Improving Management and Delivery of Outreach Services, Shaping Demand and Strengthening Accountability:
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Improving Management and Delivery
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Improving Management and Delivery
of Outreach Services, Shaping Demand
and Strengthening Accountability:
AN OVERVIEW OF SUKSHEMA'S
COMMUNITY INTERVENTION
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Improved Maternal, Newborn & Child Health
KHPT
Karnataka Health Promotion Trust
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Government of Karnataka
Department of Health and Family Welfare
National Health Mission
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PREFACE
India launched its National Rural Health Mission (NRHM) in April 2005 to tackle the high burden of
maternal, neonatal and child morbidity and mortality in India's rural populations. NRHM, now
converted to NHM to include urban populations as well, particularly in Karnataka has been very
vibrant to respond to the need through a variety of strategies to improve maternal, newborn and
child related outcomes. There are strategies toward service improvement as well as for increasing
demand generation and have yielded much success in the last few years to improve the quality of
maternal and child related outcomes. Despite success in many jurisdictions, several of these
initiatives had not been instituted across all village levels within the districts. According to
information from the DLHS-3 survey, several gaps were seen with regard to the accessibility and
reach of these services to the target groups. These findings indicated the need to understand the
grass root realities contributing to the poor uptake of MNCH services and devise appropriate
strategies to enhance the overall functioning of systems and processes to improve MNCH service
delivery.
In this regard the NHM partnered with BMGF for support to develop and adopt effective technical
strategies and health system approaches to improve MNCH outcomes in Karnataka. This 5 year
technical support project was implemented by KHPT with the support of UoM owing to their strong
expertise in various areas like evidence-based public health program design and implementation and
communitymobiltfation.
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Project Sukshema focussed on eight underserved districts in northern Karnataka (Bidar, Gulbarga,
Yadgir, Bagalkot, Bijapur, Bellary, Raichur and Koppal), where the aim is to improve MNCH service
delivery and outcomes. To achieve these results the project designed and Implemented an
intervention package. It comprised of both technical interventions aimed at quality improvement
and community centric interventions aimed at enhancing skills of frontline health workers and
demand from the community. The experience of the interventions has contributed to the state's
overall MNCH program greatly. Several ideas, innovations and activities have been piloted and scaled
up.
This document is a detailed account of the community centric interventions. It presents the overall
strategy, process details, experiences, achievements and challenges faced in the implementation
process. The project's close partnership with NHM and collaboration with the health department at
all levels has enabled smooth integration of the initiative into the existing MNCH programme. This
document can serve as a resource others working in the area of Maternal Neonatal and Child Health.
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Mission Director
Nario.ial Health mission
SrijSj/astrad, i,a.s
Commissioner
Dept, of Health & Family welfare
Sri. Atul Kumar Thvari. IAS
Principal Secretary.
Dept, of Health & Pamily welfare
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Improving Management and Delivery of
Outreach Services, Shaping Demand and
Strengthening Accountability:
AN OVERVIEW OF SUKSHEMA'S
COMMUNITY INTERVENTION
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LIST OF ABBREVIATIONS
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ANC
Antenatal Care
ASHA
Accredited Social Health Activist
AWW
Anganwadi Worker
BCG
Bacillus Calmette-Guerin
CC
Community Coordinator
DCM
District Community Mentor
DCS
District Community Specialist
DPC
District Program Coordinators
DPS
District Program Specialist
EDD
Expected Date of Delivery
ETT/CDL
Enumeration and Tracking Tool/Community Demands List
FFC
Family focused Communication
FLWs
Frontline Health Workers
Gol
Government of India
GoK
HB-FFC
Government of Karnataka
Home-based- Family Focused Communication
HBMNC
Home-based Maternal and Newborn Care
HBNC
Home-based Newborn Care
IFA
Iron and Folic Acid
IIT
Intimate Interactive Theatre
JE
Japanese Encephalitis
JHA
Junior Health Assistant
KEPT
Karnataka Health Promotion Trust
LMP
Last Menstrual Period
M&E
Monitoring and Evaluation
Maternal, Newborn and Child Health
MNCH
MO
Medical Officer
NRHM
National Rural Health Mission
OPV
Oral Polio Vaccine
PHC
Primary Health Centre
PNC
RCHO
Postnatal Care
Reproductive and Child Health Officer
RP
SCF/AM
Resource Person
Subcentre Forum/Arogya Mantapa
SCMT
Supportive Community Monitoring Tool
TB
Tuberculosis
TC
Taluk Coordinator
THO’
Taluk Health Officer
VEND
Village Health and Nutrition Day
Village Health, Sanitation and Nutrition Committee
VHSNC
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CONTENTS
1. Rationale
1.1 Focus on community engagement and community accountability in MNCH
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1.2 Findings from a qualitative assessment of utilization of MNCH services in Bellary, Gulbarga
and Bagalkot
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1.3 Findings from community-based interventions to improve MNCH outcomes
1.4 Focus on critical gaps in awareness, coverage and utilization of MNCH services and enhancing
outreach practices for Front Line Workers (FLWs)
1.5 Consultations with front line workers to explore their challenges and solutions to address the
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gaPs .......................................
2. Overview of Sukshema’s Community Intervention ...
2.1 Objectives of Sukshema’s Community Intervention
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2.2 Focus of Sukshema’s Community Interventions ....
3. Managing Sukshema’s Community Intervention in the Pilot Districts
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4. Planning and Implementation of the Community Intervention in the Pilot Districts
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4.1 Implementation Step 1: Development of job-aids and tools (FFC materials, ETT, HBMNC
andSCMT)
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4.2 Implementation Step 2: Recruitment and Training of Resource Persons (RPs) in Koppal and
Bagalkdt
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4.3 Implementation Step 3: Conducting The Baseline Community-Based Tracking Survey (CBTS)..
4.4 Implementation Step 4: Training Front Line Workers
5. Implementation of the Community Intervention in the Scale-Up Districts
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5.1 Overall Lessons Learned from Pilot Districts
5.2 Changes in Implementation Strategy in Scale-up Districts
5.3 Implementation Strategy in Scale-up Districts
6. Monitoring and Evaluating Sukshema’s Community Intervention- Community Based Tracking
Survey (CRTS)
7. DRP “Sammilana”- A Formal Handing Over Program
8. Collaborating with Government of Karnataka (Health Department) Staff
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9. Programme Costing
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10. Successes and Way Forward
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ABOUT THE DOCUMENT
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This document is a detailed account of a package of
community centric interventions aimed at enhancing
MNCH outcomes in eight northern districts of
Karnataka. It presents the process and experiences
of implementing the community interventions,
shares intervention results, showcases innovations,
captures field experiences and concludes with lessons
learned and recommendations. The information
used in the document is derived from qualitative
sources including extensive interviews, site visits and
observations over a 2-year period. We hope that this
document serves as a guide for program managers
and policy makers and others interested in learning
from the experience to develop or replicate similar
approaches in India or elsewhere to improve maternal
and newborn care.
ABOUT PROJECT SUKSHEMA
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Funded by the Bill & Melinda Gates Foundation,
the Sukshema project supports the Government
of Karnataka to develop and implement strategies
to improve maternal, newborn, and child health
(MNCH) in alignment with the Government of India
National Rural Health Mission (NRHM).The project
is implemented by Karnataka Health Promotion
Trust in collaboration with University of Manitoba,
St John’s Medical College, IntraHealth International,
and Karuna Trust. The six-year project started in
September 2011.
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To achieve this goal, the project integrated and
aligned key aspects of the Foundations MNCH
strategy with the NRHM in eight districts in
northern Karnataka, with the following four key
objectives:
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The goal of Sukshema is to: Develop and adopt effective
operational and health system approaches within the
NRHM to support the state ofKarnataka and India to
improve maternal, newborn, and child health outcomes
in rural populations.
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3.
4.
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■ An Overview of Sukshema’s Community Intervention
Enable expanded availability and accessibility
of critical MNCH interventions for rural
populations.
Enable improvement in the quality of MNCH
services for rural populations.
Enable expanded utilization and population
coverage of critical MNCH services for rural
populations.
Facilitate identification and consistent adoption
of best practices and innovations arising from the
project at the state and national levels.
Improving Management and Delivery of Outreach Services,
Shaping Demand and Strengthening Accountability:
AN OVERVIEW OF SUKSHEMA'S COMMUNITY INTERVENTION
This report contributes to Objective 4 of the
Sukshema project - to facilitate identification and
consistent adoption of best practices and innovations
arising from the project at the state and national
levels - by documenting the activities to date in
implementing the maternal newborn and child health
(MNCH) community-level interventions.
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RATIONALE
In designing the interventions, the project drew
on the latest evidence on community engagement
and community accountability in MNCH, findings
from a qualitative assessment of utilization of
MNCH services in three districts representative of
Northern Karnataka. In addition, a review of several
community level approaches in other contexts helped
identify critical gaps in coverage, awareness and
utilization of MNCH services.
1.1
Focus on community engagement and
community accountability in MNCH
Evidence shows that to improve MNCH and
reduce morbidity and mortality, efforts should focus
on building capacities at individual, family, and
community levels to ensure appropriate self-care,
prevention, and care-seeking behaviour ’. In limited
resource settings, community-level interventions can
address this, since care-seeking behaviour is strongly
influenced by the socio-cultural environment. 2
The community interventions are designed
specifically to enhance participation of community
level structures in supporting and monitoring the
1 Kerber Kate, Graft-Johnson Joseph, Bhutta Zulfi, Okong Pius,
Starrs Ann, Lawn Joy. Continuum of care for maternal, newborn,
and child health: from slogan to service delivery. Lancet. 2007;
370(9595):1358-1369.
2 Elder John, Ayala Guadalupe, Harris Stewart. Theories and
intervention approaches to health-behaviour change in primary
care. American Journal of Preventive Medicine. 1999; 17(4):275284.
utilization and coverage of MNCH services using
a continuum-of-care approach. This approach is
globally viewed as a core principle for MNCH
programs as a means to reduce the burden of
maternal, neonatal arid child deaths. 1 It promotes
care for mothers and children from pregnancy
to delivery, the immediate postnatal period and
childhood.lt recognizes that safe childbirth is critical
to both maternal and newborn health and that a
healthy start in life is an essential step towards a
sound childhood and productive life. However, for
such an approach to be successful it needs to be linked
to enhancing demand creation at community-level,
improving outreach services to promote good family
care and care-seeking practices, and strengthening
linkages with primary health care services. 3
This is in line with the Government of India’s (Gol)
National Health Mission (NHM) whose main
objectives are to reduce maternal and infant mortality
rates through community-based strategies such as
improving community access to key MNCH services
and building the capacity of community-based health
workers called ASHAs (Accredited Social Health
Activists) who provide community outreach services
and who serve as the first point of contact between
communities and health facilities. The Government
of Karnataka, last year, also identified RMNCH+A
districts which have been identified as priority regions
3 Bhutta ZA, Ahmed T, Black RE et al What works? Interventions
for maternal and child under nutrition and survival. Lancet
2008;371(9610):417-40.
Rationale ■ 9
for improving MNCH outcomes. These districts are
the same as the Sukshema project districts. The focus
of the project has, therefore, been in sync with the
government priorities for improving MNCH.
However, there needs to be a shift in viewing
communities not just as “recipients of services
designed for their benefit” but as “being active makers
and shapers of services, exercising their preferences
as consumers and their rights as citizens’4. As stated
above, communities are often passive recipients
of government programmes and are not active in
advocating for their rights to quality services or even
know what to expect from government programmes.
For example, one of the gaps identified by the
NRHM is that communities are not aware of the
role of ASHAs and do not know what to expect
from this community based volunteer. On the flip
side, ASHAs report that they sometimes struggle to
find acceptance in the community and to be seen
as a credible source of information and support.
Strengthening community accountability is promoted
as a right in itself, and to enhance quality of care,
appropriateness of health service delivery for users,
and patient satisfaction and utilization 5. Engaging
the community in planning and monitoring health
service delivery is central to enhancing the availability,
accessibility, quality and use of the public healthy
system.
The NRHM has positioned community ownership
as central to its strategy, primarily through the
Village Health, Sanitation and Nutrition Committee
(VHSNC). VHSNCs are village-level bodies
comprised of key stakeholders in a village and serve
as a forum for village planning and monitoring.
VHSNCs were formed to ensure that no section of
the village community is excluded from services; to
prepare a village health plan to suit local realities and
necessities; to provide monitoring and oversight to
all village health activities; and to ensure that untied
funds are appropriately used for improving maternal
and neonatal health in the village.
1.2
Findings from a qualitative assessment of
utilization of MNCH services in Bellary,
Gulbarga and Bagalkot
Dr. Sharon Bruce and associates carried out
a qualitative inquiry to explore participants’
4 Bhutta ZA, Ahmed T, Black RE et al What works? Interventions
for maternal and child under nutrition and survival. Lancet
2008;371(9610):417-40.
5 Standing H, London: DFID Health Systems Resource Centre;
2004. Understanding the ‘demand side’ in service delivery:
definitions, frameworks and tools from the health sector.
10
* An Overview of Sukshema's Community Intervention
understandings and health care practices surrounding
pregnancy, the birthing process and care of the
newborn (i.e., first month of life) in Bellary, Gulbarga
and Bagalkot 6.This qualitative inquiry was carried
out as a part of situation assessments by the project
Sukshema in the first year. The study aimed to
determine participants’ understandings of a healthy
pregnancy, including delivery, and ill health in a
newborn; to determine the actions or behaviours
undertaken by participants to facilitate a healthy
pregnancy and delivery, and to promote good health
in the newborn; to determine the available and
preferred health care alternatives for pregnancy,
delivery and care of the newborn; and to determine
the decision-making processes involved in pregnancy,
delivery and newborn care.
It revealed several deep-seated cultural beliefs around
pregnancy and childbirth, women’s lack of decision
making authority in key decisions around pregnancy
and childbirth, low awareness/knowledge around
immediate and exclusive breastfeeding and limited
utilization of government schemes.
Women’s lack of decision-making authority.
The study revealed that the woman’s family (her
husband, her mother/grandmother and her in-laws)
was the key decision maker in issues surrounding
pregnancy and childbirth. Decisions around place of
delivery, care of a newborn and even nutrition during
pregnancy and lactation were either made or heavily
influenced by a pregnant woman’s family.
Cultural beliefs around pregnancy and childbirth
The study identified several cultural beliefs around
pregnancy and childbirth that could adversely affect
the pregnant woman and her newborn. A number
of cultural beliefs exist around nutrition during
pregnancy such as avoiding iron-rich non-vegetarian
foods (meat, chicken and eggs) during pregnancy
because they are ‘hot foods’; avoiding sour and salty
foods because they may cause excessive phlegm
production; using particular herbs or foods to prevent
infections and to reduce ‘expansion of stomach’ etc.
“Pregnant women should take caution during solar and
lunar eclipse and not do any work. Otherwise the baby
will be born with birth defects”
“Coldfoods causes the mother's teeth to become loose and
also increase bleeding after delivery”- Bagalkot
6 Bruce et al.: A qualitative exploration of factors influencing
site of delivery (home, public or private hospital) in three North
Karnataka districts as described by pregnant women, mothers of
neonates, husbands and grandmothers. BMC Proceedings 2012
6(Suppl 5):P7.
Lack of knowledge on immediate and exclusive
breastfeeding.
The study showed that several beliefs and practices
existed about breastfeeding in all three districts. Many
believed that colostrum was ‘bad’ for a newborn and
a mother had to wait for a day or two until her milk
‘comes in’ before breastfeeding her baby. Some even
reported that their doctors advised them to do so.
Among those that believed that colostrum was bad for
newborns, many reported feeding newborns several
pre-lacteal supplements such as cow’s milk, herbal
drinks, sugar water etc.
“Bad milk comes out the first day of birth if it is given to
babies, it causes lumps in their stomach and causes them
to vomit”- Gulbarga
Limited Utilization of Government Schemes
The study showed that while most respondents were
aware of the Government incentives and schemes
around pregnancy and childcare, many reported not
receiving any because of a number of reasons. An
important reason for this was that they did not deliver
at a Government health facility or delivered at home
and thus could not avail of the incentives associated
with public institutional delivery. Although many
reported that cost was a major prohibitive factor in
delivering at private, hospitals, respondents felt tjiat
the additional costs were worth it since they perceived
quality of care and the perceived quality of care and
the facilities themselves to be superior at private
versus government hospitals. Another drawback to
choosing to deliver at home or at private hospitals
could be that ASHAs and Anganwadi Workers
(AWW) are unable to assist those families who
are eligible to receive incentives, but do not access
government health care services, since all Front Line
Workers are linked to government facilities.
“We submitted papers, but no result; we did not bother
applyingfor second child”- Bagalkot
The study stresses the importance of designing
community interventions that address these gaps
in knowledge and shape demand for facility
delivery. It also emphasizes on the need for
communication messages that are family-centric
vs woman-centric.
1.3
______________________________________________________________________________________________________________________________________________________________________________________________________________________
Home-based care of newborns - Indian Studies
There are several publications on the SEARCH,
Gadchiroli field trials 7,8 that assessed the effects
of a home-based newborn care (HBNC) package
on neonatal and perinatal mortality in rural
Gadchiroli in India. The package of interventions
had a combination of both primary and secondary
prevention interventions. The primary intervention
focused on influencing mothers’ and caretakers’
behaviours and the secondary intervention directly
addressed management of sick newborn babies. The
interventions were delivered to the communities
through a cadre of village health workers trained in
neonatal care who made home visits and managed
birth asphyxia, pneumonia, premature birth or
low birthweight, hypothermia, and breast-feeding
problems. They diagnosed and treated neonatal sepsis
and pneumonia. Assistance by trained traditional
birth attendants, health education, and regular
supervisory visits were also provided. The trials
showed large reductions in neonatal and perinatal
mortality rates and sustained gains at the end of the 7
year-trial that carried forward to the first year of life.
Similar reductions in neonatal mortality rates were
observed in the rural copimunities of Shivgarh, Uttar
Pradesh in those homes receiving postnatal home
visits along with a preventive package of interventions
for essential newborn care.9,10
Other Community-based interventions
Studies in Guatemala n, Bangladesh 12,
7 Bang AT, et al., Effect of home-based neonatal care and
management of sepsis on neonatal mortality: field trial in rural
India. Lancet 1999; 354: 1955-61
8 Bang AT, et al., Neonatal and infant mortality in the ten years
(1993 to 2003) of the Gadchiroli field trial: effect of home-based
neonatal care. J Perinatal 2005; 25: S92-107
9 Kumar V, et al., et al. Effect of community-based behaviour
change management on neonatal mortality in Shivgarh, Uttar
Pradesh, India: a cluster-randomised controlled trial. Lancet 2008;
372: 1151-62
10 Baqui AH, et al., Impact of an integrated nutrition and health
programme on neonatal mortality in rural northern India. Bull
World Health Organ 2008; 86: 796-804
Findings from community-based
interventions to improve MNCH outcomes
_______________________
related to community-based interventions and their
effects on MNCH outcomes are summarized below:
■.
In designing the community interventions, the
Sukshema project reviewed findings from similar
interventions across a variety of settings in India and
other countries. Highlights of published findings
11 Bartlett A, et al., Neonatal and early postneonatal morbidity
and mortality in a rural Guatemalan community: the importance
of infectious diseases and their management. Pediatr Infect Dis J.
1991 Oct;10(10):752-7.
12 Baqui AH, et al., Effect of community-based newborn-care
intervention package implemented through two service-delivery
strategies in Sylhet district, Bangladesh: a cluster-randomised
controlled trial. Lancet 2008; 371: 1936-44
Rationale ■ 11
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Pakistan 13 and Kenya 14 confirm that community
based intervention studies can positively influence
maternal, newborn and child health outcomes,
particularly with accompanied referral to nearby
health facilities.
The Kenyan study evaluated the effectiveness of the
community health strategy in delivering community
based maternal and newborn care interventions as
a means of influencing the adoption of essential
maternal and newborn care practices among mothers
with children aged 0-23 months. The results showed
significant changes in ANC attendance, skilled
deliveries and exclusive breastfeeding.
In summary, the findings from the evidence
review suggest that the community interventions
should include components that focus
on delivering maternal and newborn care
interventions using community outreach
techniques. It also‘suggests that trained
community health workers are used for outreach
and timely referrals to available health services.
1.4
Critical gaps in coverage, awareness and
utilization of MNCH services
Coverage: Available data indicates that the coverage
of target populations for MNCH services is poor
and inequitable - there are unreached populations
for many services, and those who are reached do
not receive a complete package of services through
the continuum of care from antenatal to newborn
care. For instance, as per the DLHS (District Level
Household Survey) for northern Karnataka, while
74% of currently married women (15-44) received
tetanus toxoid injections, fewer than 27% received
the full set of ANC visits. Similarly, only 52% of
currently married women (15-44) received postnatal
care visit within 48 hours of delivery 15. Vulnerable
populations, such as those belonging to scheduled
castes and tribes as well as migrants seem to be left
out of the registers maintained at the Sub Centres.
While the proportion of institutional deliveries has
risen in recent years, only a small proportion of
mothers* stay for 48 hours after delivery in facilities.
13 Bhutta ZA, et al., Implementing community-based perinatal
care: results from a pilot study in rural Pakistan. Bull World Health
Organ 2008; 86: 452-9
14 Wangalwa G, et al., Effectiveness of Kenya’s Community
Health Strategy in delivering community-based maternal and
newborn health care in Busia County, Kenya: non-randomized
pre-test post test study. Pan Afr Med J. 2012;13(Supp 1): 12
15 District Level Household and Facility Survery-3, 2007-08
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■ An Overview of Sukshema's Community Intervention
State Health Management Information System
(HMIS) data showed that only 38% of women
delivering in institutions during August 2010-July
2011 stayed for at least 48 hours after delivery.
Awareness: Currently, there is a lack of awareness in
the community on healthy practices and available
services for the mothers and newborns through the
continuum of care. Often, existing cultural practices
and beliefs, and poorly informed decisions, become
barriers to access MNCH services. The findings from
Sukshema’s assessment of community facilitators
and barriers for utilization of MNCH services
have reaffirmed that practices related to pregnancy,
delivery, and post-natal care, as well as the decisions
to seek care, are strongly influenced by the family 16.
The elders in the family, particularly the mothers-inlaw and the mothers, as well as the husband, play an
important role in decisions on seeking care, as well as
in perpetuating unhealthy practices.
The ASHAs being members from the neighbourhood,
are the community resources to facilitate a positive
change in awareness and practices around maternal
and child health through the continuum of care.
Although ASHAs undergo a fairly comprehensive
initial training on roles and responsibilities, in
practice, the training focus has been on referrals.,
or bringing people to services — particularly for
institutional delivery. There has been very little
emphasis and expectation from them as “change
agents” — in influencing awareness and practices
related to critical MNCH services. There are no
user-friendly interpersonal communication materials
and job-aids to facilitate ASHAs in functioning as
change agents. There also is a need to focus on key
MNCH issues that the ASHAs need to emphasize
while working with the community to improve
their awareness and practices. In addition to this,
identifying key target groups is important.
Similarly, Anganwadi Workers (AWWs) have been
working on components related to nutrition during
pregnancy (anaemia) and childhood (exclusive
breastfeeding and timely complementary feeding).
However, they lack effective communication skills,
tools and job-aids to effectively bring about positive
changes in the awareness and practices around
nutrition issue’s.
Postnatal care (PNC) gaps: The first days following
delivery are when women and newborns are at
greatest risk, yet it is often during this time that the
system breaks down. Due to constraints of workload
and travel, Junior Health Assistants (JHAs) are not
16 Community Assessments & In-Depth interviews, MNCH
Situational Assessments, “Sukshema”, KHPT, 2010-11
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able to make timely PNC visits in the community.
One of ASHAs’ roles is to visit mothers and newborns
in their homes, yet many ASHAs do not know what
they are supposed to do during post-natal visits.
According to the Government of Karnataka (GoK)
guidelines, the ASHA is supposed to weigh the
newborn as well as conduct a health check-up during
each of these visits, and counsel on danger signs for
mothers and newborns 17. Despite PNC visits being
incentivized for ASHAs, many recently delivered
women do not receive PNC visits from ASHAs and
the quality of those visits is often lacking.
•
1.5
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Consultations with front line workers to
explore their challenges and solutions to
address the gaps.
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Several gaps were identified during consultations with
frontline health workers.
