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Report for discussion on
1 Sth & 19th September 1997
NOT FOR CIRCULATION
REVIEW
OF THE,
JAN SWASTHYA RAKSHAK SCHEME
OF THE
GOVERNMENT OF MADHYA PRADESH
JULY - SEPTEMBER 1997
Community Health Cell,
Society for Community Health Awareness, Research and Action,
No.367, Srinivasa Nilaya, Jakkasandra I Main, Koramangala I Block, Bangalore - 560 034,
d
CONTENTS
Particulars
Sl.No.
I
II
III
Introduction
Objectives of Jan Swasthya Rakshak Scheme
Methodology
*
*
*
*
*
*
*
Page No
3
8
11
Identification of levels of administrative set-up
Identification of functional areas of Study
Sources of Data
Development of instruments
Sample size and Design
Methodology for collection of Data
Analysis & Interpretation of Data
IV
Selection of JSR
16
V
Assessment of Training
17
*
*
*
*
*
*
VI
Examination process
*
*
VII
VIII
Perception of Trainers
Training Process
Training Manual
JSR manual - comments of the evaluators
Suggestions by the trainers for improving the
training process
Suggestions by the trainers for improving the
functioning of the JSR Scheme
Pattern of Examination
Review of knowledge of JSRs
View of the Jan Swasthya Rakshaks on JSR
scheme
* Training methodology
Perception of Community Members and
Community Leaders of the JSR scheme
*
*
26
29
39
Community members
Community leaders
2
b
IX
X
XI
Views of the Chief Medical Officers on the JSR
scheme
Views of the Presidents of District Health
Committees on JSR Scheme
Summary of Key Findings
*
*
*
*
*
*
*
*
*
XII
41
42
44
Objectives
Selection Process
Training
Examinations
Functions of JSRs
Fee for Service
Supervision
Administrative Details
Concerns
Recommendations
51
A. Selection Process
B. Training
C. Examinations
D. Supervision
E. Functions of JSRs
F. Administrative Details
SOME CONCERNS
55
Appendices
1.
2.
3.
4.
5.
6.
7.
JSR Scheme announcement
Details of JSR scheme
Functions of JSR
Instruments of data collection
Question papers of first JSR examination
Analysis of JSR Examination Papers
Review questionnaire containing hypothetical
case studies
56
57
61
63
83
85
86
3
L fflTBODUCTION
Madhya Pradesh with the largest land mass amongst Indian states presents a
fascinating hue of cultural and geographical diversity. A total of 71,256 villages with
varying population are scattered over this region and 76.82% of the” State’s population is
rural-based. To provide “Health Care for All by 2000 AD” in such a situation is a
daunting task indeed. There continues to exist large unmet felt need for health services.
As in rest of India, rural health care is a perpetual problem. Notwithstanding the vast
network of Block and Sector PHCs and subcentres, a large percentage of rural population
is unable to obtain comprehensive health care. A comparison of rural and urban birth
rates (35 and 24.3 per 1000 population, crude death rates (12.6 and 7.3, per 1000
population) and Infant Mortality rates (105 and 75 per 1000 live births) reveals the extent
of health problems and needs lying unluliiRed"specially in rural areas.
TABLE 1 :
District Profile and Regional Disparities in Madhya
Pradesh
State/District
Total
Population
Percen
tage of
Rural
Popula
tion
Rural
Female
Literacy
Rate
Total (Rural &
Urban)
Rural
SC
ST
SR
CBR
TFR
(1984-90)
(1984-90)
Madhya Pradesh
Total
Rural
Urban
^66,181,170
50.842.333
15,338.837
28.85
19.73
58.92
14.55
14.80
15.72
23.27
28.82
4.87
931
943
893
37.2
5.0
76.82
1,359,632
967,857
582,163
307,352
960,907
1,054,741
781,815
934,552
598,378
1,166,357
735,203
1,176,220
1,318,172
1,375,673
1,284,586
79.48
79.40
41.21
77.55
84.81
80.50
83.10
80.70
86.98
70.79
81.86
80.27
84.77
78.89
93.53
14.88
23.55
16.46
16.08
9.36
10.12
15.39
14.12
14.85
26.83
23.52
22.19
22.81
12.85
11.40
19.87
22.17
23.84
27.23
19.87
18.80
23.42
25.11
20.97
21.47
20.14
18.23
15.38
7.20
11.52
6.83
0.15
5.23
1.95
12.78
14.03
4.60
4.45
16.39
11.33
14.76
16.05
13.56
54.26
31.99
826
813
818
840
848
875
868
855
901
884
908
929
946
961
934
41.2
39.0
35.1
39.5
42.6
41.4
42.1
42.6
42.2
39.6
40.1
40.7
40.9
39.3
44.3
6.0
5.8
4.7
5.8
6.3
5.9
6.1
6.6
5.9
5.5
5.3
5.7
5.8
5.3
6.7
Districts
Morena
Bhind **
Gwalior
Datia
Shivpuri
Guna
Tikamgarh
Chhatarpur
Parma
Sagar
Damoh
Satna
Revva *★
Shahdol
Sidhi
C ft I
a
Particulars
Mandsaur
Ratlam
Ujjain
Shajapur
Dewas
Jhabua
Dhar **
Indore
West Nimar
East Nimar
Rajgarh
Vidisha **
Bhopal
Senor
Raisen
Betul
Hoshangabad
Jabalpur
Narsimhapur
Mandla
Chhindwara
Seoni
Balghat
Surguja
Bilaspur
Raigarh
Rajnandgaon
Durg______
Raipur
Bastar
Total
Population
1,195,939
662,151
836,403
850,362
766,147
1,032,325
1,187,702
561,397
1,722,871
1,037,491
825,926
775,303
270,677
690,025
738,645
961,551
920,695
1,443,501
663,708
1,192,213
1,206,351
906,024
1,236,083
1,831,471
3,148,763
1,559,232
1,213,184
1,551,734
3,136,420
2,109,431
Rural
%
Female
Literacy
Rate
Rural
76.90
68.13
60.47
82.30
74.11
91.32
86.86
30.58
84,95
72.47
83.19
79.90
20.03
82.01
84.28
81.38
72.66
54.47
84.50
92.33
76.90
90.53
90.50
87.94
83.00
90.53
84.25
64.73
80.26
92.87
SC - Scheduled Caste
ST - Scheduled Tribe
TFR - Total Fertility Rate
19.88
13.94
13.76
13.58
16.20
6.83
15.64
22.53
17.58
21.04
9.46
19.54
15.15
15.07
20.45
26.71
26.32
26.06
36.55
18.57
23.58
27.14
36.27
12.50
20.92
23.48
22.24
33.01
24.40
11.79
Total (Rural &
Urban)
Rural
SC
17.35
15.19
30.25
24.64
19.55
2.79
6.85
19.82
9.76
12.26
18.70
21.68
21.68
21.73
17.56
9.58.
16.84
12.50
17.10
4.98
11.38
10.81
8.19
5.09
19.12
11.13
9.64
13.51
15.06
5.51
SR - Sex Ratio
ST
5.69
32.72
2.60
2.68
18.50
91.14
59.45
12.09
53.00
36.09
3.68
5.23
4.26
11.53
16.37
44.58
22.20
28.04
14.37
64.87
42.10
40.16
23.16
59.22
26.33
51.16
28.84
16.05
21.58
71.17
SR
951
956
936
920
933
983
960
919
956
940
927
872
873
901
884
981
904
939
915
993
967
980
1,009
969
990
1,009
1,021
1,010
1,007
1,007
CBR
TFR
(1984-90)
(1984-90)
33.5
35.2
32.1
36.6
37.0
45.4
37.2
29.6
38.4
38.5
37.7
40.1
32.5
41.2
39.1
39.0
38.0
34.1
34.6
36.5
37.0
35.7
32.8
38.2
36.7
.32.5
36.2
33.6
34.4
35.9
____ 4,1
____ «
4.2
____ 5.1
____ 5.0
7.0
5.1
3.6
____ 53_
5.2
5.3
5.6
____ 3.8
6.0
____ 5.3
____ 5.6
5.4
4.2
4,6
5.0
5.3
5.0
4.2
5.3
5.0
4.3
5.0
4.2
4.6
5.0
CBR - Crude Birth Rate
* * Districts visited by Study team
Source : Health Monitor 1994 & 1995 (FRHS)
*
All the selected districts visited except Hoshangabad had a higher percentage of rural
population as compared to the rural population in Madhya Pradesh.
*
Dhar and Vidisha districts have a lower rural female literacy when compared to that of
the State.
*
Bhind and Vidisha have one of the lowest sex ratios. Due to various causes identified
in various other studies, this does greatly influence the socio-cultural practices
specially gender related in these 2 districts.
4
*
Except Bilaspur, the CBR and TFR were higher in all the other districts visited.
*
Bhind and Vidisha have a much higher and Dhar much lower schedule caste
population when compared to rural Madhya Pradesh.
*
Dhar has 59.45% rural population belonging to schedule tribes. Bhind hardly has any
tribal population. Their percentage is low in Vidisha and Rewa.
Where most villages do not have an all season approach road, where many rural
area posts still go unfilled because of reluctance of trained manpower to settle down in
rural areas and where facilities are more or less non-existent, even an ordinary curable
illness undertakes a sinister complexion and often ends in a severe complication or,
even death. Very often the cures required are simple and one which a trained and
competent health worker can provide in the village itself. For those, illnesses that are
truly serious, early identification and timely referral by such a village based worker can
make all the difference between an early recovery or chronic illness and / or death.
Taking cognizance of the above situation and to improve health care services in
rural areas, the Government of Madhya Pradesh launched the “Jan Swasthya Rakshak”
Scheme on 19 November 1995. The scheme envisages that there will be one trained JSR
in each and every village of Madhya Pradesh. (Appendix 1)
This is very much in tune with what was recommended in 1974 by the Shrivastava
Committee - - “the creation of large groups of part-time semi-professional workers,
selected from amongst the community itself, who would be close to the people, live with
them, provide preventive and promotive health services including family planning in
addition to looking after common ailments”. These were to be essentially self-employed
people and therefore not a part of Government bureaucracy. The Rural Health Scheme
announced by the MHFW, GOI to strengthen health care services in rural areas was an
extension of the above concept. Under the scheme, every village or community with a
population of 1000, had to select one representative who was willing to serve the
community and enjoyed its confidence. The tasks expected of the community health
workers were:
*
*
*
*
immunisation of the new bom and young children;
distribution of nutritional supplements;
treatment of malaria and collection of blood samples; and
elementary curative needs of the community.
The overall philosophy of the scheme was that the health work which was till then looked
after largely by Government was for the first time to also rest in the hands of the people.
The community health worker belonging to the same community would be accountable to
them and they in turn would supervise his / her work.
The community health worker was not envisaged to be a full time health worker
and was expected to perform community health work in his/her spare time for about 2-3
hours daily. During the period of training, the trainees were given a stipend of Rs. 200-00
per month for 3 months and a simple medicine kit. Once they commenced work they
5
were given an honorarium of Rs. 50-00 per month and Rs. 600-00 worth of medicines per
year.
The responsibility of the Government was limited to provide training and
technical guidance. The philosophy of community involvement and participation in the
provision of primary health services, also implied that the community would supplement
the resources required for the continuation of this work and would completely takeover
the programme at a subsequent period of time.
The scheme which was introduced on 2nd October, 1977 evoked wide public
interest. While no one doubted the sincerity of the Government in providing health care
to the rural masses, the programme came in for adverse criticism right from the outset.
The Government was blamed for inadequate preparation, lack of pilot studies on
feasibility especially in the light of heavy investment of public funds required for its
implementation and for promoting quackery. In addition, community support remained
minimal to nil and the envisaged possibility of the community taking over the programme
was an impossible proposition under the circumstances.
Because of the above and various other reasons like non-replishnment of kits, non
payment of honorarium, etc., community health workers scheme which from the
beginning had a poor chance to succeed never really took off. Unable to wind it up, due
to various matters which are at present subjudice, the Government is now burdened with
the recurrent costs for a “non-functional” scheme - the penalty of ill planning, hasty
implementation and blind faith.
The detailed description of the 1977 CHW scheme is not out of context here. It
had many lessons to teach and because of the many similarities of the present JSR scheme
to it, it would still be worthwhile to review it - if not for anything else atleast. to avoid
repeating the mistakes of the past.
It is also necessary to understand that provision of primary health care to the rural
population by voluntary health workers is not without scientific foundation. A large
number of countries all over the world have and are extensively employing bands of
trained voluntary workers for this purpose with great success. Alternative strategies for
delivery of health care in different parts of our own country have revealed their potential.
It is true that these projects do widely vary on a number of dimensions and taking them to
scale would reveal some of their deficiencies. Despite these variations, the projects have
proved beyond doubt the potential of non-health workers in the delivery of primary health
care to the rural communities as revealed by their popularity and acceptability as well as
their fairly impressive results in improving health status and decreasing illnesses.
The present JSR scheme has tried to obviate some of the problems which plagued the old
CHW Scheme. The scheme has issued clearcut guidelines on the selection process,
training, examination, registration, functions of JSRs and code of conduct.
6
T
Details of the present JSR Scheme are given in Appendix 2.
The terms of reference of the present Review were to:
i.
document the profile of the JSRs in five districts in different regions of Madhya
Pradesh;
ii. examine the process of selection of the JSRs by the community;
iii. document the content and methodology of training in selected PHCs with a view
to strengthen this process, keeping in mind the skills required for provision of
essential child survival and safe motherhood services at village level; and
iv. document the system of examination after training for certification of the JSRs to
suggest improvements in the system.
In addition, we also looked at a few administrative and management aspects of the
scheme as well as the attitude towards and perception of the scheme by community,
panchayat and health department officials. An attempt has also been made to make
specific recommendations for strengthening the scheme.
