. Peer review of training programme
3.3. Workshop of interested and key partners on review of
JSR scheme
Findings
4.1. Profile of JSR
4.2. Selection Process
4.3. Training Process
4.4. Training manual
4.5. Examination process
4.6. Perception of trainers
4.7. Suggestions by the trainers for improving the functioning
of JSR scheme
4.8. Perception of Community members on the JSR Scheme
4.9. Perception of Community leaders on the JSR Scheme
4.10. Perception of CMOs on the JSR Scheme
4.11. Perception of District Health Committee Presidents on
the JSR scheme
4.12. Findings of the Pipariya Block Review
4.13. Peer review of training programme
Summary of Key Findings
5.1. Objectives
5.2. Selection process
5.3. Training process
5.4. Training manual
5.5. Examinations
5.6. Functions of JSRs
5.7. Fee for service
5.8. Supervision
5.9. Administrative details
5.10. Some concerns
14
19
19
20
22
24
30
31
35
37
38
39
40
41
42
44
50
51
51
53
54
55
55
56
56
57
3
VI.
Report of the Discussions of interested and key Partners
6.1. Objectives and administration
6.2. Linkages
6.3. Logistic support
6.4. Communication
6.5. Training
6.6. Criteria for recertification
6.7. Supervision - Monitoring - Evaluation (SME)
6.8. Examinations
59
60
60
60
61
62
62
62
VII.
Recommendations
7.1. Objectives
7.2. Administration
7.3. Selection
7.4. Linkages
7.5. Logistic support
7.6. Communication
7.7. Training
7.8. Criteria for recertification
7.9. Supervision-Monitoring-Evaluation
7.10. Examination
7.11. Core Project Team
7.12. Peer support
64
VIII.
Bibliography
67
IX
APPENDICES
1. Six natural regions of Madhya Pradesh characteristics
2. District profile and Regional Disparities in Madhya Pradesh
3. Jan Swasthya Rakshak Scheme Notice (30-9-1995) &
objectives
4. List of 24 functions for the Jan Swasthya Rakshak
5a Srivastava Report, 1975, Chapter 4 : Health Services and
Personnel in the community
5b Content list from the Manual for CHW (1978), GOI.
6. Questionnaires/Protocols used for JSR Field Review.
7. JSR ReviewWorkshop (18-19 September 1997)- Programme.
8. JSR Examination I - question papers
9. JSR Examination II - question papers
10. JSR Examination (used for field study)
11. Standard Project paper for TRYSEM loan
12. Some Educational materials available in MP
69
70
72
77
79
87
95
117
119
122
154
156
162
(SEE ALSO SUPPLEMENT : PEER REVIEW OF JSR MANUAL)
4
1.
BACKGROUND
The ‘Jan Swasthya Rakshak’ scheme launched by the Government of Madhya Pradesh in
1995, is a significant effort aimed at bridging the wide gaps and disparities in health and
human development in the state. It is especially significant because since the development
of the concept of the disadvantaged BIMARU region in planning circles in India
(comprising Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh) there has been a
growing concern, that these states need some radical and innovative strategies to make
health care a reality for the large numbers of marginalised and socially disadvantaged
sections of society, who are presently not reached by the existing services.
However, the idea of village based health workers and the involvement of the community
in their selection, support and supervision is not new. There have been governmental and
non governmental initiatives in this area and to contextualise the JSR Review undertaken
by us, we include a short background overview of these efforts.
1.1
Policy initiatives
The Bhore Committee report (1946) which formed the blueprint of post independence health care service development, had suggested the formation of village health committees
and voluntary health workers who needed suitable training (19). In 1975, the Srivastava
report, 30 years later suggested the utilization of part time, semi professional workers from
the community who could be trained in the management of common ailments and in basic
preventive and promotive services (20). The fourth Chapter of the report entitled “Health
Services and Personnel in the Community” is an excellent concept paper on the
significance of community based semi professional health workers (See Appendix 5a).
A few years later the ICSSR/ICMR Health for All study group (1981) reiterated once
again the need for Community Health volunteers with ‘special skills’, ready availability,
who see health work not as a ‘job’ but as a social function (21).
Finally, the National Health Policy (1982) included a policy statement on ‘Health
volunteers selected by communities and enjoying their confidence and to whom certain
skills, knowledge and use of technology could be transferred’(22).
1.2
CHW - The Indian Experience (GOI)
In 1977, the Janata Government launched the Community Health Worker (CHW) scheme,
which focussed on CHWs selected by the community, having 6th standard education, and
trained informally in the PHCs for 3 months (4). They were paid a stipend during training
and an honoraria of Rs. 50/- per month after the training, when they began work. Further
details and a comparison with JSR scheme is provided elsewhere in the report. (See Page
12).
The CHW scheme was a massive operation and was subject to some mid course reviews
(23) which identified problems including the lack of adequate preparation; the lack of pilot
or feasibility studies; the reduced support of the community; the inability of the
5
community to takeover the scheme; the non-payment of honoraria and the non
replenishment of kit boxes; the lack of professional enthusiasm with the challenge of the
scheme at all levels; the predominant selection of males as CHW and their subsequent
cooption by the system and finally the problem of the whole scheme becoming a subjudice
matter due to litigation by CHWs about enhancement of their honorarium, thus becoming
non functional!
1.3 CHW - the Indian NGO experience
Prior to 4977 and also after it, many Community Health projects in the voluntary / non
governmental sector in the country experimented with community based health workers.
Some examples are the CHWs of Jamkhed; the village health workers of the Indo Dutch
Project; the lay first aiders of VHS-Adyar; the link workers on the tea gardens in South
India; the Family care volunteers and Health Aides of RUHS A; the MCH workers of
CINI-Calcutta; the Swasthya Mithras of Banaras Hindu University-Varanasi; the
Sanyojaks of Banwasi Seva Ashram, Uttar Pradesh; CHW course of St. John’s Medical
College - Bangalore; the Rehbar-e-sehat scheme of Kashmir government; the CHVs of
Sewa Rural and the Community Health Guides of many other projects. (24)
An overview of these CHWs in the voluntary sector show that they were predominantly
women; were mostly voluntary or link workers with minimum support; most of them were
mature married volunteers; care had been taken by the project to prevent the cooption by
village leaders and there was representation of all segments; the participation of the
community in identifying the CHWs and their supervision was a goal itself; the training
programmes had innovative components and methods (28) and projects had well trained
and highly mobile field and supervisory staff; and many projects had women on
action/advisory committees or local womens groups supportive of the process. (24)
1.4
CHW - The Global experience
At a Global level also, since the late sixties and early seventies, the experiments of training
community health workers of various types took place all over the world. Significant
initiatives were taken in Mexico, Guatemala, Jamaica, Venezuela, Brazil, Ghana, Nigeria,
Sudan, Ethiopia; Kenya; Tanzania, Iran, Afghanistan, China, Bangladesh, Thailand,
Malaysia, Indonesia, Philippines and Papua New Guinea. The terminologies were vastly
different but the basic framework was similar. These included community / village health
workers; the community health aides; barefoot doctors; community health agents; rural
health promoters; national health guides; family health educators; aid posts or orderlies;
secouristes; hygienist; health auxiliary and health post volunteers. A review of these
experiments showed a remarkable diversity in framework and approaches. (25)
Nearly all the countries where these experiments took place were from the developing
countries (South). The projects ranged from pilot and local projects to regional and
national initiatives. The trainees selected ranged from illiterates, to upto 10 years of
schooling.
The duration of training ranged from 5 days to 10 weeks to 6 months and even upto three
years for different cadres. The location of training varied from subcentres and local health
6
centres to county and rural hospitals and in some instances there were training centres and
national project headquarters.
Training methods included lectures, discussions,
demonstrations, role playing, field visits, practicals, learning by doing and story telling and
dialogue. Finally the evaluation methods ranged from written tests, practicals, oral tests,
quiz, field performance reviews, role playing and trainer observations. (25)
1.5 The JSR Scheme in context
The concept of the community based health worker has been in vogue, therefore, for
many decades with a wide variety of experiments at governmental and nongovernmental
level in a wide variety of countries. The Madhya Pradesh Government’s initiative - the
Jan Swasthya Rakshak scheme - is a significant development against the background of a
series of similar initiatives all over the country and the world. This has now been in
existence for 22 months.
A critical overview of the scheme at this juncture will not only be an important mid course
assessment of the initiatives but will also be an opportunity to assess the experience against
the backdrop of a wealth of previous experience so that we do not reinvent the wheel but
ensure that the scheme evolves in a way most suited and relevant to the local realities and
challenges.
Tire
before us
....The over-emphasis on provision of health services through professional
staff under state control has been counter-productive. On the one hand, it
is devaluing and destroying the old tradition of part-time semi-professional
workers which the community used to train and throw up and which, with
certain modifications, will have to continue to provide the foundation for the
development of a national programme of health services in our country. On
the other hand, the new professional services provided under State control
are inadequate in
quantity (because of the paucity of resources) and
unsatisfactory in quality (because of defective training, organizational
weaknesses and failure of rapport between the people and their so-called
servants). What we need, therefore, is the creation of large bands of parttime semi-professional workers from among the community itself who would
be dose to the people, live with them, and in addition to promotive and
preventive health services including those related to family planning, will
also provide basic medical services needed in day-to-day common illnesses
which account for about eighty per cent of all illnesses. It is to supplement
them, and not for supplanting them, that we have to create a professional,
highly competent, dedicated, readily accessible, and almost ubiquitous
referral service to deal with the minority of complicated cases that need
specialized treatment
— Srivastava Report, GOI, 1975.
7
IL INTRODUCTION
2.1 Brief profile of Madhya Pradesh
Madhya Pradesh with the largest land mass amongst Indian states presents a fascinating
hue of cultural and geographical diversity. A total of 71,256 villages with varying
population are scattered over this region and 76.82% of the State’s population is rural
based. The State is divided into six regions, each with its own different characteristics
(Appendix 1). To provide ‘‘Health Care for All by 2000 AD” in such a situation is a
daunting task indeed. There continues to exist large unmet felt need for health services.
As in rest of India, rural health care is a perpetual problem. Notwithstanding the vast
network of Block and Sector PHCs and subcentres, a large percentage of rural population
is unable to obtain comprehensive health care. A comparison of rural and urban birth rates
(35 and 24.3 per 1000 population), crude death rates (12.6 and 7.3 per 1000 population)
and Infant Mortality rates (105 and 75 per 1000 live births) reveals the extent of health
problems and needs lying unfulfilled specially in rural areas. The above figures mask the
wide inter-district variation (Appendix 2).
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Where most villages do not have an all season approach road, where many rural area posts
still go unfilled because of reluctance of trained manpower to settle down in rural areas
and where facilities are more or less non-existent, even an ordinary curable illness
undertakes a sinister complexion and often ends in a severe complication or, even
death. Very often the cures required are simple and one which a trained and
competent health worker can provide in the village itself. For those illnesses that are
truly serious, early identification and timely referral by such a village based worker can
make all the difference between an early recovery or chronic illness and / or death.
Taking cognizance of the above situation and to improve health care services in rural
areas, 18 years and 47 days after the launch of the Community Health Worker Scheme, the
Government of Madhya Pradesh on 19 November, 1995 launched the Jan Swasthya
Rakshak Scheme under the Integrated Rural Development Programme (IRDP) for
unemployed rural youth to provide round the clock curative, preventive and promotive
health services in every village of Madhya Pradesh. (Appendix 3).
2.2 Objectives of the Jan Swasthya Rakshak Scheme
1. To improve the health in rural areas, by providing a trained worker who can give first
aid care and treat small illnesses scientifically, in the village itself. Efforts are to be
made to have both males and females in this scheme.
2. To provide a trained worker in the village who can assist in the implementation of
National Health Programmes and health schemes of the Government.
The Scheme has outlined a list of 24 functions for the Jan Swasthya Rakshak (Appendix 4). These include provision of curative services and first aid care in the village itself,
recognition of serious illnesses and epidemics and their immediate notification to health
centres so as to provide optimum health care, providing assistance in the implementation
of RCH services and other national programmes in the village, collecting health related
information and maintaining registers.
TABLE 1 : Analysis of functions of JSR as mentioned in the JSR Manual
1.
2.
3.
4.
5.
6.
Type of Function
Preventive
Promotive
Environment promotion
Health Education
Health Statistics
Curative
TOTAL
Number in Manual
1,2,16,18,20,21,22,24
3,7,8,9,10,11,16, 23
4
5,12,15.
6, 19
13, 14, 17
Total
8
7
1
3
2
3
24
Percentage
33.33
29.16
4.17
12.50
8.33
12.50
100.00
Of the 24 functions envisaged for a JSR, 8 are preventive, 7 promotive and 3 health
education related. Only 3 of the 24 functions are curative in nature.
Besides the provision of health services to rural areas, by recommending that only
unemployed, educated youth who belonged to families below the poverty line be chosen
for training, the scheme hoped to provide an occupation to atleast some of them and
9
thereby a means of livelihood. All financial assistance for training, including stipend,
contingency and loans for setting up the clinic are to come from the IRDP and the health
department has to impart the training and provide all necessary technical assistance.
2.2.1 Community Health Worker / Guide / Volunteer
This scheme is very much in tune with what was recommended in 1974 by the Shrivastava
Committee - - “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”. These were to be essentially self-employed
people and therefore not a part of Government bureaucracy. The Rural Health Scheme
announced by the MHFW, GOI to strengthen health care services in rural areas was an
extension of the above concept. Under the scheme, every village or community with a
population of 1000, had to select one representative who was willing to serve the
community and enjoyed its confidence. The tasks expected of the community health
workers were:
*
*
*
*
immunisation of the new born and young children;
distribution of nutritional supplements;
treatment of malaria and collection of blood samples; and
elementary curative needs of the community.
The overall philosophy of the scheme was that the health work which was till then looked
after largely by Government was for the first time to also rest in the hands of the people.
The community health worker belonging to the same community would be accountable to
them and they in turn would supervise his / her work.
The community health worker was not envisaged to be a full time health worker and was
expected to perform community health work in his/her spare time for about 2-3 hours
daily. During the period of training, the trainees were given a stipend of Rs. 200-00 per
month for 3 months and a simple medicine kit. Once they commenced work they were
given an honorarium of Rs. 50-00 per month and Rs. 600-00 worth of medicines per year.
The responsibility of the Government was limited to training and technical guidance. The
philosophy of community involvement and participation in the provision of primary health
services, also implied that the community would supplement the resources required for the
continuation of this work and would completely takeover the programme at a subsequent
period of time.
The scheme which was introduced on 2nd October, 1977 evoked wide public interest.
While no one doubted the sincerity of the Government in providing health care to the rural
masses, the programme came in for adverse criticism right from the outset. The
Government was blamed for inadequate preparation, lack of pilot studies on feasibility
especially in the light of heavy investment of public funds required for its implementation
and for promoting quackery. In addition, community support remained minimal to nil and
the envisaged possibility of the community taking over the programme was an impossible
proposition under the circumstances.
10
Because of the above and various other reasons like non-replishnment of kits, non
payment of honorarium. etc., community health workers scheme which from the beginning
had a poor chance to succeed never really took off. Unable to wind it up, due to various
matters which are at present subjudice, the Government is now burdened with the
recurrent costs for a “non-functional” scheme - the penalty of ill planning, hasty
implementation and blind faith.
The present JSR scheme has tried to obviate some of the problems which plagued the old
CHW Scheme. The scheme has issued clearcut guidelines on the selection process,
training, examination, registration, functions of JSRs and code of conduct.
2.2.2 JSR Scheme versus CHW scheme
The objectives and activities of the JSR Scheme do have many commonalties with the
Community Health Worker Scheme of 1977. But, there are some important differences.
Important amongst these are :
1. increased duration of training - six months (it was three months in the CHW Scheme);
2. increased stipend from Rs.200-00 to Rs.500-00 per month during the training period
with funds coming from TRYSEM (it was Rs.200/- in the CHW scheme and the funds
were not from TRYSEM);
3. no monthly honorarium is to be paid to the JSRs. Instead, JSRs who successfully
complete the course are to be given a registration certificate which will allow them to
‘practise’ in the village which nominated them for JSR training. Guidelines which
state that they are to provide curative care only for illnesses mentioned in their training
manual and for which they have been given training as well as the drugs they can use
for treatment of these minor illnesses have been established.
To assist in the
establishment of their practise, JSRs who successfully complete their course are
eligible to obtain a loan with subsidy from IRDP under TRYSEM;
4. only those who have passed upto 10th standard are eligible for JSR training (CHW
scheme permitted those with formal education upto 6th standard and above);
5. whenever qualifications and other criteria are similar, women are to be given
preference over men in the selection process.
Though on first impression, these changes appear to be minor, the scheme as now
envisaged differs in 2 radical ways from the old CHW scheme. Not providing a monthly
honorarium and allowing market forces to determine their income per se could push the
priorities of JSRs to paid curative services over preventive and promotive services
specially with the spectre of loan repayment looming over their heads. Secondly, under the
present format of certification, the Government has no direct supervisory powers over the
JSRs as they are not staff of the Health and Family Welfare department and the JSRs
theoretically have the liberty to pursue their practise and curative care without having the
compulsion of carrying out preventive and promotive services or assisting Government in
the implementation of National Health Programmes as envisaged in the scheme.
11
TABLE 2 : Comparison between CHW and JSR Schemes
Criteria
Year
Training duration
Goal
Eligibility
Stipend during training
Honoraria
Practice _
Content of manual (special)
______ CHW Scheme_____
1977
3 months
one CHW/ 1000 population
upto 6th Standard
Rs. 200 per month
Rs. 50 per month
Informal
• Mental Health
• Minor
Ailment
by
Ayurveda/Yoga/Unani/
Siddha/Homeopathy/
Naturopathy/ Medicinal
Plants (See Appendix 5)
JSR Scheme
1995
6 months
one JSR / village
upto 10th Standard
Rs. 500 per month
Loan - subsidy
Certified
• Working
with
community
Anatomy / Physiology
• Dengue/Filariasis
• STD/Blindness
• Patient examination
Further details of the present JSR Scheme are given in Appendix 3.
The aim of the present review was to assess the JSR scheme and suggest ways and means
to improve the overall performance of JSRs in context of prevailing situation in State,
where services of trained health personnel are not available at the time of need especially in
rural areas.
2.3 Terms of Reference of the present review
i.
Document the profile of the JSRs in five districts in different regions of Madhya
Pradesh.
ii. Examine the process of selection of the JSRs by the community.
hi Document the content and methodology of training in selected PHCs with a view
to strengthen this process, keeping in mind the skills required for provision of essential
child survival and safe motherhood services at village level.
iv. Evaluate the system of examination for certification of the JSRs and suggest
modifications if necessary.
v. Document in the randomly selected five districts of the state, the perception of the
local community and panchayats of the services provided by the JSRs in their village.
12
vi. Examine the functional linkages that JSR have with health staff after training.
vii. Prepare final report to strengthen JSR scheme in Madhya Pradesh
NOTE
At the outset, we would like to clarify that at the time of Review not a single JSR
had received his registration certificate - a necessary prerequisite to practice as
mentioned in the government orders on the scheme. Because of this, the actual,
practical review of the performance of JSRs in the field was not feasible. Only
indirect information of their assisting or non-assisting in the implementation of
national programmes like immunisation, etc., could be obtained. A study of the
effectiveness of the services provided by the JSRs and their benefits to the
community will necessarily have to await some reasonably long time after the
scheme is able to get off the ground. (Items v and vi of the TOR are therefore only
indirectly addressed in the Review because of the local field realities and situation of
the scheme at the time of this Review)
13
i
111. METHODOLOGY OF REVIEW process
The development of the methodology for this Review was influenced to a considerable
degree by the purpose and scope of Review and the time-constraint involved in conducting
a state-wide study. The various aspects of the methodology can be broadly classified as
follows:
1. Field Evaluation
i. Identification of levels of administrative set-up;
ii. identification of functional areas of study;
iii. sources of data;
iv. development of instruments;
v. sample size and design;
vi. collection of data; and
vii. analysis and interpretation of data.
2. Peer review of training programme
i.
Evaluation of training manual and programme objectives by NGO groups with
prior experience in similar activities.
3. Workshop of interested and key partners on field review report of JSR
Scheme
i.
Workshop to discuss review findings
By adopting this three step methodology it was felt that inputs of a large number of
individuals could be obtained in short time within the time and budgetary limitations.
3.1 FIELD EVALUATION
3.1.1 Identification of levels of administrative set-up
Keeping in view the objectives of the scheme and the operational details evolved for its
implementation, collecting and utilising information from sectors other than health
especially at the grass-root level, was considered desirable. Therefore, the levels of
administrative set-up from where the information was to be generated were decided as
follows:
I.
Organised health services set-up
a) District level concerned with operational details of scheme
b) Primary health centre complex concerned with training and implementation of
scheme at grass-root level.
14
i
II. Link between organized health services and community
Jan Swasthya Rakshak.
III. Consumers and their representatives
1) Village level
a) community members
b) community leaders
c) village level workers
2) Block level
a) Block Development Officers
b) Block Level Presidents
3) District level
a) Zilla Parishad President/members,
b) CEOs and President of Zilla Panchayat Health Committees.
Every effort was made to meet representatives at all the above levels. Though there was
no difficulty at the village level, it was not always possible to meet representatives at Block
level or District level because of transfers or previous commitments necessitating their
absence from headquarters. Also, as some of the Panchayat representatives in some places
which we surveyed, had left for the Congress convention at Calcutta which was being held
at the same time, we were unable to elicit their views.
3.1.2 Identification of functional areas of Study
The functional areas or dimensions of the scheme on which the review was based are given
below. These were worked out taking into consideration the status of implementation of
the scheme at the time of conducting the study and in keeping with the objectives and
scope of review.
i.
The extent of deviation of the scheme in its actual implementation to date in different
districts;
ii. attitude and commitment of JSR to the planned work;
iii. attitude and perception of community members, leaders and primary health staff
towards the scheme in general and JSR of their villages in particular;
iv. adequacy and appropriateness of medicines and drugs supplied to the JSRs;
v. problems and bottlenecks in the effective selection and training of JSRs;
vi. administrative and logistics aspects.
The functional areas were decided with a view to cover all the dimensions providing
thereby the factual attitudinal assessment of the implementors of the scheme and potential
15
beneficiaries. These served as guiding principles on the basis of which instruments for data
collection were developed.
3.1.3
Sources of data
The study involved collection of primary data from respondents at various levels of the
health administrative set up, as well as from the community members and leaders. Data
was also collected from secondary sources such as instructions and circulars issued at
different points of time and records of district and PHC levels.
The categories of personnel were chosen on the basis of extent of their involvement in the
planning or implementation stages of JSR scheme directly or indirectly. The number of
respondents in each category and the total number interviewed are as follows:
TABLE 3 : CATEGORY OF RESPONDENTS
Level of administrative
set-up
Category of respondents
Total no. of respondents
District
Chief Medical Officer
C.E.O.
Deputy CEO
5
2
1
Block
B.D.O.
B.M.O.
M.O. Incharge training of JSR
Block Extension Educator
Male Supervisor
Lady Health Visitor
Jan Swasthya Rakshaks
5
9
Village
Community members
Community Leaders
Village Health Workers
1
11
11
11
101
20 villages
20 villages
6
3.1.4 Development o f instruments
After having identified the functional areas mentioned earlier, different schedules meant for
collection of information from different categories of respondents were developed. In all,
6 such schedules were developed. (Appendix 6a to 6g). A number of areas were common
to some schedules.
They were introduced to obtain information from different
respondents on the same dimensions of the scheme.
The schedules contained structured and open-ended attempting to cover knowledge,
attitude and reaction of different levels of respondents. The District and Block level
schedules were in the form of guidelines and were administered in the form of
semistructured interviews.
16
3.1.5 Sample size and design
The present review was being undertaken mainly to provide midcourse corrections and
suggest ways and means to improve the overall performance of JSRs. In the absence of
any regular monitoring system and because of the logistical limitations even though a
structure was made the process was envisaged more as a qualitative review rather than a
quantitative review. Within this limitation, the diversity and vastness of the state
warranted our obtaining data from as many parts of the state as possible. Keeping in view
the quantum of information to be collected at different levels of administrative set-up
within the constraints of time and resources, a multi-stage sampling process was resorted
to. From five regions of Madhya Pradesh, two districts each were initially selected
randomly. From these two districts, one was then again selected randomly. In these
selected districts, two PHCs each were selected more on the basis of practical
consideration of time, resources and logistics rather than on the basis of rigorous statistical
requirements. In each of the PHC unit, effort was made to visit at least two villages to
discuss matters related to the scheme with community members and leaders. While
conducting the field survey, we were informed of RCH training being given to a large
group of female “JSRs” under a pilot project being funded by an international agency at
Piparia Block PHC. Since the functions and activities of this group were to be very similar
to the JSRs in other districts, we decided to review the training process at Piparia Block
PHC also. The final list of Districts, PHCs and villages visited are given below:
TABLE 4 : Districts, Block Primary Health Centres and villages visited during the Review
District
Vidisha
Bhind
Bilaspur
Block PHC
1. Peepal Kheda
Villages
1. Sunpura
2. Busran
2.
Gyaraspur
1.
2.
Furtula
Mudro Ganeshpur
1.
Phooph
1.
2.
Baralu
Deenpura
2.
Ater
1.
2.
Ater (Hamlet)
Johri Kotwal
1.
Balloda
1.
2.
Chhapra
Bachhao
2.
Pangad
1.
Menhdi
1.
Govind Garh
1.
Agdal
2.
Sirmor
1.
2.
Kirori
Raj gad
1.
2.
Gadaghat
Alipar Kheda
Rewa
Hoshangabad
Piparia
Dhar
1.
Nalchha
1.
2.
Panela
Patliyapur
2.
Sardarpur
1.
2.
Badadi
Karchi/Ruprel
17
Below is a short summary of the selected districts.
District Profile:
A District profile of Madhya Pradesh was compiled from secondary sources of data, to
locate the findings from the sample districts in a broader state context.
*
All the selected districts visited except Hoshangabad had a higher percentage of rural
population as compared to the percentage of rural population in Madhya Pradesh.
*
Dhar and Vidisha districts have a lower rural female literacy when compared to that of
the State.
*
Bhind and Vidisha have one of the lowest sex ratios. Due to various causes identified
in various other studies, this does greatly influence the socio-cultural practices
specially gender related in these 2 districts.
*
Except Bilaspur, the CBR and TFR were higher in all the other districts visited
*
Bhind and Vidisha have a much higher and Dhar much lower schedule caste population
when compared to rural Madhya Pradesh.
Dhar has 59.45% rural population belonging to schedule tribes,
tribal population. Their percentage is low in Vidisha and Rewa.
State/District
Total
Population
Percen
tage of
Rural
Popula
tion
Rural
Female
Literacy
Rate
Bhind hardly has any
Total (Rural &
Urban)
Rural
SC
ST
SR
CBR
TFR
(1984-90)
(1984-90)
Madhya Pradesh
Total
Rural
Urban
66,181,170
50.842.333
15,338.837
28.85
19.73
58.92
14.55
14.80
15.72
23.27
28.82
4.87
931
943
893
37.2
5.0
76.82
Districts____
Bhind **
Rewa **
Dhar **
Vidisha **
Hoshangabad **
Bilaspur **
967,857
1,318,172
1,187,702
775,303
920,695
3,148,763
79.40
84.77
86.86
79.90
72.66
83.00
23.55
22.81
15.64
19.54
26.32
20.92
22.17
15.38
6.85
21.68
16.84
19.12
0.15
13.56
59.45
5.23
22.20
26.33
813
946
960
872
904
990
39.0
40.9
37.2
40.1
38.0
36.7
5.8
5.8
5.1
5.6
5.4
5.0
SC - Scheduled Caste
ST - Scheduled Tribe
SR - Sex Ratio
TFR - Total Fertility Rate
* * Districts visited by Study team
Source : Health Monitor 1994 & 1995 (FRHS) - Bibliography (18)
CBR - Crude Birth Rate
18
3.1.6
Methodology for collection of data
For the purpose of collection of data, a team of two members visited the various
institutions and administered the various questionnaires to different categories of
respondents and held open-ended interviews as appropriate with the different levels of
personnel mentioned earlier. Discussions were held with community members and leaders
of identified villages based on guidelines mentioned earlier. Discussions were also held
with JSRs after they submitted their filled up questionnaires to elicit their views in a group
situation.
3.1.7
Analysis and interpretation of data
All data collected was analysed either manually or with the help of the computer and
appropriate interpretations were made from the analysed data. Information was thereby
obtained on the selection process, training process, training manual, examination system,
profile of JSRs and views of various categories of people on the scheme and its objectives.
3.2 PEER REVIEW OF TRAINING PROGRAMME
The training manual and programme objectives were distributed to a large number of non
governmental / voluntary organisations with experience in similar activities for their
review and comments. Their comments were analysed and collated. By this method,
inputs of a large number of individuals (See Supplement) were obtained on the scheme.
3.3
WORKSHOP OF INTERESTED AND KEY PARTNERS ON
REVIEW REPORT OF JAN
SWASTHYA RAKSHAK SCHEME
After the review in the field, a preliminary report of findings was prepared. This was
presented to and discussed in depth amongst an invited group of participants and key
players, which consisted of representatives from the Madhya Pradesh government, Health
Department, IRDP, District administration, UNICEF-Bhopal, and invited NGOs
(Appendix - 7) at a workshop arranged specifically for this purpose. The comments,
suggestions and recommendations of these group of participants are mentioned in depth in
the section “report of the discussions of interested and key partners”.
