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Prem Jyoti Comprehensive RCH Program Malto Tribes Jharkhand |
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About Population Foundation of India
The Population Foundation of India (PFI), earlier known as Family Planning Foundation was formed in
1970 by a group of enlightened, socially committed and philanthropically inclined industrialists, led by the
late Mr JRD Tata and Dr Bharat Ram. The Population Foundation of India provides financial and technical
support to non-government organizations working in the areas of population, reproductive and child
health, family planning and HIV/AIDS. PFI believes in formulating and implementing rights based and
gender sensitive programmes with quality of care.
Guidance
Mr. A. R. Nanda
Dr. Kumudha Aruldas
Contributors :
Dr. Sharmila Neogi, Ms. Sona Sharma, Dr. Lalitendu Jagatdeb,
Dr. Vikram Gupta, Mr. Debabrata Bhuniya, Mr. Nihar Ranjan Misra
Assistance :
Ms. Prema Ramesh
Mr. Shailender Negi
POPULATION FOUNDATION OF INDIA
B-28, Qutab Institutional Area, Tara Crescent, New Delhi-1100016
Tel.: 011-42899770, Fax: 011-42899795
Email : popfound@sify.com
Website : www.popfound.org
Comprehensive Reproductive
& Child Health Programme
for Malto tribals in Jharkhand:
Background
Raj Mahal hills in Jharkhand are home to the Maltos, notified as primitive tribal groups (PTG),
numbering about 100,000 characterised by a diminishing population, pre-agricultural level of
technology and extremely low level of literacy. They live in small hamlets (10-50 houses)
scattered in the districts of Sahibganj, Pakur, Godda and Dumka of Jharkhand State, India. Most
of the villages are remote and inaccessible and are located high up in the hills. Their primary
occupation is agriculture and forestry and cattle rearing.
The death rate among the Maltos exceeds the birth rate. The poor economy, lack of knowledge
of health issues, poor health seeking behaviour, lack of availability of quality and low-cost health
care services contribute to the high mortality, casting a shadow on the existence of the group.
The high death rate is mainly due to infectious diseases such as malaria, Kala-azar, diarrhoea,
acute respiratory infections and tuberculosis The high Infant Mortality Rate (IMR) and Maternal
Mortality Ratio indicates that the status of reproductive health is poor among the Maltos.
About Prem Jyoti
The Prem Jyoti Community Health and Development Project (CHPD), usually referred to as
Prem Jyoti, is a unit of the Emmanuel Hospital Association (EHA) has been working in
Sahibganj district of Jharkhand since December 1996. The entire district with a total
population of over a million did not have a functioning referral hospital to manage complicated
cases. In view of the need for basic health services for all communities, the Prem Jyoti Health
Centre was started in 2003 and has been functioning as a referral centre. It was upgraded as a
hospital with 15 beds in 2004. Prem Jyoti endeavours in community health work among the
Malto tribes who form about 10% of the population in Sahibganj. It is focusing mainly on their
health needs, through a network of trained volunteers from the communities, peripheral clinics
for 140 villages and a hospital. In its efforts to improve quality of life for Maltos Prem Jyoti team
has plodded on against many odds.
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PFI-Prem Jyoti Initiative
The Population Foundation of India (PFI) extended
support to Prem Jyoti in April 2005. The overall goal was
to transform the Maltos into a healthy community. Under
this project, Prem Jyoti focussed on delivering basic
reproductive and child health services in 140 villages.
These villages were divided into 13 cluster areas with 10
villages in each cluster for operationalising the
programme.
Community Health Volunteers, mostly women and few
men, were selected one from every village and for each
cluster, cluster health guides were identified. Emphasis of
the project was on training & empowerment of the
community to tackle common health problems. The
project also focussed on strengthening referral services to
the 15 bedded secondary care hospital run by Prem Jyoti.