At the outset, we would like to clarify that at the time of Review not a single JSR had
received his registration certificate - a necessary prerequisite to practise as mentioned in
the Government orders on the Scheme. Because of this, the actual, practical Review of the
performance of JSRs in the field was not feasible. Only indirect information of their
assisting or non-assisting in the implementation of national programmes like
immunisation, etc., could be obtained. A study of the effectiveness of the services
provided by the JSRs and their benefits to the community will necessarily have to await
some reasonably long time after the scheme is able to get off the ground.
IL OBJECTIVES OF JAN SWASTHYA RAKSHAK
SCHEME
Exactly 18 years and 47 days after the launch of the Community Health Worker Scheme,
the Government of Madhya Pradesh on 19 November, 1995 launched the Jan Swasthya
Rakshak Scheme under the Integrated Rural Development Programme (IRDP) for
unemployed rural youth to provide round the clock curative, preventive and promotive
health services in every village of Madhya Pradesh.
The objectives of the Jan Swasthya Rakshak Scheme are as follows:
1. For improving the health in rural areas, to provide a trained worker who can give first
aid care and treat small illnesses scientifically, in the village itself. Efforts are to be
made to have both males and females in this Scheme.
2. To provide a trained worker in the village who can assist in the implementation of
National Health Programmes and health schemes of the Government.
The Scheme has outlined a list of 24 functions for the Jan Swasthya Rakshak (Appendix 3).
These include provision of curative services and first aid care in the village itself,
recognition of serious illnesses and epidemics and their immediate notification to health
centres so as to provide optimum health care, providing assistance in the implementation
of MCH and RCH and other national programmes in the village, collecting health related
information and maintaining registers.
TABLE 2 : Analysis of functions of JSR as mentioned in the Manual
1.
2.
3.
4.
5.
6.
Type of Function
Preventive
Promotive
Environment promotion
Health Education
Health Statistics
Curative
TOTAL:
Number in Manual
1,2,16,18,20,21,22,24
3,7,8,9,10,11,16,23
4
5,12,15.
6, 19
13, 14, 17
Total
8
7
1
Percentage
33.33
3
2
3
24
Of the 24 functions envisaged for a JSR, 8 are preventive, 7 promotive and 3 health
education related. Only 3 of the 24 functions are curative in nature. From the above, it is
quite clear that a JSR will necessarily have to spend a large amount of time on preventive
and promotive activities.
Besides the provision of health services to rural areas, by recommending that only
unemployed, educated youth who belonged to families below the poverty line be chosen
for training, the scheme hoped to provide an occupation to atleast some of them and
8
thereby a means of livelihood. Thus, all financial assistance for training, including
stipend, contingency and loans for setting up the clinic are to come from the IRDP and the
health department has to impart the training and provide all necessary technical
assistance.
By involving an unemployed, educated youth of the village chosen by the village
panchayat, in preventive, promotive and curative health care, it was felt that the overall
health status of villagers would show improvement. Assisting in the removal of false
cultural beliefs, improving the environment, implementing the MCH and RCH
programmes like Immunisation, Family Welfare, Tuberculosis, Malaria, giving Health
Education to the villagers on various issues and by provision of curative care, the JSR
would help play an instrumental part in improving the overall health status of the
villagers. Needless to say, this would then have a positive influence and effect on many
other areas of the daily life of a villager.
The objectives and activities of the JSR Scheme have many commonalties with the
Community Health Worker Scheme of 1977. But, there are some important differences.
Important amongst these are :
1. increased the duration of training six months (it was three months in the CHW
Scheme);
2. increased stipend from Rs.200-00 to Rs.500-00 per month, during the training period
with funds coming from TRYSEM (it was Rs.200/- in the CHW scheme and the funds
were not from TRYSEM);
3. no monthly honorarium is to be paid to the JSRs. Instead, JSRs who successfully
complete the course are to be given a registration certificate which will allow them to
‘practise’ in the village which nominated them for JSR training. Guidelines which
state that they are to provide curative care only for illnesses mentioned in their
training manual and for which they have been given training as well as the drugs
they can use for treatment of these minor illnesses have been established. To assist in
the establishment of their practise, JSRs who successfully complete their course are
eligible to obtain a loan with subsidy from IRDP under TRYSEM scheme;
4. only those who have passed upto 10th standard are eligible for JSR training (CHW
scheme permitted those with formal education upto 6th standard and above);
5. whenever qualifications and other criteria are similar, women are to be given
preference over men in the selection process.
Though on first impression, these changes appear to be minor, the Scheme as now
envisaged differs in 2 radical ways from the old CHW Scheme. Not providing a monthly
honorarium and allowing market forces to determine their income per se could push their
priorities of JSRs to the paid curative services over preventive and promotive services
specially with the spectre of loan repayment looming over their heads. Secondly, under
the present format of certification, the Government has no direct supervisory powers over
the JSRs as they are not staff of the Health and Family Welfare department and the JSRs
9
theoretically have the liberty to pursue their practise and curative care without having the
compulsion of carrying out preventive and promotive services or assisting Government in
the implementation of National Health Programmes as envisaged in the Scheme.
TABLE 3 : Comparison between CHWs and JSRs
Criteria
Duration of training
Stipend
Honorarium
Practice
Eligibility
_______ CHWs_______
3 months
Rs.200-00
Rs.50-00 per month
No
studied upto 6th standard
JSRs
6 months
Rs.500-00
loan - subsidy
Yes
Passed 1 Oth standard
10
HL METHODOLOGY
The development of the methodology for this Review Study was influenced to a
considerable degree by the purpose and scope of Review and the time-constraint involved
in conducting a state-wide study. The various aspects of the methodology can be broadly
classified as follows:
1.
2.
3.
4.
5.
6.
7.
identification of levels of administrative set-up;
identification of functional areas of study;
sources of data;
development of instruments;
sample size and design;
methodology for collection of data; and
analysis and integration of data.
Identification of levels of administrative set-up
Keeping in view the objectives of the Scheme and the operational details evolved for its
implementation, collecting and utilising information from sectors other than health
especially at the grass-root level, was considered desirable. Therefore, the levels of
administrative set-up from where the information was to be generated were decided as
follows:
I.
Organised health services set-up
a) District level concerned with operational details of scheme
b) Primary health centre complex concerned with training and implementation of
scheme at grass-root level.
II. Link between organized health services and community
Jan Swasthya Rakshak.
III. Beneficiaries or consumers and their representatives
1) Village level -a) community members
b) community leaders
c) village level workers
2) Block level - -
a) B.D.Os/C.E.Os
b) Block Level Presidents
3) District level -
a) Zilla Parishad President/members,
b) CEOs and President of Zilla Panchayat Health Committees.
11
An effort was made to meet representatives at all the above levels. Though there was no
difficulty at the village level, it was not always possible to meet representatives at Block
level or District level because of transfers or previous commitments necessitating their
absence from headquarters. Also, as some of the Panchayat representatives had left for
the Congress convention at Calcutta which was being held at the same time, we were
unable to elicit their views in some places which we surveyed.
Identification o f functional areas of Study
The functional areas or dimensions of the Scheme on which the Review was based are
given below.
These were worked out taking into consideration the status of
implementation of the Scheme at the time of conducting the study and in keeping with the
objectives and scope of Review.
i.
The extent of deviation of the Scheme in its actual implementation to date in different
districts;
ii. Attitude and commitment of JSR to his planned work;
iii. Attitude and perception of community members, leaders and primary health staff
towards the scheme in general and JSR of their villages in particular;
iv. Adequacy and appropriateness of medicines and drugs supplied to the JSRs;
v. Problems and bottlenecks in the effective selection and training of JSRs;
vi. Administrative and logistics aspects.
The functional areas were decided with a view to cover all the dimensions providing
thereby the factual attitudinal assessment of the implementors of the Scheme and potential
beneficiaries. These served as guiding principles on the basis of which instruments for
data collection were developed.
Sources o f data
The study involved collection of primary data from respondents at various levels of the
health administrative set up, as well as from the community members and leaders. Data
was also collected from secondary sources such as instructions and circulars issued at
different points of time and records of district were PHC levels.
The categories of personnel were chosen on the basis of extent of their involvement in the
planning or implementation stages of JSR scheme directly or indirectly. The number of
respondents in each category and the total number interviewed are as follows:
12
TABLE 4 : CATEGORY OF RESPONDENTS
Level of administrative
set-up
Category of respondents
District
Chief Medical Officer
C.E.O.
Deputy CEO
Block
B.D.O.
D.M.O.
M.O. Incharge training of JSR
Block Extension Educator
Male Supervisor
Lady Health Visitor
Jan Swasthya Rakshaks
Village
Community members
Community Leaders
Village Health Workers
Total no. of respondents
5
2
1
5
10
1
11
11
11
101
20 villages
20 villages
6
Development o f instruments
After having identified the functional areas mentioned earlier, different schedules meant
for collection of information from different categories of respondents were developed. In
all, 6 such schedules were developed. ( Appendix 4a to f). A number of areas were
common to some schedules. They were introduced deliberately to obtain information
from different respondents on the same dimensions of the scheme for the purpose of cross
checking and validation of data.
The schedules contained structured, unstructured and multiple choice items attempting to
cover knowledge, attitude and reaction of different levels of respondents.
The District and Block level schedules were in the form of guidelines and were
administered in the form of open-ended interviews.
Sample size and design
Because of the diversity of the State, at the outset it was decided to obtain data from as
many parts of the State as possible. Keeping in view the quantum of information to be
collected at different levels of administrative set-up within the constraints of time and
resources, a multi-stage sampling process was resorted to. From each of the five regions
of Madhya Pradesh, two districts each were initially selected randomly. From this two,
one was then again selected randomly. In these selected districts, two PHCs each were
selected more on the basis of practical consideration of time, resources and logistics rather
13
than on the basis of rigorous statistical requirements. The final list of Districts and PHCs
are given below.
TABLE 5 : Districts, Block Primary Health Centres
District
Vidisha
Bhind
Reewa
Block PHC
1. Peepal Kheda
Villages
1. Sunpura
2. Busran
2.
Gyaraspur
1.
2.
Furtula
Mudro Ganeshpur
1.
Phooph
1.
2.
Baralu
Deenpura
2.
Ater
1.
2.
Hamlet (Ater)
Johri Kotwal
1.
Govind Garh
1.
Agdal
2.
Sirmor
2.
Bachpao
Menhdi
1.
2.
Gadaghat
Alipar Kheda
1.
2.
Panela
Patliyapur
1.
2.
Badadi
Karchi/Ruprel
Hoshangabad
Piparia
Dhar
1.
Nalchha
2.
Sardarpur
In each of the PHC unit, effort was made to visit atleast two villages to discuss matters
related to the Scheme with community members and leaders. While conducting the field
survey, we were informed of RCH training being given to a large group of female “JSRs”
under a pilot project being funded by an international agency at Piparia Block PHC.
Since the functions and activities of this group were to be very similar to the JSRs in other
districts, we decided to review the process of selection and training at Piparia Block PHC
also. The relevance of including Piparia was all the more important since at all the other
centres there were hardly any female volunteers for JSR training (0 to less than 3).
Methodology for collection o f data
For the purpose of collection of data, a team of two members visited the various
institutions and administered the various questionnaires to different categories of
respondents and held open-ended interviews as appropriate with the different levels of
personnel mentioned earlier. Discussions were held with community members and
leaders of identified villages based on guidelines mentioned earlier. Discussions were
also held with JSRs after they submitted their filled up questionnaires to elicit their views
in a group situation.
U/vx$l
14
Analysis and interpretation of data
All data collected was analysed either manually or with the help of the Computer and
appropriate interpretations were made from the analysed data.
15
IV, SELECTION OF JSR
Clear guidelines (Appendix 2) have been issued for the selection of JSRs. The
Government was supposed to give information of the Scheme via newspapers, radio and
television and by putting up notices at the Gram Panchayat Office and other prominent
places. However, during our survey, in none of the villages visited by us was the above
carried out and the only information that Gram Panchayat received was a letter asking that
one of the villagers who fits the criteria be nominated for JSR training to the Janpad
Panchayat. Also, no efforts were made to make use of locally available communication
means or other field based organisations for this activity.
The JSR nominee from 40% of the villages that we visited, was chosen by a few leaders
of the village (or the Sarpanch himself). In 3 places, there was a Gram Sabha meeting
called where the most appropriate name was suggested. Often nominations were arbitrary
and depended upon extraneous factors. As mentioned later, of the 101 JSRs who
participated in the Review process, 82.2% were selected by the Gram Panchayat and
13.8% by the Janpad Panchayat.
Some areas adopted novel methods to select JSRs. Thus to obtain the most ideal person,
in Pipariya PHC region, health camps were arranged in the villages of the district where
adequate information was then given to the village leaders and villagers of the Scheme
and the need to select the most appropriate candidate. This greatly helped in selecting the
right candidates. As mentioned earlier, it was not that all selections were arbitrary. In
some villages, the Gram Sabha did meet and chose the most appropriate candidate. But
very often, only 10-15% of the members attend the Gram Sabha and this becomes a
stumbling block to free and fair selection - since by being absent most villagers are then
unaware of the Scheme or its objectives and by fault the appropriate person does not
apply. At the same time, we did come across 3 cases where the Sarpanch himself decided
who should be sent for training and did not inform the villagers.
The inappropriate selection of the JSR trainees has many ramifications. The duties of a
JSR calls for a certain degree of commitment. The trainers clearly mentioned that during
the training period they did observe that some JSRs were not interested in the training
(they were coming as “timepass”, “for the stipend” or because it might lead to a
permanent government job later). This is bound to affect the performance of the JSRs and
will also be detrimental to the welfare of the village. The whole objective of the Scheme
would then be defeated if the villagers are not going to benefit from the Scheme.
