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OPERATIONALISING HEALTH & FAMILY WELFARE

A MANAGEMENT PLAN
ORISSA

ODA

GOO

£

/

DEPARTMENT OF HEALTH & FAMILY WELFARE
GOVERNMENT OF ORISSA
JANUARY 1993

■»

1

CONTENTS

PAGE

CHAPTER 1

NATIONAL HEALTH POLICY PRINCIPLES
AND PRIORITIES

1

CHAPTER 2

HEALTH STATUS IN ORISSA

5

CHAPTER 3

STATE HEALTH PRIORITIES

18

CHAPTER 4

STATE HEALTH STRATEGY & ACTION
PROGRAMMES

21

CHAPTER 5

HUMAN RESOURCE DEVELOPMENT

32

CHAPTER 6

DISTRICT HEALTH MANAGEMENT

62

ANNEX

I

DRAFT

WORKPLAN OF MULTIPURPOSE
HEALTH WORKER (F)

II

DRAFT

ACTIVITIES OF HEALTH
SUPERVISOR (F)

III

DRAFT

ACTIVITIES OF HEALTH
SUPERVISOR (M)

IV

DRAFT

ACTIVITIES OF BLOCK EXTENSION
EDUCATOR

V

DRAFT

ACTIVITIES OF MEDICAL OFFICER

i A

1
CHAPTER
1.

I

NATIONAL HEALTH POLICY PRINCIPLES AND PRIORITIES
One of the most important land marks in the development of
Health Services was the adoption of the National Health Policy
by the Parliament of India in December 1983. The National
Health policy has made the follow profound pronouncement which
is directing and guiding the process of Health Services
Development in India.

India is committed to attaining the goal of "Health for all by
the year 2000 AD." through the universal provision of
comprehensive primary health care services. The attainment of
this goal requires a thorough overhaul of the existing
approaches to the education and training of medical and health
personnel and the reorganisation of the health services
infrastructure. The National Health Policy gives priority to:
1.1

POPULATION STABILISATION

Irrespective of the changes, no matter how fundamental, that
may be brought about in the over-all approach to health care
and the restructuring of the health services, not much headway
is likely to be achieved in improving the health status of the
people unless success is achieved in securing the small family
norm, through voluntary efforts, and moving towards the goal
of population stabilisation.

1.2. HEALTH MANPOWER-EDUCATION-TRAINING AND DEVELOPMENT
It is also necessary to appreciate that the effective delivery
of health care services would depend very largely on the
nature of education, training and appropriate orientation
towards community health of all categories of medical and
health personnel and their capacity to function as an
integrated team, each of its members performing given tasks
within a coordinated action programme. It is, therefore, of
crucial importance that the entire basis and approach towards
medical and health education, at all levels, is reviewed in
terms of national needs and priorities and the curricular and
training programmes restructured to produce personnel of
various
grades
of
skills
and
competence,
who
are
professionally eguipped and socially motivated to effectively
deal
with
day-to-day
problems,
within
the
existing
constraints.

2

1.3. PRACTITIONERS OF INDIGENOUS AND OTHER SYSTEMS OF MEDICINE AND
THEIR ROLE IN HEALTH CARE
The country has a large stock of health manpower comprising of
private

' ‘ practitioners in various systems, for example,
Ayurveda,
Unani,
Sidha,
Homeopathy,
Yoga,
Naturopathy,
etc.

This resources has not so been adequately utilised. The
practitioners of these various systems enjoy high local
acceptance and respect and consequently exert considerable
influence on health beliefs and practices. It is,therefore,
necessary to initiate organised measures to enable each of
these various systems of medicine and health care to develop
in accordance with its genius. Simultaneously, planned efforts
should be made
to
dovetail
the
functioning of
the
practitioners of these various systems and integrate their
services, at the appropriate levels, within specified areas of
responsibility and functioning, in the over-all health care
delivery system, specially in regard to the preventive,
promotive and public health objectives.
1.4. ENVIRONMENTAL PROTECTION

While preventive, promotive, public health services are
established and the curative services re-organised to prevent,
control and treat diseases, it would be equally necessary to
ensure against the haphazard exploitation of resources which
cause ecological disturbances leading to fresh health hazards.
It is, therefore necessary that economic development plans, in
the various sectors, are devised in adequate consultation with
the Central and the state health authorities.
1.5. MATERNAL AND CHILD HEALTH SERVICES
A vicious relationship exists between high birth rates and
high infant mortality, contributing to the desire for more
children. The highest priority would, therefore, require to be
devoted to efforts at launching special programmes for the
improvement of maternal and child health, with a special focus
on the less privileged sections of society. Such programmes
would require to be decentralised to the maximum possible
extent, their delivery being at the primary level, nearest to
the doorsteps of the beneficiaries. While efforts should
continue at providing refresher training and orientation to
the traditional birth attendants, schemes and programmes
should be launched to ensure that progressively all deliveries
are conducted by competently trained persons so that
complicated cases receive timely and expert attention, within
a comprehensive programme providing antenatal, intranatal and
post-natal care.

f

3

1.6. HEALTH EDUCATION / IEC
The Health Programmes would bear only marginal results unless
a
nation-wide
health
education
programme,
backed
by
appropriate communication strategies is launched to provide
health information in easily understandable form, and to
motivate the development of an attitude for healthy living.
The public health education programmes should be supplemented
by health, nutrition and population education programmes in
all
educational
institutions,
at
various
levels.
Simultaneously, efforts would be reguired to promote universal
education, specially adult and family education, without which
the various efforts to organise preventive and promotive
health activities, family planning and improved maternal and
child health can not bear fruit.

1.7. MANAGEMENT INFORMATION SYSTEM
Appropriate decision making and programme planning in the
health and related fields is not possible without establishing
an effective health information system.
A nation-wide
organisational setup should be established to procure
essential health information. Such information is required not
only for assisting in planning and decision making but to also
provide timely warnings about emerging health problems and for
reviewing, monitoring and evaluating the various on-going
health programmes. The building up of a well conceived health
information system is also necessary for assessing medical and
health manpower requirements and taking timely decisions, on
a continuing basis, regarding the manpower requirements in the
future.

4

1.8. MEDICAL AND HEALTH SERVICES RESEARCH

Priority attention would require to be devoted to the
resolution of problems relating to the containment and
eradication of the existing, widely prevalent diseases as well
as to deal with emerging health problems. The basic objective
of health research and the ultimate test of its utility would
involve the translation of available know-how into simple,
low-cost, easily applicable appropriate technologies, devices
and interventions suiting local conditions, thus placing the
latest technological achievements within the reach of health
personnel, and to the front line health workers, in the
remotest corners of the country. Therefore, besides devotion
to basic, fundamental research, high priority should be
accorded to applied, operational research including action
research for continuously improving the cost effective
delivery of health services.

1.9. INTERSECTORAL COORDINATION
All health and human development must ultimately constitute an
integral component of the overall socio-economic developmental
process in the country. It is thus of vital importance to
ensure effective coordination between the health and its more
intimately related sectors. It is, therefore, necessary to set
up standing mechanisms, at the Centre and in the States, for
securing intersectoral coordination of the various efforts in
the fields of health and family planning, medical education
and research, drugs and pharmaceutical, agriculture and food,
water supply and drainage, housing, education and social
welfare and rural development.

5

CHAPTER-2

2.

HEALTH STATUS IN ORISSA

2.1. Health Status in Orissa

2:1.1

General

Orissa is one of the 25 States of the Indian union, on the
east coast between latitude 17.5° and 22.5° North
and between 81.5° and 88° East in longitude. It shares
boundaries with four States, Madhya Pradesh on the
West, Bihar on the north, West Bengal on the north east and
Andhra Pradesh on the south east. The Bay of Bengal forms
the eastern boundary.
Orissa has 17 revenue districts, 58 Sub-divisions, 314
developmental blocks and 4928 grampanchayats and 50972
villages. A classification is made on the districts based on
the problems.
Category I
Balasore, Cuttack, Puri and Sambalpur - more
districts and share 46% of the total population.

developed

Category II

Gajapathy,
Ganjam,
Gajapathy,
Keonjhar,
Mayurbhanj,
Dhenkanal
and
Mayurbhanj,
Sundargarh. 30-40 % of the popultion of these districts live
in difficult areas, These districts share 31 % of the total
state population.
Category III
Phulbani, Kalahandi, Koraput, Malkangiri, Raygada, Navrangpur
and Bolangir
highest proportion of Scheduled tribes and
shares 23% of the total population.
population, These are the least
developed districts.
About 40% of the total geographical area of the state is
hilly, inaccessible and poorly connected with any means of
communication - railways, roads and others. The Schedule Caste
and Tribes constitute more than one third of the population.
About 42.8% of the population live below the poverty line.

6

Demographic Data - (1991 Census)

Total Population

31,

512, 070

Males

15, 979 ,

904 (50.7%)

Females

15,

166 (49.3%)

Sex Ratio
(Females/1000 Males)

972

Absolute increase in
Population (1981-91)

51 , 417 ,

Decadal Growth Rate
(percent 1981-91)

19.50

Density (Persons/Sq.Km)

202

532 ,

99

Literacy Rate (%) 7 Plus -

Total
Males
Females

48.55
62.37
3 4.40

2:1.2 Population

Crude Birth Rate

30.0 (SRS 1990)

Crude Death Rate

11.7 (SRS 1990)

Infant Mortality Rate

122

(

ii

ii

)

Total Fertility Rate

3.6

(

ii

ii

)

Total Marital Fertility

5.1

(

ii

ii

)

Mean Age at Marriage

Male

24.17 (1981- Year book Family
Welfare 1989-90)

Female

19.04

n

n

Eligible Couples /
1000 Population

165.7 (1981 - IPDS Dept, of
FW, GOI, 1987)

Couple Protection Rate

40.2% (GOI Bulletin 1992 March)

7

The major problem is the static birth rate. The decadel growth
rate 19.50 is lower than the national average of 23.50. But
the average family size ranges from 2 + 3 to 2+4. Population
explosion is a threat to Orissa with the present high IMR.

2:1.3
a)

Child Survival and Safe Motherhood
Child Survival

Infant Mortality Rate

122/1000 Live births (SRS
1990)
The following figures indicate proportion of infant
deaths as per UNICEF report
Low Birth Weight (LBW)

35 % (Source_JJNICEF CSSM
Plan
of
Action
for
Orissa)

Tetanus

06 %

Measles

11 %

Acute Respiratory
Infection (ARI)

15 %

Acute Diarrhoeal
Diseases (ADD)

28 %

It is estimated that around 115,334 infants die every
year in the state, 316 infants every day and 13 infants
every hour.

b)

Safe Motherhood

No reliable data are available for maternal mortality
rate. Nearly 81.3 % of the deliveries are home deliveries
and
are
attended
by
untrained
birth
attendants
(source_SRS 1989).

Maternal mortality rate in India is estimated at 400500/100,000 live births. Based on this data, it is
estimated that nearly 11,200 mothers die due to child
birth in this State every year, and 30 mothers die every
day.

8

The major causes of maternal deaths are

Bleeding

22 %

Anaemia

20 %

Peripheral Sepsis - 12 %

Toxaemia

12 %

Abortion's

Obstructed Labour

10 %

12 %

Source : UNICEF
2:1.4.

Plan of Action for Orissa.

Malaria
Orissa contributes 14 % of the total malaria incidence,
33 % of Falciparum infection, and 48 % of deaths due to
malaria in India. Malaria is a serious public health
problem, especially in the tribal belts.

2:1.5

Acute Diarrhoeal Diseases
ADD is highly prevalent in the Coastal districts i.e,
Balasore, Cuttack, Puri and Gan jam, as well as in
Koraput. The case fatality is around 16-17 % (as per the
survey done by NICD in Koraput epidemic).

9

2:1.6

A Comparison is made for Orissa to the indicators to be
achieved by 2000 A.D.

SL.
NO

INDICATORS IDENTIFIED
FOR UFA 2000 AD.

TO BE
ACHIEVED/
2000 AD
(NATIONAL
LEVEL)

1.

Infant Mortality Rate

60

2.

Crude Death Rate

9.9

11.7

3.

Mortality (1-5 Yrs.)

10.0

N.A

4.

Maternal Mortality Rate

2.0

5. 5

5. .

Life Expectancy at Birth (Yrs.)
Male
Female

FIGURES
IN
ORISSA

122

64
64

57.7
56.6

10

38-40

6.

Low Birth Weight (LBW)

7.

Crude Birth Rate

21

30

8.

Effective Couple Protection
(%age)

60

41.3

9.

Net Reproduction Rate

1.00

N.A

10 .

Growth Rate (Annual)

1.2 0

1.95

11.

Family Size

2.30

5.14

12 .