Geographic Area
Project Focus
Building the capacity of the communities to take care of
own health was the goal of the project. Ensuring safe
motherhood and use of contraceptive methods for
prevention of unwanted pregnancies was the primary
focus. Malaria is a major contributing factor to maternal
and childhood deaths and therefore, reducing the
morbidity and mortality due to malaria was an essential
component of the project. Therefore, the key processes
include:
Development of change agents
The programme focussed on creating community based
mechanisms to increase information and access to health
and reproductive health care by building capacity of the
following members in these remote communities.
i. Community Health Volunteers:
118 Communty Health Volunteers, mostly women and
few men, from 140 villages were trained in general health,
aspects of mother and child health, family planning,
techniques of Behaviour Change Communications and
simple record keeping. 81 out of 118 CHVs were given
training in preparing herbal medicines for common
ailments in order to promote local cost effective remedies.
In the monthly meetings, topics on general health and
reproductive health were discussed with the CHVs. The
CHVs would coordinate for referral to CHGs and mini
health clinics for ante-natal care and child care services
and for referral to peripheral clinic and Prem Jyoti
hospital for complicated pregnancies and deliveries and
referral of sick children.
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When 25 year old Sarita Malto, resident of Oduguri village in Sahebganj district of Jharkhand conceived her third
child, the community health volunteer (CHV) of the area advised her to go for antenatal checkups. Since her husband
is physically handicapped and she is the only earning member of the family, Sarita did not follow their advice.
In the last month of her pregnancy, Sarita experienced leaking of vaginal liquid for 4 days. CHV of that area brought
her to the Prem Jyoti hospital. On examination, it was revealed that the baby was lying in a diagonal position in the
womb and had infection in the womb. Sarita immediately underwent a Caesarean operation at the hospital. The
baby was delivered and survived without any complications. This was possible only because a Secondary Care
Hospital with a surgical facility was available in 15 kms for Sarita.
ii. Cluster Health Guides:
The Community Health Guides (CHGs) are 13 literate Malto women, selected by the community, one for each cluster of
11 villages. The CHGs were trained in reproductive health, safe motherhood, new born and childcare, immunisation,
integrated management of childhood diseases, etc. In addition CHGs were given 11 days training to use simple oral
medicines, collect vital statistics, monitor growth of children etc. CHGs were then qualified to dispense all basic drugs
after passing an exam. They were given a bag for carrying essential equipment to diagnose, drugs, umbrellas and torches
etc. In order to promote sustainability, the CHG were encouraged to buy essential drugs from the project at wholesale
rate and allowed to dispense the same at maximum retail price. The patients thus get reasonable treatment in their own
area.
During the course of the project the community provided space and helped to build a room to conduct sub-centre clinic at
the level of cluster. These were later named mini health clinics where CHGs are available to provide services on a fixed day
every week. CHG also visit each of the villages in her cluster once a month to conduct IEC programme, check antenatal
women and to do growth monitoring of children. She distributes tablets for deworming and supplements once in 6
months of Vitamin A to children under five years of age. She coordinates with the peripheral clinic and the Prem Jyoti
hospital for referral support and her knowledge is updated during visits of the clinical team of the peripheral clinic.
Though Mariam (Beechkepu), one of the Community Health Guides (CHGs) of Prem Jyoti project has not studied
much, she was an enthusiastic learner. In spite of her pregnancy, Mariam was a dedicated attendee in all the training
programmes. Even though her village is situated on top of a very steep hill, she regularly visited the allotted villages
for conducting antenatal checkups and to weigh children under 5 years of age.
Recently, Mariam brought a 3-year-old child named Mariam to the Prem Jtyoti Hospital suffering from kala azar
with severe anaemia and heart failure. The child's father had deserted the family and there were financial troubles,
yet at the motivation of the CHG, the villagers pooled in money to help the child. It was a difficult case to treat the
child due to heart failure and her need for blood transfusion. Since the mother had a different blood group, one of
the staff came forward to donate blood. With the timely intervention of the CHG and cooperation of fellow villagers,
the child is on the road to recovery now.
iii. Traditional Birth Attendants:
55 Traditional Birth Attendants were trained to conduct safe delivery, timely referral, treatment of simple ailments and
health education. Dais along with CHVs would refer women for antenatal check up and family planning services,
children for immunisation and other ailments, women with complicated pregnancies and deliveries to CHGs, mini
health clinics, peripheral clinics and to the Prem Jyoti hospital as felt appropriate.