Selection of JSR trainees therefore needs to be given further thought. One of the
suggestions given by one group of trainers was to make it criteria based and since the
health department staff visit every house in the village, their help be taken in
identification of right nominees from whom Panchayat can select the most appropriate
candidate based on a set of defined criteria. However, we feel selection has to be in the
hands of the people - Gram Sabha and they may take the help of teachers, anganwadi
workers or other government functionaries who are familiar with the residents of the
village. The success of the JSR Scheme to a large extent will depend on the competence
and commitment of the JSR and appropriate selection of candidates is most essential.
16
V. ASSESSMENT OF TRAINING
A. PERCEPTION OF TRAINERS
With a view to ascertain the opinion of various category of trainers on the scheme in
general and the training process and supervis’ n specifically, open-ended interviews
based on set guide-lines were held in every Block PHC visited. Ideally, we would have
liked to interview each trainer individually but because of time constraints, the whole
team of trainers were interviewed together in a group initially and later the trainers were
asked to give their individual opinions if it differed from the group opinion. The
responses from all members were then collated and analysed.
Objectives
TABLE 6 : The trainers mentioned the following objectives of the JSR Scheme:
Objectives
1. Provision of health care for minor illnesses
2. Helping the health team in National Health Programmes
3.
4.
5.
6.
7.
Assisting in immunization and motivating for FP
Chlorinating wells
Improving health of the villagers
Production of village based cadre of health workers
Provision of jobs for unemployed educated youth
Percentage
81
72
72
27
18
9
9
The above does indicate that the trainers were aware of the main objectives of the scheme.
The JSR will facilitate the health department in the implementation of National Health
Programmes (81%) was the main expectation the trainers had from the JSR Scheme.
Besides this, provision of health care for minor illnesses (72%), referral of emergencies in
time (18%), acting as a link person between community and health department (9%), were
the other main responses. Carrying out their duties sincerely and as recommended and
taught to them (63%) was the expectation from JSRs which was mentioned most
frequently by the trainers. Not becoming injection doctors or “quacks” was the other
main expectation (54%).
Two groups (18%) also mentioned improvement of
environment of the village as one of their expectations of the JSRs.
17
TABLE 7 : Treatment of ailments to be treated by JSRs as identified by trainers
1.
2.
3.
4.
5.
6.
7.
Ailments
Diarrhoea
Fever
Minor ailments
Malaria
First aid
Coughs & colds
Eye discharges
Percentage
100
100
45
18
18
9
9
From the above, it is clear that the trainers do not want JSRs to go beyond their brief from
training.
Since the JSRs had not yet started practising, it was not possible to elicit their level of
functioning and discuss about their referrals to the PHC. Three groups (27%) mentioned
that they do receive referrals from JSRs.
According to the trainers, all the JSRs took part in the Pulse Polio campaign and some
even in the blindness camps. About 45% do assist the health team during immunisation /
family planning activities when the health team visits their villages. Others are not
conducting any health related activity or assisting the government in the implementation
of National Health Programmes or any of their other identified activities.
Using and giving injections as the main treatment (72%), using drugs beyond what
they are permitted (45%), going beyond their brief (27%) were the main worries of the
trainers regarding the JSR Scheme. The attitude of “just waiting to start practise” and
becoming “doctors” troubled one group of trainers. Four groups (36%) went to the extent
of saying they were worried that they were assisting in the production of “quacks”.
Three groups (27%) mentioned that once certified, the JSRs would only do curative
work and will not be interested in preventive and promotive activities. Because of
poor and delayed administrative actions (issuing of certificates, loans, holding of
examinations), three groups (27%) mentioned that the JSRs were losing interest and
moving over to other fields and jobs. One group mentioned that based on the population
in which the JSR was to practise (the village that recommended him for training) he
would not be able to earn sufficient amount even if he took a loan and opened up a
shop. A view that was expressed by one group where many of the JSRs who came for
training lacked interest was - “poor, uninterested and unfit selection of members for
JSR training as was often the case now would be determental to the scheme in the long
run”. This group also mentioned that non-release of funds allotted for training purposes,
and contingency amounts decrease the quality of training given as teaching aids and
audio-visual materials could not be purchased.
18
B. TRAINING PROCESS
Prior to starting the training of JSRs, the Block Medical Officers of all Block PHCs where
training was to be given were invited for a training of trainers programme. In our sample,
10 BMOs underwent training at medical colleges at either Indore, Rewa or Bhopal. In one
of the places, since the BMO could not attend, the medical officer was deputed. The
training was of varying duration - 5 hours to 4 days (supposed to have been for 4 days
officially) and quality. The training at Rewa was of 4 days duration and well planned and
the one at Indore for 3 days. Emphasis was more on “dont’s” than do’s (do not tell them
this, do not teach beyond this level, etc...) or a revision of technical contents of the course.
Also, in one of the training centres, the training consisted of “you know what to do, you
are experienced enough” and the whole training was completed in a few hours. There was
absolutely no mention or reference to teaching methodology how to conduct training
effectively or adult education techniques at any of the Centres.
In none of the 11 Block PHCs visited, did the trained person conduct any training for
other trainers (other PHC staff) or impart any information of the training process to the
other trainers. This is of immense relevance as training of JSRs was mainly conducted
not by the BMO (who did take a few sessions/classes as and when he found time from his
many duties) but by the other medical officers and PHC staff (health assistants,
supervisors, LHVs, laboratory technician, compounder, etc.)
The JSR training programme clearly outlined the schedule of training to be followed (see
training manual - p.222 to 232). A total of 145 lectures were to be taken during this
period. The 26 week period of training included a posting of 10 weeks at the sub-centre
nearest to the village of the JSR.
The posting at the PHC was to be rotational amongst the various sections -and also
included daily clinics.
All the PHCs in our survey found it extremely difficult to adhere to the mentioned
training. schedule. The reasons were varied and often trivial. They included the
extremely busy schedule of the BMO, non-deputising of his sessions to others, non
involvement of BEE in training (18%) - (the manual mentions he is to be warden of the
hostel and hence no other duty was assigned to him). But, by far and large it was the
extremely busy schedule of the BMO (including court cases and travels for other reasons)
which was most disruptive of the training schedule. Very often, the BMO had handed
over his responsibility to the BEE or other senior PHC staff for coordinating the training
process. The 10 week posting at the sub-centre level ranged from 0 weeks to 8 weeks in
actuality. During this period, the JSR was supposed to observe and note all the activities
carried out by the MPW (F & M). This part of the training was often a formality and
quite non-productive to the JSR - since the MPW hardly took interest in training of JSR
in most places. A possible reason for this could be that the MPWs were not clearly briefed
about their role and responsibilities in the scheme. An interesting feature noticed in two
centres (18%) was that training times were adjusted to the timings of the bus coming to
the village.
19
One has to admit that often the BMO has many responsibilities. It was heartening to note
that inspite of their busy schedules in three centres (27%) they did find sometime during
the day (usually late evenings) to take their lectures. Also interesting was the conduct of
exam oriented training and refresher classes including mock examinations at 8 centres
(72%).
The training was not of uniform standard in the various PHCs. Only one centre had
received contingency funds which were utilised to buy charts and furniture. Another
centre also received the funds but no purchases were made and since the BMO was
transferred, we were unable to determine how those funds were utilised.
All PHCs were able to identify a room for training purposes which could accommodate
30 people. Because of lack of furniture in all training centres except one, as mentioned
earlier, the JSRs had to sit on the floor. None of the rooms had adequate ventilation and
fans - and the trainers did complain of heat and humidity. Blackboards were available
only in 2 (18%) PHCs. None of the PHCs had any other audio-visual equipment. In none
of the PHCs was assessment carried out of the training given or the methodology adopted
for training. There is a need for furniture, teaching aids and blackboards to enhance
quality of the training.
In all the PHCs, the trainees were rotated between OP clinic, ward, compounding section,
laboratory, injection room and dressing room. In each of these sections, the respective
staff explained / demonstrated the various activities conducted to the trainees. The
trainees were taught how to dispense, how to stain slides (not read), how to dress wounds
and how to give injections. However, it was the last mentioned activity in which the
trainees showed maximum interest. Atleast in three (27%) centres we were told by the
LHVs how the trainees would gravitate to the injection room, even if posted elsewhere,
ask various questions on injections, show tremendous enthusiasm and pester the staff for
allowing injections to be given by them. Thus, training on injection administration
became a reality even though the JSR training manual clearly states that the JSRs are not
to use injections in their practise. Also, if this is so, then why should they be trained on
injection giving methods and posted to the injection room?
We are extremely worried on the quality of training in these rotational postings. The
register maintained by the compounder is illegible in most PHCs. In one Centre, because
the compounder could not find paper, he was dispensing the tablets to the hands of the
patients’ relatives. The dressing rooms in 6 (54%) centres had used and discarded cotton
waste and bandages scattered on the floor or just outside the room. The autoclave for
boiling syringes had carbon particles and was black and sooty in 10 (90%) centres.
Worse, in every centre we found plastic disposable syringes, needles and IV sets being
reused. A trainee exposed to such a pathetic situation needs to be told and taught what
not to do - rather than what to do! On questioning the technicians, compounders, and
other staff, we found out that the doctors never accompanied the trainees to these sections
and their training was done only by the paramedical staff.
None of the centres had any concrete plans for regular supervision of the activities of
JSRs once they set up practise. In fact, no group had given any thought to future
supervision, follow-up, refresher classes, attendance at monthly meetings, etc.. This was
20
not even told to the MPWs of the sub-centres where the JSRs were supposed to have had
their field training. It was as if “we have done our job of training - our responsibility ends
there”. On probing though, most BMOs did agree on the need for some sort of follow-up
of JSR training activities and 36% of the PHCs were categorical that the JSR performance
should be monitored on a regular basis. Even the training manual clearly mentions the
need for supervision and how this is to be done. During our Review, in none of the
PHCs we found a schedule/plan or a written check-list for supervision. Also since the
JSRs had not yet started working, none of the PHCs had started maintaining any records
of supervisory activities. Possibly, once the JSRs start practising, monitoring and
supervision may become a regular feature.
3. TRAINING MANUAL
The training manuals were not obtained in time for the first batch in 6 (54%) of the PHCs,
the delay period being ten days to two months. Because of this, it is likely that the first
batch trainees in these centres were not able to obtain optimum training - as a technical
subject like medicine is extremely difficult to follow without the text-book. This may
also be one of the reasons for the poor performance in the examination of the first batch
trainees (total pass percentage < 30%). In all the centres, manuals were obtained in time
for the second batch of trainees.
All respondents felt that the manual covered all locally prevalent health problems which
could be managed by JSRs and that the manual respected local customs/culture. Though
all the respondents found the manual appropriate for the work envisaged from JSRs, some
of the suggestions for improving the manual were as follows:
=> the contents are theoretical; more emphasis should be given on practical aspects,
specially on management of illnesses;
=> increase contents in Paediatrics and Orthopaedics.
On direct questioning on whether Anatomy/Physiology was very detailed, all the
respondents felt it was not so and that it was necessary to study basic sciences to that
degree so as to understand well the functioning of the human body. This would facilitate
understanding disease causation and how the body gets affected in illness and what
happens during the recovery process. In fact, one respondent felt that these subjects
should be given in greater depth.
D. JANASWASTHYA RAKSHAK MANUAL - COMMENTS OF
THE EVALUATORS.
1. The contents of the Manual are easily understandable to a matriculate, simple in
presentation and with no ambiguity.
21
2. Chapter 1 on Duties of JSR is comprehensive, yet medicalised, with
* focus on Tb, Leprosy and AIDS;
* elaborate duties in area of Malaria, Water purification, MCH.
These are overlapping and duplicating the roles of ANMs and MHWs.
Some degree of differentiation of activities is required to avoid duplication of
activities and obtain maximum benefits of the different cadres of field workers.
3. Chapter 2 - Health team in community focuses more on disease than on Health
(except MCH area). A shift in focus to more health promotive activity is required.
4. The Section - on Anatomy Chapter 3 is more elaborate than required and confusing
because of the Latin/English names used. Also the translation/presentation of terms is
not accurate, e.g., for SKULL, MANDIBLE, AORTA, and illustration of brain (p.37),
in section on female genital tract, etc.
5. This section needs to be revamped thoroughly and presented as HUMAN BIOLOGY
including structure and function in a simpler manner.
6. Chapter 4 - presents the Agent - Host - Environment concept well but needs
elaboration with examples to make it more understandable. The three levels of
Prevention also needs to be added to this Chapter and given due emphasis.
7. Chapter 5 - is adequate. Chapters 6 to 8 dealing with Malaria, TB, Typhoid, Filaria
and Dengue
* offer only medicalized/patient oriented preventive measures
* have no socio-economic, cultural/other roots of these diseases discussed
* need elaboration on ‘Community Action’ for prevention/control.
8. Chapters 9 to 13 are too elaborate and need to focus down to essentials for the JSRs to
help them learn their roles/duties adequately and maximally.
9. Chapter 14 - (pl 15) has a highlighted foot note whose message is contradictory to
matter in text. [ “ALL CHILDREN less than 2.5 kg need to be seen by a Doctor” box mentions 2.0 kgs.)
10. Chapter 15 - the presentation/details of dehydration and rehydration are too clinical.
Common and noticeable signs of dehydration / rehydration
like urination, cry,
activity etc., of child also needed to be added. Practical knowledge of home based
ORS and that rehydration is ‘thirst’ based need to be included.
11. Chapters 16 to 19 are elaborate, but good. Some simplification may make it easier to
comprehend.
12. Chapters 20 and 21 need to be revamped, helping JSRs understand and utilize
Traditional and Local practices safely for minor ailments and first-aid, utilizing WHO
and GOI manuals on these. The ‘symptomatic’ use of Allopathic, Homeopathic and
Ayurvedic medicines can be supplemented with safer, locally available resources.
22
13. The “Appendix” - Anusuchi -3 on medicines always to be available with JSRs include
drugs like Analgin and Decadron which are not recommended. Also, medicines like
Magnesium hydroxide. Benzyl Benzoate, Sulfacetamide drops in text are not
mentioned here. The three Homeopathic and three Ayurvedic drugs also do not find
any mention in the list. These discrepancies need to be taken care of to avoid
confusion and contradictions.