They are:
•
Limited knowledge among women and their
families on healthy MNCH practices and
available services
•
Cultural practices and beliefs that act as barriers
for positive health seeking behaviour
•
Poor community engagement in supporting and
monitoring MNCH service uptake
•
Poor coverage of target populations by frontline
workers for MNCH services- unreached target
populations and reached by incomplete package
of services Currently there are no tools and
methods available for FLWs to map and track
pregnant women and children to enable them
to monitor and plan coverage out for services
through the continuum of care.
17 Guidelines for incentives to ASHAs, Directorate of Health and
Family Welfare Services, Government of Karnataka, July 2011
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The current tools for the FLWs do not present an
integrated approach to the health of the mother
and the baby, nor help her be a change agent to
encourage improved MNCH practices in the
community.
There is a need for innovative tools that can
aid FLWs in screening for danger signs among
mothers and newborns and be able to quickly link
them to skilled care when needed.
Lack of capacities among the FLWs to counsel
and engage family members of the pregnant
women to change attitudes/ behaviours as well as
support them in accessing care services
Lack of uniformity in planning by ASHAs
Poor coordination and communication between
the ASHAs and the JHAs
Lack of job aids/ checklists to help ASHA workers
in making their home visits effective, particularly
for screening for danger signs among pregnant,
postpartum mothers and newborns so that they
are able to quickly link them to skilled care when
needed
Lack of tools to help ASHA identify specific
counseling needs
Lack of community platforms for planning and
monitoring village health programs.
The perception of monitoring very authoritative,
probing and, supervisory rather than supportive
and participatory
Lack of ownership and accountability of the
village health programs in general and MNCH
issues in particular in the community
Widening gap between the needy community and
the health service system
Poor awareness and hence lack of participation
of VHSNC members in supporting the frontline
health workers at the village level to improve
MNCH outcomes
1
1
s
02
OVERVIEW OF SUKSHEMA'S
COMMUNITY INTERVENTION
In order to address the above gaps, Sukshema’s
package of community interventions was envisioned
after joint deliberations at the field level. All the
community interventions are linked to one another
and aim at addressing gaps at the level of the Front
line health worker and community structures such as
the VHSNC. The package of interventions comprise
of both Tools and Processes that address the felt
needs on the field.
The community interventions are designed on the
premise of the principle of decentralization. It has
been an effort to develop scalable and effective
strategies evolved by the community members
themselves. In the Karnataka context, as in other
regions of India, communities have commonalities as
well as diversities. Addressing both these are critical
while designing and implementing interventions. The
community intervention package has drawn from
the cultural principle of people leading people and
communities changing communities. Through the
CI package efforts were to integrate all interventions
rather implement the programs in a parallel fashion.
Since the larger community is the envisioned
beneficiary, the receiver’s involvement at every stage
of the interventions’ plan, design and implementation
has been elicited and provided scope for.
2.1
Objectives of Sukshema’s Community
Intervention
The Sukshema community interventions have been
designed and implemented with the following
objectives:
1. To increase the frequency and quality of
interactions between beneficiaries and frontline
health workers (FLWs).
2. To ensure that all pregnant and postpartum
women, newborns and infants enter into MNCH
care continuum.
3. To ensure that all pregnant and postpartum
women, newborns and infants continue in
MNCH care continuum.
4. Enhance participation of community-level
structures in supporting and monitoring the
utilization and coverage of MNCH services.
2.2
Focus of Sukshema’s Community
Interventions
Sukshema’s community interventions have three main
areas of focus:
•
Maternal health care of pregnant women and
14
■ An Overview of Sukshema's Community Intervention
•
•
mothers of newborns (antenatal and upto 42 days
postpartum)
Health care of infants (upto one year of age)
including newborns (upto 28 days)
Health care of children (upto 18 months)
The main strategy for Sukshema’s community
interventions is to empower the FLWS (ASHA, AWW
& JHA) and community representatives to sustain
a supportive community monitoring environment
through tools-and-processes based facilitation and a
mentoring approach.
The project’s core target groups for the community
interventions are the FLWs (ASHAs, AWWs and
JHAs) and the Supportive Community Monitoring
Team comprised of 6 VHSNC members.
Sukshema’s MNCH community intervention
integrates elements of improving tracking of pregnant
women and children; management and delivery of
outreach services with components that strengthen
accountability and shape demand (refer to text box).
Components of Sukshema’s Community
Intervention
lhere are 5 main components of Sukshema’s
community intervention that aim to improve
management and delivery of outreach services,
shape demand and strengthen accountability.
Improving management and delivery of
outreach services and shaping demand
1. -Community Demand List to help-in
enumeration and tracking for ASHAs to
improve coverage (CDL)
2. Integrated maternal and newborn
management tool for ASHAs to improve
identification and actions for postnatal
danger signs (HBMNC)
3. Family focussed communication tools and
materials for ASHAs to use with families to
influence awareness and practices (FFC)
Strengthening accountability
1. Supportive Community Monitoring tools
(SCMT) for Village Health Sanitation
and Nutrition Committees (VHSNCs) to
strengthen accountabilicy
2. Sub centre forum (SCF - Arogya Mantapa)
!
i
FLWs and VHSC members to collectively identify
issues in their individual areas of work, shape
appropriate solutions jointly and support each other
to implement it, RPs will also facilitate formation of
Arogya Mantaps (AMs) or Sub-centre forums whose
members will be ASHAs, JHAs, Anganwadi workers
and VHSC presidents within a given sub centre’s
limits.
CDL
SCF
SCMT
FFC
ASHAs facilitated the implementation of the
community intervention, in tandem with their
supervisors, the Junior Health Assistants (JHAs).
During the pilot phase of the implementation,
the project also employed a new cadre of full time
Resource Persons (RPs) who mentored and supported
ASHAs; they were integrally involved in all project
implementation activities. The Sukshema project
trained RPs (Resource Persons) in all components
of the comrhunity'intervention, starting with FFC
training.
ASHAs use CDL to track gaps in coverage across
essential MNCH services and HBMNC to guide
ASHA in her home visits helping her recognize
danger signs to facilitate timely referral of the
pregnant women and the new born. These tools help
manage gaps in knowledge, awareness and access
to MNCH services within their communities. The
FFC trainings also help enhance the coordination
and coordination of among the frontline workers
as well as guide them with necessary skills to adopt
a family centric approach in their outreach and
interactions during counselling. ASHAs also enhance
community knowledge and awareness and influence
practices on key MNCH issues through FFC-based
communication tools and materials during their
home visits. The use of these tools and aids has helped
ASHAs and JHAs improve referral processes and .
ensure continuity of care for referred cases.
In addition to mentoring and supporting ASHAs, RPs
will also facilitate the formation of SCMT committees
within VHSNCs that will be trained in the SCMT
tool, which is geared towards strengthening
community ownership of and engagement in
planning and monitoring availability, accessibility,
quality, utilization and coverage of MNCH services.
In an on-going effort to create an opportunity for
The implementation strategy of the community
interventions occurred in two phases. In Phase 1,
all 5 components of the community intervention
were launched in two pilot districts - Koppal and
Bagalkot. A total of 106 RPs - 53 for Koppal and 53
for Bagalkot were recruited and trained to provide
support to 8270 ASHAs and 2007 JHAs in the two
districts. Support the FLWs (ASHAs, AWWs and
ANMs) through a cadre of Resource Persons. Support
was leveraged from the government departments for
rolling out the trainings.
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In phase 2, the project scaled up the community
intervention in the other 6 project districts after
certain modifications and adaptations based on the
experience in the pilot districts and in consideration
of other administrative/ management implications in
Phase 2.
The community interventions package is intentionally
being implemented across all districts to derive lessons
about implementing the intervention at scale. It is
anticipated that if this intervention proves successful,
the GoK would adopt the processes, tools and job
aids to replicate this intervention in other districts in
the state.
Overview of Sukshema's Community Intervention ■ 15
%
MANAGING SUKSHEMA'S COMMUNITY
INTERVENTION IN THE PILOT DISTRICTS
Context
The Sukshema project developed a management
structure and management processes to oversee
implementation of the community intervention.
A core technical managers’ team, which handles
both technical and administrative matters based in
Bangalore, provides guidance and support to the field
teams. Every member from the central core team also
played the additional role of the district program
coordinators (DPC) who acted as the point persons
for the three interventions at each of the districts.
The core team at the district level consists of District
Community specialist (DCS), District Program
Specialist (DPS) and District M&E Specialist, who
are the Technical Leads for the different components
of the Sukshema project such as community
interventions, mentoring interventions and M &
E, respectively. This team has a mandate to support
the taluk level teams headed by taluk community
coordinators and supported by 8-12 Resource persons
(RPs) each. Each of these resource persons are in
charge of 1-2 PHC areas.
Figure 1: Management Structure of the
Community Interventions in Pilot Districts
District
Program
Specialist
RP
Taluk
Co-ordinator
District
Program
Co-ordinator
District
Community
Specialist
RP
RP
Taluk
Co-ordinator
District
M&E
Specialist
District Program Coordinator
As mentioned above, DPCs are based centrally n
Bangalore. They routinely visit the project districts
to provide supportive supervision to the DCS,
DPS and M&E specialists, TCs and RPs, advise
on management processes and anticipate and
troubleshoot issues as needed.
RP
RP
District Community Specialist
At the district level, a District Community
Specialist (DCS) based in each district is
responsible for implementation, follow
up and monitoring of the community
interventions in the district. The District
Community Specialists are expected to:
• Assist in the recruitment of RPs and
TCs
•
Build rapport with the FLWs
•
Provide handholding support to TCs
and RPs in their routine field activities
• Conflict resolution
• Hold district level review meetings
• Review and summarize RP reports
along with TCs
• Hand hold TCs in identifying gaps
using CDL output every month
• Prioritize PHCs for greater focus and
also follow-up on CBTS outcome
•
Coordinate field visits for staff, trainers,
consultants and other visitors
•
Interface and liaison with government
district officials
•
Regularly update the central team
(DPCs) about the implementation
activities in their districts.
•
Coordinate with the DPS and M&E
specialists on ground.
•
Convergence/ integration of CI and
mentoring initiatives
Taluk Coordinators (TC)
TCs are based at the Taluk level in each of
the pilot districts. They are responsible for:
•
Mentoring and handholding RPs in
their respective taluks.
•
Interfacing with taluk health officials
•
Having more of an advocacy role
with the Health Department and
DWCD (dept of women and Child
Development) at the taluk level
• Training, handholding and supportive
supervision of RPs
• Assist RPs with FEW trainings and
handholding
• Hand hold RPs in identifying gaps
using CDL output every month
•
Prioritize sub centres for greater focus
and also follow-up on CBTS outcomes
•
Regularly update the DCSs about
implementation activities in their
Taluks
16 ■ An Overview of Sukshema’s Community Intervention
Hi
04
PLANNING AND IMPLEMENTATION OF THE
COMMUNITY INTERVENTION IN THE PILOT DISTRICTS
Implementation Strategy
The implementation strategy adopted by Sukshema
includes:
•
Field test the methods and tools in 2 districts —
Bagalkot and Koppal
• Support the FLWs through a new cadre of
Resource Persons (RPs)
•
Leverage the support from the government
departments for rolling out the trainings in tools
and methods
• Timely and regular review of the interventions’
impact on key indicators towards improvement of
MNCH
•
Scale up the tools and methods to other districts
based on the learning in two districts
Preparation and implementation of the various
components has been a step-wise process as noted
below:
Implementation Step 1: Development of job-aids,
tools, processes and mechanisms to support FLWs
with community and FLW consultation
Implementation Step 2: Recruitment and Training
of RPs
Implementation Step 3: Baseline CBTS surveys
(refer to the Monitoring Section)
Implementation Step 4: Training Frontline Workers
a. FFC Roll-outs
b. CDL Roll-out
c. HBMNC Roll-out
d. Arogya Mantapa Roll-out
e. SCMT roll-out
4.1
The timeline for these activities in the Pilot districts is
presented below:
IMPLEMENTATION STEP 1:
Development of job-aids and tools (FFC
materials, ETT, HBMNC and SCMT)
Context
Implementation Steps
in Pilot districts
Dates
1. Development of job
aids and tools
April, 2012
2. Recruitment and
Training of RPs
March 2012
2a. FFC Training of
Trainers (ToT) for RPs
May, 2012
2b. ETT Training of
Trainers (ToT) for RPs
Sep 2012
S
n
2c. HBMNC Training of Jan 2013
Trainers (ToT] for RPs
3. Baseline CBTS
surveys
June, 2012
4 .Training Front-line
Workers (ASHAs and
JHAs)
Aug, 2012
a. FFC Roll-outs
b. CDL Roll-out
c. HBMNC Roll-out
d. Arogya Mantapa
Roll-out
e. SCMT roll-out
I'
I
!
■
July, Aug & Sep 2012
Oct, Nov & Dec 2012
Jan, Feb 2013
Sep 2012
May 2013
■J
Currently there are no tools and methods available
for ASHAs to map and track pregnant women and
children; to help them monitor and plan outreach
services through the continuum of care. Also, the
existing tools do not present an integrated and
comprehensive approach to the health of the mother
and the baby, and do not help ASHAs to tailor their
behaviour change messages to encourage improved
MNCH practices in the community(do you also
want to add that there are no user friendly tools
for community monitoring or platforms/ process
for coordination). There was also lack of adequate
supportive supervision for FLWs(good to add this
in the gaps - one ASHA mentor per taluka of 200
ASHAs was hardly sufficient for supporting or
reviewing ASHA work).
The project has developed, field tested and
implemented a set of tools and job-aids that equip
ASHAs with competencies in improving the
coverage for routine MNCH services, help in better
communication with families about the importance
of availing MNCH services and adopting healthy
practices for pregnant women and newborns, and
help them screen, identify and refer danger signs,
especially during the critical postnatal period.
For the development and pretesting of tools and
training modules and the required processes for
implementation, the following activities were carried
out prior to finalizing tools and job-aids:
Planning and Implementation of the Community Intervention in the Pilot Districts ’ 17
x
STEP la: A tool development consultation workshop
was organized. The participants in this workshop
included a selected group of ASHAs (28), ANMs (8),
AWWs (5), ASHA mentors (2), VHSC/Panchayat
members (6), RPs (4), Taluk Coordinators (2) and
district coordinators (2), the project technical leads
and managers, district program specialists and district
M & E specialists.
The objectives of the workshop were to:
i. draft the tools for FLWs and community
structures
ii. draft the guidelines in the use of these tools
iii. draft the training module
iv. draft the training roll out plan.
The involvement of the target groups (FLWs and
community structures) in the drafting of tools and
training methods helped the project to achieve a set of
tools that are relevant in the field, that are more likely
to be helpful to the FLWs and community structures.
This workshop was a three day long intensive sessions
where the project staff and the FLWs discussed and
critically evaluated the relevance, applicability and
usefulness of the interventions and the tools. After the
workshop, the tools and the intervention processes
came closer to the reality on the ground.
STEP lb: The draft tools and training modules
developed in the workshop were pretested and
finalized. The finalized Community Demand List
(CDL), Home-based Maternal and Newborn Care
Tool (HBMNC), Family-Focussed Communication
(FFC) tools and Supportive Community Monitoring
tools (SCMT) were ready for the ground following
this process.
4.1.1 Family Focused Communication (FFC)
Purpose
FFC intervention was planned strategically to address
the gaps seen among the front line workers in the
field. ASHAs, AWWs and JHAs lacked motivation,
skills and perspective on the causes of and the
solution to high maternal and infant mortality and
morbidity in Koppal and Bagalkot. Another key
gap that FFC aimed to address was that the women
failed to engage with family members while trying to
communicate healthy practices and accessing services
during the pregnancy and child birth. In addition to
this, the ASHA, JHA and AWW seldom met together
to discuss challenges and work together for a common
objective.
Thus, a need was identified for an intensive training
that brings these three key workers together and
takes them through a process of critical thinking,
18
* An Overview of Sukshema’s Community Intervention
reflection and evaluation of issues around MNCH
the gender-social perspectives. It is also primarily
intended to put into perspective how realities of
gender roles, power structures and inequalities shape
a woman’s behaviours and practices. FFC training
also emphasises the coordination between all the
three front line workers, ASHA, AWW and JHA, to
avoid duplication of efforts and build an enabling
environment where all three of them can work
effectively through mutual support towards improving
the health of mothers and infants.
Results: Development ofFFC
FFC was chosen as the key tenet of Sukshema’s
community intervention in order to address the
following gaps in order to improve outreach and
communication:
•
Poor or no focus on significant family members in
the communication process.
•
Existing materials were information- oriented
rather than behaviour- oriented. They were not
user friendly.
• Tools and job aids were neither ASHA- friendly
or beneficiary-friendly.
•
Birth preparedness was not the focus in any of the
materials
•
None of the materials addressed the male folk
•
Lack of focussed communication messages across
the MNCH care continuum.
VOICES FROM FFC TRAINING
“In my 30 years ofexperience I have not attended
a training ofthis kind. - JHA, Bagalkot
“Uns is the first time that all the FLWs were
- brought under the same rooffor a trainings. It
was an excellent thing to do”
“While I did home visits earlier my concentration
was only on pregnant women!mother/child, but
at the end ofthis training I realised thatfamily
members also should be considered as they have
greater injluence on women” — ASHA, Bagalkot
“First ofall, our perceptions need to change.
We need to understand that we are workingfor
WOMEN and not justfor any dept. ”-AWW
Koppal
“We need to think beyondjust medical causes into
deeper social causes to bring abourholistic well
bring of women”
i
♦
The evolution of FFC comprised of activities to
ensure that communication is effective and desired
messages are transferred to the beneficiaries. Linder
this component of the intervention, behaviour change
communication materials, keeping the woman and
her family as focus, were developed and introduced to
the FLWs. The following activities were carried out as
part of FFC:
FEW reminder cards are a set of 30 rotatable,
business or visiting card-sized cards strung
together on a key ring. Each card has messages and
corresponding pictures on both sides. Therefore,
there are about 60 messages based on eight
communication objectives listed below:
1. Birth preparedness
2. Danger signs during pregnancy
3. Danger signs during delivery
4. Danger signs in women during the PNC
period
5. Danger signs in the newborn
6. Anaemia
7. Newborn care
8. Family planning
1. FFC training for ASHA, AWW and JHA
This training first establishes an understanding among
women about the social and gender contexts around
the issue of MNCH through its initial sessions and
moves on to build their communication skills and
coordination functions not just as individual workers
but as a team that has a common goal- to improve
MNCH. The FFC training was structured in such
a way as to facilitate attitudinal changes and dispel
individual misconceptions and roadblocks. It was so
designed that the FFC training was the first training
that all three FLWs attended; in order to provide a
good foundation for the project to start work. It has
a three day training module in place which addresses
socio-cultural and gender issues.
FLWs are taken through 8 main topics areas over the
course of 3 days. These are:
•
FFC concept and the need to focus on families
•
How to communicate- Assessing and building
communication skills
•
Status of women in society
• Analysis of gender issues and impact on MNCH
•
Health services for improving maternal and child
health
• The need for coordination among FEW
•
Roles and responsibilities of FEW
• Attitudes of FEW
The very last session gives the FLWs an opportunity
to provide feedback and the general consensus is that
all the FLWs appreciate the content and the training
methods (refer to box below).
This material is linked to the HBMNC Tool which is
intended to help ASHAs counsel women.
Figure 2: Image of the Index of the ASHA
Reminder Cards
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Advantages ofthe cards
•
"
•
•
•
2a. Reminder cards for FIWs - a set of cards
that can easily be carried and referred by the FLWs
during the home visits, to remind them about
the key messages that need to be conveyed to the
woman and her family members during home visits.
■■':
W?****^ ***^*,(**W*
2. FFC materials
FFC material focuses on enhancing the ASHA’s
skill of communicating with the woman as well
as her family members and trains her to plarf her
communication messages based on the need and the
context within each family. The 2 key FFC materials
developed by Sukshema are FEW reminder cards and
a birth-preparedness calendar for pregnant women.
etcLf
The cards are very handy because of their size
and can be easily carried by ASHAs in their bags
wherever they go.
Each of the 8 thematic areas have been colour
coded and cards with messages under each area
follow the same code, making it convenient for
ASHAs to easily choose the right card with the
relevant message.
Each card has either a green or a red symbol in'
the corner. The cards with the red symbol indicate
danger signs that need immediate referral to
facilities. The green symbol directs ASHA for
onsite counselling.
Every card is dominated by a visual that conveys
the message and has minimal text. This makes it
easily understandable for rhe ASHA. These images
are black and white with colour being used only
in aspects that need to capture the attention of
the ASHA.
Planning and Implementation of the Community Intervention in the Pilot Districts ■ 19
1.
All cards are attached to a key ring which makes
them rotatable.
The cards are printed on thick, laminated paper
that protects them from water and routine wearand-tear.
They easily replace bulky reference material
since they have the same information in a more
minimalistic fashion serving the ASHA’s purpose.
•
•
•
Use ofcards
ASHA will use these cards as reminders to ensure
that their communication messages are focussed,
complete and timely. She could also use these
cards during her one-on-one interaction with
women during ANC, INC and PNC periods.
2b. Birth Preparedness calendar - The purpose of
the calendar is to help pregnant women and their
families orient themselves on pregnancy and birth
preparedness. The birth preparedness calendar is
designed in the form of a table calendar with 15
pages. It has messages that focus on the aspect of birth
preparedness, printed on both sides of a page.
All the messages in the calendar are sequential and
direct the women to prioritize their actions with
respect to birth preparedness. Some of the messages
communicated are:
1. Importance of registration and testing
2. Iron tablets- Myths and misconceptions
3. Nutrition and vaccinations
4. Lifestyle during pregnancy
5. Danger signs during pregnancy
6. Government Schemes and how to avail them
7. Institutional delivery
8. Savings
9. Preparedness with respect to transportation to the
health facility, labour partners, finances, babies’
clothes
10. Breast feeding and new born care
Figure 4 : A page from the Birth Preparedness
Calendar
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Figure 3: Image of a danger sign in Newborns
Advantages ofthe calendar
•
9.
•
•
The messages are communicated throughout the
calendar using a simple storyline contextualised to the
womens local realities.
Every page in the calendar has three parts:
1. The storyline with a picture, related to the key
communication message.
2. Creative ideas on cooking, mehndi and rangoli/
games/ riddles/ puzzles that are usually of interest
to women in rural areas. This helps women stay
involved and interested.
3. Home and beauty tips for women to use in their
daily life to motivate women to keep reading the
calendar and not discard it.
20
• An Overview of Sukshema's Community Intervention
•
•
It is handy and can be placed anywhere in the
woman’s house and does not need to be hung.
Its design ensures that it is visible to people
viewing it from either side.
Each page has either a green or red symbol
in its corner. The pages with the red symbol
indicate danger signs and alert women to seek
immediate care at the nearest health facility. The
green symbol indicates healthy practices during
pregnancy.
The storyline keeps the interest of the reader. The
story line is communicated through drawings
which are rustic keeping the local context in
mind. The drawings are black and white with
colour being used only in aspects that need to
capture the attention of the woman or her family.
Though it is intended as a birth preparedness
calendar, it has information across ANC, INC
and PNC stages so that that the woman and her
L
•
•
field.
Use ofcalendar
FFC training needs to focus more on changing
attitudes and perspectives rather than building
FEW skills. Gender and social issues should
dominate the content of the trainings.
Training methodology is critical for FFC.
Participatory approaches and involvement of all
the FLWs is essential for its success.
All FLWs appreciated the pictorial nature of the
ASHA reminder cards. It was particularly useful
for ASHAs with low literacy skills.
Linking the reminder cards to the HBMNC tool
is useful in supporting the ASHAs improve the
effectiveness of carrying out home visits.
•
This calendar will be provided to every
beneficiary. She will use it to orient herself and
be well informed about her pregnancy. This can
also be used to keep the other family members
involved with the womans pregnancy. This will
also help the ASHA to build a rapport with the
women during her initial visits.
•
•
•
Lessons learned: FFC training and material
development
•
The training sessions need to be linked ensuring
that the messages of one session are connected to
the session that follows. It is crucial to provide a
sense of continuity since otherwise, the focus may
shift and the outcome may be watered down.
Training needs to be followed immediately by
handholding support so that the learning is
immediately translated into actual action on the
•
family are well informed and prepared right from
the beginning.
The last page of the calendar has a list of
questions which either the ASHA can ask the
woman during her home visits or the woman can
use to check how well she has internalised these
messages.
The FFC training paves the way for the
other interventions to be launched. All the
interventions need to be viewed holistically as
a package rather than as individual activities at
every stage of implementation.
