Experiments in Monitoring & Triangulation

1. Experiments in Monitoring & Triangulation The Rayagada Experience Orissa Jai Singh Shekhawat State Programme Manager-NRHM

2. How it happened…… 2001 :Govt. of Orissa launches the IMR Reduction Mission 2003 : Rayagada District sets up the District Level Advisory Committee (DLAC) to guide the District IMR Mission, with inputs from UNICEF and CARE. 2005 : Mitra, CHD of Christian Hospital,Bissamcuttack, brought in to DLAC ; Project PHMIS launched

3. The DLAC met on the 20th of each month • The District Administration : Collector, Sub-Collectors, CDMO, ADMO’s, DSWO • 11Block Teams consisting of the BDO, MO, CDPO and BLAC • Resource Persons from Unicef, Care and Mitra

4. The Rayagada IMR Mission MIS Collection of Data in the Field Collation at the Block Level (BLAC) Analysis at the DSWO level Presentation on Power Point to the DLAC Interpretation, Discussion and Utilisation

5. Child Births and Deaths - 2006 • Total Deliveries – 21,591 • Institutional Deliveries - 3491 • Delivery by Skilled Person (ANM) - 4007 • Home Deliveries- 14093 • Total Live Births 19,256 • Total Infant Deaths 1,900 • Total under-five deaths2,563 IMRcontributes to 74% of U-5 deaths

6. Under-5 Mortality Rate of the District for the Year-2006 Muniguda Chandrapur Bissam - Cuttack Kalyansingpur Kashipur Kolnara Padmapur Ramanaguda Rayagada Gunupur Deaths per 1,000 live births Gudari <100 101 - 125 >125

7. Geographical Information on IMR of Rayagada District-2006 Muniguda Chandrapur Bissam - Cuttack Kalyansingpur Deaths per 1,000 live births Gudari <90 Kashipur 91 - 100 Kolnara Padmapur >100 Ramanaguda Rayagada Gunupur

10. Comparative Age wise Analysis on Infant & U-5 Death

11. Comparative Analysis on Grade wise Infant & U-5 Deaths U-5 INFANT

12. Comparative Analysis on Causes of Infant and U-5 Deaths of the District INFANT U-5

14. Project PHMIS Towards a Peoples Health Management Information System A joint project of Rayagada District Administration, Unicef, Orissa & Mitra, Christian Hospital, Bissamcuttack 2005-2006

15. Why ? - To add Value to the DLAC through Epidemiology Consultancy - To Take the Discussion and Campaign to the Gram Panchayath Level What ? - Component A : Epidemiology Consultancy - Component B : Creating GP HMIS

16. Project PHMIS : A. Epidemiology Consultancy Sub Components : Providing inputs at the DLAC, to help interpret and utilise the monthly data for focused interventions • Production of a monthly bulletin – Epidemiological Reflections, that raises issues related to the data • Running a Validation System that surveyed 22 randomly selected villages each month, cross-checked death reports in the system and calculated the monthly Under Reporting Factor. This was shared through monthly Validation System Reports.

17. Project PHMIS : B. Panchayath HMIS Sub Components : • Recruited 8 interested GP’s • Ran GP Mela’s on the theme of Health For All, and Child Deaths • Trained GP Core Teams on setting up the Swasthya Patta System (GP HMIS) d. Provided hand-holding and follow-up support ; fed the output data into the DLAC for triangulation

18. Pictures of Project PHMIS Capacity Building Gram Panchayats in Health Information Management In pursuit of Health For All Rayagada District, Orissa

19. Inauguration of Project PHMIS : 17th Jan 2006

20. Day 1 : Welcome to the GP Mela

21. GP Mela – Lamp Lighting

22. Can we dream of a healthy panchayat ?

23. Group Work : Each village lists Births & Deaths of the last 12 months

24. Village Data on a Panchayat Map

25. Yellow Seeds for Births ; Red Seeds for Deaths

26. Finish off with a meal altogether

27. Day 2 & 3 : Core Group Training on the Swasthya Patta System

28. Day 4 : Learning to Collate & Use Health Information

29. Keeping the Focus : It's OUR children's lives

30. Some Key Players in the Rayagada Initiative The District Collector : Dr Pramod Meherda, MBBS, IAS (presently Collector, Jagatsingpur District) The ADMO : Dr M M Patnaik (presently CDMO, Kondhamal District) The DSWO : Mr Subhash Chandra Rout (Now Retired) Ms Gayatri Singh of Unicef, Bhubaneswar (now with Unicef, Lucknow) Mr Manik Mishra DLC, IMR Reduction Mission

31. Reflections - 1 Even in the most “Backward” Districts, the system can perform. - Reported IMR rose from the impossible 50 to a credible 100 - BDO’s, CDPO’s and MO’s could be inspired to undertake Participatory Governance, based on authentic data - Under-Reporting decreased from 61 % to 26 %

32. Reflections - 2 The “Why ?” of Monitoring should be - Not to find fault, but to add value - If you don’t like the message, don’t shoot the messenger - Carry the Team with you ; Use the Data they report for Interventions ; Share the Joy of making a difference.