14. The lecture schedules of 145 hours show an unwarranted medicalization, offering 110
hours of Medical College subjects, of which 26 hours of Paediatric and Obstetrics &
Gynaecology seem proper.
15. Thirty hours of Community Health and 5 hours on Health Education are inadequate to
prepare the JSRs for their roles in the community. National Health Programmes do
not find the place in the lecture schedule they deserve, except Malaria, Immunization
and MCH. Relevant Sociology subjects are missing from the manual and need to be
added.
16. The Disease and Medical Orientation of all the chapters needs to be made Health and
Community activity oriented, bringing in the principles enunciated in Chapter 4 and
evolving avenues for practise - to make it a practically useful manual for the JSRs.
The high failure rate of the JSRs; was attributed to inadequate training and preparation by
JSRs (9%), not enough of hard work and commitment (9%) and the examination process
(18%). Five respondents (45%) said their centre did not have high failure rate and were
happy with the performance of their trainees.
E.
SUGGESTIONS BY THE TRAINERS FOR IMPROVING
THE TRAINING PROCESS:
0
more appropriate selection of trainees - motivation to be an important criteria;
0
Involvement of the health staff in selection which is to be based on fixed scalable
criteria
0
more staff members (fill up vacant MO posts so that BMOs can devote more time to
training process)
0
Provide audio-visual aids (these were to be obtained from one time grant of funds
which 90% of the centres did not receive).
0
Provide appropriate training to all trainers so that they could give better quality
training.
0
Hostel facilities (to facilitate regularity and attendance). This was to be arranged from
contingency funds which were not received by 81% centres.
23
0
Release of funds and stipends on time to maintain interest and commitment
0
Improve Review process - make it less theoretical and more practical
0
Include more information on National Health Programmes in their curriculum.
0
Provide each JSR with a copy of “Where there is no Doctor” (this was to be provided
to each candidate from contingency funds - but was not ordered except at 1 centre)
0
Increase internal assessment marks, so that the trainers (BMOs) can have more control
over the trainees. (Note: Internal assessment is not meant to control, it should be
formative)
0
Simplify administrative procedures. Right now it has too many authorities and levels
involved in its control which affects training.
F.
SUGGESTIONS BY THE TRAINERS FOR IMPROVING
THE FUNCTIONING OF THE JSR SCHEME
All the trainers were asked for suggestions for improving the functioning of the JSR
Scheme. Their responses are given below. Some were mentioned by more than one
training unit.
0
Improve administration. Right now too many departments are involved. These need
to be streamlined to avoid bureaucratic delays.
0
Release training funds, contingency funds and stipends on time. This will enhance
commitment from all concerned.
0
After completion of the training period, regular contacts should be maintained with
JSRs. One group suggested they could be called at sector level meetings once every
2 months. Another group suggested that they should attend the monthly meetings at
the PHCs.
0
Strict supervision of JSR, specially at field levels is required,
courses should also be arranged.
0
TA/DA to be provided to JSRs to attend the above meetings.
0
The JSRs be given a regular monthly emolument (like the old CHW Scheme) to
increase their commitment to their functions specially preventive and promotive
activities.
0
Every contact of health team with JSRs be utilised to enhance their skills.
Regular refresher
24
0
Have more staff at sector PHC. Training of JSRs did suffer considerably because of
shortage of staff specially in those PHCs where there was only 1 MO. Very often the
MO, LHV and BEE all would be on travel.
0
To overcome the above problems, have training at District level. The staff there have
experience and facilities are better.
0
The other advantage of District level training would be the compulsory hostel stay
which would greatly assist in regular attendance.
0
Modify selection process - so that the most deserving and committed candidates are
selected. Introduce criteria based selection process.
0
Since it is extremely difficult to register girls who have passed 10th standard, minimal
qualifications for them should be reassessed and reduced to Sth standard, especially in
Tribal areas.
0
JSRs need enhanced visibility. Their role and activities need to be clearly explained
to villagers, so that their services are maximally utilised.
25
Vl examination process
Two batches of JSRs had completed their training and taken examinations at the
time of our conducting the Review of the Scheme. The first batch had their examinations
at the end of their training period. For the second batch, the examination was held four
months after completion of their training. The results of the first batch (November 1995
to June 1996) were announced within two months of their examinations. Unfortunately,
the second batch (August 1996 to February 1997) results were not announced even 3
months after their examinations. It must be mentioned here that the Block PHCs where
training was held were informed only 3 days prior to the examination date (II
examination) and it was a herculean task for them to inform all the candidates of the
examination date. In the bargain, some trainees specially the failed trainees of the I batch
(who did not receive any further training) could not take the examination as they were not
informed on time. Obviously, this led to a lot of disappointment and bitterness. The
solution lies in streamlining the whole process, with fixed, dates, announced in advance.
Pattern of Examination
As mentioned earlier, the internal assessment carried 100 marks and external examination
400 marks (2 papers). To be declared successful, a candidate had to obtain a minimum of
50% in internal assessment and each of the 2 external examination papers.
The first examination consisted of one sentence to short answers (Appendix 5) and
measured the theoretical knowledge in great depth. There was also a feeling “it was
tough” and that it did not evaluate the capability of the trained JSR appropriately. There
were very few questions related to their future proposed functions and practical
applications. It was at too high a level for JSRs specially considering the scope of their
future activities.
The second examination was a multiple choice type of paper, with no negative marking
(Appendix 6). The questions though very simple and easy to figure out had the advantage
of assessing the practical knowledge that a JSR would require and was more evaluative of
their future functions. It definitely had less theoretical component. In our discussions
with the JSRs, who had taken both the examinations, we were informed that they found
the second examination very simple, were able to complete it much before time and were
able to answer all questions unlike in the first examination where there were quite a few
questions which they were unable to answer.
There was one major administrative problem with the second paper. The districts were
sent a copy each of the question paper and they had to photocopy adequate numbers for
every JSR undertaking the examination in their district. This entailed photocopying 12
pages for each candidate, a total of 7000-8000 pages in each district. With the meagre
funds and limited facilities for photocopying at district headquarters, this was a major
problem in some areas. To prevent leakage of papers, they could not photocopy a day or
two before the examinations. Also being unaware of the pattern of question paper, they
had anticipated a 2 page question paper as in the first examination. Practical problems
like the above should be avoided in future. Also, by utilising all available photocopying
26
machines in the district headquarters, chances of the paper leaking were magnified
greatly, specially since so many people were dealing with the photocopying part. Ideally,
printed question papers should be distributed. This would avoid problems like the above
mentioned one.
The pass percentage in the first examination varied between the various districts. Since
JSRs of each district were evaluated locally, one reason for this could have been the
criteria adopted for Review. To avoid bias and for uniform Review, MCQ type of papers
would be ideal; but they have their own limitations and in case the MCQ pattern is
combined with short answer questions, centralised evaluation should be adopted so that
marking is uniform.
During our Review survey, the JSRs were administered case studies which simulated
conditions they would encounter during their practice (Appendix 4). This was done with
the intention of trying to find a more appropriate method of examining their knowledge
and skills and overcome some of the criticisms of the examination patterns adopted so far.
A detailed report of the performance of JSRs in the Review process based on this format
is given below:
Review o f knowledge of JSRs
As the JSRs had not yet started practising, it was not possible to examine their
effectiveness in the field when they provide services.
Their competence at the end of the first course to be certified as JSR was determined by a
written test which was felt to be very theory oriented by most and which did not assess
their competence in a comprehensive manner (Appendix 5). As time did not permit our
examining their clinical competence and curative knowledge, it was instead decided to
administer a questionnaire to them which would simulate conditions thar they were likely
to face in reality (Appendix 7). Determining their level of response to this questionnaire
presumably would be able to give a clearer picture of their competence and possibly be
helpful in providing a better method to assess their knowledge, attitude and practices.
The results of this Review were as follows:
TABLE 7-A : Marks received in the Review questionnaire:
Marks Received
(Maximum 100)
<30
31 -39
40-49
50-59
60-69
>70__________
Total
% of candidates
I. 15
II. 50
22.58
29.89
27.58
2.30
100.00
27
The performance was similar in all districts with some performing well and some faring
poorly in each district.
The Review revealed the following knowledge attitudes and practices:
TABLE 7-B : Knowledge, attitude and practices of JSRs.
1.
2.
3.
4.
5.
6.
Condition
Diarrhoea
Protein/energy/ malnutrition
Tuberculosis
ARI
Family Planning
Epidemics
Knowledge
Good
Good
Good
Good
Good
Poor
Attitude
Good
Poor
Poor
Good
Good
Poor
Practice
Good
Poor
Poor
Good
Good
Poor
It is worth noting that all the attitudes and practices were curative oriented and KAP of
prevention was minimal, revealing the need of focussing on these deficiencies during
training. Preventive has to be emphasized in the manual, training of trainers and in the
teaching/leaming of the trainees.
28
II
Vil Views of the j an sWasthYa rakshaks on
JSR SCHEME
As part of the Review process, the JSRs were asked to give their views to certain
identified issues covering the whole gamut of activities of the Scheme in a questionnaire
form (Appendix 4). During our Review visit to the various districts, we were able to
contact a total of 101 JSRs who belonged to either the first batch or second batch of
trainees. Given below are the various details and responses of these 101 JSRs on various
issues pertaining to the JSR Scheme.
TABLE 8 :
Age distribution of JSRs who were contacted during Review exercise
Age (Years)
Frequency
Percentage
15 - 19
20-24
25 -29
30-34
35-39
40-44
45-49
>50
TOTAL:
1
22
39
22
11
3
2
1
101
1.0
21.8
38.6
21.8
10.9
3.0
2.0
1.0
100.0
16.9% of the JSRs were above the upper age limit of 35 years, (most of these are old
CHWs, who have been nominated for JSR training).
TABLE 9 : Age and Sex distribution of JSRs who were contacted during Review
exercise.
Age (Years)
15 - 19
20-24
25-29
30-34
35-39
40-44
45 -49
>50
TOTAL:
SEX
Female
0
2
1
0
0
0
0
0
3
Male
Total
1
I
20
38
22
11
3
2
1
98
22
39
22
11
3
2
1
101
Percentage
1.0
21.8
38.6
21.8
10.8
3.0
2.0
1.0
100.0
16.9% of the JSRs were above theupper age limit of 35 years, (most of
these are old CHWs, who have been nominated for JSR training)
29
The 3 females in this evaluative process was quite reflective of the
actual percentage of females who underwent training to become JSR.
Females do not volunteer to undergo JSR training. This is unfortunate
as more than 60% of the JSRs activities are CSSM & RCH related. The
reasons given by the trainers and community leaders for their not
volunteering are as follows:
*
no qualified candidates; (most girls stop studying after VIII standard
as most villages do not have a high school);
*
it is not safe for them to travel alone;
*
there might be times when they may have to travel alone at nights;
*
no hostel facilities;
*
they get married at an early age;
*
they have small children and they have to take care of them as well as
the other family members;
*
the elders do not permit them to seek work outside the house.
F
TABLE 10 : Distance from village of JSR to training places (Block PHC)
Distance (Kms.)
0-4
5 10 - 14
15 - 19
20 - 24_
'25-29
30 - 34
35 - 39
40 - 44
>45
Total:
Percentage
11.9^
20.8 J
Frequency
12
21
15
7
15
10
10
5
5
1
101
14.9]
6.9 \ 3s
14.9 J
9.9
9.9
5.0
5.0
1.0
100.0
30.8% had to travel more than 25 Kms. one way to reach the Block PHC
where training was being given. Not only did this mean a long travel time
but also higher cost of travelling. Additionally, it also meant that their
time of reaching the PHC was absolutely dependent on the bus timings usually leading to their decreased time for training at PHC.
__________ \
o
\f ( J V\5
?>
Pj i 1U. S
v
I6
lo
IL
30
m
____________
34
4
i*\
H
r TABLE 11 : Marital status of JSRs
Marital
status
Married
Unmarried
TOTAL:
Frequency
Percentage
88
13
101
87.1
12.9
100.0
87.1% of the JSRs in our sample were married. Mamed JSRs are less likely to
leave the village in search of greener pastures.
TABLE 12 : Education status of JSRs
Education status
PG
Graduate
PUC
SSLC
TOTAL:
Frequency
2
16
28
55
101
Percentage
TO
15.8
27.7
54.5
100.0
45.5% had qualification higher than the lowest level prescribed. Though
advantageous in many ways, it could also lead to their searching for more permanent,
more lucrative offers.
TABLE 13 : Occupation distribution of JSRs
Occupation
Agriculture
Carpenter
Labourer
Service
Nil
TOTAL:
Frequency
54
1
7
1
38
101
Percentage
5T5
1.0
6.9
1.0
37.6
100.0
Majority of the JSRs worked as agriculturists, but large percentage (37.6%) did
not have any occupation.
TABLE 14 : Residential status of JSRs in village selected.
Resident in
village
Yes
No
TOTAL:
Frequency
Percent
101
0
101
100.0
0
100.0%
All JSRs reside in the same village which nominated them for training.
31
TABLE 15 : Sources of Information on JSR Scheme (for JSRs)
Source
Gram Panch
Gram Panch, Newspaper
Gram Panch, Radio
Panchayat Secretary
Sarpanch, Panch
Sarpanch, TV
Frequency
Percent
62
2
3
61.3
2.0
3.0
1.0
1
1
31.7
1.0
101
100.0
32
TOTAL:
61.3% heard of the JSR Scheme from Gram Panch; 31.7% were given information
by the Sarpanches. For the others, the source was either Gram Panch or Sarpanch along
with radio (3) / newspaper (2) and TV in (1) case.
TABLE 16 : Source of Selection of JSR
1
Percentage
822
13.8
3.0
1.0
101
100.0
Frequency
Source of selection
Gram Panchayat
Janpad Panchayat
Sarpanch
Sarpanch Secretary
83
14
3
TOTAL:
82.2% of the trainees were selected by the Gram Panchayat and 13.9% by Janpad
Panchayat.