Antenatal Care to Pregnant
Mothers (%)

100

13 .

Deliveries by Trained Birth
attendants (%)

100

23.9

14 .

Immunisation (%)
Infants :
BCG
DPT
OPV
Measles
Tetanus Toxoid
Mothers
10 Yrs
16 Yrs

85
85
85
85

N.A

%age

100
100
100

15 .

Leprosy-% of assisted cases out
of those detected

80

4.59 %
(PR)

16 .

TB-% of assisted cases
out of those detected

80

2.39 %
(PR)

17 .

Blindness

Incidence %

* N.A

NOT AVAILABLE

P R

PROVISIONAL

■k

0.3

N.A

10

2 . DEPARTMENT 01'' HEALTH & FAMILY WELFARE - ORGANISATIONAL STRUCTURE

CHART

FLOW

MINISTER

I

COMMISSIONER & SECRETARY

3

ADP

HAL

RH

FW

MED

DY DIR(IEC)

DY DIR(DEMO)

DY DIR(NUR)

SECRETARY

MEDICAL
COLLEGES

JOINT
DIRECTOR

JOINT
DIRECTOR

ADDITIONAL

DIRECTOR
MEDICAL
EDUCATION
& TRG.

DIRECTOR
HEALTH
SERVICES

DIRECTOR
FAMILY
WELFARE

ADDL.SECY
& PROJECT
DIRECTOR

I

PLAN

IB & LEP

DY DIR(MCH)

PH

OPI.

DY Dlki^

/

C D M 0

ADDL. COMO

DTD

DLO

MO (CHC)

I
ADMO(P)

DIP OFFICER

ME 10

PHCS

SDMO

II

ADMO(M)

ADMO(PH)

II

11

1.1

SECRETARIAT

Secretary heads the department, being assisted by Addl.
Secretaries, Joint Secretaries & Deputy Secretary. The
major functions of the secretariat are policy, planning
and finance.
1.2

DIRECTORATES

1.2:1

Director of Health Services
DHS is responsible for :
Preventive, promotive and curative
subdivisional and district level.

care

block,

at

Implementation of the National Health Programmes



Malaria Eradication Programme



Leprosy Eradication Programme



Programme for Control of Blindness



AIDS Control Programme



TB Control Programme

Collection and compilation of vital statistics

Planning

Co-ordination with ICDS

Enforcement of Prevention of Food Adulteration Act
Enforcement of Civil Registration Act

1.2:2

Director of Family Welfare
DFW is responsible for :

National Family Welfare Programme
Child Survival and Safe Motherhood Programme (DIP Plus)

Inservice Training Programmes
Health Education Activities

Collection
information

&

compilation

of

demographic

data

&

12
1.2:3

Director of Medical Education & Training
DMET is responsible for :
Medical Education
Nursing Education

Deputation to Incountry & Overseas Training

1.2:4

Director of Area Development Programme
Project Director of ADP provides support for the
strengthening the basic health care services in rural and
tribal areas. ADP functions as the major catalyst for the
overall development of health care service delivery
system in the State.

1.2:5

Externally assisted programmes

1.2:5.1

AREA DEVELOPMENT PROGRAMME

Ministry of Health & Family Welfare Govt, of India
developed a Model Plan for Area Development in health
sector with the following main objectives :
a)

Strengthening health and family welfare service
delivery system by integrating health and family welfare
services.

b)

Improving utilisation of existing facilities.

c)

Increasing the health and family welfare
infrastructure through extension of the health sub­
centre system.

d)

Improving the referral system from village and SHC
level through Primary Health Centre (PHC) sub-divisional
hospital to district hospital.

e)

Improving the quality and coverage of services by :



Strengthening health & family welfare management.



Improving professional skills of health care and family
welfare personnel.



Re-orienting the health and family welfare staff towards
community work and involvement.

f)

Creating demands within the community for health and
family welfare services.

f5

13

Creating responsibility within the community for its own
health needs and for mobilising local resources in
solving health problems.

g)

The Components of ADP includes :


Physical Infrastructure - construction, renovation,
watersupply, electricity, furniture equipment, vehicles.



Human Resource Development



Information, Education & Communication



Management Information System



Alternate approaches to health care delivery services



Community participation

In
Orissa,
the
British
Overseas
Development
Administration provides technical and financial support
to the development of ADP. ADP covers 11 out of 17
districts for strengthening physical infrastructure and
the whole state for HRD/IEC/MIS.
The external aid
investment, since inception, will total
totaJ about £ 32
million.

1.2:5.2 CHILD SURVIVAL SAFE MOTHERHOOD PROJECT
Jointly financed by IDA (WB), UNICEF and Govt. of India.

Major Objectives are
a) Child survival







Sustaining the universal immunization programme
Diarrhoeal diseases control and management
Control of acute respiratory infections
Prophylaxis against blindness due to Vit A deficiency
New born care
Breast feeding

b) Safe motherhood







/

Prophylaxis and control of nutritional anaemia
Birth spacing and timing
Strengthening and further development of community
based maternity care
Provision of support to First Referral institution and
strengthening essential obstetrics care capabilities
(E.O.C)
Safe delivery and safe delivery kits

I4

c)

Institutional system deve.1 ppment








Tra i ning
Work routines
Information, education and communication
Programme monitoring
Materials and supplies management
Health equipment maintenance
Community participation/ Mother's meetings

CSSMP is being implemented in phases in Orissa from 1992
onwards.
1.2:5. 3

Integrated child development services project (financed
by IBRD/IDA (World Bank)
Major components are :

a)

Service delivery

Covering pregnant women, nursing women, chi Idren 6-36
months, children 3-6 years of age etc. through Anganwadi
workers at villages.
b)

Work organisation, supervision, facilities, supplies
and equipment, therapeutic food supplementation,
health-nutrition co-ordination, nutritional
rehabilitation, pre-school education training,
communication, and community mobilisation are the other
important elements of the project.

ICDSP under WB funding will cover 191 blocks in Orissa.

1.2:5.4

DANISH INTERNATIONA!. DEVEI .OPMENT AGENCY_iDAN I DA)

In Orissa, DANIDA provides technical and financial
support to :♦


1.2:5.5

Multi drug treatment programme for Leprosy
Drinking water project
PROJECTS IN PIPELINE_UJWER_WORLD_BANK ASSISTANCE








National Programme for Control of Blindness (NPCB)
National Leprosy Eradication Programme (NLEP)
National Malaria Eradication Programme (NMEP)
National Tuberculosis Control Programme
Secondary Level Health Care Development
Social Safety Network Project

11>
1.2:5.6

UNICEF ASSISTED PROGRAMMES

Besides supporting the CSSM programme, UNK’EF i r: n I so
encouraging demand generation and mass health
educational activities. They are supporting a
and
revolving fund for grassroot
level
transport,
incentives to good performers (presently only to MPHW(F))
in the field of total immunization.

UNICEF is supporting a chemoprophylaxis programme f or
mothers and preschool children on Malaria in Keonjhar.
This will be extended to Bolangir and Suiidarga rh
districts.
1.2 : 7.7

CARE

Care is already involved in the state's nutri11 ona I
programme in
districts and training of AWWS i n
Dhenkanal. Their expertise in training of skills and
another
motivational aspects
is being extended to
district.
1.2:5.8

NEED FOR COORDINATED APPROAC’•
All the above mentioned programmes are only supplements
to the regular ongoing health and population programmes
in the State. The objectives, approaches and the target
groups are almost the same for all the programmes.

Therefore, it is very important to co-ordinate all these
projects and the future ones in such ways as the
beneficiary receives all the benefits and the provider
will be able to meet the demand and to provide qua I ity
care.

In order to reach the goals of UFA 2000 we I 1
This co-ordination becomes very cruela 1 .

i n t i me.

This is discussed further in the chapter on training, For
other aspects the State Govt, has proposed.

1.2:6

District
Chief District Medical Officer is overall in charge of
all health and family welfare activities at the district
level. He is assisted by Addl . CDMO who is directly
responsible for - Family Welfare, Child Survival & Safe
Motherhood programmes, Area Development Programmes, and
number of programme officers for individual national
programmes.

16
1.2:7

Health Manpower Availability
Primary Health Care

1.

Multipurpose Health Workers (F)

7004

2.

Multipurpose Health Workers (M)

4755

3.

Health Assistant (F)

1102

4.

Health Assistant (M)

176

5.

Pharmacist

1772

6.

Computer

314

7.

Block Extension Educator's

329

8.

* Staff Nurses (CHC/UGPHC)

2060

9.

Public Health Nurses

104

10 .

Medical Technician -

11.

Lab Technician
X-ray Technician

Medical officers (PHC/CHC) A/S TOTAL
* Source : Dept. of Family Welfare, GOO

114

2603

Secondary Health Care (SDH/District Hospital)

1.

General Doctor's

2.

Specialists

Medicine
Surgery
O&G
Paediatrics
Orthopaedics
Opthalmology
ENT
Cardiology
3.

Nurses

4.

Medical Technicians

Staff Nurses

TOTAL-3056

36/13=49
36/13=49
73/26=99
55/13=68
8/11=19
-/32=32
-/13=13
-/I =1
2133

• Laboratory Technicians
351
_______ * X-ray Technicians
* Staff Nurses : 2133 & Nursing Sisters 235.
★ Source :

(BM) & (D)

i \

L7

1.2:8

*

Availability of Health Facilities

a)

Sub Centres

5927

b)

Primary Health Centres

8 24

C)

Community Health Centres

1 52

d)

Sub Divisional Hospitals

37

e)

District Hospitals

14

f)

Teaching Institutions

3

Source Data :Surja Patnaik

18

CHAPTER
3.1

3

STATE HEALTH PRIORITIES

Government of Orissa identified 5 major health problems as
immediate priorities and all the intervention and support
programmes should address the five health priorities.
FIVE PRIORITIES

Population
Child Survival & Safe Motherhood
Diarrhoeal Diseases Control & Prevention of Deaths
Malaria Control & Prevention of Deaths
Special focus on reduction of incidence and prevalence of
Tuberculosis, Leprosy and AIDS.
3. 2.

BROAD STRATEGIES

Strengthening health promotion & social mobilisation (Demand
generation)
Strengthening physical infrastructure
Quality care & coverage
Strengthening training & manpower development
Strengthening the management information system
Encouraging innovative activities.
3.2.1

Health Promotion & Social Mobilisation

To create awareness and to motivate the community to generate
demand for preventive, curative and referral care services
available to them.

The proposal is indicated in Chapter - 4 .
3.2.2

Physical Infrastructure

The
infrastructure
necessary
for
Preventive & Curative services are :

providing

a) Sub-Centre (SC) at the village level
b) Primary Health Centre (PHC) at the sector level

c) Community Health Centre (CHC) at the block level
d) Logistics and Support

Promotive,

19

3.2.3

Development of system for Quality Care and Coverage for
services
The demand for basic health services proposed to be generated
has to be matched by providing quality care in the SC, PHC,
CMC and higher referral level institutions like the subdivisional, district, teaching hospitals.

One of the accepted ways on preventive quality care is through
Skill & Competence Development. This could be done through :
By organising on the job skill oriented training programmes.

• ' By planning the management information system appropriately
designed for each activity.
By ensuring uninterrupted
proper management.

supplies

and

resources

through

By integrating the basic health services with nutritional,
educational services & weaker sectoral programmes.

3.2.4

Quality care depends heavily on an effective management
information system (MIS). A separate chapter has been provided
for this.

Innovative Schemes

3.2.5

Simultaneous with the above programmes, a few specific
innovative activities are proposed to be developed in
collaboration with the agencies participating in the State
health activities.

3.2.5.1

Population Control
Social marketing of contraceptives
Community based distribution of contraceptives

3.2.5.2

Child Survival & Safe Motherhood

Social marketing of Oral Rehydration Salts (ORS)
Social marketing of Safe Delivery Kits (SDK)

Establishing a distribution centre in every village,
stocking ORS packets, contraceptives, vitamin 'A' tablets
and safe delivery kits.

! \

20

3.2.5.3

Malaria Control & Prevention of Deaths
Use of chloroquine as a prophylactic in all the endemic
areas of the state

Introduce the use of impregnated mosquito nets

Social
mobilisation
for
quick
examination and radical treatment

3.2.5.4

slide

collection,

Others Innovations

a) 'Using alternative sources of energy for sterilization of
medical equipments, for running cold storage equipments and
for providing potable water in brackish and saline belts.

b)

Encouragement to the NGO and the private sector to participate
in the above priority health programmes of the State including
provision of curative services.

c)

By initiating programmes to make the paying section of the
society contribute towards curative services.

d)

Administrative and financial innovation.