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4.1.2 Community Demand List (CDL)
Purpose
CDL 1 is a visual tool that will help ASHAs list
their target population (pregnant women, women
who have recently delivered and newborns) in their
allotted geographic area in a particular month, and
track this population throughout the continuum of
care, i.e. pregnancy, delivery, 42 days post delivery
and 18 months of immunization of a child. It allows
ASHAs to organize outreach information into 6
broad categories: identification details, antenatal
care details, delivery details, post natal care details
and immunization details. Additionally the tool has
information on the identification details of the ASHA
herself - the district, taluka, PHC, Sub centre and
village names as well as the estimated number of
pregnant women in her area, as per the Community
needs assessment carried out by GoK.
This tool attempts to address the following gaps at the
frontline worker level:
•
Confusion on who is responsible for planning
•
Lack of uniformity in planning
•
Communication gap between JHAs and ASHAs
•
Lack of clarity on the purpose of planning
•
Lack of a common format/registpr for data entry
• Using multiple registers for entry
• Lack of ability to track a registered mother across
the care continuum
• No provision to track migrant women
Components of CDL 1
The CDL 1 has the following components:
a. Tracking tool for ASHA in her area (CDL 1)
b. Community Demand List (CDL 2) which is a
self reflection and planning and consolidation tool
for the ASHA
c. CDL 3 which is a self-reporting tool
d. Guidelines for the use of both the tools that has
standard definitions for every indicator
a. Tracking tool (CDL 1)
The following information is collected in this tool by
the ASHA for every given pregnant woman in her
area. There‘are a total of 59 indicators in this tool,
some of which are listed below.
Section 1: Identification details
(1) Serial number
(2) names of the woman and her husband as well as
her blood group
(3) ASHA registration- Registration of the name of
pregnant woman, new mothers and children also
includes the date of registration
(4) Thayi card number and date issued
22
■ An Overview of Sukshema’s Community Intervention
(5) contact number of the woman
(6) current age of the woman
(7) Caste group-whether the woman belongs to a
scheduled caste or a scheduled tribe
(8) whether the woman has a BPL card or not (9)
current gravida and para of the woman
(10) and (11) number of male and female living
children
(12) age of the youngest child
(13) Complications experienced during the previous
pregnancy/delivery
All this information is collected during the first time
the ASHA meets a woman and is used to determine
whether there is a need to prioritize services.
Section 2: Antenatal care (ANC) and delivery
details
In this section the ASHA records details of ANC
services utilized by the woman — either directly
through the ASHA or through the JHA, AWW or at a
private facility. The details include
(14) Date of last menstrual period - LMP,
(15) expected date of delivery — FDD
(16) gestational month at the time of registration
(17) , (18), (19) and (20) dates of first, second, third
and fourth ANC checkups before delivery
(21), (22) ar^d (23) dates of receiving the first, second
and booster doses of Tetatus Toxoid (TT) injection
(24), (25) and (26) dates and number of Iron-Folic
Acid (IFA) tablets received — in three separate visits,
and
(27) Complications associated with the current
pregnancy.
(28) Serial Number given to Pregnant Woman
The delivery details in ETT include:
(29) date and place of delivery
(30) type of delivery - caesarean, assisted or normal
(31) Name and sex of the newborn, and
(32) Birth weight of newborn
Section 3: Postnatal care (PNC) details
The post-natal care details include
(33), (34), (35), (36), (37) and (38) dates of post
natal care visits on the 3rd, 7th, 14th, 21st, 28th and
42nd day after the delivery and whether the woman is
currently using family planning
Section 4: Child immunization details
The immunization details include
(41) Date of BCG vaccination
(42) , (43) 0 dose immunization dates for OPV and
Hepatitis 0
(44), (45) First dose (OPV and Pentavalent)
immunization dates
(46), (47) Second dose (OPV and Pentavalent)
immunization dates
1
i
(48) , (49) Third dose (OPV and Pentavalent)
immunization dates
(50) Date of Measles vaccination
(51) Date of receiving Vitamin A
(52) Date of Japanese Encephalitis (JE) vaccination
(53) , (54) Date of Booster dose (DPT, OPV) (55) Date of Second Dose of Measles vaccination
(56) Date of second dose of JE vaccination
Section 5: Information on Migration
(57) and (58) Outbound Migration (date on which
the pregnant woman left the village) and inbound
migration (date on which pregnant enteredvillage).
Section 6: Reasonsfor mother and child mortality
(59) The date along with reasons for the death of the
mother or child as recognized by the ASHA
1.
2.
Reporting of the previous month s progress which
enables the ASHA to record total demand and
review her performance on the specific 16 tasks
outlined by Gol.
Planning - Capture the planning for the next
month in terms of her targets. This is an extract
of the following month’s CDL 2. She copies her
CDL-2 data as is, in this section.
On the 21st of every month, after she completes CDL
2 of the reporting month and planning (CDL2) for
the next month, then she abstracts her CDL2 data
in to CDL3. CDL 3 is to be submitted to the RP/
ASHA facilitator during the ASHA meeting that will
be conducted on the 21st of every month.
Figure 5: Flow of information across levels for
gap analysis
b. Community Demand List 2 (CDL2)
The CDL 2 serves as a self-reflection and review
tool. It has a list of 16 indicators derived from the
CDL 1. It helps the ASHA to identify and list only
those indicators that are very critical to MNCH
care such as registration of the pregnant woman,
TT injection, PNC visits, family planning and so
forth. This tool is designed to help the ASHA carry
out self assessment of the progress she has made on
these critical indicators, develop a plan to effectively
address the gaps seen, evolve her monthly action plan
and reinforce her personal targets as well as engage
in constructive reflection of her performance and
challenges.
One additional indicator on Family planning has
been included in CDL2 which is exclusive (not a part
of CDL 1). FP guidelines require that information is
captured about those eligible for family planning but
are not yet pregnant; and thus is outside the scope of
CDL1. Information for this indicator would be taken
from EC register.
The Community Demand List 2 provides the ASHA
with information of beneficiaries due for services
during the month as well as tracks those who have
received services during that month. CDL 1 has the
list of the names of the beneficiaries. However, CDL
2 will only have their corresponding serial numbers.
Therefore the ASHA does not need to write the names
of the beneficiaries each time that she identifies their
service due in this format. The CDL 2 is expected to
be filled by the ASHA the 21st of every month as her
reporting period is from the 21st to the 20th of the
next month.
c. Community Demands List 3 (CDL 3)
RP
Consolidates
Analysis of
gaps/problems
t
( CDL 3I Self Report
CDL2-
—B
Sub
centre/
PHO level
\
/
1
—
] X. [
Self Report J
CDL1-
] -
Self Report/
ASHA
level
d. Guidelines
Guidelines for both the tracking tool and the CDL
are provided to each ASHA. The guideline for the
tracking tool (CDL 1) has definitions of all the 58
indicators while that of CDL 2 has information on
how to define targets and achievements. The purpose
of the guidelines is to maintain uniformity and have a
common standard definition for all indicators used in
the tools. This ensures that there is a shared common
understanding among ASHAs while using the tool for
planning and tracking.
The entire CDL package has been piloted in Koppal
and Bagalkot for a period of one year and the tools
have now attained a final stage. The key learning from
the pilot is that the trainings for CDL should not
focus on individual tools rather on the CDL as one
entire package with the three tools.
■■■■■■
Use oftool
ASHA will record the names of all the women
in her area who are either currently pregnant, or
have a child under age 1 8 months, irrespective
of whether she is a usual resident of her area
or a visitor to her area (for pregnancy/delivery
purposes). One row is allocated for one woman.
Similar to CDL2, CDL 3 has two componentsPlanning and Implementation of the Community Intervention in the Pilot Districts ■ 23
1
Thus she will have, at any given point of time,,
about 60 women who are her current target
groups (about 20 currently pregnant women,
about 20 recently delivered women and about 20
women who have delivered in the previous year).
Every month, ASHAs with the help of JHAs
and RPs, will use CDL to plan their outreach
services. Tills planning will be done by
identifying, from the CDL, who is due for what
_ type of service during a given month, based
on (1) whether a woman is due for a service as
per the prescribed schedule for MNCH service
delivery and (2) whether the woman has already
received a service due for her in that month.
Based on the target as well as the number of
women receiving services, the ASHA will fill tool
CDL 2 at the end of every month to carry out
an assessment of her own performance on key
indicators. ASHAs then fill out CDL 3, which
' is a abstract of CDL-2 and will submit it to
the RP during the ASHA meeting that will be
conducted on the 21st of every month.
place over a 10 - month period. Developers referred to
existing GoK tools, Gol tools and ASHA guidelines
to prepare the content of the tool.
After obtaining approval from the NRHM Mission
Director, the tool was field tested in the pilot districts
of Koppal and Bagalkot.
Lessons learned: CDL development
•
•
easily.
•
•
Results: CDL development
It is expected that frontline workers will find value
in using the tool to help them better serve their
communities.
Several considerations guided the design of the
new tool to enhance its appeal to frontline workers
including that it:
•
Serves a handy tool for the ASHA to carry with
her wherever she goes and update information
regarding all services she delivers, irrespective of
what they are and where they are given.
•
Enables her to keep track of her daily progress
and guides her follow- up.
•
Reduces duplication of documentation.
•
Is a systematic approach to simplify and organizes
ASHAs work.
•
Helps consolidate data even at the JHA level.
•
Is a simple tool that can be used by all ASHAs
irrespective of their literacy levels.
•
Enables tracking of migrant women.
•
Provides all beneficiary information in one tool
rather than having to refer to multiple registers.
•
Enables ASHAs to assess their performance and
review their own work
•
•
•
•
The Sukshema technical team led the development
of this tool in consultation with other Sukshema
staff, several frontline workers, and the University of
Manitoba. The iterative development process took
24
* An Overview of Sukshema's Community Intervention
Iterative changes: The tool/job aid, which was
designed initially as a chart for listing down
pregnant woman details in a village by an ASHA
worker, was later customized to ease operations at
the field level. The tool had to go through several
changes after testing on the field.
Hardbound tool: The tool had to be provided in
a hard bound book or a Diary for retention rather
than a separate hand out which used to be lost
Practical training: FLW training strategy for the
tool should involve practical field exercises which
should be facilitated by an experienced JHA/
ASHA mentor/ASHA Facilitator in the field.
Rigorous handholding: Information such as
Gravida, Parity and Abortion status and EDD
of pregnant women included in the tool will
require rigorous handbolding of ASHA workers
to ensure its effective usage. The importance of
estimating expected date of delivery (EDD) in the
tool should be reinforced to the ASHA workers in
the consecutive review meetings. EDD would not
only help effective planning of ANC/Delivery/
PNC services but would also aid in informed
decision making of the family to avail free
government MNCH schemes
Grading ASHAs: Grading of the tool’s users
based on their ability to write and understand
the tool is essential for planning the frequency of
handholding by facilitator/trainer for each of the
poor graded ASHA worker.
ASHA advocacy: Advocating with the Health
department for absorption of tool within the
system is critical but the advocacy role is the
ASHAs’ and not Sukshema staff. The users of the
tool should advocate for its inclusion. ASHAs’
acceptance of ETT/CDL would eventually lead to
system acceptance.
Simplicity: Tools need to address ASHA needs.
They need to be simple and easy to use rather
than be a means of data generation for the project
or the government.
Meet community demands: The main purpose of
the tool should be to meet community demands
and help ASHAs plan better on how to meet
these demands.
1
k 4.1.3 ASHA Diary
4.
Purpose
The ASHA DIARY was developed in order to provide
a comprehensive record for ASHAs that would
encompass the ETT/CDL tools in addition to other
relevant job aids and tools. It encompasses a daily
activity record, monthly calendar with important
days marked, a set of pictures for communicating key
messages regarding care during ANC, delivery and
PNC periods, contact numbers of key officials, tools
for planning and tracking beneficiaries, tools for self
review and reflection, MNCH messages that serve as
reminders, ASHA incentive list for her claims, EDD
calculation calendar as well as tools to record other
services she provides such as HIV, TB. The diary
serves as a job aid that has proven to successfully
provide a one stop solution for most of the issues that
the ASHA has been facing on the field. The Diary
makes available all related formats for MNCH service
delivery and follow up, local ASHA area level data for
reporting and planning, communication material for
home visits, monthly calendar for planning activities
and other essential information for ASHA both
within and outside the MNCH context in a single
record.
Components ofthe Diary
1.
2.
3.
Preface - this introduces NRHM and its key
objectives, ASHAs role, the MNCH community
intervention designed to support her work in the
field and the purpose of the diary.
Personal information - this provides space for the
ASHAs to record her personal information such
as Name, area of work, address, contact number,
birthdays, anniversaries and so on.
ASHA Information - space for filling details about
other ASHAs in her sub centre area. This will
help her know whom to contact if the need arises,
especially for referrals.
Figure 6: Image of front cover of ASHA Diary
1015-2016
e
5.
6.
PHC and Sub centre information - details about
PHC and sub centre such as address, names and
contacts of staff. Sub-centre wise Anganwadi
worker details are also included. This will help
ASHAs in referrals and for when she needs to
contact these health workers.
Important contact numbers - space to fill contact
numbers of Gram Panchayat President, PDO
(Panchayat Development officer), VHSNC
president, TH and DH, SHGs (Self help Groups)
is provided.
Yearly calendar with holiday list is provided in the
diary.
7.
Space for daily notes - This will help ASHA
record her daily activities.
8. Important local festivals - information and dates
of festivals and cultural events which also include
full moon (hunnime) and newmoon (Amavasya)
days. This is important to know because very few
women in rural settings remember significant
dates. Instead, they keep track of days using dates
of local festivals and hunnime and amavasya. This
also helps in the calculation of EDD and LMP.
9. Motivational and health related tips/ sayings
provided at the bottom of every page to help
ASHAs in their communication.
10. Monthly non MNCH data sheet - At the end of
every month, the diary also has a page allotted
for ASHAs to collect non MNCH data in her
area. She will update this data at the end of every
month, since she is needs to report this data to
the department every month. This space will help
her accomplish this task as well, in addition to her
prominent role in MNCH.
11. LMP-EDD calendar - This is a tool that readily
suggests the possible EDD for pregnant women
based on her known LMP. ASHA will find it
useful to plan her service cycle.
12. HBMNC (Home Based Maternal and Newborn
Care) tool and guidelines are enclosed in the
diary. The tool is a sample copy. This tool can be
used by ASHAs to improve quality of interaction
with women and their families.
13. Communication material - ASHA reminder cards
are reproduced in the diary. These pictorially
depict important practices during ANC, delivery
and PNC periods. ASHAs can use this in their
communication with women and families during
home visits.
14. Guidelines for conducting Arogya Mantapa - the
diary also has guidelines for ASHAs to conduct
monthly sub-centre forums (Arogya Mantapa).
This will help ASHAs support the process
along with the JHAs, AWWs and the VHSNC
president.
15. SCMT (Supportive Community Monitoring
Tool) - A sample of this tool and guidelines to
use it is enclosed in the diary. This tool guides the
Planning and Implementation of the Community Intervention in the Pilot Districts • 25
t
ASHA to be involved with the VHSNC members
in their supportive monitoring processes.
16. Notes - Space has been provided in the diary for
ASHA to make notes on any important subject
or issue. That space can be used by her at her own
discretion.
17. ETT (Enumeration and Tracking Tool) - This tool
has been included in the diary with guidelines to
use it. ASHAs will use this tool to identify gaps
and effectively address them. ASHAs and JHAs
will also be able to prioritize at the sub centre and
PHC levels based on ETT.
18. ASHA incentives checklist - the diary also has
enclosed the incentive checklist for ASHA which
will help her to keep track of the payments
that she has received every month for all the 26
suggested line items.
Results: ASHA Diary Development
The ASHA diary evolved based on the feedback
gained from the experiences of ASHA using it on the
field, department officials in PHCs as well as district
and state offices and from the field level staff who
have been closely supporting the use of this diary on
ground. One ASHA diary is to be used by ASHA
for each ASHA area. Therefore, each ASHA will
maintain as many diaries as the number of ASHA
areas that she covers. Example: Ratnamma looks after
two ASHA areas since there has been a drop out in
her neighbouring village. Ratnamma therefore, will
maintain two ASHA diaries for both Mudhol village
and the neighbouring Amlapura village. This will help
to have area-wise information readily available which,
in case of new ASHA recruits, can be passed on to
them for follow up.
Over 2000 ASHAs have been trained in the
use of this tool. The Goverment of Karnataka
has adopted this DIARY as is, as part of its
commitment to enhancing the skills of and
supporting ASHAs through a systematic, user
friendly, simple and contextual job aid that
will empower and equip her to meet her daily
challenges on the ground.
Advantages of the diary
It helps the ASHA to do the following:
•
Record her daily work including personal details
•
Record non-MNCH data such as TB, blood
smear, VHND and VHSNC related data in her
area.
•
Record individual and area-wise service delivery
data in the enclosed ETT.
•
Calculate LMP and EDD of the pregnant women
in her area.
•
Use the pictorial information to communicate
MNCH related messages with pregnant women,
new mothers and family members during home
visits.
•
Use HBMNC tool to collect information during
home visits.
•
Conduct VHSNC and Sub centre level forum
(Arogya Mantap) meetings based on guidelines
enclosed.
Comparison of project monitoring data in areas
where ASHA Diaries were available and not
available
Data collected indicates that availability of ASHA
diaries has a positive impact on several MNCH
outcomes in an area. On comparing the results in
Koppal based on the availability of ASHA diaries
Table 1: Number of ASHAS who received Diaries
in Koppal and Bagalkot during Pilot
I
SL#
;l
J 1
District
|BAGAL-
Sanc
Working
tioned
ASHAs
ASHA
positions
ASHAs who
received
Diaries with
one-day
training and
orientation
1227
1019
1019
j KOT
2
“
806
2313
1825
1825
TOTAL
JI
J
(Fig. 7), fewer women delivered at home and a higher
percentage of women breastfed within one hour
of birth in the 52 areas where ASHA diaries were
available, compared to the 12 areas where ASHA
diaries were not available. An increased percentage of
women also stayed at a health facility for > 48 hours
after birth and more newborns received Oral Polio
Vaccine at birth (OPVO) in areas where ASHA diaries
were available compared to areas where diaries were
not available.
Fig.7 Monitoring data in areas where ASHA
diaries were available and not available in Koppal
100.0
75.0
50.0
25.0
0.0
84.1
,
56 5
Hn 52 9
Bi H M
Home deiiveries Breastfed within 1 OPVO given
hr
>48hrs
At health facility
po&tnataliy
“ Diary available
4.1.4 Home-based Maternal and Neonatal Care
Tool (HBMNC)
Purpose
I
K0PPAL ’°“
that the Diary is accepted and promoted by the
department and by the ASHAs in all districts
of the Karnataka, and not just the project areas.
This would ensure uniformity in ASHA reporting
processes.
The purpose of tool is to improve quality of
interactions between front line workers and pregnant
and postpartum women. It works as checklist of
relevant messages that need to be communicated
during ANC and PNC visits by the ASHA. The
tool also has information about danger signs and
quick referrals. The tool helps ASHAs focus more on
communication while making home visits rather than
mere information gathering.
The tool is meant to be used by an ASHA during
each home visit to a pregnant woman or a woman
in the post-natal period (42 days after delivery)
and to use as a checklist for screening and linking
them to appropriate services. The key objective
of the HBMNC is to guide an ASHA to provide
comprehensive home based care and enhance
effectiveness in her routine outreach services.
This tool attempts to address the following gaps at the
frontline worker level:
• ASHAs did not know the purpose of a home visit,
despite being trained in home-based care by Gol.
• Their interactions during home visits lacked focus
and quality.
•
Existing home-based care tools were lengthy, were
not user-friendly and hardly anyone was using
these existing tools.
■ Diary not available
Components ofHBMNC
Lessons learned: ASHA Diary development
The HBMNC tool has the following components:
•
•
•
•
Multiple registers merged in to one: ASHAs are
now able to access all the necessary information
in a single place (the diary), compared to earlier
when they would refer to multiple registers and
information sources. The ASHAs treat the diary
more like a handbook that provides a one stop
solution for most of the issues that ASHA faces in
her daily work.
Include non-MNCH topics: ASHA Diary
should also cover non MNCH aspects such as TB
status etc.
Comprehensive: It should be comprehensive
with visuals, guidelines, and information about all
the interventions.
ASHA advocacy in all districts: It is important
Section 1: Identification
This has identification details of the ASHA and the
pregnant woman/ nursing mother’s background
information. The ASHA collects this information
during the first home visit which is usually in the
ANC period. During the course of her informal
discussion, she will gather this information which will
serve as the starting point of establishing rapport with
the pregnant woman and her family.
Tie beneficiary’s social and economic background,
previous pregnancies and other personal details are
gathered at this stage, to enable an ASHA to discern
or assess the kind of family environment that the
Planning and Implementation of the Community Intervention in the Pilot Districts ■ 27
1.
I.
4.1.6 Arogya Mantapa (AM)
Purpose
Arogya Mantapa is a sub centre level collaborative
forum of front line health workers. Its members
are all the ASH As, JHAs, AWWs and the VHSNC
president falling under that given sub center limits.
The JHA plays the role of coordinating the activities
of the Arogya Mantapa and the project RP assists
their efforts when requested for and also be special
invitees occasionally. AM’s purpose is to create an
opportunity for FLWs and VHSC members to meet,
identify issues in their individual work fields, shape
appropriate solutions jointly and support each other
to implement it.
AM also aims to create the space for building stronger
team relationships by understanding each other’s
struggles, and safeguarding each other’s self respect.
Arogya Mantapa ’s monthly meeting process
The duration of the meeting usually does not exceed 2
hours. The meetings are conducted at different sites in
the villages such as the Panchayat offices, Sub centre
offices, Anganwadi centres, Community halls and
sometimes even at FLWs homes.
During the first hour of the meeting the FLWs
usually update everyone on the status of their
work with regard to the Sukshema’s community
interventions (please see table below). The second half
of the meeting generally focuses on team building
activities and entertainment such as craft and cooking
demonstrations, home remedies for illnesses, potlucks,
rangoli competitions etc. The proceedings of the
meeting are recorded.
Table 2: A model AM meeting plan
r
Process ofstarting an Arogya Mantapa at a
Sub-Centre
The formal process to begin the Arogya Mantap will
comprise of the following activities:
1. Project field staff has one-on-one discussions with
FLWs, the VHSC presidents in their area about
this concept .
2. These discussions are documented in order
to elicit if such an effort is a felt need and
accordingly take it forward in their areas. The
belief is to implement activities only in response
to the felt needs of either the community or the
front line workers.
32
■ An Overview of Sukshema's Community Intervention
I Duration
1
Prayer, Welcome
5 minutes
2
Monthly announcements
5 minutes
3
Experience sharinga. Pregnant woman count
from the previous month
b. Child deliveries in the
current month in my area
(I nstitution/Home)
c. Details regarding
successful distribution of
services among pregnant/
new mothers
d. Specific problems
stopping the distribution
of services
25 minutes
4
Expected Support from
the VHSNC
15 minutes
5
Preparation of nutritious
food (This can also be
utilized to celebrate
birthdays of members,
anniversaries, etc)
15 minutes
6
Entertainment (Songs,
jokes, funny moments
during work, etc)
15 minutes
7
Indoor games/
competitions (Musical
chairs, etc)
25 minutes
8
Details regarding the next
meeting & vote of thanks
5 minutes
I
No.
The Arogya Mantapa is guided by the following
principles and values:
•
Gender equality and respect for women
•
Respect for individual differences and
heterogeneity
•
Strong belief in the common vision for reducing
IMRandMMR...................................... w
•
Mutual respect and trust
• Transparency and democratic values
• Valuing local realities and context for planning
strategies
•
Non hierarchical in field relationships
• Team work and respect for every individual
member’s sensibilities
• Value for community participation and
involvement
•
Inclusiveness and respect for marginalized groups
On assessing the field situation, the project
implementation team will proceed with the Arogy;ra
Mantapa formation.
Issue
SI.
.
I
Ii
l
i
1
Role of resource persons! Projectfield staff
The RP coordinates the first meeting of the Arogya
Mantapa almost entirely. They assist the JHAs in
planning future meetings. They attend subsequent
AM meetings to ensure that participants are aware of
the purpose of AM. They assist in resolving conflicts
during meetings. They track participation during
meetings and support JHAs to ensure that all the
members including the VHSC presidents are regular.
They help review meeting documents prepared by
FLWs. They ensure that the issues and decisions made
at the meeting regarding the community interventions
are followed up in the field.
Indicators to check results
The following indicators reflect the current status of
Arogya Mantaps in the districts:
•
Total number of Arogya Mantap;•as formed in the
district
•
Total number of active Arogya Mantapas in the
state
•
Total number of Arogya Mantapa meetings
conducted
•
Total number of members present at Arogya
Mantapa meetings
•
List of issues discussed at Arogya Mantapa
meetings- ETT, HBMNC, communication
hurdles.
