NATIONAL CHILD SURVIVAL AND SAFE MOTHERHOOD PROGRAMME
Item
- Title
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NATIONAL CHILD SURVIVAL
AND SAFE MOTHERHOOD PROGRAMME - extracted text
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NATIONAL CHILD SURVIVAL
AND SAFE MOTHERHOOD PROGRAMME
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A
PLAN AND IMPLEMENT
MCH SERVICES
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E
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Ministry of Health and Family Welfare
Government of India
New Delhi
1992
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GOALS AND COMPONENTS OF
THE CHILD SURVIVAL AND SAFE MOTHERHOOD PROGRAMME
GOALS
o
o
o
o
o
o
o
o
Infant mortality rate reduced from 81 to 75 by 1995 and 50 by 2000.
Child (1-4 years) mortality rate reduced from 41.2 to < 10 by 2000.
Maternal mortality rate reduced from 400 to 200/100,000 by 2000.
Polio eradication by 2000.
Neonatal tetanus elimination by 1995.
Measles - prevention of 95% deaths and 90% cases by 1995.
Diarrhoea - prevention of 70% deaths and 25% cases by 2000.
Acute respiratory infections - prevention of 40% deaths by 2000.
Components of this package would be:
Children
Newborn care at home - warmth and feeding.
Primary immunization by 12 months - 100% coverage
Vitamin A prophylaxis (9 months to 3 years) - 100% coverage
Pneumonia - Correct case management at home/health facilities.
Diarrhoea - Correct case management at home/health facility; ORS in every village.
Pregnant Women
Immunization against tetanus - 100% coverac
Anaemia prophylaxis and oral therapy - 10C
Antenatal check-up - at least 3 check-ups in
Referral of those with complications
Care at birth - promotion of clean delivery
Birth timing and spacing
PLAN AND IMPLEMENT
MCH SERVICES
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ADAPTED FROM WHO MODULE
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PLAN AND IMPLEMENT
MCH SERVICES
Published by :
Ministry of Health & Family Welfare
Government of India
Nirman Bhawan
New Delhi.
First Published
Revised
Revised
Revised
Revised
Revised
Revised
1985
1986
1987
1988
1989
1990
1992
COMMUNITY HEALTH CELL
326, V Main, I Glock
Koran-i<>ng 1 ■
Bangalore-tbudSA
India
This publication is available in English only
List of abbreviations
ANC
AWW
AE
BCG
BEE
BDO
CDPO
CHC
CMO
CHAI
DRDA
DHO
DWCRA
EDO
FOGSI
FWC
HW(F)
HQ
IAPSM
IFA
IUD
ICDS
IMA
IAP
LBW
LHV
MPW
MIS
MO
MCH
MS
NFE
NGO
NSS
NSSO
NCC
ORT
ORS
OPV
PHC
PNC
PPC
PO
SC
TT
TBA
TV
UBS
VHG
Ante-natal Care
Anganwadi Worker
Adult Education
Bacillus Calmette Guerain
Block Extension Educator
Block Development Officer
Child Development Project Officer
Community Health Centre
Chief Medical Officer
Catholic Hospital Association of India
District Rural Development Agency
District Health Officer
Development of Women and Children in Rural Areas
Expected Date of Delivery
Federation of Obstetrics and Gynaecology Societies in India
Family Welfare Centre
Health Worker (Female)
Headquarters
Indian Association for Preventive and Social Medicine
Iron and Folic Acid
Intra Uterine Device
Integrated Child Development Services
Indian Medical Association
Indian Academy of Paediatrics
Low Birth Weight
Lady Health Visitor
Multi-purpose worker
Management Information System
Medical officer
Maternal and Child Health
Mukhya Sevika
Non Formal Education
Non Governmental Organization
National Service Scheme
National Sample Survey Organization
National Cadet Corps
Oral Rehydration Therapy
Oral Rehydration Salts
Oral Polio Vaccine
Primary Health Centre
Post Natal Care
Post Partum Centre
Programme Officer
Sub-centre
Tetanus Toxoid
Traditional Birth Attendant
Television
Urban Basic Services
Village Health Guide
CONTENTS
Introduction
1
Learning objectives
2
1.0
Estimation of Eligibles
4
1.1
1.3
Exercise A
Ready Reckoner for estimating eligibles in a year
Compare estimated eligible with enumerated eligibles
5
6
6
2.0
List activities for implementing programme
7
2.1
2.2
2.3
At village/subcentre level
At PHC level
At District Level
7
3.0
Plan and Implement
15
3.1
18
3.2
3.3
3.4
3.5
3.6
3.7
3.8
Plan Immunization/MCH Sessions
Plan catch-up and mop-up rounds
Plan Home visits
Plan Work Routine of Field Workers
Use checklist for various MCH activities
Conduct MCH/immunization session
Conduct catch-up and mop-up rounds
Conduct home visits
4.0
Supervise and Monitor Implementation
38
4.1
4.2
4.3
4.4
What ?
How ?
When ?
Follow-up
39
40
5.0
Provide Systems support
52
5.1
5.2
5.3
5.4
5.5
Management Information System (MIS)
Materials Management
Training
Communication
Social Mobilization
53
54
55
57
63
1.2
District Plan of Action
Annexu res
Mother-infant immunization card
1
Mother Child Care record
II
Monthly PHC Report
III
IV
Monthly District Report
Delivery kit for health workers
V
Time table of scheduled immunization/MCI 1 sessions
VI
10
12
19
20
26
29
31
32
33
41
42
68
PLAN AND IMPLEMENT
INTRODUCTION
This module will enhance your skills in planning and implementing delivery of child survival
and safe motherhood services in the area of your responsibility. The five key components
of this module are shown in the flow chart given below :
i
2
3
Estimate
Eligibles
List activities
for implementing
programme
Plan and
Implement
At Village/
Sub-centre
Plan Immunization/
MCH sessions
At PHC/CHC Level
Plan Catch-up and
Mop-up rounds
4
->■ Supervise&Monitor
<— Implementation
5
Provide System
Support
What?
M I S
How?
Material Management
When?
Training
Fol low-up
Communication
At District
Plan
Home visits
Plan work routines
of Field Workers
Social Mobilization
Use Checklist for
MCH activities
Conduct
Innuni zat i on/MCH
Session
Conduct Catch-up
and mop-up rounds
I
Conduct
Home visits
For a good plan, it is necessary for you to understand the details of various activities carried
out by health workers in their sub-centre areas; hence you will, in this module, learn about
activities at the sub-centre and then those at the PIIC and finally at the district. You should
read the Manual for Health Workers carefully so that you can support, supervise and
monitor your health workers better.
1
Learning Objectives
You will acquire skills to plan, implement and monitor child survival and safe motherhood
services in the area for which you are responsible.
As a manager of child survival and safe motherhood programme it is your responsibility to
schedule immunisation/MCH sessions and to ensure the following:
o
All pregnant women receive essential ante-natal care including TT immunization and
Iron & Folic Acid tablets (IFA) and those with complications are promptly identified
and referred to a facility with requisite manpower and capability to handle such
complications.
o
AU deliveries are conducted observing the 5 CLEANS i.e.
*
*
*
*
*
clean surface
clean hands
clean razor blade
clean cord tie
clean cord stump - no applicant
o
All women in the reproductive age group have access to information and services for
contraception to ensure birth timing, spacing, and limiting.
o
All newborns are weighed at the time of birth and are initiated with breast-feeding
early, given home-level care (warmth and feeding) if birth weight is between 2000 and
2500 gms and are referred to a paediatrician if birth-weight is less than 2000 gms.
o
All infants receive immunization against the six vaccine preventable diseases covered
under UIP before completing one year of age.
o
All children less than five years have correct case management and access to
ORT/ORS packets when they suffer from diarrhoea.
o
All children in the age group 9 months to 3 years receive five doses of Vitamin A at
six monthly interval and those suffering from Vitamin A deficiency two extra mega
doses.
o
All children less than 5 years suffering from pneumonia have correct case
management and have access to cotrimoxazole and referral when seriously ill.
r
2
This module describes tasks and organization of work routines which should be performed
to achieve universal coverage under child survival and safe motherhood programme. You
may have other responsibilities in addition to this programme, therefore the tasks and work
methodology described here should be co-ordinated and performed in conjunction with other
tasks.
PLANNING FOR CHILD SURVIVAL AND SAFE MOTHERHOOD PROGRAMME
Success of the programme will depend on the thoroughness of plans made by you. Various
activities must be done correctly and in time.
To prepare a plan of action you should have the following information at sub-centre,
PHC/CHC and district levels.
o
The number (determined by enumeration) of pregnant women, infants, children
between 9 months and 3 years of age and children less than 5 years of age.
o
Manpower in the health system and in other sectoral programmes.
o
Health facilities - their functional status as referral institutions for children and
pregnant women.
o
Availability of supplies and support systems.
o
Geographical terrain, accessibility of different areas and communication facilities.
o
Resources and assistance that can be tapped from other sources.
Tasks related to Management Information System (MIS), materials management and
training have been discussed in brief only, as they have been described in greater detail in
other modules.
Please take a few minutes to look at the flow chart so that you understand the relationship
between various activities.
Several tasks can be done simultaneously and they need not follow the order given
in the flow chart. For example major tasks 3, 4 and 5 can be done simultaneously.
3
1.0
ESTIMATION OI ELIGIBLES
i
2
Estimate
Eligiblcs
4
3
List activities
for implementing
programme
Plan and
Implement
5
Supervise and Monitor
Implement ion
Provide System
Support
Your aim is to ensure universal coverage of various components of Child Survival and Safe
Motherhood programme. In order to do this you must have an estimate of number of
pregnant women, infants, children less than 3 years and children less than 5 years. You
should be able to estimate these eligibles in each one of the following areas:
*
*
sub-centre area
PHC area
*
CHC (block level) area and
District
The number can be enumerated from total population for the area based on these norms:
NO.
BENEFICIARY
PROPORTION OF
TOTAL POPULATION
SERVICES PROVIDED
1.
Pregnant Women
3.2 7,
Essential ANC, referral for
complications, 100% coverage with
TT & IFA tablets. Anaemia therapy
2.
Live-births and
post-natal cases
3 7.
Safe delivery with 5 cleans,
referral, identify & care LBW
render post-natal care
3.
Infants alive
at 1 year
4.
Children 9 months
to 3 years
5.
ChiIdren below
five years
92% of livebirths
100% coverage against six vaccine
preventable diseases
8%
Booster-DPT/OPV to child 1-2 years
5 doses of Vitamin A to all
2 doses of Vit A for deficiency
13%
Correct case management for
diarrhoea and pneumonia. Access to
ORT/ORS;ORS depot in every village
EXAMPLE
Using the norms given above, estimation of beneficiaries in a sub-centre area of 5,000
population.
Pregnant women - It is expected that 160 pregnant women will be in a sub-centre area in
one year
(5()()() x 3.2) = 160
100
Livebirths - There will be 150 live births in one year.
Infants alive at one year - About 138 infants will be alive at age one.
Children 9 months - 3 years - About 400 children in this age group will be enumerated.
Children less than 5 years - There will be 650 children in this age group.
4
1.1
EXERCISE A
Estimate the number of beneficiaries in a PHC area of 30,000 population and a CHC
catering to 100,000 population. Use the space provided below for calculations:
BENEFICIARY
PHC - 30,000 POPULATION
CHC - 100,000 POPULATION
Pregnant Women
Livebi rths
Infants alive at 1 Year
Children 9 months - 3 years
Children less than 5 years
Work space for EXERCISE A
5
1.2
READY RECKONER FOR ESTIMATING ELIGIBLES IN A YEAR
BENEFICIARY
1.3
SUB-CENTRE
PNC
C H C
DISTRICT
5,000 Population 30,000 population 100000 population 2000000 population
Pregnant Women
160
960
3,200
64,000
Livebi rths
150
900
3,000
60,000
Infants alive at 1 Year
135
810
2,700
54,000
Children 9 months - 3 Years
400
2,400
8,000
160,000
Children less than 5 years
650
3,900
13,000
260,000
COMPARE ESTIMATED ELIGIBLES WITH ENUMERATED ELIGIBLES
You should compare the estimated eligibles with the number of eiigibles actually
enumerated by health worker (with the help of VHG, TBA and /WJW) to ensure
completeness of registration.
At any given time all (i.e. 100% of the estimated number) infants and pregnant
women1 should be registered. There can be a variation of 10% from your
estimates due to differences in age and sex structure of any population.
However, if the number enumerated by a worker differs from the number estimated
by you by more than 10% you should get the lists checked and updated by the
health supervisor immediately.
You should encourage your health workers to use the mother-infant immunization
card to enumerate the eligible pregnant women and children in her area. Use of
mother-infant immunization cards for enumeration is a very effective tool for social
mobilization. Your health workers while carrying out this process will be able to
inform the beneficiaries and their family members about various services that are
essential and are available as a part of the child survival and safe motherhood
programme.
1 At any given point of time during enumeration, you will be able to enumerate at least 50%
of all pregnant women who are likely to deliver in one year. This is because pregnancy is a 9months event and most women in India will be willing to acknowledge their pregnancy around
the third month. Under the programme, you should ensure that pregnancy is enumerated and
registered as early as possible, i.e. between 12 and 16 weeks.
6
2.0
LIST OF ACTIVITIES FOR IMPLEMENTING PROGRAMME
1
2
3
4
Estimate
Eligibles
List activities
for implementing
progranme
Plan and
Implement
Supervise & Monitor
Implement ion
5
Provide System
Support
I
At Village/
Sub-centre
At PHC/CHC Level
At District
A detailed plan of action including who will do what, when, where and how is the
logical first step to ensure proper implementation of your programme.
