Enhancing Community Health Through Mitanin Programme

1. Mitanin Programme- an introduction The Integration of Training, Deployment, Support and Monitoring of Community Health Activists ( Mitanins) to yield measurable outcomes .

2. 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 capabilites

3. 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.

4. 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 fever- must be seen on Day One. • Health education requires someone from within the community who knows the local idiom and perceptions,

5. How is increased utilisation of health care services effected? • By providing information on health care services • By creating awareness on key health care services- as an entitlement- the rights based approach. • By facilitating the delivery of healthcare services- coordination with TBA,ANMs ,anganwadis and PHC • By local advocacy- pressure for ensuring access to these services: • IN PARALLEL IMPROVEMENTS IN HEALTH CARE DELIVERY

6. What are the special features of the Mitanin Programme( as compared to earlier such programes) • 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 • Preferably be a married woman • Should be able to give time( supportive family circumstance) • Preferably Should have been involved in some social work • Education not a must but preference to good literacy level

7. 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 systems- not 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.

8. Selection Problems- Who speaks for the community? • Method 1: ANMs/AWWs made selections- declared per Mitanin selection rate of compensation: Too many got selected, the selected were familiar/obedient to ANMs/sarpanch. They had expectation of wage; Little community acceptance or motivation. • Method 2: Collector gives deadlines to panchayats. Entire selection completed within a month. All sarpanches do the selection in expectation of wage/influence. Little knowledge of programme. Even ANMs do not own it – leave alone community. Weaker section representation poor.

9. Selection Problems- Who speaks for the community? • Method 3: The anganwadi worker and helper selected as Mitanin. Programme took off very well- as they did not want a competitive cadre to emerge- but in 3 months programme started flagging, and in 9 mnths they declared that if imposed more work they could go to court!!! Zero community ownership • Method 4: Contracted out to NGOs- selected persons familiar/associated to them. ANMs refused to own selection. Sarapanches variable on support. Weaker sections well represented but negotiation poor.

10. Approach to 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 communitymobilization to generate participation and number of volunteers to choose from. Kalajathas were used extensively to convey /explain three key messages: • Hamar Swasthya Hamar Haath • Swasthya hamar adhikar hawai • Mitanin is a volunteer of the community

11. How to facilitate selection: • Identify one person (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. • Insist on consulation meeting between different stakeholder groups( prereak) • Orient them on this programme- 3 to 5 day workshop • Help them( training and mentoring) to develop insights on gender, caste and power equations.- same 3 days • Ensure/monitor no.of meetings, at least 3 in each hamlet. • Hold some public events(kalajatha, aam sabha) to explain the programme. • The formal gramsabha selection . • Then written endorsment by panchayat. • Documents all of these, verify and then only confirm. • 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.

12. What actually happened in Mitanin • Only 30% selected in this way. • But the first four wrong types of selection were less than 20% . • Even where ANM and AWW chose they chose better then they would have done otherwise. So in effect 80% effective Mitanins. • Assembly questions and political protests easily faced!!! With written endorsements. • AND LESS THAN 5% DROPOUTS

13. Approach, Objectives and specific activites of Mitanin programme, An understanding of the health and related services available/should be available in their area. An understanding of how to improve access to and utilisation of health services An understanding of child health – why we are focussing on it, what are its causes and how to tackle it.( nutrition including breast feeding, diarrhoea, ARI and immunisation). A brief introduction to issues involved in women’s health The training programme- first round-

14. Forming a data base of families and children under 5 in her area Assessing state of current utilisation of services Maintaining record of some relevant health events begins Organising womens meeting Focus is on health education work- both in group meetings and with home visits - emphasis on child nutrition and child health Focus is on developing Mitanin’s understanding of health Following the first round – action at the village

15. Training Content: Child health understanding strengthened Utilisation of health services – the role of the village health register Management of diarrhoea, ARI; worms,anemia, child malnutrition, Village Level Action: ANM visits facilitated by negotiating/publicising her visits Gaps in child health care and pregnancy care services addressed All TBAs identified and trg scheduled. Health education & Home visits gain momentum Village health register introduced Mitanin training- the second round

16. Training Content Womens health Adolescent health Care in pregnancy Maternal entititlements Anemia in women Violence & women RTIs After training: Strengthen womens group meetings and collective actions Radio programmes on womens health Campaign against anemia Better utilisation of pregnancy related services and birth planning- Janini suraksha yojana Mitanin Training – Round 3

17. Training Content: Community role in Malaria control – early diagnosis and treatment; vector control Management of Gastoenteritis outbreaks Village Level Action: Community initiates local level planning for vector control Back up in these campaigns provided by sensitised, trained PHC staff Mitanins trained for making blood slides and giving chloroquine. Mitanin Training – Round 4

18. Training Content: Introducing the village medical kit Herbal and home Remedies First Aid Basic symptomatic care and care in minor illness Village Level Action: Mitanin provided with drug kit. Provision of first contact care begins Mitanin Training –Round 5

19. Strengthening training on the the village medical kit and Basic symptomatic care and care in minor illness Tuberculosis and leprosy- early detection, referral and assistance in case retention. Adequate first contact care skills established. TB and leprosy referral moves up to Village level action Community initiated case detection drive and control measures in leprosy ( as part of campaign on skin diseases) and in tuberculosis. Mitanin Programme- Round 6

20. Training Content Intersectoral health determinants Control of waterborne disease --Water and sanitation Food Security School retention Panchayat role Comprehensive micro-planning for health Village Level Action: Drawing up a panchayat level health plan Health and human development index for capability building and ensuring adequacy of local level processes – Mitanin Training- Round 7

21. What does the Mitanin do? Which can be monitored? • Mitanin visits every single newborn family – on the first day of child-birth and package of six messages/practices to be ensured • Every pregnant woman’s family is met with in the last month—and the birth is planned for – and ANC is checked/on completed. • Every child with diarrhoea, ARI, Fever is met with/receives appropriate home care on first day and a fair% of them get referred

22. What does the Mitanin do? Which can be monitored? • Mitanin attends the Immunisation Day- which means that left out children/ women are brought in. • Mitanin knows every malnourished child in her area and has visited them more than thrice for counseling on preventive, curative care and feeding practices • Mitanins are functional DOTS providers • Mitanins hold a hamlet level health meeting – as part of a SHG or as part of independent health committee.

23. 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.

24. 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)

25. 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 on- the-job training on at least two days between two rounds of training. Approximately 20 days of work every month for 12 to 18 months.

26. 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.

27. 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 2600 of which is on training and support • Rs 400 on training materials and supplies • Rs 200 is on selection and mobilisation • Rs 500 is on monitoring and support. • Rs 300 is state and district adminstrative overheads • Rs 10 per capita of population plus Rs 6 per capita on drugs plus on incentives …….

28. Thank you