TABLE 17 : Additional number of applicants
No.
0
1
2
3
4
5
7
8
9
>10
TOTAL:
Frequency
Percentage
66
9
3
5
3
2
652
8.9
6.9
2.0
3.0
5.0
3.0
2.0
1
1.0
3
3.0
101
100.0
7
2
In 65.2% cases, there was only one single candidate who was nominated for JSR
training. In 14 (14%) cases, there were 5 or more applicants.
32
>
Training Methodology
The training methodology consisted of postings in ward, field, laboratory,,
injection room, OPD, pharmacy, dressing room along with lectures, demonstrations and
discussions.
11 (10.9%) of the respondents did not answer this question. The trainees in most
places were divided into groups of 6 and they rotated amongst the various departments.
Our observation during the Review visit to the Block PHCs mirrored the same
findings.
TABLE 18 : Number of JSRs registered in a batch for training at the Block PHC
No.
14
26
27
28
29
30
35
TOTAL:
Frequency
1
2
1
8
11
60
18
101
Percentage
L0
2.0
1.0
7.9
10.9
59.4
17.8
100.0
Majority (59.4%) of the JSRs belonged to batches consisting of 30 trainees. There
was only 1 JSR who belonged to a batch consisting of 14 trainees.
TABLE 19 : Explanation of training subjects
Proper explanation
Yes
No
TOTAL:
Frequency
100
0
100
Percentage
100.0
0
100.0
All JSRs felt that the training subjects were properly addressed and they were free
to discuss with their teachers any problem they faced.
TABLE 20 : Distribution of written material
Distributed
Yes
No
No response
Total:
Frequency
73
25
3
101
Percentage
723
24.7
3.0
100.0
72.3% mentioned that they received written material (notes, etc.,) during the training
process.
\
33
u
TABLE 21 : Usefulness of written material provided to JSRs
Usefulness
Yes
No
No response
TOTAL:
Frequency
88
6
7
101
Percentage
87.2
5.9
6.9
100.0
87% of JSRs found the material that was provided to them as handouts useful in
their training.
TABLE 22 : Opinion of JSRS on training
Satisfied
Yes
No
TOTAL:
Frequency
94
7
101
Percentage
93.1
6.9
100.0
93% JSRs mentioned that they were satisfied with the training received.
TABLE 23 : Grading of Training process
Grade
Very good
Good
O.K.
Not very good
Not good at all
TOTAL:
Frequency
9
60
25
5
2
101
Percentage
8J
59.4
24.7
5.0
2.0
100.0
68.3% JSRs rated their training as good or very good. 24.7% felt it was OK and
only 7% did not give a good rating to the training process.
TABLE 24 : Did training address local needs?
Addressed local
needs
Y
N
TOTAL:
Frequency
98
3
101
Percentage
9Tb
3.0
100.0
97% JSRs said that training addressed local needs.
34
u
TABLE 25 : Appropriateness of training material (for JSR activities)
Appropriate
Yes
No
No answer
TOTAL:
Frequency
69
24
8
101
Percentage
683
23.8
7.9%
100.0
68.3% felt that the training was appropriate for the perceived functions of JSRs.
TABLE 26 : Physical space for JSR training
Sufficient space
No
Yes
TOTAL
Frequency
13
88
101
Percentage
1Z9
87.1
100.0
87.1% mentioned that there was sufficient space for training. But as mentioned
earlier, our observation revealed that though sufficient space was available, the facilities
for training were non-existent and there were no chairs, fans, etc.
TABLE 27 : Sufficiency of Trainers
Sufficiency
Yes
No
No answer
TOTAL:
Frequency
92
7
2
101
Percentage
9L1
6.9
2.0
100.0
91.1% JSRs expressed there were sufficient number of trainers during their
training process.
TABLE 28 : Use of Teaching Aids during training process
Use of teaching aids
Yes
No
No answer
TOTAL:
Frequency
73
18
10
101
Percentage
723
17.8
9.9
100.0
17.8% JSRs mentioned that no teaching aids were used during the training
process. This is likely as some Block PHCs did not even have a blackboard to use for
training.
35
u
TABLE 29 : Sufficiency of material in training manual to deal with local illnesses.
Sufficiency
Yes
No
TOTAL:
Frequency
67
34
101
Percentage
663
33.7
100.0
33.7% JSRs felt that the manual did not have sufficient information to deal with
local illnesses, even though 97% mentioned that training addressed local needs. The
manual thus requires to be carefully evaluated to detect the deficiencies.
TABLE 30 : Suggestions for improving manual
1.
2.
3.
4.
5.
6.
7.
8.
9.
Suggestions
Information on drugs
More information on techniques of injections and
names of injections
More detailed explanation
Information on more diseases (including minor
ailments)
More pictures
Management techniques of diseases in rural areas
Information on diseases like ENT and Dental
disorders
More information on local herbs and their use
Provide other books
Frequency
23
13
Percentage
22.77
12.87
11
8
10.89
7.92
2
2
1
1.98
1.98
0.99
1
1
0.99
0.99
As can be seen from the above table, the JSRs were keen to obtain more practical
knowledge, which drugs to use in different conditions, names of different drugs, more
information of injection techniques, names of different injections and more information
on different diseases including minor illnesses. Only one JSR evinced interest on local
herbs and their uses.
TABLE 31 : Areas identified by JSRs which require more training
Subject Areas
1. AIDS
2. Injections (including IV)
3. Drugs
4. Anatomy
5. Surgery
6. Prevention of diseases
7. Family Planning
8. Tuberculosis
9. First Aid
10. Diarrhoea control
11. Malaria
12. Gynaecological diseases
13. Balanced diet
14. Orthopaedics
15. Children’s diseases
16. Ayurveda - Homeopathy
Frequency
17
16
13
12
8
1
2
2
2
3
5
1
1
1
1
Percentage
26.73
16.83
15.84
12.87
11.88
7.92
4.95
2.97
1.98
1.98
0.99
0.99
0.99
0.99
0.99
0.99
36
Anatomy was one subject which 13 JSRs identified as an area which requires more
training. As mentioned earlier, information and use of drugs and injections, names of
drugs and injections to be used in specific conditions, were the other main areas
identified. Though JSRs are to treat minor illnesses and provide first aid when necessary,
12 JSRs wanted more training in surgery' and 5 on Gynaecologic disorders.
TABLE 32 : Availability of JSR Kit
Availability
Yes
No
No response
TOTAL:
Frequency
n
88
2
101
Percentage
IO
87.1
2.0
100.0
87% JSRs did not receive the kit which was to be given to them to assist in their
functions. Like delayed payment of stipend and nonpayment of contingency funds, this is
also an administrative problem which needs to be studied further and streamlined.
TABLE 33 : Distribution of marks between External Examination & Internal Assessment.
Correctly distributed
Yes
No
No response
TOTAL:
Frequency
81
12
8
101
Percentage
802
11.9
7.9
100.0
80.2% respondents mentioned that the pattern of mark distribution between
Internal assessment and external examination was correct (100 marks for Internal
assessment and 400 marks for external examination).
TABLE 34 : Views of JSRs on the Review process & suggestions for its improvement.
Frequency
Views / Suggestions____________
22
I. Appropriate
16
2. Examination of skills to be done also
(practical)
11
3. Monthly test
2
4. Announce examination date early (atleast
one month in advance)
2
5. Conduct examination on time
5
6. Examination at training centre (Block PHC)
6
7. Objective + Essay type
2
8. Viva type of examination also to be given
5
9. objective type questions only
2
10. Cover all chapters
4
II. Review to be done at district level
1
12. Trainee to be given chance to go through
answer script
Percentage
21.78
15.84
10.89
1.98
1.98
4.95
5.94
1.98
4.95
1.98
3.96
0.99
i
37
u
41 (40.6% ) JSRs had no suggestions on the Review process and 22 (21.8%) felt that the
method of examination was appropriate. The main suggestions of the remaining JSRs
were as follows :
16 (15.84%) JSRs wanted examination of skills in the Review process; 4 (3.96%) wanted
a combination of objective and essay type. 5 (4.95%) JSRs wanted examination to be
conducted on time and 6 (5.94%) wanted the date to be announced early. Another 5
(4.95%) JSRs wanted examination to be conducted at their training centre.
The JSRs also mentioned the following views which though not related to the Review
process are important to their training process.
These views were :
*
*
*
*
*
*
*
having a full time teacher conducting the training;
increasing the duration of training to one year;
payment of timely stipend;
material (kit) to be given at the end of the course;
explaining with posters and charts;
training for trainers; and
training by doctors only.
From the above, it is clear that more than 80% JSRs found the training process, the
trainers and the manual appropriate and adequate. Though physical space for training was
adequate, there is need for more audio-visual aids and charts as well as furniture and fans.
Funds were earmarked for this, but unfortunately not disbursed to 90% of the training
centres. The JSRs mentioning that stipend be given on time and that they be provided
with a kit after completion of course were genuine needs and administration needs to gear
up to avoid such tardy implementation. Our group discussions with the JSRs revealed
some more insights which they had not put in writing. The first batch trainees felt their
examination process was much tougher and not appropriate for JSR level specially when
compared to the second examination. The trainers also concurred with this view.
Secondly, most of the JSRs had the impression that undergoing the training process was a
prelude to the Government absorbing them subsequently as multipurpose workers or in
some such posts. Some of them were told so by their leaders during the selection process
and others held on to this belief hoping things would ultimately work out. It was difficult
to convince them that the Government just does not have the type of resources that would
be required to absorb all of them or even for paying a monthly honorarium and hence the
permission being given to the JSR to practise.
There were very few female trainees. This is unfortunate because many of the activities
of the JSR are MCH related. Group discussions revealed the inherent socio-cultural
problems which prevented their volunteering.
The selection process as revealed in their written views did not clearly reveal the extent of
bias and malpractise that went on in a few areas as was mentioned to us by a few JSRs
during oral discussions. But it was heartening to note that there were also many JSRs
who were selected because of their commitment, capability and merit.
The JSRs are eagerly looking forward to starting their practise. They await right now
their certificate, kit and some of them - a loan.
38
u
VHl. PERCEPTION OF COMMUNITY MEMBERS AND
THE COMMUNITY LEADERS OF THE JSR SCHEME
A. COMMUNITY MEMBERS
80% communities surveyed were not aware of the scheme, its objectives, its functions and
only 15% communities know the person selected as JSR from their village.
2 out of 20 communities selected the CHW of the old scheme for JSR training.
Only 20% communities responded that they have health committees but
aware whether the health committees ever met.
they were not
As all trained JSRs have not yet started working, communities do not have any idea of
their functions and services and service charges to be paid by them to the JSR.
15% communities expressed that for preventive and promotive work, government should
pay the JSR some remuneration.
In 10 out of 20 (50%) communities surveyed, the selected JSR was related to the sarpanch
or panch of the Gram Panchayat.
B. COMMUNITY LEADERS
i. Village level leaders
In 5 out of 20 communities, even panchs were not aware of selected JSR.
In all communities, panchayat members got information on selection of JSR from
Janpad Panchayat.
Leaders of 30% communities said they have health committees.
These committees do not meet frequently and separately, but their meeting is along
with the general meeting of Gram Panchayat.
Community leaders were aware of objectives of JSR scheme upto certain extent.
In all communities, some panchayat members were involved in selection process of
JSR and expressed their satisfaction with the process and person selected.
All expressed that JSR needs encouragement in his activities but they were mot sure
how this could be achieved.
In 60% communities, community leaders said that JSR has met them after completing
his training.
39
H
In few communities, leaders expressed that there should be workshop/seminar on
schemes and plans for panchayat leaders. This would help leaders understand their
responsibilities / working pattern of scheme and their plans and limitations.
ii. Block level leaders
In all Janpads, president of Panchayat was involved in recommending the person for
training selected by Gram Panchayat.
Health committees of Janpad Panchayat never visited and supervised the training in
any of the Block PHC.
In most of the Janpad Panchayats, elected members are not clear of the scheme and its
objectives and functioning.
iii. Zilla level leaders
Some of the district health committees are not aware about the scheme and its
objective and functioning.
In one of the districts visits, Zilla panchayat president is quite interested in the
successful implementation of the scheme. In other districts, even presidents are not
very clear about the functioning of the scheme and have not taken proper steps to
implement the scheme.
There exists a lot of gap on information about the scheme among and within
panchayat agencies.
Lacunae exist in passing of this information from Executive officers to elected bodies
at various levels. Information received by them is not transmitted or communicated to
the Panchayat leaders or committees.
All the CEOs were supportive of the scheme and its objectives. One of the CEOs
expressed the limitations of the TRYSEM scheme to give loans to all applicants as the
funds received were not adequate even for l/3rd of all type of applicants. Also the
amounts to be released as loans for other professions were much lower. Two CEOs
were critical of the selection process and mentioned that since 2 departments are
involved, many hindrances are likely to occur in its proper implementation.
40
. VIEW'S OF C.M..OS ON THE J.SJt SCHEME.
Our interviews with the Chief Medical Officers (CMOs) revealed that all of them thought
the JSR scheme was a good scheme and would assist in reducing the health problems of
the community by providing a trained resource in the villages itself At present, even for
minor health problems they had to come to district hospitals, towns or consult private
practitioners who often charged them heavily. These problems would be obviated to a
large extent.
Another positive feature of the scheme cited byjhfim waslhe^assistance, the present field
functionaries would obtain from the JSRs in the implementation of National Health
Programmes and other preventive and promotive activities.