Area Health Committees
In order to ensure ownership of the programme Area Health Committees with community representatives, CHVs & CHG of
that cluster, the Village heads and other area leaders were constituted for the 13 clusters. The Area Health Committee
consisted of 25-30 members. Its role is mainly focussed on enhancing health related work carried out in the villages.
The committee meets once a month and is responsible to
mobilise the community to avail the services of the CHVs
& CHG and to adopt healthy practices. A supervisor from
Prem Jyoti acts as a facilitator in these meetings. Health
problems of the villages are discussed in the meetings and
the suggestions and the plan for addressing the problems
are made. The problems raised by the committee are
noted and presented at the meetings held in the hospital
by the supervisor. After analysis of the problem the
appropriate action suggested is implemented in
consultation with the committee members in each area.
Training and skill building of the community
As most of the community members are illiterate the
project had to think of innovative ways of training the
volunteers at the community level. A lot of pictorial
material and audiovisual aids were used to train the
community health functionaries so that they could
become effective change agents. The project successfully
utilised nurses working at the hospital specially trained on
RCH as key trainers in all its training programmes. Some
of the training methodologies were:
Health Songs and skits:. The project has developed over
20 songs on health topics in Malto language with
traditional tunes as the Maltos are also very fond of singing
and dancing. These songs summarise the thrust messages
for any health problem. Some songs have even made the
drug dosages easier to remember and this is very helpful
for the CHVs to remember. The songs have also been
recorded in an audio cassette. A song book with all the
lyrics has been printed and distributed to all the CHVs. Its
effectiveness can be seen from the statement of a
Community Health Volunteer. “We enjoy while learning.
And while practicing, instead of recalling the doses of
medicine, we recall the song and the doses are their in the
song. It is good that we have these songs so that we are
able to treat many common diseases, even though we
don't know how to read and write. The Maltos are very
good at enacting skits and therefore they were trained to
perform skits for mass awareness programmes.
Flash Cards and Posters: To help the CHVs explain clearly
about health problems, flash cards have been prepared in
the Malto cultural setting. This is widely used by all the
grass root level workers as well as in the mobile clinics and
base hospital. Posters have been developed on malaria,
immunisation and disposable delivery kit.
CHV Festival (Mela): This is a special annual event, where
all the CHVs from different areas come together for fun,
games, cultural programmes, dancing and sharing of
experiences. Group discussions are held with them in
which CHVs share how their life was before they became
CHVs, how they are now, how they would like their
community to be in the future. The CHV mela presented a
good opportunity to collectively motivate the CHVs to be
regular and to persevere in their important role.
As opined by a trainer “the training really helped me a lot
in discovering new ways to train. In the training I had to
sing songs like malaria songs, dance with CHVs, eat with
them and on the whole become one of them”.
Community level Behaviour Change Communication
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The key to lasting change in the health scenario of a
community is improved health awareness. Various methods
are adopted to improve the health awareness & preventive
measures regarding the issues of safe drinking water,
mosquito nets, plastering of mud walls, immunisation of
under five children, utilisation of health services, safe
motherhood, family Planning and RTI/STD/ HV/AIDS.
Films: Films procured from various sources was used by
the project in its BCC programmes which covered issues
like immunisation, child care, women's health, malaria,
Kala Azar, nutrition, HIV/AIDS etc. A documentary on
early marriage translated into Malto language for mass
communication on health education was well received by
the community.
and CHGs mobilised communities during their field visits
for availing services from the peripheral clinics. During
field visits the CHGs counsel women with health and
reproductive health problems individually to make them
aware on the importance of primary health care services
and motivate them to seek and utilise the services
provided through the project.
Group meetings and IPC: After the training the CHVs and
CHGs were encouraged to carry out BCC at the
communities. Group meetings were held by CHVs on
various health related issues and RH issues. The CHVs
Service delivery
Peripheral Clinic: The Malto villages are located far away
from the roads. The villages are scattered in small hamlets
all over the hills. This makes accessibility a difficult
problem. Therefore, they have been grouped into 13
clusters. Each cluster has a monthly peripheral clinic at a
selected village accessible for both the medical team and
the villagers. It supports the work of the CHVs and takes
secondary level health care as close to the people as
possible. The CHVs are actively involved in bringing
pregnant women for check up and under five children for
immunization. They also motivate women for copper-T
insertion. An average of 15 villages gathers at a peripheral
clinic which is held in the veranda of a big house or
sometimes in the community hall or school building.
