Technical Consultation on the Role of Community Based Providers in Improving MNH

1. Technical Consultation on the Role of Community Based Providers in Improving MNH Making MNH & FP Access Reality: Role of Community & Community Based Providers – A case of Odisha, India Supported by India A Presentation by Mr. Sudarsan Das, Secretary,HDF

2. MDG and MNH At the turn of the millennium, India, along with the rest of the world, committed itself to a common vision for the future - the Millennium Development Goals (MDGs). The MDGs provide the world time-bound targets for several development goals, The two of these goalposts were for child health (MDG 4) and maternal health (MDG 5).

3. Realizing the Goals… The realization of goals requires active engagement and ownership of the community which remains passive recipient of services for long with emphasis on Gender and rights based concerns.

4. Status of Maternal, Newborn Health & Fertility Level – Current Scenario *Sample Registration System (SRS) , 2011 ** Target by 2010

5. Policy Directions The National Population Policy 2000 reiterates government’s commitment to safe motherhood programmes within the wider context of reproductive health programmes by setting the 2010 targets as high as 80 percent of all deliveries at institutions and all deliveries to be attended by trained professionals. The National Rural Health Mission, which brought in an architectural correction in public health, targets reduction of Infant Mortality Rate to 30/1000 live births and of Maternal Mortality Ratio to 100/ 100,000 live births by 2012. –Mission Document-NRHM

6. The Reality We are yet to achieve the targets and far behind our commitments. There is large rural and urban gap. Access to health services by rural people and the urban poor is limited Major challenge is how to bring health services closer to community?

7. The answer lies with… Community Health Providers • Auxiliary Nurse Midwife (ANM) • Accredited Social Health Activist (ASHA) • Anganwadi Workers (AWW) • Traditional Birth Attendant (TBA)* Community level institutions • Village Health & Sanitation Committees (VHSC) • Self-Help Groups (SHG) • Community Based Organisation (CBOs) *TBAs are now out of the system the ASHA has replaced the TBAs

8. Community Based Providers: Positioning in Indian Health System • A three-tiered system- primary, secondary and tertiary health care. • In 1977 first official announcement of the Indian Government to introduce a CHW Scheme across the country envisaging "provision of health services at the doorsteps of villager”. –Which did not work well. • In 2005 with the advent of National Rural Health Mission (NRHM) systemic changes were made by design to induct CHWs in the name of Accredited Social Health Activist (ASHA).

9. Purpose-ASHA (CBW) • ASHA acting as the interface between the community and the public health system. • To play a central role in achieving national health and population policy goals. • Not a civil servant but a community based volunteer receiving performance based incentives.

10. Roles of ASHAs (CBW) A women from the village… • Community mobilization & Village health plan • Behaviour change communication for health & well being • Coordination with AWW, ANM, MPW (M) and connecting to health system • Escort the patient/pregnant women to hospital • Depot holder • First aid • Knowing people in the village • Facilitate Record and registration of vital events

11. Progress so far • Village with 1000 population have a female ASHA • There are 6,38,000 villages in India (0.63 million). • Total 8,55,168 (0.85 millions i.e presence is >100%) ASHAs up to 30th September 2011 (there are ASHAs even for 300 population in hilly and difficult areas). • 70% of ASHAs are active. • Monthly earning ($30 to $40) per ASHAs based on incentives for: • JSY (MNH-Institutional delivery), • FP, • Morbidity, • Monthly meeting

12. Cultural & Social Challenges • Myths & Misconceptions • Different Social Taboos & Practices • Poverty • Low level of Education • Mobility • Capacity issues • Motivational and other issues Capacity building and incentive to ASHA is necessary but not enough to ensure their performances

13. Community Perspectives • People are not informed • Those informed do not have access to health services • Those who have access need better health services

14. Improving MNH through community based volunteers – Intervention through CBD in Ganjam, Odisha Increasing access to Information and services for non clinical contraceptives – A Community Based Distribution (CBD) October 2010 to December-2012 A joint Initiative of Dept. of Health and Family Welfare,Govt.of Odisha, UNFPA & HDF

15. OBJECTIVE S OF CBD • To Promote health of mothers and children by addressing unmet need for spacing between births. • To Promote Accredited Social Health Activists (ASHAs) and her spouses as community based volunteers for increasing information and access to non-clinical contraceptives. • To Promote & Protect couples and families from HIV through community based approaches by providing condoms COVERAGE All 22 blocks of the Ganjam district covering Population 3.53 million (2011 census), 3171 villages, 82 PHC (N), 460 Sub Centers, and 2792 ASHAs.

