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NEWS |
| 24 Dec 2010 |
 JICA TQM Consultant invited as Guest Speaker for the Seminar on Bio Medical Waste Management in Gwalior (24th December 2010) .. .....Details |
| 16 Dec 2010 |
 The Common Review Mission visits Damoh district (16th - 22nd December 2010) .. .....Details |
| 6 Dec 2010 |
 National Dissemination Seminar of JICA MP RH Project held at NIHFW, New Delhi .. .....Details |
| 19 Nov 2010 |
 JICA Consultants oriented the Data Officers of DoHFW on use of GIS .. .....Details |
| 13 Nov 2010 |
 JICA team invited for the Partners Forum on Womens and Childrens Health, New Delhi .. .....Details |
| 19 Oct 2010 |
 JICA TQM Consultant invited to present a paper at the Asian Network for Quality Congress Delhi 2010 .. .....Details |
| 12 Oct 2010 |
 Dr. Kiran Ambwani, Deputy Commissioner (FP), MoHFW, GoI, visits Tikamgarh for the District level planning for MCH centres of Sagar division .. .....Details |
| 9 Sept 2010 |
 Dissemination Seminar held to share the findings of the Terminal Evaluation Mission .. .....Details |
| 8 Sept 2010 |
 Joint Review Meeting of JICA Project held on 8th September 2010 .. .....Details |
| 30 August 2010 |
 JICA TQM Consultant presented a poster at the Global Maternal Health Conference .. .....Details |
| 17 August 2010 |
 Madhya Pradesh becomes the first State to start the Public Health Management course at State owned Health Institute (SIHMC), Gwalior .. .....Details |
| 14 June 2010 |
 JICA TQM Consultant invited to present paper at Lal Bahadur Shastri National Academy of Administration, Mussoorie .. .....Details |
| 15 June 2010 |
 Chief Representative, JICA India Office visited Project site .. .....Details |
| 24 May 2010 |
 JICA Consultant nominated by DoHFW, GOMP, for Training of Master Trainers on BEmONC at New Delhi .. .....Details |
| Abbreviations |
COUNTERPARTS |
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| Ministry of Health & Family Welfare |
| Department of Health & Family Welfare |
Inspiring Stories
Inspiring Stories
“Inspiring Stories” are reported from the field. The writing
style resembles that of the “case study”, but differs from it in two ways.
First, particular names are mentioned without alteration. Second,
implications are explicitly discussed here. The objective is to spread the
message that changes can happen. The change agents introduced here are no
big heroes or heroines. They had slightly clearer visions, more optimism and
firmer dedication than the average health workers or managers.
New Rule of sharing Monetary Incentive
Equipment, Facility, and what Next?
Community Participation for Conflict Management
Conflict
Janani Suraksha Yojana (JSY) is a monetary incentive scheme
under NRHM for the promotion of institutional deliveries. Not only the women
who delivered at the CHC, but also the persons who escorted them will get
the “motivation” money. While the JSY has successfully made the
institutional delivery popular, it has also created some social problems.
When the ASHAs were designated as the only escorts, other groups of women
involved in the pregnancy care expressed dissatisfaction. In a village
called Vinti in Hatta block of Damoh district, the following groups of
people claimed for a fair share:
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The Dais used to escort the expecting cases and receive the “motivation” money as compensation for their lost job of assisting the home deliveries. Appointment of the ASHAs deprived them of the compensation too. In protest, many Dais boycotted the ritual of post-partum purification called “Saur uthana”, leaving the women in an “impure” status.
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The AWWs became involved in the pregnancy care when the Department of Women and Child Development (DWCD) was involved in the NRHM. The AWWs thought it is logical that they be entitled to the NRHM incentives.
Resolution
The JICA team of consultants invited the AWW, Panchayat
representatives, ASHA, teachers and some other community members for
discussion. The consultants deliberately let the discussions escalate until
the grudges against each other were put on the common platform. Then they
asked the ANM to count the total ANC cases. They were 12. Based on this
information, the community made the following decisions:
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To distribute the 12 ANC cases among the four “motivators”: Four cases to the ASHA, four to the Dai, and two each to the two AWWs.
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The motivators would be responsible for ensuring that their cases go to the ANC clinics conducted by the ANM in the village, instead of asking the ANM to visit each home.
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The ANC care package consisting of three minimum checkups, timely immunization, consumption of IFA and proper nutrition, would be the prerequisite for the motivator to claim for the motivation money.