They were in full agreement with the functions envisaged of the JSR but did mention that
there waslot of overlap with other health functionaries. Four of the CMOs also
mentioned that from reports that they received of the interest shown by JRS on “Injections
and IV fluid administration”, and keeping in mind ground realities and expectations of
rural people, they were sure that the JSRs would use “injections” and even provide
irrational treatments and try tackling problems beyond their brief or training. Much as
they were convinced of the need of the scheme to provide health care specially for those
who have difficulty in reaching/obtaining curative care because of the distance/transport
limitations, etc., they are also worried that they are helping in the production of “potential
quacks”. These contradictory viewpoints do not brood too well for the JSR scheme, for
the above position and ambivalence can have severe repurcussions all down the line.
The CMOs did find the training duration, manual, curriculum and training methodology
to be adequate and appropriate. Two of the five CMOs mentioned the need to hold the
training at district level because of the facilities available (training centre, staff, hostel,
etc.). They also mentioned this would improve the quality of the training. This does
indicate that the CMOs were aware of the lesser than expected quality of training being
given to JSRs at some block centre PHCs.
As to the acceptability of the JSRs in the village all the CMOs mentioned that there would
be no problem and in fact because the JSR belonged tp the same village and would take
care of the villagers needs, they would find easier acceptability than outsiders.
The high failure rate (>70% on an average) in the I Batch examination was attributed to
the inappropriate questions asked and inadequate preparations by the JSRs.
The ability of the CMO and staff of his office to interact appropriately with the IRDP
officials was very important in smooth functioning of the programme and release of funds
and stipends. Our survey revealed that when jhese- relationship was cordial .and
successful, funds for contingency and stipends were made available more easily unlike in
2 centres where there was hardly any interaction. The interest of the CMO in the scheme
is very important for its successful implementation as this becomes a measure for other
implementators in the department to follow. This will be all the more important, once the
training is based at District level as is planned from the III batch.
41
u
'2,
I—
-
- M
V'TXa
-
p
x. Views of the presidents of district
HEALTH COMMITTEES ON JSR SCHEME
Because of the Congress convention at Calcutta which was taking place at the same time
as our Review survey, we were able to meet only two pjresidents of District Health
Committees as the others were participating in the convention.
The President of Vidisha District Health Committee was a very well informed young
lady. She was fully conversant with all the objectives of the scheme and functions of the
JSRs and what the Government hoped to achieve from the implementation of the scheme.
According to her, the scheme was a good idea and will be very useful to the villagers,
specially those that are remote and without approach roads. She found the training in her
district to be satisfactory but mentioned that “those who are interested only will learn”.
One of her worries was since the training was given in Government centres, the villagers
will identify the JSRs as “Government Employees” and ask for free treatment and free
medicines. Since they had not yet received the certificate or kit nor the loans to set up
practise, they were unable to start their practise, were slowly losing interest and even
drifting to other jobs. Her recommendation was that the Government should fix a pay for
them so that their commitment increases and they will work with devotion. The other
alternative recommended by her was to increase their period of training to MPW level and
provide them jobs by filling up existing vacancies.
>7 She also suggested regular reviews of the scheme and constant supervision to maintain
7 quality of service and also to make JSRs feel that they are cared for and part of the health
team.
One of their major likely problems would be the wordings in their certificate. It does not
mention that the JSRs can “practise” and hence legally their right to practise and giving of
drugs can be questioned.
She also felt that loans to JSRs should be given with no conditions attached so that they
could utilise it most appropriately. For example, the loan specifies the quantity of drugs
to be bought and amount to be spent on drugs - many of these are available at the PHC
and could be obtained from there, instead of being “bought”.
At present most villagers are ignorant of the scheme and the functions of the JSRs. She
^wanterL JSRs tn be given prominence in all village meetings/affairs as for example in
“Mahila Jagruti Sibirs’\ so that they would get an identity7~the villagers will come to
“know them” and seek their sendees. She felt along with their certificate they should be
given a “nameboard” which they can put up at their “shop”, so that people can come to
know of their qualifications and avail of their services.
The President of Health Committee at Bhind was also a very dynamic young lady. She is
very active and supportive of health programmes and camps in the district and her
excellent ability to communicate to masses is made good use of by the health department
42
u
in the district. Unfortunately, no one from the department had given her any information
about the JSR scheme and she had no idea of its objectives or functions. She took to task
the nodal officer for JSR scheme in Bhind for the department not keeping her informed
and asked for all relevant documents and files. This clearly reveals that even elected
representatives are not getting necessary information of the various schemes.
She had been able to garner enough support including financial for eye and disability
camps and it was unfortunate that her help was not sought by the health department in
their funding problems from IRDP. Worse was not giving her information of the scheme,
for when it was explained, she was very supportive of the scheme. We feel, this is not an
isolated happening; in two places we found even the Zilla Panchayat President was
having a very sketchy idea of the scheme.
.She felt that the scheme has not been given good publicity, and because of this may not
find optimum utilisation. She mentioned that they are many loan applicants under
TRYSEM from the various professions and also that there are many committee members
with their own priorities. Hence the money meant for this scheme should come under the
head of Health Department so that the budget is clearly earmarked for the scheme and not
diverted for other activities.
/ / She also suggested streamlining the administration to speed up the examination pattern,
/ / announcement of results and release of stipends.
Rjyt) Vv\ <>Vvx
43
u
XL SUMMARY of key findings
1. OBJECTIVES
*
In the department of Health, the objectives of the JSR scheme were known to all.
Majority of responses mentioned were:
i.
to provide first aid care in injuries and treat minor symptoms and diseases
ii. to assist in the implementation of National Health Programmes
iii. to refer serious cases in time
*
As far as the village leaders are concerned, they mainly mentioned the first function
and on prompting agreed with second and third.
*
Eighty percent of communities surveyed are ignorant of the functioning of the scheme
and only 15% of the communities know the person selected as JSR from their village.
*
There was a lot of attrition of information by the time it reached the Gram Panchayat
and Block PHC level. This transmission loss happened at each level of onward
transmission - from state capital to district; from district to block level; from block to
gram level. The reasons could be many - from lack of interest to wilful non
transmission of information to the concerned persons.
With the elected
representatives still not frilly cognizant of their rights and responsibilities and with
bureaucratic officials not yet fully adjusted to the changed circumstances and actively
accepting the changed power equations at district and block levels any new
programme introduced at this stage is bound to have a few hiccups.
*
The other major problem was the inadequate funding of activities of the scheme. The
JSR scheme is a health related project dependent upon IRDP for finding of its
activities. DRDA - with many committee members including MLAs, MPs, each with
their own priority projects has very little funds left after these “individual” needs are
met. Hence the funds dependent components of the JSR scheme always suffered in
each district - leading to non-disbursement of contingency funds and training grants
to most training centres, delayed payment of stipends and non-granting of a single
loan application (under TRYSEM) till the time of our field Review. Because of this
and non receipt of certificates and kits even after successful completion of course,
none of the JSRs have “started practising” and the second major objective of the
scheme that of employment generation has received a serious set back ultimately
slowly leading to trained JSRs seeking other avenues of employment and income.
1. SELECTION PROCESS
*
Selection process was done according to guidelines - but by far and large, the
selection of candidate was inappropriate for the following reasons:
44
u
*
Selection of “family” - in 10 out of 20 communities surveyed, the selected JSR
was related to the sarpanch or panch.
*
Selection of person with recommendations
*
Selection of practising CHWs (old scheme) in 10% of the villages surveyed who
are already using :injections” / drug cocktails.
*
Selection of “overqualified candidates” /non-committed who will join other
professions at the first opportunity; specially if it provides a permanent income.
*
Hardly any females were selected even though JSRs functions are mainly MCH
related; 3 out of 101 in our sample of JSRs.
Reasons for the non-selection of females are :
*
*
*
*
*
*
*
women do not volunteer
not enough qualified women
“purdah system” - permission not granted by family members
travel problems.
no appropriate boarding and lodging facilities(no hostels)
children - family problems
lack of “safety” - and harassment
3. TRAINING
This seems to be one of the weakest sectors of the scheme.
*
The training of trainers of this new scheme though planned was often cursory (4-5
hours in lecture). The training was given in medical colleges by medical college
faculty to the BMOs of the Block PHCs where training was to be held. The
training in Rewa was of 4 days duration and about 3 days at Indore. The training
focussed mainly on technical aspects and what level of information was to be
given to the JSRs (more of what not to tell them). There was little or no
community component - possibly because the faculty must have rightfully felt that
BMOs have more experience on this aspect. However, unfortunately the
training did not deal with methods of training JSRs and adult learning
principles - both of which could have greatly facilitated the training process.
Training should include methods to enhance motivation and appropriate use
of audio-visual aids.
*
The trainers did not train other PHC staff after returning from their training
*
Except one centre which had received “training” and contingency funds from
which charts were bought for training, rest of the centres had no audio-visual aids
45
except a blackboard. Some centres did not even have this and training was mainly
done through oral lectures and demonstrations.
*
On paper it has been shown that training has been done as per schedule. In reality,
it was done as per the convenience of BMO - who had to struggle to find enough
time to conduct training. In many centres, it was conducted after morning
outpatients which often goes on till 2 p.m.
*
Very often the BMO and sometimes the CHV/Supervisors/BEE are also on field
programmes or court cases, etc., The training does get disrupted at Block PHC
because of this and hence such centres should have adequate MOs and other staff.
*
The manual is very curative based and does not emphasize preventive and
promotive aspects. There is also very little reference to sociology. The national
health programmes need to be dealt in greater details.
*
Attendance varied and was between 50-80%, being poor in some centres for
various reasons like distance, disinterest, lack of hostel facilities, non-receipt of
stipend, etc.
*
Training was mostly done via lectures/ health centre postings/field postings.
*
Field posting entailed accompanying the subcentre staff during rounds. It was
done very haphazardly and the field worker was never explained/prepared for the
task or given any further training to train the JSRs appropriately in the field. For
the trainee JSRs it mainly consisted of accompanying the health worker on his/her
rounds and carrying the vaccine box for the health worker.
*
Though most topics were covered, “practical and hands on training” was very
poor.
*
In most centres, training was mainly conducted by LHVs, health supervisors and
the BMOs. Technical subjects were mainly taken by BMOs and sometimes MOs.
The BEE was not involved in 2 of the 11 centres visited as the manual did not
specify any training role for him. (except that of warden of the hostel)
*
BMOs and the PHC staff found the manual to be comprehensive and good by far
and large, and there were very few suggestions like making it more practical and
adding more details in some subjects like Anatomy for its improvement.
*
Even the chapters on basic subjects were found OK (i.e., not too much). Universal
feeling was that if the JSRs had to function well, they needed this degree of
information.
*
The JSRs found the manual to be good and adequate. A few mentioned that the
manual did not cover “practical” / how to manage type of information and 23%
wanted more information on drugs and injections.
46
*
Those who saw the book : Where there is no doctor” found it will complement the
manual in the training process and rectify the defects existing in the manual.
*
Many places held refresher classes and examination oriented training sessions
indicating the concern of health centre staff for their trainee JSRs.
4. EXAMINATIONS
*
Internal assessment : usually 3 to 5 tests were held at regular intervals on portions
covered during that period. It consisted of objective, short notes type and the
marking was fair. Each centre adopted its own technique of assessment.
*
The first External examination was very theory oriented and most trainees found it
tough. It did not examine what the candidates knew and instead it tried to evaluate
what the trainees did not know.
*
The second External Examination was found to be very simple (all will pass).
This was the view of everyone interviewed.
*
The second examination was held 3-4 months after completion of the training
course. Hence, many candidates did not receive information of the examination
on time, missed their examination and are now losing interest in the scheme also.
*
Evaluation was fair at District level. “Copying” was usually not permitted,
specially first test was conducted very well. There was some laxity during second
examination as revealed by the trainers.
*
Results are announced many months after the examination is conducted. This
entails trainee JSRs visiting the centres often to find out whether the results have
been announced. For some, this is expensive and for most, time consuming.
Administration needs to buck up in this regard.
*
The examination tests only theoretical knowledge. No assessment is carried out of
practical skills or applied knowledge. There are no problem solving type of
questions.
5. FUNCTIONS OF JSRs
*
None of the JSRs have set up their practise (shop) in areas visited by us.
*
Those providing curative care are old CHWs who were sent for training, two of
whom have their own “clinics”.
47
ii
*
The Certificates have not yet been distributed. This in spite of exams being
conducted more than a year ago. The delay was for various reasons. Standard
format has now come from Bhopal - the CMO/CEO sign it. The CEO has still not
signed in many areas.
*
*
Not one loan has been sanctioned to date to JSRs in areas visited by us.
JSRs do help in immunization camp activities, but their interest is waning.
*
Similarly, some JSRs are also referring cases to PHCs and it is likely that once
they start “practising” they will be more helpful to the villagers.
*
In a few places, they have been made depot holders and distribute bleaching
powder/chlorine tablets, ORS packets, etc.
*
The other health preventive and promotive activities like chlorination of wells,
registration of births and deaths, motivating for family planning are presently not
being performed by JSRs in areas surveyed by us.
6. “FEE FOR SERVICE”
*
Except the old CHWs who have now received training, no JSR was found
practising
*
The villagers do agree that they should pay for the service, but JSRs clearly
expressed that unless they inject, they will not receive any fees and villagers are
reluctant to pay for only consultations or oral medicines.
*
JSRs lack money/funds to buy any equipment and it is not surprising that they
have not yet started practising.
*
Some trainers doubted whether JSRs can earn enough from their practise as they
basically would be catering to a total population of around 1000-1500 villagers
and competing against “established practitioners”. Hence it can only be a part-time
activity.
7. SUPERVISION
*
This has been planned in the scheme and mention of it has been made in the manual.
But what was disturbing was the absolute lack of planning/interest in this activity at
Block PHCs with none of the centres having chalked out a programme or given a
thought as to how this will practically be earned out once the JSRs start practising.
*
Presently there is hardly any further contact between the training centre and JSRs once
they have completed their course. Even at village level, there is hardly any contact
between field workers and JSRs.
48
8. ADMINISTRATIVE DETAILS
*
There was very little time between announcement of JSR scheme and its
implementation at block PHC level.
