Transcript Document

Mitanin Programme
Building a State-Wide Community
Health Activists Programme .
Objectives of the
Mitanin Programme:
• Improve awareness of health and health
education.
• Improve utilisation of existing health care
services
• Provide a measure of immediate relief to health
problems.
• Organise community ,especially women and
weaker sections on health care issues
• Sensitise panchayats and build capabilities
Operational Objectives
• 1. Select a Mitanin in every hamlet of the
state- 60,000 in all. A mitanin is a woman and
-fully voluntary - selected by the community
and approved by the panchayat.
• 2. Train the Mitanin over 18 months- 20 days
of camp based training and 30 days of on the
job training at the village.
• 3.Provide support to her in her work and
closely coordinate with ANM and AWW for
maximal effectiveness.
What are the Compulsions for a
Community health volunteer?
• 4000 subcenters, 26,000 villages and 54,000
hamlets- If infant mortality must fall further
then in every hamlet every newborn, every
diarrhoea, every ARI, every case with fevermust be seen on Day One.
• Health education requires someone from within
the community who knows the local idiom and
perceptions,
What are the special features of the
Mitanin Programme( as compared to
earlier such programes)
1.
2.
3.
•
The volunteer is a woman – and so are all her trainers(
59,000 women require approx. 2900 trainers)
The selection is hamlet/village based
The selection is through a 3 to 6 month process where
the community makes the choice but facilitated by a
trained prerak drawn (largely from but not necessarily)
from NGOs.
While selecting a Mitanin four guidelines to remember
1. Preferably be a married woman
2. Should be able to give time( supportive family
circumstance)
3. Preferably Should have been involved in some social work
4. Education not a must but preference to good literacy level
Special features of the
Mitanin/ASHA Programme
• Curative care is complementary and essential –
but not central part of the programme.
• Continued training and support for the entire
duration of the programme – not merely an
initial effort.
• Parallel strengthening of public health systemsnot a substitute to strengthening public health
systems – but forms a context in which it
becomes more accountable and functional.
• State- civil society partnership at all levels.
Selection ProblemsWho speaks for the community?
• Method 1: ANMs/AWWs made selections
• Method 2: Collector gives deadlines to
panchayats. All sarpanches do the selection.
• Method 3: The anganwadi worker and helper
selected as Mitanin.
• Method 4: Contracted out to NGOs- selected
persons familiar/associated to them.
• In each of the above situations other stakeholders
reluctant to accept the Mitanin- and expectation of
Mitanin is neither well informed to community or to
Mitanin. Also assumes a homogenous village, where
everyone would agree on a “ best person”.
Approach to selection:
Facilitated Selection;
• Faciliation has four aspects-
– Informing the community of the programme
– Ensuring that women and weaker sections are consulted in
the choice..
– Ensuring that the panchayat approves the choice of the
gram sabha.
– Ensuring that there is enough preceding community
mobilization to generate participation and number of
volunteers to choose from. Kalajathas were used
extensively to convey /explain three key messages:
• Peoples health in Peoples hands
• Health is our right
• Mitanin is a volunteer/ organiser of the community to secure
the above.
Facilitating selection:
1. Consulation meeting between different stakeholder groups to
understand programme and recommend the prereak.
2. Identify one prerak per cluster of villages – about 10 to 15 persons
for a block. Maybe ANM/AWW worker or from NGO or from any
other source by consultation amongst multiple stakeholders.
3. Orient them on this programme- 3 to 5 day workshop. Orientation and
support helps prerak develop insights on gender, caste and power
equations other than to understand programme
4. Ensure & monitor no.of meetings, at least 3 in each hamlet- held by
prerak before final selection.
5. Hold some public events(kalajatha, aam sabha) to explain the
programme to the public before final selection process.
6. Formal gram-sabha selection .
7. Written endorsement by panchayat.
8. Documents all of these, verify and then only confirm.
9. Block level coordination of selection by an active ICDS persons and
one Active ANM/MPW and two or three NGO members or one lead
NGO.
But what actually happened
in Mitanin
• Only 30% selected in this nine step recommended process.
• But the typical four wrong types of selection – by ANM
alone, by sarpanch alone or the anganwadi worker made by
order or by NGO familiarity-- were less than 20% .
• Even where ANM and AWW chose they chose better, with
more consultation and understanding then they would have
done otherwise. So in effect we have over 80% effective
Mitanins.
• With this approach assembly questions and political
protests easily faced!!! With written panchayat
endorsements.
• AND PROOF---LESS THAN 5% DROPOUTS
The training programme• First round- 4 days: Understanding Health/Health
Services & Child Health And Nutrition.
• Second round – 2 days- repeat
• Third Round- 3 days- Womens health
• Fourth Round- 2 days- Malaria and GE epidemics
• Fifth Round: 4-Mitanin Drug kit and 1st contact
curative care
• Sixth Round: 2 days- TB& leprosy
• Seventh Round:3 days- Village Level Planning
Mitanin Activities- in a
normative month…
1. Initially visiting each household regularly for health counseling
with focus on child health. Later families seeking Mitanin’s help
for simple illness and Mitanin visiting families with newborn or
pregnant women. ( about 6 hours per week – about 25 houses)
2. Attending the immunisation day once a month.( 1 daycompensated)
3. Attending the Mitanin cluster meeting once or twice a month.(
4 hours – half day)
4. Conducting village level mahila meetings once or twice a month(
evening two hours)
5. Maintaining register
6. Attending the training camp – average 2 days per month.( 2
days- compensated)
• Total Work Time – Uncompensated – about 6 to 8 hrs per week
and Compensated: One to two days per month.