/ X

4

CHAPTER

STATE/ S_ 11EAI ,TII STRATEGY AND ACTION PROGRAMMES

4.1. Demand Generation
The proposed strategies identified in para 2.2 relating to
health programmes, social mobilisation and demand generation
is proposed to be achieved involving the voluntary sectors and
the sister departments of the State Government. At the village
level, the Mahila Swasthya Samiti (MSS) and the Youth Club
(YC) are proposed to be formed. At the district level all the
NGO's working in the field of health and family welfare are
proposed to be coordinated through another NGO and finally at
the State level, the district level NGO coordinators are
proposed to be guided by a State level NGO. Appropriate
linkages by the NGO with the district administration and the
state administration is proposed to be formed. The details are
indicated below.

IEC Motivation
Coordination
I
I
Demand Generation

zss
1

Service
Support
1
I
Skills
Logistics
Management

DTT/CDMO/ADDL. CDMO
DISTRICT

MO

MEIO

X/

BLOCK

MO

BEE

VILLAGE

HA
I

FLOW OF SERVICES

t

DEMAND GENERATION
SOCIAL MOBILISATION
EMPOWERMENT

\/
MPHW

MSS

i V

I

BENEFICIARY
ZoS
C MO
M^IO
BiuE

Mt'HW
t S

pT’r

ZILLA SWASTHYA SAMITI
CHIEF DISTRICT MEDICAL OFFICER
MASS EDUCATION INFORMATION OFFICER
BLOCK EXTENSION EDUCATOR
MEDICAL OFFICER
HEALTH ASSISTANT
MULTIPURPOSE HEALTH WORKER
MAHILA SWASTHYA SAMITI
DISTRICT 'I'RAIMTNG TEAM

22

4.2

The first battle ground in delivery of primary health care is
the Health Sub-Centre. Each HSC covers a population of 3000 5000, or 600 - 1000 households, 3-5 revenue villages, 3-5
TEAS, 3-5 Anganwadi Workers, 3-5 Primary school teachers.

I

Therefore, HSC is the first point for convergence of basic
services like education, health and nutrition.

2.

VILLAGE GROUPS
Otherwise called Mahila Swasthya Samiti (MSS) or Youth
clubs (YC). They will be encouraged to empower themselves with
all socially acceptable decision making and implementation.

3.

MAHILA SWASTHYA SAMITI

a) In each HSC village,
a MSS will be formed with
representatives from the local mothers selected in the ratio
of 1 per 10 households. The other informal and interface
functionares like traditional birth attendant and village
health guides will be the support members. (Responsibility
MPHW & HA)
b) MSS will be supported by a group of grassroot level workers
like :
♦ Multipurpose Health Workers
♦ Anganwadi workers
♦ Primary/Secondary School Teachers
♦ Other Departmental village staff like forest guards, home
guards
♦ Village N.G.O (VINGO)
♦ Practitioners of Indian system of medicines



c) MSS have already been formed and functioning in the following
districts under a GQI scheme (temporary)

DISTRICTS

NO OF MSS FUNCTIONING

Dhenkanal, Sambalpur,
599
Bolangir, Cuttack,
Balasore, Puri &
Ganjam______
* Source : Dept, of Family Welfare, GOO



In 93—94, the State's endeavour will be to extend this
programme to all the other districts and increase the numbers.

I \

23
PROGRAMME

d)

♦ The MSS will be encouraged to met on a fixed day every month
(First/Second/Third/Fourth Thursday of every month or the
First/Third Friday)
♦ The members will decide what are the village/community's
problems and what they would like to discuss with the health
staff. The health staff will provide such information but will
continuously guide the discussions towards preventive health
education, especially in the five priority areas. The health
workers will assist the MSS in all aspects of communications,
stressed on locally acceptable/modes/ways .
♦ MSS will be encouraged to organise mass awareness camps
' on prevention of dehydration due to diarrhoea (May, June,
July, Aug, Sept), prevention of malaria (pre and post
monsoon), on family planning, immunisation, nutrition.
the village
will
be
encouraged
to
be
the
♦ MSS
or
YC
Centre.
It
will
keep
ORS
ORS
packets,
It
will
Distribution
Contraceptives, Vit-A, Chloroquine, and Safe Delivery Kits.

These special quarterly drives are planned in such a way that
the awareness programme precedes the actions.

♦ MSS along with village NGOs (VINGO) will organise the periodic
disinfection of drinking water sources and to motivate
people to ensure environmental sanitation. In places where the
community demand is high for sanitary latrines, VINGO will be
provided with support through Govt, programmes.
♦ HA/ BEE will provide the technical support to MSS at village
level and the MO will provide the finance support either from
DFW or ADP.
e ) The MPHW (F) will be the facilitator of the MSS meeting.

f).

MONTHLY MEETING



IEC centre with the assistance of ADP, UNICEF, CARE will
develop appropriate materials Example : Photo folders, flip
books, slide tapes & videos. The themes & messages will cover
the 5 major health priorities of the State.



MSS will also take up special village contact drives to
coincide with every local festival where mass community
participation is expected.

24



IEC centre, in consultation with the ZSS will select the
best performing MSS and congratulate them in the Republic
Day celebration at the district and State level.
YOUTH CLUBS

g)

a) Similar action to involve the Youth clubs on the same day
will be initiated by the MPHW (M) and HA (M).

b) A major responsibility of the youth club will be to
identify persons and transport which can be used at short
notice to move elders, mothers and children to referral
centres.

4.3.

DISRICT LEVEL NGO GROUP

An exercise has already been initiated to bring together
all NGOs working in each district the field of health and
family welfare. They are in the process of selecting one
amongst them as the district coordinator (DINGO). rThe
"’
DINGO,
by being a member of the ZSS would then play an important role
in guiding and monitoring the activities of all NGOs.
Ghunsum Mahila Samiti is the DINGO for Phulbani. Other
districts have not confirmed.

4.4.

STATE LEVEL NGO GROUP
The DINGOs would decide who will be their State level
coordinator (SINGO). The SINGO will perform the same guiding,
training, coordinating and monitoring functions at the State
level, as each DINGO does for the district level.
The SINGO will have a direct link with the Health and Family
Welfare Department, and its Directorates.

25

State

SINGO

DINGOl

HFW/ADP/DIRS

r

1

DINGO2

DINGO3

District

DINGO

DINGO4

— > ZSS

Role of DINGO

'I

- Guidance
- Training
- Monitoring
- Coordination

i

NGO1

NGO2

NGO3

NGO4 .

Village
* SINGO
■k

DINGO

STATE NGO
DISTRICT NGO

4.5. State IEC Centre
In order to plan and develop IEC activities in the State,
relating to H&FW' issues, different IEC units in the Health
Directorate were <combined under the umbrella organisation. The
State IEC Centre was constructed and equipped to carry out its
tasks through the staff attached to the District and Block
health administration units.
IEC STATE STAFFING PATTERN
DIRECTOR IIS

SECRETARY

II

DIRECTOR

FW

DY.

DESIGNING &
PROCESSING
UNIT

TECHNICAL
OFFICER

PROD.
DISDN
UNIT

PRN .
UNIT

ADM. Ci
ACC UNIT

PRODN.
SUPRNT.
IIIEO(H)
OFFICER FW OFFSET
PRESS

DIRECTOR

& FW
DIRECTOR MED.
FW

(HEM)

OPERN.OF IEC
A SC1I EH EH ( FW&MCH )

HEO

(FW)

IEC TRG.
AV UNIT

1IEO

(11)

EDITING &
PUB. UNIT

ASOT.EDITOR

IEC DISTRICT/BLOCK STAFFING PATTERN

District Mass Education & Information Officer
1
Deputy District Mass Education Information Officer
1
Block Extension Educator

EDU

&

TRG .

26

The IEC structure has not risen to its expectations probably
because :

• its top management are not IEC professionals
• the control structure in the field is dual, and
• the personnel have been neglected in training and
motivational aspects
The awareness generation programme involving the NGO's and
Sister departments will need the active support of the IEC
organisation. This is proposed to be achieved in the following
ways :





by recruiting competent people, including professionals on
'contract basis, and by continuous upgradation of skills and
knowledge
by converting the IEC Centre into an independent Directorate
by placing the field personnel under direct administration
command of the IEC
by building a mechanism for coordination with the service
providing units at :
the State (DBS, DEW),
the District (CDMO)
the Block (MO) levels
by linking it with the State Institute of Health & Family
Welfare, when it comes up

4.6. Strengthening the Quality & Coverage of Services

Quality and Coverage of health services largely depend on:
• Availability of physical infrastructure
• Logistics & Support

• Training to improve Skill and Competence
• Health Information System to provide support for planning
& monitoring
4.6.1

Physical Infrastructure
The table below indicates the requirement of Subcentre,
Primary health centre and Community health centre in the State
as per the National norms, the number presently available and
the backlog.

7.7

ESTABLISHMENT :

TYPE

NO. REQUIRED
AS PER
NATIONAL
NORMS

SC

AVAILABLE

BACKLOG

6467

5927

540

PHC

1035

824

211

CHC

227

152

75

* Source : Surja Patnaik
It is essential that 75% of the SC's, 50% of the PHCs and 25%
of CHCs need to be upgraded in terms of buildings, logistics
& support and manpower. Preference to tribal areas.

4.6.2 Strengthening the First Referral Unit
The PHCs/CHCs will be strengthened to provide the first
referral care in terms of qualified manpower, improved
diagnostic facilities & upgraded specialist care. The concept
of Block Health Teams will provide adequate scope for
improving :

• Health promotion & social mobilisation
• Provision of quality care & coverage of basic health
services effective.
• Use of health information system for effective planning
& monitoring
4.6.2 SUPPLY MANAGEMENT

In order that the demand generation matches with the health
care service, an essential and continuous input of supplies of
all types is essential. This is over and above the basic that
is prescribed for every institution.
The list of such supplied are indicated for each Sub-centre,
Primary Health Centre and CHC for the CSSM programme is
available in the 1991 CSSM Plan of Action. The requirement
under the Population Control Programme is available.
Other
programmes need few equipments, An attempt is necessary to
combine all these prescribed equipments under various
programmes, Sub-Centre wise, and make it available to each
Sub-Centre as their bare requirement for the 5 priority
programmes. A similar exercise should be done in respect to
each of the following:

28

1.
2.
3.
4.

Basic furniture
Basic and minimum stationary
Basic facilities for postal communication
Provision of mopeds for increasing mobility and outreach.

4.6.3

Human Resource Development

HRD being the most acceptable way of improving the quality of
services, a separate chapter on it has been provided for in
the document.
4.6.4

Health Information System

Collection of relevant data at appropriate levels,
in
manageable quantities, its analysis for planning etc. is
proposed to be strengthened by continuous efforts, The
village-wise and family-wise health registers being maintained
in the Sub-Centre provide the most basic source of all
planning information. However, as different programmes have
tended to prescribe different
formats
for
such data
collection, including the recently introduced Health Card
system, there is need to ensure that the health worker finds
it possible to collect the information and understand its
usage. An effort at the State level to discuss the various *
reporting formats to avoid duplication is also necessary.
Coordination excercises between different programmes
*
prescribing data collection from the village and subcentre
levels has to be undertaken.

The information which is to be kept by a family as a part of
its health education, knowledge and follow-up requirements,
and should also be subject to periodic field testing and
review in order to make it effective.
The most efficient way of collecting such basic information
and analysing it at various levels for management function is
the next step that is proposed to be taken. Appropriate and
co-ordinated development of Management Information System will
be attempted as a priority item. Assistance of participatory
agencies will be sought.

4.6.5

4.7

A separate chapter has been provided on managerial
effectiveness.
Specific Action Programmes
Specific action programmes relating to some crucial
specific problems

state

29

4.7.1 Strategy for reduction of infant mortality

Field

Level practicability.

At any sub-centre level, number of births every year will be
of the order of 150 (if the CBR is 30/1000).
If the IMR is
122/1000. then the infant deaths for every 150 births will be
18-20 per year. The full package of programmes under the CSSM
is expected to have
a definite impact on the reduction of
such infant mortality in ievery sub-centre area. Therefore,
this programme will be sincerely followed.
followed. Mother-inlaw
training will be stressed as 81.3% of all deliveries are
conducted at home.
4.7.2^ Strategy for population control
A national strategy of population control has been formulated.
A state strategy paper is under finalisation.
The broad
aspects cover education for the female, employment for the
female, the age of marriage, awareness promotion about the
need for small family and the facilities available for
adopting a small family. Incentives for individuals and
communities have also been proposed.

Specific strategies related to the development of a package of
programmes aimed at the girl child from adolescent stage still
she becomes a mother of two children.
At every point along
this development, a basic input in terms of information and
service is proposed to be given.
Diagram

indicating package of services under FW.