•
Percentage categorization of issues discussed and
followed up.
•
Type of activities conducted by the Arogya
Mantapa.
•
Number and type of services extended and
problems solved by health temples during
emergencies
•
Instances where Arogya Mantapas have given able
support to ASHA workers
Results: Arogya Mantapa development
In the FFC training program (the first of our
community interventions) conducted for more than
3000 FLWs in Koppal and Bagalkot districts, the
overall feedback was that “there is a continued need
for all of us to work together and we have to motivate
ourselves to fan the flame in us to move forward for
achieving our goal of improving maternal and child
health”. There was also a suggestion that expounded
the idea of some sort of a platform in close proximity
to their respective homes where they could assemble,
share their experiences, their struggles, and listen
and support each other. Many expressed the need
to involve the community often and seek their
support in addressing health concerns of mothers
and children. Therefore, the AM concept was born
with the intent to bring them together as a team,
streamline their joint discussions into something
concrete, and to give their discussions structure,
purpose and a set of operational guidelines. Through
the AM, the FLWs not only benefit from each other’s
experiences, but are also able to review the progress
of the community interventions, understand the areas
of support that the FLWs need, assist any FLWs who
need additional support in their field work.
4.1.7 PHC level Convergence Meeting
Purpose
In addition to the five core Community interventions,
the PHC level convergence meeting has also been
supported by the team on the field. This is a monthly
ASHA review and planning meeting. This is a Medical
Officer (MO)-led meeting at the PHC level that was
intended to be a forum where the MO-PHC, JHAs
and the RPs can review the ASHAs’ work, collect
and compile reports and provide incentive payments
to ASHAs. Although this meeting is not a new
component of the health system that was introduced
by Sukshema, it can still be considered an important
component of the project because Sukshema helped
strengthen the functionality and effectiveness of this
meeting. It is one of the three important forums on
which the project’s handholding strategy for ASHAs
is based.
PHC level convergence meeting process
Each RP is mandated to handhold (i.e. build capacity
through on job training approach) around 20 ASHAs.
The PHC level ASHA convergence meeting is used
by the RPs to handhold ASHAs, since an ASHA’s
reporting period is the 21st of the current month to
20th of the following month. Since it is MO-led, it
is the only scheduled contact meeting between the
MO-PHC and the ASHAs. Therefore, it is an ideal
forum for ASHA diary verification, the assessment
of CDL usage as a self-planning, self-review and
self-reflection tool, grading of ASHAs based on their
handholding needs, submitting the listed community
demands/needs to the concerned JHA and MO, and
receiving incentives for the services rendered during
the previous month. Based on their assessment of the
handholding needs of different ASHAs, the RPs and
ASHAs make a combined handholding action plan.
Planning and Implementation of the Community Intervention in the Pilot Districts ■ 33
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4.2
IMPLEMENTATION STEP 2:
Recruitment and Training of Resource
Persons (RPs) in Koppal and Bagalkot
In designing the community interventions, a key
decision was to determine the profile of resource
persons. At a minimum, RPs had to be at least
secondary school graduates and had to be from
Koppal or Bagalkot. A hiring committee was created
with respective team leaders from Sukshema’s
Community Intervention team.
The hiring committee crafted a 3-tier hiring strategy
to identify the best candidates. Because of the varied
skills that RPs need to possess, it was thought that
a conventional hiring process of screening CVs and
interviewing candidates might not be sufficient to
fully assess a candidate’s capacities for the position.
Also the project’s need to hire many candidates at
once offered opportunities for more creative group
based assessment processes. This process is important
owing to its priority on appointing local candidates,
female candidates, persons from backward caste.
Identifying local capacity helps in sustainability as
well as reducing turnover and drop out.
Information on each level of the hiring process is
presented below.
First level ofscreening
The project placed local advertisements in local
Kannada newspapers at the taluk and district level
and posted position openings in Dec, 2012. The
project received around 400 applications. Interested
male and female candidates with the above listed
qualifications were asked to submit self-written
applications.
The applicants were asked to mandatorily provide the
following information.
1. Name: 2. Sex: 3. Date of birth: (Age) 4.
Educational qualifications: 5. Residence, postal
address: 6. Permanent address: (Village, Town,
Taluk, etc has to be clearly stated) 7. Marital
details: 8.Experience of serving in a rural area: (In a
minimum of 10 lines) 9. Opinion of the candidate
about the personal qualities and capacity he or
she possesses to work as a resource person: (In a
minimum of 10 lines) 10. Signature
Additional desired information to be included was:
1. Telephone number: 2. Present occupation/
Unemployed: 3. If employed, monthly income: 4.
Interests/Hobbies: 5. Training programs attended:
(E.g. Health, Leadership, Development, etc) 6.
Information about interests in drama, music, arts,
oratory, report writing, photography, etc
36
■ An Overview of Sukshema's Community Intervention
RP Qualifications
•
RPs should be above 18 years and below
35 years (For suitable scheduled caste/tribe
candidates)
• The candidate should have a minimum
educational qualification of SSLC and
candidates who have studied above this will
be given preference. (If suitable candidates
with this educational qualification are not
available, the.qualification limit can be
relaxed to the 7th standard level)
• Should be a resident of a village in Koppal
or Bagalkot district for the last five years.
(A proof of residence stating the above
mentioned qualification should be submitted
during the interview)
• Should be committed to work in all villages
as per program specifications
Of the 441 applicants in each district, the hiring team
selected about 250 candidates in each district based
on their applications.
Second level ofscreening
The selected candidates from the first round of
screening were sent a questionnaire which they
had to fill out and mail back to the project offices
by a stipulated date. The questionnaire comprised
of questions related to a range of topics including
linguistic abilities, personal socioeconomic details,
emotional details, MNCH topics. Also, information
on their participation in social activities within their
communities was asked. Of the 250 questionnaires
received, about 100 applicants were invited to attend
a 2-day workshop in each district.
Third level ofscreening
The project team organized a 2 day workshop
for candidates that included discussions on rural
health management, an exercise involving a group
discussion, emotional creative expression tests,
oratorical tests, and teambuilding and communication
tests.
Checklists were used by the assessors to aid in
objective scoring of the candidates across different
competencies. After the 2 day session, about half of
the candidates (about 50 of the 100 candidates) were
offered positions.
Pre-induction and Induction Training
A total of 106 RPs (about 1 per PHC) in the two
districts were recruited during the month of March
2012. The newly recruited RPs engaged in a one
An RPsuccess storyfrom Koppal district
Kumar, an RP in Koppal, faced a number of
challenges in the project and his first hurdle
was getting buy-in from the ASHAs, MO and
JHAs for the ASHA diary. FLWs felt that
filling out the ASHA diary was a duplication
of effort since they were already filling our
the RCHO diary. Kumars supervisor asked
him to fill the diaries for the ASHAs. After
filling out 3 diaries, he realized that this was
not a sustainable solution and would possibly
have a negative impact on the project. He was
disheartened and came very close to resigning
his RP position. Meanwhile, Kumar was alerted
about a maternal death at a village nearby. He
visited the village along with the MO, during
which he briefed the MO about the purpose of
the ASHA diary and convinced him that this
death could have been averted if the ASHA
diary had been used properly. Also, Kumar
reasoned that since Sukshema was providing
free diaries, it was in the PHC’s best interest
to save printing costs and use their untied
funds for other activities and services. After
some deliberation, the MO recommended that
. AS.HAs at flT.af.PHC use .only the. ASHA diary.
When Kumar heard that the PHC needed
more Sukshema case sheets, he contacted their
Nurse Mentor who did not respond to him in a
timely manner. He immediately contacted the
Koppal office and carried 40 case sheets back
to the MO. When asked what the urgency was
he replied “If there is no case sheet, they don’t
record and refer the case. And if this continues,
then dealing with a number of case sheets
becomes difficult and this may lead to maternal
death.”
During the RP assessment process, project team
leaders found that Kumar was very systematic
and organized. He had documented all issues
and actions taken at that PHC, with signatures
from the MO so that the MO was made aware
of everything which would make it easier for
Kumar to follow-up. Kumars dedication and
effort was appreciated in front the entire district
team and the KHPT project leads gifted him a
book. Kumar got very emotional and told one
of the project leads that this was rhe first time
that he had got any appreciation for his work.
month pre-induction profiling of their respective
PHCs (1 RP: 1 PHC). RPs collected information on
the number of sub-centres and ASHAs and engaged
in other activities such as planning for training
activities, sensitization and relationship building with
the Medical Officers, Taluk Health Officers etc. There
were several dropouts, both initially and once roll-out
had started. However, since there were 2 RPs who
were shordisted per cluster there was always an RP
available to fill in vacant positions due to dropouts.
Three-day induction training was conducted in
three rolling batches during 12-17 March 2012 at
Kudalasangama in Bagalkot district. The training
covered the following topics (a) introduction to
project Sukshema - goals, objectives, technical
interventions and solution levers (b) maternal,
newborn and infant care services during ANC, intra
partum, post-partum and postnatal periods (c) service
delivery mechanisms (d) proposed interventions at
the community level for the FLWs and community
structures. The resource persons included the
technical leads and managers at the central office,
district program specialists, and district M & E
specialists. The training method included lectures,
group works and role plays.
On the last day of the induction training, all RPs
had to plan for taluk-wise FFC trainings. There were
about 20 drop-outs in total in both pilot districts.
Role ofRPs in Sukshema- Handholding Support
The major role of RPs in the project was to supervise
and provide handholding support to ASHAs. RPs are
provided with a number of supportive supervision
and monitoring tools to guide their work. A list of the
tools is given below (refer to annexures for complete
tools).
• RP analysis format: This is a sub-centre level
tool that RPs fill out each month. The tool has
several key Maternal and Newborn/Child health
indicators that RPs track each month, as well a
section for gap analyses.
• SCMT handholding checklist: This is a checklist
for RPs to follow when SCMT meetings/
VHSNC meetings are conducted. RPs grade the
meetings based on performance, using indicators
such as adequately filling SCMT tool, member
participation, functioning effectively without RP
assistance etc
• AM handholding checklist: This checklist helps
RPs assess AM meetings using indicators such as
attendance by all members, gap analyses carried
out at AM meeting, preparing monthly action
plans etc
•
HBMNC checklist: This checklist helps RPs
assess the quality of interaction between an
ASHA and her client (in this case, a pregnant
Planning and Implementation of the Community Intervention in the Pilot Districts ■ 37
•
or postpartum woman) using indicators such as
using appropriate counseling messages and tools,
effective communication skills, scheduling follow
up visits etc.
RP reporting format: This is a consolidated
reporting tool for the RP to refer to as needed. It
has 5 forms that need to be filled out by RPs
• Day-to-Day Handholding reporting format
• Monthly ASHA Grading Format
• RP monthly handholding reporting format
(Abstracted verson)
• Sub-centre wise monthly progress format
• PHC convergence meeting report
As mentioned above, providing handholding support
to ASHAs is the main role of the RPs. RPs help build
the capacity of ASHAs with on-the-job training. RPs
use the checklists as guides to help them grade ASHAs
based on their ability to adequately fill out the tools
and to know what and who to focus on during the
handholding process (Please refer to the Scale-up
for more information on Handholding and ASHA
Grading).
Lessons learned: Hiring RPs
What worked well:
•
The process followed for identifying, and
recruiting RPs worked well. The candidates that
were ultimately selected were the best performers
on various assessments and evaluations.
•
•
The pre-induction profiling of their respective
PHCs and their 5 day induction training proved
valuable as candidates had additional time to
learn about the job responsibilities. (Any drop
outs?)
The hiring process was effective in identifying
strong candidates but the process itself required
a substantial level of engagement of senior
project staff that may be difficult to replicate in a
government system at scale.
Challenges:
• Initially, the transition from a community
mobilization approach in the VHSNC project to
a technical support task of MNCH project took
time.
•
RPs had poor grasp of key MNCH content and
were still in the VHSNC and HIV mind-set from
previous projects.
•
There was a need for extensive handholding
support of RPs in the initial couple of months
• Acceptance of RPs among the department officials
took time initially.
• Taluk Co-coordinators and CMOs had to
translate all abbreviations into Kannada and
refreshers were provided at each contact period.
•
RPs youthfulness and lack of experience, in some
cases, might posechallenge to their ability to
establish credibility with the FLWs and more
experienced PHC staff.
4.3
IMPLEMENTATION STEP 3:
Conducting The Baseline Community-Based
Tracking Survey (CBTS)
Context
Purpose
CBTS is a simple and rapid sample survey of target
populations to measure intended outcomes in the
population. The survey is conducted once every 4
months in a representative sample of women who
have delivered in the past 2 months to collect data on
•
Knowledge of mothers on key MNCH issues
•
Utilization of MNCH services from the front line
workers and health facilities
•
Practices regarding maternal and newborn care
CBTS provides information on short-term changes
and relatively more real-time data that are required
for program monitoring. It is short, more frequent,
and better focused to track short-term changes in
indicators at smaller geographic areas. Results from
the CBTS helps the central project team and field
staff tweak program implementation strategies in
order to stay focused on outcomes. Data from CBTS
is used by ASHAs to prioritize outreach activities.
NOTE: For further information, please refer to
the section titled “Monitoring and Evaluating the
Community Intervention”. .
For Round 1 (Baseline) of CBTS, RPs collected
baseline CBTS information and conducted household
surveys over a period of 2 months. However,
subsequent rounds of CBTS were conducted by
trained enumerators.
4.4
4.4.1 Training Front-line Workers (ASHAs and
JHAs): Family Focussed Communication
(FFC) Roll-outs
IMPLEMENTATION STEP 4:
Training Front Line Workers on all five
community interventions
The FFC and ETT ToT for the RPs and a few selected
FLWs, was a 3 day residential training. Both FFC and
ETT were combined into one ToT because of lack of
time. The topics covered included:
•
perspectives on community outreach
•
improving basic communication skills among
FLWs
•
achieving coordination among AWWs, ASHAs,
JHAs and VHSNCs at the village level
•
skills to facilitate sub centre level meetings and
coordination among functionaries.
This was similar to the FFC roll-outs for the FLWs
which is detailed below.
FFC roll-outs were the first in the set of training
workshops. FFC is designed to train all three FLWs
(namely ASHAs, JHAs and AWWs) in a given sub
centre. Training of the FLWS in FFC was carried out
in two stages:
1) Stage 1: Pilot or ‘Soft’ Roll-out
2) Stage 2: Full-Fledged FFC Roll-out Training
Pilot or ‘Soft" roll-out: Two pilots of FFC were
conducted at each Taluk. Resource teams of 4-5 RPs
per team were assembled, with at least 2 RPs per team
being more experienced. Although, only 2 FFC ‘soft’
pilots were conducted at each Taluk, all RPs were
encouraged to observe the roll-out trainings.
Lessons learned: FFC Pilot or ‘Soft’ roll-out
What worked well:
• FLWs were organized and received the trainings
with much interest
Challenges:
• RPs lacked co-ordination and there was poor
transfer of content and loss of key messages
initially. TCs and CMOs had to provide intensive
handholding support
•
FLWs were already trained in key MNCH topics
as part of the Gol guidelines, so it was difficult
for RPs to keep them engaged and ‘tuned-in’
during trainings
•
RPs youthfulness and lack of experience, in
some cases, posed a challenge to their ability to
establish credibility with the FLWs.
•
Hierarchical differences were apparent during
interactions among ASHAs, AWWs and JHAs.
Full-fledged FFC roll-out training: Based on the
learnings from the ‘soft’ roll-out, the full fledged
FFC roll-out training was planned in all Taluks of
Koppal and Bagalkot. This was a three day residential
training guided by participatory methodology and
use of activities in all Taluks of Koppal and Bagalkot.
RPs were the primary facilitators of this training, with
occasional assistance from already trained ASHAs and
JHAs
Training agenda and schedule
Day 1: After the personal introductions and a
preview to Family-centric communication, the rest
of the day focused on enhancing communication
skills- verbal and listening skills, individual and group
communication skills.
Planning and Implementation of the Community Intervention in the Pilot Districts ■ 39
Day 2: After a few sessions on enhancing
communication skills, the rest of the day focused
on women’s issues, dealing with societal biases,
understanding power dynamics between men and
women.
Day 3: The last day focused entirely on co-ordination
of the 3 FLWs using concepts like Three sisters and
the discussion of roles and responsibilities of AWWs,
JHAs and ASHAs.
•
•
Lessons learned: Full-fledged FFC roll-out training
What worked well:
•
The experience of rolling out FFC trainings
was very encouraging. The FLWs were very
appreciative of the methodology followed in the
training.
• The project team found it extremely beneficial to
start with FFC training during the initial stages of
the project s work. It set the stage for project staff
to launch all other components of Sukshema’s
community intervention.
•
It brought all the FLWs together for the first
time and this served as an opportunity for them
to understand each others roles, challenges and
helped them mutually support each other both
professionally and personally.
•
£LWs learnt to work as a team. Acqprding to
one AWW from Gangavathi , “Hair will be
disorganised if it is not tied properly. ASHA, JHA
and AWW are like three strands of hair. It looks
beautiful if all three are tied properly. To make
our work more smart, all three of us should be
tied together”.
The training also dealt with socio-cultural issues
around MNCH which helped build perspective
of the team. FLWs shifted their focus to include
families as well and not just areas such as ANC,
immunizations etc
FLWs acceptance of RPs was markedly increased
after the FFC trainings. For eg. FLWs invited RPs
to participate in non-Sukshema activities such as
immunization days
Challenges:
•
Residential aspect of training was challenging
both logistically as well as in terms of convincing
FLWs and health officers
• Travel allowances were an issue (since only
ASHAs get TA/DA)
•
Bringing FLWs from 2 different departments
(ASHAs and JHAs from Health and AWWs from
Woman and Child departments) was a challenge
•
Some Taluks had a large number of ASHAs
and AWWs to train, so there had to be parallel
trainings with several RPs.
• Training venues and providing refreshments were
challenging,
. .. .
. .
4.4.2 Training Front-line Workers (ASHAs and
JHAs): CDL Roll-outs
Context
This was a non-residential training conducted in
stages. Community Demands List (CDL) is for
training ASHAs. The trainers for CDL trainings
were selected from a pool of ASHAs or JHFAs with
good communication skills, understanding of the
field and the subject with high confidence levels in
their respective sub-centres. RPs provided them with
handholding support through the process.
•
Training agenda
Similar to the FFC trainings, training of ASHAs in
ETT was carried out in two stages:
1) Stage 1: Pilot or ‘Soft’ CDL Roll-out
2) Stage 2: Full-Fledged CDL Roll-out Training
•
Both Pilot CDL roll-out trainings and full-fledged
CDL roll-out trainings had similar formats with
various levels to the trainings:
•
Level 1- ToT for facilitators at PHC level for 1
day
•
Level 2- Training ASHAs at sub centre levels for
1 day
•
Level 3- Use of tool on field by ASHAs for 2-3
days
•
Level 4- Consolidation and conclusion of training
with ASHAs at sub centre level for 1 day.
•
•
•
•
Lessons learned: CDL roll-out and usage oftool
What worked well:
•
Feedback on the CDL training was positive.
•
The tool was well received by ASHAs and is
beginning to bring positive results with improved
planning and outreach at the ASHA level.
•
One ASHA from Bagalkot found CDL to be “
the most simple tool that we have ever used and
it has drastically simplified our recording process
and the burden of referring to many registers has
been reduced through this”.
• A major success of the tool is the fact that
the CDL tool helps ASHAs track every single
pregnant woman in their area all through her
continuum-of-care course.
•
CDL was designed to replace at least 13 different
registers that previously housed MNCH data and
therefore general acceptance and buy-in among
FLWs is very high. ASHAs and other FLWs prefer
the ASHA diaries and CDL over existing GOI/
GOK tools.
•
FLWs feel that the ASHA diaries enable effective
sharing of data since all the information is in ‘one
spot’. An entire year’s data is on a single form and
this makes it easier to access data whenever there
is a request or query. In one taluk, the ASHAs
were so relieved that they could share CDL data
with their supervisors/nurses even by phone as
opposed to having to physically carry all their
registers. One ASHA pointed out that there has
been a role reversal because after the introduction
of the CDL, the JHAs now depend on ASHAs for
information on child immunization, ANC etc.
FLWs find it easier to know what their targets are
and also to identify gaps in target achievement. In
particular, ASHAs feel a sense of empowerment
because they can calculate their targets and
achievements themselves as opposed to the earlier
way of getting JHAs doing it for them.
ETT targets and target achievements help FLWs
in planning their monthly activities a few months
in advance, where previously they were only told
what to do for one month at a time.
ASHAs are able to calculate EDD which helps in
referrals to facilities for delivery
JHAs find great benefit in CDL because
reporting has now become more streamlined
and less inconsistent as a result of similar data
formats.
FLWS are able to quickly problem solve around
gaps in services and health care access
ASHAs feel that the CDL has improved their
interactions with JHAs with respect to
• ease of generating monthly reports
• consistent targets and achievements for both
ASHAs and JHAs
• sharing of responsibilities for data reporting
since data is now consistent and clear
• monitoring and supervising ASHAs by JHAs
Challenges:
•
ETT abstracts were a big challenge (and still are)
with some RPs doing the abstracts for the FLWs.
•
Some areas where there were no ASHAs, JHAs
did not find value in the tool and its abstracts
• Achieving uniformity of consolidated information
was difficult, with respect to targets and
achievements. RPs found this challenging in the
beginning.
• ASHAs were unhappy about referring back to old
registers since even older cases had to be included
in CDL
•
•
•
JHAs did not know how to calculate EDD and
GPA prior to training
CDL indicators and their linkages had to be
stressed
ASHAs were categorized as A and B based
on ability to calculate LMP and EDD, with
B category ASHAs requiring more intensive
handholding support from RPs
Planning and Implementation of the Community Intervention in the Pilot Districts ■ 41
*-► 4.4.3 Training FLWs: HBMNC Roll-out
A sample training agenda from the HBMNC training
is given below.
Context
Sukshema’s HBMNC training did not focus on
clinical skills, since ASHAs are already trained by the
GoK Health Department on home-based care. The
training focused on improving the quality of home
visits through improved communication skills and
prioritizing messages by ASHA.
Since the HBMNC roll-out followed the baseline
CBTS, results from the baseline CBTS in each Taluk
were used to orient ASHAs on gaps identified in the
community’s health seeking behaviour (For eg. In
one Taluk, birth planning & preparedness was an
identified gap along with poor knowledge of danger
signs in pregnant women, mothers & newborns) in
that particular Taluk. These gaps then serve as focus
areas for the ASHA during their home visits.
In order to generate more ownership of the tool and
its implementation in the Department of Health,
TOTs were conducted not only for Sukshema RPs
but also for staff from GoK’s Department of Health
including senior JHAs, active ASHAs, ASHA mentors
etc. In each Taluk, GoK Health Department staffs
were identified based on their earlier exposure a$
resource persons for the Home-Based Neonatal Care
(HBNC) training of the department, as mandated by
Gol. In addition to that, the Health Department staff
had very strong clinical/technical knowledge about
home based care which needed to be tapped into for
Sukshema’s HBMNC training roll out. The roll out
trainings were conducted at the PHC level by GoK
department staff and facilitated by the Sukshema
RPs, with GoK staff handling a major part of all the
technical aspects of HBMNC.
Also, in order for the RPs to identify whether ASHAs
can prioritize messages based on results from CBTS to
ensure correct usage of communication material and
tool based on the needs of the individual and family, a
Checklist for supportive supervision and handholding
was developed for the RPs.
Training agenda
It was a one day training and it was conducted at
the PHC level with about 20-25 ASHAs in every
batch. The trainings mainly focused on enhancing
communication skills and tool orientation and not
on building clinical skills since all ASHAs had already
been trained on HBNC by the health department.
42
■ An Overview of Sukshema's Community Intervention
,
......... m7
\ Time
I 10-10.45
I Session
Sharing experiences on
previous HBNC training
conducted by the Health
department
1
10.45-11.15
Sharing results of
Community behavior
Tracking Survey: An
Overview, The need for home I
based care for mother &
newborn
i
11.15-11.30
Tea break
11.30-01.30
Uses of HBNC tool,
Introducing the revised
HBMNC tool
1.30-2.00
Lunch break
2.00-3.30
Using Communication skills
&.IEC materials in home
based care
3.30-3.45
Tea break
3.45-4.00
Wrap-up
I
I
Lessons learned: HBMNC roll-outs and usage of
the tool
What worked well- Roll-outs:
•
Having the training content not focus on clinical
skills and focus more on communicating key
messages during home visits was a good strategy,
since all ASHAs had already been trained in Gol’s
home based care.
