Activities of the Program |
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 Behavior Change Communication (BCC) |
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BCC is the first tier
of program implementation on which the utilization and success of
all other services depend. Through this activity, the first delay
in the three delays model – the delay in identifying risk
and need for care – is addressed. Communication focuses on
information and the practices related to antenatal, natal and postnatal
care and asserts the advantages of institutional deliveries. |
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BCC requires constant contact and
communication with the target population. The following activities
are conducted to bring about behavior change in the community with
respect to practices of Safe Motherhood and Child Survival. |
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Interpersonal Communication through
Home Visits: The VLHWs and TBAs conduct home visits
for educating women in the identification of danger signals
during pregnancy, postpartum period and early infancy,
convince them about the importance of institutional deliveries
and nutrition during pregnancy and lactation and make the
people aware of the availability of emergency transport
vehicle provided by the Foundation
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Group Meetings and Gram Sabhas: Village and falia meetings, film shows, skits, exhibitions,
awareness programs and camps are conducted to generate awareness
and promote community participation in program intervention
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- Fortnightly Gujarati
Newspaper: A fortnightly Gujarati newspaper “Deep
Jyoti” is published as a supplementary insertion
in a leading Gujarati newspaper and distributed to community
stakeholders in villages and town headquarters. Its purpose
is to create awareness and sensitization among community
gatekeepers about the emerging health issues in the communities
and the activities undertaken by the Foundation to address
these problems
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Delivery of Health Care Services and Strengthening of
Government Health Systems |
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One of the main
interventions of Deepak Foundation is to facilitate the delivery
of health care services to the community. This includes strengthening
the existing government health delivery system as well as
providing new services to the community. The Foundation promotes
the use of existing government health delivery system by conducting
weekly gynecological and pediatric OPDs at SCs and CHCs, in
tandem with the teaching staff of government medical college,
and by activating the health centers in the area. Grassroot
level health paramedics and rural development workers of the
government support this endeavor.
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Mid-term Modification: Activation
of Government Sub Centers |
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All the efforts in the Foundation’s
program are directed towards motivating women and their families
to utilize the government health centers for deliveries and other
health services offered. The Sub Centers is the first interface
between the government health infrastructure and the community.
Covering a population of nearly 3000 in tribal areas (3-5 villages),
a SC is run by an ANM or a trained Female Health Worker (FHW). The
primary duty of the ANM was initially envisaged to cater to the
reproductive health needs of the women of the village. Over a period
of time, the ANM was drawn more into meeting the targets of Family
Planning and dealing with the paper work associated with it. Reproductive
health work got restricted to immunization and providing iron tablets.
Antenatal Care (ANC) clinics took a back seat. |
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As a consequence of this change
in work profile, ANMs started staying away from the village where
the SC was located resulting in the decreased use of the SC for
midwifery, thus defeating the very purpose for which the SCs were
set up. As a result, the SCs remained unused. Facility surveys conducted
by DF in the tribal areas revealed that only 19% of the government
SCs were being opened for 24 hours, which is a prerequisite for
attending to delivery cases. Majority of the SCs were closed for
most part of the day and were not being utilized for deliveries
and other activities like health education, antenatal and postnatal
care or referrals. The ANMs posted at these SCs were unable to fulfil
their responsibilities related to the upkeep and maintenance of
SCs and failed to conduct home visits. The unavailability of the
staff at the center to cater to deliveries and emergency cases and
lack of basic infrastructure and amenities (water and electricity)
lead to underutilization of the SCs for any health services, including
safe intra-partum care. |
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In order to strengthen the preparedness of the SCs to receive delivery cases and to motivate the beneficiaries to utilize the government health centers for delivery purposes, the Foundation started a process of “activation” of these SCs. Since the government infrastructure, on which a considerable amount of resources had been invested, already existed, DF joined hands with the government to activate the SCs in order to promote institutional births. Following steps were taken to activate the SCs
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- Ensuring round the clock availability of staff at the SC by placing VLHWs and TBAs at SCs for eight hours each
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Efforts were made to provide basic amenities and equipping the centers with telephone connections for prompt referral of complicated cases
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Community participation was also elicited in activating the redundant health centers so that institutions for safe intra-partum care could be made available at the doorstep of women
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The Block Health Officers (BHO) participated wholeheartedly in equipping the SCs
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The villagers supported the initiative by helping to tidy up the building, repairing electrical fittings, doing plumbing works and providing water
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The RCH society provided funds for curtains to assure privacy in the labor room
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The results so far are very encouraging.