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The family members could assign someone else to escort the delivery case, but the money should be given only to the assigned motivator.
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Whoever the motivator would be, the traditional service of ‘maalish’ (massage) and ‘saur uthana’ (purification) should be done by the Dai, who would be paid according to the customary practices.
JICA consultant facilitating the discussion
Bi-Products
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Community support to ANM
The community recognized the important role of the ANM. When the JICA team mentioned that she had no proper premises for her SHC and was constantly moving between the two Anganwadi Centres, the community decided to secure a space for her in the main village. -
Stakeholder meeting
After the hot discussion, the ANM, AWWs and ASHA of Vinti agreed to undertake monthly planning meetings for coordination. The sharing of the forthcoming ANC cases among them would be an important agenda. -
Expansion of the community mobilization activities
The facilitation skill shown by the JICA team was quickly learned by the LHV and the Male Supervisor, who applied it to other communities. The process of stakeholder meeting was universally accepted. The Vinti formula of quota became a reference.
Lessons Learnt
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Introduction of an incentive scheme may cause a new social tension.
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Community has a mechanism to solve such a tension. Both male and female members participated equally for discussion on this mahila (women’s) issue. The elders and the teachers gave a final shape to the agreement.
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External bodies (like JICA in this case) can be the catalyst for hot discussions.
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Hot discussions can result in mutual understanding as well as self esteem, if the resolution is agreed by the participants.
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The data provided by the ANM and the LHV are vital for constructive discussions.
Empowerment of a BMO as the Manager of CHC
Tendukheda is a small town about 70 km south of the district
capital of Damoh. The name comes from abundant Tendu trees, the leaves of
which are plucked for bidi (local cigarette) curling. This idyllic name
suggests Tendukheda’s infertility and backwardness. Until recently, driving
bad roads from Tendukheda to the nearest big town of Damoh took up to three
hours. Due to this backwardness and relative isolation, JICA selected
Tendukheda as one of the four blocks for specific intervention.
In October 2005, JICA team visited Tendukheda for the first time. On
interviewing Dr. Gupta, Block Medical Officer, for assessment of equipment
needs, JICA team found Tendukheda could make a showcase of TQM. The BMO
showed two faces. On one side, he exhibited all the frustration of a manager
posted in a remote station. He showed many defects of the facility, and one
typical example was the half constructed Maternity Ward left unfinished for
the last ten years. On the other hand, he showed respect to a senior ANM
whom he invited for discussion. The ANM shared with JICA practical ideas
such as needs of cabinets for storing the medical instruments. Dr. Gupta had
enough reasons to be cynical. His strong frustration was an evidence of his
will to make a change.
Tendukheda Labour Room – Before |
 Tendukheda Labour Room - After |
As soon as Dr. Gupta saw the quality of equipments supplied
by JICA, he understood JICA’s genuine interest. Quality Circle meetings were
held and Staff Nurses complained that the roof of delivery room had leakage.
By the year 2006, increase in number of institutional deliveries had
aggravated the situation. JICA consultants witnessed mothers with new born
babies lying in the corridor.
Instead of funding directly, JICA advocated to the District Collector and
CMHO, Damoh, on behalf of Tendukheda CHC. Thanks to the prompt decision by
the Collector, the leaking roof was repaired in June 2006, just before the
onset of the rainy season. Thanks also to the active management by Mr.
Thomas, District Program Manager, the district of Damoh decided in December,
2006 to avail Rs. 2 lakhs from RCH funds for construction of a part of the
unfinished building. Construction was approved on 7th March 2007 and quickly
commenced on 15th March 2007. On 30th June 2007, the new labour rooms were
inaugurated. For external observers, the change might seem sudden, but it
happened because of 1.5 years of negotiation, which itself was empowered by
10 years of frustration.
Inspired by this renovation, further arrangements were made for Staff
nurses’ duty room, post delivery room, water cooler, etc. just to list a
few. For the rest of the unfinished building, the DPM has promised to
provide budget out of the RCH fund, while the MLA has promised to give some
contribution from the MLA fund.
Money is not a problem for NRHM/RCH-II, as most State officials put it. The
problem is how to flow it to the right target at the right time. JICA’s
major role in this episode was to channelise the messages on needs and
demands to those who hold the resource. JICA is glad to see this role has
been taken over by the DPM, Damoh.
