VILLAGE HEALTH AND NUTRITION DAY IN COMPLETE CONVERGENCE MODE (VHND) UNAKOTI DISTRICT, TRIPURA

1. VILLAGE HEALTH AND NUTRITION DAY IN COMPLETE CONVERGENCE MODE (VHND) UNAKOTI DISTRICT, TRIPURA

2. DISTRICT PROFILE • Most remote district in Tripura (now bifurcated into two districts) • Bordering Bangladesh, Mizoram and Assam • Formal agriculture in plain areas, subsistence shifting agriculture i.e. Jhum in tribal hilly areas. • Numerous habitations without electricity road, drinking water, telephone connectivity. • Hardly any private practitioner doctors, only single doctor PHCs in tribal areas

3. FEATURES OF SOCIAL INFRASTRUCTURE • Physical infrastructure more or less developed • Most of PHC’s run by one medical officer in remote tribal areas. So difficult for doctors to go into the remote villages. • Due to low education levels, recruitment criterion diluted • Numerous Anganwadi workers illiterate,specially in tribal areas, training is scarce and ineffective • Monitoring difficult due to duality of control in tribal areas, of Tribal Areas Autonomous District Council and Govt of Tripura

4. BACK GROUND OF THE INITIATIVE • In April to June 2010, 24 people (19 infants), died in Kangrai, a very remote village • No information filtered out of the village for three months, while the deaths were going on. • No road, no electricity, no mobile connectivity • NO REACTION from the families, death accepted as a way of life. • No complaints against Health or Social Welfare department. • This was the pivotal force to start VHND in complete convergence mode.

5. ANALYSIS FOR IMPROVEMENT IN SERVICE DELIVERY • There were 8 AWWs, 9 AWHs, and 7 ASHA workers in the village. • As per records, Anganwadi Supervisor, and MPW, had both, done meetings in the village. A health camp had been done two weeks ago.The Chairman of the village, the Headmaster of the school, also were supposedly present in the village but information did not come to the Block or Sub-Divisional level. • The registers and charts of the MPW, AWW and AWS were all fully maintained. • Meeting of CDPO and MO in PHC had been held. • Online reports were generated for state portal. • Due to lack of public awareness, the actual service delivery is dependent on personal integrity and ground level staff.

6. POSITIVE FEATURES ALREADY AVAILABLE IN TRIPURA Government has provided the physical infrastructure in each village. (Anganwadi Centre Buildings and Health Sub Centres available in most villages) The staff has been deployed Reports are being generated, meetings are held, figures are reported. A fund of approximately 1 crore was already available in the district under NRHM, ICDS and IEC funds of other schemes, for awareness generation. Yet how to monitor and coordinate the activities of 1915 Anganwadi workers, 1402 ASHA workers etc, is the main challenge?

7. DIFFERENCE b/w NEED and DEMAND FOR SERVICES • Thus there is need for health services in rural areas. • But there is no demand for the same • Shockingly, people are not even aware who are their field level functionaries • PRI member’s focus on MGNREGA, IAY etc • Need to establish accountability of grassroot government functionaries • Need for coordination between and within departments like Health, Social Welfare, Drinking Water and Sanitation, Rural Development, Panchayat and School Education.

8. VHND AS EXISTING IN NRHM, BUT PRACTICALLY NOT BEING IMPLEMENTED DUE TO… • No awareness of the concept of VHND among general public and PRI’s • Distributed amongst all AWCs, meaning 7-8 VHND’s per month per village to be held as per paper. • Rs 125 per AWC given, Rs 300 per AWC given to Health • Hardly 10 to 20 women used to attend (if at all!) • Complete lack of co-ordination between AWW and ASHA, MPW even though 4 out of 6 ICDS services need coordination. • System of data recording was not there, thus no monitoring • No PRI involvement • No way of checking whether an AWW, MPW, ANM etc have gone to a village or not.

9. BASIC IDEA OF VHND IN CONVERGENCE MODE • Instead under new initiative, ALL the Anganwadi Centres in 3-4 habitations will come together for VHND. • All the functionaries of various departments will come together. • Schedule of VHND will be painted on walls of Panchayat in advance. • EVERY activity related to health, nutrition, drinking water and sanitation, irrespective of scheme or deptt which requires mobilisation of people or awareness generation to be merged. • Fund for IEC activities merged. • Onus on PRI bodies. • All women, children in Anganwadis, Schools attend.

10. CONVERGENCE OF FUND • Existing funds PUT TO USE in a planned manner • From health dept. Rs.300 per VHND per month x 5 = Rs.1,500. • From ICDS Rs.125 per AWC per VHND per month i.e. X 5 = Rs.625. • Total fund available Rs.2125 per VHND per month x 2 X 182 villages X 12 months = Rs 1.32 crores • Additional fund for IEC activities from District Blindness Control Program, AIDS society, Tuberculosis Program, Malaria Control Board, Drinking Water Scheme, Total Sanitation Campaign,etc.