19
FINDINGS
During our Review visit to the various districts, we were able to contact a total of 101
JSRs who belonged to either the first or second batch of trainees. Given below is a profile
of the JSRs included in the study and from whom various details and responses were
elicited While this profile gives us an idea of various characteristics of the JSRs
included in the study, care must be taken not to extrapolate these findings to the
wider population of JSRs because of the nature of the sample studied
4.1 PROFILE OF JAN SWASTHYA RAKSHAKS
(included in the Review)
4.1.1 Age and Sex distribution
TABLE 5 : Age and Sex distribution of JSRs who were contacted during review exercise.
Age (Years)
15-19
20-24
25 -29
30-34
35-39
40-44
45-49
>50_______
TOTAL
SEX
Female
Male
0
1
2
20
1
38
0
22
0
11
0
3
0
2
0_________ j___
3
98
Total
1
22
39
22
11
3
2
j___
101
Percentage
1.0
21.8
38.6
21.8
10.8
3.0
2.0
1.0
100.0
16.8% of the JSRs were above the upper age limit of 35 years, (most of these are old
CHWs, who have been nominated for JSR training).
4 .1.2 Selection of Females : some problems
The sample of 3 females in this evaluative process was quite reflective of the actual
percentage of females who underwent training to become JSR. Females do not volunteer
to undergo JSR training. This is unfortunate as more than 60% of the JSRs activities are
CSSM & RCH related. The reasons given by the trainers and community leaders for their
not volunteering are as follows:
*
no qualified candidates (most girls stop studying after VIII standard as most villages
do not have a high school);
*
the elders do not permit them to seek work outside the house;
*
it is not safe for them to travel alone and there might be times when they may have to
travel alone at nights;
*
no hostel facilities at training venues;
*
they get married at an early age and are not permitted to volunteer for this work;
20
*
they have small children and they have to take care of them as well as the other family
members.
4.1.3 Distance from village of JSR to training places (Block PHC)
TABLE 6
Distance (Kms.)
0-4
5-9
10- 14
15 - 19
20-24
>25
Total
Frequency
~ 12
21
15
7
15
31
101
Percentage
11.9
20.8
14.9
6.9
14.9
30.8
100.0
30.8% had to travel more than 25 Kms. one way to reach the Block PHC where training
was being given. Not only did this mean a long travel time - a further deterrent to women
participation, but also higher cost of travelling. Additionally, it also meant that their time
of reaching the PHC was absolutely dependent on the bus timings - usually leading to their
decreased time for training at PHC. If hostel facilities are arranged at the site of training
these problems could be obviated.
4.1.4 Distribution of JSRs by District and batch of training
TABLE?
Batch
District
Vidisha
Bhind
Rewa
Bilaspur
Dhar
Total
I
0
5
16
20
1
42
Total
II
4
8
30
14
3
59
4
13
46
34
4
101
41.58% of the JSRs belonged to the first batch of trainees and 58.42% to the second
batch. 45.54% of the JSRs in our sample were from Rewa district and 33.67% from
Bilaspur. The number of JSRs from each district varied because of various reasons like
difficulty in contacting JSRs, non-interest, being away on some other work and non
communication of information to JSRs by district and block health authorities.
4.1.5 Marital status of JSRs
Marital status
Married
Unmarried
TOTAL .
TABLE 8
Frequency
88
13
101
Percentage
87.1
12.9
100.0
21
87.1% of the JSRs in our sample were married. Married JSRs are less likely to leave the
village in search of greener pastures.
4.1.6 Education status of JSRs
TABLE 9
Education status
PG
Graduate
PUC
SSLC_________
TOTAL:
Frequency
2
16
28
55
101
Percentage
2.0
15.8
27.7
54.5
100.0
45.5% had qualification higher than the lowest level prescribed. Though advantageous in
many ways, it could also lead to their searching for more permanent, more lucrative offers.
4.1.7 Occupation distribution of JSRs
TABLE 10
Occupation
Agriculture
Carpenter
Labourer
Service
Nil_________
TOTAL:
Frequency
54
1
7
Percentage
53.5
1.0
1
1.0
37.6
100.0
38
101
6.9
Majority of the JSRs worked as agriculturists, but a large percentage (37.6%) did not have
any occupation.
All JSRs were resident in the village selected.
4. 2
SELECTION PROCESS
Clear guidelines (Appendix 2) have been issued for the selection of JSRs. The
Government was supposed to give information of the scheme via newspapers, radio and
television and by putting up notices at the Gram Panchayat Office and other prominent
places. However, during our survey, we found that in none of the villages visited by us
was the above carried out and the only information that Gram Panchayat received was a
letter asking that one of the villagers who fits the criteria be nominated for JSR training to
the Janpad Panchayat. Also, no efforts were made to make use of locally available
communication means or other field based organisations for this publicity.
22
TABLE 11 : Sources of Information on JSR Scheme (for JSRs)
_______ Source
Gram Panchayat
Sarpanch,
Radio
Newspaper
Panchayat Secretary
TV
TOTAL:
Frequency
67
33
2
1
1
101
67 heard of the JSR Scheme at the Gram Panchayat; 33 were given information by the
Sarpanches. Media was a source in very few cases (6) indicating possibly its limited use
and reach.
The JSR nominee from 8 (40%) of the villages that we visited, were chosen by a few
leaders of the village (or the Sarpanch himself). In 3 places, there was a Gram Sabha
meeting called where the most appropriate name was suggested. Often nominations were
arbitrary and depended upon extraneous factors. However, information provided by JSRs
given in the following table reflects that, of the 101 JSRs who participated in the review
process, 82.2% were selected by the Gram Panchayat and 13.8% by the Janpad Panchayat.
TABLE 12 : Source of Selection of JSR
Source of selection
Gram Panchayat
Janpad Panchayat
Sarpanch
Sarpanch Secretary
TOTAL:
Frequency
83
14
3
1
101
Percentage
82.2 "
13.8
3.0
1.0
100.0
Some areas adopted novel methods to select JSRs. Thus to obtain the most ideal person,
in Pipariya PHC region, Gram Swasthya melas (health camps) were arranged in the
villages of the district where adequate information was then given to the village leaders
and villagers about the scheme and the need to select the most appropriate candidate. This
greatly helped in identifying the right candidates.
It was not that all selections were arbitrary. In some villages, the Gram Sabha did meet
and chose the most appropriate candidate. It must be kept in mind though that very often
the attendance in the Gram Sabhas is extremely poor and in reality a handful of leaders
take most of the decisions. The poor attendance at the Gram Sabha thus becomes a
stumbling block to free and fair selection - by being absent most villagers were unaware of
the scheme or its objectives and out of ignorance of the scheme, the most appropriate
candidates do not apply. We did come across 3 cases where the Sarpanch himself decided
who should be sent for training and did not inform the villagers.
The inappropriate selection of the JSR trainees has many ramifications. The duties of a
JSR calls for a certain degree of commitment. The trainers clearly mentioned that during
23
the training period they did observe that some JSRs were not interested in the training
(they were coming as “timepass”, “for the stipend” or because it might lead to a
permanent government job later). This is bound to affect the performance of the JSRs and
will also be detrimental to the welfare of the village. The whole objective of the scheme
would then be defeated specially if the villagers are not going to benefit from the scheme
because of a disinterested and poorly trained JSR.
Selection of JSR trainees therefore needs to be given further thought. One of the
suggestions given by one group of trainers was to make it criteria based and since the
health department staff visit every house in the village, their help be taken in identification
of right nominees from whom Panchayat can select the most appropriate candidate based
on a set of defined criteria. Opinion of the community and of teachers, anganwadi workers
or other government functionaries who are familiar with the residents of the village should
be taken into consideration. The success of the JSR Scheme to a large extent will depend
on the competence and commitment of the JSR and appropriate selection of candidates is
most essential.
4.3 TRAINING
4.3.1 Training of trainers
Prior to starting the training of JSRs, the Block Medical Officers of all Block PHCs where
training was to be given were invited for a training of trainers programme. In our sample,
10 BMOs underwent training at medical colleges at Indore, Rewa or Bhopal. In one of the
PHCs, since the BMO could not attend, the medical officer was deputed.
The training in these centres was of varying duration - 5 hours to 4 days (supposed to have
been for 4 days officially) and quality. The training at Rewa was of 4 days duration and
well planned and the one at Indore for 3 days.
Emphasis was more on “dont’s” than do’s (do not tell them this, do not teach beyond this
level, etc...) or a revision of technical contents of the course. Also, in one of the training
centres, the training consisted of “you know what to do, you are experienced enough” and
the whole training was completed in a few hours.
There was absolutely no mention or reference to teaching methodology how to
conduct training effectively or adult education techniques at any of the Centres. In
effect content far overshadowed the focus on process of training.
In none of the 11 Block PHCs visited, did the trained person conduct any training for
other JSR trainers (other PHC staff) or impart any information of the training process to
the other trainers. This is of immense relevance as training of JSRs at PHCs was mainly
conducted not by the BMO (who did take a few sessions/classes as and when he found
time from his many duties) but by the other medical officers and PHC staff (health
assistants, supervisors, LHVs, laboratory technician, compounder, etc).
24
4.3.2 Training at PHCs
The JSR training programme clearly outlined the schedule of training to be followed
(training manual - p.222 to 232). A total of 145 lectures were to be taken during this
period. The 26 week period of training included a posting of 10 weeks at the sub-centre
nearest to the village of the JSR.
The posting at the PHC was to be rotational amongst the various sections and also
included daily clinics.
All the PHCs in our survey found it extremely difficult to adhere to the mentioned training
schedule. The reasons were varied and often trivial. They included the extremely busy
schedule of the BMO, non-deputising of his sessions to others, non-involvement of BEE in
training (18%) - (the manual mentions he is to be warden of the hostel and hence no
other duty was assigned to him). But, by far and large it was the extremely busy schedule
of the BMO (including court cases and travels for other reasons) which was most
disruptive of the training schedule. Very often, the BMO had handed over his
responsibility to the BEE or other senior PHC staff for coordinating the training process.
The 10 week posting at the sub-centre level ranged from 0 weeks to 8 weeks in actuality.
During this period, the JSR was supposed to observe and note all the activities carried out
by the MPW (F & M). This part of the training was often a formality and quite non
productive to the JSR - since the MPW hardly took interest in training of JSR in most
places. A possible reason for this could be that the MPWs were not clearly briefed about
their role and responsibilities in the scheme. An interesting feature noticed in two centres
(18%) was that training times were adjusted to the timings of the bus coming to the
village, a very practical proposition but with many limitations.
One has to admit that often the BMO has many responsibilities. It was heartening to note
that inspite of their busy schedules in three centres (27%) they did find sometime during
the day (usually late evenings) to take their lectures. Also interesting was the conduct of
exam oriented training and refresher classes including mock examinations at 8 centres
(72%).
The training was not of uniform standard in the various PHCs. Only one centre had
received contingency funds which were utilised to buy charts and furniture. Another
centre also received the funds but no purchases were made and since the BMO was
transferred, we were unable to determine how those funds were utilised. None of the
other centres received any contingency funds for the purchase of training materials.
All PHCs were able to identify a room for training purposes which could accommodate 30
people but lacked adequate facilities for conduct of proper training. None of the rooms
had adequate ventilation and fans - and the trainers did complain of heat and humidity.
Blackboards were available only in 2 (18%) PHCs and none had any other audio-visual
equipment. In none of the PHCs was assessment carried out of the training given or the
methodology adopted for training. There is an urgent need for providing teaching aids
and blackboards to enhance quality of the training.
In all the PHCs, the trainees were rotated between OP clinic, ward, compounding section,
laboratory, injection room and dressing room. The respective staff explained /
25
demonstrated the various activities conducted in each of these sections to the trainees.
The trainees were taught how to dispense drugs, how to stain slides (not read), how to
dress wounds and how to give injections. However, it was the last mentioned activity in
which the trainees showed maximum interest. Atleast in three (27%) centres, we were
told by the LHVs how the trainees would gravitate to the injection room, even if posted
elsewhere, ask various questions on injections, show tremendous enthusiasm and pester
the staff for allowing injections to be given by them. Thus, training on injection
administration became a reality even though the JSR training manual clearly states that the
JSRs are not to use injections in their practise. What we fail to understand is, if this is so,
then why should they be trained on injection giving methods and why were they posted to
the injection room?
We are extremely worried on the quality of training in these rotational postings. The
register maintained by the compounder is illegible in most PHCs. In one Centre, because
the compounder could not find paper, he was dispensing the tablets to the hands of the
patients’ relatives. The dressing rooms in 6 (54%) centres had used and discarded cotton
waste and bandages scattered on the floor or just outside the room. The autoclave for
boiling syringes had carbon particles and was black and sooty in 10 (90%) centres. Worse,
in every centre we found plastic disposable syringes, needles and IV sets being boiled and
reused. A trainee exposed to such a pathetic situation needs to be told and taught what
not to do - rather than what to do! On questioning the technicians, compounders, and
other staff, we found out that the doctors never accompanied the trainees to these sections
and their training was done only by the paramedical staff.
None of the centres had any concrete plans for regular supervision of the activities of
JSRs once they set up practise. In fact, no group had given any thought to future
supervision, follow-up, refresher classes, attendance at monthly meetings, etc.. This was
not even told to the MPWs of the sub-centres where the JSRs were supposed to have had
their field training. It was as if “we have done our job of training - our responsibility ends
there”. On probing though, most BMOs did agree on the need for some sort of follow-up
of JSR training activities and 36% of the PHCs were categorical that the JSR performance
should be monitored on a regular basis. Even the training manual clearly mentions the
need for supervision and how this is to be done. During our Review, in none of the PHCs
we found a schedule/plan or a written check-list for supervision. Also since the JSRs had
not yet started working, none of the PHCs had started maintaining any records of
supervisory activities. Possibly, once the JSRs start practising, monitoring and supervision
may become a regular feature.
26
4.3.3 View of JSRs on training; process
Analysis of the view of the JSRs on various aspects of the training process are given
below:
Training Methodology
The training methodology consisted of postings in ward, field, laboratory, injection room,
OPD, pharmacy, dressing room along with lectures, demonstrations and discussions on
topics given in the manual.
11 (10.9%) of the respondents did not answer this question. In most places, the trainees
were divided into groups of 6 and they rotated amongst the various departments
mentioned above.
*
All JSRs felt that the training subjects were properly addressed and they were free to
discuss with their teachers any problem they faced.
*
Only 72.3% (73) of JSRs mentioned that they received written material ( handouts,
notes, etc.) during the training process.
*
87% (88) of JSRs found the material that was provided to them as handouts useful in
their training.
*
93% (94) JSRs mentioned that they were satisfied with the training received.
*
97% (98) JSRs said that training addressed local needs.
*
68.3% (69) felt that the training was appropriate for the perceived functions of JSRs
*
91.1% (92) JSRs expressed there were sufficient number of trainers during their
training process.
TABLE 13 : Physical space for JSR training
Sufficient space
No
Yes
TOTAL
Frequency
13
88
101
Percentage
12.9
87.1
100.0
87.1% mentioned that there was sufficient space for training. But as mentioned earlier,
our observation revealed that though sufficient space was available, the facilities for
training were inadequate.
TABLE 14 : Use of Teaching Aids during training process
Use of teaching aids
Yes
No
No answer
TOTAL:
18
Percentage
72.3
17.8
10
101
9.9
100.0
Frequency
73
27
17.8% JSRs mentioned that no teaching aids were used during the training process. This
is likely as some Block PHCs did not even have a blackboard to use for training.
TABLE 15 : Sufficiency of material in training manual to deal with local illnesses
Sufficiency
Yes
No
TOTAL:
Frequency
67
34
101
Percentage
66.3
33.7
100.0
33.7% JSRs felt that the manual did not have sufficient information to deal with local
illnesses, even though 97% mentioned that training addressed local needs. The manual
thus requires to be carefully evaluated to detect the deficiencies.
TABLE 16 : Areas identified by JSRs which require more training
_______ Subject Areas
1. AIDS
2. Injections (including IV)
3. Drugs
4. Anatomy
5. Surgery’
6. Prevention of diseases
7. Family Planning
8. Tuberculosis
9. First Aid
10. Diarrhoea control
11. Malaria
12. Gynaecological diseases
13. Balanced diet
14. Orthopaedics
15. Children’s diseases
16. Ayurveda - Homeopathy
Frequency
31
17
16
13
12
8
1
2
2
2
3
5
1
1
1
1
Percentage
26.73
16.83
15.84
12.87
11.88
7.92
4.95
2.97
1.98
1.98
0.99
0.99
0.99
0.99
0.99
0.99
Anatomy was one subject which 13 JSRs identified as an area which requires more
training. Information and use of drugs and injections, names of drugs and injections to be
used in specific conditions, were the other main areas identified. Though JSRs are to treat
minor illnesses and provide first aid when necessary, 12 JSRs wanted more training in
surgery and 5 in gynaecologic disorders.
TABLE 17 : Availability of JSR Kit
Availability
Yes
No
No response
TOTAL:
Frequency
11
88
2
101
Percentage
10.9
87.1
2,0
100.0
28
87% JSRs did not receive the kit which was to be given to them to assist in their functions.
Like delayed payment of stipend and nonpayment of contingency funds, this is also an
administrative problem which needs to be studied further and streamlined.
TABLE 18 : Grading of Training process
Grade
Very good
Good
O.K.
Not very good
Not good at all
TOTAL:
Frequency
9
60
25
5
2
101
Percentage
8.9
59.4
24.7
5.0
2.0
100.0
When asked to grade the training process, 68.3% JSRs rated their training as good or
very good. 24.7% felt it was OK and only 7% did not give a good rating to the training
process.
The JSRs opined on measures for improving the training process. These were:
*
*
*
*
*
*
*
having a full time teacher conducting the training;
increasing the duration of training to one year;
payment of timely stipend;
material (kit) to be given at the end of the course;
explaining with posters and charts;
training for trainers; and
training by doctors only.
4.3.4
Suggestions of the trainers for improving the
training process:
0
More appropriate selection of trainees - motivation to be an important criteria
0
Involvement of the health staff in selection which is to be based on fixed scalable
criteria
0
More staff members (fill up vacant MO posts so that BMOs can devote more time to
training process)
0
Provide audio-visual aids (these were to be obtained from one time grant of funds
which 90% of the centres did not receive).
0
Provide appropriate training to all trainers so that they could give better quality
training.
0
Hostel facilities (to facilitate regularity and attendance). This was to be arranged from
contingency funds which were not received by 81% centres.
29
0
Release of funds and stipends on time to maintain interest and commitment
0
Improve Examination process - make it less theoretical and more practical
0
Include more information on National Health Programmes in their curriculum
0
Provide each JSR with a copy of “Where there is no Doctor” (this was to be provided
to each candidate from contingency funds - but was not distributed except at 1 centre)
0
Increase internal assessment marks, so that the trainers (BMOs) can have more control
over the trainees. (Note: Internal assessment is not meant to control, it should be
formative and the BMOs should be clearly explained about this).
0
Simplify administrative procedures. Right now it has too many authorities and levels
involved in its control which affects training.
4.4 TRAINING MANUAL
4.4.1 Issuance of training manual
The training manuals were not obtained in time for the first batch in 6 (54%) PHCs, the
delay period being ten days to two months. Because of this, it is likely that the first batch
trainees in these centres were not able to obtain optimum training - as a technical subject
like medicine is extremely difficult to follow without the text-book. This may also be one
of the reasons for the poor performance in the examination of the first batch trainees (total
pass percentage less than 30%). In all the centres, manuals were obtained in time for the
second batch of trainees.
4.4.2 Comments of trainers
All felt that the manual covered all locally prevalent health problems which could be
managed by JSRs and that the manual respected local customs/culture. Though all the
respondents found the manual appropriate for the work envisaged from JSRs, some of the
suggestions for improving the manual were as follows:
*
the contents are theoretical; more emphasis should be given on practical aspects,
specially on management of illnesses;
*
increase contents in Paediatrics and Orthopaedics.
On direct questioning on whether Anatomy/Physiology was very detailed, all the
respondents felt it was not so and that it was necessary to study basic sciences to that
degree so as to understand well the functioning of the human body. This would facilitate
understanding disease causation and how the body gets affected in illness and what
happens during the recovery process. In fact, one respondent felt that these subjects
should be given in greater depth.
30
4.4.3 Comments of JSRs
TABLE 19 : Suggestions for improving manual
1.
2.
3.
4.
5.
6.
7.
8.
9.
______________Suggestions________________
Information on drugs
More information on techniques of injections and
names of injections
More detailed explanation
Information (on more diseases (including minor
ailments)
More pictures
Management techniques of diseases in rural areas
Information on diseases like ENT and Dental
disorders
More information on local herbs and their use
Provide other books
Frequency
13
Percentage
22.77
12.87
11
8
10.89
7.92
2
2
1
1.98
1.98
0.99
1
1
0.99
0.99
23
As can be seen from the above table, the JSRs were keen to obtain more practical
knowledge, which drugs to use in different conditions, names of different drugs, more
information of injection techniques, names of different injections and more information on
different diseases including minor illnesses. Only one JSR evinced interest on local herbs
and their uses.
4.5 EXAMINATION PROCESS
Two batches of JSRs had completed their training and taken examinations at the time of
our conducting the review of the scheme. The first batch had their examinations at the end
of their training period. For the second batch, the examination was held four months after
completion of their training. The results of the first batch (November 1995 to June 1996)
were announced within two months of their examinations. Unfortunately, the second
batch (August 1996 to February 1997) results were not announced even 3 months after
their examinations. It must be mentioned here that the Block PHCs where training was
held were informed only 3 days prior to the examination date (II examination) and it was a
herculean task for them to inform all the candidates the examination date. In the bargain,
some trainees specially the failed trainees of the I batch (who did not receive any further
training) could not take the examination as they were not informed on time. Obviously,
this led to a lot of disappointment and bitterness. The solution lies in streamlining the
whole process, with fixed, dates, announced in advance.
4.5.1 Pattern of Examination
The internal assessment carried 100 marks and external examination 400 marks (2 papers).
To be declared successful, a candidate had to obtain a minimum of 50% in internal
assessment and each of the 2 external examination papers.
31
The first examination consisted of one sentence to short answers (Appendix 5) and
measured the theoretical knowledge in great depth. There was also a feeling “it was
tough” and that it did not evaluate the capability of the trained JSR appropriately. There
were very few questions related to their future proposed functions and practical
applications. It was at too high a level for JSRs specially considering the scope of their
uture activities.
The second examination was a multiple choice type of paper, with no negative marking
(Appendix 6). The questions though very simple and easy to figure out had the advantage
of assessing the practical knowledge that a JSR would require and was more evaluative of
their future functions. It definitely had less theoretical component. In our discussions with
the JSRs, who had taken both the examinations, we were informed that they found the
second examination very simple, were able to complete it much before time and were able
to answer all questions unlike in the first examination where there were quite a few
questions which they were unable to answer.
There was one major administrative problem with the second paper. The districts were
sent a copy each of the question paper and they were told to photocopy adequate numbers
for all JSRs taking the examination in their district. This entailed photocopying 12 pages
for each candidate, a total of 7000-8000 pages in each district. With the meagre funds and
limited facilities for photocopying at district headquarters, this was a major problem in
some areas. To prevent leakage of papers, they could not photocopy a day or two before
the examinations. Also being unaware of the pattern of question paper, they had
anticipated a 2 page question paper as in the first examination. Practical problems like the
above should be avoided in future. Also, by utilising all available photocopying machines
in the district headquarters, chances of the paper leaking were magnified greatly, specially
since so many people were dealing with the photocopying part. Ideally, printed question
papers should be distributed. This would avoid problems like the above mentioned
one.
The pass percentage in the first examination varied in the various districts. Since JSRs of
each district were evaluated locally, one reason for this could have been the criteria
adopted for marking. To avoid bias and for uniform marking, MCQ type of papers would
be ideal; but they have their own limitations and in case the MCQ pattern is combined with
short answer questions, centralised evaluation should be adopted so that the marking is
uniform.
32
4.5.2 Views of JSRs
TABLE 20 : Views of JSRs on the Examination process & suggestions for its
improvement.
___________ Views / Suggestions____________
I. Appropriate
2. Examination of skills to be done also
(practical)
3. Monthly test
4. Announce examination date early (atleast one
month in advance)
5. Conduct examination on time
6. Examination at training centre (Block PHC)
7. Objective + Essay type
8. Viva type of examination also to be given
9. Objective type questions only
10. Cover all chapters
II. Review to be done at district level
12. Trainee to be given chance to go through
answer script
Frequency
22
16
Percentage
21.78
15.84
11
2
10.89
2
1.98
4.95
5.94
1.98
4.95
1.98
3.96
0.99
6
2
5
2
4
1
1.98
41 (40.6% ) JSRs had no suggestions on the examination process while 22 (21.8%) felt
that the method of examination was appropriate. The main suggestions of the remaining
JSRs were as follows :
16 (15.84%) JSRs wanted examination of skills in the examination process; 4 (3.96%)
wanted a combination of objective and essay type. 5 (4.95%) JSRs wanted examination to
be conducted on time and 6 (5.94%) wanted the date to be announced early. Another 5
(4.95%) JSRs wanted examination to be conducted at their training centre.
TABLE 21 : Distribution of marks between External Examination & Internal Assessment.
Correctly distributed
Yes
No
No response
TOTAL:
Frequency
81
12
8
101
Percentage
80.2
11.9
7.9
100.0
80.2% respondents mentioned that the pattern of mark distribution between Internal
assessment and external examination was correct (100 marks for Internal assessment and
400 marks for external examination).
4.5.3 Views of trainers
The trainers mentioned that both the examination types (I and II) had their advantages and
disadvantages. They also felt that both types were not ideal and a better system needs to
be evolved. In all the centres, the trainers mentioned the logistic problems faced in the
conduct of the second examination (photocopying) and inadequate funds allotted for the
conduct of the examination. The high failure rate of the JSRs in the first examination was
attributed to inadequate training and preparation by JSRs (9%), not enough of hard work
33
and commitment (9%) and the examination process (18%). Five respondents (45%) said
their centre did not have high failure rate and were happy with the performance of their
trainees.
4.5.4 Results of review of knowledge of JSRs by evaluation team
As the JSRs had not yet started practising, it was not possible to examine their
effectiveness in the field when they provide services.
Their competence at the end of the first course to be certified as JSR was determined by a
written test which was felt to be very theory oriented by most and which did not assess
their competence in a comprehensive manner and did not cover all chapters of the manual
equally (See Appendix 8c). As time did not permit our examining their clinical
competence and curative knowledge, it was instead decided to administer a questionnaire
to them which would simulate conditions that they were likely to face in reality (Appendix
10). Determining their level of response to this questionnaire presumably would be able to
give a clearer picture of their competence and possibly be helpful in providing a better
method to assess their knowledge, attitude and practices.
The results of this review were as follows:
TABLE 22 : Marks received in the review questionnaire:
Marks Received
(Maximum 100)
% of candidates
<30
31 -39
40-49
50-59
60-69
>70______________
Total_____________
I. 15
II. 50
22.58
29.89
27.58
2.30
100.00
35.23% of the JSRs received less than 50 marks.
The performance was similar in all districts with some JSRs performing well and some
faring poorly in each district.
The review also revealed the following knowledge attitudes and practices of the JSRs for
certain conditions.
TABLE 23 : Knowledge, attitude and practices of JSRs.
_________ Condition________
1. Diarrhoea
2. Protein/energy/ malnutrition
3. Tuberculosis
4. ARI
5. Family Planning
6. Epidemics
Knowledge
Good
Good
Good
Good
Good
Poor
Attitude
Good
Poor
Poor
Good
Good
Poor
Practice
Good
Poor
Poor
Good
Good
Poor
34
It is worth noting that all the attitudes and practices were curative oriented and KAP of
prevention was minimal, revealing the need of focussing on these deficiencies during
training. Prevention needs to be emphasized in the manual, training of trainers and in the
teaching/learning of the trainees.
4.6
PERCEPTION OF TRAINERS
With a view to ascertain the opinion of various category of trainers on the scheme in
general and the training process and supervision specifically, open-ended interviews based
on set guide-lines were held in every Block PHC visited. Ideally, we would have liked to
interview each trainer individually but because of time constraints, the whole team of
trainers were interviewed together in a group initially and later the trainers were asked to
give their individual opinions if it differed from the group opinion. The responses from all
members were then collated and analysed.
4.6.1
Perception on objectives
TABLE 24 : The trainers mentioned the following as the objectives of the JSR Scheme:
______________________ Objectives____________________
1. Provision of health care for minor illnesses
2. Helping the health team in National Health Programmes
3. Assisting in immunization and motivating for FP
4. Chlorinating wells
5. Improving health of the villagers
6. Production of village based cadre of health workers
7. Provision ofjobs for unemployed educated youth
Percentage
81
72
72
27
18
9
9
The above does indicate that the trainers were aware of the main objectives of the scheme.
4.6.2 Expectations from JSRs
The JSR will facilitate the health department in the implementation of National Health
Programmes (81%) was the main expectation the trainers had from the JSR Scheme.
Besides this, provision of health care for minor illnesses (72%), referral of emergencies in
time (18%), acting as a link person between community and health department (9%), were
the other main responses. Carrying out their duties sincerely and as recommended and
taught to them (63%) was the expectation from JSRs which was mentioned most
frequently by the trainers. Not becoming injection doctors or “quacks” was the other main
expectation (54%). Two groups (18%) also mentioned improvement of environment of
the village as one of their expectations from the JSRs.
35
4.6.3
List of ailments identified by trainers which could be
treated by JSRs.
TABLE 25 : Ailments to be treated by JSRs as identified by trainers
1.
2.
3.
4.
5.
6.
7.
Ailments
Diarrhoea
Fever
Minor ailments
Malaria
First aid
Coughs & colds
Eye discharges
Percentage
100 '
100
45
18
18
9
9
From the above, it is clear that the trainers do not want JSRs to go beyond their brief of
training.
4.6.4 Functioning of the JSR scheme
Since the JSRs had not yet started practising, it was not possible to elicit their level of
functioning and discuss about their referrals to the PHC. Three groups (27%) did mention
that they do receive referrals from JSRs who have completed training.