Centers to avoid confusion with the government sub-
centres. The communities decided the location of the
centres. They also contributed the bamboo and wood
needed for construction. They voluntarily worked to put
up the centres. As they expressed their inability to buy tiles,
tiles were provided to each of the 13 centres through
funding from Emmanuel Hospital Association, Canada. It
was encouraging to find community getting together to
pool their resources for a common cause. The CHGs and
CHVs are also involved in motivating community for
participation. Each of these Mini Health Centers was
provided with basic equipments like furniture medicines
for common ailments, stethoscope, blood pressure
machines, thermometer etc. The CHGs have fixed up time
and days for providing services at the Mini Health Centres
in consultation with the communities. The maintenance
of the centres is taken care of by cluster health committees.
In the absence of accessible sub centres these mini-health
centres serve as a good alternative in these remote areas.
Integrated services for maternal, child health,
immunisation, birth spacing, nutritional advice etc are
provided at the peripheral clinic. Each clinic starts with a
short session for health education. After this the infants
are immunised in one section. Mothers for antenatal
check up or child spacing are looked after separately.
There is a separate nurse or doctor who attends to the
other general patients including TB. Having such a clinic
reduces the distance and expense of travelling to a
hospital and also the loss of work days. The clinics also
help in building a rapport in the community. Since the
village people are familiar with the staff of the medical
team, they are not afraid to come to the hospital when they
need help. It also enables to train the CHVs and CHGs
clinically and enhances the image of the CHV in the
community. She/He also gains in self confidence.
Mini Health Centers: It was decided to call the centres built
by the community at the cluster level as Mini Health
Referral unit: The hospital is considered as an integral
part of the community health programme. The hospital
exists for the community. Therefore the name
“Community Hospital” it provides essential secondary
care and treatment of patients referred from the target
villages by CHVs / CHGs / Peripheral clinics. This is
urgently needed especially in cases of complicated labour,
cerebral malaria and other acute emergencies. It is located
between two Malto villages. The hospital staffs learnt to
speak the Malto language. Moreover, all the non-
professional staffs are Malto tribals. Therefore the Maltos
feel comfortable to come to the hospital. This is important,
because this tribe has been suppressed by other
communities over the centuries and are very timid and
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easily intimidated. The secondary care for the Maltos is highly subsidised. Delivery for women who have had at least 3
antenatal check-ups costs only Rs. 100/- irrespective of the mode of delivery. All other charges are also reduced, so that
hospital treatment becomes affordable for the Malto patients. The utilization of base hospital facilities has increased in
number especially in RCH and Kalazar. The Maltos have been a down trodden community for centuries. They are afraid
of interacting with other communities. There was a fear that making the hospital open for the general public may be
intimidating for the Malto tribals. However, this has not happened because of various steps taken by the project. a) Half of
the Prem Jyoti team members are Maltos. Malto is the common language spoken in Prem Jyoti so Malto patients feel
comfortable to communicate in their own language b) Maltos are given priority especially if they have been referred to by
the CHV/CHG/Peripheral clinic c) As the hospital is located in Malto land, this gives a sense of ownership and identity as
a Malto hospital d) No private wards built to avoid different levels of care to the rich and poor. The increasing number of
pregnant mothers coming to the hospital for delivery reflects the increasing trust of the community on Prem Jyoti as a
center for obstetric care. The focus is on providing low-cost quality care.
Devi Malto was going to have her tenth baby. She had been coming regularly for check up to the mobile clinic. The nurse
advised her to come to hospital for delivery, as her blood pressure was high. She was brought to the Prem Jyoti hospital
and was induced for delivery. She was not progressing normally and Caesarean Section had to be done. Since she had
come for full antenatal checkups, she had to pay only Rs. 100/- for the Caesarean Section. Had she stayed at house, she
was very likely to have died since eclampsia is one of the main causes of maternal mortality. “We are encouraged by the
change in the mindset of our Malto people to take good advice” says the Project Director, Dr. Vijula Isaac.