11. SCHEDULE OF VHND The CDPO, MOIC, Deputy Inspector of Schools and Sub ZDO meet quarterly and make draft schedule. Location, Date, Names and Mobile numbers of village level functionaries of 5 key deptts given village wise. The village programs where health camps of PHC, Disability Rehab, TB, AIDS, Malaria, Blindness Control, Mobile Medical Unit etc are to be merged are shown Schedule approved, sometimes with amendments, by Block level PRI body, known as BAC/PanchayatSamity. Painted on walls of Panchayat/Schools

12. CONVERGENCE OF STAFF • AWW • AW Supervisor • MPW / MPS • ASHA • Pump operator of Drinking Water Department • GRS under MGNREGA and RPS • Gram Pradhan • Field facilitator • Livelihood facilitator • Youth volunteers • Dalabandhu • Headmaster of School • Teacher of Mid Day Meal • Mid day meal cook and helper • Disaster Management • District Disability Rehabilitation Centre • Awareness volunteers of District Administration etc,

13. COMPULSORY ACTIVITIES CARRIED OUT IN VHND DAY • Awareness discussion on 14 issues of preventive health care for the community , using the VHND FLIP CHART by Headmaster of School • Small quiz for mothers and children on health issues • Immunization of children • Ante Natal Check up and health monitoring of pregnant mothers. • Weighment of children and plotting of WHO chart • School Health Program • Chlorination/ Cleaning of water sources and discussion regarding their maintenance and repair. • Filling up of forms for fresh issuance and renewal of RSBY smart card. • Supplementary nutrition, Mid Day Meal

14. OPTIONAL ACTIVITIES CARRIED OUT IN VHND DAY • Blindness Control Board • Malaria Eradication Program • Revised National Tuberculosis Control Program • AIDS prevention • All health camps • School health camp by doctors • District Disability Rehabilitation Centre activities • First Aid Training under Disaster Management

15. INVOLVEMENT OF SCHOOL EDUCATION DEPTT • All HeadMasters given 1 day training on modalities of VHND • The school health program is also merged in the VHND. • The students up to 10th class attend the VHND with Headmaster and teacher in-charge of mid day meal. • The headmaster has been given the responsibility of giving an awareness talk using the 14 flip charts under the project. • The mid day meal is merged with community meal cooked during VHND and supplementary nutrition program of ICDS

16. BENEFIT OF CONVERGENCE OF MID DAY MEAL INTO VHND Thus parents and villagers partake of the food distributed in MDM/SNP of AWC, on day of VHND and if there is divergence in quality of food distributed normally in school/AWC vis-à-vis that, on day of VHND, the students report the same, as happened in a few villages, thus leading to overall improvement in quality of Mid Day Meal.

17. CULTURAL ACTIVITIES DONE TO ENSURE LARGER PARTICIPATION Local Dance Group song. Quiz on health issues. Fully immunized baby show. Sports activities for children and mothers. Street drama. (All done using the Rs.10,000 per village given to Village Health and Sanitation Committee from 13th Finance Commission fund.)

18. FOCUS ON MALNOURISHED CHILDREN • Training of AWWs on plotting of WHO chart for identification of malnourished children. • As per SW & SE dept, GR-III and GR-IV malnourished children will be given double ration. • During the few hours of duration of VHND, to create awareness amongst the parents and villagers regarding malnourishment a yellow ribbon is tied on the wrist of malnourished children.

19. IEC MATERIAL DEVELOPED 14 Sheets of large size plastic printed material To be used as a flip chart by the headmaster to talk about health issues so that vital points are not missed out In Local language 42 sheets given per village Also put up as posters for mass dissemination

20. MOVIE FOR AWARENESS GENERATION A national award winning director, Father P. Joseph has made a movie in Kaubru, Kokborok language, English subtitles, of 28 minutes duration – Better Tomorrows The setting is the Primitive Tribal village of Kangrai Issues like drinking water, sanitation, malaria, avoiding witchdoctors etc dealt with. SHG of Reang boys is showing the movie on incentive based payment pattern in remote tribal villages using DG set and projector etc.

21. TEAM OF AWARENESS VOLUNTEERS • A team of boys age group 18 to 22 mostly 12th passed or in college from Reang community have been trained regarding various health related activities organized in four groups of 5 each. • They are formed into an SHG and paid as per performance and in their free time they also attend the VHNDs in the remote areas. • They are called in the district and sub-divisional level workshops and meetings held quarterly.