Till date, 91 centers (83 SCs and 8 PHCs) have been activated. Whereas
no deliveries were conducted in these health centers before the
activation, a total of 774 deliveries have been conducted in the
“activated” sub centers in 12 months of the project initiation,
giving a boost to the institutional deliveries in the areas. We
have set a target to make functional all 158 SCs which have their
own building in the four talukas. |
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| 24 x 7 Emergency Transport Facility (EmTF) |
For receiving
any health care, villagers in the tribal blocks have to
travel at least 10 kms; a distance of nearly 40 kms is to
be covered to reach a PHC or CHC. Unavailability of adequate
transport facility and poor condition of roads add to the
misery, resulting in the preponderance of home based health
care and home deliveries, with or without trained assistance.
major initiative undertaken by the Foundation was the introduction
of emergency transport facility in four tribal talukas on a pilot basis.
A Memorandum of Understanding (MOU)
was signed with the Government of Gujarat in this respect and the
network was inaugurated on 12th August, 2005
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Features of EmTF |
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Twentyfour hour Emergency Control
Room (ECR): The set up is made at field headquarters,
Bodeli with three operators on rotation duty, equipped with
maps of the four talukas showing the locations of the available
health facilities
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Vehicles: A total of ten
vehicles, five each from the government and DF are pressed into
service to attend to emergency calls
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Mobile Phones: All the
10 drivers are given mobile phones to take emergency calls
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Emergency Phone Number : Emergency mobile number obtained for this purpose - 94267
24500 – has been widely publicized through hoardings,
stickers and wall paintings. The VLHWs and ORWs also propagate
the service in villages
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Other Emergency phone numbers: A directory of all important telephone numbers in the blocks
such as Government Functional Health facilities, Community Health
Centers (CHCs), Primary Health Centers (PHCs), Block Level Officials
like Block Health Officer (BHO), Taluka Development Officer
(TDO) and Child Development Project Officer (CDPO), police stations,
post offices, etc. that could be contacted in emergency has
been prepared and circulated across the four talukas. There
is one consolidated directory and four taluka-wise directories
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Linkages with Health Facilities : All medical facilities available in the project
area have been identified (Government, private practitioners
and NGOs) and those willing to receive emergency cases are taken
on as partners and cases are referred to when needed
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User fee: A token fee
of Rs. 2/- per km is collected from users to instill a sense
of participation and to prevent misuse. Those who cannot afford
to pay are provided the service free of cost.
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Training: All project
staff associated with the project, including drivers, are imparted
training by experts to handle emergency cases. The training
consisted of first aid, sharing experiences, some does and don’ts
and handling calls at the control room. Mock drills were held
at regular intervals
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Management Information System: Four log books are maintained to keep track of cases and accounts.
All the data are compiled and analyzed monthly to assess the
utilization and are shared with the Government staff concerned
i.e. District Development Officer (DDO), Chief District Health
Officer (CDHO), Regional Deputy Director (RDD), Health Commissioner
and partner NGOs
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Since its inception, the emergency
transport facility has served nearly 4000 cases, averaging to more
than 300 cases per month. Majority (80%) of the emergency cases
are related to women. Nearly two-third (68%) of all emergencies
pertain to delivery complications and newborn care. Though it started
mainly for obstetric emergencies, the EmTF also attends to other
problems like snake-bites, accidents, fractures, etc. An analysis
of calls received vis-à-vis calls attended has revealed that with
time, the gap between demand and supply has been growing. As a result
of this, the Foundation is considering the option of involving local
transporters in the provision of emergency transport services in
the areas. |
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| Help Desk |
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To take the project
to its logical conclusion, a HELP DESK at the Sir Sayajirao Gaekwad
Hospital in Vadodara (District Government Hospital) was inaugurated
on November 11, 2006. Three coordinators with mobile phones manage
the Help Desk round the clock. The help desk is informed about the
arrival of an emergency case from the tribal areas by the health
workers in the field. The personnel at the help desk ensure that
cases referred from the field receive immediate help at the hospital
when the patient arrives. Patients are assisted in filling up case
papers, procuring blood, etc. by the help desk coordinators. |
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| Comprehensive Emergency Obstetric & Newborn Care (CEmONC)
Unit |
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Of the three delays
that lead to avoidable maternal deaths during delivery, the delay
in accessing quality care at the referral center is one. In the
tribal blocks, quality emergency care for obstetric cases was grievously
lacking. The nearest health facility for dealing with complications
and emergency cases was 70 km away. |
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To
provide quality emergency obstetric and pediatric care at
the taluka level and on viewing a serious lack of the same
in the tribal areas, it was decided to set up a CEmONC unit
in the premises of the Community Health Center at Jabugam,
Pavi Jetpur. The 7-bedded CEmONC, built at a cost of around
58 lakhs was inaugurated by Sri S. R. Rao, Principal Secretary,
Department of Health and Family Welfare, on February 10,
2006. The unit works in collaboration with the Pediatric
Department, Sir Sayajirao Gaekwad Hospital (SSG), and is
envisioned to protect lives of women having complications
during pregnancy and postpartum. The emergency unit is
linked with the Community Health Center and has its own support staff, in addition to a Medical
Officer and a Gynecologist. It serves as the first emergency referral
unit covering a population of over seven lakhs and attends to roughly
230 cases per month. |
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Main Features of CEmONC
- Round the clock availability of doctors (specialist and medical
officers)
- Twice weekly OPDs
- Availability of lab technician and other support staff
- Free services including meals, medicines and baby kit
- Essential equipment such as sonography machine provided by
the Department of Health and Family Welfare
- 24 hour referral
- Link up with Deepak’s Emergency Transport Network
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| Promoting Community Participation |
Community Participation is encouraged
at the village level through the formation and activation
of Village Health Committees (VHCs). As many as 443 VHCs have
been formed to ensure regular and efficient service delivery
through government personnel and infrastructure and also to
register vital events such as births and deaths. VHCs include
the VLHW, sarpanch, anganwadi worker, woman representative
of the panchayat, primary school teachers, private
practitioners in villages, community leaders, the village
TBAs and resident workers of Roads and Buildings Department.