According to the trainers, all the JSRs took part in the Pulse Polio campaign and some
even in the eye camps. About 45% do assist the health team during immunisation / family
planning activities when the health team visits their villages. Others are not conducting
any health related activity or assisting the government in the implementation of National
Health Programmes or any of their other identified activities.
Using and giving injections as the main treatment (72%), using drugs beyond what
they are permitted (45%), going beyond their brief (27%) were the main worries of the
trainers regarding the JSR Scheme. The attitude of “just waiting to start practise” and
becoming “doctors” troubled one group of trainers. Four groups (36%) went to the extent
of saying they were worried that they were assisting in the production of “quacks”.
Three groups (27%) mentioned that once certified, the JSRs would only do curative
work and will not be interested in preventive and promotive activities. Because of
poor and delayed administrative actions (issuing of certificates, loans, holding of
examinations), three groups (27%) mentioned that the JSRs were losing interest and
moving over to other fields and jobs. One group mentioned that based on the population
in which the JSR was to practise (the village that recommended him for training) he would
not be able to earn sufficient amount even if he took a loan and opened up a shop. A
view that was expressed by one group where many of the JSRs who came for training
lacked interest was - “poor, uninterested and unfit selection of members for JSR
training as was often the case now would be detrimental to the scheme in the long run”.
This group also mentioned that non-release of funds and contingency amounts allotted for
training purposes, decrease the quality of training given as teaching aids and audio
visual materials can not be purchased and used for training purposes.
36
4.7
SUGGESTIONS BY THE TRAINERS FOR IMPROVING
THE FUNCTIONING OF THE JSR SCHEME
All the trainers were asked for suggestions for improving the functioning of the JSR
Scheme. Their responses are given below. Some were mentioned by more than one
training unit.
0
Improve administration. Right now too many departments are involved. These need
to be streamlined to avoid bureaucratic delays.
0
Release training funds, contingency funds and stipends on time.
commitment from all concerned.
0
After completion of the training period, regular contacts should be maintained with
JSRs. One group suggested they could be called at sector level meetings once every 2
months. Another group suggested that they should attend the monthly meetings at the
PHCs.
0
Strict supervision of JSR, specially at field levels is required. Regular refresher courses
should also be arranged.
0
TA/DA to be provided to JSRs to attend the above meetings.
0
The JSRs be given a regular monthly emolument (like the old CHW Scheme) to
increase their commitment to their functions specially the preventive and promotive
activities.
0
Every contact of health team with JSRs be utilised to enhance their skills.
0
Have more staff at sector PHC. Training of JSRs did suffer considerably because of
shortage of staff specially in those PHCs where there was only 1 MO. Very often the
MO, LHV and BEE all would be on travel.
0
To overcome the above problems, have training at District level. The staff there have
experience and facilities are better.
0
The other advantage of District level training would be the compulsory hostel stay
which would greatly assist in regular attendance.
0
Modify selection process - so that the most deserving and committed candidates are
selected. Introduce criteria based selection process.
0
Since it is extremely difficult to register girls who have passed 10th standard, minimal
qualifications for them should be reassessed and reduced to Sth standard, especially in
Tribal areas.
0
JSRs need enhanced visibility. Their role and activities need to be clearly explained to
villagers, so that their services are maximally utilised.
This will enhance
From the above findings and recommendations, it is clear that more than 80% JSRs found
the training process, the trainers and the manual appropriate and adequate. Though
37
physical space for training was adequate, there is need for more audio-visual aids and
charts as well as furniture and fans. Some suitable educational materials have already been
produced by local groups like the MP Voluntary Health Association (see Appendix - 12).
Similar materials should be identified. Funds were earmarked for this, but unfortunately
not disbursed to 90% of the training centres. The JSRs mentioning that stipend be given
on time and that they be provided with a kit after completion of course were genuine needs
and administration needs to gear up to avoid such tardy implementation. Our group
discussions with the JSRs revealed some more insights which they had not put in writing.
The first batch trainees felt their examination process was much tougher and not
appropriate for JSR level specially when compared to the second examination. The
trainers also concurred with this view. Secondly, most of the JSRs had the impression that
undergoing the training process was a prelude to the Government absorbing them
subsequently as multipurpose workers or in some such posts. Some of them were told so
by their leaders during the selection process and others held on to this belief hoping things
would ultimately work out. It was difficult to convince them that the Government just
does not have the type of resources that would be required to absorb all of them or even
for paying a monthly honorarium and hence the permission being given to the JSR to
practise.
There were very few female trainees. This is unfortunate because many of the activities of
the JSR are MCH related. Group discussions revealed the inherent socio-cultural
problems which prevented their volunteering.
The selection process as revealed in their written views did not clearly reveal the extent of
bias and malpractise that went on in a few areas as was mentioned to us by a few JSRs
during oral discussions. But it was heartening to note that there were also many JSRs who
were selected because of their commitment, capability and merit.
The JSRs are eagerly looking forward to starting their practise. They await right now their
certificate, kit and some of them - a loan.
4.8 PERCEPTION OF COMMUNITY MEMBERS ON THE JSR
SCHEME
80% communities surveyed were not aware of the scheme, its objectives, its functions and
only in 15% communities the person selected as JSR from their village was known to the
members contacted.
Two (10%) communities selected the CHW of the old scheme for JSR training.
Only 4 (20%) communities responded that they have health committees but they were not
aware whether the health committees ever met.
As all trained JSRs have not yet started working, communities do not have any idea of
their functions and services and service charges to be paid by them to the JSR.
Three (15%) communities expressed that for preventive and promotive work, government
should pay the JSR some remuneration.
In 10 (50%) communities surveyed, the selected JSR was related to the sarpanch or panch
of the Gram Panchayat.
38
4-9
ofcommunity LEADERS ON THE- TSP
SCHEME-
i
Village level leaders
In 5 (25%) communities, even the panchs were not aware of selected JSR.
lanpadPaThZr Pa”d”y8,
8°, il’fOrn",1“ ™
from
Leaders of 6 (30%) communities said they have health committees Further
questioning revealed that these committees do not meet frequently and separately but
their meeting is held along with the general meeting of Gram Panchayat. ?
Community leaders were aware of objectives of JSR scheme upto a certain extent
proc ssOomfrajSRtieaSndV1tTed’
7tayat memb6rS
mV01ved m the selection
selected
Y
Satlsfaction with
process and person
All members expressed that JSRs need
encouragement in their activities but they were
mot sure how this could be achieved.
Ihe'traiX”’
»»that JSR met them after completing
Some leaders expressed that there should be workshop/seminar on t
for panchayat leaders. This would help leaders understand theirschemes and plans
/ responsibilities /
working pattern of scheme and their plans and limitations.
ii Block level leaders
In all Janpads, president of Panchayat was involved in
recommending the person for
training selected by Gram Panchayat.
of th,ehBloTpHCS °f ,“Pa<l PanChayat "ever ViSit“i anti Supe™sed the ,raininS in
In most of the Janpad Panchayats, elected members
are not clear of the scheme and its
objectives and functioning.
iii Zilla level leadens
^J.of th; d,strict.health committees are not aware about the scheme and its
objective and functioning.
39
very clear about the functioning of the scheme and have not taken proper steps to
implement the scheme.
There exists a lot of gap on information about the scheme among and within panchayat
agencies.
Lacunae exist in passing of this information from Executive Officers to elected bodies
at various levels. Information received by them is not transmitted or communicated to
the Panchayat leaders or committees.
All the CEOs were supportive of the scheme and its objectives. One of the CEOs
expressed the limitations of the TRYSEM scheme (Appendix 11) to give loans to all
applicants as the funds received were not adequate even for l/3rd of all type of
applicants. Also the amounts to be released as loans for other professions were much
lower. Two CEOs were critical of the selection process and mentioned that since 2
departments are involved, many hindrances are likely to occur in its proper
implementation.
4.10 PERCEPTION OF C.M.Os ON THE J.S.R. SCHEME.
Our interviews with the Chief Medical Officers (CMOs) revealed that all of them thought
the JSR scheme was a good scheme and would assist in reducing the health problems of
the community besides providing a trained resource in the villages itself. At present, even
for minor health problems, the villagers have to come to district hospitals, towns or
consult private practitioners who often charged them heavily. These problems would be
obviated to a large extent.
Another positive feature of the scheme cited by them was the assistance, the present field
functionaries would obtain from the JSRs in the implementation of National Health
Programmes and other preventive and promotive activities.
They were in full agreement with the functions envisaged of the JSR but did mention that
there was lot of overlap with other health functionaries. Four of the CMOs also
mentioned that from reports that they received of the interest shown by JRS on “Injections
and IV fluid administration”, and keeping in mind ground realities and expectations of
rural people, they were sure that the JSRs would use “injections” and even provide
irrational treatments and try tackling problems beyond their brief or training. Much as they
were convinced of the need of the scheme to provide health care specially for those who
have difficulty in reaching/obtaining curative care because of the distance/transport
limitations, etc., they are also worried that they are helping in the production of “potential
quacks”. These contradictory viewpoints do not brood too well for the JSR scheme, for
the above position and ambivalence at the top, can have severe repurcussions all down the
line.
The CMOs did find the training duration, manual, curriculum and training methodology to
be adequate and appropriate. Two of the five CMOs mentioned the need to hold the
training at district level because of the facilities available (training centre, staff, hostel,
etc.). They also mentioned this would improve the quality of the training. This does
indicate that the CMOs were aware of the lesser than expected quality of training being
given to JSRs at some block centre PHCs.
40
As to the acceptability of the JSRs in the village all the CMOs mentioned that there would
be no problem and in fact because the JSR belonged to the same village and would take
care of the villagers needs, they would find easier acceptability than outsiders.
The high failure rate (>70% on an average) in the I Batch examination was attributed to
the inappropriate questions asked and inadequate preparations by the JSRs.
The ability of the CMO and staff of his office to interact appropriately with the IRDP
officials is very important in the smooth functioning of the programme and release of funds
and stipends. Our survey revealed that when these relationship was cordial and successful,
funds for contingency and stipends were made available more easily unlike in 2 centres
where there was hardly any interaction. The interest of the CMO in the scheme is very
important for its successful implementation as this becomes a measure for other
implementators in the department to follow. This will be all the more important, once the
training is based at District level as is planned from the III batch.
4.11 PERCEPTIONS OF THE PRESIDENTS OF DISTRICT
HEALTH COMMITTEES ON JSR SCHEME
Because of the Congress party convention at Calcutta which was taking place at the same
time as our review survey, we were able to meet only two presidents of District Health
Committees as the others were participating in the convention.
The President of Vidisha District Health Committee was a very well informed young lady.
She was fully conversant with all the objectives of the scheme and functions of the JSRs
and what the Government hoped to achieve from the implementation of the scheme.
According to her, the scheme was a good idea and will be very useful to the villagers,
specially those that are remote and without approach roads. She found the training in her
district to be satisfactory but mentioned that “those who are interested only will learn”.
One of her worries was since the training was given in Government centres, the villagers
will identify the JSRs as “Government Employees” and ask for free treatment and free
medicines. Since they had not yet received the certificate or kit nor the loans to set up
practice, they were unable to start their practise, were slowly losing interest and even
drifting-to other jobs. Her recommendation was that the Government should fix a pay for
them so that their commitment increases and they will work with devotion. The other
alternative recommended by her was to increase their period of training to MPW level and
provide them jobs by filling up existing vacancies in the MPW cadre.
She also suggested regular reviews of the scheme and constant supervision to maintain
quality of service and also to make JSRs feel that they are cared for and part of the health
team.
One of their major likely problems would be the wordings in their certificate. It does not
mention that the JSRs can “practise” and hence legally their right to practise and giving of
drugs can be questioned.
41
She also felt that loans to JSRs should be given with no conditions attached so that they
could utilise it most appropriately. For example, the loan specifies the quantity of drugs to
be bought and amount to be spent on drugs - many of these are available at the PHC and
could be obtained from there free instead of being “bought” by the JSRs.
At present most villagers are ignorant of the scheme and the functions of the JSRs. She
wanted JSRs to be given prominence in all village meetings/affairs as for example in
“Mahila Jagruti Sibirs”, so that they would get an identity and the villagers will come to
“know them” and seek their services. She felt that along with their certificate they should
be given a “nameboard” which they can put up at their “shop”, so that people can come to
know of their qualifications and avail their services.
The President of Health Committee at Bhind was also a very dynamic young lady. She is
very active and supportive of health programmes and camps in the district and her
excellent ability to communicate to masses is made good use of by the health department
in the district. Unfortunately, no one from the department had given her any information
about the JSR scheme and she had no idea of its objectives or functions. She took to task
the nodal officer for JSR scheme in Bhind for the department not keeping her informed
and asked for all relevant documents and files. This clearly reveals that even elected
representatives are not getting necessary information on the various schemes.
She had been able to garner enough support including financial for eye and disability
camps and it was unfortunate that her help was not sought by the health department in
their funding problems from IRDP. Worse was not giving her information of the scheme,
for when it was explained, she was very supportive of the scheme. We feel, this is not an
isolated happening; in two places we found even the Zilla Panchayat President having a
very sketchy idea of the scheme.
She felt that the scheme has not been given good publicity and because of this may not find
optimum utilisation. She mentioned that they are many loan applicants under TRYSEM
from the various professions and also that there are many committee members with their
own priorities. Hence the money meant for this scheme should come under the head of
Health Department so that the budget is clearly earmarked for the scheme and not diverted
for other activities.
She also suggested streamlining the administration to speed up the examination pattern,
announcement of results and release of stipends.
4.12 FINDINGS OF THE PIPARIYA BLOCK REVIEW
As mentioned earlier, we visited Pipariya block CHC in Hoshangabad district because we
were given the information that there was a whole batch of only female JSRs who were
undergoing training here. Since in all other places, it was extremely difficult to get female
volunteers, there being not more than 2 or 3 in a single batch, we were curious to know
how villages in Pipariya block were able to stimulate so many female volunteers. This was
of direct relevance to the programme as there is a large component of RCH in the JSR
scheme and female JSRs are therefore more suited to the programme needs.
42
During our visit, we found that two types of training being given here. There was a small
batch (17) of JSRs comprising male and female trainees and another batch of exclusive
female trainees undergoing RCH training. The second batch of trainees belonged to a pilot
project which was being implemented in a few selected districts all over India and funded
by an international donor agency, the objectives of which were quite similar to the JSR
scheme but which focussed exclusively on the provision of RCH services. The duration of
training was much longer (about 1 year), the stipend better and they were all provided with
a functional kit very early in the training period.
The socio-cultural dynamics in Hoshangabad district are quite different from the northern
districts of Madhya Pradesh. Even then, it was interesting to hear about how the training
programme managed to rope in female volunteers from all the target villages. The
procedure adopted by the district health office and Pipariya CHC was to organize a two
day “Swasthya Mela (health camp)” in each village during which they gave adequate
information to the village leaders and villagers about the scheme and the need to select the
most appropriate female candidate only for the successful implementation of the
programme objectives for the ultimate benefit of the villagers. Surprisingly, by this
process they were able to attract volunteers from each village. A marginally better stipend,
assured hostel facility and a higher overall female literacy in the district may have been
additional reasons. Since we were unable to visit the villages of this project we were
unable to obtain the views of the villagers and village leaders. However, our discussions
with the female JSRs as well as the staff of Piparia CHC revealed that it was the “health
camp” which was largely responsible for stimulating so many females to volunteer for this
scheme.
As far as the training process was concerned, there was not much difference between the
training being given in Piparia CHC and other PHCs. Overcrowding, lack of adequate
facilities, shortage of teaching staff and inadequate involvement of all CHC staff in the
training process were some of the major problems encountered. On the positive side was a
greater involvement of the field staff in the training process, construction of a big shed for
exclusive use of the training process, hostel facilities and the provision of kits to all
trainees during the training process itself. A lot of this was possible because of timely and
extra funding (in addition to the JSR training funds) provided by the donor agency. Our
talks with the trainees revealed the same aspirations (absorption by the Government permanent, salaried jobs) and similar worries and problems as trainee JSRs in other PHCs.
In addition, they were quite worried as to why no examination was yet conducted for them
(even after 1 year) and what sort of certificate would they be given (? similar to JSR; ?
permission to practice, etc.). The other major findings were as follows
0
Age distribution of these trainees is similar to that of JSRs (in our sample) except in
the age group <20 years where RCHWs are 18% compare to 1% in the JSR sample.
0
Distance from Pipariya to respective villages of RCHWs was similar or even more
when compared to other JSRs. But this was taken care of by providing hostel facilities
to trainees at Piparia CHC.
0
Largely belonging to the younger age groups, 40% of RCHWs were unmarried as
compare to 13% JSRs.
43
0
85% RCHWs had studied upto SSLC.
studied upto middle school only.
0
The sources of information for RCHW training was similar to that of JSRs i.e.. Gram
Panchayat and Sarpanch except in 5% cases where health workers and literacy mission
people provided the information.
0
70% RCHW graded their training programme as very good to good.
0
There were a lot of training materials available unlike in other PHCs. A video-TV,
flipcharts and similar training materials were used to impart RCH training.
0
The trainees felt the need of more training in the conduct of labour, gynaecological
problems, antenatal care, management of malaria, leprosy, microscopic investigations
and IV administration.
Some had higher qualifications,
15% had
The major lesson learnt by our visit to Pipariya CHC was that given enough interest and
provided enough efforts were made and necessary facilities provided, it is possible to
stimulate women with the necessary qualifications and criteria to undergo JSR training.
4.13
PEER REVIEW OF TRAINING PROGRAMME
As mentioned in the methodology, the manual and programme objectives were circulated
to NGO groups with prior experience in similar activities for their comments. Their
feedback is summarised in this section.
A.
GENERAL COMMENTS
Most of the reviewers mentioned that the launching of a state-wide village health worker
programme in today’s context is definitely a commendable step taken by the Government
of Madhya Pradesh and this highly needed scheme deserves to be implemented extensively.
However, most reviewers felt that the creation of this new cadre is not conceptualized or if
it is then it has been done very hazily and also there is a lack of clarity about the roles and
responsibilities of the JSRs.
The other issues raised by the peer group are given below:
*
the concept of such a worker and the new stated focus on RCH are very interesting
and encouraging. However, the actual contents of the job description and the manual
revealed that there was not much that was new about the contents and the role of the
JSR vis a vis the health care system was still that of a subordinate helper at the village
level.
*
Jana Swasthya Rakshaks cannot work in isolation primarily because they do not enjoy
credibility as a healer. The priority health needs of the people cannot be fulfilled by
44
them. They can function as link workers in the reflected glory of the credible health
care delivery system.
*
A crash curriculum in the indoors, does not imbibe required skills. They learn by
doing. The inwork training adapted to the local situation by a visionary trainer is
required. Abstract learning is difficult for them.
*
Preparing a handbook for a skills list with photographs/illustrations as a compendium
to the manual may prove helpful.
*
The legal status of CHWs using allopathic medicines needs to be studied
*
The NIP PHCs have to serve large populations and there is general lack of enthusiasm
for CHWs at that level. The six months training model is expensive and poor on cost
benefit. Given a choice, it would be more worthwhile to develop distance training
material, interactive training tools at some institutes and short-term contact training
facilities for skills and attitude training. The training could be staggered with inbuilt
evaluation. Also, however urgent the task, the backroom preparations have to be
thorough and effective, otherwise the end result would be one more wasted
opportunity.
B.
COMMENTS ON THE MANUAL
The curriculum-cum-manual has been prepared the first time by any government machinery
so soon and with a different vision than the usual vertical programme based technical skill
development manuals have. This sincere effort is a very credible and positive sign.
However, its hastiness reflects in the overall nature of the manual.
The manual should assist the JSRs to tackle a wide range of health related problems in
their communities, serve as a reference manual and assist them to function effectively in
the future. It should enable each JSR to acquire a range of understanding and skills to
carry out various health activities in her/his community. When seen in this context, most
peer group reviewers found the manual falling far short of expectations and suffering from
many deficiencies at every level. Their comments are summarised in the table given below.
No.
1.
2.
_____._________________ Comments______________________
The first aid section, child nutrition, domestic cleanliness etc., are treated
in a better manner than other sections._________________________
Approach to the role Such a manual would be expected to have a decisive influence in defining
the role of the JSR and shaping the attitudes of thousands of future JSRs.
of JSR
What comes across is that the JSR is a peripheral govt, functionary whose
main job is to implement govt, health and F.P. programmes and to keep
records. Caring for the sick is a very low priority and awareness
generation on health issues or articulating the needs of one’s community
relation to health issues is not even mentioned. The section on working in
the community never mentions anything about trying to understand the
priorities of people vis-a-vis health or the problems they face with the Govt,
health infrastructure.
_____ Issue
Good aspects
This is no mention of the special relevance and role of the JSR as a
community health worker, and there is no clarity about the roles and
45
responsibilities of the JSRs. The JSR appears as the lowest Ring of
government health service rather than a front-line person involved in
promoting health in her/his community.
3.
Contents
4.
Objectivity
5.
Approach to health
and disease
In the tradition of our educational system, there is a lot of emphasis on
acquiring (largely abstract and often irrelevant) knowledge, and very little
emphasis on practical skills and not even an attempt to deal with attitudes.
Inadequate, especially clinical chapters. The stnicture of the book is
disjointed and there is extremely uneven level of detail regarding various
topics. Human biology' needs trimming of some areas and addition in
certain areas. There is no balance between state driven health sendees and
the demand driven services; the former are more than the latter. If they
would "practice” then they would do more of what they were trained jess.
Now'here have clear learning objectives been defined and so the text is not
fine tuned to the needs and often much material is given without clearly
defining its relevance. It overshoots or underserves the purpose of most
topics. Ideally, each chapter should start with learning objectives and a
brief introduction.____________________________________ __________
The entire approach to understanding health and disease is extremely
piecemeal and superficial. One repeatedly gets the impression that the JSR
is just supposed to follow set procedures or take adhoc measurres rather
than creatively thinking to make diagnosis, identifying health problems in
his/her village or understanding disease in either an individual or
community. Thus even the understanding of the human body and disease
laid out in the book suffers from serious deficiencies.
There is not even a mention of basic concepts like infection, immunity;,
inflammation which are essential for an elementary understanding of
disease and healing.
*
Categories of micro-organisms are mentioned (eg., viruses, bacteria)
without ever describing what they are, how they are seen, etc. Such a
simple and practically relevant concept like : by and large bacterial
diseases can be treated by anti-microbials whereas common viral
diseases cannot; is never mentioned.
*
The fact that much disease is caused by social conditions and factors is
never dealt with systematically; where environmental causes are
mentioned it is in a largely victim - blaming and condescending
fashion (eg., chapter 5).
*
Anatomy, physiology' and epidemiology' should be taught with the
respective health problems rather than as separate topics as in Chapter
3 and 4.
*
Similarly, what health education will have to be provided to the
patients, patients’ relatives and the community should be covered with
the respective health problem.
*
There should be a separate chapter on common gynaecological
problems like white discharge, excessive bleeding, etc.,
Apart from minor ailments that can be treated by a CHW, there must be
advice on what CHW must do in various serious/moderately serious
illnesses at the village level as first aid. There are atleast 25-30 important
illnesses in which CHW has some role of detecting diseases early, limiting
damage, follow up. There could be a section on what to do in such matters.
Detection of hypertension, diabetes, PID, Peptic ulcers, cancers, mental
46
illnesses, tuberculosis etc., must be prominently discussed, not just
mentioned.
There is need to orient CHWs on geriatrics, herbs in health, occupational
medicine, village toxicology' (first aid), etc.
6.
History'
Examination
and
The disgnostic system is totally absent. Without this, how is the person
expected to practice ‘‘first contact care” is an emigma. The entire concept
of a distinction between a symptom and a disease is never made which is
the basis of making a diagnosis, even at an elementary' level.
History7 taking is dispensed of in a few lines (paradoxically under the
heading - points for examination). There is no concept of presenting or
major complaint nor special points to be enquired regarding particular
complaints (eg., cough, pain abdomen).
An extremely detailed protocol of physical examination, which one
presumes is to be applied to all patients without discrimination is given in
the manual. There is no mention of the distinction between symptom and
disease (eg., fever vs. malaria) nor sign versus disease (eg., jaundice vs.
hepatitis). Thus there is no clarity on how to approach a diagnosis and the
entire description of physical examination does not seem to lead anywhere.
The protocol for physical examination runs into two and a half pages
without any demarcation into systems or prioritisation based on the
patients presentation.
There is absolutely no description on how to go about conducting any of
the examinations; eg., of the throat, chest, abdomen. The JSR is just
instructed to examine tonsils, thyroid, liver, spleen, lungs etc., without a
clue of how to do this. The text is unencumbered by any explanatory
diagrams.
7.
Taking of pulse is repeated at three different places in the protocol! On
the other hand, simple points like examining the tongue for pallor,
palpation of the abdomen for tender areas, pedal edema are not mentioned.
The significance of any abnormality in the all important pulse, is never
mentioned so it appears to be just a magical ritual to be followed for its
own sake! In fact there is no guideline on interpreting any of the findings
arrived at after the detailed rigmarole of examination. This chapter ends
with a pedantic instruction to give more importance to detailed history
taking than to physical examination. This is unfortunately contradicted by
the authors themselves who devote exactly two lines to points to be
enquired in history and devote two and a half pages to physical
examination._________ _________________________________________
Clinical medicine The entire subject of clinical medicine for the JSR seems to be treated as
the lowest priority even though it may be a high priority for both the
and treatment
community and the JSR. This is reflected in devoting just 6 pages to
treatment of minor ailments whereas anatomy/ physiology runs into 22
pages and record keeping into 17 pages!
There is a totally ‘cookbook’ approach of Tor this - do this’ which is not
only grossly inadequate but also instills irrational treatment practices from
the very inception of training.
There is a mixture of allopathic, ayurvedic, homeopathic and home
remedies advised but none of these modes of treatment, let alone their
integration, has been discussed anywhere in the book.
47
8.
Illustrations
9
List of medicines
Despite the previous detailed description of anatomy, there is no attempt to
deal with diseases system-wise which would make it somewhat more
logical. The reason for the particular ordering of ailments is obscure till
one realises that the table is translated from an (english) alphabetically
listed table of simple ailments starting with abscess and constipation and
going upto vomiting and worms!
In fact, there is no description of any of the diseases mentioned - w hich is
the affected organ/system, what is the derangement, natural history, basis
of treatment, complications etc. For a six-month full time course this
seems to be grossly inadequate clinical information. There is no mention
of many common problems like sore throat/tonsilitis, amoebic dysentery',
pyoderma, infected woulds, trachoma, simple dysmenorrhea etc. The
scanty and disjointed information given is also confusing and at times
incorrect. Many things are treated simplistically, ear pain for instance.
This could be an ASOM as well, which needs different treatment. Same
thing about “khansi”; Management of this solely depends upon the
underlying illness. All this needs to be specified otherwise the CHWs are
likely to loose credibility._________________________________________
Highly inadequate, needs many more pictures, especially photographs.
Many of the diagrams do not hayze labels and explanatory captions. Quality
of diagrams needs to be improved.__________________________________
Needs to be expanded (anusuchi 3). Information about each medicine has
to be included in easy to read format. Reference should be made to the
WHO-SEARO list..
9a) List of medications to be used by the JSR:
*
This list does not contain most drugs recommended in Chapter 20
(whether correctly recommended there or not) :
Magneisum Hydroxide tab., Menthol, Eucalyptus oil,Sulfacetamide
eye/ear drops, Lashunadi Vati, Mahayograj guggulu, Coloi 6(7), Mag
Phos 6, Benzoic Salicylic oint., Cyana 30, etc.
*
This list does not contain certain basic medications which can be quite
useful for treating a range of ailments eg., Metronidazole.
Aspirin/Ibuprofen, Mebendazole, Vit.A, Gentian Violet, etc.
*
This list contains certain drugs which are either hazardous or
redundant and surprisingly, precisely these have been mentioned by
brand name rather than scientific name (hopefully just an accident) :
Analgin : A drug widely banned, for which safe and inexpensive
alternatives exist.
Avil : Does this refer to tablets or injections? What are the specific
indications?
Decadron : In either tablet or injection form what are the indications
for use by the JSR? Are we not promoting irrational therapy by
putting this on the basic drug list? Neosporin powder/oint. - Costs
much more than, and is probably as effective as Gentian Violet or
plain Neomycin.
9b) Herbal medicines:
Almost absent. Mentioned only in one or two places. Often it is difficult
to endorse herbs in a govl. sponsored scheme. But this must be overcome
with a consensus of Govt. Vaidyas and other experts.
48
10.
Missing sections:
*
A chapter on the Public Health System : The staff and their functions
at least at PHC and sub-centre levels, and some overall idea about
National Health Programmes.
*
A more detailed chapter on basic epidemiology, linking it with
preventive strategies and describing in some detail environmental and
social causation of disease. (The present chapter is exactly 2 pages).
*
A chapter on local and traditional remedies or its appropriate
integration in relevant chapters.
*
A chapter on basic pharmacology and some details about commonly
used medications; some description on non-allopathic systems and
home remedies.
*
11.
Role of CHWs in
and
illnesses
procedures
12.
Disease description
13.
Technical errors
14.
Language and style
A glossary with all the technical terms used in the book explained in
clear Hindi.
*
Lacking. Some simple tools of diagnostics are mandatory' if they are
expected to do clinical work independently.______________________
There seems to be some confusion about what the CHW is expected to do
about many things. For instance, there should be a clear direction as to
which illnesses he/she should treat and what is the responsibility in other
problems. If this approach is developed properly, many unnecessary' details
will go away and many vital details will demand inclusion. This needs to
be planned.____________________________________________________
Inadequate and sketchy. Readers must understand some intricacies rather
than ‘do as directed’ (see typhoid, dengue, etc.)