INPUTS

- Health
Education
- Population
Problems

- Health Edn.
- Health Edn.
- CSSM
- CSSM
- Age of Marriage - Child Spacing - Safe
- Safe
- Population
dely.
delivery
Problems
Child
Perma­
nent
Spacing
Member of methods
MSS
- Member
of MSS

I

I

School
Children

Adolescent
Girl '

BENEFICIARY

I
Wedding

First
Child

1

Second
Child

4.

30
4.7.3 Strategy to reduce deaths clue to diarrhoea

Diarrhoea as such has to be accepted in any community. We can
only reduce the incidence as well as the deaths arising out of
diarrhoeal dehydration. Accordingly, the present strategy to
control diarrhoea is three-fold.
(a)

To bring about awareness on sanitation and personal hygiene

(b)

Immediate
intake of
fluids
to
continuation of normal feeding.

counteract

(c)

Judicious and
diahorreants.

antibiotics

restrictive

use

of

losses

and

and

anti-

’ The strategy proposed in the Govt of India Diahorrea
Management programme is to be continued, especially promotion
of the use of ORS packets for moderate and acute cases.
ILLUSTRATION
Under 5 population in SC area will be 12% i.e; 600. If each
child gets 3 episodes of diarrhoea, the total episodes will
be 60 * 3 = 1800. This could be controlled.

• Education

90 % - Home Available fluids + ORS (1620
episodes)

• Services

9 %

• Referral

1 %

4.7.4

HFA + ORS 4 AB (162)
- IV fluids (18)

Strategy to reduce Incidence and deaths due to Malaria
The present strategy for controlling malaria and reducing
malarial deaths has two aspects. The first one aims at
controlling the breeding of mosquito (Source Reduction) and
the second is aimed at immediately treating the person
affected by malaria, so that he does not become a source for
further spread of the disease.

Since the present strategy has been found to be inadequate in
controlling malaria in India, the Govt, of India are in the
process of developing a "tribal area specific strategy".
However, pending further inputs on this aspect, a set of basic
strategies are proposed to be continued with
innovative
interventions in some areas. Pre-monsoon and post-monsoon
spraying to control the breeding of mosquito, preventive doses

31
of chloroquine for all fever cases, immediate examination of
slides and radical treatment are the measures proposed to be
continued.
In some areas like Keonjhar, Bolangir, Phulbani
and Koraput, the use of chloroquine as a prophylactic by mothers
and preschool children will be continued.
The results received
after one year's experiment should indicate any definite trend.
Similarly in these districts programmes to introduce impregnated
bed nets will also be tried.

4.8

Special programmes for tribal areas
The same 5- priority items of work are proposed to be carried
out in the 118 tribal blocks of the State but with added
inputs in terms of infrastructure, mobility, resources etc.
wherever possible. The immediate areas identified are

a)

Accommodation for Sub-centres and Primary Health Centres

b)

Adequate
provision
of
preventive
and basic
especially of the type they are habituated to.

c)

Involvement of the practitioners of the Indian system of
medicines by providing them with similar facilities as
extended to the allopathic and other para-medical health
workers.

d)

Supporting the development of local talent for the demand
generation as well as for service delivery.

e)

Supporting innovative schemes in tribal areas integrating
health, nutrition, education and economic activities.

4.9

Strengthening the network of interface workers

medicines

Efforts will be made to establish strong linkages with the
interface workers like :

• Traditional Birth Attendants
• Anganwadi Workers
• Link women volunteers

• Village health guides
The SC with these strong linkage and support from the
interface workers and MSS will be in a better position to
function more effectively in the delivery of quality care and
coverage of basic health services.

u ( ..


n

I A

voO
11.178 . ^3

32

CHAPTER

5

HUMAN RESOURCE DEVELOPMENT
MACRO STRATEGY FOR INSERVICE TRAINING OF HEALTH &
WELFARE PERSONNEL

FAMILY

5.1

JUSTIFICATION

5.1.1

Though the effectiveness of health care delivery services
may be dependent on multiple factors, perhaps the most
important is the competence of the personnel involved
in delivering the services.

5.1.2

The current
practices in Continuing Education of the
health functionaries suggest that :
the training efforts had been adhoc in nature
lack of uniformity in duration, emphasis and methodology
training is subject and theory-based rather than skill
and programme oriented
no clear cut policies for deploying all the categories of
staff for training at defined intervals
low priority for training
and
not linked with
promotional policy

5.1.3

As the newer approaches and programmes are introduced,
enormous funds are spent on providing training on one
isolated activity (eg) UIP/ARI/ADD Control. The result
is that same functionaries rotates in training many a
times
yet
not getting a comprehensive package of
training. Various programme Officers with WHO/UNICEF
assistance
tend
to conduct unilateral training
programme in technical and supervisory aspects at all
levels which result into excessive disturbance into the
health care delivery system.
Moreover, there is no
system to monitor the effectiveness of these training
programmes.

5.1.4

Keeping the above perspectives in view, there is a need
to develop a comprehensive, broad-based
combining
management and technical aspects and integrated training
strategy for in-service training of health personnel at
all levels. The objectives of this training system have
to be appropriately linked with the required objectives
of
the health care delivery system and they
should
aim to improve :

33

Technical competence
Managerial effectiveness
Communication skills
Building training competence of the trainers
Development of appropriate learning materials
5.2

OBJECTIVES

5.2.1

To improve
the efficiency of
human
resource
development and training
systems
by
developing
a
systematic plan for competence based continuing education
programmes where each functionary gets a chance to be
inducted in the specific job, receives periodic update
and on the job reinforcement of knowledge and skills.

5.2.2

To strengthen
the existing
training
capacity and
expand it to meet the proposed training requirements.

5.2.3

To improve the quality of
supervision with training.

5.3

STRATEGIES

5.3.1

National Institute of Health & FW (NIHFW) New Delhi
developed the document on " MACRO STRATEGY FOR INSERVICE
TRAINING OF HEALTH & FAMILY WELFARE PERSONNEL ".

training

by

dovetailing

The document clearly specifies the training needs and the
programmes upto district level. NIHFW is also involved in
developing the training system in 11 states in the
country.
The approach for Orissa has been adopted from this
document with modification to suit the local needs.
5.3.2

Development
as required

of different types of
by each category (eg)

A.

Induction Course

B.

Promotional

Course

C.

Continuing

Education

training

courses

Fixed periodicity institutional based 2 weeks duration once every 3-4 years

Minimum periodicity - on the job training
3 days once in three months

34

Dissemination of Health Information such as
Handouts, Newsletter,
Bulletins etc.
D.

Special

E.

Advanced training - Laboratory/X-Ray

training - 2 weeks duration in surgical skills
for MOs at PPC/Dist HQ and HW (F) in
child spacing at CHCs

technician

at

Public
Health
laboratory
and
management
;and
educational
technology
at
N I H FW ,
IIMS/ASCI/outside India

5.3.3

Strengthening the training facilities at all levels with
adequate and appropriate infrastructure, training of
trainers programmes, systematic development of learning
materials based on the training needs and revised and
updated curricula.

5:4

APPROACHES

5:4.1

VILLAGE LEVEL ( HEALTH SUB CENTRE)

(a)

HEALTH PROMOTION & AWARENESS

Training on communication of health related information,
and training on selected interventions like ORS use :
by MPHWS, AWWS, Teachers
on fixed days
on areas of their concern
with IEC support from HWS, & BEES
to MSS & YCS. They are to be motivated to communicate
this information/training to every village household.
IEC and resource materials will be provided by the IEC
State Hqtrs., non-governmental and private agencies, and
as far as possible using local folk media groups.
(b)

STRENGTHENING SERVICE DELIVERY THROUGH INSERVICE TRAINING
BY VILLAGE TRAINING TEAM

b-1.

TRADITIONAL BIRTH ATTENDANT

3 days on the job skill oriented
provided to TBAs by the HW / HA (F).

training

will

be

The focus will be on

Identification of Antenatal cases for early registration
with HSC

n

35

Identification of High Risk Pregnancy :
(EG) •

Short statured

Primi

Multipara
Previous Bad Obstetric history

Odema
Conduct of safe and clean delivery using disposable
delivery kit.

ANGANWADI WORKER

b-2.

One day orientation once a month will be provided by HW
/ HA (F) on the Child Survival Safe mother hood
programme.
PRIMARY HEALTH CENTRE - BLOCK LEVEL - BLOCK TRAINING TEAM
(BTT)

5:4.2
a)

COMPETENCED BASED CONTINUING EDUCATION

a-1

Block Health Team Comprising of :

Medical Officer
Health Assistant (M) & (F)

Block Extension Educator
Computer

will be organising the on the job, skill oriented training to
a group of HWS & HAS at PHC/HSC level on a rotation basis.
a-2

The training duration will be for 3-4 days once in 3
months and 3 slots will be provided every year.

This method has many advantages :
Field staff need not be drawn too many times for
training

All the programmes are integrated like ADP/CSSM/ICDS

Each worker will get reorientation every year (5% the
working days)

36

a-3

Proposed Slots
Slot I

- Focus on maternal & child health ( CSSM)

Slot II

- SC work planning, managing the resources and
preventive maintenance (ADP)

Slot III - Nutrition (ICDS) and control of communicable

diseases
By this way, all the five health priorities of the state
will be covered under the training programme.
FIVE PRIORITIES OF THE STATE

'

I

POPULATION
CHILD SURVIVAL & SAFE MOTHERHOOD

CONTROL OF COMMUNICABLE DISEASES

I
I

MALARIA

DIARRHOEA
LEPROSY & TB
a-4

The field training programme will
close by December.

at

B.T.T
L~~I~
T ~
PHC
2

r~
PNC
i

commence

from April

and

CMC

ZZZ1
PIIC
3

APRIL

MAY

>

JUNE

C. S. S. M

JULY

AUGUST

>

SEP I EMBER

I C D S

OCTOBER

NOVEMBER

>

DECEMBER

IISC MGTADP

j

I
J7

I
I

a-5

Training Materials

B T T will be
prepared by :

provided

with

• National Institute of Health &

Training

Resource

Materials

rw

• C S S M

• Operational guide for HSC management & main tonancc
prepared by ADP)
b)

(

to bo

SPECIAL TRAINING

ON CHILD SPACING

B T T / D T U will organise 2 weeks intensive training on
child spacing methods with special focus on 1U1) and OP for the
HW(F)/HA(F). The training resource materials wi 11 be prepared
by ADP with guidance from NIHl'W.

5:4.3 DISTRICT TRAINING UNIT
Under the revised strategy, it is proposed to establish one
District Training Unit (DTU) at district head quarters.
There were 19 ANM Schools r.pread ewer 13 districts
3 Schools which were functioning in a rented building were
closed and the staff have been rearranged within the
system.

2 Schools i.e; one at Sambalpur and one at Jeypore (Koraput)
were retained for basic training
14 Schools were converted as centres for continuing education
which will be taken over by District Administration as
District Training Unit. The detailed break up is given in the
next page for reference.

38

SL.

NO.

LOCATION OF ANMTS

DISTRICT

1.

Bhubaneswar

To new districts

2.

Daspalla

To new districts

3.

Puri

Puri

4.

Cuttack

Kendrapada

5.

Balasore

Balasore

6.

Mayurbhanj

Baripada

7.

Dhenkanal

Dhenkanal

8.

Keonjhar

Keonjhar

9.

Bolangir

Bolangir

10.

Phulbani

Phulbani

11.

Ganjam

Berhampur

12.

Kalahandi

Bhawanipatna

13.

Sundargarh

Sundargarh

14 .

Sambalpur

Deogarh

DTUS

* New buildings will be constructed for District Training units in
the newly formed district and the staff at the ANMTS will be
deployed to fill up the newly established DTUS, other training
institutions and districts.
a)

STRATEGY

a-1

ESTABLISHING THE DISTRICT TRAINING UNIT
Faculty : Each ANM School has 7 teachers
One Principal Tutor
4 Public Health Nurses
2 Sister Tutors
Support Staff

Additional Requirement :

Medical

Health Education
Statistics

39
Proposal
Under the new strategy. the Addl .
CDMO is the Training
Coordinator at the district level
supported
by Assistant
District Medical Officer (“
(Project). The
-;
faculty
requirement
could be drawn as follows :

1.

Medical Officer

: from leave reserve port
(preferable o & G/ Paediatrics/Public

2.

Health Education

: BEE/Dy. MEIO from mass media wing

3.

Statistics

: District statistical assistant
(could be used as resource persons)

4.

MCH Field
Prograimne

: District Public Health Nurses

(1,2,3,4 will be drawn as resource
persons)

ADMINISTRATIVE STRUCTURE PF THE DTUS

ZILLA SWASTIIYA SAMITI
ADDL CHIEF DIST. MEDICAL OFFICER

SUPPORT

ASST. DIST. MEDICAL OFFICER (P)

MEDICAL OFFICER

ANMTS STAFF

*

HEALTH EDUCATOR *

Could be drawn as resource persons.