• Since all ASHAs had been trained in HBNC,
they were already familiar with the format of
Sukshema’s HBMNC tool.
• Involving the Department of Health staff in the
trainings and roll-out as the actual trainers, in
contrast to the ETT roll-outs where Sukshema
RPs were the trainers, created a sense of
ownership in the GoK staff and helped make
HBMNC implementation less challenging.
•
Both the health system staff (JHA, LHV) and
Sukshema RPs conducted the trainings together
and this worked well because tapping into the
GoK staff’s technical skills with respect to home-
•
based care also helped in a smoother roll-out of
HBMNC.
FLWs appreciated the simple tool and found it
easier to use than one used by the department.
What worked well- usage oftool:
•
Overall, the ASHAs find the HBMNC tool
easy to use and fill, even for those ASHAs with
low literacy levels and the following are their
comments:
• They are able to identify high risk women and
counsel all women using the communication
materials appropriately and are able to
immediately refer if needed
• The previous (GOI and GOK) tools focused
only on the newborn while the current
Sukshema tool focuses on both mother and
child and is more of a checklist
• It helps them plan the timing of their home
visits and what to do/look for at each home
visit. The GOK tool does not guide them
clearly around what to look for/when to
provide counselling/when to refer.
• The tool encourages them to streamline their
counseling and also focus certain messages to
other family members of the pregnant woman,
and not just the pregnant woman herself.
GOK tool does not help them to identify
behavioural & cultural practices, where
as the HBMNC helps in identifying and
acknowledging these practices.
• They like that the tool focuses on one
individual so that the ASHA can refer to what
was done during previous visits
• It helps them track whether the woman’s
health has improved since the last visit, for
instance, whether the woman’s bleeding has
stopped.
• JHAs and RPs used the HBMNC tool as an entry
point when planning their interactions with
women that choose home delivery
• Acceptance of tool in implemented districts is
high. Sukshema staff and FLWS felt that overall
the HBMNC tool and roll-out was the least
challenging of all the other tools/interventions.
• There has been no negative feedback yet from
Dept of Health. The earlier GOI HBNC tool has
been phased out and the acceptance of HBMNC
state-wide is high. Despite initial hesitation,
Reproductive and Child Health Officers
(RCHOs) of Koppal and Bagalkot are advocating
for HBMNC since they see value in using it.
•
•
•
•
although RPs were knowledgeable about the
tool and communication skills, they were not
sufficiently trained in the clinical skills aspects
of HBMNC to be effective in handholding.
Therefore, involving health department personnel
to handhold would likely have worked better.
Inability to assess decision-making: HBMNC
helps ASHAs provide information to families
but does not enable them to assess the pregnant
women’s decision making ability. For instance,
while the tool helps ASHAs screen danger signs in
a pregnant woman, it does not help them assess
whether this woman was motivated enough to
visit a facility to address the danger sign(s).
Visuals in HBMNC: Despite the tool being a
simplified version of Gol’s HBNC, many ASHAs
still find it difficult to use because of all the
documentation needed. Based on feedback from
the FLWs, the central team is considering other
pictorial alternatives as well
Need for Incentive attached to filling HBMNC:
ASHAs feel that there should be an incentive
attached to filling out tool since they see it as
extra work. However subsequent trainings on
tool will focus on using the tool for improved
interactions and not merely a tool-filling exercise
Shift from tool-filling to using it as a job-aid:
Some ASHAS still see it as a reporting tool for
Sukshema and not as a job-aid want to know
what to report from the HBMNC tool. RPs have
to routinely convince them that the HBMNC is
meant to be a job-aid and there is no reporting
expectation based on the tool. This reinforces the
previous point that ASHAs see this as a tool
filling exercise.
-•“s r- -
H
Challenges:
•
Ineffective handholding: During the follow
up period after the roll-outs, Sukshema RPs
were unable to adequately provide handholding
support to ASHAs on HBMNC. This is because
tn
’
4.4.4 Training Frontline Workers: Arogya
Mantapa Roll-out
•
Context
Arogya Mantapa (AM) introductory training for the
RPs was a 1 day district level training in Koppal and
Bagalkot. However, ASHAs were not formally trained
in the AM concept.
AM Training
AM trainings for FLWs (ASHAs, JHAs and AWWs)
occurred alongside of the ETT roll-outs with
the intent that this would help in gap analyses.
For example, any gaps identified by the ETT
in immunizations or ANCs could be addressed
immediately in the monthly AM meetings, by all
3 FLWs. At the PHC level RPs advocated with the
Medical Officer and at the sub centre level they
worked with the JHAS to initiate this process. JHAs
were appointed as the point persons for conducting
AM meetings, with Sukshema RPs providing
handholding support throughout the process.
Lessons learned: AM roll out
What worked well:
•
In. the ipajority of AMs formed, no travel,,
allowance was demanded by the FLWs attending
the AMs. There was ownership of the forum and
the process, which is quite rare.
•
Some issues got resolved jointly by jha, asha,
aww- community level n system level issues,
these were discussed and resolved. Saving lives of
mother n child,
• MO has used this platform on many occasions,
especially to stress on specific needs of the sub
centre. He would plan his field visit days on AM
days. He would get everyone together.
•
Representation from VHSNC helped
since they (FLWs) could put forward their
recommendations/ support needed in the Am
forum.
•
Capacity building sessions were also undertaken
in the AM (FFC skills// COL etc) need based by
the rps based on the need.
•
•
•
•
perspectives first.
It was not very effective to build their perspectives
which would be critical for sustaining such a
process as the AM.
Very little scope for personality development.
Important to be an informal process rather than a
formal structured process. RPs not to control the
AM.
Purpose of AM is also to bring the two
department workers together (JHA, AWW). But
since the JHA was supposed to be leading the
AM, the AWW seemed to take a back seat. Work
related rivalry/ work plan clashes/ departmental
divides interfered with this purpose. We therefore
changed our strategy to ensure participation from
both by scheduling the AM during the VHND
or thayiandara sabhe days when both parties were
anyways present.
Based on our pilot experience, include the staff
nurse in the AM is essential especially in the
context of enhancing convergence. The 3 sisters
represent the community, the staff nurse could
be the 4th sister who represents the system. Their
mutual coordination would be critical to ensure
that issues are resolved at both the community
level and the health systems level.
Arogya Mantapa - A Case Study
In Bagalkot, a pregnant mother of 4 female
children regularly missed her ANC check
ups. Her family refused to send her for ANC
services since “all her older kids were girls
anyway”. ASHAs and AWWs visited the family
and tried to convince them to let her attend
ANC clinic but that still did not help. The
FLWs then alerted the VHSNC president at
an Arogya Mantapa meeting and the issue was
discussed at length. After this, the VHSNC
president personally approached the family and
managed to convince her family that attending
regular ANC check-ups was important.
Challenges:
•
Initially, JHAs were dependant on the RPS to
organize AMs and there was no real ownership
of this initiative. This led the team to include
the recreation aspect in the AMs and discussion
around their sub centres to better engage the
FLWs in the concept.
•
But initially we started off AM with the idea
of the FLWs discussing ETT/ CDL targets n
achievements in the AM That created a gap. We
should have focussed rather on building their
44
* An Overview of Sukshema's Community Intervention
?
/.a
4.4.5 Training Frontline Workers: SCMT
Roll-out
Context
The SCMT roll-out initially started with RPs being
the primary facilitators. However soon after, there
was general consensus between the central team and
the field teams that this was an additional burden on
RPs and that for the roll-out to be more successful
it needed to be outsourced. Thus, in order to roll
out SCMT trainings, KHPT partnered with Janani
Suraksha Abhiyan - Karnataka (JSAK), a campaign
promoted by SAMUHA to promote zero-tolerance to
maternal and infant deaths in Karnataka. This alliance
was aimed at developing a clear implementation plan
to achieve the following objectives:
•
Build capacities of the VHSNC to take on
supportive monitoring roles in a systematic and
consistent fashion using the SCMT
•
Develop a mechanism where the outcome of these
monitoring experiences are channelized towards:
• Building the collective vision of VHSNC
members in ensuring long term sustainability
of supportive health monitoring and its impact
on the community’s well being
• Strengthening accountability in MNCH
service delivery
• Enhancing demand for MNCH services
within the community
Thus, the SCMT roll-out was a two-day training
where a central team of external facilitators was
created to lead the trainings. The RPs provided
support only where required. A 3-day ToT was
conducted for RP Teams of Bagalkot and Koppal
districts.
The SCMT members’ were carried through a 2-day
residential training. However, though the roll
out started with a 2-day residential training for
the SCMT members, the central facilitator team
developed three versions of the training module to
use based on the diverse needs of certain taluks or
districts. The different versions of the training process
were:
• Version 1: Two-day residential training
• Version 2: Two-day non-residential training
•
Version 3: Three hour village level SCMT/
VHSNC training
Around 181 two-day SCMT trainings were
conducted and about 5770 SCMT members were
reached from 1212 villages across the two districts.
Around 121 village level SCMT/VHSNC hand
holding trainings were conducted.
Training agenda
A sample agenda from the 2-day SCMT training is
given below.
Day 1: The first day focused on Sukshema and the
objectives of the project, the SCMT tool and its
purpose, awareness on maternal and infant morbidity
and mortality and how the entire village is responsible
for the health of its community, particularly mothers
and children, the role of SCMT and how it fits in to
NRHM and Sukshema.
Day 2: The second day focused on creating an SCMT
action plan and the processes involved, how to bring
about societal change, further discussion about the
responsibility of the SCMT team and how to utilize
resources.
I
A Case study-SCMT training
'■7 J
J
An SCMT training program had been
organized in Belur, with participants from 6
villages. When the issue of postnatal home
visits was discussed, representatives from
Nagarala, Shivapura and Banashankari got
into a heated argument about missed home
visits by the ASHAs. In reality, there was only
one ASHA for Cholachagudda, Banashankari,
Nagarala and Shivapura and due to her extra
work load, she could not visit all the new
~ mothers. All the participants felfthat it was
pointless trying to conduct a training program
when there was a serious lack of ASHAs
1
in their villages. Then the local Karnataka
Municipal Administrative Service Officer,
who was also present at the training, called
the District Health Officer (DHO) and
conveyed the issues faced by the three villages.
Understanding the gravity of the situation,
the DHO promised to appoint extra ASHAs
in these villages.
'There are currently 2 new ASHAs in these
villages and one more has been recruited. As
a result, all the village representatives are very
cooperative towards Sukshema activities.
Planning and Implementation of the Community Intervention in the Pilot Districts ■ 45
Lessons learned: SCMT training roll-outs and usage
oftool
•
What worked well:
• External and internal trainers: Some Sukshema
RPs felt that the external teams were more
effective trainers for SCMT and felt that there
would have been gaps if Sukshema RPs had
conducted all SCMT trainings. Also, having
training teams comprise of external facilitators
and RPs was a bonus since each group had their
own strengths.
• Tool Simplicity: Some VHSNC members were
able to describe the purpose of the tool and the
information it provided. They found the smiley
and frowny faces easy to follow and they noted
that it helped them assess their community’s
health. One VHSNC member described the tool
as the lifeline of their work “This is the heart of
life”.
•
Increased awareness: Some VHSNC members
said that they gained knowledge from the
trainings. They learned about anemia counseling,
community ‘seemantha’ (a traditional South
Indian ritual carried out usually in the 7th
month of pregnancy to invoke blessings for a safe
delivery and a healthy baby), regular check-ups,
myths and misconceptions around pregnancy
and child birth etc. Since the SCMT enables
the VHSNC to identify high-risk women and
children, they are able to contact/alert their PHC
as a precaution
•
Effective training methods: Training was very
simple and even members with low literacy levels
could understand the content. Most VHSNC
members liked the role-play activities during
training
• Increased ability to focus on MNCH issues: A
VHSNC president from Bagalkot felt that even
though they met regularly before the introduction
of the SCMT, the tool helped them focus on
MNCH issues, immunizations, IFA tablets etc
and provided a clear way forward. The tool helped
them identify health gaps in their village on a
monthly basis, assess where their village was on
a number of MNCH indicators (based on the
number of smiley and frowny faces), and to chart
a course of action.
• Advocacy: Some VHSNC members expressed
a desire for the entire village to be trained on
the SCMT and not just VHSNC members. At
Koppal, one VHSNC decided to share the tool
with the rest of the village and was successful
in doing so. One of the greatest successes of the
SCMT is that based on their own experiences,
some VHSNC members have been advocating
for SCMT in neighbouring villages to increase
adoption of the tool. SCMT training in one
46
■ An Overview of Sukshemas Community Intervention
•
•
•
•
region helped advocate for and get more ASHAs
from the Dept of Health
Improved Accountability of ASHAs and
AWWS: A VHSNC president stated that using
the SCMT improves accountability of ASHAs
and AWWs back to their VHSNCs and ensures
that they are doing their jobs properly’. Health
gaps are discussed at the SCMT team meetings
and the team works together to meet targets.
ASHAs also find the tool very useful. An ASHA
in Koppal claimed that before SCMT, there
was nobody to question the ASHAs work. But
after the introduction of SCMT, the ASHAs feel
a greater sense of responsibility towards their
communities since they are accountable to the
VHSNC.
Community empowerment: Following the
SCMT introduction, one village in Koppal
decided to mobilize Gram Panchayat funds to
improve their MNCH status. Another village
dealt with their IFA stockouts, as identified by the
tool, by contacting the District Health Officer in
person and making him aware of the situation.
Identified need: When asked if SCMT should
not be introduced in villages that already have
processes of tracking health, the unanimous
answer was that every village needs SCMT since
other processes do not provide the specifics that
this tool provides.
ASHA-centric approach: The training teams
realized that using an ASHA (VHSNC member
secretary)-centric approach for the SCMT is
key. For instance, one RP was not allowed into a
village by the VHSNC members but the ASHA
assisted in getting her to their village.
Improved Interactions with PHCs and other
health department staff: Earlier, VHSNCs did
not have meaningful interactions with JHAs,
AWWs and PHC staff. However, SCMT provides
them with the knowledge and opportunity to
discuss their communities’ health with PHC staff
and a relationship has been built. One member
stated trustworthy relationships have been built
between VHSNC members and PHC staff since
they see each other “like a chain”.
Challenges:
• Outsourcing trainings: Initially, Sukshema
RPs felt territorial about external facilitators
conducting the SCMT roll-outs and trainings.
However, acceptance of external teams by
Sukshema RPs was high after they realized
that RPs would also be involved in the roll-out
process.
• Mobilizing SCMT teams: Encouraging all 6
SCMT members to attend the SCMT trainings
was a major challenge. It happened only in 21%
of the total number of the targeted villages. The
•
•
•
average number of participants per village was
4.7. VHSNC presidents and youth representation
was poor (62 & 54% respectively) and only 29%
of male participation.
Residential training: The residential aspect of the
trainings was another major challenge. Less than
30% of trainings ended up being residential due
to various constraints.
Training process: The training teams felt that the
SCMT trainings should be a 4 day process , and
the training modules should be a combination of
the 3 different versions that the teams developed.
They felt that this would not only help better
understanding of the SCMT tool and the
responsibility of the SCMT members but would
also foster greater cohesion among SCMT team
members. They also felt the need for on-going
process documentation and dissemination so
that the whole process becomes iterative and the
training process can be refined as needed.
Ineffective follow-up and handholding support:
RPs found handholding support for SCMT
(after the SCMT trainings) at the actual VHSNC
meetings to be very challenging due to inability
of VHSNC members to attend trainings. Project
team leaders believe that effective handholding
•
•
support will be a problem in scale-up districts
as well. Some districts teams proposed that
organizing trainings and providing handholding
support should occur simultaneously but be
handled by separate teams, a training team and a
handholding team.
Lack of capacity in Scale-up districts with
respect to VHSNCs: Project team leaders
felt that scale-up of SCMT was going to be
particularly challenging because villages in the
scale-up districts lack VHSNCs. To compound
this challenge, VHSNCs seem to require a lot
of initial facilitation to reach a level of useful
engagement. Thus, returns may be low compared
to the effort required keeping in mind human
resource and time constraints in scale-up districts.
Monitoring and Evaluation of SCMT data: One
VHSNC member told us that they do not discuss
those health issues that have a smiley face. This
could be the result of having a rating scale where
good=Smiley face and bad=frowny face. Also, the
SCMT data is not being used for health planning
in terms of setting timelines for action points so
that there is a commitment to actually following
through on the action points.
1
LI
r1
1
IMPLEMENTATION OF THE COMMUNITY
INTERVENTION IN THE SCALE-UP DISTRICTS
5.1
Overall Lessons Learned from Pilot Districts
•
The three tools (namely HBMNC, ETT/CDL
and SCMT), three processes (namely convergence
meetings, Arogya Mantapa and FFC) are
workable and scalable concepts.
The ASHA diary is a concept that is not only
scalable but has also been embraced whole
heartedly by the GoK.
The quality of roll-out (one-time) trainings needs
to be emphasized.
In addition to one-time trainings, on-the-job
handholding trainings and regular review &
reflection based trainings need to be emphasized
as well. Both the set of trainings should go hand
in hand, and not one after another.
There is a need to reduce reliance on external RPs
to be the driving force behind the interventions.
This is will impact sustainability
•
•
•
•
5.2
Changes in Implementation Strategy in
Scale-up Districts
Based on the lessons learned in the pilot districts,
several changes were made in the implementation
strategy during scale-up. This is not to say that pilot
experience was a mistake but the team learnt what
works better. Similar principles guided the processed
in both phases.
Changes in staffstructure- District Resource
Persons (DRPs)
One of the main changes was in the staff structure in
the scale-up districts. During the pilot/ experimental
phase we needed an intensive program to learn
from the experience; later we refined the programs
to ensure that it fits into the existing system and
henace the whole cadre of Sukshema RPs has been
eliminated for the scale up districts. In order to
ensure sustainability, as given in the figure below,
instead of Sukshema RPs, the scale-up districts will
rely on District Resource Persons (DRPs) who are
recruited from within the Health Department. A
team of DRPs for each Taluk will be chosen from a
pool of high-performing ASHAs, ASHA facilitators,
JHAs, AW supervisors etc. They are supported by a
Sukshema team of Taluka Community Co-ordinators
(CC). DRPs will be mentored and supervised by
a new cadre called District Community Mentors
(DCM). The DCM is the point person for the DRPs
in the scale-up district. Similar to the pilot districts,
the District Community Specialists are responsible for
48
* An Overview of Sukshema’s Community Intervention
all management-related decisions in the community
intervention at the district level.
As is evident from the changes in staff in the scaleup districts, sustainability is the driving force behind
the interventions during scale-up. In addition to
increased reliance on DRPs from within the Health
Department to power the interventions, the name &
logo of the project have been removed from ASHA
diary.
a) Advisory role of Central Team
In the scale-up districts, the project team is striving to
have more of a technical advisor and facilitator role in
addition to the technical service provider role that the
team had in pilot districts.
b) Shift to Experiential Learning
The emphasis has shifted from class room trainings
Figure 9: Staff structure of the District Teams
and Local Teams
District Project Co-ordinator
District
Program
Specialist
District
Community
Specialist
District
M&E
Specialist
Team B
(Project
Team)
CC1
CC2
CC3
CC4
I
District
Resource
Persons
Team A
(Local
Team)
r'.*
F
c- -
'''A
■
•1
to more experiential learning such as on-the-job
handholding, and group review and reflection centred
trainings. Scale-up districts also have a Taluka (CC)
centric action plan for implementation rather than
the District (DCS) Centric action plan in the pilot
districts. In the scale-up districts, more emphasis
is given to handholding rather than the roll out
trainings. Thus, the total number of training days
for FLWs are reduced compared to the pilot districts
and a total of three interactions have been planned
between ASHA supervisors and ASHAs .
c) Focus on Behaviour change rather than
information dissemination
The ultimate goal for Sukshema’s communication
strategy for the community intervention was that
it should go beyond information dissemination
and raising awareness—it should focus its limited
resources on concrete actions and influencing
behaviour change. However, this was not
operationalized to its fullest extent in the pilot
districts because of the sheer volume of trainings
and roll-outs that drained all the district teams.
Also, the district teams were so focused on delivering
high-quality trainings and IEC material that the
end goal often became blurred. Thus, in the scale up
districts, a concerted effort has been made to re
orient the district teams to the ultimate goal which
is to influence voluntary behavior of target audiences
(such as FLWs, community, district health staff) to
achieve better MNCH outcomes rather than merely
to disseminate information.
d) Changes to Arogya Mantapa
In scale-up districts, there is no emphasis on the
discussion of targets or CDL/ETT during the
trainings and the meetings. Based on the learnings
from the pilot district, the team realized that for the
FLWs to take ownership of the AM process, they need
to set their own agenda for the AM monthly meetings
and they were entitled to use the forum for more
social activities rather than to discuss MNCH issues,
since the intended purpose of this intervention is to
facilitate improved co-ordination of FLWs’ activities.
e) Transition HBMNC tool to Health Department
Officials
The responsibility to train the FLWs on this tool and
scale it up to all districts has been handed over to the
Government of Karnataka. Efforts are being made to
transition the tool in its entirety (including printing
and distribution) to the Government of Karnataka
since the Government of India has already accepted
and approved of the HBMNC concept based on its
success in the pilot districts.^
f) New Home-based-Family Focussed Counselling
tool (HB-FFC)
The HB-FFC tool is an interactive dialogue-based
behaviour change counselling tool. It consists of 12
key messages around the issues of MNCH. These
priority messages emerged from the CBTS outcomes
as key needs/ gaps on the field. This tool is entirely
pictorial. It serves as a job aid for the ASHAs while
counselling (one-on-one) the pregnant women and
family during her home visits. (Please see section
below for more details)
g) Implementation guided by CBTS outcomes
All implementation activities in the scale-up districts
were based on CBTS outcomes. While CBTS
outcomes guided implementation activities in the
pilot districts as well, there has been a concerted effort
by the central and field teams to use the CBTS data
iteratively to guide implementation in the scale-up
districts.
li) Filling-up vacant ASHA positions to improve
coverage
During the process of selecting DRPs, the field teams
(CCs, DCMs and DCSs) were able to identify vacant
ASHA positions and to advocate with the Health
Department to fill these positions. In addition, they
were also able to identify eligible candidates through
the DRP network, notify the Health Department,
organize their trainings and get them recruited.
5.3
Implementation Strategy in Scale-up
Districts
•
•
The implementation strategy in all the scale-up
districts of Bijapur, Bellary, Yadgir, Bidar, Gulbarga
and Raichur is outlined in the tables below. The
activities in scale-up have been categorized into
A(Central Team Activities), B (Roll-out activities) and
C (Regular mentoring activities).
In some taluks, the ASHA diary orientation and
distribution preceded the FLW trainings. This strategy
also seemed to work well for the ASHAs.
DRPs see their main role as being ASHA trainers.
They also identified co-ordination between
departments to be one of their main roles. In addition
to their roles as ASHA trainers, they also
•
facilitate village health and nutrition days and
VHSC meetings
•
provide handholding support for ASHAs and
support with HBMNC and ETT/CDL formats.
Consolidate ASHA reports
Conduct and facilitate Arogya Mantapa meetings
Selection Process ofDRPs
The central team helped develop the criteria for the
selection ofDRPs. The criteria were as follows:
•
SSLC pass
•
Should have training experience
•
Should have good communication skills
Selection of DRPs was undertaken by the CCs
and the DCMs after consultation with the Health
Department staff. A number of venues and forums
had to be used for identifying and selecting DRPs
such as PHC-wise ASHA meetings, SC visits, field
visits, some VHSNC meetings etc. As mentioned
above, the DRP teams in the scale-up district
comprised mainly of ASHA Facilitators (39%) and
JHAs (38%). For example, in Yadgir, 96 DRPs (38
ASHA Facilitators+ 42 JHAs + 7 Anganwadi Worker
Supervisors + 1 Block Health Education Officer) were
selected and a strong DRP team has been formed.