You should determine who is responsible for various components of the
programme. Hence you will have to define tasks and responsibilities. You will make
a list of activities and allocate responsibilities to your staff. Following is the list of
activities that will have to be undertaken at different levels :
2.1
AT VILLAGE/SUB-CENTRE LEVEL
o
Enumerate eligibles
★
*
★
children in the age groups
0-1 year
1-3 years
3-5 years
pregnant women
women in the reproductive age group (15-45 years)
o
Identify and meet influencers
o
Meet villagers and establish rapport
o
Attend mothers’ meetings
o
Identify communication sites for wall-paintings and hoardings
o
Identify drop-outs and non-participants in various maternal and child health
activities
7
o
Conduct immunization/MCH sessions 2
*
*
★
★
*
*
★
*
*
*
*
o
Immunize all eligible children and pregnant women
Administer Vit A first dose along with measles dose
Administer Vit A second dose along with DPT/OPV booster dose
Administer Vit A third to fifth doses to children between 1 'l2 to 3
years at six-monthly intervals
Administer two doses of Vit A at monthly interval to those with signs
of Vit A deficiency (diagnosed during home visits or MCH sessions)
Give IFA tablets to all pregnant women for prophylaxis (@ 1 tablet
every day for 100 days)
Diagnose anaemia in pregnant women clinically
Give IFA tablets to all anaemic pregnant women (@ 2 tablets every
day for 100 days)
Make available ORS packets to the village-based depot holder and
dispense directly in case child with diarrhoea presents
Assess child with acute respiratory infections (in case it presents
during the session) and treat with cotrimoxazole tablets
Give OPV to all children below 3 years regardless of their
immunization status twice in a year (at a gap of one month) in case
the village falls under a polio eradication area.
Conduct home visits
*
*
★
Identify priority houses and visit them
Motivate beneficiaries for availing services during Immunization/MCH
sessions and sub-centre clinics
Meet village level workers - Traditional Birth Attendant (TBA), Village
Health Guide (VHG), Anganwadi Worker (AWW), Village-level
Informants
o
Conduct community-based surveillance activities for cases and deaths due
to vaccine-preventable diseases, pneumonia, diarrhoea, and neo-natal and
maternal deaths (described in detail in the module ’Conduct Disease
Surveillance’).
o
Organize activities for control of outbreaks/epidemics
o
Identify depot holders for ORS, contraceptives and provide supplies.
20ne such session should be carried out in every village at least once a month. In larger
villages, i.e. with population more than 2000, more than one session will be necessary. In smaller
villages, i.e. with population less than 1000, the Immunization/MCH session may be combined with
similar sessions organized in a neighbouring village on the same day.
8
o
Register births, deaths and vital events
o
Line list cases of poliomyelitis as well as neo-natal and maternal deaths.
Initiate filling up of respective investigation forms.
o
Provide supportive supervision and on-the-job training to village level health
and support functionaries. Train TBAs at sub-centre/home deliveries for
observing the 5 Cleans during delivery. In addition, TBAs will attend all .
mothers’ meetings.
o
Organize sub-centre clinics (once a week for MCH activities and at least
once a month, immunization activities will also be carried out). In addition
to various activities outlined in immunization/MCH sessions, the following will
be done:
★
Provide ante-natal care
check up - blood pressure and weight
faetal growth and well-being through fundal height and faetal
heart sounds
diagnose anaemia clinically and give therapy after deworming
identify complications and refer to the identified first level
referral centre
*
Provide contraceptive services such as insertion of intra-uterine
device (Copper-T), provision of oral pills, and conventional
contraceptives
*
Weigh low birth weight infants referred by village-level workers and
advise warmth and feeding if weight between 2000 and 2500 gms
and refer to a hospital with paediatrician if weight below 2000 gms
*
Assess dehydration in a child with diarrhoea and ensure correct case
management and referral
Assess a child with acute respiratory infection and ensure correct
case management and referral
o
Maintain records, including daily dairy, and make monthly reports for
submission to the PHC. Update mother and child care register every month.
9
2.2
AT PHC/CHC LEVEL
2.2.1
Prepare a plan of action for every PHC. For coverage of eligible infants as
well as children upto 5 years and pregnant women, schedule
Immunization/MCH sessions in every village at least once a month. Every
village should be visited by your health worker for home visits as per criteria
laid out under Section 3.3 (priority houses)
2.2.2
Prepare a schedule for sub-centre clinics, immunization/MCH sessions in
villages and home visits in consultation with Medical Officers of your PHC
and dispensaries as well as the health workers who are to run these
sessions/clinics. You should also ensure that Immunization/MCH sessions
in the villages and sub-centre clinics are organized in sub-centre areas
which are at present without health workers. This will have to be done by
redeploying certain health workers/supervisors for running these
sessions/clinics and also for ensuring timely supply of vaccines and other
supplies.
2.2.3
Mobilize resources and cooperation of other government departments,
voluntary organizations, community leaders and others. This subject is
covered in detail later (sections 5.4 and 5.5).
2.2.4
Brief your staff and explain the programme content, responsibilities and
depute functionaries for a training programme (Section 5.3). Keep an
updated list of trained functionaries in your area. Conduct continuing
education during monthly meetings. Prepare a list of topics to be covered
every month for training/orientation of your workers in consultation with the
health supervisors and other medical officers. The topics will have to be
need-based and appropriate to your local conditions.
2.2.5
Schedule catch-up rounds for immunization and other MCH activities in
villages and sub-centre areas poorly covered for these services towards the
end of the year. Schedule mop-up rounds for polio eradication activities as
a part of your Immunization/MCH sessions and sub-centre sessions in
districts identified for polio eradication.
2.2.6
Calculate, procure and distribute in time, required quantities of vaccines and
other supplies, i.e. the drug kits for sub-centre (containing ORS packets, Vit
A concentrated solution, cotrimoxazole tablets, IFA tablets) as well as IUDs,
oral pills, and conventional contraceptives. Plan for replenishing specific
items in the drug kit from sub-centres where some of these items may not
be used to those which consume them earlier.
2.2.7
Arrange for required quantities of kerosene, ice packs, contingencies for
mobility of staff, payment of reporting fee to TBAs, etc. You should also
include in your plan by name, workers/supervisors who will be responsible
for transporting vaccines, Vit A concentrated solution and IFA tablets to the
10
villages where immunization/MCH sessions will be conducted.
2.2.8
Ensure the use of mother-infant immunization card for enumeration and
thus information, education and communication to mobilise the eligible
beneficiaries to avail of various services under the programme. In addition,
you will arrange for wall-paintings/hoardlngs and hand bills on the sessions
and services organized in different villages. Emphasis on communication
activities will have to be on action at individual level for self-help and
acceptance of services and thus demand generation.
2.2.9
Monitoring and supervision of work done by your health workers and
supervisors should be essentially for problem-solving and organizing the
planned services without any disruption. You will monitor whether the
planned Immunization/MCH sessions, sub-centre clinics and the home visits
are being carried out regularly. If any of these sessions are missed, as a
manager, you will try and determine the reasons and also make alternate
plans to take care of the problems which led to missing certain sessions.
You may use the supervisory check-list to assist in your work and to solve
performance problems. This is also discussed later (Section 4.0).
2.2.10
Line list all cases of poliomyelitis as well as neo-natal and maternal detahs
occurring in your area. Investigate all neo-natal deaths and poliomyelitis
cases using standard proformae (Forms 12 and 13) Ensure that your health
workers are carrying out community-based surveillance (through a system
of village-level informants) for cases and deaths due to vaccine-preventable
diseases, diarrhoea, and pneumonia as well as neo-natal and maternal
deaths.
2.2.11
Prepare and analyse monthly monitoring report. Carry out various
surveillance activities, including preparation of disease charts and maps.
Support coverage evaluation surveys done in your area and use the
information obtained to identify gaps in your services and take corrective
action.
2.2.12
Make a list of hospitals closest to your PHC area (even if they are in a
neighbouring district) for referring newborns with birth weight below 2000
grams and pregnancies with specific complications. This list should be then
available and known to every health worker and other village level health
and other sectoral workers.
2.2.13
Obtain from your district health officers, list of nearby health institutions
which have vaccines and other MCH supplies storage facilities. This will be
helpful in obtaining vaccines and other supplies such as Vit A concentrated
solution, ORS packets, IFA tablets, cotrimoxazole tablets in case of an
urgent need.
11
2.3
AT DISTRICT LEVEL
2.3.1
Prepare a plan of action for the district. This will be done by compiling the
plans of action of all PHCs and urban areas in your district. While
preparing the district plan of action, you will review the plans of action of all
the PHCs in your area along with the medical officers in charge of these
PHCs. Specific attention should be paid to ensuring scheduling of
Immunization/MCH sessions in every village (once a month), sub-centre
clinics in every sub-centre (once a week), and home visits to all priority
houses in the village. The plan will also include action required for polio
eradication (mop-up rounds), elimination of neo-natal tetanus, sustaining
high levels of Immunization coverage (catch-up rounds), training medical
officers and health workers of the district, maintenance of cold chain and
other equipment (e.g. anaesthesia, laboratory and operation theatre
equipment in first level referral centres and sub-centre and PHC delivery
kits). A sample format is given at the end of this module.
2.3.2
Mobilize resources and cooperation of other government departments,
voluntary organizations and organized sectors (see Section 5.5).
2.3.3
Arrange briefing session with concerned officers of PHC, hospitals, medical
colleges and other agencies including voluntary organizations.
2.3.4
Define tasks and responsibilities at district level. Identify a nodal person at
the district level for coordinating various activities under the national child
survival and safe motherhood programme. Coordinate the work of various
agencies involved in similar tasks as functionaries of the health system.
2.3.5
Calculate the vaccine and other supplies (such as drug kits for sub-centres,
ORS packets, IUDs, oral pills, etc.) requirement on the basis of number of
beneficiaries and number of sessions. These have been discussed in detail
in the module "Manage cold chain and other supplies".
2.3.6
Arrange for collection of vaccines, maintain cold chain and other supplies
from WIG location. Distribute vaccines and supplies as per norms and
requirements outlined in the module on "Manage cold chain system and
other supplies".
2.3.7
You should also have a plan giving details of alternate vaccine storage
locations, WICs, etc. in case of prolonged electricity failure, vaccine storage
etc. This list should be shared with your colleagues in PHCs and CHCs of
your district.
12
2.3.8
Check if all supplies and equipment required are available. You will ensure
that your district has a good maintenance plan for equipment, spare part
management system, and an effective logistics system for movement and
managment of supplies. The objective of such a plan would be to ensure
that services are delivered without disruption and that high quality and
standards are maintained.
If there is a WIC in your district, it should be functional at all times. At any
point of time, not more than 2% of ILRs/deep freezers could remain out of
order. All break-downs will have to be attended immediately and minor
repairs carried out within 7 days and major repairs within 21 days. As a
district manager, it is your responsibility to ensure that these objectives are
met. For this, you will have to ensure that you have access to adequate
quantities of spare parts and float assemblies for carrying out repairs.
2.3.9
Make a list of all hospitals within the district and also in the neighbouring
districts (which are close to the PHCs/CHCs of your district) which can act
as referral centres to provide:
★
emergency care and treatment to complications during pregnancy
and delivery and
newborns with complications, including low birth weight (<2000
grams).
Communicate to all functionaries in the district where these referral
institutions are located.
2.3.10
Identify 10 medical officers and 20 other senior health functionaries within
the district to constitute the district core training team. Arrange for their
training in the district or any other location identified by the state MCH
Officer.
2.3.11
Constitute five training teams out of the district core training team and
organize training of all health workers and supervisors in the district at five
different locations.
2.3.12
Arrange for investigation of cases of poliomyelitis, neonatal deaths and
maternal deaths. Identify sentinel centres for surveillance, analyse and
interpret surveillance data from routine monthly reports and sentinel
surveillance reports.
13
2.3.13
Monitor and supervise activities at the PHC, sub-centre and village levels.
Emphasis will have to be on ensuring carrying out of the schedules and
identify problems which result in either missing sessions or outbreaks of
diseases. You should as the district manager promote analysis of the
problems and identification of solutions by your PHC medical officer. In
case these solutions are not likely to yield results, you should point them
out and suggest changes/remedies.
You will also receive, review, and analyse reports on services carried out in
your area and surveillance for diseases and deaths. Based on your analysis
and interpretations, you will give feedback to your health functionaries in the
district. Sample check-lists for supervision have been provided in Section
4 of this module. You may use them for a comprehensive review/
supervision. Supervision should include on-the-job training of your health
functionaries.
2.3.14
14
Conduct or facilitate coverage evaluation surveys as discussed in the
module "Evaluate service coverage".
PLAN AND IMPLEMENT
3.0
1
2
Estimate
Eligibles
List activities
for implementing
progranrne
3
5
4
Plan & Implement — Supervise&Monitor
— Implementation
Provide System
Support
Plan
I rnmri i zat i on/MCH
Sessions
Plan Catch-up and
rounds
Plan
Home visits
Plan work routines
of Field Workers
Use checklist for
MCH activities
Conduct
Imnunization/MCH
Session
Conduct catch-tp
and mop-up rounds
Conduct
Home visits
Under the child survival and safe motherhood programme,you will ensure the
following for your beneficiaries:
Pregnant women
I.
Essential care for all
o
o
o
register by 12-16 weeks
check-up at least 3 times (BP, weight and fundal height)
immunize with 2 doses of rl'T
15
o
o
o
o
o
o
II.
Early detection of complications
o
o
o
o
o
III.
give prophylactic IFA tablets (@ 1 tablet a day for 100 days)
diagnose anaemia clinically and treat with IFA (@ 2 tablets a day for
100 days)
deworm with mebendazole (during 2nd/3rd trimester), if there is a
history of passing worms
advise rest
care at birth ensuring 5 cleans
post-natal care, including advice and services for limiting and spacing
births
clinical examination to detect anaemia
Bleeding indicating APH (before labour) or PPH (after delivery)
weight gain of more than 5 kg in a month or systolic BP more than 140
mm Hg
fever - 39°C and above after delivery (during post-partum) or after
abortion
prolonged labour (for more than 24 hours) indicating obstruction
Emergency care for those who need it (in an institution - first level referral
centre)
o
o
o
o
o
o
o
o
perform vacuum extraction
administer anaesthesia
give blood transfusion
perform caesarian section
perform manual removal of placenta
carry out suction curettage for incomplete abortion
insert intrauterine devices and
perform sterilization operations
All women (in the reproductive age group)
o
o
o
timing of births (between 20 and 30 years of age)
spacing of births (at least three years between successive pregnancies)
limiting of births (not more than two children)
Infants
Newborn care - Birth weight of all newborns within two days.
o
16
Exclusive breast-milk to be initiated within 2 hours of delivery and
continued at least till the age of 4 months
o
o
Advise warmth and feeding at home if birth weight between 2000 and
2500 gms.