STATISTICIAN *

DPIIN

40

a-2

Training of Trainers
Trainers at DTU (About 10) will be trained for 10 days every
year Jan-Feb. The content include :

- Training skill & Methods
- Training Resource Materials
- Management of Training Course
- Developing Annual Training Plans for district
When it comes up (SIHFW), DTU members will be trained in
Regional Training Centres (HFWTC/RHTC) with support from State
Institute of Health & FW (SIHFW).
For 1992-93, DTU members will be trained by Scientific
Illustration and Educational Technology (SIET) with local
support i.e; trainers/teachers drawn from HFWTC/Districts.
From 93-94 onwards NIHFW will take up the responsibility of
training of trainers of DTUS.

a-3

Training Resource Materials
NIHFW modules will be utilised for the training courses with
necessary modifications to suit the local needs. SIHFW will
prepare trainer's book and trainee guide for the new training
programmes ( the ones NIHFW have not prepared) with technical
guidance from NIHFW.

a-4

Training Programmes at District Training Units

a-4.1

Training of Block Training Team
*

BTTs will be given 6 days training on

- Skill development for Quality Care and Coverage of services
at Subcentres.
- Support Supervision and Supplies to strengthen the Quality.
- Monitoring, Performance appraisal and feed back.
- Communication skills
*

4 BTTs could be trained as one batch i.e; 4*5= 20. 2
courses could be done in every month i.e; 8 Blocks could be
covered/month. All the blocks could be covered within 2-3
months.

SCHEDULE

APRIL

MAY

JUNE

ALL BTTs TRG.

41

a-4.2 SUPPORT STAFF TRAINING

Pharmacist
Clerk cum
Store Keeper

- Logistics/Stock/Stores
(Materials Management)

Administration

Lab Technician

| Technical Training

X-ray Technician
The trainees will be housed in the DTU and theory classes will
be conducted in the DTU and the practical demonstration will
be organised in the district hospital.
Each programme will be organised by a Core group trainers at
the district level.

The schedule for the support staff training is given below for
reference.

PHARMACIST

MATERIALS MANAGEMENT

SEPTEMBER

CLERK

ADMINISTRATION

OCTOBER

TECHNICIAN

TECHNICAL

NOVEMBER

X-RAY TECHNICIAN

TECHNICAL

DECEMBER

LAB.

a-4.3

Special Training

JULY/AUGUST

DTU has the flexibility to accommodate special training for
HW(F) & HA (F) in child spacing methods. With special focus on
IUD insertion^ Oral Pills. The training resources materials
will be prepared by ADP with technical guidance from NIHFW
Schedule for special training.

Special training on communication packages will be taken up in
pilot districts by training groups and organisations who have
significant contributions to make. For instance, CARE,
GANDHIGRAM, PSI.

42

ACTIVITY SCHEDULE

SL
NO

ACTIVITY

1.

TOT-BTT

2.

SPECIAL
TRAINING
ON CHILD
SPACING

3.

MATERIAL
MGT.
PHARMA­
CIST

4.

ADMINISTR
-ATION
CLERK

5.

LAB. TECH
TRAINING

6.

X RAY
TECH.
TRAINING

7.

DTT

8.

PREPARATI
ON OF
ANNUAL
TRG. PLAN

9.

MOBILISAT
ION OF
RESOURCES

TOT

A
P
R

M
A
Y

J
U
N

J
U
L

A
U
G

S
E
P

O
C
T

N
O
V

I)
E
C

J
A
N

F
E
B

M
A
R

43

a-5

Learning Resource Materials (Including IEC)
Financial and technical assistance to develop & procure the
LRM would be sought from :

• ADP
• State level institutes

• National Institute Health & FW

•World Health Organisation (SEARO)
• UNICEF

• Local folk media unit production
a-6

Furniture
Financial support will be provided for furnishing the District
Training Units.

a-7

Physical Infrastructure
• A condition survey is proposed for the 14 ANM schools and
renovation plans will be prepared to upgrade them as
DTUs. Financial support will be provided.

• For the new districts like Malkangiri, Rayaguda Gajapathi, and
Navrangpur,
Navrangpur r feasibility study either to convert existing
facilities with renovation or to construct new building will
be conducted.
• For the districts of Koraput & Sambalpur, new construction
will be done.
• Similarly, new ANM school will be constructed in Sambalpur.
a-8

Vehicle

To monitor the field training activities by the BTT transport
will be provided for DTUs.

44

a-9

State Training System & Child Survival Safe Motherhood

a-9.1 An attempt will be made to fit CSSM training into the
State Model

i. e ; DISTRICT -> B.T.T -> V.T.T

Interface (TBA/AWW) -> MOTHERS

State Model of the 3 days on the job training at sectoral
level once in 3 months provides scope for accommodating
CSSM/ICDS/HSC Management.
a-9.2 CSSM district - wise coverage is given below for reference.

1992

93

Ganjam
Keonjhar
Sambalpur

1993

94

Koraput
Bolangir
Sundargarh

1994

95

Balasore
Mayurbhanj

1995

96

Phulbani
Kalahandi

1996

97

Puri
Cuttack
Dhenkanal

a-9.3 Since CSSM is a vertical programme and has to be done
through the system identified by CSSM. ADP will concentrate on
the other districts during 1992-93 & 1993-94 and take up the
CSSM covered districts during 1994-95. The break-up is given
for reference.
YEAR

CSSM

A D P

92

93

1.
2.
3.

Ganjam
Keonjhar
Sambalpur

1. Puri
2. Cuttack
3. Dhenkanal

93

94

4.
5.
6.

Koraput
Bolangir
Sundargarh

4 . Phulbani
5. Kalahandi
6. Balasore
7. Mayurbhanj
8. Ganjam
9. Keonjhar
10.Sambalpur

94

95

7.
8.

Balasore
Mayurbhanj

11. Koraput
12. Bolangir
13.Sundargarh

95

96

9. Phulbani
10. Kalahandi

96

97

11. Puri
12. Cuttack
13. Dhenkanal

45

5.4.4

REGIONAL TRAINING CENTRES

5: 4.4.1 Health & Family Welfare Training Centre (HFWTC)
There are 2 Health and Family Welfare Training Centres at :

Sambalpur
Cuttack
* HFWTC

undertake :

• Basic Training for Health Workers (Male)

1 year

course.

• Inservice Training for :
• Medical officers
• Block Extension Educator

• Health Assistant
* HFWTC have

good facilities for classrooms, library, hostel,
dinning facilities.

•k

HFWTCs have been provided financial assistance by ADP in
strengthening

- Learning Resource Materials
- Transport
Renovation
Their linkages with the State Institute, the DTUs and BTTs
will be clearly established, so that they do not train on
issues which are not directly relevant to the State training
concept.

I

46

* STAFF POSITION IN RFWTC

INSERVICE TRAINING

SL.NO

DESIGNATION

1.

Principal

2.

Medical Lecturer-cum- Demonstrator

3.

Health Education Instructor

4

Health Education Extension Officer

5.

Senior Sanitarian

6.

Social Science Instructor

7.

Asst. Director of Statistics

8.

Senior Health Inspector

9.

Public Health Nursing Instructor

10.

Artist-cum-Draftsman

11.

Projectionist
BASIC TRAINING

SL.NO

DESIGNATION

1.

Epidemiologist

2.

Dist. Public Health Nursing
Officer

3.

Sanitary Engineer

4.

Management Instructor

5.

Communication Officer

a

ESTABLISHMENT

SL.NO

DESIGNATION

1.

Head Clerk

2.

Computer

3.

Accountant-cum-Store Keeper

4.

Stenographer

5.

Clerk-cum-Typist

6.

Driver-cum-Mechanic

7.

Sr. Clerk (Basic Health Scheme

8.

Junior Clerk-cum-Typist
(Basic Health Scheme)

9.

Cook

10 .

Peon-cum-Daftary

11.

Aya

12 .

Watchman-cum-Mali

13 .

Peon

14.

Sweeper

15.

Peon (Basic Health Scheme)

5:4.4.2 RURAL HEALTH TRAINING CENTRES (RHTCS)
•k

t

RHTCs are attached with the Department of Social and
Preventive Medicine of Med ica1 Co 1 leges. There are 3
RHTCs :

SL NO

MEDICAL
COLLEGE

RHTC LOCATION

1.

CUTTACK

JAGATSTNGHPUR

2.

BURLA
(SAMBALPUR)

ATTABIRA

3.

BERHAMPUR

DIGAPHANDJ

48

* Basically RHTCs are involved in :

Internee's (Medical) training
(Rural posting for 3 months)
Staff Nurse Training
(Community Health Nursing)
* RHTC

Jagatsinghpur was upgradated during Phase I of ADP
on par with HFWTC and conducts the same
programmes as HFWTCs.

* RHTCs Attabira & Digaphandi will be upgraded during Phase II
’of ADP through inputs so that they could be upgraded as
Regional Training Centres.
*

a)

Each HFWTC/RHTC Jagatsinghpur has their own geographical
coverage for inservice programmes. Sooner all the RHTCS are
upgraded, each institution will cater to a particular
geographical area for inservice training activities.
ROLE OF REGIONAL HEALTH TRAINING CENTRES

a-1. Training Programmes
a-1.1 Training of Trainers of District Training Units.

a-1.2 Medical officers
Induction Course for 8 weeks

I

Inservice Course for 2 weeks
Peripheral Specialists Programme in
coordination with the medical colleges.

a-1.3 Block Extension Educator - IEC management training
a-2

Support to District Training Units
RHTCs will provide technical support to DTUs in the

• Preparation of annual training plans
• Provision of learning resource materials
• Providing support in the training programmes organised at
DTUs

I

49

,5:4.5 STATE INSTITUTE OF HEALTH & FAMILY WELFARE
Health manpower has increased tremendously over the past 10
years.
Many new programmes,
projects and intervention
programmes are introduced in the health care system. As
discussed in the earlier chapters, it is very crucial that the
demand generation created through health promotion and social
mobilisation programmes should be adequately and appropriately
met by Quality and Coverage» of health services for which
training plays a major role.
At present there is no definite system existing in Orissa in
Manpower planning, Training and Development. Now Govt, of
Orissa through ADP is keen to develop a systematic approach to
the above mentioned issues. This document describes the entire
process of training system development through bottom up
approach. Therefore the need to establish an apex body at the
State level becomes very crucial in the overall development of
manpower planning, training and development.
a)

JUSTIFICATION
Area Development Programme Phase I in Orissa provided very
important lessons in the areas of training and IEC.

a-1. College of Nursing Berhampur
The College was constructed, furnished and equipped through
ADP's financial assistance during Phase I. But the college is
yet to take off even inspite of 6 year's existence because of
lack of foresight on the availability of the trained manpower
planned staff and institutional development. The college will
face these problems in the coming years unless the faculty
position is adequately strengthened to get the recognition
from Indian Nursing Council and university of Berhampur.
a-2. Information Education Communication (IEC) Centre Bhubaneswar
IEC Centre was constructed, furnished and equipped through
ADP's financial assistance during Phase I. The staff were
trained in India and in the UK. But the performance of the
centre is highly disappointing as the centre was reduced as an
appendage to the Director of Family Welfare.

The State Government is planning some administrative changes
in the IEC structure and reporting, in order to make the IEC
effective in its role.

50

a-3 . Therefore learning from the two experiences, one should be
cautious in planning the SIHFW so that such slippages could be
avoided and SIHFW becomes a viable and active apex body to a
sustainable training system.
a-4. In India under World Bank assisted India Population Projects
11 States have been covered for Training & System Development
Projects. They are:

• Andhra Pradesh

• Madhya Pradesh

• Uttar Pradesh

• Jammu &Kashmir

• Gujrat

• Punjab

• Karnataka

• Assam

'• Rajasthan

• Haryana

Himachal

Pradesh

National Institute of Health and Family Welfare New Delhi is
involved in developing the Training & System Development
Project in these States. Orissa will be funded through ODA for
the Training & system development through ADP. Therefore there
is an urgent need to set up the project as early as possible
in order to be in confirmity to the National Health Policy and
approach to develop the training systems in a more integrated
fashion so that Orissa could provide adequate technical and
managerial skills to the service providers at different level
in health care system.

a-5. Further Govt. of Orissa's 5 health priorities and the
programmes addressing the 5 health priorities are in operation
and being contemplated. Unless the systematic approach is
developed to provide an integrated package to the service
providers, all the efforts in addressing the 5 Health
priorities will be a futile exercise.
a-6. Govt, of Orissa's new initiative of demand generation for
health services through intensive and innovative health
promotion and social mobilisation
programmes is bound to
create demands from the user's side. These demands should be
adequately and appropriately met by Quality care and coverage
which is possible through systematic development of health
manpower through integrated packages of training programmes
and through well define and organised training system.