Another example is AIDS section - which fails to carry any details of the
clinical features and gravity of the illness. Such descriptions serve little
purpose.______________________________________________________
Some things seem to be wrong or missed in its real meaning, for instance
on pp. 109, Pregnancy toxemia is indicated to be an infection (Sankramari).
Needs to be rewritten in a more readable form. The language fluctuates
between sanskritised, over by technical Hindi and technical English
translated into Devanagari (often erroneously). There are attempts to use
simpler Hindi also in a few places but by far and large, the penchant to use
formal words makes the language lifeless, stiff and administrative.
Cryptic writing is no good for readers who are going to practice as health
workers. Separate ideas should be presented in separate paragraphs.
15.
Layout
16.
Giving statistics
17,
18.
Textual errors
Follow-up,
monitoring,
Evaluation
There is no clear sequence of section numbers, headings/sub-headings in
almost all chapters. There should be a clear style of headings, sub
headings and section headings and consistently followed numbering. The
chapters should end with a brief summary. In general, the manual will
need a lot of editing to make it simple and appealing.__________________
Monotonous! Needs to be made more lively and pleasant. Columns would
break the text into readable sections. Type size is good but lacks
beautification._______ _______________________________________
Speak for the village. National statistics is difficult to comprehend. For
instance, see chapter on Andhatva Niwaran. How many cataract cases are
expected in the village is more important than MP figures.______________
Almost every page has some typing error. This needs to be taken care of.
There is no record format for CHWs clinic records. Proper supervision is
not possible without this. Also, there is no mention of how drug supplies
will be obtained and dispensed as well as the maintenance of drug-related
records.
49
V. SUMMARY of key fin dings
5.1 OBJECTIVES
*
In the Department of Health, the objectives of the JSR scheme were known to all
Those mentioned most often were:
i.
to provide first aid care in injuries and treat minor symptoms and diseases
ii. to assist in the implementation of National Health Programmes
iii. to refer serious cases in time
*
As far as the village leaders are concerned, they mainly mentioned the first function
and on prompting agreed with second and third.
*
Eighty percent of communities surveyed are ignorant of the functioning of the scheme
and only 15% of the communities know the person selected as JSR from their village.
*
There was a lot of attrition of information by the time it reached the Gram Panchayat
and Block PHC level. This transmission loss happened at each level of onward
transmission - from state capital to district; from district to block level; from block to
gram level. The reasons could be many - from lack of interest to wilful non
transmission of information to the concerned persons. With the elected representatives
still not fully cognizant of their rights and responsibilities and with bureaucratic
officials not yet fully adjusted to the changed circumstances and readily accepting the
changed power equations at district and block levels any new programme introduced at
this stage is bound to have a few hiccups.
*
The other major problem was the inadequate funding of activities of the scheme. The
JSR scheme is a health related project dependent upon IRDP for funding of its
activities. DRDA - with many committee members including MLAs, MPs, each with
their own priority projects has very little funds left after these “individual” needs are
met. Hence the funds dependent components of the JSR scheme always suffered in
each district - leading to non-disbursement of contingency funds and training grants to
most training centres, delayed payment of stipends and non-granting of a single loan
application (under TRYSEM) till the time of our field review. Because of this and non
receipt of certificates and kits, even after successful completion of course, none of the
JSRs have “started practising” and the second major objective of the scheme that of
employment generation has received a serious setback ultimately slowly leading to
trained JSRs seeking other avenues of employment and income.
50
5.2 SELECTION PROCESS
*
Selection process was done according to guidelines - but by far and large, the selection
of candidate was inappropriate for the following reasons:
*
“Selection of family” - in 10 out of 20 communities surveyed, the selected JSR was
related to the sarpanch or panch.
*
Very little publicity was given to the scheme before implementation (only 3 out of
101 JSRs had heard/seen information of scheme on Radio/TV). No local
communication methods were used to publicise the scheme prior to the selection
process.
*
Selection of person with recommendations
*
Selection of practising CHWs (old scheme) in 10% of the villages surveyed who
are already using injections” / drug cocktails.
*
Selection of “overqualified /non-committed candidates”who will join other
professions at the first opportunity; specially if it provides a permanent income.
*
Hardly any females were selected even though JSRs functions are mainly MCH
related; 3 out of 101 in our sample of JSRs (figures from PHCs are similar).
Reasons for the non-selection of females are :
*
*
*
*
*
*
*
*
women do not volunteer
not enough qualified women
“purdah system” - permission not granted by family members
travel problems.
no appropriate boarding and lodging facilities(no hostels)
children - family problems
“lack of safety” - and harassment
Inappropriate selection (non-motivated, non committed) of candidates is leading to
attrition of number of JSRs.
5.3 TRAINING
This seems to be one of the weakest sectors of the scheme.
There are no clear-cut objectives of learning at any level of training (PHC, sub
centre, community).
*
The training of trainers of this scheme though planned well was often cursory (4-5
hours in lecture). The training was given in medical colleges by medical college
faculty to the BMOs of the Block PHCs where training was to be held. The
51
training in Rewa was of 4 days duration and about 3 days at Indore. The training
focussed mainly on technical aspects and what level of information was to be given
to the JSRs (more of what not to tell them). There was little or no community
component - possibly because the faculty must have rightfiilly felt that BMOs have
more experience on this aspect. However, unfortunately the training did not
deal with methods of training JSRs and adult learning principles - both of
which could have greatly facilitated the training process. Training should
include methods to enhance motivation and appropriate use of audio-visual
aids.
*
The trainers did not train other PHC staff after returning from their training
*
Except one centre which had received “training” and contingency funds from which
charts were bought for training, rest of the centres had no audio-visual aids except
a blackboard. Some centres did not even have this and training was mainly done
through oral lectures and demonstrations.
*
On paper it has been shown that training has been done as per schedule. In reality,
it was done as per the convenience of BMO - who had to struggle to find enough
time to conduct training. In many centres, it was conducted after morning
outpatients which often goes on till 2 p.m.
*
Very often the BMO and sometimes the CHV/Supervisors/BEE are also on field
programmes or court cases, etc., The training does get disrupted at Block PHC
because of this and hence such centres should have adequate MOs and other staff
involved in the training process.
*
The manual is very curative based and does not emphasize preventive and
promotive aspects. There is also very little reference to sociology. The national
health programmes need to be dealt in greater details.
*
Attendance of JSRs during training varied and was between 50-80%, being poor in
some centres for various reasons like distance, disinterest, lack of hostel facilities,
non-receipt of stipend, etc.
*
Training was mostly done via lectures/ health centre postings/field postings.
*
Field posting entailed accompanying the subcentre staff during rounds. It was
done very haphazardly and the field worker was never explained/prepared for the
task or given any further training to train the JSRs appropriately in the field. For
the trainee JSRs, this training component mainly consisted of accompanying the
health worker on his/her rounds and carrying the vaccine box for the health
worker.
*
Though most topics were covered, “practical and hands on training” was very poor
and superficial.
52
*
In most centres, training was mainly conducted by LHVs, health supervisors and
the BMOs. Technical subjects were mainly taken by BMOs and sometimes MOs
The BEE was not involved in 2 of the 11 centres visited as the manual did not
specify any training role for him (except that of warden of the hostel). The
technical and clinical quality of training were affected where BMOs did not
participate actively and whole-heartedly.
*
Many places held refresher classes and examination oriented training sessions.
*
Advantages / disadvantages of District Training (as perceived by us)
5.4 TRAINING MANUAL
*
Some chapters (environment, personal hygiene) are informative and useful for
trainees who will provide first contact care.
*
There are hardly any diagrams/pictures/photographs to clarify things.
*
None of the chapters have objectives of learning defined at the outset
*
Most chapters have medical orientation and not community activity orientation.
*
The Anatomy, Physiology sections have a lot of unnecessary, detailed information
for training at J SR level.
*
There is poor emphasis on social, cultural preventive and promotive aspects of
health and disease.
*
There is no mention about inflammation - healing infection - immunity as basic
defensive responses of human body. Without this, it is not possible to understand
the supportive role of external interventions like drugs, immunisation,
environmental interventions, etc.
*
Discrepancies exist in some areas as in the drug list.
*
The diagnostic system is totally absent. Since the JSRs are to provide curative
service, this section is a must.
*
The health education messages are sometimes incorrect and are inadequately
emphasised.
*
BMOs and the PHC staff found the manual to be comprehensive and good by far
and large, and they had very few suggestions like making it more.practical and
adding more details in some subjects like Anatomy for its improvement.
53
*
Even the chapters on basic subjects were found OK (i.e., not too much). Universal
feeling was that if the JSRs had to function well, they needed this degree of
information.
*
The JSRs found the manual to be good and adequate. A few mentioned that the
manual did not cover “practical” / how to manage type of information and 23%
wanted more information on drugs and injections.
*
Those who saw the book : “Where there is no doctor” found it will complement
the manual in the training process and rectify the defects existing in the manual.
5.5 EXAMINATIONS
*
Internal assessment : At most training centres, usually 3 to 5 tests were held at
regular intervals on portions covered during that period. It consisted of objective,
short answer type and the marking was fair. Each centre adopted its own
technique of assessment.
*
The first External examination was very theory oriented and most trainees found it
to be tough. It did not sufficiently examine what the candidates knew and there
was inadequate evaluation of the skills required by them. It was set by medical
college teachers and did not involve field based personnel.
*
The second External Examination was found to be very simple (all will pass). This
was the view of everyone interviewed. It was of the MCQ type.
*
The second examination was held 3-4 months after completion of the training
course. Hence, many candidates did not receive information of the examination on
time, missed their examination and are now losing interest in the scheme also.
*
Evaluation was fair at District level. “Copying” was usually not permitted and the
first test was conducted very well. There was some laxity during second
examination as revealed by the trainers.
*
Results are announced many months after the examination is conducted. This
entails trainee JSRs visiting the centres often to find out whether the results have
been announced. For some, this is expensive and for most, time consuming.
Administration needs to buck up in this regard.
*
The examination tests only theoretical knowledge. No assessment is carried out of
practical skills or applied knowledge. There are no problem solving type of
questions.
*
The question papers (second examination) had to be photocopied at the
examination venues - thousands of pages, expensive, time-consuming, difficult
process. Additionally, leakage chances were very high.
54
5.6 FUNCTIONS OF JSRs
*
None of the JSRs have set up their practice (shop) in areas visited by us.
*
Those providing curative care are old CHWs who were sent for training, two of
whom have their own “clinics”, (injection, IV based with liberal use of antibiotics
of all generations).
*
The Certificates have not yet been distributed; this in spite of exams being
conducted more than a year ago. The delay was for various reasons. Standard
format has now come from Bhopal - the CMO/CEO are to certify. The CEO has
still not signed in many districts.
*
Not one loan has been sanctioned to date to JSRs in areas visited by us.
*
JSRs do help in immunization activities, but their interest is waning.
*
A few JSRs are also referring cases to PHCs and it is likely that once they start
“practising” they will be more helpful to the villagers.
*
In a few places, they have been made depot holders and distribute bleaching
powder/chlorine tablets, ORS packets, etc.
*
The other health preventive and promotive activities to be carried out by them like
chlorination of wells, registration of births and deaths, motivating for family
planning are presently not being performed by JSRs in areas surveyed by us.
5.7 UFEE FOR SERVICE’
*
Except the old CHWs who have now received training, no JSR was found to be
providing curative care.
*
The villagers do agree that they should pay for the service, but JSRs clearly •
expressed that unless they inject, they will not receive any fees and villagers are
reluctant to pay for only consultations or oral medicines and are very used to
receiving “injection treatment” for all their health problems.
*
JSRs lack money/funds to buy any equipment and it is not surprising that they have
not yet started practising.
*
Some trainers doubted whether JSRs can earn enough from their practise as they
basically would be catering to a total population of around 1000-1500 villagers and
competing against “established practitioners”. Hence it can only be a part-time
activity.
55 ’
5.8 SUPERVISION
*
This has been planned in the scheme and mention of it has been made in the manual.
But what was disturbing was the absolute lack of planning/interest in this activity at
Block PHCs with none of the centres having chalked out a programme or given a
thought as to how this will practically be carried out once the JSRs start practising.
*
Presently there is hardly any further contact between the training centre and JSRs once
they have completed their course. Even at village level, there is hardly any contact
between field workers and JSRs.
5.9 ADMINISTRATIVE DETAILS
*
There was very little time between announcement of JSR scheme and its
implementation at block PHC level.
*
A scheme like the JSR scheme that is to be implemented in the whole state needs
adequate lead time for appropriate implementation and also wide-scale publicity to
create awareness. Unfortunately, the scheme was implemented within a very short
period and hardly had any gestation time. Obviously this ruled out any pilot project
which would have allowed for any corrections/changes.
*
The scheme was to be widely publicised through posters, radio, TV and at panchayat
meetings. On enquiring from the villagers in the areas we visited, we realized that no
such activities were carried out. Oral discussions with JSRs revealed that only 3 of
them had heard about the implementation of the scheme on radio and 1 of them had
seen information about the scheme being given on TV. The scheme was implemented
in a hurried manner with inadequate preparation.
*
There is a lot of attrition in transfer of information from state level downwards to
village level. Often the Panchayat leaders were found to be ignorant or having
superficial information about the scheme. This impedes their proper involvement in the
scheme.
*
None of the centres had received the Rs. 5,000/- for training materials that they were
supposed to receive. Kits were not distributed in 90% of the training centres visited.
*
Contingency amount was not released in 81% areas for the first batch training and in
all centres for second batch training.
Hence, it was not possible to make hostel
arrangements or buy audio-visual items for training. This money was also meant to be
disbursed to staff for conducting the training and hence they were also unhappy and
had lost interest in the training process.
*
Stipend was not disbursed in time in most areas. Because of that, many students had
problems. Some received their stipend much after the course was completed. Many
56
from second batch have still not received their last instalment. The trainees had to
make repeated trips to the PHCs to collect the stipend.
*
The loans were to come from TRYSEM which also caters to many other activities and
trainings for other professions. The JSR activities which come under health category
(not a priority area for most) requires the largest amounts under loans and subsidies for
disbursement and often is a casualty for that reason itself It is therefore not surprising
that no loans have been sanctioned to date.
It is likely that the non-disbursement of stipend, contingency and training funds was
due to a multiplicity of factors - lack of funds, low priority in TRYSEM, poor and
delayed work of district health department, excessive bureaucracy and bureaucratic
apathy.
*
Manuals did not reach till quite some time for first batch. The second batch received
it on time.
*
Most CEOs/Panchayat Presidents are not aware of details of scheme implementations
like, loan sanctioning, the amount of subsidy, kit distribution, etc.
*
At present, no department (health or IRDP) has all the details of all the trainees - their
total number district wise, their profiles, the number that have passed, the number who
have applied for loans, etc. This is very important and necessary information specially
for any future review of JSR services.
5.10 SOME CONCERNS
*
Only 3 out of 24 (12.5%) functions of JSRs are curative based. The remaining 21
(87.5%) are preventive / promotive (non renumerative).
*
The certificate to be given to JSRs, does not state that the JSR can “practise” (and
therefore prescribe drugs). This could lead to problems later (the Pharmacy
Association has already raised this issue).
*
Continuing education and institutional support for improving the quality of JSRs by
their constant professional enrichment has not been planned for.
*
The attendance was poor and irregular in some centres. The main reasons were festival time, farm work during certain seasons, long distances to travel, non-receipt of
stipend and therefore no funds for bus tickets, lack of interest and lack of commitment.
*
Loss in terms of numbers - trained JSRs shifting to other fields/professions because
of delay in sanctioning of loans and issuing of certificates to them.
*
Many who failed first external examination have not come back or taken examination
again.
*
Without funds, the JSRs are not able to set up their practice.
57
*
Many in the health department including the trainers are worried that JSRs will cross
their brief, use IV injections, give treatment for diseases for which they do not have
permission or have not received training, use drug combinations in short, practise
“quackery”. Their other fear is once they get busy in their practises, they will not give
any attention to preventive and promotive activities.
*
The scheme defines how the loan money is to be utilised by the JSRs. The planned
breakdown may not always be useful or necessary to all JSRs. Some of them may not
require funds for rent or furniture. They may not require to purchase the amount of
drugs specified. There should be flexibility in the way the loan can be utilised. Also
in many areas, officials are asking for expenditure receipts before they sanction the
loan - an improbable happening - for how is the JSR to obtain the receipt without
paying9 He needs the loan amount to make the payments! Also, the amounts specified
to be spent specially for drugs - requires JSRs to purchase large amounts of drugs which he may not be able to utilize or which he could obtain from the PHC. The
TRYSEM loan mechanism for JSRs thus seems irrational in many areas.
*
No provisions have been made in the scheme for regular contacts between JSRs and
the health system and for refresher courses for JSRs. These activities are very
important for the maintainance of quality of service of JSRs.
58
Vi. REPORT OF THE WORKSHOP OF INTERESTED AND
KEY PARTNERS (SEPTEMBER 1997)
The field study findings and recommendations were presented to a select group of invitees
(Appendix - 7) following which extensive and in-depth discussions were held on various
issues pertaining to the scheme as well as the problem faced in its implementation with the
intention of streamlining its functioning The items discussed ranged from ways to
identify a set of objectives for the JSRs different from that of the MPWs to ways of
legitimizing the entire experiment in the eyes of the medical fraternity who at present look
at it with a certain amount of hostility.
6.1 Objectives and administration
None of the participants had any doubt that under the existing circumstances it s a highly
needed scheme and deserves to be implemented extensively. However, the findings did
reveal that the creation of this new cadre of health workers was not clearly
conceptualized possibly due to the haste in its implementation. There was no clarity
about their roles and responsibilities of the JSRs whether they are the lowest rung of the
Government health hierarchy or the implementors of Government health schemes with a
little bit of a need-based service or independent practitioners or combination of all9
Clarification of this issue is likely to help in the reduction of hostility.
The operational process was also found to be riddled with problems - whether it was
selection, training and certification or logistics of TRYSEM loan and kit supply. Worse,
even though well-outlined in the training manual, there was absolutely no involvement or
concern of any of the involved departments in the planning of future supervision/regulatory
mechanisms or maintenance of regular contacts with the JSRs once they start practicing.
To facilitate better coordination and to streamline its functioning, the group felt that the
programme should be located in the health department The group recommended that
the day to day programme management at the state level is to be guided by a Health
Committee under the leadership of the Commissioner, Health Department. Other members
of the Committee include representatives of:
- the Health Department
-IRDP
- Rajiv Gandhi Mission for the Control of Diarrhoeal Diseases
- Dept, of Women and Child Welfare
- Zilla Panchayat
- UNICEF; and
- representatives of people’s organizations.
At the district level, a district level health management committee consisting of Zilla
Panchayat President, the Chief Executive Officer/Collector, the President of the District
Health Committee and the District Chief Medical Officer (Convenor) will oversee the
functioning of this scheme. The task manager for supervision will be the Joint Director of
the Health Department.
59
It was also decided that the programme objectives will be redefined with new job
responsibilities and defined job charts for key functionaries.
6.2 LINKAGES
Till date, no efforts have been made for inter-sectoral coordination and forming linkages
with related sectors for gainful and appropriate use of available trained manpower (JSRs).
The group recommended that efforts are to be made for consciously engineering linkages
with professional bodies, medical bodies, NGOs and other relevant sectors. The
availability of JSR services will be advertised to other sectors like sanitation, PHED, etc.
and for any services rendered, the organisations will be asked to renumerate JSRs
appropriately. It is hoped that by this, their image as professionals will be enhanced and
would also ensure that they are not dependent on bureaucratic benevolence.
6.3 LOGISTIC SUPPORT
To strengthen the logistic support to the scheme, recommendations for training, finance,
procurement of material, sanction of loans, communication, supervision, etc. and the funds
required for all these activities needs to be reexamined. All efforts should be made by the
State to ensure complete logistic support for the scheme. This support should also include
redesigning of the kit and its timely delivery as well as networking possibilities.
Exhaustive instructional and self-learning material as well as information on networking
with various organizations will also be included in the kit so that the JSRs can refer to
these when in need.
6.4 COMMUNICATION
One of the weakest sectors of the scheme, this will also require a thorough overhauling.
To make the scheme known to a greater audience, detailed information about the scheme
needs to be directly sent to all Zilla Panchayat and Janpad members with a request that
they widely advertise the scheme in all their meetings and functions and during their
contacts with the villagers. A handbook containing all information on JSRs needs to be
prepared for the information of the public. Briefs on their activities should also be
regularly issued in the “Panchayat Gazette”. A certain ambience elevation through
linkages with professional bodies and NGOs needs to be built. Resources for the above
activities can be met through the creation of funds for communication activities at district
level and state level.
All Gram Sabhas, Janpad Panchayats and Zilla Panchayats should be asked to discuss the
JSR scheme, its functions and usefulness to the communities at their meetings so as to
bring widescale awareness. Local communication means like folk music, Kalapathakas,
etc., should also be made use of for advertising the scheme and for informing the public.
The group also recommended that to facilitate constant upgrading of knowledge and skills
of JSRs, NGOs providing free health related literature and information for health workers
be provided with a list of JSRs and their addresses to facilitate direct mailing.
60
6.5 TRAINING
Recognising this as the most important component of the scheme and a very important
factor for its success and also realizing that the training conducted so far was far from
perfect, the group conducted extensive discussions to analyze the problems, find solutions
and suggest ways to improve the overall quality of training.
The training for the first two batches was conducted at the Block PHC / Subcentre. This
was found to be unsatisfactory on various counts and it was decided that training be
conducted at the Pistrict level only. However, as mentioned earlier, this may not be ideal
and satisfactory on all counts. Various suggestions were made by different members
during the group discussions on what would be the ideal method and venue to impart
training to the JSRs. Consensus was difficult. However, keeping in mind the logistics
involved and the problems and inadequacies at Pistrict level / Block PHC level for many
aspects of training, a 4 phase programme based on definite guidelines for different field
levels which can be adopted is outlined below:
SUGGESTED JSR TRAINING METHODOLOGY
TABLE : 26
Nature of training___________________
Problem identification_________________
Community experience________________
Problem evolving_____________________
Community experience and (PRA and final
evaluation)
Phase
Phase I
Phase II
Phase III
Phase IV
Venue______
PTC________
Back in village
PTC________
Back in village
Period
2 months
1 month
2 months
1 month
To determine the contents of training, the group felt that the training needs should first be
determined and the learning objectives should be based on task analysis, knowledge and
skills analysis. For ideal training to be conducted, tutor and learner guides needs to be
provided with all tasks clearly defined in a step-wise fashion. Also, the training needs to
shift from content orientation to process orientation and a balance needs to be achieved
between lectures and skills development, the present system being highly lecture-biased. It
was suggested that adopting a problem-based and integrated approach would be more
suitable for achieving this balance.
At most centres, the trainers were found wanting and this had a direct bearing on (the
poor) quality of training imparted. It was felt that training of trainers should include
training on adult education methods as this requires additional skills. A team of 4 trainers
has been given this training in all districts under RCH programme and their services needs
to be utilised for TOT of JSR scheme.
To encourage more female and tribal applications (for JSRs), efforts need to be made to
provide all necessary facilities like hostels and secure training areas. Further, age limits
should be removed and the education limit reduced to VIII standard pass.
61
The group also suggested that alternative possibilities of training on a turnkey basis should
be investigated. Methods suggested were handing over training to locally capable and
competent NGOs or mission hospitals wherever possible.
The training manual requires many changes as has been mentioned in the findings and
recommendations sections. The group suggested that the task be handed over to a^group
of experts well versed in this activity.
Finally, to enhance the skills and to continuously upgrade the knowledge of JSRs, the
group recommended that regular refresher courses should be arranged for them, preferably
through an Open University.
6-6 CRITERIA FOR RECERTIFICATION
The group recommended that every successful JSR should be instructed to seek
recertification on a periodic basis (preferably every 5 years). This should be made
contingent on:
the approval of her/his continuation as a JSR by the Panchayat
=> having attended at least one refresher course
=> having attended at least 4 Gram Sabha meetings
=> her/his being active and carrying out designated functions.
6-7 SUPERVISION - MONITORING - EVALUATION (SME)
As often happens in many training programmes, once the training is over, all links between
the trainee and the training group snaps, to the detriment of both groups. This is all the
more unfortunate for a scheme like the present one where continuous upgradation of skills
and further honing of acquired skills is so essential. Even though SME is inbuilt into the
scheme, in practice, it is being completely neglected. The group discussed various ways by
which this could be made a reality. Also, to make later evaluations more meaningful, it is
very necessary that qualitative, quantitative and process indicators be evolved right from
the beginning. All health staff should play a role in SME activities, specially the field based
staff. As mentioned earlier, recertification would depend on the JSR attending refresher
courses along with other criteria.
lhe SME component, much underplayed till now, needs not only to be strengthened
immediately, but should also be made an integral part of JSR training and future activities.
6.8 EXAMINATIONS
Since training is being conducted at many centres scattered throughout the State,
conducting a common end-of the course examination posed many hurdles. Bureaucratic
delays further compounded the problems and the declaration of results was unduly
delayed. As mentioned earlier, lack of clarity on their exact status in the health system
resulted in the JSRs being examined in a “very medical and theoretical format” rather than
on the (processes) practical skills and knowledge more appropriate to their field based
functions.
62
*
To overcome all the above mentioned problems, the group recommended that the
conduct of the examination should be handed over to a “professional examination
body” on a turnkey basis. In future, the examination could have a judicious mix of
short answers, MCQs and simulated case studies.
63
Vll.
RECOMMENDATIONS
Various recommendations are given under each heading earlier. Attention is
drawn to them. The most important ones are highlighted once again.
I. OBJECTIVES
1. To achieve the objectives of the scheme, it is necessary to have further
clarification of job responsibilities, functions and functional linkages of
the JSRs.
2. The JSR should ultimately become a resource person in health for the
community under Panchayat supervision
II. ADMINISTRATION
For better coordination and streamlining of the functioning of the scheme,
the programme should be located in the Health Department. There has to
be a health project committee to organise the scheme, with appropriate
representations from all other related sectors
III. SELECTION
1. Every effort should be made to select more female candidates.
1. Widescale and effective publicity should be given to the scheme at
community level specially before selection of trainees.
3. To enhance selection of female candidates, reduce education limit to
VIII standard pass and remove age limits, especially for women and
tribal candidates.
IV. LINKAGES
Develop linkages with all sectors (intra and inter sectoral) at the village
level and at all other levels.
V LOGISTIC SUPPORT
Adequate and timely availability offunds for the smooth functioning of
the scheme should be assured.
64
VI. COMMUNICATION
Communication about the scheme should be enhanced at all levels
• village
• panchayats
• taluk
• district
• inter and intra departmental
Use appropriate, effective, local media.
VII. TRAINING
1. The venue(s)
of training should be suitable for
problem
identification, community experience, problem solving and other
relevant aspects of training should be given their due consideration.
2. Learning objectives for each function of JSR should be clearly defined.
The training should shift from content orientation to process
orientation using integrated and problem based approach.
3. The training manual needs to be rewritten, rectifying the various
lacunae pointed out keeping in mind the level of trainees and the
knowledge and skills required for their effective functioning.
4. Regular refresher courses and continuing education preferably through
an open University should be arranged ( distance learning modules
approach supported by contact workshops).
5. To facilitate more female and tribal applications, all necessary
supportive facilities including hostels should be provided
I. CRITERIA FOR CERTIFICATION
Recertification on a periodic basis (preferably every 5 years) by health
trainers contingent on defined criterias should be made mandatory and
linked to continuing education (see ¥11-4 above)
II. SUPERVISION - MONITORING - EVALUATION (SME)
1. The SME component much underplayed till now needs to be
strengthened and made an integral part of JSR training and future
activities. Even though JSR will be under Panchayat, technical
65
li
supportive supervision can be built into scheme linked to the health
training/health centres.
2. To make later evaluations more meaningful, qualitative and
quantitative indicators to measure process and impact need to be
evolved and data for these indicators collected in collaboration with
JSRs, Panchayats and the PHC Health team.
X. EXAMINATIONS
1. The conduct of the examination should be handed over to independent
professional examination bodies on a turnkey basis (this could be a
credible NGO trainer or a medical college PSM department, etc.)
2. The examination should assess process (practical skills) and knowledge
by a judicious mix of short answers, MCQs and simulated case studies.
3. To reduce wastage in training effort and to enable candidates, who had
failed in the earlier examinations, short courses should be conducted to
help them pass subsequent examinations.
Xl.CORE PROJECT TEAM
A core project team should be formed who will train the trainers, monitor
the JSRs in the field, ascertain feedback from JSRs, community
representative and PHC health teams and continuously innovate and
introduce improvements in the scheme.
XW.PEER SUPPORT
The Core Project team should be supported by a peer group of trainers
from government and non govermnent backgrounds who are training in the
Hindi belt and who will form a supportive network - sharing experiences
and innovations and helping in the constant reorientation of the training
process and manual, to enhance their relevance and impact.
66
BIBLIOGRAPHY
1. Jana Swasthya Rakshak - Parishisht 1 (Hindi Booklet)
2. Jana Swasthya Rakshak Manual (Hindi)
Jana Swasthya Samiti Prashikshan Module (Hindi)
4. Manual for Community Health Worker, Ministry of Health and Family Welfare, New
Delhi, 1978
5. JSR Examination I - Prashan Patra - One and Two (Hindi)
6. JSR Examination II - Prashan Patra - One and Two (Hindi)
7. Standard Project for sanction of loan under IRDP for Jana Swasthya Manual Personal Communication
8. Ashtekar, Sham, 1997 - Comments on JSR Scheme - September 1997.
9. Ulhas, Jajoo, 1997 - Personal Communication, September 1997.
10. Bhargava, Ashok, 1997 - Comments on the Manual - September 1997.
11. Phadke, Anant, 1997 - Some critical comments on the overall structure of the JSR
Manual.