Referral to paediatrician if birth weight less than 2000 gms.
Immunization
BCG
DPT
Polio
Measles Vitamin A
1 dose at birth
3 doses beginning 6 weeks at monthly interval
3 doses beginning 6 weeks at monthly interval
1 dose at 9 months of age
1 dose (100,000 I.U.) with measles dose
Children (1-3 years)
Vitamin A
2nd dose at 16 months with DPT/OPV booster
3rd to 5th doses at 6 monthly interval
ChiIdren(0-5 years)
IFA (small) tablets if anaemic
Correct Case Management including Home Available Fluids to those with diarrhoea
and no dehydration and ORT/ORS for those to those with dehydration
Assess ARI and treat Pneumonia with Cotrimoxazole tablets
The programme is an integral part of primary health care and services are provided
through existing health infrastructure. The programme will have to be continued on
a long term basis and coverage levels sustained for many years. Please note that you
will have to in your plan include redeployment of certain health workers/supervisors
to areas with vacant posts to ensure that all eligible benificiaries in your area have
access to the above-mentioned services.
17
3.1
PLAN IMMUNIZATION/MCH SESSIONS
You will provide immunization/MCH services both through fixed centres and through
outreach sessions. Immunization sessions and MCH sessions can be held separately
at the fixed centres according to the convenience of the community and the health
functionaries. However, in outreach sessions it is desirable to organize a combined
immunization and MCH session. In difficult areas it may be necessary to organize
special campaigns to cover children and pregnant women.
Institutions which have vaccine storage facilities (ILRs/Deep Freezers) are termed as
fixed centres for immunization.
All vaccines included in the programme, Vitamin A concentrated solution, IFA
tablets, ORS packets, Cotrimoxazole tablets, Oral pills and conventional
contraceptives should be available at every immunization/MCH session.
All immunization/MCH sessions organized in sub-centre area (including sub-centre
HQ village) are termed as outreach sessions since sub-centres do not have any
vaccine storage facilities.
Fix date and time of immunization/MCH sessions. Consult various members of the
community before fixing the date and time. Remember if the date or time is not
convenient, few will attend. Make sure that your workers conduct the sessions on the
designated day. This should be prominently displayed at the fixed centres. In case of
outreach operations, advance information must be given to the community and
relevant workers.
Ask responsible persons in the community to identify contact person(s) for you. The
contact person(s) should know when your worker will come; she (he) can inform
mothers and other beneficiaries to avail of various services and find other people to
help you. The contact person(s) should help your worker to collect eligibles in time
at the immunization site.
Depending on the convenience and facilities available, it may be necessary to adopt
a combination of strategies. Whatever strategies you may adopt, you should cover all
eligible beneficiaries in your area. Please rememberOxyou will have to sustain services
and high levels of coverage.
Read the checklist of items to be carried for outreach sessions and ensure that your
health workers have all these items. You will also take steps to deliver vaccines on
the days of the sessions.
You should ensure that the planned Immunization/MCH sessions
are conducted in every village.
18
3.2
PLAN CATCII-UP/MOP-UP ROUNDS
From time to time you will have to organise special campaigns in areas which cannot
be covered either by fixed centres or by outreach operations. Teams of health
workers move from village to village carrying adequate quantities of vaccines and
other supplies. It may be necessary to mobilize manpower for a short period from
other areas such as the district headquarters.
In certain villages/areas within your district, coverage levels for Immunization and
MCH activities may be very low. Every effort should be made to ensure that no
planned sessions are missed, and thereby coverage levels are sustained. However, due
to a variety of reasons such as inaccessibility during rains/floods, etc., it may be
necessary for you to schedule special sessions in certain villages or pockets to allow
the coverage levels in these areas to catch up with those of other villages/areas of
your district. You will plan such sessions only towards the end of your reporting year,
i.e. based on the coverage levels obtained in the first 8 months of the year, the catch
up rounds will be planned for 3 successive months - 9th to 12th months of the year.
Polio eradication strategies
As a part of the fixed day Immunization/MCH sessions, you will organize
communication/mobilization drives to give an additional OPV dose to all children
below 3 years regardless of their previous immunization strategy. This will be done
if your district has been identified as one of the districts to be taken up for polio
eradication activities. Two successive rounds of such immunization at one-month
interval will have to be organized. Additional doses of OPV will have to be made
available. No individual records on doses given need to be maintained. Only tally
marking and the reporting of total number of children so immunized will be done.
In case of an outbreak of poliomyelitis (in areas of coverage above 80%, even a
single case of poliomyelitis will be treated as an outbreak), you will organize
containment activities around the area where the polio case is detected for 2000-3000
children (to all children below 3 years) in urban areas and within a radius of 5 kms
in low-density rural areas. The interval between the two rounds will be one month.
The first round of OPV dose administration will have to be conducted within one
week of onset of paralysis.
Mop-up rounds for polio eradication will be implemented in areas where coverage
is relatively high and yet cases of acute poliomyelitis occur. These are to be
implemented to replace the wild virus with the vaccine virus. They should be done
before the epidemic season, which is generally between May and August. Therefore,
the two mop-up rounds should be organized ideally during March and April when
transmission is lowest. For each round, one dose of OPV is given to all the children
less than 3 years (about 10,000 children in a PHC/block area) regardless of their
immunization status.
19
3.3
PLAN HOME VISITS
Home visits of health workers, both female and male should be scheduled on fixed
days of the month as noted in the section on planning of work routines for field
workers. You will ensure that the health worker (female) is supported by health
worker (male), TBA, VHG and AWW. You will also ensure that the HW(F) knows
the "priority houses" to be visited. During supervisory visits you will assess the
worker’s knowledge and skill in providing relevant services to eligibles. If she is not
able to perform a particular task efficiently, show her how to do it. Appreciate the
worker for jobs done well.
It is necessary that the health worker during her field visits is able to use the time for
effective delivery of services and to contact those who need services but do not avail
of these during sessions. This is done by making a list of those houses which require
priority attention. During home visits, your worker should not be visiting all houses
in an area but economise her time by visiting a few for maximum effect.
PRIORITY HOUSES are those with any one of the following. Where there is
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
a pregnant woman (who is not enumerated or registered as yet)
a registered pregnancy with any of the complications or not attending MCH
clinic for the second or third ante-natal visit in time.
a post-natal case not seen following delivery
a post-natal case with a low birth-weight baby
a new oral pill/IUD acceptor
a child with pneumonia
a child with diarrhoea
a child with vitamin A deficiency not turning up for the second therapeutic
dosage
a mother of infant not turning up for various doses of immunization in time
a case referred to PHC/CHC/hospital by you during an earlier
visit/clinic/session
a person acutely and serious ill
a couple who is a prospective client for any birth spacing, timing or birth
limiting measure
a child who has adverse reaction to any immunization during a previous
visit/session
a neonatal death
an infant, child or maternal deaths
a recent case of acute poliomyelitis
Before proceeding for home visits, the health worker should ensure that she has all
the necessary items as per check-list included under Section 3.5.
20
EXERCISE B
Do steps 1 through 5. Check your answers with a course facilitator when you have
completed step 5.
1.
Determine the annual eligible population (number of children to receive
immunizations for the year) for each village on the map shown on page 22.
For this exercise, assume that the number of children to receive immunizations
is 3% (0.03) of the total population. Use columns 1 and 2 of the worksheet
provided on page 23 to do your work.
2.
Determine the number of immunization/MCH sessions (minimum and
maximum) to schedule for each of the villages on the map. Use columns 3
through 6 of the same worksheet you used for step 1.
♦
*
♦
Divide the annual target population of each village (from step 1) by 12
in order to determine the monthly target population (number of
children to receive immunization doses per month) (column 3).
Multiply the monthly target population of each village (from step 2a)
by the number of contacts per child, which you can assume to be 4
(column 4).
For each village, divide the total number of contacts per month (from
step 2b) by 10/30 (the minimum or and maximum number of infants
recommended for an immunization/MCH session). This will give you
the maximum number of sessions per month (column 5).
Following is an example of how steps 1 and 2 should be performed:
The total population of a village is
Annual target population
Monthly target population
No. of contacts per month
Maximum no. of sessions per month
Minimum no. of sessions
No. of immunization sessions3
to schedule (minimum)
3,000
3,000 x 0.03 = 90
90/12
= 7.5
= 30
7.5 x 4
30/10
= 3
30/30
= 1
3 every month and
1 every month
3 For a single immunization session, the minimum child immunization contacts should be 10
(to be cost-effective) and maximum could be 30 (to avoid complications due to worker fatigue).
21
e
I
I
I
/
11
/ /
/ /
T> •
2,000
/ 9 ooo /
A
Heal It
CfcKtte
C»
\,000
B.
5^Ooo
F.
7,500
G
500
Total Population (51,000)
Village A
Village B
Village C
Village D
Village E
Village F
Village G
22
26,000
5,000
1,000
2,000
9,000
7,500
500
Scale
10 Kilometers
All-weather Roads
Bus Routes
WORKSHEET FOR EXERCISE B, STEPS 1, 2 AND 3 (p.21)
Annual Infant
Beneficiaries
Monthly Infant
Beneficiaries
I 12
Population
Vi llage
7.5
90
3,000
Example : x
Monthly Infant No.of Sessions to be scheduled
Minimum
Maximum
Contacts
I 30
I 10
x 4
3
Every week
30
1
Once a month
A
8
C
D
E
F
G
MCH SESSIONS SCHEDULE
[ Including Vitamin A, ORS, Cotrimoxazole and IFA Tablets ]
Health Centre
0
A
Y
AFTERNOON
MORNING
EVENING
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
MCH SESSIONS SCHEDULE (FOR MAXIMUM SESSIONS)
Health Centre
Outreach activities for
Village or Immunization Site
Day
Time
Person Responsible
23
3.
Use your answers from steps 1 and 2 above to schedule
immunization/MCH session for every village on the map. Be sure you
schedule the appropriate number of sessions for each village.
Assume that you have enough staff members to conduct as many
immunization/MCH sessions as you need to. Also assume that you
have talked to mothers in each village in order to determine which
day and time would be most convenient for them to attend
immunization/MCH sessions and that you have learnt the following:
Village A
Mothers prefer different days, but most can
come in the morning.
Village B
The market is held on Wednesday and Saturday
mornings. Mothers are too busy to come in the
morning, but they can come in the afternoon.
Villages C,
D and G
Mothers have time to come to the immunization
during the market hours of Saturday morning.
Village E
and F
Markets are held on Wednesday and Saturdays,
but mothers are too busy throughout the day to
attend immunization/MCH sessions on those
days.
As you determine the specific day and time for the
immunization/MCH sessions for each village, fill in the spaces on the
blank immunization/MCH session schedule forms provided on page
23. For this exercise do not write in the column labelled "person
responsible", even though you will fill in this column when making
immunization/MCH session schedules for your health centre.
24
4.
List at least ten possible obstacles which could prevent
Immunization/MCH sessions from being conducted as scheduled.
Use the workspace provided on page 25 to do your work.
5.
Describe the precautions you can take in order to prevent the
problems which might arise from three of these obstacles. Use the
workspace provided on page 25.
J
o
Workspace for answers to steps 4 and 5
4.
5.
Obstacles which prevent conduct of sessions
(i)
(vi)
(ii)
(vii)
(iii)
(viii)
(iv)
(ix)
(v)
(x)
I
Precautions you will take to overcome 3 of the above obstacles
CO
00
(iii)
25
*
rrr
!
3.4
PLAN WORK ROUTINES OF FIELD WORKERS
Broad principles for planning work routines are:
o
Health worker (female) is the best worker available at village level. However
to meet various objectives of child survival and safe motherhood
programme you should ensure that she is able to take maximum help from
four other workers available at village and SC levels - health worker (male),
TBA, VHG and NNW. Many tasks can ‘ be shared amongst these
functionaries at village level. Mothers’ meetings at the village level provide
very useful opportunities to share knowledge and responsibilities. The
health worker (female) should ensure that these meetings are attended by
all mothers of the village as well as the TBAs, VHG and AWW.
o
Work routines of health workers - female and field supervisors should be
scheduled and rationalized so that maximum number of eligibles receive
services.
o
During field visits, the workers should visit homes as per priority houses list
on page 20.
Basic assumptions/premises for work routine scheduling:
26
o
Field workers have approximately 24 working days in a month. The time
taken for provision of immunization/MCH services would not need more
than 16 days a month. This leaves 8 days for the field worker to attend
meetings, maintain records, carry out activities related to family planning,
etc.
o
It is assumed that 4 hours of work can be carried out on a field visit day
with the remaining time spent on travel. This time is sufficient for conducting
home visits using the concept of priority houses visit.
o
Health assistants (male & female) should spend a minimum of 8 working
days per month in field supervision of which half should be working with
health worker at clinic/session and half during home visits. Thus each health
worker will receive support and on the job training from a supervisor twice
in six weeks - once at a clinic and once during ’home visit’.
o
Every PHC, CHC and district level medical officer should spend a minimum
of 4 days a month in field work for the child survival and safe motherhood
activities. The remaining time is adequate for administrative and curative
work load. Thus, these visits can be enforced by the supervising officers at
every level.
PREPARE THE WORKPLAN OF HW(F)
STEP 1
At the time of planning work routines of your health workers, you should have the
following information:
*
★
*
★
number of villages in the sub-centre area and their population
distance between the PHC and HQ village and other villages
means of communication - whether bus is available, Vaccine and other supplies
can be sent on the same day from the nearest vaccine/supplies depot.
specify vaccine delivery i.e. who will carry. Look for other resources who will assist
in vaccine delivery e.g., milk carrying vehicle, bus, train, etc.
SAMPLE MONTHLY WORK PLAN
Week
Monday
Tuesday
Wednesday
Thursday
Friday*
Saturday
**
First
Home
Visit
Village 1
FP
services
SC (MCH)
clinic
*lmmun.
Session
Village 3
Home
visit
Village 5
Open
Second
Home
Visit
Village 2
FP
SC(MCH)
Immun.
clinic
*lmmun.
Session
Village 4
Immun.
session
in hamlet(s) left
out
Open
Third
Home
visit
Village 3
FP
SC(MCH)
Clinic
*lmmun.