Therefore the need to establish SIHFW is absolutely vital in
the overall development of health human resources in Orissa.

51

b)

APPROACH

b-1. The existing IEC Centre at Bhubaneswar could be upgraded as
SIHFW. IEC Centre has classroom, library, documentation
facilities. The additional requirements will be additional
classrooms and hostel apart from renovation of the existing
building.

b-2. GOO will
identify the resources to provide financial
assistance
for furniture,
equipment,
learning resource
materials to upscale the production capacity of the Institute
for developing training as well as IEC materials.
GOO will identify the resources to provide full support in
terms of technical and financial inputs to upgrade the IEC
Centre as SIHFW.

c)

FUNCTIONS

SIHFW will : aim to be a training institution rather than an
academic body.
c-1. Assist the Government to evolve health promotion and human
resource development policy.
c-2. Assist
plans.

the

Government to develop annual

and

training

I EC

c-3. Organise the training programmes for :
3.1

Training of Trainers of Regional/District units.

3.2

Management
Teams.

Development

Programme

for

the

District

Health

c-4. Organise need based workshops/seminars in HRD/IEC.

c-5. Undertake monitoring and evaluation of the training courses.
c-6. Develop training resource materials with technical support
from NIHFW.
c-7. Develop programme based, audience centered IEC materials for
health
promotion-designing,
pretesting,
printing,
distribution.

c-8. Publish monthly/quarterly
Development.

news

letter

on

Health

Services

c-9. Laise with NIHFW in the consortium of training institution in
India
and
publish
the
experiences
from
Orissa
in
National/International forum.



LIBRARY
AND

•o t

INFORMATION

)

CENTRE

Giov- (00

11178

52

d.

STRUCTURE

d-1. SIHFW should be an autonomous institution right from inception
for sustainability and operational efficiency

d-2. SIHFW should be headed by (Preferable) medically qualified
Public health expert
d-3. SIhFW should have the training cadres (Lecturers, Reader &
Professor)

d-4. Following disciplines are absolutely essential :
d-4.1

Health Services and Administration

d-4.2

Epidemiology, Bio statistics and Demography

d-4.3

Behavioural Sciences and Communication

d-4.4

Management Sciences - Until the faculty strength is fully
developed, the resources from Xavier Institute of
Management could be drawn)

d-4.5

Education and Training with Administration,
Library & Documentation and Computer support.

Finance,

d-5. SIHFW should grow and develop.
Therefore a 10 years
institutional frame work is given on next page for reference.

53

TECHNICAL COMPETENCE REQUIRED IN 10 YEARS

1.
2.
3.
4.
5.
6.
7.

HEALTH SERVICES AND
ADMINISTRATION
Community Health Services & Admn 4
Hospital Administration
Nursing Administration
MCH
Nutrition
Environmental Sanitation
Lab Technology

8.
9.
10.

EPIDEMIOLOGY, BIOSTATISTICS &
DEMOGRAPHY
Epidemiology
Biostatistics 4
Demography

11 .
12.
13 .
14 .
15.

BEHAVIOURAL SCIENCES &
COMMUNICATION
Sociology 4
Psychology
Anthropology
Electronic media 4
Health & Extension Educator 4

19 .
20.

MANAGEMENT SCIENCES
Health Planning
Quantitative Methods
System Analysis / OR 4
Health Economics
Qualitative Methods
Organisational Behavior +
Evaluation Methods

21 .
22.
23 .
24 .

EDUCATION & TRAINING
Curriculum Planning 4
Curriculum Evaluation
Learning Methods
4
Training Methods

16.
17.
18.

54

In practice it is very difficult to set up every thing
required immediately. Therefore to start with SIHFW should
have essentially 1-2 faculty members. The details are given
below for reference.
Health Services and Administration

1. Community Health Services & Administration
— Medical

--

Nursing

Epidemiology, Bio statistics and Demography

2. Bio Statistics

Behavioural Sciences and Communication

3. Sociology
4. Electronic media
5. Health & Extension Educator

Management Sciences
6. System Analyst
7. Organisational Behaviour
Education & Training

8. Curriculum Planning
9. Learning Methods

Administration, Finance, Library & Documentation and Computer
Centre.
To initiate ADP could finance the staffing until the project
period. As SIHFW guns depending on the needs, the other
positions could be filled in future.

|

55

d-5. PROPOSED STRUCTURE

DEAN/DIRECTOR/PRINCIPAL

IEC WING

TRAINING WING

I

I
1

2

3

6

5

4

FINANCE

LIBRARY &
DOCUMENTATION

1. HEALTH SERVICES & ADMINISTRATION
2. EPIDEMIOLOGY BIO STATISTICS & DEMOGRAPHY
3 . BEHAVIOURAL SCIENCES & COMMUNICATION

4. MANAGEMENT SCIENCES
5. EDUCATION & TRAINING
6. MATERIAL PRODUCTION

7 . MATERIAL DISTRIBUTION
8 . MONITORING & EVALUATION

8

I

I
ADMINISTRATION

7

COMPUTER
CENTRE

56

d-6. COMMITTEES

d-6.1

GOVERNING BODY

Details are provided in the annexe I.
STRUCTURE

CHAIRMAN

Commissioner & Secretary, Dept. of Health &
FW

VICE CHAIRMAN

Director Area Development Programme
Director Medical Education
Director Family Welfare
Director Health Services
Deputy Director IEC

MEMBER SECRETARY- Director SIHFW
MEMBER

- Secretary Deptt. of Finance
Secretary Deptt. of Planning & Coordination
Secretary Deptt. of Education
Secretary Panchayat Raj
Secretary Public Works Deptt.
British Council Division
UNICEF
State Resource Centre
Xavier Institute of Management
Gopabandhu Academy of Administration
Joint Secretary(ADP) Ministry of H & FW
Director -NIHFW New Delhi
ICMR

57
d-5.2

EXECUTIVE COMMITTEE
ISSUES SANCTION

CHAIRMAN

Director SIHFW

MEMBER SECRETARY- Faculty member

MEMBER - Joint Secretary (training)
Director of Medical Education
Director of Family Welfare
Director of Health Services
Deputy Director (IEC)

d-5.3

TECHNICAL ADVISORY COMMITTEE

Advises on technical issues - contents, curriculum, methods &
media courses and materials.

Chairman

Director SIHFW

Member Secretary - Senior faculty SIHFW
Members
- Director of family welfare
Director of health services
Director of medical education
Director Area Development Programme
Director voluntary health Association
Director ICDS
Dy. Director IEC
NIHFW Delhi

d-5.4

PAY STRUCTURE
The pay scales of Department of health & FW, Medical colleges,
University are enclosed in the Annexe III.
It is desirable to adopt the UGC pay scale. If not, atleast
pay structure of medical colleges should be adopted.

e)

ROLE OF NATIONAL INSTITUTE OF HEALTH & FAMILY WELFARE (NIHFW)
NEW DELHI
NIHFW will be the consultant for developing the Health and
family welfare training and systems development in Orissa. The
terms of reference will include :

e-1. To provide technical and management support in developing the
training & system development.

provide
technical
and
management
e-2. To
institutional development of SIHFW.

support

in

the

58

e-3. To provide support in the provision of learning resource
materials ( print & audio visual materials) and guidance in
the local designing and production of learning resource
materials.
e-4. To provide support for faculty identification, recruitment,
pre placement training and continued guidance in faculty
development.
e-5. To provide support in the preparation of byelaws and
constitution of committees, body and working group and in the
organisation of meetings of these committees until SIHFW is
strong enough to do in their own.
e-6. To establish linkages for SIHFW with the other training
institutions in the country (consortium) and provide support
for exchange visits.

e-7. To establish linkages for SIHFW with institutions in the UK
especially Nuffield Institute Leeds University and Liverpool
School of Tropical Medicine institutes in S.E.Asian countries
for specific inputs for faculty and institutional development.
e-8. To advise the consultancy requirement (local/India/UK) and
channelise
them
in
consultation
with
British
Council
Division/WHO etc.

e-9. To advise SIHFW/Government of Orissa and British Council
Division on the Technical Cooperation Training Programmes.

e-10.

To affiliate SIHFW in the event of NIHFW being declared as
deemed University to commence post graduate diploma courses in
Public Health & Health education. This is a long term
requirement.
NIHFW will open a cell for Orissa in the Institute (Delhi) for
effective Coordination, support and guidance.

f)

TECHNICAL COOPERATION AND TRAINING PROGRAMME
It is absolutely essential to develop the potentials in the
areas of :







(

Public Health
Management
Planning
Health Economics - utilising the TCTP slots.
IEC

59

The following recommodations are suggested for building up a
system for effective training and manpower development as long
term measures.
MEDICAL PROFESSION

f-1. Govt, of Orissa should insist that the Jr. class I specialists
to undertake Diploma in Public Health (Calcutta or Indian
Institute of Health Management Research Jaipur) before they
are promoted to Senior class I. This is very important to gain
overall view of the National Health & Family Welfare
'Programmes and update the skills in management.

f-2. Those officials who have public health qualifications and
background should be encouraged to take up master courses in
Health Planning and Epidemiology in the UK.
f-3. Those officials who have public health qualification and
background should be encouraged to take part time MBA at
Xavier Institute of Management.

EXTENSION EDUCATION

f-4. Graduate BEES/LHVS/DY.MEIOS subject to their age limit should
undertake Diploma in Health Education. Conditions should be
imposed that only BEES with DHE Qualification should be
considered for promotion as Dy. MEIO.

NURSING EDUCATION
f-5. Govt, of Orissa should depute minimum of 3 graduate nurses to
undertake MSC courses within India.
f-6. Govt, of Orissa should insist that DPHNS should undertake
Diploma in Health Education asi a pre-condition for their
promotion as Assistant Director.

f \

60

PAY STRUCTURE IN DEPARTMENT OF HEALTH & FAMILY WELFARE, GOVT, OF
ORISSA HEALTH SERVICES

1. Assistant Surgeon/Specialist (class II)
Rs. 2000-60-2300-EB-75-3200-100-3500.
Advancement scale of pay of assistant surgeons/specialist in
rules 1985

Rs. 1975-65—2040—70—2250-75-2700-EB-80-3100
2. Junior class I

Rs.

2200-75-2800-EB-100-4000

3 . Senior class I

Rs. 2800-100-3600-EB-125-4350
4. Joint Director level II

Rs.

3200-100-3700-125-4700

5. Joint Director level I

Rs.

3700-125-4700-150-5000

Director of Health Services/Family Welfare
Rs.

4800-150-5700-200-6300

MEDICAL EDUCATION

1.

Lecturer

2.

Asst. Professor

3.

Associate Professor - Rs. 3700-125-4950-150-5700

4.

Professor Rs. 4500-150-5700-200-6300 (3 advance increments)

5.

Director of Medical Education Rs.
advance increments)

Rs. 700-40-1100-50-1300-EB 50-1800
Rs.

3700-125-4950-150-5700

4500-150-5100-200-6300 (2

61

UNIVERSITY GRANTS COMMISSION
1.

Lecturer

2.

Senior Lecturer Rs.

3.

Lecturer Selection grade and Reader
Rs. 3700-125-4950-150-5700

4.

Professor Rs. 4500-150-5700-200-7300

5.

Vice Chancellor

Rs. 2200-75-2800-100-4000
3000-100-3500-125-5000

Rs. 7600 (Fixed)

62

CHAPTER

6

DISTRICT HEALTH MANAGEMENT
District is
the functional unit for all the activities of the
Government. In health care system, the district assumes greater
importance and plays a vital role in supporting and strengthening
the delivery system at sub district, block, sub block and village
levels. Therefore it is very important that special focus and
attention should be given to the district health management. In
order to ensure the coverage and quality of health care services.
STRUCTURE

DISTRICT COLLECTOR

ADDL. CDMO

CHIEF DISTRICT MEDICAL OFFICER

ADMO
(M)

ADMO
(PH)

DIO

I DMD

DLD

DTO

ADMO
(P)

DSA

ADMINISTRATIVE & SUPPORT STAFF

DPHN
i

DIO
DPHN
MEIO
DSA
ADMO
(M)
(PH)
(P)
DMO
DLO
DTO

I

DY. MEIO ||

DISTRICT IMMUNIZATION OFFICER
DISTRICT PUBLIC HEALTH NURSE
MASS EDUCATION & INFORMATION OFFICER
DISTRICT STATISTICAL ASSISTANT
ASST. DIST. MEDICAL OFFICER
MEDICAL
PUBLIC HEALTH
PROJECT
DISTRICT MALARIA OFFICER
DISTRICT LEPROSY OFFICER
DISTRICT TUBERCULOSIS OFFICER

]

63

6.1

SITUATION ANALYSIS

6:1.1 PLANNING
a)

Over all planning is done at the State level and the
districts are informed about the activities, targets and
the budget provided from the state level to directorates:

DIRECTOR OF HEALTH SERVICES (DHS)
DIRECTOR OF FAMILY WELFARE

(DFW)

b)

DFW gets 100% central assistance for family welfare activities
'which include establishment,
programmes
(training),
activities, vehicles, motivation, IEC activities. The State
provides some additional incentives for sterilisation.

c)

DHS gets some funds & material from GOI on Malaria and Filaria
control, and assistance for :
National Programme for Control of Blindness

National Programme for Aids Prevention & Control

National

TB Control Programme

National Leprosy Eradication Programme
All the remaining programmes of promotion of secondary health care,
establishment, medical education etc. are met from the State funds.