To promote the Right to Information, key health indicators
of the village based on the information maintained by the
local VLHWs are displayed through wall paintings at public
places in each village decided by the VHC . The number of
villages where the VHC data is displayed has reached 690 by
the end of February 2007. Gram sabhas (village meetings) are
also organized to increase community participation. Meetings
with Panchayati Raj Institute (PRI) representatives
are held for the smooth functioning of OPDs
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| Training and Monitoring |
As implementers
of effective safe motherhood and child survival interventions,
the greatest challenges lie in the Foundation’s ability
to promote life-saving behaviors among pregnant and nursing
women and their families. To do this, the Foundation has
trained and organized its outreach health cadres from the
local community – VLHWs and TBAs/Dais - to conduct behavior
change communication in the community.
As many as 1325 VLHWs have been trained by the Foundation.
Training of Traditional Birth Attendants (TBAs) is also
undertaken by the Foundation and 277 Dais have been trained
in Core and Extended role as per the Dai Sangathan curriculum.
We envisage that these trained VLHWs would be absorbed into
the government system to serve as Accredited Social Health
Activist (ASHA) under the National Rural Health Mission
(NRHM) in the future.
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The Major Aspects on
which Training is Provided |
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- Behavior Change Communication
- Promoting institutional deliveries
- Promoting antenatal and postnatal care
- Importance of nutrition during pregnancy and postnatal period
- Community mobilization through Gram Sabha and Village
Health Committee
- Promotion of birth and death registration
- Managing data in Management Information System
- Conducting referrals
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Dai Sammelan |
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The Vadodara District Level Dai
Sammelan was hosted by DF on World Health Day i.e. April 7,
2006 in Vadodara. It was an effort to bridge the gap in networking
with the grassroot level government functionaries and the dais with the goal of promoting institutional deliveries and referrals
through various mechanisms such as incentives, trainings and social
security. The sammelan served as a platform to bring all dais together and to reinforce their roles in the public
health system, thus further strengthening the linkages with other dais, the dai sangathan and the government on
issues related to women’s and children’s health and
overall wellbeing of the families. The theme of the day was “Working
Together for Health” and hence it was considered appropriate
to harness the GO-NGO partnership to promote the cause of dais.
The function was organized in partnership with the Health Department
of the Government of Gujarat. In all, about 900 people attended
the conference, which included 500 dais from the tribal
areas of Vadodara District. |
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| Computerized Management Information System (MIS) |
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The MIS system was
developed to manage information at the grassroot level and to carry
out process and impact evaluation. The details of all the beneficiaries
are recorded by VLHW at the village level and data entry is carried
out at the block level. Key indicators are derived from the data
on a monthly basis to review the progress and decide upon future
strategy. The Block Coordinators plan their monthly activities
based on the review of monthly status of key indicators. The data
and the indicators are shared within the organization in monthly
meetings and also with the government health authorities for further
planning and coordination. |
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Our Thoughts at Present…. |
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The SMCS program is
based on the “three delays model”. It seeks to address
the delays in accessing care through a combination of BCC, EmTF
and CEmONC, complemented by supportive activities like intensive
trainings, community participation and a strong MIS. Most of these
efforts, including the activation of the government SCs, are geared
towards increasing and sustaining the rates of institutional
deliveries or deliveries with trained assistance, both of which
are proxy indicators for “safe deliveries”.
Though the MMR has not changed significantly after the implementation
of the SMCS program for nearly two years now, the process indicators
show positive trends. The institutional deliveries have increased
from 14% to nearly 36%. At the SCs, after their activation by DF,
more than 600 deliveries within a period of 11 months were conducted.
The EmTF services are used by more than 300 women in a month. About
1500 pregnancy related cases reached CEmONC in a few months of its
existence. Overall, the indications are that if quality services
are provided and publicized, the community does take advantage and
positive results are bound to follow. If the processes continue
at the same pace and once institutional deliveries become the norm,
reduction in MMR can be expected.
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