Practical advices and a few words of praise
It can do wonders
“Arre, humko to laga aap chale gaye ho, ab nahi aaoge.” (I
thought you all had gone back and will not visit my centre) exclaimed Razia,
when the JICA team visited her SHC on 17 July 2007. Razia Sultan is a smart
and pro-active ANM posted at Banwar SHC in Jabera block of Damoh district.
Her good skill level was highlighted during the six days ANC skill training
at Damoh. The JICA consultants informed the participants during the training
that they would be visiting their work areas/SHCs for further follow up.
This was not taken very seriously by Razia and was surprised to see the JICA
team actually visiting her SHC, while on the way to Damoh from Jabera CHC.
It was 5 pm in the evening and Razia was attending to a pregnant woman who
had come for her ANC check up. One of the two rooms at the SHC is used as
the clinic, while the other room is used by her as her residence. The SHC is
equipped with a chair, table and a bench for the waiting patients. The
clinic was highly disorganized and ill maintained. The medicines and other
supplies were carelessly kept at the centre. Razia informed that she had not
yet started conducting structured ANC clinics at the SHC, while she
conducted the immunization sessions at the AWC, adjacent to the SHC
building.
However, some positive steps had been initiated by her at the centre. She
used some of the untied fund for whitewashing the exterior walls of the
building as well as for painting a couple of health messages. Some health
education posters were displayed at the clinic. The JICA team appreciated
her efforts/initiatives and gave the following suggestions for further
improvement/beautification of the SHC:
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Proper organization of the room to conduct ANC check up as per norms told during the training e.g. curtain partition, table for abdominal check up, scale for height, weighing machine ( can be procured from the untied fund), almirah to systematically store the drugs and other supplies, fixing a particular day and time for ANC clinic
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Conduct immunization sessions in the sub-centre building
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Make posters on ANC and nutrition during pregnancy
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Utility of filling up ANC cards and proper filling for each case
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Stick/paste vital ANC parameters on the wall for remembrance
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Repair the fencing using untied funds and put a hedge plantation.
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Get the filling done so as to avoid the accumulation of water in front of the entrance to the SHC.
A new, highly motivated Razia could be seen at the end of the discussion. She assured that she would soon organize the clinic as suggested by the JICA team and confidently invited them to visit the clinic once again.:
:
Medicines at SHC Banwar_Before |
Razia at SHC Banwar_Before |
Arranged medicines at SHC Banwar_After |
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After about 15 days, the JICA District Coordinator again visited Banwar SHC and was surprised to see the SHC with a new look. All the medicines and other supplies were neatly stacked; a curtain partitioning the area for abdominal check up was available and several health education posters were displayed. Razia welcomed the District Coordinator with a warm smile and happily showed around the arrangements.
Sharing joy of cooperation, not the sense of guilt
It was a windy Thursday morning when the JICA Block
Coordinator of Hatta block, accompanied by the District Coordinator, started
for yet another visit to the SHCs in the project area. At about 10 am, the
Coordinators reached this particular SHC, which is about 15 km from the
block headquarter. The Coordinators, who were warmly welcomed by the ANM at
the SHC, were happy with a good beginning of the day. However, on entering
the SHC, the happiness slowly faded away.
The SHC was in a very bad condition. The room was highly disorganized and
all the materials were just dumped in one corner of the room. It seemed as
though the room had not been in use for months. On enquiring, the ANM
informed that they were confused regarding the organization of the SHC. The
Coordinators sensed that there was an understanding amongst the health
workers regarding the usage of the funds provided for the upkeep of the SHC,
which had not been used in a justified manner. The ANM then invited the
Block Coordinator to meet the other health workers during the sector meeting
after 2 days.
The Block Coordinator took this opportunity to meet the Male Supervisor,
LHV, MPW and the ANM. It was a regular monthly meeting and discussions were
held on issues related to the health services provided by the workers in the
previous month. The Coordinator then came up with the issue of usage of
funds for the maintenance of the SHC. This caused some tension and fear and
the health workers started fighting amongst themselves. JICA coordinator
gave them space to surface up the conflict, which helped them to realize
their mistake. The workers got two messages very clearly: first that JICA’s
role is not as that of an Inspector; and second, that there is a possibility
of other visitors from the district and State to monitor the field
activities. The Coordinator observed that inspite of all the tension and
fear amongst the health workers; they all shared a unique coordination – a
sense of guilt.
The Coordinator then explained to them that it was not too late and they
could still plan for organizing the SHC and making it functional. They saw a
ray of hope and immediately started discussing on what to do next. The Male
Supervisor was the first to make a contribution, followed by the rest of
them. They decided to use this money to equip the SHC with a cupboard, an
examination table and curtains, to start with.