At the present moment there is little scope for planning at
the district level.
However, an exercise is on to decentralise planning. The first step
being proposed in this direction is a district-wise reallocation of
the 93-94 budget. The districts would be asked to plan for their
respective needs within this financial ceiling and keeping in mind
some policy guidelines.

Health care will form the part of the district plan.

i

64
6:1.2 IMPLEMENTATION

a)

All the National Health & Population programmes and the
regular curative care services are implemented by the
district health officials. For each programme, there is
a responsible official at the district level.

b)

All these programmes are implemented through the CHC / PHC /
HSC by the respective health and paramedical staff and
monitored
individually
by
the
respective
programme
officers.

c)

In short, the multipurpose workers scheme stops at the level
of PHC / CHC and from there onwards only individual
vertical programme implementation and monitoring commence and
continue upto the State level which results in :

• Individual vertical programme - priority
• Multiplicity of Controls by Individual programme officers
• Confusion at the field level for programme priorities
• Dilution of the Concept of Comprehensive package of health
care delivery
• Lack of Coordination between the programme officers at
district/state level
• Least scope of developing proper plan of implementation for
the comprehensive package of services
d)

These deficiencies lead on to certain problems in the field
level :
• Poor supervision and monitoring
• Poor Quality and Coverage of services

• Poor demand generation for health services
e)

These problems lead on to the :

• Status Quo in the health status and parameters
• Growing unmet demands
• Wastage of human resources, materials and time

..

V

65


6:1.3

Management - Adjustment

a)

Additional CDMQ
His / Her job description extensively covers the :
• Materials and Child Health - child survival & safeguard
• Population
• Training

!

I E C

4

• M I S ( To a greater extent )
But in practice, majority of the Addl. CDMO'S time is spent on
administration and not on programmes - even if one argues for
programmes, again it is limited to :

• sterilisation target & achievement

!

• Immunization target & achievement
6:1.4

Delays in transfer of information

Extensive delays occur in transmitting the changes in the
schedule (for eg. immunization) or technology from the
State to district and district to the grassroot which result
even in poor updating of IEC materials (locally produced) and
skills.

i

6:1.5

Confusions in the training programmes
There is more confusion in the field level especially among
workers and supervisors as they have been drawn to
different
training
programmes
by
different
programme
agencies/officers at different points of time which results in
poor coordination and wastage of human resources and time.

I

IJ

6:1.6

Limited use of health information system

Data and information collected from different resources are
pooled at the district level and passed to state without
proper analysis. There is no system at the district level for
use of data and information for monitoring and planning
purposes. The analysis done at the district level is the :
Review of Target against Achievement

r

66
STRENGTHENING HEALTH MANAGEMENT INFORMATION SYSTEM

6:2

a)

ADP supported new HMIS provides for :
SC





Introduction of family card system
Withdrawal of individual programme registers
Streamlining the information flow at fixed day in month
Feed back from PHC / CHC on Performance & Quality Care
PHC/CHC/DISTRICT

• Development of support information system :
- Mortality, Morbidity, inventory, etc.
1
;;

• Development of Performance indicators on Quality Care
indicators.

• Streamlining the flow of information and feed back system
• Using the data and information for monitoring & planning
• Installation of Computer facilities at the district level
and linkage with national net work
b) Conduct of Specific Surveys
DHMS will organise specific surveys on :

• Infant mortality

• Coverage evaluation for UIP

Cluster technique using WHO
formats in one HSC in each
block every year.

• Utilisation of services at HSC-

All the HWS (F) & (M) AND HS (F) & (M) about 30 of the health
personnel will carry out the survey in one HSC every year.
(EG) Each HSC has 1000 house holds i.e; 5000 population. If the HWS
are about 20, each one of them can survey 50 houses in 3-4 days
under the supervisors guidance.
This survey should be linked during April-May when the updating of
ELCO is done.
No extra cost and no additional manpower are required.
If the district has 20 blocks, then the DHMS will get the sample of
20 * 5000 = 100,000 population. All the required data and
information collected for this sample size is statistically
significant and all the morbidity, fertility and mortality rate
could be calculated per district.

67

c) Retrospective Study on Communicable Diseases

Data on Communicable diseases like Diarrhoea, Malaria, T.B and
Leprosy could be collected from the secondary data i.e; from the
registers & records and they constitute the reported cases. The
data collection should be for the past 3 years containing
information on month wise, area wise, age & sex wise
distribution.
Such exercise will give the information on

What is the problem ?
Where is the Problem ?
When is the problem ?
Who are affected ?

An example is illustrated below for a PHC in Puri district.

Diarrhoeal Disease
Puri district - P.H.C.
750
700•650-

/

600-

7

550-

+

\
\

500-

i-

----- V.___

450-

400------>
350-

+

300'j

VT-

.......

• A.

250
APR

MAY.JUN

JUU■AUG

SEP

OCT NOV

DEC

month

89-90

+-- 90-91

-K- 91-92

JAN

FEB MAP

68
With the installation of computer at the district, such type of
information could be brought about. ( Some more illustrations are
given in the annexe )

The advantage of such exercise is manifold.

• Tells the epidemiological forecasting.
• Provides the planner the scope of mobilising the resources well
in advance.

• Using the epimaps, with the planned programme the incidence &
prevalence could be brought down considerably.
d) District Data Bank

With the Computer and trained manpower, district data bank could
be established which will provide information :

Manpower - (Unit wise)
Inventory - Furniture, Equipment, Vehicle (Unit wise)
Performance data

for comparison
Survey (special) dataEpidemiological forecasting for control of epidemics
Developing tools for monitoring the coverage and quality

Planning the programmes.
6:3

STRENGTHENING THE HUMAN RESOURCE DEVELOPMENT

Discussed extensively in the chapter 5
6:4
a)

b)
*
•k

*
*
*

STRENGTHENING THE HEALTH PROMOTION & SOCIAL MOBILISATION
The strategies have been discussed extensively in the chapter
4. The most important aspect is the support and logistics
required for the strengthening of Block Communication cells
and District Communication unit.
ADP will provide financial, and technical support in
strengthening the Block and the district in terms of :

Equipment
Furniture
Transport
Facilities for production of print materials
Provision of Audio Visual materials

I >

69

Both the block cell and the district unit will supplement the
block teams and the district training teams.

c)

STATE

Z S S

I

C D M O
I

ADDL. CDMO
I
DISTRICT IEC
(MEIO/DY. MEIO

SUPPLIES

DISTRICT TRAINING
UNIT

1

T

BLOCK CELL (BEE)

MEDICAL OFFICER
CHC/PHC

DEMAND
GENERATION

QUALITY & COVERAGE

M S S

M P H W J
I
BENEFICIARY

1

6:5

DISTRICT HEALTH COMMITTEE/ZILLA SWASTHYA SAMITI

a)

District should be made as the focal point of planning
implementation
&
monitoring
of
all
the
health
care
services with support from the State. Govt. of Orissa
realising
the
important
role
<
of
the district
health
management system established District Health Committee called
zilla Swasthya Samiti under chairmanship of the district
collector and CDMO/Addl. CDMO as the member secretary, The
major objective of ZSS :

70

To obtain support of entire district level machinery for
demand generation, quality & coverage of health care services,
effective use of information in planning, implementation and
monitoring of programmes and financial flexibility.

District level planning
Decentralisation
financial powers

and

delegation

of

administrative

and

Flexibility
’Effective use of information system

6:6

CHANGES FOR PROPOSED MANAGERIAL EFFECTIVENESS

1.

It is proposed that CDMO will be overall in charge but his
focus and attention will be specially on :

• Hospital - Curative Care

• Administration
• Finance through ZSS
• Public Health Matters
The role of Addl. CDMO will be modified and he will be
nominated to look after all the schemes which include the 5
health priorities of the State.
2.

It is proposed that all the district level officers like
DIO/DMO/DLO/DTO etc. will be instructed to review all the
5 health priority programmes of the State while they are on
tour and keep Addl. CDMO and the respective programme officers
informed.

3.

It is proposed that the MEIOs will be entrusted with the
responsibility for demand generation under the direct
supervision of CDMO/Dy. Director (IEC). MEIOs will be directly
responsible for establishing linkages with ICDS,
education (literacy campaign) and MSS.

I \

I

71
6:6.4

PILOT EXPERIMENT

All the individual programme officers will be redesignated as
programme officer 1,2,3 etc. with definite area jurisdiction.
They will be responsible for all the programmes under their
jurisdiction under the direct supervision of Addl. CDMO.

ADDL. CDMO

I

pf1
I

I

PO2

I

PO3

I

PC 4

I

PC 5

I

I

PO6

I

2 BLOCKS

The pilot experiment will be carried out in the district of
Keonjhar for a period of one year. It is also preferable to
take up one Phase-I and one non project district in this
experiment. The experiment will be closely monitored for a
period of one year and if successful it will be expanded
through out the State.
6:6.5

SUBDIVISIONAL LEVEL

The present•system of SDMO supervising the CHC/PHC will be
restricted only to the referral system. The programme officers
will directly supervise the CHC/PHC for all the programmes
under the guidance of Addl. CDMO and overall supervision of
the CDMO.

6:6.6
a)

At the block level, the BEE will be sguarely responsible for
all demand generation and coordination activities and with
Medical officers service support, they will develop linkages
with ICDS, adult literacy campaign, opinion leaders and MSS.
They will work under the direct control and supervision of
MEIOs.

b)

MO of PHC/CHC will be responsible for servicest logistic
support for programmes.

• c)

/ \

BLOCK LEVEL

BEE will be responsible in organising training programmes
especially for' MSS for demand generation where as MOs will be
responsible for organising training programmes for services
and support.

72

d)

6:6.7

All the block level functionaries i.e; MO, BEE HA (F) & (M)
will carry out their work and supervision as per the fixed day
schedule (enclosed in annex II)

VILLAGE LEVEL

HWS will strictly adhere to the fixed day schedule
(enclosed in annex III)

Training focus at this level will be more in skill
development.
The programmes at this level will be of a team approach.
( HA, MPHWS, TEAS, VHG, MSS etc.)

Village level workers will provide support to MSS/YC in
each village.

/ \

REFERENCES :

/

1.

National Health Policy - Ministry of Health & Family Welfare,
Government of India.

2.

Action plan for revamping the family welfare programme in
India - Ministry of Health & Family Welfare, Government of
India.

3.

Population Control - Challenges and strategies - Ministry of
Health & Family Welfare, Government of India.

4.

Seventh population project document of the World Bank 1990.

5.

Concept paper on Evolution and Relevance of Area Development
Dr. Harcharan Singh.
Programmes (H & FW)

6.

Health Management Information System in India Dr. G. Narayana.

7.

Child Survival and Safe Motherhood - A plan of action for
Orissa, Department of Health & Family Welfare, Government of
Orissa and UNICEF 1991.

8.

Macro Strategy for Inservice Training of Health & Family
Welfare Personnel - J.P. Gupta, S. Bhatnagar & A. Banerjee National Institute of Health & Family Welfare, New Delhi.

9.

An approach paper on Health Human Resource Development - ODA
assisted Orissa Health & Family Welfare Project Phase-II - Dr.
M.R. Bhupathy etall.

10.

Orissa Population Scenario 1992 - Frame work for alternative
strategies - Dr. M.R. Bhupathy & Ms. Alison Dembo Rath.

11.

Health Status in Orissa 1990 & 1992

Dr. Almas Ali etall.