Table 3: Implementation activities in Scale-up Districts
I Strategic Activities
Training/ implementation
Activities
Follow up Activities
j Al Conceptualising, developing and
J fine tuning the 3 tools-HBMNC,
I SCMT and CDL/ETT
Bl 4-day DRP ToTs
Cl Taluk level monthly
DRP meetings (One per taluk I
per month)
I——
A2 Conceptualizing, developing and
fine tuning the 3 processes- FFC for
HBMNC, Arogya Mantapa, PHC level
_ process for promoting convergence
B2 2-day FLW trainings
C2 PHC level monthly ASHA
review meeting
A3 Conceptualizing, developing and
printing ASHA diaries 2013-15
B3 2-day SCMT trainings
C3 SC level monthly Arogya
Mantapa
A4 Conceptualizing and developing
strategies & processes for
encouraging and handholding DRPs
B4 1-day ASHA Diary
orientation & distribution
C4 Village level monthly
VHSNC meeting
A5 Developing training modules all
training processes (20 training days)
B5 ASHA reminder
card orientation and
distribution
C5 Village level ASHA
handholding - with CDL
(once per month per ASHA)
A6 Complete Process documentation
of Community Interventions
B6 Advocacy for filling-up
vacant ASHA positions
C6 and C7 Household level
ASHA handholding - with
HBMNC and FFC (One family
visit per ASHA per month]
t
50
■ An Overview of Sukshema's Community Intervention
Lessons learned during DRP selection
What worked well:
•
The process followed for identifying and
recruiting DRPs worked well. The project was
able to recruit high calibre DRPs. This view was
mirrored by Health Department officials as well.
• All DRPs greatly appreciated being selected as
DRPs and said that they were glad that Sukshema
recognized their potential and skills as key
resource persons.
• ASHAs, who were initially reluctant to become
DRPs, had a boost of self-confidence and started
taking on more leadership responsibilities once
they were led through the ToTs
•
DRPs did not need extensive training, compared
to the Sukshema RPs in the pilot, since they
already had a good amount of technical MNCH
knowledge
Challenges:
•
Conceptual shift for district teams: Some field
staff in the scale-up districts (such as CCs, DCMs
and the DCS) had originally worked in the pilot
districts. So there had to be a conceptual shift
to the need for DRPs in scale-up districts vs
Sukshema RPs in the pilot districts. As a result,
they found it challenging to articulate the need
for DRPs and to convince health department staff
to help identify DRPs
•
Limited support from Health Department in
some districts: In some of the districts, initially,
the MO and other senior officials were not
interested in sticking to the criteria for short
listing DRPs and the CCs had less support from
them. This was probably because Yadgir is a new
District with new Health department staff.
•
Potential bias in DRP selection: Although the
DRP selection process was intensive, it is possibly
not free of bias of the health department staff.
•
Limited DRP pool: Some taluks had a smaller
DRP pool to choose from, and as a result DRP
selection was challenging. Also, it took CCs over
2-3 months to select DRPs. They had to consult
with ASHAs and community members to ensure
that the right candidates were recruited as DRPs.
• ASHAs’ reluctance to become DRPs: Some
ASHAs were hesitant to become DRPs since they
thought that they would have to take on more
responsibilities.
•
Power dynamics within DRP teams: Although
the intent was to for the DRP pool to comprise
mainly of ASHA facilitators and not ASHAs, in
some taluks the CCS had to select some ASHAs
as DRPs, in addition to ASHA facilitators. This
led to a shift in power dynamics within certain
DRP teams. To counter these negative group
dynamics, the Bijapur team of CCs, DCM
and DCS started team building sessions in
clusters, and had started internally grading their
DRPs as A, B and C. By doing so, they were
able to provide C category DRPs with more
opportunities to observe and participate.
Lessons learned about the DRP concept in scale-up
districts
What worked well:
•
Clear understanding of roles and project
objectives: DRPs were able to articulate their
roles very clearly. They were able to communicate
the vision of the program clearly.
•
Ownership of project: The ownership of the
entire program seems high and immediate
since they feel that the project recognized
their strengths and skills and made room for
expression. Also, they do not see their roles as
DRPs separate from their roles as FLWs.
• Established skill sets and linkages: The internal
DRPs seem to work much better than external
Sukshema RPs in the pilot districts. The DRPs
already have the knowledge, the department
connections and understand the field.
•
FLWs’ acceptance of DRPs: DRPs are not
perceived as a threat but rather as examples by the
rest of the FLW fraternity.
• Appreciate the ‘Grass roots approach’ of
Sukshema: The biggest achievement is that they
recognize that this process is an entirely bottomup process and not a top-down approach. THO,
Bijapur felt that the key gap in the Department is
the absence of this approach.
Challenges:
• Sustaining motivation among DRPs: One of
the major challenges that the project and Gol will
face with DRPs will be to find ways to keep this
team motivated about their work as facilitators
in the community intervention processes.
Recognition and appreciation of their efforts is
a key strategy to prevent the DRPs from getting
frustrated, discouraged and tired of the project.
• Tailoring on-the-job support to DRPs’
needs: All DRPs have varied skill sets. Thus the
handholding process would need to cater to
individual level gaps.
•
Power dynamics within DRP teams and Non
co-operation: Personal agendas and power
struggles could taint the group dynamics of
DRPs. Perspective building exercises should
address this. On the other hand, non cooperation
from other FLWs is a possibility due to jealousy,
personal ambitions and absence of vision oriented
action
•
Multi-tasking DRPs: Compared to the
Sukshema RPs, DRPs are not able to spend as
Implementation of the Community Intervention in the Scale-Up Districts “ 51
•
•
•
much time in the field since they have other
responsibilities as well. For example, some of
them are ASHA facilitators and even ASHAs, so
their responsibilities place an additional burden
on their field activities.
Historical hierarchies: A peer led approach
might take time to establish itself in a strongly
hierarchical set-up which has been, until now,
used to a supervisory approach rather than a
supportive one.
Health Department’s changing priorities: New
programs and newer responsibilities is a reality
within the health department. So there is a high
possibility of losing focus on MNCH goals.
Lack of DRP remuneration: DRPs are not being
remunerated for their time. Considering that all
DRPs already have other Health Department
responsibilities, there needs to be some advocacy
at higher levels to compensate DRPs for their
time spent as DRPs.
DRPTOTs
The Four-dayToT for DRPs is one of the 19 project
activities of Sukshema’s community interventions. The
implementation of this activity began in the last week
of September 2013, and was completed successfully
in March 2014. During this period, a.totaljjf 19 ToTs
were organized and 865 DRPs were trained across the
six scale-up districts. Bijapur and Gulbarga district
teams conducted the highest number of ToTs because
of higher volumes of DRPs in these districts.
When asked about what they had learned during
the TOTs, in addition to mentioning some of the
technical content, such as the tools and processes
of Sukshema, almost all the DRPs mentioned soft
skills such as the importance of working together and
learning how to work in a systematic way. The most
repeated response, however, was that they learned
how to communicate well. One example given was
an AW supervisor who, despite being in her position
for 26 years, was not able to speak at meetings. But
after the TOT, she was able to articulate herself well at
meetings.
Lessons learned during DRP TOTs
What Worked Well
•
Good training design and methodology:
The flow of the sessions, the methodology,
participation and co-ordination seemed very
good. Also, the sessions seemed to have broken
the ice and brought about attitudinal changes
very successfully. DRPs learned to respect each
others responsibilities. One of the MOs in Yadgir
considered the ToTs as a refresher for the DRPs
and thought that it helped strengthen their
52
* An Overview of Sukshema’s Community Intervention
•
•
•
skills. On the flip side, the DRPs felt that while
the trainings did not teach them anything new
in terms of their technical knowledge, it taught
them how to be systematic.
Appreciated stress on conceptual issues: DRPs
liked the emphasis on conceptual issues, such
as women right’s and engaging the entire family
during home visits, rather than interventions.
Many DRPs appreciated this and that was their
favourite part of the training.
Improved communication skills among DRPs:
DRPs spoke about an improvement in their
communication skills. This seemed to have been a
great which the ToTs met. DRPs felt empowered
because of this.
One of the Yadgir DRPs felt that “After the ToT,
our skills just took a U-Turn”
DRPs empowered: When asked whether they
could sustain these efforts if Sukshema CCs were
not around, everybody had an unequivocal yes’ as
a response. This was a major difference from the
pilot districts.
Challenges:
• Better planning: The central team felt that there
needed to be better planning of the ToTs. In the
first five months of scale-up implementation
(Sept 2013 to Jgn 2014) they organised 7 ToTs. „
But subsequently, in the next 50 days the teams
successfully conducted another 12 ToTs.
5.3.2 Changes in FEW Training Strategy in
Scale-up Districts
FEW trainings follow the DRP ToTs and are
conducted by the DRPs. This is a 2-day nonresidential training where all the FLWs are oriented
towards the projects tools and processes and are also
given a chance to learn from each other. During
the time of the visit, only a few FEW trainings had
occurred.
Some of the key changes that have been made in the
FEW training strategy in the scale up districts are:
•
DRPs are the ones conducting the FEW trainings
in contrast to the pilot districts where the
Sukshema RPs conducted the trainings.
• The training content has changed considerably
in the scale-up districts. In the scale-up districts,
most of the interventions are addressed in the
FEW trainings instead of starting with FFC and
then having multiple trainings for the other
interventions (which was the strategy in the pilot
districts).
•
Class room training hours have been reduced
drastically and there is more emphasis on on-thejob handholding trainings and monthly reviews
and reflections (eg ETT/CDL, FFC)
•
There is more focus on experiential learning
rather than a didactic format.
There is more emphasis on a group approach and
more on reviews and reflection-based self-learning
processes.
Table 4: DRP Scoring System
Areas for Scoring
Reward
Points
DRP review meeting
100
Lessons learned during FLW trainings
PHC Meeting
100
What worked well:
•
DRPs as trainers: DRPs seemed very confident
and did a really good job at the one training
observed. They had excellent communication
skills and were lively and interactive. DRPs
were able to emphasize soft skills’ such as
changing attitudes and perceptions rather than
interventions, which is good strategy to employ
since it creates a strong foundation for the
project.
•
FLWs understand project objectives: FLWs
are able to articulate why all 3 groups have been
brought together. They felt that the trainings
increased their confidence.
•
Plan for Post-Training Activities: In Bijapur,
they seemed to have a plan for post- training
activities such as CDL discussions at cluster levels,
linking Arogya Mantapa to VHSNC/ VHND. A
DRP-wide post roll out plan should be in place at
the taluk levels, with CCs and DCMs leading the
process.
Arogya Mantapa Handholding
50
ASHA Handholding
100
SCMT Handholding
50
Attitude, involvement, creativity
100
TOTAL
500
•
Challenges:
•
Lack of support for trainings: There seemed to
be a lack of manpower and leadership during the
trainings and all CCs talked about a general lack
of support from the MOs.
•
Ensuring only DRPs lead trainings: DRP teams
are new but they should be encouraged to lead
the trainings and CCs should be encouraged to
support the DRPs and not facilitate the trainings
themselves. The CCs’ focus perhaps should be to
really invest in and strengthen the DRPs which
will then trickle down.
DRP Scoring
The central team has developed a transparent
scoring system to address the concerns outlined
above regarding sustaining motivation levels
among DRPs. The CCs will score the DRPs on
5 areas every month for a total of 500 Reward
Points (see table below). This scoring will be
discussed at the monthly DRP meetings. The
team will evolve different ways of translating
these reward points into tangible expressions of
appreciation.
I
I
I
5.3.3 Community Co-ordinators (CC) and Their
Role in Scale-up Districts
Community Co-ordinators are a new cadre of staff
introduced in the Scale-up districts. Their main role is
to support and handhold the DRPs. However, some of
their supplementary roles have been to conduct DRP
ToTs, conduct VHSNC surveys, collect case studies
on maternal and infant mortality and facilitate Arogya
Mantapa meetings. Most of the CCs in the scale-up
districts were Sukshema RPs in the pilot districts.
CCs faced a number of challenges carrying out their
roles as CCs in the scale-up districts. Some of them are:
•
Initially, CCs had to build rapport with PHCs
and conduct field visits to understand things at
the ground level. They had to understand the
community and culture in their taluks. It took
them about 5-6 months to carry out this process.
This was in stark contrast to the pilot districts since
they had already spent a whole year building these
connections.
•
The demographics of the population in the scale-up
districts were very different from the pilot districts.
For instance, there are more lambani groups, poor
literacy, increased migration, fewer ASHAs and
AWWs, fewer MOs etc
•
Bijapur was a challenge because of its history with
HIV/AIDS NGOs so Sukshema staffs were looked
at very suspiciously.
•
One of the main changes that they had to deal with
was to think of themselves as CCs and not RPs,
since in contrast to the pilot districts where they
were direct implementers, in the scale-up districts
they played more of a supportive and managerial
role to DRPs. They all felt that they had more
responsibilities as CCs than as RPs.
•
One of their key challenges also was to identify the
right department officials to liaise with and how to
Implementation of the Community Intervention in the Scale-Up Districts ■ 53
•
focus their communication and clearly articulate
issues with them, such as the how to speak to the
MO and what to discuss with the THO.
Another main challenge that they faced was the
differences in FLWs between scale-up and pilot
districts
• Based on the need for handholding support,
CCs felt that FLWs in scale-up districts had
poorer literacy skills
• Non-working ASHAs were higher in number
• Non-local ASHAs were higher in number, i.e.
they travelled from other towns/villages to
their allotted catchment areas and as a result
their field work and home visits suffered
• Sindagi was a particularly challenging taluk
since there is a lack of manpower i.e. fewer
ASHAs and JHAs and a very poor NGO
history.
5.3.4 Tools and Processes in Scale-Up Districts
As mentioned above, there are some changes to the
tools and processes in Scale-up districts, compared
to the pilot districts. However, even in scale-up
districts, most of the components of the community
intervention still remain the same and aim to improve
management and delivery of outreach services, shape
demand and strengthen accountability.
Improving management and delivery o£
outreach services and shaping demand
1.
ASHA Diary
a. Enumeration and tracking tools and
methods for ASHAs to improve coverage
(CDL Package)
b. Integrated maternal and newborn
management tool for ASHAs to improve
identification and actions for postnatal
danger signs (HBMNC)
2.
Home-based Family focussed
communication tools and materials for ASHAs
to use while counselling families (HB-FFC)
Strengthening accountability
3.
4.
5.
Supportive Community monitoring tools
(SCMT) for Village Health Sanitation
and Nutrition Committees (VHSNCs) to
strengthen accountability
Sub centre forum (SCF — Arogya
Mantapa)
Increasing functionality of the Primary
Health Centre (PHC) Convergence
Meetings
i
■-
54
■ An Overview of Sukshema's Community Intervention
The experience in the pilot has been encouraging
and the FLWs have been sufficiently empowered to
function more effectively. The focus in the scale up
districts has really been to strengthen handholding
and sustainable processes on the ground.
Note: Only the tools and processes that are different
in the scale-up districts, compared to the pilot
districts, are discussed below. For more information
on all tools and processes in the pilot districts,
please refer to the section “Overview of Sukshema’s
Community Intervention”.
a. Community Demands List (CDL) Package
Purpose ofthe CDL package
The objective of the CDL package is still the same as
it was in the pilot districts, i.e., to provide tools that
help in the consolidation of th e information and
reduce (if not eliminate completely) duplication of
efforts. The purpose of the improved CDL package in
the scale up districts is to help ASHAs record, plan,
review and report her work in a systematic manner.
The improved CDL Package has the following
components:
a. Tracking tool for ASHA in hier area (CDL 1).
_ This is a recording tool.
b. Community Demand List (CDL 2) which is a
self reflection and planning and review tool for
the ASHA
c. CDL 3 which is an abstract of CDL-2 and a self
reporting tool.
All the three CDL tools- 1, 2 and 3 are to be filled by
ASHAs.
In addition to the introduction of the new CDL
package in the Scale-up districts, all the changes in
CDL package have also been introduced in the pilot
districts. The entire CDL package has been piloted in
Koppal and Bagalkot for a period of one year and the
tools have now attained a final stage. The trainings
for CDL will not focus anymore on individual tools
rather on the CDL as one entire package with the
three tools.
Similar to CDL 2, CDL 3 has two components1. Reporting of the previous month’s progress which
enables the ASHA to record total demand and
review her performance on the specific 16 tasks
outlined by Gol.
2. Planning - Capture the planning for the next
month in terms of her targets. This is an extract
of the following month’s CDL 2. She copies her
CDL 2 data as is, in this section.
Figure 10: Flow of information across levels for
gap analysis
ASHA
Facilitator
Consolidates
[
CDL3I Self Report
Analysis of
gaps/problems
CDL2Self Report J
CDL1] ■
Self Report J
Sub
centre/
PHC level
ASHA
level
On the 21st of every month, after she completes
CDL 2 of the reporting month and planning
(CDL 2) for the next month, then she abstracts her
CDL 2 data in to CDL 3. CDL 3 is to be submitted
to the ASHA facilitator during the ASHA meeting
that will be conducted on the 21st of every month.
Roll-out process of CDL-3
In the pilot districts, there was an exclusive training
only for CDL (as mentioned in Chapter 2). However,
in the scale up districts, it is a part of the ASHA
Diary orientation. ASHA Diary and the CDL package
will be a 1 day orientation through DRPs at the PHC
level, in the presence of MO and THO.
Supportive supervision of ASHAs*
As mentioned above, DRPs are responsible for
providing handholding support to ASHAs in the
scale-up districts. The emphasis in the scale up is onthe-job training. As the initial step, all ASHAs will
be encouraged to fill out CDL 1, listing all pregnant
women and children under 2 years of age in their
catchment areas. Based on that the ASHA facilitator
will help the ASHA plan for the month, i.e., how to
set targets. Handholding interactions happens three
times in a month (see below).
First interaction - This happens on the 21st of
every month and is at a PHC level. Every ASHA is
supposed to complete her CDL 1 and fill her
CDL 2 (both the progress and planning sections) She
will then abstract the details of CDL 2 into CDL 3
and submit CDL 3 to ASHA facilitator
Second interaction - ASHA facilitator meets the
ASHA at the AM and provides handholding support
to her. The ASHA facilitator also helps the ASHAs
with any personal or professional problems that she
may have.
Third interaction - ASHA facilitator meets the ASHA
in the village where she will check CDL 1 / CDL 2
details.
ASHA grading
The purpose of ASHA grading is to enable ASHAs
to self-monitor their performance in a given month.
The basis for this approach is ‘self improvement
through self grading’. This grading process also helps
the ASHA facilitator with providing handholding
support, since she would know who needs more
support in the following month. As mentioned above,
every ASHA facilitator meets with her ASHAs on the
21st of each month. All ASHA names are recorded
and are graded as follows:
•
Grade 1 ASHA- Completion of all three CDL
tools (where all the 5 objectives are met)
•
Grade 2 ASHA- Completed CDL 1 and 2
•
Grade 3 ASHA- Completed CDL 1
•
Grade 4 ASHA- Has received ASHA DIARY but
not filled out CDL 1
•
Grade 5 ASHA- Has not received ASHA diary
•
Grade 6 ASHA- Absent ASHA (or data
unavailable for that ASHA)
ASHA facilitator grading
There are 50 ASHA facilitators in every district.
ASHA facilitators are graded similar to the DRP
scoring mentioned above. The CCs score the ASHA
facilitators on 5 areas every month for a total of 500
Reward Points (Refer to the DRP scoring section
above for further details). This scoring is discussed at
the monthly meetings. The team will evolve different
ways of translating these reward points into tangible
expressions of appreciation.
b. Home-Based Family Focussed Communication
(HB-FFC)
The HB-FFC tool is an interactive dialogue-based
behaviour change counselling tool. It consists of 12
key messages around the issues of MNCH. These
priority messages emerged from the CBTS outcomes
as key needs/ gaps on the field. This tool is entirely
pictorial. Every message has four sections:
1. Pictorial representation of the message
2. The key message (in words)
3. An interactive question to check whether the
message has been understood by the recipient
4. Call to action
Purpose
It serves as a job aid for the ASHAs while counselling
(one-on-one) the pregnant women and family during
her home visits. The HB-FFC evolved as a simplified
and pictorial tool to strengthen to the existing
HBMNC tool. This tool helps ASHAs counsel more
effectively. HB-FFC tool can also be viewed as an
improvisation to the reminder cards.
Implementation of the Community Intervention in the Scale-Up Districts ■ 55
Every ASHA has a copy of the tool. When the ASHA
first meets the pregnant or lactating woman at her
home in the presence of her family members, she tries
to assess the woman’s knowledge on key areas. Based
on the woman’s current knowledge and need, the
ASHA chooses the messages that are most relevant to
her. She uses the pictures in the tool to discuss this
further. She verifies that the woman has understood
the message and encourages her to make a decision
regarding it.
Testing ofand Orientation to the tool
The tool has been field tested in two PHCs of
two districts. There have been several consultative
meetings with the district teams regarding the
tool. This involves orientation to the tool and its
implementation. There has also been advocacy
with district, taluk and PHC level officials to build
acceptance of the tool. The roll-out of this new and
improved tool was carried out in campaign mode, and
was done alongside the SCMT roll-out.
Training
The tool will be introduced to the DRPs and other
ASHA facilitators at the monthly review meetings.
ASHA facilitators will then train the ASHAs on the
tool and its usage at the PHC level. Handholding of
trained ASHAs will happen soon after jhe orientation
(i.e. on-the-job handholding).
Monitoring
HBFFC usage is one of the line items for reporting
by the ASHAs, as part of the monthly progress report
of the ASHA facilitators. The ASHA facilitators will
report on its progress to the ASHA mentors and CCs
at the DRP meetings.
Efforts are underway to advocate with the State to
incorporate HB-FFC within the existing MOTHER’S
CARD and the ASHA Diary.
c. Supportive Community Monitoring Tool
A campaign mode was adopted for SCMT roll-out to
enhance community participation and was called The
“Namma Habba” campaign.
Purpose
The Supportive Community Monitoring tool
(SCMT) attempts to involve the community through
Village Health Sanitation and Nutrition Committees
(VHSNC) in planning and monitoring village health
service delivery to realize community participation and
ownership of village health programs as envisaged in
the goals of NRHM. It aims to strengthen community
accountability towards village health and improved
MNCH outcomes and to provide opportunities for
56
■ An Overview of Sukshema’s Community Intervention
FLWs to be supported by the community in their
efforts to improve MNCH outcomes.
SCMT teams serve as an effective medium that the
VHSNC committee members can utilize to get first
hand information regarding mother and child health
in their villages. Sukshema has been instrumental
in the formation of these SCMT teams (see section
titled “Supportive Community Monitoring Tool”) in
the pilot and scale-up districts. However, what still
remains unclear is how these SCMT teams interact
with and support the ASHAs and the other FLWs.
Thus, in the scale-up districts, the project has
attempted to address these concerns by creating a
festival like atmosphere (Namma Habba means ‘Our
Festival’ in Kannada) through adopting a campaign
approach at the sub center level where the SCMT
teams are formed and the ‘torch of health’ is handed
over to them.
The shift from a didactic method of behaviour change
communication to a more organic campaign mode
was in the wake of the following:
•
It provides scope for better advocacy since it is
escapes the formal requirements of a traditional
classroom training methodology
•
This campaign mode should not be considered
a routine activity but as an accelerator. It is
part of a layered approach to behaviour change
communication and is complementary to all the
other components in Sukshema’s community
intervention.
• The acceptance and appeal of a process like
the campaign mode (using theatre), which
touches the cultural and emotional threads of
the community and focuses on real time needs
of communities, is always higher rather than
a formal training process. In fact this shift has
garnered a high level of acceptance from the
Health Department as well.
• This mode of training could also serve as a means
of strengthening and increasing the engagement
of the FLWs and VHSNC members in the the
Arogya Man tapas.
•
It provides scope for social proofing. Transparency
and unanimity is evident in such a process.
• It involves various players such as general
community, AWW and all FLWSs along with the
VHSNC members
• Motivational shift from VHSNC to the FLWs is
paving the way for greater accountability from
both ends
•
Such a process is empowering in itself for DRPs
•
In the pilot district, the focus was only on skill
building but in this approach the focus is more
on building perspectives. Skill development will
happen through the handholding process.
•
■' f
Details of The Namma Habba campaign
The purpose of the Namma Habba campaign is
to sensitize the SCMT members regarding the
SCMT tool and its use. During the initial scale-up
implementation activities, the district teams realized
that not all VHSNCs in the scale-up districts were
active. Thus, in the scale-up districts, DRPs are trying
to form and strengthen the VHSNC in areas where
they are not strong or functional, during handholding
visits and Arogya Mantapas. All the SCMT teams
in a given Sub centre will be involved during the
Namma Habba campaign. The campaign aims to help
VHSNCs understand the importance of utilizing
the SCMT teams and the tool to plan and monitor
MNCH in their villages.
Objectives of the habba:
1. To introduce the SCMT tool within the
VHSNCs
2. To form as well as restructure VHSNCs wherever
needed
3. To bring community representatives and FLWs
together
The themes for the Namma Habba movement are
standardized across districts to build message recall.