One year old, Santosh Malto was hospitalised at Prem Jyoti hospital with no hope for survival as he had high fever
and severe breathing difficulty. He has difficulty in swallowing due to his shallow and fast breathing. He was
diagnosed with Broncho Pneumonia. His parents brought him to Prem Jyoti hospital.
The doctor at Prem Jyoti Hospital briefed the parents about the health condition of the child and treatment began.
There were visible signs of improvement from the second day itself and by the 3rd day, he started taking small
amount of food. By the 5th day he became active and started to play and was discharged. His parents thanked the
hospital staff for giving their child a new life.
Ruth Malto (15 years) was admitted to the Prem Jyoti hospital with severe swelling in the left thigh. She was neither
able to walk nor stand. After incision and drainage, more than 1 litre of pus was removed from her left thigh. She had
also developed abscesses in her back. She was diagnosed with Pott's Spine (Tuberculosis of Spine) and treatment
began immediately. She stayed in the hospital for almost 2 months. With the love and care of nurses, she slowly
recovered and was discharged from the hospital. The staff gifted a spinal brace to her. Now, she is able to walk and to
go back to school.
Key findings of the comparative evaluation
A baseline and an endline survey were carried out at the
beginning and the end of the project respectively to assess
the change in health and reproductive health situation.
Sample Size and Methodology: Both quantitative and
qualitative methods of research were used to collect the
required information. The total sample size for both the
quantitative surveys at the beginning and the end of the
project was 589 women in the age group of 12-49 years. A
multistage random sampling design was followed both for
baseline and the endline evaluations. Apart from this,
qualitative techniques such as Focus Group Discussions
and In-depth Interviews were done with the key stake
holders to gather necessary qualitative information
especially during the end line survey.
Background information: As a background the
community was found to be primarily an agrarian society
living in nuclear families with over 90% illiteracy among
women. The median age at marriage was found to be 16
years and age at first childbirth was found to be 17 years.
Since Malto is a primitive tribal group characterized by
diminishing population numbers, Government of
Jharkhand is not encouraging family planning methods in
this tribe. However, in order to promote safe motherhood
and child survival, information and services for the
spacing methods were provided in the project.
Achievement in key indicators: Quantitative survey show a positive change in indicators related to health and
reproductive health status of women and children
Indicator
% of women accessing services from Prem Jyoti
% of women covered by full ANC 31%
% of women receiving TT from the project
% of Safe deliveries
% of women giving supplementary feeding from birth
% Children in 12-23 months with Full Immunisation
% increase in awareness of RTI/STI 28%
% increase in awareness of HIV/AIDS
% of women reporting incidence of Malaria in last 3 months.
Family Planning
Baseline
36%
57%
30%
9%
23.3%
24%
49%
9%
48%
Endline
86%
83%
18%
4.9%
51%
18%
40 %
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Indicator
% increase in awareness of HIV/AIDS
% of women reporting incidence of Malaria in last 3 months.
Family Planning
%Increase in awareness of condoms
% Increase in awareness of pills
% increase in awareness of IUD
Baseline
9%
48%
Endline
18%
40 %
27%
57%
64%
84%
78%
87%
Challenges and Innovations
? The greatest challenge in this project was
contextualising health care, especially RCH for such a
scattered and endangered tribal group, in a way that is
appealing, affordable and sustainable.
? The current Government system relies on the ANM to
deliver health services for a population of 3000. This
would mean covering about 25 Malto villages. This is
not feasible even for the most committed / motivated
ANM, simply because of the distances involved and
the near-absolute lack of transport facilities. The
Cluster Health Guide who is selected and monitored
by the community is intended as a more suitable and
community-friendly alternative who is constantly
available for any emergency. The Mini-health centres
are a sustainable alternative to sub centres.