Session
Village 1
Home
visit
to
hamlets
Open
Fourth
Home
visit
Village 4
FP
SC(MCH)
Clinic
*lmmun.
Session
Village 2
Immun.
Session
Village 5
Open
Fifth
For missed work on any day of above day due to leave or holiday and
meetings
*
Fixed immunization day as per state guidelines - not to be changed, wide publicity to be given.
**
Can be changed to another day e.g. if a fixed family planning camp is held at your PHC on every Friday then
change Tuesday with Friday and vice versa.
Open means - State/District to indicate activities like mothers meetings / sectoral meetings, etc.
Use one day of the week to organise home visits, immunization sessions etc. for additional villages / hamlets
with population above 500 by rotation
27
You should plan a fixed monthly routine for the health worker in consultation with
them and their supervisors. Such a routine will ensure effective programme
implementation and will make it easier for you to achieve targets. You should give
sufficient time to make such a routine. A sample monthly Health Worker’s (Female)
work plan is given on page 27 for your guidance. You can make necessary
changes and alterations keeping in view your area specific needs.
According to the schedule on page 27, a minimum of 5 Immunization/MCH
sessions, 5 home visits and 4 sub-centre MCH clinics (of which one will be an
Immunization/MCH clinic) can be organised every month. In addition, the health
worker can visit, by rotation, hamlets/areas left out every week. The days and
number of immunization/MCH sessions, however, will be scheduled by you based
on needs and as per Section 3.1. For example, if the HW (F) has 4 villages, then
only 4 sessions will require to be fixed in a month. The working days beyond Day
28, may be used for any of the missed activities.
Preoccupation with specific peak time workload during certain months should not
interfere with planned delivery of services under child survival and safe
motherhood programme. It will not interefere with achievement of targets of other
programmes. On the contrary, mothers’ confidence in health workers builds up
through provision of good MCH care under child survival and safe motherhood
programme. This will facilitate achievement of targets of other programmes as well.
STEP 2
CONSOLIDATE SUB-CENTRE WORKPLANS TO MAKE PHC PLAN
Once you have planned a monthly work routine for every sub-centre in your PHC
or CHC area, you will have to consolidate all of them especially for
immunization/MCH session days. This will ensure that all sub-centres on a
particular route organize immunization/MCH session on the same day of the week
or month so that you can easily transport vaccines and other supplies to all sub
centres by a single person/vehicle.
28
3.5
USE CHECK-LIST FOR MCH ACTIVITIES
Immunization/MCH session
adequate number of sterilized syringes (usually 20) and needles
adequate vaccine vials in vaccine carrier (2 vials of DPT, and 1 each of
other vaccines with diluent for a village of 1000 population)
container for used syringes and needles
ampoule file, cotton, forceps
sauce pan with lid or sterilizer, stove, match box
village MCH register, immunization cards (counterfoils and new cards)
IFA and mebendazole tablets
vitamin A concentrate solution with measuring spoon
contraceptives (condoms, oral pills, IUD)
ORS packets
cotrimoxazole tablets, a spoon, thermometer and a watch with second’s
hand
ergometrine injection
soap, towel, pen, paper
disposable delivery kits (for distribution)
weighing scale (infant)
MCH Clinic at subcentre
All items listed above plus stethoscope
blood pressure instrument, measuring tape
weighing scale (adult)
Home visits
village MCH register and list of priority houses
mother-infant immunization cards
IFA and mebendazole tablets
ORS packets
cotrimoxazole tablets
vitamin A concentrate with measuring spoon
BP instrument, stethoscope, measuring tape
colour coded weighing scale (infant)
soap, towel, pen, paper
daily diary
disposable delivery kit (for distribution)
29
3.7
CONDUCT CATCH-UP AND MOP-UP ROUNDS
You have on page 18 learn about planning for catch-up and mop-up rounds. You
will organize these activities specifically in areas identified as requiring either catch
up rounds for accelerating coverage or mop-up rounds for polio eradication
activities in your district.
Catch-up rounds need to complement the routine immunization services provided
through the primary health care system, as the fixed-day strategy becomes
institutionalised ensuring regular contact of the health worker with every village
every month, catch-up rounds will need to be implemented progressively in fewer
areas and districts covered under the programme. Catch-up rounds are to be
implemented where coverage levels are low, specially in areas that remain cut-off
due to natural calamities. You should note that catch-up rounds should not be a
strategy for covering areas with vacant staff positions. Such areas should form
part of regular fixed-day strategy with functionaries from other areas being
redeployed on the designated day.
Mop-up rounds are implemented only in areas taken up for polio eradication
strategies. They should not interrupt regular service delivery and therefore should
be implemented as a part of the Immunization/MCH session. This means that
health workers will complete the primary immunization of all those children under
one year of age first, and then subsequently, children below 3 years will be given
OPV regardless of their previous immunization status. The OPV given during mopup rounds will not be entered in the Immunization Card, unless it is part of the
primary immunization that is due for an infant on that day. The health worker will
have to submit a statement on the total number of children below 3 years of age
who have been given OPV and does not need to identify children by name or
address.
Since mop-up rounds are implemented to replace the wild virus, it does not matter
if a few children are left out, or a few children over 3 years of age are included.
House-to-house listing of children below 3 for mop-up rounds is not
recommended. Instead, it is advisable that all children below 3 years are brought
to the immunization session through a village-level social mobilization and
communication initiative.
32
3.8
CONDUCT HOME VISITS
Once a fixed monthly plan is prepared and the HW(F) is visiting homes as per
schedule, you should ensure proper time management by the worker .The worker
should be aware of what is to be done in how much time in each priority house
visited. A sample is given below.
ANTE-NATAL CARE
There will be about 160 pregnant women in a sub-centre area during 12 months.
At any point of time, there will be half of them who are registered and not
delivered. It is possible to register 13-15 pregnant women every month. They will
need a thorough ante-natal examination and advice. Those registered earlier will
require check up which will take short time period unless they have complications.
In a new ante-natal case, the health worker will :
o
register and prepare a mother and infant immunization card
take history to rule out too old (>30 years) or too young (<20 years)
primigravida and examine clinically to diagnose anaemia.
do an abdominal examination to detect lie, rule out associated general
diseases, record blood pressure, weight, give IFA tablets, take weight and
motivate for first dose of TT (can be done at sub-centre clinic)
give ante-natal advice on (i) diet (ii) rest and (iii) danger signs
o
(complications)
if there is history of worms, give mebendazole tablets (only in second/third
o
trimester)
motivate pregnant women to attend ante-natal clinic at least three times
o
o
o
During the 2nd visit, the health worker will:
specifically look for anaemia, give IFA tablets and give mebendazole tablets
if there is history of worm infestations (only in second/third trimester)
record BP
motivate for 2nd dose of TT
record weight and determine if there is adequate weight gain
Weight gain of more than 5 kg in any month is an early warning sign
for toxaemia - can be done at SC clinic
reinforce diet, rest and inform about warning signs such as bleeding, loss
of foetal movements, headache, dizziness, blurred vision for which the
pregnant woman should seek immediate help from health worker/medical
officer.
33
During the 3rd visit, the health worker will carry out all activities:
included for 2nd visit (except deworming and TT dose, unless not given
earlier)
enquire about place of delivery and motivate for institutional delivery, remind
5 CLEANS
give a disposable delivery kit (where available)
advise regarding preparation for labour including 5 cleans during delivery,
early initiation of breast feeding, i.e. within 2 hours of birth of the baby.
Several ante-natal activities can be carried out by TBA or AWW and hence HW(F)
can easily complete examination of a new ante-natal case in 30-45 minutes and
subsequent visits in 10-15 minutes.
NATAL CARE
All deliveries should be conducted, observing 5 CLEANS:
clean surface, clean hands, clean razor blade, clean cord tie, and clean
cord stump (no applicant)
POST-NATAL CARE
There will be about 13-15 new post-natal cases every month in a sub-centre area:
look for complications i.e. foul smelling discharge, bleeding as well as fever
and refer to primary health centre for antibiotic therapy/examination
advice on cord care and exclusive breast feeding
motivate for spacing/limiting subsequent births.
If the baby is of low birth weight, i.e. <2500 g (LBW)
It has been observed that one out of three babies has low birth weight, about four
babies in a sub-centre area may be identified as LBW every month. Your health
worker should:
advise warmth, frequent feeding and prevention of infections by handling
the baby minimally and washing hands before touching the baby.
if the baby is unable to be fed, or has jaundice, or infection, then refer to
hospital or community health centre.
34
If the weight of the baby is less than 2500 g and the child is unable to suck, your
worker will have to transport the baby with the mother (to provide warmth through
body contact) to a health facility for further assessment and care.
In a child with acute respiratory infections, your worker will:
determine if the child is breathing fast (more than 60 times per minute in
children below 2 months, more than 50 in a child of 2 to 12 months and
more than 40 times in a child aged 1-5 years).
give co-trimoxazole as per dose schedule (refer to ’Interventions Module)
Inform mother to bring child for assessment after 2 days.
Inform her of the danger signs requiring urgent attention.
Refer if there is chest indrawing or difficulty to wake up or child has fits
or severe undernutrition.
In a child with diarrhoea, your worker will have to ensure correct case
management after assessing for dehydration. You will have to train her to:
assess degree of dehydration by looking at general condition, eyes thirst
and feeling for skin pinch
demonstrate how to prepare ORS solution and how much to give
advise increased fluid intake and continued feeding
identify and stock possible depot holders in every village with ORS packets
within the village to children with diarrhoea and dehydration
To a new oral pill/lUD acceptor, your worker will:
Reassure and look for side effects as described under drug kit pamphlet.
35
SAFE MOTHERHOOD
LIST OF ACTIVITIES TO BE DONE AT DIFFERENT LEVELS
Level
ANC
Delivery
Post-natal care
HOME
(by other women
and family)
- extra diet and rest
- regular intake of IFA tabs,
daily
- self referral if bleeding/
high fever (more than 39OC)
- prepare for home delivery
or arrange transport if
institutional delivery
decided upon.
- Contact trained TBA at
onset of labour
- ensure 5 cleans
o clean hands
o clean surface
o clean cord tie
o clean razor blade
o clean cord stump
- Self-referral for PPH/
prolonged labour
- Start breastfeeding as
early as possible.
- Self-referral if foul
smelling discharge
- Warmth/feeding for
LBW baby
VILLAGE
(by TBA/AWW)
- register early
- advice on above ♦ TT
immunization
- coordinate with ANM for
AN care
- Referral* in case of
complications
- use aseptic technique i.e.
5 CLEANS
o clean hands
o clean surface
o clean cord tie
o clean razor blade
o clean cord stump
- appropriate referral if
prolonged labour, PPH
- as above
- advice on cord care
- referral if fever
or bleeding present
SUBCENTRE
(ANM/LHV)
Some of these
activities caOxbe
carried out by
ANM at village during
MCH/Immuni zation
sessions also.
- 3 antenatal check ups (last
at 32-38 weeks)
- take history
- screen for anaemia, age,
weight gain
- Give TT, IFA tablets
- Deworm if required (2/3rd
trimester)
- Referral in case of
compIicat ions
Same as above
- look for bleeding
- look for fever
- treat mild sepsis
- advice spacing/timing
- weigh baby at birth
- advise warmth &
feeding
- provide oral pill,
IUD, condoms
PRIMARY HEALTH
CENTRE
(Medical Officer)
- all above +
- treat toxemia, UTI,
fever (malaria)
- refer to CHC/lst level if
bleeding or systemic
diseases present
all above +
care of referred cases
and referral after
stabiIi zation
- all above +
- treat referred cases
of sepsis, UTI
- provide IUD/pills/
steriIi zation
CHC/POST PARTUM
CENTRE
DISTRICT HOSPITAL
1st level referral
- All above +
- Treat severe anaemia by
blood transfusion
- Treat eclampsia,
associated diseases
- Manage APH/PPH
- all above +
- Delivery in eclampsia
severe anaemia, systemic
disorders
- Ceasarian section and
blood transfusion
if indicated
- All above
PREFERENTIAL ATTENTION AND MANAGEMENT OF ALL REFERRED CASES
REFER APPROPRIATELY
It is extremely important that complications during pregnancy or delivery are recognized early. You
should ensure that cases are referred to the appropriate health facility. For example, referring a case
of post-partum bleeding to a PHC which does not have any facility for blood transfusion will be counter
productive.
36
The duration between onset of a complication and death is VERY SHORT
as given below:
AVERAGE INTERVAL FROM ONSET OF
COMPLICATION TO DEATH
COMPLICATIONS
Bleeding before delivery (APH)
Bleeding after delivery (PPM)
Ruptured uterus
Eclampsia
Obstructed labour
Infection (sepsis)
12 hours
2 hours
1 day
2 days
3 days
6 days
Thus it is vital that all your staff and village level functionaries are aware of
when to refer and where to refer as quickly as possible.
When to refer
Where to refer
A. PREGNANCY
History of: - difficult labour/caesarean
- elderly primigravida
- bleeding/spotting
During
pregnancy
- more than 5 kg weight gain in a
month
- blood pressure >140/90 mm
- severe pallor
- spells of headache
- high fever (>38 C)
- bleeding
- abnormal lie
For detailed examination and
investigation at PHC/CHC
r investigation at PHC/CHC
■ treatment at PHC
- blood transfusion at CHC/dist
- investigation at PHC/CHC
- investigation at PHC/CHC
- treatment at 1st referral
centre (CHC/district)
B. DURING DELIVERY AND POST NATAL
- Excessive bleeding
)
- No progress in labour for 24 hours)
- Severe headache/convulsions
- High fever
C. NEWBORN
- Low birth weight (<2000 gm)
- Jaundice
- Congenital anomalies
- blood transfusion & surgery
(CHC/district)
- first level referral(CHC/Dist
- injectable antibiotics and IV
fluids at PHC
To a health facility with
paediatrician
REFERRAL SHOULD BE IN TIME
(e.g. immediately for bleeding after delivery)
REFERRAL SHOULD BE TO APPROPRIATE FACILITY
(e.g. obstructed labour to CI IC/Dist. Hospital with surgical facilities)
REFERRED CASE SHOULD GET URGENT AND ADEQUATE
CARE AT PHC, CHC OR DISTRICT
37
4.0
SUPERVISE IMPLEMENTATION
1
2
Estimate
Eligibles
List activities
for implementing
programme
3
4
5
Plan & Implement — Si^ervise&Monitor — Provide System
— Implementation
Support
What?