16. Rationale behind CBD project • To address high unmet need for FP • To create a continuum of care covering MNH & FP • To engage male partners • To promote reproductive rights • To provide information and services of spacing methods at door steps.

17. Approaches For achieving the objective of the project a two axis approach has been pursued. Community based ASHAand her Spousefor reaching out to couples with unmet need for information and appropriate services Strengthening of logisticsand supply system towards ensuring improved availability of contraceptives

18. Addressing the missing links of the existing system Strategic Intervention • Development of resource and communication material and critical mass of Resource Persons and • Environment building • Training of CBDV - ASHA and her spouse from the community and the ANM as Mentor • Regular supplies of oral contraceptive pills and condoms through the Health Systems ensured • MamtaDiwas for promoting family planning services - Information, Counseling and Administration of checklists • ELCO Survey jointly by ASHA and ANM • MIS developed and reporting through AMAR by ASHA • Documentation and Advocacy ______________In the continuum of services____________

19. MIS - ASHA Monthly Activity Report (AMAR) Project achievement

20. MIS - ASHA Monthly Activity Report (AMAR) Project details cont..

21. No more MTPs for Rama Rama Gauda-village Sirikoi ,Belleguntha Block Married in in the year 2003. 1st child 3 years after the marriage -male child who is 6 years now. Rama wasn’t keen on increasing the size of the family. But she also not aware of temporary methods of contraception as a result she conceived frequently and had to undergo MTP (Medical Termination of Pregnancy) each time. Rama was feeling very weak because of these repeated MTPs. She discussed with her husband to adapt to alternatives to avoid frequent pregnancy. Being illiterate, ignorant and guided by the age old conception of the reproductive responsibility of women, Ramesh did not shoulder his share of responsibility. One day Rama consulted RajalaxmiNayak -ASHA of the village. Rajalaxmi informed Rama that she used oral contraceptive pills (OCP) and her husband used Nirodh .She also explained Rama in detail about different temporary methods of contraception and their benefits clarifying all doubts of Rama regarding the use of contraceptives. Rajalaxmi also told Rama that she could take Nirodh and OCP from her at any time absolutely free of cost. Since then Rama has been using Mala N contraceptive pills from Rajalaxmi and avoids pregnancy. Initially she did not inform her husband of this. Now her husband also understands the benefits of temporary contraceptives and they are happy.

22. Outcome • CBD Project has been successful in promoting spirit of voluntarism among ASHAs in Ganjam. • Overcome socio-cultural barriers for mother and child care. • Availability, accessibility and acceptance of nonclinical contraceptives has increased. • Enabling Environment at every level by the project has been built, resulting scope of sustainability of the project. • CBD Project has been promising in bridging gap between User and the service providers under Health & Family Welfare to promote rights based programming.

23. Change in ASHA Knowledge, Attitude Practices after CBD • Results from the independent study • Knowledge on family planning services, advantages and side effects among ASHAs is more in the CBD implemented districts (mean score 36.7) than non-CBD district (mean score 32.9 significant at p=0.028) • Information on sex selective abortion is higher in CBD district (51% in CBD; 13% in non-CBD) • ASHA as a major source of Condom and OCP users in CBD districts • The misconception about FP in the intervention area are about 1/3rd less than the non-intervention areas. • Regular supply of OCP/Condom is reported by ASHA for their distribution in CBD district (78%) than in non CBD district (22%) • ASHA actively perform Eligible Couple Survey by themselves (81%) in CBD district • Study by • Dr. NishithaRanjan Dash, • Ravenshaw University, Odisha, April 2012

24. Way forward: Communitisation- the Key for promoting MNH • One of the most important and vital component of NRHM is that it provides mechanisms for what we call “Communitisation” i.e. • Community participation • Community involvement • Community based planning • Community management • Community monitoring • In short Community action and Community ownership Needs attention for intervention

25. Way forwardBringing the Public back into Public Health • by allowing community members and their representatives to directly give feedback about the functioning of public health services, including giving inputs for improved planning of the same which will in turn bring in transparency, accountability and effectiveness of the system.

26. Communitization Framework Health system (health care providers & managers) Community (community-based organizations & NGOs) CommunitizationProcess Local self government institutions

27. Epilogue No major change is possible without organized involvement of people; If people are organized and mobilized, no change is impossible Can we direct our efforts towards this…….?????

28. THANK YOU….. Supported by India