12. Shukla, Abhay, 1997 - Comments on Jan Swasthya Rakshak.
13. Mankad, Dhruv, 1997 - Personal Communication.
14. Bang, Abhay, 1997- Personal Communication.
15. Chatterjee, Prabir, 1997 - Comments on JSR Manual.
16. IDEAL, 1995, How to Develop a training programme with special reference to
grassroot health workers (Hindi Handout)
17. IDEAL, 1996, How to Develop Health Education programmes (Hindi Handout)
18. Health Monitor, 1994 & 1995, FRHS.
19. Central Bureau of Health Intelligence, 1985 - compendum of Recommendations of
various committees on Health and Development (1943-75)
20. Srivastava Report, 1974, GOI - Health Services and Medical Education
programme for immediate Action.
A
21. ICSSR/ICMR, 1981 - Health For All - an Alternative strategy.
67
22. Ministry of Health & Family Welfare, GOI, (1982) - National Health Policy.
23. National Institute of Health & Family Welfare (1983) - An Evaluation of Community
Health Workers Scheme - A collaborative study, Technical Report No.4.
24. Pachauri, Saroj (Ed), 1994 - Reaching India’s Poor : Non governmental approaches to
Community Health, SAGE, 1994.
25. World Federation of Public Health Associations (1983) - Training Community Health
Workers : information for action (issue paper).
26. Ashtekar Sham & Ashtekar Ratna (1995) - Diagnostic Aids for first contact care in
villages, Bharat Vaidyaka Sanstha Publication.
27. Ashtekar Sham, Mankad Dhruv, Damle Archana, Kanade Savita - A profile of
Community Health workers in VACHAN project - a CDRD, Pune, Report.
28. CHC (1991) - Education Policy for Health Sciences : A Community Health Trainers
Dialogue.
68
APPENDIX - 1
NATUIUL REG11ONS AND CHARACTERllSTllCS
Regions
No. of
districts
Sample District
1. Western
15
Dhar, Vidisha
♦ High migration to Urban;
♦ Large scale of tribal displacement
2. Maha Koshal
09
Hosangabad
♦ Dry land fanning
♦ Predominantly tribal
♦ Migration during lean period
3. Chambal
05
Bhind
♦ Caste tensions
♦ Social oppression
♦ Feudalism
4. Bundel Kliand
05
5. Baghel Kliand
04
Rewa
♦ Heavy industrialisation
♦ Displacement of tribals
♦ Unskilled labourers
6. Chhattisgarh
07
Bilaspur
♦ Highly tribal population
♦ Land holding highly skewed
I
Characteristics
♦ Land ownership highly skewed
♦ IMR highest in the State
S’
8K
69
J
APPENDIX - 2
District Profile and Regional Disparities in Madhya Pradesh
State/District
Total
Population
Percen
tage of
Rural
Popula
tion
Rural
Female
Literacy
Rate
Total (Rural &
Urban)
Rural
SC
ST
SR
CBR
TFR
(1984-90)
(1984-90)
Madhya Pradesh
66,181,170
50.842.333
15,338.837
28.85
19.73
58.92
14.55
14.80
15.72
23.27
28.82
4.87
931
943
893
37.2
5.0
76.82
Morena
Bhind **
Gwalior
1.359,632
967,857
582,163
79.48
79.40
41.21
14.88
23.55
16.46
19,87
22.17
23.84
6,83
0.15
5.23
826
813
818
41.2
6,0
5.8
4.7
Datia_____
Shivpuri
Guna_____
Tikamgarh
Chhatarpur
Panna_____
Sagar_____
Damoh
Satna_____
Rewa **
Shahdol
Sidhi
Mandsaur
Ratlam
Ujjain
Shajapur
Dewas
Jhabua
Dhar **
Indore
West Nimar
East Nimar
Rajgarh
Vidisha **
Bhopal
Senor_____
Raisen
Betul
307,352
960,907
1,054,741
781,815
934,552
598,378
1.166,357
735,203
1,176,220
1,318,172
1,375,673
1,284,586
1,195,939
662,151
836,403
850,362
766,147
1,032,325
1,187,702
561,397
1,722,871
1,037,491
825,926
775,303
270,677
690,025
738,645
961,551
77,55
84.81
80,50
83.10
80,70
86,98
70.79
81.86
80.27
84.77
78,89
93.53
76.90
68.13
60.47
82,30
74,11
91,32
86.86
30.58
84.95
72,47
83,19
79.90
16,08
9.36
10,12
15.39
14,12
14,85
26,83
23.52
22,19
22.81
12.85
11,40
19.88
13.94
13.76
13.58
16,20
6,83
15.64
22.53
17.58
21,04
9.46
19.54
15.15
15,07
20.45
26.71
27.23
19,87
18.80
23,42
25,11
20.97
21.47
20.14
18.23
15.38
7,20
11.52
17.35
15,19
30.25
24,64
19,55
2.79
6.85
19,82
9.76
12.26
18,70
21.68
21,68
21.73
17.56
9.58
1.95
12,78
14,03
4.60
4,45
16,39
11,33
14,76
16,05
13.56
54,26
31,99
5,69
32,72
2,60
2,68
18,50
91,14
59.45
12,09
53,00
36,09
3,68
5.23
4,26
11,53
16,37
44.58
840
848
875
868
855
901
884
908
929
946
961
934
951
956
936
920
933
983
960
919
956
940
927
872
873
901
884
981
39,5
42,6
41.4
42,1
42,6
42.2
39.6
40,1
40.7
40.9
39,3
44.3
33,5
35,2
32.1
36.6
37,0
45,4
37.2
29.6
38,4
38,5
37,7
40.1
32,5
41.2
39.1
39.0
Total
Rural
Urban
Districts
20,03
82,01
84,28
81.38
39.0
35.1
70 o'
5,8
6,3
5,9
6,1
6,6
5.9
5,5
5,3
5,7
5.8
5,3
6,7
4,1
4,6
4.2
5,1
5,0
7,0
5.1
3.6
5,3
5,2
5.3
5.6
3,8
6,0
5,3
5.6
L
Particulars
Hoshangabad * *
Jabalpur
Narsimhapur
Mandla_____
Chhindwara
Seoni
Balghat
Surguja
Bilaspur
Raigarh
Rajnandgaon
Durg______
Raipur_____
Bastar
X *
Total
Population
920,695
1.443,501
663,708
1,192,213
1,206,351
906,024
1,236,083
1,831,471
3,148,763
1,559,232
1,213,184
1,551,734
3,136,420
2,109,431
Rural
%
Female
Literacy
Rate
Rural
72.66
54,47
84,50
92,33
76,90
90,53
90,50
87,94
83.00
90,53
84,25
64,73
80,26
92.87
SC - Scheduled Caste
ST - Scheduled Tribe
TFR - Total Fertility Rate
26.32
26,06
36,55
18,57
23,58
27,14
36,27
12,50
20.92
23,48
22,24
33,01
24,40
11.79
Total (Rural &
Urban)
Rural
SC
16.84
12,50
17,10
4,98
11,38
10,81
8,19
5,09
19.12
11,13
9,64
13,51
15,06
5.51
SR - Sex Ratio
ST
22.20
28,04
14.37
64,87
42,10
40,16
23,16
59,22
26.33
51,16
28,84
16,05
21,58
71.17
SR
904
939
915
993
967
980
1,009
969
990
1,009
1,021
1,010
1,007
1,007
CBR
TFR
(1984-90)
(1984-90)
38.0
34,1
34,6
36,5
37,0
35,7
32,8
38,2
36.7
32,5
36,2
33,6
34,4
35.9
5.4
4.2
4,6
5,0
5,3
5,0
4,2
5,3
5.0
4,3
5,0
4,2
4,6
5.0
CBR - Crude Birth Rate
* * Districts visited by Study team
Source : Health Monitor 1994 & 1995 (FRHS)
71
APPENDIX
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APPENDIX
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73
Appendix - 5a
3
HEALTH SERVICES
AND
MEDICAL
EDUCATION
— a programme for immediate action
REPORT OF THE GROUP ON
MEDICAL EDUCATION
AND
SUPPORT MANPOWER
!
79
COMPOSITION OF THE GROUP ON MEDICAL
EDUCATION AND SUPPORT MANPOWER
Dr. J.B. Shrivastav,
Director General of Health Services.
Chairman
Dr. C. Gopalan,
Director-General,
Indian Council of Medical Research,
New Delhi.
Member
Prof. V. Ramalingaswami,
Director,
All India Institute of Medical
Sciences, New Delhi.
- do -
Dr. P. N. Chuttani,
Director,
Post-Graduate Institute of
Medical Education & Research,
Chandigarh.
- do -
Shri J. P. Naik,
Member-Secretary,
Indian Council of Social Science
Research, New Delhi.
- do -
Shri C.R. Krishnamurthi,
Director,
Ministry of Health and Family Planning,
- do -
Dr. Sharad Kumar,
Deputy Director General of Health
Services (Medical).
Member-Secretary
tn
80
i
da
CHAPTER
HEALTH SERVICES AND PERSONNEL IN
THE COMMUNITY
The first assistance that any community needs in the form of health
4.01
services should be provided within the community itself.
For some of these services, it is necessary to provide paid and
4.02
‘ iin public service. Some other services may be pro
t trained professionals
vided by fully trained professionals who are self-employed. It is, however,
erroneous to assume that these services should be provided only by these two
categories of professional staff. At the community level, what is needed most
is not professional Expertise so much as nearness to the community, its
confidence, emotional rapport with the people, willingness to assist, low cost,
and capacity to spare the needed time. It is, therefore, necessary that some
of these services should be provided by the members of the family itself and
also by part-time trained para-professional persons who operate on a self
employment basis. Even in societies which are affluent enough to provide all
health services through fully-trained professional persons, either in public
service or in self-employment, it is now becoming increasingly evident that
the quality of life and of the health services will improve through the introduc
tion of suitably trained part-time para-professional persons working on a
self-employment basis. For developing countries whose resources are
extremely limited, this method of providing health services is not only desirable
but also inescapable.
4. 03
It may be recalled that, in the past, almost all health services used
to be provided by part-time para-professional persons from the community
itselfwhoworkedonaself-employment basis. The practitioner of indigenous systems
of medicine trained in a family tradition or the village dais who still perform the
bulk of deliveries are instances of this practice. While the advantages of the
11
31
system, such as its closeness to the community or low cost, are obvious, its
main weakness lies in the fact that the training provided is limited and unrelated
to modern developments in the medical and health sciences so that it often leads
to quackery. The modern system which employs only the fully trained persons
on a professional basis is no doubt very competent from a technical point of
viewr. But it lacks some of the emotional, psychological and social advantages
of the traditional system and is so costly that we will not be able to universalize
it. What is necessary,therefore,is to combine the good features of both the
systems. If we carefully select the individuals and train them, according to
the best knowledge and skills made available by the latest developments in
medical and health sciences, a large number of people from the community
itself would be available for providing the elementary health and medical
services needed by the community. Such a programme would serve three
important purposes: (1) It would create an agency w-hich is close to the
people, has their confidence and is economical to operate, for providing
the immediate, simple and day-to-day medical and health services needed
by the community; (2) it wall also create the foundation on which a superstru
cture of fully-trained and professional referral services can be advantageou
sly built; and (3) it would have created a pattern of medical and health
services which would be qualitatively better than the present system and
still remain within the financial resources that are likely to be available in
the near future.
4. 04
Various steps will have to be taken to organise the large number of
para-professionals who will be needed in every community to provide the
first essential, simple and oay-to-day health and medical services. Aptitude
for such work is often developed within the family itself through participation
in the provision of such services or in attending upon sick persons. This
motivation would have to be strengthened further through the education system
which should provide a core of health education to every student and also
require him, as a part of work-experience or social service, to nurse sick
persons in his own family or outside and also to participate in the development
of services of a promotive or preventive character. This w'ill enable a large
number of individuals to discover their own interests and aptitudes. Many of
them may later become para-professionals by acquiring the specialised
skills necessary and operate on a part-time self-employment basis or become
full-time professionals within or outside the public services.
4. 05
It would also not be proper to regulate the number of such workers.
Such a step would lead to the creation of a scarcity and monopoly situation
with well-known adverse consequences. It should, on the other hand, be open
to any individual with the necessary aptitude, background and talent to acquire
the necessary skills and to provide the services. In fact, the more such
trained people in a community, the better for all concerned.
4.06
In every community, we should have trained local, semi-professional,
12
82
J
part-time workers of at least the following categories
(1)
An adequate number of dais to provide maternity services
(some of them could also be trained to provide the whole range of MCH
services including family planning).
)
A large number of family planning workers from among adults,
(2)
and public functionaries.
L
young men, house-wives
(3)
Persons who will be able to dispense a set of specific remedies
selected from all systems of medicine for ordinary , common ailments.
(4)
Persons who have been trained in the skills needed in programmes
for the control of communicable diseases and whose services can be harnesse
readily in case of emergencies.
(5)
Persons who can help to develop promotional and preventive
health activities (especially those relating to improved
mental sanitation, control of common diseases, yoga, physical exerc
so on).
4 07
These skills
could be
to selected^young
selected young persons
skills could
be imparted
imparted to
persons from the
community who may have the necessary aptitudes. One important group wmc
may be (-------x ----- L
remotest rural
now number about 2.5 million and are Present even
whotave" considerable acceptability and status in the community.
areas aimportant group would be that of educated housewives. An mcreasAnother
is now becoming available even in rural areas
ing pool of educated women
(the census of 1971 records 1.5 million women in rural areas who are
enumerated as housewives or non -workers but who are educated up to matricua large and useful pool for the training of
lation and beyond) and these form
UM"
tor toMr P^S-
TOrkers’ “
b<!
pointed out, need not necessarily be multipurpose.
4. 08
We would like to emphasize the point that periodical retraining of
these personnel is extremely important as well as to provide them wit
necessary guidance and counselling in their day-to-day work. The referral
services should also be made available to them. In fact they should be
looked upon as important links between the community and the trained pro
fessionals and the organized referral services.
4. 09
This emphasis on the creation of a large band of semi-pro
fessional and part-time health workers in the community itself is propose
merely as a second-level supplementary personnel to fully-trained
professionals and not as a substitute for them. Where doctors or other
personnel trained in indigenous or modern system of medicine are
13
33
L 1
available, their services should be fully utilised, not only to provide health
care to the people in the way best suited to each case, but also to train
(or retrain) and assist other workers, honorary or part-time, of a semiprofessional character. We visualize that these two cadres would work
closely together in an integrated fashion, the para-professional personnel
in the community relieving the trained professionals of the innumerable
small things over which their time would otherwise be wasted and the
trained professionals taking over the more complicated cases direct and
also providing referral and guidance services to the para-professional
people. '
4.10
It would not be desirable to try to convert these para-pro
fessional workers into a cadre, to give them remuneration from State
funds or to supervise them. This will alienate them from the people
and convert them into petty bureaucrats with all their faults. The general
policy should be to leave them free to work with the community on the
basis of the trust and confidence they can generate. The investment of
the State in the organization of this group of para-professionals within the
commxmity should be limited to the provision of training and retraining,
free of cost, on as large a scale as possible and to the provision of
guidance and counselling through health w’orkers, the proposed health
assistants and doctors. Where necessary, the State should make supplies
of materials (such as specified remedies) available at reasonable prices
and on an assured basis. The overall financial investment on all thes e
items would be comparatively small; but the returns therefrom would be
far greater.
4.11
These proposals might perhaps cause an adverse reaction in
certain quarters on the ground that they would create, and let loose on the
community’, a large number of quacks who, in the long run, may do more
harm than good. But a close examination will show that this will not be
the case. The role assigned to these para-professional functionaries in
the fields of promotive or preventive aspects of health and family planning
are basically educational and are capable of doing immense good without
any untoward implications. Some apprehensions may arise with regard
to the role in curative aspects of health. But here, as we have emphasized,
their function will be limited to the use of a few specified remedies for
simple, day-to-day illnesses. There are also several safeguards in these
proposals such as careful selection, provision of training and retraining,
guidance and counselling and also periodical evaluation. Care has also
been taken to ensure that they supplement the work of the professionals
and not work in conflict or in competition with them. AU things consi
dered, w'e share no apprehensions on the subject and actually feel
enthusiastic about most features of the scheme. ;
4.12
The details of several problems will have to be worked out before
14
84
j
the scheme becomes operational.
For instance, we will have to decide upon
selection criteria for workers;
the duration and content of their training and retraining,
the provision of guidance and counselling, including
periodical evaluation,
the preparation of materials for these personnel in simple
terms and in all the Indian languages, and
determination of the institutions where their training^etc.,
will be conducted, including the training for the trainers.
We recommend that these details should be worked out by the
Director General of Health Services, once the programme is accepted in
principle by Government.
4.13
It is obvious that the. scheme cannot immediately be started all
over the country. Similarly, it would also be futile to start it in a few areas
only.. What is needed is a fairly large beginning and a fairly rapid generaliza
tion in the light of the experience gained which should be evaluated
continuously. We^ the refer e^ recommend that
(1)
All the details of the scheme should be worked out by the
Director General of Health Services as early as possible;
(2)
After early consultations with the States, the scheme should
be finalized quickly and at any rate before the end of the current year;
(3)
The necessary financial provisions for the scheme should
be made in the Central and State budgets for 1976-77 as a centrally-sponsored
scheme of the Fifth Five Year Plan;
(4)
The work of the scheme should begin in selected areas in each
State/Union Territory in 1976-77; and
(5)
The scheme should be expanded to cover a fairly large part
of the country by the end of the Fifth Plan and the entire country by the end
of the Sixth Plan.
These bands of community-level health workers, once created,
4.14
will form the links between the people at large and the multipurpose
workers functioning at the sub-centres and the doctors at the PHC level.
This will make a much better utilization of their time and energy possible.
15
85
I
Their training should,therefore,be adequate to ensure that, while they can
freely offer services within a well-defined sphere of simple, urgent and
day-to-day needs of the community, they would be able to decide when a
case needs referral or consultancy from trained professional staff and
take action accordingly without hesitation or delay.
15
86
Appendix - 5b
Manual for
Community Health Worker
Ministry of Health and Family Welfare, New Delhi
87
FOREWORD
On 2nd October. 1977 a massive programme was launched by the Government of
India for the delivery of health care in the rural areas through Community Health
Workers. These workers are selected by the people of the community to which they
belong.jind they serve a population of about 1,000. They are trained to educate the
people in the villages as to how to keep healthy and how to prevent disease by taking the
necessary- immunizations, drinking safe waler, eating nutritious and clean food, mainlin
ing personal and environmental hygiene, and utilizing the available services for maternal
and child health, family planning and medical care.
Each Community Health Worker is provided with a kit containing a few simple
medicines so that he or she can give immediate treatment for common minor ailments
and provide first aid before referring the sick or injured to the Subcentre or Primary
Health Centre for medical care.
The Manual for the Community Health Worker is meant to serve as a guide and
reference book for the Community Health Workers, to enable them to carry out the tasks
which they have been trained to perform. It contains chapters on maternal and child
health, family planning, nutrition and the control of communicable diseases including
immunization and environmental sanitation. It also contains chapters on rendering first
aid to the injured and simple treatment of minor ailments.
Our country has a wealth of knowledge in various traditional systems of medicine,
and chapters on these systems have also been included in the Manual, so that in those
areas where indigenous systems of medicine are popular, the Community Health Workers
can be trained to use these traditional remedies.
The second edition of this Manual has incorporated suggestions received from
several individuals and institutioijs. It also contains two additional chapters on
Naturopathy and Medicinal Plants which, it is hoped, the Community Health Workers
will find useful.
In the task of promoting and maintaining the health of our people, it is necessary'
for the Community Health Workers and the Government Health Workers to coordinate
their efforts and to develop a deep sense of dedication to the community which they serve.
W'e have great expectations from the Community Health Workers and feel sure
that they will serve as an important link in the chain of delivery of health care to our
people.
New Delhi
October 2. 1978
(RAJESHWAR PRASAD)
Secretary to the Government of India
Ministry of Health and Family Welfare
Activities of Community Health Worker
Note: A Community Health Worker will be expected to cover the population of a village or.
if the village is a large one, a population of about 1,000. He/she will receive technical guidance from
the Health Worker (Male/Female).
After training, the Community Health Worker will be able to carry out the following
activities:
i.
Malaria
1.1 Identify fever cases.
1.2 Make thick and thin blood films of all fever cases.
13 Send the slides for laboratory examination.
1.4 Administer presumptive treatment to fever cases. ■
1.5 Keep a record of the persons given presumptive treatment.
1.6 Inform the Health Worker (Male) of the names and addresses of cases from whom blood
slides have been taken.
1.7 Assist the Health Worker (Male) and the spraying teams in spraying and larvicidal
operations.
1.8 Educate the community on how to prevent malaria.
2.
Smallpox
2.1 Identify cases of fever with rash and report them to the Health Worket (Male).
2.2 Inform the Health Worker of infants aged zero to one year requiring primary vaccination
as follows:
2.2.1 In the intensive area inform the Health Worker (Female).
2.2.2 In the twilight area inform the Health Worker (Male).
2.3 Assist the Health Worker (Male/Female) in arranging for primary’ vaccination.
2.4 Follow up cases who have been given primary vaccination.
2.5 Educate the community about the importance of primary vaccination.
3.
Communicable diseases
3.1 Inform the Health Worker (Male) immediately an epidemic occurs in his/her area.
3.2 Take immediate precautions to limit the spread of disease.
3.3 Educate the community about the prevention and control of communicable diseases.
4.
Environmental sanitation and personal hygiene
4.1 Chlorinate drinking water sources at regular intervals.
4.2 Keep a record of the number of wells chlorinated.
4.3 Assist the Health Worker (Male) in arranging for the construction of the following:
4.3.1 Soakage pits
4.3.2 Kitchen gardens
4.3.3 Compost pits
4.3.4 Sanitary latrines
4.3.5 Smokeless chulhas.
4.4 Educate the community about the following:
4.4.1 Safe drinking water
4.4.2 Hygienic methods of disposal of liquid waste
4.4.3 Hygienic methods of disposal of solid waste
4.4.4 Home sanitation
4.4.5 Kitchen gardens
89
0.2
MANUAL LOR COMMUNITY HEALTH WORKER
4.4.6 Advantages and use of sanitary latrines
4.4.7 Advantages of smokeless chulhas
4.4.8 Food hygiene
4.4.9 Control of insects, rodents and stray dogs.
4.5 Educate the community about the importance of personal hygiene.
5.
Immunization
5.1 Assist the Health Worker (Male/Female) in arranging for immunization.
5.2 Educate the community about immunization against diphtheria, whooping cough,
tetanus, smallpox, tuberculosis, poliomyelitis, cholera and typhoid.
6.
Family planning
6.1 Spread the message of family planning to the couples in his/her area and educate them
about the desirability of the small family norm.
6.2 Educate the people about the methods of family planning which are available.
6.3 Act as a depot holder, distribute nirodh to the couples, and maintain the necessary
records of nirodh distributed.
6.4 Inform the Health Worker (Male/Female) of those couples who are willing to accept a
family planning method so that he/she can make the necessary arrangements.
6.5 Educate the community about the availability of services for Medical Termination of
Pregnancy (MTP).
7.
Maternal and child care
7.1 Advise pregnant women to consult the Health Worker (Female) or the trained dai for
prenatal, natal and postnatal care.
7.2 Advise pregnant women to get immunized against tetanus.
7.3 Educate the community about the availability of maternal and child care services and
encourage them to utilize the facilities.
7.4 Educate the community about how to keep mothers and children healthy.
8.
Nutrition
8.1 Identify cases with signs and symptoms of malnutrition among pre-school children
(birth to five years) and refer them to the Health Worker (Male/Female).
8.2 Identify cases with signs and symptoms of anaemia in pregnant and nursing women and
children and refer them to the Health Worker (Male/Female) for treatment.
8.3 Assist the Health Worker (Male/Female) in administering vitamin A solution as
prescribed to children from one to five years of age.
8.4 Teach families about the importance of breast feeding and the introduction of
supplementary weaning foods.
8.5 Educate the community about nutritious diets foi pregnant and nursing women.
9.
X'ital events
9.1 Report all births and deaths in his/her area to the Health Worker (Male).
9.2 Educate the community about the importance of registering all births and deaths.
10.
First aid in emergencies
10.1 Give emergency first aid for the following conditions, refer these cases to the Primary
Health Centre as necessary and inform the Health Worker (Male/Female).
10.1.1 Drowning
10.1.2 Electricshock
10.1.3 Heat stroke
10.1.4 Snakebite
90
activu ies or COMMUNITY health worker
10.1.5 Scorpion sting
10.1.6 Insect stings
10.1.7 Dog bite
10.1.8 Accidents.
10.2 Carr}- out procedures in dealing with accidents.
10.3 Keep a record of first aid given to each patient.
11.
Treatment of minor ailments
11.1 Give simple treatment for the following signs and symptoms and refer cases beyond
his/her competence to the Subcentre or Primary Health Centre:
11.1.1 Fever
11.1.2 Headache
11.1.3 Backache and pain in the joints
11.1.4 Cough and cold
11.1.5 Diarrhoea .
11.1.6 Vomiting
11.1.7 Pain in the abdomen
11.1.8 Constipation
11.1.9 Toothache
11.1.10 Earache
11.1.11 Sore eyes
11.1.12 Boils, abscesses and ulcers
11.1.13 Scabies and ringworm.
11.2 Keep a record of the treatment given to each patient.
12.
Mental health
12.1 Recognize signs and symptoms of mental illness and refer these cases to the Health
Worker (Male/Female).
12.2 Give immediate assistance in emergencies associated with mental illness
12.3 Educate the community about mental illness.
91
ACKNOWLEDGEMENTS
This Manual has been the joint endeavour of several institutions and individuals,
especially the Central Training Institutes and the various departments of the Ministry of
Hea th and Family Welfare. The final draft was prepared by the,Manual Cell of the Rural
Health Division in the Ministry of Health and Family Welfare, assisted by Dr J Galea
W HO Public Health Officer, and Miss K. Ase, WHO Public Health Nurse, under WHO
Project HMD-006.
This second edition of the Manual includes changes and additional chapters or
sections suggested by programme officers of this Ministry as well as by other individuals
and institutions. We are especially grateful to Dr. Shanti Ghosh, Head of the Department
ot Pediatrics, Safdarjang Hospital, and the Director General, Indian Council of Medical
Research, for their valuable suggestions. We would also like to acknowledge with thanks
the assistance of Dr. B. Venkat Rao, Nature Cure Hospital, Hyderabad, in the
preparation of the chapter on Nature Cure, and of Dr. K.N. Udupa, Professor of Surgery
and Director, Professor S. N. Tripathi, Head of the Department of Kayachikitsa, and
Dr. C.M. Tewan, of Banaras Hindu University, in the preparation of the chapter on
Medicinal Plants.
The illustrations for this Manual were prepared by the National Institute of Health
and Family Welfare, and by the artist provided by the UNICEF.
The UNICEF has provided the financial assistance for the printing of this edition
and of the previous edition of this Manual.
New Delhi
October?, 1978
(C.R. KRISHNAMURTHI)
Joint SecretaryMinistry of Health and Family Welfare
CONTENTS
Activities of Community Health Worker
I
Chapter 1
MALARIA
Identification. Thick and thin blood films. Despatch of slides. Presumptive
treatment. Records. Informing Health Worker (Male) of cases. Assistance in
spraying and larviciding operations. Health education.
chapter 2
SMALLPOX
Identification. Arranging for primary vaccination. Follow-up. Health education.
Chapter 3
COMMUNICABLE DISEASES
Informing Health Worker (Male) about epidemics. Precautions to limit spread.
Health education. Tuberculosis. Leprosy.
Chapter 4
ENVIRONMENTAL SANITATION AND PERSONAL
HYGIENE
Chlorination of drinking water sources. Records of wells chlorinated. Assistance in
constructing soakage pits, kitchen gardens, compost pits, sanitary latrines, smokeless
chulhas. Health education (safe drinking water, disposal of liquid and solid wastes,
home sanitation, kitchen gardens, sanitary latrines.smokelesschulhas. food hygiene,
control of insects, rodents and stray dogs). Personal hygiene.
Chapter 5
IMMUNIZATION
Arranging for immunization. Health education (diphtheria, whooping cough,
tetanus, smallpox, tuberculosis, poliomyelitis, cholera, typhoid).
Chapter 6
FAMILY PLANNING
Need for small families. Methods of family planning (IUD, oral contraceptives,
foam tablets, jellies and creams, rhythm method, tubectomy, nirodh. withdrawal,
vasectomy). Responsibilities of depot Holden. Informing Health Worker about
cases desiring a family planning method. Medical Termination of Pregnancy.
Chapter 7
MATERNAL AND CHILD CARE
Prenatal, natal and postnatal care. Tetanus toxoid in pregnancy. Facilities for MCH
services. Health education.
Chapter 8
NUTRITION
Identification of malnutrition. Treatment of anaemia. Administration of vitamin A
in children. Breast feeding and supplementary weaning foods. Nutritious diets for
mothers and children.
Chapter 9
VITAL EVENTS
Reporting births and deaths. Importance of registration of births and deaths.
Chapter 10
first aid in emergencies
-
Drowning. Electric shock. Heatstroke. Snake bite. Scorpion sting.
«li. Insect sting. Dog
bite. Accidents (wounds, sprains and dislocations, fractures,, bums and scalds),
Procedures in dealing with accidents (splints, bandaging, treatment of shock.
control of bleeding).
Chapter 11
TREATMENT OF MINOR AILMENTS
Fever. Headache. Backache and pain in the joints. Cough and cold. Diarrhoea.
Vomiting. Pain in the abdomen. Constipation. Toothache. Earache. Sore eyes.
Boils, abscesses and ulcers. Scabies and ringworm. Records.