How?
When?
Follow-up
The success of child survival and safe motherhood programme depends on whether
your field functionaries are performing tasks assigned to them properly. If certain
tasks are not done or done incorrectly you will not be able to achieve programme
objectives.
Supervision includes giving support, overseeing, directing and above all assisting your
staff in carrying out their responsibilities. The purpose of supervision is to reinforce
when your staff perform well and to identify areas requiring assistance and support
and not for finding faults only. A good system of supervision includes the following
two essential elements:
o
o
periodic visit by supervisors; and
periodic reports by staff to the supervisors
It is necessary for you to observe the work of your staff frequently in the field and
study the reports submitted by them carefully. To be a good supervisor, you should
be able to carry out yourself, all the tasks your supervisees, i.e. the health workers,
supervisors, the cold chain mechanic, pharmacist, etc., are normally expected to do.
38
4.1
WHAT?
You will select those items for supervision. For example, they may be:
*
most critical for correct service delivery e.g. "fixed day" for immunization and
MCH services held as scheduled or not.
*
elements which are difficult e.g. recognizing chest in-drawing in a case of
pneumonia; and
*
programme components in which the expectations of the community are not
met or there are complaints from the community.
In general, what you supervise can be grouped under the following areas:
*
activities of health worker i.e. assessment of the condition of the beneficiaries
and provision of services e.g. clinical assessment for anaemia and therapeutic
dose of IFA tablets in a pregnant woman with anaemia.
*
knowledge of mothers e.g. mother’s understanding of actions to be undertaken
by her at home level for coughs and colds.
*
logistics e.g. availability, storage and optimal utilization of drugs, vaccine,
equipment and essential supplies.
*
outcome of services i.e. monitoring results of activities e.g. recovery or death
or referral of a case with pneumonia at sub-centre, occurrence of an outbreak
of poliomyelitis in immunised children, etc.
*
record keeping - scrutiny of records and registers, daily diary, monthly reports.
*
community participation - utilization of services, assistance rendered by
members of community during sessions, interactions with village leaders etc.
Supervision does not mean identifying problems for corrective action only but
also assisting functionaries and helping them in case of difficulties.
Opportunity should be given to functionaries to clear their doubts whenever
they arise. You should, by your supervision, ensure that your community is
provided the best MCH services under the prevailing circumstances. Peoples’
experience of sessions and home visits will have a major effect on their
motivation. Hence you should ensure that every health functionary under you
is reliable, punctual, polite and friendly.
<1
39
4.2
HOW?
Supervisory checklists are included at the end of this section. You should use them
for supervising functionaries at various levels. Activities for supervisor have been
limited to those considered essential for the success of the programme. Depending
on your local, area specific situations you can modify and add to these checklists.
However, it is always beneficial to use a checklist for supervision so that you do not
forget. Also a completed checklist will serve as a good record of the outcome of
supervision.
Review records, observe health workers as they do their work and talk to health
workers and mothers. Determine if activities listed in the checklist are being done
correctly or incorrectly or not being done at all. Determine what is being done well.
As you supervise, record on your checklist your assessment and any important
observations.
Use this opportunity to compliment health workers for doing a good job. Ask them
about the problems they face. They may have certain ideas for improving their own
work and the ways you can help them. Answer questions they may ask and give
information (on-the-job training) that will help solve problems. During supervision,
one of the key interventions will be demonstration of activities your functionaries are
unable to perform correctly. Make special efforts to show by your action, what you
expect from your health workers and supervisors.
How to supervise - some of the frequently used methods for supervision are:
METHOD
REMARKS
1. Observe the health worker
actually doing work
It is vital that workers know that you are not
observing them to criticise but to help them
improve quality of services.
2. Talk to health worker
You can identify problems and solutions. It
gives you an opportunity to compliment workers
when they perform well.
3. Review record
You should ensure that records are properly
maintained and are up-to-date.
4. Meet members of the
community and discuss
You can determine mothers’ knowledge and
their understanding of actions to be taken at
home. You can also get an idea of their
complaints or suggestions about services.
5. Review Monthly
Monitoring reports
To assess trends, reported coverage etc. and to
identify problems and solve them.
40
4.3
WHEN?
Supervisory visits should not be too frequent since this will not allow sufficient time
to pass to implement recommendations of the previous visit. On the other hand,
visits should not be too infrequent as they are essential to sustain staff motivation.
Supervision should not be for pointing out mistakes, but for problem-solving.
Depending on category of personnel, performance at each unit and stage of
programme you should ensure that:
a)
every health assistant (male and female) should spend a minimum of 8
working days per month in field supervision of which half should be working
with health workers at clinic or sessions and half on a home visit. Thus
each health worker will receive support and on-the-job training from a
supervisor twice in six weeks - once at the clinic and once during home visit
day.
b)
every PHC and CHC MO and district level officer should spend a minimum
of 4 days a month in the field working for Child Survival and Safe
Motherhood programme. Thus it is expected that each PHC/CHC medical
officer can provide supervision and on-the-job training to the health
assistant and multipurpose worker of a sub-centre once every quarter at the
clinic or immunization/MCH sessions and once every quarter on a home
visit.
Performance at each unit
You should identify poor performing units and provide supportive
supervision more often to determine and solve problems which lead to poor
delivery of services and coverage. Thus a PHC/CHC medical officer should
visit a sub-centre which is below average in performance at least twice as
often as a better performing unit. Similarly the district level officers should
visit PHCs and CHCs performing below average more frequently.
Stage of programme implementation
During the first few months of implementation of the programme,
supervision at all levels should be more frequent. This will ensure smooth
operationalization of the programme in every village, sub-centre, PHC and
urban area.
41
4.4
FOLLOW UP
Once a problem is identified, you should determine its cause.
The cause could be:
a)
Lack of necessary skills in a worker, e.g. Cotrimoxazole is not given
for pneumonia because the worker cannot count respiratory rate.
Arrange an informal on-the-job training for staff and ask the
supervisor to follow up.
b)
The worker lacks motivation. In other words he/she knows how to
perform the task but does not do it. You should reward good
performance through positive comments/public recognition.
c)
There are obstacles in the way of doing a task e.g. lack of time (due
to improper time management, lack of equipment or supplies, lack
of authority etc.) This would require appropriate management action
on your part to eliminate obstacles.
Supervisory checklists :
In the next few pages, sample supervisory checklists are given for use by
various health functionaries to supervise and support functionaries at the
next level. These check-lists include certain items on each category of the
tasks carried out by various health functionaries. You may, depending on
how well your district is performing, modify items in the check-list. It is,
however, important to remember that monitoring and supervising to ensure
that the fixed-day sessions for various child survival and safe motherhood
activities are held as per schedule.
The check lists included are for use by :
42
(a)
health worker - female during visit to villages
(b)
health assistant during visit to a sub-centre/village
(c)
Medical Officer during visit to a sub-centre and its areas
(d)
Medical Officer at village during session/home visit
(e)
District Level Officer during visit to PHC and its areas
A.
FOR USE BY HEALTH WORKER (FEMALE) DURING VISIT TO VILLAGES
(HOME VISITS)
Village
Sub-centre
PHC
Name(s) of trained TBA/VHG/AWW who was/were provided supportive supervision
Workers assessment
o
5 cleans during delivery, observed;
knows when and where to refer
a complicated delivery
YES/NO
Can weigh newborn and identify
low birth weight babies?
YES/NO
o
Can identify priority houses correctly?
YES/NO
o
Record of priority houses kept well
YES/NO
o
Can recognize neonatal tetanus/poliomyelitis YES/NO
o
Adequacy of stock position :
ORS packets
IFA tablets
Vitamin A solution
Condoms (where applicable)
Disposable delivery kits
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
o
Are they distributed correctly
YES/NO
o
Are mothers aware of location of depot
YES/NO
Problems identified/solved
Details of any on-the-job training provided:
Date:
Name and signature of the Health worker
43
B.
FOR USE BY HEALTH ASSISTANT TO SUPERVISE HEALTH WORKERS
Village:
HW (F):
During home visit
o
No. of visits scheduled last month
actually conducted
o
o
Is a list of priority houses kept?
Does the worker know how to use BP instrument,
foetoscope and delivery kit?
Does she do ante-natal check-up properly?
Can she correctly identify and refer
complicated cases to the appropriate
institution?
Is she assisted by TBA/AWW
Time management by worker satisfactory
Problems narrated by women
o
o
o
o
o
YES/NO.
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
Details of any on-the-job training provided
During session
o
o
o
o
o
o
o
Whether a session was planned last month?
Was it conducted?
During the current immunisation session :
session held/not held; if not held, Why?
worker not available
vaccine not available
needles/syringes not available
transport not available
People/eligibles did not come
any other, please specify
Attendance of beneficiaries less than expected
Is she polite and considerate?
Assistance from TBA/VHG/HW(M)/AWW
Problem identified/solved
Date :
44
YES/NO
YES/NO
YES/NO
YES/NO
Name & Signature of Health Assistant
J
45
CHECK LIST FOR SUPERVISION DURING SESSION/HCME VISIT
■ items to Monitor i
immunization
Correct
Assessment cf
El igibles
For Immunization
Y/N
| Diarroh. Disease!
Pneumonia
For degree of
dehydration
for fast breathing/chest
inarawing
Vitamin A
For Vit. A
prophylaxis for
every child
9 months-3 years
JFA Tablets
iSM i ANC/Delivery
PNC
For Prophylaxis
For FDD
For risk factors
including
anaemia
Mother ■ for
fever/fcul smel
ling discharge
- bleeding
birth spacing
Neonate; for
birth weight
Inj. T.T.
Deworming in
case of history
of worms
- Treatment/
referral of
complication
- Care of Low
birth weight
baby
- birth spacing
For Anaemia
For Deficiency
s i gns
- Demonstration & - Appropriate use - Correct Dosage
- Cold chain main
(prophylactic/
provision of
of Cotritained - YES/NO
therapeutic)
moxazole
- Sterilization of
ORS
- Appropriate use • Appropriate
syringes and
referral
of antibiotics
needles - YES/NO
- Appropriate
- One needle/syringe
referral
for one inj. -Y/N
- Correct technique
of vaccination - Y/N
2.
Correct
Provision of
Servi ces
|3.
instructions | - About mild side
to Motners
effects
- Y/N
! - When to come back
- Y/N
Records
! - Proper filling of
Card
- Vi 11 age Register
updated
about fluids, - About home
management of
feeding, ORS
coughs & cold
when to go to a
health facility - When to come
back for going
to health
facility
- Recording on
Register/daily
diary
Kerosene, sterilizer - Adequate ORS
packets
adequate vaccine &
avaiI able
syringes available
cards
- Correct Dosage
(prophylactic/
therapeutic)
- Regular use and - For Diet
- Need to come
come back next - Rest
back for next
- Warning Signs
month for
dose
continuation of
- increased
intake in diet j prophylaxis
- Recording on
the Card
- Village
Register
Updated
• Recording on
Card
- Village
Register
updated
Adequate cotrimoxazole
available
Adequate Vit. A
syp. available
- Disposable
Adequate 1FA
delivery
tablets available
kit
5.
Logistics
6.
Outcome of
earlier
services
Any case in a
vaccinated child
Recovery,
referral or
death
Recovery,
referral or
death
Recovery from
night blindness
Recovery or
referral
7.
Mothers'
Response
Satisfied with
Services
(Y/N)
Satisfied with
services
(Y/N)
Satisfied with
services (Y/N)
Satisfied with
services (Y/N)
Satisfied with
services (Y/N)
8.
Problems
identified
during
supervision
9.
On-the-Job
Y/N
Y/N
Y/N
Y/N
Training
1*0. Any o'her
• Recording on
Mother & Child
Card
- Recording on
Register/
daily diary
Satisfied with
services (Y/N)
- Diet
- Care of newborn
if LBW
j- Advise for
birth spacing
- Recording on
Card/Register
Contraceptives
- condoms
- oral pills
- IUDs
Satisfied with
services (Y/N)
c.
FOR USE BY MEDICAL OFFICER DURING VISIT TO SUB-CENTRE
Name of the PHC
Name of the sub-centre
Population covered
No. of villages
FROM MONTHLY REPORTS
[Please complete this section before proceeding for field visit]
S.No.
D
E
S
C
R
I
P
T
I
0
N
1.
Number of infants completely immunized from
the beginning of year
2.
No of PW given IT vaccine - 2nd dose/booster
3.
New ANC
4.
Pregnant women with complications referred
5.
IFA tablets given - prophylactic/therapeutic
6.
Number motivated for spacing
7.
Nunber motivated for sterilization
8.
Deliveries conducted
9.
Acute Diarrhoea cases reported
10.
Pneumonia cases reported
11.
Vitamin A doses given
12.
LBW babies identified
13.
No. of immunization/MCH sessions conducted
No. as reported
Expected
Comments/Satisfactory [Y/N]
cases registered in the last 1 month
Problem identified/solved by Medical Officer:
Problems identified/solved by LIIV (as per supervisory visit record)
[During field visit please concentrate on performance problems that can lead to above identified
problems]
46
D.
FOR USE BY MEDICAL OFFICER DURING VISIT TO VILLAGES/SESSIONS
Date of visit
Name of village
During an immunization/MCH Session
o
No. of sessions scheduled last month
No. of sessions actually held
If immunization session not held. Why?
worker not available
vaccine not available
needles/syringes not available
mobility not available
People/eligibles did not come
any other, please specify
o
o
o
o
o
o
Attendance of beneficiaries less than expected
Disorderly movement of people, long waiting
Impolite or rude behaviour of worker
Assistance from TBA/VHG/HW(M)/AWW
Supervision by LHV satisfactory
Problems narrated by worker
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
During a Home Visit
o
oo
o
o
o
Priority houses correctly identified
Help from VHG/TBA/HW(M)/AWW
Supervision by LHV adequate
Impolite or rude behaviour of worker
Time management by worker satisfactory
Problems narrated by worker
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
47
Action suggested by you for the Health Team
1.
Medical officer (for supplies, intersectoral activity)
2.
Block extension educator (BEE)
(for communication needs)/others
3.