The health workers did feel guilty, but found it very difficult to express.
Here, JICA roped in and gave them an appropriate platform to speak up and
vent out. This yielded very positive results as their fear and sense of
guilt were reduced to a great extent. The health workers exhibited a
different kind of coordination altogether- the coordination of cooperation.
This was visible from the discussions of the health workers to make the SHC
functional. Thus, a new experience was created by this incidence; wherein
the coordination of cynicism was transformed into that of cooperation.
The Genesis of SLIS
LHVs showed the synergetic approach
LHV of the sector Dhilla
From the early days of the Project, JICA has been seeking for “synergy”
between the four components. The HMIS and IEC/BCC components have been
included in the ANC training (HRM). The team of consultants has been
visiting the Blocks and Sectors for enhancement of the Management Skills
(TQM). Among the sites visited, the Sector Dhilla in Prithvipur Block,
Tikamgarh District was most promising. Poona Sahu, the Lady Health Visitor
(LHV), was leading a team of 5 ANMs and 5 MPWs working in the 5 SHCs
covering 19 Panchayats (village clusters), 31 villages and a total
population of 29,500. The following is a synopsis of the interaction between
Poona Sahu and the JICA consultants. The lessons learnt are now formulated
as the Sector Level Intervention Strategy (SLIS). (Note: From September to
December 2006 Yamagata had to leave the Project temporarily, so that the
“JICA team” consisted of four Indian consultants only.)
01-06 May 2006, ANC training: Poona Sahu was an
enthusiastic learner of ANC during the training course. She readily
understood JICA’s emphasis on the quality of the training. On the final day
of the course, she shredded tears in remembrance of the ladies who had died
during pregnancy. To her regret, their lives might have been saved had she
had enough knowledge on ANC. She then committed herself to implement
whatever she had acquired from the training.
11 Oct. 2006, Hand holding at Prithvipur CHC: Poona Sahu
was among the 7 attendants. JICA gave the 7 participants (including Poona
Sahu) Hb colour strips and Uristicks and explained how to use them. These
tools were to replace the old laboratory techniques that had been introduced
in the training. ANC cards were distributed for field testing, and Poona
Sahu gave feedback on 14 Oct 2006.
02 Nov. 2006, Hand holding at Sunoniya SHC: Poona Sahu
insisted that the hand holding session should be given to all the 7 ANMs of
her sector including those 3 who had not attended the JICA training course.
Poona impressed the JICA consultants by good arrangement for the ANC clinic.
After ANC check ups, the ANC cards filled by various ANMs were given to the
ANM in charge of the Sunoniya SHC, who was instructed to follow up the cases
(combination of HMIS and HRM). JICA team gave technical guidance for the
complicated ANC cases. The ANMs shared health education songs on the folk
tunes with the JICA consultants (IEC).
23 Feb. 2007, Prototype of SLIS: The JICA team visited
Dhilla SHC and facilitated discussion between the health service providers
and the community leaders (Sarpanch, Panchayat Sachiv, Mahila Panch, Panch,
Teachers, Chowkidar,etc.) The Sarpanch and the Sachiv agreed to construct a
boundary wall and to assure the daily water supply for the SHC. The ANM
declared that the untied funds of the year 200-07 would be spent for writing
important information on the wall of the SHC (combination of IEC and TQM).
22 Mar. 2007: The Consultation Mission from Tokyo visited
SHCs of the Dhilla sector. The ANMs had started holding ANC clinics and
filling the ANC cards. Micro planning was introduced to rationalize the
field activities by the ANMs (combination of HRM and TQM). The Sarpanch
agreed to use the walls of the Panchayat building for writing about the main
schemes like the JSY, Prasav Hetu Parivahan Yojana, Citizen Charter, and the
Village Statistics such as the number of births, deaths, marriages, etc
(combination of IEC/BCC and HMIS).
“Synergy” and “cross cutting” are the
terms which are frequently spoken by the development specialists but very
rarely practiced. The front line workers, on the other hand, naturally work
for cross cutting issues without using such terms. SLIS is a joint effort
between the specialists and the workers to practice it and study about it.
The joint venture brought a formula called SLIS. JICA was happy to find
Poona Sahu, and Poona was happy to be empowered by JICA. Our next challenge
is how to extend the SLIS to other areas where the LHVs may not be prepared
to the level of Poona Sahu.