Appendix 11.1
Guide for the'Use and Administration of Drugs
Appendix 11.2
Contents of Kit for Community Health Worker
Chapter 12
MENTAL HEALTH
Recognition of mental illness. Emergencies. Mental health education.
93
AYURVEDA
Chapter 13
Diet. Sleep. Spiritual life. Seasonal Conduct. Social Conduct. Ayurvedic treatment
for common ailments: Fever. Cough. Vomiting. Diarrhoea. Indigestion. Constipa
tion. Pain in abdomen. Joint pain. Backache. Headache. Skin diseases. Boils and
abscesses. Burns and scalds. Cuts and scratches. Dog bite. Snake bite. Insect bite.
Scorpion sting. Lice. Bleeding. Eye trouble. Earache. Toothache. Wounds. Sprains.
Appendix 13.1
Guide for the Use and Administration of Ayurvedic Drugs
Chapter 14
YOGA FOR HEALTH
Asanas. Pranayama.
UNANI MEDICINE
Chapter 15
Six Essentials for health. Fever. Sunstroke. Cold. Cough. Vomiting. Diarrhoea.
Indigestion. Constipation. Joint pain. Backache. Headache. Scabies. Ringworm.
Boils and abscesses. Burns and scalds. Cuts and scratches. Dog bite. Snake bite.
Insect sting. Scorpion sting. Lice. Bleeding. Eye trouble. Earache. Toothache.
Sprain. Wounds.
Appendix 15.1
Guide for the Use and Administration of Unani Drugs
Chapter 16
SIDDHA
Personal hygiene and health. Diet. Sleep. Mental health. Seasonal conduct. Social
conduct. Siddha treatment for common ailments: Fever. Cough. Vomiting. Pain in
the abdomen. Diarrhoea. Constipation. Joint pains. Worms. Skin diseases. Bums
and scalds. Cuts and scratches. Toothache. Earache. Dog bite. Snake bite. Sore eyes.
Boilsand abscesses. Backache. Headache. Indigestion. Wounds. Sprains. Difficulty
in breathing.
Appendix 16.1
Guide for the Use and Administration of Siddha Drugs
Chapter 17
HOMOEOPATHY
Introduction.. Preparation, handling and storage of homoeopathic medicines.
Administration of medicines. Regimen during homoeopathic treatment. Referral
and records. Homoeopathic treatment for common ailments: Fever. Headache.
Backache. Joint pains. Diarrhoea. Cold. Cough. Vomiting. Pain in the abdomen.
Indigestion. Constipation. Earache. Sore eyes. Toothache. Boils and abscesses.
Ulcers. Scabies. Ringworm. Bums and scalds. Wounds. Sprains. Dog bite. Scorpion* ■
sting and insect stings. Snake bite. Lice.
Appendix 17.1
Homoeopathic Medicines to be Carried by Community
Health Worker
Appendix 17.2
Guide for the Use and Administration of Homoeopathic
Drugs for External Use
Chapter 18
NATUROPATHY
'
Chapter 19
Introduction. General rules for maintenance of health. Routine programme for
prevention of disease. Causes of disease. Regimen for preventing diseases: Diet.
Fasting,\Panchabhootas. Physical work’. Prayer. General methods for treatment of
diseases: Enema, Mud pack, Bath. Some diseases and their treatment: Indigestion,
Cough, Fever, Influenza, Dysentery. Diarrhoea, Constipation, Common cold,
Headache.
MEDICINAL PLANTS
Introduction. Ajamoda. Amalaki. Ardraka. Bhringaraja. Bilva. Brahmi/Mandukaparni. Dhanyaka. Eranda. Guduchi. Haridra. Haritaki. Kantakari. Lashuna Maha
nimbu. Maricha. Musta. Nimba. Puddinah. Tulasi. Vasa.
94
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I
APPENDIX §.9
Review of JSR Scheme (Govt, Of Madhya Pradesh)
0heck-1ist to assess working JSR’s activities (JSR)
Certificate
1. Certificate
2. Manual
Yes
Yes
Available
Available
No
No
I
I
II. Drugs
Name of drug
In stock beginning
(June 1997)________
Used
June
in
Added
June
in
Stock as
of 30/6/97
1) Chloroquine_____
2) Cotrimoxazole
3) Analgin_______
4) ORS powder
5) Iron & Folic Acid
6) Paracetamol_____
7) Avil
8) Decadron______
9) Condoms______
10) Oral pills
11) Neosporin powder
12) Gauze bandage
13) Savlon_______ _
14) Chlorine tablets
rrr.Patients' Illness Register:
1. Maintained
Yes
/ No
2. Total No. Consulted:
< -1
1-5
M F
M F
6-14 15-20 >21
M F M F M F
3. Diseases seen (details)
4. Total No. Of Illnesses : Total No.
Of Correct PX according to DiagasS5'
5. Total No. Referred :
104
IV. Birth Register
Yes
1. Maintained
2. No. of Births
No
/
months)
(in
:
3. Delivery Conducted at:
4. Who Delivered?
ANM
TBA
Dai
JSR
5. Any difficulty during delivery ?
6. Weight of baby :
2.5 kgs
2-2.5 kgs
< 2 kgs
V. Death Register
Yes
1. Maintained
2.
SI.No
Age at Death_____
No
/
3.
Age (years)
Cause of death
----- Cause-----
4. Health personnel consulted before death:
105
■'[■7. Marriage Register :
1. Maintained
Yes
/
No
2. No. of Marriages
■Vli. Antenatal Register
No
Yes /
1. Maintained
2. Total No.
3. No. being appropriately managed:
^Hl. Eligible Couple Register
No
1. Maintained :
Yes /
2. No. of Couples on register:
3. No. adopting temporary measures :
4. No. adopting permanent measures :
AA". Chlorination
(In one week)
1. No. of wells in the village
2. No. chlorinated
:
:
X Immunization Register:
1. Maintained :
Yes
2. Total No. of Children
3. No. immunized on time
I
No
XI. Growth Chart Register
No
Yes I
1. Maintained :
2. No. Of Children :
3. No. Whose charts are maintained correctly :
106
I.
appendix ,6D
Community Members (CM -1)
Review of Jan Swasthya Rakshak Scheme
(Govt. Of Madhya Pradesh)
July • August 1997
Issues to be discussed in group discussion with Community Members
Name of village:
Name of sub-centre:
Name of PHC:
District::
A1.
What are the major problems in your village?
A2.
What are your main health problems?
A. General
1. Are you aware of the JSR Scheme?
2. How did you come to know about it?
3. What is the JSR Scheme?'
4. Do you know who is the JSR selected for your village?
5. Were you consulted in his/her selection?
6. Is there a health committee in your village?
7. Does it meet regularly?
107
B. Functions of JSR
1. What in your opinion are the objectives of the scheme?
2. (a) What are the main responsibilities/functions of the JSR?
(b) Out of these, which functions does the JSR of your village do?
i
3. Is there any additional activity that you would like him to do?
(a) Do you think that the JSR has received adequate training to take care of
your common health needs?
4. For which conditions wouldkjo to him?
5. Name some conditions for which you would not go to him but go to see
somebody else.
6. Do you feel comfortable discussing your problems with the JSR?
7. Can you contact (get) your JSR easily?
8. Are you satisfied with his examination, services and treatment?
(a) If not, give reasons:
9. Are you satisfied with his approach/behaviour?
(a) If not, give reasons:
10. Did he give you medicines or did you have to purchase it from elsewhere?
11. How much does he commonly charge?
12. Do you think this is reasonable?
108
13. Would you recommend the services of JSR to others’ in your village?
14. Does the village committee supervise his work?
15. Suggest means by which the quality of.services given by the JSRs can be
improved.
16. Do you think that the village should pay some remuneration to JSR for
(preventive/promotive and other such work) chlorination, helping build
latrines, soakage pit, fever slides, etc...?
17. Has the JSR Scheme decreased your inconveniences in obtaining health
care?
18. Do you think that the Government should implement this scheme in every
village?
109
APPENDIX
6E
Community Leader (CL-1)
Review of Jan Swasthya Rakshak Scheme
(Govt. Of Madhya Pradesh)
6
July-August 1997
e
Issues to be discussed in individual/group discussion with community leaders
Name of viHaae:
Name of Sub-centre:
Name of PHC:
District:
A. What are your main health problems?
Villaae Health Committee
1. Is there a village committee (or similar mechanism for collective decision-making)
for commumty’s health and .health related affairs?
Yes/No
2. Is this committee statutory?
Yes/No
3. Does the JSFt member attend this committee Yes/No
4. If yes, what is his status in the committee? (E.g. Secretary, treasurer, member,
etc.)
no
5. What are the functions of this committee?
c
- Deciding on priorities for local health action.
- Mobilizing local resources for health activities
- Obtaining outside resources for local health activities
- Planning, implementing and supervising health activities
. - employing village health workers
- Supervising non-technical aspects of JSR’s work
- Effectively dealing with emergency health situations.
6. How often does the health committee meet?
/.
What was discussed in the last meeting?
8. Are minutes of the committee meeting maintained?
9. Are there any other committees in the village?
10. If yes, please give their names:
Ill
/
About JSR
o
1. How did you become aware of the JSR Scheme?
2. Do you know the objectives of the JSR Scheme?
3. How was the JSR selected?
4. Were you involved in his selection?
Yes
/
No
5. Were you satisfied with the selection process?
Yes
/
No
6. According to you, what are the main functions of the JSR?
7. What functions does the JSR of your village carry out?
8. Are you satisfied with his work?
(b) If no, specify why
Yes
/
No
9. Does the village health committee supervise the functions of JSR? Yes
/No
10. Has the JSR scheme helped in reducing community health problems? Yes / No
11. Do you think health workers’ needs to be encouraged in the performance of non
health activities (Environmental, water, etc..)?
Yes /
No
12. If yes, give details on how this should be done?
13. After completing his course, and before starting his activities, did the JSR come
to meet the village leaders?
Yes /
No
14. (a) Do you believe in the competence of JSR for treating common ailments?
Yes /
No
(b) If no, specify why : -
15. Give suggestions -for improving the functioning of the JSR Scheme.
112
APPENDIX 6F
Review of Jan Swasthya Rakshak Scheme
(Govt, of Madhya Pradesh)
July - August 1997
Issues to be discussed with senior Govt. Functionaries (DHO, etc.) and officers incharge of Scheme at Bhopal
1. What is your opinion of the objectives of the scheme?
2. Do you agree with the functions envisaged of the JSR?
3. Do you think that the curriculum is adequate and appropriate?
4. Are you comfortable with his training level?
o. Are you comfortable with the way their training was carried out?
6. What is your opinion about the acceptability of the JSR in the village?
7. In your opinion, in what ways will the JSR’s activities improve the health
conditions of the community members?
8? What according to you are the reasons for such a high failure rate?
9. Any suggestions for improving the functioning of the scheme?
113
APPENDIX - 6.G
Review of Jan Swasthya Rakshak Scheme
Govt, of Madhya Pradesh
July ■ August 1997
Issues to be discussed with trainers
Name of PHC:
Name of District:
A. General
1. What do you feel are the objectives of the JSR Scheme?
2. What are your expectations from the JSR Scheme?
3. What are your expectations from the JSRs?
4. What are the common health problems in which JSR can play a role?
5. How would you rate the functioning of the JSRs who are already working?
(a) very good (b) good (c) fair (d) poor (e) very poor
6. Do these JSRs refer cases beyond their skills in time?
7. Do you receive case referrals from JSRs which they could have managed?
8. Do the JSRs cooperate and help you in your activities in their villages?
9. Do you think the villagers are happy with the functioning of the scheme?
10. Do you have any worries regarding the scheme?
11. Any suggestions for improving the functioning of the JSR Scheme?
114
TR- 2
B. Training Process
1. Did you receive any training to become a trainer for this scheme?
2. Is there a schedule to be followed for training?
o.
Were you given any additional resources for conducting this training?
4. Was training assessed by anybody?
5. How was the training conducted (method)?
6. Will training be followed up through regular supervision system?
7. Will JSR performance be monitored?
8. Is there an adequate supply of training manuals?
9. Does training manual cover all locally prevalent health problems which can be
managed by JSR?
10. Does the training manual contents respect local customs/cuiture?
11.1s the material in the training manual appropriate for the work envisaged from
JSRs?
12. If no, give details/suggestions on how the manual can be improved?
13. What audio-visual aids did you use during the training process?
14. Do you think curriculum for the JSR's in adequate and appropriate
15. What according to you are the reasons for the high failure rate of JSRs?
16. Any suggestions for improving training process?
115
TR-3
C. Supervision Process
1. Do you supervise the activities |i]&a.ctiyJiies of the JSRs?
2. Is there a schedule/plan for supervision of JSRs?
3. Is it a necessary part of JSR training?
4. How often do you conduct supervision?
5. What activities do you supervise when you meet the JSR in his village?
6. What methods of supervision do you adopt?
7. Are there any written check-lists for evaluating the performance of JSRs?
8. Do you train/demonstrate any technical skills to the JSR during supervision?
9. Do you maintain a record of supervisory and follow-up activities?
116
APPENDIX-7
16th September, 1997
Ref: CMC: JSR/97
Fax. No: 0755-563623
Dr. Y.N. Mathur, Project ofiiccr, UNICEF, E-l/191, Arora Colony, Bhopal - 462 016,
Madhya Pradesh.
of JAN S^ASTIF/A SAKSIBJV SCHEME - SOVT. OF M.P.
DATE
18- 19 SEPTEMBER 1997
VENUE
Conference Hall, Manipal Hospital, Airport Road,
Bangalore - 560 017.
ORGANISED BY
Community Health Cell and Associates.
CONTACT PERSON
:
Dr. Pankaj Mehta, H.O.D, Community Health Department,
Manipal Hospital (3 : 5266441 - Extn. 270)
PROGRAMME
13th September 1997
(Thursday)
Session I
Chairperson:
Dr. C.M. Francis, Consultant, Planning
& Management, CHC_________
Introduction
of CHC / Participants
9.30 a.m. - 10.0 a.m.
and
Welcome
participants
10.00 a.m. - 10.15 a.m.
The Review Process - An Overview
10.15 a.m. - 10.30 a.m.
Background to the introduction of JSR Mr. R. Gopalakrishnan,
Secretary to Chief Minister,
Scheme
Govt, of Madhya Pradesh.
10.30 a.m. - 11.15 a.m.
Presentation of Review Findings
Dr. Ravi Narayan, CHC
Dr. Pankaj Mehta
Mr. As Mohammad
117
11.15 a.in. - 11.30 a.in.
11.30 a.m. - 1.00 p.m.
I 1.00 p.m. - ] .45 p.m.
- COFIT E -
Discussions on the evaluation report
Participants
-LDNCHSession II
Chairperson : Dr. D.K. Srinivasa,
Consultant. Rajiv Gandhi University of
Health Sciences
1.45 p.m. - 3.00 p.m.
Presentation
on
other
voluntary Invited
trainers
from
sector/Govt. experience in the provision Voluntary'
sector/Govt.
of rural health care through voluntary projects.
health workers and their training process
3.00 p.m. - 3.30 p.m.
3.30 p.m. - 4.30 p.m.
- TEA Implications of these experiences for the Participants
JSR Scheme
19th September 1997
(Friday)
9.15 a.m. - 9.45 a.m.
9.45 a.m. - 10.45 a.m.
10.45 a.m. - 11.00 a.m.
Session 111
Review of Day One / process for Day Participants
Two
Group discussions on modifications Chairperson Rapporteurs for
required in the implementation of JSR Groups 1 and 2 will be
scheme:
chosen by the group
Group 1 : Selection, training, evaluation
Group 2 : Supervision, Administration,
other issues
- COFFEE Session IV
Chairperson: Mr. R. Gopalakrishnan,
Secretary to Chief Minister, Govt, of
Madhya Pradesh.
11.00 a.m.- 12.30 p.m.
Presentation of Reports and discussion
on them.
12.30 p.m. - 1.30 p.m.
The JSR scheme : The Way Ahead
1.30 p.m.
A summing up
- LUisCH 118
APPENDIX - 8A
JSR Examination : June 1996 Paper No. 1
Duration 2 hrs.
Max. Marks 200
1.
2.
3.
Number of bones in human body
What is clavicle
What is stomach
4. What is aorta
5. Types of muscles
6. Functions of skin
7. What is prostate
8. Functions of skin
9. What is blood pressure
10. Functions of small intestine
11. Functions of kidney
12. What is protein, fat & carbohydrate
13. What is ORS
14. Drugs used in malaria
15. What are oral pills
16. What is iron & folic acid
17. What is the use of savalon
18. What is the use of paracetamol
19. Use of gauze bandage
20. Function of heart
21. Why is post-mortem conducted
22. What are symptoms of death by hanging
23. How is a case of drowning treated
24. Symptoms & signs of poisonous snake bite
25. What should JSR do in case of epidemic outbreak
26. First aid for dog bite
27. Name the National Health Programmes
28. What advise should JSR give to a TB case
29. What is compost pit
30. Advise to be given to parents of malnourished children
31. Records to be maintained by JSR
32. What is sanitary latrine
33. What is birth & death rate
34. How to chlorinate a well
35. What is filaria
36. Name four viral diseases spread by air
37. Name diseases spread by contaminated water
38. Precautions to be observed while making blood films
39. Symptoms & signs of leprosy
40. Symptoms & signs of tuberculosis
41. Precautions to be observed for drinking tank/pond water
42. Name four contagious diseases
43. What is dengue fever
44. Way for safe disposal of garbage
45. What is tuberculin test
46. What is use of bleaching powder
47. Name four diseases spread by mosquitoes
48. Contraindications for use of oral pills
49. Functions of liver
50. Name three causes ofjoint pains.
119
APPENDIX - SB
JSR Examination June 1996 Paper No.2, Duration 2 Hrs. Max. Marks 200
1. Causes of toothache
2. What is dental caries
3. Treatment of toothache
4. Symptoms & signs of typhoid
5. Treatment of leprosy
6. When to refer a case of headache to PHC
7. Causes of gastroenteritis
8. What are the signs of shock
9. What are the causes of abdominal pain
10. First aid for wet bums
11. Causes of earache
12. Causes of deafness
13. Treatment of foreign body in ear
14. Cause of nasal bleeding
15. What are the main causes of cough
16. Causes of blindness in India
17. What is cataract and how is it treated
18. What to do immediately after an eye injury
19. Howto diagnose conjunctivitis
20. How to treat dust/foreign body in eye
21. What is the main objective of Blindness Control Programme
22. How can you help in Eye Camps
23. How to prevent nutritional blindness
24. What is refractory' error
25. Give dosage schedule for Vitamin A administration
26. How will you treat pneumonia in a child
27. How will you treat diarrhoea in a child
28. What is polio
29. How to prevent polio
30. Which are the vaccine preventable diseases
31. Main causes of cough in children
32. What is the first food for a new bom
33. How to diagnose malnutrition in children
34. What is the responsibility of JSR for safe motherhood
35. Cause of anaemia in pregnancy
36. What are the problems during pregnancy and after delivery
37. Advantages of small family size
38. Where are female sterilization services available
39. Symptoms and signs of gonorrhoea
40. What is AIDS
41. How is AIDS transmitted and how to prevent it
42. Uses of Cu T
43. How will you look after a new bom
44. Reasons for population increase in India
45. First aid for sprain
46. Treatment of sun stroke
47. How & when to use splints
48. Symptoms & signs ofjoint pains
49. First aid for head injury'
50. ;iJSR will meet the community’ needs”, describe in your words.
120
£J2£IlIIILLX__=i_SC
(paper 1: See annexure Sab)
Analysis of JSR Examination Questions against
topics in JSR Manual
Chapter
Topics in Manual
No .
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11 .
12.
13.
14.
15.
16.
17.
18.
19.
20.
21 .
22.
Responsiblities of J5R
Working with Community
Anatomy and Physiology
Disease Transmission
Environment Hygiene and
personal habits
Malaria
Tuberculosis
Typhoid/Dengu/Filaria
Leprosy
Eradication of Blindness
S.T.D
Family Welfare
Safe Motherhood
Care of Newborn
Significant Diseases of
Childhood
Immunisation
Child Growth and Development
Nutrtion/Malnutrition
Examination of Patient
Treatment of Minor Illness
First Aid in Emergency
Documentation/Recording
JSR
Exam I
JSR
Exam II
1%
1%
13%
3%
0.5%
0.5%
8.5%
4.5%
6%
2.5%
4.5%
3.1%
2.1%
2.5%
5.0%
4.5%
11.5%
7.5%
5.0%
qo/
O
/o
4%
3%
c. '(>
7%
3%
5%
6%
1%
9.5%
8.0%
1.5%
7.0%
1.1%
6.5%
4.0%
0.5%
6%
2%
n o.-
O'O
1%
10%
15%
2%
*
97%
100%
*----
*21, 22 Postmortem ?
* 27 National Health Programme ?
- Dr. A.R. Sreedhara,
CHC.
121
APPENDIX - 9 (Paper i;
-1
WI- 2 w
$^3j^-200
i.
41 ■’d d^ild Id ^311 D 3h {<41
d-d I chid
:
A — WP^d
lid
^l^dld d? ITTd qFT4 did I
B — PHJ pp] ITjd dRqli dP-H'-'l dlddH rddlp-dd did I
C — Rd HI RPTT dt TlddlP did! Rd ii HI’d <41 HI (I, J'Jddl dT 3 did
D — dMild Pdt
2.
dd RdTpd i^Td, RdlPd dd Rd RlH^W dT fep HTq 4<d d PII :
A — RdTPd fidiTT dd RdPd dHI d RUd dldHd iddI
B — VdW Hd ill Hid RdTPP dftrfd d RIcRdf dT dftdR dcdld dFf
C _ idl'd dT RdTPd dl4dH UH^Idl lid 3Hdt dTdT did
□ _ 3Wd RTdt
3.
ddldl
ehH cbH-TT ? :
A — ^l<l<
cHHI
B — dHHH Pi^fad
C —
M|-dHI
D — d M <1 Th ^r^t
cH ychl^l TT cFTR-UT
4.
<^4HI t ■
A _ fadll44
B — fadlftH
C _ fadlfad ?
5.
qilT PTVW [chdd HTq
?Tcft ? :
A—
B — 3T4fe^E
C D — dM{lrh ^pft
6.
eil$4ci oFni WI
A —
fepr ^TPTIHHT t:
3F<(
B — fn?
C -
Tf
D_
(i)
122
7.
Slifellg if fchriHl
iTcft ? :
A -
B C - cfh
8.
^TT^fr^KT WT? :
A -• W^if
B - ’5?Hit
C - 3raT?if
9.
^TTg fchdd M cbK eH ^rrT ?
A —
B — ’Hdd
C - mf
0 _
10.
UPsh’Mlfdch
WR
feR WT if <^cidl ? :
A — 3W7T4
B —
C - w?t 3#a
D - ^T3W
11.
3"fr STTcTl^Tzt 3Ti?T TF
?Tdt t:
A — W
B — 7W
mrRfe^T^Mt ?
12.
A - ^f
B - sm
C—
13.
Utst 3TT?T cFt
^cidl t
:
B — ^HT 3TFT ^TWIT t
Q
D — <3M<I vb
^tf ^(4
t
(2)
123
14.
WR HrTT ? :
RenfTd lyr^T Rch fafe if [chdHl
A - 20
B - 30 RK
C - 40 RR
D - 50 ^R
fcb’MI R ^RT-R 3RT RRT eRT ? :
15.
A - Tp
B c - wt
D - RRT
16.
R^RUT R TvF
^tR-R W
3RH ? :
A — RR^ W
B — el lei d-Ri
C - RTRf
D _ cFt^ Rt R^f
R?R (RvF rTHT)
17.
<dMcb<U|
R fcH^ll ^Idl ? :
A — 41 HI Jdl Id Hl Hl d<
B — ebPHlHHIHld<
C — WRR7
D — RR^ Rf H q !
18.
RTRRRH: Hfeeil dH RRTW R RRReft feRRT ^tRT t ’
A - RR
B - Rt
C - RtR
D - RR
19.
■ferr
cHt MlW 31TO (<4^.4
t'
A
■qr^^r^IH
B — Hl4^ P4H
c — TvFTRR Weft
20.
VRtl
<IHIUI feR WR Mgrid ? :
A — WRTR
B — ^dRH Reft R
C — M'dHH 31 jl) R
D _ RHtR
(3)
124
21.
RrTRt TBit
(U^’d)
A — R Jll R
B —
^HT 3TT^V^ ? '
qW
Q)
(FTd)
C — ^ld M (Uj
D - RRT
22.
R^rrfr tbt
wr ?:
A — wn
RRR H
B — K^rir
C —
D _ RRR
23.
H
IdHlciRsd
^tdT ? :
A —
B — Mlki^l
C —
cEt dlHKl
D _
24.
IdMfdfed R
eJImO c^dNj (Schili7^l) TT
t’
A — ZlfRlfg
B — n'lki'Mi
C — <^<1
Tt Old4
35.
TRT^k-KT t:
A — MlfcHi
B - ihn
c—
D 26.
M)c£| ^TRT TUT ^T-TTT t:
^fu?T
A —
RrTR
B —
C D — WWI
27.
^tr
it
inr
t•
A — fwftRT
B — STTcTW
C
<|^|cb
D _ HdR^I
(4)
125
^h£icMU| fct.tjl ^TTFTr 6 :
28.
A _ cKd l<H q?f wfl TT
B — c^flRq
tl
C — Midi <5'Jld cF{
D _
29.
UcH W (0.5
cRdHH
TT
cfe( Ml^T
TcH«*4f
Id I ? :
A — 50 dk<
B - 5 cte<
C - 20
D - 100 W<
30.
HldWd:
fchdd 377 aHINd 3T35I Slcid ? :
A —
317
B - 7rW3Ii^3R
C — 37? H
3R
D -
31.
cblcrl TT ^T-HTil
1! ^>ddi
itn
WT
t:
A — WTWFTI
B — wfw
Q _ ctidMK
D — HT^lfs
32.
alHRl KtHT t:
cKUdcHl
A - tsn
B - zt.4t.
c—
D33.
3?l"7-ii 7(3 Lndld^ f *
A — dl^l^
B — 4(3^1
C — ^PdTIK
D - 77*4?
34.
cFT^ 37 ch 16^1 77 3^-771773 ^Idl
A — 3177^ tnr (<4)d)
B — 3^77
C — <gxjidl
□ _ 3ai3fe (f^ftfiTU)
(5)
126
35.
eftfir RR ^!dOR ^7 cTlHlO HR R7TT RR :
A _ yrra HTH RiRH W R R^J RH R
B - HTRH HRH RTRH HTR R R2I UH R
C — URH
RU RTR RRH R
D _ 3MO Th RUi
<14II 4 chid-ebld TT RT^TUT
36.
:
< 3THi
A — ch'-W-Tl
B - W^^Tc^inT
C — ^WRePHRT WRT STH;
D — 3 M{|
37.
r4i
<JcF <de4t<h RWRd HclR’Ml TW
cb??l<lcbJlH
fcbddl Wit ^T rlife^HSO felTL iftO
A — IRW
B — RT Wi
C — RR WT
D — RR Jlld!
38.
id rTR gT^ 3? 3"^
^t fchddi wn ^TT
mAR'UI
cKdRlcHH (150 fcri.)
:
a B C - 7^
D - 3IT*ft
39.
8RT R ^iTRlfid ddRoi TW o? HT fchdd
era? ^THT
:
A — MfdRH RTRfRR cT^
B — ot RTRRFR
C — TTW R
RT
D — W^R^ERR
40.
cRdl<|<K?H
fed aTTeTt UR STR RHT SOd^ch t •
A — <1R oWl <3ldl
H
B — ROT UHfRRIT H R
C - 0-1 ^fnrfRTTHR
O — dMOThRH
(6)
127
41.
^t.TTer.w. fb3chi4 Hferr
h^u h <m^i<3
yX _
^4T H H^jR 34 <didl ?
B — 3T3R 44 Rj^4 3RT 3 4TW 33^ 3T34 3344
C — 4417 34 H fe^cH 41 33jR WT 3T3 ?
D - 41r4T
42.
4<cTR eft iq(Ud fHdd T{ cRTT cb!<c4:
A —
Rrh ^rfi 4RH!
B — WT
qp HFTRI
Q — cTHT eRd 34 TcF Rfl RHHT
Q _ <RT cR^ 34 TvE Rft dHHI R4 cK1I<|Rkh 44 Jildf 34T
on thrift fen
43.
tt wt ?:
A —
B — HI ^1 q cfd IR 4^1 d^i < J d 1R4U
C _ HI$=bl4^dlR44 rnft
— dl -ll 4-4 ch M
44.
WRTT^iwI:
5RTTnfr(3tA)
A B — Hl <4 044
C D — dldHH dld-HI^
45.
ddld'R 15 ^r^T^tut
4^3444 dnRl 3<dcb ^RTHcrSJ^T^TcT t;
^13 F"
^Idl
^’ifr-3>’*ft 753 3TTHT t W 33T cPiat | 3417 WHT W 3?T ^7 3TT^nrTT^ I 3^
RiHkdfajd 44feF 3I4R1 33
t•
A — 5^3 443
B - 3T4:W(34T)
C D — d'-Rlvh H 37? '4T 744
^H-HT
46.
^t ^idl :
B — R^i^TlRn
C — ^I’UlIRli'dld
D — ddHI^facH
(7)
128
VI.
3T.3T. 33 414 l<l 47 333 W 4? fel 3T3 3 333 3Tf34 ^TdT t:
A — 3341^14
B — 334334
C - 3331
D - 33
48.
3,4T. 33 414 HI o-, 1 3T3 ch 33^ 373 34 4 Th rid ch I q333T ? :
A — 33447334
B — 3433
C — 4333 47 313
D — ^4 47 313
49.
3T^3T^3 33 4 i 4 i fl 3134 733 3 33T g :
A - 33
B — 333
50.