Health supervisor - female (LHV)
(for technical skills)/others
4.
Health supervisor - male (HS)
for assistance in work/others
5.
Health Worker - male (MPW)
for assistance in work/others.
Follow up action on your recommendations during last visit
Not done at all/inadequately done/adequately done
Problem identified/solved
Date:
Name & Signature of the Medical Officer
THIS IS AN IMPORTANT DOCUMENT
PLEASE KEEP ALL FILLED SUPERVISORY FORMS IN CH RO NO-LOGICAL
ORDER IN A FIELD SUPERVISION FILE.
GET THIS FORM INITIALLED BY DISTRICT OFFICER DURING PHC VISIT.
48
E.
FOR USE BY DISTRICT LEVEL OFFICER DURING VISIT TO PHC AND FIELD AREAS
Name of PHC/CHC
No. of sub-centres :
Total population :
FROM MONTHLY REPORTS
Problems identified
o
No. of sessions scheduled
If immunization session not held, why?
.. No. of sessions actually held
worker not available
vaccine not available
needles/syringes not available
transport not available
people/eligibles did not come
any other, please specify
o
Disease surveillance
No. of cases reported with low vaccine coverage
Cases in immunization persons
Large number of cases while coverage is high
o
Performance coverage less than expected for:
Immunization (antigenwise)
Iron & Folic Acid
Vitamin A prophylaxis
Diarrhoea treatment
Pneumonia treatment
High dropout rate
IUD acceptors
Oral pills
Sterilization
ANC coverage
o
- YES/NO
- YES/NO
- YES/NO
YES/NO (specify)
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
Supply and equipment
Wastage rate for vaccine - too high
High cold chain sickness rate
Response time for cold chain equipment satisfactory
Others (adverse reaction etc.)
- YES/NO
- YES/NO
- YES/NO
[During PHC/CHC visit concentrate on the performance problem causing the above identified problem]
49
Supervision during PHC/CHC Visit
Name of Medical Officer in-charge or doctor available:
Vehicle - available/not available, on road/off road
Staff position and training
Staff
No vacant
Health Assistants
Male
Female
Heal th Workers
Male
Female
No in position
Plan of action
No not trained
available/not available
Supervisory visits
No. of sub-centres visited in last one month (specify)
by Health assistant
by Medical officer
adequate/inadequate
adequate/inadequate
Has the PHC been visited by
Medical officer of CHC in the last one month
District/state level officer in the last six months
YES/NO
YES/NO.
Intersectoral activity (if yes, specify)
ICDS/Social welfare
Education - primary school
NGOs
Panchayat
Does intersectoral activity need improvement
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
Immunization sessions
No. scheduled last month
No. actually conducted
Main reasons for cancellation of schedule
Vaccine distribution to session site
a)
b)
50
PHC staff delivers Sub-centre staff collects -
same day or one day prior
same day or one day prior
same day/after one day
Unused vials received back Observations on a vaccination session at facility
Problems identified in scheduling or conducting session
by district officer
Supplies
Vaccines
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
Nil stock or more than 1 month requirement Temperature book maintained Frequent rise of temperature above 8 degree celcius Defrosted timely Vaccines stacked haphazardly or beyond date of expiry
Drug Kits
Inadequate stock at any sub-centre for Vit A, IFA, ORS, Cotrimoxazole
Drug kits distributed to each sub-centre in time -
YES/NO
YES/NO
Care of referrals from field (types of cases seen in last one month)
YES/NO
YES/NO
YES/NO
YES/NO
Knowledge of medical officers adequate
Treatment of referred cases adequate
Supplies and equipment for care of referrals
Essential obstetric emergency services adequate
Communication and Social Mobilization
Does block extension educator perform his extension duties
for child survival and safe motherhood well
IEC materials available
Problems identified in IEC activity
YES/NO
YES/NO
Follow-up action
Action on suggestions/recommendations
made during your last visit adequate
Suggestions/recommendations made during this visit.
YES/NO
Any other observation/remark
Date :
Name & Signature
Designation
51
COMMUNITY HF '* I TH CELL
326, V Mf'in, I 3iock
Koram-r.g Ifl
Bangalore-LG0034
India
5.0
PROVIDE SYSTEMS SUPPORT
i
2
3
4
Est imate
List activities
for implementing
programme
Plan & Implement
Supervi se&Moni tor
Implementation
El igibles
5
Provide System
Support
M I S
Material Management
Training
Comnunication
Social Mobilization
Child survival and safe motherhood programme requires the support of several
systems. These include:
*
♦
*
♦
♦
52
An information system through reports on activities and causes of diseases and
deaths you aimed to prevent (Management Information System)
Effective maintenance of equipment, including those related to cold chain,
deliveries at the sub-centre and hospitals, and anaesthesia and laboratory
support services. These equipment should be functioning effectively and need
regular maintenance and repairs.
Training of manpower, i.e. training of health workers as well as those related
to providing systems support for child survival and safe motherhood
programme.
All health and non-health functionaries involved in the programme will act as
communicators to create a demand for service and also to ensure utilization
of services. I here needs to be a system of disseminating accurate, consistent
and reinforcing information related to the programme elements.
Mobilization of the beneficiaries through a system of informants and through
prominent individuals within the village is also an integral part, which you
should be aware of as a programme manager.
5.1
MANAGEMENT INFORMATION SYSTEM (MIS)
Child survival and safe motherhood programme has several interventions as discussed
earlier. Many components of programme implementation like training, supplies,
equipment, communication etc. have to be coordinated at various levels of
management i.e. PHC/CHC, sub-district and district. Therefore, it is necessary to
establish a system which provides at every level the correct information in time which
will allow analysis of data. MIS for child survival and safe motherhood programme
includes the following components:
i)
Monthly Monitoring Reports - These are compiled from sub-centres to central
level. They include information on :
*
*
*
*
*
surveillance
performance
supplies
status of essential equipment and
untoward reactions.
The standard format of such a report is given in Annexure-III. Please go
through it carefully and discuss with your course facilitator for any
clarifications.
ii)
Evaluation of service coverage - It is an extended form of CES many of you
may have undertaken under UIP. It is discussed in detail in the module
"Evaluate Service Coverage".
iii)
Epidemic investigation - Standard formats for investigating cases of
poliomyelitis, neonatal tetanus and gastroentenities should be used by you.
These have been discussed in the module "Conduct disease surveillance".
Two records at village and sub-centre level are very important to ensure quality of
data generated at grassroot level. These are (i) mother and child protection card and
(ii) village register. You should ensure correctness of information in these vital
records. The formats of these records are given as Annexures I and II in this
module.
53
5.2
MATERIALS MANAGEMENT
It is absolutely essential that the supply of vaccines, drugs, cold chain equipment and
other supplies are provided in time in adequate quantities at each level of operation.
It is your responsibility to correctly calculate, procure, distribute and maintain these
supplies for your area. This component of systems support has been discussed in
detail in the module "Manage cold chain and other supplies". You should determine
needs and requirements in relation to following items:
54
a)
Vaccines : These depend on the number of pregnant women and children as
well as number of sessions to be conducted. Also you may need extra doses
of OPV to undertake ring immunization and pulse immunization in your area.
b)
Cold chain equipment : It is estimated that the cold storage capacity at
district level should be for roughly 30,()()() to 40.000 vials. A PHC would need
400 to 500 vials for a month. Cold boxes, vaccine carriers and day carriers
would be needed to carry vaccines to PHC and to sub centres/villages. Norms
for supply of equipment is given in the module "Manage Cold Chain and other
supplies".
c)
Drugs and other supplies : You will need sufficient stocks of vitamin A
solution, cotrimoxazole, ORS packets, I FA tablets inj./tab ergometrine,
contraceptives and IUDs. You can use a ready reckoner for these and other
supplies as given in the module "Manage’Cold Chain and other supplies"-;
5.3
TRAINING
It is obvious that unless the quality of services is very good, the objectives of child survival
and safe motherhood programme will not be achieved. To maintain a high quality of service
training for each category of health personnel involved in the programme delivery is
essential. You will organize and coordinate training activities at your level of programme
implementation as follows:
A.
Training of Medical Officers
o
senior state and district health functionaries, district public health nurse and
faculty members of medical colleges and HFWTCs will be trained at national
or regional level for 7 days.
o
all other Medical Officers within the district will be trained for 6 days at
divisional/district level in batches of 30. The course will cover 5 modules on :
Plan and Implement MCH services
Evaluate service coverage
Conduct disease surveillance
Manage cold chain and other supplies, and
Programme Interventions
o
B.
In addition the first batch of 30 which will include faculty members of
ANM/LHV training schools and BEE will be trained in using the "Health
Workers Manual" for training health workers.
Training of health supervisors and health workers
All health workers and their supervisors will undergo a 5 days skill oriented training
within your district at an ANM/LHV or a similar training school. Each batch would
be of 30 persons.
C.
Orientation of Village level non-health functionaries
Anganwadi workers, VHGs or other development functionaries in your district will
be oriented in home based and village based actions for two days at sub-centre level.
D.
Specialists skills training
In every district, first level referral institutions will be identified. Two specialists from
each of the disciplines - paediatrics, obstetrics and gynaecology, anaesthesia, blood
transfusion and laboratory services (thus a total of 10 specialists per institution) will
be given specialists skills training to handle complications.
55
READY RECKONER FOR ESTIMATING TRAINING REQUIREMENT AT
DIFFERENT LEVELS
Category of Personnel
Per SC - 5000 Popn.
Per PHC - 30,000 Per CHC/PHC - 100,000
Per Dist. 2000,000
Medical Officers
NIL
1-2
Special Skill Training
NIL
NIL
Health Worker
1
6
20
400
Village Level Functionary
2-3
20
75
1500
10
10 PER UNIT
210
40
Based on your estimation of training needs you can use the following workspace for
planning training.
WORKSPACE FOR PLANNING TRAINING
Category of Personnel
Training
Current No.
At PHC At Dist.
Medical Officers
Special Skill Training
56
No. can be trained No. of courses Suggested Material
per course
requi red
Dates
Required
30
NIL
Health Workers
Village Level Worker
No. needing
T raining
30
NIL
\
5.4
COMMUNICATION4
Effective communication will publicise child survival and safe motherhood programme
and its components and support health functionaries to promote a change in
behaviour based on new health knowledge.
To ensure community participation, it is essential that people should be informed
about the diseases and deaths occuring in young children and pregnant women which
can be controlled by encouraging families to take health action at home and utilize
health services when required.
Principles of communication strategy
The following principles of communication in UIP will be adapted in child survival
and safe motherhood programme:
♦
The central theme is protection. Therefore, you should always stress on the
protection offered by each of the interventions under Child Survival and Safe
Motherhood programme e.g. Vitamin A doses protect the child from
blindness, ORS protects from death due to dehydration etc.
*
Unified strategy - The concept of "shishu rakshak" (child protection) mela
should be dilated to incorporate all other activities to protect the health of
mothers and children.
*
Linking services with communication - At district level and below, you should
always try to shift the communication focus away from demand creation
towards action. Therefore, it is essential that all services are available to the
eligibles. You should ensure that fixed day schedules as discussed in work
routines earlier are being followed.
♦
Communication must facilitate an "enabling process" in the community. It
must encourage "self-help attitude" in solving health problems as much as they
can.
*
Communication must also highlight the "timely action", i.e. the right action at
the right time. Self-referral for expert care at the appropriate time must be
made very clear to the masses.
a
4 The best communication is an effective and continuous service delivery which satisfies
majority of the community.
57
*
Consistency of messages : An unclear message or too many messages may
confuse the mother. Therefore, you should ensure that village level
functionaries are able to impart accurate and consistent messages. You
should ensure that services of BEE at PHC/CHC level are adequately utilized
to upgrade the communication skills of health workers.
5.4.1 Objectives of communication
♦
Create continued awareness regarding immunization and the importance of
full immunization before the age of one year.
♦
Inform people about fixed day services including the time and place.
*
♦
*
*
♦
*
*
*
*
58
Encourage mothers to give plenty of home available fluids (HAF) and
continue feeding during episode of diarrhoea in children.
Increase knowledge and change practice of mothers regarding correct mixing
and administration of ORS and ensure ORS packets availability at village level
through ORS depots.
Reinforce mothers beliefs about dangers of pneumonia and encourage timely
action at home and ensure the practice of referring early to health worker.
Disseminate knowledge .of mothers regarding availability of first dose of
vitamin A with measles immunization and four subsequent doses of vitamin
A at six monthly intervals.
Communicate the importance of TT immunization for pregnant women and
the dangers of lack ot it to the newborn and mother.
Promote the five cleans during delivery vigorously [clean surface, clean hands,
clean razor blade, clean cord tie and clean cord stump (no applicant)].
Communicate that the pregnancy which is a happy event in a woman’s life
should not run into risk and hence the need for ante-natal care and referral,
when necessary.
Inform mothers about the importance of taking tablets of iron and folic acid
for 100 days, and the dangers of not taking it.
Educate, inform and motivate mothers, fathers and mothers-in-law about
importance of birth spacing for the sake of health of the mother and child.
Inform about availability of contraceptive services (village depot) and the
services for limiting births after 2 children.
*
Provide family life education to adolescent girls and boys for preparing them
for married life.
*
Educate the mothers about the importance of early (within 2 hours of birth)
and exclusive breast-feeding of babies.
*
Teach mothers on the art of home-level care of low birth weight babies,
especially keeping baby warm, frequent feeding, etc.
5.4.2
Prepare a District Plan for Communication
Inter-personal communication will be the key strategy for success of the
project. You will make all efforts to involve media for demand generation
and utilization of services. However, emphasis will be on total care. The
following principles will be adhered :
*
*
*
*
communication for action;
communication linked to service delivery;
the overall theme of "protection";
the same theme tune and logo in all communication material.
You will include the following themes in communication. You may do this by
preparing appropriate handbill messagesand wall-paintings which should be displayed
prominently for all to see and avail of services.
*
Care of pregnant women:
ensure early registration, check ups, tetanus
toxoid, iron and folic acid, early detection of
complications and referral.
*
Clean delivery:
ensure clean hands, clean surface, clean razor,
clean cord tie, and clean cord stump (no
applicant).