I

I.,'
Draft

Activities of Health Supervisor-Female (L/lV/
(a)

TECHNICAL SUPERVISION
(1)

Immunization:

Sterilization of Needles .and' Syringes,
" '
Maintenance of Cold
Chain and Immunization skill of Health Worker
(2)

Maternal Care:

Skill to conduct tante
‘ natal
...
check-up, weighing of the mother
and babies, Care at birth,
.i
", P
Post-natal
visit of the previous
F/eeVs delivery, Prophylatic anti-malarials To
pregnant
mothers (Keonjhar dist,)
(b)

SUPPLIES AND EQUIPMENTS

Physical verification of stock at Sub­
centres and arranging
replenishment of supplies
(c)

i

7

\

(d)

TRAINING
(1)

On the job training for health worker-female

(2)

Supervising TEA training

(3)

Mother’s meeting

SCRUTINY OF RECORDS

(1)

Mother Child Care Record

(2)

Counterfoils of Mother-Infant Immunization Card

(3)

Village-wise Coverage Register

(4)

Eligible Couple/Acceptor Register

(5)

Community Based Surveillance

(6)

Ante-natal/Delivery/Post-natal Regis ter

(7)

Reporting Fee Disbursal Record

■I

(e)

(f)

FAMILY PLANNING

(1)

Follow up of IUD acceptors/Tubectomy

(2)

Verification of lUD/Oral Contraceptives

ORT/ARI

Visiting any child of diarrhoea or ARI to assess home-practices of
management and health workers skill to manage such cases
(g)

ICDS
Visit Anganwadis, monitor the progress of third and fourth degree
malnutrition and follow up of referral cases

(h)

SCHOOL HEALTH
Health Education, promotion of personal hygiene and conducting
school immunization.

(i)

REPORTING

Sector level collation and compilation of reports
Preparation of epidemic report

(J)

AREA SPECIFIC ACTIVITY

Supervision of malaria chemoprophylaxis (Keonjhar)

r
£

Draft
SAMPLE MON'i HLY WORK PLAN,J

r

*

I
$

MPHW (F)

Week

Monday

Tuesday14

Wednesday

Thursday

F rid ay

Saturday15

First

Home
Visit
Village 1

FP •
services

SC (MCH)
clinic

*Immun.

Home
visit
Village 5

Open

Home
Visit
Village 2

FP

Open

Third

Home
visit
Village 3

Fourth

Home
visit
Village 4

Second

Session
Village 3

SC(MCH)
Immun.
clinic

*lininun.
Session
Village 4

Immun.
session
in hanilet(s)
left out

FP

SC(MCll)
Clinic

*Iinniun.
Session
Village 1

1 lonie
visit
to
hamlets

Open

FP

SC(MCH)
Clinic

*lmmun.

Innnun.
Session
Village 5

Open

■■

Fifth

Session
Village .2

-ItoL-

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.
I

Must be done :
- IUD insertion
Updation of data - Under 1
- CC/OP distribution
- Under 5
- Immunization
- ELCO
- Pregnant mothers
- Fever cases
Motivation for FP, MCH, Safe delivery, ORT & Chloroquin for fever.

I.

13

.

This is only a model workplan. This may be changed to suit local conditions. Mothers’
meetings, contact with informants for community based surveillance and supervision of
ORS/Chloroquine/Condom depot holders will be held as a part of the home visit or
Immunization/MCH session at the village level

14

This may be changed to some other day depending on the pattern followed in individual
PHO areas. The activities of the corresponding day may accordingly be exchanged

15

Open - state or district concerned may idcnlifiy specific activities which can include,
mothers’ meetings, sectoral/PHC meeting, sessions in hamlets not covered on other days;

V.'

.‘!Or:THLY WORKPLAN C- HEALTH SUPERVISORS F MALE (LHV;
! Week

’Monday

T uesday

i------

— i---------



i

i

i

i

’First

!Sub-Centre-6
!Field Visits

i
i

Sub-Centre-5
Field Visits

i

’Wednesday

JThursday

i-------------

i-----------

'Friday

! Saturday

i

i

i

i

i

!Sub-Centre-1
!MCH/
!Immunization

!Sub-Centre-4
‘Field Visits

!Sub-Centre-2
’ Field Visits

ISector Meeting

i

i

i

i—

—!

i

i

i

i

i

i

i

i

i

i

i

i

JSecond

!Sub-Centre-1
I Fie Id Visits

!Sub-Centre-3
•Field Visits

!Sub-Centre-5

i

i

Family Planning ! Sub-Cert re-2
Camps at PHC/
!MCH
Sector


1HCH/
!Immunization

i

HOL

i

i

i

I

i

i

i

i

i

i

i

i

i

i

• Sub-Centre-3
!MCH/
!Immunization

’Sub-Centre-6
’Field Visits

!Sub-Centre-1
!Fie Id Visits

ISector Meeting

i

i

i

i

i

i

•’Third
i

i

!Sub-Centre-4
!Field Visits

!Sub-Centre-3
‘Field Visits

i

i

i

i

i

i

i

i

i

i

i

i

i

! Sub-Centre-5
!Field Visits

! Sub-Centre-6
!MCH/
’Immunization

i

i

i

i

i--------------

i
i

i

i

! Fourth

!Sub-Centre-2
’Field Visits

!Family Planning !Sub-Centre-4
!Camps at PHC/
!MCH/
! Sector
!Immunizaticn

i
i

i

i

i

i

i
i

i

I

i

’Fifth

!Any missed activities on scheduled day.

i

i

!

!1 mother’s meeting per month

Last Working day PHC meeting

JSector Meeting
i

Draft

Ma Ie Supervisors ’ Acti vj ty Schedu1e
the

col 1ected on

(1 )

Cross checking blood smears
day or previous day.

(2)

Check radical treatment being g i ven/comp1 eted.

(3)

Supervise the
spray period.

(4)

Health education on environmenta1 sanitation,
personal protection against mosquito bites.

(5)

Verify drug position
rep 1 en ishment

(6)

Support
areas

(7)

Supervise and update
of Health worker

(d)

Verify maternal1 deaths, Neo-natal deaths and
po1io cases <and
--- seek Medical Officers help.

(9)

out-break
Investigate Meas les
conta inment measures.

(10)

and
supervise
containment
Organize
for
polio
in
his
sector
.
immuni zation

(12) a)

( 14)

vaccine

in

spray

the

duri ng

DDC/FTD

and

ensure

to

SC

in

transportation

service/education

and

grey

skill

take

up

Verify quality of ante-natal care gliven to a 1 1
includes education on
pregnant women, which
TEA
toxoid
coverage,
nutrition,
tetanus
coverage and referral if required.

(11)

(13)

insec11cida 1

Group meetings
condom use.

for promoting

vasectomies

and

b)

Regularity of use of condoms.

c)

Ensure supply of Nirodh and oral pills.

d)

Verify updating of Eligible Couple registers.

Verify all diarrhoea1/ARI episodes of 24 hours
duration.
Supportive supervision for case assessment and
management of the above and conducting of
mothers meeting etc.

management
case
for diarrhoea.

and

(15)

During
epidemics
containment measures

(15)

Assess
village
level
ORS
ensure
ORS
availability
through workers/vo1unteers .

(17)

Verification of supply logistics
needs and ensure reallocation.

(13)

Scrutinize record maintenance, loca1
and initiate necessary actions.

(19)

Check drinking water sources, promote use of
water from safe sources and educate personal
and food hygiene.

(20)

School health - personal health, provision of
safe water and environmental sanitation.

(21 )

General
sanitation
-Promote
sanitary
latrine, safe disposal of refuse (composting)
and waste water (soakage pit)

(22)

Verify all births
cause of death.

(23)

Investigate area specific health problems and
initiate remedial action.

and
aval 1abi 1 i ty
in
each
v i 1 1 age

and deaths

and

as

per

the

ana 1ysis

investi gate

MONTHLY WORKPLAN FOR MALE SUPERVISOR

Monday

Wednesday

!Field Visit
!Sub-Centre-3

{
{Supervision
!MCH/
‘Immunization

i

First

1

Tuesday

i

!
.

\ {
.
I.
* i NSS
^1 Sector
ISiib-Centre-4
! Sub-Centre-2 ’ {Meetings

i
i ’

. i
i
i
i

i

{Clinic’

!

i

i

i

‘Sub-Centre-5

!

i

i

i

i

i

i •

’Field Visit
!Sub-Centre-1

!Sector
{Meetings

i

i

i

!Sub-Centre-1

!Sector
!Meetings

i

i

!Sub-Centre-5

!Field Visit '
!Sub-Centre-4

!Sector
{Meetings

!Sub-Centre-3

!

i

!Sub-Centre-5

i

!Sub-Centre-6

i

I

- .

.

/

I

i

i

i

i

!

i

i

i

i

Fifth

i

j

* !
-

‘Field Visit
!Sub-Centre-1

{Family Planning !
iCamp
{Sub-Centre-2

i

i

i

{Family Planning !
{Camp
!Sub-Centre-6
{

Fourth

i

{Family Planning {

!

Thi rd

Saturday

i

i

Second

Friday

---- 1

i

Visit to
PHC

Thursday

!Meeting at PHC

Any missed activities on scheduled day .
Collection and analysis of data

i

‘Last Working
‘Day


* Community Day

Touring by Units

Draft
WORKPLAN FOR BEE

WEEK

TUESDAY

30-1/13

RB/V
Motivation

30-2/14

FP
Comp

30-6/18

30-3/15

RB/V
Motivation

30-7/19

30-4/16

FP
CaMp

0

I

0
II

0
III

8

IV

«



3C-5/17







S
30-8/20

SAIunoAY

FRIDAY

THURSDAY

WEDNESDAY

MONDAY

Sector I
Support to■
R33/Y3
Meeting

9

Sector 2
Support to
M33/Y3
Meeting

0

Sector 3
Support to
M33/Y3
Mooting

0

Sector 4
Support to
H3S/Y3

0

3C-9/21

Sectoral
Meeting
3-1

30-10/22

3-2

30-11/23

3-3

30-12/24

3-4

Mooting
Review Health

Educat 1 cxi
efforts
and plan for
next Meeting

V

PHO
•oeting

-->

Update Staff on
1 priority Issue
& oDBontial coMMunication points
(1

tKXjr)

BEE Mill support 1 sub-centre in one soctor/each Meek by rotation.
Orte nub-centre in each
sector Mill get his support, Mherein tw Mill use audio-visuals and conduct mass meetings.

RB/V Motivation :
Resistant beneficiaries/vi1 lags direct motivation
Soc tora 1 kh) ting:

To plan and implement prob lorn/intervention
specific publ ici ty/domand generation effewts.

Hors numbering is given assuming that there are four sectors and each sector tuts got G sub­
centres.
i)

Di root support to hoalt/i trorkors. to improve their coourun i ca t i on skills

H)

Contact Local influoncoa (Isadora) for FW/MCH/InBocticidal Spray

Hi)

Each sub-centre Mi 11 be visited a 1 ternate eon ths, and in tt>o sub-centre all vi 1 Iagos Mill be
visited in each year.

/Isgugpt long:

1 BEE per Block PfiC
No. of sub-centres to be supervised

Task?;

a)
b)

c)
d)
e)

f)

\

24

= 4 sectors.

Supporting to improve Interpersonal communication skills of HWs.
Demand generation for services
Promoting utilization of services
Mass Media activities
Preparing area specific
Ensuring of reaching of communication materials

MONTHLY WORKPLAN’ G" MEDICAL OFFICER

i

i

Monday

-------------I-

J

I

OP/IP

1

J

i—

‘First

! OP and Review
!
with Male
i
Supervisor

i

Tuesday

i

i

i

Field Supervision j

!

i

Sub-Centre-1

Wednesday

i

i

Thursday

I

OP

i

OP/IP

i

i

i

i

i

i

Friday

Saturday

i

-------- 1

!OP/Irnmunization !
!
HCH Clinic
!

!

i

Sub-Centre *
Clinic 6

i

GP/IP

i

i

i

i

i

i—

i
i

Sub-Centre
Clinic 5

i

OP/IP
Sectoral
Review

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Sub-Centre^

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Clinic-4

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i-----------------t

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’Second

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‘Family Planning ‘

Camp
!

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Field Supervision !
Sub-Centre-2
!

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“do”

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OP/IP
"do”


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Third

"do"

I

i--------

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Sub-Centre
Clinic 6

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OP/IP

OP/IP

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OP/IP, SR

i—

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!

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Sub-Centre
Clinic 5

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Sub-Centre
Clinic-4

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OP/IP

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OP/IP, SR’

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Sub-Centre
Clinic 6

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i

i —

"do"

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OP



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Sub-Centre
Clinic 5

!

Sub-Centre
Clinic-4

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Fourth

"do"
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OP/IP

"do"

'Family Planning !

!

Camp

!

Sub-Centre
Clinic 6

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OP/IP
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OP/IP, .SR

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Sub-Centre
Clinic-4

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Sub-Centre
Clinic 5

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Fifth

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Last

Working

Day

PHC

Meeting
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X

Suo-centre clinics once a week in 2-3 farthest sub-centres-.

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CHILDREN BY CHOICE NOT CHANCE

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Position: 980 (5 views)