73^3774133 4? ^'-141< 7 433-37 tjdi£
3T3T ? •
A — TWlfeR
B —
44IH4H
c - 333
D — 4;id[$H4dl4ltf
51.
4)1 <ui 4<n t:
(31 fey| 3^7)
A — fw^t^iwr)
B — TKW
c — vsTMiuj, (^IchilRqi)
D — m<4IcTi (M<mi^d)
52.
(STfern^TT337) 4?t 114)4iq 3)
337-TT
33(31 fcg:
A — 3W 3 4313 3^3 33 33
B — 3437 31713 341^ 3T fe^314
C — 43 Pi31<4 44133 47 333
D — <sM <1 vh 33T
53.
33 34)144) 33
:
A — 3qI
B — 3313
(8)
129
54.
fanfcdfea 3 7T 33H-KT 343 TBT 33 clgHTT 6 :
r\ _ 333 34 31^ HldI 31 did 43 34 33T
B - 3T3T 34 4J3 353 33 3433 4 333
Q _ 333T33 3T 33 33
□ _ 334T3 33
55.
343 43 34313 3 ^73 ? :
A — 413
B — Jldd
56.
1343 333 3 343 43 31 ^did <33 33133 (6 W 4T 4333) 3ddf t •
A — Hl 444433
B — H<rd44Tld<l
C _ 3HT3T
57.
343 443 34 $dld 3? 3T4T3 3qT 4433 3lf^:
A _ mR^k
B — ^333 4
C — 333W4
58.
3T3^T 3^3
3T3?3 3? 37^1 chl<U|
f:
A — 333Tf43
B — ^44 33
C _ fadiRn 3 3133
D — <34(13 33
59.
33 eng nl^dl 33 60 3f 31 374-33 33
437 3g7 33 fe T13 f^T dd<4i3 3 737?
373T gTU 33 fedl^r 34 3g 3H^I Hgt 37^, 333t 3m3 3T 3ddl 41^ igTsTT^ <? 4gT 37 I dWl
3 37^ dI!d31 37 3gt 37, 34t 333-477 473 g7 47337 ? :
B —
C _ sfe^T <4^Hu|
D — fadlfad
34 3441
STBsT 37 f34T 33 3 3T<<R*I3 33?T3T3t ? :
60.
A — 3ll43
B - 33T3
C - 4fe3^
D _ 4T3 3
(9)
130
37 W3i 3H 3fte K
61
?RTT t:
A - WT
B — *lda
62.
J4iid<4lfe< 3? 3WR H H3T 32 fa3 Id f^3T ^131 ? :
A - W
B - Wd
63.
A — tlfi
B - ^RTd
64.
^fe^Rrulkd ^rr ^3 stwt wtwr cRJRif u^ihi wt? .A — wr
B — WRT
65.
cjfedm 33 d3di3 3W d4IM
37 33 3F 743c?l ? :
A — 71 q!
B — 4idd
66.
sfhj 3JM 3R cTlq|<) 3? 3^n-Tr HgTUT ? :
A —
H dldl
^dd
B — W W3 3HT
C — <1 dHi H
d'ldd 4 d^d'lSh
D — 3W3T{Mt
67.
Oifidl
3TRJ 3TH
:
A — ^IRT
B — ^FtelRT
C —
TT
D - TrMT
69.
^dl3 3?T <^141?! 37T 33T ^dld t •
A _ hijirii44I 800
B — 3dl<l3dl4
C — MilfaldIHId
D - W
(io)
131
70.
3RT ? :
cRRT^feTT cET
A — oFWWWd
B —
C — UdidNH
71.
$i<4
fen ej|HI-Tl if fen :
TRd
A — WR
B — felHlfedl
C D - RR
7^
Trfecft WT RT nTRRTHcTlHlfl
chi<u| 3RR WRI
cKT RT
R4 pFT
RWHTT^fr? :
A — ’HqI
B — Jldd
73.
<rRTPIKR V7
:
A — Wf
B — JMa
74.
^j^TT
:
A - chleiuj
B - '-IHI'JJ
C _ Rmnj
75.
^r gTi^ri ferr rr ^ddi t ‘U SWRr RR <4R<£ £RT
A — M^PHd
B _ ^RpR RfR 3TT 7R cR R
C — ^Tbfad WT
D — <JM<lrb TfMt
fifTTJ 3TT
T^JT 1^) ?t MTRT
76.
|:
A-W
B - ;;;
77.
■Q^n ^f a) ill Pl fen chi<ui ifedi |:
A — 7TR feR RR <sib) R
B — fefe R
TI
c — :gR4fen
D — ^fefad Rfe
(H)
132
78.
TRzferr cfe? 4? 777J[ 447 ? :
A — cIRdi Tn 4<4d{ ij 37cR
B — 777 37 if Rd Io T7 77 4 fel
C — 7R7R IddlHH 7 4747 377777 7 W 377477717
D _ 441
79.
7T
7? 377 zf 47T TT 771 fed HI 3fe ?HT 4Tfe<:
A — Tn 77
B - 7177
c _ 7H77
D _ rfe 77
SO.
if ynfife) uR^dn ferr 37 if ?TdT ?:
A - 9^ 10
B - 11 TT 13
C - 15 18
D - 18 £ 21
81.
clScbl if ^nRRcb tiRcidd fen 37 if KTrTT £ :
A - 9 it 10^1
B - Wit 12 77
C - 13 it 15 77
D - 18 it 21 74
82.
fe? fer (nfer?) ^7 74T7741 •
A — did 7TRT
B — ^I'JjTTHT
C —
7TRT
D —
n 77^ 4
83.
1^14 (SJTrfr) 77 471777 ? :
A _ nfen (3fe) 4TF7
B _ ^TferfefdTTHT
c _ WHTH fefr 47T3T
D -W
84.
Nrfe W Rhdd fe7 (TTTTfe) ffetfd t •
A — Tn
B - 71
C - TH
D - 7R
(12)
133
85.
4 ^cf fed Hl ■'fl fedT WT ? :
WFRT^ ^11 fed I o? IjQ)
A -
20
B —
28
C - W30
D 10
86.
Trafeirsra difedT to
TO?fr ?:
A — dP^di fe'o fdd'idd
infedl
dim
B — Kidl^d-.d
’d MRddH
c — W-! 'J1 ■’TH ^11 d d I dd ddrfdd -A:
D - ATsfefe
87.
TOffedA 61 fed? ffer TOT A faeAd fe fefr dlfe:
A — TAAdld feZIdl ATZR W d Kl
B — n'r fe a/efraz at fentt
C — fez AT few fe ^NARiH
D - Zfe
88.
Zlfern AT dTdldl TO TOTR ZT cTlZH ZMit^d fed R zfe I fed AT feifedA ■‘fifed') A
fTO AT fefe gTi fe TOT TT TO ft {Id A •'llfedi AT AAZ cF
cT 3TT^
3TT? <Hcl fed TJR
TsTH AT dZfel
d<fel fe
TOT I 3TO 3ZT ATT TOTq TO fe MlgdRI A
A — TTTOfefeferT
B —
Rh ZT eft I
C — TOTO fe fe
D — Adxdl^d fATZTfer
89.
ildfeo AT Midldl Z ZTlfe fe 3TJUR J?lfedT Tfet ^TA AZ dt l fel dT? dA fe ;dd
fer A gTT^T AAr A AT A? HT fez H ART TO A? fee 3TTO fe dRd 3TTAT STlfe ^T fe
ddf AZ 3TN AA ZTd $fr:
A — dA fefr ffefe zfe Z^ fe
feft AT ffer Z AZ
B—
fe AT fe 3TO A fe AT feft fet Ad A
C — fen WTT nt fe AZ d TO fefe A? 7TA fe A TO ATT fed fez
feft TTOTZTA AT
D — fe TO fefe
90.
Zfefe AT d{dIcfl ft ZA TO HA ftdftd ftfedT ZTO 1
dlgdl t fe 3Tfe TO feATT
zfe I feftftdA ft fed*) AT HA fez A? ffe ffe ft- ZJA AZ :
ch CM IU | dd d? dldH dRT ’
A — fen fen at fezi wr fer ftr zfet ffe zr
B — WW A fed fe
C — Wfe fe fe AT
D — TTATOT^dTd
(13)
134
*4 fed I oH 3RQWT
91.
W cM3Ml
g:
A £3 — JI d d
92.
cbP-K-ZT ddH cn
3HUW
oRB -difei^:
A — 7^ d kl I o' 34 <{
B — ZT d'-di q 34<<
C —
93.
d \d 1 c-
34 < <
BlWul tlfefe^id'Jl if WR-BT d4IH
cRd fehrd FBRT dB? *1? 5TB13 ch Id T^di t:
A — 6 RR
B — 1
FRF
c - 3^CIB
94.
fZTTST
RcT 4H THT EFT eflHHJ TF^FT 3FT <BT
WH ? :
A — W7
B — ZBd
95.
■QcF fent?T
<4U<H1 fchddl ^Tt fetTT
BoTcTT ? :
A —
B
3H^qR
C —
cRERZ d
96.
3-1 fey H Q) fdli ffed4 fcRT 3^ Bid Id R ^Tcff oFFTT V^TT ? :
^cTh £RT 4 fed i
A — BETF fBT ^TW
FRf t:
B — BRfZZ^Tq
C — BBfed
D — Wfa
97.
WT d(4ci<) 31I^H 3? fedMI^I
W
34WTB 4 ^cff T^TT R^TT t:
A — wr
B - BZRT
98.
^<JT WT
?TP?f
^4 4 ^IshNj 3THT
:
A - ^t •
B - ZF
(14)
• 135
99.
if fTO’ if H feH-fe^T3Ei
cbTLR-^t dJlH
A — 3T?TR WIq it
B —
^TT
;
if *IT^T
HqI^KI if
^T5T STRT^ TvE ^FH
C —
n
D - ftMt
R<^HI
1()(). HclfcHil^rf
fFT^^TF-FTT WI dM<4vh
?:
A -’
B — 3fenw(uRFiwi
C - fTO*I i
(15)
136
cd
S.
v3ca7
3.
'Jodx
P.
\3cdx
V.
Vcd\
1
D
26
A
51
A
76
A
D
27
C
52
D
77
ID
3
D
28
D
53
A
78
D
4
B
29
C
54
D
79
C
5
D
30
B
55
A
80
B
6
B
31
B
56
B
81
C
7
B
32
C
57
A
82
B
8
B
3J
D
58
D
83
D
9
C
34
A
59
A
84
A
10
B
35
D
60
B
85
B
11
A
36
D
61
B
86
A
12
B
37
D
62
A
87
D
13
D
38
C
63
B
88
B
14
C
39
A
64
A
89
B
15
D
40
A
65
A
90
A
16
A
41
D
66
D
91
B
17
B
42
D
67
D
92
A
18
B
43
B
68
C
93
C
19
B
44
C
69
A
94
A
20
D
45
C
70
A
95
A
21
D
46
D
71
C
96
A
22
D
47
C
72
A
97
B
23
B
48
C
73
A
98
B
24
A
49
A
74
C
99
D
25
C
50
B
75
D
100
A
137
APPENDIX 9 (Paper 2)
2
3JJR
TO-2 W
3T^ - 200
1.
IcFSJ ’TOcT c^<H cE (HU fnhfeiRsin if ■$■ cpR-KT cn?T 3l(d^ch ? •
A -,. WR IT RW ^pfR
B —
^<dl
C _ dHd<i
crisqir
D — 31 33 3T3IT 33RT ^TqT q3T 3TR IRRT 3 3TT3T Kt
^TIH
2.
^T?T
i?n7 MHidP^d if IT
:
A —
B C — cRI-'^ IT fdM HcfrA
D _ ft^t IT ^T KT*T
3.
IpfW WU child 3? fHI7 KTH ch led 3? fniJ M H Rd fed if H 33U-ITT <1133 3144131 371%^:
A — HI if 3 4 ci *3 £11141
B —
c — nnfui 33
D — wurhtuti
4.
Tgif^H TTHU 3?
qTUH 37 fHIi 3UH-ITTITRH 343xh |:
A — 4311335 3PII
B — 39TK 33 fH3T
C - wnt
D — lUI^ng
5.
ITO^TK 3W 3?
WT 313=31 cPTHT 31^^:
A — 333 HKt
B — ■JTt3I33HIT
C — 3o9! UH
D — HdcH
6.
firn if li 3^-13 3dl3WI 33 KHSjTCn UK? |:
A — HlPuU) u4 33 UKT 3W
B — IJUq U3U HI pH 3 di 3TTHT
C _ HRf 33 32 33 U3UT
£) _ HlPM3i 33 33 PidPHd IqHT
(i)
138
7.
<UH3F^3R snifetjhv^r
rrarferrrtw40fer? i
g3TT 2TT I 3JcT RH;
^FT RT 3TTR 3TT cRTl KHIq <?T:
A — STTTO ^7 W
cHd l cfl 77?
B — Rfe oET
77 T^fe 3R
C — ^rodi RdTF-^I d-.ldd-.d l 77 d id 7nu-fe 771 y
8.
WTRT w^fr Trf^TT ^TT fed HI
(cHTq)
"QW •‘Ilfe’UT
A
60
B - 80
C - 100
D - 120
9.
fer oTHT qkHI
A —
fel cFH STHTH(HTq)
RKTl
STRRH WT ^TT
qI
B — Jldd
10.
RW 3? 37R TTEWR if Mfedl oTT fedH TTR^T37 37^7 3I7Udld
^THT 37%^:
A - 2W
B - 12 W
C - 1 fe
D - 2fin
11.
feTVi 33 fecT 37
71141’33 fed Hi KT37 ? :
A - 70 TT 80
B - 100 77140
C - 160 77 200
D — 200 77 37T33
12.
4^?ldl3I^ 33 377 24 3R j? 3q 344)1 ^7777 W 3T4T 6 ^TTg 33 ? I fcjH 77T? 3 344)1 334 5
fec3 33 441 I ^773) 777313 3773?T f414^ <<>611 ($4144 4^3 <4)314 c£ 3)l70i) 434)1 37P7
37^7^77)7 3)^4:
A — 34 737753^33
B — 3T5Tfi73 737^3 433/41^41^4) 73TP3 333
C — 47? 37 3777
13.
37773 3? 3T^ T3R7T3 500 fR.cft. 77
?tHTTlrft 3H 3731 •
A — 77qT
B — Jldd
139
(2)
14.
WcT
'Q? ^IM H
^TFT) if
:
TJrft
A - Bit
B _ TfT^r
15.
Wq 3 24 w: TT 3jfg-ctj rFTT ^gSTHeTT 12 ’dU£ 17 3TtdeF T^cit ? ?F eFT c[{ci
W WTT
A — ’Hol
B — JI d ci
16.
■fy^T IJrg '47^'1 ehiw
?:
A — W
^Ph/^ctj T^pj
W4 *4^4 SWT^
B —
C — ^^414
^^4^1
D — 3W4-) ^‘4i
444id f^T
17.
Ml Meh-Sad-)< 3c^T CldchMl -dif^:
A — del
B — 4idd
18.
^3H WT era" eFT
HH
:
rTerT
A —
B - W
19.
thifdMI eft dTT cT^IT
7WTPhcdi 800
(1.8 kg) d^4 3F '§317 ? I STTM 3TT o<TT
<4c1Iq ^T:
20.
A —
MI F
B —
w
W
C — WB WF d)l4d)dS
MFF ir^F
D — ftr?T TPT fdiw
4OT
3F ^FT
A — 3RT
M^dlr^WdMM
ch {HI dlf^H:
ePAf
B — 4 IF 6
C — 24 W 37 313
D — cWt (34 37 3T3
(3)
140
21.
RMfedPjd K K cKR-TT RT8W d^ciid
K TJrR KM KTH ? :
A — M K? KKK KTs fKMT (2.5 kg) K KK MR/RTMT
RT
B — dqKId K Mild-4! TTK MFT/JRT K UHWi
c - KR 3TRT
0 _ <5MJ|rh K'K
?7
M K? KKK KR MR KM KM KK fKRKK KT WT H MT KM MT K ciUddl Klf^i^dlfcb KRI
KR KTR H KT :
A - W
B — MR
23.
kt
3AT7 3TT TIW rTR KTq
§3rr ? 3tr
swr
W^^TT ^cHIq ^7 :
on <^<i^
3Tt
^dig w 3tu ?
A —
KT ^FT
B — RT^T^K^Wt
C — KTK KT KK7U KTT
D _
W K KM KJ KTHl
24.
KT ctii Vq<Hi dK cixxl K? fdl^ ^ifHcbI<cb q :
A — 'H q!
B — *Ha
25.
TURK M M KMT
fR M KR MK? R WT MT H M; ^^fjMMTR feKTKTRT
A — -eq M 3MT KRKTTK
B — RM KT W KTWJ ‘OR TO M VRT KT MZ KT^
C _ RM KT TO WKKXMMRRKM
D — dH<1 vh K R Kl^ ’IcJ
26.
fediftH tt
KKft ferr 37 7 3TT KK? ■gTKT
:
A — 6 WH3KT?
B - 3 K 5 k4
c - 5KKK7K^
27.
[cidlfcM TJ^KTKt TTK)tH-3fT <M1MR1 fKHT t:
A — fc^dtl
B - 3FKKT
C — TKRTTK
D _
141
(4)
28.
TOH TO Pbd TOTO/TOTO 4 PidlPlH IT TOT^ITO MM I P £Ml £ :
A — totototoPto
B - TOR
Q _ iRFI 3TO IT^ TOTTO
D - TORiTO TOTO
29.
9w
fyr^r q^t PcidiPH it qtt
ferfr Wi if ^rr -cii^u:
A — 1 <3ra <TRd
B — 3 ?rra wz
C - 2 TO TUTO
D — 50
MPid
30.
IcbUlHC’iR’lMI 3TR fq’dld-H TOTd fen TO TORT P ^tcTT t:
7\ _ KTZR q?T
B — 1<4dlPi<4 IT
7^-qf
C — PidlPlH tfi <F1 qhHi
D —
31.
nfe TOt PidlPiM IT TOT TO TOT TOT 3TTTO TO PhdMl ’dll TO fad Ml TOp^:
A — 3 d<lTO
B — 5 d<iTO
C - 7TOTTO
D _ 9 7TOTO
32.
^RTd
WT
1^
^ETiJpTT
^73 f^T 3Tl7 3<sil< W- cT^T TOT I
TOT TO Sit 3TTTO) PiTO PTO P TOH-TO 7PT t ’
IR
R
T^T 2TTI
TT
Ml<41 TOTfe 3TO^ <4W TTO
A B — MdpMI
C — PiHlPiMI
D — TOTO P H TOi TO
33.
Pi Ml Pi <41
10 W
33 MplPHPid ^TT WT:
A - 20
B - 30
C - 40
D - 50tT3rfra
(5)
142
34.
fa Ml Pi 41 Q) cTSTtfl 44T ? :
A — M’HoTl
xicHI
■g _ cTER R
Rq RR 1RRT RT
Q _ d-cd EFT RR 3TTdR 3HIdI Ri, dHH R Idd^-.d RT
E) - RWvE RR[
35.
H Mild "-I I 4? ^RiRT R 4RR-RT
cjR :
A — WT^RRRTRFd
B — MM-31 did
C — WrE RTRT
D — WRE R R RTt R^T
36.
A —
w
gwi W^)
B — 4<lkldNId
C — 3Wrh
37.
<$13
RRR R?T R^ll R 3RR4) R^^JU?
RRoFT WhU 3THWI
A — RqI
B — 4ldd
38.
3RR qRT 4? RRT ^aR/ 3W 3TTRT ?, <R 3R 4RT qt^R t ’■
A —
B — fs^Al (RlRR)
C - cMrrr
D — dl Mi I
39.
A — ^R-^R ReT WHT 3TRT
B —
C — RR-RR RcRTT TOHI
D — 3M{lw R R Rlt
40.
RRT 7TR H TTRT oft IJRJ feR 4RUI
A — fad dl =h<(Ji
B — 3TRTt 4T
C — feRER^^dR
D — <iM<lrh RTRf
143
(6)
41.
H^rnj q^JT ? :
Pb^ciieM'Jj
A — dTPRE ujpj -qa ■RT3T <rNH
B — WT
3jra UK tpiH Efjj 3THT
C - ^TEH if Kp^H/WTTn
D _ 3w?e nnf
42
anr
^hh nf ^r
W n^cqijui
^TT ? :
nr chi ^et w ki<cTot
$cr TqHJ rnf^:
A — wr
B 43.
cTEEK if
A — KFAT^' if 3JUT^ WT
B _
41 Pd^
Q _ cj^ EET <3Hf cfq cR cKU
f) — KTRRI n 3KT WT w 4
44.
HKT 3? Tpft ^T niMW WHT^TT
:
A - W
B — Jidci
45.
^7 Br.rH WT if Wci-Hi -elI^JJ:
3JT.3JR.iTH. it)
A - 250 fWT W2
B - 1W
C - 1.5 W2
D — 100 fadi cTld<
46.
3TT.3JR.ITK.
UT^J 3?T ch A cH 37^ IchrA TWT
3m4h
<H4l
A - 1 wn
B
12 WT
C - 24 Rtkt
D — ^WJE if iT TEff
47.
3jT.3TK.I7n. 37T W
K rHl KTTgR:
Wt
A —
B - W
48.
34luA> ^RT if Efir HJsUI H
32<T ^TA
KHT dMN ^TRT :
A — 3JT.3TR.Ith. 3T WT fWH 3E7 W
B _ PUdl'WI K KT ATTd^WT^Trt
< 4 hh
C _ Tp-l^ol
!Q4dl
TT^i WKK
ndi£
3tT
TpT
D — 3M<lvb nnr
(7)
144
49.
fferfeffer if n fen Jim hi 37 31373777? n tft vfegw n^t w? •■
A — 331
B — fe d Ml
C - fen 7
D -W
50
fed 37 if nfe 37 fe.7T.3T. 313137^1 37 U^cdl
fe d Id I ? :
A — 37^7 3 7-777
B—
C - 6W
D - 9n 12 W
51.
fen 37 37
37 TTTH 37 3137 cPTTTT 3777 ? ’
A — 37777 7777
BW
C - 6W
D - 93 12W
52.
^t.nt.ST. 3717 4'1 H4I TH
•SMsxl ch cfe fed Hl 3737 FHT riifelJ:
A — TTcR
B — 7T£ W
C - 6W
D - 1 37
53.
^r.ur.st.Iqtt vwsraferr 37
a - 9^ 12 w
6-18^24^
C - 24^30HT?
D - 5^4
54.
fe.fe.fe.37 ..
C\
felT 37371 •*
■fen 37 if 37 ^n?ff ? :
A - 11
Bc - 10^f
D - 16^f
55.
73173^1
fen 7773 3^77 fed3 31337^3 37fe37 rVllMI 377371:
A — fe7 F fe 37W3B
B — 777 777
C-6W
D - 9W
14 5
(8)
56.
cF^T iji tT^T
37^ FP/rT ^R-vTT <ilchlch<U| fem mH!
:
A — Tmru
B — ^fefe/'-nife-Ti
CD _ fed <4
57.
^TW^Tf if feXH mr c^TU frmr fed-r 3F5TRH’m
MIq
A —
B —
cptrt -d i Pq^ :
’■A ’<11 q
C - T^TT^
D58.
W
Mi few I eFT ^raiT
cH 5RT cHlI^I ^TTHT ? :
A — ■H q f
B — 4ldd
59.
K1WT TT^i, Wft, cRJR afk
^iTR
fe<TT
?:
A — ’HeP
B — Jldd
60. 'ciMdNi^ mt sfermtfferfem^t.^t.mr. sjk ^jfr.^/utfedi mt<g<m ^tmj
3Hm m? 3fer Hwm xfet fef h m? hr m
i trh msft mt nv
mwi 6 W ? 3TFT 3^1 dfeicMUI m {4^^ mTT <4dl^ $Jt:
A — mm ^t.m.zt/mfem mt fefe xtm-i^m w mmr m itn
B — ^R
m nfe mwfe
C — m w mt hh nrn
mt tfet mr ztmr fe
D — 3wm if m mt^ fer
61.
mi fen mi <H^mi it.^t.nt./ mi Rd41 mt mm itm mr^ mfet fer mu fe^fem ^t
mm i m^R mt sfe mrni fe fer ?cmr
mfr ^m^id mnfr m w mt ufr mt mi,
snrnmmrmfrT:
A — feiPtRinid mt fem
B — femdr fe <4h^i^i fm mm mtfemt. mt rihi^ mmm t
C — <feim fen
D — rnnttm fr fem fe
62. dfeimtm tr m ^TtH mmt mt WlcA
M^MfeferPl
^Rmr mrmBr mr rRT
A - 4W
B - 12 W
C - 24 W
D — mr? fer Pruffer fef
(9)
146
63.
dfelcMUi
ffej fech cfe fer
chld|U|<fad felfe
Tji7 WT ^RlHld WW
:
A - TIW
B — 4ldd
64.
cfer wr ctwt ctw wfer mi < life
wr ^ct
:
A — 771? I
B _ JlTTd
65.
■fVTTT ToTH W
KT%
d4ldl ? :
A - 3^
B - 6W
C - 9W
D - 12 W
66.
few wfefr W £iT fad Id I tlfedl fel 3TW MfedlSTT fel 3N8JT 3jfe^ W3R WT W-W-^dl
tfer?:
A — W
B — 41 d d
67.
RHmd
oW Q)N< ?fe ? :
A —
fel ife 3W dlHiilqf 77 WW
B — j/wi
C — wi/w^rw
D — 3WvF ‘HWT
68.
Hc4<d Id fe^T ^7 W 3? ^?T fe 3ldl3l
fer
4 d ch Id WT Wt
A — ’HqI
B — 4ldd
69.
feyr wr few w h cb-cidi-Wdi wht dW
:
A - 3W
B - 5W
C - 7W
D - l^f
70.
cfer WT 37Ht
dldd 3TR faMd H fewt £ldd H
fadHI
A —
B - W
147
(io)
71.
TT^ gif er. cTk^Q) cr! y Id lid 5 7 6 TH dl(4 TuR CRT TTlfT^:
A - W
B — ddd
72.
TJ7 oTT £ ST cF^T oTi ToTH 37
fudidl
(I:
A — 6W
B - 12 7iE
C - 18 713
£) — 3Fs{ cF~F
73.
3TT4
W5R if chcitf 3jNisid ^vH
cET ft 3WH aETdl -dilf :
A — del
B — dcia
74.
^?iT7UT
cT^TUT f :
A —
dsh[
<siHI
B — rdsCdsHH/TTr fl ^TRT
C — 7R-7R 7WT TsTT
D — WliH 77t
75.
RC7R chMlMUj Cl8^7177T:
A — 7^37 3TT7 7 3777 77 ^131 377 Mddi fl di f
B — 777 7 ^dd 37 dldT f
C —
41 7137713T77 RJ7dl t
D — 3 M <1 rb R 7 chi f Mt
76.
733
A —
Mp-ciH 1373 Ncbll 3?T STT M'tidl ? :
3TR •iltsHl' 33" PT ’TPTT TSHT
B — 'd^l Tdi <d i d I
c _ r^ddl 777 72 wit 773 7T.UT 7T7T 73 7F7
D _ PTWPP
77.
7T7RT «TfxF
Tift IJ^ ft33 if RhddI
ftHT f :
A - 60 7 77
B - 70 3 80
C - 90TT100
D - 100
148
(H)
—--—- -
<£4-ll
78.
RT yri^faq-. Tarns?
A W Ki
B — RF|T
RTTR H TKT KT
C — 3WKT
D — na TTKT nrn KT RTT Ki
if ckH
79.
{
oTFT
5 TKH TT ^TTKT
3T 3TK HT ETKK KT
:
A — ^TFTT r4nH
B — 3R RRR TaH
q _ uriRhm
D —
cEf
80.
XR cEq 'irinT :
qFi WR
WTq
ql
R 3^7 <sUr||< c^T :
A —
cET cTl d I TT TTFE a-rAi
B — KcT 3K 4k -old f!
C — -ndT-J^TldlH 15^ K^TT jra T^ <1 Rrd^lcf 3TT Rpd4l TBT
D — =FH ^T KFK B TTFE 337T
81.
KTEKT ^T ftUH 24 W: KT <a<3l< 3TT TK? t I
<) <H q<TT KKT
3TTK^ W $dl^
f^Tl 3TW K TTT
$dld
:
A — ^-dVl^WH nt ntfdnr K4T
B — KRT wft KT P-lTnH nvTT
C — WHTZTWT nt Rpdn KHT
o — RFT nt TO KKT^f KKT
82.
■froTO Tn tor tok nro nn^H, 3fero nti aroif to stot stut to Kt ?tr i^t toto tot
UtlRrdiJid TOT -nlidTO KTO7 TO TOT TO :
A — TO
B - TOTO
83.
ktoto nr nr ntKt n KK Ktn to tor ntit nt tor ■’roft s-to TOm if nror frorm? ifn fnro
ijn ntif nt 3totr kh n s^ro n to toh i dTO to to tokt if ttto Kn
PiHldfbd TT TOT TOTTK TO:
A — TO nt TOK 3TOR
B — TO Iroiin dlPdn
to w i snv to
TTO nt TOTO
c _ msrfHnTOITO^TOTOtTO
D _ 3M<in nrf TO
149
(12)
84. te if te ite
(4 h Rd ted if ir atete w te -
A —
85.
B — 3-TWH M-JRd-4-, otes
11 Rd■4i
C — wtewi
D — tedH
aa teaw
1tei te ^-ddi cH saw ch tei'Rw if p otew wra wte ? •
A — ’Hldd MHI Ti HqHI
B — tel^d tedlUd cddH1
C - ate Rw
: aw ter
D — ’'jite ter aten wte wte w
86.