*
Immunization
ensure that the infant receives full immunisation
(3 doses of DPT, 3 doses of OPV, one dose of
BCG and measles)
*
Vitamin A
every child at 9 months of age should receive one
dose of Vitamin A ; and then, every six months
four times more till the age of three years - total
five doses
*
Diarrhoea
give more fluids; continue feeding.
If no
improvement, give ORS. Get ORS from a village
functionary or from other sources. If no
improvement, seek medical help.
59
*
*
Pneumonia
can be dangerous; if difficulty in breathing, or fast
breathing, see HW-F and Medical Officer
Birth timing, spacing
and limiting
no pregnancy before 20 years of age and
after 35 years; minimum 3 years interval
between births and not more than two children.
Every district will have various resources and varying needs for communication
efforts. The district team lead by CMO or DHO should prepare a plan for
communications in consultation with the district information officer and/or district
health education officer and media officials.
You will also take into account the following district or area specific factors before
deciding the correct "Media Mix" for your area:
*
*
*
*
*
Reach of media (TV, radio, newspapers, cinema) in the district. Assess what
percentage of population is regularly exposed to these media.
Literacy rates in rural areas of the district especially whileplanning print
messages.
Traditional or folk media are very useful in increasing the "reach" of your
communication in areas where TV, radio, print or cinema do not have adequate
coverage.
The availability of sites suitable for wall paintings and hoardings.
Exhibitions, fairs, religious broadcasts etc. need to be assessed for their potential
to propogatc messages.
You will make use of mothers’ meetings and village contact teams to organize the
communication events. Efforts will be made to popularise the mother-infant
immunization card and the fixed-day strategy.
The messages will be few, frequent, recurrent and right ones. You should also
prioritize messages according to the specific needs of your area. For example, if
coverage with 'IT is low and there arc many cases of neonatal tetanus then you
should give high priority to the messages of 5 cleans during delivery and TT
immunization during ante-natal period.
You will print handbills and circulate them widely. The handbills will essentially
promote the fixed day strategy and services and ensure that everyone in your
district knows where these services are organised and when. You should identify
the person(s) controlling or inflencing the media and orient them on child survival
and safe motherhood programme. You can take them to demonstrate programme
activities in an area where such activities are being done particularly well. Plan
news items, features etc. in consultation with media personnel. Motivate them at
regular intervals.
60
The communication package can also be channelized through non-health
government sector as well as non-governmental organizations (NGOs) at district
level and below.
5.4.3 Communication strategy at PHC level
All available channels of communication (radio, TV, field publicity, print, folk arts
etc.) are being used to promote essential messages on child survival and safe
motherhood programme. However, coverage through media (print, TV, radio,
cinema) is limited. Therefore you should focus and concentrate on INTER
PERSONAL communication using all credible communicators in the community.
Every person is converted into an effective communicator. They will talk about the
availability and regularity of services in their villages and in the sub-centres. Block
Extension Educator (BEE) would be the main person responsible at PHC level to
help you plan the strategy.
Family should be taken as the unit for communication package. Your communication
efforts should encourage families to take health action at home (e.g. during
pregnancy, delivery, an episode of pneumonia or diarrhoea) and utilize health
services when required. The evidence of an effective communication is the real
attitudinal changes that take place in the families.
Enumeration as a mobilization strategy
The annual enumeration activity and its quarterly updating is an important
mobilization strategy. It links perfectly the service with communication. Therefore,
you should ensure that during the "enumeration week" all village level workers along
with health workers make a team. While one or two of them are helping health
worker in identification and registration of eligibles, the rest should:
- promote home based care for diarrhoea, pneumonia and newborn care;
- promote early and appropriate referral of cases who need emergency care or
additional care;
- promote 5 CLEANS during delivery, immunization of all infants and pregnant
• •
4 « a w* a a •
v* a a %-•
- protection of all children with Vitamin A concentrate solutions; and
- essential ante-natal care to all pregnant women.
Other contact points for communications
Immunization sessions, MCH clinics, home visits and mothers’ meeting in an
Anganwadi centre should be utilized for promoting specific messages for child
survival and safe motherhood programme. Village market and festivals can also be
61
used effectively for demand generation and utilization of services.
Field publicity at village level
This can be achieved by wall writings and distribution of hand bills. Village
influencers e.g. panchayat members, religious leaders etc. should be specifically
contacted and motivated to support the programme.
5.4.4
Indicators on effectiveness of communication
The best indicator of success of your programme communication are the behavioural
changes and compliance by the family of various activities in your messages.
Following are some of the indicators:
i) % of eligibles issued Mother-Infant
Immunization card
% of cards retained
(Card holding rate)
No. of cards issued
=
Total no. of eligibles
No. of cards retained/brought to session
Total no. of cards issued
Dropout rates = Highest Covered Antigen Dose - Lowest Covered Antigen Dose
(HCAD)
(LCAD)
x 100
HCAD
ii) % of fully immunized under 5 children
iii) % of pregnant women registered and number of appropriate referrals.
iv) % of children with diarrhoea
- Given ORS
- Given HAF
- Given continued feeding
iv) % of children with pneumonia brought to health centre.
% of children with pneumonia treated by Cotrimoxazole
t
I
I
62
I
5.5
SOCIAL MOBILIZATION
The surest way of achieving the objectives of child survival and safe motherhood
programme is through fully protected hamlets, villages, panchayats, blocks, districts and
states. This is possible only with complete involvement of the government development
functionaries from health and non-health sectors as well as the non-government
organizations (NGOs). Following is a list of possible partners who can help in child
survival and safe motherhood programme. You can check how many of such allies are
functioning in your area. Ensure each one of them familiar with various components
of child survival and safe motherhood progrmame. The district magistrate should be
motivated by you to preside over these meetings and enlist co-operation of various
agencies.
5.5.1
List of sectors and NGOs
Inter-sectoral activity
o
o
o
o
o
o
o
o
Social Welfare (PO/CDPO/MS/AWW)
Rural Development (BDO & his staff/DWCRA/DRDA functionaries)
Urban Development (UBS/Municipal bodies
Education (Primary School Teachers/AE Project/NFE/Others specify)
Information & public relations (District public relation officer)
Public Health Engineering Department (Water Supply & Sanitation
Progam me)
Women’s groups
Any Others
Non-Governmental Organizations (NGOs)
o
o
o
o
o
o
o
o
Panchayats (Pramukh/Mukhiyas)
Youth associations (NSS/NCC/Nehru Yuva Kendra)
Professional associations (IM A/I AP/FOGSI/Trained
Association/Others)
Service clubs (Rotary/Lions/Others)
Employees associations
Women’s organizations
Field health and development activitists - local groups
Organized health missions e.g. CHAI, Ramakrishna Mission etc.
Nurses
Once you have identified all possible partners and allies you should try to focus
on the possible actions each of these can undertake for the programme. The
check list of possible activities which can be undertaken is given in the next page.
63
5.5.2
64
List of possible intersectoral activities
Sustain Immunization
Enumeration
Publicise fixed day and fixed place
Remind dropout
Promote complete immunization
Eradicate Polio
Identify and report cases
Promote immunization
Publicise fixed day and fixed place
Assist in outbreak response
Eliminate
Neonatal Tetanus
Identify and report neonatal deaths
Promote safe delivery practices with 5
CLEANS
Inform people about trained help
Measles Reduction
Promote 100% coverage, to all infants in
time
Manage Diarrhoea
Promote HAF and continued feeding
Stock and distribute ORS packets round
the clock (depot-holder)
Demonstrate preparation of ORS
Advise referral if signs of dehydration are
present
Promote safe drinking water
Promote personal hygiene and hand
washing
Manage Pneumonia
Home care of coughs and cold
Help mothers recognize pneumonia early
enough
Know the nearest source of cotrimoxazole
and refer accordingly
Prevent Vitamin A deficiency
Promote 5 doses of vitamin A at 6
monthly interval to every child between 9
months and 3 years.
Refer children with symptoms of vitamin
A deficiency to subcentre or PHC
Promote Vitamin A rich locally available
foods.
Prevent Anaemia
Distribute tablets of iron and folic acid to
all pregnant women for 100 days.
Refer pregnant women who are pale to
sub-centre or PHC
Promote iron-rich foods.
Promote Safe Motherhood
Mobilize people for various activities for
safe motherhood
Inform about nearest source of
contraceptives - the depot-holders in the
villages
Information on child spacing to all women
and limiting family size to 2-child norm
Promote immunization and ANC
registration
Refer pregnancies with complications to
the nearest referral centre
Facilitate timely transport to those with
complications
Advice on diet, rest and warning signs
Promote stock and distribute disposable
delivery kits
Produce disposable delivery kits in groups
Promote 5 cleans to be observed during
home deliveries
Promote institutional deliveries
Appropriate education for adolescent girls
Non-Governmental Organizations (NGOs)
You should enlist the active support of NGOs who meet one or more of the
following criteria:
Can they take the responsibility of sustained programme implementation in a
given geographic area.
Will they visit the community, identify the eligibles and follow up and motivate
drop outs.
Are they able to win over and work through opinion leaders.
Can they help arrange immunization sessions, emergency transport or waiting
maternity homes near first referral hospital.
You should clearly spell out the tasks assigned to the NGOs while making a plan
of action. All or some of the actions listed earlier under 5.5.2 can also be
performed by NGOs. However, some of the major roles of NGOs can be to:
65
o
o
o
o
o
5.53
promote messages of child survival and safe motherhood programme,
inform on births and deaths (especially neonatal and maternal deaths)
identify complicated pregnancies/labour and provide for emergency transport
activities related to immunization
distributing ORS, IFA, contraceptives
Plan of action for intersectoral activity at district Level
To effectively coordinate intersectoral activities following tasks should be
undertaken:
5.5.4
Constitute district child survival and safe motherhood co-ordination committee
with district magistrate as the Chairman and all partners/sectors nominating
representative of theirs as a member of the Committee.
o
Invite representatives of all partners (esp. the major partners i.e. ICDS, UBS,
Education and water and sanitation) during the workshop for district action
plan.
o
Form an intersectoral district task force for random field visits and feedback
to district committee.
o
Include child survival and safe motherhood review in developmental
programme review meeting.
o
Monitor intersectoral activity. Conduct joint field visits with district level
officers of ICDS, UBS, education etc.
Plan of action at block level/PHC
o
o
o
o
o
o
66
o
Constitute a block level committee
Work with other partners during preparation of block level plan of action. Ask
them to specifically agree to assist in any or all activities listed earlier.
Include child survival and safe motherhood review in block level meetings.
Plan joint field visits with CDPO and block development officers.
Encourage health workers and their supervisors to coordinate with other village
level functionaries and volunteers.
Strengthen and develop Mahila Swastha Sanghatan (MSS) or women’s groups
5.5.5
Items for review in the intersectoral committee
% of fully immunized infants
% of fully immunized mothers
% of villages/bastis in project area having ORS round the clock (depot holder)
% of villages having cotrimoxazole round the clock
% of cases in which birth weight recording by village level worker or health
worker is being done.
o % of deliveries conducted by untrained birth attendants
o % of delivery cases referred
o % of cases where support was received from referral institution
o % of villages in project area where health education sessions held involving
sectors/partners
o % of fixed day immunization sessions held as per schedule.
o
o
o
o
o
The above indicators may be used to rate the progress ot the programme and
specifically identify who would assist with various aspects to ensure better service
delivery, utilization and outcome.
67
DISTRICT PLAN OF ACTION
Name of the District:
PARTI
BACKGROUND INFORMATION
Demographic Profile
o
Population (1991 Census)
O
Growth Rate (annual)
Projected Population: 1992
1993
1994
1995
Age and sex structure
o
o
Rural
Urban
Male
Age Group
o
i
5
15
45
1
4
14
44
60
60
Female
Total
Years
II
II
II
II
Socio-economic Profile
o
o
Percentage of population below poverty line
Literacy rate - overall
female
Health Profile
o
o
o
10 Leading causes of mortality in less than 5 years (use hospital data)
10 Leading causes of morbidity in less than 5 years (use OPD data)
5 Leading causes of maternal mortality (use hospital data)
Coverage Rates 1991-92
Reported % coverage
Parameters
DPT3
0PV3
BCG
Measles
TT (2 doses)
Vitamin A Prophylaxis
Ante-natal care
Delivery attended by trained personnel
ORS use rate (if available)
couple protection rate
68
■
C E S
District Resource Inventory
o Health facilities
Rural
- Sub-centre
- PHC
- CHC
- Others
Urban - FWC
- PPG
- Hospitals
- Others
o List of Hospitals within the district or closest to the district to serve as referral
institution :
a) Newborn care (<2000 g birth weight)
b) Diarrhoea with severe dehydration
c) Pneumonia
d) Severely anaemic pregnant women
e) Pregnant women with bleeding/obstructed labour
f) Pregnant women with toxemia
g) Pregnant women/post-natal women with fever
69
•I
' !
o
Manpower
- Medical Officer
- District Public Health Nurse
- Block Extension Educator
- Health Supervisor (male)
- Health Supervisor (female)
- Health Worker (male) ’ ■
- Health Worker (female) '
o
Departments identified for social mobilization/collaboration
!
O
Non-governmental organizations identified for intersectoral activity
I
PART II
A. District’s year-wise goals and objectives for Child Survival and Safe Motherhood
Programme
YEAR.
Current Level
toverage Goals
i
i
I
B. Programme interventions
o
Sustain immunization
r
o
Neo-natal tetanus elimination
o
Polio eradication
70
Disease & death reduction objectives
o
Vitamin A prophylaxis
o
Pneumonia therapy
o
Control of diarrhoeal diseases
o
Essential care of all pregnant women including clean delivery (5 cleans)
o
Early identification of complications and referral
o
Emergency care to those with complications
o
Birth timing, spacing and limiting.
C. Operational strategy
Summary of plan of action of each rural/urban unit
Name of
Uni t
Immun. Session
Popu Enumerated No. of viIlages scheduled per month Home visits scheduled
lation eIi g i bIes with hamlets
Outreach
Fixed
per month
Remarks
RURAL
URBAN
TOTAL
List planned campaigns/intensive drives (if any)
71
SYSTEMS SUPPORT
MIS AND FEEDBACK (mention here the dates of review meetings at PHC and district levels)
MATERIAL MANAGEMENT
Quantity
Estimated Requirement
L
0
Detai Is of obtaining
Details of distribution
Cold Chain Equipment
- ILR
- Freezer
- Vaccine Carriers
o Vaccines
- DPT
- OPV
- BCG
- Measles
- TT
o Drugs/SC Kits
o
Other supplies
TRAINING PLANS
WORKSHEET FOR PLANNING TRAINING
Category of Personnel
Training
Current No.