Standardized messages conveyed during the Habba
are:
•
The health of our village is our responsibility
• A hospital has the responsibility to treat
•
•
•
•
mothers and children, while the VHSNC has
the responsibility to safeguard the village’s health
status.
Let us set aside one day a month for our village’s
health
The community supported monitoring team or
SCMT team is our support platform
Let’s put our mistakes behind us, and take our
next step with confidence
ASHA is the light of our village and the SCMT
team is the fuel.
Duration of the Habba and key stakeholders:
The Namma Habba campaign is a one day program at
the sub centre level involving all the VHSNC members
of the villages under that sub centre as well as the
Front line health workers. ASHAs, AWWs, JHAs, all
VHSNC members and the 6-member SCMT team are
the primary stakeholders. Along with these members,
the local Medical Officers at the PHC level and other
health workers can also be invited.
This one day program brings together all the VHSNC
members from the villages of that sub centre where the
Intimate Interactive Theatre team (consisting of DRPs)
involves them in a discussion through interactive
theatre around issues such as gender, maternal and
child death, role of community and the VHSNCs
responsibility in improving health conditions of
their community. This performance is preceded by
competitions and programs such as singing, rangoli,
acting with the objective of bringing the VHSNC
Implementation of the Community Intervention in the Scale-Up Districts ■ 57
members together. Officials such as the medical officer
and other department officials were also invited for
the program. In this festive milieu, the team launches
the SCMT tool at the end of the program and the
VHSNCs draw up the next action steps.
This habba commenced on Independence Day and
end on Gandhi Jayanthi (August 15th to October 2nd).
•
Implementation Process
The process of implementing the Namma Habba
movement within a sub-centre comprises of the
following activities:
• Designing the ‘Habba’ concept and
Consultative Meetings : The central team first
assesses the situation at the grass roots level (with
respect to how active the SCMTS are and whether
there are functional VHSNCs in the area)and
the findings are used at the time of planning the
Habba. This is followed by a consultation meeting
with the district teams, as needed. A rough draft
of the design concept is then prepared.
• Engaging the DRPs: A meeting is arranged with
DRPs at each Taluk where they are introduced to
the concept, design and importance ofNamma
Habba. Their roles and responsibilities at the
Habba, will also be clarified here. DRP tegms in
each Taluk are given a target of staging 10—15
shows within 45 days. The dates of the Habba are
also finalized at this meeting.
•
Consultations with GoK Staff: Consultations are
held with officers of the Health and Woman and
Child Development departments at the district,
taluk and PHC levels. Since this Habba is being
voluntarily staged as part of the Arogya Mantapa,
a written permission from the departments is not
necessary. However, this step is key to obtain buyin from the two main GoK departments involved.
Training and Formation of the Intimate
Interactive Theatre (IIT) team: A ToT for the
IIT is arranged for four important members of
the district implementation team (the IIT team
comprises of the DCS, the DCM and 2 CCs) .
The interactive intimate theatre is designed to be
deliver the target messages effectively. A script is
prepared, the cast is identified, facilitators and
directors of the play are also identified and a
pilot screening of the play is staged in at least 2
subcentres in a Taluk. However, the IIT teams
during implementation will comprise of FLWs as
well.
Monitoring and evaluation indicators to gauge the
success ofNamma Habba:
•
•
•
The number of VHSNC members, SCMT
members, ASHAs, AWWs and Karnataka
Municipal Administrative Service members who
participated in the Habba
The number of S£MT meetings conducted and
decisions taken during the duration of the Habba
The support extended by officers from different
levels of the health and woman and child
development departments.
Table 2. Personnel Costs in Six Scale-Up districts
... .
District
# of Habba
conducted
# of VHSNC
| trained
| # of VHSNC
# of SCMT
formed
1 reformed
■
J
I Bellary
255
526
20
526
Raichur
177
779
189
813
Yadgir
160
470
62
470
Vijaypura
238
608
278
537
Kalaburgi
317
823
210
823
■
Bidar
268
619
68
598
6
Total
1415
3825
1451
58
* An Overview of Sukshemas Community Intervention
‘
3767
F
E
-
1
■
Lessons learned: Namma Habba campaign
•
•
•
Have a clear focus for the Habbas: The initial
plan was to use the habba as an orientation
platform for both Arogya Mantapa and the
SCMT Tool. But the teams realized that this
approach was diluting the focus since both
concepts are very distinct from each other. Thus,
the habba is now focused purely on introducing
the concept of SCMT and strengthening SCMT
teams.
SCMT training will lead to strengthening of
VHSNCs in Scale-up: In the pilot districts,
VHSNCs were already established and functional
which was an advantage to the SCMT roll
out. Conversely, in the scale up districts,
VHSNCs were either not yet formed or were not
functioning effectively. Thus, the strategy in scale
up districts was to start with the SCMT training
and roll-out, with the hope that this would
organically lead to building and strengthening the
VHSNCs eventually.
Common Habba formula for all districts
works: The implementing teams realized that
having a common formula to conduct habbas
•
in all the districts works well, as long ;as a basic
framework and clear expected process; level
outputs were articulated. The teams could then
innovate and tailor habbas in their districts or
taluks to suit local needs.
The initial plan was to have a DRP orientations
and ToTs simultaneously across all taluks but we
changed the strategy are waited to finish the DRP
orientations, TOTs and begin implementation in
one taluk and then move to the other taluk. That
gave the field teams enough experience to carry
out this process elsewhere.
Challenges during implementation:
•
•
•
•
Eliciting support from the department and
the panchayat needed continuous effort and
engagement
Facilitation skills of the team of performers
needed rigorous honing since the IIT team was
in-house and not everyone had experience in
handling such an exercise
Ensuring that the campaign sent uniform
messages across all sub centres was not easy
Sustaining this process at low cost
fl
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Positive instances from the field that emerged
during the Namma habba process:
1.
Kavalaga Subcentre (Farathabad PHC) of
Kalaburgi district had been closed for the last
2 years. There was a barber shop in the same
building, hence women stopped coming to this
sub-centre. The JHA of this SC made an attempt
to shift the barber shop. This issue was discussed
with the GP president during the occasion of
“Namma habba”. The GP President directed those
concerned to vacate the shop and now the sub
centre has started functioning as usual.
2.
Many of the families in Harji village of Kalamoda
SC (Sonta PHC) in Kalaburgi district were not
immunizing their children and this was a huge
challenge to the FLWs. Tills issue was raised
during Namma habba and everyone agreed to
stage rhe namma habba process with similar
performances using IIT techniques in Harji
village to educate these families. Now all the
families have agreed to immunize their children.
Their attitudes have been positively changed.
4. During rhe Namma Habba at Gunadala SC
(Kambagi PHC) in Vijayapura district, the
VHSNC President who attended it realized the
importance of VHSNC. He therefore invited
key people from the village and reformed the
VHSNC as per the guidelines. He also invited
members for the 1st VHSNC meeting and started
discussions using the SCMT tool. One of the
AWWs expressed her dissatisfaction with the
Panchayat and the department for not appointing
an AWW helper. A member of the VHSNC came
forward to resolve this issue. He recommended a
marginalized woman from the community for this
job and finalized the candidate at the meeting.
He also recommended that the Panchayat pay her
salary in case the department failed to. He has
paid her a salary advance of 500 Rupees.
During the Namma Habba discussion at the
Baradola SC in Vijayapura district, the VHSNC
president questioned the FLWs on a recent
infant death in the village and asked them why
they did not conducting any health camps in
Vittalanagar village for the past year. The FLWs
responded saying that the access road to the
village was bad and transport facilities poor. Tie
3. During the discussion following the Namma
habba performance at the Halagani SC
President discussed this with the MO who was
. .. (Bhabuksbwar^PHC) in. Vijayapura district, the,_ ... _ present.^The MO agreed tp provide a vehicle to
AWW reported that eggs were not given to the
conduct immunization camps. Now the camps in
Anganwadi children due to delays in releasing
Vittalnagar have resumed.
funds from the department. The PDO present at
the habba took this issue up with the Panchayat
6. At Haranal SC (Nidagundi PHC), Vijayapura
and directed them to release funds. The AWW
district, the issue of ASHAs’ irregularity at work
also shared that the kitchen in her Anganawadi
came up during the Namma habba discussion.
did not have a door and people often walked
ASHAs responded that they had not been
in and out and dirtied the place. VHSNC
given incentives on time. So, the VHSNC
president and other members responded to this
president decided to bring this issue up with
and took up the repair work and installed a door
the Panchayat and requested them to provide a
monthly honorarium of Rs. 1000 per ASHA. On
to the kitchen. This serves as a good example of
discussing this, the Panchayat made allocation for
intersectoral support as a result of the namma
habba campaign.
this under the NREGA scheme.
5.3.4 Coordination between project components
in scale-up districts
Although the levels of change for Sukshema’s
Nurse-Mentoring intervention and the Community
Intervention are different (facility and community
respectively), it is crucial that both interventions are
well coordinated to affect MNCH outcomes within a
community and are viewed as being complementary
considering the project’s focus on providing services
across continuum of care and integration. The
project saw great scope for the three teams to work in
harmony (Nurse mentoring, Community intervention
and M & E)
60
■ An Overview of Sukshema’s Community Intervention
5.
The platforms for coordination such as district
level coordination meetings chaired by DPCs and
zonal level coordination chaired by zonal DDs and
the central level coordination chaired by technical
directors have been put in place to ensure that there is
greater coordination between the two interventions.
To assess the level of coordination between the
mentoring and community interventions, mentors,
CCs and RPs in Koppal District were interviewed
in October 2013. Project staff collected qualitative
information on district-level coordination again in
April 2014 in Gulbarga and Yadgir districts where the
restructured community intervention was still being
scaled up. This included focus group discussions with
mentors and community teams in one district and
observation of a district-level coordination meeting in
another.
Early Stages of Coordination
As of October 2013 the level of coordination
between the two different project interventions was
still in the early stages in Koppal and other districts.
Mentors were asked to describe the community
intervention. Collectively, they were able to name the
key components, but no single mentor was able to
readily describe it. Features they mentioned included
the Arogya Mantapa meetings, the ASHA diaries, the
RPs who work with ASHAs and JHAs and key chain
counseling cards. Two mentors had seen ASHAs with
their diaries.
Mentors met the community team in February 2013
when they were first hired and again in August 2013.
It required extensive probing to get them to recall
this meeting, but they described that they shared
information about what each group was doing and
discussed how they could support each other. One
example given was getting CCs and RPs to help with
access to ARS meeting funds.
By April 2014, the project leadership was more
intentional about promoting coordination and
introduced a meeting platform call the district
coordination meeting in which teams from the
mentoring and community intervention components
met once a month in each district. This meeting
included the DPS, M&E specialist, DCS, district
community mentor, CCs and mentors. RPs were not
present in this forum, which was for project staff only.
In some districts, facilitation of the meeting rotated
among the DPS, DCS and M&E officer. The project
also tried for a short time to appoint a central team
member to serve as adistrict coordination manager
(DCM)for each district, although having eight
individuals serving in this capacity for eight districts
created challenges in standardising approaches.
According to project staff, the district coordination
meetings tended to vary from district to district. In
Gulbarga, the two teams met together seven times
between September 2013 and April 2014. These
joint meetings helped build a sense of connectedness
among project staff.
As one mentor noted, “Earlier we used to think
these people were with another project [referring
to CCs] but now we realize that we work together.”
In joint meetings, participants discussed problems
they saw in their PHC service areas. They reviewed
indicators from the mentoring program and quarterly
community-based tracking surveys that the project
Examples of Coordination
One CC related a story to illustrate
coordination. During his yisit to a PHC to
attend an ASHA monthly meeting, he learned
that the PHC’s delivery volume was low. ASHAs
were complaining about the PHC because staff
had stopped giving drugs to speed up labour,
so they were now referring women to another
PHC that still practised labour augmentation.
The CC tried to explain to them why labour
augmentation was not a good practice. He then
informed the mentor who counseled staff nurses
at that PHC to stop labour augmentation.
Another example of how the two programme
components tried to support each other was
when mentors and CCs identified low-yolume
PHCs and worked together to see if they could
increase deliveries. In one PHC, the mentor
identified that hardly any deliveries were coming
from certain sub-centres and informed the
CC. The CC learned from the RP that ASHAs
in that area were not referring women to that
PHC but referred instead to a nearby CHC.
The CC met with the RP and them to advise
ASHAs to counsel mothers to come to the PHC
for deliveries. This type of intervention also
- happeHed 1n three oiHer PHCs.'KteJesfffig^
CCs stated that deliveries had increased in the
three PHCs, although mentors and programme
monitoring data did not show any noticeable
increase. Nevertheless, this promising example
illustrates how CCs and mentors worked
together to identify a challenge and take action
to try to resolve it.
carries out. During the meetings, mentors and
CCs jointly prepared action plans for their PHCs
and district-level staff (DCS, DPS, DCM, M&E
specialist) prepared separate action plans. They also
made plans to do joint visits to PHCs.
Lessons learned: Community intervention linkages
The linkages between the two programme
components evolved somewhat organically as
the two teams got to know each other and found
ways to work together. As the project moves into
its final year, it will be important to develop clear
guidance on what role mentors can play in extending
AMMA to the community level and how this
relates to the community intervention. Mentors’
ad hoc participation in ASHA monthly meetings
and collaboration with CCs have been interesting
examples of how this support could be more
intentionally provided in the future.
Implementation of the Community Intervention in the Scale-Up Districts ■ 61
n XUO
MONITORING AND EVALUATING SUKSHEMA'S
COMMUNITY INTERVENTIONCOMMUNITY BASED TRACKING SURVEY (CBTS)
In addition to routine monitoring data collected
at the districts as well as data from GoK,
Sukshema also conducted routine community
based tracking surveys (CBTS) in each district.
CBTS is a simple and rapid sample survey of
target populations to measure intended outcomes
in the population. The survey is conducted once
every 4 months in a representative sample of
women who have delivered in the past 2 months
to collect data on
•
Knowledge of mothers on key MNCH issues
•
Utilization of MNCH services from the front
line workers and health facilities
•
Practices regarding newborn care
CBTS provides information on short-term
changes and real-time data that are required for
program monitoring. It is short, more frequent,
and better focused to track short-term changes
in indicators at district level. Results from the
CBTS help the central project team and field
staff tweak program implementation strategies in
order to stay focused on outcomes.
Table 5: CBTS Sample Implementation in the pilot
districts of Koppal and Bagalkot.
| Bagalkot | Koppal
J
Round-1
Start date
05-Jun-12
06-Jun-12
End date
10-Jul-12
05-Jul-12 I
Sample areas
400
400
EW identified
853
888
Response rate 99.7
99.2
Round-2 Start date
-
01-Mar-13 01-Mar-13
End date
19-Apr-13
18-Apr-13
Sample areas
200
200
‘ErrdentiKed
839^
896
Response rate 61.0
67.2
~
Survey Design and Methodology
Round-3 Start date
The area covered by an ASHA is the primary
sampling unit. In each district, approximately
200 ASHA areas will be selected. With Taluka
and PHC as strata, ASHA areas will be selected
systematically (areas without an ASHA will also
be listed in the sampling frame). Within each
selected ASHA area, the households will be
enumerated in a clockwise fashion with a random
start, eligible women were listed and interviewed,
until the target of 5 mothers who have delivered
in the last 2 months is achieved. Thus, the target
sample is 1000 respondents per district.
For Round 1 of CBTS in the pilot districts,
RPs collected baseline CBTS information and
conducted household surveys manually over
a period of 2 months. However, the mode of
conducting the surveys has changed from round
2 onwards. From round 2 onwards, the survey
has been administered by trained external
enumerators (10 enumerators per district/month)
and data recorded electronically using mobile
phones on to which the survey questionnaire has
been loaded. The data is transmitted from the
phones to a central location for processing
and analyses.
62
■ An Overview of Sukshema's Community Intervention
18-Jul-13
17-Jul-13
End date
17-Aug-13 25-Aug-13
Sample areas
200
200
EW identified
910
815
Response rate
63.9
70.9
'
'
: it
Round- 4 Start date
23-Nov-13 26-Nov-13
End date
22-Dec-13 28-Dec-13
Sample areas
200
200
EW identified
911
888
Response rate 61.1
69.1
* EW- Eligible Women
-
Critical indicators to be measured through the
community behaviour tracking survey
Once every 4 months, the survey periodically tracks
the priority indicators listed below:
la. Percentage of pregnant women visited by ASHA
at least once during this pregnancy
lb. Percentage of pregnant women visited by ASHA 3
or more times during this pregnancy
2a. Percentage of pregnant women visited by ASHA
within the first trimester during this pregnancy
2b. Percentage of pregnant women registered within
first trimester by JHA during this pregnancy
3. Percentage of women who delivered at a health
facility
4. Percentage of women who received postnatal care
for 48 hours or more at a health facility
5. Percentage of women who received a postnatal
home visit by ASHA within one month of delivery
6. Percentage of women who received 6 postnatal
home visits by ASHA
7. Percentage of children who received BCG Vaccine
at birth
8. Percentage of children who received Oral polio
vaccine at birth (OPV 0)
9. Percentage of children who received Hepatitis B
Vaccine at birth (HepB 0)
10. Percentage of women who initiated breastfeeding
within an hour of birth
11. Percentage of women who received the full range
of continuum-of-care services (Percentage of women
who had 3+ ANC visits & Institutional Delivery &
Stayed at least for 48 hrs in the facility after delivery
& Received at least one PNC home visit from ASHA)
12. Percentage of pregnant women who consumed
100 IFA tablets during the pregnancy
b. Identify a doctor
c. Vehicle to reach health facility
d. Vehicle to return home
e. Arrangements for expenses
f. Warm clothes for newborn
g. Food arrangement for family
h. Childcare arrangement
15. Percentage of recently delivered women who are
able to correctly identify the danger signs during
pregnancy listed below:
a. Swelling of hands and feet
b. Excessive fatigue
c. Bleeding
d. Convulsions
e. Visual disturbance
f. Hypertension
16. Percentage of recently delivered women who are
able to correctly identify maternal danger signs during
postpartum period listed below:
a. Excessive bleeding
b. Convlusions
c. High/Low BP
d. High fever
e. Lower abdominal pain
f. Foul smelling discharge
g. Severe headache
1/.Percentage of recently delivered women who are
able to correctly identify the danger signs among the
newborns during the postnatal period listed below:
a. Baby not crying
b. Blue tongue and lips
c. Poor breastfeeding
d. Convulsions
e. Lethargic
f. Breathing difficulty
g. Cold to touch
h. Fever
i. Redness/ pus around cord
j. Yellow staining of palms and soles
18. Percentage of recently delivered women who are
able to correctly identify the elements of essential
newborn care listed below:
a. Breastfeed soon after birth
b. Exclusive breastfeeding
c. Ensure warmth for baby
d. Apply nothing to cord
e. Wipe neck, face and underarms
13. Percentage of women who did not apply anything
to their babies’ cords
14. Percentage of recently delivered women who
are able to correctly identify each element of birth
planning and birth preparedness listed below:
a. Identify a health facility
£ Bathe after cord stump falls off
g. Put nothing in eyes and ears
h. Immunize
19. Percentage of recently delivered women who are
able to correctly identify the specific government
schemes and incentives to promote utilization of
Monitoring and Evaluating Sukshema's Community Intervention- Community Based Tracking Survey (CBTS) ■ 63
MNCH services listed below:
a. Janani Suraksha Yojana
b. Prasuti Araike
c. Madilu kit
d. Thayi Bhagya
e. Bala Sanjeevani
Using CBTS data to maintain projectfocus
After each round of CBTS, data for all the indicators
is shared with project staff at all levels as well as
with FLWs for further deliberation. However, of the
20 core indicators, only 7 of the indicators listed
below are considered ‘dashboard indicators’ and their
progress is tracked very closely by the central and
district project teams on a regular basis.
Any deviations in the data would suggest that the
district teams need to increase the depth of outreach
Using CBTS data for project implementation
in Bellary District- A Unique Approach
The Bellary district team decided to use CBTS
data to review the progress made in their
district, in a unique way. Taluk teams were
^fofmed*comprising"ofa Nursb Mentor & a '
CC in each team. Each Taluk team chose one
CBTS indicator such as 48hrs post-delivery
stay in the facility, breast feeding within 1
hour of birth, etc. that they would monitor
in their Taluk. Both the Nurse mentor and
CC in each team developed a joint action
plan and conducted a situational analysis
based on consultations with facilities and
interactions with FLWs and the community
they served. From these consultations, they
understood the need for the Nurse mentor
and the CC to conduct joint visits, as well
the need for a convergence meeting between
the community & the facility. Based on these
learnings, they worked out joint facility and
community strategies to improve their chosen
CBTS indicators. This joint action plan was
first ‘piloted’ in one PHC, and then scaled
up to the rest of the PHCs in their taluk.
These learnings were shared with the district
coordination team comprising of DCS, DPS,
District M& E specialist, DPC, CCs and
Nurse Mentors. Thus, the Bellary district
team used CBTS indicators to not only guide
their implementation process but also to help
improve co-ordination between rhe facility
intervention teams and the community
intervention teams.
64
■ An Overview of Sukshema's Community Intervention
or tweak program implementation to regain focus. In
addition, routine use of the CBTS data has enabled
all the district teams to have a common focus while
being involved in a complex set of interventions.
This was a major learning from the pilot districts,
because despite having put in a tremendous
amount of energy into trainings and roll-out, the
subsequent rounds of CBTS found gaps in coverage
of beneficiaries by FLWs. This was a wake-up call for
the district teams to direct their attention to a more
impact-oriented roll-out and to support the FLWs
with on-the-job training rather than focus more on a
classroom-type training.
Using CBTS data during trainings
Usually, a round of CBTS (baseline or Round 1)
is conducted in a district prior to start of
implementation. This data is then analyzed in a timely
manner and shared with the district teams as well
as the FLWs. This ‘baseline’ CBTS data is then used
by trainers during training sessions, thus providing
FLWS with a ‘context’ for their outreach activities.
Table 6: Key focus CBTS indicators for the
community interventions
#
11
I
Progress indicator (Community
Interventions!
______________________________
Percentage of pregnant women visited
3 or more times by FLWs during
pregnancy
2
Percentage of women who were NOT
visited by FLW within one month of
delivery
3
Percentage of women who were visited
by FLW within 1 day of delivery
4
Percentage of women who were visited
by FLW within 3 days of delivery
5
Percentage of Infants who received
BCG Vaccine
6
Percentage of mothers who initiated
breastfeeding within an hour of
birth(CBTS)
7
Percentage of women who did not
apply anything to the newborn's
cord(CBTS)
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CBTS: Voices from the field
"CBTS data has been an eye opener for me. For example, previously we never used to give
the Thayi card to all the pregnant women. Now we ve started giving Thayi card to all”
- Sarojini, JHA of Gote PHC, Jamakliandi taluk,Bagalkot district
"While CBTS data gives us a broader understanding of the district, it also helps me get a
better understanding of the progress in my taluk. It helps me see where I have to focus in
my taluk.”
- Amaramma, Additional CC, Gangavathi taluk, Koppal district
"It gives very minute level findings, that helps me gauge where I really need to focus. For
example, cord care practices, as per our field experiences nothing was applied for the cord,
but CBTS data says that still around 30% of mothers are applying turmeric powder/oil/
talcum powder. This made us rethink and focus our efforts to improve this particular
behaviour. I can honestly say that every round of CBTS data help me to think more
innovatively to achieve project goals.”
- Manjunath Dodwad, District Community Specialist, Bijapur district
"At the zonal level, it gives me a broader understanding of the progress made in the
districts. It helps me understand which indicator is performing well in the district. This also
helps inform the district plan and helps revisit the implementation process accordingly.”
- Prathibha Rai, Zonal manager-CI
"CBTS data is like a vehicle dashboard. It helps me see where I am and where I have to go.
It helps me see which behaviour needs to be addressed & also when to address it.”
- Suresh Chitrapu, DD-Communication
■
Below are the outcomes of the various rounds of CRTS conducted in the pilot and scale up districts.