Support Activities to keep the
Mitanin Programme going
•
•
•
•
•
•
•
•
•
Visits by Trainers, DRPs, officers, VIPs;
Cluster Meetings- with bonding activities
Training Camps- with bonding activities
Radio Programmes- weekly simultaneous broadcast twice –
14 part serial.
Public meetings of felicitation. Support, grievance
redressals etc.
Village Level Planning for vector control and over all
indicator based
Refilling drug kit regularly.
Good Response to Referrals:
Incentivisation- Yet to start.
Programme Structure
• State level- SHRC – a state civil soceity
partnership institution guided by a State
Advisory Committee. Has a 30 persons training
cum monitoring team.
• District level- District RCH society and dt
coordination committee/task force.
• Also district team of 15 to 30 Dt training
team. Chosen as 3 per block- 2 of whom are
from NGO and one from govt and at least one
woman.
Programme Structure
• Block is the central unit of operation. Has
appox 400 Mitanins.( 120 ASHAs).
• Wide variety of block level programme
organisation- from govt led to NGO led
• Block coordination committee. Has one
lead NGO, the BMO and per plan the block
panchayat rep.as well as the three block
coordinators(DRPs)
Block level programme
management
• Block has 15 to20 trainers one for 20 Mitanins –
all women, all full time paid Rs 50 compensation
per day of work.
• Each trainer has to take 25 days of camp based
training and to be part of training team for four
mitann training camps.
• Also every trainer has to visit Mitanins for onthe-job training on at least two days between two
rounds of training. Approximately 20 days of work
every month for 12 to 18 months.
About trainers
• Trainer also conducts cluster level Mitanin
meetings along with ANM/AWW
• Trainers are ALL women and emerge from
after the selection phase.
• Trainers- preferably ,but not necessarily
they may be all drawn from one NGO.
Budgetary Outlay.
• Out Rs 4000 per Mitanin per year or about Rs 15
per block or about 18 crores for state: plus cost
of drugs( Rs 12 crores /year for a 12 drug/20
item drug kit): plus incentives/honoraria
•
•
•
•
•
Rs
Rs
Rs
Rs
Rs
2600 of which is on training and support
400 on training materials and supplies
200 is on selection and mobilisation
500 is on monitoring and support.
300 is state and district adminstrative overheads
• Rs 10 per capita of population plus Rs 6 per capita
on drugs plus on incentives …….
What are the Mitanin outcomes?
Which can be monitored?
1.
Mitanin visits every single newborn family – on the first
day of child-birth and package of six messages/practices
to be ensured:
Currently Over 80% change in all “performing” blocks.
2 Every pregnant woman’s family is met with in the last
month—and the birth is planned for – and ANC is
checked/on completed.
Instiutional delivery defined by supply side problemsbut ANC increase immediately apparent- no external
measure available
3. Every child with diarrhoea, ARI, Fever is met
with/receives appropriate home care on first day and a
fair% of them get referred: “35% get adequate visits”
What are the Mitanin
Programme outcomes?
4. Mitanin attends the Immunisation Day- which means that
left out children/ women are brought in. 75% outcomes in
performing blocks
5. Mitanin knows every malnourished child in her area and has
visited them more than thrice for counseling on
preventive, curative care and feeding practices. Over 75%
outcomes in Performing blocks
6. Mitanins are functional DOTS providers- Less than 15%
7. Mitanins hold a hamlet level health meeting – as part of a
SHG or as part of independent health committee. About
48% in performing blocks
Other indicators- 84% maintaining register; 30% panchyat
involvement
How does Mitanin impact on
IMR? The process indicators
•
Trend of Infant Mortality Rate
0-1 year deaths per 1000
live births
The case of Jamkhed, Maharashtra
200
150
100
50
0
1972
1976
1980
1984
Year
1988
1992
Four first day “life saving”
visits- newborn, diarrhoea,
fever and ARI
• Facilitate closure of
service gaps (esp.
immunisation & ANC.)
• Referrals- Inst. Delivery;
& for sick child and
neonate.
• Child nutrition counseling.
• 75 key messages that
every family will know.
Above four first day visits
alone can guarantee a 40
pt. IMR decrease:
Health Status Outcomes
• Rural IMR declining – from 95 to 77( over
3 years)While urban IMR remains static at
55. Main Mitanin years to be captured yet
• Immunisation, ANC rates should show
improvement – but external data needed
• Number of institutional deliveries and
skilled deliveries – internal reports show
improvement but external data needed.
Further Action Needed to
Strengthen Programme
•
•
•
•
•
•
•
•
Need to Build up confidence that this is a five year programme
Need External Outcome Evaluation.
Need to introduce Incentivisation.
Need to ensure regular flow of funds for sustaining training and
support.
Need to strengthen drugs refill to Mitanins
Need for further innovations – Mitanin communication kit, AT kit;
Ayush components, limited clinical skills, addressing social
exclusion issues etc
Need to sustain/build up administrative/political support at all
levels
Need to build in diversity and sustainability linkages: with
sanitation, nutrition; social marketting etc.
Thank you