*
A scheme like the JSR scheme to be implemented in the whole state needs adequate
lead time for appropriate implementation and wide-scale publicity to create
awareness. Unfortunately, the scheme was implemented within a very short period
and hardly had any gestation time. Obviously this rule out any pilot project which
would have allowed for any corrections/changes.
*
The scheme was to be widely publicised through posters, radio, TV and at panchayat
meetings. On enquiring from the villagers in the areas we visited, we realized that no
such activities were carried out. Oral discussions with JSRs revealed that only 3 of
them had heard about the implementation of the scheme on radio and 1 of them had
seen information about the scheme being given on TV. The scheme was implemented
in a hurried manner with inadequate preparation.
*
There is a lot of attrition in transfer of information from state level downwards to
village level. Often the Panchayat leaders were found to be ignorant or with very
superficial information about the scheme. This impedes their proper involvement in
the scheme.
*
No centre had received the Rs.5,000/- for training materials that they were supposed
to receive Kits were not distributed in 90% of the training centres visited.
*
Contingency amount was not released in 81% areas for the first batch training and in
all centre for second batch training. Hence, it was not possible to make hostel
arrangements or buy audio-visual items for training. This money was also meant to
be disbursed to staff for conducting the training and hence they were also unhappy
and had lost interest in training.
*
Stipend was not disbursed in time in most areas. Because of that, many students had
problems. Some received their stipend much after the course was completed. Many
from second batch have still not receive their last instalment. The trainees had to make
repeated trips to the PHCs to collect the stipend.
*
The loans were to come from TRYSEM which also caters to many other activities and
trainings for other professions. The JSR activities which come under health category
(not a priority area for most) requires the largest amounts under loans and subsidies
for disbursement and often is a casualty for that reason itself. It is therefore not
surprising that no loans have been sanctioned to date.
*
Manuals did not reach till quite some time for first batch. The second batch received
it on time.
49
♦
The CEOs/Panchayat Presidents are not aware of details of scheme implementations
like, loan sanctioning, the amount of subsidy, kit distribution, etc.
At present, no department (health or IRDP) has all the details of all the trainees - their
total number district wise, their profiles, the number that have passed, the number who
have applied for loans, etc. This is very important and necessary information
specially for future Review of JSR services.
9. CONCERNS
♦
Loss in terms of numbers - trained JSRs shifting to other fields/professions because
of delay in sanctioning of loans and issuing of certificates to them.
♦
Many who failed first external examination have not come back or taken examination
again.
*
Without funds, the JSRs are not able to set up their practise.
♦
Many in the health department including the trainers are worried that JSRs will cross
their brief, use IV injections, give treatment for diseases for which they do not have
permission or have not received training, use drug combinations in short, practise
“quackery”. Their other fear is once they get busy in their practises, they will not
give any attention to preventive and promotive activities.
*
The scheme defines how the loan money is to be utilised by the JSRs. The breakdown
given may not always be useful to all JSRs. Some of them may not require funds for
rent or furniture. They may not require to purchase the amount of drugs specified.
There should be flexibility in the way the loan can be utilised. Officials are asking for
these receipts before they sanction the loan - an improbable happening - for how is
the JSR to obtain the receipt without paying? He needs the loan amount-to make the
payments! Also, the amounts specified to be spent specially for drugs - requires JSRs
to purchase large amounts of drugs - which he may not be able to utilize or which he
could obtain from the PHC. The TRYSEM loan mechanism for JSRs thus seems
irrational in some areas.
No provisions have been made in the scheme for regular contacts between JSRs and
the health system and for refresher courses for JSRs. These activities are very
important for the maintainance of quality of service of JSRs.
sjt
At present, no department (Health or IRDP) has all the details pertaining to the
trainees, their total number district wise, their profiles, the number that have passed,
the number who have applied for loans, etc. This, very important information
necessary for any evaluation of the scheme on a later date is not presently available.
50
RECOMMENDA TIONS
A. Selection Process
B. Training
C. Examinations
D. Supervision
E. Functions of JSRs
F. Administrative Details
XIL RECOMMENDATIONS
A. SELECTION PROCESS
*
Widely publicise the scheme through health camps/health melas and local means of
communication before seeking applications for JSR training. With greater awareness,
it is likely that more and appropriate candidates will apply.
*
Discourage applications of people who are already practising “quackery” - (e.g., using
injections, IV fluids, etc.)
*
Reduce the minimum eligibility to VIII standard pass (instead of X standard) specially
for women and tribal candidates.
*
Assure proper hostel accommodation and proper training hours so that women
candidates are encouraged to apply.
B. TRAINING
*
Identify what the trainees have to learn / do at Block PHC and sub-centre field
postings and to set clear-cut objectives of learning at all levels of training.
*
Training to be conducted by Doctors mainly and by other staff who directly deal with
certain activities at the PHC (e.g., LHV, ANMs, BEE). The doctors should supervise
training at all levels. If training is at the district, there can be other educators also.
*
Hostel accommodation to be provided at training venue (District and block) so as to
improve regularity of attendance and avoid absenteeism. This might also lead to more
females applying for JSR training.
*
Emphasize preventive and promotive aspects along with curative aspects. Include
sections on health education and sociology.
*
Have guest lecturers and experts address the JSRs and take certain training sessions
(specially on homeopathy and ayurveda).
*
Enhance emphasis on locally prevalent problem and national health programmes.
*
Conduct the initial first 13 weeks for theoretical/clinical training at district level as
planned for III batch. For the field based training send them to the Block PHCs for 6
weeks and subcentres for 2 weeks (8 weeks). Have the trainees come back for last 5
weeks to District Centre once again to consolidate curative/preventive/promotive
training and prepare for examinations.
*
Introduce intersectoral cooperation and activities into the training curriculum.
51
*
Improve the quality of training by making use of charts and other audio-visual aids.
*
Make the manual more “practical” giving greater details on symptoms, treatment,
drugs to be used and with greater emphasis on national health programmes. Make
necessary changes as suggested in comments of the evaluators on the manual. Surface
Anatomy and Human Physiology can be demonstrated and practically done by using
the trainees themselves.
*
Provide the book :Where there is no Doctor” to each trainee at the beginning of the
course and refer to it during training as a “practical community reference book”.
*
During the training process, give emphasis to problems that are encountered at village
level.
*
Periodical tests should be regularly conducted to assess progress of trainees. Their
average should be taken as internal assessment marks.
*
Have a detailed plan for continuing education and institutional support for further
development of JSR and to improve their quality of service.
C. EXAMINATIONS
*
Hold the examination immediately after completion of the course. The dates should
be fixed atleast 3 months in advance and should not be changed under any
circumstances.
*
Field based personnel who have full knowledge of the objectives of the JSR scheme
and functions of the JSR should be part of the team setting the question papers for the
examinations.
*
Give simulated case studies to assess their knowledge rather than only objective type
questions. A suggested examination pattern is given below:
i. Objective type questions
ii. Short answers
iii. Problem solving
- 50% marks
- 25% marks
-25% marks
Examples of problem solving questions are enclosed (Appendix 7).
*
Print the required number of question papers and send to various examination centres.
This is to obviate the problem of photocopying question papers at all centres as they
neither have the facilities nor the funds. This will also prevent leakage and avoid
malpractice.
*
Give guidelines to various training centres on the proposed 3 “Internal Assessments”.
*
Results to be announced within 15 days of completion of the examinations.
52
*
Appropriate arrangements to be made for preventing copying by trainees during the
examinations.
E. SUPERVISION
*
Send instructions from the concerned Health Officials to the implementing agencies
and training centres to be sent requesting that the “supervision” activities for the JSRs
should be planned in advance and become an integral portion of the training of JSRs.
*
Give emphasis to supervision during the training process.
*
A guide (instructions) on monitoring and supervision of JSRs by the PHC should be
circulated to all PHCs.
F. FUNCTIONS OF JSRs
*
JSRs need enhanced visibility. Their role and activities need to be clearly explained
to villagers at various village meetings so that their services are maximally utilised.
*
JSRs must devote sufficient time to preventive and promotive activities once they
start practising. Their importance needs to be stressed to the JSRs.
*
There is a lot of overlap of JSR activities with the activities of the multipurpose
worker, dai and other field based personnel. These need to be streamlined and
rectified for the most efficient use of limited resources.
*
Modify the drug list for JSRs. They are at present clear-cut deficiencies in the list.
Dings like Analgin should not be used any more and Decadron has very specific uses
but can be easily misused. Drugs mentioned in the manual for JSR use do not figure in
the list of drugs to be maintained by JSR. This needs rectification.
*
JSRs should interact with other health functionaries as well as with functionaries of
related sectors at local level.
G. ADMINISTRATIVE DETAILS
This is one area which really needs to tone up. Hasty implementation of the scheme after
conceivement without adequate preparation has affected the quality of training and raised
many administration related problems.
*
Widescale publicity should be given to the JSR scheme so that the end-users
(villagers) are made aware of its objectives and functions and start
demanding/utilizing the services provided. It will be more effective and appropriate
53
to use local means of communication (tom toming, camps, etc.) rather than making
use of TV or radio.
*
One nodal person needs to be identified at the district level (other than the CMO, e.g.,
Media Officer) to coordinate the whole programme and ensure its smooth functioning.
All necessary details of all trainees should be maintained at the nodal office of the
district for future reference. Maintain all necessary details of all trainees at the nodal
office of the district for future reference.
*
Streamline the disbursement of stipends, contingency funds and training grant so that
they are made available on time.
*
Distribute certificates and kits within a specified date after completion of the training.
*
Provide appropriate assistance to successful trainees for loan application and
obtaining the loan under TRYSEM.
*
Reexamine the process of sanctioning of the loan under TRYSEM. A group
competent in Accounting and Financing needs to examine it in detail and suggest
feasible alternatives which can be practically implemented.
*
Workshops with participation of Panchayat representatives and concerned officials
(from health and IRDP Departments) on the JSR scheme need to be organized in all
blocks and districts as soon as possible. This will greatly facilitate transfer of
information and creation of awareness of the scheme among elected representatives
and concerned officials.
*
To prevent attrition of information it may be necessary to communicate directly with
Panchayat, Block and Zilla representatives on issues regarding the scheme.
*
Plan and implement the distribution of manuals better, so that all training centres
receive them before the training course is started.
*
Provide a nameboard along with the certificate to all
giving them an identify.
successful JSRs to help in
54
SOME CONCERNS
Attrition of JSRs
Training of each JSR costs the state a substantial amount (time and money). All
preventive efforts need to be taken to ensure that they do not dropout during training or
are not lost after training. This would require:
*
*
*
*
*
*
*
*
proper selection
building commitment
appropriate training and training facilities
correct evaluation
timely registration and provision of kits
assistance in obtaining loan
regular assistance and supervision
continuing education and refresher courses.
Small number of women candidates
The activities of the JSR are to a large extent CSSM/MCH activities. Women JSRs
would therefore be most appropriate to carry out these functions. There are also other
advantages like stability, not being lost to other professions, etc., when a village selects a
woman to undergo JSR training. However, very few women apply. The challenge lies
in overcoming their resistance and convincing the community of the benefits they will
accrue if a woman becomes their JSR. Steps need to be taken to address these challenges.
Preventing unethical practise
If JSRs go beyond their brief, start treating diseases for which they have not been given
the competence, use drugs illogically, have an injection - IV based practise then there will
be very little difference between them and the present “quacks” scattered all over Madhya
Pradesh.
How do we assure that the JSRs carry out their duties with commitment and ethically, not
only focus on curative medicine but give due emphasis to preventive and promotive
aspects are other major challenges which need to be addressed.
55
APPENDIX 1
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56
APPENDIX 2
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to toto tjr r w wh to 4mhi to wr ■'Wi^q rjr;
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fton, snj towr
wg sto 3R^ 4mcii4 ^tot toto.
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tor. 4<2jh to Ito dii Rtow "q? w tok tor snto ftoto to toto
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tow to^ w w totowrtoto to tow to qtoiitod toito to
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w toi fton
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totowtotor to totow to srtoto to zto ?w torw to
wto qtort tornr.
$yto ftoto tof Rdi tor ftorr 'Jiitoii.
towtototo to fwr ftoM to tow to^ w ntotorfto toto toto. to to rr
^to toww4f to tortor tor ftor Riton.
tow to artoto to to^ ffr tort tototo.
tow e w w torr.
to? townto to hi^h tow to wto w toto to tor tow to ?rh
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60
APPENDIX 3
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65
?
APPENDIX 41
vjpj ^nwr vm? 4)viHT
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(h.^. <kq>k)
1997
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(H.n. tixcnr)
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71
APPENDIX 4C
Review of JSR Scheme (Govt. Of Madhya Pradesh)
Check-list to assess working JSR’s activities (JSR)
I. Certificate
1. Certificate
2. Manual
Available
Available
Yes
Yes
No
No
/
/
II. Drugs
Name of drug
In
stock
beginning
(June 1997)
Used
June
in Added in Stock as
June
of 30/6/97
1) Chloroquine
2) Cotrimoxazole
3) Analgin_______
4) ORS powder
5) Iron & Folic Acid
6) Paracetamol
7) Avil_________
8) Decadron_____
9) Condoms_____
10) Oral pills
11) Neosporin powder
12) Gauze bandage
13) Savlon________
14) Chlorine tablets
///.Patients’ Illness Register:
1. Maintained
Yes
/ No
2. Total No. Consulted:
<-1
1-5
M F
M F
M F
6-14 15-20 >21
M
F
M F
3. Diseases seen (details)
4. Total No. Of Illnesses : Total No. Of Correct PX according to DiagssB'>5 is
5. Total No. Referred :
72
IV. Birth Register
1. Maintained
2. No. of Births
Yes
No
/
:
months)
(in
3. Delivery Conducted at:
4. Who Delivered?
Dai
TBA
JSR
ANM
5. Any difficulty during delivery ?
6. Weight of baby:
< 2 kgs
2 - 2.5 kgs
> 2.5 kgs
V. Death Register
1. Maintained
2.___
Sl.No
Yes
Age at Death____
No
/
3.