At PHC At Di st.
No. Needing
Training
Medical Officers
Special Skill Training
30
NIL
30
Health Workers
Village Based Worker
NIL
SUPERVISION
Details of fixed routine field supervision of
District Officers
Medical Officers - PHC/CHC wise
Health Supervisors
Checklist for supervision
72
No. That can be
No. of Courses Suggested Materials
Requi red
trained per course
requi red
Dates
COMMUNICATION STRATEGY
Media mix decided
i) Inter-personal methods
ii) Hand-bills / Wall-paintings / Hoardings
iii) Cinema slides
iv) Village talks, Mothers’ meetings
v) Others
f
Priority messages
Activities
SOCIAL MOBILIZATION
Details of district child survival and safe motherhood committee
Details of intersectoral activity
Details of non-governmental organizations support
73
REMEMBER THIS ABOUT PLAN MCH SESSIONS
♦
*
List activities to be undertaken for implementing the programme from village level to the level
of your responsibility.
*
Fixed centres, outreach operations, campaigns/intensive drives and home visits are the main
strategies of operation.
♦
Schedule fixed day immunization session at fixed as well as outreach centres in such a way that
approximately 30 sessions are held in 30,000 population per month. Generally, you will schedule
4 to 6 sessions in a subcentre area.
*
Plan fixed monthly work routine of health workers having 4-6 immunization sessions and 6 home
visit days per month.
*
During home visits priority houses should be visited by health worker (female) and she should
be supported adequately during her work by village level workers (VHG, TBA and AWW).
*
Supervise implementation of the programme at recommended frequency using the supervisory
checklist. Identify and solve the performance problems during your supervisory visits.
*
Mother and child register and mother and infant immunization cards are main records to
generate data at village level. Ensure that these are properly maintained and review monthly
monitoring report for local action.
♦
*
74
Estimate the number of each category of eligibles according to the proportions of that category
in general population. Compare with enumerated eligibles.
Make a communication plan in consultation with BEE. Use every contact including
enumeration for interpersonal communication. Ensure accuracy and consistency of messages.
Mobilize support of other government departments especially ICDS, UBS and DWCRA. Make
joint field visits, constitute coordination committees and review intersectoral activity. Mobilize
NGOs service clubs, youth associations for specific activities support.
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INSTRUCTIONS FOR FILLING UP SUB-CENTRE MOTHER AND CHILD CARE
RECORD
1. Th:s register has been developed for you to record all MCH activities of the sub-centre „
area.
2. Separaters are provided to separate the records of each village.
3. On the separaters fill in the details of the village.
4. Binding of the register is such that it will help you to insert extra leaves whenever
required.
5. On the top of every page enter the year. For example enter 1992-93 for cases to be
registered during 1st April 1992 to 31st March 1993.
6. Col.2
During the field visit you should identify all pregnant women and register them in this
column after giving a Serial No.
7. The same Serial No. should also be entered in the MCH Card. Please remember to
indicate the year of registration in the card for example a case listed at S.No.2 in 1992-93
should be written on the card as 2/92-93.
8. Col.5
The number of pregnancies the woman had including the present one should be entered.
9. Col. 10, 14 & 18
While examining the pregnant women look for certain danger signs which may require
your personal continuous supervision and/or referral. These danger signs are:♦
Anaemia
B.P. above 140 mm Hg.
* Abnormal weight gain (>5 kg/month)
♦
First pregnancy with age less than 20 and more than 30 years
♦
More than 4 pregnancies
* Bleeding during pregnancy (APH)
♦
Ceasarian operation during previous pregnancy
* Abnormal/lack of movements
Convulsion
Please enter appropriate code from the above list.
♦
77
Col, 19
10
Please choose the appropriate code from the following:
*
*
*
At home
At sub-centre
Other institution including private hospitals
Col. 20
11.
Please enter appropriate code from the following on the basis of delivery conducted by:
♦
*
Doctor
ANM/LHV/Nur>e
Trained Dai
Untrained Dai and/or others (relations etc)
Col. 12
. 12.
Choose the appropriate code from the following and enter in this column.
*
*
*
*
13.
Mother and child healthy
Mother died
Child died
Dead child born
Col. 23
Please enter:
*
*
*
♦
You are aware that the primary vaccination i.e. one dose of BCG, three doses of DPT
and OPV each, one dose of measles and the first dose of Vitamin A should be given
before the completion of the first year of the child. Hence at Col.36 fill in the code as:
14.
78
If the child was healthy upto 7 days;
If the child was healthy upto 28 days;
If the child dies within 7 days, and
If it dies after 7 days but before 28 days
*
if primary immunization was completed before the first year of the child;
*
if primary immunization was not completed before the first year of the child.
MOTHER AND CHILD CARE RECORD
MOTHER S RECORD
No.
Name cf
pregnant
Age
1
woman
2 ”
0
SI.
\C
Husband’
Order
Expected
name 4
Date of
delivery
TT-1
date
IFA
Wl
Danger
TT-2/B
IFA
Wt
Address
of
pregnane
Qty
Kg.
Code *
Date
Qty.
4
3
6
7
8
9
10
11
12
I
ANC-1
ANC-2
ANC-3
Data
Kg
Danger
Code •
13
14
15
Place
Delivery
Delivery
IFA
Wl
Danger
of
attended
outcome
Qty.
Kg
Code *
delivery
by
18
17
18
19
20
21
oc
MOTILER AND CHILD CARE RECORD
REGISTRATION YEAR 199
CHILD S RECORD
V^eicht
nt
birth
Child wnj
healthy upto
22
23
7 or 26 days
Nome
of the
child
24
Date
Sex
of
Birth
25
28
Date
of
BCG
27
Dates of OPV Doses
1st
28
2nd
29
3rd
30
Dates of DPT Doses
1st
2nd
31
32
3rd
Date of
Measles
Date of
VH. A
1st dose
33
dose
34
Immun. *
Status
1st year
35
36
Date of
Dote of
OPV-B
dose
37
DRT-B
dose
2nd dose
38
39
Dates of Vit. A doses
3rd dose 4th dose
40
41
Sth dose
42
■J
MONTHLY PHC REPORT
Reporting Date:
P.H.C.
District
State
Month
Year
II) Pregnant Women
Yearly Target I) Infants
b) Actually Held
Number of Sessions a) Planned
A. SURVEILLANCE
Number Reported
Disease
For the Month
Cases
Deaths
Commutative Since April
Cases
Deaths
Diphtheria
Pertussis
Neonatal Tetanus
Tetanus (others)
Poliomyelitis (Acute)
Measles
Under
five
years
Tuberculosis
Pneumonia
Acute Diarrhoea
Dysentry
Maternal Deaths (Repoorted) : Before Delivery
During Delivery
Within 6 weeks of delivery
B. PERFORMANCE
Dose No.of Beneficiaries Cunrnulative since April
1
2
B
T T
PREGNANT
WOMEN
I FA
TABLETS
BCG
1
0 P V
1
2
3
DPT
1
2
3
MEASLES
Vitamin A
OPV Booster
DPT Booster
i
i
i
i
CHILDREN
Vi tarnin A
Initiated Completed Initiated
Completed
Under lYr Under 1Yr Under 1 Yr
Under 1 Yr
(Prophylactic)
(Theraputic)
1
2
3
4
5
81
C H 1 L D R EN
DT (5 Years)
1
2
B
TT (10 Years)
i
B
TT (16 Years)
1
2
ANTE-NATAL CARE
During the month
Cases
Cunrnulat i ve since April
Registered
Institutional Deliveries
Complicated Cases referred
Domi ci 11iary
deliveries conducted
by
Condition of newborn
at birth
HW(F)/LHV
Trained Dais
Others
Weight below 2,000 gm.
Weight 2,000-2,500 gm.
Wei ght 2,500 and above
Wei ght not taken
Still born
'Abort i on
C. SUPPLY POSITION
Opening
Balance
Vaccine/Drugs
DPT
OPV
BCG
MEASLES
TT
DT
Syringes 2 ml
Syringes 1 ml
Needles 20 G
Needles 23 G
Needles 26 G
Immunization Cards
I
Received during Consumed during Balance at the
end of month
the month
the month
_______ _______ ______
D. STATUS OF EQUIPMENT (inlcuidng deep freezers, ILRs, voltage stabilizers, vaccine carriers, cold
boxes, weighing machines, BP instruments, vehicles etc.)
Equipment/
Make
Mach i ne
Number
Whether
working
If not, date
of breakdown
Date of
Intimation
Remarks*
Please mention in this column:
a)
If machine is beyond repair
b) If the machine has been attended to by the mechanic within a week of breakdown.
*
E. UNTOWARD REACTIONS
1.
2.
3.
Reported deaths associated with immunization
Number of absessess
Other complications
Date:
Signature of Medical Officer
To:
The District M.C.H. Officer
82
MONTHLY DISTRICT REPORT
Reporting Date:
No. o* PHCs
■ District
State
Month
Yearly Target I) Infants
11) Pregnant Women
Number of Sessions a) Planned
b) Actually Held
A.
Year
SURVEILLANCE
Number Reported
Disease
For the Month
Cases
Deaths
Cummulative Since April
Cases
Deaths
Diphtheria
Pertussis
Neonatal Tetanus
Tetanus (others)
Poliomyelitis (Acute)
Measles
Under
five
years
Tuberculosis
Pneumonia
Acute Diarrhoea
Dysentry
Maternal Deaths (Repoorted) : Before Delivery
During Delivery
Within 6 weeks of delivery
B. PERFORMANCE
Dose No.of Beneficiaries Cummulative since April
1
2
B
T T
PREGNANT
WOMEN
I FA
TABLETS
Initiated Completed Initiated
Completed
Under 1Yr Under 1Yr Under 1 Yr
Under 1 Yr
(Prophylactic)
(Theraputic)
BCG
1
0 P V
1
2
3
DPT
1
2
3
MEASLES
Vitamin A
OPV Booster
DPT Booster
1
1
1
1
CHILDREN
Vitamin A
DT (5 Years)
I1
2
B
83
C H I L D R EN
TT (10 Years)
1
B
TT (16 Years)
1
2
ANTE-NATAL CARE
During the month
Cases
Cummulative since April
Registered
Institutional Deliveries
Complicated Cases referred
Domi cilliary
deliveries conducted
by
Condition of newborn
at birth
HW(F)/LHV
Trained Dais
Others
Weight below 2,000 gm.
Weight 2,000-2,500 gm.
Weight 2,500 and above
Weight not taken
Still born
Abortion
C. SUPPLY POSITION
Vaccine/Drugs
Opening
Balance
Received during Consumed during Balance at the
the month
end of month
the month
DPT
OPV
BCG
MEASLES
TT
DT
Syringes 2 ml
Syringes 1 ml
Needles 20 G
Needles 23 G
Needles 26 G
Immunization Cards
D. STATUS OF COLD CHAIN EQUIPMENT
Equipment
ILR/DEEP FREEZER
Total
Suppli ed
Total not
working
No. attended to No. not working for No.Beyond
more than 1 month* Repair
within 1 week
ILR 300 Litre
Deep freezer 300 Litre
ILR 140 litre
Deep freezer 140 litre
*
Excluding those beyond repair.
*
Please attach details of beyond repair equipment as:
Location
Machine No.
Date of installation
UNTOUARD REACTIONS
E.
1.
2.
3.
Reported deaths associated with immunization
Number of absessess
Other complications
Date:
District MCH Officer
To:
1.
2.
84
Monitoring and Evaluation Unit
Child Survival & Safe Motherhood Programme Division
Ministry of Health & Family Welfare, Nirman Bhavan, New Delhi - 110 Oil.
State MCH Officer
Out of order since
ANNEXURE-IV
DELIVERY KIT FOR HEALTH WORKER
I tai description
S.No.
Qty.
1.
Aneroid Sphygmomanometer
1 each
2.
Color coded Weighing Scale (Baby)
3 each
3.
Instrument SteriIizer SS 222 y 22 x 41 mm
1 each
4.
Spring Type Dressing Forceps - Stainless Steel (150 mm)
1 each
5.
Kidney Basin - Stainless Steel (825 ml/280 oz)
1 each
6.
Sponge bowl - Stainless Steel (600 ml)
2 each
7.
Uretheral Catheter (12 Fr) rubber
1 each
8.
Clear vinyl plastic sheeting (910 mm wide)
2 each
9.
Enema can with tubing
1 each
10.
Clinical oral thermometer (Dual Celsius/Fahrenheit Scale)
leach
11.
Clinical rectal thermometer (Dual Celsius/Fahrenheit SCale)
1 each
12.
Surgeon's hand brush with while nylon bristles
1 each
13.
Mucus Extractor
1 each
14.
Artery Forceps
2 each
15.
Cord-cutting scissor
1 each
16.
Cord ties/rubber band
1 packet
17.
Hail Clipper
1 packet
18.
Foetoscope
(Stethoscope Foetal)
1 packet
85
NATIONAL IMMUNIZATION MISSION
Time table of scheduled immunization session
Village
Date of
Session
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Scheduled
Actual
Scheduled
Actual
Scheduled
Actual
Scheduled
Actual
Scheduled
Actual
Scheduled
Actual
FOR DISPLAY AT SUB-CENTRE
ALWAYS USE ONE NEEDLE, ONE SYRINGE FOR ONE CHILD
*
86
Nov
Dec
Education is empowerement. Every girl and boy must be helped to
complete at least primary education in school. This will facilitate
attainment of good health. In this endeavour all of us can contribute and
make a difference.
You can :
* ask every family you meet during your health work, whether their
children are in primary school;
♦ persuade them to send all their children including girls, to attend and
complete primary school, if they are not in school;
* identify the primary school teachers of the villages covered by you;
* facilitate communication between the family and the school teacher
whenever possible;
* encourage all functionaries working with you to actively promote
school attendance and completion of primary school; ask them
regularly, what they have done;
* include a panel/discussion on primary education whenever you
organize a health exhibition/camp.
- Media
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