Slfei on 3W if w 3TT TqT ZTTI Site W STR te KT 2ITI
site sttht craw te ftteartea if tt wh-ht swt ote te cjw:
a — srtei^ te <i^4i tewi
H 3H
B — WTRfelW? 3T2W d<IHI$lte W HdcH d'lHi
IW
C — sftef
D—
87. te- a? w ar $did if teaRafea n if ate-w ftej aw^ur ? .A — ana? te ahaa ate if ate aw
B — teiteiaid tete tea
C — te WdT aw
D — tea w ter if ter aaw war
88.
w ten aa aw swn ^t w 1 w ww agw
te ar te ste ate if
ttw arw Titeitfte? ad djiw< fw te ten
1 aw te
ijnR te
^stt 1 sw te artery aar tea ■
A—
te ww^aa wterawa
B — nr tew ww tea ian awr
C — ate'dddax wrwaw
D — w-te
h war
89. sR^dai te aa iteRdfajci if tefaw ate te aw tete •
A — teateawaw
B — a 1 a) Midi d<d pate ter
D_
4
M wh
anfd
(13)
150
90.
3c if O 3H 3? 313 '^33 if
OT C33TT oTHT :
A — 4<1 CodHid 34 nild'-fl O
B —
34 ran
C — R’dld-iH 34 raft
D — 3/1 d i^h 3d i4i d 34 ran
91.
3d4 3? 3id 3<<i I3i3cHl if riH if TT ’3M-TTT CU31{ R^T 343 ‘
Z\ _ 3RT 34
3Fn if 13HT
B — ’Ol4F-d3 Hd$H dHMi
C - Wd 34 ra drar
D — 3TT(d RqI^H 3Td34T
92
O’ 3? 3led 07 4hI3H 3TR RTdf 7T 373 3tT 37357 37q R 313.{ Ipdi{f id.3 Hd^H dJll4 33
3TPT 3? $dM 3? fdl^:
A — 4doH dJ11 a 7^
B — RT3 34 Rfi 3133
C — 3iid3,43I ^30 3^ fe? fefed^1-.
W 33
D — O 3T3 W 3? fd4 £73? dOT 3
93.
373 if 33 3337 3 RTc 34? W7f 37 37337 if 337373? O eFTT, 3433 33 37 343 end {I 3743
if ran ran ? 1 ffeidfed if ir dfeir 3Udr rafn:
A — 3473 34 ran ir ran, 3773 if 34ft ran ra fraran, ranrirara^ ^n rara
B — 3KU 34 ra ir RdRT
C — 3^7if ^3 34 3p 'Slddi
D —
94,
TrMt
333 34 idHfdfcjd if 3477-477 3773 3744 :
A — 4P77 37 44331'373. fePd if <{371
B — 1J7 34 3714 34 cbl[4d377H7
C — <3<Medl 334 Rfr 34 $4dHld 343? 1JT 34 fed 4 fe
D — 3 M <13 44*71
95.
H cPH
fdMIdRjd
A — tnft
B — TPfr
c - infra
141 if R
3W
oHTT:
VHt £lddl
VFH
O’
D — tnft ot <3 d i {4-4 31 wt 34 o ran
(14)
151
ch ied m om-nr mr mr:
96.
A — UdldkH
B — UH di
C — WW
D — wnmm
Rfr ornr:
in iHHk’iHjd if n
97.
A — ^rzt
B — ^3
3? 3m
PIH
TT+jf
C —
cbMSI RT^HT
m KR-p mft Tl H ^HT
fim 3JT W
WIT
D — ^3 ipF-JTH iR RR dJIHi
98.
t ^TqTT WIT WTT, KT^T-in 3^ ^RT, HTgt rRT ^TT
Hep
ijfaT, sir’ll, $c<hi ^1H
3TRT; 3fem3TRT:
A — Hqf
B — mra
99.
■£R
HRR ?d HTR-RT 3W HRTT:
A — mi Pi 4^ T^T
B — TvF
(TT 331H TH?
^T dM4Hl m WR Hl d'dMI
C —
^T 33414^44; 3R 31
D — 3H<i xb 3nft
Mi
100. HR LNdm t — Fcldi^ 3T
A — H^i
B — 4ldia
05)
152
q
\3TvTY
q
xScdx
q
\3cdx
q
\5cdx
1
B
26
A
51
D
76
D
2 I A
3 i B
—i-
27
B
52
B
77
B
28
D
53
B
78
4
A
29
A
54
B
79
C
5
A
30
B
55
A
80
C
6
D
31
B
56
B
81
B
7
C
32
C
57
C
82
A
8
C
33
D
58
B
83
C
9
A
34
D
59
A
84
C
10
A
35
A
60
A
85
C
11
B
36
A
61
C
86
B
12
B
37
A
62
A
87
C
13
A
38
B
63
A
88
B
14
A
39
C
64
A
89
C
15
A
40
A
65
B
90
B
16
D
41
D
66
A
91
C
17
B
42
A
67
D
92
C
18
B
43
A
68
B
93
A
19
D
44
A
69
B
94
D
20
A
45
B
70
A
95
C
21
D
46
C
71
A
96
B
22
A
47
B
72
D
97
B
23
A
48
D
73
A
98
A
24
B
49
D
74
D
99
B
25
D
50
B
75
D
100
A
-- b
i
153
APPENDIX .IQ
VSTef? zjl v| rf |
viH
JSR-E
(n.n.
(FIELD STUDY)
ciTHTt
arl
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(21 ^) afU
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I)
sflY WTa) t
3Wp WI 3HcPl
Tjl? 3
vl 5 anv
■
§3TT t,
g<aR ’’fl t 3fR
W '’ft VJI-f—lf]^|
3ii'J
)
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cFY \Sl g!
fcJiTFT 3ftV xSTtHV
jpH
c|dII
3iih H5rf rf TIJ-ii 3417 Trfrfrf '4 tprntTuI cl&l’7! cTCJ
qrf7Fm .-pr TiFug 3iiv
sph “cfTfcm i
xrHI
H'Tc’ ^1 W
|
HI rfrf qRlTR qH
'fh'R £ I ^frtfl,
^Tk W 3 4 f^iTn^
ffcJH - cRii
<nn atR oRrt ?
f^fcpid <7 xeTT ? I
vr^n on qOepi
154
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4.
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3T R RI Fsff^ 3fr< JeTR
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JRT ■qaT^J ?
5.
Ha=ft 3hR RRn vi'l HkRR 4764IR ■PlJsPH
3^rq cpTT FRTiF’ R'l7'! I SRR
W WTJ
6.
7iEI
THHcIiR'F-fi
^f^JTq 3fR <161S TJVcf t I
Rp <il6 tpl IRp
4^1 'FTFil ci. •MH vH'p'l
I
cFl t SIT?
v>
FTcTTg,
vTISJ
RraUTp'rai ak SFJTm
‘TH 3^HM £ I
\5WI -iTTRFl 3fl^ <pvI ?
155
APPENDIX-11
”i|”
STANDARD PROJECT FOR SANCTION OF LOAN UNDER IRDP
FOR JAN SWASTHYA RAKSHAKS
INTRODUCTION
Madhya Prmlenli has recently approved a
Government of I
Swasthya Rakshaks. This scheme will be
scheme of Jan
<
1 November throughout the state. A copy of
launched oni 19'"
follows:
enclosed. The scheme is briefly as
the scheme is
:
village by the gram
One person will be selected for each
Rakshak for that
panchayat to work as
as Jan
Jan Swasthya
for
the
Jan
village.
The
essential qualif i’cat ions
Swasthya Rakshak are :
village or at
1. He/ehe should bei a resident of the same
panchayat area.
least of the saine^ gram
<_
Tite/she Should be at least class 10
2.
selected by the gram panchayat
P»n=hayat they will
After being
undergo a 6
department « TRYSEM.
At the end of
the training an
done under will be taken by the Directorate of Medical
examination
1Those who
,
J' this
t-Jjo examinaci
pvamination will be
_______
Education.
pase
Qf given
thig
the
a certificate by the DME,
t>^, and
, (,|.on
nrP(1 ns Jan Swanthya
bo t og i fitc rod a fi
will
certificate they^
r
.r-n^t
ice
e as
as Jan Swasthya
to- practic
Rakshak. They will village
be a 11 owedfor
have
which
been
they
Rakshak
in
the village
for
a
iIments,
will
treat
minor
ailments,
and
registered.
They aid
will
^eat
to patients
in the villages, and
administer first aid to patients
cases to the hospitals, lhey
com
will refer more complicated
in National
will also help the government Health System
Health programmes.
aTt> e9bloc"in^r ^r'X^tbal.T,.? will be
ECONOMIC VIABILITY OF THE PROJECT
.* villages are of minor nature
Most of the dineason m the
serious complication,if remain
which however can lead
to childhood
...
'-’ of
mortality is because
untreated. Almost 28% c.
of a simple disease
muI 1ei rt
every child lens than '> y-'.u •> vear.
Similarly ;a mmpie
}___ _ SliniJarly
episodes ol diarrhoea evmy lead
y
to pneumonia, Another
disease like common cold may
is because <_of pneumonia.
28% of childhood mortality
1
156
Recently a purvey wan <conducted by an
an NGO in Biiaspnr
oiSL-rict, which
winch showed that in a period of three months
more than one lakh rupees
rupnen went.
went out of
the vill.-iqe on
of the
I cc'.h , and d
i u<pi . j| n ejua
medical so
seii v.
v.lcen,
dnuin.
(jun.Nl
.1 i 1 1led
cd person jo
available in the village lie/she can easily
easily make
make a living.
t makes sense for the village
people
as
e people as well. If a
person living m a remote village
village goes
goes to
to a
a government
health facility located 10-15. kilometer away, he may get
free medical attention, but he
lie looses a day's wage, and
spends on transport. On the other hand if
i f he pays a Jan
Swasthya Raknhak a sma
I I riiim
small
fium of money lie*
he naven
naves a day's
wage, and transport expenses. This added to the effort
required, <and’ ‘the
’
mental and physical anguish caused in
transportingj a
a sick
sick person to long distances makes
payment of user fees to’the J; m Swasthya Rakohak, an much
favoured option. We have no doubt
doubt Chat
Chat competent, and
qualified Jan Swasthya Rakshaks will easily make a living
from their profession, and will also prove an asset to
the village community.
LINKAGE OF IRDP AND TRYSEM
The Jan Swasthya Rakshaks will be trained under TRYSEM.
They will then be provided financial assistance under
IRDP, thus strengthening I hn link of
of IRDP
I RDF with TRYSEM.
THE PACKAGE TO BE GIVEN
The package to be given under Ch^
t.li
scheme
Swasthya Rakshaks will be as follows :
a.
Fixed CapiCal
j. .
Furni C u re
Co
Che
Jan
a . One ol f i
I ah I o
b . ( )ll»' i:x am i i in C ion I a hl c
c . One bench
d. Two Stools
e . Two Chairs
f . One Procedure table
9 • One aImi rail
l‘n).oo
.I'XXJ.UO
lUOU.UO
400.00
XXX).00
J .(XX). 00
2S00.00
Total
KXJ0.00
o
157
2.
One Kit of equipments containing the following :
i
JAN SWASTIIYA RAKSHAK EQUIPMENT KIT
NAME OF EQUIPMENT
Weighing uiadi.inc - C.'hiJdWeighing machine - Adult
Urine testing equipment:
1 . Spirit lamp
2 . Test tube
3 . Test tube holder
4 . Benedict's solution
Haemoglobin testing equipment:
1. Pipette
2. Hemoglobinometer
3. Hydrochloric acid
First aid kit
Sterilizer*
Stove
Thermometer
Torch
Measuring tape
BP equipment.
Soap
Towe 1
Syringe
Needle
Set of instruments for
I&D of abscess
Instruments for conducting
normal labour
Bic ycle
____________
QUhNTITY
RlijUUlRED
COST
1
1
2 50
500
90
1
t
5
r
2
5 bottles
550
1
1
2 bottles
1
.1
3.
3.
1
3.
1
10
2
10
50
1 set
500
1000
500
50
50
10
15 0 0
3 00
100
250
50
500
1 ’Set
1000
oim
150 0
b. Working Capital
1.
Rent of one room for clinic in the village <?> Rs 100
per month for 12 months amounting to Rn 1200/-.
3
158
J
2 . A kit of drugs and other connumnblen.
coimlnt of the lollowing :
Tho kit will
JAN SWASTIIYA RAKSHAK DRUG KIT
NAME OF DRUG
Aspirin
* ■
Paracetamol
Chlorphenarimine
Mebandazole
Pyrental palmoate
Metronidazole
Tetracycline capsule
Chloroquine tablet
Benzyl benzoate
Tetracycline eye applicaps
Baralgan tablet
Nconporjuo ointment
No.onporino powder
B-CompJ ex tablet
IFA tablet
ORS
Contrimoxazole tablet
Avi 1
Chlorine tabled.s
Oral pills
Condoms
Gauge
Bandage
Cotton
Adhes ive plaster
Tincher .iodine
Detol/Sevl on_
Tola;
QUANTITY
REQUIRED
COST
300
500
300
300
100
300
500
500
1
200
200
20
20
500
5000
100
500
1 00
6 0000
300
2000
25
75
25
10
5
150
300
250
50
300
1 00
500
’•.00
10
250
300
1000
J 00
3 00 0
1000
500
J 00
100
200
100
50
200
9200
•
27000
Total coot of tho package
4
159
r-Rrv •
MONITORING PROFORMA FOR THE
JAN SWASTHYA RAKSHAK SCHEME
Form 1
Name of
district
Name of
block
Number of
Doctors
posted
Number of
doctors
trained
Number
of
blocko
Number of
blockn
whe re
training
has started
Number of
JF.Rn
idcnti fled
Total
Form 2
Name of
District
Number
of JSRs
be i ng
trained
Total
1
160
*!
Form 3
N a tie o t
Dlitrlct
Number
o( JSR«
be 1 ng
trained
Honey
re 1 taard
ao
p 11 pend
to
t ra 1nnnn
Money
i c 1 r a neJ
to 1-nr I nr
foivJur ting
11 a 1 ii 1 ng
Tool
k I C9
illotrlbuted
Where
t r a In!ng
m.niu.i 1 n
d 1 n t r1buted
In no
doctor
book
.11 nt i I but nil
Total
Form 4
Name of
District
Name
of
block
Number of JSRs
who passed in the
inonthly internal
ovalualion
Number
of JSRs
be i ng
L ra 1 tied
Total
>
■
2
161
Appendix
12
MP VHA PUBLICATIONS :
POSTERS ON MATERNAL CARE
’nrr-ft =n-n
3.
?
Spsvtr
'• r. 1:: -i TT-! nd ? !
qT^rfr ITFU ^7 CT^Tn
■*'
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r-r y'TFT« 1
TTtrrft 7T7T -ifr TZTTX Sf ?T3,1JT : -
4TV .n>-' ? TT-i l ‘■d CCHi
TT5 -Y cTTTi
sf.rr !• r '-T 'i~- ,* .
7:
at ~.v~d srn ft q.r-rr
■Tt y
(i) 71
d $:» !ri-: ti t»; Trnnr
•n TT-T.v yrr £;
FT
fii) Ht
:i T=5 <f! 'TrT-5 ti-K
:
7T
o -Far T qra -ST
I. rnrr'TK HtRd 4K ntr^rfr 3 td-TT 1
?. :pr snni tmtht i
r.
at fr?.-=R 7
at
3 . ar^-Tt ?FiT TT tH# >77 rFFTi I
x. -TP! autanw JF7TI
«.. qrn ft in ^hikt rhn i
£ '</3T7^7MTW':i3 «t
3T=F:r qf-HTST « HR fc,
jt vrx v4 ntn ii ?nyn’
^IZ
f,. s^rr if n Tcptn JT< fWcT3t |
at z-pft -it
Tpr rrrr to)
KPftfrl
.j, iTrnd’Tfrrfx ;i ra
(ii)
(i)^5i\fit<n
7TH 7 ffTT 57 r?T ft,
'n.'T'i 7t^-.kt' ft
a>TcTT Tt.HT
®>~ai rnpn
varrxt:
|
w.di *! < H? srfwrn m
7F FT7 > !
S'pMogL.
1 r?;7 nvT'ft Jrnnsn <e' ^'ir^
srfS.T’K ■Jn’-vXF'T
?
Cr
• »4fe srf SKI 'KT
rd 17 ■'XT? « f"TV
I__ KEWH 'TZT H
A SERIES OF 20 COLOURED POSTERS
ON MATERNAL CARE [ HINDI ] :
Which enables a village woman To realize the importance of maternal care.
i.
ii. To detect pregnancy at early stage.
iii. To identify high risk pregnancies.
iv. To conduct safe deliveries.
v.
To take care of the new born.
Contributory price Rs. 60/- per set
vn £f srra
I. 3W3 ’W 7 TX=r
nr s> 0? r tth
3<i»i
Mn
trf? tn & irz a rs <t ^hk ttik TfY t tt
9W d ®i»>ra'z sand 11 , . ...
st is
ii
it .Tfl
n n? tttt FTtfr > i
c
0 «i < 97 4
a™ fl >:-ri !
•trF$H7«TT |
Z7 M'-Mt
I
e a'tnq ri«i>T»28»caTir*rT«7Wtfff;J|
• » mt 4-,T«r®tn
« -.tot r«R cj ;7
; 7 >aSra;':
» rn yarai
ww=n s^rRi
s.1 at« w<r Jt*
*r ;
I
'
txra rf ■
3RT I
PTTn. TW? >”=T
rrjri J’T i
J. =^7 lild'-- '*■■
jna- yrri
an
• ^fi^f^ft«’n7B^w»KnR.3rFFriH’ra'
‘
TTF -1.T5 C '.., >7> :z -yz f
FT ’^’T I
4. TZR TTlt rw »T3I |
5. ra s-‘ irF
i rar i
6. TTTr
nF 57TF 7 I77T I
_
qr 7 777 Fm 3171
id
Twf=rv;
7=^ i ;‘-.r- -. q >-
sw *7
Ftt Fm »rr'r7
frT?
~
s^riajr - n
_• -fna sw xrr '■tzsi n j-rr;
sftx’^rrhrrdT’nfrt-
zamr-T. S’- FT’anwr--T^'
i
:
[
j— =^> •# -r •to -rr. r
s
n « -.x t_x» ’rt *» ; f
----- :>;t
162
j
POSTERS ON TUBERCULOSIS
A SERIES OF 10 COLOURED
POSTERS ON TB CONTROL: [HINDI]
’
« tt fLt tn
Which enables village community 3^4 rft ** «>
»
)
•
Of
it H
r fr
r wn
1.
*ri
rrm ?
W 3^ •r* i
vii r-rti vt i;r :5 »
Sfriri tfi rnn
•nw ptr’m m r^r
rw' Tber-t i.«<> m ;<n *
w-i r u^r. Il i
To know basic information on TB.
W4 r- ;
rx tht a "rtf' 5
a w
m inir arSi >n» * B’ j
t'
ii. To identify suspected cases of TB.
•
i
i
•
I
v. (I rf: --r <rtt < v: ?> th t
iii. To refer suspected cases for medical i
rrtT~
r*!1! | jrnjrjfi n 5--»-i
examination.
1.-1?^
.. .
b
|
iv. To realize the importance of regular treatment.
v. To be aware of the responsibilities of health
department in TB control.
SitfkgSgg
Contributory price Rs. 30/- per set
POSTERS ON DIARRHOEA
L'
CONTROL OF DIARRHOEA AT
VILLAGE LEVEL:
.£i UcKtrnr
itt; m
j
»
it; u’vr arn
Xhr*; » |
!
lawn
(A.1H M I
i.
(IiV-CH’* •rr..-'ir : atf
•sj •’»; t-err ». .vTT’i’fc.ir
TA *»ft i
•
1«> ? c ; -mT
»i -A ar.-il c i
re ^*rr c -t
a-Ai tli
-re.
— j 3.*
r7«^r
Importance of diarrhoea control.
ii. Ill effects of diarrhoea.
!
•
<£t
A series of 10 coloured posters in Hindi on
diarrhoea control informs villagers on -
iii. Treatment of diarrhoea and preparations of
ORS.
IV.
Precautions during diarrhoea.
V.
Control of diarrhoea at village level.
. ■«
•
«.
C
<.<* I *
’
WJ »W1»A
•’’O*
/I * . \
(J. , ./Fa
•
I
I
I
L j
Contributory price Rs. 30/- per set
163
POSTERS ON MALARIA
UHfnn 9; cttr ekt? frn
rf ?
A SERIES OF 8 COLOURED POSTERS
ON MALARIA CONTROL IN HINDI
WHICH -
1
• r= H4 wri It t* tr-frsT srcpt it r’ffl > i
• Tflj ’41’4 ’F fs. u-tfrm f\ nr’ntt * Lf
I. h’s < tri 1rv7.tr ws’ rrfl sr? i
n:t ir.<n war wi rfi >
1.
J. n-r cv.ir n-.’J »• 'imti 'T^f t!' rl ktt > ,
| • BM fi’n T xtft TT rpn jrf> 4; insvi H rwi f ,
! irrff « ya ' crs.-SSnr «r4 It 1
• tpsfrw « trap spit f <r prA
erar ? flt
tpt w* » fc a tr^p crt nr tj't rfa
fH tn ini |t 1
• ai'i’tl ♦ ITSF H Trn • eTrir X ustt fj
T I'.r Xft r.4 > ,
rrx 't-r
>,
:. ns’ * n< Wfl a
I ws irfl c ;raa crfl *i
W itfl c 1 in frrvr
T"rn n htt ai naxt
,
itWfl nm 4 n)
; toi si irfv-s if .7
ii < n i 1
j j
>. iv- wfl c m
I 4
. m'n-infawiw’ll
ii.
M A i * '4 < «n *TcTPT ErT HinzTHT
1 fftr 4 nwfrvr 8; treort tfr S■!j;i <il sm {V4T
ni_(. « n^, .
r •. •wj :. t in -wit «•j»: n. o.
t-B»: it rm rre/I a rr«4j, aj>
<,T4|
iHv-r vi-rttfir
•fn-.ii 1
Gives an assurance of malaria control by
villagers initiative.
Provides all basic information on malaria and
malaria control.
i
t • J r ir»-.w trj
-fit? I
2 wHutt K trvrl e frsrpr fmi;
a-;
» mtu r
wirf
we rft « f.-n rpn v. v J rfl'T’’
i. w rw-rfl -ofc^sl ow ivmv i
I
-7 i
:
* ctt r t
v »wj nj
J 'TMI *• TW1 »7 IFTS 4 ox «P MTW
tjflfl V I
4 ttt f xwrnj
«rz ’nrr« fan *
m ’»t
v. «t <rvr a mny 4 nt r»
iii. Provides information to villagers on selective I > Tfl
bin »i wt«t wn/wtSTi’n
MRn)fc»nti
breeding control of anopheles mosquitoes.
«
«t wrf n i
j
J <M iKfl 4 I srwfrin i
htw f?
arfirf >fra trr-r wfr d »ft 9n rrfl It 1)
iv. Provides a guideline and importance or
proper treatment.
Contributor^’ price Rs. 25/- per set
Lra .^4-r.s
•
•1 '’--fl
TW. -fl41 4l
4>4 K> c JIT 4 «4 t f
POSTERS ON SANITATION
STnt 5>'T 'J7«7VT
* s’W’T r
4?-4T> 'a aftt =rn fl'* f 1
■ C! Tfl 'ni r irf’ ui
fl fern attn ? i
;q 'fur Knptrrs r? 'ni’arf'C.
fl’ V,’5" SIT 3#|i
1 ;nu
A series of eight posters on sanitation in Hindi:
|
1.
I |
w-n ¥
I
aH?
~ fcfRl’’ n r> a -I 3^
ip; i
trrr.. ww. dfl
trrr..
•H’ wit. wra-'t t:
5 cfora «h m
n a’i4 *
| fen ysH n< w w«. Mtp f1 tn.' .i«. is .-’.1
pul jft-n t.Fht , j tfts »
.T4TT
t m trrr-n^• .-e» =- MT-" =« I n^CT-.T
n.
----~------ 1— I
Lr1
I ’
I
Provides a simple information on relationship
between "Lack of sanitation and diseases."
Which creates awareness on proper disposal
of human waste.
i^\
tt imr >
w s sfiJstij tj” 0 ci ftft irr
oh X sra rwjiftipfft awi Itrff. '
j U”J
it «tsnj ijx ft mr rv nr fapc w> & ^?J IT'|
|t ft!r ffti jftt »n pv ft Ufa awr
J.1
ar-tu <fl m
I
ftr ii 0-T ci t
/nrrfw fl wr > tn
irft iw ft prx vtst iifr? 1
j
ft
b)|H
,
_
iii. Which highlights importance of personal i
hvgiene.
Jn r rr-” " IT"
j f*r- 4 WM1 <rai nm a* * **
7
f, •’’fl tl
7UFT -p^vn
7*rrvT> -fin
'firi Ii
nJ ir Wil Htfrv I 6
+i S4F-
V)
WHAT IS SANITATION ?
ir4wi ErTai C Fm jnur Tfi ’ •T^tr< ii JZM ?. 'HJ-W »’} !
I
‘
rft wa €; nfftre! irft ft jirft ft
wnrfl 1 rai > jct«r wfl ft rmw eft a oct
iv. Which provides information on control of 1
common flies.
—-
nnft ft pm ftr ftft crj
Contributory price Rs. 20/- per set
e? tDTtTTq
T? r*
•r? itfi’? n.» 7-5 > .
** iflT
EK ?rft R ETSxft
■tf’W
a.’"
T--. -T^i ?
f
POSTERS ON MALNUTRITION
MALNUTRITION AMONG CHILDREN :
71
: aval fc;r jfts ¥ tjin
ft
*1
nl ft ip’ fa-fl'*1
1
; qpA ’IF fl" <17 nvi ii ‘ft I
* irrrai jh »ft it < 1
1. v< w? ft IK:-1 ttsif *1 ft! fti jfl *
MHfT tf.n
• rresrrcj
;~7’ 4- ». CT? T;,1 ».- rr,-: n-r .-rp r
WTr.-wrAwnft’.-tris i.T
Tt
A
C
A series of 6 coloured posters (in Hindi) on
malnutrition among children provides
information on i.
Causes of malnourishment.
ii. Identification of malnourished children.
JTCnTTH
wfxrtjM:
ft JI4IT7 ft! 1) FFStr
Itl
4 rf
<) MfftT ft wbre «n
faHTR I
« wj »> ftl Fi ^4 I Vi ft tft Tt IT
fa=T41 wfr.? •
«rrr ft o'; tns « m kt nrrsi;
• m wr f ,r>’4 i’.t ii'i mi ft
a •■4t otfao. Xi
it.-tni. art*, I*
’1
fa'’11
’1 ’’far* ,t'
>!*>»*
Rr.’ Mlf-: |
•44141
•MTiT
>11
s
rmh
• T4PH. 4.rTi. jTM Xi <F«Vl
» ik »---: i- 04 m .-..-j r sn m > fl v nri r'- iC7l,
• 4 Z.r: r
i
.’ -r^ ■ r .r.^ f :~ '.14r-
iii. Village level care of malnourished children.
UW.TTI
TH, 'r4’ Tb’n 1
iv. Referral of high risk cases.
Contributory price Rs. 20/- per set
164
_—
j
I
BOOKLETS
t....
0IT?f2IljEiT
Fci "■ ■ '*’ i&t-'
*
A Booklet in
Hindi as a guide
on maternal care
for a village
woman.
C o n t r i b u to ry
Price Rs. 3, -
hl
. El
/X Booklet i n
Hindi on "How to
control T.B. at
village level".
Contributory
Price Rs. 5 -
~y-
•;
I
fefcyR
i
/\ Booklet in
Hindi on "Ilow to
control Malaria at
village level" as a
guide
to
P a n c h a y a t
leaders.
C o n t r i b u t o ry
Price Rs. 5/-
The book is only
a collection or
in formal ion from
tribal traditional
healers regarding
medicinal plants
and its use .
C o n t r i b u t o ry
Price Rs. 5/-
A Booklet on how
to prepare herbal
medicine
for
different diseases.
C o n t ribu tory
Price Rs. 2.50 -
LEArLETS & EYE CARE K?T
LEAFLETS ON DIFFERENT
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HEALTH PROBLEMS :
With a purpose of providing simple and
relevant information on different health
problems. MP VHA published leaflets
on the following
subjects :
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J 1. TB 2. Malaria 3. Scabies 4. Dental
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Care 5. Phneumonia 6. Malnutrition
7. Worms 8. Iodine deficiency 9. Anemia
10. Polio 11. Vitamin-A 12. Diarrhoea
13. Immunization
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Conti i )l
€ pi I
Rs. 6.50
C os i o f ea c a i e a Pi c 1 ■ ?. 5 <; c a i s
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AN EYE KIT
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FOR SCREENINGCASES OF EYE PROBLEMS
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tMUICMBO. I'VXF^MICD > DI T?V! nT’TTD
Madhya Pradesh VHA,
9/4 Manormaganj, Street No.5,
Opp. St. Paul Primary School,
Indore - 452 001.
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Phone : 0731-493 496
Fax : 0731-493 103
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165
/...
goaC of fieaftf for aff can only 6e
/ reached through a fully democratic process :
it must he a programme of heahth for the
peophe, heaCth of the peopCe and heahth hy
| thepeophe....
/
...It is therefore necessary to abandon the
existing centralized and top-down approach
to the organisation of health services and
create a new system of budding from below
with community based health services, dhis
wild be possible in a democratic,
decentralized, and participatory system of
government in which the people in a
community have the authority, resources
and expertise to prepare and implement ad
plans for their welfare, including health. It
is this larger system that one should strive
to create...
- Health for All - An Alternative Strategy ICSSR & ICMR , 1981.
- Media
REACHING HEALTH.pdf
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