Age (years)
Cause of death
“Cause-----
4. Health personnel consulted before death:
73
'PY.Marriage Register :
1. Maintained
Yes
I
No
2. No. of Marriages
Vn. Antenatal Register
1. Maintained
Yes /
No
2. Total No.
3. No. being appropriately managed:
^m. Eligible Couple Register
1. Maintained :
Yes /
No
2. No. of Couples on register:
3. No. adopting temporary measures :
4. No. adopting permanent measures :
JX Chlorination
(In one week)
1. No. of wells in the village
2. No. chlorinated
:
:
X Immunization Register:
1. Maintained :
Yes
2. Total No. of Children
3. No. immunized on time
/
No
X/. Growth Chart Register
Yes /
No
1. Maintained :
2. No. Of Children :
3. No. Whose charts are maintained correctly :
74
/
APPENDIX 4D
Community Members (CM -1)
Review of Jan Swasthya Rakshak Scheme
(Govt. Of Madhya Pradesh)
July-August 1997
Issues to be discussed in group discussion with Community Members
Name of village:
Name of sub-centre:
Name of PHC:
District::
A1.
What are the major problems in your village?
A2.
What are your main health problems?
A. General
1. Are you aware of the JSR Scheme?
2. How did you come to know about it?
3. What is the JSR Scheme?
4. Do you know who is the JSR selected for your village?
5. Were you consulted in his/her selection?
6. Is there a health committee in your village?
7. Does it meet regularly?
75
B. Functions of JSR
1. What in your opinion are the objectives of the scheme?
2. (a) What are the main responsibilities/functions of the JSR?
(b) Out of these, which functions does the JSR of your village do?
3. Is there any additional activity that you would like him to do?
(a) Do you think that the JSR has received adequate training to take care of
your common health needs?
4. For which conditions wouldno to him?
5. Name some conditions for which you would not go to him but go to see
somebody else.
6. Do you feel comfortable discussing your problems with the JSR?
7. Can you contact (get) your JSR easily?
8. Are you satisfied with his examination, services and treatment?
(a) If not, give reasons:
9. Are you satisfied with his approach/behaviour?
(a) If not, give reasons:
10. Did he give you medicines or did you have to purchase it from elsewhere?
11. How much does he commonly charge?
12. Do you think this is reasonable?
76
13. Would you recommend the services of JSR to others’ in your village?
14. Does the village committee supervise his work?
15. Suggest means by which the quality of.services given by the JSRs can be
improved.
16. Do you think that the village should pay some remuneration to JSR for
(preventive/promotive and other such work) chlorination, helping build
latrines, soakage pit, fever slides, etc...?
17. Has the JSR Scheme decreased your inconveniences in obtaining health
care?
18. Do you think that the Government should implement this scheme in every
village?
77
APPENDIX 4E
Community Leader (CL ■ 1)
Review of Jan Swasthya Rakshak Scheme
(Govt, Of Madhya Pradesh)
4
July-August 1997
e
Issues to be discussed in individual/group discussion with community leaders
Name of village:
Name of Sub-centre:
Name of PHC:
District:
A. What are your main health problems?
Village Health Committee
1. Is there a village committee (or similar mechanism for collective decision-making)
for commumty's health and.health related affairs?
2, Is this committee statutory?
Yes/No
Yes/No
3. Does the JSR member attend this committee Yes/No
4. If yes, what is his status in the committee? (E.g. Secretary, treasurer, member,
etc.)
i
78
5. What are the functtons of this committee?
4
6
- Deciding on priorities for local health action.
- Mobilizing local resources for health activities
- Obtaining outside resources for local health activities
Planning, implementing and supervising health activities
- Employing village health workers
- Supervising non-technical aspects of JSR’s work
- Effectively dealing with emergency health situations.
6. How often does the health committee meet?
/.
What was discussed in the last meeting?
8. Are minutes of the committee meeting maintained?
9. Are there any other committees in the village?
10. If yes, please give their names:
c
o
79
4
o
About JSR
■4
e
1. How did you become aware of the JSR Scheme?
2. Do you know the objectives of the JSR Scheme?
3. How was the JSR selected?
4. Were you involved in his selection?
/
No
5. Were you satisfied with the selection process?
Yes
Yes
/
No
6. According to you, what are the main functions of the JSR?
■7. What functions does the JSR of your village carry out?
8. Are you satisfied with his work?
(b) If no, specify why
Yes
/
No
9. Does the village health committee supervise the functions of JSR? Yes
/No
10. Has the JSR scheme helped in reducing community health problems? Yes / No
11. Do you think health workers’ needs to be encouraged in the performance of non
health’activities (Environmental, v/ater, etc..)?
Yes /
No
12. If yes, give details on how this should be done?
13. After completing his course, and before starting his activities, did the JSR come
to meet the village leaders?
Yes /
No
14. (a) Do you believe in the competence of JSR for treating common ailments?
Yes /No
(b) If no, specify why : 15. Give suggestions for improving the functioning of the JSR Scheme.
80
APPENDIX 4 F
1
1
Review of Jan Swasthya Rakshak Scheme
(Govt, of Madhya Pradesh)
July-August 1997
Issues to be discussed with senior Govt. Functionaries (DHO, etc.) and officers incharge of Scheme at Bhopal
1. What is your opinion of the objectives of the scheme?
2. Do you agree with the functions envisaged of the JSR?
3. Do you think that the curriculum is adequate and appropriate?
4. Are you comfortable with his training level?
5. Are you comfortable with the way their training was carried out?
6. What is your opinion about the acceptability of the JSR in the village?
7. In your opinion, in what ways will the JSR’s activities improve the health
conditions of the community members?
8. What according to you are the reasons for such a high failure rate?
9. Any suggestions for improving the functioning of the scheme?
81
APPENDIX - 4g
Review of Jan Swasthya Rakshak Scheme
Govt, of Madhya Pradesh
July-August 1997
Issues to be discussed with trainers
Name of PHC:
Name of District:
A. General
1. What do you feel are the objectives of the JSR Scheme?
2. What are your expectations from the JSR Scheme?
3. What are your expectations from the JSRs?
4. What are the common health problems in which JSR can play a role?
5. How would you rate the functioning of the JSRs who are already working?
(a) very good (b) good (c) fair (d) poor (e) very poor
6. Do these JSRs refer cases beyond their skills in time?
7. Do you receive case referrals from JSRs which they could have managed?
8. Do the JSRs cooperate and help you in your activities in their villages?
9. Do you think the villagers are happy with the functioning of the scheme?
10. Do you have any worries regarding the scheme?
11. Any suggestions for improving the functioning of the JSR Scheme?
82
<
APPENDIX 5A
6
JSR Examination June 1996 Paper No 1
o
-
6
S.
9.
10
11
12
13
14
15
16
IS
19
20
21
23
25
26
2S
29
30
31
32
33
34
35
36
3”
38
39
40
•! n
43
-- 5
-6
4"
4S
49
'5 0
Durat ion
hrs Max marks 200
Numb e r o f bone s in human body
Wha i is clavicle
Wha t is stomach
Wha t is aorta'
Type s of mu sc 1 e s
Functions of blood
What is prostate
Functions of skin
What is blood pressure
Functions of small intestine
Functions of kidney
What is protein, fat k carbohydrate
What is ORS
Drugs used in malaria
Wha t are oral pills
Wha t i s i ron & folic acid
Wha t i s the use of sava 1cn
What i s the use of paracetamo1
Use of gauze bandage
F u nc tion of heart
Why i s post-mortem conducted
What are symptoms of death by hanging
How is a case of drowning treated
Symptoms <Sr signs of poisonous snake bite
Wha t should JSR do in case of epidemic outbreak
First a id f or dog- bite
Name the National Health Programmes
Wha t advise should JSR give to a TB c a s e
What is compost pit
Advise to be given to parents of malnourished children
Records to be ma int a. i ned by JSR
What i s s ani t ar y latrine
What i s birth & de a th rate
How to chlorinate a we 1 1
Wh a t i s filaria
Name four viral diseases
d i s e a s e s spread
s p r e a d by
b > air
Name diseases spread by contaminated water
Precautions to be observed while making blood films
Symptoms 6: signs of leprosy
Symptoms &• signs of tuberculosis
Precautions to be observed for drinking t a n k / p o n d wa t e r
f our contagious
c ont a g i o us diseases
Name four
Wha t is d e it g u e f e v e r
Way for safe disposal of garbage
Wha t i s t u b e r c u 1 i n t e s t
Wha t i s u s e of bleaching pcv.der
f c u r d: i s e a s e s spread by mosquitoes
•? o n t r a i n d 1 cat i o n s for use of oral pills
Funet io ?s of 1 i v e r
N a m e t r r a e c a u s e s o f joint pa i ns
83
APPENDIX 5B
J 8 R E x a m i n a t i o n ' u n e 1 9 9 6 P a p e r h‘ o 2
D u r a t i o n 2 h r s . Max marks 200
C a u s e s o f t oo thack?
What is dental c a r i e s
T r e a t m e n t f toothache
Symptoms V s i g n s o f t y p h o i d
Treatment of 1 e p r o s y
6 . When to refer a case of headache to. PHC
Causes of gastroenteritis
y
What are the signs of shock
9 . •What aare
r e tthe
he causes of abdominal p a i n
10 . F1 r s t a i d for wet b u r n s
1 1 . Cau s e s o f ea r a ch e
12 . C a u s e s o f d e a f n e s s
13 . T r eat me nt of foreign body in ear
1 4 . Ca s e o f na s a 1 b 1 eed i ng
15. What are the main causes of cough
1 6-. Causes of b1i ndness in Indi a
1". What is cataract and how is it treated
18. What to do immediately after an eye injury
19. How to diagnose conjunct ivi t is
20 . How to treat dust/foreign body in eye
1. What is the main objective of Blindness Control Programme
How can you help in Eye Camps
23 . How to prevent nutritional blindness
24 . Wh a t is re f r a c t o r y error
2 5 . Give dosage schedule for Vitamin A administration
26 . How will you treat pneumonia in a chi Id
. How will you treat diarrhoea in a chi 1 d
2 8 Wha t is po1io
29 . How to pre
prevent
vent polio
3 0 . Which are the vaccine preventable cl i s e a s e s
31. Main causes, of cough in children
32. What is the first food for a new born
3 3 . How to diagnose malnutrition in children
34. What is the responsibility of JSR for safe motherhood
3 5 . Cause of anaemia in pregnancy
36 . What are the problems during pregnancy and after delivery
37 . Advantages of small family size
38 . Where, are female ster i-1 izat ion services aval 1ab1e
39 . Symptoms and signs of gonorrhoea
40 . What is AIDS
41 . How is AIDS transmitted and how to prevent it
42 . Uses of Cu T
43 . How will you look after a new born
44 . Reasons for population increase in India
4 5 . First aid for sprain
46 . Treatment of sun stroke
47 . How & when to use splints
48 . Symptoms & signs of joint pains
49 . First a i d for h e a d i nj u r y
50 . “JSR will meet the community needs”. describe in your words
84
APPENDIX
Analysis of JSR Examination Questions against
topics in JSR Manual
Chapter
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Topics in Manual
JSR
Exam I
JSR
Exam II
1%
1%
13%
3%
0.5%
0.5%
8.5%
4.5%
6%
3%
4%
3%
2%
7%
3%
5%
2.5%
4.5%
3.1%
2.1%
2.5%
5.0%
4.5%
11.5%
7.5%
5.0%
Responsiblities of JSR
Working with Community
Anatomy and Physiology
Disease Transmission
Environment Hygiene and
personal habits
Malaria
Tuberculosis
Typhoid/Dengu/Filaria
Leprosy
Eradication of Blindness
S.T.D
Family Welfare
Safe Motherhood
Care of Newborn
Significant Diseases of
Childhood
Immunisation
Child Growth and Development
Nutrtion/Malnutrition
Examination of Patient
Treatment of Minor Illness
First Aid in Emergency
Documentation/Recording
O/o
1%
6%
2%
9.5%
8.0%
1.5%
7.0%
1.1%
6.5%
4.0%
0.5%
3%
1%
10%
15%
2%
*
97%
100%
*--------
*21, 22 Postmortem ?
* 27 National Health Programme ?
S5
Il A- '
APPENDIX 7
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86
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4.
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5.
H8^ sfR TRTI <f7t Mf^R cf^M 4>|4^H
3TTH W ^TT?
^gfqUT^ aft? tidl£
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6.
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87
|
I
J.
TR-2
B. Training Process
1. Did you receive any training to become a trainer for this'scheme?
2. Is there a schedule to be followed for training?
3. Were you given any additional resources for conducting this training?
4. Was training assessed by anybody?
5. How was the training conducted (method)?
6. Will training be followed up through regular supervision system?
7. Will JSR performance be monitored?
8. Is there an adequate supply of training manuals?
9. Does training manual cover all locally prevalent health problems which can be
managed by JSR?
10. Does the training manual contents respect local customs/culture?
11. Is the material in the training manual appropriate for the work envisaged from
JSRs?
12. If no, give details/suggestions on how the manual can be improved?
13. What audio-visual aids did you use during the training process?
14. Do you think curriculum for the JSR’s in adequate and appropriate
15. What according to you are the reasons for the high failure rate of JSRs?
16. Any suggestions for improving training process?
88
TR-3
C. Supervision Process
1. Do you supervise the activities gjgaetivttieS of the JSRs?
2. Is there a schedule/plan for supervision of JSRs?
3. Is it a necessary part of JSR training?
4. How often do you conduct supervision?
5. What activities do you supervise when you meet the JSR in his village?
6. What methods of supervision do you adopt?
7. Are there any written check-lists for evaluating the performance of JSRs?
8. Do you train/demonstrate any technical skills to the JSR during supervision?
9. Do you maintain a record of supervisory and follow-up activities?
89
Position: 13 (111 views)