33. Reflections - 3 Making a Difference Inspires Enthusiasm Eg. Rayagada District ARI Deaths 2006

34. Reflections - 4 District Specific Indicators Tracked and Local Plans Developed : • Decided to track PNMR and U5MR • Made 3 Core Teams to study and develop District-specific strategies for reduction of deaths due to LBW, ARI and Malaria

35. Reflections - 5 Cultivate Multiple, Independent Sources of Information, including ‘Neutral Umpires’, Sentinel Centres, Community Sources etc Build in Validation Systems Triangulate the Data to get the best shot at Truth

36. DLAC – PHMIS Data Triangulation

37. Reflections – 6Quo Vadis Community Monitoring ? “Community Monitoring” is hot stuff now We suggest : Move from - Community Monitoring to Community Governance Move from - Tracking Utilisation Indicators and Staff Performance to Outcome Indicators and Health Status Interventions Move from - The Provider Perspective to the Consumer Perspective

38. Reflections - 7 Innovative, Out-Of-the-Box, Performance Leaps in the health systems of the districts seem to occur only when driven by young, motivated, health-oriented IAS District Collectors. It would be strategic to invest on orienting and co-opting IAS Officers before they reach the Collector level, through an imaginative, generic and epidemiology-based training programme. .

39. Reflections - 8 • Collector-Driven Initiatives tend to stop when the Collector is transferred. • And yet, they are valuable in that they • raise the bar, • inspire staff, and • give credibility and hope

40. Reflections - 9 • District Public Health Systems can perform well • even in remote regions. Some crucial ingredients : • - Leadership, • - Inter-Sectoral Involvement, • - In-Sourcing Technical Resources from Civil Society • - Basic Epidemiology Skills at all levels

41. STENTHENING OF MONITORING & EVALUATIONTAMIL NADU EXPERIENCE

42. M&E FRAMEWORK INPUT → PROCESS → OUTPUT → OUTCOME → IMPACT NRHM support State resources External factors Functional outputs Service outputs Service utilization Long term Impact (reduction in burden of disease) Planning Implementation Immediate Outcomes (reduction in morbidity) Programme Based Population Based

43. Formal M&E System in Tamil Nadu • The concept of M&E is well known and understood in the organization • There is specific M&E mandate with elaborate procedures, functions and activities • There is a specific section of staff assigned to carry out the M&E mandate • A set of M&E tools and techniques is available for use

44. Contd…. • Regular reporting is done and feedback received • Information synthesized and disseminated to cross section in and outside • Information and analysis is ploughed back into the planning regularly • A functional MIS (manual and computerized) exists • Financial support is made availableby the State and NRHM

45. MONITORING SYSTEM IN TAMIL NADU GOI State Health Society Tamil Nadu Health System Project State Bureau of Health Intelligence State Monthly reports compiled by Assistant Director (Statistics) and Statistical officers of district hospitals and respective programmes District Weekly reports compiled by VHN, SHN, CHN, Block health statistician Primary Health Centres Health Sub Centres Basic registers of maternal and neonatal consultations

46. Innovative Monitoring Tools

47. PHC online reporting system List of information collected online Health Mela / Varumun Kappom Thittam - already operational • Mobile medical units Outreach Camps- already operational • Muthulakshmi Reddy Maternity Scheme/JSY- already operational • Effective Disease Surveillance Information System-trials in place • PHC OP Morbidity- trials in place • Immunisation- trials in place • Pregnancy and Infant Cohort Monitoring-trials started in April • Integrated Management of Neonatal and Childhood Illness-to be started • Civil Registration-to be started

48. PHC Online monitoring • New initiatives- Infrastructure report of the PHC’s now collected through OMR sheets will also be converted to online reporting • Family Welfare and RCH reports now collected through email are being converted to online reporting directly from the PHC’s. • Financial reporting for NRHM/RCH to be integrated into the online reporting • Data to be entered at the PHC level using PHC staff. VHNs to make the data available during weekly meetings • Other alternatives such as simputers for the VHN’s, smart card systems for pregnancy and child tracking to be explored on pilot basis.

49. Pregnancy Cohort Monitoring

50. IMNCI