? Song as a medium of training techniques was an
innovative method that has borne fruit. A lot of
progress has been made in the way of behaviour
change. The fact that the Maltos are aware of safe
drinking water, use of mosquito nets, the importance
of early treatment for malaria, antenatal care and so
on reflects a change in the thinking and attitudes
towards health problems. For example safe delivery,
immunisation coverage and antenatal coverage have
almost doubled in three years of project
implementation.
? On repeated advocacy with district authorities the
road to Barharwa, a major stumbling block for access
to services, has improved greatly contributing to
improving the quality of life. The project was visited by
many national and international NGOs who have
provided support to the hospital in the community
activities. Few examples are contribution from EHA
Canada for building roof of mini health centres,
organisation of eye camps and surgical camps in
collaboration with CBN-India and Medvision
(Tamilnadu) for benefit of the community.
? Prem Jyoti developed the infrastructure through
various sources which will add value to the secondary
care services these included the installation of V-Sat
for effective communication, renovation of staff
quarters and wards, purchase of equipments like
ultrasound machine and expansion of hospital and
construction of new building. The results were
reflected in terms of marked increase in the number of
out patients, admissions and deliveries. Supply of
water was also improved through newly dug well. The
hospital and the field level staff received training inputs
from various sources for improving their skills in
program implementation.
? A number of nursing and medical students have visited
and the initiation of training nursing students from the
community was made when Mariam Malto became
the first Malto ANM student, selected at EHA hospital
Satbarwa. This is the first step towards fulfilment of a
dream to see Malto professionals taking over the
health work. Since then 3 more malto girls were
selected for training as ANMs. Training of Malto
women as ANMs would help to ensure sustainability.
A young Malto boy, two years of age, was hospitalized for the treatment of complicated tuberculosis. His sister, Mariam
Malto took care of him at the hospital. During this period Mariam had regular interaction with the nurses of the ward
and developed an interest in their work. Having completed her Matriculation, she expressed her keen desire to work as
a nurse. She began working in full earnest as a volunteer at the hospital and realizing that she had the potential to learn,
the Prem Jyoti project staff encouraged her to learn. Ms Shashi Bala, a senior nurse at the hospital, took her under her
wing and began tutoring her with the aim of preparing her to take the entrance examination for nursing. Mariam
familiarized herself with medical terminologies and the English language. Auxiliary Nurse Midwife (ANM) courses are
conducted at some of the hospitals linked with the Emmanuel Hospital Association. The efforts paid off and after six
months, she was selected for training at the Navjivan Hospital at Satbarwa. Knowledge is power and this was a
milestone for Prem Jyoti to be able to empower the Malto community to take care of their health in a better way.
Collaboration with the government on various health programmes (malaria, kala Azar, T.B) has been fruitful for
the project .Collaboration with UNICEF on immunisation is another example of good liaisoning. Advocacy is on
for getting the referral centre recognised under JSY.
Government Support
The project has a good rapport with the Government officials at the block and district levels. Support has been received
in the following areas:
? Immunization campaign was conducted often in collaboration with UNICEF/Government. Financial assistance was
provided by UNICEF for an intensive immunisation drive for 4 months in 2005.
? DDT and pyrethium spraying programme was done in collaboration with government.
? The government provides of essential drugs for TB & Kala Azar apart from vaccines and other essential drugs.
? Procurement of drugs for malaria and 4400 impregnated mosquito nets was made from the government and
distribution of the same was carried out in the target community. The community health organizers and the
supervisors worked very hard to complete the massive task. It also gave a good opportunity to build rapport with the
people and the government officials.
? Prem Jyoti has registered the ultrasound machine as per the PCPNDT Act. An ultrasound machine has now been
purchased and the community can avail the benefits.
? Prem Jyoti has been included in special Kala Azar elimination programme in four districts of Santhal Pragana. A MoU
has been signed with Government of Jharkhand (GoJ) recognizing Prem Jyoti as one of the 15 selected treatment
centres. This provides for the expenses for hospital stay, patient's diet, consultation fees, drugs etc.
? Liaisoning is also being done with Jharkhand Government regarding recognition of Prem Jyoti as a centre under
Janani Suraksha Yojana
Project Directors - Dr. Vijila and Dr. Issac