CRTS outcomes on selected maternal care indicators
Pilot districts
100
90
80
70
60
50
40
30
20
10
0
95
82.8
82.6
80.9
B Round 2 (Mar-13)
■ Round 3 (Aug-13)
47.4
« Round 4 (Dec-13)
33.7
& Round 5 (April-14)
■ Round 6 (Aug 15)
■ Round 7 (Dec-15)
Received at least 3
ANC checkups
100
90
80
70
60
50
40
30
20
10
0
92.9
89.8
94
Institutional deliveries Received postnatal Received PNC visits at
checkup for 48 hours
home by ASHA
In facility
Continuum of care
Scale-up districts
84.6
885
79 i
1
II
B Round 1 (Apr/Jun-13)
68.1
■ Round 2 (Aug/Oct-13)
36.6
32.5
26.4
iM
Received at least 3
ANC checkups
Institutional deliveries Received postnatal
checkup for 48 hours
in facility
Received PNC visits at
home by ASHA
Continuum of care
■/. Round 3 (Dec/Apr-14)
■ Round 4 (May/Jul-14)
■ Round 5 (Aug/Dec-14)
The pilot district results are shown from 2nd round onwards in order to be close to the period of 1st round in the
scale up districts. Still around 10% home deliveries exist in these districts, but 48 hour stay in facility has been
improving and this has helped in improving the levels of continuum of care services accessed by the beneficiaries.
Continuum of care includes 3+ANC visits, institutional delivery, 48 hr stay, PNC home visit by ASHA. This has.,
shown more than 10 percentage point increase.
Contact with ASHA workers during ante-natal period
Pilot districts - Bagalkot & Koppal
100 -I
90
86
90 -
86.6
79.6
79.7
80
80
72.:
54.8
60 50
40 -
20 -
I
i
10
0
Ever contacted by
ASHA
M Round 3 « Round 4
73.4
70.9
70 -
70 -
30 -
Scale up districts
100 i
3+ times
contacted
I
rS:
58.1
60
50 -
42.:
45.1
40
30
20
f
Contacted within
1st trimester
Round 5 S Round 6 ■ Round 7
10
0
Ever contacted by
ASHA
R Round 1
3+ times
contacted
■ Round 2 % Round 3
Contacted within
1st trimester
Round 4 ■ Round 5
Though ‘ever contacted’ was already higher in pilot districts, three or more contacts by ASHA shows increased
improvement in the scale-up districts whereas contact in 1st trimester was higher in the pilot districts. At any
time in the districts, the vacancy situation is around 15% to 20% of all the designated ASHA areas, if the areas
happen to be far off from the designated working areas, in-charge ASHAs or in-charge ANMs/AWWs are unlikely
to provide required services.
Monitoring and Evaluating Sukshema's Community Intervention- Community Based Tracking Survey (CBTS) ■ 67
Newborn immunization results in scale-up districts
Scale-Up Districts
100
a 90
*c
3
g
i
C
80
70
60
■ Round 1
50
z
uo
sc
■ Round 2
40
Round 3
30
Round 4
20
g- 10
%
0
BCG
OPVO HepBO
CBTS results indicate that as of Round 4 of
CBTS, i.e. within last 6 months, there have been
substantial gains in the percentage of newborns who
received all their birth immunizations in all scaleup districts. However, overall gains in percentage
of newborns immunized are not uniform for all the
key newborn vaccines. The percentage of newborns
who received BCG at birth has increased in Round
4 compared to Round 1, albeit to a lesser degree.
Further examination of the results indicates that the
districts of Yadgir and Raichur are lagging behind
in terms of early BCG administration (50% and
60% respectively). The percentage of newborns
who received HepBO in scale-up districts has almost
doubled, particularly in Gulbarga from around 20
to 40%.
68
* An Overview of Sukshema’s Community Intervention
All of
the
above
1
Monitoring Of Community Interventions- Our Experience
i.
that was required to be collected and collated was not
Both data from the CDL and CBTS were envisaged
manageable with the existing number of project staff.
to help in programme monitoring. While CBTS
Had the tool been institutionalised or had there been
helped in measuring mainly outcomes, CDL 1 & 2
minimum reporting hassles with greater number of
were aimed at generating evidence for improvement
ASHAs using the tool, CDL would have served as a
in coverage of beneficiaries and strengthening the
programme monitoring tool as envisaged.
data of Mother and Child Tracking System (MCTS),
which is maintained by Department of Health and
The data from the CBTS on the other hand helped
Family Welfare. . However, the experience of the
monitor the impact of the community interventions.
implementation of the CDL tools (both CDL 1 and
The CBTS approach provided valuable information
2) in the scale-up districts was different from that of
on the key MNCH indicators the project expected to
the pilot districts. Majority of the ASHAs (70%) were
influence in a timely manner. Though the CBTS data
able to use CDL 2 to do an opportunity gap analysis
worked best at the aggregate level (district level), the
with regards to coverage of services at the village level
data from the CBTS was still made available to the
on a regular basis in the pilot districts. This level was
teams at the taluk level to enable the teams develop
achieved in June 2014 and after that this was reduced
a better understanding of the data that was a result
to 40% in December 2014. The ASHAs in the scaleof their effort on the ground. The timely availability
up districts derived other simpler ways of ensuring
of the data allowed the project staff to act on the
that the gaps were identified and addressed. While
information, focus efforts and to know whether
CDL 1 was used extensively, fewer ASHAs (only5%
the focused efforts had yielded any improvements
to 30% in scale-up districts as on December 2014)
within a few months of time. However, some of
used the CDL 2 to derive summaries. Gaps in the use
the CBTS indicators, influenced mainly by deeply
of CDL 2 in the scale-up districts could be due to
rooted cultural practices, would not change in a short
our complete dependence on the ASHA facilitators
duration of time and so it was not realistic to track
to handhold ASHAs. Whereas, in the pilot districts
changes in those indicators.
we had large presence of project staff (community
coordinators) to closely support the ASHAs in the
... A validation exercise was conducted to look at
process during the period of-intensive intervention;
responses of beneficiaries on few indicators in both
the gaps in use of CDL was also related to capacities
the CBTS and CDL. The purpose of this exercise
of the ASHAs and ASHA vacancies which was close
was to assess the accuracy of reporting in CDL in
to 25% at any time of the year.
comparison to CBTS. The validation exercise proved
that use of ASHA diary helped in identification
CDL therefore provided us with incomplete
of more pregnant woman and thus improving the
information on the coverage status of critical MNCH
coverage in MNCH services. The following chart
services in as far as deriving the estimates at the block
illustrates that wherever the ASHA had diary, most of
or district level The tool therefore came to be viewed
the outcomes of CBTS were also better as compared
as an output monitoring tool rather than an outcome
to areas where the ASHA did not have a diary.
or impact monitoring tool since all ASHAs were not
reporting and further, the volume of information
100.0
90.0 -80.0 70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0 -
85 2
89.1
kiiLhliii
ASHA visited ASHA visited Three or
during the within first moreANC
pregnancy
trimster
visits
-
76 F.F
5 584 1
Ml___
82 182.1
Home
deliveries
■ Diary available
Breastfed
within one
hour
BCG given
OPVO given HEPBO given Stayed in the
health
facility 48+
hours
■ Diary not available
Monitoring and Evaluating Sukshema's Community Intervention- Community Based Tracking Survey (CBTS) ■ 69
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DRP "SAMMILANA"A FORMAL HANDING OVER PROGRAM
The team conceptualised a program to formally mark
the handing over of the community interventions and
the concepts to the real owners of the entire exercisethe department and the community members.
•
each taluk are invited to speak)
Inter-taluk cultural competition for about half
hour where every taluk team will be invited to
perform
Award function- This includes distribution of
certificates of appreciation to the DRPs, taluk
awards for achievement in different areas around
the interventions. For example: SCMT roll
out, CDL data, Namma Habba roll out, HBFFC handholding. Each of the taluks will be
recognized for their excellence in any one of the
core areas and the memento will be handed over
to the THO. Also included is the award for a
district for its contribution and excellence in any
of the following areas: Departmental support,
Coordination among FLWs, DRP performance
etc.
Group photos of taluk and district teams
Speeches by district official sharing experience
and commitment
Closing ceremony
•
Lunch
•
•
The DRP Sammilana (get together) was planned to be
an event to appreciate and recognize the achievements
and successes of the interventions, share learnings
and express commitment to the department. The
Sammilana marks the stepping back of the project
and the surging forward of the department in
carrying the work forward and sustaining the field
level impact of Sukshema project. This end-of-project
event was successfully conducted in all the districts.
The participants include all district and taluk level
officials such as the DHO, DPMO, RCHO, taluk
health officer, officials from the Women and Child
Department, all the DRPs in the district (about 120
per district), ASHA mentors and ASHA facilitators.
Tlie project Community coordinators start preparing
for the Sammilana and the date is decided after
consultation with key officials. The day begins with
registration. The program is facilitated by the DRP
or CC.
The schedule for the day is as follows:
•
Registration of all participants
•
Informal start to the program by inviting
volunteers from the participants to perform on
stage-singing, mono acting, dance etc
•
Formal inauguration and introductory speech
about Sukshema and the way forward
•
Experience sharing by DRPs (A few DRPs from
•
•
During Sammilanas, taluk teams will also set up
exhibits with different themes. For example, in
Raichur district, the exhibits were around themes of
Nutrition, Gender and general handicrafts. Stalls are
usually set up the previous day.
The Sukshema team felt that the DRP Sammilana
gave everybody a chance to reflect on the project
activities, their impact and the way forward for the
department staff and community representatives. The
Sammilana provided opportunities to DRPs and other
officials to share their thoughts on stage.
ISSo
Voices from Sammilanas:
Health Department Officials:
“Most of the time we don't recognize the people
who work on the ground (like the ASHAs). It is
important to recognize and appreciate them. I also
want to add that mentoring intervention has helped
us a lot especially the case sheets and the M & E
specialists' contributions to the department has been
tremendous”
- Dr. Srikanth Basur, DHO, Koppal
“Sukshema has laid a foundation for us and we will
build on that foundation... Case sheet, ASHA diaries
are very usefur
- Dr. Gundappa, DHO, Vijaypur
“This sammilana is an excellent programme. We will
make sure that we organize similar events in future
that helps all of us to come together”
- DHO, Raichur
“Namma habba has given us the needed recognition
in the community. The VHSNC did not know
anything about the work of the ASHA/AWW/JHA.
But after the Habba program they are contacting
us and we are beginning to work together. I thank
Sukshema team for bringing us together”
- DRP, Vijaypura district
The Project team members usually share their
reflections at the end of the project period. They
add that they have successfully been able to leave
behind a very strong cadre of DRP as well as FLWs.
They see increased confidence and self esteem
levels among FLWs, greater coordination among
themselves, increased understanding of MNCH
issues. In addition to this, the team also feels that
the department officials have begun to view DRPs
as a real resource and have begun to recognize their
contribution to the system.
Sukshema central team members:
DRP Voices:
“Arogya Mantapa is helping us work in a coordinated
manner”
- T)RP, Bagalkot district
“I developed the courage and the confidence to
address a gathering and speak to people only because
of the exposure and training given to us through the
Sukshema Project”
— DRP, Koppal district
“This is not the end. It is the beginning. What
Sukshema has started, we will complete. Cannot
thank Sukshema enough for giving us the ASHA
dairy. It has helped us a lot”
- DRP, Koppal district
“We have not only helped FLWs realize their potential
and identify their skills but have also equipped them
to use their skills effectively.”
“No one in the field was obligated to participate and
neither did we at any point of the project promise
monetary benefits. In spite of this, we achieved
excellent participation.”
“All tools and processes have been successfully
institutionalized within the system.”
“Promoting and strengthening DRPs has only been
half success achieved. We should have aimed at
bringing them together as a team at the district level.”
s
5
COLLABORATING WITH GOVERNMENT OF
KARNATAKA (HEALTH DEPARTMENT) STAFF
In the scale-up districts, Sukshema’s community
interventions were largely carried out by the
Government of Karnataka health department staff,
unlike the pilot districts. This was possible because
of the introduction of the DRP cadre in the scale up
districts (since DRPs are GoK staff) and aggressive
rapport-building with the Health department staff by
the district field teams. This resulted in all the ToTs
and the roll-outs being facilitated by GoK staff. Thus,
unlike the pilot districts, there was greater ownership
of the interventions right from the beginning.
Key informant interviews with the Health department
staff (Medical Officer, Taluka Health Officer and the
Reproductive and Child Health Officer) re-iterated
these points. The various GoK staff interviewed
for this documentation were not just aware of the
various components of the Community Interventions
in their districts, but were very appreciative of the
efforts of several Sukshema staff. In general, the
various tools and processes were well accepted by
Health Department officials,. The ASHA diary was a
particular favourite among the key informants.
®
Bi
I 1
la.
The THO was in line with Sukshema’s objectives of
enhancing grass-roots level planning and monitoring,
as opposed to extensive policy decisions which may
not address the real barriers to health care access
and uptake on the ground. The THO’s opinion was
that FLWs were good at handling crises but failed
at regular monitoring and he felt that this was a gap
that Sukshema could address. Also, he stressed on the
need to ensure that FLWs and DRPs understand why
MNCH indicators were important.
At all levels Sukshema interventions has worked
in collaboration and convergence with the Health,
Women and Child Development and Rural
Development and Panchayat Raj departments. The
principle of convergence has helped integration
of project activities into the existing diaspora of
initiatives across these departments. Efforts have
been made through the community interventions to
bring this convergence right down to the level of the
individual villages where activities are not driven by
departments but by needs. Ensuring integration has
been a key mantra guiding the teams across all levels.
PROGRAMME COSTING
A multi-faceted community-based intervention using
frontline workers and VHSNCs was piloted and
scaled up within the context of the Sukshema project
in eight districts of northern Karnataka from 2012
to 2014. This chapter describes the costs involved in
implementing the programme.
Costing Considerations
The actual expenditure for implementing the
programme in eight districts from March 2012August 2014 was considered for the cost analysis.
• A major percentage of the costs are related to staff
(salaries, travel, per-diems), material costs (printing
of tools and job-aids) and events (training, refreshers,
review meetings).
• The costs are mentioned both in Indian rupees (INR)
and US dollars (USD) considering the exchange rate
of 58 INR per USD.
• The costs are categorized into one-time and recurring
costs. One-time costs include expenditures that were
made once during the time of intervention such as
DRP meetings, trainings, whereas the recurring costs
include expenditures that recur regularly such as staff
salaries, travel, per-diems etc.
Total Expenditure ofSukshema’s Community
Intervention
The total cost for implementing Sukshema’s
community intervention was INR 67,636,786 with
the average cost per month being INR 2,332,303.
Programme costs, such as TOTs, FEW trainings,
family focussed communication, printing of tools and
job-aids etc and personnel costs, such as staff salaries,
formed the largest proportion (-82%) of the of the
total cost.
Total Expenditure from March 2012 to August 2014
Programme Costs
- 6 Scale-Up
Districts
Office
Maintanance
4%
15% A
MOB
Bl
'•
Personnel
Programme
■ 2 Pilot Districts
Iravek-.'•/
74
■ An Overview of Sukshema's Community Intervention
Recurring staff-related costs
The Sukshema project developed a management
structure and management processes to oversee
implementation of the community intervention.
A central technical management team based in
Bangalore handled both technical and administrative
matters and provided guidance and support to the
district field teams. The core team at the district level
consisted of District Community specialist (DCS)
who supported and supervised the taluk level teams
headed by the taluk community coordinators. Each
Taluk Community Co-ordinator, in turn, supervised
and supported 8-12 District Resource Persons
(DRPs). Additionally, district community mentors
(DCMs) mentored taluk community co-ordinators
and DRPs and formed a mid-level cadre of district
personnel in each district. In the 2 pilot districts,
district level staff were employed for a total duration
of 30 months while the district level staff in the 6
scale-up districts were employed for a total of 18
months.
Salaries and travel costs of central management
team in Bangalore
The central technical team involved in the overall
management and implementation of the community
intervention comprised of 2 Zonal Technical
Managers, 2 Senior Community Specialists, a project
documentation specialist, an administrative assistant
and the Community Intervention Team Leader. The
Zonal Technical Managers were involved in guiding
the teams through strategic/ programmatic inputs
throughout the project implementation; they were
offered monthly salaries of 50,000 INR each and
a monthly travel allowance of INR 14,000 (which
included accommodation, travel and per diems) for
about 8 days a month for a period of 30 months.
The Zonal Technical Managers reported to the
Community Intervention team lead, who was the
overall lead for implementing this intervention.
Salaries and travel costs of district level staff in the
pilot and scale-up districts
Each district had a District Community Specialist
(DCS) who managed all the taluk level staff in his/
her district. Thus, there were a total of 8 DCSs (social
work graduates with seven year work experience in
the development sector) who were offered monthly
salaries of around INR 22,000 and travel costs of
about INR 4000 each. The District Community
Mentors (8 in total; 2 in the Pilot districts and 6 in
the Scale-up districts) were graduates with experience
in co-ordinating programmes at the field level and
V
\ K 'Ifc I
liaising with community structures such as Gram
Panchayats. They were offered salaries of INR 12,000
each and INR3500 for travel costs. Community
Co-ordinators (CCs) has a minimum of Standard 12
education. Their attitudes, skills and abilities were
assessed during recruitment and they were offered
salaries of INR 12,000 each and INR2500 for travel
expenses. There were a total of 42 CCs (10 in the
pilot districts and 32 in the scale-up districts). In the
pilot districts of Koppal and Bagalkot, there were a
total of 75 Resource Persons who had a minimum
qualification of SSLC, and were offered salaries of
INR 6000 each and INR 2000 for travel. This cadre
was only recruited in the 2 pilot districts. Initially,
for about 5 months of implementation, a total of
75 ‘Supportive to Community Co-ordinators’) were
recruited in the pilot districts to assist in rolling out
the trainings, which was an intensive process. They
had a minimum Standard 12 education and they were
only recruited for 5 months. They were offered salaries
of INR 6000 each and INR 2000 for travel. Total
costs for staff and their travel in the 2 pilot districts
were INR 24,840,000 or USD 414,000 (See Table 1).
Table 1. Personnel Costs in Pilot districts of Koppal and Bagalkot
Category
| Sub-
\ Unit Rate | No. of \ No. of
[ category • (INR)
District
Community
Specialist
(DCS)
District
Community
Mentor
(DCM)
Community
coordinators
Resource
Persons
Supportive to
Salary
22000
[ Units
2
Total costs
Total costs
f Comments
I USD
j months
30
1320000
22000
4000
March'12March'15
::
Travel
4000
2
30
240000
Salary
12000
2
30
720000
12000
Travel
3500
2
30
210000
3500
Salary
12000
10
30
3600000
60000
Travel
2500
10
30
750000
12500
Salary
6000
75
25
11250000
187500
Travel
2000
75
25
3750000
62500
Salary
6000
75
5
2250000
37500
Travel
2000
75
5
750000
12500
24840000
414000
March'12March’15
Community
Coordinators
TOTAL
i
Programme Costing ■ 75
.__ _
MOS
1
r, I
A ¥
Similarly, in the six scale-up districts, 32 ‘supportive to Community Co-ordinators were hired for 5 months.
They were standard 12 educated and were offered salaries of INR 8000 and travel expenses of INR 2500. Total
costs for staff and travel in the 6 scale-up districts were INR 14,514,000 or USD 241,900 (See Table 2).
Table 2. Personnel Costs in Six Scale-Up districts
Category
District
Community
Specialist
(DCS)
District
Community
Mentor
(DCM)
Community
coordinators
Supportive to
Community
Coordinators
I Sub| Unit Rate
| category I (INR)
No. of
Units
No. of \ Total costs
months \
i Total costs
Salary
22000
6
18
2376000
39600
Travel
4000
6
18
432000
7200
Salary
12000
6
18
1296000
21600
Travel
3500
6
18
378000
6300
Salary
12000
32
18
6912000
115200
Travel
2500
32
18
1440000
24000
Salary
8000
32
5
1280000
21333
Travel
2500
32
5
400000
6667
14514000
241900
TOTAL
76
■ An Overview of Sukshema’s Community Intervention
Comments
I USD
March’12March'15
March'12March'15
Programme costs in pilot and scale-up districts
The total programme cost for all the community
intervention activities in the 2 pilot districts of
Koppal and Bagalkot was INR 14,171,164 which
worked out to be an average expenditure of INR
488,678 per month. For the breakdown of expenses,
please refer to the table below.
Total programme cost for the implementation
activities in the 6 Scale-up districts was INR
10,247,583 which worked out to be an average of
INR 353,365 per month.
General Category of
i Expenditures
Table 3: Programme Costs for Koppal and
Bagalkot (Pilot Districts)
Category
I
IJ
I
Total
\ Expenditure |
\ from -01Mar-12 to
j 31-Aug-14
| Total
| Expenditure 11
I from -01-
Family focussed
communication
478,065
Mar-12to
31-Aug-14
Micro Planning
40,132
Participatory Programme
Review
366,718
TOT
1,141,322
Rollout Trainings -Residential
595,261
Family focussed
communication
4,735,439
Community Monitoring &
structures
2,378,802
Mid Media/Arogya Mantapa/
Sub Center Forum
552,139
Rollout Trainings - Non
Residential - Followup
2,221,381
Mass Media (include CFAR)
190,130
SCMT Non Residential
2,143,956
Innovations
121,871
DRP Meetings
1,256,150
Micro Planning
1,730,175
Arogya Mantapa
1,674.773
Printing of Tools & Formats
1,421,047
TOTAL
10,247,583
Rollout Trainings -Residential
142,391
Rollout Trainings - Non
Residential - Followup
2,076
SCMT Non Residential
251,647
Asha Dairies
2,502,108
Asha Reminders
143,849
TOTAL
14,171,164
I
I
wF '
1
10 SUCCESSES AND WAY FORWARD
Sukshema has implemented a top-notch, scalable
MNCH program in eight priority districts in
northern Karnataka: Bagalkot, Bellary, Bidar,
Bijapur, Gulbarga, Koppal, Raichur and Yadgir,
over the last 4 years. The project has introduced
simple yet innovative solution levers to support
the Governments of Karnataka and India improve
maternal, newborn and child health outcomes in rural
populations. The entire process of implementation,
using the “Think Big, Start Small and Scale-up”
philosophy, has been a resounding success since
the experiences gained from the pilot districts have
helped the project teams re-evaluate some of their
activities during scale-up and rethink their strategy to
achieve Sukshema’s ultimate goals.
In particular, Sukshema’s community intervention
has utilized innovative strategies to support
communities and FLWs take ownership of their
health and wellbeing. The ASHA Diary has been,
arguably, the most well-received innovation by all
levels of the health system, from the FLWs to the
District Health staff. In fact, the Goverment of
Karnataka has adopted this Diary in its current form,
as part of its commitment to enhancing the skills
of and supporting ASHAs through a systematic,
user friendly, simple and contextual job aid that
will empower and equip them to meet their daily
challenges on the ground.
The Arogya Mantapa or Sub-centre forum is another
innovation that has enjoyed tremendous acceptance
and ownership by FLWs. The intended purpose
of this intervention is to facilitate improved co
ordination of FLWs’ activities. Initially in the pilot
districts, there was a greater emphasis on FLWs
using this forum to discuss ETT/CDL targets and
achievements and to troubleshoot any issues that
arise. However, the FLWs saw it as a social forum
and this has helped them take ownership of the
Arogya Mantapa process. They set their own agenda
for the AM monthly meetings and use the forum for
more social activities rather than to discuss MNCH
78
* An Overview of Sukshema's Community Intervention
issues. This organic evolution of the AM process
will probably lead to greater sustainability of this
intervention even after Sukshema is long gone.
Concurrent monitoring through CBTS was received
very well by the state. This helped strengthen the
existing data on the field. Sukshema’s approach of
convergence and integration trickled down even to
the lowest levels. This has been a huge success for the
project.
In addition to that, none of the interventions have
been borrowed from an already existing experience
but were designed, tested and scaled up based on the
local context and need in collaboration with the end
users such as the FLWs and the community members.
The focus has been to address a gaps in the MNCH
care continuum and not individual gaps in specific
services. The effort has been to change the ASHA
from being a service provider to a change agent with
the right attitudes, skills, confidence and vision for
community health. This brought in tremendous
ownership of our interventions. ASHAs began to view
themselves differently and so did the community.
The transition of project interventions, activities
and processes to the Government is a key aspect of
Sukshema’s phasing out. However, the foundation
for this has already been laid by virtue of extensive
involvement of the Health Department staff
(particularly at the DRP level) in all implementing
districts and the high level of buy-in that the
Government has demonstrated towards the project,
so there will be a relatively seamless transition of the
project’s processes to the Government of Karnataka.
Encouraging and building ownership by the state of
the interventions has been strived for at all levels by
the project’s staff at the centre, district and field levels.
With the state functionaries and department officers
being involved at every stage of the project, transition
has already begun.
Successes and Way Forward
V*'': /'i
Publisher:
Karnataka Health Promotion Trust
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Behind KSSIDC Administrative Office
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Karnataka, India
Phone: 91-80-40400200
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