22. INTEGRATION OF DISASTER MANAGEMENT AND JICA After recent earthquake at Sikkim, Disaster Management team is also being participated in VHND to show the various first aid measure. In some VHND specially in the hilly area the JICA facilitator is also encourage to participate and create awareness activity regarding their various scheme to the public.

23. TRAINING IMPARTED • Preparatory meeting with health, ICDS and other related dept. • Sensitization of top level PRI leaders. • Standardized training module with CDPO / MO I/C as resource person, BDO as organizer for 100% Gram Pradhans, and AWWs, Health & Panchayat staff, at PHC level, with training material and checklists. • Training of Headmasters of all Schools • Preparation of pamphlet in Bengali and quarterly calendar of VHND • Sub-Divisional level training for officers.. • TRAINING MOVIE of 8 minutes in Bengali for showing an ideal, converged VHND to grassroot workers.(recently developed) • Intensive trainings for 2 months.

24. CHECKLIST USED DURING TRAINING OF FIELD STAFF To ensure coordination between various functionaries, necessary to fix specific responsibility on each functionary For Example, Anganwadi Worker should know her specific role Checklist given in Bengali language. Detailed Checklist for every functionary in the chain, including CMO down to ASHA worker and including Headmasters, CDPO, AW Supervisors, Gram Pradhans, NYK volunteers, dalabandhus under SGSY etc.

25. ADMINISTRATIVE ORDERS FROM STATE LEVEL TO ALL PARTICIPATING DEPARTMENTS The project was started after approval in District Level Health Society co-chaired by DM & Sabhadipati. However, resistance was encountered due to additional work and responsibility. Thus, Chief Secretary, Principal Secretary, School Education, ICDS, Health, Drinking Water etc all issued written instruction to their departments for participation, on written request of DM for the same.

26. MONITORING PROCEDURES Any project which involves convergence of schedules, funds and manpower of multiple departments needs robust monitoring procedures for sustainability. Thus village level VHND Register provided which is to be maintained in the village Panchayat by Rural Panchayat Secretary. Reporting Register with duplicate perforated sheets for sending upwards upto CDPO level where they are entered into online website Validation of data entered by health department Register to be counter signed by gram pradhan and various deptts to avoid figure fudging Discrepancy in figures reported by various deptts analysed systematically, thus cooking of figures not possible and quality of health data is much more reliable and robust. Block level and Sub Divisional committees active headed by BDO and SDM with compulsory attendance of commensurate PRI leaders for monitoring the VHND reports. Online website put on public portal for 100% transparency in reporting.

27. VILLAGE LEVEL REGISTER CONTAINS.. Resolution by village committee to hold VHND Attendance Chart Visitor Sheet Awareness Generation Immunization, Ante Natal Check Up and other health activities Accounts of expenditure

28. DISTRICT WEBSITE SNAP SHOT

29. OUTCOMES OF PROJECT

34. FEVER DETECTION AND DEATHS

36. DIARRHOEA DETECTION AND DEATHS

38. MALARIA District was 2nd highest in Malarial deaths in the country in 2009-10. PF malaria is widespread.

40. MATERNAL DEATH

41. IMMUNIZATION STATUS

42. FULL IMMUNIZATION

44. Weaknesses in Implementation • The formats of reporting and online reporting website, have further scope of improvement • Monitoring of quality of services like Ante natal check up, haemoglobin testing etc. • Keeping up the enthusiasm, month after month, requires regular workshops, trainings, monitoring. • Wastage of vaccine vials is a possibility, maintenance of cold chain is to be closely monitored.

45. SUSTAINABILITY Now a demand has been generated in the rural and tribal areas for regular VHND every month The number of complaints against Govt functionaries of health and ICDS deptt of all levels has skyrocketed, which in itself is a positive feature, showing public is demanding service delivery In the PIP under NRHM for year 2010-11, GOI has given fundas to the district as per our new pattern of implementation All young officers presently holding posts of BDO, SDM have received hands on training in running this program There is 100% PRI support to the program, with Sabhadipati involved in its design and implementation at every step and upto Chief Minister level the program has been recognized and is now reviewed.

46. REPLICABILITY As the program received stupendous public response in first 3 months itself, Chief Secretary asked all other districts in the state to implement the same program A committee formed by health deptt to study the same Independent evaluation by NRHM Consultants from GOI Already being implemented in other districts of Tripura in abridged forms Is encouraged by a vibrant PRI presence

47. TRANSPARENCY No large funds involved in implementation Funds of few hundred Rupees distributed to each Panchayat The same accounted for by the Panchayat Secretary in VHND Register Performance of VHND put in public portal on website Fudging of figures becomes difficult as each health indicator is now possible to break down to village level

48. THANK YOU